The Hospital as a Beacon of Science? Parisian Academic Medicine around 1800

Abstract

Owing to medical historian Erwin H. Ackerknecht’s (1906–1988) pioneering study “Medicine at the Paris Hospital, 1794–1848” (1967), the year 1794 is seen as the decisive separation date on which the development and reorganization of the Parisian clinical school—as a broad movement and a system of medical education and clinical practice—distanced it from the traditions of the 18th century. This precise dating is based on the “Rapport et projet de décret sur l’établissement d’une École centrale de Santé à Paris” (1794) by the French clinician and naturalist Antoine-François Fourcroy (1755–1809), which appeared five years after the French Revolution. Fourcroy was asked by the Conseil d’État to submit a detailed report in which he was obliged to comment on the existing health situation and the state of medical care and research. His report thereby ventured so far as to request the continued dissolution of all medical faculties in France, as these institutions were seen as counter-revolutionary hotbeds in the wider educational landscape of the Grande Nation. Fourcroy’s recommendations were implemented a short time later; he had recommended that medical training should be established again in the traditional locations of Paris, Montpellier, and Strasbourg in France yet in the different settings of so-called health schools, Écoles de Santé. In this article, I look at the corresponding training and care structures after the French Revolution, as well as some of the specific reasons which led to the complete suspension of teaching in academic medicine at the time. In the more recent research literature, Ackerknecht’s view has undergone some modifications, whereby the fixation on the date 1794 has been challenged since the French traditions of the royalistic period have hardly been considered. Furthermore, it has been argued that the reorganization of medicine during the time of the Empire remained largely based on knowledge structures derived from the previous 18th century. In order to keep the complex scientific, institutional, and socio-economic conditions of the context of Parisian Academic Medicine aligned, I first explore some developments up to the time of the French Revolution (1789), before assessing the implications of the reform of knowledge structures and curricular programs instigated since the 1790s, as these remain relevant to medical history in the 19th century.

1. Introduction

In 1991, the American medical anthropologist Fred W. Hafferty coined the term “ambiguous man” to describe an epistemic view of the human body as representing both an individual and social subject and that of an object exposed to medical research and unrestrained volition. On the one hand, Hafferty drew attention to the human body’s vulnerability while emphasizing its capacity to pass on diseases that naturally had to be considered. This view necessarily shortens the scope of doctors’ clinical and epistemic perspectives in medicine. On the other hand, he pointed out that a human being’s personality was ultimately connected to subjective perception, along with the individual and social positioning of their body (Hafferty 1991, p. 17). What ultimately characterizes people as human beings is their life in health and suffering during periods of illness. Hafferty also concluded that modern medicine tended to ask itself far too rarely the deep question of what constitutes the nature of man and the social and political place of personhood in medicine, a context to which French historical epistemologist Michel Foucault (1926–1984) had drawn attention earlier in his analyses of biopolitics concerning the modern biomedical enterprise (Foucault [1975] 1997, p. 242). In this current article, I aim to show which major developments in French medical history led to a conundrum regarding the medical, social, and political status of the human body using the example of Parisian academic medicine around 1800. I aim to dedicate the case examples and main foci of the argumentation to the evolution of what has been called the “clinical method” or the historical development of the “Clinical School of Paris” and shall introduce some of the basic medical findings which became associated with the theory of nosology, as well as the treatment of patients. In the second half of this article, the development of scientific medicine in the 19th century is examined, based on the example of physiology as the leading scientific paradigm that emerged from the reformed medical curriculum of the Écoles de Santé in post-revolutionary France (Stahnisch 2012, pp. 81–114).

The tumultuous period between 1750 and 1850 in France gave rise to the modern form of clinical medicine as it now exists in all major industrialized countries (Foucault 1996). By and large, as a result of Ackerknecht’s groundbreaking study “Medicine at the Paris Hospital, 1794–1848” (Ackerknecht 1967), the year 1794 is regarded in medical historiography as the decisive separation date on which the development and reorganization of the Parisian clinical school distanced it from the prior traditions of the 18th century (La Berge and Hannaway 1998). This epistemic setting correlates with the report of the physician and co-developer of modern chemical nomenclature, Fourcroy, five years after the French Revolution. With his political report on the medical faculties in France (see Figure 1), Fourcroy responded to the Conseil d’État when examining the current health system and the situation in medical research and practice. Fourcroy proposed in his recommendation that medical training be restored in the traditional locations of Paris, Montpellier, and Strasbourg and that so-called health schools, Écoles de Santé, needed to be created to include a teaching curriculum based on the natural sciences, mathematics, and multiple administrative applications (Gross 1979, pp. 231–36).

The prominence of this date has, however, been questioned in the research literature regarding academic medicine during the French Revolution. An objection has, for example, been raised given that the traditions of the previous period—even in France itself—have been under-considered. Also, the reorganization of medicine during the time of the Empire under Napoléon Bonaparte I (1769–1821) drew, to no small extent, from the know-how of 18th-century physicians (Pickstone 1981, pp. 115–42). In order to avoid a strict chronological setting, I will forego Ackerknecht’s tidy categorization in this article while still keeping the year 1794 as an important reference point in describing events. The complexity of the scientific, institutional, and socio-economic conditions of medicine before the French Revolution is explored in the first section of this article. To further our understanding of the organization of Parisian academic medicine, some clarifying points regarding the organization of the older and even the significantly longer-standing Montpellier school of medicine are needed here (Martin 1990, p. 111).

After presenting the historical development and contours of the ‘Paris School of Clinical Medicine’ during the post-revolutionary period, I will point out several individual causes and factors according to which this form of medicine emerged and could be epistemically and practically delineated. The changes that this historical school of postsecondary medical learning brought about, growing into a leadership role at the global medical scale in outside nations such as Great Britain, Austria, the German states, and the United States, will also be demonstrated. Finally, the long-term points of connection which the ‘Paris clinical method’ continues to have with today’s forms of academic and allopathic medicine are demonstrated within the biomedical research enterprise in Western health systems (Bates 2000, p. 502)1.

2. The Period between 1750 and the French Revolution

The forms of medicine preceding the 18th century and the changes caused by the clinical method after the French Revolution display the conjoint features outlined in the common model provided by Ackerknecht:

Medieval medicine focused on libraries and written records. During the following three centuries, as in classical antiquity, it focused on the individual sick bed. Yet it was not until the 19th century that it found its focus on hospitals. Hospitals became a crucial factor in the development of medicine since the Romantic era […], so that this period can be described as that of ‘hospital medicine’ in contrast to its predecessors, “library” and “bedside medicine” and their successor that could be called “laboratory medicine”.

(Ackerknecht and Murken 1992, p. 103; author’s transl.)

The treatment practice of Leiden-based Hermann Boerhaave (1668–1738), considered one of the most important clinicians and medical teachers at the beginning of the 18th century, can be seen as a special example and expression of this early form of bedside medicine (Rothschuh 1973, pp. 68–75). Theoretically, however, he is regarded as an eclectic who integrated a variety of contributions from basic iatrochemical and iatromechanical medical approaches into his epistemological and nosological system. This theoretical activity emanated from vivid discussions during the early 18th century regarding the ideas of the French philosopher René Descartes (1596–1650) that viewed humans solely as a physical machine (Descartes 1664), leading many physicians to believe that human illnesses could also be described solely by using the means of contemporary physics and mechanical engineering (Rothschuh 1970, pp. 337–40). Physicians’ healing methods were often based on traditional empirical experiences, while in practical terms, Boerhaave made Leiden University Hospital one of the most attractive medical locations in Europe—one which brought numerous students to the Netherlands, many of whom were among the most famous academics of the time, including the Scottish surgeons Alexander Monro (1697–1767) and Robert Whytt (1714–1766) (French 1990, pp. 98–107). Moreover, hundreds of foreign students accompanied Boerhaave on his home visits in downtown Leiden—the “outpatient clinic”, which he planned and carried out together with his entourage of doctors. This practice can be seen as an early form of clinical rounds, with the small but decisive difference being that it took place in the homes of the (mostly affluent) patients themselves. Boerhaave reflected on this practice theoretically too: the process of disease changing over time could only be adequately understood in a normal home situation, but he admitted the most seriously ill or difficult-to-observe patients exclusively to his “large inpatient clinic”. According to his Institutiones medicae, this consisted of a total of only sixteen beds, which were strictly separated according to gender and age (Boerhaave 1727).

