CC BY
24DOI 10.23859/2587-8352-2017-1-1-2 UDC 94 (475.5): 61
Tatyana Shestova
Doctor of Historical Sciences, Associate Professor, Perm Branch of the Presidential Academy of National Economy and Public Administration
Perm, Russian Federation [email protected]
The development of health in Perm and Vyatka provinces (guberniyas) at the end of 19th - early 20th centuries
Abstract. The article is devoted to the history of health care development in the context of zemstvo (county council) activities in Perm and Vyatka provinces (guberniyas). Significant archive materials are considered, with the use of reporting materials of zemstvos; the material and technical base is discussed, as well as personnel support and the description of process of training physicians at the expense of zemstvos. Training of dedicated personnel for the benefit of the region is described in great details, which is related to a certain stage in the development of zemstvo medicine; questions of participation of zemstvo health workers in the public life of Russia are also covered.
Keywords: history of health care, Perm and Vyatka province (guberniya)
Introduction
The turn of the 19th-20th centuries was a significant stage in the change of directions of zemstvos' activities, shifting from anti-epidemic work to permanent contact with the population. Zemstvos, established in Perm and Vyatka provinces or governo-rates (guberniyas), belonged to the largest zemstvos of Russia pursuing a long-term policy of creating a system of medical care directly for the population. The objectives of this study are to research the changes in the types of medical care, analyze the qualitative dynamics of professional skills of physicians and consider the role of zemstvos in solving the problems of public and urban medicine.
Even in the first half of the 19th century, Perm province was the leading region in Russia, in which the so-called 'factory medicine' was developed. Hospitals were part of the infrastructure of the cities with factories, so modern research on the history and economy of the Ural noble families invariably, albeit briefly, consider this topic1.
1 Mezenina T.G., Mosin A.G., Mudrova N.A, Nekljudov E.G. Rod Stroganovykh [The family of the Stroganoffs]. Yekaterinburg, 2007; Pirogova E.P., Neklyudov E.G., Larionova M.B. Rod Turchaninovykh [The family of the Turchaninovs]. Yekaterinburg, 2008; Mosin A.G. Rod Demi-dovykh [The family of the Demidovs]. Yekaterinburg, 2012; Chagin G.N. Rod Shuvalovykh [The
Bringing hospitals into the architectural appearance of the city-factories was investigated by R.M. Lothareva . Many of these hospitals were transferred by their owners to zemstvos after the abolition of the serfdom. In the local history publications and reviews of the public buildings special attention is paid to the hospital premises . The source of the research mainly comes from the journals depicting meetings of Perm and Vyatka provincial assemblies, which reflect discussions on several current problems facing the zemstvo medicine of the Ural provinces. Some facts were published in the editions associated with the current statistical data4.
At the beginning of the 20th century, there appeared large survey works on the history of zemstvos, timed to coincide with the jubilee dates. As a leading edition, it is appropriate to name B. Veselovskii's book 'The history of the zemstvo for forty years'5. By the tercentenary of the Romanovs' house in Russia, a massive collection of statistical and historical information about the country was conducted. Per the results of the sanitary-hygienic exhibition, Z.G. Frenkel prepared an impressive work 'Essays on zemsky medical and sanitary affairs'6. The material for Perm province was reflected in the writings of the local historians and was re-issued at the end of the 20th century, which indicates its undoubtful value for the researcher7.
In the first decades of its existence, the Soviet historiography was guided by Lenin's assessment of zemstvo as "the fifth wheel in the cart of the Russian government," but by the mid-20th century, the negative attitude towards zemstvos had subsided. The history of medicine was studied in many specialized universities, and cono
ferences on this subject were held . The main attention was paid to the capital region,
family of the Shavalovs]. Yekaterinburg, 2013; Mikitjuk V.N., Mosunova T.P., Nekljudov E.G. RodPoklevskikh-Kozell [The Poklevsky-Kozell family]. Yekaterinburg, 2014.
2 Lotareva R.M. Goroda-zavody Rossii, XVIII - pervaia polovina XIX veka [City-factories of Russia. 18th century - the first half of the 20th century]. Yekaterinburg, 2011.
3 Zavialova E.N. Zdravookhranenie v Lys'venskom okruge [Public health in Lysva district]. XIIISmyshliaevskie chteniia [13th Smyshliaev Readings]. Perm, 2013, pp. 103-108; Vshivkov A.A., Dmitrieva E.V., Melyukhin G.M. Po Komi-permiatskomu okrugu. Kratkii putevditel' [Along the Komi-Permyak district. A Short Guide]. Perm, 2016. 48 p.
4 Beresnev F.I. Kratkii ocherk narodnogo zdraviia i postanovki meditsinskogo dela v Viatskoi gubernii [A short essay on public health and arranging medical affairs in Vyatka province]. Statistical Yearbook of Vyatka Province for 1899. Vyatka, 1900.
5 Veselovskii B. Istoriia zemstva za sorok let V 4 t. T. 1 [History of zemstvos for forty years in 4 vol., vol.1]. St. Petersburg, 1909.
6 Frenkel Z.G. Ocherki zemskogo vrachebno-sanitarnogo dela (Po dannym rabot, proizveden-nykh dlia Drezden. i Vseros. gigien. vystavok) [Essays on Zemsky medical and sanitary affairs]. St. Petersburg, 1913.
7 Trapeznikov V.N. Letopis' goroda Permi: K 275-letiiu osnovaniia [Chronicle of the city of Perm]. Perm, 1998; Verholantsev V.S. GorodPerm', egoproshloe i nastoiashchee: Krat. ist.-stat. ocherk; Vstup. st. i primech. T.I. Bystrykh [The city of Perm, its past and present: Short historical -statistical essay; introductory article and notes by T.I. Bystrykh]. Perm, 1994.
