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Paper 1 Key topics 1 and 2 (1250-1500, 1500-1700)

Year 11 GCSE

Paper 1 – Medicine Information booklet

Medieval 1250-1500 1500-1750

Enlightenment Modern

1900-present 1700-1900

Case study:

WW1

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) Key topic 1.1 – Causes of 1250-1500

At this there were four main ideas to explain why someone might become ill.

Religious reasons - The Church was very powerful at this time. People would attend church 2/3 a week and nuns and monks would care for people if they became ill. The Church told people that the Devil could infect people with disease and the only way to get better was to pray to God. The Church also told people that God could give you a disease to test your faith in him or sometimes send a great to punish people for their sins. People had so much belief in the Church no-one questioned the power of the Church and many people had believed this explanation of illness for over 1,000 years.

Astrology -After so many people in Britain died during the Black (1348-49) people began to look for new ways to explain why they became sick. At this time doctors were called . They would check someone’s urine and judge if you were ill based on its colour. They also believed they could work out why disease you had by looking at where the planets were when you were born. They would check where the planets were and believed if they were in a bad order this could disease in people. Although the Church disagreed with it because it challenged their view that disease was caused by the Devil or God it became more popular after the .

Miasma – this was the belief that when food or people rotted away they released a bad gas called miasma. This would enter the body and make the person sick. Therefore many people took great care to keep their home smelling nice.

The Four Humours – this was an idea put forward by the Ancient Greeks and Romans. They saw that the natural world was balanced into four elements (earth, air, fire, water) and believed the must be the same. It was put forward by a Greek called Hippocrates and developed by a Roman called . They believed there were four humours (liquids/elements) in the human body which were made from our food. Each person had their own balance of these humours, which would even affect your personality. If you ended up having too much of one humour you would become unbalanced and become sick. The four types were;

Blood – from cuts, or when coughed up Phlegm – the thicker watery substance from your nose or eyes Black bile – clotted blood that you might find in excrement (poo) or vomit Yellow bile – vomit or from a

This could explain both physical and mental problems. It was also linked to astrology as the and planets were linked to each. If you were sick you would go to a who would check the stars and tell you what the problem was with your balance based on this.

Why did these ideas continue during this period? The Church controlled at this time so they made sure that only traditional ideas about medicine were taught. For example the Church taught physicians about the four humours so this is what they used to find out about disease. Because the Church trusted the work of Hippocrates they copied books by these men, used them to teach other physicians and stopped anyone challenging their ideas. However without the technology there was no real way to find out what actually caused and nobody wanted to disagree with the church for fear of going to Hell by going against the idea of the Four Humours or the role of God in causing disease.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

1.1 Key facts – causes of disease 1250-1500 • Medieval people did not understand the behind how people became ill. They looked to the Church which told them it was a punishment from God • Others blamed a bad order of planets or miasma – bad air that came from rotting things that people believed entered your body and made you ill • The theory of the Four Humans came from the ancient work of Galen and Hippocrates • It said the body had four main fluids and if one was imbalanced it would make the person sick • The power of the Church and lack of scientific understanding saw little progress in understanding illness at this time. Key topic 1.2 – Prevention and treatment of illness 1250-1500

How did people treat diseases and try to prevent themselves becoming sick?

The Church- people were told that illness was sent by God as punishment for sin so you would have to pray to God for forgiveness as well as get help. People would pray in Church, go on a pilgrimage to a holy place where saints had been buried hoping this would them and go without food (fasting) to show God how sorry you were about your sins. The Church taught people that only through God’s forgiveness would he take away your illness.

Balancing out the humours - Today if someone is ill (e.g. coughing with a high temperature) we try and kill the germs causing the disease rather than just trying to stop the person coughing. In the Medieval period each symptom (and not the disease as they couldn’t detect this) would be treated. People believed an imbalance of your humours caused illness. People would do the opposite of the humour they had an imbalance of to correct this. For example if you had too much black bile, people would have a hot bath (check the diagram above).

Phlebotomy – The most common form of treatment was called phlebotomy or bleeding. People would pay a barber surgeon or wise women to cut a vein in their arm, use leeches to suck blood from them or scratch their and use hot cups to suck the blood out. Many people actually died from having too much blood taken from them. This was done when physicians believed there was too much blood in someone’s system. Purging – people believed that the body used food to create the four humours so sometimes you would have to get rid of all the food in your body to start again. People would take something called an emetic (such as or bitter herbs) to make themselves vomit. They could take a like linseeds. One physician would even squirt a special mixture up a person’s anus using a greased pipe attached to a pig’s bladder to help people go to the toilet more. This was called a clyster or . Thus was done when physicians believed there was too much yellow bile in someone. Remedies – people would also take herbal if they were ill. A famous medicine was something called theriaca. It was made by apothecaries and contained 70 different ingredients such as ginger, pepper, viper flesh and opium (heroin). Because the famous Galen had written about this medicine, people believed it would work. Taking remedies was much cheaper than seeing a physician so most poor people tended to take these.

How to prevent diseases? Everyone at this time was Christian and believed by going to Church, giving a tithe and trying not to sin God would not punish you with an illness. The Church also told people that being clean was almost as important as believing in God. People took advice from books Galen and Hippocrates had written about called the ‘regimen sanitatis1’. It told people to wash their hands before eating, do not overeat, bathe regularly and avoid extremes of heat, cold, dryness or humidity. As only the rich could afford private baths ordinary people would go to public baths or swim in rivers. The regimen sanitatis also told people to breathe clean air that did not contain miasma (rotting things) so people used sweet smelling herbs in their homes and some local towns even tried to organise the collection of rotting animals and cleaned smelly public toilets.

1 We can translate this as meaning have a clean regime or lifestyle 3

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) What was Medieval medicine like? - Asking for medical advice was expensive and not guaranteed to work (due to their limited medical knowledge) so most people chose to be looked after at home by the women in their family.

Physicians -However wealthy people could afford to pay for physicians (what doctors were called at this time). They only diagnosed why someone was ill and told them what to do, they would not treat the person themselves. First they would check the patient’s urine, blood and faeces. They would then find out when the person was born and check where the planets and stars were when they were born. They would then check their books and use these to tell them what they needed to do to re-balance their humours (e.g. bloodletting or purging). Most of the people educated to by physicians were priests who were not allowed to bleed patients. Only the wealthiest and members of the royal families could afford physicians.

Apothecaries – they used their education, training and books like Materia Medica to make herbal remedies to give to people. Physicians would tell apothecaries what to make and they would give this to people.

Barber surgeons – these were the least qualified of all the medical professionals in Medieval England. Many were actually hairdressers who because they were good with scissors and sharp knives would carry out minor , pull out bad teeth and carry out bleeding. A few were highly trained. They tended to be even more knowledgeable than physicians as they learnt by studying the human body and not just reading from books like physicians.

How were people cared for?

There were about 1,100 hospitals all over England by 1500 ranging from tiny houses with 6 beds for patients to hospitals that could look after hundreds. Some hospitals looked after people with the special illness of but most just offered hospitality (looking after guests) to people travelling to religious places. This is why they are called hospitals. 30% were run by the Church, monks and nuns the rest were funded by people leaving money in their will to look after the sick. Although the hospitals were kept clean by nuns they didn’t treat the sick people. Instead they believed that only prayer could fix an illness that God had sent. However the majority of people would be treated at home if they became ill. The women of that family were expected to look after the sick person and use herbs grown in the garden to help them become better.

1.2 Key facts – prevention/treatment of disease 1250-1500

• People believed disease was caused by God so they responded by praying, fasting and going on pilgrimages when ill. • Some people used spells or amulets to scare off illness. The Church was against this • People would try to rebalance the humours through eating differently, bleeding or purging • Without good treatment people focused on living a healthy, clean (regimen Sanitatis) • Physicians advised rich patients of how to balance their humours • Apothecaries gave out herbal remedies. Surgeons carried out operations with little training • Hospitals were run by monks and didn’t treat illnesses, this was done at home by the women in the family

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) 1.3 Case Study – Black Death 1348-49

This disease spread across Europe and killed 1/3 of the population of England. It was spread by and if you caught it you had about a 70% chance of dying within 5 days.

Beliefs about causes

People believed that God was punishing them for their sins through the Black Death. The fact that there was a strange alignment of planets a few years before convinced people it was a terrible punishment. People also believed that the disease was spread by bad air (miasma) maybe from a volcano or earthquake and some people even blamed the Jewish community (even though all Jews had been expelled from Britain in the 1200s).

Beliefs about treatments

As most people believed that illness was a punishment for sinning people would pray to God if they caught the Black Death. When people went to physicians they recommended the traditional methods of bleeding and purging to correct the imbalance of the humours. However this only sped up people’s . People tried remedies like theriaca or bursting their buboes (which helped some survive) but most techniques had little impact. As people did not know what caused the disease they did not know how to treat it.

How to prevent catching the Black Death

People continued praying and going on pilgrimage to ask God to forgive their sins so they wouldn’t become ill. Many people at this time became flagellants. They would walk through streets whipping themselves to prove to God how sorry they were.

People tried boiling vinegar (a strong smell) to stop miasma entering their home and physicians even told people to stop having baths because they worried it would open up the pores of your skin and let the miasma in. As there was no cure for the Black Death the best way to survive was to prevent yourself catching it. Many wealthy people left the towns and cities to escape the outbreak but poor people could not afford to leave their homes.

