Editor's Note Child Psychiatry and the History of Medicine in America We fear our image is bad. Competition in the marketplace is fierce. Worse, the public does not understand what we do-or how we differ from other health professionals. Even we do not seem to agree among ourselves about what models we should use, or what constitutes appropriate treatment! A unique predicament in American medicine? Not at all. It is a situation that has existed in the past-in the mid to late 1800s to be exact. American medicine at the time was engaged in a prodigious struggle to find its identity in the face of competing political and economic forces, and the average practitioner was faring very badly in all of this. The situation has been described in a lively and colorful series of articles originally published in the Journal of the American Medical Association and republished as a monograph (King, L. S., American Medicine Comes of Age, Am. Med. Assoc., 1983).Child psychiatristswho read the accounts should be particularly interested in the answers to two questions: how did physicians in America come to fare as badly as they did, and how did they ultimately find a solution to their woes? Medicine in the early part of the nineteenth century in America was greatly influenced by the prevailing model of training and practice overseas. There was, in Europe, a two-tiered system of medical care in which the rich sought help from the accredited physicians and the poor sought help from apothecaries or irregular practitioners. Given the relatively poor scientific understanding of disease at the time, such a system might not have been as inequitable as it may seem to us today. In America, moreover, medical schools were accredited by the state legislatures, in a process that was politicized and largely out of the hands of physicians themselves. Such schools were money-makers, founded regardlessof need or scholarship. More graduates meant larger profits, and their owners were motivated to admit and graduate any and all comers. Even among well-trained physicians (graduates of European universities or of the small number of first-rate American medical schools) there were serious problems. The growth of cults-organizations founded by charismatic individuals proposing various models to explain illnessand its treatment-led to rancorous bickering and feuding within the existing medical societies; consequently, the societies became largely ineffective in influencing the legislaturesand the public upon which their economic fortunes depended. The cults existed both within and without organized medicine. Each made known its claims to the public through advertising while demanding that the legislatures recognize its brand of treatment as meriting sole support, always, of course, in the name of best patient care. By the 1840s, the state legislatures had grown tired of the holy exhortations of the various brands of practitioners. They saw the claims as largely self-serving and as failing to address the fact that there were more than a few incompetents among the ranks of the so-called elite. In 1844, the New York State Legislature proclaimed the era of "free trade in medicine": all medical licensure was to be abolished; anyone was to be allowed to practice and anyone could call himself a physician. This move spread across the land. This was a disaster for organized medicine in America. Poor quality medical schools continued to multiply, and by the 1860s medicine was filled with numerous clinical practitioners, many of whom held outlandish beliefs and few of whom could earn a living. How was this state of affairs resolved? Largely through two reciprocal developments: the rise of medical science, and the banding together of the best practitioners from the previously warring groups. The sciences of bacteriology, pathology, and chemistry transformed the practice of medicine. For the first time disease could be understood in terms of germ theory, and diagnosis could be made using the microscope and the chemical laboratory. It became easier for well-trained physicians to point to what good medical education and practice must entail and more difficult for the diploma mills to maintain their reputations. Specialty societies began to stress a greater degree of professional excellence, so that excellence, per se, rather than professional affiliation, became important. Judicious approaches were made by the medical societies to the legislatures, stressing what competent physicians could do with the new sciences. By 1900 medical licensure laws satisfactory to the profession had come into being, and by 1915 a program for the reformation and revitalization of medical education was in place. What can this history tell us as child psychiatrists? It suggeststhat moral exhortation and rectitude, no matter how correct, are not enough. Appeals for reform based upon high principles can easily be lost amid the economic realities of state and federal budgets. If we fight among ourselves and see all competitors-both within our specialty and from other disciplines-as enemies who must be annihilated no matter what their individual competency, we will not be listened to. Elitism based on scientific principles, compassion, and good sense has its place. It will take the best people working with the best science to solve our problems, and this won't happen overnight. P.E.T. 408