John Harley Warner. Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine. Princeton, N.J.: Princeton University Press, 1998. x + 459 pp. $49.50 (cloth), ISBN 978-0-691-01203-2.
Reviewed by Michael L. Dorn (Department of Geography, University of Kentucky)
Published on H-SHEAR (April, 1999)
Between 1815 and the 1850s, some one thousand medical students and practicing physicians traveled to Paris from the United States for "improvement." They carried with them expectations of what they would experience in the great medical Mecca of the early nineteenth century and of how it would transform their lives and their practices. Paris symbolized many things to these education-seekers: revolution, modernity, enlightenment, and first-hand experience. For every tie to family, community, and landscape that dissuaded them from making such a journey, there were overpowering incentives. In an age obsessed with refinement, Parisian training represented the finest polish for the gentleman-doctor. Doctors returned from France expecting and often achieving an elevated position in the profession. Forming medical societies and writing for journals, they burnished this polish until it shone for all to see. In the process, they created their own narratives of the Paris experience, retrospective reconstructions that served the particular needs of an American medical profession struggling to establish and defend its authority.
This is the thesis of John Harley Warner's new work Against the Spirit of System, documenting an oft-neglected chapter of the early American republic. The author, a medical historian at Yale, has researched manuscript collections across the Eastern United States, Canada, and the United Kingdom, unearthing a wide variety of artifacts and souvenirs, from personal journal accounts to purchased books and anatomical specimens. The stories of this unique set of travelers and adventurers are the centerpiece of Against the Spirit of System, and yet the travelogue is only a beginning. Warner's analysis transforms his material into a strikingly original tale of epistemological reform and cultural geographic dynamism, reworking and deepening the characterizations of American medicine's French impulse presented by such medical historians as William Osler, Erwin Ackerknecht and Richard Shryock.
As has long been noted in this historiography, the fortunes of various European centers of medical education have waxed and waned over the centuries, as students have chosen to migrate towards various European medical capitols. The attractions of a Paris, a Vienna, or an Edinburgh may have been readily apparent to these aspiring physicians when they made their decisions to travel abroad, but it is more difficult for medical historian to discern exactly which features gave one center the advantage over its competitors. Warner surpasses earlier work in the his thorough and careful analysis of the decisionmaking process. Tracing the different narrative stuctures of letters to family, friends, and colleagues, Warner is able to contrast the various meanings that medical travelers derive from their experiences i) before leaving home, ii) while in the foreign city, iii) upon returning home again, iv) after establishing themselves in their careers, and finally v) at the close of their careers, looking back over their accomplishments and seeing their views superceded by those of a younger, differently trained generation.
Through these stories, Warner carefully exposes the many layers of symbolic meaning and organizational complexity to be found in the vast Parisian network of hospitals, dissecting rooms, university facilities, museums, and medical fraternities. The stories of learning pathological anatomy and physiology in the clinics of the French masters are often very detailed, sometimes morose, and frequently titillating. American physicians simultaneously reveled in, and were repulsed by, the ease with which they were allowed to examine portions of the human (particularly female) anatomy that would otherwise have been unavailable in their homelands. Some aspects of Parisian medicine were deemed translatable into an American context, such as anatomical knowledge and statistical methodology, while others, such as the apparent "therapeutic nihilism" and indifferent bedside manner of French physicians, were not simply idiosyncratic, but downright undemocratic.
One striking aspect of Warner's own historiographic methodology is the use of differences in gender, ethnicity, regional, and national identity within the diverse group of physicians studying or vacationing in the medical capitol. For example, the vast majority of American physicians who traveled to Paris chose not to officially enroll at French universities. This was thought unnecessary since the French government subsidized free admission to the clinics for all interested parties. Only American students from Francophone Creole families living in or near New Orleans were found to have officially enrolled (p. 54).
Perceptual differences in the lessons derived from Paris training can also be observed cross-nationally. While American medical students most clearly valued the access to the human body afforded by the clinics and dissection rooms, English students were more likely to stress the importance of French medical polity--the way that the medical system was structured and subsidized by the state to afford such ease of entrance and observation. Such comparisons are possible because of the trans-Atlantic reach of Warner's archival excursions.
