Medicine through time

What are continuity and change?

Continuity is when something stays the same. This could be an attitude, belief of a medical practice. Change is when something different happens. This might be a new attitude or belief, or a new treatment.

Why is it important that we study continuity and change?

Medicine through time is a development study so its important that we look at how and why things have got from where they were in the past to how they are today. This allows us to compare the key features of different societies at different periods of time.

What examples are there of continuity over time?

Lots of things have stayed the same throughout time. Thing about what you do if you’re feeling unwell. The odds are that you’ll ask your parents for advice. This hasn’t changed through time. Usually its your mother that you’d ask, again this is something that hasn’t changed over time. For many ilnesses the treatment offered by a parent will be no different to treatments offered in the past. Simple but effective things like resting, having a hot or cold drink, some herbal remedies etc have been around for as long as we have recorded these things. Some beliefs have also continued to stay the same. Religion has always had an influence on medicine; there have always been superstitions; some people have always been frightened of new treatments and technologies. Similarly, ‘common sense’ has always had a role in medicine. For example the idea of isolating people with disease to prevent it spreading is nothing new.

Why have these things stayed the same?

One of the main reasons why something stays the same is the simple fact that it works! Other reasons are beliefs haven’t changed – people have always believed in spirits and gods, for example.

Why have some things changed over time?

New discoveries and technologies can lead to change. The invention of a new medical technique which is proven to work will, over time, lead to a change in the way that things are done. Attitudes can also change. This is often because the need for something to change becomes aparent. An example of this is the change in attitude of governments towards Public Health. As society changed, so did the attitude of those in power.

What might an examiner ask me about continuity and change?

All sorts! You could be asked to compare and contrast treatments in two different periods of time, in order to gauge the amount of change in that period. For example:

Comparing surgical techniques in 1800 with those in 1900 or the modern world.

Comparing methods of dealing with the Black Death with the way that people tried to deal with the Great Plague.

Comparing the treatments available in 1900 with those available today.

What is medical technology?

Medical technology refers to the machines that can be used to help identify an illness or treat it. This includes scanners that can look inside the body, X-Ray machines, Camera technology and equipment used to test samples.

What medical technologies have been developed in the Twentieth Century?

Just before the start of the Twentieth Century William Rontgen discovered how to make use of X-Rays. The use of X-Rays developed in the first part of the Twentieth Century and has improved the way that doctors identify broken bones etc.

One of the first X-Rays taken

In 1943 the first Dialysis machine was used. This was invented by Willem Kolff and replaces the functions of Kidneys which means that people with certain kinds of Kidney Failure can receive daily treatment for their condition.

In 1957 the EEG was introduced. This measures brain activity and is used to identify whether people have conditions such as Epilepsy.

1965 saw the first portable defibrilator. This allows ambulance crews to use the device to help reestablish a normal heartbeat.

Defibrilator

In the same year the first commercial ultrasound device was made available. This is another form of medical imaging which allows doctors to see the inside of the body. It is particularly useful when assessing how well a pregnacy is progressing, or for looking at the way in which specific parts of the body are functioning.

One of the best improvements to medical technology in recent years was the introduction of the CT Scanner in 1971. Invented by Godfrey hounsfield this machine scans the whole body and produces a 3D image of the inside of the body. This can be used to determine where disease is located and to see if it is spreading. In 1980 another improvement to medical imaging was made when the MRI scanner was introdced. This uses magnets to scan and can distinguish between healthy and unhealthy tissues, making it easier to spot things like Cancerous cells.

CT Scanner

What has been the impact of these machines?

Each of these machines makes diagnosis much easier and enables treatments to be accurate and undertaken at an early stage in an illness. This means that recovery is more likely and the quality of life of patients improves.

For a list of other new medical technologies, have a look at this timeline on Wikipedia.

What is the NHS?

The NHS is the National Health Service. This is a publically funded service that provides healthcare to people in the United Kingdom. This includes doctors, dentists, hospitals, health visitors and the ambulance service.

When was the NHS started?