Government – the local government did not have much power at this time but they tried to do things to stop the terrible spread of the disease. They organised to have the streets cleared of rotting food and dead bodies to stop the spread of miasma. An important change during this plague was the invention of - the separating of people who were ill. The government passed a quarantine law which meant that when someone new came to a town they had to be kept away from other people for 40 days. This meant that if they were ill they wouldn’t spread this to other people. However rich people and priests could move around as they wished which weakened the impact of this new invention.

1.3 Key facts – Black Death (1348-49)

• Just like diseases – people blamed God, miasma and planet alignment for the plague • People prayed and flagellated themselves to stop the plague. Others used strong smells to combat the miasma • Some physicians continued to use bleeding and purging but this made things worse • Prevention was best. Rich people left the city and people avoided people in their family who were infected. • For the first time the local government began to quarantine people who might be carrying the plague (this did not apply to the rich or the church)

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

Key topic 2.1 causes of disease 1500-1750

Overview

Little changed during this period. Although people began to look for new ways to explain why we got ill people were still treated in the same way as before. People continued to believe that miasma caused disease. Even though the rest of Europe realised the Four Humours did not explain why people became sick, most people in England continued to believe in it. This period was known as the Renaissance as people rediscovered their love of being curious and finding out answers to questions. Some of the power of the Church began to decline and scientists began to come up with new ideas, they just weren’t followed or believed by the general public.

Ideas that changed a lot Ideas that changed a little Ideas that did not change Scientists began to better understand Although physicians continued to People continued to the human body (our anatomy) treat people using books, more believe that disease was Physicians realised you couldn’t physicians began to actually began spread by miasma (bad diagnose someone just looking at to observe their patient. air). This became even their urine Most people now began to accept more popular during Scientists stopped believing in the God didn’t cause illness, but people widespread disease Four Humours, but physicians still still turned back to God during outbreaks () used it with patients as they plagues understood it Less people used astrology to help diagnose them New ideas

A key figure during the Renaissance was Thomas Sydenham. He was called the ‘English Hippocrates’ as he had such an influence on medicine in England. At this time people would ask the person what was wrong with them and use books to give them a cure for each symptom individually rather than treating the illness. Sydenham taught people to observe the symptoms and to treat the disease that was causing them. People had believed that as illness was caused by the imbalance of the four humours, each illness was individual to each person. Sydenham believed that different people could suffer from the same disease and that diseases could be grouped into similar groups. This was an important change in thinking about what caused disease, however it wasn’t widely accepted by many people.

Improved communication

In 1440 a man called Johannes Guttenberg invented the printing press. This meant that books no longer had to written by hand. This meant more books could be produced, they would be cheaper and more people would have access to them. This meant that more people could learn about scientific discoveries and new ideas about medicine. It also meant that the Church was no longer in control of producing books (as monks had been mostly responsible for producing books). This allowed new ideas which disagreed with the teachings of the Church to be produced, such as criticising Galen. However, it was not until much later that this really helped to change medical understanding.

Another new idea was the Royal Society. As people carried out more experiment to find out about the world, scientists wanted to find a way to share their findings. In 1660 they created the Royal Society – a place where they could share their work. The fact that King Charles II supported this society helped to give them more respect. They published different scientist’s work to share with others which we call a journal. For example if shared the work of a scientist called Leeuwebhoek who used a new invention called the to draw pictures of the he saw. This was the first time that people had been able to see bacteria. Although he did not what they did he 6

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) called them ‘animalcules’. A scientist called Hooke used this information published in the Royal Society journal to carry out his own and prove that bacteria did exist.

2.1 1500-1700 – Causes of disease

• Little change in how diseases were caused so little change in how they were detected • Physicians no longer believed that an imbalance of the humours caused diseases but didn’t have

any new ideas to replace it so continued to use it when diagnosing illnesses • Sydenham encouraged other doctors to observe their patients and treat their symptoms together rather than just using books to treat each symptom separately

• The printing press and Royal Society made it easier for scientists to share their work • Hooke used the Royal Society journal to prove the existence of animalcules (bacteria)

Key topic 2.2 Ideas about prevention and treatment 1500-1700

What didn’t change What did change Preventing People still believed that prayer and People now also thought that your condition at disease charms could stop illness birth played a role as well as not doing too much of something Being clean This was still very important, people People stopped using public baths as they thought would always wash their hand it spread . People washed their clothes more instead of washing themselves Regimen People continued to follow these People began to think disease could be linked to Sanitatis instructions (eat healthy, fresh air) weather Miasma People believed rotting bodies The government started to pay to remove things released a gas which spread disease that would cause miasma in cities (e.g. sewage and rubbish from streets)

People continued to use herbal remedies to cure their illness, however a new idea was the importance of the colour of the disease. People would drink red wine if they had red from having small pox or eating something yellow if their skin turned that colour.

A new science was emerging at this time called medical chemistry which tried new chemicals to try and fix illnesses. A metal called antimony would be mixed with a liquid to help someone ‘purge’ their body in the hope of rebalancing their humours. Although too much could poison someone this metal had cured King Louis XIV of France who had typhoid so it had made it more popular.

As no one had found a good way to make someone better when they became ill the most important way people thought about their was preventing them becoming ill in the first person. Lots of the old ways of preventing sickness remained important during this period ( and regimen Sanitatis) with a few changes. People began to link how strong and large you were at birth and believed that babies who were small and weak would be more likely to catch diseases. Less people began to attend public baths from 1546 when King Henry VIII closed them down. People had been catching the STI syphilis when attending them so they were shut down (though this was because bathhouses were often brothels as well). The government also wanted to take steps to prevent disease so they tackled the causes of miasma. They fined people who left rubbish outside their house and arranged for criminals to be punished by going around and picking up rubbish on the streets. All of this was designed to reduce the ‘causes’ of miasma.

How were people looked after?

Apothecaries continued to hand out remedies to sick people who could not afford physicians, however with medical chemistry growing they now had new ingredients to mix in. Education increased for both apothecaries

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) and surgeons. They now had to have a licence to operate which improved the quality of people who carried out this job and they began to have more training which made them even better at their job.

Physicians continued to be trained at university with only small changes. Most physicians continued to learn from books rather than observing the human body and new ideas about the spread of disease were slow to catch on. However with the printing press new books which challenged the Church’s ideas about health began to spread (such as the work as Vesalius). This meant that physicians began to learn more about how the human body worked. With the church becoming less powerful it was now no longer ideal to carry out dissections for physicians to see how the body worked for themselves. However physicians still thought it was the job of the lower skilled surgeons to carry out operations and it was hard to get a supply of human bodies for universities to experiment on.

Vesalius and anatomy – was a Belgium scientist who wanted to find out more about the human body. He worked at the famous Padua University in Italy which was the number one in the world. Vesalius made a deal with the local police force there who allowed him to dissect the body of executed criminals. This was one of the first examples of a scientist actually looking inside the human body to see how it worked. He was therefore able to disprove lots of the older ideas about human anatomy, for example writing a list of 300 mistakes that Galen had made in his work – including that men did not have fewer ribs then women. He therefore encouraged more doctors to carry out their experiments to find out more about the human body and challenge many of the ideas they had learnt about from their old books. Vesalius published lots of books – many with lift up flaps to show how the human body worked. His most famous book was On the Fabric of the Human body

Hospitals

At the start of the 1500s the role of hospitals began to change. Hospitals actually began to cure people with illnesses like and skin conditions as they received healthy meals, herbal and a visit from a physician. All of this was provided by the Church. However in 1536 King Henry VIII took control of the entire church during the English Reformation. He closed monasteries and churches down which meant that the hospitals they ran also closed down. There were only 5 hospitals left in England by 1700! Gradually some hospitals began to re-open but these were run by charities and were not run by the Church. However most people continued to be looked after at home by women in the family.

Another change in hospital care was the emergence of pest houses, these were hospitals which only looked after specific illnesses. People realised that some diseases were easily spread (though they didn’t know why) so they put these people in the same place.

2.2 1500-1700 – prevention and treatment • Treatment changed little. Herbal remedies, bleeding and purging are all still common • New ideas in medical chemistry saw more chemicals used to try and cure illnesses. New ingredients from newly explored countries were also used. • People still believed in miasma so kept a clean home and used strong smells to stop it spreading • Apothecaries and surgeons have to have a licence and receive more training • Physicians begin to study more about anatomy thanks to Vesalius and a ban on dissections being removed due to declining power of the Church • Vesalius carries out experiments to show how the body works. He disproves Galen’s ideas and shows them in a new books – Fabric of the Human body • Less hospitals due to monasteries being closed by Henry VIII, those that remain begin to focus more on treatment. Most people are still looked after by women at home.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) 2.3 Case study ( and the Great Plague)

Harvey

William Harvey was a scientist just like Sydenham who believed more in basing your judgements on what you saw in the patient rather than following what medical books told you to do. Harvey built on work by other scientists to show that human veins had valves, when you pumped blood through them, it could only go one way – which proved the old theories of Galen wrong (that when you ate something it would be converted into blood by the and then be used up by the body). Harvey showed for this to work the liver would have to make 1,800 litres of blood a day – equivalent to 23 full baths!

