Private Practice: In the Early Twentieth-Century Medical Office of Dr. Richard Cabot

• Chapter 2: Organizing a Private Office
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• Johns Hopkins University Press
• pp. 30-70
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30CHAPTER 2

ORGANIZING A PRIVATE OFFICE

BETWEEN HOME AND HOSPITAL

On a late December afternoon not long ago, I found my way to the doorstep of 190 Marlborough Street in Boston. One hundred years earlier, this address had been the home and the private medical office of Richard Cabot. The building that I peered up at that afternoon through a scattering of snowflakes was a narrow brick house with a slate roof that cannot have looked very different in Cabot’s time. Set flush into a line of similar nineteenth-century row houses, it opened almost directly onto the street. In a few steps, I could have knocked on the door and perhaps met the occupants. Instead, I turned and walked east down Marlborough Street through the neighborhoods where Cabot lived and worked for several decades after he first began practice in 1896. I was following in the footsteps of one of Cabot’s patients, a woman who visited him in January 1902, perhaps on a similarly chill and dusky day.

Mrs. Moore, as I shall call this patient to preserve the privacy of her medical records, was about forty when she visited Cabot’s office.¹ Her trip was not a long one, because she lived in Boston herself, and she returned to visit several other physicians besides Cabot that year. In one evening, I was able visit the addresses of all these physicians, whose offices had been in the same Back Bay neighborhood, in the blocks around Marlborough Street bounded by Boston Common, the Boston Public Library, and the Charles River. How did such a network of a private office practices grow and sustain itself in this neighborhood, and what kinds of collaboration and competition linked the individual practitioners? Mrs. Moore’s path through the streets of Back Bay one hundred years earlier had traced some of the boundaries and associations of Cabot’s medical community, outlining the local geography surrounding and supporting a single office.

The corner of Marlborough Street and Exeter Street, Boston, ca. 1880. Cabot’s office at 190 Marlborough would have been just off of the left edge of the frame. Courtesy of the Boston Public Library, Print Department.

Lined with marble stoops and stretches of brick sidewalk, Marlborough Street offered a quiet and elegant venue for my walk. Parts of it had not changed much since Mrs. Moore’s day; gas streetlights came on as night approached, but with a look of feigned old-fashionedness that was surely an imitation of 1900 rather a remnant of it. Since its reclamation from the marshy banks of the Charles River in the 1860s, Back Bay had long been home to many of Boston’s wealthier citizens. The blocks that I walked east from Cabot’s office offered me a peacefully unbroken line of brick and cut-stone row houses. In 1902, Mrs. Moore had visited the office of an ophthalmologist here soon after she saw Cabot. The other direction west up Marlborough Street had taken Mrs. Moore on another day to the house at number 226, where she visited the surgeon and otolaryngologist Dr. Eugene Crockett. When I reached the next intersection at Clarendon Street, I turned left and walked one windy block toward the Charles River to reach Beacon Street and the house of another otolaryngologist, Dr. Joseph L. Goodale, whom Mrs. Moore also saw later that same year. Along the way, I passed one house marked with a bronze plaque listing professional offices inside. Discreetly visible from the sidewalk, the plaque announced the practices of a licensed social worker, several PhD-certified counselors, seven MDs, and a group calling itself Trauma Recovery Associates. One hundred years after Mrs. Moore’s journeys through this neighborhood, it remained a place where you might go looking for therapy and advice. Yet much about medicine and medical practice had changed, even during Cabot’s lifetime. What guided people like Mrs. Moore through these streets in 1902, and what did they find to hold their allegiance inside the parlors and offices of Dr. Cabot and his colleagues?

The success of Cabot’s clinic rested on meetings and exchanges with patients, to whom the attractions of twentieth-century technical medical treatment may just have been becoming evident. They needed guidance at times in engaging physicians who offered such services. The records of Cabot’s practice provide a remarkable window into the routine structures of medical office practice in the early twentieth century. It is possible to map the routes that led people like Mrs. Moore to the doorstep of 190 Marlborough Street and the routes that led them away and into the offices of other affiliated doctors and healers in the New England of the day. The development of this clinic suggests how a network of scientific and technical services captured the patronage of a segment of people who were out searching for medical assistance.

Cabot and his peers developed office practices that were a hybrid between established, nineteenth-century medical arrangements and the novel forms that would increasingly define medicine in the later twentieth century. These practices gave the familiar problems of disease a persuasive technical reality that drew people away from home and family, but that also provided reassurance for those anxious about being cared for outside the traditional context of domestic treatments and healing. Medical neighborhoods and office practices that were organized around technical services made the problems of being sick efficiently expressible outside of the home, in part through a set of concrete, material exchanges. Practices like x-ray photography, surgical excision, pharmacotherapy, and therapeutic uroscopy translated the basic needs of sickness into a set of easily articulable requests that patients and physicians alike could act on, although they remained within the bounds of a comfortable model of personal medical service to families in domestic settings. Relying on the assistance of his colleagues, Cabot channeled his patients into the offices of a growing range of specialized physicians and practitioners providing these and other such services. Still, Cabot practiced, like many of his neighbors and peers, out of his own home, and visited people in their homes on occasion to provide care. Patients paid directly for their care in this practice in accordance with a sliding scale of charges that promised to take account of their personal circumstances, so that fees were matched to the individual ability to pay. Office practice fitted into a growing market for urban specialized medicine; yet it was also a market that remained personalized and was regulated through the relationships established between individual doctors and patients.

Boston’s Back Bay neighborhood. Enlarged from Outline and Index Map in the Atlas of the City of Boston—Boston Proper and Back Bay—from Actual Surveys and Official Plans by George W. and Walter S. Bromley (Philadelphia: G. W. Bromley, 1908). Layout by Matthew Scanlon. Boston Public Library / Rare Books Department. Courtesy of the Trustees. Unless otherwise specified, the addresses are ca. 1906.

Disease was certainly the focal point of Cabot’s technical management. But the management of disease had to match existing expectations about medical care. Domestic care, individual circumstances, and personal service were features of a model that focused on disease but recognized that patients had troubles that extended beyond the narrow confines of technical medicine. Cabot thus sometimes directed patients into a parallel network of spiritual advisors, mental health therapists, counselors, and charitable societies for additional support. While his overriding consideration was the identification and management of disease, his response to any individual patient was flexible. It was a style of practice that succeeded in drawing in, supporting, and motivating the many people who came seeking the resources of scientific practice in Back Bay medical offices.²

Medical Tools and Specialized Practice

By his own later account, Cabot developed his private office practice initially through the promotion of his specialized skills in the examination of blood samples for colleagues around Boston. But laboratory skills with the microscope and test tube offered only a shaky foothold for a young practitioner. These technical practices were rapidly evolving and shifting in their significance for routine office practice. The course of Cabot’s own early career suggested a changing role for the laboratory in private practice. After graduation from medical school and a year’s stint as a house officer on the wards of the Massachusetts General Hospital, Cabot began researching the use of white blood cell counts in the diagnosis and prognosis of conditions like pneumonia and typhoid fever. He obtained a year of support in 1894 as the Dalton Scholar at the hospital and pursued more advanced study of the microscopic and serological properties of blood in various disease states. His success was rapid and noticeable. By 1904, his Guide to the Clinical Examination of the Blood (1896) had gone through five editions, becoming a fundamental textbook in American clinical hematology and drawing the attention of colleagues both locally and around the nation. Cabot later noted that 1896 had also been the year “I hung my shingle out.” He had begun by doing “most of the blood examinations for other doctors”; indeed, he later recalled that “the only way I got cases was through other physicians.”³ Specialized laboratory skills thus provided a route into practice for this novice physician.

With his publications gradually appearing in medical journals and his appointment as physician to the Out-Patient Department at Massachusetts General Hospital in 1898, Cabot began to attract the attention of other doctors, some of whom sent patients to him. “I am desirous that you make a complete blood examination and kindly send your report to me,” a letter referring one patient reads.⁴ As his reputation grew, doctors also wrote praising Cabot for his research and explaining that it had been an incentive for seeking his assistance. Referring physicians also began to send their patients to Cabot’s office not just for blood testing but with general questions about the nature of their disorders, leaving it to Cabot to decide about their evaluation and care.

Specialized blood testing was limited as a means to sustain a private clientele. Testing blood was not the same as providing medical care. A specialized technical practice could cement good relations with colleagues, securing a role in providing access to an interesting, new procedure, for example. But laboratory practice made one’s access to patients dependent upon the courtesy of colleagues. Some physicians, like Dr. Frank Day, wanted only the results of Cabot’s blood examinations and were perhaps reluctant to send him a private patient when a blood sample might suffice. Day wrote to Cabot in 1899 requesting, “[C]an you help me out any by giving me your inferences from the blood sent in by same mail (both on cover glasses and on paper)?”⁵ Cabot did not provide this requested blood test, although he was willing to exchange technical information on the blood counts, on one occasion, for example, sending samples of the special stains that he used to differentiate white blood cells.

The referring letters from other physicians occasionally pointed to differences between Cabot’s academic position and the more work-a-day world of conventional private practice. One Boston physician sent a man with a “glandular swelling” to Cabot’s office, who arrived bearing a letter stipulating that “as he is a patient of mine I should like to know the results of the blood count . . . and am glad you have time to do it.”⁶ This colleague suggested that Cabot’s skills were a service to him as much as to his patient, and that it was a service perhaps better left to someone free of the demands of a busy office full of patients.

