[HMD Lecture: History By The Numbers, LHC Auditorium, July 15, 2008]

Dr. Donald Lindberg: Ladies, gentlemen. I'm Don Lindberg, your jovial host, and we have a primary speaker who says, "Let's get going,” so that's good news already. The only bad part of all of this is that we're remembering Jim Cassedy, a really swell person, and a colleague at NLM for many years. [NLM Director Dr. Donald Lindberg at podium, speaking.]

Let me just pause to say a little bit about Jim. I think we all remember him pretty well, but just to restate his history. He got a BA in American Literature at Middleburg, then served in the Second World War, got a PhD in American Civilization at Brown, and taught at Williams College.

That's a pretty New England-y career, and I don't see how we ever got him out of Williams College, frankly. That would be a grand place to spend the rest of one's career. I mean, unless it should get [?].

But in any event, he did come to Washington, and he joined NIH and served in a number of positions there, but happily, by 1968, he joined the staff of the National Library of Medicine, and of course,

his prime responsibility was in editing the bibliography of the History of Medicine, which went on for decades, and he did a splendid job, only overtaken by computerization, I suppose you could say.

But he had a personal professional interest in American medicine, and the role that statistics and collection of numerical data played. And that's unusual, but it's a really wonderful thing. So his book on American Medicine and Statistical Thinking is a really classic.

Jim received just about every honor that the history associations could possibly give him, and I won't regale all of those things, but I would like to end up by reading you a very brief little paragraph that, actually, John Parascandola wrote a couple of years ago. I think it says it quite well.

He's speaking of Jim. He says, "An easygoing, friendly, and kind man, Cassedy was always eager to meet and assist colleagues who came to the library to do research. If they came too often or stayed too long, he would charm them into giving a presentation in the division seminar series."

"One of the joys of the seminars for Cassedy was the opportunity to talk shop with fellow scholars over lunch or coffee,"  and John ends by saying, "He is greatly missed by his family, friends, and his colleagues."

I think that's for sure and I'm glad that you all took the time in a busy day to stop and remember him. We are fortunate, today, in having Bob Martensen speak to us using the topic, a follow-on sort of topic, "Medicine By The Numbers: Revisiting James Cassedy’s America. " So that'll be really a pleasure.

I should tell you a little bit about Dr. Martensen by way of introduction. He's an MD, PhD and he came to NIH as Director of the Office of NIH History and Museum in October of '07. So he's a recent arrival and we're delighted that he saw fit to make that move.

A book that he is very well known for is called "The Brain Takes Shape: An Early History." And I thought, at first, that must surely be an embryology, but it isn't really, it's a historical embryology. It's the origins of the ideas and views that scholars and intelligent people have had of the brain, really interesting.

But we all have to hurry to catch up on reading his work because by fall, he's going to be at Politics and Prose with yet a new book, I'm sure that'll be one we'll all want to have and to listen to.

He's actually, Dr. Martensen, had faculty positions at a remarkable number of places, and again, a distinguished history with lots of awards, I won't take from his talk to recite them all, but he’s had positions in history, humanities, ethics, and medicine. That certainly covers a huge range.

We're delighted that he's at NIH. We're delighted that he's taken the time to prepare a talk in honor of Jim. Thank you, Dr. Martensen.

[Applause]  [Dr. Lindberg leaves the podium and Dr. Martensen approaches it.]

Dr. Robert Martensen: Hi, thank you Dr. Lindberg, I'm delighted to be here. I appreciate your coming, I see many colleagues and friends and the widow of Dr. Cassedy in the audience.

I met him once, in a sense, we shook hands when he was getting a lifetime achievement award in 2000 at the American Association for the History of Medicine, but I didn't know him. And I've come to know him as one knows another scholar through his works, a bit, in preparing for this talk.

I wanted to go into the subject because he wrote three of his five books about the broad theme of counting in American life, particularly in the 18th and 19th centuries, with a major focus from 1800 to 1860. But before saying any more, I just want to acknowledge that I am so sorry that Liz Fee can't be with us, today.

She was the person who issued the invitation to me to give this talk, and I've known Liz for a long time, and just send my positive thoughts for her recovery. What I'd like to do today is talk with you about how Dr. Cassedy described the 19th century, and particularly, themes in medicine and American growth.

So I'll be focusing on just some of his work, and mostly what he called the "demographic aspects.” These are the areas I'd like to go through briefly. Some of it is in his work, and some of it is things that I've looked at in the same time period. [Slide reading 1) Cassedy's Approach, 2) Bacon's Legacy, 3) In the Shadow of Malthus, 4) Vulnerable Populations, 5) Florence Nightingale & Statistical Persuasion, 6) Salubrity]

In Medicine and American Growth, Cassedy really was trying to establish that medicine was at the heart of this demographic enterprise that preoccupied people from the enlightenment onwards.

And, whereas economic historians, political historians, and historical sociologists have been looking at this for fifty years and more, in detail, medical historians hadn't. So he was really looking at terra incognita in the history of medicine and bringing it into the mainstream.

