H a r r y BLOCH ( N e w York , U.S.A.)

C5

SOCIAL STRUCTURE AND MEDICINE, MEDICAL EDUCATION AND MEDICAL STUDENTS

IN FRANCE AND THE UNITED STATES (1820-1861)

I n th is per iod, f rom 1820 to 1861, F r a n c e a t t a i n e d super io r i ty in med ic ine a n d m e d i c a l educa t ion . The i m m e d i a t e cause w a s t h e F r e n c h Revolu t ion in 1789. I t l ibe ra ted t h e m i n d s of m e n f rom a feudal society, a n d i ts i n t imida t ing , para lyzing, re l ig ious in s t i t u t ions . Pover ty n o longer s tood in t h e p a t h of c a r e e r s in m e d i c i n e a n d sc ience. T h e door of m e d i c a l schools w e r e open to all w h o qual i f ied ; a n d m a n y penni less y o u t h s w e r e able to achieve t h e i r che r i shed goals . Medica l schools w e r e n o w freed f rom the fe t t e r s of theology, scho las t i c i sm, a n d s a c r o s a n c t a u t h o r i t y ; a n d hosp i t a l med i c ine w a s cu l t i va t ed in p lace of end less phi losophic discctur.se.

Para l le l to th i s t r e n d w a s devot ion to m o r b i d a n a t o m y to u n c o v e r t h e sea t of d i sease a n d i t s r e l a t ion t o s y m p t o m s . « De sedibus » w a s avidly s t ud i ed ; a n d t h e s t r ang l ing t h e o r y of h u m o r s in t h e pa tho logy of d i sease w a s d i s ca rded . Pinel a n d B icha t w e r e a m o n g t h e f i r s t to express opposi t ion t o h u m o r a l i m b a l a n c e a s exp lana t ion for d i sease or igin. Cl inic ians a n d su rgeons , w h o s e a c c o m p l i s h m e n t s p lace t h e m a m o n g t h e bes t in t h e h i s to ry of med ic ine , w e r e t h e p r o d u c t s of th i s n e w teach ing , a n d b e c a m e t h e d i s t ingu i shed professors of t h e m e d i c a l schools a n d the g rea t P a r i s Hosp i t a l s . The i r r o s t e r r e a d s l ike a page f rom Gar r i son ' s H i s t o r y of Medec ine w h e r e they a re inscr ibed : Andra l , Chomel , T rousseau , Orfila, Magendie , Louis , Laennec , a n d a hos t of r e m a r k a b e su rgeons : Lisfranc, Vel-peau . Roux, Lar rey , a n d D u p u y t r e n w h o insp i red p ro found respec t a n d a w e s o m e fear, a n d w h o s e s t u d e n t s pul led h is ca ske t in r eve rence a n d grief to P e r e La Chaise ceme te ry .

Medica l s t u d e n t s f rom a l m o s t every c o u n t r y converged on t h e Pa r i s hospi ta l s , w h i c h w e r e free, a n d of m a n y types : med ica l , surgical , v e n e r e a l ; for t h e old, t h e b l ind , t h e i n sane ; t h e incurab le a n d for ch i ld ren , t h e f irs t of i t s k i n d in t h e wor ld . T h e r e w e r e t h i r t e e n genera l a n d eleven specia l ty hosp i t a l s , a n d twe lve hospices t h a t m a d e avai lable over 20,000 pa t i en t s , a n d a m y r i a d of d i seases t o inves t iga te . A plentiful supply of c adave r s , ob ta inab le for a few sous , gave access t o n o r m a l a n d a b n o r m a l a n a t o m y .

S t u d e n t s h a d t h e s t e thoscope to explore t h e ches t ; w e r e t a u g h t d iagnos is by u s e of eye, ear , a n d hand , s a w m e n t a l p a t i e n t s l ibe ra ted by Pinel f rom t h e c rue l ty of cha in s ; a n d acqu i red exper ience in obs te t r i c s , de rma to logy , ophta lmology , neuro­logy, venereology, a n d c h r o n i c a i l m e n t s . Pe rhaps , t he i r m o s t exc i t ing exper ience w a s t o observe m a s t e r s u r g e o n s , n o t e d for fami l ia r i ty w i t h n o r m a l a n d pa thologic a n a t o m y , p e r f o r m i n t r i c a t e su rge ry w i t h u n c o m m o n speed, dexter i ty , a n d skill, a n d w i t h o u t an t i seps is a n d anaes thes i a , ye t und i scove red .

