The Bleeding Founders

The history of medicine, like the history of science, is a highly bifurcated and contentious field. Some historians of medicine, Lewis Thomas and David Wootton, for example, believe that the past is decidedly inferior to the present and that nothing much good happened in medicine until the mid-nineteenth century and the discovery of germ theory. The reason that physicians do not want to read about the history of medicine, said Thomas, “is that it is so unbelievably deplorable,” with all that bleeding, purging, and misunderstandings based on theories of the human body inherited from antiquity.

David Wootton, in his book Bad Medicine (2006), goes further. He thinks doctors in the past ought to have known better. The knowledge of many diseases and their remedies was staring them in the face, and they ought to have seized upon this knowledge and saved countless lives. Instead, they were caught up in their hidebound theories and ignored the empirical evidence that was all around them; and thus for centuries they killed more people than they cured.

For the past generation other historians, such as Roy Porter and Charles E. Rosenberg, have tried to counter this kind of present-minded history by writing social histories of medicine that respect the integrity of the past. They have set forth more charitable interpretations of past medical practices than Thomas and Wootton, and have attempted to understand those past medical practices in their own terms. In other words, they have sought to treat the history of medicine as sensitive historians now treat the history of other fields of human endeavor such as politics and religion. Good historians do not go back and condemn, say, John Winthrop of seventeenth-century Massachusetts for not being more like us today, for not believing in democracy and religious liberty. Instead, they seek to understand Winthrop and his fellow Puritans in their own terms, as they understood themselves. They don’t assume that the past is inferior to the present.

So why can’t historians of medicine do the same thing? Why does the history of medicine, like the history of science in general, have to tell a triumphal story of the march of reason and knowledge out of darkness into our enlightened present? That is the question that has set the history of science and medicine apart from the other fields of history.

The problem is that most historians are relativists. They don’t privilege the present over the past, and they don’t believe in absolute values and truths. By contrast, many historians of medicine and science are universalists. Scientific and medical truths, they contend, are not relative to time and place; they are always and universally true. If the germ theory is true, then it was just as true for eighteenth-century America as it is for the rest of the world today.

Can historians of medicine and science write about the past without assuming its inferiority to the present? Can they respect the integrity of the past in the way other historians do? Is it true, as some historians of medicine now contend, “that medicine, far from tending toward absolute truth, reflects and interacts with culture, society, and politics”? The debate over these issues is often ferocious, making the histories of medicine and science very difficult to write.

With her book on the founding fathers and mothers in sickness and in health, Jeanne E. Abrams has stepped rather innocently into this divided and disputatious world of historical scholarship on medicine. Although she cites Wootton’s book in a footnote, she seems scarcely aware of the debate over the way the history of medicine ought to be written and the depth of passions involved. Abrams, who is a professor at Penrose Library and the Center for Judaic Studies at the University of Denver, selected a half-dozen founders to write about—George and Martha Washington, Benjamin Franklin, Abigail and John Adams, Thomas Jefferson, and more briefly James Madison. She says that she chose to write about these Revolutionary characters because “all of them experienced dramatic and often tragic personal encounters with disease and epidemics.” All of them left enormously rich bodies of correspondence in which they often talked about sickness and health, and all of them brought somewhat different perspectives to the problems of medicine.

Although Americans were probably healthier than most people in eighteenth-century Europe, illness and disease were everywhere in the new United States. Perhaps one quarter of all children died before the age of one. The smallpox epidemic that ravaged the country between 1775 and 1782 killed more than a hundred thousand people, at least four times as many as were killed by the British army. Washington had no children, but the widow Martha Custis had four, all of whom died before she did, one at age two, another at age three, a third as a teenager, and the fourth in his twenties.

