Injections, itches, and institutions: the experience of rural medicine in Iowa, 1920-1950, January 28, 2016

- Welcome to the History of Medicine Society Lecture. We have lectures once a month during the academic year, and this is our first lecture for 2016. If you are new to this group, and would like to get regular mailings, I have a sign-up sheet over on the right ledge, and you just need to put down your name and your email, and you'll get notices of lectures and other events that we're holding. Today I'd like to introduce Karen Mason, who's the Curator at the Iowa Women's Archive, who's going to be introducing our speaker. You go, girl. Thank you, Donna. And thank you for asking the Iowa Women's Archives to co-sponsor this event, which is particularly wonderful, since Jennifer's an old friend of mine. So I thank you all for welcoming me across the river. I got lost several times on the way, but I found it. It's really my great pleasure to introduce Dr. Jennifer Gunn today. She's an associate professor in the program The History of Science, Technology and Medicine, and Director at the Institute for Advanced Study at the University of Minnesota, where she's been on the faculty since 1997. I met Jennifer about 15 years ago, in St. Paul at a Rural Women's Studies Association Conference. We'd been at a session, and independently made a beeline for the coffee when a break came along, and got in line, and we waited and we waited and we waited, and there was some SNAFU with the coffee, which gave us plenty of time to get acquainted. And it turned out that Jennifer said she had just been having conversations with this archivist at The Herbert Hoover Presidential Library, who it turns out was my husband, Matt Schaeffer. But since Matt was not at the conference and I was, I was able to persuade Jennifer that the real place to do research in Iowa was the Iowa Women's Archives, not the Hover Presidential Library. So Jennifer came and began researching some collections, and found Clara Steen Skott, one of my favorite collections, and you'll hear some more about her today. And we've been on panels since then, but it's been too long. So we're lucky to have her here today. Jennifer is a historian of 19th and 20th Century Medicine, and she earned her MA and PhD in History and Sociology of Science at the University of Pennsylvania in 1997. She's done extensive research on the History of Population Studies, and Demography in the Inter-war Period, and on the History of Philanthropy. Her published articles include Compromising Positions, A Story of Early 20th Century Occupational Medicine on Minnesota's Iron Range, which appeared in Minnesota Medicine, A Few Good Men: the Rockefellers and Population Studies, and Factory Work for Doctors: The Early Years of the Section on Industrial Medicine and Public Health of the College of Physicians of Philadelphia, which was published in Transactions and Studies of the College of Physicians of Philadelphia in 1995. Jennifer is currently working on a book exploring the History of rural health and medical practice int he Upper Midwest in the first half of the 20th century, and as you can see, she will today speak on the topic Injections, Itches, and Institutions: the Experience of Rural Medicine in Iowa, 1910-1950. Please welcome Dr. Jennifer Gunn. - Thank, Karen, and thanks I'm really happy to be here, because this is really where my project on the History of Rural Medicine started, with a grant from the State Historical Society of Iowa, and with Karen and Matt, and their archival guidance. So I'm very happy to be here, and I was assuming that I'd be in a convey of cars on the way from Minnesota, going to the caucuses, but in fact, it doesn't look like you're getting invaded So anyway, it's a very exciting time to be in Iowa for more than one reason. And I will try to cut the fact that I have become a mad person, and that inevitably, slides get out of order, but all the slides are good, they're fun. So we'll just take them as they come. And it's hard in a way to start a talk on rural medical practice without invoking W. Eugene Smith's mesmerizing 1948 Life Magazine photo essay on the Country Doctor. And here you see probably the most famous photo from that essay. Or, alternately, Norman Rockwell's iconic image of the Family Physician that we all wished we had when we were kids. But historians tend to talk more about institutions, technology, health policy, and this a 1945 cartoon from The Des Moines Register, but you notice that could be, say two years ago, if not still ongoing. And if we really want to grab our audiences, we talk about menacing epidemics, like Smallpox in the past, or sort of how did we get to the present in this way. But I think in a way, the photographers and the wisest historians really understand that it's the faces of real people and their stories that generate empathy and identification and understanding and insight. So tonight, I'm gonna try to briefly frame an argument about the history of rural health and medicine in Iowa up front, but then I'm going to try and spend more time telling you stories about everyday realities for Iowa farm families and physicians. And so these stories involve people like Clara Steen Skott and her family, and their experiences, I hope, will give the argument some faces and life. So, what would a History of Medicine talk be without the Flexner Report? Someday I'm gonna do one without the Flexner Report. The national concern about rural health crisis has recurred decade after decade since at least the time of the Flexner Report on Medical Education. The crisis was, and is still often perceived to be one of access to medical care, especially access to doctors and medical facilities. Medical reformers had repeatedly stated that rural citizens are entitled to the same quality of medical care as their city brother. But the achievement of that principle must be seen in the light of the reality that in the United States, there has never