Revision notes

Part 1: Medieval civilisation (roughly 1000-1500)

• In the 5^th century AD, waves of barbarians such as Goths, Vandals, Saxons and Vikings invaded Western Europe.
• Europe disintegrated into a huge number of small fiefdoms, each governed by a local lord, who protected his peasants – owned by him as ‘serfs’. These tiny states could not afford universities for study, or public health systems.
• Communications were difficult and dangerous, so ideas travelled slowly.
• During the Dark Ages, the monasteries alone managed to hand onto learning knowledge, and even the ability to read and write. Many of the medical ideas of the Greeks and Romans were lost at this time, and survived only in the Muslim cities of the Middle East.
• Similarly, technology was limited, and much of the advanced technical knowledge of the Romans was lost.
• Knowledge went into reverse in the west in medieval times – many of the books of the Greeks and Romans were lost, and the knowledge they contained was replaced by mere speculation and superstition.
• Even when universities developed, after 1100 – Montpellier, Bologna and Salerno had famous medical schools – lectures on anatomy were rudimentary. They consisted simply of a butcher pointing to the different parts of a body, while the lecturer read a text by an authority such as Galen.

Disease was thought to have supernatural causes:

• Many people believed that disease was a punishment from God for people’s sins. They thought that disease existed to show them the error of their ways and to become better people. Therefore, they thought that the way to cure disease was through prayer and repentance.
• Disease was also thought to be caused by evil and supernatural beings, like demons or witches. Witches were believed to be behind outbreaks of disease.
• Some people believed that diseases were caused by evil spirits living inside someone. Members of the church performed exorcisms, using chants to remove the spirit from the person’s body.

The Church had a big influence on medieval practice:

• Medieval Europeans believed in the Christian God, so politics and everyday life, as well as medicine, were dominated by the Roman Catholic Church.
• The Church played a big part in medical stagnation in the Middles Ages. It discouraged progress by:
  • Forbidding dissection of human corpses.
  • Insisting people agree with the writings of Galen.
  • Encouraging people to rely on prayers to the saints and superstition to cure them of disease.
  • Encouraging the belief that disease was a punishment from God – this led to fatalism and prevented investigation into cures.

However, the Church did encourage people to go on Crusades, meaning that people travelled to the Middle East. Here they came into contact with Muslim doctors, who were significantly more skilled than their counterparts in Britain.

Astrology was used to diagnose disease:

• Astrology is the idea that the movements of the planets and stars have an effect on the earth and on people. Astrologers in medieval England believed that these movements could cause disease.
• Astrology was a new way of diagnosing disease. It was developed in Arabic medicine and brought to Europe between 1100 and 1300.
• Medieval doctors owned a type of calendar which included information about where particular planets and stars were at any given time. The doctors then used this to predict how patients’ health could be affected.
• Different star signs were thought to affect different parts of the body.
• The Black Death was seen as a punishment from God. Guy de Chauliac, the Pope’s doctor, blamed the Black Death on conjunction of Saturn, Jupiter and Mars.

Some treatments in medieval Britain were based on less religious faith and more on natural theories and observations of the physical world.

Four Humours Theory

The Greeks developed the first rational system of medicine. The theory of the Four Humours was brought back to Western Europe via the Islamic World. Many medieval doctors based their diagnosis and treatment on this theory.

• The most famous Greek doctor was Hippocrates of Kos. He wrote: Sickness is not sent by the gods or taken away by them. It has a natural basis. If we can find the cause, we can find the cure.
• Hippocrates is often called the ‘Father’ of Modern Medicine.’ He made several key contributions to the development of medicine:
  • The Hippocratic Oath – Doctors would swear to treat patients and keep their records and symptoms in confidence.
  • Recording of symptoms – Hippocrates encouraged doctors to question patients, finding out detailed information about symptoms and to record them accurately. This would then lead to better treatment.
  • The Hippocratic Corpus – A collection of over 60 books written by Hippocrates and other Greek doctors, noting symptoms, treatments and their effectiveness.
  • Promoted the four humours – Hippocrates encouraged doctors to look for natural causes and cures of diseases, encouraging them to move away from supernatural beliefs. Hippocrates believed that the body was made of four fluids – blood, phlegm, yellow bile and black bile. They needed to be in balance for good health.
• The theory of the Four Humours was developed further by another Greek doctor, Galen, who was born in AD129 and worked for much of his career in Rome.
• Galen believed diseases could be treated using opposites. He thought that different foods, drinks herbs and spices had a humour, which could balance the excessive humour that was causing the disease.
• The Miasma theory was also incorporated by Galen into the Theory of the Four Humours. This became extremely popular in medieval Britain.
• The Miasma Theory is that bad air causes disease when someone breathes it in. This bad air may come from human waste or dead bodies – anything that creates a bad smell.
• The Miasma Theory was so influential that it lasted until the 1860s when it was replaced by the Germ Theory.

The Four Humours and Miasma were both incorrect theories. But they assumed disease had a natural cause, rather than a supernatural one. This was important, as it suggested that people weren’t powerless against disease – they could investigate and take action against it.

• The work of Hippocrates and Galen was extremely influential in medical diagnosis and treatment.
• Hippocrates and Galen wrote down their beliefs about medicine. These were translated into Latin books, which were considered important texts by the Roman Catholic Church. Hippocrates and Galen’s ideas were considered the absolute truth.
• Many of the ideas were taught for centuries after their deaths, including the incorrect ones. For example, Galen only ever dissected animals. Medieval doctors were not allowed to perform their own dissections so they continued to learn Galen’s incorrect ones.
• Some of Hippocrates and Galen’s ideas were so influential that they continue to be used today. The Hippocratic Oath and the belief that all doctors should observe their patients as they treat them.

Islamic medicine

In the medieval period, Islamic medicine was miles ahead of European medicine. Arabic ideas eventually made their way to Europe – including knowledge of Galen and Hippocrates.

Arab doctors kept Classical Knowledge alive:

• While a lot of medical knowledge was lost in the West after the fall of the Roman Empire, medical ideas like the Four Humours and treatment by opposites were kept alive by Islamic scholars.
• Islamic medicine was generally more rational and evidence based than European medicine, partly due to their knowledge of classical medical texts.
• In the 9^th Century, Hunain ibn Ishaq translated Greek texts to Arabic.
• This classical knowledge was eventually brought to Europe by Avicenna. He wrote the ‘Canon of Medicine’, which brought together the ideas of Galen and Hippocrates, and was the most important way that classical ideas got back to Western Europe.
• The crusades also made Europeans aware of the scientific knowledge of Islamic doctors.
• Islamic doctors also made several new discoveries.
• Albucasis wrote a well thought-out book describing amputations, the removal of bladder stones and dental surgery – as well as methods for handling fractures, dislocations and the stitching of wounds.
• In the 12^th Century, Avenzoar described the parasite that causes scabies and began to question the reliability of Galen.
• Ibn al-Nafis also questioned Galen’s ideas. He suggested (correctly) that blood flows from one side of the heart to the other via the lungs and doesn’t cross the septum.
• However, because they Christian Church was at war with Islam, Muslim ideas spread slowly to Western Europe. The exception was the book by Avicenna.

