Histories of medicine over the past few decades have been written from the “bottom up,” focusing explicitly on health and disease in the lives of ordinary Americans. Jeanne Abrams, by contrast, gives us “top down” history with a vengeance. In Revolutionary Medicine she has written, in essence, a series of mini-biographies of the medical lives of Martha and George Washington, Benjamin Franklin, Abigail and John Adams, and Thomas Jefferson, with attention also paid to Dolly and James Madison. But in writing this volume she has given us much more than simply a history of the lives of the rich and powerful. Although the core of the book is a focus on perhaps the most privileged members of society, Abrams uses them to offer a window into how health and disease were experienced by ordinary folk in Revolutionary-era United States.
Abrams has carefully combed through a multitude of primary and secondary sources, most prominently the voluminous correspondence that characterizes leading figures of the era. She has gathered a wealth of information about the medical ailments that befell the “founding fathers and mothers” and their families. Although we read a great deal about the larger context of the lives of the main characters, the emphasis on health runs the risk of making it appear that all they did was deal with illness. At times the book seems to detail every ailment, major and minor, that afflicted that person over the course of a lifetime. For example, Abigail & John Adams were married well over half a century. They exchanged many letters, almost all of which mention something about illness. Did this mean they were unusually sickly? Was this level of ill-health normal in that period? Or was their personal style simply one that included consistent complaining about physical ailments? (It should be noted that Abigail lived to the age of 73 and John to 90, both well in excess of the usual life expectancy, and suggesting that whatever diseases they may have suffered from were not overly serious.) While some of the ailments noted in the letters may have been minor, there is no doubt there was plenty of life-shortening disease around, and evidence presented in the book makes it clear that the 18th century was a brutal world in which to experience health and disease. Many people died early in life, including family members of the people discussed here. All four of Martha Washington’s children died young. Five of Jefferson’s six children died before him.
The illnesses that plagued the privileged were by and large the common diseases that affected other members of the citizenry, and the book includes wonderful descriptions of specific diseases. Benjamin Franklin suffered from both gout and kidney stones, and wrote about them with both style and verve. Malaria was a common problem, as was yellow fever and dysentery. Smallpox is perhaps the disease most commonly discussed, both because of its prevalence and its importance to the nation’s history. George Washington insisted on inoculation of Continental Army en masse in the 1770s. Franklin supported inoculation. Adams’ letters to his wife during an epidemic were smoked to prevent transmission of the disease. Jefferson traveled some distance to be inoculated; he later vaccinated his entire household and thought the procedure should spread across the country.
Personal health advice probably was not that different for elite than for the masses. Much of it came from home health manuals and administered by a literate member of the household, often female, as is nicely illustrated in the case of Abigail Adams. But there was certainly contact between the elite and physicians. The social circles of the people whose lives are described in this book overlapped with physicians. Moreover, leading members of society felt quite comfortable offering medical advice. Franklin acted like a physician at times. He also invented tools that helped people with common medical conditions, including the invention of both bifocals and the first urinary catheter. Often appropriately praised as a polymath, Franklin has become prominent enough in popular culture that the comedy troupe Firesign Theatre once observed that “Benjamin Franklin is the only President of the United States who was never President of the United States.” His fellow Philadelphian Benjamin Rush really was a physician, and he plays a prominent role in the various narratives, both as an advisor and as a treating physician.
… evidence presented in the book makes it clear that the 18th century was a brutal world in which to experience health and disease. … All four of Martha Washington’s children died young. Five of Thomas Jefferson’s six children died before him.
These early American leaders not only saw good health as key for the overall strength of the nation, they also were in positions that enabled them to act on their beliefs. Sometimes this was manifest in advocating health care for groups, such as Washington’s inoculation of the Continental Army. Jefferson sought help from his physician colleagues to come up with medical questions for the Lewis and Clark expedition, including attempts to learn about the incidence of diseases. Sometimes their leadership was manifest as through initiation of organizations for improving health. Franklin played a key role in founding the Philadelphia Hospital, as did Jefferson for the University of Virginia. John Adams created the United States Marine Hospital Service, which eventually became the Public Health Service.
The book gives the reader a good sense of the particularities of life in the early republic, especially the vicissitudes of transportation. Jefferson frequently traveled between Washington and Monticello, a 117-mile trip that took him four days. Others traversed the Atlantic, a 4-6 week voyage that took its toll on the health of people such as Franklin.
Abrams gives three goals for the book: to demonstrate the critical roles the key figures played in the development of public health, to tell some quite dramatic stories about each of the figures, and to give us insight into colonial and early-republic medical treatment and practice. She accomplishes the first two goals quite well. The narrative accounts are often colorful. Abrams uses the protagonists’ words to good effect to create a lively image of the world in which they lived, and to offer intimate details of the illness experience.
But insights into colonial and early-republic medicine are made more difficult by her constant attempt to hear those 18th–century words through 21st-century ears, to speculate about how one might apply 21st–century diagnoses to 18th-century ailments. This approach tends systematically to undercut our ability to understand the period she is describing.
Consider bleeding. Abrams gives a thoughtful account of George Washington’s final illness, which was marked by considerable bleeding. She also notes that bleeding for most ailments is “ludicrous to us today.” That’s true, but unhelpful. If we want to understand the past, we need to try to understand why people bled. They did so in a genuine attempt to help their patients, their family, and their leaders.
More generally, the book doesn’t go far in providing any attempt to understand elements of 18th-century medicine that do not map easily onto our current understanding. Medical beliefs are described as either “outlandish” or “more progressive” based on what we now believe to be true. But these ideas weren’t outlandish at the time. Similarly, good people are “forward looking” or “anticipated modern medicine” if they had ideas consistent with our current ones, even if they didn’t have any evidence to support those ideas. The problem is that, as the author points out, medical ideas have changed and continue to change. That is no less true of our current ideas. As a practicing physician, I offer medical advice within the best knowledge of the time. Yet I cannot know what I am now doing that future generations will see as shortsighted, or worse. Similarly, physicians (and other health care providers) in the 18th century worked within the best knowledge of the time. To try to assess their decisions based on whether subsequent events led us to see their findings as valid or not does not further historical understanding.
That said, the book gives us dramatic stories of how health and disease played a role in the lives of some of the nation’s founders. Perhaps more important, it shows that from the very birth of the republic the founders saw the improvement of health for all as a proper role of the federal government.