Medieval Bri in c1250-c1500 What were the beliefs on the cause of disease and illness and the processes for diagnosing illness before 1500' © Apunishment by God for one’s sins; the devil could send a disease to test a person's faith. * Medieval people believe disease could be spread by the breath of the infected (e.g., leprosy) © Miasmas = bad smells. ‘©The Theory of the Four Humours: blood; phlegm, black bile; yellow bile (choler) — Hippocrates (5" century BCE) linked to seasons, elements and qualities. + Galen’s Theory of Opposites: linked the imbalance of humours causing specific illnesses (e.g., too much phlegm linked to water and the cold, could be cured by eating hot peppers). ‘+ Astrology (c1250-c1500): evaluating star charts (when a patient was born and when they fell ill) to diagnose illnesses. People believed the Black Death was caused due to a bad alignment of the planets Why was there continuity in the ideas about the cause of disease during the period c1250-c1500? ‘+ The Church promoted the teachings of Galen and Hippocrates. ‘+ Books were produced in monasteries, and libraries were maintained by the Church. Therefore, there was a lack of alternative theories being spread. © There was a lack of scientific knowledge. Dissections were mostly illegal due to the belief of the Church, ‘* Physicians were trained based on the texts of Ancient Greece and Ancient Rome. Practical experience was largely ignored or explained away. New discoveries were fit into old theories. What were the approaches to treatment before c1500 ‘* Religious treatments: healing prayers and incantations (spells); paying fora special mass; fasting; pilgrimages, ‘+ Astrology: treatments varied according to the horoscope of the patient and the alignment of the planets were checked at each stage of treatment (herb gathering, bleeding, purging, operations). ‘+ Humoural treatments: blood-letting/phlebotomy (cuttinga vein; leeches; cupping); purging; bathing; herbal remedies (e.g., theriaca, aloe vera, rose oils) ‘Physicians: first, a physician would look at a sample of urine, faeces and blood. Secondly, he would consult the astrological charts. Thirdly, he would create a course of treatment based on the humours. ‘+ Apothecaries: mixed herbal remedies (Materia Medica ~ a herbal manual). ‘+ Surgeons: barber surgeons (small surgeries; pulling teeth); trained surgical physicians. ‘© Hospitals: 30% of hospitals in England were owned and run by the Church (ran by nuns and monks); some hospitals were set up by an endowment; many hospitals did not treat the sick, but instead offered hospitality to travellers and pilgrims; infectious or terminal patients were often rejected from hospitals What were the approaches to preventing disease and illness before c.1500? ‘© Religious: regular prayers, confession and paying tithes to the Church ‘© Hygiene: advice givento physicians in the Regimen Sanitates (The Salernitan Rule of Health). Used mostly by the wealthy. Bathing was an important treatment and preventative measure (public baths). ‘* Diet: important in preventing the imbalance of humours. Eating too much is strongly discouraged. ‘+ Purifyingtthe air: spreading sweet herbs; carrying flowers (posy, Plague Doctor masks); removing waste from the streets; cleaning public toilets and baths. What were the bi ved causes, treatments and preventative methods for dealing with the Black Death 1348-49? ‘+ What was the Black Death? A bubonic plague carried by fleas who arrived to England on rats.‘© Symptoms: Buboes; fever; abdominal pain; bleeding into the skin; fingers, toes and the nose could often tum black and die; chest pains/breathing difficulties; sneezing and coughing blood, Causes: ‘© Religious and supernatural: A punishment by God; unusual positioning of the planets (1345) ‘© Natural causes: impure air (miasmas) possibly originating from poisonous fumes released by an earthquake ora volcano. ‘+ Common beliefs: In Europe, many people blamedthe Jewish population, but Jewish people had been expelled from England in the 13" century. ‘Treatment: © Religious and supernatural: Confession of sins; prayer; survival was the result of God’s will alone. ‘Natural: Bleeding and purgingto restore the humoural balance (a faster death); strongsmelling herbs believed to have cleansing properties (aloe, myrrh and theriaca); lighting fires and boiling vinegar to drive off bad miasmas; lancing (burning/poking) buboes. Preventing: ‘+ Religious and supernatural: Prayer; pilgrimage; self-flagellation (whipping yourself). ‘Natural: Carrying a posy of flowers or herbs to your nose; avoid bathing (the water could open the pores to the corrupt air) ‘* Common beliefs: Avoid those with the disease. * Government action: Quarantine laws (isolating from people for 40 days when moving to a new area; quarantining houses where the plague had broken out); local authorities stopped cleaning the streets as the foul stench might drive off the miasma causing the plague. ‘The Renaissance c1500-c1700 What were the ideas about disease and illness during the Renaissance (c1500-c1700)? People were still ikely to believe the ideas about the cause of their ines as their medieval ancestors. However, with art, Christianity and beliefs changing during this period, illness could not be as easily explained. ‘+ There was still a widespread belief in the theory of miasmas as a cause of disease and illness. ‘+ New theories about the causes of disease and illness were based on alchemy (an early form of chemistry) ‘+ New ideas and discoveries: Paracelsus 16th century (a Swiss scientist and medical professor); Girolamo Fracastoro 1546 (an Italian physician); William Harvey 1628 (an English scientist); Jan Baptiste van Helmont (a Flemish physician); Robert Hooke 1665 (an English scientist and head of experiments at the Royal Society); ‘Thomas Sydenham 1676 (an English physician); Antony van Leeuwenhoek 1683 (a Dutch scientist). Why was the impact of medical discoveries in c1500-c1700 so smal ‘© Big changes: By the end of the 17" century, very few physicians believed in the Theory of the Four Humours (still used to diagnose disease, because patients understood this); there was a better understanding of anatomy (William Harvey; Jon Baptiste van