The Surgeon at the Hôtel-Dieu : Part 3

Flaubert: A Biography
by Frederick Brown

(Page 3 of 6)

Among academic physicians, the clearest expression of their disdain for knowledge gathered by the senses, and particularly by visual observation, lay in medical nomenclature. Whereas physicians practiced internal medicine, surgery was deemed "external," meaning that only men versed in theoretical systems of pathology could locate the true seat of disease and comprehend the fundamental workings of human life. He who concerned himself with first causes sought them not in open bodies but in humoral imbalances or the derangement of vital forces. Examining guts did not reveal the secret of anything. Dissection yielded only semblances, pictures, and making pictures was bound up with, once again, the idea of the surgeon as illiterate.

When medicine at last began to tilt decisively away from ancestor worship, visual analysis gained ground. Anatomical atlases gradually supplanted classical texts. The profession conferred honor, or even quasi-mystical prestige of a Romantic kind, on the diagnostic eye, and the ability to picture what had hitherto gone unseen figures as an obsessive trope in fiction celebrating great clinicians. Thus, auscultation, if it did everything the stethoscope's inventor claimed for it, would fulfill the ambition of philosophers to "place a window in the breast," wrote one commentator. Another declared that the hospital was as much a school to the physician as the picture gallery was to the painter.

In eulogizing his teacher Pierre-Joseph Desault, chief surgeon at the Paris Hôtel-Dieu until 1795, who outraged the Augustinian sisters employed there by lecturing on operations in progress to a consistently packed amphitheater, Xavier Bichat, the father of histology, asserted that "what surgeons paint is a picture, not bookish abstractions." They attain their goal when "the opaque integuments that envelope us are no longer to their skilled eyes anything but a transparent veil revealing the organism as a whole and showing the relationship of its parts." And finally, there was the report on plans for a new medical school submitted to the Revolutionary legislature in 1794 by Dr Antoine Fourcroy, a disciple of Lavoisier. Fourcroy decried the Faculté de Médecine, which had been shut down (along with every other royal academy) several years earlier. "The old method did not give a complete course and was limited to words," he explained.

Once the lesson was finished, its contents vanished from the students' memory. In the École de Santé, manipulation will be united with theoretical precepts. The students do chemical exercises, dissections, operations, and bandaging. Little reading, much seeing, and much doing will be the foundation of the new teaching which your committee suggests [italics mine]. Practicing the art, observing at the bedside, all that was missing will now be the principle part of instruction.

As branches of the same science, medicine and surgery would be taught together, for in his view theory without practice conduced to "delirious fantasizing," while practice without theory led to "blind routine."

Not until 1803, when Napoleon took matters in hand, did this agenda become fully institutionalized. Although litters of unlicked army surgeons tumbled out of the École de Santé straight into beleaguered regiments, no competitive examinations had been given and no diploma awarded since 1790. Any quack who paid the patent fee could legally set up shop. Even so, scientific-minded youths came from far and wide to study at city hospitals with physicians who were making Paris the capital of Western medicine. Foremost among the latter stood Jean Corvisart, Napoleon's doctor and a masterful diagnostician, whose gift for predicting internal lesions by percussing, palping, and auscultating earned him enormous prestige. René Laënnec, who invented the stethoscope, learned medicine at Corvisart's knee. Elsewhere, brilliant disciples followed Desault on his rounds through the Hôtel-Dieu and subsequently did great credit to the school of pathological anatomy. There was the aforementioned Xavier Bichat, a tireless dissector of cadavers much preoccupied with disease at the suborganic level, who died young in 1802, one year after publishing his magnum opus, L'Anatomie générale. And there was Guillaume Dupuytren, the best-known surgeon of his day, who became a legendary figure thanks not only to his innovative procedures, his deftness, his pedagogical gift, and his autocratic manner but also to the jealous thrusts he delivered in unconditional warfare with rivals for stardom.

No one formulated better than Dupuytren the new imperatives that governed medicine. "Seizing the facts gathered by pathological anatomy, medicine must illuminate them and, by linking them to their causes and effects, give them a productive role," he wrote at age twenty-six in the magisterial style he had already made his own. "But this partnership must beget a new science. The phenomena of life conform to laws even in the changes they undergo; there must emerge from the observation of these laws a pathological physiology advancing hand in hand with pathological anatomy and thus transcending the prejudice that has too long divorced physiology from medicine."

Under the tutelage of Dupuytren, who must have seemed to him more than seven years his senior, Achille-Cléophas Flaubert soon demonstrated uncommon ability. After one year of medical school, when students competed for admission to the École pratique, an intensive program taught by an elite staff, he passed the examination with flying colors and was repeatedly ranked first in his class. The school twice awarded him its anatomy prize, over classmates destined to make great names for themselves - François Magendie, among others. A state grant covered tuition, and an assistantship in Baron Thénard's chemical laboratory defrayed other expenses, but Achille-Cléophas scrimped until, after another severe triage, he entered the Hôtel-Dieu in 1804 as one of its first interns. There, for the many menial tasks they performed, the chosen few were given bed, board, lamp oil, and firewood. How often interns could consult Dupuytren, who had recently been appointed the Hôtel-Dieu's second-level surgeon (chirurgien de seconde classe), is open to conjecture. Hobbled by the department head, Philippe Pelletan, a distinguished veteran clearly ill at ease with this arrogant young master, Dupuytren kept himself busy at least three hours a day with private courses given at an amphitheater or dissection room in the Latin Quarter.

Copyright © 2006 by Frederick Brown

About the Author

Frederick Brown is the author of An Impersonation of Angels: A Biography of Jean Cocteau; Père-Lachaise, Theater and Revolution; and Zola: A Life. Twice the recipient of both Guggenheim and National Endowment for the Humanities fellowships, he lives in New York City.