The significance of special laboratory skills to medical careers had been in transition over the preceding decades in this same medical neighborhood. The arrangement under which Cabot came on the medical scene—examining blood samples for other physicians—was ceasing to be a viable enterprise by the early 1900s. A comparison with the private practice by another physician a generation earlier in this same neighborhood illustrates the changing role of laboratory practice in private medical careers. William Whitworth Gannett got his start in medicine in Boston almost two decades before Cabot in 1880 in a very similar way, providing specialized laboratory analysis to his local colleagues. Gannett’s private office opened at 110 Boylston Street, about seven blocks from Marlborough Street on the Boston Common, where he initially shared quarters with an established senior physician, George Tarbell. Gannett was also a graduate of Harvard Medical School, and he obtained the same entry position in the Out-Patient Department at Massachusetts General Hospital that Cabot did. He began by offering to analyze specimens of urine and blood microscopically and chemically for a fee.⁷ But Back Bay had hosted a smaller and more personally interconnected medical community in Gannett’s day.

The exchange of fees, reports, and patients between Gannett and other doctors depended heavily on local social and neighborly connections of a sort that were becoming attenuated by the time of Cabot’s entry into medicine. Account books and laboratory notebooks from Gannett’s office show a tight network of collegial exchanges that fostered his start in practice. One of his regular supporters was, for example, his office mate Dr. Tarbell. Professional relationships for Gannett were personal and close to home. Tarbell was both host and client, and when Gannett moved out from Tarbell’s office, he took space in the office of Dr. Arthur Cabot, a relative of Richard Cabot’s, who apparently took on a similar role as a local patron. Arthur Cabot might drop off a patient’s specimen in Gannett’s office in the morning with a note asking, “Dear Billy, will you examine this urine to see if there is any trouble in the kidneys?”—and in the evening look in for the results. Another Boston physician, Dr. Morse, left a specimen with a note asking Gannett to reciprocate by stopping in later to deliver the report on it. Dr. Chamberlain came over to Gannett’s office to pick up his report but arrived before it was ready, as Gannett reminded himself in his account book, while Dr. Elliott took the precaution of leaving a note alerting Gannett that he intended to call on him the next afternoon for the results. Dr. Porter was fortunate enough to catch Gannett on the street on a day in May 1889 to ask him about a test that he had requested—a fact that Gannett also made note of in keeping his financial books up to date.⁸

These arrangements quickly established Gannett’s reputation among a cadre of his colleagues, so that in his office he likely saw as many physicians as he did patients. Access to patients came largely through his medical patrons. His colleagues recognized his dependence on their business and were occasionally solicitous in their correspondence. Dr. F. G. Morrill sent Gannett his typical $5 fee for laboratory analysis of a patient’s urine, along with a note promising to “see that you have another whack at this urine in the fall.” Gannett’s laboratory services offered a variety of attractions for the physicians who sent him their specimens. Perhaps they felt, as did Cabot’s later clients, that they were too pressed for time to do this work; or perhaps they lacked Gannett’s training and equipment. They clearly identified additional value in the ability to consult with this laboratory expert. In a short note in January 1888, Dr. M. Holbrook wrote to thank Gannett. “This patient for whom you made the analysis was sure she had Bright’s disease,” he explained, “and nothing would convince her to the contrary but this analysis by an expert.” Along with his gratitude, Holbrook enclosed “a money order for $5.”⁹

By the turn of the century, such laboratory testing services existed in larger cities around the country. The back pages of contemporary regional medical journals published in Chicago, Cleveland, St. Louis, and Charlotte, North Carolina, for example, list professional announcements by physicians providing them. Arrangements differed slightly between different practitioners. Dr. M. O. Hoge of Richmond, Virginia, advised his clients to “send specimens PREPAID, by mail or express in a well-corked bottle,”¹⁰ for example, while Dr. Jones of St. Louis noted that advice on shipping specimens and billing would be “cheerfully given” on request.¹¹

The physicians in and around Boston who patronized Gannett’s practice often sent the specimens and the payments themselves, collecting the fees separately from the patients, as their notes indicate. On other occasions, they had their patients deliver a specimen to Gannett and pay the fee directly to him. The one stable feature of their arrangements with Gannett was that the results of the analysis always went back to the initial private physician. Gannett seems not to have released his information directly to the patients. He did not attempt to circumvent his patrons, the other physicians. Since the referring doctor alone received the report, Gannett’s medical opinions and advice reached the patients only indirectly through their principal doctor, leaving it to that physician to interpret their significance.¹²

These arrangements were more delicate because Gannett operated in his practice as a physician himself, aspiring to provide expert medical opinions based on his specialized skills with the microscope and test tube. He struggled to avoid the role of a minor technician, merely processing laboratory specimens for better-established colleagues. His patrons generally cooperated in allowing him to apply his medical skills. They often sent specimens to Gannett attaching a question of particular medical significance. The surgeon C. B. Porter, for example, wrote seeking “to know the condition of [his patient’s] kidneys with regard to operation,” and received the reply from Gannett: “no bar against operating.” Gannett supplied to his patrons an opinion about the medical condition of a patient based on his analysis, rather than merely observations and measurements of the laboratory specimens. Appended to the report of the specific chemical and microscopic findings in the urine, he might report, for example, that “there is probably some general disturbance of nutrition, but there is no evidence of disease of urinary tract.” At the end of each report that Gannett provided to his physician-patrons was a section headed “opinion,” providing such interpretations. Gannett carefully acknowledged the limits of what he could discern simply from the analysis of a laboratory specimen, suggesting in a typical case, for example, “I should be unwilling to make that diagnosis [based] on the urine alone.” He always offered an opinion, but it was frequently expressed with the caution due to a close colleague.

Gannett refused to cede clinical judgments about laboratory results entirely to his referring physicians, preserving a role for his own skilled judgments, and he eventually ascended out of a limited laboratory practice, even as the techniques of chemical urinalysis became more routine and standardized. Up until the final year of his laboratory practice, for example, he avoided reporting on the chemical constituents of samples in objective, quantitative terms, preferring to list whether the levels of urea or uric acid in a urine sample were “slightly diminished,” “not increased,” or “improved.” When one physician wrote emphatically stating, “I am anxious to know how much the urea is diminished,” Gannett replied only that it was “much diminished,” although the techniques for quantitative estimates of urea were well established by that time and must have been well known to Gannett, who had studied medical chemistry and pathology in Europe for a year after medical school. Gannett tenaciously maintained his role as a medical diagnostician based on his laboratory expertise.¹³

Gannett’s aspirations seem to have been to ascend from this technical laboratory practice in support of his colleagues into a general private practice of medicine, and he eventually did so. Coincident with first opening his private laboratory service, he took on a series of unpaid positions as pathologist at Boston City Hospital, Carney Hospital, and McLean Asylum, winning local recognition for his special technical skills, as Cabot himself would later at Massachusetts General. These positions of hospital pathologist in fact served in Gannett’s day mainly as a stepping-stone to appointment to the regular medical staff. Gannett finally made this step up in 1891, when he became a staff physician at Massachusetts General, where Richard Cabot would later join him. Over the next year, he began to shift out of laboratory practice into what was to be a long, thriving private medical practice in Back Bay, establishing himself sufficiently to give up pathology and begin doing the laboratory analysis for his own patients—or perhaps sending out specimens for other workers to provide the results.¹⁴

Although Cabot’s specialization began in a way similar to Gannett’s, by 1900, both the use of laboratory services and relations among practicing physicians in these neighborhoods had changed substantially. Colleagues occasionally asked Cabot to examine only a blood specimen, without the patient, even seeking similar arrangements to those that Gannett had permitted, with a fee collected separately and forwarded to him. Cabot, however, usually declined. Other physicians in the area were providing these services too. In 1905, Dr. James Lewis sent out notices advertising laboratory services from his office on Beacon Street in Back Bay, announcing his ability to analyze specimens ranging from blood, pus, urine, and sputum, with fees clearly indicated. Lewis promised interested colleagues in an attached letter that his reports would “be rendered by telephone at the earliest possible moment.”¹⁵ Cabot’s private patients occasionally went three blocks from his office to the residence of Dr. Frank L. Burnett at 51 Hereford Street, who provided serological testing to patients for a fee in 1911. Burnett seems to have been following Gannett and Cabot in providing independent laboratory analysis out of his private office. But separate commercial medical laboratories were already to be found in Boston within the next decade. Burnett was actually among a last few in Boston to sustain this model publicly, and he too soon abandoned it. It became increasingly unusual for physicians in these neighborhoods to identify their individual private practices as sites for laboratory services. By 1914, Burnett himself had opened a separate commercial medical laboratory, called simply “The Clinical Laboratory,” at 205 Beacon Street, while maintaining a general medical practice at a different address under his name. This was among the first of several independent commercial laboratories that appeared in Back Bay under such anonymous institutional names. Individual private practitioners like Burnett and Cabot simultaneously dropped the habit of identifying their private medical offices as sites for the analysis of medical specimens for colleagues.¹⁶ With the increasingly common use and gradual standardization of the technique and instrumentation of these laboratory analyses, Cabot and his colleagues shifted routine testing to anonymous commercial laboratories.

