A Medical Student in 1867
A Medical Student in 1867
By: John Allen Wyeth
Source: John Allen Wyeth. With Sabre and Scalpel: The Autobiography of a Soldier and Surgeon. New York: Harper & Brothers, 1914.
About the Author: John Allen Wyeth was a physician and the founder of the New York Polyclinic Medical School and Hospital, which was considered the pioneer organization for postgraduate medical education in the United States. He was the president of that facility, as well as the institution's surgeon-in-chief. Wyeth served as president of the American Medical Association, the New York Academy of Medicine, the New York State Medical Association, the New York Pathological Society, the New York Southern Society, and the Alabama Society of New York City. He was an attending surgeon at St. Elizabeth's and Mt. Sinai Hospitals. In addition, he was an honorary member of the Medical Society of New Jersey and the Texas State Medical Association. In 1876, Wyeth won the Bellevue Alumni Association Prize; in 1878, he was awarded the first and second prizes of the American Medical Association. He was the author of a textbook on general surgery as well as numerous other works, including biographies, historical monographs, and essays on political and military subjects.
American medical education during most of the nineteenth century was neither rigorous nor standardized. There were no required entrance examinations, nor were there any prerequisite courses of academic instruction. There were three common types of medical education: an apprenticeship model, in which students worked directly with a local physician and learned by observation and practice, rather than by classroom study; a proprietary school model in which students attended lectures given by small groups of faculty, who also owned the school; and the university model, in which students received an education that was both didactic (lecture) and clinical (laboratory or clinical work in a university-affiliated hospital). The university medical school was typically affiliated with both a college or university and a hospital. The courses of study for the latter two models were typically brief, consisting of two four- to seven-month school sessions, with the university-affiliated students also having some combination of didactic and clinical experiences. Even at the "best" medical schools in America, there was minimal emphasis on laboratory work and only slightly more focus on practical clinical training. There was virtually no direct training in surgical or operative techniques.
The requirements for completion of a medical degree were minimal as well, even for university-affiliated schools. Typically, all a student needed to do was pass final examinations at the end of the second year of school. There were few states with licensure laws, and there were no standards for practica (demonstrable clinical skills). Since there were no overall standards for medical coursework content, no significant entrance requirements, and few licensure laws, medical school graduates covered the entire spectrum of relative competency, theoretical and practical knowledge of the human body, and aptitude to practice medicine.
For most of the nineteenth century, American medical students graduated with very little real knowledge of how to go about the actual practice of medicine. Students who possessed a strong desire, as well as ample means, to broaden their scientific or clinical experience, traveled to Europe for further study. In France, Germany, England, and Scotland, in particular, American students were able to pursue far more rigorous and detailed scientific and clinical medical education.
In an ideal scenario, those students who were not able to continue their studies abroad would join an established physician and have the opportunity to learn by observation. That quite often was not the case, however, particularly in rural and frontier areas of the country. In addition, many practicing country doctors lacked formal medical school training. Often, several generations of doctors followed the apprenticeship path. They learned by practical experience and had little, if any, actual knowledge of the principles of medicine and the anatomy of the human body.
The medical department of the university I attended was in 1867 one of the oldest and deservedly best known of the medical colleges in the United States. The course of study and the standard of requirements then prevailing at this school may be taken as typical of medical education in the United States at that period. There was no preliminary or entrance examination. Any white male who could read and write and who had mastered the rudiments of English was eligible. Neither Latin nor Greek was essential.
The requirements for graduation were a satisfactory examination at the end of two college terms of seven months each. The division of subjects was: anatomy, physiology, surgery, medicine, obstetrics, chemistry, and materia medica. Anatomy was thoroughly taught, and the didactic course was supplemented by dissecting-room work of a high class. While material was not over-abundant, there not then being the same liberal construction of the law relating to the disposition of the unclaimed dead which now prevails, the activity of our dissecting-room janitor kept us in a sufficient quantity of cadavers. How he got them we did not know, and it was probably just as well that no inquiry was instituted. His name was Peter. Students inclined to disrespect spoke of him as "old Pete," but those who had been brought up under the influence of the Westminster Confession baptized him "St. Peter," the rock upon which our anatomical church was founded, and to whom it was said the keys of Cave Hill Cemetery had been given. In physiology there were no laboratory exercises; no practical demonstrations of the living structures and of the functions of the normal organs.
The teaching of surgery and medicine was almost wholly didactic. When an operative clinic was given the students witnessed it at such distance from the subject and with so many interruptions of vision that it was impossible to follow closely the details of technique, without which the lesson of a demonstration is valueless. Not once in my two college years did I enter the ward of a hospital or receive instruction by the bedside of a patient.
This is not in the least a reflection upon our teachers, but upon the system then in vogue. The greatest names in medicine in our country had been or then were associated with this institution. In the lectures on medicine we were told that the cause of malarial and yellow fever was a miasm emanating from decaying vegetable matter subjected to a temperature of form eighty to ninety degrees Fahrenheit for about thirty days, and that those who slept upon the ground floors of buildings suffered most, while those who occupied the second, third, and higher floors escaped the baneful effects in the direct ratio of their elevation. The same comparison was used in the discourse upon yellow fever, citing the fact that in the Louisville epidemic few, if any, persons sleeping upon the upper floors of houses were affected. Knowing as we do now that the mosquito is not prone to fly high, that he infests the lower floors of houses, seldom reaching the third or fourth floor, we can understand readily the error in etiology on the part of our professor of medicine. The teaching of obstetrics was entirely didactic. In my two terms of study I examined only one gynecological case, while in chemistry and materia medica the instruction was in the lecture-room to the whole class instead of with working sections in the laboratory, and there was no course of study in microscopy or urinary analysis.
