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During the latter part of the nineteenth century, few changes occurred in drug therapy and the treatment of nonsurgical disorders, which comprised the bulk of medical practice. Major improvements occurred in the diagnosis and prevention of infectious diseases and in surgery, which was revolutionized by the discovery of anesthetics and antiseptic techniques. Dispensaries and hospitals continued to expand as providers of health care in urban areas, with dispensaries playing the larger role. Hospitals assumed a significant educational role. The number of physicians increased at a rate comparable to the growth in population in the latter part of the nineteenth century. The 55,055 physicians enumerated by the census in 1860 increased to 132,002 in 1900, about 175 physicians per 100,000 population at both dates. Medical schools graduated enough students to assure a reasonable supply of physicians in almost all towns and villages in the country, although urban areas continued to have more physicians per capita. The physician who began practice in a large city entered a highly competitive profession. He usually started by caring for the tenement population, perhaps augmenting his income by working as a dispensary or railroad physician or assisting another practitioner. His earnings were low and he had few regular patients. Eventually he found a neighborhood where he was able to attract enough patients to establish himself. Competition from other physicians and from pharmacists and dispensaries remained a problem throughout his career. A physician who chose a small town or rural area, where most of the population lived, had a different type of career. Rural families were poor and the physician’s services were low on their list of priorities. Professional relations reflected this fact. Established physicians often greeted the newcomer by sending him their nonpaying patients. Once the rural physician established a clientele, he had less difficulty keeping it than an urban physician. The stability of rural populations enabled him to retain the patronage of families from one generation to another. The rural physician worked longer hours than his urban counterpart and had to be more self-reliant because of the absence of specialists and hospitals.

During the first half of the twentieth century, both mortality rates and the incidence of infectious diseases declined, due primarily to public health measures and a higher standard of living. Developments in surgery and drug therapy improved medical care and increased the amount of specialization among physicians. On the other hand, fewer physicians were available to care for the sick because of a decline in the per capita number of medical school graduates. The urban poor continued to receive most of their care from outpatient departments in public and private hospitals, while a growing number of the middle classes became paying inpatients in private hospitals. Hospitals expanded their educational activities to include internships and residency programs. In the first half of the century, physicians became less accessible to much of the population. The number of physicians per capita decreased substantially from 1900 to 1930 and remained at that level until 1950. The greatest impact of this decline occurred in rural areas: between 1906 and 1923, communities of under 5,000 population experienced about a 25 percent reduction in the physician-population ratio, while cities of 50,000 or more experienced a decline of less than 8 percent. Young physicians especially preferred the cities. In 1906 in communities of fewer than 1,000 persons, the proportion of graduates from 1901 to 1905 who practiced in those communities exceeded the proportion of all physicians who practiced in those communities by a ratio of 1.17 to 1. By 1923 in the same size communities, the proportion of graduates of the classes of 1916 to 1920 who practiced there compared to the proportion of all physicians who practiced there dropped to a ratio of 0.58 to 1. Thus rural communities changed from locations preferred by younger physicians to locations avoided by them. The same ratio in cities of over 100,000 population increased from 0.99 to 1 in 1906 to 1.36 to 1 in 1923, which indicated the growing popularity of large cities for young physicians. Several factors accounted for the preference of physicians for towns and cities. Urban physicians earned more than rural ones and had greater opportunities to Specialize.

Medical care at the end of the eighteenth century, like that in any period, was determined by the state of medical knowledge and the available types of treatment. Some useful knowledge existed, but most of medical practice was characterized by scientific ignorance and ineffective or harmful treatments based largely on tradition. The empirical nature of medical practice made apprenticeship the dominant form of medical education. Toward the end of the century medical schools were established to provide the theoretical part of the student’s education, while apprenticeship continued to provide the practical part. The scientifically valid aspects of medical science in the late eighteenth century comprised gross anatomy, physiology, pathology, and the materia medica. Gross anatomy, the study of those parts of the human organism visible to the naked eye, had benefitted from the long history of dissection to become the best developed of the medical sciences. This enabled surgeons to undertake a larger variety of operations with greater expertise. Physiology, the study of how anatomical structures function in life, had developed at a far slower pace. The greatest physiological discovery up to that time, the circulation of the blood, had been made at the beginning of the seventeenth century and was still considered novel almost two centuries later. Physiology was a popular area for theorizing, and the numerous physiologically based theories of disease were, as a physician wrote in 1836, “mere assumptions of unproved, and as time has demonstrated, unprovable facts, or downright imaginations.” Pathology at that time was concerned with pathological or morbid anatomy, the study of the changes in gross anatomical structures due to disease and their relationship to clinical symptoms. The field was in its infancy and contributed little to medicine and medical practice. Materia medica was the study of drugs and drug preparation and use. Late eighteenth century American physicians had available to them a substantial armamentarium of drugs. Estes studied the ledgers of one New Hampshire physician from 1751 to 1787 (3,701 patient visits), and another from 1785 to 1791 (1,161 patient visits), one Boston physician from 1782 to 1795 (1,454 patient visits), and another from 1784 to 1791 (779 patient visits).