While commercial laboratories provided new and difficult analyses, such as the Wassermann test for syphilis, individual physicians like Cabot also kept available in the office the equipment for simpler laboratory procedures. Cabot made use of a number of special tools and procedures in his office, complementing the resources available from nearby colleagues and laboratories. His key piece of equipment was a microscope with an array of special staining apparatus for identifying bacteria and the various types of white blood cells. Perhaps because of his special expertise in blood diseases, Cabot frequently left notes tallying the counts of the various lineages of white blood cells in the margins of his office clinical records, confirming that he had performed the counts in the office, apparently sometimes while the patients waited. Cabot also kept basic apparatus for chemical urinalysis, of the kind that Gannett had used in his laboratory practices in the 1880s, including a device for measuring specific gravity, chemical reagents, and glassware. For blood analysis, he also used hemacytometers and several different types of colorimetric devices for estimating degrees of anemia, called hemoglobinometers. Among the basic tools that Cabot routinely used, many served diagnostic purposes. The stethoscope, the reflex hammer, and the blood pressure cuff were the most common. He must also have had a gynecologic speculum and a table for female pelvic examination, because he sometimes noted findings from examining the cervix. He also kept equipment for minor therapeutic procedures, such as trochars for tapping fluids and minor surgical equipment for incising abscesses and changing out surgical drainage wicks, judging from the notes of procedures performed in his office.¹⁷

The range of available equipment, procedures, and tests grew rapidly during the first decades of Cabot’s practice, giving him access to a growing range of radiological procedures and serology. X-ray evaluations were available by 1911 from Dr. Walter J. Dodd and his associates, who operated a private radiological laboratory at 259 Beacon Street, just around the corner from Cabot’s office. Also housed in this large nineteenth-century apartment building were the offices of six other physicians, including two who offered specialized obstetrical and gynecological services. A surgical colleague, Edward Reynolds, performed cystoscopies and other minor urological procedures, often operating in his office just a block down Marlborough Street from Cabot. One of Cabot’s patients, whose remarkable story figures in Chapter 4, followed Dr. Reynolds from this office to his operating suites in a pair of connected row houses a mile to the west on Massachusetts Avenue, the site of the recently opened New England Deaconess Hospital. The Massachusetts General Hospital also provided access to a growing array of special treatments and tests, both for patients in need of procedures not available in the local offices and for those without the means to afford them, since the hospital provided free care for people judged unable to pay.

A Network of Domestic Practices

A medical office like Cabot’s lay midway between the domestic world of nineteenth-century private practice and the twentieth century’s fast-growing institutional medical realm.¹⁸ When patients came to 190 Marlborough Street, they were entering not only a complex network of specialized practices but Cabot’s private home. The surrounding Back Bay neighborhood was a mix of residential and professional buildings, including the offices, labs, and homes of Cabot’s medical peers and other elite Bostonians. The geography of these practices reflected a professional medical world in the midst of substantial change. Physicians were reorganizing the spaces of medical practice, and the medical office was emerging as a crucial institution.

Harvard Medical School seems to have been the origin of this vigorous medical district. In 1883, the school moved from its location on the east side of the city, near Massachusetts General Hospital, across town to 700 Boylston Street, in the heart of the Back Bay neighborhood, one block from Copley Square, where the city broke ground for a new Boston Public Library a few years later. This exclusive neighborhood in the city’s center had already been developing for almost two decades, and the large landfill project that had created it was completed in 1886. Expensive new row houses on these streets were the only new houses being built inside the city from the 1860s through the 1890s that appealed to wealthy buyers, and so they quickly drew residents from among Boston’s elite merchants and business owners. It must have seemed an attractive location to live and practice to the well-connected physicians who located there toward the close of the nineteenth century. Among these, as we have seen, was William Gannett, whose laboratory practice in the 1880s relied on the patronage of physicians connected to the medical school. When the medical school moved again in 1906, to a newly built campus on Longwood Avenue at the western edge of the city, it left behind a thriving community of practitioners, who maintained their offices in the area.¹⁹

The arrangement of medical practices in this neighborhood shows the influence of the school, and something of a local hierarchy based on medical-school seniority, even after the school’s move out west to the Longwood campus. In 1906, the two blocks between Cabot’s office and the office of the surgeon Edward Reynolds at 130 Marlborough Street included four other row houses that held the practices of five other physicians, all of them graduates of Harvard Medical School and two of them with active appointments on the faculty there. All five of these physicians were, like Reynolds, senior members of the community, who had graduated from Harvard Medical School between 1858 and 1879. Among these five, three occupied separate row houses with their private offices-and likely also their residences-while the two physicians who shared an address were practicing in the related special surgical fields of ophthalmology and otolaryngology. Their younger colleagues on the next block managed less grand accommodations, however. At 129 Marlborough Street, five physicians shared a single three-story building for their offices, either lodging in smaller apartments in the same building, or commuting into the neighborhood for their practices. All five were also graduates of Harvard Medical School, of more recent matriculation, between 1880 and 1901.²⁰

If Harvard Medical School was the stimulus for this medical neighborhood, it did not limit its constituency. These blocks of fine real estate held other obvious attractions. Doctors and practitioners from a range of backgrounds flocked to Back Bay addresses. The building at 541 Boylston Street near Copley Square, for example, held the offices of five physicians listed in the Boston Medical Directory for 1906. One of them, Dr. Luther C. Rood, like his colleagues a few blocks over, was also a graduate in 1899 from Harvard Medical School. Other physicians in the same building, however, had trained in several other very different institutions. A group of women physicians also in the building included Clara J. Alexander, Mabel F. Austin, and Blanche A. Denig, all affiliated with the New England Hospital for Women and Children in the western suburb of Roxbury. These physicians were graduates respectively of Women’s Medical College of Pennsylvania, Johns Hopkins University School of Medicine, and Northwestern University Women’s Medical School. Harvard Medical School did not confer medical degrees on women until decades later.²¹ In the same building at 541 Boylston Street was also the office of Harry E. Rice, who listed himself as a graduate of the New York Homeopathic Medical College and a member of the Boston Homeopathic Medical Society. Other office buildings in the neighborhood also mixed similarly diverse groups of physicians. During the same period, 220 Clarendon Street, at the northeast corner of Copley Square, housed eight physicians, two graduates of Harvard Medical School and six others associated through membership in the Massachusetts Homeopathic Medical Society, with training at homeopathic medical schools in New York, Philadelphia, and Boston.²²

The medical profession had begun to contract and to raise barriers in education and licensing to limit access, but it still kept the broad contours of a less exclusive nineteenth-century constituency. To a medical patriarch like the Boston physician Oliver Wendell Holmes in the mid nineteenth century, homeopathy was a competing, and illegitimate, form of medical practice, one among a number of “kindred delusions.” Homeopathy nonetheless continued to hold the well-established status of a viable, well-recognized form of medical practice in late nineteenth-century Boston. Harry Rice and the other homeopathic practitioners with offices at 541 Boylston all held MD degrees from their medical schools and maintained listings in the 1906 register of “legally qualified physicians” published by the American Medical Association. Such routes into approved medical practice were rapidly closing down in Cabot’s day, however. The fates of the alma maters of the physicians at 541 Boylston Street illustrates the general trend. Dr. Rice’s homeopathic New York Medical College did not survive the reforms of the early twentieth century. Dr. Denig’s Northwestern Women’s Medical School closed in 1902, and Dr. Alexander’s Women’s Medical College of Pennsylvania only narrowly escaped the fate that befell all other traditionally women’s medical schools in the United States during this period. Boston University College of Medicine, the alma mater of one of the practitioners at 220 Clarendon Street, successfully shed its identity as a homeopathic college in 1918 and simultaneously limited the admission of women students, illustrating the reinforcement between these parallel limiting trends.²³

Markers for conventional medical practice existed in the early twentieth century in diplomas, society membership, and licensing qualifications. Reforms of the period would gradually tighten and more tightly enforce such regulatory mechanisms. But the constraints on practitioners seem not to have limited the movement of patients much at this time. Records from Cabot’s practice show that his patients sometimes traveled quite widely among an eclectic array of practitioners. One woman who wrote in 1902 had recently returned home from a visit to a doctor at a special sanitarium in Buffalo, where she had been treated by electrolysis. She reported on care that she had received variously from four different doctors in Buffalo and in Massachusetts, as well as an unnamed “herb Dr,” whose locale she did not specify. The patients frequenting Cabot’s office, considered as a whole, seem to have been a generally adventurous group, open to many different modes of therapy. They described their experiences pursuing care variously from “an osteopathic treatment every week” to homeopathy, herbalism, and Christian Science. Cabot and his specialized medical peers occupied only one corner of the health-care marketplace.²⁴

Some patients apparently stuck to visiting only physicians with formal medical certification, but they often saw many different specialists. Cabot’s office sometimes served as an intermediate stage in a long journey through medical offices in and around Boston. A given patient’s record in the files might open with a recitation of what and whom this person had already tried for their troubles. One middle-aged man suffering from back pain arrived at Cabot’s office in 1909 bearing such a story. He had already sought treatment from a professor of therapeutics at Harvard Medical School, who had prescribed “aspirin and potash.” After four months of this treatment, he went to two orthopedic surgeons, the attending physicians at Carney Hospital and Massachusetts General Hospital respectively, who shared an office at 372 Marlborough Street with a third, more senior surgical colleague. These surgeons “strapped him & corset & rest,” but this course of treatment turned out to be “no good.” The same orthopedists next “etherized [him] & stretched sciatic nerve & broke adhesions,” which helped briefly, according to Cabot’s notes on the case. This man then got a steel brace to help him walk and went back to the same two surgeons, who called in their senior office mate for another opinion. But an unfortunate setback derailed their plans, apparently. While in their office, this man was bending over when suddenly “sciatic returned & is now awful,” Cabot noted. The surgeons—at this point in Cabot’s notes, their identities become blurred—treated him with aromatic ammonia, “wh[ich] gave great relief at first.” But after five months more, they “said go to Ellis,” referring him on to a general physician, who helpfully provided morphine for his pain. Then, as the record noted, “McBurney of New York saw him at Stockbridge,” in western Massachusetts. Finally, he consulted Cabot, who diagnosed his condition as sciatica and advised him to return to the original orthopedic surgeons for further treatment. The record ends there.²⁵

