Changes in Medicine (1848-1948)
How was WWI a catalyst for change?
Medical equipment
Infections
Plastic surgery
Trenches, particularly in France were dug in farmlands which had soil that was covered in manure. Wounds were frequently exposed to this.
Trench foot was a common type of fungal infection caused by damp and unclean conditions
Affected 75,000+ British soldiers
Solution
Whale oil which helped reduce the number of cases by 1917
Gas gangrene was a kind of infection caused by the bacteria in the manure
The infection often resulted in an amputation or loss of life
Solution
British bacteriologist Almroth Wright proposed revolutionary methods on how to treat war wounds.
He strongly opposed the traditional method of pouring antiseptic into an open wound and then closing it up
His research from many case studies from the European battlefields helped to persuade his peers that his method would work
His proposal was to first clean out all foreign bodies e.g: shrapnel & soil and leave the wound open to let the body to do its natural healing process
Resistance to Wright's research meant his methods were only widely accepted after the war. However, they helped significantly in lowering the rates of infection and amputation during WWII
Context
600 B.C: The world's first written record of a plastic surgery operation was written by an Indian surgeon called Sutra
Sutra used a leaf as an outline to help him cut into the skin to create a flap
During the Renaissance period, many young people would get into duels sometimes even with swords drawn. As a result, many sustained major facial injuries e.g: losing a nose
Italian surgeon Gasper Talicotsi developed a way of taking skin from the upper arm and grafting it onto the face.
The patients hand would be brought up in a harness to attach the skin to the nose for 3 weeks.
The flap with the new blood supply from the face could now be cut and the tissue on the face was reshaped into a nose
1846: World's first operation performed under anaesthetic
WWI
The flap from the cheek or forehead would be rotated to create a new nose
Lots of sharp shrapnel caused by bombardments caused lots of cuts and facial wounds
Trench warfare meant soldiers' heads were particularly vulnerable
Surgeons first tried to sew up the large holes
individual masks were then crafted to hide the scar
Soldiers' didn't really like the masks and wanted a more permanent solution
Solution
Harold Gillies set up a dedicated unit at Queen Mary's hospital in Kent
He made sure every casualty with serious facial wounds was brought there for treatment
He began to experiment on how to fill in the soldiers' wounds with healthy skin from other parts of the body
A crucial discovery he made was finding out the skin grafting was more successful if you rolled it inwards in a "Pedicel tube."
It helped encourage blood supply to come from the ends of the pedicel and it kept infection down to a minimum as there were no raw surfaces
He replaced missing tissue with the pedicel tube to rebuld his patients' faces
The help of anesthetic
Existing chloroform masks made long operations nearly impossible
The anaesthetists developed a brand new system of using tubes that could incubate the patient which allowed them to safely operate
Gillies centre ended up treating around 5,000 patients by the end of the war
The huge numbers of patients meant his methods were throughly trialed and tested.
Gillies would go on to write the New Specialities Key textbook and became known as the father of plastic surgery
The impact of WWI on plastic surgery
Plastic surgery was never really a specialist field prior to the war
The experience of the first world war meant that surgeons from across the world could take the technique back and do things that were previously impossible
WWII
Pilots who got shot down often got serious burns if they survived the crash
At the start of the war, standard treatment of burns was to bathe them in acid, completely drying out the tissue and turning skin into leather
Solution
Gillies cousin Archibald McIndoe was put in charge of a plastic surgery unit that specialised in treating badly burned airmen
He realised that the burns on airmen that crashed into the sea healed more quickly and were more flexible.
He began to bath burns in cold salt water
Only after treating the burn for months was Mcindoe able to start skin grafting
Many operations were needed to ensure that the airmen were able to use their hands again
The Guinea Pig Club
McIndoe also wanted to make sure that his patients regained their confidence with their new hands and faces
He asked local residents not to stare and encouraged his patient's to socialise
His patients decided to set up a club to give each other the support they needed to overcome their injuries.
They named it the Guinea Pig Club as McIndoe would often try his new techniques on these patients
Public Health
Context:
Though there were vaccines available, few people had been vaccinated and diseases such as Typhoid fever, Influenza or Cholera had no cure.
The belief that disease was spread by miasma made people believe that Cholera only affected poor people who were living in unhygienic conditions. As a result, MPs didn't take much action and left the local authorities to deal with it.
