Knowlton

Calomel and the Fight for Medical Legitimacy

This is a short account of the fight over Calomel, “empirics,” and medical legitimacy in the first half of the nineteenth century. It's not Environmental History, but I think it involved a distinctly urban/rural dispute over legitimacy. As well as a bit of class conflict. And who doesn't love old accounts of crazy medical nightmares!


calomel

In March 1844 a Massachusetts country doctor named Charles Knowlton wrote a letter to the Boston Medical and Surgical Journal. He suspected himself of having infected a new mother with Erysipelas, giving her a fatal case of Puerperal Fever. Oliver Wendell Holmes had published “The Contagiousness of Puerperal Fever” only a year earlier in the New England Quarterly Journal of Medicine, and the issue of contagion was still hotly contested, so Knowlton was not only demonstrating he was up to date with the literature, he was taking a stand on a politically charged issue.[1] But he went further. Aware that his actions would be questioned by his peers, Knowlton argued:

"
if my treatment of the cases is to be criticized at all, let it not be done by the city practitioner, who, instead of spending most of his hours in buffeting the winds and storms 'o'er hill and dale,' as in country practice, may spend them at the bedside of the sick, acquiring practical experience--or in his study, treasuring up the experience of others; who can examine and re-examine both his patient and his library within the space of half an hour…But rather let it be criticized by the country practitioner, who…knows what it is…to be caught, perhaps in the night, some five or ten miles from home, at the bedside of a patient presenting urgent and alarming symptoms with which he is not practically familiar, and all this without any aid at command beyond what he may chance to have in his pockets and saddlebags. These are the circumstances that 'try men's souls,' and qualify country physicians to sit in judgment upon the practice of each other."[2]

Knowlton’s remarks suggest a certain tension between urban and rural physicians; they also point to his respect for
experience as a mark of professionalism and expertise. But Charles Knowlton wasn't a typical physician. He was a freethinker and the author of America’s first birth control manual. He had written his 1824 thesis for the medical lectures at Hanover, on the importance of anatomy. Dartmouth, like other respectable schools, held medical lectures nearby but outside the college's official walls. Dr. Nathan Smith, who had organized the medical programs at Dartmouth, Bowdoin, and the University of Vermont, was extensively grilled by Timothy Dwight regarding his religious and moral orthodoxy (and suspicions he was an “anatomist”) before being allowed to commence teaching at Yale.[3] On his graduation from Dartmouth's "lectures," Knowlton walked from Hanover directly to Worcester to serve three months at hard labor for stealing bodies from a local cemetery. But to what degree did Knowlton’s remarks reflect or speak for the developing profession? The Boston Medical and Surgical Journal holds a possible answer, in the form of a decades-long debate over the effectiveness and dangers of the drug Calomel. The conflict was between authority and experience, and the battle-lines were drawn largely on an urban-rural and class axes.

Calomel was a chloride of mercury, known since the days of the alchemists. Its use was promoted in the leading medical schools at London and Edinburgh, and eighteenth-century Americans who had studied overseas taught Calomel’s purgative, tonic, and cathartic properties to their own students at home. Along with bleeding, Calomel became a centerpiece of Dr. Benjamin Rush’s “heroic” style of treatment and was featured in authoritative American texts.[4] Calomel became such a standard part of the American
material medica that in Dartmouth lecture notes of the 1830s, students didn’t even bother to give the drug its own descriptive page. For many early nineteenth-century doctors, Calomel was the panacea, the “Samson” drug they turned to when all else failed.[5]

The harmful effects of mercury were well-known to early doctors. Along with bloodletting, Calomel was used as a “depletive,” since medical theory held first that inflammation, and later that “excitement of the blood” caused most illness. But early in the nineteenth century, the general public also began to understand the dangers of mercurial medicines, and to distrust physicians who relied on them. This distrust was fueled by popular critics like William Cobbett, who quipped that Benjamin Rush’s heroic practices were “one of the great discoveries…which have contributed to the depopulation of the earth.” More testimony against Calomel came from the legions of Thomsonian botanical healers, hydropaths and homeopaths who challenged traditional doctors in the early nineteenth century. These “sectarians” took advantage of horror stories that circulated about patients injured or killed by heroic treatment, to erode the social standing of traditional physicians they said were doing more harm than good.[6]

In 1828 the
Boston Medical and Surgical Journal (Journal) began offering doctors from New England, New York, and the western territories as far away as New Orleans a forum for sharing cases, and a place to read about medical advances. It was active in the ongoing battle against “quackery” and the struggle to establish medicine as a respected profession. The Editors of the Journal were aware of the public’s distrust of heroic treatment, and especially of the growing fear of Calomel. But rather than addressing these concerns open-mindedly, they rejected and demonized skeptics and dissenters, even when these were fellow doctors relating their cases. The continued use of Calomel and the Journal’s dogged defense of it in the face of mounting evidence from the late 1820s to the late1840s set rural doctors and urban academics in opposing camps. Leading physicians’ obvious lack of consensus on the safety and effectiveness of treatments further undermined the public’s acceptance of the profession.

