At the request of his physician father back in Boston, Mason Warren described what constituted a typical day, once he was seriously embarked.
I commonly rise a little after six. The servant comes in every morning to wake me and light my candle. From 6 until 8 I attend Chomel at Hôtel Dieu, a man at present very celebrated for his knowledge of diseases of the lungs. At 8 Dupuytren commences his visit which lasts an hour, that is till 9, and he afterwards lectures and has his consultations and operations, which occupies the time until 11. I then breakfast. …
Breakfast over, he attended a lecture on surgery, followed by another on surgical pathology until four o’clock. Dinner was at five, evenings occupied with “reading, etc.,” and lessons in French from a private tutor.
Warren was an openly affable young man whose company everyone welcomed. It was said conversation never languished in his presence. He was always agreeable, remembered Henry Bowditch. “No one ever heard aught against him.” Unlike Bowditch and most of the other Americans, Warren had come to Paris to concentrate on surgery, which, given his family background, was what everyone expected. As Holmes would write, he “never for a moment lost sight of his great objective—to qualify himself for that conspicuous place as a surgeon which was marked for him by the name he bore. …” That Warren had attended Harvard only three months before proceeding with his professional training, first at home under his eminent father, then at the Harvard Medical School, also distinguished him from others of “the medicals,” as they were called.
Students at the École de Médecine chose “lines of study” in either general medicine or surgery, and while they all attended lectures in both as part of their training, and made the rounds of the hospitals with both physicians and surgeons, those training in surgery followed a different curriculum. Thus Warren’s schedule had little resemblance to that of his friends Jackson, Bowditch, and Holmes, none of whom aspired to be surgeons. Indeed, he rarely saw them, other than for an occasional meal, even though they all lived next door to one another.
Warren was a slender, blue-eyed twenty-one-year-old. In a pencil drawing done by a fellow student named Robert Hooper, he is distinguished by a full head of hair, a thin cigar clenched in his teeth at a jaunty angle, and just a suggestion of the fancy attire for which he was known. Dressing to the nines was his nature, something inherited from his father. As a friend of the family would write, “He was, in truth, one who must have everything handsome about him, and … [he] was not slow to avail himself of the opportunities which Paris afforded for the adornment of his person. …” He liked especially bulky coats that made him look less slender, more manly, and whatever the season, his coats and trousers were “irreproachable,” his shirts, “exquisite,” each of his several waistcoats, “a separate triumph of varied color and design.” The considerable running cost of such a wardrobe seems not to have distressed his father in the least.
Poor health, mainly digestive problems, had troubled Warren much of his life—it had been the reason for his leaving Harvard after only three months as an undergraduate—but since arriving in Paris, except for some troubles with his teeth, he had never felt better. Perhaps a regimen that allowed for only two meals a day had something to do with it. (His father had urged him to eat sparingly.) Or possibly, such miseries as he saw daily in the hospitals made any complaints of his own seem scarcely worth mentioning. Or it could have been that the combined excitement of his studies and just being in Paris on his own, far from his father, gave him a therapeutic lift.
As a student, Warren was not on a level with James Jackson—but then no one was—and he was slower than others taking hold of French. He could make himself understood well enough “in regard to the necessities of life,” as he said, but in conversation felt “entirely lost.” Still, he was uncommonly self-disciplined.
As the son and grandson of famous surgeons, Warren had long known how much was expected of him. Like James Jackson, he was obliged to report regularly to his father. It was not just that John Collins Warren cared greatly about the well-being and professional progress of his distant son, but that he insisted on being kept continuously apprised of all that was new and innovative in surgical practice abroad. “Observe operations. Get as near as possible,” insisted his father, who had himself studied in Paris thirty years earlier. “Send me without delay every new book containing anything important. …” These were directions not to be taken lightly.
Like James Jackson, Warren provided his father with a detailed, running chronicle on how he was making use of his time, the procedures he was observing, his professors and what he thought of them, the books and professional journals he was reading. His letters, written in a strong, generally clear hand, customarily ran five to eight pages. In this way, as time passed, he would contribute the fullest, most descriptive of the many accounts by Americans of student life in the medical world of Paris.
II
Inside the ancient Hôtel Dieu, the long wards were each like the great hall of a castle, with rows of beds down both sides numbering nearly a hundred—a striking scene for anyone seeing it for the first time. The waxed oak floors were polished to a high gloss. All was quite orderly. Each of the beds was enclosed with its own white curtains, and high on the walls above each bed, a good-sized window provided ample light and ventilation. Even with as many as 1,200 patients in the hospital, it did not feel crowded.
Scores of Sœurs de la Charité, nuns of the order of Saint-Augustin wearing large white caps, went briskly about their tasks as nurses. Accounts by the Americans frequently express appreciation for “those excellent women,” their skill and kindness. Seeing one he knew while walking with another student, James Jackson exclaimed, “There is a face I dearly love to look upon.” Through the time of the cholera he had been witness to her unfailing devotion to the sick and the dying.
