Knowing disease 疾病：由未可知到可知 楊倍昌 疾病的解讀 (Illness as Metaphor ) 疾病的本質及過程 醫學知識的建立與傳承

流民圖:逃荒的農民。

流行病史話 張劍光‧陳蓉霞‧王錦 十四世紀，鼠疫襲擊東羅馬的首都君士坦丁堡。當時大規模的十字軍東征和日趨頻繁的商貿往來，將這場鼠疫迅速傳到了整個歐洲。在義大利，佛羅倫斯死掉了2/3 的居民，威尼斯死掉了3/4 (十萬人)，。在法國，死掉了總人口 3/4，在亞威農，隆河被丟棄的屍體弄得擁塞不通。

Disease: dis (否定); ease (身心安樂) 疾病的象形字，甲骨文中已經出現。疾，據《殷虛文字乙編》考“象矢著人腋下…知此亦疾字…按疾古訓急，訓速，最速者莫如矢，故從人旁矢，矢著人斯為疾患，故引申訓患、訓苦…”；另：卜辭有兩個字，前者像人臥於床上，後者像人在床上冒汗，釋作疾。若釋病應當也不錯，因為《說文》二字互訓：“疾，病也。”“病，疾加也。”只是疾病程度和分析的眼光不同罷了 (別人說的話) 。

疾病是什麼: 不變的兩千年 周禮》：“以五氣、五聲、五色胝(視)其死生；兩之以九竅之變，參之以九藏之功。” 左昭元年 (541 B.C.) 引醫和云：「天有六氣，降生五味，發為五色，徵為五聲，淫生大疾。六氣曰：陰、陽、風、雨、晦、明也。……陰淫寒疾，陽淫熱疾，風淫末疾，雨淫腹疾，晦淫惑疾，明淫心疾。」 清代台灣歷史文獻中 (around 1800 A.D.)，即常用「瘴」、「 瘴氣」和「瘴癘」等語詞，記載這些因地方環境條件而引 起的疾病。 劉士永: http://www.taipei120.org/content/1_history/1_change_taiwan_sick.shtml

想像之外，還能做什麼？ Homer’s Iliad (800 B.C.) begins with a plaque sent by Apollo on the Greeks. The arrows of Apollo and Artemis are often a symbol for the sudden onset of disease. the great hall ceiling dome in Nymphenburg Palace in Munich http://gallery.euroweb.hu/art/b/bernini/gianlore/sculptur/1620/apollo_d.jpg http://home.earthlink.net/~pathways/PhotoNewsletters.html For lecture only , BC Yang

She is a friend to mortals, and dances through the countryside in her silver sandals giving her divine protection to the wild beasts, particularly the very young. She rides her silver chariot across the sky and shoots her arrows of silver Moonlight to the earth below. the arrows of Apollo and his twin sister Artemis (Diana) are often a symbol for the sudden onset of disease. http://www.med.virginia.edu/hs-library/historical/antiqua/textf.htm http://www.ibiblio.org/wm/paint/auth/boucher/diana.jpg

Cholera, engraved by Gustav Richard Steinbrecher (1828-97) 1831 (engraving) (b/w photo)

A COURT FOR KING CHOLERA King Cholera dispenses contagion: the London Cholera Epidemic of 1866, George John Pinwell A COURT FOR KING CHOLERA Punch, Jul.-Dec. 1852 http://www.victorianlondon.org/disease/cholera.htm

The plague doctor in clothing worn to protect from contagion, circa 1656. We are haunted by images of the horrors of disease and death, but with the current influx of data from microbial genomes, we can expect some answers to questions about how microorganisms have evolved, causing much fear. Apart from using these data to design new drugs and vaccines, we can also explore what the molecular signature of a microorganism may mean to a host population and predict more precisely the effects of intervention (2001A.D.).

