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HMED 3002- Health Care in History II

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Jacob Steere-Williams

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Transcript of HMED 3002- Health Care in History II

HMED 3002
Health Care in History II
Spring 2012- 10:10-11:00 am, Mondays and Wednesday
Nicholson Hall, Room 35
Why American Medicine?
as Medicine
Public Health as Religion
Role of Gov't/
Health Care
Cultural Notions
Goals for HMED 3002
(1.) Skills of Historians

-Reading Primary and Secondary Sources
-Critical Analysis/Thinking
-Arguing (Using Evidence/Providing Interpretations)
-History as "Epistemology"

(2) Sensitize You to Issues You Will Come Across the Rest of Your Lives

-Health is a Politcal/Cultural/Social/Economic PRIORITY
-Health Care Practitioners
-Health Care Consumers

(3) Improve Your Writing

-Writing Intensive Course
-Clear Writing is Indicative of Clear Thinking
Antebellum Medicine as a "Cottage Industry"
What is a (Medical) Profession?
-Self Policing
-Competence (Standard Curriculum)
The "GP"
Jacksonian America
1820- First edition of National Pharmacopeia

Calomel (mercury)
Laudanum (opium)
"Old Hickory"
"Scarcely any two cases of disease are to be treated exactly alike"
Jacksonian Democracy
Lecture 2 (23 January 2012)
"Medicine in the Early 19th c."
"Vis Medacatrix Naturae" (The Healing Power of Nature)
Lecture 3 (25 January 2012)
"Medical Marketplace I: Thomsonians and Grahamites"
Samuel Thomson (1769-1843)
Lobelia Inflata
Healing = Restoring Heat
Thomsonianism as Entrepreneur
Sylvester Graham (1794-1851)
Morality, Stimulation, and Sexuality
The Abracadabra of the Nineteenth Century
Lecture 4 (30 January 2012)
"Medical Marketplace II: European Imports, Homeopathy and Hydropathy"
Vincent Priessnitz, Hydropathy or the cold-water cure, 1842.
Hydropathy (Hydrotherapy)
-Similia Similibus Curantur (like cures like)
-infinitesimal doses
-Homeopathic preparations
-Homeopathy as the biggest challenge to Orthodox Physicians- WHY?
-Efficacy in Therapy?
Medical Systems Compared- 1849
Take some calomel,
The more you take the better,
Mix it with a drop
Or two of cistern water.
Feed some to your dog
It will make him vomit,
And, may be, see stars
And perhaps a comet.
One in each half hour,
Take a rousing portion;
Say, a tumbler-full
If that suits your notion.
Should you chance to die,
As you're almost sure to,
You may safely swear,
That it did not cure you.
Take a little rum,
The less you take the better;
Mix it with the lakes
of Werner and of Wetter.
Dip a spoonful out-
Mind you don't get groggy.
Pour it in the lake
Stir the mixture well,
Lest it prove inferior;
Then put half a drop
Into Lake Superior.
Every other day,
Take a drop in water;
YOu'll be better soon-
Or, at least, you ought to
Take a linen sheet,
The bigger 'tis the better-
Wrap yourself up well
And plunge into the water.
Any water'll do
Croton sea, or cistern;
Each should make a choice
Of what best suits his notion.
When you're fairly soaked,
If you don't feel better,
Take a generous show'r bath,
And get a little wetter.
Touch no wine nor gin,
But gallons of cold water-
You'll be better soon,
If you ain't, you o'rt to
Threshold of Gentility
Benjamin Rush and Physician's MORAL Character
Benjamin Rush (1746-1813)
"Good subjects for the dissecting knife"
Why (some) American Medical Students went to Europe
Lecture 5 (6 February 2012)
Why Edinburgh?
Why London?
(1760s-1820s +)
(Hunterian, 1845)
Wm Cullen (1710-1790)
Why Paris?
St. Thomas' Hospital Theatre, circa 1822
General Hospitals
Specialist Hospitals

