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The State of Medicine in the Old West

by Christine Jeffords

Nathan Jackson frequently insists that he's "no doctor," just a man who knows "something about healing." But, in a very real sense, that was all any 19th-Century doctor was, regardless of whether he had the advantage of a specialized medical education or not.

Although the profession was a highly respected one from Colonial days, most American doctors, as late as 1876, had never even seen a medical school, or, at best, had spent a few months of required college study to receive an M.D. degree. Instead they apprenticed to an established doctor in their home town until they had learned all he knew, then put on a bit of polish by finding a school that would award a diploma for just two or three semesters of attendance--or simply got a letter of recommendation from their mentor and went into business for themselves. Often they began as assistants in a drugstore, mixing prescriptions until they learned what medicine was prescribed for which ailment, then went on to study with a local physician, a system known as "reading medicine:" the hopeful paid his teacher $100-$250, then boarded in the latter's home, read his books (concentrating chiefly on biology, anatomy, chemistry, physiology, and pharmacy), swept the office, kept the accounts, chopped the firewood, delivered messages, ran errands, looked after the horse, mixed plasters and gathered herbs and pounded drugs, and tagged along on house calls till he picked up enough medical knowledge to strike out on his own--three years was generally considered sufficient. One doctor, in 1875, described his apprentice-trained colleagues as "honest, conscientious, hard-working men, who are inclined to place great weight on their experience, and to be rather contemptuous of what they call 'book learning and theories.'" Even at Harvard in 1866-79, medical students were required to attend only two courses of lectures, not quite four months long; then, if they could present certificates from some medical school or doctor showing three years' total study, and pass a nominal examination, a degree was awarded them without further fuss. This state of affairs continued until Charles W. Eliot and Dr. Oliver Wendell Holmes, Sr. mounted a campaign intended to improve the requirements to be met by would-be doctors, and in the meantime, perhaps because quacks and malpractitioners were so widespread, the study of medicine was long frowned upon by the socially elite, who encouraged their sons to enter law or the ministry instead.

It has been estimated that of the 3500 doctors in practise at the time of the Revolution, less than 400 (11.42%) held university degrees; the rest had gone the apprenticeship route. Even Dr. William Beaumont, an Army surgeon in 1822 and the author of pioneering work on the mechanics of digestion, had never gone to medical school. The great Dr. Benjamin Rush (1745-1813) was devoted to bloodletting and calomel, backed up by physicking, sweating, diuretics, vomiting, and blisters; he trained 3000 doctors who followed the same methods, and they held sway till cut down by the Paris-trained Dr. Elisha Bartlett in 1844, though bloodletting was first called into question by Dr. P. C. A. Louis in his famous book on phthisis (1825) and in Effects of Bloodletting ten years later. As late as 1860, most cures were based on the theory that all illnesses could be cured by dramatic purging or bleeding, and as for drugs, Dr. Oliver Wendell Holmes, Sr., could baldly state, "I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind--and the worse for the fishes." Holmes showed a healthy skepticism of medical cure-alls and relied heavily upon wholesome diet and pleasant surroundings for natural cures, but he was in the minority among conventionally trained doctors. Medicine was still handcuffed by arbitrary theories inherited from the ancient and medieval worlds, based on the principle that disease came of imbalance among the "humors," or basic body elements, and that the physician's task was to restore the balance by dosage with violent drugs, bleeding, and so on. Hence his favorite weapons against disease were bleeding, cupping, harsh emetics, purgatives, blistering with hot flaxseed poultices and mustard plasters for throat and chest troubles, large doses of calomel, quinine, and jalap in equal mixture (the favorite of several strong laxatives in use), emetics of ipecac to induce vomiting, blue mass pills, Epsom salts, and castor oil. Hence too the probably needless death of George Washington in 1797: still vigorous at the age of 67, he caught cold and called in the doctors, who conscientiously weakened him by prolonged bleeding, then by calomel to purge his bowels and tartar emetic to make him vomit, then applied blistering poultices. As late as 1875, Dr. Herruck's Almanac repeated as relevant the ironic anecdote of how Rabelais, lying on his deathbed and listening to the plans of his physicians, was supposed to have said, "Pray, let me die a natural death."

