Five Little Peppers and How They Grew by Margaret Sidney is an early example from 1881. This book describes the daily life of the hardworking Pepper family and how they remain cheerful and loving despite challenges associated with 19^th century poverty. The Pepper family consists of widowed Mrs. Pepper or “Mamsie,” 11-year-old Ben who voluntarily takes on the mantle of “man of the house,” patient and selfless 10-year-old Polly, impulsive and food-loving 9-year-old Joel, gentle and conscientious 7-year-old Davie, and beloved baby of the family 3-year-old Phronsie.

Children’s literature during this era was heavily instructional and used relatable characters and stories to teach morals and values to young minds. Illness was rarely just a biological event; it was a test or demonstration of character. In a chapter aptly titled “Trouble for the Little Brown House,” the first challenge that the Pepper family faces is measles.

Notably, this book highlights the ophthalmologic symptoms and sequalae of measles, as first Phronsie, then Ben, Polly, and Joel all catch the infection. Common early symptoms of measles include conjunctivitis and photophobia, which occur before the obvious rash. Ben and Polly, the hardworking older siblings who earn money for the family by chopping wood and sewing respectively, are each in initial denial of infection because they understand the financial repercussions this will have on the family. But the historic reader understands the warning signs when Ben and Polly report visual complaints. Ben tries to reassure Polly by saying, “I’m all right; only my head aches, and my eyes feel funny,” alluding to the itchy and gritty sensation of conjunctivitis, before he becomes bedridden. The narrator describes Polly’s struggles more vividly, “An awful feeling made her clutch the back of a chair, but she managed somehow to get into her clothes, and go groping blindly into the kitchen. Somehow, Polly couldn’t see very well. She tried to set the table, but ‘twas no use.” Polly’s initial visual impairment can be attributed to severe photophobia, leading to blurry vision.

Modern day readers may not know that the measles virus can result in serious vision-threatening complications. It can cause deeper structural damage starting with keratitis – a painful inflammation or infection of the cornea, the clear front surface of the eye, which manifests as blurred vision and intense tearing. If keratitis is left untreated or a secondary bacterial infection occurs, corneal scarring can permanently impair vision. In rare instances, measles can also cause retinopathy and optic neuritis leading to blindness. The severity of eye damage from measles is heavily linked to nutrition. The virus actively depletes body stores of vitamin A. In low-income populations where vitamin A deficiency is already common, measles is more likely to cause permanent childhood blindness.

The Peppers live in poverty and hunger. Mrs. Pepper makes a meager income sewing “sacks and coats” for a local store and “had hard work to scrape together money enough to put bread into her children’s mouths, and to pay the rent of the little brown house.” There is never enough food to go around. Their main source of calories are coarse brown bread and unappetizing cornmeal mush, neither of which contain meaningful amounts of vitamin A. However, the generosity of the parson’s wife, Mrs. Henderson, helps protect some of the Peppers from blindness. Mrs. Henderson gives the Peppers “a little pat of butter,” which Phronsie and Ben put on their bread. Dairy, like milk and butter, is an excellent source of vitamin A. And later, Mrs. Henderson sends over “a little bird delicately roasted,” which Joel consumes with delight. Poultry and gamebirds are another good source of vitamin A.

However, selfless Polly saves the butter and bird for her siblings and ends up being most at risk for permanent vision loss. She develops very painful eyes, suggesting keratitis, and the doctor pronounces that “her eyes are very bad” and warns, “You will be blind!” if she doesn’t take care. Although the author attributes Polly’s illness severity to eye strain from sewing to earn money for the family, it is medically more likely due to vitamin deficiency. The therapeutic value of vitamin A in treating measles was not discovered until 1932 – 51 years after the publication of this book – when British physician Joseph B. Ellison found that administering vitamin A extracts roughly halved the death rate of hospitalized children suffering from measles [1]. Studies establishing the role of vitamin A in reducing blindness in children with measles did not occur until the 1980s [2,3].

Because moralizing 19^th century children’s literature rewards the virtuous, Polly ultimately makes a full recovery. However, reality is not so kind. Even today in the 21^st century, an estimated 15,000 to 60,000 children are blinded by measles every year globally [4]. The World Health Organization recommends that children in low income and developing regions diagnosed with measles receive immediate, high-dose oral vitamin A [5]. This simple, low-cost intervention protects the cornea and has successfully saved the eyesight of millions of infected children [6]. And, those who are vaccinated against measles are spared the risk and need for intervention completely.