been a general right to health, or an entitlement to medical care. So other medical, and while the reformers were arguing to improve rural access, other medical leaders were simultaneously arguing that people should not seek care for which they could not afford to pay, and they strenuously opposed government social programs to provide preventative health and medical care for those who couldn't afford it. Programs like the Sheppard-Towner Maternity Unit Infant Care Program in the 1920s, another program with a strong Iowa identification, and President Truman's Nation Health Insurance Plan. So in the first half of the 20th century, in this period I'm taking about today, we're looking at, one, the point at which the Nation becomes 50% rural and 50% urban, although for states like Iowa and Minnesota and Wisconsin and the Dakotas, that actually happens later, often at the end of the '40s and into the 1950s. But in this time period, we're looking at urbanization, and curiously, we're looking at a shift in higher rates of infant mortality, which we use as our proxy measure for overall health status. From the city, which was, at one point called dysgenic, because it was only migrants that were keeping cities growing, the death rate was higher than in the countryside, but now this is reversing, and it is the rural residents who have higher mortality and morbidity rates, and poorer health overall. So while medicine's technical capacity to heal is improving slightly, particularly in the two decades before World War II, and especially when things like sulfa drugs come in in the mid-1930, it is still good nursing, sanitation, nutrition, and preventative care that are as important, if not more important, as biomedicine, in determining health and longevity. And so a lot of this is now how do we get those things, and raise the standards for those things in rural areas. I want to argue that the health in rural areas isn't a cut and dry question of distance to doctors and hospitals, but a much more complex story of patient experiences, phsyician practices, diverse care givers, suddenly changing expectations. And I'll just give you a heads up, that's the hardest thing to sort of tap, and changes in the ways of living and costs, and the gradual emersion of a medical safety net, that where it existed in rural areas had largely depended on individual physicians and their altruism, their willing to care for the indigent. So, I want to just say right up front, because not every slide may have the appropriate program credit, that, as I said, this started here with the State Historical Society of Iowa, and Iowa Women's Archives, Special Collections here at the university, the Iowa State University Special Collections, Archives at the University of Kansas Medical Center, so they have the papers of Arthur Hertzler, the guy who wrote The Horse and Buggy Doctor, really Iowa shouldn't want to claim him, but he was born here. He was really kind of a Tartar, I'm not impressed. The American Academy of Family Physicians and the Minnesota Historical Society, and the National Library of Medicine. So there are very rich Iowa Archives in and particularly to get at the patient perspective, which is the hardest thing for most historians of medicine. And so I just wanted to point out some of your resources that have been of great benefit to me. So we can't miss the fact that health was a concern for farmers in their communities. When we look at the records and activities of groups like the Iowa Farm Bureau Federation, the Iowa Farm Bureau of Women of the Extension Service, letters to the U.S. Children's Bureau, and the pages of magazines like Farmer's Wife and Wallaces' Farmers, magazines, I might add, that Clara Steen Skott wrote for as a journalist and farm wife, all of those things indicate that there is an ongoing and abiding concern with health and healthcare in rural areas. But there were also issues in Iowa that we'll see throughout this period, that mirrored that national tension between medicine and public health. And it seems counterintuitive to say that there's a tension between medicine and public health, but in the U.S., we have really created a divide between what we often think of as social medicine, preventative medicine, and public health and organized, individual health care delivery, which is private, and much of the other is public. So this divide is echoed in the things we see going on in Iowa in this period. The Farm Bureau and civic organizations were heavily invested in this idea of better conditions for living. Sanitation, hygiene, lighter work loads, especially for women, nutrition and disease prevention. These were the things they saw as the route to improve health and medical care for rural families. While the Iowa State Medical Society, the American Medical Association, and major medical organizations were wedded to the quote Hospitalization Idea. That is, promoting the construction of hospitals as technological workshops for physicians and sites of care for patients. So it was sort of, if you build it, they will come. If you build a hospital, you can attract doctors that will solve the doctor shortage. And so there is this tension between what rural people really need, do they need better sanitation, do they need access via transportation, or do they need more doctors and more hospitals? Well it's tempting to think that the line between the two approaches was more blurred in rural areas, that country doctors offered a more holistic approach to health and medical care, but multiple examples show that this was not always the case. There were some gray areas for public health personnel, particularly county nurses, Red Cross, public health nurses, delivered care, and some conditions that gave rise to experiments, such as health cooperatives. This is an article in Colliers about the Elk City Oklahoma Health Cooperative that was founded in 1929. But the issues of cost competition among physicians and their ideological opposition