The first American medical school, at the University of Pennsylvania, Philadelphia, was begun in 1765, modelled after the one in Edinburgh; students were not only trained in medical theory, but had to "walk the wards" at Pennsylvania Hospital. New York got its first medical school (at King's College, later Columbia), in 1768; 39 years later it became the Columbia College of Physicians & Surgeons. By 1810 four more American medical schools had joined these pioneers--Dartmouth (est. 1798), Harvard, Yale (est. 1803), and Transylvania, besides the Maryland department of medicine (1807)--but during the next decade 20 more appeared, 40 more between 1830-40 (including Chicago's Rush Medical College, begun in 1839, when the city was barely more than a muddy hamlet), and at least another 20 1840-50. Ohio Medical College at Cincinnati (1819) and Worthington Medical College (1832) early helped to raise the level of the medical profession in the Old Northwest. By the Romantic Period a doctor was expected to have at least the degree of Bachelor of Medicine, taken after finishing two school terms (though Edinburgh required four years). Harvard was held in high esteem from 1830-50, and the University of Pennsylvania drew many from the South. By 1847 the medical schools of Philadelphia were the Mecca of every would-be doctor in the country. In the '40's, Harvard, Philadelphia, Jefferson (a Philadelphia school), and Louisville offered well-reputed medical schools; an eight-month course, spread out over two winter terms, was the extent of the training (the students sometimes spent their breaks working in neighboring hospitals for the experience), and into the following decade American schools offered programs limited to lectures, three months a year, for two years, and little or no practical training; their great advantage was their cheapness, about $146.50 for the whole. By the late '50's most medical schools had increased their terms to three years (not till 1865 was a four-year course offered in this country), though as late as 1876 one in Baltimore still granted the right to practise after only two. In most the equivalent of high school (which usually meant a private academy) was a sufficient prerequisite for entry; only Harvard attracted a majority of students with general-college degrees. Reputable ones were few and far between, and a young man seriously interested in a career as a doctor often felt he had to attend a European university if he could afford it--often Edinburgh or Vienna, though France (particularly Paris), Germany, and England were other mid-century centers of knowledge and progress. Geneva Medical College, Geneva, N. Y., existed by 1847, when Elizabeth Blackwell entered it, and offered a two-year course; Syracuse Medical College, which graduated Dr. Mary Walker, by 1855. The Women's Medical College of Pennsylvania, the first real medical training center for women, was founded in 1850; the New York Women's Medical College was established (by Blackwell) in 1868. Some doctors studied at Massachusetts General Hospital in Boston. A would-be doctor studied anatomy, physiology, chemistry, and therapeutics, followed by materia medica, pharmacy, obstetrics, and elementary surgery. But few schools, even in 1870, offered any laboratory or clinical work.

By the death of Dr. Hermann Boerhaave in 1738, Leyden had become the most respected of medical schools, and its graduates established or revitalized institutions in Edinburgh, Vienna, and Goettingen, the first of which remained formidable until at least 1845. Still, up till the '30's, most American physicians, if they studied abroad, did so in English and Scottish medical schools (Edinburgh was a favorite goal), or perhaps at Leyden; afterward they began to leave these for France and Germany. The Emperor Napoleon I, whatever his faults, did much to make Paris the new center of medical science: his medical regulations of 1803 outlined and enforced a course of study involving four years at a state school (in Paris, Montpellier, Strassburg, Mainz, or Turin), with practical demonstrations heavily emphasized, and extensive examinations in anatomy, physiology, pathology, nosology, materia medica, chemistry, pharmacy, hygiene, and forensic and clinical medicine. He also eliminated the gulf between medicine and surgery which remained in effect in Britain (where a surgeon was addressed as Mister, not Doctor) for many years. The French concept of pathological medicine (tracing disease or illness to a specific organ or bodily part) was the greatest single factor in redirecting American medical research: illness could now be studied not as a person dying of "inflammation of the lungs," but as an example of a general pulmonary condition which could be identified as tuberculosis, pneumonia, bronchitis, or pleurisy. Till at least 1840 Paris remained at the head of the discipline, attracting the best minds in it, including the more well-to-do Americans, who, even if they started out in their native land, gravitated there for additional training. London and Edinburgh ran it a close second. German doctors, many of them trained in Paris, took over in the next decade: each of the German petty states had excellent universities, which, as the Paris alumni gained power, were gradually converted into research centers, with physiology, pathology, and bacteriology their greatest triumphs. (It was Johannes Peter Muller who produced a magnificent textbook, the Handbook of Human Physiology, in 1833-40, and F. J. G. Henle's Manual of Rational Pathology appeared in 1846-52.)