[1] https://pubmed.ncbi.nlm.nih.gov/20777111/
[2] https://pubmed.ncbi.nlm.nih.gov/8486934/
[3] https://pubmed.ncbi.nlm.nih.gov/3492298/
[4] https://pubmed.ncbi.nlm.nih.gov/14998696/
[5] https://www.who.int/news-room/fact-sheets/detail/measles
[6] https://pubmed.ncbi.nlm.nih.gov/24407830/

Original Publication: The story was originally serialized in an 1880 edition of Wide Awake, a children’s magazine and later published in a hard cover edition.

Dover Publications, 2006. 224 pages

Web image by Medhum.org

Two hidden stories by two famed authors written decades apart in two countries eventually became widely known. One, Anton Chekhov’s, At the Pharmacy, was translated into English in 1998, about one-hundred years after it was published in Russia. The other, Raymond Chandler’s, It’s Alright–He Only Died, was unearthed from its unpublished state by Strand Magazine in 2018, about sixty years after it was written. Though written in different times, and using different scenarios, both stories warn of the barrier money creates to urgent and necessary health care, and of the corrosion in professionalism it causes in providers. They tell of what was to become a defeating feature of Western health care because of financial incentives, social prejudices, and human folly.

Six Kopecks or Your Life

Peter Constantine reached back from the 1990s into the 1880s to assemble a translated anthology of some Chekhov short stories not available to English-speaking audiences. Among the chosen stories in The Undiscovered Chekhov: Thirty-Eight New Stories, is At the Pharmacy.

The story begins when Egor Alexeyitch Svoykin becomes sick. His physician prescribes medicine that a pharmacy would need to prepare. Svoykin felt some relief being in a large Russian city during the late nineteenth century that would have pharmacies he could count on. This feeling of relief dissipated just after entering the pharmacy and coming before the imperious pharmacist there. 

The pharmacist eventually raises his head from a newspaper, looks at the prescription, shouts instructions to his assistants, and then returns his gaze to the newspaper while at the same time informing Svoykin the prescription will be ready in an hour. Svoykin is the only person waiting at such a late hour as it was, and he was deteriorating.

His mouth was on fire; there was a drawn-out pain in his arms and legs; foggy images tumbled about like clouds and shrouded human figures in his heavy head. He looked as if through a veil at the pharmacist, the shelves of jars, the gas burners, and the cabinets. The monotonous pounding in the marble mortar, and the slow ticking of the clock seemed to him to be coming not from the outside but from inside his head. (p. 129)

When Svoykin reports to the pharmacist that he is becoming feverish and feeling weaker, “the pharmacist “remained stock-still and, leaning his head farther back, kept on reading his newspaper. He didn’t respond to Svoykin with word or movement—it was if he hadn’t heard him.” (p. 130) When Svoykin subsequently approaches the pharmacist pleading with him to hurry the prescription, the pharmacist again brushes him off saying, “It’ll be ready soon enough…excuse me, but there’s no leaning on the counter.” (p. 131)

The next half hour was “unbearable” before the prescription came and then made more so by the dubious rituals the pharmacist performed in adorning the prescription container. The pharmacist charged one ruble and six kopecks, but Svoykin was short the six kopecks. 

Under the circumstances…I would be grateful if you would let me bring you, or maybe send you, the six kopecks tomorrow…

I’m sorry, we don’t accept credit here.

What am I supposed to do?

Go home, get the six kopecks, and then you can have your medicine.

But…I’m having difficulty walking, and I don’t have anyone I can send…

That’s your problem.

pp. 132-133

Svoykin returned home, though with difficulty. The Kopecks were there on the table, but his illness kept him from returning to the pharmacy.

Just Drunk

Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes an unpublished Raymond Chandler short story. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective, Phillip Marlowe. This story, however, written between 1956 and 1958, is about a person brought to a hospital emergency room and denied service for financial and social reasons.

As the story opens, a man who has been hit by a truck is brought into the emergency department at General Hospital. He arrives just before shift change and so the admitting clerk is already annoyed about having to assess him. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. Off the patient goes.   

The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. “It’s all right—he only died.”

Fast Forward

If they could have foreseen the current time when they wrote these stories, 140 years ago for Chekhov and 70 years ago for Chandler, they would have realized that the scenarios they created became commonplace and institutionalized in many ways.

Pharmacists may not go unseen behind a newspaper as Chekhov’s pharmacist did, but they may be buried under insurance company paperwork or piles of prescriptions needing to be filled. And certainly in a few situations, perhaps only independents, do pharmacists have ways to cover costs when patients are short on cash, credit, or insurance coverage. They are very likely to send patients away to get money even when they are very sick.