to government-supported medical care, ahd serious affects on the access to care. The Farm Bureau Women County Home Demonstration Agents wrote annual reports, and those reveal the breadth of health-related activities taken up by rural women in their local chapters, and also in the national organizations. So in 1923, local Iowa chapters offered Nutrition Training Schools. Food Study Groups. This is my personal favorite, I couldn't find a poster, but, the Limes and Legumes Program brought high school lunch programs and home nursing classes. There were two clubs in Webster County that studied Health Legislation. And in 1920, the Farm Bureau had a political platform that included a number of health-related ideas, such as State Assumption of the cost of provision of health-related services, such as Tuberculosis Control, and the provision of State Hospitals for the mentally ill, people with epilepsy and people with tuberculosis. And these Girls' Health Contests were one of the activities of local chapters, and it was also a way of providing a basic health exam, and this was probably, though I haven't been able to find the direct link, it was probably linked to Sheppard-Towner and the federal money that came into the States for maternity and child care. So these health contests to determine who was the healthiest girl, involved a physician exam. After 1938, they started charging a dollar for the exam, but until then, it was free. Milk for Health campaigns coupled clean milk, the eradication of Bovine Tuberculosis was the primary Farm Bureau initiative, with nutrition campaigns to increase child consumption of milk. Now, this was shocking to me, but in the land of dairy farms, that 25% of farm children, it was discovered in 1919, did not drink any milk. Now what did they drink? Wait and see. So the U.S. Department of Agriculture Extension Division did a survey of over 10,000 farm women in 1919, and that survey really reflected mothers' concerns, and revealed that malnutrition was a larger problem among rural children that had previously been thought. We operate a lot of times on our assumptions. And our assumptions for decades, in many cases, were that the countryside was a healthier place to be. Clean air, room to run free, be outdoors. But in fact, as cities improved the standard of living, by comparison, the poverty and other problems of isolation, 90% of farms in this survey still had outdoor toilets. These sorts of things were tipping the scales and challenging the assumption that people had had. So this is an ad for Postum, a coffee alternative, but in fact I've seen other health education pamphlets and brochures trying to get farm children off of coffee, and on to milk. So the County Extension Organizations and schools surveyed children's eating habits, and their coffee and tea-drink habits, they surveyed the family milk production and consumption patterns, and when they discovered that 25% of farm children were drinking no milk, at least one home demonstration agent was just incensed at the outcome of that survey. And here you see more, sorry, I had better access to Minnesota sources on this, although I'm sure there are great ones in Iowa, I had to laugh, because I had great slides from the Iowa Women's Archives in Iowa State, but I discovered they were just that, slides. 35 millimeter slides, so we have an odd assortment of images today. Well most of the counties report holding Sheppard-Towner Well Baby Clinics at some point in the mid-1920s. So the Marshall County Farm Bureau held 10 clinics in 1925, with doctors and nurses advising 252 women, and examining their children. So if you think about this, this is a substantial population in a rural county. But these publicly funded clinics, mostly serving poorer families, were themselves a source of conflict with the medical profession. The Farm Bureau and the Home Demonstration Agents often listed the clinics under the nutrition section of the annual reports, to stress that infant feeding information was a big focus of the clinic. Well, it was, but this seems more likely to have been a tactic by extension to achieve cooperation by the local physicians and alleviate a hostile response from the local doctors. So generally a doctor and nurse came from Iowa City. They were supplemented by the county or Red Cross Public Health Nurses, plus volunteers from the Farm Bureau Women's or local women's group chapters. And occasionally one of the local doctors participated in what was essentially screening and vaccination and education. Usually the best that the groups organizing these clinics could hope for was that the Medical Society would at least give it a tacit verbal endorsement. So what did farm women do with this health and nutrition education? If we look at the Diaries and Memoirs of people like Dorothy Unmacdicks, Zelda Wolf, Mable Windborn, and Elsie Stokes-Stratten, we can see that education was one of the tools women employed for caring for themselves and their families. There's a campaign in Farmer's Wife and also with the Farm Bureau to get emergency kits that you keep by the phone or by the door, and they have lists in there of what kinds of things you would put in your emergency kit. So we would think of it as a first aid kit, basically. But there are a lot of different ways in which these groups were trying to address the need to be prepared at home to care for your family's health, both in terms of acute injuries or illnesses, or also in that nutrition and prevention and sanitation kind of way. As the USDA Survey of Farm Women pointed out, the average distance from a doctor and a hospital were quite large. So the average distance from a doctor, and this was a nation-wide survey, was about 5.9 miles, 12 miles from a trained nurse, and 14 miles from any kind of hospital, and some things that qualified as hospitals, we wouldn't really think of that way today. Between the distance issues, the seasonal problems, travel problems, and the limited number of