Archive for March, 2014

March, 2014

The vital role of trees: from atmospheric chemistry to architecture

Dr James Levine

As an atmospheric chemist, I am interested in the influence that trees have on the quality of air we breathe and the climate we either enjoy or ‘weather’, depending on where we live.  First off, there’s the appealing synergy between people and trees: as we breathe in oxygen and breathe out CO2, trees draw down CO2 from the atmosphere and top up our oxygen supply.  If we have an immediate need for oxygen, we have a long-term need for a habitable climate, and trees again play a vital role.  In drawing down, or sequestering CO2, they reduce the burden of this greenhouse gas (GHG) that is at the forefront of our minds as we consider the climate our children, and children’s children, will inherit.  But trees have a further, much more subtle means of influencing both air quality and climate.

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The atmosphere is predominantly cleansed of gases harmful to human health, and some potent GHGs (e.g. methane), by a perhaps surprising simple chemical species, the OH radical (just an oxygen atom joined to a hydrogen atom).  Trees emit gases, so called volatile organic compounds (VOCs), that influence the abundance of OH radicals globally.  As part of Prof Rob MacKenzie’s group here at the University of Birmingham, I am involved in the Cooperative LBA Atmospheric Regional Experiment exploring the influence that the Amazon rainforest has in this regard; this is a collaboration with the University of Sao Paulo (Brazil), the University of Lancaster and the Centre for Ecology and Hydrology.  Of course, whilst trees affect the climate, the climate also affects trees; changes in climate also ‘feedback’ on the chemistry stemming from the VOCs trees emit.  Under Rob’s direction, the new Birmingham Institute for Forest Research will explore some of these feedbacks.  In particular, it is tasked with exploring the impact of climate change on UK woodland, both directly via changes in physical conditions (e.g. air temperature and humidity), and indirectly via changes in the incidence of, and resilience to, pests and disease.

I now have a confession to make: I lead a bit of a double life.  Atmospheric chemist by day, I’m an architecture student by night.  Trees and timber have important parts to play in architecture too, including one pertinent to reducing anthropogenic CO2 emissions.  Construction of the built environment, and the energy used to maintain a comfortable environment within it, account for around half the UK’s (and global) CO2 emissions.  If sustainably and locally sourced, timber embodies very little energy, or CO2 emissions; the CO2 locked up in the timber and ultimately released to the atmosphere (upon decay at the end of a building’s life), may be drawn down from the atmosphere by a tree grown in its place.  Timber construction is also readily compatible with approaches to radically reducing the ‘operational energy demands’ of maintaining a comfortable environment, reliant on high levels of insulation and air-tightness.  Built to the Passivhaus standard, for example, a house in the UK may require no more heating, year-round, than the warmth its occupants alone provide.  And it doesn’t stop there.

The use of trees and timber in architecture has a part to play in improving our quality of life and providing uplifting, life-affirming spaces.  Be it the oxygen they ‘breathe out’, the microclimates they yield, or the sense of well-being they inspire, research suggests trees benefit people living and working in their vicinity.  In schools, for example, they appear to increase children’s concentration and ability to learn.  The architect, Louis Kahn (1960), envisaged that “Schools began with a man under a tree who did not know he was a teacher discussing his realization with a few who did not know they were students.”  I wonder what role he imagined the tree played.  Did it simply provide shelter or did it also help cultivate a sense of security, that commodity which is recognised as key to learning?  We only have to look at David Nash’s Ash Dome  to see the potential the boughs of a tree have to offer both shelter and that peculiar sense of ‘rootedness’ a connection to the outdoors inspires.  For an exploration of the many and varied qualities we associate with trees and timber, Roger Deakin’s Wildwood – A Journey Through Trees makes a visceral and evocative read.

So what has motivated this brief reflection on the role of trees in relation to my dual interests in atmospheric chemistry and architecture?  It is the Trees, People and the Built Environment II conference, taking place in Birmingham this week.  Trees clearly have a vital role, be it at present or with a view to the future, and I look forward to learning in the next few days about many more, perhaps equally diverse, facets to this.

Kahn, L. I. (1960). Form and Design (1960). In R. Twombly (Ed.), Kahn (pp. 62-74). New York: W. W. Norton and Company.