A m e r i c a n s t u d e n t s , w h o n u m b e r e d abou t 700, c a m e f r o m Phi lade lph ia , Bal t i ­m o r e , N e w York, Virginia , Bos ton , a n d Char l e s ton ; a n d r e t u r n e d to con t r i bu t e to

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a n e w e ra in med ic ine a n d su rge ry in Amer ica . They c a m e poorly equ ipped for t h e p rac t i ce of scientif ic m e d i c i n e ; possessed s can t knowledge of a n a t o m y , chemis t ry , pa thology, a n d physiology, a n d m a n y w e r e lack ing in p rac t i ca l c l inical exper ience .

Let u s n o w look over t h e shou lde r s of s o m e A m e r i c a n s in t he i r lodgings , s ea t ed a t a t a b l e i l l u m i n a t e d by cand le l ight , w r i t i n g h o m e a b o u t t h e i r exper iences . J a m e s J a c k s o n b o a s t s : « I e x a m i n e abou t 100 cases of l iving d i sease dai ly : a n d t h e i n t e r e s t i ng cases a r e w i t h o u t end . »

Oliver Wendel l H o l m e s w r i t e s : « I n less t h a n t w o m o n t h s I acqu i r ed a know­ledge of d i seases of t h e sk in t h a t a s t o n i s h e d myself. I have seen in a m o r n i n g 80 cases u n d e r t h e eyes of t h e f irs t a u t h o r i t y in t h e wor ld . »

J o n a t h a n M a s o n W a r r e n exa l t s : « I w a t c h e d D u p u y t r e n a m p u t a t e a n a r m , o n e of t he m o s t beaut i ful ope ra t ions I h a d seen : Roux r e m o v e c a n c e r f rom t h e face , cu t o u t a c ance rous e lbow jo in t , r e m o v e c a t a r a c t s , a m p u t a t e t h e n e c k of t h e u t e r u s , p e r f o r m l i tho t r i ty , a n d ope ra t e on fistula-in-ano a n d h e r n i a ; L a r r e y cau te r ize an u l ce r ; Civaie pe r fo rm rh inop las ty ; R icord c a s t r a t e a pa t i en t for t ube rcu lous tes t ic les ; a n d Lisf ranc r e m o v e t h e n e c k of t h e u t e r u s . »

Ashbel S m i t h is in a q u a n d r y : « T h e r e is so m u c h offered, a n d the g r e a t e s t difficulty is t h e select ion of cou r ses . I n Amer ica , I s ighed af te r oppor tun i t i e s for i m p r o v e m e n t . » H o l m e s advises : « B e c a u s e of t h e avai labi l i ty of subjec ts , one w h o k n o w s h o w to u s e h is h a n d s m a y b e c o m e a n exper t o p e r a t o r in a few w e e k s » ; a n d a d d s : « Fol low m e t o t h e Hote l Dieu w h e r e ru les a n d re igns t h e m a s t e r su rgeon of t h e day, t h e i l lus t r ious B a r o n Dupuy t ren . » W. W. G e r h a r d t l auds Louis : « A r e m a r k a b l e m a n , very different f rom phys ic ians f rom E n g l a n d a n d Amer i ca . »

René La Roche conc ludes : « The F r e n c h p lan of i n s t r u c t i o n is super io r to t h a t found in o u r schools ; a n d F r e n c h a n a t o m y , surgery , pa thology, a n d physiology a r e t h e best in t h e wor ld . »

E l i sha B a r t l e t t c o m p a r e s : « The fami l ia r i ty of d i s t ingu i shed phys ic ians a n d su rgeons w i t h t he i r s t u d e n t s c o n t r a s t e d w i t h t h e p r o u d a n d h a u g h t y ca r r i age of s o m e of o u r N e w E n g l a n d professors . » H e advises : « By u s ing s u c h r i g o r o u s empi r ica l m e t h o d s , A m e r i c a n s can b e c o m e fact-f inders i n s t e a d of pompous phraseo-logis ts . »

Ho lmes c o n t r i b u t e s a g lowing t r i b u t e : « The s t a n d a r d of m e d i c a l t e ach ing is such t h a t t he s t u d e n t m a y r e t u r n a m o r e r o u n d e d phys ic ian a t 25 t h a n m a n y w h o s l u m b e r e d till 60 in o u r languid , scient if ic a t m o s p h e r e . » P e t e r P o r c h e r c o n d e m n s : « Teach ing m e d i c i n e in t h e Uni ted S t a t e s is so m u c h of quacks , so l i t t le of sc ience, it is qu i te t r a sh . »

H o l m e s s u m m a r i z e s w h a t h e will b r ing h o m e f rom Par i s :

« Not to guess w h e n I c an know.

