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Health and Medicine in the 18th Century       

Medicine was in a state of transition in 18th-century America. While many premodern practices and theories were still widespread, the 18th century saw the beginnings of recognizably modern medical practice. Experimental science and clinical observation began to replace the received wisdom of the ancient world, the first American medical schools were established, and male physicians began to replace midwives in obstetrics. At the same time, physicians and other medical practitioners confronted new challenges in the form of devastating epidemics.

Theories of Health and Disease The understanding of the causes of illness in the 18th century was still rooted in the humoral theory of disease, a system first developed by the ancient Roman physician Galen. In this theory, the body is composed of four "humors": blood, phlegm, black bile, and yellow bile. Each humor was associated with a degree of moisture and a temperature: phlegm, for instance, was cold and wet, while yellow bile was warm and dry. Each individual had a dominant humor in his or her body, which gave rise to personality di!erences. Some of the words we still use to describe personality, such as "phlegmatic," derive from this ancient belief.

Disease resulted when one humor overwhelmed the others. Each individual was prone to diseases that stemmed from their naturally dominant humor. A person dominated by the "hot" humors, for instance, would be prone to fevers. A person's age and sex also contributed to humoral balance. Men were "hotter" and "dryer" than women; older people were "colder" and "dryer" than young people. However, given the right circumstances, any person could develop any disease. Too much of a certain food, an upsetting experience, or exposure to bad weather could all upset the humoral balance and

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cause disease.

Eighteenth-century Americans recognized spiritual as well as physical causes of disease. God could send illness as a "correction" for sin, and many pious individuals spent time at prayer when they fell sick. Some deeply religious parents took this thinking a step further and interpreted their children's illnesses as punishment for their own sins. Prayer, fasting, and consultation with a minister were as much a part of curing illness as a visit from a physician.

Most physical treatments were aimed at restoring humoral balance, through rebalancing the body's temperature and moisture, or through purging excessive, putrefying humors. A practitioner would first determine the nature of the disease—was it a hot, dry disease with a fever, or a cold, moist disease, such as a cold? He or she would then prescribe medicines as a counterbalance. For instance, a "cold" disease would be treated with "hot" medicines such as ginger tea, served as hot as the patient could bear. Many 18th-century treatments also involved driving "excessive" humors from the body. While any humor could be in excess, blood and bile were the usual culprits. Bile could be driven out with emetics and laxatives, and excessive blood would be removed through bleeding and leeches. To remain in good health, a person needed to avoid excessive eating and drinking, dress appropriately for the weather, and avoid emotional extremes.

However, a new theory of disease was emerging in the medical schools of Europe. Elite colonial physicians who studied there brought this new theory, called the "solidist" theory, back home with them. Solidist theory holds that health and disease depend on the state of blood vessels and nerves. When these tissues are healthy, bodily fluids such as blood and "nerve fluid" move freely throughout the body. When tissues are either overstimulated or debilitated, the flow is blocked and the person becomes ill. In this view, diseases caused by overstimulation require "depletive" treatments, while diseases caused by debility require strengthening medicines.

In practice, many of these treatments looked much the same as those recommended by humoral theory. Overstimulation required bleeding and purging, much as imbalanced humors did. Only when a disease was classified as "debility" did the treatments vary: In those cases, physicians prescribed rich, strengthening foods and "stimulants" such as alcohol and opium. Most practitioners adopted an eclectic view of medicine, incorporating both theories of disease into their practices.

Types of Medical Practitioners As was the case in the previous century, most medical care was provided by practitioners with little

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formal education. Most laypeople, especially women, had extensive knowledge of herbal medicines and other folk remedies. If a person became sick, the first healer they turned to was likely to be a family member or neighbor.

Other kinds of informal practitioners included bonesetters and other itinerant practitioners who specialized in one procedure, such as tooth-drawing or the removal of bladder stones. Many of these traveling "doctors" also sold medicines and tonics of their own invention, the ingredients of which they kept secret but which frequently included a large amount of alcohol. Itinerant doctors and surgeons traveled set routes from town to town. When they arrived, they advertised their presence in the local newspaper or by printed broadside. While some claimed to have formal credentials, most simply let their reputations or extravagant advertisements speak for them.

