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Medicine of the Pioneer Period in Utah
Utah Historical Quarterly
Vol. 23, 1955, Nos. 1-4
MEDICINE OF THE PIONEER PERIOD IN UTAH
BY JOSEPH R. MORRELL
THE MORMON pioneers in Utah provided an interesting chapter in the history of American medicine. There were problems to be met, in relationships with which other frontier groups were not concerned. The Mormon religion taught dependence on faith in a Divine Power in the care of their sick, and the people, therefore, made little use of physicians. Many of the members held a resentment against all doctors, while some felt that to employ them, even in an emergency, indicated a lack of faith.
There were a few medical graduates among the pioneers. A larger number who were treating the sick belonged to a cult known as the Thomsonian doctors. These latter had a higher rating in the communities than the physicians, some holding high rank in the priesthood of the church. They practiced a system of treating disease with mild herbs, and naively referred to their medical competitors as "Poison Doctors." The combined influences reacted strongly against the doctors, and practice for them was never agreeable and smooth.
The Thomsonian cultists early organized a Council of Health, into which were admitted many of the church leaders. Regular meetings were held in which officials of the church participated actively. This gave the council a place of prestige, and the members used it to advantage to dominate the medical men. The result was a general suspicion of both the integrity and ability of the physicians. Their services were limited largely to the treatment of emergencies and the care of some who were considered of weak faith. The handicaps thus imposed restricted medical practice to a minor place in community life. And such it remained, in fact, for many years, until progress in the knowledge of disease, and its prevention and cure, had reached a point where it could no longer be kept in the background.
Many of the early converts to the church were poor, and often victims of chronic disease. They were brought into a wilderness unfamiliar to them, far removed from the nearest civilization. They had little knowledge which would protect them from the ravages of the many diseases prevalent at that time. How they met and solved their health problems, and built up strong communities, is, therefore, an interesting phase of pioneer history,
At the time of the migration to Utah the world was menaced with epidemic diseases. Cholera, typhus and yellow fever, diphtheria, and influenza made periodic invasions, with disastrous effects. Malaria, typhoid fever, and tuberculosis were prevalent at all times. The diarrhoeal diseases of infancy were always a source of anxiety. Of all the killer diseases only smallpox in any way was under control, through the recently discovered immunization by vaccination. The fear of vaccination, however, kept the people from reaping its benefits, and smallpox took a heavy toll of life for many decades.
Many of the emigrants from England and Wales, and from New England, were victims of tuberculosis. Many brought malaria from Nauvoo and the Mississippi Valley. The over-all death rates were high, variously estimated at twenty to thirty per thousand of the population per year, and about half the deaths were infants and children under ten years. The health problems alone would seem to us, at this time, to have been serious enough to discourage the strongest of them. They were used to discouragements, however, and they felt that in time the climate, which they praised in letters to their friends back home, would rid them of their health worries. Their leaders gave them advice in health matters, as they did on all other phases of pioneer life. Brigham Young and many of the elders were constantly discussing health from "the stand." They advised as to diets, hygiene, and health generally, and urged the people to "boil the water you drink." They had implicit confidence in their leaders, and the advice given usually was carried out.
There were only a few physicians among the early pioneers, and these were converts, some of whom had practiced in the East or in Europe. Medicine was of little practical value. Little was known of the causes of disease, and even less of its prevention or cure. The old theories of Hippocrates, of the fourth century B. G, still dominated medicine. The "humoral theory" of the ancients was still accepted. The humors were the body fluids, the blood, phlegm, yellow and black bile. When the humors were in balance, the body was in a state of health. When the balance was disturbed, disease appeared. Treatment was directed toward a restoration of the normal balance, and this was done by bleeding the patient, purging, inducing vomiting, and flushing the bowel with enemas. The cultists used mild herbs, emetics, and warmed the blood with cayenne pepper. The fear of bleeding, the standard method of treating most diseases, was intense. The fear of purging the sick patient was only slightly less. No method of treatment used inspired confidence, and many felt that they were safer without the doctor. They were constantly warned from the pulpit to "let the doctors alone."
That the fear of the doctors was not confined to the Utah pioneers is illustrated by an incident of that period which occurred in New York City, soon after the establishment of its health department. The city was threatened with an invasion of cholera. The mayor was urged to call the Board of Health for consultation. He replied: "I will not call the Board of Health for discussion, as I think it more dangerous than the cholera."
