In Pursuit of Your Medical Degree

Edwin M. Knights, Jr. looks at disease and medicine in the time of our ancestors.

Sickness in the Colonies
Although the Spaniards had been active in exploring North and Central America earlier, the first serious attempts to create colonies began in the 17th century. The first settlers faced considerable odds, among them being harsh weather, starvation and endless toil which made them very susceptible to disease. Poor organization and mismanagement of available supplies contributed to the failure of attempted settlements in Virginia. The first Jamestown colonists had unsuitable shelter, with the result that few of them survived long in their new environment. Nearly 40 died and most of the rest were ill; at one time there were only six healthy men in the fort. In Virginia it was heat, “miasma” of the swamps, poor sanitation, plus poor and insufficient food, all combining to affect colonists who were already in poor physical shape.

The Plymouth colony fared somewhat better, partly because of superior organization and some good fortune. Landing in November in New England could hardly be considered a brilliant strategy, but the new colonists were fortunate in that the winter was unusually mild. Local native inhabitants had cleared fields for planting, then mysteriously disappeared. There was still a heavy toll of illness and death. Some, like Richard Warren, had wisely planned ahead. He arrived on the Mayflower in 1620, but his wife and five daughters came across the Atlantic on the Anne, three years later. The surviving newcomers were hardy souls and they adapted remarkably well to their new homes but it wasn’t long before the natives and the newcomers began to clash. This culminated in King Philip’s War, in 1675-76, with bitter fighting that nearly destroyed many of the New England settlements and caused heavy loss of life to the Narragansetts, Wampanoags and Pequots. Native Americans also encountered their own new health problems. They had no immunity to common contagious diseases such as measles, and as the Europeans spread deeper into the continent, even in the next two centuries, many tribes suffered huge losses from the imported “childhood diseases” for which they had no defense.

Other than records about those who died in warfare or accidents, we do not have much reliable documentation about specific causes of death during that period. The “miasma” from the Virginia swamps probably included malaria and perhaps yellow fever. From vital records in New England, it is apparent that many wives died very young from complications associated with pregnancy and childbirth, such as infections, ecclampsia and hemorrhage. Infant mortality was high. The widower almost always remarried and had more children, so large families were common. As nearby families tended to intermarry repeatedly, the possibilities of genetically transmitted medical problems resurfacing were increased. Sickness and death were probably the greatest obstacles to colonization, requiring a high birthrate and a steady supply of new colonists to counterbalance the losses.

Ships’ “doctors” were really only surgeons and were generally only capable of handling “self-limited” (i.e. self curing) diseases.

The 18th Century
In the 18th century, physicians were very puzzled about the causes of various diseases but they felt sure the symptoms were the results of physiological imbalances in your body. They believed some conditions resulted from miasmas, unseen airborne causes from garbage, swamps or other sources of unhealthy odors. They had also begun to realize that other diseases were contagious, caused by unseen effluvia that were able to spread from one person to another.

The physiological imbalances were said to be based upon four humors: blood, phlegm, yellow bile and black bile. Imbalances among these four humors led to symptoms of disease. Treatment was based upon counteracting drugs or food.

There were those who also believed illness represented imbalances in the solid fibrous components of blood vessels and nerves, i.e. the “solid theory.” At that time both vessels and nerves were considered to be hollow. In the healthy body, blood or “nerve fluids” circulated freely while sweat, urine or feces were expelled freely.

Perhaps the greatest advances in medicine during the 17th and 18th centuries came from the anatomists, such as Vesalius, Hawey and Swammerdam, whose careful dissection and injection of vessels advanced the understanding of bodily functions.

Smallpox
Smallpox (variola) claimed many lives in colonial New England. In 1721 half of the population of Boston contracted smallpox and one-sixth of them died. Smallpox struck again in 1763. The Rev. Cotton Mather had learned how the Turks inoculated their citizens to protect against the disease. He and Dr. Zabdiel Boylston decided to try this method which had never been practiced before in America prior to the day Dr. Boylston inoculated his own son.

Word of their experiment spread rapidly, thanks in part to a couple of highly skeptical physicians. Public reaction was violent. Dr. Boylston was mobbed in the streets. A bomb was thrown into Cotton Mather’s home. It didn’t explode, but he got the message that was taped to it.

The community was sharply divided over inoculation. All the clergymen supported it; all the doctors opposed it. It was the custom to send a child with smallpox to a pesthouse. Paul Revere chose the other option. A yellow quarantine flag was hung in front of his home and a guard (someone who’d recovered from smallpox) was stationed outside. But isolation measures such as these failed to quell the epidemic and increasing numbers of Bostonians were stricken with pox. Over 1,500 others fled in terror.

