Patient Expectations: How Economics, Religion, and Malpractice Shaped Therapeutics in Early America by Catherine L. Thompson (review)

That patients are largely missing from many medical histories is an old saw of the medical historical trade. Of course, most medical historians making this observation are pointing out that patients are present passively in medical history, appearing as disease incubators, receivers of treatment, and objects of medical gazes. Catherine L. Thompson’s new work aims to challenge these narrow conventions by “repositioning patients as active shapers rather than passive recipients of their medical care” (3). By analyzing medical therapies, self-medication, changing medical economies, shifting religious beliefs, and standards for malpractice, Thompson shows that nineteenth-century patients helped shape medical therapies. This ability to shape therapeutics, however, was limited to a great extent by other forces transforming nineteenth-century American life.

Thompson first substantiates the types of medical therapies common in Massachusetts from the beginning of the Republic through the start of the Civil War. In chapter one, “Medical Practice in Massachusetts,” she uses random samples from the casebooks of five different physicians, whose collective practices covered the period from 1790-1838, to argue that doctors in Massachusetts did not administer heroic therapies anywhere near as often as the writings of Benjamin Rush might lead you to believe. Heroic bleeding and massive doses of calomel were minor players in these five physicians’ therapeutic arsenals. Thompson argues that medical therapeutics in the Early Republic should be “a narrative of continuity rather than the rise and fall of heroic depletive therapy” (32).

In chapter two, “Self-Medication and the Nineteenth Century,” Thompson mines intake interviews from the Massachusetts General Hospital to show that patients often self-administered medications (particularly heroic treatments) before seeking professional medical care. Ample tables and appendices show what types of therapies patients admitted to self-administering when speaking with their doctors about their efforts to treat their illnesses.

Thompson’s third chapter, “Money and Medicine,” makes the case that the transition from “a local exchange system to a long-distance trade system” altered the medical marketplace (50). Wealthy patients increasingly used promissory notes and other forms of credit to purchase medical treatments, while impoverished and lower class patients sought medical care in the hospital setting. Wealth created therapeutic leverage: pay patients could influence their treatment by threatening to seek another physician, while poor patients had to take or leave the hospital physician’s course of treatment (64). Thompson also found a fascinating disparity between urban and rural medical economics in the mid-to-late-nineteenth century. While wealthy Boston patients had choices for medical care, those seeking treatment in rural western Massachusetts still relied on a barter-based economy (56).

Changes in American religious life also shaped patient expectations. In chapter four, “Patient Expectations and Religious Beliefs,” Thompson argues that the Second Great Awakening changed patients’ conceptions of pain and its management. More traditional groups, like Congregationalists, continued to see illness and pain as pseudo-spiritual experiences, while more radical Transcendental and Unitarians came to understand pain as a secular or temporal challenge that could be avoided. For these believers, “pain or illness was met with active resistance, not passive avoidance” (78).

Thompson’s last chapter, “Medicine and Malpractice,” examines the changing legal definitions of medical culpability. Malpractice litigation morphed from an eighteenth-century emphasis on iatrogenic injury into a nineteenth-century judgment on whether physicians performed their duty with competency and skill (94–96). Thompson also suggests that the increase in legal action against physicians in the nineteenth century was caused by the changing role of the doctor from cherished community healer to entrepreneurial independent businessman. Other marketplace ideas influenced medical jurisprudence in the physician’s favor: judges began to routinely set aside jury verdicts against doctors due to the fear that too many settlements against medical professionals would deter physicians from offering their services (107).

Like any work, there are a few areas of Patient...