BY the time of the American Revolution, Massachusetts was an old and populous colony. Most of its 300,000 inhabitants traced their descent and culture from the thousands of Pilgrim and Puritan immigrants of the 1620’s and 1630’s. High birthrates and unusual longevity in the seventeenth and eighteenth centuries resulted in a rapid rate of natural increase in the population.1 From the seventeenth century onward Massachusetts exported some of its population to northern and eastern New England, to the neighboring colonies of Connecticut, Rhode Island, and New York, and farther south. Although Massachusetts, like other settlements in the Atlantic world, was subject to a wide range of economic vicissitudes, it was generally a prosperous, productive, developed colony. While most of its people were engaged in agriculture, domestic production, and the supporting crafts, there were also several thousands employed in fishing, and thousands more working in the most flourishing shipbuilding industry in the British empire, indeed in the entire world. The sea, the forests, and the farms furnished the products that sustained substantial commercial activity. On the eve of the Revolution, Boston remained, as it had for over a century, a leading North American port.
Compared with other eighteenth-century populations, whether in the American colonies or elsewhere, the people of Massachusetts were relatively enlightened in the broad sense, as well as with reference to the intellectual culture of contemporary Britain. Literacy among both men and women exceeded the standard in England and perhaps even Scotland, the most literate country in the world.2 Belief in witchcraft and other supernatural phenomena, once prevalent, waned throughout the eighteenth century. Farmers, the most numerous occupational group and often the most attached to old ways, were calculating their production in an increasingly precise and systematic manner, purchasing almanacs, and noting carefully the dates of planting and harvest and the quantity of their yields.3 Though there were many communities of farmers and fishermen who were vigorously insular and localistic in their outlooks, the commerce and the culture of the empire penetrated everywhere. In the major port towns, newspapers and books from England as well as local writings circulated freely among the commercial and professional elites. Though Massachusetts was far removed from Britain physically, and differed from it significantly in the distribution of wealth among its inhabitants and in its political and ecclesiastical institutions, culturally the Bay Colony had much in common with provincial England and Scotland.4
Within this setting, what were the fundamental characteristics of treatment for sick people? Did Massachusetts reproduce the conditions of provincial England? And if it differed, to what degree did social and political circumstances in Massachusetts foster or hinder medical development? To answer these questions we must begin by exploring colonial attitudes toward illness. Here, though examples are drawn only from Massachusetts, they apply to New England generally and are not necessarily unique to the culture of seventeenth-and eighteenth-century Dissenters. The subject itself, attitudes toward illness, is neither simple nor static, and one can only sketch some of the salient themes; but in order to understand the emergence of scientific analysis and treatment of disease in colonial Massachusetts, it is necessary to begin with people’s beliefs about the nature of illness.
Tradition, of course, merged the natural and the supernatural in European as well as non-European cultures. Keith Thomas’s exploration of seventeenth-century England informs us that even the most rational and learned individuals, from Isaac Newton down to farm laborers and washerwomen, saw no clear boundary between physical and spiritual phenomena.5 Given these beliefs it is not surprising that physical illness was understood largely within a framework of religious belief. For Calvinists especially, the first cause was divine, if unknowable. Yet since God worked through nature, at bottom most people in Massachusetts, for at least the first century of settlement, regarded illness as God’s judgment. Death itself was an immediate, inevitable presence, so its handmaiden, illness, could never be unexpected. Seventeenth-century devotional literature, like much in the eighteenth century, dwelt continually on submission to God’s will, inculcating resignation in the face of illness and death.6 All over Massachusetts gravestones proclaimed the stark admonition:
Lament me not as you pass by
As you are now, so once was I;
As I am now, so must you be;
All Flesh is mortal you may se.7
Ultimately resignation led to positive acceptance, as the verse on Anna Russell’s marker declared:
Beneath this Marble Stone doth Lye
Two Subjects of Death’s Tyranny
The Mother who in this Close Tomb
Sleeps with the issue of her womb
Here Death deals Cruelly you see
Who with the Fruit cuts down the Tree
Yet is his Malice all in vain
For Tree and Fruit Shall Spring again.8
Above all else, religion taught that illness and death were to be borne humbly and submissively as God’s judgments.
