Eighteenth-Century Medicine and the Modern Physician

    ALTHOUGH a patient’s medical history, elicited by a series of standard questions related to the health of his various organ systems, is still the keystone of modern diagnostic techniques, the history of medicine itself rarely finds an analogous place in the modern professional curriculum. The twentieth-century physician can fully utilize his special skills without knowing much about their past. Knowledge of the origins of current physiological concepts and health techniques is not in any way essential to providing effective health care, nor is an understanding of those that preceded them.

    This hypothesis is probably more characteristic of medicine than of the other professions. For instance, historical trends in technologies, and in fundamental concepts of man’s relationship to God and to other men, are necessary components of curricula in architecture, theology, and the law. Indeed, the day-to-day practice of law requires study of precedents that are essentially historical.

    By contrast, modern medicine looks ahead, by commonly accepted implication at least, to the future. Its forward leaps are expected by the sick and their families and are reported with enthusiasm and hope in the nonprofessional press. This generalized optimism has stimulated vast public outlays for medical research, focusing chiefly on improved laboratory diagnosis and on new surgical and drug therapies; it is unlikely that substantial improvements in taking patient histories or its complement, the physical examination, will appear.

    Earlier in this century medical history was often regarded as part of the doctor’s necessary, or at least desirable, professional, intellectual, and cultural background. In fact, it was sometimes considered his professional duty to study medical history, needing no further justification. However, perceptions of that duty varied among medical faculties, and national requirements for courses in medical history were never mandated, as they were for subjects like anatomy, pharmacology, and surgery.

    The absence of a proved relevance of medical history to medical practice probably did spawn the fruitful symbiosis between physicians and historians that spread from Johns Hopkins during the early twentieth century. Although about fifty-six percent of the members of the American Association for the History of Medicine (as of July 1978) are physicians, and about seventeen percent have professional degrees in history, very few people who might describe themselves as “medical historians” are physicians, and even fewer physicians have academic credentials in history. Thus, most physicians with an interest in the history of their profession have no more than amateur status in terms of their training.

    Whatever their academic backgrounds, students of the history of medicine illustrate one intersection of C. P. Snow’s now proverbial “two cultures,” but their credentials also lead the two groups of medical historians to different exploitations of their data. The professional historian, who brings professional medical neutrality to his specific tasks, uses his data to develop models for studying the processes of institutionalization, of scientific revolutions, of politicization, of philanthropy, or of whatever else he chooses to study. The enlarged intellectual scope and the historical framework that medical history provides today’s practicing physician may give him perspective and even pleasure, but his practical gains from the pursuit have been difficult to identify. Until recently historical data have seldom been collected with the primary purpose of answering specific modern medical questions; it is now incumbent on us to do so more often.

    Participants in a 1966 conference on education in medical history lamented that few medical school faculties had incorporated medical history into their regular curricula. Although the conferees did focus on the student physician as a primary potential consumer of medical historical subjects, possible practical uses of those subjects were not discussed, and occasionally they were even discounted. A historian, James H. Cassedy, suggested one long-range resolution of the dilemma when he pointed out that medical history needs “to fashion a service role. . . . This means accepting the premise that history can be of direct utility.” Another participant, Owen H. Wangensteen, a surgeon with a noted enthusiasm for the history of his profession, provided a second clue to directions which the subject might take in the future: “The primary purpose of history is ... to lend interpretive meaning to events, not alone of times long past but recent and current as well.... The historian is an investigator. He is asking the same types of questions as the investigator in other biologic disciplines—the why and how of causes and consequences.”1

    Over the past few years Americans have become increasingly troubled over problems affecting their health and their society. These concerns are reflected, for instance, in newspaper columns, in frankly political statements, in the proliferation of courses on “Medicine and Society,” and even in the public’s willingness (now somewhat diminished) to underwrite medical care and research. The leading role in all these reflections, however unwillingly he may undertake it, is assigned to the twentieth-century physician. At the very least, he should be able to understand how similar problems have been perceived and attacked in the past, and he needs baselines from which to measure his own contributions. As Lester S. King has pointed out, it is not the problems facing physicians that have changed, but their answers.2

    New historical data that can help the modern physician understand and solve some of his profession’s contemporary problems appear in this volume. It focuses on the normative medicine of colonial New England, not on its giants or on its most celebrated contributions to health care. To paraphrase Thomas Kuhn (by substituting the word “medicine” for his “science”): “History, if viewed as a repository for more than anecdote or chronology, could produce a decisive change in the image of medicine by which we are now possessed.”3

    Whether one accepts Bacon, Galileo, Harvey, or some other pioneer as the prime mover toward today’s emphasis on the “scientific method” and the promise of “progress” that it implies, the idea of medical progress is nevertheless firmly rooted today. Perhaps it was because the last generations of medical historians were eyewitnesses to the fastest strides in medical innovation that they tended to measure progress in quantum bits; seldom, or too quickly, did they or the practicing physicians among their contemporaries attempt to answer the kinds of predictive questions that must be answered today as we plan effective health care strategies for the future.