As this account suggests, the medical office was an important institutional base for specialists. Urban hospitals were increasingly important in the careers of Boston practitioners, and surgeons were easily identified by their hospital affiliations. But the medical office was a way station between home and hospital. The man with the back pain visited many offices, but he does not seem to have been hospitalized. Medical offices had long been a convenient extension of the physician’s primary residence, a place to proclaim one’s professional status and gather patients. In Cabot’s day, however, the medical office was increasingly not just an extension of the physician’s residence but an independent workplace in its own right. The daily routines of some of Cabot’s colleagues illustrate this. In a 1904 professional guide, an enterprising ear, nose, and throat man announced regular office hours from 9 A.M. to noon daily in Beverly, Massachusetts, and then again from 1:30 to 4:30 P.M. at an office a few miles away in Salem, bespeaking not only his mobility but his reliance on his medical offices. The surgeon Frank Balch lived on Clarendon Street, very close to Cabot in Back Bay, but had his surgical offices farther to the west at the intersection of Massachusetts and Commonwealth Avenues. Conversely, John Brainerd, a specialist in diseases of the ear, nose, and throat, who lived out in the western Boston suburb of Brookline, listed his office as being at the Hotel Copley, near the Boston Public Library.²⁶

The Development of Office Practice

In the mid-nineteenth century, the medical office had been a place where patients, family, and physicians met on the way to the patient’s home. Home visits had been the cornerstone of American medical practice before the turn of the century. Although home visits retained a powerful symbolic value for the medical profession through most of the twentieth century, their practical significance seems to have been in the early stages of a gradual decline by the first decades of the century, as the institutional basis of practice shifted. In the mid twentieth century, the medical office became a place where physicians and patients met on the way to and from the hospital. Dr. Daniel W. Cathell, a popular late nineteenth-century advisor of American physicians in matters of “professional tact and business sagacity,” recommended that the medical office should serve as a place to gather patients who would become the basis for a stable practice of home visits. Cathell’s book The Physician Himself and Things That Concern His Reputation and Success had remarkable popularity from its first publication in 1881 into the reprints of the 1920s, offering reams of pragmatic advice to the aspiring private practitioner. Cathell counseled that regular office hours were useful to the young physician in order to pick up the “overflow, emergencies, cases of accidents, calls from those who are strangers in the city and other anxious seekers,” which other established physicians would miss in their daily rounds to their patients’ homes. A contemporary of Cathell’s, the surgeon Arpad Gerster, attributed his start in private practice in the 1870s in New York City to just such an emergency visit from a patient who had found other familiar physicians away on house calls. Cathell assured his young medical readers that office hours could become more limited as their practices picked up and they came to rely less on the “transient office-patient.” He reserved the bulk of his recommendations for the cultivation of the role of a family doctor through proper comportment on home visits.²⁷

As a transitional space linking domestic and institutional worlds, the medical office in the early 1900s presented the patient with a mix of impressions. When patients came to see Cabot in his office on Marlborough Street, they entered the first floor of his home. In describing their contacts with him, they used terms occasionally that were appropriate to a personal visit, like the man who wrote in 1911 saying, “I called upon you a little more than a year ago,” or another man who recalled having “paid a visit to you on April 2.”²⁸ Other physicians also tended to refer to the medical office as identical with the place of residence, like the doctor who wrote to say that he had referred a patient to Cabot, “but unhappily, you were not home at the time.”²⁹ Other people, however, seemed uncertain about the connection between home and office. One woman wrote to Cabot in 1906 at his home address asking, “[I]f I am to go to your office will you please state what days and hours you are in your office and give me your address?”³⁰ Similar uncertainties troubled a man who wrote seeking to have Cabot examine his urine—much the way William Gannett had for patients a decade earlier. He found Cabot unresponsive and inquired: “I sent to your address a small bottle of my water some time ago and got no reply from it yet and since I have sent it I have been thinking perhaps you would rather have it sent to the hospital.” The shifting use of the medical office left patients unsure whether a physician’s principal workplace was his home or some other place, such as a hospital clinic.

Many of the physicians in Cabot’s neighborhood maintained a combination of home and office in one space. This mixing of domestic and professional space had various implications. Dr. Mary D. Dakin, an 1890 graduate of Boston University School of Medicine, maintained her private gynecological practices in a combined residence and office at 499 Beacon Street that she shared with Dr. Edward A. Dakin, presumably her husband, who had come to Boston from a homeopathic medical school in Philadelphia just a few years earlier.³¹ Cabot’s own combination of home and office followed the pattern of many of his medical neighbors. By the accounts of contemporaries, early twentieth-century medical practices in Back Bay row houses typically included a large first-floor medical office with family residences on the second and third floors above. One common arrangement consisted of a first-floor waiting room in the front of the house that opened into a large central “consulting room,” with smaller private spaces for examinations off of it.³² Younger physicians with less spacious accommodations lived in apartments connected to “make shift” medical offices in their same building, keeping their expenses low. As their practices grew, they sometimes kept their offices but moved to separate residences. But a separate residence was, as one physician who practiced out of the busy professional building at 259 Beacon Street later recalled, “a real innovation in those days.”³³ The six homeopathic physicians previously mentioned who practiced at 220 Clarendon seem to have caught on to this innovation early, since five of them listed residences separate from their medical offices by 1906.³⁴

Private medical offices at the turn of the century often seem to have struck a balance between a neutral institutional appearance and styles more expressive of domesticity. The head of the clinic, these spaces suggest, might equally be the head of the home. Advice manuals offered detailed recommendations about rugs, lamps, paintings, curtains, and wallpaper in the waiting area, taking into account the possibility that physicians might choose to keep the office separate from their residential space.³⁵ Daniel Cathell’s popular advice manual enjoined the young physician in avuncular tones about the proper balance of domestic and professional decor in the office, including “diplomas, certificates of society membership, potted or cut flowers or growing plants or vines, fine etchings, pictures of eminent professional friends or teachers [etc.].”³⁶ This list alternates between the homey and the professional, positioning medical office spaces carefully along the continuum between traditional domestic healing and an updated institutional milieu.

Guides like Cathell’s typically assumed a male audience and pitched their advice about the domestic nature of practice in a way that maintained a complicated relationship to male social authority in medicine. There was, for example, a common overlap in this guidance literature between the representation of the male physician in the office and that of the husband or father in the home. In his 1905 book How to Succeed in the Practice of Medicine, Joseph McDowell Mathews, the former head of the American Medical Association, advised the aspiring male physician to have his wife decorate his medical office—and then proceeded to offer advice on how to choose an appropriate wife for a medical career. The domesticity of the office should ideally reflect masculine oversight, rather than the male doctor’s involvement. Cathell’s manual cautioned against creating too much of a masculine look to an office space, giving it the appearance of a smoking room or hunting lodge.³⁷ A ready conflation of masculine forms of domestic authority with the physician’s role extended widely through the culture of the day. An article by Cabot that was published in the popular American Magazine in 1916 included a half-page photo of him seated with his arm over his wife’s shoulder, with two young girls playing quietly at their feet, seeming to show the doctor as the patriarch in his little family. This scene was openly contrived, since Cabot and his wife had no children. Someone at the magazine perhaps believed that this “distinguished Boston physician,” as the caption read, should appear before his readers at the head of a traditionally pictured family.³⁸ The advice literature of the day suggested that physicians might adopt a similar kind of artifice in arranging the office, seeking to represent at once both the domestic and professional manifestations of a male doctor’s authority.

Consultation and Referral

Cabot was meticulous in recording information about the doctors who recommended patients to him, permitting the determination in most cases of the nature of his relationship to these colleagues. As we have seen, a significant portion of Cabot’s practice reached him through formal arrangements with other physicians. These arrangements reveal the foundations of a tradition of medical consultation overlaid with a newer system of medical referrals that fitted patients into expanding array of specialized practices. Consultation was a well-established nineteenth-century protocol for sharing patients between different physicians that had been refined over decades of use. But Cabot and his colleagues also relied on a newer system of referrals to knit together the expanding, more differentiated American medical profession that was emerging in cities like Boston.

Richard and Ella Cabot posed with their two nieces, in a photograph dated 1911. A version of this image accompanied an article written by Cabot for the American Magazine, 1916, 81 (4). Courtesy of the Harvard University Archives.

