hist-234: Epidemics in Western Society Since 1600
Lecture 8 - Nineteenth-Century Medicine: The Paris School of Medicine [February 8, 2010]
Chapter 1. The Paris School of Medicine [00:00:00]
Professor Frank Snowden: Okay, well good morning, and we can get underway. So far, as you know, we've dealt with two major epidemic diseases, plague and smallpox. And we'll be examining quite a number more, beginning next time with Asiatic cholera. But our course, as you remember I explained in the beginning, isn't simply one epidemic disease after another. There are also other themes that are very important to us. One of those is already taking shape, I hope, in your minds and in your section discussions, and that is the history of public health strategies; that is, ways in which societies organize to defend themselves against the incursions that we're discussing.
We've noted the first form of public health, which consisted of those draconian plague measures, and we'll see that they aren't confined only to bubonic plague, but they'll be cropping up again and again in the course of our lectures. And you've also seen that smallpox brought about a second major style of public health, and that is vaccination, and clearly we'll be returning to that as well. So, public health is a major theme of our class. And a third major theme is also crucial, and that's the history of ideas, and especially medical ideas.
So, we're examining — one way of thinking about the course might be as an examination of the career of what might be called scientific medicine, from humoralism through several subsequent incarnations, down to the modern biomedical paradigm. In later weeks we'll be looking at the germ theory of disease, at the debate about contagionism and anti-contagionism. We'll be looking at the idea of tropical medicine as a concept, and its implications. But this morning I want to take another step by looking at a very crucial moment in the development of modern medicine that took place, this development, between the French Revolution and the middle of the nineteenth century, and it occurred in Paris, and is universally known as the Paris School of Medicine.
This is a development that was so important that sometimes it's referred to, maybe just a shade glibly, as the moment of transition from medieval medicine to modernity. So, our plan this morning is to look at this through first understanding major new developments that were a series of shocks to the old humoral system of Hippocrates and Galen. We'll see firstly some crises there. The second thing we'll need to do is to look at positive precursors to the developments of Paris.
Chapter 2. Limitations of Humoralism and Galenism [00:03:48]
As is so often the case, it's misleading to think of the Paris School as suddenly appearing out of nowhere. It had its bases intellectually and institutionally in a series of prior developments. Those were preconditions that made it possible. Then we'll look at what actually happened in Paris, roughly in the period 1794 to 1848; the establishment of a new concept, a new embodiment of scientific medicine. And this is a step that laid the preconditions for the germ theory that came later in the century, for reasons we'll be discussing. And then the last thing we'll do this morning is to look at the achievements, but also the limitations, of what happened in Paris.
Now, in our career in scientific medicine, we've noted the first embodiment in antiquity. We've talked a bit about Hippocrates and his establishment of the importance of naturalistic causes of disease instead of magic explanations; the rejection, if you like, of religious or demonic interpretations of disease. In Hippocrates' hands, disease was clearly a natural phenomenon with naturalistic causes. We should remember that this had an importance for medical epistemology. By epistemology, I mean what do we know, and how can we know it, what's the basis of knowledge, what are its sources?
We know that Hippocrates and his corpus of writings established or embodied a medical epistemology that held that knowledge in matters of healing is derived from direct observation, at the individual patient's bedside. It's therefore often referred to, as this first incarnation of a scientific medicine, as bedside medicine. The locus, the source of knowledge, is at the bedside, through empirical observation. We know too that this had as a corollary an educational program. How do you learn medicine? You do so by apprenticeship to doctors on their rounds to the domestic bedside where the essential task was to observe.
Then we saw another development in scientific medicine, and this was in the form of Galenism. This is to say that humoralism in Galen's writings was primarily concerned with the ancient texts, texts that Galen considered essentially infallible. They were to be enhanced, and he thought that he was the person ideally suited to do that work, but they could never be overthrown. There was no possibility of a conceptual paradigm shift, or conceptual revolution. This was what was called library medicine. In other words, for Galen there was a new understanding of medical epistemology.
Knowledge was derived from considering the ancients, from a careful study of their texts. So, it's textually based medicine. And it had, of course, an educational corollary. And indeed until 1794 in France, for example, medical education consisted primarily of lectures on the classics, delivered in Latin, and of a program of reading the ancients in the original languages. This, then, was library medicine.
