In a distinct American region where climate, race and slavery, and assumptions about "southernness" profoundly shaped illness and healing in the lives of ordinary people, Stowe argues that southern doctors inhabited a world of skills, medicines, and ideas about sickness that allowed them to play moral, as well as practical, roles in their communities. Looking closely at medical education, bedside encounters, and medicine's larger social aims, he describes a "country orthodoxy" of local, social medical practice that highly valued the "art" of medicine. While not modern in the sense of laboratory science a century later, this country orthodoxy was in its own way modern, Stowe argues, providing a style of caregiving deeply rooted in individual experience, moral values, and a consciousness of place and time.
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Doctoring the SouthSouthern Physicians and Everyday Medicine in the Mid-Nineteenth Century
By Steven M. Stowe
The University of North Carolina PressCopyright © 2004 The University of North Carolina Press
All right reserved.
Chapter OneMen, Schools, and Careers
Becoming an M.D. in the mid-nineteenth-century United States was not an outlandish choice for a young man; it was not like running away to sea. But medicine, straddling the line between trade and profession, filled with economic and therapeutic uncertainties, was anything but the main chance. In the South, before and after the Civil War, the ideal of manly success was to master a flourishing plantation, the traditional seat of a man's economic power, political influence, and social esteem. Nonetheless, thousands of southern men made orthodox medicine their choice during the mid-nineteenth century, and increasing numbers of them (including some men already in practice) decided that formal medical schools were the best place to pursue it.
This chapter focuses on southern men making this choice, viewing it as an encounter between their ambitions-framed by family, gender, and the local context of medicine-and an orthodox profession itself in the throes of change. Indeed, the fact that students were defining their personal goals at just the time physicians were rethinking education makes schools a particularly good place to analyze the tensions shaping medicine in this period. What follows builds on the well-known picture of medical innovators using schools as the means of reforming orthodoxy into a more intellectually unified and therapeutically sound medicine. The main focus here is on schools as the local institutions they were, sites for a distinct, ground-level orthodoxy in the making. Socially speaking, this means looking at schools as strikingly visible, urban institutions built on-and helping to define-a fraternity of physicians. From an intellectual point of view, it means understanding how the new medical education was caught in the friction between two goals that, as we will see, influenced physicians' view of their medicine throughout their careers. On the one hand, faculty and students imagined the school, and therefore orthodoxy, to be a cosmopolitan world apart from the surrounding vernacular culture of healing. On the other hand, they discovered that the outside world constantly impinged on the school in ways both useful and troubling.
Thus, even though most faculty and students after 1830 eagerly embraced the idea of an institutional world of their own, they were unable-and in many instances unwilling-to isolate themselves from a surrounding social matrix of ideas and influences on doctoring. In this respect, this chapter reexamines the fierce competition among schools during the nineteenth century as being about more than money, professional standards, and gatekeeping. On a deeper level, the struggle over schooling reveals that even the largest institutions, notwithstanding their genuine effort to make education more universal and abstract, actually privileged a local context for learning that encouraged physicians to focus on issues of self and locale. In particular, by fostering fraternal bonds among men, schools helped create a fluid, personal context for the very essence of medical knowledge.
This chapter considers, first, some of the moral and material realities that men-mostly young men-pondered as they made their decision to become doctors. This is followed by a look at the significance of medical schools' struggle to shape a unique world after 1830. A struggle over academic requirements, it also was a struggle over the question of physicians' identity: were they to be the harbingers of a cosmopolitan medical science or should they be content to be the repositories of familiar, local practice. Finally, this chapter considers how the issues raised by schools' academic tensions also were shaped by their continuing commitment to apprenticeships and to an urban setting. In all of these contexts, schools embraced elements of a vernacular world that they also wished to hold at bay.
Family, Intellect, and the Manly Choice
Family as the cradle of young men's prospects and character profoundly shaped how men imagined becoming physicians. Throughout the mid-nineteenth century, no clear professional career "path" in medicine existed to help men make their decision. Most men more or less backed into medicine. In the 1830s, for instance, J. Marion Sims thought that medicine was interesting mostly because it seemed more inclusive and less rigid than either law or the ministry. Another young South Carolinian, Lafayette Strait, after attempting "to go through the Citadel and fail[ing]," chose medicine in the 1850s for the simple reason that "I am very anxious to go at something." William Whetstone's older brother hoped that medicine would give William something to "put your mind upon" if only to "take it off the women." So, too, Hamilton Weedon was advised in 1851 that medical study might be a good alternative to "frolicking & Spanish segars, and extravagant clothes." Some men undertaking medical study did not foresee careers as physicians but rather hoped to acquire skills useful in planting, the ministry, or even business.
