Medicine – Part Nine

The 20th Century

A great deal of medical progress in the 20th Century, you will be unsurprised to hear, was driven by warfare. In 1900 Karl Landsteiner classified blood in to three groups, O, A and B. Alfred von Decastello and Adriano Sturli discovered the fourth type, AB, in 1902. As is known now antigens differ between people. This means their immune system will only tolerate their own blood type. This discovery paved the way for blood transfusions. This would come in handy. WWI or the Great War as it was known at the time saw new technological advances in weaponry and medical treatment had to respond as a result.

“The First World War acted as a catalyst for the rapid development of blood banks and transfusion techniques. Canadian Lieutenant Lawrence Bruce Robertson was instrumental in persuading the Royal Army Medical Corps to adopt the use of blood transfusion at the Casualty Clearing Stations for the wounded. In October 1915, Robertson performed his first wartime transfusion with a syringe to a patient suffering from multiple shrapnel wounds. He followed this up with four subsequent transfusions in the following months and his success was reported to Sir Walter Morley Fletcher, director of the Medical Research Committee.“-Infogalactic

WW1 brought death on an industrial scale. Huge numbers of casualties meant bigger and more numerous hospitals. Many country houses were converted to hospitals for the duration of the war. Men came back missing arms and legs from explosions or from having limbs amputated. New prosthetics had to be developed to cope with this. Men also came back suffering from “shell shock,” which we now know was a type of post-traumatic stress disorder. At the Battle of the Somme up to 40% of casualties were thought to be shell shocked. More troops became shell shocked as the war went on. Treatment was generally being removed from the front lines. Specialist hospitals were set up just to deal with these cases. It was a controversial issue, as many were thought cowards or that their breakdown meant a lack of moral fibre. Some were even put on trial for cowardice and executed.

As in previous eras, war gave surgeons plenty of chance to practice. Bullet wounds were common, as was trench foot and other diseases that broke out when too many people were crowded in unhygienic conditions for a prolonged time, as well as the notorious trench fever. If soldiers weren’t immediately killed by their wounds then infection became a major problem, such as gangrene. X rays had been used in medical technology in the late 19th century. They came in to their own during WW1. Marie Curie developed radiography units for the red cross and soon became the director of radiology. This helped quick diagnosis for those patients lucky enough to be near one.

Marie Curies was mentioned earlier. In 1895, Wilhelm Roentgen discovered the existence of X-rays, though the mechanism behind their production was not yet understood. In 1896, Henri Becquerel discovered that uranium salts emitted rays that resembled X-rays. Curie decided to do further research. Curie found that thorium was also radioactive and discovered polonium and radium. Crucially for medicine, Curie and her husband found that cancer cells exposed to radium were killed more quickly than healthy cells. There was now potentially a way to fight cancer other than surgery. Curie was the first woman to win a Nobel prize and won it twice in different fields. Unfortunately, Curie died in 1934 from a condition thought to be related to long term radiation exposure, the dangers of which were unknown at the time. Curie was known to walk around with test tubes containing radioactive isotopes in her pocket.

Both during the Great War and the inter war years infection remained a problem. Paul Ehrlich was a member of Robert Koch’s team that had helped Koch discover types of bacteria and how to stain them. Ehrlich wanted to develop a way to also kill them, while Ehrlich had claimed this would be like a “magic bullet” to cure the disease. In 1909 he found an arsenic compound that killed syphilis. In was the 606th version he tried (can’t say he didn’t stick to the task) so he called it Salvarsan 606.

In 1932 Gerhard Domagk found the second magic bullet after years of methodical research. This was a red dye called Prontosil. He injected mice with a lethal dose of a streptococcal infection. He then injected them with Prontosil, which cured them. Soon he had the chance to try it out on a person, his own daughter, who was seriously ill with the same streptococcal infection. Having no other cure, he injected her with Prontosil and she recovered. He later isolated the key ingredient, sulfonamide. Sulfonamides had revolutionary antibacterial effectiveness for its time. In 1939, Domagk received the Nobel Prize in Medicine for this discovery, the first drug effective against bacterial infections. He was forced by the Nazi regime to refuse the prize and was arrested by the Gestapo for a week. Magic bullets were a step forward. However, they came with serious side effects and could be lethal to the patient. In some cases, it was literally kill or cure.

