Jules Guérin and social medicine in 1848

Abstract

The significance of Social Medicine in France in 1848 as a movement led by doctor Jules Guérin is not adequately documented. Why would an orthopedist write the call to doctors in Paris proposing a union around Social Medicine? What is the meaning of the formulation on Social Medicine made by Jules Guérin in 1848? An analysis of Jules Guérin's trajectory supported by primary and bibliographic sources was made to answer these questions. The material analyzed allows us to conclude that there was no movement around Social Medicine, unlike hygiene, and closer to the revolutionary proposals of 1848. Jules Guérin was a liberal doctor who aimed to have a place in the new revolutionary government for the medical corporation. His scientific and professional work was fundamentally related to orthopedics, and the paper on Social Medicine was a circumstantial essay with liberal content.

Introduction

Controversies and different viewpoints surround the significance of social medicine. ¹ The dominant interpretation mainly stemmed from the investigations of the historian George Rosen. For him, the development of the idea of medicine as a social science occurred in the nineteenth century, in Germany, with the medical reform movement led by Rudolph Virchow and Salomon Neuman and also in France during the 1848 European Revolutions. Although in one of these papers Rosen pointed out the advance of the French social medical thought vis-à-vis Virchow, he does not refer to Jules Guérin but rather to Villermé, Benoiston du Chateneuf, and Guepin.^2,3 However, in another work, Rosen considered Jules Guérin the first author to describe the concept of social medicine, relating it to industrialization, its consequences for health, and 1848 revolutionary ideals: “At the time, when revolutionary hopes were seeking to settle, Guérin appealed to French medical professionals to act for the public good in order to create the new society to which the February Revolution had paved the way.” ^{4 :34} Rosen believed that the idea of social medicine that year was a consequence and a resumption of the ideals of the 1879 French Revolution but at a new level. ⁴

Following Rosen, Dorothy Porter included Guérin among the social and health reformers of the time, together with Rudolf Virchow and Alfred Grotjhan. ⁵ Guérin was placed alongside utopian socialist thinkers or liberals. ⁶ Porter also described Guerin as a socialist writer who had been inspired by Saint-Simon to create the concept of social medicine. ⁷ In Latin America, Rosen's ideas were mainly incorporated into studies on the origins of social medicine as a concept that related the social determinants of health to the need for social reforms. ⁸

In another interpretive perspective, a predominantly liberal hygienist movement occurred during that period. The expression “social medicine” was “…coined in 1848 by Jules Guérin to give high relevance to medical police.” ^{9 :70} Moreover, considering hygiene as an analytical object, in the 1815–1848 period, ¹⁰ Ackerknecht mentioned Guérin only in the footnote of one of his works to illustrate the relationship between the medical reform proposed by Virchow and social medicine as proclaimed in France. ^{11 :138}

In the same vein, Ann La Berge investigated the emergence of a Public Health movement led by hygienists who edited and published the Annales d’Hygiène Publique et de Médecine Légale, among whom were Villermé, Parent-Duchâtelet, and Benoiston de Chateneuf. ¹² By analyzing the growing professionalization of public health in the 19^th century, she referred to Jules Guérin as follows: “The 1848 Revolutions in France and Germany witnessed doctors demanding that medicine take a new spiritual lead in recasting values of modern society. Jules Guérin, the Gazette Médicale de Paris editor, hailed the dawn of an epoch of ‘social medicine’….” ^{12 :14}

Despite these references to Guérin, the existence of a movement around social medicine influenced by him is not adequately documented. The following question remains: why would an orthopedist write a call to doctors in Paris proposing a union on social medicine? Additionally, what is the significance of Jules Guérin's formulation on social medicine in 1848?