Men framed their goals with the language of masculine willfulness and license-and with its obverse, the idiom of honor and sober morality. "Now is an import[ant] time in my life, and I must 'make hay while the sun shines,' lest the sun might refuse to shine for me," one young South Carolinian wrote in 1856 as he prepared for medical study. Another young man felt that his "manhood had been reached" with his decision to study medicine and that with it he had "started out on Life's voyage ... to try to make something of myself." Making it while the sun shone; starting out on the voyage-the familiar images of manly effort gathered their power. Young men's families added their views, not always supportively. J. Marion Sims's father was appalled at Sims's decision to take up medicine. It was a mere trade, he told Marion: "There is no science in it. There is no honor to be achieved in it; no reputation to be made." Another South Carolinian faced family disapproval in 1856 for the quite different reason that medicine was deemed too difficult. His physician uncle "curled his nose in disgust" and said "that I would never succeed" because of a lack of self-discipline needed for a successful practice.
Other families, though, supported their sons' desire to study medicine, defining an honorable career not by wealth or fame but by social usefulness or their son's intellectual bent. Lunsford Yandell, whose father practiced medicine, "cannot remember the time when I was not spoken of in the family as an embryo doctor." Charles Hentz's father, too, had studied medicine, and although Charles's mother insisted that the seventeen-year-old attend the University of Alabama for a year, she agreed with her husband that medicine suited Charles's interest in nature and his skill with his hands. Russell M. Cunningham recalled the "beautiful night" in Alabama when he told his parents, with some apprehension, "I am going to study medicine." But his mother told him, "Go it, my son; I rejoice in your ambition."
To be sure, men worried along with their parents about the practical consequences of their decision. Charles Hentz had second thoughts in 1845 when he learned that "there are nearly a thousand young men turned out annually" from medical schools; he feared that there was too "little sickness to divide amongst so many." Hentz's mentor, Daniel Drake, himself recalled wondering whether his "home-body" self would be happy at a school so far away from home. Doubtful men turned to practicing physicians for reassurance. "Now you know me and ... something of the physiognomy of mankind, [tell me] if you think it would do for me to undertake that kind of enterprise," a fellow Alabamian asked Dr. William Wylie in 1857. Dr. Charles Harrod reassured his friend in 1845 about her prospective medical student grandson, telling her that all would be well if the youth would "come down here [to New Orleans]-I will introduce him to several of the physicians." What Harrod's quite typical offer reveals is how much the midcentury medical profession was still little more than a hit-or-miss network of personal contacts, making a man's choice of medicine inseparable from the social and moral contexts of local, individual practice. Although, as we will see, the larger medical schools by the 1840s aimed to make admission to the profession something more, this personal scale of information and aspiration stayed largely intact.
This should not suggest that the intellectual appeal of medical study did not count; for many men it mattered a great deal. Although medical students have been portrayed as a rowdy, unscholarly lot, many seem in fact to have been attracted to the intellectual challenges of medicine. Even so unfocused a young man as Lafayette Strait expected medicine to demand "the strongest mental exertion," which he welcomed as a test of his maturity. Similarly, Daniel Drake recalled that most of his fellow students took seriously the "learned, technical, and obscure" science they had chosen. "The physician, unlike the mathematician, is not the creator of his own science," one mentor observed. "Unlike the astronomer, he has no simple relations of matter to deal with; he cannot, like the chemist, make any two things which he examines or uses identical; the objects of his study [that is, his patients] are more variable than the winds and tides." Although doubtless understating the complexity of astronomy and chemistry, this view was common among physicians who saw medicine as uniquely difficult because its science would never be free from the vexing need to apply it.
