ECONOMIC obstacles also blocked the professional development of medicine in the nineteenth century. Medical practice offered too small a financial return for many doctors to invest in a lengthy professional education or for state legislatures to require one. Only in part were the meager economic rewards the result of competition with lay practitioners. The more fundamental reason was that the market for physicians’ services was limited by economic conditions that encouraged most families to care for themselves. These conditions are typical of preindustrial societies; they arise from the low level of real incomes and the geography of rural life. As these conditions changed in the nineteenth century, the economic opportunities of the medical profession expanded dramatically.
In early American society, medicine was relatively insignificant as an economic institution. Insofar as care of the sick remained within the family and communal circle, it was not a commodity: It had no price in money and was not “produced” for exchange, as were the trained skills and services of doctors. But when people in sickness and distress resorted to physicians, paid for hospital care, or bought patent medicines instead of preparing their own remedies, medical care passed from the household into the market. The shift of medical care into the market altered the social and economic relations of illness, yet the rule of market forces could never be complete. The public, as well as physicians, resisted treating medicine purely as a commodity and giving free rein to commercial impulses. And so the social history of medicine in the nineteenth century is a history of both the extension of the medical market and its restriction.
Nineteenth-century society, Karl Polanyi has written, was governed by just such a “double movement”: The market expanded continuously, reaching into almost every sphere of social life, but was met by a countermovement restraining its action. On one side, the principles of economic liberalism called for the release of the market from all constraint. On the other, the forces of “social protectionism” attempted to curb the devastating effects of the market on traditional institutions, nature, and even the economic system itself.1
These two political responses had their counterparts in medicine. The advocates of economic liberalism believed that in the care of the sick, as in other activities, private choice should prevail—hence their support for the abolition of all medical licensing. They thought people should be able to contract for treatment with whomever they wished; the market, in other words, could best regulate itself. On the opposing side of the issue, seeking protection from an unconstrained market, medical societies tried to limit entry into practice and commercial behavior, like price cutting and advertising. The countermovement was also evident in medical aid to the indigent and, after the turn of the century, government and professional regulation of the drug industry. In different ways, professionalism, charity, and government intervention were efforts to modify the action of the market, without abolishing it entirely.
THE EMERGING MARKET BEFORE THE CIVIL WAR
In one respect, the commercial nature of professional practice was more forthrightly acknowledged in America than in England. Under an ancient legal fiction, English law regarded the services of physicians as wholly philanthropic. While surgeons and apothecaries could sue for their fees, physicians could not. Similarly, the low-ranking English attorneys could sue clients for payment, but the elite barristers were presumed to be above material motives. Like the gradations of status among practitioners, these presumptions never successfully crossed the Atlantic.2 The only doctors ever barred from suing for fees in the United States were unlicensed practitioners. To be placed outside the market was an honor in an aristocratic culture, but a penalty in a democratic and commercial one.
In the late eighteenth and early nineteenth centuries, the state relinquished control over the market for professional services in what was perhaps the most crucial area—the determination of professional fees. Before the rise of laissez faire ideology in the nineteenth century, government played an active, explicit, and direct role in economic life that included the regulation of prices. In 1633 in Massachusetts the charging of extortionate prices was made punishable by law, and in 1639 the Virginia Assembly passed the first of several medical practice acts specifically providing for judicial action against “griping and avaricious” doctors levying exorbitant charges.3 In 1736, the House of Burgesses enacted a lengthy fee schedule for physicians. Whereas later schedules consisting of minimum fees would be issued by medical societies hoping to prevent price cutting, the earliest consisted of maximum fees aimed at preventing price gouging. Yet state determination of medical prices was short-lived. In 1766 the Chief Justice of Massachusetts ruled that “Travel for Physicians, their Drugs and Attendance have as fixed a Price as Goods sold by a Shopkeeper,” but this decision was reversed four years later when a physician was permitted to sue in quantum meruit (for the reasonable value of his services).4 State determination of lawyers’ fees eroded more slowly, the last traces finally disappearing around 1850.5 The price-setting mechanism shifted from law and custom to contract.
Thus the expansion of market forces in medicine originated in diminished state involvement as well as the attenuated role of the household in the treatment of the sick. In the mid-nineteenth century, particularly after the collapse of licensure in the 1830s and 1840s, the state had almost nothing to do with the private transactions between medical practitioners and their patients, except insofar as it guaranteed the sanctity of contracts and provided a means for determining and redressing negligence (malpractice). Some communities paid for medical treatment of the poor and maintained hospitals and pesthouses for contagious disease; some states gave small subsidies to medical schools, and by 1860 all the older states had constructed at least one mental asylum. The federal government maintained a limited system of compulsory hospital insurance for merchant seamen. But these functions were the extent of state intervention in the economics of medicine before the Civil War.
