MEDICINE

Between 1754 and 1829, medicine in what would become the United States passed through three stages. All of the stages originated in Europe, and American medicine remained in a colonial relationship with that continent, regardless of what was going on in politics and economics.

stages of development

At first, physicians and educated people who knew medical texts tended to think in very traditional terms and formulations that had been honored since the time of Galen in the second century a.d. People fell ill because of an imbalance in the humors—black bile, yellow bile, phlegm, and blood. To this basic scheme were added alchemical ideas, folk wisdom, and sometimes ideas about the body as a chemical or physical organism.

The second stage came in the late eighteenth century, when a number of physicians took up Enlightenment teachings. The most conspicuous and important was Benjamin Rush, a physician and teacher in

Philadelphia. Rush based his ideas on those of William Cullen of Edinburgh, who in turn inspired John Brown, also of Edinburgh, where a significant number of American physicians studied. All three of them taught highly rational systems of medicine, as was appropriate to the Age of Reason. Disease in their eyes represented either too much or too little irritability or excitability. Rush in particular held that pathology grew out of a morbid tension in the walls of the arteries.

After the War of 1812, leading American physicians began to study in France. By 1830 the French clinical school was deeply influencing the way physicians viewed and treated ill health. By correlating symptoms with local lesions found during autopsy, and by introducing a measure of skepticism concerning traditional therapies, French clinicians gave a small but growing number of American physicians a sense that empirical investigation could lead to much better understanding of disease.

ideas about disease

Except for the theories of Rush and others, and then the slow incursion of notions of localized pathology, ideas of what a disease was did not change greatly in the two-thirds of a century after 1763. Epidemics were sent by God, but individuals had some control over their own health. Something, it was held, went awry with "the system," a more or less mechanical entity that nevertheless had a vital spirit infusing it and was sensitive to the ordinary inputs of eating and sleeping and the more ominous influences from the environment (often airborne "miasmas"). Because the ideas of both the human system and inputs and environments were vague and contested, medicine remained at best an inexact science and one that was difficult to explain in that time or this. Certain features did stand out, however.

While a few diseases were distinctive, such as syphilis, cancers, stroke, and smallpox, most acute diseases were just varieties of general categories, chiefly fluxes (that is, diarrheas) and fevers. And that was what practitioners ordinarily saw the most of. But fever could come in many varieties, such as long fever (typhoid), malarial fever, putrid sore throat, and the like. In general, diseases were classified by symptoms. One of the most common diseases, for example, tuberculosis of the lungs, was described in a term suggesting the way patients wasted away: consumption.

What people at the time especially noted was how illnesses varied with season and geography. The measles of one year would be different from that of the next. Even epidemics came at different seasons—everyone knew that malaria was a disease of hot weather, that respiratory and arthritic ailments were worse in the winter. Moreover, there was serious doubt that the disease of one place was the same as that of another. It was a surprise in 1800–1801, for example, that the smallpox of New England would respond to vaccination just as would the smallpox of Old England.

As sectional identities began to develop, sectional differences appeared among physicians. Southerners encountered diseases such as malaria and yellow fever that were seldom found in the North. Northern physicians had to deal with diseases of cold weather, not only frostbite but arthritic disorders, which appeared in young as well as older adults. The trans-Appalachian West even acquired a significant disease, first described in 1809–1811. Called the milk sick, it later was found to be poisoning that came when cattle ate a common weed, white snakeroot, so that the illness was both geographical and seasonal. As settlers filtered into the West, the milk sick was a serious and sometimes epidemic disease. (The mother of Abraham Lincoln died of the milk sick in 1818.) On the basis of these different types of illnesses, physicians began to describe special regional medicines, especially southern medicine.

treating illnesses

To a remarkable extent, the therapies available then were general, designed to set the system back onto a natural course so that it had humors in balance or the amount of irritability or tenseness balanced. There could not be a specific cure until there was a specific disease to be cured. From an earlier period, there was a specific cure for the disease of syphilis: mercury. And in the 1730s, Europeans started using cinchona bark, which contained quinine, a specific for malaria. But since the bark affected one fever, many physicians used it for all fevers, since "fever" was the working category. Then, beginning in 1785, foxglove (containing digitalis) was imported from England, where it was discovered to counter dropsy (congestive heart failure). Thus, the list of specifics was a very short one, without significant additions until after 1830.

Physicians often prescribed very powerful drugs—usually herbs, including opium. Each practitioner had his or her favorites. Diet and other, more homely, devices were also used. Sweating was common. The gastrointestinal system was kept as active as possible, and stimulating medications were administered from both ends of the GI system, causing diarrheas and vomiting. "Trust in God, and keep the bowels open," was common wisdom.

Treatments were described in general terms according to the effects that they had on the system. There were stimulants (people most importantly and incorrectly imagined that alcohol was a stimulant). There were depletives, of which the most commonly employed was bleeding. And there were alteratives, such as violent purges that wracked the system and left it in a new rhythm or state after the effects had run their course.

Physicians and people practicing on themselves utilized other techniques as well. In addition to bleeding, a variety of instrumentalities existed to produce running sores and pus by means of which the body would throw off "moribific matter" or undesirable elements in the blood. The skin could be blistered with irritants such as cantharides (Spanish fly) or cupping (burning paper in a cup applied to the skin and creating a vacuum). "Issues" could be created by inserting a pea or bean under the skin to obtain a discharge. Or a seton could be made: a thread was run under the skin and then coated with an irritant and pulled back and forth, which usually produced a satisfactory discharge (done in the neck for headache, for example).