The 1948 PHA:
Edwin Chadwick was a civil servant who worked for the poor law commissions (1830s -40s)
In his 1842 report, The Sanitary Conditions of the Labouring Population, Chadwick called for more of taxpayers money to be spent on improving the housing and living conditions to keep them healthy
A General Board of Health was set up for 5 years
Local Councils were encouraged to make public health improvements
3 commissioners were put in charge of the Board of Health (including Chadwick)
Context:
The 1866 Sanitary Act made local authorities responsible for sewers
The 1875 PHA:
The 1875 Public Health Act went further, making local councils responsible for a range of public health measures which impacted housing and hygiene.
Impact of the 1875 PHA:
Local authorities had to appoint a Medical Officer who would be in charge of PH
Street hygiene & housing:
Food:
Water hygiene and sewage:
Providing clean water meant there was less chance of catching waterborne diseases such as cholera or typhoid.
It was made illegal for factories to dump their waste into rivers.
Ensuring sewage was properly treated and couldn't contaminate the water supply which reduced the chance of passing on disease
Inspecting the quality of food for sale reduced the chance of people being made ill by poor quality or infected goods.
Keeping the streets clean reduced the number of mice, rats and flies, and reduced the chance of passing on disease.
Lighting the streets meant people could avoid rubbish and dirt.
Inspecting new houses ensured there was sufficient lighting and ventilation to be healthy. Slum houses could be demolished.
Limitations
The impact of this PHA was very limited as the terms of the act were temporary.
The act allowed local authorities to improve hygiene but did not force them to. As a result some authorities took no action.
The Board of Health was only set up for 5 years and ended in 1854.
Chadwick was also known as being a difficult person who was arrogant and aggressive. As a result, he found it hard to get his ideas across.
There was no actual proof that disease was linked to hygiene.
Organised removal of rubbish
Built a sewer system
Disease
Surgery
Pain
Previous myths
Blood loss
Infection
Before 1840s:
Most patients were awake while operating
Only types of pain relief were alcohol or being knocked unconcious
The best surgeon was the one who cut the quickest
1844-5
Robert Liston was famous for his 28 second long amputation
1840s
Tourniquet would be used to reduce blood flow in the artery
1840s
Even if patients survived the surgery, a high percentage would die from infection
Operations were carried out in the patient's home
Surgeons would wear old, stained clothes and no sterilisation of equipment or washing hands was done (some did but rarely) due to lack of understanding about infection.
Nitrous oxide (laughing gas) was known to make people unaware of the pain
1846
Was used in dentistry by Horace Wells but not considered suitable for surgical operation
Dentist William Morton (USA) experimented with ether and found it had a stronger effect
Robert Liston heard about Morton's work. He used ether in a leg amputation which amazed the audience as the patient didn't need to be held down and was unaware of the operation
Drawbacks
irritated lungs, could leave the patient asleep for hours or days, Gas was flammable
James Simpson experimented on other various gasses until he discovered chloroform.
1847: Chloroform didn't have the same side effects as ether. First used it for women in childbirth.
1848
1853
Queen Victoria used chloroform on her 8th child. Simpson was her official physician
Drawbacks:
Doctors were unsure how chloroform would affect the baby
Newspaper publicity and royal approval increased popularity of chloroform. More patients requested for it during surgeries
Church was opposed to it because the bible says that childbirth was meant to be painful
Surgeons felt more confident in attempting more complicated surgeries
It was difficult to control the dosage of chloroform
John Snow invents chloroform inhaler
1848
The extended operations after chloroform increased risk of gangrene if blood supply was cut for too long
1847
Florence Nightingale goes to Scutari
Nightingale and her team of nurses:
Conditions at Scutari:
Scrubbed surfaces clean
Windows were opened to improve flow of air (she believed in miasma)
Washed sheets, towels, bandages and equipment
Cleaned kitchens and improved quality of food
New supplies bought
1861
1846-66
'Black Period' of surgery due to how unhygienic operating conditions were.
Joseph lister, Surgeon at Glasgow Royal Infirmary
He read Pasteur's work and also learned that carbolic acid was used in sewages and he linked it to microorganisms.
He used the carbolic acid to clean wounds, equipment and bandages
Death rate dropped by 30%
1878
Lister developed a carbolic spray too to make sure no microorganisms could enter the open wound.
