‘Unfallstationen!’ – a short history of the emergency department


Royal Free Hospital, Gray’s Inn Road. Accident ward.. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

The emergency department is seen as the ‘coal-face’ of any hospital, providing 24-hour-access medical assessment to members of the public.

Having just started my first job in emergency medicine, after working in general practice and in other hospital specialties, I have been struck by how distinct the challenges are facing staff in this environment. And for a specialty that is so publicly ubiquitous, it is hard to imagine that it is also one of the newest; in the UK only forming The College of Emergency Medicine as we know it, in 2005.

A brief look at the history of the accident and emergency department paints a picture of a speciality that has always adapted to the populations it serves.

Dominique Jean Larrey, a French surgeon in Napoloeon’s army, is seen as an early pioneer of many of the concepts of emergency medicine having developed a system of battlefield triage and emergency treatment. During the battles of the French Revolution in 1793 he commandeered the French flying artillery and made them into ‘ambulance volantes’ – literally meaning ‘flying ambulances’ – to transport the wounded from the battlefield rapidly.

He also improved the organisation of field hospitals and developed the technique of ‘triaging’ the wounded based on the seriousness of their injuries, rather than rank or nationality. Wounded soldier of enemy armies were also treated in his hospitals, demonstrating one of the central tenets of emergency medicine of care being open to all.

While Larrey may have been one of the first to define and formalise some of the concepts of modern-day emergency medicine, the offering to civilians began in the form of accident services set up by the citizens themselves in some cities. A 1905 article in The Lancet, describes attempts by the city of Berlin to set up municipal accident and emergency services.

Residents of a particular quarter within the city set up a ‘Sanitätswache’ – ‘first-aid station’ – by hiring out a building and setting it up with the instruments and dressing needed, and appointing surgeons to ‘staff’ them. These Sanitätswache were privately-run by committees and were subscription-fee only – a far-cry from open-access to all. Moreover, they had few visitors as they only operated at night, when accidents were less likely to happen due to the closure of factories and reduced foot-fall.

This concept was built upon by a new organisation of ‘Unfallstationen’ – ‘accident stations’ – to serve workers who wished to insure themselves against work-place accidents. Unlike the Sanitätswache, these were open during the daytime and proved to be popular among the general population, not just the workers at which they were aimed. They were still private enterprises with fees recuperated through cooperatives, or directly from individuals.

However they had their own issues, including criticisms that those with more serious injuries would be better off being conveyed straight to hospitals, many of whom had set up their services to see accidents, and had their own in-house surgeon.

Instead, a new society known as the ‘Berlin Rettungsgesellschaft’, the ‘Berlin First-Aid Society’, was created backed by the medical establishment to unite the Sanitätswache and Unfallstationen. The Rettungsgesellschaft introduced a central office with a special telephone communication service between local hospitals and the ambulance service, so that if more than one person was injured at a scene, enough surgeons and ambulances could be alerted to attend the scene.

Unfortunately, all three of the services relied on private subscriptions, and later a fight broke out over funding (sound familiar?), over whether they should be fully-funded by the municipalities which they served. The Lancet article ends with the future of civilian emergency services in Berlin hanging in the balance.

It was in the late 1800s and early 1900s that Anglo-American hospitals established ‘accident’ departments, although their official modern equivalents only becoming established in the 1960s. Prior to this, although hospitals would provide some level of accidental or urgent care this service was staffed by surgeons and general medical physicians who rotated in from other specialties. In the 60s and 70s, it became more common for surgeons and physicians to leave their respected specialties to focus primarily on emergency medicine.

In the US, emergency medicine was formally recognised as a specialty in 1979. In the UK, it was not until 2005, when The British Association for Emergency Medicine (BAEM), formerly the UK’s Casualty Surgeons Association, combined forces with the Faculty of Accident and Emergency Medicine (FAEM), a daughter organisation of six medical colleges, to form the College of Emergency Medicine, which became the Royal College of Emergency Medicine.

