Today, it is completely normal that all doctors have a comprehensive medical education, hold an advanced degree, have plenty of clinical experience, passed a licensing examination, and are deemed fit by their state medical boards to practice. However, in the late 1800s, the field of medicine was a chaotic and unregulated profession filled with quack doctors, frauds, and bogus medical schools that handed out degrees in exchange for a sum of money. How did medical practice turn into the orderly, professional, and respected field that healthcare is in the 21st century? West Virginians, most notably a man named James Reeves, contributed to these developments in medical practice by advocating for and enforcing a strict licensure law that ensured doctors were indeed qualified to take care of their patients.
While modern developments in medical licensure laws occurred after the Civil War, licensure in the United States stretches back to the colonial period. Adapting the practices of the British College of Physicians of London, colonial governments such as New York City (1760) and New Jersey (1772) passed laws to require examination and licensure.[1] This tradition continued after the American Revolution, and, by 1829, all but three states required either state approval, a medical school diploma, or the endorsement of a local medical society to practice.[2] Despite these laws, however, antebellum era licenses were easy to obtain; new medical colleges opened rapidly, setting their own standards and giving many poorly trained students the requisite medical diplomas to practice. Due to the prevalence of these poorly trained and yet diploma-certified doctors, and other Jacksonian-era cultural trends of equality amongst the white male, many states repealed their licensure laws.
James Reeves (Image courtesy of the National Library of Medicine)
It was in this environment that James Reeves began his career. Growing up in Philippi, Virginia (now West Virginia), Reeves opened his practice in Sutton, Braxton County, VA. In addition to an apprenticeship, Reeves’ educational experience came from lectures at Hampden-Sidney Medical College in Richmond.[3] By 1851, Reeves began his independent medical career in Philippi, in rural northwestern Virginia (now West Virginia). Unlike Richmond, which, as a city, had a concentration of physicians (about one doctor for every 368 people), rural Barbour County, where Philippi was located, had only one doctor for 900 people.[4]
Philippi, at the time, was a site of great activity, perfect for a new doctor to begin his career. In 1850, Virginia voted to develop a turnpike through Philippi to Fairmont, and, as part of this infrastructure, build a 300-foot covered bridge across the Tygart Valley River. This construction meant that workers spent significant time in the river, contracting and spreading typhoid around Barbour County.[5] Of the approximately 600 cases in the county, Reeves was responsible for treating 110.[6] He documented his experiences treating these patients and submitted it to the Buffalo Medical Journal in 1856.[7] He later expanded on this work to write his 1859 book, A Practical Treatise on Enteric Fever (another name for typhoid). While the work never gained wide recognition, it nevertheless made him a national reputation as an authority on typhoid and public health. In 1859, Reeves also joined the Medical Society of Virginia. This began his involvement within state medical societies, something that defined the rest of his career.[8]
In 1859, Reeves also took steps to continue his education. Later in the year, he enrolled in the University of Pennsylvania’s Medical Department, earning his Doctor of Medicine (M. D.) degree in 1860. Unlike many Southern medical students studying in Philadelphia, who protested John Brown’s raid on Harper’s Ferry and the Northern responses to it by leaving their schools and returning southward, Reeves finished his education at Penn.[9] Upon returning to Virginia, he began practicing in Fairmont, in Marion County.
It was while Reeves was in Fairmont that the secession crisis preceding the Civil War began. While a Unionist who supported peaceful reconciliation with the South, Reeves publicly maintained a neutral and non-partisan stance throughout the war, despite the conflict’s significant effects upon northwestern Virginia (now West Virginia).[10] Indeed, it was in Philippi, Reeves’ hometown, where the first land battle of the Civil War occurred on June 3, 1861. A small skirmish with no casualties and only ten injuries, Philippi was a decisive Union victory, mockingly called the “Philippi Races” because of the rapid and hurried Confederate retreat.
