WEBVTT

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Prof: Okay,
well good morning,

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and we can get underway.

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So far, as you know,
we've dealt with two major

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epidemic diseases,
plague and smallpox.

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And we'll be examining quite a
number more, beginning next time

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with Asiatic cholera.

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But our course,
as you remember I explained in

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the beginning,
isn't simply one epidemic

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disease after another.

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There are also other themes
that are very important to us.

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One of those is already taking
shape, I hope,

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in your minds and in your
section discussions,

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and that is the history of
public health strategies;

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that is, ways in which
societies organize to defend

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themselves against the
incursions that we're

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discussing.

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We've noted the first form of
public health,

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which consisted of those
draconian plague measures,

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and we'll see that they aren't
confined only to bubonic plague,

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but they'll be cropping up
again and again in the course of

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our lectures.

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And you've also seen that
smallpox brought about a second

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major style of public health,
and that is vaccination,

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and clearly we'll be returning
to that as well.

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So, public health is a major
theme of our class.

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And a third major theme is also
crucial, and that's the history

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of ideas, and especially medical
ideas.

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So, we're examining--one way of
thinking about the course might

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be as an examination of the
career of what might be called

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scientific medicine,
from humoralism through several

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subsequent incarnations,
down to the modern biomedical

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paradigm.

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In later weeks we'll be looking
at the germ theory of disease,

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at the debate about
contagionism and

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anti-contagionism.

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We'll be looking at the idea of
tropical medicine as a concept,

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and its implications.

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But this morning I want to take
another step by looking at a

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very crucial moment in the
development of modern medicine

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that took place,
this development,

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between the French Revolution
and the middle of the nineteenth

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century,
and it occurred in Paris,

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and is universally known as the
Paris School of Medicine.

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This is a development that was
so important that sometimes it's

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referred to,
maybe just a shade glibly,

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as the moment of transition
from medieval medicine to

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modernity.

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So, our plan this morning is to
look at this through first

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understanding major new
developments that were a series

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of shocks to the old humoral
system of Hippocrates and Galen.

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We'll see firstly some crises
there.

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The second thing we'll need to
do is to look at positive

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precursors to the developments
of Paris.

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As is so often the case,
it's misleading to think of the

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Paris School as suddenly
appearing out of nowhere.

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It had its bases intellectually
and institutionally in a series

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of prior developments.

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Those were preconditions that
made it possible.

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Then we'll look at what
actually happened in Paris,

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roughly in the period 1794 to
1848;

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the establishment of a new
concept, a new embodiment of

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scientific medicine.

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And this is a step that laid
the preconditions for the germ

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theory that came later in the
century, for reasons we'll be

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discussing.

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And then the last thing we'll
do this morning is to look at

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the achievements,
but also the limitations,

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of what happened in Paris.

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Now, in our career in
scientific medicine,

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we've noted the first
embodiment in antiquity.

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We've talked a bit about
Hippocrates and his

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establishment of the importance
of naturalistic causes of

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disease instead of magic
explanations;

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the rejection,
if you like,

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of religious or demonic
interpretations of disease.

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In Hippocrates' hands,
disease was clearly a natural

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phenomenon with naturalistic
causes.

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We should remember that this
had an importance for medical

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epistemology.

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By epistemology,
I mean what do we know,

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and how can we know it,
what's the basis of knowledge,

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what are its sources?

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We know that Hippocrates and
his corpus of writings

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established or embodied a
medical epistemology that held

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that knowledge in matters of
healing is derived from direct

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observation,
at the individual patient's

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bedside.

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It's therefore often referred
to, as this first incarnation of

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a scientific medicine,
as bedside medicine.

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The locus, the source of
knowledge, is at the bedside,

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through empirical observation.

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We know too that this had as a
corollary an educational

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program.

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How do you learn medicine?

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You do so by apprenticeship to
doctors on their rounds to the

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domestic bedside where the
essential task was to observe.

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Then we saw another development
in scientific medicine,

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and this was in the form of
Galenism.

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This is to say that humoralism
in Galen's writings was

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primarily concerned with the
ancient texts,

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texts that Galen considered
essentially infallible.

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They were to be enhanced,
and he thought that he was the

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person ideally suited to do that
work, but they could never be

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overthrown.

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There was no possibility of a
conceptual paradigm shift,

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or conceptual revolution.

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This was what was called
library medicine.

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In other words,
for Galen there was a new

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understanding of medical
epistemology.

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Knowledge was derived from
considering the ancients,

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from a careful study of their
texts.

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So, it's textually based
medicine.

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And it had, of course,
an educational corollary.

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And indeed until 1794 in
France, for example,

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medical education consisted
primarily of lectures on the

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classics,
delivered in Latin,

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and of a program of reading the
ancients in the original

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languages.

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This, then, was library
medicine.

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The whole humoral system,
as we've been looking at it,

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underwent a series of shocks
and intellectual criticisms.

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It didn't seem to fit all of
the evidence that emerged.

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Let's look at a couple of these
shocks to the humoral system.

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One we've already mentioned,
and that was the great work of

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William Harvey and the
circulation of the blood.

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Now, this meant Harvey's work,
although he didn't take the

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step of rejecting Galenism,
nonetheless it's true that his

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work undermined Galen's anatomy,
and it undermined humoral

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physiology.

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So, this was ultimately,
then--Harvey's discoveries were

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incompatible with the medical
thinking of his time.