在英國，英國女王伊麗莎白一世 (1558)，帶著手下一干人馬逃到北部的溫莎避難，並在溫莎一帶豎起很多絞刑架，下令凡是抓到從倫敦來的人，一律格殺勿論。 教會告誡人們這是上帝的懲罰，救贖的方法只能是懲戒撒旦的幫兇與集體贖罪。猶太人得黑死病的比率低(猶太人的「潔淨」觀念)─在上帝面前保持道德和身體的潔淨。但是基督徒，卻認為是猶太人和魔鬼合謀製造出災難。反猶太人暴動的結果是：沒有死於黑死病的猶太人，卻死在鄰居的刀下。二百多個猶太社區被摧毀，無數人被燒死。 流行病史話節錄

Disease in religion "I will say this: because these experiences I had were so tremendous, God was afraid I might be puffed up by them; so I was given a physical condition which has been a thorn in my flesh, a messenger from Satan to hurt and bother me and prick my pride. Three different times I begged God to make me well again. Each time he said, "No. But I am with you; that is all you need. 2 Corinthians 12:7-10 (TLB) Diseased 1. fever - Matthew 8:14, mark 1:31, Luke 4:38 2. leper  - Matthew 8:3, Mark 1:41, Luke 5:13 3. dropsy - Luke 14:2 4. palsy  -  Matthew 9:2, Mark 2:3, Luke 5:18 http://www.siscom.net/~direct/healing/illness_and_disease.htm

Theology and biology 有些宗教….，還提出了一套有別於世俗醫學的疾病觀和治療方法。他們大多強調，人之所以生病，主要起因於道德上的敗壞和鬼神的責罰，因此，治療方法也偏重於懺悔、祭禱、齋醮、功德這一類的宗教療法，或是以符咒、厭勝為主的巫術療法。此外，他們也採納食療、沐浴、按摩、導引、房中之類的養生術。對於世俗的醫學，他們有時會加以貶抑或拒斥，但是，通常都會兼容並蓄。 若從病人的角度來看，我們發現，宗教信仰似乎可以緩解病人在心理和道德上的焦慮和不安，而傳統中國及台灣社會面對瘟疫流行的因應之道，除了醫療救助之外，往往也採取政治改革、社會救濟和道德重整。 臺灣的宗教與醫療探討 http://www.sinica.edu.tw/info/import-results/93/52.pdf For lecture only , BC Yang

社會學的: 我要描述的……不是疾病真正的樣子，而是人們對它的想像。我的論題不是疾病本身，而是疾病被用為隱喻。我的觀點是疾病不是隱喻，考量疾病的最誠實方式是避開隱喻性思考。 桑塔格（Susan Sontag，美國的良心）2004年病逝。 《疾病的隱喻》(Illness as Metaphor) 發表於1978年，自身離癌的桑塔格不滿意隱藏在癌症背後的文化隱喻，這使她非得要揭開隱喻不可(p.114-115)。而隨後，當愛滋病在八十年代取代癌症，成為各隱喻的對象後，桑塔格又寫了一篇『愛滋及其隱喻』(AIDS and Metaphors)。由大田出版的中文版同時收錄了這兩個篇章。

實證功利主義的批判： 所有精緻、莫名其妙的想像，對於疾病的治療有什麼用處？ 實證功利主義的批判： 所有精緻、莫名其妙的想像，對於疾病的治療有什麼用處？

Dynamic changes in the concept about disease 如果你說不出好話, 那麼最好是閉嘴。 Dumbo 媽媽的告誡 如果找不到物質證據, 最好是輕鬆的等待。 BC For lecture only , BC Yang

Changing the view

Changing the view, back to old days Ann Ellis Hanson The University of Michigan Ann Arbor Home About Essays Resources Hypertexts Announcements Email Discussion List S.A.M. They were asking not "Who causes this sickness?" but rather, "By what process does this sickness occur?" However imaginative their mechanistic explanations may be, Hippocratics can defend them with arguments that appeal to process, not to a capricious or malevolent deity, and they can explain the therapies they prescribe in terms of the actions that their medicaments set in motion. http://www.medicinaantiqua.org.uk/sa_hippint.html

Hippocrates: Greek physician on the island of Cos, Greece : 460 BC-377 BC. Hippocrates began teaching that every disease had only natural causes. He was the first physician known who actually considered medicine to be a science, and to be separate from religion. He described many illnesses including pneumonia, * tetanus, * tuberculosis, * arthritis, * mumps, * and malaria * http://southmed.usouthal.edu/greece/databases.html

