Richard Cabot, 1911 [1]

According to some medical historians and sociologists, the basic structures of twentieth-century American medicine—its focus on biomedical science, its reliance on technologically based hospital care, and its systems for medical education and training—were firmly in place by the end of the Progressive Era (1890 to 1920) [2-4]. During this period in American history, most urban reformers sought to modernize society through rational planning. Inherent to this approach was the notion that reform could be achieved through developing efficiently administered bureaucratic organizations [5-7]. Recently investigators have tried to determine how medical care relates to society at large, but such attempts are not new [8-10].

The life of Dr. Richard Cabot (1868 to 1939) exemplifies a Progressive Era focus on the social context of medical care. Although Cabot is best remembered as the founder of The New England Journal of Medicine's weekly series, "Case Histories of the Massachusetts General Hospital," his career encompassed much more than medical education. His medical interests ranged from clinical research and medical diagnostics to hospital social work, medical ethics, and the interface between medicine and religion [11].

Although Cabot championed the role of basic science in medicine, he also insisted that disease, social circumstance, and even religious beliefs could not be easily separated. Medical institutions, Cabot felt, provided inadequate care when they focused primarily on disease pathophysiology [12]. However, many of Cabot's efforts attempting to counterbalance these reductionist tendencies, such as advocating social work and emphasizing ambulatory practice and training, received a low priority in the medical care of this period, largely because these practices lacked the cachet associated with the emerging biomedical sciences. Instead, the pendulum of medical practice swung away from the nineteenth-century model that had emphasized the care of the patient within his or her social context and toward an approach that reduced illness to its biologically analyzable parts [13]. I will explore Cabot's personal odyssey during this critical era in medical history.

Cabot's Background

Anyone who met Richard Cabot must have been struck by his impressive combination of interests and talents. Cabot himself shared these perceptions. In his personal notebook at the beginning of his medical career in 1894, Cabot confided, "I feel. that not to do something really great will be for me to have failed entirely. I have never heard or read of anyone with such advantages" [14].

Cabot was born in 1868; his privileged early life was characterized by famous family visitors, expansive summer homes, long European vacations, private tutors, and the arts. The Cabots were one of the five well-known families that came to dominate Boston's business and civic life before the Civil War [15]. Rather than producing dull aristocrats, the Cabots had long been "distinguished for independent thinking and acting," both traits that Richard demonstrated to an unusual degree [16]. Richard's branch of the family particularly preferred the values of spiritual and intellectual pursuits to stoking the family fortune. His father, James Elliot Cabot, had studied law and architecture but chose a more contemplative life. When Richard was a boy, his father was immersed in writing a biography of Ralph Waldo Emerson and in helping the older, enfeebled Emerson complete his last book. These two friends shared many interests in philosophy and nature, and the six Cabot boys had vivid memories of the philosopher's regular visits [17, 18].

Until his last year in college, Richard had planned to follow a career either as a Unitarian minister or a philosopher. By the time of his commencement, however, he had decided on a career in medicine. Cabot, academically gifted and self-confident, graduated from Harvard College with a degree in philosophy, summa cum laude, in 1889. In his old age, Cabot traced his decision to pursue medicine to a meeting with Dr. Edward Trudeau, a physician and former tuberculosis victim who founded the famed Saranac Lake sanitorium near the Cabot's Adirondack summer retreat [19].

Cabot saw a medical career as a more practical expression of his religious desires to serve and to lead [19]. He believed, as did many other Progressives, that the new professional classes would be the agents of moral, as well as scientific, progress [6, 7]:

The live progressive part of our age ... is the life of doctors, lawyers, teachers, and possibly ministers of our time. They are the people who are doing what certainly was never done before, who certainly do not exhibit degeneration—as possibly art and literature may [20].

During his education at Harvard Medical School in the early 1890s, Cabot's interests in medicine's spiritual aspects remained strong, often guiding his research endeavors. His senior paper, "The Medical Bearing of Mind-Cure," used epidemiologic methods to study Christian Science healing and evaluate the medical effects of faith [21]. In 1908, Cabot expanded this earlier study and examined a cohort of 100 patients who claimed benefit from Christian Science therapy. Cabot stratified these patients into two categories: those with evidence of physical pathology and those with no clear physical cause, concluding that mind cure was especially potent for the latter group [22].