Medieval Britain

Treating disease

Prayer and repentance were major treatments

• Disease was believed to be a punishment from God, so sick people were encouraged to pray. The sick often prayed to saints. Medieval people also believed that pilgrimage to holy shrines could cure illnesses.
• Flagellants were people who whipped themselves in public in order to show God that they were sorry for their past actions.
• Many doctors had superstitious beliefs, some used astrology to diagnose and treat illness, or believed that saying certain words while giving a treatment made it more effective.

Bloodletting and purging aimed to make the Humours balanced

• Bloodletting and purging were popular treatments because they fitted with the Four Humours theory.
• If someone had too much blood inside them, the doctor would take blood out of their body through bloodletting – sometimes they would use leeches. Sometimes this would actually kill people (beliefs more important than observation).
• Purging is the act of getting rid of other fluids from the body by excreting – doctors would give patients laxatives.

Purifying the air was thought to prevent disease

• The Miasma Theory led people to believe in the power of purifying or cleaning the air to prevent sickness and improve health.
• Physicians carried posies or oranges around with them to prevent catching diseases.
• During the Black Death juniper, myrrh and incense were burned so the smoke or scent would fill the room and stop bad air from brining disease inside.

Herbal remedies

• Remedies brought from an apothecary, local wise woman or made at home were all popular in medieval Britain and contained herbs, spices, animal parts and minerals.
• These remedies were either passed down or written in books explaining how to mix them together.
• Other remedies were based on superstition, like lucky charms containing ‘powdered unicorn horn’.

General

• People used lots of different healers.
• Physicians were male doctors who had trained at university for at least 7 years. They read ancient texts as well as writings from the Islamic world, but their training involved little practical experience. They used handbooks and clinical observations to check patients’ conditions. There were fewer than 100 physicians in England in 1300 and they were very expensive.
• Most people saw an apothecary, who prepared and sold remedies, and gave advice on how to use them. Apothecaries were the most accessible for those who could not afford physicians.
• One of the earliest remedy books was the Anglo-Saxon manuscript ‘Leech Book of Bald’ (950).
• Most were men and trained through apprenticeships. There were also ‘wise women’, who sold herbal remedies.

Hospitals

• Most public hospitals were set up by the Church. There were few hospitals, but they were very popular and highly regarded.
• Between 1000 and 1500, more than 700 hospitals were started in England.
• The main purpose of the hospitals was not to treat disease, but to care for the sick and elderly. The hospitals provided its patients with food, water and a warm place to stay. Most hospitals were also more hygienic than elsewhere as they had developed water and sewerage systems.
• Famous hospitals like St Bartholomew’s and St Thomas’ in London started life as church establishments.
• Some monasteries also cared for the sick, elderly or the poor.
• Most sick people were treated at home.

Surgery

• During the middle Ages, surgery was left to barber-surgeons, not trained doctors. Compared with doctors, barber surgeons were lower class medical tradesmen.
• It was a time of frequent warfare, and the constant fighting meant that surgeons’ skills were much in demand. Perhaps as a result, surgery actually progressed in medieval times.
• This is completely different from the normal picture of stagnation given to us about medieval medicine.
• Medieval surgeons realised how to use wine as an antiseptic.
• Some surgeons tried to find ways to reduce pains during operations. For example John of Arderne created a recipe for an anaesthetic in 1376, which included hemlock, opium and henbane.
• His surgical manual, Practice (1376), contained illustrations of his operations and instruments. It was based on Greek and Arab knowledge and his experience in the Hundred Year War.
• Medieval surgeons could do external surgery on problem areas such as facial ulcers and eye cataracts. There was also, surprisingly, some internal surgery undertaken, e.g. to remove bladder stones.
• There was some further progress in dealing with infection after surgery. Heodoric of Luca encouraged wounds to be cleaned and bandages soaked in wine used to dress them. This challenged the idea of Galen’s that pus in a wound was a sign that it was healing.
• One of the most famous surgeons was the French Surgeon, Guy de Chauliac. His famous textbook ‘Great Surgery’ dominated English and French surgical knowledge for 200 years. He quoted Galen about 890 times.
• However, they still had no idea that dirt carried disease. Deep wounds still caused death from bleeding, shock and infection.
• A medieval surgeon might cure an epileptic patient by trephining the skull to let the demon out.
• Cauterisation was a very common method of burning the wound to stop the flow of blood: it was actually done with a heated iron and immensely painful.

Public health in medieval Britain

• Living conditions in towns were poor.
• Most towns were small. Houses were usually made of wood and were cramped together – overcrowding and fires were common problems.
• Between 1250 and 1530, the number of towns in England grew as the population rose.
• A lot of towns did not have clean water supplies or sewerage systems – waste was chucked into the street or into rivers to be washed away. Sewerage from latrines leaked into the ground and got into wells.
• Businesses and homes were not separated – Butchers, tanners and dyers threw toxic waste into rivers and residential streets. People had to get drinking water from rivers and wells were contaminated.
• In the 13^th century, a water channel called the Great Conduit was built to bring the clean water into London, as the Thames was getting too toxic.
• In 1388 the government ordered town authorities to keep the streets free of waste. Towns introduced public health measures to tackle waste, sewage and pollution and to create a clean water supply.
• York and London both banned people from dumping waste in the street. These cities also built latrines over rivers so that sewage could be carried away.
• London eventually banned any waste from being thrown into the Thames – carters were hired to collect waster ad take it out of the city.
• Many towns, like York, ordered toxic businesses like tanners, butchers and fishmongers to move outside the city walls.
• People broke these rules and officials struggled to enforce them. People knew that dirty water and bad health were linked, but they didn’t really understand the risks. Town authorities didn’t have enough money or knowledge to properly fix the issues.

Monasteries

• Healthier than towns. They had cleaner water and a good system for getting rid of waste.
• They separated clean and dirty water.
• Most were built near rivers to carry in clean water, if there was no river, manmade waterways were built.
• Monks had access to books on healing and they knew how to grow herbs and to make herbal remedies.
• Latrines were put in separate buildings.
• Sick monks were cared for in infirmaries. They would often have their own kitchen that served good meals and meat to help sick monks to recover.
• Some monasteries had hospitals that cared for poor people. They also gave shelter to travellers. Benedictine monks believed that caring for the sick was the most important Christian duty.
• Why were they better at Public Health? – It was easier to create healthy living conditions in monasteries as they were wealthy. Monastery populations were also small and had one leader.