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We've mentioned also that the
chemical revolution,

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the work of people like
Lavoisier, was extremely

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important,
and it was important in

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undermining humoralism.

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Because you know that the
humoral approach was based on a

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theory of the four elements or
the four humors,

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essentially on Aristotelian
natural philosophy.

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Chemistry, however,
undermined the humoral

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elements,
the four elements,

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and began to replace them with
a wholly different set,

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leading ultimately to the
periodic table.

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So, the whole basis of the four
elements comes to be undermined

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by the chemical revolution.

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Indeed, there is a development
of what's called iatrochemistry,

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which is the view that health
is the balance of chemicals in

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the body,
and that healing consists

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primarily of finding the right
chemical to correct the

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imbalance.

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So, medicine,
in this view,

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becomes reduced more to
chemistry.

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An important figure in this is
Paracelsus,

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who lived from 1493 to 1541,
and was known as "the

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Martin Luther of medicine,"
a Swiss healer and a rebel

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against Galenism.

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Indeed, he burned--he boasted
that he himself had burned the

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masters' texts.

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He was a leading figure in the
development of iatrochemistry,

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which was particularly strong
in the Low Countries.

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He introduced a number of
chemicals to medical science,

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such as zinc and laudanum,
or opium.

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Another shock to the system,
of course, was the spirit

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behind the scientific
revolution.

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The scientific revolution was
empirical.

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It was a democratic process,
and it rejected the cult of

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authority.

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Authority could be challenged
by anyone's observations and

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measurements.

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And this was ultimately
incompatible with Galen's system

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of worship of the Ancient texts.

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Then there was the experience
that we've been looking at the

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last couple of weeks of epidemic
diseases.

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Epidemic diseases created
problems for humoral

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interpretations.

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How was it that so many people
in a single place and time had

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this marked imbalance in their
humors?

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And there came to be,
alongside the Galenic system,

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the idea of contagion instead,
which was a non-humoral idea.

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Indeed, Fracastoro developed
this strongly,

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and it gained a wide purchase
in popular culture,

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and the search came to be for
some agent responsible for

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epidemics,
not humors, but perhaps a

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chemical.

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Even some people postulated
that it might be a living thing

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of some kind.

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All of these were severe
criticisms for the humoral

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system.

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But although Galenism then had
these loose threads,

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if we might say,
well before 1794,

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no consensus arose around an
alternative to replace it.

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We might make a distinction
between medical science also and

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medical practice;
that is, the scientific basis

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of Galenism was eroding.

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But until indeed the late
nineteenth century,

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medical practice,
what physicians actually did at

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the bedside, remained
traditional.

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So, we see critiques of
Galenism abounding,

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chipping away at its
foundations.

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But there was no new medical
science that was robust enough

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to create a new medical
practice.

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Note also that when we talk
about the coming of the Paris

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School, a couple of things that
we won't be pointing to.

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This new revolution in medicine
that occurred in Paris was not

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based on some new development in
the natural sciences.

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It wasn't based on a
technological breakthrough.

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It wasn't based on some
path-breaking medical or

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scientific discovery.

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So, let's look now,
with that as the background,

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at this new incarnation of
medical science,

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the Paris School of Medicine,
which was a conceptual

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revolution in the understanding
of disease.

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It marked a transformation in
medical epistemology--

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where is the source of medical
knowledge?--

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and also in medical education,
and it led to a new position

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for the regular physician in
society,

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with new claims to authority,
in competition with various

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competitors,
like homeopaths or members of

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various medical sects.

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This new medicine comes to be
called hospital medicine.

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And there are a number of
classic studies,

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if you want to read further
about it, that you'll be glad to

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know aren't on the reading list;
which I'm not extending.

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But there are places that,
on a purely voluntary basis,

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I hope that you'll be going to
read more about it.

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One is the work of Erwin
Ackerknecht,

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who's one of the founders of
the modern discipline of the

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history of medicine,
and he wrote a work Medicine

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and the Paris Hospital.

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Or there's my colleague here at
Yale,

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John Harley Warner,
who's written Against the

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Spirit of System,
which is a study in particular

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of American physicians and
students,

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and their experiences as they
made a medical and intellectual

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pilgrimage to Paris.

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There's a famous book by Michel
Foucault called The Birth of

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the Clinic, and I
will wish you luck with that

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particular work.

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It's one of the classic studies
that everyone refers to with

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regard to the Paris School and
its importance.

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But let me just tell you
anecdotally that I've read it I

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think four times.

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The first time I read it in
French and thought there was

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something wrong with my French.

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So, I read it in English,
and decided there was something

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also wrong with my English.

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And then my third and fourth
times I think I decided maybe

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there was something wrong with
Foucault.

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But I'll leave that for you to
judge and make your own

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decisions.

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In any case,
it's one of the classics in the

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literature, and it covers the
ground we're dealing with this

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morning.

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Well, what were the sources of
this new medicine?

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First, I would say there's an
institutional basis that made it

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possible, and that is the
hospital.

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Hospitals already existed,
but not as places of treatment

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so much as safety nets or
dumping grounds for the aged,

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the incurable,
the orphaned.

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The Industrial Revolution and
urbanization,

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however, radically increased
the numbers of patients,

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and the hospitals were often
associated with philanthropy and

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the church.

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And Paris, the great center of
Western Europe,

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urban center of culture,
also became the locus for some

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of the most famous hospitals in
Europe: the H�tel-Dieu,

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the Charit� and the Piti�,
that we'll be seeing in a

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moment.

