Medicine Through Time notes copy.docx

History

Medicine Through Time

Topic 1

Medicine in Medieval England c. 1250-1500

Understanding of the causes of disease

Religious

Vast majority of people in England followed teaching of Catholic Church – they received most of their teaching from the Church (the Church controlled education) due to the lack of formal education

Attended services regularly

Were expected to give a tithe each month

Sin would be punished by God via disease

The Devil could send disease to test someone’s faith

God may send illness to cleanse the soul

If recovery occurred, prayer was responsible

Religious explanations also fit the diseases of this period:

Leprosy – a painful skin disease where fingers and toes would fall off and painful ulcers appeared, follower by paralysis and eventually death. There was no cure, so lepers were banished

Leprosy was used to prove God’s existence as it was cruel and visible (to deter others), therefore sent as a punishment. However, some lepers recovered meaning God had spared them due to their prayer, creating hope.

Famine also fit this reasoning as it was seen to punish a community of sinners, therefore it was also logical to blame people’s illnesses on their sins

So, blaming sickness on God acted as a ‘proof of the divine’ due to the ‘miracles’ of recovery

A lack of scientific knowledge made people accept this reasoning as well as the fear associated with religion and sin, forcing people to accept this

Astrology / supernatural

The alignment of planets and stars was considered

Physicians consulted star charts as well as when patients were born and when they became ill to find a reason for their illness

Traditionally, the Church frowned upon astrology in diagnosing disease, as it seemed close to predicting the future or fortune telling

However, during the Black Death, astrology became more popular and the Church became more acceptant of it

Theory of the Four Humours

As the universe was made up of the four basic elements – fire, water, earth and air – the body mist also be made up of four humours, which were all created by digesting foods

The Four Humours were:

• Blood – linked with air & spring
• Phlegm – linked with water & winter
• Black bile – linked with earth & autumn
• Yellow bile (choler) – linked with fire & summer

All of the humours had to be balanced and equal otherwise you became ill

Maintaining this balance was seen to be very important in preserving good health, however, age, family traits, star signs and the season of birth could make certain humours stronger.

They were also often linked to personality traits – if a person was choleric, they were thought to be quick tempered and argumentative and whilst depression was blamed on an excess of black bile (melancholic)

It was used to explain any physical or mental illness

People suffering from a fever had a temperature, causing the skin to go hot and red as it was believed they had too much blood

A person suffering from a cold had too much phlegm

Astrology was considered an important part of the Theory of the Four Humours as the humours were connected with star signs and seasons and each has its own ruling planet

This theory was very detailed and could be used to explain many types of illnesses, making it very popular as it was also easy to understand

This theory was written about by the Ancient Greek Hippocrates and continued by Galen with the Theory of Opposites

Miasma

Belief that bad air (from swamps, corpses and rotting matter) could transmit disease as it was filled with harmful fumes

Smells and vapours were also associated with God – a clean, sweet-smelling home was a sign of spiritual cleanliness (incense was burnt in Churches to purify the air) whilst badly smelling homes suggested sin and corruption.

If a person was unwashed, others would avoid them in case they breathed in the bad miasma and contracted a disease – this was also why people avoided lepers, although they believed it was a punishment from God, they also believed it was contagious

Influence on ideas of the causes of disease

A lack of scientific understanding meant that new knowledge was limited

Physicians tries to make new discoveries fit into the old theories, rather than experimenting to explain the discoveries

The Church was important in maintaining the status quo so they did not want change to occur

The Church controlled medical learning – it chose which books were copies and distributed

They liked the Theory of the Four Humours as it fitted with their teachings, so promoted it and discouraged everyone from critiquing it

Classical thinkers (such as Hippocrates and Galen) – Church promoted their books

• Hippocrates’ father was a physician and Hippocrates trained at the Asclepion at Kos – Hippocrates was known as the ‘father of medicine’
• He left the Hippocratic Corpus, a collection of 70 works on medicine – written by around 19 of his students
• He started the Hippocratic Oath, which states that doctors must always act in their patient’s best interest, and keep their medical information confidential
• He applied logic and reason to medicine to develop his Four Humours idea. The mathematician Pythagoras and his supporters praised this
• He asked patient questions about their history, and checked their pulse. All his findings were recorded
• He was the first known chest surgeon
• He prescribed rest and natural recovery over drugs – he said ‘walking is the best medicine’
• Patients were treated in well-lit rooms, and care was taken over which medical tools to use and the position of the patient on the operating table
• He kept a hygienic environment, using clean water and wine on wounds. Bandaged were kept clean and he made sure than his fingernails were short and clean
• Galen was the ‘father of anatomy,’ he has a great reputation as he was the Emperor’s doctor.
• Religion hindered his progress as he could not dissect bodies but it also stopped people discrediting him
• Galen’s ideas were promoted by the Church due to his belief in the soul

The Articella (one of the main books read by physicians included works of Hippocrates and Galen as well as other classical thinkers

Science and Technology

Printing Press – invented 1440 by Johannes Gutenberg

Led to increased ability and speed to share medical texts and new ideas

However, it did not have a great impact during the Medieval Period

Attitudes in Society

Strong belief in God – fear of criticising the Church

Physicians who did not follow old theories struggled to find work – Henri de Mondeville questioned old ways but still practiced medicine in the same way as everyone else

Treatments

Religious and supernatural treatments:

• Healing prayers and incantations
• Praying for a special mass to be held
• Fasting
• Touching holy relics
• Lighting a candle proportionally as tall as you
• Presenting an offering at a shrine
• Pilgrimages to the tombs of people with healing powers

The Church sometimes discouraged treatments as it may lessen your chances of getting to heaven

The Church also discouraged treatments such as chanting incantations or using charms or amulets

The King’s healing power

Widely believed that the king was able to heal illness – during the coronation, an oil was rubbed onto the monarch’s hands which was said to bring healing powers

Considered particularly effective for scrofula (type of tuberculosis)

Used as a way to demonstrate Divine Right of Kings

Edward I aimed to touch (to heal) 2,000 people per year

Astrology

Physicians used star charts for diagnosis and treatment

Treatments varied according to horoscope of patient

Alignment of planets checked when prescribing treatments

Stages of treatment:

• Herb gathering
• Bleeding
• Purging
• Operations
• Cutting of hair and nails

Humoural treatments

Each symptom was treated separately as each symptom represented a different humoural imbalance

Theory of Opposites – one humoural imbalance could be treated by changing the opposite

Blood letting (phlebotomy) – bad humours could be removed with blood (most common treatment)

Leeches – freshwater leeches kept hungry and placed on the skin

Use for people whose age or condition made bleeding dangerous

Cutting a vein – cutting a vein to blood (often taken from vein near elbow)

Use phlebotomy charts

Cupping – skin was pierced, blood drawn out by placing heated cup over cut to creat vacuum

Different areas treated different illnesses – back of neck helped eyes, bad breath, facial acne

Bathing – helped body draw in heat to dissolve blockages in the humours

Allowed body to stream out impurities and easy aching joints

Herbal remedies could be given this way

Common uses:

Bladder stones treated by bathing in mallow and violets, paralysis treated by boiling and bathing in fox and water

Remedies – herbal infusions to drink, sniff or bathe in

Common remedies:

• Aloe vera to improve digestion
• Blanc mangier made from chicken and almonds
• Theriaca - spice based mix containing up to 70 ingredients (Galen encouraged this to treat poison and snake bites)

Purging – purging digestive system to remove any leftover food

Believed humours were created because of food eaten

Done by giving an emetic, laxative or enema:

• Emetics consisted of strong and bitter herbs to induce vomiting
• Laxatives often consisted of mallow leaves stewed in ale and linseeds
• Clusters / enemas put into the body removing blockages (John of Arderne used water, honey, oil, wheat, soap and herbs to squirt into the patient’s anus)

Where you were treated

The Home

• Women administered the care, some of it herbal remedies, some making restorative foods, some just making the patient comfortable
• Women would be responsible for the garden to grow plants with healing qualities (such as marigolds and clover)
• Women may have been well respected from their healing skills – letters between Lady Margaret Paston and her husband, Sir John, in 1464 show neither trusted the doctors and would have been happier receiving treatment from her at home
• They would be responsible for ensuring the person is kept well-fed and warm
• Some may have performed minor surgeries and bleeding – little record

Hospitals

• A growth in numbers of hospitals in this era - by 1500, up to 1100 hospitals
• Many of them linked to the Church – 30% directly eg. in Bury St Edmunds, a place of pilgrimage had 6 hospitals
• Other hospitals tended to be funded by rich patrons (endowment – left money in will for setting up of a hospital), but as charity was linked to religion (charitable donations could help heal disease), these also tended to be run by monks / nuns
• Places of care rather than places of treatment
  People with infectious diseases or terminal illness often rejected
• Instead, a place of rest; recovery with prayer being important – Church believed God sent disease as a punishment for sin, so only prayers could cure it
  • Recovery served as proof of the divine and importance of prayer
• However, cleanliness was linked to godliness, so bedding was changed frequently and patients cleaned, helping hygiene and recovery
• Limited treatment – religious people forbidden from cutting into the body
• Patients who had a chance of recovery were able to see the altar and participate in church services from their beds to help with recovery

Who treated you

Women

• Most people were treated at home by a female family member
• Much of this care was caring for the patient and home remedies
• Women also acted as midwives (only women attended births)
• No cost – medical advice cost a lot: since the treatments were not guaranteed, most people were not willing to spend this money

Physicians

• New universities were set up that allowed for medical degrees (taking 7-10 years) – no religious sponsorship so foreign physicians without a connection to the Church were able to practice medicine
• Main role was to diagnose illness and recommend a treatment; the consultation would follow three stages
  • Looks at a sample of the patient’s urine, faeces and blood
  • Consult astrological charts under which the patient was born and time they fell sick
  • Based on this, and the humoural tendencies of the patient, a course of treatment would be recommended
• The less trained and lower paid professionals would then carry out the treatment (mainly as many physicians were clergymen, forbidden from carrying out certain procedures such as bleeding, from 1215 onwards, any operations involving cutting were also forbidden for clergymen)
• Very expensive (mainly due to the extent of the training) – royalty employed one full time, others paid for when needed

Apothecaries

• Mainly mixed herbal remedies – good knowledge of herbs and plants from studying manuals such as Materia Medica
• Usually had good knowledge or experience from family members
• Not considered as skilled or knowledgeable as physicians
• Did not prescribe treatments or medication
• Less expensive than physicians so many would see them as an alternative
• Also prescribed poison, going against an idea of physicians of doing no harm (Hippocratic Oath) – apothecaries were not bound by this oath
• No formal training needed
• Some also used alchemy and the supernatural, such as providing amulets and charms – frowned upon by the Church (divide became wider – physicians were often priests)