This paper aims to fill this gap by analyzing Jules Guérin's trajectory, publications, and debates with other doctors. The sources consulted mainly include the medical journals of the time, particularly the Gazette Médicale de Paris, Annales d’Hygiène Publique et Médecine Légale, Gazette des hôpitaux civils et militaires, L’Expérience, Journal de Médecine et de Chirurgie, and L’Union médicale, obituaries, papers on Guérin, and documents mainly related to his contributions to orthopedics by Malpas ¹³ and Quin. ¹⁴

The material analyzed shows that there was no movement around social medicine, unlike the movement for hygiene, and inspired by the revolutionary proposals of 1848. Far from being a leader, Jules Guérin was a liberal doctor who developed his career in the Orleanist period and aimed to create a place in the new revolutionary government for a medical association. His scientific and professional work was fundamentally related to orthopedics, and his paper on social medicine was a circumstantial essay with a liberal content.

The trajectory of Jules Guérin (1801–1886)

Jules Guérin was born on 11 March 1801 in Boussu, a French city that would later belong to Belgium. He initially studied at Soignies and Louvain. He went to Paris in 1821, where he obtained his medical degree in 1826. ¹⁵

Jules Guérin's participation in ministerial committees is indicative of his proximity to the Orleanist government. He was the rapporteur for the ministerial committee in charge of presenting a plan to reorganize medical education in 1830 and part of another committee with this aim in 1847. He never held an official seat at the Faculty of Medicine. As a result, his work had no significant academic repercussions or influence on students from the viewpoint of Ranse, in an obituary written in the year of Guérin's death. Although Ranse recognized Guerin's diverse merits, he considered that he did not have the characteristics of an academic leader: “It must be recognized, moreover, that Mr Jules Guérin did not have the qualities required to make a school, gathering around him a group of young workers… ^{15 :49}

Guérin's main professional disciplines were orthopedics and surgery. Together with his colleague Charles-Gabriel Pravaz, he organized a private institution called the Orthopedic Institute of Paris. ¹³ This practical activity was considered part of the institutionalization and specialization of orthopedics in France in the 19^th century and represented the creation of a private market for orthopedic and surgical devices. ¹³ As the owner and editor of the Gazette Médicale de Paris for 40 years, Guérin used the journal to disseminate his scientific ideas and the techniques that made him “famous and fortunate.” ^{13 :148} He also joined the Academy of Medicine in 1942, ¹⁴ a time when the Academy was considered an impoverished institution with a low intellectual and symbolic status. ¹⁶ At that time, although the proportion of professors at the Faculty of Medicine was already high, there was room for the entry of non-professor members.

This trajectory places Guérin outside the medical-hospital elite in Paris. The elite were established in 1802 by the French Revolution Consulate. Access to the elite was earned through internship competitions. The elite comprised professors from the Faculty of Medicine, heads of service, and members of the clinical bodies of hospitals that were approved under public examinations. ¹⁷ Thus, although Guerin developed multiple activities, he could not be considered, in Quin's opinion, a “true mandarin,” ^{14 :245}. This expression is used by Weisz to characterize the French medical elite since the 19^th century in its specialization process and relations with science and political power. ¹⁶

Main works developed by Guérin, controversies, and lawsuits

Guérin was engaged in intense controversy surrounding tenotomy with his colleagues in several sessions of the Academy of Medicine.^18,19 Guérin advocated for tenotomy and Bouvier criticized it, pointing out its adverse consequences. Guérin cited examples of successful operations, and Bouvier replied with experiments on dogs and reports of unsuccessful tenotomy cases presented at the Academy. Guérin took patients whom he had operated on but refused to submit them to the scrutiny of a commission. Bouvier swore that he would exterminate Guérin's doctrines and practice at the Muette clinic. He questioned, “…the usefulness and rationality of cutting the backs of the poor hunchbacks.” ^{20 :15}

Malgaigne also contested Guérin's statistics after examining some of his patients who were considered cured. He reported in L’Expérience the examination of these cases, in which he identified persistent deformities after surgeries performed by Guérin. Facing Malgaigne's questioning, Guérin asked to create a commission that was also criticized as it consisted of people from Muette's clients’ social circle. Henroz then demanded that the commission examine Malgaigne's criticisms and analyze what he considered to be Guérin's undue gain from the treatment of destitute children admitted to the Hôpital des Enfants Malades for whom public funds had been allocated. ²¹

