ENLIGHTENMENT PHILOSOPHY AND MEDICAL REFORM

12 May

Although  elaborate  systems fascinated  many eighteenth-century physi- cians, this period also produced  pragmatic  reformers  who realized that

one could  not  heal sailors  and  soldiers or peasants  and  workers  with learned speculations. Social and medical reformers, inspired by the Enlightenment belief that  it was possible  to  improve  the human  con- dition through  the application of reason to social problems, turned their attention to  public  health  and  preventive  medicine.  In  the  eighteenth century, to an unprecedented extent, the ship, the army barrack,  the fac- tory,  the  prison,  the  hospital,  and  the  boarding   school  were  closed worlds in which unrelated people were confined, sharing unhygienic conditions,  unhealthy  diets, polluted  air, and communicable  diseases.

Reformers  and philanthropists argued that scientific investigations

of the abominable conditions  of cities, navies, armies, prisons,  lunatic asylums,  and  hospitals  could  improve  the  health  and  prosperity   of society as a whole. Sometimes this battle was led by medical men familiar with specific constituencies, such as Sir John Pringle, surgeon general of the British armies, or James Lind, Charles Blane, and Thomas  Trotter, pioneers of naval medicine and hygiene. The English philanthropist John Howard called for the reform of prisons, while French physician Philippe Pinel attempted to reform the abysmal conditions  in mental asylums.

The  goals  and  ideals,  as  well  as  the  sometimes  authoritarian

methods  that  characterized the developing field of public health  medi- cine, are  reflected  in the work  of Johann  Peter  Frank (1745–1821), a pioneer  of  what  is now  called  social  medicine.  His  philosophy   was encapsulated in  his  1790 oration, ‘‘The People’s  Misery—Mother  of Diseases,’’ and expounded  in great detail in the six volumes of his Sys- tem of Complete Medical  Police (1777–1817). This  monumental work was a widely known  and  influential  exposition  of the social relations between health and disease. Weaving together the noblest ideals of Enlightenment thought,  enlightened  absolutism,  and  pragmatic  public health goals, Frank devoted his life to teaching Europe’s monarchs  that the people constitute  the state’s greatest  wealth  and  that  it was in the state’s  best  interest  to  see that  its subjects  should  be ‘‘as numerous, healthy,  and  productive  as possible.’’ Human  resources  could  best be maintained through   ‘‘rational  hygienic  measures’’  by  combining  the power of the state with the knowledge of the physician. For the welfare of the people, the physician must be responsible for the two branches of state medicine: forensic medicine and the medical police who enforced the dictates  of the state.

Even as a student,  Frank  felt himself driven by a profound inner restlessness.  He  attended  various  universities  in France  and  Germany before he obtained  his medical degree from  Heidelberg  in 1766. When Frank   became  personal  physician  to  the  Prince-Bishop  of Speyer,  he began to test his ideas about  a new social medicine by studying the con- ditions of the serfs and determining how the government could affect the health of its subjects. Among other things, Frank  established a school to train  midwives, hospitals  to serve the poor,  and a school for surgeons.

In 1779, Frank published  the first volume  of his Medical Police. Subjects covered included marriage, fertility, and childbearing.  The next two  volumes  dealt  with  sexual  intercourse,  prostitution, venereal  dis- eases, abortion, foundling  hospitals,  nutrition, clothing,  and  housing. Although  these  books  made  Frank famous,  they  did  not  please  the Prince-Bishop.  A position  in the service of Emperor  Joseph II provided better conditions  for Frank’s  studies of medical practitioners and insti- tutions,  public  health  measures,  and  the condition  of working  people and peasants.

By  the  second  half  of  the  twentiethth century,  the  population

explosion  was generally  recognized  as  a  major  threat  to  global  eco- nomic  and  social  welfare,  but  Frank was  most  concerned  with  the opposite problem. Medical Police reflects the economic and political concerns  of  the  rulers  of  Austria,   Prussia,  France,  and  Spain,  who were convinced  that  they needed more  people for their  armies,  indus- tries,  and  farms.  The  so-called  enlightened  despot  and  his physicians understood that  people could  only be productive  if they were healthy and able-bodied;  in other words, the welfare of the people was the wel- fare of the state.  No detail was, therefore,  too small to escape Frank’s attention if it might conceivably affect the future fertility of the people.

Medical  police would  be authorized  to  supervise  parties,  outlaw

unhealthy   dances  like  the  waltz,  enforce  periods  of  rest,  and  forbid the use of corsets  or other  fashionable  articles  of clothing  that  might constrict  or distort  the bodies  of young  women  and  jeopardize  child- bearing. If Frank’s concept of medical police seems harsh, his definition of the qualities of the true physician reflects his heartfelt  belief that  the most important qualities of the physician were the love of humanity  and the desire to alleviate suffering and provide consolation where there was no  cure.  Concerned  that  people  might  make  mistakes  in determining when death  had  occurred,  Frank provided  advice about  resuscitation and rescue, dealing with accidents, and the appointment of specialized rescue workers.

By studying  the  lives of peasants  and  workers,  Frank hoped  to

make physicians and philosophers see how diseases were generated  by a social system that kept whole classes of people in conditions of perma- nent  misery.  Eighteenth-century social  classes, as  Frank knew  them, consisted of the nobility,  bourgeoisie,  and paupers.  The great majority of all people fell into the last category. Convinced that one of the worst aspects  of the  feudal  system was the  harsh  conditions  imposed  upon peasant  women  and  children,  Frank argued  that  all pregnant  women needed care and  kindness in order  to successfully carry  out  their duty to  the  state,  which  was to  produce  healthy  new workers.  Reports  of the  accidents  that  maimed  and  killed  children  left  alone  while their mothers  worked  in the fields prove that  the past was not a golden age of prefeminist  family life. Babies cried themselves almost to death  with

fear, hunger, thirst, and filth. Sometimes pigs or dogs got into the house and  attacked  infants;  sometimes  small  children  wandered  away  from home  and  died  by falling  into  wells, dung  pits,  or  puddles  of liquid manure.

Other   aspects  of  medicine  and  its  place  in  eighteenth-century society are  reflected  in the changing  pattern of medical  professionali- zation in Europe. France, for example, entered the eighteenth century with a medical system dominated by learned physicians steeped in traditional Hippocratic doctrines.  Endless academic debates about  abstract  medical philosophies  obscured  a broad  range of therapeutic practices, as well as the  work  of  unorthodox and  unlicensed  healers.  By  the  end  of  the century,  however, French  medicine had  been transformed by two very powerful catalysts: revolution and war. Ignorant of medical philosophy, military men were known to say that many lives could be saved by hang- ing the first doctor found bleeding the wounded with his right hand and purging  them  with the left. Promoting  the ideology  of equality,  revo- lutionary  leaders denounced  academic  medicine as the embodiment  of all the worst aspects of the Old Regime, from favoritism and monopoly to neglect and  ignorance.  Ironically,  the revolutionary movement  that intended to eradicate doctors,  hospitals,  and medical institutions gener- ated  a new public  health  policy,  better  trained  doctors,  new medical schools,  and  hospitals   that  offered  unprecedented opportunities for clinical  experimentation,  autopsies,   and  statistical   studies.  Hospital reform   was  especially  difficult,   costly,  and   painful,   but   the  revo- lutionary  era established the hospital as the primary locus of sophisticated medical treatment, teaching, and research.

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