Even so, many intellectually curious students embraced medicine as the only field of study at midcentury that unified the natural sciences into a single realm of knowledge. For young Lunsford Yandell, reading through the lectures of Benjamin Rush in the 1820s, or for William Holcombe, working through French and English books on zoology and biology twenty-five years later, medicine was by definition "scientific" because it required an omnivorous reading that promised synthesis, as well as detail. The usual preparatory reading for medical students throughout the century included not only the natural sciences but also works in literature and moral philosophy, suggesting that nothing was intellectually beyond the physician's curiosity. The sense of medicine as the key to discovering a unifying "science of life" was sufficiently strong that many students would have agreed with Charles Hentz, who wrote in 1845 that his most compelling reason to become a medical doctor was his intellectual desire "to make the study of Nature one of my great occupations as well as pleasures."
Men's interest in the intellectual domain of medicine is all the more significant in that it was not matched by an expressed desire to care for the sick and relieve suffering. In the correspondence among men, their families, and their advisers, there is scarcely a mention of helping sick people or of illness as a subjective experience. Although some advisers, rather abstractly, referred to the need for "constant attention at the bedside of the sick," it was not caregiving so much as an ethic of hard work they were recommending. It is tempting to think that the silence about caregiving implies that helping sick people was so axiomatic that it did not require words. But this view sells the significance of the silence too short. The silence may well suggest, once again, that many physicians conceived of medical learning as a world apart from its application to patients. To say "I wish to study the science of all life" was to be filled with a unique aspiration and sense of adventure; to say "I want to make people well" was far less ambitious, not least because it might not be possible.
The subjectivity of illness, however, does make one brief but interesting appearance in the retrospective writing of certain physicians. In telling how they chose medicine, they include childhood memories in which someone (often themselves) is injured or suffers. Only glancingly seen and said, these allusions nonetheless suggest a personal tie between the desire to become a doctor and the realm of bodily infirmity, pain, and dependence at the heart of hands-on practice. Charles Hentz, for instance, recalling his earliest memories, remembered falling and injuring his head while chasing his sister around a tree as a child in the late 1820s. "Father sent for a doctor," Hentz remembered, "who trimmed my eyebrow & put on plasters, which filled me with a great sense of importance." Similarly, James Still remembered being vaccinated by a doctor, and throughout his career, "the sting of the lancet yet remains." Lunsford Yandell linked his decision to study medicine to the fact that he was frail as a boy, "called by the negroes 'splinter-shanks,'" and that his parents worried he might not be strong enough to work at anything. He proved everyone wrong by becoming a physician.
Medical Schools and Reform: Stretching Orthodoxy
Before 1830, relatively few American men with an interest in medicine attended medical school. Apprenticeship, which is considered later in this chapter, was the traditional means of recruiting "practical" men into the orthodox profession. But after 1830, new institutions-larger and more intellectually ambitious than any that had preceded them on this side of the Atlantic Ocean-challenged and reconfigured what it meant to become a physician. Reformist physicians seized upon formal schooling as providing an education far richer than anything solo apprenticeship could offer: ideally schools provided a concentrated intellectual environment guided by experienced men and shared with a brotherhood of inquisitive fellows. To achieve this ideal, schools aimed to be an intellectual and social world apart from the larger society. But here a striking tension arose. Attempting to create a world apart was deeply problematic given a school's obvious dependence on local resources and goodwill. Thus, even as educational reformers pursued an idea of medicine as a realm of universal values and techniques, schools remained quite permeable to the surrounding world of local health practices and assumptions.
For the most part, the history of these two linked worlds has been told as a story of how successful orthodox schools managed to break free from both competitors and the larger society alike. It is a story of linear change, the making of a twentieth-century institution. What follows here is a different kind of story. Mid-nineteenth-century medical schools are not seen as transitional institutions on the way to "modern" medicine. Rather, they are seen as an experienced now, a social and intellectual place in which orthodoxy was a fluid, protean body of knowledge stretched between two equally powerful visions of its potential.
Excerpted from Doctoring the South by Steven M. Stowe Copyright © 2004 by The University of North Carolina Press. Excerpted by permission.
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What People are Saying About This
Stowe thoughtfully and sensitively takes readers through nineteenth-century physicians' careers from medical school onward as seen from the physicians' perspective. He analyzes every aspect of their careers with particular emphasis on the relationships between physicians and the communities in which they practiced and between physicians and their individual patients.Todd Savitt, Brody School of Medicine, East Carolina University