The History of Therapeutics GUENTER B. RISSE Most modern discussions concerning the history of therapeutics generally begin with Erwin Ackerknecht’s programmatic “plea for a behaviorist approach in writing the history of medicine.”*' To mention this note written in 1967, is now almost de rigueur in the historiography of therapeutics. In his brief article, Ackerknecht urged historians to supplement the history of ‘medical ideas written by an elite of great doctors with accounts of what the average practitioner actually did when faced with patients. Here the author believed that physicians had gradually arrived at some objective knowledge through a process of first collecting subjective therapeutic experiences and then employing clinical experimentation and controls.” After a brief survey of the pertinent literature, Ackerknecht perceived a “gap” between therapeutic principles and actions as well as a “lag” in the implementation of curative practices already officially accepted. Perhaps more disturbing to Ackerknecht ‘was to discovery that traditional therapeutic measures like uroscopy, practised widely in the 1830s by German physicians, but long considered obsolete, were still alive and well.” Like surviving dinosaurs in a time warp, ancient practices were and are nevertheless viable and employed — witness for example the study of bloodletting and its renaissance in the early twentieth century.‘ Intrigued, both Ackerknecht and his student, Charles Rosenberg, concluded that therapeutics was indeed a neglected topic of historical investigation full of paradoxes and surprises.* Never shy to meet a challenge, Ackerknecht himself delivered on his original “plea.” Barely three years later, he published Therapie: von den Primitiven bis zum 20. Jahrhundert a quick survey and veritable tour de force of therapeutic practices which was translated into English in 1973. So eager was the author to demonstrate his behaviorist approach, that his breezily written survey — with touches of typical Ackerknecht sarcasm and ridicule — ended up being merely a catalogue of medical authors and their treatments. In rapid succession, kudos but mostly censures were freely bestowed on hapless historical figures. For example, probing humoralism, the author condemned the “unholy trinity” of bleeding, emetics and cathartics.’ Romantic physicians in turn were glibly characterized as “anti-progressive, divining-rod clinicians,”* while nineteenth-century French practitioners, especially Broussais, practised “vampirism,” Ackerknecht’s euphemism for frequent venesection.”In short, the hastily written book with its frequent diatribes against panaceas, polypharmacy, fads, and iatrogenic practices constitutes not only a shallow, panoramic review, but also makes for quite a depressing tale. It follows in the Whiggish tradition of another work written almost one hundred years earlier by Julius Petersen.'° Perhaps Ackerknecht deliberately conceived this work as a kind of horror story since, as he admitted in the preface, “a study of our collective experience will save for at least some physicians and their patients years of unnecessary experience.”""' In other words, Ackerknecht was willing to grant that, unlike other aspects from our medical past, the history of therapeutics could have some utility for tomorrow's doctors, not through conscious emulation of great physicians, but through actual rejection of their dastardly behaviour at the bedside. It would be, in this historian’s opinion, “the most useful book a medical historian could write.” Indeed, confronted with such a sad and repeated account of fads, unwarranted therapeutic enthusiasms, and their resulting harm to patients, young practitioners would perhaps learn caution and scepticism whenever they were ready to prescribe treatments. ‘A somewhat similar message is conveyed in a more recent book by Huldrych Koelbing, Die drztliche Therapie. Here the author is equally sanguine about the persistent and inexplicable “therapeutic optimism” of past medical professionals that must be curbed through an historical perspective. Nowhere does Koelbing attempt to explore possible reasons for this upbeat and overconfident attitude.” Indeed, as Ackerknecht had stated earlier, “the history of therapeutics has always been particularly unsatis- factory from the point of view of logic.”"