Teaching Medicine at Dartmouth

                The founder of the Dartmouth Medical School, Nathan Smith, started his medical practice in Cornish.  His wife was the daughter of Jonathan Chase, Revolutionary War Colonel and founder of the Cornish-Windsor bridge.  Doctors were not plentiful in the North Country at the time, and as Nathan’s reputation as an excellent doctor and surgeon grew, he found that he often had several apprentices working with him.  Nathan had studied at Harvard, and considered the apprenticeship system to be vastly inferior to a high quality formal medical education.  He approached the trustees of Dartmouth College with a proposal to establish a medical school there, and after a couple of years of waiting, during which time Nathan went to Scotland and London adding to his own medical education, the trustees approved the Medical School.

                Nathan had an attitude toward the practice of medicine that differed from that of other learned doctors of his day.  He taught his students to carefully examine their patients and pay particular attention to what they were experiencing. He believed that good nursing care was very important in the treatment of a sick person, and that the wise physician takes advantage of every avenue of treatment while being careful to watch for side effects.  During this time, medical knowledge was rudimentary at best, and there were many treatments commonly used on patients that were useless, and some that even harmed them and made them less likely to recover.  Nathan believed that “watchful waiting” was often the best course of action.  Other doctors commonly practiced “heroic measures” like bleeding and purging.  Before the medical school was established, Nathan had dealt with an outbreak of Typhus at Dartmouth College without losing a single one of his patients by opening the windows of the patients’ rooms, wrapping them in wet sheets and giving them lots of fluids.  In his biography of Nathan, Oliver Hayward, in his book “Improve, Perfect and Perpetuate” states that he believes that Nathan’s isolation on the frontier may have saved him from engaging some of the practices popular with more established doctors elsewhere.  Harvard Medical School had more than one doctor on the faculty, and these doctors had been established as medical eminences for a long time. They hesitated to stray from the accepted teachings and medical beliefs.  Nathan was younger, in charge pretty much in a vacuum, and had been practicing medicine in the howling wilderness where necessity was often the mother of invention.

                While Nathan was in Europe, he attended many classes and lectures that featured dissection of bodies.  These experiences made him committed to dissection of real human subjects and laboratory chemistry experiments as part of the education at Dartmouth Medical School.  The problem was, that dissection of human bodies was illegal in America at this time, and because of this, bodies were hard to come by.  It was especially difficult to obtain cadavers in rural New Hampshire and Vermont. In cities, medical schools often used the unclaimed bodies of paupers, or prisoners who had died in jail. There were more cemeteries in cities, and the cemeteries were much bigger, and a disturbed grave would not be noticed as quickly than it would be in the rural Upper Valley, where everyone noticed everything.  If a body was dug up in Hanover, everyone in the whole town would know about it immediately. 

                If a person was caught and convicted of graverobbing, they would receive a $2000 fine, 2 years in prison and 50 lashes.  There are multiple indications that graverobbing was rampant in the Upper Valley at this time.  Norwich cemetaries were a prime spot for grave robbers, and in the early town reports in Cornish there is documentation of the “problem of grave robbing” being discussed at town meeting, and stern warnings given by town officials toward potential grave robbers. Of course one wonders if Nathan Smith was behind the grave robberies in Cornish and whether or not his Chase relatives knew.

                In 1804, the Dartmouth Trustees voted to give Nathan a raise, on the condition that he would move to Hanover permanently, and bring his family with him.  Before this, Nathan had been maintaining two households.  He rented a couple of rooms in Hanover, but Sally and his sons remained behind in Cornish.  One assumes that the Trustees thought that Nathan was spread too thin, and he would do a better job if he could live with his family at Dartmouth.  The question is, was it financial considerations that kept the family in Cornish, or Sally’s disinclination to move to Hanover?  The family was living right across the road from her parents, in a house that her father owned.  With Nathan being so busy teaching medical school and carrying on his medical practice, she probably preferred to stay by her parents and siblings.  After Jonathan died in 1801, she may have been more amenable to a move to Hanover that she would have been before he died.  By all accounts, Jonathan was very close to his children and his grandchildren, in a way that Nathan may very well not have been.

Nathan Smith's Medical Practices - Cornish - Early 19th Century

Dr. Nathan Smith married Sally Chase, Jonathan's daughter, and built a thriving medical practice based in Cornish.  There were probably very few doctors in the Upper Valley, but even fewer who had been educated at Harvard.  Nathan graduated from Harvard in 1790, married Sally in 1791. Their first son, David Solon Chase Hall Smith, was born about 9 months later.

