The Citizen-Patient in Revolutionary and Imperial Paris.

By Dora B. Weiner (Baltimore, Maryland: Johns Hopkins University Press, 1993. xvi plus 444pp. $48.50).

The title of this book might lead the reader to expect a study of the politicization of health care during the French Revolution. Images of patients spouting the Declaration of the Rights of Man and Citizen from their sick beds or reciting revolutionary catechisms in front of stem doctors spring to mind. But this is not the picture that Dora Weiner paints in this solidly researched and remarkably wide-ranging study. The revolutionary and Napoleonic governments politicized health care only in the sense that they thought they must overhaul it along with everything else in sight. In fact, the author expresses considerable sympathy with the aims of revolutionary and Napoleonic administrators, legislators, and physicians, and she attributes to them nothing less than "the first modem attempt to grapple with the daunting problem of providing health care for an entire needy population" (p. xv).

Weiner shares neither Simon Schama's rosy view of reform prospects under the Old Regime nor Michel Foucault's jaundiced opinion of doctors' and hospital administrators' activities during the revolutionary period. Although she credits Enlightenment-era reformers, including the members of the Royal Society of Medicine (founded in 1776), with a sincere concern for public health measures, she argues that only the revolutionary attack on longstanding obstructions to innovation could have allowed true reform to proceed. The deputies to the National Assembly began by studying the situation in detail. In its site visits to most of the Paris hospitals in 1790, the Poverty Committee discovered for itself the "grim reality" of Old Regime institutions: orphans suffering from scabies, ringworm, scrofula and scurvy; as many as 200 men and women tormented by venereal diseases occupying a waiting room with 20-25 beds at Bicetre hospital, too sick and weak to move; and an impossibly gigantic Hotel-Dieu, with the highest hospital mortality rate in the world due in large measure to the crowding of four to six patients into every available bed.

The problems were clear, but few proposed solutions gained universal assent, and even more important, the new government lacked the financial means to implement its wish list of reforms. If anything, conditions in the hospitals initially became even more confused and chaotic as church properties were confiscated and national administrations succeeded one another at a dizzying pace. Yet Weiner rejects the now common view that nothing came of the Poverty Committee's arduous labors; she insists that the committee "in fact wrote the rules of health care for the citizen-patient in modem France" (p. 80). In its report to the National Assembly on 31 January 1791, the Poverty Committee asserted that society must provide for the legitimate needs of the indigent, including their health care. The draft legislation mandated free treatment at home for poor people by state salaried doctors who would also supervise wet-nursing, collect statistics on public health, and inoculate against smallpox. Departmental health agencies were to certify all midwives.

These recommendations fell on mostly deaf ears until 1802, when the Consulate created a Public Health Council in Paris. In the meantime, however, reform proceeded in more piecemeal fashion, but it proceeded nonetheless, Weiner insists. The Revolution changed patients' hospital experience by expanding the role of medical students, dissolving the religious nursing orders (no doubt the most ill-advised of the new measures), modernizing and regularizing the pharmacopoeia available, and in the case of maternity patients, transforming a former religous house in Paris into an up-to-date lying-in hospital and midwifery school. If patients as citizens now theoretically enjoyed the right to some kind of health care, they also faced new obligations and duties: to submit to interviews and repeated examinations, to serve as objects of medical research, and eventually to participate in bettering public health by attention to their own personal habits and to the public environment.

The steady elaboration of the citizen-patient model required administrative change. Between 1791 and 1796, various legislative measures and administrative decisions gave municipal governments control over local hospitals, and then after 1801, the new Hospital Council of the Seine Department took charge of setting priorities for reform in the capital's hospital system, thereby establishing a model for the provinces. It completed the organization of a specialized Venereal Diseases Hospital in 1802 and opened the world's first Children's Hospital in the same year. Care of newborns improved apace. The emphasis on the rights of man fueled interest in the rights of the deaf, blind, and retarded. When conditions actually deteriorated because of the drop off in patronage from the wealthy, the new government funded scholarships for the deaf and blind at reorganized national schools that aimed at training them to become independent citizens.