* Finally, Ackerknecht’s last note on therapeutics, entitled “Driving Out Devils by Beelzebub,” is another loosely arranged series of historical vignettes. It describes how, but does not attempt to explain why, certain physicians substituted a number of ineffective remedies for others of even more dubious therapeutic action. Here Broussais ‘was again one of the targets of Ackerknecht’s scorn, “another Beelzebub who condemned antimony but killed his patients with leeches and a starvation diet. This tendency to stress the deplorable state of earlier therapeutics — considered hopelessly backward in relation to modern standards of efficacy —has been the hallmark of numerous works by subsequent medical authors who wished to accentuate the beneficial character of contemporary treat- ‘ments and thus by implication pay indirect tribute to what they perceived to be medical progress. “Virtually anything that could be thought up for the treatment of disease was tried out at one time or another,” asserted Lewis ‘Thomas in a recent book.'* “It was,” he admitted, “‘the most frivolous and irresponsible kind of human experimentation.” Thomas concluded his assessment by musing that “it is astounding that the profession survived so long and got away with so much with so little outery.”"” 4Such an opinion of the sorry state of therapeutics during historical times is widely shared by the educated public thanks to several popular books written on the subject such as Guy Williams’ The Age of Agony.'* With almost morbid fascination, people even today examine the various bloodletting instruments in museums and read about what appears to have been gallons of blood spilled at the altar of medicine." Articles periodically describe how “the doctors killed George Washington.” Notorious bleeders such as Benjamin Rush and Frangois Broussais have become the object of ridicule and contempt.” This positivist stance taken by medical professionals and the public at large has even infected historians, who, often afraid to tarnish the reputations of favourite medical personalities, omit all information con- cerning their actual deeds at the bedside, deeds which in every subsequent generation were judged as primitive, ridiculous, and even recklessly dan- gerous, As John Warner recently put it succinctly, therapeutics is indeed an “unappealing vehicle for hagiographic celebration." ‘A quick glance through the pertinent literature makes it clear that even before, but certainly since the publication of Ackerknecht’s book in 1970, the focus in the history of therapeutics has remained narrowly restricted to the treatments themselves. Some therapies have been described in detail with special attention paid to practices such as bloodletting and acupuncture, as well as the employment of particular drugs.” Moreover, a number of therapeutic changes throughout history were duly noted but never explained. The result is that to date, scholars have published little comparative and interpretive work on the subject. Paradoxically, both Ackerknecht’s and Koelbing’s sweeping surveys, with their staccato recitation of physicians’ names and publications, have tended to create the impression of frequent changes in the history of treatments. However, such a dynamic perspective is very misleading, since it conceals the basic continuity and traditionalism inherent in all therapeutic activities until recent times.®* Indeed, this “pro- gressive” type of historiography masks the slow pace of change and lack of revolution in an arena in which symbols and professional identity still govern much of what passes as medical practice.” Perhaps the subject is indeed as awkward as Rosenberg has indicated, and sometimes it is unattractive, even muddled. However difficult, the study of therapeutics is nevertheless absolutely central to our understanding of medical history. The time has finally come to renew Ackerknecht’s “plea.” But instead of Whiggishly pointing a finger at particular fads, panaceas, and examples of “neophilia” — Ackerknecht’s term for the physician’s appetite for new remedies — one should focus instead on the entire context of medical practice. Thus, for the remainder of this essay, I would like to sketch this broader frame of reference and also review some of the methodological difficulties inherent in the study of therapeutics. ‘The Oxford Dictionary defines “therapeutics” as that branch of medicine 5concerned with the remedial treatment of disease equated with the art of healing.