The NHS started on July 5th, 1948. This followed a series of debates and government studies about provision of healthcare. Before the war the British Medical Association had published a pamphlet calling for a unified health service across the country. The outbreak of the second world war led to an Emergency Medical Service being estabished, which effectively nationalised the health service for the duration of the conflict. During the war the government set up an enquiry into healthcare and the resulting ‘Beveridge Report’ of 1942 called for a National Health Service, amongst other things. This was then put before parliament in 1944 and in 1946 a ‘National Health Service Act’ was passed. This legisation created the NHS, and set the timescale for it being established in 1948.

Why did the government start the NHS?

Before the NHS the health system was often based on the ability of someone to pay for treatment. There were free ‘voluntary’ hospitals and charity based hospitals but there was no guarantee of healthcare for all and services across the country were varied in terms of quality and availability. When the NHS was launched the minister in charge said that the NHS was based on three core prinicples:

* That it meet the needs of everyone
* That it be free at the point of delivery
* That it be based on clinical need, not ability to pay

What opposition was there to the foundation of the NHS?

At the time there was considerable opposition to the idea of a National Health Service. Some people argued that local authorities were better placed than the government to run hospitals. Opposition came from consultants who were concerned about the impact that the NHS would have on their income and ability to govern their own profession. There was also a fear that the poor would overburden the NHS and that there would be a prolongued ‘rush’ for pills, glasses and so on. These problems weren’t easily overcome and concessions had to be made to consultants in order to get the medical profession to accept the NHS.

What has been the impact of the NHS?

Life Expectancy in the UK has risen. In 1948 it was 71 for women and 66 for men. Now it is 81 for women and 77 for men.

Infant mortality figures have improved. Now just 6.2 deaths per 100,000 births compared with 86 in 1948.

This article on the Independent website provides further examples of the impact of the NHS.

What were the Liberal Reforms?

The Liberal Reforms were a series of government measures designed to help people who couldn’t help themselves. They included the introduction of National Insurance which included a contribution from the emplyee, employer and government which would be used to pay sick pay and unemployment benefits; Old Age Pensions were introduced; Free School Meals were given to children from impoversished backgrounds to make sure that they got at least one good meal a day and also included legislation covering medical checks of school pupils, limits to working hours and the opening of the first Labour Exchanges (job centres).

When did they take place?

The Liberal Reforms took place between 1906 and the outbreak of the First World War in 1914. The years of some of the key components are listed below:

1906 – Free School Meals
1907 – Medical Inspections in Schools
1908 – Young Persons Act
1908 – Old Age Pensions
1909 – Labour Exchanges
1911 – National Insurance

Why were the reforms introduced?

A number of factors led to the reforms. Many within the Liberal party were eager to help ordinary people and had campaigned with this as a key policy. The military had noted during the Boer War that many conscripts were not fit enough to fight – so something had to be done about it! As working class men could now vote, it was also very important to make sure that things were offered that they would vote for. The Liberals were also wary of the growing strenght of the Labour party. with whom they fored a coalition government in 1910. There was also further research into Public Health that showed that there was a need for intervention in some areas. Rowntree completed a survey of the working classes in York, for example, and Margaret McMillan was pioneering welfare work for children in Bradford at this time.

Were the reforms welcomed?

The ordinary people who benefitted from the reforms were obviously quite happy about things but there were opponents of these measures. Many people objected to the increases in tax to pay for the reforms; others complained at the National Insurance contributions they had to pay and politicians from other parties criticised the measures, to the point where there was a major consitutional crisis in 1909 when the House of Lords refused to approve the ‘Peoples Budget’ put forward by the Liberals. Some of these criticisms were from people who believed in the ideas of Laissez -Faire which basically means ‘leave them to sort it themselves’ whilst others criticised the reforms for not going far enough.

What impact did the Liberal Reforms have on health?

The Health of Children improved as a result of the reforms. By the outbreak of war around 150,000 pupils were receiving free school meals and regular medical inspections. This helped to reduce child mortality figures (as did the introduction of vaccines). Free medical care was available for some and this clearly helped to save lives. The quality of life for the elderly was also improved.

For further information see BBC Bitesize or complete the revision diagram at schoolhistory.co.uk.

What are infectious diseases?

Infectious diseases are illnesses that can be transmitted from person to person or spread through the air or water. They are spread by microbes which cannot be seen by the naked eye. Examples of infectious diseases in the past are the plague, smallpox and cholera. In recent years we have had outbreaks of swine flu, which is another infectious disease. See this youtube video for an overview of the history of infectious diseases.