physicians who might be out doing a childbirth or something else when you have an emergency, even prosperous farm women who had automobiles and phones were forced to deal regularly by themselves with serious accidents and illnesses. Self-help books and patent medicines were also a standard part of their armamentarium, and a number of these diaries talk about using their reference book. This is 1907 Guide to Health Cookbook. You can find advice in here for dealing with hydrophobia, and piles, but also making your own cosmetics. And not least, the Dr. Keen's Lineament is advocated regularly as a solution to many of your family health problems. In practice, we have to ask, how much different was this than what many physicians could prescribe or were doing at the time. So if we look at the ledgers of Dr. E.C. Brown, who practiced in Madrid, Iowa from 1893-1920, we can see the medicine he's dispensing. And by the way, he was trained at the Michigan Homeopathic Medical College, although I think the things he's prescribing are not standard homeopathic remedies by any means. He's dispensing gargle, tonic, ointment, plasters, vaccinations, Anti-Phlogistine, which I think was a patent medicine at the time, medicine for whooping cough, cough syrup, kaolin paste, croup tablets, grippe tablets, colic tablets, e-am pills, that one I don't know what it is, eye drops and eye droppers, worm tablets, mumps ointment, teething tables, lineament, and smallpox pills. As you can see, most of the patent medicines of dubious value were likewise dispensed through a physician as well as over the counter in pharmacies in more urban areas. At the turn of the century, most of Brown's visits, which specified medicines, ran between 50 cents and $1.75. And so he's charging, he is giving you the medicine along with this, but it's an easy prescription. He also seems to be charging about $15 for labor and delivery, for obstetric care in that time period, in his practice. One of the things that's interesting is that the cost of office visits and various kinds of procedures don't go up nearly as fast as you would think over about a 50 year period. What does change is really kind of enforcing the charges for rural call, for a house call in a rural area, which often runs 50 cents to a dollar per mile from the doctor's office. So you can see how quickly that would add up for farm families who needed the doctor to come to them. And of course if we think about it, at this time there's relatively limited numbers of effective medicines by contemporary standards. We did have things like Aspirin, Digitalis for heart problems, Barbiturate, which was a very common injection for these rural doctors, and Clara Skott received barbiturate injections for most of the period of her diaries for her headaches, what we would probably call migraines today. A doctor's wife in rural Minnesota told me that in the 1950s, her husband still did his own dispensing, and several of the things they dispensed, and that were really staples of their prescriptions, were Carter's Little Liver Pills, and sugar pill placebos. But you can see from women's diaries, this is Mary Henrietta Peter's, talking about going to town to get medicine, whether it's from the doctor dispensing it, or whether it's from a pharmacy, people did spend money on medicine. Not necessarily on the visit to the doctor, but on the medicine. So let's return to Clara Steen Skott, who is perhaps the queen of all Diarists, Karen, correct me, but doesn't she have 83 years of diaries in your collection? Her last diary entry, she died at 105, and her last diary entry was at 102. And I just have to say that you can not read her diaries without laughing and absolutely weeping. So Clara Steen was born in 1888 on a farm near Menlo, Iowa, in Guthrie County. The second daughter, and the fifth child, in a family of eight children. When she was 11, her family moved to West Liberty, in Muscatine County, in hopes of finding more productive land. The family prospered, and Clara's father, who had been a State Legislator from Guthrie County, F.D. Steen, went on to be a leader in venerating the State's Farm Bureaus in the early 1920s. And Clara's diaries in the Iowa Women's Archives begin in 1908, when she was 20. After graduating from high school in 1907, a singular accomplishment in itself at the turn of the century, Clara alternated terms of teaching in rural schools and attending Iowa State College, where she majored in Home Economics and minored in Journalism. Clara's wedding to her college classmate, Hans Skott, in 1917, was somewhat rushed. There was a war on, and Hans had to get married in order to take a job as the Agriculture Teacher at Bagley High School in the far north-west corner of Minnesota. The Bagley School Board thought that being married would be insurance against Hans getting drafted right away. It was a good thing that the newlyweds had each other to keep warm. That winter in Bagley, they lived in an uninsulated house, and the outdoor temperatures reached minus 52 degrees. They heated with tamarack wood. Whether it was the climate or the war, the school board was doomed to disappointment. Hans secured an appointment as a County Emergency Food Agent in January of 1918, and a week later was on his way to Vermilion, South Dakota, where Clara joined him a month and a half later. A few months later, far away from her family, Clara had a miscarriage. She conceived again soon after, and her entry for her anniversary was the first indication I found in the diary that she was even pregnant. My suspicions were aroused, however, when "Felt queer all day," or "Felt bung," or "Not feeling good" began to appear at least once a week in the summer of 1918. Clara's two-line summary for the month was not much of a surprise by then. "August brought us hope that our home will be blessed" "By the coming of a little one to us." "South Dakota gardening brings good returns." Although she never said so in her daily journal, Clara