* Not surprisingly, it is a social ritual very much shaped by the prevailing cultural milieu, the patient-healer relationship, current medical knowledge and experience, the actual therapeutic setting, and more recently, the contours of medical technology. A complete study of any given thera- peutic behaviour must, therefore, take into account all of these components. For purposes of analysis, let us look at some of them separately. When a treatment is prescribed to a patient, we ideally presuppose that the practitioner has already conceptualized the presenting complaints and defined a particular health problem. Every therapeutic action is connected to medical theory. For treatment to take place, bodies of organized knowledge must be first consulted before a particular approach can be recommended, with all the inherent difficulties which such linkage suggests.” To whose theory does the practitioner adhere? Why? Is he impressed by its internal logic, weight of tradition, or presumed empirical verification? Moreover, how strictly does the physician apply the main theoretical tenets? To complicate matters, such theoretical knowledge must be constantly recon- ciled with the practical experience acquired by the healer. How important is experience for a particular physician, expecially if it contradicts theory? How can experience actually be tested? What forms of evidence are acceptable?” What kinds of feedback can one expect from that patients themselves? Finally, what mix of theory and experience is usually employed in reaching therapeutic decisions? Who decides? How much freedom of choice does an individual practitioner have in prescribing medication?” Moreover, how do cultural and professional values dictate therapeutic action, and in turn what kind of impact do medications have on cultural assumptions and values?” How, for example, were drug standards establish- ed?" What influence do treatments have on contemporary views of science and how are therapies in turn affected by scientific ideology?” Obviously there is an ongoing debate about these issues in medicine, and students of past therapeutics must carefully consider the medical epistemology for the period under study, and if possible, unravel the philosophical position adopted by the medical personalities being investigated.” As mentioned before, therapeutic decisions often become linked to issues of professional identity, as the recent work of Warner and others amply documents. The history of medicine is replete with accounts of endless controversies and heated arguments between practitioners concerning specific treatments and the underlying theories they sought to represent."* Another frequent point of contention was the seeming difference between rational and empirical treatments. “Raw” empiricism was often equated with quackery.* Such debates not only took place in professional organizations, but were often aired in public through medical pamphlets and books. At stake were issuesnot only of professional status but of legally sanctioned positions in the ‘medical marketplace.” Just as important is the analysis of the contemporary patient-healer realtionship. How close are their respective health-related belief systems and behaviours? How do lay views of the body mesh with medical opinion?™* ‘What are the expectations on both sides regarding the nature of care and possible outcome? What is the character of the relationship in terms of social class and power? What is the professional identity and status of the practitioner? Who controls whom? What needs to be negotiated between them? How are therapeutic decisions made by practitioners? How are they made by patients? What are their respective options?” Finally, one could ask: what is the meaning of the so-called “therapeutic imperative,” the obligation to provide treatment? How is it related to acute symptoms of disease, especially pain Moreover, how can one take into account the placebo effect when studying therapeutic responses?" Closely related to the patient-healer relationship are considerations regard- ing the actual locus of the therapeutic behaviour. Whether the treatments take place in the home of the patient, a hospital or the office of a practitioner often dictates the nature of the therapy.”