But resignation and submission to God’s will did not imply dumb passivity. Prayer was the first of the healing arts, practiced among all ranks and in all regions of the colony, but it was not the only one. God had given mankind intelligence, and people were duty-bound to use it. Consequently when seventeenth- and eighteenth-century people suffered injuries or took sick, they called the minister and, if they could afford it, the doctor. Prayers and potions (including mercury and opium), blessings and bloodlettings complemented each other as bedside rituals. Though the nature and extent of religious commitment varied among individuals, virtually everyone agreed that ministering to the spirit as well as to the body was central to the treatment of disease. When it came to the healing arts, clergymen and laymen saw no conflict between the science of medicine and religion.9
This meant that for most people during the entire colonial period ministers served as both their pastors and physicians. Visiting the sick was one of a minister’s primary responsibilities—to lead prayer in the afflicted household, to pray with and over the sick person, and to recommend appropriate medical treatment. Except in Boston and Salem there was scarcely anyone, trained or untrained, whose sole occupation was medicine until the middle decades of the eighteenth century.10 The medical tradition of colonial Massachusetts joined the clerical and medical roles.
Collectively, the techniques of healing that clergy and laymen employed combined old English folk remedies and Indian therapies with up-to-date scientific techniques. These three elements in treatment coexisted during the seventeenth and eighteenth centuries, despite their diverse origins and assumptions. Massachusetts settlers, living in a quasi-frontier environment, showed some willingness to experiment with new remedies from the outset. By the beginning of the eighteenth century, if not sooner, practitioners had added some distinctly American products like sassafras to their assortment of routine prescriptions.11 Among a handful of learned clergy and physicians this empiricism was self-conscious and scientific, as in the Boston innoculation experiment of 1721; more generally, however, a popular “folk empiricism,” much scorned by the learned, was being practiced.
From the perspective of London- or Edinburgh-trained physicians, the popular, self-taught “empirics” were dangerous rivals—dangerous to the patients they treated and threatening to the emergence of medicine as a learned profession in Massachusetts. Because these elite physicians and the apprentices they trained could not conclusively demonstrate their own superiority to the public at large, their influence was limited, and they could not control colonial medical practice.12 Although historians have directed most of their attention to the handful of prominent, trained physicians, in reality the healing arts were practiced chiefly by self-taught or slightly trained “empirical” doctors, midwives, clergymen, and self-dosing laymen who, in treating themselves, their families, and their neighbors, practiced the most common of the healing arts.13 Popular medicine dominated colonial and revolutionary Massachusetts.
Yet after independence the new, republican Commonwealth of Massachusetts immediately created agencies of elite, scientific medicine, the Massachusetts Medical Society and the Harvard Medical School. Normally historians compare these developments with those in Philadelphia, and so ask why Boston lagged behind.14 They fail to recognize that the readiness of republican Massachusetts to embrace elite medicine in the 1780’s was significantly different from Philadelphia’s imitation of London models during the climactic era of colonial Anglophilism, the 1750’s and early 1760’s. Historians have never asked why, in light of the prevalence of popular medicine, a republican legislature which fervently rejected the English political and ecclesiastical establishments, immediately chose to endorse institutions that could provide the foundation for an elite, London-style medical establishment. On its face there is a contradiction here between the triumph of republicanism and the simultaneous founding of exclusive, oligarchic medical institutions like the Massachusetts Medical Society and the Harvard Medical School.
One must begin by setting aside the tempting notion that scientific medical institutions won legislative support because the medical treatment of the learned physicians was conspicuously better than popular medicine. As of 1780 or 1820, indeed even as late as the 1849 cholera epidemic, the merits of scientific medicine were open to reasonable doubt. Moreover, even if it was clearly superior it would not be surprising if people still clung to older, more familiar therapies as well as prayer. Certainly there was and remains much unscientific conservatism among physicians and laymen alike; and even in the twentieth century, despite the impressive record of scientific medicine, folk alternatives attract waves of popularity, even among legislators. Scientific medicine did not win approval simply on its merits in the 1780’s. To explain this new departure in republican Massachusetts one must look again at the colonial medical heritage.
