At the 18th century, medical help becomes a duty of the king and government. A small number of doctors, living initially on their deprived practice, puts his expert testimony at the service of the State in engage in the medical policy. Gradually, they assert an authority on the hospital to make of it a place of exercise of practical medicine to the detriment of the nuns which took care there as well bodies as hearts. Intermediary between the royal administration and the hospital administration, the doctor Jean Colombier, become "Inspector général des hôpitaux civils" (between 1781 and 1789), contributes to the "medicalization" (M. Foucault) of the hospitals. Starting from 1781, it reorganizes the medical department at the hospital by limiting the action of the Sisters and by putting at the foreground that of the doctors. With the Code hospitalise of 1787, Colombier contributes to make hospital the privileged place of the medical observation and clinical medicine.

Keywords: Doctor, Jean Colombier, Civil Hospital, Health policy, Medicalization, Paris, 18^th century

Abbreviations: AP-HP: Assistance Publique - Hôpitaux de Paris; ARCH NAT: Archives Nationales; ARCH - Dép: Archives Départementales; PU: Presses Universitaires; PUF: Presses Universitaires de France

At the 18^th century, the majority of the doctors exerting in the capital obtained the doctorate in medicine and “régence” [1], delivered by the Faculty of medicine of Paris (except the “Médecins en Cour”). Teachers, health professionals, they are also the members of a body, the Faculty of Medicine of Paris. The primary source of their incomes comes from their private practice of medicine near “patients”, who are also “customers”, of which they receive fees.

But, at the Age of Enlightenment, medical help becomes a duty of the king and government. A small number of “docteurs regents” puts also his expert testimony at the service of the State in engage in the “medical policy”, expression indicating a collective action in favour of public health with an aim of safeguarding and/or conservation. Their action extends in particular to the hospital structures. Gradually, the doctors assert an authority on the hospital to make of it a place of exercise of practical medicine to the detriment of the Sisters which took care there as well bodies as hearts. So that they contribute to make public health the heart of the medical policy and either a subset of a social policy of assistance.

This “medicalization” of the hospital, term borrowed from Michel Foucauld [2], object of many debates but useful to think the relationship between medicine and policy, mixes personal interests and collectives with the doctors. This stepladder of analysis results in wondering on the conditions of action of the “docteurs regents” in the hospital sphere and about the role of the one of them, particularly active in this field: Jean Colombier (1736-1789). How does the individual course of Jean Colombier, become Inspector of the civil hospitals (between 1781 and 1789), influence the trajectory of the group of the "doctors régents" in the hospital field? How, by its individual action, Colombier does it enable them to affirm their expert testimony and the legitimacy of their intervention in the field of the royal medical policy?

The mobilized sources are administrative (regulations and deliberations emanating of the Office of the Administrators of the Hospital of Paris, Commission Reports on the Hospital), and accountants; but also, medical (surveys, reflections of Colombier and the doctor’s regents on hospital medicine). Initially, we will see in what the course of Jean Colombier contributes to consolidate the presence of the doctor’s regents at the hospital. In the second time, we will analyse the way in which Colombier manages to become a central actor of the medicalization of the hospitals and an intermediary between the hospital administration and the royal administration. Lastly, we will question the finalities of this action: how to make hospital the new place of predilection of the observation and teaching of medicine?

Jean Colombier’s first objective: Consolidate the presence of the doctors at the hospital

Until 1772, the influence of the “docteurs regents” in the structure’s hospital remains limited. In theory, only of the doctors of the faculty of medicine of Paris, covered quality of “regent” for at least ten years, have been able to hold a position with the Hospital of Paris. Therefore, a professional experience is required but also financial ease. Indeed, the load of hospital doctor is demanding in time and in attention and leaves only one small place to the private exercise of medicine. The increase amongst doctors with the Hospital aims to better answering the surge growing of patients, with the addition of new rooms of patients. It is often consecutive at the periods of epidemics. In Paris, the doctors’ titular, known as ordinary “médecins pensionnaires” or “médecins ordinaires” [3], receive salaries since 1619, neither being nourished nor placed at the hospital. Starting from 1636, the “médecins expectants” are instituted but not remunerated. They exert free with the Hospital and the old people’s home of the Incurable ones. Auxiliaries, they become “médecins ordinaires” at each vacancy of station. The nomination of the doctors belongs to the Office of the administrators, after consultation of the doctors already in station at the hospital.

