MEDICAL PROFESSION

12 May

During the colonial period, there were few legal or social obstacles to the practice of medicine. Individuals with or without special education or training could present themselves as healers. Eventually, physicians established a legally protected professional identity by banding together in professional societies that lobbied for medical licensing laws that would exclude sectarian practitioners. But claims for professional expertise and legal restraints on medical practice did not accord with the cultural climate of the developing nation. By 1845, several states had repealed their medical licensing laws. Aware that licensing laws were increasingly unpopular and that state societies were unable to achieve their goals, regular physicians established the American Medical Associ- ation in 1847 in order to provide a national platform to promote the interests of the profession. By the end of the nineteenth century, despite the efforts of competing medical sects, physicians had essentially achieved an effective monopoly on state sanctioned medical licensing. In pursuit of professional recognition, orthodox practitioners also attempted to gain control over medical education. Most aspiring doc- tors could not afford to study abroad, but attendance at a formal medi- cal school became increasingly more respectable than training through apprenticeship alone. By the 1820s, proprietary medical schools began to compete with the few medical schools that had been established in connection with medical societies or colleges. Usually founded by one or more doctors as a for-profit enterprise, these independent schools were supported by students’ fees. Thus, the ability to pay tuition was usually the only qualification students needed to meet.

As the proprietary schools continued to multiply, physicians realized that they had transformed the medical marketplace from a venue with a chronic shortage of regular doctors to one with an excess. Between 1765 and 1800, less than 250 doctors had graduated from American medical schools. During the 1830s, American medical schools produced almost 7,000 graduates; during the 1850s the number of grad- uates was approaching 18,000. Although graduates of the proprietary medical schools might have mastered very little of medical theory or clinical practice, they were formally qualified and could join the battle against sectarians and quacks. Regular physicians like Dr. William Currie (1754–1828), author of An Historical Account of the Climates and Diseases of the United States of America (1792), warned against the unorthodox practitioner: ‘‘though he may kill by license, he can only cure by chance.’’ The bills of mortality, Currie argued, would show that ‘‘more lives have been destroyed by the villainy of quacks .. . than by disease.’’ He expressed surprise that ‘‘our enlightened legislatures’’ had not prevented the activity of quacks. In addition to denouncing the ‘‘villainy of quacks,’’ regular physi- cians argued that medical practices that had been developed in other countries were not directly applicable to the needs of American patients. Because epidemic diseases varied with specific environmental, climatic, social, and occupational conditions, only physicians with extensive experience and training appropriate to the American environment should practice in America.

Like Jefferson and Rush, nineteenth-century American doctors assumed that residents of the countryside would be healthier than those who lived in towns and cities. Only experienced doctors would understand that the kinds of treatment tolerated by active farmers were quite different from those appropriate to sedentary city people. A farmer with acute rheumatism might easily lose 60 to 70 ounces of blood in treatment, but a sedentary resident of the city could hardly tolerate the loss of half that quantity. In contrast to Europe, most doctors in early America had to serve as physicians, surgeons, and pharmacists. By the mid-nineteenth cen- tury, however, as urban populations expanded, some doctors found it possible to focus on the treatment of disorders of the nerves, lungs, eyes, ears, and so forth, while others were able to confine their practice to sur- gery or even the traditionally female field of midwifery. This was a great departure from the past, when ‘‘specialists’’—such as those who set broken bones or removed decayed teeth—were dismissed as quacks. Dentistry and pharmacy actually established a separate professional identify in America before the Civil War. The first American dental text and journal were published in 1839, just a year before the Baltimore College of Dental Surgery and the American Society of Dental Surgeons were founded. Pharmaceutical journals, professional societies, and schools of pharmacy were established in the 1820s, but national and state professional societies were not founded until the 1850s. Medical societies in the nineteenth century provided a forum in which orthodox physicians could claim membership in the international scientific community. Knowledge of recent developments in European medicine allowed some physicians to look at patients in hospitals and asylums, and even private practice, as clinical material for research, or at least focused observation.

Admirers of the work of the great French physician P. C. A. Louis, such as Henry I. Bowditch and George C. Shattuck, attempted to apply his ‘‘numerical method’’ in American hospitals. Bowditch established the first physiological laboratory in America at the Harvard Medical School in 1871. Physicians who had studied abroad were eager to import and translate new scientific and medical texts and adapt European research for American practitioners. As the numbers of medical schools increased, so did the market for textbooks. Despite the well-known deficiencies of most American medical schools, before the Civil War they served as a key source of science edu- cation for American students. Even the medical schools with the lowest admission standards and the worst facilities accepted the concept that medical education required lectures in anatomy and pathology, or morbid anatomy, supplemented by the dissection of human bodies. Although postmortems were historically important to coroners and in criminal proceedings, few families were receptive to the use of the autopsy as a way of achieving diagnostic specificity or for the advancement of medical science. In America, as in Europe, cadavers for anatomical demonstrations were always in short supply. Because the practice of human dissection was generally regarded with horror and legal means of providing cadavers for medical education were rare, rumors of grave-robbing led to fear, hostility, and even violence, such as New York’s ‘‘Doctors’ Riot’’ in 1788. When American doctors were involved in scientific studies, they tended to follow a practical path that could expand botanical knowl- edge and lead to new remedies. By collecting geological and meteo- rological observations, and keeping careful case records, they tried to corroborate ideas about the relationship between local environmental factors—soil conditions, temperature, humidity, rainfall, and so forth— and health. In addition, they searched for correlations between what might be called sociological data and patterns of disease.

