During the last forty years several preoccupations have driven historians to examine the work of public health authorities in Britain. Most recently it has been the effort to explain the fall in mortality during the nineteenth century. The issue has been raised in its contemporary form by the well-known works of Thomas McKeown and associates, who grant to conscious human intervention – clinical medicine, public health, or social welfare – only a small part in the mortality decline before the twentieth century. While conceding that the construction of sewage systems, the provision of protected water supplies, and vaccination for smallpox had some effect on human mortality and suggesting that spontaneous changes in the virulence of its agent accounted for the diminished mortality from scarlet fever, these authors have argued that only improvements in the standard of living, especially in nutrition, could account for the magnitude of the mortality decline. For some years historians accepted this analysis with little question, showing particular appreciation for McKeown's demonstration that clinical intervention could not possibly account for mortality decline on such a scale. But recently they have turned their attention to the most debatable part of McKeown's thesis, the role played by mass intervention by public authorities. So important has this issue become, that it dominates the discussion of public health in the new Cambridge Social History of Britain. For England and Wales some of the most interesting recent work is by Simon Szreter and Anne Hardy.

If Naturphilosophie promised to transform medicine into a true Wissenschaft, it was a decidedly odd brand of medical science that would emerge from the metamorphosis. For Naturphilosophie treated medicine in a way that was virtually oblivious to the practical concerns and social milieu that physicians confronted in their everyday working lives. That was part of its attraction: its siren call was the unity of knowledge through a transcendental poetics of life, with Schelling and his followers playing the role of bards who would sing its truths. But to physicians who did not seek to pursue a larger vision of Wissenschaft, and who identified more with medicine as healing than with the avant-garde of Jena Romanticism, the pretensions of the Naturphilosophen were not merely by degrees silly or outrageous, they were also fundamentally inimical to the true nature of medicine and medical science. Partly in response to the Naturphilosophen, but partly too as their own contribution to shaping public consciousness about the profession, these physicians gave voice to a different version of medicine, one emphasizing its healing mission.

This chapter will explore that alternative vision for medicine, as seen through the writings of physicians who in no way sympathized or identified with the aims of the Naturphilosophen. The picture that emerges from these sources consists of three intimately connected elements: first, a justification of the dignity and social worth of the profession; second, an epistemology of medical practice; and finally, a program of medical education.

The previous chapter described how the eighteenth-century medical profession was shaped by (and in turn gave form to) reformist impulses that were proclaimed under the banners of Enlightenment, social welfare, and the pragmatic uses of knowledge. The responses formulated by physicians to those impulses, as that chapter suggested, were a complex amalgam of defensive and offensive postures. At the most general level, those responses were structured by two issues. The first issue, hinted at by the discussion of Bildung, consisted of how someone conceived of the profession's relationship to the state. Did medicine exist to promote the state's enlightened ends (for example, by means of public health), or should physicians stake their identity on a more individual and personal level, for example in terms of their selfless service to patients, or their claim to cultivation of personal freedom through Bildung? The second issue concerned physicians’ sense of the relationship between theory and practice in medicine. Should theory be cultivated with an eye toward its application at the bedside, or could medical theory rightly lay claim to being a profound inquiry into the mysteries of organic nature? How in fact did bedside practice represent an “application” of a physician's theoretical knowledge?

Two points must be made to clarify these issues. First, in some ways their presentation as choices between alternatives is deceptive, because they did not necessarily represent mutually contradictory stances.

In recent years, the professions have been a subject of growing fascination for historians and sociologists. The reasons are not difficult to find. Talcott Parsons may have overstated the centrality of the professions when he claimed in 1968 that they were “the most important single component” in modern society, but there is no denying the prominent position occupied by professional “experts” of various stripes. One has only to take in the nightly news broadcast on public television, where it seems that nearly every matter of current interest is rendered as a debate between experts, to appreciate the role they play in our world. Or consider that in 1993, when Hillary Rodham Clinton began putting together a proposal for reforming America's health care system, her first act was to gather together a group of professional experts on various aspects of health care to discuss the framework of such a plan. It is not that fundamental political and ideological issues – such as the desirability of guaranteeing medical care to every citizen – were thereby rendered meaningless or unimportant in the face of such consultations. But the political questions were shaped in significant ways by what those experts had to say about the way the world is.