Medical societies tried to assume some functions the state had abandoned. “The law nowhere settles the precise value of professional opinion or advice,” noted an article in the New England Journal of Medicine and Surgery in 1825. “A fee table settles this . . .”6 Yet the fee bills often went unobserved and had, as one writer put it, “little importance as authorities.” A Philadelphia journal, publishing a fee schedule of the local College of Physicians in 1861, noted that this would be the first time most practitioners in the city had ever seen it, as charges had “not been guided by any fee-bill” at all. “Like literary labor,” the journal observed, “medical attendance is worth in the market what it will bring.”7
Most physicians were paid by a fee per service or a fee per case. Some were retained for a fixed fee per annum to provide all needed care to a family, a plantation, or the indigent members of a community. Called “contract practice,” this method—actually a primitive form of insurance—was frowned upon by many doctors, who believed they were exploited under the system because of the unlimited services they might be asked to provide. Indeed, such arrangements did place the entire burden of risk on the individual physician; the existence of such contracts testifies to the weak bargaining position of many doctors. However, despite its name, contract practice was no more or less contractual than other forms; the contract was just explicit, rather than implied. The legal system presumed a contract between doctor and patient (or someone acting on the patient’s behalf) even where none was expressly made.8
Much medical care was provided on credit. Physicians tried to collect their fees quarterly or annually, but they lost a substantial portion of their income through unpaid bills. The credit system, like contract practice, was a source of much irritation to doctors, but they were in no position to eliminate it. As probate records for New England doctors in the early 1800s indicate, many were enveloped in a tangled web of debt and credit relationships until their deaths. Practitioners in New England in the 1830s rarely received more than $500 a year in gross income. Much of this was paid in kind rather than money.9
The supply of physicians in the early and mid-nineteenth century was unrestricted by significant institutional barriers to entry. Because of the proliferation of medical schools, offering easy terms and quick degrees, the cost of medical education, in both money and time, was kept relatively low. Nor was an education beyond an apprenticeship always necessary. In five New England counties during the period from 1790 to 1840, the proportion of medical school graduates among practicing physicians ranged from 20 to 35 percent.10 In eastern Tennessee in 1850, according to a doctor of the era, there were 201 physicians, only 35 of whom (or 17 percent) were graduates of a school; 42 other practitioners claimed to have taken a course of lectures.11 The total investment necessary to enter medical practice in 1850, including direct expenses and opportunity costs, probably ranged between $500 and $1,300, depending on the degree of schooling.12 By contrast, the cost of establishing a farm in the West during the same period was likely to be larger, in the range of $1,000 to $2,000.13 And since neither licensing requirements nor a limit on the number of places in medical schools impeded entry into medicine, the supply of practitioners grew. Between 1790 and 1850, the number of physicians in the United States rose from five to forty thousand, a rate of growth faster than that of the population. As a result, the number of people per doctor dropped from about 950 to 600 during the same period.14 Doctors complained continually about overcrowding in the profession.
As a result of unrestricted entry into practice, doctors were apparently well distributed through rural areas. “Physicians, even in surplus quantity, were available to the most remote New England towns, but the competition was keen and not always amiable. The most common problems of new practice were the dearth of patients and lack of rapport with established doctors.”15 This pattern was repeated elsewhere. Preceptors often suggested to their students that they seek “stands” (practices) in the frontier communities in the West and South, but according to a recent study, “Wherever and whenever they went, acceptable stands were difficult to find.” In 1836 a young Vermont doctor thinking of settling in Georgia was told that the “only way to get practice would be to underbid those already practicing”; another, who graduated from Dartmouth in 1832, moved to a small village in Virginia because the best Virginia locations were already taken.16
Had educational and licensing requirements for medicine been more rigorous, physicians would undoubtedly have been more scarce, especially in rural areas. The money to be made in small towns and rural communities was too meager to recoup the investment in a lengthy education. The limited training of nineteenth century doctors was not so much an expression of ignorance as it was a response to economic realities—the limits of effective demand.17
THE CHANGING ECOLOGY OF MEDICAL PRACTICE
The Local Transportation Revolution
Low use of professional services was the fundamental constraint on medicine in early American society. Many physicians found it extremely difficult to support themselves solely from medical practice. A second occupation, usually farming, often proved necessary. “The resources of a farm,” Benjamin Rush observed in his advice to medical students, “will prevent your cherishing, even for a moment, an impious wish for the prevalence of sickness in your neighborhood.”18 Later, many doctors, especially in small town and frontier areas, ran drug stores; and druggists, if they were not previously doctors, often took up medical practice as part of their work. (One historian records a doctor who, “not satisfied with his practice, robbed stagecoaches on the side” before he was captured in 1855 and sent to prison.19 But he may have been looking for excitement.) Starting out in practice frequently meant protracted underemployment and hardship. “The fact is,” stated the Boston Medical and Surgical Journal in 1836, “there are dozens of doctors in all great towns, who scarcely see a patient from christmas-time to christmas-coming.”20
This pattern, Ivan Waddington has shown, is typical of medical practice in preindustrial societies. In eighteenth- and early nineteenth-century France and England, as in the United States, the demand for professional advice was limited by the inability of the great mass of the population to afford services and the persistence of traditional and domestic forms of treatment. Doctors had difficulty setting themselves up in practice and many abandoned the occupation entirely.21 The structural problem everywhere was the same: Given the limited extent of the market, physicians could not lucratively monopolize the medical work available in the society. In Europe, a small elite of physicians confined itself to practice among the rich and separated itself from other practitioners. This “status professionalism” had broken down in America. The more numerous American physicians, scattered among small communities or overcrowded in the towns, struggled on under modest circumstances.