How do we treat infectious diseases today?

In the western world there are vaccines available for many of the most dangerous infectious diseases. These vaccines mean that the spread of the disease is prevented. However these vaccines are not available in every country – something that the World Health Organisation is trying to rectify. For new variants, like swine flu, it is impossible to vaccinate in advance of the disease spreading. When this form of disease emerges scientists work hard to try and create a vaccine. Whilst they are doing this, people with symptoms are often quarantined, movements are restricted and painkillers and supressants are given to people who are ill.

Who discovered a way of tackling these diseases?

The first vaccinations were carried out by Edward Jenner who created a vaccine for smallpox. However he didn’t understand how the vaccine worked so it wasn’t until work by Louis Pasteur in the 1860’s that the cause of infectious diseases was proven to be germs. After this was established scientists like pasteur and Robert Koch were able to identify the microbes that caused certain diseases and develop vaccines for that disease.

What factors led to this discovery?

Eaxh of the scientists involved in the fight against infectious disease was a determined and highly motivated individual, so the Role of the Individual cannot be underestimated here. However the vaccines themselves were produced in huge quantities with governments funding both the research and the production of the vaccines. Often this has been prompted by involvement in wars. The development of vaccines has therefore been the result of a combination of factors.

How quickly did scientists manage to defeat different diseases?

Esward Jenner’s first experiment with a smallpox vaccine was in 1792. It took years for his ideas to be universaly accepted and smallpox was not eradicated until 1980! (Eradication of smallpox verified by WHO on 8th May 1980). Even after Jenner’s first use of vaccination it was not until the 1860’s that further breakthroughs were made. After Germ Theory (1862) there were a number of vaccines produced. Even these took time to create. A vaccine for Cholera was developed in 1879, followed by Rabies in 1885, Tetanus in 1890 and Typhoid in 1896. In the Twentieth Century vaccines have been developed for numerous other diseases – see http://en.wikipedia.org/wiki/Timeline_of_vaccines for a list of these.

How successful have scientists and doctors been in the fight against infectious disease?

In the modern world relatively few people die as a result of catching an infectious disease so it looks like scientists and doctors have been quite successful in the fight against these diseases. However not all infectious diseases have vaccines and they are not available everywhere yet. There are still outbreaks of infectious diseases that cause widespread concern. For example the spread of swine flu in recent years has caused much alarm and Bird Flu several years earlier also caused concern.

What is Public Health?

Public Health are things that a government does to try and ensure that things are clean and healthy for the public. Things like providing sewers, clean water etc.

When was the Industrial Revolution?

Most of the events that I’ll be talking about here happened in the 19th century. Industrialisation started a little earlier than this, in the mid 18th century.

What was the problem?

Industrialisation led to a really rapid change in the way that people lived and worked. As factories developed people rushed into towns to get jobs in them. A lot of the housing that was provided had been built quickly and without enough consideration of things like cleanliness, removal of human waste, provision of clean water, education of access to a healthy diet. As these areas grew in size, the problem got worse. These areas, slums as they are known, were rife for the spread of infectious diseases and life expectancy in some of them fell as low as 11 or 12!

How did they solve the problem?

It took a while for much to be done. In the 1830’s there was a review of the Poor Law which led to some changes in the way that por relief was given out but it was quite limited. As diseases like Cholera and Typhoid hit different parts of the country in that decade there were a series of local reports produced about health. It started to become clear (to some!) that something needed to be done to ensure that there were minimum conditions. This belief was reenforced by edwin Chadwick’s report on Health, which painted a pretty bad picture of conditions for the people living in poorer areas. The people who felt like this formed the Health of Towns Association which acted as a pressure group trying to persuade government and local councils to take action. As a result the government passed a Public Health act in 1848. Improvements were limited though in many places and Cholera once again returned and ravaged parts of the country. Despite the work of John Snow little was done to improve conditions until after the second reform act, when ordinary men were given the vote. This now made Public Health a real political issue – it was a vote winner! Soon afterwards there was a Royal Sanitary Commission established (1869) and its findings led to a Second Public Health Act (1872). This act placed responsibility for health on local authorities. As the implications of Pasteur’s Germ Theory became more widely understood it was clear that further action was needed – as some authorities had done little. A 3rd Public Health Act was introduced in 1875 which made the requirements very clear. This act was followed by lots of legislation about all sorts of health and building issues. In the twentieth century these pieces of legislation were followed up with slum clearances (they’d stopped slums being built but hadn’t ordered existing ones to be knocked down in the 19th century) and work was done on improving the health of children. The Liberal Reforms of the early 20th century and later introduction of the Welfare State are more recent examples of Public Health initiatives.

