Saturday, August 13, 2011

American Medical Students in 19th Century Paris

‘It’s no trifle to be a medical student in Paris’
American Medical Students in 19th Century Paris
by Doug Capra © 2011
This spring I read a fascinating book, The Greater Journey: Americans in Paris, by David McCullough. It chronicles American intellectuals in Paris from about 1830 to 1900. McCullough focuses on painters and artists, but he does cover other professions. It’s interesting to see how this experience changed them and how it influenced the development of this country in many ways.
At this point you may be wondering what all this has to do with the history of medicine, and with modesty and privacy in particular. Chapter 4 is titled “The Medicals.” It tells the story of American medical students who traveled to Paris to study because that was the place to be. Why Paris became the center of medical education is a long story best told in another post. It’s disappointing that McCullough doesn’t even touch on this story. In brief, after the French Revolution, the hospitals were secularized. Before that, many had been run by religious orders. The ethic and medical worldview changed and, in essence, medical students and doctors finally had almost unlimited access to bodies, both living and dead.
“It’s no trifle to be a medical student in Paris,” wrote Oliver Wendell Holmes. McCullough points out that Paris offered at least two advantages over medical studies in the U.S. First of all, in Paris, medical students had “ample opportunity to examine female patients as well as men.” In America, “most women would have preferred to die than have a physician – a man – examine their bodies.” In reality, many women did die because of this, and American medical students’ knowledge of female anatomy came mostly from books. McCullough’s source for this is a book published in 1848 by surgeon Augustus Gordon, Old Wine in New Bottles: Spare Hours of a Student in Paris. Wanting to delve deeper into McCullough’s sources, I read Gordon’s book.
The flight of so many talented American medical students to Paris –frankly, only those who could afford it – did concern leaders in American medicine. A Philadelphia surgeon, Gardner, visited Paris to observe the medical education system. “The French woman…knows nothing at all of this queasy sensibility,” he wrote. “She has no hesitation, not only to describe, but to permit her physician to see every complaint.” Interestingly, this modesty issue seems to be one of the major reasons for wealthy American medical students to go to Paris. “In this respect,” wrote Gardner, “the Paris educated physician enjoys superior advantage to the homebred man.”
The second advantage of a Paris medical education involved the “supply of cadavers for dissection.” In the U.S. dead bodies were expensive and difficult to obtain. In fact, trade in dead bodies had been illegal in Massachusetts until after 1831. Medical involvement in grave robbing wasn’t uncommon. Doctors and medical students could get bodies of those who died in prison or who were executed, or, in the South, the bodies of slaves. But it was still difficult.
In Paris, it was claimed that even those about to die in hospitals were “aware of their fate,” knowing and accepting they were headed to dissecting room. Due to disease and poverty, cadavers were cheap – about $2.50 or an adult and less for a child. An American medical student living in the Latin Quarter, described watching carts full of naked bodies, men and women – dumped, “as you do a cord of wood upon the pavement,” to be distributed to the dissecting rooms. Six hundred students could work at the same time at the Amphitheatre d’Anatomie at the Hospital de la Pitie. Gardner observed that the blood and pieces of flesh on the floor are regarded “as the sculptor does the fragments of marble lying round the unfinished statue.” Caged dogs were kept outside and fed the discards. In summer, the heat and stench was so bad that dissecting was suspended.
Students and observers like Gardner, took instruction from such noted female obstetricians, called sage femmes, as Madame Marie-Louise La Chapelle. For the first time, these male medical students and doctors were allowed to examine with their hands the wombs of pregnant women. Student Henry Bowditch said he “learned more about midwifery from Madame La Chapelle in her private course than he had in three years at the Harvard Medical School. Oliver Wendell Holmes saw La Chapelle – as did other American medical students -- as a good argument for allowing women to study medicine. Americans also saw students of color studying medicine successfully, and that convinced many of them that American blacks were capable of being doctors.