Since treatment modalities tended to persist from the late eighteenth into the nineteenth century, the style of treatment rather more than the specific details defined changes in medicine. Beginning in the 1790s, and especially under the leadership of Benjamin Rush, who thought his extreme measures had some effect against the yellow fever epidemic in Philadelphia in 1793, so-called heroic medicine flourished in the United States. The more serious the symptoms, the more powerful were the treatments. "It is but trifling with the life of a man to give him less of a remedy than his disease calls for," wrote a southern physician in 1828.

Heroic treatment consisted of the usual therapies carried out with more than usual vigor and dosage. "Copious bleedings" took place—to an extent that scandalized later generations. Although extremely violent purgatives were used, "the Samson of the material medica" was mercurous chloride, or calomel. Calomel was used as a stimulant, and it did stimulate the gastrointestinal system. Calomel also caused classic symptoms of mercury poisoning. The mouth could turn ash gray, ulcers of the oral area appeared, and teeth could become loosened. Patients often took calomel until they "salivated"—another sign of mercury poisoning.

Heroic treatment spread most famously to the West and South. The practice of many New Englanders and other physicians was often relatively restrained and mild—and empirical. But already by the 1820s, a popular reaction had set in, and many lay people as well as medical practitioners were criticizing heroic styles of practice. At the same time, an active stance regarding an individual patient's disease was part of a professional identity.

surgery

In colonial medicine, physicians, even those trained in England as surgeons, did only limited kinds of surgery. Since there was no anesthesia, and since infection almost invariably followed cutting into the body, only in urgent cases would anyone resort to surgery. A competent practitioner would set a simple fracture or correct a dislocation. He would lance abscesses and extirpate growths on the skin. He might couch a cataract. In a case of a compound fracture, or in warfare when a bullet broke the skin, amputation of the limb was called for. Infection otherwise would almost certainly kill the patient. The only generally accepted procedure that involved cutting below the skin on the body or head came when a patient was dying with bladder stones that prevented urination. Then a physician could "cut for stone"—often with considerable success.

Occasionally some foolhardy or desperate practitioner would attempt to intrude into the thorax to cut a dangerous growth or condition, though such incidents became more common in the nineteenth century. The most famous instance was that of Ephraim McDowell, a practitioner of Danville, Kentucky, who in 1809 operated on a woman with a large ovarian tumor. He subsequently repeated the operation successfully, reporting his cases in 1817. And all through the late eighteenth and early nineteenth centuries, many practitioners ingeniously invented or copied new and better surgical instruments, many of which have survived in museum collections.

medical practice and self-treatment

Almost all practice was carried out in patients' homes or, to a lesser extent, the physician's home office. Charitable hospitals appeared only slowly. The Pennsylvania Hospital had been founded in 1751 (and the New Orleans Charity Hospital in 1736), and others came and went. But no one would willingly choose a hospital over home care. Nursing, either institutional or domestic, was carried out by servants or relatives.

Because of the isolated life of many settlers, and because a large and growing proportion of the population was literate, many Americans avoided the expense of seeking medical advice and used their own means to treat their illnesses. Sometimes family recipes or folk healing sufficed. A growing number of advice books was available, either imported from Europe or printed in America in pirated editions. Throughout the period, almanacs like those compiled by Benjamin Franklin contained medical advice. Most notably, proprietary or "patent" medicines, offered commercially, attracted many customers. Newspaper ads for English preparations first appeared in significant numbers during the 1750s, and by the 1820s Thomas Dyott of Philadelphia, a former bootblack, was becoming one of the richest men in the country by marketing nostrums.

In 1830 American medicine was poised for great changes. For the first time, Americans would be contributing significantly to world medicine. (The physiology of digestion, surgical anesthesia, and landmark therapeutic skepticism all came in the 1830s.) Cholera, which terrorized the population and stimulated changes in medical practice; health reform movements; and the railroad, which enabled professionals to organize, all lay in the future. Meantime, in the 1820s, many signs of the future were already in place. Sulfate of quinine—in place of "bark"—came in. A national pharmacopeia appeared in 1820, with a promise of revision every ten years. The Philadelphia College of Pharmacy was established in 1821. The first state mental hospital to signal a wave of reform that swept the country, the Eastern Lunatic Asylum (later Eastern State Hospital), was established in 1824 in Lexington, Kentucky. And by 1829, 105 American physicians had returned from studying in Paris. Of course, they still had to practice right alongside a very large number of practitioners of various degrees of education, apprentice training, self-education, and simple commercial cupidity.

See alsoAsylums; Epidemics; Health and Disease; Malaria; Mental Illness; Pain; Patent Medicines; Professions: Physicians; Smallpox .

bibliography

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Estes, J. Worth, Philip Cash, and Eric H. Christianson, eds. Medicine in Colonial Massachusetts, 1620–1820. Boston: Colonial Society of Massachusetts, 1980.

Gevitz, Norman, ed. Other Healers: Unorthodox Medicine in America. Baltimore: Johns Hopkins University Press, 1988.

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Reiss, Oscar. Medicine in Colonial America. Lanham, Md.: University Press of America, 2000.

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John C. Burnham