Hospital personnel do not now actually reach into the pockets of unconscious patients to see if there’s enough cash for admission as Chandler conjures in his story, but he would see them still check for money in the form of insurance cards or proof of sufficient financial means. He would also see that the scenario he described in which patients without money get transferred to county hospitals had progressed to a degree that people are moved around among different health care providers based on health care insurance plan coverage or lack thereof. But the poor treatment of patients in need of emergency care can even occur in the “right” hospitals when they are held for hours to days in hallways or holding wards for beds to become available.

Scenarios such as these can and have been addressed to varying degrees through government welfare programs, regulatory requirements, technology advances, and professional practice standards among other responses. The two stories, though, also expose human folly not so amenable to these actions. What can be done about the pharmacist who won’t put the newspaper down to address the needs of a person seeking help for an acute illness? What can be done about the physician who after a cursory evaluation brushes off an unconscious patient as “just drunk?”

Chandler makes an attempt at addressing the human folly he and Chekhov reveal by describing how it fails humanity on both professional and personal levels, and in shaming the character, who is ostensibly standing in for those behaving as this doctor in the story did.

All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it?  Should it?  

Chekhov and Chandler are perhaps hoping that those in the care of others will exhibit more humane and professional behaviors when they ask themselves many decades later: “Am I a doctor?”“Am I a pharmacist?” “Am I a human being?” Would it make a difference? Should it?

Notes

Title image:
A young girl waiting for a pharmacist to make up a prescription.
Photogravure, 1912, after J. Jendrassik, 1896
Licensed under the Creative Commons Attribution 4.0 International

End image:
Nurse Aide Rocky FordHospital CO
Mennonite Church USA Archives, No restrictions, via Wikimedia Commons

Henry’s severe illness and his difficulties accessing treatment prompted Green to contemplate the horrifying statistics of tuberculosis and the paradox of our extensive knowledge about it. More than one million people still die every year from this ancient disease; yet the bacterial cause was elucidated a century and a half ago, and effective treatments have been around since the 1950s. Barring eradication, the germs mutate and become resistant. Given dire living conditions, it spreads. Effective therapy can be prohibitively expensive. “The cure is where the disease is not, and the disease is where the cure is not” (p. 5). People die where cures cannot be obtained. 

History is woven though Henry’s story, but so are politics, culture, and economics: the discoveries, the 19^th-century romanticization of ‘wasting away,’ the hard realities of pharmaceutical development and delivery. Henry has survived, become healthy and an inveterate TikToker and youtuber. He even has an episode on the power of storytelling. But other people that we encounter through this tale have died. 

We still have tuberculosis because statistics de-personify it, and geography allows ignoring it. Green uses Henry’s story to invite us to ‘[t]hink about how rare and precious humans are, and how many of them you get to worry for and care about. Then if you can, find a way to multiply that 1,250,000 times’ (p. 189).  

The book flows easily in language that is clear and accessible, a tribute to Green’s experience in writing young-adult fiction. In the end, without denying the benefits of medical interventions, he calls for a focus on the real cause of tuberculosis: injustice—tolerated and unchallenged. ‘Ultimately,’ he writes, ‘we are the cause’ (p. 184).  

Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection
John Green
New York: Penguin/Crash Course Books
2025
ISBN 9780525556572 

Web image created by Medhum.org

Soto explores his uncertain status in relation to his family, and to the larger society in “You’ve Gone Too Far.” Detailing the “evolution” of his siblings and cousins, who “were no longer Mexican rednecks,” but “held down jobs” and “stopped jamming parking meters for free time,” Soto describes how his family nevertheless feels uncomfortable about him. “My family feared that I had evolved too far.” Drunken Christmas horseplay with his brothers reveals their distaste and distrust of his intellectualism and sophisticated clothes. “They tore my book in half, / and stripped me of my Italian belt.” Only when they have succeeded in making him sick/drunk do they accept him (at least temporarily) back into the family fold. The poem illustrates well the difficulties that can arise when one member of a family elects to live life differently from the rest yet wants to maintain a relationship with its members. The situation has resonance for the children of immigrants, for children who are more educated than their parents, or for anyone who has chosen a life unfamiliar to family or friends.  

“TV in Black and White” focuses on the role of television (in the 1950s/1960s) in shaping, reflecting, and failing to reflect American society. Soto remembers his childhood in which “[we] were sentenced to watch / the rich on TV …”. Sitcom characters played golf, ate steak, and dressed fashionably (the Donna Reed Show, Ozzie and Harriet). “While he swung / we hoed / Fields flagged with cotton . . .”  

Now life is for many relatively luxurious, “Piano lessons for this child, / Braces for that one — “ “But if the electricity / fails in this town, / a storefront might / be smashed /” “and if someone steps out / with a black-and-white TV, / it’s because we love you Donna, / we miss you Ozzie.”  