During the pre-Civil War years, though there were still physicians who sweated and purged, patent-medicine manufacturers who made fortunes, and "steam doctors" or eclectic physicians who dosed patients with herbs, more and better doctors were being trained and more research being done in medical theory than ever before. By 1815 digitalis was in use to treat cardiac patients, though for some time the doses were often too large and therefore fatal. From 1825 on there was a nationwide trade in artificial arms and legs. A Caesarean section was performed as early as 1827 in rural Ohio by one Dr. John L. Richmond (who was also a Baptist minister), using only candlelight and his pocket case of instruments; the child died, but the mother, a Negro, survived the experience and returned to work in only 24 days. Before 1850, 213 different medical journals were published; many lasted only a few issues, but at least 20 proved lasting. By 1865 there were 34 local and state medical societies, which established professional standards, raised morale, and provided means of professional cooperation. The stethoscope was in general use by 1826, the clinical thermometer by the 1830's, the otoscope by the '60's. Dr. Crawford Long used ether to produce surgical anesthesia in 1842, and administered it to his wife during the birth of their second child two years afterward. Unaware of Long's work, Dr. W. T. G. Morton first operated on an etherized patient at Massachusetts General Hospital in 1846, thereby convincing doctors of the great utility of that anesthetic ("Gentlemen," declared one observer, "this is no humbug!"); though it found immediate use in operations on Mexican War casualties, it met with a hard-minded opposition at first (pain had great ethical value, ether and chloroform could be used as intoxicants), until 1849, when Dr. Walter Channing, Professor of Midwifery and Medical Jurisprudence at Harvard, published a summary of over 500 instances of its successful use, and most doubters within the profession were satisfied. The substance was first used to achieve painless childbirth in Edinburgh in January of 1847, though it wasn't fully accepted until 1853, when Queen Victoria (who was almost as revered in this country as in her own) bore Prince Leopold under its influence. Still, even right on through the Civil War, many surgeons believed that "surgical shock" was necessary for the success of an operation.

Dr. Oliver Wendell Holmes, Sr., published his Contagiousness of Puerperal Fever in 1843; four years later Dr. I. T. Semmelweis discovered the connection between childbed fever and puerperal infection and was able to reduce deaths in the Vienna General Hospital's Maternity Ward from 12.4% to 1.27% in only two months, simply by requiring his students to wash their hands in chlorinated lime water and scrub their fingernails with a handbrush. Unable to convince hospital authorities to adopt his discovery as policy, he returned to his native Budapest, where in 1850 he was able to enforce antiseptic practises in the obstetrics ward of St. Rochus Hospital, and in 1861 he published his Childbed Fever. Surgeons, however, still refused to follow his lead, and it was left to Joseph Lister to initiate the age of antisepsis when, in August, 1865, he devised a continuous spray of carbolic acid to be used during operations, and developed a lint bandage soaked in carbolic acid. At this time Pasteur had just discovered that microscopic organisms caused fermentation in wine, and Lister seized on the similarity between fermentation and the formation of pus to "confirm" his theory that it was not air, but airborne bacteria, that caused infection in wounds. He also advised that surgeons wash their hands in a 1:20 carbolic acid solution. Though he was surrounded by a band of faithful students, many older surgeons especially looked on them as "crazy believers in vain things like germs." Lister was received politely when he came to America for the Centennial, but despite their generally progressive character, American surgeons were slow to adopt his teachings. It was in von Bergmann's clinic in Berlin that thorough disinfection of surgeons' hands, and the boiling of instruments, towels, gowns, etc., in the sterilizer, became common, leading to an increase in safe, successful abdominal surgeries. Not till the '80's were Listerian principles adopted at Mount Sinai Hospital in New York, and of course the custom spread to the hinterlands even more slowly. Until they became widely accepted, most surgeons amputated in cases of compound fracture because infection almost always set in; hence the great number of Civil War veterans missing one or more limbs. Yet as early as 1765 one London doctor was able to save a patient's leg following such a mishap, even though a long recovery was necessary. Lack of asepsis also meant that on the frontier an abdominal wound was almost always fatal. For all that, one Kansas doctor, in treating over 2500 pregnant women in the course of his frontier career, lost only two to infection, and in both cases the houses were described as filthy.

