Science or Art? Medicine as a desperate sleuthing.
order versus disorder
public health | stages in knowledge | nature | phases in diagnosis | germ theory | summary | society
A Medical imagination as an arbiter of health and disease
René and Jean Dubos
The White Plague: Tuberculosis, Man, and Society (1952)
Chapter One: The Captain...
multiple personalities are characteristic of diseases also
p. 3.
"the fact that succeeding ages have looked at tuberculosis from various points of view, emphasizing the different aspects of it. The never ending metamorphosis of words is the method by which language adapts itself to the impact of new discoveries, and to changes in attitude concerning the nature of disease and its effect on man."
TB can effect
| anatomical | respiratory system | throat | digestive system |
| locus | pulmonary, lungs |
laryngeal, vocal chords |
intestinal, bowels |
| symptoms | congestion, | loss of voice, | diarrhea, |
Tubercle bacilli can reside anywhere in the body, as the appearance of generalized nodules in a variety of organs and lymph tissue, or TB can manifest locally:
Other TB effects
| Affected area, organs | disease |
| inflammation of the brain's membranes | Meningeal TB |
| kidney tissue | Renal TB |
| spine (curvature) | Potts disease |
| skin | Lupus |
| lungs | Consumption, phthisis |
p. 4
The White Plague, Chapter 1:
Tuberculosis as a disease had symptoms and TBs' presence is signaled by these symptoms, such that Dubos says: "signs are described frequently and at length by Hindu, Greek, and Roman writers, who lived in urban societies, but they are barely mentioned in the Bible and the lore of pastoral peoples."
6
Pulmonary consumption was recognized in the earliest English hospitals in the 1650s --causing one death in five-- and peaked in 1780s to 1850s in England and the Americas.
8
Maybe as high as half the English population of the 1840 were exposed to tuberculosis and had consumption
9
1824, The Lancet noted the number of young West Indian boys the majority of whom become "scrofulous."
10
Chapter 2: Death Warrant for Keats (& morbidity for Shelley)
"the perverted attitude of the romantic era toward the disease and the ignorance of ... medicine concerning its diagnosis, nature and treatment."
11
Chapter 3: Flight from the North Winds
"Keats and Shelley symbolize the romantic and consumptive youths....They were part of a great pilgrimage ...leading the sick ...toward the Southern sun."
19
Chapter 4: Contagion and Heredity
1546, Florentine physician Hyeronymous Fracastorius, advanced the contagion theory: communication by exposure to air, breath or fluids of consumptive patients.
1699 Spain and Italian city states passed regulations to control the unnecessary spread of consumption.
28-29
1650, The Faculty of U. of Paris Medical School doubted the Italian theory of contagion.
33
Phthisiologia by Richard Morgan, in 1688, described the inherited condition to account for the spread of consumption as opposed to "contagion."
Louis 13th and Louis 14th were consumptives, both died of it TB.
33
Examples of familial TB:
Bronté family
Ralph Waldo Emerson family
Thoreau family
"the disease was the outcome of a bad hereditary constitution"
42
"born with a predisposition to phthisis"
"only balmy air and sunny skies, it was thought, could arrest the destruction of lung tissue and the sapping of strength that otherwise drove the consumptive to certain death..."
43
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Chapter 5: Consumption and the Romantic Age.
"disease may also color the moods of civilizations."
44
Common in the literature of romantic writers for characters to die of consumption
47
Opera La Boheme, flower girl heroine dies of TB
50
Dickens in Nicolas Nickleby describes TB as the agent that rarifies the body to take the spirit form
It is noted that some relation exists between TB and genius, particularly expressed by Alexander Dumas,
59
"The health of nations"
from Tuberculosis to Influenza: 1710 - 1919
"Epidemics have often been more influential than statesmen and soldiers in shaping the course of political history."
44
outbreaks of TB
Stages in the development of understanding the disease of consumption
Ancient - Symptomatic-descriptive: phthisis
1000 BC evidence in bones of Egyptian mummies of TB
400 BC. De Morbis, Hippocrates -phlegmaticRenaissance - Anatamo-pathologic: consume
1640, Contagion theory advanced in Italy
1650, Parisian Faculty propose the familial, hereditary agent in phthisis
1679, Franciscus Sylvius; "tubercles"Modern - Germ theory - tuberculosis
1722, Benjamin Marten "animalcule … gnawing
1840s the first appearance of the term "tubercles" as an anatomical designation
1865, Jean Antoine Villemin, Etudes sur
3/24/1882, Robert Koch: T. bacillus as biological agent, a "germ" or pathogenic bacteria
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Poor Laws 1700s
Industrial urbanization 1760squarantine & sanatoriums 1790s
Public Health movement 1830s (UK), 1850s-1890s (America)
Social Darwinism 1859-1995
war and diseaseCrimea, 1850
S. Africa, 1898
Europe, 1914
India, 1920
By 1900 "tuberculosis remained the greatest killer of the human race…"
(186)
"The passion for financial gains made acquisitive men blind to the fact
that they were part of the same social body as the unfortunates who operated
their machines. TB was, in effect, the social disease of the 19th century, perhaps
the first penalty that capitalistic society had to pay for the ruthless exploitation
of labor." (207)
Manchester Board of Health, 1796
Report of an appointed commission to the Board
"Children and others who work in large cotton factories are particularly disposed to be affected by the contagion of fever, and when such infection is received, it is rapidly propagated, not only amongst those who are crowded together in the same departments, but in the families and neighborhoods to which they belong."
"To him who follows her way, Nature reveals many roads that lead in the
direction of truth."