Giovanni Battista Morgagni (1682-1772) Morgagni showed beyond any doubt that specific disorders cause suffering and death. We find a ruptured appendix, syphilis of the aorta, and epidural hematoma. A lifetime of compassion and clear thinking lies behind this chamber of horrors. 為了要能找出罹病的器官, 我們得先能分辨出其哭喊聲的意義. 臨床檢查的四原則: 視診、敲診、觸診、聽診

疾病的居所 Seats and Causes of Disease Investigated by Anatomy.(1761) The first English translation of Morgagni's work appeared in 1769. This three-volume set was published in the original Latin in Switzerland in 1779. 頭部之疾病 胸腔之疾病 腹部之疾病 外科及一般性之疾病 遺補及索引 醫學在 Rudolf Virchow 出現之前，稱不上是一門嚴謹(？)的學問 (1894) Note: 誰的嚴謹？

Percussion: 敲診 Auenbrugger, Leopold, 1722–1809, Viennese physician. His findings on the use of percussion in diagnosing chest diseases were published in 1761 (tr. On Percussion of the Chest, 1936). Although ignored for some 40 years, his method, revived by Jean Nicolas Corvisart, was ultimately generally adopted. http://www.whonamedit.com/doctor.cfm/309.html 酒棧的兒子 (Auenbrugger, L) 在敲他爸爸的啤酒桶時發明敲診

Stethoscope (聽診器; 1816); ori from Gr. stethos (胸部) & skopos (觀察者) Auscultation (聽診); ori. from Latin: auscultare; coined by the French physician René Théophile Hyacinthe Laënnec (1781-1826; the father of chest medicine ) Stethoscope (聽診器; 1816); ori from Gr. stethos (胸部) & skopos (觀察者) 沒有正確的診斷, 就沒有合理的治療 (其實當時也沒有啥好的治療方法!). http://inventors.about.com/gi/dynamic/offsite.htm?site=http://www.antiquemed.com/tableofcon.htm http://www.antiquemed.com/monaural_stethoscope.htm

Camman, George Philip 1804 - 1863: Inventor of the modern stethoscope. Breath and voice sounds in common lung conditions Consolidation Pneumo-thorax Pleural effusion Collapse Pulmonary fibrosis Breath sounds Bronchial Decreased Decreased Bronchial above Decreased or absent Voice sounds Bronchophony Whispering pectoriloquy Decreased Aegophony above 如何克服音痴??

中國的診法與辨證, 存而不論??? 中醫在診斷上以"四診"(望, 聞, 問, 切)作為基本的診察方法。 以"八綱"(陰, 陽, 表, 裏, 虛, 實, 寒, 熱)作為辨證的綱領。 並結合氣血辨證, 六經辨證, 臟腑辨證, 經絡辨證, 三焦辨證, 等作為判斷疾病原因, 部位, 性質的主要方法, 從而為治療提供依據。

吹牛皮用的傳說、傳說、傳說、傳說、傳說…….. 扁鵲 針灸　山東微山縣兩城山 (史記:至今天下言脈者,由鵲也。) 鵲是利用脈診來判斷疾病的第一人。扁鵲 (407-310 B.C. 戰國時期)，曾學醫於長桑君。他號稱通過切脈,望色,聽聲，即能知病之所在。傳說當時趙國的趙簡子得了重病，已經昏迷了五天。扁鵲通過脈診,斷定趙簡子病是由於血脈不通暢造成的，很快便將他治好。 吹牛皮用的傳說、傳說、傳說、傳說、傳說……..

Back to the fundamental question: Why and who did it? 冤有頭，債有主

每床兩個人? Sad end Triptych showing the Hôtel Dieu in Paris, about ad 1500. http://www.mja.com.au/public/issues/177_11_021202/dec10354_fm.html "The contagiousness of childbed fever": a short history of puerperal sepsis and its treatment; by Caroline M De Costa

In 1844, Ignac Semmelweis (a native of Hungary) was appointed assistant lecturer in the First Obstetric Division of the Vienna Lying-In Hospital, the division in which medical students received their training. He was appalled by the division's high mortality rate from puerperal fever — 16% of all women giving birth in the years 1841–1843. In contrast, in the Second Division, where midwives or midwifery students did the deliveries, the mortality rate from the fever was much lower, at about 2%. Semmelweis also noted that puerperal sepsis was rare in women who gave birth before arriving at the hospital http://general-anaesthesia.com/images/ignaz-semmelweis.html Sinclair WJ. Semmelweis: his life and his doctrine. Manchester: Manchester University Press,1909.