Franklin lost one of his two sons to smallpox at age four. The Adamses had six children: one was stillborn, another died at fourteen months, a third died of alcoholism at age thirty, and their first-born daughter died of breast cancer in her forties. An epidemic of dysentery in 1775 killed hundreds of Bostonians, including Abigail’s mother and one of her maidservants. John Quincy Adams’s wife Louisa suffered seven miscarriages but gave birth to four living children, only one of whom survived to old age. When Martha Wayles Skelton at age twenty-three married Jefferson, she had already lost her mother, two stepmothers, her first husband, and a son aged three. Jefferson lived to eighty-three and saw death all around him. He outlived his wife, five of his six children, six of his ten siblings, and even several of his grandchildren. Abrams’s statement “that illness and death were a constant factor in the daily lives of people from all walks of life” can scarcely do justice to the reality.

Much of Abrams’s book is a conventional narrative of the lives of her selected founders. She fills that narrative with every reference to their health and their illnesses that she could find in their letters. From her account it seems as if they talked about nothing else but their various aches and pains and their experiments with diverse remedies. Washington’s robust appearance was belied by his frequent illnesses, for which he was always bled. He had many respiratory and intestinal problems and, as everyone knows, he eventually lost all his teeth. When he became president in 1789 he had only one remaining tooth.

Shortly after taking office he developed an inflamed tumor on his thigh that seemed life-threatening. The frequency of his ailments convinced him that he was about to depart “for that country from whence no traveler returns.” He died in 1799 at age sixty-seven of a throat infection that would be curable today. On his deathbed he was bled four times. A tracheotomy suggested by one of his attending physicians might have saved him, but the senior physician present rejected it as too dangerous.

John Adams was always complaining of ailments, but because he lived to be ninety-one Abrams calls him a hypochondriac. Many of the letters exchanged between him and Abigail were filled with matters of health and sickness, not only of each other, but also of friends and family members. In 1818 Abigail contracted typhoid, which led to her death at age seventy-three. In the 1990s a historian and a physician diagnosed John Adams from afar and concluded that he suffered from a thyroid condition—a diagnosis that Abrams quite rightly questions. Even Jefferson, despite all his exercise and his diet of vegetables and wine, suffered from a number of ailments, including severe migraine headaches, which many historians, including Abrams, attribute to stress. He died at age eighty-three. Like Adams, Madison constantly complained of his weak constitution and expressed fears of a short life, but he lived to be eighty-five.

All of the founders, in other words, surpassed the average age of life expectancy for the late eighteenth century. That age Abrams puts at late forties to early fifties for males. But these statistics for average life expectancy are tricky and have to be used with caution. With so many infant deaths the average age of life expectancy was bound to be low. Life expectancy is not the same as life span. To get an accurate picture of life spans, we need a base other than birth from which to measure life expectancy in order to get a more accurate picture of how long people lived. What was the expectancy if one could reach age twenty, or forty, or fifty? When Washington was born, Abrams says, the average life expectancy in Virginia was only about twenty-eight to thirty-five, implying that if a male lived longer than that then he was extraordinary. That is not the way statistical measures of life expectancy work.

With all the evidence of sickness and death and the ineffectiveness of most remedies in the late eighteenth century, it is not surprising that Abrams has a somewhat condescending attitude toward the past. She tells us over and over that “doctors of the period had virtually no understanding of germs and their role in spreading disease.” She points out that the great Dr. Franklin advocated the use of “a common garden weed to treat cancer,…demonstrating that even leading minds of the era could be misled.” “Anesthesia for childbirth or even for major surgery were unheard of at the time.” Washington was bled many times, “demonstrating once again how often bleeding was used, even in instances where the procedure appears to us today as clearly counterintuitive.” It seems as if most of those poor benighted souls back then did not possess much of our present medical knowledge and advantages.