Midwives were on the boundary between informally trained practitioners, such as traveling bonesetters, and credentialed practitioners, such as physicians and surgeons. Midwives delivered most of the babies in the 18th century. In addition, midwives took care of many "female complaints," including infertility. Some also o!ered more general services to their communities, such as basic first aid, herbal medicines, and nursing care. Midwives usually began their practices with an informal apprenticeship with another woman, gradually gaining enough experience to practice on their own. Since it was impractical for a woman with young children to practice midwifery, most midwives began their careers in middle age. Midwives were assisted in their work by their patients' female relatives and neighbors, who traditionally gathered to support mothers in childbirth.

The medical profession itself had three di!erent levels: surgeons, apprentice-trained physicians, and physicians with a university degree. Surgeons were formally trained but had a lower status than physicians. Their lower rank stemmed from the premodern tradition that a "gentleman" did not work with his hands. Since surgery was a manual skill, it was a lesser profession than medicine, which depended on knowledge and education. Many surgeons learned their trade in the military, and then continued to practice once their service was ended. Surgeons set bones, removed cancerous tumors, and performed amputations. As the century progressed, the old distinction between physicians and surgeons disappeared, and surgery rose in status alongside the rest of the medical profession.

Most who called themselves physicians or doctors did not have a university degree. The usual career path for a doctor was to learn his skill through an apprenticeship. Most of these apprentice-trained doctors were respected members of their communities and made a good living, but they did not yet have the high status that physicians would achieve in the 19th and 20th centuries.

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The 18th century also saw the emergence of a new kind of physician: an ambitious young man from a good family with a degree from an elite university who saw himself not just as a healer but as a scientist. These men usually studied in London or Edinburgh, where they learned anatomy through dissection of cadavers, observed surgical procedures in hospitals, assisted researchers with medical experiments, and attended lectures on the latest developments in medical science. Edinburgh students then wrote a thesis based on clinical observation or original experiments. Dr. Benjamin Rush, noted for both his contributions to American medicine and his leadership during the Revolution, was an excellent example of this new breed of physician.

Americans who obtained their degrees through this system usually returned to establish practices in large cities, where they catered to the elite families who could a!ord their services. However, their influence on the profession was out of proportion to their small numbers. The European-trained physicians were the founders of the first American medical schools, and they helped transform American physicians from cra"smen to professionals.

Eighteenth-Century Changes in Medicine The 18th century saw important changes in several areas of medical practice. European-trained surgeons developed new techniques for common operations, male physicians began delivering babies, and some doctors began advocating for inoculation to prevent smallpox.

Surgery in the 18th century was severely limited by two things: lack of anesthesia, and lack of sterile technique. The lack of anesthesia meant that operations had to be performed as quickly as possible to limit the patient's pain. The lack of a germ theory and antisepsis meant that almost all surgical wounds became infected. As a result, surgery was considered a treatment of last resort, and very few operations entered the chest or the abdomen. Surgeons dealt with trauma cases and lesions of the skin, eyes, or extremities. Within these limitations, however, the new science of the 18th century allowed some innovations in surgery. European-trained American surgeons developed new methods of treating bladder stones, removing cancerous tumors, and tying o! arterial aneurysms.

The 18th century also saw important changes in childbirth and obstetrics. American doctors trained in Edinburgh and London popularized the use of obstetrical forceps—a tool that helped doctors deliver infants who were stuck in the birth canal. Physicians could o!er both the forceps to assist with di!icult births and laudanum (an opium derivative) to soothe pain. As a result, some a!luent women in American cities began to look to male physicians instead of midwives to provide safety and comfort in childbirth. This change remained controversial. Midwives rallied to defend their profession, arguing

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that their methods were gentler and protected a woman's modesty. The claims of greater safety made by physicians were undermined by the damage done by men using forceps without proper training or experience. Throughout the 18th and 19th centuries, physicians and midwives practiced in parallel, and for many women a midwife remained the only available option. However, the 18th century marked the beginning of physician-assisted birth in America.

Another important change in 18th-century medicine was the introduction of smallpox inoculation. Inoculation is not the same as vaccination, although the two techniques are similar. While vaccination uses a related virus to induce an immune response, inoculation injects a full-strength smallpox virus under the skin of the patient. For reasons that are still not clear, this method usually results in a mild, survivable case of smallpox, which nevertheless gives the patient full immunity.

Inoculation had been used in Africa and Asia for centuries, reaching Europe around 1700. In America, the method was first proposed by Onesimus, an African slave in the household of the Reverend Cotton Mather of Boston. In 1721, the Boston physician Zabdiel Boylston collaborated with Mather to try inoculation in America. When a smallpox epidemic broke out in the city, Boylston injected smallpox scabs under the skin of his six-year-old son and two of his slaves. All three survived the procedure, and none developed smallpox again.

