The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885by John Harley Warner
This new paperback edition makes available John Harley Warner's highly influential, revisionary history of nineteenth-century American medicine. Deftly integrating social and intellectual perspectives, Warner explores a crucial shift in medical history, when physicians no longer took for granted such established therapies as bloodletting, alcohol, and opium and began to question the sources and character of their therapeutic knowledge. He examines what this transformation meant in terms of patient care and assesses the impact of clinical research, educational reform, unorthodox medical movements, newly imported European method, and the products of laboratory science on medical ideology and action. "Combining a prodigiously researched and thoroughly fascinating depiction of actual nineteenth-century therapy with a sophisticated and widely applicable model of scientific change, The Therapeutic Perspective is a superb book, likely to become a classic in the literature of medical history."--Martin S. Pernick, Science"Warner tells his story in powerful and lucid ... prose.... [He] has written an important and radical book."--Steven Shapin, The Times Higher Education Supplement"[The Therapeutic Perspective] is a clearly written and well-organized analytic study that should bring much credit to its author, for he has made far more understandable an important aspect of our history."--Gert H. Brieger, M.D., Journal of the American Medical Association
"Combining a prodigiously researched and thoroughly fascinating depiction of actual nineteenth-century therapy with a sophisticated and widely applicable model of scientific change, The Therapeutic Perspective is a superb book, likely to become a classic in the literature of medical history."Martin S. Pernick, Science
"Warner tells his story in powerful and lucid . . . prose. . . . [He] has written an important and radical book."Steven Shapin, The Times Higher Education Supplement
"[The Therapeutic Perspective] is a clearly written and well-organized analytic study that should bring much credit to its author, for he has made far more understandable an important aspect of our history."Gert H. Brieger, M.D., Journal of the American Medical Association
"[Warner] pursues a sophisticated argument with extraordinary diligence, thus producing a carefully crafted book. . . . Judged by its methodology, insights, presentation, and prose, this book ranks as a model of American scholarship."Dora B. Weiner, Social History of Medicine
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The Therapeutic Perspective
Medical Practice, Knowledge, and Identity in America, 1820â?"1885
By John Harley Warner
PRINCETON UNIVERSITY PRESSCopyright © 1997 Princeton University Press
All rights reserved.
Intervention and Identity
In a commencement address to Cincinnati medical students in 1877 on "the dignity and sanctity of the medical profession," the speaker asserted that "its chief excellence is, not that it is scientific, but that it is redemptive." To understand and explain illness were important parts of the physician's task, but did not constitute the whole of it. The physician was more than a natural scientist; he was also a healer. Dissenting from the emerging but still novel view that professional identity in medicine should be defined chiefly by science, the speaker admonished the graduates that "the physician is not only the interpreter of Nature."
However necessary this admonition may have been by 1877, during the first two-thirds of the nineteenth century no American physician would have questioned it. The physician's "redemptive" role, his active therapeutic intervention in an effort to redeem patients from disease, was at the core of what it meant to be a physician in America.
Although Alexis de Tocqueville may have overstated Americans' valuation of practice over theory, he nonetheless perceived correctly their predilection for activity. His observation that the American was above all a "man of action" closely matched the views American physicians held of their professional role and identity. In 1833, two years before Tocqueville toured the United States, a young Bostonian studying medicine in Paris proposed to his father the idea that he pursue the Parisian plan of clinical research for several years before starting practice. Pierre Louis, the student's French mentor, endorsed this scheme, and wrote to the boy's physician father, "I recommend this to you, because no one is more capable than he is of cultivating the science and thereby of making progress in the practice, for what is practice but science put into operation?" But the father, James Jackson, Sr., could not consent to this postponement of activity for the sake of observation. He rejected his son's proposal, arguing that for an American physician scientific investigation was not a legitimate substitute for practice. "In this country," the elder Jackson later explained, "his course would have been so singular, as in a measure to separate him from other men. We are a business doing people. We are new. We have, as it were, but just landed on these uncultivated shores; there is a vast deal to be done; and he who will not be doing, must be set down as a drone. If he is a drone in appearance only and not in fact, it will require a long time to prove it so, when his character has once been fixed in the public mind."
The antebellum American physician derived his professional identity from practice, in which a primary imperative was to act therapeutically. Yet among the most persistent myths about medical therapeutics in America is the notion that from the 1820s through the 1860s therapeutic skeptics and nihilists appeared in the regular ranks to denounce and abandon traditional therapy. This myth matters, because it suggests incorrectly that a physician could preserve proper professional identity and at the same time reject active intervention. In the United States a truly noninterventionist posture either in normative statements or at the bedside was not an option. The physician had to do something; a "do-nothing" physician, as critics often caricatured skeptics, would be bereft of professional legitimacy, would in fact not be a physician at all.