Why did it take so long to solve the problem?

Remember: CAFE

Cost – who was going to pay for the huge amount of work needed?
Attitude – people should learn to help themselves (called a Laissez Faire approach)
Fear – what will the working classes want next?
Evidence – is there any proof that the spending will improve things? until Germ Theory, there wasn’t any…

What was the revolution in surgery?

The term ‘revolution in surgery’ is used to describe a period of time when a series of breakthroughs led to surgery becoming cleaner, relatively pain free and much safer. Before this period surgery was quick, dirty and dangerous with patients having a large death rate due to blood loss, pain and infection. After the revolution in surgery each of these issues was minimised.

What period of time are we talking about?

Really open to interpretation here as some would argue that we’re still in this period. Here, I’m talking about surgery from about 1750 to about 1900.

What was surgery like before this period?

In simple terms: it was QUICK (it had to be to prevent blood loss); DIRTY (because people weren’t aware of the causes of infection) and PAINFUL (because there were few effective painkillers). Each of these three problems combine to make it very dangerous – though it was sometimes successful!

How was the problem of pain overcome?

Throughout time people have tried to overcome the problem of pain during surgery. They used things ranging from alchohol to hemlock to try and numb the pain, but numbing it was all that it really did. In the 19th century surgeons made some huge advances. Through experimentation they developed anaesthetics that meant that surgery became much less painful. Early attempts were the use of carbon dioxide (1820’s) and nitrous oxide (laughing gas) in 1846. Both had some pain relieving qualities but weren’t highly successful. Around the same time Crawford Long secretly made use of Ether on a patient. The same anaesthetic was then used by William Morton in 1846. News of his successful use of Ether led to it being tried by surgeons around the world. Ether had drawbacks though – patients sometimes vomitted as a result of being given it and it was highly flammable. The use of Ether was largely replaced by the use of Chloroform in the UK. This was first used by James Simpson in 1847 and became popular after it was made known that Queen Victoria had used it as a painkiller during childbirth.

Use of these painkilling anaesthetics developed. Local anaesthetics were introduced in 1877 and in the 20th century ways of inducing sleep and relaxing muscles were discovered.

How was the problem of blood loss overcome?

Surgeons had always known that loss of blood was a real problem and attempts had been made to replace it for some time. For example, in the 15th century Pope Innocent VIII had blood from 3 young boys infused into his body (basically pured down his mouth). It didn’t work – but the notion of transfusion was clearly recognised by some at that time. Experiments on animals and several humans took place throughout the 16th and 17th centuries with small amounts of blood from animals successfully being infused into several humans. All attempts to place large amounts of blood into people failed though. The first successful transfusion was in 1818 when James Blundell extracted 4 ounces of blood from his arm and successfully transfused it into his wife. Between 1825 and 1830 he carried out a further 10 transfusions and in 1840 he was part of the team who performed the first whole blood transfusion.

Even though they had worked out how to replace blood during surgery many patients still died. This was because the wrong kind of blood was often used. In 1901 Karl Landsteiner discovered blood groups. After this, surgeons could match blood groups and reduce the risk of there being a fatal reaction / rejection of the blood.

This just left the problem of having enough blood available. This problem has largely been solved through the development of blood banks and improved storage methods that have been developed over the past 100 years.

How was the problem of infection overcome?