Helmont); physicians understood that urine was not directly related to a person’s health. ‘+ Small changes: Physicians carried out more observations, but relied on texts for looking up symptoms (knowledge gaps); most people recognised God did not send disease, but religious causes were still considered; astrology became much less popular but people still wore charms to ward of disease in times of epidemics. ‘Continuity: The idea that disease was spread by miasmas remained constant throughout this period. ‘+The small impact was largely due to three factors: 1. The lack of quality medical instruments 2. There were still huge gaps in knowledge3. The general public believed in the Theory of the Four Humours Why were there change: the way ideas about the causes of disease and illness were communicated during the Renaissance peri ‘+ The rise of humanism: A love of learning, the freedom of academic exploration and discovery of the truth, Humanists rejected the Christian view that God was responsible for everything that happened and they returned to the texts of ancient scholars ‘+ Reductionin the powerof the Church: Where the Church had previously had significant control and influence (promoting Galen’s works); the rise of humanism saw that the Church had less authority in everyday life. It was becoming more widespread that Galen’s theories of the human anatomy had been wrong (Vesalius) ‘+ Literacy: More people than ever previously before were able to read and write. ‘©The Printing Press: Around 1440, Johannes Gutenberg, aGerman goldsmith, created the first printing press By 1500, there were hundreds of presses in Europe. The Church could not longer prevent ideas they disapproved of from being published, ‘+ The Royal Society: The Society was formed by scientists in London who wanted to talk to each other about new discoveries and ideas. The Society received its royal charter from Charles !I which led to donations and support. In 1665, the Society published the world’s first scientific journal, Philosophical Transactions. The Society made it possible for physicians and scientists to access and study each others’ research. Treatment towards disease and illness c1500-c1700: Continuity or chang ‘* Continuity of treatment: Humoural treatments such as bleeding, purging and sweating remained popular. ‘+ Change: the theory of Transference (an illness or disease could be transferred to something else). For example, it was believed that you could get rid of warts by rubbing them with an onion (the warts would transfer onto the onion). ‘© Change and Continuity: Herbal remedies continuedto be popular. New remedies and plants started to appear fromthe New World (sarsaparillato treat the Great Pox; ipecac from Brazilto treat dysentery}. Remedies were chosen based in their colour or shape (e.g., yellow herbs to treat jaundice) ‘+ Change: With the growth of alchemy came the science of iatrochemistry (medical chemistry) which was extremely popularin the 17" century. Inspired by Paracelsus, medical chemists experimented with metals as cures for common ailments. A remedies manual, The Pharmacopeia Londinesis is publish in 1618, by the College of Physicians. ‘+ Change: Andreas Vesalius first publishes the Six Anatomical Tables, in 1537. Vesalius publishes De Humani Corporis Fabrica (On the Fabricof the Human Body), in 1543, Vesalius’ 1543 book noted around 300 of Galen's mistakes (who dissected animals and not people). ‘© Change: William Harvey's (early 17* century) research involved dissecting human corpses. Harvey proved that arteries and veins were linked together into one system. Harvey criticised and disproved Galen’stheories on the role of arteries and veins. Preventing disease and illness c1500-c1700: Continuity or change’ © Conti ity: Avoiding the disease altogether and practicing the regimen sanitatis. + Continuity: Avoiding draughts, exhaustion, rich and fatty foods, too much strong alcohol and being too lazy. * Continuity: Being born small and weak might be used to explain death from an illness in adulthood (‘constitution’) ‘Change: Bathing became less fashionable since the arrival of syphilis. Henry Vill closed bathhouses down in London (early 16" century) due to the spread of syphilis between visitors to the bathhouses (which were often also brothels) ‘© Change: inthe 16" and 17" centuries, people were far more likely to clean themselvesby rubbing themselves with linen and changing their clothes regularly, rather than going to public baths.Change: The idea that certain weather conditions/surrounding atmosphere spread diseases was becoming more popular. New instruments ike barometers and thermometers were being used to investigate a link between the weather and disease. Change: More steps were taken to remove bad miasmas. Homeowners werefined for not cleaning the street, outside their house. Projects were set up to drain swaps and bogs. Removing sewage and picking up rubbish from the streets was a punishment given to minor criminals. Medical Care c1500-c1700: Continuity or chang Change: Education for apothecaries (e.g,, iatrochemistry) and surgeons increased considerably. With wars being fought with new technology, new wounds on the battlefield meant more surgery was necessary. Continuity: Services provided by surgeons and apothecaries continued to be a more affordable service than that of physicians Continuity: Training for physicians changed very little during this period. Most learning was still from books and not practical experience. Change: with the Hippocratic focus on observation, physicians began to challenge old teachings and investigate for themselves. This became more popular in the 17 century. Change: The Printing Press made medical texts easierto access with a wider variety than ever before. With the rise of Protestantism, artists previously occupied by decorating Catholic churches, now created detailed drawings for medical textbooks (fugitive sheets were used by students who couldn’t afford a whole book). Change: Andreas Vesalius first publishes the Six Anatomical Tables, in 1537. Vesalius publishes De Humani Corporis Fabrica (On the Fabricof the Human Body), in 1543. Vesalius’ 1543 book noted around 300 of Galen's mistakes (who dissected animals and