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And, so, for a second then I
think it's worth doing a little

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bit--taking you for a moment on
a bit of medical tourism.

19:28.170 --> 19:33.470
And in doing so,
we go to the center of Paris,

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here, when we see the location
of the H�tel-Dieu hospital,

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here in the middle of the
Seine, on the Ile de la Cit�.

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The H�tel-Dieu was perhaps
the oldest hospital in the

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world.

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It had a history of providing
care on this very site ever

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since the seventh century,
and it was the largest general

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hospital in Paris.

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And as you can see,
it's located at the very center

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of the city.

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This is its architectural plan.

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It was a very large structure.

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By the end of the old regime in
France, it had four great wards

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that could accommodate 4,000
patients, often sleeping several

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to a single bed.

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We can see another picture of
it.

20:34.588 --> 20:40.118
This is a picture of the
entrance to the church and the

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hospital, taken in 1871,
at the time of the Paris

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Commune.

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And we can see its present-day
structure.

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This is the great courtyard of
the H�tel-Dieu.

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And I'm pointing it out to us
because it's impossible to

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understand the Paris School of
Medicine and the new

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understanding of medical science
without taking into account the

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great hospitals of Paris that
were its site and were crucial

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in the development of its ideas.

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This is the H�tel de la
Charit�, another one of the

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great hospitals.

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And this is the Hospital de la
Piti�.

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So, the new hospitals become
places of instruction,

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under the control or auspices
of a centralized state.

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They're large,
and have an enormous array of

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patients, and they're
dedicated--and this was

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crucial--to furthering
scientific knowledge.

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Indeed, they're more dedicated
at this stage to furthering

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knowledge than to treating
people.

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Then there are--if that's an
institutional basis then,

22:02.760 --> 22:07.640
the great hospitals--there are
also philosophical origins for

22:07.641 --> 22:09.351
the Paris School.

22:09.348 --> 22:15.198
The first is the Enlightenment,
with its questioning of

22:15.201 --> 22:19.971
authority, its skepticism,
its empiricism.

22:19.970 --> 22:25.990
And then I'd like to turn to
John Locke in particular,

22:25.990 --> 22:30.910
the great figure from 1632 to
1704,

22:30.910 --> 22:35.450
and his crucial work,
the essay "Considering

22:35.452 --> 22:39.052
Human Understanding,"
of 1690,

22:39.048 --> 22:43.218
which some people regard as so
important that they place it at

22:43.221 --> 22:47.601
the very beginning of the whole
movement of the Enlightenment.

22:47.598 --> 22:52.718
Well, Locke postulated,
as you already know,

22:52.715 --> 22:58.895
that the mind at birth was a
blank slate or tabula

22:58.903 --> 23:00.453
rasa.

23:00.450 --> 23:06.880
And his idea was what's called
philosophic sensualism;

23:06.880 --> 23:12.580
that is, that ideas and
knowledge gained by the mind are

23:12.580 --> 23:18.490
not innate but are derived
entirely from sense impressions

23:18.489 --> 23:22.739
and reflections on those
impressions.

23:22.740 --> 23:27.540
This is the cover of the
"Essay Concerning Human

23:27.538 --> 23:29.568
Understanding."

23:29.568 --> 23:35.998
So, we have in Locke then a
radical idea of epistemology.

23:36.000 --> 23:42.140
The source of knowledge--hence
the word sensualism--is the five

23:42.143 --> 23:47.893
senses used to conduct a
rigorous examination of nature.

23:47.890 --> 23:50.180
Locke, also in his
epistemology,

23:50.176 --> 23:53.126
not only saw the source of
knowledge,

23:53.130 --> 23:56.430
but set rigorous limits to what
we can know,

23:56.430 --> 23:58.020
putting God,
for example,

23:58.017 --> 24:03.277
beyond the realm of knowledge,
and establishing rigorous steps

24:03.284 --> 24:08.264
for being certain of the things
that we can know.

24:08.259 --> 24:11.419
Then there's another very
important figure,

24:11.423 --> 24:14.963
and this is someone we've also
mentioned before,

24:14.961 --> 24:17.901
who's becoming an old friend to
us.

24:17.900 --> 24:21.920
This is Thomas Sydenham of the
seventeenth century,

24:21.920 --> 24:26.760
who was in fact a close friend
of John Locke and is called

24:26.758 --> 24:29.898
variously the English
Hippocrates,

24:29.900 --> 24:32.750
the father of English medicine.

24:32.750 --> 24:36.760
Well, Sydenham was politically
a radical.

24:36.759 --> 24:44.399
He was a Puritan,
a left-wing Protestant,

24:44.400 --> 24:49.160
who rebelled against the Crown
in the Civil War in England,

24:49.160 --> 24:53.420
and served, in fact,
as an officer in Cromwell's

24:53.415 --> 24:54.045
Army.

24:54.048 --> 24:58.128
He was also radical in his
medical ideas.

24:58.130 --> 25:04.080
His prescription for medical
practice was rooted in the idea

25:04.076 --> 25:05.686
of sensualism.

25:05.690 --> 25:11.240
He called for a rigorous return
to observation of the patient,

25:11.240 --> 25:17.630
and he himself called for the
idea of abandoning theory and

25:17.632 --> 25:21.822
all pre-established medical
systems.

25:21.818 --> 25:26.768
The advance of medical
knowledge would proceed by a

25:26.765 --> 25:30.815
systematic comparison of case by
case,

25:30.818 --> 25:37.108
setting aside the classics and
setting aside general system and

25:37.114 --> 25:38.844
general theory.