8 Zabludovskii P.E., Zhuk A.P. Stoletie obshchestvennoi meditsiny v Rossii [Centenary of public medicine in Russia]. Ocherki istorii russkoi obshchestvennoi mysli [Essays on the History of
Petersburg and Moscow provinces. Only in the 1990s, the generalizing works of V.T. Selezneva and S.A. Kukoviakin appeared, describing the situation with the medicine in Perm and Vyatka provinces, respectively9. Unfortunately, the authors were doctors of medical sciences and therefore, were unable to use some of the documents available to be read by historians.
Useful theoretical and methodological data are contained in the works of some foreign authors who are looking to study the problems of sanitation and public medicine both in European and American cities10 and in late imperial Russia11. In general, the literature on public medicine is very extensive, but the task of this study is related to a narrow segment that deals only with Perm and Vyatka provinces.
Main body
After the abolition of serfdom, the staff of the Urals physicians was changed quite
a bit: a large layer of medical pupils disappeared, and former serfs began to take ex-
12
aminations for a doctor's degree outside the Urals . The healer disciples were replaced by paramedics, and in the 1880s there appeared an institute of nurses of mercy.
Zemstvo and city reforms marked the development of local self-government and orientation to wider segments of the population, previously hardly ever served by
Russian Public Medicine. Digest of Articles]. Moscow, 1955; Kanevskiy L.O., Lotova E.I., Idelchik H.I. Osnovnye cherty razvitiia meditsiny v Rossii vperiod kapitalizma [The main features of the development of medicine in the period of capitalism]. Moscow, 1956; Strashun I.D. Russkaia ob-shchestvennaia meditsina vperiodmezhdu dvumia revoliutsiiami 1907-1917 [Russian public medicine in the period between the two revolutions of 1907-1917]. Moscow, 1964.
9 Selezneva V.T. Ocherki po istorii meditsiny v Permskoi gubernii [Essays on the history of medicine in the Perm province]. Perm, 1997; Kukoviakin S.A. Zemskaia meditsina v Viatskoi gubernii [Zemskaya medicine in Vyatka province]. Kirov, 1996.
10Bernhardt C. (ed.) Environmental problems in European cities in the 19th and 20th centuries. Münster, 2011; Schott D., Luckin B, Massard-Guibaud G. (eds.) Resources of the city: contributions to an environmental history of modern Europe. Aldershot, 2005; Douglas I., Hodgson R., Lawson N. Industry, environment and health through 200 years in Manchester. Ecological Economics,, 2002, no. 41, pp. 235-255.
11 Bradley J. Obshchestvennye organizatsii v tsarskoi Rossii: nauka, patriotizm i grazhdanskoe obshchestvo [Public organizations in tsarist Russia: science, patriotism and civil society]. Moscow, 2012; Friedgut Theodore H. Iuzovka and Revolution. 2 vols. Princeton, 1989; Hutchinson J.F. Tsarist Russia and the bacteriological revolution. Journal of the History of Medicine, 1985, vol. 40, pp. 420-439; Henze C.E. Disease, health care and government in late imperial Russia: life and death on the Volga, 1823-1914. Leningrad, 2011; Mazanik A. Sanitation, urban environment and the politics of public health in late imperial Moscow: A dissertation in History for the degree of Doctor of Philosophy. Budapest, 2015.
12 Uzunova N.M. Iz istorii formirovaniia krepostnoi intelligentsia [From the history of formation of serf intelligentsia]. Ezhegodnik Gosudarstvennogo istoricheskogo muzeia [Yearbook of the State Historical Museum]. Moscow, 1960, p. 33.
doctors: peasants, women and children. Many of Uralic natives began to receive education through targeted scholarships at the local paramedic schools.
In the health management system, the main body was the Medical Board - from the second half of the 19th century it was renamed as a department. Its staff had undergone some changes. If in the first half of the 19th century it included an operator (a surgeon), an inspector and an obstetrician, then in the early 20th century there would
13
be an inspector, an assistant and a pharmacist . The obligations of a zemsky doctor were also very extensive. They were responsible for hiring and dismissing staff, supervising the site, monitoring paramedics and midwives, attending the board meetings, preparing all types of reporting and drafting medical and topographic descrip-
14
tions .
In pharmacies, there was a branched structure. In the state pharmacy service, in the first half of the 19th century various specialists worked: pharmacists, pharmacist assistants (comrades) and apothecary students; sometimes materialists and laboratory assistants helped for the preparation of chemical medicines15. Apothecary students first received general medical education, and after some time it became specialized. This was done so that when working in remote factories or mines, a person could combine the posts of a medic and an apothecary student16.
Towards the end of the 19th century, a pharmacist would work in a medical department; whereas provisors (chemists) worked directly in the pharmacies themselves. Sometimes in the reports of the governors, the terms changed places, but pharmacists were always opposed to qualified pharmaceutical chemists (provisors). Only towards the end of the 19th century, women could work in the pharmacies. Thus, in 1897 Perm provincial zemstvo sent a pharmacy student Y.K. Chekhovskaya to Kazan to take an exam, which lets us suggest that she had already worked in a pharmacy
17
and was familiar with pharmacology . The staff of the pharmacies differed from the hospitals by their continuity: often a person could work all his life in one workplace, in the same pharmacy.
By the beginning of the 20th century, the approach to the purchase of specialized literature had changed. Zemstvo moved to the creation of libraries in hospitals, where the funds could be used by a larger number of personnel, instead of meeting the re-
13 Ustav vrachebnyi [Statutory Medical]. Polnyi svod zakonov Rossiiskoi imperii [A Complete Set of Laws of the Russian Empire]. Book 2. Vol. 9-16. St. Petersburg, 1911, p. 3086.
