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The French connection: Drs. Jean-Charles Faget and Edmond Souchon, the first Americans to achieve the rank of Internes des Hopitaux des Paris (IHP).

INTRODUCTION

We often look at medical education as a product of a nation's history and wealth of experience in the care of the ill. Medical education of a nation can become decidedly 'nationalized', a unique product of the socio-political environment that supported, or in some cases, actively guided, its development: American residency training, for example, is a system wholly American, with its own clinical requirements before and after medical school and licensure nuances that make it distinct from the method France, Germany, or Canada use to produce their physicians. (1) Still, the experience of caring for and learning from the ill has a kind of international reach, devoid of borders. It is the rare medical student and physician who seek out these opportunities of excellence. Much can be learned from these individuals, whenever they appear in history. The 19th century Louisiana physicians Jean-Charles Faget and Edmond Souchon stand out as pioneers. Faget and Souchon became well known here and abroad for their clinical achievements and scholarship but began their careers in France, having achieved a coveted medical rank earned through one of the most competitive educational experiences at the time--Interne of the Hospitals of Paris.

JEAN-CHARLES FAGET (1818-1884)

Jean-Charles Faget was born in New Orleans in 1818, the son of refugees who had escaped the ongoing revolution in Hispaniola during that period. Growing up in well-to-do Creole society, the young Faget received the best of a bilingual education and then, like many similar sons, was sent to Paris to complete his education. The University of Paris, which oversaw all of the medical education in the city, was the best in the world, attracting students from all over the globe. Its practitioners were the first to develop seminal objects in medicine like the stethoscope and thermometer. Young Faget could simply have graduated, like most French and non-French students, from two years of study as a hands-off observer, or stagiaire, who, in the mid-19th century, could now go back, perhaps to New Orleans, and set up shop. Instead, Faget elected for the most difficult course for medical students at the time, the curriculum leading up through Externe and, ultimately, Interne of the Hospitals of Paris in 1842.

To understand the significance of young Faget's accomplishment and what was to follow in his career, we should first explain the origins of the institutions of medical training that made France unparalleled in the world. (2,3)

By the 1850s, French medicine and education established many institutions that became the standard bearer of excellence and scholarship in both hemispheres. It wasn't always so. Napoleon Bonaparte noted the dire state of French medicine after the guillotines of the Reign of Terror were carted away in the mid-1790s. At the time of the French Revolution, there was no rigid requirement for a diploma to practice medicine; one only had to pay a fee. In response, Napoleon created the Internat des Hopitaux de Paris or Interns of the Hospitals of Paris (IHP) in 1802. The Napoleonic reform was to centralize medical studies with clinical teaching "at the bedside" in hospitals and practical teaching in the Faculty of Medicine for anatomy (i.e. dissection of cadavers), physiology, pathological anatomy, chemistry, etc.

Training doctors to care for patients in the countryside or village required only graduation from the medical school with a medical degree. For patient care in the Parisian hospitals, however, two different medical staffs were required. First, the fully trained doctors, or Medecins des Hopitaux, were created. They were the heads of hospital departments and addressed with the avuncular epithet of Patron by their students and assistants. These Medecins would spend the morning at the hospital and, perhaps, the afternoon in their private practice somewhere in town. Second, the Internes des Hopitaux were created, nominated from the medical student class by a board of physicians or hospital cursus. The Internes and their assistants, the Externes, did most of the work in the hospital, a sort of residential life, being present all day, and night in rotation. Unlike the American title of "intern," the title of Internes was far more difficult to achieve. It was a revered and exclusive class that distinguished itself by excellence and clinical skill. The Internat represented an extraordinary training structure, unique in the world, and attracted students from dozens of countries, especially the United States where such opportunities rarely existed.

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Faget excelled at the Ecole de Medecine, the famed and historical school located in the Latin Quarter of the quaint left bank. He would have been among only 10-12% of his stagiaire class nominated for the first of the famed hospital courses--the Externat. The Externe was in charge of four to six patient beds and spent every morning writing progress notes and performing minor medical tasks.