In contrast to Boerhaave’s clinical medical practice, nevertheless, the development of philosophical medical systems was widespread in the early 18th century, a time when contemporary doctors primarily sought to present new medical theories as comprehensively and orderly as possible. The resulting classificatory schemes were intended to integrate inconvenient findings with many auxiliary arguments and a few “ifs” and “buts”. Yet physicians hardly tried to investigate, explain, or refute deviant findings from bedside observations in their patients, nor did they apply any laboratory experimental means. This process of nosological system formation did not stop short at the medical–clinical textbooks. It was also intended to cover practical medical work. For example, the French science historian Joseph Schiller (1906–1977) noted for the basic physiological research process that classification tables borrowed from zoology were still present in almost all French physiology textbooks up to around 1840 (Schiller 1980, p. 134). They hardly ever reported on any bedside observations or the production of experimental data from active research. With regard to systematic and classificatory approaches to diseases, the notorious Swedish physician and botanist Carl von Linné (1707–1778) deserves special attention here. His classification approaches in botany and zoology are still used today, while he also created a large number of magnificent parks throughout Europe that acted as his stratum of identification, research, and culturing of botanical items—e.g., those in Vaexjoe, Sweden, or Sans Souci Palace in Potsdam, Prussia (Broman 1989, pp. 36–53). With such systematics, not only Linné but also François Boissier de Sauvages de Lacroix (1706–1767), who was significantly influenced by him and became one of the founding figures of the ‘clinical school of Montpellier’, wanted to classify diseases according to their nature and cure them with the appropriate drugs and therapies. Both naturalists shared the belief that such a natural order of diseases corresponded directly to an external order of medicines in their natural habitats and sympathetic affinities with the human body. Sauvages described around 2400 diseases which he located in the system of his Nosologie méthodique (Boissier de Sauvages 1772). However, success in the actual healing process proved a long time coming, and dissatisfaction with this approach became widespread, even without any theoretical and therapeutic alternatives coming to the fore to replace it.

Compared to developments in internal medicine, the situation looked much better for surgery. The 18th century has even been called the “century of surgery” (Schlich 2004, p. 63). Regarding the political context, absolutist monarchs calculated that better medical care for the rural population and their soldiers would also be economically worthwhile in a protracted period of civil and international warfare. On the one hand, a few academic surgical schools, so-called Écoles de Chirurgie, were set up in France in the early 18th century, and more binding training curricula were gradually established. As early as 1728, Montpellier introduced the Doctorat de chirurgie, a specialized surgical training program at a high technical level but separate from academic medicine (Haigh 1984, pp. 72–86). From 1734 onwards, then, internal medicine students at the University of Montpellier had to complete four compulsory anatomical dissections (meant to be practical training for them in surgery) covering the entire course of their medical studies, in which they also needed to provide and discuss information regarding their surgical knowledge—even if this was taught in a fairly abstract (namely postmortem) manner. The situation was similar in Paris; from 1721 onwards, it had introduced an additional voluntary surgical dissertation option for its medical graduates (Ackerknecht 1967, pp. 61–100). From 1724, a two-week anatomy course followed, and from 1735, a surgical demonstration course was combined with anatomy and ongoing examinations. Particularly important surgeons who emerged as graduates from the Paris surgical school include Jean Louis Petit (1674–1750). He performed the first operation on the mastoid bone and wrote important books on osteological pathology and the metastasis routes of breast cancer. In addition, Pierre-Joseph Desault (1744–1795) made notable contributions to traumatological and war surgery, along with sophisticated wound dressing theory. He was the surgical teacher of Marie-François-Xavier Bichat (1771–1802) too, who supervised the students in Desault’s clinic from 1795 to 1798 and published his teacher’s main works after the latter’s death. During his training, he became famous as a private teacher of surgical and pathological anatomy while developing an outstanding role as a postsecondary teacher during the development of the Paris clinical school (Haigh 1975, p. 74).

Yet, the general appreciation of surgery was not limited to the classes of academic surgeons alone; it also drew in those surgeons who traveled across the country and offered their services either as itinerant market surgeons or as public surgeons for larger municipalities, where they assumed health preservation roles for larger communities. In France, they received more solid training at the Royal Academy of Surgery, newly founded in 1731 by Georges Maréschal (1658–1736) and François de la Peyronie (1678–1747). While doctoral theses and dissertations at universities were still written in Latin, this was a special situation, as barbers and wound surgeons were now also offered instruction in the vernacular language of French (Temkin 1951, pp. 248–59). These new university-trained wound surgeons were themselves employed in French armies in their wars of expansion against Italy and Spain, along with France’s naval conflicts with Great Britain—situations which underscored the importance of warfare and military surgery for the development of the clinical method (Stahnisch 2013, pp. 1–32).

Despite the remarkable achievements in surgery and some important scientific developments by its protagonists, the most characteristic developments in medicine in the 18th century arose in close connection with the philosophy and culture of the Enlightenment period. With its empiricist approach of emphasizing people’s perception of their knowledge, but also critically questioning it, this movement reached its zenith in France, from which it spread across the whole of Europe (Staum 2003, pp. 187–88). The philosophy of the French Enlightenment fortified the centrality of the human subject, not only in theoretical terms but also in concrete legal and social philosophy. In medical treatises, not only the subjectivity of the doctor and scientist but also that of the patient became increasingly reflected in these works, insofar as an emphasis on society, regarding the public health obligations and social security roles of the state, was concerned. Furthermore, these new philosophical values were prevalent in the philanthropic social philosophical concerns represented in the works of the early encyclopedists; Denis Diderot (1713–1784) and Jean le Rond d’Alembert (1717–1783) tried to present the state of knowledge of their time as comprehensively as possible and to make it available to broad sections of the French population (D’Alembert and Diderot 1798, p. 265). The anthropological designs of Julien Offray de la Mettrie’s (1709–1751) “L’Homme Machine” (De La Mettrie 1748) and the liberal treatises of François-Marie Arouet de Voltaire (1694–1778) were widely embraced by the natural scientists and physicians of the time. In the field of educational sciences and, a little later, medical therapy as well, Jean-Jacques Rousseau (1712–1778) enriched both theory formation and clinical practice, although his theories centered around naturopathy and self-help rather than academic medical research. Rousseau not only wanted to free people from their social bondage in political terms as an aim pursued through the French Revolution per se, but he also postulated that human illnesses were, in many respects, the result of social unrest. Healing, according to Rousseau, involved gaining philosophical insight into one’s own naturalness—similar to the epistemic figure of the “ambiguous man” (Hafferty)—and, in the broadest sense, into the use of naturopathic approaches and methods by promoting the discovery of natural cures through nutrition, dietetics, and gymnastics (Williams 1994, pp. 96–98). Health education, especially for children, contributed to medical successes while being aligned with such 18th-century naturopathic and alternative medical procedures.

In addition to general developments in medicine and philosophical currents, it is important to address the particularly competitive and sometimes oppositional relationship between emerging Parisian medicine and the so-called “Montpellier School” (Martin 1990, pp. 111–37). Throughout the 18th century, Montpellier’s medical faculty was a much livelier and busier place than its Parisian sister at the Rue de la Bûcherie. In Montpellier, surgery and internal medicine had never been separated in the same local and educational manner seen in Paris. Relevant historiography has emphasized that some of the Montpellier graduates even became the most famous Parisian doctors, as well as some of the king’s personal physicians, such as the surgeon Pierre Chirac (1650–1732) (Olmsted 1944, p. 51f). The surgeon Antoine Portal (1742–1832), professor at the famous Collège de France and founder of the French Academy of Medicine; the nosologist Philippe Pinel (1745–1826), who will be discussed later; and Guillaume François Laënnec (1748–1822), the uncle of René-Théophile-Hyacinthe Laënnec (1781–1826) who would invent the stethoscope in internal medicine—they were all Montpellier graduates who nonetheless left their legacy in lieu of the Paris Clinical School (Rosenberg 2007, pp. 516–17). What was special about the Faculté de Médecine de Montpellier, however, was not only that it had a second school next to Paris, sufficient cause for offense in the Age of Absolutism, but that the southern French school’s teachings were based on two of the most famous medical professors in the country, the nosologist Boissier de Sauvages and the physiologist and physician Paul Joseph Barthez (1734–1806). The latter represented his own, very influential theoretical system of medicine, which was further developed by physiologist Théophile de Bordeu (1722–1776) for practical medical applications (De Bordeu 1767).

