Thomas Addison

Thomas Addison

Because the neurologist I shadowed at Southampton General Hospital told me to research about Thomas Addison, I have decided to write a blog about him.ThomasAddison

Thomas Addison (April 1793- June 29 1860) was an English Physician who studied at Guy’s Hospital, London. During his time at Guy’s, Thomas Bateman, an acclaimed dermatologist, brought about his fascination with skin diseases.   Addison is known for his discovery of Addison’s disease (a degenerative disease of the adrenal glands) and Addisonian anaemia (pernicious anaemia) – a haematological disorder later found to be caused by the failure to absorb vitamin B12.

Addison’s disease

Addison’s disease (primary adrenal insufficiency/ hypoadrenalism) is a rare, chronic condition brought about by the failure of the adrenal glands so that not enough cortisol or aldosterone is produced.

adrenal glands 2The adrenal glands are situated above the kidneys; the inner core (medulla) produces the stress hormone adrenaline whereas the outer shell (cortex) produces the steroid hormones cortisol and aldosterone. Cortisol’s function is to control inflammation, regulate the body’s nutrients, stimulates the liver to produce blood sugar and regulates water content of the body. Aldosterone helps the kidneys to regulate salt and water levels which affect blood volume and blood pressure (your blood pressure drops if your aldosterone levels drop too low).

Adrenal failure is generally brought about as a response to the immune system. When Thomas Addison first discovered the disease in 1855, the main cause was as a complication of TB (this still remains a main cause in developing countries). In third world countries, HIV (AIDS) is becoming an infectious disease that causes adrenal failure. The most common cause of adrenal failure is destructive atrophy- this is where an over-active immune system starts attacking the body’s own organs (including the adrenal glands). This affects more women than men and accounts for 70% of all cases. Rarer causes include adrenal cancer, adrenal haemorrhage (eg. as a result of a car accident) and certain fungal infections.

This disease is not usually apparent until over 90% of the adrenal cortex is destroyed (this can take months to years).

Early stage symptoms:

  • Fatigue
  • Muscle weakness
  • Low mood
  • Loss of appetite and unintentional weight loss
  • Increased thirst

Over time, the symptoms can become more severe and others can also develop

  • Hypoglycaemia
  • Hyperpigmentation- darkened patches of skin, gums or lips
  • Nausea and vomiting
  • Dizziness and fainting
  • Cramps
  • Exhaustion

Addison’s disease is treated with medications to replace the missing hormones which will be needed to be taken for the rest of your life. If left untreated, it can be fatal. With the treatment, symptoms can be mainly controlled so the patient can live an active life but they may experience times of fatigue. There may also be associating health conditions such as diabetes or an underactive thyroid.

Addisonian anaemia (pernicious anaemia)

This disease occurs when a lack of vitamin B-12 affects the body’s ability to produce fully functioning red blood cells. This occurs when the immune system attacks stomach cells that produce a protein vital for the absorption of vitamin B-12.

Gastric parietal cells

Gastric parietal cells

Vitamin B-12 is absorbed into the body through the stomach- gastric parietal cells in the stomach secrete a protein called intrinsic factor. People with pernicious anaemia produce antibodies that attack the parietal cells so that not enough of the protein is produced. As the vitamin B-12 can therefore not be absorbed, the body is unable to produce fully functioning red blood cells. Patients tend to have red blood cells that are underdeveloped or large than normal (megaloblastic anaemia).

Atrophic gastritis- damage to stomach lining

Atrophic gastritis- damage to stomach lining

Pernicious anaemia is the most common cause of B-12 deficiency in the UK and is most likely to occur in women over the age of 60. Having another autoimmune disease (such as Addison’s disease or vitiligo) can increase the risk of developing pernicious anaemia.

