George Weisz is a Professor of Social Studies of Medicine at McGill University. In his book, Divide and Conquer: A Comparative History of Medical Specialization he traces the origins of modern medical specialization to 1830s Paris and examines its spread to Germany, Britain, and the US, showing how it evolved from a feature of academic teaching and research into the dominant mode of medical practice since the 1950′s. In the excerpt below we look at the beginning of specialization in America.
Few of the conditions that produced specialization in early nineteenth-century Paris existed in the American states of this era. Neither hospitals nor the few medical schools in existence at the time were publicly controlled or very large. Consequently they faced few of the pressures for administrative rationalization that promoted specialization on the European continent. Nor was there much incentive to create research communities on the Paris model. As Tocqueville famously perceived, Americans valued practice over theory, and this applied as much to doctors as any one else. John Harley Warner describes the negative response of Dr. James Jackson, Sr., to his son’s desire to spend several years in Paris pursuing clinical research, and explains: “for an American physician scientific investigation was not a legitimate substitute for practice.” It is thus hardly surprising that we have few indications of significant specialty development during the first half of the nineteenth century. What is perhaps more astonishing is the swift spread of specialization in the years that followed.
There is no evidence for the significant development of specialties in the United States before 1855. Historical studies of pre-Civil War American medicine are almost completely silent on the subject. … no national medical directories existed at this time, but several collections of medical biographies, while not representative of the profession as a whole, suggest how little specialized elite American medicine was at midcentury and how speedily this situation changed in the following two decades.
Stephen W. Williams’s collection of medical biographies appeared in 1845. His 104 subjects were all deceased, which meant that many had pursued their careers in the eighteenth or early nineteenth century. As one would thus expect, there is little mention of specialist interests. Only two traditional domains are occasionally described in peripheral ways: surgery and obstetrics. John Bartham was a general practitioner who “obtained some celebrity in the practice of surgery,” and Andrew Harris was the most distinguished surgeon in eastern Connecticut. Thomas James was “a distinguished obstetrician”; William Potts Dewees was “[f]avorably introduced to the citizens of Philadelphia as a practitioner, and to the professional public as a teacher of, the science of obstetrics, his practice became extensive.” Several individuals directed asylums, but only Eli Todd “devoted his life to the subject of insanity” and to “diseases of the brain and nervous system.”
In the context of American medicine, the desire to limit practice along European professional lines can look to historians like an early precursor of specialization. In contrast with the situation in Britain, where the medical elite was sharply divided institutionally between physicians and surgeons, with accoucheurs becoming increasingly distinctive, the norm in the sparsely populated United States was to combine all three branches (often with drug-dispensing as well). But as cities developed, the separation of activities became more feasible. In 1765, after spending five years studying medicine abroad, John Morgan publicly announced that he would limit his practice to physic and renounced surgery and drug-dispensing. His action, like his stated justification that each of these activities required distinct skills, can be seen either as an attempt to import the professional divisions of eighteenth-century Europe into the colonies or as a foreshadowing of the logic that would drive specialization a century later. There is, however, no question that surgeons became an increasingly visible and distinctive category of practitioners in the nineteenth century and that the process of segmentation continued in major cities.
A half-century after Morgan’s declaration, the Boston physician James Jackson, having already renounced the practice of surgery, felt called upon in 1818 to send a letter to his patients to explain why he was also renouncing the practice of obstetrics. While such a limitation was not unknown in other cities, he wrote, “[i]t has not been the custom here.” The reasons he offered for his action were not dissimilar to those that would apply to later specialists: the unpleasantness and physical difficulty of certain activities; the greater perfection that could be achieved by concentrating on a single field; the need to adapt his practice to the teaching and research duties associated with his university professorship in medicine. Such motives would be invoked for the ever narrower forms of specialization that gradually made their appearance. But until much later in the century, the most common form of specialist practice involved emphasis on a particular field within a predominantly general practice. Thus Jackson’s younger colleague Walter Channing received special training in obstetrics in Scotland and Britain and set himself up as one of the leading obstetricians of Boston. All the while he maintained a general practice and served as first assistant physician and then physician at the Massachusetts General Hospital.
There is also a dearth of specialists in Samuel David Gross’s edited volume, Lives of Eminent Physicians and Surgeons, published in 1861. Here there are essays on thirty-two deceased American medical men. Among these are a considerable number of surgeons, but only five individuals presented as having some specialist interest.
Thomas C. James, who held the first chair in midwifery in Philadelphia, was described as an obstetrician. Jacob C. Randolph was characterized as “devoting himself to the treatment of stone in the bladder.” Daniel Drake was presented as an all-round physician but especially as a distinguished oculist who had “acquired no little skill as an ophthalmic surgeon.” In the case of Charles Frick, “urinary pathology had become a favorite subject with him.” Amariah Brigham was not described as having any special interests, but the career discussed was nonetheless centered on asylum posts and psychiatric publications. Gross’s collection suggests only a modest development of specialization during the first half of the century. The impression that this was indeed the case is confirmed by William Atkinson’s 1878 work briefly describing a large number of living practitioners, the “real workers in the profession,” who “by their work had brought themselves more or less prominently to notice.” A little less than 20 percent of those profiled were described as having some sort of specialty interest. (If we add those whose careers consisted of an unbroken series of specialist posts even if a specialty was not specifically invoked, the figure is slightly higher.) These figures include surgery, treated by now pretty much like any other specialty interest. Atkinson’s essays suggest clearly that certain forms of specialization had become widespread by the 1870s, but they also confirm that this was new. Most of those described as specialists obtained their MD diploma after 1850 and did not necessarily begin practicing as specialists until after 1860. Very few obtained their medical diploma before 1840.