The inadequacy of local markets stemmed partly from Americans’ ingrained self-reliance, their disbelief in the value of professional medicine, and the ease with which competitors entered the field. Some may wish to argue that all these factors were ultimately reducible to the ineffectiveness of contemporary therapeutics. It is not clear, however, that doctors’ economic problems would have been resolved if they had the scientific knowledge of 1920 under the economic and cultural conditions of 1850 or even 1880. I leave aside, for the moment, the question of whether such knowledge would have been as widely recognized as authoritative. The basic problem would have remained the same: Most families could not have afforded to rely on physicians’ services.
The heart of the economic problem was not that the physicians’ fees were so high, but that the real price of medical care was so much higher than their fees. The price of medical services consists not only of the direct price (the physician’s fee, the charge for a hospital room) but also of the indirect price—the cost of transportation (if the patient travels to the doctor or sends another person to summon one) and the foregone value of the time taken to obtain medical care. In most discussions, only the direct price is taken into account, but this bias is unwarranted.22
In the early and mid-nineteenth century, the indirect price of medical services probably outweighed the direct price. Dispersed in a heavily rural society, lacking modern transportation, the great majority of the population was effectively cut off from ordinary recourse to physicians because of the prohibitive opportunity cost of travel. For a farmer, a trip of ten miles into town could mean an entire day’s lost work. Contemporary observers and historians have continually drawn attention to the isolation of rural life and most small communities before the twentieth century. This was as much an economic as a psychological fact.
The self-sufficiency of the household in early American society was never complete, but it was quite extensive, particularly in the frontier, back-country, and rural communities where most Americans lived. Families produced not only food for their own consumption, but also clothes, furniture, household utensils, farm implements, building materials, and many other necessities. After 1815 household manufacturers rapidly declined in New England; according to Rolla Tryon, the transition to shop and factory-made goods there was nearly accomplished by 1830. Elsewhere it took longer; the presence of a large frontier population through mid-century meant that the transition was “always taking place but never quite completed” in the country as a whole. “As soon as manufactured goods could be supplied from the sale or barter of the products of the farm, the home gave up its system of manufacturing, which had been largely carried on more through necessity than desire. Generally speaking, by 1860 the factory, through the aid of improved means of transportation, was able to supply the needs of the people for manufactured commodities.”23
A similar, but slower transition from the household to the market economy took place in the production of personal services. For rural families, the time it took to procure specialized services outside the household greatly increased their cost. The growth of cities, the advent of modern means of transportation, and the building of hard roads radically altered the structure of prices. By reducing the opportunity and transportation costs for services, urbanization and improved transportation generally promoted the substitution of paid, specialized labor for the unpaid, unspecialized labor of the household or local community. Getting a haircut, visiting a prostitute, and consulting a doctor all became, on the average, less expensive because of reduced costs of time.
Data contained in nineteenth-century fee tables provide a basis for estimating the relation between direct and indirect prices. The fee bills published by medical societies may be poor indicators of average charges, but they are probably reliable as indicators of the relative value of different services. In addition to a basic fee for a physician visit, almost all nineteenth-century fee schedules list a charge per mile if the doctor needed to travel out of town. The charge for mileage represents an estimate of the foregone value to the doctor of the time spent in traveling, plus the expense of his personal transportation (a horse, or horse and buggy). We may assume that time had about the same value for patients as for their physicians. (This assumption probably holds for the nineteenth century, though it would be untenable today because of the high median income of physicians relative to the population at large.) Thus the monetary value doctors assigned to travel may give us an estimate of the indirect prices faced by patients when they called on the doctor.
