In the hospital it was his practice to submit to the students for

inspection and consideration only the most serious and the most typical

cases. From the bedside he went, in company with the entire class, to

the amphitheatre, and there entered upon a more complete description and

discussion of what they had witnessed in the ward. If the patient died,

then he took them with him to the dead-house and showed them whatever

the autopsy revealed. Before doing so, however, he read to them a brief

history of the case, in order to refresh their memory. Then, after the

autopsy had been completed, he reviewed and compared the two sets of

facts. As the author of this particular eulogy remarks, “One can imagine

with what intense interest the students followed this last act in the

course of instruction which Corvisart gave them.”

When Bonaparte was made Emperor of France one of his early acts was to

appoint Corvisart, who had been instrumental in effecting his recovery

from a serious pulmonary attack, his First Physician. This position was

not, as might easily be imagined, that of a mere personal adviser; it

was a much more important office, or at least it became so in the hands

of Dr. Corvisart. He felt very strongly that he must use this great

increase in his personal influence, not for himself nor for his

immediate circle of friends, but for the benefit of the nation and for

the advancement of the science of medicine. As an illustration of the

spirit in which Corvisart interpreted the attitude which he should

maintain in the face of his new responsibilities I will mention the

following incident:—On one occasion, when the Emperor startled him with

the announcement that he held in his hands the official appointment of

his brother to a position connected with the Government, Corvisart

remarked: “Allow me, your Majesty, to decline, for my brother, this

position; he does not possess the necessary capacity. I know that he is

poor, but that is a matter which concerns only myself.” After Corvisart

left the room Napoleon, turning to one of his ministers who happened to

be present, asked him: “Do you know of many men like this man?” On

another occasion, when Corvisart happened to be the subject of

conversation, the Emperor remarked: “He is an honest and skilful man,

but a little brusque.”

Among his numerous acts of generosity toward his friends and benefactors

there were some which showed that he did not forget his teachers nor

even the hospitals. He established at _l’École de Médecine_ a prize fund

which had for its purpose to aid those who found it impossible, through

lack of funds, to continue their scientific experiments.

Finally, it should not be forgotten that it was Corvisart who suggested

to Bonaparte,[22] the First Consul, the propriety of erecting at

Hôtel-Dieu the monument in honor of Desault and Bichat. (See page 167.)

By reason of the various responsibilities which very soon began to

burden Corvisart he was obliged to give up, one after the other, his

clinical teaching and finally his practice; it had become impossible for

him to do justice to so many things. Thus, he resigned his Chair of

Clinical Medicine in 1807, and in 1814, after the fall of Napoleon, he

retired to his countryseat, where he hoped to regain in some measure the

health which had begun to break down under the numerous burdens which he

had been carrying. His death occurred on September 18, 1821.

From among the comments that were published by his contemporaries soon

after Corvisart’s death I select the following as well adapted to

complete the portrait of this remarkable man:—

Among his professional brethren Corvisart was admitted to have gained a

high degree of skill in the power to diagnose diseases of the chest by

means of percussion, and especially to have advanced our knowledge of

affections of the heart and its annexes. No less important are the

services which he rendered to physicians through his valuable and

inspiriting clinical teaching. It was particularly in this form of

teaching that he showed in what a rare degree he possessed the power of

interesting his auditors in the case which happened to be at that moment

under consideration. Corvisart was equally successful as a teacher of

pathological anatomy, and nobody, since the time of Bichat, did more

than he to develop in France the love of researches in pathological

anatomy. However, despite their fascination with the study of the

pathological lesions presented by the different organs of the body after

death, these pupils rarely seemed anxious to harmonize them with the

symptoms manifested by the patient during his lifetime. They persisted

in forgetting the remarks made by their teacher on this very point, to

wit:—

The most desirable thing, the thing which we should particularly

strive to find out because it is that which is most important in

practical medicine, is not what are the peculiarities

discernible in the cadaver, but to recognize the existence of

these pathological lesions from certain signs and symptoms

manifested during life.

The only works which Corvisart has handed down to posterity are the

following:—

“Essai sur les maladies et les lésions organiques du coeur et

des gros vaisseaux,” Paris, 1806. (3d edition, 1818.)

“Nouvelle méthode pour reconnaître les maladies internes de la

poitrine, par la percussion de cette cavité,” par Auenbrugger;

ouvrage traduit du latin et commenté par J. N. Corvisart, Paris,

1808.

Corvisart’s comments constitute a large and important part of the book

last mentioned, and virtually make of it an original work by Corvisart.

Auenbrugger’s original treatise was published in 1763 and was then,

according to Dezeimeris, entirely forgotten, notwithstanding the fact

that in 1770 it was translated into French by Rozière de la Chassagne.

Auenbrugger was the first physician who recognized the fact that, by

percussion of the walls of the chest, a diagnosis may be made of some of

the diseases affecting the organs contained therein. Corvisart practiced

Auenbrugger’s percussion method during a period of twenty years and was

in the habit of demonstrating it to the numerous students who attended

his courses in clinical medicine. It was this long experience in the

practice of percussion that enabled him to extend, correct and modify

the method as it was set forth in Auenbrugger’s little treatise. If he

had not done this and had not published the results in his French

translation (of 1808), Auenbrugger would not have won the credit for his

glorious discovery. The delicately considerate manner in which Corvisart

engineered the whole scheme throws a flood of light upon the noble

character of Napoleon’s First Physician.

------------------------------------------------------------------------

CHAPTER XIX

LAËNNEC AND THE INVENTION OF THE MODERN METHOD OF AUSCULTATION;

PAUL-JOSEPH BARTHEZ

RENÉ THÉOPHILE HYACINTHE LAËNNEC (1781–1826) was born at Quimper in

Brittany, France. I am not able to furnish any details concerning his

early history. His subsequent career as a physician, however, and

especially his writings, show very clearly that he must have received a

very careful and thorough education. Previous to 1816 auscultation of

the chest was carried out in the same manner as it was in the time of

Hippocrates,—that is, by applying the examiner’s ear, either directly or

through an interposed piece of linen, to the surface of the skin

overlying the particular part which he was desirous of examining.

In 1816 I was consulted [writes Laënnec] by a young woman who

presented certain general symptoms that pointed to the existence

of some disease of the heart, and in whom, by reason of her

_embonpoint_, simple palpation and percussion could scarcely be

expected to furnish satisfactory information in regard to the

nature of the disorder. The age and sex of the patient not

permitting me to make such an examination as I have just

mentioned I was compelled to adopt some other measure; and I

then recalled to mind the acoustic phenomenon with which

everybody is familiar, to-wit: if the ear be applied to one end

of a wooden beam it will perceive with perfect distinctness the

sound made by the scratching of a pin’s point on the opposite

end of the beam. From this circumstance I inferred that in the

present case I might advantageously utilize the principle

underlying this phenomenon. Accordingly I rolled up into a

cylinder-shaped, stiff-walled tube several sheets of

writing-paper, and, resting one end of the cylinder on the skin

of the precordial region, I applied my ear to the other end of

the tube. I found to my surprise and pleasure that I was now

able to hear the pulsations of the heart much more distinctly

than I had ever before heard them when I applied my ear directly

to the chest-wall.

This first experience made such a deep impression on the mind of Laënnec

that he promptly instituted a series of experiments which had for their

object (1) the determination of the form of instrument that would best

answer the desired purpose, and (2) the discovery of the various cardiac

and pulmonary conditions that might advantageously be studied by the use

of this instrument. Such were the first steps taken in one of the most

useful medical discoveries of which we have any record. Auscultation,

the importance of which had been dimly foreseen by Hippocrates the

Great, became now for the first time, in the early part of the

nineteenth century, one of the most effective aids to the physician in

ascertaining the true nature and extent of certain diseases located in

the cavity of the chest, in watching their progress, and in regulating

their treatment in accordance with the physical conditions revealed by

the aid of the method. The history of medicine has few more important

events to record than this discovery made by Laënnec, one of France’s

greatest physicians.

As a result of the experiments to which I have just referred there was

soon substituted for the crude thin-walled paper cylinder a solid column

of light wood, hollowed out centrally throughout its length by a narrow

tubular channel. To this new instrument the name “stethoscope” was

given. It would require too great an amount of space to give here the

full and very explicit instructions supplied by Laënnec regarding the

manner in which this instrument is to be employed in actual practice;

and, furthermore, they are to be found in the best modern textbooks

which deal with diseases of the chest.

[Illustration:

LAËNNEC

(Copied from an old French print in the possession of the New York

Academy of Medicine.)

]

Stethoscopic auscultation is by no means the simple operation which many

physicians believe it to be. It is an art which must be learned through

long practice, and is attainable to its fullest extent only by those who

possess, in the first place, a thorough knowledge of the anatomy of the

organs contained within the thoracic cavity,—both the gross anatomical

relations of the different organs and the minute structure of the

different subdivisions of the pulmonary mass. A good knowledge of the

mode of action of all this vascular and respiratory machinery, under

normal conditions, is also necessary. He who really becomes an expert in

the art of successful auscultation must necessarily be equipped with a

knowledge of the different acoustic phenomena that present themselves to

the examiner’s hearing under the various pathological states to which

both the heart and the lungs are liable. All these facts are brought out

with great fulness of detail by Laënnec in the second edition (1826) of

his treatise. (I have not examined the English translation of Laënnec’s

treatise, but presumably all these details have been accurately

reproduced in that version.) A man without a delicate sense of hearing

and a well-trained imagination,—which latter gift may truly be said to

be possessed by comparatively few of those who practice medicine,—will

soon confess to himself that he is able to gain only a very meagre

modicum of satisfactory information from the practice of the art of

auscultation.

Laënnec reports a large number of cases in which various pulmonary and

pleural disorders developed as complications of the original affection,

and in each such case he mentions in full detail all the phenomena that

were discovered on auscultation and percussion of the chest. Some of

these histories are extremely interesting; they constitute a rich mine

of clinical data from which the practicing physician may draw a great

fund of useful information. A mere list of the headings of these reports

would fill several of the pages of this treatise. From the statements

already made the reader is likely to infer that Laënnec is particularly

strong in his presentation of the facts relating to the pathological

anatomy of pulmonary and cardiac diseases, as well as in his treatment

of the subject of auscultation in all its phases; and in drawing this

inference he would be wholly in the right. Laënnec’s treatise furnishes

an exhaustive and thoroughly practical discussion of the various

diseases of the heart and lungs, and stands for all time as a glorious

monument in his honor.

Magendie, speaking before a class of medical students at Hôtel-Dieu

about the difficulties which the physician occasionally encounters in

his efforts to interpret correctly the significance of certain sounds

heard during auscultation, narrates the following experience:—

Here, gentlemen, is the heart of a young woman who recently died

in this hospital. I believe that I have already published an

account of her case, which is one of exceptional interest; but,

however this may be, I remember perfectly well all the details

of the results ascertained (during life) by a careful

auscultation of her heart. The first sound was heard without any

difficulty, but the second one was entirely lacking. What, it

will be asked, was the cause of this phenomenon? At first I was

disposed to believe that she was affected with hydrothorax, but,

when I came to make a more careful examination, I was obliged to

reject this hypothesis; and, although I suspected that the

absence of the second sound was due to an obstacle of a

mechanical nature,—one that nullified the stroke communicated by

the heart to the sternum,—I was unable to form any idea as to

the real nature of this obstacle. The present autopsy furnishes

the desired explanation. As a result of a former attack of

pericarditis the anterior surface of the heart was covered with

a thick layer of false membranes; ... the tip of the organ, on

the other hand, still preserved its usual smooth and polished

aspect.... In my judgment the interposition of false membranes,

which had been deposited upon the surface of the heart, acted as

a cushion, thus preventing the transmission of the sound by

annulling the shock which would otherwise result from the blow

upon the sternum. Lower down, at the tip of the organ, where no

false membranes had been deposited, the blow upon the thorax,

caused with each systole of the heart, produced the normal

degree of noise.

(From Magendie’s “_Leçons sur les Phénomènes Physiques de la

Vie_.”)

I should perhaps add here the statement that Laënnec’s researches into

the question of auscultation of the chest were made at the Necker

Hospital in Paris, and extended over a period of eighteen years.

[Illustration:

The _Faculté de Médecine_ and the Cathedral at Montpellier, France.

(Courtesy of Monsieur le Pasteur Paul Barnaud, of Sainte Foy la Grande

[Gironde], France.)

