Pioneering cardiac surgery in Sheffield

Will Parker describes the work of a pioneer of cardiac surgery, Judson Chesterman.

The first mitral valve replacement is generally credited to Nina Braunwald (1928-1992) in March 1960, the patient surviving for around 4 months. The first Starr-Edwards caged ball valve followed in the same year and the procedure subsequently became widespread. There is good reason, however, to believe that the first operation of this kind was carried out in 1955 at Sheffield’s City General (now Northern General) Hospital by Judson T. Chesterman (1903-1987, Figure 1).

Chesterman studied at Bristol but settled in Sheffield, where his great-grandfather had set up a prominent engineering firm. He developed a practice in cardiothoracic surgery, performing over 100 heart operations a year by the 1950s. However, many cases of heart valve disease, including those resulting from regurgitation (leaking) rather than stenosis (narrowing), remained inoperable and often fatal.

Charles Hufnagel (1916-1989) of Washington D.C. had reported the implantation of an artificial valve for aortic regurgitation in 1954. Chesterman began designing artificial valves, but focussed on the more difficult problem of replacing the mitral valve, the most commonly affected by then-common rheumatic fever.

Initially working with copper prototypes, these evolved into refined Perspex creations. The hospital pathology technician, Clifford Lambourne, turned the valves, consisting of an oval double-flanged ring in which sat a tethered disc, on a huge lathe (Figure 2). Lambourne told the hospital newspaper years later: ‘Turning left a roughish surface and it had to be smooth…My wife and I were keen cinema-goers. We sat in the cinema, watching films, me with a piece of silk cloth in my hands, polishing the pieces…It took about three feature length films to get the valve smooth enough.’

On 22 July 1955, Chesterman implanted the prosthesis into a 34-year-old man with end-stage mitral valve disease. Lacking cardiopulmonary bypass, he cooled the patient, cross-clamped the vena cavae then quickly performed the operation.

Though acutely successful, as Chesterman later wrote: ‘He read the evening paper and was comfortable at night when I last saw him. He was found dead in the night at about 3.30 am.’ The valve had dislocated. Retrieved at post-mortem examination, it still exists. (Figure 3)

Chesterman realised cardiopulmonary bypass would be key to further procedures of this kind. He subsequently visited Walton Lillehei and Richard De Wall in the US, who had developed the pump oxygenator. Chesterman went on to build and use his own machine in Sheffield on 26 February 1957, one of the first outside America to do so. (Figure 4) 

As well as technological contributions, Chesterman’s legacy includes the subsequent flourishing of a cardiothoracic unit in Sheffield, now housed in the Chesterman Wing at the Northern General Hospital. In addition, he had an interest in archaeology and, after retiring from clinical practice, he  founded the University of Sheffield Osteology Laboratory. 

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The patient: from neglected factor to media star

Is the patient a case, a body or a partner with power? Christine Gowing looks at the changing perspective in medical history.

Nursing Times, 22 March 1988,
nursingtimes.net

In 1945 the patient voice was merely a distant echo. That year the medical historian Douglas Guthrie published a paper The Patient: a neglected factor in the history of medicine[1], arguing that the patient’s part in the march of medical progress had long been missing while attention had been devoted to the achievements of science and physicians.

The history of medicine was the history of doctors, or, as Roy Porter put it, ‘a history from above and populated with heroes.’[2]  It was only in the 1960s and 1970s that historians began to look at how wider sociological contexts – social, cultural, professional and economic frameworks – influenced medicine’s history.[3]

But how culpable are we still as medical historians when we push the patient out of the narrative?

The presence of patients throughout history has often been denied, simply due to lack of information about them – and at what point did patients anyway emerge with any significance or autonomy in the doctor-patient encounter?

