Science and the City (Osiris Series/18) available in Paperback
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Seeking to unite the history of science and urban history, this book emphasizes the active role cities play in shaping both scientific practice and scientific knowledge. Furthermore, the authors argue that cities themselves have to be viewed as mediated by science. Four interconnections of science and the city are discussed: the relationship between scientific expertise and urban politics; science's role in the cultural representation of the city; the embedment of scientific activity in the city's social and material infrastructure; and the interaction between science and everyday urban life.
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Osiris, Volume 18
SCIENCE AND THE CITY
The University of Chicago Press
Copyright © 2003 The University of Chicago Press
All right reserved.
The City of Paris and the Rise of Clinical Medicine
By Dora B. Weiner and Michael J. Sauter
This article argues that the city of Paris played a unique role in shaping clinical medicine at the Paris hospital at the turn of the nineteenth century. Under outstanding clinicians such as Corvisart, Pinel, Bichat, Desault, Alibert, Bayle, and Laennec, who headed the "Paris School," teaching and research became hospital-based. New methods such as percussion, mediate auscultation, and psychological evaluation were introduced, and autopsies became routine. Chaptal, a physician and minister of internal affairs under the Consulate, played a key role by creating the Paris Hospital and Health Councils, the Central Pharmacy, and central triage for hospital admissions. These municipal councils supervised the practice and teaching of anatomo-clinical medicine and the concomitant social changes involved in the delivery of health care to a city of six hundred thousand inhabitants. These changes included the orderly provision of bodies for dissection, the subordination of nurses to physicians, the teaching of preclinical courses, and the adaptaion of the confiscated religious buildings to house patients grouped according to their diseases. The new arrangements fostered the rise of medical specialties, including public health, practiced by hygienists who turned Paris itself into a patient.
THE "PARIS SCHOOL"
At the turn of the nineteenth century, the city of Paris played a unique and prominent part in shaping clinical medicine. In the city's twenty modernized hospitals, crucial aspects of modern medicine were elaborated through the research and teaching of the "Paris School," the innovative group of clinicians headed by Corvisart, Pinel, Bichat, Desault, Alibert, Bayle, and Laennec. Long acclaimed for creating modern medicine at the Paris hospital, these men taught the new methods of physical examination, percussion and auscultation, and thus the anatomo-clinical method of diagnosis flourished.
Despite the large number and diverse pursuits of these doctors, Paris's intellectual agora was (and remains) quite intimate: starting from the St. Michel fountain, for example, and walking up the boulevard St. Michel for five minutes, one is two streets away from the Sorbonne and the Collège de France to the east or from the old medical faculty to the west. From there, it is but a quarter-hour's walk to the Academy of Sciences, unless one stops at the legendary "Procope" for a meal.
Owing to the Revolution, all sorts of traditional limitations vanished, and documents of the 1790s reveal the excitement of Revolutionary reformers about the opportunity to innovate. Paris's academies, botanical gardens, colleges, theaters, salons and cafés had long attracted both Frenchmen and foreigners. European thinkers, scientists and physicians, such as Alexander von Humboldt, Gall, and Hahnemann, sought the approval of the Paris scientific world as the ultimate arbiter of their work. In the discussion of these issues, as in the design and implementation of reforms, the intellectual climate in Paris and the interconnectedness of doctors, scientists, and reformers was key. The Parisian medical, scientific, and intellectual elites constantly stimulated each other. Scientific journals and publishers abounded. One result was the emergence of a new group of professionals, the hygienists, who developed that quintessentially modern notion of the city itself as a patient. The presence of so many talented and enterprising doctors and so many opportunities for innovation at a time of deep socioeconomic and political change accounts for the unique phenomenon of the "Paris School."
In London, in contrast to Paris, the medical world was fragmented into "pockets of research," as Georg Weisz has recently argued. Though larger than Paris, the English capital lacked a medical school, a center where students intermingle, and the numerous well-endowed voluntary hospitals-Guy's, Westminster, St. George's, St. Bartholomew's, St. Thomas's, Middlesex, London-taught students in a competitive arrangement. Oxford and Cambridge harbored the intellectual elite, and Edinburgh, though small and distant, lured away many British students.
