TheHistoryofMedicine

byRochelleForrester

Copyright2015RochelleForrester
AllRightsReserved
Themoralrightoftheauthorhasbeenasserted
Anyonemayreproducealloranypartofthispaperwithoutthepermissionoftheauthorsolongasafull
acknowledgementofthesourceofthereproducedmaterialismade

emailrochelle.fo@xtra.co.nz

Published23June2015

Preface

Thispaperwas writtenin order toexamine the orderof discovery of the significantdevelopmentsinthe

historyofmedicine.Itispartofmyeffortstoputthestudyofsocialandculturalhistoryandsocialchange
ona scientificbasis capableof rationalanalysisandunderstanding.Thishasresultedinahardcopybook
HowChange Happens: A Theoryof Philosophyof History, SocialChange and CulturalEvolution
anda
numberofwebsitessuchas
HowChangeHappensand
HowChange HappensRochelleForresters Social
Change, Cultural Evolution and Philosophy ofHistorywebsite
.There arealsopaperson
Academia.edu
,
Figshare
,
Mendeley
,
Vixra and
Social Science Research Network websites and other papers on the
Discovery of Agriculture
, t
he Discovery of the Atomic World and the Constituents of Matter
, and on
GuttmanScaleAnalysisanditsusetoexplainculturalEvolutionandSocialChange
.

Tableofcontents

Chinesemedicine
IndianMedicine
GrecoRomanMedicine
DarkAges
ArabMedicine
MedievalEuropeanMedicine
TheRenaissance
CirculationoftheBlood
JennerandVaccination
TheDiscoveryofAnaesthesia
TheGermTheoryofDisease
Antiseptics
Antibiotics
MedicalStatistics
DiagnosticTechnology
ModernSurgery
Analysis

Illness and injury are as old as humankind.Stone agehumanremainsshowevidenceofdiseases

such as arthritis, tuberculosis, inflammations, dental problems, leprosy bone tumors, scurvy, spinal
tuberculosis, cleft spine, osteomyelitis,sinusitisand various congenital abnormalities andinjuries.These
diseasesshowin human skeletalremains andif morecompletehumanremainswereavailable,itislikely
a muchgreaterrange of diseasewould be apparent. Given that humanbeings donotlikepain,deathand
sufferingtherewasaclearneedtotryandfindacurefordiseasesandinjuries.
Thecuring and preventionof diseaseofteninvolvesanexplanationofthecauseofthedisease.In
theabsence ofknowledgeofgerms,bacteriaandviruses andofhumananatomyandphysiologystone age
humansascribed disease, injuries and death tosupernaturalforces,justasotherinexplicableeventssuch
as storms,earthquakesand volcaniceruptions wereconsidered tobe caused bysupernaturalforces.This
lead to the need for a method of influencing the supernatural forces which required a person with
knowledge of the supernatural world who could communicate with and placate the godsor spirits that
causedthediseaseand injury.Priests,shamans,witch doctors andmedicine menwere often responsible
forprotecting the health of stone agehumans bymeans ofappropriateritualsandspells.Acavepainting
of whatisconsideredtobeaStoneAgemedicinemandatingfromaround15,000BCisonthecavewalls
ofthe
LesTroisFreres
caveinthePyrenees.
Stone Age medicine men would mostlikely havesupplemented their spellsandrituals with the
use of various herbs, roots, leaves and animal parts and other medicines. Given the bodys natural
tendencytohealitselfandplaceboeffects,itwouldhavebeendifficultforprehistorichealerstoworkout
whether theirspells andherbs wereactually working.Onlyin recent timeswithmodernwrittenrecords,
statistical techniques and double blind studies involving control groups, can it be reasonably clear if a
particularmedicineisworking.
Theearliestclearexample of asurgicaloperationistrepanningwhichinvolvesboringaholeinto
the skull. This operation was firstcarriedout inNeolithic timesusingstonetools.Some of the patients
survived as shown by healing around the holes and some skulls even had severalholesbored inthem,
indicating repeated operations. It is not clear why such a painful operation was carriedout, butitmay
have been to allow evil spirits that were causing migraines, epilepsy or madness to escape from the
patients skull.Itis alsolikely other surgicaloperations,such asthe lancingofabscessesandthesewing
upofwoundswithboneorflintneedles,wereperformed,butthereisnoclearevidenceofthis.
Whennomadichuntergatherersfirstbegantosettleinpermanentvillages,whichgrewintotowns
and then cities, new health problemsarose. Large numbersof people concentrated in small areas meant
disease would quickly spread through populations. The domestication of animals resulted in many
diseasesspreadingfromanimalstohumanssuchasmeasles,smallpoxandtuberculosisfromcattleandflu
from pigsanddogs. However afurther resultfromlivingin citieswasthedevelopment ofwritingwhich
allowed amoreorganizedmedical profession and the possibility ofaccurate recordingofsymptomsand
remedies.
WritingbeganinMesopotamiabefore 3,000 BCwhen itwasinventedby theancientSumerians.
TheSumerianswroteonclaytablets and onesuch tabletcontainslistsofdrugs,chemicalsubstancesand
plants used for medical purposes. Magic and religion however played a major role in Mesopotamian
medicineasinjuryanddiseasewereconsideredtobecausedbyGods,demons,evilspiritsandwitchcraft.
Numerous magic spells, incantations and sacrifices were available to combat particular diseases and