The historian Edward Shorter blamed the science of healing in the 1940s and 50s for overwhelming the art of healing[4], extending Foucault’s claim that clinical medicine was responsible for depersonalisation and the sidelining of the patient.[5]

The patient contributes

It was psychoanalyst Michael Balint’s work in the 1950s that first recognised and encouraged the emergence of the patient in the medical consultation.[6] Balint’s psychodynamic analysis and his understanding of the patient’s contribution enhanced the consultation as a therapeutic tool. Increasingly accepted, this approach encouraged the involvement of patients in the management of their condition, although in the 1980s, medical ethicist Jay Katz would still argue that the doctor-patient power relationship was impacting patients’ decision-making.[7]

And nurses’ relationship with patients? It may be a surprise to hear that it was only in 1962 that nursing training formally recognised the importance of this relationship by including an element on the topic for the first time in the training syllabus.[8]

But now we find the patient as a media star. Remember the momentous day of the first Covid-19 vaccination (outside of a trial) on 8 December 2020? What a victory for science and medical research, for the extraordinary work of the laboratory teams in developing the vaccine and giving hope to a pandemic-torn world. 

However, the image that we probably recall most vividly on that day – and the one that dominated the media throughout the world – was of the first vaccinated patient, 90-year old Maggie Keenan.  On 9 December 2020, the Daily Express exclaimed:

‘ONE SMALL JAB FOR MAGGIE …ONE GIANT LEAP FOR ALL OF US’

On the same day, the Metro showed an image of nurses providing a guard of honour as she left the vaccination clinic. What we remember in the future when recounting the narrative of Covid-19 – along with the triumph of science and physicians – may be the image of Maggie. 

A named patient placed at centre stage.

Christine Gowing has an MA in the history of medicine with research on 18th and 19th century electrotherapy. She later gained a PhD in the history of the relationship between complementary and alternative medicine (CAM) and biomedicine. The development of the therapeutic alliance in healthcare is a particular interest.


 References

[1] Guthrie, D., A History of Medicine(1945).

[2] Porter, R. (ed), Patients and Practitioners (1985).

[3] Waddington, K., An Introduction to the Social History of Medicine: Europe since 1500 (2011).

[4] Shorter, E., Bedside Manners: the troubled history of doctors and patients (1985).

[5] Foucault, M., The Birth of the Clinic (1989).

[6] Balint, M., The Doctor, his Patient and the Illness (1957).

[7] Katz, J., The Silent World of Doctor and Patient (1984).).

[8] National Archives, Kew, London, General Nursing Council papers, confidential minute, Education and Examination Committee (7 September 1960), DT38/155.

‘Blitz Spirit’ in the Time of Pandemic

Frances Williams looks at the historic concept of ‘Blitz Spirit’ and its evocation during this period of pandemic

Themes of resilience and strength have been drawn from the Second World War and put to use in the current pandemic – including the psychological defence, ‘Blitz spirit’. Yet a risk is run when nostalgia distracts us from important differences between the past and present. They can further skew historical accuracy, too.

Health Secretary Matt Hancock stated in early 2020: ‘Our generation has never been tested like this … Our grandparents were, during the Second World War, when our cities were bombed during the Blitz. Despite the pounding every night, the rationing, the loss of life, they pulled together in one gigantic national effort.’

Working directly with the older generation, palliative care doctor, Rachel Clarke (@doctor_oxford) said they certainly seemed to have taken the ‘Blitz spirit’ to heart, thinking themselves stoic and resilient. Dangerously – and sometimes tragically so – some of over 70s weren’t washing their hands or taking lockdown measures seriously enough, even though the pandemic deaths were mostly among their own age group.

(Photo: Aldwich Tube station 1940, Imperial War Museum)

Historical dispute

The ‘Blitz spirit’ has always been a disputed phenomenon, reflecting contested post-war histories of ‘morale’. Certainly, in the lead-up to war, the government was worried about the likelihood of ‘bomb neurosis’, a form of shell shock that civilian populations might suffer if subjected to prolonged bombing.

A new era of ‘total war’ fed a perception of the vulnerability of citizens to ‘knock out’ blows from the air, that might lead to febrile mental states. A network of specialist hospitals – called ‘neurosis clinics’ – was set up outside UK cities, but ultimately little used.