Surgeons

• Barber surgeons – least qualified medical professionals (barbers who performed surgeries as well as they had a steady hand)
  • Performed surgeries such a as pulling teeth and bleeding patients
• Some surgeons were highly trained – encouraged to study surgery alongside medicine in university
  • Could set a broken limb, remove an arrow or remove cataracts
• Usually based on experience rather than knowledge from a book
• Only small operations as the wound could become infected

Henry, Prince of Wales was struck in the face by an arrow – recovered fully due to the treatment of a physician (General John Bradmore) who used honey, alcohol and a specifically designed surgical instrument to extract the arrow head

Prevention

Strong focus on prevention rather than treatment

The Church

Leading a life free from sin – regular prayers, confessions, offering tithes ensured any minor sins were forgiven

Regimen Sanitatis

Loose set of instructions provided by physicians to help maintain good health

Ideally, a physician would provide a regimen sanity’s specific to their patient but this was only done for the very rich

Took into account lifestyle and predominant humours

Common instructions:

• Exercise
• Diet
• Sleep
• Avoid stress
• Keep clean

Although sometimes also included:

• Stay on friendly terms with neighbours
• Avoid barking dogs
• Live away from the ground floor

First appeared in the work of Hippocrates where it was later picked up by Galen – advice was widespread by 1250

Bathing

Bad smells indicated a miasma – believed cleanliness was next to godliness

Only wealthy could afford a private bath of hot water, public baths (stewes) were available for free, poorer people swam in rivers

Although only the wealthy bathed regularly, everyone washed their hand before and after meals

Purifying the air

Attempted to keep the air free from miasma

Spread sweet herbs (such as lavender) – either carried as a bunch of flowers (posy) or inside a pomander (a large locket, worn around the waist)

Tried to keep homes smelling sweet:

• Floors swept regularly
• Rushes laid to soak up any mess
• Sweet smelling herbs spread with the rushes

Local authorities (under direction of magistrates or nobles) put in place measures to keep towns clean:

• No rotting animals left lying around
• Pulled down or cleaned public toilets

Diet

Since the humours were thought to be produced by digestion, when and what was eaten as important in preventing humoural imbalances

Eating too much was strongly discouraged – several medieval kings died of eating too much or having too rich a diet: Edward I died of dysentery

Case Study – the Black Death (1348-49)

Outbreak of the bubonic plague in 1348

Bacteria were carried in the digestive system of fleas on rats

Spread by flea bites (although may also be spread in air)

Main symptoms – buboes (swelling in the armpit or groin, filled with pus), fern sneezing and coughing blood, chest pains and breathing trouble

Usually killed people in 3-5 days

At its height in London, 200 people were being buried every day

Around 30-50% of the population of England died – numbers were only recovered in 1750

After this, the plague returned every 10-20 years although killed fewer people with each outbreak

Understanding of the causes

Religious

Many believed that it was the result of God deserting mankind

Also believed it was punishment for sin in the world

Supernatural

In 1345, there was an unusually positioning of the planets Mars, Jupiter and Saturn, which astrologers interpreted as a sign that something wonderful or terrible was to happen

Church began to accept this

Natural causes / scientific

Miasma corrupted the body’s humours

Believed that this miasma originated from poisonous fumes from an earthquake or volcano

Common beliefs

In Europe, many blamed the Jewish population, but they had been expelled in England in the 13^th century so was not the case in England

Treatments

Religious

Confession of sins and ask God for forgiveness through prayer

However, people also believed that once God had sent the disease to you, it was God’s will that the patient should die so there was no cure

Natural / scientific

Firstly, physicians attempted bleeding and purging to correct any humoural imbalance

However, it only seemed to make patients die more quickly

Recommended strong-smelling herbs such as aloe and myrrh which were believed to have cleansing properties

They also prescribed theriaca which was believed to work for many ailments

Lighting a fire and boiling vinegar could drive off bad air

Sometimes lanced the buboes - occasional, people whose buboes burst survived

Transference

Rub a chicken on buboes – would take away illness by giving it to the chicken

It became clear that neither physicians nor priests could cure the disease

Apothecaries sold remedies and herbs were mixed in the home, but they had uncertain and unpredictable results

The lack of medical knowledge of the causes meant it was impossible to know the cures

Prevention

Religious

The main advice given by priests:

• Pray to God
• Fast
• Go on a pilgrimage
• Make offerings to God
• Show God your repentance by self-flagellation (whipping yourself)
  • Large groups of flagellants wandered the streets of London, chanting and whipping themselves

Natural / scientific

Escaping the plague – Guy de Chauliac (the physician to the pope) advised people to ‘Go quickly, go far, and return slowly’ – it was essential to escape the miasma to stay healthy

Carry a posy of flowers or fragrant herbs and hold it to your nose – avoided breathing in miasma

Avoid bathing – believed that water would open up the skin’s pores to the corrupted air

Common beliefs

An Italian physician recommended doing joyful things – willing to suggest anything to prevent the disease

Many stopped visiting family who had caught the disease – common belief of needing to avoid those with the disease so avoided their houses as well

Government action

Local authorities (and king & counsellors) attempted to prevent the disease from spreading

• New quarantine laws – stopped people moving around too much
• People new to an area has to stay away from everyone for 40 days
• Authorities quarantined houses with the plague
• Considered banning preaching and religious processions to prevent large gatherings

However, as the local government did not have a great deal of power, they could not fully enforce the laws: rich people continued to move freely and the Church continued to run as normal

Due to the belief in miasma, the local authorities stopped cleaning streets – they believed that the foul stench would drive off the miasma

Edward III ordered the Mayor of London to remove the ‘filth lying in the streets’

• By 1370s, there were 12 teams of rakers (removing animal dung from streets)
• Fines for littering were increased
• Butchers punished for letting blood and slaughtered animal body parts onto the streets
• Attempts to ensure cleaner water supplies: London had water supplies through lead pipes and other towns had followed this eg. Exeter used aqueducts, Gloucester paid for a piping system
• Latrines were regulated, built away from water supplies, and night cards were used to collect human waste from them in a number of cities eg. London, Hull and Southampton

Overall, the Black Death caused a rejection of God, and allowed for the developing of Public Health and quarantining

However, death rates of medical professionals (& priests / nuns / monks) increased, there was still no understanding of the causes of disease and the treatments remained counter productive

The Medical Renaissance c. 1500-1700

Understanding of the causes of disease

Much of the general population continued to believe in these causes:

• Punishment from God
• The Four Humours
• Miasma
• Astrology / the supernatural

However, many of these were challenged during this period

Religious

Most people now recognised that God did not send disease, however, in times of epidemics (such as during the Great Plague), religious causes were still considered

Less acceptance of the Catholic Church as scientific approach and exploration flourished – more dissections as the Church could no longer control this created understanding of the body

The Theory of the Four Humours

Very few physicians believed this by the end of the 17^th century, though it was still used when diagnosing disease, because patients understood it

Challenging the theory

Paracelsus (mid 1540s) – a Swiss alchemist, scientist and medical professor

• One of the first medical professors to recognise that physicians required a solid academic knowledge in the natural sciences, especially chemistry. He pioneered the use of chemicals and minerals in medicine
• In 1526 theorised diseases were caused by poisons brought from the stars. He claimed the complete opposite of Galen. If a star or poison caused a disease, then it must be countered by another star or poison
• Paracelsus challenged the internal nature of the Four Humours

Jan Baptiste van Helmont (1660s) – a Flemish physician

• Developed a better understanding of the digestive system – published Ortus medicinae (1648) – he argued against subjects such as that food was digested due to the body’s internal heat, claiming that cold-blooded animals could not live otherwise
• His own opinion was that digestion was aided by a chemical reagent to ‘ferment’ within the body, such as inside the stomach (similar to modern discovery of enzymes)
• Challenges simplicity of Four Humours

Thomas Sydenham – an English physician

• Theorised that illness was caused by external factors
• Groups of illnesses rather than individuals getting their own illnesses
• Promoted observation and recording to allow for a more scientific diagnosis – diagnosed Scarlet Fever (1660s) by this approach
• Treated symptoms together rather than separately (as previously) as he did not believe that disease depended on the patient‘s individual factors
• Identified that measles and scarlet fever were separate diseases
• Developed a number of new treatments eg. instead of using the popular ‘sweating’ method for treating smallpox, he prescribed air bedrooms, light blankets and cold drinks
• Published theories in Observationes Medicae in 1676

These rejected the simplicity of the Four Humours, suggested that disease is caused by external factors and grouped diseases

Miasma

Miasma was popular in the Medieval Period because it made sense as there were lots of bad smells

Still remained popular during this period and became more widespread during epidemics

Challenging miasma

Girolamo Fracastoro – Italian based physician from Padua (many of the leading universities were in Italy)

• Disease was caused by seeds, spreading in the air
• Remained influential for nearly 3 centuries before being superseded by Germ Theory
• Published On Contagion in 1546

Astrology / supernatural

Although astrology was much less popular from 1500, in times of epidemics people still wore charms to ward off the disease

Ideas based on alchemy also became popular

Printing Press

In around 1440, Johannes Gutenberg (a German goldsmith) created the first printing press

The popularity of this grew quickly: by 1500, there was hundreds across Europe

• • This allowed for information to be spread accurately and quickly as it no longer had to be copied by hand – there were fewer inconsistencies in the same version of text
  • More scientists could publish their work and share it with others – spread of ideas
  • Created increased literacy of public —> rejection of religion
  • Took book copying out of the hands of the Church meaning a wider variety of subjects were written about rather than only religious topics
  • The Church was no longer able to prevent ideas they disproved of being published – work critiquing Galen’s work could now be published

Royal Society

Desire to explain world in secular terms due to humanism led to an increase in the number of experiments being carried out

Scientists wanted to share their discoveries and new ideas – founding of Royal Society

• • Met for first time at Gresham College London in 1660
  • Their aim was to promote and carry out experiments to further the understanding of science, the sharing of scientific knowledge and encouraged argument over new theories and ideas
  • In 1662, the society receive its royal charter (granting power or a right) from Charles II – as it was backed by the monarchy, it showed that the king endorsed science over religion – meant it was also trusted by society as writing was critically reviewed before it was published
  • Began publishing Philosophical Transactions in 1665 (a scientific journal) – first scientific journal in the world and continues to be published today
  • The journal consisted mainly of letter, books reviews and summaries of experiments
  • Offered funding for translation of European scientific texts and encouraged its members to write their reports in English instead of Latin and in language all could understand
  • Copies of submissions would be made available for anyone to study