By sharing patients, physicians emphasized the collective nature of their professional enterprise and reinforced their joint authority. Referral and consultation, as mechanisms for sharing patients, expressed different forms of professional authority. Under the protocols of consultation, the attending physician invited the consulting physician to meet with him in the patient’s home to confer about a course of care. This older, nineteenth-century practice emphasized a joint personal connection to the patient, cautiously negotiated between different physicians in the presence of the patient and family. Consultation modeled the service of the physician on the traditional analogy of domestic care. The doctor came to the home to visit the ailing patient, and when two physicians came, they arrived together to pool their expertise. Consultation fitted neatly into a world where physicians worked from offices in their homes and largely inside the homes of their patients. Nineteenth-century advice on consultative etiquette stressed the need for the appearance of accord and the importance of choosing carefully before admitting other practitioners to the legitimacy of consultation.³⁹

Referrals instead tended to distinguish among physicians according to what they did, rather than whom they visited, or whose practices they associated with. In a referral, one physician sent the patient to another physician, often with an accompanying question about a special procedure or a problem to be considered. Patients coming on referral to Cabot’s office sometimes carried, or were preceded by, letters from their physicians outlining the question. Referrals usually implied functionally distinct services, and the movement of patients outside the home between different medical institutions like private offices, laboratories, or hospitals. A system of referrals took shape partly through the definition and provision of specialized technical needs. The process of referral required practitioners and patients alike to resolve illness into discrete problems, each amenable to specialized intervention. Confirmation of the diagnosis might require referral for an x-ray to a physician providing radiological services. Treatment might require referral to a general surgeon or to a urologist or a gynecologist. The purpose of the referral also depended in part on the qualifications and skills of the referring physician. A specialized colleague might refer a patient to Cabot with narrowly phrased questions about blood disease, while another doctor might request only general medical care.

Referral and consultation taken together provided slightly less than half of Cabot’s total practice. A large number of people joined his practice without any formal direction from another practitioner. About three-fifths of the individuals in a random sample of cases from the records of 1900 to 1915 made their way to 190 Marlborough Street independently, without the apparent guidance or advice of another doctor. They were sometimes brought there by word of mouth or happenstance or were attracted by Cabot’s reputation. In the one-fifth of cases sent by referral, Cabot’s records indicate the name, and often the address, of the practitioner who had sent the patient. The final one-fifth of the cases in the sample consisted of people whom Cabot saw in consultation with another physician, meeting together at the patient’s home (see table 1.2).⁴⁰

The physicians in Cabot’s acquaintance displayed a ready familiarity with the arrangements for consultation and were generally attentive to its protocol. Cabot carefully noted when a patient was seen at the home “cum [with]” another physician in consultation. His colleagues generally tried to arrange with him in advance to meet together at the patient’s home, although timing might prove difficult. One colleague wrote later after a consultation to chide him that he had not arrived in sufficient time for a previously arranged consultation. This out-of-town physician was the attending physician for a patient who was dying at home. “I tried to get you on the 29th but you could not get here until the following morning,” he wrote Cabot after the patient’s death.⁴¹ Consultation had obvious limitations in providing timely assistance, although it held other attractions for the physicians who engaged in it.

Patients too demonstrated a familiarity with the methods of consultation, although they had their own questions about its details. One man writing to Cabot in 1914 recalled how Cabot “had been called in consultation with Dr. Davidson and Dr. Sweet of this City. Dr. Davidson the attending physician.” Indeed, Cabot recorded that he had traveled to the patient’s home outside of Boston the previous year for this consultation, “C[um] Dr. Davidson.” The patient who met with Drs. Cabot, Sweet, and Davidson reminded Cabot that at the time, “you all agreed with Dr. Davidson’s diagnosis of the case.” He was concerned, however, that a degree of collusion had affected their deliberations. “Dr. Davidson told me,” he informed Cabot, “that he had written several closely written pages of type written matter describing my life & case for your benefit before you saw me.” He wanted to know: “Is that the common practice among physicians in consultation?” He seemed to wonder if the joint consultation had been preempted by too close an association among his physicians, impeding their independent judgments on his case. Although patients sometimes used consultation in this specific sense of the term, they also used it in the general sense of medical advice, as with the man who wrote, “[A]fter consulting you I returned home and have been doing as you advised.”⁴² This man clearly intended for consultation in this instance to refer to his visit to Cabot’s office, as though he were the attending physician seeking an opinion and Cabot his consultant.

As measures of collegiality, the standards for consultative conduct were scrutinized and debated among American physicians in the latter part of the nineteenth century. Physicians in consultation were representatives of general professional conduct, meeting to confer together before the audience of their patients. The American Medical Association’s 1892 Code of Ethics included an extensive entry, under Article Four, on “The Duties of Physicians in Regard to Consultation,” specifying in ten numbered sections the details of proper behavior. Although the code was clearly intended as a guide rather than a description, the fact that the code was reviewed, debated, and modified repeatedly highlights its importance as an agreement about ideals for practice. Through its various iterations and revisions, the code spelled out what to do, for example, if the consulting physician arrived at the patient’s home before the attending physician (wait); and how to respond if a patient requested a consultant who was not “considered a regular practitioner” (demur). Whatever the actual influence of the code, physicians clearly attended carefully to the management of consultation as a reflection of their professional duties and connections. One nineteenth-century surgeon recalled that among his colleagues in New York City, “the ceremony of consultative procedure was strictly maintained.”⁴³

During the period in the late nineteenth century when consultation still reigned as a defining element of medical conduct, debates over the proper etiquette for consultation echoed common concerns about the challenges facing physicians in private practice. The problem of competition among physicians was, for example, foremost in consideration. The two physicians who shared responsibilities for a patient in consultation ideally met in formal, face-to-face encounters. Consultation enforced some restraint among physicians, at least in theory, in vying for the patronage of a patient to the detriment of professional reputation. Anything done by one physician would be known to the other, and using consultation as a means of replacing the attending physician was forbidden. The American Medical Association’s complete discussion of consultative protocol addressed in detail misdeeds like wooing away another practitioner’s patients. The other professional controversy over consultation turned on the question of which practitioners could properly receive the benefit of collegial association. Again the Code aimed to restrain competition, in this case, by excluding practitioners identifiable as outsiders from professional association.⁴⁴

During Cabot’s decades in practice, the value attached to proper consultation gradually began to wane, probably tracking the general slow decline in the significance of house calls in private medical practice. The declining significance of consultation was evident to the physicians who lived through the early twentieth century. Consultative visits in the patient’s home were still part of private practice in the 1930s but were a rapidly disappearing phenomenon. Dr. Dunbarton Shields, an internist in practice in Concord, New Hampshire, for the middle third of the twentieth century, recalled the change in his practice. He described how in the 1920s and 1930s, he had traveled to consult with colleagues in their patients’ homes about heart problems, in the manner of his nineteenth-century predecessors. After World War II, however, his specialty practice shifted into professional offices adjacent to the central hospital in Concord. He and his partners now received their patients in the office clinic, sometimes on referral from the same outside physicians whom they had previously met with in consultation. Shield’s son grew up to become a doctor too, and the father lamented that his son never once had the experience of making a professional house call.⁴⁵ The shift from consultation to referral figured in the experience of many physicians in widely different circumstances in the early twentieth century. Dr. Lewis Moorman, a practitioner in a prairie town, remembered a first difficult childbirth in 1902 that had required him to call in an older physician from another town, who arrived just in time to provide crucial assistance. Moorman recalled that by the 1920s, his medical office had been crowded with the patients referred to him by other practitioners, conveying the sense that cultivation of his office practice had been the key to his success, in line with Cabot’s account of the growth of his Boston practice.⁴⁶

As consultation diminished in significance, the American Medical Association’s intermittently revised Principles of Medical Ethics reflected the emergence of referral as an important element of professional behavior. Focused in its earlier incarnations on the etiquette of consultation, this code had been silent on questions about referral in the versions of 1892 and earlier. The revision of 1903, however, included in the section on consultation a new set of stipulations for those unusual cases in which physicians who were sharing the care of a patient were not able to be present for consultation together. The code thus acknowledged that the traditional conference at the patient’s home between attending and consulting physician might not always occur. The 1912 version went further, expanding the section on consultation to address the instance “when a patient is sent to [a physician] specially skilled in the care of the condition,” that is to say, in the case of a referral.⁴⁷ Advice on the ideals of conduct had to keep pace with the changes occurring in daily practice.

Referral and consultation manifested different forms of medical authority for physicians and so presented different sorts of troubles in their management. Consultation placed professional authority on display under the guise of collegiality. Physicians gained reputation collectively in consultation by their ability to collaborate, to reach agreements, or to cede gracefully to one another. Essayists in medical journals cited the importance of maintaining the outward appearance of mutual respect and accord among consulting physicians, while acknowledging that the reality might not always be so pretty.⁴⁸ Both referrals and consultations supported the individual physician with the collective authority of the profession. In consultation, this professional authority was manifested as a collegial, interpersonal, and deliberative practice.