The Black Death

• The Black Death (BD) first arrived in Britain in 1348. People tried to limit its spread but couldn’t stop the disease. Some historians think at least a 1/3 of the British population died as a result. There were further outbreaks throughout the middle Ages.
• The Black Death was a series of plagues that swept Europe. It was really two illnesses.
• The bubonic plague spread by the bites of fleas from rats carried on ships. It caused headaches and high temperature, followed by pus filled swellings on the kin.
• Pneumonic plague was airborne. It attacked the lungs and would leave the victim coughing blood.
• The BD was spread by bacteria. This bacteria thrived in the stomach of fleas that lived on the blood of rats. When the rats died of the plague, the fleas moved onto humans.
• Death could be very quick for weaker victims. The Black Death spread quickly due to overcrowded ports and towns, and the disposal of dead bodies did not stop the plague from spreading.
• People didn’t know what caused the Black Death. Some people believed it was a judgement from God. They thought the disease was caused by bad air (miasma theory) and carried strong smelling herbs or lit fires to purify the air.
• Some people carried charms or used magic potions containing arsenic.
• Local governments tried to prevent the spread of the disease.
  • For example in Winchester people thought you could catch the plague from being close to the dead. When the town’s cemetery got too full the townspeople refused to let the bishop extend the cemetery in the town. Instead they insisted new cemeteries be built outside of the town.
  • The town of Gloucester tried to shut itself off from the outside world after hearing about the BD. Their aim was unsuccessful.
  • In November 1348, the disease reached London. In January 1349, King Edward III closed Parliament.
• The Black Death had huge economic and social consequences. Fields went unploughed. Food was not harvested and it rotted in the fields. Whole villages were often wiped out by the plague, but those who survived often faced starvation. Towns and cities also faced food shortages as nearby villages could not provide them with enough food.
• After the Black Death there were fewer workers around. This meant they could demand higher wages and move around to find better work. The cost of land also decreased, allowing some peasants to buy land for the first time.
• These changes threatened the power of the elites. The government created laws, such as the 1349 Ordinances of Labourers, to try and stop peasants moving around the country.
• Another impact of the Black Death was that opinions of the Catholic Church changed, some of the churchmen were criticised for cowardice when they deserted their villages. This was balanced out by the number of priests who died. They lost a vast number of experienced clergy.
• Also due to the misunderstanding of the causes of the Black Death, there was widespread persecution of minorities such as foreigners, beggars and lepers.

Part 2: The beginnings of change – The Renaissance

The Renaissance was a time of new ideas and fresh thinking. People began to challenge old beliefs, and put forward new theories.

• The Renaissance was a time of continuity and change. There was a rediscovery of knowledge from classical Greek and Roman times, Western doctors gained access to the original writings of Hippocrates, Galen and Avicenna. These had not been available in the medieval period. This led to greater interest in the Four Humours Theory.
• The Renaissance also saw the emergence of science as we know it from the magic and mysticism of medieval medicine. People thought about how the human body themselves and came to their own conclusions about the causes of disease.
• People began to question Galen and other ancient doctors.
• Although religion was still very important the church no longer had so much control over the medical teaching due to the Reformation.

Six key changes

Some knowledge of Western civilisation at the time of the Renaissance will help you understand the medicine of the Early Modern Age.

• Governments – such as that of Henry VIII – were strong, the economy boomed and trade prospered. People could afford doctors.
• Artists, such as Michelangelo, Leonardo da Vinci and Titian, revolutionised painting – this led to the study of the body in more detail, and was connected to improved knowledge of anatomy.
• There was a revival of learning. Universities established schools as an experiment colleting observations, then coming to a conclusion. At first, scholars merely claimed that they were renewing the perfection it has amongst the ancient teachers’, but soon they began to conduct experiments which led them to question the knowledge of the Greeks and Romans.
• The invention of the printing press by Johannes Gutenberg allowed new ideas to spread more quickly around Europe.
• The discovery of America by Columbus mean that new food and medicine were brought back from the New World.
• The invention of new weapons, especially gunpowder, led to soldiers getting different sorts of wounds, which battlefield doctors had to deal with.

Andreas Vesalius

• Born in 1514 and was a medical professor at Padua University, Italy.
• He believed that successful surgery would only be possible if doctors had a proper understanding of the anatomy.
• Vesalius was able to perform dissections on criminals who had been executed.
• He wrote books based on his observations using accurate diagrams to illustrate his work. The most important was the ‘Fabric of the Human Body’ (1543).
• His works were printed and distributed around the world. Printing was invented in the 1440s. The first British printing press was in the 1470s. This meant books could be copied more easily. This allowed ideas to be shared and discussed. People could learn from Vesalius’ discoveries.
• Vesalius’ work helped to point out some of Galen’s mistakes. For example he showed that there were no holes in the septum of the heart.
• His findings encouraged others to question Galen. Doctors also realised that there was more to discover about the body because of Vesalius’ questioning attitude.
• The work of Vesalius didn’t have an immediate impact on the diagnosis or treatment of disease. However, by producing a realistic description of the human anatomy and encouraging dissection, Vesalius provided an essential first step to improving them.

William Harvey

• British doctor born in 1578. Studied medicine at Padua, Italy. Then worked in London at the Royal College of Physicians.
• He became a physician to James I and Charles I.
• Harvey studied both animals and humans. He realised he could observe animal hearts in action and that his work would also apply to humans.
• Before Harvey, people thought that there were 2 kinds of blood and that they flowed through two completely separate systems of blood vessels (Galen’s idea).
• Harvey realised Galen was wrong. He thought that the blood must circulate round the body. He published his book ‘On the motions of the heart and blood’ in 1628.
• Harvey was a careful scientist who drew conclusion from methodical observation and experimentations.
• Harvey’s ideas, shown in his books, gave doctors a map of how the body worked. Not everyone believed his theories. It took a long time before doctors used them in their treatments.

Ambroise Paré

• French barber surgeon born in 1510. Worked in a public hospital, then became an army surgeon.
• He treated many serious injuries caused by the war, this helped him improve surgical techniques. At this time, gunshot wounds often became infected. Doctors didn’t understand why this happened or how to treat it. The usual treatment was to burn the wound with a red hot iron or to pour boiling oil onto it. This often did more harm than good.
• During one battle Pare ran out of oil and resorted to a simple cool salve (type of ointment) instead. To his surprise the patients treated this way did better than the ones scalded with oil.
• Pare invented a method of tying off vessels with threads (ligatures). This was less painful so reduced the chance of the patient dying of shock. However, there was still a chance of infection.
• He also designed artificial limbs and improved the treatment of amputations.
• Pare published his ideas to enable other doctors to read about them. British surgeons used the methods of Pare and took inspiration from his work. Over time, his ideas helped improve surgical techniques.
• In 16^th century England, there was a number of surgeons who followed Pare’s Renaissance approach to surgery: these surgeons observed, questioned and experimented with new ideas. The most famous was William Clowes.
• Doctors resisted Pares’s ideas. He eventually became surgeon to the King of France and with his support his ideas started to be accepted.

Medical treatment

• Many doctors were reluctant to accept that Galen was wrong. This meant that they continued to use similar treatments to the Middle Ages, like bloodletting and purging.
• Doctors tended to focus more on reading books than treating patients.
• Doctors were still very expensive. Most people used other healers such as apothecaries or barber surgeons. Herbs were still the main ingredient in many drugs.
• Superstition and religion were still important. People thought the King’s touch could cure Scrofula. 1000s of people are thought to have visited King Charles I.
• Some people sold medicines that didn’t work, and often did more harm than good – this was known as quackery. They had no medical knowledge.
• The introduction of the printing press helped ordinary people collect books on herbal remedies, such as the English doctor Nicholas Culpepper’s ‘the complete herbal’ (1653). Culpepper used plants and astrology in his treatments.
• Explorers on voyages of discovery brought back new natural medicines. The bark of the Cinchona tree from South America contained quinine, which helped to treat malaria.
• From 1600 the College of Physicians started to license doctors to stop quackery.
• In the 1700s, electricity started to be used in some medical treatments, although it was rarely effective.

