I RECENTLY READ A MARVELOUS book entitled Doctor Franklin’s Medicine1 by Stanley Finger. If I knew much at all about Franklin before reading this book, it was in his more traditional role as a Founding Father of the United States and, perhaps, his famous experiments with electricity. While reading this book, however, I became more interested in Franklin the scientist, researcher, thinker, and even physician. Perhaps it is fitting on this 300th anniversary of his birth that we contemplate some of his accomplishments and how they relate to us.
Franklin did not have formal medical training, but neither did many of the “medical” men of colonial America. In the 1770s, only a small minority of the people who were practicing medicine even had a college degree. And, of course, the sophistication of medical practice was much more nascent. There were patent medicines that usually contained some plant-derived active ingredient such as opium or digitalis. Most of these had a “secret” formula, so to allow the inventor to profit from selling a concoction that only he/she could produce. As a relatively young man, Franklin was already financially well off because of his successful publishing business, so one might argue that he did not need to make a lot of money from his discoveries. There is evidence that Franklin shared much of his knowledge because of his altruistic nature.
Franklin was a prolific writer on many topics; luckily we have access to a great body of his writings through his letters and even his Poor Richard’s Almanac. Many of his witticisms are, of course, legendary: “Early to bed, early to rise, makes a man healthy, wealthy, and wise.” In essence, though, Franklin was a pragmatist and a keen observer of the world around him. He made several discoveries that he shared freely for the benefit of future generations, including our own. Among his inventions were the Franklin stove, which provided a better way to heat homes without the excessive smoke and soot that caused chronic lung ailments; bifocal spectacles that allowed him to see both near and far simultaneously; and a reacher, which he called his “long arm,” that allowed him to reach a book from his chair when his gout flared to the point that it was too painful for him to walk. Franklin did not invent electricity, but his experiments yielded many results that are still in use. He invented the lightning rod, which was initially intended to provide protection from lightning for ships at sea, but subsequently was used ubiquitously on land as well.
Franklin’s experiments with electricity are particularly interesting when it comes to his attempts to cure “palsies” or patients with an inability to move a limb. He (among others) noted that electric current, when applied to a body part, resulted in involuntary movement. One might consider this the foundational physiologic observation that led to our electrodiagnostic techniques. He then proceeded to conduct experiments to see whether the return of voluntary function would follow if the paralyzed limb were stimulated repeatedly. Ultimately, he concluded that no prolonged benefit could be derived from his technique and he abandoned these trials. One might conclude that these were some of the earliest experiments with functional electric stimulation. Along the way, he discovered that there was a significant benefit from strong electric stimulation for patients suffering from “melancholia,” thus predating by about 200 years the routine medical use of electroconvulsive therapy for depression.
How can we apply this information to what we do today? Franklin was a natural scientist and had a keen interest in discovering how natural physical forces worked. He tried to apply this knowledge to help people deal with their disabilities and ailments. We know more about the physical world and forces now, and we can still apply that knowledge to better the human condition. Franklin was not afraid to abandon a practice if it demonstrated no useful benefit. And, once he made a discovery that improved the human condition, he shared it freely with the world. These timeless principles remain essential to our field of physical medicine and rehabilitation.
General health and fitness figured prominently in Franklin’s thinking and writing. He was a strong proponent of daily physical activity, especially swimming and horseback riding, as a way to promote and maintain health. He even taught some colleagues to swim, in an era when most people believed that voluntarily immersing one’s self into a body of water was dangerous and was to be avoided if at all possible. Nonetheless, Franklin personally experienced the advantages of staying physically fit and used his abilities as a writer to spread the word as widely as he could. Also, at a time when most people kept their homes tightly closed to avoid outside air, Franklin promoted the taking in of fresh air daily. It is certainly understandable that the general population would be apprehensive about his philosophy because, although the contagious nature of many diseases was still to be elucidated, it was generally known that one could become ill from “germs” spread by the wind. Nonetheless, Franklin seems to have known from his own experience that the combination of physical activity and fresh air could confer some immunity to the body and help ward off illnesses.