Harvey proved lots of Galen’s old ideas wrong. He proved that the arteries and veins were linked together and that the heart was a pump which pumped blood around the body in a circuit. He believed that the heart pumped blood to the and then the heart pumped blood around the body in a circuit. He also showed that the veins and arteries just carried blood which proved Galen wrong who believed it carried both blood and pneuma (the air you breath and your soul). The fact that Vesalius had already begun to prove Galen wrong and that King Charles I picked Harvey as his personal physician gave him more credibility. However although his work and books encouraged other scientists to carry out more experiments on the human body people had yet to figure out how this new information about the heart and arteries could actually improve health.

The Great Plague 1665

What caused the plague?

In 1665 another plague hit England with 1 in 5 people dying in from it (100,000). It terrorised the people and no-one realised it was spread by fleas on , just like the Black Death.

People still believed it had been caused by God punishing us or by a bad alignment of Mars and Saturn however even more people believed it was spread by miasma. Bad air made from rotting things which hid in the ground and came out when the weather got hot. As the outbreak happened in June, this seemed to confirm people’s thoughts about it.

How to treat the plague?

As people had the same beliefs about the causes of the plague, they used the same treatments. Physicians told people to wear heavy clothes beside a fire so they could ‘sweat’ out the illness. People tried to transfer the disease to other things by strapping live chickens to their buboes to draw out the poison. Many people took advantage of people’s suffering and made up fake herbal remedies to ‘cure’ the disease – these were called quack doctors.

How did people try and prevent the plague?

Physicians told people to pray, carry strong smelling balls with them called pomanders and to quarantine people who had the plague. Plague doctors wore bird masks as they were associated with attracting disease in the hope that the mask would distract the disease from entering the person.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) Apothecaries sold people traditional herbal remedies as well as new ones made from exotic new spices that were coming into England. People were also encouraged to smoke as it would scare away the miasma with its strong smell. As the STI syphilis also gave you buboes, people believed catching the lesser disease would stop you catching the plague. People went out of their way to catch this STI, however it wouldn’t stop you contracting the plague.

The biggest change at this time was how much action the government took. King Charles II ordered people to eat less food (fast) and gave lots of instructions of what people should do. Local governments carried these out and banned public meetings where disease could be spread (like funerals or theatre), streets were cleaned, fires were lit to keep off the miasma and people were ordered to kill animals they believed spread disease – cats, dogs and pigeons (40,000 dogs and 200,000 cats!). The mayor appointed people to check the spread of the disease. If a house had someone sick in it they would be quarantined with a red cross painted over the door for 28 days. The local church would bring food to this home and carts would collect dead bodies when they were left on the street. As people didn’t know how to cure the disease preventing its spread was the most important thing they could do.

2. 3 Key facts – Case study 1500-1700 (Harvey and the Great Plague)

• Harvey proved that blood circulated around the body and was pumped by the heart. • He proved Galen’s ideas about blood being made in the liver from food and absorbed into the body as wrong. • People could not translate this new information into medical care yet so it had little impact on people’s health

• His biggest impact was inspiring more scientists to carry out more experiments on the human body to find out how it worked • Great Plague - People continued to believe that plagues were caused by God, planets being in a

bad position or miasma • People began to realise that the plague could be spread from one person to another (but didn’t know how)

• People believed in miasma so they used strong smells to scare it away to prevent catching it • The government took more action than during the Black Death (closing theatres and public places, cleaning streets, killing 40,000 dogs and 200,000 cats and mayors ordering houses to be

quarantined for 28 days if someone became ill)

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

Key topic 3.1 – Causes of disease 1700-1900

This period was very excting in terms of medical change. People no longer looked to the Church for all the answers, and tried to find explanations in science instead. They rejected the idea that people should be told what to think by the Church, the nobles or their government. This was called the Enlightenment. It also became even more important to find scientific causes for disease as more people were living close together in cities, so diseases like and could spread more easily. The search for scientific explanations led to the Scientific Revolution, when lots of new techniques and ideas were discovered.

At first, in the 1700s, people moved away from their belief in the four humours (although most still believed in miasma). However, they didn’t have a proven idea to replace it. The new theory was that disease was caused by ‘’. This idea said that microbes, which is a general name for disease-causing creatures (we now call them bacteria, germs and ), could be suddenly created out of rotting matter, and were spread through miasmata (plural of miasma).

Then, in 1860, came a huge breakthrough in the French Academy of Science by a man called . Pasteur had been working on disproving the idea of ‘spontaneous generation’. He used a microscope to see what happened when he left wine and vinegar open to the air, and they went ‘bad’. He discovered that tiny microbes, which he called germs, appeared on the wine and vinegar as they went bad. But were these things produced by the wine and vinegar as they rotted, or did they cause the rot? He then did an experiment where he sterilised some wine and vinegar and covered it. As no air could get in, the wine and vinegar didn’t go off. This proved that the germs weren’t produced by rotting wine and vinegar, but caused them to rot instead, and must have been carried in the air. This gave him the idea that human diseases might also be caused by something carried in the air, instead of something produced by rotting matter and carried in a miasma.

This idea didn’t spread quickly – in Britain, a famous doctor called Henry Bastian continued to support the idea of ‘spontaneous generation’, and others copied him, refusing to listen to Pasteur. People did not want to believe Pasteur’s idea that microbes in the air caused disease as they also saw microbes (using ) in perfectly healthy people. They didn’t know that some microbes are healthy for us and some are harmful.

It wasn’t until German scientist furthered Pasteur’s research that people really started to listen. Koch proved that certain types of microbe are good, but others cause disease. He did this by discovering the bacteria that causes tuberculosis, a common and deadly disease, in 1882. In 1883, he began working on , and identified the bacteria that caused it. He did this by looking at water samples from an area in India where a cholera had broken out. He saw a particular shaped bacteria under the microscope when looking at the water, and proved that it caused the disease. Finally, he invented a way for scientists to grow more of these bacteria in order to study them, by using jelly in a petri dish (invented by his colleague Joseph Petri). This inspired other scientists to go on and discover the microbes that caused other diseases (e.g. , the plague, ). He won the for Medicine in 1905.

At first, not many doctors paid attention to this, as the government continued to spread the idea that miasma caused disease. However, eventually, these discoveries had an enormous impact on doctors’ knowledge about disease. Now, they could identify that actually caused the disease, and find effective ways to stop them. An example of a disease that was stopped in this way was , which caused a painful and fever, especially in children, and eventually stopped them from breathing. 11

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

3.1 Key facts – causes of disease 1700-1900 • The Enlightenment and Scientific Revolution both happened during this time, leading to more discoveries. • Many scientists tried to prove that ‘spontaneous generation’ was wrong. • Louis Pasteur discovered microbes were carried in the air in 1860, and caused food to rot. • Many people, e.g. famous doctor Henry Bastian, didn’t listen to Pasteur at first. • German scientist Robert Koch found out that microbes caused diseases. First discovery was tuberculosis, 1882. Also invented petri dish and agar jelly, so microbes could be studied. • Government was at first resistant, but eventually this allowed treatment of many diseases e.g. diphtheria

Key topic 3.2 – Prevention and treatment of illness 1700-1900

Just because there were new, proven theories about what caused disease didn’t mean treatment changed straight away. In fact, it would take a long time to research and find things that stopped the microbes from causing disease. This meant that people carried on using herbal remedies for many years. There was also lots of continuity in terms of how people prevented diseases, because stopping the spread of germs also involved being clean, as physicians and priests had advised in the medieval period (remember the regimen sanitatis).

Hospital treatment:

After Henry VIII closed down the monasteries, new hospitals weren’t built to replace them. In fact, there were only 5 hospitals left by 1700 (from 1,100 in the medieval period)! However, during the 1700s, some wealthy people such as lawyers and businessmen started donating to set up new hospitals, to replace the monasteries. As these hospitals were not linked to religious houses, they were seen more as a place to go when you were sick, rather than a place to rest and pray. Doctors played a bigger role, and people were cared for by untrained nurses rather than nuns. There would also be a surgeon or apothecary on site for treatments. However, conditions in the hospitals were still unhygienic; although infectious patients were isolated, doctors went from patient to patient without washing their hands, and diseases spread quickly.

These hospitals mostly treated ‘the deserving poor’: this means working class people who had a job, but couldn’t afford their medical bills to doctors at home. Vagrants (homeless people) or others, whose was blamed on laziness, were not treated. Nor were the wealthy: they preferred to be treated in their own homes, even having there. Nevertheless, this was still an important change, as it meant that poor people had access to proper doctors for the first time.

One individual who had a huge impact on hospital treatment in the 1800s was Florence Nightingale. She was born in a wealthy family and, after having a religious vision, convinced her parents to allow her to train as a nurse. She was well-trained, and became head of nurses at King’s College Hospital in London. In 1854, the Crimean War broke out between Britain and Russia, and newspapers reported that soldiers fighting in the war were suffering due to the lack of good hospitals in the Crimea. Nightingale convinced the government to send her and 38 other nurses to help improve the hospitals. She made several improvements: clean bedding and good meals were provided; nurses were organised to treat 2,000 soldiers; and 300 scrubbing brushes were ordered to keep conditions cleaner. This was very effective – the death rate in the hospitals went from 40% to 2%!

