Two of the great figures of nineteenth-century medicine conveniently bookend one of the narratives of medical history that informs this essay. The first is the French physiologist Claude Bernard, who in 1865 published his seminal work An Introduction to the Study of Experimental Medicine. “It is … clear to all unprejudiced minds that medicine is turning toward its permanent scientific path,”Footnote 1 Bernard announced, arguing that such a path can “be established only by experimental means, i.e., by direct and rigorous application of reasoning to the facts furnished us by observation and experiment.”Footnote 2 Following the revolutionary impact of Pasteur's germ theory, first published in 1861, Bernard's approach exemplifies a belief in scientific method that would come to govern orthodox medical practice in the late nineteenth century. Looking back on that same period in 1901, William Osler – a Canadian born to British parents who dominated medical education in the United States during the 1880s and 1890s – would also characterize the nineteenth century as a period when scientific medicine (especially the fields of pathology, anatomy and physiology) would usurp the purely theoretical or superstitious thinking of the past. “The study of physiology … within the past half-century has done more to emancipate medicine from routine … than all the work of all the physicians from the days of Hippocrates,”Footnote 3 he told the Johns Hopkins Historical Club. One story of late nineteenth-century medicine, as framed by the figures of Bernard and Osler, is the story of the triumph of scientific principles.Footnote 4
Such neat characterizations are, of course, rarely the whole picture. It is important to emphasize that this is “one story” because important to my readings of Jewett and Phelps are the alternative (or “unorthodox”) paths that other medical practitioners often trod during this period. A pervasive cultural uncertainty about the sources of medical authority – in some parts of the country, even in the decades after the formation of the American Medical Association in 1847, “you were a doctor simply if you said you were”Footnote 5 – meant that the practices which scientific medicine sought to usurp still retained a foothold in everyday life. One important example of this is the ongoing existence of “folk practitioners,” usually female members of small communities who administered their own idiosyncratic methods of healthcare that tended to take the form of traditional herbal remedies or superstitious rituals. Alongside such practices, moreover, one could still find the lingering influence of more formalized medical fashions. Thomsonianism,Footnote 6 for instance, had been highly popular in rural areas of antebellum America, and in some senses was simply a more expansive and pseudoscientifically sanctioned form of the more disparate and localized folk medicine. In the words of one historian, Thomsonianism “epitomized the influence of rural botanical medicine,”Footnote 7 and perhaps because it appealed to these traditional forms of knowledge whilst also having a veneer of modern science, “[t]he many-faceted appeal of Thomsonianism enabled the movement to sweep through rural areas in all sections of the country.”Footnote 8
The continuing existence and belief in these forms of medical practice testify to the incompleteness of any one-dimensional story of postbellum medicine. Deborah Lupton, building explicitly on a Foucauldian framework, first summarises what she calls the “orthodox medicalisation critique”: modern Western medicine, “despite its alleged lack of effectiveness in treating a wide range of conditions and its iatrogenic side-effects, has increasingly amassed power and influence.”Footnote 9 This is essentially the story that Bernard and Osler would seem to personify, a unilinear advancement of institutionalized, scientific medicine. Lupton goes on to point out, however, that a more nuanced picture insists that there is “not a single medicine but a series of loosely linked assemblages, each with different rationalities.”Footnote 10 Rather than simply affirming the straightforward dominance of scientific medicine, an approach properly attuned to historical circumstances acknowledges the ongoing existence of “subjugated knowledges,” “knowledges that tend to be buried and disguised beneath more dominant, often more ‘scientific’ or ‘expert’ knowledge.”Footnote 11 The simultaneous existence of contradictory, competing sources of medical authority in the postbellum period illustrates this contentious account of medical practice.
This essay focusses, as the title suggests, on representations of country doctors in two postbellum novels – Phelps's Doctor Zay (1882) and Jewett's A Country Doctor (1884) – but it also gestures at, and, I hope, contributes to, the much wider series of debates about medical history that have been alluded to so far. As my introductory outline of the postbellum medical scene suggests, this essay argues that the ongoing, uneven and incomplete nature of the scientific–medical paradigm shift poses distinct issues for the literary representation of medical figures. In particular, it is the country doctors – and “country” here is as important as “doctor” – found in Phelps's and Jewett's novels that allow us to apprehend more fully the complex interaction between this historical context, literary representation, and the geographical dispersal of medical knowledge.