Skin diseases
Venereal diseases
Women in Childbirth
Xavier Bichat
Rene Laennec
“the climates of London and Paris were entirely different from our own; the diet and habits of the people altogether different; and that these with other circumstances so modified the constitutions of the people and the character of the diseases, as to make the latter totally different from the diseases of this country.” (A. Louisville)
“the hospitals of those great cities were very extensive and filled with persons labouring under great varieties of diseases; but they were from the very dregs of society, a class whose constitutions have been depraved by intemperance and want, and modified by vice, habit and climate until they possess no analogy in constitution or disease to any class in our own country.” (Charles Caldwell)
Pierre Louis
Lecture 6: Women, Childbirth,
and the rise of Obstetrics
Childbirth as a social (domestic) event
Men enter the birthing chamber
William Smellie- (18th c. Scottish surgeon/man midwife)
Science takes over the birthing experience
BUT- Women chose!
Obstetrics Kit
Blunt Hooks
Arrow Perforator
-Fanny Longfellow,
“I never was better or got through a confinement so comfortably… I feel proud to be the pioneer to less suffering for poor, weak womankind. This is certainly the greatest blessing of this age, and I am glad to have lived at the time of its coming.”
"Your death has entered into you" (Cotton Mather)
"Thirty years ago the practice of midwifery was principally in the hands of experienced women, who had no difficulty, but the doctors have now got most of the practice into their own hands... These young, inexperienced doctors... have little knowledge, except what they get from books, and their practice is to try experiments.... The midwife's prace was one dollar; when the doctors began to practice midwifery in the country rural areas, their price was three dollars, but they soon after raised it to five: now they charge twelve to twenty."- Samuel Thomson
Lecture 7: Women as Doctors in the mid 19th century
"a blank wall of social and professional antagonism"
Elizabeth Blackwell (1821-1910)
-First woman to earn M.D.
(Geneva Medical College)
-Zealous moral reformer
-Women especially apt for medicine: moral + sensitive
Geneva Medical College (Seneca Lake, NY)
I had not the slightest idea of the commotion created by my appearance as a medical student in the little town. Very slowly I perceived that a doctor's wife at the table avoided any communication with me, and that as I walked backwards and forwards to college the ladies stopped to stare at me, as at a curious animal. I afterwards found that I had so shocked Geneva propriety that the theory was fully established either that I was a bad woman, whose designs would gradually become evident, or that, being insane, an outbreak of insanity would soon be apparent."
Elizabeth Blackwell- shortly after starting at Geneva Medical College
Blackwell after an anatomy class
A trying day, and I feel almost worn out, though it was encouraging too, and in some measure a triumph; but 'tis a terrible ordeal! That dissection was just as much as I could bear. Some of the students blushed, some were hysterical, not one could keep in a smile ... My delicacy was certainly shocked, and yet the exhibition was in some sense ludicrous. I had to pinch my hand till the blood nearly came ... Dr. Webster, who had perhaps the most trying position, behaved admirably." (Diary, Nov. 22, 1847)
After Geneva?
la maternité (Paris 'lying-in' clinic)
St. Barts, London
Mary Putnam Jacobi (1842-1906)
-MD from Women's College of Penn
-120 Scientific articles, 9 books
-Professor at Women's Medical College (Blackwell's School)
“immersion in technical studies is like arsenic eating- once begun, you must go on, and at a continually increasing dose” (Jacobi, to mother)
Female Medical College, Penn
Two kinds of 19th c. feminism:

1. Feminism and morality (Blackwell)
2. Professionalism and science (Jacobi)
James Miranda Barry (Margaret Bulkley)
successful- Scottish-trained surgeon
"Every woman is born a doctor. Men have to study to become one." Dr. Ella Flagg Young
“a system of life constructed on a wholly new principle”
Class 9: Disease, Industrialization, and Poverty
Technological Revolution- Railways
The Nation's Industry
- Coal Mining
19th century Housing
A Universal Category- "Filth"
Poverty = key social category
Epidemic Disease
Food and Food Safety?
King Cholera
No. 72 — Mary Barrett, aged 14. June 15.