Grasping the tight connection between therapeutic intervention and professional identity is the most important key to understanding the course and meaning of nineteenth-century therapeutics. Because therapeutics in part defined professional identity, therapeutic change involved the risk of destabilizing its supports. Therapeutic ideology and debate were dominated and constrained by their implications for the profession's image and standing. The integrity of regular therapeutics could not be radically challenged without an implicit threat to regular professional identity as well. Traditional remedies such as bloodletting, elements of the regular creed and identity, held a symbolic significance that transcended and added meaning to their use at the bedside. Orthodox practitioners were, after all, largely distinguishable from their sectarian competitors by their practices. The link between identity and intervention molded regular physicians' evaluation of knowledge and its sources, the ways the profession sought to portray itself and its practices, and the interactions among regular physicians sectarian practitioners, and the public.
Medical treatment, the core of the physician's "redemptive" role, was the essence of what patients expected. Throughout the antebellum period "prescribing" for a patient was a widely used synonym for making a professional visit. The rural sick, who sometimes wrote to physicians in lieu of the more costly option of sending for them, ordinarily wanted drugs more than explanation or hygienic advice. Yet the patient could obtain treatment from a variety of sources, among them home remedies and lay healers, so the provision of therapy was in itself insufficient to define a distinctive identity for the physician.
In the perception of physicians, what gave the proper practitioner of medicine a distinctive identity was his profession, his proclaimed worthiness of confidence in performing the task of healing. "Physic is not a trade," one New England physician declared in 1834. "It is a profession made by its members, that is, a declaration, an assertion, that the candidate possesses knowledge, skill, and integrity, sufficient to entitle him to confidence." Among the elements of that profession, he continued, was the "moral obligation" to intervene. The physician professed, in effect, that he had faith in his ability to act, and that this merited in turn the confidence of the public.
Professional identity was principally based upon practice, not, as it became to a large extent after the late nineteenth century, upon a claim to special knowledge. Knowledge was, to be sure, a necessary attribute of the competent physician. "By his profession," one physician observed, "he has already declared that he has done all, according to his best ability, to fit himself for the all-important and trust-worthy situation which he has assumed. In other words, he declares that he has a good medical education." Extensive knowledge about the basic sciences was desirable, but not essential to proper professional identity. What was essential was that the physician be able to act, and to do so in accordance wih regular values. The common, defining body of learning that all regular practitioners shared was knowledge about practice. Further, it was practice that mattered most to physicians in assessing the orthodoxy of their fellows.
A professionally respectable practitioner could remain ignorant of much of basic medical science. While one physician traveling in the rural South in the mid-1840s could observe that the regular practitioners of the district "are not familiar with the minutiae of Anatomy, Physiology, and Pathology," he could nonetheless avow "that a more able and skilful set of practitioners is not to be found in any country... They are men of close observation, and sound judgment; above all they are well acquainted with the peculiarities of the malignant diseases with which they have to contend, and act with promptness and skilful decision." Their deficiencies did not undermine their legitimacy as regular physicians. Similarly, in evaluating the qualifications of an applicant for a Confederate Army surgical post, one physician could advise the examining board that even though the candidate was "entirely ignorant of Anatomy, Surgery, Physiology, Pathology and Chemistry," he was nevertheless "a pretty fair practitioner in the ordinary acute diseases of the Country." The knowledge required to sustain professional identity was of the sort that could be gained through experience, as in apprenticeship.
Conversely, the possession of extensive knowledge about medical science was insufficient to make a person a physician. There was little place in American society for a nonpracticing physician: the two terms were contradictory. Someone with medical training and perhaps an M.D. degree could and often did take up an occupation other than medical practice (such as business, farming, or teaching), but by doing so exclusively he lost his professional identity as a true physician and became something else. In antebellum America the physician was a practitioner.
Enthusiasm for scientific investigation could even diminish the practitioner's capability at the bedside by diverting his attention from the primary task of intervening, physicians maintained. "I almost think that a man may learn so much before he begins to practice as to prevent his doing well," an eminent Boston physician cautioned. "Too much knowledge of the dangers &. difficulties tend to paralyze one's powers—or at least to check one's efforts." Harvard medical professor John Ware was typical in continually reminding his classes that the final purpose of medical education was not the mere acquisition of knowledge but to prepare the student for practice. "He may be an excellent anatomist, pathologist, chemist—nay, he may be minutely acquainted with the history and treatment of disease, and yet be totally unfit to take charge of a single patient." The useful physician, he urged, had to learn how to "apply this knowledge with a wisdom which is sometimes altogether beyond that which merely high attainments in science can confer."
