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Lecture 2

249 - Week 8 – Lecture 2 - the Laboratory Revolution .docx

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HIST 249
Faith Wallis

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Week 8 – Lecture 2 (24/10/2013) History 249 - Health and Healer in the Western World Modern Medicine 2 – the Laboratory Revolution Now in the process of analysing how traditional western medicine became the medicine that is recognisable today – though it is still in a world that is very different to ours and not yet modern medicine, certain elements do come recognisable - can see how the understanding of body and disease is changing - central = not simply determined by the nature of things but also a product of the social setting in which the new kind of medicine emerges  medical knowledge depends on the ways in which it was being produced o e.g. doctor’s method = examination of the living patient trying to discover internal workings and then checked this when the patient had died; only possible in particular situation e.g. Paris e19thC  knowledge is entirely bound to it’s political and social context • pathological anatomy emerged in the context of Paris clinical medicine in the French context = meant not only the anatomical, pathological and clinical method, but the statistical method also - why was this such a good environment for the stat method? o The hospitals were big = many cases and record-keeping was developed  E.g. Pierre Louis  used the numerical method in order to find out if a particular therapy works when it is done in a particular way = a probability based approach • Have to thus translate these probabilities to the individual patient  later becomes problematic when working out what kind of medical knowledge is desirable  Target of Louis’studies = ‘heroic therapy’ • Francois Broussais = approach was that there is continuum through the normal and pathological/health and disease  they were points on a spectrum i.e. physiological concept, not ontological perspective o Belief that the digestive system was the place where most of the processes of disease esp. inflammation  overcharged digestive system as most diseases were csaused by too much eating and drinking  The doctor thus has to empty the system  Prescribed an actual treatment = hospital medicine had brought to people’s attention that most diseases went the way they went  not truly altered by clinical intervention  diseases were either self-limiting and the patient got better anyway  OR they were inevitably fatal e.g. Laennec  pessimistic that people could recover from TB or heart disease = not much the doctor can do – this is called ‘therapeutic scepticism’ • Means that the doctor is somewhat obsolete • Caused a new interest in Hippocrates (old medical tradition is reused again and again at different points in time)  role of nature in disease e.g. Laennec was a student of H, focusing on the healing power of nature – the idea that phsysis, nature itself, is working with the body to heal it and the doctor is there to watch over Others criticised this pessimistic view of disease – tantamount to refusing to treat the patient  what the Paris school was accused of = accused of being callous towards the patients - e.g. students came from the USAand the letters they wrote back = wrote of their surprise at the poor treatment of the patient and the concerns of the patients are being ignored o French school could sort and classify diseases = ‘diagnostic optimism’ o BUT they could not do anything to treat them = ‘therapeutic scepticism’  E.g. reflected in the caricature ‘the Physician’by Honoré Daumier 1833)  Though people demanded treatment and some was given, there was simply limited belief in it’s utility • H = doctor whom knows a lot but can’t necessarily do a lot in response Part 2 Modern Medicine – Laboratory Revolution - one way of addressing the problem of therapy was finding the causes of disease = what doctors tried to do from mid- 19thC o they entered the laboratory in order to produce a new kind of knowledge that would potentially be more useful = laboratory medicine is produced  transformation of knowledge based on science (science now replaces scholarship as doctors base their claim to understand the process of disease whilst man’s appropriation of medicine was based on texts of H etc. whilst it then moved to Science  shift from the clinic i.e. Paris to the laboratory • laboratory = the most reliable source of causes, course and cures for disease • different kinds of laboratory o normal types where information is being found and produced – physiology o more direct use of the laboratory also for the diagnosis of disease on a chemical basis – Bright heating the urine of his patients to find protein or later diagnosis of TB by identifying bacteria People who work in the laboratories are increasingly scientists rather than just doctors e.g. Louis Pasteur whom was not a doctor by a chemist = scientist makes an income from scicnce and their workplace is the laboratory which is filled with equipment - experimental approach – not just observation but subject phenomena to experiment 4 sciences of the laboratory revolution – physiology, microscopy, bacteriology and biochemistry 1 – Physiology meets Pathology - physiology replaced pathology as the cutting edge science of the time – interest in the functions of the body rather than just the structures o French school of physiology works on the beliefs of Boussais that there is a continuity – pathological  Belief in the use of ‘normal’– something which Galen and Hippocrates would never have used since the body and disease was ‘natural’ • Normal and abnormal replaced natural and contra-natural o Absolute and specific terms whereas normal and non-normal were a spectrum o