Cover Story
The Historians
Physicians find that studying medicine’s past prompts critical thinking about the present.
By Kate Ledger
As a pre-med student in the 1960s, Bruce Fye got an unlikely tip that would add a twist to his career. A bookseller, who knew that Fye was both an avid collector of old books and an aspiring doctor, suggested he shift the focus of his collecting to medical volumes. Fye did, and by the time he finished medical school, he had amassed a collection of several hundred unusual texts. What Fye hadn’t expected was that the experience would pique his interest in the history of medicine.
Now a cardiologist at Mayo Clinic, Fye has become a specialist in both fields and calls himself a clinician-historian. He’s not the only physician to delve into medicine’s past. Many do extra reading or take an occasional extracurricular humanities course. But he’s one of about 100 in the country who have jumped in whole-heartedly. A typical day might find them holed up in medical archives, poring over old books and journals, or even sorting through boxes of once-abandoned papers as they search for clues about the past. Some are even pursuing graduate degrees in medical history. And they’re publishing historical articles in many of the same journals in which their clinical papers or research reports appear.
As it turns out, Minnesota is a great place to be a clinician-historian, both because of the state’s rich and varied medical past—many firsts have taken place here—but also because the University of Minnesota boasts one of the country’s premier history of medicine departments (see “The Wangensteens’ Legacy,” p. 32).
Studying the history of medicine is no longer just about learning names and dates, says Fye, who serves as president of the American Association for the History of Medicine, a professional organization dedicated to the study of the history of health, healing, and disease. Nor is it solely tracing the evolution of medical advances. In fact, the history of medicine is about describing the various social forces, organizational tensions, philosophical trends, and global events that have shaped medical practice today. And what physicians are getting, along with well-honed analytical skills, is a sense of perspective to help them consider the current state of medicine.
Evolution of a Specialty
Peter Kernahan, M.D., was a surgeon with HealthPartners and Regions Hospital in St. Paul until he retired five years ago and embarked on a Ph.D. in the history of medicine at the University of Minnesota. During the years he practiced, he’d been interested in history as a hobby and had read up on the history of medicine in his spare time. As one career was drawing to a close, he suddenly envisioned pursuing another. “I decided I’d go the whole nine yards,” he says of his decision to go for a Ph.D.
The topic that convinced Kernahan to pursue an academic career stemmed from his background. He’d long been intrigued by a book called Medical Chaos and Crime, written by Dr. Norman Barnesby in 1910, which depicted some of the operations that took place at one New York hospital in the days before surgery was regulated. “All a doctor needed was the nerve and a willing patient,” Kernahan says, “and the results were often disastrous.” Using the book as a starting point for his own research, Kernahan dove into the archives of the American College of Surgeons. He read medical literature from the beginning of the century, newspaper and magazine accounts, as well as reviews of the 1910 book. “I was just fascinated,” he says.
He determined that Barnseby’s book reflected the culture of the early part of the century, when exposés and muckraking were common. But Kernahan also saw the book’s publication as an indication of a turning point in the field of surgery. At the time, doctors were licensed as physicians and surgeons; few dedicated their practice solely to surgery. Also, more types of operations were being done, and the sheer number being performed was burgeoning. Barnesby drew public attention to the lack of regulation in the field. In 1913, the American College of Surgeons formed, setting out to establish standards for the training and licensing of surgeons. Kernahan’s paper describing this period of transition was published two years ago in the Journal of the American College of Surgeons.
His research took off from there, and his interest in the history of surgery has formed the core of his dissertation. He’s investigating the period between 1880 and 1940, tracing not only the evolution of surgery as a specialty but also how it almost immediately began fragmenting into distinct areas of subspecialization. What he’s discovered is that the boundaries and definitions of the field have been “constantly shifting.”
What’s there to learn from all of this? “It’s a question of how we got to where we are,” he says. “None of it was preordained.” As general surgeons now engage in discussions about the future of the field, whether it will continue to exist or whether the specialty is being further fragmented, it’s helpful to know that the developments are part of an ongoing process. “There’s never really been a time when you could say, ‘This is general surgery.’ We’re just experiencing the latest iteration of the definition of the field,” he says. “The borders have been changing all along.”