I have worked down in pit five years; father is working in next pit; I have 12 brothers and sisters — all of them but one live at home; they weave, and wind, and hurry, and one is a counter, one of them can read, none of the rest can, or write; they never went to day-school, but three of them go to Sunday-school; I hurry for my brother John, and come down at seven o'clock about; I go up at six, sometimes seven; I do not like working in pit, but I am obliged to get a living; I work always without stockings, or shoes, or trousers; I wear nothing but my chemise; I have to go up to the headings with the men; they are all naked there; I am got well used to that, and don't care now much about it; I was afraid at first, and did not like it; they never behave rudely to me; I cannot read or write.
Bread and dripping all the week
Pig's head on Sunday
Half a crown on Saturday night
A farthing left for Mondy
(Sir) Edwin Chadwick
Class 10: The Sanitary Movement: Chadwick, Farr, and Nightingale
Understanding Class in the mid 19th century
Reform Act of 1832- men owning household worth £10
Reform Act of 1867- all men- no proprety requirements
"A Country of Two Nations"
Two nations between whom there is no intercourse and no sympathy; who are ignorant of each other's habits, thoughts and feelings, as if they were dwellers in different zones or inhabitants of different planets; who are formed by different breeding, are fed by different food, are ordered by different manners, and are not governed by the same laws ... THE RICH AND THE POOR

Benjamin Disraeli, 1845
Politician- Barrister- Mastermind of 1834 New Poor Law
1842- "Report on the Sanitary Conditions of the Laboring Population of Great Britain"
Aged or infirm men.
Able bodied men, and youths above 13.
Youths and boys above seven years old and under 13.
Aged or infirm women
Able-bodied women and girls above 16.
Girls above seven years old and under 16.
Children under 7 seven years of age.
Workhouse Categories
New Poor Law of 1834
(1) Workhouse Test
(2) Principle of Less Eligibility
1842 Sanitary Report
1848- 1st Permanent Board of Public Health
1848- 1st Public Health Act
William Farr
Statistician- Compiler of Abstracts at the Registrar-General's Office

Statistics crucial to public health and "Sanitary Movement"
Class 11: Debating Germs- Chemistry, Epidemiology, and Bacteriology
Disease Theory around 1850
-Contagion (spread by personal contact)
Smallpox, Rabies, Syphilis?

-Miasma (Anticontagionism)
Cholera, Yellow Fever, Typhoid, TB, (most epidemic diseases)
Edwin Chadwick- "all smell is disease"

Florence Nightingale- Pavilion Hospitals
"All Smell is Disease"
The Usual Suspects
Joseph Lister (1827-1912)
Louis Pasteur (1822-1895)
Robert Koch (1843-1910)
-Debt to Hippocratic Humoralism
Predisposing Causes Crucial

-Hierarchy of Causation
Nightingale wards: design and disease theory
Max Von Pettenkofer (1818-1901)

-German Physician (Bavaria- Munich)
-Most sophisticated of Anti-contagionists
-Groundwater Theory-X-Y-Z
-1855 Treatise on Cholera
Political Manifestations: Quarantine
Anticontagionism- Liberal Freedom
Contagion- Absolutist- Gov't Control
John Snow (1813-1858)
Epidemic Cholera
Major Outbreaks- 1831 (2), 1848(9)
1854(5), 1866

-Major fear- killed quickly
-Unusual Symptoms
“a disease that could seize a British soldier in perfect health, reduce him six hours later to a whimpering infant unable to control the discharge from his bowels, and lay him out a corpse six hours after.”
-Pioneer Epidemiologist
-Water-borne theory of cholera
-Broad Street Pump Study
-Metropolitan Water Companies Study
Scottish Surgeon-
Asepsis and Anti-sepsis
-Carbolic Acid Spray
French Chemist/Microbiologist
-Fermentation/Spontaneous Generation
-Swan-neck flask experiments
German physician/bacteriologist
-1876- Bacillus anthracis
-1884- Cholera vibrio
-Koch's Postulates
Class 12: The Laboratory Revolution- The Curious Case of Diphtheria
Robert Koch
1870-1880: General Practitioner & Health Officer in Wollenstein (East Prussia)

-1880-1885: Bacteriologist at Imperial Health Department

-1885-1891: Professor of Hygiene, University of Berlin

-1905: Nobel Prize
1877: Etiology of Anthrax
1882: Etiology of Tuberculosis
1884: Etiology of Cholera
Koch's Postulates
-Plausible Cause: Must be present in all cases
-Cannot be present incidentially
-Experimental Test:

(a) Isolate Organism
(b) Grow in Pure Culture
(c) Produce Disease in Healthy
(d) Recover from the inoculated case
Koch's Importance
1. Specific Formal Criteria for understanding disease
2. Development of standard techniques
3. Use of Pure Cultures
4. Staining techniques
5. Micro-photographs
6. Research Laboratories: Koch's Students
-No identification of viruses
Not visible with light microscope
Not capable of culturing until tissues cultures introduced in 1930s
-No concept of Healthy Carriers
(until 1910s- we'll return to with the case of "Typhoid Mary"
-Artificiality of "Pure Culture"
Germ Hunters....
Find causal organism- create vaccine
Context = Smallpox Vaccination (arm-to-arm)
-Bacteriologists seemed to have new answer
Diphtheria- "Childhood's Deadly Scourge"
Pasteur (and his students):
-1879- Chicken cholera vaccine
-1881- Anthrax vaccine
-1883- Swine Erysipelas
-1885- Rabies (Read Geison article!
“By keeping these animals under observation for a few days, we are enabled to detect just how large a quantity of this bouillon containing the living bacilli from each of the cultures is needed to destroy the life of the animal. When this has been determined, we select four or five of the most virulent cultures to use for the production of the toxines.” –WH Park and HM Biggs, Diphtheria Antitoxin
"When we can introduce from two hundred to three hundred cubic centimeters of strong toxine into the horse without producing serious symptoms, we can feel pretty certain that the horse's blood contains anti-toxine in sufficient amount to be used for healing purposes."
"throat distemper" "morbus stranglatorius" "croup"
"malignant ulcerous sore throat" "angina maligna"
Diagnosis- Breakthrough = Wm Park + H. Biggs
Wm Park (1863-1939)
1893- New York City Health Department- bacteriological diagnosis of diphtheria mandatory for all suspected cases

-Park's Culture Kit: Tube, Swab, Clear Instructions
-Physicians would send to NY Bacteriological Laboratory- (Herman Biggs in charge)
Herman Biggs (1859-1923)
The Laboratory Breakthrough
1883- Edward Klebs- First Described Bacillus Diphtheria
1884- F. Loeffler- First to grow in Pure Culture (Koch)
1888- Emil Roux and A. Yersin- Discover Diph. Toxin
1890- E. von Behring- First Immunized guinea pig with toxin
1890s- Paul Ehrlich- First use of Antitoxin in humans
Note: Midterm on Wednesday
No Section this week
"Once a Charitable Institution"
German Medicine and the Transformation of the American Hospital
Carl Ludwig
Blood-pressure rhythms in dogs, cats and humans in response to the sounds of musical instruments.
Experimental set-up for measuring reaction time
Effects of Blood letting on pulse
Effects of sound on blood pulse
Upcoming Themes
-The "New" Public Health
-Am. Medical Education
-Massive Changes in Am. Hospitals
(Vienna/Berlin, Many Others)
Why Germany?
-Timing Mattered (American Civil War)

-Clinical Training

-Research/Teaching Specialties (Bacteriology, Histology, Physiology, Pathology)

-German University System Unique- Gov't Sponsored

Am. Civil War (1861-65)
-Watershed Event (Cliche- but Yes)

-Challenged Jacksonian Democracy & Rugged Individualism

-1st Draft & 1st Income Tax

-Society dependent on new Technologies (RR) and new patterns of living (peak of industrialization after war)
Breslau, Leipzig, Strasbourg, Dresden, Prague, Vienna , Berlin
Wm. H. Welch
Connecticut medical elite
-Studied in Germany with Koch and Ludwig
-Early bacteriological research on gas gangrene
-Dean of Johns Hopkins School of Medicine-
"Dean of American Medicine"
Physiological Institute Leipzig
Ludwig's Kymograph
Shaped like an "E"
Antebellum Am. Hospitals
-Welfare institutions (private)
-Patients = poor + immigrant
-Philanthropy and Paternalism
-Dangerous- "Hospitalism"
Changes in last 2 decades of 19th c. (1880-1900)
-Middle Class "Bachelor Movement"
-Life Expectancy Rising (old folks?)
-Changing Urban Living Patterns
-Antisepsis and Asepsis
-New Design Overhauls (Nightingale)
-Germ Theory makes the HOME dangerous
-New Medical Technologies
-New German lab. influence
Technology in the Hospital
Henry Fisher- Pathology lab @ Penn. Hospital, c.1890s
Lab Technicians @ Penn Hospital, c.1920s
Nurse Anesthetist- Deana Murphy
1924- Residents and Interns- Penn Hospital
Figures from Penn & NY- 1900 and 1920
New Tools
Crowing Achievement = X-Rays
Wm Roentgen- German physicist @ Würzburg
1895- 1st Report on X-rays (tested his wife's hand)
Light passing an electrical current through a cathode-ray tube (Crookes tube)- produced new ray (radiation)
Early use
"I have seen my death"
"no one will for a moment suppose that the vacuum-tube and induction-coil will, or ever can, displace the sense of touch guided by a well-balanced and experienced mind"
Slow introduction of x-ray machines into rural areas