not people). Change: Hospitals which had previously serviced travellers, pilgrims, the elderly and few sick people, now treated people with wounds and curable diseases (e.g., fevers and skin conditions). Servicesincluded agood diet, visits from physicians and apothecary medicines. Change: As the vast majority of hospitals were connected to the Church, veryfew were able to stay open after Henry VIII’s dissolution of monasteries in England in 1536. Change: Traditional hospitals would admit contagious patients. Whilst there were Lazar Housesin the Middle Ages (leprosy houses), new types of hospitals began to appear that catered only for people sufferance from plague or pox {known as pest houses, plague houses or pox houses). Continuity: Most sick people continued to be treated at home. Women continued to play an important role in care giving. These women often sold popular simple herbal remedies (cheaper than a physician or apothecary). A lot of womenin big cities were prosecuted by the London College of Physicians for practising medicine without a licence What were the ideas about the cause of the Great Plague in London, 1665? Continuity: The Theory of the Four Humours had not been replaced with a proven alternative. Most people still blamed the disease on being apunishment from God, miasmas (the most popular theory), and astrology. Continuity: By 1665, many believed that disease could be spread from person to person. Plague victims were quarantined. How did people try to treat the Great Plague of 1665? Continuity: Physicians advised that patients be wrapped in thick woollen cloths and laid by a fire to sweat the disease out (purging) Change: The theory of ‘transference’ was popular. Treatment methods included strappinga live chicken to a bubo, or lancing a bubo with a feather plucked from a live chicken (supposed to draw out/transfer the poisonous disease}Continuity: Herbal remedies continued to be extremely popular (medicines, poultices or rubs). Change: Quack Doctors took advantage of public fear. They mixed remedies and advertised them as cures. How did people try to prevent the Great Plague of 166: The College of Physicians recommended: prayer and repentance (continuity); quarantine the infected (continuity); various diets such as fasting or garlic and sage friend in butter (continuity); carrying a pomander containing perfumed substances (continuity); plague doctor masks filled with sweet smelling herbs (continuity); physicians cloak treated with wax to prevent pus and blood soaking into it (change) Change and continuity: apothecary remedies (‘plague water’) were popular. Some included herbs that had been used forcenturies (e.g,, mintand rosemary). Otherscontained new, exotic ingredients (e.g,, nutmeg and sugar), Change: Smoking tobacco (from the New World) was encouraged to ward off miasmas. Change: As buboes were also a symptom of Syphilis some believed becoming infected with syphilis would prevent them from catching the Great Plague. They were not correct. Change: Although local governments tried to prevent the spread of the plague inn 1348, they did more in 1665. - Charles It decreed people should fast regularly and issued list of actions to be carried out by local government officials of each city. Public meetings, fairs and large funerals were banned and theatres were closed. - Fires were set to burn on street corners, often in barrels of tar or strewn with sweet-smelling herbs (to drive away miasmas). = Cats, dogsand pigeons were killed. Around 40,000 dogs and 200,000 cats were killed as it was feared that they were spreading the disease. The mayor appointed searchers and wardens to go from house to house, checking for plague victims. Ifa household was infected, the inhabitants were taken to the pest house or quarantined inside the house for 40 days (with a red cross and the words, ‘Lord have mercy on us’ painted on the house) - Every day, carts travelled through the city to collect the bodies of the dead 18'" & 19" Century Britain (c1700-c1900) What were the ideas about the cause of disease and illness? Change: The Enlightenment movement during the 18" century made it popular to seek answers to questions about the world. The influence of the Church was quickly decreasing. Continuity: Whilst the Theory of the Four Humours had been discarded, people still believedin the theory of miasma in the 18” century Change: Scientists in the early 18" century developed the theory of spontaneous generation (rotten matter created microbes). Improvements in glass lenses meant scientists could see microbes present on decaying. (rotting) matter. It took until the 19" century to make a link between microbes and disease. Change: Louis Pasteur’s 1861 Germ Theory (medical breakthrough) proved the theory of spontaneous generation was wrongas decay did not happen tosterilised matter left undisturbed (microbes caused decay) = Pasteur theorised that as germs were causing decay, they might also cause disease in the human body (Germ Theory of Infection, 1878) - HOWEVER, the theory of spontaneous generation continued to be important in Britain until the 1870s (promoted by powerful British doctor, Henry Bastian). Change: Robert Koch identified that different germs caused many common diseases. Koch discovered the bacteria that caused tuberculosis in 1882, Cholera in 1883 (proved it spread in water supplies in 1884), and published his methods that could be used to identify disease-causing microbes. - Koch's work inspired other scientists. Over the next two decades scientists went on to discover the microbes responsible for other diseases, such as diphtheria, pneumonia, meningitis, the plague and tetanus.Doctors now studied the disease itself, rather than just the symptoms. + The birth of the study of Microbiology. Continuity: Itwas notuntil the 20" century when the work of Pasteur and Koch started to be widely accepted. How did the prevention of disease and illness change during the 18" and 19" century? Continuity of attitudes: In the 18 century, as more people beganto attend hospitals, hospitals became less sanitary. Doctors went from ward to ward without washing their hands or changing their clothes. Diseases spread quickly as people didn’t understand that disease