Humanism

The idea that humans should learn, making their own mind up about the world, encouraging scientific experiments and studying

Rejected the idea that God was responsible for everything (but hadn’t figured out an alternative) – people returned to the original texts of classical thinkers

More experimentation began to take place due to the decreasing authority of the Church

New ideas began to gain support (but this did not have an impact on medical treatment)

In the 1500s, the Protestant Reformation took place, converting many to Protestant over Catholic

• • Decrease the power of the Church – less fear
  • Ability to test new theories (eg dissections)
  • Spread of new ideas —> medical advancement

Microscope

In 1665, Robert Hooke (a scientist involved in the Royal Society)

• • Developed a more powerful microscope and use to it observe living organisms
  • He published Micrographia in 1665, containing descriptions of plant cells

Antony van Leeuwenhoek (referred to as ‘the Father of Microbiology’)

• • Observed and described microorganisms, referring to them as ‘animalcules’ (meaning little animals in Latin) using his handcrafted microscopes
  • First to document microscopic observations of muscle fibres, bacteria and spermatozoa, and blood flow in capillaries
  • Did not write a book, but used the Royal Society to communicate ideas

Treatment

Andreas Vesalius

Challenged Galen and changed the ideas of anatomy in the 16^th century

• Educated in Paris, he was the most famous anatomist of the period (1530s onwards)
• In 1537, published Six Anatomical Tables, showing the different parts of the human body
• Published De Humani Corporis Fabrica in 1543 (meaning On the Fabric of the Human Body)

Unlike during the Medieval Period, in which the physician would read the Articella or other book by a classical thinker to instruct others how to carry out the procedure, Vesalius carries out the procedure himself as a physician

As Church laws allowed limited dissections, Vesalius was able to dissect human bodies rather than only animal ones as previously (1536 – Vesalius travelled to where a criminal had just been executed and smuggled the body into the city) – the animal anatomy is slightly different meaning Vesalius was able to correct previous mistakes from classical thinkers such as Galen

He encouraged doctors and students to compare their findings with Galen’s – claimed this was vital if medical advancements were to be made

Vesalius found around 300 mistakes in Galen’s original work on anatomy, such as:

• The human lower jaw was in one part, not two (due to the dissections on monkeys)
• The vena cava did not lead to the liver
• Men did not have one fewer pair of ribs than women (mistake based on religion)
• The human liver did not have 5 separate lobes
• The human breastbone was in 3 parts, not 7

Vesalius laid the foundation for other to investigate the anatomy of the human body

He dedicated the Fabric of the Human Body to the Holy Roman Emperor Charles V

He worked as a doctor as the Court but not an anatomist, but he had enough backing to produce as 2^nd edition of his book which was published in 1555

Vesalius left the Emperor’s Court in 1564

Other works:

• The Tabulae Sex
  • A collection of labelled drawings
  • He displayed Galen’s ideas next to his observations to draw attention to Galen’s mistakes
  • Helped students, anatomists and doctors to understand how each part of the body linked and worked together
  • He made Fugitive Sheets available (individual copies of pictures) so the whole book would not have to be bought again to correct old theories

Vesalius made the study of anatomy fashionable – it became the central part of medicine

Caused huge controversy – traditional physicians were angered that he criticised Galen and claimed that the the mistakes were due to the body changing since the time of Galen

His work was heavily copied and plagiarised

Inspired other anatomists – some correct his mistakes in his book

He hoped that by correcting Galen’s mistakes, more people would begin to use the ancient texts

William Harvey

• Born in 1578
• Studies medicine at Cambridge and then at a medical school in Padua
• Became a lecturer of anatomy at the College of Physicians in 1615
• By 1618, was one of the royal doctor of James I

Had taken a keen interest in dissection and observing the human body

He carried out public dissections

Taught his students that it was vital to observe the body and believe that over classical texts

Harvey proved that the blood in veins flowed towards the heart (after being told that the veins contained valves) by pumping liquids through the other way

This contradicted Galen’s theories about the blood

Also disproved Galen’s theory that blood was made in the liver as a product of digestion and flowed through the body to provide energy and burned up

He was influenced by the new invention of the mechanical pumps that fire engines used

Harvey’s research involved dissecting cold-blooded animals to observe the movement of their blood

He proved that arteries and veins were linked into one system by tying a cord around an arm and observing the flow of blood when cut – his theory was that blood must pass from arteries to veins through tiny passages

Criticised Galen’s theories that blood flowed through pores in the walls of the ventricles to the other side of the heart and that veins carried both blood and pneuma (air and soul) which was picked up by the lungs – he shows that the veins carried only blood and the the heart acted as a pump

Factors enabling Harvey’s discoveries:

• Attitudes in society
  • More interest in science and medicine due to the ‘Medical Renaissance’
  • People began to look for scientific explanations over region
• Institutions
  • Decline of the Church enabled Harvey to be critical of Galen’s theories
  • He was employed by Charles I as his physician, giving him credibility and status
• Scientific breakthroughs
  • Dissections became more common, allowing Harvey to look at the body in detail
• Technology
  • New technology inspired Harvey to question how the heart worked such as as the mechanical firefighter pump
• Individuals
  • Vesalius had already proved some theories wrong, making it easier for Harvey to do the same

Transference

The idea that an illness or disease could be transferred to something else

If you rubbed an object on an ailment, the disease would be transferred onto that object eg.

rubbing warts with onions

The same principle was used to transfer a fever from a human to a sheep

Chemical remedies

Instead of relying solely on herbs and blood-letting, the grown of alchemy led to people looking for chemical cures

This was known as ‘medical chemistry’ (or ‘iatrochemistry) and was very popular during the 17^th century

Inspired by Paracelsus, medical chemists experimented with metal cures for common ailments

• The Pharmacopoeia Londinensis
  • Published by the College of Physicians in 1618
  • A manual of remedies, including a chapter on salts, metals and minerals
  • Among its 2140 remedies were 122 different chemical preparations
  • Antimony was widely used, causing sweating and vomiting, fitting with the idea of purging the body for disease of the Four Humours (however, it is extremely poisonous in its pure form) – antimony potassium tartrate was said to have cured Louis XIV of France of Typhoid fever in 1657 and became widely popular afterwards

However, explorers going to the new world brought back diseases such as Syphilis

• • Syphilis spread across Europe very quickly after likely being brought back by sailors who travelled to the new world with Christopher Columbus
  • Sores and spots would appear on the body, the patient would suffer from tiredness, headaches, a fever and ache in their bones, some patient developed tumours and some could be blinded, paralysed and go insane
  • Doctors were powerless to treat syphilis

The Theory of the Four Humours

Belief remained very strong

Led to excessive purging and bleeding of the body, causing negative side effects of weakening the patient further

Some of the chemical remedies still relied on causing a rebalance of the Four Humours

Herbal Remedies

Continued to be extremely popular, families used family recipients, handed down from generations eg. the use of honey was very common

Remedies were often chosen due to their colour or shape eg. Saffron to treat jaundice (no benefit but good logic)

Some physicians believed that herbal remedies within each country would cure the disease from that country

Some new herbs / plants were used

Many new remedies came from the ‘new world’ eg. Thomas Sydenham used cinchona bark from Peru, containing quinine (used to treat malaria today)

Mary Doggert in London used a mixture of liquids to fight scurvy, including vitamin C

The printing press meant many books were produced, recommending homegrown remedies eg. Nicholas Culpepper’s Complete Herbal which was very popular

Physicians also tested new arrivals such as tea, coffee, nutmeg, cinnamon and tobacco

Religious / supernatural

The Church was losing power, however, people continued to pray to be healed

Use of charms remained strong

Still relied on mythical cured eg. Charles II is estimated to have touched 92,000 expel with scrofula, a skin disease, known as the King’s Evil in his 22 years as king (The King’s Healing Power)

Apothecaries

Continued to mix remedies

In the period 1250-1500, apothecaries were organised into guild systems – men would carry out an apprenticeship and then spend several years practicing as a journeyman (an experienced member of a profession who was not yet experienced enough to have his own business. Usually worker for a master until they had enough experience to start their own business), before becoming an apothecary themselves

Continued to provide services to those unable to afford physicians

Education increased significantly

Introduction of iatrochemistry introduced new ingredients into the stores of apothecaries

Now must possess a licence

Surgeons

Continued to carry out simple operations

Organised into guild systems during the period 1250-1500 (see apothecaries above)

Continued to provide services to those unable to afford physicians

Education increased significantly

With wars being fought with new technology, new wounds on the battlefield meant that more surgery was necessary

Now must possess a licence

Physicians

Continued to be trained at universities

• • Training courses changed very little
  • Some new ideas emerging, but were slow to take effect

Most learning still from books rather than practical experience

Lectures were still dictated in Latin

Very little practical training

Although dissection had been legalised, still very difficult to get a supply of corpses

Very few universities had an anatomy theatre – thought it was not necessary to train a physician in anatomy as it was not needed

New subjects were introduced into the medical curriculum, like iatrochemistry and anatomy

New ideas about human anatomy and iatrochemistry started to be shared, so doctors were inspired to challenge old teachings – Hippocratic focus on observation became more popular

Trainee physicians had access to a wider variety of medical textbooks – printing press made it easier to find books and made them much cheaper

Protestantism rejected highly-decorated churches, so artists that found themselves in need of work were able to create detailed drawing for new medical textbooks

For medical students who were unable to afford a new medical books, individual copies of pictures were available – known as fugitive sheets

Hospitals

Whereas before, people attended hospitals for food, shelter and prayer (only people without contagious diseases or incurable diseases), people with wounds and curable diseases such as fevers and skin conditions attended

Many did not spend long in hospitals before being discharged, suggesting that they got better

A patient could expect:

• A good diet
  • The restorative effects of food were still important, as many did not have access to a lot of food that was good for them
• A visit from a physician
  • Hospitals has contracts with doctors, who would visit the patients sometimes as often as twice a day to observe symptoms and prescribe treatments
• Medication
  • Many hospitals had their own pharmacies and an apothecary to mix the medicines

However, the dissolution of the monasteries in England in 1536 dramatically changed the availability of hospital care in England

• • Vast majority were connected to the Church – very few could stay open
  • Hospitals were attached to abbeys, monasteries and convents and monks and nuns administered the care
  • With the convents and monasteries gone, the hospitals also went
  • Saint Bartholomew’s hospital in London, which was founded in 1123, only survived as Henry VIII re-founded it himself in 1546

