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The Medical Education of William Brooks Bigler (1863)
- York Hospital; York, PA 17405 Acknowledgments: The author thanks Charles E. Letocha, MD, of York and David A. Smith, MD, of Harrisburg for reading the manuscript and offering suggestions and Steve Moyer for invaluable assistance with photography. Requests for Reprints: Suzanne M. Shultz, Director of Library Services, York Hospital, 1001 South George Street, York, PA 17405; e-mail, li_sshultz@yorkhospital.edu.
William Brooks Bigler was born on 6 October 1833 in Fairview Township, York County, Pennsylvania. During the Civil War, he was one of the first to volunteer for the defense of Harrisburg, Pennsylvania, at the time of the Confederate invasion and was stationed at Camp Curtin for a few weeks. He read medicine under his brother-in-law, Dr. B.F. Porter [1], entered Jefferson Medical College in Philadelphia in 1863, and graduated on 10 March 1865. No copies of his doctoral thesis, entitled “Specific Remedies,” are available. After beginning medical practice in East Prospect, Bigler moved to Wrightsville, returned to East Prospect, and finally settled in Dallastown (all in York County, Pennsylvania). He married 6 months after graduation from medical school and had three children. A writer, local historian, school director, and member of the Pennsylvania legislature (1883-1884) [2], Bigler died on 1 April 1915 of “senile debility” at his home in Dallastown [3].
When Bigler entered Jefferson Medical College in October 1863, the midpoint of the Civil War had passed. The battles of Chancellorsville, Gettysburg, Vicksburg, and Chickamauga were history. Chattanooga was still to come. At the outset of the war, the almost 200 southern medical students left Jefferson Medical College to return home; hence, Bigler's classmates were all northerners.
Jefferson Medical College was founded in 1824-1825 through the efforts of Dr. George McClellan. The medical faculty consisted of six instructors who taught classes by didactic lecture in the Old Tivoli Theater at 518-520 Prune Street (now Locust Walk) [4]. By the time of Bigler's admission in 1863, only one new faculty position had been added to the medical school, which had relocated to 10th and Sansom streets. College clinics were conducted for clinical instruction. Two class sessions, each 20 weeks long, were held every year.
The faculty at Jefferson in October 1863 consisted of Drs. Samuel H. Dickson, Samuel D. Gross, Franklin Bache, Joseph and William Henry Pancoast, Ellerslie Wallace, Thomas D. Mitchell, and Robley Dunglison. These gentlemen were representative of America's finest, but aging, medical minds. Only Wallace and William Pancoast were relatively recent medical graduates (1843 and 1856, respectively). Mitchell was 72 years old, and Bache died between sessions.
Samuel H. Dickson, MD (1798-1872), assumed the chair in theory and practice of medicine on the death of John Kearsley Mitchell, MD, in 1858. Dickson was 60 years of age when he accepted this position. A graduate of Yale University (1814) and University of Pennsylvania Medical Department (1819), Dickson was eminently qualified to speak with authority on fevers. The title of his dissertation was History of Yellow Fever, and he authored several papers on the general topic of fevers. He said of himself in 1860 [5]:
“I have passed my whole life in Minorities-political, religious, professional. I was one of the few Democrats in College in the War of 1812-I was a Clay Whig and a Union Man in the Midst of Calhounism and Nullification. I am a Southern Slaveholder living among Abolitionists. I am a Unitarian-Rationalist-Freethinking-Man. I have been always a Humoralist-almost alone for much of my life. I became an early convert [-] a Contagionist and qua[s]icurtinist.”
The standard of American medical education before the Civil War was poor [6]. Didactic lecture was the sole teaching method, and the student's only activity was listening [7]. The quality of instruction was no better than the prevailing fund of medical knowledge-it still looked back to Sydenham and Rush. Students had little or no clinical contact. According to Rothstein [6], “Weaknesses in medical education were due only in part to the inadequacies of the faculty. Deficiencies were largely those of medicine itself.”
Lecture notes, such as Bigler's, are important indicators of the level of wisdom and the state of medical practice at the time. Mitchell's “Materia Medica” lectures resembled a pharmacopeia, and Dickson's “Practice of Medicine” lectures (held daily except Wednesday) dealt primarily with fevers. They constitute the bulk (92 of 119 total pages) of Bigler's notebook for the fall semester for 1863. Notes from Bache look like a periodic table; from Wallace, pelvic anatomic measurements for 23 patients are noted; from Gross, six pages are written on medical therapeutics and trauma; and from Pancoast and Dunglison, nothing.
Bigler's notebook (Figure 1) is a 3″ × 5″ leatherbound book about 0.5″ thick. It is part of the Philip A. Hoover, MD, Library historical collection at York Hospital and was brought to light when a cataloging project was initiated in the fall of 1997. It may have been donated by Dr. Hoover, who is older than 90 years of age. The notebook is written in pencil (Figure 2), although one of Bigler's expenses was for ink. Presumably, he used the paper and ink for letter writing; a series of letters that he posted is listed toward the end of the book. The punctuation is representative of its time, with many dashes and few periods. Some capital letters are in script and are difficult to decipher. Spelling, abbreviations, drug notations, and doses require translation, and some words remain enigmatic. Nonetheless, the notebook is remarkably revealing.