In 1847 nitroglycerin was shown to be useful in relieving the symptoms of angina pectoris (chest pain); amyl nitrate was found effective 20 years later. An appendectomy was performed by one Dr. Hancock as early as 1848. Claude Bernard demonstrated the glycogenic function of the liver in 1850. By the '50's the physician's knowledge of chest, heart, and kidney diseases had been much extended. The ophthalmoscope was invented by Helmholtz (author in 1856-66 of the Manual of Physiological Optics) in 1851 and quickly led to the development of surgical operations beneath the optic surface; the laryngoscope, which permitted the removal of tumor of the larynx (until then a sentence of death by suffocation), appeared three years later (invented, curiously enough, by a singing teacher named Manuel Garcia). In 1852 a Dutch army surgeon named Mathysen first impregnated bandages with plaster; the following year Alexander Wood used the hypodermic syringe for subcutaneous injections, and graduated needles came into general use in the following decade. Florence Nightingale introduced hygienic standards into military hospitals in 1855, during the Crimean War. In 1857 Louis Pasteur proved that fermentation was caused by living organisms, a giant step toward the articulation of the germ theory, which he tentatively articulated four years later in a paper refuting the idea of spontaneous generation. Henry Gray's Anatomy of the Human Body was published in 1858 and remained a standard text for over a century (Nathan almost certainly owns a copy of it). In 1859 Alfred Barring Garrod's Treatise on Gout and Rheumatic Gout showed that Galen, in the second century, had erred in blaming gout on overindulgence; instead, he said, it came from an excess of uric acid in the blood and could be controlled by avoiding foods high in purine and by using drugs such as colchicine. Barbiturates were first synthesized in 1864. The first successful operation for gallstones was performed on June 15, 1867, by Dr. John Stough Bobbs of Indianapolis. Massachusetts instituted the first State Board of Health in 1869--in which year the Harvard Medical School rejected President Eliot's demand that students be given written examinations, because "A majority of the students cannot write well enough"! In 1874 improved surgical dressings were pioneered by two inventors from East Orange, N.J., who succeeded in manufacturing an adhesive and medicated plaster with a rubber base. By 1876 doctors knew how to give anesthetics (though not exactly how much was too much) and administer transfusions (though they didn't yet know about blood types, only that some transfusions worked and some didn't). By 1880 European doctors had been operating successfully for cataract for a dozen years, and corrective surgery could be performed on crossed eyes. Local anesthesia--the injection of a solution of cocaine into nerve endings--was first used in 1884 by the great surgeon William Stewart Halsted. Between 1873-90 112 medical schools were established. Some, of course, were second- and third-rate institutions, inadequately staffed and funded, and others little more than diploma mills; almost any physician or group of physicians could start a medical school, get it attached to a college, and obtain a state charter. Attempts at licensing by medical societies bogged down in battles between rival schools of medical theory, political partisanship, and claims of preferential treatment. Not till 1849 did the American Medical Association, founded only two years before, establish examining boards which approved qualified schools, the first step to certification. But even in 1875, a two-year course, following four of college, was sufficient to allow a man to write M.D. after his name.

Particularly in pre-War years, there was a broad variety of schools of medical thought--Regulars, Irregulars, Allopathics, Broussarians, Sangradoarians, Morrisonians, Brandethians, Beechitarians, Botanics, Regular Botanics, Homeopathians, Hydropathists, Rootists, Herbalists, Florists, Eclectics, Electricals, Magnetics, Experimentals, Thomsonians, Reformed Thomsonians--and nothing prevented a man from following two or more, including herbal medicines, all at once. "Botanic medicine" was originated by Samuel Thomson, a New Hampshire farmer who based his cures on herbal remedies which, he said, combined with steam baths, restored the body to proper temperature and cured the disease. The medicines were the most important element; his prescriptions derived from 60 basic mixtures (pat. 1813), listed in a textbook which, with a license to practise, cost $20. In that same year he joined forces with an itinerant evangelist, Elias Smith, who helped him promote his system nationwide; it was especially popular in the rural areas and small towns of the South, the West, and New England, where herb doctors had been known for generations. By 1832 there were enough botanical doctors to hold a national convention; they published journals, founded schools, and established their own societies. In 1833 Worcester Beach published a competing manual, The American Practice of Medicine, which was based on an "Eclectic Medicine" composed not only of herbs but of minerals, which Thomson would not prescribe. Both systems (and there was little difference) spread swiftly: by 1840 it was estimated that three to four million people annually were treated by botanic physicians.

