Health Care and the American Medical Profession, 1830-1880

The Patient Protection and Affordable Care Act (Obamacare) is a landmark healthcare reform law that expands opportunities for care by providing more Americans with access to affordable health insurance. The goal is to provide health insurance to all Americans not covered by their employers or other health programs. However, many Republicans have derided the law suggesting that it imposes too many costs on businesses, its premiums are too high, and it oversteps the proper domain of the federal government with their so-called intrusion upon businesses, the states, and the lives and choices of individuals. The Republican-controlled government is now well on its way to repealing and replacing Obamacare with a version of the law titled the Better Care Reconciliation Act. Some people on the Right have praised the new law, while others worry they may be one of the millions who may lose health insurance with the repeal of Obamacare.

Navigating health care has always been a challenging part of our nation’s history. There have been at various times too few physicians, inadequate care or delivery of service, and rising costs of health care all situated alongside a growing public demand for adequate medical care. These debates are personal and political and have their roots in public expectation and the social contract between the medical profession, people, and government.

In the nineteenth century there was very little that physicians could do to treat many conditions or diseases. It was not until what Michael Bliss has described as “the coming age of modern medicine between 1885 and 1922”– a period which saw the growth of medical technology, the rise of academic medicine, new organizational standards, government support in the form of licensing regulations and anatomy acts and the acceptance of the germ theory–that medical care was transformed.[1] In the wake of these broader changes, and as the medical profession matured and secured a new authority as elite, scientific practicing physicians, consumer demand and social expectation combined with an appreciation of what medical science might be able to offer, created new demands for medical care. The Civil War years were an important period for the training and professionalization of American physicians.

Before 1820, the apprenticeship system served as the principal mode of medical training. Just after the War of 1812 proprietary medical schools emerged in the United States, supplementing the informal apprenticeship system. These schools were not attached to a university or hospital but operated independently. Most proprietary medical schools consisted of two, four-month terms of lectures, with the second set of lectures identical to the first. Because very few of these schools were associated with or had access to hospitals, the chief method of teaching and learning was through didactic lecture. In the 1830s and 1840s the penalties for practicing without a medical license were ignored or removed, coinciding with the withdrawal of state recognition for medical societies. This led to the formation of an unregulated medical marketplace and intensified the competition between orthodox and unorthodox physicians and elite and rank and file orthodox physicians.[2]

Efforts to address the problems compounded by the growth of medical schools took shape in 1847 and 1848 with the formation of the American Medical Association. By the 1850s the elite of American medicine pressed for stricter standards, the regulation of medical practice, and the reform of medical school curricula along more scientific lines. Many of these elite physicians had studied abroad in the medical schools in Europe and saw there the possibilities of science-based practice. The medicine of the Paris Clinical school, which emphasized pathological anatomy and localized pathology to specific disease conditions, reshaped traditional ideas about disease and the body and the practice of medicine.[3]

Yet, although these physicians published widely and made a strong case for the reform of American medicine, by 1860 the use of pathological anatomy remained remote from most areas of practical medicine. The war years would challenge traditional ideas about disease and the body. Rank and file physicians were exposed to ideas learned overseas as the elite of American medicine, who had long championed pathological anatomy and experimental medicine, moved from the periphery to the center of wartime medicine. The opportunity to reshape medical practice to their standards, with the support of the government, and the concomitant advances in industry and infrastructure in the Northern and Midwestern cities, set the stage for the medical modernization that followed the war.[4]

On the eve of the Civil War there were 55,000 practicing physicians in the country and more than 16,000 of these physicians came to the colors (many others doctored in non-official capacities).[5] After a reorganization of the medical department after the first year of the war, William Hammond was appointed Surgeon General of the Union Army. Hammond inherited a medical force reflecting the diversity of the American medical profession. The majority were orthodox physicians educated in the traditional doctrines in which the physician used physiologically derived medications and procedures to treat diseases. Others were part of alternative medical sects including homeopaths, botanics, and eclectics, who were popular with different segments of the patient community. However, since Hammond was a scientifically oriented teacher of physiology and pathophysiology, sectarian practitioners were excluded from military service, which helped raise the status of orthodox physicians. His immediate task was to train all physicians, regular and volunteer, into an effective therapeutic and prophylactic cadre, keeping the soldier healthy and when injured returned to duty as rapidly as practical. This assured citizens that those who went into harm’s way for the Republic were receiving the best care available.

