– by Wood Institute travel grantee, Jonathan Jones*
What sources can tell us the most about the health of nineteenth-century Americans, their aches and ailments, malaise and medicines? Diaries might come to mind, or letters between family members. These narrative sources are familiar to historians, and are more-than-commonplace in archives. On the one hand, narrative sources can be windows into the health of nineteenth-century Americans, revealing how they coped with the horrifying sicknesses and symptoms that plagued them. On the other hand, letters and diaries are impressionistic, better for figuring out how people felt about their health than the fine details of healthcare.
But what about the other stuff, the nitty-gritty details of medical history? Where can historians turn if, for instance, we want to find out how often the average nineteenth-century American saw a doctor? Or how much he charged them for lancing a boil or delivering a baby? What if we needed to know the most commonly prescribed medicines in nineteenth century America, like mercury, calomel, or opium? How can we investigate these questions with numbers and not just with quotes? Historians using only narrative sources would likely be unable to. Luckily for us, most nineteenth century American physicians kept account books, which contain invaluable quantitative data that historians can use to illuminate historical health patterns, supplementing impressionistic sources with hard data.
I started working with physicians’ account books while conducting research for my dissertation at The College of Physicians of Philadelphia’s Historical Medical Library. My dissertation—a historical study of opiate addiction in the Civil War era—documents, among other things, the factors that caused an epidemic of opiate abuse among Civil War veterans. I wanted to know exactly how veterans came to be addicted. I suspected a few patterns, like overprescribing, based upon research in nineteenth century letters, diaries, and medical journals. But I needed quantitative data about opiate prescribing practices to confirm my hypotheses. Narrative sources were simply not providing this kind of information, and I was stumped about where to turn. So taking a cue from historians of slavery, who have had great success at extracting meaningful information about slavery from the financial data recorded in plantation ledgers, I started looking into physicians’ account books. I ended up stumbling across a wealth of medical data that went a long way toward answering my central research questions.
WHAT ARE ACCOUNT BOOKS?
Physicians’ account books are financial records of medical practices. Every physician’s practice was a small business. If they hoped to turn a profit, doctors needed to keep careful records of services rendered to patients and payments received for those services. This was the essential purpose of account books. Ironically, because financial records had pragmatic value that directly affected a physician’s livelihood, account books were often kept safe and sound for decades while other materials, like letters from patients describing their health concerns to doctors, were routinely destroyed. As a result, nineteenth-century American physicians’ account books are easy to come by in medical archives, while narrative sources reflecting the perspectives of patients are rare.
Account books are relatively straightforward to understand and work with once you know a few tricks. The format of medical account books is remarkably consistent. Nineteenth-century American physicians for the most part shared common record keeping practices, because like other businessmen doctors usually learned basic accounting from arithmetic books that provided basic education for much of the 19th century. Doctors also occasionally picked up record-keeping skills from their medical mentors during apprenticeships. Physicians typically kept accounts using single-entry bookkeeping, and in two kinds of volumes called “daybooks” and “ledgers.”
Daybooks are essentially notebooks in which physicians recorded interactions with patients in chronological order as the doctor proceeded through each day; hence the name daybook. Daybooks sometimes contain rough notes about patients’ health, including the purpose of the visit and treatments the doctor administered or medicines prescribed. For example, the physician John Hyde of Freeport, Massachusetts visited a man named David Knowalter on February 23, 1839 to perform bloodletting upon the man. Hyde charged him a modest fee of 50 cents. Doctors like Hyde often visited multiple patients in the course of any given day—Hyde visited six on the same day he bled Knowalter—so it can be difficult to locate individual patients in daybooks without time-consuming spadework. Luckily for historians, when a doctor had some time to spare, he transferred the information from the daybook to a second book called a ledger.[i]
Ledgers are lists of charges and debits consolidated from daybooks and sorted by patients (or, “account holders”). These volumes are physically large and detail rich, often encompassing about 400 pages—they were certainly not meant to be carried around! Charges issued to patients for medical services (or, “debits”) are indicated by the symbol “Dr.” and payments made to the doctor (or, “credits”) are sometimes indicated symbols “Cr” or “paid off.” Often times doctors consolidated several years’ worth of daybook entries into one or two pages in a ledger—this makes ledgers a convenient starting place for historians working with account books. Ledger volumes typically begin with an alphabetized index, enabling historians to locate individual patients relatively quickly. The downside of ledgers, however, is that they often only include general descriptions like “visit and medicine” for charges, rather than specific diagnoses or prescriptions. So to construct a proper portrait of an individual patient’s medical history, it can be beneficial to work with ledgers and daybooks in conjunction with one another. With a little luck and some tenacity, historians can readily find data in when daybooks and ledgers are used in conjunction with one another.[ii]
WHAT CAN’T WE LEARN FROM ACCOUNT BOOKS?
