The persona of the physician in the early German Enlightenment: An analysis of the mediation of epistemic strategies in medical textbooks and advice literature

Abstract

This article uses medical textbooks and advice literature to analyze the persona of the physician in the early German Enlightenment. The article pursues three lines of argument. First, it uses medical textbooks to situate the physician in the context of early modern observational life, focusing in particular on epistemic virtues, techniques, and technologies for conducting and documenting observations. Second, it introduces the concept of epistemic advantage to analyze the ways in which medical advice literature – ranging from ideal accounts of the political physician to satirical portrayals of the Machiavellian physician – mediated strategies for using medical knowledge to shape people’s conceptions of disease as well as of the physician as a medical authority. Third, it launches the concept epistemic contestation to capture situations of distrust and dispute, in which the physician’s authority was challenged both by patients and by other medical practitioners. Such mediation of epistemic virtues, techniques, technologies, and strategies in medical textbooks and advice literature must be understood in relation to an emerging media landscape that fundamentally affected the conditions for cultivating and performing a medical persona. By adopting this comprehensive approach to medical personhood, the article appeals to readers interested in early modern and Enlightenment medicine as well as those concerned with the broader intersections of medical persona, authority, power, and knowledge.

Introduction

Historians of medicine have long pondered how to interpret the expansion of medicine in the Enlightenment. ¹ Why did physicians enjoy increasing recognition and status despite continued high death rates, modest progress, and reliance on risky and often feared treatments such as bloodletting? Intrigued by this paradox, historians have proposed a number of explanations. While some have argued that physicians did make some clinical progress after all, others have highlighted their political and organizational skill, their ability to capitalize on their status as learned authorities, and their readiness to promote this picture in new and popular media forms. ² Underlying the latter explanations is the social constructivist assumption that physicians were able to meet society’s expectations precisely by shaping them, by creating and controlling the concepts and narratives of disease and of themselves as medical authorities. ³ Yet, even if departing from this slightly narrower assumption, the question of how physicians shaped societies’ expectations still involves a range of actors, institutions, technologies, genres, discourses, and concepts that can all be addressed in a number of different ways. An answer can therefore only be cumulative; each analysis contributes another piece of the puzzle. This article does so by analyzing the shaping and negotiation of such expectations in the medical textbooks and advice literature of the early German Enlightenment. While these genres had long existed, the early German Enlightenment stands out as a period when more efficient and cheaper printing technology turned physicians into public writers who could use popular and lucrative genres both to promote their own medical personae and to tap into and direct ongoing debates on medical authority and power. To further explore this context, the article zooms in on the mediation of epistemic strategies. By this I mean the mediation of strategies that harnessed medical learning, clinical skill, and social ability to perform, maneuver, and maintain medical authority in encounters with patients, lay people, and other medical professionals. Such strategies involved decisions about whom to treat; how to treat; how to interpret and present diseases, disease processes, treatments, and outcomes; and how to deal with objections and failures. By labeling these strategies epistemic, I want to underscore the role of medical knowledge in this broader sense. By emphasizing mediation, I want to highlight the active role of physicians as authors in shaping, negotiating, and disseminating these strategies. The concept offers a dynamic analytical approach to a context in which medical authority and power were intimately intertwined with writing.

Against this background, the article pursues three lines of argument. First, it draws on the concept of persona as an office, and on the connected analysis of epistemic virtues and techniques, to analyze the physician. The analysis focuses particularly on how the persona of the physician featured epistemic virtues, techniques, and technologies adopted from both medicine and philosophy. Second, it introduces the analytical concept of epistemic advantage to analyze the ways in which the increasingly popular literature on the political and the Machiavellian physician provided extensive and concrete advice on how the physician should conjoin and mobilize medical learning, clinical skill, and social ability to shape people’s conceptions of disease as well as of the physician as a trustworthy medical authority. Third, it launches the analytical concept of epistemic contestation to capture situations of distrust, where patients challenged physicians’ expertise using their own medical concepts and discourses and where fellow practitioners were sometimes allies and sometimes cunning competitors. The final section revisits the central question and discusses what conclusions can be drawn, focusing on how the material constituted a central aspect of an emerging media landscape that in many ways changed the conditions for the formation of a medical persona and for the performance of medical authority. Rather than passively reflecting reality, these sources represented active, lucrative, and potentially effective attempts to negotiate and shape it through writing.

The persona of the physician

The analytical concept of persona has emerged in recent decades as a powerful tool for understanding socially recognizable types or offices in the early modern period. ⁴ To understand offices such as the natural philosopher, the experimentalist, the mechanicus, or the metaphysician, it is necessary to pay attention both to practices of self-fashioning and to the larger social and institutional contexts in which identities were recognized and negotiated. ⁵ It was thus by refining the senses and the intellect and by cultivating epistemic virtues such as attention, diligence, discipline, and control, alongside epistemic techniques for producing, documenting, and circulating new truths and facts of nature, that philosophers were able to challenge the scholastic tradition and to reform science. ⁶

