“A Face of Anguish”: Pain and Portraiture in the Civil War Hospital

Abstract

“I like a look of Agony / Because I know it’s true—,” the poet Emily Dickinson announces in the opening lines of an 1862 poem. For Dickinson (2005: 152), the “look of Agony” that conveys suffering is a distinctly facial expression of pain. “The eyes glaze once—and that is Death— / Impossible to feign,” she writes before noting in the poem’s final line, “The Beads upon the Forehead / By homely Anguish strung” (152). On the one hand, this poem wrestles with one of Dickinson’s recurrent themes: what Vivian Delchamps (2019: 125) describes as the poet’s portrayal of pain as an “unfathomable” experience.¹ Indeed, as Thomas Constantinesco (2022: 116) observes, despite this poem’s ostensible claim, the speaker’s equation of pain with death ultimately insists on the former’s unknowability. At the same time, though, the speaker is concerned not only with whether pain can be known, but also with how it might best be understood. Introducing a visual strategy for knowing pain, Dickinson’s poem suggests that to look upon the face of one in pain is to gain authentic access to the sufferer’s experience. When she penned these lines one year into the Civil War, Dickinson may have been thinking of the images of dead, dying, and injured soldiers that circulated widely in mid-nineteenth-century media.² If, as Dickinson implies, facial appearance makes pain visible and thus legible, then observing the countenances of wounded soldiers would enable viewers to confront the war’s impact head on.

Dickinson might just as easily have referred to what she called a “look” of pain as an expression, the nineteenth-century term for “an almost unnamable ‘something’ that is pictured forth upon a person’s face” (Blackwood 2019: 5).³ As Sarah Blackwood (2019: 47, 6) has shown, the concept of expression provided “a contact point between external appearance and inner life,” and, as a result, facial portraiture offered artists and writers alike a method for rendering visible a host of internal qualities and experiences. In this essay, I examine the pain experienced by Civil War soldiers as one such invisible, subjective experience that nineteenth-century writers sought to understand and convey through the lens of expression. Suzannah Biernoff (2017: 37) argues that portraits of veterans have become so ubiquitous in contemporary Western culture that “it is through the portrait . . . that we have come to experience—to feel—the human dimension of violent conflict.” This ongoing association between violence and visage, I propose, was forged partly within the context of the Civil War, when photographic records of pain proliferated and writers, too, adopted the tropes of portraiture in an effort to make soldiers’ suffering legible.

I focus in particular on writing by Louisa May Alcott and Walt Whitman, both of whom carefully documented the faces of the soldiers they tended to in Civil War hospitals: Alcott in her largely autobiographical Hospital Sketches (1863) and Whitman in dispatches to the press as well as the 1867 edition of Leaves of Grass, Memoranda during the War (1875–76), and Specimen Days and Collect (1882).⁴ Upon their late 1862 arrivals at the Union army hospitals where they each volunteered, both writers were surrounded not only by injured soldiers but also by photographers and physicians attempting to produce visual records of their pain.⁵ Throughout the war, soldiers’ pained expressions were captured for two primary purposes: the circulation of war photographs in Northern media outlets made the horrors of war visible to the public, and the Army Medical Museum documented the experiences and treatments of wounded soldiers in order to further medical knowledge. Alcott and Whitman each transposed these visual registers into their writing, portraying their patients’ expressions as windows onto their otherwise elusive pain. For both writers, portraiture provided a literary method for documenting what Whitman (1863a) referred to as the “deep things, unreckoned by current print or speech” that filled the hospital’s wards.

While Elaine Scarry (1985: 4, 19) has famously claimed that pain “actively destroys” language and is therefore defined by its “inexpressibility,” the nineteenth-century notion of expression offered an alternative medium for communicating and interpreting suffering. In 1862, the same year that Alcott and Whitman began their caregiving work, the French neurologist G. B. Duchenne de Boulogne published his Mecanisme de la physionomie Humaine (The Mechanism of Human Facial Expression), which featured portrait photographs representing various human emotions—including pain—alongside captions describing the muscles engaged in producing them. Duchenne de Boulogne (1990: 29) insisted that the facial contortions represented in these images constituted “a universal language” of feeling that all humans were innately able to both produce and interpret.⁶ Indeed, both Alcott and Whitman rely on expression in order to understand their patients’ experiences. In Hospital Sketches, for instance, Alcott (1863: 45) observes “the silent eloquence of those long lines of faces” that fill the wards. Whitman (1863b) uses strikingly similar language in an entry in the Brooklyn Daily Union in which he describes “the convulsive want I see every day or night in the expressions, the silent yet eloquent faces” of his patients. Whitman (1863b) insisted that such countenances went “deeper than words” in conveying the soldiers’ suffering. The surface expression that Whitman (1867: 20b) called “a face of anguish” provided both writers with a means of accessing their patients’ internal pain. Scarry herself invokes the elusive “inner life” for which nineteenth-century Americans mined expression when she describes the difficulty of knowing another’s pain (Blackwood 2019). “When one hears about another person’s physical pain,” Scarry (1985: 3) writes, “the events happening within the interior of that person’s body may seem to have the remote character of some deep subterranean fact” that “has no reality because it has not yet manifested itself on the visible surface of the earth.” Expression promised to convert something as intangible as pain into a more legible “reality” by bringing it out of the realm of internal, private experience and into the public eye.