Some smaller hospitals opened to fill the gap left by the dissolution of the monasteries, funded by charities, but there was a big change in the amount of medical care provided in these hospitals

Many hospitals reopened without their religious sponsors, but it took a long time for the number of hospitals to return to what it had been before

Pest Houses

Versions of these had existed in the Middle Ages, where there were lazar houses for lepers

There was a growing understanding that disease could be transmitted from person to person so new types of hospitals began to appear only for people suffering from plague or pox – these were known as pest houses, plague houses or poxhouses

These were the only type of hospital that would admit contagious patients – patients could not risk infecting their families so came here

Community Care

Most sick people continued to be cared for at home

Local communities provided others with support – advice and mixing remedies mainly

Women continued to play an important role in the care of the sick

• • Included rich and well-born women such as Lady Grace Mildmay (1552-1620), who kept detailed notes of the healing and treatment she carried out
  • Also included poor women working in big cities to support their families
  • Many were prosecuted by the College of Physicians for practicing medicine without a licence
  • Usually sold simple herbal remedies to purge the body or cure a particular ailment
  • Very popular, probably because they were cheaper than licensed physicians or apothecaries

Prevention

Considered to be the best method to avoid dying from the disease

Since treatments had not improvements, there was little certainty of recovery, so prevention was the best method

Religious / supernatural

Still heavy reliance on prayer and superstition as well as charms / amulets

A person’s constitution

The ability of a person to fight illness / disease naturally

Related to the Medieval idea of a person’s humours and personality being influenced by the season in which they were born

Condition at birth

Being born small or weak may be used to explain death from an illness in adulthood

Cleanliness

Still considered important – home and body must be kept free from miasma / bad smells

Declined since the arrival of syphilis

• • It had spread so quickly among people who regularly visited stewes or bathhouses
  • In London, Henry VIII had to close them during the early 16^th century
  • Thought that bathing led to disease
  • People began rubbing themselves down with linen and changing their clothes regularly to keep clean

Regimen Sanitatis

Continued use to prevent catching the disease

However, avoidance methods became much more about changing your surroundings from an area with a disease as they were about looking after yourself

Weather conditions

Certain weather conditions, or the surrounding atmosphere, spread disease – idea became more popular

New instruments such as barometers and thermometers were used to measure and record weather conditions over long period to see if there was a link between weather an outbreaks of disease

Public Health

More steps were taken to remove miasma from the air

• • Homeowners were fined for not cleaning the street outside their house
  • Projects were set up to drain swamps and bogs
  • Removing sewage and picking up rubbish from streets was a punishment given to minor criminals

People also believed you could avoid disease by practicing all things in moderation as well as avoiding draughty, exhaustion, rich and fatty foods, too much alcohol and being too lazy

Case Study – the Great Plague (1665)

In 1665, a serious outbreak of the plague swept across England

Lasted from June – November

Rate of infection peaked in September, when 7,000 deaths were recorded in 1 week

100,000 Londoners died – 1 in 5 people

Last serious outbreak of the disease in England

Was spread by fleas carried on rats

Understanding of the causes of disease

Astrology

Unusual alignment of Saturn and Jupiter in October 1664 and between Mars and Saturn on 12^th November – seen as unlucky combinations that suggested trouble

A comet had been spotted too

Religious

Believed that the disease was a result of mankind’s wickedness and that God had sent it to clean up his kingdom

Miasma

By far the most popular theory (contrasting the Black Death of 1348)

Miasma had been created by the rubbish and dung hills within 17^th century city life

The vapour was present in the soil, where it would stay as long as the weather stayed cold, however, when the weather turned warmer, the vapour would pour out of the earth as a plague-carrying miasma

This fitted the pattern of infection: plague outbreaks generally occurred when the weather became warmer

Other ideas

By 1665, many people believe the correct idea that disease could be spread from person to person, although, as there was no proof, it was not the most popular theory

However, plague victims were still quarantined

Many people who also believe that miasma was the cause still believe that once people had caught it, they could pass it on to others

The village of Eyam, Derbyshire was infected from fleas on cloth that had been shipped from London

The village was quarantined to stop the disease spreading

Food was brought and left at the edge of the town and the villagers left money in a trough of vinegar to make sure it did not spread the disease

Over 14 months, at least 273 people died out of 350, but the disease did not spread outside of Eyam

Treatment

Not many records as people were quarantined

Theory of the Four Humours

Physicians advised that patients be wrapped in thick woollen clothes and laid by a fire so the patient could sweat the disease out

Transference

Strapping a live chicken to a bubo

Lancing the bubo with a feather plucked from a live chicken

Meant to transfer the disease by drawing out the poison and help the patient recover

Herbal remedies

Continued to be extremely popular

Took the form of medicines, poultices or rubs – one remedy was ‘plague water’

Quack doctors (without medical training) took advantage of the general panic – they mixed remedies and advertised them as cures, hoping to make money

Little understanding of the case so no effective treatment – best advice was to avoid catching it

Prevention

Advice from physicians

The College of Physicians recommended a variety of methods:

• Prayer and repentance
• Quarantine anyone who had the plague
• Carrying a pomander to drive away miasma
  • A pomander was a ball containing perfumed substances
• Various diets were suggested
  • Fasting
  • A diet heavy with garlic and sage fried in butter
• Plague doctors wore special outfits to avoid catching the plague
  • Consisted of hooked, bird like masks with sweet smelling herbs to ward off miasma – bird were meant to attract the disease, so it was thought the disease might be attracted to the bird shape and leave the patient
  • The cloak would be treated with wax so none of the pus or blood soaked it

Advice from other healers

Most people turned to advice from local healers

Recipes for plague water (a ‘treatment’) were popular among apothecaries

Some relied on native herbs such as mint and rosemary

Some used new, exotic ingredients such as nutmeg and sugar

Smoking tobacco was thought to ward off the miasma

Some believed that syphilis would prevent the plague as buboes were symptoms of both diseases – they would try to be infected with syphilis

Keep some dried manure from someone who had died of plague

Government action

More action was taken from local governments and the king

Charles II decreed as list of preventative methods:

• Fasting
• Banning theatres, funerals, public meetings etc
• Streets and alleyways to be kept clean
• Fires to be burned one street corners to ward off miasma, often in barrels of sweet-smelling herbs
• Cats, dogs, pigeons were killed on the streets if they were seen (40,000 dogs and 200,000 cats slaughtered) as people thought they were spreading the disease

The mayor appointed searchers and wardens to monitor the spread of disease

• • Searchers would go house to house, checking if there were any plague victims
  • If a household was infected, the inhabitant were either taken to the pest house or quarantined inside the house for 28 days
  • The house was painted with a red cross with the words ‘Lord have mercy on us’
  • Parish officials were in charge of bringing food and necessities
  • Everyday, carts would travel through cities to collect the bodies

Many believed that the best way to avoid the disease was to run away

Still no understanding of the cause so they focused on prevention as there was no known cure, since some preventative methods had been successful in the past

Industrial Period c.1700-1900

Scientific Revolution – end of Renaissance (old theories discredited), Industrial Period (new ideas replaced the old)

The Enlightenment – made it fashionable for rational explanations

Cities began to grow as people moved there in search of work – new cities not well planned and quickly became dirty and disease-ridden

Understanding of the causes of disease

Spontaneous Generation

Developed in the early 18^th century – improvements in the quality of microscopes meant microbes present of decaying matter could be seen

Meant that the rotting material created microbes which were spread throughout the air through miasmata

So, the microbes were the product of decay, rather than the cause of it – the reason that rotting matter and filth were considered a cause of disease

In the 18^th century, this was just a theory and theory was no proof until the 19^th century when scientists made a solid link between these microbes and disease

Germ Theory (1861) – Louis Pasteur

Pasteur trained as a chemist in Paris, developing an interest in biology

Worked at Lille University, specialising in fermentation – investigated why vats of beer kept going bad

In 1860, the French Academy of Science challenged scientists to come up with evidence to either prove or disprove the theory of spontaneous generation

Pasteur discovered that the beer was going bad due to microorganisms in the beer

Called these germs as they were germinating

Theorised that the germs caused the decay

Not the first to discover microorganisms but he was helped by the powerful microscope lenses which could magnify 1000 times

Applied his theory of decay by microorganisms in the beer the cause of disease in humans

Identified the bacteria which was causing the disease attacking silkworms in the French silk industry

Also proved that bacteria could be killed by heating a liquid in a flask which was then sealed

Basic principles of Germ Theory

• The air contains living microorganisms
• Microbes are not evenly distributed in the air
• Microbes in the air cause decay
• Microbes can be killed by heating them

Pasteur disproved spontaneous generation as decay did not happen to sterilised matter than was left undisturbed – microbes in the air were causing disease

Published his germ theory of infection in 1878

To begin with, Pasteur’s work had little impact on British ideas about the causes of disease – much of his work focused on decay rather than disease

The theory of spontaneous generation continued to be important until the 1870s – it was promoted by Dr Henry Bastian who had great power as a doctor

Some scientists started to look for a link between the microbes and disease

• • Joseph Lister linked Germ Theory to the problems of infection in surgery
  • John Tyndall discovered that there were small, organic particles in the air
  • January 1870, Tyndall gave a lecture, linking his discovery with Germ Theory and Lister’s work on wound infection
  • Theorised that dust particles carried the germs that caused disease
  • Medical world did not trust Tyndall as he was not a doctor so continued trusting Bastian’s beliefs
  • Lister’s ideas were doubted as he could not prove his theory
  • Although microbes could now be seen, doctors could not identify what they were and what role they played – many microbes even in healthy people so seemed impossible that they could cause disease

So, Pasteur’s theory had limited impact in Britain – attitudes among doctors meant people refused to recognise the link between germs and disease

Microbes – Robert Koch

Born in Germany in 1843

Doctor who became interested in Pasteur’s work so began to study bacteria

Pasteur and Koch were rivals – encouraged them to try to out do one another – moving them forward

Franco-Prussian war broke out in 1870

• • Created rivalry between both countries
  • Government of France and Germany paid of much of their research

Successfully identified that different germs cause many diseases

Discovered that bacteria caused tuberculosis in 1882

Published his ideas of methods that could be used to identify disease-causing microbes

• • The microbe is present in every case of the disease
  • Once taken from the body, the microbe can be reproduced into a pure culture (bacteria grown under controlled conditions)
  • The disease can be reproduced in test animals using that culture
  • The microbe can be taken out of the test animals and used to start a fresh culture