Referrals raised very different regulatory concerns. Guidance on proper conduct for referrals was largely subsumed into a larger, and often quite heated, controversy in the early twentieth century over fee-splitting, a practice in which a specialist, usually a surgeon, shared a portion of the fee paid by a patient with the referring physician. It was a form of collusion in which the referring physician was compensated—and so gained an incentive to refer—from the specialist’s higher fees. In the form most widely denounced by physicians, fee-splitting took place without the patient’s knowledge and often with some prearrangement between the specialist and the referring physician. Although physicians were generally happy to denounce the practice in this crude form, they did occasionally defend alternate versions, especially if they involved some kind of disclosure to the patient. Professional ethics generally forbade the practice outright.⁴⁹

The differences between the problems of fee-splitting and the problems of consultation reflected the changing nature of professional relationships in the early twentieth century. The ethical regulation of consultation was concerned with creating formal cooperation and accord among physicians, whereas the regulation of referrals was concerned with preventing conspiracies, as, for example, in private collusion over the sharing of fees. A level of cooperation among physicians was already inherent in the practice of referring patients.⁵⁰ The increasing integration and consolidation of the medical profession in the early twentieth century shifted the nature of the challenges to its regulation. The complaints of Cabot’s patients also occasionally shed an intriguing light on the complementary weaknesses in these two methods of sharing patients among physicians. When consultation succeeded, it brought physicians into close association. So the patient who was concerned about the written notes shared with Cabot by his attending physician, Dr. Davidson, suspected that his doctors were colluding. Patients encountered a very different problem when they traveled between referring physicians. Too little communication occurred, because referring physicians assumed that the physicians taking their referrals would assess the problems themselves. One woman, who was sent to Cabot’s office by her main physician, Dr. Prescott, wrote to complain to Cabot that she was disappointed, saying, “I fancied that . . . Dr. Prescott had told you all the things connected with my case which I myself answered so inadequately yesterday.” She worried that she was bearing too much responsibility in carrying the information between her two physicians. Her concern seems to find confirmation in other correspondence, such as a letter from a physician who wrote to Cabot to let him know tersely that his patient “will tell you about her present symptoms at greater length” when she reached his office on referral. Physicians seemed at times to value the independence of opinion allowed by referrals, writing to Cabot, for example, to “please give [the referred patient] advice as freely as you would if he were not my patient.”⁵¹

The collective power manifest in referrals lay in the ability of each physician to do his or her special job well. The referring physician had no control over the actions of the physician who received the referral. Responsibility for choices about care passed to the next physician. So when a patient was referred to another doctor for a specific technical service, he or she did not necessarily get the service. Seeing a man with a draining opening in the skin under his arm, Cabot sent him to the Boston surgeon, Dr. Daniel F. Jones, who kept a private office around the corner at 267 Beacon Street.⁵² Cabot apparently hoped that a surgical operation to excise the source of the drainage would remedy the problem. Jones wrote back after the visit thanking him “for referring him to me” but advising “a few months of letting [the opening] alone.” Cabot, who had wanted the surgery performed, wrote on the chart: “Jones did nothing.”⁵³

Referrals assumed tacit cooperation among physicians. Cabot generally required only minimal arrangements by the referring physicians to receive patients. Dr. Walter Sawyer a general practitioner from Fitchburg, Massachusetts, sent a polite handwritten note to Cabot on his letterhead in May 1910: “I have a patient whom I would like to refer to you. . . . He will come to Boston to see you at your office at whatever time it is convenient for you.”⁵⁴ Sawyer had apparently discussed the arrangements with his patient at least briefly before writing. “Would Thursday or any day in the latter part of the week be satisfactory?” he asked Cabot.⁵⁵ The arrangements and preparations could on occasion be more elaborate, however. The prominent Boston neurologist James Jackson Putnam saw a man with seizures on referral from another doctor in 1913 and sent over a carbon copy of the original referral letter for Cabot to have on hand when he saw the patient.⁵⁶ Some patients came bearing special personal appeals, as with the woman who brought a letter stating, “This will introduce to you my friend . . . [who] has been sacrificing herself in the fight for social justice in progress on the pacific coast. She is entitled to the best consideration that we can show her.”⁵⁷ In this case, the referral was based on a personal, or really political, connection with Cabot, unrelated to technical medical services. Other referrals were accompanied with less ceremony or import. For example, Dr. Sarah Bond, a graduate of Boston University, who had an office on Boylston Street in Back Bay, not too far from Cabot’s, in the 1910s, wrote simply to say that she was “desirous that [my patient] may have the benefit of your opinion.” No special arrangements were requested, beyond that “she will go to your office tomorrow—Saturday.”⁵⁸ The understanding seems to have been that the patient’s willingness to present herself at the office when Cabot was in and perhaps wait until he was free would be sufficient to get a visit.

As specialized referrals among doctors in Cabot’s circles overlaid existing arrangements about consultation, they occasionally created interesting hybrids. Some patients and their doctors wanted to meet Cabot in his office together, combining referral and consultation. One Boston doctor wrote to Cabot in 1906 “to ask if you can make an appointment to have [my patient] come to your office, at which time I would come with him as also would his sister.” The arrangement was perhaps a bit unusual, and so the writer continued: “I would suggest that perhaps the best way to arrange this matter would be for you to phone me at your convenience.” Cabot was not the only physician involved with such improvised arrangements. One patient wrote to him from New Hampshire in 1908 describing how a doctor whom he had visited in Boston “wished me to see other Drs before I returned home and he took me to two specialists [while in Boston].”⁵⁹ Anxieties about referrals may have encouraged this hybrid practice of visiting the office with the patient. These physicians were, after all, turning their private patients over to a new doctor. “He never came to me professionally after [seeing you], but told me on the short that you did not agree with me,” one referring doctor wrote back to Cabot about their one-time mutual patient.⁶⁰

Referrals were a flexible system that permitted the physician’s services to be woven into a wide range of parallel professional and charitable services available to the sick. Cabot made use of referrals extensively to manage the many different problems that he identified as afflicting his patients. People who stayed in sanitariums for specialized treatments were both referred out and received back from their stays, like a woman from the neighboring town of Roxbury, Massachusetts, who was pleased to report back that after a fourteen-week stay in one facility, she “came home nice and well.” Osteopaths referred patients to Cabot, as did homeopaths. Cabot in turn referred patients to an osteopath on occasion. He also used the group spiritual counseling by Elwood Worcester’s controversial Emmanuel movement as a kind of referral, noting in the charts of patients, for example, that he had sent a patient on to Worcester for further care. He sent a destitute patient to Boston Consolidated Charities and a patient without a job to a restaurant where he expected that they might be hiring. These actions might reasonably be construed as a kind of referral system, and Cabot recorded them in his notes using the same format as for referrals to specialized physicians.⁶¹

Referrals also organized and permitted access to an ever-growing range of specialized physician’s services, suggesting a seemingly limitless potential in modern medical progress. There was always something new, or at least something different, to try. Patients in Cabot’s clinic followed fairly complex and exhausting paths on occasion through the clinics of his colleagues. Between 1902 and 1909, Mrs. Moore, the middle-aged woman whose path I followed through the wintery streets of Back Bay, saw Cabot sixteen times for related difficulties. She went to him first reporting recurring attacks of “buzzing” or “ringing” in her ears, along with dizziness, headaches, nausea, and sometimes vomiting. She described her troubles in her letters variously as “sick headaches,” “biliousness,” and “roaring ears.” Her quest took her first, in 1902, on the referral of Cabot, to an otolaryngologist, who treated her without any great success. After trying several medicines to treat her himself, Cabot then noted that he had “referred [her] to Crockett,” which meant Dr. Eugene Crockett, a second otolaryngologist. After four unsuccessful visits there, Cabot referred her next with worsening troubles to Dr. W. H. Kilburn, an ophthalmologist, who fitted her with eyeglasses. Dr. Kilburn wrote to thank Cabot “that you were good enough to refer to me” and to offer the modest claim that “if you find nothing besides eyestrain to account for her vertigo [dizziness], I shall be surprised if she does not get relief.” For more than a year, she was putatively better with her glasses, but the dizziness returned after she had a hysterectomy in 1905. In the prior year, she had visited Cabot several times for heavy menstrual flow, and after treatments including “injection of citrate of iron,” had a hysterectomy performed by a surgical colleague, and distant relative, of Cabot’s. She returned to 190 Marlborough Street for postoperative care, and began to report dizziness again. For the next couple of years, she continued to seek relief in the offices of a third otolaryngologist, and again with Dr. Kilburn to adjust her eyeglasses. Cabot noted that these visits were sometimes “without any consid[erable] gain to her,” but on other occasions, the attacks seemed “less severe and sudden.” In July 1909, Cabot referred her back to Dr. Crockett to try his original treatments again.⁶² She was never completely well, but she never stopped trying to get the right help.

The specialized services of Cabot and his colleagues must have derived part of their attraction from the promise of new medical science. To a public familiar with the remarkable stories of nineteenth-century rabies vaccines, diphtheria antitoxin, and, briefly at least, Dr. Koch’s tuberculin, there was always the possibility that the next scientific breakthrough would provide assistance. Mrs. Moore gave her own testimony to the powers of this promise. By 1914, Cabot had communicated to her his strong pessimism about the prospect of finding a lasting medical solution for her troubles. But her own pessimism was more easily shaken. In February 1914, twelve years after she had started seeing Cabot, she wrote concerning an exciting new development. Dr. Crockett, she reported, after several other unsuccessful attempts, “wanted me to try a new treatment—radium at the Huntington Hospital.” She reported that she had shared Cabot’s discouraging prognosis with Crockett, only to have him dismiss it. When Crockett suggested to her that radium treatment might finally “stop the roaring in my ear . . . I told him you said it would never stop.” But medical science provided an effective response. Dr. Crockett, she reported, had replied that “he would have said so too a short time ago,” but then radium had appeared on the scene. There was a new cause for hope, a reason to try additional therapies and the doctors who provided them. Mrs. Moore went to the Huntington Hospital for radium, expressing a blend of anxiety and hope about specialized medical procedures that is common in the correspondence of Cabot’s patients.

A system of referrals offered one means of endorsing the promise of new medical techniques and of channeling the aspirations that it stirred. People writing to Cabot seemed willing to try to create such a system where they found it lacking. In June 1909, a letter arrived in Cabot’s office from a desperate father seeking advice on “my little boy 4 1/2 years old” who had become tragically sick. The trouble started when the child “became ill 3 weeks ago and 1 week ago the local physician diagnosed the trouble as leukemia and . . . [a specialist] confirmed this 5 days ago and classed it as lymphatic.” This father wrote to Cabot, he explained, having found that he was the author of the chapter on blood diseases in a prominent medical textbook. The father communicated that he had the resources available to seek out the very best medical care for his child. His question was where to look. He explained the awful challenge facing him and his son: “As all authorities seem to agree the disease is necessarily fatal in the present state of medical knowledge my only hope is to get in touch with those who are close to the centers of research and study that if the little boy under the present treatment is temporarily restored we may learn quickly of any new discoveries in the treatment of this disease.” Perhaps a new advance in science could save his son. Would Cabot refer him to the proper specialist?