The literary qualities of both Alcott’s and Whitman’s accounts of pained expressions do more than simply document these scenes; they also instruct readers by teaching them how to interpret the visual records of pain that proliferated during the war. As Susan S. Williams (2016: 3) argues, the daguerreotype and antebellum literary culture had a mutually influential relationship. Writings about photographic and other modes of visual art vested new meaning by illustrating both the scenes themselves and ways of interpreting them. While Duchenne de Boulogne insisted that humans were innately able to recognize pain via expression, Alcott and Whitman suggest the importance of cultivating a trained eye. Upon entering the hospital, both writers had to learn how to decipher what Alcott (1863: 64) called the “marks of pain” on soldiers’ faces in order to care for their patients’ particular needs. Their ekphrastic writings demonstrate how a careful assessment of soldiers’ expressions could clarify not only the fact of their suffering but also more precise information such as the degree, source, and nature of their pain. These descriptive accounts thus model the ability to interpret and respond to expression, establishing the face as a crucial source of information for clinicians and popular audiences alike.

In what follows, I begin by tracing the visual cultures that emerged around Civil War soldiers’ pain in both popular and clinical media. These forms foregrounded expression as both affectively and clinically significant. From there, I turn to texts by Alcott and Whitman that adopt the trope of portraiture in order to make soldiers’ suffering legible to a wider audience. After demonstrating how both writers engage with their patients’ expressions, I argue that these ekphrastic accounts make visible not only soldiers’ suffering but also the act of observing and interpreting it. I show how Alcott’s and Whitman’s descriptions of faces invite their readers to similarly attend to expression in their own efforts to understand pain. I conclude by considering the ongoing centrality of expression to contemporary efforts to render pain legible. I suggest that by bringing into focus the process of perceiving another’s pain, the study of portraiture offers an important complement to both the field of narrative medicine and health humanities approaches to studying visual art.

Portraits in Civil War Media and Medicine

By the time the Civil War broke out in 1861 Americans had long registered violence as a visual concern. Many believed that witnessing the infliction of pain could have a transformative, galvanizing effect on the viewer. As early as 1787, in a treatise on public punishments, the physician Benjamin Rush (1787: 6; emphasis original) insisted that “by an immutable law of our nature, distress of all kinds, when seen, produces sympathy, and a disposition to relieve it.”

Operating under this theory that a visual encounter with pain could produce a desire for social change, later antebellum reformers made illustrations of physical pain central to their social critiques. Abolitionists and other reformers were highly attuned to the visual impacts of abuse, and, as Karen Halttunen (1995: 327) argues, “commanded readers to act as imaginative witnesses to the spectacle of suffering” by depicting, in both image and word, flogging and other violent acts in graphic detail.

When the war began, then, it quickly became clear that a Northern public accustomed to such spectacles of pain would need visual access to the conflict in order to confront its horrors. Beginning in 1861, Mathew B. Brady led a corps of photographers (many of whose images were displayed in Brady’s New York gallery under his own name) alongside Union soldiers (Gidley 2015: 95). Technological limitations, however, made it difficult to capture actual battles, and so the gruesome scenes typical of reform literature were left out of frame (Richards 2009: 14). Instead, photographers captured the aftermath of war. Indeed, as a reporter for the London Times explained in 1862, “the photographer who follows in the wake of modern armies must be content with conditions of repose, and with the still life which remains when the fighting is over” (quoted in Trachtenberg 1989: 73). Civil War photographers thus conveyed the horror of the war not through images of soldiers’ actual wounding but rather by making visible their already wounded bodies.

The image of the war-wounded body, as Lisa A. Long (2004: 9) has shown, helped “make the war real on some basic level.” For instance, Brady’s 1862 series titled “Dead of Antietam,” which featured photographs actually taken by one of his employees, Alexander Gardner, put the bodies of fallen soldiers on display first for New York audiences and later for readers of Harper’s Weekly, where they were reproduced as woodcuts (Richards 2009: 21). Upon the photographs’ initial display, the New York Times (1862a) heralded the instructive power of the corpses’ faces in particular: “Blackened faces, distorted features, expressions most agonizing, and details of absolute verity, teach us a lesson which it is well for us to learn” about the “horrors of the battlefield.” A few weeks later, the New York Times (1862b) returned to the images to declare that “Mr. Brady has done something to bring home to us the terrible reality and earnestness of war.” The following year, Oliver Wendell Holmes Jr. wrote of the same images in The Atlantic, “Let him who wishes to know what war is look at this series of illustrations” (quoted in Trachtenberg 1989: 90). Visual representations of casualties, these accounts suggest, provided a stand-in for the violent action of the war itself.

Importantly, such images of strewn corpses were interpreted through the lens of facial portraiture. Many of the men in Brady’s “Dead of Antietam” series lie on their backs, their faces visible to the viewer, and the New York Times described these images as a kind of disrupted portrait. “The poor subjects,” the reporter laments, “could not give . . . sittings, and they were taken as they fell” (New York Times1862b). Given the photographs’ technical limitations, these images were not taken “as [the subjects] fell” in the sense that the photographer could not capture the instance of death itself. But rather, the writer suggests that the slain soldiers’ portraits were taken “as they fell” insofar as their expressions register that elusive moment. Describing visitors to Brady’s gallery in 1862, the New York Times (1862b) reports “hushed, reverend groups standing around these weird copies of carnage, bending down to look in the pale faces of the dead, chained by the strange spell that dwells in dead men’s eyes.” Viewers were drawn not to the wounds that killed the men but rather to the deceased’s compelling countenances, which promised to convey far more.