The Great Plague – 1665

Similarities to the Black Death

• Many treatments of the Plague were based on magic, religion and superstition, including wearing lucky charms or amulets, saying prayers or fasting.
• Bloodletting was still used, even though it probably made the plague worse – it created wounds that could get infected.
• Some people also thought that miasma caused the disease, so they carried posies of herbs or flowers to improve the air.
• Many people still believed that the plague was a punishment from God for their sins, the real cause was the fleas that lived on rats.

Differences to the Black Death

• Town and parish Councils tried to prevent the spread of the disease. Plague victims were quarantined to stop them passing on the disease. The victim’s house was locked and a red cross painted on the door.
• ‘Bills of Mortality’ were published, to publicise the course of the disease.
• ‘Examiners’ and ‘searcher’ were appointed, who established whether members of a household had contracted the plague. If so, they then shut up house for a month, and its inhabitants had to stay indoors.
• Surgeons were appointed, who examined the dead to establish the extent of the plague.
• Areas where people crowded together were closed (e.g. theatres).
• The dead bodies of plague victims were buried in mass graves away from houses.
• Constables were appointed, who made sure no one left such houses.
• Bodies were buried at night in huge pits, and mourners were not allowed to attend.
• ‘Pest houses’ were set up, to quarantine
• Householders were ordered to collect all waste, which was then removed by ‘rakers’.
• Stray pigs, dogs, rabbits and cats were killed.

The responses to the plague came from local councils – they did more to try to combat the Great Plague than they had ever done for the Black Death. But there were no national government attempts at prevention.

The plague gradually began to disappear. Many people think the Great Fire of London in 1666 helped wipe it out, by effectively sterilising large parts of London – it burned down the old, crowded houses, killing the plague bacteria.

Doctors and surgery

• Many doctors in Britain trained at the College of Physicians, which was set up in 1518. Here they read books by Galen, but also studied recent medical developments. Doctors who trained at the college gained a licence, which separated them from the large numbers of quack doctors.
• However, a license didn’t guarantee doctors could be just as good.
• New weapons like cannons and guns were used in the war. This meant surgeons had to treat injuries they hadn’t seen before, forcing them to quickly find new treatments.
• Dissections became a key part of medical training in the 1700s.
• In the middle Ages, there were two types of surgeons. There was a small number of professional surgeons, who trained at University and were highly paid. Then there were the barber surgeons. Surgeons were not respected compared to doctors.
• In the 1700s and 1800s, surgeons began to gain the same status as doctors. In 1800 the London College of Surgeons was created, which set training standards for the first time.
• Sydenham was an English doctor who was famous for recognising the symptoms of epidemic diseases such as scarlet fever and for classifying illnesses and medicine correctly. He was critical of quack medicine and also stressed the careful observation of symptoms.
• However, he dismissed the value of dissections and ignored Harvey’s discovery because it did not help with treating patients. He still used all the bleeding methods and often advocated doing nothing and letting nature take its course.

John Hunter

• Well known surgeon and scientist. Hunter joined his brother at his anatomy school in London. Dissecting human corpses was a large part of the school’s teaching.
• Over 12 years he was present at more than 2000 dissections.
• Hunter became an army surgeon in France and Portugal and a popular surgeon and teacher in England.
• He made several important medical discoveries. He learned more about veneral disease and introduced a new approach to the treatment of gunshot wounds.
• In an operation in 1785, he introduced a new way to treat an aneurysm in a man’s thigh. Hunter tied off the blood vessel to encourage the blood flow through the other vessels in the leg, preventing it from having to be amputated.
• He encouraged better approaches to surgery. This included good scientific habits like learning as much about the body as possible to understand illness, experimenting to find better ways to treat disease, and testing treatments (e.g. on animals) before using them on people.
• Hunter’s pupils included doctors such as Edward Jenner. This meant that his methods were passed on, improving the way people conducted scientific research as a whole.
• In the 1530s, Henry VIII closed down most of the monasteries. Since most hospitals had been set up and run by the monasteries, this also led to the closure of a large number of hospitals. As a result, Britain has relatively few hospitals until the 18^th century.
• Before the 18^th century, many hospitals focused only on caring for people. In the 18^th and 19^th centuries treating diseases became more important.
• From the early 18^th century several charity hospitals opened, including the Middlesex infirmary, the London Hospital and Guy’s hospital. They were funded by the rich, and offered largely free treatment to the poor.
• By 1800 London’s hospitals were handling 20,000 patients a year. Compared to 1400 when each of the 470 hospitals had room for only 10 patients at most.
• Only those that were likely to recover quickly were admitted – this was partly because of a lack of space and because the rise of contagious illnesses spreading. The ‘deserving poor’ had a greater chance of being admitted.
• Dispensaries provided free non-residential care to poor people. Medicine and non-surgical services from people like dentists and midwives were given without charge.
• Most poor people were treated in workhouses – large buildings that people went to if they could no longer look after themselves. Conditions were poor – from the 1850s a partially successful movement began to improve conditions in workhouse infirmaries.
• In the 19^th century some hospitals were founded alongside universities or medical schools, including Charing Cross Hospital, University College Hospital and King’s College Hospital. These hospitals were used as training schools for doctors, and for conducting scientific research.
• Doctors likely to gain an official post at a hospital, still primarily used the Four Humours approach of bleeding and purging.
• Cottage hospital, run by GPs, opened from the 1860s. They provided care for people in rural areas.
• In the 18^th Century specialist hospitals also opened for example, Bethlem for the mentally ill.
• The Founding Hospital was opened in 1741 to care for orphaned children.

Florence Nightingale and improved nursing standards

• Studied to be a nurse in 1849. She helped nursing become a profession and disciplined.
• When the Crimean war broke out in 1853, horror stories emerged about the Barrack Hospital in Scutari, where the British wounded were treated. Sidney Herbert (the Secretary of War and a friend of her family) asked for Nightingale to go to Scutari to sort out the nursing care in the hospital.
• The army opposed women nurses, as they were considered inferior and a distraction. Nightingale went away, taking 38 handpicked nurses with her.
• Using methods she had learned from her training in Europe, Nightingale ensured all the wards were clean and hygienic, that water supplies were adequate and their patients were fed properly.
• Before she arrived the death rate in the hospital was 42%. Two years later it had fallen to just 2%.
• Many of Nightingale’s nursing practices were used in hospitals in Britain.
• In 1859, Nightingale published a book, ‘Notes on Nursing’. This explained her methods – it emphasised the need for hygiene and a professional attitude. It was the standard textbook for generations of nurses.
• The public raised £44,000 to help to help her train nurses, and she set up the Nightingale School of Nursing in St. Thomas’ Hospital, London.
• Nurses were given three years of training before they could qualify. Discipline and attention to detail were important.

Edward Jenner and vaccination

In the 1700s, smallpox was one of the most deadly diseases – in 1751, over 23500 people died of smallpox in London alone.