The second and more famous stage, the Internat des Hopitaux (IHP) or Internat stage, necessitated three to five years of special studies to prepare for both written and oral exams where family, friends, and/or the interested public would be allowed to sit in attendance (Figure 1). These public tests were particularly stressful. They were timed, involved the candidate sitting at a table in front of four to seven Professors of the Faculte, and the amphitheatre itself, around which rows and rows of attendees would be seated in awe, were uncomfortable and foreboding. (3)

The requirements for the two hospital courses were in addition to the normal University courses of the stagiaire. Fewer than 15% of Externes succeeded to the Internat stage; fewer than 10% of those who tried were successfully admitted as IHP. Faget passed his exams magnificently, achieving the third highest score in the 1842 class of 33 candidates. [1]

IHPs, like Faget, would truly live in the hospital and were the real managers of the patient wards or salle des malades. [2] Some of the best Internes were selected to be chiefs of the clinical teaching departments in the hospital, or Chefs de Clinique, and they were in charge of teaching at the bedside or au lit du malade. Happy attendees of the sessions would include the stagiaire, the Externes, and visitors from abroad (Oliver Wendell Holmes, James Jackson, and William Osler all made the trip). After a two-year period, and at the behest of a mentoring professor, a high quality thesis would be written. Faget presented his thesis on December 28, 1844. It centered on the role of cystotomy tubes in the management of pediatric obstructive uropathy. He dedicated the work to his professors Lisfranc, Basin, Malgaigne, and Auvity. Having satisfied all the requirements of the University cursus and the title of Docteur en Medecine de la Faculte, physicians like Faget would now be called a "former" or ancien IHP (AIHP). Thus, Faget's selection for Externat and the Internat was a confirmation by his peers and superiors that he was an exemplary student of medicine and a model physician. Such was the honor of being AIHP that physicians would often, and still do, write AIHP after their name. Upon returning to New Orleans in 1846, Faget used the English translation of AIHP, "Medical Doctor of Paris" (MDP), to follow his own signature (Figure 2).

The greatest of scourges in New Orleans at the time Faget began his US practice were the malarial and yellow fever epidemics. Years away from understanding the microbiologic etiology of these two killers, and still decades away from simple public hygienic maneuvers to prevent them, Faget's New Orleans would be a heated society of opinion about these diseases based on loose medical reasoning influenced by racial and societal stereotypes. [4] Faget, whose training as an IHP required the bedside learning of the au lit du malade, would shed some light on the matter. Using a device as simple as a thermometer, he diligently recorded the human temperature as an aspect of disease that had heretofore not been yet widespread in the United States. Faget noted, for example, that a unique aspect of yellow fever was that the pulse can either drop with constant body temperature (Faget's sign), or the pulse can remain constant despite fever escalations. These observations, known as Faget's Law, remain bedside methods in diagnosing yellow fever, and Faget's sign is still somewhat pathognomonic of the disease. Faget went on to publish works on the yellow fever epidemics of New Orleans in 1858. In 1861, he wrote a chapter in a book about the yellow fever epidemic of Lisbon, published in French in Europe and in the United States under the pseudonym of P.F. Alvarega.

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A tall fellow with distinctive white hair pulled back to reveal his high forehead, Faget would be seen in formal attire, visiting the ill with his trademark long, black cape and low-crowned beaver hat, giving him a "priestly appearance" (Figure 3). It may have been intentional. Faget was known to be exceedingly pious, often asking patients about their spiritual dedication. (5) He came to near blows with Charles Delery, another US graduate of the University of Paris who had not achieved the rank of IHP. Delery, an argumentative, erstwhile poet, contended that anybody who was exposed to yellow fever could contract it. Faget felt otherwise, that Creoles, the older term for those born in New Orleans of French or Spanish descent, carried some innate immunity and that the confusion was only a matter of better diagnostics. The often contentious arguments, bordering on personal attacks, were voiced at meetings of the New Orleans Medical Society during June and July 1860. It was a summer of particularly high consequence for the United States on the eve of Civil War. Faget, Delery, and their supporters published detailed arguments--all in French--lambasting each other's diagnostic interpretations of various physical signs, such as whether differences in jaundice implied different diseases.

"As you can see," wrote Dr. Joseph Sabin-Martin that autumn in a scathing article titled Protestation contre quelques attaques du Dr. Charles Faget, "he goes about quite freely, putting the destinies of his causes at risk for so little ... Sir, give it up!" (3)

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The ever-belligerent Delery, however, felt compelled to do more than write down mere words and challenged Faget to a duel. (4) The latter refused, citing his religious background, and the matters were left for more modern times to resolve. (8)

During the Civil War, Faget returned to Paris where he found other refugee southerners like himself. He was awarded the Legion of Honor by Napoleon III for his work against the epidemic fevers and published a treatise on obstetrical anesthesia in 1880. He died in 1884, a pioneer in education and a proponent of women's and infant health. His grandson, Henry Guy Faget (1891-1947), discovered an important treatment for leprosy; Henry's son was Maxime Faget (1921-2004). He became the chief engineer for the US Gemini space project and had an illustrious career in NASA. Fagets still live in New Orleans, including the renowned Faget jewelers, but it will be Jean-Charles Faget who holds the title of the first American AIHP.