14 Zhurnaly 9 ocherednogo permskogo uezdnogo zemskogo sobraniia 1878 g. s dokladami permskoi uezdnoi zemskoi upravy [Journals of the 9th Regular Perm District Zemstvo Assembly in 1878 with Reports of Perm County Zemstvo]. Perm, 1879, pp. 435-437.
15 State archives of Sverdlovsk region (SASD). F. 643. Op. 1. D. 1102. L. 43.
16 Russian State Historical Archive (RGIA). F. 880. Op. 1. D. 409. L. 39; GASO. F. 101. Op. 1. D. 578. L. 15.
17 State Archives of Perm Krai (GAPK). F. 44. Op. 4. D. 1. L. 10.
quirement of buying literature by a county or a city doctor. Medical periodicals be-
18
came more widely available .
To address the requirement of new medical knowledge for the doctors of Perm province, a specialized medical library in Kazan was of great importance. Scientific visits of doctors to the university towns initiated by zemstvo allowed them to get acquainted with the novelties of the literature.
At the beginning of the 20th century, in Perm and Vyatka provinces special attention was paid to training of female doctors as per zemstvo personnel policy. Since 1897, in St. Petersburg the Women's Medical Institute began to work, where future doctors were trained. Zemstvos considered female doctors as a reserve of personnel for working with peasant and female population in the national regions19, because women too often did not seek help from male doctors due to being ashamed and embarrassed. Although maternity wards operated in provincial hospitals since the time they were established, the actual obstetric work began only at the turn of the 19th and 20th centuries20. The local governments also used the work of female doctors to create nurseries. One should note that in the central provinces of Russia, nurseries were
created to improve the life of female workers, whereas in other provinces of the coun-
21
try, the newly created nurseries were orientated towards peasant women .
18 State Archives of Orenburg Region (GAO). F. 15. Op. 1. D. 6. L.162; GAPK. F. 44. Op. 4. D. 12.L. 14.
19 Central State Historical Archives of St. Petersburg (TSGIA SPb). F. 224. Op. 1. D. 1747.
L. 1.
20 Dashkevich L.A. Stanovlenie akushersko-ginekologicheskoi sluzhby na Iuzhnom Urale [Formation of obstetrical and gynecological service in Southern Ural]. Materinstvo i ottsovstvo skvoz' prizmu vremeni i kul'tur: Materialy Deviatoi Mezhdunarodnoi nauchnoi konferentsii RAIZhI i IEA RAN, 13-16 okt. 2016, Smolensk: v 2 t. [Maternity and Paternity through the Prism of Time and Cultures: Proceedings of the 9th International Scientific Conference of Russian Association of Reserachers of Female History (RAIZHI) and Institute of Ethnology and Anthropology of Russian Academy of Sciences. 13-16 October 2016, Smolensk: in 2 volumes], general editor N.L. Pushka-reva, N.A. Mitsyuk. Vol. 1. Moscow, 2016, pp. 217-219.
21 Severtseva O.V. Materi-rabotnitsy promyshlennykh predpriiatii vo vtoroi poloviny XIX-nachale XX vekov [Mothers-workers of industrial enterprises in the second half of the 19th and early 20th centuries]. Materinstvo i ottsovstvo skvoz' prizmu vremeni i kul'tur: Materialy Deviatoi Mezhdunarodnoi nauchnoi konferentsii RAIZhI i IEA RAN, 13-16 okt. 2016, Smolensk: v 2 t. [Maternity and Paternity through the Prism of Time and Cultures: Proceedings of the 9th International Scientific Conference of Russian Association of Reserachers of Female History (RAIZHI) and Institute of Ethnology and Anthropology of Russian Academy of Sciences]. 13-16 October. 2016, Smolensk: in 2 vol], general editor N.L. Pushkareva, N.A. Mitsyuk. Vol. 2. Moscow, 2016, pp. 140-143; Fro-lova I.V. Sezonnye iasli-priiuty kak forma prizreniia detei na territorii Novgorodskoi gubernii v kontse XIX v. [Seasonal nursery-shelters as a form of charity for children in Novgorod province at the end of the 19th century]. Patriotizm i grazhdanstvennost' v povsednevnoi zhizni rossiiskogo ob-shchestva (XVIII-XXI vv.): materialy mezhdunarodnoi nauchnoi konferentsii 14-16 marta 2013 g. [Patriotism and Citizenship in the Everyday Life of Russian Society (18th-21st Centuries)] General. Ed. V.A. Veremenko]. St. Petersburg, 2013, pp. 40-45.
If in the second half of the 19th century, the best staff was concentrated in Perm province hospital, by the beginning of the 20th century, it was decided to send doctors from the provincial hospitals to the county ones. At the same, it can be noted that Alexandrovsky hospital in Perm province introduced dedicated experts (a total of up to five-six specialties). The innovation would be the use of assistance of external students22.
Until late 19th century, zemstvos had the problem of combating 'feldsherism', when in rural areas doctors were deliberately replaced by paramedics. In Perm province, zemstvos reduced medical rates in the following uyezds (districts): Perm, Verk-
23
hoturye, Ekaterinburg, Irbit, Krasnoufimsk, Cherdyn, Shadrinsk . The doctors were assigned only anti-epidemic work. The remaining doctors strongly opposed the independent practice of paramedics, seeing them as opposition, although the reason was the financial policy of zemstvos.
'Feldsherism' was associated with the 'traveling system'. The main functions of the service were assigned to paramedics; doctors would come to consult them several times a month. Mild cases were treated in the villages, whereas difficult cases would be referred to the city. This system allowed zemstvos to save on doctors' salaries. The doctors themselves insistently demanded a 'stationary' treatment system, when the hospital would be in the center of a medical district. It was possible to transfer to the stationary system only at the beginning of the 20th century; which was replacing,
24
as far as possible, paramedic centers for medical ones . As B. Veselovsky noted, "three-four feldsher's stations were replaced by one doctor, and this almost did not
25
increase any zemstvo's expenditure estimates" .