In desperation, the Selectmen granted “Liberty to the inhabitants to inoculate their families.” this was not vaccination as we know it, first practiced by Edward Jenner in England 12 years later. Jenner had astutely noted that milkmaids were immune to smallpox, and he used cowpox for his vaccine. In contrast Dr. Boylston was transferring a minute amount of material from a fresh smallpox vesicle into an open wound in the subject, inoculating the person with a small dose of the active disease. Now, however he was joined by Drs. Sprague, Warren, Church and 16 other Boston physicians. Together they inoculated nearly 5,000 people, of whom only 46 died. Of about 700 others who contracted smallpox “naturally,” 124 died. Gradually the refugees returned to Boston and life resumed as before.

Anatomical dissection and the study of surgical anatomy and pathology became more widespread towards the end of the century and the perfection of microscopes would soon add a new dimension to the understanding of disease. The first post-mortem autopsy in America had been performed in 1691. By the end of the 18th century, a coroner system had been developed in Britain to investigate suspicious deaths, and in 1796 a coroner was appointed in Boston. His name was Paul Revere. Most of his 40 cases were sailors, probably drunk, who fell from spars on ships in Boston harbor, either hitting the deck or drowning.

The 19th Century
To understand medical genealogy, it is necessary to appreciate the challenges faced and overcome by one’s ancestors and to try to get an appreciation of the common medical problems of that era. We are fortunate in having a resource that gives a well-recorded picture of the medical scene in the early 19th century. It was then that the British and American navies adopted the policy of keeping logs of the medical problems encountered on shipboard. Ship’s “doctors” were not highly trained in medical diseases, most being classified as “surgeons.” They were fortunate in having to deal with the ailments of an essentially healthy group of young males in which 95 percent of the complaints were for symptoms which were “self-limited,” i.e., diseases that cured themselves. From their logs we can get a picture of the everyday practice of medicine.

The most common illnesses were catarrhs (headcolds), influenza, consumptions (often tuberculosis) and pneumonias, constituting 50 percent of the cases in sick bay. Other more serious diseases were intermittent fever (usually malaria), diarrhea and dysentery, and “bilious fever.” Rheumatisms, “lumbago,” and sciatica were common afflictions in sailors, soldiers and the working poor ashore. Gout was seen in senior officers and the wealthy ashore. Scurvy was no longer common after 1795 when lime juice was mixed into grog. But venereal diseases, such as syphilis (lues) and gonorrhea (gleet) were occupational hazards. Yellow fever and cholera were threats to the seaman, and typhus was commonly known as ship fever at sea and gaol fever ashore. Drunkenness was more of a problem in ports than at sea. The Royal Navy adopted the custom of a daily grog ration of rum diluted with water, but this practice was never followed in the American navy.

There are some diseases that the genealogist might strongly suspect but will never be found in the medical records. It has been a long-standing tradition in medicine that some diagnoses are not “politically correct.” Just as we are reluctant today to publicly identify some persons with AIDS, it was true then. A king did not get the gleet, but knights did.

Medications
Although the sea-going doctors had opportunities to improve their surgical and dental skills through practice, all without benefit of anesthesia, they largely relied upon the same types of medications used by their better-educated counterparts ashore. A review of the available drugs suggests their patients fared little worse than the landlubbers. Their therapeutic agents were of five types:

Tonics: Their object was to strengthen a body weakened by disease. Cinchona was a favored drug, also called “Peruvian bark.” It actually worked well for the “intermittent fever” of malaria.
Cathartics: These were used to flush out the “unbalanced humors.” Typical were calomel (mercurous chloride), jalep (a resinous cathartic plant from Mexico), medicinal rhubarb, castor oil and cremor tarter (sodium potassium tartrate).
Emetics: These induced vomiting to remove foul humors from the stomach and strengthen stomach muscles. Examples included ipecac and tartar emetic (antimony potassium tartrate).
Diaphoretics: These helped the patient “sweat out” unbalanced humors.
Narcotics: Opium and laudanum, the alcoholic solution of opium, were known to cause addiction, and their ready availability often made victims of medical practitioners. Coca leaves from Peru also became popular.