The administrators of the hospital want to offer a permanent medical department and of quality from where need for stabilizing medical staff and for imposing a strict regulation to him. The doctors are not always very assiduous as the multitude of deliberations of the Office of the administrators shows it on the medical department, in particular in 1735 and 1750, lawful periods of pushes. First half of the 18th century seems to be a time of integration of the requirements of the service in hospital medium by the “docteurs regents”. According to the administrators, the majority of the doctors do not respect the schedules and the two hours minimum duration to realize their visits. On the initiative of the administrators of the hospital, the medical department is reorganized in 1735. From now on, it is ensured by seven “médecins pensionnaires” and seven "médecins ordinaires". The Règlement of May 18th, 1735 [4] demonstrates a willingness to supervise the practice of these health professionals by the Office of the Administrators. Each day, in each room, a sheet of observation is held by the "Mère d’Office" which indicates the hour to which the doctors begin and complete their visits, as well as observations on those which do not express enough patience or of attention towards the patients. Therefore, the doctors are supervised by the Sisters. 

If the organization of the medical department escapes to them, the doctors assert themselves in the field of the regulation of the therapeutic cures. The Formulaire des médicaments en usage dans l’hôpital presented to the Office on April 29th, 1739 [5], is the first collection of specifically applicable remedies within a hospital framework. Instrument of standardization, it is a means of codifying what is regarded as the good practice of hospital medicine and of being distinguished from “empiriques”. Indeed, the latter were sometimes authorized by the Office of the administrators to test their medicamentous preparations, like the pills of Augustin Belloste. The Formulaire is the fruit of the work of the fourteen doctors of the hospital. In his capacity as senior of the doctors of the hospital, Élie Col de Vilars consigns and develops common work. Whereas the Formulaire relates to the therapeutic one, no apothecary is consulted. The “Docteurs regents” having selected the drugs controls of it the composition, the clothes industry, the quantities to be prescribed and know the effects and counter-indications of them since they prescribe them themselves each day with the Hospital. The doctor’s contributors of the project have solid theoretical knowledge: five were professors of medical matter at the faculty of medicine of Paris between 1730 and 1739.

In the first edition of 1753, the Formulaire is written in French. It is an instrument of standardization of the hospital practices and follow-up of the evolution of the patients. Since each doctor sees several patients, if all adopt the same pharmacopeia, it is easier to deduce nature from the treatment previously ordered. The Formulaire seems to realize the will of a common work between professionals confronted with same pathologies, acting near the same patients. By reinvesting the hospital structure, the doctors act near communities and either only near suffering individuals. This scaling of intervention authorizes the medical preventive actions. This new medical design invites to a modification of the medical paradigms and time of intervention of the health professional.

However, in view of the multiplicity of panaceas offered to the Hôtel-Dieu, the administrators decided on December 29^th, 1779, to authorize only medications approved by the faculty of medicine of Paris. It is a means there of preserving dangerous judged remedies but also of not crushing Faculty from which the doctors come from the hospital.

The fire of the Hôtel-Dieu, in December 1772, acts like revealing of the relative questions to hygiene and the public assistance. The therapeutic vocation of the place continues. The “docteurs regents” extend their field of intervention while engaging in the reflection on hospital architecture, according to three axes: The choice of the place, the provision of the establishment, manner of exploiting it. The hospital becomes community facilities equipped with a precise architectural program having its own form adapted to its functions. The structure of care transforms space where it is established and contributes to the medical framing of a territory. However, doctors’ ideas do not lead to concrete achievements.

The decisive impulse comes from the minister Jacques Necker. This last wants to make assistance a great civil service where the hospitals appear before just like instruments of maintenance of the public order by the State. On August 17^th, 1777, Necker transforms the question of the hospital into public debate, while forming, by stop of the council, a commission of sixteen members seeking the means of improving the mode of the hospitals while starting with those of the town of Paris [6]. The commission intervenes in a field monopolized by the Church and the Parliament. By his presence, Jean Colombier inaugurates the participation of the doctors in the administrative commissions where he works with the former “intendant de la généralité” of Montauban, Antoine Chaumont of Millière [7]. The commission of 1777 deals with two questions: The reform of the financial situation of the hospitals and improvement of hygiene conditions.

