In the preface to his “BibliothÈque de ThÉrapeutique,” which was published first in 1828, A. L. J. Bayle says that the art of treating diseases has been greatly neglected, in comparison with the enthusiastic efforts made to promote some of the other branches of the science of medicine, especially that of pathological anatomy; and, as a result, this art has in reality actually retrograded. Indeed, he goes on to say, quite a large number of agents which, up to a recent date, had been considered efficient remedies, have been entirely forgotten or even, in some instances, proscribed. This unfortunate tendency, he adds, may be attributed to many different causes. One of the most important of these, he believes, is to be found in the fact that certain physicians have allowed the idea to take root in their minds that the lesions which have been discovered in the different organs of the body at post-mortem examinations were the cause of the symptoms that, taken in the aggregate, constitute the particular disease under consideration; and, acting under the influence of this idea, they have assumed that their therapeutic efforts should be directed solely to these lesions. “Experience has not confirmed the correctness of this theory; on the contrary, it has shown that, if pathological anatomy is useful to the practitioner, it is chiefly so because it throws light upon the course and prognosis of certain diseases, and not because it has furnished a basis upon which the treatment may be built up.”

There is still another equally strong reason, says Bayle, why the art of therapeutics has been prevented from making a satisfactory advance, viz., the propagation of the physiological doctrine (Broussaism), a doctrine which admits the existence of practically only one disease—irritation, in its varying degrees of intensity, together with a single class of remedies—anti-irritants. Modern therapeutists reject most of these ideas, and experience also shows that, in the matter of therapeutics, these anti-irritants often produce harmful results. “A treatise on therapeutics,” he goes on to say, “should contain the substance of all the good memoirs that have been published on the treatment of the different diseases and on the remedies employed; it should also mention all the circumstances which indicate or contra-indicate the employment of remedial agents, the best forms in which the latter may be administered, all the cases in which they have succeeded in affording relief as well as all those in which they have failed to accomplish this result; all the authors who have written on the subject under consideration; and, finally whatever additional facts may give the practitioner confidence in the reality of the results proclaimed.”

There came under public notice, at about this period of time, a French physician who evidently held very much the same beliefs as were put forward by A. L. J. Bayle and which I have very briefly stated in the preceding paragraph. I refer to Armand Trousseau, who was born (1801) in Western France, and who received his early medical training under that prince of physicians, Bretonneau, of Tours. In association with his friend, Hermann Pidoux, he published (in two volumes, Paris, 1836–1839) an excellent treatise on materia medica and therapeutics. The spirit which guided him in the preparation of this treatise is well expressed in his own words as follows:—

Medicine is both a science and an art.... It is an art when it becomes necessary to apply it to a human being who is ill, and this is especially true when the manner of treatment is under consideration. It is in this art that the physician reveals how much talent he possesses; he reveals himself as a true artist by the particular form of remedial preparation which he decides to administer to his patient, by the felicitous choice which he makes between remedies, and by the favorable manner in which he combines them.

Dujardin-Beaumetz then adds the important statement that in his belief Trousseau was—at the time when he gave utterance to these words—the living personification of the truth of what he said, for nobody had carried the therapeutic art to a higher state of perfection than he had. To this statement may be added, with perfect truth, the opinion held by many of his contemporaries to the effect that the publication of the Trousseau-Pidoux treatise promoted effectively the growth of a sound and trustworthy therapeutic code. The mere fact that in 1875 this treatise had already reached its ninth edition furnishes strongly corroborative proof of the correctness of this opinion.

The scantiness of the space which I consider it proper to devote to this single memoir appears to me to justify the omission, from this point onward, of everything that does not add to the description of Trousseau’s career as one of the greatest clinical teachers in the domain of internal medicine in France. I am the more strongly impelled to adopt this course because so many of my personal friends among the physicians who returned to New York, during the years 1860–1864, spoke in such terms of praise of the success attained by Trousseau in this particular branch of medical education.

His profound earnestness as a clinical teacher and his incessant watchfulness over the interests and rights of the patients who served as material for his bedside lectures are brought out so clearly in one of his addresses to the class at the beginning of one of his regular courses that I shall be pardoned, I am sure, for reproducing it here in considerable fulness of detail:—

Gentlemen:—Before making any remarks to you about my service at the hospital I feel impelled to tell you what I understand by the expression ‘clinical instruction’ and to put before you what I consider to be the respective duties of the professor and of those who regularly follow his lessons.—It is for me a very pleasant thing, as you may readily imagine, to see, crowding around the beds in the ward and seated on the benches of the amphitheatre, a large number of pupils; but the consciousness that I am fulfilling a useful mission and am sowing in the minds of these young men ideas that will later be fertilized, affords me a much greater pleasure. However, both as regards the professor and also as regards the pupils who listen to his teaching, there are needed certain conditions in the absence of which the clinical instruction must necessarily prove sterile.