Drawbacks
Spray made it harder to grab slippery instruments which slowed down the operation
Doctors who did not use Lister's techniques properly found the carbolic acid ineffective
Robert Koch invents steam steriliser
Some doctors didn't believe in Pasteur's germ theory so they saw no need for antiseptic techniques
Nurses were irritated by the extra work needed and cleaning in dressing patients' wounds
Pasteur had shown that microorganisms could be killed by heat. Koch used this idea to sterilise equipment
Aseptic surgery - Preventing microorganisms rather than curing them
1895-WWI
Operations were carried out in clean operating theatres
No spectators
Surgeons wore clean clothes including rubber gloves and masks
Operations had to be quick to minimise blood loss
1881
Lister had been experimenting with ways to reduce blood loss
Ligatures were threads tied to the end of blood vessels but they could become hard and prevent the wound from healing or be a source of infection
Blood vessels that were cut were sealed painfully by cauterisation. This involved placing a hot iron against the vessel and sealing the ends by heat.
Lister experimented with silk ligatures soaked in carbolic acid but they weren't always effective
Lister and catgut
Lister published results of his work on using catgut as ligatures.
Cat gut could be soaked in carbolic acid so it couldn't infect the wound AND it could dissolve in the body after 2-3 weeks.
1884
Cocaine was used before this but not very suitable as it was addictive
Cocaine was discovered to be a good local anaesthetic, only numbing in a part of the body
1905
Novocaine was developed to be a safer version of Cocaine
X-rays
Wilhelm Röntgen discovers X-rays and publishes his findings
Many hospitals had an X-ray installed the following year
In war, X-rays helped reduce the surgery time as the surgeon was able to see exactly where the bullet was rather than searching through the open wound, reducing the chance of infection
1901-07
Blood transfusions in the past often lead to death but people couldn't understand why
1901: Austrian doctor Karl Landsteiner discovered blood types A,B & O (AB discovered in 1902).
Doctors realised that patients can die if given the wrong blood type (O found to be universal donor in 1907 but reason was not fully understood)
Successful blood transfusions significantly helped patients with blood disorders e.g: Anaemia and leukaemia
Drawbacks
Donor had to be present to transfer blood making it impractical in WWI
Blood would quickly clot once it left the body
Technology to store blood and prevent clotting still needed to be overcome
Tuberculosis could also be detected as a shadow on the lungs when X-rayed
Drawbacks
Wounded person had to remain still for a long time. Difficult when they were in pain
Glass tubes in the X-ray often overheated. Machines could not be in continuous use
1915
American doctor Richard Lewisohn discovers that adding sodium citrate could stop blood clotting
Impact
Richard Weil found that blood could be stored longer when refrigerated
Lawrence Bruce Robertson pioneered use of indirect transfusion - transfusing blood before surgery
Impact
Improved chances of patient surviving surgery
Impact
Larger volumes could be stored allowing for transfusions on a greater scale
Blood could now be stored and ready to use in emergency
1916
Francis Rous & James Turner found that adding glucose citrate increased the time blood could be stored (4 weeks max).
Impact
Stores of blood could be built up before a battle, increasing chance of survival for injured soldiers
1915
X-rays caused burns. Dangers of radiation were not fully understood then
1917
The Thomas splint
Broken bones had a tendency to break through the skin when broken, creating a wound.
Robert Jones develops on idea by his uncle Hugh Thomas on keeping the leg still
1917: Carrel-Dakin method of using sterilised salt solution in the wound through a tube was discovered to be the most effective alternative to carbolic lotion.
Survival rate improved from 20% - 82%
Prosthetic limbs
Over 240,000 soldiers lost a limb.
Prostheses became more advanced: lighter alloys and advanced mechanisms.
Drawbacks
Prosthetics took time to make, lead to long waiting list
Brain surgery
Little surgery on the brain pre-WWI
Harvey Cushing (USA) experimented with the use of magnets to draw out pieces of metal from the wound
Using local anaesthetic was also found to be better than general anaesthetic since general caused the brain to swell.
The NHS:
Early 20th century: New laws had been passed that gave the government a role in keeping individuals healthy.
1939: Emergency Medical Service created tto help co-ordinate hospitals and healthcare
Beveridge's report identified 5 key problems, named the 'Giant Evils:'
Want - Problems of poverty and not having enough money or food
Disease
Ignorance - Lack of education, meaning people were unlikely to get better jobs or to develop a better understanding of society
Squalor - Living in dirty and unhygienic conditions
Idleness - Unemployment, meaning people were more likely to become depressed and possibly turn to alcoholism or crime
The Welfare State
1945: at the end of the war, the labour government was elected. PM Clement Attlee announced that a welfare state would be set up to ensure everyone had an acceptable standard of living
Welfare system would be funded by National Insurance contributions (founded 1911 by Lloyd George
1946: The National Insurance Act provided old age pensions, maternity benefits and payments to sick and unemployed.
What caused the setting up of the NHS?
