Enlightenment Philosophy And Medical Reform

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Although elaborate systems fascinated many eighteenth-century physicians, 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 condition 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 factory, 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 medicine, 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 System 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 conditions 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 diseases, 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 institutions, 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 economic 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, industries, 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 welfare 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 permanent 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 hanging the first doctor found bleeding the wounded with his right hand and purging them with the left. Promoting the ideology of equality, revolutionary 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 generated 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 revolutionary era established the hospital as the primary locus of sophisticated medical treatment, teaching, and research.

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