When Nightingale returned to Britain, she was celebrated as a hero. She used this respect to improve the hospitals in Britain as well, focusing on the design of hospitals and the training of nurses. She recommended that hospitals be designed with large windows, big airy wards, and separate rooms. This helped germs to escape and stopped diseases from spreading as quickly. She also set up a nursing college at St Thomas’ Hospital, called the Nightingale School for Nurses, in 1860. This made nursing a more respectable profession, and attracted more people to become nurses.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) Overall, this period saw a huge change in hospital care. Hospitals were now seen as a place to give medical treatment to make the sick better. Doctors had a central role, nurses were better trained, and hospitals were designed in a much cleaner way. They also used to prevent (see below).

Surgical treatment:

In the 1700s, surgery was difficult due to 3 main problems: bleeding, pain (opium was sometimes used to calm patients, but there was nothing to numb the agonising pain) and infection (even if surgery was completed quickly to limit bleeding, often set in afterwards). This meant that surgery was limited, often to basic and essential operations like amputation. However, two developments in this period hugely improved surgery: anaesthetic (for pain) and antiseptic (for infection).

Ether was the first anaesthetic to be discovered in the 1800s, and used in America. However, it was problematic: it made patients cough while anaesthetised during surgery, and it caused vomiting after they awoke. James Simpson, a surgeon from Edinburgh, wanted to find a better chemical to use. He experimented in 1847 with his friends, using a substance called chloroform and sniffing it to see what happened. They all passed out and were discovered later by his wife! They woke unharmed: clearly this was a good anaesthetic. It wasn’t perfect (you had to be very careful with dosage, as people could die easily from an overdose) but it was much better than ether. It was used on Queen Victoria in 1853, during the birth of her son, and became even more popular. Chloroform allowed much more effective and complicated surgeries to be carried out. However, it wasn’t popular straight away: some surgeons thought patients were more likely to die when anaesthetised; other people thought that things like were meant to be painful as part of God’s plan; and since anaesthetics allowed more complex surgeries, they actually increased the number of deaths from infection.

Surgeons didn’t know how infections were caused and so didn’t take precautions we do today. They often wore their dirtiest, most stained coats to show how experienced they were! This changed with the discovery of a man called . Lister looked at infected and noticed that the flesh seemed to be rotting. He remembered Pasteur’s discovery, that microbes caused food to rot, and thought that microbes might also cause infection. He wanted to find a substance that would stop microbes from causing wounds to become infected, and knew that carbolic was used to treat sewage. In 1865, he soaked a bandage in carbolic acid and applied it to a surgical wound, and the wound healed perfectly. He then published his research in a medical magazine called ‘’, recommending that surgeons spray carbolic acid in the air during a surgery. However, it took a long time to catch on: carbolic acid made surgeons’ hands dry and sore, so many refused to think it could be good for patients, and Lister hadn’t done any research on why the spray worked, only that it did. By 1890, better methods of preventing infection had been discovered (as we will see in the next key topic). However, the use of carbolic acid was important in making surgeons realise that things could, and should, be done to prevent infection.

Prevention by the government:

The 1800s involved a big change in the government’s role in preventing disease. In the late 1800s laws were passed to make voting fairer, and give the vote to more men. 56% of men could vote by 1885. This meant that people thought the government, as the people’s representatives, should do more to help ordinary people’s health. In the 1860s, the government started taking responsibility to improve living conditions in cities. 1,300 miles of sewers were built in London by 1865, and slums were banned in Birmingham. In 1875, the Act was passed. This set many new laws for cities to follow, including the building of public toilets, public parks for exercise, checking the quality of food in shops, and providing clean water.

Prevention through :

One of the things that the government took responsibility for was vaccination against smallpox (when people were injected with a small quantity of a less deadly disease, so that they developed to smallpox). 13

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) was the doctor who invented vaccination. He was a GP in Gloucestershire, trying to find a way to prevent smallpox. This was a very deadly disease – there were 11 smallpox epidemics in London during the 1700s. The previous method of stopping the disease from spreading was ‘’ – where you infect someone with a small quantity of the actual disease. This was risky as people often developed the full-blown disease anyway. Jenner noticed that milk maids, who worked on dairy farms, often did not catch smallpox when there was an epidemic. He found out that the milk maids who didn’t catch it had already had a similar disease, which was much less deadly, called cowpox. Jenner decided that if you had cowpox, in must make you immune to smallpox. He tested this by giving cowpox to a local boy, and then later, trying to infect the boy with smallpox. The boy did not catch smallpox. Jenner did more tests and then published his work in 1798, calling it ‘vaccination’ after the Latin word for cow (‘vacca’).

Jenner’s idea was not popular straight away. Some people were wary anyway about purposefully infecting someone with a disease. The Church opposed it as they believed that using animal infections in human medicine was against God’s will. Finally, the Royal Society refused to publish it, as it was unpopular with many doctors who already made money from the alternative, inoculation. Its impact was also limited by the fact that it only worked for smallpox – other diseases did not work in this way, with a less deadly disease that could be used to prevent the more deadly one.

However, the government preferred vaccination to inoculation as it was less risky and cheaper. They therefore appointed ‘public vaccinators’ (doctors paid by the government to vaccinate people against smallpox) in 1871, and made vaccination compulsory for everyone in 1872. After this, the number of people catching smallpox fell dramatically. This had a huge impact on what was a very deadly disease at the time.

Even though the smallpox was the only one that could be developed using a less deadly disease to prevent a more deadly one, scientists still tried to develop ways to prevent other diseases. Louis Pasteur discovered that for some diseases, you could produce a weaker version, which could then be used to vaccinate people. Pasteur first did this for a disease called chicken cholera – cholera that affected chickens. He also developed using weakened versions of and – two other animal diseases. Pasteur didn’t know why this worked at the time. However, his research inspired many other scientists to create vaccines for deadly diseases affecting humans. Now, we know that this works by causing the bodies of people who have been vaccinated to produce (particles in the body that attack and kill germs. Each germ has a matching ). Then, if the person encounters the disease again in its stronger form, they already have the antibodies to fight it off, so won’t become ill.

3.2 Key facts – prevention/treatment of disease 1700-1900

• Hospitals were in poor condition at the start of the 1700s – there were only 5, they were unhygienic, and only for the ‘deserving poor’. • Florence Nightingale, celebrated for her work in improving hospitals in the Crimea (death rate of soldiers went from 40% to 2%) improved hospitals in Britain, too. She designed new hospitals to be airier, and started the Nightingale School for Nurses at St Thomas’ Hospital, 1860.

• James Simpson replaced ether (a problematic anaesthetic) with chloroform in 1847. This allowed more complex surgeries. • Joseph Lister discovered antiseptic carbolic acid in 1865, making surgeons realise that they could – and

should – take action to prevent infection. • The government took a bigger role in disease prevention from the late 1800s, e.g. by passing the 1875 Public Health Act. Sewers were built, water was cleaned, and parks for exercise were provided.

• Edward Jenner replaced the risky inoculation for smallpox with vaccination in 1798 (using cowpox). Thiswas made compulsory in 1872. This inspired Pasteur to discover animal vaccines (e.g. chicken cholera), and others to work on more human vaccines.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) 3.3 Case study: Cholera in London

Cholera was a horrible disease that was spread through water or person-to-person contact. It caused severe sickness and diarrhoea, making people dehydrated from loss of water. This would cause your blood to thicken and blood vessels to burst under your skin, giving the skin a blueish look (it was nicknamed the ‘blue death’). Cholera arrived in Britain in 1831, and in London in February 1832. It was very deadly: there were 5,275 deaths in London by the end of 1832, and a total of 21,882 deaths across the country. There were then three further epidemics in following years: 1848-49 (53,293 dead), 1853-54 (20,097 dead) and 1865-66 (14,378 dead). It mostly affected the poor, as they lived close together in dirty conditions.

The government had tried to stop the spread of cholera with little success. As the belief in miasma was still popular among many people, the streets were cleaned, and efforts were made to clean the water supplies. However, this was not done thoroughly enough to have a real impact.

This was when a surgeon called , who lived in London, decided to research the cholera epidemic and try to find out what caused it. He wrote up his ideas in 1848-49. He decided that, since cholera affected the digestive system and not the lungs, it couldn’t be spread through the air (or by miasmata). Having looked at the sewage system, where faeces were being disposed of in the drains, he decided that this sewage must be finding its way into the water supply and causing cholera.

In 1854, an outbreak of cholera happened where Snow lived, in Soho. There were 93 deaths. Snow drew a map of the area and marked on where the deaths happened (see picture). He noticed that the deaths seemed to be focused around a water pump on Broad Street (people got their water from a pump in the street and carried it into their homes, rather than from a tap in the home). Around the pump, there had been 200 deaths. A factory that used the pump had 18 deaths. A brewery nearby, which had its own water supply (and allowed the workers to drink beer rather than water) had only 5 deaths, out of 535 workers. One strange case that seemed to go against this was a woman who lived in Hampstead, several miles from the pump, who died from cholera. Snow questioned her family and it turned out that she used to live by the Broad Street pump, and had a bottle of water brought to her from the pump every day, because she liked the way the water tasted! Snow removed the handle from the pump, stopping people from using it, and the cholera outbreak stopped. Later, it was found that the pump was only one metre away from a cesspit (an underground pit for storing sewage). The cesspit’s brick walls had cracked, allowing sewage to get into the water.

