History of Inhalation Anesthesia
History of Inhalation Anesthesia
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Ancient Greek Medicine 09032014 Continuity Medical ethics some issues are still applicable from Hippocratic Corpus We do not know who wrote Oath of Hippocrates did not come from Hippocratic medicine quotneither will I administer a poisonquot Euthanasia was common in Greece hemlock was the noble death Abortion also readily available Specialization cut for gallbladder stones Con dentiality would have t in during that time Hippocratic Corpus Justice Hospice concept of medical futility extraordinary means perform all this calmly with cheerfulness and serenity Paternalism opposite of informed consent Physician s image look healthy respectable looking 323 BCE 30 BCE death of alexander the great the death of cleopatra of egypt during these 3 centuries there was an outpouring of Greek culture science medicine and knowledge Alexander the Great s generals split up the great kingdom he conquered and split into Hellenistic states Alexandria Egypt became center for medicine in the world Museon temple of the muses where rst de nitive proof of dissection of human body for anatomical purposes Great Library of Alexandria The lighthouse of Greek knowledge Ptolemy l declared himself king of Egypt and made base at Alexandria make it greatest research center in the world oversaw building of museon and Great Library total intellectual freedom gave the doctors the protection required to per form a dissection richest man Herophilus 335280 BC the father of human anatomy lived between 210 and 250 bc was able to differentiate between the nerve and blood vessels counted pulse using a water clock Erasistratus 310250 BC father of physiology however this is wrong because the word physiology did not exist student of Herophilus very progressive said diseases were located in the blood tissues and organs beleived that pneumaair was necessary for life formulated hypothesis regarding how different parts of the body were supplied with essential substances via arteries veins and nerves distinguished the cerebrum from the cerebellum in the brain correlated animal intelligence with brain impulses after one century of intellectual freedom in the museon it changed to intellectual dogma and prosecution outside political and religious forces unnamed Ptolemy amp Physcon executed many of the researchers and exiled others 2nOI century BC Two bitter schools he chose people to be executed and those who remained had to chosehelenistic and alexandrian schools of medical thought which led to medical arguments with no science to back each side up 4 very different views on theories of disease causation 1 Dogmatists anatomy dissecting worthwhile Plato and Aristotle medical theory 2 Empiricists refute physician could really know what goes on in body philosophy medical skeptics learn nothing from dissection 3 Methodists rejected all generalities of medicine every patient is unique 4 Pneumatisits air was needed for life and that all disease was caused by an imbalance in quotpneumaquot air drift into Roman World where they meet a long entrenched view of disease causation 7th century BCE based on agriculture and religion of country sides disease result of sins anger of gods common diseases Malaria Anthrax and Typhus Fever Religion superstition magic Pater Familias the male head of household responsible for healing based on oral tradition women left out of healing except midwifery men prayed and mixed medicine adopted healing gods but open minded to accepting new heling gods Built Asclepiad Temple When four Hellenistic groups met with Rome As greek medical concepts became more popular greek iatros searched for and wanted to have them come to rome Given things they couldn t resist latros offered roman citizenship no military service no taxation Some nobility and small part of lower class but majority strongly opposed these foreign doctors and their philosophical medicine clung to their common sense medicine by pater familias Enciclopidists went around collecting data on treatment of disease no questioning though just facts of what areas did Cato the Elder On Agriculture medical writer Aulus Cornelius Celsus On Medicine partially condemned the philosophical approach of greek doctors Pliny the Elder Natural Historv 2379 AD No greater critic of greek iatros mount Vesuvius exploded Pompeii buried Pliny dead decried latros Instruments found in Pompeii largely surgical instruments none found in Rome Galen of Pergamon 129216ACE Had a major impact on Encyclopedia of Roman Empire Practicality Most Hellenistic ideas rejected surviving ones merged with traditional roman medince folk medicine and cures to form practical type of medicine Big Time Public Health Contributions Confronted large health issues caused by having a ton of people 1005 ofthousands Largescale organization to ensure water supply and keep Rome up and running public baths communicable diseases more for the rich lavish get clean but diseases could also spread easily men and women bathed together aqueducts 312 BC226 AD built eleven of them over 400 year period all major cities need fresh water supply tremendous engineering capabilities start of modern engineering Indoor latrines For the rich Public toilets Don t say who used them Built underground sewers to remove excrement from the cities Built by engineers known for massive projects valetudinaria solely military hospitals HUGE The average roman citizen distrusted the physicians Quackery Medicinetrade unlike today where it is a profession Afraid to perform on seriously injured patients in fear of bad rep Romans required their physicians to be their friends It was better to go to a healing shrine and dieties than going to a pater familiasphysician Consulted quotdoctorsquot after all home remedies had failed Physicians would give public lectures to try and attract paying customers many refused to heal seriously ill patients because they would get a bad rep Rejected in Egypt and Gaul Magic and Religious Medical Practices heavy use of amulets healing power of dreams Some surgery but not very much Roman Medicine Synthesized some of the best medicine from Greece Hellenistic medicine Papis Familia and Astrological Religious Medical Beliefs Roman Doctors had rep for successfully healing low level psychosomatic illness itches coughs etc Relied on rest and diet to help patient average citizen was better to rely on shrine or family that the most well intentioned physician latros seen as last ditch efforts One great Medical Figure To Emerge Galen of Pergamon had a major impact on the development of Western Medicine BYZANTINE AND ARABIC MEDICINE Galen of Pergamon 129c 215 AD born to a wealthy family in Pergamum could have done anything he wanted decided to be an iatros physician apprenticed himself to a local iatros after he learned all he could there he left to learn in Alexandria Egypt museon read scrolls no more dissection there but still greatest resource at that time on his way back he studies in Sparta Athens and then returns back to Pergamum official physician of the gladiatorials because dissection was not allowed trauma exposure learned if you pour wine on an open wound it heals learned how to sew back up the Achilles tendon learned that if you spill wine on an open wound it heals better Off to Rome he goes maybe in early 205 He gets the most incredible role you can get as a physician becomes the physician for Marcus Aurelius the emperor He had the emperor s protection no one could touch him had an in nite supply of recently dead bodies from the Colosseum But he didn t do dissection in humans He believed that what he sees in animalsis what we see in you anatomy by analogy which becomes the belief