In spite of its relative youth as a recognised specialty, the importance of emergency treatment has been recognised in some capacity for hundreds of years, particularly in the field of battlefield medicine. And while we recognise it faces many modern pressures, Emergency Medicine’s long history of flexibility in the face of changing demands, is uniquely one of its strengths.

Words by Dr Flora Malein

 

Sources used:.

The College of Emergency Medicine [archived page].

Howard, MR. “In Larrey’s shadow: transport of British sick and wounded in the Napoleonic wars”. Scott Med J. 1994 Feb;39(1):27-9. doi: 10.1177/003693309403900109.

The Lancet, Volume 2, Part 2 (p. 1808-1809).

Suter RE. “Emergency medicine in the United States: a systemic review.” World J Emerg Med. 2012; 3(1): 5–10. doi:10.5847/wjem.j.issn.1920-8642.2012.01.001.

Mystery object – Frimley Sanatorium

Mystery object 1: an illustration by a patient in a letter sent to the Lady Almoner at Frimley Sanatorium in 1952. Image source: Royal London Hospital Archives & Museum: RLHBH/AL/3/27/9

Mystery object 2: an image from the Wellcome Trust library that is related to Mystery object 1. Image Source: Wellcome Image Library.

Both the illustration and above object performed the same function.

Can anyone name them?

Answer to be published on Friday 17th July.

 

*** Update. See below for the answer ***

 

Mystery object 1 is an illustration of an object written by patient WA, a recovered tuberculosis patient, to the Lady Almoner at Frimley Sanatorium. WA refers to it colloquially as a ‘Brompton Muzzle’ that ‘were in common use to ease restricted breathing’. 

His illustration features an area for an absorbant sponge along the same lines as the absorbant sponge at the bottom of mystery object 2 which is an illustration of a Burney Yeo mask.

The Lady Almoner contacts the Dispensary in regards to the patient’s enquiry, and notes the following:

‘Dispensary say that they have a Burney Yeo’s improved inhaler which is a different shape but appears to fit over the mouth and nose and is on the same principle. Dispensary say that there should be no difficulty in obtaining this mask. It is in use in most hospitals’.

The Almoner replies, ‘I have made enquires in our Dispensary and I find that we have a small mask which serves the purpose that you describe. It is on the same principle, but is a square shape and much smaller.

The ‘Burney Yeo’ appears to be several iterations of a type mask used in the treatment of tuberculosis in which the patient inhaled an antiseptic liquid via an absorbant material.

If anyone knows of any other examples of the Burney Yeo mask or what the ‘solution’ that the patient inhaled might have been, please do comment below.

Images submitted by Dr Flora Malein.

 

Sources used:

The Royal London Hospital Archives and Museum

Wellcome Trust Library

Poems and Pandemics in the Plague Village

Simon Armitage’s newly released poem, ‘Lockdown‘, recalls the Eyam plague of 1665/6, effectively evoking feelings that reverberate in our current situation, and remind us that we are not the first to find ourselves in such a position.

Elizabeth Hancock drags the body of a family member to the Riley graves. She lost her husband and all six children during the outbrak. Illustration from The Brave Men of Eyam by E.N. Hoare published by SPCK, 1881.

In Lockdown, the Poet Laureate touches on some of the most notable features of the story. ‘Thimbles brimmed with vinegar wine’, for example, refers to the practice of Eyam’s residents leaving coins in holes in the rock at the parish boundary. These would be exchanged for vital supplies by the neighbouring villagers, hinting at an understanding of antisepsis not widely acknowledged to be present at that time.

We find new resonance in the story of Emmott Sydall and Rowland Torre, betrothed lovers who found themselves on either side of the cordon sanitaire, seeing each other only from a distance until Emmott failed to appear one day, having tragically succumbed to the plague.

Such stories of ordinary individuals were passed down in the oral tradition, and whilst making it more difficult for historians to corroborate beyond births, marriages and deaths, this adds a somewhat mystical glow to this period.