Dr James Levine is a Research Fellow at the School of Geography, Earth and Environmental Sciences, University of Birmingham.

March, 2014

Starting a Conversation about Imperfect Cognitions. Lisa Bortolotti

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This week, Ema and I have been writing about some of the issues we are working on as part of the Epistemic Innocence project.

One of the goals of the project is to start a conversation about imperfect cognitions, among academics from different backgrounds, and involving also the general public. In this spirit, Ema and I created and are still developing a network of researchers (psychologists, philosophers, psychiatrists) interested in discussing the potential pragmatic and epistemic benefits of inaccurate beliefs and memories. The result is a lively blog, called Imperfect Cognitions, where people regularly post news about their research, submit relevant conference announcements and reports, and present new books in the field. We hope to further expand the network in the near future, and we are very proud that so far it includes researchers at different stages of their academic career, from graduate students to professors, and from different geographical areas.

Our first project-related event was a public engagement activity which Kengo Miyazono organised during the Arts & Science Festival at the University of Birmingham. On 17th March, we invited Dr Matthew Broome (Department of Psychiatry, University of Oxford) to talk to a general audience about his experience of the relationship between psychiatric diagnosis and responsibility for criminal action. He described an interesting case of a man attacking his neighbour as a result of suffering from delusions and hallucinations, and kicked off a lively discussion. The presentation was followed by discussion groups on the Anders Breivik case in Norway and other high profile cases of people whose accountability for criminal action has been assessed on the basis of the nature of their psychiatric symptoms or diagnoses. Additional information about the event and some follow-up resources have been made available to participants on the event website.

Another initiative we have promoted is an online reading group in the philosophy of mind and psychology hosted by the Philosophy Department blog at the University of Birmingham. Currently, we are reading an exciting new book by Jakob Hohwy (philosopher and cognitive scientist at Monash University in Melbourne, and member of the Imperfect Cognitions network). The book is entitled The Predictive Mind (OUP, 2013) and explores and defends the theory that the brain is essentially a hypothesis-testing mechanism, attempting to minimise the error of its predictions about the sensory input it receives from the world.

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And this is just the beginning… In October 2014, I shall start a new five-year project, funded by the European Research Council, and called PERFECT (Pragmatic and Epistemic Role of Factually Erroneous Cognitions and Thoughts), where the notion of epistemic innocence will be developed in collaboration with a team of postdoctoral researchers and PhD students. As part of PERFECT, I shall organise three academic workshops and three meetings with clinicians and service users, as well as a final two-day conference to explore all the implications of the notion of epistemic innocence for philosophy of mind and epistemology, psychological research into normal and abnormal cognition, and clinical interventions in mental health.

March, 2014

Saving Humans from Implicit Bias. Ema Sullivan-Bissett

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This week Lisa and I have been writing about our research on the Epistemic Innocence Project. This is the fourth in a series of five posts. I will be briefly discussing implicit bias, why it is harmful, and why investigating the epistemic status of implicit bias might be important when we are thinking about how to tackle it.

By implicit bias I will follow Jules Holroyd in meaning something like the following:

An individual harbors an implicit bias against some stigmatized group (G), when she has automatic cognitive or affective associations between (her concept of) G and some negative property (P) or stereotypic trait (T), which are accessible and can be operative in influencing judgment and behaviour without the conscious awareness of the agent. (Holroyd 2012: 275)

Worryingly, empirical work has shown that such biases are held by ‘most people’, even those people who avow egalitarian positions, or are members of the targeted group (Steinpreis et al. 1999). You can discover your own implicit biases by taking the tests here (warning: results may be very disconcerting!)

Implicit biases can affect decisions and actions, often negatively. For example, it is well documented that a female CV is rated less well than a male CV (even when those CVs are otherwise identical) (Steinpreis et al. 1999), and that when asked whether they saw a hand tool or a gun, participants who previously saw a black face instead of a white face are more likely to respond that they saw a gun (Payne 2006). The implications of this should be obvious: implicit biases put stigmatized groups at a distinct disadvantage.