must have worried about this second pregnancy, especially when the Spanish Influenza Pandemic spread to Ames and Vermilion in the late fall. So, this has to be the most famous picture in Iowa medical history, just so you know. At her alma mater, Iowa State, there were more than 1250 cases of Influenza and Pneumonia in sequelae at one time. Clara recorded that 51 students at Ames, and at least three of the boys at the Army Training Camp at Vermilion had died. Local Red Cross Chapters, and this is true of very, very small town and rural area Red Cross chapters, made Flu Masks. We now doubt that these had very much effect, but people were doing what they could. One of Clara's borders, and her next door neighbor, contracted influenza, and in January, Hans was diagnosed with the flu. One of the local physicians gave Clara three, quote, Flu Inoculations. We can only guess what was in, whether this was his own invention, the doctor's own invention, or one of the many ineffective commercial products that flourished in the wake of the killer viral epidemic. A series of three inoculations against the flu, developed at the Mayo Clinic, and were marketed widely in the Midwest, interestingly, at the State Department, there was also one developed in the Bacteriological Labs at the University of Minnesota. The State Department of Health in Minnesota would not endorse either of these, but they did facilitate their dissemination if counties wanted them. The presence of such alleged preventatives for la grippe, or the flu, and the common cold, ultimately led the Surgeon General of the United States to issue a warning to the public not to waste their money and their hopes on these worthless nostrums. And yet, into the mid-1930s, Clara Skott's account books regularly show expenditures of one dollar for Cold Shots, and even 5 dollars for a series of inoculations against Scarlet Fever. And again, is this the doctor's own concoction, are these vitamins, is this a tonic? What is in these things? We don't really know. But it was clear that Clara was a mother concerned to prevent the spread of illness in her family. She seems to have had a very strong orientation, and willing to put her limited dollars to work for prevention. And here's just an example, I hate it when people say I know you can't read this, but I did want you to just see what Clara's diaries looked like. And this one is particularly interesting, because she's summarizing some of the years here. Well, Clara's second pregnancy had a happier outcome than her first. Hilda was the first born, and interstingly, later the diary refers to the fact that Hilda didn't learn to walk until she was 16 months, but Hilda was morn at home on April 4th, 1919, and her diary shows the focus of a nervous new mother on breast feeding, the baby's sleep patterns, and weight gain. The Skotts moved back from Vermilion to Iowa to a rented farm near Maquoketa, am I pronouncing that right, Iowans? Thank you. And Hans' parents. By the time her fourth child, Frank, was born, Clara was again taking pregnancy and child birth in stride. The only indication in the diary of Frank's impending birth is that Clara began making diapers. She was a phenomenal seamstress. But a really, really lousy knitter, they almost kicked her out of the knitting group in Bagley, because she could not knit worth a darn. The year before her marriage, Clara, in driving a horse and buggy, so this must have been in West Liberty, and when she was, when the buggy was hit by a car, causing the horse to bolt, and Clara's daughter Hilda reported that the back injury Clara received plagued her for the rest of her life. A year after the accident, Clara underwent strenuous Osteopathic treatments for several weeks. But neither the short duration of the treatment nor the diary indicates that these were very helpful. In her 40s, Clara's back pain periodically interrupted her normal duties, and in fact, her wedding was postponed because she was having back pain, and then she was putting up curtains the day before the wedding, and she actually tore ligaments and broke some ribs. So she continued to have problems related to the back pain. But then it was highly unusual for her to comment. Because there are hundreds of entries where she records her recurrent "Sick Headaches," what I said we'd probably now consider migraines, and her diaries are riddled with descriptions of colds, Pink Eye, other common contagious illnesses, Scabies, or The Itch, and "Just feeling bung." And here's Clara in Bagley, Minnesota, at her wood stove. Rarely did these conditions affect her production, in canning, turning, managing a poultry business, making over old garments into clothes and shoes for the children, washing the hated cream separator, her most hated job, hauling water, helping Hans around the farm, milking when the men weren't available, writing up the local news, or starting a book club. At one point, she tracked her time, and you can see this emergence of sort of scientific motherhood, because Clara is incorporating these new ideas of child psychology, of tracking her time in the home for greater efficiency, and she discovered that the basic chores, dishes, cooking, laundry and cleaning, took about 12 and a half hours every day, which was slightly more than the 11.3 hours estimated as the average for farm women, and since it was only 12 and a half hours, she thought that would then give her time to do some sewing for her children's clothes. The meticulous detailed account books confirm that for many years, Clara did not even get patent medicines for her ailments, the exceptions being two bottles of, quote, Aspine, which I think was the mail Oxford tongues of its time, during the period when she was having stomach problems. We can speculate that she sacrificed doctors visits for herself for those of the hired men. She treated one of her children's injuries at home with the leftover medication the doctor had given the hired man a few weeks before for