« Not to t a k e a u t h o r i t y w h e n I c an h a v e fac ts .

« Not to t h i n k a m a n m u s t t a k e phys ic because h e is sick. » Pa r i s w a s n o t only t h e apogee of w o r l d m e d i c i n e t o A m e r i c a n s t u d e n t s , bu t

an exci t ing ci ty of Gallic r e f inemen t , pol i tness , a n d cu l tu re , of t h e a t r e , a r t , m u s i c , l i t e r a tu re , d r a m a , opera a n d m u s e u m s . Char les T h o m a s J a c k s o n no tes , « T h e F r e n c h a r e pol i te a n d u r b a n e . »

J a m e s Young Basse t t , Osier ' s A l a b a m a S t u d e n t , accep ts a n ex te resh ip u n d e r Velpeau, a n d a s s u r e s M r s . B a s s e t t t h a t a l t hough th i s good f o r t u n e wil l p ro long his s tay in Pa r i s , it wil l , a lso , « keep h i m ou t of b a d c o m p a n y ».

H o l m e s rev iewing Pa r i s i an e n t i c e m e n t s pledges : « To t a k e h is w o r k w i t h

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all h i s migh t , a n d h is p l easu res very m o d e r a t e l y . » This , apparen t ly , w a s t h e fine ba l ance adop ted by all h i s c o m p a t r i o t s . T h e r e w e r e n o s canda l s .

I t is i m p o r t a n t to u n d e r s t a n d w h y A m e r i c a n m e d i c a l s t u d e n t s left t h e i r c o u n t r y a n d u n d e r t o o k a difficult, h a z a r d o u s sea voyage a t t h a t t i m e to s t u d y in F r a n c e .

F o r m a n y it w a s cost ly, involved sacr i f ices , a n d a long pe r iod of sepa ra t ion f rom family .

The Amer i can med ica l scene in t h e 19th c e n t u r y w a s , in l a rge pa r t , b a r r e n a n d depress ing . Prof i table p rop r i e t a ry schools mul t ip l i ed a n d o p e r a t e d w i t h o u t r e s t r a i n t n o r b a r r i e r s to a d m i s s i o n ; a n d the c u r r i c u l u m provided, a t t h e h ighes t fee ob ta inab le , a se r ies of s h o r t l e c tu r e cou r se s over a t w o y e a r per iod . P rac t i ca l i n s t r u c t i o n w a s usua l ly lacking, a n d l imi t ed hosp i ta l facil i t ies p r ec luded observa­t ion of s ick pa t i en t s . F e w schools p rov ided n o r m a l o r pa thologica l a n a t o m y , s ince the avai labi l i ty of c a d a v e r s w a s severely l imi t ed d u e to w i d e s p r e a d opposi t ion t o d issect ion. A g r a d u a t e w h o sough t p rac t i ca l c l inical exper ience , b e c a m e a n app ren t i ce for t w o yea r s , a n d accompan ied a p recep to r a n dai ly s ick cal ls .

To t h e s ince re phys ic ian en t e r ing t h e p rac t i ce of med ic ine , d iscovery of w i d e s p r e a d q u a c k e r y a n d i ncompe tence w a s d i s t r e s s i n g ; a n d equal ly painful w a s t h e publ ic d u s t r u s t a n d c o n t e m p t for physic a n d phys ic ians .

As ear ly a s 1818, J o h n S t e r n s , p r e s iden t of t h e N e w York Medica l Society, a s se r t ed , « w i t h few except ions p rac t i t i one r s w e r e ignoran t , d e g r a n d e d , a n d con tempt ib le ».

S a m u e l D. Gross , a d i s t ingu i shed su rgeon a n d pa thologis t , ca l led it , « a hope­less s i t ua t ion ».

N a t h a n i e l C h a p m a n , f irs t p r e s iden t of t h e A m e r i c a n Medica l Associa t ion , p r o c l a i m e d : « The profess ion h a s b e c o m e co r rup t a n d d e g e n e r a t e a r i s ing f rom t h e r e a d y a d m i s s i o n of ind iv idua l s by w h o m it is d e b a s e d . » Wil l iam H . Welch t hough t , « t h e r e w a s no prospec t for i m p r o v e m e n t ».