In our project, one of the things we are interested in is the epistemic status of beliefs based on implicit biases. I think that at least some of these beliefs are what we are calling epistemically innocent. A belief is epistemically innocent if it meets the following two conditions:

1. Epistemic Benefit: The belief delivers some significant epistemic benefit to an agent at a time (e.g., it contributes to the acquisition, retention or good use of true beliefs of importance to that agent).

2. No Relevant Alternatives. Alternative beliefs that would deliver the same epistemic benefit are unavailable to the agent at that time.

I suggest some reasons for thinking some beliefs based on implicit bias meet these conditions, in my post on our project blog.

Let’s assume that I’m right about the epistemic status of beliefs based on implicit bias; that they are at least sometimes epistemically innocent. Why does this matter? I am interested in the following question: if beliefs based on implicit bias are epistemically innocent, does this have implications for how we ought to tackle implicit biases? I think the answer to this question is yes, which is why it is really important to work out whether beliefs based on implicit bias are, as I suspect, epistemically innocent. If they are, we need to rid them of this status, we need to make it the case that beliefs based on implicit bias are not epistemically innocent, and we should do this by making alternative beliefs available (that is, we should stop beliefs based on implicit bias from meeting the No Relevant Alternatives condition).

We should seek to make people aware of their biases, and more ambitiously, make it the case that they do not have them in the first place. One way to do this is to expose people to counter-stereotypes, studies have shown that expose to counterstereotypical exemplars (women, black people) can reduce implicit bias or the manifestations thereof (Saul 2012: 259) (examples of counterstereotypes include the photo of Martin Luther King above, and Marie Curie below).

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If beliefs based on implicit bias are epistemically innocent, such that alternative beliefs are not available, this suggests that we need to raise awareness of implicit bias, which might help us understand the phenomenon better and work towards controlling the influence it has over our beliefs, and present us with alternative epistemically more worthy, beliefs.

March, 2014

Distorted Memories and the Self. Lisa Bortolotti

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A distorted memory is a report of a past event where the past event is misrepresented in some key respect, for instance incorrectly located in place or time. There is no awareness of the distortion and, thus, no intention to deceive. Consider the following case. A woman with Alzheimer’s disease has a vivid recollection of walking on the beach with her parents. She believes the trip occurred that very morning, when actually the trip occurred sixty years earlier, when she was a girl. Such a memory is inaccurate and engenders a number of false beliefs (e.g., that the woman’s parents are still alive, and that she is still young). Thus, it has obvious epistemic costs. However, in a context in which access to autobiographical memories is limited and declining, as in dementia, one such vivid recollection may help the woman connect with important aspects of her personal history in the absence of other reliable information. Her distorted memory may be instrumental to her retaining some important information about herself, despite the gaps and the inconsistencies.

The book Contented Dementia by Oliver James argues that it is possible to enhance wellbeing in people with Alzheimer’s disease by not challenging and often actively encouraging the person to revisit memories and form beliefs that can be partially inaccurate. For instance, the person with dementia may present herself as “the able gardener” or “the good bridge player”, remembering her past achievements and erroneously believing that the relevant skills have been preserved. The proposed method requires that the caregiver be supportive of the person’s distorted memories and delusional beliefs in order to minimize stress, increase wellbeing, and build a working interpersonal relationship that is likely to bring mutual contentment. But the method is predictably controversial. Even if it were successful in achieving its goal, that is, making the life of people with Alzheimer’s disease more pleasant, the concern is that the whole life of the person with dementia may end up following a carefully worded script, involving many repetitions and deceptions. Many feel uneasy about this, because they sense that there is a trade-off: the person with Alzheimer’s disease attains happiness at the expense of knowledge, and her life lacks authenticity.

This is a well-rehearsed problem in psychology: Ulric Neisser argued that memory plays a double function, aiming at the same time at veracity and utility. As he and many others after him have observed, these two aims can conflict. We can feel better about a past event by putting a positive spin on that event, but the ensuing memory may not represent reality faithfully. The point we want to make in the Epistemic Innocence project is that the trade-off view of the relationship between pragmatic and epistemic benefits of distorted memories may be too simplistic. What if distorted memories played an important role in the retention of true beliefs about the self? This line of thought does not amount to a vindication of any specific approach to dementia care. It does not necessarily follow from this that distorted memories should go unchallenged, or that caregivers should live in the often delusional world of the people with dementia. Rather, the suggestion is that we should reconsider the role of memory distortions in the overall cognitive economy of the clinical population and of the individual, and make sure that interventions and interpersonal regulation are informed by what we discover about the epistemic features of distorted memories.

