Historiography of the Market for Health

Parallel to my research on socio-educational institutions for the deaf, I’m hoping to tie together themes of technological progress, entrepreneurialism and consumerism with the broad and diverse medical community and marketplace—what we can aptly call medical pluralism. There’s been a lot of historical scholarship on the complex dynamics that wove together a diverse group of sellers, consumers, and products, and on spatial dimensions for a “market” for health services. I thought I’d introduce a few key readings and themes on the topics for scholars unfamiliar with the historiography of the medical marketplace and charlataninsm.

Harold Cook’s model, as outlined in The Decline of the Old Medical Regime in Stuart London (1986), speaks of the “medical marketplace” as reference to not just the plurality of healers and the primacy of market forces (often directed by the patient’s needs and desires), but also on the emergence of an abstract concept of economic space that is governed by the process of commercialization. In the brilliant and meticulously book, Cook aims to uncover  “how the physician of seventeenth century London tried to maintain the dignity of learned medicine by exercising the juridical authority of the College of Physicians and how they ultimately failed in the face of deeply felt economic, intellectual, and political changes” (19). By setting the micro-history of College as the central focus of his analysis, Cook provides a glimpse of how various medical practitioners responded and reacted to the large-scale changes in seventeenth-century medicine during the time of the ‘scientific revolution’ (or the ‘seventeenth-century crisis’). While arguing that this “old medical regime”—a group of men who legally dominated medicine and tried to shepherd other practitioners intellectually and politically—faced an unraveling of their powers and legal limitations imposed on them by the House of Lords, Cook also demonstrates how the legal, intellectual, and political conflicts within this regime encouraged, if not was directly responsible for, the emergence of innovations in medical practice outside the ranks of the learned physicians of the College. Barber-surgeons, apothecaries, and unlicensed “irregulars” steadfastly tended to the need of ordinary Londoners, forming what Cook refers to as the “medical marketplace.” As the medical marketplace formed complex interconnections in society and politics, the old medical regime ultimately failed in the face of deeply felt economic, intellectual, and political changes in the beginning of the eighteenth century.

Margaret Pelling as well, raises critical questions about how large segments of the population—the common lot—experienced illness, health, and disease in early modern England. The Common Lot: Sickness, Medical Occupation and the Urban Poor in Early Modern England (1998) focuses mainly from the archives of Norwich and London. Pelling’s essays cluster around three main topics: the urban environment and experiences of illness by the poor, experiences of health and illness of various types of population groups (disabled, old, women), and the occupational diversity of medical practitioners. Pelling makes it clear that sick people “shuttled” among practitioners in search of relief and did not discriminate between various types of practitioners who chose to specialize. While physicians placed a great deal of effort in creating an acceptable social identity, they were still subjected to the opinions and control of the lay and local populations. One of the most significant arguments made by Pelling was her notion that medicine was an occupation, rather than a vocation. For physicians, the diverse character of the medical occupation was often full of pitfalls and undesirable associations, directing attacks against those deemed as ‘quacks,’ while at the same time helping to shape their definitions of what a profession should be.  Pelling provides a tremendous amount of quantitative and qualitative evidence to argue the complex nature of the social and professional world of medicine, and how concepts of illness as perceived by the populations helped to shape the occupational realms of medicine and their applications of treatment.