For students, the great advantage of study in a hospital of such size was in the number of sick and wounded of all descriptions, and thus in the number of different diseases and ailments to be observed firsthand. They might attend a physician’s examination of half a dozen or more cases of tuberculosis, say, not just one or two, or any of a dozen other maladies as well. Over a period of a few months, a student might take part in the examination of as many as fifty cases of tuberculosis. In the United States, in all but a few medical schools, no experience of any kind in hospitals was required of students.
The first rounds of the wards began at six in the morning, before dawn. They were conducted by candlelight, and when led by one of the more eminent physicians, attended by as many as two-or-three hundred students, which for most made it nearly impossible to get near enough to the beds to see much. To the Americans the French students seemed inordinately eager to get as close as possible, and competition for a vantage point could be fierce. James Jackson described how on more than one occasion he had worked himself up to the bedside, determined to take part in the examination, only to find that when he went to put his ear to the patient’s back, “a French head would slip between mine and that same back.” And this, Jackson hastened to add, would be accomplished always with an ever-ready “Pardon, Monsieur!”
Wendell Holmes would remember students piling up on the back of the chief surgeon, Baron Guillaume Dupuytren, in an effort to see as he bent over a patient, to the point where he would “shake them off from his broad shoulders like so many rats and mice.” (With his remarkable facility with language, Holmes had from the start little or no trouble understanding what was said in the lectures, and within a year was taking notes in French.)
Dupuytren, one of the medical giants of France, let no one doubt he was the reigning presence in the Hôtel Dieu. He was handsome, squarely built, and intimidating. A former battlefield surgeon, he had been made a baron by Napoleon. Clad in his long white apron, he marched heavily through the wards like “a lesser kind of deity,” it seemed to the diminutive Holmes. He had the flushed face of a bon vivant and reputedly spent most nights at one of the better gambl
ing houses at the Palais Royal. The state of his mood at the start of each morning, his students alleged, was the sign of whether he had won or lost the night before. Many mornings his temper was vile.
But to see Dupuytren at work with scalpel in hand was to witness a great performance. He talked the whole time he worked and loved to “make a show.” To the French, it seemed, everything was theater—un spectacle—even surgery.
Mason Warren watched as Dupuytren, working by candlelight, removed cataracts from the eyes of several patients, and from another, a tumor of the tongue the size of a peach. He saw Dupuytren extract gallstones from the bladder of a child, and perform the operation for an artificial anus for which he was also famous. “His operations are always brilliant and his diagnosis sometimes most wonderful,” Warren wrote. “He is always endeavoring to convince us that he is a great man. …”
Warren attended as well the lectures and operations of surgeons Philibert-Joseph Roux at the Hôtel Dieu and Jacques Lisfranc at La Charité, both known for their skill at amputation. He thought Lisfranc’s removal of toes and fingers “very neat and rapid.” He saw Lisfranc remove a cancerous penis “with one stroke of a large amputating knife.” Another day, he observed Roux amputate an arm from one patient, then a leg from another.
Surgeons were known for their steady, quick, dexterous hands. Theirs were the hands of an artist, it was said. To watch them was not simply a matter of seeing how it was done, but beholding an artist at work, and the work, one was told, must be done in the words of the ancient motto, cito, tuto, and jucunde—quickly, surely, and agreeably.
That the eminent Dupuytren and the other surgeons used no anesthetics or bothered ever to wash their hands before proceeding, or sterilized their instruments, was not recorded or remarked upon by Mason Warren and others for the reason that no one as yet knew anything about such precautions.
Nor did Warren write of the screams of the patients.
The attitude of several of the French surgeons toward their patients did, however, trouble Warren and others considerably. The show of professional sangfroid seemed overdone. Lisfranc’s operations were performed in a “kind of off-hand way,” it seemed to Warren, “depending entirely on the state of the disease for the extent to which he carries them. I have seen him work away on a cancer of the eye, chiseling the bones of the head, till I expected every instant to see part of the brain make its appearance.”
Lisfranc was a phlebotomist, a great believer in drawing blood. On one occasion Wendell Holmes saw him order that ten or fifteen patients be bled. (The Hôtel Dieu maintained a ready supply of leeches for the purpose and a full-time keeper-of-leeches was part of the staff.) To Holmes, Lisfranc was little more than “a great drawer of blood and hewer of members.”
Too often it seemed the surgeon’s primary motivation was the desire to operate, with little or no consideration for the patient. Philibert Roux had insisted in carving open an old man for a tumor of the shoulder, and the patient died only an hour later. “Without it he would probably have lived five or six years longer,” Warren wrote. How much of the surgery practiced, he wondered, was intended more “to perform an operation beautifully and quickly” than to save a life?
By Warren’s estimate more than two-thirds of those upon whom amputations were performed died afterward. In fact, most patients who survived surgery of any kind at the hands of the most skilled surgeons later died and nearly always of infection. The work of the French chemist Louis Pasteur on the role of bacteria in the spread of disease and that of the English physician Joseph Lister in antiseptic surgery were still in the future.