It is always hard for anyone to admit they are wrong It is always hard for anyone to admit they are wrong. "Okay, so I was wrong about the Cubs winning the pennant." Not so hard to admit. But if the item is central to your profession, and admitting it not only questions your judgment but implicates you, although at the time unknowingly, in the many deaths your error has caused, that is a little harder to swallow. Obviously, many would, and did, deny the error rather than face the upset. The Doctors' Plague by Sherwin B. Nuland Semmelweis wrote a series of “open letters” to his former professors, accusing them — rightly, as it turned out — of being “medical Neros” and “murderers”. (錯誤的策略)

In 1866 Joseph Lister (1827-1912) suggested antiseptic surgery In 1866 Joseph Lister (1827-1912) suggested antiseptic surgery. His rational was: Putrefaction is caused by microbes Wound sepsis is a form of putrefaction Wound sepsis is caused by microbes (只是建議，而無方法證明) Carbolic acid, phenol

Note by Sir James Simpson: Hospitalism 1867 截肢手術的傷亡率: 在英國超過 300 床的大醫院死亡率會超過 41%. 開業醫小診所死亡率約 11%. 巴黎: 死亡率約 60%. 蘇黎世: 死亡率約 46%. 格拉斯柯: 死亡率約 34%. 柏林及其他城市: 死亡率約 34%. 美國麻省: 死亡率約 26%. 美國賓州: 死亡率約 24%. 蛇杖的傳人 p:439(?)

Lister 高估了空氣中的雜物，其實病原菌來自於手術器械, 醫師的手….. Joseph Lister was ridiculed, criticized, and harassed. The medical community didn’t like having its status quo questioned. The nurses regarded Lister’s procedures as eccentric, and they resented the extra work his obsessions with cleanliness were causing. The doctors were angered at the implication they were responsible for some of the deaths. Louis Pasteur and Joseph Lister were personal friends and supported each other when the medical community viciously attacked them. Sometimes they felt they were alone in their struggles to bring the truth to light. People were needlessly dying, and it seemed nobody was listening. Lister 高估了空氣中的雜物，其實病原菌來自於手術器械, 醫師的手….. www.biblehelp.org/ misunder.htm

李斯特在 King college 上課的學生減少到只有10-20 人 Samuel Gross 1805-1884; American surgeon, teacher of medicine, and author of an influential textbook on surgery and a widely read treatise on pathological anatomy (He still did the job in traditional way.). 李斯特在 King college 上課的學生減少到只有10-20 人 The Gross Clinic (by Eakins, Thomas) 1875 Oil on canvas (96 x 78 in). Jefferson Medical College of Thomas Jefferson University, Philadelphia

為什麼只有軟弱的說服力?

A short history of microbiology On spontaneous generation: 1668, Francesco Redi (with cover, against); 1749, John Needham (simple boiling, for); 1765, Lazzaro Spallanzani (extensive boiling, against) 1673: Anton van Leeuwenhoek (microbes) 1678: Robert Hooke (cell structure) 1861: Louies Pasteur (gooseneck bottle; against) 1870: Joseph Lister (1% carbolic acid, phenol in surgical procedure) 1881: Robert Koch (Koch’s postulate) 1892: Dmitrii Iwanowski (Tobacco Mosaic Virus) 1909: Paul Ehrlich (chemotherapy, arsenicals against spirochetes) 1915: Frederick W. Twort (bacteriophage) 1940: O.T. Avery (DNA as transforming factor) 1953: James D. Watson & Francis H.C. Crick (DNA structure)

