Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century

A major problem which characterizes many of the studies of the history of American medicine is that they, like Sargent, ascribe sole importance to the physician, thereby attaching little importance to the patient's perspective. For example, Paul Starr's recent popular work, The Social Transformation ofAmerican Medicine, includes the following phrase in its subtitle: "the rise of a sovereign PROFESSION" [capitals ours]. Once again, the occupational or vocational aspects of American medical development are greatly accentuated. J. Worth Estes and David M. Goodman's new work, The Changing Humors ofPortsmouth, is a study of the development of medical practice in the town of Portsmouth, New Hampshire, from 1623 to 1983. It is unfortunate that this study, like many others, places undue emphasis on the physician. Hence, the authors provide long lists of diagnoses made by physicians in seventeenth, eighteenth, and nineteenth century New England, as well as data on changes in the doctor's fees. The reader, however, is provided with little insight into these basic aspects of developing American medicine: the patient's reasons for visiting a doctor, the patient's expectations of physicians, community acceptance of various medical sects, and so on. The view of "medicine" which is provided in this book dwells on physicians and their concerns and provides little which illuminates the changing expectations of centuries of American patients. Despite the aforementioned criticisms, this book has several strengths. First, as the subtitle states, the book is essentially "the medical biography of an American town." By focusing on a specific population (Portsmouth, New Hampshire), the authors provide a complete and continuous record of medical development in a single locale. This continuity is of vital importance and allows the reader to develop an almost stratigraphic view of the different phases of medical development in this one town. It should also be added, at this point, that the authors have thoroughly researched their topic. Second, several of the chapters provide the reader with valuable information on more specific topics, such as the rise of epidemiology and control of epidemics at the turn of the twentieth century and the gradual movement of health care into hospital settings. To conclude, while the study of medical history in America is in need of many more studies which provide a continuous record of medical development in one location, studies should be less physician-oriented. The study of "medicine" should place an equal emphasis on the patient, for it is often the patient who provides us with the most valuable information. This fact was recognized long ago by the eminent English cardiologist Sir Thomas Lewis, who is reputed to have said, in reference to the topic of physical diagnosis, "Listen to the patient, HE is telling you the diagnosis."