ACKERKNECHT, ERWIN H.

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A Plea for a "Behaviorist" Approach inWriting the History of MedicineERWIN H. ACKERKNECHT*NOT long ago my collaborator, Dr. Hans Walser, discovered thatin the Franco-Prussian War of 1870-71 many amputations wereperformed without the benefit of anesthesia ("Der Krieg und dieAerzte"). This observation shocks us somewhat, in view of thefact that general anesthesia had been introduced successfully, ac-cording to our textbooks, a quarter of a century before. Our sur-prise is only possible because the medical history we read and writetoday is still based mostly on the writings of an elite of medicalmen. We are primarily students of scientific literature. Excellentas this may be, it teaches us relatively little concerning what thiseUite actually did, and even less of what the average physician orsurgeon did. Since our contemporaries in consultative practice arewell aware of the gap which even now exists between the medicinepreached and the medicine generally practised, and since studiesare available which reveal the width of this gap in the 20th century,it is time that historians looked hard at the actualities of the past.Probably most of us have encountered in the course of our re-search other examples illustrating this gap in our knowledge. Manyof our misconceptions are due, of course, to the fact that we thinkin terms of the present and tend to underestimate the time spanextending between an invention and its general acceptance andapplication in times gone by, the famous "lag" of the sociologists.But as a short review of my own "surprises" seems to show, severalother forms of ignorance are involved in addition.My own somewhat oversimplified concepts were first seriouslyshaken when I found out (see Ackerknecht, E. H. Malaria in theUpper Mississippi Valley, Baltimore, 1945, pp. 115 £F) that despiteP. Louis and Marshall Hall's proofs of the negative effects of bleed-ing (ca. 1830) the habit began to recede seriously only in the 1870s.(Cf. Leon C. Bryan, Jr. Blood-Letting in American Medicine,1830-1892. Bull. Hist. Med., 1964, 28, 516-29.) Study of the cata-logues of medical supply houses issued around the turn of thecentury not only support this contention, but reveal an almostincredible number of ancient instruments still in use. While these• Institute of the History of Medicine, University of Zurich, Zurich, Switzerland.Copyright 1967 bj JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES, Inc.212 Journal of the History of Medicine: JULY, 1967are examples of "lag", the fact, e.g., that at the time of Portalonly very few physicians were able to palpate successfully, or thatBroussais, according to his adversary Velpeau, was in spite of histheories a successful therapist can not be explained this way.(Ackerknecht, Medicine at the Paris Hospital, 1794-1848, Balti-more, 1967.)My collaborator, Dr. Otto M. Marx, found contradictions be-tween therapeutic advice of 19th century psychiatric treatises andthe actual practices of their authors as described in medical travelliterature so pronounced that he is now making a special study ofthis travel literature.We must admit to ourselves that we often do not know the mostelementary facts of either medical practices or of the social aspectsof medical practice even for periods not very far removed at all.How high a percentage of the population was seen by a doctor ahundred years ago? (O. Esser: Der praktische Arzt im Rheinland,1750-1850, unpublished thesis, Bonn, 1963, p. 49, gives some amaz-ing figures on this.) How many of those doctors who publicly con-demned mesmerism or homoeopathy used it? When and how didtreatment by correspondence come to an end? Who knew till Wue-therich's recent publication that uroscopy was practised widely byGerman practitioners up to the 1830s? ("Das Ende der Uroskopie.")What were the real practices of those who, in Europe, actuallytreated the great mass of the population up to the middle of thelast century, the surgeons and apothecaries? Even the most intensivepreoccupation with the writings of court physicians, academiciansor university professors will never answer this crucial question.We know very little of die history of the precepts of medicalethics, though A. Nussbaumer's recent thesis on the Stahlian,Johann Storch (Zurich, 1965) has considerably added to our knowl-edge in this direction. We know even less to what extent theserules were applied. We do not know exactly when the honorariumwas replaced by the fee. In spite of George Rosen's pioneer effort{Fees and Fee Bills, Baltimore, 1946) we know little of the historyof fee bills and "tariffs." We