Which was Worse, the Treatment or the Disease?
A fast pulse was considered the hallmark of fever, with the increased body heat explained by arterial irritability caused by some mysterious miasma or effluvium. The primary goal of treatment was to reduce the irritability and the fast pulse. First, the physician tried a depletive or evacuant regiment, using emetics, antispasmodic cathartics and narcotics. They also attempted to reduce arterial tension by bleeding. Patients were to avoid red meat, exercise or anything that “fed the fires of inflammation.”

If you survived the first onslaught of treatments, “tonic” measures were used, hoping to strengthen the heart and arteries. These included cold water and virtual starvation. What was achieved by this regimen is not well documented, other than contributing to Darwin’s theory of the “survival of the fittest.” Yet even today we still hear, “Feed a cold and starve a fever.”

Occupational Diseases
Review of where a family settled and how the members were employed can pay big dividends in acquiring an understanding of its medical history.

Those immigrants who brought expertise in a trade or crafts such as carpentry, farming, animal husbandry, seamanship, tailoring or perhaps metal craftsmanship usually found employment or a means to make a living providing they could communicate with their neighbors. Others, such as the blacks, arrived unwillingly as slaves and most lived in relative poverty in the south. There they probably coped with the heat better than most Europeans, but many had to withstand back-breaking labor and an inadequate diet. Lacking shoes, many developed hookworm disease, which led to gastrointestinal bleeding, anemia and chronic fatigue.

Shiploads of Irish immigrants poured into New England as a result of famine in Ireland. The men worked as laborers and many women sought jobs as maids and housekeepers. Most of the women, however, ended up in textile mills, where respiratory diseases were common. Their crowded living conditions also encouraged spread of pulmonary tuberculosis and scrofula through the families. Large Italian families also filled the cities and had to put up with poor sanitation, soot-filled air and overcrowding which resulted in periodic epidemics of infectious and contagious diseases. Heavy drinking was common and combined with deficient diets, led to cirrhosis of the liver.

As the industrialization of America continued, coal became the principle source of heat and power. Sailing ships were replaced by steamers and smoke-belching locomotives pulled the trains. Some of the most crippling occupational illnesses afflicted the ever-increasing numbers of coal miners, may of whom had started working as soon as they were old enough to use a pick and shovel. On the streets and highways, replacement of horses by the gasoline powered vehicles only succeeded in trading one type of environmental pollution for another.

A Swiss Misinterpretation
Probably 25,000 Swiss citizens emigrated to the American colonies just between 1734 and 1744, in spite of Swiss governmental measures to discourage them. Switzerland is a beautiful country, they admitted but “you can’t eat the scenery.” By the 19th century, passports were being issued and some of these carry considerable information. The Bernese recorded height, hair and eye color, shape of forehead, nose, mouth, chin and faces as well as special markings. At the same time, they saw this as an opportunity to rid themselves of “undesirable elements.”

Junius H. Browne published a book in 1871 called Sights and Sensations in Europe. Browne loved the landscape but was not enthralled by the inhabitants. He wrote:

“The traveler in Switzerland is constantly struck with the difference between the country and the people. The contrast is painful for the magnificence of the one throws into bolder relief the wretchedness of the other. Excessive toil and irremediable poverty have made the Swiss as a people homely, misshapen, hard... Throughout the Rhine Valleys and the Vale of Chamoinis, unsightly creatures glare at you on all sides. You turn from a lofty peak, or a magnificent gorge, to a monstrously swollen neck or a gibbering imbecile. Your admiration for a picturesque cascade or a splendid glacier is interrupted by the petition of a hideous cripple or the stare of a wandering idiot.”

To his credit, Browne recognized these unfortunate people were suffering with goiter and cretinism, but what he didn’t know was that these conditions were largely the result of insufficient iodine in their diets. Because entire families were affected, the condition was deemed to be hereditary. Those emigrating to North America could not expect complete cures but they could expect normal offspring unless they selected Michigan or some other area lacking iodine. So don’t be too alarmed if your Swiss ancestor was short, with a protruding tongue, broad flat nose, widely set eyes, sparse hair, dry skin and a protruding abdomen. It’s a complicated subject, and there is some inherited susceptibility, but if you feel you’re getting that way, take another pinch of salt (iodized, of course!)

The 20th Century
We have packed more medical advances into the past 99 years than we made in all the time before that. By 1901, government had already assumed increased control over the lives of Americans. Along with this came an understanding of the importance of public health, documentation of diseases and organized attempts to improve sanitation and eliminate diseases. One only needs to visit the so-called “third world” countries to appreciate the achievements of our public health systems.

