Section 1: Medicine Through Time Theme 1: Disease and infection 1 Medicine in the ancient world, c. 10,000BC–c

AQA (A) GCSE Schools History Project: Exam practice answers

• 
  the theory of the four humours
  
• 
  germ theory
  

Unfortunately, the idea wasn’t completely for the best because some of the treatments used in this theory may have been dangerous, and may have killed people. This theory dominated medicine for around 2000 years partly because, when the theory gained the backing of the Roman Catholic Church, it became the orthodox approach to medicine so it was a dangerous heresy to challenge its truth. Research into other ideas may have stopped, or considerably slowed down, so it held back progress in finding cures and developing scientific medicine. However, although it did play an important part in the future development of medicine as the theory focused attention away from supernatural, spiritually based ideas about the cause of disease and treatments, I do not think the theory of the four humours was the most important contribution that the Greeks made to the history of medicine. There are other aspects such as the Hippocratic Oath or clinical observation.

Germ theory was proved by Louis Pasteur who published his findings in 1861. He showed that germs were the cause of disease in a scientific way. He used swan-necked flasks to show that germs in the air caused liquids to go bad and then went on to show that germs caused disease in animals. This clearly disproved the previously held belief in spontaneous generation as the cause of disease and decay. In this theory, the germs that could be seen under microscopes when something went bad or rotted were the result, and not the cause, of disease. Pasteur showed this was wrong. The discovery of germ theory also started the science of bacteriology and set scientists looking for the specific germs responsible for so many killer diseases. One such scientist was Pasteur’s rival, Robert Koch. It was Koch who went on to develop the tools of the germ hunters as well as finding the germ for tuberculosis, a disease that condemned thousands to a slow death.

The implications of germ theory in the 1860s were profound and affected all areas of medicine. In the field of surgery Joseph Lister realised why hospital infections happened in otherwise successful surgery and as a result took measures to make operations safer through the use of antiseptics. In the field of public health, when governments realised that germs caused disease and illness was not due to miasma or bad air, the prevention of disease by providing effective public health facilities was given a big boost. Germ theory explained so many things such as why Jenner’s vaccination worked and why John Snow was right about cholera.

In the beginning the theory of the four humours was a great leap forward to a more rational and natural explanation of disease, but the longer it was believed, the more it became an unchallengeable orthodoxy that held back progress and a more scientific approach to medicine. On the other hand germ theory was the most important development in the history of medicine. It explained so much about disease and opened up the way for many cures. We have built modern medicine on the foundations laid by germ theory.
Exam practice (page 21)

3b. Which of these two individuals contributed more to the treatment of disease and infection?

• 
  Louis Pasteur
  
• 
  Robert Koch
  

Whilst conducting experiments for the French wine industry in 1857–61 Louis Pasteur, a research chemist, managed to prove that airborne germs were causing the wine to sour. Although Pasteur’s findings were not universally accepted this was a breakthrough and Pasteur went on to demonstrate that germs were responsible for certain animal diseases, such as those found in silkworms.

Pasteur went on to build a skilled research team and, as a result of chance, one of them, Charles Chamberland, chanced upon a vaccine for chicken cholera when a batch of chickens were wrongly injected with a weakened dose of the chicken cholera germ. The process of vaccination had been known about since Edward Jenner had discovered the smallpox vaccine in 1796 but no one knew how it worked. Pasteur and his team managed to show how injecting a weakened strain of a disease built up the body’s defences so that it recognises and is able to fight off a stronger strain of the disease when exposed to it. Pasteur and his team continued to work on this technique so that vaccines against anthrax and then rabies were quickly developed.

Pasteur’s main rival at this time was a German doctor, Robert Koch. Germany had only just defeated France in the Franco-Prussian War and both men were spurred on by national, as well as personal pride. In the 1870s Koch took Pasteur’s work a stage further when he devised a technique for making germs visible using a microscope and an industrial violet dye. This was particularly important since there were those who doubted the validity of Pasteur’s work and even the existence of germs. Now, Koch had at last provided irrefutable proof of invisible, airborne germs.

Like Pasteur, Koch led a highly skilled research team and they went on to photograph and classify different germs. Koch called his work ‘microbe hunting’. In 1882 Koch and his team identified the specific germ that causes tuberculosis. Koch’s work was highly influential and other scientists such as Paul Ehrlich and Sacahiro Hata began using his methods: within twenty years the germs that cause typhoid, diphtheria and pneumonia had been identified.

I think that Louis Pasteur made the greatest contribution to the battle against infectious disease because his work provided the initial breakthrough. Although Robert Koch’s work contributed more directly to saving human lives with the discovery of the tuberculosis and cholera germs, for example, Koch would not have been able to do this work without Louis Pasteur laying the foundations of germ theory: with his work for the French wine industry and with vaccines for animal diseases.

