50 Years of Fibre-optic Colonoscopy

2019 marks 50 years since the advent of fibre-optic colonoscopy. This blog discusses the development of this widely used technique and associated technology, and its impact on modern medicine.

Colonoscopy is a technique that allows direct visualisation of part of the large intestine (the colon). A flexible tube (endoscope) with a light source is inserted into the anus and images from the inside of the colon are projected onto a monitor. As well as being used for diagnostic purposes, colonoscopy can also be therapeutic, for example allowing for the removal of pre-cancerous growths.

The technique of modern colonoscopy is largely thanks to the work of several doctors in the 1960s and 1970s. The fibre-optic colonoscope was developed by Dr Niwa and Dr Yamagata at Tokyo University. Two physicians based in America, Dr William Wolff and Dr Hiromi Shinya, then pioneered its use, performing the first modern colonoscopies in June 1969. They described ‘over 1000 successful and totally uncomplicated endoscopic examinations’. The colonoscope, unlike the flexible sigmoidoscope, allowed for visualisation of the complete colon. Wolff and Shinya later developed and started using an electrosurgical polypectomy ‘snare’ to remove polyps. They published a seminal paper in 1973 demonstrating the utility, safety and cost-effectiveness of colonoscopy. The practice of colonoscopy increased during the 1970s and 80s, facilitated by the associated public exposure when President Ronald Regan underwent several colonoscopies to remove polyps in the mid-1980s. The New York Times quoted the advice given by Ronald Reagan’s surgeon who stated that the president should ‘undergo an examination of his intestines, a colonoscopy, within six months and every year after that, as well as periodic blood tests to check for possible colon malignancy’.

So how has colonoscopy changed over the past few decades? Well, to be truthful, not much! The technique is very much the same. However, the instruments used today are more flexible, making them easier to manipulate. This allows for better visualisation of the colon and reduces the amount of time needed to perform a colonoscopy.

Colonoscopy is essential in the diagnosis of bowel cancer which is the fourth most common cause of cancer in the UK. It is used for both the surveillance of patients with previous bowel cancer or significant risk factors, and in screening for bowel cancer. Colonoscopy can also be therapeutic. It can facilitate the removal of lesions and the cessation of bleeding in the bowel, through electrocoagulation, injection therapy and the use of special clips secured over bleeding blood vessels.

 

Endoscopic examination of a patient’s gut by Dr A.I. Morris, Royal Liverpool University Hospital. Drawing by Julia Midgley, 1998. Wellcome Images.

 

Improvements in optical imaging have already increased the quality of the images seen on the monitor as a colonoscopy is being performed. Higher definition images mean more subtle lesions and even small polyps can be visualised. Less invasive imaging modalities, such as virtual colonoscopy (computed tomography colonography) and capsule endoscopy, have been developed as potential options for those who are unable to undergo a complete colonoscopy.

Many believe that colonoscopy will grow to play a bigger therapeutic role in the future. Watch this space…

 

 

Further Reading

William Wolff and Hiromi Shinya, ‘Polypectomy via the Fiberoptic Colonoscope,’ New England Journal of Medicine, 288, No.7, February 15 1973, pp. 329-331.

Bernard Weinraub, ‘Reagan’s Doctors Find Cancer In Tumor But Report Removal Leaves His Chances Excellent,’ The New York Times, July 16, 1985. Available at: https://www.nytimes.com/1985/07/16/us/reagan-s-doctors-find-cancer-tumor-but-report-removal-leaves-hischances.html

 

Lucy Havard

The Flint Water Crisis: have lessons from history been forgotten (again)?

‘That men do not learn very much from the lessons of history is the most important of all lessons that history has to teach’Aldous Huxley

The Flint Water Crisis, which started in 2014 and is still on-going, is a contemporary example of where lessons from history have been ignored.  Briefly, the authorities in Flint, Michigan, decided to replace the water supply from Lake Huron with the less expensive water from the Flint River. Unfortunately, the Flint River was heavily polluted and this led to Legionnaire’s disease and lead poisoning among residents using the water supplied by lead pipes. Of particular concern is the expert opinion that almost 9,000 Flint children are at risk of developmental difficulties and long-term conditions due to lead poisoning. The authorities have been heavily criticised for not testing the safety of the Flint river water in advance and for the delays in both accepting that there was a problem, and in implementing the changes necessary to supply safe water. The crisis has sparked intense political and media debate and several prosecutions are pending.

 

Image 1: Gums and tongue from a case of lead poisoning. Credit: St Bartholomew’s Hospital Archives & Museum, Wellcome Collection.

In the nineteenth century, several reports of lead poisoning secondary to lead pipes in Britain and the USA appeared in the medical literature and the popular press. The problem in Britain was widespread but particularly evident in Yorkshire, Lancashire and Scotland. In Sheffield, the problem was first reported in 1885 by the Medical Officer of Health and was traced to the water from one reservoir that corroded lead supply pipes and lead-lined cisterns, hence contaminating the domestic water supply. The resistant Sheffield Water Company only agreed to add lime to the water after a public inquiry in 1890. Of even greater concern is the shocking 120 year delay in accepting that lead poisoning in Glasgow was due to a combination of the water supply from Loch Katrine and lead supply pipes.