In early 20th century, the relationship between doctors and paramedics was assessed more calmly by the contemporaries. It became obvious that it was impossible to provide comprehensive medical assistance to all sites; paramedics were more trusted by women and children as they were approached territorially and were more evenly distributed26.
22 Zhurnaly permskogo gubernskogo zemskogo sobraniia 28 chrezvychainoi sessii s dokladami upravy i komissiei semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 28th Emergency Session with Reports of the Council and the Commission to the Meeting]. Perm, 1896, p. 63; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 37 ocherednoi sessii i doklady komis-sii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 37th Regular Session and Reports of Commissions to this Meeting]. Perm, 1907, p. 78; GAPK. F. 44. Op. 4. D. 18. L. 20, 40.
23 Veselovskii B. Istoriia zemstva za sorok let [History of zemstvos for forty years].
St. Petersburg, 1909, p. 334.
25 State archive of Kirov region (GAKO). F. 616. Op. 6. D. 136. L. 49.
25 Veselovskii B. Istoriia zemstva za sorok let [History of zemstvos for forty years]. St. Petersburg, 1909, p. 338.
26Beresnev F.I. Kratkii ocherk narodnogo zdraviia i postanovki meditsinskogo dela v Viatskoi gubernii [A short essay on public health and arrangement of medical affairs in Vyatka province]. Statistical Yearbook of Vyatka Province for 1899. Vyatka, 1900, p. 261.
Zemstvo recruited more doctors; the increasing number of visits to doctors led to the habit of seeing a doctor among the population, and there were not enough doctors in the province of Perm again. 'Feldsher' staff was more permanent B. Veselovsky noted that in 1904 doctors of Perm province accepted only 63.9 % of patients and called it 'disguised medical assistance'. Since 1909, Vyatka provincial zemstvo preferred to train "paramedics - both men and woman - for holding positions for inde-
27
pendent paramedic posts" .
In Perm province, in the wake of the revolutionary events of 1917, the paramedics
demanded that they be given the right to "practice their knowledge and their special
28
or acquired experience" . The Society of Physician Assistants fought for benefits to
29
be received by paramedics upon admission to medical faculties .
During the Russo-Japanese War, Perm provincial zemstvo offered job retention for
30
the mobilized doctors . In the First World War (since 1915), it required the government to send civilian doctors back to the province from the battle-fields. In 1917, an appeal followed, addressing the Provisional Government to return "all medical personnel from their captivity, as individuals belonging to the ranks of the Red Cross,
31
per resolution of the Geneva Conference" .
By 1915, the medical contingent of Perm province was twice as large as the composition of a similar service in Vyatka province and four times bigger than that in Orenburg province. At the same time, the number of paramedics in Vyatka and Perm provinces was comparable; both zemstvo provinces significantly outstripped Orenburg province in terms of paramedic numbers.
The reason for this difference lied in the underlying training system. In Orenburg province, the staff was recruited with the participation of the Rules Committee; whereas in Perm and Vyatka provinces, provincial and district zemstvos took over the training of personnel in the said provinces. There were several ways of training. 'Feldshers' were trained in paramedic local schools, whereas doctors were trained in universities relying on scholarships for residents; dedicated specialists were trained through the system of external studying. Any zemsky doctor could improve their qualification through scientific or field trips, attendance at medical congresses and exhibitions.
Training of doctors based on scholarships was in effect since the very start of existence of Perm provincial zemstvo. Uyezd zemstvos also took part in it for a short pe-
27 GAKO. F. 616. Op. 1. D. 200. L. 34.
28 GAPK. F. R-79. Op. 1. D. 2. L. 1.
20 GAPK. F. R-79. Op. 1. D. 7. L. 5, 29.
30 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 35 chrezvychainoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly, the 35th Emergency Session and Reports of Commissions to this Meeting]. Perm, 1904, p. 20.
31 GAPK. F. 143. Op. 1. D. 704. L. 15-19; F. R-79. Op. 1. D. 2. L. 10.
riod, but by the beginning of the 20th century, all scholarships were administered by
32
the provincial zemstvo .
Vyatka provincial zemstvo permanently financed 11 scholarships (per number of uyezds (counties) in the province) for female doctors at Women's Medical Institute
33
and Bestuzhev courses; Perm provincial zemstvo prepared new doctors as needed .
Both provincial zemstvos often faced the refusal of graduates to work off the scholarships. In the documents of Vyatka zemstvo, the following quotation revealed this fact: "they say that peasants are irresponsible, but now we those who have received a higher education are even worse than that"34. The students of Perm zemstvo, in their turn, were unhappy comparing the payers "with a cash register providing loans but requiring repayment for obligations signed by a hungry student when they could sign
35
any commitment" . Former students were asked to pay the money back in installments in case of refusal to work; an effective measure was the publication of the names of 'refuseniks' in the central press. By 1910, in the province of Perm 58 people repaid the borrowed funds (8 %). The number of those who volunteered for repayment was 55 (48 %o); 9 %o paid through their legal advisers, 45 people did not pay their fees at all (35,4 %)36.
The innovation of Perm province in the early 20th century was the introduction of
37
external studies . County doctors were given the opportunity to obtain their profile specialization through a provincial hospital, and the latter received a medical resident with minimum payment. An extern in the first year of training received 600 rubles, in the second year - 900 rubles, which was one third and one half of the salary of a doc-
32 Zhurnaly 9 ocherednogo permskogo uezdnogo zemskogo sobraniia 1878 g. s dokladami permskoi uezdnoi zemskoi upravy [Journals of the 9th Regular Perm District Zemstvo Assembly in 1878 with Reports of Perm County Zemstvo]. Perm, 1879, p. 411; Zhurnaly permskogo gubernsko-go zemskogo sobraniia 19 ocherednoi sessii s dokladami komissii [Journals of Perm Gubernia Zemstvo Assembly of the 19th Regular Session with Reports of Commissions]. Perm, 1889, p. 4950.