• 
  Ambroise Paré
  
• 
  William Harvey
  

As an army surgeon Paré developed a new treatment for gunshot wounds. The usual method was to cauterise them with a hot iron and boiling oil. This was painful and disfiguring. By chance, Paré ran out of cauterising oil as a group of wounded soldiers were admitted to his hospital. For some time he had been considering an alternative treatment based on a soothing ointment made from egg yolks, turpentine and rose oil, but had not yet tried it out. With no alternative, Paré applied the ointment to the soldiers’ wounds. His patients recovered with less pain and wounds healed better. Paré went onto use a new method to stop patients bleeding: he used ligatures made of silk threads to suture or stitch wounds and also pioneered the use of artificial limbs. His book Works on Surgery (1575) contained descriptions of his methods and detailed drawings. It became very popular and was translated into many languages in Europe and the Middle and Far East.

However, Paré did not completely remove pain from surgery. His use of anaesthetics was limited and patients felt pain as their wounds were sutured. Paré did not use antiseptics and the silk threads used for the ligature could introduce infection into the body. Although much of modern surgery may have its origins in Paré’s work, he was not particularly influential in his lifetime. Firstly, many surgeons preferred to operate at speed and found Paré’s methods fussy and slow. Secondly, most of Paré’s contemporaries had been to university and felt that they had little to learn from an uneducated barber surgeon. In any event Paré and his ideas were initially ignored.

William Harvey contributed to knowledge about the structure and working of blood in the human body. Harvey conducted a series of scientific experiments on such animals as rabbits and reptiles and discovered that blood is pumped around the body by the heart. This circulation of the blood theory disproved Galen’s idea, which had stood largely unchallenged for almost 1500 years, that the blood was a fuel that was burned up by the body. Harvey kept detailed records of his observations and experiments and these became the basis of his book, On the Motion of the Heart and Blood, published in 1628.

Although Harvey had received a university education his ideas also met with resistance. Firstly, Harvey could not explain how blood moved from the arteries to the veins as there were no microscopes available at the time powerful enough to see the capillaries. As a result Harvey’s circulation model was incomplete and challenged by those who clung to Galen’s ideas. Secondly, Harvey’s work did not help doctors cure their patients and was largely ignored as doctors continued to prescribe treatments based on the four humours. This is shown by the treatment given to King Charles II in 1685. No one would benefit from Harvey’s circulation of the blood theory until blood groups were identified by Karl Landsteiner in 1901 and blood transfusions became possible. Consequently it took at least 50 years for Harvey’s work to be accepted and taught to medical students in universities.

Comparing the contributions of Paré and Harvey to the development of surgery and anatomy, Harvey stands out. Paré made practical suggestions that directly helped patients. His work was done through trial and error and, of course, chance. Harvey, on the other hand, used a more scientific approach and was more of a Renaissance figure. Paré directly helped his patients, whereas Harvey helped other doctors and scientists, though not immediately. Harvey’s work had a long-term impact and contributed to the knowledge that doctors, scientists and surgeons use today, while Paré’s work was limited in its impact, had defects in practice and contained risks as with the use of ligatures. Harvey’s work remains valid today whereas Paré’s has long been overtaken.

• 
  Ambroise Paré
  
• 
  Andreas Vesalius
  

While serving as an army surgeon Paré developed a new treatment for gunshot wounds. At this time the usual method used to treat gunshot wounds was to cauterise them with a hot iron and boiling oil. This was painful and produced ugly, disfiguring scars, although it did act against the poisoning effect of the gunshot wound. Paré doubtless learned this technique by observing other battlefield surgeons. By chance Paré ran out of cauterising oil as a group of wounded soldiers were admitted to his hospital. For some time Paré had been thinking about trying an alternative treatment based on a soothing ointment made from egg yolks, turpentine and rose oil, but had not yet tried it out. With no alternative, Paré applied the ointment to the soldiers’ wounds and found that his patients recovered with less pain and that their wounds healed more neatly. Paré went on to use a new method to stop patients bleeding. He used ligatures made of silk threads to suture or stitch wounds and also pioneered the use prosthetics or artificial limbs. His book Works on Surgery published in 1575 contained descriptions of his methods and detailed drawings of artificial hands with mechanical levers replacing the fingers. Works on Surgery became very popular and was translated from its original French into many languages in Europe and the Middle and Far East.

Nevertheless, Paré did not completely remove pain from surgery. His use of anaesthetics was very limited and patients felt pain as their wounds were sutured and in the post-operative recovery. Paré did not use antiseptics and the silk threads used for the ligature could introduce infection into the body. Although much of modern surgery may have its origins in Paré’s work, he was not particularly influential in his own lifetime. Firstly, many surgeons preferred to operate at speed and found Paré’s methods fussy and slow. Secondly, most of Paré’s contemporaries had been to university and felt that they had little to learn from an uneducated barber surgeon. In any event Paré and his ideas were initially ignored.