Gender differences in experience and response amongst students also receives due attention. Many of the travelers recorded their impressions of the attempts of women to gain medical and anatomical knowledge. Elizabeth Blackwell's mid-century pioneering efforts to enter Paris hospitals, the first American woman to seek such an experience, were at first thwarted (p. 105). Eventually she would, on the advice of Pierre Louis, admit herself at La Maternite, a former convent, for intensive obstetrical training, thus setting a pattern that other American women would follow. In later chapters, Warner details the decision-process that leads subsequent women to break away from Blackwell's mold, applying for admission to the prestigious Ecole de Medecine (p. 325) and eventually switching countries altogether, following the late century pilgrimage to the laboratories of Vienna. From evidence in the letters and journals, this distinct subset of medical travelers attracted much attention from their male counterparts. The gendered aspects of these narratives of travel and travail are also carried over into the medical vocabulary, such as the phrases some American doctors used to defend of New World therapeutic practice. Their readings of Parisian therapeutics often contrasted Americans' "energetic and bold" masculine approach to the enfeebled "expectant" plan they witnessed at the clinics of Louis and Andral (p. 286).
Once these medical travelers returned to the United States and set about establishing themselves in the profession, their understandings and recollections of the Paris experience inevitably shifted. American physicians reframed the French medical revolution as an empirical one, heralding a return to sensory experience. During the 1830s and 1840s, many students had been were attracted to the clinic of Pierre Louis, promoter of the "numerical" method of analysis. For these disciples, many of whom returned to assume positions of eminence and would dominate the medical politics of coastal cities, the numerical analysis of the effectiveness of the different remedies in the medical armamentarium was a fundamental part of the assault on rationalist systems of practice, whether advanced by Benjamin Rush or the Parisian François Broussais.
The "campaign against the spirit of system" undertaken by Louis's American students met substantial opposition, however. Many Ohio Valley doctors maintained that Louis's numerical method rested on premises that were foreign to the everyday experiences of Western physicians, under constant attack from sectarian practitioners of various stripes, Thomsonian and eclectic, homeopathic and hydropathic, in an unconstrained medical marketplace. In such a position of continual provocation and professional degradation, "regular" doctors felt compelled to defend all traditional therapeutic measures, even bloodletting and calomel, against potential slander, particularly by their statistically-inclined brethren.
Historians of medicine and science in the early American Republic owe John Warner a tremendous debt of gratitude for having taken on the mammoth task of harnessing this material to such a neat comparative framework. On the other hand, it is important for others engaged in this research to add their own hatching to his richly modeled picture. For all of its breadth, Against the Spirit of System shows the signs of its own enabling delimitations. As Warner notes:
The French impulse was a crucial ingredient in transforming American ideas about disease, the organization and function of hospitals, the education of physicians, the production of new medical knowledge, perceptions of the patient as an object of research, and the practices of diagnosis, surgery, and medical therapeutics. Yet in each of these instances, much of the complex nature of influence would best be revealed by more focused and intensive studies that explore French medicine as any one among myriad other factors in promoting change. Further--and partly because it has not been my aim to produce an exhaustive influence study--I have focused chiefly on internal medicine and surgery and have given little attention to certain other important medical fields, such as psychiatry, forensic medicine, pediatrics, or public health. (p. 6)
In other words, the work of tracing the French impulse in the early American republic is only in the beginning stages. In this spirit, I would like to extend Warner's interpretation by drawing on my ongoing dissertation research on Dr. Daniel Drake and early American medical geography. Late Enlightenment concerns over the effect of the physical and moral environment on human health diffused to the United States as part of this French impulse and are evident in the writings of Ohio Valley physicians.
While Warner has been careful in his concluding chapter, "Remembering Paris," to present the impulses at work in the resistance of the American disciples of the Paris School to the advent of German dominance in the second half of the nineteenth century, similar attention needs to be paid to another group of dissidents discussed in Chapter Four, "Contexts of transmission"--those that resisted the rising authority of the Louis's empiricism during the 1840s. Ohio Valley physicians such as Daniel Drake and Charles Caldwell are cast as conservatives in Warner's typology, resisting the siren's call of Paris and advocating a Western regionalism in therapeutics (pp. 148-9, 263). Such resistance to the new tide of empiricism, however, may rest less on an evident Francophobia, than on a healthy respect for Hippocratic doctrines as articulated by generations of French medical leaders over the past century. Drake's attention to the physical and moral relations in health and disease, and Caldwell's ongoing interests in phrenology and physical anthropology, can only be fully understood in relation to vitalist understandings of Hippocratic tradition, commonly linked to the provincial medical schools such as Montpellier in southern France and the revolutionary medical philosophies of the Ideologues. Known collectively as the "science of man," this work in anthropological and geographical medicine continued to engender support in Paris after the Revolutionary Era and was carried to the United States through medical periodical and texts, and in the opinions of French medical travelers and emigres. The resistance of Ohio Valley doctors to the rising power of the American students of Louis during the 1840s should be credited at least in part to their respect for these alternative philosophical currents within the French medical tradition.