Guérin defended himself by claiming to charge only nonindigent patients. In response, he filed a lawsuit against Henroz, then Editor-in-Chief of the L’Expérience, and Malgaigne and Vital (de Cassis). The tone of the debate, in this case, was belligerent, and Henroz attributed this hostility to Guérin's contradictory interests, implying that there were commercial interests in the dissemination of Guérin's surgical results. ²²

The controversy between Guérin and other doctors unfolded throughout 1843 from papers published in both the Gazette Médicale de Paris, a newspaper controlled by Guérin, and in L’Expérience, which was directed by Henroz. Concerning this controversy, Paris surgeons addressed Guérin through a letter published in L’Expérience, where they criticized the exceptional position he held in Parisian hospitals, obtained without public examination, and the unrealistic statistics released by him. ²³

There was another reaction signed by around 150 doctors in Paris who defended the right to criticism as a resource in the face of quackery, entitled “Déclaration de principes des médecins et chirurgiens de France, à l'occasion du procès intenté par M. J. Guérin.” ^{22 :272} Among the signatories were Villermé, Fouquier, and Cornac. This was followed by several others signed by interns from the hospitals of Paris, Alençon, Loire, and other regions that were published in L’Expérience, under the title “liberté de discussion.” These facts reflect a mobilization of doctors against Guérin, but mainly against the fact that he started a legal process to bring the matter to justice instead of being limited to the academic debate within the Academy of Medicine.

Many doctors and lawyers followed the trial of the case brought by Guérin. In the end, Malgaigne was acquitted. Vidal (de Cassis) and Henroz were found guilty. Although partially victorious, Guérin was defeated regarding the validity of his statistics, and his position at the hospital that had been obtained without public examination was contested.

Jules Guérin and social medicine

An analysis of Guérin's intellectual and professional focus during the 1930s revealed that he concentrated his interest in orthopedic surgery at his private clinic. Why, after the controversy with many other doctors in Paris, did he write on March 2, 1848, just after the February Revolution, a paper on social medicine, ²⁴ a topic quite distinct from his professional concerns? Understanding the meaning of this text requires a new perspective on its content. However, above all, it requires an analysis of the state of the medical field in France at the time and Jules Guérin's position within it.

The French medical field in 1848

The medical field was undergoing a reorganization and the onset of specialization, mainly due to the redefinition of hospitals’ roles and changes in theories of disease with the emergence of the clinic and pathological anatomy. ¹⁷ Hospitals underwent a medicalization process and abandoned their former function as prisons to become places of care, science, and training. ²⁵ At the time, as mentioned above, the medical field's dominant group was formed by hospital–university elite professors who were selected by public examination, as established with an 1822 reform. ¹⁷ Access to posts in hospitals was made through public examination, and the Medical Academy also exercised some control over the practice through debates and memoirs published in its journal L’Expérience.

Guérin held a post at the Hôpital des Enfants Malades, obtained without a public examination, probably due to his social capital and ties to the July Monarchy. Although few records exist on Guérin's political performance in the 1830s, Leonard considered him an Orleanist ²⁶ The fact that he was never nominated for a chair at the Faculty of Medicine and that his surgical practice was contested by other doctors, members of the Academy, and those better situated in the medical field is indicative that he did not have an established leadership role in this social space.

