The history of homeopathy in the Russian Empire
until World War I, as compared with other European countries and the USA: similarities and discrepancies

by Alexander Kotok, M.D.
On-line version of the Ph.D. thesis improved and enlarged
due to a special grant of the Pierre Schmidt foundation.

3.5 Physicians within zemstvo medicine

Head quarters of Anglo Russian Hospital (Petrograd)

First of all, the greatest difficulty in the collaboration of physicians and zemstvo authorities consisted in the legislative structure for managing medical affairs in zemstvos. Physicians, like other representatives of medical staff (feldshers, midwives) or teachers, were the so-called "third element", i.e., hired employees whose voice was exclusively advisory. This often led to conflicts between zemstvo physicians and the zemstvo authorities over the building of local systems of providing medical support. While zemstvo physicians insisted on free-of-charge zemstvo medicine, the authorities charged the peasants with payments for smallpox vaccinations (and fined them for refusal to vaccinate their children), for hospitalizations and for medicines. Although those payments were definitely symbolic in character and were aimed at accustoming the peasants not to make excessive use of medical staff and to carefully treat the medicines they received from doctors25, zemstvo physicians usually strongly resisted even the idea of charging patients for treatment26.

Another point of permanent conflict, which lasted until the end of the 1880s, related to the system of the day-to-day work of zemstvo physicians. From the beginning of zemtsvo medicine, the elective deputies at zemstvo meetings [zemtsy] adopted the circuit [raz'ezdnaia] system indicating when physicians should have to make visits to the feldsher stations where the patients were waiting. In the opinion of the zemstvo authorities,

Physicians, who settled at hospitals and only treat, eliminate themselves from sanitary [i.e., preventive] medicine. Thus, the main aim and usefulness of zemstvos - to know more about the causes of diseases, as well as to disseminate some information about these diseases among the people, is disappearing27.

This approach led to the situation that physicians were hardly available for the population. Although this was evident, the authorities did not quickly move to a new system because they did not wish to increase the cost of keeping dispensaries. The opinions of physicians were either neglected or ignored. Only by the 1890s, almost everywhere, either the stationary or mixed (stationary-circuit) system of rendering medical support was adopted. According to V. Kanel', by the end of the 19th century, in 138 districts there were "pure" stationary, in 219 — mixed, and in only 2 — was the circuit system accepted28. Nevertheless, zemstvo physicians were forced to serve huge territories. By the end of the 19th century, only in the Moscow province the radius of 10-12 "versta" (about 10,5 — 12,8 km) was accepted as normal, taking the area of physician's activity as a circle, whilst in other provinces the radius was 17-18 "versta" (about 18,1 — 19,2 km)29. According to Veselovsky, in 1905, "in a typical district" one physician served 25,000 people, while the radius was about 16-17 "versta" (about 17,0 — 18,1 km)30. Yet according to other sources, the data presented by Veselovsky seem to be too optimistic. The statistics published by Z. G. Frenkel, indicate that the average population served by one physician evaluated in 1900 was about 33,000, while the average radius of physicians bailiwick was about 21 km. Ten years later, in 1910, according to the same source, the picture seemed to be almost as far from ideal as it had been in 1900. The average radius was about 18 km, while one physician served an average of 28,000 people. The augmentation of the number of physicians employed by zemstvos during ten years, from 1900 to 1910, was scarcely sufficient for Russia and its huge sizes. From 2,398 physicians in 1900, it increased to 3,082 in 191031. For Russian physicians a bailiwick was viewed as comprising ideally a ratio of one physician to 10,000 inhabitants or less and the radius should not be more than 5-8 km. In reality, in 1910 only eight zemstvos could report adoption of this ratio.

It would not be too soon for Russia as a whole to achieve this ratio, but then one has to increase the present number of physicians and the expenditures by 3 times!32

Furthermore, generally speaking, the style of physicians' behavior itself was also a reason for numberless conflicts in the zemstvos. I bring here only one of the most typical contemporary instances where physicians and legislative officers clashed:

It has become usual that physicians at the zemstvos establish some kind of a caste. They do not hide their indignation when somebody endeavors even a minimal intervention in their affairs. So, one physician called a deputy 'profanator' at the Perm zemstvo meeting. The deputy tried to offer his sensible opinion on some medical affair. Another physician was rebuked for not taking into account a remark of another deputy for 'this remark belongs to a person having no medical education'! Because of some disagreements in the hospital at Atkarsk [a little town in the Perm province] all the physicians left their places. Such examples are numerous33.