]

* * * * *

PAUL-JOSEPH BARTHEZ, one of the most distinguished physicians of France

during the eighteenth century, was born at Montpellier on December 11,

1734. His father, who was a civil engineer and well known as a clever

mathematician, practiced his profession at Narbonne, and it was there

that the son spent the first years of his life. At a very early age he

manifested a decided love for study, and his parents took great pains

with his education. During the period of youth he displayed two marked

characteristics—sincerity and very little inclination to indulge in

social pleasures. On more than one occasion he submitted to chastisement

rather than to tell a lie. As he advanced in age he showed a marked

tendency to choose an ecclesiastical career, but his father was not at

all disposed to encourage him in such a choice, and finally induced him

to give the preference to medicine. Accordingly, Paul-Joseph, during the

month of November, 1750, was enrolled as a medical student at the

University of Montpellier. Three years later he passed the required

examinations with great credit and was given the degree of Doctor of

Medicine. In 1761 he made his first appearance at Montpellier as a

lecturer and met with a fair degree of success. Up to this time he had

experienced a good deal of anxiety caused by his pecuniary troubles, but

during the succeeding years his practice steadily increased and he was

soon relieved from this source of trouble. In 1781, after the death of

Dr. Tronchin, he was called to Paris to take the doctor’s place as the

private physician of the Duke of Orleans. In the meantime, despite the

greatly disturbed condition of political affairs in Paris, and also

despite the persistent efforts of his enemies to drive him out of the

capital, Barthez managed to accumulate a fortune amply sufficient for

all his reasonable needs. In 1802 the First Consul, Bonaparte, appointed

him and Corvisart Government Physicians,—Barthez for Montpellier and the

southern part of France, and Corvisart for Paris and the northern part;

and, a little later, Barthez was appointed Bonaparte’s Consulting

Physician.

Toward the end of his life Barthez suffered a great deal from bladder

trouble, which proved eventually to be dependent upon the presence of a

calculus. Instead of submitting at this time to a surgical operation,

the only measure that offered him any chance of permanent relief, he put

his faith in the use of lithontriptics; and then, when these proved to

be impotent to give him relief, he expressed his willingness to submit

to an operation. But by that time his general condition had become so

unfavorable that it was not considered safe to operate. His death

occurred on October 15, 1806, after he had passed through several weeks

of very great suffering.

In order that one may form a correct estimate of Barthez’ professional

career it is necessary that certain facts should be borne in mind. In

the first place, he was endowed with a prodigious memory, a remarkable

capacity for grasping facts, unlimited patience in studying their

different aspects, great ability in ascertaining their relations to one

another, and wonderful facility in following out the connections between

abstract ideas. Then, in addition, his acquaintance with both ancient

and modern languages made it easy for him to familiarize himself with

the sayings of the philosophers and scientific men of all times and

countries.

[Illustration:

The “Court of Honor” of the _Faculté de Médecine_ at Montpellier,

France.

(Courtesy of Monsieur le Pasteur Paul Barnaud, of Sainte Foy la Grande

[Gironde], France.)

]

In 1785, after the death of Imbert, who at that time occupied the

important position of Chancellor of the University of Montpellier, the

highest medical office in the southern half of France, Barthez was

chosen his successor.

Were it not for the difficulty presented by the lack of space I should

be glad to add here, by way of example, a reproduction, in English, of

one of Barthez’ “_Consultations_,” some of which are most instructive,

and which furnish at the same time an excellent picture of the manner of

procedure followed by this celebrated French diagnostician and teacher

of the science and art of medicine. Merely to furnish a _résumé_ of one

of these chapters would not serve a sufficiently useful purpose, and I

must therefore abstain from making any attempt whatever to supply the

desired portrayal. To those, however, who are interested more

particularly in the subject of syphilis I will venture to suggest the

perusal of Consultation XXXVI. (pp. 381–396), in which Barthez gives a

very complete report of the infection, with that disease, of an entire

family (father, mother and several children). This report is well worth

reading. In addition to the “_Consultations de Médecine_,” which was

published in 1820 by Lordat, Barthez wrote the following treatises:—

“_Nouveaux Eléments de la Science de l’Homme_,” Montpellier, 1778 (1

vol.); Paris, 1806 (2 vols.); “_Traité des Maladies Goutteuses_,” Paris,

1802 (2 vols.); “_Nouvelle Mécanique des Mouvements de l’Homme et des

Animaux_,” Carcassonne, 1798; “_Discours sur le Génie d’Hippocrate_,”

Montpellier, 1801.[23]

------------------------------------------------------------------------

CHAPTER XX

EARLY STUDIES OF THE DISEASE NOW UNIVERSALLY CALLED TYPHOID FEVER

Up to the year 1829 the disease now universally called “typhoid fever”

was known by a great variety of names, all of them more or less

objectionable and therefore not acceptable to the majority of

physicians. Here are a few specimens of these terms: “gastritis” or

“gastro-enteritis”; “enteric fever”; “slow nervous fever”;

“gastroentero-cephalitis”; “abdominal typhus”; “pathogenic fever,” etc.

It is only in the last-mentioned name that we find evidence of an

attempt—only a very feeble attempt, it is true—to suggest some

connection between the term proposed and the real cause of the disease.

Chomel, in 1834, very quickly disposed of the first two names suggested

when he wrote: “At the present time no physician who is a careful

observer of disease and who at the same time is well versed in

pathological anatomy, looks upon typhoid fever as a gastritis or a

gastro-enteritis.” At about the same time Philippe Pinel, the

distinguished author of the work entitled “_Nosographie Philosophique_,”

made the following statement with regard to typhoid fever: “In this

disease one cannot fail to observe that there exists, toward the end of

the small intestine, a violent inflammation of the mucous membrane.” To

go back farther still in the history of medicine I will mention here the

fact that Galen attributed this and other epidemic fevers to the

drinking of infected water. Huxham and Pringle, two of the best English

authorities on fevers, frequently mention, as a cause of typhoid fever,

the drinking of polluted water in which are contained decomposing animal

matters. So far as I am able to ascertain, however, Johann Peter Frank

was the first to throw doubt upon the correctness of this mode of

causation, or at least upon the correctness of the form in which the

statement is made. Putridity alone, he says, does not satisfactorily

explain the characteristic features of the disease. “The cause of these

nervous fevers,” he adds, “is not to be found in putrid matter but

rather in some principle, or primary element, which easily combines with

it,—an element the nature of which is unknown to us.” Putrid matter,

then, was recognized by Frank as being simply the vehicle of the cause

of the disease (viz., a special _contagium vivum_). Budd, in 1856, held

very much the same view; and Murchison, in 1857, agreed in the main with

Budd.

[Illustration:

Montpellier. Vestibule of the _Faculté de Médecine_ at Montpellier,

France.

(Courtesy of Monsieur le Pasteur Paul Barnaud, of Sainte Foy la Grande

[Gironde], France.)

]

The next suggestion of a new name for typhoid fever came from

Bretonneau, of Tours, France; his proposition being that the disease

should be called “_Dothiénentérite_” (from δοθιὴν, the Greek word for

pimple, and έντερον, intestine). Certain authors attributed the

associated fever to these pimple-like lesions in the small intestine,

but Bretonneau held that the latter are the products of an infection and

not the cause of the fever; and that view has been universally accepted

as correct ever since his time. This new term for typhoid fever,

however, was not favorably received, and was very soon forgotten. On the

other hand, the expression “typhoid fever” (from τῦφος, stupor, and

εὶδος, form), which simply described the most noteworthy feature of the

disease, was promptly adopted. Charles A. P. Louis,[24] Chief of Clinic

at the _École de Médecine_ of Paris, and Member of the _Académie Royale

de Médecine_, to whom we are indebted for the final settlement of this

troublesome question, gives the following brief account of the

considerations which led him to urge the final acceptance of the term

“typhoid fever”: “After seeking carefully for a term that would express

the anatomical features of this disease, without jarring too decidedly

upon the ear, as ‘_dothiénentérite_’ does, and having failed to discover

any better expression than ‘typhoid fever,’ I finally decided to employ

it in preference to all others.” And since that time no physician has

succeeded in supplanting it with a term more acceptable to the

Profession. As to the real underlying cause of typhoid fever I shall

have nothing to say, as this is a matter which belongs strictly to the

domain of modern medicine; and I have no wish to trespass upon the

territory of the writer of this most important section of the history of

medicine.

As to the contagiousness of typhoid fever Louis states that, out of 117

cases which he had observed, there were only three that might be imputed

to contagion.

A few words more concerning Charles A. P. Louis, to whom I have already

referred briefly in connection with the subject of selecting a suitable

name for typhoid fever. Marshall Hall, the famous English physician,

characterizes him as the greatest pathologist of any nation or of any

age. In another place he says:—

Monsieur Louis is the Bacon of Medicine; he has taught us how to

observe, and how to deduce important laws from the facts

observed.... Monsieur Louis is a man of such talent, labour,

exactness, truth, and probity, as I never met with in any other

man. His labours I shall consider as the chief ornament of these

lectures, and my chief claim to your consideration.

In still another place Marshall Hall quotes Louis’ own account of the

early years of his professional career, as follows:—

After having practised as a physician in a foreign country, I

returned to France, at the age of thirty-three, determined to

give myself up to the observation of disease; and, in order to

obtain my end more effectually, I resolved to forego all other

employment. I pursued this course for nearly seven years; in

other words, during that time I devoted myself exclusively to

the observation of all the cases admitted into St. John’s and

St. Joseph’s wards at the hospital of _La Charité_. Three years

elapsed before I ventured to publish, at the request of a

friend, my first memoir, on the perforation of the small

intestines; my object being to observe for myself, and not to

describe what I might have observed.

[Illustration:

CHARLES A. P. LOUIS

]

------------------------------------------------------------------------

BOOK X

BROUSSAIS AND BROUSSAISM

------------------------------------------------------------------------

CHAPTER XXI

THE HARMFUL EFFECTS OF BROUSSAIS’ TEACHING

FRANÇOIS JOSEPH VICTOR BROUSSAIS was born in 1772 at Saint-Malo, a

seaport on the north coast of France, in the Department of

Ille-et-Vilaine (formerly a part of Brittany). His early medical

training was obtained at Paris, where he attended for a short time one

of the courses of instruction given by Bichat. On reaching the age of

forty-two he entered the service of the Military Hospital at

Val-de-Grâce, and not long afterward was chosen Professor of General and

Special Pathology and Therapeutics at the University of Paris. The

lectures which he delivered on these subjects so fascinated the students

and the numerous physicians who attended the course in increasing

numbers, that—as Pagel expresses it—a general impression was created,

during a period of several successive years, that the whole of French

medicine was represented in the person and doctrines of Broussais. The

correctness of Pagel’s statement is corroborated by the following

extract from “J. L. H. P’s sketches”:—

Monsieur Broussais is unquestionably the most remarkable medical

writer of the present age. Splendid works, celebrated lectures,

and a great number of proselytes, have in a few years spread far

and wide his name and his opinions.... There are, on the other

hand, many physicians, who, too old to return now to their

studies, and witnessing with no pleasure all these innovations,

say that the professor of Val-de-Grâce is only a sectary, in

whom passion holds the place of genius, and hardihood of

force.... His brutal attacks on men, whether dead or

living,—French or foreigners, surrounded with the esteem and

admiration of all,—have found approval only among the personal

enemies of the contemporaries whom he criticises, and this too

in a generation greedy of novelty, and imposed upon by his rough

manners and bold speech.

The extract also shows that not a few French physicians refused to

accept the “fascinating” doctrines promulgated by Broussais, and

reported by him to be “founded on physiological principles.” As

Broussaism played such an important part, during the early years of the

nineteenth century, in hindering the advance of the real science of

medicine, my readers will pardon me, I am sure, if I devote considerable

space in the attempt to elucidate the meaning of Broussaism. These

revolutionary ideas regarding “physiological medicine” were first

published in book form in 1816. Two later editions followed,—one in 1821

and another in 1829. The text is arranged in the form of propositions or

“physiological principles,” of which there are 568. Pagel describes them

as “not being related in the remotest degree to modern physiology.” In

the following paragraphs I have reproduced (in the form of translations)

a few of these “_Propositions de Médecine_” as they are printed in the

edition of 1829:—

A. PROPOSITIONS BELONGING TO THE DOMAIN OF PHYSIOLOGY

II.—Heat, from whatever source it may be derived, is the first

and most important of all stimuli; and, when it ceases to exert

its vitalizing power upon the economy, all other stimuli lose

their power to produce any effect upon it.