The physicians of the Montpellier medical school, like their counterparts from the Parisian clinical school, called for a purely observational or external approach at the bedside and in laboratory settings that would not require anything beyond the functioning of the intact body. This was not laissez-faire empiricism but rather the precise observation and classification of diseases into certain classification systems which were intended to ultimately lead to more rational forms of therapy (Pickstone 1981, pp. 115–41). However, while the Paris clinical school opened up much more quickly to the experimental methods of laboratory medicine and functional physiology, the vitalists of Montpellier relied on the argument of the artificiality of surgical interferences with the body in operational (human) and vivisectional (animal) settings. They heralded natural observation of disease processes and remained adamantly opposed to experimental interventions, rejecting laboratory physiology as a pure medical working method (Stahnisch 2003, pp. 23–24). Nevertheless, from 1760 onwards, an “anticipation” of the philosophical and pedagogical approach of the Paris clinical school can also be seen in the Montpellier school (Lenoir 1993, pp. 70–102).

Another point that the research literature on the topic has highlighted is the reception of general tendencies in European medicine in the second half of the 18th century. Attention has been drawn, for instance, to the fact that France was increasingly eager to catch up to the scientific and medical developments of other nations (Weisz 2006, pp. 210–26). In Italy and Great Britain, anatomical training and the pathological perspective were already much more integrated into medical training and eagerly received in the basic science perspective in leading medical hubs such as Glasgow, Edinburgh, and London. In 1761, Giovanni Battista Morgagni (1682–1771), who initially worked as a practitioner in Bologna and later as a professor of medicine and anatomy in Padua, wrote his main work on the origins and causes of diseases, published as “De sedibus et causis morborum” (Morgagni [1761] 1827–1829). In this work, which became known far beyond Italian borders, he presented his comprehensive pathological theory of organ lesions and the signs of diseases. Morgagni’s basic theoretical work was of far-reaching importance for the subsequent understanding and interpretation of diseases; it departed from explaining diseases in terms of humoral pathology based on a theory of body fluids or krasen but rather assigned a respective disease a specific location in the body. The number of cases described which he drew from the rich trove of his entire professional life, including countless medical dissections and autopsies, was of particular importance (Lesch 1988, pp. 100–38). In the same year that Morgagni published his magnum opus, a separate work, “Inventum novum”, by the Viennese clinician Leopold Auenbrugger (1722–1809) also appeared, in which the latter introduced his newly designed physical diagnostics method—plethysgraphy (Auenbrugger 1761). This was a palpatory procedure in which extracutaneous tapping of the body cavities or changes in sound were used to determine morphological changes in the internal organs. Medical students were acquainted then and still are today with this procedure within the intimate learning situation of so-called “tapping courses” and examination settings, if not already learned in palpatory procedures on the basis of clinical ward instruction in the Vienna hospitals (Harris 2016, pp. 47–48). In particular, determining the organ size of the heart’s contours through plethysgraphic diagnostics goes back to Auenbrugger. Nevertheless, this work received relatively little response during Auenbrugger’s lifetime, although it is now seen as one of the most important contributions of the Vienna clinical school and is widely used in modern examination practices through percussion techniques (ibid., 51–53). It is quite interesting and crucial to his method that Auenbrugger was a music fanatic who incorporated this enthusiasm directly into his medical work. As history would have it, he himself was the composer of several operas and had already learned about the percussion of hollow bodies based on the wine barrels owned by his father, a Graz innkeeper (Maulitz 1987, pp. 36–82). As is so often the sad case in the history of medicine and science, many important discoveries are out of place and misunderstood in their own time.

In addition to the individual scientific discoveries and medical developments in neighboring European countries discussed, medical historiography has also pointed out the institutional developments that took place, particularly in Great Britain, during the 18th century. The Edinburgh and London medical academies were foremost in trying to establish comparative standards teaching, the development of scientific standards, and the exchange of international information. Yet the furthering and integration of innovations into everyday medical practice—something that can perhaps be granted to the traditional views of the Paris clinical school—can be seen as a special outcome and a lasting influence during the period of post-revolutionary France (Pickering 1992, pp. 65–112). One can rightly speak of a “medical revolution” in the sense of considerably improved disease diagnosis, hospital treatment, and clinical management of patient outcomes seeing their heyday in academic medicine during this time in France and beyond2.

As an interim conclusion, it can be stated that the foregoing situation within 18th-century medicine built the foundations for coming morphological, pathological, and surgical innovations in medical education—indeed, this appeared in the contemporary context during the revolutionary year of 1789. With 24 universities, France had an extremely high density of academic training centers, including 20 faculties offering medicine. At the end of the Ancien Régime, both Montpellier and Paris had eight professors each, while in French provincial cities like Caën, Reims, or Nantes, the basic teaching for students had to be provided by a skeleton faculty consisting of one or two full professors and a penumbra of medical lecturers, including médecins agrégéés as adjunct instructors in their respective clinical settings. Médecins agrégéés were only brought in from their medical practice to the university to teach medical students about the specialized subjects according to their own interest and practical experience. The doctors in each city chose the professors themselves, a situation which almost naturally turned into an uncontrollable local patronage system. It was very rare for university doctors to be able to change universities several times after completing their studies. Parisians stayed in Paris and doctors from Nantes in Brittany. Furthermore, a nationally binding training curriculum for medical students did not exist (Weisz 1995, pp. 155–88).

It was not until 1773 that the military medical academy in the southern French naval port of Toulon introduced the first binding curriculum for its surgical students, presenting them with a full program of scientific and clinico-medical rounds similar to that of the traditional medical schools in France. However, this situation meant that actual medical training was mostly carried out as a kind of apprenticeship and on-the-job training. Students literally “bought into” a more or less famous doctor (by paying personal tuition fees to their clinical instructors) so that they could accompany him (medicine remained an exclusively male profession for most parts of the 19th century) to his clinic in the city. The family networks of medical students also meant that one needed to have the right connections to place their offspring in the care of a doctor friend and receive his practical instruction. Since medical lessons were far from being regulated, lectures were freely presented in the hospital setting in a viva voce style. Students repeatedly complained about this system, but their appeal submissions to the faculty almost never led to any consequences. Some students had to content themselves with a situation in which their academic teachers showed up to their classes at all, as the absence of professors and lecturers became a recurring complaint in this period (Lesch 1984, pp. 82–84).

As for the number of students within the training situation for surgical students in Paris, there were only forty places available at the École Pratique de Dissection as a specialized practical surgical school. The program also had to be completed by the general medical students before they could graduate from their fuller program. Of course, this number was far too small, as there were already estimated to be several hundred medical students in the period before the French Revolution. Numerous submissions from these students thereby offer some information as to what the practical training of contemporary doctors was actually like. Questions about the path to completing a medical degree in this system are somewhat addressed by observing the students who moved back to the provinces. Only 40 percent of all students who started their first semester in Paris stayed there until their doctorate. In addition, the purchase of internship certificates and signatures from doctor friends of students’ parents and relatives for licensing credentials was rampant; in short, there existed a widespread system of corruption (Gallot 1790). News made rounds in the public sphere that doctoral degrees were being sent to card files and that exams were not actually taking place at the Paris faculty. It was an open secret that even well-known Parisian medical professors wrote doctoral theses for money. These were paradise-like conditions for the privileged and influential offspring of doctors, as well as the offspring of the impoverished nobility (Bonner 1996, pp. 61–102).

Thus, it makes sense that the prominent German medical historian Henry E. Sigerist (1891–1957) later described the Paris faculty as “a fossil” that was based on the structures of absolutism, including traditional theories, practices, and hierarchies, as it sought to continue these teaching programs and protect its traditional social and academic privileges (La Berge and Hannaway 1998, p. 5). Furthermore, doctors were generally not held in high esteem, as they were often considered to have little moral integrity, to be economically corrupt, and to be guided by their own political interests, which frequently stemmed from their high social position in the Ancien Régime (Neuhaus 1993, p. vii). In addition to the internal difficulties within the medical system in France, the profound and immediate social changes at the time of the dawning revolution must also be considered (Crosland 2004, p. 237). The heyday of absolutism, the spread of manufacturing, and an increase in large impoverished social classes characterized this historical situation. Severe famine periods and recurrent epidemics determined the disease situation in the broader French population, a situation which contemporary academic medicine could hardly counteract and change (e.g., Magendie 1816, pp. 66–77). This crisis was also manifested in the revolutionaries’ idea that academic medicine should be abolished due to it being a kind of “extended arm” of the aristocracy. In the first revolution year of 1789, all faculties were officially closed, and only basic training in some of the colleges and military schools remained socially tolerated so that they could continue to admit new students.

