Medicine OverviewColonial EraFrom 1776 to the 1870sFrom the 1870s to 1945Since 1945Alternative MedicineOverview For centuries, sick and injured Americans typically received their medical care at home, either from family members or informally trained healers. The first permanent hospital did not open until 1751; the first medical school in 1765. The medical profession remained weak and divided; even the creation of the
American Medical Association in 1847 did little to help. The half‐century spanning the years 1875 to 1925 brought revolutionary changes to American medicine. The germ theory of
disease led to the availability of new diagnostic and therapeutic procedures, such as
diphtheria antitoxin (1894). The locus of practice shifted from home to hospital as the number of general
hospitals mushroomed from no more than 150 in 1875 to nearly 7,000 50 years later. Medical practice, heretofore virtually unregulated, became subject to licensing laws. With the new Johns Hopkins Medical School (1893) leading the way,
medical education improved dramatically.
In one of the most significant developments in all of American history,
life expectancy at birth increased from under thirty years at the time of the
Revolutionary War to about seventy‐seven years in 2000. Surprisingly, before the mid‐twentieth century, when antibiotics became available, therapeutic medicine contributed little to this improvement. The great killers of nineteenth‐century Americans—infectious diseases such as
tuberculosis,
influenza, and pneumonia—were declining for decades before physicians discovered effective ways to treat or prevent them. Of greater importance were
public‐health measures such as improved sanitation, purified water, and compulsory
smallpox vaccinations for children. Better
food,
housing, and personal hygiene also helped reduce mortality rates.
Ronald L. Numbers
Colonial Era For all the grievances against Great Britain enumerated in the
Declaration of Independence, the American revolutionaries offered no evidence that imperial regulations had inhibited colonial medical practice. This simple fact of noninterference is important for a general understanding of health care in colonial America. Indeed, during the
Colonial Era, perhaps fewer than 20 percent of all identified medical practitioners were immigrants. Of these, most came from provincial England, where the regulatory powers of London's medical guilds, such as the Royal College of Physicians, were relatively weak. Few were college or medical‐school graduates, although many had gained experience by serving apprenticeships or working as surgeons in the military or on passenger and cargo vessels. Of the vast majority of colonial medical practitioners who were native‐born, most had no formal training; those who did typically served an apprenticeship, averaging little more than a year, with an established doctor. The first American medical school did not open its doors until 1765 in
Philadelphia.
A diversity of Old World medical practices and healing traditions, including self‐medication, formed an important part of the cultural baggage colonists brought to America. The absence of effective regulation assured the continuation of such diversity. As in provincial England, the American landscape abounded in general practitioners, herbalists, minister‐physicians, and innumerable self‐taught itinerants who offered their services as dentists, bone‐setters, and fever doctors. Given the high colonial birthrate, female midwives modestly prospered until the eighteenth century, when male physicians became competitors in larger communities. Medical services were usually delivered at the patient's residence rather than in an office or
hospital. Although poorhouses and workhouses occasionally cared for the sick, the first permanent hospital did not open until 1751, again in Philadelphia. The evidence suggests that these colonial healers exercised considerable independent judgment and avoided dogmatic adherence to such practices as vigorous bloodletting, purging, or the administration of highly active drugs. Healers included some Native American herbal remedies among their generally imported armamentarium.
With the notable exceptions of African‐American slaves and the very poor, colonial Americans generally enjoyed better health and greater longevity than their English counterparts. Their most common complaints included injuries, dysentery, common colds, and ague or
malaria. Periodic epidemics of measles,
diphtheria, and
smallpox afflicted European and Native Americans alike.
The most important
public‐health development of the Colonial Era occurred in connection with a smallpox epidemic that struck
New England in 1721. To combat the epidemic in
Boston, the Reverend Cotton
Mather enlisted Dr. Zabdiel Boylston in a pioneering effort to inoculate volunteers with the live smallpox virum. Despite considerable medical opposition, led by the town's only school‐trained physician, William Douglass, the risky experiment saved many lives. Douglass himself became a convert and in 1730 helped to organize the first colonial medical guild, the Boston Medical Society, which collectively endorsed smallpox inoculation. During the
Revolutionary War this practice was employed successfully by the medical corps of the Continental Army.
Efforts by colonial legislatures to regulate medical practice began as early as the 1640s in Massachusetts. In the later Colonial Era, one finds in the larger colonial cities a growing professionalism, manifested especially in the formation of medical societies. Perhaps the epitome of the colonial surgeon was Dr. Silvester Gardiner (1708–1786) of Boston. A colonial‐trained apprentice, Gardiner studied with surgical luminaries in Paris and London, and in Boston compiled an impressive record in lithotomy (removal of stones, or urinary calculi, in the bladder), and in general
surgery. In 1741, before the Boston Medical Society, Gardiner successfully removed a large stone from a six‐year‐old boy. To combat the improper dispensing of drugs, Gardiner also established apothecary shops in Boston as well as in Meriden and Hartford, Connecticut.
In general, however, licensing laws and the move toward professionalization had little effect on the practice of medicine throughout the colonial period. Local medical societies, though more numerous than in provincial England, proved ineffective as regulatory agencies. The experience of medical practitioners in the Revolutionary War would inspire the creation of various state medical societies, but on the eve of independence, the estimated 3,500 medical practitioners in the American colonies were little regulated and enjoyed few legal protections against the encroachment of ill‐trained interlopers or quacks. More than a century would pass before these problems were solved. Nevertheless, Dr. Benjamin
Rush of Philadelphia, a signer of the Declaration of Independence, saw the Revolution as a foundational event in the exuberant, patriotic process of creating an American medical profession.
See also
Demography;
Dentistry;
Disease;
Health and Fitness;
Indian History and Culture: From 1500 to 1800;
Midwifery;
Slavery: Slave Families, Community, and Culture.
Bibliography
John Duffy , Epidemics in Colonial America, 1953.
Philip Cash , Medical Men at the Siege of Boston, April 1775–April 1776, 1973.
Whitfield J. Bell Jr. , The Colonial Physician and Other Essays, 1975.
Jane B. Donegan , Women and Men Midwives: Medicine, Morality and Misogyny, 1978.
J. Worth Estes , Therapeutic Practice in Colonial New England, in Medicine in Colonial Massachusetts, 1620–1820, eds. Philip Cash, Eric H. Christianson, and J. Worth Estes, 1980, pp. 289–383.
