Touby's Notes on the History of Modern Medicine Part 1

1. Introduction -- 1/29/01
   • Medicine has been a changing interaction between bodies (anatomy), patients, healers, and disease.
     • Small pox killed 1/4 in early modern Europe (17th c.) eraticated by 1977 -- Lindmann 48-9
   • These entities and their relationships with eachother have changed over time.
     • Things are generally only disease if they are considered abnormal.
       • Forgetfulness vs. Alzhymer's disease
       • Hypertension -- if your blood pressure is significantly higher than normal.
       • Dropsy was a disease, not it's a sympton (swelling, etc) -- Lindmann 21-2
   • sinful ?=? high risk
   • constitution vs. is the patient "a figher"? -- still used today?
2. "Livin and Dying in the Ancient Regime" 1/30/01 -- who died and from what
   • Why did this person die? Why do people die in this place?
     • marshland 30/1000 people die each year -- life expectancy (e0):31
     • highland 25/1000 people die each year -- e0:44-55
     • 17th-18th c. start seeing lots of info about cycles of mortality
     • classifications of disease (nosologies) -- began 17th c.
     • infant (and child) mortality high until mid 18th c. when it began to decline -- 50% dead by 10yrs
     • lower/working class infant mortality etc much higher --Lindmann 23
       • Poor had too little protein + vitamins, rich had too much protein
     • maternal mortality lower than generally thought (abt 1%)
     • Interesting side note, lepers are immunt to TB -- Lindmann 26
     • God's will as cause of disease less common in 18th c. than earlier --Lindmann 28
       • Innoculation and vaccination introduced in 18th c.
         • focus begins shift to prevention not cure
         • introduced by lady Montague who had been in Turkey (1721 had daughter innoculated)
         • superstition (which was discouraged by Voltaire) and religion prevented widespread use, and therefore not cummon until roughly 1770
         • cowpox-->smallpox vaccination by Jenner et. al end of 18th c.
     • contagonist vs non. (environmental) and mixtures
       • drain swamps, fumigate atmosphere of diseased houses (more later)
3. "Theoretical Basis of Medicine" 1/31/01
   • 4 Humours
     • Phlegm -- Brains - cold, slow - water, winter
     • Bile (choles) -- liver - angry - fire, summer
     • Blood -- heart - Brave, hot-blooded - air, spring
     • Black Bile -- spleen - melancholy (splenic) - fall, earth
     • mixture of four humors make up one's constitution
     • disease is an imbalance in the body / health is balance in the body
     • constitution altered by physical and emotional events (blocked or excessive emotion leads to disease)
   • treatement
     • aging = cooling and drying up / babies are warm and wet
     • in form of "regimen" how to eat, drink, rest, exercise, excrete, manage emotions
     • bleeding, purging, cupping and vomiting
     • Association --if a plant looks like an organ use it to treat -- if a saint was decapitated, use for migranes
   • Examples and details -- Peter the Venerable as example of regimen bloodletting etc., importance of Galen, Rhaze's writing, Hippocrates (dietary, etc) in medicine from Siraisi, Nancy "Medieval and Early Renaissance Medicine", pp. 115-123, 133-136 -- humoral (esp Phlegm) Lloyd's "Hippocratic Writings" p.242-9
4. "Mechanizing the Body"2/5/01
   • 15th c. Vassalias important in documenting Gallen's errors
   • diff types of bodies -- relevant, but out of order
     • Humoral
     • Mechanical -- 17th- 18th c. -- popular again in 19th c. b/c need for concept of disease as spatial and temporal process
       • Hooke -blood color when oxygenated/not(just after Boyle), Boyle - animals die in vacuum(1660), Lavoisier + Priestley Oxygen supports life (late 18th c.)
       • Giambapttista Morgani -- importance of anatomy and symptoms in medicine -- example pulse (at injury and rest of body) Morgagni, Giambattista "The Clinical Consultations of Giambattista Morgagni", pp.169-171
     • Fluid Mechanical body -- after descarte (Treatise of Man) 18th c., esp after Harvey (who's work was the "last major blow to Galen"cited by lindmann p.78) 19th c. heart/circulation stuff
       • Boerhaave -- hydrolic body
       • George Cheyne -- 1733 - "human machin" as complex interaction of pipes and channels weakened by age, 'vapours', melancholy, etc.
     • Nervous -- late 17th c. on -- start with fixed amt of energy and it's wasted with stimulants (Brownlow), poor conditions, etc important for public health reform, etc b/c emphasis on environmental and social darwinism
       • Cullen -- prob with nervous system cause of all disease -- treat be sedating, etc. --lindmann p.83
       • John Brown -- life just is product of external excitement (can be quantified in Brunonianism)
5. "Categorizing the Body: Gender and Race" 2/6/01
   • Men and women made of the same stuff, but in different proportions.
   • Women classified on abstinance, menstral properties, complexion
   • Great chain of being: angels->good Men->good women->...->birds->...
