Medical Education. “Orthodox” or “regular” medical practitioners included those who had received recognized training in an apprenticeship, medical school, or both. Medical education was available at only a handful of institutions in the United States. The University of Pennsylvania began offering medical degrees in 1765, but eighteenth-century Americans had no other alternatives except apprenticeship or study in Europe, primarily Edinburgh, London, or Paris. Harvard University offered medical lectures as early as the 1780s but did not offer full medical degrees until 1810. Yale Medical School began offering degrees in 1818. American medical education generally did not include laboratory science other than anatomical dissection until midcentury. Students could acquire their degrees after as little as two sixteen-week terms, mostly spent listening to lectures. Clinical training was not a standard part of medical education until the late nineteenth century, but many (if not most) medical graduates supplemented their education by apprenticing themselves to established practitioners.
Humoral Theory. The practice of medicine prior to the discovery of bacteria in the 1880s was governed by an understanding of the body that had prevailed for two thousand years. According to humoral theory, first articulated by the Roman physician Galen, the human body was composed of four humors, or fluids: blood, phlegm, black bile, and yellow bile. Every individual had his or her own unique balance of the four humors. Physicians believed that all the leading causes of death in the antebellum period, the endemic (“ever-present”) diseases such as tuberculosis, influenza, pneumonia, dysentery, typhus, and malaria, resulted from a single general cause: imbalance of the humors. Such an imbalance could result from internal factors, such as teething, puberty, menstruation, worry, or overexpenditure of energy. External factors, such as a change in diet or exposure to miasma (bad air, foul smells, fumes), could also provoke imbalance and lead to disease.
THE SURGEON OF THE FLEET
Cadwallader Cuticle, M.D., an Honorary Member of the most distinguished Colleges of Surgeons both in Europe and America, was our Surgeon of the Fleet. Nor was he at all blind to the dignity of his position; to which, indeed he was rendered peculiarly competent, if the reputation he enjoyed was deserved. He had the name of being the foremost Surgeon in the Navy, a gentleman of remarkable science, and a veteran practitioner.
[N]othing could exceed his coolness when actually employed in his imminent vocation. Surrounded by moans and shrieks, by features distorted with anguish inflicted by himself, he yet maintained a countenance almost super naturally calm; and unless the intense interest of the operation flushed his wan face with a momentary tinge of professional enthusiasm, he toiled away, untouched by the keenest misery coming under a fleetsurgeon’s eye. Indeed, long habituation to the dissecting-room and the amputation-table had made him seemingly impervious to the ordinary emotions of humanity. Yet you could not say that Cuticle was essentially a cruel-hearted man. His apparent heartlessness must have been of a purely scientific origin.
But notwithstanding his marvellous indifference to the sufferings of his patients, and in spite even of his enthusiasm in his vocation , . , Cuticle, on some occasions, would effect a certain disrelish of his profession, and declaim against the necessity that forced a man of his humanity to perform a surgical operation.
Treatment. Standard treatments for disease were driven by a desire to restore the balance of the humors. Physicians generally saw such physical manifestations as vomiting, diarrhea, or blood loss as signs of the body attempting to restore its own balance. The physician’s job was to start that process or help it along. Standard treatments for most diseases therefore included bleeding by using the lancet or leeches, purging by using emetics to induce vomiting or diarrhea, and cupping, the application of a heated glass to the individual’s back to raise blisters that were subsequently drained. From the late eighteenth century to the 1830s the practice of “heroic” therapeutics prevailed. Heroic therapeutics simply meant practicing the standard medical treatments to extremes, such as bleeding a patient until he fainted, or purging her to the point of causing extreme weakness.
Prestige of Doctors. The practice of medicine had never been a highly regarded or remunerative profession in the United States, but doctors experienced a dramatic decline in prestige in the 1830s. This development had at least two causes. First, the 1820s and 1830s were years of rapid population growth, which led to increasing population density in urban areas. Endemic diseases had long been the leading causes of death, but in an age without adequate water or sewage systems, urban crowding resulted in major epidemics of yellow fever, typhoid fever, and typhus that provoked waves of panic throughout the early nineteenth century. Then, in 1832, a new and more frightening disease appeared. Cholera was a depletive disease with a high mortality, meaning that it struck swiftly, caused massive fluid loss through diarrhea and vomiting, and killed rapidly. A person could leave his house perfectly well in the morning and be dead by afternoon. Traditional medical treatments were devastating under these conditions because they exacerbated dehydration and hastened death. Doctors found themselves helpless in the face of an epidemic with a mortality rate of more than 50 percent. People lost faith in heroic treatments that, with epidemics raging, seemed ineffective in comparison to the amount of misery they caused. Second, a climate of anti-authoritarianism characterized the period. Many people viewed doctors as un-American because they monopolized information and tried to establish standards that would lead to an exclusive profession of the educated elite. Patients began to turn in large numbers to people who could provide gentler alternatives to traditional medicine.
American Medical Association. One of the ways that physicians responded to their declining prestige was to form an association to try to enhance their professional status. Local and state medical societies already existed throughout the country, but in 1847 orthodox physicians joined forces to form the American Medical Association (AMA). The founders of the AMA had two major goals. First, they sought to define the boundaries of legitimate medical practice by drawing up a code of ethics that urged physicians not to consult with sectarian or other lay practitioners. Second, they sought educational reform. They wanted to raise the standards of medical training and establish uniform minimum requirements for medical degrees, emphasizing science and clinical training in hospitals. Leading medical schools did move in the direction of a science-based curriculum and clinical training, but most of the reforms envisioned by the AMA at its founding would not have a significant influence until the early twentieth century.
HEROIC MEDICINE: ARGUMENTS FOR AND AGAINST BLOODLETTING
For: It would be difficult to determie whether greater injury has risen in the practice of physic, from undue, or from inefficient bloodletting. To neglect the full use of this most important of our remedies when it is required, or to institute it when it is not so, is equally to endanger the safety of the patient.
Bloodletting is not only the most powerful and important, but the most generally used, of all our remedies. Scarcely a case of acute, or indeed of chronic disease, occurs in which it does not become necessary to consider the propriety of having recourse to the lancet, or to estimate the effects of bloodletting already instituted.
Against: The practice of bleeding for the purpose of curing disease, I consider most unnatural and injurious. Nature never furnished the body with more blood than is necessary for the maintenance of health. If the system is diseased, the blood becomes as much diseased as any other part; remove the cause of the disorder, and the blood will recover and become healthy as soon as any other part; but how taking part of it away can help to cure what remains, can never be reconciled with common sense.
Sources: Marshall Hall, Researches Principally Relative to the Morbid and Curative Effects of Loss of Blood, second American edition (Philadelphia: E. L. Carey & A. Hunt, 1835):
Samuel Thomson, New Guide to Health, or Botanic Family Physician, ninth edition (Columbus, Ohio: Jarvis Pike, 1833).