Eric H. Christianson , Medicine in New England, in Medicine in the New World: New Spain, New France, and New England, ed. Ronald L. Numbers, 1987, pp. 102–53.
Laurel Thatcher Ulrich , A Midwife's Tale: The Life of Martha Ballard, Based on Her Diary, 1785–1812, 1990.
Eric Howard Christianson
From 1776 to the 1870s Of about 3,500 physicians in America at the time of the
Revolutionary War, only one in ten held an M.D. degree. The establishment during the 1760s of the first medical schools, societies, and licensing laws had encouraged a growing sense of corporate identity. Yet male physicians played a modest role in the medical care of sick Americans, who more frequently turned to midwives and other women healers and to herbalists, bone‐setters, nostrum vendors, and domestic medical guidebooks.
During the early decades of the republic, expanding medical institutions sustained a new, confident professionalism. The organization of local and state medical societies—which adopted ethical codes and fixed fee scales—helped regularly trained physicians distinguish themselves from other healers, a move state legislatures reinforced by placing licensing power in the hands of the societies. Apprenticeship, sometimes supplemented by lectures, remained the core of
medical education. Harvard (1783) and Dartmouth (1798) joined existing medical schools in
Philadelphia and
New York City, while an elite continued to study in London and Edinburgh. Starting in the 1810s, medical schools proliferated rapidly—twenty‐six were founded between 1810 and 1840, and another forty‐seven by 1877. Most were proprietary ventures, run by the professors for profit. Typically the student attended lectures for four months, duplicating in the second year the courses attended during the first. Keen competition for paying pupils kept requirements low.
Although Americans insisted that European precepts were often unsuited to New World practice, their understanding of
disease was strongly informed by the theoretically elaborate, rationalistic systems of eighteenth‐century British medicine. University of Pennsylvania professor Benjamin
Rush, who received his M.D. in Edinburgh, was in the late eighteenth century the most influential medical teacher in America, and his theories promoted the so‐called “heroic” therapeutics that dominated American practice through the 1830s. Disease in Rush's scheme was essentially an overexcited condition remedied by aggressively depleting the body by bloodletting and mineral purgatives such as calomel (mercurous chloride). If depletion was sometimes practiced by rote, physicians nonetheless argued that treatment should be individuated to patients and environments, an attitude that promoted investigations of the relationships among topography, climate, and disease.
From the 1820s through the 1860s, Americans who traveled to Europe for medical study favored the
hospitals of Paris, which offered unrivaled access to the body, living and dead. These physicians returned committed to grounding medicine on empirical observation and
symptom‐lesion correlation—that is, tracing the symptoms of disease viewed in the living patient to their underlying pathological lesions in the body's tissues revealed at autopsy. They denounced rationalistic systems, like that of Rush, and challenged heroic drugging while calling for greater trust in nature's healing powers. By midcentury, supportive and stimulative treatment was supplanting depletion.
The ideas, practices, and social pretensions of the regular profession also came under assaults from antiorthodox healers. Samuel Thomson's botanic system of domestic practice, consolidated by his
New Guide to Health (1822), gained a large following. Thomsonians attacked heroic medicine and tapped into the Jacksonian Era's egalitarian distrust of claims to privilege based on special learning. Eclecticism (a parallel botanical healing system in which professional practitioners supplanted self‐help), hydropathy (water cure), and a wider health‐reform movement flourished in the 1840s and 1850s. During the same decades homeopathy, introduced to America in 1825, became the most powerful challenge to the regular profession, boasting institutions such as the Homoeopathic Medical College of Pennsylvania (1848) and the first national medical association, the American Institute of Homoeopathy (1844). During this period the states revoked virtually all medical licensing laws, leaving American medicine the freest from regulation in the western world.
It was in this
laissez‐faire context that a movement toward orthodoxy arose. In 1847 the
American Medical Association (AMA) was founded, partly to promote educational reforms but chiefly to establish a unified front and demarcate the orthodox faithful. The association initially exerted little political influence, but its code of ethics was a culturally powerful device to enforce orthodoxy by forbidding members to associate professionally with practitioners the AMA derisively called “sectarians.”
The absence of state regulation facilitated women's access to M.D. degrees earlier than in any other nation. When in 1849 Elizabeth
Blackwell received an M.D. from Geneva College in upstate New York, she became the first woman anywhere to win that degree. Male opposition kept most schools closed to women. In 1850, however, the Female Medical College of Pennsylvania opened as the world's first M.D.‐granting medical school entirely for women. Over the next several decades a number of other women's medical colleges (orthodox and homeopathic) opened, as did women's dispensaries and hospitals.
Hospitals in antebellum America remained chiefly charitable asylums for the sick poor. Elite physicians sought hospital appointments for access to clinical teaching, experience, and investigation; thus, at the Pennsylvania Hospital in Philadelphia, William Gerhard used his Parisian experiences as the model for the clinical instruction he offered starting in the 1830s and for research that differentiated
typhoid fever from typhus (1843). While some institutions for the mentally ill dated from the
Colonial Era, the emergence of moral treatment and the campaign that Dorothea
Dix launched in 1841 to reform the care of the insane poor fostered a host of state insane asylums created before the
Civil War.
American innovations, chiefly in
surgery, won international attention. Ephraim McDowell's 1809 operation in Kentucky for an ovarian cyst and J. Marion Sim's operation for vesicovaginal fistula, developed on slave women during the 1840s, were celebrated as exemplifying native mechanical ingenuity. William
Beaumont's experiments on the physiology of digestion—performed during the 1820s and 1830s on a patient with a gastric fistula that provided a direct opening to the stomach—also drew European notice. The most celebrated American achievement, although clouded by priority disputes, was the first public operation on a patient anesthetized with ether, an 1846 performance at the Massachusetts General Hospital in Boston during which William T.G. Morton administered the anesthetic and John Collins Warren performed the surgery.
The state, little involved in regulating the medical profession, also had meager involvement in
public health.
Cholera and
yellow fever epidemics prompted the creation of municipal boards of health to orchestrate sanitation (based on the belief that miasms or emanations from filth produced disease) and quarantine. But through the mid–nineteenth century, such activities were temporary. The Civil War did not transform medicine, but the organizational skills and commitments on display in the U.S. Sanitary Commission (1861) raised expectations of state responsibility for public health. In 1869 Massachusetts established the first state board of health; by 1880, twenty such boards existed. In 1879 Congress created the National Board of Health, a short‐lived but important precedent for federal involvement in public medicine.