It is, therefore, the geographical dynamic at play in much of this medical context that is crucial, and as such I start with a fairly commonplace assumption: that cities act as the generating centre of modern medical practices and, more broadly, mature capitalist modernity itself. Whilst this idea is not simply dismissed – mainly because it is, on the whole, true – this essay suggests that representations of country doctors can complicate the picture by decentring it; by, in a sense, allowing us to trace and question the narrative of the rise of scientific medicine from a place usually assumed to remain beyond its epistemological reach. Moreover, the essay intervenes in literary debates by tracing how the medical context that both Phelps and Jewett were engaging with determined, constrained and embedded itself into the generic strategies of the texts themselves. In an effort to address both of these considerations, the argument is divided into two sections: first, the dialogue these works have with postbellum medicine as a historical context in itself, and second, the literary implications that arise from that dialogue. It is, however, the geography of modern medicine's production and legitimation that underpins and finally unites both of those strands.
Such a discussion might well turn for some theoretical guidance to what Michel Foucault has to say about the location of medical discourse in The Archaeology of Knowledge, especially as he has nineteenth-century medicine specifically in mind. His assertion, familiar enough by now, is that medical discourse is a specialized form of language spoken by the “statutorily defined” doctor figure, someone whose role is “an intermediary in the diffusion of medical knowledge.”Footnote 12 Most pertinent to my argument here, however, is Foucault's insistence that medical discourse is generated at “institutional sites” – he lists them as the hospital, the private practice, the laboratory and the library – that in turn form the “legitimate source and point of application” of that discourse.Footnote 13
We might also add that those sites are, especially in the nineteenth century, almost exclusively urban-based. The eminent nineteenth-century surgeon John Shaw Billings, for example, commented in 1875 that “[w]e have in our cities … physicians … [who] take good care to be supplied with the best instruments, and the latest literature,” physicians who, he claimed, were “the patrons of medical literature … the men who are usually accepted as the representatives of the profession.”Footnote 14 In the same year as Billings's statement, Thomas Eakins would exhibit The Gross Clinic (1875). Portraying the celebrated Dr. Samuel Gross attending to an operation on a man's thigh bone, Eakins's painting has become one of the most celebrated in American realist art. As a document of medical history, it portrays the deferential aura that surrounded figures like Gross and, crucially, shows the kind of site where pioneering medical work was taking place – in Jefferson Medical College on this occasion, situated in the heart of Philadelphia. Billings's comments and, more indirectly, Eakins's painting start to illustrate the urban-centric nature of scientific medicine both in the professional community and in the wider cultural imagination.
As the orthodox medical profession increasingly aligned itself with clinical and scientific approaches during the course of the postbellum period, so it inevitably became focussed in the medical institutions, laboratories, societies and libraries found in urban areas. Cities, after all, “provided an essential cultural milieu as well as ready access to the background work on which scientific activities are based.”Footnote 15 A modern, scientifically grounded and institutionalized medicine finds its home in the city simply because the city provides the density of people most conducive to developing bodies of knowledge, allowing for a “continual exchange of ideas, practices and objects.”Footnote 16 In the process of communicating that knowledge into provincial and rural areas, however (a process embodied in Phelps's and Jewett's country doctors), the city ceases to be a spatially delimited object and becomes the centrifugal centre of an ever-increasing “urban fabric”;Footnote 17 the originating site, in other words, of an increasingly incorporative and nationalized standard of medical knowledge. What, then, are the implications of an urban-centred medical profession for the figure of the country doctor, someone who seeks professional legitimacy but remains geographically tied to areas where the “nonscientific” and “subjugated” forms of medicine still retain some authority? More importantly in the context of this essay, what does the urban-centric nature of modern, scientific medical knowledge mean to the representation of medical figures who do not speak or operate from those privileged sites?