And the approach he took was a social history approach. He said, "I want to describe, I want to provide a compendium, I'm not going to make judgments about the quality of the various kinds of numerical efforts that were taken, but  I want to just organize it, comment on it, and put it out there.”

And this was very much a way of recovering voices and pieces of history that was, in historiographic terms, predominant in his career, the turn to social history and applying it to areas of history of medicine.

Now, he cut off his work in 1860, and, at first, when I read that, I thought, well, it's probably because of the Civil War.

But from reading him, and, again, not knowing him, so I could be mistaken, he wrote that he stopped in 1860 because he thought  "the numerical method" was increasingly under fire as medicine started taking its cues from laboratories, primarily German and French laboratories, at that time, where devotion to numbers for number's sake was waning.

And I want to explore that a little later. One of the things that the people Dr. Cassedy was writing about, everyone from The Enlightenment onward in natural philosophy, medicine, the liberal arts, in a sense, was a Baconian.

We credit Bacon as being kind of the founding figure in modern science. Here's a picture of the Lord Chancellor.

What Bacon wanted to do, what he codified, what other people were already starting to do, was, in his utopian think tank, Solomon's House, which he describes in New Atlantis.

He wanted a group of people who would be compilers and abstractors to condense experiments in titles and tables, to codify all the observations and axioms out of them.

So it was a way of making visible, in numbers, all kinds of observations about the natural world. And he thought, through that, one could deduce general principles. So it's very much a way in which science went, large parts of science.

And Bacon was very clear that this was going to be a secular activity, a huge tension in his time, and going forward, through the English Civil Wars of the 17th century, were debates about the role of spirit. Spirit in nature, spirit in politics, the role of spirit in organized religion, how much spirit should be acknowledged, where spirit should be restricted.

And, again, Bacon was anticipating the future. He said, "No, we're going to keep astrology out of it. We're going to only have common, direct observation.”  But the method caught on in the 17th century, and it directly informs what Americans did, that's why I’m giving a rather long preface.

Even one find, Halley of Halley's Comet, at the end of the 17th century, looking at Breslau bills of mortality and using them to construct more effective life expectancy tables for annuities and life insurance.

Now Halley went to Breslau because the Germans had much better records. But, as one looks at the 18th century, if one were looking at the English side of this, you would see Britain’s colonial administrators getting data from everywhere.

Illnesses, medicinal plants, numbers of population, components of that population, weather. Every self-respecting physician was going out twice a day to record the temperature, and sometimes once at night, then constructing these elaborate weather tables of their local area.

And if one looks at early scientific records that are published in the philosophical transactions, for instance, the Royal Society, one finds lots of just those kinds of observations, "I did this and that and this and that about this and that,” just listed in tables.

One of the more prominent Baconians in the United States, and Dr. Cassedy writes about him extensively, is Daniel Drake, whom some of you may be familiar with.

Drake was a major figure in midwestern medicine, he’d been trained by Rush, he went into the midwest, founded a few different medical schools, many medical societies, and he was a modern, 19th century Baconian, par excellence.

In fact, you get a sense of that if you look at, what I think is Drake’s version of Baconianism, arguing that “the first business of philosophy" by which he means natural philosophy, "is to observe and register (facts of nature),” that's very Baconian.

"The second to arrange them into orders, and the third and highest, to deduce from them." So the ambition was that one could draw general principles from this mass of data about all of these strange new things in this expanding material and natural culture which Europeans and now Americans were being exposed to.

But Drake was cautious, as had been people like John Locke. Everything was tentative, one didn't want to go forward and make expansive claims. The goal is to get probable knowledge, not absolute knowledge. So that's a kind of epistemological boundary around what they were doing.

And Drake was also preoccupied, as were many many people in France, Germany, and Europe in medicine in the 18th and 19th Centuries with Nosology, the classification of natural phenomenon. Just think of Linnaeus in the middle of the 18th Century, there's Linnaeus coming up with the most successful classificatory scheme.

Drake's Nosology has five large classes of fevers, subdivided into genus and species and so forth. All of these people were laboring under, what I’ve called here, "In the Shadow of Malthus, " but it’s really broader. It's the sense that starts as soon as one starts having the nation-state, that the wealth of the state is based on its population.

A big population means a wealthy state. Later, that expands, it's not only the size of the population, it's the composition of the population, it's the health of the population, it's the mortality rate of the population, and so forth into what has evolved, in a rather continuous way, into the modern census.

But one finds it, you know, even as early as the Tudors in the time of Bacon and going forward.

And the preoccupation at the dawn of period Dr. Cassedy writes about is the vulnerability of the American population.

Here is Dr. Cassedy's America at the beginning of the period he writes about in 1800. And you can see, as Americans perceived, that the U. S. was sparsely populated. It meant, as contemporaries perceived it, that America was very vulnerable to foreign attack.

