Vom Kranken zum Patienten: "Medikalisierung" und medizinische Vergesellschaftung am Beispiel Badens, 1750-1850

Journal of Social History, Summer, 1996 by Thomas Broman

One aspect of medicalization that has received considerable attention has been its association with the disciplining of behavior, most prominently in connection with mental illness, but also more generally in the adjustment of social habits to the dictates of medical science. In the German literature, this concept of social disciplining has been linked to the emergence of the absolutist state in the seventeenth and eighteenth centuries. The connection was given its most influential formulation in the 1970s by Gerhard Oestreich, who claimed that the extension of bureaucratic regulation by modernizing absolutist monarchies dissolved the territorial particularism of the Holy Roman Empire and gradually introduced new forms of social discipline. Drawing on Oestreich, Ute Frevert's Krankheit als Politisches Problem 1770-1880 (1984) described how a discourse of medical enlightenment was formulated that served the interests of both academically educated physicians, who sought monopolistic control over healing, and of state bureaucracies, which saw in public health an opportunity to extend the reach of "rational" administration. Thus, Frevert's interpretation of how health and disease became matters of political interest was unabashedly based on a top-down model of social control.

Loetz will have none of this. Not that she denies the fact of medicalization, but she strenuously attacks the interpretation of it as top-down social disciplining and also its connection with the eighteenth-century discourse of medical enlightenment. Her argument rests first on an examination of contemporary medical literature, from which she claims to see physicians presenting themselves in a more active and mutually supportive exchange with patients and lay healers than might be supposed from Foucault's presentation of patients being analyzed by the medical "gaze," or by Frevert's argument for the subjection of female patients to the dominance of male physicians.

When she turns to her archival sources, Loetz finds abundant evidence to support a more complex picture of medical change than can be maintained by straightforward medicalization arguments. In the first place, the government of Baden pursued a pragmatic course in matters pertaining to public health and did not act to support creation of a monopoly by physicians. Loetz describes how the government actively promoted the creation of a well-trained cadre of midwives, and despite numerous proscriptions on unlicensed medical practice, it actually did little to prevent lay healers from serving patients. Secondly, the system of providing medical care for the poor was quite liberal in allowing patients to choose their own healers (Americans ought to have it so good!) and not forcing the poor into institutions. Disciplining was not entirely absent from government policies, to be sure, as demonstrated by programs for smallpox vaccination and measures taken to combat the cholera epidemic of the 1830s.

Loetz finds that patients too had considerable scope for making choices in medical care. The evidence for this is indirect, based largely on the reports of district physicians and the hearings of the state medical board, yet her conclusions appear reasonable in most cases. In part, she argues, patients' calculations were economic; medical care by licensed physicians or surgeons and even by lay healers was expensive. Therefore, licensed healers were consulted most often by adults in their working years, while the elderly and the very young received such attention less often. Loetz also concludes that the choice of healer was variable and pragmatically oriented toward factors such as the healer's accessibility and reputation.

What emerges from all this is a strong - and even more strongly worded - attack on the standard historiographic picture of medicalization. In place of viewing medicalization merely as oppressive social disciplining, Loetz proposes a model inspired by the sociologist Georg Simmel's concept of Vergesellschaftung, which translates roughly as "socialization." For Simmel, Vergesellschaftung denoted the summation of all the drives, needs, and beliefs held by the individuals who constitute a society. It is the interplay of those drives, needs, and beliefs that forms society and lends it its particular structure. For Loetz, Vergesellschaftung suggests that medicalization arose not from a top-down program of enlightened administration by government coupled with the professional aspirations of university-educated physicians, but instead from the interplay of needs and interests on the part of governments, patients, and healers.

Loetz's point about the mutually interactive nature of medicalization is well taken, especially in contrast to a German-language historiography that rarely ceases to attribute nearly unlimited motive force to the absolutist state. But all the same, her interpretation does have two problems. First, despite the book's title, medicalization is virtually nowhere to be seen between 1750 and 1850. The only concrete instances of it which Loetz can identify are the measures taken against cholera in the 1830s and smallpox vaccinations after 1810. However, these programs hardly qualify as medicalization, which mostly has to wait for the period after the one covered in the book (see comments on pp. 318-319). Second, while Loetz's use of Simmel's Vergesellschaftung does useful remedial service, its vision of consensual social interaction underplays the original critical motivation of the medicalization thesis. After all, medicalization is about the authority that accrues to members of the medical profession, and it has been used by various writers to foster a more skeptical attitude toward medicine. Frevert's book was produced with just such intentions in 1984, and at that time it marked a dramatic departure from most histories of German medicine, which celebrated the triumphs of medical science. Although Loetz is undoubtedly right in criticizing Frevert for her inaccuracies, she fails to appreciate that Frevert was writing more about a set of cultural dispositions than about the social history of medical care. Thus for all its virtues as a social history, Loetz's book does not quite come to grips with its central topic.