3. The “Clinical Method” in Paris

France (see Figure 1) and specifically Paris were the starting points of a new way of practicing medicine at the bedside, initially applied within large numbers of existing and newly founded municipal hospitals. While individual religious hospitals, such as the traditional Hôtel Dieu, existed in addition to university teaching hospitals before the outbreak of the revolution, several almshouses and hospitals contributed to the general medical care system as well. Many were founded in quick succession: in 1775, the Clinique de Perfectionnement; in 1778, the later children’s hospital Hôpital de Necker; in 1780, the Cochin military hospital, where the late French President François Maurice Adrien Marie Mitterrand (1916–1996) would later be treated; Beaujean in 1784; and the Maison de Santé in 1781. These legacy hospitals, with their illustrious history in Paris, still form the backbone of high excellence in academic clinical training in France. As early as 1788, the number of hospital beds had already reached a total of 20,341 in the 48 Parisian hospitals of the time (Maulitz 1987, pp. 36–82). The French Revolution not only led to major political changes but to comprehensive changes in the social and scientific order too. As early as 1789, the old universities, academies, and traditional institutions were dissolved because of their suspected counter-revolutionary potential and that of their professoriate. For medicine, this meant that from the time of the storming of the Bastille to university reform in 1794, medical training was only possible at military institutions—and even then, only for surgeons. Efforts for change arose between 1790 and 1794, particularly linked to the name Félix Vicq d’Azyr (1748–1794). Vicq d’Azyr himself was an anatomy professor at the École Vétérinaire d’Alfort and is still known to modern medical students learning about brain anatomy and dissecting practices owing to the Vicq d’Azyr bundle and the Vicq d’Azyr strip (Schmitt 2009, pp. 145–93). He had been a personal physician to Marie-Antoinette (1755–1793), Queen of France, and from 1788, he took over naturalist Georges-Louis Leclerc, Comte de Buffon’s (1707–1788) seat at the Académie Française. Perhaps it was these links with the traditional system that robbed the reform program of d’Azyr’s immediate impact (Vicq d’Azyr 1790). For example, he called for a uniform medical training curriculum with standardized examination requirements that included anatomy, surgery and patient observation, examinations in the national language, and an extended course of study for six years. Yet, it took until Fourcroy’s decree for his suggestions to be reflected in the restructuring of medical education.

As early as the beginning of the 19th century, the term “École de Paris” appeared in the French literature, which referred particularly to the reorganization of hospital medicine in Paris, primarily as an administrative and pedagogical endeavor and not as a movement associated with the faculty of medicine in the French capital. The number of beds in Paris’ hospitals had now increased even further, and foreign visitors, such as the German clinician Carl Reinhold August Wunderlich (1815–1877) from Leipzig, reported in amazement in their letters, never having seen such a hospital or bed density before. They drew attention to how many observations and dealings with the patient were incorporated into the general teaching of medical students. He put it this way:

The hospital is the backbone of all medical thought; Only here can everything be confirmed, together with the dissection room.

(Wunderlich 1841, quoted in Ackerknecht 1967, p. 15)

At this time, Paris had important teachers, good scientists, and medical education oriented towards sick patients, all of which made it very attractive. One can rightly say that it had developed into a “Medical Mecca”, and the number of international students and scholars who were drawn to Paris is legion, ranging from the above-mentioned Wunderlich to the Jena anatomist Johann Joseph Ignaz von Doellinger (1799–1890) and the famed Berlin naturalist Alexander von Humboldt (1769–1859), who was a member of the French Academy of Sciences for two decades. It was standard practice in Paris clinical training around 1800 that the 1000 students per year (at this point) had to go on internships to surrounding hospitals for four months. After its modification in 1802 with the creation of the externat student rotations and the boarding school system, this larger system—i.e., practical sections during the course of study itself and the assignment to specialist training after the doctorate or passing the modern concours (the national state examination)—has largely continued to this day in France. While previously there was no day of vacation on the agenda at all, at present, one week of Christmas vacation, three weeks of spring vacation, and the month of August are generally planned as a recreational period. The time without lectures and classes corresponds to that of normal employees in France, something which is all too often overlooked in discussions about the organization of studies outside of the country’s borders in both a negative and positive way (Weisz 2003, p. 548).

Beyond the descriptions and views of the doctors associated with the conditions in Paris’ hospitals, it is important to examine the existing institutional and social circumstances in these hospitals themselves. A quote from the legendary report of the surgeon Jacques-René Tenon (1724–1816) on the Hôtel Dieu offers great insight in his description of his previous experiences from 1788, when he served as a member of the Parisian hospital committee:

[…] another thousand individual things and contingencies add to the general and constant circumstances of the polluted air. Altogether, they bring me to the conclusion that the Hôtel Dieu is the unhealthiest and most uncomfortable hospital of all, and that of every 9 patients admitted, 2 die within the hospital walls.

(Tenon 1788, p. 344; author’s transl.)

The Berlin medical professor Johann Ludwig Casper (1796–1964) reported in 1822 that it was generally an honor for a foreign doctor to be able to work in a Paris hospital. Although they were not palaces compared to the large (though singular) municipal hospitals of London which Casper had also visited, their operating theaters and baths were altogether well equipped, and the kitchens seemed to work well. However, he complained about the cold in the hospital wards, which he estimated at 5 degrees Celsius. Doctors of the post-revolutionary period—famous examples were the surgeon Guillaume Dupuytren (1777–1835) and the pathologist Bichat—were often poor and shuffled down the corridors in wooden shoes (Lesch 1977, pp. 82–84). Ownership that would have made it at all possible to finance large hospitals was not the situation for the previous private and clerical owners. Multiple economic, political, and administrative efforts were needed during the time of the Empire to instigate some improvement in care for the sick Parisian population, as can also be gleaned from the trends regarding the death rates in the city’s municipal hospitals (Ackerknecht 1967, p. 19):

• 1805–14: 1 patient from 5.35
• 1815–24: 1 patient of 5.82
• 1825–34: 1 patient from 8.00
• 1835–44: 1 patient from 9.59
• 1850: 1 patient from 11.03 (Tenon 1788, p. 344)

The health implications of the Parisian hospital system following the French revolution were reflected on by Michel Foucault when he dealt with the emergence of the Paris clinical school. In his groundbreaking work “Naissance de la Clinique” (1963), he described the emergence of the hospital system as an important platform for the development of the Parisian clinical method (Foucault 1996, pp. 137–85). The hospital was just the place or, in Foucault’s terminology, “the room” in which new patient observations could be made and developments in medicine could take place. In his opinion, the institutional and epistemic conditions of the municipal hospital system offered a new “medical gaze” into the human body. This medical view of Parisian doctors was primarily characterized by the scientific paradigm of tissue pathology and the development of gross pathological anatomy. Both depended highly on the influence of academic surgery as it progressed from the changes in Parisian clinical medicine. The time immediately following the revolution, as well as the period of the Empire, were characterized by constant military activities in France—civil war, as well as wars of conquest abroad, demanded a constant and large supply of military surgeons (Temkin 1951, pp. 248–59). Between 1792 and 1815, not a year went by without military conflict. In a modification or specification of the words of the Prussian general Carl von Clausewitz (1780–1831), one could probably state in this context that not only was “war was the father of all things” but it was particularly the father of an important aspect of clinical medicine, namely its localizational and lesion-based approach (Gelfand 1980, pp. 87–98). Almost all of the great surgeons’ innovations, including Dupuytren’s work on contractures, Baron Dominique-Jean Larrey’s (1766–1842) contributions to cleft surgery, and Pierre Nicolas Gerdy’s (1797–1856) studies in peripheral neurosurgery, originated from surgeons who had completed part of their medical training in the revolutionary forces or the armies of the expanding Empire; they were particularly well versed in traumatology and wound care (Legée 1977, pp. 67–80).