We had a small standing Army and Navy, we had a sparse population, we had huge borders for boundaries. And, particularly after some of the humiliations of the War of 1812, there was a sense that the task of America was to become populous.

Now the people saying that were imagining it would be populous with white Europeans and some of them imagined it should be populous with imported Africans as slaves.

But this gives a sense of where America is at the end of the period Dr. Cassedy looks at, 1860. So you can see that the densities have gone up dramatically. And people who were counting people, in those days, paid a lot of attention to what kinds of people they were counting.

This gives a graphic on the distribution of slaves in the United States, in the middle of the century, yeah, 1860, just before the Civil War.

When I say people were laboring in the shadow of Malthus, Malthus, as were many of his contemporaries, was very concerned with the issue of population. It was the dominant theme in American's list of the period. Malthus was a skeptic.

He didn't believe in the perfectability of man, he was, politically very conservative, and his account of nature was rather parsimonious. But Americans read him. People Cassedy wrote about read Malthus, and they were always comparing the American situation with the European situation.

Dr. Cassedy used the term demography, which is what historians now use to describe the activity about all this counting of people, but it's interesting that "demography” is a rather later term. It comes up towards the end of the 19th century, and I think it’s a common instance of how historians of science and medicine face this problem, in a sense.

We're describing things using words of today or one hundred years ago, to describe events before that, when those words didn't exist. For example, I've written some about the Scientific Revolution and some of you know a great deal about it, and others recognize the term, that period from roughly Copernicus to Newton.

Nobody during that period used the word "scientist” to describe themselves Science was not an active term in that sense, and “revolution" was not how they viewed their participation in advancing the new theories.

Nonetheless, historians of science commonly say it's the Scientific Revolution, just as we now use the terms demography and demographer to describe what these people were doing in the 19th century, prior to 1860, but they didn’t describe themselves that way.

They thought they were doing medical numerology, medical statistics, those are the phrases that pop up. But theme was constantly, "America needs a growing population. " And after the Napoleonic Wars ended and it was easier to emigrate from European countries to the United States, the gates opened and the stream of immigrants went dramatically up in a big way, [?] subsequent.

But this lyric from Parson Weems gives a sense of how people were thinking. This is from, I think, 1835. And this little kind of ditty he has, I'll give you a moment to read it...but it's that sense of how, reproduce and reproduce now, to fill us up, so we can stand  up to the European powers.  [Slide reading: List then, ye Bach'lors, and ye Maidens fair, If truly  you do love your country dear; O' list with rapture to the great decree, Which thus in Genesis you all may see; "Marry, and arise up soldiers, might and main," then laugh,you may, at England, France, and Spain.

And, for those who think the Victorians were incredibly closeted about matters sexual, I find the publication, Hymen's Recruiting Seargent, rather a counterexample anyway. But people were optimistic in 1800, 1810, and so forth, about our demographic prospects. This is from the statistical analysis from about 1830, I'm sorry I don't have a date on it.

But they could look at America and see that it was different than Europe. "Few of our citizens are concerned in unhealthful occupations, our towns are not yet so large..."

and fatal epidemics, although our port cities kept suffering yellow fever epidemics, were not as bad, or perceived to be as bad, as devastating, as they were in Europe.

And in this quote, you can see the sense of, "Yo, America's different. America's exceptional. It's not that Malthus is wrong, but that America, in some sense, has escaped. Now if one looks at the French population theorists, people like [?], they’re much more optimistic than Malthus.  [Slide with quote: "The process of doubling population, wthout Malthus, and without theory, without artificial or natrual wants, goes on, I am sure, on the banks of the Ohio as rapidly as anywhere in the world. Why should it not? The climate is mild, the cartte need little care or housing, and mutiplie rapidly. Grain requires little labour in the cultivation, and the children only need a pone of corn bread and a bowl of milk."]

So people can look at the issue of population and see different things. And even if one looked in  the United States in1820, 1820, particularly after 1830, one would find in Francophone United States, that is, New Orleans, a different take on this issue. People generally had a more French orientation towards the use of medical statistics. Doctor Cassedy focused mostly on the Anglophone literature.

I became aware of differences between French and American medicine, the more I lived for several years in New Orleans. In fact, that's kind of where I was before I came here. And so down there, I would start looking into French 19th century medicine in Louisiana, and the orientation is somewhat different.

Statistics, there's more counting in hospitals, coutable hospitals on the Eastern seaboard and so forth. But I don't really have time to go into that today.

There is an idea about what the land needs to be, and I'll be commenting on this as we go forward, to be healthy. The sense that people are healthy, land is  healthy, rock can be healthy or unhealthy. [Slide reading: 'While the country is entirely forested, it is ordinarily healthy. While it is passing form this state into that of general cultivation, it is usually less healthy. Only with an eventual substantial advancement of agriculture, settlement, and civilization could any important return toward the original level of salubrity be expected."]

