HEALTH AND MEDICINE

It is impossible to discuss health in the period 1820–1870 without discussing disease. Consistent good health was the possession of only a small percentage of a population rapidly approaching ten million. Lacking a germ theory of disease, people ate contaminated food, drank contaminated water, and lived amid animal and human waste without blinking. Lacking knowledge of good nutrition, people suffered from chronic indigestion (or dyspepsia), fatigue, anemia, food poisoning, and other digestive ailments. The unchecked spread of bacteria, viruses, and insects resulted in epidemics of "ague" (malaria), cholera, diphtheria, dysentery, polio, smallpox, and typhoid, crippling or abbreviating many lives. Tuberculosis, commonly known as consumption, was the leading cause of death in the nineteenth century. Chronic bouts of influenza, pneumonia, and other endemic maladies further reduced not only life's quantity but its quality. Life expectancy in this era was somewhere between thirty and forty years, nearly half of all children died before their tenth birthdays, and countless women died in childbirth.

WOMEN'S HEALTH

Females who survived into adulthood were not exactly robust. Victorian ideals of womanhood encoded a form of embodiment that mimicked diseased states. Middle-class white women were expected to be frail, delicate, nervous, emotional, and moody. The term "hysteria" derived from the Greek hyster, or womb, and the disease itself, which reached near-epidemic proportions as the century advanced, was said to be caused by the uterus's ties to the nervous system as well as its potential to float untethered in the body, wreaking havoc. Hysterics fainted, raved, wept, choked, threw fits, entered trances, tore out their hair, behaved frenetically. Though the disease was rampant in the nineteenth century, hysteria lives on in the early twenty-first century only as a pejorative term, leading some historians to speculate that it allowed nineteenth-century middle-class white women to enact their rage against confining gender roles, to perform femininity with a vengeance.

A slew of medical advice books directed at the female invalid only further established her as a type and as a widespread cultural concern. In perhaps the most famous lay advice book of the 1850s, Letters to the People on Health and Happiness (1855), the educator and reformer Catharine Beecher (1800–1878) sounds the alarm about the "terrible decay" in health among Anglo-Americans since the time of their ancestors. She especially laments the state of women's health, claiming in one letter that for all her travels among and conversations with married women she could number less than ten whom she would consider vigorously healthy. Beecher identifies upbringing, fashion, poor hygiene, and the lack of both exercise and fresh air as culprits, but she also points a blaming finger at women's inherently frail and delicate nature. She is as wont to chastise women for overstimulating their more easily taxable brains as she is to chastise the culture for failing to provide women with stimulating occupations.

When it came to etiology, the medical establishment tended to come down heavily on the side of nature rather than culture. According to prevailing medical doctrine, women were inherently and recurrently susceptible to disease, if only because they were afflicted by such avowedly pathological cyclical processes as menstruation, reproduction, and menopause. Many doctors believed their female patients to be governed by their wombs, and according to theories of bodily energy as circulating within a closed system, this was the healthiest regime, for if energy were to be diverted away to another vital organ—say, the brain, through studying or reading—the resulting depletion in the uterus would "unsex" the body, shriveling its breasts and ovaries, stimulating hair growth, and rendering the perpetrator sterile and unfit for her crowning destiny: wife- and motherhood. Those who achieved (or

desired) neither goal faced warnings of more diseases and a shorter, stunted life.

The fact that the majority of the nation's women were held to no such standards and labored by the sweat of their brows without falling into hysterical fits did little to dissuade many physicians and ideologues that women were by nature shrinking violets, pedestal-bound. Of course, women across the socioeconomic spectrum did contract real illnesses, resulting from improper nutrition and sanitation, from overwork and restrictive fashions, from infection and from childbirth.

Complications associated with childbirth, chief among these puerperal fever—infection following childbirth—were a leading cause of death in women from this period, so that with each pregnancy the expectant mother had to face her own mortality. Birth-control methods and abortifacients were discreetly advertised in the newspapers and whispered between friends. Those whose pregnancies went full term were usually attended throughout their travail by female family members or a local midwife (also typically female).

In the early decades of the nineteenth century, as the birthrate still hovered around seven births per married woman (a statistic that held within it the makings of a potentially lucrative medical practice) physicians began sounding the alarm about the safety of female midwifery, even while conceding that modesty made this lay healer a logical choice. As William Ray Arney has noted, the medical profession saw the midwife as a "social, political and economic impediment to the development of obstetrics along the lines members of the profession wished to pursue, and the profession implemented a political program to solve the 'midwife problem'" (p. 3). An example of this program can be seen in the remarks of a Harvard doctor who in 1820 questioned women's moral suitability to the practice, finding their inherent passivity and their excessive sympathy a dangerous mix in the birthing chamber. Although midwives continued to deliver more than half of all babies well up until 1910, their authority was routinely challenged by members of the emergent field of obstetrics.