In his 2012 work, War on Fear: Solly Zuckerman and civilian nerve in the Second World War, Ian Burley cites a visiting commentator from the US who observed the British public’s capacity for ‘pluck’ and such outsider reflections were fed back to the public in the form of propaganda. A prominent psychologist of the day advocated biscuits and nips of whiskey to allay ‘nerves’ during bombing raids, reported by Edward Glover in 1940 in The Psychology of Fear and Courage.

Covid-19 spirit?

In her new book, Blitz Spirit: Voices of Britain Living Through Crisis, Rebecca Brown re-visits the ‘alleged phenomenon’ of the Blitz spirit, delving into diaries from The Mass Observation Archive, daily diaries kept by hundreds of people during the war. These cast fresh insight into our current pandemic, she proposes, because they show the nuance and diversity of everyday feeling.

Many popular descriptions of our of states of mind in lockdown now are anecdotal: a ‘corona coaster’ of high and low moods, sleeplessness and vivid ‘pandemic dreams’.  Speculations centre on how we might arrive at the right level of panic – especially given we get much of our information from internet sources of variable reliability.

Professor Nikolas Rose in Mental Health and Social Change in the Time of Covid-19 points out that the pandemic and the measures taken in response, such as severe restrictions to physical interactions and our daily routines, are discrete and separate. Added to this are widespread uncertainty and distress about the virus, loved ones, education, work and money. Increased anxiety and fear are normal in the circumstances. ‘We need be wary of rushing to frame them in terms of mental health,’ he warns.

As the NHS staff operate on ‘the front line’ of our current battle, it may be that they bear the longer term psychological cost – including diagnoses of PTSD – than the wider ‘civilian’ population on the ‘Home Front’. For now, these are speculations.

In the interim, it is important to consider the ways in which the pandemic is not like a war, and the risk that ‘nostalgic framings’ might distract us from our own mistakes, as says Martha Lincoln in her blog On Memorys Battlefield: The Pandemic as Our Next Forgotten War (2021).

Frances Williams completed her PhD in arts, health and devolution in 2019 and is currently Visiting Researcher at Glyndwr University.

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There is death in the pot

On the bicentenary of chemist Freidrich Accum, J.D. Dayan and A.D. Dayan discuss how his public-health legacy to expose ‘food adulteration’ has been largely forgotten…

Portrait of chemist Friedrich Accum (1769–1838). Source: Edgar Fahs Smith Collection (P/AC25 M).

The essential importance of using new scientific discoveries in the public interest is a belief that has long been preached, but few have had the drive and understanding to put it into practice.

Some innovators must make great sacrifices in return for ephemeral headlines, whilst others achieve international fame in their lifetime, only to have their names and vital legacies forgotten.

Friedrich Accum is such a scientist, whose contributions to both public and governmental awareness about the extent of food adulteration, its risks to health in the early 19th century and the widespread fraud on consumers have gone tragically neglected, even as we grow ever more concerned about what is in our food.

From Hanover to London

Accum was born on 29th March 1769 in Bückeburg, a small town in the state of Hannover, to a Jewish father who had become a committed Christian[1]. Young Accum’s life was marked by tragedy as his father died when he was only three years old, and his mother was left to raise her large family alone. Instrumental to their fortunes was the family soap business which gave Accum exposure to practical chemistry and no doubt influenced his decision to emigrate to England in 1793 to work for Brande pharmacies in London[2].

By 1800 Accum’s career as a young(ish) scientist was starting to flourish, and he set up a base of operations at 11 Old Compton Street, which he turned into “a unique establishment”[3]. From here Accum took on a diverse range of tasks, from offering commercial chemical analytical services to inventing and producing novel scientific instruments and later offering classes in practical chemistry.

In the early 19th century he became deeply involved in the pioneering installation of gas lighting in London, conducted analyses of natural spring waters and common medicines, as well as acting as an expert witness in legal actions. His frequent scientific work on behalf of the government and growing role as a public intellectual made him nationally known, and he increasingly wrote on matters of general, as well as scientific, interest.