It's not a vitalist notion, it's a holistic notion, however, it goes from the atmosphere down into the Earth, and how will this support a population?   And it's particularly acute for an America that's being settled by settlers, pioneers who are finding and selecting spaces. Now within this broad optimism, there is a sense, at the time, 1810, 1815, all the way through the end of the period Dr. Cassedy looks at and beyond, that there are vulnerable populations within the United States. [Slide reading: Vulnerable Populations]

And particularly the situation of the Indians, draws a fairly widespread awareness by whites of demographic catastrophe, early on. I'm using de Tocqueville here, he wasn't a physician, but Dr. Cassedy quotes him occasionally, and he certainly, I think, could write quite eloquently about the situation. [Slide  reading: "Not only have these wild tribes receded, but they are destroyed; and as they give way or perish, an immense and increasing people fill their place. There is no instance upon record of so prodigious a growth or so rapid a destruction."]

Smallpox was the most devastating of the epidemics to affect the Indians, and this gives the observations of a Dr. John Barnes, who was based in St. Louis, Barnes Hospital was named after him, there, of the devastation faced and experienced among the Indians.  [Slide reading: "The Pawnees lost two-thirds, and the Omahas, Ottoes, Missourias and Kansas lost at least half of their people."]

Now, efforts to counter that rather feeble, proposals were advanced, not accepted, from a very early date in 1816. [Slide reading: Believing that it was "dictated by humanity," Colonel William A. trimble recommended smallpox vaccination of the Commanches to Secretary of War John C. Calhoun in 1816.]

De Tocqueville, of course, could stand back from a French perspective and note the differing patterns of how Europeans and Native Americans mingled or didn't mingle. The other vulnerable population that got a lot of attention, in Dr. Cassedy's accounts and in the literature, I think he’s very representative of the literature, is the health of both slaves and free blacks.

Here I'm just going to talk about free blacks, due to constraints of time. Here's de Tocqueville on their situation. This is published in 1832.  [Slide titled Free Blacks' Health and reading: "On some accounts they are still more to be pitied than the Indians, since they are haunred by the reminiscence of slavery, and they are cannot claim possession of any part of the soil. Many of them perish miserably, and the rest congregate in the great towns, where they perform the meanest offices and lead a wretched and precarious existence."]

And then in New York in 1835, Dr. Charles Lee laments that "not one tenth" of the black population "have any regular employment, but depend on transient jobs, stealing, begging and public charity for support. " So this kind of information was widely published and widely known.

I'd like to turn, now, to something Dr. Cassedy didn't explore, and I'm obviously going out of America, so it wasn't in his writ to do it, but it does come back into America, and it’s an example of how some people were able to use statistics not in just this publication table after table, but use them persuasively to affect policy in the middle of the 19th century. Nightingale goes to, here she is in about 1850, she goes to Crimea and she starts looking at causes of mortality. [Slide titled: Florence Nightingale and the Persuasive Power of Graphs]  [Image of Florence Nightingale]

First in Bulgaria, and then in the Crimea. The light blue are deaths from infection, the purple are deaths from other causes, and the red are deaths from wounds. And what she's demonstrating, in a whole series of graphs, are that adoption of certain kinds of hygienic measures will lead to lower deaths from infections and therefore a vastly reduced military mortality rate. [Slide showing bar chart with blue, red, and purple bars.]

But she then does it in some very spectacular graphs. And many of you may be familiar with these. This kind of wedge graph then puts it out what happens month by month and what people are dying of. And she uses this to persuade her allies in Parliament to change policies for hospital design and for support of the organization of military medical efforts, particularly in battlefield situations. [Slide displaying graph with blue, red, and purple wedge-shaped sections.]

So it's a sense in which I think it's one of the most sophisticated graphics I've ever seen. The blue wedges, and I'll show it again. It was a little bit exaggerated, so just. . .

The blue wedges are death by sickness, but the message of the graphic is that most deaths in war are from sickness, and improvements in hygiene dramatically reduce those death rates. Here, you can see, this is another version of this. And again, she's using it going month by month, and trying to identify what's preventable. She, as was everyone else in this time period, were talking about, from the 19th century going back to antiquity, is operating under a model of health and disease in which an achievement of salubrity is the goal.

"Salubrity" is a very old word, but it resonates right through the Progressive Era, ending around 1925, which I'll go into in a moment. [Slide titled Salubrity]

To be salubrious, was to be healthy in one's body, and to be in a place that was healthy, physically, and, to some extent, being in a social context that was health-promoting.

It involved achievement in maintenance of balance, flexibility, adaptability, resilience. So one, particularly in America, when one looks at the settler literature, what they wrote in their diaries and how they viewed things -- here's a definition from 1913 -- you can see it's a holistic notion. [Slide titled Salubrity Definitions and reading: Webster's Dictionary 1913, Salubrity, The quality of being salubrious; favorableness to the preservation of health, salubriousness; wholesomeness; healthfulness; as, the salubrity of the air, of a countyr, or a climate.]

It pops up all over the promotional literature for settling what was then the West, and in people's private, private notes.