In addition to such widely publicized images of slain soldiers, photographs depicting surviving soldiers’ maimed bodies also proliferated. Scenes of hospital life were among those that Brady published in album cards, prints, and stereographs (Trachtenberg 1989: 72, 84). As in “Dead of Antietam,” Brady’s hospital images group soldiers’ bodies together, though here in rows of hospital beds. Their faces, like those of the dead, are turned toward the viewer, but unlike their fallen comrades, these men do indeed “give . . . sittings”; they sit upright on their hospital beds posing for their collective portraits. These photographs, too, served an important social function by helping to “bring home” a war that changed the culture of healthcare by taking patients out of the home and into the hospital in record numbers (Rosenberg 1995: 98).

Most of the photographs taken in hospitals, however, were kept out of the public eye. Established in 1862 as a repository for the medical knowledge acquired in the military hospitals that proliferated during the war, the Army Medical Museum collected photographic evidence of “specimens of morbid anatomy” taken mostly by a team of professional photographers led by former Brady employee William H. Bell but also occasionally by doctors themselves (quoted in Gidley 2015: 98).⁷ In such images, the wounded soldiers are seated, invoking the pose of conventional portraiture, but their bodies are also contorted in order to center their injured body parts. The soldiers’ faces and expressions are certainly captured by the camera’s lens, but their postures convey that the wound is each portrait’s intended subject. Even soldiers with facial injuries were photographed with their heads turned so as to position the wound—rather than their expression—at the center of the frame.⁸

Despite its marginalization in medical portraiture, however, expression was vital to how Civil War physicians documented pain. In Gunshot Wounds and Other Injuries of Nerves (1864), physicians Silas Weir Mitchell, George R. Morehouse, and William W. Keen (1864: 103) reported of a burning sensation they observed in patients, “As the pain increases, the general sympathy becomes more marked . . . the face becomes anxious, and has a look of weariness and suffering.”⁹ The escalation of pain here is made visible by a corresponding intensification of expression. The six-volume government record of the war, The Medical and Surgical History of the War of the Rebellion, 1861–65 (1870–88), which was compiled from healthcare workers’ records during the conflict, similarly referenced suffering soldiers’ “expressions” and “countenances.” For example, a description of a patient with a gunshot wound to the neck reports that “his expression was extremely anxious—symptoms indicating a critical condition and demanding active steps to be taken” (U.S. Army Surgeon General’s Office 1870: 415).¹⁰ In addition to observing faces in order to determine interventions, doctors also debated the causes of various expressions. A surgeon writing in The Medical and Surgical History admitted that while a colleague had described “an expression of anxiety as very peculiar in penetrating wounds to the chest . . . I am satisfied that this expression is much less common in such injuries than in penetrating wounds of the abdomen, and that the explanation is to be sought in the lesser implication of the sympathetic system of nerves in chest wounds” (639). The look on a patient’s face was therefore significant medical information that could indicate both the severity of suffering and the nature of an injury.

By their own accounts, physicians witnessed and documented painful conditions that profoundly changed sufferers’ appearances. A footnote in The Medical and Surgical History describes a case of spotted fever in which the patient displayed “an expression of countenance indicative of a state of great depression; the features were sunken and cadaveric, and so altered that I hardly recognized him” (U.S. Army Surgeon General’s Office 1879: 496). Mitchell (1884: 116) makes a similar point in his 1884 novel, In War Time, set during the war, when describing the facial transformation of a wounded major. “The major is such a wreck,” a physician character reports to a colonel, “that I did not know the photograph [of him] taken two years ago. Pain is a relentless sculptor.” Mitchell applies portraiture as a method for understanding pain in two ways here. First, he asserts photography as a realist mode of representation—the physician expects the major to resemble the photograph taken of him—and thus a reliable tool for assessing the extent of a patient’s injuries. At the same time, Mitchell figures pain as itself an artist, suggesting that pain is so signaled by facial expression that to understand the sufferer’s experience requires the same analytical skills needed to interpret a portrait.

Mitchell’s depiction of pain as a “sculptor” also invokes the plaster casts that he and other Civil War physicians created of their patients for the Army Medical Museum. These casts, which Mitchell refers to throughout Gunshot Wounds, captured the minute contortions not only of wounded limbs but also, strikingly, of injured faces (Mitchell, Morehouse, and Keen 1864: 48, 54). About 11 percent of the soldiers admitted to army hospitals had injuries to the head or neck, and such men make up a significant portion of the patients described in Gunshot Wounds (Bollet 2002: 88). Unlike photographers who sought to capture a subject’s expression, the physicians creating casts deliberately preserved its absence. In their accounts of patients who experienced facial wounds, the authors of Gunshot Wounds consistently noted whenever the men’s “muscles of expression” failed to function properly. Much like the “anxious” countenances of suffering soldiers, the incapacity for expression was itself an important medical phenomenon that required observation, interpretation, and response.

The faces of wounded Civil War soldiers, then, were immensely important to both popular and medical understandings of pain during the war. For general audiences and physicians alike, the pained expressions on wounded soldiers’ faces took that which was remote—whether far off battlefields or interior bodily functions—and brought it into the frame of visibility. As both caregivers and writers, Alcott and Whitman synthesized these dual uses of expression in their efforts to craft textual portraits that not only supplemented efforts to make the war’s wounds legible but also trained readers to interpret the pained expressions they encountered.