COUNTRY DOCTORS AS HISTORICAL PROBLEM
Doctor Zay tells the story of young Bostonian Waldo Yorke, who, on a trip through the “gentle fields … [and] pastures”Footnote 18 of rural Maine has a serious horse-riding accident and comes into the care of Dr. Zaidee Atalanta Lloyd – Dr. Zay, as she is known in the village she serves. Almost from the moment Waldo awakens from his short coma, his vulnerable position becomes clear to him and an ingrained suspicion of country doctors surfaces: “The thing which worried him most was the probable character of this Down-East doctor upon whose intelligence he had fallen … [H]e thought of some representatives of the profession whom he had met in the mountains, and at other removes from the centres of society” (38). Waldo is, in these early sections of the novel, established as a stereotypical urban dweller, viewing the rural landscape through touristic eyes but resisting provincial medical standards. What is more, that distrust is based around the assumption that rural villages like this one will lack the modern medical fashions and techniques he demands:
“I suppose there is n't a homœopathist short of Bangor?”
“Our doctor is homœopathy,” said Mrs. Butterwell, instantly on the defensive; “but you need not be uneasy, sir, for a better, kinder” –
“My mother will be so glad!” interrupted the young man, feebly. He gave a sigh of relief. “She would never have been able to bear it, if I had died under the other treatment.” (38–39)
Phelps undercuts the urban man's wariness of rural medical practice by defying his assumptions, placing a practitioner of a popular medical fashion in a rural – and assumedly premodern – setting. The passage hints at the geographical dimension of a particular contemporary concern: the controversy surrounding homeopathy had, by the 1880s, reached its zenith.Footnote 19 Homeopathy became fashionable amongst a wealthy urban clientele, mainly because its less invasive methods appealed to the delicate sensibilities of the postbellum middle classes: “By the end of the century, approximately 10,000 homeopaths – about eight percent of all practitioners – practiced throughout the nation. The homeopaths were concentrated in the urban states like Massachusetts, New Jersey, and Illinois.”Footnote 20
Waldo, coming from a wealthy Boston family, is clearly meant to represent this group of homeopathy's followers. He is more concerned with the method of his treatment than with its actual effects, and his mother seems to care less about whether her son lives or dies and more about the vogue of his treatment. The conversation, entwined in the cultural uncertainty about the nature of the various medical treatments on offer to postbellum Americans, is predicated, crucially, on a not-unreasonable assumption that such remote rural areas would not have a practising homeopath – the nearest one, Waldo assumes, would be in the city of Bangor.Footnote 21 Dr. Zay turns out, of course, to defy this assumption – an unlikely occurrence in rural Maine, and especially because homeopaths only constituted eight percent of all practitioners in the first place. While this links her to the kind of “unorthodox” medical practice that would eventually lose cultural credibility, it is a tie not to the kind of folk medicine associated with rural backwaters, but to modern medical fashions (and specialisms) that are predominantly associated with urban practice. In one sense, Dr. Zay unsettles any city–country binary by providing an epistemological bridge between the two.
She has been educated in cities, after all: first by following her father (also a doctor) around the laboratories of Bangor (87), and then in her formal education, which, she tells Waldo at one point, took place at “New York, Zürich and Vienna” (74). Her wider scientific interests also signal a particular modern consciousness, as when she discusses the “spontaneous movements of plants” with Waldo: “I have some books that you may like,” she says to her patient, “one of Darwin's especially” (103). It is a pointed reference, probably to Darwin's The Movements and Habits of Climbing Plants, which had first been published in journal form in 1865, and as a book in 1875. A related study, The Power of Movement in Plants (1880), is even more contemporary with Phelps's novel (published in 1882.) While Dr. Zay's homeopathic methods link her more to the urban arena of modern medicine than to any lingering influence of traditional folk medicine, her professional training and her awareness of current trends in scientific thought secure her as a figure whose medical authority is derived at least in part from the legitimizing knowledge economy of urban institutions.
