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The Arbitration of Change TENSIONS BETWEEN the commitment to progress and loyalty to tra­ dition became particularly acute in the discussions about therapeutic change that flourished in medical circles from the 1850s through the 1870s. The function of these discussions was at once explanatory and normative, for through them physicians sought to account for the dra­ matic transformation that had taken place in practice since the early decades of the century and to establish a consensus for current and future practice. Evaluation of past therapeutic change and disputation of present therapeutic truth were parts of a single endeavor. This en­ deavor is illustrated here by an analysis of the profession's discussions about the decline of the two treatments most securely linked with early-nineteenth-century therapeutics, general bloodletting and calo­ mel, and about a drug broughtforward toreplace venesection, veratrum viride. Such discussions clearly exhibit physicians' reasoning about change and the range of factors they regarded as meaningful in ex­ plaining, judging, and advocating it. The potential of therapeutic criticism to indict both professional tradition andcurrent efficacy washigh, and regular physiciansobserved certain tacit rules commensurate with the risk. Internal therapeutic criticism rarelydrew intoquestion thevalue in principle of established remedies. (In contrast, sectariansgenerally charged that orthodox ther­ apies were in themselves damaging.) Discussion among regulars or­ dinarily dwelled instead on theory, the rationale for therapeutic beliefs, and the extent to which particular practices were or were not useful in certain defined conditions. Even if the actual use of a practice was modified or the theory sustaining it changed, its value could nonethe­ less be fully upheld in principle. Criticism of theory and practice could 208 THE PROCESS OF CHANGE thus bring about what was regarded as progress with only minimal threat to tradition. A further stricture upon internal criticism was that it be kept as far as possible out of public view. External criticism was by nature and calculation conducted in a manner that drew public attention; a pri­ mary obiective of sectarians was, after all, to discredit orthodox practice in the public view. Regulars realized that internal discord could in­ advertently serve the same end, and therefore they established rules for conducting therapeutic discussion that were designed to blunt its potential harm. The committee on ethics of a local Ohio medical so­ ciety was typical in the advice it gave its members on maintaining the appearance of a unified therapeutic front. Disagreements that arose in consultation, for example, were to be discussed and resolved without allowing the public to become aware of professional disharmony. "Nei­ ther the subject-matter of such differences nor the adjudications of the arbitrators," the committee concluded in 1853, "should be made public as publicity in a case of this nature may be personally injurious to the individuals concerned and can hardly fail to bring discredit on the faculty."1 No therapy occupied a more prominent position in the ideology of early-nineteenth-century medicine than did venesection. Yet even in the 1820s the attitude of most regular American physicians toward general bloodletting was ambivalent. Professionally respectable phy­ sicians did not challenge its value in principle and accepted as a solidly established truth the proposition that it could be of substantial ther­ apeutic worth Many did, however, question the measure of venesec­ tion's therapeutic benefits as well as the vigor with which it was practiced.2 During the 1830s and 1840s a heretical challenge to the principle of bloodletting was also voiced, but only by those outside the regular profession Sectanans assailed the notion that it could ever be of ther­ apeutic value. This assault encouraged both regular physicians and the public to reassess its use but also elicited from regulars a defensive reaffirmation of bloodletting in principle. Onhodox physicians, reflect­ ing in their thinking the simplistic dichotomy between good and evil tvpical of sectarian conflicts in general, attributed the sectarian attack on venesection chiefly to irregular ignorance and duplicity, yet ac­ corded a portion of the blame to regular excesses ; Bv the 1830s most regular physicians agreed that bloodletting had been abused. It was perhaps the profession's most valuable treatment, according to this view, and did inestimable good when iudiciously The Aibitration of Change 209 employed. But, as one Cincinnati student explained in 1831, "many Physicians bleed indiscriminately for, finding they have a certain rem­ edy in many dangerous diseases [they] conclude from its power, not fully apprehending its qualities!,] that it may be useful every where."4 In the appraisal of physicians...


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