L'avenement de la medecine clinique moderne en Europe, 1750-1815: Politiques, institutions et savoirs (review)

A controversy over the role of the "Paris School" in the development of clinical medicine around 1800 has agitated historians for more than thirty years. It began with two devotees of the political, social, and medical history of the Revolution and Napoleonic era, George Rosen and Erwin Ackerknecht. It reached a wide public when Michel Foucault issued the provocative claim that Revolutionary physicians used their power over huge numbers of destitute hospitalized proletarians to extract and promote medical knowledge. Foucault's denunciation of medical power coincided with the wave of student protests in the late '60s and '70s and fueled the general assault on authority, whether wielded in the seminary, the army, the factory, the prison, the hospital, or the asylum.

Since then, several collections of essays debating the Foucault thesis, or nibbling at the edges of the Ackerknecht thesis, have drawn a wide array of scholars, including Othmar Keel, into this controversy over the rise of clinical medicine. The debate hinges on the role of pathological anatomy and of the anatomo-clinical method. It concerns the transition from a medicine that searches for the lesion or "seat" of the disease at autopsy (and relates these findings to clinical observations of the living patient) to a medicine that focuses on the history of the disease derived from the observation of large numbers of hospitalized patients. From an analysis of the structure of the disease we move to the analysis of disturbed function.

In Avènement, Keel reaches his long-sought goal: to broaden the eighteenth-century base for the rise of clinical medicine. He shows convincingly that all over western Europe students learned anatomy and surgery in civilian and military amphitheaters, and medicine at the bedside. The Enlightenment being a cosmopolitan age, physicians traveled and research was often stimulated by foreign ideas. Keel finds it essential to challenge the originality and centrality of the "Paris School," the group of clinicians headed by Corvisart, Pinel, Bichat, and Laennec. Two examples will show the advantages and limitations of his thesis.

First, Keel argues that the changes in pathological anatomy, basic to the methodology of the Paris School, were previously elaborated in London—mainly by John Hunter, his associates, and his students, particularly James Carmichael Smyth and Matthew Baillie. It is simply wrong, writes Keel, to credit Pinel and Bichat with originality when they maintained that the seat of diseases should be sought not in organs, as Morgagni had taught, but in tissue systems distributed throughout the human body. Even the shift from anatomy to physiology, fundamental to Bichat's fame, was part of an innovative vision conceived by British investigators—though it is not impossible that everyone was indebted to Morgagni who, Keel tells us, "often observed analogous affections (such as inflammations) of certain membranes situated in different regions, but of similar structure" (p. 437 n. 66; this and following translations are my own).

Second, Keel maintains that historians have shortchanged Vienna where, in 1761, Auenbrugger published Inventum novum, the method of percussion so valuable for physical diagnosis. Percussion has been hailed as the method that Corvisart made famous by translating the book into French in 1808. Yet Keel himself reports that Van Swieten and De Haen, the leading professors of the "First Vienna Clinical School," never mentioned Auenbrugger in their writings, and he can document only a "slow, hesitant, but nevertheless real progression in the recognition, reception and application of the new diagnostic method" (p. 195). As for Corvisart, Keel argues that he misunderstood the "sound of tympanic nature" in hydrothorax and mistranslated the Inventum regarding the "tonality, intensity and timber" of...