Although aware of its dangers, the medical profession defended Calomel in its publications. In April 1828, Dr. Finley of Bainbridge Ohio proposed using solutions of water and “tartarate of antimony for checking mercurial salivation,” indicating that the problem was already well-known.[7] A September report of a British lecturer’s comment, “To calomel I am averse; on some bowels it acts roughly, and I have seen it apparently occasion miscarriage,” suggests that by the late 1820s the use of mercurials was falling out of favor across the Atlantic.[8] In America, doctors had begun reporting cases of “Ptyalism” and “Gangrenopsis.”[9] The effects of Calomel poisoning on patients, particularly children, were gruesome. One doctor described a ten-year old girl who was treated (by another doctor) with eight doses of calomel over the course of three weeks. She complained of swelling and soreness in her mouth that the other doctor had dismissed as canker. This swelling progressed “uninterruptedly to gangrene and sphacelation [morbidity] of both lips, and the greater part of the right cheek, before her death, and left such a hideous spectacle…as made it desirable she might not survive.” In another case, a forty-year old man “to whom much mercury had been given, and pursued for a considerable time, in small doses, and even after profuse ptyalism had been established…His mouth and face swelled; he could not distinctly articulate for several months; his teeth fell out; and portions of his lower jaw, including the sockets of the teeth, came out. At the end of nine months he died…”[10]

Dr. George Packard of Saco Maine wrote in 1830 about treating “an uncommonly healthy” ten-year old girl for fever. He gave several doses of calomel, and on the second day of treatment, her cheek began to swell. Packard was “confident that the constitutional effect of calomel was not produced, though…a fetor, somewhat resembling that of a mercurial sore mouth, was for some days perceived.” In the fourth week of treatment, the girl’s left cheek became swollen and painful. The doctor tried blisters, poultices, and tonics with no success. The "mercurial fetor" gave way to a gangrenous stench, and “a large slough came away” from the inside of the girl’s cheek. The “erosion proceeded rapidly,” and the girl began to have regular hemorrhages, which finally killed her in the eighth week of her illness. By this time, the erosion, “commencing at the angle of the mouth, passed by the nose to the upper edge of the malar bone,—thence, by the ear…came anteriorly, including half of the throat and chin.” The girl was unable to eat for much of the two months she suffered from this erosion, and her death “was for many days heartily desired by her attendants and friends, and, when it came, was not an unwelcome visitor.”[11]

Although it continued to print alarming letters from country doctors describing catastrophic results of Calomel use, the
Journal was unwilling to offer an opinion contradicting medical canon. In early 1831 the Editors denounced a “REFORMED Medical College” that had been opened by Dr. John J. Steele in Worthington Ohio. The college’s “chief object of reform,” they said, would be to “dismiss from the material medica, the internal use of mercury, antimony, lead, iron, copper, zinc, arsenic, and other poisonous materials.” The Editors called this “the most weak, absurd and contemptible affair…we ever met with in print.”[12]

In 1834 Dr. Stephen W. Williams of Deerfield, Professor of Medical Jurisprudence at the Berkshire Medical Institution, wrote in defense of mercury. Williams gave the case of a ten-year old boy with scarlet fever, to whom he had prescribed calomel. After nine days of treatment, the boy was “attacked with severe haemorrhage from the small arteries of the cheeks and gums, which continued without much intermission for two or three days, and prostrated his strength considerably.” Williams complained, “about this time I was attacked, with the ferocity of a tiger, for administering mercury in this case and destroying the patient…Such is often the gratitude that is awarded to physicians.” Dr. Williams insisted the patient would have died under any other treatment, and proceeded over several pages to cite dozens of medical authorities supporting his use of mercury. His citations went back to the seventeenth century, and included advocates of heroic treatment like Rush.