Franklin’s belief that maintaining one’s body physically has significant health benefits was a concept that seems relevant even today. As the number of labor-saving devices has expanded, we have become progressively more sedentary as a population. Giving our attention to physical fitness as a way to maintain and preserve our patients’ health, as well as our own, is a concept that must remain central to our holistic physiatric practice.
Among Franklin’s own maladies later in his life were gout and an ongoing problem with bladder stones. He generally treated the gout through rest and adherence to a Spartan diet, avoiding red meats and alcohol, which seemed to aggravate his symptoms. Another of Franklin’s many inventions was a urinary catheter that he had a local silversmith fabricate. While urinary catheters of various materials had been used since at least the days of the Roman Empire, his solution was particularly ingenious. He instructed the silversmith to fabricate the catheter from interlocking small rings that would bend to conform to the anatomy of the urethra but would have the stiffness required for insertion. He sent the original version to his older brother (who also had trouble with a bladder stone) and provided explicit written instructions for its use. In his pragmatic way, Franklin contemplated a problem that led to pain and loss of function and designed a solution to the problem. In an era of puritan moralities, he did not shy away from addressing taboo or embarrassing issues.
Our patients have disabling conditions that may not be as evident as a hemiparesis or a missing limb. Sometimes these conditions involve basic physiologic function, such as the bowel, bladder, or sexual functions that can be uncomfortable or embarrassing for them to discuss—even in a doctor’s office. It is important that we recognize this and empower our patients to discuss openly these issues by creating an environment that is professional and supportive. We must anticipate the problems that people may be experiencing based on the underlying physiology of their disease or disability.
Another glimpse into Franklin’s character is afforded by his handling of an inquiry into the scientific veracity of Franz Mesmer’s techniques, now known as mesmerism. Mesmer’s theory, in a nutshell, postulated that there existed a force in nature he called “animal magnetism,” which he and his disciples could control to cure various maladies. In 1784 Franklin was asked to head a French commission that would investigate whether these techniques had a scientific basis. Franklin took an ingenious approach to the task. Rather that trying to disprove that Mesmer’s technique cured people, he set about to find evidence that such a force did exist. He tried to measure the force with all the instruments at his disposal and found that there was no identifiable measurement for the proposed force. Therefore, he concluded that the tools at his disposal could not substantiate such a force. Realizing that not all forces might be measured using the instruments of his day, he went a step farther and set up a test-retest paradigm. He demonstrated with this method that the force was not reproducible. The commission’s report resulted in Mesmer being discredited and he left France. Of course, Mesmer’s “force” subsequently became the foundation of what we now consider hypnotism. We have some well-accepted practices in physical medicine and rehabilitation today that are not easily proven to be effective, especially those practices that may prevent further deterioration or disability. So lack of evidence of efficacy of a treatment does not necessarily equal lack of efficacy. We still do not understand fully how the human body and mind work.
Being willing and able to challenge the scientific veracity of new, or even established, treatments can be a lonely and thankless task. Having the courage to do the research, however, is critical to the success of our medical specialty.
What were Franklin’s qualities that lead me to believe he would have been a great physiatrist? First, he was concerned about his fellow man and the maladies that caused pain and decreased function. In our current parlance, he was evidence-based and used the experimental techniques at his disposal to test how things worked. He was inventive. He came up with pragmatic solutions to compensate for some of the disabling conditions he (and others) experienced. He believed that maintenance of bodily function through exercise was key to a healthy life. He was so invested in freedom from regulatory injustice that he was an active supporter of America’s War of Independence. Last, and perhaps most important, he was altruistic and shared his knowledge so that others would not suffer.
Clearly, the ideal physiatrist is someone who thinks about the impairments and disabilities that afflict him/herself, the people he/she serves, and mankind. The ideal physiatrist is a person of action who does not shy away from controversy, is not easily deterred because an idea is unpopular or unconventional, and wants to personally view the evidence. Where there is no evidence, physiatrists should use pragmatic experience in their practices and rely on scientific methods to evaluate theories. They must subject their findings to peer review and publish their results, thus sharing their knowledge with the world. They must not abide regulatory tyranny and they must actively advocate for the needs of people with disabling conditions.
Perhaps we cannot really call Benjamin Franklin the “first physiatrist,” but if we emulate his example, the field of physical medicine and rehabilitation, and all of mankind, will certainly benefit.
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