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Disciplining Medicine: Science and the Rhetoric of Medical Education Reform in Britain, 1770-1858 a DISSERTATION SUBMITTED to TH

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Disciplining Medicine: Science and the Rhetoric of Medical Education Reform in Britain, 1770-1858 a DISSERTATION SUBMITTED to TH Disciplining Medicine: Science and the Rhetoric of Medical Education Reform in Britain, 1770-1858 A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF THE UNIVERSITY OF MINNESOTA BY Kimberly A. Thomas-Pollei IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Dr. Richard Graff, adviser August 2012 © Kimberly A. Thomas-Pollei 2012 i Acknowledgements The historical research for this dissertation required me to rely on the generosity of librarians, who graciously located documents in their libraries’ collections. I thank Lois Hendrickson at the Wangensteen Historical Library for her support of my project. She was able to answer all of my questions and helped find crucial documents. I also acknowledge the help of the staff at both the Wellcome Library (History of Medicine Unit) and the British Library in London. This project emerged from my interest in the intersections of rhetoric and medicine, an interest that continues to challenge and intrigue me. I express gratitude to my colleagues in the Department of Writing Studies at the University of Minnesota, many of whom helped shape my project. I thank my writing partner Linda Freeman; she and I worked tirelessly toward the finish line and became great friends along the way. My dissertation committee members were instrumental in my progress and intellectual development: Karlyn Kohrs Campbell, Mary Lay Schuster, and Karen-Sue Taussig. The dedication of my advisor, Richard Graff, deserves my deep appreciation. His commitment to excellence, careful thinking, and sound advice made this project much better than it would have been without his guidance and mentorship. Indeed, his influence on my work will continue beyond this project. I appreciate my family for their encouragement and support. They individually and collectively helped me finish. Finally, Douglas Pollei’s patience and belief proved the most important to me. He unfailingly listened, encouraged, and reminded, for this, and many other things, I thank him. ii Dedication For Douglas, Collin and Miles iii Table of Contents Acknowledgements i Dedication ii Table of Contents iii List of Figures v Chapter One Introduction 1 Early Rhetoric and Medicine: Challenged Disciplines 5 Ongoing Affiliations between Rhetoric and Medicine 9 Theoretical Considerations 18 Nineteenth-Century Medical Education Reform in Britain 21 Preview of Chapters 27 Chapter Two Historical Context: Medical Education in Britain through the 18th Century 31 University Medical Education in Europe 32 Opposing Loyalties: Vitalism versus Mechanism in Medical Education 38 (Dis)Orders in Medicine: A Catalyst for Reform 45 The Rise of the General Practitioner and Medical Education Reform 55 The Rise of the Hospital and Clinical Instruction at Edinburgh 58 Chapter Three System, Science, and the Practice of Physic: William Cullen and Scottish Medical Education 68 William Cullen: Brief Biography 70 Cullen, Science, and the Scottish Enlightenment 74 Cullen as Pedagogue: Teaching Methods and Influence 76 Cullent the Reformer-Teacher: Amending Medical Doctrine 80 Cullen’s Nosology as “Modes of Inquiry” 84 Cullen’s Focus on System Reorients Medical Pedagogy toward Science 103 Conclusion 112 Chapter Four British Medical Periodicals and the Rhetoric of Reform, 1805-1830 113 History of the Medical Periodical 116 Medical Periodicals as a Source of Medical Knowledge for Practitioners 121 The Medical Periodical and Medical Education Inside and Outside the Universities 130 Medical Education and Medical Practice in the Medical Periodicals 138 Commentary on Institutional Patterns in Medical Education and Practice 143 Conclusion 151 Chapter Five Parliamentary Papers: Britain Reforms Medicine, 1830-1858 153 iv Parliamentary Papers 155 Royal Commission of Inquiry into Scottish Universities, 1830 160 Report from the Select Committee on Medical Education, 1834 171 First, Second, and Third Reports on Medical Registration and Medical Law, 1848 182 Conclusion 192 Chapter Six Conclusion 193 Implications of This Study 197 Bibliography Primary Sources 203 Secondary Sources 211 v List of Figures Figure 3.1 Cullen’s Nosological Classification System 101 Figure 3.2 Sample Student Ticket to Alexander Monro’s Anatomy Class 106 Figure 3.3 Edinburgh Medical School Course Offerings 1763-1826 107 Figure 4.1 EMSJ Advertisement 1805 119 Figure 4.2 Plan for Improving Evidence in Medicine 126 Figure 4.3 Regulations for Medical Education by RCP 135 Figure 4.4 Conditions for Clinical Pupils 137 Figure 4.5a-b Requirements and Regulations of Edinburgh Medical Degree 149 Figure 5.1a-d Courses of Study for Medical Degrees and