Just as the reformation of science was possible only given the existence of the kind of persons necessary to carry it out, so too the medical reform sometimes referred to as the medical Enlightenment can be understood as directly linked to a specific type of medical persona. ⁷ Many leading early modern physicians thus crafted their accounts of medicine and the physician in relation to the discourses and practices of the new natural, experimental, and eventually mechanical philosophy. ⁸ While this development appears to have taken place gradually in the sixteenth and seventeenth centuries in Italy, France, and England, in the German territories it began only in the second half of the seventeenth century, with the Academia Naturae Curiosorum (known as the Leopoldina) and the Universities of Jena and Halle as important sites of knowledge production. ⁹ While scholars have long acknowledged that the Leopoldina was modeled on the Italian tradition of collecting and synthesizing medical knowledge, Ian Maclean has shown that British experimental philosophy became increasingly important from the 1670s. ¹⁰ Similar points have been made by Vera Keller, who has argued that the Leopoldina was especially progressive when it came to the synthesis and mediation of knowledge by various medical figures such as learned physicians, apothecaries, surgeons, and midwives. Drawing on work by historians of science, she concludes that the members thus skillfully combined social and literary technologies for the production and dissemination of medical knowledge. ¹¹ Similarly, scholars have shown that the Universities of Jena and Halle played key roles in the advancement of a medicine based on the new natural, experimental, and mechanical philosophy. ¹² Founded in the 1690s as a direct result of an educational reform that emphasized useful knowledge over a scholasticism considered hopelessly cumbersome and retrograde, Halle attracted some of the most progressive physicians of the time. ¹³ The leading German physicians Friedrich Hoffmann and Georg Ernst Stahl, who both studied medicine in Jena before moving to Halle, and who both became members of the Leopoldina, were products of and prominent players in this development. ¹⁴ Hoffmann thus cultivated close ties with a large number of progressive philosophers and physicians during his travels in the 1680s before launching his own iatromechanical system of medicine, first in the programmatic Foundations of Medicine from the Mechanical Principles of Nature (Fundamenta medicinae ex principiis naturae mechanicis, 1695) and then in the monumental multivolume Systematic Rational Medicine (Medicinae rationalis systematicae, 1718–40). ¹⁵ At the core of Hoffmann’s system was the assumption that the physician must combine rigorous empirical observations with reasoning based in learning and particularly an iatromechanical understanding of physiology and pathology. ¹⁶ In encounters with patients, the physician should observe every minor detail and collect information about the specific condition as well as patients’ general constitution and habits. This information should then be carefully documented and collected in catalogues of cases and diseases. “True experience is born from observations documented with great care, which include the entire history of the disease, with all the circumstances pertaining to the matter, from which the greatest utility of medical observations is evident.” ¹⁷ Similar points were made by Hoffmann’s colleague and competitor Georg Ernst Stahl, who, in Clinical-Practical Observations (Observationes clinico-practicae, 1718), emphasized that physicians ought to combine the use of disease histories with clinical observations of symptoms and inquiries into patients’ constitutions and habits. ¹⁸ In the Stahlian Practice (Praxis Stahliana, 1728), the author suggested that the physician should include in the anamnesis information about the constitution of the subject or the sick – temperament, sex, age, diet, habits, hereditary dispositions, mental illness, previous diseases, excretions; and about the specific illness – whether it is sporadic, epidemic or endemic, acute or chronic, simple, compound or complex, solitary or connected to other diseases, conventional or unconventional, frequent or sporadic, fierce or mild, inclined toward death or recovery, easily transformed into other diseases, or prone to relapsing. ¹⁹ The author further recommended that physicians visit each patient several times, sometimes several times a day, depending on the severity of the condition, and that they keep careful records of their work.

A Medicus or Practicus, if he wants to keep his affairs in order, must keep a regular diary, and enter everything that he encounters daily with all the circumstances also all the various prescriptions: so he can find after many years what he wants; and also sometimes consider in what his practice has improved or worsened. . . . I staple together a) for a whole year 6 to 7 sheets of paper in long octavo, make 2 columns on each page, and call this a memorial: in this booklet I only note the names of my patients, the visits, and the formulas contained in the prescriptions. . . . Next to this booklet I keep another diary, also bound in long octavo, and consisting of a book of paper: in this I write, according to the order of the previous one, during the day at an idle hour, or in the evening, what I have encountered with each patient during that day. ²⁰

The second bound diary was particularly useful when it came to analyzing and drawing conclusions from specific cases.

With regard to the bound diary, remark that I notice the year and date on which I started it on the outside of the edging; so I can find in time of a quarter of an hour what I have from several years ago. If I now want to apply even more diligence, and draft useful observations from this diary; so after completing the course of treatment, I take a case in particular before me and add my reasoning, remonstrate or reflect on how this or that change came about, how the medications behave, and what possibly contributes the most to health, or what has been conducive to another’s death. ²¹

Although the persona of the physician, as well as the epistemic virtues and techniques attached to it, were partly adopted from natural, experimental, and mechanical philosophy, there was in fact a long and profound medical tradition of conducting, documenting, and communicating observations. As regards the early modern context, Michael Stolberg has shown in a recent pioneering study that clinical bedside observations were probably much more common in sixteenth century Italy than historians have previously believed. ²² From around the same time, it also became increasingly common to compile observations into medical case histories (Historia morbi/Observationes). ²³ Gianna Pomata has convincingly argued that collections of medical cases constituted an epistemic genre in the sense of a literary technology for the collection and organization of the raw material of medical experience. ²⁴ Drawing partly on Pomata’s notion of epistemic genre and partly on Ursula Klein’s concept of paper tools, Volker Hess and Andrew Mendelsohn have studied in some detail the forms and functions of such technologies in medicine from the seventeenth to the twentieth century, focusing particularly on how various kinds of notes and records were composed into extensive disease histories. ²⁵ In a similar vein, Stefanie Retzlaff’s study of early- and mid-eighteenth-century Germany has shown that Hoffmann, Stahl, and many other physicians relied heavily on these technologies for the production and circulation of medical knowledge. ²⁶ In a recent publication, Mendelsohn has pushed the analysis even further by suggesting that documentation and accountability constituted a central feature of a civic medicine, at the core of which was the physician who collected, compiled, and mediated knowledge and knowledge practices, thereby shaping society far beyond the field of medicine. ²⁷ In a similar vein, Chiara Crisciani has suggested that the physician was an expert among experts in the sense that, through the very performance of his persona, he exemplified what an expert is and should be in society. ²⁸