caused germs. Change (cleanliness): (1850s-60s) Florence Nightingale promoted ‘pavilion style’ hospitals where infectious patients were kept in separate wards, clean bedding and sanitary areas. Change (cleanliness): By 1900 cleanliness was now of the upmost importance and hospitals focused on cleaning up germs using antiseptics. ‘The development of vaccinations: A scientific breakthrough = There were nationwide epidemics of smallpox in 1722, 1723 and 1740-42. In London, there were 11 epidemics of smallpox in the 18” century, the worst of these being in 1796. - _ Edward Jenner (an English doctor) gathered evidence on over 1,000 cases of failed inoculations. Jenner regularly treated dairy maids for cowpox and noticed that they did not catch smallpox and decided the two must be connected. = 1n 1796, Jennerinfecteda|ocal boy, James Phipps, with cowpox. Six weeks later he attemptedto infect Phipps with smallpox which he did not catch. Afterrepeating the process on other locals, in 1798, Jenner wrote up his findingsin An Enquiry into the Causes and Effects of the Variola Vaccinae (vacca = Latin for ‘cow’, - The number of smallpox cases fell dramatically from 1872, when the government started to enforce compulsory vaccinations. However, this was a one-off as scientists were unable to develop other vaccines based on Jenner's methods. ~ Other vaccines inspired by Jenner: Pasteur develops a vaccine for chicken cholera in 1879, anthrax and rabies. In 1890, Emil von Behring developed a new vaccine against tetanus and diphthe Why was there a rapid change in surgical treatments in the 18" and 19'* centuries? Inthe 18" century, the three big problems surgeons faced included bleeding, pain and infection. Surgeries were often performed at home and infection often set in. The most common type of surgery was amputation. In the 19" century, significant developments occurred. Anaesthetics helped with pain and antiseptics helped to prevent infection. Anaesthetics: - 1795: Humphry Davy (a dentists’ assistant), tried inhaling nitrous oxide (laughing gas) and discovered that. it numbed pain. Laughing gas was quite successful for small operations (e.g., tooth pulling) - 4 jiam E. Clarke (an American chemist and doctor), successfully used ether to anaesthetise a patientto remove atooth. In 1846, Robert Liston (a London surgeon) successfully anaesthetised a patient and amputated his leg. However, ether often made patients vomit, the gas irritated the lungs which caused coughing and it was very flammable - 1847: James Simpson (a surgical professorin Edinburgh), discovered chloroform. In 1853, Queen Victoria used chloroform during the birth of Prince Leopold (given by John Snow) and spoke favourably aboutit. However, it was easy to overdose on chloroform and the chemical sometimes affected the heart which could cause death. Antiseptics: = 1865: Joseph Lister (an English surgeon) theorised that if microbes in the air caused wine and vinegarto go bad (Pasteur’s Germ Theory), perhaps microbes caused flesh to rot. In 1865, Lister operated on a patient with a broken leg and added a bandage soaked in carbolic acid and the wound healed cleanly. From this, Lister developed the use of spraying carbolic acid in the air during operations, = By 1900, instruments were being steam cleaned, operating theatres scrubbed clean, rubber glovesand surgical gloves were introduced and surgeons used face masks during operations,Why was there resistance to change in the practice of medicine? ‘+ People were reluctant to discount old theories and continued to believe the theory of spontaneous generation rather than the Germ Theory until the late 19” - early 20” century. Physicians and surgeons did not want to believe that they might have been responsible for the infections that killed their patients. * Many people rejected John Snow’s cholera theory (which he could not prove), with the General Board of health clinging onto the theory of miasma. ‘* Anaesthetics allowed surgeons to operate deeper into the body than ever before attempted. The death rate increased whilst surgeons developed new surgical techniques. This suggested to some people that anaesthetics were bad, ‘* The Victorians believed pain relief with interfering with God's plan (e.g, using chloroform to ease the pain of child birth) ‘+ Some doctors believe patients were more likely to die if they were unconscious during the operation, rather than awake and screaming, * Vaccines: Jenner was not able to explain how or why his smallpox vaccine worked which made people suspicious. The vaccination was slower to become popular in Britain due to anti-Jenner propaganda, How significant was the intervention of the government on preventing the spread of disease? ‘+ With the rise of industrialisation of Britain and the urbanisation (growth) of towns and cities from c1700, living conditions became worse. Populations in towns and cities were living in cramped conditions, sharing privies, and dirt and human waste piled up on the streets. Factories led to ill health (particularly lung conditions). The government had little interest in improving conditions (Laissez-faire approach) John Snow and cholera: Snow (a surgeon) observed the cholera epidemic of 1848-49 and wrote up his theories On the Mode of Communication of Cholera suggesting it could not be transmitted by miasma, because it affected the guts, not the lungs and concluded that cholera was transmitted by dirty drinking water. - In 1854, during a cholera outbreak in Soho, Snow created a spot map investigating the locations of the deaths in the area and noticed a pattern of deaths around the water pump on Broad Street. Snow removed the handle from the pumpand the cholera outbreak quickly ended and later inspections showed a cesspit was seeping into the water welll and spreading cholera. = 1n11855, Snow presented his findings toa House of Commons committee. This along with ‘The Great Stink’ of 1858, the government agreed to invest in anew sewer system. - Government intervention: In 1840, the government makes inoculation a crime and agree to provide children with vaccinations at the taxpayers’ expense. In 1852, the government makes smallpox vaccinations compulsory. In 1871, Public Vaccinators are appointed