The ultimate frustration for surgeons must have been to successfully operate, reduce blood loss and make sure that pain didn’t overcome the patient, only to see them die a few days later from an infection. Of course until Germ Theory was developed and accepted, surgeons weren’t sure what caused these infections and so they could only guess at what to do to limit the risk. One of the first to do so successfuly was Ignaz Semmelweiss. He insisted on cleanliness and had much better survival rates than other surgeons doing similar work – but he wasn’t able to convince others to do the same. The breakthrough came in 1867. Joseph Lister was a surgeon in Glasgow. He read about Germ Theory and realised that this was connected to the infections he saw. When he heard about a spray being used in sewers to reduce the risk of disease he decided to investigate. He quickly came to the conclusion that using Carbolic Acid to clean wounds and bandages would significantly reduce infections. His ideas were adopted by the German army in the Franco-Prussian war and the positive outcome helped to convince people that his methods were effective. Following this, Robert Koch worked on sterilisation of surgical equipment, which led to further improvements. This ‘big idea’ is antiseptic surgery – and antiseptics are still widely used today. These ideas have been developed so that nowadays not only are the bandages, wounds and equipment clean, so is the air! Modern operating theatres have filtered air streams and are ‘asceptic’ (ie totally clean).

Did everyone approve of the changes?

Some of these developments encountered lots of opposition. becase some of them were quite experimental they didn’t always work. This cast doubt over the merits of the ideas and until scientists ‘got it right’ there were many who doubted them. There are also moral and religious objections to some of these ideas, for example, Blood Transfusion.

What’s Renaissance and when was it?

Renaissance means re-birth. Its a period of time when lots of old ideas were challenged. When did it happen? Roughly the 14th to 17th centuries (AD).

What happened?

The churches power and authority were challenged! This might not seem to make much difference to medicine – but it did! Because the church had done most of the teaching about health, it had been hard to look for new ways of treating illnesses, or to explore the workings of the body. To do so could have been been seen as being anti-god (heresy). People who were thought of like that tended to get executed – so naturally people didn’t challenge the church often!

How did this affect medicine?

It meant that people were more willing to challenge the work of people like Galen, and also that they might be more willing to break some of the rules of the church. For example, dissection was still banned but now the authority of the church was questioned some anatomists were willing to take a risk and started dissecting. Results? Knowledge of the anatomy improved quite dramatically. Andreas Vesalius was able to produce a very detailed set of drawing of the human body and Wiliam Harvey discovered that blood circulated around the body: both were massive breakthroughs.

Massive breakthroughs? How did this help people at the time?

Heres the catch. People like Vesalius and Harvey made massive improvements to our knowledge about the way that the body worked and were able to spread their ideas quickly because of the printing press. However, neither of them knew what caused diseases so their findings were impressive but of little immediate use to doctors or patients. The area where there were breakthroughs that had an immediate and lasting effect on treatments was in the field of Surgery. Here a chance discovery in a battlefield hospital led to a massive improvement in the way that wounds were teated. A French surgeon, Pare, found that lotions he had concocted out of desperation, worked! He went on to gain a lot of support from the French monarchy and made several other breakthroughs – the use of ligatures, for example.

So, there were lots of new ideas – what about treatments?

Much the same as in earlier periods of time. Most people were still reliant on family members or trusted elders. There were an increasing number of trained doctors but they remained expensive. After the dissolution of the monasteries in the UK, there was also fewer places for the poor to go to receive help, though there were some more hospitals built. The doctors of King Charles II recorded the medicines they gave him in his dying days. They remained a combination of natural and supernatural attempts to tackle disease.

And Public Health, did that change?

Not particularly. There were some localised rules about waste and so on but in general investment was quite limited as other things remained more important to our rulers. The most significant chang in the UK came after the Great Plague and Fire of London. When the city was rebuilt, it was done so in a much more open and clean manner.

So did things get better during this period?

On a day to day basis for ordinary people with common ailments, probably not much. Scientists now had a lot more knowledge though, medicine was on the brink of being able to make massive leaps forward.

When was the Medieval period?

Different people put different dates on periods. For this post I’m talking about the period between the fall of Rome through to roughly 1450. Note – some medicine through time courses start in 1350…

What happened when the Roman Empire collapsed?

When the Romans left, so did much of the organisation and investment. In many areas the fall of Rome was quite violent and much was destroyed. This included books and some of the buildings that helped with Public Health. For a long time afterwards there was relatively little spent on Public Health as it was expensive and the money wasn’t availabe because it was often being spent on war. This led to some elements of medicine and health going backwards (regression).

Did everything get worse?