In terms of case histories, one particularly interesting source is the multivolume Consultative Medicine (Medicina consultatoria, 1721–39) in which more than 600 cases were presented in some detail. ²⁹ Although the analyses were framed for the reading public as the result of discussions held at the Faculty of Medicine, there is no indication of who else besides Hoffmann himself was involved, nor of how the meetings actually unfolded. Retzlaff has suggested that many cases were sent to the faculty and that Hoffmann’s role was to select, analyze, and compose some of these for publication – essentially working as a writer who, in addition to his clinical work, spent much time compiling textbooks and medical case histories. ³⁰ This picture of Hoffmann aligns with Mendelsohn’s account of a civic medicine in which knowledge production was intimately conflated with writing and mediation. ³¹ Against this background, the Consultative Medicine mediated Hoffmann’s ideal of a “rational medicine” that combined reason and experience, theory and practice, observations and demonstrations. ³² In the introduction to the first volume, Hoffmann thus remarked that the reason why many physicians perform so poorly is that they often draw hasty and incorrect conclusions from inadequate observations. ³³ It was important to rigorously conduct and record observations and disease histories and to systematically analyze and draw conclusions from this material. While the former demanded sensory discipline and focused attention, the latter required judgment.

But in order to be able to discover more and more unknown truths from known ones, and to resolve the cases and observations, and to use them correctly, it is necessary that the physician have a good judgment, meditate diligently, evaluate all things and competing circumstances well, take time for it, and see how he is to assert his conclusions. ³⁴

Against this background, Consultative Medicine provided, in the German language, an extensive and exemplary account of how to analyze and draw conclusions from specific observations and cases and to derive more general truths from these. The first, particularly elaborate, case revolved around a man who became suddenly ill and died nine hours later. Sempronius was a slightly hot-tempered fifty-six-year-old man who, apart from occasionally taking some medication for an upset stomach, “was vigorous, healthy and lively, with a good appetite, had carried out his master’s business without hindrance, had even eaten on the day of his death, had not complained of anything when rising at four o’clock in the morning on October 3, 1719.” ³⁵ He drank three or four cups of chocolate with cinnamon served by his daughter before leaving on horseback at about five in the morning. Not long afterwards he began to complain of stomach pains, and after returning two hours later he suffered severe vomiting and was put to bed. He then deteriorated rapidly, threw up a lot of phlegm and bile, had diarrhea and complained of cold hands and feet and of a severe tearing and cutting pain in his abdomen. At noon, around two hours before death, his pulse was so weak that the barber could hardly feel it.

Not long before his death he became all red and flushed in the face, lost his speech, and finally passed away after 2 hours, so that from the ingested chocolate to the death 9 hours passed. After death, no particular tumor or swelling of the abdomen was felt, although the nails on the fingers were blue, and some blue streaks were visible from the neck to the armpit, but on the chest and left sides here and there small stains, the size of needle buttons, could be seen, but in the face he looked as if he were alive. ³⁶

Given the severity and rapidity of the illness, the question was whether Sempronius had been poisoned or rather died of a disease. To determine this, the collegium systematically ruled out a number of diseases (heart attack, cholera, dysentery, and acute colic were consistent with some but not all symptoms) before returning to the question of poisoning. Discussing this possibility in more detail, it turned out that the medical literature in fact quite unambiguously listed the symptoms of (1) sudden illness, (2) violent vomiting, (3) great coldness in hands and feet, (4) stomach pain and diarrhea, (5) weakened pulse, (6) convulsions shortly before death, and (7) streaks and spots on the deceased’s abdomen as typical for white arsenic poisoning. Given that these symptoms were exactly those exhibited by Sempronius, that white arsenic was more or less universally available, and that the daughter held a grudge against her parents, misbehaved, and also had a relationship with one of the farmhands (these latter factors were labeled “moral causes” and “external evidence”), the collegium concluded that she had poisoned her father by mixing arsenic in his chocolate. ³⁷

The case of Sempronius provides a glimpse of what the ideal of “medical rationality” looked like in practice. The physician should strive for a broad picture in which specific symptoms, the patient’s constitution and lifestyle, and even social factors ought to be taken into account. Alternative explanations should be listed, carefully considered, and systematically ruled out before a diagnosis could be established and medication prescribed or, as in this case, a cause of death established.

The persona of the physician took shape through a multilayered medical practice where observations were conducted, assembled, and documented, where information should be compared and analyzed in relation to existing medical literature, where different explanations and conclusions had to be carefully considered, and where, over the years, the physician built up a considerable archive from which general lessons could be drawn and disease histories composed. Thus, the physician was at the very core of what historians of science have described as the early modern observational life. ³⁸ Much like the natural and experimental philosopher, the physician should cultivate sensory and intellectual virtues in order to become a keen, disciplined, and patient observer with sharp attention, judgment, and reasoning skills. While the persona of the physician, as well as the epistemic virtues and techniques attached to it, was indeed modeled on natural and experimental philosophical templates, it also reflected historically significant paper technologies and epistemic genres from the field of medicine. It is important to note that these – ranging from brief daily notes to the compilation of extensive medical histories – structured medical thinking and thus also the medical persona. The performance of the persona of the physician therefore cannot be understood without them.

Another important factor epistemically distinguishes the situation of the physician from that of the natural and experimental philosopher. As historians of science have emphasized, the experimental epistemic logic worked since technologies such as air pumps, telescopes, and microscopes revealed new and hitherto unknown phenomena that could be witnessed, documented, and circulated to the wider community. ³⁹ From a modern perspective, these technologies thus worked in the sense that they established new indubitable facts and truths of nature. Although experiments also proliferated in medicine, the field as a whole continued to be characterized by the discrepancy between physicians’ advanced diagnostic skills and their equally inadequate therapeutic abilities. ⁴⁰ In fact, from a modern biological point of view, most therapies and medicines did not work. Instead, the body remained a “black box” where, as Hoffmann emphasized, it was often difficult to assess the true efficacy of medicines. What made this problem even worse was that not only physicians but also patients and the broader public were acutely aware of these limitations. A steady stream of cartoons, pamphlets, and satires mocked physicians and often asserted that avoiding treatment was usually the best option. ⁴¹ It is against this background that French and others have argued for a social constructivist interpretation, emphasizing the ongoing struggle of physicians to manage public expectations of medical practice. In this endeavor, epistemic virtues and techniques for conducting, analyzing, accumulating, and documenting observations and experiments were essential for establishing medical authority in clinical situations. At the same time, however, these situations themselves became increasingly prominent topics in the medical advice literature. For this reason, in addition to reconstructing clinical situations from medical textbooks, we must also consider how these very situations were represented in the advice literature. Far from being merely supplementary, this popular and profitable genre played a pivotal role in negotiating and disseminating the norms that defined the persona of the physician in the early German Enlightenment. To explore this dynamic, the following section shifts focus from academic publications to the mediation of epistemic advantage in medical advice literature.