Gardner wrote of his experience studying midwifery:
“Whenever a female is in labor, a signal is placed at the door indicating this fact. All, who see the notice, enter. The first comer is the accoucheur under the direction of the resident sage-femme. Around the bed, railings keep off the multitude, who often number fifty or more. I have seen the room crowded during the performance of such operations… The patient is uncovered as the labor advances, for the benefit of those around. How many of the very lowest classes in the United States would be thus willingly exposed? Yet hither quite decent women are frequently brought…” (203)
I want to point out that the medical perspective is that these female patients don’t really care about all this exposure. But that’s the medical perspective. We never get the patient perspective. I grant that mores and cultures differ as to modesty. Perhaps these women didn’t care one way or the other. But Gardner makes another statement that I believe is enlightening – a quote that McCullough leaves out – a perspective we must understand if we want to really compare modesty in France and the U.S. at this time period. He writes:
“Every patient who enters a hospital is, in a certain degree, Government property, and, not only through life, but even after death, is subject, in some cases, to the control of the physician. Thus science is benefited by the post-mortem examination, which is made of every disease that is marked with anything peculiar, whether objected to by friends or not. (161).”
I want to make it clear – these medical students in Paris brought back many positive medical techniques. They saved many lives and dramatically improved the quality of medical training in the U.S. The were heros during serious epidemics and helped the wounded during the Franco-Prussian War. They studied under celebrated teachers like Pierre-Charles Alexandre Louis who was known, even ridiculed “for his extended questioning of patients, his slow, careful examinations and endless note-taking.” He insisted on precise observations, that is, really listening to what the patient had to say. He encouraged careful use of the stethoscope, an instrument invented in 1819 by French physician Rene Laennec. I’m not implying at all that this Paris medical education was not positive. Most of it enriched the medical culture of this country and contributed to better lives for Americans.
According to McCullough, between 1830 and 1860, nearly 700 American students came to Paris to study medicine. And most of these would have come from wealthy, influential families -- thus, many of not most would have been leaders in the American medical field.
It was said of Mason Warren -- "Apart from all other considerations, the mere fact that of his long absence in Europe caused a degree of importance to be attached to him, as in those days few of our countrymen traveled abroad..."
McCullough writes: "Decades later, in the 1890's, William Osler, one of the founders of the John Hopkins Medical School and as respected a figure as any in American medicine, would write that 'modern scientific medicine' had had 'its rise in France in the early days of this century.' More than any others, it was the pupils of Pierre Louis who gave 'impetus' to the scientific study of medicine in the United States."
Seventy of those who had trained in Paris, one out of three, taught in American medical schools.
-- William Gibson became chief of surgery at University of Pennsylvania.
-- Henry Williams became the first professor of ophthalmology at Harvard. He later wrote three important books on diseases of the eyes.
-- George Shattuck became dean of Harvard Medical School.
-- Henry Bowditch became professor of clinical medicine at Harvard. He was an expert in diseases of the chest, especially T.B. He published a book, The Young Stethoscopist, in 1846, used by medical students until the early 20th century.
I could go on and on. These men created modern scientific American medicine and ended up saving and improving thousands and thousands of lives.
But these American doctors, I’m suggesting, may also have brought back other, less positive attitudes and perhaps behaviors. Modesty shouldn’t matter at all. Once you’re in the hospital, you are really there, not just to get well, but for the benefit of science, and you need to accept the fact that you’re a teaching tool and may be observed, in any state of undress, by whomever few we see fit to permit access. Modesty is an old fashion, not worthy of modern human beings, especially when it comes to medical treatment. We know this attitude isn’t part of the codes of conduct or core values of the profession or the hospitals in which they work. We know it’s not the ideal. But the system isn’t perfect
We see this attitude in some literature of the later 19th and early 20th century. In Chapter 1 of Part 2 of Anna Karenina (1873-77) by Leo Tolstoy. Eighteen-year-old Kitty has been ill throughout the winter and she gets worse as spring arrives. The first two older, family doctors do nothing but give her cod liver oil, iron, and nitrate of silver. They perform no examination. The family doctor recommends a “celebrated physician” be called. Tolstoy writes:
“The celebrated physician, a very handsome man, still youngish, asked to examine the patient. He maintained, with peculiar satisfaction, it seemed, that maiden modesty is a mere relic of barbarism, and that nothing could be more natural than for a man still youngish to handle a young girl naked. He thought it natural because he did it every day, and felt and thought, as it seemed to him, no harm as he did it and consequently he considered modesty in the girl not merely as a relic of barbarism, but also as an insult to himself.”