No. People still had access to wisewomen, herbal remedies and could turn to religion or the church for help. Richer people could still pay to see a doctor and there were still surgeons of varying levels of skill. For an ordinary person living in Britain, healthcare would have been little different – the noticeable change would have been the reduced number of trained doctors / surgeons. So whilst there were periods of chaos and war and a lack of learning about medicine, on a day to day level for ‘normal’ people things were little different in terms of medical practices.

What ideas stayed the same?

People still used common sense cures, went to family members for advice and used herbal remedies. There was also continued belief in supernatural causes of disease. A good example of the varied beliefs are the measures taken to try and prevent the Black Death spreading. This ranged from people whipping themselves to try and punish themselves for being sinners (they thought god was punishing them by sending the Plague) to quarantine being introduced in places. Charms, crosses and prayer were used by some, others linked it to bad smells and tried to clean the air. (Many tried a combination of these).

Did anything get better?

Lots of people make the mistake of thinking that things either got worse or just stayed the same in the Middle Ages. Thats not entirely true. As the church became more powerful there were increased numbers of monasteries. These provided infirmaries and helped the poor. The church also helped spread ideas and was largely responsible for the reintroduction of the ideas of people like Galen. Universities began to be built and there were some hospitals built.

What about breakthroughs and big ideas?

There wasn’t a ‘huge’ breakthrough or development in this period (in Europe at least), which is why some people think nothing got better. There were ‘little’ breakthroughs though! Theodoric of Lucca found out that it was best to drain pus from a wound and hemlock was being used to kill pain. Some of the new ideas being developed in the Islamic world started to spread into Europe as well (See this page for a brief introduction to Islamic Medicine).

When was Ancient Rome?

Historians believe Rome was founded in 753BC. It grew from being a small kingdom into a large Republic. From the first century BC until the fifth century AD, Rome had a large empire – and its the spread of Roman ideas around this empire that we’re interested in!

How was Ancient Rome organised?
For the purposes of this post, we’ll look at the Empire. Unlike the Greek civilisation the Romans were quite rigid in their organisation. At the top of the pile was the Emperor and beneath him the senate. The members of the senate were elected by citizens of Rome. Around the Empire control would be handed to a governor. He often had a large military force at his disposal to ensure law and order. In Briton some areas retained their old rulers, who acted as tenant kings and governed locally under Roman supervision. In areas where there had been lots of opposition, Roman rule was direct and enforced by the Roman army.

What was Roman Culture like then?
The Romans were pragmatic and borrowed ideas from many of the areas that they conquered or controlled. This meant that a lot of Greek ideas were widely accepted by Romans, as were religions and ideas from elsewhere in the empire. The Romans also enjoyed gladiatorial games and chariot racing. In general though the Romans weren’t as big a set of ‘thinkers’ as the Greeks, they tended to be more focussed on the practical side of things and ‘got on with it.’

How did this influence medicine?
On a simple level the Empire results in the spread of ideas and practices from as far apart as the North of England to Palestine, Egypt and into Persia. Roman values also meant that they took their own way of life with them: this meant that their liking for baths, for example, spread quite quickly. The Gladiatorial games gave surgeons loads of opportunities to look at different kinds of wounds and the importance of the army meant that there were lots of hospitals, surgeons and roads – all of which help to improve health.

Did the Romans create anything new then, or was it just a lot of borrowed ideas?

They certainly borrowed a lot – supernatural ideas continued, for example – but they also created a lot as well. The two ‘big’ things that this period is best known for are a person and an idea. The person was Galen, the idea: Public Health.

Whats Galen important for then?
Galen wrote LOADS. He came up with lots of new ideas about how the body worked and developed the ideas of people like Hippocrates. His real claim to fame is that his ideas were accepted for so long – all the way into the Renaissance! He wasn’t always right – Vesalius later corrects some of his more glaring errors – but he provided fairly sound advise on all types of illness / surgical need and, as doctor to the Emperor, had the clout to get his message heard!

Whats important about Public Health?
Nowadays we’re reminded that ‘coughs and sneezes spread diseases.’ They do… but infected water does a pretty nasty job of spreading disease too! The Romans brought clean water into towns and cities using Aqueducts and took dirty water away using Sewers. They also invested in public toilets and bathhouses. Whilst they didn’t know it, in doing so they were limiting the number of germs that could be spread through the water supply. Result? Healthier towns and cities – though don’t for a second think that this means that all Roman towns were clean and disease free as that wasnt the case!