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Three phases of understanding TB:
- Descriptive diagnostics
- Anatomo-Pathology diagnostics
- Diagnostic - Germ Theory & inoculation diagnostics are descriptive
There is a persistent difficulty of any degree of certainty in curing TB, even in the modern period/
In the absence of physiological data; error abounds.
Descriptive diagnostics
Hippocratic corpus, 400 BCE
malaise -- a symptom of many diseases; listless
phthisis --wasting of the body due to lung infection
catarrh -- chest pain, progressing to the excessive production of yellow sputum
lymph nodules infected -- tubercles (1679) of diverse shape, appearance, location in lungs, stomach, bowels.
1650, Fernal; 1679, 1700, Manget; 1790, Baille
insufficiency of descriptive science in health studies
Integration of pathological & clinical techniquessound of the lungs -- percussion 1761
stethoscope for auscultation in 1816
microscope -- 1590 first invented; turned on TB in 1840s
René Théophile Hyacinthe Laënnec; 1781-1826
"Laënnec gave precise and original descriptions of clinical symptoms and post-mortem appearances of pulmonary tuberculosis, pneumonia,… " based on the description of heart and chest sounds (87)
within 10 years of 1819 the technique of "mediate auscultation" with a stethoscope was widely practiced.
92) necessity of experimental proof
"hundreds of sanatoria sprang up along all the European shores." well respected by 1882
Edward Livingston Trudeau brought the idea to America at Saranac Lake in the Adirondack Mountains
sometime after 1865 he contracted TB.
"fond of hunting and of life in the wilderness."
"a longing I had for rest & peace in the great wilderness."" a rough inaccessible region" (179)
"Tuberculosis has waxed and waned several times in the course of human history."
"A peculiar fact emerges…,that TB began to decrease long before any specific measures had been instituted against the disease - before there was any scientific basis on which to formulate anti tuberculosis campaigns." (185-86)
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Part Two: The Causes of Tuberculosis
Chapter 6: Phthisis, Consumption, Tubercles
1881, Medical Practitioner's argued the non-contagious quality of TB
1882, Koch identified the growth of bacteria as the cause of TB
69
"damage caused by bacilli multiplying in the infected tissues."
"a confusing array of signs and symptoms...as the expression of different maladies."
"an orderly system based purely on clinical and pathological criteria," before the 1882 discovery
70
fqoe (phthoe) Greek term for shriveling under high heat, temperature, wasting away, root of phthisis.
71
"every system of classification suggested a new theory of the nature of pulmonary phthisis."
74
"This anatomical knowledge served as a basis for the formulation of hypotheses concerning the evolution of each disease from its early phase to its ultimate manifestation."
76
1761, percussion by Auenbrugger
1816, mediate ausculation w/ a stethoscope by Laënnec
76
Chapter 7: Percussion, the Unitarian Theory
1761, percussion was used by Auenbrugger to listen to the sound of the chest by listening.
77
Laënnec could not prove his theory" "the unitary theory of phthisis"
92
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Chapter 8: The Germ Theory
1722, Benjamin Marten, first proposed a microbe "gnawing away" as the cause of TB instead of contagion
94
Double blind experiments, where the agent induces the disease in lab animals.
101-103
Bovine forms of TB, transported in unpastuerized milk were a principle suspect in the origins of the disease.
109-110
Chapter 9: Infection and Disease
"Tubercle bacilli are minute rods , so small that large numbers of them can be packed inside the microscopic white cells of the blood and tissues."
"They produce a new generation approximately twice a day, twenty times slower than most other microorganisms."
111
Part Three: Cure and Prevention of TB
Thomas Young, recovered TB victim and physician, in 1815 published recommending measuring pulmonary capacity.
132
"Thomas Young
131
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Part Four: TB and Society
Chapter 14: The evolution of Epidemics
1650 and 1850 the high mortality periods for TB in Europe.
morbidity rates
185
long before the microbiological discovery of TB bacteria, the rate of morbidity & mortality was falling, even before the anti tubercular campaign.
186
"end of a natural epidemic wave"
187
Chapter 15: TB & Industrial Civilization
"each and every vice -- was regarded as a cause of consumption during the nineteenth century."
p. 197.
Chapter 16: TB and Social Technology
"What is the cost of the disease to the community?"
p. 208.
Summary
"Admittedly the medical techniques used in the management of the tuberculosis patient, whether carried out in a city hospital of in a secluded country sanatorium, are of benefit to both patient and society. But it is probable that equally good therapeutic results would be obtained with more certainty, less time, and at lower cost of human and economic values, if knowledge were available of the factors that affect the course of tuberculosis."
226
But the complete control of tuberculosis in society goes beyond medicine in its limited sense. It is a problem in social technology,."
227
"Once more it becomes urgent to force upon social consciousness the realization that progress does not consist merely in doing more and more of what proved profitable in the past."
227
"This is true of the infections caused by tubercle bacilli which, however widespread, are always less destructive in societies that live and function according to physiological common sense."
"The final step in the conquest of tuberculosis may well depend upon knowledge of the factors that prevent silent infection from manifesting itself in the form of overt disease."
228
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
Lessons:
medical science …confirmed the value of certain ancient practices.
228
"the art of achieving fitness between human urges and the natural environment."
"many primitive civilizations have achieved" this.
There remains a need to "incorporate physiological principles in the complex fabric of industrial society."
The disease today is recurrent due to a growing resistance of the TB "germ" to antibiotics due to the relentless pressures of natural selection.
"the number of persons suffering from tuberculosis is not declining as fast as the death rate."
p. 221.
The matter of control strategies
Overview | Part One: | Part Two: | Part Three: | Part Four: | Summary | Lessons