After the war in 1868, Howard University in
Washington, D.C., established the first medical school for
African Americans. In 1871, Harvard adopted a three‐year graded medical curriculum, but with diploma mills still flourishing, few other schools followed this lead. In 1873 New York's Bellevue Hospital established a
nursing school modeled after Florence Nightingale's plan, and over a dozen such institutions appeared before the end of the decade. Reflecting the elevated status of expert knowledge in
Gilded Age American culture, by the 1870s some states reinstituted medical licensing laws, usually broad enough to encompass homeopathic, eclectic, and orthodox physicians.
Although few important new therapies had arisen by the 1870s, some doctors were looking to the experimental laboratory as the wellspring of therapeutic progress. Americans studying abroad shifted to German laboratories and clinics, and in 1871 Henry Pickering Bowditch returned from Leipzig to set up at Harvard the nation's first laboratory for experimental physiology and to occupy the first full‐time post in physiology. The most dramatic early post–Civil War change in American medical practice was the rise of specialization, patterned after German models. Ophthalmologists formed their own society in 1864; otologists (who specialized in diseases of the ear) in 1868. During the 1870s such specialty societies proliferated, testimony both to social reality and to the public's esteem for specialization as a hallmark of the emerging medical order.
See also
Mental Illness;
Professionalization.
Bibliography
William G. Rothstein , American Physicians in the Nineteenth Century, 1972, reprint 1992.
Paul Starr , The Social Transformation of American Medicine, 1982.
Regina Markell Morantz‐Sanchez , Sympathy and Science: Women Physicians in American Medicine, 1985.
John Harley Warner , The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820–1885, 1986; reprint 1997.
Charles E. Rosenberg , The Care of Strangers: The Rise of America's Hospital System, 1987, reprint 1995.
John Duffy , The Sanitarians: A History of American Public Health, 1990.
Gerald N. Grob , The Mad among Us: A History of the Care of America's Mentally Ill, 1994.
Judith Walzer Leavitt and Ronald L. Numbers, eds., Sickness and Health in America: Readings in the History of Medicine and Public Health, 3d ed., 1997.
John Harley Warner , Against the Spirit of Systems: The French Impulse in Nineteenth‐Century American Medicine, 1998.
John Harley Warner
From the 1870s to 1945 In 1876, American physicians gathered in
Philadelphia to survey the nation's first hundred years of medical progress. A parade of speakers celebrated the introduction of anesthesia and antisepsis in
surgery, the use of new chemical discoveries to treat fever, and the profession's growing knowledge of
disease, grounded in the pathological and microscopical research of the previous fifty years. America's special genius, they suggested, lay in applying these European accomplishments. Laboratory studies shed new light on the workings of blood and bodily chemistry, while American sanitary institutions contained the once dreaded
cholera when it had last arrived in 1866 and 1873. At the same time, speakers warned, American
medical education remained in a parlous state, while sanitary reform lacked the public support it deserved. Nor, they might have added, did physicians get the material rewards and respect they sought.
The next seventy years witnessed unprecedented improvements in the social and economic status of U.S. physicians, in medical knowledge about the causes of specific diseases, and in
life expectancy.
Hospitals were transformed from refuges for the urban poor to surgeons' workshops patronized by the middle and working classes. Bacteriologists identified the causes of the major infectious diseases, though control over viral diseases eluded them. But if physicians gained new frameworks for understanding disease from the laboratory, they clung to their caste's prejudices in making sense of their society: categories of race and
gender figured prominently in medical thought and action. Meanwhile, both professional and social progress were unevenly distributed. Specialists and urban practitioners earned far more than their rural counterparts, while sanitary improvements only slowly reached working‐class, rural, immigrant, and
African‐American citizens. Nonetheless, medicine's scientific and institutional accomplishments engendered a belief in progress that neither social inequality nor injustice could refute.
Science, Disease, and Public Health.
In 1882, the German physician Robert Koch (1843–1910) demonstrated that
tuberculosis, probably the leading cause of death in western Europe and the United States, was caused by a living microorganism, the tubercle bacillus. More important, he laid down a set of procedures (Koch's postulates) for researchers to follow in determining the bacterial causes of specific diseases. By 1906, European researchers had identified the microorganisms responsible for
typhoid fever (1880–1884),
diphtheria (1883), cholera (1884), gonorrhea (1885), pneumonia (1886), tetanus (1889), plague (1894), dysentery (1898), and syphilis (1905). Americans doctors like William H.
Welch and Frederick Novy (1864–1957) traveled to Europe to train in the new bacteriological techniques. American companies, quick to realize the commercial potential of the new “germ” theories, marketed disinfectants like Listerine and Radam's Microbe Killer. Bacteriological concepts held less appeal for medical practitioners, who continued to view disease as a complex interaction among the “constitution” of individual patients, the susceptibility of particular “racial” groups, and exposure to specific bacteria.
Although physicians who were trained after 1890 increasingly viewed infectious diseases as caused by specific microorganisms, the new science failed to fulfill its early therapeutic promise. Although diphtheria antitoxin (1894) rescued thousands from a disease that had routinely killed a quarter of those infected, subsequent vaccines and antisera proved far less effective, as did chemical anti‐infectives prior to the introduction of sulfa drugs in the 1930s. Many practitioners avoided innovative treatments with dangerous side effects, such as pneumonia serum or Paul Ehrlich's salvarsan, a celebrated antisyphilis drug. Nowhere was medicine's therapeutic impotence more vividly demonstrated than in the viral epidemics of
poliomyelitis, which in 1916 killed 2,400 children in
New York City alone, and
influenza, which killed more than 315,000 Americans in 1918–1919, many of them young adults.
In contrast to medical practitioners,
public‐health departments readily embraced the new bacteriological science. New York City's public‐health laboratory, opened in 1892, was but the first to adopt routine bacteriological testing. By 1906, health officer Charles V. Chapin of Providence, Rhode Island, could write disparagingly of the “fetich [
sic] of disinfection” that had led earlier sanitarians to emphasize the removal of offensive but innocuous urban nuisances. Stop worrying about rotting vegetables and “sewer gas,” Chapin advocated, and instead block the specific infection path of each disease‐causing organism: for
yellow fever, kill the mosquito; for typhoid, purify water, milk, and food.