• At the time, the only way to prevent smallpox was inoculation. This was promoted in Britain by Lady Mary Wortley Montagu, who learned about it in Turkey. Inoculation was successful in preventing the disease but meant patients had to experience smallpox before they could become immune – some died as a result.
• It involved making a cut in a patient’s arm and soaking it in pus taken from a swelling of somebody who already had a mild form of smallpox.
• Edward Jenner (born 1749) was a country doctor in Gloucestershire. He heard that milkmaids didn’t get smallpox but they caught the much milder cowpox.
• Using careful scientific methods Jenner investigated and discovered that it was true that people who had had cowpox didn’t get smallpox.
• In 1796 Jenner tested this theory. He injected a small boy, James Phipps, with pus from the sores of Sarah Nelmes, a milkmaid with cowpox. Jenner then infected him with smallpox. James didn’t catch the disease.
• Jenner published his findings in 1798. He coined the term vaccination using the Latin word of cow, vacca.
• Jenner faced some opposition to his vaccine:
  • Many people were worried about giving themselves a disease from cows.
  • Some doctors who gave the older type of inoculation saw it as a threat to their livelihood.
  • One doctor, William Woodville, claimed that Jenner’s vaccination worked little better than inoculation, after several smallpox deaths occurred at his hospital.
  • When vaccination became compulsory in 1853, several groups were formed to campaign against it – they didn’t like the idea of the government telling them what to do.
• But his discovery got the approval of parliament. In 1802 they gave Jenner £10,000 to open a vaccination clinic. And another £20,000 a few years later.
• In 1840, vaccination against smallpox was made free for infants. In 1853 it was made compulsory.
• The vaccine was a success – it contributed to a big fall in the number of smallpox cases in Britain.

Part 3: A Revolution in Medicine

Germ Theory

Germs and other micro-organisms were discovered as early as the 17^th century. Scientists thought these microbes were created by decaying matter, like rotting food or human waste – this theory was known as spontaneous generation. It led people to believe that disease caused germs.

• The French chemist Louis Pasteur was employed in 1857 to find the explanation for the souring of sugar beet in fermenting industrial alcohol. His answer was to blame germs.
• Pasteur proved that there were germs in the air – he showed that sterilised water in a closed flask stayed sterile, while sterilised water in an open flask bred germs.
• In 1861, Pasteur published his Germ Theory. In it he argued that microbes in the air caused decay, not the other way round. He also suggested that some germs caused disease.
• In 1867, Pasteur published evidence proving there was a link between germ and disease, demonstrating that germs caused a disease in silkworms.
• Pasteur’s discovery was partly due to Antonie van Leeuwenhoek’s invention of the microscope in 1677. More advanced microscopes were developed during the 1800s. They allowed scientists to see much clearer images with a lot less light distortion.

The Germ theory was first met with scepticism – people couldn’t believe tiny microbes cause disease. It didn’t help that the germ theory responsible for each disease had to be identified individually, as this meant it was several years before the theory became useful. Eventually however it gained popularity in Britain.

• The theory helped to inspire Joseph Lister to develop antiseptics.
• The theory confirmed John Snow’s findings about cholera.
• The theory linked diseases to poor living conditions. This put pressure on the government to pass the 1875 Public Health Act.

Robert Koch

• The German scientist Robert Koch built on Pasteur’s work by linking specific disease to the particular microbe that caused them. The technique was called ‘microbe hunting’.
• Koch identified anthrax bacteria (1876) and the bacteria that caused septicaemia (1878), tuberculosis (1882) and cholera (1883).
• Koch used revolutionary scientific methods:
  • He used agar jelly to create solid cultures, allowing him to breed lots of bacteria.
  • He used dye to stain the bacteria so they were more visible under the microscope.
  • He employed the newly invented photography to record his findings.

Pasteur and Koch weren’t friends – in 1871 Germany beat France in the Franco-Prussian War, so there was a great national and personal rivalry between the two scientists. This competition fuelled their next discoveries.

• In 1877, hearing of Koch’s discovery of the anthrax bacteria, Pasteur started to compete in the race to find and combat new microbes.
• Pasteur’s assistant, Charles Chamberland, injected some chickens with a cholera culture that had been weakened by being accidently left out on the desk while he was on holiday. The chickens survived. The team tried again with some newly cultured cholera, but the chickens still survived.
• They worked out that the weakened cholera had made the chickens immune. Chamberland’s error had produced a chance discovery.
• The team produced a weakened version of the anthrax bacteria to make sheep immune. They showed this in a public experiment in 1881. They used a similar method to find a vaccine for rabies.

Other scientists used Koch’s methods to find and combat the bacteria that caused other diseases.

• The diphtheria germ was discovered by Edwin Klebs in 1883.
• Friedrich Loeffler cultured the diphtheria germ and thought that its effect on people was due to a toxin it produced. Emile Roux proved Loeffler right.
• In 1891, Emil von Behring produced an antitoxin from the blood of animals that had just recovered from diphtheria. This could be used to reduce the effect of the disease.
• Ronald Ross received the Nobel Prize in 1902 for his discovery of how malaria is transmitted.

Magic Bullet – Salvarsan 606

• Antibodies were identified as a natural defence mechanism of the body against germs. It was known that antibodies only attacked specific microbes – so they were nicknamed magic bullets. In 1889, Paul Ehrlich set out to find the chemical that could act as synthetic antibodies.
• First, Ehrlich discovered dyes that could kill the malaria and sleeping sickness germs.
• In 1905 the bacteria that causes the sexually transmitted disease syphilis was identified.
• Ehrlich and his team decided to search for an arsenic compound that was a magic bullet for syphilis. They hoped it would target the bacteria without poisoning the rest of the body. Over 600 compounds were tried, but none seemed to work.
• In 1909, Sahachiro Hata joined the team. He rechecked the results and saw compound number 606 actually appeared to work. It was first used on a human in 1911 under the trade name Salvarsan 606.

The Germ Theory led to the introduction of new vaccines, antiseptics and government intervention in public health. But it didn’t really affect treatments in Britain that much – Salvarsan 606 was only a treatment for one specific disease and the second magic bullet (prontosil) wasn’t discovered until 1935. It wasn’t until the pharmaceutical industry took off in the 1940s that ordinary people began to benefit from the Germ Theory.

Anaesthetics

Pain was a problem for surgeons, especially since patients could die from trauma of extreme pain. Natural drugs like alcohol, opium and mandrake had been used for a long time, but effective anaesthetics that didn’t make the patient very ill were more difficult to produce.

• Nitrous oxide (laughing gas) was identified as a possible anaesthetic by British chemist Humphrey Davy in 1799 – but he was ignored by surgeons at the time. He did a public demonstration in 1845 but had the bad luck of choosing someone who was unaffected by nitrous oxide – it was ignored.
• In 1842, American doctor Crawford long discovered the anaesthetic qualities of ether, but didn’t publish his work. The first public demonstration of ether as an aesthetic was carried out in 1846 by American dental surgeon William Morton. News of the American anaesthetic experiments quickly spread to Europe. It was effective and used by British surgeons. However, ether is an irritant and is also fairly explosive, so using it this way was risky.
• James Simpson, was a Professor of Midwifery at Edinburgh University, who tried to find a safe alternative to ether that women could take during childbirth. He began to experiment with other chemicals and tested them on himself.
• In 1847 Simpson discovered the effects of chloroform. He found it easier to use than ether. It took effect more quickly and less was needed to achieve the same results.
• In the early days of chloroform, patients died as it was difficult to set the right amount needed for different people. The most famous case was Hannah Greener who died in 1848 during an operation to remove her toenail.
• After Queen Victoria gave birth to her 8^th child while using chloroform in 1853, it became widely used in operating theatres and to reduce pain during childbirth.