But some apparently did. And so Abrams finds some of the founders, at least on occasion, able to anticipate our present superiority; and those who were able to do so are given high marks. Despite his mistaken remedy for cancer, Franklin was “surprisingly forward-looking” in cautioning “about what we today would consider mental health issues.” Even though he didn’t know about germ theory, “Franklin seems to have intuitively understood that many common illnesses such as colds and influenza were spread by close contact and that fresh air could mitigate the transfer of sickness.” Both he and Jefferson were also right in emphasizing the importance of fresh air, exercise, and moderate diet, “a regimen advocated by modern medicine today.” Franklin also observed that human beings “eat about twice as much as nature requires” and he “appears to have understood the concept of burning calories.” “It takes little imagination,” Abrams says, “to predict how Franklin would have reacted to America’s addiction today to high-calorie fast foods.”

Although John Adams “never attained the sophisticated scientific understanding of medicine displayed by both Franklin and Jefferson,” he and his wife were not without some knowledge of the future. Abigail especially had “advanced views about health and medicine,” for she was “familiar with preventive medical treatment for a number of illnesses,” and “possessed an intuitive understanding of the connection between the mind and the body.” But it was Jefferson who was most in tune with our present medical world. “He had an intuitive and advanced understanding of contagion,” and he emphasized the importance of preventive medicine. Above all, he doubted the efficacy of many eighteenth-century remedies, especially bleeding.

Nearly everyone believed in bleeding as the most important therapeutic treatment for a multitude of ills. Abigail Adams did, Franklin did, and Washington certainly did. Benjamin Rush, who was the most celebrated physician of the Revolutionary era and who weaves in and out of Abrams’s account, was a notorious bleeder. In good Enlightenment manner Rush sought to simplify the taxonomy of diseases. He carried his enlightened project to its ultimate conclusion and reduced hundreds of diseases to only one—fever, caused by convulsive tension in the blood vessels. Unfortunately for his patients, he overestimated the amount of blood in the human body. He thought most people had twelve quarts of blood, double the six quarts in the average person. Since he often took from his patients as many as five quarts of blood in a day and a half, it is not surprising that so many of them died. The journalist William Cobbett termed Rush’s method of bleeding “one of those great discoveries which have contributed to the depopulation of the earth.” This became one of the statements that Rush used in his successful suit for libel against Cobbett.

Despite his excessive bleeding, Rush remained the most famous and sought-after doctor of the period. In fact, bleeding and purging had been the principal remedies for many diseases for centuries, and they continued to be so for Americans well into the nineteenth century. The problem facing the historian is to explain why these apparently wrongheaded medical practices lasted as long as they did.

Several times Abrams raises the question of why “sensible and medically sophisticated” founders such as Franklin “found the procedure [of bleeding] helpful, as there is no medical explanation.” “Why,” she asks, “would Abigail Adams, who was progressive in her thinking concerning politics, women’s rights, and education, cling to these primitive medical procedures [of bleeding, blistering, and purging]”? It was “even more puzzling” that Abigail would think as she did, given the advanced thinking the Adamses had shown on the issue of inoculation. The best answer she offers to her questions is that “purging and bleeding were considered by most leading medical practitioners as advanced therapeutic procedures.” Besides, she writes, Dr. Benjamin Rush believed in bleeding and purging and nearly everyone respected him.

This just begs the question of why the leading medical practitioners believed as they did and had done so for centuries. A good historian would offer an explanation for these medical practices that had persisted for so long, and not simply dismiss them as primitive things that had to be outgrown. In 1979 the distinguished historian of medicine Charles E. Rosenberg in an important article presented just such an explanation.^* A medical system that lasted so long, he argued, must have worked, even if not in a sense immediately intelligible to a twenty-first-century clinician.

Rosenberg’s sophisticated explanation is not easily summarized. For centuries physicians viewed the body in holistic terms. They believed that all parts of the body were related to one another and to the environment. The constant interaction with the environment was visible in the body’s intake and output—food, perspiration, feces, urine, secretions, and the like. Everything in the body had to be in balance if the individual were to remain healthy. It was not the absence of a particular disease that constituted health, said Rosenberg; it was maintaining the body in equilibrium. Illness occurred when the body became unbalanced.