Alcott, Whitman, and Expressions of Pain

By the time they began publishing their accounts in 1863, both Alcott and Whitman were immersed in the war’s visual “culture of pain” (Morris 1991). They would not only have encountered the images of suffering that circulated in the Northern press; they each published writing about their hospital work in such newspapers—Alcott in the abolitionist magazine Boston Commonwealth, where Sketches first appeared in 1863 and Whitman for a variety of publications including the New York Times in 1863 and 1864. They also encountered portraiture in the clinic. Based in Washington, DC, both the Union Hotel Hospital where Alcott volunteered for six weeks and the various barracks converted into government hospitals where Whitman was a regular visitor until the war’s end would have been frequent sites of photography and plaster casting for the Army Medical Museum’s collection. Writing from within this clinical context for a broader readership, Alcott and Whitman worked to bridge the popular and medical media that circulated images of and reported on soldiers’ pained expressions.

Both Alcott and Whitman represent expression as an important tool for clinicians. They suggest that by reading their faces, healthcare providers can gain access to patients’ interrelated physiological and psychological suffering and thus provide more informed and holistic care that addresses individual needs. By publishing their descriptions of both this gaze and the faces it observes, both writers also suggest broader, extraclinical applications of this skill. Of photographs that capture profound pain, Susan Sontag (2003: 42) proffers that “perhaps the only people with the right to look at images of suffering of this extreme order are those who could do something to alleviate it—say, the surgeons at the military hospital where the photograph was taken—or those who could learn from it.” As laypeople providing care in Civil War hospitals, Alcott and Whitman collapse this distinction between supposedly appropriate viewers for whom these sights are educational and those others whom Sontag (2003: 42) calls “voyeurs.” They invite their readers, too, to learn about the pain of others from the expressions they encounter in their texts.

Though Whitman (1882: 80) famously declares in Specimen Days that “the real war will never get in the books,” he turns to portraiture in an effort to create just such a record. For Whitman “the real war” is defined by “countless minor scenes and interiors” and “not the official surface-courteousness of the Generals, not the few great battles.” Whitman himself ultimately relies on the trope of expression to bring such interior experience to the surface. A true account of the war, he suggests, is a portrait: one depicting “the actual solider of 1862-’64, North and South” (81). Lamenting how much of this “civic and military” history has been and will be “buried in the grave,” he figures the body’s wounded surface as a record of the conflict he must probe in order to excavate what he calls “those lurid interiors” of the war (81). For Whitman as well as for Alcott, attending to soldiers’ expressions offered a means of caring for and documenting the intertwined physical and emotional suffering the war produced.

Both writers clearly understood their endeavors in terms of visual art. While the “sketches” in Alcott’s title ostensibly refer to her loosely autobiographical text’s short form, Alcott was also sensitive to the term’s visual implications. As Mary Cappello (1994: 64) argues, Alcott’s protagonist, Tribulation Periwinkle, has unique access to the “censored sight” of the injured male body, and Alcott’s text reproduces that view for readers. While Tribulation certainly looks at men’s bodies throughout Hospital Sketches, she often focuses her gaze on her patient’s faces in order to construct portraits of their pain. Describing her time on the night shift at the hospital, Tribulation reflects, “I would have given much to have possessed the art of sketching, for many of the faces became wonderfully interesting when unconscious” (Alcott 1863: 49, emphasis mine). Her sudden desire to represent her surroundings visually is prompted by the expressions on the sleeping soldier’s faces, suggesting that these imagined portraits would reveal something critical about her patients’ experiences—including, as she demonstrates elsewhere in the text, their pain.

Whitman shared Alcott’s awareness of the centrality of the visual to public understanding of the war (Erkkila 1996: 214; Feldman 2005: 2).¹¹ In fact, Robert Leigh Davis (2015: 43) suggests that during the war, Whitman “explored an ethics of intimate attention,” drawing on the increasing popularity of photography to produce “poems and prose sketches that resemble a Mathew Brady daguerreotype.” In an 1864 piece in the New York Times entitled “Hospital Visits” Whitman (1898: 21) explains, “As this tremendous war goes on, the public interest becomes more general and gathers more closely about the wounded, the sick, and the government hospitals, the surgeons, and all appertaining to the medical department of the army.” Perhaps recalling the crowds that “gather[ed] . . . closely about” the images of dead soldiers in Brady’s “Dead of Antietam” series in New York, where Whitman lived, Whitman identifies his readers’ desire to actually see, rather than simply hear about wounded soldiers. Echoing Alcott before him, Whitman plays on the double meaning of “sketch” when he writes that “the following sketch is made to gratify the general interest in this field of the war” (21). Similarly, in his famous poem “The Dresser,” which first appeared in the 1867 edition of Leaves of Grass and was retitled “The Wound Dresser” in the 1881–82 edition, Whitman’s speaker imagines himself as an artist: an “old man . . . among new faces” who implore him not only to “tell” them about his experiences but also to make them visible by “paint[ing] the mightiest armies of earth” (Whitman 1867: 31a). For both writers, invoking visual forms of representation was vital to satisfying the expectations of audiences accustomed to photographic evidence of soldiers’ “indescribable” suffering.