And you can see it flowing through here, into the early 20th Century, the last word in article 10. So it's a concept that resonates, and yet it's now fallen out, in the last 90 years or so, we don't use it much anymore. It's been wonderfully described by Conevery Bolton Valencius.

This is "Health of the Country," it was published in 2004 by Basic, and it gives accounts, lots of primary sources, of how the Mississippi and Missouri valleys got settled and how people approached land and selected rich land, it was rich but it might be dangerous, such as delta land, salubrious land, and so forth.  [Slide featuring image of the cover of a yellow hardbound book titled The Health of the Country.]

Daniel Drake, of course, argues that you need to go straight down into the Earth to know and at times wonders, did cholera happen more commonly when there's a limestone under the soil, or when there's granite, or when there's sandstone.

These speculations seem quaint to us, but they were very resonant in the time. Here is something from Drake, looking for instance, at the standard description, the way you would describe a city. One links its latitude, longitude, temperature swings, seasonal mean variations in temperature, rainfall, and so forth, and then there’s a genealogical study that goes along with it.

Now one could find much of this if one were looking in the philosophical transactions of the Royal Society in 1750, one hundred years previous to this.

So it's very much a Baconian instrument, a Baconian approach. There are instruments for measuring salubrity. Americans imported them, but after about forty years of doing that, we developed our own industry for medical instruments and all kind of measuring instruments of all kind. The eudiometer is a device to measure -- I have a picture of one coming up -- a physical volume of different gases in the atmosphere.

It's a kind of crude barometer in a sort. And here's Ulysses S. Grant, he's on his way to Mexico, this is from the 1840s, it's drawn from his memoirs. And he's in Natchitoches, Louisiana, and he finds this place that’s high, it's by a river, it's a ridge, it's sandy, which means the soil drains, it has cool and pure water, and he names it Camp Salubrity.

Because it's relatively mosquito-free and so forth. There was also a movement, in the middle of the 19th century, which Dr. Cassedy didn't go into, but I want to with you, a bit. The idea of how one creates salubrity, particularly in urban environments. The reality was that both large American cities and large European cities were experiencing increasing mortality rates.  [Slide titled Creating Salubrity and reading: From 1840 to 1880, a loose collaboration of physicians and landscape designers crafted a health/environmental dualism that informed the design not only of large urban parks, which were then a contested public undertaking, but also of military encampments and hospitals, the one-room schoolhouse, 'rural' cemeteries, and early suburbs.]

In fact, in London in 1845, the death rate for people in every decade was higher than it was in 1815. So the industrialization city-dwellers were dying off more frequently. In fact, London couldn't replace its population naturally, only by immigration, until the middle of the 19th century, and London was deemed to be healthier than New York.

So what I want to talk about is this collaboration that took place between some physicians and landscape designers, and I'll talk about just two or three who traded ideas and used medical theory to inform a design vocabulary for public parks, as well as hospitals -- Nightingale figures popularly in that -- the one-room schoolhouse, rural cemeteries, and early suburbs.

It's a shared vocabulary, and two main practitioners were John Rauch, a Chicago physician, and a founder of Rush Medical School, and a co-founder of the American Public Health Association. Unfortunately, I can't find any image of him anywhere, so if anyone knows of one, I'd love to see it.

But what he does, he's not a design person, he's a quantitative environmental analyst, and he looks at unhealthy places in Chicago and argues, successfully, in a political sense, that the city fathers in Chicago need to spend money to reshape the land forms of Chicago to make Chicago more salubrious.

And he gets very concerned about the contaminated water supply of Chicago, which is, by his analysis, downcurrent from the principal Chicago cemetery. Chicago cemetery emanating bad miasma, bad cause of infections. How to counter that?   Move the cemetery, reshape where the cemetery sits.

I'll show some images of what happened in a moment. His correspondent was Frederick Law Olmsted. And Olmsted would merit a few talks on his own because he was a polymath, he had such a broad career. [Image of Frederick Law Olmsted]

I want to talk just a little bit about his new park design, right around the time that picture was taken, and his partner in the park designs, Calvert Vaux. What Olmsted, Rauch, and their collaborators did was make a design theory based on the predominant communicable disease model counter to salubrity in the pre-bacteriological era, miasma theory. [Image of Calvert Vaux]

And at its simplest, miasma theory, which stretches back to the Hippocratics, assumes that when things are stagnant and decayed, when there's not circulation, when bad humors coalesce, when there's dirty water, rotting meat and vegetables, this accounts for most epidemic diseases, their term for infectious diseases, and it's epidemic diseases that account for most human affliction.

Remember, it's a time when 85 percent of people, more or less, are dying of infections, not cancer, not degenerative multi-system organ problems. The argument is, if stagnation and decay can be prevented at the both physical and social levels, and the two were always linked in the 19th century, health is likely to ensue. So what does Rauch do when he's talking to these various civil groups that he's talking to in Chicago?