Referrals could engage and support the hope for something better among patients. Mrs. Moore moved widely through the circles of Boston specialists as she pursued different evaluations and treatments. Nonetheless, she seemed to maintain a model of referral in which Cabot certified her quest as appropriate and perhaps offered reassurance that she was not straying too far. Considering the option of the radium, she wanted his advice, writing, “I longed to [come?] and ask you if I should [try the radium treatment].” Her solicitation of advice preserved the stability of her relationship with her physician, who had been directing her use of different specialized medical services for years. As she asserted about her own and her family’s medical care: “[Y]ou see we can’t bear to do anything without your approval.” No records remain with the correspondence to indicate Cabot’s response about the radium. But there would likely be other possible treatments ahead if the radium failed to help.

Not all who went searching for medical assistance availed themselves of the reassurances of a referral. Other patients sought their care independently among a complex array of practitioners without the guidance of physicians or other practitioners. Some of them found their way to 190 Marlborough Street. Among the people who reached Cabot’s office independently, many arranged an appointment themselves, but others must simply have arrived at his door. One woman who had grown dissatisfied with her local physician had heard of him and decided that she would visit. She was the correspondent mentioned earlier who wrote asking if he would “please state what days and hours you are in your office and give me your address?”⁶³ She would presumably just drop in. People who had regular physicians in attendance could also, of course, arrange to see Cabot on their own initiative, without the knowledge of their physician. One woman who had recently visited wrote back recounting how “my doctor here dropped in the 14th and I told him I had been to see you. . . . He seemed surprised.”⁶⁴ The chart of her original visit had not recorded the existence of this other physician. Dissatisfaction with service from another physician could be a reason to make an independent request for care from Cabot. A man writing to Cabot in 1912 about his father expressed an interest in leaving behind the physicians who were caring for him. “The local physicians in [his town] seem to me to be unsatisfactory,” he wrote, adding, “at least they have not diagnosed his case and he has not obtained any relief.”⁶⁵ Patients typically assumed that some preliminary arrangements were necessary for a visit, and many tried to set an appointment. By 1912, they might telephone to establish a time to come to the office.⁶⁶ People sometimes announced a special concern that triggered their need for medical attention, as with the woman who wrote, “I feel uneasy about the small lump that has formed in my right breast and would like your opinion before seeing any one else. Is it possible for me to make an appointment for Friday?”⁶⁷ She also suggested that Cabot’s office would not be the only stop on her quest for assistance with this problem.

Conversely, of course, Cabot could visit his patients in their homes. Some people requested this, such as a woman in nearby Brookline who wrote in 1901 describing “nausea” and “gripping pains in my bowels-nothing serious-but very disagreeable,” saying, “I would like to see you if you can pay me a visit.”⁶⁸ He occasionally made home visits for established patients for a single treatment or assessment, but he rarely returned to orchestrate care for an entire episode of illness. Among the loose-leaf notes from his early practice records is a case from 1897 in which he had initially been called at 10:30 P.M. to the home of a patient who had fallen from a rocking chair. He subsequently provided a long series of home visits over the next several weeks attending to her broken arm. By 1900, however, cases of extended home visits had become very rare in Cabot’s practice.⁶⁹ Home visits were seemingly unusual enough later for him to note one in the margin of the patient’s chart. More commonly, when Cabot did visit a home, it was as a consultant meeting with the attending physician.⁷⁰

Cabot’s Clientele

An appreciable part of the analysis in this book derives from what Cabot’s patients had to say about their health and their medical encounters. We might wonder, then, about their identities. Who made up this clientele? Where did they come from? What were their livelihoods and backgrounds? Cabot kept careful, but carefully circumscribed, records of the identities of his patients, which allow some conclusions about the people who constituted his practice.⁷¹

Cabot’s private patients were in general neither Boston’s wealthiest citizens nor its most disenfranchised. Many came to him in Back Bay from the circle of suburban towns that grew up around Boston in the late nineteenth century. Not all patients have both an occupation and an address listed in their records, but those who do give a sense of the range of people who found their way to 190 Marlborough Street. Among patients whom Cabot saw in the first few years of his practice were, for example, a tailor from Boston, a professor from Salem, a carpenter from Watertown, a nurse from Jamaica Plains, a garment inspector from Somerville, a masonry boss from Everett, a piano tuner from Dorchester, and a law student from Cambridge.⁷² The occupational backgrounds of his patients were clustered among professionals, merchants, and skilled laborers, but he also exceptionally saw the son of a prominent industrial tycoon and an unemployed immigrant.

The leveling effects of office medical practice also shaped the presentation of the data on patients’ identities. Their occupations provide some clues. Although patients in the sample were aged from four to eighty-five, most were working adults, with an average age in the sample of thirty-eight and a median age of thirty-nine. In the random sample, slightly less than one-fifth of the women have an identifiable occupation noted in their charts, compared to three-fifths of the men. Many of these women are listed as married and likely worked exclusively in their homes. But I found nothing to reassure me that there were not many whose other occupations Cabot systematically neglected to inquire after or note. The occupations listed for the 104 women in the random sample range from kitchen girl, chambermaid, and former nanny to bookkeeper, nurse, and saleswoman. It is noteworthy that 5 out of the 104 women in the sample have their husbands’ occupations recorded as their own, even when the husband’s livelihood was no longer directly relevant (e.g., “junk dealer’s widow”). Was the woman recorded as “salesman” married to a salesperson or one herself?⁷³ Work limited to the home was typical for wealthier married woman in the early twentieth century; but perhaps Cabot’s assumptions about their roles led him to miss other information. After all, a practice in an urban medical office may well have selected for an independent group of women inclined to venture outside of their homes for care.

Judging the occupations of male patients entails a different kind of bias. Cabot tended to flatten out the reported occupational status of his patients. A range of occupations is represented, from lawyer, judge, professor, medical student, and “flannel manufacturer” to “peddling fruit,” cab driver, stable keeper, and steel laborer. The occupational records are, in addition, skewed toward the professional by a number of physicians who were patients. In the random sample of two hundred patients, there were six male doctors and three women recorded as the wives of doctors. Given the nature of these records, however, someone whose occupation is recorded as “watch factory” may have worked in a factory or have owned it. These records tend to blur the distinctions between very different occupations, emphasizing the product of the work rather than the position of the worker. So while one person identified as a “shirt waist maker” actually did sew shirtwaists, based on the information in the notes, another man described only as a “piano-maker” is identified in an accompanying obituary as the treasurer of a prominent piano factory. A man recorded only as a “roofer” is shown by his own impressive letterhead to have been the owner of a commercial roofing company, while a man whose occupation is recorded as “iron foundry” is described in a letter from his son as the foreman of the foundry. The occupation of the man called a “janitor” may seem clear, but someone whose occupation was “shoe factory” may equally well have been the owner, the floor supervisor, or a day laborer. The instance of a man whose work is noted only as “saloon” raises interesting questions. Did a man of whom it was noted, “sells candy,” sell it by the bag from a stall, one wonders, or by the truckload from his factory?⁷⁴

It is tempting to speculate on the significance of Cabot’s flattened occupational designations. He tended to level the socioeconomic characteristics of patients, so that in these medical records, the piano maker and the shirtwaist maker seem more similar than they would have appeared outside the medical setting. The important differences between patients, the differences highlighted by these records, are differences in medical condition or diagnosis. Medical categories superseded other social roles. Occupations received particular attention, for example, with regard to their specific effects on health. Thus, the occupation of a patient who was pale and weak might be recorded simply as “indoor work,” capturing tersely a significant medical feature of a job away from sunlight and fresh air. With other patients, the nature of their occupations seemed more significant, and Cabot specifies, for example, that one man’s occupation was “scouring wet cloth finishing (10 yrs).”⁷⁵

Gender rather remarkably offers a similar example of the leveling effects of the medical condition in certain instances. Roughly half of the patients visiting this office were women, 52 percent in the random sample. Typically, it was easy to discern the gender of the patients from these records; yet in some cases it was difficult and in others impossible to do so. These records classify people primarily according to disease, and only secondarily according to more commonplace social identities, like gender, age, occupation, or race and ethnicity. In the cases of a patient with pernicious anemia and another with myocardial weakness, for example, the nature of the disease is evident, but not the patient’s sex. Listed only by their surnames, without other identifying information, these patients exist in the charts only as diseases.⁷⁶ Pernicious anemia meant special blood testing and treatments with arsenic, x-rays, thorium, or splenectomy. Myocardial weakness might entail advice about a regimen of rest and the use of stimulating medications like digitalis. The identity of these patients beyond their need for specially defined medical services is obscure.