    For instance, if today we are concerned with providing optimum medical care for Americans now and into the future, we will do so best if we can call upon historical data to help us delineate those settings in which optimum medical care was provided in the past. To accomplish this task, for which history is uniquely able to provide the necessary tools, we must devise methods for identifying and measuring the successes, and the failures, of medicine in the past.

    As a corollary, we need to explore ways of assessing the impact of specific therapies—surgical, preventive, pharmacological—on the health of American populations in the past, to help us predict their impact in the future. That is, eighteenth-century data, collected just before both the Industrial Revolution and the rise of modern micro-biological attacks on disease, should be exploited as negative control data, because most eighteenth-century therapy, especially with drugs, can now be regarded as having been ineffective by modern criteria.

    Although we can now recognize that most eighteenth-century patients could not have received definitive therapies, they continued to seek professional medical assistance, and they paid for it. This is not a paradox, neither does it suggest that placebo therapy was widely exploited. Rather it suggests an opportunity for further study of the doctor-patient relationship in the past. Its “disappearance” is often deplored today, but the data in this volume may suggest that the nature of the relationship has merely changed as new technologies and opportunities for medical care have developed. At least, that is the new hypothesis to test before we can conclude that something “good” has vanished.

    On the other hand, today’s physicians sometimes deplore the increasing demands being made on their professional activities, as reflected in burgeoning malpractice suits and in the establishment of peer review mechanisms. The true extent of the novelty of these trends, as well as their efficacy and their defenses, can be most effectively assessed in the light of new knowledge about their earliest manifestations. Again, knowledge of what the colonial patient could legitimately expect from professional medicine will shed light on what his twentieth-century descendant can expect, and help us to differentiate what could then be expected from what was actually delivered, a difference which is still pertinent.

    Implicit in all these concerns is the changing attitude toward death as the last event in ill health. Colonial Americans expected to die; we do not. Study of changing concepts of death and its close corollary, old age, should, then, help us in our planning for increasingly “socialized medicine.” Such study should help modern physicians help their patients who are approaching death, and help physicians understand the limits of their own roles in the process.

    Many of modern America’s concerns about the care of its health are intertwined with modern ideas of scientific progress, specifically of the social uses of science. The eighteenth-century medical experience should illuminate some earlier ways in which man has perceived generic science. The late colonial period, in particular, was accompanied by the blossoming of new concepts of nature and its order. Those embryonic concepts led late eighteenth-century physicians and patients to conclude that medicine was synergistic with nature, not with God, whose intervention had been taken for granted throughout the earlier colonial years. The historical lessons will have to be studied very closely if we are to cope successfully with today’s assumption that medicine can go beyond nature, that doctors can thwart her. The doctor who finds himself unable to meet all of society’s demands on his professional skills will have to delineate, from available historical data, the extent of what doctors and patients in the past have regarded as possible and desirable; he will have to document his conclusions with data that permit evaluating the actual impact of professional intervention on the course of disease. For instance, although the discovery of antibiotics has been widely regarded as one of modern medicine’s greatest triumphs, historians have been able to recognize that deaths attributable to infectious disease had been declining steadily for at least a century before, as a result of gradual improvements in man’s sanitation practices and his social environment.

    Much of society’s mounting attack on medicine is directed toward the profession’s institutions and its collective image. It comes as an historical surprise to find Jonathan Swift penning a savage attack on medical research organizations in 1726,4 much as selected federally funded research projects are lampooned by politicians today. The modern physician will be better prepared to appreciate and exploit his own institutions when he understands the circumstances of their origins, and can then relate them to modern circumstances.

    Heretofore we have had few data pertaining to colonial New England medicine. From the 1977 tabulation of Research in Progress by members of the American Association for the History of Medicine it appears that less than three percent of specifically titled projects are concerned with colonial America, although an equal proportion at least touch on the same time-space conjunction. (Over twenty-seven percent of all projects centered on specifically American topics, forty-four percent on historical medicine in all other countries, and twenty-nine percent on topics without national or specific chronological boundaries.) About twice as much medical historical attention was being given to the years 1600–1800 in Britain, France, and other countries as in contemporary colonial America. This volume, which includes many projects not reported in the 1977 tabulations, should help fill the gaps implicit in them.

    Contemporary physicians will find in these essays much of the background that will help them begin to solve the problems that face them as a group today, especially when they consider the solutions devised by their professional ancestors. They will learn how doctors in eighteenth-century New England identified themselves, and how they differentiated themselves from other healers. They will learn how colonial New Englanders learned medicine and its skills. They will learn how colonial patients were treated, what the patients expected of their doctors, and what colonial doctors exploited from their own past. Finally, today’s doctors will learn how those of six to ten generations ago related to the society in which they worked, and to the still rudimentary science that underlay their healing skills.

    Philip Cash

    Eric H. Christianson

    J. Worth Estes