Mediating epistemic advantage

The concept of epistemic advantage is used here to capture specific strategies by which the physician could apply his medical knowledge – in the broad sense of learning, clinical skill, and social ability – to shape people’s perceptions of disease as well as of physicians as reliable medical authorities. Strategies for applying medical knowledge were thus also social strategies useful in specific situations. The medical literature had long provided instructions on how to achieve this form of control. Hippocrates thus stressed that it was crucial for the physician to cultivate and maintain his reputation through proper clothing and manners as well as the display and strategic use of medical equipment, learning, and practical knowledge. ⁴² This kind of advice appears to have occupied a fairly stable and important position in much medieval, Renaissance, and early modern medical literature. ⁴³ Stolberg has shown in a number of studies that strategies for mobilizing authority played an important role in sixteenth- and seventeenth-century medicine. Similar points regarding medical “authorization” have been made by Dominik Groß and Jan Steinmetzer. ⁴⁴ Jumping forward to seventeenth- and eighteenth-century Germany, we find Hoffmann, for instance, emphasizing that “the physician should proceed cautiously, for he can easily lose his reputation by a rash prognosis.” ⁴⁵ In a similar vein, the author stressed in Stahlian Practice that the physician, “apart from visiting the patient . . . must also be diligent in recording the circumstances and coincidences of the illnesses, so that he not only knows the true history of the illnesses, but that such observations of cases can also serve to save his honor and reputation in cases that arise.” ⁴⁶ This point is important as it suggests that the kind of paper technologies we discussed earlier not only served an epistemic function, but were also mobilized in social contexts to establish and secure medical authority. Within the broader context of civic medicine suggested by Mendelsohn, we see once again how documentation and accountability were integral parts of the physician’s persona. ⁴⁷ Yet, in order to chart the increasingly comprehensive and concrete mediation of epistemic advantage, we need to address the new media landscape and shift focus from academic textbooks to medical advice literature.

New, cheaper printing technologies not only enabled physicians such as Hoffmann and Stahl to publish their own magnum opuses but also paved the way for an increasingly popular body of medical advice literature. ⁴⁸ Although toward the end of the seventeenth century vernacular publications became more common, the fact that this literature was either written directly in the vernacular or translated from Latin into German testifies to the ambition to attract a wider readership. ⁴⁹ In seventeenth- and eighteenth-century Germany, a particularly popular genre ranged from idealized accounts of the political physician to satirical and mocking depictions of the Machiavellian physician. ⁵⁰ On the one hand, the genre reflected a long tradition of handbooks and advice literature. As Pamela Smith has shown, the rapid increase of handbooks in the fifteenth century brought about a shift from oral to written knowledge. ⁵¹ The handbooks not only transmitted but fundamentally structured and organized knowledge in ways that were crucial to early modern science. Similar points have been made by Matthew Eddy, who has used the concept of paper machines to capture the way in which paper technologies such as notebooks structured human cognition and knowledge production in the early modern age. ⁵² This argument applies to the type of notebooks in which Hoffmann, Stahl, and others wrote as part of their clinical practice, but could also be extended to aspects of the advice literature. On the other hand, the advice literature also reflected the more immediate context of what Mendelsohn and others have referred to as civic medicine. ⁵³ The genre was part of a changing media landscape in which it became newly possible and important for physicians to mediate their medicine and, by extension, their own personae. ⁵⁴ Publishing both serious and mocking medical advice literature was a lucrative and effective way for physicians to provoke debate that simultaneously drew attention to themselves as public figures. Wolfgang Eckart has emphasized that in this context “political” (politicus/politische), unlike today’s understanding of the term, referred to norms and virtues in the overlap between private and public. ⁵⁵ The genre thus concerned how the physician should be and behave, as did its counterpart on the Machiavellian physician. In other words, these genres featured the very persona of the physician. As Eckart and others have argued, both reflected and shaped a larger discourse that was ultimately fueled by the rather obvious discrepancy between the physician’s pretentions and his limited capacity. ⁵⁶ While this is certainly an important aspect, I argue that these contrasting depictions in fact shared underlying assumptions regarding how physicians could mobilize epistemic advantage in relation to patients and society at large. The analysis focuses on Hoffmann’s Political Physician (Medicus politicus, 1738; Politischer Medicus, 1752), Johann Samuel Carl’s Decorum Medici Purged of the Machiavellian Follies and Set Up According to the Standards of Christianity (Decorum medici von denen Machiavellischen Thorheiten gereiniget und nach dem Maaß-Stab des Christenthums eingerichtet, 1719), Johann Friedrich Zehner’s Medical Morals (Medicinische Moral, 1741), Jakob Barner’s anonymously published Machiavellian Physician (Machiavellus medicus, 1698; Der medicinische Machiavellus, 1722), and Ernst Gottfried Kurella’s Discovery of the Maxims of Becoming a Famous and Rich Physician without Wasting Time and Effort (Entdeckung der Maximen ohne Zeitverlust und Mühe ein berühmter und reicher Arzt zu werden, 1750). ⁵⁷ While Hoffmann’s, Carl’s, and Zehner’s works fall within the category of the political physician, Barner and Kurella provide “Machiavellian” accounts.