A contemporary of Paré, Andreas Vesalius, made his contributions to the study of the structure and working of the human body and corrected many of the long-standing errors based on the works of Galen, who had been the authority on surgery and anatomy to this point. Influenced by the Renaissance spirit of observation, enquiry and experiment, Vesalius decided to repeat Galen’s investigations into anatomy. Unlike Galen who only dissected animals such as apes, dogs and pigs, Vesalius was able to dissect human corpses and in doing so discovered several of Galen’s mistakes. For example, Vesalius discovered that the human jawbone has one part, not two as Galen had said because he had only studied apes. Similarly, the human kidneys are located side by side and not, as Galen said, one on top of the other as they are in dogs.

Vesalius’ findings, which he published in his book The Fabric of the Human Body in 1543 marked the beginning of the end of Galen’s dominance of medical knowledge, but as with Paré, Vesalius’ impact was limited in his lifetime. This was because many doctors and scientists would not accept that Galen could be mistaken. Vesalius was seen as some arrogant upstart for daring to suggest that he was. Finally, Vesalius’ work was seen as having little practical value. Doctors were unable to use Vesalius’ anatomical drawings to cure their patients and so The Fabric of the Human Body was largely dismissed.

So who contributed the most to the development of surgery and anatomy, Paré or Vesalius? Paré made practical suggestions that directly helped patients. His work was done through observation, trial and error and, of course, chance. Vesalius, on the other hand, used a more scientific approach and was more of a Renaissance figure. Paré helped his patients by relieving some of their pain for example, whereas Vesalius helped other doctors and scientists but not for some time. Vesalius’ work had a long-term impact and contributed to the knowledge that doctors, scientists and surgeons use today, while Paré’s work was limited in its impact and had defects in practice and contained risks such as the use of ligatures, which could introduce infection into the body. Vesalius was anatomically correct and his discoveries are still valid whereas Paré’s work has been superseded.

• 
  war
  
• 
  science and technology?
  

Although war is usually seen as devastating and disruptive, throughout history there have been examples of warfare contributing to advances in certain fields, including surgery. War was common in the Middle Ages and surgeons had no shortage of wounded soldiers on whom they could practise new techniques and methods. It was during the Middle Ages, for example, when wine was first used for cleaning wounds and opium was introduced as an anaesthetic. In the sixteenth century Ambroise Paré introduced a new method of treating wounds using a soothing ointment rather than cautery irons, and although this development is normally regarded as the result of chance, Paré was working as a surgeon in the French army when the opportunity to test his idea was presented to him.

During the First World War, blood groups were identified and successful blood transfusions were first performed. Similarly, a method of storing blood for later use using sodium citrate to prevent the blood from clotting was first introduced at this time. The discovery of how to mass produce penicillin by Howard Florey and Ernst Chain was made during the Second World War, so that penicillin could be given to wounded Allied soldiers after the D-Day landings in June 1944.Techniques for plastic surgery and skin grafting were pioneered in the First World War and further developed by Archibald Macindoe in the Second World War. War has driven notable developments in reconstructive surgery – a direct result of modern-day conflicts in Iraq and Afghanistan has been the rebuilding and replacement of shattered limbs caused by improvised explosive devices.

The role of science and technology in the development of surgery cannot be ignored. Wilhelm Röntgen discovered X-rays in the early twentieth century and this enabled doctors to look deep into the human body without cutting into it. Modern-day cancer treatments are rooted in early-twentieth-century physics and the work on radiology pioneered by Marie Curie.

In the 1950s and 1960s transplant surgery was introduced. Science and technology contributed to developments here through not only the manufacture of precision tools, but also in life-support apparatuses that enabled the patient to be kept alive while vital organs such as the heart and lungs were removed. Powerful antiseptics and auto-immunosuppressants to prevent the rejection of foreign tissue have been developed by drug companies, and these have proved so effective that complex operations such as heart transplants (first done successfully by Christiaan Barnard in 1967) are now possible. Surgeons today prefer to operate without making large cuts in the body and wherever possible operate through tiny incisions. This keyhole surgery uses fibre optic cables containing cameras and lasers instead of knives or scalpels.

So which of these two factors, war or science and technology has contributed the most to the development of surgery? Science and technology has undoubtedly made significant contributions including those necessary for successful transplants, and while some of these have come about as a result of war, such as the mass production of penicillin, it is doubtful whether many of the advances made in wartime such as the discovery of X-rays or the improvements in prosthetic surgery could have been sustained without the support from science and technology.