Bettina Wahrig, Werner Sohn. Zwischen Aufklärung, Policey und Verwaltung: Zur Genese des Medizinalwesens 1750-1850. Wiesbaden: Harrassowitz Verlag, 2003. 212 S. EUR 59.00 (cloth), ISBN 978-3-447-04822-4.
Reviewed by Kathleen Crowther (Department of History of Science, University of Oklahoma)
Published on H-German (March, 2006)
Patients, Practitioners and Power
The essays in this volume examine the transformation in medicine in the German states between 1750 and 1850. This transformation had three facets: first, a shift in the organization of medical practitioners from guilds to professions--a process that involved the exclusion or marginalization of certain types of healers; second, a new interest of German states in the health of their populations and in the regulation of medical care; and third, the gradual triumph of an Enlightenment ideal of a rational, standardized medical knowledge and practice--a process that entailed the relegation of certain ideas and practices to the realm of the "superstitious." Each author studies a particular thread in the complex web of relationships between the professionalization of medicine, the late absolutist state and the Enlightenment. The result is a thought-provoking volume that presents new work on this important period in the history of medicine and suggests future directions for research.
The essays in the first section explore the rising status of physicians and their changing relationship to the state. Sibylla Flügge's essay traces the shift in the organization of medicine between the beginning of the sixteenth and the end of the eighteenth centuries. In the early modern period, different types of medical practitioners--including physicians, surgeons, apothecaries and midwives--each dealt with particular groups of patients and certain kinds of suffering. Although physicians had the highest status they did not control other groups of practitioners. This arrangement changed as territorial rulers and civic authorities increasingly turned to physicians to make and enforce medical ordinances, and physicians themselves took the initiative in encouraging rulers to establish such ordinances.
Werner Sohn's essay picks up where Flügge's ends. He argues that the social and professional aims of academically-trained physicians coincided with the aims of late absolutist states. For example, nineteenth-century medical ordinances that made physicians the overseers of all medical care corresponded to a new conceptualization of the inhabitants of a territory as the "wealth" of the state, a form of wealth that needed expert management.
The picture painted by Flügge and Sohn is complicated by the essays of Bettina Wahrig and Thomas Broman, who use analyses of periodical literature to suggest that the professionalization of medicine can be linked to the development of a bourgeois public and the growing print market as well as to the development of state power. Wahrig discusses several periodicals of the late eighteenth and early nineteenth centuries devoted to the topic of "medical police." These periodicals were aimed at doctors, but also at a wider public, and Wahrig demonstrates that they served several functions. Contributors worked to educate the public about competent and incompetent practitioners. They were also concerned to establish the importance of doctors to the state, arguing that a healthy population was crucial to a strong state and that physicians had the knowledge and expertise to improve the health of the population. Other articles instructed doctors on proper manners and etiquette and argued that cultivating genteel behavior was essential to raising the generally low reputation of physicians. According to Wahrig, the "discourse" of medical police served to shape both the image and the self-image of physicians.
Thomas Broman shows that German periodicals in the second half of the eighteenth century contained discussions of sickness and health that were neither created exclusively by doctors nor controlled by them. Thus the dissemination of medical ideas can be seen as at least partly independent of "professionalizing" physicians or the efforts of a centralized state. On the other hand, the development in these same periodicals of "criticism" as an important form of "literary praxis" furthered physicians' claims to possess expert knowledge about health and disease (p. 105).
The essays in the second section deal with the control or exclusion of other practitioners by physicians. Jutta Nowosadtko's essay examines the gradual exclusion of executioners from medical practice. She notes that executioners have been doubly marginal in the history of medicine, first because they were "unofficial" or "unauthorized" healers, and second because their treatment methods have been seen as "magical" rather than "rational." However, such a distinction between "rational" and "superstitious" imposes modern definitions onto eighteenth-century practices. Executioners usually were called on to treat wounds, contusions and broken bones. Their work thus overlapped with that of surgeons, a fact that led to conflicts between these two groups of healers. Most executioners learned their medical skills from their fathers. Nowosadtko argues the "informal" nature of executioners' medical training and not the "superstitious" character of their practices led to their marginalization over the course of the eighteenth century.