THE PROFESSION OF MEDICINE

For most of the nineteenth century, practicing medicine rarely proved lucrative. Paul Starr reports that New England doctors typically made $500 or less a year, charging fees per service or per case, a sum that also included bartering and credit arrangements. Nor did medical practitioners earn much in the way of respect, as conventional medicine in this period was routinely criticized for its "heroic" methods. The invasive, aggressive therapeutics practiced by nineteenth-century doctors was advanced by such notables as the Philadelphia physician Benjamin Rush (1745–1813), who himself learned them from his teacher William Cullen of Edinburgh. "Bleed, blister, and purge" were the mainstays of the heroic practitioner's repertoire, though "puking" patients through emetics was another core practice. The use of toxic drugs such as calomel, which contained mercury, violated the physician's oath to first do no harm. About the only remedies in a regular doctor's arsenal that had any therapeutic effect were digitalis (for heart problems or "dropsy"), lime juice (to treat scurvy), and quinine for malaria.

Of course doctors also routinely performed more useful, less invasive interventions, such as prescribing diets and bed rest, setting bones, removing growths, and draining abscesses. The success of these more benign remedies and the failure of more aggressive interventions helped to turn the tide against heroic methodologies, which were on the wane by the 1860s and more or less obsolete by the 1870s. Not only were they by this point proven ineffective when compared to nature's healing powers and recent scientific advances, but they had been challenged all along by homeopaths and other alternative or "irregular" practitioners.

Along with the desire for more income, power, and status, these challenges—which only increased "regular" doctor's concern over the exponential rise in "quackery"—became a major impetus behind attempts to organize and regulate the medical profession. J. Marion Sims (1813–1883), who began his term as president of the American Medical Association in 1875, reflected in his autobiography on the status of his profession earlier in the century, confessing that "the practice of that time . . . was murderous. I knew nothing about medicine, but I had sense enough to see that doctors were killing their patients, that medicine was not an exact science, that . . . it would be better to trust entirely to Nature than to the hazardous skill of the doctors" (p. 150).

Faced with widespread public distrust of the profession's attempts to assert its expertise, along with a mounting crisis over lax medical education and licensing, a National Medical Convention was held in New York in 1846, out of which the American Medical Association—whose first meeting was held in Philadelphia in 1847—was born. By the time the country entered its Gilded Age, the medical profession had gained much in legitimacy and clout. Still, it was actually only in the first decades of the twentieth century that medical practitioners finally achieved what Starr terms "professional sovereignty," boosted by genuine end-of-the-century advances in technology and therapeutics, especially in the fields of bacteriology and germ therapy.

In the same year that the National Medical Convention was held, the first modern woman doctor, Elizabeth Blackwell (1821–1910), was applying to medical schools, and the country's first medical school for women only—Boston Female Medical School—was but two years from opening. The historian Regina Morantz-Sanchez contends that American medicine was defined from the outset via a dialectic between "sympathy" and "science," and that, in the main, male practitioners identified (or were identified) more with the scientific definition of their profession, while female practitioners proclaimed (or were acclaimed for) their sympathetic capacities. While heroic techniques like frequent bloodletting and heavy dosing remained popular among those who considered themselves scientists, a number of those who defined themselves as sympathetic healers argued for the scientific merits and benefits of more moderate remedies.

The groundswell of support at mid-century for women's admittance into the medical establishment stemmed in part from a belief that women's inherently empathic natures, when partnered with science, would make for better doctors and, consequently, better patients. As Angenette A. Hunt insisted in 1851, "It is certain that the health of the world, depends on the women of the world and at least, some of the qualities needed in the medical profession—as gentleness, patience, quick perceptions, natural instinct which is often surer than science, deep sympathy . . . all these belong to the [female] sex in an eminent degree" (Morantz-Sanchez, p. 28). The very capacity for sympathy, for feeling, that made women so susceptible to disease in one lexicon in yet another proved their capacities as healers.