system in ancient medicine for 1000 years His words become dogma he publishes a huge amount of material No one has claimed to ever study with him or follow him Galenism parts of these two schools and one man combination or Hippocrates of Cos Aristotle and Galen of Pergamum after Galen no other signi cant medical gures are ever mentioned his death marks end of progress for medicine in Rome Disintegration of the roman empire early 4th century AD doom on the wall for Rome Barbarians attacking edges all over the empire Christianity becomes a power in the Roman Empire In a last ditch effort to save Rome he transfers capital Constantine emperor of Rome shifts the capital from Rome to Byzantium later called Constantinople Byzantine Empire 395 AD 1453 AD In 1453 Constantinople fell to the Turks ending the Byzantine Empire This empire replaced Rome as center for intellectual study was dominated by Christian theology and strong military Religion was so strong that is often hindered studies especially medical research with exception of pharmacology Byzantine scholars scribed annotated and studied many classical texts from Athens Antioch Alexandria and Constantinople Power to back up religious philosophy harsh censorship society that did not believe in drugs surgery anyone challenging these religious dogmas was literally taking life into their own hands Byzantium Control the Four Great Centers of Learning Alexandria Antioch Athens Constantinople Constantinople Preserved Galenism translators of Grecoroman literature Oribasius 315403 AD translation of Galenism in the byzantine empire in obstetrics Aetius of Amida early 6th century AD gave us the works up other great roman scholars Alexander of Tralles 5amp 605 AD major compiler of early medical works directly attributed to Galen himself Rufus of Ephesus 1st century AD Paul of Aegina 7th century AD More Galenism says he has nothing to contribute ancients knew it all no progress left to be made Medicine in Byzantine based on Christian doctrine professional poisoners sorcerers amulets all considered healers saints given certain medical attributes St Artemis ailments of genitals Byzantium s only real contribution was translation of GrecoRoman medical texts After its collapse they sent many top scholars to Europe in escaping Turks where they translated texts into Latin Islamic Empire had a much greater role than the byzantine empire in preserving previous works and in advancing medicine they actually did medical science various tribes lived along the water or were nomadic tribes different kingdoms depended nearbyon Byzantine Persia and Abyssinia for political stability Mohammed 570 632 AD his family belonged to a wealthy ruling tribe in Mecca married rich widow and became a rich merchant at the age of 40 came the life changing event that changed his life and the world forever Was in a cave where he claims he was the last voice of god told him he was to be successor ofJesus his success uni ed many tribes socially spiritually and militarily Muslim rule was extended some 4000 miles by horseback and foot Islamic presence in India today due to this expansion Church council of Nicea in 325 AD Tried to patch up between eastern and western Catholic church Nestorians born near Mt Torus in Armenia became a priest rose to patriarch of Constantinople within Eastern Orthodox church alienated other leaders of the Church over various religious views because of his heretical doctrine he was excommunicated and became known as Nestorians migrated from Constantinople to Greek community of Edessa until eastern orthodox church army sent to wipe them out they moved to JundLShapur Jundhshapur for four centuries this was the intellectual center for the ENTIRE western world Nestorians continued their translations in 529 AD nestorians attracted scholars form Greece India China and Jews all intellects from all over together in one community 636AD captured by Islamic Empire impressed by intellectuals basically left JS alone Nestorians were trusted because a number of Nestorians had successfully treated Muhammad and his successors also stood in awe of the intellectual power more tolerant to other religions at that time muslim empire actively searched for historical documents form the places they conquered and sent documents back to Jundishapur or after the shift to Baghdad Baghdad moved from jundishapur to Baghdad compelation of scholars saved many of the GrecoRoman studies and knowledge that we know about today Muslim expansion in Spain up to 750 CE Went in southern Spain and into some of France Battle of Tours nally stopped the push of Islamic armies then pushed them back out Cordoba between half a million and a million people largest intellectual center in Europe numerous mosques 50 different hospital type buildings university with medical school after destroyed by barbarians intellectual center moved to Toledo Toledo medical center shifted from Cordoba to Toledo the medical people made truce any European healers invited by Arabic who ran the university Sicily Greeks Muslims and Europeans in peace lots of trading where many texts were translated into Latin The third major source for transmitting the ancient medical works from islam to western Most notable of these men Constantinus Africanus Constantine the African c 10181087 AD transmission of the writings of Haly Abbas native of Carthage traveled between southern Europe and Islamic World known for helping impose Galenism on Western Europe into 17th century Muslim world produced many scholars who contributed greatly to medicine Rhazes 850932 produced many treatises in the area of surgery wrote extensively on surgery wrote over 200 treatises did make one very serious medical breakthrough found a way to clearly differentiate between smallpox and measles in 910 1890 Sir William Osler copied down almost word for word what Rhazes said Avicenna 9801037 AD a very big time philosopher studied medicine and practiced in the great hospital in Baghdad graduated with the equivalent of an MD at the age of 16 wrote quotCanon Medicinequot textbook for internal medicine Galenism becomes the textbook used in all medical schools of that century Haly Abbas 930994 He wrote the perfect work of the art of medicine Another main textbook in western Europe for centuries Rabbi Moses Maimonides 11351204 AD Greatest Jewish Arab scholar medical fame grew till he became personal physician to the sultan Salomon wrote what we could call the rst clinical book of psychiatry wrote Medical Af risms disease discriptions and cures widely respected text in western Europe The Guide to the Perplex rst writing on psychiatric diseases Oath of Maimonides still exists and is used by some medical students We nd medicine tailored to urban populations and all classes in the urban area had access to a healer rst time all large cities had a number of hospitals that served the population also functioned as centers for education renowned even today for their humane kindness nancially poor patients were often given money so they could go home and rest and not starve Pharmacy and Pharmacology advances made in these eld credit Islamic medicine for rst drug store and the sugar coated pill large number of herbal and chemical drugs limitation put on them by the Koran Hospitals set up just for optimality Koran forbid dissection and illustration of the human body required physicians to rely primarily on rest diet surgery limited mainly to cauterizing wounds strict hygiene rules limited diet no pork Physicians paid extremely well by the rich and were enabled to go take care of the poor in general hospitals a few days a week w government official who oversaw the quality of food drugs and cleanliness of public baths infectious disease control in todays terms