Changes in Medicine - IGCSE History

Causes of disease 1848 - Four Humours

Causes of disease 1848 - Four Humours

-The idea that disease was caused by an imbalance of the bodys humours (Plegm, blood, yellow bile, black bile). Treatments were based on the theory of opposites.

What was the theory of opposites?

-The idea that if your illness was caused by too much of one humour, the balance of your humours could be restored by eating or drinking something with the opposite qualities

Causes of disease 1848 - Miasma Theory

-The idea that disease was carried in unpleasant smells and harmful fumes in the air. People understood that there was often a high rate of disease in poor, unhygienic conditions, and disease tended to spread more quickly in hot weather. This made miasma logical - bad smells which were worse in summer were linked with disease.

Causes of disease 1848 - Spontaneous Generation

-This was the theory that rotting material such as food remains, excrement, dead animals etc. created maggots, fleas and disease

Why was there a limited understanding of the body?

-At the time, doctors would observe a few dissections during their training but due to religion, most wanted to be buried. The bodies doctors used were mainly those of criminals who had been executed, so it was difficult to analyse any symptoms of disease such as arthritis.

Factors affecting progress - Technology

The lack of understanding was closely linked with the level of technology available at the time. If microscopes had been stronger, perhaps scientists would have been more curious about germs.

Factors affecting progress - Funding

The issue of funding for research and development of new ideas limited progress. The government did not feel responsible for issues like this and hospitals usually relied on charity for funding. This meant that little money was left over for research.

Factors affecting progress - Attitude

Many doctors didn't want to have to learn new ways of treating patients. Also there was no proof that their methods were wrong so they continued with this.

Florence nightingale's background

Wealthy middle class background.
Her family was shocked that she wanted to work, let alone be a nurse as it was considered a very low status job.
There was no formal training for nurses in Britain at the time, so she spent time in various hospitals in Britain during the 1840's.

Conditions at Scutari

-Overcrowding-sharing beds or lying on floors
-Clothes ingested with lice and fleas
-Diseases-cholera and typhoid fever were common
-Many patients had diarrhoea
-Medical supplies were limited
-Food was limited and of poor quality
-Dirty wards infested with rats and mice
-Hospital was built in the site of an underground cesspool, where human waste was collected. This affected the water supply and the air in the hospital

Nightingales actions are Scutari

-Cleaned all sheets, towels, bandages and equipment
-Believed In miasma so kept windows open to improve air flow
-Cleaned kitchens and improved food quality
-A fund of money meant that she could buy new supplies like towels, plates and cutlery

Reaction to nightingales prior to changes

-Army medical staff had resisted the idea of nurses coming out to work in the Crimea as they felt women would not be able to cope with the conditions there. They also felt that women's medical knowledge was limited. When nightingale arrived, they resented and criticised her.

Reaction to Nightingale's work in Scutari

-Her habit of making a final round at night, checking all the patients etc gained her the nickname of 'The lady with the Lamp' and made her very popular with the patients and back in Britain.

Death rate at Nightingales hospital

The death rate at nightingales hospital was higher than at the other hospitals, even with her improvements. It was not until 1855, when a government sanitary commission repaired the drains and improved the supply of drinking water, that the death rate began to fall dramatically.

Conditions of surgery in the 1840's

Medical training for doctors took 4 years. Surgical operations such as cutting open a boil or cutting out a tumour or amputation.

The problem of Pain

Pain was a major issue in surgery, and before 1840's, the only types of pain relief available were alcohol, a form of opium, or being knocked unconscious. In most operations the patient was hysterical so had to be held down by surgeons, assistants or dressers. The best surgeon was not the most skilful but the one who cut the quickest.

The problem of Blood loss

Blood loss was an issue so a tourniquet (something wrapped tightly around limb to reduce blood flow) was used to restrict blood flow in the artery.