From Eugenics to Genetics
Internist and preventive medicine specialist Neal Holtan, M.D., had once considered majoring in history but headed into medicine instead. He realized he still had the history bug while he was working on a master’s degree in public health after completing his residency and took a few survey courses about medical history dating back to ancient cultures. But he again put history on hold until a few years ago, when he received a Bush Fellowship that enabled him to study at the University of Minnesota. “I was just going to do some brushing up,” he recalls. “I took the history of medicine seminar and got hooked.” He wound up getting another master’s degree over the next year and a half.
Holtan’s thesis was on the heyday (in the 1920s) of the Minnesota Eugenics Society, which endorsed surgically sterilizing residents of the School for the Feeble-Minded in Faribault. The practice was supported by Minnesota state law. Holtan wanted to find out what kind of people were sterilized, how it was done, and what the legal ramifications were. Combing through records from the institution, he learned that as many as 1,200 people had been subjected to surgery, about 80 percent of whom were women with IQs between 50 and 80. All were wards of the state. The surgery “was a means to keep them from having children,” he explains. The society was disbanded in the early 1930s for a slew of reasons, including the lack of scientific backing for eugenics and the fact that “the Nazis gave eugenics such a bad name,” he says.
The Wangensteens’ Legacy
Walk through the halls of the program in the history of medicine on the University of Minnesota campus, and you’re likely to see a surprising age range among the students, says acting director Jennifer Gunn, Ph.D. Some go straight into the program after finishing their undergraduate work. Others have entire careers behind them. Gunn says the younger historians have a longstanding interest in medicine and science but want a more humanistic expression of those interests. Most of the older students have been or continue to be practitioners, who wish to reflect about their roles and the nature of their profession. The mix of students leads to stimulating discussions.
The program was established 40 years ago by former chief of surgery Owen Wangensteen, M.D., and his wife Sally, a medical editor. Historically a graduate program, it was intended for physicians.
In addition to the academic program, the Wangensteens also helped grow the Historical Library of Biology and Medicine, which has an impressive collection of nearly 70,000 volumes, many of which are rare texts. Among them is an original illustrated text by 16th century Belgian anatomist and physician Andreas Vesalius.
The university’s academic program in medical history is one of only about a dozen in the United States offering graduate degrees. Most recently, it merged with the program in the history of science and technology—a marriage that makes sense, according to Gunn. “Those histories are often intertwined.” In fact, the faculty members’ areas of expertise can overlap. Topics range from the rise of the pharmaceutical and medical device industries to the development of ergonomics in Nazi Germany. Gunn’s own research began with an exploration of how residency became the model for advanced medical training.
Significantly, the program maintains close ties with the medical school. Faculty members give lectures to first- and second-year students, and medical students can take an elective in the department. To bring the broad range of historical studies into the medical community, the program’s monthly lecture series is held over the noon hour so that anyone from the Academic Health Center can attend.—K.L.
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Some of the themes of that project resonate in Holtan’s current research on the origins of public health genetics. For example, the founder of the Minnesota Eugenics Society, Minneapolis physician Charles Dight, ultimately bequeathed his life savings to the University of Minnesota to start a human genetics program in 1941. The program, “one of the earliest in any university,” Holtan notes, led to the development of and coining of the term “genetic counseling” by University of Minnesota geneticist Sheldon Reed in 1948. Reed joined what had become the Dight Institute in 1947 and began working with the university’s department of pediatrics to counsel patients and families about genetic diseases. During his first year, Reed did 81 consultations. The next year, he handled 135 cases. The demand for genetic counseling soon grew beyond what the university could offer. “The [faculty] people there said, we can’t handle all this. The state has to help,” Holtan says.
In 1960, Minnesota became the first state to establish a human genetics unit in its health department and hire a staff geneticist.
Holtan, who has a private practice and works part time as the medical director of the St. Paul-Ramsey County Department of Public Health, says public awareness about Huntington’s disease in the 1950s likely sparked demand for genetic counseling and led to the Department of Health’s establishment of a statewide registry for the disease. Other registries were soon developed as well.