failure to comply with him were extremely severe and often fatal abattoir official center of place of animal slaughtering hakim bashi chief physician regulated physicians in communities physician made report of diagnosis or treatment copy given to patient who coukd the complain to the hakim bashi and a decision made lslam had a well advanced health care system high praise for both translations of texts and advances in hospitals and pharmacology best in medicine form 7th to 12th century when there was unfortunately a decline Greeks considered cutting into a body a desecration of the body no human dissection took place Aristotelian view you have substance form animating spirit or force Because the form limits the way function can be expressed it s meaningful to study anatomy The animating force is limited by the structure In Aristotelian sense a human brain has different parts than a dog that allow different expression no need to dissect because it can be inferred Beasts think lower because their heads are lower toward the ground humans stand upright By studying animals you don t need to dissect humans you can understand them Much comparative anatomy in the works of Aristotle No references to dissection until Huerastasis History of Dissection from Herophilus to Vesalius Carey D Balaban PhD The Greek Tradition Human Dissection The idea of cutting the body was considered desecrating the body They did not believe that this impeded science they believed compartive biology could teach you everything you needed to know about shape and function 1 Aristotle and Comparative Biology 384322 BCE 2 Herophilus and Erasistratus Dissection in Alexandria ca 300250 BCE 3 Apparent hiatus Social and intellectual issues 1 Dignity and sanctity of the human body Aristotle quote 2 Medical knowledge gained from dissection Is it better than comparative anatomy 3 Dogmatism versus Empiricism Neither group believed in Euthanasia spirit is required to make the body an actualization a dead body without the spirit is not a full human being hand made of stone or wood or bronze has the form but does not have the spirit hand of a dead body has the same form as a statue it can t move can t manipulate Aristotle asks about who is the designer of the body human hand is fashioned by actions of air and earth then joined by life spirits any part has to be shaped for that design with a purpose behind it in comparative biology if you can understand the shape and purpose you have higher philosophical understanding of why and the purpose without needing to dissect understand how and why it is constructed and so what it s function is by studying development we can understand why they develop Aristotle would say the entire body has animated spirits my hand can think in Aristotelian world if you are breathing and your heart is beating you are alive notion of what is the sanctity of the human body when do cease to be a human body with personhood do become like a couch or statue Different levels of anime rational anime gone then maybe locomotive anime person got the anime at conception anime gains ability to express themselves as it develops ex Moving enutero Because the body had housed the Anime of your loved one it s still sacred and they even believed the body could still feel after death quotan intetectual argument about form function and actualization vs the human shape or form or matter Centuries after Aristotle Allegations of dissection and vivisection in Alexandria from Celsus de Medicina texts of Medicine that argue for the dissection of humans Two schools Dogmatic School based on scienti c principles believe you need to know about the body to be a doctor graphic executions live dissection were commonplace so where is the outrage about the dissections argues that internal pain cannot be cured if the doctor cannot recognize what is damaged the horrid death of a view criminals to bene t the innocent of all ages body is being used for higher good in those who have the anime and are alive same argument as organ donation Empirical School don t need to know exactly what s going on just prescribe the correct medicine argue that a doctor is sworn by oath to cure humans it is atrocious to cut into a person something can be learned by observation or do not need to be learned at all by cutting into the live person you are injuring them and changing the live parts anyways so what can be learned how can you say you get value out of it You are murdering people or desecrating the dead physicians should observe while trying to heal others wounds you don t need to cut a human open we have enough knowledge from comparative anatomy form animals Roman Anatomy is the sanctity offset by the usefulness of the information Human Dissection 1 Did Galen dissect humans Errors in human anatomy 2 Apparent hiatus Catholocism and Science Social and intellectual issues Celsus quote Augustine quote quotDignity took presidence over necessityquot That sounds really neat Do you have any plans for the night I can understand the universe and divine plan by understanding the body Highest order of expression is to express the rational anime what makes humans different form beasts humans were not created like animals who are not rational and look toward the ground while humans look toward the heavens Human being displays certain aspects of physics chemistry and the universe Expression of higher level rationality and contemplating things above a human can speak and write and accomplish other crafts is the perpose of creation beauty art or usefulness All useful parts also add to the body s beauty certain 39brutal physicians dissect humans lack humanity arguing that there is no value to dissection the purpose or whole view of the body is beauty the beard is regarded as an adornment dignity takes precedence over necessity or utility Sanctity is going up and anatomical knowledge going back down Human Dissection Becomes Commonplace Human Dissection Surgical and Forensic Dissection Second half of 13th century in Bologna records of dissection taking place for forensic purposes knowing if there was a murder took precedence over dignity Surgeons William of Saliceto Thaddeus of Florence Bartolomeo da Varignana Mondino de Luzzi Anathomia Mundini active 130025 2 Naturalism in Art Dissection by Artists mid15th mid16th centuries Andrea Verrocchio 14351488 Andrea Mantegna ca 14441524 Leonardo da Vinci 14521519 Albrecht DUrer 14711528 Michaelangelo 14751564 Raphael 14831521 understand the body to render the beauty 3 Andreas Vesalius Bruxellensis 15141564 Fabrica Corpus Humani questions Galen s Anatomy quot11 Social and intellectual issues 12991300 Bu of Pope Boniface Vlll Persons cutting up the bodies of the dead barbarously cooking them in order that the bones being separated from the esh may be carried for burial into their own countries are by the very fact excommunicatedquot Lectures of Curtius quote from Anathomia Mundinl referring to the practice of transporting bones home after a year of being buried where they died during crusades technique developed where bodies were boiled in lye bones were then obtained and sent home to be buried in consecrated ground Catholic Church did not approve of this technique no dignity or necessity Knowing anatomy can tell you exactly what function will be lost based on the injury sustained nature created no organ without purpose therefore all parts of the body have functions of their own as intended by nature Nature has not created anything without purpose Augustine Book 1 CHAP 13REASONS FOR BURYING THE BODIES OF THE SAINTS Nevertheless the bodies of the dead are not on this account to be despised and left unburied least of all the bodies of the righteous and faithful For if the dress of a father or his ring or anything