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Clinic/hospital medicine

As well as offering some form of health care to the ill and poor, hospitals have also provided the opportunity for aspiring doctors to learn. Before the 1700s this often involved medical staff taking their own students around the wards informally and viewing any interesting cases among the patients. This kind of training is sometimes called 'bedside learning', with observation and teaching combined directly in a clinical setting - the word 'clinic' comes from the Greek for 'bed'.

Learning in hospitals throughout the world

Such 'bedside learning' has been traced to the early Islamic hospitals. In Europe it emerged within Renaissance hospitals, including the San Francesco Hospital in Padua where, in the 1500s, the physician known as Montanus occasionally instructed his students.

Boerhaave’s first-hand teaching methods

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However, the system of medical instruction as we know it today, in which hospitals are central to the training of medical staff, can be traced to Leiden in the 1700s. Here the Dutch physician Hermann Boerhaave regularly admitted a dozen interesting cases to the hospital’s clinical wards at the St Caecilia municipal hospital in Leiden where he taught. Boerhaave illustrated his lessons with actual cases. The method caught on quickly and was introduced at teaching hospitals across Europe, including those at Edinburgh, Freiburg and Vienna.

The spread of ideas

As was common at the time, students would come from across Europe to work with a famous physician before retuning to their country of origin, taking new ideas with them. Such was the case with Gerhard van Swieten, a former student of Boerhaave’s. Van Swieten not only made Vienna a major medical centre when he introduced bedside learning, he also compiled textbooks which spread Boerhaave’s method across Europe.

Practical training - more access to patients

Whether accompanied by an instructor like Boerhaave or not, from the 1700s, students demanded greater access to hospital patients. For those who could afford it, medical apprenticeships concluded with a period walking the wards. This practice was introduced to many London hospitals at this time. The large metropolitan hospitals in London, as well as other capitals including Paris and Vienna, offered students such practical training on a greater variety of cases than they would have seen in even the largest private practices.

The French Revolution - new hospitals, old ideas

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In Paris clinical teaching attained new heights following the French Revolution in 1789. Originally, the revolutionaries aimed to abolish hospitals and medical schools - and even doctors, who were assumed to have been corrupted by the regime that supported them. Instead the revolutionary period saw the creation of new hospitals and an improved form of medical education. Like the teaching of Boerhaave, the French approach drew on a much earlier tradition of practical learning, based on careful observation, going back to Hippocrates. Medicine in Paris was also influenced by the teaching of Enlightenment thinkers. As a result, a new generation of doctors, including Cabanis and Pinel, taught their students to ‘read little, see much, do much’; that is, to base their actions on observation and experimentation, rather than relying on textbooks.

New technology - following diseases in death

Clinical training in Paris introduced many innovations, including physical examinations, and technological developments such as the stethoscope, which allowed students and practitioners to look beyond a patient’s immediate external symptoms. Ultimately it involved following the disease in death by means of autopsy, as was regularly advocated by the physician Xavier Bichat. Undertaking autopsies allowed doctors to confirm their diagnoses by locating lesions, the evidence of disease in the patient’s body.

Paris: centre of clinical excellence

Medicine in the decades after the French Revolution is sometimes described as ‘the birth of the clinic’. It relied on practitioners having access to large numbers of patients, which would have been impossible without the clinic. This concentration of patients also facilitated the rise of statistics, which allowed practitioners such as Pierre Charles Alexandre Louis to confirm findings across a great range of cases. Until the 1850s, Paris was seen as the centre of medical innovation, and so the methods employed there spread quickly.

The importance of science in treating illness

The changes in medical practice seen in Paris have been associated with the rise of a medical ‘gaze’, the point at which doctors began to rely more on their own observations than patients’ description of their own illness. This trend only increased from the 1850s, when students began to flock to the German university medical schools instead of French hospitals. Here, science was becoming increasingly important to the diagnosis and treatment of illness, the beginning of what we now call laboratory medicine.

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Bibliography

 E Ackerknecht, Medicine at the Paris Hospital, 1794-1848 (Baltimore: Johns Hopkins Press, 1967)

M Foucault, The Birth of the Clinic: an Archaeology of Medical Perception, A M Sheridan trans (London: Tavistock, 1976)

C Hannaway and A La Berge, Constructing Paris Medicine (Amsterdam: Rodopi, 1998)

Glossary:

Apprenticeship

An agreement where a person learns a trade from a skilled worker over a fixed period of time.

Stethoscope

A device which is used to listen to sounds produced by the human body. Ordinarily a stethoscope consists of rubber tubing in the shape of a Y.