History - Medicine Through Time

Hunter-Gatherer - They hunted animals for food, and collected berries, nuts etc for food.

Nomadic - They travelled from place to place, rather than living in one place.

Life Expectancy - Around 19-25 years, hunting was dangerous, mothers and babies died in childbirth.

DIFFICULTIES: No written language, so there's no written records of how they treated illness.

EVIDENCE: Other hunter-gather societies (e.g. Aborigines), Egyptian and Roman written records, artefacts such as bones and cave paintings.

Explanations - Evil spirits entering the body, cursing someone with a pointing bone, people losing their own spirits.

Medicine Man: Provides spiritual comfort and medical help, contacts spirit world to decipher treatment.

Treatments -
Chants and dances: Medicine Man claims the heat causes a trance.
Charms: Warn off evil spirits.
Trephining: Creating a hole in the skull with a stone knife, for the evil spirits to escape.

Illness - Learn remedies from mothers, herbs, plants, minerals and animal parts.

Trial and Error - Plains Indians: squaw root relax uterus during childbirth. Willow tree leaves used for aspirin to stop pain and inflammation.

Injuries - From hunting, accidents and fighting. Common sense, mud set broken limbs, splints made of wood.

Causes - Injury, Childbirth complications, Infections.
Healers - Women (natural), Medicine Men (supernatural).
Explanations - Natural accidents (hunting, fighting), Supernatural spirits (evil spirits or losing spirit).
Treatments - Natural remedies (herbs, plants, minerals, animal parts, mud, splints). Supernatural remedies (chanting, dancing, charms, trephining).
Factors for Change - Lifestyle did not change, so neither did medicine. More concerned with hunting for food than medicine.
Impact - Treatments spread slowly due to slow communication.

Farming - Developed along River Nile, flooding kept land fertile. Success made Egypt wealthy, the rich had time and money to focus on medicine and religion.
Religion - Medicine Men became priests, belief in spirits became a religion, developed ideas of afterlife and Gods.
Written Language - Signs called hieroglyphics, written ideas could be shared, historians could interpret documents.
Tools - Developed for use in medicine.
Doctors - Careful training, still religious figures using charms, prayer and chanting, alongside natural remedies.
Cities - People settling in one place, problems caused by waste disposal and epidemics.
Trade - Goods traded between countries, for example medical herbs, ideas were also developed this way.

Temples - Recieved treatment if rich enough and condition was serious enough.

Priests - Used common sense and supernatural.

Physicians - Specialist doctors, also priests, employed by pharaohs.

Imhotep - The Pharoah's doctor, an architect, chief minister and was considered a God on Earth.

Irj - A doctor, "Guardian of the Anus".

Disease - Looked to nature for explanations, an example was "Blocked Channels".

Injuries - Understood they happened at work, during battles and hunting. Broken bones from falling, animal bites and other obviously caused injuries were treated naturally.

Treatments - Made from herbs, plants, minerals and animal parts. Honey was used as a natural antiseptic.

Injuries and Disease - No obvious cause, for example infections, were treated by Gods. Sekhmet was the bringer of epidemics, Bes watched over women in childbirth, Imhotep was a Pharoah's doctor during life and died as a God.

Treatment - Spells, Charms and Prayers.

Dissections - Not used due to needing body for afterlife .

Mummification - Method of embalming, preserved bodies buried in tombs and pyramids. Stomach, intestines, lungs and liver removed and placed in canopic jars. Brain removed through nose with a hook.

Knowledge - Blood was carried by veins and arteries.

River Nile - Had channels for irrigating crops, if blocked the crops would die.

Comparison - If veins and arteries were blocked, humans became ill, the same way the crops die if the channels are blocked.

Treatment - Induced bleeding, vomiting and emptying of bowels.

Baths - Washed twice a day, particularly clean when worshipping to please the Gods.

Toilets - A seat with a hole cut in, with a cup or bowl beneath it.