Chapin's advice fit well with the
Progressive Era's “social‐engineering” ethos, which sought to put all social reforms on a “scientific” basis. By
World War I, Chapin and others increasingly emphasized the importance of personal habits in stopping infectious disease. Scientific policing of water and food supplies could do little, they argued, if housewives did not wash their hands and refrigerate their milk. Sanitary fairs, public‐health “propaganda,” and school‐hygiene campaigns joined other contemporary efforts aimed at the “Americanization” of immigrants and the “modernization” of the poor. Forced testing of prostitutes for
venereal disease marked another area where new science sanctioned existing middle‐class mores.
Long before the germ theory's triumph, urban reformers had championed purified water systems and underground sewers for waste disposal. In the closing decades of the nineteenth century, death rates for waterborne diseases like typhoid fever plummeted in cities adopting these reforms. Not everyone benefited: Residents of Pittsburgh's low‐lying, working‐class districts experienced five to six times the typhoid mortality of middle‐class districts. African Americans living in Kansas City, Cincinnati, and Indianapolis between 1910 and 1920 had typhoid mortality rates two to four times those of whites in the same cities. Regional variations compounded those of race and class. Despite northern‐led campaigns against hookworm and pellagra, most rural counties in the
South remained without full‐time health officers until Franklin Delano
Roosevelt's New Deal. As late as 1940, the heavily rural and African‐American states of South Carolina, Georgia, and Alabama reported some of the nation's highest rates of typhoid and enteritis mortality. Local initiatives sometimes countered the effects of regional
poverty and prejudice. African‐American women in Atlanta, Georgia, and Salisbury, North Carolina, for example, launched antituberculosis campaigns that reached across racial lines, as did North Carolina's dynamic public‐health department, led by Watson S. Rankin (1879–1970).
Between 1900 and 1930, American life expectancy at birth climbed from 47.3 to 59.7 years. Many observers concluded that infectious diseases were “conquered,” despite continued deaths from tuberculosis, pneumonia, and syphilis. By 1920, medical researchers were turning their attention to the detailed workings of the body's “chemical machinery,” the chemical reactions that regulate nutrition and excretion, growth and reproduction, activity and rest. Biochemists like the University of Wisconsin's Conrad A. Elvehjem (1901–1962) and Johns Hopkins University's Elmer V. McCollum (1879–1967) discovered numerous vitamins, while other researchers studied “metabolic pathways,” the chemical reactions that govern the body's use of carbohydrates, proteins, and electrolytes. Apart from the discovery of insulin in 1922, however, this added knowledge had little impact on everyday medical practice. Vitamins nonetheless became the best‐selling drug products of the 1930s, while numerous urban practitioners measured the “basic metabolic rate” of middle‐class women, to identify the causes of their irritability, anxiety, and fatigue. Here again, new science underwrote existing social beliefs.
Political Economy of Medical Practice.
In 1870, some 64,000 physicians were practicing in the United States. For the majority, economic security was uncertain at best. Much illness was self‐treated; for the rest, physicians faced competition from midwives, lay healers, and patent‐medicine vendors. In rural Wisconsin, for example, three‐quarters of all physicians had to supplement their medical earnings by farming, teaching, or operating small businesses. In metropolitan centers such as New York or Philadelphia, a handful of physicians succeeded by offering postgraduate hospital training that gave them opportunities both to teach and to cultivate the socially prominent benefactors of the city's charitable hospitals. Yet even well‐connected young physicians could fail. John Sedgwick Billings, son of one of the country's most prominent physicians, ended his career where it began, as an employee of New York City's health department, after several unsuccessful efforts to build a private practice.
Most physicians in 1870 had been trained through an apprenticeship, supplemented by up to two years of study at a medical college. Virtually any group of physicians could start a medical college. From midcentury, medical leaders sought to raise standards of medical training, and with it practitioners' social and economic status. Success came in the early twentieth century, when Abraham Flexner's
Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (1910) capped educational reforms begun by the
American Medical Association. Flexner (1866–1959), a lay educator, called for the closure of 124 of the country's 155 medical schools as either redundant, inadequately staffed and equipped, or lax in their entrance requirements. By 1920 only eighty‐five schools remained. (Of these, only two were dedicated to training African‐American physicians and one to training women.)
After 1900, new physicians increasingly opted to practice in larger cities, especially in the newly emerging downtown business districts. Doctors' preferences for urban, wealthy communities paid off. By 1928, physicians' mean annual income ($9,000) put them above all but 1 percent of the population. Doctors were overwhelmingly white, native‐born males at a time when 11 percent of the population were immigrants, nearly 10 percent were African Americans, and 49 percent were women.
Sharing the prejudices of their class and gender, physicians endorsed public‐health policies that held immigrants and African Americans responsible for spreading infectious disease, and attempted to regulate sexual and reproductive behavior through educational campaigns and, at times, the active sterilization of poor women.
Most physicians worked in solo “private” practice. Like other small business owners, they fared badly in the Great Depression of the 1930s, with average net annual incomes declining nearly two thousand dollars. Specialty practice was one means to make good: From 1930 on, a majority of medical‐school graduates eventually became specialists.
Surgery was among the first of the full‐time specialties. The advent of antiseptic and then aseptic surgery in the late nineteenth century enabled surgeons safely to perform intra‐abdominal surgery on a routine basis. Operations like appendectomies flourished, as hospitals became the preferred surgical sites for surgeons and middle‐class patients alike. By 1928, 74 percent of admissions to Philadelphia's hospitals were surgical or obstetrical.
Social as well as technical innovations engendered the modern hospital. Religious groups—Protestant, Catholic, and Jewish—founded hospitals, as did small‐town doctors who saw the advantages in hospitalizing patients. Hospitals not only provided surgeons with operating rooms, x‐ray equipment, and diagnostic laboratories, but with nurses to care for patients. By 1939, more than half of the nation's babies were being delivered in hospitals, as obstetricians (and their patients) followed surgeons into the hospital.