and in 1872 the government begin the enforce the compulsory vaccination ‘+ The first PublicHealth Act, 1848: Aimed to improve the sanitary conditions of towns in England and Wales by encouraging cities to set up boards of health and provide clean water supplies. It was not compulsory so the Act had little impact. ‘+The Second Public Health Act, 1875: City authorities had to follow the rules set out including: - Providing clean water to prevent diseases spread by dirty water (e.g., cholera). - Disposing of sewage. ~ Building public toilets to avoid pollution. ~ _ Ensuring new houses were of better quality to prevent damp and overcrowding, = Checking the quality of food in shops. ‘Impact: The last cholera epidemic in Britain was in 1866-67 with a lower mortality rate than previouslyC1900-present: Medicine in modern Britain What were the i jeas about the cause of disease and ii Iness? Change: With the Germ Theory (1861) and link between microbes and disease, this isthe first period where doctors were working solely with evidence based scientific discoveries. Doctors now understood that the body produced antibodies to fight diseases that had previously infected it. Change (the science of genetics): In 1900, it was clear that microbes did not cause all inesses and diseases (e.g., hereditary diseases present from birth). ~ 1902: Archibald Garrod (an English doctor), theorised that hereditary diseases are caused by missing information in the body's chemical pathways. = 1941: US scientists George Beadle and Edward Tatum prove Garrod’s theory. = 1951: At King’s College in London, Rosalind Franklin and Maurice Wilkins create images of DNA using x- rays. By this time, scientists knew that characteristics were passed down from parents to children. = April 1953: Watson (an American biologist) and Crick (an English physicist) and the discovery of the human gene. Using the x-rays provided by Franklin and Wilkins and input from Franklin, Crick was able to solve the puzzle of the structure of the DNA (double helix) - 1990: The Human Genome Project was launched. For a decade, 18 teams of scientists were working towards the goal of mapping the human genome (completing theif first draft in 2000). It was now possible to look for mistakes/mismatches in the DNA of people suffering from hereditary diseases. ‘The impact of lifestyle and health: = Smoking: Although increasing in popularity fromthe 1920s, had begun to be linked to lung cancer by the 1950s. Doctors also began to make links between smoking and a variety of cancers, heart disease and tooth decay, for example. - Diet: Gettingthe right amount of nutrients is important in maintaining good health. Too much sugar can cause type 2 diabetes. Excessive drinking can lead to liver diseases and kidney problems. - Bodily fluids: intravenous drug using and unprotected sex can lead to the spread of diseases. How has technology led to a better understanding of the causes of disease and illness? Advances in microscopes and the abiity to produce higher-poweredimages enabledscientiststo identity and examine DNA (e.g., Ernst Ruska and Max Knoll’s electron microscope, 1931). Diagnosingillness and disease through new technology now means doctors no longer have to use surgery to diagnose diseases. Blood tests (from the 1930s). ~ Blood pressure monitors (from the 1880s). = Endoscopes (from the 1900s). = Blood sugar monitoring (from the 1960s). - X-rays (from the 1890s). ~ MRI scans (from the 18706). - CTscans (from the 1970s) = Ultrasound scans (from the 1940s). ~ ECGs (from the 1900s) What was the impact of new medicines? Chemical cures: ‘magicbullets’ was the term used to describe a chemical ure that would attack the microbes in the body causing the disease, whilst leaving the body unharmed. - Paul Ehrlich’s arsenic compounds (by 1907 he had tested over 600 but none of these cured syphilis); Japanese scientist, Hata, retested Ehrlich’s compounds and found #606 did cure syphilis. Hata named this drug, Salvarsan 606, which became the world’s first ‘magic bullet’ - In 1932, scientist Gerhard Domagk discovered Prontosil (a bright red dye) killed bacterial infections. Scientists at the Pasteur Institute in Paris later discovered that Prontosil worked by preventing thebacteria from multiplying (allowing the body's immune system to kill the bacteria). These drugs are called - _ 1n 1938, British scientists developed M&B 693 (a bacteriostatic antibiotic). Antibiotics: The first true antibioticwas penicillin. This was different to Salvarsan 606 and Prontosil as it was created using microorganisms, not chemicals. It inspired other scientists to investigate moulds and fungiin the search for more antibiotics. = Penicillinwasisolated froma mould sample by Alexander Flemingin 1928, and developed into ausable treatment by Florey and Chain in 1940. - Streptomycin was discovered by American scientist Selman Wakston in 1943 (effective against tuberculosis). = During the 1950s and 1970s, even more antibiotics were discovered = Impact: In the short term, antibiotics have been a miracle cure for a variety of diseases. Long term, new antibiotics are still being developed because some bacteria have developed a resistance to antibiotics. Testing and trialling: Previously, new drugs/medicines did not have to go through a testingand trail process. meaning mistakes were made (e.g., thalidomide in the 1960s). Whilst this slows down the progress, drugs are now deemed safe before being used widely. Improvementsin technology: The mass production of pills; the development of capsules that dissolve in the stomach; hypodermic needles allowing for a precise dosage; insulin pumps delivering insulin without an injection. How did medical care improve from c1900-present Continuity: Inc1900 most sick people were still cared for at home by women. Doctors still had to be paid and so were only used for serious illnesses. Change: In 1919, the government set up the Ministry of Health to help determine the level of health care across the country. ‘The National Health Service (NHS) launched in 1948 by the government: - Phase One (improved access): The government aimed to provide the same level of care for everybody in the country. To begin with, there were more hospital in