Early anaesthetics actually led to a rise in death rates:

• Anaesthetics led to longer and more complex operations. This was because surgeons found that unconscious patients were easier to operate on, meaning that they could take longer with their work.
• Longer operating times led to higher death rates from infection, because surgeons didn’t know that poor hygiene spread disease. Surgeons sometimes wore the same coats for years which were covered in dry blood from previous operations. Operations were carried out in unhygienic conditions (sometimes the patient’s home). Operating instruments also caused infections because they were unwashed and dirty.
• The period between 1846 and 1870 is sometimes known as the ‘Black Period’ of surgery because of the rise in deaths.

Antiseptics

There are two main approaches to reducing infection during an operation. Aseptic methods are used to kill germs that get near surgical wounds. Aseptic surgical methods aim to stop any germs getting near the wound.

• Ignaz Semmelweis showed that doctors could reduce the spread of infection by washing their hands with chloride of lime solution between patients. However, it was unpleasant so was not widely used.
• Joseph Lister had seen carbolic sprays used in sewage works to keep down the smell. He tried this in the operating theatre in the early 1860s and saw reduced infection rates.
• Lister heard about Germ Theory in 1865 – he realised that germs could be in the air, on instruments and people’s hands. He started using carbolic spray on instruments and bandages.
• His first experiment with an antiseptic method was in august 1865. A young boy, Jamie Greenless had been run over by a cart and fractured his leg. The bones were sticking through the skin and the normal procedure would be to amputate his leg. Instead Lister set the bones and used dressings which had been soaked in carbolic acid. The dressings stayed in place for 4 days and after that the fracture and skin were healing well.
• The use of antiseptics immediately reduced death rates from as high as 50% in 1864-66 to around 15% in 1867-70.
• Lister published his work in March 1867.
• Lister faced opposition. Doctors didn’t like to use the spray as they found it unpleasant on their skin or to breathe in. People were also not very aware of Pasteur’s germ theory.
• In 1877, Lister used a well-publicised operation at King’s college Hospital to promote the use of carbolic spray.
• Antiseptics allowed surgeons to operate with less fear of patients dying from infection. The number of operations was 10x higher in 1912 than 1867.

Since the late 1800s, surgeons have changed their approach from killing germs to making a germ-free (aseptic) environments. Aseptic surgery reduced the need for carbolic spray. For example instruments are now carefully sterilised, theatre staff sterilise their hands and wear sterile gowns, masks and gloves. Surgical gloves were invented by William Halsted in 1889.

Women doctors in the 19^th century

In the 18^th century, the place of women in medicine was mostly limited to nursing. However, as the 19^th century progressed, women began to play a greater part in medicine.

• Elizabeth Blackwell – gained a medical degree in America, 1849, and set up the New York Infirmary for Poor Women before returning to England, where she was accepted onto the Medical Register in 1858.
• Elizabeth Garrett – acquired a licence from the Society of Apothecaries, 1865, then set up the Dispensary for Women.
• Sophia Jex-Blake – studied medicine at Edinburgh University, 1869, but had to take her degree in Switzerland and get her licence to practise medicine in Ireland. In 1874 she founded the London School of Medicine for Women.

These women were, however, the exceptions. Most male doctors were opposed to women doctors, and each time a woman found a loophole that allowed her to progress in her career, the medical profession changed the rules to stop it happening again. In 1911 there were only 495 women on the Medical Register in Britain.

Public Health

The industrial revolution began in the 18^th century. Lots of people moved into cities like London to work in the factories. The places they lived were cramped, dirty and great for spreading disease like cholera.

• During the 18^th and 19^th centuries, lots of people moved from the countryside to the cities to work in factories. The towns grew so quickly that good housing couldn’t be built fast enough – instead houses were built as close together as possible, with little outside space and poor ventilation.
• Overcrowding was a big problem, Workers had little money so tried to live in the smallest possible space – families with 4 or more children lived in a single room. The poorest lived in cellars.
• People didn’t understand the need for clean water or good sewerage systems. Most houses had no bathroom – they shared a toilet outside, called a privy.
• Each privy was built above a cesspit. Cesspit and household waste was collected by nightmen, who threw the waste into rivers or piled it up for the rain to wash away.
• Water companies set up water pumps which were shared between houses. The water was often contaminated.

Cholera reached Britain in 1831 and by 1832 it was an epidemic – over 21,000 people in Britain died of cholera that year.

• Cholera spreads when infected sewerage gets into the drinking water.
• It causes extreme diarrhoea – sufferers died from loss of water and minerals.
• Both rich and poor caused this disease.
• People did not know what caused the disease. The best theory was miasma.
• The government started regulating the burial of the dead, but this did little to help.
• Cholera epidemics recurred in 1848, 1853-54 and 1865-66.

Edwin Chadwick and the 1848 Public Health Act

• In 1842, the social reformer Edwin Chadwick published a report on poverty and health. The report showed that living conditions in towns were worse for people’s health than conditions in the countryside.
• The report suggested that the government should pass laws for proper drainage and sewerage systems, funded by local taxes.
• Chadwick’s report and another cholera epidemic in 1848 (which killed 53,000 people) put pressure on Parliament to pass a Public Health Act.
• In 1848 the Act was set up by the central Board of Health and allowed any town to set up its own local board of health as long as the town’s taxpayers agreed.
• The impact of the 1848 Act was limited – towns could set up health boards but very few chose to, and those that did, often refused to spend money improving conditions. Chadwick annoyed a lot of people, and was forced to retire in 1854. The central Board of Health was dismantled in 1858.

John Snow

• John Snow showed that there was a connection between contaminated water and cholera in 1853.
• He studied a cholera outbreak on the Broad street area of London and noticed that the victims all used the same water pump. So he removed the handle from the pump- ending the outbreak.
• Snow’s work received little attention at first. Most people still believed diseases were spread by miasma.
• Despite the work of Chadwick and Snow, public health didn’t improve – cholera returned to Britain in 1865.

The Great Stink

• A lot of waste in London drained into water sources.
• In the summer of 1858 the hot weather caused the river’s water level to drop and bacteria to grow in the waste. This produced a smell that affected large parts of London.
• To reduce the stink, engineer Joseph Bazalgette was appointed in 1859 to build a new London sewerage system.
• The sewers transported waster that was normally dumped in the Thames away from heavily populated areas to the Thames Estuary.
• About 1300 miles of sewers were built.
• When Bazalgette started work in his sewers, people still didn’t understand how disease spread. They were trying to get rid of the bad smells coming from the Thames. The fact they stopped cholera by cleaning the drinking water was unintended.

For most of the 19^th century, people believed in a laissez-faire style of government (the government shouldn’t interfere). But then things began to change:

• Evidence from Chadwick and Snow, and Pasteur’s Germ Theory showed that cleaning towns could stop the spread of disease.
• In 1867, the Second Reform Act was passed giving nearly 1 million more men the vote, most of which were industrial workers.
• Now they had the vote, workers put pressure on the government to listen to concerns about health. For the first time, politicians had to address workers concerns in order to stay in power.
• Several reformers helped to change to attitudes towards health. William Farr was statistician who recorded causes of death. He used his statistics to press for reforms in areas where death rates were high.