The whole humoral system, as we've been looking at it, underwent a series of shocks and intellectual criticisms. It didn't seem to fit all of the evidence that emerged. Let's look at a couple of these shocks to the humoral system. One we've already mentioned, and that was the great work of William Harvey and the circulation of the blood. Now, this meant Harvey's work, although he didn't take the step of rejecting Galenism, nonetheless it's true that his work undermined Galen's anatomy, and it undermined humoral physiology. So, this was ultimately, then — Harvey's discoveries were incompatible with the medical thinking of his time.
We've mentioned also that the chemical revolution, the work of people like Lavoisier, was extremely important, and it was important in undermining humoralism. Because you know that the humoral approach was based on a theory of the four elements or the four humors, essentially on Aristotelian natural philosophy. Chemistry, however, undermined the humoral elements, the four elements, and began to replace them with a wholly different set, leading ultimately to the periodic table. So, the whole basis of the four elements comes to be undermined by the chemical revolution.
Indeed, there is a development of what's called iatrochemistry, which is the view that health is the balance of chemicals in the body, and that healing consists primarily of finding the right chemical to correct the imbalance. So, medicine, in this view, becomes reduced more to chemistry. An important figure in this is Paracelsus, who lived from 1493 to 1541, and was known as "the Martin Luther of medicine," a Swiss healer and a rebel against Galenism. Indeed, he burned — he boasted that he himself had burned the masters' texts. He was a leading figure in the development of iatrochemistry, which was particularly strong in the Low Countries. He introduced a number of chemicals to medical science, such as zinc and laudanum, or opium.
Another shock to the system, of course, was the spirit behind the scientific revolution. The scientific revolution was empirical. It was a democratic process, and it rejected the cult of authority. Authority could be challenged by anyone's observations and measurements. And this was ultimately incompatible with Galen's system of worship of the Ancient texts. Then there was the experience that we've been looking at the last couple of weeks of epidemic diseases.
Epidemic diseases created problems for humoral interpretations. How was it that so many people in a single place and time had this marked imbalance in their humors? And there came to be, alongside the Galenic system, the idea of contagion instead, which was a non-humoral idea. Indeed, Fracastoro developed this strongly, and it gained a wide purchase in popular culture, and the search came to be for some agent responsible for epidemics, not humors, but perhaps a chemical. Even some people postulated that it might be a living thing of some kind.
All of these were severe criticisms for the humoral system. But although Galenism then had these loose threads, if we might say, well before 1794, no consensus arose around an alternative to replace it. We might make a distinction between medical science also and medical practice; that is, the scientific basis of Galenism was eroding. But until indeed the late nineteenth century, medical practice, what physicians actually did at the bedside, remained traditional. So, we see critiques of Galenism abounding, chipping away at its foundations. But there was no new medical science that was robust enough to create a new medical practice.
Chapter 3. Hospital Medicine [00:14:47]
Note also that when we talk about the coming of the Paris School, a couple of things that we won't be pointing to. This new revolution in medicine that occurred in Paris was not based on some new development in the natural sciences. It wasn't based on a technological breakthrough. It wasn't based on some path-breaking medical or scientific discovery. So, let's look now, with that as the background, at this new incarnation of medical science, the Paris School of Medicine, which was a conceptual revolution in the understanding of disease. It marked a transformation in medical epistemology — where is the source of medical knowledge? — and also in medical education, and it led to a new position for the regular physician in society, with new claims to authority, in competition with various competitors, like homeopaths or members of various medical sects.
This new medicine comes to be called hospital medicine. And there are a number of classic studies, if you want to read further about it, that you'll be glad to know aren't on the reading list; which I'm not extending. But there are places that, on a purely voluntary basis, I hope that you'll be going to read more about it. One is the work of Erwin Ackerknecht, who's one of the founders of the modern discipline of the history of medicine, and he wrote a work Medicine and the Paris Hospital. Or there's my colleague here at Yale, John Harley Warner, who's written Against the Spirit of System, which is a study in particular of American physicians and students, and their experiences as they made a medical and intellectual pilgrimage to Paris.