   • differences not based on physiology (men are hotter... that's why organs are external, etc.) -- Aristotle --Male only genetics
   • "RACE"
     • not till 19th c. that races widely considered biologically different (to have innate differences)
       • Theological diffs like saved vs. not saved vs. not saved and at fault/sinful
     • in 16th c. -17th c. race debated in terms of politics or religion
     • climate vs constitutional fit much more important to medicine than innate diffs.
6. Ulrich, Laurel's "A Midwife's Tale"2/7/01 -- all about Martha Ballard
   • late 18th-early 19th in hallowell, maine
   • midwife as occupation -- more popular for deliveries than physicians
   • diverse medical market place: midwives, physicians, surgeons, travelling medical people, etc.
   • difficulties with getting to patients (fall through ice, thrown from horse, cross river, etc)
   • lots of other jobs... had 9 kids (3 of which died young (w/in 10 days of eachother))
   • has an understanding of medicine roughly the same as that of physicians, surgeons, etc.
   • sympathetic medicine example : dog days more get sick
   • no real medical tools available (no real distinction btwn those with/without)
7. "Medical Practics and Practitioners in the 18th century" 2/12/01
   • Those who earn their living in medicine
     • Generally controlled by a guild (legal and economic overlap: guilds regulate who can do what in town, but kings, nobility, and town council can also give you that right (except in france there were two places for physicians to get certified for the whole kingdom))
       • Physicians -- focus on internal medicine
         • heavily trained in theory (anatomy, latin, etc.) (heavily into medical jargon)
         • certified by a corporate body
         • university trained "in part" after apprenticeship
       • Surgeons -- focus on external disease (broken bone, etc)
         • apprentice based (in france it was textbook based as well as aprenticeship)
       • Apothecary/pharmacist - making and selling of drugs
         • derivitive from grocers guild
         • no real prescription... lots of self medication or pharmacist directed medication
       • specialists -- do the same (fringe) things over and over
       Not in guild
       • Midwives --usually no guild... more than just delivery and after care (burns, injury, pediatrics, treating women's probs)
       • Itinerants --folk healers, may speak latin, claim to heal special things, "believe in experience", travel from place to place
     • School teachers, priests, Noble women, clerks, etc often expected to know how to treat the sick
   • they all put out adds...
   • Reverand Ralph Josselin variety in treatment, approach to medicine, etc (live pious life?) and importance of self-medication -- lindmann 202-3
   • major points : all types existed simultaneously and several diff types were often consulted, wide range of healers, no real specialties, no real distinctions between major and minor medical problems
   • selling an image...
   • France maybe 1/2 physicians can live off pay, surgeons pay ok in city, bad outside; Britain physicians not as good pay as lawyers, but still pretty good!, surgeons paid less.
   • Market... not pay till cured contracts, negotiation on treatment, consult multiple healers
8. "Hospitals" 2/13/01
   • France
     • Hapitaux - old, infirm, children (orphans, etc) -- warehousing for poor... 10-20 beds
     • Hapitaux General -- Biggie size Hapitaux -- Louis XIV (1767) orders all cities of a certain size must have/maintain one
     • Hotel Dieu -- middle aged, shorter stay, people with injuries, fever, infections, etc - still mostly nursing sisters
     • Military -- only for those in army/navy - tried to get them out faster - separation of fever cases - cleaner - increased use of Autopsy - more statistics
     • generally religious till 1789 (french revolution leads to separation of church and state... simmilar effect spreads through europe)
     • by beginning of 19th c. keeping more poor out of hospitals (using alternative methods like soup kitchens, etc) -- Lindmann 135
   • England
     • less religious earlier due to Henry VIII's reformation (mid 16th c.)
     • Moral and Medical regime (no putas, cervesas, etc)
     • either charitable endowment, or voluntary (subscription, started 18th c. example of enlightenment)
   • Hospitals spend most $ on food.
   • hospital is a place to teach
   • once we kick the nuns out we can do autopsies to our hearts content! (place for social mixing and autopsy before becoming Dr.s ---what Susan Lawrence calls "safe science" safe experimentation on patients)
   • increasing professionalization of medical staff (esp after reformation/revolution)
9. "Three Dr. Dick Weeks's and Jacques Tenon abt Hotel Dieu" 2/14/01
   • Dr. Weeks (1. Dr. Dick (brother) 2. Dr. Father 3. R. Weeks (medical student)) beginning of 19th c.
     • increasing objectification (surgeries, at first feels feint then later laughs at a friend who get sick from seeing bodies)
     • send home medical tools + curiosities from the city
   • Jacques Tenon
     • reformer late 18th c.
     • talks about problems with dirty air + lack of ventillation (and it's balance with temp esp in winter) (miasma!)
     • gross heaps on diseased clothes
     • patients not separated by disease
     • uses loads of statistics
10. "Policing the Body, Policing Society: Hygiene in the 18th c." 2/19/01
    • Navy Physcians in England
      • Explorations and campaigns in west indies => need to deal with probs of long sea travel etc.