London and the South East than there were across the rest of the country. As more people began to visit GPs, waiting times increased and appointmenttimes decreased. Access had improved, but provision had not improved (in the short term) During the 1960s the government implemented changes to improve the NHS (hospitals spread evenly, GPs to work in group practices). - Phase Two (high-tech medical and surgical treatments): The development of new machinery to treat the body improved treatment in hospitals. These include radiotherapy (combined with chemotherapy) to treat cancer; dialysis (kidney failure); heart bypasses; prosthetic limbs; transplants (microsurgery); laparoscopic (keyhole) surgery; robotic surgery. How were diseases prevented during the 1900-present? Change: The Laissez-faire (leaving things to take their own course) approach of the government was now behind them. With better understanding of the causes of disease the government recognised that their intervention could now change things. Government interve! Compulsory vaccinations throughout the 20" century (1942, Diphtheria; 1950: Polio and Whooping 961, Tetanus; 1970, Rubella; 1968 Measles). - Clean Air Acts (1956 and 1968), and adding chemical fluoride to the water supply (to prevent toothdecay).. - Lifestyle campaigns (advertisements e.g,, ‘Stoptober’), quarantine measures (e.g,, the 2014-2015 Ebola outbreak), communicating risks to the population - However, many people reject government intervention and choosenotto vaccinate their children. Whit vaccination is the best way to prevent the spread of epidemic diseases, there isstill freedom of choice to reject this method.Why did cases of lung cancer rise after c1900 and how was it dealt with? Increase: There were very few cases of lung cancer discovered in the 19" century and only 1% of lung cancers found at autopsy were caused by lung tumours. By 1918, this had increased to 10%, and by 1927, this had increased to more than 14%. = 1n 1950, the British Medical Research Council published their study conclusively linking lung cancer to cigarette smoking. Aggressive advertising by the tobacco industry since the First World War had led to a huge rise in the number of smokers. Even so, death rates continued to rise in men and women. = By 1985, smoking related deaths cost the NHS £165 million a year. However, the government earned around £4 billion from the tobacco tax. Diagnosis: Before more advanced technology, lung cancer was diagnosed using an x-ray machine. However, x-ray machines were often not detailed enough to accurately diagnose cancer. Today, patients are likely given a CT scan, followed by either a PET-CT scan or a biopsy may be taken. Technological treatment: surgical removal of the tumour/affected lung; transplants; radiotherapy; chemotherapy. Government prevention: = Changing behaviour (laws): smoking is banned in the workplace (2007), smoking in banned in cars carrying children under 18 (2015), the legal age for buying tobacco is raised from 16 to 18 (2007), increased taxation on tobacco products (more expensive to buy). - Influencing behaviour (communication): television advertisements for tobacco is banned (1965), advertisements are banned entirely (2005) including in major sporting events, campaigns to advertise the dangers of smoking, education to discourage young people included in school. The British Sector of the Western Front, 1914-18: injuries, treatment and the trenches How did the trench system work? Context: Britain declared war on Germany on August4 1914, Germany invaded France through Belgium and by the end of 1914, much of Belgium and northern France had been occupied by the Germans (although they had been stopped from advancing into the heart of France. Unlike previous wars, the First World War became a static war based on trenches which needed to be defended fromthe enemy. Attemptsneededto be made to advance from the trenches to seize land from the enemy, A line of trenches was eventually established from the English Channel in the north, to Switzerland in the south with a more complex trench system evolving from 1915 (generally dug to a depth of about 2.5m) Trenches typically held three-four lines, (the frontline trench, the support trench, the reserve trench, and a communications trench). Trenches were easier to defend than attack. Machine guns could fire rapidly and barbed wire was placed in no-man’s-land to slow down the progress of any attack New tactics were developed to deal with the advantages held by the defenders (such as the use of gases). What were the common medical conditions and their treatments on the Western Front? Medical Conditions: Trench foot: Painful swelling of the fect caused by standing in cold mud and water. In the second stage, gangrene (decomposition of body tissue) set in Trench fever: Flu-like symptoms (headache, high temperature, aching muscles). Itaffected an estimated half a million men on the Western Front. Shellshock: Symptoms included tiredness, headaches, nightmares, loss of speech, uncontrollable shaking and complete mental breakdown. It has been suggested that about 80,000 British troops experienced shellshock‘Treatment: Trench foot: prevention (rubbing whale oil into the feet, keeping feet dry and regularly changing socks). If gangrene developed, amputation was the only solution to stop it spreading along the leg. Trench fever: By 1918, the cause of trench feverhad been identified as contact with lice. Delousing stations were set up. After this, there was a decline. Shellshock: The condition was not well understood at the time, it is compared now to PTSD (post-traumatic stress disorder). Some were accused of cowardice and were punished (some were even shot). The Craiglockhart Hospital in Edinburgh treated 2,000 men for shellshock. What were the key battles on the Western Front and how did they affect injuries? ‘The First Battle of Ypres (Belgium), 12 October - 11 November, 1914: The Germans launched an attack on the British positions to the east and north-east of Ypres. Although the British lost over 50,000 troops, they held on to Ypres which meant they controlled the English Channel ports. The mines at Hill 60: The British used the method of offensive mi Germans in April 1915, by tunnelling into and under the hill. Five mines were place when they exploded, the British were able to take this important position ‘The Second Battle of Ypres: This took place asa series of battles from 22" April - 25 May 1915. Itis the first time that the Germans used chlorine gas on the Western Front. British losses totalled about 59,000. ‘The Battle of the Somme, 1916: The British attack on the Somme aimed to take ground from the Germans (launched on 1" July 1916). Casualties on both sides were enormous. The British tried two newstrategies that would contribute to increased casualty rates: 1. The Creeping barrage: Artillery was launched from the trenches towards the German|ines as the British infantry advanced forwards. 