After seeing how evacuated children ended up growing up in poverty, there was a new need to improve the quality of life
People were more willing to have the government involved in their everyday lives
Significant medical breakthroughs meant more could be done for the sick
WWII showed the need for hospitals and medical staff to be organised
1946: National Health Service Act officially introduces the NHS which combined all aspects of medicine and care into one organisation.
Opposition to the NHS
Beveridge's report first proposes the idea of the NHS
Minister for health Aneurin Bevan did the actual work of setting up the NHS.
Doctors didn't like the idea of being controlled by the NHS. They preferred running their own private clinics. A survey showed that 40,000 medical practitioners disapproved of the NHS Act. Fewer than 5,000 agreed to it.
Doctors' main source of income was from private patient fees. Doctors were afraid to lose money because they couldn't control their own fees
Bevan eventually agreed to pay practitioners according the number of patients they saw
GPs were also given the choice to work privately or for the NHS
1948: 90% of doctors enrolled in the NHS
Impact
Previously, most women & children were not protected by the 1911 National Insurance System. The NHS made people more willing to visit the doctors as they didn't have to worry about the financial aspect.
Further developments in surgery, medicine and prevention increased life expectancy dramatically in late 20th century.
The role of women
Florence Nightingale
Elizabeth Garrett
Others
First female physician in UK
Influenced by meetings with Elizabeth Blackwell (first female physician to receive a degree in the US)
Denied entry to medical schools
Number of schools refused to train her
Decided to train as a nurse in Middlesex Hospital
Tried to go to lectures for male doctors but was banned after complaints
Enrolled to train as a doctor at Society of Apothecaries
1865: Passed her exams and received certificate to practice medicine
Society of Apothecaries banned women after
Practising medicine
1866: Set up a dispensary for women
1870: Started visiting patients at East London Hospital
Gaining a degree
Studied at University of Paris
Gained degree but British Medical Register refused to recognise her qualification
Changes for other women
1872: Garrett established the New Hospital for Women in London
1883: Became Dean of London School of Medicine of Women
The 4 humours
Miasma
Spontaneous Generation
Disease was carried by unpleasant smells and harmful fumes in the air
developed based on what Ancient Greeks could see (symptoms)
Idea that rotting material created maggots, then fleas, then disease
Doctors'' knowledge
Understanding of the body was also limited
People understood that there was a higher rate of disease in dirty, unhygienic places.
Doctors would observe the body through a few dissections during training but they weren't common
Scientists at the time knew microorganisms existed but little research had been done on them
The 4 humours: Blood, Yellow bile, Black bile, Phlegm
Believed that disease was caused by imbalance in these humours. Treatments were based on theory of opposites
This made it difficult to do any thorough research pm the syptoms of disease
Pasteur & Germ Theory
1854: Pasteur was asked to investigate why beer was turning sour
He found that the beer contained microorganisms
According to the theory of spontaneous generation, microorganisms should have only appeared while the mixture was decaying. Pasteur didn't believe this
He suggested that microorganisms were the ones that were making the beer go sour
Theory was proved when he discovered that the microorganisms could be killed by heating the liquid. If this was done, the beer did not go sour
Further experiments showed that mixtures turned bad when left in the open air, showing that microorganisms were carried in the air.
Different samples were collected from different locations. He found that air was 'cleaner' in mountains than in cities as they contained less micro organisms. This showed that microorganisms weren't evenly distributed
1861: Pasteur publishes his experiments on Germ Theory
1878: Officially publishes 'Germ Theory and its Applications to Medicine' after he made the link between germ theory and disease
Problems with Germ Theory
Hundreds of microorganisms could still be seen in the body of a healthy person: GT couldn't explain why some caused disease and others didn't.
People were still unsure how Germ Theory could help medicine: GT couldn't explain how the knowledge of how diseases spread could help cure the disease
The London Sewer System
1858: 'The Great Stink' exposed the rubbish and excrement that had accumulated on the river banks of the Thames. MPs decided whether their meetings should be held in a different location but later realised that action needed to be taken
The Broad Street Pump
1849: John Snow (Chloroform inhaler guy) suggested that Cholera was being spread by polluted water
1854: Another Cholera outbreak
Snow investigated the outbreak in Soho, London and found that most of the deaths centred around a pump on Broad Street
Handle was removed from the pump and deaths from Cholera stopped
Later found that there was a crack in the brick wall lining the cesspool which leaked into the Broad Street Pump
Effects
Snow had proved the relationship between Cholera and infected water
This put pressure on the water companies, local authorities and parliament to improve water supplies
Despite new understanding about polluted water, little had been done to improve public health until 1858...