33 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 35 chrezvychainoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 35th Emergency Session and Reports of Commissions to this Meeting]. Perm, 1904, p. 156; The Reports of Perm Zemstvo Board to the Provincial Zemstvo Assembly of the 41st Regular Session and the Reports of the Commissions to this Meeting. Perm, 1911, p. 1; GAKO. F. 616. Op. 1. D. 133. L. 1546.
34 GAKO. F. 616. Op. 1. D. 194. L. 68.
35 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 36 ocherednoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 36th Regular Session and Reports of the Commissions to this Meeting]. Perm, 1904, p. 260-261.
36 Zhurnaly Permskoi zemskoi upravy gubernskomu zemskomu sobraniiu 41 ocherednoi sessii i doklady komissii semu sobraniiu [Journals of Perm Zemstvo Board to the Provincial Zemstvo Assembly of the 41st Regular Sessions and Reports of Commissions to this Meeting]. Perm, 1911, p. 673.7
37 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 30 ocherednoi sessii [Journals of Perm Gubernia Zemstvo Assembly of the 30th Regular Session]. Perm, 1900, p. 136.
38
tor, respectively . Externs had the right not to participate in the anti-epidemic work; their main responsibility was their medical specialization. In 1902, Perm provincial zemstvo tried to transform the provincial hospitals into clinics, which meant significant reduction in the number of beds. This was avoided owing to externs. Their train-
39
ing was called the business of the whole province .
After five years of such practice, the recruitment of externs ceased. Perm provincial zemstvo planned to expand the contacts with the capital's medical faculties by inviting students to practice, but in 1908, at the convincing requests of the administration of provincial Alexandrovsky hospital, the externship returned40.
Perm and Vyatka provincial zemstvos exercised the doctor's right to a scientific business trip with great difficulties. It was only possible to claim for further training in Vyatka province if the doctors had at least three years of experience in zemstvo service, and the in-service training lasted no more than six months with partial repayment of expenses. It was more difficult to resolve the issue of redistributing responsibilities between doctors for the periods of absence of one of the personnel. Only in 1915, the doctors were paid bonus for this type of extra work. Further training took place in university towns and specialized clinics, which gave positive results, because "modern representations in scientific centers were continuously and very rapidly moving forward," as the reports suggested41.
In the first decade of the 20th century, both provincial zemstvos defined the minimum experience for a doctor, as well as the period during any trip to obtain further qualifications. If uyezd (county) doctors could be trained at a provincial hospital, psychiatrists as well as sanitary and epidemiological doctors were sent first and fore-
42
most beyond the boundaries of Perm province .
38 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 32 ocherednoi sessii [Journals of Perm Gubernia Zemstvo Assembly of the 32nd Regular Session]. Perm, 1902, p. 230.
39 Ibid, p. 221, 229.
40 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 32 ocherednoi sessii [Journals of
Perm Gubernia Zemstvo Assembly of the 32nd Regular Session]. Perm, 1902, p. 91; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 41 ocherednoi sessii i doklady komissii semu sobra-niiu [Journals of Perm Provincial Zemstvo Assembly of the 38th Regular Session and the 39th Extraordinary Session]. Perm, 1908, p. 93.
42 GAKO. F. 587. Op. 10. D. 240. L. 53; F.616. Op. 1. D. 135. L. 767.
42 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 32 ocherednoi sessii [Journals of Perm Gubernia Zemstvo Assembly of the 32nd Regular Sessions]. Perm, 1902, p. 178; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 41 ocherednoi sessii i doklady komissii semu sobra-niiu [Journals of Perm Gubernia Zemstvo Assembly of the 41st Regular Sessions and Reports of Commissions to this Meeting]. Perm, 1911, p. 117; GAKO. F. 616. Op. 6. D. 106. L. 103; Op. 1. D. 200. L. 92.
In Perm province, it took a long time to determine the length of the service allowing to qualify for a business trip, but that practice stopped for four years with the right of a repeated departure, and an internship was allowed abroad43.
Thus, the developers of vaccines and sera V.A. Khomyakov and I.V. Belorusov went to study on several occasions; whilst the doctor of Perm province hospital A.F. Tsander was on a study course abroad. Female doctors E.P. Serebrennikova and O.I. Skvortsova became heads of the eye and maternity departments respectively after their specialized internships44.
In addition to zemstvo medicine, the 'great reforms' resulted in appearance of urban medicine; however, its role was too small. At the turn of the centuries, provincial zemstvos spent millions struggling against epidemics, whereas cities would spend a little over forty thousand rubles for that purpose. In any provincial town, there were state and zemsky as well as free-practicing physicians, i.e. a large city avoided spending on hiring city doctors by using someone else's medical expertise. The opposition of provincial and district central zemstvos was typical of Perm and Vyatka. The counties flatly refused to open uyezd hospitals in the provincial cities. In Perm province, there were two or three persons representing public town doctors, except for 1903 and 1904, when nine and seven people worked respectively. In the following period, public town doctors were not mentioned in the reports of the governors at all45.
Nevertheless, the cities began to use an equivalent of outpatients' reception widely. Perm and Vyatka had dispensaries, although before the First World War, they would account for no more than 50 %o of the cities. Perm entered top ten cities that estab-
43 Zhurnaly permskogo gubernskogo zemskogo sobraniia 27 chrezvychainoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 27th Extraordinary Session and the Reports of the Commissions to this Meeting]. Perm, 1895, p. 36; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 30 ocherednoi sessii [Journals of Perm Gubernia Zemstvo Assembly of the 30th Regular Session]. Perm, 1900, p. 43; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 36 ocherednoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 36th Regular Session and Reports of the Commissions to this Meeting]. Perm, 1904, p. 105; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 41 ocherednoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 41st Regular Sessions and Reports of the Commissions to this Meeting]. Perm, 1911, p. 116.