In Vienna, the other Continental capital where clinical teaching flourished, a reticence to appreciate the unusual seems to have stifled progress, despite spectacular medical reforms by Emperor Joseph II. Take the example of Leopold Auenbrugger (1722-1809), who published Inventum novum in 1761, describing the new method of percussion. Neither Gerard Van Swieten nor Anton De Haen, the leading professors of the "First Vienna Clinical School," ever mentioned him in their writings. Only after Nicolas Corvisart (1755-1821), the prominent Paris clinician, translated Auenbrugger's book into French in 1808 did percussion become world famous.
To be sure, Paris did not invent bedside teaching but continued a tradition that had begun in Padua in the sixteenth century and spread to all major Western cities. And brilliant inventions of the Paris School, such as Bichat's famous formulation of tissue pathology and Pinel's psychologic treatment of the mentally ill, had roots deep in the Enlightenment, in France and abroad. The controversy over the importance of Paris in the rise of clinical medicine began some forty years ago with the publication of Michel Foucault's Birth of the Clinic (first published in French in 1963 and translated into English in 1975), with his provocative indictment detailing the doctors' presumed bid for power over the hospitalized indigent patient, in the Paris clinic and in the asylum. Erwin H. Ackerknecht's Medicine at the Paris Hospital (published in 1967) may well have given Revolutionary Paris doctors credit for developments that had begun earlier or abroad. These two arguments are documented by Lawrence Brockliss and Colin Jones (1997), who underlined Paris's debt to the Englightenment, by Othmar Keel, who showed how much the Paris School owed to research done in London, especially by John Hunter (1728-1793), and they are further explored in a recent collection of essays, Constructing Paris Medicine. Keel mistakenly implies that Foucault's condemation of doctors expresses the consensus of historians of medicine.
But why single out Paris for an inquiry into the field of anatomo-clinical medicine? The question is more novel than may at first appear. While many scholars have identified the French capital as a likely incubator for innovation, few have concentrated on understanding Paris, the city, as a site for creating medical knowledge. We need to consider the French capital as a particular place, filled with tensions, opportunities, and obstacles, some of which created the Revolution, others that were fashioned by it. In this narrower context, two factors emerge as determinative: first, the Old Regime's medical infrastructure. Paris bequeathed to modern researchers buildings and bodies. Many of the buildings were inappropriate for medicine and unwieldy, conditions that induced architectural adaptation and reform. As for bodies, Paris was the largest city on the European continent-three times the size of Vienna or Berlin-and it usually harbored about six thousand indigent and acutely ill patients who needed hospitalization in public institutions. The Revolutionary government established new regulations that made such patients accessible for examination and, if they died, their cadavers available for necropsy in numbers never equaled anywhere. Nobody questioned the use of pauper patients for teaching purposes nor did anyone protest the use of unclaimed corpses for the study of anatomy and dissection. These bodies, both living and dead, were absolutely essential to the research and teaching of the Paris School.
The second inducement to innovation was the dispersal of medicine's largely medieval organizational forms. The Revolution broke the religious orders' hold over hospitals. Whereas the nuns had often kept researchers away from patients, after 1789 the hospitals' civilian administrators favored their close observation. The Revolution also broke the ossified Paris Medical Faculty's hold on medicine. Traditionally, professors had emphasized commenting on medical texts, and students hardly ever saw a patient. The Revolution brought radical change through the development of "free" instruction, in which students learned at bedside, rather than in the lecture hall. Since the government now gave physicians-in-chief considerable leeway to follow their own teaching methods and research interests, hospitals specialized and accommodated patients according to medical criteria. Eventually, France's postrevolutionary governments provided the final push toward modernization by creating centralized bodies that regulated the new practices (though not always for the better).