The use of hospitals for medical care became more varied after 1950. More patients were admitted for a wide variety of conditions and more different types of treatments were provided. Many new technologies were adopted that have raised costs considerably. Hospitals employed more residents, foreign medical graduates, and nurses. Between 1946 and 1983, hospitals grew both in size and importance in the health care system. The number of short-term nonfederal hospitals increased by only one-third, but the number of beds and the average daily census doubled and the number of admissions increased 2.6 times, while the U.S. population grew by only two-thirds. Much of the additional use was for nonsurgical care. During the 1928–1943 period, 74 percent of all hospital admissions were surgical. This declined to 60 percent between 1956 and 1968 and to 50 percent between 1975 and 1981. Outpatient care grew even more rapidly than inpatient care, with the number of hospital outpatients doubling between 1965 and 1983. The hospital system has become dominated by large hospitals, practically all of which have affiliated with medical schools. In 1983, the 18 percent of nonfederal short-term hospitals that had 300 or more beds admitted 50 percent of the patients, carried out 59 percent of the surgery, and had 55 percent of the outpatient visits and 61 percent of the births. They employed 72 percent of all physicians and dentists employed in hospitals and 90 percent of all medical and dental residents. At least 60 percent of them had nurseries for premature infants, hemodialysis units, radiation therapy or isotype facilities, computerized tomograhy (CT) scanners, and cardiac catheterization facilities, and almost one-half had open-heart surgery facilities. Most also offered types of care not traditionally associated with hospitals. Practically all of them provided social work services and physical therapy, at least 75 percent provided occupational and speech therapy, and 40 percent provided outpatient psychiatric care. On the other hand, fewer than one-third provided family planning, home care, or hospice services, or partial hospitalization for psychiatric patients. The expanding services of nonfederal short-term general hospitals has led to the employment of larger numbers of workers.

During the first half of the twentieth century, American medical education underwent drastic changes. Greater costs of operation and the requirements of licensing agencies forced many medical schools to close and most of the others to affiliate with universities. The surviving medical schools were able to raise their admission and graduation requirements, which was also made possible by the rise in the general educational level of the population. The growth of the basic medical sciences led to the development of a new kind of faculty member whose career was confined to the medical school. During the first half of the twentieth century, the educational level of the population rose significantly. The proportion of the 17-year-old population with high school educations increased from 6.3 percent in 1900 to 16.3 percent in 1920, 28.8 percent in 1930, and 49.0 percent in 1940. The number of bachelors’ degrees conferred per 100 persons 23 years old increased from 1.9 in 1900 to 2.6 in 1920, 5.7 in 1930, and 8.1 in 1940. Between 1910 and 1940, the number of college undergraduates more than tripled. Because the number of medical students did not increase, medical schools were able to raise their admission standards. At the same time, many new professions competed with medicine for students. Between 1900 and 1940, dentistry, engineering, chemistry, accounting, and college teaching, among others, grew significantly faster than the traditional professions of medicine, law, and the clergy. Graduate education also became an alternative to professional training. Between 1900 and 1940, the number of masters’ and doctors’ degrees awarded, excluding medicine and other first professional degrees, increased from 1,965 to 30,021, or from 6.7 to 13.9 percent of all degrees awarded. Colleges and universities decentralized their organizational structure to deal with the increasingly technical and specialized content of academic disciplines. They established academic departments that consisted of faculty members who shared a common body of knowledge and taught the same or related courses. Departments were given the responsibility of supervising their faculty members, recruiting new faculty, and operating the department’s academic program. By 1950, departments existed in most of the sciences, social sciences, and humanities.