But, why call on Jean Colombier? Two brief replies can be brought. In addition to the knowledge of its writings on the military hospitals [8], Necker sees in him a confidential agent who could be to him recommended by the marquis de Castries, his friend. The choice of the men is important because they must carry a collective work. Chaumont of Millière and Colombier could cross via Prince de Montbarrey. This one is nearest collaborator to the Count of Saint-Germain, Secretary of State to the War, to which Jean Colombier was introduced in 1777 like the doctor able to fill his wishes compared to hospital. Colombier was surgeon of a regiment and employee in the sedentary hospitals of the army (of 1753 to 1763). It conceives a plan of reform of the hospital honoured with the approval of Count of Saint-Germain, a criticism of arbitrary and negligences of the administrators of hospital. Colombier plans to put the hospitals under the direct dependence of the king by attaching them to a ministry. He proposes a fair distribution of their incomes by subjecting them to a common legislation whose application will be controlled by an inspector of the hospitals. Colombier intends to take part in the movement of centralization and unification wanted by the State.

1781: A partial victory for Jean Colombier

The letters patent of April 22nd, 1781 is only one half-victory for Jean Colombier. They give whole satisfaction to the Office of the administrators of the Hospital and take again part of its deliberations. However, the adopted measures, mixing imperative hygienic and therapeutic, follow the regulations of doctor Colombier. Each of the 2,500 patients will have an individual bed. The 500 convalescents, additional pregnant women and patients will be installed in double beds separated by a partition so that each one has one to sleep particular without being able to see itself nor touching itself.

Jean Colombier must take care of the application of the new plan of organization, in connection with the Office for all that relates to construction, the distribution and furnishing. It becomes a kind of liaison officer between the Office of the Administrators and Necker. The doctors of the Hôtel-Dieu agree to the reforms all while making some practical modifications there while being based on their professional experiences as well within the private framework as hospital. For example, they consider it useless to transpose to the hospital the system of the double visit, except in a real-life situation medical need.

Although the medical ideas of Colombier are taken again, article VI of the letter’s patent of 1781 gives the totality of the powers to the administrators to which are entrusted the development of the regulations of service and discipline. The doctor is returned to a role of simple advisor and not of operational decision maker. The letters patent of 1781 seal the success of the policy of the Office of the administrators of the hospital having obtained full and whole satisfaction. However, for Necker, the assistance must become a civil service managed by a centralized administration, composed of professionals of the medicine whose activity and competences make it possible to know the reality of the needs. Within the framework of the continuation of a policy of centralization of the hospital question, Necker establishes a department in charge of the monitoring of the hospitals within the system check, in 1780. It is directed by the former intendant of finances, Chaumont of Millière. In January 1781, the medical section of this department is entrusted to doctor Colombier, covered title of “Inspecteur général des hôpitaux civils, des dépôts de mendicité, prisons et maisons de force du royaume” [9]. Colombier is assisted by two other doctors: François Doublet, doctor of the old people's home of Charity, a close relation of Mrs Necker; and Michel Augustin Thouret, member of the Société Royale de Médecine of Paris. Thouret took part in the research on the treatment of the rage initiated by the Lieutenant of police of Paris, Lenoir, and with its implementation with Senlis in 1780.

By creating the load of “Inspecteur général des hôpitaux civils”, demanding of qualities of observer and negotiator, Necker wishes to have an agent of confidence able to describe to him the reality of the direction of the hospitals, to lead each administration to adopt the provisions of a nature and economy validated by the government. Therefore, it must contribute to a standardization of the practices of the administration and hospital management. Colombier in depth inspects the interior life of the establishments visited to identify the causes of their failures. The doctor becomes an active member of the group of experts consisted Necker. Being sharpened, Colombier cannot take the chance to deviate from the policy of Necker. He manages a team of doctors, surgeons and made, whose total sum of the salaries for the year 1783, is almost 28,000 livres. Its mission is to impose on all the hospitals of the kingdom new measurements to increase and ensure healthiness.

Colombier, “Inspecteur général des hôpitaux civils”: An actor in the medicalization of hospitals

As head of the “inspection Générale des hôpitaux civils”, Colombier becomes an actor of the medicalization of the hospitals. It has two great ways of action. First of all, the drafting of reports; then, the rehabilitation of a pre-existent structure: the “dépôt de mendicité”.