Historiography on the medical market—and on quackery—reveal that healers were far from restricted to the old-age pyramid of physicians, barber-surgeons, and apothecaries. These works have questioned and/or modified Cook’s model. In The Medical World of Early Modern France (1997), L.W.B. Brockliss and Colin Jones adopt a Braudelian approach in examining the experience of illness and health in early modern France. Dividing their tremendous text into two phases—before and after the plague as an endemic experience—they investigate the various ways in which medicine was adopted and experienced by a culture dominated by political absolutism in the early 17th century, and scientific optimism in the late 17th century. Building upon the existing historiography of the “medical marketplace,” the authors argue that the model of the medical world consists of two parts: (1) the “corporatist core” consisting of the tripartite ensemble of physicians, surgeons and apothecaries in various legally recognized collective; (2) the core is surrounded by the “medical penumbra,” which is composed of different groups and healers who operated within the core despite not having formal training or corporative status (i.e. the “popular practitioners). The model opposes the analytical dyad of elite/poplar medicine, which Brockliss and Jones argue does nothing but to draw battleground lines and is a misreading of the way medical ideas were diffused. Rather, they argue as the lines between the core and the penumbra became increasingly permeable, the sick found access to all sorts of medical practitioners and did not stigmatize those practicing on “Quack Street.” Furthermore, they point out that the core did not despite charlatans because they were economic competitors, but because charlatans represented an affront to moral and social order—they threatened the dominant social and cultural values held by the population. The enlightenment brought a shift in mentalité—what Brockliss and Jones call “valorization of empiricism”—and provided new egalitarian attitudes for viewing practitioners as social useful, particularly in the provincial press. For instance, a physician’s restraint to newer ideas of therapeutics could actually be harmful for the population, especially if there were more effective “empirical” treatments available. Public opinion, shaped by consumerism and “fashions,” also dictated the medical world, directing the popularity of certain practitioners or certain treatments over others.

A different model is presented in David Gentlicore’s Healers and Healing in Early Modern Italy (1998), a work that is essentially a study of medical pluralism: This book is a study of medical pluralism: the diversity of healers and forms of healing in the kingdom of Naples from 1600 to 1800, particularly from the standpoint of the sick people. Like Cook and Pelling, Gentilcore undermines old myths about early modern medicine, particularly the notion that all healers were neatly categorized accordingly to the pyramid of physicians, barber-surgeons, and apothecaries. Instead, Gentilcore argues that this neat division did not apply to Italy as it did in England; not only were physicians in liberal supply, but many of titles and formal structures they held did not always reveal the practices of healing. Instead, Gentilcore advocates a “medical sphere” model, showing how all types of healers and all explanatory models of illness co-existed, overlapped, competed, and contributed to one another. This model consists of three main divisions that all overlapped with each other—popular, ecclesiastical, and medical—and emphasizes overlapping, but not homogeneous healing communities. Medicine in early modern Italy thus was a complex affair involving physicians, surgeons, apothecaries, official state bodies, quacks, charlatans, magic, religion, and astrology; different kinds of professional boundaries were also created (e.g. “popular healing,” “cunning folk,””midwifery”). On the discussion of irregular practitioners—charlatans, quacks, itinerants, mountebanks—Gentilcore argues that they were far from being automatically labeled as tricksters (e.g. as with the Orivetan case). Even official licensing bodies, such as the Protomedicato, did not aim to impose a unified form of medical practice or eliminate the presence of charlatns; defending the distinctness of each type of healer, official bodies rather aimed to regulate the circulation and growth of charlatans and maintaining professional boundaries. Additionally, Gentilcore argues that patients played as much as of a role in constructing medical pluralism as official bodies and economic concerns: patients were as driven towards their choice of healers as much as by their cultural allegiances to a particular set of healers within their communities. The decline of the medical pluralism in 18th century Naples, Gentilcore argues, was the result of the emergence of a “medical consensus” which strove to create two separate healing cultures (“high” and “low”), a reason he alludes to the enlightenment trends of the period.