In 1855, Snow presented his findings to Parliament. Eventually he convinced them to improve the sewage systems in London. However, they were still slow to do this. The General Board of Health still insisted that cholera must be spread through the air. This is likely because admitting that cholera was spread by water would force the government to take expensive action to fix the problem. It is also because at this time, people didn’t understand why dirty water would spread disease: Pasteur wouldn’t publish his Germ Theory until 1860, and Koch didn’t discover the bacteria that caused cholera until 1883. It was only in 1858, during a very hot and dry summer, that the ‘Great Stink’ caused them to take action. The hot weather meant that the Thames water was very low, and sewage was being washed up on the banks of the river. The heat then warmed it up and made it smell awful! In

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) 1860, work on an improved sewage system started. A man called Joseph Balgazette designed this, and it was completed in 1875.

3.3 Key facts – Cholera in London (1831-1875)

• Cholera arrived in London in 1832 – over 5,000 people died in that year. • Belief in miasma was still widespread, limiting the effectiveness of efforts to stop cholera. • John Snow was a surgeon who started studying cholera. In 1854, an outbreak near where he lived allowed him to discover that cholera was spread through dirty water. • Snow found that the Broad Street water pump was causing cholera to spread through the area. He removed the pump’s handle and people stopped getting cholera. • However, Parliament was slow to act. Snow didn’t have proof of why water spread cholera (Pasteur wouldn’t publish the germ theory until 1860). Also, it would be very expensive to change the sewers. • Eventually, after the ‘Great Stink’ of 1858, the government was persuaded to improve the sewers. This was started in 1860, and completed in 1875.

Key topic 4.1: Causes of disease 1900-present.

Overview:

The 1900s saw huge changes in medical knowledge, due to improved laboratory research. Instead of just looking at and talking to patients in order to find out what disease they had, doctors could now do medical tests. They took samples of things like blood, (samples of a small piece of flesh) and urine and tested them in labs. They also did x-rays and other types of scan to see inside the body. This made diagnosis much more accurate, and was a very important change.

Understanding of genetic causes of disease:

After the discovery of microbes as a cause of disease (Pasteur and Koch, 1860-1883), one thing still puzzled doctors: why were some people born with hereditary diseases (diseases that have come from passed on by your parents)? Over the first part of the , scientists came up with several theories for how diseases (and other traits) are inherited, but had no proof. For example, English doctor Archibald Darrod theorised in 1902 that inherited diseases are called by missing information in chemical information stored inside the body. This wasn’t proven correct until 1941, by 2 scientists in the US. By 1951, scientists had an idea that substances in cells passed information from parent to child, which then dictated the child’s characteristics. Finally in 1953, DNA (deoxyribonucleic acid) was discovered.

DNA was discovered by , an American, and , an Englishman. They were sharing an office at Cambridge University, and were both interested in human . They saw some x-rays that showed DNA, taken at King’s College London (by and ). They discovered that DNA was shaped as a ‘double ’ (a symmetrical structure that twists around – see picture). To divide and produce a new , the symmetrical structure would split in half and then duplicate (double) itself.

There were many factors that contributed to the discovery and development in our understanding of DNA. One was technology: in 1931, the was developed, which was much more powerful than the older microscopes. It magnifies samples by 10,000,000 times, compared to 2,000 times on the old microscopes. Scientists also worked together to improve their understanding. For

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) example, in 1990, the Human Project was made, allowing scientists to share their understanding of how DNA works,

Now that this was discovered, doctors could take action to treat and prevent diseases. For example, doctors could test for a that increases the risk of breast , called BRCA1. If someone has the gene, they can perform a mastectomy (where the breasts are removed) to greatly reduce their risk. A famous example of someone who had this procedure and spoke about it in the media was Angelina Jolie, in 2013. Her risk of developing was reduced from 85% to less than 5% (she had been tested as her mum died from the disease). However, although we now understand the genetic causes of disease, there are still many that can’t be cured despite our understanding of how they occur. Down’s syndrome and Huntingdon’s disease are two important examples.

Understanding of lifestyle causes of disease:

We have also gained a much better understanding of how lifestyle affects health over the 20th century. Doctors have found out the damaging effects that a bad diet, , smoking, sun tanning, use and unprotected sex can have. It is now widely known that eating too much sugar and fat causes , and this can cause other problems (including type 2 diabetes, where the body cannot process sugar). For smoking, it was noticed during the 1950s that the number of men suffering from cancer had increased, as had the percentage of smokers (after smoking became more popular in the 1920s). Now, it has been discovered that smoking is the biggest cause of preventable diseases in the world (including lung, throat and , heart disease and decay). Alcohol is known to cause liver disease and problems; intravenous drug use (where you inject the drug into your vein) and unprotected sex can spread infections such as HIV; and tanning causes skin cancer.

Improvements in diagnosing diseases:

New technology has made diagnosing diseases much easier for modern doctors. CT scans and x-rays can see inside the body without opening it up, meaning that problems can be accurately diagnosed without surgery. See the diagram below for more examples:

4.1: 1900-present – Causes of disease key facts

• This time period saw big change in medical testing – blood & urine samples, biopsies, x-rays, CT scans, MRI scans, ultrasounds, ECGs, endoscopes, blood pressure monitors, blood sugar tests. • Electron microscopes were developed in 1931. Magnified x 10,000,000 (vs. x2,000 previously). • In 1953, DNA was discovered by Watson and Crick. They discovered its ‘double helix’ shape and how it duplicates. • Breast cancer is one disease that can be prevented through genetic testing and a mastectomy, e.g. Angelina Jolie. Down’s Syndrome and Huntingdon’s disease cannot be treated. • We now know that bad diet, alcohol, smoking, sun tanning, drug use and unprotected sex have damaging effects, e.g. type 2 diabetes (diet) and liver disease (alcohol).

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

Key topic 4.2: Ideas about prevention and treatment, 1900-present

Antibiotics to treat disease:

In 1890, doctors started studying antibodies. These are the chemicals that the body produces to fight off diseases (a small number are produced when the body is given a vaccine, staying in the body and meaning that the person can’t catch the illness again). Doctors began looking for man-made antibodies that could be given to somebody to stop them from becoming ill, or cure them if they were already sick. These would be incredibly powerful: they would stop disease, without causing any other harm to the body. For this reason, they were called ‘magic bullets’. The first ‘magic bullet’ was produced in 1909, by a Japanese scientist. It was called Salvarsan 606, and cured syphilis (a STI). The second was an called Prontosil. It stopped bacteria from multiplying in the body, so that the body could kill the remaining ones. A similar antibiotic, called M&B, famously cured of pneumonia in 1938 (while he was leading Britain in WW2). Perhaps the most famous ‘magic bullet’ was an antibiotic called . We will learn about this in our case study, in lesson 4.3. Overall, these have had a huge impact on curing diseases. Some diseases, like tuberculosis, are now extremely rare after having been treated with antibiotics, even though we once thought that they were incurable. However, a limit to this is that eventually, bacteria that cause disease might develop so that they are resistant to antibiotics (hospital ‘superbug’ MRSA has already done this). This would mean that these drugs would no longer work. We therefore cannot be sure of the long-term impact of antibiotics.

Improved treatment through technology: 18

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) As well as improving doctors’ ability to diagnose diseases, technology has also improved treatment. For example, pills can now be mass-produced in factories, rather than being made slowly by hand. This means that they are cheaper, and there are more of them available, so more people can access them. For diabetics, insulin pumps are another example of how technology has helped to treat disease. Diabetes is where your body can’t process the sugar in the blood, as it doesn’t produce enough of a substance called insulin. The pumps involve a tiny needle being attached constantly into someone with diabetes’ skin. It delivers the amount of insulin they need to process the sugar in their blood automatically, so the person doesn’t need to inject it.

The impact of the NHS in treating disease:

The National Health Service (NHS) began in 1948. It was set up by the government, to make sure that everyone in Britain had access to healthcare if they needed it. It would be paid for through a special tax called ‘National Insurance’, which everyone who earned over a set amount would pay. It has three main parts: hospitals, GPs and dentists, and other services (e.g. ambulance service).

This did not immediately improve medical care. At this point, there were 2,688 hospitals in Britain, and the government took over them all. This meant that at first, the hospitals weren’t really changed or improved: there were too many to suddenly change and update. Similarly, even though around 20% of GPs’ surgeries were labelled as not good enough, the government couldn’t fix this all at once (especially as more people began using the GPs after the NHS made it free).

This meant that in the 1960s, the government started a programme to improve the NHS hospitals and GP surgeries. They built more hospitals across the country (there had previously been more built in London and the South East). They also introduced the GPs’ charter, which encouraged GPs to work together to improve their knowledge.

Since then, there have been many new developments in the treatments available in NHS hospitals. This would likely not have been possible without the funding of the government. For example, new types of x-ray machine have made possible for treating cancer. Developments in robotics have also enabled the development of prosthetic limbs, for people who have lost legs or arms in accidents or in battle. In surgery, it has become possible to perform keyhole operations, where surgeries are performed through a tiny hole in the patient’s body using a camera. This allows a much quicker recovery time.

Preventing disease:

As well as improving treatment of disease through the NHS, the government has also played an important role in preventing disease. After the vaccination against smallpox was made compulsory in 1872, many other were introduced. For example, the , and vaccination is often given to children, and the diphtheria vaccination was made compulsory in 1942. The HPV vaccine, which is given to teenage girls, is another example (this stops you catching an STI called HPV, which can cause cervical cancer).