Could the Flint water crisis happen again? Yes, sadly it could, and the words of Huxley resonate strongly here. But, if we listen to the lessons of history, and learn from them, such needless harm can be prevented.

 

Further Reading

  • Anna Clark, ‘Nothing to worry about. The water is fine,’ The Guardian.17thJuly 2018, accessed 24/1/19. Available at: https://www.theguardian.com/news/2018/jul/03/nothing-to-worry-about-the-water-is-fine-how-flint-michigan-poisoned-its-people.
  • Mona Hanna-Attisha et al, ‘Elevated Blood Lead Levels in Children Associated with the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response,’ Am J Public Health.Feb 2016.106(2): 283-90.

 

Mike Collins

 

 

Caricature, contestation and the making of ‘Typhoid Mary’

The story of Mary Mallon (1869-1938), reprehensibly branded ‘Typhoid Mary’ by the American press, provides an excellent example of how caricature and animation played an intrinsic role in the dissemination of information in relation to epidemic disease. ‘Typhoid Mary’ was the first healthy carrier of typhoid to be identified in the United States. An immigrant from the shores of Ireland, Mary was a cook by trade and had efficiently been serving up typhoid bacteria along with her food since she first set foot in an American kitchen in 1900. In 1907, the New York health authorities discovered her infective potential: as a result, she was isolated and quarantined for a total of 26 years. Mary Mallon was formally held responsible for infecting 53 people with typhoid fever, three fatally so. However, historian Richard Gordon clarifies that her casualty list was probably far larger than this, there is even speculation that she caused the 1903 epidemic at Ithaca, New York, which had a devastating 1,400 victims.

 

Image 1: ‘Typhoid Mary’, Wikimedia Commons. The image first appeared in The New York American on June 20, 1909.

The negative media portrayal that Mallon was subject to encouraged her forceful treatment by the health authorities. The papers delighted in depicting Mary as a devious cook, out to poison her employers. Mary Mallon was, as Roy Porter so aptly describes, “rapidly demonised”: by 1909, macabre cartoons in the popular press depicted her cracking egg-like skulls into a frying pan. The juxtaposition of such images of habitual domestication with deadly disease generated fear and panic amongst the American public. Mary herself was very aware of the bad reputation she was accruing, stating to the New York Times that she was “treated like a leper”. Mary’s description was not an exaggeration: she was banished to an island, destined to live the rest of her days in enforced solitude.

Mary Mallon’s story sparks social, moral and legal debate that has extensive contemporary societal relevance when considered within the context of epidemic disease. It is a mark of the infamous nature of this case that the phrase ‘Typhoid Mary’ still carries strong connotations, defined figuratively in the Oxford English Dictionary as “A person who… is the source of undesirable opinions, emotions, etc.; an unpopular or subversive person”. The power of caricature was instrumental in rendering ‘Typhoid Mary’ an inextricable part of American popular culture.

 

 

Further Reading

– Richard Gordon, An Alarming History of Famous and Difficult Patients, (United States of America: St Martin’s Press, 1997).

– Roy Porter, The Greatest Benefit to Mankind, (London: Harper Collins Publishers, 1997).

– “‘Typhoid Mary’ Must Stay: Court rejects her plea to quit riverside hospital”, New York Times, July 17, 1909, 3.

– “Typhoid Mary”, Oxford English Dictionary, www.oed.com.

 

Lucy Havard

Elizabeth Garrett Anderson: a modern woman 100 years ahead of her time

As a junior doctor possessing two X chromosomes, it is easy to applaud the achievements of Elizabeth Garrett Anderson (1836-1917), widely revered as the first British female doctor. It is infinitely harder to establish exactly how she succeeded and to quantify the relevance of this extraordinary woman who died just over 100 years ago. Can we still learn from her example, or has too much time passed to draw significant parallels in today’s modern world?

 

Image 1: Elizabeth Garrett as a young woman, Wellcome Images

Elizabeth Garrett Anderson wrote to a friend in 1864: ‘My strength lies in the extra amount of daring which I have as a family endowment. All Garretts have it.’ EGA did have ‘daring’, and she wasn’t scared to do things differently. She is frequently referred to as ‘a pioneer’, and with just cause: EGA was the first woman to qualify in Britain to practice medicine, the first woman to qualify as a doctor of medicine in France, the founder of the first hospital staffed by women, the first female member of the British Medical Association (BMA), the first female Dean of a British medical school, the first female mayor in Britain; the list goes on. EGA’s nature as ‘the first’ engendered two conditions: one, that the medical profession as a whole had not expected, nor prepared, for the possibility of a female attempting admission to their ranks; and two, that any doors that remained open within the medical profession were swiftly slammed shut soon after EGA had passed through them. The permission for women to take the Licentiate of the Society of Apothecaries (LSA) examinations to obtain a medical degree, and admission of females to the BMA may be cited as examples here. Consequently, EGA’s nature as a ‘pioneer’ conferred a significant advantage, and it was initially harder, as opposed to easier, for women to qualify as doctors after Elizabeth Garrett Anderson had succeeded.