This b a r r e n per iod in m e d i c a l e d u c a t i o n a n d sc ience w a s , in g rea t pa r t , t h e r e su l t of u n c h e c k e d , l imi t less free en t e rp r i s e . I t began in 1800 w h e n m a c h i n e s rep laced m a n power in m a n u f a c t u r i n g . The I n d u s t r i a l Revolut ion , in t i m e , t r ans ­f o r m e d the Uni ted S t a t e s f rom a hand ic ra f t , a g r i c u l t u r a l e c o n o m y in to t h e lead ing i n d u s t r i a l n a t i o n in t h e wor ld . I t s g r o w t h a n d expans ion in t h e 19th c e n t u r y w a s possible w i t h doc t r i ne s of laissez-faire t h a t r e a c h e d only for r u t h l e s s power , money , a n d u n c h e c k e d ind iv idua l i sm r ega rd l e s s of i t s mora l , physical , environ­m e n t a l , o r h e a l t h consequences .

A m o u n g i ts casua l t i e s w e r e educa t ion , med i c ine a n d m e d i c a l educa t ion , sc ience, a n d the essen t ia l r egu la t ions in the p rac t i ce of med i c ine for publ ic p ro tec t ion . S h a t t u c k in 1845, decr ied t h e affect « on t h e h e a l t h of t h e popula t ion of th is r eck l e s s specu la t ion a n d t h i r s t for w e a l t h in A m e r i c a ».

S iger i s t bel ieved, « p r o p r i e t a r y m e d i c a l schools w e r e a n express ion of a soc ie ty t h a t wor sh ipped pr inciples of u n c h e c k e d free en te rp r i s e a n d u n l i m i t e d laissez-faire, a n d n o t so m u c h t h e re su l t of e m e r g e n c y a n d need of doc to r s ». H e a l so t h o u g h t t h a t in th i s pe r iod « w h o e v e r gave u p m o n e y - m a k i n g to live for sc ience w a s cons ide red a c r a n k » . Welch w a s r e g a r d e d as too i n c o m p e t e n t t o p r a c t i c e med ic ine and , hence , h is choice of l abora to ry med ic ine a s a ca ree r .

F o r t u n a t e l y , t o w a r d s t h e e n d of t h e 19th cen tu ry , a m o r e efficient govern­m e n t a b a n d o n e d laissez-faire ; a n d funds e s t ab l i shed b y m o r e rea l i s t i c f inanc ie r s m a d e possible A b r a h a m Flexner ' s d r a m a t i c Bul le t in n u m b e r 4 in 1910, w h i c h g radua l ly l iqu ida ted a n d e leva ted m e d i c a l schools a n d m e d i c a l educa t ion .

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R E F E R E N C E S

1 JONES R. M. — American doctors and the Parisian medical world, 1830-1840, Bull. Hist. Med., XLVII, n° 1, pp. 40-60, n° 2, pp. 177-205, 1973.

2. Ibid. — American doctors in Paris, 1820-1861, J. Hist. Med., 25, pp. 143-157, 1970. 3. SHYROCK R. H. — Medicine and Society in America, 1660-1860, New York, N.Y.

University Press, 1960, p. 127. 4. OSLER W. — The Alabama Student, Oxford University Press, London, Humphrey

Milford, 1926. 5. ACKERKNECHT E . H . — Elisha Bartlett and the philosophy of the Paris clinical

school, Bull. Hist. Med., 24, pp. 43-60, 1950. 6. Ibid. —• Medicine in the Paris Hospital, 1794-1848, Baltimore, Johns Hopkins Press, 1967. 7. LA ROCHE R. — Account of the origin, progress, and present stage of the medical

school of Paris, Am. J. Med Sci., 8, pp. 109-125, 401-418, 1831, and pp. 351-388, 1832. 8. The Parisian Education of an American Surgeon : Letters of Jonathan Mason Warren

(1832-1835). Notes and introduction by Rüssel M. Jones, Philadelphia, The American Philosophical Society, 1978.

9. BLOCH H. — P. C. A. Louis, Influence on American Medicine, 69, New York State, J. Med., Dec. 1, 1969.

10. MORSE J. T. — Life and Letters of O. W. Homes, London, Sampson Law, 1896. 11. BLOCH H. — Medical research and education in 19th century America, N.Y. State,

. Med., 74, pp. 1071-1074, June 1074.

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