From a socio-historical perspective, however, it is important to point out the large numbers of the fallen and wounded for whom the French health system had to care and lay to rest. Continued episodes of warfare contributed to about 900 health officers, officiers de santé, dying among the ranks of the French army between 1793 and 1794 alone (Crosland 2004, pp. 232–34). The figures were alarming and began to continuously jeopardize the entire health care system in France. This may have contributed to the restructuring of medical education from 1794 onwards; this was when a system of general public access to university education was introduced and surgery became increasingly integrated, as an academic subject, into the training of future doctors, until it was made an essential part of medical education in 1802. Another aspect of the clinical method that related to surgery was its immediate practical relevance when system-building was still widespread in medical theory and educational programs. Such reforms had already taken place in year III of the revolutionary calendar, i.e., 1794—when the French statesman Maximilien François Marie Isidore de Robespierre (1758–1794) was already dead. The Jacobins had, however, remained in power, trying to base the social and political system, as well as school and university institutions, on the ideals of the French Revolution. In such a challenging context, Fourcroy’s report was about to transform medical training, health care, and clinical research in France. The late French medical historian Jean-Charles Sournia (1917–2000) even spoke of it as “such a brutal break!” in the history of French medicine, one that transformed clinical institutions, public health prevention, and the integration of surgical and medical education into Parisian clinical medicine (Sournia 1992, p. 74).

As already mentioned, in 1802, the centuries-old separation of surgery and internal medicine in the medical faculty and in medical training had come to an end, offering new innovative potential for programs in health care education. In addition to physicians with doctorates who had trained at medical faculties (for an average of 3–4 years with a doctorate as final degree after a 3–4 h final examination in front of the entire faculty), further opportunities for the training of health officers were created to compensate for the physicians and surgeons fallen in France’s military struggles. They were increasingly trained at new postsecondary universities in the French provinces, along with the newly created college system in the capital, where their teaching consisted of an introduction to medical examination practice, materia medica (internal medicine and pharmacology), chemistry, pharmacy, and surgery (Ackerknecht 1967, p. 129). Medical teaching and the writing of dissertations in the spoken national language became possible for the first time in France with the decree of 1802, which opened this course of study to other areas of society and education, too. Despite the practical relevance advanced by the reformed curriculum, large parts of the medical studies program still took place outside universities for some students due to the poor teaching and supply situation. At the colleges that emerged from pre-revolutionary clerical schools, students were now provided with private lessons by younger faculty members. However, established professors taught there as well, such as Laënnec (see Figure 2). Young faculty members were extremely popular because they had recently trained and taken examinations and later even showed themselves to be experimentally oriented (Coleman 1985, pp. 49–70).

Beyond the direct practical relevance of the training sections in surgery, there were also changes in relation to patients’ medical diagnoses, which need to be viewed as holding potential for medical innovation towards more practical relevance for contemporary students, who were strongly influenced by both the philosophers of the Enlightenment and the politicians of the French Revolution (Staum 2003, pp. 187–88). French physicians even had many revolutionaries in their own ranks. As medical historian Temkin pointed out, the epistemological considerations of the group of philosophers, scientists, and administrators among the Idéologues were central to the formation of new theories in medicine at the time. The Idéologues formed a group of French thinkers and scientists at the end of the 18th century who promoted a thematic movement away from dealing with metaphysical questions of medical system-building and towards more epistemologically relevant problems received from the natural sciences, including the relationship between comparative anatomy and zoology, nutrition physiology and chemistry, and cardiovascular circulation and medical physics (Temkin 1946, pp. 10–35). Madame Anne Louise Germaine de Staël-Holstein’s (1766–1817) salon proved to be an influential platform for philosophers to meet and exchange with physicians, scientists, administrators, and politicians. Her engagement with leadership education, which influenced the pedagogical reforms beginning after the revolution, was later replaced with French academic philosophy in the guise of the spiritualistic eclecticism of Victor Cousin (1792–1867). This followed the Catholic Church’s success in gaining enough political influence during the Restoration to undo the Idéologues (Staum 1980, pp. 4–6). Their scientific and philosophical orientation was particularly based on the sensualism of Abbé Etienne Bonnot de Condillac (1714–1780). The Idéologues followed his epistemology, which emphasized the primary importance of sensory impressions for progress in the natural sciences and medicine. Moreover, the Idéologues supplemented Condillac’s views with functional statements about the physiology and anatomy of human perception, thereby providing a theoretical foundation for bedside observation and clinical examination practice. One could thus boldly state that the contemporary philosophy of vision transitioned into a new form of observational medicine based on nosology, physical examination, and a reclassification of disease phenomena based on physicians’ bedside experiences (Ackerknecht 1967, p. 3.)

While these views appear with modern readers’ hindsight to be completely normal and normalizing (Canguilhem 1998, p. 52), perhaps even trivial given the way clinical medicine is practiced in an evidence-based epistemological framework today—including with regard to clinical auscultation skills (Harris 2016, pp. 39–42)—it nevertheless must be pointed out how dominant the frame of reference from medical classics—above all, Hippocrates of Kos (c. 460–c. 370 B.C.)—was at the time in medical curricula in Paris and elsewhere. Even in the Age of Enlightenment, the systematic reference regarding existing doctrines and theoretical systems made it extremely difficult for new knowledge (based on direct experience) to be integrated into medical education at large. What was crucial here was not primarily doctors’ varying approaches to their patients at their bedside or their observation of the individuality and course of illnesses but rather the comparison with book knowledge and the priority that such book knowledge held for prognosis and the therapy derived from it (Ackerknecht and Murken 1992, p. 103). In medical terms, a new approach was particularly reflected in the epoch-making work of physician and philosopher Pierre Jean Georges Cabanis (1757–1808) “Du degré de certitude de la médecine” (Cabanis 1797) and in “Sur les Rapports du physique et du moral de l’homme” (Cabanis 1802), which were widely read and found expression in many different areas of medicine. One of the most powerful clinicians in whom the influence of the Idéologues could be clearly detected was the psychiatrist and nosologist Pinel (Koehler 2013, pp. 93–122). He became popularly known as a liberator of the insane from their chains since he assumed that their psychological or, as he called it, moral development and healing depended primarily on physical means of restoring their normal physiology. He rejected the punitive and restraint treatment methods prevalent in the mental asylums of the time, such as being put in chains or placed in straitjackets and chairs. Beyond his work for the insane, he was likewise an important internal medicine clinician and teacher at the Parisian medical faculty (Weisz 1995, pp. 159–88). Pinel’s depictions of inflammatory diseases and tumorous lesions, for example, influenced several prominent university teachers in France, including the internist and heart specialist Jean-Baptiste Bouillaud (1796–1881) and the pathologists Bichat and Gabriel Andral (1797–1876). They all took a prominent localizationist view of disease, according to which certain lesions only appeared in particular regions of the body because—according to the clinical gaze and the empirical auscultatory findings of physicians—specific pathological constellations and aberrations of the normal composition of the human organs could be found there in states of illness and disease (Dobo and Role 1989, pp. 146–62). I would now like to address and expand on this idea, which recurs particularly in Bichat’s views and his tissue pathology, in relation to the new patho-morphological perspective that formed another important pillar of Parisian academic medicine around 1800.

4. Pathological Anatomy

In the historiography of modern biomedicine, the importance of the French clinic to the emergence of pathological anatomy in general, and tissue pathology in particular, has become a common medical trope with regard to the late 18th and early 19th centuries (Bates 2000, pp. 502–18). It is linked to the localization concepts of disease etiology and attempts to use the knowledge gained from pathological dissections for a general understanding of the processes in healthy organisms (Canguilhem 1998, p. 77). In comparison to the localization efforts of the medical clinic, the pathological–anatomical research program of the Parisian surgical instructor and laboratory researcher Bichat represented a most influential and foundational approach within morphology-oriented medicine. Bichat already presented the main ideas and contours of this approach in his groundbreaking work “Traité sur les membranes en général et de diverses membranes en particulier” (1800)—an approach on which he later expanded. In this analytical work on tissue pathology, Bichat tried to demonstrate the actual loci of the disease processes which his contemporaries Pinel, Laënnec, or Bouillaud had postulated nosologically; Bichat intended to relate them back to the underlying tissue changes that were causative of the development of inflammation, bleeding, or tumor growth in human organs (Bichat 1800b). Against the backdrop of a theory of illness influenced by vitalism, Bichat specifically tied the decentralized conception of life phenomena back to individual body tissues. In doing so, he turned away from the localization tradition that still relied on Morgagni’s organ pathology and saw the functions and morphological structure of the organs as particularly dependent on their tissue basis. Bichat’s experimental practice was mostly subordinate to his pathological–anatomical research interests (Haigh 1975, pp. 72–86). Yet there is also an important social distinction to observe between Italian anatomical pathology and its French academic successor. Morgagni took decades to correlate symptoms with local lesions that he had discovered postmortem based on patients from his own limited medical practice. Bichat, on the contrary, was able to amass far more data more quickly. Bichat did not simply have the advantage of great numbers of dying patients: he also had the advantage of control over their dead bodies. In fact, Bichat’s practice became increasingly the norm in modern medical research and clinical practice (Underwood 1971, pp. 120–23).