Nineteenth-century fee bills vary from one region to another, especially between urban and rural areas, but the importance of indirect prices is evident everywhere. A few examples will suffice to make the point. In 1843 in Addison County, Vermont, the fee for each visit by a doctor was 50 cents at less than half a mile; $1.00 between a half mile and two miles; $1.50 between two and four miles; $2.50 between four and six miles and so on. In Mississippi the same year, according to a report in a Boston journal, a visit cost $1, while the charge for travel was $1 per mile during the day ($2 at night).24 These ratios between charges for service and mileage are typical. Even at relatively short distances, the share of the total price due to traveling and opportunity costs exceeded the physician’s ordinary fee; at a distance of five or ten miles, the mileage charges typically amounted to four or five times the basic fee for a visit.25
For major services, the indirect price became less significant; the fee for serious operations could overshadow the charge for mileage. So indirect prices especially limited use of physicians’ services in routine illness. In rural areas, many families would not think of calling in a doctor except under the most grave conditions.
When patients were treated at home, before the advent of the telephone, the doctor had to be summoned in person. So the costs of travel were often doubled, as two people, the physician and an emissary, had to make the trip back and forth. Furthermore, since the doctor was often out on calls, there was no guarantee that he would be found when someone went in search of him. A doctor from the District of Columbia, observing that no physician in Washington during the 1840s or 1850s kept regular office hours, later recalled, “Patients and other persons wishing to consult [a doctor] waited at irregular times for indefinite periods, or went away and came back, or followed in pursuit in the direction last seen, and sometimes waited at houses to which it was known the doctor would come. . . . The only certain time at which one could be found was when [one was] in bed and had not instructed the servant to deny the fact.”26
Before the construction of hard roads, according to one Illinois practitioner, “The doctor did not often go more than ten miles from his home.”27 Within that radius were a limited number of patients. The size of the market might be enough to keep village practitioners hard at work, but not enough to enable them to set the terms of business and limit their practice to an office. The doctor of the early and mid-nineteenth century passed much of his day (and many of his nights) traveling along back country roads. Autobiographies of nineteenth-century doctors dwell on these long periods of solitude and the weariness that often came over them on their rides. As one doctor put it, he spent “half of his life in the mud and the other half in the dust.”28 In several nineteenth-century fee schedules, a fee for an entire day’s attendance by a doctor is given as $5 or $10. (The average daily income for doctors, depending on locality, probably fell within or below this range.) These same fee schedules list the charge for an office visit at $1.00 or $1.50.29 It seems likely, therefore, that doctors in the early and mid-1800s were seeing no more than an average of five to seven patients a day (in urban areas perhaps more, in rural areas less).
The high costs of travel contributed to the individualism and isolation of medical practice. The country practitioner had to rely on his own devices; consultations were not readily available. Practitioners might be long out of touch with new developments; or if apprised of them, completely on their own in carrying them out. “The first appendectomy many a doctor saw was the first he himself performed after this operation came into use in the late 1880s and the 1890s,” remarks a historian of medicine in Oregon.30
As more Americans and more physicians began to live in larger towns and cities, they came in closer contact with both their patients and their colleagues. The proportion of Americans living in towns of 2,500 or more increased from just 6 percent in 1800 to 15 percent by 1850; it then jumped to 37 percent in 1890 and 46 percent in 1910.31 In the late nineteenth century, doctors moved to cities even more rapidly than the population as a whole. Between 1870 and 1910, the number of physicians per 100,000 people grew from 177 to 241 in the large cities, while it fell from 160 to 152 in the rest of the country—this during a time when the overall ratio of doctors to population was still increasing.32
The rise of cities was brought about partly by the building of canals and the development of steamboats and railroads. This “transportation revolution” widened the markets of cities and enabled the larger and stronger producers to penetrate what were previously fragmented local markets. On a more modest scale, the railroads and the telegraph helped widen doctors’ markets by expanding the territory they could cover. This proved a boon especially to consultants; one mentions logging ten thousand miles of railroad travel in a half year.33 If the railroad did not take physicians all the way to their destination, a carriage might be waiting for them when they alighted. Doctors were such frequent users of railroads that some treated injuries to railroad workers in exchange for a travel pass. The railroads also brought in patients from a distance and naturally doctors wanted to be in towns along the routes to enjoy the benefits. In cities, they had a similar incentive to locate along the routes followed by streetcars.34
The transportation revolution of the nineteenth century has generally been considered from the standpoint of regional and long-distance flows of commodities, information, and even disease. But there was also a revolution in local travel. One historian remarks, “The automobile and the telephone did not greatly lower the cost of transportation as had been the case with the railroad in the 19th century.”35 Though this may be true of inter-city transportation between two points along main routes, it does not apply to local travel.