? There are also regional differences often linked to perceived environmental factors which affect treatment. Historically, institutional frameworks such as hospitals with their particular relationships of authority and social-class have had the power to shape medical practices significantly, including the restriction of diets and drugs according to established rules. In more recent times, the availability of medical technology, another factor in the therapeutic context, is closely linked to the actual site and degree of specialization of medical practice."® In the end, we should return to the methodological difficulties encountered by scholars interested in the history of therapeutics. How can one find out what a physician really did rather than what he said must be done? Most published sources, such as medical treatises, pharmacopocias, and dispen- satories, merely furnish the contemporary recommendations and acceptable list of drugs. This helps, of course, provide a valuable baseline and establish the necessary context of medical practice in any given historical period. Given the great diversity of therapeutic behaviour exhibited by practitioners in all ages, itis imperative that certain parameters of normalcy are defined. However, since individual texts tend to gloss over the blatant discrepancies between accepted medical theories and therapeutic principles, as well as actions, they should only be used as guidelines for understanding the treatments of any period.* In 1967, Ackerknecht realized that the core sources for a more sophisticated history of therapeutics are the patient records found in hospitals, asylums, dispensaries, and private practice case books.” Similar ‘materials depicting medical management can be occasionally extracted from 7 a |private diaries, letters, pharmacy prescription books, health insurance audits, and court records. To demonstrate the importance of such documentation, I am happy to report that the use of such materials is rapidly spreading and several books, including those of Roy and Dorothy Porter,** Judith Walzer Leavitt,“ Regina Morantz Sanchez," John Warner, and myself have made ample use of such records. Other important projects by Jack Pressman, ! and Mary Fissell™ are in progress. The essential documentation, however, is now being threatened every- where because of the rapidly rising costs of storage and, in the U.S., new schedules for record management and disposal. Paradoxically, if present trends continue, we shall have more therapeutic records from the nineteenth century available for the researcher than from the twentieth. We are all grateful for the efforts of numerous archivists who are helping us identify and preserve these records. In this regard one may mention the efforts of the British Hospital Records Project organized by the Wellcome Institute in association with the Public Record Office.* In the United States, we are presently engaged in setting up a Health Care Archive, sponsored by the Department of the History of Health Sciences, the library and archives of the University of California, San Francisco, and a broad array of local and regional organizations. To conclude, I believe that the major point should by now be clear. We need to devote ourselves more earnestly to the history of therapeutics, a critically important aspect of medical history which, with rare exceptions, has been neglected and at times ridiculed. In pleading for more research on this complex topic, I want to argue strongly for a contextual approach in the form of a systematic analysis that will include the most important factors shaping therapeutic behaviour. It is to be hoped that this volume, the outcome of a symposium sponsored by the International Academy, will stimulate further study and debate. REFERENCES 1. E.H. Ackerknecht. “A Plea fora ‘Behaviorist” Approach in Writing the History of Medicine.” J. Hist. Med. 22 (1967) 211-214, 2. E.H. Ackerknecht. “Die therapeutische Erfahrung and ihre allmahlige Objek- tivierung.” Gesnerus 26 (1969) 26-35. 