Two recent books that closely investigate the topic of medicine in the early US offer sharp insights about the roots of the nation's health care attitudes and practices. Both first monographs, these works contribute to the field of American studies by offering interdisciplinary evidence that US medicine has always been heavily infused with changing human sensibilities and that empiricism does not necessarily correlate with fact. These books look at the beginnings of the infrastructure of US health care, which today comprises one-fifth of the US gross domestic product, and within a decade will account for $6 trillion in national spending.Footnote ¹ The subject itself is massive, and as health conglomerates change the way we heal one another, a review of how health care has evolved in the US can only serve to make us more discerning about the direction of US medicine.

The first monograph, The Medical Imagination: Literature and Health in the Early United States, weaves together a history of medicine and science, literary works, studies of the body, racial theory, and even cartography in the early US to explore what author Sari Altschuler calls “the interdisciplinary complexity of health as a topic.”Footnote ² The discussion focusses on doctors in the late eighteenth to mid-nineteenth centuries, men who fashioned themselves as “physician-writers” (3) and who saw the boundaries between medicine and the literary arts as fluid. Altschuler documents key associations among physician-writers (or physicians and writers) to show how they brought the same sensibilities to both medicine and literature. Texts and ideas from approximately the first hundred years of US medicine reveal it as a “period of uncertainty” (126), when practitioners had scant information with which to confront scourging epidemics, resolve ambiguity about human bodily difference, and process scientific discoveries that redirected centuries of medical knowledge. Part of the book's argument is that physician-writers used their literary imaginations to investigate complicated medical issues that were minimally understood – hence the “medical imagination” of the title.

The first half of the book covers familiar ground in the discussion of medicine and early American literature. Chapter 1 is a primer on the analogies that eighteenth-century transatlantic medical writers drew between the functions of the body and social or political constructs (e.g. William Harvey saw the circulatory system as a monarchy with the heart as king). Chapters 2 and 3 revisit accounts of the medical debates over yellow fever and cholera, making the same argument for both diseases (and one that Cathy Davidson made thirty years ago), that the Gothic novel provided an ideal venue for communicating the terrors of epidemic. Writers like Edgar Allan Poe tried to describe the sinister spread of sickness through space and the body. Poe's theory of the fungal origin of fevers undergirds his 1839 story “The Fall of the House of Usher,” in which a pestilential vapor rises off the very stones of the Usher household, contaminating the bodies and psyches of its inhabitants. Here Altschuler provides an enticing piece of evidence for her argument that literature contributed to the production of medical knowledge. She suggests that Poe influenced his acquaintance, physician-writer John Kearsley Mitchell, who in the 1840s wrote medical essays with a “gothically inflected argument that fevers … arise from minute fungi that proliferate unseen, permeating the environment” (106, original emphasis). Additionally, Altschuler shows how science shaped cholera fiction. In one extended section, she describes medical cartography produced by Americans (physicians and cartographers) who tracked the global epidemic (1829–49) before British physician John Snow identified it as a waterborne disease in 1854. At least one novelist, Charles E. Averill, found inspiration in medical cartography as he wrote The Cholera-Fiend, or, The Plague Spreaders of New York (1850), in which he fictionalized the use of maps to spread the disease rather than contain it.

The Medical Imagination identifies itself as a work that embraces the looseness and interdisciplinarity of the medical-humanities field. Its strength is that it gathers in one place many scattered illustrations of the convergence of science and human creativity in the early US. It does not, however, fully support its claim that “the imagination and literary form robustly contributed to medical knowledge” (19). While the imagination – or creativity – is clearly fundamental to scientific exploration, this book more convincingly demonstrates the converse, that scientific (in this case, medical) exploration sparked the literary imagination. Medical breakthroughs were great fodder for fiction because they altered the human connection to the physical world. For instance, the discovery that pain could be optional (anesthetized) rewrote the parameters of sympathy, according to Altschuler. Physician-writer Oliver Wendell Holmes (1809–94), who named anesthesia, explored the idea of living without feeling in several of his novels, notably Elsie Venner (1860–61), in which the protagonist is a person without feeling. The Medical Imagination offers many similar examples of how fiction drew from scientific principles (such as molecular permeability) or medical concepts (such as pain and sympathy) to investigate human nature. It also presents textual evidence of how imagination and politics in the early US shaped our understanding of observed fact in the natural world. The book does these things, presumably to reframe “our understanding of both medical and literary history” (5).