Continued to look for microbes causing disease

Discovered cholera in 1883

In 1884, he proved that its was spread by water supplied when he found it in the drinking water in India – proof for John Snow’s theory

Made it easier to study bacteria – new method of using agar jelly in a Petri dish

Made it easier to study the bacteria under a microscope

Developed a method for staining them with industrial dyes to make them easier to see

Received the Novel Prize for Medicine in 1905

Considered to be the father of bacteriology

Koch’s work inspired others:

• • 1876 – Anthrax (RK)
  • 1882 – Tuberculosis (RK)
  • 1882 – Typhoid
  • 1883 – Cholera
  • 1883 – Diphtheria
  • 1886 – Pneumonia
  • 1887 – Meningitis
  • 1894 – The Plague
  • 1898 – Dysentery

Influence in Britain:

Enormous breakthrough in the diagnosis of disease

• • Before, doctors had studies and treated symptoms
  • Now studied the disease itself

Medical profession had begun to recognise that the microbe created the symptoms for the disease, and it was the microbe that needed to be removed

1883 – microbe causing diphtheria was found

Diphtheria – disease mostly affecting children, causing painful cough and fever, leathery skin grew over tonsils and back of throat so patient could not breathe

Scientists were able to observe that the microbe produced a poison which stayed in the throat and caused the symptoms

Scientists were able to seek ways of attacking it directly, rather than treating the symptoms

Koch’s influence:

• • By developing the dye to stain microbes, Koch made it easy to see microbes
  • Before Koch’s discoveries, symptoms were studied. After, diseases themselves were studied
  • Koch’s new methods of growing microbes made it easier for other scientists to study specific diseases
  • The British government did not listen to Koch’s discoveries in the short term
  • Koch inspired others to look for microbes responsible for other diseases

Development of Germ Theory:

• • 1854 – John Snow used observation to show that cholera was water-borne
  • 1861 – Pasteur identified that microbes were causing decay in wine
  • 1870 – physicist John Tyndall theorised that disease was spread through dust particles
  • Koch developed a new method for growing and observing bacteria
  • 1882 – Koch identified the microbe that caused tuberculosis
  • Joseph Lister read Pasteur’s work and linked it with infection problems in surgery
  • Leeuwenhoek observed microbes and wrote to the Royal Society about them
  • Dr Bastien promoted the theory of spontaneous generation until his death in 1915

Impact of Germ Theory in Britain:

Progress in treatment and prevention using Germ Theory slow

Once Pasteur and Koch had found the specific disease-causing microbes, cures and vaccines could be tested – Germ Theory began to have a direct impact on treatment

British government rejected the Germ Theory

When Koch travelled to Calcutta in 1884 to study an outbreak of cholera, he proved that it was caused by microbes in the water – ignored by British government

Kept to the idea that disease was present in the soil, and the miasma was brought out by the weather – made sense

Despite the setbacks, Germ Theory had a huge impact in the 20^th century:

• • Recognised that many diseases are caused by a microorganism (bacteria, virus or fungus)
  • Doctors look for symptoms to match them to a disease cause by a specific microbe when diagnosing disease

Took a little more time for this to be accepted by medical profession, but there was now evidence – led to treatments based on science to be developed

Factors affecting the understanding of the causes of disease:

• Institutions: the British government
  • The government was not interested in getting involved in every day life for much of the 19^th century
  • However, as more people gained the ability to vote, the government was more willing to intervene (although still more interested in practical solutions to epidemics)
  • Since Germ Theory offered no practical solution, they did not promote it
• Science
  • The second part of the Scientific Revolution focused on finding answers to questions of science
  • Improved communication enable scientists to share their work to draw conclusions from findings
  • Tyndall’s 1870 theory of germs causing disease was based on the work of Pasteur and Lister
  • Ideas were shared across branches of science – Pasteur’s work on animal diseases inspired other scientists to use his methods to diagnose humans
• Technology
  • Microscope made Germ Theory possible – clearer images and higher magnification allowed most microorganisms to be seen (not viruses)
  • Koch developed a way to grow microbes
  • Joseph Petri developed the Petri dish
  • Experiments with dyes allowed bacteria to be observed
• Attitudes in society
  • The Enlightenment caused people to be more interested in rational explanations for disease
  • Overcrowding and poor living conditions led to outbreaks of disease – believed action must be taken
  • Unhealthy population could not work – believed action must be taken
  • However, people’s reluctance to change their minds slowed the spread of Germ Theory
  • Took a long time to show that specific microbes were always present when suffering from a particular disease
  • Until proof was provided in the 1880s, Germ Theory was not fully accepted

Treatment

Hospitals – Florence Nightingale

Most of England’s hospitals had closed during the Dissolution of the Monasteries in 1530s – by 1700, there were only 5 left in the country which were all in London —> worsened care

The country did not invest in new hospitals

New hospitals began appearing in other cities during the 18^th century, founded by donations —> less religion in medical care

Some doctors offered their services free of charge so they could practice their skills

Hospitals increasingly became placed where the sick were treated rather than rest and pray – doctors visited patients regularly and a surgeon or apothecary provided daily treatments – a small staff of untrained nurses cared for patients

Most people still received treatment in their homes – generally, patients admitted were the ‘deserving poor’ (respectable, working class people who could not afford medical bills)

This gave poor people access to trained doctors for the first time

However, as more people started to attend, hospitals became less sanitary as they became less strict about turning away infectious patients – although there were separate wards for infectious patients, doctors went between wards without washing their hands or changing their clothes

So, disease spread quickly and did to take steps to avoid spreading germs

After training as a nurse in Germany and Paris and becoming the superintendent of nurses at King’s College Hospitals, London, Florence Nightingale convinced the government to allow her (and 38 other nurses) to improve the hospitals in Crimea during the Crimean War (1854-1856 – Russia vs Britain, France, Turkey and Sardinia over who would control various colonies of the Ottoman Empire – 300,000 soldiers killed)

Changes to the care of wounded soldiers:

• Nightingale demanded 300 scrubbing brushes to get rid of dirt
• Nurses were organised to treated nearly 2,000 wounded soldiers
• Clean bedding and good meals were provided

Led to mortality rate dropping from 40%-2% in 6 months

Gave Nightingale credibility when she returned to Britain in 1856, largely from the publicity

The Crimean War highlighted problems with hospitals (such as lack of ventilation, overcrowding, no cleanliness) so attempts were made to improve them on Nightingale’s return to Britain – the way hospitals were designed and the training of nurses

Nightingale changed training of nurses nursing:

• Made it into a respectable profession, staffed by middle-class women
• Set up training
  • In 1860, she set up Nightingale School for Nurses at St Thomas’ Hospital, London
  • Nurses mainly trained on sanitary matters
• Rigorous training turned nursing into a profession rather than a simple, unskilled job
  • Encouraged more women to sign up
  • Number and skill of nurses grew rapidly

Changed the design of hospitals:

• Hospitals were build out of easily cleaned materials – as they believed dirt spread disease, floor and walls were washed
• Promoted Pavilion Hospitals
  • Improved ventilation
  • Larger rooms
  • More windows
  • Separate isolation wards
• Clean bedding
• Good meals
• Separate wards build to ensure infections patients were kept separate

Operating theatres and specialists departments for new medical equipment

• Improved cleanliness – first focused on cleaning up germs using antiseptics, then prevented germs getting in (aseptic)
• More access to doctors (particularly junior doctors) and trained nurses lived nearby

The function of hospitals had changed completely – people were now treated

However, a lot of sick people were still treated at home by family members – hospital places were still limited

Apothecaries were now known as pharmacies – Boots opened in 1849

Surgery

Surgery was dangerous and usually fatal during the 18^th century

3 main problems:

• Bleeding
• Pain (shock)
• Infection

Although substances such as opium had been used to calm patients, without anaesthetic, many patients were sent into shock by the pain of surgery

Surgeries had to be performed quickly to prevent bleeding

However, even if the patient survived the operation, infection often set in as surgeries were not performed in sanitary conditions

So, surgical treatment was limited – most common type was amputation (often due to accidents or complications relating to tuberculosis)

Other types of surgeries were rare as the risk was so great

Anaesthetic

Tackled the pain causing shock due to surgery

Surgeries had to be performed very quickly to avoid patients going into shock from the pain – Robert Liston amputated a leg in under 2½ minutes (but was the only operation with a 300% mortality rate – assistant, surgical spectator, patient)

During the Middle Ages, alcohol, mandrake, herbs and hemlock were used, but these were largely ineffective and had been known to kill the patient

Laughing gas (nitrous oxide)

Used during 1800s

Early experiments proved quite successful for small operations (but ineffective for others)

However, caused irritation to eyes, lungs and sickness

Ether

Used by Robert Liston

Discovered and used in America by surgeons

However, made some patients vomit, gas irritated the lungs causing coughing

Also highly flammable – dangerous, especially with the candles or gas lamps used to light the room

Chloroform (James Simpson)

James Simpson and his friends inhaled some different chemicals

After inhaling chloroform in 1847, they all passed out

So, chloroform was an effective anaesthetic

Although they were not detected during Simpson’s experiments, chloroform had some negative side effects:

• Easy to overdose a patient and kill them so the dose had to be carefully controlled
  • Hannah Greener, a 14 year old girl, who was having an infected toenail removed in 1848, became one of the first patients to die from an overdose of chloroform
• The chemical sometimes affected the heart, which caused some people to die after inhaling it
• Some surgeons did not want to use it as they believed that pain-free surgeries were unnatural – impact of religion
• Some doctors believed patients were more likely to die if they were unconscious

Development of chloroform:

• • 1847 – discovered by James Simpson, a surgical professor
  • 1853 – administered to Queen Victoria during her birth of her son (people believed it was safe)
  • Other ‘celebrities’ used it eg. Charles Dickens’ wife
  • Became popular – the first widely used anaesthetic

As patients no longer died of shock, surgeries could take longer

Surgeries tried other, more complicated operations and experimented

This led to infection developing deeper and major blood loss

This was known as the ‘Black Period’ of surgery (1850s-70s)

Antiseptic

Tackled infection

Previously, surgeons did not attempt to keep their surroundings or themselves clean due to the lack of understanding of germs

• • Many would wear stained coats to show their experience
  • A large number of people would be present during operations (medical students and ‘dressers’ who kept the patient still during surgery
  • Instruments were not washed

As a result of this, many patients who survived operations, died shortly after from infection such as gangrene or sepsis

Carbolic acid (Joseph Lister)