IV.—If heat is withdrawn for a certain period of time all those

phenomena of the economy which are of a conservative, reparative

or medicative nature cease all activity; and the same is true

when oxygen is withdrawn.

XX.—Assimilation, which is a phenomenon of the very first order,

cannot be explained by the assumption that it is due to the

action of sensibility and contractility; it should be looked

upon only as a manifestation of a creative force,—as an act of

vital chemistry.

XLII.—Instinct consists of nervous impulses or stimuli—sometimes

associated with consciousness and sometimes not—which originate

in one of the viscera, and which call upon the central nerve

power to execute such acts as are necessary to the exercise of

the functions of that viscus.

XLIV.—Acts which are originated by instinct are most frequently

observed in infants, and are witnessed with diminishing

frequency as the child’s intelligence becomes more perfect.

XLVII.—As may be said with equal truth of insanity the passions

furnish an example of the triumph of the viscera—that is to say,

of instinct—over intelligence; and, on the other hand, it is

well-known that the passions themselves produce insanity.

LI.—The intellectual faculties may be exercised without any

participation of passion, but never without an accompaniment of

either pleasure or pain.

LXIV.—An excess of haematosis or sanguification in an organ

increases at first the sum total of its vitality, but this

increase is subject to limitations. If, for example, the

excitation is kept up beyond a certain length of time the

continued hyperaemia establishes in that organ a condition which

deserves to be called disease.

B. PROPOSITIONS BELONGING TO THE DOMAIN OF PATHOLOGY

XCIX.—When irritation causes the blood to accumulate in a part

or tissue, and when, further, this accumulation of blood is

accompanied by such an exceptional degree of swelling, redness

and heat as to threaten the disorganization of the part thus

irritated, it is customary to apply to this complex phenomenon

the name of “inflammation.”

CXXVII.—Tubercles, cancers, etc., of the brain owe their origin

to a chronic inflammation of that organ.

CLXVIII.—I have never seen tubercles of the lungs except in

cases where these lesions had developed from an antecedent

inflammation; and it does not appear to me that the tubercles

which are observed in the lungs of infants at birth, may rightly

be considered as having originated independently of

inflammation.

CXCV.—All the different varieties of acute and subacute

inflammation possess the power to produce cancer.

CCCVII.—He who does not know how to manage properly a case of

irritability of the stomach will never be able to treat

successfully any other malady. In short, the key to a knowledge

of pathology is to be found in an intimate acquaintance with

gastritis and gastro-enteritis.

CCCXLII.—Pulmonary phthisis may be prevented by putting an end,

by means of antiphlogistic remedies and revulsives, soon after

its presence is discovered, to any existing irritation of the

respiratory apparatus.

[Illustration:

BROUSSAIS

]

These dozen or more of Broussais’ “_Propositions_” or fundamental

medical doctrines should suffice, it seems to me, to give the reader a

correct idea of the kind of physiology and pathology that found favor in

France during the third and fourth decades of the nineteenth century,

and that too despite the thoroughly sound and admirably logical, but

less fascinating, teachings of such authorities as Morgagni, Bichat, Ch.

A. P. Louis, Bayle, Corvisart and Laënnec.

It was toward the end of this same year (1821) that Laënnec began

teaching his new method of auscultating the chest by means of the

stethoscope—which had first been made known to the world by Auenbrugger

in 1761, but which had been completely ignored until Corvisart published

a French translation of Auenbrugger’s book in 1808. As early, however,

as in 1819 Laënnec had published reports of a number of instances in

which, by means chiefly of this method of exploration, he had correctly

diagnosed the presence of tuberculous and other deposits in the lungs of

certain patients. The publication of these reports evidently excited

very much the wrath of Broussais, for in the new edition of his book

(viz., that of 1821) he criticises Laënnec’s statements most unjustly

and in a manner that reveals how completely his mind was saturated with

the belief that what he calls “inflammation” is at the bottom of most of

the pathological phenomena encountered in medical practice. Lack of

space will not permit me to quote here more than one or two of

Broussais’ comments on the conditions reported by Laënnec:—

The pathological alterations, considered by themselves, are

simply curiosities, and are not of the slightest utility to

anybody who may feel disposed to study them; because they are

all either the products of simple inflammation, or else they owe

their origin to some cause which does not fall legitimately in

the domain of physiological pathology.

(Copied from pp. 674, 676, 677, and 679 of Vol. II., edition of

1821.)

Further on in the same volume, speaking of melanotic cancers, Broussais

says:—

... this is all that it is important for the physician to know;

and, as to what Monsieur Laënnec has written about black

cancers, I may say that it is simply the product of his

imagination, a gloomy romance, which I found difficulty in

reading from the beginning to the end.

It seems proper that I should furnish some information concerning

Broussais’ methods of treatment in different diseases. In the last

analysis it will be found that in nearly all cases he adopted such

remedial measures as tended to allay or arrest inflammatory action.

Thus, in beginning pulmonary consumption he prescribed the application

of leeches to the infraclavicular region; in jaundice they were to be

applied in the hypochondriac region, in pharyngitis and tonsillitis to

the side of the neck, in dysentery to the anus, in articular rheumatism

to the neighborhood of the affected joint, and, in maladies that were

not distinctly localized, the epigastrium was the region to be chosen by

preference. When simple irritation was present Broussais prescribed

revulsives—such, for example, as blisters, emetics and laxatives. As a

rule, however, he gave the preference to direct antiphlogistic measures.

He is credited with having had a profound contempt for the _vis

medicatrix naturae_. It was said that his pupils showed a tendency to

push his pathologic teachings to an extreme. Desruelles, for instance,

was in the habit of treating his syphilitic cases, not with mercury or

any other of the specific remedies commonly employed at that period, but

with leeches applied locally.

As early as in 1816 Broussais announced that, as a result of his

doctrine, “the mortality of Val-de-Grâce had greatly diminished, to the

grand astonishment and admiration of the world.” This assertion not

having been noticed, Monsieur Broussais, in 1821, went a step further.

He then predicted, in the Preface to his “_Examen des Doctrines_,” that

his doctrine would soon exert an influence on population more marked

than that exerted by vaccination. This was pretty strong, but not,

however, sufficient; for in 1822, “the Prospectus of _Les Annales de la

Médecine Physiologique_ declared that, in the hospitals where the

physiological doctrine was adopted, the mortality was only one in

thirty, while in the others it amounted to one in five.” These results,

which caused great astonishment, induced Monsieur Brasquet, a physician,

to inspect the records with a view to ascertaining the exact facts. Thus

it was discovered that, during the five years from 1815 to 1819,

Monsieur Broussais had lost more patients than his contemporaries had

lost during the same period; his mean mortality having been one in

thirteen. (The results of Monsieur Brasquet’s inquiry were published in

the _Revue Médicale_.) “Monsieur Broussais replied in _Les Annales de la

Médecine Physiologique_, but his reply was not at all satisfactory. He

did not deny the correctness of the figures published in the _Revue

Médicale_, but he maintained that they proved nothing against him.” The

proof, however, that he had lost _one patient in thirteen_, and not _one

in thirty_, as he had claimed, remained unshaken.

It was probably this experience that marked the beginning of the

downfall of the doctrine known as “Broussaism”; but many years had to

elapse before this doctrine vanished entirely from the accepted medical

textbooks. August Hirsch, in his “History of the Medical Sciences in

Germany” (1893), passes the following judgment upon Broussais’ work:

“Under the title of ‘Physiological Medicine’ Broussais presented to the

world a system which for narrowness of scope, for arbitrariness and for

the perniciousness of the treatment which was deduced from the premisses

that grew out of the theory, could be compared only with Rasori’s

therapeutic method.”

Broussais died in 1835.

------------------------------------------------------------------------

BOOK XI

THE GOLDEN AGE OF SURGERY IN FRANCE

------------------------------------------------------------------------

CHAPTER XXII

J. L. PETIT, OF PARIS, AND HIS CONTEMPORARIES IN SURGERY—SABATIER,

CHOPART, DESAULT AND DUPUYTREN

In the history of surgery in France there is a conspicuous absence of

distinguished names from the list of men who succeeded Ambroise Paré,

until we reach that of J. L. Petit, a surgeon whose career shows him to

have been worthy of all the praise and esteem which the French have

lavishly bestowed upon him.

* * * * *

JEAN-LOUIS PETIT was born at Paris in 1674, and already at the early age

of twelve manifested a strong inclination to adopt a surgical career. By

the time he had reached his sixteenth year he had become so expert as a

dissector that he was entrusted with the duties of a demonstrator of

anatomy, a position which he filled to the entire satisfaction of both

the students and the superior authorities of the medical school. Two

years later,—that is, in 1692,—he entered the military service and was

given the position of Army Surgeon. He was present at the siege of

Namur, and served through all the succeeding campaigns up to the year

1697, at which time he was placed in charge of the Military Hospital at

Tournay. In 1700 he retired from the army and returned to Paris, where

he engaged in private practice and at the same time gave instruction in

anatomy and surgery. From this time forward his reputation as a skilful

surgeon rose rapidly until he was universally acknowledged to be the

leading surgeon of the capital, a fact which was confirmed by his

election to the position of Director of the Royal Academy of Surgery.

It was said of him by a very competent critic (A. Richet) that Petit was

one of the boldest and most skilful surgeons of his day. He possessed a

profound knowledge of the anatomy of almost every region of the body,

and at the same time was remarkably skilful in the handling of his

bistouri. He also seemed to possess, on the spur of the moment, an

intuitive knowledge of what he should do in any situation of affairs

that might suddenly develop in the course of an operation. The

reflections which he made as he progressed in the work with which he

happened to be busied, were most original, and led somebody to say of

him, on a certain occasion: “He must have invented surgery.” On reading

his treatise on surgical maladies one is struck with the originality of

his remarks, with the profoundness of his thinking, and with the

closeness and accuracy of his observations. His writings make most

attractive reading for the surgeon.

In order that my readers may judge for themselves how cleverly and how

wisely Petit dealt with some of the surgical problems which presented

themselves for solution in the course of his private practice I will

give here, in the form of very brief translations, three instances which

seem to me to possess to-day a peculiar interest in that they reveal the

important fact that a correct diagnosis may occasionally be made without

the aid of some of the complicated and expensive machinery which not a

few of our modern surgeons think indispensable to the ascertainment of

the truth. I should perhaps modify this last remark by stating that the

extraordinary cleverness and practical wisdom exhibited by J. L. Petit

are gifts not often bestowed by Nature upon physicians, and that

therefore the X-ray and other modern inventions which compensate for the

infrequency of such gifts, are to be considered in the light of very

important blessings conferred upon suffering humanity.

[Illustration:

JEAN-LOUIS PETIT

]

(1) “The man, whose case history I am about to relate, said that

the symptoms from which he had suffered, during the preceding

twelve months, were the following: a frequent but dry cough,

with loss of appetite; almost constant thirst; difficulty in

obtaining sleep; night-sweats, more marked in the region of the

head and neck than elsewhere; and irregular chills and fever.

The physicians whom he had consulted were led to believe that he

was affected with consumption, and they treated him in

accordance with this belief, but so far without success.—On

examination I found that two of his teeth were carious, and I

advised their extraction. A rapid restoration of the patient’s

health followed in less than a fortnight.”

(2) “The late Princess of Condé had interested herself greatly

in a young girl whom she had taken into her service. Upon her

return to Paris she took the girl with her, in the hope that the

physicians of that city would be able to cure her of the

hemicrania (‘_Migraine_’) from which the girl had frequently

suffered during the preceding five years. Bloodletting was the

remedy adopted at that period for nearly every malady, and these

Paris physicians let her have a full taste of this remedy,

prescribing in rather rapid succession twenty such bleedings,

the arm, the foot and the region of the throat being the

localities selected for this operation. Medical students were

thought to be quite sufficiently competent for the management of

the arm and foot bloodlettings, but it was I who was obliged to

officiate when it became necessary to carry out the bleeding

from the neck. As this was the first occasion on which I saw the

patient I asked her a number of questions in order to learn the

more important facts concerning her malady; and then, failing to

discover any that seemed to me to justify the numerous bleedings

to which she had been subjected, I examined her mouth, not as a

casual matter, but because she had told me about having

experienced a sense of heaviness and numbness in her lower jaw.