Cabot and Medical Science

By the time Richard Cabot completed medical school in 1892, the understanding of disease had begun to change dramatically [23]. Whereas nineteenth-century physicians primarily viewed disease as an imbalance between the patient and his or her environment, French physicians began to correlate clinical findings with autopsies. The work of the "Paris School" led doctors to conclude that many diseases arose from disturbances in specific organs. The germ theory, developed in the 1870s and 1880s, led to the identification of microorganisms as causes of diseases [24]. The role for technology and the laboratory in the diagnosis of disease grew with these scientific advances [25].

In America, these scientific advances were seen as the key to a whole new approach to the patient, involving not just the study of disease but also the structures of medical education and health care services. Johns Hopkins Medical School and Hospital, founded in 1884, epitomized this new alliance between medicine and science, introducing laboratory studies into the medical school curriculum and formalizing clinical teaching of medical students [26, 27]. Many other medical schools and teaching hospitals, both before and after the influential 1910 Flexner Report [28], also began to emphasize the role of laboratory-based inquiry in medical training and care [4].

Cabot's career, at least initially, resembled those of other physicians of his generation who embraced this scientific approach. Cabot was one of the few American physicians who undertook full-time postgraduate training in laboratory research. After his 1893 internship, Cabot spent a year as the first Dalton Research Fellow at the Massachusetts General Hospital. During this time, he focused on the new field of hematology, leading to his paper, "The Diagnostic and Prognostic Importance of Leucocytosis," which typified the era's concern about disease classification [29]. The results of Cabot's paper showed that the leukocyte count increased during systemic infection.

Like other elite university-educated physicians, Cabot believed fervently that medicine's future depended on its strong ties to science. Many of his writings exalt the importance of research in the biologic sciences [12, 30]. The following acclamation of the laboratory researcher was not only typical of Cabot, it represented his era's general reverence for scientists [12]:

You and I (doctor and social worker) can only alleviate a little suffering here and there. We are pygmies of human helpfulness compared to those giants who work beyond and behind the sick patient in the foreground ... I want you to feel as I do the spiritual nobility of scientific work.

Despite the importance that Cabot felt for the laboratory, the concerns of the patient were always primary. He clearly distinguished the profession of medicine from the practice of medical science. After his research fellowship, Cabot was offered but did not accept an appointment as the first bacteriologist at the Massachusetts General Hospital. It is apparent from his letters, however, that he privately agonized about his choice to follow a career as a purely laboratory-based physician. He confided to his wife, "I feel all my bent in the other half of medicine, the practitioner's (sic) part, the looking after bodies with souls in them rather than bodies without" [31].

Bringing a scientific approach to the clinical setting better suited Cabot's temperament. He became recognized as an expert diagnostician at Harvard Medical School and the Massachusetts General Hospital. Making diagnostic thinking more "scientific" became Cabot's hallmark. In 1896, at the age of 28, he wrote A Guide to the Examination of the Blood [32], followed in 1905 by Physical Diagnosis, which became the standard textbook on diagnosis for many years [33]. Also during this period, with considerable input from then medical student and later distinguished physiologist, Walter Cannon, Cabot developed the Clinical-Pathological Conference [34].

Cabot's research also became entirely clinical. His best known scientific paper, "The Four Common Types of Heart Disease," published in 1914, typified his predilection for research that helped the clinician diagnose accurately [35]. In this paper, Cabot correlated autopsy results with patient histories to establish diagnostically useful probabilities on the main causes of heart disease.

Despite his advocacy of scientific medicine, Cabot's allegiance to patient care led him to question some of the ramifications of medicine's new emphasis. He took exception, for example, to the growing sentiment that basic science in medical education should be rigorous enough to challenge the medical scientist. He thought that the practicing clinician used only 10% of basic sciences taught during the first 2 years of medical school and, therefore, should receive no more than this percentage [36].

Moreover, although Cabot saw medical specialization as a substantial improvement over general solo practice, he perceived this innovation as having both benefits and drawbacks [37]. The use of increasingly technical and specialized medicine ran the risk, he felt, of dehumanizing medical care. Reminding his colleagues not to forget the human element in caring for the sick, he wrote, "All that tends to make us build up a diagnosis at a distance from the patient is dangerous" [38].