Soto’s critique is still relevant today. The ubiquity of television and streaming, even in low-income households, confers enormous power on the images and narratives presented. Now there are many more options for viewers of different cultural and economic backgrounds. Yet the dominant culture still exerts a major influence. The gap between representation and reality continues to be an important source of social dissatisfaction and unrest. 

Gary Soto 
https://garysoto.com/
https://www.poetryfoundation.org/poets/gary-soto#tab-poems

Mexicans Begin Jogging
Online: https://www.zocalopublicsquare.org/by-gary-soto/  
New and Selected Poems, Chronicle Books, San Francisco, 1995, p. 51

You’ve Gone Too Far 
Published in Junior College, Chronicle Books, San Francisco, 1997, p.24

TV in Black and White 
New and Selected Poems, Chronicle Books, San Francisco, 1995, p.50

Web image by Jr Korpa 

Demon Copperhead is nothing if not a novel centered on social concerns. It tells the story of a child born to a drug addicted mother in an oxycontin-ravaged community in western Virginia. He is delivered inside an intact amniotic sac, an anomaly that foreshadows a life-long fixation to see the ocean, any ocean. His mother has abysmal taste in men and repeatedly chooses to live with men who abuse her and physically threaten Demon. When she dies of a drug overdose, Demon is placed in foster care and forced to work countless hours as a virtual slave under horrible circumstances, without any consideration for his safety, by the person who is supposedly responsible for his wellbeing. He runs away and has a miserable encounter on the road with a streetwalker who entraps him and steals the hard-earned money that he has secretly saved and stashed away. Against all expectation, Demon reconnects with his dead father’s family, and they place him in a much more stable and secure environment – the home of the venerated coach of the local high school football team.  

The coach takes a liking to Demon. He recognizes Demon’s hidden strengths and talents and encourages Demon to try out for the football team. Much to his surprise, Demon achieves star status as a tight end, no longer a faceless hillbilly from the back country of mobile homes. But true to the trajectory of the novel, Demon suffers a major injury to his knee. He refuses surgery and tries to tough it out. Pain medication is key to this strategy and, of course, this being Appalachia in the late 1990s, oxycontin is too easily prescribed by doctors and too accessible to patients. A painful decline into addiction and despair ensues. Many of Demon’s peers fall victim to the oxycontin plague. But unlike them, Demon is resilient. He is a talented artist, and from early childhood he would draw cartoon-like sketches to escape from his desultory life.  

With the help and support of an art teacher who takes him under her wing during high school, Demon creates a comic strip that dramatizes life in the backwoods of Virginia and that gains regional notoriety. As the novel nears the end, there is a dramatic passage in which Demon confronts his social nemesis on a mountain ridge during a windswept rainstorm. It evokes a climactic episode in Kingsolver’s earlier prize-winning book, The Poisonwood Bible, where the life of a key character is threatened by an attack of army ants in the middle of the night. Ultimately, Demon enters drug rehabilitation, perseveres through the rigors of withdrawal, and gets clean. Against all expectations, Demon finds love and redemption. The woman of his dreams has been there all along, but when it happens, you cannot help but smile as you watch the two lovers acknowledge their feelings for one another. 

The title of the novel is a dead giveaway of who inspired it and Kingsolver acknowledges her debt to Charles Dickens in the postscript. Like her Victorian predecessor, Kingsolver is writing to protest the neglect and abuse that people, but especially children, living in post-manufacturing America have been forced to endure at the end of the 20^th century and into the next. In her vision, the grim experiences of people like Demon and his family, whose lives are attached to the land, are profoundly different from city dwellers. After their land was stripped of its natural resources, the rural communities in states like Virginia and Tennessee were left to languish economically and fall victim to predatory pharmaceutical companies which promoted the use of drugs that the proprietors knew would increase dependence and addiction.  

There is a relentlessness to this story and Kingsolver’s voice in many respects echoes the Biblical prophets. For some readers, the book is almost too depressing. But I think that fails to give enough credit to her Dickensian style and outlook. The sequence of episodes in different locations and with a revolving cast of characters is reminiscent of the publication of Dickens’ novels in serial installments that can almost stand alone. The narrative pulsates with non-stop action and there is an optimism that Demon will always pull through. He is an engaging character, blessed with emotional reserves and intellectual gifts that enable him to overcome his baleful surroundings. In that sense, his story, like Dickens’ novels, may strike some as unrealistic. Perhaps that is the most effective way a writer can successfully enlist readers to rally to her social cause, by offering a vision of personal triumph over social and cultural adversity. 