There's a famous book by Michel Foucault called The Birth of the Clinic, and I will wish you luck with that particular work. It's one of the classic studies that everyone refers to with regard to the Paris School and its importance. But let me just tell you anecdotally that I've read it I think four times. The first time I read it in French and thought there was something wrong with my French. So, I read it in English, and decided there was something also wrong with my English. And then my third and fourth times I think I decided maybe there was something wrong with Foucault. But I'll leave that for you to judge and make your own decisions. In any case, it's one of the classics in the literature, and it covers the ground we're dealing with this morning.
Chapter 4. Institutional Foundations [00:18:12]
Well, what were the sources of this new medicine? First, I would say there's an institutional basis that made it possible, and that is the hospital. Hospitals already existed, but not as places of treatment so much as safety nets or dumping grounds for the aged, the incurable, the orphaned. The Industrial Revolution and urbanization, however, radically increased the numbers of patients, and the hospitals were often associated with philanthropy and the church. And Paris, the great center of Western Europe, urban center of culture, also became the locus for some of the most famous hospitals in Europe: the Hôtel-Dieu, the Charité and the Pitié, that we'll be seeing in a moment.
And, so, for a second then I think it's worth doing a little bit — taking you for a moment on a bit of medical tourism. And in doing so, we go to the center of Paris, here, when we see the location of the Hôtel-Dieu hospital, here in the middle of the Seine, on the Ile de la Cité. The Hôtel-Dieu was perhaps the oldest hospital in the world. It had a history of providing care on this very site ever since the seventh century, and it was the largest general hospital in Paris. And as you can see, it's located at the very center of the city. This is its architectural plan. It was a very large structure. By the end of the old regime in France, it had four great wards that could accommodate 4,000 patients, often sleeping several to a single bed. We can see another picture of it.
This is a picture of the entrance to the church and the hospital, taken in 1871, at the time of the Paris Commune. And we can see its present-day structure. This is the great courtyard of the Hôtel-Dieu. And I'm pointing it out to us because it's impossible to understand the Paris School of Medicine and the new understanding of medical science without taking into account the great hospitals of Paris that were its site and were crucial in the development of its ideas. This is the Hôtel de la Charité, another one of the great hospitals. And this is the Hospital de la Pitié.
So, the new hospitals become places of instruction, under the control or auspices of a centralized state. They're large, and have an enormous array of patients, and they're dedicated — and this was crucial — to furthering scientific knowledge. Indeed, they're more dedicated at this stage to furthering knowledge than to treating people.
Chapter 5. Philosophical Foundations [00:21:58]
Then there are — if that's an institutional basis then, the great hospitals — there are also philosophical origins for the Paris School. The first is the Enlightenment, with its questioning of authority, its skepticism, its empiricism. And then I'd like to turn to John Locke in particular, the great figure from 1632 to 1704, and his crucial work, the essay "Considering Human Understanding," of 1690, which some people regard as so important that they place it at the very beginning of the whole movement of the Enlightenment. Well, Locke postulated, as you already know, that the mind at birth was a blank slate or tabula rasa. And his idea was what's called philosophic sensualism; that is, that ideas and knowledge gained by the mind are not innate but are derived entirely from sense impressions and reflections on those impressions. This is the cover of the "Essay Concerning Human Understanding."
So, we have in Locke then a radical idea of epistemology. The source of knowledge — hence the word sensualism — is the five senses used to conduct a rigorous examination of nature. Locke, also in his epistemology, not only saw the source of knowledge, but set rigorous limits to what we can know, putting God, for example, beyond the realm of knowledge, and establishing rigorous steps for being certain of the things that we can know. Then there's another very important figure, and this is someone we've also mentioned before, who's becoming an old friend to us. This is Thomas Sydenham of the seventeenth century, who was in fact a close friend of John Locke and is called variously the English Hippocrates, the father of English medicine.
Well, Sydenham was politically a radical. He was a Puritan, a left-wing Protestant, who rebelled against the Crown in the Civil War in England, and served, in fact, as an officer in Cromwell's Army. He was also radical in his medical ideas. His prescription for medical practice was rooted in the idea of sensualism. He called for a rigorous return to observation of the patient, and he himself called for the idea of abandoning theory and all pre-established medical systems. The advance of medical knowledge would proceed by a systematic comparison of case by case, setting aside the classics and setting aside general system and general theory.