If you want to know more about how the Epistemic Innocence project addresses the issue of distorted memories, you can read relevant posts on the Brains blog and the Imperfect Cognitions blog.

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March, 2014

Saving Humans with Delusions. Ema Sullivan-Bissett

This is the second in a series of five posts Lisa and I are writing on our Epistemic Innocence Project.

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In this post I will write about delusional beliefs, whether they might be epistemically innocent, and why this matters.

Here is where we have got to with what we mean by epistemic innocence. A cognition is epistemically innocent if it meets the following two conditions:

1. Epistemic Benefit: The cognition delivers some significant epistemic benefit to an agent at a time (e.g., it contributes to the acquisition, retention or good use of true beliefs of importance to that agent).

2. No Relevant Alternatives. Alternative cognitions that would deliver the same epistemic benefit are unavailable to the agent at that time.

The fifth addition of the Diagnostic and Statistical Manual of Mental Disorders defines delusions as ‘Fixed beliefs that are not amenable to change in light of conflicting evidence […]’ (DSM-V). Examples of delusion include: thought insertion (these thoughts are not my own), Capgras (my husband has been replaced by an imposter), Cotard (I am dead), Somatoparephrenia (this is not my arm but my mother’s), erotomania (George Clooney is in love with me), perceptual bicephaly disorder (I have two heads). One of our network members, Richard Dub, has designed some great icons representing common delusions, which can be viewed here.

Delusional beliefs have a bad reputation when it comes to their complying with epistemic standards. They are usually false, lacking in empirical support, and are inconsistent with the subjects’ other beliefs and behaviour. With respect to the first inconsistency, during one interview, a subject with delusions claimed that her husband was a patient in the hospital where she was a patient, and that her husband had died four years ago and was cremated (Breen et al. 2000). With respect to the second inconsistency, that between the delusional belief and the subject’s behaviour, subjects with the Capgras delusion—the delusion that their loved one has been replaced by an imposter—may worry that their loved one has disappeared, but they may also act in a cooperative way with the alleged imposter (see Lucchelli and Spinnler 2007). Delusional beliefs may also be unresponsive to counterevidence. It is part of the DSM-V definition of delusions that they are ‘not amenable to change in light of conflicting evidence’ (DSM-V).

In the project we are interested in whether or not delusional beliefs meet the conditions on epistemic innocence. I think that they do, and suggest some reasons for thinking so in my post on the project blog.

Determining whether delusional beliefs are epistemically innocent might have ramifications for treatment in the clinical domain. Clinical interventions may be justified by the claim that they enhance the wellbeing of the patient, but whether this is true may well depend in part on the epistemic status of delusional beliefs. For instance, Daniel Freeman and colleagues suggest that ‘[c]hallenging or evaluating delusional explanations should be done only in the context of an alternative explanation that the patient finds acceptable’ (Freeman et al 2004: 679). If the patient with a delusion does not have an alternative belief available to explain the experiences she is having (No Relevant Alternatives condition), and further, if the delusional belief bestows some epistemic benefit she would not otherwise have (Epistemic Benefit condition), challenging the delusion may not be good for her wellbeing. It is in this sense that reflecting on epistemic innocence may inform clinical decisions.

March, 2014

The Stigma Associated with Mental Illness. Lisa Bortolotti

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In January 2014 in the UK a new parliamentary enquiry was launched into mental health equality. Mental health charities (Rethink Mental Illness and Mind) and the Royal College of Psychiatrists urged Parliament to investigate how the Government can give mental health equal priority to physical health and improve the quality of life of people living with mental illness. One issue affecting quality of life in general, and health services in particular, is the stigma associated with mental illness. What philosophers can do is to provide cogent arguments to undermine some of the widespread but inaccurate claims that contribute to the stigmatisation of people with mental illness, and inform both psychological research into psychiatric disorders and clinical interventions.