know even less of what the differentkinds of healers actually received.M. H. Koelbing has recently drawn attention to the fact thataround 1830 Paris was still full of "ambulant oculists" (Medecineet Hygiene, 1964, 22, 925-6). George Rosen's excellent pioneerstudy, "The Specialisation of Medicine" (New York, 1944), hasunfortunately not been continued by other scholars searching inthe same direction.ACKERKNECHT: Plea for "Behaviorist" Approach 313Henry E. Sigerist undoubtedly alluded to these gaps in ourknowledge, when he wrote (A History of Medicine, New York,1951, vol. I, p. 14): "The history of medicine, however, is infinitelymore than the history of the great doctors and their books. Medicalscience is important, but it is wasted unless its findings are appliedon a large scale. . . . We therefore must pay attention to the historyof the rank and file doctor and the other medical workers." Buthis time ran out before he could give us his results in this direction.Th. Puschmann, F. H. Garrison, and P. Diepgen (in his chapterson "Das arztliche Leben") have probably been, so far, those medi-cal historians who in their treatises have paid most attention tothese problems, but their discussions remain extremely frag-mentary. When some more recent books have touched upon them,like, e.g., The Midwest Pioneer by M. E. Pickard and R. C. Buley(New York, 1946), they have unfortunately remained too much onthe anecdotal level, a common defect of this type of study. But E. S.Turner's Call the Doctor (London, 1958) shows that even such an"anecdotal" book can be quite useful.I should be completely misunderstood if what I have said abovewere to be interpreted as a plea for abandoning the type of re-search we have been doing so far. This work remains essential,useful, and very, very far from being exhausted. We do not evenhave a thorough Galen study! Only, the older I get, the more I feelthe necessity of additional studies to complete our picture of thepast. And as researchers in the history of medicine fortunatelygrow more numerous, this should be feasible. It would be all theeasier if medical historians would devote their efforts to differentobjects, and cease imitating, in their own way, the slaves of fashionin other fields. It is a somewhat melancholy sight to observe medi-cal historians these days clustering around certain "great men",while others and other problems of equal importance, are passedIn order to answer questions like those raised above, othersources will, of course, have to be tapped. They are most of thetime not as "brilliant" as the traditional sources, and often demandeven more caution in their interpretation. But they do exist, ingreater numbers than is often suspected, and they often have theirown charm. There are, of course, above all, case histories, withdata on treatment, which exist in profusion, especially after the16th century. Owsei Temkin's admirable pioneer study of the his-tory of the case history (Kyklos, 1929, 2, 42-66) has unfortu-nately found no successors. We have already mentioned travel214 Journal of the ^ History of Medicine: JULY, 1967reports. We should also like to draw attention to the extensivepamphlet literature accompanying the medical reform movementsin Europe around the middle of the 19th century, "cahiers dedol£ance", as it were, of the medical profession. I once listed over400 such publications for Germany alone around 1848 (SudhoffsArchiv, 1932, 25, 164-80). And such pamphlets are by no meansrare for the 17th or 18th centuries. Medical periodicals or societytransactions—I need only remind my readers of the early trans-actions of the A.M.A.—are full of relevant data. As a matter offact, doctors have never suffered in silence. Governmental archivescontain very enlightening reports. Diaries, autobiographies, oreven contemporary novels, sometimes yield valuable information.As everything seems to need a name, I would suggest calling theapproach I am here pleading for the "behaviorist approach"—notin deference to the psychological doctrines of the late J. B. Watson,whose lack of interest in "conscience" revealed a one-sidednessand lack of understanding of the totality of reality similar to KarlMarx's contempt for the "superstructure"—but taken in its literalsense. In this sense the word "behaviorist" expresses rather wellwhat I am aiming at: more extensive and more critical analysisof what doctors did in addition to what they thought and wrote.I am fully aware of the fact that the elements of the equation are,of course, very closely related.

A Plea for a "Behaviorist” Approach in Writing the History of Medicine

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