The question of reputation featured infrequently in Hoffmann’s and Stahl’s academic textbooks but was a central concern in the political and the Machiavellian literature. A first important consideration was the severity of disease. While mildly ill patients are likely to recover and bolster the physician’s reputation regardless of treatment, those who are severely ill place higher demands and pose a greater threat of failure. In the case of “incurable diseases,” Hoffmann bluntly recommended that “it is best not to deal with them.” ⁵⁸ Furthermore, the question of social status added complexity to the matter. On this issue, the political and the Machiavellian literature agreed: it was more profitable and beneficial for one’s reputation to take on patients from the upper strata of society since “the more respectable they are, the more honor he gets when he has helped them.” ⁵⁹ That said, the stakes were also higher because powerful people were more prone to damage or even ruin one’s career in case of failure. For this reason, it was important to be careful when treating seriously ill patients from the upper classes, to watch one’s tongue, and to take precautions such as appointing a second attending physician who could share responsibility and reduce the spread of rumors. ⁶⁰ Carl, whose Decorum Medici was written in direct opposition to the Machiavellian literature, advised readers to stay away from the court, an environment that, in addition to being dangerous, also threatened to drag the physician’s soul into depravity. ⁶¹ Regarding social class, in the Machiavellian Maxims of Becoming a Famous and Rich Physician, Kurella gave the particularly cynical advice that seriously ill poor people offered a unique opportunity to safely experiment with medicines. “He also has the advantage of being able to test the nature of such poor patients, who are of low origin, and see which remedy is best in this or that case, in order to be able to proceed more safely with others in the future.” ⁶² While political and Machiavellian literature often overlapped in their advice, this passage is typical of the way in which the latter portrayed the physician as a ruthless opportunist driven solely by desire for wealth and fame. Nonetheless, these portrayals differed primarily in their intentions and motives; both shared the assumption that the physician could and should use his knowledge – that is, his epistemic advantage – to socially strengthen medical authority and reputation.

A second group of considerations revolved around the patient encounter in the broadest sense, including relatives, friends, staff, and others who might be present. The need for doctors to be educated was emphasized fairly universally. After all, it was this feature that distinguished the licensed physician from “apothecaries, chemists, surgeons, barbers, barber-surgeons, occultists, tailors and stonemasons, bakers, hucksters, cleaners. . ., midwives and nurses, . . . old women, swindlers, crystal seers, village priests, hermits, mountebanks, jesters,” to mention just a few of those competing practitioners who populated the largely unregulated medical market in the early modern period. ⁶³ While the political texts highlighted education as vital to the establishment of trust and respect, typically by depicting the physician as a learned, honest, and modest Christian, the Machiavellian literature emphasized learning as a more active means of power. ⁶⁴ The physician should thus gain trust by combining small talk with learned terms and discourses in Latin. ⁶⁵

If appearance and manner were important, so was the number of visits. In the Political Physician, Hoffmann advocated frequent visits since “the presence of the physician inspires confidence in the patient, and the hope he gives of recovery lifts the patient’s spirits.” ⁶⁶ In addition to establishing trust, frequent visits also provide important information on the development of the disease, which might allow the physician to establish a prognosis. The Machiavellian literature also stressed the importance of frequent visits during which the physician established trust, instilled hope, and collected useful information by diligently observing the patient. ⁶⁷ Underlying this apparently similar advice, however, were the considerably more worldly prospects of reputation, fame, and wealth. Paying frequent visits to patients, and staying no matter the disease, made a good impression; establishing trust and even reliance secured future customers; and thoroughly examining the patient provided crucial information for strategic decisions.

A third group of considerations concerned diagnosis and therapy. Hoffmann emphasized that the physician should “observe the disease and the patient, notice the signs, and daily note the particular changes. In all cases, a practitioner should know the nature of the place, the order of food and drink, the nature of the waters and persons.” ⁶⁸ This involved studying external signs of disease, taking the pulse, studying the urine and stool, but also obtaining information on temperament, eating and drinking habits, and so on. In Medical Morals, Zehner recommended that the physician should enter the sickroom quietly and discreetly, observing the patient’s condition with minute accuracy, and inquiring into the symptoms and cause of disease. ⁶⁹ This information should then be noted down, carefully analyzed, and kept for further use. ⁷⁰ As for severe or deadly cases, Hoffmann emphasized that the physician should still be cautious in his diagnosis. “He can say that there is danger, and that many have died who were in the same condition, but one should hope for the best; however, one should not neglect the contemplation of death, because it is required of every Christian, even if he is perfectly healthy, to be ready to die.” ⁷¹ Giving patients hope strengthened their ability to fight disease, but at the same time the physician should not promise anything. If diseases were particularly severe and uncertain, “the physician should be cautious in his prediction and make such a judgment in regard to health or death, from which the inquirers will not know what to conclude.” ⁷² Carl underscored in Decorum Medici that it was important to be honest, but that one should sometimes downplay dangers in conversation with patients while being more open with relatives. ⁷³ Similarly, Zehner remarked that “in certain and very special cases, it could be allowed to use a little white lie, especially in the case of sensitive people. . . . Or to pull the wool over the patients’ eyes, or to use strategy.” ⁷⁴ As Mariacarla Gadebusch Bondio has shown, there was a long tradition, going back to Hippocrates and Galen, of qualifying whether, to what extent, and in what contexts physicians should tell the truth to their patients. ⁷⁵ Generally, it was recommended to downplay truths that could deprive patients of hope and worsen illness. From the Renaissance into the early modern period, this discussion flourished in medical textbooks and advice literature.

While Hoffmann, Carl, and Zehner stated that vague advice or even white lies could sometimes be preferable, the Machiavellian literature inverted this logic by claiming that the physician could in fact profit from exaggerating the severity of diseases.

