Institutionalization of Medical Education

The establishment of the University of Maryland School of Medicine in 1807 and its clinical arm, the Baltimore Infirmary in 1823, helped to turn the tide in public health in Baltimore City. Here, medical students were trained in a consistent and professional manner. Unlike the training offered in many other medical schools of the period, students at the University of Maryland were exposed to the clinical reality of medical care through bedside training in the Baltimore Infirmary. The advantages of such instruction were promoted in the University's Annual Circular:

The Hospital department of the University, in the immediate vicinity, and nearly opposite the Medical College, from its proximity, offers advantages for Clinical studies not to be found elsewhere. Here the student can, day by day, watch the progress of disease and the operation of remedies, and become familiar with the aspect of both acute and chronic complaints -- can not only witness surgical operations, but also what is equally important, the nature and result after treatment -- advantages not to be obtained, where the Hospital is at a distance and visited only at long intervals.¹⁹

By 1848, clinical instruction was a mandatory part of the University's medical curriculum, enabling the training of doctors who were experienced with a variety of diseases before they set up their own practices.

In addition to classes in chemistry, surgery, and midwifery, students were offered courses in practical anatomy and dissection. The university catalogs did not hedge on the availability of cadavers for study, noting that "It is well known that in the city of Baltimore the materials for the pursuit of Practical Anatomy are most ample, and easy of acquisition. In no city in America is public sentiment so indulgent in this respect."²⁰ The public was not always so tolerant. In 1788, an angry mob raided the University dissection room where Dr. Wiesenthal and his students were working on the body of Patrick Cassidy, an executed murderer whose body had been given to the school for dissection. Cassidy's body was forcibly taken by the mob and dragged through the streets.²¹ In 1807, another dissection riot occurred after Dr. Cocke²² purchased a corpse through a questionable procurer. A few days later, an angry mob gathered on the steps of the school and stormed the building, destroying its interior and furnishings. After parading the corpse through the streets of Baltimore, the crowd deposited the cadaver on the steps of the home of Dr. John Beale Davidge, the University's founder.²³

It was the Baltimore Infirmary that would be the professors' crowning achievement. Here, the professors of surgery and theory and practice of medicine gave daily lectures, giving students the opportunity to observe disease at the patient's bedside and accompany the doctors on their daily rounds. University graduates recalled making their rounds with Dr. Nathan Ryno Smith,²⁴ the Infirmary's clinical surgeon:

[His students] remember well how, with a zeal which occasionally provoked the youthful impatience of some of the neophytes -- an impatience which soon gave place to admiration and gratitude -- he would walk the wards before daylight, attended by his class, passing from bed to bed, and instructing them at each. The drowsiest eyes would open, as in brief, clear, pregnant words, he explained the case and the treatment, pointed out the facts that was most important they should know, and imparted that knowledge which only a thorough teacher at the bed side can give. In these clinics he was never deterred from attendance by any inclemency of the weather; and the students knew well, that whoever else might be absent, their teacher would always be found at his post of duty.²⁵

Although clinical instruction in the Infirmary was initially optional, by 1848, two sessions were required for graduation. The introduction of clinical instruction brought a new dimension to medical education as evidenced by David Sterret Gitting (1797-1887), a graduate of Dickinson College, who, at his admission to the University of Maryland, wrote:

The lectures do not commence until the 22nd of this month, neither are the clinical wards open, therefore I am deprived of an opportunity of forming an opinion of them as yet, but I am a daily visitor to the hospital and of that my opinion is perfectly established. Though a doctor by title, I feel myself but ill qualified to enter on the responsibilities attached to the practice of medicine. Though Dr. Davidge is a man of the first talents, and deservedly holds the highest rank among his professional brethren in Baltimore, and though I am confident I would not exchange the medical opinions he has taught me for any the world can offer, yet do students of his, labor under one of the greatest disadvantages: They see nothing of the practice of medicine and without disease is studied at the bedside of the patient, as well as in an office, it can never contribute with safety to the sick or ease of conscience as regards the physician.²⁶

The establishment of a teaching hospital and the introduction of clinical instruction were major innovations in medical education. Prior to the institutionalization of medical education, students received their training by apprenticing themselves to a local physician who served as a preceptor. By the early nineteenth century, the standard fee of $100 bought a student access to a preceptor who furnished all of the books and equipment required for the course of study. Under the doctor's supervision, an apprentice prepared medicating powders and pills, accompanied the doctor on rounds, and observed and assisted in treatment. Direct access to the physician provided ample opportunity to ask questions and discuss cases and to be quizzed by his mentor.²⁷ The apprentice's education was supplemented by a course of reading from the preceptor's personal library that generally included materia medica, physiology, chemistry, anatomy, botany, and clinical medicine.