Cabot also criticized the increasingly popular notion of the modern hospital as a bedside laboratory, where, "the study of the patient and the study of the experimental animal can then go hand in hand" [39]. Although Cabot did believe that this approach could be useful, he thought it was sometimes overvalued and could distort patient care. "In the practice of medicine outside of the hospital," he wrote, "psychical elements are everywhere present and often paramount, while in the laboratory they are reduced to a minimum" [40]. When laboratory-oriented physicians practiced medicine, Cabot feared that they often continued to rely on patterns of thinking and on organizational structures that minimized social, psychological, and environmental factors.

Going beyond Medical Science

Because of his concerns with the increasing importance placed on the laboratory sciences, Cabot set out to re-emphasize the need to consider the patient and his or her environment. Cabot's opinion that the medical profession often gave scant attention to social issues was fueled by his increasing role in outpatient care. Four years after he finished his fellowship at the Massachusetts General Hospital, Cabot began to work in its outpatient department (OPD). Although this choice actually resulted from his limited early (1898) job options in Boston, Cabot immediately realized the clinic's importance [19]. Cabot's colleagues often denigrated the clinic setting as a vestigial remnant of nineteenth-century medical practice [41, 42]. With the growing importance of technology and the laboratory to clinical medicine, however, the inpatient setting assumed a much larger role in patient care by the end of the nineteenth century [3].

Ironically, just as outpatient clinics and dispensaries declined in popularity as training grounds for physicians, the demands placed on them multiplied. The large number of immigrants arriving in American cities had limited access to private medical care and, therefore, had to rely on the outpatient departments of large hospitals [43, 44]. Not surprisingly, such care was often rushed and makeshift. Cabot once observed that in the outpatient department, "Our patients shoot by us like comets, crossing for a moment our field of vision, then passing out into oblivion" [12].

Cabot was outraged by the neglect of outpatient care and began a vigorous campaign to " ‘show 'em’ the OPD was the most important department in the MGH". Armed with statistics on patient visits, Cabot noted that "whereas there are 3000 (patients) in a month on the wards ... there are a thousand a day in the OPD" [19].

Cabot claimed that outpatient work gave the doctor a better perspective on important social issues related to health [45, 46]. Unlike inpatient care, where a patient's individuality was often almost obliterated, social factors were more evident in the clinic. In fact, social circumstances often dwarfed the medical issues, leaving a frustrated Cabot to write [12]:

I found myself constantly baffled and discouraged when it came to treatment. Treatment in more than half of the cases ... involved an understanding of the patient's economic situation and economic means, but still more of his mentality, his character, his previous mental and industrial history, all that brought him to his present condition in which sickness, fear, worry, and poverty were found inextricably mingled ... facing my own failures day after day ... my work came to seem intolerable. I could not ... face the patients when I had so little to give them.

However, Cabot was not long daunted by either inadequate medical practices or by difficult social issues. In 1905, tired of what he described as medicine's blindness to the social context of illness, he conceived of and then implemented what may be his most enduring achievement: hospital social work. Although social work at the turn of the century was beginning to be recognized as a profession with distinct social welfare activities, such as the Settlement House work, it was not yet associated with hospital care [47]. Cabot's idea of an auxiliary medical worker who could pay close attention to a patient was not entirely new. Yet, "Lady Almoners," employed by British hospitals to monitor for charity abuse, were decidedly not patient advocates. In this country, Cabot's close friend, Dr. Joseph Pratt, had instituted the "friendly visitor" in 1905 as part of his treatment of tuberculosis patients [11].

Cabot expanded Pratt's "friendly visitor" into a new concept of professional medical care. Cabot's initial vision of medical social work was far more ambitious than the version that eventually gained acceptance [48]. At first he saw social work as a near-equal partner to physician care, with doctor-directed medical diagnosis and social worker-led social diagnosis complementing each other [12]. The complicated bureaucratic hospital—if it was to serve human health in the broadly conceived manner that Cabot believed was its ultimate mission—had to include such multidisciplinary interactions. The physician, although still the central figure in hospital function, had to cede control of nonphysical patient issues to those with greater expertise in these matters, namely social workers, nurses, and even spiritual counselors [49, 50].

Cabot fought doggedly, with monetary as well as moral support, for the recognition of social work at the Massachusetts General Hospital. He buttressed his position with statistical analyses of medical practice. In an infamous 1910 paper he argued that the unacceptably high percentage of diagnostic errors seen in hospitalized clinic patients was often caused by the failure of physicians to take adequate social histories [51]. This work, along with his public exhortations for prepaid medical practice, nearly led to his expulsion from the Massachusetts Medical Society in 1915 [52]. Nevertheless, by 1919 social work became a department at the Massachusetts General Hospital; other hospitals soon followed suit [48].