            Nathan quickly became well known on both sides of the Connecticut River.  In 1798, Typhus Fever hit the Upper Valley and as Nathan traveled throughout the area treating patients, he was able to track the appearance of the disease from one place to another. He tried to figure out how the disease was transmitted and also how to treat it.  His “Medical and Surgical Memoirs” published after his death, contains an essay that describes his experiences treating typhus.

            In the essay, he states that he believes that typhus is a contagious disease.  He did not believe it is caused by “miasma”, poisonous vapor coming off of swamps, for the simple reason that the cases  typhoid fever that he treated did not happen in families living near swamps, nor did the families living in the backwaters of the Connecticut River seem more likely to contract the disease.

            He believed Typhus was contagious because it was possible to track its spread as families became sick.  It always amazes me how far people traveled in those days, even though transportation was limited to horseback or stagecoach.  Dr Smith treated many people in Thetford who came down with Typhus.  The outbreak started when a woman from Thetford went to Chelsea to take care of her sister who was sick with the disease.  The sister died, the woman came home, got sick and died, and then her whole family came down with it.  In the end, 40 people in Thetford died of Typhus.

            In his essay, he tells the story of a young man from Plainfield who went to Western New York State for a while, then returned home.  On the way home, he became sick and when he arrived home he was diagnosed with Typhus. Soon after he was diagnosed, 9 more members of his family came down with it. He does say that although there is some evidence of contagion, some people get sick with the disease without any clear evidence of their having caught it from someone else who had it. Another reason he gives for it being a contagious disease is that if a patient got Typhus and recovered, they couldn't get it again, which was the case with other contagious diseases like mumps, measles, smallpox and whooping cough.

            In his essay, Nathan laments the lack of knowledge the medical profession has about how contagion works. He says, “Contagion may be considered as the antecedent to all which follows its application and without it no effect would be produced.  But how this cause operates on the system, or on what part it makes its first impression, or how this first impression produces the ultimate effects, we are wholly ignorant.”

            By the time he was summoned to Dartmouth College, where there were 50 or 60 students sick with Typhus, Dr. Smith treated them and only one died. Possibly this was because of his “cutting edge” treatment, or because Dartmouth students were great candidates for surviving a serious disease. They were all young, and because they were mostly from well-to-do families, they would have been raised well-fed.   The fact that they were at college presupposes that they were healthy to begin with, because young men who were sick would not have been at school. 

            Nevertheless, by the time Typhus appeared at Dartmouth, Nathan had some definite ideas about how to treat it.  He admits that “I have never been satisfied that I have cut short a single case of typhus, but have been able to enable the patient to live through it more comfortably.  Like smallpox, measles and whooping cough, it must run its course.  Powerful medicines can make a person worse.”

            One of the medicines he listed was tartrite of antimony, which apparently contained some amount of potash.  This was used to make a patient throw up.  At the time, people believed that if you were sick, it was because your body was full of toxins, and if a doctor could cause you to lose bodily fluids, some of the toxins would be lost with the fluids, thus you would have less of them in your system. Medicine that makes people throw up is called an emetic.  If you threw up, you would lose some fluid and thus some of the toxin that was making you sick.  In his essay, Dr. Smith said that the only thing accomplished by giving a patient an emetic was to make him sicker.

 

            thumb lancet

 
            Another way doctors tried to get rid of the poison in a patients' systems is by bloodletting. Bloodletting, or bleeding the patient, involved making a cut in the patients forearm and letting some blood drain out.  Again, bleeding was viewed as a way to get some liquid out of a patient, and along with it, the poison that was making the patient sick. Often patients lost so much blood during bloodletting that the procedure weakened them enough to kill them. In their webpage Red Gold, the Epic Story of Blood, PBS reprinted the article “Bloodletting Over the Centuries” by Gilbert Siegworth, MD, first published in the New York State Journal of Medicine in 1980. In the article, Siegworth

describes how a thumb lancet was used to bleed a patient.  In using a thumb lancet for bloodletting, a practitioner followed a specific procedure. “ The arm of the patient was bound above the elbow with a broad tape tight enough to compress the vein, but not tight enough to diminish the arterial pulse. The blade of the lancet was grasped between the thumb and forefinger, and the hand was steadied by the other three fingers. The lancet was then introduced into the vein in an oblique direction until blood rose up at the point. The front edge of the lancet was then pulled up in as straight a line as possible to make the skin wound the same size as that in the vein. The thumb of the left hand which was compressing the vein distally was removed, and the blood was allowed to flow into a bowl for measurement. Care was taken to avoid transfixation of the vein, accidental arteriotomy, or injury to the nerve or tendon. The spurting blood was caught in various types of vessels. Barber's shaving bowls were sometimes used. (http://www.pbs.org/wnet/redgold/basics/bloodlettinghistory2.htm)