The problem of infection

-Even if the patient survived the operation, they often died due to infection, which there was little understanding of at the time
-Surgeons often wore old clothes stained with blood and pus and would rarely wash hands
-Equipment was wiped between patients though not sterilised, bandages were reused
-Lots of people in the operating theatre such as surgeons, assistants and viewers like students made infection even more likely

Use of nitrous oxide

-Nitrous oxide (laughing gas) was known to make people unaware of pain when full conscious, and it was used in dentistry in the USA in 1844-5 by Horace Wells, but wasn't considered suitable for surgical operations. Then, William Morton, a US dentist experimented with the gas ether and found it had a stronger effect

Use of ether

-Robert Liston in UK heard about Mortons work and later in 1846 used ether in an amputation of a leg. He was astonished the patient didn't need to be held down and was completely unaware the operation took place.

Problems of ether

-Although a seemingly great form of pain relief, it had issues. Ether sometimes caused vomiting and it irritated the lungs, making the patient cough. It could also leave the patient asleep for hours or days. The gas was also highly flammable which was dangerous when the operating theatre was lit by candles

Chloroform

-James Simpson wanted to find a better anaesthetic, and after various experiments inhaling gases, he discovered chloroform was an effective anaesthetic.

It didn't seem to have the same side effects of ether and Simpson often used it in childbirth.

Why did Chloroform become more popular?

-Simpson soon became physician to the Queen Victoria in Scotland and she had chloroform when having a child in 1853. Partly due to the newspaper publicity about this miracle pain relief and partly due to royal approval, patients began asking for chloroform in their operations and it became much more widely used.

Impact of chloroform-problems

-Christian church was opposed to its use in childbirth

-Many doctors were opposed to it in childbirth as they didn't know how it would affect the baby

-It was difficult to get the dosage right

-Some doctors felt that a patient who was unconscious was more likely to die than one who was awake

-By using chloroform, some surgeons felt more confident to attempt longer more complicated surgeries, often deeper inside the body. This greatly increased risk of infection.

Chloroform inhaler

-In 1848, John Snow invented the chloroform inhaler, which controlled the dosage of chloroform.

Problem of infection

-Chloroform gave surgeons time to work, so they could conduct more complicated surgeries deeper in the body. However due to lack of understanding of infection, dirty hands and equipment caused infection in the body. Many patients developed gangrene around the wound, which often developed into sepsis until the patient died.
-The increased length of surgery also meant if blood supply to a body area was cut off too long, risk of gangrene increased

Industrial Revolution

Changes in farming and the rapid development of factories caused many workers to move to new industrial towns in the early 19th century. Houses were very poor quality as they were built quickly, and landlords felt workers only needed basic homes and they also knew factory workers had low wages so could only pay small amounts of rent

Living conditions

-Back to back housing
-Overcrowding
-Dampness and little light or ventilation
-Polluted water sourced from rivers

Killer diseases

There were many killer diseases in the UK at this time. Although a vaccine had been made to prevent smallpox, few people had been vaccinated.
-There was no prevention for typhus, typhoid fever or influenza. Many patients who survived these were so weak that they died if they caught another disease like pnuemonia

Cholera

-This was a water born disease which killed very quickly, and the symptoms involved general pain and muscles spasms together with vomiting and diarrhoea, until death was caused by dehydration. Approximately 20,000 had died in the epidemic of 1831-32

Dealing with cholera

-When there was an outbreak in 1848, matters were left to local authorities who adopted measures based on the ideas of miasma. Miasma made it seem that cholera would mainly affect the poor, who lived in very unhygienic conditions.

Edwin Chadwick

-Chadwick had been involved with workhouses which were funded by local taxes.

-In 1942, Chadwick published 'The Sanitary Conditions of the labouring population' in which he suggested that it would be better to spend tax money on improving housing and living conditions and keeping the poor healthy. This would mean they wouldn't become too ill due to bad conditions.