Fleming recounted that the date of his discovery of penicillin was on the morning of Friday, September 28, 1928. The traditional version of this story describes the discovery as a fortuitous accident: in his laboratory in the basement of St Mary’s Hospital in London (now part of Imperial College), Fleming noticed a Petri dish containing Staphylococcus that had been mistakenly left open, was contaminated by blue-green mould from an open window, which formed a visible growth. There was a halo of inhibited bacterial growth around the mould. Fleming concluded that the mould released a substance that repressed the growth and caused lysing of the bacteria.

Fleming was a famously poor communicator and orator, which meant his findings were not initially given much attention. He was unable to convince a true chemist to help him extract and stabilize the antibacterial compound found in the broth filtrate. Despite the lack of a true chemist, he remained interested in the potential use of penicillin and presented a paper entitled “A Medium for the Isolation of Pfeiffer’s Bacillus” to the medical research club of London, which was met with little interest and even less enthusiasm by his peers. Had Fleming been more successful at making other scientists interested in his work, penicillin for medicinal use would possibly have been developed years earlier.” –Infogalactic

Apologies for the BBC video. Florey and Chain were involved in the mass production of penicillin before and during WW2. By 1940 Florey and his team had shown that penicillin could cure bacterial infection in mice. But to be of effective use in the war a way was needed to mass produce it. By 1942 they only had enough to treat 10 patients. The US war production board got involved in 1943. As the war raged on many soldiers were once again dying from infections. The country could not afford to lose men, especially with potential invasions of Europe and Japan in the future. The results of fermentation research on corn steep liquor and deep tank fermentation allowed 2.3 million doses to be available by the time of the D-Day landings.

You knew it was coming. Our NHS. (Not much diversity in the video either.) In 1942, William Beveridge, a civil servant, advised the government to set up a welfare state, including a free national health service, which was to give benefits ‘from the cradle to the grave’ for all. The plans were passed by the post-war Labour government in 1946. Two years later the National Health Service (NHS) began. It was available free to everyone in the nation and was to cover every aspect of health care.

Liberal economist William Beveridge, who identified five “Giant Evils” in society: squalor, ignorance, want, idleness, and disease, and went on to propose widespread reform to the system of social welfare to address these. The Report came in the midst of war, and promised a reward for the sacrifices undertaken by everyone. Highly popular with the public, the report formed the basis for the post-war reforms known as the Welfare State, which include the expansion of National Insurance and the creation of the National Health Service.“-Infogalactic

This had a positive impact on health and life expectancy. Children evacuated to the countryside had highlighted the poverty and poor conditions in cities like London. Governments had known since Roman times that providing public health was a good idea to keep workers healthy and productive. The NHS also coincided with new drugs like penicillin being available.

Life expectancy had been rising steadily since the industrial revolution. There is a strong correlation between life expectancy and GDP per capita (It’s as though Capitalism works, or something). Other developed countries have not used the NHS model, yet have similar or indeed sometimes higher life expectancy. The NHS has been dogged by funding issues, even from early on. A prescription charge was brought in in 1951. Today it is still having funding issues and seems to require ever greater amounts of money for a seemingly reducing service. Many complain of the difficulty in making doctors appointments and have gone to A+E instead, placing further strain on hospitals. There seems to be a winter crisis every January. Health boards and hospitals cite record demand. A combination of people living longer and needing more care, alongside letting in +200,000 people through net migration means the service is under strain. Some diseases that haven’t been seen in the UK for decades or centuries are turning up again. Of course, it is not for me to say where they are coming from. Perish the thought.

