What It Was Like To Be Sick In 1884

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Perhaps most annoying to physicians was the competition provided by druggists. Pharmacists in cities and small towns often served as primary-care physicians. (In rural areas, on the other hand, doctors often served as pharmacists, buying drugs in wholesale lots and selling them at retail.) Aside from simply recommending patent medicine, druggists might well use prescriptions written by local physicians for the same patient in a previous illness or those issued to another patient suffering from what seemed to be the same ailment. As an indignant doctor put it, this amounted to “surreptitiously appropriating the doctor’s brain and recipe to guillotine the doctor’s income.” No statutes regulated the use of prescriptions, and most laymen felt that, once paid for, a prescription was their property. Logically enough they had the prescription filled whenever “it” struck again. Similarly, no laws controlled access to drugs; no distinction was made between prescription and over-the-counter remedies. Only their pocketbooks limited laymen’s drug purchases. Patients could and did dose themselves with anything from opium to extremely toxic mercury, arsenic, and antimony compounds. It is no accident that some physicians were beginning to discern a growing narcotic-addiction problem and urged control over the sale of drugs. Their critics dismissed such demands as self-serving attempts to monopolize the practice of medicine.

Just as there were no rigid controls over the sale of drugs, so there were almost no legal constraints over medical education and access to medical practice—and it was also a period without health insurance and with an enormous number of working people and small farmers too poor to employ a private physician. America in 18S4. then, was a highly competitive medical marketplace—one in which the number of paying patients was small in comparison with the total number of men (and a few women) calling themselves physicians and seeking to earn a living through practice. A handful of prominent urban consultants might earn as much as ten thousand dollars a year: but this relatively small group monopolized practice among the wealthy. Their far more numerous professional brethren had to scuffle day and night to make a modest living from the fees paid by artisans, small shopkeepers, and farmers. Codes of ethics adopted by medical societies at the time (though enforced only sporadically) were in good measure aimed at avoiding the most brutal aspects of competition: speaking behind another practitioners back, for example, or selling and endorsing secret remedies, or guaranteeing cures. A more subtle tactic involved planting newspaper stories detailing a spectacularly successful operation or unexpected cure.

It was not until the end of the 1880s that the first effective state licensing laws were enforced. Before that almost anyone could hang out a shingle and offer to treat others. From the perspective of the 1980s, even the besteducated physicians had invested comparatively little time or money in their education, while many successful practitioners had trained as apprentices with local doctors and had never graduated from a medical school or seen the inside of a hospital ward. Even graduates of the most demanding medical schools had followed curriculums based on formal lectures with little or no bedside or laboratory training to supplement textbooks and lectures. In 1884 reformers had just succeeded in extending the length of medical school training at the best institutions to three years of classes. But each years session lasted only six months and still failed to include much in the way of clinical training. Furthermore, not even the leading medical schools demanded more than a grammar school education and prompt payment of fees as an admission requirement. A minority in the profession had always found ways to supplement their limited formal education by hiring tutors, traveling to Europe for clinical training, and competing for scarce hospital staff positions. But even such efforts and the financial resources they implied did not guarantee economic success once in practice: patients often chose doctors on the basis of their personalities, not their skills.

Just as there were no rigid controls over the sale of drugs, so there were almost no legal constraints over medical education and access to medical practice—and it was a period without health insurance.

Medicine was a family affair. A successful practice was, by definition, what contemporaries termed a family practice. The physician treated not individuals but households: husband and wife, children and servants, and—in rural areas—farm animals as well. Minor surgery, childbirth, the scrapes, scars, and infectious diseases of childhood, as well as the chronic ills of invalid aunts or uncles and failing grandparents—all were the family doctor’s responsibility. To call in a consultant was, in some measure at least, to confess inadequacy. Of course, in rural areas, and in most small towns, the option of consulting a specialist did not exist, while calling in another local practitioner was to risk the chance that the new doctor might “steal” the first practitioner’s family. A few oblique words could undermine the confidence that a physician had spent years cultivating.