The telephone made it less costly to reach a physician by greatly reducing the time formerly spent tracking down the peripatetic practitioner on foot. Phones first became available in the late 1870s. Curiously, the first rudimentary telephone exchange on record, built in 1877, connected the Capital Avenue Drugstore in Hartford, Connecticut, with twenty-one local doctors.36 (Drugstores had often served as message centers for physicians.) The first telephone line in Rochester, Minnesota, set up in December 1879, connected the farmhouse of Dr. William Worrall Mayo with Geisinger and Newton’s drugstore downtown.37 As telephones became more widespread, families could, of course, keep continually in touch with the doctor without a visit. In an apt analogy, one manual for medical practice in 1923 commented that the telephone had become as necessary to the physician as the stethoscope.38
As automobiles, first produced in the 1890s, became more reliable after the turn of the century, they further reduced time lost in travel. Doctors were among the earliest to buy cars. Physicians who wrote to the Journal of the American Medical Association, which published several supplements on automobiles between 1906 and 1912, reported that an auto cut the time required for house calls in half. “It is the same as if the day had forty-eight hours instead of twenty-four,” a doctor from Iowa rejoiced.39 “Besides making calls in one-half the time,” wrote a physician from Oklahoma, “there is something about the auto that is infatuating, and the more you ride the more you want to ride.”40 In a 1910 survey of readers that drew 324 replies concerning automobiles, three out of five doctors said they had increased their income; answering a slightly different question, four out of five agreed that it “pays to own a car.” The survey asked physicians using either automobiles or horses to give their annual mileage and costs, including maintenance and depreciation. The 96 physicians still using horses reported costs that work out to 13 cents a mile; for the 116 who owned low-priced cars (under $1,000), the cost per mile was 5.6 cents. It came to 9 cents for 208 doctors who owned cars priced over $1,000. However, the initial investment in purchasing a car was greater than in buying a horse.41 “To assert that it costs no more to run a car than to keep up a team is absurd,” insisted one physician. “But if one considers the time saved on the road, and the consequent additional business made possible, to say nothing of the lessened discomfort, a busy practitioner will find a large balance on the side of the motor car.”42
Besides saving time, the automobile, like the railroad, widened the doctors’ market geographically. In 1912, a Chicago physician noted that the residential mobility of patients required doctors to drive a car. “Chicago today is a city of flats [apartments], and people move so, that a patient living within a block today may be living five miles away next month. It is impossible to hold one’s business unless one can answer calls quickly, and this is impossible without a motor car. I have not only held my own, but have increased my business by making distant calls promptly . . . [averaging] about 75 miles a day . . .”43
Just as telephones, automobiles, and hard roads enabled physicians to cut down on traveling costs, so they enabled patients to do the same in visiting doctors’ offices. Reduced traveling time in both directions cut the cost of medical care and raised the supply of physicians’ services, by increasing the proportion of doctors’ time available for contact with patients.
The reduction of indirect prices from the local transportation revolution and the rise of cities put medical care within the income range of more people; in this way, it had the same effect as cost reductions from new technology in manufacturing. Underlying the shift from household to market in manufactured goods were radical changes in productivity that drastically altered relative prices. In the production of textiles, for example, family manufacture was virtually eliminated in a remarkably short period. In 1815 the power loom was introduced in Massachusets; by 1830 the price of ordinary brown shirting had fallen from 42 to 7.5 cents a yard. A woman at home could weave 4 yards of the cloth in a day; one worker in a factory, tending several power looms, could turn out 90 to 160 yards daily. There was no way women at home could compete.44
In medicine, no radical or sudden change in technology drastically cut the cost of producing physicians’ services; there was only the gradual erosion of indirect prices that came from more rapid transportation and more concentrated urban life. Though difficult to measure, the “productivity” of physicians (measured simply as services to patients per day) significantly increased. I mentioned before that physicians probably averaged no more than five to seven patients a day in the mid-nineteenth century. In contrast, by the early 1940s, the average load of general practitioners, rural and urban, was about eighteen to twenty-two patients daily.45 Such figures suggest a gain in productivity for practicing doctors on the order of 300 percent. For surgeons, the gains have been much larger, considering the infrequency of surgery before antisepsis.
The local transportation revolution also improved the efficacy of treatment by reducing the isolation of medical practice. It made possible more rapid intervention in emergencies, and the ambulance was meant to accelerate that process. Reduced distances may also have had a psychological effect: Increasingly, one came to expect the doctor’s intervention. Improved access ultimately brought greater dependency.