They have also passed laws to make the environment healthier, such as putting fluoride (the substance in toothpaste) into the water supply to prevent . The Clean Air Acts of 1956 and 1968 aimed to clear the pollution in cities like London. Finally, the Health Act of 2006 made it illegal to smoke in all enclosed places of work.

Thirdly, the government have launched several ‘lifestyle campaigns’, designed to educate people about the risks of unhealthy lifestyles or epidemics. An example of this is when broke out in West Africa in 2014-15, and the government quarantined people who had travelled from the affected region. Furthermore, the Change4Life campaign educates people about the need to eat healthily and exercise.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) Overall: extent of change, 1900-present Things that have not changed Things that have partly changed Things that have completely changed New diseases keep appearing and Many people still take herbal Far fewer infectious diseases: developing: we will probably medicines, bought at , to caused 25% of deaths in 1900, never have a cure for every treat illnesses (e.g. cough sweets). compared to less than 1% in 1990 disease that exists. However, there are many more sophisticated drugs now available. Lifestyle still causes many deaths. We now have antibiotics to treat Huge change in how easy it is to In fact, obesity is getting worse. infections. However, drugs are access care outside of the home developing resistance to this. (through free GPs and hospitals). Many more vaccinations, e.g. Government lifestyle campaigns, HPV, diphtheria, measles, mumps e.g. Change4Life. and rubella.

4.2: 1900-present – Prevention and treatment – key facts

• ‘Magic bullet’ antibiotics were discovered in this period, for diseases such as syphilis and tuberculosis. However, some diseases are becoming resistant (e.g. MRSA). 4.3 Case study (Fleming, Florey and Chain’s discovery of penicillin) • New technologies have been developed for treatment, e.g. chemotherapy and insulin pumps. • The NHS was set up in 1948. It is paid for by tax – ‘national insurance’. During the 1960s, it significantly improved GPs’ surgeries, and the treatment available in hospitals (e.g. prosthetic

limbs, keyhole surgery). • The government has also increased vaccination, e.g. against diphtheria, measles, mumps and rubella and HPV.

• Laws have been passed to improve the environment, e.g. fluoride in water, 2006 Health Act. • Lifestyle campaigns aim to raise awareness, e.g. ‘Change4Life’.

4.3 Case studies

Fleming, Florey and Chain’s development of penicillin

Alexander Fleming was a British doctor working in London. He had worked in battlefield hospitals during WW1, and after having seen the effect of the first ‘magic bullet’ on syphilis, was shocked to see how many men died of simple infections. During the 1920s, he decided to research things that could kill the infections. He was growing some of a common bacteria called in petri dishes in his lab. After havin left the dishes for a while, he noticed that mould had grown on them. What was interesting was that around the mould, there was a circle, where the bacteria couldn’t grow. After experimenting with the mould more, he extracted the substance that killed the bacteria, and called it penicillin. He published this research in 1929. Others had discovered the power of mould before: Lister had used it in a surgery in 1871. However, more people paid attention when Fleming discovered it, as they were more aware of how drugs could be used to treat disease. At first, Fleming didn’t think it would be effective in humans, because it didn’t work when mixed with blood in test tubes.

However, two other scientists called Howard Florey and Ernst Chain (who had escaped Nazi Germany) decided to test the mould more. They grew some mould, took out the penicillin, and used it to treat infected mice. It was effective, however it took a very long time to grow and required growing a lot of mould – when the scientists decidedto grow more, they used a bath tub to grow it in! By 1941, they had grown enough to test it

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) on a human, and it improved his condition. However, Florey and Chain couldn’t grow enough to treat him completely, and he died.

In June 1941, Florey visited the US and persuaded a big company to start mass-producing penicillin in their factories (companies in Britain were too busy producing things for WW2). This was still very slow – after a year, they still only had enough penicillin to treat 10 people. However, by 1944, more companies had been convinced to grow it. The US government had funded 21 companies to produce it, and British companies also started making it in 1943. By the end of the war, there was enough to treat all of the British, French and American war casualties. Penicillin is now widely used to treat and prevent infection. It has also inspired the discovery of other antibiotics (such as , effective against tuberculosis).

The fight against lung cancer:

Causes:

The number of people developing lung cancer increased hugely over the twentieth century. In 1900, only 1% of cancers were found in the lung. However, by 1927, this had increased to over 14%. This was due to the increase in the number of people who smoke cigarettes. Cigarettes were much more widely advertised after the First World War, and in 1950, the British Medical Council published research that blamed this. It is also sometimes caused by other chemicals in the air, such as radon gas, and sometimes by nothing in particular.

Diagnoses:

One problem that makes it hard to tackle lung cancer is that often, by the time it is diagnosed, it is already very advanced. Until recently, doctors had to rely on x-rays to detect lung cancer. This was not very good as other things, such as abcesses, could be mistaken for cancer (or worse, the other way around). Nowadays, CT scans are used to create a detailed picture of inside the lungs. If it looks like cancer is present, but not very advanced, the patient will get a more accurate version of a CT scan, called a PET-CT scan. This identifies exactly where the tumour is. If the cancer is advanced, they will have a bronchoscopy. This is when a small tube with a camera on the end is put into their lungs. It collects a sample of the cancer cells for assessment. When doctors have found out how severe a cancer is, they will draw up a plan for treatment

Treatment:

One type of treatment is to operate and remove the tumour and part of the lung. Another is to perform a transplant, when a healthy set of lungs from a donor is swapped from the cancerous lungs. Thirdly, radiotherapy can be used, where waves of radiation are aimed at the tumour to either shrink it, or stop it from growing. Chemotherapy similar, but it involves drugs being injected into the patient in order to shrink the cancer or stop it from growing. Often, patients will have more than one of these types of treatment, for example surgery to remove a tumour followed by radiotherapy. A very new type of treatment involves looking at someone’s genes, and using this to decide what type of chemotherapy drug to use. It has been proven that some drugs work better in people with one type of gene compared to another. This is called pharmacogenomics.

Prevention:

The government was very slow to take action to stop deaths from lung cancer. The research linking smoking to cancer was published in 1950. However, by 1985, smoking-related deaths cost the NHS £165 million per year. This may have been because the government made £4 billion in tax from tobacco every year. Furthermore, thousands of people had jobs in the tobacco industry. Perhaps the government didn’t want them to lose their jobs. Some say that the government didn’t act as they didn’t want to tell people what they were and weren’t allowed to do. However, the government had to act eventually. The Health Act of 2006 banned smoking in public places, and now adverts are placed on cigarette packets, warning of their dangers.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

4. 3 Key facts – Case studies 1900-present (penicillin and lung cancer)

• Penicillin was first published to the medical community in 1929, by .

• It was then developed by Florey and Chain, but was very slow to produce. • US government encouraged 21 factories to produce penicillin in 1941. British factories joined in in 1943. By 1944, there was enough to treat all allied soldiers.

• Penicillin has inspired the discovery of other antibiotics, e.g. streptomycin • Lung cancer was made much more common by smoking. It is also caused by gases in the air, e.g. radon gas.

• In 1900, 1% of cancers were in the lung. By 1927, this was over 14%. • X-rays were initially unreliable to diagnose. Now, we use CT scans, PET scans, and bronchoscopies.

• Lung cancer is treated by removal, transplant, radiotherapy, and chemotherapy. • The government was slow to stop the spread: The British Medical Council linked it to smoking in 1950, but action wasn’t taken until much later (e.g. Health Act, 2006).

Key topic 5: World War One

Key topic 5.1 – Historical context of medicine before WW1

At the beginning of WW1 a number of important breakthroughs had happened in surgery and treatment.

A. Aseptic surgery

Prior to the 1700s infection had been very common after surgery as doctors were not aware that germs could cause infection. Based on Louis Pasteur’s idea of germ theory (that germs caused wine to go off and rot) Joseph Lister used carbolic acid to disinfect wounds and equipment. By the 1900s most surgery was carried out in aseptic conditions (e.g. making sure everything is clean to prevent infection).

B. X-rays

These were developed in 1895 by a German scientist called Roentgen. He discovered a special type of radiation that could take a photograph of our bones and any metal in our body. Doctors saw this could be an incredibly important tool in identifying broken bones and removing pieces of metal stuck in our body. Only a year later (1896) doctors in Glasgow were using x rays to find pennies in children’s throats and a doctor in Birmingham used x-rays to help find a needle stuck in a lady’s hand so he could remove it. However there were many problems with using x-rays at this time:

• It would take 90 minutes to take an x-ray of the hand. • Scientists did not realise how dangerous x-rays could be, they used x-rays which are 1,500 times stronger than we use today which could cause hair loss or even skin . • X-rays machines were either too big to move around or smaller ones were very fragile and easily broke.

C.