Just as the physician authors of Gunshot Wounds and The Medical and Surgical History portrayed the face as a crucial locus of medical information, both Alcott and Whitman suggest the importance of interpreting patients’ faces in order to understand their pain. For example, describing the faces of sleeping soldiers, Alcott (1863: 50) writes, “Many almost seemed to speak . . . though they made no confidence in words, I read their lives.” Pain is central among the stories the men’s faces tell, and Tribulation observes that it was “as if pain borne silently all day, revenged itself” on their countenances (49). As critics have noted, this scene represents a breakdown of gendered constraints, as the sleeping soldiers unknowingly forego masculine stoicism to reveal the extent of their suffering (Laffrado 2009: 92–93; Smith 2018: 193). Throughout Hospital Sketches Tribulation finds that even the waking faces of wounded soldiers are far more reliable than their words at conveying pain. Of the men’s masculine efforts to suppress their pain, she recalls that “scarcely a cry escaped them, though I often longed to groan for them, when pride kept their white lips shut, while great drops stood upon their foreheads” (43). As Tribulation becomes fluent in such unspoken expressions, she becomes a more discerning nurse. “He seemed asleep;” Alcott writes of one patient, “But something in the tired white face caused me to listen at his lips for a breath. None came” (41). Her sensitivity to expression alerts Tribulation to her patient’s death, signaling the urgency of such interpretive skill.

Throughout his accounts of the war, Whitman (1867: 32a) similarly reflects on learning to read and interpret what he describes as the “appealing eyes” of a suffering soldier as a substitute for verbal articulations of pain. Across his writings from and about his time at the bedside, Whitman juxtaposes silence with facial forms of expression. On April 15, 1863, he wrote to his mother from Washington. Toward the end of his correspondence, he describes a soldier dying of pneumonia: “He could not articulate—but the look of his eyes, and the holding on of his hand was deeply affecting” (Whitman 1898: 67).¹² He similarly wrote to his close family friend, the reformer Abby H. Price on October 11 of that year describing the “mute look in [the wounded soldiers’] eyes” (Whitman 1898: 127). In 1864 he detailed for the New York Times’s readership the death of a particular patient who “utter’d nothing except a low groan now and then” but nonetheless conveyed his suffering to Whitman when “the water ran out of his eyes from the intense pain, and the muscles of his face were distorted” (Whitman 1864). In Memoranda during the War, Whitman continues to present the face as a unique indicator of pain. “In the main there is quiet—almost a painful absence of demonstration;” he writes of the hospital, “but the pallid face, the dull’d eye, and the moisture of the lip, are demonstration enough” (Whitman 1875–76: 11). These disparate accounts reveal that for Whitman, as for Alcott, soldiers’ faces consistently convey the pain that they will not—or perhaps cannot—articulate, making observations of expression crucial to nursing work.

Beyond its correspondence with physical wounds, expression enabled both Alcott and Whitman to acknowledge their patients’ emotional suffering. In the nineteenth century, physicians and writers alike accepted that although they were distinct, emotional and physical pain were also ultimately “inseparable” phenomena (Altschuler 2018: 161). As both a part of the human body and a signifier of one’s emotional state, facial expression bridged these corporeal and affective dimensions of pain.¹³ If, as Shari Goldberg (2019) suggests, body and mind closely cohere in Civil War–era accounts of trauma, then expression provides the site on which the two converge and become legible to others.

Of one of Tribulation’s favorite patients, John, whom she “watched. . . . for a night or two, before I made friends with him,” Alcott (1863: 55) writes, “A most attractive face he had, framed in brown hair and beard, comely featured and full of vigor, as yet unsubdued by pain; thoughtful and often beautifully mild while watching the afflictions of others, as if entirely forgetful of his own.” Beyond its beauty, which critics have long noted (Wardrop 2005: 33; Laffrado 2009: 95; Smith 2018: 191), John’s countenance is also, importantly, “as yet unsubdued by pain.” John stands out among the sea of suffering faces because, though wounded, he does not display agony but rather, like Tribulation herself, “watch[es]” the suffering of others. Alcott’s inclusion of “as yet,” however, suggests that John, too, will experience pain. His eventual pain is the product of an emotional rather than physical injury that takes place under Tribulation’s watchful eye. “The only time I saw his composure disturbed,” Tribulation reflects, “was when my surgeon brought another to examine John, who scrutinized their faces with an anxious look” (Alcott 1863: 55–56). In this scene, John inverts the clinical gaze, “scrutiniz[ing]” his physicians’ expressions as potential sources of medical information. Alcott’s narration, however, medicalizes his reaction, as John adopts the “anxious” expressions that Civil War physicians interpreted as indicating pain, though it is not his wound itself but the doctor’s implicit prognosis that hurts him.

Whitman, too, viewed expression as an index of emotional pain. In an 1863 entry in the New York Times, he recalls of one patient, “I . . . noticed his glassy eyes, with a look of despair and hopelessness, sunk low in his thin, pallid-brown young face. One learns to divine quickly in the hospital . . . I saw as I looked that it was a case for ministering to the affection first, and other nourishment and medicines afterwards” (Whitman 1863c). Here Whitman suggests that differentiating among different forms of pain is crucial to performing his duties. His ability to “divine” the nature of his patient’s pain determines his responses. As Peter Coviello (2013: 50) has argued, Whitman saw himself as more than a nurse to the men—he inhabited a more capacious, “surrogate” role as “also confessor, sibling, and very often parent—mother no less than father, intimate companion no less than witness and scribe.” As a result, the poet was intent on providing diverse forms of care that went far beyond tending to the men’s wounds. For Whitman, expression granted him access not only to their interior experiences of pain but also to their broader inner lives, enabling him to forge “ardent intimacies” at the bedside (Coviello 2013: 50).