3. Ackerknecht. “A Plea.” Page 212. 4. G.B. Risse. “The Renaissance of Bloodletting: A Chapter in Modern Thera- peutics.” J. Hist. Med. 34 (1979) 3-22. 5. Erwin H. Ackerknecht. Therapeutics, From the Primitives to the Twentieth Century. New York: Hafner Press, 1973, especially the introduction, pp. 1-3. Also C.E, Rosenberg. “The Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth-Century America.” In The Therapeutic Revolution, edited by A 8 paMorris J. Vogel and Charles E. Rosenberg, pp. 3-25. Philadelphia: University of Pennsylvania Press, 1979. 6. Erwin H. Ackerknecht. Therapie von den Primitiven bis zum 20. Jahrhundert Stuttgart: F. Enke Verlag, 1970. 7. Ackerknecht. Therapeutics. Page 94. 8. Ibid, p. 97. 9. Ibid. p. 83. 10. Julius Petersen. Hauptmomente in der geschichtlichen Entwicklung der medicini- schen Therapie. Kopenhagen: 1877, reprinted, Hildesheim: Olms, 1966. 1 Thid., preface, p. IX. 12. Tbid., p. IX. 13, Hluldrych M. Koelbing. Die aerztliche Therapie. Grundzige threr Entwicklung. Darmstadt: Wissenschaftliche Buchgesellschaft, 1985, especially the introduction, pp. XI-XIIL. See also by the same author “Lehren aus der Therapiegeschichte — der therapeutische Optimismus und seine Tiicken.” Schweiz. Med. Wochenschr. 113 (1983) 1378-84, 14, E.H. Ackerknecht. “Aspects of the History of Therapeutics.” Bull. Hist. Med. 36 (1962) 389. 15, E.H. Ackerknecht. “On Driving Out the Devils by Beelzebub in Thera- peutics.” Gesnerus 44 (1987) 190. 16. Lewis Thomas, “Medical Lessons from History. New York: Viking Press, 1979, p. 159. 17. Tbid., p. 159. 18. Guy R, Williams. The Age of Agony: The Art of Healing c. 1700-1800. London: Constable, 1975. 19. Audrey Davis and Toby Appel. Bloodletting Instruments in the National ‘Museum of History and Technology. Washington, Smithsonian Institution, 1979. 20. See, for example, F. Pirruccello. “How the Doctors Killed George Washing- ton.” Chicago Tribune Magazine, (Feb. 20, 1977): 32-34, Also N.E. Davis et al “William Cobbett, Benjamin Rush, and the Death of General Washington.” TAM.A, 249 (1983): 912-915. 21, For some scholarly accounts, see L.S. Bryan, Jr. “Bloodletting in American Medicine, 1830-1892.” Bull. Hist. Med. 38 (1964): 516-529. Also J.1. Waring. “The Influence of Benjamin Rush on the Practice of Bleeding in South Carolina.” Bull. Hist, Med. 35 (1961): 230-237. 22, John H. Warner. The Therapeutic Perspective. Medical Practice, Knowledge, ‘and Identity in America, 1820-1885, Cambridge, MA: Harvard University Press, introduction, p. 2. 23, See, for example, William Brockbank. Ancient Therapeutic Arts. Springfield: Thomas, 1954, Also Lu Gwei-djen and J. Needham. Celestial Lancets: A History and Rationale of Acupuncture and Moxa. Cambridge: Cambridge University Press, 1980; Leonard J. Goldwater. Mercury. A History of Quicksilver. Baltimore: York Press, 1972. 24, R. Forman. “Medical Resistance to Innovation.” Med Hypotheses 7 (1981): 1009-1017. 25. Warner makes this central point in both his dissertation and above cited book. In Medusa and the Snail. o oo26. The Compact Edition of the Oxford Dictionary, vol. Il. Oxford: Oxford University Press, 1971, p. 3284, 21, See J. Parascandola. “The Theoretical Basis of Paul Ehrlich's Chemo- "J, Hist. Med. 36 (1981): 19-43. 28. See, for example, J.W. Estes. “Making Therapeutic Decisions with Proto- pharmalogic Evidence.” Trans, Stud. Coll. Phys. Phila. 5 (1979): 116-137. 29. For a specific example of these issues, consult Guenter B. Risse. “Hospital Care: State of the Medical Art.” In Hospital Life in Enlightenment Scotland, Care and Teaching at the Royal Infirmary of Edinburgh. Cambridge and London: Cambridge University Press, 1986, chap. 4, pp. 177-239. 30, E.D. Pellegrino. “The Sociocultural Impact of Twentieth-Century Thera- peutics.” In M.J. Vogel and CE. Rosenberg, editors, The Therapeutic Revolution. Philadelphia: University of Pennsylvania Press, 1979, pp. 245-266; for a case study see G.B. Risse. “Calomel and the American Medical Sects during the Nineteenth Century.” Mayo Clinic Proceedings 48 (1973): 57-64, 31. G. Sonnedecker. “Drug Standards Become Official.” In J.H. Young, ed. The Early Years of Federal Food and Drug Control. Madison: American Institute for the History of Pharmacy, 1982, pp. 28-39. 