Our Present Complaint: American Medicine Then and Now (review)

The suffering associated with disease has always been the province of medicine, and disease has always been invested with social meanings that transcend medicine. Western interpretations of disease and its role in human life underwent a major shift with the advent of scientific medicine in the early nineteenth century; that shift has brought immeasurable gains in medicine’s efficacy and lasting dissatisfaction with the interpretive consequences of the reductionism that made those gains possible. Such are the roots of Our Present Complaint, Charles Rosenberg’s most recent collection of essays.

Pre-modern conceptions of disease focused on the balance of forces in the individual sufferer, a balance susceptible to disruption from social and behavioral as well as straightforwardly physiological causes. Risk for disease was, as Rosenberg puts it, configured in idiosyncratic, multi-causal, and contingent terms. Physicians took cognizance not only of physiology but of lifestyle, environment, constitutional proclivities, and social circumstances in diagnosing symptoms and in prescribing. The roots of our present complaint go back to the early nineteenth-century developments in basic science that began the intellectual transformation of medicine into its present shape. The development of basic science, especially pathological anatomy, led to an acceptance of the notion of diseases as specific entities existing apart from the individual people in whom they manifested themselves by causing pathological lesions. Such lesions were produced according to pathophysiological mechanisms that science could elucidate and, perhaps, interrupt. The notion of disease as specific entity was strengthened later in the nineteenth century by the advent and triumph of the germ theory. As medical schools began to integrate basic science into their curricula in the 1880s and 1890s, the new outlook began to affect clinical practice, leading to complaints about scientific medicine’s depersonalization of patients, complaints that have continued to the present.

Rosenberg has spent much of his career exploring this territory; his early work on cholera and the broader intellectual world of nineteenth-century American medicine set the stage for the essays collected here, in which he traces the manner in which we have continued to attach broader meanings to disease in spite of our seemingly value-free scientific disease concepts. Such tendencies have been especially notable in the case of behavioral ills—hence Rosenberg’s attention to psychiatry, the focus of several chapters in the present work. Yet our attachment of blame, guilt, and anxiety to bodily conditions is perhaps even more notable when we make such connections to physical rather than behavioral illness. The chronic diseases that loom so large in early twenty-first-century medicine would at first sight appear less amenable to such connections than psychiatric ills. Yet we have preserved important aspects of premodern thinking about disease by focusing not only on illness perceived as such but on conditions likely to lead to the latter: risk factors, which in the case of hypertension and hyperlipidemia have been granted the status of diseases. Physicians grappling with patient risk factors once again focus on lifestyle and individual responsibility, and here pharmacological manipulation of mechanism often takes a back seat to moral exhortation as the means of effecting risk factor modification. This focus on regimen and individual agency in achieving bodily harmony looks a lot like the medicine of the past—our present mechanistic understandings having proven no barrier to the moralization of risk factor modification. That is not surprising, as reductionist medicine cannot alter our proclivity to invest our bodily imperfections with moral meaning, although it may determine the shape that those meanings take on.

The behavioral ills of psychiatry and risk factors for somatic disease are just two topics through which Rosenberg illuminates the intrusion of value into reductionist science. Alternative medicine and contemporary genetics are two more. In other cases he shows us how scientific medicine is brought into the service of perennial forms of cultural criticism, such as that of contemporary urban life or material progress. Finally, he reminds...