EDMOND SOUCHON (1841-1924)

The second American AIHP was Dr. Edmond Souchon, grandson of a soldier in the army of Napoleon Bonaparte. Edmond's father, also named Edmond Souchon, was a dentist practicing in New Orleans. Edmond, Jr. was raised in a household in which the lingua franca was heard, and he became fluent in it. Still, despite his formal education in Louisiana and Alabama, his parents decided that the best course of action was to send the young man to Paris to improve his cultural education and start medical studies (Figure 4).

Souchon had some contacts in Paris with distant descendants of his original French family. As most were soldiers, they had little financial means. Times were tough for Souchon during the American Civil War, and these soldier-relatives were unable to help his financial situation. Worse, during that war, he was forced to cut all contacts and correspondences with his family and was required to stay in Paris as a "rebel."

At 19, he managed to enter as a student at La Charite Hospital in the service of Professor Velpeau (1795-1867), for whom he quickly became a dedicated translator during visits from Anglo-Saxon colleagues. The great American surgeon Marion Sims came to Paris and Souchon, just as Southern in heart and mind as Sims, was always at his side as a translator. Souchon's translation of Sims' new surgical procedures was published in the November 22, 1861 issue of the Gazette Hebdomadaire. This landmark paper represented a communique to the Parisian surgeons who observed Sims' famous gynecologic operations at La Charite Hospital at the behest of Professor Velpeau. Thus, as a surgical and linguistic aid to Sims, Souchon was enabled to greatly improve his own surgical practice. (9)

Above all, Souchon wished to become a great surgeon and set his efforts on the completion of the Internat des Hopitaux de Paris concourse, a novel challenge of great importance to him.

"To have done something original," he reminisced in 1915, "be it ever so little, is ... the supremest achievement." (10)

Settling into the city, and thanks to monthly financial assistance from Marion Sims himself, Souchon afforded the opportunity to stay in Paris and prepare for the competition--no longer receiving any help from his family who remained in the American South. Souchon was finally nominated Interne des Hopitaux in 1865 on his first exam, placing fourth of 42, indeed a very rare achievement. (5)

The death of Souchon's father forced him to leave Paris much sooner than he had hoped, and he returned to New Orleans to support his elderly mother. He continued his studies at the Medical College of Louisiana, graduating in 1867. Introduced to Professor T.G. Richardson by a letter from Marion Sims, Souchon was very well received, and Richardson sought every means to lessen his dire financial situation. He became Richardson's prosector, preparing dissections for the professor's classes and later, his teaching assistant at the "Charity Hospital." Finally, he became a well-paid associate in Richardson's private practice. Souchon began his own private practice in town, where he quickly flourished. In 1869, he married a jeune fille of French descent, a Miss Corinne Lavie, related to the old families of Creole French settlers, the Sabatiers and Mazureaus.

Souchon was eventually appointed "Demonstrator of Anatomy" in 1872 at the medical college, then "Professor of Anatomy and Surgery" at the newly established Tulane University in 1885. He quickly became one of the most famous surgeons and anatomists of the great American South and was elected president of the New Orleans Medical Association, as well as vice president of both the American Medical Association and the American Surgical Association. He became an expert on public health matters, quarantine, and the history and control of epidemic yellow fever, documenting the great debates of Faget and Delery. (8)

Souchon always kept great respect and admiration for his first mentor, Marion Sims, and penned a classic article appearing in French in the April 27, 1895 issue of the Gazette Medicale de Paris. A chapter he wrote about Sims in Original Contributions of America to Medical Sciences appeared in 1917. (9,11)

After a prestigious career at Tulane and The Louisiana State Board of Health, he retired in 1908 to develop the Souchon Museum of Pathological Anatomy. There, he developed a particular method of preserving anatomical specimens in their natural hues, thus creating the "only museum of its kind in the world ... in which color is seen." Proudly, he himself pointed out that it was only the sixth museum in the world named after a surgeon. (8) He was known as a tireless advocate of education, of reaching for an ideal level of self-teaching and learning that resonates well with today's views of medical enrichment. (12)