In crucial ways, then, Dr. Zay is a country doctor whose medical legitimacy must be affirmed elsewhere, a figure who resists some aspects of orthodox medicine's march but who nevertheless finds her professional status reliant on modern urban networks. In an effort to balance the “country” aspect of Dr. Zay's position as a “country doctor,” Phelps counters this urban-looking tendency with a somewhat romanticized connection between Dr. Zay and the rural locale she inhabits. I want to return to the generic implications of this in a little while, but for now it is enough to cite a passage from the novel where the medical implications of such contrasts are implicitly present. One evening, Dr. Zay's rustic assistant and stable-boy Handy observes her through her office door:
Doctor Zay was sitting by her office table. A half-open drawer showed surgical instruments. Rows of vials exhibited mysteries of white pellets and powders. Medical books lay open underneath her hat and gloves … But Handy regarded these points with the apathy of familiarity … Doctor Zay, who drove the fastest horse in Sherman, who always knew by an awful omniscience whether you missed a pailful or shook the oat-measure … was bent and bowed over her office table, her face crushed into her resolute hands, as if she had been stricken down by a power that no man could see. (116–17)
Phelps seeks to construct Dr. Zay as a modern, professional doctor – signposted by the instruments and medical books – who also displays attributes apparently at odds with that status: traditional agricultural know-how and the emotional vulnerabilities of womanhood.Footnote 22 This characterization has led some critics to suggest that Phelps effectively posits a synthesis of modern scientific medicine with a sympathetic, nurturing femininity, so that the novel “imagines a spiritualized, deeply compassionate, feminized medical practice.”Footnote 23 The novel's cultural operation, in this interpretation, is to offer “an important antidote to the narrow thinking of modern science” by using “the wit of romantic comedy to underscore the unimaginative language of medicine.”Footnote 24
But there is an assumed opposition here between the clinical detachment of modern medicine and a more humane, sympathetic impulse. Whatever ways such oppositions may be read as gendered (as Baym and Browner do), the novel is just as intent on delineating this contrast as one located in a geographical divide: the apparent urban character of the medical profession, and the “rural virtues” of humane sympathy. In other words, Phelps's novel at times reimports a pastoral sensibility – what Raymond Williams calls a “romantic structure of feeling”Footnote 25 – that tempers the apparent impersonality of urban medicine by championing the community-based intimacy of rural life. While such a construction is firmly grounded in a literary tradition – an issue the final part of this essay addresses more fully – its application to a postbellum medical context feels, in the face of the geographically indiscrete flows taking place between urban and rural space, anachronistic and naive. Phelps recognizes that, within the social context of the 1880s, Dr. Zay needs to be part of a fundamentally urban-based knowledge economy if her status as a modern, professional doctor is to be legitimate and believable. Such a recognition, however, undermines the romantic associations and implicit ethical binary of a city/country divide. The city is no longer simply the site of a corrupted inversion of organic rural life: the two are entwined by their systems of material exchange and increasing cultural simultaneity. The historical moment in which the novel is grounded invalidates its apparent investment in a dehistoricized divide between city and country.
This intersection of geographical and medical issues is something addressed more directly in Jewett's A Country Doctor. The novel tells the story of Nan Prince, an orphaned girl in the village of Oldfields who is taken under the wing of local physician Dr. John Leslie, and who eventually trains to become a doctor herself. The text's awareness of the geographical dimension of medical knowledge (signalled first and foremost by its title) has been picked up in numerous critical discussions, but often only as a way to implicitly restate the romantic city–country associations just mentioned. Marjorie Pryse therefore reads Nan's teacher, Dr. Leslie, as epitomizing “the juxtaposition of the premodern in ‘country’ and the professional in ‘doctor’”;Footnote 26 from this perspective, Nan's choice to also become a country doctor similarly “reflects the intermingling … of country and city, of the premodern and the modern.”Footnote 27 Stephanie Browner sees the novel in an antimodern light, stating that A Country Doctor offers medicine as a cure to the “intellectual mediocrity, spiritual emptiness, and moral vacuity” of modernity, so that it “bridges the opposites that mark Jewett's fictional world – new and old, city and country … the individual and the community.”Footnote 28 These readings seem not only to hypostatize the terms of their analysis, positing a simplified binary between city and country even as they seek to undo it, but also to read Jewett's novel uncritically on its own terms.