Modificiation of the ideas of the ancients therefore - Pioneer = Francois Magendie = most famous aphorism is ‘medicine is nothing but the physiology of the sick man’– all disease arises from the disturbances of the ‘natural’or ‘normal’ o All pathology is physiology that has gone wrong – understanding the latter, it is possible to understand how physiological abnormality causes disease and thus one can cure it  Focus on the absorption of food and nutrients – cornerstone of physiological activity • Can thus understand what later came to be known as metabolism o Much of his work was done with experiments on animals e.g. with new drugs whilst he also changed the structure of the animal e.g. cutting a particular nerve and seeing what happened o Had surgical training = needed this in order to carry out his experiments since he needed to selectively cut one nerve  focus on changing just one factor within the animal – necessary to be good at surgery, though he was NOT a doctor but a physiologist - Magendie’s student = Claude Bernard o One of the most important 19thC figures in French science o Disease was again a disturbance of physiology = created the concept of homeostasis: living bodies are programmed to maintain a constant internal environment (the milieu interiuer) and the animal body was able to regulate their own internal environment e.g. temperature, water levels, concentration of substances like potassium and sodium o One mechanism that he found out about = secretion of substances within the body; found that the liver secretes glucose into the bloodstream o Said that the body tries and can resist factors that try to alter this programme = the bodies resistance to operations within the programme is what causes disease = disease is the body responding to something which upsets it’s internal milieu  It is necessary to intervene under controlled conditions to discover this process  Has to be a circumscribed, well-controlled intervention and have to be able to record the changes that occur as a result of this intervention = possible to therefore reveal particular functions of the body  Experimenter can turn a body function on and off at will  we know about the body function if we are able to turn it off and on o Removed organs and replaced them = demonstrating skill with a scalpel – experimentation is the basis of anatomical physiology  Intervention = certain and viable treatment; ability to control body functions is real knowledge and is based on active intervention, not passive observation • Determinism is also important – if one controls all the factors and conditions of the experiment, one always obtains the same result o Because nature is determined through its laws = one is in search of the laws of nature  Once a law has been identified it always applies o If one does not get the same experimental result, then there is something wrong with your experiment o Not a question of personal experience or ability but laws Different modes of knowledge in medicine? 3 different kinds: 1 – clinical experience: doctor does something often, knows how it works and knows what will happen  this knowledge resides in the person of the doctor 2 – experimental determinism – try to determine the laws of nature and they always apply 3 – statistics – theAmerican method – a population based approach that results in probabilities = 3 modes of knowledge emerge in the cause of the 19thC and they remain evident today Bernard – rejected clinical experience as the sole basis of medical knowledge; he wanted to offer something more reliable and certain - instead decided to experiment as he subordinated clinical experience to experimental science: ‘I consider the hospital the antechamber of medicine; it is the first place where the physician makes his observations but the laboratory is the temple of medicine(?)’ o also considered his approach as superior to the statistical approach of quantification  criticised the objective approach of Louis power to control life-forms can thus be extended to the clinical environment and then can be extended to control disease since this is nothing but a further life form/law of nature = experimental physiology is ‘experimental medicine’and he wrote on this a book which is still widely renowned different schools of physiology also though – French sees biology or life as one that can never be reduced to non-biological entities such as chemistry or physics = a ‘vitalistic’approach; even Bernard wanted to determine the laws of nature but they cannot be reduced to pure chemistry other approach = reductionist approach; tended to be the German approach as they searched for chemical and physical explanations of biological processes; even attempted to look for the reduction of life processes in chemical and physical terms - most famous: Carl Ludwig in Leipzig which was state-run  different German states at this point and many paid for expensive laboratories = under these conditions, scientists were expected to pick their research topic themselves for the sake of producing new knowledge (NOT as a service!) – pattern became a model for other countries as it became the idea of basic science o kymograph was used = physics measurement; one has the output of a curve, with the input of pressure from an animal or human artery (thus measures blood pressure!)  specific feature is that it produces a curve itself – it is not a human hand that produces this, it is a machine  real kind of objectivity in the mechanical process • manifestation of the notion of measuring in medicine – counting not just seeing; e.g. thermometer – counting, not just seeing -, blood pressure and multiple kinds of empirical data o sheer existence of this laboratory approach to medicine does NOT mean it was accepted im
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