Observing some irregularity in the arrangement of her teeth I

counted them, and discovered that there were eighteen instead of

the sixteen which are usually present; and it also seemed to me

that the second molar tooth on each side was crowding the

others. After stating these facts to the Princess, and obtaining

her approval of the step which I proposed to carry out, I had

the two molars extracted; whereupon, to the great astonishment

of her ladyship and all of us, the girl found herself, at the

end of twenty-four hours, entirely cured of a malady which had

often, during the preceding five or six years, been so

distressing that she could not perform her regular duties.”

(Copied from Petit’s “_Traité des Maladies Chirurgicales_,”

etc.)

(3) In another part of the same volume Petit reports in detail

the history of a case of middle-ear inflammation in which, after

the lapse of a few weeks, there developed symptoms that pointed

very strongly to the presence of a subdural collection of pus

behind and above the inflamed middle-ear. Whereupon, at a

consultation that was held between the physicians in attendance

upon this patient, Petit urged the desirability of trephining

the skull in order to give vent to the contents of this assumed

abscess. Such a proposition, however, was promptly voted down by

the other consultants. (The events here described, it should be

remembered, occurred somewhere between 1750 and 1774.) Two or

three weeks later, the patient’s pain having become in the

meantime more severe, the timid consultants at last withdrew

their opposition, and Petit performed the trephining with

success. Much foul-smelling pus was evacuated, and after the

lapse of a few weeks the patient was pronounced cured.

It would be easy to furnish here, from the printed record already

mentioned, additional instances showing the courage, wisdom and skill

exhibited by J. L. Petit in his practice of the art of surgery. But the

instances already cited amply suffice, as it appears to me, to show the

admirable character of the man and his right to be considered the worthy

successor of Ambroise Paré.

Petit’s death occurred in 1760.

Petit made comparatively few contributions to medical literature, and of

these the shorter ones will be found in the “_Journal des Savants_,” the

“_Recueil des Mémoires de l’Académie des Sciences_,” and the “_Mémoires

de l’Académie Royale de Chirurgie_.” His great work, which was published

in three volumes at Paris in 1774 (also a later edition in 1790), bears

the title: “_Traité des Maladies Chirurgicales et des Opérations qui

leur Conviennent_.”

* * * * *

RAPHAEL-BIENVENU SABATIER was born at Paris on October 11, 1732. His

father, Pierre Sabatier, was one of the earliest members of the

_Académie Royale de Chirurgie_, and it was therefore quite natural that

Raphael chose medicine for his profession. There was nothing remarkable

about his early career. He worked hard at his studies of anatomy and

cultivated at the same time experimental physiology. At the age of

twenty-four he succeeded Balleul as Professor of Anatomy at the Royal

College of Surgery. In 1773 he was made a member of the _Académie des

Sciences_, and a few years later, when the war broke out, he was ordered

to report, as a consulting surgeon, at the headquarters of the Army of

the North, at Mons. But, his strength not permitting him to perform the

duties of this new position for any length of time, he was soon allowed

to return to his private practice. Toward the end of his life Napoleon

appointed him one of his consulting surgeons, and at about the same

period of time the decoration of the Legion of Honor was conferred on

him. When the _École de Santé_ was established he accepted the Chair of

Operative Surgery. His death occurred on July 19, 1811.

Sabatier was highly esteemed by his professional brethren. Unlike

Desault he brought forward no new inventions or methods of treatment,

but he constantly sought how he might introduce some little improvement

in existing well-established methods. He was not of an enthusiastic

temperament and rarely did anything to call forth opposition on the part

of his associates. As a consequence he led a most peaceful life.

Sabatier’s contributions to medical literature were fairly numerous, and

among them the following deserve to receive particular mention:—

“_Traité d’Anatomie_,” 3 vols., Paris, 1764.

“_De la Médecine Opératoire_,” 3 vols., Paris, 1796; a second

edition appeared in 1810; and a third (in 4 vols.) in 1821–1824.

* * * * *

FRANÇOIS CHOPART was born at Paris in 1743. During his youth he received

a thorough preliminary training. From the very beginning of his medical

course he showed a decided preference for surgery. Then, for a certain

length of time, he served as an _interne_ at Hôtel-Dieu. Afterward he

was transferred first to La Pitié Hospital and then to Bicêtre, where he

devoted his attention mainly to syphilitic affections. In 1767 he

divided the prize offered by the _Académie de Chirurgie_ for the best

memoir on the subject of “The Nature and Treatment of Wens.” In 1768 he

was given an “Honorable Mention” for his memoir on “Injuries of the Head

produced by Contrecoup.” In 1770, after passing with great credit the

examinations required, he was given on July 20, 1770, the degree of

Master of Surgery; and only one year later he was appointed Professor of

Practical Surgery. His pupils were very much attached to him on account

of the interest which he manifested in their work and because his

teaching was so methodical and was so clearly delivered. On March 13,

1782, he was chosen successor to Bordenave, the Professor of Physiology;

and a little later he was elected to the Chair of External Pathology.

While on a visit to England he made the acquaintance of John Hunter, and

kept up an active correspondence with him during the following years. He

was also one of Desault’s intimate friends. Being open-minded and frank

he got along pleasantly with all who came in contact with him. He died

in 1795 from an attack of cholera morbus.

Among his writings which deserve special mention are the following:

“_Traité des Maladies Chirurgicales et des Opérations qui leur

Conviennent_,” Paris, 1780, 2 vols.; and “_Traité des Maladies des Voies

Urinaires_,” Paris, 2 vols., 1701, and a later edition in 1821.

Chopart is known to American and English surgeons chiefly through the

fact that he devised an amputation of the foot which is commonly known

as “Chopart’s amputation.” The procedure is thus briefly described by

Dr. Thomas L. Stedman in his Medical Dictionary: “Disarticulation at the

metatarsal joint, leaving only the astragalus and calcaneum, with the

soft parts of the sole of the foot to cover the stump.”

* * * * *

PIERRE-JOSEPH DESAULT was born on February 6, 1744, at Magny-Vernois, a

small village in the Department of Haute-Saone, on the western slope of

the Vosges mountains. At the time of his birth his parents were living

upon the income derived from a modest fortune, and they found it very

difficult to support their family of seven. As soon as Pierre was old

enough to receive regular instruction he was placed under the care of a

private teacher at the neighboring village of Lure, the chief centre of

that district. In this way he acquired an elementary knowledge of Latin

and was fitted, by the time he reached the age of twelve, to enter the

fifth form or class at the Jesuits’ college in Lure. His favorite study,

as soon became evident, was mathematics, and this branch of knowledge he

cultivated with such assiduity and success that already at the age of

seventeen he had reached the point where all the elementary treatises to

which he had access no longer afforded him any satisfaction. At a

somewhat later period of his life, when he could no longer receive help

from his parents, this decided preference for mathematics stood him in

good stead, enabling him to contribute to his own support by giving

lessons in geometry. It also aided him in making useful applications of

its principles to the art which he was soon to cultivate with such

conspicuous success—viz., surgery. He took special delight at this time

in the perusal of Borelli’s celebrated treatise “on the movements of

animals,” and even went so far as to write a long commentary on this

work. Nothing, however, is now known about the fate of this document, as

Desault never published it nor showed at any time a wish to become an

author.

Bichat, from whose eulogy of Desault I have derived most of the facts

which are reported in the present brief sketch, says that during the

years immediately preceding the period which is now under consideration,

surgery was cultivated by artisans rather than by artists; and that, in

consequence of this situation of affairs, it was very slow in making any

advances which were worthy to be characterized as genuine steps of

progress. “Genius, when not appreciated, escapes as mere froth; its

efforts result in nothing unless glory is the reward. Little by little,

as the public learned more and more how great was its need of surgery,

this art began to receive a larger share of consideration; and thus, as

it became more honorable, it was cultivated to an ever greater degree,

and as a result it advanced at a more rapid pace toward perfection. In

its different branches, which were all working to accomplish some useful

purpose, new discoveries were constantly being made, and thus it came

about that from the middle of the eighteenth century onward French

surgery rapidly outdistanced the surgery of all the other nations.”

(Bichat.)

It was at this period that Desault began his career as a surgeon, and in

the course of that career he did at least his full share in the work of

supplying the deficiencies that were observed in some of the methods

commonly employed at that period, in removing the positive defects that

were discovered in others, and in devising entirely new procedures. At

the same time Desault did not fail to recognize the importance of making

the foundations of his knowledge as solid and firm as possible, and with

this idea in mind he spent all the time that he could possibly spare

from the clinical lessons which he was then giving, in utilizing the

anatomical material available in the dead-house of the hospital. As his

rivals stuck closely to the old methods of instruction, and in addition

were not endowed with his remarkable gifts of teaching, of drawing all

sorts of interesting inferences from the anatomical relations of the

part or limb that was under consideration at the moment, Desault rapidly

outdistanced all his competitors. He was, so far as I am able to learn

from the printed records of this period (1766), the pioneer of this

particular type of instruction (anatomical, pathological and clinical)

in surgery in the great Paris hospital Hôtel-Dieu. The young men who

attended these courses in ever increasing numbers were fascinated by

what they heard and saw,—for Desault always taught with the cadaver or

the living subject before him,—and it soon became very noticeable that

the attendance upon the lectures given by his rivals (_i.e._, the

regular professors) was falling off. Actuated by bitter jealousy these

men managed at first to have his permit to teach taken away from him.

But Antoine Louis and La Martinière, two of the most influential

surgeons of Paris, at that period, interfered and so arranged matters

that Desault was able to resume his private courses. In fact, Louis made

it clear, by his presence at several of the sessions, that he approved

of this teaching and that he proposed to protect Desault against all

interference on the part of rivals. Desault’s method of teaching, says

Bichat, constituted the first development, in France, of what is now

known as surgical anatomy, a very extensive and important department of

the art of surgery.

Another striking feature of Desault’s manner of giving instruction is to

be found in his invariable practice of demonstrating, whenever it was

possible for him to obtain the materials necessary for doing this, the

alterations which are produced in a part by disease or by accidental

injuries, and also the influence exerted by these lesions upon the

neighboring tissues or organs. In these demonstrations he never allowed

his mind to wander in the direction of pointing out something akin to a

discovery in pathology; he stuck closely to the questions that were

under immediate consideration, thus giving preference, over everything

else, to what was of chief importance to the students.

By thus conducting his teaching always with an eye single to the best

interests of his pupils Desault became, in the course of a very few

years, the most celebrated teacher of surgical anatomy in France. His

rivals laid stress upon this particular feature of his fame in the hope

of thereby belittling, in public estimation, the equally important

celebrity, which he was now shortly to attain, of being also a great

surgeon. It is in some such words as these which I am using that Bichat,

who was his favorite pupil and righthand man during this period of his

career, records the efforts made by his jealous rivals to interfere with

Desault’s professional success.

In the early stages of his career as a surgeon Desault gave instruction

in operative surgery, but in a comparatively short time he advanced

beyond this stage and showed that he possessed considerable originality.

He invented a very effective method of treating a fractured clavicle by

the application, to the shoulder, the elbow and the chest, of a bandage

which even to this day is known as “Desault’s bandage.” In planning this

bandage its inventor first calculated with great care the forces which

play the principal part in causing the displacement of the two segments

of the fractured clavicle. This manner of attacking the problem of how

best to treat such a fracture was, so Bichat declares, not that which

had usually been followed by his predecessors, but it nevertheless

proved to be the correct way of finding the right remedy. He believed,

for example, that, inasmuch as the external segment or fragment is

pulled downward by the weight of the shoulder and forward and inward by

the action of the muscles, the right course to pursue must, first, be to

furnish proper support to the shoulder, and at the same time to draw the

external fragment outward and backward. He realized that by the

employment of continuing extension it would be practicable to effect

these results. So, placing a cushion over the chest, to serve in some

measure as a point or angle of resistance, and resting the arm firmly

against it, he was able, by pressing the lower part of the arm closer to

the chest, to cause the upper part, together with the fragment attached,

to stand out from this part of the trunk. Thus, as it were by a single

stroke, he succeeded in obtaining a result which, for a very long period

of time, had eluded the best efforts of the surgeon’s art. This was a

great triumph for Desault, but its importance was not immediately

appreciated. The bandage was successfully used at the Salpétrière, one

of the larger hospitals of Paris, but the full recognition of its value

came only after the lapse of many years,—indeed, not until after the

death of its inventor. To-day it occupies an important place in the

history of surgery.

