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This chapter examines the publicly provided health care at Philadelphia General Hospital (PGH), which was of critical importance to poor African American women, who needed a safe and respectful place to care for their own and their children's medical needs. This hospital was the most successful institution in the city in terms of the quality of the services it provided and the loyalty it commanded from a wide range of citizens. As increasing numbers of African American women sought and received subsidized treatment at PGH, critics charged that its policies encouraged “illegitimacy” and irresponsible state expenditures. Yet these same policies played a vital role in encouraging and enabling working-class African American women to choose PGH over all of the other hospitals in the city and turn it into a place they called their own.

During the early nineteenth century, medical practice became professionalized and medical treatment standardized as medical school training became more popular and medical societies and journals were organized. Dispensary and hospital care increased with the growth in urban populations. Medical students became dissatisfied with the theoretical training in medical schools and turned to private courses from individual physicians and clinical instruction at hospitals and dispensaries. By mid-century, private instruction had become almost as important as medical school training. Because little progress occurred in medical knowledge during the first half of the nineteenth century, the quality of medical care remained low, although it became more standardized due to the greater popularity of medical school training. Diagnosis continued to be unsystematic and superficial. The physical examination consisted of observing the patient’s pulse, skin color, manner of breathing, and the appearance of the urine. Physicians attributed many diseases to heredity and often attached as much credence to the patient’s emotions and surmises as the natural history of the illness. Although the invention of the stethoscope in France in 1819 led to the use of auscultation and percussion, the new diagnostic tools contributed little to medical care in the short run because more accurate diagnoses did not lead to better treatment. Few useful drugs existed in the materia medica and they were often misused. According to Dowling, the United States Pharmacopoeia of 1820 contained only 20 active drugs, including 3 specifics: quinine for malaria, mercury for syphilis, and ipecac for amebic dysentery. Alkaloid chemistry led to the isolation of morphine from opium in 1817 and quinine from cinchona bark in 1820. Morphine was prescribed with a casual indifference to its addictive properties and quinine was widely used in nonmalarial fevers, where it was ineffective and produced dangerous side effects. Strychnine, a poisonous alkaloid isolated in 1818, was popular as a tonic for decades, and colchine, another alkaloid discovered in 1819, was widely used for gout despite its harmful side effects. Purgatives and emetics remained the most widely used drugs, although mineral drugs replaced botanical ones among physicians trained in medical schools because their actions were more drastic and immediate.

This chapter examines Thomas Sadler Roberts’ medical education at the University of Pennsylvania in 1882, believing that natural history was not a gentlemanly vocation. Staying in Germantown where his Aunt Cornelia Roberts’s family lived, Roberts was presented with an opportunity to put down a few roots in his father’s hometown by spending some time with his Quaker relatives. During his stay, Roberts showed his skill in memory. One noteworthy display of this skill was when he quoted a textbook verbatim on an oral exam. The rigors of medical school, however, led to Roberts neglecting his bird studies. His journals omitted anything about avian presence in Philadelphia. But his interest did not vanish entirely as during his second year, he accepted an invitation to become a member of the American Ornithologists’ Union. The chapter concludes by describing his residency at the Philadelphia General Hospital.

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.