Learning from Experience

“HE is of the clinical class of physicians,” the visiting Scottish physician Dr. Alexander Hamilton observed of Dr. William Douglass in 1744, “and laughs att all theory and practise founded upon it, looking upon empyricism or bare experience as the only firm basis upon which practise ought to be founded. He has got here about him a set of disciples who greedily draw in his doctrines and, being but half learned themselves, have not wit enough to discover the foibles and mistakes of their preceptor.” This was the same Dr. Douglass who, on professional grounds, had opposed Mather’s inoculation experiment. Perhaps he had been chastened by the epidemic of 1721, for his doctrinaire attitude on that occasion was not typical of his career. From the point of view of a European physician at the time, the work of Dr. Douglass and his fellow Americans already revealed a striking emphasis—an interest in practical ways of treating particular diseases.

American doctors had been encouraged to such an emphasis by a number of circumstances, and especially by their informal system of medical education. Until 1765 there was no medical school in British North America; since few Americans could afford to study in Edinburgh, London, or Leyden, the apprentice system became standard. In 18th-century Virginia, only about one doctor in nine had a medical degree, and this seems to have been about the general proportion throughout the colonies at the outbreak of the Revolution. Zabdiel Boylston, perhaps the most effective and independent physician of colonial New England, had been taught by his father. The Clark family in Boston, the most eminent medical family of the colonial period, felt little need for a medical school: six generations of Clarks received their medical training at home. Between the first John Clark (who may have held an English medical diploma and who came to New England about 1638) and the seventh (who secured an M.D. degree in 1802), not a single one of these successful doctors had been given formal medical instruction.

All up and down the colonies, apprenticeship was the usual, almost the exclusive, path to the profession. Indentures surviving from early 17th-century Virginia reveal that the established doctor would keep a young man in his household for seven years doing chores as nurse, janitor, coachman, messenger, prescription-maker, and assistant surgeon, while reading a few books and learning mostly by observing his master. Though even this method of training was seldom cheap—the best Virginia practitioners asked about one hundred pounds a year—there was always considerable competition to enter the household of the most reputable masters.

Many colonial physicians recognized the special value of learning medicine where one was going to practice. In 1766, Dr. Thomas Bond observed in his clinical lectures at the Pennsylvania Hospital:

Every Climate produces Diseases peculiar to itself, which require experience to understand and cure…. No Country then can be so proper for the instruction of Youth in the knowledge of Physic, as that in which ’tis to be practised; where the precepts of never failing Experience are handed down from Father to Son, from Tutor to Pupil. That this is not a Speculative opinion, but real Matter of Fact, may be proven from the Savages of America, who without the assistance of Literature have been found possessed of Skill in the cure of Diseases incident to their climate, Superior to the Regular bred, and most learned Physicians, and that from their discoveries the present practice of Physic has been enrich’d with some of the most valuable Medicines now in use.

Others, however, including some leaders of the profession, complained that American training was crude and inadequate; they urged the requirement of a more formal medical education. John Morgan (1735-1789) of Philadelphia was prominent among these. After a typical American medical training (apprenticeship under Dr. John Redman and experience as military surgeon for an expedition to Fort Duquesne), Morgan went abroad for a medical Grand Tour which included Edinburgh, London, Paris, Parma, and Padua. On his return to Philadelphia, Morgan announced his determination to engage in medicine “without turning apothecary or practising surgery.” He made no headway in persuading other American doctors to leave cutting to surgeons and the mixing of medicines to apothecaries, but he did help persuade the trustees of the College of Philadelphia to establish the first American medical school, and he was himself appointed Professor of the Theory and Practice of Medicine. His now famous Discourse upon the Institution of Medical Schools in America, delivered in May 1765, is one of the best contemporary descriptions of the American medical profession. Morgan bitterly attacked the informality and lack of sharp subdivisions, what he called “the levelling of all kind of practitioners.” Although he had studied long and hard and traveled widely, he complained, “yet I have been told, that to expect to gain a support here by my medical advice and attendance only, without becoming a surgeon and apothecary too in order to help out, is to forget that I was born an American.” He pleaded for the “separate and regular practice of physic, surgery and pharmacy” such as was found abroad. Plainly Morgan had not yet discovered the truth which Henry Adams preached to Americans in the late 19th century: that just as important as drawing on European experience was learning the ways in which “the experience of mankind was useless to them.” Nowhere was this more important than in the American learned professions, for there, more than anywhere else, in Adams’ phrase, “the weight of society stifled their thought.”

No one can deny that the American situation had impoverished medicine in many ways: the colonies were barren of theoretic advances and of imaginative and fruitful laboratory investigations. Although there was some progress in medical practice—for example, in immunology and public health—there were no epoch-making advances in medical science. What 18th-century American medicine saw was simply the advance of a novel medical profession. The frontiers of speculative medicine remained in the European centers. Still, in what Dr. John Morgan disparagingly called “the infant state of the colonies,” lay an American opportunity. By allowing crude, fluid experience to overflow the ancient walls between departments of medical knowledge, men might see relations in nature which had been obscured by guild monopolies and by the conceit of learned specialists.