ALTERNATIVE MEDICINE

Enlisting the aid of a female healer may have been one option for those disgruntled with their regular male practitioners. But in the days before the medical profession had earned the public's trust, a number of alternative routes to health were pursued. Starr identifies three spheres of medical practice and rates them of roughly equal importance: in addition to physicians there were also lay healers (such as midwives) and "the medicine of the domestic household" (p. 32). The home was where most of the sick were attended to, where herbs, charms, and potions were administered as remedies for ailing family members and where the mother figure or an older female relative usually presided over the sickbed. Many households relied for guidance on William Buchan's Domestic Medicine, the most popular and most reprinted (some thirty editions) of such manuals throughout the early 1800s, until it was replaced in popularity by John C. Gunn's Domestic Medicine, published in 1830. While these manuals promoted naturalistic interpretations of disease, there were those who still interpreted illness through a moral valence, seeing in each malady the hand of God punishing sinners. Sufferers swayed by such moral interpretations often entrusted their care to God's or their preacher's hands.

Though many a domestic healer brewed her own medicines at her own hearth, a number purchased the patent medicines and gadgets advertised in the papers and hawked by snake-oil salesmen. Lydia Pinkham's vegetable compound was by far the most popular of these nostrums. Remedies were also available for purchase from the unregulated sectarians whose popularity and organizational force increased as aversion to conventional medicine's aggressions mounted.

The first page of Dr. Benjamin Rush's chapter "Defence of Blood-Letting" in his Medical Inquiries and Observations (1805) defends the medical practice of "bleeding":

Blood-letting, as a remedy for fevers, and certain other diseases, having lately been the subject of much discussion, and many objections having been made to it, which appear to be founded in error and fear, I have considered that a defence of it, by removing those objections, might render it more generally useful, in every part of the United States.

Rush, Medical Inquiries and Observations, 4:285.

The skeptical rebellion against "regular" (i.e., licensed and schooled) physicians in the early decades of the nineteenth century was led by the Thomsonian sect. The New Hampshire farmer Samuel Thomson (1769–1843) proposed his botanical method of healing—learned in part from a female herbalist—as a democratic challenge to the establishment (a particularly effective strategy in the anti-elitist Jacksonian era). His motto would become "every man his own physician." Thomson claimed to have spent thirty years studying and experimenting with medicinal herbs and to have developed a safer system than that of conventional medical practice. Identifying heat with life and cold with death, he sought to provide the fuel through food and medicines to keep people alive rather than to poison them, as he accused regular physicians of doing. He generated this vital heat in his patients by peppering, steaming, and puking them. During the early decades of the century, after obtaining a patent in 1813, his agents sold "family rights" to his practice for twenty dollars. Thomsonians and other herbalists believed their botanical cures to be both life-saving and money-saving, especially when compared to being "doctored to death" by the allopaths.

Thomsonianism dominated the alternative sects from about the 1810s to the 1840s. Those who remained true to Thomsonian methods thereafter typically joined forces with the eclectics, doctors who resisted heroic methods and frequently dispensed botanic medicine, hoping to combine the best of the various schools. They were outnumbered by the homeopaths, devotees of a therapeutics developed by the German physician Samuel Hahnemann and imported to the United States around 1825, with resounding success. Homeopaths held to two central tenets: they believed that the substances that would produce disease in the healthy would cure the sick (the law of similars), and they also believed that medicine becomes more effective as the dosage is decreased (the law of infinitesimals—a law that also suggests home-opathy's governing faith in nature's healing powers). The popularity of homeopathy surged by the time of the Civil War, with hundreds of thousands of devotees—roughly two-thirds of whom were women—who willingly opted for the benign interventions that stood in such stark contrast to the physician's heroic therapeutics.

A number of other sects appealed to those in search of alternative treatment. Of these, perhaps the most popular and least harmful was hydropathy, yet another sect popularized in the United States in the early decades of the nineteenth century and distinguished by its rejection of drugs altogether. Hydropathic therapies, often administered at facilities that functioned as retreats, relied solely on water—used in multiple ways including baths, douches, and wraps—combined with fresh air, exercise, and diet. Other health reformers championed diet, dress reform—the abandonment of corsets and other constrictive fashions and the adoption of such health-promoting costumes as "bloomers"—and attention to proper hygiene. Advocates took to the lecture circuit to inform the populace of their recommendations, providing not only information and entertainment but often conflicting guidance to a citizenry in pursuit of health.