The symptoms vary from patient to patient (most probably due to different physiologies) but according to the Pernicious Anaemia Society, the most commonly reported symptoms include:

  • Fatigue
  • Exhaustion
  • Loss of memory
  • Lethargy
  • Weariness

In order to treat this disease, patients are given injections of vitamin B-12 in the form of hydroxocobalamin and they need to be taken every 3 months for the rest of the patient’s life.

All About Anaesthesia…

The literal translation of anaesthesia is ‘loss of sensation‘.

anaesthesia

Anaesthetics are the medications used that cause anaesthesia which are used during tests and surgical procedures. Anaesthetics block the signals that pass along your nerves to your brain; after the anaesthetic has worn off, the nerve signals will be able to reach your brain and your feelings will return.

Types of Anaesthesia

There are a number of different types of anaesthetic and only general anaesthetic makes you unconscious.

  • Regional anaesthetic:- used for larger/deeper operations where nerves are more difficult to reach (this is commonly used for Caesarean sections). Only ever conducted in an environment where a team is able to easily provide general anaesthesia if necessary.
  • Epidural anaesthetic:- a type of local anaesthetic usually used to numb the lower half of the body. A needle is used to locate an area of the spine known as the ‘epidural space’ and can numb areas such as the thoracic area (chest), abdomen, pelvic area and legs
  • Spinal anaesthetic:- type of regional anaesthetic that is used to numb the nerves of your spine so that surgery can be performed in this area.
  • Sedation:- sometimes used for minor procedures- a sedative relaxes you physically and mentally.
  • Local anaesthetic:- used to induce the absence of sensation in part of the body ( local insensitivity to pain). Anaesthetics sometimes combine both local and general anaesthesia techniques.
  • General anaesthetic:- a drug that has the ability to induce a reversible loss of consciousness. These are given to a patient in order to facilitate surgery so that they don’t feel any pain

There are a number of theories about how general anaesthetics work, however, the precise mechanisms remain unknown.

Side Effects

Anaesthetics consist of a number of medications that can cause side effects in some people.
These are some of the side effects of general or regional anaesthetics:

  • Nausea or vomiting (1 in 3 people feel sick after an operation)
  • Sore throat
  • Aches and pains
  • Dizziness
  • Blurred vision
  • Headache
  • Itchiness
  • Bruising and soreness

These side effects do not last very long and can be treated with further medication if necessary.

Risks

Anaesthesia has become much safer over the years and advances have meant that serious problems are uncommon.
However, there are always potential complications:

  • Permanent nerve damage (cause numbness or paralysis)
  • Anaphylaxis (serious allergic reaction)
  • Death (approx. 5 deaths for every million anaesthetics given in the UK).

History of Anaesthesia

Thankfully, anaesthetics have been developed and so now they are used commonly under safe situations. However, it has not always been like this.
The concept of anaesthesia has been around since they have been performing surgery.

Early anaesthetics such as soporifics (which dull the senses and induce sleep) and narcotics (including opium, mandrake, jimson weed, marijuana, alcohol and belladonna) were all used as substitutes of today’s drugs. Although all of these can provide some pain relief, sedation or amnesia, there were no guarantees.
In mid 1840s, opium and alcohol were the only two substances used regularly as anaesthesia in industrial countries. There were many negative side effects to using these:

  • Patients could easily become addicted
  • The doses needed to provide the amount of pain relief/ sedation could easily result in death.
  • Surgery usually resulted in the tortured screams of patients because the anaesthesia wasn’t good enough.

1845– Dr Horace Wells was the first person to use nitrous oxide to pull teeth out

Dr Horace Wells

Dr Horace Wells

1846– Dr William Morton removed a tumour for the jaw of a patient. He used a sponge soaked in ether and the patient claimed he had no memory of the surgery or any pain.

Dr William Morton

Dr William Morton

Chloroform was first used as an anaesthetic in the mid 1840s by Dr James Simpson. It is highly toxic and so ether was used instead in the early 1900s.
Using a sponge made it hard to control the dosage and therefore, nitrous oxide is now used as an inhalable gas. Anaesthesiologists administer the drugs via machines that measure the specific amount necessary for each individual patient.

