epidemics test 3

clinical teaching in hospitals

allowed young practitioners to gain hands on training compared to the normal purely theoretical one based on books and theories

it started in the 16th century

Hotel Dieu

(Hotel of God) is the hospital usually located next to the cathedral and under the bishop's control in Medieval France. That in Paris was one of the largest. It had a very high mortality. Often patients were two or more to a bed.

systematic autopsies

involve the thorough examination of body systems and organs after death to determine cause of death and any underlying diseases

part of the revolutionary Paris with new ideas

medical observatory

hospitals

enabling physicians and surgeons to investigate disease in a new way, relying on systematic autopsies and slightly later also on quantitative methods.

surgeon/localist

Surgeons (mainly outside Italy) favored the vernacular and were mostly trained by apprenticeship, not at university. All surgeons (low and high class) were localists who focused on the local effects of disease.

physicians

Physicians were university trained, wrote in Latin, and focused on the causes of disease, both within humoral doctrines and later views (acid-alkaline imbalance). They usually prescribed remedies to be ingested.

Rene Laennec

Relying on pathological anatomy, early in his career Laennec studied and named a number of conditions, such as liver cirrhosis [yellow liver], peritonitis, and melanosis [=melanoma].

Laennec invented the stethoscope

Jean-Nicolas Corvisart

physician to Napoleon & translator into French of Auenbrugger's treatise on chest percussion

Pathological anatomy

define characteristics of diseases

François-Joseph-Victor Broussais

(1772-1838) was a highly visible if simplistic and extreme physician and surgeon, and Laennec's arch-rival. Broussais claimed that diseases were not independent entities and fiercely opposed nosology.

his main therapeutic tool/remedy = leeches (bloodletting/phlebotomy)

Inflammation

For Broussais diseases were altered physiological states originating from inflammation. Tackling inflammation was his key therapeutic strategy: his main tool was bleeding.

Leeches

Broussais’ main therapeutic tool/remedy

Bloodletting/phlebotomy

leeches

did not have an effect on cholera

P Louis

pioneered the usage of what he called the "numerical method"

Louis compared the effects of different medications and questioned the usage of phlebotomy. His analysis was hotly disputed by the medical establishment: they argued that individual cases had features ill-suited to forming general classes.

Stethoscope

invented by Laennec

He states that since his patient was fat, young, & female, he could not put his ear to her chest. With a folded paper, Laennec was surprised to hear sounds very clearly. He then established a correspondence between lesions and sounds produced when breathing, talking, or coughing.

Necker Hospital

At the Necker Hospital Laennec invented the stethoscope, a paper or wooden tube, which enabled him to investigate more thoroughly consumption through the sound of diseased lungs and to relate symptoms observed in live patients to lesions found at autopsy. He states that since his patient was fat, young, & female, he could not put his ear to her chest. With a folded paper, Laennec was surprised to hear sounds very clearly. He then established a correspondence between lesions and sounds produced when breathing, talking, or coughing.

Consumption

Laennec showed that scrofulous tubercles found in different body parts, such as the lungs, lymphatic system, spine, etc., were part of the same condition, namely consumption (soon to be called tuberculosis).

Consumption was associated with several symptoms such as cough, spitting blood, cold fevers, etc. But confusingly, some symptoms could be present even without consumption.
Hence the importance of providing a univocal identification of the disease.

Johann Schonlein

In 1832 physician - (1793-1864) coined a term, tuberculosis, for the old consumption. The new name relied on the defining character of the condition, as it was then understood, the presence of tubercles, regardless of where they were found. Soon, however, new major findings made the new name obsolete .

Tuberculosis

very slow burning - could be sick for years

Localization

A principle of pathological anatomy is localization. But scrofulous tubercles are not truly localized: "In consumptive patients it is very uncommon to find the tubercles confined to the lungs: almost always they occupy the intestinal coats, at the / same time, and are the cause of the ulceration and consequent diarrhœa so general in this disease. There is perhaps no organ free from the attack of tubercles, and wherein we do not, occasionally, discover them in our examination of phthisical patients".

Meditate Auscultation

Laennec’s Treatise - Laennec published his major work on this in 1819. Here he announced the discovery of the stethoscope and discussed the sounds he could hear in the lungs and (more problematically) in the heart. He focused on the physical examination of patients and postmortems to confirm in the cadavers the lesions he had inferred in live patients.

Pectoriloquy

voice heard through the chest, possibly indicating a cavity

Succession Splash

the sound of free fluid in the chest

Metallic Tinkle

like "a little bell that has just finished ringing, or a fly buzzing in a porcelain vase", indicating pneumothorax (=air in the pleural cavity) or a large cavity

Egophony

the bleating voice of a goat, indicating pleural effusion

Resonance

indicating emphysema

Broad St. Pump

was thought to be the cause of the London cholera epidemic

Epidemiological Map

are used in the hope of detecting patterns of disease

John Snow

was known both for his work on Asiatic cholera and for pioneering anesthesia (with ether), then a novelty. He was trained both as a surgeon (1838) and a physician (1844).