A commonly held view about mental illness is that those who suffer from it are different from the “normal” population in quite radical ways. It is controversial what the difference is. Those attracted to a strong medical model of mental illness tend to believe that people suffering from it are damaged and diseased, due to genetic predisposition or trauma and abuse. Those attracted to a forensic model of mental illness tend to believe that people suffering with mental illness are irrational, weak-willed and prone to other character failures. The radical difference view is that damage, weakness, or a combination of the two compromises the autonomous decision making of people with mental illness, and prevents them from making a valuable contribution to society.

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In the Epistemic Innocence project (funded by an AHRC fellowship awarded to me in September 2013, and featuring Ema as a research fellow), we aim to dispel some of the myths surrounding mental illness by arguing that the cognitions featuring as symptoms of psychiatric disorders (delusional beliefs, distorted memories, confabulated narratives) are on a continuum with cognitions we all experience on an everyday basis. They are “imperfect” as they can be inaccurate, they are not well-supported by the available evidence, and they are often not shared by others. But they may also have benefits of a pragmatic and an epistemic nature. It is widely recognised that, say, an inflated conception of myself will increase my confidence and make me feel better about myself (thus having some pragmatic benefits). But if such a conception of myself is false, it will lead to further false beliefs and inaccurate predictions, and the idea that it might contribute to the acquisition and retention of true beliefs (and thus have epistemic benefits) sounds implausible.

In the next four posts this week Ema and I will attempt to make this idea more plausible by describing how some imperfect cognitions have epistemic benefits and gain a sort of epistemic innocence. Our argument will apply to the beliefs, memories and narratives that are symptoms of mental disorders such as schizophrenia and dementia, but also to everyday beliefs, memories and narratives in the non-clinical population. Distortions of reality are a common feature of human cognition, not the exception to the rule, and any theory of the mind or account of mental illness that does not acknowledge this idealises the capacities of human agents and fails to meet the criteria for psychological realism.

The themes of the Epistemic Innocence project will be further explored in a workshop hosted by the University of Birmingham. It is entitled “Costs and Benefits of Imperfect Cognitions”, and will be held on 8th and 9th May 2014. The workshop will promote exchange between philosophers and psychologists on the potential pragmatic and epistemic benefits and costs of beliefs, memories, implicit biases, and explanations. It is funded by an AHRC Fellowship awarded to myself. The Analysis Trust provided bursaries to the graduate students attending. There may still be some places are available should you be interested (just contact Ema by March 27th at the latest). Speakers include Katerina Fotopoulou (Senior Lecturer, Psychoanalysis Unit, Psychology and Language Sciences Division, University College London), Martin Conway (Professor and Head of the Department of Psychology, City University London), Ryan McKay (Senior Lecturer, Department of Psychology, Royal Holloway) and Maarten Boudry (Post-doctoral Researcher, Philosophy, University of Ghent), Miranda Fricker (Professor of Philosophy, University of Sheffield), Jules Holroyd (Lecturer in Philosophy, University of Nottingham), Petter Johansson and Lars Hall (members of the Choice Blindness Group, Philosophy and Cognitive Science, University of Lund).

Our plan for the week is as follows. Ema will talk about epistemic status of delusional beliefs on Tuesday (tomorrow), I shall address the potential benefits of distorted memories on Wednesday, and Ema will come back on Thursday to discuss beliefs based on implicit bias. On Friday, I shall tell you about what else we are doing to engage junior and senior researchers from different disciplinary backgrounds and the general public in the themes of the project.

March, 2014

Next week’s bloggers of the week. Ema Sullivan-Bissett and Lisa Bortolotti

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Lisa Bortolotti (right hand avatar) is Professor of Philosophy at the University of Birmingham. Ema Sullivan-Bissett is a doctoral candidate in Philosophy at the University of York and Research Fellow in the Philosophy Department at the University of Birmingham. Lisa and Ema work in Philosophy of Mind and Epistemology, and are especially interested in beliefs and delusions. They are currently working on the Epistemic Innocence project, funded by an AHRC Fellowship awarded to Lisa last September. Next week they will be blogging about the project and its wider societal implications.