The other two essays in this section examine the ways in which physicians gained control over the instruction and licensing of other practitioners. Christine Loytved examines the case of midwives, using Lübeck as a case study. In early modern Lübeck, midwives selected and trained apprentices. Beginning in the 1730s, the city employed a midwifery instructor (either a surgeon or a physician) who gave apprentice midwives some instruction in obstetrical theory. By the 1790s, midwives were complaining to the city council that wealthy women were choosing to be delivered by physicians, reducing the midwives' clientele to the city's poorer women. Physicians who attended births often were accompanied by apprentice midwives. In 1809, the new midwifery instructor began offering not only theoretical but also practical training, using poor women as teaching subjects. By the early nineteenth century, Lübeck midwives were selected and trained by a physician, not by older midwives. Loytved shows that this development was made possible not only by the rising status of physicians, but also by the growing divide between established midwives and their apprentices and by the gradual dissolution of the guild structure that earlier had represented the interests of the midwives to the city council.
Gabriele Beisswanger's essay analyzes changes in the drug trade in the second half of the eighteenth century, using the duchy of Braunschweig-Wolfenbüttel as a case study. She notes that in the middle of the eighteenth century there was virtually no control over the production and sale of drugs except that internal to the apothecaries' guilds. Only about half of all drug use followed from consultation with a doctor. Between about 1750 and 1800, physicians were able to gain control over the drug trade by establishing control over the apothecaries. Physicians gained the authority to examine apprentice apothecaries and thus control entry into the trade. Beisswanger demonstrates that, while this process was not uncontested, the testing of apprentices by physicians was favored by many apothecaries who saw this as a way of assuring and maintaining the quality of apprentices and of improving the professional status of apothecaries.
The essays in the final section focus on patients and their role in shaping the development of medicine. Iris Ritzmann's essay examines the demand for medical services for children in Haina and Zürich in the second half of the eighteenth century. Ritzmann's picture, while carefully documented, is disappointingly static and gives no sense of how parents' choices impacted the types of care available or of how the demand for medical care changed over the course of the eighteenth century.
Eberhard Wolff focuses on the development of Jewish societies for the care of the sick in Dresden. In the early nineteenth century, young Jewish men began to form mutual aid societies to protect themselves against the potentially devastating financial consequences of injury and illness. These societies offered members financial support during times of sickness, both to supplement lost wages and to help pay for medical care. They differed from more traditional Jewish organizations dedicated to the care of the sick in their focus on mutual aid rather than charity. Wolff suggests that the creation of sickness insurance should be seen not just as the initiative of the centralized state but as a process shaped "from below" by consumers.
The final essay, by Mary Lindemann, offers a historiographic overview of changes in the history of medicine over the last decades. Since the 1960s, the history of medicine has increasingly broadened its scope and focus. Patients' experiences, "other" healers, the social construction of disease and the history of the body have all become thoroughly respectable areas of study. If anything, the history of physicians and learned medicine has taken a back seat. These reflections on the field form an interesting contrast with some of the other essays, whose authors clearly see a focus on patients and "quacks" as a very new development. For example, Flügge's essay begins with the assertion that, "[u]ntil recently, the history of medicine has been written almost exclusively as a history of scientifically educated doctors" (p. 17). This contrast reflects some of the differences between history of medicine in a German context and an Anglo-American one.
Despite the number of essays, this is a slim volume. All the essays are short and most leave one wanting more and deeper analysis of the points they raise. To take just one example, several essays raise but do not explore in detail the construction of the categories of "rational" and "superstitious" medicine. These left me wondering about how these categories were defined, and by whom. How did these terms shift over time? Lindemann's discussion of the meanings of the term "epidemic" in the eighteenth century provides a wonderful model of how the creative use of archival sources can recover the meanings of terms in the past and avoid anachronism. If this volume does more to whet the appetite than to satisfy it, there is much food for thought here for specialists in both the history of medicine and in Enlightenment Germany.
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Kathleen Crowther. Review of Wahrig, Bettina; Sohn, Werner, Zwischen Aufklärung, Policey und Verwaltung: Zur Genese des Medizinalwesens 1750-1850.
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