He must declare the diseases, however minor, as severe and dangerous, to then immediately provide great relief, yes! a perfect improvement must be promised, so that, if such occurs, it may be said that he has cured a serious and very dangerous disease. This has the advantage that if the patient passes, then he has freed himself in advance from a bad repute, but if he gets well, then he can increase all the more his merits, that he has so happily cured such a serious disease. ⁷⁶

According to the Machiavellian literature, the physician should furthermore be careful not to expose his own ignorance. If encountering an unknown, dangerous disease, he should feign expertise and prescribe a suitable treatment. ⁷⁷ When prescribing medicines, the physician should replace the names of well-known remedies with his own eye-catching names in German, as though they were his own inventions. ⁷⁸ Prescriptions should be “written big and spacious because then people believe them so much more,” and when treatment and medication did not work, the doctor should have a number of excuses at hand. ⁷⁹ Thus, one should (1) blame “what happened before the treatment, because before patients got the medicine they generally used other things,” (2) “say that you were called to the patient too late, because generally people in illnesses wait three to four days,” (3) “blame the patient for not keeping the diet,” or (4) “if you cannot blame any other thing for the death, then attribute everything to death itself and to severe disease.” ⁸⁰ Thus, the physician would have a repertoire of excuses at hand for all occasions.

The growing prominence of the physician as a public figure was intimately linked to the new media landscape and to popular genres such as those depicting the political and the Machiavellian physician. Historians of medicine have emphasized that these genres took form at the intersection between medical ideals and reality, between the representation of the physician as a virtuous and competent practitioner, on the one hand, and as a sly and driven careerist on the other. ⁸¹ While acknowledging this central dynamic, I use this literature to spotlight its underlying epistemic logic. Regardless of whether the physician was painted in white or black, whether he was depicted as a Christian benefactor or a Machiavellian puppet master, both strands relied on the assumption that success reflected the ability to mobilize medical knowledge or, as I have suggested, epistemic advantage. By reading the signs of disease, the physician received important information that could be transformed into strategic decisions, which in turn could be dressed up in the language of medicine and presented with the full weight of the medical persona. Clinical experience and skill in combination with medical learning were here crucial to decision-making, which itself was always formed, presented, and adapted to specific social situations. Just as the performance of the medical persona was a social event, so too was the mobilization of medical knowledge.

Elke Maar has used the concept infotainment literature to capture the way in which writers in the German Enlightenment adopted genres that combined entertainment with education. ⁸² These aspects are crucial if we wish to understand why the medical advice literature became so attractive and important for physicians in this context. For them, revisiting this popular and frequently debated topic in an entertaining, partly provocative, yet morally educational way offered important income, a chance of bolstering their public reputation, and a means of shaping and mediating epistemic strategies for securing authority and power in encounters with patients, lay people, and competing medical professionals. The advice literature thus emerges more as a lucrative, beneficial, and active means of shaping reality than as a passive description of it.

Epistemic contestation and medical authority

The analysis of epistemic advantage may give the impression that physicians possessed, as they do today, an epistemic authority that was hard for patients to challenge. Havi Carel and Ian James Kidd have, for instance, shown that such authority allows modern physicians to systematically neglect and minimize patients’ epistemic credibility, thereby subjecting them to epistemic injustice. ⁸³ In sharp contrast, early modern physicians often found themselves in a subordinate position of economic dependence on their patients. ⁸⁴ Edward Palmer Thompson’s now-classical notion of moral economy can be used here to capture the way in which criticism of physicians’ moral character and conduct was often an integral part of patients’ attempts to negotiate fees. ⁸⁵ Yet, as we will see in this section, even if there might be economic incentives at bottom, criticism and negotiation between physicians, patients, and lay people, as well as between various medical professionals, were often epistemic insofar as actors typically claimed different forms of medical knowledge. In this section, I analyze representations of such conflicts in the medical advice literature using the concept of epistemic contestation. By this, I mean precisely the kind of strategic negotiation that could occur when the physician’s medical expertise was challenged. The section first charts epistemic contestation between physicians and patients, then considers similar encounters between medical practitioners.

Academic textbooks sometimes described situations of epistemic conflict. In Stahlian Praxis, the author thus stressed that the medical record, in addition to its purely medical function, could also serve as evidence.

How often does it not happen that one is accused by another as if he had overlooked one thing or another in the course of treatment: if he has not written down the case on paper or recorded the course of the disease daily, how will he defend himself? Memory is slippery, what happened 2 days ago, let alone 2 years ago, is probably forgotten. Yes, there are cases when one has to calculate from 10 or more years ago. Whoever is sloppy in annotations, how will he be able to present a true account or defend himself in a dispute? ⁸⁶

That patients could not be trusted but often constituted potential counterparties was also emphasized in Decorum Medici.

Because it is well known how many bad snares are often laid for the physician, whether one could catch him somewhere, be it with mere words and gestures. The peasants and women lurk with their urine divination, so that they in fact silently put him to the test. How often is the disease and its external causes kept from him out of shame, fear, malice? How do they not feign other interventions than those done by the physician? Saying that it worked well, that they don’t need it after all: secretly consult other physicians and surgeons . . . asking slippery questions, etc. ⁸⁷

The best way to deal with such cunning patients was to cultivate the virtue of wisdom. With this advantage, the physician would not be deceived, and could meet every objection with solid knowledge and medical arguments. The difficult nature of many patients was also emphasized by Hoffmann. If they refused to follow advice, it was best to leave promptly, “so that, when things go badly, the physician is not blamed by unreasonable people.” ⁸⁸ It might also be necessary at times to simply lie, for example by presenting dreaded purgatives as harmless tonics. “[I]f they appeal to the physician not to prescribe such things [purgatives], he may reply that, no, I will not give such things, but I hope you will take a strengthening tonic.” ⁸⁹ One particularly interesting topic concerned how medically specific and detailed the doctor should be in communication with his patients. Whereas in the case of completely uneducated patients an overall explanation often sufficed, reasonably well-educated ones typically required a more detailed account; “if one omits this, the patient thinks that the physician does not understand much.” ⁹⁰ However, there was also a third category of:

learned patients who understand natural philosophy, who have browsed through some curious medical books, and particularly those that are about the condition by which they are afflicted. They have then gradually acquired a not too small science from the long habit and contact with the physician or also through diligent reading of books; they have learned the medical language, albeit at some expense, and therefore often present the physician with the most learned questions, to which it is no small matter to answer. ⁹¹

In such cases, one should speak to the patient as an equal, providing rational and learned explanations of the conditions as well as convincing arguments for possible cures.