an infected So there is, you see commonly in a number of these diaries, a closer attention to the health care of the hired workers, who, until the 1960s, many of these hired men and hired women are also living with the family. And when they are injured, like an Amish hired man almost cut off his toes with a scythe, so he was taken to the doctor, who sewed him back together, and then he helped the grandmother tear up old clothes to make comforters while he was recuperating inside over the winter. And here we see Clara in her garden. She also was a prolific gardener and canner. It was only knitting she really couldn't muster. So March of 1928 was a typical period in the Skott's lives. On the sixth, Clara canned 13 quarts of meat, made sorghum cookies for once, it was a raw day, mended 17 garments after super. The previous day, she had ironed, made current jelly, given the milking machine its weekly overhauling, cut up quite a lot of pork, and worked on her egg business. Three days later, she started the Soap Making Business, and finished weeks of mending, and had a new washing machine that she was eager to try out. And so her daughters turned the, quote, New Hand Washer because they were so anxious to, and Frank, who I think by contemporary standards, would be diagnosed as having ADHD, Frank stuck his fingers in the cogs of the hand wringer, and got them peeled and bruised. A couple of days later, she wrote that "Frank has a very bad cold," "And Signe's cough and cold are bad," "She got in mud over her high overshoes walking to school." The girls were home with sore throats, Clara had a sore throat, but she's still canning, even though, quote, "I felt bunk, with a miserable cold." And Frank also continued to have problems. She was tired, but she's out planting tomatoes, and doing her regular chores. There was even a month when the road conditions were so bad that she did not get off the farm for an entire month. When Hans was sick she had to help, and in fact, help with other tasks on the farm. Velma, Hans' younger sister, who was closer in age to the Skott children than to her older brother Hans, was living with them shen she had her tonsils removed. A month of chronic illness spread through the family, around the time that Velma had her tonsils out, but there was no resort to any medical care other than, one presumes, the home remedies. Not even a trip into town for patent medicine, cough syrup or anything like that. Only Velma saw a doctor, and that was for surgery. And most of the women's diaries show that they resorted to doctors for extremely serious illnesses, such as the sleeping sickness, they believed to be contracted from a horse, or when someone needed to be sewed up. And Frank needed to be sewed up a lot. Rural physicians' records ... He also had a tendency to sit in the mop pail when she tried to mop the kitchen floor. Rural physicians' records for this time period revealed a land office business in tonsillectomies and adenoidectomies. They could be done on an outpatient basis or in the hospital, and the charge ranged from $10 to $30, depending on the doctor and location. Today, physicians are hard-pressed to explain what tonsils actually do, something with the immune system is the general hypothesis, but I'm happy to be educated on this, and antibiotics for throat infections have largely reduced the frequency of tonsillectomies and adenoidectomies. But in 1928, the pre-antibiotic era, tonsillectomy was often seen as a judicious therapeutic response to repeated throat infections, or sound preventative medicine. Clara herself, after decades of sore throats, had her tonsils removed in 1938, in the Methodist Hospital in Dubuque. The doctor's charge then was $35, plus the cost of a one-night stay in the hospital. Like one of her diarist's predecessors, the 18th-century Maine Midwife, Martha Ballard, Clara rarely expressed direct emotion, or complained about her burdens. She was matter-of-fact about the health problems she and her family suffered. Her account books reveal a wicked sense of humor about farm and family economics. She had a humorous motto for every month. Inside the back cover of her account book for 1936, she has written, quote, "For reasons why we did not keep within the budget," "See appendix." Here is the appendix The most poignant and serious medical episode in Clara's diaries, the one that had me weeping in the archives, occurred in 1925. In November, Clara was pregnant with her fourth child, suffering from The Itch, scabies, and very painful varicose veins. The children had various ailments throughout the fall, and then on November 2nd, Clara wrote, "Hilda's leg worse, and she couldn't go to school." This was the first mention of anything wrong with Hilda's leg. By the next day, Clara reported that "Hilda ate nothing, worse." "Despite rain and mud that mired the car" "Until a team could pull them out," "We took Hilda to doctor, who says" "Acute Inflammatory Rheumatism in the left knee." "The next two days were tough." "Hilda and I put in a bad night." "I was up about a dozen times." "Hilda cried often in the night with pain," "But was better in the daytime." "We ran out of ice for her in eve," "Itch bothered me greatly." Hilda's fever ran high for another eight days, was only partly relieved by snow in her ice pack to supplement when they ran out of ice. The six-year-old's recovery was slow to non-existent, adding to Clara's work at a time when in addition to the regular washing, poultry and cooking chores, she was also sticking Christmas Geese to ship to Chicago, helping Hans install a new furnace, and sewing for the coming baby. So finally on December 18th, she writes, "Doctor Frank came to see Hilda, thinks infection of bone." "I helped Hans with furnace 'till I got heavy cold." "Sneezed all p.m." "Hans and Frida, that hired woman," "Took Hilda for x-ray of leg." "Infection, probably from a boil." A simple, common household ailment. On December 20th, quote, "I cut Hilda's