“The world’s first human-to-human heart transplant was performed by South African cardiac surgeon Christiaan Barnard utilizing the techniques developed by Norman Shumway and Richard Lower. Patient Louis Washkansky received this transplant on December 3, 1967, at the Groote Schuur Hospital in Cape Town, South Africa. Washkansky, however, died 18 days later from pneumonia. On December 6, 1967, at Maimonides Hospital in Brooklyn, New York, Adrian Kantrowitz performed the world’s first pediatric heart transplant. The infant’s new heart stopped beating after 7 hours and could not be restarted. At a following press conference, Kantrowitz emphasized that he did not consider the operation a success.

Norman Shumway performed the first adult heart transplant in the United States on January 6, 1968, at the Stanford University Hospital. A team led by Donald Ross performed the first heart transplant in the United Kingdom on May 3, 1968. An allograft is the technical term for a transplant from a non-genetically identical individual of the same species. Brain death is the current ethical standard for when a heart donation can be allowed. Worldwide, more than 100 transplants were performed by various doctors during 1968. Only a third of these patients lived longer than three months. The next big breakthrough came in 1983 when cyclosporine entered widespread usage. This drug enabled much smaller amounts of corticosteroids to be used to prevent many cases of rejection (the “corticosteroid-sparing” effect of cyclosporine)”-Wikipedia

DNA as we know it had a breakthrough in 1953. DNA was known about previously, but James Watson and Francis Crick came up with the double helix model.  These findings allowed the modern science of molecular biology. This has opened up possibilities such as gene therapy. Problems with cells may be able to be fixed at source by replacing mutated DNA with healthy. This can be done with either somatic or germline therapy. Scientists are in some cases now using modified viruses to deliver the DNA changes, as viruses introduce new DNA in to cells in order to replicate.

The first approved gene therapy took place in 1990 in the United States (not on Our NHS, strangely). A child was treated for an immune system problem. The fix was successful but temporary. Cancer gene therapy was introduced in the early 1990s. The 2000s saw DNA inserted in to the brain for the first time. In August 2006 scientists successfully treated metastatic melanoma in two patients using killer T cells genetically retargeted to attack the cancer cells. In 2007 and 2008, a man was cured of HIV by repeated stem cell transplantation. Clinical trials of gene therapy for sickle cell disease were started in 2014. Although this is beyond the 20th Century the foundations were laid before.

“Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well designed and conducted research. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.[1] Use of the term rapidly expanded to include a previously described approach that emphasized the use of evidence in the design of guidelines and policies that apply to groups of patients and populations (“evidence-based practice policies”). It has subsequently spread to describe an approach to decision making that is used at virtually every level of health care as well as other fields (evidence-based practice).

Whether applied to medical education, decisions about individuals, guidelines and policies applied to populations, or administration of health services in general, evidence-based medicine advocates that to the greatest extent possible, decisions and policies should be based on evidence, not just the beliefs of practitioners, experts, or administrators. It thus tries to assure that a clinician’s opinion, which may be limited by knowledge gaps or biases, is supplemented with all available knowledge from the scientific literature so that best practice can be determined and applied. It promotes the use of formal, explicit methods to analyze evidence and make it available to decision makers. It promotes programs to teach the methods to medical students, practitioners, and policy makers.”-Infogalactic

“Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.5 cm) elsewhere in the body.

There are a number of advantages to the patient with laparoscopic surgery versus the more common, open procedure. Pain and hemorrhaging are reduced due to smaller incisions and recovery times are shorter. The key element in laparoscopic surgery is the use of a laparoscope, a long fiber optic cable system which allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location.

There are two types of laparoscope: (1) a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip), or (2) a digital laparoscope where the charge-coupled device is placed at the end of the laparoscope.”-Infogalactic

There are many other medical advances in the 20th Century, but this article is already too long and is supposed to be a brief overview. Have a look at some more here. Next we go in to the 21st Century and look to the future.

© Jonathon Davies 2018

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