he wore be precious to his children in proportion to the love they bore him with how much more reason ought we to care for the bodies of those we love which they wore far more closely and intimately than any clothing For the body is not an extraneous ornament or aid but a part of man39s very nature And therefore to the righteous of ancient times the last offices were piously rendered and sepulchres provided for them and obsequies celebrated and they themselves while yet alive gave commandment to their sons about the burial and on occasion even about the removal of their bodies to some favorite place The idea that the brain is designed for higher level rational function spinal cird digestive system nutrition anime heart vital anime but the heart still has rational anime it cannot express Milestone marking change in thought assumes we can build something that looks like a human you could make mechanical things that move on their own the replicas of human beings will resemble form and movement of real humans the body is not more than a statue or machine formed by God the human being becomes a machine with anatomical processes with some sort of anime by the brain and nervous system where the rest is a biological machine concept of brain death is close to proof of this belief that our humanness exists in our brain radically different view from the ancient world 393 ma a ashein 341W N1quot W C k E 09 GM mp mam VFWWW B LB MW Gqu i iM W153 p t Wm 13r m Knows A quot r W g 3 mth Mr 3k We m awn f 5 l w H DP W L39Hl v 3 A i Welng Chmwmuiplm J 399 4 0 WLWr xd 0 W t gnJ r GMM W C UM M k M3 mm c r 3 MULI g L Eikj r39 i Wu qrqm ea iz v 35 A 39 11mm r l i is howMW he gum W E 90 ux 1 A 3 M myblgw r WWW f a T 39 39 quot u39I39 V quot39 i 7 1 X af39 f 39av I v 1 w Ll V I I x I V I 39 f w gt I 7 quoti m w l V I r l I J l r q39 p39r 39 39 l l I V r w 7 9 35 7 1 Itle an JV VEL 9 v 15 MRD W H quot s nape Paw E MEAN 3 13gtiQ k a m E f 95 ad 5 3 m k I 1 A CD JH X ij39lgmf quot thw iw k LY M 39 1 id C Of A 39 1W g 1 pt if mm J r If I Q E 394 W 56quot mum lam gm ML w Mgb M I quotJON pal e k W 1sz um my J I f F m L Um if ifquot 5 59 1 w dr r 1 39 39 Xquot 939 57 laquot 39 3 I t V 7 A ML i a tad quot w O rt Max234 1m l p a 39 of own M ma ta C6W 1quot mm 1 cf 3 aw i I all i v u i IFI If y 3932 5 1 p V13 3 39 l ir rrll l 1 3 I Lquot r H I H M Iquot t ML r a i Jr LLULEUKK I a J iffy Lem i a g f Mimi Lat L H F 39 n a 39 39 39 39 or y U39 L i 39 L cuqu L 1 Eu quot1 V r I 74 a x 1 h l 5 an mm m 2 J m an k I E r 4 K M We PLAGUETHE GREAT MORTALITY 13481350 Black death fear because cause unknown seemed to strike completely randomly rich poor young old Family members forsake and abandoned each other Plague could have been brought by the traders who told about upcoming calamities Wasn t called the black death until later called the Great Mortality Great Mortality Black Death 13481350 Caffa biological warfare 1347 ltalain city under siege attacking army dies from balck plague ltalians rejoiced then general of army catapulted bodies over the walls spreading the plague survivors ed toward Italy where they infected an entire continent ed to Genoa Genoa ltalian city state 1348 It was thought people were being punished by an angery god for their sins the plague acquired the name the Black Death then Bubonic Plague untold millions doomsday had arrived major port cities like Genoa were infected even the best physicinas had no idea how to stop or help How was the disease spread All they knew was that the symptoms were horrible beyond belief 39 rst prickles then a hard boil then a putrid fever as the skin cells of the victim died their body turned black and as they were alive their body stunk od decomposing must have been horrifying to relatives some died in hours but most suffered for ve days The most terrifying question was why Philosophers looked to the stars and thought god caused the planets to align to cause the plague or comets god made bring the plague Others believed it came from the earth that earthquakes had released deadly gases into the air people were desperate they knew it was coming All places in Europe did not suffer the same only a handful in Mulan while Venice lost half of population not everyone died or even caught the plague even when side by side with victims seemingly completely random compared to an arrow attack St Sebastian became patron saint because he had been pierced by arrows and survived as the plague continued people turned to St Roche who had suffered the plague but miraculously survived St Sebastian patron saint of plague victims St Roche patron saint of plague victims Most in Europe believed god had forsaken them Scared of what lay beyond the grave possibility that their souls could be damned for life especially if they did not receive their last rite the Black Death killed so many that last rites could not be given to everyone Pope Clement Vl In response to the many he gave absolution of sin to all who died of the plague many of the living were not comforted by this and many resulted in forming their own ingenious cures Paris 1349 Succumbs to the plague 800 people a day would perish medical knowledge overwhelmed one common cure was blood letting which could have even spread the disease more often the church people and doctors were infected and succumbed to the plague People made up their own strategies London citizens walled themselves into their city to lock out the plague half of their population died popel of venice enacted a law that all incoming ships had to be quarantined for 40 days this was enacted too late and half the population died Most confusing was how it was spread many believed it was the smell of the sick doctors wore bizarre out ts mask like a bird lled with herbs to purify the air some didn t even look at the people affected masks also included eye pieces to shield this no cures seemed to work doctors turned to pigeons to suck the blood or applying hot onions to the sores people would sniff posies closed windows avoided naps gave up washing changed diets the sick were often objects of fear and loathing some even murdered in Milan all people reported to be in a house with someone with the plague were walled in and left to die in Milan it did not spread as other places Pope Clement Vl apparently miraculously survived the plague walled into a castle burning herbs and sulfur probably much less rats than in the general population self quarantine bloodletting quarantine begun in Venice 1349 corrupt air agellants violent religious fanatics as 1349 closed and the plague continued to ravish the survivor s psyches were torn trust was ruined in communities and families how people responded were just as sporatic as the plague some threw themselves into sensuality gluttony etc Others dedicated themselves to service and charity they confront the plague and try to nurse the sick do their Christian duty others driven to violence and hatred Flagellants swept across Europe almost like the plague if they harshly punished themselves for their sins God might spare them from the plague wearing black cloaks they went form village to village and performed bizarre and terrifying ritual where they chanted in a circle then fell down in position of their worst sin then the leaders would beat them with a whip ironically this probably spread the plague more their blind religious zeal released religious plague of hatred and bigotry agellants blamed Jews for the plague often burning down entire Jewish communities By 1350 Black death had enveloped all of Europe and about half the population had perished then suddenly is receded occasionally it came back sporadically but never as badly of before in three years Europe was brought to its knees as many as 40 million people died