correct recitation was necessary for an effective cure. Whether apatientwould survive ornot couldbe
divinedbyexamining the liver of asacrificedsheep or goat. The Code of Hammurabi,a lawcodemade
by a Babylonian King, sets out medical fees for various services and penalties for errors made bythe
doctor. Servicesreferred to involvedtheopeningof anabscess,the treatmentofbrokenlimbs,eyesand
intestinalcomplaints.
Our knowledge of ancient Egyptian medicine comes from certain medical papyriandfrom the
embalming of Egyptian dead. The papyricontainvariousdescriptionsofmagicspells designed todrive
out the demon causing a particular disease and of various prescriptions, including the dosage for
particular diseases. Drugs used included castor oil, hartshorn, bile and fat from animals and copper
sulphate. Treatmentwas prescribedforwounds and bruisesandsurgicalinstrumentsappeartohavebeen
usedandbrokenbonesweretreatedwithsplints.
The Egyptian practice of embalming and the favorable conditions of Egypt for the natural
preservation of bodies shows us some of the diseases the Egyptians suffered from. Arthritis and
inflammation of the periosteum and osteomyelitis were common. Spinal deformations and spinal
tuberculosis, gout and virulent osteomas have been found in Egyptian mummies. Tooth decay was as
common as inmoderntimesandthereisgoodevidenceofkidneystonesandgallstones,appendicitisand
stomachandintestinaltroubles.The lowerclasses inparticularsufferedfrom infectious diseasessuchas
plague,smallpox,typhus,leprosy,malaria,amoebicdysenteryandcholeraandvariousparasiticdiseases.
Egyptianphysiciansknowledgeof anatomywasnotextensivedespitethepracticeofembalming.
Thisisbecause embalmingwascarriedoutbyspecialist techniciansandnotbyphysicians. Knowledgeof
internalorganswaslargelylimitedtoanawarenessoftheiroutwardappearance.

ChineseMedicine

TheearliestChinese medicine,incommonwithmostotherancientcivilizations,assumeddisease
and illness were caused by the gods or by demons. The correct remedies for illness involved ritual
exorcismsandappealstotheGods.
AmorenaturalisticexplanationofillnessdevelopedwiththebeliefinYinandYang.TheYinand
Yangprinciples wereconsidered tocontrol everythingand their interactioncontrolled thefunctioningof
the human body. Yin was feminine, soft, cold, moist, receptive, dark and associated with water while
Yang was masculine, dry, hot, creative, bright and associated with fire. Human health depended on a
balancebetweenYinandYang. Further factors effecting disease werewind,rain,twilightandbrightness
of day so therewas atotalof six diseasemakinginfluences. Anyofthesesix influences couldupsetthe
balanceofQi,whichwasavitalspiritsimilartobreathorair,whichexistedthroughoutthehumanbody.
Chinese knowledge of anatomy wasverylimiteddueto astrictprohibitiononthedissection of
the humanbody.Chinesebelief concerning the inner organs was largelyerroneous. Theybelieved there
were five firm organsthat acted asreceivingorgansandlayoppositefivehollow organs whoserved
thepurpose of evacuation.Thefirmorgansweretheheart,spleen,lungs,liverandkidneys.Theheartwas
considered to betheplace ofwisdom and judgement whiletheliver andthelungs wereassociatedwith
thesoul.Themalesright kidney was seen as the sourceofspermanditsconnectionwiththepassageof
urine wasnotunderstood.Theholloworganswerethebladder,gallbladder,colon,smallintestineandthe
stomach.