He uses mortality statistics, he uses current patterns in Lake Michigan, he uses the eudiometer, to construct environmental profiles and then persuades people that fixing this environmental problem will benefit the entire community. Here's the top of a eudiometer, it looks kind of like a barometer, and it serves a similar function on different physical principles. What it meant was, if a place wasn't salubrious, it had to be re-engineered.  [Image of the top portion of a eduiometer.]

This is Boston's Fenway before and after, it's an Olmsted project from the late 19th century, it's a kind of sewage dump, and as Boston's Back Bay expanded out in that direction, there was a civic movement to create a necklace of parks, the Emerald Necklace, of which Olmsted was the champion.  [Two images of Fenway before and after its remaking under Olmsted.]

It wasn't fully realized, but the area we're looking at here, is the before picture, and if you've been in Boston, nearby is the Boston Museum of Fine Arts, several blocks away is Harvard Medical School, the Garden Museum, that's this area.

This project was massive in the sense that the records indicate a railroad car coming every forty-five minutes, being loaded with dirt and so forth, to get the levels right so that the water would stream into Back Bay, and of course Back Bay was dammed up to create the Charles River Basin.

Here's Prospect Park, which is in Brooklyn, a park of about four hundred acres, I think. Here it is in 1792, and it's described, as you can see in the foreground, as kind of marshy. It's described as a low, kind of nefarious area of miasma. How can it be re-engineered? [Drawing titled Site of Prospect Park, Battle Pass in 1792]

It's dredged and dammed, trees are planted around the perimeter to give good gases and so forth. Circulation patterns, particularly in Olmsted's model, are highly emphasized so that you can have potentially pestilential things, horse manure, confined to one circulation path, people on another, carriages are separated from pedestrian so that one avoids collision and so forth. Here's Prospect Park, the "after" picture.

A lake is created, rivulets of waterfalls are created and so forth.

This just gives an example, if you've been in Central Park in New York, of how complicated the circulation paths are that are created. Central Park,when it was built, was the largest public works project in New York City's history. It was massive. [Image of bridge, titled Bridge by Vaux in Central Park]

What you see there wasn't there. If you've been in Golden Gate Park in San Francisco, which was done by McLaren on an Olmstedian kind of concept, it's the same, it was kind of barren sand dunes. So there's that sense, the drive in the 19th century, based in part on these quantitative analyses of environment, and based on the predominant medical theory of the day, wow do you form a medical theory into an aesthetic theory?

And although people were skeptical at the time, there was opposition to spending public money on Central Park, the argument being, why would you have different classes mixing, what's the point, you're going to taint proper classes by the improper classes. And yet, when it's done, there's general widespread celebration of what it's achieved. Olmsted wanted the mixing to happen unconsciously.  [Slide reading: Central Park is "the most striking evidence of the sovereignty of the people yet afforded in the history of free institutions...it is a royal work, undertaken and achieved by the Democracy--surprising equally themselves and their skeptical friends athome and abroad."

He was highly influenced by some early 20th century Scottish and American theologians who talked about the unconscious in a kind of pre-floridian(?) way. But to use that term, he wanted a kind of harmony to just emerge. One could be in a space, be in a salubrious space that salubrity really operated unconsciously.

And the task of designers -- and he worked with Rauch on the design of some of the Chicago suburbs -- was to create environments where that could happen, where one didn't have to think about it

And it's very interesting, some other work I've done in the last couple of years is talking with some landscape designers, contemporary ones, working all the way from prisons to very fancy private undertakings, about these theories as they are playing out today in both rehabilitation in the penal system, and in creating gardens for the disabled and so forth.

Here's just Bethesda Fountain in Central Park in 2000.   [Color image titled Bethesda Fountain, Central Park in 2000]

It's no longer used for fresh drinking water, but in the 19th century, that was one of the few places in New York where the public could get free drinking water. So there was a kind of utilitarian ethos behind many of these designs and similarly, Prospect Park had a dairy, where one could obtain fresh milk and so forth. So the sense, based on environmental analysis and how does one create salubrity.

Well, I'm going to kind of zoom through a broad array, but then the 19th century is replete, and one of the things in working with Dr. Cassedy's materials, his archives must have been something else, just massive, I'm looking at his wife, because the amount of material that he was making sense of is just huge.

This preoccupation with counting and measuring and transforming that into improved medical policies, design theories, hospital wound hygienic measures so forth, it was staggering. The Victorians were very energetic.

Thank you very much.

[Applause]

Dr. Lindberg: Would you stay to answer questions?

Dr. Martensen: Yes.

Dr. Lindberg: So we can have a few questions, and if you have one, please punch the button so we can hear what you said.

Audience members: [mumbling]

Dr. Lindberg: Is somebody saying something?

Dr. Martensen: I think they're just talking privately.

Dr. Lindberg: Maddie, you have to push the button so we can hear you. Otherwise we'll have to eavesdrop. So where may one see a eudiometer?   Steve, do we have a eudiometer in our possession?  [Dr. Lindberg stands at the podium taking questions, while Dr. Martensen stands to his right.]