Account books are not panaceas. There are a few important drawbacks to understand before beginning your own archival work. Incomplete bookkeeping is a major drawback of nineteenth-century physicians’ account books as historical sources. Like their twenty-first century counterparts, physicians of yesteryear were busy people. Between purging and bleeding sick patients, staying up all night attending women in labor, or riding long hours between rural plantations, record keeping sometimes fell by the wayside. Many physicians’ account books were untidy, to put it mildly.
The information recorded in account books also varied widely depending on the doctor who kept the book. There was no uniform level of specificity or detail required of the information to be recorded in account books. Consequentially, some doctors meticulously wrote down everything for which they charged an accountholder down to the last pill, while other doctors simply jotted down “visit and medicine” to summarize decades of charges. This means that the medical problems for which patients saw doctors is often not included in account ledgers, and sometimes not included in daybooks. It is often impossible to know how specific, and therefore how useful, any given account book will be without flipping through its pages.
Account books are poor sources for investigating the lived experiences of nineteenth century patients. Doctors abstracted patients’ aches and pains and sicknesses into dollars and cents in ledgers, often recording only enough information to jog their own memories about these charges. Patients’ voices tend to be absent from physicians’ account books, because doctors did not intend for their ledgers and daybooks to record the perspectives of patients. Occasionally one might find letters from patients requesting medical care folded between the pages of daybooks and ledgers. But more often these kinds of requests can be found in doctors’ diaries, not their account books. Account books are also gendered. Accountholders were usually men, with the exception of widows. This means women and children appear only as third parties in account books. Oftentimes accounts will be listed under men’s names, with charges for services rendered to “dependents” interspersed throughout the account. This bookkeeping practice obscures the voices of women and children, who appear in account books as passive recipients of medical care rather than agents who sought out or refused doctors’ remedies.
Account books provide windows into therapeutic practices of medicine, but they often reveal little about medical theory. Doctors often recorded dosing patients with opiates, for example, but not why they administered the drugs. A better source to investigate nineteenth-century medical theory would be medical school lecture notes, which are also ubiquitous in medical archives.
WHAT CAN WE LEARN FROM ACCOUNT BOOKS?
With these important caveats aside, however, nineteenth-century physicians’ account books are a uniquely valuable and severely underutilized genre of sources for historians of medicine for several reasons.[iii] First, account books kept by physicians are essentially the only medical records of many, if not most, nineteenth-century Americans. Historians often find commentary on health in people’s letters and diaries, but this information is fragmentary at best. Most Americans lived, got sick, and died without leaving any of these records behind. So in an era before modern medical records, the financial information recorded by physicians in their account books constitutes some of the only systematic medical data about nineteenth-century Americans. David Knowalter, the man who was bled by John Hyde in 1839, would have left behind no medical records at all had not Hyde preserved his medical daybooks for bookkeeping purposes.
The information recorded in physicians’ account books is extremely valuable when we consider what historians still do not know about nineteenth-century healthcare. Historians have done thorough investigations of most aspects of nineteenth-century healthcare, including medical ideas, scientific breakthroughs, the experiences of the patient and doctor, and the development of the medical profession. But we still lack quantitative models of many aspects of therapeutic practice. Thanks to the historian John Harley Warner, we do have a solid view of healthcare in nineteenth-century American hospitals, some of which kept records that are extant today. However, hospitals were relatively uncommon until late in the century. Most medical care was either done by patients themselves, a relative, or by so-called “country doctors” who recorded their medical endeavors in account books. With this in mind, physicians’ account books can give us a more realistic view of ordinary therapeutic medical practices than we have at present.