Paris was not the only large city to produce medical innovation. But the unparalleled opportunity to rebuild after the Revolution, the lively state of science and medicine, and their intimate interdependence were special to Paris; together these factors created a new medical world, the one in which we still live. In the following essay, we explore the establishment of a unique relationship between the city of Paris and clinical medicine. In "From the Old Regime to the Republic," we explore four topics: 1) the proliferation of anatomy courses in Paris, due in part to the unique availability of bodies for dissection; 2) the Revolution's impact on Catholic hospitals and nurses; 3) the consequences of war for medical education; and 4) the role of architectural adaptations in shaping modern medicine. Many of these developments apply to France in its entirety. All are strikingly clear in Paris.
FROM THE OLD REGIME TO THE REPUBLIC
By the mid-eighteenth century, dissecting a human body was the well-established manner of learning anatomy and surgery. Paris at midcentury boasted an enlightened and progressive community of surgeons and attracted hundreds of young men to the study of anatomy and dissection in preparation for a career in the medical sciences. Their field was enriched by the pathological anatomy of Giovanni Battista Morgagni (1682-1771), whose writings taught that a disease had its "seat" in an organ and that postmortem study could confirm previous clinical observation. But it was the Paris hospital, with its thousands of approachable patients and available cadavers, that transformed these insights into the anatomo-clinical method-a method of observation, analysis, and teaching. Paris offered a unique combination of advantages that fostered research in this field, not least among them an extraordinarily high mortality: the Paris Hôtel-Dieu alone registered more than five thousand deaths a year, ensuring a continuing supply of bodies for dissection. In the words of Pierre Huard: "From the mid-18th century on, Paris was the capital of the cadaver."
Anatomy was officially taught at the Hôtel-Dieu by chief surgeon Pierre Joseph Desault (1728-1795) and by the staff at the Hospice of the College of Surgery. In addition, the Practical Dissection School had trained students since 1750. Its enrollment rose from 24 students when it was founded to 120 in 1799. But the demand far exceeded the space available for official courses, and therefore private dissection classes abounded: anyone could rent a floor in some shabby house, draw the shades, and set to work. Desault himself began running one in 1766; he had room for fifty to sixty cadavers and attracted more than 200 students. After the Revolution, Xavier Bichat (1771-1802) continued this tradition, supervising 130 students, four to a cadaver. But where did the surgeons find the hundreds of bodies needed for this instruction?
The quest for legal "subjects" had a long history, but no amount of bodies for dissection ever satisfied the insatiable demand. Some medical scientists benefited from royal favors: thus the Paris faculty had a traditional right to the bodies of deceased prisoners; the corporation of surgeons as well as the researchers at the Jardin du roi had private and confidential arrangements with the Salpêtrière. Yet even under the Republic, the government could only raise limited supplies. These insufficient legal arrangements were dwarfed by the power of money, as the laws of supply and demand funneled cadavers to the private anatomy courses. Documentation from police archives and courts points to the existence of an illicit network connecting gravediggers at the Clamart and Ste Catherine cemeteries (the main burial grounds for Hôtel-Dieu patients) with owners of cabriolets and coaches (preferably those with curtains), and corrupt policemen or gendarmes. Among the stories of graverobbers is that of Bichat and his helpers, apprehended on November 25, 1797. "The justice of the peace let them go," reads the document, "upon their promise to come back to the court, if called." That the law respected the needs of medicine suggests how important medical research had become to the city.
The courts might not wish to hinder medical research, but concern for cleanliness within the city led to public health measures that did interfere with the gruesome trade in cadavers. The municipal government gradually replaced urban cemeteries with new ones located out of town, such as the Père Lachaise (opened 1804). Suppliers now had to go as far as Bicêtre or the workhouse at St. Denis to fetch their merchandise. How could the private courses and laboratories manage, if even the medical school lacked cadavers? The street map of the area around the Place Maubert near the Hôtel-Dieu suggests a likely answer: the dissection schools were all located a few steps from the rue de la Bûcherie. (See Figure 1.) Consider the addresses: rue des Lavandières (Desault's school), rue des Carmes (Bichat's laboratory), rue des Anglais, des trois Portes, de la Huchette, du Fouarre, du Coeur Volant. A large heavy door on the rue de la Bûcherie led to the hall where the Hôtel-Dieu collected its dead and sewed them into sacks.
