Alexis St. Martin and William Beaumont have one of the strangest relationships in the history of medicine — a young French-Canadian fur trapper with a hole in his stomach from an errant shotgun blast and the American army physician who cared for him, and then made his own career by turning Alexis into a human guinea pig. Through the decades of their complicated relationship, they’d revolutionize our understanding of the physiology of the stomach, put American medicine on the map, and start a conversation about the ethics of human experimentation that goes on to this day. Plus there’s a new #AdamAnswers about whether or not your body temperature and fevers can “run low”. All this and more on the latest episode of Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine.
- Beaumont W. Experiments and Observations of the Gastric Juice and the Physiology of Digestion. Plattsburgh, NY: FP Allen; 1833.
- Mackowiak PA et al, “A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich.” JAMA. 1992 Sep 23-30;268(12):1578-80.
- Mackowiak PA, “Feel the heat: a short history of body temperature,” BMJ. 2017;359:j5697
- Markel H, “How William Beaumont and Alexis St. Martin Seized the Moment of Scientific Progress,” JAMA, August 19, 2009—Vol 302, No. 7.
- Myers NA and Durham Smith E, “A Debt to Alexis: The Beaumont-St Martin Story,” Aust NZ J Surg (1991) 67, 534-539.
- Numbers RL, “William Beaumont and the Ethics of Human Experimentation,” Journal of the History of Biology, Vol. 12, No. 1 (Spring, 1979), pp. 113-135.
- Obermeyer Z et al, Individual differences in normal body temperature: longitudinal big data analysis of patient records. BMJ. 2017; 359: j5468.
- Osler W, “William Beaumont: A Pioneer American Physiologist,” JAMA Vol XXXIX No 20, Nov 15, 1902.
This is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. This episode is called Alexis and William, and it’s about the relationship between two men — a young French Canadian voyageur with a opening in his stomach and the brash Army doctor who employed him as his servant — and his human guinea pig.
Our story starts at an outpost at the edge of the known world, in what is now the U.S. State of Michigan. In the early years of the nineteenth century, the Great Lakes region was the northwestern boundary of the fledgling United States. Long settled by the Chippewa and the Ottawa peoples, by the sixteenth century, the French had come, attracted by the enormous natural wealth of animal furs. They incorporated the far away territory into their colony of New France, ringing it with a series of military forts. And one of the most strategic was built on the island of Michilimackinac, located between Lakes Michigan and Huron and strategically guarding the approach to both the upper and lower peninsulas. The name meant “The Great Turtle” in Ojibwe, but today, we’ve shortened the name to “Mackinac,” spelled with a C. The fort’s central location, easily accessible via water, made it a hub of the fur trade, and position that would outlast the French, the English who would seize and fortify it even further, and finally the new nation of Americans, who would incorporate the island into the new Michigan Territory. The tiny island was strategically important in the War of 1812, when the British easily captured the fort from the Americans and subsequently fought them off in a bloody battle. And even with the peace that followed, the island took on a new type of strategic importance. John Jacob Astor chose the island to be the center of his fur empire that would make him the first multimillionaire in the United States. And so every summer thousands of trappers descended on the island to sell their pelts. And guarding this annual event was a small American garrison stationed in a fortress of the island’s imposing cliffs.
It’s here, on this tiny island, surrounded by wilderness, that Alexis St. Martin and William Beaumont would be violently hurtled into each other’s lives.
On June 6th of 1822, Alexis St. Martin was 28 years old (not 18, as is commonly reported). He had spent the past winter trapping in the wilderness, and had joined thousands of his French-Canadian counterparts at the American Fur Company’s annual gala on Mackinac island. Per an eye witness, he was waiting in line at the company store, hoping to barter. Then out of nowhere there was a blast — a shotgun accidentally discharged, with Alexis’ abdomen less than three feet away. An eye witness recalled the scene: “the wadding” — that is, a small piece of cloth, as well as duck shot — “entered, as well as pieces of his clothing; his shirt took fire; he fell, as we supposed, dead”.