After each inspection, Colombier produces a report from five to six pages, accompanied by a plan of the visited hospital, transmitted to the minister, with the intendant of the general information, the administrators of the inspected hospital [10]. A system of exchange of comments on this writing sets up. After a general presentation, Colombier examines the management of the hospital, described the rooms (healthiness, food, employees, patients, medical department), the state of the lingerie and pharmacy [11]. The part “Observations” is the place of the evaluation and the indications of the modifications to be made as well to the level of the medical department as to the levels of the organization, management, the administration. Actually, Colombier wishes that each hospital obtains a regulation and insists on the necessary exactitude of the visits of the doctors and surgeons. Cleanliness and storage remain two requirements for the doctor. But, its will to modernize the modes of hospital administration runs up sometimes against conservatism buildings of jealous men to preserve the plenitude of their powers. In April 1789, against the opinion of the intendant, Colombier proposes to transfer the hospital from La Flèche to the house Saint-François, located in a salubrious environment, offering the buildings and water necessary. He criticizes the lack of care of the intendant to get informed about the position of the “Soeurs hospitalières de Saint-Joseph”, in order to avoid any opposition [12]. Colombier does not hesitate to enter in conflict with the intendants what shows the force of its Parisian supports.

To answer the requirement to center the action of the hospital on the reception of the patients and the therapeutic treatment, it develops a solution with the national scale by redefining the roles of a pre-existent structure: The “Dépôts de mendicité”. Set up by the “Arrêt du Conseil” of October 21^st, 1767 [13], the “Dépôts de mendicité” are opened to 150 (and up to 200) wandering old men, disabled person, insane and venereal, with the expenses of the king, in each general information. Thought like a palliative of the deficiencies of the hospital, the “Dépôts de mendicité” allows an evolution of it. From now on, the hospital is centred on its therapeutic function, the social and police function becoming secondary. Removed by the general inspector of Turgot Finances, preferring the workshops of charity to ensure of work the poor, the “Dépôts de mendicité” receive nothing anymore but the sick, foolish or crippled poor. They are restored in 1776 by Clugny de Nuys, new general inspector of Finances. Precise instructions are given on their administration which it is a question of standardizing. For that, he is called on Jean Colombier, manner for Necker of officializing the intervention of the doctors in the process of bureaucratization of the social police.

Colombier starts by regulating the Dépôts de mendicité with the Règlement concernant la constitution et le régime général des Dépôts de mendicité du Royaume, les principes de leur administration et de leur régime [14], of 1785. The text insists on the principles of hygiene. All is implemented to contribute to the wellness of the patient. They are placed by par, in camp beds equipped with two berths covered with straw, separated by a partition. Each pair has its own chamber pot and a ladle to serve broths. Each group of four beds has a commode chair.

Although not published, the Colombier’s Réglement of 1785 seems effective. The deposit of Paris contributes to the unchoking of the hospitals by operating a sorting among the received populations. Between 1782 and the 1784, 4 000 poor are allowed with the “Dépôt de mendicité” of Paris (either a little more than the one poor one out of two for this period). However, starting from September 1788, the number of the poor accommodated with the “Dépôts de mendicité” deposit of begging increases (of 10 points between November 1788 and January 1789). Although this may be a consequence of the winter of 1788-1789, when temperatures reached -18° in Paris, Colombier allots this surplus to the overzealousness of the police and the bad distribution of the patients since some should be sent to Bicêtre [15]. Colombier insists on the necessary setting in network of the various structures of care intended for the poor. Here, seems to sting the need for an organization of centralization of the medical offer and management of the places available in real time. Many criticisms relate to the cost of the “Dépôts de mendicité” but they are to be moderated because they come magistrates wishing to recover the management of the begging in their remit, and who believe that it was confiscated by the doctors.

After the departure of Necker, the hospital question falls to Baron de Breteuil, become in 1784, “Secrétaire de la Maison du roi”, key department, in liaison with the Court, the clergy, the officers of the town of Paris. Breteuil requests the royal Academy of sciences in order to draw aside the police chiefs of Necker of work of studies. But, the administrators of the Hôtel-Dieu remain faithful to the conclusions of the Necker commission. How to complete its action?