In the 1870s the government finally took action to improve public health.

• In 1871-72, the government followed the Royal Sanitary Commission’s proposal to form the local Government Board and divided Britain into ‘sanitary areas’ administered by officers of public health.
• In 1875, Benjamini Disraeli’s government passed another Public Health Act. It forced councils to appoint health inspectors and sanitary inspectors to make sure that laws on things like water supplied and hygiene were followed. It also made councils maintain sewerage systems and keep their towns and streets clean.
• The 1875 Public Health Act was more effective that the one passed in 1848 because it was compulsory.
• Disraeli also bought in the Artisan’s Dwelling Act in 1875. This let local councils buy slums with poor living conditions and rebuild them in a way that fit the new government backed housing standards.
• Few councillors used the Artisan’s Dwelling Act. An exception was Joseph Chamberlain, who became Mayor of Birmingham in 1873. Chamberlain persuaded the city authorities to buy the local gas and water companies to make sure people had good supplies of both.

There were several changes to public health during the industrial revolution, and the 1875 Public Health Act was the biggest. The government and individuals like Chadwick, Snow and Farr were key to these changes. Technology, the 1867 Reform Act and the cholera epidemics were other factors that prompted improvements.

Part 4: Modern Medicine

The Impact of the First World War

The war gave surgeons opportunities to find new techniques for diagnosis and for carrying out more complex operations.

X-rays

• William Rontgen discovered x-rays in 1895. X-rays passed easily through soft flesh, but less well through bone.
• X-Rays were used from the start of WWI to find broken bones, but the equipment included glass tubes that were unreliable and stopped working. Also it was located miles from the battlefields.
• William Coolidge had invented a more reliable tube in 1913. The ‘Coolidge tube’ is still used today.
• In 1914, Polish scientist Marie Cure developed mobile x-ray units which allowed doctors to transport x-ray equipment.
• The war also increased the number of radiologists. Curie and French scientist Antoine Beclere set up training schools to teach people how to use the equipment.

Transfusions

• The idea of blood transfusions were known from the 17^th Century but they were rarely successful.
• In 1900, Karl Landsteiner discovered blood groups. Certain blood groups could not be mixed together as the blood would clot, blocking the vessels. This discovery meant doctors could perform more successful transfusions.
• During WWI more blood was needed so they needed to find a way to store the blood.
• In 1914, doctors found that sodium citrate stopped blood clotting so it could be stored.
• In 1917, this discovery allowed the first ever blood depot to be set up at the Battle of Cambrai.

Plastic Surgery

• Doctors in France and Germany had been working on skin grafts techniques since before WWI.
• Harold Gillies set up a plastic surgery unit for the British Army during the war. He was interested in reconstructing facial injuries so that patients could have a normal appearance. He developed the use of pedicle tubes, and kept detailed records of his achievements.
• Gillies work continued during WWII by assistant Archibald McIndoes.

Shell Shock

• The mental strain of war could cause psychological damage known as shell shock.
• Some shell shocked soldiers had panic attacks; others shook all the time or were unable to speak or move.
• To begin with, the British Army refused to believe that shell shock existed and many of the men were treated as cowards. However, by the end of the war there were so many cases of shell shock that it was officially recognised. Today the condition is known as post-traumatic stress disorder.

Penicillin

• Alexander Fleming saw many soldiers die of septic wounds caused by staphylococcal bacteria when he was working in an army hospital during WWI.
• Searching for a cure he identified the antiseptic substance in tears, lysozyme, in 1922 – but this only worked on some germs.
• One day in 1928 he came to clean up some old culture dishes on which he had been growing staphylococci for his experiments. By chance, a fungal spore had landed and grown on one of the dishes.
• Fleming noticed that the colonies of staphylococci around the mould had stopped growing. The fungus identified was Penicillin notatum. It produced a substance that killed bacteria.
• Fleming published his articles between 1929 and 1931. However, nobody was willing to fund further research, so he was unable to take his work further. The industrial production of penicillin still needed to be developed.
• Since it is naturally produced, penicillin needs to be purified. A breakthrough was made by Howard Florey’s team in Oxford between 1938 and 1940. Ernst Chain, a member of the team, devised a freeze-drying technique which was an important part of the purification process.
• At first Florey and Chain didn’t have the resources to produced penicillin in large amounts. Their patients began to recover, only to die when the penicillin ran out.

Florey knew that penicillin could be vital in treating the wounds of soldiers in WWII. British chemical firms were too busy making explosives to start mass production – so he went to America.

• American firms were also not keen to help – until America joined the war in 1941. In December 1941, the US government began to give out grants to businesses that manufactured penicillin.
• By 1943, British businesses had also started mass-producing penicillin. Mass production was sufficient for the needs of the military medics by 1944.
• After the war, the cost of penicillin fell, making it more accessible for general use.
• Fleming, Florey and Chain were awarded the Nobel Prize in 1945.
• Other antibiotics were discovered after 1945.

While individuals, like Fleming, Florey and Chain, were important in making the discovery of penicillin, it was a large institution like governments that funded its mass production.

Modern treatments

• In the late 1800s, the chemical industries in places like, Britain, Germany, Switzerland and the US were booming.
• The late 19^th and 20^th centuries also saw the discovery of new drugs including aspirin (1899), insulin (1921), sulphonamides (1932) and penicillin.
• The chemical companies began to manufacture these drugs on a large scale, and make them available to a lot of people.
• The success of their mass-produced drugs in the 1940s helped the modern pharmaceutical industry take off.
• Pharmaceutical companies have played an important role in researching and developing new medicines. They also mass produced these drugs to sell worldwide.
• These companies have been important in treating new diseases, by researching new forms of treatment.
• Chemotherapy began to be developed in WWII, and pharmaceutical companies have been producing cancer drugs since the 1960s.
• In 1981, doctors identified a new illness, AIDS, which was caused by the HIV virus. In 1987, pharmaceutical companies began mass producing a drug called AZT, the first approved drugs to treat HIV.

Drugs have to go through a series of clinical tests before they are given to patients. This is to make sure they work properly and have no side-effects.

• In the 1950s, the drug thalidomide was released without proper testing. It was originally used as a sleeping pill, but it soon became popular among pregnant women as a treatment for morning sickness. Tragically, thalidomide affected women’s unborn babies, causing thousands of children to be born with undeveloped limbs and other problems.
• The government responded to this tragedy in 1963 by setting up a Committee of Safety of Drugs to make sure all new drugs were safe before being given to patients.
• Pharmaceutical companies have high costs for research and development of new medicines. Rare diseases sometimes go under researched because companies tend to focus on treatments for common diseases that will make a lot of money.
• Antibiotic resistance is when a type of bacteria adapts so it isn’t affected by antibiotics anymore. This resistance develops when doctors and patients overuse antibiotics – the more they are used, the more likely it is that bacteria will become resistant to them.
• Around 25,000 people in the EU die every year as a result of infection caused by antibiotics resistant bacteria.

Transplants

• In 1905 the first successful transplant of the cornea of the eye was performed.
• The first complete organ to be successfully transplanted was the kidney.
• The first heart transplant was carried out by South African surgeon Christiaan Barnard in 1967. The patient only survived for 28 days – he died of pneumonia.
• Since the 1970s the development of drugs that stop the immune system from attacking the implant have become increasingly effective.