While this reframing is not clearly argued throughout, one good example focusses on the studies of oxygen conducted contemporaneously by British chemist Joseph Priestley (1733–1804) and French scientist Antoine-Laurent Lavoisier (1743–94), the father of modern chemistry. Each scientist conceptualized the properties of oxygen according to his personal political bent: Priestley, a supporter of the French Revolution, saw oxygen as “a ubiquitous and exceptional gas defined by its independence from corrosive material”; Lavoisier, a nobleman and a member of the Ancien Régime, defined oxygen as “only one element in a broader chemical order whose structure illuminated a model of orderly hierarchy in nature” (44–45). Altschuler then explains how physician-poet Samuel Latham Mitchill (1764–1831) strained to negotiate a common ground between these two theories as he developed his own theory of contagion through inhalation of nitrous oxide (laughing gas, or what he called “septon”). He even wrote a poem about it called “The Doctrine of Septon.” Even though Mitchill's poem was a failure and his theory of contagion was proved erroneous, he is now considered one of the pioneers of the development of modern anesthesia based on his early study of the effects of nitrous oxide. Altschuler uncovers the delicate pathway from Priestley and Lavoisier to Mitchill's early work on anesthesia and his reorientation of medical perception that showed “how health worked at the molecular level” (41). This example illustrates how medical knowledge – and indeed, our understanding of one of the most basic elements of the natural world – has always been shaped by personal and political sensibilities.

In some ways, this book might better be titled “The White Medical Imagination” because the physician-writer at the center of the discussion is predominantly male, white, and formally trained in medicine. This set of individuals, who were situated in both the literary and medical fields, largely excluded woman healers, medical practitioners of color, and alternative healers of diverse backgrounds. There are other figures in the discussion who were not physician-writers per se, but rather novelists, poets, scientists, and doctors, and they are also mostly white and male, with the exception of a few, such as Harriet Beecher Stowe, Frederick Douglass, and Martin Robison Delany. This is not a criticism of the book by any means because Altschuler accurately presents the reality that white male physician-writers were the authoritative voices that shaped both the practice and the philosophy of professional medicine in the US for multiple generations. During the same period covered by the book, the male-dominated American Medical Association was established (1848), and with it a more systematized approach to medicine that included intransigent ideas about racial difference and the perceived association between morality and bodily well-being. Consequently, despite the empirical turn in medicine in the nineteenth century, many dubious theories about health and illness had already become embedded in medical practice. In presenting a snapshot of the historical moment when this process began, The Medical Imagination demonstrates that, no matter how outwardly rational the human mind claims to be, it is always infused with its own sensibilities, which insinuate themselves into authoritative medical discourses – in early America and today.

Indeed, what lingers in the mind after reading this book is not how the imagination might have advanced medical knowledge, but how it most certainly led to misconceptions of observed fact about infection, pharmacology, and the physiology of the human body. Supposedly empirical studies of human bodily difference and recognition of distinct groups of people such as Africans, Native Americans, and new immigrants to the US forced Americans “to reevaluate the basic premises of human health” (125). Altschuler describes the intellectual interplay between physician-writers Samuel George Morton (1799–1851) and Robert Montgomery Bird (1807–54) as they explored the idea of human difference. Morton was an originator of the American school of ethnography, which espoused the theory of polygenism, or the separate origins of multiple human races. His theories were based on his study of ancient Egyptian skulls, in which he saw proof that a hierarchy of intelligence existed within the human species. Bird, unconvinced by Morton's empirical evidence, came to a similar conclusion about human difference through a fictional exploration of human sympathy, which he tested in his novel Sheppard Lee (1836). In this work, the protagonist dies but his wandering spirit enters into the bodies of diverse Americans across the continent, and he discovers that the only unifying feature of bodily life is pain.

As a whole The Medical Imagination is a discomfiting reminder that empirical observation is not always enough to counterbalance the human imagination that believes what it wants to believe.

The Epilogue calls for a recuperation of “the spirit” (203) of the literary–medical intersections that existed up to the mid-nineteenth century. It makes a case for the medical humanities by proposing a reinvigoration of the art of medicine practiced by the physician-writers of the early US, who, through their culture, education, and sensibilities, made the practice of medicine more human. And yet, as the next monograph under discussion demonstrates, the human element in medicine is not necessarily compassionate; it can be deeply flawed and even malicious.