The general training of medical students within the new research program in pathological anatomy remained, nonetheless, was limited by the challenging context of Bichat’s own dissection practice (Albury 1977, p. 77). It can be characterized by clinical localization theory and a dissecting research practice, whereby the positive heuristic orientation of the program was aimed at a closer understanding of the tissue lesions underlying individual disease processes. In the course of his research, however, the pathological anatomist’s interest shifted from a classification approach to an experimental pathological approach. Bichat’s pathological perspective indeed shifted the focus of the experimental program to disease phenomena, while normal life phenomena received little consideration. Their explanation came about as a detour via pathological anatomy. The basis of Bichat’s morphological physiology remained vague for a long time because he made no systematic attempts to support his views experimentally (Pickstone 1981, pp. 115–41). Thus, pathological anatomy primarily had an impact on clinical diagnosis and the development of histology. In contrast, the qualitative change in meaning from body or tissue-specific life activities to physiological functions only took place from the middle of the 19th century onwards. This was a scientific development that began with Bichat but was cut short by his untimely death as the result of an infection he contracted from a cadaver during dissection. Despite such misfortune, he had definitely investigated pathophysiological phenomena in his practice and research program, while, for example, seeking to investigate and demonstrate the brain’s effect upon the heart and its normal functions—such as the modulation of cardiovascular pulse, which was carried out by means of simulating the various steps in time that lead to cardiac arrest and finally the death of the animal:

It has been shown in the present article that the actions of the lungs can be disrupted by eliminating the actions of the brain. The same could be said with respect to the heart: It stops beating when the brain is dead. We should investigate how this happens. Obviously, there can be only two causes for this phenomenon: (1) The heart completely depends upon the actions of the brain; or (2) because there is a third organ that lies between and mediates these, this organ is now affected first and is therefore responsible for the cardiac arrest.

(Bichat 1800a, p. 106; author’s transl.)

As an acknowledgement of his influence, when the French medical community held its first national meeting in 1845, it decided to erect a statue of Bichat in the forecourt of the Paris medical school on Rue de L’École de Médecine, the site of the most important medical institutions for 110 years. For over 55 years, French medicine dominated general developments worldwide, before passing on its pioneering role, if one wants to give it that title, to scientific medicine in Germany (Stahnisch 2012, pp. 131–74). Lyon-based physician Jean-Baptiste Montfalcon (1792–1874) described the Paris faculty—in keeping with the Grande Nation’s self-image at the time—as “the first in the universe” (Montfalcon 1826, p. 2). The development of the Paris medical clinic was also represented by a large number of prominent, influential physicians and surgeons. In traditional medical historiography, this has often led to the glorification of the individual achievements of these Parisian doctors, who, as intellectually brilliant and outstanding as they were, have served as pillar saints for a wide variety of approaches and disciplinary historiographies (Corlieu 1877). Although such a hagiographic medical history is certainly delusive and ill considered, the importance of individual doctors and medical societies to the development of new concepts and approaches in medicine in the Parisian context can hardly be neglected. It was both a special social milieu and a particular combination of large hospital wards, innovative diagnostic practices, new instruments, and the availability of pathological research and modern surgical training that enabled these groundbreaking contributions of progress-oriented Parisian physicians on the one hand, as well as complex socio-economic conditions, on the other hand, that led to the enormous developments and far-reaching successes of the Paris clinical method (Ackerknecht 1967, p. 129). These have become a mainstay of modern biomedicine up to our own times.

An exposé of influential Parisian pathological anatomists should commence here with François-Joseph-Victor Broussais (1772–1838), whose work acted as a major reference point for contemporary pathology, even though he did not count among the inner circle of the Parisian clinical school. Nevertheless, many of the efforts made by his scientific peers, as well as subsequent physicians, reflect on his actual standing in the medical community. Born in Saint-Malo in Brittany, Broussais first studied medicine at the Hôtel Dieu in his hometown and then at the École de Chirurgie Navale in the Atlantic naval port city of Brest. As a ship’s surgeon, he gained privileged access to numerous patients that he could observe for very long periods of time under controlled conditions. These assembled patient data later served him well for continued postgraduate investigations at the research-intensive medical faculty in Paris. Although Broussais, on the one hand, was inclined towards the localizationist view held by the new pathological anatomy paradigm of the Paris school since it represented an organ-related view of individual lesions of the body, his pathogenetic concept remained influenced, on the other hand, by the humoral pathological and iatrophysical attitudes of the past. In short, “even if all diseases manifested themselves locally”, the interaction of body fluids and the different irritabilities of the organs were crucial for understanding a disease and treating it (Broussais 1834, p. 155). Broussais located these ideas in his approach to “physiological medicine”, which offered a different theoretical framework for conventional medical treatment practice but was not yet experimentally oriented. This was closely based on the stimulus–response model of the Edinburgh doctor John Brown (1735–1788). Broussais’ therapeutic efforts primarily aimed to minimize damaging stimuli to the entire body, reflected impressively in the widespread practices of bloodletting and cupping (Duffin 1996, pp. 262–63).

Under his influence, there was a rapid increase in the use of leeches in southern France. In 1827 alone, there were around 33 million of them sucking the skin of the ailing French day and night, supposedly to restore the physiologically correct ratio of physical irritability (Williams 1994, pp. 213–20). However, Broussais’ “physiological medicine” at Montpellier made no explicit provisions for verifiable control of bodily functions as the basis of medical and therapeutic action, quite unlike what could be found in the Parisian clinical approach to pathological anatomy and later to physiological experimentation in laboratory medicine. His compatriot from Brittany, the internist and inventor of the stethoscope Théophile-René-Hyacinthe Laënnec, can even be seen as one of his most visible opponents when it came to attempting further systematic research on heart and lung diseases. Laënnec understood Broussais’ “physiological medicine” as yet another nosological system and a purely theoretical approach that did not elicit any hidden causes of disease. Working in Paris, Laënnec vehemently opposed Broussais’ ideas from Montpellier that local organ diseases could be treated through general applications to the human body such as cupping or bloodletting. Rather, he argued not only the cause but also the therapy of somatic diseases would have to be locally oriented (Lecadre 1868). The introduction of auscultation into clinical diagnostics in 1819 and the technical invention of the stethoscope by Laënnec to auscultate heart rhythm in living patients at their bedside were foundational moments in the modern clinical treatment of diseases of the chest (Laënnec 1819). As his friend the French pathologist Gaspard-Laurent Bayle (1774–1816) reported, Laënnec’s observation of children playing in the court of the Louvre likely gave him the idea for “a funnel” through which the beating heart’s sound could be transmitted by sound conduction (Duffin 1996, pp. 251–74). He adopted an idea, as simple and ingenious as it was, from the children he observed; they happened to build small funnels with large leaves or sheets of paper, holding them to their ears and scratching their outer side with leaf stems—an enormously entertaining play activity. Even if the history of medicine and science is full of such anecdotal episodes, such episodes are not entirely devoid of plausibility, as we have already seen from Auenbrugger’s example in Vienna (Gordon 1997). In addition to his diverse descriptions of sounds, rhythms, and the significance of changes in heart morphology, modern medicine also owes to Laënnec the concept of a wide variety of physiological and behavioral symptoms in the pathology of tuberculosis of the chest3. Laënnec worked over long periods at the Hôpital Necker (1816–22) and at the Charité (from 1822) in Paris. At the same time, he held the prestigious chair of medicine at the Collège de France. Today, almost all larger hospitals in France have a ward (unité de soins) named in his honor. Laënnec’s noteworthy fate is that he himself died early at the age of 45 from the disease he had most intensively studied during his scientific career—pulmonary tuberculosis. It was his particular contributions to clinically redirecting the medical profession’s concentration away from patients’ bodies exclusively and linking it to clinical diagnostic procedures at the bedside which were subsequently further developed in a variety of exemplary ways. Ackerknecht has alluded to the centrality and pioneering character of Laënnec’s work in relation to the epistemic and technological make-up of the Paris clinical method:

The symbol of the doctor from the Middle Ages until the 18th century was the urine glass. The symbol of the modern doctor is the stethoscope, one of the many contributions of the Clinical School of Paris between 1794 and 1848. Writing a history of this school seems a legitimate undertaking.

