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.

Chapter Three
Homeopathy and zemstvo medicine

3.1 Introduction

Speaking of the development of Russian homeopathy within the period under study, it is not possible to leave such an important phenomena of Russian medical history as zemstvo medicine out of the body of my study¹. In fact, both Russian zemstvo medicine and homeopathy developed rapidly throughout the Russian Empire since the 1870s. Till the 1890s they developed separately. Nevertheless, the paths of zemstvo medicine and homeopathy had to meet earlier or later: it indeed happened in the 1890s. This collision of interests on zemstvo soil might have been predicted with certainty. Russian homeopaths and their lay supporters could not fight regulars within the allopathic state medicine. Therefore, the army and navy, non-zemstvo city hospitals and the medical faculties at the universities were lost to the direct influence of homeopaths. On the contrary, zemstvo medicine was the most appropriate object for homeopathic propaganda. Although the topic of the emergence and development of zemstvo medicine is not of prior importance for my research, I take it into consideration for two reasons. First, Russian zemstvo medicine had no analogous institutions, neither in the countries selected for comparison in my research nor anywhere else. Thus, as an opportune comparison seems impossible, the reader should be acquainted with the original Russian system of offering medical help known as zemstvo medicine. Second, a more detailed knowledge of the peculiarities of zemstvo medicine will be helpful for a better understanding of the development of Russian medicine in general. This knowledge may be important for the reader to grasp the kind of environment in which Russian homeopaths and their supporters were fighting for the spread of homeopathy.

3.2 Russian medicine before the introduction of the zemstvo system

Generally speaking, the system of public health in the early 1860s which had been left unchanged since the Empress Catherine the Great had issued in 1775 the Province (Guberniia) Reform which "codified many of the public health proposals of the 1760s and provided for the systematic extension of professional practitioners and treatment facilities to the provinces"². This law put the matter of the health of non-serf population in the hands of the Health Commissions (so-called Prikazy obshchestvennogo prizrenia). The further slight changes which had been introduced until the zemstvo system period, manifested themselves mainly in the numerical augmentation of the bodies responsible for public health, but without any virtual improvement of the latter.

Until introducing the zemstvo system, public health was in the hands of many bureaucratic institutions, like prikazy obshchestvennogo prizrenia, vrachebnye upravy [the medical boards], komitety obshchestvennogo zdravia [the committees of public health], vedomstva gosudarstvennykh imushchestv i udelov [departments of the State properties and appanages], the Meditsinskii sovet [the Medical Council]. The officials produced a lot of documents without any knowledge of the needs of medicine. The prikazy comprised the governor-chairman, one nobleman, one merchant and one peasant. They had not the slightest idea about medicine but nevertheless were the full managers madhouses and hospitals as well as feldsher schools. From 1845, the committees of public health, comprised of a district marshal of the nobility, a district police officer, a district physician, the mayor and the chief of city police [...] helped them [the prikazy]. Sometimes also the Ministry of State Properties and Appanages, the Boards of the Military settlements, manufacturies and factories, the representatives of the clergy were also involved. The Ministry of State Properties and Appanages hired physicians and assigned means requested for accounts, etc. The hospitals were opened […] without taking into account minimal needs - stink, darkness, lack of clothes for patients and of medical equipment [were common]. Moreover, the rural population did not get any medical support at all, except from the badly taught children from the peasants enlisted [and later appointed as feldshers of the lowest rank]. But even this 'help' was only available for the state and appanage peasants. The serfs were put at the disposal of their landowners³.

Dr. Korzhenevsky, in his work dealing with the analysis of the development of zemstvo medicine in the Tver' province, stressed:

Till the establishment of the zemstvo system, there was no out-patient treatment. In fact, in-patient treatment was absent as well. The hospitals were not medical institutions but just casemates. Only extreme poverty [...] could lead people there...⁴

It is not surprising that these hospitals were usually empty as the people made every effort to avoid hospitalisation. A contemporary medical inspector over medical institutions in the Voronezh district, Dr. Rozov, testifies in the same spirit regarding the infirmaries at the factories:

The infirmaries [attached to] private persons and to factory owners, except of those under Demidov, Stroganov, Yakovlev [...] were only mentioned in order to be included into account. [They are] located inside other installations like stables, kitchens, metal workshops. These infirmaries may be recognized only by the signboard. Otherwise, no one could imagine them to be medical facilities neither by external nor internal conditions. In these infirmaries, protected from inspection by the right of private property, one could hardly speak of caring for patients and intending to help them⁵.