The division Whitman implies between experiences of pain that can be treated with “affection” and those that require “medicine” was a slippery one. The blurred boundary between these two forms of suffering is particularly evident in Alcott’s account of a patient with a facial wound: Alcott (1863: 36) describes a patient “with a gun-shot wound through the cheek,” who “asked for a looking-glass, and when I brought one, regarded his swollen face with a dolorous expression.” This scene provides the closest representation of a visual facial portrait in Alcott’s Sketches. When the soldier holds the mirror to his face, he poses for a conventional military hospital portrait of his wound, but, as his expression shifts, he also creates a secondary portrait of his emotional response to the sight of his injury. The soldier’s visage is equally characterized by his “swollen face” and the “dolorous expression” it produces in him. As the dual subjects of the self-portrait captured in the looking-glass, these two facial features illustrate the simultaneously physical and emotional experience of pain.

Because expression promised to make emotion visible, it provided both Alcott and Whitman with a framework for understanding the affective impact of the conflict. In doing so, they established the wounded face as a record of the war that produced it, applying a logic that would later become central to public memory of World War I, when images of facial wounds gained “iconic significance” (Gilman 1999: 161). Though facial injuries are not the focus of their Civil War writings, both Alcott and Whitman do frame wounded soldiers’ faces as windows onto the conflict. Describing the expressions of Tribulation’s sleeping patients, Alcott (1863: 49) writes, “Some grew stern and grim, the men evidently dreaming of war, as they gave orders, groaned over their wounds, or damned the rebels vigorously.” This description of pained expressions puts “wounds” and “rebels”—both figured here as antagonists in the soldiers’ nightmares—into close proximity. According to Alcott, the men don’t only reveal their pain; they also relive the scene of their wounding, and this narrative is relayed on their faces. Although, as Jane E. Schultz and Elizabeth Young each have demonstrated, Tribulation establishes her authority in Hospital Sketches by adopting a “militaristic voice and style” (Schultz 1992: 104) and a “soldier persona” (Young 1996: 448), these countenances are as close as Tribulation ever comes to what she calls the “front.” Indeed, they offer her such a direct link to the battlefield that Alcott (1863:50) writes of a deceased patient, “[His] face was shrouded and [his] fight was done.”

Whitman, too, portrays suffering soldiers’ faces as proxies for the war. “I have at night watch’d by the side of a sick man in the hospital,” he writes in Specimen Days, “one who could not live many hours. I have seen his eyes flash and burn as he raised himself and recurr’d to the cruelties on his surrender’d brother, and mutilations of the corpse afterward” (Whitman 1882: 81). The battlefield scene Whitman witnesses in his patients’ eyes is partially a photographic record. The “mutilations of the corpse afterward” recall the bodies strewn across “Dead of Antietam” and similar sets of wartime images. However, the “cruelties” of the battle itself depicted in the soldier’s eyes exceed wet-plate photography’s technological reach. The soldier’s expression, then, contains a unique visual record of the war that can only be accessed in this mediated form. Daneen Wardrop (2005: 38) has proposed that Civil War nurses’ narratives that foreground the body in pain inevitably resist a political order that “depend[s] upon the unrepresentability of pain in order to polarize power.” By attending to expression specifically, Alcott and Whitman make visible the physical suffering caused by the conflict, but they also call attention to the pain produced by the subjective experience of war itself.

Both writers frame their ability to observe and interpret their patient’s pain as a carefully cultivated skill rather than the innate human ability Duchenne de Boulogne defined. In Hospital Sketches, Alcott (1863: 96) suggests that an attention to expression in particular can actually counteract the “inur[ing]” to pain that she acknowledges sometimes accompanies hospital work. Antebellum reformers who depicted scenes of violence worried that such images would “harden” readers’ hearts, and Alcott figures such apathy as an occupational hazard for clinicians in particular (Halttunen 1995: 329). She describes a surgeon, Dr. P., who “remorsefully confided to me that he feared his profession blunted his sensibilities, and, perhaps, rendered him indifferent to the sight of pain” (Alcott 1863: 97). Alcott concurs with Dr. P.’s self-assessment, noting that although a “capital surgeon” he has developed “a somewhat trying habit of regarding a man and his wound as separate institutions” (97). Rather than observe the expressions of his patients, he engages with “bandage[s]” and “limbs” alone (97). He is not only neglectful of expression but antagonistic toward it: he “expected the patient . . . to restrain all demonstrations during the process” of minor surgeries (97). Tribulation recalls a particular patient who “looked at [her] imploringly” during one such session. Importantly, it is she, rather than surgeon, who registers this facial display of suffering. As such, she sutures back together the “man and his wound” by recognizing not only the painful injury and procedures but also the patient’s subjective experience of it.

In addition to modeling this alternative to Dr. P’s apathy, Tribulation insists that his indifference is not an innate product of medical practice—it happens only in “some cases” (97). She offers as a counterexample a surgeon she refers to as “Dr. Z.,” who she recalls “often paused to ask: ‘Do I hurt you?’” during surgery (99). She recalls that “seeing his solicitude,” through this inquiry, “the boys invariably answered: ‘Not much; go ahead, Doctor, though the lips that uttered this amiable fib might be white with pain as they spoke” (99). The white-lipped faces of the patients provide an unspoken answer to Dr. Z.’s question, one he interprets and then responds to by redirecting their focus. He doesn’t only treat their injuries but also engages them in “conversations upon subjects foreign to the work in hand” that allow the patient to feel briefly as if they were “anywhere but in a hospital ward” (99). Both Dr. P’s apathy and Dr. Z’s sensitivity to his patient’s expression provide important context for Tribulation’s own clinical care. Her attention to expression is neither a universal human trait nor an exceptional quality unique to her, but rather a learnable skill.