-His recommendations had included providing clean water and removing rubbish and sewage

Support for Chadwick's ideas

At first, Chadwick's ideas had little support. As the cholera epidemic worsened, more people became eager to help as it also affected the middle and upper classes.

1848 Public health act

-Set up a general board of health
-Allowed towns to set up their own board of health, employ a medical officer, organise rubbish removal and build a sewer system.
-Appointed 3 commissioners for the board of health, one was Chadwick.

Impact of the Public health act 1848

-The impact of the act was very limited. One issue was the terms of the act were temporary; The board of health was only set up for 5 years and ended in 1854. Also, the act allowed local authorities to improve hygiene but did not force them to do so, so many local authorities took no action. Another issue was that Chadwick was a difficult person who was often arrogant and aggressive, so many were reluctant to accept his ideas.

John snow and the Broad street pump

-John snow used an outbreak of cholera in 1854 to prove his belief that cholera was spread by polluted water. His work demonstrated the link between cholera and infected water, and this put pressure on local water companies, authorities and parliament to improve water supplies. Very little was done however to improve public health until 1858.

The great stink

-In the summer of 1858, the river Thames in London began to dry up, leaving rubbish and excrement along river banks. Mp's passed an act to provide money for a new sewer system; Joseph Bazalgette was chosen to design it. However the most significant improvements in public health did not happen until after Pasteur developed his germ theory.

Who was Pasteur?

Louis Pasteur was a French research chemist, and in 1854 was asked to investigate why beer was turning sour. Due to advancements in technology, he discovered by microscopes the beer contained microorganisms. According to spontaneous generation, these microbes were created as the beer decayed. Pasteur didn't believe this, he thought the microbes were affecting the beer and making it sour. He proved his theory when he discovered these microbes could be killed by heating which if done, the beer didn't go sour.

Pasteur's further tests

Pasteur also carried out tests on milk, wine and vinegar and believed microbes floated in the air.

Pasteur germ theory -1861

-Air contains living microorganisms
-Microorganisms in the air cause decay
-Microorganisms can be killed by heating them
-Microorganisms are not evenly distributed in the air
-His ideas were often resisted and ridiculed but gradually over time they became accepted

Germ theory and medicine

-It wasn't until 1978 when he published 'Germ theory and its application to medicine' and even then, his ideas were not fully accepted.
-It was not clear how germ theory could help medicine, and didn't show how this knowledge could be used to cure disease.

Germ theory's impact on public health

-The germ theory helped explain the link between hygiene and health.

Joseph Lister

-Professor of surgery at Glasgow University
-Then in 1861 became surgeon at Glasgow Royal Infirmary, and as leader of the new building, hoped deaths could be reduced if there was greater emphasis on hygeine therefore less infection.

Lister - Carbolic acid

-He read Pasteur's work, and when he was told carbolic acid was used at the Carlisle sewage works to treat sewage, he realised the acid was killing the microorganisms responsible for the decay and smell. He also realised the smell of wounds was similar to that of sewage. This made him wonder if it could be used to prevent infection

Lister-young boy

-In one case an 11 year old boy was brought in with a broken leg. The treatment would have been amputation, but Lister set the broken bone and covered the wound in bandages soaked in carbolic acid. The wound healed without infection

Lister-antiseptic

-He began to use carbolic acid to clean wounds, eqipment and bandages in all operations, and the death rate from infection dropped dramatically. This method was called antiseptic.