Work, Time and the Segregation of Disorder
A second development also contributed to the saving of professional time and the expansion of professional opportunities. This was the growing concentration of patients in institutions. I have already mentioned that the development of large hospitals in Paris in the early nineteenth century was a factor in the emergence of modern clinical investigation. For both economic and scientific reasons, the rise of hospitals was a key precondition for the formation of a sovereign profession. In the case of psychiatry, hospitals constituted the basic framework of professionalism. There was no private practice in psychiatry in the early nineteenth century. The mental asylum created not only a new institutional market for doctors, but also a new sphere in which they could exercise authority.
In the early nineteenth century, there was little demand for the services of general hospitals in America. Almost no one who had a choice sought hospital care. Hospitals were regarded with dread, and rightly so. They were dangerous places; when sick, people were safer at home. The few who became patients went into hospitals because of special circumstances, which generally had to do with isolation of one kind or another from the networks of familial assistance. They might be seamen in a strange port, travelers, homeless paupers, or the solitary aged—those who, traveling or destitute, were unlucky enough to fall sick without family, friends, or servants to care for them. Isolation was also related, but in a converse fashion, to the kindred institutions of pesthouse and asylum. There, isolation (or respite) from the community was the intent rather than the occasion of removal to an institution.
The rise of mental hospitals followed closely upon the rise of cities in America. In the colonial period, the mentally ill, along with other classes of dependents, were treated as a local responsibility, primarily within their own or other families. The growth of cities in the early nineteenth century changed the character of the problem. An increase in scale brought higher concentrations of the insane, the breakdown of informal controls, and a greater demand for order and security. The first of the new institutions for the mentally ill in America were philanthropic. Originally intended to serve the entire community, they gradually became oriented to the more affluent, as their resources proved inadequate to make available free care to the indigent. Beginning in the 1820s, some purely proprietary asylums were also opened for the insane from prosperous families. In the late 1820s, studies of public welfare recommended a general shift from “outdoor” relief (in homes) to “indoor” relief (in institutions); the expansion of asylums under state authority began in the next decade. By the 1840s a psychiatric profession had begun to appear. As Gerald Grob suggests, the institutions played a greater role in shaping psychiatry in the nineteenth century than psychiatry played in shaping the institutions.46
The explanation for the emergence of specialized institutions for the mentally ill is not, of course, strictly demographic. The need for urban security might have been met by other means, such as the expansion of almshouses. But the changes in material life in the late eighteenth and early nineteenth centuries took place against the backdrop of greater optimism about the plasticity of human nature. During the French Revolution, reforms introduced into the treatment of the mentally ill expressed a new conviction that the insane could be cured rather than simply restrained. The new “moral treatment” of Pinel in France was introduced independently by Tuke in England. Americans were acquainted with these efforts, and the broader religious and ideological currents in American society favored the same kind of positive effort to cure. Although the new treatment in all three countries was as much moral as medical, the leading figures were physicians.47
For American doctors, mental asylums offered important opportunities. Superintendents received between $1,000 and $2,000 a year.48 Moreover, asylums offered the physician the chance to exercise judgment and control in a sphere where there was relatively little resistance to his authority. Some of the superintendents also used their positions as platforms from which they lectured the public on the relationship of mental illness, vice, and the disorders of modern civilization. Although, by the 1840s, most superintendents were doctors, they kept aloof from other physicians. And, increasingly, as mental hospitals shifted from therapeutic to custodial functions, psychiatry became primarily an administrative rather than a medical specialty.49
Although the earliest general hospitals predate mental asylums, the period of most rapid growth occurred about a half century later. In 1873 a government survey counted fewer than 200 hospitals. By 1910 over four thousand were counted, and by 1920 more than six thousand.50
Changes in both the family and the hospital affected their relative capacity to manage treatment of the sick. The separation of work from residence made it more difficult to attend the sick at home. With industrialization and high geographic mobility in America, the conjugal family also became more isolated from the threads of kinship, and so fewer relatives were close by in case of illness. To say, however, that there was a shift from an extended to a nuclear family in the nineteenth century may exaggerate the degree of change. Average household size declined from 5.7 persons in 1790 to 4.8 in 1900. On the whole, family structure seems to have had a “modern” shape in America even before industrialization.51 But significant change did take place in the size of upper-class households. In 1790 in Salem, Massachusetts, the households of merchants averaged 9.8 persons, master carpenters 6.7, and laborers 5.4. By the end of the nineteenth century, families in different classes were equally small.52 Well-to-do households diminished in size because of the decline in the number of domestic servants as well as children. Also, urban growth led to higher property values, forcing many families to abandon private houses for apartments in multi-family dwellings, which limited their ability to set aside rooms for sickness or childbirth. A 1913 analysis of the decline of home care of the sick noted, “Fewer families occupy a single dwelling, and the tiny flat or contracted apartment no longer is sufficient to accommodate sick members of the family. . . . The sick are better cared for [in hospitals] with less waste of energy, and their presence in the home does not interrupt the occupations and exhaust the means of wage earners . . . The day of the general home care of the sick can never return.”53