The fort doctor was called, and it’s here that William Beaumont met the man that he’d soon come to know as “Alexis”. Beaumont at this point was already an experienced Army doctor; he had served as a surgeon in the War of 1812, and then returned to a private practice in his native New York, but soon grew bored and re-enlisted. And now, as he rushed down from the fort on the hill, he saw St. Martin lying on the ground, his clothes charred and tattered, a massive wound in his belly. Beaumont initially thought he was dead. He later recalled:
The shot had “literally blown off integuments and muscles of the size of a man’s hand, fracturing the fifth rib, lacerating the lower portion of the left lobe of the lungs, the diaphragm, and perforating the stomach. The whole mass of materials together with fragments of clothing and pieces of fractured ribs, were driven into the muscles and cavity of the chest.”
Beaumont brought the injured man to his clinic, sure that he would die. He slowly and deliberately removed as much duckshot and burnt clothing as he was able, slowly cutting away dead tissue, and applied a poultice of vinegar and ammonia. Despite this, Alexis was stricken with fever, a grim sign in those days. Reading through Beaumont’s notes with a modern eye, sepsis from his dirty wounds seems likely. But by the 11th day of Beaumont’s care, the fever broke, and the wound started to heal. At his point, Beaumont mentions a hole in Alexis’ stomach that was “large enough to admit the whole length of my forefinger.” Beaumont’s attempts to feed the young man failed, with food pouring out of this whole, and he resorted to “nutritive enemas.” Beaumont nursed Alexis back to health, and his body healed — but this opening to his stomach remained, and slowly healed into what Beaumont called a “natural anus” — what we’d now call a gastric-cutaneous fistula, a connection between the stomach and the skin.
Beaumont describes his attempts to close this fistula, in what must not have been fun procedures, by “exciting adhesive inflammation” — essentially curetting the scarred tissue and hoping that it would form back together. Finally, Beaumont proposed just cutting the fistula off and trying to suture this new wound shut, but Alexis refused.
Unfortunately, we only have Beaumont’s account of these times. Like many poor young men in the frontier, Alexis was illiterate, and he was hundreds of miles from home his home. But it’s clear that Alexis was enfeebled and weak, and very dependent on Beaumont. Furthermore he had no money — his livelihood depended on his ability to survive in the wilds for months at a time. His situation became even more precarious, when the local government described Alexis a pauper and made motions to deport him back to Canada.
At this point, there was nothing to suggest that William and Alexis had anything but a fairly typical doctor-patient relationship for 1823 at least. But a crazy idea that Beaumont had on May 30th 1823 — almost a year after the accident — would intimately tie their lives together. Beaumont was trying to give Alexis a cathartic to make him vomit, which was the standard of care in the early nineteenth century. But instead of making the man swallow it, as I’m sure he had many times before, he decided to put it directly into Alexis’ stomach via his fistula, using a small funnel. We’ll never quite know why, nor whose idea it was. But Beaumont’s eyes were opened that night, as he melodramatically wrote, “I gave a cathartic, administered, it is presumed, as never medicine was administered to man since the creation of the world.”
We can only imagine what the two talked about that night, but the very next day, Beaumont invited St. Martin to move into his home. We’ll never know, of course, but Beaumont presents it as “mere motives of charity, and a disposition to save his life, or at least to make him more comfortable” in response to government threats to deport Alexis. What happened next might suggest more personal motives though.
St. Martin was now officially employed by Beaumont as a handyman, cleaning, chopping wood, and doing odd jobs, and living in his house with Beaumont and his wife. But his second job rapidly became to be a human guinea pig. We have no idea when Beaumont began to experiment on Alexis, though we know he had collected the “free flowing” gastric juices as soon as a few months after the accident. But by 1825, a year after Alexis had moved in, Beaumont was ready to conduct formal experiments with St. Martin’s fistula.
All of these are described in great in detail in Experiments and Observations on the Gastric Juice and the Physiology of Digestion, Beaumont’s famous publication It’s in the show notes if you’re interested. And you can read in great detail the experiments he puts Alexis through — 253 in total.
I might as well describe the first few experiments, since they set the tone for what was to come. He had Alexis fast for 17 hours, and then placed a bulb thermometer through the fistula into his stomach. It was 100 degrees. He then placed a tube inside the stomach and drew out some gastric juice, which he put in a sealed vial along with a piece of cooked meat. He then placed it in water also 100 degrees and made detailed observations over time on the process of digestion outside the body. The next day, he used the same methodology to place the same beef *inside* Alexis’ body, this time attached to a string. He would then remove the string at the same intervals to make observations. This time, he found that the actual stomach digested much faster. He correctly notes that “agitation accelerated the solution in the vial, by removing the coat that was digested on the surface, enveloping the remainder of the meat in the gastric juice, and giving this fluid access to the undigested portions.”