Mosquito Nets - Slept beneath them, prevents uncomfortable bites, unknowingly prevents malaria.

Makeup - Eye makeup was worn to look attractive, unknowingly contained elements such as copper ore and malachite, which prevented eye infection.

Causes - Epidemics spreading in cities, washing for Gods tended to keep people healthy.
Healers - Women from home, Doctors in temples.
Explanations - Blockage of veins and arteries, Gods (Sekhmet) sent epidemics.
Treatments - Purging, bleeding, praying.
Factors for Change - Writing allowed sharing of information, Religious embalming allowed knowledge of the body.
Impact - Embalming and Treatment was for the very rich.

Greek Empire - Began around 1000ac, extended to Italy, Sicily and North Africa.

Great Thinkers - Richer from trading goods, they spent time thinking and learning, an example was Hippocrates.

Gods - Gods for all aspects of life, such as God of War, God of Wisdom and God of Wine. Life intertwined with these beliefs, such as good harvests meaning gods were pleased, and earthquakes meaning gods were angered.

Asclepius - Greek god of medicine, believed to cure most illnesses.

Asclepion - Where cures by Asclepius took place, had baths, a stadium, temple of Artemis, and an abaton where they slept and were visited by Asclepius.

Natural Methods - Bathing, exercising and sleeping.

Supernatural Methods - Asclepius and his daughters visited and cured illness during patients sleeping.

Natural Influence - The four elements (Water, Earth, Fire and Air), and the four seasons (Spring, Summer, Autumn and Winter).

Four Humours - Developed by Hippocrates. Blood, Phlegm, Yellow Bile and Black Bile. An inbalance of any humour was believed to cause illness.

Link to Seasons - Certain symptoms were more common at certain times of year, for example spring brought on a fever, a raised temperature led to the belief that the patient had too much blood.

Treatments - Rebalancing humours, such as bleeding patients with too much blood, advising exercise for too little bile.

Asclepion - Exercising, bathing and sleeping.

Hippocrates - Suggest personalised health regimes.

Wealth - Rich people just rested and relaxed.

Poverty - Poor people given medicine because they weren't able to stop working.

Women - Provided bulk of care at home, some midwives supported women through dangerous childbirth.

Hippocratic Collection - Hippocrates books containing his methods.

Clinical Observation - Doctors built a collection of notes about varying symptoms, treatments and their effectiveness. This improve future diagnosis and treatment.

Hippocratic Oath - An oath in which doctors promise to do their patients no harm and follow strict confidentiality, an oath doctors still take today.

Alexander the Great - Conquered Egypt around 330bc, build the city Alexandria.

Great Library - Built in the city, contains medical books from around the world, including the books by Hippocrates.

Dissection - Actually allowed at Alexandria, doctors had much more knowledge about anatomy and surgery.

Causes - Farming, Hunting and Fighting injuries. Childbirth complications, epidemics spread in cities.
Healers - Women at home, doctors following Hippocrates, Asclepions provided medical care.
Explanations - Imbalance of the four humours, gods such as Asclepius.
Treatments - Bleeding, purging, exercising, going to an Asclepion.
Factors for Change - Hippocrates' individual genius allowed the theory of the four humours, treatments based on this, and clinical observation.
Impact - Richer people affected mostly, but treatments based on four humours were inexpensive.

     SIMILARITIES -

• Four Humours and Clinical Observation were still used.
• Believed in Gods, Romans borrowed some Greek Gods, such as Asclepius to help during the plague.
• Medicine centered around home, women used herbal remedies.

DIFFERENCES - 

• Romans believed in bad air and smells making people ill, their prevention included cleaning themselves and not building near marshes.
• Romans were not concerned with doctors, some were seen as money-grabbers and a last resort. They believed in prevention more than cures.

Public Health: An idea to keep their army and citizens healthy. They were good engineers and builders, and were very rich so could tax a lot for what was needed.