Antiseptic definition

-Something that will fight the infection by killing the microorganisms

Carbolic spray

-Lister also developed a carbolic spray to ensure there was no microorganisms in a surgeons hands or equipments that could enter the open wound

Opposition to Lister's ideas

-The spray made equipment slippery and hard to grip, which slowed down the operation
-The spray made the surgeons hands cracked and sore
-Many doctors didn't accept Pasteur's germ theory as they saw no need for antiseptic techniques
-Some doctors who tried the techniques didn't do them properly so they weren't effective
-Many nurses were irritated by the extra time and work involved in treating wounds
-Many doctors had simple techniques including soap and water, and saw no need for new techniques

Little progress in Public health

-By 1960 there was little progress in public health because councils weren't forced to do so

London sewer system

-John Snow's work on cholera and the great stink in 1858 convinced the government that the sewer system in london needed to be improved. £3 million was given to the London Metropoliton Board of works, and Bazalgette was the chief engineer

Features of the london sewer system

-Very large oval brick sewers instead of small narrow round pipes. Sewage was less likely to get stuck in oval tunnels
-The whole system was planned to bring waste down to the lower stretches of the Thames, where the river was tidal and the sewage would be washed out to seam

Laissez-faire

Policy that government should interfere as little as possible in the nation's economy. People didn't want the government to take action if it meant taxes increased

Changing attitudes

As the work of Pasteur became known, people began accepting that disease could be passed through polluted water, and access to clean water, the removal of rubbish and sewage etc would improve public health. Although several towns took action, the government would need to pass laws to create a national system of improvements. Also, as people gained the right to vote, there was more pressure on parliament to get involved.

The 1875 public health act made local authorities responsible for:

-Dealing with sewage in a way that would prevent polluting washing and drinking water
-Building public toilets
-Ensuring that new housing was built to good standards to avoid problems of dampness and overcrowding
-Inspecting conditions in lodging houses
-Employing Health and sanitary inspectors
-Creating street lighting to prevent accidents
-Checking the quality of food on sale

Impact of the act

-The act was hugely significant in showing how the attitudes of laissez faire was changing and parliament was now passing laws to enforce a national standard of public health
-It also showed the way the national government in London had to rely on local authorities in towns to implement parliaments orders.

Progress in hospitals

-So far, there was little progress in public health and the prevention of infectious diseases during most of this period. At the same time, the lack of understanding of causes of disease meant there was little progress in the treatment of disease or the care offered in hospitals

Hospitals

-Small organisations relying on charity for funding
-Only admit a few patients so patints had to get a letter of recommendation from a respected individual
-Cottage hospitals established in 1860-12 bed
-Infirmaries were larger
-Standard of care in hospitals was low

Florence Nightingale

Her work in Crimea made her famous, and when she returned to UK in 1856, she was regarded as an expert in nursing
-In her book 'Notes on Hospitals' she stated recommendations about space, ventilation and cleanliness
-Her ideas made hospitals more hygienic and reduced infection

Training for nurses

-Her book 'Notes on Nursing' in 1859 gave advice on ventilation. light, bedding, cleanliness for patients, and also nurses personal cleanliness
-In 1860, she established Nightingales school for the training of nurses
-She wrote over 200 books on hospital design and nursing

Traditional attitudes towards women

-Throughout history, women were responsible for daily care of the sick within the home
-Few women became doctors due to their perceived lack of intelligence and education
-They were expected to stay home and support their husband, not go to university or have any form of higher education

Nightingale-role of women

-Nightingale made it acceptable for women to train as nurses, though people thought women could not cope with the unpleasant aspects of medical training, and the desire to train as a female doctor was unnatural

Suffragists

Those who were active in seeking voting rights for women as an inherent right for all individuals in the nineteenth and early twentieth centuries.

Elizabeth Blackwell

First women to qualify as a doctor in US
-Inspired Elizabeth Garret anderson at a lecture, who came from a wealthy family who were horrified at the idea of her training as a doctor. She applied to study medicine at seceral schools but they all refused due to her being female. She paid for private lessons

Steps to qualifying as a doctor

-Complete a university medical degree
-Pass examinations
-Be accepted by one of the three medical societies
-Be listed on the medical register

Garret

-Completed a course in medical training but couldn't be accepted by a society
-Her father threatened to sue the society of apothecaries, thus she was accepted, and qualified as doctor in 1865

Garrets achievements

-1866 opened a medical dispensary in london for women
-1972 dispensary opened 10 bed ward staffed entirely by women
-Became member of British medical association
-First female mayor in England

Robert Koch

-German doctor interested in Pasteur's ideas
-He didn't focus on symptoms of disease in humans, though instead investigated microorganisms in lab tests

Pasteur and chicken cholera

-He and his team was studying chicken cholera by injecting chickens with a culture of bacteria. When his assistant went on holiday, a culture of bateria was left on the side and wasn't used until weeks later. The chickens inkected with this culture did not develop cholera, so they were injected with a fresh culture, though still didn;t get it.

