The Organization of American Medicine
The Organization of American Medicine
Changes in the Field of Medicine. Between 1850 and 1877 American medicine became more professionalized. Modern hospitals began to appear in the 1860s and 1870s, and along with them came the professionalization of nursing. The nation’s physicians, however, lacked the professional cohesiveness that American scientists were beginning to find during these decades; not until the early twentieth century would a unified and independent medical profession be established in the United States. The delay occurred largely because of the lack of standardized educational and licensing requirements for doctors and because of the sharp divisions that existed within the medical community.
American Physicians. By 1850 the United States had forty-two medical schools; France, by comparison, had only three. Quantity did not signify quality, however. Many schools were established by doctors to enhance their own prestige rather than to promote a true medical education. Standards were frequently low, and the length of study was often kept to a minimum. In the 1820s, moreover, state legislatures had begun to repeal medical licensing laws that had been enacted in the eighteenth and early nineteenth centuries because many Americans viewed licensing as an abuse of privilege and an opportunity for favoritism. Lack of licensing requirements meant that American medicine in the mid nineteenth century included doctors who practiced conventional medicine and those who preferred homeopathy and other non-mainstream forms.
RISE OF WOMEN PHYSICIANS
In 1849 Elizabeth Blackwell became the first woman in the United States — and in the modern world — to earn a medical degree. Her sister Emily received her M.D. in 1854, and the two women lobbied for women’s hospitals and greater access to professional medical education for women. In an 1864 address Elizabeth Blackwell describes the opposition she met in her quest to practice medicine and reflects on the progress women have made in the field since then:
Let us then take up the main question, and that we may realize that the practice of medicine by women is a growing influence, and cannot be overlooked, allow me to state a few facts drawn from personal experience.
In 1845 when I resolved to become a physician, six eminent physicians, in different parts of the country were written to, for advice. They all united in dissuading me, stating, “That it was an utter impossibility for a woman to obtain a medical education; that the idea though good in itself, was eccentric and Utopian, utterly impracticable!” It was only by long-continued searching through all the colleges of the country, that one was at last found willing to grant admission. When I entered college in 1847, the ladies of the town pronounced the undertaking crazy, or worse, and declared they would die rather than employ a woman as a physician. In 1852, when establishing myself in New York there was the utmost difficulty in finding a boarding-house where the simple name, as physician could be placed; ladies would not reside in a house so marked, and expressed utmost astonishment that it should be allowed in a respectable establishment. I presented American and foreign testimonials of medical qualification, to one of the city Dispensaries, asking admission as assistant physician, in the department of diseases of women and children; the request was refused. I asked permission to visit in the female wards of one of the city hospitals; the application was laid on the table, not being considered worthy even of notice. There was a blank wall of social and professional antagonism, facing the woman physician, that formed a situation of singular and painful loneliness, leaving her without support, respect, or professional counsel,
. . . Since that time ten medical schools have received women as students, and given them the diploma of Doctor. In three states, female medical schools have been established, holding charters granted by State legislatures; the diploma conferred by them placing their graduates on exactly the same legal footing, as the ordinary physician; the corporators of these female colleges being respectable bodies of men and women, and in some instances enlisting the sanction, by subscription, of a very large number of influential citizens. From the most accurate data, which we have been able to collect, several hundred women have been graduated as physicians at these schools within the last ten years.
Source: Elizabeth and Emily Blackwell, Address on the Medical Education of Women (New York: Baptist & Taylor, 1864).
Attempts at Reform. In 1846 a group of physicians met in New York to establish the American Medical Association (AMA). Composed mainly of younger, less-well-established doctors, the organization’s main goals were to raise and standardize educational requirements for a medical degree and to create a code of ethics that would distinguish “regular” doctors from “irregular” ones who practiced homeopathy or other “natural” forms of medicine. The AMA received little support in its first few decades: irregular practitioners, of whom there were many, viewed the organization with disdain, but established regular physicians also remained lukewarm in their support. Not until the early twentieth century did the AMA begin to exert significant influence in the medical community.
Postwar Changes. The medical field began to move toward greater professionalization after the Civil War as doctors, like other professionals, realized that unity would help protect their economic interests. Calls for the restoration of medical licensing increased in the 1870s, and states began to reimpose such requirements. At the same time, the rise of the modern university in the United States influenced medical education: like the German schools on which they were modeled, American universities increasingly stressed professional training. Educational reformers, such as Harvard University president Charles William Eliot, led the way in establishing higher educational standards for medical students: beginning in the fall of 1871 the academic year at Harvard Medical School was extended from four months to nine, students were required to attend three rather than two years of school, and laboratory work became mandatory in certain courses. Other universities soon adopted similar changes.
Nursing. Until Florence Nightingale emerged from the Crimean War as the most celebrated woman in the world, most nurses were not professionals but rather neighbors or relatives of homebound patients. Nurses who worked in hospitals were usually untrained and were sometimes conscripted from penitentiaries or almshouses. After the Civil War the growing number of hospitals increased the need for trained, professional nurses; but even then it was social reformers, rather than doctors, who initiated the change. In New York in 1872 a group of female, mostly upper-class reformers organized a committee to regulate treatment in almshouses and hospitals. At Manhattan’s Bellevue Hospital they found that patients were being kept in “unspeakable” conditions, and they noted many examples of unsanitary and negligent practices. When reformers established training schools for nurses in New York, New Haven, and Boston in 1873, they began the establishment of nursing as a profession. They attempted to attract nurses only from the “respectable” classes so as to make hospitals more attractive to the middle class and to have an uplifting effect on the poor.
Hospitals. The rise of nursing made possible the emergence of the modern hospital. During much of the nineteenth century hospitals did not occupy a central role in medical treatment. Since medical technology existed at only a rudimentary level, patients could obtain the same treatment at home as in the hospital; therefore, although some Americans visited doctors’ offices, dispensaries, or outpatient clinics, most received their medical care in their homes. Hospital patients consisted mainly
of the poor. The first American hospital survey, conducted in 1873, listed only 173 hospitals in the nation. These institutions were small, were not usually affiliated with medical schools, and did not emphasize medical research. During the Civil War conditions in hospitals began to improve. Basing their ideas on methods employed in the 1850s by the English nurse Florence Nightingale, organizations such as the United States Sanitary Commission drew attention to the need for proper medical sanitation and hygiene. Continued emphasis on hospital cleanliness and order after the war and the professionalization of nursing helped attract more Americans to hospitals in the 1860s and 1870s. Joseph Lister’s invention of antiseptic surgery in 1867 also began to change the nature of hospitals, although most physicians did not adopt the practice until the late 1870s. By 1877 hospitals were improving, but not until the end of the nineteenth century would they begin to resemble the institutions of today.
Public Health. Epidemics of cholera and yellow fever, which occurred on a fairly regular basis in some cities, led in the antebellum years to the organization of citizens’ sanitary associations. These groups attempted to prevent outbreaks of disease by keeping cities cleaner. Louisiana established the first state board of health in 1855, but not until the postwar years did cities and states create effective public health organizations. New York City’s Metropolitan Board of Health and the Massachusetts Board of Health, established in 1866 and 1869, respectively, helped set the standards for public health agencies. In 1872 doctors and reformers founded the American Public Health Association, which advocated greater regulatory powers for public health departments. In general, however, European countries were ahead of the United States in organizing health agencies: not until the twentieth century did the federal government organize a permanent public health department.
Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge: Cambridge University Press, 1987);
Charles E. Rosenberg, The Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987);
Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).