44 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 27 chrezvychainoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 27th Extraordinary Session and the Reports of the Commissions to this Meeting]. Perm, 1895, p. 36; Trapeznikov V.P. Letopis' goroda Permi [Chronicle of the city of Perm]. Perm, 1998, p. 54; Selezneva V.T. Ocherki po istorii meditsiny v Permskoi gubernii [Essays on the history of medicine in Perm province]. Perm, 1997, p. 60.
45 Obzory Permskoi gubernii za 1893-1905 gg. [Surveys of Perm Province for 1893-1905]. Perm, 1894-1906.
lished their 'first aid' service46. In the medical service, city councils paid attention not to the treatment of residents, but to the sanitary conditions of the premises, especially if there were fairs and markets around them.
Doctors would usually meet at a general congress. Unfortunately, in Perm and Vyatka provinces, the first experience of such a congress was quite negative. An agenda for such a congresse would be prepared by an ambulance doctor; however, on one of such occasions, doctors I.I. Molleson in Perm province and V.O. Portugalov in Vyatka province were either arrested or lost their jobs because of their populist views. Thus, in both provinces, Zemsky Medical Council was engaged in preparing
47
the congress . Zemstvos often took opinions that were questionable from the government's point of view. During the 1905 revolution, 13 of 53 members of the district committees were expelled from Perm province, and the chairman of provincial zemstvo, L.V. Yumashev, was removed from his office48.
The congresses of doctors were of an advisory nature. Their main task was to discuss the expansion of medical care. The presence of zemstvo officials without any medical education but possessing budgeting skills contributed to a more realistic view of the problems. On the other hand, zemstvos showed solidarity with the doctors when the congresses were subjected to pressure from a governor or a medical inspector. In Perm and Vyatka provinces, congresses were abolished twice (in 1904 and 1915) due to the military operations49.
By the beginning of the 20th century, in the Russian Empire numerous charitable societies and charitable institutions were founded. The three most important of the medical communities were the following: Pirogov Congress of Physicians, the Society for Guarding Public Health and the Russian Red Cross Society (RRCS). Whilst the first two societies enjoyed the full support of Perm and Vyatka provincial zemstvos, the relationships with the Red Cross were much more difficult.
In the provinces, traditionally the local branch of the RRCS was headed by the governor's wife, but sometimes zemstvos refused to help the Red Cross, ignoring any possible conflicts. Thus, Vyatka zemstvo refused to help with the purchase of an X-
46 Kanevskii L.O., Lotova E.I., Idel'chik H.I. Osnovnye cherty razvitiia meditsiny v Rossii vperiod kapitalizma (1861-1917) [The main features of medicine development in the period of capitalism]. Moscow, 1956, p. 133; Verkholantsev V.S. Gorod Perm', ego proshloe i nastoiashchee: Krat. ist.-stat. ocherk; Vstup. st. i primech. T.I. Bystrykh [The city of Perm, its past and present; Introductory article and notes by T.I. Bystrykh]. Perm, 1994, p. 150.
47 GAKO. F. 616. Op. 1. D. 229. L. 250; D. 398. L. 193; F. 617. Op. 2. D. 639. L. 12; Op. 5. D. 3941A. L. 138, 141.
48 Nevostruev N.A. Rossiiskoe grazhdanskoe obshchestvo i vlast' v krizisnykh situatsiiakh v nachale XX veka (na primere Urala) [Russian civil society and power in crisis situations in early 20th century (on the example of the Urals)]. Vlast' i obshchestvo v ekstremal'nykh istoricheskikh situatsiiakh [Power and Society in Extreme Historical Situations]. Perm, 2013, p. 162.
49 GAKO. F. 617. Op. 5. D. 3941A. L. 143; F. 616. Op. 1. D. 58. L. 97.
ray machine to its Red Cross branch during the Russo-Japanese war, and the Permian also refused to finance, quoting the fact that it had already sent 25,000 rubles on Perm detachment sent to the Far East50.
The societies of doctors, which were created in the provinces by the efforts of several best doctors, were also supported by small amounts from zemstvos51.
By 1913, statistical data was collected in the provinces, and several thematic exhibitions were organized. In St. Petersburg, a sanitary and hygienic exhibition was widely announced. Perm provincial zemstvo did not have time to prepare exhibits for it, and its place was taken by Perm uyezd zemstvo. Vyatka province did not partici-
52
pate in this expensive project .
The expenditure of zemstvos and factory administrations differed as far as construction of hospitals and payment of wages was concerned. The objects of 'factory medicine' were built or rebuilt in stone in the 1930-40, and zemstvo increased the number of hospitals; thus, zemstvos spent more on material and technical maintenance, whereas the factories would spend more on doctors' salaries. In general figures, the salaries for 'factory medicine' and those in Perm provincial hospital matched
53
each other closely53. In Perm provincial zemstvo, people remembered the experience of private plant owners, who could invite doctors only advertising an increased wage. Since the 1870s, zemstvo was one of the first in the country to raise their wages from 1200 to 1500 rubles54.
Further on, these payments became more targeted. In 1895, zemstvo decided to increase "the wage of one of the doctors who receives a salary of 1500 rubles a year by 300 rubles, to keep the best medical staff in Alexandrovskaya Hospital." In the first decade of the 20th century, the salary of an attending physician (ordinator) was 18002000 rubles, whereas in the second decade it was 2500 rubles. The senior physician
50 GAKO. F. 616. Op. 1. D. 194. L. 86; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 35 chrezvychainoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly, the 35th Emergency Session and Reports of the Commissions to this Meeting]. Perm, 1904, pp. 16, 22.