The reference to medicine is an appropriate one, because in one sense this book is about the origins of the modern medical profession. Put that way, of course, the project sounds a little grandiose.

Revolutions do not conform to a single historical pattern. Some follow a logic of development that builds to a radical denouement, while others may incorporate moments of radicalism, but never reach a climactic resolution. Instead, they simply lose energy gradually, like a hurricane whose force is spent by traveling over land. Beyond any question, the Brunonian revolution resembled the second kind. As the first years of the nineteenth century slipped by, the energy and rancor of the debate over Brunonianism diminished noticeably. This was so much the case that by 1811, when Andreas Roschlaub published a letter in the Journal der practischen Heilkunde declaring in effect that he no longer held to the principles of Brunonianism, the gesture had little dramatic impact. Hufeland, the editor of the Journal, permitted himself a smug, self-congratulatory observation to mark the occasion, but the moment passed largely unnoticed.

Although the final act of the Brunonian revolution may have played before a nearly empty house, its impact on German medical theory and practice was substantial. At least for the short term, the most significant product of the controversies over Brunonianism was the construction of a stout wall between theory and practice. The great majority of physicians who wrote on practice after 1810 continued to speak of it in terms of a Kunst characterized by the physicians' creative synthesis of judgment, experience, and talent.

Of necessity, the image of mid-eighteenth century German medicine presented in the preceding chapter was one frozen in time. Yet the constituents of that picture – the intimate connection between medical profession and the universities, and the location of both in the larger society – should be conceived of dynamically, not statically. For all its seeming clarity, as soon as the depth provided by time is added to the picture, the details begin to blur and lose their sharp outline. At no time were there ever institutions such as “the medical profession” or “the universities” for which we can give a precise description. Rather, such institutions are always a more or less discordant blend of meanings and functions, incessantly driven in new directions by unfulfilled expectations (which can themselves be dissonant) and held back by the weight of established practices. If these institutions appear stable at mid-century, it is only in comparison to the changes that would overtake them in the years around 1800.

It is worth remembering this when we consider the forces that acted upon the universities and the medical profession, propelling them into a new relationship. These forces did not act on inert matter. There was no reform “movement” that suddenly arose in the 1700s to resuscitate a group of “outmoded” universities and incompetent physicians.

For all the real disagreements – especially regarding medical education – that existed between the Naturphilosophen and those who believed medicine to be a vocation to healing, in a curious way the two groups could tolerate each other fairly well. That is because both implicitly accepted a degree of separation between theory and practice. For their part, the Naturphilosophen were not especially interested in designing their theories to provide useful guides to practice. Even a theorist who did seek to close such links, such as Johann Christian Reil, contented himself with alluding only in the most general way to the therapeutic implications of the system described in “Von der Lebenskraft”, recognizing that a real unification of theory and practice lay somewhere in the future. Until such a time should arrive, Reil readily accepted the “empirical” methods of practice advocated by Hecker and Gruner. On the other side, Christoph Wilhelm Hufeland too claimed on occasion to see a future when medical practice would become an applied science, although he held deep misgivings over its desirability. Hufeland's image of that future therefore tended to be far more remote than Reil's. These doubts about a unified science of medicine did not prevent Hufeland from attributing some value to theory, and he proclaimed medical theories welcome for their service in broadening physicians’ perspectives on the phenomena of disease.

Although neither of these groups chose the most radical of the possibilities offered in the 1790s, other physicians did.

THE IDEAL DOCTOR

During the eighteenth century, it was standard practice for medical professors to present their subjects as a series of lectures based on textbooks written either by themselves or by other scholars. Many professors preferred to write their own text, no doubt in part for the income they hoped to earn from its purchase by students, but they could just as reasonably select someone else's work if it suited their purposes. Thus one student, who enrolled at the Prussian university of Duisburg in 1763, recalled later that during his first semester he heard one of his professors lecture on surgery “from his own manuscript”, and on anatomy “according to Heister's compendium”. More remarkable, perhaps, is what the student reported about the other member of the Duisburg medical faculty. From that professor, he wrote, “from 8–9 o'clock I heard physiology according to Boorhaave's [sic] compendium, from 9–10 o'clock pathology, likewise according to Boorhaave, and from 3–4 in the afternoon therapy, again from Boorhaave”.