Nostradamus 15031566 Physician who became known as a prophet developed his own measures to counter the plague he suggested people breathe fresh air moderate exercise and bathing regular physicians discouraged this but the people were desperate and willing to try despite efforts 300 years of the plague continued Medical visionary official physician had MD became interested in astrology wrote quatrains that very vaguely predicted the future or that s how it was taken Bogus that great medical strides happened because of the plague if anything progress was made in quarantining Marseilles 1721 Last city to suffer major losses due to the plague Alexandre Yersin 1896 Isolated the plague bacteria under a microscope concluded that rats and the eas they carried were the cause of the plague after rats died the eas moved to people Fleas could cause widespread epidemic especially in the tight living quarters of Europe The eas may have come in caravans and ships from the farthest end of earth this lead researchers to China s Gobi dessert Bacteria found there traditions protected them from the bacteria could hunt certain rodent and once they saw too many dead rodents they would move on have not been a plague like that since 17005 but there are still remnants of it Ring around the Rosie Ebola causes massive hemorrhaging most victims die in a few days it is a virus and not reacted to antibiotics could spread very quickly could be very devastating we do not know how it attacks The blood loses it s ability to clot so it bleeds under the skin and those areas then turn dark like a bruise if there is enough bleeding circulation to skin is cut off and skin begins to breakdown it takes 4 to 5 days to reach that state The plague is a major outbreak in the US because of illegal immigrant scenario beginning people are now aware it is very curable now but it must be recognized early enough Bubonic plague refers to enlarged lymph nodes Remember disease is much more lethal when population is already vulnerable people were already starving and malnourished In the death count they lumped in all death The Church was a bigger loser in this even when the priest does everything quotrightquot and two days later he dies of the plague people start to lose faith in the protection of the Church religious historians ask would there have been a Martin Luther without the plague the Church never regains the total power and trust that it had had People moved into towns from the manors they were used to living in start of urban life with a growth of merchant working class futile society had maximum wage laws as less surfs were available had to pay more and many lords went bankrupt guilds Physicians could either be cowards and run away or be seen as incompetent when they couldn t cure patients Catholic church embraced Gaelentic medicine as well as Greek thosophy Vesalius and the Advent of EvidenceBased Anatomy Carey D Balaban PhD Struggle between ancients and modernists over who has the correct view Let s work together the discover but ancient ndings cannot be dismissed rejected by modernists Scienti c communication ancient world had to write it out printing press more modernist Change in societal values before it was completely orthodox now there is not just one philosophical theological view etc Andreas Vesalius 31 December 1514 Brussels1564 Isle of Zante Modern research suggests he was a dwarf Education University of Louvain in Pedagogium Castrense Castle School 16yo 19yo classical education University of Paris Medical Studies with Jacobus Sylvius Jacques Dubois 14781555 and Johann Guinterius of Andernach top institution of that time University of Louvain Medical Studies Preparation and publication of thesis Paraphrasis in nonun librum Rhazae medCi arabis clariss ad Regem Almansorem Basel 1537 Baccalaureate in Medicine 15371542 University of Padua Doctorate in Medicine 5 Dec 1537 Appointed Expicator Chirurgiae Publication of Tabuae Anatomicae Sex Venice 1538 Galenic work with illustrations by Johannes Stephanus of Calcar Publication of Venesection Letter1539 Preparation of De Humans Corporis Fabrica 153940 1542 published in Basel 1543 using multiple artists went to Basel in 1542 for proofs 15431556 Court Physician to Emperor Charles V Carlos I Published Epistoa rationem modumque propinandi radicis Ch ynae decocti quo nuper invictissimus Carous Vimperator usus est pertractans Basel 1546 Prepared and published second edition of De Humans Corporis Fabrica Basel 1555 15561559 Private practice with Imperial pension 15591564 Court Physician to King Phillip ll of Spain In early 1560s Accusation he dissected ie performed autopsy prior to death brought to Inquisition Protected by King Phillip ll Died while returning from a pilgrimage to Jerusalem Key features of De Humanis Corporis Fabrica Beginning of evidence based anatomy do I believe my own eyes or the ancients Perspective is completely Galenic Some Anatomical details that he found contradict Galen Eg humans do not have a premaxilla marrow in bones of hand pits in cardiac septum are not perforated three not seven fused bones in sternum manubrium body and xiphoid process three not ve liver lobes lack of 05 cords found in cattle in humans Conclusion Galen did not dissect humans Reaction to De Humanis Corporis Fabrica Scholastic fundamentalism see quotes from letters of Vesalius Dispute was academic not theological Note Earlier surgical books that criticized Galen eg Thomas Morstede ca 1440 A Fair Book 0f5urgery statement about dissection quotAnd be these manner of ways Galen in men s bodies appraises swine and in many other beasts come to the truth of the knowledge of anatomyquot had criticized Galen without a storm of criticism An opening volley of quotThe Battle of the Booksquot Ancients vs Moderns Jonathon Swift Entry from The Catholic Encyclopedia Appleton amp Co New York 1910 quotThe story that towards the end of his life Vesalius came into con ict with the Inquisition is found in a letter written at Paris under date of 1 Jan 1565 by Hubertus Languetus to Kaspar Peucer A rumour brought from Spain said that Vesalius had dissected a distinguished man whose heart still beat and was therefore accused of murder by the family of the deceased In order to secure a more severe punishment the family also made an accusation of atheism against him before the Inquisition Only the personal intervention of Philip II saved him from the death penalty and Vesalius was obliged as penance to undertake a pilgrimage to Jerusalem and Mount Sinai Modern historians regard the report as a malicious invention and all the more as according to his own statement Vesalius never had an opportunity in Spain to perform a dissection At that era a scholar with so many enemies one who generally struck out new ideas in opposition to the commonlyheld opinion could easily be accused of heresy To many his relations with Protestant scholars appeared suspicious When a young man he had a dispute about 1536 with the theologians of Louvain because he differed from them as to the seat of the soul About the same time an opponent characterized Vesalius in connection with a dispute about bloodletting as the quotLuther of the physiciansquot There is not a single sentence in his writings which has even the appearance of heresy In speaking of the seat of the soul he blames the theologians for wishing to solve such questions without understanding anatomy Personally he avoided expressing his opinion in order not to fall under suspicion of heresy In that age there could be only one reason for such a dangerous journey as one to the Holy Land namely strong religious feeHng Because he was given to Inquisition it has always been a question of if it was theologically involved as well Extracts from letters of