Historians can fruitfully employ account books to extract quantitative data about the therapeutic practice of medicine. For example, nineteenth-century medical textbooks indicate a legion of hypothetical remedies taught to American medical students for pneumonia, diarrhea, syphilis, and other common ailments. But what medicines did physicians most frequently dole out in practice? Account books can illuminate the types of medicines, dosages, frequency, and sometimes even if the medicines worked or not. How much did doctors charge for medical services like bleeding, pulling teeth, or delivering babies? Account books can reveal the cost of healthcare for ordinary people and the lucrative (or not!) business of medicine in nineteenth century America. Did physicians tend to sell cheaper drugs that their patients could afford on a budget, or more expensive drugs that might yield higher profits? Did doctors prescribe different therapies to men versus women, adults versus children? Accounts books often demonstrate long running relationships between patients and their doctors. Does this mean people were generally happy with the medical care provided by their doctors? And how often were people able to see a doctor in the first place? Was it easier to see a doctor in urban places than rural America? How did doctors’ therapeutic practices vary by place and evolve over time? Comparing account books from multiple regions and decades can speak to these essential questions about historical healthcare.
For my own research purposes, physicians’ account books provide a window into the use of opiates during the Civil War era. Among the scores of account books held by The College of Physician’s Historical Medical Library are the account books of the prominent Harrisburg, Pennsylvania, physician William Rutherford. In my dissertation, I argue that the widespread prescribing of opiates lent itself to physician-caused opiate addiction among soldiers. But anecdotal evidence aside, what did overprescribing actually look like in practice? Rutherford’s account books provide a compelling example of this phenomenon. Rutherford’s ledger reveals that he treated 55 Union soldiers during the war, including eight generals and future president William McKinley, in addition to other prominent individuals like the governor of Pennsylvania, the soon-to-be governor of Minnesota, and Lincoln’s first Secretary of War. Rutherford relied heavily upon opiates in his practice, like most elite Civil War-era physicians. He prescribed opium, morphine, and Dover’s powder to many soldiers and civilians under his care during the war and after. Rutherford prescribed 143 opium and Dover’s powder pills in just three months in 1863 to one Union captain, F.A. Maulsby, healing from a gunshot wound. It is difficult to imagine that Maulsby left Rutherford’s care without an opiate addiction.[iv]
Extremely detailed account books like Rutherford’s, which records medicines prescribed down to the last pill, are exceptional. I sifted through dozens of daybooks and ledgers before I found cases like that of Captain Maulsby. But the effort was certainly worth it. The quantitative medical data contained in nineteenth-century physicians’ account books are without parallel in narrative sources. In the future I will be using account books to quantify patterns such as the medical conditions for which opiates for prescribed, the opiate prescription rate relative to other drugs, and especially how these patterns evolved after the Civil War in response to panic about physician-caused opiate addiction.
I highly recommend account books as an evidentiary pool for historians seeking to investigate the fine-grained patterns of nineteenth century American medical care. And with scores of account books from various regional settings dating from the 1700s to the twentieth century in its collections, The College of Physician’s Historical Medical Library is an inimitable place to conduct that research.
Sources:
[i] Entry for February 23, 1839, John A. Hyde Daybooks, MSS 2/0222-01, Historical Medical Library, The College of Physicians of Philadelphia,
[ii] For an accessible introduction to bookkeeping practices in the nineteenth-century U.S., see Christopher Densmore, “Understanding and Using Early Nineteenth Century Account Books,” The Midwestern Archivist V, no. 1 (1980), 5-19.
[iii] John Harley Warner provides a beneficial overview of the various kinds of sources—narrative and quantitative—available to historians of nineteenth century American medicine. See John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885 (Cambridge, Mass.: Harvard University Press, 1986), “A Note on the Sources for the History of Therapeutics.”
[iv] Account book, 1863-1873, William W. Rutherford and A. T. Dean account books, MSS 2/317, Historical Medical Library, The College of Physicians of Philadelphia. F.A. Maulsby’s accounts on 92, 106.
*Jonathan Jones is a Ph.D. Candidate at Binghamton University. He received an F.C. Wood Institute Travel Grant from the College of Physicians of Philadelphia in 2017.