32. J.H. Warner. “Therapeutic Explanation and the Edinburgh Bloodletting Controversy: Two Perspectives on the Medical Meaning of Science in the Mid- Nineteenth Century.” Med. Hist. 24 (1980): 241-258. 33. For some discussion see L.S. King. “Medical Theory and Practice at the Beginning of the Eighteenth Century.” Bull Hist. Med. 46 (1972) 1-15. 34, William G. Rothstein. “Medical Practice among Physicians.” In American Physicians in the Nineteenth Century. Baltimore: Johns Hopkins University Press, 1972, pp. 41-62. 35. J.S. Haller. “Aconite: A Case Study in Doctrinal Conflict and the Meaning of Scientific Medicine.” Bull. N.Y. Acad. Med. 60 (1984): 888-904, 36. See A.K. Lingo. “Empirics and Charlatans in Early Modern France: The Genesis of the Classification of the ‘Other’ in Medical Practice.” J. Soc. Hist. 19 (1986): 583-603. 37. J.H. Warner. “Power, Conflict, and Identity in Mid-Nineteenth Century American Medicine: Therapeutic Change at the Commercial Hospital in Cin- cinnati.” J. Am. Hist. 73 (1987): 934-956. 38. See, for example, R. Porter. “Laymen, Doctors, and Medical Knowledge in the Eighteenth Century: The Evidence of the Gentleman's Magazine.” In Roy Porter, ed., Patients and Practitioners, Lay Perceptions of Medicine in Pre-Industrial Society. Cambridge and London: Cambridge University Press, 1985, pp. 283-314. 39. Many of these issues are examined for Georgian England by Roy and Dorothy Porter in their book, Patient’s Progress, Doctors and Doctoring in Eighteenth-Century England. Stanford, CA: Stanford University Press, 1989, especially chap. 9, “Therapies,” pp. 153-172. 40. N. Tomes. “The Interventionist Imperative.” Med. Hum. Rev. 1 (1987): 35-39. 41. A recent detailed treatment ofthis subject is Howard Brody. Placebos and the Philosophy of Medicine: Clinical, Conceptual, and Ethical Issues. Chicago: University of Chicago Press, 1980. 10 a42. G.B. Risse. “Typhus Fever in Eighteenth-Century Hospitals: New Approach- 8 to Medical Treatment.” Bull. Hist. Med. 59 (1985): 176-195. 43. LH. Wamer, “The Selective Transport of Medical Knowledge: Antebellum American Physicians and Parisian Medical Therapeutics.” Bull Hist. Med. 59 (1985): 213-231, 44. Risse. Hospital Life. See especially, “The Context of Hospital Care.” Pages 182-189. 45. See Joel D. Howell. Machines’ Meanings: British and American Use of Medical Technology, 1890-1930. Ph.D. diss., University of Pennsylvania. Ann Arbor: Univer- sity Microfilms, 1987. 46. Warner. Therapeutic Perspective. See especially part II, Change.” Pages 83-232. 47. John H. Warner and I are collaborating on a forthcoming article tentatively titled, “Reconstructing Clinical Activities: Patient Records in Medical History.” 48. Porter and Porter. Patient's Progress. Also In Sickness and in Health: the British Experience 1650-1850. London: Fourth Estate, 1988. 49, Judith Walzer Leavitt. Brought to Bed: Childbearing in America 1750-1950. Oxford and New York: Oxford University Press, 1986. 50. R.M. Morantz, C:S. Pomerleau, and CH. Fenichel,eds., Jn Her Own Words: Oral Histories of Women Physicians. Westport, CT: Greenwood Press, 1982. 51. Pressman is exploring the development of American psychiatry in the twentieth century through a study of psychosurgery and has therefore worked a great deal with patient records 52, Fissel’s study is concerned with the provision and uses of asylums Northwest England, in especially in Lancashire, from the late eighteenth century to the early ‘twentieth. 53. This project directed by Julia Sheppard (Wellcome Institute) and Alexandra Nicol (Public Record Office) with Jenny West (also Wellcome Institute) as the researcher, aims to assemble information about the records of hospitals in the United Kingdom. See also A. Nicol and J. Sheppard. “Why Keep Hospital Clinical Records?” Brit. Med. J. 290 (1985): 263-264. 54. The California Health Archive Project secks to develop historical collections dedicated to health-care delivery issues while also serving as a clearinghouse for similar efforts elsewhere, At a recent conference sponsored by the National Library of Medicine, participants underscored the urgent need for creative solutions to the problems of collecting and preserving twentieth-century documents that contain information about medical care, including therapeutics. ‘The Process of n