 

 

 In his “Medical and Surgical Memoirs”, Nathan doesn't say much one way or the other about bleeding the patient.  He writes that there are some symptoms that can be alleviated by bloodletting (when pain accompanies a sense of fullness in the head or chest).  He does not advocate bloodletting as a standard procedure when treating Typhus.

            He was definitely against blistering, which was yet another way doctors tried to get patients to lose fluid.  Doctors would apply poultices  - wet rags – dripping wet with scalding hot water onto a patients chest in order to burn them.  This would raise blisters and when the blisters broke, the patient would lose the fluid in the blisters and thus lose a little of the poison in their system.

            Nathan recommends giving the patient as much as he wants to drink, keep cool air in the sickroom by opening the windows when at all possible, and wet the patients bedsheets with water to bring the fever down.  This may not seem like cutting edge medicine, but these were revolutionary ideas at the dawn of the 19^th century.  People believed it was dangerous to leave the windows open, and that night air was bad for you to breathe.  They believed that the “miasma” from swamps could come in through an open window and make you sick!

             I have read several biographies of Dr Nathan Smith that say that he believed in “watchful waiting” and emphasized the care and comfort of the patient.  I don't see that in his “Surgical and Medical Memoirs”.  In fact, mention of patient comfort is striking in its absence.  He cautions against using bloodletting as a standard procedure, absolutely does not believe in blistering, and thinks that emetics make the patient sicker. He believes that these things do not help the patient get better, and may very well make sickness worse. He never mentions that causing sick people to experience even more pain for no good reason is a terrible idea because burning them, cutting them and making them throw up makes them even more miserable than they already are.  He doesn't believe in performing these procedures because they may not help and may make people worse, and may cause people to die rather than get better.

            Nathan's focus was on survival, not patient comfort, not because he was heartless, cruel and uncaring but because he really couldn't afford to focus on what his patients were feeling.  He was a surgeon.  One of the focuses of his practice was surgery, and probably the most surgeries he performed were amputations, and he did them without anesthesia!  The only anesthesia available was whiskey.  By the time surgeries progressed, the patient either passed out or went into shock, which caused them to be somewhat senseless, but doctors in general and surgeons especially had to have a certain amount of callousness toward their patients' pain.

            Even when he wrote about “enabling his patients to live through Typhus more comfortably”, I wonder if he was really talking about lessened suffering.  He could have meant “by a comfortable margin”, meaning not snatching patients back from the brink of death by the skin of their teeth, but treating patients in a way that assures they will recover, where their survival is never in question. Other than that one comment, he never mentions the comfort of his patients.

            In 2014, we can look read Nathan's Medical and Surgical Memoirs and we know where he was right and where he was sadly wrong.  Neither bloodletting, blistering or emetics help patients get better, so he was right regarding all of that.  He was also right to treat Typhus fevers by keeping them hydrated and giving them plenty of fresh air and doing everything possible to bring their temperature down.     There are two types of Typhus, Typhus and Typhoid Fever.  They are both called Typhus because both diseases can cause delirium and temporary psychosis.  Typhus is carried by fleas or lice.  A person with Typhus has back pain, high fever, a rash, joint pains and severe headache and muscle pains.  Typhoid Fever is spread through the feces of an infected  person, and is usually contracted through contaminated water. People who have Typhoid Fever start with a low grade fever that gradually becomes worse.  Some Typhoid Fever patients can have severe diarrhea,  but others can be constipated.  Typhoid Fever can affect a patient's heart and lungs, and can cause severe delirium. I believe the Typhoid essay in Nathan's book addressed Typhoid Fever as opposed to the Typhus transmitted by fleas, because he comments on the diarrhea and constipation. Because of vastly improved sanitary practices and clean water supplies, Typhoid fever is very rare in modern America,