The hydropathic school was built on the theory that the internal and external use of water was a natural and effective curative for a variety of ills, excepting broken bones and obvious surgical cases. American interest came from the work of Vincenz Priessnitz, who in Silesia, Germany, in 1829, opened a hydropathic hospital with 45 patients and devised 18 different kinds of baths (not including sponges, showers, and various internal dosages), combining his water-cure with a strict regimen of grain, vegetables, and exercise. By 1843 he had 1500 patients and his methods were known all over the world. The method was introduced to the U.S. by R. T. Trall, who opened a water-cure hospital in New York in 1844, and Joel Shew, who opened his at Lebanon Springs, N. Y., the following year. They and their disciples listed over 50 diseases that could be cured by hydropathy, while other adherents of the system elaborated it by introducing steam baths, Turkish baths, sitz baths, wet-sheet treatments, and other refinements. (Mark Twain wrote that his mother, an ardent follower of the discipline, nearly drowned him on more than one occasion, but many 19th-century diseases involved fever, and advocates of hydropathy, who bathed the victims and packed them with wet cloths, may have saved some before it cooked their brains.) The American Hydropathic Society (later reorganized as the American Hygienic & Hydropathic Association of Physicians) was formed in 1849, and a number of hydropathic training schools opened in the '50's, but the majority of hydropaths were traditionally-trained physicians who had been converted to belief in the method. By the mid-'50's there were at least 30 major water-cure institutions and dozens of mineral-spring hotels and resorts which advertised hydropathic treatments. By the '60's many hydropathic institutions adopted an anti-tobacco, anti-alcohol, anti-tea-and-coffee regimen and gave instruction in dress reform, religion, and sex as well as the usual baths and dosages. Within another decade the hydropathic element in these institutions had all but disappeared, the emphasis being placed instead on exercise, diet, mental calm, and personal and spiritual development. The institutions themselves gradually became "sanitaria" or "health resorts."

The most serious threat to "traditional" medicine was homeopathy, which had impeccable medical credentials and a sophisticated theory behind it. It postulated that most illnesses were forms of an internal irritation which upset the body's "vital principle;" they could be cured by the prescription of drugs which produced an effect similar to the disease. The founder of the discipline, Samuel Christian Hahnemann (1755-1843), believed that people have the ability to heal themselves from within, and that a doctor's task is to stimulate that ability. He taught that medicines were to be prepared by diluting the original ingredient with water, shaking the mixture by hand 100 times, banging the sealed bottle down hard on a surface such as an old leatherbound book, and repeat again and again, diluting the mixture still further. At last one part of it would be added to 100 parts water and administered. His Organon of the Rational Art, published in Germany in 1810, became homeopathy's handbook; Hans Gram, an American-born Dane, opened the first homeopathic office in the U.S. in New York in 1825. The first homeopathic training school was Allentown Academy (later the Homeopathic College of Pennsylvania), followed by the Hahnemann Medical College of Philadelphia (1848), New York Homeopathic College (1860), and the Hahnemann Medical College of Chicago (also 1860). Homeopaths believed that small doses of medicine made the best cures, and thought that watering a substance down and shaking it made it more powerful because its "vital force" was released. They subscribed to "hair-of-the-dog" remedies and treated headaches with a diluted solution that actually caused headaches. In a day when people demanded a good money's worth of vile-tasting medicine guaranteed to give violent emetic or purgative effects, they dispensed pink pills or sweet colorless liquids which inflicted little, if any, suffering on their patients. Oddly enough, some were made from raw materials that included such deadly mineral and vegetable poisons as arsenic and belladonna. Yet they were quite safe--"potentized," or diluted, to such a level that hardly any of the original material remained. Many homeopathic medicines bore the terminal number "6," which meant that for every part of the substance for which the medicine was named (belladonna 6, for example) there were no less than 9,999,999,999,999 parts of lactose. But they also recommended for many diseases a simple set of remedies--cleanliness, good spirits, and rest; they believed in a good diet and a clean body, and they underwent fairly rigorous training in chemistry, pharmacology, surgery, physiology, and botany. Their system immediately attracted public support; by the mid-'30's graduates of homeopathic schools were practising in most of the states, there were homeopathic medical societies, and journals, books, and manuals circulated widely. The meeting held in Cincinnati in 1849 to form a national professional organization attracted 1000 delegates. Homeopathy was simple to explain and logically consistent; it shared terminology and training with orthodox medicine and made use of all the advances of chemistry, physiology, and instrumentation available to other physicians. In most communities its practitioners were accorded equal status with the allopaths ("traditional" doctors).