hair, packed her suitcase," "Put a new head on her doll." And on the 21st, Clara risked a trip to town. "Left here about 7:30 with Hilda." "We bought a doll for her in town." "She and Hans went on the 8:50 train to Davenport," "And thence to Iowa City to the hospital." Hans returned the next evening. On December 23rd, Clara wrote, "Hilda had operation for infection on bone above knee" "In the State University of Iowa Hospital." "We washed in kitchen with INJUNS." Another sort of washing machine. I doubt the busyness of daily life kept Clara from worrying about Hilda, but Clara was helpless to be with her small daughter in Iowa City, as we realize reading her entry for Christmas Eve. "I baked big batch of bread, helped Hans with furnace," remember, they're installing the furnace, "Sewed a bit after dinner, called Dr. Frank at 3:00." He and Mrs. Bock, a neighbor woman who sort of acted as the doctor's assistance for childbirth, came. "Baby Frank Oscar was born at 5:00." "Nurse couldn't stay." "Hans got his mother to come for overnight." "He took Signe and Catherine over there." Three days later, Clara notes that baby Frank had, quote, "Started in having colic, quite severe and heave." By New Year's Eve, she was, quote, "Feeling fine, anxious to be up." The separation and the hard choices that the Skotts faced in December of 1925 illustrate the complex patchwork of healthcare that was available to rural Iowans. Hilda's ultimate treatment at the University Hospital has several possible explanations. Before 1930, only five counties in Iowa had Public Hospitals, despite the fact that Iowa was the first state in the Nation to pass enabling legislation to levy taxes to build county hospitals. The small proprietary facilities that filled the gaps in most counties were little more than houses or rooms in a doctor's house, and there were no hospitals in the small trading communities in Jackson County surrounding the Skott's farm. Osteomyelitis, Hilda's diagnosis, was often fatal in the pre-antibiotic era, suggesting that her condition required treatment by a surgical specialist, who tended to be located only in the largest cities. The next two slides are maps of interurbans. And part of the reason that I wanted to show this is because it showed what most farm families had to do to get to a major hospital for care like Hilda had, but it also showed that they did have some choices about who they would see as doctors if they could get there. And in the Skott family case, and in several others I've seen, until the interurbans were put out of business, they used these to enable them to choose to see an Osteopath, or a Chiropractor, or a different doctor for labor and delivery than they might see for ordinary colds. It's most likely that Hilda ended up at the Iowa City Hospital because of Iowa's Perkins and Haskell-Klaus Laws, which provided hospital care for indigent and crippled children, and served both welfare of the poor and the crippled, and the welfare of the Medical School. It insured a steady supply of patients with a wide range of medical problems, for the education of medical students. In other words, clinical material came from the indigent poor all over the State of Iowa, and they were given travel vouchers and allowed to have companions to bring them to Iowa City. However, throughout the 1920s through '40s, this legislation was also a source of political controversy, and may have actually retarded the development of the Distributed County Hospital System, because of the University Hospital's monopoly on State money allocated for indigent healthcare. And here's another interurban map. And Washington County was the first to build a County Hospital under this 1909 law that was promoted by Dr. E.E. Munger of Spencer Iowa. But as I noted, there were fewer than five of these hospitals built between 1909 and 1930. And ironically, this to me is one of the most fascinating stories, the idea of having a County Hospital was rejected shortly after the law was passed in Munger's home town of Spencer Iowa. And I want you to note how there's a lamppost with posters hanging on it. The doctors in Spencer Iowa, who appear to have been afraid that if a County Hospital were built in the County Seat, their patients would go there, specialists would come in, and they would lose business. So they went around in the middle of the night, putting placards on the sidewalks and the lampposts, claiming that a hospital would spread tuberculosis in the community, that it would concentrate germs, dump them in the local river, and spread disease. And the referendum to build a hospital in Clay County was initially defeated. So patients had choices. But I talked in the beginning about sort of the ways in which doctors provided a social safety net. And part of what's happening in this period is that over time, the distribution of physicians is changing. In 1923, there are 200 graduates of the State Medical College. 70 of them practice in cities of 100,000 or greater. 50 of them practice of towns of 2500 or fewer, which is really quite a respectable number, give n the trends of the time. But more and more of them are moving away from the places of less than 1000, and into that zone of the 10 to 25 thousand person town or market center. And as that happens, several things happen. One, the cost of getting care becomes more expensive for people who live further away. So even if their income isn't changing, the portion of it they need to spend just on transportation to get get to the doctor is greater. But it's also that the doctors now have a larger pool of patients, and many of them are increasingly refusing to treat patients who can't pay. And there's another tears moment in Signe's memoir about her mother. When her father developed appendicitis, it seemed that his appendix had ruptured, and the doctor required payment on the spot. So Clara leaves Hans with the doctor, she drives home, and she collapses in the car over the steering wheel, in sobs