Considering instead the more specific medical context that the novel engages with, we get a clearer understanding of the problematic conjunction of literature, geography, and medicine. This is not to say that A Country Doctor does not construct some overt differences between urban and rural life and the ways in which these differences inflect constructions of medical knowledge: the central plot is really a kind of Bildungsroman concerning the medical education of Nan Prince,Footnote 29 and seems to attempt, aesthetically and thematically, a realistic portrayal of a child growing up in New England who becomes a respected female doctor. On the surface at least, the novel places its sympathies squarely with the rural way of life it represents; the pastoral setting of Nan's childhood therefore becomes directly indicative of her sympathetic impulse to heal. Elderly village stalwart Mrs. Meeker, for instance, describes Nan's surprisingly mature girlhood activities: “I [saw her] yisterday, and one of the young turkeys had come hoppin' and quawkin' round the doorsteps with its leg broke, and she'd caught it and fixed it off with a splint before you could say Jack Robi'son”.Footnote 30 Nan is later described as having an “aptness” (109) for medicine, and that as a child “she had been nicknamed ‘the little doctor’” (109). Passages like these evoke, of course, a standard romantic construction of the intuitive child of nature, and do so in a way that echoes the communal, humane connotations of folk practitioners. The origin of her medical knowledge is therefore implicitly situated, not in the institutional sites of urban scientific medicine (what Foucault calls the “legitimate sources”), but in her subjective rural intuition.
Such an alignment becomes a defining narrative tension. In a conversation between Dr. Leslie and his well-travelled colleague Dr. Ferris, the latter lightheartedly warns Leslie about introducing Nan to too much scientific theory, recognizing its changeable and unstable qualities: “You surely aren't going to sacrifice that innocent creature to a theory! I know it's a theory; last time I was here, you could think of nothing but hypnotism or else the action of belladonna in congestion and inflammation of the brain” (71). While Jewett recognizes the tendency for medical theories to quickly become discredited as medical science advanced in the postbellum period, that pejorative use of the word “theory” suggests a certain suspicion towards the apparent advancement of orthodox medical knowledge to begin with. Along with the suggestion that Nan's innocence would be “sacrificed” to these theories, the statement posits a romantic desire for the intuitive child untouched by the corruptions of overcivilization. When Dr. Leslie describes Nan sitting and reading one of his old medical dictionaries, a similar point is raised:
I couldn't help looking over her shoulder as I went by, and she was reading about fevers … as if it were a story-book. I didn't think it was worth while to tell her we understood things better nowadays, and didn't think it best to bleed as much as Dr. Rush recommended.Footnote 31 (72)
Nan's youthful curiosity (not to mention precociousness) brings her to reading material that seems appropriate for a science-minded child, yet the status of that science as modern is nullified by its obsolescence and trivialization as a “story-book.” Laying the foundation for a plot that must legitimate and valorize Nan's eventual status as a country doctor, the child is presented as a figure well read in medical sources and yet preserved as essentially innocent and antimodern by the distancing of those medical sources from contemporary scientific debates. The narrative constructs Nan as “scientific,” but also as connected to some innocent essence that exists beyond the impermanence of science. The sense of medicine's uneven and contested progression towards a more scientific basis is therefore something the novel seeks to evade in its efforts to install a simplified contrast between rural and urban knowledge spheres: it irons out the intricacies and complexities of medical authority by constructing a science/sympathy divide that aligns with a similar urban/rural divide.
