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Preface AT THE CORE of this book is the contention that neither ideology nor behavior can be understood adequately except in relation to the other. To understand how nineteenth-century American physicians fash­ ioned individual and collective identities, why they represented their knowledge and practices as they did, and how they transformed their professional world, we need to connect their rhetoric in medical jour­ nals, textbooks, and ceremonial orations with what they actually did at the bedside. When I began writing this book at the start of the 1980s, a grow­ ing historical consensus encouraged this approach. Yet, in the history of medicine and science it was more often encountered in program­ matic statements voiced around the seminar table than in the litera­ ture of the field. It has been satisfying, therefore, to have watched during the past decade as practice has moved to center stage in histor­ ical work. Just as historians of science have looked increasingly at the practice of experimentation, in part to move away from theory-domi­ nated accounts of the construction of knowledge in the laboratory, so historians of medicine have turned their attention to the workaday acts of healing by physicians and other practitioners. The rise of the new cultural history has furthered this transformation in the atten­ tion of historians, in which the technical activities of medicine and science have joined other cultural practices such as appropriation, representation, the construction of identity, and the deployment of language as historiographic preoccupations. As a graduate student in the late 1970s and early 1980s, at a mo­ ment when intellectual history was struggling to find a reconfigured, viable identity and when the new social history was in full ascendence , it was perhaps overdetermined that I was inclined to turn to cliometric analyses of previously unexplored records of everyday be­ havior. The pivotal sources I used in my reconstruction of nineVll V l l l PREFACE TO THE PAPERBACK EDITION teenth-century therapeutic practice—patient records from private and especially hospital practice—have also come into vogue in the decade since this book was first published in 1986. Like historians of science who have turned increasingly to laboratory and field notebooks, his­ torians of medicine have recognized patient records as particularly rich sources for reconstructing not only therapeutic interventions but also diagnostic practices, the uses of technologies, and so on. These records do not give the historian privileged access to reality—a some­ how true account of what happened—but they offer an invaluable source of insight into what doctors actually did in managing both diseases and patients and enacting their identity as professionals. What can emerge from comparing clinical behavior with its portrayal in other texts are reconstructions that draw together ideology and be­ havior, technical content with institutional context, the professional agendas of physicians and the realities of patient experiences.1 Ln retrospect, I wish I had been bolder in spelling out not so much the novelty of my methods and arguments as some of my premises. Reviewing The Therapeutic Perspective, Steven Shapin commented that it was "an important and radical book." Yet he went on to note critically that I had been "regrettably timid on the question of relativ­ ism" and that the book was "written in a way that masks its radical­ ism."2 Although I briefly acknowledged my methodological relativ­ ism in the Introduction, I have grown convinced that, especially in a study focused on medical therapeutics, I should have made more of it. I am not suggesting that in trying to understand the past we should, or can, set aside what we know now. But historians have proven themselves to be vastly more comfortable holding in abeyance judg­ ments based on a positivism informed by hindsight in analyzing past medical beliefs and theories than in dealing with medical practices, particularly therapeutics. By the 1970s, instead of judging past theo­ ries in the light of modern scientific knowledge, historians increas­ ingly had set out to understand their construction in the context of their own times and to assess what gave them meaning; during the 1980s, this approach was assimilated into the mainstream. Yet, re­ markably, many of the same historians continue to be cavalierly dis­ missive in treating the therapies of the past. This asymmetrical historical management of medical theory and medical practice has enabled historians to avoid fully confronting an argument of Charles Rosenberg that I made one of my fundamental premises in this book: namely, that during the first half...


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