Vesalius from O Malley CD Andreas Vesalius ofBrusses 15141564 University of California Press Berkeley 1964 pp 218224 1 quotThey ought to be grateful to me as the rst who has dared to attack man s false opinions to lay bare the extraordinary frauds of the Greeks and to provide our contemporaries with an unusual opportunity for searching out the truth Such however is not the case because Galen s authority you will nd many who having glanced at my efforts only super cially and without investigation of the cadaver still maintain that what Galen wrote is wholly correctquot revolutionary bc he trusted his own eyes over dogma 2 quotThe writings of many learned men commend my youthful efforts far more than they deserve and willingly confess that they prefer to put trust in their eyes rather than in Galen s writings nevertheless I understand that there are many who although they agree that my work has virtue and credit me with ability beyond my merits yet are angry with me for Galen s sake Among them is Jacobus Sylvius leading physician of our day who in a letter transmitted by your son expressed his opinion very strongly even though he declared that he had not read my books De humani corporis fabrica Consequently you can easily gather what was in the letter I sent you from Nymwegen so that it might be transmitted to Sylvius by your son In that letter I replied to Sylvius adding things here and there that in my disturbed state of mind seemed a proper reply but most of them referring to anatomy remarks by which the falseness of his assertions was revealed and by which my own position was explained There was a personal attachment with those who had studied Galen and his texts and ideas almost as they must defend the existing thought emotionally charged quotSylvius replied in his usual way declaring that he did not consider himself of sufficient erudition or authority to desire to judge in such an important matter but that nevertheless he would express his opinion brie y because I had asked for it After he stated that I had improperly criticized Galen he asserted that He declared that he remains rmly convinced that Galen s description of the human body is without error in every instance in which I claim that Galen s description is partly or wholly incorrect or that he has been forgetful and explained the body s function imperfectly or used faulty reasoning to support his doctrines Sylvius is the last one from whom I should have expected such an opinionNor can I accept his proposal that if I withdraw my false statements regarding Galen and attribute them to my youthfulness and the in uence of the Italians who oppose Galen he will do his best during his lectures to conceal from his audience the fact that he does not approve of my work He wrote that he made this offer because he likes and respects me and wishes to keep my friendship and because he feels that we could not remain friends if we were to disagree over Galen In order to frighten me still more he added that even if he were to remain silent himself others might disclose his true opinion of my work for some of his students whom he considers as very capable anatomists are sharpening their pens against me because they are indignant that I should make remarks against Galen master of all physicians Hence he asked me what I wanted him to do for me in the matter and of course he meant that I ought to desire to retract and so escape those sharp pens of his studentsquot Acasdemic dispute no discussion of is his anatomy ndings are correct or not how dare you disagree with the ancients our small minds we are mentally incapable of challenging the acients quotI began my letter to Sylvius by saying that l was less upset by his remarks because I had seen many very learned physicians and philosophers who had been just as angry as he because I had said such things about Galen These men could not believe that the father of medicine had made such mistakes in the anatomical books he felt had been written with so much care and accuracy the more so since it was a subject in which he had acquired greater authority than anyone else even during his own lifetime However reluctantly they came to put more faith in their eyes than in the words of Galen It is my hope that eventually Sylvius too will change his mind as he reads through what I have written and that he will not deny me his good will and friendship However as I wrote whatever the case may be I should consider it as merely one of the misfortunes of mortals that must be borne as l have not yet learned to speak counter to my own belief Furthermore that which he criticized in me becomes greater every day That youthfulness with which Sylvius charges me has passed but my increased years have not made me change my opinion I shall not mention how much I was hurt by the retreat that he offered me the pretense that the Italians dislike Galen because nowhere is Galen more respected and honored that in Italy This is fully proved by their publication of his works even if they have not entirely discarded the Arabs and removed them from the medical curriculum I should certainly be guilty of the greatest impertinence if I were to accuse such learned men my kind friends to whom I am indebted of being responsible for what he calls my error Those ltalians like Sylvius usually opposed me although I had never seen any of them put a hand to the cadaver before they rst attended my dissections and they are well aware that none of them was ever my instructor or helper in these mattersquot The nature of the opposition to him that he was saying Galen is wrong and never dissected a human every student of medicine learned in amphitheater from the works of Galen with a limited view of the dissection peers and teachers felt personally attached that he was attacking the very foundations of medicine remainder of the reaction to him was varied would rather believe in the sanctity of the ancient text than go with Vesalius Rational of people ignoring inconsistences by saying Galen was right and they have a defective cadaver In 1500 years 300 years of continuous dissection it was the societal value placed upon the words of the ancients Details of anatomy were not considered all that important questions in theology invited questions in sciene He maintained Galenic systems but questioned the details Once it is acceptable to challenge Galen challenges to more works opened up Belief humans had degenerated since the ancient world William Harvey 15781657 and the Advent of EvidenceBased Physiology Carey D Balaban PhD Transition from Galenic view to view of blood circulating Galenic view From vital system left side of heart and arterial tree blood in arteries and veins had no direct connection to nutritive William Harvey s views are inconsistent with Galen Education 15931597 Ordinary student Gonville and Caius College Cambridge 15971599 Medical studies Cambridge 15991602 University of Padua top school at the time Student of Fabricius comparative method discovered valves in the veins at the same time Harvey was studying under him Doctorate in Medicine 25 April 1602 London Permissus Licensate of College of Physicians 5 Oct 1604 Appointed Physician at St Bartholomew s Hospital 16091643 Appointed Lumleian Lecturer to College of Physicians 1615 De Motu Cordis 1628 published in Frankfort to maximize circulation Physician to James and Charles Response to attack ofJean Riolan the younger of Paris Exercitationes duae anatomicae de circulatione sanguinis 1649 Harvey begins to scienti cally investigate circulatory system Go from distinct arterial and venial blood to the idea that the heart is a pump and blood circulates Deductive argument in De Motu Cordis based upon observations Based on observations from vivisection of animals the