Oddly, Sydenham did not wholly reject humoral medicine. But his ideas, in fact we could say, were — and his practice — were still influenced by Hippocrates. But what he did was to suspend ideas of general theory and return from the texts to direct observation of the patient at the bedside. In some sense he was skipping over Galen and returning to Hippocrates. He believed that the physician should trust his own independent reasoning based on experience. He distrusted bookish learning and university education — although he himself had attended Oxford — and in return he was scorned by the medical and academic elite of his day.
Sydenham gave his attention also to epidemic diseases. He studied smallpox, malaria, tuberculosis and syphilis. Indeed, he would be a good figure for talking about the impact that epidemic disease had on the undermining of humoralism and the rise of a new scientific paradigm. He's known also for his work on hysteria, and on gout, from which he himself was a great sufferer. In his work on malaria, he also did something radically new, of reaching the conclusion that he was dealing not with a humoral imbalance in general, but rather with a specific disease entity. Indeed, he thought he was one of the harbingers of the idea that diseases are all specific entities, rather than a single dyscrasia, and he suggested that the time might come when they would be classified in the manner of Linnaeus. He even wrote, "All diseases ought to be reduced to certain determinate kinds, with the same exactness as we see it done by botanic writers in their treatises on plants."
Sydenham also was new and radical in sometimes embracing the idea of contagion in his dealing with epidemic disease. He wrote, for example, of the plague: "Besides the constitution of the air, there must be another previous circumstance to produce the plague; namely the effluvia or seminum from an infected person, either immediately by contact or immediately by some pestilential matter conveyed from some other place." So, we see here a radically different idea. And he wrote a work, a famous work, of 1676 called the Observationes Medicae, a revealing title stressing medical observation.
Sydenham is famous for introducing a number of practices into medicine, as well. He popularized the use of quinine for malaria. He introduced opium into his practice. He used cooling drinks and fresh air to treat fevers, rather than bloodletting, and he introduced the cool regimen that we talked about for smallpox. Often, he wrote, the best advice he could give a physician was to do nothing at all.
There was another important philosophical influence, and that's this man, Pierre Cabanis, a French philosophe who lived from 1757 to 1805. He was a physician, a physiologist and medical philosopher. He was also an administrator of the hospitals in Paris, and an early supporter of the French Revolution. But the point I want to stress today was that in terms of medical philosophy he was a sensualist. He believed that all mental processes are derived from the five senses, and therefore in medicine the source of knowledge should not be ancient texts but direct observation of patients.
Chapter 6. Influences of the French Revolution [00:30:24]
So, that was — these series then we've seen institutional foundations and philosophical ones. I now want to look at a third major foundation for the coming of the Paris School, and this is the French Revolution itself. This is a famous painting of Eugène Delacroix of "Liberty Leading the People." You get the idea. What I want to stress is a general feature of the French Revolution, that it was an opportunity to wipe the slate clean, that it marked a radical new departure that facilitated opposition to older authorities, and in specific nature to medical corporations. It was also a time of French nationalism which urged on that instruction should take place no longer in Latin but in the vernacular; that is, in French.
There are also some other specific features that made the French Revolution an important moment for the development of a new medicine. One was, of course, that this was a time of continuous warfare — from 1792, for a whole generation, until 1815 — and therefore there was an urgent practical need for physicians and for adequate hospitals. It was a time of reform in the structure of medicine as a career and a profession, and also of medical training.
It was a time too, during the French Revolution, when the hospitals were reformed, centralized. There was only one patient to a bed. They were state-owned and centralized. And the wards became specialized — and this was crucial for the development of new medical ideas — specialized according to the type of patient being treated. These hospitals were no longer devoted to hospice and orphanage care, but rather they became scientific institutions.
Patients were seen as having a service to perform in the name of science and the advancement of knowledge. Their bodies were made radically accessible to physicians and students, both in life, and very crucially also after death in terms of post-mortem examinations. Alive, the patient was a source of knowledge, as physicians conducted physical examinations to study the signs and symptoms of disease with rigor and precision. In death, their lesions were a source of knowledge to pathologists, to surgeons who practiced their techniques, and to anatomists and physiologists.