Mather and Boylston's successful experiment was greeted with strong opposition. Many feared (with reason) that inoculated patients would spread smallpox to healthy populations; others questioned the ethics of deliberately inducing disease in healthy persons. Eventually, the city of Boston banned the practice, and other towns and cities followed suit. Within 30 years, however, the tide of public opinion had turned. By the time of the Revolution, inoculation was accepted enough that Benjamin Franklin, John and Abigail Adams, and other leaders had themselves or their children inoculated. Smallpox inoculation represented a crucial first step in the prevention of a terrible disease.

Epidemics and Infectious Disease Despite progress in such areas as inoculation, epidemic disease was a major killer during the 18th century. The thriving port cities were o"en the first victims, as ships from around the world brought deadly germs to America. In addition, the growing population of the cities combined with lack of proper sanitation to create epidemics of waterborne disease.

Smallpox continued to erupt in America throughout the century and remained widely feared. Unlike in Europe, where smallpox had a permanent foothold, smallpox in America would disappear for a time

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before recurring. When epidemics broke out, the virus would encounter a population with no immune members, resulting in a high death toll. The typical pattern was for a ship carrying an infected passenger to dock in a city. As the disease spread, frightened inhabitants fled to the countryside, bringing the disease with them. Thus, an outbreak that began in Boston could spread as far as Canada. Outbreaks in New York City followed the fur trade along the Hudson River and spread far into the interior of the continent. Outbreaks occurred in New England about every 10 years; in New York and Pennsylvania, with their important ports of New York City and Philadelphia, they occurred about every 5 years. The South su!ered the least, perhaps because there was only one major port city, Charleston, South Carolina.

Some of the most significant outbreaks occurred during wartime. Both the Seven Years' War (1756–63) and the Revolutionary War (1775–83) were accompanied by outbreaks of smallpox. The disease followed the armies and thrived on the malnutrition, social disruption, and crowded conditions created by war. During the Revolutionary War, George Washington initiated an inoculation campaign to keep his troops healthy. Even with such measures in place, many more soldiers (and civilians) died of smallpox than in battle.

Yellow fever was another disease that attacked port cities. Yellow fever is a mosquito-borne, tropical virus. It attacks the digestive tract and the liver, giving rise to the jaundice (yellowing of the skin and eyes) for which it is named. It probably originated in Africa and came to the Americas on trading ships. The first epidemic broke out in Boston in 1693, but the disease appeared more o"en in Philadelphia and Charleston, where the hot, humid summers allowed the vector mosquitoes to survive. In 1699, one outbreak in Charleston killed half of the members of the colonial assembly.

Unlike smallpox, yellow fever did not spread far beyond its point of origin, and it always disappeared when the weather became cold enough to kill mosquitoes. Since yellow fever was perceived as a disease of cities in the summer, many wealthy urbanites began purchasing country houses where they could spend their summers without fear of infection.

Philadelphia su!ered a devastating epidemic in 1793. A shipload of French refugees from the revolution in Haiti arrived in Philadelphia that July, and the epidemic began shortly therea"er. Since Philadelphia was then the nation's capital, the work of the federal government shut down a"er President Washington and Congress fled the city. By the time the epidemic ended in November, somewhere between 3,000 and 5,000 of the city's 55,000 inhabitants had died.

Even when there were no epidemics of yellow fever or smallpox, 18th-century cities were unhealthy

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places. The sanitary practices of the time could not guarantee a clean water supply, and outbreaks of "flux" or "bloody flux" (typhoid and dysentery) were common. In cities, two or three families o"en shared one privy or pit toilet. While the usual practice was to fill in and re-dig privy pits every few years, the growing population meant that privy vaults filled quickly. In areas with a high water table, the contents could easily seep into wells and contaminate drinking water. In addition, some cities had ordinances requiring that garbage, street sweepings, and animal manure be disposed of in the river, creating another potential source for water contamination. In the countryside, population densities were lower, but leaky privies and the common habit of relieving oneself on the ground meant that rural areas were not immune either.

Intestinal diseases were particularly deadly to children. Parents feared the "summer flux," which carried o! many infants and toddlers. Unlike yellow fever and smallpox, which appeared dramatically and then disappeared, the flux was a constant threat in most areas.