Apprenticeships were popular with physicians as well as students since the system provided an additional source of income as well as assistance on medical cases. Yet for all its practicality, the apprenticeship system had its limitations. The education was haphazard at best and its quality depended upon the level of attention paid by the mentoring physician. The preceptor's library was often limited and outdated and apprentices had little practical knowledge or experience with chemistry or anatomy.²⁸ By the second quarter of the nineteenth century, medical knowledge had advanced beyond the ability of a single preceptor to provide his apprentices with a proficient medical education. Improving the quality of practicing physicians required the development and dissemination of a standard body of medical knowledge, a goal that would prove elusive until the institutionalization of a systematic medical education.

The University of Maryland was not the only school offering medical training in Baltimore during the nineteenth century. Between 1807 and 1912, eleven medical schools were established in the city. One school, The Medico-Chirurgical and Theological College of Christ's Institution, never functioned. Another, the Maryland College of Eclectic Medicine and Surgery, was by 1914 unrecognized by the Maryland State Board of Medical Examiners and dissolved in 1915. The University of Maryland absorbed three more medical schools either directly or indirectly and the remaining four became extinct. Prior to the Civil War, the Washington University School of Medicine²⁹ of Baltimore, founded circa 1827 by Dr. Horatio Gates Jameson, was the only formidable rival to the medical curriculum of the University of Maryland. By 1848, Washington University provided a curriculum similar to the University of Maryland, which was offered during a four and a half-month session over a three-year term. In addition, Washington University offered clinical instruction at its own hospital and provided further clinical instruction at the Baltimore Almshouse where medical students were able to obtain additional first-hand experience. In spite of the school's promising beginnings, unwise building expenditures and other financial transactions bankrupted the school, forcing its closure in 1851.³⁰

19	University of Maryland, Annual Circular of the Faculty of Physic of the University of Maryland. Session 1844-5 (Baltimore: John Murphy, 1844), p. 5.
20	University of Maryland, Annual Circular of the Faculty of Physic of the University of Maryland, for the Session 1841-'42 (Baltimore: John Murphy, [1841]), p. 5.
21	John R. Quinan, Medical Annals of Baltimore, From 1608 to 1880… (Baltimore: Isaac Friedenwald, 1884), p. 18; Callcott, History of the University of Maryland, p. 18.
22	Dr. James Cocke (ca. 1780-1813) studied medicine under Sir Astley Cooper at Guy's Hospital, London, 1801-1802. In 1804 he received his medical degree from the University of Pennsylvania, moving to Baltimore shortly thereafter. He was one of the founders of the University of Maryland and served as professor of anatomy from 1807 to 1813.
23	Callcott, History of the University of Maryland, pp. 21-22.
24	Dr. Nathan Ryno Smith was born in Cornish, New Hampshire, May 21, 1797, the son of Dr. Nathan Smith (1762-1829) and Sarah Hall Chase Smith. He was educated at Yale, receiving his M.D. degree in 1823. In 1828, he was admitted to the Medical and Chirurgical Faculty of Maryland and served as its president from 1870 to 1872. Smith held a professorship at the University of Maryland and was the founder of Jefferson Medical College in Philadelphia. With his wife Juliette, Smith had at least three sons, including Alan Penniman Smith (b. 1840), who was one of the incorporators of Johns Hopkins University, and Berwick B. Smith, who was a demonstrator of anatomy at the University of Maryland from 1852 until his death in 1859. Dr. Smith died in Baltimore on July 2, 1877 of chronic bladder disease and was buried in Loudon Park Cemetery.
25	Brantz Mayer, Baltimore As It Was and As It Is: A Historical Sketch of the Ancient Town and Modern City, From the Foundation, in 1729, to 1870 (Baltimore: Richardson and Bennett, 1871), p. 470.
26	Carroll, "Medical Students 1818 and 1834," pp. 37-38.
27	William Rothstein, American Physicians in the 19th Century: From Sects to Science (Baltimore: The Johns Hopkins University Press, 1985), pp. 85-87.
28	George Callcott, History of the University of Maryland (Baltimore: Maryland Historical Society, 1966), pp. 102-103.
29	Although the hospital is now gone, it played an important role in Baltimore's literary history, having provided the medical care of Edgar Allen Poe in his final illness. For details on Poe's care while in the Washington University Hospital, see Charles Scarlett, Jr. "A Tale of Ratiocination: The Death and Burial of Edgar Allen Poe" Maryland Historical Magazine 73 (December 1978): 360-374.
30	Harold J. Abrahams, The Extinct Medical Schools of Baltimore, Maryland (Baltimore: The Maryland Historical Society, 1967), pp. 1-2.