Reference has already been made to the well-known hostility of trained physicians like William Douglass to the mere “empirics” and lesser practitioners who abounded in the Bay Colony, and to the fact that there were two streams of empirical medicine, one learned and the other popular. While these two were distinct, they were not wholly separate. For although Douglass and his professional colleagues were not disposed to learn from their inferiors, the common practitioners of the healing arts—clergymen, self-taught “empirics,” midwives, and ordinary people in general—were eager to learn from their betters, and if they could not afford sustained medical instruction, they did buy, borrow, and read popular medical books, and clip from the newspapers reports of new treatments.15 For the most part the sources of this medical literature were English and Scots, and so the so-called “folk” medicine of colonial Massachusetts was actually quite similar to provincial British treatment, a mixture of learned practice with home remedies. Learned medical practice possessed theoretical explanations for maladies and gave greater attention to precision than the popular variety, but actual procedures and beliefs about the nature of the human organism were connected. The sharp distinction that learned physicians drew between their own practices and those of their self-taught rivals did not in fact exist. The self-serving consciousness that the learned displayed rhetorically was intended to convince people that elite and popular medicine were totally different, when in fact they were part of the same medical spectrum and overlapped considerably.
What did clearly separate learned medical practice from its popular rivals was its social not its scientific characteristics. Degree-holding practitioners were largely confined to the port towns, especially before the Revolution, and their fees discouraged many ordinary people from seeking their treatment. Doctors trained through apprenticeship were more numerous and accessible, but it was the self-taught practitioners who were most numerous and commonly available.16 Individual diagnoses and treatments might, indeed, vary widely between a self-taught practitioner and a learned one, but such variations existed within a common range of therapeutic alternatives, including bleeding, purgatives, and placebos.17 Often the merits of treatment existed largely in the eyes of the beholder. As Joseph Kett puts it with reference to seventeenth-century England, “the physician who arrived in sartorial splendor, waving his gold-headed cane and spouting Latin aphorisms, was likely to have the same reassuring effect on a gentleman that an experienced village woman would have on her neighbor.”18 At the patient’s bedside the chief distinction might well be social rather than medical.
By the mid-eighteenth century, however, this distinction was taking on a new significance that threatened the future of learned medical practice in Massachusetts. For the British-trained physicians who desired to imitate the hierarchical and monopolistic structure of the London medical professions—divided among physicians, surgeons, and apothecaries—were entering a larger social and political conflict that strained Massachusetts’s equilibrium. John Murrin has characterized this conflict as pitting the friends of Anglicization against defenders of the Puritan and popular traditions of Massachusetts. In medicine and law, in politics and in religion, royal officials and Atlantic merchants led a movement to bring Massachusetts institutions into conformity with Georgian England. The formal creation of a medical establishment modeled on that of London, complete with exclusive licensing procedures, a medical school, and a hospital—as was being introduced into Pennsylvania—could not be considered by itself because it coincided with the formation of the Massachusetts bar, the organization of an Atlantic merchants’ society, and an expansion of the Anglican presence, including the establishment of a missionary church adjacent to Harvard yard.19 To allow British-trained physicians a free hand meant not only repudiating the medical practice of locally apprenticed physicians, clergymen, and laymen all over Massachusetts; it implied a repudiation of Yankee culture in favor of the corrupt pretensions of London and the Royal Court. Massachusetts doctors, like the three Worcester practitioners who entered a partnership in 1771 as “Traders in the Art, Mystery and Business of an Apothecary and the practice of Physick,” might be driven from the field.20 The state of the healing arts in Massachusetts was similar to that in provincial Britain, but in the Bay Colony an even more open, fluid, and decentralized standard had flourished. Now, just before the Revolution, the emergence of a self-conscious, learned medical profession was threatening to redirect medicine toward the London model.
Yet paradoxically the fulfillment of revolutionary republicanism in the 1770’s and 1780’s did not destroy elite, scientific medicine; it promoted it in a distinctly American way. Here the warfare itself was crucial. For the war led to the exile of several leading Anglophiles, including notable physicians like Silvester Gardiner, John Jeffries, and Nathaniel Perkins, and it destroyed the political influence of those who remained.21 The war also elevated republican physicians like the Warren brothers: Joseph, the martyr of Bunker Hill, and John, who became a key figure in caring for the American army. Indeed it was John Warren who in 1780 gave the fourth series of medical lectures in Boston, on anatomy, to an audience of slightly trained army surgeons.22 It is precisely here that the critical impact of the war on medicine is evident. For, by creating an acute demand for full-time physicians, the war joined the most highly trained professionals and the slightly taught practitioners in an overt, deliberately tutorial relationship. The professionally trained could and did bemoan bitterly the incompetence of their self-taught colleagues, but within the context of the republican war effort there was no alternative but a massive “apprenticeship” to educate the amateurs rapidly, including ad hoc lectures like John Warren’s.23 During the war, and in the army particularly, the tutorial relationship between scientific and popular medicine that had long been implicit in popular consumption of British medical books suddenly became explicit and legitimate. The aloof disdain of scientific physicians was breached, and the way was opened for a medicine that could be both scientific and republican. The creation of scientific medical organizations became more than a mimetic anglophile display; it now embodied patriotic service to the Commonwealth of Massachusetts and the American republic.