Francesco Redi (1626-1697) In the medical field Redi promoted a reform of therapeutical methods recommending natural procedures (diet, purges and clysters) to purify the body of impurities, according to the Hippocratic rules. The origin of scabies from mites, demonstrated by Giovan Cosimo Bonomo and Giacinto Cestoni. It was in fact Redi who published the Osservazioni intorno a' pellicelli del corpo umano (Observations On The Worms Of The Human Body) in 1687, with Bonomo's name only. This work proved that the disease was caused by a microscopic worm which introduced itself by laying eggs under the patient's skin. This discovery was a "Copernican revolution" in the history of pathology, since it shifted the attention of physicians from the sick subject to the pathological agent and suggested new therapeutic methods in the treatment of infectious diseases. http://galileo.imss.firenze.it/multi/redi/emedic.html

Just for the one who reads German 略 Redi entlarvte die jahrtausendealte Theorie über die Urzeugung der Insekten durch ein epochemachendes Experiment als falsch, und führte zugleich eine völlig neue Methode der Forschung in die Wissenschaft ein. Diese Methode, bis heute die Grundlage der experimentellen Biologie, besteht darin, dasselbe Experiment auf verschiedene Weise durchzuführen, indem jeweils nur ein "Parameter", eine Bedingung, geändert wird, und zugleich passende Tests durchgeführt werden. http://home.tiscalinet.ch/biografien/biografien/redi.htm

Big person in microbiology Louis Pasteur, 1822-1895, French

L. Pasteur at "scientific evening" of the Sorbonne University in Paris Pasteur's own drawings of the swan-necked flasks " And I wait, I watch, I question it!-begging it to recommence for me the beautiful spectacle of the first creation. But it is dumb, dumb since these experiments were begun several years ago; it is dumb because I have kept it from the only thing the human mind does not know how to produce: from the germs which float in the air, from Life, for life is a germ and a germ is life.“ " The germ theory is not a philosophical theory of life, but merely a body of factual observations from a series of practical operations."

有工具、有新想像仍不足以說明疾病！ 還缺了甚麼？

Big person in microbiology http://www.unikk.ch/forum/pages/ritual3.2.htm Robert Koch,1843-1910, Germany

The missing piece of mystery; the last hit Robert Koch made the actual discovery of the bacteria that causes cholera in 1876. 6 bacterial pathogens in wound infection in 1878. Specifically in 1884, Koch isolated Vibrio cholera from the polluted Elbe River in Germany.

Communication and classification (人的知覺特性，邏輯屬性的來源?) By making photomicrobiographs, I can reveal the bacteria true to nature and free of subjective misinterpretation ---Robert Koch

Privy Health Officer Berlin W, 15, June 30, 1904 Dear Sir, I still remember very well the first time I took an oil system into my hands and myself witnessed the dramatic progress achieved by the optical workshop of Carl Zeiss under the direction of Professor Abbe's ingenious advisory board. Every time I subsequently used oil systems, I thought with admiration and gratitude of the magnificent gift made by the Zeiss optical workshop to everyone working with a microscope. After all, I owe a large percentage of the success I have had the privilege of achieving for science to your excellent microscopes which were of enormous benefit to me in the expedition to South Africa which I have just completed. Respectfully yours, R. Koch http://www.zeiss.com/C12567A100537AB9/allBySubject/DAF3D66784516F2CC1256B45003DA810

An obvious true is never easy to be recognized and accepted (工具背後的理性？) By making photomicrographs, I can reveal the bacteria true to nature and free of subjective misinterpretation ---- Robert Koch 1843-1910 Now leave everything as it is, and go to Koch, This man has made a magnificent discovery ----Julius Cohnheim 1817-1891 Whole business seemed quite improbable; Anything I couldn’t see with a dry lens wasn’t worth looking at. ----Rudolf Virchow 1821-1902 Koch’s demonstrations in the Institute of plant pathology; University of Breslau (15 Nov. 1876)