American experience thus broke down the social as well as intellectual distinctions between different branches of medical science. In the 18th century a prosperous New England physician dressed well and drove in a coach to see his patients. His English counterpart would have worn a powdered wig, a coat of red satin or brocade, short breeches, stockings and buckled shoes, a three-cornered hat, and would have carried a gold-headed cane. The snobbery of the European physician was no mere personal peccadillo; it divided the body of medical science, separating theory from practice, medicine from surgery and midwifery, and all of them from pharmacy. Simply to reduce or to remove this snobbery, whether by design or by the force of American circumstances, was to rejoin sundered fragments of experience. Not until well into the 19th century had medicine and surgery in Europe become more or less equal in the social scale; only then could their practitioners collaborate freely. In America their equality, hastened by the apprentice training they shared, had existed from the beginning.

His apprentice training inducted the young American physician into what, in more sophisticated modern terms, we would call a “clinical” emphasis—that is, a tendency to be more interested in the observation and treatment of actual patients than in artificial laboratory experiments. “At a time when in Paris and most European universities, medicine was taught purely theoretically, without any concrete bedside illustration,” Dr. Henry E. Sigerist remarks in his history of American medicine, “in America it was learned in daily practical contact with patients.” This emphasis, though, was one which no one had designed or intended and which men of respectable learning were actually trying to prevent. Its most eloquent defense was to be made in the next century by Dr. Oliver Wendell Holmes (whose own work was a brilliant if unconscious product of the same emphasis), in his famous introductory lecture (1867) on “Scholastic and Bedside Teaching” delivered to medical students at Harvard:

When I compare this direct transfer of the practical experience of a wise man into the mind of a student,—every fact one that he can use in the battle of life and death,—with the far off, unserviceable “scientific” truths that I and some others are in the habit of teaching, I cannot help asking myself whether, if we concede that our forefathers taught too little, there is not a possibility that we may sometimes attempt to teach too much. I almost blush when I think of myself as describing the eight several facets on two slender processes of the palate bone, or the seven little twigs that branch off from the minute tympanic nerve….

I can hear the voice of some rough iconoclast addressing the Anatomist and the Chemist in tones of contemptuous indignation: “What is this stuff with which you are cramming the brains of young men who are to hold the lives of the community in their hands? Here is a man fallen in a fit; you can tell me all about the eight surfaces of the two processes of the palate-bone; but you have not had the sense to loosen that man’s neck-cloth, and the old women are all calling you a fool? Here is a fellow that has just swallowed poison. I want something to turn his stomach inside out at the shortest notice. Oh, you have forgotten the dose of the sulphate of zinc, but you remember the formula for the production of alloxan!”

“Look you, Master Doctor,—if I go to a carpenter to come and stop a leak in my roof that is flooding the house, do you suppose I care whether he is a botanist or not? … If my horse casts a shoe, do you think I will not trust a blacksmith to shoe him until I have made sure that he is sound on the distinction between the sesquioxide and the protosesquioxide of iron?”

—But my scientific labor is to lead to useful results by and by, in the next generation, or in some possible remote future.—

“Diavolo!” as your Dr. Rabelais has it,—answers the iconoclast,—“what is that to me and my colic, to me and my strangury? I pay the Captain ofthe Cunard steamship to carry me quickly and safely to Liverpool, not to make a chart of the Atlantic for after voyagers!”

The American apprentice system, with its early combination of theory and practice and its immediate transfer of the wisdom of the practitioner, seems to have made the American doctor a more successful healer in his daily rounds. In 1820, Dr. Nathaniel Chapman commented that, although European physicians were more learned and original, in no country was medicine better practiced than in America.

This was not all. The dissolving of ancient boundaries between theory and practice, between the “higher” and the “lower” medical services, provided a freer atmosphere in which American medicine made its distinctive advances. Although 18th-century America produced no great medical scientists, it produced competent practitioners whose clinical interests would eventually bear their own fruit. A few Americans, not always doctors by profession, were aware of this promise. Dr. Thomas Bond noted (in 1766) that “more is required of us in this late settled world, where new Diseases often occurr.” He urged an open-eyed, empirical, piecemeal approach. Where else could the exchange of experiences be so important? Jefferson, four decades later, still hoped to see here “the first degree of value set on clinical observation, and the lowest on visionary theories.”

