Book Review

The History of Medicine

Langstaff: A Nineteenth-Century Medical Life

N Engl J Med 1994; 331:816-817September 22, 1994

Article

Langstaff: A Nineteenth-Century Medical Life
By Jacalyn Duffin. 383 pp., illustrated. Toronto, University of Toronto Press, 1993. $60. ISBN: 0-8020-2908-6

Jacalyn Duffin, a professor of the history of medicine, has spent a decade analyzing the unique wealth of daybooks and account books from the 1844-1889 medical practice of Dr. James Miles Langstaff of Richmond Hill, north of Toronto. She shares with us the medical, social, financial, and political activities of a country doctor who was a careful record keeper: studious and thoughtful, with excellent powers of observation. Langstaff clearly described Cheyne-Stokes respiration, Kussmaul's breathing, Courvoisier's sign of pancreatic cancer, tenderness over McBurney's point, and patients who may have had Marfan syndrome, Osler's nodes, and Guillain-Barre syndrome. Some of these findings were original observations that had not yet been described in medical journals.

Duffin makes potentially dull statistics come to life. She summarizes Langstaff's consultations with more than 150 doctors over 40 years, notes the number of new doctors near Richmond Hill in each 5-year period, and gives a “tenacity index” for these doctors. We learn of the tariffs for medical services: a visit within one mile was $1 by day and $2 at night; childbirth attendance was $5, but the fee doubled if complications ensued; fractures and dislocations also carried a $5 fee. By 1875, when anesthetics were occasionally administered, the charge ranged from $2 to $4. At the time, the average laborer's wage was $1 per day. Langstaff collected less than one quarter of the fees he charged for his work. The records of the general store during these years show that the patients indebted to the doctor were often equally or even more indebted to the storekeeper.

At any one time, Langstaff's practice consisted of 2000 or 3000 people. He dressed wounds, extracted teeth, set fractures, and lanced abscesses; he performed occasional amputations and even fewer mastectomies. Duffin tabulated the causes of 535 deaths in his practice; 218 of the patients who died were children, and one quarter of them had diphtheria. The most common cause of death among adults was childbirth and its complications. Langstaff was attending more than half the births in his district by the early 1870s -- a surprisingly early date for physician-attended births. Only 1 percent of all the women in his practice who gave birth were unmarried; only three women gave birth to two or more illegitimate babies. Between 1857 and 1884, there were nine suicides and four attempts at suicide.

Infectious diseases accounted for a large part of Langstaff's practice. Virulent strains of streptococcus caused scarlet fever and erysipelas. He regularly encountered typhoid fever, typhus, hepatitis, peritonitis, and nephritis. There were five cholera epidemics. His last diagnosis of malaria was made in 1879. Before the age of radiography, he diagnosed tuberculosis in only 51 men, 25 women, and 6 children over the course of 45 years.

Medicolegal events were surprisingly common, even by the standards of the next century. Langstaff made about 120 court appearances in connection with 71 legal cases. He gave evidence at 33 coroner's inquests, at half of them reporting on autopsies he had performed.

At one time or another, Langstaff subscribed to 13 medical journals, including the New England Journal of Medicine, and daily and weekly newspapers, one of them in French. Duffin analyzes the changing pattern of clinical practice as technology improved and relates this pattern to the clinical debut of each medical instrument and the first mention of it in the Canadian medical literature. Langstaff first used a stethoscope in 1849, obstetrical forceps in 1851, a flexible stethoscope in 1865, a clinical thermometer in 1878, and an ophthalmoscope in 1886. He purchased an electrotherapy machine in 1861 and a microscope in 1879. He first used ether in 1850, chloroform in 1857, carbolic acid in 1868, chloral hydrate in 1872, and salicylates in 1878. In some instances, he began using instruments and medications remarkably soon after they were first described in medical journals.

James Miles Langstaff, the eighth child of a farm couple who lived north of Toronto, was born on June 3, 1825. He studied at John Rolph's Proprietary Medical School in Toronto and returned to his home community on September 10, 1844, to begin practice. He pursued postgraduate studies at Guy's Hospital in London from 1846 through 1848; his notes from a number of lectures and a list of surgical operations he observed there have been preserved. In 1849 Langstaff took and passed the licensing examination of the Upper Canada Medical Board. He then practiced medicine continuously until his death from nephritis at the relatively young age of 64 years.

Duffin's account is well written, well organized, and placed squarely in the context of the times. Duffin sought legal advice and permission from appropriate authorities before providing the names of most patients in her copious footnotes. The book includes six appendixes, many helpful tables, and an excellent selection of photographs.

Duffin looks at Langstaff's 40 years of practice through the “compound lenses of medical sympathy and historical cynicism.” She admits that we do not know how representative Langstaff or his practice might have been, but one certainly gains the impression that he was well above average in his knowledge, interests, and abilities. This book is a must for every medical school library; its relatively low price makes it available to any student or practitioner with an interest in the history of medicine. Those who assume that doctors in Langstaff's time knew little and often did more harm than good will be surprised when they read this fascinating history.

C. Stuart Houston, M.D.
Royal University Hospital, Saskatoon, SK S7N 0W8, Canada