9 Paradigm Lost or Paradise Declining? American Physicians and the ‘Dead End’ of the Paris Clinical School John Harley Warner By the middle of the nineteenth century, Erwin Ackerknecht asserted in Medicine at the Paris Hospital, 1794–1 848 (1967), ‘French medicine had maneuvered itself into a dead end , as all empiricisms had done so far in medical history’. 1 Somewhere in the course of drafting his text Ackerknecht adjusted the date of that event from 1850 to 1848, bringing his medical story into line with a political narrative. 2 ‘By 1848, Paris “hospital medicine” had come to a dead end, its momentum spent’; the Paris School, the dust jacket put it more luridly, was ‘swept away by the Revolution of 1848’. 3 In more recent years, both his depiction of the Paris School and the discontinuity implied by its putative dead end have been drawn into question. Our emerging image of the Parisian medical world of the first half of the nineteenth century is more complex than Ackerknecht’s bold portrait – far less monolithic in its consecration to radical clinical empiricism and exclusion of the basic sciences, for example – while the notion that exhaustion of the empiricist programme brought the whole thing to a dead end has begun to appear overstated and simplistic. It is surprising, therefore, that what Ackerknecht invoked as the most powerful testimony to a dead end – the massive shift in the stream of foreign medical students that once flowed into Paris toward German cities instead – has remained little questioned. The imposing influx of German, British, and American medical practitioners into Paris after the peace of 1815, according to Ackerknecht’s interpretation, offers unambiguous evidence of the intellectual vibrancy of the Paris Clinical School. Equally, the redirection of students after mid-century from France to Germany – that is, to both the states that later would form a unified Germany and other 337 Paradigm Lost or Paradise Declining? German-speaking centres in Austria-Hungary such as Vienna – is a clear indication that the vigour of the Parisian medical model had been spent. ‘French medicine paid for its practicalism, clinicism, and conservatism by losing its superiority to Germany’, Ackerknecht asserted, a loss of supremacy the shift in migration betokened. 4 With the creative promise of the Parisian empiricist programme lost, those abroad in search of medical science at its cutting edge duly abandoned Paris in favour of the next ascendant centres in Germany, where the laboratory-based medical sciences ostracized by the Paris clinicians were vigorously cultivated. Others have shared this interpretation. Historians of American medicine, for example, charting the transformation from its ‘Paris period’ to the German period that followed, have seen the shift in itinerary of American physicians abroad both as evidence of the shifting balance of intellectual power in medicine and as among its inevitable consequences. 5 The shift in destination of American physicians was real enough, but its interpretation is rather more problematic. Ackerknecht assumed, without analyzing, the motivations that lay behind the migration of American doctors. In particular, he assumed that French superiority in medical science, so celebrated by the Americans, was what attracted them in such large numbers to Paris, just as the supplanting of French by German medical leadership was what redirected their travels to Vienna and Berlin. As the French medical model brought Paris to its dead end, the power of the Paris School to attract students waned, while at the same time the ascendancy of the German medical model made Vienna and Berlin natural destinations for American physicians pursuing study in Europe. It is the underlying assumption that what attracted students to one centre rather than another was the prospect of studying at the cutting edge of Western medicine that gives migration its utility as an index of the rise and fall of the Paris School. My objective here is to begin to reassess these assumptions – and thereby the conclusions based on them – by looking closely at the experiences and perceptions of the American medical migrants to Paris. My starting premise is that the reasons why Americans journeyed to Paris cannot be equated with the stories they later told about its significance or the meaning they came to attach to their studies there. We must look instead at what they actually did, at what they most valued in Paris, and at the process of decision- making that informed their choices, recognizing that they were selective reporters who sometimes misunderstood the French system and its workings. To comprehend why they travelled in such 338.