 

Image 2: Elizabeth Garrett Anderson, Wellcome Images

Not only did EGA have an unwavering belief in herself and her ability to become a doctor but she put her career first: this was unprecedented in mid-Victorian Britain. She married comparatively late, at the age of 34, despite the average age of contemporary females entering matrimony being just 23 years in 1871. Importantly, marriage took place only after she had successfully completed her studies to become a fully qualified doctor. She had previously declined an offer of marriage in 1865 from her sister Millicent’s future husband, the MP Henry Fawcett. Even after becoming engaged to James Skelton Anderson, she worried that this might jeopardise her career as a doctor and her fight for women’s suffrage: ‘I believe I should almost die of the sense of something akin to guilt, if I found myself, three years hence, really out of the medical field’. This excerpt clearly demonstrates an immense sense of duty. EGA felt herself carrying the weight of the future of women’s rights on her shoulders, and this was constantly in the forefront of her mind.

Elizabeth Garrett Anderson changed the course of women in medicine indefinitely, and more broadly, had an integral role in promoting the women’s suffrage movement on a national scale. Women today can identify with EGA given that she mastered the ability of the ‘modern woman’ to ‘have it all’ – with both a successful career and a fulfilling family life. In 1871, The Lancet proposed ‘if [Elizabeth Garrett Anderson] succeeds in combining the two functions of mistress of a household and medical practitioner, she will have performed a feat unprecedented in professional history, and added another notable incident to this annus mirabilis’.

 

Quod erat demonstrandum.

 

Further reading:

  • Glynn, J. (2008). ‘The Pioneering Garretts – Breaking barriers for women’, Hambledon Continuum, London.
  • Garrett Anderson, L. (2016). ‘Elizabeth Garrett Anderson 1836-1917’, Cambridge University Press.

 

Lucy Havard

The Gripe Water

Early modern receipt books may be defined as collections of food recipes, medicinal remedies and household tips. These handwritten manuscripts were generally compiled by the housewife; she would use the receipt book as a means to record her own recipes as well as those borrowed from friends, neighbours, family, and even doctors and surgeons. Receipt books were highly valued and were often passed down through the generations; they were even formally bequeathed in wills. These manuscripts provide intriguing evidence of the homemade medicinal remedies in use in the early modern period. This blog is focused on a recipe for ‘Gripe Water’ from a receipt book attributed to Mary Chantrell, dated 1690. The manuscript can be found at the Wellcome Library in London and it is also available in a digitised format online via their website.

 

Wellcome Library MS.1548, 53.r-v

 

The layout of this recipe is interesting: it is written in prose, and there are no separate lists of ingredients or utensils as is often the case in modern-day recipes. It must have been rather difficult for early moderns to make sure they had all the ingredients required before starting to make the recipe!

One of the most striking things about this particular recipe is the number of individual ingredients used: ‘gilley flowers’, ‘rosemary flowers’, ‘borage flowers’, ‘blacke cheryes’, ‘strawberyes’, ‘rasberyes’, ‘mint’, ‘balme’, ‘angellicoe’, ‘rue’, ‘morella cheryes’ ‘coriander seeds’, ‘caraway seeds’, aneseeds’, ‘nutmeg’, ‘cloves’, ‘mace’, ‘cinamon’, ‘ginger’, ‘pennyroyall’, ‘brandy’, ‘sherye’ and ‘white wine’. Some of these herbs and spices were difficult to cultivate in seventeenth-century English gardens necessitating their purchase from specialist suppliers. Exotic spices, such as ginger, mace, cinnamon and nutmeg often had to be imported. The housewife would need to know where to obtain these individual items as well as how to judge their quality in the making of this remedy.

The quantities of ingredients is notable: a gallon each of strawberries and raspberries, 12 pounds of cherries, three gallons of brandy, a gallon of white wine and a gallon of sherry! Such quantities would have made the recipe expensive. Perhaps the large amounts used were due to the recipe being made for a large household, or maybe the intention was to share or exchange the final product amongst others in the local community. Perhaps the ‘Gripe water’ would be made once and then kept and stored for future use over the coming months or even years.

Finally, the equipment used is interesting. The recipe mentions the use of a ‘Limbeck such as the Apothecaryes use’. This ‘Limbeck’ (more commonly termed an ‘alembic’), was an apparatus used for the purposes of distillation. Using this kind of equipment supports the notion that activities commonly associated with the history of science might be performed in the home, and encourages us to consider the domestic environment as an ‘experimntal space’.

Early modern receipt books, like this one, raise many questions. But they also provide us with a tantalising window through which to view early modern domestic medicine.

 

 

Further reading

  • Lynette Hunter, ‘Women and domestic medicine,’ in Women, Science and Medicine 1500-1700, eds. Lynette Hunter and Sarah Hutton (United Kingdom: Sutton Publishing, 1997).
  • Elaine Leong, ‘Collecting knowledge for the family,’ Centaurus55, (2013): 81-103.
  • Anne Stobart, Household Medicine in Seventeenth-Century England(London: Bloomsbury Academic, 2016).

 

Lucy Havard