Although clinical instruction represents the crowning stage of your medical studies, I would not have you believe that this particular part of your medical training should not be begun until you reach the last period of your student career. From the very day when a young man decides that he wants to be a physician he should lose no opportunity of visiting hospitals. It is desirable that he should see sick people—not occasionally, but as frequently as possible. The materials which are thus at first stored in one’s memory in a confused and disorderly condition are nevertheless excellent materials. While they may not to-day appear to possess a useful character, you will find them at a later period stored away among the genuine treasures lodged in your memory. To-day I have reached the period of old age, and yet I remember distinctly the patients whom I saw forty-three years ago when I took the very first steps in my career of physician; I recall the most important symptoms, the pathological lesions, even in some cases the patient’s name or the number of the bed which he occupied. The recollections are at times of service to me, they even afford me instruction, and occasionally you may hear me refer to them at our bedside conferences. I therefore urge upon even the youngest among you, the practice of visiting regularly every day the hospital. On the whole I believe that you will find it more profitable to give the preference at first to the medical rather than to the surgical wards.... You will not derive real profit from frequenting the latter until after you have acquired some knowledge in anatomy, whereas the possession of a few superficial conceptions regarding physiology will be found sufficient for the student who is beginning his first medical studies.

Little by little you will find that you are becoming more and more able to judge, from a mere inspection of the patient’s face and expression, how serious is the malady with which he is affected; you will learn how to feel his pulse and to appreciate correctly its different qualities; and you will begin to acquire some knowledge of auscultation and percussion; etc....

I cannot too often repeat to you the fact that a knowledge of anatomy is not to be acquired by listening to lectures upon the subject; in order to gain such knowledge you should have before you, a human cadaver—a cadaver around which sit two or three other students besides yourself, all busily engaged in the work of dissecting, and near you there should be an older and more experienced pupil upon whom you can depend for guidance. Similarly, knowledge of actual disease is to be learned by the student only at the hospital, and with the aid of one of the resident physicians or of a chief of staff, who is competent to teach you how a patient should be questioned and how a systematic examination of the case should be conducted.... And here let me remind you that the patients who are to be found in our wards are poor people, people who are compelled by their suffering and by their lack of money to take refuge in a hospital. A knowledge of this situation of affairs should lead us to show them some consideration and respect. So far as the men are concerned I admit that it is permissible for us to treat them with less delicacy. From the viewpoint of modesty there is very little indelicacy in removing the clothes from a man in order to make an examination of the surface of his body; on the other hand, it is not right to do this if the examination is at all likely to affect his health unfavorably. And now that we are discussing this subject, I am obliged to confess that young men are only too apt to forget that, after the clothing has been removed from a man whose skin is wet with perspiration, it is very dangerous to expose him even for a short time to the contact of a chilly air. It is also not permissible, even in the interest of science, to prolong a physical examination or to carry out the manipulations required in auscultation and percussion if you find that it is exhausting the poor patient’s strength. In the latter case it is better to leave the examination incomplete than to increase the feebleness of a patient who is already in such a state of weakness....

It was my intention to introduce at this point a citation from Trousseau’s “Clinique de l’HÔtel-Dieu” of sufficient length to reveal fairly well his manner of conducting clinical instruction at the bedside of a patient. My decision to do this was based upon the assumption that I should find among the printed accounts of these supposedly impromptu lectures one or more which would serve the required purpose. I soon discovered, however, that not a trace of the off-hand character of such instruction remained in these reports. As they appeared in print they were elaborate and quite exhaustive memoirs, suited for the edification of men who had already long since passed the undergraduate stage of medical training, and I was therefore obliged to abandon the plan which I had so much desired to carry out. If I had, from the very first, given more serious thought to the scheme which I had in mind I would have quickly realized the fact that no teacher of wide experience and universally recognized as an authority in the diagnosis and treatment of disease would be likely to commit to print lessons which were meant to be useful to medical students who had only just reached the threshold of their professional career.

Trousseau died on June 23, 1867, in his seventy-second year. The only important treatises which he published are the two which I have already mentioned.