Journal of the Early Republic

Catherine Thompson's book has two primary goals: to demonstrate that patients played an active role in shaping both their own care and the development of therapeutics; and to show that physicians' practice in the early republic was shaped by both science and market forces. She argues that patients' religious backgrounds and expectations about cure shaped their relationships with physicians and the circumstances under which they chose professional care rather than (or in addition to) help from lay practitioners. Physicians' practice was shaped by shifting ideas about physiology and appropriate treatment, but also by individual relationships with patients, the need to make a living in an economic environment that was steadily replacing traditional payment practices with fees for service, and the threat of malpractice. Ultimately, Thompson only partially supports these arguments: The book provides enough evidence to justify most of her assertions, but does not provide enough detail about either therapeutic practice or the patients themselves to make the [End Page 160] study feel complete or compelling. There is much here to praise, but the work is not as substantial a contribution to the literature as Thompson's primary sources suggest it could have been.

Thompson places her work against a backdrop of medical history that describes the early republic as a period in which "heroic" therapeutics gradually gave way before practices that were increasingly informed by European medical practice and by modern scientific knowledge. Focusing on Massachusetts, Thompson argues that the nineteenth-century shift away from heroic therapies to an emphasis on milder drugs and an "expectant" approach to treatment that made space for the body to heal itself, was driven as much by patients' expectations and demands as by the march of medical science or the ideas of medical professionals. Scholars of medicine in the colonies and early republic have long understood that public mistrust of European intellectual and cultural authority helped to shape colonists' suspicion of medical authority, and the spread of almanacs and popular health manuals supported early Americans' insistence on self-medication. Thompson's work adds nuance to this narrative by examining the ways in which medical practice was also shaped by market forces. The commercializing/industrializing economy made cash payments for treatment more desirable, and doctors were beginning to think of themselves as businessmen as well as scientists: They needed to market cures, attract patients, maintain relationships with clients, and increasingly to collect fees in cash rather than exchanges. Patients in turn made more frequent use of the courts to sue for malpractice, and court records have much to tell us about differing expectations for cure as opposed to mere relief of symptoms and about the role of medical authority in the diagnostic process and of physicians in communities. Patients' expectations for the results of professional treatment were shaped by their own experiences within an increasingly commercialized economy and by their religious background.

Thompson has much rich material and an important contribution to make to our understanding of medical practice and the experience of the patient in the early republic, both by giving patients more agency and by employing a quantitative analysis of physicians' case records. Yet Thompson fails to fully explore the implications of her data (much of it included in appendices) or to clearly and fully tell the story she outlines. Physicians' records could have been much more effective in augmenting historians' understanding of the circumstances under which patients chose to supplement self-medication with professional consultation, and [End Page 161] the influence of patients, had Thompson connected the data on physicians' prescribing patterns to physicians' records documenting their negotiations with patients. She alludes to scholarship on patient– physician relationships in Massachusetts General Hospital, but fails to mine that work for comparison in her own explication of patient agency in diagnosis and treatment. Similarly, the chapter on economic influences on practice and physicians' growing perception of themselves as economic as well as professional actors reads as a general discussion of the issues clearly informed by the work of Christopher Clark, with much less discussion of the physicians whose records she examined.¹

Thompson's quantitative evidence on therapeutic practices suggests a complex web of relationships that could usefully illuminate the disconnect between professional prescription and regional or local practice, but Thompson does not sufficiently examine remaining records from these physicians to further explicate their ideas about treatment, even though the introduction makes it clear that the records would support such examination. Nor does Thompson flesh out the cases of individual patients beyond quotes that suggest there is much more to these stories—a difficult task, but one that would have made a stronger book. The chapter on malpractice has much rich material, but the sheer number of cases and shifting back and forth between decades and concepts makes both the thread of Thompson's argument and her discussion of the development of legal theory and practice challenging to follow at times. The chapter on religious background is also underdeveloped: Thompson's argument that religious background informed patients' ideas about cure and their expectations shifted in the course of the nineteenth century from an acceptance of illness as God's will to expecting a complete cure from illness is sound, but she does not support the argument fully or connect it sufficiently to the rest of her discussion about patients' relationships with physicians.

Thompson frames the study as challenging the work of earlier historians whose work focused on therapeutics from the perspective of physicians, focusing the reader's attention on that (unnecessary, if not largely false) conflict rather than Thompson's real insights. Charles Rosenberg's work on John Gunn, John Harley Warner's on regional differences in [End Page 162] practice, and Thompson's own work all demonstrate that there is no consensus among historians on the decline of heroic therapy—scholars have recognized for some time that individual physicians reconciled their own scientific knowledge and training with the real world of practice and their relationships with local folk practitioners.² This study would be much more effective if Thompson emphasized her work's insight into patients' expectations as one of the complex forces shaping therapeutic change, rather than challenging a master narrative that excludes patients altogether.