New England Medicine in the Early 19th Century
Research Notes
This was a research note I wrote while I was doing background reading on early American medicine in order to better understand Dr. Charles Knowlton. It connects also with the notes I posted yesterday about Nathan Smith.
Digging into Charles Knowlton’s background has led me to several questions about the medical profession in the first half of the nineteenth century. During his life, Knowlton had trouble with the clergy, he spoke out against quackery, and he had several very public disagreements with neighboring (or competing) MDs. Some of his difficulties can be attributed to personality (he wasn’t easy to get along with) and beliefs (he was a fairly militant atheist). But I was left wondering about the practice of medicine itself. To what degree was medicine a profession during Knowlton’s time? How did physicians view themselves? How did others view them? How effective were their methods, relative to available alternatives? If the results of doctors were no better than those of “quacks,” how did medicine manage to become a professional practice during this period?
One of the basic observations made by modern physicians about the medicine of the late eighteenth and early nineteenth century is that it was dominated by a “preoccupation with system.” (Lester S. King, M.D., Transformations in American Medicine From Benjamin Rush to William Osler, Baltimore: John Hopkins, 1991, 19) Drawing on the philosophical systematization of the universe by Descartes, Leibniz, Spinoza and Newton, medical doctors looked for all-inclusive conceptual systems that would explain all disease. Lacking knowledge of bacteria, viruses, and other causes of disease, doctors frequently treated observable symptoms as disease itself. But their lack of data was exacerbated by a preference for comprehensive systems rather than limited, specific theories.
The goal of these systems was to make broad, universal generalizations out of (limited) observed facts. The doctors’ preference was clearly for the system rather than the supporting data. Benjamin Rush, for example, declared that facts, piled together, “would soon tumble to pieces, unless they were cemented by principles.” King compared this to Kuhn’s idea of paradigm creation in The Structure of Scientific Revolutions. The key difference, I think, is early physicians’ willingness to jump from limited data to universal explanations. “Their alleged facts,” he observed, “were in large part not facts at all, their reasoning not cautious but wildly speculative. But at the time this was not apparent” (King, 24). It’s ironic that one of the most successful and internally consistent “systems” of the nineteenth century was the completely erroneous technique of homeopathy (King, 22).
“The scientifically valid aspects of medical science” in this period, according to another medical textbook, “comprised gross anatomy, physiology, pathology, and the materia medica” (William G. Rothstein, American Medical Schools and the Practice of Medicine, A History, New York: Oxford, 1987, 15), but there was a wide range of valid and invalid information contained within these broad categories. For example, although Rothstein said New England physicians around the turn of the nineteenth century used about 225 different drugs, he noted that “the range of action of these drugs was very limited” and that “the evacuants and opium were the most effective.” (Rothstein, 16)
The beliefs of New England doctors in the efficacy of their treatments were an important issue in their struggle to establish themselves as professionals. In retrospect, “the only drug of value in a wide range of illnesses was opium,” (18) but opium was hardly the only drug New England doctors regularly prescribed. If many of their treatments were ineffective or even poisonous, as their critics claimed, then their success has to be attributable to something else. Skin irritation, for example, was a large part of many doctors’ practice, based on the belief that blistering would remove poisons from the body. A wide range of cantharides were used, all of which are now known to have been “of no medical benefit.” (Rothstein, 17) The emerging profession’s stubborn insistence that their drugs were working and that their opponents’ treatments were not, was a major feature in their campaign for the public’s respect. The fact that the public was rightly skeptical of their claims probably impaired their message and delayed public acceptance of doctors’ unqualified authority on these issues.
Physicians’ very limited ability to observe only the surface symptoms of their (living) patients and to infer from impaired function, led them to classify most diseases as varieties of fever. A clearly observable related symptom was inflammation, understood as a “local accumulation of blood.” (King, 38) Phlebotomy (bleeding) was a logical treatment, observed to reduce inflammation and fever at least temporarily. Drawing on this information, Benjamin Rush made an inductive leap and developed a unified theory of disease. All fever, Rush announced, was a “morbid excitement” of the blood vessels. Thus the doctor’s response to all disease should be the same. Rush’s heroic bleeding techniques called for the removal of enough blood to render the patient unconscious. In some cases, this meant regular bleedings of 16 to 24 ounces, until the patient recovered or died. Heroic bleeding wasn’t accepted by the public without some skepticism, even at the time. George Washington famously died after being relieved of nearly a gallon of his blood to treat a minor infection. In 1800, William Cobbett remarked that Rush’s technique was “one of the great discoveries…which have contributed to the depopulation of the earth.” (Alex Berman, “The Heroic Approach in 19th-Century Therapeutics,” Sickness & Health in America, Judith Walzer Leavitt & Ronald L. Numbers, eds., 77) Rush sued Cobbett for libel and won.
In contrast to the grand theorizing of “highly trained physicians of Edinburgh” like Rush, King observed that “poorly trained rural practitioners of New England” often attained a higher degree of “insight, discrimination, and critical judgment.” (King, 79) An important example was Dr. Nathan Smith, whose article on “Typhous Fever” is cited as an example of the new, more empirical medicine of nineteenth-century New England. Smith analyzed his data more critically than other medical writers and came to limited conclusions that “remained close to the observations.” (86) But Nathan Smith, although he had begun his career as a Vermont village school-teacher, had also trained in London and Edinburgh. Rather than education, the key difference between doctors like Smith and their predecessors seems to have been the scientific (and specifically empirical) orientation that replaced an earlier, scholastic world-view. It’s interesting that physicians like Smith who embraced the specificity of science were precisely the men most opposed by conservative religious leaders like Timothy Dwight at Yale.
The first New England medical schools were established in the 1760s in New York City and Philadelphia. Harvard’s first medical classes were given in 1783, and in 1797 Nathan Smith began Dartmouth’s medical school as a one-man operation. Smith left Dartmouth around 1812 to help establish Yale’s program and went on to participate in the founding of several other New England schools. (oddly, Rothstein de-emphasizes Nathan Smith’s involvement, not even mentioning his name in connection with Dartmouth, where he was the “one-man” school Rothstein described. 29) But these medical schools were not “true academic departments” in the colleges they shared their names with. They were private businesses owned by their faculties, who received no support from the colleges and financed their operations on student tuitions. Nor were medical students usually drawn from the undergraduates of these colleges. At the beginning of the nineteenth century, a third of Yale or Dartmouth graduates became ministers. Another quarter became attorneys. (Rothstein, 29) The ten percent of overall graduates who became doctors generally never associated with the other students at the colleges. They took none of the undergraduate classes the college offered to their other undergraduates. Instead, they had their own fourteen to sixteen week schedule of lectures, after which most returned to a preceptor, usually the doctor in their home-town, with whom the students were required to complete a three-year apprenticeship in order to earn their degrees.
King said the medical “elitism” that motivated the founding of the American Medical Association (AMA) in 1847 was partly ideological and partly economic. (King, 210) The 1846 convention that resulted in the AMA’s formation addressed the competition of homeopaths and other “sectarians” in great detail. Complaining that “the community did not hold physicians in proper esteem,” the delegates discussed ways of establishing their profession on an equal footing with lawyers and clergymen. It’s not a surprise, then, that they emulated these two other esteemed professions and dedicated themselves to a set of canonical texts. The Committee on Ethics called on members of the new AMA to preserve their ideological purity by strictly refusing to give the “slightest countenance” to the “empirical imposture” of “presumptious pretenders.” (King, 211) These physicians imagined they were “people of the book” just as attorneys and ministers. It awaited a new generation of men like Smith and Knowlton to embrace science and make medicine reflect reality.