In addition to the exigencies of everyday life that might throw off the equilibrium, the body had to pass through several crises of development inherent in living—menstruation and menopause in women and teething and puberty in both sexes together with seasonal changes in climate, all of which required bodily adjustments. All these moments of change and instability represented points of potential danger as the body sought to establish a new internal equilibrium. Physicians did not tend to think in terms of specific diseases; instead, they saw their role as one of regulating the secretions—extracting blood, promoting perspiration, or urination, or defecation, which demonstrated that they had helped the body regain its customary equilibrium.

Even inoculation for smallpox, said Rosenberg, could be fitted within this explanatory frame of seeking balance in the body. Physicians always accompanied the inoculations and later the vaccinations to prevent smallpox with an elaborate regimen of cathartics, diet, and rest—designed to help assimilate “an anomalous procedure into the physician’s accustomed picture of health and disease.”

Drugs were not ordinarily designed to cure specific diseases; rather they were used to adjust the body’s internal equilibrium. Texts about “materia medica” were usually arranged not by drug or disease but by their physiological effects—as diuretics, cathartics, narcotics, emetics, and diaphoretics. Quinine, for example, was categorized as a tonic and prescribed for numerous ailments besides malaria and almost always with a cathartic. Physicians persisted in these treatments because they seemed to work—“that is,” as Rosenberg said,

by providing visible and predictable physiological effects; purges purged, emetics vomited, opium soothed pain and moderated diarrhea. Bleeding, too, seemed obviously to alter the body’s internal balance, as evidenced both by a changed pulse and the very quantity of the blood drawn.

This same system helps explain the popularity of mercury as a flexible drug. Mercury induced a series of progressively severe and cumulative physiological effects that could end with full-blown symptoms of mercury poisoning. But mercury’s obvious capacity to alter the balance of forces in the body made it especially useful to physicians. The founders certainly used it; even Jefferson, despite his caution about bleeding, applied mercury to a rash and became deathly ill.

This explanatory approach, brilliantly described by Rosenberg, was satisfying to both physicians and laymen. It fit their understanding of the way the body functioned, which in turn was reinforced by the available therapeutic treatments designed to balance the elements within the body. “The secretions could be regulated, a plethoric state of the blood abated, the stomach emptied of a content potentially dangerous.” The system was “all-inclusive, antireductionist, capable of incorporating every aspect of man’s life in explaining his physical condition.” Even when physicians at times felt some anxiety over their treatments, they could take comfort from knowing that they were following practices endorsed by reason and centuries of clinical experience.

Rosenberg’s historical explanation of eighteenth-century medical thinking is beyond Abrams’s ken. In her account of medicine in the Revolutionary era she makes no serious effort to explain why physicians and patients believed and behaved as they did. She is mainly interested in giving high grades to those founders who were “forward-looking” and in lamenting those who were stuck in the past. She especially seeks to bring to our attention the founders’ contributions to our present understanding of medicine. She refers several times, for example, to John Adams’s signing into law in 1798 the establishment of the Marine Hospital Service that a hundred years later evolved into the modern Public Health Service.

Abrams never misses an opportunity to show that suggestions made by the founders, such as Franklin’s use of herbal remedies, have some connection to the present. Indeed, “many of his theories remain sound today.” Thinking about our present medical debates, she is particularly eager to demonstrate that Franklin and others recognized “that the state had an important role to play in fostering public health and protecting citizens from contagious epidemics.” She even regards Abigail Adams’s relief over Boston’s temporarily allowing people to get inoculated for smallpox as evidence that “Abigail clearly supported a strong role for government in the health arena.”

In the end Abrams wonders what the founders would have made of President Obama’s Affordable Care Act. Given their commitment to the public good,

they would have looked with approval on providing the opportunity to access good health care for all Americans…. But given their fierce commitment to the principles of individual liberty, they surely would have balked at requiring all citizens to purchase health care insurance, as will occur under the new federal mandate.

Perhaps this is carrying our preoccupation with what the eighteenth-century founders think about us in the present a bit too far.