The Beginnings of Modern Public Health, Medical Education, and Hospitals The crises created by epidemics led to some of the first public health measures in American cities. Smallpox outbreaks led to a number of quarantine laws, some of which were rooted in ancient practices. For example, ships with sick passengers were required to wait 20 days before unloading. Some cities went further, placing all members of infected households under house arrest or requiring them to hang colored cloth on their doors. New England cities and Charleston, South Carolina, founded publicly funded quarantine hospitals, which were built on islands or other isolated sites to protect the city from contagion.

A"er the 1793 yellow fever outbreak in Philadelphia, the city founded a permanent public health committee. The committee established a public hospital to care for victims of the epidemic, sent workers to sweep and scrub the homes of the sick, and created street cleaning crews to sprinkle water on the roads to control dust and remove garbage and other filth from the city streets. In early 1794 these services were made a permanent part of city government. Soon therea"er, the public health committee authorized the building of the first city water treatment plant.

Hospitals were another innovation of the 18th century. While previous centuries had cared for the sick poor in almshouses and poorhouses, the 18th century saw the first institutions sta!ed by physicians and dedicated exclusively to the care of the sick. The first was the Pennsylvania Hospital in Philadelphia, founded in 1751 by Benjamin Franklin and Dr. Thomas Bond; the second, New York

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Hospital, was proposed in 1769 by Dr. Samuel Bard and opened in 1791. In both cases, the hospital provided both medical services and training and research material for physicians.

Finally, the 18th century saw the beginnings of modern medical education. The hospitals in New York and Philadelphia attracted many of the young men who had trained abroad. These same physicians saw the need for an Edinburgh-style medical school in America. In Philadelphia, John Morgan and a group of prominent physicians founded a medical school as part of the College of Philadelphia (later the University of Pennsylvania) in 1765. The curriculum was based on that of the University of Edinburgh, stressing direct clinical observation as a supplement to academic lectures and reading. King's College (later Columbia University) opened its own medical school along similar lines in 1767, and it became the first American school to award the MD degree.

All of these events foreshadowed the development of a scientifically based, professionalized practice of medicine and public health that would dominate the 19th and 20th centuries. While the 18th century remained part of the premodern medical world in many ways, important changes were already under way.

Further Information

Bell, Whitfield. The Colonial Physician and Other Essays. New York: Science History Publications, 1975.

Benes, Peter, ed. Medicine and Healing: Proceedings of the Dublin Seminar for New England Folklife. Boston: Boston University Press, 1992.

Brown, Kathleen M. Foul Bodies: Cleanliness in Early America. New Haven, Conn.: Yale University Press, 2009.

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

Du!y, John. Epidemics in Colonial America. Baton Rouge: Louisiana State University Press, 1953.

Earle, A. Scott. Surgery in America: From the Colonial Era to the Twentieth Century. 2d ed. New York: Praeger Publishers, 1983.

Estes, J. Worth, and Billy G. Smith, eds. A Melancholy Scene of Devastation: The Public Response to the 1793 Philadelphia Yellow Fever Epidemic. Canton, Mass.: Science History Publications, 1997.

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Fenn, Elizabeth A. Pox Americana: The Great Smallpox Epidemic of 1775–82. New York: Hill & Wang, 2001.

Leavitt, Judith Walzer. Brought to Bed: Childbearing in America, 1750 to 1950. New York: Oxford University Press, 1986.

Powell, John Harvey. Bring Out Your Dead: The Great Plague of Yellow Fever in Philadelphia in 1793. 1949. Reprint, New York: Arno Press, 1970.

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

Tannenbaum, Rebecca J. The Healer's Calling: Women and Medicine in Early New England. Ithaca, N.Y.: Cornell University Press, 2002.

Ulrich, Laurel Thatcher. A Midwife's Tale: The Life of Martha Ballard, Based on Her Diary, 1785–1812. New York: Alfred A. Knopf, 1990.

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Record Information

From: Health and Medicine in U.S. History

Series: Themes in U.S. History

By: Rebecca J. Tannenbaum

Published: 2018

Record Type: Encyclopedia Entry

Table of Contents

Ch. 1: Health and Medicine in the 16th Century Ch. 2: Health and Medicine in the 17th Century Ch. 3: Health and Medicine in the 18th Century

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Ch. 4: Health and Medicine in the 19th Century Ch. 5: Health and Medicine in the 20th Century Ch. 6: Discussion Questions: Health and Medicine

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Cotton Mather Demonologists Fellows of the Royal Society Humorism Inoculation Midwifery

Osteopathic medicine in the United States physician smallpox vaccination

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