By comparing patterns of morbidity and mortality in the new nation with those of the Old World, American doctors expected to provide scientific proof that the American environment and the institutions of the new nation pro- moted physical and mental health. The life and work of William Beaumont (1785–1853) demonstrates that when presented with the opportunity to carry out physiological research, even a doctor with little formal training could plan and exe- cute ingenious experiments. Indeed, Sir William Osler called Beaumont ‘‘the first great American physiologist.’’ Beaumont’s reputation is based on the remarkable series of observations and experiments described in his Experiments and Observations on the Gastric Juice and the Physiology of Digestion (1833). Beaumont’s work was important not only in terms of his scientific observations, but as a landmark in the history of human experimentation and biomedical ethics. Except for his apprenticeship with Dr. Benjamin Chandler, in St. Albans, Vermont, Beaumont was a self-educated man, without bene- fit of university or college. Beaumont grew up on a farm in Connecticut and became a schoolteacher in order to escape from farming. Compen- sating for the lack of formal education, Beaumont, like many of his con- temporaries, pursued an extensive program of reading that included important medical authorities, as well as the writings of Shakespeare and Benjamin Franklin. His notebooks from 1811 to 1812 describe his training, reading program, and early medical practice. In 1812, just before the United States’ declaration of war with England, Beaumont was able to secure a position as surgeon’s mate. His experiences in dealing with diseases and wounds support the adage ‘‘war is the best medical school.’’ After the war, Beaumont’s attempts to establish a private practice were unsuccessful and he reenlisted in the Medical Department of the Army.

He was sent to Fort Mackinac, which was then a remote army post on the Western frontier. Mackinac Island, in the straits of the Great Lakes, was an outpost of the American Fur Company. Here, Beaumont frequently encountered patients with intermittent fevers, typhus, dysenteries, and rheumatism. Gunshot wounds were not uncommon, but the accidental shot that struck Alexis St. Martin, a young French Canadian, in the abdomen in 1822 had unique results. The shot created a wound bigger than the size of a man’s hand, fractured the lower ribs, ruptured the lower portion of the left lobe of the lungs, and punctured the stomach. Beaumont thought the wound would be fatal, but he cared for St. Martin to the best of his ability with poultices of flour, charcoal, yeast, and hot water. He changed the dressings frequently, cleaned the wound, removed de- bris, and bled the patient to fight against fever. Surprisingly, St. Martin survived, but all attempts to close the wound were unsuccessful. Beaumont soon realized that St. Martin’s permanent gastrostomy (new opening into the stomach) provided a unique opportunity to study digestion in a healthy human being. Various kinds of foods and drugs could be inserted directly into St. Martin’s stomach and samples of the gastric juices could be removed. Beaumont planned to conduct lecture tours to demonstrate his experiments, but St. Martin frequently ran away. In 1832, Beaumont and St. Martin signed a contract that gave Beaumont the exclusive right to perform experiments on St. Martin. This document was the first such contract in the history of human scientific experimentation. Despite St. Martin’s later complaints about the discomforts of being a human guinea pig, Beaumont’s physiological experiments did not seem to harm him. St. Martin and his wife Marie had seventeen children, but only five were alive when he died in 1880.

In addition to Beaumont’s famous contributions to the physiology of digestion, his career provides insights into the evolution of medical education, professionalism, and even medical malpractice law in the first half of the nineteenth century. Although malpractice suits were rare in the 1840s, Beaumont was involved in two such battles. The first was the result of Beaumont’s unsuccessful attempt to save the life of a man who had been struck on the head with an iron cane by a carpenter named Darnes Davis. Beaumont attempted to relieve cranial pressure by per- forming a trephination. When the case came to trial in 1840, Davis’s lawyers argued that Beaumont had caused the death by drilling a hole into the victim’s skull in order to perform experiments on the brain, just as he had left a hole in St. Martin’s stomach in order to do experiments on digestion. Four years later, Beaumont and Dr. Stephen Adreon were sued for medical malpractice by an indigent patient named Mary Dugan. In the 1840s, the regular physicians in the St. Louis area were battling for strict licensing laws that would give them control over medical practice and inhibit the activities of irregular practitioners and quacks. Thus, the trial threatened to become a major landmark in establishing the limits of malpractice jurisprudence. Despite the efforts of the regular physicians to distinguish themselves from their irregular rivals, prevailing popular sentiment at the time favored the repeal of whatever state and local regulations of medical licensure still existed. This malpractice suit revealed a great deal about tensions within the medical community and the fact that the regulars were not only battling irregulars and quacks; they were also diverting much of their energy into internal rivalries.

Adreon had examined Dugan before asking Beaumont and his partner Dr. James Sykes to act as consultants. After all three physicians agreed on a diagnosis, Adreon lanced the patient’s abscess, drained it, and applied poultices. But Dugan later complained of complications that the doctors diagnosed as ‘‘typhlo-enteritis’’ (purulent inflammation in the intestinal tract) unrelated to the surgical procedure. Dr. Thomas J. White, who was extremely hostile to Beaumont and Adreon, per- suaded Dugan to file a malpractice suit for $10,000 in damages. White argued that that Adreon punctured a hernia and cut the intestines through negligence and lack of skill. The jury sat through a two-week trial before acquitting Adreon and Beaumont. When Dugan died in 1848, White performed the autopsy. The autopsy results, which were published in the St. Louis Medical and Surgical Journal (1848), seemed to refute the original diagnosis of Adreon and Beaumont. Being acquit- ted was little consolation to Beaumont in the face of such hostility from rivals within the medical community. In response, Beaumont refused to deal with the Medical Society of St. Louis or participate in the establish- ment of the American Medical Association.

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