By Meegan Kennedy
(Ohio State, 2010) x + 261 pp.
Reviewed by Athena Vrettos on 2011-08-02.

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Meegan Kennedy's valuable contribution to the expanding field of nineteenth-century medicine and literature begins and ends with the case history, mapping the trajectory of its development from the "New Science" of the eighteenth-century to the psychoanalyst's couch. In between these historical signposts, Kennedy traces the case history's complex methodological interplay with the Victorian novel and literary realism. On the one hand, the case history drew upon literary tropes and conventions to shape its narrative form; on the other hand, it influenced the structure of narrative vision and realist methodology in British writers such as Charles Dickens, Elizabeth Gaskell, and George Eliot. "The nineteenth-century case history," Kennedy claims, "faces a uniquely heterogeneous set of demands: it must produce both a fact and a story, represent both a disease and a person, display both the disinterested stance of the man of science and the physician's subjective insight" (23). As a result of these generic tensions, Kennedy argues, the case history was reinvented numerous times over the course of the century in ways that often intersected with developments in the Victorian novel.

In tracing this intricate relationship between medical and literary narratives, Kennedy's work responds to recent studies such as Janis Caldwell's Literature and Medicine in Nineteenth Century Britain (2004) and Jason Tougaw's Strange Cases: The Medical Case History and the British Novel (2006). Yet Kennedy challenges some of their distinctions between Romantic and materialist (Caldwell) or sympathetic and diagnostic (Tougaw) modes of reading; according to her, the case history offers new (and often overlapping) models of vision and representation that became increasingly interwoven with the narrative practices of the nineteenth-century novel. Kennedy also takes up the challenge of Lawrence Rothfield's Vital Signs: Medical Realism in Nineteenth-Century Fiction (1992) to show how Victorian novels employed some of the techniques of clinical observation beyond specific portrayals of illness and drew these techniques into the very methodology of literary realism.

In her particularly compelling opening chapter, "Curious Observations, Curious Sights," Kennedy explores the methodological tensions within eighteenth-century case studies and sets up some of the conflicts and contradictions that shaped the development of the genre over the following century. At the beginning of the eighteenth century, Kennedy notes, the medical case history validated dispassionate objectivity through "mechanical" models of observation even as it flirted with sentimentality through representations of unusual medical conditions that sought to evoke readerly sensibilities. In Kennedy's detailed rhetorical analyses of some of these early case histories--analyses which engagingly combine (in a mirror of her subject matter) rigorous investigation and medical "curiosity"--we meet such perplexing medical spectacles as tongue worms, the treatment of madness through a transfusion of calf's blood, an elderly woman who suckles her grandchild, and a blind boy restored to sight. This preoccupation with medical curiosities, Kennedy shows, potentially disrupted the scientific authority of the case history and was eventually replaced by a new model of clinical medicine that demanded new narrative forms. Yet traces of this earlier fascination with "curious sights" reemerged, we learn, in both the Victorian enthusiasm for unmasking medical and scientific deception and in the sentimental evocation of sympathy in both medical and literary portrayals of human suffering.

In the chapters that follow, Kennedy traces the intricate relationship between nineteenth-century literature and the case history. Using a wide array of primary sources (periodical literature, medical treatises and manuals, scientific journals, letters, book reviews, and published lectures), she explores--among other things--debates about the validity of medical speculation, the rise of the hypothesis as a key component of the scientific method, assessments of the accuracy (and inaccuracy) of new visual technologies such as the microscope, and the embrace of imaginative projection (and geographical exploration) as models for the psychoanalytic method. While this list is heavily weighted towards the history of the medical sciences, and Kennedy's research certainly leans in that direction, she makes a persuasive case for the relevance of these topics to debates within literary realism, particularly in two later chapters. These show George Eliot employing quite different models of realism (and making quite different assumptions about the accuracy of medical and narrative vision) over the course of her career. While Kennedy's fourth chapter examines Eliot's use of "mechanical observation" and visual technology as a model for literary realism in Adam Bede, the subsequent chapter traces Eliot's increasing skepticism about this ideal of mechanical observation and the accuracy of human perception, and delineates her embrace of more intuitive, speculative, and experimental forms of vision in Middlemarch. This fifth chapter, "Speculation and Insight, Experimental Medicine and the Expansion of Realism," is perhaps the strongest in the book. As Kennedy demonstrates, the shift in the metaphoric underpinnings of Eliot's realism paralleled important developments in mid-century clinical medicine, including debates about the necessary intervention and interpretive insight of the observer in microscopy, and the rise of imaginative speculation and scientific hypotheses as central components of the "new, romantic role for the physician" (161) in experimental medicine.

Kennedy's earlier chapters on the fiction of Dickens and Gaskell seem a little thinner than her study of Eliot, and in the case of Dickens a little more predictable in its literary analyses, though Kennedy persuasively shows how Dickens's and Gaskell's portrayals of illness mirror the blending of clinical and sentimental medicine in case histories from the early decades of the nineteenth century. In the moments of "aggressive sentimentality" that mark some of his deathbed scenes, Kennedy argues, Dickens asserts a "causative link" (100) between curious medical sight and moral insight, and between the affective impact of a sentimental scene and the transformative social power of the Victorian novel. Turning to Gaskell's Ruth, Kennedy concludes that the gritty, realistic portrayal of the typhus epidemic, and the heroine's insistently embodied acts of nursing, demonstrate how Gaskell embraces the clinical model more fully than Dickens, but in the service of an even more "transcendental ideal" (107). The erasure of Ruth's body at her deathbed and the emphasis on her "beatific self-sacrifice" (116), Kennedy contends, ultimately subvert both the goals of clinical medicine and the tenets of literary realism in favor of a sympathy that requires the absence of clinical detail to achieve its moral effect. Only in later versions of literary realism, like Eliot's, does the Victorian novel find a means of achieving sympathy through clinical observation, ultimately rejecting the "sentimental eye" with which the fiction of Dickens and Gaskell gazed on illness and death.

After the detailed discussion of Eliot's fiction, Kennedy takes an unexpected leap to a concluding chapter on Freud and the convergence of the psychoanalytic case history with the imperial romances of H. Rider Haggard. While Freud offers a logical end point for studying the nineteenth-century trajectory of the case history, the gap between Eliot and Freud makes the literary side of the study feel somewhat truncated. Furthermore, Kennedy's account of Haggard in the final chapter consists mostly of a brief summary and narrative comparison with Freud's case histories in the penultimate section. Nevertheless, in exploring the generic tensions and literary conventions invoked in Freud's early case histories, she persuasively argues that Freud "juxtaposes the realism of the clinical report with antirealist genres" and "recuperates precisely those aspects of the eighteenth-century case history that were ostensibly repudiated by clinical medicine" (169). It was this rhetorical "return of the repressed" (175)--the invocation of genres and rhetorical strategies that had been strategically discarded over the course of the previous century--that "endangered [Freud's] bid for professional authority" (169). While many of Kennedy's observations about the literary components of Freud's early case histories cover familiar ground, they gather new meaning when linked to the trajectory traced by the book as a whole. This final chapter, then, shows how the complex history of debates about narrative form and scientific methodology illuminates the literary and scientific tensions in Freud's work, and it is a testament to the success of Kennedy's project that the reader emerges at the end with a much richer, more detailed sense of that history than when we began.

Athena Vrettos, Associate Professor of English at Case Western Reserve University, is the author of Somatic Fictions: Imagining Illness in Victorian Culture (Stanford, 1995).

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