2. The first use of tanks in warfare (although they had many technical problems are we not very successful - By the end of the Battle of the Somme in November 1916, itis estimated that the British had suffered over 400,000 casualties. Tunnels, caves and quarries at Arras: = In 1916, the British decided to link the existing tunnels, caves and quarries to create an underground network to act as shelters against German attacks. - Tunnelling companies from Britain and New Zealand dug more than 2.5 miles of tunnels in five months (up to 25,000 men could be stationed in the tunnels) The tunnels contained electriclights, running water, alight railway system and a fully functioning hospital. ‘The Battle of Arras, 1917: In April 1917, 24,000 men hidingin the tunnels near the German trenches attacked. ‘The British advanced about eight miles, but progress slowed. By the end of May, there were nearly 160,000 British and Canadians casualties. ‘The Third Battle of Ypres, 1917: The British launched theirmain attack on 31 July, advancing two miles on the first day. Soon, the weather turned to rain and the ground became waterlogged (many men fell in the mud and drowned). By the end of the battle in November, there was an estimated 245,000 British casualties. ‘The Battle of Cambrai 1917: The artillery barrage was changed (20 October 1917) so that less warning was given to the Germans. It was accompanied by the first large-scale use of tanks (nearly 500). jing to take the hill back from the in the tunnels and What transport problems were faced on the Western Front and how did this affect medical treatments? Poor roads: The constant shelling left the landscape full of craters and holes. This destroyed many roads and led to major problems transporting the injured away from the frontline (stretcher bearers). Infected wounds: As the land had previously been usedas farmland beforethe war, the use of fertiliser meant there was a lot of bacteria in the soil that could lead to infected wounds. ‘Ambulances: When the BEF was first sent to France in August 1914, the military leadership decided not to send any motor ambulances with them. Horse-drawn ambulance wagons could not cope with the large number of casualties (this led to soldiers being left to die or being taken prisoner by the Germans).By October 1914, the appeal made by The Times newspaper had raised enough moneyto transport 512 ambulances wagons. However, motor vehicles could not operate in the muddy terrain of the frontline, so horse-drawn carriages continued to be used. Train, barge and ship ambulances: The first ambulance train arrived in France in November 1914 (some later trains included operating theatres). After concerns that the transport of the wounded around the rail network could be damaging the war effort, canal barges were used as transport for the wounded to Base Hospitals. What was the nature of wounds suffered on the Western Front? Rifles and Explosives: In a case study of over 200,000 wounded men admitted to Casualty Clearing Stations (CCS), it discovered that high-explosive shells and shrapnel were responsible for 58% of wounds. About 60% of shrapnel injuries were to arms and legs. Bullets were responsible for 39% of wounds. n (containing gangrene and tetanus from the fertiliser) entered an exposed wound, gas gangrene could set in, spreading quickly through the body. Gas gangrene could killa person within aday (there wasno cure for this type of gangrene). Cases of tetanus reduced by the use of anti- tetanus injections from the end of 1914, Head injuries: When the steel Brodie helmet (prevented the heImet being thrown off) replaced the softcap in 1915, it was estimated that it reduced fatal head wounds by 80%. Gas attacks: - Chlorine: Led to death by suffocation. First used by the Germans in 1915 at the second battle of Ypres. = Phosgene: It was faster acting than chlorine gas, and could kill an exposed person within two days. First used at the end of 1915 near Ypres. = Mustard: An odourless gas that worked within 12 hours (causing internal and external blisters), burning the skin. First used in 1917 by the Germans, How were wounds and injuries treated on the Western Front? Gas gangrene: - Wound excision or debridement (new technique): The cutting away of dead, damaged and infected tissues from around the site of a gas gangrene wound (if notall was removed, the infection would spread again). This needed to be as soon as possible and closed by stitching - The Carrel-Dakin method (new technique): Antiseptics (e.g,, carbolic lotion) were inefficient when treating gas gangrene. The Carrel-Dakin method was the mosteeffective by 1917. A sterilised salt solution was placed into the wound through a tube. As the solution was only usable for hours, this had to made itas and when it was needed + Amputation: If wound excision or the Carrel-Dakin method did not succeed, amputation was the last course of treatment. By 1918, 240,000 men had lost limbs, many as a result of preventing the spread of infection, Gunshot and shrapnel wounds: = The introduction of the Thomas Splint in December 1915 increased the survival rate of compound fractures (where the broken bone pierces the skin), from 20% to 82%. ~ X-rays: Used from the start of the war to identify shell fragments and bullets in wounds which could prevent infection developing. However, clothing fragments couldn’tbe detected, men couldn’tstay still for the x-ray, and the machines could overheat easily so machines had to be rotated often Gas attacks: The British Army gave gas masks to troops on the frontline from 1915. Only about 6,000 British soldiers died as a result of gas attacks. How significant was the development of blood transfusions? Purpose: To stop the patient from going into shock through blood loss before surgery. Those who did not experience a negative reaction to the blood transfusion generally recovered. First attempted by James Blundell between 1818 and 1829, Blundell developed techniques that would be used in the First World War. From 1915, Lawrence Bruce Robertson (a Canadian doctor) pioneered the indirect method of blood transfusions (using a syringe and tube to transfer the donor blood into the patient) on the Western Front.