Because the drugs interfere with breathing, patients are often intubated- a plastic/ rubber tube is inserted in the trachea to keep the airway open- and then, during surgery, the patient is kept on a mechanical ventilator.

general-anesthesia-coma_1

Women in Medicine

I was reading the Student British Medical Journal (BMJ) and there was an article that really struck me. They had asked the question “Do you think wider society stills thinks of medicine as a more ‘male’ profession?”. The answer really surprised me as 60% of people had said yes where only 31% had said no. Being female myself, I am not prejudiced against woman taking a higher stance in the professional world and am very proud of what women have done in the past in order to get to where we are today and the response shocked me by thinking that things had not progressed as far as I had previously thought they had.

Dr James Barry (Margaret Ann Bulkley)

Dr James Barry (Margaret Ann Bulkley)

This made me think about the history of women in medicine and I did a little research. I came across some extraordinary findings that a woman (Margaret Ann Bulkley) had pretended to be a man, taking the name of her late uncle (James Barry), for 46 years in order for her to become a doctor. She had to do this due to the fact that no British medical school admitted women and her passion to become a doctor drove her to the extremes that she went to. I find it quite sad that any person would have to pretend to be someone they are not just because a group of people do not accept women in jobs in the field of medicine. It is also upsetting to know that no one knew who she really was despite all of her great achievements; not only was she the first woman to graduate as a medical doctor in 1812 (even if it was in secret), but she was also the first British surgeon to perform a successful Caesarean section, saving the lives of mother and baby. After six months as a pupil at St Thomas’ Hospital in London, Bulkley decided to join the army to continue her career as an army medical officer. To read more about her story, here is the link:
http://www.dailymail.co.uk/news/article-527128/Unmasked-Britains-female-doctor-pretended-man-46-years.html

Another important figurehead for women in the medical profession is Elizabeth Blackwell, the first openly identified woman to graduate from medical school on 23 January 1849. She had managed to secure the necessary school funds by taking a job as a music teacher and studied in secret by reading medical books and getting private tutoring from Dr Jonathon M Allen. She applied to 12 schools and despite all of the rejection and resistance being thrown at her, she was accepted into Geneva Medical College in New York.

Elizabeth Blackwell

Elizabeth Blackwell

After graduating, Blackwell decided to go to Europe to pursue her career and was met with a lot of hostility but also met with a few people who were voluntarily willing to work with her. She was mentored by Paul Dubois, a famous obstetrician, who voiced his opinion that she  would make the best obstetrician in the United States. Unfortunately, when she was treating an infant with ophthalmia neonatorum (a form of conjunctivitis contracted by newborns during delivery), she spurted some contaminated solution into her own eye accidentally, and contracted the infection. This caused her to become blind in her left eye ultimately destroying her chances to become a surgeon.

Elizabeth Blackwell then returned to the United States to open up her own practice. She was once again faced with resistance and did not have many patients. She published a couple of books and in 1874 was successful in opening the London School of Medicine for Women. She became quite successful and took other aspiring female doctors under her wing to train. Even in her late years, she was still quite active and even published an autobiography on her life in the medical profession.

Even after reading all of this, it still left me shocked to see the response and perhaps even more so. I understand that men and women are still not treated as equals and hopefully one day that will change but the work women had to put in to do something that men could easily grasp makes me slightly angry. Why should it be harder for women? It is probably because in the past men were seen as the doctors and women were only the nurses and things are still commonly seen this way; especially with the older generations. This made me think of the first episode of ‘Greys Anatomy’ where one of the interns called the main character (Meredith) a nurse despite knowing that she was a fellow surgeon. Men could be and probably were resentful to women partly because of their gender but also because they would have been a threat if they were better than them. I am glad that things are changing and it is acceptable for women to be doctors and even for men to be nurses but I wish that more of the wider society would keep up with the times and think in the same way.

Thanks for staying with me during my rant,

Rachel.