Of the other improvements in surgical procedures that we owe to Desault

I will mention here only one—that of ligating the exposed ends of the

larger arteries which had been divided in the course of the amputation

of a limb. Ambroise Paré, it will be remembered, was the first to

introduce this practice in France (early in the seventeenth century),

but it failed to meet with general acceptance and was then abandoned for

more than a century. At Bicêtre, another of the large hospitals of

Paris, the practice of immediately ligating the divided blood-vessels

after an amputation was first revived by Desault, and not long afterward

Ferrand also introduced the revived method at Hôtel-Dieu. From this time

onward it became the standard method of procedure.

In 1788 Desault succeeded Ferrand as Chief Surgeon of Hôtel-Dieu, and

from this time forward, for five years, he conducted with great success

regular instruction in clinical surgery. Then, toward the end of May,

1793, he was thrown into the prison of the Luxembourg, the charge

brought against him being that he had refused to give his professional

services to those wounded in the affair of the previous 10th of August.

He was retained as a prisoner only three or four days; but from this

time to the day of his death (June 1, 1795) he was kept in almost

constant fear of being prosecuted, and was consequently prevented in

large degree from doing any useful work in surgery.

In his analysis of Desault’s career as a surgeon Bichat calls attention

to the fact that the establishment of a clinical school at Hôtel-Dieu

was not the only benefit which he conferred upon that hospital. He did

much more than this; he improved the arrangement and the ventilation of

the different wards, established better methods of distributing the food

systematically among the patients, increased their comfort by making

rules whereby their wants would be more promptly supplied, etc. All

matters of this nature occupied the first place in his thoughts and

drove out of his mind, long before he died, all ambition to accumulate a

fortune. Despite the stormy conditions which prevailed during the

Revolution and which upset completely all the existing arrangements in

Paris, he managed to keep up a good part of his clinical courses.

Speaking of Desault’s personal traits of character Bichat says that he

was somewhat quick-tempered, but that he promptly got over his bad

temper and was then once more gentle and reasonable in his speech.

He had his full share of enemies. In nearly all cases this enmity sprung

from jealousy. But what really great man, adds Bichat, ever passed

through life without being annoyed by enemies through jealousy? On the

other hand, Desault had excellent friends, men who—as he expressed

it—were the joy of his life.

Desault was not of a scientific turn of mind; he never wrote articles or

took active part in any discussions. Some of the best of the pupils who

attended his courses took full notes of his lectures, and these, after

Bichat had revised them and edited them, were published under the title

of “The Surgical Works of Desault.”

* * * * *

GUILLAUME DUPUYTREN was born at Pierre Buffière, France, October 5,

1778. He commenced the study of anatomy and physiology at an unusually

early age, and was appointed Prosector at the Paris _École de Santé_

before he had reached his eighteenth year. In 1802, very soon after he

had received the degree of Doctor of Surgery, he was given the

appointment of Attending Surgeon to Hôtel-Dieu. Of this early period of

his career very little need be said. He lost none of his enthusiasm for

his chosen work and was recognized by all his associates as a surgeon of

great promise. From the position of simple attending surgeon at

Hôtel-Dieu he rose in 1808 to that of Adjunct Surgeon-in-Chief. Finally,

in 1815, after the death of Pelletan, he was made full Surgeon-in-Chief

of that great hospital. So far as it was possible for Dupuytren to

advance in the endeavor to gain official recognition as a surgeon, he

had by this time risen to the highest point that it was practicable for

him to reach. Let us now consider some of the other aspects of his

career.

[Illustration:

DUPUYTREN

]

After the death of Bichat in 1802 Dupuytren turned his attention from

what was supposed to be normal anatomy to pathological anatomy. The

change was greatly favored by the fact that, in the course of his

regular work as prosector, he was constantly encountering all sorts of

pathological conditions, and thus he gradually acquired a strong

interest in pathological problems. Pathological anatomy, as newly

interpreted, was no longer a mere observing of the abnormal changes

which take place in different structures and organs of the body,—the

sort of “cold work” which had occupied in large measure the minds of

Bartholinus, Mangetus, Bonnet of Geneva, Morgagni of Bologna, and

Lieutard, and which involved practically no study of the origin of such

changes,—but what might be termed a living pathological anatomy, in

which the effort is made to ascertain the beginning, the gradual

progress and the termination of the process. Ample material for this

sort of study was constantly passing through Dupuytren’s hands, and he

made the most of his opportunities. Professor LeClerc, who is my chief

authority for the present sketch of Dupuytren, says that by means of

this new pathological anatomy much light was thrown upon both diagnosis

and symptomatology. At first the courses which Dupuytren gave in the

_École de Santé_ ran in large degree parallel with those of Bichat, but

after the latter’s death Dupuytren had the field almost entirely to

himself. He taught anatomy, pathological anatomy, and physiology, and

increased the interest in his teaching, on the part of the pupils, by

furnishing a variety of facts drawn from his wide experience. His great

skill as a dissector enabled him to demonstrate all sorts of fine

details—as, for example, not merely a limited portion of a nerve, but

nerves throughout their entire course.

After Dupuytren became full Surgeon-in-Chief at Hôtel-Dieu he ceased

teaching operative surgery and devoted himself largely to clinical

surgery. He adopted the habit of visiting the hospital at an early hour,

long before the time appointed for the arrival of the class, and thus he

was able to examine the patients leisurely and to give all the necessary

instructions to his assistants. By the time the class arrived he was

entirely ready to receive them. He was extremely punctual in attending

to his hospital duties.

In 1814 Dupuytren took an active part in caring for the wounded soldiers

on the field of battle; and again in 1830, during the civic disorders of

that period, he had the care, at Hôtel-Dieu, of many cases of wounds

from firearms.

A French physician whose identity is concealed under the initials J. L.

H. P., has published a very complete pen-portrait of Dupuytren’s most

prominent personal and professional characteristics, and Elisha

Bartlett, M.D., of Boston, has furnished us with an excellent English

translation of this work. From this book I shall take the liberty of

quoting here several sections that seem to me to be particularly

interesting.

Monsieur Dupuytren is, in my opinion a surgeon of the

most exalted merit.... He has a _coup d’oeil_ of most

admirable precision, a sure and steady hand, a coolness and

self-possession always imperturbable, and that innate instinct

or tact so necessary in all the arts. A man is born surgeon or

physician, as a man is born poet or painter.... Monsieur

Dupuytren is particularly remarkable for his diagnostic

foresight.... Arrived at the bedside of the patient, his fine

senses are all awake; in a few minutes of question and

researches, his examination is finished. One might often believe

that he has given to the case only a superficial attention, but

his subsequent lecture will prove that he has seen everything

and seen it thoroughly.... He describes a pathological

alteration, yet hidden in the interior of an organ, as though it

were visible, and, when the scalpel has dissected and uncovered

it, the truth of his description is verified by all who witness

it.... Monsieur Dupuytren is not less skilful in treating

surgical diseases than he is in detecting them.... I do not fear

that I shall be accused of exaggeration in saying that very few

surgeons have given proof of so much surgical genius in the

invention of modes of operating or so much expertness in their

execution. Monsieur Dupuytren possesses in the highest degree a

creative and inventive spirit....

So much for Monsieur Dupuytren as a practitioner; Let us now

consider him as an instructor....

Since 1815, the surgical clinic of Hôtel-Dieu has lost none of

its ancient reputation. No other clinical course in France can

be compared to this, whether for the number of students, the

abundance of cases, or, finally, for the genius of the

professor. In effect, Monsieur Dupuytren comprehends perfectly

in what clinical instruction consists; a thing that ought to be

somewhat difficult, seeing how few there are who succeed in it.

Lessons of clinical surgery have no resemblance to a course of

surgery.... A clinic is altogether a different thing. The

professor has need here to speak continually without

preparation, because the material of his lesson cannot be

regulated by himself, in advance, but is dependent upon chance,

which brings him, to-day, a strangulated hernia, to-morrow, a

fracture; and, in the same day, four or five different cases....

An excellent practitioner, Monsieur Dupuytren thus really

possesses the most essential quality of a clinical professor.

But to this first fundamental qualification others ought to be

united. The professor ought to have a free command of language

and the talent of extemporaneous speaking; he should possess a

memory sufficiently good to recall distinctly all the

circumstances of diseases, and the peculiarities of the

different treatments that he has directed; it is necessary,

that, thoroughly understanding the necessity and obligations of

his instruction, he should accustom himself to return every day

to things which he has a thousand times repeated, unmindful of

the fatigue resulting from such repetition; above all, he should

remember that he is occupied with inexperienced hearers, to whom

it is not sufficient to say things imperfectly; hearers who may

easily be dazzled and led astray, but who ought to be

instructed, an end that cannot be attained without patience. In

respect to all these things, Monsieur Dupuytren is almost

irreproachable.... As to myself, instructed by my personal

experience, and by the numerous comparisons that I have made, I

do not hesitate to believe and to say that the clinic of

Monsieur Dupuytren may be offered as a model of this kind of

instruction.

In his memoir concerning the medical schools of Paris, John Gross, an

English surgeon, says that no lectures at the _École de Médecine_ were

so numerously attended as were those delivered by Dupuytren on operative

medicine. He adds that at the lecture which he attended on the operation

for inguinal hernia, there were present about 1200 students, the

greatest number that the theatre is capable of containing. “But I must

confess that I have seldom learnt less from any good practical lecture

than I did from this. I was too far off to distinguish well what I saw,

or comprehend what I heard; and I returned home with a feeling of

regret, that what is grand should be so far remote from what is most

useful.”

Dupuytren’s health began to break down in 1833, and he was obliged to

take a trip to Italy. A certain amount of improvement resulted from this

journey, but only for a brief period of time. On February 7, 1835, he

died, leaving in his will the sum of 200,000 francs to _l’École de

Médecine_ for the establishment of a chair of pathological anatomy.

Before his death, however, he assented to the proposition that the

_École_ should assume the responsibility of providing funds sufficient

for founding the professorship and thus enable the authorities to

utilize the legacy in establishing an anatomical museum, the _Musée

Dupuytren_, where all sorts of pathological specimens may be carefully

preserved and exposed to view in well-constructed cabinets. (See

photograph of this museum in the plate facing page 260.)

------------------------------------------------------------------------

CHAPTER XXIII

WORKERS IN SPECIAL DEPARTMENTS OF SURGERY: DEMOURS, DESCEMET, DELPECH,

FAUCHARD, JOURDAIN, GARIOT

In modern times such special departments as those devoted to the care of

the teeth, mouth and jaws, to the remedying of defective eyesight and

other affections of the eyes, to the care of the organ of hearing, and

to the cure of the different disorders of the pharynx, larynx and nasal

cavities, have assumed the importance of independent fields of surgical

activity, and as such they demand and are receiving to-day the attention

which they deserve. But during the eighteenth century the practicing

physician was expected to possess the knowledge and skill necessary for

the relief or cure of all such bodily ills, and he was forced to accept

the duties growing out of these problems as a regular part of his day’s

work. In the estimation of the general public the holder of the degree

of M.D. was credited—up to a comparatively recent date—with the

possession of knowledge sufficient for the cure of _all_ bodily ills;

and one can now easily imagine how greatly most of these men must have

suffered from the feeling that they were playing a false and ignoble

part whenever they accepted—as they did in many cases of this nature—a

degree of responsibility which they were wholly unable to bear.

In the present chapter I shall discuss very briefly only these three

specialties: eye surgery, orthopedic surgery and dental surgery.

In the Middle Ages there seem to have been at least two men who were

really skilled in eye surgery and who were widely known in the southern

portion of Europe as possessing exceptional knowledge and skill in the

treatment of this class of maladies. I refer to Pierre Franco, of

Lausanne and Orange, and to Demosthenes of Marseilles. (Brief references

to the work of these two will be found in the volume on “The Growth of

Medicine.”) Then at Vienna, Austria, as I have stated on a previous

page, there were, in the early part of the eighteenth century, Beer,

Rosas, and perhaps one or two others, who did excellent work in eye

surgery, and whose writings on this subject are still to-day held in

high esteem as trustworthy authorities. In France, on the other hand,

there were only two men who, in the early part of the eighteenth

century, seem to have devoted their time and skill to the relief of

affections of the eye—viz., Demours and Descemet.