25:38.838 --> 25:45.158
Oddly, Sydenham did not wholly
reject humoral medicine.

25:45.160 --> 25:48.280
But his ideas,
in fact we could say,

25:48.277 --> 25:53.887
were--and his practice--were
still influenced by Hippocrates.

25:53.890 --> 25:58.400
But what he did was to suspend
ideas of general theory and

25:58.397 --> 26:03.137
return from the texts to direct
observation of the patient at

26:03.144 --> 26:04.414
the bedside.

26:04.410 --> 26:10.010
In some sense he was skipping
over Galen and returning to

26:10.009 --> 26:11.409
Hippocrates.

26:11.410 --> 26:16.140
He believed that the physician
should trust his own independent

26:16.144 --> 26:18.594
reasoning based on experience.

26:18.588 --> 26:23.208
He distrusted bookish learning
and university education--

26:23.210 --> 26:26.550
although he himself had
attended Oxford--

26:26.548 --> 26:32.428
and in return he was scorned by
the medical and academic elite

26:32.434 --> 26:33.694
of his day.

26:33.690 --> 26:39.450
Sydenham gave his attention
also to epidemic diseases.

26:39.450 --> 26:43.150
He studied smallpox,
malaria, tuberculosis and

26:43.154 --> 26:44.064
syphilis.

26:44.058 --> 26:49.308
Indeed, he would be a good
figure for talking about the

26:49.305 --> 26:55.515
impact that epidemic disease had
on the undermining of humoralism

26:55.520 --> 26:59.990
and the rise of a new scientific
paradigm.

26:59.990 --> 27:04.700
He's known also for his work on
hysteria, and on gout,

27:04.700 --> 27:08.700
from which he himself was a
great sufferer.

27:08.700 --> 27:12.700
In his work on malaria,
he also did something radically

27:12.701 --> 27:15.221
new,
of reaching the conclusion that

27:15.220 --> 27:18.900
he was dealing not with a
humoral imbalance in general,

27:18.900 --> 27:23.920
but rather with a specific
disease entity.

27:23.920 --> 27:28.430
Indeed, he thought he was one
of the harbingers of the idea

27:28.432 --> 27:31.782
that diseases are all specific
entities,

27:31.778 --> 27:36.708
rather than a single dyscrasia,
and he suggested that the time

27:36.711 --> 27:41.241
might come when they would be
classified in the manner of

27:41.239 --> 27:42.289
Linnaeus.

27:42.288 --> 27:45.888
He even wrote,
"All diseases ought to be

27:45.893 --> 27:49.173
reduced to certain determinate
kinds,

27:49.170 --> 27:54.750
with the same exactness as we
see it done by botanic writers

27:54.750 --> 27:58.250
in their treatises on
plants."

27:58.250 --> 28:04.710
Sydenham also was new and
radical in sometimes embracing

28:04.711 --> 28:11.881
the idea of contagion in his
dealing with epidemic disease.

28:11.880 --> 28:14.390
He wrote, for example,
of the plague:

28:14.385 --> 28:17.515
"Besides the constitution
of the air,

28:17.519 --> 28:21.679
there must be another previous
circumstance to produce the

28:21.682 --> 28:25.622
plague;
namely the effluvia or seminum

28:25.623 --> 28:31.163
from an infected person,
either immediately by contact

28:31.155 --> 28:35.785
or immediately by some
pestilential matter conveyed

28:35.788 --> 28:38.658
from some other place."

28:38.660 --> 28:44.920
So, we see here a radically
different idea.

28:44.920 --> 28:48.080
And he wrote a work,
a famous work,

28:48.079 --> 28:51.609
of 1676 called the
Observationes

28:51.612 --> 28:55.702
Medicae,
a revealing title stressing

28:55.702 --> 28:58.122
medical observation.

28:58.118 --> 29:01.418
Sydenham is famous for
introducing a number of

29:01.415 --> 29:03.975
practices into medicine,
as well.

29:03.980 --> 29:07.930
He popularized the use of
quinine for malaria.

29:07.930 --> 29:10.610
He introduced opium into his
practice.

29:10.608 --> 29:14.558
He used cooling drinks and
fresh air to treat fevers,

29:14.557 --> 29:18.427
rather than bloodletting,
and he introduced the cool

29:18.428 --> 29:21.918
regimen that we talked about for
smallpox.

29:21.920 --> 29:25.950
Often, he wrote,
the best advice he could give a

29:25.953 --> 29:29.133
physician was to do nothing at
all.

29:29.130 --> 29:34.930
There was another important
philosophical influence,

29:34.932 --> 29:38.922
and that's this man,
Pierre Cabanis,

29:38.915 --> 29:45.625
a French philosophe who
lived from 1757 to 1805.

29:45.630 --> 29:51.340
He was a physician,
a physiologist and medical

29:51.335 --> 29:53.105
philosopher.

29:53.108 --> 29:57.698
He was also an administrator of
the hospitals in Paris,

29:57.704 --> 30:01.964
and an early supporter of the
French Revolution.

30:01.960 --> 30:06.020
But the point I want to stress
today was that in terms of

30:06.018 --> 30:08.988
medical philosophy he was a
sensualist.

30:08.990 --> 30:13.480
He believed that all mental
processes are derived from the

30:13.478 --> 30:17.168
five senses,
and therefore in medicine the

30:17.174 --> 30:22.124
source of knowledge should not
be ancient texts but direct

30:22.117 --> 30:24.457
observation of patients.