The Revolutionary war had given learned physicians an opportunity to define their professional interests so that they coincided with the public good. In addition there was a utopian thrust to republican ideology that raised social expectations generally. In this context a variety of learned societies gained support in Massachusetts in the 1780’s and 1790’s, including: the American Academy of Arts and Sciences; the Massachusetts Historical Society; the Massachusetts Society for Promoting Agriculture; the Boston Athenæum; and the Salem East-India Marine Society—in addition to the Massachusetts Medical Society.24 Because the founding of the new nation had created an institutional void—royal academies and societies were now alien—the formation of elite learned societies achieved a patriotic legitimacy in Massachusetts and throughout the United States. Consequently the incorporation of the Massachusetts Medical Society in 1781, which followed by one year the organization of the Boston Medical Society, raised hardly a murmur of opposition.
Like the founders of the other learned societies, the sponsors of the Medical Society had English models in mind from the beginning. Yet at the same time there were distinctly republican departures that grew out of Massachusetts’s experience. Although the members of the Medical Society had all been trained as physicians, only a few possessed medical degrees. The Society tried until 1803 to follow the Royal College’s rule of differentiating learned “fellows” of the society from mere licensees, but the effort failed, and the Society never even attempted to create the English distinctions between physicians, surgeons, and apothecaries. Nor did the Society press for an exclusive monopoly to practice medicine. Its powers of certification were limited to those who voluntarily chose to seek examination; and to make sure access was open, the General Court required the Society to examine everyone who volunteered, or face penalties.25 The Society was aimed at raising the standard of medical practice in Massachusetts, but not by outlawing the quasi-amateur medical practices that had always flourished.
Instead, the purposes of the Medical Society reflected the longstanding interest of practitioners at all levels to increase their store of knowledge. In 1785 the Society initiated creation of county committees of correspondence open to any individual or group of doctors who chose to participate. Five years later the Society began to publish a periodical, Medical Papers, which included gleanings from these committees of correspondence.26 Its pages were open not only to members and medical professors, but to “gentlemen . . . of observation everywhere,”27 and the journal included a broad range of subjects—weather and epidemics, specific medical and surgical treatments, botanic pharmacology. The dissemination of medical information, popularizing, was an integral part of the enterprise. The Society selected articles for publication that possessed “an immediate connexion with practice, and ... a direct tendency to improve it.”28 Moreover it reprinted practical texts because “many practitioners, may, from their local situation or other circumstances [italics added], be precluded . . . early access to European publications, in the several branches [italics added] of their profession: It has therefore been thought expedient to subjoin ... a number of extracts from such books... communicating a variety of useful improvements.”29 Certainly in its first two decades the chief objective of the Massachusetts Medical Society was to leaven the mass of medical practitioners in Massachusetts. Rather than devote themselves to pure science, or attempt to create an expert monopoly of medical skills, the gentlemen of the Medical Society were missionaries of enlightenment. In its early decades the Massachusetts Medical Society resembled the Society for Promoting Agriculture more than the Royal College of Physicians.
Until well into the nineteenth century scientific medicine in Massachusetts was necessarily more remedial and practical than inquiring and imaginative in its orientation. Both the Medical Society and the Harvard Medical School aimed first at bringing the healing arts as practiced in Massachusetts up to advanced European standards. This objective provided legitimacy in the republican social environment, and built on the strengths of Massachusetts society for supporting scientific medicine—its broad literacy, its commercial and urban development, and the improving spirit that was evident throughout the state. As a result, though the tension between learned medical practitioners and popular medical treatment persisted, and self-dosing would flourish through the nineteenth century, scientific medical institutions gained a secure place and a substantial following in republican Massachusetts.30