The Code hospitalier of Colombier of 1787: The final takeover of the doctors on the Hospital

The conclusions of the Commission Reports Breteuil, in 1785, are revealing logic of expert testimony followed by the solicited scientists: that of agents in charge of a technical investigation. The staff of the Hôtel-Dieu is not solicited. On the contrary, the logic of the Necker commission was that of experts, men of ground, professionals as well of the hospital administration as of medicine. Because of the absence of conciliation between the various actors, the commission of Breteuil runs up against the opposition of the Office of the Hôtel-Dieu remained faithful to the text of the letters patent of 1781, result of its debates with the police chiefs of Necker.

On July 16^th, 1787, the Office of the administrators of the Hospital adopts the Code hospitalier written by Jean Colombier, bearing on the installation of the Hôtel-Dieu. The text does not say anything specific competences expected in the hospital doctors and the mode of recruitment of medical staff. It is centered on the reorganization of the treatments and the regulation and the homogenisation of the behaviour of the files of entry of each patient becoming collections of medical information then. The procedure of admission answers the medical requirements and breaks with the examination of religious nature imposed by the Sisters [16]. The hospital is a therapeutic space and not a house of reception. Colombier transposes in the civil world the reforms installation in the military world thus imposing a standardization of the practices. The new organization allows the teams of doctors and surgeons to take part in decision makings relating to the admission of the patients and the control of the cures.

Colombier founds a new distribution of the powers within the hospital in which the Sisters have nothing anymore but one negligible share. The doctors propose a rationalized management of the hospital by it thinking starting from the new countable unit that is the number of beds available and according to the evolution of the state of the patient. The surgeon gains in importance by owe the first auxiliary of the doctor, and the supervisor of the action of the Sisters. The regulation aims to standardize and order the visits, to give again all their place with the doctors in the procedures of admission, medical regulations and references of the patients. The doctors are vigilant as for the ranking of the patients. This operation rests on a medical evaluation and a categorization of the patients. It induces a temporal projection. The doctor takes into account the evolution of the disease but also socio-organisational temporality. There are three major targets: A hierarchisation of pathologies; an orientation of the patients towards the structure of care adapted; an exclusion of the non-sick people.

With the fall of Breteuil, at in mid-July 1788, the commission loses its attributions. The return of Necker allows in Colombier and Chaumont of Millière to find their liberty of action. Supported by the doctors of the Hôtel-Dieu, Colombier manages to settle the question of the hospital material framework in terms of structure, bureaucracy and organization. The hospital becomes one of the means of implementation of the policy of assistance of the State and a link of the health care system public. The “docteurs regents” contribute to make a therapeutic space of it by rationalizing the modes of admission of the patients and the offered medical department.

The hospital, a new place of predilection of the observation and teaching of medicine

Truly invested by the “docteurs regents” whose active role is recognized like legitimate in the name of their medical expertise, the hospital becomes a place of exercise and teaching of practical medicine. In 1785, François Doublet, collaborator of Colombier, underlines the crucial role of the hospital in progress of the private clinic and the teaching of medicine [17]. The hospital allows medical observations, whose publicity are ensured by their publication, on order of the government, in the Journal de médecine, chirurgie et pharmacie, become a true press agency professional. It is necessary to transpose the profits of hospital medicine for liberal medicine, the hospital being moulted in space of medical research. In addition to the history of the disease, the doctor can examine the value of the remedies, to distinguish the cases in which nature acts, second or slows down its evolution, therefore the situations in which its intervention is necessary. The hospital gives rise to a new type of doctor, the “observant doctor”. That modifies the appreciation of the disease seen like a succession of continuous facts.

In the last third of the 18^th century, the hospital becomes the privileged framework of clinical medicine. It is a question of treating the patients but also of teaching the anatomopathology with the “bed of the patient”, to show the symptoms, the way of identifying a pathology. Processing centre, the hospital becomes a place of active formation, as Keel [18] underlines it. As from the years 1780, the passage of a passive private clinic to an active private clinic takes place, symbol of the integration of the anatomoclinic method. The private clinic is not a means of giving an ideal table nosologic to the pupils starting from carefully selected cases, or “a manner of laying out the already acquired truth and of presenting it so that it is revealed systematically” [19]. Quite to the contrary, it is examination of the patient whom the pathological process with work results. The patient takes again the primacy on the disease. The medical supervision is then made possible.