For the next two years, Alexis would serve as Beaumont’s servant as he was stationed across America’s frontier, while in his off hours submitting to experiments. But after two years of this, St. Martin had had enough. We don’t know what finally made him leave, but it cleared made Beaumont upset, who complained about Alexis absconding “without my consent”. His health must have been excellent at this point; he met and married his wife Marie, fathered two children, and then signed up with the Hudson Bay Fur Company as a voyageur, paddling company canoes deep into the frontier.
By 1829, both men were interested in rekindling their relationship — St. Martin presumably for the financial benefits, and Beaumont for scientific interest and glory. By this point, he had shared some of those early experiments with peers and elicited some great interest. Alexis packed his entire family into a canoe and paddled down from Montreal to Fort Crawford in the Upper Mississippi in what is now the state of Wisconsin. During the few years that would follow, Beaumont and St. Martin performed the vast bulk of their experiments. Alexis had often asked for a job contract, to guarantee his support. And in 1833, the two men signed one. We still have this remarkable document today, which exists as the first contract spelling out the terms of human experimentation. It’s written in terse legalize by Beaumont (or William, as he calls himself), and signed with an X by Alexis, since he was illiterate. In exchange for his body for “such philosophical or medical experiments” on his stomach, Beaumont would pay room and board, as well as $150 for one year, and $400 for two.
Despite this contract, and the fact that Beaumont enlisted him in the U.S. Army to further entice him to stay, in 1834 Alexis would leave Beaumont once again — it turns out, for the final time.
We can certainly imagine why, and Beaumont records some reasons. First of all, the experiments could be very unpleasant.They required extensive fasting; Beaumont had discovered by patient experimenting that at least 18 hours was necessary to clear the stomach such that it was just “gastric juice and chyme”. And the experiments clearly hurt. Beaumont talks about Alexis’ pain from the thermometer itself being placed deep within his stomach: “It gives severe pain and distress at the pyloric extremity, like a cramp, or the sensation frequently described by persons suffering from undigested food in the stomach, and leaves a sense of soreness.” Beaumont would usually stop when this would happen, but he also describes sometimes ignoring St. Martin’s pain. Alexis was also clearly ridiculed for his fistula by his comrades. Again, we have almost nothing that St. Martin himself wrote, but at his funeral (he lived to the ripe old age of 86), his brother Etienne recounted stabbing someone who made fun of his brother as “the man with a lid on his stomach”.
But by the time Alexis had left for good, Beaumont self-published his compendium on their experiments, the aforementioned “Experiments and Observations”. Perhaps due to its self-published nature (there are digs in the press about the poor quality of the paper), or more likely due to the fact that America was seen was a scientific backwater in 1833, it was slow to catch fire. But within a decade, Beaumont’s observations had upended our understanding of digestion.
So let’s talk about the actual science of digestion at the turn on the 19th century, and why Beaumont’s experiments were such a big deal. What happened with digestion was the subject of a lot of speculation, and not a lot of data, stretching all the way back to antiquity. Was it fermentation, putrefaction, grinding, or “concoction” — an ancient concept by which materials are broken down into their constituent fluids? The famous physiologist William Hunter made light of this mostly esoteric debate, famously quipping:
“Some physiologists will have it, that the stomach is a mill, others that it is a fermenting vat, others, again, that it is a stew-pan; but, in my view of the matter, it is neither a mill, a fermenting vat nor a stew-pan; but a stomach, gentleman, a stomach.”
But a new and very controversial idea had just recently been introduced — that digestion was in fact the product of a chemical reaction.Right around the time St. Martin was accidentally shot, William Prout in England showed in his famous experiments that the stomach did in fact contain a powerful chemical — hydrochloric acid. To understand why this was so controversial, we have to grapple with the idea of “vitalism”. By the nineteenth century the explanatory powers of the humors had faded. But scientists, philosophers, and doctors still grappled with the idea of, “what makes life alive?” It was theorized that some some “vital spark” was present in life that made it fundamentally different than non-life. And yes, this was identified with the idea of the soul, but it was also a legitimate scientific idea. No less than Louis Pasteur felt that his experiments had proven the concept of a vital force.
