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Stanford HPS 154 - Therapeutic Revolution Rosenberg

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r ,THE THERAPEUTIC REVOLUTION-Essaysinthe Social History ofAmerican Medicine edited by MORRIS J. VOGEL *' CHARLES E. ROSENBERG Univers ity of Pennsylvania Press - 1979 @ 1 THE THERAPEUTIC REVOLUTION: Medicine, Meaning, and Social Change in Nineteenth-Century America CHARLES E. ROSENBERG Medical therapeutics changed remarkably little in the two millcnnia preceding 1800; by the end of the century, traditional therapeutics had altered fundamentally. This development is a significant event, not only in the history of medicine, but in social history as well. Yet historians have not only failed to delineate this change in detail; they have hardly begun to place it in a framework of explanation which would relate it to all thosc other changes which shaped the twentieth-century Western world. Medical historians have always found therapeutics an awkward piece of business. On the whole, they have responded by ignoring it.' Most histori- ans who have addressed traditional therapeutics have approached it as a source of anecdote, or as a murky bog of routinism from which a comforting path led upward to an ultimately enlightened and scientifically-based thera- peutics. Isolated incidents such as the introduction of quinine or digitalis seemed only to emphasize the darkness of the traditional practice in which they appeared. Among twentieth-century students of medical history, the4 Charles E. Rosenberg generally unquestioned criterion for understanding prenineteenth-century therapeutics has been physiological, not historical: did a particular practice act in a way that twentieth-century understanding would regard as effica- cious? Did it work? Yet therapeutics is after all a good deal more than a series of pharmaco- 1 logical or surgical experiments. It involves emotions and personal relation- ships, and incorporates all of those cultural factors which determine belief, identity, and status. The meaning of traditional therapeutics must be sought within a particular cultural context; and this is a task more closely akin to that of the cultural anthropologist than the physiologist. Individuals become sick, demand care and reassurance, and are treated by designated healers. Both physician and patient must necessarily share a common framework of explanation. To understand therapeutics in the opening decades of the nineteenth century, its would-be historian must see that it relates, on the one hand, to a cognitive system of explanation, and, on the other, to a patterned interaction between doctor and patient, one which evolved over centuries into a conventionalized social ritual. Instead, however, past therapeutics has most frequently been studied by scholars obsessed with change as progress and concerned with defining such change as an essentially intellectual process. Historians have come to accept a view of nineteenth-century therapeutics which incorporates such priori- ties. The revolution in practice which took place during the century, the conventional argument follows, reflected the gradual triumph of a critical spirit over ancient obscurantism. The increasingly aggressive empiricism of the early nineteenth century pointed toward the need for evaluating every aspect of clinical practice; nothing was to be accepted on faith, and only those therapeutic modalities which proved themselves in controlled clinical trials were to remain in the physician’s arsenal. Spurred by such arguments, increasing numbers of physicians grew sceptical of their ability to alter the course of particular ills, and by mid-century (this interpretation continues), traditional medical practice had become far milder and less intrusive than it had been at the beginning of the century. Physicians had come to place ever-increasing faith in the healing power of nature and the natural tend- ency toward recovery which seemed to characterize most ills. This view of change in nineteenth-century therapeutics constitutes ac- cepted wisdom, though it has been modified in recent years. An increas- ingly influential emphasis sees therapeutics as part of a more general pattern of economically motivated behavior which helped to rationalize the regular physician’s place in a crowded marketplace of would-be healers.2 Thus the competition offered by sectarians to regular medicine in the middle third of the century was at least as significant in altering traditional therapeutics 5 The Therapeutic Revolution as a high-culture based intellectual critique; the sugar pills of homeopathic physicians or baths and diets of hydropaths might possibly do little good, but could hardly be represented as harmful or dangerous in themselves. The often draconic treatments of regular physicians-the bleeding, the severe purges and emetics-constituted a real handicap in competing for a limited number of paying patients, and were accordingly modified to fit economic realities. Indeed, something approaching an interpretive consensus might be said to prevail in historical works of recent vintage, a somewhat eclectic, but not illogical position which views change in nineteenthcentury thera- peutics as proceeding both from a high-culture-based shift in ideas and the sordid realities of a precarious marketplace. Obviously, both emphases reflect a measure of reality. But insofar as they do, they serve essentially to identify sources of instability in an ancient system of ideas and relationships; they do not explain these ideas and relationships. For neither deals with traditional therapeutics as a meaning- ful question in itself. As such, therapeutic practices must be seen as a central component in a particular medical system, a system characterized by remarkable tenacity over time.3 The system must, that is, have worked, even if not in a sense immediately intelligible to a mid-twentieth-century pharmacologist or clinician. I hope in the following pages to suggest, first, the place of therapeutics in the configuration of ideas and relationships which constituted medicine at the beginning of the nineteenth century, and then the texture of the change which helped to create a very different system of therapeutics by the end of the century. The key to understanding therapeutics at the beginning of the nine- teenth century lies in seeing it as part of a system of belief and behavior participated in by physician and laymen alike. Central to the


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