Cholera was generally thought to be a miasma (=bad air), but Snow noticed that since it affected the intestines, not the lungs, it was likely due to something ingested, such as water.

William Farr

was an eminent statistician and epidemiologist. Initially he argued that cholera was due to bad air and elevation was a key factor in its occurrence.

After Snow's death, Farr accepted his view that cholera is a waterborne disease.

cholera is a -?-borne disease

water

cholera had a typical -?- tinge

bluish

Microscopy

techniques include staining with aniline dyes and oil immersion devices.

17th-century microscopes were affected by many problems, such as -, leading to -

spherical and chromatic aberrations, blurry images & artifacts.

Carl Zeiss - 1846

established a workshop in Jena (Germany), and in the next decades established industrial leadership by producing better, cheaper, and simpler instruments that could be used by students in the laboratory.

Matthias Schleiden

1804-81

was a botanist at Jena (Germany) who, relying on the microscope, argued that plants were aggregates of living cells, in which he identified the nuclei, which had been recently discovered. In 1837-8 he proposed the first cell theory.

Theodor Schwann

1810-82

recognized similar cellular structures and nuclei found in plants in animals ca. 1839.

Rudolph Virchow

(1821-1902) argued that all cells arise from cells.

He studied healthy & diseased cells as a basis for a new understanding of disease away from humoral doctrines. He argued that cancer was an uncontrolled proliferation of cells.

Cytoblastema

a fluid or gelatinous substance with no structures but with the individual components of cells

Age of Germs

The last quarter of the 19th century inaugurated the age of -, which continued in the 20th century

Age of Lesions

The first three quarters of the 19th century were the age of -.

Tissues

anatomists understood a number of parts such as mucous & serous membranes, nerves, cartilage, fibers, connective parts, etc.

Tuberculin

cure for Tuberculosis found by Koch in 1890 but was eventually found ineffective and potentially dangerous

can be used as a diagnostic tool, relying on the allergy that it induced

Sanatoria

places in areas with pure air where Tuberculosis patients could recuperate and kept in relative isolation

T. bacillus

the bacteria causing Tuberculosis

Robert Koch

physician and bacteriologist who developed multiple staining and micro-photography

did not discover the anthrax bacillus, which had already been seen, but completed the study of its life-cycle, including a spore stage, which proved extremely resistant to heat and could stay dormant for a long time

Koch infected animals to show the role of the bacillus in causing disease and suggested appropriate containment measures by burying animals deeper in the soil.

Microphotography

introduced by Koch

enabled him to provide more objective images of his microscopic preparations

Petri dish

invented by Julius Richard Petri (1852-1921) - a microbiologist and Koch assistant who in 1887 invented the so-called "-"

a short cylindrical vase filled with agar solution for culturing bacteria.

Koch’s Postulates (3 criteria)

1.  The micro-organism must be found in every instance in which the disease occurs;

2. Once extracted from the body, the micro-organism should be produced as a pure culture over several generations;

3. The disease could be induced in experimental animals by the pure culture many generations after isolation of the microorganisms.
   

Max von Pettenkofer

chemist and an advocate of public health measures against disease, including cholera.

he drank in front of witnesses a cocktail of cholera bacilli he had received in the mail from Koch. He only got a little or not at all sick

key differences between doctors and surgeons

• Doctors studied at university

• surgeons had an apprenticeship 

• doctors looked at whole body and causal agents of disease

• surgeons looked at local effects, symptoms

major developments in medical training in revolutionary France

• Clinical experience in hospitals 

• common training for surgeons and physicians

• rise of quantitative methods

benefits of training in hospitals

• Doctors have opportunity to see diseases first hand (dead and alive patients)

• “Medical observatories” 

• Hands on experience

what did Auenbrugger have to do with Laennec

Auenbrugger = chest percussion = Laennec invented stethoscope 

diseases/conditions that Laennec named

• Liver cirrhosis

• Peritonitis

• melanosis/melanoma 

what investigative method did Laennec use to discover the diseases

Pathological anatomy = define characteristics of diseases 

What did Laennec discover about 'consumptive lesions'?

Tubercles are appearing everywhere in the body  

the characteristic sounds of consumption

• Pectoriloquy - voice heard through chest possibly indicating cavity 

• Succussion splash - free fluid in the chest 

• Metallic tinkling - air in the pleural cavity  

• Egophony - screaming goat sound - plural (lungs) fusion 

• Resonance - emphysema 

What was 'phlebotomy' in the 18th/19th century? What effect did it have on consumption?

leeches/bloodletting - it was thought to relieve inflammation - quantitative/statistical/numerical analysis