• Public Toilets - Waste went into sewers as opposed to the street.
• Public Baths - Allowed washing and exercise.
• Sewers - Removed waste and emptied into rivers.
• Aqueducts - Clean water was brought into towns from springs in countrysides.
• Public Fountains - Running water for drinking and washing.
• Free Hospitals - To treat soldiers.

Early Life: Born in Greece in AD 129, studied medicine at age sixteen and became a gladiator surgeon. He later moved to Rome to be an Emperor's doctor.

Theory of Opposites: Influenced by Hippocrates' Theory of the Four Humours, an example stated that a disease caused by cold is treated with hot ingredients like pepper.

- Proved the brain controls the voice by cutting the nerves of a squealing pig.

- Proved veins and arteries carried blood around the body.

- Incorrectly thought blood was made in the liver and was used up like fuel.

1) His ideas suited the Christian Church - they showed that the human body was created by God and that all parts of the body fitted perfectly together.

2) No one proved him wrong - Doctors were not dissecting as it was illegal.

3) He wrote many books - He was a very convincing writer, so people believed everything he said, allowing his work to be used for the next 1500 years.

Causes - Battle injuries and hygiene issues in big cities.
Healers - Primarily the family, prevention over cure, doctors as a final resort, priests at Asclepions for the rich and desperate, and army surgeons.
Explanations - Imbalance of four humours, bad air and smells, gods like Asclepius.
Treatments - Bleeding, purging, public health schemes, theory of opposites, herbal remedies.
Factors for Change - Hippocrates' influence on Galen and his extensions.
Impact - Little change for countryside citizens, city citizens affect by public health, rich people could afford doctors and Asclepions.

AD 400 - AD 500: Empire collapased, countries left to fend for themselves, war broke out and Britain was invaded by tribes of Anglo-Saxons, Rome was overrun by Barbarian tribes.

• Public Health Systems - Destroyed in the process of invasion.
• Libraries - Medical books were destroyed.
• Education - Invading tribes could not read, were not interested in furthering education nor Galen's prior work.
• War - Main priority, money spent on armies as opposed to education and medicine. 
  
• Christian Church - Only powerful central body to survive the collapse.

CHRISTIANS -

• Helped: Jesus' teachings stated their duty was to care for the sick, hence hospitals were found in monasteries and nunneries.
  Preserved, translated and copied medical books.
• Hindered: Banned dissection.
  Believed ancient writings were not to be questioned, including Galen's work and the Bible.
  Only supported Galen and Hippocrates' because it suits their religious beliefs. Believed illnesses were a punishment sent from God.

MUSLIMS - 

• Helped: Followed a religious duty to care for the sick in Arab hospitals.
  Arab rulers wanted to develop education, Islamic scholars translated medical books.
  Arab doctors, for example al-Razi and Ibn Sina wrote medical books on Galen, Hippocrates and their own work.
• Hindered: Banned dissection due to belief in afterlife.
  Only supported Galen and Hippocrates' ideas because it suited their religious beliefs.

Natural Explanations: Bad air and smells, out of balance humours, poisons in the air, minority groups believed to have poisoned wells in Germany.

Natural Treatments: Clean up towns that smelled bad, purging, bleeding, use of opposites, stopped practices such as "the kiss of obedience" when knights kissed their lords as a promise to obey, herbal remedies such as honey and plantain.

Supernatural Explanations: Astrology, God's punishments, Devil causing mischief.

Supernatural Treatments: Praying, beating themselves with sticks to punish themselves for their sins (flagellation), gigantic candles burned in church. 

Bubonic Plague - 

• Infected by flea bites that had previously bitten infected rats.
• Cold and tired.
• Buboes were swellings under the arms or in the groin, filled with pus and would burst and cause blood poisoning.
• Blisters were all over, high fever, severe headaches, unconsciousness and death after 4-7 days.

Pneumonic Plague - 

• Attacked the lungs and was more lethal than bubonic plague.
• Coughing up blood.
• Infected through other people coughing on them.
• Death quickly came within a day or two.