The attitude of the pioneers toward the doctors is shown in a letter written in 1848, by Orson Spencer to Orson Pratt, who was in England. Spencer was on a Mississippi River boat with a company of immigrants from Scandinavia. Many of these passengers were afflicted with cholera, and some had died. He wrote thus: "We are now within a few miles of St. Louis, without any apprehension of another death unless a Gentile doctor aboard kills them with his favorite dose of calomel, laudanum, camphor, and brandy. This dose was given to our dead brother and sister, contrary to my wishes, and to many others who died immediately. Several I have rescued from the dose who were mortally seized, and they now live."
That the doctors themselves were well aware of their limitations is apparent from an article in the Salt Lake Sanitarian, a little health magazine published in 1887-89, by the Doctors Shipp:
It is not to be wondered at, therefore, that the people held themselves aloof from the doctors. They shared with the rest of the world the feeling that the doctors often did more harm than good. In the light of our present knowledge of disease, the common procedures of bleeding and purging, which drained the body of its protective fluids, was definitely harmful. We now transfuse new blood, and often infuse great quantities of nutritive fluids into the patient's body to give him added resistance and strength. The patient, already depleted of his fluids by cholera or dysentary, might easily have had a fatal outcome to his illness immediately following the doctor's treatment. A good doctor of that period was not satisfied merely to bleed his patient; he bled him until he fainted from loss of blood. He must be sure he had done an effective job.
The people felt much more secure in depending on the administrations of the elders, and their own resources, in the care of their sick. They felt, too, that their new environment would ultimately rid them of most of their afflictions. They wrote enthusiastically of the climate, which they considered the most healthful they ever found. In spite of their high death rates, which they considered unavoidable, they were satisfied.
The people were encouraged in this attitude by their leaders. They were admonished to exercise their faith, and in addition to use all other means of help available to them in the care of their sick. President Young expressed his attitude clearly as follows: "It appears consistent to me to apply every remedy that comes within the range of my knowledge, and to ask my Father in Heaven, in the name of Jesus Christ, to sanctify that application to the healing of my body; to another this may appear inconsistent .... But it is my duty to do when I have it in my power. Many people are unwilling to do one thing for themselves, in case of sickness, but ask God to do it all."
The church leader, however, left no doubt that he had little confidence either in the ability or the integrity of most doctors at that time. He made his ideas clear in a correspondence with Doctor David Adams, of Fairfield, Illinois, 1851. The doctor had asked him, in a letter, some questions regarding medical practice in Utah. He expressed a sympathetic attitude toward the doctrines of the church, and said he would bring "one hundred persons, good and true" with him, providing he could make a living here in the practice of medicine. Among other things, he asked specifically, "What are the prevailing diseases in Utah? Do you think a physician, well qualified in his profession, (a regular graduate, and some twenty years experience), can support a family there?"
President Young, in answer, narrated the experiences of the recent years in Missouri and Illinois, "drinking the cup of poverty, yea, even to drain it to the very dregs," living in wagons and holes in the ground, and even, in this condition, leaving their families to serve their nation in war, and going into foreign countries to carry their Gospel message. This they did cheerfully, deeming it an opportunity. "Shall we then offer inducements of earthly prosperity to any man to come and unite his destiny with ours?" He then advised him, if he cared to come, taking his chances, and obeying the laws of the Gospel in sincerity, he would be welcomed. "The Church, however, does not beg anyone to come and join with them. Those who come, however, and are deserving, will be blessed."
President Young answered his specific questions as follows:
There are several reasons to account for what may seem to be an unnecessarily harsh answer to Doctor Adams' letter. In the first place it was an unusual request that one hundred converts be permitted to come in in such a manner. Converts usually came one at a time, or only in small groups, and after much labor at conversion. These could have had other motives, and little or no knowledge of the Mormon religion. They could prove an embarrassing problem later as a dissonant body. Then again, the recent experiences in Illinois and Missouri would serve as a warning that caution was necessary. The insinuation that a doctor would end the suffering or the life of a patient by "putting him quietly away," seems to have been a prevalent opinion of that time, as it is found occasionally in the writings of the pioneers. It also comes to light occasionally in our own time, and we are shocked by a confession that such a procedure has been carried out. The practice could have been only an isolated one, and then done in violation of recognized medical ethics. There probably was no more justification for the charge made in the letter, than for a blanket charge made against doctors of today. It indicates the fear and suspicion with which doctors were regarded. This was Brigham Young's common manner of expressing himself, probably a necessary procedure in many of the problems with which he had to deal. But such bluntness of speech, perhaps not intended to offend, yet did produce reactions, and they were frequently encountered.