Well, the reform of medical education meant that the locus of medicine was entirely clinical and practical on hospital wards. You were trained as a physician, a medical student, for three years, followed by an internship. And the Faculty of Medicine in Paris now consisted of full-time professors, appointed by competitive examination. And the French Revolution was important for its values, stressing a meritocracy by the encouragement of ability instead of privilege, birth and cronyism, and by a new democratic spirit that provided a new dynamism and a world of competition. The new banners inscribed — the new mottos of the medical profession were words such as "reform," "progress," "observation"and "precision."
Chapter 7. "Peu lire et beaucoup voir": Observation-Based Medicine [00:34:37]
What, then — those are the preconditions — what was the substance of the Paris School of Medicine? And here we see an extraordinary development where one city becomes the world center of a new medicine. Paris was dubbed "the universal faculty of medicine." Its students and physicians came from all over the world to observe and to be trained in Paris. Its work was concentrated in the Latin Quarter, that became a sort of mecca for scientists and students from everywhere. Indeed, large numbers of Americans made a pilgrimage to Paris to study with its masters, to bring their ideas back to this country, and to place themselves in a position to raise their fees because of the prestige which went with the time spent on the wards of Paris.
So, in medicine, the rise of the Paris clinic was said to mark a time of transition between the medical Middle Ages and the beginning of a modern era. This was hospital medicine, based on radical empiricism and opposed to abstract theory. The great motto in Paris was Peu lire et beaucoup voir, read little but see a lot. The basis of knowledge was said to be facts, grouped into great facts, with linkages established by statistics, and no room for abstractions, apart from the facts and their mathematical linking. This was observation-based medicine. But it went beyond the medicine of Hippocrates in that — this is a picture of René Laennec, represented on a Paris ward, and what he's doing is conducting a physical examination of the patient. Laennec, in fact, invented — he was famous for his studies of masses of tubercular patients.
It's important to know that tuberculosis was rampant in nineteenth century Paris, and René Laennec had the opportunity to examine and treat thousands of patients with tuberculosis, which he himself contracted, and he died from it in the end, at a young age. Well, he invented — and this is the point I wanted to stress at the moment — the stethoscope in 1816, so that the modern physical examination became more one — not just observing the patient, but examining him or her, and the stethoscope became a hallmark and symbol of the Paris School. Indeed, it became a symbol in nineteenth-century medicine.
Here we see — this was the monaural stethoscope of the type used by Laennec. It may have been important also that he was a musician, and specifically a flutist, and that may have influenced his method of proceeding. This is the precursor of what is more familiar to us. He introduced the procedures of oscillation and percussion. He tapped and listened to the internal sounds of the body, and he described them, what he heard in the lungs of his tuberculosis patients, as rales, rhonchi, and all the other modern terms used to describe the modern sounds that he heard.
Now, this vast number of patients on the wards was crucial. A professor of medicine in Paris might examine some 5,000 patients a year. And crucially, they produced a new concept of disease; that is, disease specificity. Diseases were thought to be discrete entities that could be classified. This is the beginning really of nosology, which is the classification of disease entities, labeled variously tuberculosis, smallpox, et cetera. Rather than the humoral idea that there's just one disease, the humoral imbalance or dyscrasia, now we have a Linnaean type nosology or classification.
On wards — and this was very important — another innovation of the Paris School was that the symptoms observed on the ward, after the patient died — if the patient died, and very many did — were correlated with the lesions in organs and tissues seen in post-mortem examination. So, an important part of Paris then was the linking of medicine with pathology, a physical examination with post-mortem autopsies. There came to be another word then associated with Paris — a couple of words: localism, diseases had a particular location in the body; solidism, which set them apart from the fluids that were the humors. Instead the location of diseases was in solid organs and tissues.
Now, the main diseases in Paris at the time were pulmonary TB, pneumonia, typhoid, heart disease, puerperal fever, cholera. With these discrete entities now being classified, we also see the rise of medical specialties. So, Paris was important in moving beyond the general practitioner to create specialties of internal medicine, psychiatry, geriatric medicine, pediatrics, pathological anatomy, venereology. And there was a new notion of medical education; that is, lectures were still given, but the main place of learning was the hospital ward where famous professors, like Laennec himself, or Pierre Louis, conducted their rounds with a retinue of hundreds. Then there was the autopsy table, also in the hospital, where observation and ideas, based on the ward, were confirmed or not.