-x-ray put greater distance between doctor and patient

-Many feared they were abandoning Rush's IDEAL MD
New "Sanitary" equipment for Hospitals (marketing)
-Lighting equipment
"Beach Party a'la Roentgen"
Wm Welch- Professor of Pathology
Wm Halstead- Professor of Surgery (also Harvey Cushing)
Wm Osler- Professor of Medicine
Wm Osler and the First group of Residents at Hopkins Hospital in 1890s
First Faculty @ Hopkins
Johns Hopkins Medical School and Hospital
-Designer- John Shaw Billings- uses Nightingale model
New to Curriculum
-Co-ed from the beginning
-Prereqs- 4 year college degree, foreign language
-Less didactic training, more HANDS-On
-All students do laboratory training and Clinical Clerkship
-Length of study = 4 years of 9 month training
Pathology Department
Progressivism in late 19th early 20th c. America

-Increasing reliance on Science + Technology
-More willingness for state control (of some issues)
-Wealthy Industrialists = key image, not Farmers (Jacksonian ethos)
-Education a National Issue ( John Dewey's Progressive education, importance of Morril Land Grant Act)
Medical Professionalization Renewed

-1901- AMA revised
-1900-1920- AMA Membership increases tenfold
-Medical Schools = Gateways
-1906 Study- 160 Schools: 82 (A); 46 (B), 32 (C)
"Though medicine can be learned, it cannot be taught. Active participation- doing things- is therefore the fundamental note of medical teaching," Flexner, 1925
"The time has gone by when one mind can encompass all which has been ascertained in the medical sciences" Wm Welch, 1886.
1910 Flexner Report
-Flexner staff at Carnegie Foundation for the Advancement of Teaching (AMA asked them to do it)
-Flexner visited all 155 Schools
-School’s entrance requirements
Size and training of the faculty
Size of Endowment and tuition
Quality of Laboratories
Availability of a Teaching Hospital
All Along the Watchtower:

Abraham Flexner and the Standardization of the American Medical School
No- Changes already underway (half of the schools Flexner visited had annual incomes over $10,000
Yes- Exposed terrible conditions- pressured schools to improve
-Sensational- Muckraking Journalism
Actual # of Schools
Proposed # of Schools
The New Public Health in the early 20th c
Success of Labortaory Bacteriology around 1900?
“Except for a few diseases or except for very indirect effects, the cleansing of streets, alleys, and back yards, of dwellings and stables, the regulation of offensive trades, and the prevention of nuisances generally, have, so far as we can see, no effect on the general health, nor any value in the prevention of specific diseases.” (Chapin, 1910 page 32)
"The filth theory of the origin of disease is dead"
Diphtheria, rabies, smallpox
success: Gall bladder, Tonsillectomy
Widal test (Typhoid), Wm Park culture kit (Diphtheria), Wasserman test (Syphilis- in 1906)
-Identification of causal organisms of
(viruses not until 1930s
Basis of "New" Public Health
-based theories to
-based theories
-Knowledge of the Individual Crucial
-Locate, Identify, Test, Isolate
-Combination of Epidemiology and Bacteriology
“Bacteriology has been called the handmaid of epidemiology, but it is rather an equal partner’ (Charles Chapin, 1928)
Water, Food (Milk), Flies, Soil (Epidemiologically proven)

personal behaviors- coughing, spitting, saliva, sputum (Bacteriologically proven)
Charles V. Chapin
Health Officer for Providence, R.I. from 1884-1932
1906- “The Fetich of Disinfection” read at the AMA Meeting