But Hammond also had a vision for the larger reform of American medicine: every physician was part scientist and would themselves be motivated to contribute to the advance of military medical practice by sharing their experiences one with another. He reorganized his staff and established the new Army Medical Museum, which would house medical and surgical specimens collected and submitted from the field and hospitals. He promised the contributions would be acknowledged in the Medical and Surgical History of the War of the Rebellion. Yet many practitioners had no dissection experience and or limited practical anatomical training. In recognition of these limits he prepared and circulated instructions and he commissioned staff from his office, the USSC and others on an ad hoc basis to visit the posts and camps to provide practical guidance. Thousands of American physicians had their first practical anatomical training in such a setting. Hammond and his staff along with other elite physicians supported other avenues for growth including the dissemination of new forms of medical knowledge (especially related to disease causation, surgical techniques, and hospital construction), he supported experimental practice and the inauguration of specialty hospitals, which reshaped the medical and institutional landscape of the country.[6]

Prior to the Civil War physicians and lay people alike worried little about day to day infection; the community practitioner visited his patients at home to treat cases of illness and midwives still birthed most babies. It was not until the movement of large bodies of troops, which seemed to transport communicable diseases with them, did both war physicians and the public become more alarmed about disease transmission. These changing ideas supported the rapid expansion of public health boards, new research projects into the study of infectious diseases and clinical teaching in the hospitals wards. Germ theory researchers would spend the next few decades perfecting experimental methods that would provide unassailable laboratory evidence of disease causation (and which would later translate into vaccination programs, antibiotics, and better diagnostic techniques.) In the meantime, former Civil War surgeons went home to begin new medical practices or resume old ones. But these physicians took with them a vast practical education. Whether a physician had practiced in the temporary or general hospitals or in the field, they were required to submit case reports and medical and surgical specimens to the new medical museum; and perform autopsies and difficult surgeries. They administered new therapeutics like bromine and even learned the importance of using these drugs prophylactically to prevent diseases in the hospitals.[7]

As the political, institutional, intellectual and technical landscape of medicine was transformed during and after the war, public expectation and demand for efficacious medical care grew. Physicians routinely used political contacts and relationships to effect legislation (such as licensing laws) and they joined with national and local leaders to secure government action (the continued funding of the medical museum as one example). States slowly began passing new anatomy laws or strengthening old ones, and the American Medical Association, state licensing boards, local medical societies, and new specialist associations began to define or redefine the larger goals of the profession in the context of their own associations. New laboratory procedures were widely heralded in medical journals and the elite touted the possibilities of antiseptic surgery.

The war years were an important period of professionalization for American physicians. Physicians increasingly coalesced around a new professional model that promised specialized knowledge, service to others, morality, competence, working in partnership with patients and being accountable. This contract serves as the basis for expectations of both medicine and society. Today, with significant advances in applied medical technology, surgery, biochemistry and therapeutics, medicine can provide more comfort and extend the longevity of a person’s life. But not all American citizens have equal access to health care. Physicians have recently expressed concern about certain parts of the AHCA (and now the BCRA) including the phasing out of Medicaid expansion and the elimination of subsidies for low-income Americans which could result in the loss of coverage for millions of people.[8] It is important to remember in the midst of today’s political bickering and partisan posturing that at the root of these debates are patients in all stages of health and sickness and doctors that want to meet patient expectations. Doctors deserve regulatory procedures that are reasonable and validated, and adequate resources to practice and research. But above all, doctors deserve a health care system that promotes (and does not subvert) those values which society wishes in its healers–caring, altruism, courtesy, and competence.

 

[1] Michael Bliss, The Making of The Making of Modern Medicine: Turning Points in the Treatment of Disease (Chicago: The University of Chicago Press, 2011), 1. See also, Rosemary Stevens, American Medicine and the Public Interest: A History of Specialization (Berkeley: University of California Press, 1971); John Burnham, Health Care in America: A History (Baltimore, MD: Johns Hopkins University Press, 2015).

[2] William Rothstein, American Medical Schools and the Practice of Medicine: A History (New York: Oxford University Press, 1987); Thomas N. Bonner, Becoming a Physician: Medical Education in Britain, France, Germany and the United States, 1750-1945 (New York: Oxford University Press, 1995).

[3] John Harley Warner, Against the Spirit of the System: The French Impulse in Nineteenth-Century American Medicine (Princeton, NJ: Princeton University Press, 1998).

[4] Shauna Devine, Learning from the Wounded: The Civil War and the Rise of American Medical Science (Chapel Hill: The University of North Carolina Press, 2014).

[5] Burnham, Health Care in America, 116; Devine, Learning from the Wounded, 22-29.

[6] Devine, Learning from the Wounded, 16-18, 21, 29-49.

[7] Devine, Learning from the Wounded, 129-131; Margaret Humphreys, Marrow of Tragedy (Baltimore: Johns Hopkins University Press, 2013), especially chapter 11.

[8] As one example, see David Leonhardt, “Doctors, in Their Own Voices,” The New York Times, June 26, 2017, accessed June 26, 2017, https://www.nytimes.com/2017/06/26/opinion/ahca-health-care-obamacare.html?smprod=nytcore-iphone&smid=nytcore-iphone-share.