PUBLIC AND MENTAL HEALTH

A crucial force that may have been more responsible than any other for fighting contagion during the nineteenth century was the rising public health movement and the establishment of municipal health, housing, and sanitation departments. The unprecedented growth of urban centers and the outbreak of the Civil War only quickened the spread of disease and the pace of public health reforms. The cramped and unsanitary tenement districts in these cities became breeding grounds for disease, and calls for some sort of structural intervention were answered by those within the burgeoning public health movement. Health reform got a jump start during the war, as some six million sick and injured soldiers were tended (before the days of antiseptic surgery) in newly established hospitals by some 750,000 volunteers, including members of the U.S. Sanitary Commission.

The carnage of war may have ended in 1865, but the aftereffects lingered on. Even during the war, doctors, including S. Weir Mitchell (1829–1914), were recording and studying its effects on not just the body but the mind. Mitchell and other neurologists, including George M. Beard (1839–1883), went on to make careers out of diagnosing and treating "neurasthenia," a term Beard coined in 1869 for a constellation of symptoms, most prominent among them mental and physical exhaustion, resulting from the depletion of nervous energy. An equal-opportunity disease, neurasthenia afflicted not only what Beard called "the comfortable classes" but lower-class laborers and farmers. It was a diagnosis offered more readily to men than to women, perhaps because women were so essentially, etymologically linked to that other prevalent nervous disorder, hysteria. Beard was to conclude that neurasthenia was the price one paid for the pace and progress endemic to American civilization. U.S. citizens in 1870 may not have been appreciably healthier than they were in 1820, but they were—in Beard's sense—more civilized.

LITERARY TREATMENTS

Given health's status as national obsession and disease's identification as civilization's price, it is little wonder that both were seized upon as literary subjects. What is curious about these fictional representations is that illness is rarely discussed overtly or treated literally. Or perhaps not so curious: a culture so intimately acquainted with disease and death would value literature that offered the possibility of escape. Where authors did discuss the sick and dying, they tended to make the familiar not strange but meaningful—that is, to render illness as metaphor and to offer metaphor as solace.

The most pervasive such trope pervading antebellum literature was that of the female invalid, who was usually very young, very good, and very ill. While a number of authors sketched this figure, a few exemplary characters continue even in the early twenty-first century to capture the hearts and minds of readers. The beautiful, angelic, dying girl child remains best personified by both Harriet Beecher Stowe's (1811–1896) Little Eva and Louisa May Alcott's (1832–1888) Beth. Eva, the angelic, consumptive child heroine of Stowe's Uncle Tom's Cabin (1852), wastes away in the certain knowledge of slavery's evil and heaven's release. Eva's disease is treated evasively, though most contemporary readers would have recognized her tubercular symptoms; Stowe suggests strongly that slavery is the blight on her soul, eating away at her insides. In this one sees God's hand at work, though here Eva is not a sinner being punished but a martyr for the nation's sins, for its sickening inclination to treat human beings as things.

Alcott's Beth, the saintly March sister in the classic Little Women (1868–1869), was, like Eva, never long for this world. Surviving a brush with illness in the first book, she succumbs in the second. Beth dies, but her death represents not simply the end of life but the end of pain; Beth's face in death is "full of painless peace," and death itself is described as "the long sleep that pain would never mar again" (p. 514). Death here is no grim reaper but pain's antidote, providing release and bringing peace not only to Beth herself but, in some small measure, to mourning readers.

This emphasis on pain's surcease could derive from Alcott's attempt to explore within the safety net of fiction the seemingly inevitable outcome of her own illness. Several years prior to Little Women's publication, the author had served for six weeks as a hospital nurse and contracted typhoid pneumonia while tending to the wounded amid the unsanitary conditions of the Union Hotel Hospital in the Georgetown area of Washington, D.C. Her previously rugged constitution was ravaged in the short term by the fever and in the long term by the mercury in the medication she received. In her account of her wartime activities, Hospital Sketches (1863), drafted shortly after leaving her nursing post, Alcott breezes over her own suffering. She makes a virtue of "not complaining" (p. 55) about pain—devoting only one and a half out of roughly one hundred pages to her illness. Alcott's reluctance to elaborate upon the nurse's pain hints at a belief—a desire, never to be realized—that her recently contracted illness would prove both transitory and insignificant. Although Alcott would test numerous remedies—ranging from water to "mind" cures, from morphine to massage, from homeopathy to a nursing home—she was never again to regain her formerly robust health.