Indeed, one of the key reasons the Eyam plague may stick in our consciousness more than the countless other local outbreaks of disease over the centuries, is the fascinating cocktail of physical reminders of the plague story around the village, combined with these legends of individual suffering.

Perhaps the Eyam plague is also memorable due to its particularly high death rate. As referenced in the poem, the village tailor received a parcel of cloth from London, believed to contain fleas carrying the plague. Certainly, the tailor’s assistant George Viccars, became the first victim in September 1665.

There was a steady rate of transmission, which slowed over the Winter, but exploded the following Summer, finally petering out in the Autumn of 1666. By then, around one-third of the villagers (260) were dead.

The ‘crisis mortality rate’ in Eyam has been estimated at twice that of the London outbreak, occurring at the same time. Whole families were wiped out, helpless to prevent the rampage of the infection.

Whilst this surge may simply have reflected the exponential nature of the spread within a non-immune population, it has also been suggested that the disease switched from the flea-borne bubonic type to the much more infectious pneumonic transmission.

Rev William Mompesson (right) converses with a parishioner. Illustration from The Brave Men of Eyam by E.N. Hoare published by SPCK, 1881.

Lastly, the image of the Rector, William Mompesson, leading his parishioners in their self-sacrifice, including through the death of his wife, has created a strong narrative of stoical heroism.

This was irresistible, in particular, to the Victorians seeking to retrospectively chronicle the events of 1665/6 with little written information to go on, save a few of Mompesson’s surviving letters.

What now of the plague village? Once again, Eyam is under lockdown. Public gatherings are prohibited, churches and inns are closed, and there is anxiety and uncertainty. On the other hand, supplies from neighbouring villagers have been replaced by those from supermarket delivery vehicles, and the Priests making the decisions, by Public Health officials.

Nevertheless, the community spirit has kicked in with local support schemes in operation, and, spontaneously, numerous villagers have remarked on the renewed empathy they have for their 17th century counterparts.

‘Plague Sunday’, which is celebrated in the village on the last Sunday of August, will certainly have added poignancy this year. Indeed, the Plague Sunday procession ends at Cucklet Delph, a natural amphitheatre used by Mompesson to address the village rather than cram everyone into the church.

This year, using this venue may well once again be for the reason of public safety rather than historical re-enactment.

Words by Dr William Parker, Eyam, Derbyshire

 

Sources/Further Reading

Clifford J (1989). Eyam Plague 1665-1666, self-published.

Mead R (1720) A Discourse on the Plague, Miller & Brindley. Available at http://www.gutenberg.org/files/32171/32171-h/32171-h.htm

Massad E et al (2004) The Eyam plague revisited: did the village isolation change transmission from fleas to pulmonary? Med Hypotheses 63:911-5.

Race P (1995) Some further consideration on the plague in Eyam, 1665/6. Available at http://www.localpopulationstudies.org.uk/PDF/LPS54/LPS54_1995_56-65.pdf

Wallis P (2005) A Dreadful Heritage: Interpreting Epidemic Disease at Eyam, 1666-2000. Available at http://eprints.lse.ac.uk/22546/1/0205Wallis.pdf

Wood W (1842). The History and Antiquities of Eyam, Whitaker & Company.

Herd Immunity – what’s in a name?

“Herd immunity” recently made a controversial appearance in the context of the current COVID-19 pandemic. What does the phrase mean, where did it come from, and how helpful is it today?

As of March 2020, the OED defines it as, “resistance to the spread of a contagious disease within a population that results if a sufficiently high proportion of individuals are immune to the disease, typically as a result of having been vaccinated against it”.

The earliest use of the phrase can be traced to a 1917 report from the US Bureau of Animal Industry that dealt with a cattle infection causing death of unborn calves. A cow that had aborted was likely to become immune, and calves born and raised in such an affected herd were tolerant to the disease. The authors concluded that “a herd immunity seems to have developed as the result of both keeping the aborting cows and raising the calves”.