Cabot's reform efforts did not stop with social work. His many writings on medical ethics, particularly his advocacy of telling patients the truth and his reservations regarding the use of patients for experimental purposes, were prescient of medicine's current ethical standards [53, 54]. He proselytized for affordable comprehensive medical care, favored group practice, and argued in favor of more formal training in ambulatory medicine [55, 56]. He searched for ways to blend medicine, religion, and psychology to form new approaches to the treatment of mental illness [57, 58]. He cofounded a pastoral counseling training center at the Massachusetts General Hospital [59], and much of his free time was devoted to a wide variety of social causes, including Boston's Children's Aid Society [11].

Limits to Cabot's Influence

Early in his career, Cabot fully expected that his varied efforts would put him on a trajectory toward positions of greater power and influence within the medical profession. Yet this did not occur. His failure in 1912 to be appointed as the Jackson Professor of Medicine, one of Harvard's oldest and most prestigious chaired medical professorships, most dramatically illustrated the limited influence of his vision in an era of increasingly technological medical practice. Most observers initially presumed that Cabot would be the next Jackson Professor. At first, he had the strong endorsement from the retiring Jackson Professor, Dr. Frederick Shattuck [60]. He valued laboratory work, even if he himself was not a bench researcher; he was an outstanding clinician and teacher, and he was innovative in his efforts to upgrade medical care. Instead, a clinician with a stronger laboratory science background, Dr. David Edsall, then of Washington University, received the position [61].

Observers at the time, in Boston and nationwide, regarded Harvard's selection of Edsall as symbolic. Two years earlier, Abraham Flexner published his famous report severely judging the weak scientific basis to American medical education [28]. Flexner had noted that Harvard's clinical programs, as was the case in many medical schools, were controlled by an "old-boy" network of clinicians that promoted people on the basis of seniority rather than merit. The result, according to Flexner, was "a noticeable lack of sympathy between the laboratory and clinical men. They do not represent the same ideals" [28]. Many people at Harvard, including its president, were displeased with Flexner's criticism of its medical school [62]. The search committee, responding to Flexner's criticism of its "old boy" clinician tradition and trying to ensure that Harvard would become a leader of a new medical order, chose Edsall—both an outsider and a physician with a background in physiology—rather than the more diagnostically oriented Bostonian Cabot for the position [61].

The differences between Cabot and Edsall are illustrative of the era's medical value system. Edsall's research interests concerned disease mechanisms. He did have many active social concerns, such as clinical nutrition and industrial pulmonary disease [63]; however, both of these fields relied on the use of scientific expertise to reinforce physician authority. Like most medical scientists at the time, Edsall viewed inpatient hospital care as a kind of bedside laboratory and viewed Cabot's social work crusade as an interesting but marginal refinement of the modern hospital agenda [60].

In contrast, Cabot's later research came to focus on patients, not on diseases. Cabot knew that his passions lay outside of the realm of biologically defined medical care. With his general evangelistic tone and unabashed religious proclamations, Cabot often seemed more clergy than clinician. Cabot later admitted, "I was not interested in Disease (but was) interested in spotting it and getting people over it" [19]. His epidemiologic work—however compelling—was seen by his peers and by the search committee as reminiscent of the nineteenth-century statistical studies of Pierre Louis and William Osler and as lacking the luster of laboratory work [60].

Perhaps most importantly, most physicians viewed his priorities as too sprawling and ecumenical. In 1910 Cabot wrote [12]: "We doctors are actually beginning to abolish ourselves by merging in the wider profession of public, preventive medicine, whose activities are inextricably interwoven. with social and educational work. I am thankful that it is so". Many felt that a medical leader who urged that other service professions, such as social work, be elevated in their importance to human health was not the person to reliably consolidate and expand physician authority in this new medical era.

Certainly, Cabot's forceful personality and willingness to take on unpopular causes did not assure physicians that he would always represent their interests. Often his greatest supporters were also his detractors, such as his colleague, Edwin Locke, who was instrumental in swaying the Jackson Professorship Search Committee away from him [60]. Cabot's righteous manner was legendary. A house officer who trained under him expressed a common opinion when he said that Cabot "had very rigid ideals, the moral propriety of what was right, and what was wrong, his way he insisted was the right way" (Mcpherson D. Interview by Gifford S. 28 March 1973).