March, 2014

Surviving Burns and Overcoming Burns

Dr Jonathan Reinarz

One of the most interesting aspects of burns work undertaken by Archibald McIndoe during the Second World War (see Wednesday’s post) was the establishment of the Guinea Pig Club. The Guinea Pigs were members of WWII Royal Air Force air crews who had undergone at least two operations for their burns injuries at East Grinstead Hospital, where McIndoe was based. Originally intended to be a drinking club for patients whose injuries could be dangerously dehydrating (see Monday’s post), it counted 39 members at its launch in June 1941, a year after the Battle of Britain. By the end of the war, there were 649 Guinea Pigs, most of whom were British (62%), but it also included Canadians (20%), Australians (6%) and New Zealanders (6%); 80% had served as bomber crew during the war. As war historian Emily Mayhew has suggested, the Club was ‘an attempt to institutionalise the unique spirit of the patient community at East Grinstead’ in order to aid the psychological recovery of burn victims. Patients collectively attended operations, assisted newcomers and otherwise offered support to each other when necessary.

‘Dealing with Disfigurement’

Rather than hide away these severely disfigured airmen, McIndoe considered both their physical and (as he termed it) psychical wellbeing. He recognised that patients relied on their surgeon ‘for mental support, for hope and encouragement.’ But he also encouraged his patients to resume ordinary lives, often commencing with a joint visit to a local pub. Most wanted to resume normal lives, but their wounds often made this more difficult than expected. McIndoe knew that his patients would inevitably attract much attention the moment they ventured into town to frequent pubs or restaurants, so he prepared the residents of East Grinstead for potential encounters with patients, some of whom were mid-operation, with tube pedicle grafts nearly in place to reconstruct missing chins or noses. He also invited key members of the town into the wards, encouraging them to become ambassadors in the community by regularly hosting concerts and balls, where patients mingled with locals. In this way, he made the residents of East Grinstead recognise and accept his patients and focus on their contributions to society, rather than their disfigurements. In the process, East Grinstead became known as ‘the town that didn’t stare’, while the hospital developed an international reputation for its Maxilla-Facial Unit. The staff was so successful at its work that 80% of aircrew patients eventually returned to flying duties. Such success continued into peacetime, but the details of McIndoe’s civilian work has been less documented. Despite the positive experiences of East Grinstead Guinea Pigs, many inevitably faced challenges when they re-entered their former communities. That said, many had learned how to deal with these difficult encounters from their membership of the Guinea Pig Club; a group of about 60 original members continue to meet.

Psychological support for burns patients has continued to grow since 1941. The emotional load on staff at burns units has also been recognised, with many practitioners expressing their own challenges coping with the onerous duties involved in caring for these unique patients. Unusually, when Guinea Pigs visited America following the war, their faces were kept out of the press for fear of alarming the public. Americans would inevitably learn about the psychological impact of burns in their own ways. The 1942 Coconut Grove nightclub fire in Boston was not the worst urban fire in twentieth-century America, but it had a huge impact on burns treatment. Besides directing attention to the consequences of inhalation injury, it provided valuable insights into the immediate and long-term psychological impact of severe burns and the importance of supporting patients after their physical wounds healed. As obvious as some of these lessons were, it seems they need to be relearned every decade or so. More often these days, the memories of disasters, collective and individual, are kept alive by patient groups. Many American victims of burns and scalds owe their emotional recovery to the Phoenix Society for Burn Survivors, a national organisation dedicated to burns patient support, public education and advocacy.  In Britain, patients with burns receive the support of similar organisations, including Changing Faces, BurnAid and the Katie Piper Foundation. So successful have burns units become at saving humans that their challenges have shifted. Many victims now expect medical teams to save lives and even restore former appearances. It is with such expectations that support groups also help a new generation of patients.

New portrait of Simon Weston recently unveiled at the National Portrait Gallery.

New portrait of Simon Weston recently unveiled at the National Portrait Gallery.

Jonathan Reinarz wishes to thank Emily Mayhew, Rebecca Wynter, Naiem Moiemen, Tony Metcalfe, Shah Mamta, Ken Dunn and James Partridge for their help with his research.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

Burns and Infections: The Birmingham Accident Hospital

Dr Jonathan Reinarz

Nearly 60% of burns patients die of infections contracted after their initial injuries. Historically, burns-related infections have proved particularly challenging. Burn wounds contain devitalised tissue and remain moist and warm during the healing process, thus an excellent breeding ground for bacteria. In the early twentieth century, burns did not appear to respond to existing antiseptic methods. Many doctors believed that burns themselves released toxins and attempted to neutralise these by treating burns with dyes and acids, which often hindered recovery. As a result, many practitioners continued to regard the infection of burns as inevitable.