By concentrating on students traveling for instruction in internal medicine and surgery, Warner is able to present a clear story of American physicians' reception of French theory and practice, revolving around the Louis-inspired revolt against medical systems. Subsequent studies in the trans-Atlantic transmission of ideas and practices will allow historians of early American science and medicine to trace other currents within this overall French impulse. Until then, Against the Spirit of System will serve as the benchmark and receive the accolades that it richly deserves. Warner suggests that stories of medical Paris have much to tell us about the societies that students left behind. In his own words, "this, then, is a study of the relations between Old World and New and of the cross-cultural transmission of science and medicine. But it is above all a study of American culture and the culture of American medicine" (p. 6). By paying close attention to the life courses of a large number of these medical travelers (not just the Americans, but their English counterparts as well) and calibrating the subtle shifts between their immediate and their lasting impressions of "medical Paris," Warner is able to bring an international comparative perspective to bear on an important episode in the maturation of an American profession.
. W. Osler, "The influence of Louis on American medicine," in An Alabama Student and Other Biographical Essays (London: Oxford University Press, 1908), pp. 189-201; R. H. Shryock, American Medical Research Past and Present (The Commonwealth Fund, New York, 1947); R. H. Shryock, "Empiricism versus rationalism in American medicine," Proceedings of the American Antiquarian Society 79(1): 99-150, 1969; E. H. Ackerknecht, Medicine at the Paris Hospital, 1794-1848_ (Baltimore: The Johns Hopkins Press, 1967).
. R. M. Jones, "American doctors in Paris, 1820-1861: a statistical profile," Journal of the History of Medicine and Allied Sciences XXV: 143-57, 1970.
. J. H. Warner, "The selective transport of medical knowledge: antebellum American physicians and Parisian medical therapeutics," Bulletin of the History of Medicine 59: 28-231, 1985.
. See also T. N. Bonner, American Doctors and German Universities: A Chapter in International Intellectual Relations 1870-1914 (Lincoln: University of Nebraska Press, 1963).
. See also J. H. Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885 (Cambridge: Harvard University Press, 1986); J. H. Warner, "Power, conflict, and identity in mid- nineteenth-century American medicine: therapeutic change at the Commercial Hospital in Cincinnati," Journal of American History 73: 934-56, 1987.
. Other important works on this episode include J. C. Mohr, Doctors and the Law: Medical Jurisprudence in Nineteenth-Century America (New York: Oxford University Press, 1993); and J. S. Haller, Jr., Medical Protestants: The Eclectics in American Medicine, 1825-1939 (Carbondale: Southern Illinois University Press, 1994).
. L. J. Jordanova, "Earth science and environmental medicine: the synthesis of the late Enlightenment," in L. J. Jordanova and R. S. Porter (eds), Images of the Earth: Essays in the History of the Environmental Sciences (Chalfont St. Giles, Bucks., England: British Society for the History of Science, 1979), pp. 119-46.
. Both Caldwell and Drake were familiar with the medical literature of the ancien regime and the revolutionary period through the library collections housed at Transylvania University Medical Department (Lexington, KY), where both taught during the 1820s. The first major purchases for this library had been made by Charles Caldwell during his 1819 collecting expedition to England and France. See Transylvania University Library, Catalogue of the Transylvania University Medical Library (Transylvania University Press, Lexington, Ky., 1987).
. Examining not only the narratives of American travelers but also the considerable American periodical and textbook literature on French medicine, one sees the continued transmission of vitalist theories and readings of the Hippocratic corpus, promoted by such Philadelphians as John Davidson Godman in his Journal of Foreign Medical Science and Literature and Rene La Roche in his North American Medical and Surgical Journal. A broader understanding of currents in post-Revolutionary Paris medicine is enabled by Elizabeth Williams' recent work. According to Williams, "la science de l'homme" continued to find favor in certain Parisian circles until approximately 1850. See J. S. Haller, Jr., Medical Protestants: The Eclectics in American Medicine, 1825-1939 (Carbondale: Southern Illinois University Press, 1994); E. Williams, The Physical and the Moral: Anthropology, Physiology, and Philosophical Medicine in France, 1750-1850 (New York: Cambridge University Press, 1994; M. S. Staum, Minerva's Message: Stabilizing the French Revolution (Montreal: McGill-Queens University Press, 1996); H. F. May, The Enlightenment in America (New York: Oxford University Press, 1976); F. S. Childs, French Refugee Life in the United States, 1790-1800: An American Chapter of the French Revolution (Baltimore: Johns Hopkins Press, 1940); C.-F. Volney, View of the Soil and Climate of the United States of America: with supplementary remarks upon Florida; of the French colony on the Sciota, and in Canada; and the aboriginal tribes of America, trans. C. B. Brown (Philadelphia: J. Conrad, 1804).
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Michael L. Dorn. Review of Warner, John Harley, Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine.
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