Even though a secret black market can never be documented, all signs point to the Hôtel-Dieu as the source of thousands of bodies. This suggestion finds authoritative confirmation from Jacques Tenon (1724-1816), who served as professor of pathology at the College of Surgery. In Observations on the Obstacles to Progress in Anatomy, a memoir read to the Académie des sciences in 1785, he proposed that a study hall for students be established at the Hôtel-Dieu, next door to its morgue, to facilitate their access to cadavers. Cadavers, he knew from his years of apprenticeship, were plentiful at the Hôtel-Dieu, and there were always willing buyers. Given this powerful convergence of interests, there can be little doubt that thousands of cadavers dissected in the amphitheaters came through the Hôtel-Dieu's back door. Moreover, as Tenon's paper was given before an official body, it is likely that this brisk trade occurred with the government's connivance.
The trade in cadavers must have involved some hospital personnel. However, we cannot document the participation of the nurses who administered the Hôtel-Dieu and staffed all important position. All hospital nursing under the Old Regime had been performed by female and male religious orders, with the exception of those carried out by lay officières at the General Hospital. (The revolutionaries did not bother them.) The Augustinian sisters staffed the municipal Hôtel-Dieu, and they owned four nursing homes, one of them vast enough that city officials would eventually choose it as the site for the Père Lachaise cemetery. Another order, the Brothers of Charity, owned and staffed Charité Hospital, the model institution according to Tenon. The largest order, the Sisters of Charity, served where they were needed, with each community contracting individually for services.
Despite the orders' usefulness, the revolutionaries deracinated the entire medieval medical tradition. They confiscated all forty-eight Paris hospitals and hospices not al ready owned by the city, such as the Hôtel-Dieu, and permanently closed twenty-eight of them. These were mainly small charitable establishments such as nursing homes, day-care centers, and shelters. The remaining institutions were reorganized. In the 1790s, for example, when the entire lying-in service of the Hôtel-Dieu was permanently transferred to healthier surroundings at the periphery of Paris, pregnant women, new mothers, newborns, and foundlings all settled into new homes in former religious buildings. As for the nurses, the revolutionaries expelled the Augustinians, dispossessed the Brothers, and dispersed the Sisters of Charity. Henceforth, the sick wards would be free of the ubiquitous altars-and the dying of priestly consolation.
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Table of Contents
SVEN DIERIG, JENS LACHMUND, AND ANDREW MENDELSOHN: Introduction: Toward an Urban History of Science
SCIENCE AND THE RISE OF MODERN CITIES
DORA WEINER AND MICHAEL SAUTER: The City of Paris and the Rise of Clinical Medicine
DENISE PHILLIPS: Friends of Nature: Urban Sociability and Regional Natural History in Dresden, 1800-1850
FA-TI FAN: Science in a Chinese Entrepot: British Naturalists and their Chinese Associates in Old Canton
DAVID AUBIN: The Fading Star of the Paris Observatory in the Nineteenth Century: Astronomers Urban Culture of Circulation and Observation
THERESA LEVITT: Organizing Sight, Seeing Organization: The Diverging Optical Possibilities of City and Country
SVEN DIERIG: Engines for Experiment: Laboratory Revolution and Industrial Labor in the Nineteenth-Century City
ANTOINE PICON: Nineteenth-Century Cartography and the Urban Ideal in Paris
J. ANDREW MENDELSOHN: The Microscopist of Modern Life
SCIENCE AND THE CITY AFTER 1900
KARIN BIJSTERVELD: "The City of Din": Decibels, Noise and Neighbors in the Netherlands, 1910-1980
HANS POLS: Anomie in the Metropolis: The City in American Sociology and Psychiatry
CHRISTIAN TOPALOV: "Traditional Working-Class Neighborhoods:" An Inquiry into the Emergence of a Sociological Model in the 1950s and 1960s
JENS LACHMUND: Exploring the City of Rubble: Botanical Fieldwork in Bombed Cities in Germany after World War II
ROSEMARY WAKEMAN: Dreaming the New Atlantis: Science and the Planning of Technopolis, 1955-1985