Licenses 188 1 Chapter One Introduction Medical education evolved significantly in Britain between roughly 1770 and 1858. The doctrines established by medical teachers in the late eighteenth century not only revised or overturned received theories of disease, physiology, and therapeutics, but also entailed new approaches to instruction. In Britain, this evolution was initiated in Scotland, which had established medical schools in the early and middle part of the eighteenth century. These schools and their leading teachers would gain considerable fame for championing a medical curriculum oriented toward a system of instruction that privileged the demands of a new class of “general practitioner” and firmly established scientific and clinical approaches to teaching medicine. In contrast to the traditional philological and humanistic orientation of the medical education at Oxford and Cambridge, this new approach to medical training emphasized observation, empiricism, and an organized system of clinical observation. Institutions throughout Britain began to adopt the model offered by Edinburgh’s medical school. Though this process met some resistance, by the mid-nineteenth century the new scientific perspective had displaced the traditional humanistic paradigm and pedagogy. Many of the innovations initiated in the Scottish medical schools would be inscribed in the major nineteenth-century British Acts of medical reform, documents which demarcated boundaries between professional categories, set standards for medical education and licensing, and defined and regulated 2 various forms of medical practice – in short, the reform Acts (re)defined the field and discipline of medicine. In this dissertation I consider a set of discourses that appeared in Britain between roughly 1770 and 1850 that articulated this new understanding of medicine and promoted a spirit of reform. Focusing on documents addressed to questions of pedagogical method, curricular emphases, and doctrinal disputes, I identify the chief arguments, assumptions, and aspirations that motivated and justified innovations in the teaching of medicine at specific institutions and promoted broader, sweeping reform of the whole system of British medical education. Many of the significant specialist controversies, social upheavals, and institutional developments from the period of reform in nineteenth- century Britain have been well documented by historians of medicine, but these scholars have not considered the discourses that acted as catalysts for medical education reform in terms of the rhetoric of disciplinarity. Meanwhile, rhetoricians of science and medicine, always attuned to questions of disciplinary definition and differentiation, professional status and authority,1 have done only a little work on medical science in this period and none focused on medical education.2 I attempt to position this study as a contribution to both of those fields. This study encounters British medicine and medical education in the wake (or aftermath) of the scientific “revolution” traditionally dated to the seventeenth century. 1 For a sampling of statements and studies addressing the rhetoric of definition, differentiation, and status in the sciences and medicine, see, e.g., Lyne and Miller 2009; Taylor 1996; Locke 1992; Fuller 1991; Holmquest 1990. 2 Of the rapidly growing body of work in the rhetoric of medicine, health/illness, and medical care, only a few studies address medical thought or practices from this period (e.g., Berkenkotter 2008) and very few historically oriented studies focus on formal medical education in any period. 3 Natural philosophy had transformed into natural science, and scientific inquiry into nature and natural processes was increasingly identified with ever-improving techniques of empirical observation and measurement, experimental method, new taxonomic systems, and conformity with newly established theories or laws of physics. Connected as it was to the sciences of botany and chemistry and to the study of anatomy, medicine had by the seventeenth century taken on a more scientific cast.3 A central question for the study is how the advances in the emerging science (or sciences) of medicine, and the scientific method itself, were accommodated in the formal education of medical practitioners, especially the training of physicians in the university-based medical schools of eighteenth and early nineteenth century Britain. I will contend that this accommodation was reflected in both teaching methods and educational curricula at the new/progressive medical schools (first in Scotland), and that it entailed the inculcation, in students, of habits of mind and attitudes towards practice profoundly different from those acquired in the training received at the older institutions of Oxford and Cambridge. A second question follows from the first: To what extent were the major reform acts of the nineteenth
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