30:24.460 --> 30:29.000
So, that was--these series then
we've seen institutional

30:28.997 --> 30:32.047
foundations and philosophical
ones.

30:32.048 --> 30:38.758
I now want to look at a third
major foundation for the coming

30:38.760 --> 30:43.460
of the Paris School,
and this is the French

30:43.459 --> 30:45.919
Revolution itself.

30:45.920 --> 30:49.060
This is a famous painting of
Eug�ne Delacroix of

30:49.064 --> 30:51.764
"Liberty Leading the People
."

30:51.759 --> 30:53.979
You get the idea.

30:53.980 --> 30:58.360
What I want to stress is a
general feature of the French

30:58.355 --> 31:02.395
Revolution,
that it was an opportunity to

31:02.403 --> 31:06.933
wipe the slate clean,
that it marked a radical new

31:06.932 --> 31:11.732
departure that facilitated
opposition to older authorities,

31:11.730 --> 31:18.460
and in specific nature to
medical corporations.

31:18.460 --> 31:23.490
It was also a time of French
nationalism which urged on that

31:23.488 --> 31:28.428
instruction should take place no
longer in Latin but in the

31:28.431 --> 31:32.261
vernacular;
that is, in French.

31:32.259 --> 31:36.239
There are also some other
specific features that made the

31:36.238 --> 31:40.568
French Revolution an important
moment for the development of a

31:40.571 --> 31:41.781
new medicine.

31:41.779 --> 31:44.419
One was, of course,
that this was a time of

31:44.423 --> 31:48.443
continuous warfare--
from 1792, for a whole

31:48.440 --> 31:53.530
generation, until 1815--
and therefore there was an

31:53.527 --> 31:57.717
urgent practical need for
physicians and for adequate

31:57.721 --> 31:58.771
hospitals.

31:58.769 --> 32:04.369
It was a time of reform in the
structure of medicine as a

32:04.365 --> 32:09.955
career and a profession,
and also of medical training.

32:09.960 --> 32:13.530
It was a time too,
during the French Revolution,

32:13.530 --> 32:17.180
when the hospitals were
reformed, centralized.

32:17.180 --> 32:20.430
There was only one patient to a
bed.

32:20.430 --> 32:23.930
They were state-owned and
centralized.

32:23.930 --> 32:27.340
And the wards became
specialized--and this was

32:27.338 --> 32:31.278
crucial for the development of
new medical ideas--

32:31.278 --> 32:37.598
specialized according to the
type of patient being treated.

32:37.598 --> 32:43.388
These hospitals were no longer
devoted to hospice and orphanage

32:43.391 --> 32:48.531
care, but rather they became
scientific institutions.

32:48.529 --> 32:53.549
Patients were seen as having a
service to perform in the name

32:53.549 --> 32:57.399
of science and the advancement
of knowledge.

32:57.400 --> 33:01.620
Their bodies were made
radically accessible to

33:01.617 --> 33:05.577
physicians and students,
both in life,

33:05.576 --> 33:11.936
and very crucially also after
death in terms of post-mortem

33:11.942 --> 33:13.702
examinations.

33:13.700 --> 33:16.920
Alive, the patient was a source
of knowledge,

33:16.920 --> 33:20.700
as physicians conducted
physical examinations to study

33:20.703 --> 33:24.063
the signs and symptoms of
disease with rigor and

33:24.059 --> 33:25.059
precision.

33:25.058 --> 33:29.538
In death, their lesions were a
source of knowledge to

33:29.536 --> 33:33.316
pathologists,
to surgeons who practiced their

33:33.323 --> 33:37.803
techniques, and to anatomists
and physiologists.

33:37.798 --> 33:42.048
Well, the reform of medical
education meant that the locus

33:42.054 --> 33:45.714
of medicine was entirely
clinical and practical on

33:45.711 --> 33:47.131
hospital wards.

33:47.130 --> 33:50.900
You were trained as a
physician, a medical student,

33:50.903 --> 33:54.303
for three years,
followed by an internship.

33:54.298 --> 33:59.578
And the Faculty of Medicine in
Paris now consisted of full-time

33:59.583 --> 34:03.933
professors, appointed by
competitive examination.

34:03.930 --> 34:08.820
And the French Revolution was
important for its values,

34:08.820 --> 34:14.180
stressing a meritocracy by the
encouragement of ability instead

34:14.184 --> 34:17.264
of privilege,
birth and cronyism,

34:17.255 --> 34:22.755
and by a new democratic spirit
that provided a new dynamism and

34:22.760 --> 34:25.070
a world of competition.

34:25.070 --> 34:28.950
The new banners inscribed--the
new mottos of the medical

34:28.952 --> 34:32.342
profession were words such as
"reform,"

34:32.340 --> 34:35.660
"progress,"
"observation"

34:35.657 --> 34:38.197
and "precision."

34:38.199 --> 34:42.359
What, then--those are the
preconditions--what was the

34:42.364 --> 34:45.894
substance of the Paris School of
Medicine?

34:45.889 --> 34:49.539
And here we see an
extraordinary development where

34:49.538 --> 34:53.558
one city becomes the world
center of a new medicine.

34:53.559 --> 34:57.329
Paris was dubbed "the
universal faculty of

34:57.327 --> 34:58.717
medicine."

34:58.719 --> 35:04.359
Its students and physicians
came from all over the world to

35:04.360 --> 35:07.960
observe and to be trained in
Paris.