Responses - 

• No understanding of how or why it happened, they had no scientific explanations or technology to show it was the flea bites causing infection.
• Blamed it on bad smells, stars and planets, minority groups poisoning the water (mostly Jews), God punishing sins, imbalance of four humours, poor living conditions and dirty towns.
• Some helped by cleaning streets and burning clothes. Some did not, for example using shaved dead chickens on buboes. 

Barber Surgeon: Barbers, not trained doctors, gave medical assistance on battlefields.

• Used wine as an antiseptic, extracted arrows, stopped bleeding, amputated limbs.
• Looked down upon by doctors due to no university training.
• Physicians forbidden to perform surgery because the body was considered holy, so passed responsibility onto lower ranked barbers. 
• Compared to Muslim doctors who treated soldiers during the crusades.

• People urinated anywhere - Streams, streets, out of windows.
• Open sewers in streets - Carried waste to the river.
• Toilets - Emptied waste directly into streets.
• Drinking water wells - Close to cesspools of sewage.
• Butchers - Washed blood of animals into the streams.
• Villages - Living in smoke-filled huts, shared with animals in winter.
• Streams and rivers - Washing and drinking water was contaminated with urine, waste and blood.
• Chamber pots - Waste poured out of windows onto the street.
• Towns - Cramped and narrow streets.

• People arrested if they urinated in streets.
• Rakers were employed to remove waste from streets.
• People fined for littering and throwing waste out of windows.
• Public toilets in London.

  Monasteries remained the healthiest places -

• Located near fresh water and had toilets.
• Rich and well organised.
• Monks held the belief that being clean was worshipping God.

Wise Women: Acted as the midwife. Made natural remedies for aching and pains. Usually effective treatments, such as onions and lichens, contained natural antibiotics.

The Church: Discouraged women from taking part in medicine, as they were inferior to men. Sometimes they accused wise women of witchcraft. 

Nuns: Looked after sick people in nunneries, were not allowed to train as doctors in university, as they were run by the Church.

• Monasteries and Nunneries involved praying, reading the bible and caring for the sick.
• They had seperate hospitals for the public, run by nuns and monks who viewed it as their religious duty to care for the sick. 
• Treatments included particular diets, sleeping well, balancing four humours, and praying to God for forgiveness.
• They did not have to admit someone with an infectious disease. Not many monks died of the Black Death due to being cut off from society.
• Islamic hospitals had different wards for different diseases.

Causes: Battle injuries, poor hygiene, cramped towns, plagues.
Healers: Women at home, wise women, midwives, barber surgeons, monks, nuns, doctors.
Explanations: Bad air and smells, imbalanced four humours, God's punishment, astrology.
Treatments: Opposites, bleeding, purging, herbal remedies, praying for forgiveness, self-beating.
Factors for Change: Religion allowed training but banned dissection. War allowed practice but destroyed public health systems.
Impact: Mainly advances in treating war wounds.

• Middle Ages scholars cut out parts of medical books they did not agree with during the translation process, such as dissection.
• Renaissance thinkers wanted to translate original books by Hippocrates and Galen when they found the books again, thus discovering all the changes made in the Middle Ages. 
• This encouraged people like Vesalius to question medieval ideas by dissecting humans.
• Artists, such as Leonardo da Vinci, to look closely at nature. They studied the detail of the human body and improved knowledge of anatomy. 

• Studied medicine in France and Padua. Padua encouraged studying nature. Became a professor of surgery in Padua.
• Robbed cemeteries for bodies to dissect. 
• 1543: Wrote the book "The Fabric of the Human Body", which described bodily functions, and detailed anatomy pictures by artist, Titian.
• Corrected Galen: Jaw being made of one bone not two. Breastbone had three parts not seven. Men did not have one less rib than women.
• Church were horrified by his writings because they led to questioning.
• Printing Press: Ideas and illustrations printed in books and spread in Europe.
• BUT: Nobody was healthier, doctors refused to accept Galen was wrong.