Whitman similarly considers how others might acknowledge and interpret expression in “The Dresser” (1865). In the poem, Whitman (1867: 32a) calls upon readers to inhabit the role of witness when he asks them to “look,” as though they might see these anguished countenances, “at the patient and mute manner of our American wounded.” “Whoever you are,” he implores the reader, “follow me,” inviting them to observe as he simultaneously nurses patients’ wounds and interprets their expressions (1867: 32a). As he leads the reader “To the long rows of cots, up and down,” one patient “turns to me his appealing eyes” and it is this sight that prompts the speaker to begin visiting each patient’s bedside. As in the Medical and Surgical History and Gunshot Wounds, many of the patients in Whitman’s poem are described first by their wound and then by their corresponding facial expression. He reports on “The neck . . . with the bullet through and through” of a dying man in whom he also observes “quite glazed already the eye” (33a). Of an amputee whose “stump of the arm” the speaker cleans, he also writes, “His eyes are closed, his face is pale” (33a). “I dress a wound in the side, deep, deep,” he writes of a man who has “But a day or two more—for see, the frame all wasted and sinking, / And the yellow-blue countenance see.” In treating this final patient, the speaker makes his intentions explicit. By asking the reader who has “follow[ed]” him into the hospital to “see” both the withered body and discolored face of this dying patient, the speaker reveals that he is not only showing the reader his methods but actually training them. By repeatedly showcasing how painful injuries are expressed on patients’ faces, Whitman equips his readers to be similarly attentive to scenes of suffering. The explicitly didactic tone of “The Dresser” underscores how both Alcott’s and Whitman’s descriptions of suffers’ expressions model this strategy for knowing another’s pain.

Expression, Ekphrasis, and the Health Humanities

By simultaneously describing the suffering they observed and revealing how they interpreted and responded to such scenes, both Alcott and Whitman make visible the very process of perceiving pain. As “exercises in metarepresentation,” Blackwood (2019: 5, 6) explains, portraits don’t simply depict their subjects; they also shape how viewers come to see and know those subjects and, as a result, bring subjectivity itself to the fore. As Sari Altschuler (2018: 201) has argued, humanistic methods of observation such as close reading and textual analysis can help health professionals become “more careful, thoughtful, and informed about the act of observing.” These efforts are well underway by literature and medicine scholars, especially those working in the field of narrative medicine. Rita Charon (2006: 4) and others have demonstrated how close readings of narrative texts can prepare clinicians for the task of “recognizing, absorbing, interpreting, and being moved by the stories of illness.” Ekphrastic works such as Alcott’s and Whitman’s invite us to look beyond narrative to consider description, too, as a literary method with important applications for understanding pain. Studies of both visual and ekphrastic portraiture can offer particularly rich opportunities to lay bare the nature of observation itself and the diverse factors that shape how viewers come to understand experiences of suffering.

There is by now a well-established practice of bolstering medical providers’ and students’ observational skills through the study of visual art (Dolev, Friedlaender, and Braverman 2001; Reilly, Ring, and Duke 2005; Bramstedt 2016; Mukunda et al. 2019; Dalia, Milam, and Rieder 2020; Alkhaifi et al. 2022). Katrina A. Bramstedt (2016: 844) has identified facial expression as key to the visual literacy clinicians gain through such humanistic training because it can provide “nonverbal cues to support how they care for a patient.” Indeed, some institutions have used patients’ self-portraits as clinical tools. For instance, at the National Intrepid Center of Excellence at Walter Reed, participants in the “Creative Forces” initiative express their experiences of posttraumatic stress disorder and traumatic brain injuries by crafting multimedia masks.¹⁴ By creating what the initiative’s lead therapist, Melissa Walker, has called “a visual voice,” mask-making veterans endeavor to make the physical and psychological wounds of war visible to healthcare providers (quoted in Stone 2015). Similarly, as part of the “Portraits of Care” (2010) study at the University of Nebraska, artist Mark A. Gilbert drew and painted joint portraits of patients and their caregivers. Researchers argued that posing for Gilbert allowed the patients to “communicate through their non-verbal facial and bodily expression” and, as such, present themselves to audiences as “‘whole people,’ not fragmented by diagnoses” (Aita, Lydiatt, and Gilbert 2010: 8). Graphic medicine, a field at the intersection of comic studies and the health humanities, has also recently become a feature of some medical education programs (Ronan and Czerwiec 2020). According to Michael J. Green and Kimberly R. Myers (2010), the interactions between text and image in graphic narratives can heighten providers’ observational skills, since readers must observe visual cues in order to supplement the written text provided.

Health humanities scholars have proposed that in addition to enhancing clinicians’ ability to observe their patients’ experiences of pain, studying the visual arts also forces providers to grapple with how they observe and interpret such suffering (Marr et al. 2019). In sessions at the Museum of Art, Rhode Island School of Design, healthcare providers studied both abstract works and representational portraits before participating in guided discussions about what they noticed in the artwork, what factors shaped the meanings they ascribed to their observations, and how to navigate uncertainty and ambiguity in their perceptions. As a result of these metacognitive exercises, clinicians developed an awareness of “the inherent subjectivity, bias, and mental shortcuts that influence decision-making when it comes to treating patients in pain” (Marr et al. 2019: 1186).