He had three children. The eldest, Marion Sims Souchon (1870-1954), named after the father's mentor, was a surgeon in New Orleans and chief of staff at Hotel Dieu (now LSU University Hospital). At the later stage of his career, Marion became a serious painter whose works are still quite valued today. The Souchon name lived on into the 20th century with the jazz works of Souchon's grandson, Edmond "Doc" Souchon, MD (1897-1968), a Louisianan and Chicago-trained physician, talented guitarist, and recording artist. "Doc" helped establish the Louisiana Surgical Association, the New Orleans Jazz Club, and in 1942, the National Jazz Foundation, archiving thousands of hours of jazz music of old New Orleans. (13)

CONCLUSION

Jean-Charles Faget and Edmond Souchon, two wholly remarkable and unique American physicians of the 19th century, succeeded in reaching one of the highest echelons of medical education of their day, the Interne des Hopitaux de Paris (IHP). So impressed with the French system of Internes, Sir William Osler and the other "Big Four" of Johns Hopkins Hospital (W.H. Welch, W. S. Halsted, and H. Kelly) established the system of "resident" training, which we recognize today as Graduate Medical Education (GME). Still, Souchon and Faget preceded Osler in their prescience with their recognition of the value of bedside teaching and education. The biographies of Faget and Souchon, in their own unique way, thus serve as a reminder that the greatest rewards sometimes come from the greatest dedication to self-improvement.

REFERENCES

(1.) Bonner TN. Becoming a physician: medical education in Britain, France, Germany, and the United States, 1750-1945. New York: Oxford University Press; 1995.

(2.) Hun H. A guide to American medical students in Europe. New York: William Wood & Company; 1883.

(3.) Dunn S. Medical Education in France. Frank Leslie's Popular Monthly. 1894;37:531-7.

(4.) Carrigan JA. The saffron scourge: a history of yellow fever in Louisiana, 1796-1905. Baton Rouge: Center for Louisiana Studies; 1961.

(5.) Tinker EL. Pen, pills & pistols; a Louisiana chronicle. New York: American Society of the French Legion of Honor; 1934.

(6.) Faget J. Veme et VIeme Lettres sur la Fievre Jaune: ou, deuxieme reponse au Dr. Delery. Journal de la Societe Medicale de La Nouvelle Orleans. 1860;June 22: pp 1-17 and 19-36.

(7.) Martin J. Protestation contre quelques attaques du Dr. Charles Faget. Journal de la Societe Medicale de La Nouvelle Orleans. 1860;Sept 21: page 24.

(8.) Souchon E. True origin of the epidemic of yellow fever. Chicago; 1900.

(9.) Souchon E. Reminiscences of Dr. J. Marion Sims in Paris. New York: Trow Directory, Print and Bookbinding Company; 1894.

(10.) Souchon E. Original Contributions of Louisiana to Medical Science. New Orleans: Louisiana Historical Society. 1915; 8:66-88.

(11.) Souchon E. Original contributions of America to medical sciences. Philadelphia: Dornan Press; 1917.

(12.) Souchon E. A plea for a reform in university education. St. Louis: A. R. Elliott; 1912.

(13.) Laforet EG. Edmond Souchon, II. N Engl J Med. 1959;260(6):280-1.

(14.) Souchon E. A tribute to Dr. Pierre Rouanet, the discoverer of the cause of the heart sounds, at one time a practitioner in New Orleans. New Orleans; 1921.

John Phillips, MD; Bernard Seguy, MD, AIHP ACCA

Dr. Phillips is an Associate Professor in the Department of Urology at New York Medical College. He is also Chief of Urologic Cancer at the Urology Center of Westchester.

[1] Archives, Association Amicale des Internes des Hopitaux de Paris (AAIHP)

[2] Each hospital had an exclusive common room for meals and relaxation for the Internes, the so-called salles de garde (i.e. call rooms). These salles were famous, or infamous, for being decorated by each class with graphic, bizarre, and darkly humored artwork that stands as both a testament to the self-deprecating attitude of these individuals, as well as pride in the historic lineage that each class represented.

[3] As Sabin-Martin himself wrote, "Lui, se rendre!" (7)

[4] Delery finally did duel, challenging the famed cardiologist Pierre Rouanet over a practical joke that went awry. (14) Both physicians did, in fact, shoot each other, though not seriously, and, honor having been reestablished, went on to resume their practices.
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Author:Phillips, John; Seguy, Bernard
Publication:The Journal of the Louisiana State Medical Society
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Date:Nov 1, 2012
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