‘A Treatise of Adulterations of Food, and Culinary Poisons’

It was with this background of firmly established respectability that Accum launched into arguably the most important and ultimately most controversial part of his wide-ranging career. Drawing on his scientific abilities as an analyst and his skills as a writer he analysed many samples of the foodstuffs being sold in London, such as bread, milk, flour and sweets and published the findings in his magnum opus, A Treatise of Adulterations of Food, and Culinary Poisons, in 1820, a book better known from its subtitle ‘Death in the Pot’ (II Kings 4:40).

This was not an example of an obscure academic text being amplified into the public consciousness by the excitable media of the day, but rather a skilled scientific communicator and self-publicist scoring a public bullseye with a precisely aimed work. This is exemplified by the biblical quote which Accum deployed, that has since been used as a metonym for the publication itself: “There is death in the pot”.

The core of this explosive work was stated simply by Accum himself at the very beginning when he wrote that he was trying to “exhibit easy methods of detecting the fraudulent adulterations of food, and of other articles, classed either among the necessaries or luxuries of the table; and to put the unwary on their guard against the use of such commodities as are contaminated with substances deleterious to health.”[4]

This was not the first time that Accum had attempted to raise the alarm about poor quality food.  Indeed from almost the start of his time in England he had spoken out against the dangers of adulteration[5], but he now had a firm grasp on its nature and industrial practice.

The reading public agreed, and within a month the entire first print run of 1000 copies had been sold. That did not mean that those who could respond in print accepted his findings and their implications for the health of every consumer and the honesty of manufacturers, importers and retailers.

Critiques and legal issues…

Few of the dissenters refuted his central argument, but some disagreed about the extent of the adulteration crisis, and others believed that his remedy, the deployment of analytical chemistry to detect fraud and dangerous additives, was wildly impractical.

One of the most critical responses appeared in the Quarterly Review which lambasted Accum for being a highly intelligent, snake-oil salesman on the make[6].

Accum’s life after this point is veiled in mystery. What can be said with certainty is that he was accused of having ripped out pages from books in the Royal Institution’s library, and this led to him being embroiled in a series of legal troubles that ended with him jumping bail and returning to Germany.

There he continued writing on the application of analytical chemistry to a diverse range of food related topics, from brewing beer to making bread.

Public opinion appears to have swung quite violently with regards to his guilt, and although his refusal to attend his trial and decision to abscond certainly did his reputation no good, there were nevertheless persistent rumours that he had been framed by those he had accused of introducing ‘Death into the pot’.

Accum’s Legacy?

Whatever the truth of his predilection for page-stealing, there is no doubt that Accum was hugely influential in the rise of campaigning scientists in early 19th century Britain. In many ways Accum’s true successor was Arthur Hill Hassall, the doctor-turned-analyst who, with Henry Letheby, a physician-chemist, acted as chief scientist to the Lancet enquiry in the mid-1800s.

Hassall’s statement in 1855, to the parliamentary committee about the scale of the problem surrounding food adulteration and its significant ‘sanitary bearings’ and possible “remedies for their suppression”, caused such a public outcry that Parliament was no longer able to look the other way on the subject[7].  In 1860 the Act to Prevent the Adulteration of Food and Drink was passed, containing many of Hassall’s suggestions.

From then on, and especially in the era of Gladstonian liberalism, the state would always take a close interest in the quality of food, and the idea of having permanent government chemists review its safety went from a radical novelty to become a standard rule.

What Accum did that was so important was to combine rigorous scientific methods with a pugilistic style and in doing so, whatever his other faults, he helped to pave the path for his intellectual descendants to defend and expand the public good.

Why have we overlooked the bicentenary of Accum’s work when ensuring the quality of foods and medicines has become such an important factor in our lives? It is not too late to celebrate his achievements even if his reputation remains clouded in ignominy.

Words by J. D. Dayan and A.D. Dayan

 

[1] C. A. Browne, ‘Recently Acquired Information concerning Frederick Accum, 1769-1838’, Chymia, Vol. 1, (1948), p.2.

[2] C. A. Browne, ‘The Life and Chemical Services of Frederick Accum’, Journal of Chemical Education, Vol. 2 No. 10, (1925), p.833.

