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The Charitable Imperative: Hospitals and Nursing in Ancien Regime and Revolutionary France.

This volume brings together a series of pioneering essays, the earliest dating from 1978, on public assistance and health care in the seventeenth and eighteenth centuries. All are learned, lively, and well-argued; they reflect both Jones's exhaustive research in the archives of the Montpellier region, the basis for an earlier monograph,(1) and a prolonged effort to reassess major themes in French social history. More cohesive than most such collections, the book comprises two essays on hospitals (including one, on the Hotel-Dieu of Nimes, co-authored with Michael Sonenscher), three on hospital nursing, and three more on the treatment of groups that, although distinct from the indigent and sick population of the hospitals, "were none the less subjected to charitable-cum-repressive institutionalization": soldiers, prostitutes, and the insane. Several of the general chapters provide as useful an introduction as any to their subjects: seventeenth-century French hospitals, the role of the Daughters of Charity in hospitals, and military medicine and welfare from Richelieu to Napoleon. The more detailed discussions of the founding of the Daughters of Charity and of their activities at the Hotel-Dieu Saint-Eloi of Montpellier illuminate the workings of a remarkable and often unappreciated institution.

Several intersecting themes run through the essays, all bearing on the central problem of poverty and charitable assistance. The broadest, and least developed, is conveyed in the book's title: the importance of charity, at once a voluntary act and a moral and religious obligation, to the French system of poor relief, in contrast to the much more uniform English system funded by compulsory contributions. Jones, however, does not systematically consider the formation of the "charitable imperative" or its persistence and adaptation in the eighteenth century and beyond (a question suggestively explored early in the present century by Bernhard Groethuysen).(2) Most of Jones's considerable powers of argument are directed elsewhere, toward demonstrating the significance and rehabilitating the reputation of the hospitals and their nursing sisters, in large part for the benefit of historians of medicine, whom he charges with neglecting and underrating both. French hospitals, he reminds us, housed more inmates than in any other country of Europe; they combined, in varying degrees, charitable, medical, and disciplinary functions. On the whole, they emphasized need over sickness, though the institutions for the sick poor known as Hotels-Dieu were increasingly "medicalized" over the course of the eighteenth century. Jones rejects the view of hospitals as death-traps, with a few exceptions such as the Paris Hotel-Dieu (the overall death rate declined from about 10 to 5 percent over the course of the eighteenth century) and argues against an extreme view of hospitals as instruments of social control, emphasizing, rather, the ways in which they genuinely met the needs of the poor and victims of dislocation in times of distress. Jones offers an even more sympathetic account of the sisters of charity, women from modest backgrounds who devoted themselves to lives of service to the needy; they not only transformed (and feminized) nursing services in the hospitals, but acted as "independent medical practitioners in their own right", bleeding and bandaging patients and running hospital dispensaries, which largely displaced local apothecaries as providers of remedies for the poor. Their outlook, far from superstitious, was not diametrically opposed to that of the physicians; they deserve some of the credit for the medicalization of the hospital and for the declining mortality of its inmate population.(3) (This lightly varnished portrait, although it stops short of hagiography, is clearly a celebration, of a sort now thoroughly unfashionable in accounts of the medical profession but widespread in compensatory histories of groups deemed to have been the objects of past historiographical scorn.)

Several of the essays, finally, address a third large question: the degree to which the Revolution permanently transformed the matrix of charity, medicine, and discipline embodied in the Old Regime hospital. In a few areas the 1790s marked a watershed; prostitution, for example, entered an era of laissez-faire with the lifting of the old municipal regulations, since the Penal Code of 1810 punished only procuring, and repressive intervention by voluntary agencies such as the Dames de la Misericorde of Montpellier had been thoroughly discredited. On the whole, however, continuity predominated; even the regulation of prostitution returned, at the municipal level, albeit with far greater emphasis on preventing disease and less on correcting vice. Although the radical Revolution confiscated the hospitals' endowments and expelled the nuns and lay sisters, the Napoleonic regime reconstituted the former and restored the latter. For much of the nineteenth century, the hospital resembled its Old Regime predecessor. In practice, the assault mounted by the Enlightenment and Revolution on the hospital and traditional public assistance proved a failure. The reformers' principal contribution, Jones stresses, was to inject new ideas into an old debate; it took another century to fashion fully and then realize the model of the democratic welfare state implicit in their proposals.

If many of these interpretations are familiar, it is at least in part because Jones's work over more than a decade has helped make them so; at times, though, one has the sense that the author, in his repeated attacks on myths, old paradigms, and misguided predecessors (generally unnamed) is battering at straw men. Among the more novel arguments, a few are perhaps pushed too far. No one would dispute Jones's repeated observations that the Daughters of Charity provided medical, surgical, and pharmaceutical services, in addition to nursing support, that they constituted a recognized part of the medical network of the Old Regime, and that they should not be confused with folk healers or marketplace mountebanks; but the stronger claims about their status as independent medical practitioners and their contributions to the medicalization of the hospital and the reduction of nosocomial mortality demand fuller analysis and more substantial evidence than he provides. The book offers nothing on how the sisters learned to treat patients or their level of skill compared with that of surgeons (whose training and work as "ordinary practitioners" have received careful scrutiny in a series of studies by Toby Gelfand); it provides only scant information on their actual daily activities, the type of medicine they practiced, or their underlying conceptions of physiology and pathology. On these last questions, Jones asserts, on the one hand, that "sisters of charity had their own views of medicine and their own sets of practices and conventions", but, on the other hand, that they practiced a version of expectant medicine not far removed from the neo-Hippocratism of Enlightenment physicians, or, in another formulation, "an adulterated and diluted form of orthodox medical culture". It would also help to clarify the sisters' relationship to the medical profession and the changing role of physicians and surgeons in the hospitals, where they had at least nominal jurisdiction over patient care. Jones rehearses the well-known conflicts between doctors and nurses at the end of the eighteenth century; for the less familiar earlier period, he describes both a growing medical presence and the declining active role of physicians, surgeons, and apothecaries in the provision of medical services in the hospital, where the sisters increasingly supplanted them.

No doubt a synthetic study would have addressed these and other questions left hanging in this collection. The essays unquestionably succeed on their own terms, as object lessons on the importance of joining the history of assistance and the history of medicine. It is not quite true that specialists in one area have ignored the existence of the other, or that the hospital, the most important area of intersection, has failed to receive significant attention, but Jones is one of a rare breed of historians who know both fields well and have systematically explored the connections. The reader of this book comes away eager for more.


1. Charity and bienfaisance: The Treatment of the Poor in the Montpellier Region, 1740-1815 (Cambridge, 1982).

2. The Bourgeois: Catholicism vs. Capitalism in Eighteenth-Century France, trans. Mary Ilford from 1927 French ed. (New York, 1968), esp. chap. 10, "Almsgiving."

3. Jones develops these themes more systematically in "Sisters of Charity and the Ailing Poor," Social History of Medicine 2 (1989): 339-48.
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Author:Ramsey, Matthew
Publication:Journal of Social History
Article Type:Book Review
Date:Jun 22, 1993
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