• He was an apprentice to his brother as a barber surgeon. He was a French Army surgeon in 1536-56, then a surgeon for the kings of France. 
• Treating wounds: Gunshots were originally treated with boiling oil, but Paré ran out. He made up a poultice of egg yolk, turpentine and cold oils. Effectively treating the wounds.
• Stopping Blood: Bleeding was originally stopped using a cauterising iron (red hot metal). Paré used silk thread to tie ligatures around arteries.
• His methods were less painful, however infection still occurred. Paré's ideas were more effective after antiseptics.

• He studied medicine at Cambridge University and moved to Padua to carry on training. He moved back to London and became a doctor for James I and Charles I.
• He proved Galen's idea of blood being made in the liver and used up as fuel wrong, and also the idea of four humours.
• He proved the heart was like a pump which circulated the same blood around the body. He experimented on living people to show valves in the veins and blood flowed one way. He also wrote his book "An Anatomical Account of the Motion of the Heart and Blood". 
• He could not prove the existence of blood vessels due to insufficient microscopes.

       Short Term -

• They had no effect on treatments. Plague of 1655 included treatments such as writing abracadabra backwards and forwards, smoking tobacco, wearing lucky charms, putting the bottom of a chicken on buboes.
  
  

  Long Term - 

• Once their discoveries could be proven, for example after the development of microscopes, new treatments developed. Such as stitches, blood transfusion, artificial limbs and dissection in medical training.

• University Training: Doctors were trained in universities around Europe, e.g. Padua in Italy.
• Professionalism: Doctors were viewed as experts and worked to improve their methods through influence of others.
• Untrained People: Protected reputation by preventing amateurs from practising being doctors. Royal College of Physicians in England was set up to register and license doctors.
• The Church: After the ending of monasteries, hospitals were no longer controlled by the Church. They were now a place of medical innovation, rather than just caring for the sick.

• Training: Women could not train as doctors or go to university, all professional doctors were men.
• Wise Women: They were accused of witchcraft, discouraging women to become involved in medical care beyond their own families.
• Childbirth: Male doctors became more involved; it was considered a trend amongst the rich to have a professional doctor, as opposed to a midwife, attend their birth.
• Scientific: Childbirth methods developed, for example to use of forceps, women were forbade to use these methods.
• Medical Books: The only source for women to use at home.

• Short for Quacksalver, they were untrained people who sold medicines. The name later became an insult towards mistrusted doctors and healers.
• They were comparable to market traders, attracting customers to their stalls with music, clowns and monkeys. They stated they used secret ingredients to make a miracle cure.
• Professional doctors saw Quacks as competitors, calling them worthless and dangerous. They thought Quacks undermined the reputation of medical professionals.
• Quackery still flourished due to being far cheaper than professional doctors, so poor people had no other choices.

Causes: Battle injuries, plagues, infectious disease e.g. smallpox.
Healers: Women at home, wise women, midwives, barber surgeons, professional doctors, quacks.
Explanations: Imbalanced humours, God's punishments.
Treatments: Opposites, bleeding, purging, herbal remedies, praying for forgiveness.
Factors for Change: Some advances in war wound treatment because of Paré, but treatments mostly stayed the same.
Impact: Very little in the short term, majority stuck to herbal remedies and Galen's ideas.

• Supernatural explanations/Four Humour Theories were no longer popularised.
• Main belief was that bad smells made you ill - "Miasma" was an infected mist people thought rose from rotting food and human waste.
• Stronger microscopes were made so people could see bacteria in food, water and human waste.

• Inoculation was popularised by Lady Mary Wortley Montagu after she had seen the practice in Turkey. 
• It was spreading a small amount of pus from a smallpox scab onto a healthy persons skin. This gave them a minor case of smallpox, helping their bodies build up immunity.
• No one knew why it worked but it was successful.
• Poor people could not afford inoculation.
• Sometimes doctors got the dose wrong and caused severe cases of smallpox.
• People were reluctant because they feared inoculation as much as actually getting smallpox.