35:07.960 --> 35:12.380
Its work was concentrated in
the Latin Quarter,

35:12.382 --> 35:18.062
that became a sort of mecca for
scientists and students from

35:18.056 --> 35:19.496
everywhere.

35:19.500 --> 35:23.410
Indeed, large numbers of
Americans made a pilgrimage to

35:23.413 --> 35:27.823
Paris to study with its masters,
to bring their ideas back to

35:27.824 --> 35:31.024
this country,
and to place themselves in a

35:31.021 --> 35:35.491
position to raise their fees
because of the prestige which

35:35.485 --> 35:39.395
went with the time spent on the
wards of Paris.

35:39.400 --> 35:43.210
So, in medicine,
the rise of the Paris clinic

35:43.210 --> 35:48.060
was said to mark a time of
transition between the medical

35:48.059 --> 35:52.389
Middle Ages and the beginning of
a modern era.

35:52.389 --> 35:57.879
This was hospital medicine,
based on radical empiricism and

35:57.882 --> 36:00.632
opposed to abstract theory.

36:00.630 --> 36:06.810
The great motto in Paris was
Peu lire et beaucoup

36:06.806 --> 36:11.406
voir, read little but see a
lot.

36:11.409 --> 36:15.239
The basis of knowledge was said
to be facts,

36:15.239 --> 36:19.839
grouped into great facts,
with linkages established by

36:19.842 --> 36:23.872
statistics,
and no room for abstractions,

36:23.871 --> 36:29.011
apart from the facts and their
mathematical linking.

36:29.010 --> 36:32.650
This was observation-based
medicine.

36:32.650 --> 36:39.300
But it went beyond the medicine
of Hippocrates in that--

36:39.300 --> 36:42.410
this is a picture of Ren�
Laennec,

36:42.409 --> 36:46.869
represented on a Paris ward,
and what he's doing is

36:46.869 --> 36:51.419
conducting a physical
examination of the patient.

36:51.420 --> 36:55.270
Laennec, in fact,
invented--he was famous for his

36:55.269 --> 36:58.719
studies of masses of tubercular
patients.

36:58.719 --> 37:02.389
It's important to know that
tuberculosis was rampant in

37:02.393 --> 37:06.773
nineteenth century Paris,
and Ren� Laennec had the

37:06.768 --> 37:12.278
opportunity to examine and treat
thousands of patients with

37:12.275 --> 37:15.725
tuberculosis,
which he himself contracted,

37:15.726 --> 37:19.646
and he died from it in the end,
at a young age.

37:19.650 --> 37:23.040
Well, he invented--and this is
the point I wanted to stress at

37:23.041 --> 37:26.371
the moment--
the stethoscope in 1816,

37:26.369 --> 37:32.529
so that the modern physical
examination became more one--

37:32.530 --> 37:37.060
not just observing the patient,
but examining him or her,

37:37.059 --> 37:42.469
and the stethoscope became a
hallmark and symbol of the Paris

37:42.467 --> 37:43.277
School.

37:43.280 --> 37:48.230
Indeed, it became a symbol in
nineteenth-century medicine.

37:48.230 --> 37:52.990
Here we see--this was the
monaural stethoscope of the type

37:52.987 --> 37:54.487
used by Laennec.

37:54.489 --> 37:58.399
It may have been important also
that he was a musician,

37:58.402 --> 38:02.392
and specifically a flutist,
and that may have influenced

38:02.387 --> 38:04.487
his method of proceeding.

38:04.489 --> 38:08.089
This is the precursor of what
is more familiar to us.

38:08.090 --> 38:13.990
He introduced the procedures of
oscillation and percussion.

38:13.989 --> 38:18.779
He tapped and listened to the
internal sounds of the body,

38:18.780 --> 38:23.320
and he described them,
what he heard in the lungs of

38:23.318 --> 38:27.428
his tuberculosis patients,
as rales, rhonchi,

38:27.431 --> 38:32.291
and all the other modern terms
used to describe the modern

38:32.286 --> 38:34.326
sounds that he heard.

38:34.329 --> 38:38.089
Now, this vast number of
patients on the wards was

38:38.092 --> 38:38.862
crucial.

38:38.860 --> 38:44.420
A professor of medicine in
Paris might examine some 5,000

38:44.422 --> 38:46.212
patients a year.

38:46.210 --> 38:50.310
And crucially,
they produced a new concept of

38:50.307 --> 38:53.707
disease;
that is, disease specificity.

38:53.710 --> 38:58.130
Diseases were thought to be
discrete entities that could be

38:58.128 --> 38:59.118
classified.

38:59.119 --> 39:03.399
This is the beginning really of
nosology, which is the

39:03.396 --> 39:07.586
classification of disease
entities, labeled variously

39:07.592 --> 39:10.662
tuberculosis,
smallpox, et cetera.

39:10.659 --> 39:15.859
Rather than the humoral idea
that there's just one disease,

39:15.860 --> 39:19.550
the humoral imbalance or
dyscrasia,

39:19.550 --> 39:25.740
now we have a Linnaean type
nosology or classification.

39:25.739 --> 39:28.779
On wards--and this was very
important--

39:28.780 --> 39:35.650
another innovation of the Paris
School was that the symptoms

39:35.646 --> 39:40.876
observed on the ward,
after the patient died--if the

39:40.880 --> 39:44.370
patient died,
and very many did--were

39:44.371 --> 39:49.901
correlated with the lesions in
organs and tissues seen in

39:49.902 --> 39:52.572
post-mortem examination.

