Neo-clinicians, Clinical Trials, and the Reorganization of Medical Research in Paris Hospitals after the Second World War: The Trajectory of Jean Bernard

Abstract

Between 1940 and 1970, medical research was transformed. In France, as well as in Britain, this transformation has often been associated with the renewed importance of experimental medicine. Like the actors who participated in this transformation, historians have highlighted the “biologization” of medicine that took place and was advocated by a new generation of clinicians and fundamental biologists.1 Together, they believed that medicine needed greater input from virology, bacteriology, immunology, embryology and biochemistry, and required new spaces where clinical questions could be translated into experimental systems, examined and manipulated. In France, the Institut National d'Hygiene (INH, National Institute for Health), created under the Vichy regime, became the home institution for many researchers working on disease causation, transmission, and evolution. In the 1960s, a major reform of medical teaching and organization carried out under the presidency of General de Gaulle resulted in the creation of dozens of hospital laboratories, which participated in these developments.2 However, in the eyes of French post-war medical reformers, biology was not the “single best way” to make medicine more scientific. Another was to trust in numbers, to mobilize statistics and quantitative tools for evaluating the effects of medical care and therapeutic intervention. In contrast to the biological route, the statistical path was highly problematic, meeting resistance, if not outright hostility, from clinicians, with the result that the eventual “mathematization” of French medical research has been attributed to external pressures, resulting either from the newly found political influence of INH statisticians, or from the new research questions and tools imported from Britain and the United States, where quantification in the clinic as well as in public health had long benefited from wide support.3 According to this perspective, in contrast to their colleagues in Britain and the USA, French medical reformers favoured a form of biomedicine which, despite recognizing the importance of molecules and macromolecules, was characterized by a physiological approach to the understanding of disease and therapeutic efficacy, and allowed clinical trials only a limited role in selecting the optimal mode of medical intervention. This paper examines this scenario, focusing on the example of cancer research in France. There—as elsewhere—cancer research received impetus from public charities, benefited from increased government funding, and took a fresh turn after the Second World War, with new investigation into viruses, mutations, and immunological responses. However, while French achievements in risk factor epidemiology, which were largely due to the work of a small group of medical statisticians located within the INH, have been widely acknowledged, the French contribution to what was the most important change in cancer treatment, namely the rise of cancer chemotherapy in the 1960s and 1970s, is barely remembered.4 As a consequence, the existence of a clinical path toward controlled trials, and the quantification of bedside research that accompanied it, has tended to be overlooked in the case of France. In order to fill this gap in the literature and test the hypothesis that French “neo-clinicians” created a small, but none the less significant, medical world in which biomedicine was synonymous with diagnosis as well as treatment, with clinical trials as well as macromolecules, with patients as well as animal models, this paper examines the trajectory of Jean Bernard and his co-workers. Jean Bernard was one of the “neo-clinicians” who argued in favour of the reform of medical research in France after the Second World War, emphasizing the need for institutional and intellectual changes that would reinforce the role of biology and statistics in the practice of medicine. That this was not mere rhetoric is revealed by the work on acute leukaemia carried out by Bernard and his team at the centre for research on leukaemia and blood diseases in the Hopital Saint-Louis in Paris, which took an active part in international cancer research, and helped to establish chemotherapy as a major form of treatment for cancer in the 1960s and 1970s. In this context, the development of trial protocols, the use of control groups, and the application of computational techniques were advocated as means for the production of standards and norms that would ensure greater comparability, homogeneity, control and “objectivity” of medical practices. However, these did not lead to a complete substitution of traditional—mainly qualitative—clinical research by quantitative approaches. By following the introduction of controlled clinical trials in one particular setting, that of the Saint-Louis Hospital, this paper also shows that the project for modernizing and rationalizing French medical research was in large part inspired by cancer research in the United States, including its commitment to an industrial model of research organization. However, paradoxically, in France this project was not based on the mounting influence of private pharmaceutical firms, but rather—in a way reminiscent of British medicine—on state-supported quasi-universal access to health care, with its cortege of massive investments, and alleged co-ordination and control.5 My argument is developed in three parts. First, I summarize Jean Bernard's scientific and medical career as it exemplifies the trajectory of many French biomedical reformers. Second, I focus on Bernard's research on leukaemia, analysing the evolution of his clinical trial methodology, and examining the relationship between this evolution and the transformation of leukaemia research in the USA. In the last section, I relate these cognitive and practical changes to the political and institutional reorganization of medical research in 1960s France, which helped to make these changes a reality.