Lister was an English surgeon studying infected wounds – realised that the flesh was rotting

Compared his results with the recently published work of Pasteur (identified that germs were responsible for decay)

Theorised that, as microbes in the air caused wine and vinegar to go bad, microbes could also cause flesh to rot

Started to look for a chemical that wound clean bacteria form wounds – aware of the use of carbolic acid in sewage treatments

In 1865, he operated on a patient with a broken leg and added a bandage, soaked in carbolic acid – the wound healed cleanly

From this, Lister developed steps to ensure wounds did not become infected, including spraying carbolic acid in the air during operations

Published his results in The Lancet (a medical journal) – detailed 11 different cases where carbolic acid had been successful

However, antiseptic surgery did not catch on quickly:

• Lister’s success had spread more quickly than Germ Theory
  • Meant the science behind it was not fully understood
  • So, not all surgeons were willing to use the carbolic spray as they did not believe in Germ Theory
• It dried out the skin and left behind an odd smell
  • Some surgeons argued that, due to this, it could not be doing any good
• Lister focused on encouraging his colleagues to use the spray rather than scientifically proving his theory
• Seemed very extreme – it smelt strong and was expensive

So, in the short term, surgery did not change much due to the initial resistance from medical professionals

In the long term, attitudes changed – new antiseptic methods were developed and introduced to surgery – doctors were more concerned with avoiding infection, cleaning instruments and using face masks

Although carbolic acid was not used for long (Lister stopped using it in 1890), attitudes of surgeons towards antiseptic and aseptic (preventing microbes entering the wounding in the first place rather than killing them with an antiseptic) surgery changed – surgeons understood that safe surgery was their duty

Began to look for different methods of preventing infection – by 1900:

• • Instruments were steam cleaned
  • Operating theatres were cleaned thoroughly
  • Rubber gloves and surgical gowns were introduced
  • Surgeons wore face masks during surgeries

Prevention

Edwin Chadwick

In 1842, Edwin Chadwick (worked for government) showed the far lower life expectancy of people living in cities than the countryside

• • Published his Report on the Sanitary Conditions of the Labouring Classes
  • Concluded that this change in life expectancy was due to the filthy living conditions in cities
  • Campaigned for all cities to set up boards of health, who would be responsible for supplying clean water and disposing of sewage
  • Chadwick’s work did not have an immediate impact, but it contributed to the growing body of evidence to support the theory that clean water was vital for a healthy population
  • So, the government was more willing to act

Public Health Act, 1848

• A national Board of Health was set up
• In towns were the death rate was high, the government could force the local council to make public health improvements to water supply and sewerage and appoint a medical officer of health
• Local councils were encouraged to collect taxes to pay for public health improvements if they had the support of local tax-payers
• Councils were allowed to appoint medical officers of health

This was not compulsory, so did not have much impact on public health (did not change life expectancy)– laissez-faire attitude —> Germ Theory not discovered so people did not believe or follow it

• Most towns did not set up Boards of Health
• National Board was abolished after 6 years
• Ideas based on miasma, so did not tackle idea of microbes
• So, when cholera struck in 1848, it was devastating
  • Further attacks in 1854 cost 20,000 lives

Seemed radical – first time other than during pandemics

Public Health Act, 1875

More men had right to vote, so government began passing laws that would appeal to masses – 1867, working class people got the vote

Government starting to get more involved – reasons:

• Continued cholera outbreaks
  • 1865 – 14,000 lives
• The Great Stink in London in 1858
• Pasteur’s Germ Theory
• More men had right to vote, so government began passing laws that would appeal to masses
  • 1867, working class people in towns got the vote, doubling the electorate
  • 1884 – working class people in countryside got the vote

Timeline of Government Action

• 1840 - the government agrees to provide children with vaccinations at taxpayer’s expense
• 1848 - the first Public Health Act caused the setting up of a Board of Health, and gave towns the right to appoint a Medical Officer Health
• 1852 - vaccination against smallpox was made compulsory
• 1854 - improvements in hospital hygiene were introduced (Florence Nightingale)
• From the 1860s - the government began to take more action to improve living conditions for people in cities
  • In London, 1,300 miles of sewers were built by 1865 (designed by Joseph Bazalgette
  • In Birmingham, slums were demolished
  • In Leeds, a local business obtained a court order to from being drained into the river from which they got their water. This signified a change in the way people felt more responsible for pubic health
• 1872 - the GB government enforced the compulsory vaccination smallpox
• 1875 – second Public Health Act

Public Health Act, 1875:

City authorise had to follow the rules it set out, including:

• Providing clean water
• Disposing of sewage
• Building public toilets
• Employing an officer of health
• Ensuring new houses were of better quality
• Checking quality of food in shops
• Proving public parks for exercise

The last cholera outbreak was in 1866-67 – had lower mortality rate, due to some of the new measures

Case study – the Smallpox Vaccine (Edward Jenner)

In 18^th century Britain, smallpox was one of the most lethal diseases – it affected large cities especially, such as London (11 epidemic in the 18^th century – worst in 1796 when over 3500 people died) and Manchester, but also affected northern England in rural areas

In 18^th century Europe, 400,000 people died of smallpox annually

Nationwide epidemics in 1722,1723 and 1740-42

Smallpox caused a fever, vomiting, severe back pain, fatigue and a rash with bumps full of liquid

Treatments up to 1800:

• Doctors understood that if you had smallpox, you did not catch it again
• Therefore, inoculation (the deliberate infected of oneself with a disease, in order to avoid a more serious case later) was put forwards as a possible method to prevent it
• Pus from a smallpox scab would be rubbed into a cut of the patient or powdered smallpox scab would be blowed up the nose
• Did not always work – some patients died from the smallpox they were given
• Became very popular (seen as best chance of survival) eg. Thomas Dimsdale earned £10,000 and £500 a year for innoculation Catherine the Great and her children in 1768
• However, very expensive so many people so could not afford it

Edward Jenner

A Gloucestershire doctor in the 18^th century

Trained as an apprentice to a surgeon-apothecary and then practiced medicine at St George’s Hospital, London, before return to Gloucestershire as a GP

Interested in inoculation – gather evidence of over 1000 cases where smallpox inoculation had failed

Observed that milkmaids who caught cowpox, a mild disease causing red blisters on the skin, never caught smallpox

In the 1790s, Jenner decided to carry out experiments to test this theory

In 1796, he infected a local boy, James Phipps, with cowpox and then attempted to infect him with smallpox, but he did not catch it

He infected more people to further test his theory

In 1798, he published An Enquiry into the Causes and Effects of the Variola Vaccinae, describing how to prevent smallpox by infecting people with cowpox (called this ‘vaccination’ as the Latin word for cow is ‘vacca’) – made sure instructions were very detailed so other doctors could follow them

Impact of smallpox vaccine

Short term:

• Became very popular overseas
  • By 1800, 100,000 people around the world had been vaccinated
  • Napoleon had his entire army vaccinated in 1805
• Slower to become popular in Britain
  • Anti-Jenner propaganda promoted by inoculators
  • Sometimes people still died of the vaccine, as the doctors carrying out the procedure mixed up cowpox and smallpox samples or refused needles
  • After the Royal Jennerian Society had been founded in 1803, 12,000 British people were vaccinated

Long term:

• By the end of the 19^th century, vaccination against smallpox had become normal
  • Opposition continued by the number of people saved made it clear that the method worked
• Government enforced vaccine in 1872, smallpox cases fell dramatically
• Inspired other scientists to search for other vaccines
  • However, there were no other vaccines that worked in the same way

Pasteur’s impact

• Published his case for the germ theory of infection in 1878
• Theorised that microorganisms were responsible for disease
• Admired the work of Jenner and started to look for vaccines that would tackle lots of diseases
  • However, recognised that Jenner’s work had been the result of observation and experiments, rather than tackling the specific microbe – not possible for other vaccines
• A weakened strain of the disease would create an immune response where the body fought off the disease, creating antibodies that prevented the person suffering again from that disease
  • Pasteur did not know this was how it worked, however, methods were effective
• The key to this was identifying the microorganism specific to the disease and being able to ‘culture’ it eg. the use of Petri dishes etc.
• Pasteur tacked farm animals first: chicken cholera, anthrax and rabies
  • Proved that a weakened strain of the disease worked to vaccinate chickens against cholera in 1879
• Work had little direct impact on disease in humans
  • However, it inspired research among scientists
• Koch’s work isolating microbes that caused specific disease – very important to develop new vaccines
  • Emil von Behring developed a vaccine against tetanus and diphtheria

Smallpox and government intervention

• 1837-40 – smallpox epidemic
  • 35,000 people died
  • The Lancet blames inoculation for the outbreak
• 1840 – the government makes inoculation a crime
• 1840 – the government agrees to prove children with vaccinations at the taxpayer’s expense
• 1852 – the government makes smallpox vaccination compulsory
• 1871 – public vaccinations are appointed
• 1872 – government begins to enforce compulsory vaccination

Reactions to new vaccination:

Many people were suspicious as Jenner could not explain how it worked

Idea of infecting someone with an animal disease seen as strange – opposition

• The Church
  • Against vaccination
  • Using animal infection in human medical trials is against God’s will
• Inoculators
  • Business destroyed
  • Anti-vaccine propaganda in media
• Royal Society
  • Refused to publish Jenner’s work – lot of opposition to the ideas
• Government
  • Favoured vaccination
  • Cheaper (no quarantine), safer and more reliable

Case study – Cholera in London, 1854 (John Snow)

Cholera can spread through person-to-person contact or water contaminated with faeces of the sufferer – death would occur within 2-6 days

In 1854, an epidemic broke out in England, killing over 20,000

As the population of London increased from 1 to 6.5 million over the century, cholera spread easily

Doctors found it impossible to treat

Prevention was attempted:

• • Burning barrels of tar of vinegar to get rid of miasma
  • Smoking cigars
  • Praying or wearing lucky charms
  • Taking medicine or pills that guaranteed protection
  • Cleaning houses
  • Burning the clothes and bedding of victims

So, old ideas (such as miasma, religion and supernatural) remained powerful —> lack of progress as Germ Theory was not yet discovered

As the belief of these ideas was still widespread, local councils and populations attempted to change the filthy living conditions

• • Government encouraged cities to set up boards of health
  • Provide clean water supplies

However, this did not have great impact to living conditions

John Snow

A surgeon who moved to Soho in 1836

Already had good reputation – became London’s leading anaesthetist, administering chloroform to Queen Victoria in 1851