The process of digestion was, naturally, incredibly important to the vitalist cause. It was here that non-living products would be converted to life. Which is why the idea that a chemical reaction powered digestion was so controversial.
William Beaumont, living at the frontier of a new nation, was unaware of these controversies. But what his book provided was meticulous descriptions of a process that backed the “physicalist” position of digestion against the vitalist.
At the end of his book, Beaumont listed 51 conclusions he had made from experimenting on Alexis. His strongest findings — that gastric juice could digest outside the body, that is was, in fact, hydrochloric acid, that it was excreted by folds of stomach lining, that the stomach methodically crushed and churned its food to speed up digestion, and that different types of diets would have very predictable courses of digestion — all provided fuel to the fire that digestion was in fact powered by physics and chemistry, and not the source of a vital spark of life.
And so Beaumont’s reputation grew, first in Europe, and then in his native America. He was considered “the first American physiologist” by doctors on both sides of the Atlantic, by no less authorities by Claude Bernard in France, and William Osler in the United States. And with each passing year, he became more and more obsessed to further experiment on St. Martin.
William Osler in particular was quite the fan, and a published a collection of Beaumont’s letters, with several of St. Martin’s replies, which were likely written by the parish priest. And from them we know that Beaumont was desperate to get Alexis back for experiments — he wrote in 1836, 1837, 1838, 1840, 1842, 1846, 1851, and 1852, all trying to get Alexis to visit him in St. Louis, where he had settled after leaving the army. He described grand plans, traveling to Europe, and especially France, where the francophone Alexis had always wanted to go. And he offered increasing amounts of money, both for Alexis, and for support of his family. But Alexis would write back, apologizing that he could not travel because of illness, because of the weather, because of deaths in the family — or because of fear of his family being unsupported during the harsh Canadian winter. Eventually, Beaumont would send his son in person to entreaty Alexis, but without any luck. This correspondence would continue until Beaumont’s death at the age of 67, from slipping down ice-covered steps leading out from his home.
St. Martin, it turns out, would return to being a human guinea pig just a few years later, this time with a charlatan named Dr. Bunting, who took Alexis on a tour throughout the United States and Canada, charging money to display and demonstrate his fistula. Alexis was apparently quite ill-treated, though the media attention got PT Barnum interested in procuring Alexis’ services.
Alexis would die near his birthplace in Quebec at the ripe old age of 86 — from a newspaper article, we know that he was still chopping wood into his late 70s. His family, fearing that his body would be stolen by unscrupulous doctors, left it to decompose at home a few days before his mass. It apparently smelled so foul it had to be kept outside the service. This wasn’t a vague threat — Beaumont superfan William Osler had traveled down from McGill in Montreal to offer to buy the stomach for the medical school. And just in case, his family dug the grave extra deep to prevent “resurrectionists” from getting their hands on Alexis.
It’s hard to know what sort of relationship the two men really had. We really only have one side of the story, and they had enormous class and social differences, the prominent American physician, and the illiterate, impoverished French-Canadian fur trapper. In his correspondence, Alexis only expressed gratitude to the man he calls William, and later in life he spoke glowingly of the time he spent with Beaumont, and fair enough, after the rough treatment he had at the hands of Bunting. And Beaumont addresses Alexis as “mon ami,” enquires about his children, and offers sympathy when when his son died. But it’s also clear that Beaumont viewed Alexis as a tool with which to advance science, as well as his own career. In his book, for example, Beaumont’s preface talks about a good many physicians to whom he is indebted. Nowhere does he mention St. Martin.
And he refers to Alexis in dismissive tones when writing to others. For example, when he sent his son to entreaty Alexis, he writes:
“Keep him in his place, and strictly control his time and services. Allow no undue familiarity, or suffer him to take the slightest advantage of your age and inexperience… If he should… give you much trouble… discharge him at once.” And he complains about “the old fistulous Alexis” trying to get more money out of him, and support his entire family.