Gentlicore’s Medical Charlatanism in Early Modern Italy (2006), on the other hand, is a book about charlatans in early modern Italy: how they were represented, how they saw themselves, and how they were placed within their societies. Charlatans were more than “people who appear in the square and sell a few things with entertainment and buffoonery” (2) or curiosities on the fringes of medicine. Instead, Gentilcore defines “charlatan” as a definable identity—less than a term of abuse and more like a generic, bureaucratic label identifying a category of healer that participated in a trade or occupation. Taking upon an empathetic view of charlatans, Gentilcore argues that they offered health care to an extraordinary wide sector of the population, arguably even wider than physicians. He makes that the multi-faceted nature of Italian charlatanry was also motivated by economic concerns; needing to set themselves apart in an already overcrowded medical marketplace, charlatans often used spectacle and performance to draw attention to their goods and services—but, Gentilcore warns us, we should not use these theatrics as a reason to dismiss the charlatan. Furthermore, Gentilcore questions why the Protomedicato licensed charlatans or tolerated their “behavior,” concluding that the authorities aimed to regulate, rather than dismiss, the variety of healers. In presenting a revisionist correction of the negative role of the charlatan, Gentilcore also emphasizes that charlatans often used the same pharmaceutical ingredients in their treatments, a feature that limited the role of the authorities, who could not prohibit the sale of officially approved medicine. Charlatans, he concludes, also portrayed an important social function by providing a demand within the medical marketplace—e.g. cheaper treatment options, more accessible treatment, etc.—that were limited to patients being treated by “regular” practitioners.

Speaking of quacks and charlatans, Roy Porter’s seminal social history of proprietary medicine and quackery was first published in 1989 as Health for Sale: Quackery in England 1650-1850. In a new edition re-titled as Quacks: Fakers and Charlatans in Medicine (2003), Porter acknowledges that there has been little work published on British quack medicine in the long eighteenth century and that there was a need for a more precise history of quackery apart from its categorical opposition to a  more scientific correct ‘regular’ medicine.  Upon evaluating the changing status and identity of those who were labeled as quacks, Porter makes it clear that his definition of “quack” will not be a timeless, moralizing definition, but rather a historic one that evaluates the behavioral characteristics of certain medical operators; he also avoids any absolute, Platonic, or essential meaning for the application of the term, but takes quacks as ‘the broad spectrum of those operators who were typically pilloried as such.’ Instead of conveying blame or praise, Porter evaluates the varieties of practitioners who peddled quack medicine, contending to Margaret Pelling’s notion that medicine was an occupation and not a vocation. In addition to providing a comprehensive overview of the various ‘types’ of quack medicine, Porter also evaluates the history of medicine as a profession, looking at how market forces, the cash nexus, advertising, and print cultures played a significant role in constructing the medical marketplace.

Anne Digby’s Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (1994) examines the market for medical in 19th century England, examining the interactions between doctors and patients at a time when self-dosing was prevalent. Emphasizing the neglected field of the economic history of medicine, Digby argues doctors’ entrepreneurial activities and their working lives helped to shape English medicine into a distinctive pattern of general and specialist practice. She aims to look at the longer-term dynamics of economic change for practitioners and patients starting from the inception of the first voluntary hospital in 1720 to the National Insurance act of 1911. With much qualitative and quantitative data, Digby examines all aspects of the economic perspective of medicine, from the incomes doctors generated, to patients’ ability to pay for medical goods and services, to the competition for patients and the lack of legislative medical monopoly, and how doctors showed marked commercial flair and versatility in their attempts to expand the medical market. She also provides rich insight into the changing relations between the urban poor and medicine, especially in outlining why and how quacks were more attractive to patients in terms of cheaper costs (e.g. nostrums were popular for their quick and economic means of self-help). Digby also makes the point that the growth of a secular and consumer society that viewed health as a commodity provided a dynamic to sustain and encourage a vigorous commercialism in the medical marketplace; this not only allowed charlatans and quacks to flourish, but also encouraged professionalization as a drive towards a particular ideal or self image that practitioners desired to construct (26). Although concern about quackery waxed and waned accordingly to the state of the medical market, by the 19th century, growing pressure from regular practitioners to create an exclusive medical profession became insufficiently powerful and aimed to create a monopoly for the College of Physicians. Thus, control of the medical marketplace by practitioners became crucial in the process of medicalization as spas, dispensaries, medical charities, and voluntary hospitals became essential to English society.