科霍1884年，結核病的病原學 因惡性炭疽死亡的動物血中發現了許多規則、桿狀、無色、不動的桿狀體。 在體外，觀察這些桿狀體會生長、形成孢子，並且從孢子長出桿狀體而確認它們具有 生命，屬於低等植物類。 如果將惡性炭疽動物中含桿狀體的少量血液接種到另一隻動物身上，後者將死於惡性 炭疽病，而且其血液中含有炭疽桿菌。 但是，光這樣並不能證明炭疽病是經由此桿菌傳染的，因為血液中還有其它的物資(血 液腐敗物質)也跟著桿菌被接種進去。為了區分由血液中的桿菌或者是其他物質的感染 造成惡性炭疽病，這桿菌必須自血液中單獨分離出來，然後再進行接種試驗。接著， 科霍仔細描述在固體培養基(明膠、煮過的馬鈴薯)上培養細菌的技術。透過體外培養， 將桿菌完全分離後，在顯微鏡下已看不到血液中的其他物質。繼代培養二、三十次之 後，桿菌就不再混雜任何患病體內疾病的副產物。 當純粹的桿菌接種到健康的個體，它可以誘發此動物罹患致命的惡性炭疽病，而在發 病動物的血液中亦可發現不可計數的炭疽桿菌。 Milestones in Microbiology 1546-1940,

科霍氏準則Koch’s postulates: Suspected pathogen must be present. Pathogen must be isolated and grown in pure culture. Cultured pathogen must cause the disease. Same pathogen must be re-isolated from the subject. Robert Koch,1843-1910, Germany

Two key factors Improvement of optical instruments Establishment of pure culture system

歷史發現與分析邏輯的吻合性 邏輯項目﹨歷史文章 立場 1. 時間 ++註 - + 2. 空間 ++ 驗證操作 3. 可見物 4. 典範 +? 略 歷史發現與分析邏輯的吻合性 邏輯項目﹨歷史文章 洗手理論 Semmelweis 手術消毒 李斯特 柯霍1876 柯霍1884 立場 1. 時間 ++註 - + 2. 空間 ++ 驗證操作 3. 可見物 4. 典範 +? 5. 技術經驗 6. 對照組 說服力 7. 充分條件 8. 必要條件 9. 不完全充分或必要條件 註：-：無討論或不相關；+：證據弱；++：證據強。

看得見的力量 Diphtheria antitoxin 1901 Nobel prize

看不見的力量 The Amerindians of Mesoamerica and the Caribbean were hard hit by European diseases to which they had no immunity. The predominance of the slave trade in the region added African diseases to the mix, and the climate of the Caribbean was especially well suited to the proliferation of these epidemics. Smallpox, measles, typhus, yellow fever, malaria, tuberculosis, and pus infections decimated the indigenous populations. In 1492 it is estimated that there were approximately 250,000 Arawak and Carib living in the Caribbean. Within twenty years almost all of the indigenous population of the islands had died. http://www.ucalgary.ca/applied_history/tutor/migrations/three4.html http://www.columbia.edu/itc/law/witt/raw_images/conflicts_law_lect2/raw_images/disease.jpg

達文西也犯了錯，因為他未能成功的將其所見的知識傳播出去。 當眾人仍在沉睡，他早在黑暗中醒來。 佛洛依德評論達文西 達文西也犯了錯，因為他未能成功的將其所見的知識傳播出去。 Sherwin B. Nuland 評論達文西 (in: Doctors: the biography of medicine) 對生物科學的發展而言，這些都是廢話！

略 "Good education is amongst the rarest things going; difficult to buy at any price“ The Lancet, 1886 The medical schools which developed in London did so in close alliance with the great voluntary hospitals. Private schools attached to the larger hospitals also existed in the provinces, but outside London medical education tended to become an integral part of multi-faculty universities as soon as these developed, in close association with their science departments. In Europe the medical schools also developed within a university milieu. In London, however, the schools were firmly established before the creation of the University of London in 1836. In most cases the school was established after the hospital, and it always had a closer relationship with its allied hospital than with the University. http://www.nhshistory.net/hospitals_and_medical_education.htm

The new school provided American’s first laboratories for students. 略 The painting of the Four Doctors was of the lead teaching physicians of the Johns Hopkins School of Medicine. They were: Dr. William H. Welch, the first Dean of the school, Dr. William Osler, Dr. William S. Halsted and Dr. Howard A. Kelly.  Admission requirements included not only high academic attainment but also satisfactory completion of course in biology, chemistry, and physics, as well as a reading knowledge of French and German. The new school provided American’s first laboratories for students. The medical staff were expected to excel not only in teaching and clinical work, but in research as well (Johns Hopkins School of Medicine) By John Singer Sargent, 1905