51 GAPK. F. 680. Op. 1. D. 105. L. 4; Doklady permskoi zemskoi upravy gubernskomu zems-komu sobraniiu 41 ocherednoi sessii i doklady komissii semu sobraniiu [The reports of Perm Zemstvo Board to the Provincial Zemstvo Assembly of the 41st Regular Session and the Reports of the Commissions to this Meeting]. Perm, 1911, p. 31.
52 Frenkel Z.G. Ocherki zemskogo vrachebno-sanitarnogo dela (Po dannym rabot, proizveden-nykh dlia Drezden. i vseros. gigien. vystavok) [Essays on zemsky medical and sanitary affairs (Acording to data of workd produced for Dresden and all-Russia hygiene exhibitions]. St. Petersburg, 1913, p. 2; Doklady permskoi zemskoi upravy gubernskomu zemskomu sobraniiu 41 ocherednoi sessii i doklady komissii semu sobraniiu [The Reports of Perm Zemstvo Board to the Provincial Zemstvo Assembly of the 41st Regular Session and the Reports of the Commissions to this Meeting]. Perm, 1911, p. 126.
53 RGIA. F. 37. Op. 5. D. 15. L. 52.
54 Veselovskii B. Istoriia zemstva za sorok let [History of zemstvos for forty years]. St. Petersburg, 1909, p. 367.
of a provincial hospital, head of medical and statistical bureau, workers of a bacteriological station received increased salaries of up to 3000 rubles, followed by further remunerations of 600 rubles paid to the most deserving employees55.
During the Russo-Japanese War, Perm zemstvo began to include the time spent on the field of the military operations into the zemstvo experience; but only if the doctor was not a volunteer. Perm provincial zemstvo was not going to encourage participation in any military actions neither in Russo-Japanese nor in World War I56.
In Vyatka provincial zemstvo, the salaries of doctors were 300 rubles lower than those in Perm. The increased sums were paid only to psychiatrists and physicians, combining work in a provincial hospital with teaching in a provincial paramedic school. The uyezd (county) doctors, for obvious reasons, could not perform such
57
work, which caused much criticism. In 1909, they demanded an increase in wages .
Prior to First World War, in Vyatka province 'ordinators' - both men and women, received equal salaries; however, during military operations, male doctors were replaced by females with involvement of medical students. This resulted in further re-
58
duction in wages, which almost doubled . The work in the anti-epidemic detachments considered to be an extra for physicians. In fact, payments for this type of work in Vyatka province were often delayed59. Additional anti-epidemic staff was often invited from other provinces, whereby they were not interested in performing any quality work. In 1915, districts zemstvos proposed to the provincial zemstvos not to invite any additional personnel but to pay their own for such extra work. Uyezds (counties) were motivated by the fact that they "knew better who and how much to pay depending on the services provided." The provincial zemstvo agreed but reduced the payments from 300 rubles to 100 rubles to any doctor and from 100 rubles to 40 rubles to any paramedic60.
The financial situation was also connected with the housing problem. Private mining districts with factories erected main hospitals in stone during their reconstruction;
55 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 32 ocherednoi sessii [Journals of Perm Gubernia Zemstvo Assembly of the 32nd Regular Session]. Perm, 1902, p. 230; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 38 ocherednoi sessii i 39 chrezvychainoi sessii [Journals of Perm Provincial Zemstvo Assembly, the 38th Regular Session and the 39th Extraordinary Session]. Perm, 1908, p. 206, 251; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 41 ocherednoi sessii i doklady komissii semu sibraniiu [Journals of Perm Gubernia Zemstvo Assembly of
the 41st Regular Sessions and Reports of the Commissions to this Meeting]. Perm, 1911, p. 86, 114, 135.56
56 Zhurnaly Permskogo gubernskogo zemskogo sobraniia 37 ocherednoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 37th Regular Sessions and Reports of the Commissions to this Meeting]. Perm, 1907, p. 124.
57 GAKO. F. 616. Op. 1. D. 133. L. 733; D. 200. L. 92.
58 GAKO. F. 587. Op. 19A. D. 75. L. 53.
59 GAKO. F. 616. Op. 6. D. 58. L. 151.
60 GAKO. F. 616. Op. 1. D. 237. L. 99.
they also planned several areas for the residence of medical students61. It is interesting that nowadays there is also a similar trend - residence of a physician at the point where they provide medical care. Provincial zemstvos were more restrained in spending on housing, so they used two ways to solve the problem. During the construction of new hospitals, departmental housing was also designed, most often for unsecured paramedics. The second decision meant allocation of means for rental of apartments near the hospital, mainly for doctors. Epidemic doctors were obliged to rent their housing next to the site of epidemic per instructions of zemstvos62.
With the influx of new patients, the staff of Vyatka provincial hospital could be evicted from the apartments to accommodate new patients; in uyezd hospitals, housing for paramedics was inadequately small, damp and cold. Yaran district was the first to build housing for doctors - this measure provided it with permanent staff63. Perm provincial zemstvo saw the problem in absence of any decent housing near a hospital; therefore, it paid significant amounts for rented accommodation, but only for the most needed specialists64.
By the beginning of the 20th century, the populist views were high enough in the public services; provision of medical assistance at any time of the day began to recede into the background. The district system of servicing patients of completely different income levels, established in zemstvo provinces, did not provide for the private practice. A new generation of doctors assumed that through private practice they should be able to earn their professional earnings and improve their working condi-tions65.
Only in 1908, the 'Journal of Russian Doctors' Society' outlined the problem of work of zemstvo doctors in the rural areas. They could not access any state benefits for a long time, such as pensions, payments for their long service and full-rate holidays. One of the main requirements to protect the activities of the doctors was the assumption that any doctor should not conduct a round-the-clock reception on demand.