Jenner was a doctor in rural Gloucestershire. He heard dairymaids who caught cowpox avoided catching smallpox. He was a member of the Royal Society, therefore he believed in experimentation, so he wanted to find out the connection between cowpox and smallpox.

• He injected a young boy called James Phipps with cowpox matter.
• He later injected him with smallpox matter.
• James survived both injections, therefore Jenner tested a further 23 subjects.
• They were all successful, Jenner named this process Vaccination, after the Latin word "vacca" meaning cow.

• 1798: Jenner publishes his findings.
• 1802: Paraliament grants Jenner £30,000.
• 1803: Vaccination was now used in the USA.
• 1853: Smallpox Vaccination made compulsory in England.

• Inoculation Doctors: worried about losing business and income.
• Leading People: Did not respect country doctors.
• Government: Should not be involved in medicine, people campaigned against the compulsion of smallpox vaccinations.
• Unnatural: Some were disgusted by the thought of injecting animal matter into a human.

Louis Pasteur was a chemist in France, in 1857 he was asked to investigate why alcohol eventually went sour.

• He used microscopes to discover germs were making wine, beer and milk go sour.
• Discovered that heating liquid killed the germs, thus creating the process of pasteurisation. 

He made the link between souring alcohol and human disease, publishing his Germ Theory in 1861.
People were unconvinced due to belief in miasma, so Pasteur conducted a series of experiments in 1864.

Koch was a German doctor studying bacteria, influenced by Pasteur's work.

• 1872: Discovered he could dye/stain germs, therefore being able to identify which germs caused which diseases.
• He identified the germs causing anthrax in 1872, tuberculosis in 1882, and cholera in 1883.

• Pasteur was experimenting with chicken cholera, using Koch's method to identify the bacteria causing the disease, he injected chickens with these germs which gave them chicken cholera and killed them.
• Pasteur was away on holiday when an assistant left a batch of chicken cholera exposed to the air. Upon returning he used this exposed batch and the chickens did not die, he then gave them a fresh dose of the germs, the chickens also survived this.
• He linked the weakened germs and prevention, naming this process vaccination in honour of Jenner's prior work.
• He later developed vaccinations against anthrax in animals, and rabies in humans.

• 1909: Koch's assistant, Paul Ehrlich, investigated chemicals that would kill a particular germ in the body. From the way they stained bacteria, he wanted to make the stain something that would also attack and kill the bacteria, calling this a 'magic bullet'.
• 1911: The first magic bullet called Salvarsan 606 was discovered, which cured syphilis. 
• Gerhard Domagk developed a magic bullet curing blood poisoning, which was made from sulphonamide.
• The only drawback was that it also attacked the kidneys and liver, so its use was limited to extremely ill patients.

• 1928: Fleming went on holiday without washing his petri dishes, so the bacteria were left on his lab bench.
• When he returned, he discovered a mould called penicillin grew on the petri dish, which had killed all the bacteria around it. Joseph Lister discovered this mould in 1872, but did not take it any further than identifying it.
• Fleming experimented with the mould as an antiseptic.
• He wrote up his findings in a report, however no one viewed it as important at the time.

• Florey and Chain had read Fleming's report in the 1930's. They decided to experiment with his findings, working out a way to turn the mould into an antibiotic to be injected into the body.
• They had proved it worked on animals, then did a human trial on a policeman with blood poisoning. They treated him for five days and he got better, then they ran out of penicillin and the policeman fell ill again and died.
• This made them realise that it worked, however they needed a way to mass produce it, and they did not have the fundings to do so.