heart contracts and causes an expansion of the arteries which corresponds in time to the palpated pulse Thus contraction of the heart causes expansion of the artery Auricles atrium are related to the ventricles as the ventricles are related to the arteries Contraction of the auricle precedes contraction of the ventricle Blood in the great vessels aorta and pulmonary artery is prevented from returning to the heart by aortic and pulmonary valves Atrioventricular valves also prevent blood to return to the atria from the ventricles Observations consistent with Galen Thus the veins must be the source of blood that is pumped into the ao a Blood passes from the Galenic arterial vein pulmonary artery to the Galenic vena arterypulmonary vein through the 39strainer of the lungs He ascribes this nding as the con rmation of an ambiguous passage in Galen says change from arterial to venous must happen in the lungs The blood moves as a circle hence the term 39circulates from arteries to veins in the body Experimental support from vivisection of snakes and bandaged as in tourniquet human arm veins Says that nothing is inconsistent with Galen we misinterpreted Galen William Harvey presents something revolutionary View when we inhale we are cooling down the lungs are near the heart and cool the heart which keeps the heart form overheating that is the purpose of respiration Trachea was originally called the rough artery by misinterpretation Harvey said people assumed arteries contain air not blood Harvey concludes that arteries contain the same blood as veins and absolutely no air Blood is blood regardless of veins or arteries Talks about fetal circulation Right ventricle exists to propel the blood to the lungs therefore animals with out lungs have only 3 chamber as well as fetuses of mammals who do not yet breathe Reception Support Ren Descartes Robert Fludd and Sir Kenelm Digby Attacks James Primerose violations of Galenist dogma said Harvey was anti galen Caspar Hofmann Teleologic what is the purpose of circulation of the blood and Scienti c How does the blood travel from arteries to veins Jean Riolan NeoGalenist perspective Arguments refuted in publication by Harvey this one actually lead to some serious resistance to Harvey s work argues blood circulates in major blood vessels but not in the smaller branchesNeoGalenism trying to preserve old model of three compartments of the body 0 Harvey points to literature that shows that blood pooling in one place is not healthy 0 Must confess that there is circulation before knowing what it is for let s believe what we see and not be too much a philosopher there are things no one knows but are still accepted Tension drives progress explain observations and works Blood circulates heat cold working in circulateory system experiment with tourniquet and ice Harvey faced people losing it because their treatments were being shown to be based off of awed logic History of Medical Instrumentation Introduction Physicians and Physicists Lancet Editorial is an indicator of a profound transformation in the perceived relationship between the physician scientist and biomedical engineer Marks a profound change in intellectual focus of physician and the development of medical instrumentation This evolution change was re ected by a transition from an alliance between Physician andArtisan hence view of medicine as a subiective Art to an alliance between Physician and Physicist and the view of medicine as an obiective Physical Science The tangible mileposts of this changeMedical Instruments The Ideal quotThe nger is substituted by an instrument of precision which replaces impressions by recorded facts selfanalyzedquot pointing toward a change in medicine a physician from a philosopher to a mechanic observing speci c facts and parts of the body transition from perception of medicine as a healing art to medicine as science transition from medical instruments as products of artisans to medical instruments derived from the physical sciences leads to a functional classi cation of instruments Since goal provided an intellectual framework for the development of instruments it provides a useful framework for both classifying instruments functionally and elucidating the historical evolution of these categories of instruments A functional classi cation of medical devices 1 Physician artisan alliance beauty make re ned instruments used by re ned physicians no thought to sterilization tools were built by artisans to a standard of beauty as well as function 2 Physician physicist alliance more functional spare instruments late 19th century 0 A Instruments that assess phenomena subject to human perception o Devices which use physics to extend human senses for analysis quothidden body regions Ex Microscope stethoscope Xray Endoscopes Ophthalmoscope and Laryngoscope B Instruments from physical sciences that objectify quantify previousky subjective ndings 0 Ex Thermometer sphygmograph tonometer sphygmomanometer o C Instruments that graph things that humans cannot perceive A Therapeutic Devices Similar motivation bridges transition from Artisan to Physicist periods Treatmentoriented applications and improvements of technology Response to practical concerns in patient care and quotHealing Artsquot Incorporate changes in technological and biological knowledge However preserves the tradition of physicianartisan anage 1Medical UtensilsImplements a Surgical Instruments b Hemostasis cautery sutures electrocautery and surgical lasers c Catheters endoscopic surgical methods gamma knife surgical robots etc 2Devices to replace normal physiologic functions temporarily or permanently a Prosthetic devices eg arti cial limbs heart valves hip joint prostheses artistic work done on these as well b Arti cial ventilators HeartLung machine Ventricular assist devices Extracorporeal Dialysis arti cial heart B Diagnostic Devices 1 Assessment of events that humans can perceive A Devices which permit human senses to directly analyze body regions that are normally hidden from perception Subjective transduction and subjective analysis Applications of new technologymaterials to extend human sensation Subjective analysis preserves quotartquot of medicine thus requires specialized training to use instrument and interpret ndings 1 Compound Microscope Jansen ca 1590 van Loewenhoek Robert Hooke mid 160039s Tully and jL Lister 1830 achromatic objectives anatomic pathology Virchow mid18005 specialized histologic methods 186039spresent Lister corrected the lenses and improving the base of microscope made major advance in microscope transformed microscopy move from looking at beauty of micrology to looking at tissues theories of disease etc microscope was an enabling technology it took a while to develop 2 Stethoscope Rene La nnec 1822percussion auscultation enabled the use of listening to the chest for diagnosis ampli ed but also created a social distance that allowed it s integration into medicine had to infer sounds took more training to recognize exible stethoscopes began immerging mid 19th century 18705 1880 quotdouble stethoscope two ear pieces evolved fairly rapidly with use physician was still analyzing they still had to know what they were listening to 3 Endoscopes Evolution from Ophthalmoscope Helmholtz 1850 and Laryngoscope Czermak 1858 to modern endoscopes and arthroscopes could see back of the retina in the eye allowed physician to see hemorrhages color of retina worked it s way into diagnosis of eyes very quickly still his expertise that allowed interpretation physician is still the analyst Laryngoscope allowed view into the back of the throat 4 Xray B Devices which apply measurement methods of physics to diagnostic parameters that humans can perceive quotObjectivequot transduction of