‘As Robertson had success with transfusions Base Hospital at Boulogne, by 1917, blood transfusions were being administered in Casualty Clearing Stations (CCS) as a routine treatment. Geoffrey Keynes (a British doctor and lieutenant in the RAMX) designed a portable blood transfusion kit that, regulated the flow of blood and prevented clotting, which could be used close to the frontline. In 1915, Keynes used this method in a CCS on the Western Front. In 1901, Austrian doctor Karl Landsteiner discovered the existence of the blood groups A, B and 0 (AB was discovered in 1902). Reuben Ottenberg (an American doctor), identified blood group O as a universal blood group. Problems: The clotting of blood remained a problem, there was never enough blood to meet demand, and storing blood was a problem. Solutions: 1915, Richard Lewisohn (an American doctor) discovered that by adding, sodium citrate to blood meant donors did not need to be in the same room as patients. Richard Weil discovers later in 1915, that blood with sodium citrate could be refrigerated and stored for up to two days. In 1916, Francis Rous and James Turner found that by addinga citrate glucose solution to blood, it could be stored for up to four weeks. How significant were the experiments in surgery? Brain Surgery About 20% of all wounds in the British sector of the Western Front wereto the head. This often led to infection, confusion and unconsciousness. Very few doctors had experience of neurosurgery (surgery of the nervous system) before the war. Harvey Chushing (an American neurosurgeon) developed new techniques in brain surgery on the Wester Front. 1. Cushing experimented with the use of a magnet to remove metal fragments from the brain. 2. Cushing used alocal anaesthetic (keeps thepatient awake) when operating as the brain swelled asa resuk of general anaesthetic (putting patients to sleep). 3. He operated on 45 patients in 1917, with an operation survival rate of 71% compared to the general survival rate of 50% for brain surgery. Plastic Surgery Largely the work of a New Zealand ENT (ear nose and throat) surgeon, Harold Gillies. Head injuries could cause severe disfigurement which led Gilles to become interested in facial reconstruction. With no experience in this type of surgery, Gillies devised new operations to deal with the problemsas they occurred, Men who needed this surgery were returned to Britain. From August 1917, the key hospital providing this type of surgery was the Queen’s Hospital in Sidcup, Kent. By the end of the war, nearly 12,000 reconstructive operations had been carried out at Queen’s Hospital What was the chai of evacuation for soldiers on the frontline? Chain of evacuation Aid Posts (RAP) ~ Dressing Stations (ADA and MDS), Casualty Clearing Stations (CCS) and Base Hospitals. ~ These were the main stages but not always followed in this same order for every casualty. Royal Army Medical Corps (RAMC): The branch of the army responsible for medical care (founded in 1898) First Aid Nursing Yeomanry (FANY): The first women’s voluntary organisation to send volunteers to the Western Front. It provided frontline support for medical services. From January 1916 he British Army allowed FANY's to drive ambulances, replacing the role of the Red Cross. Opened the way for Voluntary Aid Detachments (VADs) to participate in the frontline. Regimental Aid Post (RAP): Generally located within 200 metres of the frontline (in communication trenches or deserted buildings). Made up of a Regimental Medical Officer, with some help from stretcher bearers. The purpose of the RAP was to give immediate first aid and to get as many men back fighting as possible. Serious injuries were moved to the next stage in the chainDressing Stations (ADS and MDS): Where possible, they were located in abandoned buildings, dug-outs or bunkers (protected from shelling). Each station would be staffed by belongingto the Field Ambulance unit of the RAMC (ten medical officers, medical orderlies and stretcher bearers and also nurses from 1915. They did not have the facilities to tend to wounded men for more than a week. Casualty Clearing Stations (CCS): Distanced from the frontiine (providing some safety from attacks) and often set upin buildings such as factories or schools. Located neara railway. When wounded soldiers arrived, they were separated into three groups (a triage): - The walking wounded: Could be patched and returned to fighting, - Those in need of hospital treatment: Would need to be transported to a Base Hospital = Those so severely wounded there was no chance of recovery: Made comfortable. Base Hospitals: Located near the French and Belgian coast closer to ports. Men weretreated in both Stationary and General Base Hospitals until they could be returned to Britain or were fit enough to return to fighting. AS CCSs operated on wounds quickly to avoid gangrene, Base Hospitals would usually continue the treatment begun at CCSs. Afterthe Germans launched the Spring Offensivein March 1918, much of the surgery required for wounded was now undertaken again in the Base Hospitals. Revision Tips: 1 Make flash cards on the influential figures throughout the different periods (.g., Vesalius, Simpson, Pasteur, Koch, Fleming) Make flash cards on the symptoms of the diseases below, and the different treatments throughout the periods, Smallpox Syphilis (Great Pox) MRSA’ Diphtheria Bubonic Plague Polio Cholera Pheumonic Plague Trench Foot Tuberculosis Typhoid Fever Gangrene Measles Trench Fever Shellshock,