These opinions, so freely expressed in pioneer literature, leave no doubt as to the feeling regarding doctors and medical practice generally. The doctors made little defense of themselves, perhaps realizing their limitations too keenly. It must not be assumed, however, that they were entirely incapable of any useful service. There were some among them who were graduates of the best medical schools, and who were men of sound judgment. They were honest in their convictions and devoted to their patients. They could give sound advice in many conditions, even though limited in their ability to cure infectious diseases. They probably felt that they were often unfairly judged. It must have been humiliating to them to read such comments in the Deseret News as the following: "Two physicians have moved to one of our most distant settlements, and gone to farming; three have gone to California to dig gold; three have taken to traveling and exploring the country; one has gone to distilling, and we are beginning to get some alcohol, which is desirable for gentlemen's shoe blacking, hatter's waterproofing, chemical analysis, washing the bodies of the well to prevent sickness, and the sick that they may become well, when such there be. Those physicians who remain have very little practice, and will soon have less, we hope."
Opinions regarding medical practice could be improved only by the doctors rendering a better service. The means for doing this were slow in coming. Progress was being made in Europe through medical research, but the new knowledge of disease had not yet found its way into medical practice, especially into such remote regions. Virchow, the great German pathologist, had demonstrated the cellular structure of the tissues and organs of the body, and new and more accurate conceptions of physiology had been learned. Pasteur was proving the soundness of his research with microorganisms in their relation to infectious diseases. A new medicine was in the making.
As the new facts of medical research were published, they met strong opposition from physicians generally. The established ideas regarding disease were not easily dispelled. Aristotle and Hippocrates were strongly intrenched in the medical minds. It was many years before doctors generally accepted the basic facts of Pasteur's work as sound. It was many additional years before they could be applied effectively in curing disease. But the new truths as they reached the people inspired hope of better things to come.
When the bacterial cause of infections was definitely proved, the world was electrified by the feeling that now a way would readily be found for the prevention of the epidemics which were still creating havoc over the world. Indirect methods of prevention were begun at once through the establishment of health departments, and the application of hygienic and sanitary methods of control. Protected water supplies were installed, and sewage systems built. A definite lowering of death rates from the infections established new confidence in medicine. But an effective, direct attack on the bacteria was not available, and was not to be realized for almost a century, and only after tremendous effort.
The first comment found in Utah writings regarding the new medical research was an editorial in the Deseret News written by George Q. Cannon in 1870. This was an enlightening discussion of the invasion of the body by the bacteria which had recently been described. The need for learning all the available facts, by all the people, was emphasized. The editorial concluded as follows: "The subject is one which cannot fail to command the attention of scientific men, and may be found to have close connection with the diseases which prevail here sometimes late in the summer when the atmosphere is more likely to be charged with organic matter which would make itself manifest more quickly in the tender constitutions of children than in those of adults."
One would think that with so clear a conception of the cause of infectious disease as early as 1870, that the world was on the brink of emancipation from the epidemics. However, in 1920, fifty years later, our communities were still fighting the application of standard control measures based on this fundamental knowledge so clearly presented in the editorial.
Little further comment was noted in the local literature regarding the infections for several years. The Woman's Exponent, official organ of the Relief Society, made appeals for relief in limiting the ravages of diphtheria and the intestinal infections of infants in 1875. This magazine also appealed to the doctors to help to allay the existing prejudice against vaccination, as a means of lessening the danger from smallpox.
A pathetic appeal came in an editorial in the Exponent in 1876, for help in relieving the infant diarrhoeas. The prevailing methods of infant feeding were attacked in an article entitled, "Death in the Nursing Bottle." Artificial feeding of infants was carried on at that time with a small bottle to which a rubber tube was attached with a nipple at the end. The bottle was put into the bed with the baby, where it would be kept warm, and the nipple put into the child's mouth. "Cleaning the bottle many times a day with a brush will not be done by many people. Wire brushes "were used. These are not successful. A vacuum is created in the bottle, and the child becomes exhausted sucking the milk out." The editor then advised the use of a widemouthed bottle, with a nipple which could be turned inside out and cleaned. Nipple and bottle were to be boiled before each feeding. This was the first blow struck at the cause of this fatal malady in Utah.