As with sanitary reforms, use of the new hospitals varied by class, race, and place. Only one‐quarter of African‐American women gave birth in‐hospital in 1939; a decade earlier, families earning over $5,000 had more than twice the number of tonsillectomies per capita as families with incomes under $1,200, while rural families of all incomes had surgery at rates well below those of city dwellers.
Much health care remained outside the orbit of the new, “scientific” medicine. In the 1930s, roughly 20 percent of “medical care” expenditures went for patent medicines and medical supplies, while another 8 to 10 percent went to midwives, chiropractors, and other practitioners condemned by orthodox physicians. In most years, Americans spent at least as much on funeral expenses as on hospitals.
From many perspectives, American medicine in 1945 had little in common with that of 1870. Discoveries in bacteriology, the reform of medical education, the rise of medical specialization, advances in surgery and public health, and the emergence of the modern hospital all contributed to the transformation. Yet the rewards of modernity were distributed along well‐established lines of place, race, class, and gender.
See also
Biological Sciences;
Childbirth;
Death and Dying;
Depressions, Economic;
Eugenics;
Flexner Report;
Health and Fitness;
Medicine: Alternative Medicine;
Nursing;
Professionalization;
Prostitution and Antiprostitution;
Social Class.
Bibliography
Barbara Gutman Rosenkrantz , Public Health and the State: Changing Views in Massachusetts, 1842–1936, 1972.
George Rosen , Preventive Medicine in the U.S., 1900–1975: Trends and Interpretations, 1975.
Harry F. Dowling , Fighting Infection: Conquests of the Twentieth Century, 1977.
Paul Starr , The Social Transformation of American Medicine, 1982.
Regina Markell Morantz‐Sanchez , Sympathy and Science: Women Physicians in American Medicine, 1985.
John Harley Warner , The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820–1885, 1986.
Edward H. Beardsley , A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth‐Century South, 1987.
Allan M. Brandt , No Magic Bullet: A Social History of Venereal Disease in the United States since 1880, expanded ed., 1987.
William G. Rothstein , American Medical Schools and the Practice of Medicine: A History, 1987.
Rosemary Stevens , In Sickness and in Wealth: American Hospitals in the Twentieth Century, 1989.
Harry M. Marks
Since 1945 In the second half of the twentieth century, American medicine was characterized by unprecedented technological progress and profound social disagreements over how medical care should be organized, financed, and regulated. In the years from
World War II through the mid‐1960s, widely publicized technological developments encouraged expansive optimism about what
science and
technology could ultimately do for the health of Americans. After the later 1960s, skepticism about the fruits of medical science and technology dominated public discussions, just as researchers finally began to realize their ambitions of re‐engineering the human machine.
A similar chronological divide marks contrasting approaches to financing medical services. Between 1945 and 1965, middle‐ and working‐class Americans looked to employment‐based, private
health insurance to secure access to medical care, while the federal government's role was largely restricted to infrastructural investments in hospital facilities and medical research. After 1965, Washington's role in financing health‐care markets expanded elevenfold, from three cents of every dollar spent in 1965 to thirty‐three cents in 1995. The ensuing ideological debates over the government's regulatory and budgetary role in health care largely eclipsed the more basic question of whether any one party could or should control the nation's highly decentralized $879 billion health economy.
The Early Postwar Era.
In the immediate aftermath of World War II, American physicians attempted to assimilate the legacy of war medicine. For some, the war experience offered new models of medical care and research. In July 1945, more than one in four American physicians was serving in the military. War medicine encouraged specialization, the delegation of tasks to nurses and technicians, and a hierarchical model of medical organization, with academic consultants and
hospitals at the pinnacle. Such a system, postwar planners argued, had delivered wartime medical innovations in an efficient, organized way. Rather than returning to the isolated conditions of individual general practice, planners insisted, physicians should work in groups, supported by modern, well‐equipped hospitals.
Although prewar trends toward specialization continued (three‐fourths of 1945 medical graduates entered specialty practices), the lucrative private‐practice model remained strong. In 1965, only 10 percent of U.S. physicians worked in group practices.
Development of the regional medical centers envisioned by postwar planners proved similarly slow. Although the number of cottage hospitals (under twenty‐five beds) declined after the war, the supply of small community hospitals of between twenty‐five and one hundred beds increased, abetted by federal subsidies designed to distribute hospitals more widely. Overall per capita use of hospitals doubled between 1945 and 1975. By 1960, nearly all (white) women delivered their babies in hospitals.
Patients financed their increased use of hospital and medical services through private health insurance, medical opposition having defeated successive initiatives for publicly financed insurance. Court rulings in 1949 making health insurance benefits a legitimate subject for collective bargaining accelerated the growth of private, employment‐linked health insurance. Middle‐class and unionized workers especially benefited from this development. By 1956, more than 116 million Americans had some health insurance, but the private, job‐based system meant that rural, poor, and black citizens were less likely to be insured, and thus they saw doctors and stayed in hospitals less often.
A series of innovations making
surgery easier and safer fueled increased hospital use. Intravenously administered fluids that mimicked the blood's chemical makeup and volume minimized postsurgical shock. Penicillin, the product of a publicly financed World War II crash program, was the first of many new antibiotics for controlling postsurgical infection. Intensive‐care units, the symbol of high‐technology medicine, were standard features of U.S. hospitals by 1970. Publicists promoting magazine sales, drugs, and medical charities spread awareness of these life‐saving innovations, ushering in what historian John Burnham has termed the “golden age” of American medicine.
Penicillin aside, the best‐known medical triumph of this era was Jonas
Salk's
poliomyelitis vaccine, publicized in a 1954 field test involving nearly two million school children. Although the media hailed Salk, his scientific colleagues, while acknowledging his technical skill and dedication, deemed his contribution less significant than that of John Enders, Thomas Weller, and Frederick Robbins, who received the 1954 Nobel Prize in medicine for developing the underlying technique of cultivating poliovirus in tissue culture.
The Salk episode points to a divide between medical scientists and the lay public regarding the means, if not the aims, of medical research. The most significant research in the
biological sciences in the 1950s and 1960s, which studied the structure and operations of the cell, was remote from “practical” results and everyday medical concerns. Those who sought immediate relief from suffering emphasized organized research programs targeting specific diseases. In their quest for new antibiotic and anticancer therapies, researchers built on the wartime model of screening for antimalarial drugs. Laboratory researchers following standardized protocols systematically tested thousands of substances to see what microorganisms they killed, or which tumors they might inhibit.
