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Therapeutic Change To BE FULLY exploited as a probe into the mind of nineteenth-century American physicians, therapeutic rhetoric must be interpreted against the backdrop of behavior. Only by knowing what physicians actually did is it possible to assess the significance of what they said they did and ought to be doing. The kinds of sources historians most often rely on are indispensable for describing how physicians portrayed their ac­ tivities and for understanding the purposes and ]ustifications of their therapeutic procedures, but they do not reveal their actions. Although some insights into therapeutic activity can be gleaned from such nar­ rative sources as diaries, published case histories, clinical lectures, and letters advising patients, such sources are often only anecdotal, and sometimes are more normative than descriptive. The most revealing sources of information about the therapeutic behavior of private practitioners are practice records made for personal use. A small minority of physicians kept case history books in which they logged their patients' signs and symptoms, their own therapeutic efforts, and the consequences of treatment. All too often, though, phy­ sicians recorded only exceptional cases in such volumes.1 Furthermore, many tired of the labor after a couple of years (or even days), so the duration of case history books is often brief.2 Underlying the making of these volumes was the physician's belief that by writing down his experiences he could improve his practice and perhaps contribute to collective knowledge as well; but the kinds of information recorded were often idiosyncratic. While such documents do lay open the bed­ side activities of a few physicians, they lack the uniformity requisite to support meaningful comparisons.3 Most practitioners kept patient records solely for financial pur­ poses. In the account books and financial ledgers that survive in abun­ dance, they listed their services and the corresponding charges. 84 THE PROCESS OF CHANGE Sometimes individual drugs dispensed directly to the patient are spec­ ified in such records; far more often physicians recorded only the general type of drug administered, such as cathartic or emetic, or the even less enlightening term medicine or prescription. While it issome­ times possible on the basis of these records to tell that a physician was prescribing a certain drug frequently, it is seldom certain that he was not using other, unrecorded treatments even more regularly. However, most physicians did routinely itemize certain services, including vac­ cination, tooth extraction, and attendance at childbirth. Venesection, as a surgical procedure, was among the services that were ordinarily specified for billing purposes, and therefore more can be learned about its relative frequency than can be known about any other therapy. Pharmacy prescription books are also valuable indexes of prescrib­ ing habits in communities where drugs were not dispensed primarily by physicians themselves. The prescriptions pasted or copied into such registers itemize all of the drugs ordered for the patient and specify dosages, and therefore drug usage revealed by pharmacy prescription books from different places and times can be compared statistically. Yet the usefulness of these records is limited by their scarcity for the first half of the century, the paucity of patient information theyprovide, the restriction of information to drugs (excluding diet, other regimen instructions, and procedures such as venesection and cupping), and the frequent failure to identify the prescribing physician. Virtually the only detailed, systematic information about nineteenth -century therapeutic activity over an extensive period of time that can be meaningfully quantified is that obtained through hospital records. The rigor with which hospitals recorded case histories varied widely, but the records of the two American hospitals analyzed here are sufficiently detailed and complete to illuminate the complexity of therapeutic change over the long duration. With a richness private practice documents do not offer, these records disclose the marked variability in therapeutic orientationand actual treatment that typified medical practice in different contexts; show that even within a single institution such categories as heroic depletants, palliatives, andheroic stimulants were not monolithic, and that the individual treatments within a single citegory rose and fell on diverse schedules; and force­ fully reveal the absence of outright rejection of established therapies and the continuity of therapeutic practice over time. Therapeutic change is described here on three progressively nar­ rower and more detailed levels. On the first the shifting objectives of treatment between the 1820s and 1880s are sketched. This brief ac­ count, based more on narrative sources than on practice records, ana­ lyzes how physicians thought about the end point of their therapeutic Therapeutic Change...


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