The same magazine carried an earlier article on the danger involved in the practice of kissing. "The practice is a pestilential one, murderous is the proper word, did the kissers know what they do. Diseases that can be readily transmitted by kissing are colds, sore throat, diphtheria, and many others, and often with fatal results. No surer means of spreading contagion could be adopted than the mingling of breaths and mouth secretions by kissing."
The Deseret Weekly News, commenting on the transmission of contagious diseases, suggested that doctor's beards be restricted to "modest and sanitary limits." It had been charged that the beards carried diphtheria germs. This could be true, no doubt, as contacts with the diphtheria patient were frequently intimate, the beards were luxuriant, and adequate renovation would be no simple matter.
The appeals for relief from these marauding diseases, and the obvious improvement in knowledge, in time brought a change of sentiment to the leaders. Brigham Young saw a need for training young men in medicine, and approved their going to eastern colleges for study. Eliza R. Snow, who at the time was in charge of all women's activities in the church, visualized a means for allaying prejudice by educating young women in medicine. She made an appeal to President Young and the General Authorities for support of such a plan. This support was forthcoming and the president made a public appeal, in an address in the tabernacle, for young women to volunteer for such training.
Eliza R. Snow also asked the legislature of the territory for funds with which to establish a medical college for women, where women could be trained at home in medicine. This plan failed, but women were sent to eastern schools, the expense being met largely by the Relief Society of the church. In time about twenty women were given such training and took up practice in the territory. These women physicians played no small part in the removing of prejudice against medicine in Utah. There could be no complaint against their treating women patients such as had been made against the male doctors. The charge had been made that a woman who employed a male doctor to wait upon her in illness was possessed of an adulterous spirit, "and the doctor who delights in nursing women, instead of advising them how to wait on themselves and each other, is possessed of the same spirit."
Better obstetric care was soon apparent through the training the women doctors provided for the midwives of the territory. Neonatal deaths and puerperal infections began to decline. The service these medical women rendered was an important factor in the progress of medicine in Utah. The women doctors often brought their male associates into consulation. As better trained men were coming into practice, confidence was established and fear was lessened. No phenomenal results were yet achieved in the cure of many diseases, but a more sound and rational attitude was taken, and some of the obnoxious practices in treatment were eliminated.
Other articles appeared occasionally in the magazines of the territory indicating the progress in medical knowledge. Doctor Milton H. Hardy wrote of the need for establishing a territorial health department. Health departments had been established in many large cities of the East, and there were health departments in some of the states. Doctor Hardy gave a clear picture of the need for such service in Utah. "The excuse is commonly made that the expense attached to the workings of a health department in a small place is too great to justify the attempt at having such an organization .... They fail to realize the enormous price they pay for failure and neglect." He also advocated the enactment of sensible laws covering community health. That article probably stimulated the thinking which resulted in the appointment of a health commissioner on the acquiring of statehood in 1896, and the establishment of a health department in 1898. The objectives of Doctor Hardy's article, however, were not realized until more than fifty years after it was written.
In 1887, Professor J. T. Kingsbury wrote an article on the waters of the streams supplying Salt Lake City. He made chemical analyses of all waters used for culinary purposes, and concluded that "the water of Big and Little Cottonwood Canyons, on account of having the lowest quantity of sulphuric acid, lime, and magnesia, it was the softest and best suited for most purposes." He said the solids are retained in solution largely by the carbonic acid gas, which escapes, "thus liberating the substances as the stream proceeds down the canyon and across the Bench, so that by the time it reaches the residents of the 21st Ward, it is improved both in its economical and healthful conditions." This report was written seventeen years after the editorial by George Q. Cannon warning against germs was published, and yet no mention was made of the danger from bacteria for the residents of the 21st Ward, who dipped up the water and drank it.
A second article, by Professor James E. Talmage, told of an experimental study of the waters from the streams and wells around Provo. He found all the water used in the homes of that vicinity to be badly contaminated with organic matter, which he identified as "free and albuminoid ammonia." He warned of the danger as follows: "I would be inclined to view with suspicion a water yielding a considerable quantity of free ammonia, along with 0.65 parts of albuminoid ammonia per gallon." Doctor Talmage found much diarrhoeal disease in families using the water which showed the greatest contamination with albuminoid ammonia, and advised against its use. He did not mention germs or bacteria specifically, but doubtless the article received careful consideration, as an editorial in the same issue of the magazine called attention to its importance.
The Salt Lake Sanitarian, of the same year, contained several articles specifically warning of the danger from typhoid fever in using water from wells, and from streams running through the towns. Communities were advised to install protected systems of water of known purity. These were installed, however, only after the greatest effort to convince the people of the need, which required many years of patient explanation. Better water supplies were made available, but few gave complete satisfaction.