Indolence surely had something to do with this complete reliance on Boerhaave, but the professor's contemporaries could scarcely have faulted his choice of authority, for Herman Boerhaave (1668–1738) was a figure of incomparable stature to eighteenth-century physicians. Time and again they invoked his authority in their writings, exalting him to an honored place in the pantheon of medical immortals. By the hundreds they flocked to the University of Leiden to hear him lecture on medicine, botany, and chemistry.

The emergence of the professoriate as a full-time career during the early years of the nineteenth century marked a signal change in the social organization of German intellectual life, which would have enormous consequences over the long term. In the first place, it would lead to the recruitment of students directly into the professorial ranks, creating in medical faculties a cadre of “physicians” whose attachment to the practice of medicine was uncertain. By mid-century, medical students like Carl Gegenbaur, Ernst Haeckel and Emil Du Bois-Reymond could take an M.D. without seriously intending to make a career as practitioners. Such career goals would have been virtually inconceivable in 1750, and were remarkable even in 1800. Secondly, these new professors would begin trading older forms of academic scholarship for the production of research more akin to our sense of the word: empirical discoveries meant to enrich the store of knowledge. While such research would eventually find its way into medical curricula, it was not conducted necessarily with pedagogical aims in mind, and much of what had once counted as scholarship in the eighteenth century (such as writing textbooks) no longer carried the same prestige. Of course, this is not to imply that empirical research had been unknown to eighteenth-century scholars, only to explain that the weight of research effort had shifted and that the environment for it – both institutional and cultural – had changed considerably.

Although science has a long history with roots in ancient Egypt and Mesopotamia, it is indisputable that modern science emerged in the seventeenth century in Western Europe and nowhere else. The reasons for this momentous occurrence must, therefore, be sought in some unique set of circumstances that differentiate Western society from other contemporary and earlier civilizations. The establishment of science as a basic enterprise within a society depends on more than expertise in technical scientific subjects, experiments, and disciplined observations. After all, science can be found in many early societies. In Islam, until approximately 1500, mathematics, astronomy, geometric optics, and medicine were more highly developed than in the West. Indeed, the West learned these subjects from translations of Arabic treatises into Latin. But science was not institutionalized in Islamic society. Nor was it institutionalized in ancient and medieval China, despite significant achievements. Similar arguments apply to all other societies and civilizations. Science can be found in many of them, but it was institutionalized and perpetuated in none.

An impressive array of scholarship testifies that modern science emerged in Western Europe as a result of the Scientific Revolution, a phenomenon associated overwhelmingly with the seventeenth century. That same scholarship has proclaimed that the emergence of modern science in the seventeenth century owes little or nothing to the Middle Ages. Not only did medieval natural philosophy play little, if any, role in the advent of early modern science, so goes the argument, but it was the major obstacle to it.

Twenty-five years have passed since the publication of Physical Science in the Middle Ages in 1971 in the John Wiley History of Science Series, and nineteen years since Cambridge University Press assumed responsibility for the series in 1977. In the early 1980s, I was asked to revise the book, but other duties and responsibilities made the task unfeasible. When I finally had the opportunity a few years ago, the prospect of doing a revision no longer seemed inviting. Too much had happened in the interim. Merely expanding the old version with new material – and there has been much of it since 1971 – while retaining the earlier structure and general outlook was, frankly, unappealing. My sense of the medieval achievement in science and natural philosophy and my understanding of the intellectual environment that produced it, as well as my perception of the relationship between medieval science and the Scientific Revolution, had all been fundamentally transformed.

Between 1902 and 1916, Pierre Duhem, a famous French physicist turned historian, wrote fifteen volumes on medieval science. Duhem was the first to blow away the dust of centuries from manuscript codices that had lain untouched since the Middle Ages. What he discovered led him to make the startling claim that the Scientific Revolution, associated with the glorious names of Nicholas Copernicus, Galileo Galilei, Johannes Kepler, René Descartes, and Isaac Newton, was but an extension and elaboration of physical and cosmological ideas formulated in the fourteenth century, primarily by Parisian masters at the University of Paris.