Although a growing number of medical faculties at the universities as well as the improvement of Russian medical science contributed both to the quantity and quality of Russian physicians, this hardly influenced the general situation within the Russian Empire. In fact, the existing medical system brought to nothing all the successes of the university medical education.

In the early 1860s the extant situation was that a significant number of physicians was unable to find a job. The very small number of medical institutions, the non-existent conditions for private practice both in the large cities and in the provinces - caused an artificial surplus of physicians and established poor financial compensations, an especially sensitive item for the young practitioners. In the beginning of the 1860s there was a lack of vacancies even for those graduates who had enjoyed the state support [kazennye stipendii] while they were studying at the universities⁶.

Although the state authorities tried to change this situation by ordering early retirement of physicians who reached the age of about 60 years (depending on the positions they held), 56 fresh graduates of the St. Petersburg Medical-Surgical Academy were left unemployed in 1861. The government was forced to pay a special fellowship of 20 rubles monthly till they found places in which to be employed. The medical faculties were advised "not to hurry up" with new graduates⁷.

One should take into account that this "surplus" of physicians appeared at the period (1861—1865) when, by official reports, in the Kursk province one physicians served 30,000 inhabitants; in the Voronezh province the ratio was 1:38,000, in the Samara province the ratio was 1:53,000, whilst in the Orenburg province as much as 1:70,000!⁸ Another set of statistics I found, refers to the number of medical facilities which were at the disposal of the Ministry of State Properties and Appanages before its reorganization in 1866, when its medical function passed to the zemstvos. This was at the time when the Ministry was the main body responsible for providing medical help to the non-serf population of the Empire. According to these statistics, one hospital served 721,499 inhabitants, one medical man (physician or feldsher) served 101,516 inhabitants, and one smallpox vaccinator served 5,790 of the people. Altogether, there were 269 out-patient clinics, 1200 rural kits, and 170 physicians employed at district and province levels, 51 veterinarians, 1278 feldshers, 21 "wise old women" and 3,276 smallpox vaccinators were hired by the Ministry⁹. One may conclude, having studied these statistics, that a more or less qualified medical help might have been available for the greater part of the population only by chance! It should be also mentioned, that at the same time, even those medical procedures already rooted in Russia, were dangerous for people's health because of their rather bad performance:

In the West, due to a careful organization of smallpox vaccinations, the smallpox morbidity decreased sharply. But in Russia the smallpox vaccinators also inoculated syphilis and other diseases. Naturally, the people ran away from ignorant vaccinators who did not keep elementary hygienic rules while carrying out this simple task¹⁰.

Thus, on the one hand, the population of the Russian Empire, except from a very small part living in the metropolitan cities and who could afford using private practitioners, badly suffered from the lack of medical services. On the other hand, physicians themselves - and those newly graduated physicians especially - faced serious difficulties in finding places to be employed because of the faulty organization of the public health system. These problems, together with others, no less important, had to be solved at least in legislative ways, by the tsarist government in the 1860s.

3.3 The Zemstvo system

The abolition of serfdom in 1861, followed by introducing the zemstvo (from the Russian 'zemlia' meaning land or soil) system of managing state economy in 1864, were really the main events of the "great reforms" put into existence under the Tsar Alexander II the Liberator (1818—1881)¹¹.

As to the personnel of the zemstvos, their members were elected or removed only by the local electorate. According to the "Polozhenie o zemskih uchrezhdeniiah" (The Law of the Zemstvo Institutions) issued in 1864, the zemstvos had a system of proportional representation from the three main social groups: landowners, townspeople and the peasantry.

While aiming first at improving local economic activity (the inefficiency of the latter was the chief problem of the Empire), the government entrusted to the zemstvos the following responsibilities: the maintenance of local roads and administrative buildings; the promotion of public education and public health; the maintenance of hospitals and prisons; the collection of food reserves for time of famine; measures for protecting livestock from various diseases; promotion of local trade and industry; assistance to postal operations; the management of charitable institutions and relief work; the prevention of fires and the administration of fire insurance; the supervision of certain properties previously under the control of other governmental agencies; and the arrangements for conducting local elections.