In August 1854, cholera broke out in Soho

This prompted Snow to investigate the 93 deaths in his local area

He created a spot map to show where the deaths had occurred and realised that the deaths were centred around the water pump on Broad Street – this pump was the source of the infection

He removed the handle from the pump, and the outbreak went away as no one could drink the water

Later inspections of the well underneath the pump revealed that it was extremely close to a cesspit which was leaking into the water supply

He wrote up his theories in On the Mode of Communication of Cholera in 1855, suggesting:

• Cholera could not be transmitted by a miasma, because it affected the guts, not the lungs
• Drinking water was being contaminated by the cholera-ridden faeces being disposed of in the city’s drains

Snow concluded that cholera was transmitted by dirty drinking water

The impact of John Snow

In 1855, Snow presented his finding to a House of Commons Committee, recommending that the government start making imporvements in the sewer systems of London to avoid another outbreak of cholera

The Government eventually agreed to invest in a new sewer system – deigned by Joseph Bazalgette, started in 1860 and completed in 1875 (although also due to the ‘Great Stink’ in London in 1858 in which the low Thames exposed the sewage on the riverbanks, causing a stench)

Many people rejected Snow’s work

• • Other scientists pointed out that cases would still occur among people who lived further from the pump
  • The General Board of Health clung to the theory of miasma
  • Admitting that cholera was in the water would mean having to take action that would be expensive – the Board argued there was no proof
  • Snow had practical proof rather than scientific proof – no Germ Theory

Therefore, in the short-term, Snow’s work only had an impact inside of Soho (people avoided the water) rather than in the outside area (importance of clean water no accepted)

Medicine in Modern Britain c.1900 – Present

Understanding of the causes of disease

By 1900, there was an understanding of Germ Theory and microbes causing disease

So, doctors no longer referred to miasma, the Theory of the Four Humours, supernatural or religious causes when diagnosing disease – first period that doctors were working with solely scientific discoveries

Diagnosis occurred only between the doctor and patient – the doctor would observe symptoms and consult medical textbooks, diagnosing based on this knowledge

More examination of samples, such as a biopsy (samples would be examines by microscopes and other technology

So, diagnosis could be more accurate – the exact microbe causing a disease can be identified

Instead of being based on symptoms, and the experience and knowledge of the doctor, it was now based on medical testing – ‘laboratory testing’

The science of genetics

By 1900, it was clear that microbes did not cause all disease and illness such as hereditary diseases

By 1900, a German scientist, Mendel, had theorised that genes come in pairs, and one is inherited from each parent – known as the fundamental laws of inheritance

No scientific proof – microscopes not yet powerful enough

By 1951, scientists new that characteristics were passed down from parents to children – theorised that a substance in human cells passed on this information from one person to the next, also passing on a variety of hereditary diseases

Not until 1953 that technology made it possible to discover DNA

Watson & Crick – the discovery of the human gene

James Watson (American biologist) and Francis Crick (English physicist) (both working at Cambridge University) saw the x-rays provided by Franklin and Wilkins and built a model of DNA
They shared it with Franklin, who made it correct based on her x-rays

Wilkins also shared clearer photographs of DNA

Due to this input, Watson and Crick were able to discover that DNA was shaped as a double helix (which could ‘unzip’ itself to make copies)

Published their paper in April 1953

Understanding of the shape of DNA meant they could identify the parts that caused hereditary diseases

The mapping of the human genome – The Human Genome Project

Once the structure of DNA was understood, scientists began to break it apart to understand how it worked

Understanding that information was vital to the understanding of the cause of genetic diseases

The Human Genome Project was launched in 1990, originally lead by James Watson

Attempted to decode and map the human genome (the complete set of DNA containing all information needle to build a particular organism)

Completed the first draft in 2000

Once the human genome was mapped, scientists were able to use this as a blueprint to look for mistakes in the DNA of people with hereditary diseases

• • A gene sometimes present in women with breast cancer has been identified
  • Although they cannot use this to trea the illness, it can be prevented by identifying their risk of developing the disease and preventing it

Factors helping the development of genetics:

Technology

• Made discovering the shape of DNA, understanding how it works and mapping the individual genes possible
• Advanced in microscopes and the ability to produced higher-powered images enabled the identification of DNA and examination of how it is formed
• The electron microscope
  • First developed in 1931 by Ernst Ruska (a German physicist) and Max Knoll (an electrical engineer)
  • Within 2 years, they had built a model that was able to magnify more than any of the optical microscopes
  • Work by using a bean of electrons to illuminate the sample being examined rather than just regular light
  • Allows for much more powerful magnification – can produce a clear image up to 10,000,000 times magnified rather than 2000 times

Science

• Understanding DNA required a lot of collaboration within the scientific community
  • The Human Genome Project took thousands of scientists collaborating
  • All the data produced from the study was made public, so it could benefit all

The impact of the science of genetics

A better understanding of DNA helped scientists to recognise genetic disorders – these disorders are caused by missing information in the genome

This could lead to a treatment of putting this information back in, but is not currently a treatment

Lifestyle and Health

Smoking:

• Very popular from the 1920s
• By the 1950s, doctors had stated to see a rise in the number of men suffering with lung cancer – linked to smoking
• Now recognise that smoking is associated with a variety of diseases, including high blood pressure, cancers, heart disease and tooth decay
• Biggest cause of preventable diseases in the world
• Dangerous to people inhaling second-hand smoke – more likely to develop asthma

Diet:

• Due to the Theory of the Four Humours, it was previously believed that diet had a huge impact to health
• It is recognised that diet has an impact on health (but differently to the Four Humours)
• Healthy diet:
  • Fresh fruit and vegetables
  • Most other things in moderation
  • Little sugar – excess can cause type 2 diabetes (incurable condition where the body cannot process sugar in the bloodstream
  • Little fat – excess can cause heart disease
• Not getting the right amount of nutrients or not eating enough can cause health problems

Other lifestyle factors:

• Drinking too much alcohol can lead to living diseases and kidney problems
• Sharing bodily fluids can lead to the spread of diseases
• Tanning has caused a rise in number of cases of skin cancer

Improvements in diagnosis

New methods of diagnosis:

• Development of machines and computers —> understanding of patient’s symptoms
  • X-rays and CT scans mean surgery is not necessary to diagnose all disease

Impact of technology:

• Made diagnosis more accurate
• So, impact of doctor’s ability to treat patients

Common technologies for diagnosis:

• Blood tests
  • From 1930s – use blood samples to test of number of conditions without the need for invasive diagnosis methods
• Blood pressure monitors
  • From 1880s – help to diagnose high and low blood pressure
• Endoscopes
  • From 1900s – use a camera on the end of a thin, flexible tube to see inside the body
  • Most commonly use to investigate digestive symptoms
  • Sometimes can be used to assist treatment, by carrying small surgical instruments into the body
• ECGs
  • 1900s – (short for electro cardiograms) use impulses to track heart activity
• Ultrasound scans
  • 1940s – (also known as sonograms) use sound waves to build a picture of the inside of the body
  • Helpful for diagnosing things such as gall stones and kidney stones
• CT scans
  • 1970s – more advanced form of x-rays
  • Can be used to diagnose tumours and other growths in the body
• MRI scans
  • 1970s – use magnets and radio waves to create an internal image of the body
  • Better suited to diagnosing soft tissue injuries than x-rays
• X-rays
  • 1890s – help to see inside human body without cutting into it
  • Help diagnose problems such as broken bones
• Blood sugar monitoring
  • 1960s – allows people who suffer from diabetes to check their blood sugar regularly to manage their condition

Treatment

General medicines – relieve symptoms

Willow bark was known to be a pain reliever – scientists extracted this chemical and made aspirin

Companies such as boots, Bayer and Beechams became worldwide companies

Magic bullets

A chemical cure that would attack the microbe in the body causing disease, whilst leave the body unharmed

As microbes were identified more and more during the 1800s and 1900s, scientists started to find chemicals that destroyed them

Doctors now understood that the body produced antibodies to fight diseases that had previously infected it – the basis for vaccines

This worked in the same way with magic bullets

The first big breakthrough was made in the treatment of syphilis

• Syphilis had continued to be a problem in the 19^th and 20^th centuries
• Treatment had not improved since mercury treatments in the 16^th century
• There had been some success with arsenic compounds
  • However, it is very difficult to find a form of arsenic that attacked the disease rather than the body (arsenic is poisonous)
• Paul Ehrlich tested many arsenic compounds in the early 20^th century – tested over 600 by 1907
• In 1909, a Japanese scientist, Hata, retested all of the compounds and found that number 606 cured syphilis
• This drug, named Salvarsan 606 was the first magic bullet

In 1932, scientist Gerard Domagk discovered that a bright red bye called Prontosil killed bacterial infections in mice – he tested it on his daughter who had developed blood poisoning and it worked

Scientists at the Pasteur Institute in Paris discovered that Pronotsil worked by preventing the bacteria from multiplying in the body, making it possible for the immune system to kill the bacteria – these drugs are called bacteriostatic antibiotics – Prontosil reduced the death rate for puerperal scarlet fever from 20% to 4.7% in the first half of the 20^th century

Scientists began to look for other drugs that worked in the same way – in 1938, British scientists developed M&B 693. This was another bacteriostatic antibiotic, it was used to treat Winston Churchill for pneumonia during WWII

The development of antibiotics

Antibiotic – any treatment that destroys or limits the growth of bacteria in the human body

The first true antibiotic was penicillin - created using microorganisms rather than chemicals

Inspired by the discovery of penicillin, other scientists investigated moulds and fungi in the search for more antibiotics

• • Streptomycin was discovered by Selman Wakston in 1943
  • More were discovered in 1950s and 60s

In the 21^st century, pharmaceutical companies continue to test substances to develop antibiotics – some bacteria developed a resistance to the antibiotics

In the short-term, antibiotics have been extremely effective for a variety of diseases

The impact of science and technology

• Developed medicines to target and treat specific diseases
• Incurable diseases can be managed, such as diabetes
• Improved scientific understanding —> better testing and trialing of new treatments
  • Thalidomide use to treat motion sickness in pregnant women in 1960s
  • Did not have to go through trials so did not notice that it causes birth defects
  • Now takes several years for a new drug to be trialled thoroughly

Technology has made it easier to create and provide medicines for diseases:

• Mass production of pills
  • Made the distribution of drugs much easier
• The development of capsules
  • Dissolve in the stomach to release the drug, meaning taking drugs to treat disease is easier
• Hypodermic needles
  • Allow the precise dose to be introduced directly into the bloodstream
• Insulin pumps
  • For young people suffering from diabetes
  • Deliver insulin without the need for injections