His main strength was that he was the owner and editor of the Gazette Médicale. This position, however, must be put into perspective. Dozens of medical journals were founded in nineteenth-century Paris. During the legal battle over the validity of tenotomy surgery, the demonstrations against Guérin showed his isolation and led to his disqualification from his position at the hospital for being obtained without a public examination, and the protestors addressed him as the owner of a journal. ²³

Analysis of Guérin's text: Social medicine. To France's Medical Body

An analysis of Guérin's paper, published on 11 March 1848, gives us clues regarding a meaning different from that apprehended by the reviewed authors, like Rosen. The tone was written as a manifesto and a call to doctors. It was a situational document because it was written during ongoing events, and he said “eight days ago” in the text's first line. ²⁴

Ten days earlier, on 3 March 1848, in an analysis of the revolution's significance, he considered it a distinct and more important event than all previous revolutions, including that of 1789. He considered that this revolution would benefit the medical profession, leading to decreased competition between doctors in the face of the new administration's extensive recruitment of professionals. ^{27 :156}

Although the title included the term “social medicine,” this paper did not propose a new form of medicine. It began by discussing the new era that the republic opened to science and the medical profession. It characterized the moment as a social cataclysm and drew attention to doctors’ opportunity to intervene in society's development rather than just responding to social demands. At the time, in general, all sciences were thought to contribute to social development. Before the revolution, access to medicine was practically restricted to monarchs. With the revolution, the role of doctors was expanded because of the need for them to act for the benefit of the entire population in all parts of society. Guerin, the author, pointed out that this was a right and a duty of doctors. ²⁴

In the text, Guérin considered the republic a defining agent of future change and positively evaluated the provisional government. He stressed that the moral principle of the French Revolution was to provide work for all. Medicine and doctors would have a fundamental role in ensuring basic conditions to exercise this right and also to contribute to “social regeneration” together with the entire society represented in the Constituent Assembly.

Guérin addressed the euphoria of the moment and how it affected the alleged gains brought about by the revolution. He also said that people should evaluate their viewpoints in all facets of change. Moreover, he said that the “friend of order is the same friend of progress”; that is, whoever supports order supports progress or else everything that has been built will be lost At the same time, he pointed out the need for services to be grouped and systematized to be accepted in their noblest and highest character. What was previously known as public hygiene and forensic medicine would be incorporated into the single concept of social medicine. This would be one of the first benefits of the revolution: allowing the identification of the relationship between medicine and public affairs. This has been a concern of medicine since the revolution. This change would be enough to convince even the most skeptical people because the doctor, in this case, would be the most suitable professional to solve the problem of the lower classes and define the relationship between the capacity and type of work capable by people of different ages. One of the aspirations of the time was reducing working hours and increasing wages, which could bring benefits to the worker if analyzed in the light of social medicine. Guérin described that a person who works less and earns more would work better and more efficiently with better working conditions. To make this argument clearer, he makes an analogy between men and horses saying that they both walk faster when they work less and are better fed.

Guérin defined social medicine as the key element to improving social issues and a way to answer these questions more easily. He also explained that, when implemented, social medicine would be a way to improve people's lives because this was one of the goals of the revolution, and there was no better discipline than medicine to accomplish this goal. It would be a doctor's role to develop morale throughout the body. This role would expand the doctor's contribution in society, starting with the concept of justice and labor rights. The doctor would play the role of mediator between workers and bosses in the employment relationship. He would be totally impartial, and the focus would be on the common good. For Guerin, the doctors performed a work of universal regeneration that was almost exclusively their competence. With the revolution, doctors’ roles in society would be expanded.

Considering this breadth of action, it would therefore be unnecessary to list all questions that social medicine could answer in society. Thus, Guérin puts social medicine on a high pedestal that would solve all problems arising in society.

He explained that political events magnified the priesthood of medicine and that social medicine and politics had dominated the purely scientific components of medicine. Therefore, a debate regarding whether medicine would only benefit the scientific or political field emerged.

Thus, Guérin proposed a call to doctors to act as a uniform body that could occupy a space within the emerging society. The medical association would have a larger objective because, as Guérin stated, it would be a huge “body in need of a soul,” ^{24 :184} wherein the soul would be ideas with common objectives superior than the individual ones.