Methodic and resource‐intensive, such research helped produce the antibiotics streptomycin (1944), chloramphenicol (1947), aureomycin (1948), neomycin (1949), and terramycin (1950). The National Cancer Institute's (NCI) search for anticancer drugs adopted a similar screening model but produced fewer tangible results. University scientists argued that such narrowly targeted research lacked imagination and could not produce the deeper understanding of
disease essential to its eventual control. American Cancer Society publicists drew a different lesson: The NCI program was not practical enough. New drugs needed to be tested in human beings, not test tubes.
Until the late 1960s, Congress generally sided with basic science, allowing university scientists to determine where federal funds should be spent, while rejecting proposals that medical research dollars be distributed broadly, like agricultural research support or highway construction funds. Between 1945 and 1960, as annual congressional funding for the
National Institutes of Health (NIH) increased from $2.8 million to $300 million, NIH's administrators convinced Congress that long‐term investment in basic research would ultimately bring better health.
To demographers, who measure improvements in health by increases in
life expectancy, progress after midcentury seemed almost imperceptible. But most citizens, and many physicians, measured postwar medical progress by its more tangible technological accomplishments: the penicillin shot that saved an elderly person from death by pneumonia or painlessly cured syphilis; the polio vaccine that allowed children to swim in the community pool without fear of paralysis or death. In the 1950s, only a few medical specialists gave much attention to the fact that the widespread use of antibiotics gave rise to antibiotic‐resistant pathogens, that the sexual behaviors that transmitted syphilis remained unaltered by penicillin, or that the risks of death from polio were small compared to other childhood hazards. Even the rising mortality rates from
heart disease and
cancer seemed a problem that more science and improved medical‐care delivery arrangements would resolve.
Government and Markets: Health Care, 1965–1995.
Following the defeat of national health‐insurance proposals in the 1940s, congressional Democratic leaders adopted a new strategy, seeking government subsidies for groups excluded from the private insurance system. Building on
New Deal‐Era and wartime programs, such legislation extended federal support to state governments that would provide health insurance to welfare clients and other medically needy groups. This supplementation strategy culminated with the 1965 passage of Medicare, which provided health insurance for all Americans over sixty‐five, and Medicaid, a cost‐sharing program with the states to pay for the medical care of the poor. These two laws extended medical‐care coverage to millions of underserved Americans.
To ensure the participation of doctors, hospitals, and state governments in the new programs, federal officials promised to pay for any medical care provided. They even offered special inducements, such as a 2 percent premium to participating hospitals beyond their direct operating costs. Participation mushroomed, but so did program costs. By 1975, the two programs served 47 million people at a cost of $28 billion, nearly a quarter of the nation's total health‐care expenditures.
Health care remained a national problem for the rest of the century. Federal programs created new political interests in health policy. No longer solely a concern of physicians and labor unions, health‐care policies affected hospitals, nursing homes, the
pharmaceutical industry, home health‐care vendors, and state governments. New fault lines appeared in the political landscape: medical specialists versus primary‐care physicians, teaching versus community hospitals, home care versus nursing homes, Medicare versus Medicaid recipients. The proliferation of interest groups led to a new kind of health politics, in which conventional partisan differences over such issues as “competition versus regulation” or “market versus government” were replaced by a managerial politics that emphasized administrative innovations and technocratic expertise.
By the early 1970s, policy debates focused on the explosive growth in health‐care costs, from 10 to 13 percent annually. President Jimmy
Carter promoted regional health planning under which community groups would assess medical needs and limit new hospital construction. President Richard M.
Nixon first imposed wage and price controls and then supported legislation providing federal subsidies for
health maintenance organizations (HMOs) to compete with traditional fee‐for‐service medicine. President Ronald
Reagan attempted to limit the federal share of Medicaid expenses by administrative changes in cost‐sharing formulas and eligibility rules. Following the advice of Harvard economists, President George
Bush's administration redesigned Medicare fee schedules to favor primary‐care physicians over more costly specialists.
But the federal government refrained from imposing direct limits on health expenditures. Although Washington's share of total health‐care costs rose to 28 percent by 1990, only the Medicare program was fully controlled by the federal government. Most federal initiatives in the 1970s and 1980s were indirect efforts to steer the health‐care system away from hospital‐based, specialty‐oriented care (health planning and fee‐schedule reform) and toward more cost‐conscious organizations (such as HMOs), with the overall aim of lowering costs without compromising access to medical care. These government efforts to influence decentralized, largely private health‐care markets had limited, even perverse effects. The shift from hospital and nursing‐home care, for example, fueled explosive growth in the harder‐to‐regulate home health‐care industry.
In the 1980s, public debates over soaring health‐care costs became private contests over who should pay for these costs. Businesses saddled with expensive employee‐benefit programs sought to shift a greater share of the premiums to employees while reducing coverage for retirees and dependents. The growing ranks of part‐time workers and employees of small firms often found themselves without insurance entirely. After the defeat of President Bill
Clinton's proposal for national health insurance in 1993, cutbacks in coverage reached previously protected employees in large manufacturing firms. The greatest gaps in coverage, however, remained among the poor,
African Americans,
Hispanic Americans, and citizens of rural states such as Arkansas, Mississippi, and Texas where one in four adults lacked health insurance at the end of the twentieth century.
The postwar social contract, which had offered employers labor peace in exchange for generous benefits, eroded in the 1980s. Simultaneously, the working conditions of America's physicians changed radically. As the pattern of independent practice faded at the end of the twentieth century, roughly two in five physicians engaged in patient care were employed by a hospital or other health‐care organization, and the remainder received about 40 percent of their income from managed‐care organizations that oversaw the amount and kind of treatment provided. While medicine remained among the highest paid occupations, these changes caused great anxiety among physicians.
Medical Progress and Medical Care, 1960–1995.
The details of health‐care policy concerned most Americans less than what happened when they got sick. In this realm, the changing treatment of heart disease offers a window on medical progress. In 1960, doctors could offer relatively little for the heart‐attack patient who survived long enough to reach the hospital: anticoagulants to thin blood clots and diuretics to reduce the work of the damaged heart. Coronary‐artery bypass surgery became widely available by the late 1960s, accompanied by specialized wards for monitoring the recovering patient. New therapies emerged at the end of the 1970s to dissolve or remove clots in the coronary arteries, allowing many patients to avoid open‐heart surgery. By the late 1980s, a broad array of drugs was available for treating the underlying conditions that bring on heart attacks, including drugs to lower cholesterol and regulate the heartbeat.