Coming back to the question I asked at the outset, can a novel inspired by social protest survive its era and outlive the conditions that spurred the author to put pen to paper, or fingers to keyboard? Novels like David Copperfield and The Grapes of Wrath are affirmative answers. I predict that the artistry of Demon Copperhead will ensure that it will still be read long after the environmental damage incurred by the coal mining industry and the human devastation of the opioid epidemic recede into history. Demon’s voice is so alive, his character is so engaging, and his tale is so moving that I am confident that the book will be on bookshelves or in data storage tools in a hundred years. It may be necessary to add notes to explain the ins and outs of the coal mining industry and how oxycontin was approved and marketed to an unsuspecting population, but those will be details that will not obscure the deep humanity of the book.  

Oprah In Conversation with Barbara Kingsolver

DEMON COPPERHEAD 
Barbara Kingsolver 
Harper Collins Publishers, New York, 2022, 548pp 

Web photo by George Hiles 

As the founder and director of the Centre for Health Humanities and a professor of English at the University of Reading, UK, Andrew Mangham, Ph.D., has published extensively on medicine and Victorian literature. His books include Violent Women and Sensation Fiction: Crime, Medicine, and Victorian Popular Fiction (Palgrave, 2007) and Dickens’s Forensic Realism: Truth, Bodies, Evidence (Ohio State University Press, 2016). Mangham and I exchanged questions and answers via email concerning his book, The Science of Starving in Victorian Literature, Medicine, and Political Economy (Oxford University Press, 2020).  

1, How did you arrive at the topic of your monograph? What led you to research the intersection of Victorian literature, medicine, and political economy? 

It was a bit of a circuitous route actually. At the institution where I teach, there is a key research strength in food science and food security. A few years ago, this was highlighted as an area of research focus within the University, and this got me thinking about what it was that the Victorians could bring to the table, as it were, on the question of modern food security. We’re all very familiar with the idea of the starving Victorian pauper, but I wondered what political and philosophical work this idea or image was doing on the ongoing issue of food inequity. This then set me thinking about how nineteenth-century medicine responded to the problem. Some preliminary research taught me that there was a plethora of medico-physiological works on starvation as a material phenomenon. I also noted that this side of the question had been overlooked by modern scholarship, which has tended to focus on political economy as the Victorian science of hunger. What I found, however, is that medicine spoke in very different ways about hunger and—if anything had a bearing on the birth of social problem realism as the genre of the ‘Hungry Forties’—it was this material, medical, scientific focus set against the consequentialist thinking of political economy. 

2, For readers unfamiliar with The Science of Starving, briefly sketch your main contention. Why does your study deserve attention? 

My main contention is that, in the long nineteenth century, there emerged a science of starving in which specialists in medicine and physiology spoke about what happens to the body when we starve. The realities of this process were stark and shocking, and they countered the notion, formulated mainly in the works of Thomas Malthus but swiftly adopted as ‘fire-and-brimstone’ gospel by politicians, social reformers, and authors of statutes, that those who starve are intended to do so by nature—that it is only ‘natural’ that famines sweep away large numbers of people. This propagandizing interpretation of Malthus converted the poor into a mass of immoderate and reckless burdens on the State. The physiological focus on starvation as a harrowing condition which affects individuals helped counter the conservative ideology, and it inspired the social problem fictions of Charles Kingsley, Elizabeth Gaskell, and Charles Dickens, which also take individual subjectivities, ways of interpreting poverty, and reactions to social injustices as key points of focus. Taken in conjunction, literature and medicine show us a world in which the well-meaning ideas of Malthus were exploited and warped into something much more sinister; they also show us the ways out of the problems the ideology has posed for us by returning to a consideration of the individual, the connections between people, and the material realities of modern life. 

I would argue that the book deserves attention on two major counts. First, it gives us a new context in which to read Victorian social problem fiction—a context in which we have an explanation for the emergence of realism as a socially-aware, politically-driven mode of writing. Looking at the forgotten context of Victorian food science, we see a lot of familiar and unfamiliar narratives in new light. Secondly, the book—and perhaps the most important issue—deserves attention because its questions are still with us. The conservative interpretation of Malthus has fed into and justified neoliberalism—a political approach tried and failed since the 1980s, and now enjoying a resurgence in the UK. At the heart of the neoliberal ideal is the idea that the many cannot be trusted to handle money and that economic responsibility is rightly placed in the hands of the elite few. The idea is that this will lead to a trickle-down effect, where the many will benefit from the successes of the few. The truth, as we see in the bloated account-books of internet trading companies for instance, is that wealth placed at the top tends to stay there, with some individuals now wealthier than some countries. My book can’t tackle all aspects of this issue, but it does show us where the idea of the ‘immoderate mass’ comes from; how it has justified political disenfranchisements of the poor for centuries, and that there is a more humane approach which concentrates on the experiences and the needs of individuals.  