Although the political literature stressed that the physician ought to maintain control, meet challenging patients at their respective levels, and avoid unreasonable patients altogether, the relationship between doctors and patients as a whole was not portrayed as particularly conflictual. The Machiavellian literature, in contrast, painted the picture of a more or less constant struggle between opposing wills. Its maneuvers were a direct response to the expectation that patients were likely to attack and blame the physician. While the doctor was often encouraged to use his epistemic advantage to simply overrule patients, here too situations arose that required manipulative negotiation. One such situation described in ironical terms how the physician should handle arguing women. “If women talk about the causes of diseases and cures, although they are not always right, then act as if you had not heard it, and then present their own discourse, as if it came from you, then they will give you applause.” ⁹² Medically knowledgeable, curious, and argumentative women were listed as one of the physician’s many tormentors in the anonymously published The Tormented Physician (Medicus afflictus, 1718). ⁹³

[T]he dear old matrons, who, either driven by their own curiosity, come and begin to tell of and ask about many disputes; or are sent by others, which one is not supposed to know, in doubtful, or even secret women’s affairs, sometimes also things, of which a physician is abhorred, in order to explore his judgment, and to inquire. ⁹⁴

Driven by curiosity or sent to inquire into specific matters, such matrons needed to be dealt with carefully. However, there were, in the “ignorant or sometimes even learned mob” also those who openly challenged the physician’s status. ⁹⁵

Then one says: Yes, the doctor has neglected it, he should have had him bled; another says: If only he had purgated, and used this or that. For example, when treating someone suffering from jaundice, some say: Oh, I would have cured him better than the doctor, I would only have given him to drink for one gold coin; others say: Oh, if he would only look in the vessel for wagon grease, he would probably get rid of it. The third says: if only he bled the vein on the tip of his nose, that would help right away. ⁹⁶

Thus, the questioning of the physician’s authority on the basis of his own medical concepts was not limited to the higher social strata. In addition, there were also particularly eccentric and ungrateful patients. Eccentrics thought they knew better and interrupted treatments to look for another physician, contradicted the physician’s advice, refused to take medicines, only accepted certain quantities and forms of specific medicines, or stubbornly advocated special procedures regarding bloodletting. “[T]he physician does not cure in the right way, if he decrees purging the day on which no such signs of purgation are in the calendar.” ⁹⁷ Even more difficult were the ungrateful and sly patients who stopped treatment when they began to recover, in order to avoid paying; or withheld payment, claiming that they were not yet completely healthy; or admitted they were healthy but claimed that it was due to God’s providence rather than to the physician. ⁹⁸ That monetary issues drove the criticism of physicians’ competence and moral character reflects the medical moral economy of the time, where prices were essentially negotiable and where patients could bargain by combining epistemic and moral arguments.

Situations of conflict and epistemic contestation took place not only between physicians and patients but also among medical practitioners. The political literature generally advised the physician to cultivate good relationships with other physicians as well as established practitioners such as apothecaries and surgeons. ⁹⁹ In relation to the two latter, he should acknowledge their expertise while (as the supreme medical authority) keeping a close eye on them, double-checking prescriptions and surgeries. As Keller has shown in her study of the Leopoldina, there was a delicate balance between maintaining clear boundaries with competing medical professions on the one hand, and cooperating with, benefiting from, and integrating their knowledge into learned medicine on the other. ¹⁰⁰ The Machiavellian literature, while representing serious medical practitioners mostly as allies (although subordinate ones), was more ambivalent on this point. On the one hand, the physician should exclude the common people by speaking Latin with other physicians, just as it was important to find allied physicians when patients and the public threatened to tarnish his reputation. On the other hand, like most craftsmen, doctors also hate each other. ¹⁰¹ Hence, Barner recommended three strategies in the Machiavellian Physician. If the patient of another physician dies, one should pay close attention to whether medically qualified women and lay people more generally blame the remedy itself or the doctor, and if so, one should make sure to provide a more specific reason for the failure. “So you say, yes, of course, and add a reason, because they will secretly slander him and say, yes, he has done it.” ¹⁰² A second approach was to question whether the ingredients in the prescription really complement each other and to then consult the pharmacist in order to have this suspicion confirmed. The third strategy was to question another physician’s advice. “Blame only some advice, which he gave, say: I am afraid it is too hot, Madam, don’t you notice the heat. The bystanders will take the hint and conclude that the physician has been negligent. Afterwards, change this supposed mistake into a bigger one, and tell it to others secretly.” ¹⁰³ That many physicians do their best to damage each other’s reputation was also emphasized in The Tormented Physician. The author distinguished between direct and indirect ways of doing so.

Directly this happens when one discredits another with words, and cannot listen to others praise him without objecting, nor regard him without anger, when others go to him and consult him; when trying to find, bring to light and publicly state everything that can be harmful, insulting and detrimental to the other. ¹⁰⁴

Direct disregard is not only devastating for the accused but also risks backfiring. In contrast, indirect disregard was concealed behind feigned approval and courtesies. Examples of indirect disregard are (1) diminishing and mocking the good things said about another; (2) “tell[ing] something under the pretense of speaking good of him, but under it . . . touch[ing] on one or more of his faults, which are greater than the good that is said of him”; (3) contradicting his advice in the presence of others; (4) advocating alternatives during patient appointments, without explicitly criticizing the other’s advice and medication; and finally (5) “when in incurable diseases where one knows he cannot succeed nevertheless recommend[ing] and even consult[ing] him to then lay the blame on him.” ¹⁰⁵ These strategies reflect the ongoing struggle, in which unscrupulous physicians resorted to epistemic tricks in order to raise their own reputation at the expense of their competitors.