As a large family, the association would fulfill this role and expand doctors’ actions beyond the scientific field and into the political field. ^{24 :185} Guérin argued that doctors’ power, and consequently that of the proposed association, would lie in the fact that doctors are accepted in society's most diverse sectors. As a result, doctors would have the power to work on societal regeneration and focus on public interests.

The content of Guérin's paper was therefore predominantly political and not theoretical or conceptual regarding social medicine. The term “social medicine” appeared not as a new concept but as a new name for everything that referred to the public (hygiene, public health, and forensic medicine). It constituted a paper position, a manifesto, and a leadership document addressed to his professional colleagues, calling on them to participate in the ongoing political process.

In that paper, the February 1848 Revolution, to which Guérin referred, was a reaction by the sectors of the bourgeoisie and the proletariat to the domination of the residual bourgeoisie linked to financial capital during Louis Philippe's July Monarchy. In the first month of the revolution, a provisional government was formed by a coalition between the Journal National representatives, representing the Republican-Bourgeois Fraction, and La Réforme, representing the petty bourgeoisie. ²⁸ Several deputies were linked to the old regime. Guérin considered this mainly conservative government as “…a providential stone placed in front of the revolutionary chariot to prevent it from rolling over the abyss….” ^{24 :183}

Encouraged by the prospect of broad participation during the 1848 Revolution, several clubs and associations were created in Paris, with varying political orientations. Doctor François Raspail, a doctor of the poor, led the Society of Friends of the People. The club movement represented a bustling moment for the organization of sectors of society that wished to influence the definition of the direction that the republic would take. ²⁹

Doctors also participated in this process. Published just below the paper on social medicine was a text entitled “Feuilleton. Chronique Médicale. Le corps médical pendant et après la revolution.” In that paper, Guérin said that this section of the Gazette would not discuss the usual topics but instead would discuss the republic. He referred to Dr Aubert Roche, who prevented further bloodshed. He also mentioned Lesseré, the captain of the national guard, who cared for the wounded. He praised the work of several doctors, pharmacists, and health officials who anonymously cared for the wounded on long journeys. However, the paper also referred to doctors who held positions in the government: Buchez and Recourt at the Paris city hall and Londe and Sanson in more modest government positions. He additionally referred to the support given by the Academy of Medicine and the Faculty to the Provisional Government and claimed to be certain of the triumph of liberal and democratic ideas in most doctors.

The 1848 revolution and doctors

Doctors welcomed the 1848 Revolution. Although most said that they were Republicans, there were doubts, and the expression “day-after Republicans,” frequently used, referred to all dissatisfied Orleanists and legitimists. Three among the various medical journals seem to have had a more significant influence on doctors’ political thinking at the time: The Gazette Médicale de Paris, the Gazette des Hôpitaux, and the Union Médicale.

Soon after Guérin's paper on social medicine in the Gazette Médicale, a call was made for a meeting of the presidents of the medical associations and for the assembly of doctors to be held the following week, where candidacies to the National Constituent Assembly would be discussed. ²⁴

The assembly was held on Sunday, 26 March 1848. It was chaired by Melier, who was the president of the neighborhood Medical Association. Approximately 700 to 800 doctors attended, according to an editorial report by the Gazette Médicale entitled “Political Medicine, Electoral assembly of doctors in Paris.” Guérin, who was the editor of the journal and probably wrote the article, analyzed the various candidacies and reported the assembly's decisions. Those present decided to nominate four names to run for the Legislative Assembly for the Medical Association. Guérin believed that the assembly's climate showed the doctor's strength as more significant than any club did in Paris, referring to the club movement that boomed at the onset of the revolution. He considered that most doctors were Republicans, although he noted opposition to this statement during the assembly, which he believed was unfair. He made a remark on the type of republic that was advocated by most of the assembly as follows: “In a nutshell, the assembly was broadly and cordially Republican: not the category of red caps, fanatics without respite, but true, firm, elevated and above all intelligent republicanism.” ^{30 :243} The paper's author then evaluated the candidates presented to the assembly. He believed that the absence of Buchez and Trelat was justified because they held administrative positions in the new government. In Guyot, he admired the qualities of order and freedom and criticized his mediocre way of expressing himself. Concerning the others, he disqualified some for being poorly known in Paris and others for their diction. He revealed his grudge toward Malgaigne and accused him of receiving votes from both legitimists and Republicans and of being a supporter of Saint-Simon, Fourier, and even communists.