3, Describe your research methodologies for this book. You use the first chapter to stage the broader historical context, describing the major theories of political economy and medical understandings of hunger, digestion, and gastrointestinal anatomy. Your subsequent chapters then situate medical texts alongside examples of Victorian fiction. What is your larger methodology? 

I suppose my methodology could be identified as a kind of new-historicism, where the powers and meanings of literature are best understood when we pay attention to their original, historical and social, contexts. But this isn’t a straightforward process of identifying where an author picks up his or her ideas. I try to read literature as actively involved in the shaping of history; ideas may begin in medicine and/or political economy, for instance, but they are soon transformed and made to do something special when they work their way into works of fiction. What this work is depends on the styles and objectives of individual authors, but it is certainly the case, I think, that ideas become bolder when they are explored in works of fiction. Zola famously had the idea that the novel was an experiment—a trial of ideas and concepts—and I think that whether an author intends it or not, their work tests the meanings, potentials, and limits of ideas within a certain historical timeframe. I therefore think it’s important to read the fiction produced by any time period we are seeking to understand fully, to go back and to see how and why ideas first emerged through the ways they are tested and dissected in the form of fiction. 

4, Some readers might naturally assume a kind of intrinsic rivalry between art and medicine, fiction and scientific rationalism. Yet your book emphasizes that Victorian writers neither snubbed medical science nor regarded it as antithetical to their literary ambitions. Why is it important that these writers transcended disciplinary borders? 

It’s important that the field of ‘literature and science’, which has become quite busy in recent years, moves away from the idea of the two cultures—the notion, that is, of warring approaches to interpreting the world. This is a modern idea, forged in the twentieth century, and is not actually representative of the work science or literature does. To those of us who spend any time with the ideas of science and/or medicine, we’re used to seeing how the intellectual work involved here is no less beautiful or imaginative than the ideas of fiction and poetry. Similarly, we can point to authors whose work has all the hallmarks of scientific rationalism. It is important to see how writers transcend their so-called disciplinary borders because this shows us how ideas evolve when they are passed from specialism-to-specialism; it also shows us how ideas were never meant to be confined in disciplines. Appreciating the true interdisciplinarity of how ideas work opens up a world of possible collaborations and curiosity.  

5, Writers, as you show, were certainly influenced by the era’s medical texts, but were physicians reading the works of these literary figures? In other words, was there a mutual exchange of influence and recognition between Victorian physicians and writers? Were physicians aware of their impact on shaping the literary texts you examine? 

Yes, certainly. This question could have formed the basis of another book—volume 2 perhaps. We know that medical figures read fiction—there is a famous account of the physiologist and surgeon Benjamin Brodie reading The Pickwick Papers in his carriage between consultations; other medics saw literature as crucial to the kind of work they did. The surgeon Anthony Carlisle perceived there to be similarities with the progress of illness and/or injury and the progress of a story. He is thought to have written a gothic novel. For other medical and scientific figures, literature was a ‘switch off’ activity. We have accounts, for instance, of Charles Darwin and Richard Owen reading Dickens in the evenings. In later psychological texts of the period, Dickens’s characters are often held up as case studies of complex conditions like dementia. Whereas we have an obvious written record of medicine’s influence on literature (we can look at specialist language working its way into fictional plots), proving the inspirations in the opposite direction is more challenging, but I wonder whether the evidence is less ‘tangible’. I think the centrality of narrative in case studies and accounts of experiments, for instance, owes much to the powerful example of literature; I also think questions of causation, biological determinism, psychological wellness or aberration have their roots in the long social and psychic studies of the novel. 

6, While these writers used medical language to ground their plots and characters in the materiality of poverty, one wonders if these descriptions would have eventually desensitized readers to the shock of starvation’s physical dimensions. That is, did the language of medical science and physiology become subsumed into what later readers may have recognized (and disparaged) as sentimentality? Did the language of physiology eventually lose its trenchancy as it became an established feature of these Victorian writers’ works? 

It’s a good question. Certainly, in respect to the long nineteenth century, I think the science of poverty offered something of a stimulant to ways of reading which had become desensitized. We often hear of social-crusade literature, or poverty tourism in the nineteenth century, as intending to jolt the Victorian reader with confrontations from a world they had chosen to ignore, or which their middle-class existences sheltered them from; but by the 1840s, the world of letters, politics, and social reform were overwhelmed with newspaper reportage, government blue books, and philanthropic pamphlets. Writings about the stock figures of the starving mother and child, for instance, were very common and it’s unlikely that these would have had the confrontational power it would be all-too-easy to ascribe to them when read out of context. In the nineteenth century, however, physiology was relatively new; people were used to medicine as the treatment of the sick, and to anatomy as the study of bodies, usually dead ones, but the science of life—the science of the processes of life—was relatively fresh. This new science had new things to say about hunger—how it operates, what causes it, and how it proceeds if it is unchecked. I think this did emerge into something confrontational, something which had a powerful political ballast. I think it still does.  