While the gains in treating heart disease were exceptional, there are few cases where medical researchers cannot point to substantial differences between the “dark ages” of the 1960s and the ever‐emerging present. The return of infectious diseases in the 1980s, including new infections such as
acquired immunodeficiency syndrome (AIDS) and older infections in newer, drug‐resistant forms, such as
tuberculosis and pneumonia, suggested the limits of technological progress. Although the emergence of new infections was rooted in social behaviors, including sexual practices, drug use, and the medical and commercial abuse of antibiotics, the preferred solution for medical researchers and the general public alike remained technological.
Beginning in the late 1960s, a disparate group of economists, philosophers, and
public‐health advocates vocally challenged contemporary medicine's technological orientation as intrusive, financially ruinous, and ultimately counterproductive. The trajectory of the women's health movement was instructive. In the 1970s, feminist activists, defending women's autonomy against medical domination, challenged existing obstetrical practices and explored alternatives to technologically oriented hospital births; popularized surgical alternatives to radical mastectomy for breast cancer; and identified the risks of technologically defined birth control, such as oral contraceptive hormones. Yet the autonomy of the 1970s became the consumer activism of the 1990s, as activists lobbied to assure that women's diseases would be researched and treated as aggressively as those of men. AIDS activists similarly demanded quicker access to experimental drugs. Autonomy was redefined as the right to pursue nontraditional treatments alongside the latest NIH innovations in cancer therapy. As with the politics of health care, the nation's social arrangements for assuring medical progress as the twentieth century ended were embroiled in struggles among groups of consumers over who would win the most favorable position at the medical table, and who would be left waiting.
See also
Bioethics;
Biological Sciences;
Birth Control and Family Planning;
Childbirth;
Feminism;
Health and Fitness;
Medical Education;
Medicare and Medicaid;
Medicine: Alternative Medicine;
Nursing;
Science: Since 1945;
Welfare, Federal.
Bibliography
Stephen Strickland , Politics, Science and Dread Disease: A Short History of United States Medical Research Policy, 1972.
John C. Burnham , American Medicine's Golden Age: What Happened to It? Science 215 (19 March 1982): 1472–9.
Paul Starr , The Social Transformation of American Medicine, 1982.
Daniel M. Fox , Health Policies, Health Politics: The British and American Experience, 1911–1965, 1986.
Rosemary Stevens , In Sickness and in Wealth: American Hospitals in the Twentieth Century, 1989.
Alan Derickson , Health Security for All? Social Unionism and Universal Health Insurance, 1935–1958, Journal of American History 80 (1994): 1333–56.
Harry M. Marks , The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900–1990, 1997.
David J. Rothman , Beginnings Count: The Technological Imperative in American Health Care, 1997.
Rosemary Stevens , American Medicine and the Public Interest: A History of Specialization, 1998.
Harry M. Marks
Alternative Medicine Although the cast of healers has changed dramatically, the medical marketplace in America has always been diverse and competitive. In the
Colonial Era, patients sought out bonesetters, midwives, preacher‐healers, and root‐and‐herb doctors, as well as a broad range of school‐trained and apprentice‐trained physicians, known as regular, orthodox, or, in the nineteenth century, allopathic practitioners. At a time when many regular physicians bled, blistered, puked, and purged their patients—and when the population was largely rural and scattered—Americans often treated themselves and their families, relying on domestic recipes, almanacs, or, by the later eighteenth century, medical manuals.
Thomsonianism, Physiomedicalism, Eclecticism, Homeopathy, Hydropathy.
Some medical entrepreneurs offered patients distinctive forms of treatment. In the 1790s, for example, the Connecticut physician Elisha Perkins began treating pain and
disease with metal rods, or “tractors.” The state medical society expelled him, but he obtained a patent for his device and built up a considerable practice. In 1806, the New Hampshire farmer turned healer Samuel Thomson (1769–1843) began selling “family rights” to his system of botanical medicine, which relied heavily on the emetic
lobelia, steam baths, and hot pepper. Proclaiming “Every Man His Own Physician,” he attacked not only physicians but priests and lawyers as well. In the 1830s, Thomson's supporters pressured state legislatures to repeal licensing laws, which in any event had had little effect on medical practice. At the height of his popularity Thomson (generously) estimated that three million Americans were using his system, but by the late 1830s his movement was in sharp decline.
With the demise of Thomsonianism, two other botanic groups arose to fill the vacuum. The first, physiomedicalism, was formed by restless Thomsonians who wanted trained botanical physicians. The second, eclecticism, was started in the 1830s by a regularly trained physician, Wooster Beach. Like their physiomedical competitors, the eclectics established medical schools and societies. Their largest institution, the Eclectic Medical Institute in Cincinnati, Ohio, ranked among America's largest medical schools at midcentury. Eclecticism flourished well into the twentieth century.
Even more successful were the homeopaths, followers of a system developed by the German physician Samuel Hahnemann in the early nineteenth century and brought to the United States around 1825 by German‐speaking immigrants. Rejecting orthodox drugs and doses, homeopathic practitioners relied on the law of similars (like cures like) and the law of infinitesimals (the smaller the dose the more potent). During the second half of the nineteenth century, homeopathy became the most significant professional and economic rival to orthodox medicine. By the 1880s homeopathic medical colleges and hospitals existed in most major cities, including women's homeopathic schools in Cleveland, Ohio, and
New York City.
A much smaller medical movement, hydropathy or the water cure, appeared in the mid‐1840s. Relying on various water therapies developed by a Silesian peasant, Vincent Priessnitz, American hydropaths set up coeducational schools to train hydropathic physicians, established scores of water‐cure institutions, and published the popular
Water‐Cure Journal, which claimed 100,000 subscribers. Many water‐cure enthusiasts also embraced the health‐reform movement launched in the 1830s by the Massachusetts temperance lecturer and sex reformer Sylvester Graham (1794–1851), who preached the virtues of a twice‐a‐day diet devoid of meat, rich foods, tea, coffee, spices, and commercially made bread.