In most of these areas, changes in health care proved incremental rather than revolutionary. Treatment of the blind and deaf, for instance, changed little in practice, and the introduction of sign language and Braille's systems lay far in the future. A stronger case can be made for innovations in the treatment of mental patients. The National Assembly simply assumed that healthy people had been locked up by lettres de cachet on the pretext of madness; in fact, however, site visitors to Charenton found that every inmate there was indeed mad. But there was plenty of room for improvement in the treatment of the insane--or rather in the nontreatment of the insane, since the role of most mental wards had been largely custodial under the Old Regime. In the 1790s Jean Baptiste Pussin, himself once an inmate at Bicetre, and the better known Philippe Pinel insisted that those deemed mad be released from their shackles and treated as patients suffering from "mental alienation," which might be cured by skillful therapeutic measures. From his post as superintendent at Bicetre Pussin introduced Pinel to the new techniques of humane treatment and to his notion of the necessary authoritarian role of the asylum supervisor. Pinel in turn encouraged Pussin to formalize and record his observations of the inmates' psychological behavior. Pinel soon published his views and succeeded in making the study of mental illness respectable. He was appointed to a professorship at the Paris Health School (established in 1794) where he taught the tenets of an emerging psychiatric profession to large numbers of students.

Although Weiner rightly draws attention to the influence of the revolutionary principles of equality and the rights of man, most of the significant changes that she chronicles occurred during the Consulate and afterwards. Too often she treats the revolutionary decade and the subsequent Napoleonic regimes as one monolithic revolutionary bloc and makes very little of the difference between them. Her valid point is that the Napoleonic regimes carried forward many of the projects of the Enlightenment and the 1790s, yet in almost all areas of health care the chronology itself tells an important tale: in the 1790s reformers proposed a host of new ideas and projects, but few concrete changes took place before the great institutional consolidation of the early 1800s.

Although Bonaparte himself may have felt "contempt for medicine" (p. 285) and set back the development of military medicine by abolishing army medical schools, reducing the number of army hospitals, and curtailing the army's medical staff, his administrators nonetheless created the very institutions that organized the first substantial steps toward the policing of public health. The First Consul personally supported the creation of the Paris Public Health Council in 1802. It dramatically extended its activities after 1807 by inspecting factories, flour, and meat markets; testing chemicals and drugs and tasting wines; recommending changes in the water distribution system; monitoring sanitation problems from the number of horses in the city to the waste water that flowed into the Seine river; and regulating the burial of corpses and the use of cadavers for teaching purposes. The Napoleonic government did not set up a national health service along the lines first suggested by the Poverty Committee in 1791, but it did establish effective control over the hospital system, promote free vaccinations for smallpox, support new initiatives such as nursing homes and infirmaries as substitutes for hospitalization, and renovate hospitals in order to insure cleanliness, orderliness, and single beds for patients. In other words, a more authoritarian and centralized government was able to put into practice many of the ideas first broached under the Old Regime and turbulent decade of the 1790s. A revolution may have been necessary to clear the way of obstructions to reform, but reform did not therefore necessarily follow immediately or easily.

This is not to say that Napoleon Bonaparte should be viewed as the unsung hero of health care reform. But more attention to the difference in political and ideological conditions between the 1790s and early 1800s might have provided different insights into the workings of reform efforts and given a clearer chronological structure to the mass of useful and often fascinating information that Weiner has gleaned from almost every imaginable source (the bibliographic essay is a goldmine of information in itself). What made the relatively rapid consolidation of 1801-1802 possible? Was it just part of the general Napoleonic reorganization? Or had health care reforms reached a critical juncture on their own thanks to previous piecemeal efforts?

The downplaying of chronological differences is probably also related to Weiner's occasionally anachronistic language. Did contemporaries really think in terms of health care reform or a national health service; did even doctors imagine themselves as practicing "pediatrics," "neonatology" or "psychiatry.?" None of these terms was in use at the time, it seems, and most of them were only beginning to emerge as distinct concepts. The author's case would have been even stronger if she had devoted some attention to the changing meaning of medical terms and of conceptions of health care.

But these are relatively minor quibbles when viewed in the context of Weiner's truly substantial achievement. With striking empathy for doctors and nurses, administrators and patients, Weiner has written a comprehensive history of the delivery of health care between the 1780s and the 1820s in France. This is history of the highest quality; it shows the hard work of years of archival research as well as familiarity with the interpretive literature in a variety of intersecting fields. Weiner appreciates both the theory and the practice of health care and gives us a rich source for pondering the past as well as our own futures.