Book Review

Contracting a Cure: Patients, healers, and the law in early modern Bologna

N Engl J Med 1999; 341:853-854September 9, 1999

Article

Contracting a Cure: Patients, healers, and the law in early modern Bologna
By Gianna Pomata. Translated from the Italian by the author, with the assistance of Rosemarie Foy and Anna Taraboletti-Segre. 294 pp. Baltimore, Johns Hopkins University Press, 1998. $42.50. ISBN: 0-8018-5858-5

In Bologna, Italy, and surrounding cities in the 15th through the 18th centuries, physicians had to have a license to practice medicine, although fees and privileges (and much controversy and in-fighting over these) were determined according to rank (charlatans, midwives, barbers, and physicians). There was a professional body, authorized and controlled by the state — the Protomedicato (the emphasis of Professor Pomata's fascinating book) — that dealt with licensure and discipline but seemed more interested in professional standards and self-protection than in issues of malpractice. Women healers experienced “constraints set by their gender,” yet they challenged the system, often successfully. Filippo Vitali, who was licensed to practice dentistry, hung a life-sized portrait in the public square of Bologna in 1771 to advertise his services. There was, with all due respect to Susan Sontag, even illness as metaphor: “In Counter-Reformation Bologna, the term oppilation signified not only a pathologic condition of the body but also a state of spiritual disease whereby sinners closed their souls to the word of God and their mouths to confession. Saint Antoninus drew an explicit parallel between the sacrament of penance and medical evacuation: `Penance is a purging of ill humors, that is, an evacuation of vices.'” Finally, in 1666 Lorenzo and Andrea Adriani, a father-and-son team, prescribed to an innkeeper on whom Lorenzo had operated for hernia a postoperative diet of “some chicken or capon broth, and in this way we will gradually bring the cure to completion.” Sound eerily familiar? Even the remedy of chicken soup goes way back!

Advertising, women's roles in medicine, issues surrounding professional dominance, controversies about licensure and professional discipline, complaints and substantiated evidence about physician-centered rather than patient-centered concerns — all new, all old. Yet there is more. If these historical antecedents sound familiar to the reader, they are downright nightmarish to me, since I spent 13 years as a consultant to the Connecticut Department of Health and still, since 1986, serve on the state's medical examining board, the state-sanctioned licensure and disciplinary body. For nine years I was the chairperson. Although holding the two positions was coincidental, they complemented each other wonderfully. The analogous body in Bologna, and the subject of Contracting a Cure, was the Protomedicato, a judicial body selected by lot from the College of Medicine in Bologna, an institution dating to 1378. The Protomedicato adjudicated medical and legal matters from roughly the second half of the 16th century to the end of the 18th century. Reading about the sometimes reasonable, sometimes petty distinctions involving training with respect to licensure, the turf wars over which parts of the body belonged to which specialty, and the sharing and nonsharing of what is claimed to be proprietary knowledge in medicine all reminded me of a saying I am surprised Professor Pomata did not use. Fond of quoting Molière in French, she would have done well to quote as well Alphonse Karr's famous aphorism: plus ça change, plus c'est la même chose.

Thus we find 17th-century turf disputes: When, in 1697, a woman healer, Marie-Jeanne Dassonville, obtained permission from the city council in Lille, France, to treat hemorrhoids, the surgeons' guild unsuccessfully opposed her license. Maybe the orthopedists in Connecticut read an early draft of Professor Pomata's book when they successfully sued, some 15 years ago, the podiatric surgeons of this state, demanding that they cease and desist operating on the ankle, a clear case of a judge defining anatomy (what is the foot and what is not — i.e., the ankle). Only a year or so ago, I presided over an interminable declaratory ruling on whether nonphysicians could use lasers to remove hair. (They cannot, at least not in Connecticut — or at least not without supervision by a physician.)

Again, as Pomata notes, despite current medical ethical injunctions against such a practice, “Men of learning and illiterate charlatans alike seem to have shared a keen interest in medical secrets.” It is not unreasonable to wonder whether the 1990 battle of Moore v. Regents of the University of California over whether one owns one's spleen or not began back in the 17th century.

Contracting a Cure is a fascinating look backward at a medical milieu that is frighteningly similar yet wondrously different from that of today. Perhaps the most striking difference involves the contract for a cure. The title of the book refers to an arrangement already on its way out — at least for licensed physicians — at the time of the Protomedicato — that is, payment of a fee for the cure of an illness. Only over the next several centuries, a transition admirably chronicled by Pomata, did the fee-for-cure arrangement succumb to today's fee-for-service system. The original contract called for a specific goal (cure) over a specific period of time for a specific amount of money, with no cure yielding no payment. That was the good news. The bad news was that recurrences of an ailment were treated for free, and reductions in fees for incomplete results were determined by the Protomedicato in the event that a patient appealed. And the patients living in early modern Bologna were not bashful about appealing. Their documented appeals make “Night Court” seem tame.

Although one hesitates to recommend too enthusiastically a book about the state of medicine 300 years ago, I would heartily endorse Contracting a Cure as very entertaining and informative reading for almost anyone interested in medicine. Pomata makes the contracts, ailments, querulous patients, and practitioners of the 1500s and 1600s come alive with the success of such authors as Emmanuel Le Roy Ladurie and Carlo Ginzburg (whom Pomata acknowledges for his assistance). There is not a boring page in the book. Pomata accomplishes this in large part through her judicious use of material culled from an encyclopedic familiarity with almost everything legal and medical that was published between 1300 and 1800 in Italy. Her range of scholarship in general extends from Roman law to Bakhtin, and from laws and primary and secondary sources written in Latin, French, German, Spanish, and English over the course of hundreds of years to pertinent works in sociology, cultural history, and anthropology.

Although I think some of Pomata's arguments about the vertical practice of medicine (paternalistic and protective, as exemplified by the Protomedicato) as compared with the horizontal approach (contractual and therefore peer-defined, as exemplified by the agreement for a cure between a patient and a healer) are oversimplified, they are nonetheless well stated and stimulating. As Edmund Pellegrino has pointed out many times in many places, there is no such thing as parity in a supposedly horizontal healer–patient relationship (a fact Pomata eventually acknowledges). Other minor criticisms are the author's scant references to the much-cited fear of poisoning during this time, generalizations that all modern medicine is physician-centered, and her assertion that one of the basic tenets of medical professionalism is that medical practitioners “deserve to be paid because they are licensed members of the profession.” Physicians have never sat in their offices and been paid merely for pointing to the sheepskins on their walls. They are paid for the service they provide. Whether that service is cure-defined is a separate criterion for payment. Even smaller quibbles are occasional lapses in the translation of foreign passages in the notes, especially those in Latin, and inelegances of style (repeated use of “basically” and “in any case”) that are ungenerously uncorrected by the translators or are editorial lapses. The editing is otherwise very good, as one has come to expect from the Johns Hopkins University Press.

Contracting a Cure is a book that medical legislators, public health administrators, physicians, and historians of medicine would do well to read and reread. Besides, it is so enjoyable that the reader forgets, when looking up from the page every now and then, that he or she has just been living in a different century, or, rather, the same century some 300 years ago.

Richard M. Ratzan, M.D.
University of Connecticut Health Center, Farmington, CT 06030