High seas, ICs and health care
“John Stone, aged 25, private marine; feels pain in the throat… difficulty of swallowing… diluted sulphuric acid used as a gargle”. The British Royal Navy medical officer who wrote that report didn’t say if the patient got better, and presumably the patient never said anything ever again, so we’ll never know if the cure worked. His colleague who treated fever cases with a tepid salt water bath did however note the salutary effects on all his patients, even though, technically speaking, they all died soon afterwards. If you’ve got an hour or two to waste (as I hadn’t when I was supposed to be writing this article) take a look at this collection of reports compiled by Royal Navy Surgeons and Assistant Surgeons from ships, hospitals, naval brigades, shore parties and on emigrant and convict ships in the period 1793 to 1880.
For the casual reader like me, the most interesting aspects are stuff like being attacked by a walrus, stealing a skull, being struck by lightning, or accidentally circumcising yourself when playing a joke on your shipmates (anything for a laugh). For the less frivolous, the records are a mine of information on a whole range of medical topics. Mortality for instance: half the deaths on warships were from disease, ten times the proportion killed in battle. Or medical methods and technologies. Apart from the descriptions of acid gargles or blowing tobacco smoke into a drowned sailor’s lungs to revive him (it worked), the reports list more mundane treatments. “Amputation” appears a lot. In fact, on a quick reading it seems to be the main surgical activity on the ships, and other sources describe how during a naval battles, the surgeon’s assistants (“loblolly men”) could fill tubs with severed limbs.
Many of those who survived the surgery died later from infections, and this was the case for civilian patients operated on shore as well. That would change by the end of the period covered by these reports, with the Victorian “surgical revolution”, brought about by the introduction of anaesthesia in the 1840s, antisepsis in the 1860s and x-rays in the 1890s. We often talk about “medical science”, but what happened over that half century had nothing much to do with science. It was a technological and organisational revolution that would mark medical care well into our times.
In this article, Jim Connor reminds us that knowledge of chemical or physiological principles had little to do with the advent of anaesthesia or explaining how it works. There was little scientific basis for antisepsis when Lister introduced it. And Roentgen was pioneering radiology before any theoretical explanation for x-rays was available. Technology was not the servant of science, or of the market. As Connor argues, there was no call for these innovations from practitioners, and many patients were even reluctant to undergo anaesthesia for fear of what the doctors might do when they were unconscious.
The revolution came from the interactions of science, technology and medicine among each other and with economic and social trends. If the state and business get involved in such a process, the result is what John Pickstone calls “technoscience”, where scientific knowledge and its applications become marketable commodities. The result in the 19th century was to change the position of the surgeon from an independent artisan, owning his own tools and premises and seeking out clients, to essentially an employee of a large organisation that centralised demand and supplied the equipment, bought from an increasingly powerful group of outside suppliers.
This fundamentally changed health care as a calling and as a business. Today, another revolution is underway, driven by ICTs, or what we might call tele-technoscience, and responding to what a new OECD report identifies as “social and demographic changes, the rise in chronic diseases, and the need to improve the efficiency and quality of healthcare delivery”. ICTs and the Health Sector: Towards Smarter Health and Wellness Models looks at how mobile devices, the Internet and ICT in general can be used to support self-management, behavioural modification (not as sinister as it sounds) and “participatory healthcare”, and allow health care systems to learn.
The streams of data flowing from medical devices and research programmes are the raw materials the new systems will be built on. But data as such are of relatively little value if they can’t be processed, turned into useful information and shared. Those old naval records contained masses of data on cases, living conditions, even climate and geography, as well as potentially life-saving information on best (and worst) practices. But this information couldn’t be shared significantly using the technologies available at the time. The OECD report talks about a similar situation with today’s technology and analytical tools, arguing that they can’t effectively manage or even capture the many data streams available and turn them into useful information.
The Victorian revolution produced the hospital-centred, doctor-oriented system we know today. The ICT revolution could produce a system that is based on the patients, their family and community, with more emphasis on evidence-based approaches and personalised care, and a less prominent role for the clinician’s training and experience in diagnosis and treatment. These will remain important though, as will the practitioners’ attitude to their job. Bruno Pappalardo, the specialist in charge of the Royal navy collection, told The Independent newspaper that despite the harsh environment the naval medical officers worked in, “their compassion shines through – they did their utmost to care for people.”