Yet the novel cannot finally escape the fact that by the 1880s medical knowledge and medical authority were things profoundly connected to the growing urban world. Jewett attempts, like Phelps, to construct a country doctor who is also a legitimate medical figure, but recognizes that that legitimacy requires an engagement with a knowledge economy based beyond the rural setting. Sources of knowledge are therefore city-based, transmitted into rather than emanating from rural space: a new book Dr. Leslie is reading at one point, “a stout French medical work of high renown” (84), has been sent from New York; trips to Boston are a necessary pleasure because there he can “visit the instrument-makers' shops, and some bookstores,” or the “Athenæum library” (102); and when the issue of Nan's medical education arises, he acknowledges that the two of them are separated “from the groups of men and women who are responsible for what we call the opinion of society” (121). Even when Dr. Leslie has taken Nan to her medical college in Boston and begins the lonely ride home, he is content that he has “provided himself with some most desirable new books” (129). The “high renown” of that French medical work and the desirability of the books he picked up in Boston point not only to the centrality of the urban arena in the physical exchange of medical material, but to the geographical reach of an urban-based system that sanctions modern medical knowledge.
These all suggest the material reasons why urban medical practice is the defining site of medical legitimacy, underlining the point made earlier about the city allowing for a “continual exchange of ideas, practices, and objects.”Footnote 32 On a more abstract level, however, the modern scientific medicine of urban practice serves as a meta-discourse underwriting any claims to medical authority; even Dr. Leslie, who seems dedicated to his country practice, had only taken up the post “somewhat unwillingly” and now relies on a network of knowledge exchange that links him to urban medical practice. He studies alone in his quiet country village, but the medical research he performs is only validated by its recognition in the wider medical community: “little by little he gained great repute among his professional brethren” (65), urban colleagues who “thought it a pity” that he should “be burying himself alive” in “provincial life” (65).Footnote 33 Jewett suggests that rural-based medical research can also be respected as modern and professional, but the historical circumstances in which she was writing dictated that the status of “modern knowledge” could only be bestowed by the urban-based medical profession.
Dr. Leslie's recognition of urban institutions as an increasingly necessary site of authorization means that he must maintain a dialogue with his urban colleagues to ensure a legitimate career path for Nan: “For her sake he reached out again toward many acquaintances from whom he had drifted away, and he made many short journeys to Boston or to New York” (127). It is, as well, to an urban medical school that Nan must travel – Wegener suggests that Jewett had the New England Female Medical College in Boston in mindFootnote 34 – in order finally to fulfil her “natural” talent: “she must enter the medical school to go through with its course of instruction formally, and receive its authority to practice her profession” (128–29). The point is finally made explicit here: for all of Nan's folksy medical abilities, for all of her romantic characteristics, her position within the medical profession is only secured or made tenable by submitting to the authoritative processes of modern, scientific medicine.
In writing a novel about a country doctor that celebrates the legitimacy of rural medical practice, Jewett cannot help but record and acknowledge that the source of that legitimacy lies in the modern expansion of an urban-centred knowledge economy. The point about the city's installation as the “essential cultural milieu” of scientific progress prescribes any attempt to represent a country doctor in late nineteenth-century fiction. The contemporary social context of medicine which frames Jewett's narrative, like Phelps's before, disrupts the attempt to imbue Dr. Leslie and Nan with dehistoricized “rural virtues.”
COUNTRY DOCTORS AS GENERIC PROBLEM
There is also, implicit in my discussion until now, a way of exploring the same issues through a more specifically literary focus. The connections between literary form and geo-medical issues are not easy to trace, but there is a crucial element to this argument that brings these strands together and illustrates not just the historical conditions outlined so far, but precisely why literary texts offer a distinct way of coming to terms with them.
A good way into such a discussion is the descriptions of the Maine countryside found at the beginning of Doctor Zay, when Waldo's gentle horse ride is described in particularly heightened literary rhetoric:
Forest and sea vied to win his fancy … He became, perforce, a worshipper in Nature's cathedrals … Galleries of wonder beckon you on … Sketches which Nature seems to have begun, but never cared to finish, unfold before you, vast, imperfectly interpreted, evanescent … Motionless cattle in the pastures, stray, solitary children on the fences … pass him by rhythmically. (9–11)
The heavily romanticized language of such a passage is clearly embroiled in a complex relationship with the position of both the character being narrated and the narrative voice itself: Waldo seems to achieve a sublime oneness with a personified nature, yet the elevated register in which the passage is narrated – the rest of the novel, mercifully, does not keep up this level of romantic gush – clearly indicates that such a vision of nature is knowingly exaggerated. There is a geographical element clearly at play here, in that Waldo is implicated as yet another urban tourist who romanticizes the scenery of rural Maine (his comeuppance arrives in the form of a near-fatal riding accident), and in the process the narrative positions itself to imply a default realist standard from which Waldo's position is being judged.