To sum up, epistemic contestation complicates the picture of how physicians managed people’s conceptions of diseases and the physician by highlighting disputes and controversies. Rather than a frictionless process, the physician’s attempt to establish and maintain medical authority often unfolded as a rather messy engagement with both patients and other medical practitioners. This picture aligns with that painted by historians of the early modern medical field as a chaotic and largely unregulated market in which a range of actors and interest groups competed. In this moral economy, patients had fairly good chances of negotiating prices, while the physician in turn worked to protect his good reputation. Given these dynamics, it may seem strange that the negative accounts of the Machiavellian physician were launched by physicians. ¹⁰⁶ After all, why would they tarnish their own reputation? However, the adoption of the infotainment genre can be seen as a clever way to combine criticism with entertainment, to take control of the debate by painting the physician in excessively ironic and farcical terms – sometimes positive and sometimes negative. Such interpretation is perfectly aligned with Mendelsohn’s account of the physician as a largely public writer who, by collecting, composing, and disseminating information, shaped society and its institutions on a broad scale. ¹⁰⁷ Regardless of how the representations of the Machiavellian physician are interpreted, the concept of epistemic contestation highlights how negotiations and conflicts often took epistemic forms. In a world where many families kept their own household pharmacies and where calling in a physician was considered both riskier than treating yourself and more expensive than consulting a less scrupulous practitioner, people were ready to challenge and undermine physicians’ authority. Ironically, the rather messy contestation emerging from this situation, and depicted in the advice literature, confirms interpretations of the early modern period as a time of greater epistemic justice than today. ¹⁰⁸

Concluding discussion

The medical Enlightenment was not merely the result of medical progress, of more accurate theories and efficient practices; rather, it reflected broader social, institutional, and material processes such as the organization of medical professionals, the expansion of medical institutions, and the emergence of a new media landscape. All these factors conditioned what it meant to cultivate and perform a medical persona. First in Italy, France, and England, then in Germany, a new medical persona was formed on the model of the natural and experimental philosopher. The rational physician was at once a dedicated practitioner and a theoretician, a disciplined and diligent observer and writer who documented numerous cases that were then subjected to rigorous analysis from which authoritative conclusions could be drawn and reliable facts established. In Germany, the Leopoldina, the medical faculties at Jena, and later the reformed university in Halle became important sites for the cultivation of this persona, which was then mediated in medical textbooks and advice literature. While such publications had long been important in disseminating the persona of the physician, the new media landscape changed the relevant dynamics. On the one hand, with new and cheaper printing technologies it became possible for Hoffmann, Stahl, and others to promote their own systems of medicine as well as themselves as diligent and methodical observers and analysts. On the other hand, the more the physician became a public celebrity, the more he became the subject of controversy. Fueling these debates was the discrepancy between physicians’ bold claims and the harsh realities of medical practice. High death rates remained a fact, emphasizing physicians’ limited abilities.

One of the most striking expressions of this predicament was the increasingly popular body of early modern medical advice literature, ranging from idealized accounts of the political physician to satirical representations of his Machiavellian counterpart. While scholars have rightly argued that this highly polarized genre reflected the discrepancy between ideal and reality, this article argues that this literary genre provides important clues as to how physicians met society’s expectations by shaping them. Drawing on French’s claim that physicians used clinical experience and theoretical learning to shape people’s conceptions not only of disease but also of the physician, the article suggests that the mediation of the persona of the physician in the advice literature included instruction in epistemic strategies for achieving this control. First, underlying the contrasting pictures presented by political and Machiavellian literature was the common assumption that the physician could combine learning, clinical knowledge, and social skill to make strategic choices and maneuver past failures. The article uses the concept of epistemic advantage to analyze the explicit and often very concrete advice regarding whom to treat; how to approach patients depending on, among other things, social standing; and how to present diseases and discern their likely course, outcome, and possible treatments and cures. Second, whereas the concept of epistemic advantage might suggest that the physician controlled the situation in a rather frictionless way, medical encounters were characterized by conflicts between a large number of competing patients, lay people and medical practitioners. Using the analytical notion of epistemic contestation, the article seeks to capture both the ways in which patients and lay people challenged medical authority by adhering to popular medicine or adopting the physician’s own medical concepts and explanations, and the ways in which physicians maintained a delicate balance between trust and scheming among themselves. In contrast to the academic controversies over medical theory that have long caught the interest of historians of medicine, persistent themes in the advice literature indicate that epistemic contestation figured in the everyday practice of medicine, involving individuals and groups from different social strata and with different interests.

Which conclusions can be drawn from this obviously and deliberately tendentious material? To what extent did the material reflect and impact the underlying social reality in which the various participants in the medical field operated? These questions can be answered in two ways. On the one hand, as stated in the introduction, this study offers just one piece of a much larger puzzle whose assembly would require additional analyses of institutions, actors, and discourses in different sources. Analyses of patient and lay perspectives, as well as those of other professional actors such as pharmacists and surgeons, would likely impact the overall picture. On the other hand, it is crucial to acknowledge that the mediation of the persona of the physician in textbooks and advice literature was not a passive reflection or a deliberate distortion of an underlying social reality, but also an attempt to change it. If we wish to understand the ways in which physicians interacted with others to shape the conceptions of disease and of the physician as a medical authority, it is important to further investigate the genres and discourses that mediated these patterns of behavior as well as the larger media landscape of which they were part.