phenomema and subjective evolving to objective analysis Link with physicist Objecti cationquanti cation Replace subjective observer with objective instrument therefore the clinical course of the patient could be followed reliably and reproducibly Often the analysis initially subjective because it is direct representation of clinical perception later it evolves to objective ie quantitive modes of analysis by incorporating standard methods and population norms Required development of graphical methods of analysis for inferences about pathophysiology 1 Pulse watch Floyer 1707 watch with second had could measure pulse rather that fast or slow there as a number 2Clinical thermometry Wunderlich 1868 Temperature could be measured reproducibly over time to analyze the characteristic course of different fevers Liquid that expands or retracts due to temp mercury or alcohol see through so thin but strong and a scale original was 100 degrees is human body temp and 0 was freezing point of salt water by 18605 the more modern type of thermometer changes in glass making allowed thermometers to become much more acceptable in use 3 Sphygmograph Marey 1849 Pulse transduced as graph of displacement over time Mackenzie 1902 A syphmogram may therefore be de ned as the diagrammatic representation of the variations of pressure within an artery becomes more sophisticated records size and duration or each wave physician is now making measurements becomes objective no longer in use but it introduced to medicine the idea that you can measure abstract traces 4 Sphygmomanometry RivaRocci 1896 record systolic and diastolic blood pressure over time use in intraoperative monitoring ca 1900 5 Digital plethysmograph noninvasive transduction of pulse pressure over time 2 Devices that objectively transduce phenomena that humans cannot perceive quotObjectivequot transduction and subjective evolving to quantitative analysis QUINTESSENTIAL STATEMENT OF PHYSICIAN AS PHYSICISTPHYSICAL SCIENTIST Device is derived directly from instrumentation of basic research Requires intellectual recognition of common basis of biological and physicalchemical phenomena eg Faraday and animal electricity biochemistry Table from Magendie Skepticism of Physicians Relevance to clinical care must be veri ed Analysis quantitative and statistical based upon standardized methods and population norms Test result is numerical and must be integrated into total clinical impression popular conception of patient as machine or set of numbers 1 Clinical chemistry eg blood chemistry antibody titers and enzyme activity levels 2 Clinical electrophysiology eg ECG EEG and electroretinogram earliest recorded were in 1870 s by 1883 humans were measured The more abstract and dif cult to interpret the less quickly accepted it was Xray accepted very quickly compared to Cardiology and EKGs Important insight quotAnimal electricityquot obeys same laws as physical electricity Faraday 1833 Case study Electrocardiography documentation of bioelectric activity of heart during cardiac cycle Kolliker and Miller 1855 development of capillary electrometer in physics Lippmann 1874 application of capillary electrometer to recording electrical activity of vertebrate muscle and heart Marey and Lippmann 18746 rst published human electrocardiogram ECG with capillary electrometer Augustus Waller 1887 development of string galvanometer demonstration of PQRST complex of human ECG Willem Einthoven 1889Nobel prize in 1925 emergence of clinical electrocardiology Thomas Lewis 19081913 The statement from the Lancet then provides useful insight into a driving force in development of biomedical instrumentation and science The apex of medical science was exempli ed by the assessment of the sphygmograph that quotThe nger is substituted by an instrument of precision which replaces impressions by recorded facts selfanalyzedquot Presages the development of Devices designed to replace the physician as diagnostician Computerbased diagnostic systems The future of medicine Technicians enter objective test data device provides standardized 39objective39 diagnosis some people survived the plague how many 433 survivors half the village of Eyam some believe the town could have been infected by anthrax not black plague similar symptoms this explanation would explain the high survival rate historians look for mass die off of animals where anthrax came from no evidence of livestock die off pointed again toward out break of the plague perhaps because the town was more open than the cities allowed for higher survival rate link taxation records to who was wealthier and poorer the poor would be more crowded evidence showed that cramped living conditions etc had no affect Some people not only survived the plague but never caught it at all the Hancock family one by one Elizabeth mother buried 6 of her children and her husband in one week despite daily contact there is no evidence she ever became ill The village gravedigger handled hundreds of infected bodies but never contracted the plague Assume there is something biologically different in the survivors The few survivors intermarried wondering if scientists could look at the descendants and analyze genetic make up to nd a mutation that provided protection form the plague Theory that a mutation could block the gateway into the cells and prevent infection in the body Eyam had not a lot of in uence from outside throughout the generations all who were tested were direct descendants of those that survived the plague The mutation is present in the ancestors mutation is seen is 14 of the sample signi cant proportions in genetics it was much higher in the days after the plague Is there a way to prove the mutation existed during the plague began to map the mutations in different populations the gene frequency was not the same Africa was totally zero as well as in Asia and India Conclusion levels of mutation in Eyam were only matched in other European parts affected by the plague and in America which was populated often by survivors of the plague map of mutation matched the plague map Want to estimate the date when the mutation occurred so they could con rm the dramatic uptake was caused by the plague Discovered mutation erupted in Europe about 700 years ago discovered that 700 years ago candidate was the Black Plague dates were perfect match Signs indicate that the mutation gave select few block from infecting the cells those with mutation survived Why were some completely immune while others were infected then recovered Would people with only one copy of the mutation have just enough resistance to stay alive but not enough to completely ght off the disease Those with two copies survive those with one recover those with none die Turns out that those survivors passed on genetics Research shows that the plague and HIV attack the body in very similar ways both target and take over the white blood cells Begin studying people exposed but not infected by HIV Blood sample bombarded by 300xs the amount of virus needed to infect and the blood was not infected Looking at the DNA blocking mechanism provided by Delta 32 mutation same as the plague passed down by European ancestors people with one copy showed delay in development of AIDS those with two immune to AIDS did not have the entry port for HIV HIV positive person goes in for bone marrow transplant the donor had Delta 32 and the HIV positive person converted back to HIV negative but he is still a carrier In New Jersey this happened again The hope is they can create Delta 32 arti cially the people are cured but still dangerous and we don t know if it is a lifetime cure or if they can be reinfected The closest we have at the moment to curing HIV AIDS
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