39:52.570 --> 39:59.160
So, an important part of Paris
then was the linking of medicine

39:59.155 --> 40:03.615
with pathology,
a physical examination with

40:03.617 --> 40:06.377
post-mortem autopsies.

40:06.380 --> 40:11.940
There came to be another word
then associated with Paris--a

40:11.936 --> 40:15.766
couple of words:
localism, diseases had a

40:15.769 --> 40:21.809
particular location in the body;
solidism, which set them apart

40:21.809 --> 40:25.089
from the fluids that were the
humors.

40:25.090 --> 40:30.830
Instead the location of
diseases was in solid organs and

40:30.826 --> 40:31.866
tissues.

40:31.869 --> 40:37.969
Now, the main diseases in Paris
at the time were pulmonary TB,

40:37.969 --> 40:41.269
pneumonia, typhoid,
heart disease,

40:41.268 --> 40:44.168
puerperal fever,
cholera.

40:44.170 --> 40:48.280
With these discrete entities
now being classified,

40:48.275 --> 40:52.125
we also see the rise of medical
specialties.

40:52.130 --> 40:56.490
So, Paris was important in
moving beyond the general

40:56.492 --> 41:00.342
practitioner to create
specialties of internal

41:00.342 --> 41:04.662
medicine,
psychiatry, geriatric medicine,

41:04.661 --> 41:08.351
pediatrics,
pathological anatomy,

41:08.353 --> 41:09.833
venereology.

41:09.829 --> 41:12.999
And there was a new notion of
medical education;

41:13.000 --> 41:15.730
that is, lectures were still
given,

41:15.730 --> 41:20.440
but the main place of learning
was the hospital ward where

41:20.436 --> 41:24.236
famous professors,
like Laennec himself,

41:24.237 --> 41:29.197
or Pierre Louis,
conducted their rounds with a

41:29.204 --> 41:31.524
retinue of hundreds.

41:31.518 --> 41:35.628
Then there was the autopsy
table, also in the hospital,

41:35.630 --> 41:39.130
where observation and ideas,
based on the ward,

41:39.130 --> 41:41.110
were confirmed or not.

41:41.110 --> 41:45.650
The new medical education was
practical instruction,

41:45.650 --> 41:50.100
and it was hands on,
with training on the ward from

41:50.101 --> 41:51.171
day one.

41:51.170 --> 41:54.860
And the students who attended,
attended year round,

41:54.858 --> 41:58.248
with no vacation,
and there was a roll call for

41:58.253 --> 41:59.363
attendance.

41:59.360 --> 42:04.490
Remember, this was introduced
at the time of the revolution

42:04.489 --> 42:06.789
and then under Napoleon.

42:06.789 --> 42:11.859
And under the Empire,
professors even had ranks and

42:11.864 --> 42:13.494
wore uniforms.

42:13.489 --> 42:17.029
So, the practitioners were
doctors.

42:17.030 --> 42:20.990
But there was also a new
licensing system,

42:20.985 --> 42:26.575
and students were encouraged to
learn through their senses,

42:26.583 --> 42:30.543
through seeing,
hearing and touching.

42:30.539 --> 42:34.219
This was sensualism not only in
theory,

42:34.219 --> 42:37.849
but we might call it applied
sensualism,

42:37.849 --> 42:43.579
with a rejection of dogma,
of theory and of authority

42:43.577 --> 42:45.997
simply as authority.

42:46.000 --> 42:51.580
Note too that there was not an
integration into this of the

42:51.583 --> 42:53.223
basic sciences.

42:53.219 --> 42:57.209
This was medical science in a
sense on its own,

42:57.208 --> 43:02.068
without what we would now--they
called the basic sciences

43:02.065 --> 43:04.055
accessory sciences.

43:04.059 --> 43:08.939
Now, the weak aspect of the
Paris School though was its

43:08.943 --> 43:10.303
therapeutics.

43:10.300 --> 43:16.390
This was a medical revolution
in terms of medical science.

43:16.389 --> 43:22.169
It was less revolutionary in
terms of its therapeutics.

43:22.170 --> 43:25.780
The new understanding of
disease did not lead

43:25.784 --> 43:30.224
automatically to improved
treatment for the patient.

43:30.219 --> 43:34.329
Indeed, visitors from Britain
and the United States often

43:34.327 --> 43:37.987
expressed severe moral
reservations about what they

43:37.994 --> 43:41.154
observed going on in the Paris
clinics.

43:41.150 --> 43:46.910
There was said to be little
concern to alleviate suffering

43:46.907 --> 43:49.127
or to preserve life.

43:49.130 --> 43:54.160
Knowledge and its advancement
were what counted most.

43:54.159 --> 43:56.779
The patient,
some visitors said,

43:56.775 --> 44:02.085
was an object to be observed,
as in a Natural History museum;

44:02.090 --> 44:05.980
more to serve science than to
recover.

44:05.980 --> 44:09.770
One American said,
in fact, that a French version

44:09.773 --> 44:13.883
of Uncle Tom's Cabin
ought to be written about

44:13.882 --> 44:17.362
hospital patients on the wards
of Paris.