The State Board of Health passed an ordinance early in 1900, requiring vaccination of all school children before entering school in the autumn. This aroused an immediate, state-wide opposition, and a demand that the ordinance be rescinded. The editor of the Deseret News took up the fight for the opposition, and a long series of editorials was published attacking the ordinance, the health commissioner, and the Board of Health responsible for its passage. Many others joined in protest with letters to the editor. Mass meetings were held and speeches delivered with unrestrained charges of incompetence and abuse of power by the health commissioner and the Board of Health. They were condemned as unnecessary evils in the community, and an encumbrance to progress.
The legislature was induced to pass an ordinance which would rescind the vaccination ordinance. The bill was vetoed by Governor Heber M. Wells, but was passed over his veto. The heroic efforts to control smallpox were thus nullified, and for another twenty-five years the price for neglect was paid in needless suffering and many deaths. Confidence in public health supervision was undermined, and was re-established only after many years, and with painful effort.
During the time of this controversy a physician of Brigham City wrote a letter to the editor asking his opinion regarding the cause of prejudice which had always existed in Utah against the doctors. He felt that there was an unwarranted opposition still prevalent against medical practice, and that harmful remarks were occasionally heard from the pulpits. He was anxious to know the true attitude of the church toward its members who practiced medicine, feeling that they were in line of their duty, and were also loyal to their church. Many other doctors had doubtless been similarly troubled, but had not expressed themselves openly.
The editor answered frankly, to the effect that the doctor was too sensitive to criticism, and misinterpreted statements made against his profession. He said the church was not opposed to learning in any field, but rather encouraged it. Some people belonging to the church "give expression to their notions in rough and ready and offensive manner to sensitive minds, but they are not the Church." He further said to the enquiring doctor, "Hostility is sometimes aroused by the airs of superiority assumed by the Professionals . . . and a style and bearing which they seem to think is so overwhelmingly imposing as to strike all their former associates with awe and aduration." He did not accuse the doctor of such an attitude, but said it was prevalent "in some well-understood directions."
This probably expressed the real feeling toward medicine on the part of the editor, and as he had written much on medical subjects for many years, the effect was perhaps a potent factor in the general feeling which was prevalent against medicine, and about which the physician complained.
Many doctors of territorial days doubtless endured the difficulties they encountered in silence, because of the regard they had for their church and its leaders. What the reaction was of the doctors who were not members of the church is not known, Some, as Doctor Washington F. Anderson, who practiced for fifty years in Utah, were close personal friends of President Young, and were occasionally called into consultation in his family. An illustration of the sincerity of one doctor, who was a church member, is given in the diary of his daughter. Doctor George W. Hickman was one of the earliest doctors of Utah County. He was a graduate of Oberlin College, from which he also received a degree in medicine. He planned to practice in California, but remained in Utah, a convert to Mormonism. He settled near Payson, but was destined not to practice for long. "President Young counselled father not to practice medicine because he wanted to teach the people faith and dependence upon God .... This was a stunning blow to a young man who had spent years in preparation for a profession suddenly to have his staff knocked from under him." He was poorly fitted for the life of a frontiersman or rancher, and he knew nothing of agriculture. He ceased practice, as he had been counselled to do. In time he began to practice a little, but he felt that he had no right to make a charge for his work. If any patient chose to pay him a fee voluntarily, he accepted it. There probably could be no better example of humility and devotion to disprove the charge of arrogance and egotism. There was probably no more reason for such a charge against the doctors than could be made against any other group.
As medical education improved, better trained doctors came into practice, and adverse sentiment began to subside. Better support was accorded to physicians, although the people maintained devotion to their religion, with dependence on administrations of the elders. These administrations still are carried on in harmony with the services rendered by the doctors, in both the homes and the hospitals.
Some hospitals were built during the last quarter of the last century. The first established were used largely for emergency purposes. Some were simply converted homes, and provided beds for the patients of one or only a few doctors. The hospital for the care of patients suffering from mental diseases was the first regularly built hospital in the territory. It was approved by the Salt Lake City Council in 1869, but was not built until 1872. It was located in Salt Lake City near where the pioneer monument now stands. It was financed by the city, but provided care for the mentally afflicted of the entire territory. It was transferred to the care of Doctor Seymour B. Young, a private physician, in 1876, and was sold to him in 1878. Doctor Young conducted the hospital, which was known as Doctor Young's Insane Asylum, and commonly called the White House on the Hill, until the State Mental Hospital was erected at Provo in 1885.