Surgery has three main problems – blood loss, infection and pain. Scientists like Simpson had discovered chloroform to ease the pain of patients (1847) and Lister had used carbolic acid to reduce infection. However many people continued to die from blood loss. A scientist called James Blundell first tried blood transfusion (giving a patient someone else’s blood) in 1818, almost a hundred years before WW1. As there was no way to stop blood from clotting (thickening and turning into a scab) he had to hook up the patients directly and put a tube between the donor and the vein. Almost half the patients’ survived (which was a big improvement!) however there were still serious problems to solve. In 1894 scientists had begun to use chemicals to stop blood 22

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) clotting such as sodium bicarbonate but this still lead to some people having fits when given the stored blood. A key reason why blood transfusion did not work was that we didn’t understand that we have different blood groups. This was figured out before WW1 by a doctor called who discovered blood groups A, B and O, and later AB. By 1907 a doctor had carried out the first successful blood transfusion of similar blood types and discovered that type O could be used by everyone. This would be incredibly useful during WW1 to help soldiers who had lost a large amount of blood.

5.1 Key facts – Historical context of medicine before WW1

• The work of Lister (carbolic acid had made surgery more aseptic and therefore caused less infection. • X-rays had been developed in 1895 but were hard to move around and often caused burns • Blood transfusions were beginning more common but there were still problems with storing blood and matching up people’s blood types.

5.2 Context of the British sector of the Western Front

WW1 broke out in 1914 between the Triple Entente (Britain, France and Russia) and the Triple Alliance (Germany, Austria-Hungary and Italy). It was fought all over Europe but we will focus on the trenches in France and Belgium. The war quickly developed into a stalemate (neither side winning) and so both sides dug trenches to protect themselves from enemy fire. These trenches were over a thousand miles long. As they were dug in the countryside and on farmland these trenches were wet, muddy and dirty.

Trench system

Both sides faced each other in trenches. The space between Britain and Germany’s trenches was called no-man’s land. The trenches closest to the enemy were called the ‘front line’, soldiers would only spend 15% of their time here as they would face the most amount of fighting and attacks. The trenches behind were there to support the front or firing line by bringing ammunition, messages and food forward. There were stations close to the firing line to help soldiers who were injured.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

Trench cross-section

Trenches were cut out of the ground so were muddy, damp and often waterlogged (full of water). Soldiers had dugouts to sleep in and could expect constant attack by artillery shells, snipers and attacks by the enemy.

The different battles of WW1

WW1 was made up of lots of different battles that sometimes lasted for months. These battles saw huge loss of life for little gain of land and gradually generals (the leaders of armies) tried new techniques and weapons to break this stalemate.

A. First Battle of Ypres (1914) – British army surrounded on three sides

Ypres was an important Belgian town as it protected the ports that allowed the British army to ship supplies to and from England to their soldiers. It was heavily attacked by the German army and Britain lost 50,000 soldiers from October to November. Although Britain managed to keep the town they were surrounded on three fronts by the Germans. This was known as Ypres salient (surrounded on three sides) and left the army vulnerable.

B. Hill 60, Ypres (1914) – Britain blows up hill

Hill 60 was a large hill that overlooked the town of Ypres. Germany controlled it which allowed them to fire their guns down on the British soldiers. In April 1915 the British army had tunnelled underneath the hill and placed huge explosives there. They placed 5 mines (explosives) under the hill and blew it up, allowing them to take this important position.

C. Second Battle of Ypres (1915) – Germans use chlorine gas

This started as soon as the explosion went off and lasted from April to May. Britain lost 95,000 soldiers and the Germans moved closer to the town of Ypres. Chlorine gas was used as a weapon for the first time leading to horrible .

D. Battle of the Somme (1916) – huge British losses and first use of tanks and creeping barrage

The first day saw 20,000 soldiers dead and 37,000 seriously injured (all needing medical treatment). Tanks were used for the first time but they broke down and were not very effective. The British army experiment with the creeping barrage, using their more accurate guns to fire just in front of their soldiers as they marched toward the enemy. By the time the battle had finished (1st July-Nov) Britain had suffered 400,000 casualties.

E. Battle of Arras (1917) – tunnels used to protect against attack and underground hospital

In April 1917 24,000 British soldiers emerged from the tunnels they had dug underground to surprise the German army. After making early gains of 8 miles the attack ground to a halt and a month later the British and Canadian army had suffered 160,000 casualties.

F. Third Battle of Ypres (1917) – mud adds to huge losses

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) The British army wanted to push the Germans back so that they were not trapped on three sides in the salient. However there was huge amounts of rain which turned the battlefield to mud leading to many soldiers drowning in it. By the time the battle had finished in November Britain had suffered 245,000 casualties for 7 miles of gains.

G. Battle of Cambrai (1917) – first large scale use of tanks

500 tanks were used in this October battle and the British gave less warning to the Germans by not firing lots of artillery shells before attacking. The tanks helped to roll over the barbed wire and used their machine guns against the German soldiers.

Transporting the injured and communicating across the trenches

The rain and shelling quickly turned the ground to mud and destroyed the roads which made it difficult to move around. The fact that this area was mostly farmland meant lots of manure (animal poo) was used to fertilise the waste which meant when this mud contacted soldiers’ wounds it quickly led to infection. Injured soldiers were carried away from no-mans land by stretcher bearers whose job it was to get the soldiers off the front line as quickly as possible. The sooner an injured soldier was removed from battle the more likely they were to survive.

The British army continued to use the old method of using horses to move the injured soldiers away from the front line. However they could not handle the huge amount of casualties which meant many soldiers were left behind and those who were transported complained of the painful (bumpy) journey by horse. The Red Cross and Times newspaper ran a campaign to fund and buy over 500 motorised ambulances to carry the injured. However these ambulances could only work on dry roads. For really muddy battles, horses continued to be used. Some soldiers were also transported by train back to the larger hospital bases or on barges via the canals that ran through this area.

5.2 Key facts – Context of the British sector of the Western Front • Ypres was an important town, close to ports (and therefore naval links to Britain). Many important battles took place there from 1914 (the first battle, where the Ypres salient began; the blowing up of Hill 60 using mines; and the second battle, where the Germans used chlorine and 95,000 Brits died) to 1917 (the third battle, where 245,000 men died for 7 miles of gained territory. • Other significant battles happened at the Somme (1916 – 400,000 casualties), Arras (1917 – where tunnels were used to protect and there was an underground hospital) and Cambrai (1917 – the first large scale use of tanks) • The trench system was over a thousand miles long, designed to protect from enemy fire. The space in between was called no man’s land. They were muddy and waterlogged. The trenches closest to the enemy were called the front line, but soldiers only spent 15% of time there. • It was very difficult to injured people out of the area of the trenches. The farmland they were in meant that it was muddy, and manure fertiliser caused infections in wounds. Ambulances also couldn’t get to the injured easily, so horses were used, but they were slow, bumpy and their numbers limited.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) Key topic 5.3 - The Medical problems of the trenches

Soldiers faced the problem of smelly sewage and rotting bodies in the summer and flooding and frostbite in the winter. The trenches were infested with rats and mud was everywhere. This led to many soldiers becoming ill.

A. Injuries

In terms of battle injuries, 58% were caused by shrapnel (fragments of metal that flew off when a shell exploded). 60% of these wounds were to soldiers’ arms and legs. 39% were caused by bullets. Machine guns were widely used during WW1 and they could fire over 450 bullets a minutes (over 7 a second!). These would break bones or damage organs. At the start of the war soldiers only wore a soft cap on their head, offering no protection. A new metal helmet called the Brodie helmet was issues in 1915 which reduced deaths by head wounds by 80%! It also had a strap to prevent it flying off if the soldier was injured.

B. Infections

Whenever a bullet or shrapnel struck a soldier it would take small pieces of their clothing or uniform with it when it entered the body. This often contained mud which carried bacteria for both tetanus and gas . Although soldiers were getting vaccinations for tetanus in 1914 which reduced this risk, there was no cure for gangrene. Gangrene would infect an area and prevent blood getting to it, leading to it rotting away. produced a gas which inflated the area around a wound. Gas gangrene spread quickly and could kill someone within 24 hours.

C. Gas attacks

This was a new type of weapons used in WW1by both sides. Doctors had never seen it before so had no idea how to treat it. The types of chemical weapons used were chlorine and phosgene (which stopped the person breathing so they suffocated) and mustard gas (which led to the lungs and skin blistering and bleeding). Although soldiers feared gas attacks the most, as they were so painful, only about 6,000n in total died from gas. The first victims of gas attacks used cotton pads soaked in urine which neutralised the chemicals in the gas but by 1915 all soldiers had a gas mask. Doctors needed to find new ways to treat this new type of .

5.3 Key facts – conditions requiring treatment in the trenches • Problems of sanitation caused illness. Sewage, rats and rotting bodies caused problems in the summer, and frostbite was difficult in the winter. Trench was caused by standing in dirty water. • 58% of injuries were caused by shrapnel and 39% by bullets. At first, soldiers had no helmets, so the Brodie Helmet was introduced in 1915 (reducing deaths by 80%). • Infections were caused by manure in the mud, as well as by bits of clothing being forced into an injury when shrapnel/bullets pierced the skin. The mud also carried tetanus (which many were vaccinated against) and gangrene (for which there was no cure). • Gas attacks were new in WW1. They were therefore difficult to treat. Chlorine, phosgene and mustard gas were all used. After the first attack, gas masks were provided for soldiers.

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

Key topic 5.4 – The RAMC, FANY and treating soldiers

Figure A shows the chain of evacuation for an injured soldier.

Step 1 – Stretcher bearers. Carried from the battle back past the front line.

Step 2 – Regimental Aid Post (RAP). This was about 200 metres back from the front line in a support trench or nearby building. The Regimental Medical officer’s main job was giving immediate first aid and trying to get soldiers healthy enough to get back fighting. This aid post wasn’t set up to deal Figure A with any serious injury.

