This study analyses the reception and influence of Dutch Cartesian medical reformers in German culture during the Early Enlightenment period. The impact of their proposed reforms, involving the rejection of traditional Galenic-Aristotelian theory and practice, and placing medicine in an essentially new, mechanistic scienceoriented Cartesian philosophical framework, is discussed in the context of the large number of German translations of their works, published often in several editions in various parts of Germany between the late 1680s and the early eighteenth century, and in relation to the wider context of social and cultural reform. The study opens with an examination of factors that facilitated the reception of Dutch medical ideas in Germany, such as the large number of German medical students studying in the Netherlands, the preponderant impact of the Dutch universities in the promotion of the ‘new’ philosophy and science during the second half of the seventeenth and early eighteenth century, and the presence of physicians trained in the Dutch universities at the medical faculties of German Protestant universities, and as court, city, and army physicians. Supporting evidence is also drawn from the massive impact of Dutch publishing on the German book market, the proliferation of periodicals, book reviews and book production in Germany aimed at the general public in the vernacular. It is argued that the translated works of Comelis Bontekoe, Steven Blankaart, Heidentryk Overkamp and their Cartesian followers intensified debates about medical theory and practice and the new life-style issues of tea and coffee drinking and tobacco-smoking and considerably influenced their adoption in society. The concerns voiced by translators and influential German medical scholars, including Friedrich Hoffmann, Georg Ernst Stahl and Albrecht von Haller, show that their iatrochemical mechanist conception of how to preserve health, prevent illness and prolong life, and their advocacy of a virtual abolition of blood-letting and purging, contributed to a change in people’s perceptions of illness and attitudes to health care in some sections of society, and exerted a far greater impact on German medicine than has so far been recognized.

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Many vascular disorders require surgical procedures to overcome failing blood supply. Deficient arteries are replaced by prosthetic or vein bypass grafts to recover normal blood flow. However some grafts fail after operation. Therefore graft surveillance programs are important to increase the patency rate of grafts. Although there are a number of methods for medium and long term graft surveillance, these are not suitable for monitoring grafts immediately after operation to detect early graft failures which account for 20% of the total. This dissertation describes a computerised graft monitoring system which is suitable for continuous or intermittent monitoring of grafts immediately after surgery. The system comprises a floating point DSP board, an IBM compatible computer and a purpose built CW Doppler board. The Doppler board is designed to be installed in the computer. The possibility of implementation of DSP algorithms for obtaining directional information is extensively discussed. This study shows that digital techniques outperform their analogue counterparts. Therefore in this system, apart from the quadrature demodulation of the Doppler signals all processes are implemented digitally. Maximum frequency envelope detection algorithms are also discussed. The results obtained from monitoring seven patients are presented and practical difficulties encountered during the monitoring process are highlighted.

This dissertation represents an investigative critique of the philosophical approaches to defining health and disease, going beyond pure conceptual analysis and straight into historical-philosophical analysis in an attempt to unpack the very discourse which underpins the discussion. Drawing on the notion of language as a medium of social instruction, it problematizes various specific features of the debate’s intellectual format, for example pointing out that its preoccupation with linguistic precision ought to be replaced with a focus on expressing the complex multidimensional nature of disease in a relatable manner. After presenting evidence of clinical reasoning’s inherent susceptibility to bias, the thesis exposes naturalism’s historical roots as an ideologically driven counter-reaction to nineteenth century vitalism, thereby discrediting the ideal of neutrality. Despite this skeptical start, it rejects eliminativist positions that philosophical attempts to produce health/disease definitions are pointless and unnecessary, and argues that the debate needs to be maintained due to such discussions’ important implications for medical and social identities, patient narratives, the negotiation of treatment objectives, or even the effectiveness of public health programmes (as a population’s inclination to comply with state-mandated public health measures is directly influenced by the notions it holds about health and disease). This is followed by an exploration of the conceptual limitations faced by the most commonly applied strategies of defining disease, after which their advantages are re-combined in an optimized hybrid account of disease supported by a philosophical distinction between the categories of ‘symptoms’ and ‘clinical signs’. Finally, this account is tested on a wide range of problematic cases, to ensure its capacity to deliver the promised results whilst also overcoming challenging influences such as the ones posed by bias, discursively shaped diagnostic labels, or unwarranted pathologization.