In Paris, the teaching of clinical medicine appears at the hospital of Charity under the impulse of the doctor regent Louis Desbois of Rochefort. Appointed doctor as a second at the hospital of Charity in 1780, it opens a medical private clinic and counts among its pupils Jean Nicolas Corvisart. By 1787, Corvisart gives lessons of internal clinical medicine to Charity. It is responsible for the service of general medicine where the patients are received randomly from their arrival, except for venereal, scabious, contagious and incurable ones. Corvisart replaces Desbois of Rochefort deceased, in 1788. Immediately, Corvisart imposes a ranking of the patients by gathering those whose symptoms lead to the same forecast.

Practical teaching is the principal vector of the bases of clinical medicine. In addition to the fact of contributing to progress of medical science, the private clinic allows improvements in education of the young doctors.  

CONCLUSION

At the end of this article, the role of Jean Colombier appears determining to define and sit the place of the doctors within the civil hospital structure at the 18^th century in Paris. The ambition of Colombier is to regulate and organize the hospital medical department. While contributing to exclude the Sisters from the therapeutic decisions and to restrict their field of intervention, Colombier takes part in the movement of medicalization of the hospital. Mainstay of the policy of assistance controlled by Jacques Necker, Colombier operates the connection between the administrative power and the medical professional skills. This individual course influences the “docteurs regents”, a Parisian medical elite, which it makes it possible to reappropriate hospital space, to make of it a place of professional exercise and formation to practical medicine.

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2.   AP-HP (2013) Archives nouvelles séries, Liasse 707, Hôtel-Dieu, Délibérations relatives aux médecins, pp: 1536-1788.

3.    Règlement du 18 mai 1735 (1883) Collection de documents pour servir à l'histoire des hôpitaux de Paris: Imp. Nat.

4.  AP-HP, Hôtel-Dieu, Liasse 882, 4233 (1739) Instructions pour la composition de tous les différents remèdes qui s’emploient dans l’Hôtel-Dieu pour la guérison de chaque genre de maladies.

5.  Louis S, Greenbaum, Necker J (1984) The reform of the Paris hospitals on the eve of the French Revolution eighteenth century life, pp: 9-15.

6.  Antoine Chaumont of Millière (1812) « maître des requêtes », then administrator of the « Ponts-et-Chaussées et des hôpitaux » starting from 1777.

7.  Colombier J (1775) Préceptes sur la santé des gens de guerre, ou Hygiène militaire. Paris: Lacombe.

8.       ARCH. NAT., F/15/2866.

9.  ARCH. DÉP. DE LA SOMME, C (1595), Rapport de l'inspecteur général des hôpitaux de sa visite à l'Hôtel-Dieu d'Amiens, et Observations de M. Colombier, inspecteur général des hôpitaux, sur ledit mémoire.

10. ARCH. NAT., F/15/226, (1785) Rapport d’inspection de Jean Colombier sur l’hôpital de Pézenas, 19 octobre.

11.    ARCH. NAT., F/15/228/2, (1789) Observations de Jean Colombier sur l’Hôtel-Dieu de La Flèche, Paris, 15 avril. 

12.  Thomas MCSTAY ADAMS (1990) Bureaucrats and beggars, French Social Policy in the Age of Enlightenment. Grande-Bretagne: Oxford University Press.

13. Pierre PINON, « Dépôts de mendicité », in Alain MONTANDON (2001) Lieux d’hospitalité: hospices, hôpital, hostellerie. France: PU Blaise Pascal.

14. ARCH. NAT, H/566 (1990).

15. ARCH. NAT (1990) F/15/2811 et F/15/230, Opérations de mendicité en 1788, à Paris.

16.Jones C (1989) The charitable imperative. Hospitals and nursing in ancient regime and revolutionary France. Grande-Bretagne: Routledge.

17. Doublet, F (1785) Observations faites dans le département des hôpitaux civils. France: s. n.

18.Keel, O (2001) L’avènement de la médecine moderne en Europe, 1750- 1815. Politiques, institutions et savoirs. Canada: Georg éd.

19. Foucault, M (2003) Naissance de la clinique. Une archéologie du regard médical. France: Puf.