Such an approach to portraiture can allow us to reevaluate existing strategies for knowing pain. For example, it might trouble our understanding of the widely used Wong-Baker FACES Pain Rating Scale (FACES Scale), which asks pediatric patients to describe the degree of their pain by identifying with one of six simply drawn facial expressions. The FACES scale actually originated as an experiment in portraiture: in the 1980s, over fifty children were given a numerical scale and asked to draw corresponding facial expressions (Wong-Baker FACES Foundation n.d.). The participants were specifically prompted to “think back to their own experiences” of pain and then depict these, meaning that each individual scale was deliberately subjective, depicting an individual child’s pain, their recollection of it, and the facial expressions they believed best represented that memory (Wong-Baker FACES Foundation n.d.). The standard scale that was composed based on patterns across these drawings makes far less room for such individualized expression. In order to convey their pain, patients using the scale must interpret the images presented and then determine which among these limited options hews most closely to their own internal experience.

In her essay “The Pain Scale” (2007), writer Eula Biss addresses the limitations of the FACES model by describing images of faces that fail to map onto the scale’s progression from “No Hurt” to “Hurts Worst.” She writes, “The face I remember, always” when thinking about pain “was on the front page of a local newspaper in an Arizona gas station. The man’s face was horrifyingly distorted in an open-mouthed cry of raw pain” (Biss 2007: 13). Recalling that while the man’s house had been destroyed in a fire, he “himself, the article revealed, had not been hurt,” Biss highlights the porous division between such emotional anguish and the physical pain the FACES scale seeks to represent (13). She describes, too, “a newspaper photo of an Israeli boy with a bloodstained cloth wrapped around his forehead. His face is impassive” (13). While the injury indicated by the bloodied bandage would seem to indicate significant pain, the boy’s emotionless expression would rank him surprisingly low on the scale. Finally, Biss reflects on an image of a concealed face: “a newspaper photo of an Iraqi prisoner standing delicately balanced with electrodes attached to his body, his head covered with a hood” (14). Grappling with how to interpret such an incomplete but nonetheless evocative portrait, Biss asks the reader, “No face, no pain?” (14). Biss’s provocative, unanswered question underscores and unsettles the extent to which expression is seen as a uniquely reliable indicator of one’s pain.

At the same time, Biss’s descriptions of these various faces reveal the importance of contextualizing expression. Taken together, the portraits she describes create their own ekphrastic pain scale. Much like Alcott and Whitman describe both what they believe to be the sources of their patients’ pain and their strategies for responding to that suffering, Biss employs ekphrasis to reveal her own interpretations. Her reference to the house fire contextualizes the first man’s pain as emotional, and her curt description of the wounded Israeli boy’s “impassive” expression reveals her disbelief that this apparent neutrality actually reflects the absence of pain. The wartime contexts implied in her specification of the Israeli and Iraqi subject’s nationalities, too, invite readers to consider whether the FACES scale can account for the psychological toll of such conflicts. Through these descriptions, readers don’t only access the faces Biss has witnessed; they also see her perceptions.

The subjectivity evinced by Biss’s ekphrastic portraits of pain returns us to the nineteenth century, when the materiality of the daguerreotype made viewers of portraits visible alongside the subjects they observed. As Williams (2016: 34) notes of the daguerreotype, “Holding it one way, viewers can see the image, but holding it another, they see a reflection of themselves.” Alcott herself acknowledges this kind of double portrait in Hospital Sketches. Although she frames her Sketches as realist literature by insisting that “several of [her] comrades” have given their “approval” and confirmed the accuracy of her account, she also concedes the subjective nature of her text (Griffis 2016: 266–69; Alcott 1863: 101).¹⁵ “As no two persons see things with the same eyes,” Tribulation admits to the reader in her postscript, “my view of hospital life must be taken through my glass and held for what it is worth” (Alcott 1863: 101). In the nineteenth century, “glass” certainly referred to the spectacles that could enhance one’s ability to see, but it could just as easily be shorthand for a “looking-glass,” or mirror, such as the one Tribulation earlier provides for her patient with the facial wound. When viewed within the frame of this looking-glass, the text of Hospital Sketches emerges not as a simple representation of her patient’s expressions and experiences but rather as a self-portrait of the observer herself. Today, this mirroring quality remains crucial to portraiture’s utility in understanding pain. As one viewer of Gilbert’s 2010 “Portraits of Care” series remarked, “You can tell a lot about a person from their face, but the way we perceive that face and body tell a lot about us” (Aita, Lydiatt, and Gilbert 2010: 11). Studying both visual and verbal portraits can thus enable clinicians, caregivers, patients, and scholars to look plainly at the biases, experiences, and existing frameworks that varyingly cloud our vision and clarify our perceptions. By bringing portraiture into the frame of health humanities scholarship, we can look at pain in the face while also remembering that we are seeing only what Whitman (1875–76: 15) called “a fragment, a reflection afar off of the bloody scene” of suffering itself.

Sincere thanks to Lindsey Grubbs, Jessica Horvath Williams, Clare Mullaney, and Sarah Nance for their feedback on early drafts of this essay.

Notes

References