"It cannot be doubted that many men in this class have obtained certificates who are not qualified to treat the sick; but while this is unfortunately the truth, it is a consoling fact that this class of doctors will grow less and less as the years go by." James ReevesAnnual AdDress by the President of the Medical Society of the State of West Virginia, 1882
Following the war, Reeves took steps to organize physicians in the new state of West Virginia. In a state deeply divided between Unionists and former Confederates, Reeves attempted to organize physicians across WV to establish a state medical society, which occurred in April 1867. Of the 390 physicians listed in the census, 22 were at this original meeting, where Reeves spoke of how he wished to make an organization where science was emphasized over charlatans, thus professionalizing the industry.[11] At the conclusion of the meeting, Reeves was elected the secretary of the new medical society, which planned to hold its first official meeting in six months.[12]
Reeves’ relationship with the WV Medical Society soured shortly thereafter. Fellow founder and physician John Hupp, who served as Treasurer of the Society and led the committee to organize the first official meeting, announced that six Wheeling physicians who had not been at the Fairmont meeting nor elected members of the new society would be joining its ranks at the meeting.[13] One of these members was Hupp’s father-in-law, A. S. Todd, the proprietor of Todd’s Antibilious Pills. These pills, which were frequently advertised in newspapers and accompanied by letters to the editors endorsing them, openly violated the American Medical Association’s code and the ethics provisions barring the marketing and providing of patent medicine.[14] In 1872, Reeves brought this matter to the AMA, forcing Todd to resign from the Medical Society of WV.
Hupp continued to act in ways that challenged Reeves’ vision, creating a society that was more political than professional and represented the interests of Wheeling (and thus, largely Republican) doctors, rather than all West Virginian doctors, many of whom were still sympathetic to the former Confederacy and not included in society meetings. Disillusioned with the society he had helped found, Reeves, who by this time had also moved to Wheeling, did not run to be re-elected as secretary, leaving the April 1868 meeting before its second day.[15]
During this April 1868 meeting, the rift between Reeves and Hupp also grew. Reconstruction-era politics, namely Reeves’ vocal Democrat opinions and friendships with former Confederates, resulted in a friction between him and Hupp.[16] Furthermore, a dispute over expenses and dues, which continued through 1869, further pushed the two apart.[17] Reeves privately sent a letter to the Society asking for his account to be settled, only to find, a few days later, an article in a local Wheeling newspaper detailing the dispute, publicly discussing his letter and private diplomacy with the Society.[18] Convinced that Hupp was responsible for this article, Reeves was infuriated, but let the matter settle for the time being. The Society appointed a committee to investigate this issue, and in response to their inquiries, Reeves sent a scathing letter that was deemed so offensive that the Society’s Board of Censors decided that Reeves would be expelled unless he apologized. Placing his pride aside, Reeves did indeed apologize, resulting in his membership being fully reinstated by the Society. In response to this latest controversy, Hupp printed these events in the official record and, the day after Reeves’ apology, the Wheeling papers. It took another seven years for Reeves to fully return to the Medical Society of WV and the feud to end.[19]
During this period, Reeves gathered allies in West Virginia’s medical community to oust Hupp from his position of prominence in the Medical Society of WV. His supporters, including Hugh Brock, the professor who started the medical program at the newly established West Virginia University, and George Baird, a Wheeling councilman, encouraged the state society to evaluate Hupp’s conduct in response to Reeves’ official written grievance.[20] Shortly after, Reeves confronted the local Medical Society of Wheeling and Ohio County to expel Hupp. After a period of internal politicking, Hupp did, indeed, lose his position of prominence. In October 1879, the Medical Society of Wheeling and Ohio County selected Reeves to represent them at the upcoming AMA meeting, replacing Hupp, their previous delegate.[21] Shortly after an uneventful AMA meeting, Reeves travelled to Parkersburg for the Medical Society of West Virginia’s 1880 meeting, where the society’s Board of Censors expelled Hupp.[22]
His dispute with Hupp settled, Reeves turned his attention to a larger matter: medical licensure. Throughout the 1870s, state legislatures began introducing licensure laws, though many of them failed or were reduced to weakened and toothless regulations. This, too, was the case in West Virginia; after two unsuccessful tries to pass a licensure law, the MSWV decided in 1875 to encourage the creation of a board of health.[23] The creation of this bill was tabled until 1877, when it was endorsed by both the outgoing WV governor, John Jacob, and the AMA.[24] However, economic turmoil in West Virginia and labor disputes once again put the creation of the state board of health aside, and once again, Reeves and the MSWV had to wait until the convening of the next legislature, in 1881.