Some of the above mentioned responsibilities were obligatory, such as the management of charitable institutions, represented by the hospitals, whilst others — the promotion of public health among them — were non-obligatory. When the budget of the charitable institutions was turned over to the zemstvos¹², other kinds of medical activity were not financially supported. In fact, no explanations regarding medical affairs were made in the "Polozhenie". This caused the creation of a unique situation where the elected representatives had no legislative limitation in maintaining medical affairs, except keeping the hospitals and their staffs whom the zemstvos had inherited. The zemstvos were absolutely free to assign or not to assign resources to medicine; whether or not to invite additional physicians, feldshers or other medical staff. It is of great importance to note that the zemstvos were also free to adopt anyone of different medical systems: allopathy or homeopathy. This was indeed a lucky gift for homeopaths. We shall see later whether and to what degree they succeeded to take advantage of it.

3.4 Introducing the zemstvo system of medical services. First steps of zemstvo medicine

Having read many Russian works on the subject of zemstvo medicine, I have been unable to find any critical analysis, neither contemporary nor posterior, of the subject answering the requirements of truly historical investigation, while the researches on the zemstvo system made by the foreign scholars hardly deal with medicine. The interpretation of many facts related to the history of the development of zemstvo medical services indeed seems to be difficult. There is no doubt that zemstvo medicine played an extremely important role in providing medical services Russia-wide, primarily in the rural localities. Nevertheless, I believe that the success of zemstvo medicine could have been incomparably more impressive if zemstvo physicians would have considered attracting intelligent laymen to be supporters in medical matters, including the offering of first aid in emergencies. In reality zemstvo physicians strongly resisted this idea, demanding that only reliable "scientific" medicine and "scientific" methods of treatment be provided by physicians. Yet neither the state of medicine till very late in the 19^th century, nor the capacity of the Russian medical faculties to train new graduates, nor the financial ability of the zemstvo to offer additional, better paid vacancies for physicians, could allow such a "scientific" approach in pre-revolutionary Russia.

During the very first years of the zemstvo system, there were no serious changes in the field of public health. For the most part the zemstvos assigned extremely modest resources for medical activity. The expenditures of maintaining the charitable institutions were covered by the interest obtained from the capital funds which had earlier been received from the government¹³. For a long time no additional physicians were appointed. The zemstvos usually confined their role to a complementary payment for the state physician working at the province or district hospital. The physician had, therefore, to carry out his professional medical duties at the hospital and to control the activity of feldshers and local smallpox vaccinators in the locality.

By 1868, that is to say, five years after the zemstvo system was introduced, [...] as many as 50 district zemstvos from among the 324 which existed then, assigned nothing for medicine. Many zemstvos assigned for medicine extremely pitiable sums, but even those were pretty often left unspent¹⁴.

According to Veselovsky, "There were 288 zemstvo physicians (this is to say, not employed by other, non-zemstvo institutions), or an average of 0,87 physicians per district in 1866"¹⁵. The author shows that the number of physicians at the zemstvos had grown to 2,608 physicians in 1904, or to an average of 7,07 physicians for one district¹⁶. If we focus exclusively on the number of physicians who worked among the rural population, one should take into account that the statistics of Veselovsky also include those physicians who were employed at the district and provincial hospitals. So, according to "The Great Medical Encyclopedia", there were 610 physicians employed at the zemstvos in 1870¹⁷. Although even this number seems to be more than simply pitiful, Zhuk clarifies:

In 1870, among 350 districts having zemstvo medical services, 44 districts had no physician, 131 districts had one physician, 102 districts had two physicians, 53 districts had 3 physicians [...]. However, being aware that at least one physician was employed at each of the district hospitals [...] we may conclude that hardly more than 150-200 physicians were working in the rural localities¹⁸.