• Howard Florey went to America to try and fund the mass production of penicillin.
• 1942: The Second World War was in full force, soldiers needed to be treated for blood poisoning and other illnesses.
• The US government saw potential and paid for the mass production of penicillin.
• 1944: There was now enough penicillin to treat soldiers injured in D-Day invasions.
• Also in 1942: Fleming used penicillin from Florey and Chain to treat a friend with meningitis in St Mary's Hospital, when his friend recovered, Fleming and penicillin were famous.

1800 - 

• Hospitals were seen as places to die as opposed to get better.
• They had cramped and stuffy wards, the lack of fresh air allowed infection to spread quickly.
• Nursing staff lacked training, they were criticised for being dirty and drunk.
• There were few toilets and the sewage systems were poor.
• Wards were ineffectively cleaned, and cleaned rarely.

1900 -

• Florence Nightingale persuaded the government to change hospitals in Britain and to properly train nurses, thus making hospitals a place to get better, as opposed to a place to die.
• Nightingale encouraged sanitation, stating it was the first duty of her nurses to keep everything sufficiently clean.
• Infection and death rates in hospital were reduced.
• Nursing schools were all around the country to teach Nightingale's methods.

• Came from a rich English family, who were against her being a nurse.
• She was trained in Germany to become a nurse.
• She was a superintendent of a Woman's Hospital in London.
• The Times had published reports of the conditions in the Crimea, she volunteered to help and the government agreed, thanks to having powerful friends such as the Minister of War.
• She cleaned up the army hospital at Scutari.
• She wrote Notes on Nursing and founded a Nursing school at St Thomas' Hospital in London. She was awarded the Order of Merit in 1907.
• She did not believe the Germ Theory, but she believed in Miasma, she also did not approve of women being doctors.

• Born in Kingston, Jamaica. Her father was a scottish soldier, and her mother a free black slave who ran a boarding school.
• Gained knowledge from her mother who treated illness at the boarding house using herbal remedies.
• 1850: She treated and saved many when cholera came to Kingston.
• She heard about the cholera epidemic in the Crimea, travelled to London, volunteered to the army and Nightingale but was refused due to 'lack of training'. So she travelled to Crimea by her own expense.

• She set up a British Hotel close to the front, she sold food and drink to soldiers, which funded her treatments for them.
• She treated patients on the battlefield, and reportedly treated soldiers on both sides while the fighting occurred.
• When she returned to London, she was bankrupt due to funding the trip herself. The Times and Punch attempted to support her, however she never gained enough money to treat patients again.
• She carried out operations on people suffering from knife and gunshot wounds.
• During the Panama cholera epidemic, she carried out an autopsy and learned about how the disease attacks the body.

• Lifestyle: Educating people helped improve lifestyle, such as not smoking helps prevent lung cancer, this helped reduce the number of people getting cancer.
• Early Diagnosis: People at risk were screened, such as smear tests for cervical cancer in women over 25, or screening blood pressure levels.
• Palliative Care: Treated disease symptoms rather than curing, allowed people with diseases to live many more years with a good quality of life.

• New infectious diseases, such as AIDS, were appearing. There is no cure for AIDS but drugs were developed which lessened the symptoms. However, these were expensive and hard to obtain.
• Super-bugs emerged that were resistant to antibiotics, for example MRSA. These were prevented by cleaning hospital wards and hands with anti-bacterial lotion.
• Old diseases were still around that were becoming resistant to drugs, for example Malaria. This was prevented by providing mosquito nets in affected areas.

Causes: Infectious and water-borne diseases such as smallpox and cholera, bad lifestyle, diseases of old age such as cancer and heart disease.
Healers: Doctors, hospitals.
Explanations: Early 19th century was Miasma, from 1860s onwards was the Germ Theory.
Treatments: Herbal, vaccinations, chemical drugs, antibiotics.
Factors for Charge: Government made vaccination compulsory, war boosted Pasteur and Koch's rivalry, science and technology allowed necessary developments.
Impact: Germ Theory improved public health for everyone, vaccination was made compulsory for everyone, NHS introduced in 1948 and so doctors, hospital and drugs were available for everyone.

