(The following blog post is by Julie Miller, early American historian in the Manuscript Division.)
How did 18th-century Americans pay for their medical care? A leather-bound volume of patient payments kept by Philadelphia physician William Shippen Jr. between 1775 and 1793 helps answer this question. The volume is in the Shippen Family Papers in the Manuscript Division of the Library of Congress.
In Philadelphia, Shippen practiced medicine and taught anatomy, surgery and “man-midwifery” – as obstetrics was called when it was practiced by a man – for more than forty years, except for an interval during the Revolutionary War when he was director of hospitals for the Continental Army. His income came from his medical practice, teaching and also from his real estate transactions, which are also documented in the Shippen Family Papers.
Shippen’s income was bolstered by two medical innovations: inoculation for smallpox and the obstetrics training he had received in England. Smallpox inoculation was available in Philadelphia by the 1730s, but it wasn’t until the 1750s, after an outbreak, that Philadelphians began to adopt it as a regular preventive practice. The result was a rising level of immunity in the population and a significant decline in incidences of smallpox. Historian Sarah Blank Dine, who has written extensively about William Shippen, points out that Philadelphians’ adoption of smallpox inoculation was a watershed for the city’s doctors, since it gave them the opportunity to provide an income-generating service to families on a nonemergency basis. (I would like to thank Sarah Dine for kindly sharing an unpublished conference paper with me.)
Delivering babies had a similar effect on doctors’ incomes, since it too was a service frequently required by families. Male-midwifery, however, was a new idea at the beginning of Shippen’s career and it took decades to catch on. In colonial America, babies were normally delivered by female nurses and midwives without formal medical training. Doctors were typically called in to cope only when there were complications. This began to change in the 1780s as American doctors such as Shippen, who had been introduced to man-midwifery in Europe, finally won the confidence of families and began to attend routine deliveries.
Shippen organized his records by name of household head, with approximately 330 families represented. Each entry records visits, diagnoses, procedures, prescriptions, charges and payments and in many cases stretching over decades. His family connections, his acquaintance with George Washington dating from his service to the Continental Army and the presence of the national capital in Philadelphia during and after the Revolution meant that he had many patients who could pay “cash in full.”
One of these was Pennsylvania Chief Justice Thomas McKean, to whose daughter, Molly, Shippen paid an emergency nighttime visit in 1781. In 1784 he treated a Spanish diplomat, Don Francisco Rendon (for diarrhea, among other things – maybe American food disagreed with him) and also rented him a house, earning £350 for the year – much more than the £3.10 he earned for his medical services. In 1791 he visited President Washington to treat one of his slaves, Hercules. The same year he delivered one of the 12 children of Lucy Knox, wife of Secretary of War Henry Knox. Secretary of State Thomas Jefferson was another of Shippen’s patients.
Patients without ready cash paid Shippen with goods: coffee, tea, wine, and beer; lengths of muslin, linen, and calico; handkerchiefs, silk stockings, a tablecloth, looking glasses, crockery, a tea table. Sometimes Shippen took a chance on things of dubious or uncertain value: once he accepted a lottery ticket in payment; another time he took what he described as a “bad painting.”
People who had neither goods nor cash to spare paid in labor. Bakers paid in bread, carpenters with woodcraft, tallow chandlers with candles and a barber with “dressing, &c. [etc.]” Mr. Bates, “horseman,” housed Shippen’s mare in exchange for advice on his nephritis. Some people never paid. After the name of one patient Shippen wrote “bankrupt,” after another, “gone.”
Shippen convinced a few of his wealthier patients to pay in advance with annual contracts not unlike the “concierge” plans that some doctors offer today. In January 1789, he recorded that General Stewart “agrees to pay me 15 guineas p[er]. annum for my advice & attend[an]ce &c.” Another patient, William Whiteside, agreed to the same arrangement, but had a hard time keeping up. He paid in two installments, supplementing his cash with tea and muslin. After two years he dropped the contract and resumed paying for individual services.
Because the volume is organized by family, it reveals who belonged to each household Shippen visited. Eighteenth-century households typically included not only husbands, wives and children, but also apprentices, servants and slaves. Many of these household members were legal dependents of the husband, father and master. So, for example, in 1783, Ralph Izard, a South Carolina representative to the Continental Congress, paid for medical care for his “man Frank.”
Husbands and fathers paid for wives and children but sometimes the lines of money and power in a family were unexpectedly complex. In 1783, for example, Shippen visited the family of coachman Henry Otto several times, mostly to treat his wife, who Shippen does not name. As head of household, Otto paid Shippen in washing. But women did laundry, not men. Thus it is likely that Mrs. Otto paid for her own medical care with her own labor, which her husband, as her master, owned.
Harder to work out are cases where people paid for the medical care of others outside their households. In 1789 Shippen cared for Elizabeth Hayes Darby through an illness that involved 10 visits, two “operations” and “tapping.” Darby is one of only a few women listed on her own in the records, so she was probably a widow or a spinster. In 1792 a member of the Lloyd family paid her bill of £15. The Lloyds were related to the Shippens. Could Shippen have approached a wealthy relative of his own to pay Darby’s bill? The volume doesn’t say. What it does reveal are clues about the networks of relationships that tied the city together through family, friendship and mutual obligation but also through social hierarchies that made servants, slaves and the poor dependent upon the self-interest or uncertain goodwill of the better-off.
It is worth asking just what Dr. Shippen’s patients got from him in exchange for their tea urns, tablecloths and “cash in full.” Shippen’s training in anatomy probably made him adept at repairing the dislocated wrists and broken bones he saw. But like all 18th-century doctors he purged and dosed his patients with drugs that probably did more harm than good. His smallpox inoculations protected many Philadelphians from a terrible disease. But during the epidemics of yellow fever that struck Philadelphia in the 1790s he, like every other Philadelphia physician, was helpless. When the epidemic first appeared in 1793, half of the population, including Shippen’s patients Thomas Jefferson and the Washingtons, left the city; about one-tenth of the population, many of them working people who did not have the means to flee, died. Shippen may have saved some mothers and babies from death during childbirth, but childbirth and infancy remained risky in the 18th century. Of the 12 children Lucy Knox gave birth to, nine died before they grew up.
And what about poor Miss Rhea, who he charged £7.10 for “extirpating tumor and dressing”? When she suffered this illness in 1790, Rhea still owed Shippen money from 1785 and 1786. He recorded her new charges but not that she paid. Evidently a spinster, she lived outside the protective, if controlling, canopy of a family. I wish it was possible to snatch Miss Rhea out of the 18th century and transport her to the office of a 21st-century oncologist, insurance card in hand. There she would not only have a chance to get well but to have the dignity of paying her bill, wiping out the unpaid debt that remains to this day in Shippen’s records.
Today the cost of medical care and who will pay for it are at the center of national debates. In the 18th century, as Shippen’s records show, they were worked out privately between doctor and household head. With no pool of insurance premiums to draw on, Shippen’s flexibly adapted to his patients’ abilities to pay. But the records also show that access to medical care was dependent on who could pay for you if you could not pay for yourself. In a perilous medical environment it was a chancy and deeply inequitable system that relied on social hierarchies and ties of dependency that were out of joint with the vision of equality that Shippen heard debated in Revolutionary and early national Philadelphia.