61 GASO. F. 643. Op. 1. D. 1327. L. 28, 77.
62 GAKO. F. 587. Op. 14. D. 156. L. 1, 4.
63 Adres-kalendar' Viatskoi gubernii. 1892-1901 [Address-calendar of Vyatka Province. 18921901 years]. Vyatka, 1891-1901; GAKO. F. 170. Op. 2. D. 81. L. 68.
64 GAPK. F. 44. Op. 4. D. 14. L. 34; Zhurnaly Permskogo gubernskogo zemskogo sobraniia 33 ocherednoi sessii i doklady komissii semu sobraniiu [Journals of Perm Gubernia Zemstvo Assembly of the 33rd Regular Session and Reports of the Commissions to this Meeting]. Perm, 1903, p. 161.
65 Zabludovskii P.E., Zhuk A.P. Stoletie obshchestvennoi meditsiny v Rossii [Centenary of public medicine in Russia]. Ocherki istorii russkoi obshchestvennoi meditsiny. Sbornik statei [Essays on the History of Russian Public Medicine. Digest of Articles]. Moscow, 1955, p. 1-13.
Only by 1917, doctors were granted a shortened working day ending at six o'clock, the practice that is still common today66.
The rural doctors were also irritated by the fact they could not take a day off at the weekends as they needed to be available to the peasants. Their day off was per rolling schedule. Health professionals were granted rest during the entire weekend only after 190567.
Doctors of Perm provincial hospital demanded that zemstvos determined the length of the leave accurately, as it was intended to be used for their scientific trips. The doctors insisted that their absences "had completely different purposes"68. Their holiday usually lasted for a month with a possible increase in time to six weeks, if a doctor was not on holiday in the preceding year69. In uyezds (counties), a doctor could go on holiday only by providing a replacement doctor; thus, there were people who did
70
not take any leave for 15 years .
The end of the 19th - early 20th centuries were marked by major epidemics and pandemics. Many doctors died performing their duties or lost their ability to work;
71
many began to apply for benefits to be received from the provincial governments . This resulted in the discussion about insurance for medical workers affected at work. The Ministry of Internal Affairs took part in the development of general rules for in-
72
suring medical personnel, which were introduced only in 1910 .
Perm provincial zemstvo defined the amount of payments to family members of deceased physicians. 5,000 rubles were allocated to any doctor; 4,000 roubles were envisaged for a student who had completed 10 semesters; 3,000 roubles were envisaged for a student who had completed 8 semesters; students in their 6th-7th semesters, paramedics and paramedic midwives would receive 2,000 rubles; 1,000 roubles were allocated for nurses' and paramedic assistants and 500 rubles were allocated for attendants and nurses. The factory doctors were insured only on condition of coopera-
73
tion with zemstvos. In Perm province, paramedics asked for additional insurance .
66 Strashun I.D. Russkaia obshchestvennaia meditsina v period mezhdu dvumia revoliutsiiami 1907-1917 [Russian public medicine in the period between the two revolutions of 1907-1917]. Moscow, 1964, p. 59; GAPK. F. R-79. Op. 1. D. 7. L. 20; RGIA. F. 51. Op. 1. D. 291. L. 4.
67 GAKO. F. 616. Op. 1. D. 153. L. 9; F. 587. Op. 11. D. 81. L. 30; Op. 10. D. 240. L. 6.
68 GAPK. F. 44. Op. 4. D. 495. L. 229.
69 GAPK. F. 44. Op. 4. D. 25. L. 44, 49.
70 GAKO. F. 616. Op. 1. D. 183. L. 282.
71 GAKO. F. 616. Op. 6. D. 62. L. 115; Op. 1. D. 153. L. 518.
72 Doklad po meditsinskoi chasti Permskoi zemskoi upravy gubernskomu zemskomu sobraniiu [Report on Medical Affairs of Perm Zemstvo Board to the Provincial Zemstvo Assembly]. Perm, 1910, p. 51; Doklady Permskoi zemskoi upravy gubernskomu zemskomu sobraniiu 41 ocherednoi sessii i doklady komissii semu sobraniiu [The Reports of Perm Zemstvo Board to the Provincial Zemstvo assembly of the 41st Regular Session and the Reports of the Commissions to this Meeting]. Perm, 1911, p. 141.
73 GAPK. F. 143. Op. 1. D. 740. L. 1-2, 5, 7, 10, 18, 25; F. R-79. Op.1. D. 5. L. 3.
Since the beginning of the 20th century, Perm provincial zemstvo began to pay its most valuable staff 'therapy' money for visiting health resorts when being ill; and since 1908, zemstvo had bought land in Alupka for the construction of a resort for treatment and reduction of mortality rates among its staff.
Conclusion
Thus, the 'Great reforms' revived zemstvo's and city's medicine. Zemstvo medicine was aimed at the broad peasant strata; whereas city councils focused their attention on the sanitary conditions of city life. The contacts between provincial and uyezd zemstvos were rather complicated. In Vyatka province, there was a good interaction of zemstvos through the system of lending to the construction of hospitals provided by the provincial administration. In Perm province, these ties were less significant and were related to the financing of anti-epidemic work.
Both zemstvo provinces passed the stage of 'feldsherism' and moved to the stationary system of providing services for the population. During this experiment, a unique district service system was created, when a doctor would work with the residents representing different walks of life, beyond their private practice, and receive wages from zemstvo. It was difficult to develop a payment schedule for physicians, a system of additional payments for work during epidemics, and further on insurance for the loss of ability to work or even death. The doctors had long sought synchronization of their weekend with the other segments of the population.
Both zemstvos had good tax revenues and a large territory. The distinction of Perm province was in use of its heritage of 'factory medicine' in the first half of the 19th century. Quite a few of the medical personnel received scholarships and scientific internships in central cities and abroad, in honor of their long work for zemstvos as well as training from the residents through some profile schools.
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