1910- The Sources and Modes of Infection (academic book- standard textbook in public health)

1917- How to Avoid Infection (popular book based on 1910 book)
Prevention Strategies center on Individuals:
*Immigrants and Children*

1. Infant Milk Depots

2. School Hygiene Movement
Federal Government Gets involved with funding major initiatives in 1930s

1935- Child Health Services
1938- Venereal Disease Control
1944- Tuberculosis
1947- Mental Health
1947- Industrial Hygiene
1947- Dental Health
1909- U.S. Public Health Service- Bulletin 56
Detailed 500 outbreaks of milk-borne disease from 1880-1907
Pott's Disease
Tenement Living- Jacob Riis "How the Other Half Lives" 1890
Henry Livingstone Trudeau and the Saranac Lake Sanatorium
Saranac Lake = Model
Education + Change Personal Behavior
Surgical Solution?
Pneumothorax- collapse lung
Social Solution?
Anti-TB Associations- National and Local
“Cure sometimes, Relief Often, and Comfort Always”
Tuberculosis, Sanataria, and American Progressivism
Most of 19th century- TB = Multiple Diseases
1. Patients required to be outside "taking therapy" from 9-noon, 2-5 everyday
2. Patients must have no exercise
3. Solid, Substantial Diet- 4 Compulsory meals (goal about 4,000 calories/day)
4. Constant vigilance by staff- no alcohol, tobacco, sex, gambling, etc.
Koch- isolates mycobacterium tuberculosis in 1882
The "Germ" of Laziness- Hookworm in the American South
Charles Wardell Stiles
Hookworm life cycle
Hookworm distribution
Caricature's of the South
-Origins of "Cracker"
Path to "Happiness"
Wickliffe Rose
Frederick Gates
Final Exam Review Activity
Question 1
In whose celebrated physiological laboratory did late 19th early 20th century American medical school reformer William Henry Welch study?
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
What U.S. Medical School opened in 1893, becoming the first German modeled school to integrate laboratory research and clinical practice? As a bonus point, who were the “Big Four” professors to have the biggest impact on American medicine in those early years?
What group of Americans first began to use (and pay for) therapeutic intervention in the hospital in the late 19th century, and what drove them there?
German physicist Wilhelm Roentgen developed one of the most transformative medical technologies in the history of medicine. What did Rontgen discover, and how was this technology used in the early 20th century?
Johns Hopkins Medical School was co-educational from the first day it opened its doors in 1893?
What ‘wonder-drug’(and who discovered it), which was widely used by the 1940s, was deliberately withheld from individuals participating in the infamous Tuskegee Syphilis Study?
This American medical scientist, who began his career as a zoologist, was the first Director of the Zoology Division of the U.S. Public Health Service. He played a leading role in the Hookworm Eradication Campaign?
This social and medical movement was led by American women in 1914 and 1915 as a means to gain control over the birthing process
When Abraham Flexner visited all 155 medical schools in the U.S. and Canada, he was looking especially for five characteristics of each institution- what were they?
Question 10
Question 11
Question 12
Which of the following was NOT a Federally-funded initiative to curb massive public health problems of the mid 20th century- Venereal Disease Control, Anti-Tuberculosis Campaign, Dental Health, Mental Health, Industrial Hygiene, Anti-Cholera Movement, or Child Health Education Campaign?
What healthcare related organization originated in the late 1920s as part of Baylor university hospital?
The infamous “Typhoid Mary” was a BLANK of typhoid fever, which helps explain why the case was so controversial.
Question 13
Question 14
Question 15
Although private organizations, Friendly Societies and BLANK were the European forerunners of government-sponsored healthcare plans that emerged in the late 19th and early 20th century.
"At no time can we afford to lose the productive energies and capacities of millions of our citizens. nor can we permit our children to grow up without a fair chance of survival and a fair chance for a healthy life... a great and free nation should bring good health care within the reach of all its people."
"The treatment of this disease in the negro consists of fresh air and plenty of it, proper food and clothing and enough of them, and at the same time preventing the patient from infecting others and reinfecting himself."
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