      • James Lind -- ideas about contamination (?of food?)
      • (wasn't this guy army?)Thomas Trotter -- separate based on disease, talks about how you should go from healthiest to least healthy so not to spread disease
    • environmental
      • miasma ("corrupted air") --John Arbanoth circulation is necessary => ventilation and chemical disinfectants
      • draining swamps in 1760s (both england and france)
      • Johan Behrends remove animal refuse + cemetaries to outside the cities
    • personal hygiene 1)George Cheyne (same one mentioned previously I think) - comfort and health more important than fassion 2)for educated and sophisticated in France
11. "the City and Disease" 2/20/01
    • Rosseau -rural simplicity is better than croweded unhealthy cities
    • Do I need to know anything other than that crowding in city lead to disease? (there was no reading and class was confusing)
12. Hales's Ventilator and Frank's reform 2/21/01
    • Stephen Hales ventillators for boats in British navy (sell to landed gentry) example of miasma, cites stats and experiment (horrible dog with breating tube exp.), plagarism is a big issue ('need ot obviate a false report...')
    • Johann Frank misery of commoners
      • noblesse oblige - king needs to govern poor + stupid so they can live better (social reform of sorts?)
      • physical conditions bad (medicine's not enough)
      • laws are not protecting people from bad physical conditions
      • lindmann talks about Frank (he's one of her examples of someone who wants to get dr's into countryside and increase failing hygiene)
      • probs with distribution of dr's after guilds loose power and monarchs gain power
13. "fevers miasma and public health reform" 2/26/01
    • William Farr -- idea of healthy districs -> propaganda tool
    • Chadwick Env->disease->poverty - england mid 19th -- prevent rather than cure, shift focus form moral racial to environmental cause -- cholera easier to tolerate than chadwick :) -- Villerme stats essential, increse in % poor => increase % mortality with cholera
    • Alison poverty(->Env)->disease - scottland mid 19th
    • Shattuck poorIrish->env->disease - america (some time later ?)
    • France improvements must be local, but laws in England make it faster/better at adopting new reforms
    • Reading from Bynum 55-91 -cites frank, lind, chadwick, jenner (see prev sections) Malthus resource probs with philanthropy, industrial rev of early 19th c. causes birth of cities, mid 19th c. much more stats, rising dislike for dr's in 19thc (anatomy act etc) john snow shows cholera's water borne (mid 19th c.) Budd sewer is "continuation of the diseased intestine", 1875 public health act
14. "Cholera in the 19th c." 2/27/01
    • cholera isn't the most deadly epidemic, but it affects all groups and is quick and ghastly (one of the few things I remember from Physiological Foundations is that cholera bacterial makes cholera toxin which is a protein that binds G-proteins and keeps them from deactivating, so the associated Na+ channels stay open to the lumen of the intestine and Na+ pours out, water follows osmotically and you die from "catastrophic diarrhea")
    • Not in europe till 1832
    • minimal after 1854
    • Hamburg not filtering water, so big problem in 1893 "I forget I am in Europe"
    • poor think people actively poisoning them -- foreigners, hospitals -- don't use knowledge of mild fever = choler b/c no real pain initially
    • incurable, dr's called in but have little authority
    • quarantine -- separate goods and people
    • snow links to water => filtering sewage by 1890s
15. Alison and Chadwick primary source 2/28/01
    • see previous talk about alison and chadwick
16. "Seeing the Body: The Paris Clinic" 3/5/01 -- evidence based medicine 1750-1850
    • surgical (localised) vs medical (non-localised) diseases
    • William Cullen - 18th c. classification based on symptoms, one diseases leads to others (pthisis after TB)
    • 19th c. paris clinic no longer humoral context, localization of medical disease, track single disease through spatial / temporal change in various stages (not diff diseases)
    • PreRequisites
      • need lots of bodies
      • teachers have control of who (which patients) they admit
      • unification of surgical / medical training (1794 act reqs similar base training and dr.'s must do 6 real life type disease treatment death/release traces)
    • Desault -- system of daily treatment: outpatient->in patient->autopsy (tells you if you were right or wrong!)
    • Corvisart -- tissue classfication
    • Bayle -- focus on lesions not symptoms, stages of lesions in disease (all same lesion though), temporal connection of stages of disease
    • Laennec -- connects the stages of TB as temporal, invents stethescope (uses for early diagnosis in TB), auscultation-sounds of lungs as disease progresses, also collected info on climate temp humidity - no revolution happens overnight
17. "Medical Practice in the 19th c. (Europe)" 3/6/01
    • 18th vs 19th
      • competative medical market place with multiple players in both centuries
      • 18th has separate surgical and medical training, while 19th has unified medical training
    • success is based on connections and clientel (not laws or education)
    • lawyers >> drs >> farmers
    • more women get babies delivered by male dr's