The general hospitals at first were extremely primitive. The St. Mark's Hospital in Salt.Lake City was established in a converted residence at Fourth South and Fifth East streets. It was used largely for the care of miners who had developed lead poisoning. The Holy Cross Hospital was built in 1875, on Fifth East Street, between South Temple and First South streets. The W. H. Groves Latter-day Saints Hospital was not built until 1905, and the Salt Lake County Hospital in 1912. These hospitals have been described in detail by recent writers.
The Deseret Hospital had a unique experience in pioneer history. It was established by the Relief Society in 1882, in the old Twelfth Ward, at Fifth East Street, between South Temple and First South streets. It was conducted for the Relief Society by the group of women physicians whose education they had largely financed. The hospital was abandoned in 1890, when it became too great a financial burden. Only when the general hospitals established training schools for nurses did the women doctors in charge discontinue the training of practical nurses, which service they had provided from the beginning.
The services rendered by these early hospitals were substantial, and marked a definite advancement in medical care, even though they were limited in equipment and modern conveniences, Elective surgery was not very general until the turn of the century, although some surgery was being done. The old hospitals throughout the world had been sources of infection, until knowledge of control of bacterial diseases had become available, and there was a general fear of them. They had been used for the most part when hospital treatment was inescapable, and patients submitted usually with a feeling that they would never leave the hospital alive.
The doctors, at the turn of the century, were getting a much better training. The medical schools were graded, and the poorer schools eliminated. The doctor still could not cure many diseases, but he was becoming better equipped. There was a personal devotion, however, on his part, which established greater confidence, and compensated, in some measure, for his deficiencies.
Pioneer medicine merged slowly and almost painlessly into the scientific medicine of our own recollection. It lost the controversial aspects of treatment as improved research developed the new facts relating to all diseases. More effective methods of treatment came rapidly into use, the new replacing the old with constant improvement in therapeutic agents and in techniques. The obsolete practices, so repulsive to the patients, could well be spared. More effective methods were gratefully accepted.
With improved methods of treatment, however, complications arose which created new problems. Treatment became more expensive. World conditions changed, and these were reflected in medical care. Methods of rendering medical service changed so rapidly that adjustment was not easy. Relationships between doctors and patients often were strained. While many more patients could now be cured, the treatment was complicated and much more expensive, and many patients complained. Most nations solved the problem by the state assuming control of all medical service. The results have been extremely controversial, and remain so to the present time.
Only in the United States, and a few of the smaller countries, is a "free" type of medicine still possible. Even here, the present system has its difficulties, and there have been demands from the federal agencies, and some other sources, for some form of state medicine. Under the present administration, the demands have lessened to some extent, but the President twice has requested Congress to pass a law which would improve the medical service for certain groups.
The controversial problems are those of costs of the service rendered, and what has come to be known as "mass medicine." Medical care has passed gradually from the general practitioner, practicing in isolation, to the clinics. These are made up of specialists, or groups of specialists, and general practitioners. Specialists in many fields are being called into consultation much more frequently. As a result, diagnosis has become complicated and more expensive. Far better results are possible to the patient, but many, even though cured of their ailments, are unhappy with the results. Lack of close contact with the doctor of their choice, insufficient explanation of the conditions found, and the costs of the service, hospital and medical, are the commonest complaints.
These problems must be solved to the satisfaction of all classes of patients before the present fine medical service available will be appreciated fully. Experimental methods of prepaid insurance of various kinds are becoming popular, and are solving some of the problems. Intensive study of public relations by the clinic and the individual doctors, as well as by the public generally, each trying to learn the other's point of view, also is having a good effect.
There is still a general feeling, however, that further changesin relations will be necessary. The clinic must come nearer to the ideals of the old family doctor. He had little to give but his interest and sympathetic contact, but these created a feeling of security in the family. The lone practitioner, while he still exists in many places, is slowly becoming as obsolete as the frock coat he once wore. He still can function in the clinic if he has a full understanding of the need.
The matter of the cost of service to the patient will remain a controversial problem until a way is found to make medicine available to him at a price he can afford to pay, without affecting the security of his home. Far too many are convinced that that happy state has not yet been reached. It will require concessions by doctors, patients, and local and national governments to achieve that end. There must be an honest and unselfish effort to understand all the problems involved. Only then can the splendid medical service now available become applicable for the general good.
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