The introduction of homeopathy touched off a "medical reform" movement that included many new disciplines which were far more favorably disposed toward female practitioners than was the establishment. (The first traditionally-trained female doctor in the U. S., Elizabeth Blackwell, took her diploma, after considerable opposition and difficulty, in 1849.) As early as the 1830's the homeopaths and their various kindred disciplines accepted female students and conferred degrees upon them. More than one woman trained under a doctor of one of these theories, obtained a title such as Doctor of Botanic Medicine, and set up practise in some little country town. What she did wasn't so different from the work of a visiting nurse a century or so later: go into a home, open the windows, bathe the patient, keep a sharp eye on the diet, administer herbal cures of a kind familiar to pioneer women from the earliest days, and lecture the family on the need for cleanliness and fresh air. Her fees would be modest, but she could live on them, perhaps with help from a father or uncle, or a little farm or other investment to provide a backlog. Country people respected the independence of such a woman and valued her advice all the more highly for its modest cost. One of the best-known disciplines of the type was the Physio-Botanic System, which avoided bloodletting, blistering, and drugs such as opium and calomel in favor of fresh air, cleanliness, frequent hot baths, the inhalation of steam, prolonged application of wet dressings, copious use of herbal teas, emesis and enemas, a carefully chosen diet rich in fresh fruit and vegetables, plenty of impressive-looking pills that were really no worse than mild purgatives, frankness as to the nature of the complaint, and reassurance about "the proper means of relief and future avoidance." Its vogue was strongest in the Midwest, centering on Cincinnati, where "Mother" Mary Ann Bickerdyke, later to gain fame as "the bulldog of the Sanitary Commission," studied it. It was easily learned, and required no preliminary stint at "reading medicine," though it was considered outrageous and radical by orthodox doctors. It was also inexpensive for the patient: the wife of an Ohio Valley brewing magnate could be properly ill in a hermetically sealed room, soothed with laudanum, purged with calomel, and scientifically bled by a frock-coated, silk-hatted orthodox physician; the river boatman's wife had to content herself with a fifty-cent-a-visit botanic whose advice was probably the better of the two. It enjoyed great popularity because of its success in treating fever, cholera, and yellow fever. Early in her career Bickerdyke encountered a localized outbreak of smallpox, of which her biographer, Nina Brown Baker, says:

Medical science knew no treatment for [it]. Once a victim contracted it, there was nothing to do but isolate him to keep him from infecting others. He got well or he died. Most communities had a building that was used as a pesthouse, and there the sufferers were taken. Food and water were left outside the door; the patients themselves could distribute it. When enough had died to make the effort worthwhile, men could be sent to bury the bodies. Meanwhile, not even a doctor would visit the place.

[Bickerdyke] rounded up a corps of [working-class] helpers who had once had smallpox and were immune to it...had the dead removed, the filthy bedding burned; then she proceeded to clean up the place...scrubbed the floors, whitewashed the walls, filled in the old outhouse and dug a new one. The patients were bathed, put to bed in clean clothes on clean bedding, dosed with black root and goldenseal, sassafrass tea and beet juice, and fed all the milk and fresh vegetables they would take. A surprisingly large number of them recovered.