Dr. Williams’ article marks a perceptible change in the rhetoric surrounding the Calomel argument. Spurred by growing concern over the profession’s declining public image, the Editors of the
Journal chose to stand for tradition and the authority of medicine’s canonical texts. “A great change is evidently taking place in regard to the old mode of theorizing,” the Editors complained. “Facts are now first demanded, and every one may then dispose of them according to his own individual fancy.”[13] Country correspondents of the Journal objected to this “intolerant and overbearing” approach, charging that if any doctors “have the boldness or temerity to doubt their infallibility…they [the Editors], in the plentitude of their wisdom and power, are determined to inflict summary vengeance on them…by a ten times more frequent and greater use of the article in question, than they otherwise would have done.”[14] But the Editors continued, in columns like their “Remarks on Itinerants,” to declare that “although mercury is “anathematized by quacks and their unconscious dupes, it is a valuable medicine, and could not be dispensed with in general practice.”[15]

The basis of the Editors’ argument for Calomel seems to rest squarely on the authority of tradition. In 1838 the
Journal devoted several issues to reprinting a London lecture on Materia Medica that traced mercury’s use from Pliny and Dioscorides, through the Arabians, to Paracelsus and the alchemists, for whom it was “the summum magnum of all their labors.”[16] In an 1839 conclusion to a “Medical Essay,” on another subject, the Editors attacked “the empiric…[who] is absolutely ignorant of the nature and proper operation of calomel, and therefore in his hands it becomes an edged-tool, which should never be in the hands of the ignorant, the prejudiced, or the insane.”[17] Though the term empiric was then widely used as a derogatory catch-all for Thomsonian herbalists, homeopaths, and others, its literal meaning is equally relevant. In the minds of the Editors and their supporters, physicians, like contemporary professionals practicing law and the ministry, claimed their authority not from experience, but from their mastery of medicine’s ancient, canonical texts.

The battle raged on, in literally dozens of
Journal articles and letters. Most often correspondents and country doctors argued from their observations, while the Editors and their academic experts argued from the texts. At the same time, the Journal and other organs of the medical press complained of physicians' low social standing relative to ministers and lawyers. One of the first priorities of the American Medical Association, founded in 1847, was setting minimal standards of education for its members. While this ultimately resulted in the highly empirical, science-based medicine we are familiar with today, at the time it may have functioned like the Association's committees to investigate secret remedies, patent nostrums, and other “quack” cures: more as a reinforcement for authority over experience than as a search for new discoveries.[18]

By mid-century the weight of evidence was unbearable. Its acceptance coincided the establishment of medical schools
within the elite institutions that had once held them at arm's length. Perhaps moving inside the walls gave medicine the prestige it needed to address its critics. Experience became institutionalized as medical science and Calomel faded from use. In his 1850 “Valedictory Address” to the AMA, President John C. Warren remarked “I do remember that at one time most diseases were attacked by mercurials; not only general but local; inflammations and fevers; affections acute and chronic, syphilitic and scrofulous; in short, nearly all diseases, all ages, both sexes, were invaded by this potent mineral.”[19] Warren’s position as Professor of Anatomy at the Harvard Medical School thirty-seven years after Nathan Smith arrived at Yale under a cloud of suspicion illustrates how much had changed in a little over a generation. Memory faded rapidly regarding the divisiveness of the Calomel debate and the authoritarian philosophy of medicine it illustrated. Young doctors were no longer jailed for studying anatomy on stolen corpses. The profession had grown up and empiricism had won, if not a decisive victory over authority, at least a seat at the table.

Notes:

[1] “A gentleman’s hands are clean,” claimed opponents. Meigs, C. D. (1854). On the nature, signs, and treatment of childbed fevers; in a series of letters addressed to the students of his class. Philadelphia, Blanchard and Lea. Holmes article was reprinted in Holmes, O. W. (1883). Medical essays, 1842-1882. Boston, Houghton Mifflin.
[2] Massachusetts Medical, S. and S. New England Surgical (1844). "Erisypelas and Puerperal Fever." The Boston medical and surgical journal.
XXX(5): 89-95.
[3] Smith, E. A. (1914). The life and letters of Nathan Smith, M.B., M.D. New Haven, Yale University Press; [etc.].
[4] Eberle, J. (1834). Notes of lectures on the theory and practice of medicine, delivered in the Jefferson medical college, at Philadelphia. Cincinnati, Corey & Fairbank.
[5] Cobbett, W. (1885). How to get on in the world, as displayed in the life and writings of William Cobbett. New York, R. Worthington.
[6] Thomson, S. (1822, 1972). A narrative of the life and medical discoveries of Samuel Thomson; containing an account of his system of practice, and the manner of curing disease with vegetable medicine, upon a plan entirely new; to which is added an introduction to his New guide to health, or botanic family physician, containing the principles upon which the system is founded, with remarks on fevers, steaming, poison, &c. New York, Arno Press.
[7] Massachusetts Medical, S. and S. New England Surgical (1828). "Letter." The Boston medical and surgical journal.
I(9): 137.
[8] Massachusetts Medical, S. and S. New England Surgical (1828). "Lectures Delivered at Guy's Hospital." The Boston medical and surgical journal.
I(29): 458.
[9] Massachusetts Medical, S. and S. New England Surgical (1828). "Letter." The Boston medical and surgical journal.
II(43): 679.
[10] Massachusetts Medical, S. and S. New England Surgical (1830). "Some Account of Affections of the Face." The Boston medical and surgical journal.
II(48): 758.
[11] Massachusetts Medical, S. and S. New England Surgical (1830). "Letter." The Boston medical and surgical journal.
III(21): 337.
[12] Massachusetts Medical, S. and S. New England Surgical (1831). ""REFORMED" Medical College." The Boston medical and surgical journal.
IV(6): 101.
[13] Massachusetts Medical, S. and S. New England Surgical (1835). "Self Limited Diseases." The Boston medical and surgical journal.
XII(26): 413.
[14] Massachusetts Medical, S. and S. New England Surgical (1835). "Letter." The Boston medical and surgical journal.
XII(26): 411.
[15] Massachusetts Medical, S. and S. New England Surgical (1837). "Remarks on Itinerants." The Boston medical and surgical journal.
XVI(1): 14.
[16] Massachusetts Medical, S. and S. New England Surgical (1838). "Mercury, from Dr. Sigmond's Lectures on the Materia Medica." The Boston medical and surgical journal.
XVIII(9): 133
[17] Massachusetts Medical, S. and S. New England Surgical (1839). "Medical Essay." The Boston medical and surgical journal.
XX(6): 94.
[18] Davis, N. S. B. S. W. and ed (1855). History of the American Medical Association from its organization up to January, 1855. Philadelphia, Lippincott, Grambo & Co.
[19] Massachusetts Medical, S. and S. New England Surgical (1850). "Dr. Warren's Valedictory Address." The Boston medical and surgical journal.
XLII(20): 409.
Bibliography:
Primary:
Cobbett, W. (1885). How to get on in the world, as displayed in the life and writings of William Cobbett. New York, R. Worthington.
Davis, N. S. B. S. W. and ed (1855). History of the American Medical Association from its organization up to January, 1855. Philadelphia, Lippincott, Grambo & Co.
Eberle, J. (1834). Notes of lectures on the theory and practice of medicine, delivered in the Jefferson medical college, at Philadelphia. Cincinnati, Corey & Fairbank.
Holmes, O. W. (1883). Medical essays, 1842-1882. Boston, Houghton Mifflin.
Massachusetts Medical, S. and S. New England Surgical (1850). "Dr. Warren's Valedictory Address." The Boston medical and surgical journal. 
1828-1850
Meigs, C. D. (1854). On the nature, signs, and treatment of childbed fevers; in a series of letters addressed to the students of his class. Philadelphia, Blanchard and Lea.
Smith, E. A. (1914). The life and letters of Nathan Smith, M.B., M.D. New Haven, Yale University Press; [etc.].
Thomson, S. (1822, 1972). A narrative of the life and medical discoveries of Samuel Thomson; containing an account of his system of practice, and the manner of curing disease with vegetable medicine, upon a plan entirely new; to which is added an introduction to his New guide to health, or botanic family physician, containing the principles upon which the system is founded, with remarks on fevers, steaming, poison, &c. New York, Arno Press.
Secondary:
James Cassedy,
American Medicine and Statistical Thinking, 1984
John Duffy,
From Humors to Medical Science, 1993
William Rothstein,
American Medical Schools and the Practice of Medicine, 1987
Michael Sappol
, A Traffic of Dead Bodies, 2002
------------, “The Odd Case of Charles Knowlton: Anatomical Performance, Medical Narrative, and Identity in Antebellum America,”
Bulletin of the History of Medicine, 2009.
Jayme Sokolow,
Eros and Modernization, 1983