* * * * *

PIERRE DEMOURS was born at Marseilles in the early part of the

eighteenth century, began the study of medicine at Avignon, and then

went to Paris for the completion of his professional training. He

received his doctor’s degree, however, at Avignon in 1728, probably

because the graduation fees in the latter city were not so large as

those required in Paris. At a still later date he returned to the

capital for the further prosecution of his professional studies, and

while there he was given the appointment of Assistant to Duverney, the

celebrated anatomist, who at that period, despite his advanced age

(eighty years), was still actively engaged in research work. Two years

later, upon Duverney’s death, Demours was invited to accept the

associated positions of Demonstrator and Custodian of the Cabinet of

Natural History at the Jardin du Roi. He had occupied these positions

only a short time when Jean-Louis Petit, the celebrated French surgeon,

who had observed the excellent character of the work performed by

Demours, advised him to direct his studies more particularly to the

anatomy and maladies of the eyes. Demours was quite ready to accept this

advice, and thus it came about that in a few years he acquired

considerable reputation as a successful practitioner in affections of

the eye, a reputation which he continued to hold up to the time of his

death on June 26, 1795.

Among the contributions which Demours made to the literature of

ophthalmology the following deserve to receive special mention:—

Letter to Petit giving the report of an eye complication that

developed as the result of an inoculation with the virus of

small-pox; together with an account of some new observations

relating to the anatomy of the eye and a few general comments on

diseases of that organ; Paris, 1767.

A new series of remarks upon certain features in the anatomy of

the cornea; Paris, 1770.

Observations on the structure of the _corpus vitreum_; Paris,

1741.

Observations on the cornea; Paris, 1741.

Dissertation on the mechanism of the movements of the pupil and

on certain characteristics of the _fibrae rectae_ of the uvea,

in “_Mémoires des Savans Étrangers_,” tome II.; and the

following articles in the “_Journal de Médecine_” edited by

Vandermonde: “On an affection of the eyes which sometimes

develops after a perfectly faultless cataract operation

(extraction),” in tome XVI.; “Reply to Monsieur Descemet’s

article on the cartilaginous layer of the cornea,” in tomes

XXXI. and XXXIII.

* * * * *

JEAN DESCEMET, born at Paris on April 20, 1732, was the pupil and friend

of Duhamel-Dumonceau, one of the greatest teachers of that period and an

enthusiastic scientist, but not a physician. Vicq-d’Azyr says that the

list of the papers which he published during his lifetime (he was

eighty-two years old at the time of his death) is very long and reveals

the fact that he was interested in a great variety of topics, the

majority of them relating to commerce, the arts, vegetable physiology,

agriculture, and marine questions. To Descemet the influence of such a

powerful mind, so enthusiastic and yet so precise in all its operations,

could not fail to have been very great, and one of its earliest effects

was to lead him to take a strong interest in botany and in anatomical

research work. His graduation thesis, which—in accordance with the

prevailing custom—he publicly defended early in 1758, dealt with the

subject of the minute anatomy of the cornea and the lens. As the

investigations which he made in regard to these important structures

were strictly original, the scientific authorities accorded to him the

honor of having his name attached to the membrane which lines the

internal face of the transparent cornea, and which at the same time

envelopes the aqueous humor. The reason why this membrane was selected

by preference was this: Descemet was believed to have been the first

person to describe in great detail this previously unknown structure.

Demours, in 1767, published an article in which he claimed that the

honor of this discovery belonged to him and not to Descemet. I cannot

pretend to decide upon the justice of this claim; but, so far as I am

able to learn, nobody has in modern times seriously disputed the

propriety of retaining the name “Descemet’s membrane.”[25]

Descemet was held in high esteem by all his associates in the Paris

Faculty of Medicine. He was generally recognized by the medical men of

France to be a skilled anatomist and a careful and trustworthy observer.

The various offices which he held at one time or another in the course

of his active life give further proof of the correctness of the estimate

which I have furnished of this admirable French physician. His death

occurred at Paris in 1810.

Among his published writings the following deserve to receive special

mention:—

“_An sola lens crystallina cataractae sedes?_”—Paris, 1758.

“Catalogues of the garden plants cultivated by the apothecaries

of Paris,” Paris, 1759.

“Mémoire et observations sur la choroïde, etc.,” in “_Mémoires

des Savans Étrangers de l’Academie Royale des Sciences_,” tome

V., 1768.

In the last-named article valuable information is furnished with regard

to the membrane which bears his name. Here, for instance, is revealed

the fact that with advancing age the attachment of the membrane to the

cornea gradually becomes less firm until finally, at the age of about

sixty, it becomes completely detached.

* * * * *

JACQUES DELPECH was born at Toulouse, in the south-western part of

France, in 1772. After he had completed his preliminary studies at

Toulouse he went to Montpellier, took the regular course in medicine at

the university, and was given the degree of Doctor in Surgery in 1801.

While residing in that city he acted as an _Officier de Santé_ in one of

the military hospitals. The following year he was given the position of

Instructor in Anatomy at the Toulouse Medical School, which at that

period bore the title of “_Société de Médecine et de Pharmacie_.” It was

here that he first manifested his great gifts as a teacher, his success

in this respect being truly remarkable. In 1812 he offered himself,

along with several other competitors, as a candidate for the chair of

clinical surgery in the Faculty of the Montpellier Medical School, and

was given this coveted position. It should be stated, however, that

previous to this event, for a period of several years following his

brief service as an instructor in anatomy at Toulouse, he had devoted

himself with great zeal and thoroughness to the study of surgery in

Paris, and was therefore specially well prepared for this competitive

test. In the new field in which, from this time forward to the end of

his career, he worked with unflagging enthusiasm, Delpech had ample

opportunity to show to the world his great talents as a teacher of

surgery.

There was one branch of surgical work in which he took a greater

interest than in all the others, made many ingenious discoveries, and

thus gained great distinction; I refer to the pathology and treatment of

deformities, the science of orthopedics. He not only built up a large

practice in cases of this nature, but he also wrote a valuable treatise

on the subject. This work, which was published in Paris in 1828–1829,

bears the title: “_De l’Orthomorphie, par Rapport à l’Espèce Humaine, ou

Recherches Anatomico-Pathologiques sur les Causes, les Moyens de

Prévenir, Ceux de Guérir les Principales Difformités, et sur les

Véritables Fondemens de l’Art Appelé Orthopédique_.” It is, briefly

stated, a complete treatise on the pathology and treatment of

deformities of the human frame, one of the first (possibly the very

first) of its kind published in a modern language. From statements which

he makes in the course of his text it appears that Delpech recognized at

an early date that it is upon the muscles surrounding a joint that its

solidity is chiefly dependent, and consequently that all lesions

involving the muscular apparatus in the neighborhood of a joint are very

potent factors in the causation of deformities. In addition, he states

that the absence of exact fitting of two opposite articular surfaces,

one upon the other, during the period of development of the skeleton,

constitutes another and very important cause of deformities both in the

limbs and in the trunk. To these general causes, he says, there may be

added the following: muscular debility, the effects produced by certain

attitudes of the body, by the paralysis and also by the contractures of

certain muscles, by the effects of rheumatism, by softening of the

bones, etc.

In other sections of the treatise he discusses in a most practical and

interesting manner the subjects of diagnosis and treatment of

deformities. In the remarkable orthopedic hospital which he established

in Montpellier he treated, with enthusiasm and untiring faithfulness,

large numbers of patients suffering from deformities of all sorts, thus

gaining a wide experience in this particular class of cases, and

constantly increasing his skill in treating them successfully.

In the earlier years of his practice Delpech also published an important

paper on the subject of hospital gangrene, under the title: “_Mémoire

sur la Complication des Plaies et des Ulcères, Connue sous le Nom de

‘Pourriture d’Hôpital’_”; Paris, 1815. This memoir is esteemed by his

biographer to be the best treatise that had been written on hospital

gangrene up to the year 1834.

Delpech, says his biographer, will always be classed as one of the most

distinguished professors of the Medical School of Montpellier during the

early part of the nineteenth century.

On the 28th of October, 1832, he was assassinated by a merchant of

Bordeaux upon whom he had operated for varicocele during the preceding

year, and who, immediately after killing his victim, destroyed his own

life.

* * * * *

PIERRE FAUCHARD, A. JOURDAIN AND J. B. GARIOT.—Although it is the

general belief that dentistry did not become a separate and independent

branch of surgical practice until a comparatively recent date, there is

nevertheless some evidence that efforts were made by certain surgeons,

many years ago, to engage in this special field of work. The earliest

record of this fact, so far as I have been able to discover, is

furnished by Francis Gribble in his book entitled: “Lake Geneva and its

Literary Landmarks.” According to his statement a dentist, toward the

end of the sixteenth century, applied to the Governing Body of Geneva,

Switzerland, for permission to settle in that city and practice his

profession. As the civic authorities, however, did not appear to

comprehend just how much risk, either to the bodies or to the souls of

the Genevese, was involved in granting the desired permission, they

referred the question to Théodore de Bèze, the great theologist, who, in

the temporary absence of John Calvin, was acting as the Syndic or Mayor

of the city. We are not told by Gribble how the matter was at last

decided, but there can be scarcely any doubt that the dentist was

finally permitted to hang out his shingle and go to work.

The explorations made among the ruins of ancient Egypt show that even at

that remote period, three or four hundred years before the Christian

Era, there were men who knew how to fill carious cavities in human teeth

and to perform other surgical acts which call for the skill and

knowledge of the practical dentist. But the discovery of such isolated

facts does not demonstrate clearly that dentistry was practiced at that

early period as a special department of the surgical art; and,

furthermore, many centuries after that date elapsed before there was

discovered any further evidence that dentistry had survived during the

long intervening period. In fact, the records do not throw much light on

this subject until we reach the seventeenth century. Then it appears

that a certain Alexandre Poteler, during the latter part of that

century, attained considerable celebrity, in France, as a skilful and

experienced dental surgeon. Further details concerning this man are

lacking.

Sprengel, in his history of medicine, mentions the names of several

men—Germans, French and English—who during the early part of the

eighteenth century occasionally performed operations in the field of

dentistry, but among this number I find only three who appear to have

attained eminence in their special line of work—viz., Pierre Fauchard,

A. Jourdain, and J. B. Gariot. I will furnish here the few details which

I have been able to obtain concerning the career of these men.

* * * * *

PIERRE FAUCHARD was born in France toward the end of the seventeenth

century. After receiving the regular training of a physician he entered

the service of the Royal Navy, ultimately attaining the rank of

Surgeon-Major. Subsequently, having first taken a special course of

instruction under Alexandre Poteler, he settled at Paris and practiced

dentistry in that city for a period of more than fifty years. During the

course of his career he published a treatise on the surgery of the

mouth, and in the preparation of this work he received efficient aid

from Jean Devaux (1649–1729), one of the most learned surgeons of his

time in France. This treatise, according to the testimony of his

biographer, contains many reports of cases which were observed by

Fauchard in actual practice; and, he adds, the book still possesses

considerable value as a work of reference. Among the unusual

pathological conditions described and occasionally pictured the

following deserve to receive special mention:—“Abscess or Softening of

the Dental Pulp without Recognizable Alteration of the Cortical

Substance” (relief was obtained by trephining the tooth); “Defective

Teeth of Many Different Kinds,” and the proper manner of remedying such

defects, both in cases where only a part of the tooth is defective, and

also in those where it is found necessary to supply an entire tooth or

even several teeth; “On the Art of Remedying Defects in the Palate”; “On

the More Extensive Employment of Lead Fillings, etc.” The treatise here

referred to bears the following title: “_Le Chirurgien Dentiste, ou

Traité des Dents_, etc.,” with 40 engraved plates; 2 vols., Paris, 1728;

a second edition, which was published in 1746, contains many important

additions.

* * * * *

ANSELME-LOUIS-BERNARD-BRECHILLET JOURDAIN, who was born in Paris,

November 28, 1734, was one of the most distinguished French physicians

of the eighteenth century who devoted himself largely to the study and

practice of dentistry. He was also interested in medical science

generally, having acted for several years as an associate editor of the

_Journal de Médecine_. Among the treatises which he wrote on topics

relating to dentistry the following deserve to receive special

mention:—“_Nouveaux Élémens d’Odontalgie_,” Paris, 1756; “_Traité des

Dépôts dans le Sinus Maxillaire, des Fractures et des Caries de l’Une et

de l’Autre Mâchoire; Suivi de Réflexions et d’Observations sur Toutes

les Opérations de l’Art du Dentiste_,” Paris, 1760; “_Essai sur la

Formation des Dents, Comparée avec Celle des Os, Suivi de Plusieurs

Expériences, tant sur les Os que sur les Parties qui Entrent dans leur

Constitution_,” Paris, 1766; and “_Traité des Maladies et des Opérations

Réellement Chirurgicales de la Bouche et des Parties qui y

Correspondent, Suivi de Notes, d’Observations Interessantes, tant

Anciennes que Modernes_,” Paris, 1772, 2 vols.