Such generic positioning is hardly unusual for 1882, and certainly not in a novel set in contemporary times representing a modern professional at work – a classic realist subject. Moreover, and particularly significant in the context of this argument, the ascendancy of realism as the dominant literary mode of the era is mirrored in the world of professional medicine itself. Lawrence Rothfield has been the most convincing of the critics to argue that realism as practised in the literary-aesthetic sense shares a fundamental connection with the increasingly scientific nature of medical practice in the nineteenth century. Capturing reality means, after all, “maintaining faith” that details and particularities are typical and shared “in the same way that medical diagnosis assumes that signs and symptoms will resolve into cases of disease.”Footnote 35 Equally, Rothfield adds, “realism's sincerity is analogous to the disinterested benevolence claimed by the medical profession.”Footnote 36 As realism became the dominant literary mode in American fiction during the course of the postbellum period, so its fundamental aesthetic strategy of authorial distancing finds a counterpart in medical practice's own shifts. But as the account of postbellum medical history given earlier revealed, and as the opening of Doctor Zay begins to suggest, both of these apparently linear narratives of change are far from the whole story. Just as orthodox scientific medicine existed simultaneously (and often antagonistically) with other, competing forms of medical knowledge, so realism was merely the most prominent generic mode amongst others operating within the fiction of the 1880s.
There is a coming together here, in other words, of the three crucial elements of this argument: the postbellum medical context, the geographical element at play in that context, and the intimate connection of these two things to the literary strategies of the works in question. A further look at the passage from Doctor Zay, quoted earlier, where Handy observes her sitting in her office, reveals that at times all three elements are present at the same moment. The material signifiers of Dr. Zay's modern professional status – the surgical instruments, the anonymous medicines and the medical textbooks – are narrated in the affectless prose and single-clause sentences of self-conscious realism. The focal shift to Handy's point of view, however, is a shift to a more emotive and subjective characterization, narrated in adjective-heavy prose, which emphasizes Dr. Zay's rural status: she drives the “fastest horse” in the village, has an experienced knowledge of country customs, and is stripped of her professional veneer by her human vulnerability. The oscillation between romantic and realist idioms is one linked to the unsettled medical context that frames the narrative, that is itself imbued with a geographical element that feeds back into those same generic shifts.
Even the structure of the novel is implicated in these issues. Cynthia Davis points out that from mid-century on there was a growing belief in the need for an “empirical and non-reciprocal” relationship between doctor and patient,Footnote 37 or, as Paul Starr puts it, “One way of looking at the changes that took place between the 1870s and the early 1900s is that the social distance between doctor and patient increased”Footnote 38 – a problematic context for a story whose narrative arc works in exactly the opposite direction. The realist stance that the novel adopts has to give way as Dr. Zay and Waldo become emotionally closer. The first half of the novel is mainly concerned with Dr. Zay's treatment of Waldo, and contains the most medically oriented parts of the plot as well as a repeated emphasis on the professional distance between the doctor and her patient. Halfway through, however, the tone changes; now we have a fairly standard love story, emptied of most of the medical descriptions that mark the first half and ending in the inevitable union of doctor and former patient in their idyllic village setting. While the novel superficially appears, as Michael Sartisky claims, to adhere to the Howellsian realism of the 1880s,Footnote 39 the truth is something less straightforward. The “realistic” representation of a country doctor in this historical context entails an acknowledgement of an increasingly complex medical profession, but it is that acknowledgement that threatens to undermine the generic stability of the text itself.