In the 1940s, important research in this field began to be undertaken in the English midlands at Birmingham Accident Hospital. When an existing general hospital on Bath Row in the city centre was moved to facilities behind the newly constructed Birmingham Medical School in 1938, the old site was renovated and reopened in 1941 as the Birmingham Accident Hospital. (Incidentally, the site was also the last voluntary (or charity) hospital established in England and Wales before the introduction of the National Health Service). The new hospital’s Surgeon-in-Chief and Clinical Director William Gissane (1898-1981) regarded this as an experiment in the care of trauma in order to improve local accident services, which were inadequate across the country. At the outbreak of the Second World War and the associated production of military hardware, this had become obvious; the incidence of local industrial injuries, including burns, increased by 40%. During 1943, a small unit to treat burns and scalds was opened, and Gissane invited Leonard Colebrook (1883-1967) to be its first Director. Like Gillies (see yesterday’s post), Colebrook was a veteran of the Great War and contributed to a Government-appointed war wounds sub-committee run by Archibald McIndoe during the Second World War. Colebrook had investigated the bacteriology of wounds at the burns unit at Glasgow Royal Infirmary, where he had previously investigated puerperal sepsis in maternity cases. He therefore had experience of both burns and streptococcal infections when called on by Gissane to run the Medical Research Council-funded unit.

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‘The Topical and the Local’

On arrival, Colebrook quickly turned to the investigation of streptococcus infections in burns. With new topical anti-microbial agents, such as penicillin and propamide, he and his team managed to reduce the prevalence of these infections to 5%. Controlling infection, whether through topical creams, or ventilated wards and bandaging stations, allowed for new burns treatments, such as early excision, which is still described as an important measure to prevent infection as well as disfiguring contractures. When he retired in 1948, Colebrook turned to organising local and national burns prevention campaigns, focusing, for example, on safer electrical heaters and the introduction of less flammable clothing for children.

Colebrook’s successor was Edward Lowbury (1913-2007), who became bacteriologist at what was later renamed the MRC Industrial Injuries and Burns Research Unit in 1952. Among other things, Lowbury initiated the first properly controlled clinical trials in burns, and infection rates continued their downward trend, until the emergence of antibiotic-resistant bacteria in the late-1950s. The introduction of silver nitrate in 1966 halted this rise, but rates would continue to fluctuate, as safer alternatives were introduced. By 1963, the burns unit had already become a large regional centre comprising 36 beds, a ‘clean air’ dressing station and expanding research facilities, with Lowbury compiling a unique record of resistance changes until his retirement in 1979. Treating over 18,000 burned patients between 1941 and 1993, the burns unit developed a planned, systematic approach to the treatment of these injuries, which greatly reduced the frequency of associated infections.

Problems of infection in hospitals in the wider Birmingham region led to the establishment of the Hospital Infection Research Laboratory in the grounds of Dudley Road Hospital (later City Hospital) in 1964. Administered by the MRC Burns Unit and under the direction of Lowbury, the laboratory assessed the number of infections in regional hospitals, determining causes when possible. Although the Accident Hospital closed its doors in 1993, the Infection Control Research Laboratory continues to exist in a new location. Many of its earlier recommendations for controlling infection are still in place today. With the laboratory celebrating its 50th anniversary this year, staff have organised a commemorative conference, and the History of Medicine Unit at the University of Birmingham has organised an exhibition on ‘the history of hospital infection’, which will be on display in the foyer of the Medical School until the summer.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

