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October 1996
Volume 60 |
Number 10
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| Medicine in the
19th Century: The Search for Answers |
Jonathan C. Berman, M.D.
Wood Library-Museum of Anesthesiology Fellow (1992)
Little progress had occurred in medical knowledge in the first
half of the 19th century prior to William T.G. Morton's demonstration
of ether anesthesia. Diagnosis of illness still relied only on
pulse, color, character of breathing and appearance of urine.
Many physicians subscribed to the theories that human disease
was an imbalance of the body's four humors (blood, phlegm, black
bile and yellow bile), which correlated to the ancient Greeks'
pathogenic concept of disease based on the four elements -- earth,
air, fire and water.
Physicians and surgeons were treating patients for such conditions
as dysentery, pneumonia, scarletina, syphilis, typhoid and tuberculosis.
Medicines were scarce and the choices few in number. A few common
prescriptions were mercury for syphilis, quinine for malaria,
ipecac for amebic dysentery and digitalis for heart failure. The
first United States Pharmacopoeia was written in 1820. Though
there were few specific drugs, it was estimated that the people
of Massachusetts spent more than $2 million dollars per year obtaining
them.
Therapy for these illnesses consisted of bloodletting, which
involved the incision of a vein and the draining of blood -- the
sicker the patient, the more blood removed (the procedure was
so common that the lancet became the leeching, another form of
bloodletting. It was believed that cupping or blistering was another
way to rid the body of bad humors. This involved superficial incisions
in the skin, after which heated glass cups were applied. As the
cup cooled, a vacuum was created, ridding the body of vapors and
raising blisters. Sweating and diaphoretic, emetic and purgative
agents were also employed. These practices, though under attack
by the better educated physicians, were the standard at the time.
Historian James H. Young stated, "From the patient's point
of view, the arduous impact of disease was aggravated by the arduous
impact of therapy."
Most surgeons of the day treated wounds, ulcers and fractures.
Surgeons were adept at vascular ligations and joint operations.
Few had ventured into the abdominal cavity. There was knowledge
of opium, morphine (since 1817) and alcohol to dull the senses,
but rarely were they used. The lack of surgical anesthesia and
knowledge of the cause of infection hampered medical progress
in the early 19th century. This did not deter one physician, Ephriam
McDowell, who in December 1809 removed a 20-pound ovarian tumor
with no anesthesia, no antisepsis and no antibiotics. Throughout
the 25-minute operation, the patient, Mrs. Crawford, recited psalms
(this was possibly a self-induced form of Mesmerism or hypnotism,
which was also popular around this time). There are also other
accounts of remarkable surgeries -- laparotomy for intussusception,
jaw resections, hip amputations and ligation of arteries for aneurysm.
The daily operating room schedule, however, would have to wait
for the advances in anesthesia.
There were less than 40,000 physicians in the United States in
1846, with few minority or women physicians. Medical schools,
dispensaries and hospitals were expanding, and the training of
physicians was a variable process, having reached its nadir in
terms of quality at this time. Medical school varied in length
from five to 18 weeks to graduate plus a three-year apprenticeship
to obtain a degree; a previous college degree was not a prerequisite
to attend medical school. Other routes to becoming a physician
included teaching in hospitals or dispensaries, training as an
apprentice and taking private courses. This variability unfortunately
led to many unqualified physicians.
In 1840, medical schools had an estimated attendance of 2,500
students, resulting in 800 graduates per year. There were approximately
30 to 40 degree-granting medical schools (not including the various
private institutions). A medical school education consisted of
anatomy, physiology and chemistry as the preclinical requirements
while medicine, surgery, therapeutics, pharmacy, obstetrics and
diseases of women and children were standard clinical subjects.
Hospital training was not required. Many students who could afford
the expense traveled to Europe to apprentice, some of them becoming
the more famous and influential physicians of the times. Fees
for schools were no more than $200 per year, and apprentices were
paid approximately $100 per year to complete their training.
Teaching was by lectures, rounds and popular amphitheater clinics.
Journals and textbooks were of significant importance. Textbooks,
now with American authors, helped to standardize medical teaching.
Journals published at the time reported about medical societies,
medical schools and hospitals along with European reprints and
original articles. By 1857, more than 178 medical journals had
been founded; of these, only 30 survived.
Affiliation with colleges was becoming the standard due to the
ability to grant a medical degree. Competition was fierce. Schools
owned and operated by doctors were primarily for profit. Professors
were paid directly by student fees and were tempted to enroll
as many students as possible. Many became wealthy, and many became
the leaders of the medical profession, writing textbooks, editing
and publishing in journals, and becoming the leading consultants
in their community.
To heighten the problem, sectarian colleges -- homeopathic, eclectic
and "botanic" schools -- began to open because of public
demand for alternative medicine. Legislators deemed one type of
training as good as the other and left it to the people to decide
which services to obtain. When doctors protested this decline
in medical practice, they were accused of seeking a monopoly.
Despite the outcries of many state medical societies and individual
practitioners in 1845, most states west of the Appalachians did
not enact licensing laws, and most states repealed earlier regulations.
This turmoil led to a group of physicians meeting in New York
in 1846 to consider the formation of what would become the American
Medical Association (in 1847).
Even though the first hospital in the United States was created
in 1751, hospitals were not the most common place to treat patients.
The public was treated at dispensaries, in their homes if they
had money or at almshouses for the poor. In 1845, the United States
had few voluntary and public general hospitals. The hospitals
treated mostly infectious diseases. Many admissions were surgical,
but few operations were performed -- remember, there were no operating
rooms located in hospitals until the latter half of the century.
Morton's demonstration using ether for Gilbert Abbott's operation
for a jaw tumor took place in an amphitheater at Massachusetts
General Hospital in Boston. Hospitals were changing, accepting
cases of trauma and sudden illness. Almshouses were being converted
into public hospitals, and separate asylums were created for the
mentally ill.
Dispensaries, which treated an ambulatory population, were thriving.
Soon came the development of specialty clinics for eye and ear
disease, chest disease and surgical diseases. Dispensaries produced
opportunities for medical students and medical graduates to obtain
further education. The students became house officers, paying
for the privilege of receiving hospital experience. These clinics
were able to attract medical staffs for as little as $250 per
year because of the valuable clinical training. Physicians in
Boston at the time were billing about $800 per year and collecting
$600. This education provided the young physician with the experience
to enter private practice.
Hospitals did not enjoy the same reputation as dispensaries among
physicians. There were fewer paying patients to admit into private
practices, and the growth of separate specialty hospitals competed
for learning cases. Hospitals were actively used for education
purposes. Many built amphitheaters and permitted ward rounds.
They were becoming an important element in medical education,
an association that has continued to develop to this day.
Medicine in 1846 did not provide many answers to the maladies
of humanity. Medicine and medical education were unregulated and
ripe for reform. Finally, on October 16 of that year, medicine
did provide hope against the pain and suffering that had long
characterized illness. Morton's demonstration of ether anesthesia
was a pivotal discovery, a distinctly American discovery that
would echo throughout the world and provide patients with the
hope of a cure for pain and an end to suffering. The profession
of anesthesiology continues in that tradition today.
A bibliography is available from the author upon request.
Jonathan C. Berman, M.D., is Director of
Obstetric Anesthesia at St. Anthony Central Hospital, Denver,
Colorado.
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