Zhuk also mentions those internal conflicts, although his point of view is characteristic for a Soviet historian:

The struggle of progressive young physicians with the masters of the Zemstvo [i.e., zemstvo deputies and officials] had developed from the beginning of zemstvo activity. The struggle was about the necessity of hospitals for the common people, about the detriment of independent feldsherism, about circuit or stationary systems and about official rights and duties of physicians. The discussions often developed into conflicts that ended with the transference of physicians to other zemstvos or to their leaving the zemstvo service altogether34.

In my opinion, the arrogant and sometimes even provocative behavior of physicians obviously made mutual understanding of physicians and zemstvo officials rather difficult.

Furthermore, many deputies at the zemstvo meetings, especially those who came from the gentry and sometimes also from the peasantry, often preferred keeping 3-4 feldshers35 instead of one physician, stressing that "vrach — barsky lekar', feldsher — muzhitsky lekar'" (a physician is a doctor for wealthy people, a feldsher is a doctor for the peasants)36.

Probably, no issue in zemstvo medicine brought more bitter discussions within the zemstvos then that of so-called "feldsherism". In fact, feldshers in Russia were persons with very different medical education backgrounds37. There were those who had been chosen in their younger years, then "taught" by the landlords' wives; there were those who had been "taught" in a similar way during their service in army or navy [rotnye feldshery]; there were also graduates of the feldsher schools [shkolnye feldshery] after 3-4 years of training. Nevertheless, zemstvo physicians saw all feldshers as poorly educated persons who might be allowed to practice exclusively under the supervision of physicians. Although some zemstvo physicians called "feldsherism" an "affront to zemstvo medicine"38, the clearest expression of this opinion was presented in the book of Osipov et al.

Feldsherism is placing independent medical activity at the disposal of the lower medical staff which has neither appropriate training nor even elementary basic education. Such an approach can solve the problem of the organization of zemstvo medicine just mechanically, by establishing a lot of cheap 'doctors'. Yet this undermines those scientific and cultural grounds of zemstvo medicine which are of great importance for the rational provision of care for people's health39.

Besides caring for the medical welfare of the common people, physicians were anxious about their own. So, the proposals of Dr. Herzenstein at the 5th Meeting of the Russian Physicians were rejected and strongly criticised. Comparing the number of physicians in Russia and England, Dr. Herzenstein stressed that the bailiwick on which a Russian physician works is 135 times greater than that of his English colleague. Thus, Russian physicians can do nothing without the help of feldshers. Dr. Herzenstein proposed that, on the one hand, where feldshers already provided treatment, this situation should be legitimized; on the other hand, the training of feldshers ought to be improved. The members of the meeting firmly rejected those proposals, for they feared that the zemstvos would employ such "improved" feldshers instead of physicians40.

Many of the zemstvo managers (this post was introduced by the government in 1890) had a different point of view on the problem of hiring feldshers. The managers stressed that the zemstvos do not have the means to provide the local populations with a sufficient number of physicians, or even feldshers. So, Alexander Novikov, who summarized his 7-years experience as a zemstvo manager, wrote in his book:

The chief reason that the conviction regarding the unfitness of feldshers still exists is that the experts are physicians. Naturally, they say that there is no one who may judge on medical affairs except them. [...] In order to make medical support accessible and useful, and nearer as well, it is required that the sick should be visited at home. Thus, we should establish at least one dispensary in each small rural district [volost']. Such dispensaries have to be managed only by feldshers, for even in one hundred years from now we could not afford to employ a physician in every volost'. The quality of treatment, probably, would be low, but it would be compensated hundredfold by the accessibility of treatment for the population41.

This conflict with feldshers, as I wrote above, led, in turn, to permanent conflicts within the zemstvos, but did not bring the expected benefits for the physicians. B. Veselovsky noted that while in some provinces the number of feldshers, feldsher stations and feldsher schools decreased, in other zemstvos the picture was opposite42. Nevertheless, later statistics show that the number of feldshers decreased between 1890 and 1910, from 2, 800 independent feldsher stations in 1890 to 2, 620 in 191043. Yet this statistical phenomenon did not reflect a decreased demand for feldshers. On the contrary, in the 1870s the zemstvos started opening their own feldsher schools in order to provide some provincial hospitals with needed medical training.

By 1915, there were 80 civilian schools throughout the Empire training feldshers and feldshers-midwives, 36 of them were supported by the Zemstvo. These zemstvo schools taught slightly over half of the 6,500 students enrolled in all schools. The graduates of these increasingly sophisticated feldsher schools were on the whole quite respectable medical practitioners: most had completed at least 8 years of primary education plus 4 and sometimes 5 years of training in a feldsher school, [whilst some], mostly women, had 10 to 12 years of primary and secondary education followed by the same feldsher training. As medical practitioners, these better-educated feldshers compare favorably with the American country doctor of the same period. [… ] Throughout much of the zemstvo period, however, feldshers in independent practice tended to be either 'company' [i.e., of army or navy, rotnye as I mentioned above — A.K.] feldshers or the worst graduates of the zemstvo schools, the best qualified usually seeking some kind of urban practice44.