Pasteur and chicken cholera

-They realised the first batch had been weakened by the delay of using it, and by injecting this weakened version, the chickens natural defenses were stimulated so it could fight against the fresh culture. This paved the way for further research to develop vaccinations against other diseases

Pasteur's anthrax vaccine

In 1881, Pasteur combined Koch's work with his own to prove that an anthrax vaccination could be used to protect sheep and cows. He wanted to investigate vaccines from human diseases but he could not carry out experiments on people.

Koch and bacteriology

Koch investigated human diseases to see if he could identify specific microorganisms. Koch identified that the microorganisms for TB in 18822 and cholera in 1883.
Koch developed the use of agar jelly for growing cultures in a Petri dish and also experimented with different coloured dies.
'father of bacteriology'.

The impact of Lister's antiseptic techniques

Doctors weren't convinced of his ideas.
The germ theory and Lister's antiseptic techniques were slowly becoming accepted, especially after Koch identified the microorganism causing blood poisoning in 1878. Lister's carbolic spray made operations difficult.

Aseptic surgery

Operations were carried out in clean operating theatres without spectators. In addition, surgeons wore clean clothes, put masks over their mouths and wore rubber gloves to prevent microorganisms entering the wound.

Blood loss

Hard to stop as surgeries got loner and more complicated

Catgut

Made from sheep intestines. which are emptied and used like threads or thin fibres.

Pain relief - cocaine

Cocaine was used but it was not very suitable as it was addictive. In 1884 it was found that it could be used as a local anaesthetic. In 1905 a safer version called novocaine was developed.

The Impact of the 1875 Public Health Act

1) Ensuring sewage was properly treated and could not contaminate the water supply reduced the chance of passing on a disease.
2) Providing clean water meant there was less chance of disease.
3) Keeping the streets clean reduced the number of rats carrying disease.
4) Lighting streets meant that people could avoid rubbish.
5) Local authorities appointed a Medical Officer.
6) Inspecting houses ensured that there was sufficient light and ventilation to be healthy. Slum houses could be ruined.
7) Inspecting the food quality for sale reduced chance of infection.
8) It was made illegal for factories to dump their waste in rivers.

Artisans' Dwellings Act

1875
Gave local authorities the power to buy and demolish slum housing.

The Food and Drugs Act

1875
Tried to improve the standard of food being sold. At this point, many dangerous practices were common, for example, butchers would often paint their meat red so that it appeared fresh.

River Pollution Prevention Act

1876
Made it illegal for factories to put their waste, including chemicals, into rivers.

Infectious Disease (Notification) Act

1889
Ordered householders or doctors in London to report any cases of infectious disease to the local Medical Health Officer. This law was extended to the rest of the country in 1899. This also led to new isolation hospitals being built.

The Park Hospital in London

Was opened in 1897
This was one of the five new hospitals built to cope with causes of infectious disease in London. It had 48 wards for up to 368 patients with scarlet fever, and 24 wards for up to 120 patients with diptheria and fever. There were also isolation wards where there was a large distance between patients.

Factors affecting Public Health

The government had a major impact on the public health in the years 1875-1905 because it passed a number of laws which made changes in hygiene and living standards.
The role of science and technology was crucial. New understanding about microorganisms and how disease spread showed the importance of improved hygiene.
New understanding showed it was necessary to isolate patients.