Surgery

• Advances in science and technology have led to improvements in the treatment of diseases like cancer. The discovery of radiation in 1896-98 by Antonie Henri Becquerel, Marie Curie and Pierre Curie led to the creation of radiation therapy.
• The development of lasers since the 1950s led to their widespread use in medicine in the 1980s. Laser surgery is used to correct vision problems, and lasers are also used in cancer treatments and dentistry.
• Advances in video technology led to the development of keyhole surgery in the 1980s.

Alternative treatment

• Mistrust of modern medicine and technology means some people use alternative therapies. For example acupuncture and homeopathy.
• Unlike mainstream treatments, alternative therapies are not based on evidence gathered from scientific research. As a result, there is little scientific evidence that alternative treatments work effectively, and some doctors think they might do more harm than good.
• However, some doctors are now working with alternative therapists to see if using a mix of alternative and mainstream medicine might result in benefits to the patients.

The Liberal Social Reforms

In the 19^th Century, people believed the government should have little involvement in public health. This all began to change after 1900, when the Liberal Social reforms were introduced to deal with poverty.

• Slums and other poor, overcrowded housing were still common in industrial towns in 1900. The poor worked long hours for low wages.
• Many people couldn’t afford doctors or medicine – they could barely provide their children with three decent meals a day.
• There were no unemployment benefits or pensions for the elderly. Workhouses provided basic food and lodging in exchange for working long hours in brutal conditions.

2 reports showed how widespread poverty was:

• Booth’s report – Charles Booth’s 1889 ‘Life and Labour of the People in London’ showed that 30% of Londoners were living in severe poverty, and that it was sometimes impossible for people to find work, however hard they tried. Some wages were so low that they were not enough to support a family.
• Rowntree’s report – Seeborn Rowntree had a factory in York. He didn’t believe the problem was as bad there as living in London – so he did a survey of living conditions. His report ‘Poverty, a Study of Town Life’, (1901), showed that 28% of the people in York couldn’t afford basic food and housing.

The lack of access to good health care meant that most people’s health was pretty poor. When the Boer War broke out in 1899, army officers found that 40% of volunteers were physically unfit for military service.

Booth, Rowntree and the Boer War showed that there was link between poverty and ill health. The newly elected Liberal Government and its Chancellor, David Lloyd George, realised it had to take action.

• 1906 – Free school meals introduced
• 1907 – Local Education Authorities started giving children at their school free medical inspections.
• 1908 – Old age pensions were introduced for the first time – for people over 70. It was the first ever welfare scheme to be paid for by national taxes.
• 1909 – Labour exchanges were introduced to help unemployed people find work.
• 1911 – The National Insurance Act was passed. This introduced health insurance for workers – the worker, their employer and the government all contributed to a central fund that the workers could use for sick pay or pay for a doctor.

The Liberal reforms were the first real effort by the national government to improve people’s living conditions as a way of improving their health. The reforms were a result of changing attitudes towards the role of the government, and changed people’s attitudes further.

Public Health and the World Wars

WWI and WWII broke down social distinctions and brought people together whose lives had been very separate.

• Raising armies had made government and military officials more aware of the health problems of the poor. Powerful people were more concerned with solving these problems when at war because they needed a strong army.
• The evacuation of children in WWII increased awareness in richer rural communities of how disadvantaged many people were in other parts of the country.
• After WWII people looked for improvements in society. Such feelings led to the 1945 victory for the Labour Party, which promised healthcare for everyone and full employment.
• Towards the end of WWI, Prime Minister David Lloyd George promised to tackle the poor-quality housing by building ‘home fit for heroes’. Some new council houses were built in the 1920s and 1930s, but many of them were too expensive for the poorest families, who still lived in slums.
• During WWII, destruction from bombing and a lack of construction led to severe housing shortages, making the situation worse.
• After the war, the Labour government built 800,000 homes between 1945-51. In 1946, it passed the New Towns Act – this created completely new towns near major cities.
• Governments in the 1950s and 1960s demolished over 900,000 old, cramped slums – around 2 million inhabitants were rehoused.
• In 1961, a report called ‘Homes for Today and Tomorrow’ gave specific standards for new housing, including adequate heating, a flushing toilet and enough space inside and outside. This was the final step in tackling the issues of overcrowding, poor nutrition and poor waste disposal that had caused major public health problems.

The Beveridge Report

• In 1942, William Beveridge published ‘The Beveridge Report’.
• In the report, Beveridge called for the state provision of social security ‘from the cradle to the grave’. Beveridge argued that all people should have the right to be free from want, disease, ignorance, squalor and illness. He called these the five ‘giants’.
• Beveridge said the government had a duty to care for all citizens, not just the poor or unemployed. To achieve this, Beveridge suggested the creation of the welfare state – a system of grants and services available to all British citizens.
• The 1945 Labour government was elected with the promise to implement Beveridge’s proposals.
• One of their first acts was to pass a new National Act in 1946 to support anyone who couldn’t work.
• The Labour Party’s National Insurance Act went further than the one introduced by the Liberal Government – anyone could apply for Labour’s National Insurance without having to take a test to find out if they were eligible.

National Health Service

• The National Health Service was established in 1948. It was Beveridge’s last proposal.
• Aneurin Bevan was the Labour Minister for Health who introduced the NHS.
• The government nationalised hospitals and put them under local authority control.
• Treatment was made free for patients

There were arguments for and against the NHS:

For:

• During WWII the government took control of all hospitals, creating the Emergency Medical Service. Its success led many to support the creation of the NHS.
• The NHS would make medical care free so it was accessible to everyone.
• The NHS guaranteed that hospitals would receive government money, rather than having to rely on charities for money.

Against:

• Many Conservatives opposed the NHS as they believed the cost would be huge.
• Doctors saw themselves as independent professionals – they didn’t want to be controlled by the government. They also worried that they would lose a lot of income.
• Many doctors threatened to go on strike in protest against the NHS (The government finally convinced doctors by offering them a payment for each patient and letting them continue treating fee-paying patients).

• Although many Conservatives were opposed to the creation of the NHS, they could not abolish it when they came back into power in 1951 – It was too popular.
• The NHS increased the number of people with access to healthcare – the number of doctors doubled between 1948 and 1973 to keep up with demand.
• Today the NHS provides a range of health services, most of which are free and accessible to everyone.
• In the long term, the NHS has contributed to a dramatic improvement in people’s health and a rise in life expectancy. In 1951, men could expect to live to 66 and women to 72 – by 2011 this had risen to 79 for men and 83 for women.

 The NHS faces several challenges now…

• The increase in life expectancy means there are more older people in Britain today than there were in 1948, who are more likely to suffer from long-term conditions like diabetes and heart disease. They need regular medical attention and require a lot of NHS time and resources.
• Many people’s lifestyle choices are putting a strain on the NHS. Smoking, obesity and alcohol consumption can all harm people’s health and may require expensive treatment.
• Many modern treatments, equipment and medicines are very expensive, and the NHS has to face rising expectations of what it can and should offer.
• As a result of all these factors, the cost of the NHS is rising rapidly – in 2015/16 the NHS budget was £116 million overall.