Industrialization and urban life also brought an increase in the number of unattached individuals living alone in cities. In Boston between 1880 and 1900, boarding and lodging house keepers rose in number from 601 to 1,570, almost double the rate of population growth for the city. An array of new establishments—laundries, eating places, tailors—sprang up to meet the needs of this class. The hospital, as Morris Vogel points out, was one of these “corollary” institutions. In England and America, many of the first hospitals to care for private patients were built with lodgers and apartment-house dwellers especially in mind.54
All these changes meant less labor power and physical space at home to handle the acutely ill. Talcott Parsons and Renée Fox have further speculated that the modern urban family lost some of its emotional capacity to deal with illness. They argue that the small size and increased isolation of the conjugal family make it peculiarly vulnerable to strains created by illness: One member of the family cannot be attended at home without draining emotional support and attention from the others. When one becomes ill, others are often likely to be overly indulgent, inviting perpetuation of sickness, or possibly overly severe, disrupting recovery. Illness, they suggest, has become an increasingly attractive “semi-legitimate channel” of withdrawal from daily routines. And so the growth of hospitals can be explained as the emergence of an alternative mechanism to handle these motivational problems to encourage recovery and the resumption of normal obligations.55
Working-class households did not undergo the changes in size and structure that this line of argument presumes. They were small even before the nineteenth century because of high infant mortality and the early departure of children into the labor force. But the Parsons-Fox hypothesis seems more plausible when restricted to the middle and upper social strata. One newspaper account in 1900, emphasizing that hospitals were “A Boon Not Only to the Poor But to the Well-to-do,” describes them as affording “great relief to the family from physical as well as mental strain.” Observed a hospital director, “It can be put down as one of the advantages of a hospital that the relatives and friends do not take care of the patients. It is much better for them not to be under the care of anyone who is overconcerned for them.”56
From the beginning of the industrial era, changes in work and family structure probably created a growing disposition in favor of extra-familial care. However, the dangers of infection in general hospitals led families to manage physical illness at home if they could possibly do so. The reforms in hospital hygiene and the advent of antiseptic surgery both came after the Civil War and probably account for the delay in the growth of general hospitals until after the mental asylum had become widely accepted. General hospitals were also more directly affected by changes in transportation. In an unmechanized rural society, the general hospital is inaccessible in most cases of short-term acute illness, but use of a mental hospital depends less on quick access. Because of its relation to broad cultural concerns over the stability of the social order, the mental asylum has had a different history from the general hospital. The asylum could serve the public functions of the control and confinement of mental disorder when the general hospital was still unsuitable for illnesses of a more purely physical character.
Both institutions relieved the household of obligations that interfered with employment in the market economy. The segregation of sickness and insanity, childbirth and death was part of a rationalization of everyday life—the exclusion from daily experience of disturbances and strains that made difficult participation in the routine of industrial society. The segregation of disorder also reflected the growing tendency to exclude pain from public view. As John Stuart Mill once remarked, “One of the effects of civilization (not to say one of the ingredients in it) is, that the spectacle, and even the very idea of pain, is more and more kept out of the sight of those classes who enjoy in their fullness the benefits of civilization.”57
Yet this very deep-run current to segregate pain and illness as private events reinforced the desire of more prosperous families to receive physicians in the privacy of their own homes, rather than go to the more public setting of the office or hospital. The different loci of medical care had different moral connotations. Treatment in offices and hospitals was generally regarded as a mark of lower status. It is a measure of the changing position of the profession and medicine’s success in overcoming the feelings of delicacy accentuated by the Victorian sensibility that this stigma was gradually overcome. By the turn of the century, the office and the hospital were losing their traditional moral taint, and the home was in decline as a place for physicians’ services. Again, economic considerations were partly at work. The telephone made it much easier for patients to see physicians at their offices at a prearranged time, reducing the risk of dropping in while the doctor was out on call; it also made office practice more attractive to doctors, who could now make orderly appointment hours and see more patients than when relying on an uneven stream, or trickle, to their door. As physicians’ incomes rose relative to the population at large, patients had an increased incentive to substitute their own travel time for that of the doctors. The shift from home to office was also encouraged by the growing use of clinical equipment and ancillary personnel. And as the doctors’ social position rose, they increasingly expected the patient not to waste their time, which had become so much more valuable.