It’s even harder to figure out quite where the St. Martin and Beaumont story stands in the history of medical ethics. The relationship between the two men is ethically, shall we say, icky by my standards at least, and I would suspect to a number of you as well. But as recently as 50 years ago, Beaumont was actually seen as a pioneer of medical ethics. Henry Beecher described their relationship as producing “the oldest America code” around human experimentation:
- There must be recognition of an area where experimentation in man is needed….
- Some experimental studies in man are justifiable when the information cannot otherwise be obtained.
- The investigator must be conscientious and responsible….
- A well-considered, methodical approach is required so that as much information as possible will be obtained whenever a human subject is used. No random studies are to be made.
- The voluntary consent of the subject is necessary….
- The experiment is to be discontinued when it causes distress to the subject. ..
- The project must be abandoned when the subject becomes dissatisfied.
I think this is trying too hard to make Beaumont a hero, however. Medical ethics as field did not exist, and wouldn’t really take off until the atrocities of Nazi doctors were revealed in the Nuremburg trials. Beaumont clearly didn’t sit down and draw up a 7-point plan on how to ethically experiment on St. Martin.
But at the same time, Beaumont is clearly deeply motivated by ethical principals — just not ones that we hold anymore in the 21st century. In particular, it’s clear that he felt he had a moral duty to experimenting on Alexis to advance the cause of science, even if it brought Alexis harm. And in the response from the medical world, we can see that these were commonly accepted through Europe and North America. The historian Ronald Numbers has performed a catalogue of commentary on Beaumont’s book, and they’re full of similar sentiments — towards pain and suffering being permissible in the advance of science, and condemning Alexis for wanting to return home.
Numbers also places their relationship in context by looking at other experiments on people with fistulas throughout the 19th century. Some of them are downright cruel, like a Finnish physiologist at the turn of the 20th century who taunted a five year-old boy with a fistula with treats so he could repeat Pavlov’s experiments on humans. I’ll quote his conclusion:
“Still, when compared with his contemporaries, Beaumont appears to have been no more insensitive or less concerned about the welfare of his subject than other nineteenth-century physiologists. Indeed, his paternal interest in St. Martin may place him a cut above his contemporaries.”
So what are we to make of the relationship between Alexis and William? Not friends, nor partners, but not just guinea pig and experimenter either. I don’t know what to call their complicated relationship. But society now recognizes not only Beaumont, but St. Martin as well. Eighty years after his death, the Canadian Physiological Society discovered Alexis’ previously unmarked grave and erected a monument there. The final words are printed in both French and English and are appropriately fitting: “Through his affliction he served all humanity”
Well, that’s it for the show! But wait, it’s time for #AdamAnswers!
So now I have an absolutely wonderful question from Dr. Katie Thilo, who I went to residency with back in Oregon. She asks, “I have been meaning to send this one in for a while given that it’s been a long cold/flu season… I often hear patients say that their temperature of 99 degrees is a fever for them because they usually run a few degrees colder. Is there any truth to that?”
So the short answer is, yes. And to get to the long answer, we’re going to have to unravel the sweater.
So bear with my analogy here. It’s tempting to view medicine as a sweater — a collection of knowledge artisanally woven over the centuries by our predecessors. Maybe every now and then there’s a loose thread there, like, say using antiarrhythmics after heart attacks. But we realize our mistakes and do some mending.
But every now and then, I like to play a game. And I have really weird hobbies, so your mileage may very. I take one of these facts that I was taught in medical school, and then I open the nearest textbook. Just kidding, I don’t use textbooks, because it’s 2018. So UptoDate then, and I find their source, and then I pull, and I keep pulling until I get back to the beginning of the thread. And when you pull enough threads, you’ll start to notice that many of the things we’re taught as immovable facts of medicine rest on a pretty shaky foundation.
And that’s why I love your question, Dr. Thilo, because human body temperature is one of these facts. So let’s pull the string all the way back to Carl Wunderlich, in the middle of the nineteenth century. The idea of a “fever” is ancient, and would simply be measured by placing a hand on the patient’s body and, well, feeling. In a world that lacked modern nosology, fever was considered a disease state in and of itself. All this would change in the 19th century, and especially with Dr. Wunderlich, who pioneered the idea of temperature charts. In 1850, Dr. Wunderlich was placed in charge of the university hospital at Leipzig. During his tenure, he made detailed measurements of the body temperatures of his patients at different times of the day, with different diseases, and with different patient characteristics with respect to gender and age. His thermometer was esoteric, to say the least. It was over a foot long, and required 20 minutes to take an accurate reading. Still, he managed to collect information from over 25,000 patients — millions of data points in total — and he released his results in his 1868 “The Course of Temperature in Diseases”.
