IN 1884 ALMOST three-quarters of America’s fifty million people lived on farms or in rural hamlets. When they fell ill, they ordinarily were treated in their own homes by someone they knew, someone who might not be a trained physician but a family member, neighbor, or midwife. Only a handful of smaller communities boasted hospitals, for they were still a big-city phenomenon. And in those cities, only the workingman and his family, the aged and dependent, the single mother, or the itinerant laborer would normally have received institutional care. For the middle class, a bed among strangers in a hospital ward was a last resort. Even within the working class of America’s rapidly growing cities, the great majority of patients too poor to pay a private physician never entered a hospital but instead received free outpatient care from dispensaries, from paid municipal physicians, and from hospital outpatient departments. The hospital was a place to be avoided—often a place in which to die—and not the fundamental element in medical care that it has become in the twentieth century.

Some of the ills Americans fell victim to a century ago were the same as those we still suffer from—bronchitis, rheumatism, kidney and circulatory ailments; others have become either uncommon, like malaria, less common, like syphilis, or entirely banished, like smallpox. Tuberculosis was by far the greatest single killer of adults; gastrointestinal ills were the greatest scourge among children. Both tuberculosis and the “summer diarrheas” reflect and document the grim realities of a society in which food was sparse for many, work exhausting, living conditions filthy, and sanitation and water supplies well suited to the spread of infectious disease.

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