Atkinson’s list is fragmentary and cannot be taken as a representative sample of American doctors during this period. Nonetheless, it suggests a number of general observations.
As was the case almost everywhere else, surgery was a pivotal category because it existed long before specialization as one of the two basic divisions of medicine. Once it became possible to think of medicine as divided into specialties, surgery eventually became the largest, and in many ways prototypical, specialty. Similarly, obstetrics loomed very large in the development of specialist self-consciousness because it had been established as a distinctive medical activity since the eighteenth century. By the nineteenth century, in the United States as elsewhere, it was represented by lying-in hospitals and professorships in medical schools. When the American Medical Association was founded in 1847, it immediately treated midwifery as a distinct professional category.
Obstetrics traditionally included diseases of women and young children within its boundaries. But by midcentury, gynecology was on its way to becoming an autonomous medical category and was becoming very visible among the budding specialties in America. Among Atkinson’s subjects who took their MD after 1845, more than one-third included “diseases of women” or “gynecology” among their specialty interests. In many cases this was combined with midwifery, but in many others it was not. Similarly, in a Philadelphia Medical Directory of 1885, nearly 30 percent of those who identified themselves with a specialty used one or both of these terms.
Gynecology, like other specialties in the United States, based its claims to acceptance on the need to advance medical science and invent new procedures. But there also existed a strong utilitarian orientation among specialists that was less strongly developed in countries where hospitals were public institutions. The fact that American hospitals were philanthropic establishments appealing to patrons for support meant that they had to be seen to offer medical procedures that provided significant practical benefits to the deserving poor. One model for specialty development was for an early specialist to develop a procedure, build a hospital or dispensary around that procedure, and then pursue further clinical research. This is the pattern followed by the pioneering gynecologist Marion Simms. As is well known, Simms spent several years in the late 1840s experimenting on women slaves in order to develop surgery to repair vesico-vaginal fistula. Several years later he moved to New York City, where in 1855 he convinced prominent citizens to fund the Woman’s Hospital, which was largely devoted to fistula surgery. This hospital was presented, Deborah Kuhn McGregor has suggested, as a philanthropic effort to alleviate the suffering resulting from childbirth. It went on to become a place for both charitable care and further clinical study and research.23 Although this was not reflected in Atkinson’s book, ophthalmology also seems to have constituted an important early specialist category in the United States, due to the capacity of its practitioners to combine scientific and philanthropic impulses.
George Frick of Baltimore is generally considered the first American practitioner to study in Vienna and to then restrict himself to ophthalmology (from 1819). By the 1820s several American cities had infirmaries, dispensaries, or hospital wards devoted to eye diseses. This early activity almost certainly reflected widespread familiarity with medicine in Britain, where a large number of eye hospitals were founded during the same period. A small number of difficult but frequently successful procedures—notably removal of cataracts, therapy for lachrymal fistula, and removal of objects embedded in the eyes—provided specialists with activities requiring considerable skill, alongside more routine treatments for inflammations and infections utilizing topical and systemic medications. This allowed founders of eye hospitals to present their activities as immediately beneficial means to combat blindness. Thus the appeal to the public in 1823 of George McClellan’s unsuccessful Hospital for Diseases of the Eye and Ear in Philadelphia argued that in London and Vienna, “[t]housands have been annually relieved and cured of diseases of the eye and ear, who otherwise would have lost the use of these all important organs and proved a burden to themselves and to society.” Similar sentiments were expressed by Henry Noyes in publicizing his New York Eye and Ear Infirmary, founded in 1820.28 Such utilitarian motivations did not, of course, preclude the advancement of knowledge. On the contrary, Isaac Hays published regular reports on Philadelphia’s Wills Hospital (where he had an appointment) in his American Journal of Medical Science. “It is unquestionably in such institutions that these diseases can be studied with most advantage, and we hope in these reports, especially should our colleagues unite in the plan, that most of the forms of the disease to which the eye is subject will eventually be illustrated.”29 Following the invention of the ophthalmoscope in 1851 and the publication of Donders’s work on refraction, ophthalmic clinics in Vienna began attracting many American doctors and the field took on especially high intellectual stature.30 In 1864 its practitioners organized one of the first specialist societies in the United States.
Finally, it is worth noting that in the United States, as elsewhere, the spread of lunatic asylums provided the institutional foundations for the relatively early visibility of psychiatry. However, the fact that we identify so many of these practitioners from institutional appointments and publications, rather than specific references to special interest in the diseases of the insane, suggests that many early practitioners defined themselves primarily as administrators of special institutions rather than as specialists producing new knowledge. Whatever its basis, their sense of identity was real and was bolstered by the early foundation (in 1844) of a professional society, the Association of Medical Superintendents…they kept their distance from the AMA and the medical profession more generally into the practice of more ambitious generalists.