Thus, during the very first years of the zemstvos' existence there were few changes in the medical policy of the local zemstvo authorities and the number of physicians employed at the zemstvos increased slowly. Nevertheless, at the same time the general improvement of the economic situation in the Russian Empire stimulated the processes of further urbanization. In its turn, this increased the demand for physicians, both for those who practiced privately and for those hired by different institutions, in rapidly growing cities¹⁹, whilst many physicians who were disappointed with the poor conditions of their service (poor salaries, many different duties, which increased during the period of swift urbanization) had abandoned the practice of medicine at the end of the 1860s. In 1871, only eight years after the zemstvo system had been introduced, Dr. Yacov Chistovich²⁰ wrote:

There is no department which is not complaining of the impossibility of filling the vacant places for medical staff. The Military Department has about 200 of such vacancies. [Even] the Ministry of Internal Affairs with its table of organization of staff established at the time of Empress Elizabeth, seems to be left without physicians at all. Also the zemstvos [...] are experiencing serious difficulties seeking physicians. Thus, the zemstvos are being forced to grant their fellowships to those studying medicine at the universities²¹.

The increasing demand for physicians during the 1870s led to the gradual improvement of the position of the employees of the medical services. Thus, this indicates that the zemstvo authorities were actively seeking new physicians by 1871. Eight years to formulate and implement new policy was certainly not a long time in the context of Russia.

Yet the analysis of these statistics leads to the conclusion that medical support in the rural localities seemed to be absolutely unsatisfactory at the beginning of the 1870s. As before, qualified medical help was still unavailable for common rural people. Chemistry Prof. Alexander Engelhardt (1832—1893), who had been exiled by the tsarist government to a village in the Smolensk province because of his political views, and who lived there about 20 years, shares with his readers his observations made in 1872:

There is a disastrous situation regarding treatment, not only for a peasant, but also for an impecunious landowner in the case of disease in the village. The nearest physician is situated in a city 30 versta [about 32 km] away. If you become ill you will send for a physician from the city. One will send a troika [three horses put together] or at least a suitable carriage. A physician's visit costs 15 rubles, 10 rubles minimum. Then you have to return the physician to the city and buy there [the prescribed] medicines. [...] Impecunious landowners, small tenants, priests [...] and so on, though relatively prosperous in comparison with the peasants, cannot afford to send for physicians. Mostly they call to help those feldshers in their locality who had previously managed dispensaries and pharmacies for the rich landowners during the serfdom period. But even such feldshers are too expensive for the peasants, as a feldsher's service has to be paid with 3 [...] or 5 rubles. Only the most prosperous peasants turn to feldshers. The others have recourse to self-educated feldshers [...], old women and old men as well as anyone who has minimal understanding of healing²².

Reflecting about the reasons which led to this situation, I presume that the zemstvos, which had just started their independent economical life, could not exactly evaluate what proportion of their budget could be assigned for medicine after the fulfilment of the zemstvos' obligatory responsibilities. Being afraid of being accused of malpractice, the zemstvos were fearful of financing any non-obligatory responsibilities. As a result of this inaction which lasted until the end of the 1880s, there were many places where the two groups of zemstvo institutions — the uezdnoe (district) and gubernskoe (province) zemstvos could not decide on sharing responsibilities and financial co-operation with each other in providing medical facilities (hospitals at first) in the localities. Although by the 1890s the problem lost its acuity, the financial details were left unsolved until the Bolshevik Revolution of 1917²³.

I briefly described above the development of zemstvo medicine during the first 5-6 years of its existence primarily to give the reader a general picture of the obstacles that existed in the provision of medical help in the rural localities. The history of further developments of zemstvo medicine is beyond the scope of this study. Gradually the problems mentioned above which were connected with the lack of trained medical staff and insufficient financing found a partial solution (during the 1880s and onward). Nevertheless, the main medical problem of the Empire, i.e., providing the rural population with qualified personnel, such as physicians, did not lose its sharpness until the Bolshevik period:

[...] At best only 30 percent of Russia's civilian physicians practiced in rural areas during the pre-1914 period, while almost 80 percent of the country's total population lived in the countryside. The shortage of physicians was thus an almost exclusively rural problem, a fact that absolute figures illustrate better than percentages. In 1913, for example, there were only about 7,000 civilian physicians employed in rural practice throughout the Empire. Here they were expected to serve a rural population in excess of one hundred million people. In cities, the ratio of physicians to population in 1913 was 1:1,400, which was roughly equivalent to that in other European cities. In rural areas, however, the average ratio was 1:20,300. In many outlying provinces, of course, this ratio was much larger²⁴.

Another set of problems had not been solved even until the zemtsvo system was abolished by the Bolsheviks. Homeopaths were well aware of those problems and used them in their anti-allopathic propaganda. These problems will be discussed separately in the next chapter.

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.