In the end, Doctor Zay cannot quite reconcile this tension, so that what Nina Baym sees as Dr. Zay's “deeply compassionate … medical practice” is really Phelps's attempt to marry two incommensurate things: the increasingly urban character of medical knowledge and the romantic associations of a pastoral setting. The novel's interest in literary-historical terms lies in this formal conflict, because deeply embedded in these issues are traces of the ongoing, uneven and incomplete transitions of modernity itself; it is testimony, in its very failure, that there are no simple narratives to tell of the medical, geographical and literary transformations of the postbellum years.
A Country Doctor grapples with these same generic and formal problems. In a much more overt way than Phelps, Jewett evokes a literary pastoralism as a way of linking her principle character, Nan, to a romanticized vision of childhood:
the young girl quickly crossed the rude stile and disappeared among the underbrush, walking bareheaded with the swift steps of a creature whose home was in such a place as this … [T]he birds which she had startled came back to their places directly, as if they had been quick to feel that this was a friend and not an enemy, though disguised in human shape. At last Nan reached the moss-grown fence of the farm and leaped over it, and fairly ran to the river-shore … [where] the old cedar held its many branches above her and around her. (111)
Such passages emphasize Nan's innate connection to the rural landscape at the same time as constructing that landscape in romantic terms: the “rude stile,” the personified birds, the “moss-grown fence” and the cedar are quintessential touches of pastoral scene-setting. In creating an idyllic rural origin for Nan, Jewett is securing her in a position that will soften her later medical status – attempting, in other words, to imbue the rational scientism of Nan's professional career with the humane connotations of her rural upbringing. The novel nods towards a romantic aesthetic, represented most typically by the figure of an innocent child, while its frames of reference and idiomatic register – the medical context quoted earlier – are invested in a realist one.
Jewett constantly tries to represent Nan as grounded simultaneously in both an idealized, community-oriented rural life and the progressive world of scientific, professional medicine, a meeting (to put it another way) of a literary sensibility with a historically specific medical context. When Dr. Ferris talks of his distaste for “book learning” because it takes “one to more theory and scientific digest rather than to more skill,” we are aware once again of the confluence of medical, geographical and literary spheres that compete within this complex vision: “It is all very well to know how to draw maps when one gets lost on a dark night … but hang me if I wouldn't rather have the instinct of a dog who can go straight home across a bit of strange country” (74). Modern scientific medicine, in Dr. Ferris's characterization, gives rise to a series of new theories and textbooks that all vie for authoritative status. One answer to this confusion is to rely not on the objective bodies of knowledge posited by medical education, but on subjective and intuitive knowledge. Dr. Ferris's contrast is, tellingly, between a cartography that seeks to represent mimetically an external, objective reality – the stated aim, and ultimately doomed project, of realism – and the reliance on subjective instinct to navigate through space that is essentially “strange,” a move that gestures at romanticism. The novel replicates on a generic level a point made earlier about its thematic content: it strives to retain the legitimacy of scientific realism even as it also strives to retain some connection to a pastoral romanticism.
Nina Baym's reading of the novel condenses many of the points I have been discussing: “Through Dr. Leslie's views of medicine, which Nan adopts, A Country Doctor attacks modern medicine as a materialist, competitive, faddish, theory-driven, status-hungry departure from the pastoral ideal of the doctor as counselor, confessor, and spiritual healer.”Footnote 40 In explicitly referring to the “pastoral ideal,” Baym hints at the geographical frame of analysis employed here without following through on its implications. These novels operate within a particular historical situation: the coming-into-being of a scientific medical orthodoxy that focuses its legitimating institutions in urban settings, even as the standardizing influence of those institutions extends the notion of “the urban” beyond its physical boundaries. It is this context, I finally want to argue, that constricts these novels on both a thematic level – the source of medical legitimacy, and therefore the legitimacy of the characters themselves, lying beyond the idealized connotations of the story's setting – and a generic one: the need for a return to romantic motifs within a literary-historical moment that venerates realism. It is these very problems, however, that serve to encode some of the complexities of postbellum medical and literary history in a way that destabilizes simplistic or teleological historical narratives. In the medical issues they embody, and not least in the thematic and generic instabilities they provoke, Phelps's and Jewett's country doctors stand as significant coordinates in a geography of medical knowledge that maps the transformed cultural and spatial relations of postbellum America.
