Advocacy and Community: The Social Roles of Physicians in the Last 1000 Years. Part II in a 3-Part Series.

Karen E. Geraghty, PhD (c), Matthew Wynia, MD, MPH

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In This Article

The Eighteenth Century:

The mathematization and rationalization of the world begun in the previous century cast a long shadow into political developments of the 18th century. From the 16th century onwards, Europe had been characterized by the development of cities and nation-states with increasingly centralized and more powerful governments.[2] Colonies were established in the Western hemisphere, and trade and commerce became integral to the wealth and security of the state. As this consolidation continued in the 1700s, statistical data, which had emerged with the empirical methods of the new science, shifted attention to larger population patterns of illness and disease than could be observed in the focus on individual patients alone. And as morbidity and mortality rates were calculated, they revealed a dire need for public health reforms. Political rulers, eager to secure authority and establish powerful nations, thus looked to forms of rational administration - a political arithmetic - to strengthen the state through improving the health of the population.

Growing rationalism throughout Europe meant a decline in the belief of spiritual healing found in the monasteries and hospitals, which had served as places for sheltering and providing religious instruction to the sick and destitute since the Middle Ages. Hospitals were progressively moved from religious to secular jurisdictions - a move that often required the heavy hand of state governments. Austria's Emperor Joseph II typified the Enlightenment's trend toward rationalizing and centralizing the care of the sick, and also the poor, with the large-scale closing of monasteries throughout the countryside and the construction of the 2000-bed General Hospital in Vienna, which opened in the summer of 1784.

The shift of 18th century medicine to serve political rather than religious goals also served to heighten medicine's position of prominence in social affairs, while raising again the occasional tension between physicians' obligations to individual patients and to "civic duties." Throughout continental Europe, regulation and licensing requirements increased as physicians were more often employed by states for both public and private care.[3] A frighteningly strong alliance between medicine and the state emerged with a concept of social medicine put forth by Johann Peter Frank, which took hold in Italy, Eastern Europe, and the German-speaking countries of the late 18th centuries. The system of "medical police," by which was meant the use of medical means to regulate and administer an enlightened state, was intended to control virtually all aspects of citizens' lives from birth to death. In Frank's view, the state was responsible, using physicians as its agents, to provide the conditions necessary for health, by regulation of both social conditions and the habits of individual citizens. This system promoted a deeply paternalistic relationship between representatives of the state, including physicians, and its citizens.[4]

Despite this movement toward the formalization and regulation of the profession, there was still a great deal of inconsistency in the education of physicians and delivery of care throughout Europe. Folk healers along with quacks and charlatans continued to find profitable niches in society. Hospitals fulfilled a variety of roles -- from prisons and insane asylums to infirmaries and orphanages. Poor sanitation, overcrowding, and the grouping together of patients in an undifferentiated fashion contributed to the spread of communicable diseases and exceedingly high mortality rates, particularly in the Parisian hospitals. Large-scale reforms were needed in organizational aspects of medicine ... but it would take a political revolution to produce the model of medical education and practice that would eventually lead to improvements in medical care.[5]

History of the French Revolution: Bonaparte dans l'hopital des Pestiférés. Image courtesy of the National Library of Medicine

In one protracted, bloody spasm, the French Revolution of 1789-99 swept away all institutions of the Old Regime. This included the closing of the medical academies and teaching institutions, which were viewed as associations of the corrupt elite. In a state of unfettered democracy, laissez-faire medicine prevailed, with professional and amateur healers practicing without legal limitations. Healers of varying skills and questionable motives -- many quacks and charlatans practicing for pecuniary interests -- treated patients without regulation.

The results of France's "experiment" with an unregulated free market for medical services were rapid and dramatic. The disastrous consequences of these practices, along with the desperate health needs of a population and military ravaged by the violent revolution, prompted the French government to act. Prior to the Revolution, the French medical profession had been tightly controlled by the medical faculties based in the major universities. Entry into the profession was strictly limited, creating a small class of elite who jealously guarded the privilege to practice. Not wanting to reestablish this monopoly, and distrusting local medical faculties to reform the system, the French government assumed full control and regulation of the profession. Medical education, which had been fragmented into various colleges and academies, was unified under a single system. A standard curriculum was created, which integrated surgery with medical training, and by 1803 a national system of licensing was in place. Medical schools were supplied with full-time faculty members and admission was opened to all qualified students on a competitive basis. Thus did the needs of the public, in the wake of a Revolution and a brief foray into completely unregulated medical care, cause the French to establish the first true national healthcare system.

Paris hospitals were likewise transformed and aligned with medical schools for the training of students. The movement of surgery into the curriculum emphasized the importance of training in anatomy and pathology, and the hospital assured a steady supply of bodies of deceased patients. Breaking with the theoretical training of the old medicine, the new medicine emphasized bedside training and treatment of disease.[6,7]

The Paris medical schools became the blueprint for modern principles of medical training, practice, and professionalism. It was here that the disparate organizational and conceptual developments of the previous centuries merged to create dramatic advances in medical epistemology and practice. In addition, the plague abated on the European Continent - at least in part due to the public health measures implemented by state-supported physicians - creating a population explosion that coincided with the advent of industrialization and rapid commercial growth. These social factors would challenge and transform the healing practices of the 19th century.

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