Step 3 – Dressing Stations and Ambulance. About 400 metres back from a RAP you would find an Advanced Dressing Station. These were supposed to bandage up a soldier to help protect their wound. There also should have been a Main Dressing Station a further half mile back but this often wasn’t the case. These dressing stations were staffed by ten medical officers and stretcher bearers. They would often be in buildings like schools or sometimes tents. They were designed to handle 150 soldiers.

Step 4 –Casualty Clearing Station (CCS). These were far enough back to be safe from the fighting but close enough for the ambulance to reach them quickly. They were set up in buildings like schools close to train lines to evacuate the patients off when they had finished with them. The CCS specialised in operating on critical injuries like those to the chest to prevent soldiers dying. Once admitted soldiers would be split into three groups:

1. Walking wounded – those the CCS could patch up and return to battle 2. Hospital treatment – they would be sent onto the base hospital as soon as any life threatening injuries had been operated on 3. Severe injuries with no hope of recovery – would be made comfortable but medical efforts would then be focused on people who could survive.

Case study – Third Battle of Ypres. In this area there were 24 CCSs which had 379 doctors and over 500 nurses. They treated over 200,000 casualties during the battles and had to operate on 1/3 as they had such severe injuries. Although only 3.7% of their patients died in the CCS, many would die later when moved on in the chain of evacuation.

Step 5 – Base Hospital. These were located near the coast so it would be easier to return recovering patients back to England. As people realised the importance of carrying our operations quickly to stop infection spreading more operations happened at the CCS than Base Hospitals. Therefore Base Hospitals took more of a role of supporting the recovery of those soldiers operated on. These had to become bigger whenever a large military operation was taking place. For example 3 new hospitals with 2,500 beds were opened to support the new battles of 1917. As base hospitals had so many patients and were doing less operations they began experimenting. They started to put patients with similar needs into the same wards, for example one ward for chest injuries, one for head injuries. This allowed doctors to begin specialising in a type of wound to help increase the chance of survival. 27

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) An example of a new type of base hospital was that at Arras. It was part of the huge tunnel system that helped to hide 240,000 British soldiers from the Germans for a surprise attack. The hospital was built into 800 metres of tunnels and caves and had fresh water, electricity, space for 700 stretchers and an operating theatre. It was sometimes called Thompson’s cave after the RAMC member who designed it

Who looked after soldiers?

RAMC – Royal Army Medical Corp. This was the group responsible for all the medical care of the British army. They had to grow enormously to cope with the huge casualties so that half of all the doctors in Britain were working for the RAMC by the end of the war. This organisation grew from 3,000 officers to over 13,000 by 1918 and had another 130,000 soldiers working to help them treat injured soldiers. The RAMC would keep detailed records of every soldier admitted to an aid post or CCS in order to record what type of injury they had and how they were treated.

FANY – First Aid Nursing Yeomanry. This was a voluntary organisation where women from Britain travelled to the trenches to help the injured soldiers by providing first aid or transporting injured soldiers on a motorised ambulance. However at the start the British army refused their help so they helped injured Belgian and French soldiers, they were so effective that they were allowed to treat British soldiers by 1916. Although there numbers were small at 450, they paved the way for other women’s organisations such as the VADs to support injured soldiers at the frontline.

5.4 Key facts – The RAMC, FANY and treating soldiers • The RAMC was the Royal Army Medical Corp. Half of all doctors in Britain worked for the RAMC by the end of the war. They kept detailed records of all soldiers admitted to aid posts or Clearing Stations. • The FANY was the First Aid Nursing Yeomanry. British Women could volunteer to travel and help injured soldiers. At first the British refused their help, so they helped the Belgians and French instead, finally persuading the British government to accept them. There were only 450 members, but they paved the way for other groups like the VADs. • Transport consisted of stretcher bearers, horses and motor ambulances. The Red Cross and Times newspaper ran a campaign to fund and buy over 500 motorised ambulances, but horses were often more suitable for muddy conditions. • Regimental Aid Posts (RAPs) gave immediate first aid, 200 metres back from the front line. 400 metres back from the RAP was the Dressing Station and Ambulances. They bandaged up wounds so that soldiers could be carried by ambulance to a CCS. The Casualty Clearing Station (CCS) was where soldiers would be operated on, to either go back to the front line or be taken to a Base Hospital. Finally, Base Hospitals were near the coast, so patients could go back to England easily. An example is at Arras, where an underground hospital was built (sometimes nicknamed ‘Thompson’s Cave’).

Key topic 5.5 - Medical developments during WW1

Just because there were new, proven theories about what caused disease didn’t mean treatment changed straight away. In fact, it would take a long time to research and find things that stopped the microbes from causing disease. This meant that people carried on using herbal remedies for many years. There was also lots of continuity in terms of how people prevented diseases, because stopping the spread of germs also involved being clean, as physicians and priests had advised in the medieval period (remember the regimen Sanitatis).

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Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700)

A. New techniques

It was impossible to have aseptic surgery in the Casualty Clearing Stations due to the dirt and mud of the soldiers. Amputations - The RAMC faced huge problems with infections caused by gangrene which saw 240,000 soldiers have amputations (limbs cut off) to prevent the infection spreading to the rest of their body. The Carrel-Dakin method - Carbolic acid did not work against gangrene infections so doctors started washing the wound with a sterilised salt solution. However the solution would only stay sterile for six hours so it couldn’t be stored, this make it hard to disinfect wounds when lots of casualties were being admitted. Wound excision - Doctors and nurses would also cut away the dead or infected around a wound and then re- stitch it. This prevented the infection spreading but had to be repeated regularly to prevent further disease spreading.

B. The Thomas Splint

Soldiers injured in the leg only had a 20% chance of survival due to the bullet or shrapnel breaking the leg bone, creating a compound fracture which led to huge blood loss. Stretcher bearers would attach a splint to the broken leg (a long piece of wood) but this wouldn’t stop the leg moving around and losing lots of blood. A new type of splint was used called the Thomas Splint. This kept the leg totally still and prevented further blood loss. It increased survival rate from 20% to 82%.

C. Mobile X-rays Doctors used x-ray machines in base hospitals to remove bullets and shrapnel. This helped to save many . However there were some problems with these machines. They overheated quickly so hospitals would use three machines in rotation, switching to another machine when one became too hot. It was not until 1917 when America joined the war did the RAMC have access to the better US models which didn’t need to cool down. The x-rays also did not show the pieces of uniform stuck in the body along with the metal. Doctors realised they had to look for these scraps of clothing in the same place as the bullet to prevent infection. Also X-rays still took a long time, some patients had to lie still for 7 minutes during the X-ray (hard when you are in lots of pain!)

D. Blood banks Blood transfusion became more widely used during WW1. New developments such as the discovery that sodium citrate could be added to blood to prevent it clotting meant that blood could be transfused without having to have the donor there. At the same time it was discovered that blood with sodium citrate could be refrigerated and kept for two weeks, and later that adding glucose solution to blood and cooling it could keep the blood good for 4 weeks. These new discoveries allowed blood to be transfused not just in base hospitals but also Casualty Clearing stations. New portable devices were also developed which helped give soldiers blood transfusion much closer to the battle. The British army was planning a huge attack in Cambrai in 1917. To prepare for the injured soldiers they knew they would receive they created the world’s first . A British doctor who had studied in America used type O blood kept in special bottles which he stored in ammunition boxes protected by sawdust and cooled by ice. Robertson used this ‘blood depot’ to save the lives of 11 out of the 20 severely injured soldiers who would have died without his transfusions.

E. Brain surgery 20% of all injuries were to head, neck or face as it was the body part most exposed above the trenches. These injuries could lead to significant problems with the brain. They could lead to large blood loss, problems moving these patients and the fact very few doctors had experience of operation on the brain (). Doctors 29

Paper 1 Medicine Key topics 1 and 2 (1250-1500, 1500-1700) had to develop new ways to operate. An American doctor called Harvey Cushing used magnets to move shrapnel rather than having to dig them out and would use local anaesthetic whilst operating as caused the brain to swell. He improved survival rates of brain surgery from 50% to 71%.

F. Many soldiers suffered horrible injuries which would leave them scarred for life. Doctors began to develop new techniques to try and fix these injuries so soldiers look less disfigured. A New Zealand doctor called Harold Gillies. He developed new techniques such as skin grafts to help repairs areas of large damage.

5.5 Key facts – Medical developments during WW1 • There were huge new problems in the trenches that could not be solved by techniques like carbolic acid. Doctors had to experiment with new things. For example, amputations as a way to prevent the spread of gangrene, as well as the Carrel-Dakin method (salt solution). • The Thomas splint was introduced to stop soldiers’ legs from moving around after being shot and broken, which caused more blood loss. It increased the survival rate for these wounds from 20% to 82%. • Mobile x-ray units were used to help doctors to see and remove shrapnel and bullets. However, they were problematic: they often overheated and couldn’t show up bits of clothing that would cause . • Blood banks for transfusions were developed by adding sodium citrate to the blood and chilling it. Portable devices for transfusion allowed this much closer to battles. A key example of blood bank use = Cambrai (11/20 severely injured soldiers survived when treated with one doctor, Robertson’s transfusions.

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