However, the senior author, Dr Adolph Eichhorn, Chief of the Pathological Division, made no reference to herd immunity in a monograph to which he contributed a major section on biological therapeutics just two years later. His biologically apt coinage does seem to have been picked up in US agricultural circles, but it was not universally adopted, with “immunity of the herd” being used instead.

The concept of herd immunity next appeared in British bacteriologist William Topley’s epidemiological studies of bacterial infection, which examined the resistance of a population of mice after immunising animals with suspensions of bacteria. He used “herd-resistance” to describe the natural resistance of individuals within a population. And he discussed the implications of his work with the “mouse herd” for the “human herd”.

The human herd entered this experimental realm at about the same time. In 1922, Surgeon-Commander Sheldon Dudley studied a diphtheria epidemic at Greenwich Hospital School. He found that the longer boys had been resident the greater the proportion who were immune, and that increases in immunity correlated with each outbreak. He extended such studies to other infectious diseases and used herd immunity to explain his findings.

In 1928, all boys in the school were actively immunised against diphtheria. The most senior became immune (Schick-test negative) twice as quickly as the most junior, suggesting prior exposure to the disease (see Figure). These results paralleled earlier work in animals, except for the fact that “a herd of human boys were used in lieu of the guinea-pigs”.

Dudley was unapologetic for using the prefix herd to denote the properties of a community, pointing out that psychologists had earlier popularized the phrase “herd instinct”. Besides, on evolutionary grounds, there was “little fundamental difference between a herd of deer, a herd of swine, and a herd of Homo sapiens”.

Notions of herd immunity have become more sophisticated in recent decades owing to the increased importance of vaccination. Today’s NHS website defines the benefits thus: “If enough people are vaccinated, it’s harder for the disease to spread to those people who cannot have vaccines. For example, people who are ill or have a weakened immune system”.

The reader is also directed to more information and an animation on the website of the Oxford Vaccine Group’s Vaccine Knowledge Project . This site suggests that a better name for herd immunity is “herd protection” because it helps to protect those especially vulnerable to infectious diseases. “Community immunity” appears as an alternative.

Conveying the value of herd protection or community immunity to the public will be critical in successful vaccination against COVID-19. One must worry that the lazy use of a century-old phraseology rooted in the farm, mouse lab and human guinea-pigs, as well as a contemporary profusion of alternative terms, may prove more of a hindrance than a help.

 

Words by Edward Wawrzynczak

 

Sources used:

  1. Horton, R. (2020) Offline: COVID-19 – a reckoning. Lancet, 395, 935.
  2. https://public.oed.com/updates/new-words-list-march-2020/.
  3. Eichhorn, A. & Potter, G.M. Contagious Abortion of Cattle. In: Farmer’s Bulletin 790, Washington DC: United States Department of Agriculture, 1917.
  4. Winslow, K. & Eichhorn, A. Veterinary Materia Medica and Therapeutics, Eighth Edition. Chicago: American Veterinary Publishing Co, 1919, pp.525-563.
  5. Beechy, L.P. (1920) Abortion disease in cattle. Bulletin of the Ohio State University Agricultural College Extension Service. Vol. XVI, No. 1.
  6. Smith, T., Little Further studies on the etiological role of Vibrio fetus. J Exp Med, 32, 683-689, R.B. &Taylor, M.S. (1920).
  7. Topley, W.W.C. & Wilson, G.S. (1923) The spread of bacterial infection. The problem of herd-immunity. J Hyg, 21, 243-9.
  8. Topley, W.W.C. Wilson, J. & Lewis, E.R. (1925) Immunisation and selection as factors in herd-resistance. J Hyg, 23, 421-436.
  9. Greenwood, M. & Topley, W.W.C. (1925) A further contribution to the experimental study of epidemiology. J Hyg, 24, 45-110.
  10. Dudley, S.F. (1922) The relation of natural diphtheria antitoxin in the blood of man to previous infection with diphtheria bacilli. Brit J Exp Pathol, 3, 204-209.
  11. Dudley, S.F. The Spread of Droplet Infection in Semi-isolated Communities. Medical Research Council, Special Report Series, No.111, London: HMSO, 1926.
  12. Anon. (1927) The spread of infection in schools and ships. BMJ, 1(3443), 34, 1 Jan.
  13. Dudley, S.F. (1928) Natural and artificial stimuli in the production of human diphtheria antitoxin. Brit J Exp Pathol, 9, 290-298.
  14. Dudley, S.F. (1929) Herds and individuals. J R Army Med Corps, 53, 9-25.
  15. Fine, P., Eames, K. & Heymann, D.L. (2011) “Herd immunity”: a rough guide. Clin Infect Dis, 52, 911-916.
  16. https://www.nhs.uk/conditions/vaccinations/why-vaccination-is-safe-and-important/.
  17. https://vk.ovg.ox.ac.uk/vk/herd-immunity.
  18. Betsch, C. et al. (2017) On the benefits of explaining herd immunity in vaccine advocacy. Nat Hum Behav, 1, 0056.
  19. Hakim, H. et al. (2019) Interventions to help people understand community immunity: a systematic review. Vaccine, 37, 235-247.