44:17.360 --> 44:23.340
And Eug�ne Sue,
the Charles Dickens of France,

44:23.340 --> 44:27.120
who wrote the famous work
The Mysteries of Paris,

44:27.119 --> 44:31.049
did a caricature of Pierre
Louis, one of the heroes of the

44:31.054 --> 44:35.674
Paris School,
who appears as Dr.***Griffon;

44:35.670 --> 44:39.190
and in Dr. Griffon,
in the story,

44:39.190 --> 44:44.970
tells his students on the
rounds, on the ward of the

44:44.969 --> 44:48.879
hospital,
that the lesions that they're

44:48.876 --> 44:52.646
observing--
that is, the symptoms--they can

44:52.648 --> 44:57.118
soon look forward to seeing when
the patient dies.

44:57.119 --> 45:02.389
Griffon declares that a patient
is a human sacrifice on the

45:02.391 --> 45:04.121
altar of science.

45:04.119 --> 45:08.889
So, the Paris clinic was also
sometimes described by visitors

45:08.887 --> 45:13.187
as a theater,
with patients as stage props,

45:13.188 --> 45:19.038
and where surgeons saw human
bodies as a means to greater

45:19.039 --> 45:21.129
manual dexterity.

45:21.130 --> 45:25.660
Physicians and their students
were not taught that their

45:25.657 --> 45:30.677
primary mission was to heal,
but rather to advance science.

45:30.679 --> 45:37.109
Treatment remained what it had
been for a long time.

45:37.110 --> 45:44.470
Therapy--we can see one of the
lynchpins was still venous

45:44.465 --> 45:48.795
section or bleeding by leeches.

45:48.800 --> 45:52.960
Here we see a picture,
very widespread on the Paris

45:52.958 --> 45:56.618
wards, where
hundreds-of-thousands of leeches

45:56.617 --> 46:00.357
were imported monthly by these
hospitals.

46:00.360 --> 46:05.170
And indeed they discovered
also, made a medical discovery,

46:05.166 --> 46:07.946
how do you get a leech to bite?

46:07.949 --> 46:10.279
Well, I can tell you the answer
to that.

46:10.280 --> 46:15.150
What you can do is you can wrap
the poor thing in a towel and

46:15.148 --> 46:18.148
soak the towel in wine or
vinegar,

46:18.150 --> 46:22.710
which irritates it enormously
and makes it bite the next thing

46:22.713 --> 46:24.213
that it can reach.

46:24.210 --> 46:29.910
So, the therapeutics then were
traditional and not different

46:29.911 --> 46:35.711
from what humoral physicians had
been doing for centuries.

46:35.710 --> 46:40.910
The strengths of the Paris
School were in diagnosis,

46:40.905 --> 46:45.895
pathology, classification,
surgery and anatomy.

46:45.900 --> 46:49.650
Leading figures:
Laennec, Pierre Louis,

46:49.650 --> 46:52.910
Pierre Cabanis,
Claude Bernard.

46:52.909 --> 46:58.849
But this stimulated imitation
in other countries.

46:58.849 --> 47:00.009
In England, St.

47:00.010 --> 47:03.650
Thomas Hospitals and Guy's
Hospital in London;

47:03.650 --> 47:07.680
in Austria, the Vienna School
of Medicine was directly

47:07.684 --> 47:10.544
influenced by Paris;
and in the U.S.,

47:10.539 --> 47:13.639
our own country,
the linking of the Harvard

47:13.635 --> 47:15.695
Medical School with Mass.

47:15.699 --> 47:21.159
General Hospital was directly
based on the idea that had

47:21.157 --> 47:23.337
originated in Paris.

47:23.340 --> 47:27.940
But by mid-century,
the dynamism of Paris was on

47:27.943 --> 47:33.823
the wane, and it had to do
particularly with therapeutics.

47:33.820 --> 47:37.070
There was a therapeutic
pessimism.

47:37.070 --> 47:41.520
All of the statistical methods
of the Paris School revealed

47:41.518 --> 47:46.198
that standard medical practices
were of doubtful efficacy,

47:46.199 --> 47:50.949
and tremendous advances in
medical knowledge had done

47:50.952 --> 47:53.972
little to advance therapeutics.

47:53.969 --> 47:59.749
Medical science and medical
practice were quite distinct.

47:59.750 --> 48:03.240
So, it's in the second half of
the nineteenth century that

48:03.244 --> 48:07.814
we'll be looking to yet,
very soon, another incarnation

48:07.811 --> 48:13.271
of scientific medicine,
when scientific medicine moves

48:13.271 --> 48:19.301
from France to Germany,
and from the hospital ward to

48:19.297 --> 48:23.877
the university and to the
laboratory.

48:23.880 --> 48:27.980
Then we'll see a new
epistemology that stresses the

48:27.976 --> 48:31.826
laboratory bench as the source
of knowledge,

48:31.829 --> 48:36.149
and we'll talk about the coming
of laboratory medicine and

48:36.146 --> 48:39.476
experimental medicine as a
paradigm shift.

48:39.480 --> 48:42.400
But all of that would not have
been possible,

48:42.400 --> 48:46.030
and we wouldn't have the coming
of the germ theory of disease,

48:46.030 --> 48:50.370
if it hadn't been for the idea
of specificity and

48:50.369 --> 48:55.339
classification that were
developed in Paris between 1794

48:55.340 --> 48:59.410
and the middle of the nineteenth
century.

48:59.409 --> 49:04.469
And next time we'll turn to
another epidemic disease--

49:04.469 --> 49:08.459
and this is a timely one as
we're moving into the nineteenth

49:08.456 --> 49:11.566
century--
and that is Asiatic cholera.

49:11.570 --> 49:17.000