• Pain: Patients felt everything throughout the operation, therefore they could die from shock due to pain.
• Infection: Wounds often became infected after the operation, which often killed patients.
• Blood Loss: Patients bled to death during and after the operation. 
• Due to these three main problems with surgery, operations had to be extremely fast, which led to mistakes like cutting off the wrong parts of the body.

In 1847, Simpson discovered chloroform sent patients to sleep so they would not feel pain, he tried it on himself and friends first.

• Benefits included patients being asleep so they felt no pain, and the fact they were still and not dying from shock meant more complicated operations could take place.
• However, the dosage was sometimes too much and patients died. Also, death rate from infection went up after anaesthetics developed, due to deeper operations meaning deeper infections. The full advantage of anaesthetics could only be seen when someone figured out infections.

• Some doctors thought the pain of childbirth was naturally sent from God, therefore women should have to endure it, meaning that anaesthetics should not be used during labour.
• People were alarmed by the death rate from the use of chloroform, and the infections from more complex operations.
   
• However, the use of chloroform was promoted when Queen Victoria used it to ease the pain of childbirth in 1857.

Lister researched gangrene and infection, with knowledge of the germ theory. In 1865, he used carbolic acid to kill germs during operations. Before carbolic spray, half of his amputations lead to death, whilst afterwards only 15% died.

• Deaths from infection after operations fell significantly.
• Lister was very careful when using carbolic acid, whereas other doctors were not as thorough, therefore infections were still common.

• Cleaning wounds was hard work and slowed operations, whilst surgeons still prided themselves on speed.
• People viewed it as going to extreme lengths, the spray covered everything and everyone.
• Many people still did not believe in the germ theory, surgeons used to joke about shutting the door in case "one of Mr Lister's microbes flies in".

• Prior developments included Paré's ligatures to close arteries, Harvey proving blood needed to be replaced if lost. People tried using animal blood, but it did not work.
• 1900: Landsteiner discovered humans have different blood groups.
• 1907: First blood transfusion was done using matching blood groups.
• WW1: Methods of storing blood were developed, therefore blood could be taken before it was needed.
• WW2: National Transfusion centres were set up in the USA and Britain.

• X-rays: 1895 - Röntgen discovered x-rays, this allowed doctors to see inside the body without incisions.
• Aseptic Surgery: Antiseptic surgery (cleaning wounds) was replaced with Aseptic surgery (cleaning everything in the room).
• Keyhole Surgery: Cutting a small hole in the skin and using a fibre optic cable and cameras to see inside, this allowed delicate operations such as mending holes in the hearts of newborn babies.
• Replacement Surgery: Joints can be replaced by plastic or metal ones when they have worn out due to old age.

• Transplant Surgery: 1967 - First heart transplant carried out by Christiaan Barnard. 1986 - First heart, liver and lung transplant carried out. 
• Plastic Surgery: WW1 - Soldiers who suffered burns led to development of skin grafts, doctors now paid attention to the appearance of a patient after operating. WW2 - Burned faces and hands of pilots were rebuilt, Archie McIndoe used drugs such as penicillin to prevent infection. 2005 - First facial transplant was done, after a woman was left disfigured after a dog attack, she was given facial tissue of a dead person.
• IMPACT: Most improvements are available through the NHS. However, hi-tech surgery is expensive and fundings are limited, and ethical issues are raised about which operations are prioritised. 

Causes: War injuries and old age ailments such as arthritis.
Healers: Surgeons became specialists in one part of the body.
Explanations: The germ theory.
Treatments: Anaesthetics e.g. chloroform, antiseptics e.g. carbolic spray, blood groups/blood transfusion.
Factors for Change: Lister showed individual genius and commitment, technology allowed transplant and keyhole surgery, war also allowed some developments.
Impact: 1948 onwards, NHS made high quality surgery available to all, demand outstripped resources available though.