I was graduated in the spring of 1869. I had been looking forward to the day when I should received my diploma and start out on my career as a practising physician and surgeon; but I can never forget the sinking feeling that came over me when I unfolded this sacred document in the privacy of my own room and realized how little I knew and how incompetent I was to undertake the care of those in the distress of sickness or accident. However, like Macbeth who was so far advanced in blood that it was as easy to go ahead as to recede, I felt I might just as well do as my predecessors had done and let the world take its chances.
The possessor of a pair of doctor's saddle-bags which held two rows of medicine bottles, diminutive apothecary scales for weighing dosage, two forceps for extracting teeth, and a small minor surgical operating set of instruments, and last, but not least, a tin sign, I rented an office in my home town, and after dark one night in March, 1869, I tacked my sign to "the outer wall." It was the irony of fate that my first call was obstetrical. If there was anything in the world I didn't want it was this kind of a case; but I didn't have the courage to back out. I thanked God it was a normal labor, for I had nothing to do but tie and cut the umbilical cord and tell the mother it was a boy. A strapping young farmer with lobar pneumonia came next, and he survived. For my first surgical operation I rode twenty-three miles and back the same day. My preceptor, an ex-army surgeon, gave the chloroform, and looked on as I dissected out some sort of tumor from the shoulder-blade of an elderly lady, whose resistance enabled us to register it as successful.
As we were starting home, the appreciative and grateful husband told us he didn't have any money, but, pointing to his apple orchard, then in bloom, said he had a "still," and would send us a barrel of apple-brandy in the fall. He kept his word, and I realized twenty dollars for my share.
Then came my Waterloo in a case of diabetes mellitus which progressed rapidly to a fatal termination. I cannot describe my feelings nor measure the depth of my depression and despair as I watched this patient die. I was overwhelmed with the conviction that I was unfit to take the grave responsibility of the life and health and happiness of those who might be willing to place themselves under my care. I needed a clinical and laboratory training under teachers of experience, and I determined to give up my practice until I could secure this training. That night, two months after I had tacked it up, I took my sign down and put it in my trunk, where it reposed for several years.
Even among those physicians who had received university-affiliated medical training, overall understanding of the functioning of the human body was limited. Anatomy was studied by dissecting cadavers in the laboratory, but the study of the disease process in living humans was quite limited. Most of the beliefs concerning medical treatments were based on folklore or trial-and-error, rather than on sound scientific method. At that time, there was no general understanding of bacteria or of the germ theory of disease. Among the more common medical practices and remedies used during the first half of the nineteenth century were bloodletting, calomel (mercury chloride, typically used as a purgative—its use sometimes resulted in death and almost always resulted in the patient becoming quite ill), quinine, jalap, Epsom salts, castor oil, cupping, sweating, diuretics, emetics (to induce vomiting), and poultices of hot flaxseed or mustard applied to the chest or neck to treat upper respiratory ailments. None of these techniques had any real curative value. Many made the symptoms worse or made the patient sicker in other ways by causing new, and more dire, physical problems. Sometimes the patient died not because of the original illness, but as a consequence of the "cure." Until the last quarter of the nineteenth century (and beyond, in some areas), there was a dominant belief among medical practitioners that almost anything could be cured by serious purging or bleeding.
Almost all medical treatment took place either in the doctor's office or in the patient's home; by 1873 there were only 149 hospitals in the United States. Most hospitals had very limited standards of care and cleanliness, were staffed by nurses with little or no formal training or education, and catered to the destitute or dying patient. In most areas of the United States, all aspects of medical care were provided by local physicians, although many towns had midwives, who also acted as practical nurses. In 1870, the U.S. population was over 39 million and there were 62,000 individuals who described themselves as practicing physicians (a ratio of one doctor for every 642 people). In contrast, there were 44,000 clergy (a ratio of 1 to 905), 41,000 lawyers (a ratio of 1 to 971), and 11,000 bankers (a ratio of 1 to 3,620). There were 110 medical schools in America at that time, and they graduated approximately 2,000 new physicians per year (about eighteen graduates per medical school). Quite often, physicians were paid "in kind" for their services. It was not uncommon for physicians to receive food, livestock, quilts, or handmade clothing as payment for services rendered.
There was a limited pharmacopoeia, and the most common drugs utilized were the quinine, calomel, and digitalis (for heart ailments). Because there was, as yet, no mass production of pharmaceuticals, these medications often were in short supply. As a result, many doctors collected herbs and wild plants—such as spearmint, peppermint, raspberry leaves, fleabane, and mustard—that contained similar ingredients to the commercially prepared medications. Even when using manufactured drugs, which were obtained in bulk quantities, the doctor had to mix his own doses and proportions.
Doctors' equipment was equally limited in the latter half of the nineteenth century. In their saddlebags (the typical means of carrying necessary tools from the office to the patient's house), physicians usually carried bottles of medicines in various strengths and dosages, forceps (for pulling teeth and sometimes for assisting in difficult deliveries), a catheter, a stomach pump, a heating iron, some syringes (the hypodermic needle was not yet available), and assorted splints and bandages. Stethoscopes and thermometers were not readily available; a doctor placed the inside of his wrist against the patient's forehead to check for fever and placed his ear against the patient's chest to listen to heart and lung sounds. Wounds were anesthetized by rubbing them with morphine or opium; morphine was also administered orally for pain. Limbs that were mangled or badly broken often were amputated. Contagious diseases were most effectively treated by isolating the sick from the healthy and cleaning the areas previously inhabited by the sick persons.
A revolution was underway in American medicine by the end of the nineteenth century. In the first quarter of the twentieth century, this revolution resulted in sweeping changes in the system of medical education and in rapid scientific and technological advances fueled by a clear understanding of the germ theory and of sanitary methods.
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