[3] R. J. Cole, ‘Friedrich Accum (1769-1838). A biographical study’, Annals of Science, Vol. 7 No. 2, (1951), p.129.

[4] F. Accum, A Treatise of Adulterations of Food, and Culinary Poisons, Project Gutenberg, (2006), p.iii.

[5] C. A. Browne, ‘The Life’, p.1028.

[6] J. Sumner, ‘Retailing Scandal: The Disappearance of Friedrich Accum’, (Re)creating science in nineteenth-century Britain, Cambridge Scholars Publishing, (2007), p.4.

[7] A. Hassall in ‘Adulteration of Food, Drink, And Drugs. Being the Evidence taken before the Parliamentary Committee’, London, (1855), Googlebooks, p.1.

A digital future for studying History of Medicine?

Dr Mike Davidson reflects on his experience of completing a Masters of Letters (M.Litt.) degree via distance learning…

Saint Jerome in his study. Oil painting.. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

I recently completed a three-year distance learning M. Litt. in Scottish Heritage at the University of Aberdeen. Considering the current restrictions on conventional study and academic meetings by which many of us pursued our interest in the History of Medicine (HOM), I wondered if my experience offers a future option for HOM study.

I undertook the course to improve my academic skill-set, to write, and present my history of medicine research in a way that was appropriate for an academic audience. I could not find an appropriate postgraduate course within a 100-mile radius of my home willing to take on a student, part- or full-time, who did not have an undergraduate Humanities background. The University of Aberdeen ‘Masters in Scottish Heritage’ is a fully online, part-time course that anyone with a 2:1 honours degree or appropriate professional experience can apply to.

Teaching was delivered through MyAberdeen, an online Virtual Learning Environment. Screenshot courtesy of Dr Mike Davidson.

It provides the materials, tools and support needed for your studies. A potential weakness of distance learning course is library access, unless you can make local arrangements. I purchased some standard books for my library.

The recommended study time needed is 15 – 20 hours per week per term, more at assessment times. The total course fees were £8,700 paid in yearly allotments; other smaller regular payments are possible. The course comprised four taught modules of 30 credits, each over 12 weeks, two modules a year. There is flexibility in the time period to completion: students can prolong the course if personal circumstances demand.

The final year was a 20,000-word dissertation on a subject agreed with your supervisor. My dissertation title was “A Scottish doctor’s observations and experiences of the British West Indies; a comparative analysis of the pre-emancipation journals of Jonathan Troup (1764 – 1800).”

Each week of study had clear objectives, supporting material and notes relevant to the lecture or audio clips.  Lectures were delivered as downloadable PowerPoints. Videos and audio clips are a valuable addition to the course, these ranged from two experts debating a course topic to original archive visual material. Primo provides valuable, easy access to many online resources, including e-books, journal articles and academic databases.

Virtual discussion boards with classmates and tutors replaced seminars, Tutors started debate by offering a series of questions or statements relating to the week’s work. The discussion boards have potential downsides compared with face-to-face sessions. As it is a written format some students produced almost mini referenced essays rather than spontaneous comments. This dampens debate and can feel very intimidating. If you take part late in the week, you may find the subject has been done to death and you have little to add. You can become a silent participant if more confident or over-prepared colleagues dominate the board.

An example of the online discussion board. Screenshot courtesy of Dr Mike Davidson.

An undoubted weakness of an online delivered course is the loss of direct face to face mentoring opportunities. I resolved this by occasional planned visits to Aberdeen, including attending two weekend retreats for postgraduate history students and History department staff. The retreats were excellent, giving me an opportunity for networking, constructive criticism, presenting your own work to an academic rather than clinical historian audience.

Having finished the degree, I have been reflecting on whether this approach could not be adapted to gain a qualification in the History of Medicine?

I feel an online tailored modular course would offer aspiring healthcare historians’ a way of gaining appropriate researching and writing skills. Accumulation of credits would offer a path towards a formal qualification for those who wish. It just needs an academic institution to run with the idea. I suspect there is a market out there.

Words by Dr Mike Davidson