And among many other concepts we take for granted that come from this work is Wunderlich’s observation, and I’ll quote here, that “the general temperature of the body maintains itself at the physiological point: 37 C = 98.6”. You want me to blow your mind a little more? This was supposedly axillary temperatures and NOT oral, and I, at least, was taught in medical school that 37 C is the average oral body temperature.
It took over a hundred years for this to be disproven, with many small trials with modern thermometers suggesting that the average body temperature is actually a fair bit cooler than Wunderlich suggested — an influential study of health young adults showed an average oral body temperature of 36.8 C, or 98.2 F, and with an upper limit of normal as 37.7 (99.9) rather than 100.4. And in fact, in the AM, the upper limit of normal appeared to be only 37.2, or 98.9! Which would mean 37.3 was a “fever” at 8 in the morning.
So, Dr. Thilo, getting a little deeper in your question, your “running low” patients probably just have a normal body temperature, and their “low-grade fevers” may be actual fevers. But we’re going to pull at the string just a little harder.
One of the reason Wunderlich was so influential his massive data set. So a group of doctors attempted to use the modern mess of EMR to achieve a similarly diverse dataset. It’s in the shownotes if you want to see it, which despite all the methodological problems is still fascinating. So it analyzed temperature measurements from 35,488 patients, and like pretty much every other study found a lower average body temperature of 36.6C, or 97.9F. But one of the most interesting findings was that variations of a patient’s own temperature distribution predicted mortality — so predictive, in fact, that a one standard deviation increase from that patient’s baseline was equal to an 8.4% increase in one-year mortality! This strongly suggests that your patients’ intuition is right — if you have a lower average body temperature, you have a lower cutoff for what constitutes a fever.
So to take this all back to your question, Dr. Thilo — your patients are correct. The human body runs cooler than we’ve been taught, and a fever likewise is lower. And even then, what constitutes a fever does appear to be a increase above a patient’s own baseline temperature.
I know I have a lot of medical students and residents who listen to this podcast, so I want to step up on my soap box and give a teaching point. When I was an intern, I was derided by an attending for calling something a “low-grade fever”. My attending was so certain — there was either a fever, or there was not.
Well, that certainty was in fact pseudocertainty, which I realize now. That assertion was based on something that was taught decades ago in medical school, based off a book published in 1868, off axillary measurements from a foot long thermometer. It was further reinforced by an electronic medical record system that arbitrarily decided to make some vital signs show up in the color “red” based on these measurements from 150 years ago. When it’s put that way, it all seems a little ridiculous, doesn’t it?
I want you guys to challenge similar assertions in your own career. Science is not a collection of facts; it’s a process. And by challenging such assumptions and unraveling the sweater, we all become doctors.
Okay, thank you so much Dr. Thilo, for helping me to destroy that sweater! And to you, dear listeners, if you have any burning questions that you have, or you want to try and get me on a soapbox again, please tweet at me @AdamRodmanMD.
Okay, so that’s really it for the show! I managed to write and record this during a particular horrific three week stretch. Fortunately, I’ll be taking a little break at the Society for Hospital Medicine conference in Orlando. If you’re going to be there, let me know on Twitter and I’d love to meet up! Also, if you’re a new listener to the show and you’re liking what you hear so far, please tell your friends, or write a review on iTunes. Just last week I was described unironically as “hosting a modestly successful medical podcast,” which I took as a huge compliment, and it’s actually becoming something of a reality. So thank you to all you guys who somehow keep listening to me month after month.
You can listen to the whole back catalogue on the website at www.bedside-rounds.org, or on Apple Podcasts, Stitcher, and now Spotify too. I’m on facebook at /BedsideRounds, and I’m on Twitter @AdamRodmanMD, where I tweet mostly about medical history and share some of the cool stuff I find in old articles. So drop by and say hi!
All my sources are in the shownotes.