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Introduction: Therapeutics and the Transformation of American Medicine BETWEEN THE 1820S and the 1880s medical therapeutics in America was fundamentally altered. Traditional medical practices, founded on assumptions about disease shared by doctor and patient and oriented toward visibly altering the symptoms of sick individuals, began to be supplanted by strategies grounded in experimental science that objec­ tified disease while minimizing differences among patients. Concur­ rently thebases of physicians' professional identity were also transformed. Through the mid-nineteenth century professional identity was based on proper behavior and on a medical theory that stressed the principle of specificity, the notion that treatment had to be matched to the idiosyncratic characteristics of individual patients and their environ­ ments. During the last third of the century a new conception of profes­ sional identity, defined by allegiance to knowledge generated and validated by experimental science and characterized by universalized diagnostic and therapeutic categories, was clearly in ascendance. I have elected to use thestudy of medical therapeutics asa context in which to evaluate these changes in professional identity, scientific knowledge, and medical practice. This is, then, a therapeutic perspec­ tive on the culture of orthodox medicine in America and its transfor­ mation between the 1820s and 1880s. As the core of medical activity, therapeutics was central to the professional image and legitimacy of physicians. Moreover, therapeutics, regarded asboth a cognitivesystem and a set of social practices, is a useful mdicator of the changing real and perceived roles of scientific knowledge in medicine. A study of therapeutic change, its determinants, and its meaning is thus a sin­ gularly productive means of assessing physicians' professional values and their perceptions of what constituted proper sources of knowledge. 2 INTRODUCTION Yet as Charles Rosenberg has cogently commented, "Historians have always found therapeuticsan awkwardpiece of business. Onthe whole, they have responded by ignoring it."1 In part, the dearth of research in the history of therapeutics is a reflection of the methodological difficulties inherent in determining what nineteenth-century physicians actually did at the bedside. Ther­ apeutic theory is readily accessible to the historian through an abun­ dance of published and manuscript narrative sources that present not only normative statements by physicians but also exemplary case his­ tories. Yet therapeutic behavior at times bore little resemblance to therapeutic theory or principle, and reliable knowledge about actual therapeutic practice must come from sources that are less conventional in historical research, such as medical case history records.2 Still, the self-conscious quest of historians during the past two decades for new types of sourcesin reconstructing the social experience of the past makes methodological impediments less than compelling as an explanation for lack of interest in the history of therapeutics. With some exceptions, the same investigators who have perceived much promise in studying the history of disease and health care have seen little in medical therapeutics that seems to meet their theoretical or personal agendas. Therapeutics has appeared to be ground too arid to warrant tilling either by the physician exploring his or her profession's past or by the professional historian interested in using medicine as one mirror of society, thought, and values. Nineteenth-century ther­ apeutic practice is certainly an unappealing vehicle for hagiographic celebration, and its usefulness as a spade in the archaeology of values is far from obvious at first sight. Identifying the boundaries of my study will spare the reader a search for something that is not here. My concern is with medical therapeutics, not with surgical and dental therapeutics.31have further restricted my analysis to orthodox (also called regular) physicians, and I examinethe beliefs and practicesof irregular orsectarian practitioners only where they impinged upon the regular profession. Moreover, the endpoints of my study are not rigid. I have selected the opening date to include a time when speculative systems of practice were still in­ fluential and the turn toward empiricism was just beginning. Mystudy closes when experimental laboratory science was ascendant but not yet hegemonic, and when bacteriology intrigued many American phy­ sicians but had yet to engender the frenetic activity of the 1890s. I have made several assumptions about how medical therapeutics ought to be regarded in order to be productively exploited as a guide to the culture of nineteenth-century American medicine. What phy­ sicians actually did matters as much as their normative statements, INTRODUCTION 3 and neither behavior nor ideology can be adequately interpreted with­ out knowledge of the other. Erwin Ackerknecht called a decade and a half ago for what he termed a...


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