7, Readers might consider the extent to which illustrations—in Dickens’s writings, specifically—also worked to visually articulate the language of physiology. For example, John Leech’s illustrations in Dickens’s Christmas Carol depict the children “Innocence and Want.” These child figures are gaunt, shivering, and spectral; their clothes are tattered. Are readers to understand these illustrations as also reflecting Dickens’s broader efforts to draw on medical science to ground material representations of starvation? 

Yes, I think so. ‘Ignorance and Want’ was an image I originally intended to include in the book but left it out in the end because it will be very familiar to a lot of my readers. We know that Dickens exerted a pernickety attention to detail when it came to his illustrations and, as John Leech set about creating the engraving, Dickens would have overseen the process closely. What’s interesting about this image is the fact that it is set in London and yet has a mill in the background, which would have been more identifiable with an industrial town like Manchester. This is an obvious nod to the industrial context—how the inequities of the profits of capitalism result in ignorance and want. The image pays particular attention to bodies in a way that echoes how the literature develops what Terry Eagleton has called ‘corporeal materialism’; in the contexts provided by the spectacle of starvation, skinny, gaunt and raggedy bodies spoke a radical, political message against the status-quo. 

8, At the time these writers were drawing on medical science to recalibrate literary representations of starvation and poverty, did the era’s readers and literary critics observe, even minimally, this changing perspective? Did book reviews, for example, detect this shift in language and representation by responding to or critiquing its efficacy? If not, what may have accounted for this critical oversight? 

Reader response is a difficult thing to measure, but reviews are an interesting insight. These differed wildly and depended, of course, on the politics of the reviewer and the magazine or newspaper they were writing for. There certainly was an acknowledgement of the social aspects of the literature and some account of the realism as well. I think that the radical qualities of the literature can be seen in just how often it raises the heckles of a conservative reviewer. It was not uncommon, for instance, for authors to take umbrage with the dogged materialism of an author like Gaskell (which is not an entirely accurate summation—she was very much interested in religion, spirituality, and feeling); Kingsley was also taken to task for his focus on bodies—unseemly, some said, in a man of cloth. And Dickens himself was attacked for the unrelenting nature of his focuses on the poor—for his seeming preference for the characters and situations of low life. Not many critics saw this—at the time—as part of a new way of thinking about poverty, but it’s certainly the case that materialism had long been associated with radicalism. Those readers who appreciated these authors often spoke of their truth and their accuracy and I think this is part of a larger, cultural (largely unspoken) acknowledgement of the powers of social problem realism. By the time we get to the next wave of social problem fiction—Arthur Morrison, George Moore, George Gissing—we’re in different territory and there is, I think, a more critical and analytical reflection on corporeal materialities.  

9, Historians of medicine, political scientists, and literary scholars will certainly note the importance of The Science of Starving. Aside from these readers, what do you want your research to convey to today’s medical students and practicing physicians? 

I’m fairly happy leaving medical students and practicing physicians in peace. They do extraordinary work and don’t need me to tell them how to make their work more humane or socially responsible. Politicians, on the other hand, I’m very happy, in the words of Dickens, to ‘fall upon’. The emergence of the far right, the zombie-like persistence of neoliberalism, and general intolerance among conservative politicians are all things which suggest that some of our civil servants might take a leaf out of the book of the nineteenth century. I would love it if my research could convey to some individuals that consequentialist thinking, knee-jerk policies, and political essentialisms have all been tried and tested, have failed, and done irreparable damage. One thing the authors of fiction and the pioneers of science and medicine have taught us is the power of thought—the importance of keeping an open mind and being willing to abandon ways of thinking whose fixedness is preventing us from growing as individuals and societies. We can learn a lot by looking to the past and we need these lessons more now than ever. 

Andre Mangham’s most recent book is We Are All Monsters: How Deviant Organisms Came to Define Us published in February 2023 by MIT Press.  

An earlier version of this interview was published in the NYU Literature, Arts, and Medicine Database (Litmed).
Web image from The Cleveland Museum of Art

The Science of Starving in Victorian Literature, Medicine, and Political Economy  by Andrew Mangham 

Sebastian Galbo Jun 2, 2025

A compelling study of how Victorian writers used medical science to expose and challenge political economy’s misconceptions about starvation.