Medicalizing Blackness: Making Racial Difference in the Atlantic World, 1780–1840, by Rana A. Hogarth, investigates the “preoccupation with blackness” (2) that pervaded medicine in the late eighteenth to mid-nineteenth centuries, granting treacherous levels of medical authority to white physicians and contributing to the institutional oppression of black people throughout the Atlantic world. The construction of racial difference and the medicalization of blackness occurred simultaneously, Hogarth notes, each feeding into the other, and giving medical authority to the notion that “blackness was perceived to influence health” (3). The book tracks the flow of racialized medical knowledge in the southern US and the greater Caribbean, specifically between the slaveholding societies of Jamaica and South Carolina, to make three critical points that have been obscured in the historical record. First, information about black people's bodies was founded on limited empirical evidence and gross assumptions made by white physicians who then circulated it in “very banal ways” (45) throughout the Atlantic world's medical network. Second, some white physicians used their knowledge of the black body to bolster their own careers, and, in the southern US, to compensate for a regional medical education that was considered inferior to that in Europe and the northern states. Third, and most importantly, investing blackness with medical meaning erased black suffering because it implied that black people experienced illness differently from white people, that their humanity was altogether separate.

The book is organized into three sections that investigate ways in which blackness was medicalized, each section revealing progressively more destructive and exploitative forms of racialized medicine. The ultimate result is that, in the early American and Caribbean medical arena, a black person's body transformed from a subject of potential healing to an object of corrupt commodification. The first section examines how black and white bodies were thought to respond differently to the same infection that caused the yellow fever epidemics of the 1790s. The second section analyzes the misunderstood practice of dirt eating (Cachexia Africana), classified as a black pathology, to investigate the claim that black people suffered from different ailments than white people. The third and final section of the book describes the confinement and exploitation of black people in hospitals to offer evidence of how medicalizing blackness was fundamental to the building of the medical infrastructure of the US and greater Caribbean. Hogarth's aim in this book is “to amplify the experiences of enslaved people as recipients of white medical treatment.”Footnote ³ While she does not present it as a work of medical humanities, it is nonetheless a worthy example of scholarship in that field.

Any study of this nature must contend with the extreme imbalance of a historical record that contains voluminous medical treatises, records, and correspondence from white practitioners but minimal information from black people about their own medical conditions and healing practices. This book uncovers a partial picture of the medical reality of black people in the eighteenth to nineteenth centuries by tunneling through the white professional medical discourse that shrouds racially inflected practices. Hogarth also scrutinizes ordinary forms of communication that are less guarded in their language and presentation, for instance newspaper advertisements. White physicians placed advertisements that published their self-proclaimed expertise on black bodies while slave hospitals announced training sessions in dissection when the bodies most likely to be dissected were those of black people. Hogarth traces the insidious line between advertised health care for enslaved people and a physician's later claim of expertise in the anatomy of the human body. One surgeon advertised treatment for “diseases of the eye” in people of color in 1826, and three years later was appointed chair of pathological and surgical anatomy at Charleston's medical college. Hogarth insists that the medicalization of blackness cannot be dismissed as a consequence of racial prejudice or political defenses of slavery alone; more so, it was a tool of white self-interest. Categorizing black bodies as inherently different allowed white physicians to claim specialized knowledge of those bodies, and thus to promote themselves professionally and secure the health, wealth, and social well-being of whites.

While this monograph begins in a familiar place, with the yellow fever epidemics of the 1790s, it digs relentlessly into the theory of innate black immunity, which the author characterizes as “blunt biological determinism” (51). Hogarth gathers convincing evidence that innate black immunity was, from the beginning, an insubstantial claim made by eighteenth-century physicians who had limited and racially inflected information. That information was then passed down through “conservative modes of medical education [that] stressed the emulation of revered figures in the profession rather than clinical engagement with cases of the disease” (44). One of those revered figures was Charleston physician John Lining (1708–60), who explained his theory of black immunity to yellow fever in a letter to a colleague in 1753, and the letter was subsequently published by the Philosophical Society of Edinburgh in 1754. From there, Lining's theory became entrenched in medical thought for the next hundred years. The assumption of black immunity to yellow fever fueled another more reckless assumption of the overall hardiness of the black body that could supposedly resist fever and should therefore stand in for the white body that withered in the tropical heat. With such assumptions taken as reality, the aim of healing a black person became perverted. Hogarth presents a meticulous case study of a yellow fever infection on board the transport ship Regalia, which arrived in Barbados in 1815 with eight hundred sickly Africans on board, creating a serious medical crisis. The starting point for medical and military responses to the crisis was that the black recruits and white crew on board the ship were responding differently to identical morbific conditions. When William Fergusson, the inspector general of British army hospitals at the time, wrote of the Regalia case in his memoir thirty years later, his main point was to rebuke the British military for its failure to “take advantage of black people's physiology” in serving the needs of the empire (51).