(Ackerknecht 1967, p. vii; author’s transl.)

The Parisian physician Jean-Baptiste Bouillaud belongs in the same category of bedside-trained, nosologically oriented, and diagnostically driven physicians as Laënnec. Even if his career was somewhat overshadowed by Laënnec’s own clinical and scientific successes, Bouillaud made significant contributions to the pathology of cardiac diseases himself and dedicated his career to the special study of stroke and apoplexy. He considered stroke to be a particularly suitable research tool, a kind of “natural experiment,” as it was called in the language of the time. Following Bichat’s earlier and pioneering work, pathological anatomists were already pointing out the noticeable and sharply defined foci of brain injury in apoplectic patients. Clinical researchers like Bouillaud now put two and two together by first observing and describing the clinical phenomena of apoplectic patients and then—following intensive postmortem autopsies—tracing them back to the specific lesions in the morphological substrate they observed. Bouillaud also made a name for himself as an aphasiologist when he described the various symptoms of speech and language pathologies and—even before Pierre-Paul Broca (1824–1880)—described the so-called motor speech center in the transition area from the frontal to the parietal lobe of the brain (see Figure 3). In contrast to Broca, however, his work was scarcely taken up internationally, and the so-called “Broca–Bouillaud Aphasia” remains a purely French idiom (Stahnisch 2024, pp. 12–14). Nevertheless, Bouillaud’s case can be seen as a vivid representation of how widely the localization paradigm had infiltrated clinical medicine in France; neighboring countries only noticed the “tip of the iceberg”, being widely receptive to aphasia research in neurology, psychology, and rehabilitation medicine (Schiller 1979, pp. 65–73).

Laënnec and Bouillaud, among many others, were all influenced by the organizational talent, empiricist emphasis, and natural science leaning of one medical teacher, Napoléon’s personal physician Jean-Nicolas Corvisart des Marest (1755–1821). Corvisart, who was born in French Champagne, was another leading figure in the anatomically–pathologically oriented Paris clinical school. His particular interest, like that of the aforementioned physicians, was in clinical diagnostics and therapeutic options for diseases of the chest. Early on, Corvisart pioneered and adopted the percussion method described by Auenbrugger in 1761 and published his writings in the French language in 1808 (Corvisart 1808) (see Figure 4). It is somewhat surprising that—from a scientific point of view incorporating the observations of multiple actors such as nurses, students, and other medical colleagues—he alone published a textbook on heart diseases, Nouvelle méthode pour reconnaitre les maladies internes de la poitrine (1808), in which he meticulously described pericarditis, cardiac dilatation, and its hypertrophy.

Once Napoléon appointed him as his personal physician in 1807, Corvisart constantly took part in his campaigns and was only rarely seen teaching at the Parisian faculty of medicine. Even after Napoléon’s political demise, the physician was soon reappointed as the highest-ranking doctor in the French medical system and, in this capacity, was constantly occupied henceforth with a diversity of social–medical administrative tasks (Lesch 1988, pp. 100–38). Countless prominent physicians were among his students, such as the psychiatrist Antoine Laurent Bayle (1799–1958), the internist Pierre Fidèle Bretonneau (1778–1862), and the surgeon Dupuytren, along with the influential natural historian and curator of the Musée Naturelle in Paris, Georges Cuvier (1769–1832). These well-known physicians and scientists of the Paris clinical school formed the significant community behind the “medical revolution”, and they represented various important steps according to which the clinical method came into being (Gross 1979, pp. 231–71). Further scientific and evidential rigor was introduced into clinical research and hospital medicine by the early biostatistician Pierre Charles Alexandre Louis (1787–1872). His work represented an important step during the transitional period to connect the introduction of the clinical localization method with the emergence of the new experimental methods of basic science in burgeoning institutional laboratories (Stahnisch 2008, pp. 72–99). In his study of the emergence of modern hospital medicine, Foucault underlined the importance of the statistical method in the development of evaluative, normative, and, to a certain extent, disciplinary medical procedures at the bedside since these involved recording the number of patients, the variety of their symptoms, and the temporal progression of their physical symptoms (Foucault 1996, pp. 137–85). Yet Louis’ name goes unmentioned by Foucault, even though he was one of the first clinicians to attempt a mathematical and statistical evaluation of large quantities of comparable disease phenomena and individual diseases. By this means, he tried to ascertain the postulated regularity of their natural course and reach a general classification of their character and typology. Louis worked primarily at the Paris Charité and at the Hôtel Dieu. His method of recording was used in the study of tuberculosis and typhus, for example. Louis was also one of the first to reject the widespread use of bloodletting in Paris hospitals as not only ineffective but even dangerous. He did so well before experimental physiologists could raise considerable, evidence-based doubts about this treatment practice (Morabia 1996, pp. 1327–33).

Quite exemplary in this respect was the prominent experimental physiologist at the Parisian Collège de France (see Figure 5) Claude Bernard (1813–1878), who notoriously voiced the new “war cry” of experimental physiology vis à vis the doubtful practices of clinical medicine:

I consider hospitals only as the entrance to scientific medicine; they are the first field of observation which a physician enters; but the true sanctuary of medical science is a laboratory; only there can he seek explanations of life in the normal and pathological states by means of experimental analysis.

(Bernard [1865] 1957, p. 146)

With Bernard’s provocative statement, major confrontational lines were drawn that have since become constitutive for modern medicine—somatic versus psychosomatic approaches; pathology versus physiology; research in humans versus animals; the suffering and ill individual versus the group collective of test persons; and the laboratory versus the clinic—which still have often not yet found coherent and substantial reintegration (Weisz 2006, pp. 210–26). The historical implications of this problematic field lie at the epistemological center of modern medical practice, a conundrum where the intricate relationship between science, technology, and clinical diagnostics needs to be analyzed with critical philosophical means.

Of course, it could be stated on the one hand that the clinical method as practiced by Laënnec, Bouillaud, and many others was itself a form of clinical medical science. In their research endeavors, they aimed to get to the bottom of the origins and causes of disease, using observational isolation, sophisticated investigative methods, new instruments like the stethoscope, and numerical frameworks to quantify the observational phenomena and sense data from their patients’ bedsides—viz. they were “getting to their bodies” (Stahnisch 2012, pp. 74–80). A variety of comparative observations were made about the morphological make-up and pathological value of specific lesions, while the pathophysiological development and nosological nature of observable phenomena in human diseases were given special consideration. Yet the representatives of the Paris clinical school were almost exclusively medical professionals and clinically active doctors who added their respective research portfolios to an often extensive load of clinical work and teaching at the École de Médecine and its collaborating academic hospitals. Apart from free access to anatomico-surgical dissection workshops and hospital morgues—for example, under the direction of Dupuytren’s surgical service at the old Hôtel Dieu—none of these medical research pioneers worked in a specifically carved out and staffed laboratory. These physician–investigators also did not resort to animal experiments except for in the study and occasional simulation of particular pathological processes of interest (Maulitz 1987, pp. 36–82). This is a surprising finding given the important successes in mechanical physics or certain areas of physiology that preceded the emergence of clinical medicine in Paris, including, for example, British natural philosopher William Harvey’s (1578–1657) discovery of the twofold blood circulation system (Fuchs 2001, pp. 43–64). This epistemic incompleteness of the picture drawn by the Parisian clinical method was also a concern expressed in the widely received study by John E. Lesch on “Science and Medicine in France”. It emphasized that basic scientists were certainly involved in the development of Parisian medicine, but they often played their role removed from the physicians who saw their patients at the bedside and communicated their findings to their scientific colleagues in a rather indirect way or through the mediation of assisting clinical physicians (Lesch 1984, pp. 97–99). Yet despite, for example, Louis’ critique of the quality of contemporary therapeutic practice and the soundness of given theoretical developments, it also needs to be noted that many of the health scientists of the time, often trained at Écoles de Santé, actively collaborated with doctors. They appeared as science administrators and as health commissioners in the French context—one in which the legacy of the Parisian clinical method is still tangible today.