Yet another writer who attended the bedsides of Union wounded was Walt Whitman (1819–1892), already famous (or infamous) for his Leaves of Grass. Called to the hospital on behalf of his injured brother George, Whitman stayed to comfort other "poor boys," the recipients of his copious sympathies. His book of war poems, Drum-Taps (1865), encompasses the war from its earliest, most fervent and patriotic beginnings through the myriad horrors of the battle-field and hospital, closing with his beautiful elegy for the assassinated president. Whitman is one of the few writers to graphically represent pain and suffering on the page. In his poem "The Dresser," for instance, Whitman describes the pails overflowing with bloody rags, the putrefaction of gangrene, the bullet wounds, the amputated limbs. But he details these calamities with a compassionate rather than objective eye, a "soothing" if "impassive" hand, and a breast aflame with fellow-feeling.

At one point in this poem Whitman rhapsodizes about the merciful advent of "beautiful death." His fellow poet Edgar Allan Poe (1809–1949) also associated death and beauty but for very different reasons. In "The Philosophy of Composition," Poe argues that beauty (which he declares the provenance of poetry) moves one most deeply when the subject is sad and that therefore the "soul" of poetry is that most melancholy of topics, the death of a beautiful woman. The poem he anatomizes in this essay, "The Raven," evokes a beautiful woman's death via her lover's remorse; it reiterates his melancholic desire, abetted by the Raven's repetitions, to relive the anguish of their parting. Throughout Poe's corpus, death often figures as more titillating than terrifying. Dead or dying women populate Poe's works, from "Annabel Lee" to "Ligeia" to "The Fall of the House of Usher," and his recurrent device of resurrecting these lost loves uncannily evokes many readers' sense of the thin, permeable line dividing the living from the dead.

Whereas Poe's beautiful female protagonists are, as Diane Price Herndl attests, exceptional for being "the most unrelentingly sickly" (p. 91), Nathaniel Hawthorne's (1894–1864) female characters are often at least initially robust: indeed, the more robust they are the greater seem the odds of their early demise. Beatrice in "Rappacini's Daughter" (1844), Georgiana in "The Birth-mark" (1846), and Zenobia in The Blithedale Romance (1852) all possess vigorous health at the outset but wind up dead by the close. A woman's illness may have threatened her own life, but Hawthorne's stories suggest that a woman's health may threaten others, including the men around her as well as the patriarchal order to which these men subscribe.

One sees this same logic operating in a quirky doctor-authored novel published on the eve of the Civil War. Oliver Wendell Holmes (1809–1894) was at once a Harvard professor of anatomy and physiology, a founding member of the American Medical Association, the beloved "Autocrat of the Breakfast Table," a poet and essayist who coined the term "Brahmin" for Boston's elite, and a regular contributor to the Atlantic Monthly. In 1859 he began serializing in that journal his first attempt at a novel, Elsie Venner (published in book form in 1861). It is, as he argues in his preface, an attempt to substitute a naturalistic interpretation of disease for a moralizing one; his protagonist is not to blame for her actions, determined as they were in utero, when a snake bit Elsie's pregnant mother. Elsie may be serpentine, but she is also healthy—that is, until she comes under the supervision of not one but three doctors.

Holmes's first novel can be read as an attempt to assert the power of the clinical gaze at a time when that assertion would have been met with the raising of many a skeptical eyebrow. In the days before the medical profession had achieved authoritative status, this doctor-authored novel sharply differentiates a medical and pathological way of seeing. Elsie's "mesmerizing," passionate eyes signal her disease to the novel's three clinical observers, who coolly observe and diagnose but offer no remedy. Better, it seems, for Elsie's poisoned and poisonous femininity to self-destruct than to allow it to continue to cause dis-ease in those around her. It cannot be entirely coincidental, during this bumpy period in American medical history, that the narrative asserts the power of medical vision rather than intervention, of diagnosis rather than cure, strategically grounding its authority in the former at a time when the latter's success could not be guaranteed and, if enacted, might undermine the observer's objectivity and credibility.

Where disease was treated, then, few verifiable cures were offered, either in life or in literature. Suffering was commonplace, alleviation scarce.

Nature ran its course, and sometimes that course led the sufferer back down the road to health. Where it did not, hope still lingered that not only the life—however truncated—but the disease—however painful—possessed some greater meaning.

See alsoDeath; Domestic Fiction; Leaves of Grass;Mental Health; Mourning; Popular Science; Psychology; Science; Sexuality and the Body; Urbanization

BIBLIOGRAPHY

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Alcott, Louisa M. Little Women. 1868–1869. New York: Modern Library, 1983.

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Beecher, Catharine. Letters to the People on Health and Happiness. New York: Harper & Brothers, 1855.

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Cynthia J. Davis