Laughter is the best medicine

Anyone who has read doctor-turned-comedian Adam Kay’s best-selling ‘This Is Going to Hurt’ about his experiences on the obstetrics wards will be aware that medicine provides rich pickings for humour and satire.

But Kay is not the first person to draw on medical experiences to amuse his audiences. For as long as modern medicine has existed, medics and patients have been finding the humour in their experiences, helping to inform on attitudes and experiences from that time.

One such example is this excerpt from the October 1869 magazine, Punch. Written by Francis Cowley Burnand, a nineteenth century comic writer and playwright whose popular column ‘Happy Thoughts’ describes the difficulties and distractions of everyday life.

In this excerpt, Burnand turns his attentions to the doctor’s waiting room, in a scenario that will be very familiar to anyone who has ever made an appointment to see their General Practitioner. The narrator’s attempts to catch the doctor’s eye and jump to the front of the queue are ultimately dashed and he is forced to wait his turn like everyone else. The incident ends in embarrassment when he misplaces the doctor’s fee inside the lining of his coat.

The gentle observational humour illustrated in this column gives insight into the type of medical treatment available to the upper classes, while also demonstrating how little doctor’s waiting rooms have changed in the last 150 years.

The working relationship between doctors and nurses is also very neatly satirised in the following engraving from 1891. The Doctor asks the Nurse: “How is the patient this morning?” To which she replies, “Well – he has been wandering a good deal in his mind. Early this morning I heard him say ‘What an old woman that doctor is!’ – and I think that was about the last really rational remark he made.”‘

This comedic interchange about a delirious patient could just have easily occurred on one of today’s NHS medical wards.

As well as providing entertainment, humour and satire have also been used to highlight public health and social issues. In the following satirical cartoon from an 1893 issue off Punch, ‘Mr Punch’ remonstrates with a policeman about a quack doctor selling his ‘remedies’ on the streets of London. Saying, ‘And if Punch’s ready bâton lays its thwacks on any back with special zest, it is on charlatans and quacks.’

The cartoon highlights the movement against quackery towards the end of the nineteenth century, with a higher degree of ‘outcry’ against quacks that promoted false and unproven health claims for financial gain. While we are less likely to see ‘cure-alls’ pedalled on street corners, ‘quackery’ in the form of misinformation regarding vaccination and cancer treatments still exists as a scourge in modern medicine.

 

Flora Malein

The October 1869 Happy Thoughts article in full:

Image courtesy of Peter Burke

Sources used:

Chisholm, Hugh, ed. (1911). “Burnand, Sir Francis Cowley” . Encyclopædia Britannica. 4 (11th ed.). Cambridge University Press. p. 848.

The Wellcome Library