One of the first fruits of the American emphasis was an improvement of hospitals and of nursing. In 17th- and 18th-century Europe, hospitals were too often social cesspools in which the poor, the insane, and the miscellaneous unfortunate festered in the accumulated vermin of generations. American hospitals were not built in any numbers until the 18th century, when the curable sick, the insane, and the contagious had begun to be separated. Even in 17th-century Virginia the patient was more frequently housed in the residence of his physician, where the mere absence of institutionalized filth was itself a great advantage

The Pennsylvania Hospital, founded by Dr. Thomas Bond in 1751 with the energetic assistance of Benjamin Franklin, was extraordinarily successful by the standards of its day. Erected as “a means of increasing the Number of People, and preserving many useful Members to the Public from Ruin and Distress,” the hospital admitted 8831 patients between its founding and 1773; among these the managers reported 4440 complete cures and only 852 deaths. Its mortality rate was half that of general hospitals abroad. Dr. Benjamin Rush boasted in 1774 that by comparison with the hospitals of Europe “the Pennsylvania Hospital is as perfect as the wisdom and benevolence of man can make it.”

The few important American medical publications of the colonial age, some of which we have already noticed, had an unmistakably clinical flavor. In Boston, Dr. William Douglass’ report on the scarlet fever epidemic of 1735-36 was the first adequate clinical description of the disease to appear in English. Dr. Thomas Cadwalader’s Essay on the West-India Dry-Gripes, printed by Benjamin Franklin in 1745, demonstrated that many gentlemen were suffering from lead-poisoning because they had been drinking Jamaica rum that had been distilled through lead pipes. In Charleston, Dr. John Lining prepared an accurate account of the yellow fever epidemic of 1748. From Philadelphia in 1750 came Dr. John Kearsley’s detailed observations on yellow fever. Numerous observers described the course of smallpox and the relative efficacy of different treatments.

American colonial medicine produced nothing notable in a theoretical way. Dr. Benjamin Rush, following the dogmas of Cullen’s disciple John Brown, made the most strenuous effort at an all-embracing medical theory: his doctrine of “sthenia” and “asthenia” attributed all disorders to an improper state of “tension.” Rush’s theoretic effort showed the medical doctrinaire at his worst, but even he was not doctrinaire in all things. He promoted the more humane treatment of the insane; and he tried to improve public health in Philadelphia by such common-sense expedients as sewage disposal, pure water, and clean streets.

Even into the 19th century the conspicuous successes of American medicine confirmed its clinical approach; the American accomplishments were the work of an undifferentiated medical profession under the pressure of emergencies. Two heroic figures, proper patron saints of American medicine, were melodramatic symbols of the peculiar opportunities of the New World. The first was Ephraim McDowell (1771-1830), a backwoods doctor who had studied in Edinburgh for one year but had not taken a medical degree. He encountered a woman patient who appeared to have a large abdominal tumor, so large in fact that he had originally mistaken it for a pregnancy. Before McDowell’s day the range of surgery had included amputations, removal of stones, mending of ruptures, and some other items, but never a serious abdominal operation. On December 13, 1809, McDowell, assisted only by an apprentice nephew, laid the patient on a table in his house in Danville, Kentucky and, within twenty-five minutes, while she recited psalms to keep up her courage, he opened the abdominal cavity and removed the cystic tumor of the ovary. When McDowell returned to visit his patient five days later she was making her own bed; she lived thirty-one years more. This was the first ovariotomy in medical history; it might not have been performed except for the stringency of backwoods life and the scarcity of learned specialists.

The second heroic figure, William Beaumont (1785-1853), was an army doctor whose whole training had been by the apprentice method. On June 6, 1822, while Beaumont was stationed at remote Fort Mackinac in northern Michigan, a French-Canadian employee of the American Fur Company received a load of buckshot in his left side. Despite all that Beaumont could do to make it heal, the hole in the victim’s stomach (technically called a “gastric fistula”) remained open. Beaumont had the inspiration to take advantage of this rare opportunity to observe through the unhealed opening what actually was going on in the stomach. He took the man under his own roof, where he carried on his observations with exemplary skill and imagination but without benefit of books or laboratories. He noted the operation of the gastric juices and the effects of different stimulants such as tea, coffee, and alcohol. The result was his Experiments and Observations on the Gastric Juice and the Physiology of Digestion (1833), which became a classic of clinical medicine; this unpretentious little book laid foundations for the physiology of digestion and the science of nutrition. Were the works of McDowell and of Beaumont primarily the fruits of genius or of provincial opportunity? It is impossible to say. But if either of them had been more learned or could have called in an appropriate specialist, would he have dared as he did?

The immediate future of American medicine seemed to be at the bedside or in the clinic rather than in the laboratory. Perhaps the most important medical innovation which America exported to Europe during the 19th century was surgical anesthesia, a definitely practical and clinical discovery. Preventive medicine, dentistry, public health, clinical research, and general medical practice were the areas of special American competence. They were also the areas where the American standard of living, the loosening of social and professional distinctions, and the varied experiences of a new continent counted most.

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