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Epistemology, Social Change, and the Reorganization of Knowledge BETWEEN THE 1820S and the 1850s American physicians held stead­ fast to their belief in the necessity of therapeutic activism and in the value in principle of traditional remedies. Yet far from being static, this was a period of signal change in therapeutics. Although they re­ tained their faith in such established therapies as bloodletting, alcohol, and opium, practitioners began to use these treatments with frequen­ cies and intensities that deviated sharply from earlier conventions. More fundamentally theyincreasingly questioned the sources and char­ acter of their therapeutic knowledge. How could thepractitioner assess the worth of therapeutic practices, and how was therapeutic progress to be effected and judged? The answers rationalistic systems of practice provided made physicians more and more uneasy. Their mounting at­ tack on such systems and their concomitant celebration of empiricism pervaded the medical literature. This transition in epistemological thinking was among the most important and revealing transformations of medical therapeutics in nineteenth-century America. From the 1820s on, many American physicians began to see a reorientation from rationalism to empiricism in therapeutic knowledge as crucial to the clinical and social success of their profession. It is in some respects surprising that epistemological issues mattered so much to them. After all, American physicians saw themselves as preemi­ nently practical men who valued practice over theory, as active ther­ apeutists more than as truth-seeking scientists. Their intense concern with the epistemological foundations of therapeutic knowledge sug- 38 ANTEBELLUM MEDICAL THERAPEUTICS gests that more was at stake than the underpinnings of theories. The production of epistemological rhetoric becomes more understandable if it is viewed as a form of behavior elicited by professional anxieties. The vigor with which American physicians assailed rationalistic sys­ tems and the praise they lavished on therapeutic empiricism were among their varied reactions to perceived shifts in the profession's social standing.The vehemence that typified epistemological criticism stemmed in large measure from the desperation of a profession that believed itself to be in decline. Members of all professions in America during the second quarter of the nineteenth century shared the complaint of declining power and status. In medicine, even though many individual practitioners main­ tained prestigious positions in their communities, regular physicians believed that their profession asa whole had been debased in the public view. Populistic medical sectssuch as Thomsonianism, aswell as sects like homeopathy that appealed to a more affluent clientele, challenged both the orthodox profession's claims to intellectual and therapeutic superiority and its economic well-being. The rescinding of medical licensing laws by the states in the 1830s and the 1840s institutionalized the stripping of professional privilege. Such laws had been principally honorific but had nonetheless distinguished regular physicians as sin­ gularly legitimate.1 Beyond these external indicators of deterioration, physicians de­ tected ample evidence of decline within the regular profession itself. The proliferation of proprietary medical schools, many with low stan­ dards and purposes, greatly increased the number of poorly trained practitioners holding M.D. degrees. This erosion of standards con­ firmed chargesof unmerited pretensions. The overabundance of regular physicians increased the difficulty of earning a living by practice, a circumstance that heightened competition, discordant rivalry, and professional disunity. Tensions were aggravated by the fact that while the lowest levelsof the profession weregrowing, sotoo was the topmost layer. More American physicians than ever before were acquiring rig­ orous medical training, particularly in Paris. These men often held inflated aspirations for the profession's knowledge, practice, and in­ stitutions and were well prepared to believe the worst of the large masses of meagerly educated regular practitioners. "Our own profes­ sion, what with its ignorance, its heresies, and its moral sense, has lost the respect of the community and sunk to the level of a trade less honest & less useful than that of the rudest mechanic," one prominent Philadelphia physician lamented in 1857. "Alas! it should be so when every year is adding to the learning & science, & skill of our leading The Reorganization of Knowledge 39 men & those around them."2 This growth at the extremes created a group of ambitious, thinking physicians anxious to improve the stand­ ing of their profession by uplifting their backward brethren.3 The desire to shore up the profession was expressed in a variety of ways. State and local medical societies multiplied, and the national American Medical Association was formed in 1847 to promote unity among physicians, distance regulars from sectarians, and reform med­ ical education. Societies attempted to arbitrate difficult interactions...


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