It is remarkable, that "feldsherism" was especially widely spread in the zemstvos where the representatives of the peasantry had a strong influence (so-called "krest'ianskie zemstva"). It goes without saying that zemstvo physicians criticized the "obscure, ignorant" peasants for their "blind" preferences:

It is improper to refer to the opinion of the peasants who are incompetent in this matter. They can be satisfied with feldshers, as they [the peasants] have not seen any better and did not have any criterion for judgement [...]. Naturally, there are people who are satisfied also with the treatment of a wizard, but it does not ensue from this that wizards are successful45.

In fact, the conflicts around co-operation between physicians and feldshers harmed zemstvo medicine as a whole46. It is to be regretted that physicians spent their energy in this quixotic struggle with the "windmills". Obviously, physicians fought for their influence and for improving their financial positions at the zemstvos. As long as there were "malicious" competitors like feldshers who were also involved actively in the treatment (sometimes successfully) of the local rural population, physicians could not increase their influence and dictate their will to the zemstvos.

The independent feldsher, of course, was an embodied denial of the physician's exclusive competence. Feldshers who acquired popular success, even on the basis of their proven skills as practitioners, inevitably tended to postpone the day when the physician's license itself may serve as an adequate claim for popular confidence47.

The main problem, in my opinion, consisted in the opposition between the interests of the physicians and those of the zemstvo authorities. Physicians, who usually came from educated urban families, were alien to the day-to-day existence in the village. They were not able to understand that besides public health the zemstvos had a lot of other duties to be carried out. Moreover, being educated in the spirit of the enlightenment, they wished to improve things too quickly, while they could have been improved gradually, together with the transformation of the state political system and the people's consciousness. While required by the authorities to deal only with their professional affairs, they had been quickly dissatisfied with the poor sanitary conditions and with rural people's ignorance, and often left the zemstvo service. It should not be forgotten that

Since even the most advanced nineteenth-century medicine was powerless to deal with most serious diseases once they had developed, physicians were not able to sustain their claims to exclusive medical competence on the basis of results alone48.

Prof. Engelhardt, to whose book I like to refer for the rare evidence provided by someone who lived for many years among the peasants, testified in 1877:

Sometimes I met in St. Petersburg young physicians who had served somewhere in a zemstvo and returned as they found their activity among the people to be useless. 'What kind of medical help can be rendered to the people when it has nothing to eat?' they asked. At that time I believed them. But now, after living 5 years in the village, I see what a benefactor a humane and industrious doctor could be for the peasants. If some young physician [...] would settle in my village, I suppose that 24 hours a day would not be sufficient for rendering help to all the sick who would turn to him. Without even speaking of a direct medical support [...], a whole generation could be saved just by paying attention that the peasant's house be fumigated with arsenic because of cockroaches [...]. What enormous educational influence would this man have!

Naturally, first of all, one has to be a businesslike man. Once at the zemstvo meeting I heard the report of a young physician who complained that the patients were plagued with bedbugs [...]. My God! Instead of taking boiling water and boiling out the bed sheets and covers, and smearing the splits [in walls] with turpentine, the physician had left his patients to be eaten by bedbugs and eloquently sermonized about this at the zemstvo meeting!49

Although the zemstvo service was doubtless hard and often dangerous for physicians for their day-to-day involvement in the treatment of severe infectious diseases and even epidemics50, the reward (approximately some 1200 rubles yearly during the whole zemstvo period and even up to 1600–1800 rubles after 1905, when many disappointed physicians left the zemstvo service) was significant enough51.

The Zemstvo's efforts to get physicians' service for cheaper salaries at the end of the 19th centurywere thus as a rule unsuccessful, for physicians proved too well organised and did not hurry to occupy these low-rewarded vacancies. At the same time, feldshers usually received a salary of some 300–400 rubles52.

Briefly summarising this chapter, I would like to stress again that the zemstvos did not succeed to make medical help more accessible for the population because of financial limitations on the one hand. On the other hand, the zemstvos suffered from internal conflicts with physicians, at first because of the exorbitant demands of the latter. Homeopaths were witnesses to these problems within the zemstvos and used them in their propaganda53.

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Copyright © Alexander Kotok 2001
Mise en page, illustrations Copyright © Sylvain Cazalet 2001