Steve Greenberg: We don't, but I suspect we do somewhere. Probably in the Medical Science Division.

Dr. Lindberg: I'm going to head right down there. What does it look like?   Can you tell us more about it?

Dr. Martensen: Well, the base is usually in mercury, it’s glass, and you take a sample of air and the gases dissolve in the mercury and you're measuring really the difference in the partial pressure.

So it looks somewhat like a barometer, and then they're dressed up, inexpensive ones, expensive ones, and portable ones. Physicians would have their portable ones, they'd carry them around and do their environmental investigations and then write it down.

One of the professional aspects of this that I haven't really gone into much today is that since you’re in a professional milieu, in the early 19th century, the professional monopoly is very thin. The licensing starts falling away, the medical schools proliferate, there's no regulation, so that how does one professionally become known as a solid physician, as a person of education, as a person of skill.

Well, the apprenticeship model, you find the best practitioner and you hitch up with them, or you have some other distinguishing characteristic. And the idea of being a "natural philosopher, " the term that antedates "scientist, " was a way to do that. So one finds, looking at provincial physicians, meaning in those days, physicians out in Illinois, or in Kentucky, or in the South,

when you look at what they did, and how they spent their time, and what records they've left that are extent, one finds these natural history recording things of, "I went out and I measured the temperature at 9 this morning and 5 this evening and I got [?] at night, and my water gauge is here."

They were recording everything, collecting medicinal specimens, botany, counting birds, identifying birds and so forth because it was something that natural philosophers did. And therefore, in a professional way, it gave one an edge, versus just being empiric.

Now, the counter to that is that even unorthodox physicians, homeopaths and so forth, also were very much into the whole same sphere of activities. Homeopaths were also highly educated and came from a German tradition of value and that kind of natural inquiry. So it was a complicated way of how professionals read each other, in the professional domain. Nowadays, we don't think about it.

People have state licenses, there's a monopoly, people without an MD can't practice medicine, and so forth. But it was a much more chaotic professional landscape, particularly in the Jacksonian period to late in the 19th century.

Dr. Lindberg: How about you. Question?

Male Audience Member 1: About a month ago, there was an article in the Lancet by a woman named Snow, who is the wife of a great-great-great-grandchild of John Snow, questioning whether Snow should be considered the father of epidemiology, and her argument was really that Snow’s work was not really appreciated until the 1930s when epidemiologists for other reasons wanted to enshrine a hero.

From what you've said, the idea that he was really the first to do a numerical analysis of disease prevalence is not valid either because clearly the people in the early 19th century America, and Florence Nightingale, were doing such analyses before Snow. So how do you put Snow and the pump handle into that perspective?

Dr. Martensen: I think that epidemiology has several parents in different countries.

For instance, if one goes back in England, John Graunt publishes a statistical analysis of the English population in 1662 and he uses bills of mortality covering a 60 year timespan to look at deaths from different causes, in the London census.

If one looks at the German literature, you could say Pettenkofer is a father, or you could say that Werkhof when he goes into deaths amongst Silesians and epidemics, and he looks at Silesian miner's diseases and makes correlations.

Certainly Snow is in the pantheon, but I think it's a well-populated pantheon because it's such a widespread activity. In a sense, everyone's a Baconian for about 250 years. So that would be my response.

Dr. Lindberg: [Pointing] Please push the button.

Male Audience Member 2: If I could add to that, I think that something Jim knew very well and talked about, and I don’t remember how much of it was in his books, but that's the influence you alluded to of French statistics, of French medicine. The French had a system of doing all of these things, measuring the temperatures all over the country, and indeed all over their colonies as early as 1776, correlating that all with health.

And I've never known, I've never understood what effect that had on America in the late seventeen and early eighteen hundreds, but clearly in the 1820s and 1830s when American medical students were walking the Paris hospitals, they brought all of this back to America, [?] and Gerhardt, and Jackson Jr.

So I think, while John Snow was a medical student, all of this stuff was going on in France, far more sophisticated than the British were at the time. And Snow sort of reinvented the wheel in a way, because all of it was there a generation before him.

But it may be that it got imported to America from France, rather than from England. And Osler sort of made that case in the 1890s and I don't think it's been developed very well, but it's an interesting link that hasn't fully been made.

Dr. Martensen: I appreciate those remarks, and actually the National Library of Medicine History of Medicine Division will be looking in the 150th anniversary of his birth, Oliver Wendell Holmes, in 2010. And Holmes, who went to Paris, brought some of that model back into the United States and then wrote about it, so that's why I'm mentioning Holmes, and used that as an argument.

And of course the French model was, after Louis and the others, was to start questioning "heroic therapies," what were known as "heroic therapies," massive doses of purgatives, emetics and so forth. And Drake and the Americans, Rush had such an influence in the United States. Now, Rush was a busy counter of many things, but Rush had a model of America, kind of an exceptionalist model.