One of the attributes Ware had in mind was judgment, something informed by learning but developed through experience. Professional judgment came only from practice, and generated a confidence that knowledge alone could not command. A New Orleans practitioner wrote of his physician brother that although "his understanding of the theory and principles of his profession is superior to that of nine tenths of the physicians in the country," he "is too distrustful of his own abilities." He explained to their mother that "one thing is wanting in him & but one to ensure abundant success—confidence, self-confidence, the all indispensable prerequisite for an undertaking in our country." More often than not, physicians elected to praise a colleague by characterizing him as a man of good judgment or sound experience rather than one of great learning. Still, cultivated experience and judgment were not so much essential ingredients in professional identity as signs of the practitioner's expected maturation.
More essential to proper professional identity was moral character. Being a moral man was deemed crucial not merely to the physician's standing in the community, but also to his effectiveness as a healer. A high standard of "moral excellence," the Committee on Ethics of an Ohio medical society declared, "is a duty every physician owes alike to his profession and to his patients. It is due to the latter as without it he cannot command respect and confidence and to both because no scientific attainments can compensate for the want of correct moral principles." "Moral influence" was both a source and an expression of the physician's healing power and was regarded as an active force that daily made a difference in the sickroom. Partially for this reason physicians often perceived challenges to the regular profession's therapeutic acumen in moral terms. At the same time, anything that debased the practitioner's moral integrity threatened his professional identity and imperiled his therapeutic effectiveness.
Practical knowledge, morality, and interaction with patients (in accordance with the regular belief system) were, then, what physicians held to be the essence of their professional identity. The genre of medical literature that set exemplars for the profession, such as introductory lectures at medical schools, presidential addresses to medical society meetings, and medical theses, identified many other characteristics that were desirable in the physician. These included a sense of responsibility, duty, judgment, piety, intellectual achievement, patience, industry, Christian faith, and citizenship—in other words, an inventory of those qualities esteemed in contemporary American society. And as women made incursions into regular practice from midcentury onward, most medical men added being male, hitherto assumed, to their list of important traits. Thinking physicians also urged that they, like lawyers and clerics, had a special responsibility and capacity for providing community leadership, particularly in the country's newer regions, and expressed this by participating in temperance movements, developing cultural institutions, and instigating public health measures. But even though these admirable features made a more successful physician, they did not define professional identity, only enhanced it.
The physician looked to his profession for much of his identity but derived little of his status from that source. During a large part of the nineteenth century many practitioners enjoyed the public's high esteem at a time when the profession as a whole was in a degraded position. The simple fact of membership in the regular medical profession had little to do with the individual physician's status, which came more from his own interactions with patients and other practitioners and from such factors as family and community connections. But even though the practitioner's status was largely independent of his profession, the welding of his personal professional identity to that of the collective physician gave him reason to care about the position of the profession and motivation for defending and bettering its image. Thinking physicians sought to uplift the standing of the profession for reasons that transcended improving their individual socioeconomic positions.
Medical institutions had more to do with forming the image of the aggregate regular profession, and the status of some individuals, than they did with shaping the characteristics of the individual that determined whether or not he was a physician. Medical schools, licensing societies, and journals were all vehicles through which regular values could be affirmed and regular beliefs codified and transmitted. Institutions were also one means by which the individual physician could acquire esteem: a professorship, society membership, publication, and hospital appointment were all tools for improving a practitioner's status. Many a thinking physician recognized the potential of medical institutions as platforms to elevate the profession as a whole and thereby to enhance his personal professional identity; but for the unambitious rural practitioner's everyday activity, self-perception, and place within his community, such institutions might have little meaning. From the 1820s through the end of the antebellum period, a medical practitioner in America could lack an M.D. degree, be unlicensed, belong to no professional society, and not read (much less write for) a medical journal, yet still undeniably be a regular physician. Physician-intellectuals might deplore his ignorance and seek to distance themselves from him, but would still recognize him as a physician—legitimate, however regrettable.
All of the elements of professional identity pivoted upon action. Professional knowledge was of doubtful value if it did not direct activity. It was this emphasis on useful knowledge that informed the persistent ambivalence of nineteenth-century American physicians toward scientific knowledge, represented in turn by the products of speculative system building, pathoanatomical investigation, and laboratory research. Members of the medical profession vigorously debated the value of chemistry, physiology, and even anatomy for the practitioner, but no one questioned the value of knowledge about practice, knowledge that would guide action at the patient's bedside.
Excerpted from The Therapeutic Perspective by John Harley Warner. Copyright © 1997 Princeton University Press. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
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