Dans le domaine de la santé, la mesure d'utilité permet d'exprimer la valeur que peut donner un individu à un état de santé, comprise généralement entre 0 (la mort) et 1 (meilleur état de santé envisageable). L'utilité permet de valoriser simultanément le résultat clinique et son impact sur l'état de santé du patient, et d'exprimer ainsi la qualité de vie liée à la santé. Nous nous sommes intéressés dans ce travail à l'approche indirecte d'estimation d'utilité, consistant à dériver une utilité à partir des échelles psychométriques de mesure de l'état de santé (questionnaires génériques). Cette approche permet de répéter la mesure de l'utilité dans le temps et ouvre des perspectives pour l'analyse du changement d'utilité. Les objectifs étaient de définir un seuil de changement pour l'utilité dérivée des instruments de mesure psychométrique de la qualité de vie, et de prendre en compte dans l'interprétation du seuil la présence des comorbidités ou d'un phénomène de response-shift. Afin de répondre à nos objectifs, nous avons étudié, d'une part, le changement d'utilité mesurée par le SF-6D dans une cohorte de patients atteints d'arthrose des membres inférieurs (cohorte KHOALA) et l'effet des comorbidités sur l'utilité et son changement. D'autre part, nous avons estimé l'utilité de donneur vivant de rein à partir des questionnaires EQ-5D et SF-6D avant et 3 mois après le prélèvement du rein. Un seuil de changement a été estimé et un phénomène de response-shift a été recherché. Les résultats ont montré l'effet délétère des comorbidités sur la mesure de l'utilité chez les patients atteints d'arthrose, et mis en évidence l'importance de la sévérité fonctionnelle de l'arthrose dans l'expression de l'utilité et son changement. Chez les donneurs vivants de rein nous avons mis en évidence une diminution significative de l'utilité à 3 mois, avec une proportion de plus de 30% de donneurs ayant atteint le seuil de détérioration significative. L'estimation du seuil de changement diffère selon la population étudiée, l'instrument de mesure de l'utilité, et la méthodologie appliquée pour définir ce seuil. En conclusion, l'évaluation du changement d'utilité doit tenir compte de l'existence des comorbidités ainsi que de l'adaptation du jugement de valeur que l'individu porte sur son état de santé lorsque celui-ci évolue. La complexité des méthodes psychométriques pour la mesure de l'utilité doit amener à être prudent sur leur prise en compte dans les modèles d'évaluation économique. L'identification d'un seuil pour l'interprétation du changement peut être un élément complémentaire utile dans la démarche d'analyse décisionnelle / In health economic, the concept of utility was used to describe a state of health in patients. The unit value of health state utility ranges between 0, representing "death" state, and 1 representing a "perfect" health state. It is possible to recover through the measurement of utility both the clinical outcome and their impact on the health of the patient, and thus express the quality of life related to health. In this work, we used the indirect approach for estimating utility that is derived from a generic utility scales (quality of life questionnaires). The objectives of this thesis were to define a threshold of change for the utility derived from psychometric instruments measuring quality of life, and to take into account for the change interpretation, the presence of comorbidities or a response-shift phenomenon. We used data from a cohort of patients with osteoarthritis of lower limbs (KHOALA cohort) for estimate the impact of comorbidities in utility measured by the SF-6D its change over 3 years. We are also interested in the particular case of living kidney donors. The utility was estimated by the EQ-5D and SF-6D before and 3 months after kidney donation. A threshold of significant deterioration has been estimated and the presence of a response-shift phenomenon was controlled. The results showed the deleterious effect of comorbidities on utility measurement for patients with lower limbs osteoarthritis, and highlighted the importance of the functional severity of osteoarthritis in the expression of utility and its change over time. Living kidney donors experienced a significant decrease in their utility score in the short term, and more than third of donors have reached the threshold of significant deterioration. The threshold of utility change varies depending on the population studied, the measurement instrument, and the methodology used to define the threshold. In conclusion, the assessment of utility change must take into account the existence of other diseases and the adaptation of the individual on his health state variation. The complexity of measuring individual preferences by psychometric instruments should lead to be careful about introducing them in the economic evaluation. The use of a threshold for the interpretation of utility change can be an additional element in the decision-making process