The new medical education was practical instruction, and it was hands on, with training on the ward from day one. And the students who attended, attended year round, with no vacation, and there was a roll call for attendance. Remember, this was introduced at the time of the revolution and then under Napoleon. And under the Empire, professors even had ranks and wore uniforms. So, the practitioners were doctors. But there was also a new licensing system, and students were encouraged to learn through their senses, through seeing, hearing and touching. This was sensualism not only in theory, but we might call it applied sensualism, with a rejection of dogma, of theory and of authority simply as authority.
Note too that there was not an integration into this of the basic sciences. This was medical science in a sense on its own, without what we would now — they called the basic sciences accessory sciences. Now, the weak aspect of the Paris School though was its therapeutics. This was a medical revolution in terms of medical science. It was less revolutionary in terms of its therapeutics. The new understanding of disease did not lead automatically to improved treatment for the patient. Indeed, visitors from Britain and the United States often expressed severe moral reservations about what they observed going on in the Paris clinics. There was said to be little concern to alleviate suffering or to preserve life.
Knowledge and its advancement were what counted most. The patient, some visitors said, was an object to be observed, as in a Natural History museum; more to serve science than to recover. One American said, in fact, that a French version of Uncle Tom's Cabin ought to be written about hospital patients on the wards of Paris. And Eugène Sue, the Charles Dickens of France, who wrote the famous work The Mysteries of Paris, did a caricature of Pierre Louis, one of the heroes of the Paris School, who appears as Dr. Griffon; and in Dr. Griffon, in the story, tells his students on the rounds, on the ward of the hospital, that the lesions that they're observing — that is, the symptoms — they can soon look forward to seeing when the patient dies. Griffon declares that a patient is a human sacrifice on the altar of science.
So, the Paris clinic was also sometimes described by visitors as a theater, with patients as stage props, and where surgeons saw human bodies as a means to greater manual dexterity. Physicians and their students were not taught that their primary mission was to heal, but rather to advance science. Treatment remained what it had been for a long time. Therapy — we can see one of the lynchpins was still venous section or bleeding by leeches.
Here we see a picture, very widespread on the Paris wards, where hundreds-of-thousands of leeches were imported monthly by these hospitals. And indeed they discovered also, made a medical discovery, how do you get a leech to bite? Well, I can tell you the answer to that. What you can do is you can wrap the poor thing in a towel and soak the towel in wine or vinegar, which irritates it enormously and makes it bite the next thing that it can reach.
Chapter 8. Effects of the Paris School [00:46:23]
So, the therapeutics then were traditional and not different from what humoral physicians had been doing for centuries. The strengths of the Paris School were in diagnosis, pathology, classification, surgery and anatomy. Leading figures: Laennec, Pierre Louis, Pierre Cabanis, Claude Bernard. But this stimulated imitation in other countries. In England, St. Thomas Hospitals and Guy's Hospital in London; in Austria, the Vienna School of Medicine was directly influenced by Paris; and in the U.S., our own country, the linking of the Harvard Medical School with Mass. General Hospital was directly based on the idea that had originated in Paris.
But by mid-century, the dynamism of Paris was on the wane, and it had to do particularly with therapeutics. There was a therapeutic pessimism. All of the statistical methods of the Paris School revealed that standard medical practices were of doubtful efficacy, and tremendous advances in medical knowledge had done little to advance therapeutics. Medical science and medical practice were quite distinct. So, it's in the second half of the nineteenth century that we'll be looking to yet, very soon, another incarnation of scientific medicine, when scientific medicine moves from France to Germany, and from the hospital ward to the university and to the laboratory. Then we'll see a new epistemology that stresses the laboratory bench as the source of knowledge, and we'll talk about the coming of laboratory medicine and experimental medicine as a paradigm shift.
But all of that would not have been possible, and we wouldn't have the coming of the germ theory of disease, if it hadn't been for the idea of specificity and classification that were developed in Paris between 1794 and the middle of the nineteenth century. And next time we'll turn to another epidemic disease — and this is a timely one as we're moving into the nineteenth century — and that is Asiatic cholera.
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