By 1881, Reeves had amassed several allies in the legislature to assist his efforts in creating a state health board, most significantly, James Ferguson and Joseph Woods. Ferguson, a shrewd politician known as the state’s Daniel Webster, was the Democrat leader of the WV House of Delegates and a highly influential figure in Gilded Age West Virginia. Similarly, Joseph Woods, a state senator who later became the Speaker of the WV House, held equal prominence.[25] Woods introduced SB 35, an act to create the State Board of Health, while Reeves devoted his time to lobbying the legislature.[26] In March 1881, Reeves triumphed as Governor Jacob Jackson signed the law. This new law stipulated that the WV Board of Health was composed of six “reputable” physicians, two from each Congressional district. Unlike other states, which tended to have weaker boards staffed by unqualified people, West Virginia was the first state with a board run by regular physicians with a reputable medical education.[27] Of course, one of the doctors serving on the first board was Reeves himself.
Most significantly, the law did indeed have a physician licensure section. To ensure that doctors were qualified, they needed to either present a diploma from a reputable medical college, an affidavit that they practiced in the state for more than ten years, or pass an exam administered either by the state board or a county medical board to ensure that they met the strict standards set forth by Reeves and the rest of the Board.[28] While there were several contentious moments between the Board, in its first year, the licensure process was extremely successful. In 1881, 843 physicians were given certificates of licensure, mostly based on diplomas or ten years of practice.[29] This statistic is extremely remarkable, since, per the 1880 census, the state had 939 physicians.[30]
Difficulties with the licensure process began, however, in 1882. In May, Reeves delivered a speech to the MSWV criticizing “cheap diplomas.” As an example, he used an anonymous WV doctor who failed the Board licensing examination, travelled to Columbus Medical College in Ohio, and obtained his diploma without completing any courses.[31] Reeves intended for this criticism to defend his friend, James Baldwin, a founder of Columbus Medical College who had been fired after objecting to the school’s practice of handing diplomas to any student that paid them enough, but it soon spiraled out of his control.[32]
Shortly after Reeves’ speech, the identity of the “anonymous” WV doctor became clear. Arthur Melville Dent of Weston was the only West Virginian in Columbus’ class of 1882. Dent, in response, claimed that Reeves acted in deliberate malice. Furthermore, John Hamilton, owner of Columbus Medical College, claimed in the Wheeling papers that he would send copies of Dent’s final examination to anyone, proving definitively that Dent deserved his degree.[33] Soon thereafter, the Board itself passed criteria that included course requirements for all diploma holders, as well as a stipulation that students must have attended at least 80% of all classes. Given the state of Columbus Medical College, the Board refused to recognize any diplomas issued after 1881, which affected only one doctor: Arthur Dent, who moved to Ohio, which had less strict licensure laws, and practiced there until his death in 1900.[34]
Arthur’s cousin Frank was also affected by Reeves’ strict licensure laws. Frank, who helped his father, William, at his Newburg medical practice and drugstore, began calling himself “Dr. Dent” in 1876 and seeing patients independent of his uncle. When William applied for his license, he also applied for a license for “M. Dent” based on thirty years of practice.[35] By 1882, it became clear: “M [Marmaduke] Dent,” Frank’s grandfather, was bed-ridden after suffering a stroke while Frank had been using the license in his name to practice. Frank, in response to Reeves’ inquiry into this scheme, claimed that he had received a diploma from a Cincinnati medical college and did not receive a response. This, however, was another lie; the local board had rejected Frank’s certificate since it came from an institution that was unrecognized and unqualified.[36] Reeves, infuriated by this deception, had Frank arrested and indicted for violations of the Board of Health Act in November 1882.