What did Karl Landsteiner discover?

1901
He discovered that there were different blood types; A, B and O.
In 1902, he discovered a fourth blood type AB.
Doctors realised that patients could die if they were given the wrong type of blood.
In 1907 - It was discovered that type O could be given to anyone safely.

Blood donor problem

The main problem was that the blood donor had to be present in order for the transfusion to be carried out and it was not always possible to find a donor of the right blood type.
Blood starts to clot as soon as it leaves the body so the tubes used in transfusion could also become blocked.

Improvements in scientific knowledge

Koch's use of agar jelly to grow cultures of bacteria, and his use of chemical dyes to stain bacteria, made it much easier to study microorganisms.
However, there were no treatments were available yet.

What was Dipheria?

Caused by microorganisms in milk. Nowadays, these microorganisms are killed when milk is pasteurised. In the 19th century. Dipheria killed 8,000 children each year.
1890 - Dipheria was cured due to antitoxins.

Paul Ehrlich and the first magic bullet

Discovered the magic bullet - a treatment that would kill the disease- carrying microorganisms without affecting other cells in the body.
If left untreated the disease syphilis affects the brain and can lead to a stroke, dementia, vision problems and heart problems.
In 1905, Ehrlich tried to discover another magic bullet which would treat syphilis without affecting other cells in the body.

The Development of X-Rays

1895 - Rontgen found that the photographic plate showed an image of a hand, with the bones and wedding ring showing clearly.
Rontgen published his findings but he did not take out a patent. As early as 1896, many hospitals including the London Royal Hospital, had an X ray machine.

How did X rays help diagnose diseases?

Doctors found X rays useful to diagnose diseases. Tb showed up as a shadow on the lungs if the patients X ray was looked at.
Bone tumours could also be seen.

Impact of Marie Curie

Mare did not patent her work which meant that other people could use it freely.
Doctors experimented with the use of radioactivity, for example, testing it as a treatment for epilepsy and acne. Dangerous side effects were noted, but its benefits in cancer cases were clear. The importance of Curie's work was recognised and awarded as a Nobel Prize in 1911.

Marie Curie and Mobile X Rays

During WW1, Curie used her own money to help to equip ambulances with X ray equipment. She even drove ambulances to the front lines herself. It meant that injured soldiers could be X rayed and operated on as soon as possible.
The Red Cross made Curie head of its Radiological Service and she ran training courses to teach medical assistants and doctors about the new techniques.

1906: Free school meals

The government paid half the cost of providing free school meals and the number of meals increased from 3 million in 1906 to 14 million in 1914.
Children would have warm food and good nutrition, making them healthier and less likely to become ill.

1906: Board of Education leaflet on hygiene.

This explained the importance of washing regularly, brushing teeth, changing clothes and washing clothes regularly.
Good hygiene helps to prevent the spread of diseases passed on through personal contact.

1907: School Medical Service set up.

Children would be inspected at school for signs of infectious disease or conditions such as ringworm or lice.
Health Visitors would visit home.
If a health problem was found, unfortunately some families often couldn't pay for treatment.

1908: Old age pensions introduced.

People over the age of 70 who earned less than £31.50 per year would receive 25p.
Made sure that older people who couldn't work had a standard of living and were not in poverty. It wasn't given to alcoholics or if they had been in prison in the previous ten years.

1908: Children and Young Persons Act.

It became illegal to sell a child alcohol or tobacco.
It was also illegal to send a child out begging or to neglect a child.
Helped children to not become imprisoned and also to keep them off the streets.

1909: Labour Exchanges set up.

Jobs were advertised so that unemployed people could look for work.
Made sure that if people had a regular wage, they, and their families, were more likely to be able to eat properly and live in decent accommodation.

1911: National Insurance Act.

Workers, employers and the government all paid into a fund that could be used to provide healthcare for workers who became sick; additional payments could also be made to provide unemployment and maternity benefits.