The following excerpts are from the lectures of Samuel H. Dickson on the practice of medicine.
Fever
Bigler wrote:
“Fever is a mass of irritation, inflammation and congestion. Idiopathic leaves no mark of irritation or inflammation. Rhythmical character of some fevers. Others are continued. A crisis in remittents. Period fevers subdivided as they occur. Autumn and quartern are idiopathic.”
“What of blending types of fever? … Does intermingling produce a new disease? Yes.”
“What difference between ephemeral and intermittent? Ephemeral consists of but one paroxysm, hence the name. Ephemeral may be produced by causes of other fevers. Can we tell intermittent from continued fever at the beginning of the first paroxysm? No.”
“Intermittent fever kills by degeneration into other fevers in our climate.”
Two relatively contemporary texts, George Wood's A Treatise on the Practice of Medicine (1849) [8] and Austin Flint's A Treatise on the Principles and Practice of Medicine (1866) [9], classify fever as a disease by itself rather than as a symptom or manifestation of a recognized disease. Both authors particularize fevers by pattern. Real distinctions begin to appear with discussion of theories of causation and differentiation of fevers. Wood claimed that inflammation and irritation arise from miasmata, contagion, and epidemic influences, and he carefully described the theories of causation as humoral, nervous, local origin, or eclectic. Flint noted, “Of the nature of the pathological condition which constitutes an essential fever we have no positive knowledge.” Bigler's notebook seems to place Dickson's thought closer to Wood's version than to Flint's ideas. Neither Wood nor Flint discussed “blending of fevers.”
Malaria
Bigler continues:
“Malaria: what is it? Malaria has real existence but cannot be detected. There is (or may be) a latent period during which the poison does not exhibit itself. One room in a house may be malarious, the others not. Intermittent may leave a locality for a number of years and then return.”
“With us, moisture, heat and low grounds favor the existence of malaria. Hence malaria must have weight. As our winds are mostly from south and west, in summer, hence eastern and northern sides of streams and swamps are most subject to malaria. Drinking the water of malarious districts to be avoided, as it may have absorbed the poisons.”
In 1717, Giovanni Lancisi thought that malaria was caused by poison found in marshes and was perhaps transmitted by mosquitoes. John Kearsley Mitchell, Dickson's predecessor at Jefferson, believed that a parasite of “cryptogamous origin” was the cause of malaria. Flint [9] set forth the following characteristics of malaria:
1. It affects low, moist localities.
2. It almost never develops when the temperature is lower than 60 °F, and its evolution is checked at 32 °F.
3. It is more abundant and virulent near the coast and closer to the equator.
4. It has an affinity for dense foliage, but forests and woods help to prevent transmission; it can be carried by atmospheric currents.
5. It may develop in previously healthy places by turning the soil.
6. It is attracted to and absorbed by bodies of water.
7. Experience alone can enable us to decide the presence or absence of malaria.
8. As previously malarious countries are cleared and thickly settled, periodic fevers disappear and are in many instances replaced by typhoid fever.
Bigler's notebook reflects the confusion of the medical community in 1863 regarding the origin of malaria, a disease endemic to Philadelphia. Although effective treatment was known (quinine), prevention was difficult without a clear picture of the cause. There seems to have been recognition that swamps and marshes were somehow related to the disease. Dickson warned against drinking water in malarious districts; about carriage of malaria by wind across streams and swamps; against living on the north and east sides of swamps; and about hot, moist, low grounds because malaria “sinks” there as a result of its weight.
Therapeutics
The drug armamentarium in 1863 was primitive by today's standards. Although the amount of the drug might be accurately measured, the purity and strength of the ingredients varied so that no two concoctions could be identical. Peruvian or cinchona bark, from which the quinine alkaloid was extracted, came in three colors: gray, yielding cinchonine; yellow, yielding quinine; and red, yielding both alkaloids. Early in fever treatment, quinine was prescribed as a tonic and was not generally given until fever had abated or remitted. It fell to the frontier doctors, such as Thomas Fearn, to experiment with ever-increasing doses to the point of inducing cinchonism [10]. Treatment was accomplished largely by titration; doses were increased until toxicities began to manifest and were then reduced to therapeutic levels. Wood used quinine as a tonic in enteric (typhoid) fever but found it to be less effective than in remittent fever. He believed that large doses were “wholly inapplicable to this disease” (typhoid) and that it was “incapable of arresting the disease.”
In a paper published in 1846, Dickson stated that he regarded quinine as a narcotic. However, Bigler's notebook seems to indicate that Dickson still regarded quinine as a tonic, with dosing to be initiated after the paroxysm of fever or at the earliest remission; this was the prevailing theory in the 1820s. Dickson subsequently lectured that quinine directly affected the nervous system, an idea that represented a later theoretical shift. He spoke of administering large doses of quinine bark with opium (1 ounce in 1 dram) for treatment of typhoid and mentioned the use of quinine “freely” to abort catarrhal fevers (influenza). He recognized quinine toxicity, which he noted “in some cases affects eyes and ears.”