5. Regarding the Aftermath of the “Parisian Clinical Method”

As a future-looking summary, it can be established that the thesis that the development of the “Paris Clinical Method” stood firmly on many scientific and medical developments of the 18th century, which then became integrated into a new socio-economic and political context, is not without foundation. In particular, the rituals, social standing, and scientific enterprises of elite medical culture in the making led to new ideological frameworks and innovative research techniques and clinical practices in the contemporary French medical community (La Berge and Hannaway 1998, pp. 1–10). In addition to its theoretical and systematic starting points in Hippocratic and Galenic medicine, Parisian medicine was born out of a network of diverse political and technological changes. It was based on techniques and concepts that were not only completely unknown in antiquity or early modern times but also based on the systematic physical examination of patients and reliant on all qualities of physical perception, in particular feeling and listening. The concept of structural lesions determined and guided their understanding of disease, and pathological anatomy promised to provide an integrative model of etiopathogenesis, i.e., the theory of the cause of disease. An early form of biostatistics provided an evidence-based epistemic framework and research culture through the contributions of Louis (Knorr-Cetina 1999, pp. 1–40)—namely working with tables, quantitative recording of how many patients suffered from certain diseases, and records of how many were given a variety of medications came into use in the first half of the 19th century. This is perhaps most visible in the case of the visiting clinical researcher Ludwig Traube (1818–1876). For this Berlin-based professor of clinical physiology who had trained for an extended period of time in Paris before his return back to Prussia, different epistemic levels of datasets, diagnostic repertoires, came to be united with new instrumentalist practices, such as fever thermometry, represented in the all-ubiquitous patient charts attached close to individual beds on hospital wards; he pioneered this practice on his return back from Paris (Hess 2000, pp. 39–47). Such important pioneering steps towards more sophisticated mathematical statistics paved the way for aspects of evidence-based medicine, modern biometry, and quantitative physiology as we know them in the field of biomedicine today (Bates 2000, pp. 502–18). And yet the period between 1794 and 1848 witnessed a major qualitative leap in medical and surgical education, as well as hospital-based patient care, in France. This development also led to the infiltration of academic medicine into almost every aspect of everyday life to an extent that had perhaps never been seen before and—perhaps most importantly—stretched medical care into the broadest sections of society (Szabo 2009, pp. 58–112). The different levels of care and demands of the sick in Paris’ hospitals could be summarized as follows:

The most important features of the Paris clinical method:

• The establishment of a specifically modern type of hospital.
• The use of the cadavers of marginalized and poor patients, who had died in hospital, for systematic dissection practices to help correlate their clinical symptoms with identified postmortem alterations.
• The development of pathological anatomy and its integration into medical education.
• A vast increase in bedside observations for diagnostic and nosological purposes, based on the new training formats of the externat and the internat at academic hospitals.
• Physical examination of patients, palpation, auscultation, and diagnostic instrument use became widespread standards in medical education and hospital care.
• A protostatistic numerical method was introduced, which bridged research and clinical endeavors between bedside observations and the emerging experimental physiology trend towards laboratory medicine.

The importance and impact of the Paris medical school was not limited to France itself. Rather, it developed an enormous international influence on the medical world: hospital medicine appeared in almost all larger European cities, such as Dublin in Ireland, London in England, and Vienna in Austria. The importance of Paris clinical medicine was highlighted by many international medical gazettes and journals, while the travel literature that the natural scientists and doctors who visited France left behind is legion (Warner 1998, pp. 32–75). International visitors included such prominent names as the physiologist Carl Vogt (1817–1895), the physiologist Moritz Schiff (1823–1896), the comparative anatomist Joseph von Gerlach (1820–1896), the internist Johann Ferdinand Heyfelder (1898–1969), the anatomist Hubert von Luschka (1820–1875), the surgeon and ophthalmologist Maximilian Joseph von Chelius (1794–1876), and the pathologist Friedrich Theodor von Frerichs (1819–1885). Larger hospitals were put in place after the 18th century in France’s neighboring countries; these were further developed to gradually resemble the organization and outlook of the Parisian hospitals in the home countries of medical visitors to the French capital. One of the first larger hospitals and academic training centers was the Berlin military training center of the Pépinière, which emerged in 1727 from an existing plague and pauper hospital (Schneck and Lammel 1995). A large medical hospital for the poor was founded in Braunschweig in 1780. Bamberg followed in 1789 with a sizable general hospital, and Munich did as well in 1810. The number of these large care and training hospitals increased exponentially until 1840 and was correlated with the growth of large cities in Europe and, increasingly, in North America as industrialization began to pick up speed (Warner 1998, pp. 330–64). Beside the enormous social impact of an individualized workforce made up of hundreds of thousands of young men and women from rural areas who had moved to large cities and were unable to find care within the social network family system in the event of illness, new types of illnesses emerged. At least some of these diseases now appeared with different quantities of cases: tuberculosis, typhus, and cholera killed tens of thousands of sick people in poor social housing conditions and caused the number of hospital patients to skyrocket by the second half of the 19th century (Szabo 2009, pp. 58–112).

6. Discussion

This article has offered a synoptic perspective of the historiography of medicine after the French Revolution by drawing on various implications, refinements, and inclusions of Erwin Ackerknecht’s highly influential work on Medicine at the Paris Hospital (1967). When looking closer at the socio-cultural contexts and organizational set-up of the Parisian clinical method as it emerged between the French Revolution at the end of the 18th century and the period of the Restoration towards the middle of the 19th century, many of the antecedents of the modern biomedical paradigm (which would change the landscape of clinical practice and medical research forever) become visible (Bates 2000, pp. 502–18). We have been able to follow and address the development of the clinical model in France during the 18th century while also noting the expansion of French academic medicine alongside (and in conversation with) developments in Great Britain and Germany. The “Rapport et projet de décret sur l’établissement d’une École centrale de Santé à Paris” (Fourcroy 1794) by the French clinician and naturalist Fourcroy marked the beginning of a groundbreaking development that was about to transform medical training and clinical care in France. From there, the new paradigm spread to many other countries across the globe.

As was the case in France’s overcrowded hospitals in bigger cities and urban centers with their specialized departments for infectious diseases and surgical care, specialized medical institutions allowed for detailed and frequent clinical observations, postmortem dissection studies, and later also the experimental identification and analysis of large quantities of “sick material”, as it was euphemistically called in the parlance of the time. Patients, who were often socially uprooted, not affluent, and vulnerable, had hardly any personal rights; obtaining permission to perform an autopsy after their death in a hospital or mental asylum did not pose a major obstacle for their doctors. The medical culture of the time was based on a severe power differential, paternalistic value systems, and a science-driven system in which patients had hardly any say about their treatment plans, the procedures performed, or the conditions of their discharge. Such was the frame of reference in which there existed an over-concentration on hospital medicine. The historical implications of the Paris clinical school, nevertheless, are that it offered organizational and scientific opportunities for a progressive trend towards the subspecialization of medicine in the later 19th century—a trend that followed a steep rise in scientific findings, hospital data, and administrative tasks, which made the success and growth of the modern biomedical enterprise manageable (Weisz 2006, pp. 210–26). Initial progress happened in the areas of internal medicine, psychiatry, dermatology, geriatrics, and forensic medicine during the period assessed in this article. However, from 1850 onward, the triumph of laboratory medicine extended to microbiologist Louis Pasteur’s (1822–1895) “revolution” in medicine after the French defeat in the Franco-Prussian War of 1870–71 (Latour 1988, pp. 111–45). Often at the expense of hospitalized patients, Parisian academic medicine, and its clinical paradigm around 1800, developed into a beacon of science in which the “clinical method” came to be based on new observational practices informed by surgical learning, strengthened through statistical data, and connected to a pathological understanding of human morphology. The re-entry of the patient perspective, communitarian ethics values, and community-engaged science, however, would be delayed for almost two centuries because the social and ecological contexts of disease following the late 18th century vigorously suppressed patients’ voices, superelevated doctors’ hierarchical positions, and led to an inconsistent paternalist ethics framework in everyday medical practice.