Book Review

Improve, Perfect, and Perpetuate: Dr. Nathan Smith and early American medical education

N Engl J Med 1999; 340:1601May 20, 1999

Article

Improve, Perfect, and Perpetuate: Dr. Nathan Smith and early American medical education
By Oliver S. Hayward and Constance E. Putnam. 362 pp. Hanover, N.H., University Press of New England, 1998. $35. ISBN: 0-87451-860-1

Educators at recently established rural medical schools throughout the world share various challenges and satisfactions. Serving on faculties that tend to be small, they must often be versatile teachers. Medical-library holdings are limited, students arrive with academic preparation of varied quality, and attending to the needs of widely dispersed populations poses difficult challenges. Yet the opportunity to build and innovate, the beauty of the countryside, and the chance to see one's graduates bring medical care to the region and make their own contributions to medical education frequently serve as rewards.

Some two centuries ago, physician and surgeon Nathan Smith (1762–1829) — who founded the medical school at Dartmouth College and helped establish those at Yale, Bowdoin, and the University of Vermont — faced challenges and satisfactions that were similar yet even more intense. Initially the only member of the Dartmouth medical faculty, Smith taught anatomy, chemistry, materia medica, surgery, and clinical medicine, and he essentially served as dean and treasurer of the medical school. He traveled many miles by horse to care for patients throughout New England. And over the years, he watched his students form much of the medical community of the region and assume professorships of their own.

Improve, Perfect, and Perpetuate (a phrase from a graduation address given by Smith) traces the life of this pioneer of American medical education and medicine. Much of the book focuses on his career as a medical educator. The politics and finances of founding and running the medical schools are addressed, including town–gown tensions, struggles between factions of faculty members, and efforts to obtain funds from state legislatures. The book also addresses Smith's travails in procuring sufficient numbers of cadavers for instruction, as well as the content and style of his teaching, which was practical, unpretentious, and often case-oriented.

The book also describes Smith's own medical education, which consisted of an apprenticeship followed eventually by study at Harvard Medical School and abroad. His basic medical approach, unlike that of many of his contemporaries, emphasized experience rather than theory, and he largely eschewed bleeding and purging, favoring support of the body's own healing powers and attentiveness to the patient's comfort. The book presents Smith's achievements and innovations in surgery, including one of the first successful operations in the United States to remove an ovarian tumor; his experience in treating cataracts, removing bladder stones, and amputating limbs; and the apparatus he developed to extract coins from the esophagus. Among additional topics that the book touches on are Smith's financial difficulties and his family; all four of his sons and many other descendants became physicians.

As the authors indicate, there is insufficient source material to portray Smith fully. Thus, although the book includes examples of Smith's wit, it conveys only a limited sense of his personality. Likewise, it provides little insight into his motivations. The authors do, however, piece together much about Smith and his activities from various sources, including letters, students' notebooks, and financial records. They also provide a context for the story of Smith's life, especially the practice of medicine at the time. The text of the biography runs to 267 pages; supplementary materials, including an introductory essay on American medicine in the period and endnotes and a bibliography, occupy about 100 more pages.

More than 30 illustrations enhance the book and offer relief from a text that, visually and otherwise, tends to be dense. Many of the illustrations are institutionally owned portraits of Smith, his colleagues, his students, and his kin. Also shown, however, are documents, buildings, and other items relating to Smith. There is even a recent photograph of the countryside where Smith practiced in his early years.

Those without a special interest in the subject of this book may not have the patience to read it in detail. Yet many readers — including graduates of the institutions Smith helped found, readers interested in the history of medicine, and educators at rural and other medical schools — may enjoy spending some time with this book. Fortunately, the structure of Improve, Perfect, and Perpetuate allows for easy browsing and sampling. Smith, with his practical bent and concern for others, might very well have approved.

Barbara Gastel, M.D., M.P.H.
Texas A&M University, College Station, TX 77843-4111