The American is stronger than the kind of finicky, weak European, therefore Americans need stronger medicines, so he would really dose you with galome. And when you get the French coming through, and you can see it in the tensions in the New Orleans professional community. The French are arguing a nihilistic model...

"No, it's better to let nature take its course, don't do these things, and we have the statistics to prove it." And that comes straight out of the Paris Hospital tradition. But the counting tradition in French medicine antedates the revolution, in other words, there's a long continuity there and it's not in British medicine.

Dr. Lindberg: Would this relate at all to TB sanitaria? I'm a member of the American Clinical and Climatological Association, kind of a strange move, but it was founded by Osler. And most of their concern at least initially was, to use your word, whether an area was salubrious with respect to curing TB.

Dr. Martensen: Right, well Osler made this great comment about TB that the Philadelphians, in 1894 Philadelphia was debating, do we have to register every consumptive, every person with tuberculosis, because tuberculosis has this distinct cause, Koch has identified the tubercucilis in the 1880s, and Osler kind of demurs.

But what he says I thnk is very apropos of this [?], this holistic approach. He says, with tuberculosis, it's the seed and the soil. It's the soil as much as the seed, meaning the nutritional status and general health status of the patient. And that's certainly true as we see, we had an antibiotic that cures tuberculosis in the 1940s and yet tuberculosis is rampant on a global basis.

Dr. Lindberg: But it is amazing that those people did record temperature and wind velocity 10 times a day.

Dr. Martensen: And their hospitals very nicely had solaria, so you could. . .

Dr. Lindberg: Oh yeah, sleeping porches and all that, and [?].

Dr. Martensen: Right. Absolutely. Anything else? Sir.

Male Audience Member 2: Yes, I just wanted to ask you about your comments about these reformers like Olmsted and Rauch, of the later generation and how they sort of used miasmitism as a way of doing their good. Because they were responding to a theory that was becoming increasingly discredited during their lifetimes.

And I'm just recalling that Segarist and other historians had made the point, a long time ago, that, as miasmitism began to fade away as scientifically justifiable throughout  the 1800s, that reformers in various countries, like Chadwick in England, sort of winked and said, well, we don't really believe it, but this'll get the politicians to fund all of the reforms we want.

And so, at some point, they were sort of faking it in a way, I guess, as it became clear that many diseases were not related to miasmas, as infectious diseases began to be discovered, and organisms began to be discovered, the reformers didn't want to get rid of the theory because it had popular appeal and it was accepted by older generations of politicians, who would then vote for the reforms. At least that's what's said...

Dr. Martensen: Well, let me give a slightly different perspective on that, because I think that the concept of achieving harmony in one's body, on the level of the individual body, and balance, it's a very ancient concept. It goes across all manner of healing traditions, meaning ours, [?], Chinese traditional medicine, and it's certainly resurgent in the United States today.

If you surveyed what people do or if you looked at the sales of various nonregulated health remedies, they're astronomical. And various pursuits of balance, all of the movement regimes, the drugging regimes, and so forth. But the argument, Nightingale never believed in the germ theory. She was opposed to the germ theory, because she was always linking the individual, the social, and the moral.

And even if you look at the Main Journal of Syphilology, at the turn of the 20th century, in 1904, it's called the Journal of Sanitary and Moral Prophylaxis, which is similar in that sense of the Oslerian climate, it's linking everything, that sense that harmony requires a lot of different components.

And one of the challenges, or one of the areas where there's some variant historiography is when one looks at the tradition of scientific medicine, as written by a highly educated, university-based group of physicians, all that tends to drop out and it looks like the germ theory comes in and goes right across, but in fact, it's resonating at lots of different levels in society, and one can argue, now, in much of the world.

If you want to cut infection rates, you educate women, you provide clean water, you introduce soap, you do various things that are all hygienic measures that Nightingale would've put in place 150 years ago. And these mortality rates would fall for every decade.

Dr. Lindberg: Did you watch, the other day on TV, seeing the miasmas above Beijing?

Dr. Martensen: Yeah, the word has just stayed and it resonates with a completely different continent.

Steve Greenberg: Well ,I just wanted to back to John Graunt for a second, because I'm a big fan of John Graunt. And of course, if you're familiar with Graunt, you'll know he was not a physician, he was a haberdasher.

But the thing that always interests me about the mortality tables that come out in London in the 17th century is that they start much earlier than that. They start in printing them in 1602, 1603.

They don't have a breakdown by causes of death, but they are broken down by parish, so you could tell which were the healthy parishes, which were the non-healthy parishes, but even more than that, there was a decision made by the London Town Council to make these numbers public.

And at a time when you could have your fingers and ears cut off for printing a letter written by your brother on the Continent, the idea that publicly available broadsides giving statistics, causes of death, places of death in 1603, always struck me as being remarkable.

It's the very first time you see a publicly printed and distributed public health document.

Dr. Martensen: Well, thank you, that's fascinating. Thank you, well we're up on our time, so maybe we should stop.

Dr. Lindberg: Thank you.

Dr. Martensen: But thank you very much.

[Applause]

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