Here we begin to see this new gender-neutral worldview emerging. It’s never stated outright, but the fact that he is a young doctor, newly trained, and “celebrated” indicates that he was foreign trained, most likely in Paris. That Tolstoy says he maintains his position with ”particular satisfaction” underscores his condescending attitude. Modesty is for barbarians, the uneducated, uncivilized masses – for the “herd,” as Nietzsche might say. It’s the “I do this every day. There’ s nothing you have that I haven’t seen” attitude we sometimes see even today. A patent exhibiting modesty represents an insult to this doctor’s status, to his moral and intellectual superiority. No respect is shown to the patient, nor is the patient’s dignity preserved. Everybody in Kitty’s family is uncomfortable with what the “celebrated physician” wants to do, even the family doctor, but they reluctantly agree. Tolstoy continues:
“There was nothing for it but to submit, since, although all the doctors had studied in the same school, had read the same books, and learned the same science, and though some people said this celebrated doctor was a bad doctor, in the princess's household and circle it was for some reason accepted that this celebrated doctor alone had some special knowledge, and that he alone could save Kitty. After a careful examination and sounding of the bewildered patient, dazed with shame, the celebrated doctor, having scrupulously washed his hands, was standing in the drawing room talking to the prince.”
The doctors confer alone. The family doctor starts to give his opinion. “The celebrated doctor listened to him, and in the middle of his sentence looked at his big gold watch. "Yes," said he. "But..." The whole issue of the value of this “celebrated” doctor’s time is brought up with the symbol of his “big gold watch.” The family is called in for the results and Tolstoy writes: “The celebrated doctor announced to the princess (a feeling of what was due from him dictated his doing so) that he ought to see the patient once more. "What! another examination!" cried the mother, with horror. "Oh, no, only a few details, princess." "Come this way." And the mother, accompanied by the doctor, went into the drawing room to Kitty. Wasted and flushed, with a peculiar glitter in her eyes, left there by the agony of shame she had been put through, Kitty stood in the middle of the room. When the doctor came in she flushed crimson, and her eyes filled with tears.”
Here we see clearly the gender neutral, patient as object worldview that a significant number of these Paris trained doctors brought back to their countries. That view hasn’t disappeared today. Indeed, I might suggest that with the introduction of all the technology today, sometimes the patient is viewed more as an xray or an ultrasound, than as a person. Sometimes doctors spend more time with “images” of the patient than with the patient him or herself.
For another example of a more idealistic young Paris-trained doctor, Tertius Lydgate, read George Eliot’s (Mary Anne Evans) Middlemarch (1872). Interestingly, British sensibilities would never allow a Victorian female novelist to write as bluntly as Tolstoy does about the physical examination of a young girl. With Lydgate, we see more of the positive gifts such Paris-trained doctors brought back to their countries.
There has always been a dark side to science and medicine. The data gathered by some Nazi, Japanese, and, yes, even American doctors using unethical, immoral procedures on unsuspecting or coerced patients – that data could be very useful to save lives. Do we use it? Or do we discard it because of how it was obtained? As long as a patient is cured, a life is saved, a baby born alive and healthy – is that all that matters? Or is preserving the patient’s dignity, privacy, and modesty equally important as the end result? Do the ends justify the means?
This worldview I’ve highlighted has not disappeared from American medicine. It’s still out there. But medicine is dramatically changing as write with a new generation of doctors and nurses entering the field. How they’re trained, the cultural assumptions behind the training, is as important as the technical medical information they learn. How they are taught to complete exams and procedures, the human aspects of human contact, is as important as the scientific information they need to save lives. And this training isn’t just embedded in their formal schooling. It’s also intimately embedded in the culture within the institution where they work, and within the general culture of our society.
The hidden curriculum, what they learn day to day from their supervisors and colleagues, what they learn from our media, is as important as what they learned in their formal training.