Even the best of the surgeons seemed to have no feelings for the patient. They could be rough and ill-tempered. For outright physical brutality to a patient, “the great Guillaume Dupuytren” had no equal.
If his orders are not immediately obeyed, he thinks nothing of striking his patient or abusing him most harshly [Warren wrote]. A very favorite practice of his during his consultation is to make a handle of the noses of his patients. Whenever a man enters with any disease of the head, he is immediately seized by the nose and pulled down onto his knees where he remains half in sorrow and half in anger at the treatment until he is allowed to rise and describe his disease.
The open, often vociferous enmity between some of the surgical prima donnas also came as a surprise to the Americans, and those like Jackson and Warren, who had been raised in the medical profession, found this disgraceful. It was said the tongues of the faculty were more cutting than their scalpels. Lisfranc in particular could hardly deliver a lecture without attacking the reputations of Dupuytren, Roux, or Velpeau.
At six feet, Lisfranc was taller than most men and had a voice like thunder. He wore a rusty black-and-red cap and baggy trousers that flapped in the wind as he rounded the front gate into La Charité. “In his lectures he speaks with that loud style and gesture used by our stump orators,” Warren reported to his father. When angry, he would let fly with “a tremendous volley” of foul language. “When any other man’s ideas come into collision with his own, he gives him no quarter, but lavishes upon his opponent every epithet of abuse that the language affords. …” His most savage invective he saved for Dupuytren, his former teacher and idol, whom he customarily referred to as “le brigand,” the highway robber, or worse.
Crude and unpleasant as all this could be, no student had cause to complain of dull lectures or that any of the faculty were below standards. The great Dupuytren was indisputably the greatest French surgeon of the time. His lectures were spellbinding. It was he who named the contraction of the palmar fascia of the hand, which is still known as “Dupuytren’s contracture.” Alfred Velpeau was to become increasingly popular with the American students, not just because of his celebrated rise from humble beginnings, but because he took an interest in them. In later years, Holmes, recalling Velpeau’s origins and ability, said “a good sound head over a pair of wooden shoes is a good deal better than a wooden head belonging to an owner who cases his feet in calf-skin.”
In addition to the quality of the hospitals, the number of patients, the ability and eminence of the faculty, and the variety of instruction provided, medical training in Paris offered two further important advantages over medical training in the United States. Both had almost entirely to do with the difference in how people saw things in the two countries.
The first was that students making the rounds of the wards in the hospitals of Paris had ample opportunity to examine female patients as well as men. This was not the case in America, where most women would have preferred to die than have a physician—a man—examine their bodies. It was a “delicacy” nearly impossible to surmount, and as a consequence a great many American women did die, and young men in medical training in America seldom had any chance to study the female anatomy, other than in books.
In France this was not so. “The French woman, on the contrary, knows nothing at all of this queasy sensibility. She has no hesitation, not only to describe, but to permit her physician to see every complaint,” wrote a Philadelphia surgeon named Augustus Gardner, who came to observe medical practice and training in Paris. “In this respect therefore the Paris educated physician enjoys superior advantages to the homebred man.”
The second great difference was in the supply of cadavers for dissection. In the United States, because of state laws and public attitude, dead bodies for medical study were hard to obtain and consequently expensive. Until 1831, trade in dead bodies in Massachusetts had been illegal, which led numbers of medical students of earlier years, including Mason Warren’s father, to become grave robbers. The new Massachusetts law permitted only the use of corpses buried at public expense, which meant mainly the bodies of those who died in prison. New York, too, had such a law and other states—Connecticut, Maine, New Hampshire, Illinois, Tennessee— would follow. In the South it was the general attitude that, with the consent of the slave owner, the body of any slave could be dissected.
In Paris there was n
ot the least prejudice against dissections. Even mortally ill patients in the hospitals, “aware of their fate,” and knowing that two-thirds of the dead were carried off to the dissecting rooms, did not seem to mind. Beyond the hospitals, due in large part to the ravages of disease and poverty, cadavers were readily available and cheap—about 6 francs for an adult, or $2.50, and still less for a child.
John Sanderson, after taking a room in the Latin Quarter, where he was “living a kind of student’s life” near the hospitals, described seeing carts “arrive and dump a dozen or so of naked men and women, as you do a cord of wood upon the pavement,” these to be distributed to the dissecting rooms.
Delivery time for corpses at the Amphithéâtre d’Anatomie, on the rue d’Orléans near the Hôpital de la Pitié, was at noon. Wendell Holmes wrote of how he and a Swiss student split the cost of their “subject” and by evening had “cut him into inch pieces.” Thus could all parts of the human body—nerves, muscles, organs, blood vessels, and bones—be studied, and this, Holmes stressed, could hardly be done anywhere in the world but in Paris.
The Greater Journey: Americans in Paris Page 13