The strongest example of the suppression of social identity is in the instance of race. Scattered observations on the racial and ethnic characteristics of Cabot’s patients reveal more by what they omit than by what they include. Cabot identifies a national origin for very few of his office patients, noting occasionally that the individual was Swedish, or from “Italy.” A couple of patients are noted as “colored.” Another small group of patients are identified as “Hebraic”—sometimes derogatively.⁷⁷ Most patients, however, received no ethnic or racial designation. The great majority in this group with Anglo-Saxon surnames, like Miller, Burt, Greene, Taylor, Webster, Allen, or Drew, are not otherwise identified in terms of ancestry or ethnicity. This suggests that the group warranted no separate identification in Cabot’s view.⁷⁸ Still, the names of the patients indicate a diversity of backgrounds that found no other direct expression in Cabot’s clinical records. It is noteworthy that one significant group among Boston’s citizens is almost unrepresented among the clientele of this clinic. Judging by the surnames in these records, Boston’s Irish seem not to have gone to 190 Marlborough Street for their medical care, although they would have been well represented among the patients that Cabot saw in the Out-Patient Department at Massachusetts General Hospital, just across town.⁷⁹

Race mattered to Cabot in clinical reasoning, as he explains in his textbook on diagnosis in various places. Referring to specific cases, he says, for example, that “any pain of this type occurring in a man of fifty-nine suggests aneurysm or angina pectoris, especially if the patient is a negro,” and that “there is no reason for accusing the stolid Italian laborer of the ‘vapors.’ ” although he does not elaborate on the basis for these observations.⁸⁰ People of different racial and national backgrounds suffered from different distributions of disease and described their symptoms in what seemed predictably different manners. But once again the significance of disease seems to have overwhelmed the need to account explicitly for race in these records. The fact that it appears in the records prominently only in the case of nervous disorders is explored in Chapter 5 below.

Sliding Scale of Payment

Cabot’s medical records configured the patient’s social role as an element of information with specific relevance to medical practice. Medical authority in the clinic functioned partly through the ability to create these transitions and bridges from the patient’s external social world into the oddly intimate, technical focus of the clinic. Social roles and identities mattered, but they mattered most in their implications for medical management. Setting fees for medical service offered an interesting expression of the power to translate occupation into information relevant to practice. A so-called sliding scale of fees linked the patient’s perceived socioeconomic status to the amount charged for service. Cabot used such a sliding scale of fees, and the letters of other physicians and patients suggest widespread familiarity with this system and general anticipation of its use. Patients who seemed able to afford higher fees were in general billed more, while those who seemed poor were billed less. While referring physicians took the most visible role in negotiating fees, patients too petitioned for reduced charges based on their means, circumstances, and occupation. They occasionally sought a lenient fee without any reference to their means, as in the case of a patient who wrote on her personal stationary in a tidy hand: “If it would not be trespassing too much on your kindness and time would you let me come to you for the same sum ($3.00) you allowed me to see you for eight months ago?” But more typically, people appealed to the doctor on the basis of their work, salaries, and financial obligations.⁸¹

The referring physicians usually petitioned on behalf of their patients, as when Dr. Chase sent a patient bearing a letter to Cabot describing her care and noting that “their circumstances are moderate. Husband is a grocer.”⁸² In other cases, a more complex set of considerations was invoked. Writing in 1905 that her patient’s husband was of limited means and “if in justice to yourself you could show him any special consideration in the way of a slight reduction of fee, I assure you I would appreciate your kindness,” Dr. Sarah Bond seems to petition as much on the basis of her relationship with Cabot as on behalf of her patient. This patient’s husband, she explained, had a reasonable salary as a university professor but was “unfortunately carrying a heavy load of both his wife’s family and his own.”⁸³ Another physician wrote, similarly, “What I wanted to do was to see if I could make some arrangements . . . that the cost to him would be as little as would be consistent with his means.”⁸⁴ Other subtleties of negotiation are also evident in the records. One physician wrote of his patient to Cabot that “he is not in very good circumstances but would raise the money somewhere if he had to go and see you.” When he saw this patient on referral, however, Cabot noted in his chart that this man had already “been osteopathic—$90 worth.” Apparently, the patient in question found money to pay other practitioners. Cabot submitted and was paid a bill for $15 for the visit, not substantially less than similar charges in the same period of practice.⁸⁵

The sliding scale went up as well as down, although discussions over higher fees were considerably more circumspect. The physician’s willingness to lower the expected fee in the case of straitened circumstances was naturally a more acceptable message to convey. There were few people who wrote, as one did, saying, “as I am not one who wants ‘something for nothing’ I hope you will charge me well for all your trouble,” but colleagues of Cabot’s seem to have been willing to hint when someone could well afford the fees.⁸⁶ Some physicians writing in referral seem to imply that they are seeking not a reduction in fees from Cabot but restraint in increasing them, as in the case of the doctor who wrote to ask Cabot to “kindly make the charge as reasonable as possible,” explaining, “patient not in affluent circumstances.”⁸⁷

More went into Cabot’s assessment of his fees than the patient’s ability to pay, of course. The most important factor was probably the nature of the services rendered, although this is often difficult to assess from these records. A statistical analysis comparing the fees charged in individual cases with the number of laboratory tests performed suggests a correlation here.⁸⁸ Consultations were more expensive on the whole than referral visits, accounting for the costs of Cabot’s travel. In addition, the vagaries of Cabot’s reporting on occupational status make it hard to compare occupations with levels of charge. On three separate visits during one week in 1914, Cabot billed a singer nothing, a carpenter $15, and a “telephone man” $25. The next week a “judge” had a visit, recorded in some detail, for which he was billed $5. The effects of the sliding scale are most evident at the extremes, with patients who were recent immigrants paying unusually low fees, while a wealthy tycoon received a bill for $200, which he seemingly paid without hesitation.⁸⁹

Cabot occasionally provided free services to patients. In some cases, it was simply charity. But free services functioned in other ways too. In 1913, Cabot saw an insurance agent suffering from “bladder trouble” and advised him to consult a urologist. No fee was charged for the visit, with the notation “free,” added in the chart.⁹⁰ It is possible that this man was actually unable to pay, but his visit seems to have been a brief one, judging from the records, and perhaps Cabot felt that he had performed only a minimal service. There was likewise no charge, perhaps on similar grounds, when Cabot saw a child suffering from bedwetting and found that “all my measures tried and n[o] g[ood].” It is equally possible that other factors influenced the provision of free care. Cabot generally offered professional courtesy to other physicians, to their family members, and to nurses, for example. Other personal connections counted as well. Cabot also provided free services to various of his relatives when he saw them as patients.⁹¹

THE SLIDING SCALE OF MEDICAL FEES linked the provision of care with the patient’s economic and occupational standing and softened, or at least obscured, the influence of social position or wealth in controlling access to care. At least figuratively, it took money off the table in negotiating services with a doctor. In some markets, you could buy whatever you could afford. A sliding scale made obtaining a doctor’s services depend less on what you could afford and more on what the physician was willing to provide. The sliding scale provided at least some potential shelter from competitive market pressures, and so expressed the interests of professional autonomy as much as the obvious desire to make a good living. Perhaps a wealthier client could obtain better services merely by paying more—but perhaps he only paid more for the same services.

The issue of the sliding scale provoked lively debate among Cabot’s peers in the early twentieth century. Doctors of the day typically offered two slightly different justifications for the sliding scale, depending on whether they discussed only lowering fees or both lowering and raising them. The justification for lower fees was the obvious argument for charity. Physicians arguing a disinterested case for the raising and lowering of fees had to appeal instead to the general social good. The appeal to charity seems to have been more common and was more readily defensible.⁹² Dr. Roger Lee, also of Boston, argued that charity allowed physicians to reduce their fees to accommodate a limited income. They should not, however, raise fees just because other patients were able to afford them.⁹³ Richard Cabot’s brother Hugh made one of the more cogent arguments based on justice, contending that sliding scales should run both ways, so that wealthier patients subsidized the care of poorer ones. He went so far as to compare the sliding scale of fees to a system of graduated income taxes. The sliding fee permitted a measure of equity, administered by the physician.⁹⁴

The discussion here will leave aside the question of how well or how fairly the sliding scale worked, which would be difficult to resolve given the nature of the evidence. Critics have been quick to point out that sliding scales provided a handy mechanism for maximizing medical fees without much oversight or disclosure.⁹⁵ Physicians charged whatever they thought a patient could pay and claimed to be obliged to do so by an open, competitive market. In the face of criticism over fees, turn-of-the-century physicians tended to fall back on the general defense that however they billed, they frequently went unpaid in any case; and patients, they noted, tended to create their own sliding scales, paying whatever a service seemed to be worth to them.⁹⁶ Stories abounded in professional communications of physicians who were able to exact a fair payment from a reluctant patient, usually through gentle subterfuge. But such stories most often took the form of jokes.⁹⁷ Doctors took care not to seem too serious about this matter, perhaps reflecting the delicate task of preserving the image of beneficence when they routinely earned their livings from families in circumstances of crisis, debility, sickness, and loss.

Whatever its actual use, the sliding scale offered American physicians at least hypothetical shelter from external economic pressures, sheltering physicians in part from a competitive market, while equally seeming to buffer the individual physician against the influences of wealthy patronage. Such arguments appealed to Richard Cabot, with his concern for the physician’s autonomous and legitimate control of practice. Cabot echoed a common criticism by American physicians before the advent of medical insurance in arguing that the best medical care went to the wealthiest, who could afford the full cost for surgeries, x-rays, or hospitalization, and to the poor, who often received identical, charitable care. It was the middle class, Cabot argued, who were shut out from the most advanced medical services. Only a system of group, prepaid medical insurance, he claimed in his popular writings, would remedy the flaws in a system of direct payment for services that relied on medical charity and covert shifting of costs.⁹⁸