Black people's bodies were exploited to strengthen the white medical profession and the British Empire itself, but their illnesses were their own. Despite evidence that Cachexia Africana, or dirt-eating, existed even among the ancient Greeks and poor whites in the mid-nineteenth century, it was recognized as a racialized pathology by white physicians who did not know how to cure it and who viewed it as a form of resistance by enslaved blacks. Any practitioner who could ensure slave health, and by extension slave labor, took power away from alternative healers who contested white authority. Still, Cachexia Africana perplexed white physicians and jeopardized their professional security to the point where they threatened dissection of black bodies that succumbed to the disease. This “last and final degradation” served to “reassert control over slaves’ bodies and reinforce the beliefs that black people's bodies required a specific kind of discipline to keep them in order” (97). In short, Cachexia Africana was blamed on its victims, who were thought to lack self-restraint, and white supervision of black bodies was accepted as a form of prevention.

Hogarth's discussion of Cachexia Africana neatly circles back to her earlier one about yellow fever as she parses the conflicting medical logic of the white medical establishment. Whereas blackness was thought to offer immunity against one disease (yellow fever), it was also thought to make one susceptible to another (dirt eating). “Blackness,” Hogarth concludes, “had variable and often contradictory meanings” (125) that white physicians manipulated to “extend control over already subjugated black bodies” (130). Hogarth observes that the “clinical significance of race” (188) had no logic at all, as evidenced by the fact that the theory was used to support opposing positions on slavery itself. In the 1790s, Rush had argued for innate racial difference to communicate the evils of slavery; half a century later, Dr. E. M. Pendleton from Sparta, Georgia argued for it to prove that black people were better suited than whites to labor in the hot southern climate (189). In both cases, a white physician assumed the authority to profess his particular expertise on the black body.

The Medicalization of Blackness deepens the historical record on the experience of black people who have been exploited for their so-called immunities and subjugated for their so-called pathologies. Hogarth vividly illustrates how racialized medical theory can become the basis of law and then the bedrock of an oppressive medical infrastructure. Some laws “criminalized enslaved black people's attempts at choosing their own course of medical therapy” (168), a crime punishable in some cases by the death penalty. Other laws, such as the New Act of Assembly of the Island of Jamaica (1788), included provisions for ensuring humane measures for the care of slaves, an effort that in reality was intended to secure civic and racial order and solidify “white planters’ collective authority” (135). In Medicalizing Blackness, health care for black people and the free movement of black people are part of the same discussion. Mobility in Caribbean and US slave societies was associated with rebellion, and therefore hospitalization (i.e. confinement) became a tactic of social control, particularly of unsupervised and presumably deviant slaves. More perniciously, these hospitals offered white physicians a space in which to experiment with black people's bodies and to create “small-scale teaching academies for white medical students” (177). The slave system and the culture of racial hierarchy in the South ensured a steady supply of black bodies for clinical study. The irony, Hogarth notes, lies in the contradiction between the claim that black bodies were inherently different and the insistence that they were legitimate clinical specimens from which to learn how to heal white bodies.

Even in the twenty-first century, the idea of innate racial difference affects how we understand health and sickness. Hogarth suggests that her book is only the background to what is now a normalized way of medically categorizing black bodies without even defining what “black” means. She points to the pervasive medical theory that hypertension is linked to race, a notion that gains traction in the media and in popular culture when it is affirmed by trusted figures such as Dr. Oz and Oprah Winfrey. Hogarth acknowledges that hypertension may in fact be linked to race – not because of innate racial difference but because black people are far more likely than white people to live under stressful conditions created by institutional racism (191). Clinging to innate racial difference as an explanation for medical conditions prevents further inquiry into the social determinants of illness, Hogarth warns: “the use of the term ‘diseases afflicting the black race’ should give us pause” (193).

Together, the authors of The Medical Imagination and of Medicalizing Blackness call for more humanism in medicine, but from different angles. Altschuler steps inside the mind of the white male physician who dominated medical thought in the first century of the US; Hogarth steps inside the mind and body of the black person who lived with the consequences of that medical thought. What stands out when considering these monographs in tandem is the voluminous evidence we have of the meanderings of the white medical imagination in the eighteenth and nineteenth centuries when there is no equal and balanced record of black people's thoughts on their own health and well-being. One wonders if it is a wasteful indulgence to create a sense of importance around how the white mind works, when what matters most is how people behave. Hogarth's book shows how people behave – specifically how white physicians in early America falsely promoted themselves as experts on black physiology and used their influence to oppress black people and erase their suffering. It may be worth considering the early sparks of the white medical imagination in order to identify where racial disparities in health care originate. Hogarth's book, despite its look into the past, suggests that it is even more crucial to examine existing medical reality, to determine who is genuinely suffering and how they might be healed right now.