Undergirding Victorian-era political economy was the influential work of the British cleric-economist, Thomas Malthus, and the rise of statistics. Malthus’s well-entrenched theories maintained that starvation, or large-scale famine, was a natural (and therefore inevitable) response to overpopulation. “In Malthus’s thinking,” Mangham clarifies, “hunger is the greatest tragedy in human economics: in the worst of times it rises up as a horrible check on those nations whose resources have been overrun by improvident birth rates” (1). These theories further solidified within religious contexts, which produced the peculiar notion of “salutary starvation” (26) or “the providential law of starvation” (30)—an understanding of famine and other disasters as just consequences for exceeding the material capacities of God’s “natural system” (26). Malthus’s theories, imbued with religious interpretations, were pernicious and far-reaching, seeping into how the British government and affluent classes viewed and (mis)understood poverty.  

Mangham also maintains that Malthus’s theories were augmented by the emergence of statistics during the first several decades of the century, which enabled the government to measure and evaluate epidemiological patterns, demographic data, and other information about human populations (53). He notes that while statistics were used to collect data about starvation, the data were frequently presented in ways that skewed the prevalence of malnutrition, food scarcity, and diseases and mortality rates related to starvation (56). Using a range of literary and primary sources, Mangham underscores that support for statistics was far from monolithic, that for all the scientific certitude that government officials invested in the discipline, there were critics who vociferated about how statistics were often reductive representations of human experience. In other words, masses of tabulated numbers created a cold, mathematical distance between government authorities and those human lives suffering starvation (56–57). Overall, Mangham outlines a bleak picture of Victorian political economy and its views of material privation. 
 
For Mangham, then, one of the most injurious consequences of political economy was its failure to observe starvation (and its manifold health complications) as a material, indeed physiological, experience. As noted, political economists viewed starvation as anything but a form of bodily suffering, using theories instead to explain the naturalness and necessity of hunger and thus blaming the poor, not government and industry, for their problems (31).  

While political theorists were preoccupied with these explanations, Mangham traces the era’s concurrent developments in medicine that examined the physiology of hunger and digestion. The gastrointestinal research of the Italian Lazzaro Spallanzani influenced Victorian physicians, namely John Hunter, Charles Thackrah, George Henry Lewes, Thomas Southwood Smith, and others, who sought to describe the anatomical workings of the stomach and explain the bodily sensations of hunger (36). Against this backdrop, Mangham argues that Charles Kingsley, Elizabeth Gaskell, and Charles Dickens—united in their “antipathy towards Malthusianism” (17)—recognized the power in articulating starvation using physiological terms, and turned to science to limn “. . . the material sufferings of the starving and, more importantly, on detailed analysis of what it means to go hungry and to observe and to write about it in a way that seeks to be truthful” (16). In chapters that individually examine each author’s literary works (among them Kingsley’s Yeast, Alton Locke, and Two Years Ago; Gaskell’s Mary Barton, North and South, and Sylvia’s Lovers; and Dickens’s Bleak House and others), Mangham demonstrates how “. . . physiological ideas offered both an alternative way of thinking about hunger and an exploration of the ways in which it might be interpreted” (47). This volume’s close readings of these authors’ various novels, journalism, and speeches reveal that medical science offered a language that could undermine theories that misunderstood human starvation and the sociopolitical conditions that perpetuate it.  

Mangham’s study traces compelling connections among nineteenth-century political economy, medicine, and literature, demonstrating that writers looked to science for inspiration to critique feckless government policy and represent the concrete physicality of hunger. If writers could emphasize that impoverished people experiencing starvation were undergoing an “unnecessary, unjust, and unnatural” process, their stories could begin to demystify for readers the opposite claims of political economy (18). Kingsley, Gaskell, and Dickens used new science to depict not only physiologically accurate but also humanized renderings of the poor and Mangham provides close readings of novels to emphasize how these authors used physiology’s vocabulary to describe the material dimensions of poverty, which enabled them to push back against the theories of political economy. It is not that Victorian writers resorted to stale clinical language, but instead worked in confidence, knowing that what they represented in their narratives was grounded in scientific fact. Mangham’s analysis shows how literature and medicine intersected in ways that produced trenchant critiques of government policy. 

The Science of Starving in Victorian Literature, Medicine, and Political Economy
Author Andrew Mangham 
Publisher Oxford University Press 
Place Published United Kingdom 
Edition 2020 
Page Count 240 

An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).
Web photo from The Cleveland Museum of Art 

Interview with Andre Mangham

Sebastian Galbo Jun 2, 2025

Andrew Mangham explores how Victorian literature, medicine, and political economy intersected to shape powerful narratives about hunger and poverty.