Almost all pre-War doctors were in general practise, and practically all treatment took place in the doctor's office or the patient's home: as late as 1873 there were but 149 hospitals in the entire country, and as late as 1869 the average one was still a rather filthy place, its patients poor and its nurses little more than wardmaids; many were drunk-and-disorderly women working off 10-day sentences. In pre-War days the institutions were sometimes lunatic asylums as well, and almost invariably pauper places whose chief value was to provide medical students with diseases to study, operations to watch, and cadavers to dissect. Nobody really approved of them: they were places for sick paupers, whose relatives couldn't care for them at home, places where doctors "experimented," learning their trade on indigent human guinea pigs. Nurses were recruited from the almshouse, the asylum, and the prison; a woman denied employment as a domestic because of objectionable habits, and too old and ugly for harlotry, as a last resort turned to public nursing. Dickens's Sairey Gamp was a recognizable portrait of a nurse for hire. Not till '73 did regular nurses' training begin at Bellevue. Indeed the small-town doctor was for long the primary bulwark between the public and all sorts of ill health: villages and hamlets of 50-100 persons generally had at least one, and small towns of 1000 might boast four or five--sometimes as many as six or seven. (In addition, in any village or range of villages (such as those scattered across a given valley), there was very likely to be at least one woman known as a midwife, and often she served as a practical nurse too.) In 1870, when the census found a population of 39,818,449, there were over 62,000 physicians (c. 1:642) in the United States, as against 44,000 clergymen (1:905), 41,000 lawyers (1:971), and 11,000 bankers (1:3620), and 110 medical schools turning out 2000 new ones (18 per) a year. Like other professionals, they generally had to be willing to accept payment in "kind" as well as cash: sometimes they owned farms on the edge of town where they could keep animals and feed taken on account, and even if they lived within city limits they still had room to fatten pigs, house chickens, and store farm produce in the family cellar. One doctor, having visited a farm 23 miles from town to remove a tumor from a woman's shoulder, received a barrel of apple brandy. He sold half of it for $20 (certainly a fair remuneration, if not all he might have asked), and presumably drank the rest himself. Villagers too compensated their doctor by services, such as gravelling his driveway, cutting his lawn, and working his garden. Nathan probably takes a good deal of his pay in this fashion: laundry and clothing repair, stableage for his horse, hams and sides of beef, feed, livestock, and garden truck which he can sell to the livery and restaurant, handmade quilts and socks, etc. Although he doesn't own property where he can grow his own herbs, he may well have arranged with some of his patients to provide them as a sort of advance compensation for services to be rendered.

If a community was lucky, its doctor was a man of high intelligence, great compassion, and as much technical knowledge as a year or so in a medical school could offer (meaning that he had some understanding of anatomy and could set bones and clean a wound); if he possessed in addition some common sense, his patients were fortunate indeed. A country doctor was priest, confidant, and friend rather than skilled specialist; in the absence of professional nurses he remained with a patient until a crisis had been passed, strengthening the courage of family members with his bedside manner and perhaps administering drugs against the pain. He knew his patients as friends and neighbors, not merely "cases," and if he had been in practise in the locality any length of the time, he was likely to know a good deal about their family histories as well. He knew how many bushels of corn Tom Jenkins had sold last year, what losses he had sustained in the recent drought, what domestic difficulties he faced, his general physical, financial, and spiritual condition. Frequently he grew what medicines he could in his own back yard, and often he used native medicinal plants. He was also not unlikely to operate a drugstore (perhaps downstairs from his office/consulting room) on the side--which might earn him more than his practise did. In the early years his skills extended no further than setting broken bones, binding up wounds, delivering babies, and doing amputations, and he was as helpless as anyone else in case of a really serious illness. His instruments consisted chiefly of scalpels, forceps, and probes, plus the trusty lancet used for bloodletting. Yet he could at least inspire confidence and give hope to the sick, even if the malady puzzled him and his pills were nothing but sugar-coated opiates. And his emergency operations, frequently performed on the kitchen table with only a hired man to hold the patient down and a barn lantern or kerosene lamp to provide light, saved many a life that might otherwise have been lost before the victim could possibly have been taken to a hospital, even if one existed. Usually, owing in large part to financial considerations, he wasn't called in till an illness defied all nostrums (some of them noxious indeed!) known to the housewife or the local quack. Due to his irregular hours he took little interest in either politics or most other community activities, but because of his standing his wife often dominated the organized social life of the town. His advertisements usually consisted of a brief card stating his name, specialty, and location of his office.

