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Not surprisingly, business relationships between doctor and patient were casual. A well-organized physician presented bills every few months, but this was regarded as optimistic; surviving financial records indicate that accounts could run on for years with small payments being made from time to time. In some cases only death would bring a final settlement (usually at a substantial discount). Practitioners in rural areas often were paid in kind when paid at all. A young Minneapolis physician in the early 188Os, for example, received oats, hay, cords of wood, a watch, and a dissecting case in lieu of cash, as well as services ranging from haircutting and mowing to buggy repair and housecleaning. The same physician also supplied his neighbors with a variety of drugs and patent medicines and served as house practitioner to a local bordello (at least this account paid cash!).

DOCTORS SOUGHT TO IMPROVE their shaky circumstances in various ways. Some offered discounts for prompt payment—and threatened to add interest charges to bills remaining unpaid after ninety days. But most physicians were too insecure economically to take the chance of badgering patients and simply assumed that a substantial proportion of their accounts would never be paid. A rule of thumb was that bad debts should be limited to a third of the total billings.

Physicians also sought to bring some regularity to their economic relationships by adopting fee tables in their local medical societies—schedules specifying minimum charges for everything from ordinary home and office visits to obstetrics and assorted surgical procedures. In Scott County, Iowa, physicians agreed, for example, to charge one to five dollars for “office advice, ” a dollar for vaccination, ten to twenty-five dollars for obstetrics—and ten to one hundred dollars (strictly in advance) for treating syphilis. Fee schedules always included rates for night attendance and mileage, which was particularly important in rural areas where the bulk of a doctor’s time could be spent in travel. (Bicycles were already being suggested as a way of speeding the progress of an up-to-date physician’s rounds.) In some counties physicians adopted an even more tough-minded stratagem: they blacklisted deadbeats—patients able but unwilling to pay. But none of these measures could alter the fundamentally bleak economic realities most practitioners faced.

One consequence, however, was a doctor-patient relationship very different from the often impersonal transactions to which we have become accustomed. Economic dependence was only one factor. Most physicians practiced in small communities where they knew their patients not simply as cases but as neighbors, as fellow church members, as people in families.

Physicians arrived at the patient’s home with an assortment of ideas and practices very different from those available to their successors in 1984. Particularly striking was the dependence upon the evidence of the doctor’s own senses in making a diagnosis. The physician could call upon no X rays to probe beneath the body’s surface, no radioisotopes to trace metabolic pathways, no electrocardiograph to reveal the heart’s physiological status. Most diagnoses depended on sight and touch. Did the patient appear flushed? Was the tongue coated? Eyes cloudy? Pulse fast or slow, full or shallow? What was the regularity and appearance of urine and feces? Was there a family history that might indicate the tendency toward a particular illness or an idiosyncratic pattern of response to drugs? Even more important than the doctor’s observations, of course, was the patient’s own account of his or her symptoms. (An infant’s inability to provide such information was always cited as a problem in pdiatrie practice.) The physician’s therapeutic limitations only emphasized the importance of diagnostic and prognostic skills. As had been the case since ancient times, a physician’s credibility and reputation were judged inevitably in terms of the ability to predict the course of an illness.

THIS IS NOT TO SUGGEST that medicine’s diagnostic tools had remained unchanged since the days of Galen. The stethoscope had been in use since the first quarter of the nineteenth century and had been improved steadily; available evidence indicates, however, that many practitioners were not proficient in its use, while some failed to employ it at all. Doctors who had never been taught to use the stethoscope found it easy to dismiss as an impractical frill.

The thermometer also was available to practitioners in 1884, and it was becoming more than an academic curiosity to the average doctor. Its hospital use was growing routine, although the first temperature charts in American hospitals actually date back to the 1860s. The thermometer was adopted slowly because mid-nineteenth-century versions were hard to use, expensive, and seemed to add little to what most physicians could easily ascertain by looking at a patient, feeling the pulse, and touching the forehead; any grandmother could tell when someone had a fever.