Medicine in Europe and the United States
From Enlightened To Clinical Medicine
The age of Enlightenment (and revolution), even in medicine, is how historians conceive of the eighteenth century. Centers of new or innovative medicine shifted over the centuries: ancient Athens and Rome, Salerno, Montpellier, Edinburgh, Leiden, Vienna, London, Paris, New York, and so forth. After the medieval creation of universities, learned or academic medicine, often connected to a clinic or a hospital, played a major role in reorienting medicine in theory and sometimes in practice. In spite of the profession's hero worship of Hippocrates, what was going on in faculties of medicine by the late seventeenth century had little to do with classical medicine. At Leiden, then "the medical center of the world" (Ackerknecht, p. 130), teaching was organized on the basis of subjects rather than the teachings of the great doctors; bedside teaching and the dissection of corpses had also become important. Hermann Boerhaave (1668–1738) was at the center of the new dispensation. His students included the founders of the great centers of clinical medicine in Edinburgh and Vienna. Boerhaave, inspired by experimental natural philosophy, concocted a hydraulic model of the body with a corresponding mechanistic explanation of disease. His mighty text The Institutes of Medicine (1708) ran through ten editions and endured a few translations into vernacular tongues. In 1724 Boerhaave wrote up a famous case history of a male who had died of a ruptured esophagus. It can been argued that this was the first modern form of this literary genre, covering the patient's history, a physical examination, a diagnosis, the course of disease, and an autopsy. Boerhaave developed a modern medical curriculum with a sequence of natural science, anatomy, physiology, and pathology, complemented by clinical instruction in a twelve-bed ward. This looks like the birth of that elusive entity the clinic; Michel Foucault insists that it was a protoclinic, for Boerhaave still struggled in the "old age of the clinic" (Foucault, ch. 4).
It had become clear that death could give insight into disease, possibly even establish its cause. Though tedious to use because of its two correlating indexes, the prolix work On the Sites and Causes of Disease (1761), by the Paduan anatomist Giovanni Battista Morgagni (1682–1771), achieved part of its noble aim of establishing a connection between the patient's symptoms and the lesions of the diseased organ in the corpse. Morgagni logged in some seven hundred autopsies. A new etiology of disease shifted it from a general theory to a specific organ, a site, where lesions produced by morbid changes in the organ could be matched with symptoms of disease in the patient. The London doctor Matthew Baillie (1761–1823) carried this anatomo-pathology further in a famous work on Morbid Anatomy … (1793), which provided classic textbook descriptions of diseases, including cirrhosis of the liver and emphysema.
In Paris the hospital came to dominate medicine through surgery and teaching. At the gigantic Hôtel-Dieu, Xavier Bichat (1771–1802) did six hundred autopsies as a basis for his Treatise on Membranes and his book General Anatomy applied to Physiology and Medicine (3 vols., 1801). Bichat's famous, complex theory of tissues, or membranes, shifted the etiology of localized disease from the organ to lesions of specific tissues. This shift allowed a lesion to be more precisely identified according to the particular tissue affected rather than the whole organ: inflammation of the heart was replaced by identification of inflammation of membranes or the muscle itself. "Life, disease and death now form[ed] a technical and conceptual trinity," as Michel Foucault put it in consecrating "death [as] the great analyst" (p. 144). Death, formerly the domain of the priest, had become part of medicine, and, along with life and disease, integrated into the medical gaze. Or, as Roy Porter puts it in ordinary discourse, Bichat's "work laid the foundations for nineteenth-century patho[logical] anatomy" (p. 265). Medicine could become a science enabling diagnosis to be more precise. The tool was the modern physical examination (still the doctor's best diagnostic tool), which consecrated the techniques of inspection, palpation, percussion, and auscultation. The patient's symptoms and the signs detected by the doctor could be related to the lesions that had been observed in diseased organs. With a galaxy of stars—Jean-Nicolas Corvisart des Marets (1755–1821), René Laennec (1781–1826), and Pierre Louis (1787–1872) prominent among them—Parisian hospital medicine enjoyed its day in the sun as a model having considerable influence on medical thought and education.
What was the clinic? The teaching clinic meant different things in different countries. In France clinical medicine put an emphasis on surgery, chiefly in large city hospitals. Military demand was a powerful stimulus to medical growth in the eighteenth century, and the need for army doctors rose during the French Revolutionary and Napoleonic wars. British clinical education was also mainly an affair of London institutions and provincial hospitals; Edinburgh and Glasgow resembled more the German model. In the German states small university-affiliated clinics and infirmaries provided practical education. The public hospitals of Paris had twenty thousand beds in which to stack, examine, and perhaps cure—an autopsy was more frequent—the city's vast diseased population. Medicine in Paris distinguished itself by the accessibility of public hospitals to students wanting instruction from great men like Laennec and experience in bedside medicine and dissection. Lots of corpses were available, for mortality at the Hôtel-Dieu was about 25 percent, two and one half times that of most English hospitals. Foreign students and doctors found Restoration Paris a profitable place in which to learn the latest French medical fashion; on returning home, they carried versions of the French model with them to many cities, including Vienna, Boston, and even London. London, whose population reached a million and a half by 1831, developed large teaching hospitals. Paris, whose population did not reach a million until 1846, was notorious for its concentration of patients and after the 1830s the development of medical specialization. The bedside tradition foundered when dozens or even many more students crowded round the patient's bed to receive the master's instruction. More profitable instruction was to be had from private courses organized by Parisian doctors. Limits on numbers were also imposed through elite selection in intern and extern examinations. The lecture shifted to the amphitheater. In spite of the fame of Paris hospital medicine, a student got a better education in private instruction by a great man, perhaps even Laennec, who gave a private course in the small ward of a big hospital, thus providing the advantages of both pedagogical worlds.
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