 
March, 2014

War burns and the birth of plastic surgery

Dr Jonathan Reinarz

The majority of historical research into burns has concentrated on the remarkable reconstructive work undertaken on burns casualties during the First and Second World War. In fact, some argue that plastic surgery as a specialty first emerged during the First World War. Soldiers in both wars sustained horrific injuries and dreadful deformities from high velocity missiles, explosives and burns, many of which would previously have defied repair. A young ear, nose and throat (ENT) surgeon from New Zealand, Harold Delf Gillies, began the war in a surgical unit at the Cambridge Hospital, Aldershot. Alarmed by the number of face and jaw reconstructions he was having to perform, Gillies visited two plastic surgeons in France before setting up a larger surgical unit in 1917 at Sidcup, where he brought together a team of specialists, including ENT colleagues and dental surgeons. Gillies is best remembered for the tubed pedicle, a flap of skin which was harvested from the arm or chest, for example, stitched into a tube, so as to retain a blood supply and gradually migrated to the area where it was required. By the end of the war, Gillies had developed many other surgical techniques and performed over 11,500 operations. Many of these are included in his best known publication, Plastic Surgery of the Face (1920), which, along with Gillies’s archives, has recently been digitised and made available online as part of activities to mark the centenary of the First World War.

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From Airman’s Burns to Hiroshima

In one of those accidents of history that historians have become used to over the years, many severe burns in the Second World War were placed in the hands of another young surgeon, Archibald McIndoe, who happened to be the cousin of Harold Gillies. Unlike most of the casualties seen by cousin Harold, McIndoe treated primarily flame injuries that largely resulted from a decision to relocate the petrol tanks of fighter aircraft in front of the cockpit and pilot. The consequences of placing 48 gallons of fuel in the nose of a Spitfire rapidly became apparent during the Battle of Britain in 1940, when burn casualties mounted and the medical community defined a new injury, ‘Airman’s Burn’. Nearly 400 Royal Air Force (RAF) crew sustained serious burns to their face and hands in 1940 alone, Richard Hillary becoming perhaps the best known due to his memoir, The Last Enemy, in which he described his injuries.

‘I looked at my watch: it was not there. Then for the first time I noticed how burnt my hands were: down to the wrists, the skin was dead white and hung in shreads: I felt faintly sick from the smell of burnt flesh.’

While the smell of burn victims and high fatality associated with serious burns had led many to be isolated, removed or even excluded from nineteenth-century hospital wards, Hilary was lucky to be treated in a specialist burns unit by one of only four plastic surgeons operating in Britain at this time (including Gillies who would spend his second war at Park Prewitt Hospital in Basingstoke). Appointed civilian consultant surgeon to the RAF, McIndoe became responsible for Hillary and many other air-force casualties at a surgical unit which was established in a cottage hospital in East Grinstead, 40 miles outside of London. Here, he treated hundreds of burned airmen and developed surgical techniques in order to improve on existing plastic surgery techniques, which often left much to be desired. According to Mcindoe, in these early years of reconstructive surgery ‘the end result seemed to convert the pathetic into the ridiculous’. Rarely satisfied with his first attempts, McIndoe worked 12-hour days and frequently subjected his patients to more than a dozen operations. He rapidly became recognised as the authority in the field, influential in developing new operations and discarding older treatments, such as the use of tannic acid to coat burns injuries. He hosted many visiting surgeons at East Grinstead, which had trained 60 surgeons by 1943, and secured his reputation in 1944 when 50 North American plastic surgeons attended his unit for ten days to train in preparation for the D-Day landings. He also increased the levels and training of nurses on his wards and introduced saline baths into burns treatment.

After the 1945 atom bomb attacks on Japan, the attention of doctors turned to the impact of modern warfare on both military and civilian casualties. McIndoe himself argued that burns would likely outnumber all other injuries in future wars. McIndoe’s colleagues similarly promoted such ideas, suggesting that ‘atomic flash’ burns necessitated whole hospitals be transformed into burns units, arguments reinforced in the aftermath of Hiroshima and Nagasaki and during the Cold War. Many more units like that at East Grinstead were established in the 1950s, and McIndoe continued to work in his 50-bed Burns Centre at East Grinstead until his retirement in 1959. In a lecture to the Royal College of Surgeons in 1958, he comprehensively outlined his views on reconstructive surgery and paid homage to ‘the greatest plastic surgeon of all times’, Harold Gillies. McIndoe died in 1960, aged 59. A statue is being planned to recognise his work; if realised this will be one of only three existing British public monuments in England commemorating surgeons.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

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