Against The Spirit of System: The French Impulse in Nineteenth Century American Medicine By John Harley Warner (review)

Against The Spirit ofSystem: TheFrench Impulse in Nineteenth Century American Medicine . By John Harley Warner. Princeton: Princeton UP, 1998. Pp. 510. $49.50. John Harley Warner's book, Against the Spirit ofSystem: The French Impube in Nineteenth Century American Mediane, asks a seemingly simple question: why did so many Americans travel to France to continue their medical education in the early 19th century? One might have thought they'd have gone to England, where there were fewer language barriers. Later in the century, they chose Germany over France. But from about 1810 until about 1860, France was the place to be. Warner's answer is complex. He characterizes the "Paris school" as "a celebration of empiricism," an attitude that he contrasts with the French "animus against rationalistic systems." The action was in Paris because Parisians were unwilling to accept theory without empirical evidence to back it up. They insisted that doctors needed to examine patients and perform autopsies, and they provided students with easy access to both patients and cadavers. They collected raw data about clinical presentations, and they correlated these with pathologic findings. All in all, this empirical approach fit well with Americans' pragmatism. Warner contrasts the Paris school with what was going on in London. Interestingly , it was not drat the doctors in London were less eminent, the schools less excellent, the therapeutics less advanced, or the science less rigorous. But the political and social atmosphere was different. In Paris, instruction was free. Government subsidies allowed anybody access to both lecture hall and laboratory in Paris, whereas London imposed hefty fees. Furthermore, "what principally drew Americans across the Atlantic was access to instruction from the living body at the bedside .' ' There was a spirit ofinquiry in Paris that contrasted with the spirit ofcommercialism in London. As one student wrote home, "In Paris, I am to study under the influence of men whose aim is science—at London, gain" (p.72). Finally, Paris was more of a meritocracy, whereas London was still an aristocracy. In Paris, as Americans noted, the appointment of clinical professors and interns was determined by concours, a democratic system ofcompetitive examinations that tested merit. In London , by contrast, American observers asserted that more often than not, clinical appointments for students were sold as part of a lucrative enterprise" (p.73). The early 19th century was a troubled time for American medicine. New scientific developments were changing the nature of medical practice. There were numerous schools of thought aboutwhat medicine ought to be and do and how doctors ought to be trained. American doctors who traveled to France came home with strong passions for a particular style of practice. In 1849 Walter Hayle Walshe, a physician with Paris experience who had translated Pierre Louis's treatise on phthisis, introduced his course on clinical medicine at University College Hospital by telling students that there were two categories of practitioner, "those who theorize prior to experience, and base treatment upon such theory—the so-called Rationalists; and those who, unbiased by preconceived notions, record, analyze, count and interpret the results of observation and the action of remedies—the Observers." And, Walsh asserted, "It is to the Observers, and not to Rationalists, that all die real üiumphs of our art are due" (p.225) . Warner notes that: "Epistemological positions became distinctly value laden, with empiricism and rationalism linked not only to divergent ways of knowing but more profoundly to integrity and dishonesty respectively . . . 152 Book Reviews Empirically determined medical fact was rhetorically identified with sincerity, honesty , authenticity, and above all, simple unadorned truth. On the other, rationalism was identified with deception, hypocrisy, and fraud, while its fruits were framed as captivating but ultimately false" (p.241). Perhaps the most interesting argument in Warner's book is in the chapter entitled "Science, Healing and the Moral Order of Medicine," where he shows that die attraction of Parisian medicine was not based on its medical outcomes. In fact, many Americans noted that Parisian doctors seemed more interested in the science of diagnosis than the arts of healing or therapeutics. Warner writes, "French clinicians , as Americans portrayed them, by and large placed little value on preventing suffering or preserving life . . . Surgeons were...