and tells the children that their father is going to die, because she can't figure out how to get the money yet to pay for the operation. Fortunately, Hans lives. But this was not a uncommon story, and it's commented on by a Rockerfeller Foundation General Education Board's Sponsored Study of the distribution of physicians in the 1920s. That the basic willingness of physicians to treat the poor, or to work on a kind of sliding scale, to take barter, to take, as one doctor did, make patients sign notes for their care, has now, it is now dropping dramatically. So I have plenty more to say, but I'll just conclude, so that we have a little bit of time for questions. When we focus on the history of how doctors actually practice, and ordinary people's experience of health and illness on the ground in rural areas, we can learn a lot that has implications for our contemporary concerns. And that learning is both about the development of the American Healthcare System and the choices we've made, for example, the choice that when we finally do start putting Federal money into a healthcare system at the end of World War II, there are other Federal programs before that, but in the most substantial way, the Hill-Burton Hospital Construction Act, we choose to build hospitals. And one of the things that people don't know ... but that doesn't solve the problem of doctors and x-ray technicians and trained nurses. And one of the things people don't know is that thesecommunities build brand new hospitals under Hill-Burton, and some of them closed within two years, because there are not people to staff them. So we make choices to provide the facilities and the hardware of medical care, instead of the education for physicians and nurses, although over time we do invest in that. And instead of providing some form of national health insurance. And this is a particularly strong issue, because the medical leadership that American Medical Association and the politicians in the United States that oppose a National Health Insurance Plan are very fearful that it is the inequity of care and the problems of access to care in rural areas that is the Achilles Heel of our private medical system, and might bring it down. And bring it down meaning be the advent of, open the door to socialized medicine. So the other thing I think we learn a lot is about what kinds of care people really need, and what is the range of possibilities for who delivers that care. And how that care is delivered. From family care givers to Midwives to Public Health Nurses, to physicians. And the last thing, which is obviously an issue we're thinking about today, because we haven't solved that access to care problem for rural areas. And the other thing I think we learn is why there are good ideas that don't succeed as planned, and why. Like the tax to build County Hospitals in Iowa, like the Sheppard-Towner Maternal and Child Health Program, like the health cooperatives in rural areas. Oh and the State Medical Society's recommendation that Iowa Medical Students to a year of internship, they recommend that in 1907, but they can't require it for practical reasons, numbers of internship places, until decades later. So we learn a lot about the complex of factors that make good ideas not practical and not implementable in the way that people hoped and planned. Thank you. I was gonna do my shout-out to the Iowa Women's Archives. So do we have time for questions, did I take all available time? - [Man] I just have a couple of comments. I was absolutely amazed about the consumption of coffee of non-dairy things in the teens of 20s of the early twentieth century. Just mind-boggling. I think when you look at the instance of Brucellosis in those later years, Undulant Fever, it was the farm families that were affected. They were drinking that milk raw. Because commercial pasteurization was And then finally, as the President of the Iowa Rural Health Association, I'm going to take your concluding message back to them, because they have a hard time getting in all States, to get some recognition, and some leadership about what to do in accord to critical access hospitals and trying to keep things viable and what have you is a big, big problem. - I mean, I think the thing, I think we've gone though a period in the History of Medicine when we tend to overstate the idea that economics and economic concerns dominate a lot of doctors' and organized medicine's decisions. I mean, 'cause I don't want, when I say this social safety net that had been provided by individual doctors is I mean, that's not necessarily just a critique of doctors having more economic power and using it. They also are struggling to make a living. Although as Elsie Stratten-Stoker, or Stroker-Stratten, I always get them mixed up, who works as a hired girl for a doctor, says, the standard of living and her perception of the class issues in the house of the doctor, Dr. Royal, she works for, are very different than the family she came from and the other farm families she works for. So many doctors are making a decent living, by particularly the standards of cash-poor farm families. But it's not without its struggles as well. It's really, and you know, rural doctors, and again, in Iowa, they really have to push a reconfiguration of the idea of health insurance as Blue Cross and Blue Shield are developing in the 1930s, because they're oriented towards hospital care. S that means if a doctor sets a broken bone in his office, or her office, and Hilda went on to become a doctor, and Signe did too, initially, they can't get reimbursed under health insurance. So part of the idea of the Doctor's Insurance Plan, controlled my the State Medical Society, Blue Shield, is the idea that it's going to, again, kind of fend of government intervention, by providing a private alternative. But then the first iterations of it turn out they won't help rural doctors and rural patients, because it's entirely oriented towards covering hospital care.