18 days later, an Act provided £3 million to the London Metropolitan Board of Works to improve the sewage system
Chief engineer Joseph Bazalgette put in charge
Bazzalgette's ideas
Design of sewers: Large, oval & made out of brick as sewage was less likely to get stuck in oval tunnels
Move the exit further down: Waste should be brought down to the lower stretches of the Thames so sewage would be washed out to the sea
Role of Authorities
Work of Snow and Chadwick highlighted the importance of access to clean water and removal of sewage
Government was previously 'laissez-faire' and only stepped in during serious events like Cholera epidemics
1866: Sanitary Act forced all towns to employ inspectors to check on water supplies and drainage
Local governments began to take more action to improve public health
Examples:
Local council in Manchester made regulations about size of rooms and size of windows to ensure that sufficient light and ventilation entered
Joseph Chamberlain, mayor of Birmingham, improved water supplies and demolished slums
Pasteur's effect on Authorities
People began to accept that disease could be passed through polluted water
Access to clean water, the removal of sewage and improve hygiene could help improve public health
Several town councils took action and government passed laws to standardise the improvements
Changing attitudes and increased voting rights put pressure on the government to get more involved with public health
Koch & Anthrax
Anthrax was a disease in farm animals that was spread through infected blood
Koch was interested in Pasteur's ideas and wanted to prove that the anthrax microorganism was the one that caused the disease Anthrax
1876: Koch discovered the anthrax microorganism caused Anthrax and published his work
He developed methods of staining and photographing microorganisms
1878: Published his work on bacterial infections of wounds
Significance of Koch's work
Fleming & Penicillin
Showed that his lab test techniques could be used to investigate a number of diseases and could lead to new ways of preventing disease
Though he was a doctor, he focused on the cause rather than treating the symptoms of the disease. Investigated microorganisms in lab tests
Pasteur & Cholera
Pasteur & his scientists studied chicken cholera by injecting chickens with a culture of the bacteria
Koch was moved to Berlin where he received funding from the government and developed a team of researches
When Pasteur's assistant went on holiday, a culture of the bacteria was left on the side and not used until a few weeks later
The chickens injected with this culture didn't develop chicken cholera
They were then injected with a fresh culture, but they still didn't catch cholera
They realised that the bacteria had been weakened while it had been left out. So the chicken knew how to fight the Cholera.
This provided understanding on how to use vaccines in the future
Pasteur & Anthrax vaccine
1881: Pasteur combined Koch's work with his own to prove that anthrax vaccination could be used to protect animals
After a while, animals that didn't get the vaccine all died and 4 cows were feverish
Pasteur began working on a vaccine against rabies
1885: 9-year-old Joseph Meister was brought to Pasteur after being bitten by a rabid dog.
Though it was still in its experimental stage, Pasteur used the vaccine on Joseph and he was saved
Kock & Bacteriology
Koch wanted to be able to identify specific microorganisms that caused particular diseases
He tested different microorganisms and created different cultures
He then injected these cultures into animals to see what diseases they would develop.
1882: Microorganisms for tuberculosis identified
1883: Microorganism for cholera identified
Developed idea of using industrial chemical dyes to stain microorganisms. This made they easier to study under the microscope
Developed idea of using industrial chemical dyes to stain microorganisms. This made they easier to study under the microscope
Identified microorganisms responsible for tuberculosis and cholera
Developed the use of agar jelly to grow cultures
Effect
Study of bacteria grew and became a separate branch of science called 'Bacteriology'
Koch became known as the 'father of bacteriology' because his unique methods and discoveries became the starting point for further discoveries
Mary Curie & Radiation
1891: Moved to Paris and married physicist, Pierre Curie
Henri Becquerel discovered radioactivity. Marie and Pierre began to work together on radioactive material.
1898: They announced the discovery of Polonium and Radium
1903: Becquerel and Curies awarded Nobel Prize for Physics due to their work on radiation
1910: Radium Institute was created for Marie Curie in the University of Paris so she could continue researching on radium
Curie led research into using radioactivity to shrink or kill tumours
How it works
Radium is placed as close to the tumour as possible then inserted into the tumour itself
Curie didn't patent her work so doctors could freely use it
Doctors experimented with the use of radioactivity to treat epilepsy and acne
1911: Curie is awarded Nobel Prize for Chemistry
Marie Curie and Mobile X-rays
Marie used her own money to equip ambulances with X-ray equipment
Effects
Injured soldiers could be X-rayed and operated as soon as possible
International Red Cross made Curie head of its Radiological Service.
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