Holtan points out that many threads weave into the history of public health genetics including social and legislative changes such as the rise of the feminist movement and legalization of abortion, as well as medical developments such as the introduction of amniocentesis. All of these factors, he says, are what “got people thinking this was bigger than private practice medicine, bigger than the program at the university, bigger than clinics. The state had to do this.”
As for whether the past is relevant to the present, Holtan says historians are sensitive about the notions that you learn from the past or that history repeats itself. “I don’t think there are any direct lessons to be learned,” he says. Still, Holtan sees value in studying history and understanding how many different pressures can converge during a particular time period. “There’s context, a cultural framework, to these events,” he says. “Trying to understand why people made decisions in their context might help us understand what our own context is.”
Not Just a Job
What’s clear to those who study medical history is that issues that feel distinctly modern have roots that reach back in time. As Bruce Fye puts it: “History teaches humility.” He received a master’s degree in the history of medicine at Johns Hopkins in 1978 at the same time he was completing his fellowship in cardiology. His first published historical article broke ground: It traced the concept of active of euthanasia in Western medicine to an English schoolmaster in the 19th century. What most surprised Fye was that the discourse hadn’t changed over time: “Almost all of the arguments for and against an easy death were articulated 120 years ago.”
Fye has gone on to study the history of medical education and the history of his own specialty, cardiology. He has turned his research into two books: The Development of American Physiology: Scientific Medicine in the 19th Century (Johns Hopkins University Press, 1987) and American Cardiology: The History of a Specialty and its College (Johns Hopkins University Press, 1996), which won a prize from the American Association for the History of Medicine. He’s currently finishing The Mayo Clinic and Cardiology: Specialization in the 20th Century. “This is a passion,” he says. “I don’t think of this as work.” He hopes to share this enthusiasm at the 83rd annual meeting of the American Association for the History of Medicine this April in Rochester (see p. 12), which will draw attendees from around the world. The organization, which started in 1925, was once made up only of physicians. Today, nearly one-fourth of its 1,300 members are physicians; the rest are historians, medical librarians, and anthropologists.
Toward Broad Thinking
There’s little doubt that having a sense of the past can add an important dimension to medical education. For instance, in a history course, medical students might begin to think about how and why the number of women physicians has increased dramatically during the last quarter century and how that might affect the field. Or they might gain insight into how our understanding of disease is shaped by the social contexts in which they arise. For instance, “monomania” is a term that was used for centuries to describe a condition in which people obsessed about one thing. In our own frenetic era, Holtan points out, we grapple with a diagnosis that sounds very much like its opposite, attention deficit disorder, in which people have an inability to concentrate at all. “Students begin to see how something might seem definitive in one period of time, but not later,” says Jennifer Gunn, Ph.D., an associate professor and acting director of the history of medicine program at the University of Minnesota.
Even for established medical practitioners, history can prompt more critical thinking about the present. “I don’t think all physicians are aware of the positions of their professional organizations, and the clout of those organizations, in political debates over time,” Gunn says, noting that the American Medical Association first approved national health insurance for workers before World War I, then later on opposed it in part because the idea seemed too “German.” Having a sense of how the organizations assumed their stances, and the rhetoric involved, can help physicians evaluate and analyze current topics, she suggests.
On a personal level, a glimpse into history can be reassuring. Fye wrote in a paper, published in 1989 in the New England Journal of Medicine that history can offer solace to any doctor feeling wearied by the strains of the profession. Reading diary entries and correspondence written in the early 20th century by William Osler, Fye found repeated references to Osler’s fatigue, even when he was at the height of his career as a physician, teacher, and educational consultant. Fye determined that Osler was run ragged. It’s a detail that can be relevant to physicians who today struggle with work-life balance. “You start to think, if a person of Osler’s stature can burn out,” Fye says, “maybe we can all feel a little better about ourselves.” MM
Kate Ledger is a freelance writer in the Twin Cities and a frequent contributor to Minnesota Medicine.