From the lecture notes, it is difficult to ascertain Dickson's therapeutic position on the use of quinine for treatment of fever. He is probably representative of the average American physician of his time, who really did not know how to administer quinine.
Yellow fever is alluded to in the notebook only in terms of treatment with mercurial purges. “Under all circumstances, in Heaven's name, give maximum doses [of] mercury and often as possible,” Bigler quotes Dickson. “We are rather extremists in our use of purging … on the whole purging is a heroic remedy, yet at times, it is the least of two evils.”
Typhoid and Typhus
Bigler's notebook expresses Dickson's perplexity in distinguishing typhoid from typhus fever. Dickson said that even the best pathologists were often in doubt with regard to whether a condition was typhoid or typhus. Dickson believed that both fevers arose from the same cause, although he did not identify it. He said that they were closely connected because they were both contagious; both, he noted, prevail in crowds. He recognized the intestinal lesions (ulceration of Peyer glands) of typhoid and an abdominal rash that was “not always characteristic.” He recorded the dark petechial freckles of typhus. He believed that typhoid and typhus should be treated the same. Wrote Bigler,
“Typhus and typhoid appear to arise from the same cause. All varieties of continued fevers connect themselves with dense population. Typhoid and typhus closely connected. Both are contagious. Most continued fevers contagious.”
“The air and clothing absorb the cause of disease, and thus, in all ventilation rooms, disease is contagious. The hair retains fumes or smells of surroundings. In typhoid, don't allow two patients in same ward or room, to avoid concentration of poison. Is quarantine useful?”
“The patient doubts his locality, or imagines himself not home [and manifests a] wandering muttering speech, but can be roused by touch. Often the mutterings are strangely connected; on recovering, these are forgotten; forgetfulness of what transpired since ill.”
In 1837, in a series of papers in the American Journal of the Medical Sciences, William W. Gerhard, MD, enumerated the differences between typhoid fever and typhus, noting in particular the intestinal lesions diagnostic of typhoid but absent in typhus. Flint [9] clearly covered the state of the art on the issue of differentiation. “Very few hold the opinion that typhoid and typhus are identical,” he noted. He characterized intestinal lesions of typhoid and provided a general review of systems. Flint described the “typhoid state” as one of confusion, incoherent muttering, “inability to carry on connected trains of thought,” and dreaminess. Recognizing that typhoid was endemic and was not passed by contagion “under ordinary circumstances,” Flint ascribed its cause to “emanations from obstructed drains and cesspools, or from drinking-water tainted with sewage.” With regard to typhus, Flint said, “There are points of sufficient contrast to indicate typhus and typhoid are different diseases.” He also observed that the intestines were unaffected and a characteristic skin eruption in the form of a petechial rash occurred. Also called ship fever, typhus seemed to be diffused by contagion. The disease was contracted by persons in immediate proximity to infected patients.
At the time of this lecture in 1863, medical knowledge on the differentiation of typhoid and typhus is fairly clear. As Flint [9] summarized, 1) typhoid has peculiar and remarkable abdominal lesions; 2) skin eruptions belong to different classes [typhoid causes papulae and typhus causes maculae]; 3) each disease has its own cause; 4) neither disease, as a rule, is experienced twice; and 5) typhus is diffused by contagion, whereas typhoid is rarely communicated. In addition, typhoid is indigenous and endemic, whereas typhus is an imported disease and is epidemic.
Bleeding
Bigler mentions bloodletting, leeching, or cupping seven times in his notebook. Two references are made to the utility of bleeding or cupping for typhoid and one is made to bleeding for catarrhal fever. One reference each counsels against use of bleeding for yellow fever and against leeching and cupping for catarrhal fever. Judging from the two remaining references to bleeding for malaria and typhus, Dickson's position seems noncommittal. In 1849, Wood recommended bleeding or leeching for most fevers. By 1866, Flint recommended using methods other than bloodletting to achieve “salutary ends.” Dickson recommended cold affusion (pouring liquid on the patient) for both yellow fever and remittent fever as a substitute for bloodletting.
Because the practice of bleeding and cupping declined slowly over the 19th century in the United States, it would not be unusual to find a few references to the practice by medical teachers and writers until late in the century. Dickson's lectures probably reflect both the prevailing trends and his personal preferences from experience.
Conclusions
Flexner said of pre-1850 medical education, “The best products of the system are thus hard to reconcile with the system” [11]. The era of the Civil War was a turning point for American medicine. In the decades to come, revolutionary advances in histology, pathology, bacteriology, thermometry, microscopy, and public health radically changed the practice of medicine. In Bigler's experience, it seems that the medical school faculty was no better prepared than the average early 19th-century American medical practitioner. Samuel Dickson, a learned and able physician for his time, is representative of the slow progress from empirical to scientific medicine. Given that William Bigler lacked modern-day ease of building on his education, one wonders how he advanced his fund of medical knowledge on returning to York County.
Suzanne M. Shultz, MA
York Hospital; York, PA 17405
- Copyright ©2004 by the American College of Physicians