With two members of the Dent family having faced scrutiny by Reeves and the Board, the Dents saw a personal vendetta against them. Frank turned to his cousin, Marmaduke (Arthur’s brother), to plead his case. The first person to earn a baccalaureate degree from the newly created West Virginia University (WVU) and the first to receive an MA from WVU, Marmaduke was already a successful lawyer.[37] Marmaduke tried to overturn the indictment, claiming that the law was unconstitutional; however, the court refused, and Frank plead not guilty. Despite this plea, Frank was found guilty by a judge in April 1883 and fined fifty dollars. Marmaduke immediately appealed this decision from the Circuit Court to the WV Supreme Court.[38]
While Frank’s license was at stake, the larger motive of the Dents’ legal arguments was for the overturn of the Board of Health Act. Marmaduke Dent called the law unnecessary, a sham to empower the “charlatan” [Reeves] who lobbied its creation. His biggest legal argument against the Board of Health Act was that it violated the Fourteenth Amendment by enforcing a law that unequally granted citizens the freedom to practice medicine.[39] Despite these arguments, however, the four-member Court unanimously rejected Dent’s appeal. Chief Justice Thomas Green, who wrote the opinion, noted that states had legitimation to regulate commerce and that the law was fair and constitutional.[40]
Despite two losses, Marmaduke was not deterred. A month after losing in West Virginia, he filed to appeal the decision in the United State Supreme Court. It was not until December 1888 that Dent presented his arguments before the Supreme Court, and when he did, he focused entirely on the Due Process Clause of the Fourteenth Amendment.[41] This clause, which stipulates that no state shall “deprive any person of life, liberty, or property, without due process of law,” meant that, according to Marmaduke, Frank was deprived of his medical practice by the state of West Virginia, which Dent argued was his property.[42] Conversely, Alfred Caldwell, Jr., the WV Attorney General, argued that legislatures held legitimate powers to ensure public health, the law did not discriminate against any person or class, and that states had a right to pass laws to prevent “objectionable practices.”[43]
Justice Stephen Field wrote the court’s unanimous decision, which was delivered five weeks later. Field strongly rebuked the assertion that anyone who wished to have the right to practice medicine could, writing that few citizens could judge the skills and education of physicians, and that “for the protection of society,” states were justified to establish licensure laws.[44] Unlike other careers, which, Field wrote, were much more inclusive as to who could practice them, medicine was a special case and governments could regulate the profession differently.[45] Furthermore, the law itself, Field wrote, provided Dent with remedies that he had not used, including a licensing examination.[46] As such, the Board of Health law was constitutional, and the judgements of the state courts were accurate.
While few newspapers outside of Wheeling highlighted this decision, Dent v. West Virginia was extremely important for the future of the medical profession. By upholding WV’s licensure law, the Supreme Court set the precedent for more states to sanction a licensing process which allowed qualified physicians to regulate their profession. The Supreme Court’s decision meant that every state could follow West Virginia in implementing license laws with serious criminal consequences if doctors practiced unlicensed. While this process occurred gradually on a state-by-state basis, eventually, these sorts of strictly-enforced licensure laws spread across America. These laws marked the transformation of the larger medical profession from a chaotic marketplace filled with quacks masquerading as doctors to an industry that was rooted in science, education, and rigorous standards of quality enforced by the government. Thanks to Reeves and many other advocates for licensure and public health, the practice of medicine professionalized, creating the highly-respected and credible field that exists today.