The NHS
The National Health Service was launched in 1948 by the government (Nye Bevan was the health minister, Clement Attlee was the prime minister)

Aim was to provide the same level of medical care for the entire population of Britain
Paid for by National Insurance contributions

Largest government intervention in medical care

NHS took over existing hospitals and medical services

To begin with, hospitals were not much changed by NHS – post-war Britain did not have much money to spend on medical care

Many hospitals and GP surgeries were in need of modernisation and hospitals needed to be spread out more – many more in London and the South East than the rest of the country

Made worse by number of people visiting GPs – waiting times increased, appointment times decreased

So, access had improved, provision had not in the short-term

However, during the 1960s, the Government implemented changed to improve the NHS – hospitals were spread evenly across the country, a GPs charter was introduced in 1966 (encouraged GPs to work in group practices and keep up with medical developments)

Government managed NHS – improved standard of care

Organisation of NHS:

• Hospitals
  • Managed by regional boards
• GPs and dentists
  • Primary care
• Additional services
  • Such as ambulances and health visitors

High-tech medical and surgical treatments in hospitals

Before 1900, blood transfusions did not exist —> 3 main problems of surgery solved —> more complex surgeries

Medical treatments:

• Advanced x-rays
  • Target and shrink tumours using radiotherapy – effective for cancer (combined with chemotherapy)
• Smaller, cheaper machines
  • Dialysis (blood is cleaned by a machine after kidney failure) and heart bypasses (machine performs the function of the heart) became more widely available as machines are more portable
• Robotics
  • Better prosthetic limbs
  • Partly due to number of soldiers surviving bomb attacks in recent wars

Surgical treatments:

• Microsurgery
  • First successful kidney transplant performed between identical twins in USA in 1956
  • Allowed for other transplants of organs, including lungs (from 1963) and livers and hearts (from 1967)
  • Made possible by improve surgical techniques, including microsurgery to reattach nerve endings and blood vessels
• Laparoscopic (keyhole) surgery
  • Using tiny cameras and narrow surgical instruments to operate inside the body through tiny incisions some distance away from the area that must be operated on
  • Allows for quicker healing and less trauma to the body
  • Also cheaper, less invasive and better for the patient
• Robotic surgery
  • Use computer to control instruments inside the body, allowing for more precise surgery with smaller incisions
  • Operations can be performed on a tiny scale where precision is vital eg. brain surgery

Extent of change in care and treatment

Treatment:

• Each symptom no longer has its own treatment
• In 1900, 25% of deaths caused by infectious diseases, by 1990, it was less than 1%
• Less people taking herbal remedies as there is a wider variety of effective medicines
  • However, problems with treatments led to many people still using herbal medicines, acupuncture and homeopathy

Access to care:

• In 1900, most sick people were still care for at home, by women
• Doctors had to be paid, so were only used for serious illnesses
• In 1919, government set up Ministry for Health
  • Helped determine the level of health care across the country
• Improved availability of care due to NHS from 1948
  • Made it clear that hospitals were places of treatment, rather than rest as previously
  • Left a gap in services for the elderly

Penicillin – Alexander Fleming

Alexander Fleming was a British doctor, working at St Mary’s Hospital, London

Had an interest in bacteriology and had been one of the first to the the magic bullet for syphilis

Worked in battlefield hospitals trying to improve treatments for wounded soldiers during WWI – dismayed at number of deaths from simple infections

Researched substances to combat infections during 1920s

In 1928, noticed that mould had killed off staphylococcus bacteria in a Petri dish

Tested the mould – identified it as penicillin (not first person to notice capabilities – Middle Ages people were aware that mouldy bread had healing properties, Joseph Lister used it to treat a patient in 1871 but Fleming published results when others were looking for chemical treatments, so more noticed it)

Published findings in 1929

Fleming did not believe penicillin could work to kill bacteria in people – first experiments showed that it was ineffective when mixed with blood in test tubes, so did not pursue any further tests

Howard Florey (Australian pathologist working at Oxford Medical School) and Ernst Chain (escaped Nazi Germany where he had worked as a biochemist) were conducting research into antibiotics – looking across neglected research

Came across Fleming’s findings and tested it further – Chain grew the mould in his lab and use extracts of it in tests

In 1940, they tested their extracted penicillin on infected mice – results were promising

Difficult to produce penicillin in large quantities (active ingredient in the liquid produced by mould only represented 1 part per 2 million) – grew as much penicillin as possible

By 1941, they had a human patient (a local policeman who has fatal blood poisoning) – showed signs of recovery immediately (although they did not have enough penicillin to cure him)

Proved penicillin to be effective in fighting infection in the body

Needed to be mass-produced

Florey first approached British pharmaceutical companies for assistance – during WWII so they were busy producing materials for war effort

However, USA had not joined the war – Florey visited USA in July 1941 and convinced pharmaceutical companies to begin penicillin production

Companies started growing penicillin in beer vats

However, it was a very slow process – after a year, they only had enough to treat 10 people

However, once this had begun, the impact could be shown – US Government funded 21 pharmaceutical companies to begin mass producing it

British companies became involved in 1943

By D-Day (June, 1944), there was enough to treat all allied casualties

Factors enabling development of penicillin:

• Institutions
  • US Government agreed to fund Florey’s research for 5 years
  • Enabled him to develop methods to mass produce the drug
• Individuals
  • Florey and Chain built on the work of Fleming
  • All 3 were actively looking for a chemical treatment
  • Florey refused to patent the drug, saying it should be available to everyone —> developing it did not cost as much
• Science
  • Scientists were able to observe how penicillin attacked staphylococcus bacteria
  • Enabled them to modify it to attack other types of bacteria
• Attitudes in society
  • No treatments for simple infections during WWI
  • Need to find solution became more important during WWII
  • So, clinical trials and evidence needed before the treatment was made available was minimal
• Technology
  • Development of new ways of mass production and storing penicillin made the drug available in vast quantities

Use of penicillin

Effective in treating diseases caused by an entire family of bacteria

Also used to prevent infection, particularly with patients who had teeth extracted

Also encouraged scientists to look for other mould that could be used to fight bacterial infections, such as streptomycin (first drug to be effective against tuberculosis)

Once Dorothy Hodgkin had mapped the chemical structure of penicillin, scientists were able to begin working on synthetic versions of it that were slightly modified to treat specific diseases

Confidence in medical treatments began to rise – doctors offered treatments against a wide range of illnesses

Patients were more willing to seek out medical treatments from doctors

Some bacteria are now resistant to penicillin – bacteria can mutate to resist attacks from penicillin mould

The first penicillin-resistant strain of bacteria appeared in 1942 – pharmaceutical companies continue to work hard to develop new forms of penicillin and other antibiotics that will kill off the bacteria

Development of penicillin

• • 1928 – Fleming identifies penicillin in his lab
  • 1929 – Fleming published his findings
  • 1939 – Florey and Chain revive Fleming’s research
  • 1940 – Florey and Chain successfully treat mice with penicillin
  • 1941 – Florey Chain trial penicillin on a human, with some success
  • 1942 – US pharmaceutical companies begin mass producing penicillin
  • 1945 – Dorothy Crowfoot Hodgkin, a scientist at Oxford University, identifies the chemical structure of penicillin
  • 1957 – Chemist John C. Sheehan creates a chemical copy of penicillin. This allows for the drug to be charged to in order to target different diseases

Prevention

By 1900, the government took responsibility for providing clean water and removing waste

The public understood the importance of this, due to the development of Germ Theory

As more people were given the vote, the government paid attention to the public’s needs

The government no longer adopted a laissez-faire attitude – reasons:

• Increased understanding of the cause
  • Government recognises that intervention can have an impact
  • Without this understanding, little action would have been taken as they did not know that intervention could change things
• Increased understanding of methods of prevention
  • Prevention could be tested an introduced once the causes of disease and health problems were understood, such as:
    • Compulsory vaccinations - inspired by the positive impact of the smallpox vaccination, other campaigns were launched in the 20^th century
    • Passing laws to provide a healthy environment – these included the Clean Air Acts and adding the chemical fluoride to the water supply to help prevent tooth decay
    • Communicating health risks – lifestyle campaigns to identify and tackle health risks. During times of global epidemics, such as during the 2014-15 outbreak of Ebola in West Africa, the government tracked travellers from affected regions and put quarantine measures in place

Charities also contribute to healthy lifestyle campaigns – British Heart Foundation creates adverts to encourage people to protect their heart by giving up smoking, eating less fat and exercising

Vaccinations

Government introduction of vaccinations:

• • 1942 – diptheria
  • 1950 – poliomyelitis and whooping cough
  • 1961 – tetanus
  • 1968 – measles
  • 1970 – rubella

National vaccination campaign against diphtheria launched in 1942 – the first of its kind due to fears that the cramped conditions of air-raid shelters during WWII might lead to an epidemic

Before this, local governments were responsible for vaccination campaigns that were not funded by the central government, so they were not widespread – around 3,000 children died each year of diphtheria

Infection rates plummeted- diphtheria was seen as a disease of the past

Another significant vaccination campaign was against poliomyelitis (polio)

In the early 1950s, there were 8,000 cases reported in Britain every year

The vaccination was developed in the USA by Jonas Salk and was introduced to the UK in 1956, followed by a more effective vaccination in 1962

Number of infections dropped very rapidly – last case in the UK was in 1984

Some vaccines are aimed at protecting future generations – rubella can be dangerous if a pregnant woman catches it as it will affect the unborn child

Other vaccines target diseases that can lead to other diseases – HPV vaccine protects women from a disease that has been linked to cervical cancer

There continues to be controversy surrounding vaccines:

• • Many people resent government intervention so chose not to vaccinate
  • A lack of trust in the medical profession means many believe that vaccines are unsafe
  • There is still freedom of choice to reject vaccines

Government legislation

Clean Air Acts

Clean Air Acts of 1956 and 1968 – triggered by episodes of smog in London in 1952

Smog is heavy fog caused by air pollution – largely due to the coal usage

Government continues to pass laws to prevent air pollution eg. limiting car emissions

Smoking

The Government passed legislation making it illegal to smoke in all enclosed workplaces on 1^st July 2007 as part of the Health Act of 2006

Government lifestyle campaigns

Government aims to prevent disease by promoting healthier lifestyles:

• Advertising campaigns warning against dangers to health, such as smoking, binge drinking, recreational drug use
• Events such as Stoptober, which encourage people to stop smoking for a month
• Initiatives to eat more healthily and get more exercise, such as the Change4Life campaign