The concentration of patients in hospitals and offices (and the relocation of physicians’ offices next to hospitals) added to the effects of urbanization and improved transport: The space in which the physician worked became steadily more compressed. The doctor of the nineteenth century was a local traveler who knew the interior of his patients’ homes and private lives more deeply than did others in the community. By the early twentieth century, many physicians went to work at hospitals or offices and had little contact with the homes or living conditions of the patients they treated. These radical changes in the ecology of medical practice enabled physicians to squeeze unproductive time out of their working day. This had obvious advantages. One physician commented in 1909 that “as a matter of dollars and cents I can attend ten patients in a hospital at less cost to myself than I can attend to perhaps three cases outside, because in a few minutes I can go through the whole hospital list, whereas, in the three cases outside, no two of them might be nearer together than two or three miles.”58
The local transportation revolution, urbanization and the rise of hospitals widened the medical market and created new opportunities for physicians. Among these was specialization. The division of labor, as Adam Smith pointed out in his key discovery in The Wealth of Nations, varies according to the extent of the market. As the medical market grew, so did the opportunity and the incentive to specialize. Specialization gives producers partial relief from competition and enables them to take advantage of whatever comparative advantage they may enjoy. The specialist typically gives up those services offering the lowest return and concentrates on those offering the highest. In medicine, these are often services performed in hospitals because of the indirect savings in time to the physician and the standard of higher fees for procedures that are or were at one time complex.
The changing ecology of medical practice thus had tremendous economic significance in enabling physicians to reduce their unit costs, to increase the volume of their practice, and to specialize. But these were not the only effects of changes in the market. The same changes that brought increased opportunities also brought greater competition.
THE MARKET AND PROFESSIONAL AUTONOMY
The expansion of the market made possible a transformation of the profession but did not guarantee it. While demand for services grew, so did the supply of professional time. Not only did doctors continue to become more plentiful, but each doctor represented more medical service as a result of the squeezing of wasted time from the professional working day. Furthermore, midwives and other practitioners who specialized in tasks claimed by physicians could potentially share in the growth of the medical market. The concentration of patients in hospitals might give hospitals control of doctors. Physicians stood to benefit only if they could control the supply of practitioners, the division of labor, and their own relation to organizations.
The effect of improved transportation was also to expose doctors to more competition from nearby colleagues. The practitioner in a small town who formerly enjoyed a monopoly, albeit a small one, now had to worry that his patients might use a practitioner or a hospital in another town. As improvements in transportation and communication put a larger market within reach of the practitioner, they also put the practitioner within reach of competition from his peers and distant institutions.
The same processes were at work throughout the economy in the nineteenth century. Local businessmen continually found their markets invaded by outsiders. The widening of industrial markets brought about by the railroads was analogous to the increased radius of medical practice brought about by railroads, automobiles, and telephones. As the local businessman struggled to survive the rise of the big corporation, so the small-town general practitioner had to contend with the increased accessibility of the urban specialist and hospital.
The expansion of the market affected the development of medicine in Europe as well as America, but the impact was somewhat different. In England, the rise of a middle-class market for medical care contributed to a decline in the dependence of doctors on aristocratic patrons. “The widening of the market for professional services,” writes the S. W. F. Holloway in an account of changes in English medicine between 1830 and 1858, “had a profound effect upon the relationship between the practitioner and his clients. As the demand for medical care increased, the importance for the doctor’s livelihood of any one patient declined. Instead of a small group of wealthy and aristocratic patients, the market now comprised a large and growing section of society. . . . In the eighteenth century the patient was the dominant figure in the relationship; in the nineteenth century the power positions were reversed.”59
The traditional hierarchy of English medicine broke down in the mid-nineteenth century as a consequence of these economic developments and the impact of new scientific advances that began in France. By the 1830s the leading surgeons were no longer confining themselves to manual operation, but were also practicing as physicians. At the same time, the emergence of concepts of localized pathology and modern techniques of clinical examination made it difficult for physicians to continue refusing to perform any manual procedures. An increasing number of physicians and surgeons began engaging in “general practice” (as it was now being called) among the growing middle classes. The line between these general practitioners and the apothecaries became unclear, especially as apothecaries could now receive a higher education at University College London. In fact, two out of every five members of the College of Surgeons also held a license from the Society of Apothecaries. The preface to a medical directory in 1847 noted that the traditional system of classification had become “almost obsolete.” Physicians, surgeons, and apothecaries were “by the force of a public convenience they cannot withstand, being gradually classed into Consulting and General Practitioners.”60 In 1858 Parliament created a a single register for all medical practitioners and a council to coordinate all medical education in the United Kingdom. This was the key step in the emergence of an autonomous and unified medical profession in Great Britain. American doctors would wait another half century for an analogous breakthrough in medical education and state support.