Jourdain’s death occurred on January 7, 1816.

* * * * *

JEAN-BAPTISTE GARIOT was born in France during the latter half of the

eighteenth century. The French records furnish very scanty information

concerning his professional career. For example, among other matters of

minor importance, it is stated that he was a member of the Royal College

at Madrid, that he was the dentist of the King of Spain, and that he

published a treatise which bears the following title: “_Traité des

Maladies de la Bouche_,” together with an account of the structure and

functions of the parts that enter into the formation of the mouth, the

diseases to which these parts are liable, the means that may be employed

for maintaining them in health and beauty, and the different operations

which belong specially to the domain of the dentist; with 15 plates,

Paris, 1805.

------------------------------------------------------------------------

BOOK XII

DESGENETTES AND LARREY, FRANCE’S MOST CELEBRATED MILITARY SURGEONS

------------------------------------------------------------------------

CHAPTER XXIV

MILITARY SURGERY

The two most distinguished military surgeons in Europe during the

eighteenth and nineteenth centuries were Desgenettes and Baron Larrey,

both of them natives of France.

* * * * *

AIMÉ-NICOLAS DUFRICHE DESGENETTES was born at Alençon, France, in 1762.

His early medical training was obtained at the University of

Montpellier, and the degree of Doctor of Medicine was bestowed upon him

in 1789. Four years later he entered the French military service and

participated in the campaign of Egypt and Syria, during which he rapidly

rose to the position of Chief Physician in that part of the army which

was officially designated as the Army of Italy. In 1802, after the close

of the campaign, he was appointed First Physician of the Military

Hospital at Paris, and at the same time was given the position of

General Inspector of the Health Department of the Armies. From that time

to the year 1814 he visited, in his official capacity, Russia, Prussia

and Spain; and amid scenes of carnage and destruction he never failed to

display the character of a high-minded physician, a benevolent and

guardian spirit. His career as a medical officer was largely that of a

man of action, who exhibited at the same time a keen sympathy for those

who stood in need of his services. To quote the words of his biographer,

“he extended his cares to the sick of all nations,—to the Turk and the

Christian, to the men of the South as well as to those of the North,

and, as disinterested also as the Great Hippocrates, he retired poor

from his labors, though he might easily have made himself rich. Often

placed in opposition to military power and faction, he always exhibited

an unwavering inflexibility and energy of character. His thorough

knowledge of men and things, his skill in the practice of his art, and

his vigorous and unbending mind distinguished him for more than twenty

years at the head of the medical service of the French armies.”

This splendid showing, I venture to remark, could scarcely have been

realized if Bonaparte had not been endowed with two admirable traits of

character. In the first place, he seemed to possess almost infallibly

correct judgment in his choice of men who were to act as generals or as

chief surgeons of his various armies; and then, in the second place, he

was in the habit of supporting these men loyally whenever, later on in

their career, disputes arose as to the wisdom or patriotic purpose of

their decisions. The history of the wars that occurred from 1793 to

1814, between France and the different European nations which opposed

her, abounds in instances that confirm the truth of what I have just

stated. Corvisart, it is also highly probable, deserves much of the

credit for Bonaparte’s loyal treatment of his chief army surgeons.

The biographer of Desgenettes relates two occurrences which throw

additional light upon the nobility of character of this admirable

physician. These occurrences are briefly narrated as follows:—

A contagious disease appeared in the Army of the East and spread

rapidly from one man to another. The soldiers were struck with

terror and despair, and were ready to die, merely because they

considered death imminent and inevitable.... Monsieur

Desgenettes assured them that the hideous buboes with which they

were covered were not symptoms of the plague, and he proved it.

How? By the following heroic experiment. He took the matter of

these buboes and inoculated himself in the presence of the

soldiers. This proof was conclusive in their eyes, hope was

again kindled in their bosoms, and the mortality diminished.

Here is one of those brilliant actions which history delights to

preserve and transmit from age to age.

[Illustration:

DESGENETTES

]

On another occasion Desgenettes manifested equally great courage. The

occurrence is narrated by his biographer in these words:—

Made prisoner in the retreat from Russia, he demanded boldly his

liberty, not as a favor, but as a right; he invoked the

sacredness of his ministry and in particular the cares which he

had lavished alike on the Russians and on the French. An

imperial ukase immediately rendered him his liberty. The Emperor

Alexander called him into his presence and expressed to him his

sentiments of high esteem and regard. He received soon after

from Sweden the order of the Polar Star.

Desgenettes’ death occurred in 1837. He made no contributions to medical

literature; and his enemies brought against him the charge that, when he

delivered a lecture, he spoiled it by telling too many anecdotes about

the different wars in which he took part.

* * * * *

JEAN-DOMINIQUE LARREY was born in 1776 at Baudéan, a French village at

the foot of the Pyrenees. At the age of thirteen years, shortly after

the death of his father, he quitted his native village and came under

the care of his uncle, Alexis Larrey, who was Surgeon-Major and

Professor at the Hospital of Grave, near Toulouse. Under the wise and

kindly guidance of the latter he pursued his studies so earnestly and

with such intelligence that he was able, on attaining his twentieth

year, to pass successfully the examinations required for an appointment

to the position of Assistant Surgeon in the French Navy.

The sloop-of-war “_La Vigilante_,” the vessel in which he gained his

first experience in the naval service, met with disaster and Larrey was

nearly shipwrecked. As soon as possible after this thrilling experience

he went to Paris and took service in the great Hospital of Hôtel-Dieu,

under the orders of the famous surgeon Desault. This was at the

beginning of the severe winter of 1789, an eventful time in the history

of France. The Revolution was now in full swing, and Larrey not only was

an eye-witness of the troubles which characterized its early stages, but

he also had the opportunity, under the orders of Desault, to render

professional service to the first victims of those tragic days. Three

years afterward, while serving in the Army of the Rhine, under the

command of Marshal Luckner, he was able to put to good use all the

admirable surgical training which he had received under Desault at the

Hôtel-Dieu.

When Larrey was about twenty-one years old and while he was attached to

that part of the French Army which was then stationed in the vicinity of

Milan and Venice, he interested himself actively in the establishment of

an army ambulance service. Already three or four years earlier he had

become sensible of the inconveniences of the French ambulances which

were then in use. In the first place, these vehicles were of such a type

as to be ill-suited to the work which they were intended to perform;

they were too heavy to be driven with reasonable speed to and from the

battlefield, and they were also so rigidly constructed that at every

irregularity in the ground over which the wheels passed the wounded

soldier experienced a painful jolt. Then, in the second place, aside

from the faulty construction of these vehicles, the regulations

governing their management were so badly planned as to leave the wounded

lying unaided on the battlefield sometimes for several hours together.

It was customary, for example, to station the ambulances at a spot about

three miles distant from the troops who were shortly to engage in

combat, and they were not despatched to the battlefield until after the

fighting had ended. In this way hours often elapsed before the wounded

could receive any aid whatever from the surgeon.

In working out a solution of this complex problem Larrey’s very

practical mind quickly reached certain conclusions: first, that it was

most important to remove the wounded from the battlefield to a place of

safety much earlier than had hitherto been the custom; and, second, that

the type of ambulance then universally employed was altogether too heavy

and too rigid to serve well the purposes for which it was needed. He

realized fully that this last part of the problem was the more important

part, and that, if he could invent a less ponderous and at the same time

more elastic vehicle for use as the field ambulance, he would by this

very act be placed in a position where he could effect in a large

measure a solution of the second half of the problem.

[Illustration:

BARON LARREY

]

Larrey promptly set about the work of providing a new type of field

ambulance and in a short time was successful in obtaining a most useful

vehicle for the purpose. It is described by his biographer in the

following words:—

This invention of Larrey’s was a kind of carriage hung on

springs, uniting great strength and solidity with lightness.

Such indeed was its lightness that it was able to follow all the

movements of the advance guard with as much speed as flying

artillery. These _ambulances volantes_, as they were called,

were first used by the French in a defile of the Rhine near

Koenigstein. Here the ambulances invented by the talented and

benevolent French surgeon bore the wounded rapidly away from the

neighborhood of the enemy instead of leaving them either to die

or to sustain a protracted agony on the field of battle.

In this work of inventing a field ambulance of a greatly improved

pattern Larrey revealed an exceptionally fine trait of character, viz.,

a strong desire to utilize his talents and the opportunities afforded by

his official position for the benefit of his fellow men, both the

wounded of the French army and those of the enemy forces. He revealed

the same trait in many other ways—as, for instance, when he took

infinite pains, after a battle, to provide proper shelter, food and care

for the wounded in the town or village nearest to the site of the

conflict, and that too in a part of the country which belonged to the

enemy. He revealed it again in the fighting which took place in Eastern

Prussia and in the course of the numerous retreats which Napoleon’s army

was forced to make in the Russian campaign.

Among the incidents which occurred during that long and disastrous

retreat of the remnants of Napoleon’s army from Moscow there was one

which reveals in a very clear light the high sense of duty that

characterized Larrey’s actions as Surgeon-in-Chief of the French Army

and the complete faith which the individual soldiers composing that

army—or at least the better disposed among them—placed in his

disinterested and loyal service in their behalf. The incident to which I

have reference occurred while the disorganized French troops were

crossing the Beresina River and is thus described by Larrey’s

biographer:—

The Russian general arrived at the head of 50,000 men and began

the fire among the division of General Partonneaux, the soldiers

of which division immediately wished to cross the Bridge all at

once. The conveyances collided with one another, and some of the

unfortunate men were crushed, while others, losing all spirit,

threw themselves into the stream.... There was throughout a

frightful mixture of imprecations, of clashings, and of

strugglings, whence arose indescribable disorder and a breaking

of the overloaded bridge. The Russian Army approached, and with

its formidable artillery tore the ranks of the French mob of

soldiers.... In this immense disaster what had become of the

distinguished Surgeon-in-Chief of the Grand Army? After having

crossed over the Beresina with the Imperial Guard, he discovered

that requisites for the sick and wounded of his countrymen had

been left on the opposite bank. With equal humanity and heroism,

he recrossed the river, and hardly had he done so when he was

surrounded by a wildly excited crowd. He was almost suffocated

in the midst of it.... No sooner was he recognized than he was

carried back with great rapidity in the arms of the soldiers

across the river. On all parts was heard the cry, in nearly

these words, “Let us save him who saved us!” The soldiers almost

forgot their own safety in their desire to preserve an officer

whose tender kindness they had so often experienced.

I believe that I have now shown with sufficient fulness of detail what

were the prominent characteristics of Larrey as a man and as an

executive army medical officer. It still remains for me to furnish some

evidence of the excellent judgment which he displayed in his work as a

practical surgeon.

In one of the French hospitals, during the war, Larrey’s attention was

called to a Russian soldier who had been shot in the forehead by an iron

ball weighing 217 grammes. This projectile had pierced the frontal bone

above and a little to the outside of the right eyebrow, and had

penetrated into the interior of the skull. Despite the bulk of this iron

ball, the opening which was perceptible in the bone did not exceed six

or eight millimeters in diameter, and, by introducing a small probe, one

might feel the ball. The smallness of the opening in the bone, says

Larrey, may be explained by the elasticity of the osseous fibres, some

of which the ball would have to push aside in order completely to

penetrate the outer table of the frontal bone, and which consequently

would yield instead of fracturing. In the present case the bony angles

at the edge of the circular opening were cut away by the surgeon and the

opening itself was made large enough to permit the removal of the ball

by means of an elevator and pincers. A great quantity of coagulated

blood and some small fragments of bone were then evacuated. The brain

itself presented at this spot a depression of about seven millimeters in

depth. In a short period of time the wound healed, and apparently

complete recovery followed.

In order to judge correctly of the credit which rightfully belongs to

Larrey for his successful treatment of this case of gunshot wound of the

skull and underlying brain, one must remember that in the early part of

the nineteenth century it was considered a very bold surgical act to

operate upon the injured brain, and particularly so in the almost

complete absence of adequate surgical equipment.

As an instance of Larrey’s quickness in meeting an emergency I will

narrate here very briefly an experience which he had at Smolensk,

Russia. When the French troops entered that city, after a severe battle,

they found that the inhabitants had already fled, owing in part to the

fact that many of their dwellings had been destroyed by fire. Larrey, as

soon as was practicable, converted fifteen of the largest buildings

which had not been devastated by the flames, into hospitals for the

wounded. Unfortunately, all supplies or stores of any kind had either

been destroyed by the enemy or removed by them in their orderly and

premeditated retreat. For the large number of wounded there was a

deficiency of linen and splints; but Larrey discovered a store of

archives in one of the buildings which had escaped the fire, and he

promptly substituted sheets of paper for linen and utilized the thick

parchment covers for splints. He toiled with little intermission night

and day, and the French surgeons generally, in imitation of their chief,

were indefatigable in their attention to the wounded, who were about

10,000 in number.