The focus of public health has shifted considerably to meet current needs. Early in the century, emphasis was placed on such things as control of infectious and contagious diseases, for these were the days prior to antibiotics. Reservoirs and water purification systems were developed; health departments established routine inspection of food, milk and restaurants. Large hospitals and sanitariums were established to accommodate and isolate patients with chronic infectious diseases. Specialty hospitals were created to cope with children’s diseases, orthopedic problems, “lying hospitals” for deliveries and sanitariums for chronic tuberculosis. The “alms houses” of the 1800s gradually became community hospitals and around these developed many prominent medical schools. Doctors devoted much time treating “charity” cases. These patients were worked up by medical students, interns and residents under the supervision of the best physicians in the community, so they often received the very best medical care at no cost.

“Iron lungs” assisted children with paralyzed respiratory muscles caused by polio.

Medical research provided new understanding of many diseases and new ways of dealing with them. It also changed the names of many of the illnesses, so you need to know what nomenclature was in style at the time your relative acquired the condition. Poliomyelitis was known as “infantile paralysis” prior to the 1950s, by which time the viral etiology was becoming understood and vaccines were being developed to prevent the disease. Polio was seasonal and often spread to cause paralysis of respiratory muscles. Many of these children ended up in “iron lungs,” respirators which mechanically assisted breathing.

Inherited Diseases
Genetic research advanced rapidly early in the 20th century, spawning the misguided proponents of eugenics. The inheritance of human disease is a massive subject and we cannot do it justice in a short review. Instead, we refer the reader to any standard textbook of internal medicine.

Genetic diseases tend to fall into one of three categories: Chromosomal disorders involve the excess, lack or abnormality of one or more chromosomes. Simply inherited disorders (Mendelian) are brought about by a single mutant gene. They can be separated into the autosomal dominant, autosomal recessive, or X-linked types. Multifactoral disorders result from the interaction of multiple genes with multiple environmental or other outside factors. These have complex inheritance patterns, with much less risk to families than the single-gene Mendelian disorders.

If you have accumulated enough clinical information, make a little chart, going back as many generations as possible. Make the males squares and the females circles, or use some other configuration so you recognize them. Now blacken the squares or circles of those who seem to have a particular disease. Just by looking at the resulting pattern, you may be able to tell the type of chromosomal disorder affecting the family.

Blood Diseases
Blood diseases have undergone many name changes over the years, especially as atypical white cells and red cells became identified and their functions understood. Just a few examples:

Cooley’s anemia, known also as beta-thalassemia major, is probably the most severe form of congenital hemolytic anemia. There is also a “minor” type, causing a very mild anemia, plus several other genetic subtypes.

Sickle cell anemia, properly known as drepanocytosis, was first discovered in 1910, when Herrick found sickle-shaped red cells in the blood of a Jamaican medical student. It looked fairly simple in 1949 when it was found that just a single amino acid separated hemoglobin S from normal hemoglobin Since then, however, several hundred structurally different hemoglobins have been identified. Fortunately, only about a third of these cause symptoms.

For the genealogist, trying to determine the cause of anemia in an ancestor is like answering the old question of how many angels could dance on the head of a pin. Unless you are exceedingly fortunate, you are faced with two dilemmas: in the 19th century they knew too little about anemias and now they know too much! Just about anything can cause anemia — abnormal hemoglobins, atypical metabolic pathways in the red blood cell, direct toxic effects, destruction of red cells by antibodies agglutinins, drug trauma, heat, cold, uremia and hypertension. You can get hemolysis (destruction of red blood cells) from marching, from karate, even from bongo drums. In the last century doctors bled their patients, creating an anemia where none existed. Present- day physicians relying upon the laboratory instead of clinical history and physical diagnosis, are accused of ordering so many lab tests that the patient may run out of blood.

Worst of all, “anemia” is anything but a precise definition. It’s based upon what is considered normal for a male or female in a certain age group, but normal is also difficult to define. There are countries where “normal” hemoglobin is just about half what it is in the US and Canada.

Spotted fever can cause confusion, because it represents one of a whole family of febrile (fever-causing) diseases transmitted by ticks or mites. Although its usual name is “Rocky Mountain Spotted Fever,” it has been found in nearly every state, as well as Canada and Mexico. At one time the mortality was 20 percent but this has lessened considerably. Its tick is carried by wild rodents or dogs. Closely related are endemic and epidemic typhus, transmitted by fleas or body lice. This helps to explain why typhus was once called “gaol fever.” All of these diseases, plus Q fever and Trench fever, are caused by rickettsial organisms, which are intracellular parasites about the size of bacteria.

This article originally appeared in the September/October 1999 issue of Family Chronicle.