Edsall, a gifted medical administrator, served as the Dean of Harvard Medical School for 18 years and facilitated the development of biomedical science. Edsall respected Cabot, but in reviewing the Jackson Professorship selection process to a friend, he concluded that Cabot's talents and evangelism would be more appropriately used as the Public Health Commissioner for Massachusetts [64].

Cabot publically supported Edsall unequivocally: He even wrote a long article on Edsall's arrival in Boston for the principal local newspaper [65]. Privately, however, he was crushed. A hint of his disappointment can be found in a letter to Cabot from William Osler. Cabot's original letter is unavailable but the tone of Osler's reply makes it obvious that Cabot was worried about his prospects. Osler answered [66]:

Nothing can make or break you now—'tis done! How many fellows of your age have your record to look back upon? Think of all the good and stimulating work you have done! And you have the warm appreciation of your colleagues the world over.

Regardless of Osler's high appraisal of Cabot's value, the Jackson Professorship decision made it clear that Cabot's priorities were not shared by an increasingly powerful group of academic physicians. In old age, Cabot speculated in his notebook about what he would have been like as the Dean of Harvard Medical School and concluded that it "probably would have been a good thing for me but bad for the Medical School" [19].

Cabot probably could have advanced further in the national medical hierarchy had he been willing to leave Harvard. This kind of move, however, appears to have been unthinkable. His brother, Hugh Cabot, an academic urologist who had left Boston early in his career, frequently criticized this aspect of his elder brother's Boston Brahmin parochialism [18].

Although Harvard Medical School made accommodations to keep Cabot at the Massachusetts General Hospital, he ultimately concluded that his broad concerns could not be addressed from his position as the clinical chief of a medical service. His experience as a World War I field officer in France may have hastened his impatience with clinical medicine. His military and academic colleague, Dr. Paul Dudley White, recalled Cabot's wartime frustration "with the mere healing of wounds and illnesses, and the education to be found in most schools ... Morons can be superbly healthy, criminals can be highly educated. It was the spiritual quality of the individual that attracted his attention" [67]. Thus, it was not surprising that he accepted an offer to chair the Department of Social Ethics at Harvard College in 1920, even though citing his commitments to medicine, he had turned down a similar job offer in 1907 [68]. Cabot continued to maintain a clinical presence at the Massachusetts General Hospital until his death in 1939 but on a part-time basis only.

Conclusion

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It is perhaps fitting that Cabot decided to move beyond his career in clinical medicine at the close of the Progressive Era. As with many early Progressive reformers, Cabot started his career with a near-missionary zeal toward the curing of bodies and souls. He continued to emphasize these broad humanistic goals but found his interests further and further separated from those of mainstream academic medicine which, for the next 70 years, would primarily focus on the applications of biomedical science. By 1920, he believed that he could better function as an agent of change from outside of the medical profession.

His vision of health care depended on successfully counterbalancing the dehumanizing tendencies of modern medical institutions with services, such as social work, that addressed broader health care issues. Cabot's reform efforts provided needed, albeit imperfect, solutions to this dilemma. Yet, these measures, as they eventually evolved, were not enough for the spiritually minded Cabot.

Although few medical leaders ever matched Cabot's exuberance for religious matters, he was not alone in his criticism of medical care. Even Abraham Flexner, later in his career, viewed with alarm the untoward effects of a medicine that strayed from its broader social commitments [69, 70]:

Finally, the very intensity with which scientific medicine is cultivated threatens to cost us at times the mellow judgment and broad culture of the older generation at its best ... the roots of medicine go deep into the cultural soil; its ideals are fundamentally humanistic, scientific, and philosophic.

The life of Richard Cabot reminds us that the growing emphasis of laboratory-based science to clinical medicine was not inevitable. During the Progressive Era, medicine chose to look to the biological roots of disease rather than to the illness as experienced by the patient [13]. Solutions that correct these tendencies have never been easy to find. Today, as we face the social and ethical concerns that inevitably constitute clinical medicine, we continue to struggle along the same path that Richard Cabot traveled 90 years ago.

The opinions and conclusions in this article are those of the author and do not represent the views of the Robert Johnson Wood Clinical Scholars Program or the Department of Veterans Affairs.

Quotations from the Richard Clarke Cabot Papers, Harvard University Archives, are made with the permission of the Trustees, clause IV, under the will of Richard Clarke Cabot.