Most physicians charged according to a "fee table" fitted to the economic realities of the specific practise: a country or small-town doctor might make $3000-$4000/yr. as early as 1840 (though some managed no more than $1040--which, at $86 and change a month, was still a good deal better than most nonprofessional workers), an aggressive city physician in the '50's $80,000. Even a Western practise could bring in an annual income of $7000--a very large sum in those days. Typical charges included the following: sterilization and bandaging of a cut (not requiring stitches), 20-50c.; lancing of a carbuncle, 50c.; use of syringe, $1; bleeding, $1-$2; treatment of a wound made by a bullet that went clean through, the same; removal of a bullet, $1-$5; cleaning, stitching, and bandaging of a wound, $2; cupping, $2-$5; correction of a broken nose, $4; surgical operations, $5-$25 (presumably depending upon difficulty); delivery of a baby, $25-$50 (though most demanded only $10), plus a 50% surcharge by night. Mileage was extra, up to 50c. per (sometimes the first mile was $2 flat), with country visits at night double the day rate, a dollar for the consultation, and medications as needed (usually 25-50c./dose) plus $1-$1.50 prescriptive fee. A single visit in town (or a consultation at the doctor's office) cost $2, two on the same day $3, and a night visit in town $3. If the doctor doubled as a dentist, he might charge from 25c. to $1.50 to pull an infected tooth, 50c.-$2 to fill one (probably varying with the substance employed), $1-$3.50 for dentures, and $47 for complete extraction, including hypodermic, false teeth, and three days' bed and board.

City doctors relied more heavily on "office practise" than did those of small towns, but even the most successful of them kept generous daily hours, even on Sundays. Even so, most of their callers were transients and first-timers, for the vast majority of middle-class patients preferred to have the doctor come to them. One typical New York physician, Dr. John Burke, left a detailed log of his normal day's schedule in 1866. He rose at seven, received his early office patients, read the morning newspaper, and, if he had time, ate a hurried breakfast before setting out on his house calls by 8:30. Between noon and one P.M. he broke his circuit to visit a local dispensary. More calls followed till three, then two hours of office visits. Between five and seven he ate supper and took a nap, then returned to his office till 8:30. He made one final round of three to five house calls before returning home about eleven to spend an hour in reading before he retired.

Very common in the West were self-taught "irregular" doctors with little or no formal training (Nathan is obviously just such a one), often Indian-raised and inclined to Indian medicines. Most of these became healers through happenstance, because they successfully suggested treatment for someone and thus gained a reputation; some were quacks, drunks, or both, but many were men with whom a regular doctor would be happy to share a town's practise. In many places, including Kansas, there was no state examination or medical association, and no inquiries into a high rate of failure: you simply did your best and literally buried your mistakes, hoping to learn something from each. The pioneer doctor tended to forego "book-learning" altogether and rely on good sense, keen observation, and a strong horse--plus a lingering faith in bleeding and purgatives.

Irregular or not, once a doctor became known for curing the sick and healing the wounded, he could ride the trails confident that the worst of badmen would let him pass unmolested; they didn't dare offend him, for they never knew when they might desperately need his services! Often, in mining country, he was given dust or nuggets to carry to the local express office, and he always got it through safe and sound. Some doctors carried the familiar black leather bag, while others packed their equipment in two leather pouches fitted up with compartments for bottles and connected by a broad, heavy leather strap that was placed across the saddle. As late as the 1890's, even in the "civilized" East, country roads were seldom more than a pair of rough wheel tracks, winding through swamps, meadows, and woodlands, often ankle-deep in mud in spring and drifted high with snow in winter. But regardless of weather, the physician made his round of patients day by day, though he often had to drive 50 or 60 miles a day to do it. And often the life of a patient depended upon the speed with which he could get to some backwoods cabin. So he necessarily had to own a "roadster," or a pair of them--ideally Morgans, noted for their strength, courage, almost unbelievable endurance, and a high action of gait, which made it possible for them to travel long distances over rough roads at a speed no other breed could match. All country practitioners equipped their buggies, if any, with scoop shovel, ax, wire cutter, and lantern--and often a rifle, especially in regions where wolves, mountain lions, and bears remained a threat--in case of mishaps on the road.

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