Las Cases, in his “Memorial of St. Helena,” published after he had

returned to Europe, reports Napoleon as having uttered the following

words on October 23, 1816: “What a man, what a brave and worthy man is

Larrey! What care was given by him to the army in Egypt and everywhere!

I have conceived for him the highest esteem. If the army were to raise a

column to the memory of any one, it should be to the memory of Larrey.

He has left in my mind the idea of a truly honest man.” In his will

Napoleon wrote: “I bequeath to the Surgeon-in-Chief of the French Army,

Larrey, 100,000 francs. He is the most virtuous man I have ever known.”

The reader will pardon me, I am sure, if I furnish here additional proof

of Larrey’s sound judgment in questions of a purely surgical nature. He

insisted, for example, on the importance of promptly resorting to

amputation in cases where the gunshot wound had caused a complicated

fracture of the bone or had inflicted serious destruction of the soft

parts; and he particularly recommended this course of action in the case

of individuals who were cachectic or below par. He expressed himself in

favor of the circular incision in preference to that which was intended

to furnish flaps. (From “_Mémoire sur les Amputations, etc._,” Paris,

1797.)

In another place Larrey mentions, somewhat in detail, the reasons why

primary amputations are to be given the preference in military surgery.

They are the following:—

(1) The inconvenience which attends the transportation of the

wounded from the field of battle to the military hospitals on

badly constructed carriages; the jarring of these wagons

produces such disorder in the wounds and in all the nerves, that

the greater part of the wounded perish on the way, especially if

it be long, and the heat or cold of the weather be extreme.

(2) The danger of remaining long in the hospitals. This risk is

much diminished by amputation; it converts a gunshot wound into

one which is capable of being speedily healed, and obviates the

causes that produce the hospital fever and gangrene.

(3) In case the wounded are of necessity abandoned on the field

of battle: In this event it is important that amputation should

have been performed, because—when it is completed—they [the

wounded] may remain several days without being dressed, and the

subsequent dressings are more easily accomplished. Moreover, it

often happens that these unfortunate persons do not find

surgeons sufficiently skilful to operate, as we have seen among

some nations whose military hospitals were not organized like

ours. (From Vol. 2 of Larrey’s “Memoirs of Military Surgery.”)

(In judging the quality of the advice given here the reader should not

overlook the fact that it was pronounced in the early part of the

nineteenth century.)

Larrey’s death occurred on July 24, 1842. A few years previous to this

date he had received the title of Baron.

------------------------------------------------------------------------

BOOK XIII

A FEW OF THE IMPORTANT HOSPITALS AND THE PRINCIPAL ORGANIZATIONS IN

PARIS FOR TEACHING MEDICINE AND MIDWIFERY

------------------------------------------------------------------------

CHAPTER XXV

HOSPITAL OF “LA MATERNITÉ,” THE GREAT FRENCH MIDWIFERY SCHOOL

John Cross, the author of an excellent memoir entitled “Sketches of the

Medical Schools of Paris,” has written such a full and satisfactory

account of _la Maternité_ and its admirable teaching machinery that I

shall not hesitate to use it freely as my guide in preparing this and

the following chapters. I am the more ready to adopt this course

because, first, I have had no personal experience whatever with this

department of medical science, and, second, because Dr. Cross’ account

is not compiled from the writings of other physicians, but is based upon

his own personal observations and upon information which he derived at

first hand from Monsieur Chaussier, the Physician-in-Chief of the

hospital. Here is what he writes (1815) upon this important subject:—

The midwifery department of _l’Hôpital de la Maternité_ is

converted to an admirable purpose by being made a school for the

educating of _Sages-Femmes_ (midwives); and I was not a little

surprised at my first entering this hospital with Monsieur

Chaussier, the Physician-in-Chief, to find the wards crowded

with female students. This midwifery-school was founded about

twelve years ago (about 1803), since which time young women have

come annually from all parts of France to study there. Some

pursue their education at their own expense; but most of them

are chosen by the _Prefets_ of the different _Départements_ of

France or by the governors of country hospitals, by whom all

expenses are paid. For six-hundred francs these women are

lodged, boarded and educated, during one year. They reside in

the hospital, and cannot go out of its precincts without

permission. After a twelve-months residence and an examination,

they receive their diplomas from _l’École de Médecine_—or the

_Faculté de Médecine_—to practice as midwives.... They follow

the Physician and Surgeon in their daily visits, and each pupil

makes a clinical report in writing of the patients under her

care. The accuracy and minuteness of some of these reports,

presented to Monsieur Chaussier during his visit, could not have

been greater if they had been made by an experienced

practitioner....

During the first five years of the existence of this _École

d’Accouchement_, nearly five-hundred well-educated women were

sent to practice midwifery in different parts of France.... In

June, 1814, the month in which the new students are admitted,

and those who have finished their education are dismissed,

one-hundred and thirty, who had followed the lectures and

practice of midwifery at _la Maternité_ during the preceding

year, were examined, and received certificates of their being

qualified to practice as _accoucheuses_.... Monsieur

Baudelocque was, to the time of his death, a zealous promoter

of this school of midwifery, and a copy of his catechism _sur

les Accouchements_ is given to each pupil as soon as she is

admitted. This school is an institution which, from the

novelty and excellence of the plan, the manner in which it is

carried on, and the benefits that must spring from it to

society, does honor to the country which has founded and

supported it.... _Les Élèves Sages-Femmes_ who reside for

twelve months at _l’Hôpital de la Maternité_, and about whose

instruction so much pains are taken and so much attention

bestowed by the medical men attached to it, are, there can be

little doubt, quite as good practitioners at the completion of

their education, as the male students in midwifery in any

country.

What is here written by Dr. Cross refers to the condition of _la

Maternité_ as he found it in 1815,—that is, after the institution had

been in successful operation for nearly if not quite twenty years. To go

back to the time when it was first organized I should state that, upon

the breaking up and disorganization of the _Faculté de Médecine_ and the

_École de Chirurgie_, there was erected, upon the ruins of these,

_l’École de Santé_, in which Baudelocque was given the place of

Professor of Obstetrics; and at the same time he was appointed

“Surgeon-in-Chief and Accoucheur” of the recently established

_Maternité_. From the very first both the general public and the great

majority of physicians reposed almost absolute confidence in

Baudelocque, and consequently it is not strange that he was the guiding

spirit in the development of this important hospital and training

school.

Sprengel, the author of one of the earliest and best histories of

medicine, gives unlimited praise to Baudelocque for the clearness,

practical character and conciseness of his writings on the subject of

midwifery. His treatise on obstetrics, he adds, is decidedly superior to

that of the English surgeon, Thomas Denman, whose writings, which cover

the same field, were published at about the same period of time.

As to the details of the management of _la Maternité_, the mortality

experienced, the number of infants born, etc.... I must refer the reader

to Dr. Cross’ memoir, in which he gives, in addition, an account of the

somewhat similar work done at the famous Dublin Lying-in Hospital. There

remain, however, a number of interesting details concerning the life and

career of Baudelocque which cannot well be omitted from this sketch, and

I will therefore proceed at once to supply them here.

Professional jealousy, which seems to have existed in those days in a

particularly virulent form, left Baudelocque very little peace of mind

and undermined his health to a serious degree. One of the most striking

experiences of this nature is the following:—

A certain Dr. Sacombe set out to increase his reputation—or, rather, to

gain notoriety for himself—by attacking violently all those physicians

who sanctioned the operation of Caesarian section as permissible in

certain cases; and, inasmuch as Baudelocque was the most distinguished

one among these physicians, he directed his most violent efforts against

him. There having recently occurred, in the latter’s practice, a case of

tedious labor in which it had been found necessary to remove the head of

the foetus by amputation, Dr. Sacombe intimated that Baudelocque in this

instance had been guilty of what apparently amounted to a double murder.

Both public opinion and the courts were very prompt in judging this to

be an infamous calumny on the part of the accuser. Although Baudelocque

was completely exonerated from the charge, he nevertheless suffered

keenly from the brutality of this attack upon his character. In fact, it

was believed that the cerebral affection from which he died on May 2,

1810, was brought on by the worry which was associated with Dr.

Sacombe’s attack. Shortly before his death the news reached him that he

had been chosen to take charge of the _Accouchement_ of the Empress,

Marie Louise, but even this vindication failed to be of any benefit at

that late hour.

The two most important treatises published by Baudelocque are the

following: “_Principes de l’Art par Réponses, en Faveur des Élèves

Sages-Femmes_,” Paris, 1775. This work was written entirely for the

guidance of midwives, the Government purchasing 6000 copies. “_l’Art des

Accouchements_,” Paris, 1781, 2 vols. Later editions were published in

1789, 1796, 1807, 1815 and 1822. Baudelocque also published a number of

memoirs and reports of cases.

The success of _la Maternité_ as the great French Lying-in Hospital and

Training School for Midwives was probably as much due to the wise and

painstaking management of the widow Lachapelle as to the skill and great

experience of Baudelocque. It is therefore only fitting that I should

give here a brief biographic sketch of this admirable woman.

* * * * *

VEUVE LACHAPELLE, whose maiden name was Marie-Louise Dugès, was born at

Paris on January 1, 1769. Her mother, Marie Jonet, was at first a sworn

midwife (“_Sage-Femme Jurée_”) at the Chatelet Hospital, but later

(1775) she was promoted to the position of Midwife-in-Chief of

Hôtel-Dieu, the largest hospital in Paris. Madame Jonet made her home in

Hôtel-Dieu, and she performed the duties of her very responsible office

with such zeal, such conspicuous ability, and such faithfulness that the

Government awarded her, when she retired after a long service, a liberal

pension. The daughter Marie, who had been brought up with great care

under the constant supervision of her mother, and who had lived from day

to day as it were in the midst of pregnant women and women actually

undergoing confinement, absorbed unconsciously a great deal of

information, both theoretical and practical, concerning the art of

midwifery. Although she married, in 1792, Monsieur Lachapelle, the

Resident Surgeon of the Hôpital Saint-Louis, she continued her residence

at Hôtel-Dieu, with her mother, to whom she was strongly attached; and

after the death of her husband, which occurred not long after they had

been married, this attachment rather increased. Madame Lachapelle, who

from this time onward was known as _Veuve Lachapelle_, showed such a

keen interest in her work and performed all her hospital duties with

such skill and such excellent judgment that in 1795 the Government

appointed her the Associate Chief Midwife of Hôtel-Dieu.

At a somewhat later date, during the administration of Minister Chaptal,

the Maternité Hospital was organized, and Madame Lachapelle was made the

Resident Directress of the new institution. Baudelocque was appointed

Surgeon-in-Chief and Professor of Obstetrics, and Madame Lachapelle was

given the position, under him, of Instructress in Midwifery. François

Chaussier, Baudelocque’s successor and one of the most distinguished

French physicians of that period, declared that Madame Lachapelle was a

most successful teacher of the art of midwifery, and added that her

usefulness in this field extended far beyond the period of her active

connection with the Maternité Hospital; for she had made a regular

practice, during her residence in that institution, of keeping an

immense number of carefully prepared records of the cases which came

under her observation, and these, which form the basis of the volumes

published after her death, by her nephew, constitute—as Chaussier

believes—a most useful work of reference, second in value only to the

great work of Baudelocque.

Veuve Lachapelle’s death occurred on October 4, 1821. The work referred

to in the preceding paragraph bears the following title: “_Pratique des

Accouchemens, ou Mémoires et Observations Choisies sur les Points les

plus Importans de l’Art_,” publiées par Antoine Dugès, neveu de

l’auteur, Paris, 1821–1825, 3 vols.

------------------------------------------------------------------------

CHAPTER XXVI

FURTHER DETAILS CONCERNING THE PARIS FACULTÉ DE MÉDECINE AND CONCERNING

SOME OF THE LARGER HOSPITALS OF PARIS

The present chapter is intended to supply, in as condensed a form as

possible, some of the facts relating to the growth of the Paris School

of Medicine, and also information concerning one or two of the larger

hospitals of Paris. As such details are not likely to possess interest

for more than a comparatively small number of my readers I

unhesitatingly advise all others to skip this chapter.