The growing popularity of alternative‐healing movements spurred the founding in 1847 of the
American Medical Association (AMA). Its code of ethics, made compulsory for member societies in 1855, barred consultation with anyone “whose practice is based on exclusive dogma,” an obvious reference to eclectics, homeopaths, hydropaths, and other sectarians. Enforcement of the code frequently created awkward moments, as when in 1878 a county medical society in Connecticut expelled Moses Pardee, a regular physician, for consulting with his wife, Emily, a homeopathic practitioner. In 1884 the New York State Medical Society split, with rural general practitioners upholding the AMA code while urban specialists, often German‐trained, claimed that truly scientific physicians could recognize legitimate expertise regardless of creed. A revision of the code in 1903 recognized this latter view. Henceforth, homeopaths and eclectics who embraced “scientific medicine” and abandoned their sectarian identities were welcomed as members.
Christian Science, Osteopathy, and Chiropractic.
In the late nineteenth century, as the practices of allopaths, homeopaths, and eclectics increasingly converged under the banner of science, three new alternative‐healing movements, all offshoots of mesmerism or animal magnetism, rose to prominence:
Christian Science, osteopathy, and chiropractic. Christian Science, a religion founded by Mary Baker Eddy in the 1860s, taught that disease and death do not exist physically but only mentally; thus treatment consists of helping the sick alter their state of mind. Osteopathy, originated by a magnetic healer and bonesetter, Andrew Taylor Still, focused on removing obstructions to the flow of body fluids by manipulating out‐of‐place bones, particularly vertebrae. In 1892, Still opened the American School of Osteopathy in Kirksville, Missouri. Daniel David Palmer, a magnetic healer from Davenport, Iowa, started the chiropractic movement in 1895, initially as a spiritual healing sect employing spinal adjustments to relieve pinched nerves that impeded the flow of “Innate Intelligence.” Despite the return of medical licensing laws in the later nineteenth century, by the early 1930s roughly 20 percent of all healers in the United States were unorthodox. Some forty‐six states legally recognized osteopathy, and thirty‐nine permitted chiropractic practice. After many legal battles, Christian Science practitioners, too, had won the right to pursue their activities.
When Abraham Flexner issued his muckraking survey
Medical Education in the United States and Canada (1910), he excoriated the homeopathic, eclectic, and osteopathic schools he had visited and dismissed chiropractors as “unconscionable quacks” unworthy of “serious notice in an education discussion.” The
Flexner Report and Flexner's unwillingness to “compromise between science and revelation” profoundly shaped elite attitudes toward alternative medicine in America. But the public's increasing reliance on
hospitals and medical specialists did not necessarily undermine support for medical alternatives. And the often racist and anti‐Semitic admissions policies of many orthodox medical schools led many
African Americans and Jews to study osteopathy and chiropractic (as well as
dentistry and
optometry) instead of medicine. Throughout the twentieth century, ethnic and racially segregated communities commonly used herbalists, midwives, medical advisers, and spiritual healers—often for complementary rather than alternative care.
Alternative Medicine in the Later Twentieth Century.
By the 1960s and 1970s, American physicians faced increasing criticism as elitist, overly interventionist, and too Eurocentric. Critics compared Western scientific medicine to the allegedly gentler, more humane, and more natural
health practices of other cultures, such as those of Native Americans, Asians, and Hispanics. Communes and some college campuses welcomed alternative medicine. In 1969, Michigan State University established the first university‐affiliated osteopathic school, followed in the 1970s by state universities in Texas, West Virginia, Oklahoma, Ohio, New Jersey, New York, and Maine. In 1966 the U.S. Department of Defense accepted osteopaths as military physicians and surgeons, and soon thereafter osteopaths gained admission to hospital residency and fellowship programs. In 1972, Congress mandated Medicare coverage of chiropractic, but, facing continuing discrimination, American chiropractors in 1976 sued the AMA for violating antitrust laws. Although the AMA revised its code of ethics to allow physicians the freedom “to choose whom to serve, with whom to associate, and the environment in which to provide medical services,” it eventually lost the suit.
During the 1980s and 1990s, growing public fascination with so‐called *New Age healing (a mixture of naturopathy, homeopathy, Ayurvedic healing, and other Eastern vitalist systems) gave rise to various alternative schools and numerous health‐food stores and magazines. The growing incidence of chronic diseases for which orthodox medicine offered no cure—especially
cancer, rheumatoid arthritis, persistent fatigue, and
acquired immunodeficiency syndrome (AIDS)—spurred interest in unorthodox treatments. Recognizing the public's growing interest in alternative healing, Congress in 1991 created an Office of Alternative Medicine in the
National Institutes of Health.
Meanwhile, the practice of alternative healing flourished. In 1993 the prestigious
New England Journal of Medicine published news of a recent survey in which over a third of the respondents “reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy.” This report also revealed that Americans annually paid more visits (425 million) to alternative practitioners than to “all U.S. primary care physicians” combined, and spent more money on alternative healers ($13.7 billion) than on out‐of‐pocket expenditures for hospitalization. A follow‐up survey seven years later reported a 47.3 percent increase in visits to alternative healers. Among the fastest‐growing unconventional therapies were “herbal medicine, massage, megavitamins, self‐help groups, folk remedies, energy healing, and homeopathy.” So popular had alternative medicine become that by 2000 well over half of American medical schools were offering courses on the subject.
See also
Childbirth;
Food and Diet;
Medical Education;
Medicare and Medicaid.
Bibliography
Guenter Risse, Ronald L. Numbers, and Judith W. Leavitt, eds., Medicine without Doctors: Home Health Care in American History, 1977.
Norman Gevitz, ed., Other Healers: Unorthodox Medicine in America, 1988.
Barbara Barzansky and Norman Gevitz, eds., Beyond Flexner: Medical Education in the Twentieth Century, 1992.
John S. Haller Jr. , Medical Protestants: The Eclectics in American Medicine, 1825–1939, 1994.
Ronald L. Numbers and Darrel Amundson, eds., Caring and Curing: Health and Medicine in the Western Religious Traditions, 1998.
Naomi Rogers , The Making and Remaking of Hahnemann Medical College and Hospital of Philadelphia, 1998.
Robert B. Baker, et al., eds., The American Medical Ethics Revolution: How the AMA's Code of Ethics Has Transformed Physicians' Relationships to Patients, Professionals, and Society, 1999.
Naomi Rogers