Colin Jones’ article, “The Great Chain of Buying: Medical Advertisement, the Bourgeois Public Sphere, and the Origins of the French Revolution” (The American Historical Review vol.101 (1996): 13-40)is my absolute favourite essay ever; I read it every time I’m in need of some inspiration. The Great Chain of Buying (a pun on Arthur Lovejoy’s The Great Chain of Being) is a horizontal concept grounded in human sociability and exchange and posits an open and relatively egalitarian social organization undergirding a commercial society. The article aims to build a historiographical consensus intersecting three areas: the economic origins of the French Revolution, the medical profession, and the provincial press. Jones also attempts to restore credibility to a historical approach emphasizing an economized version of capitalism, particularly Habermas’ bourgeois public sphere; it is from this sphere, Jones argues, in which political and revolutionary actions emerges. Jones focuses his historical examination to the archives of the Affiches, the provincial newspapers of France that specialized in advertising while still carrying news and commentary. According to Jones, the Affiches confirm the presence of Habermas’ public sphere and the role of the public in constructing an ideology based on public opinion: as the Affiches were directed to merchants, traders, businessmen and the like, not only was the public sphere bourgeois, but since the editors wouldn’t publish anything to offend their readers, there also existed an ideology implicit in the press viewed as “public opinion.” Furthermore, Jones argues that the Affiches also contained a particular ideology implicit in their advertisement, that is, the notion that commerce would lead to a higher level of civilization and a greater degree of human happiness. Jones analyzes this point by focusing on medical advertisements in the Affiches, arguing that they are relevant for three reasons: 1) advertisements for medical products and services provide historical evidence for a growing medical entrepreneurialism; 2) medical advertisements reflect the growing demand for medical goods and services as well as a growing consumer base; 3) preoccupation with health and the body also had important political implications (e.g. health of the body = health of the nation). As complex as Jones’ argument is, his primary goal in emphasizing the role of the bourgeoisie in participating in the political and social fervor of the nation is important for constructing a historical examination of the lives and thoughts of a large section of the population.

Finally, Mark S.R. Jenner and Patrick Wallis’s Medicine and the Market in England and its Colonies, c.1450-1850 (2007)seeks to undertake a critical examination of the term “medical marketplace” and unpack its various ambiguous meanings. Broadly focusing on the nature of the medical provision and its economic, institutional, cultural and political contexts, this work presents a series of essays that evaluate the scale, scope, and boundaries of the internal dynamics of the market for medicine. Some of the key questions addressed are: what emergences in the medical marketplace? Is the term “medical marketplace” in due of a revision, as Margaret Pelling has argued? Is medicine to be viewed as a market or an economy of health care (and is there a difference)? How do we use a model of the marketplace to historicize and analyze the structure of therapeutic practice and its complex internal and external dynamics? Should historians shift their thinking from an abstract and generalized concept as “medical marketplace” towards a more focused concept of medical goods and services?

Although each essay in the anthology holds its own merit, Michael Brown’s “Medicine, Quackery and the Free Market: The ‘War’ against Morison’s Pills and the Construction of the Medical Profession, c.1830-c.1850” best closely relates to my own research interests. Making the point that while the 18th century has been characterized by a fluidity and plurality of knowledge and practice as well as a cultural of commercial individualism, Brown notes that the 19th century rather saw a hardening of boundaries and the elaboration of more antagonistic cultures within health care (239). He accounts for this shift by building upon Roy Porter’s explanation of the two factors governing the 19th century: the emergence of medical professionalization and medical reform. Within this historiographical context, Brown sets out to explore the mechanisms of the transformation of the mid-19th century English medical marketplace and evaluate how the anti-quackery campaigns of the 1830s and 1840s sought to radically restructure the commercial states of medicine and its relationship to the public (240); he does so by examining the (ideological) “war” against Morison’s Pills, which was a part of a wider attempt to establish the social, legal, and intellectual authority of “orthodox” medicine. He also emphasizes in this paper that the movement for medical reform is essential for understanding the changing perceptions of “quackery” within the 19th century.

There’s lots more scholarship on the topic, more than I can ever write in a blog post, but I hope this is a good beginning  for those interested.

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