Guérin's papers did not stir much debate. Some of his articles, published in the Gazette and other journals helped in clarifying the possible significance of social medicine for him. On 18 March 1848, a second paper was published in response to letters from readers who questioned whether social medicine was equivalent to socialist medicine. In this text, social medicine corresponds to a discipline with the objective “…to point out all the circumstances in which medicine can help the social organization or well-being and improvement of society. Therefore, social medicine does not prejudge any medical, philosophical, or political theory: it serves all without adopting any.” ^{31 :203} It would correspond to “…the set of relationships between medicine and society, considered independently of any doctrinal or systematic idea.” ^{31 :203} On the other hand, socialist medicine would be medicine from the viewpoint of a Fourier socialist doctrine, for example. It would be a particular way of looking at medicine according to the principles of that doctrine. Building on Rousseau, he drew an analogy between society and medicine: between the architect and the social doctor. He thus defined pathology, hygiene, and social therapy. Social pathology corresponds to the principles and practices taught by Moses, Muhammad, and Jesus Christ, which would prevent people from suffering from diseases inherent to their constitution or environment. Social hygiene, for Guerin, concerns the form of government. With regard to social therapy, he questioned whether the factors facilitating conquerors to establish themselves in conquered countries should be sought in the gods or in medicine.

In the Gazette Médicale, a letter signed by Dr Boudin entitled “Social Medicine. New viewpoints of Social Medicine” adopted social medicine's proposition, which he understood as a form of doctors’ participation in the public sphere. Boudin considered that doctors had, until then, declined to be involved in public issues. He argued that the revolution consecrated a new era for doctors. Previously, 30,000 scholars previously relegated to the background by the defeated regime were called upon to play an essential role in solving the country's problems. He stated that doctors were ostracized during the monarchy. They were considered unsuitable for administrative and legislative functions and allegedly had a confused spirit (“esprit brouillon”). He particularly highlighted doctors concerned with public hygiene issues, a branch of medicine relegated to the accessory sciences. ¹⁷ The solution to major social, economic, and political problems called for the intervention of doctors. To that end, Boudin proposed the creation of an Association of French doctors, the prelude to the World Association of Doctors. ³² He referred readers to his paper entitled “Political Medicine,” a term he believed was more appropriate than “social medicine.” However, the severe problems listed by Boudin as social medicine priorities were not health problems of the less fortunate but the system of quarantines affecting international trade and the acclimatization of French soldiers in North Africa with repercussions on colonization.

Final comments

Jules Guérin, editor and owner of the Gazette Médicale de Paris, dedicated his professional career to orthopedic surgery. He founded one of the first private clinics in Paris to treat orthopedic diseases. His participation in the events of the 1848 Revolution was related to corporate and club activism in support of the bourgeois republic. Although many doctors had been actively involved in the revolutionary process, most of them, including Guérin, were linked to the Orleanist regime and could be considered last-minute Republicans.

Mixing religious ideas with specific references to Rousseau, Guérin's conception of what social medicine would be was outlined in his article. At no time did he present facts regarding the social determination of diseases or refer to works by Villermé and Parent-Duchâtelet, his contemporaries. Social medicine's objective was not health and disease and their relationship with society but society's issues that could be addressed with medical expertise. In other words, it was not related to what would become the conceptual, theoretical social medicine of the 20^th century. Likewise, there is no evidence on the relationship between the hygienist movement linked to the Annales d’Hygiène Publique et de Médecine Légale and Jules Guérin and his circumstantial writings on social medicine.