Chinese doctors attempted to make adiagnosis bystudying the stateof the pulse.Thispractice
knownassphygmologyinvolved attemptingto recognize some very subtle variationsinthepulse.There
were considered to be 51different varietiesof pulsewhichwere tobetaken in11 differentareasof the
body. Chinese doctors were attempting to obtain far more information from the pulse, than it could
possiblyprovide.
Acupuncture, aimed torestore the balanceof Yin and Yang,andinvolved insertingneedles into
particular parts of the body.Therewere 388 areas ofthebodyintowhich the needles couldbeinserted
and they neededto be inserted atthecorrecttime,basedupontheweather,thetimeofdayand thephases
of the moon. Theneedleswere leftin anythingfromfiveto fifteen minutes.Acupuncturedoesappearto
be effective for pain relief as the needles seem to make the bodyproduceendorphins,thebodysown
natural painkillers. Claims have been made that acupuncture cancuremany diseasesincludingmuscle,
bone, respiratory and digestive disorders. A further Chinese treatment was Moxa which involved
inflictinga slightburnontheskin.Itwasconsideredtobeatreatmentforavastrangeofcomplaintssuch
asdiarrhea,abdominalpains,anemia,vertigo,nosebleeding,gout,toothachesandheadaches.

IndianMedicine

Indian medicine began with the belief that illnesswascausedbytheGodsorbydemons andwas

a punishmentforbadbehavior.Overtimehoweverotherbeliefsarosesuchasthatwhichconsideredgood
healthrequiredabalancebeingkeptbetweentheelementsofair,bileandmucous.
India developed surgery toahigherstandard,thananyoftheotherancientcivilizations.Thiswas
because the prohibition onhumandissectionwhich existedin Europe, China and the Arabworlddidnot
existinIndia.Thisenabled the Indianphysiciansto obtaina goodknowledgeofhumanbones,muscles,
bloodvesselsandjoints.Awidevarietyofsurgicaloperationswas carriedout,includingcosmeticsurgery
onpeoplewhohad beenmutilated as part of alegalpunishment.Anadulterouswifecouldhavehernose
cutofasapunishmentandIndiansurgeonslearnthowtorepairthedamageandreplacethenose.
India is a landofmany diseases andIndiandoctors werefamiliarwith1,120different diseases.
They guessed the connectionbetween malaria andmosquitoes,noticedthattheplaguewasforeshadowed
bythedeath of largenumbersofratsandthatfliescouldinfectfoodcausingintestinaldisease.Theywere
alsoawarethatcleanlinesscouldhelpinthepreventionofdisease.

GrecoRomanMedicine

Greek medicine derived its earliest beliefs and practices from Egypt and West Asia. Greek
medicine later spread around the Mediterranean during Roman times and was to form the basis ofthe
medical knowledge of Medieval Europe. Our knowledge of Greek medicine mainly comes from the
HippocraticwritingsandfromGalenwritinginthesecondcenturyAD.
TheearliestGreekmedicinewasbasedonreligion.Asclepius,thesonofApollo,wasabletocure
disease and patients sleeping at his shrines would see the God in their dreams and receive advice on
appropriate treatments. Around the sixth century BC Greek medicine began to change with a greater
emphasis on rational explanations of disease involving natural rather than supernatural causes. The
Hippocratic writings,probablywrittenbyanumberofauthors,suggestedliquidswerethe vitalelementin

all living things. The human body contained fourfluids or humors,phlegm,yellow bile,blackbileand
blood. Disease was caused by an imbalance of these fluids in the body. Such an imbalance could be
caused by the weather or by extreme behavior such as over eating or excessive drinking.Themedical
practice ofbleeding,which was topersistforseveralthousandyears,originated fromthebeliefthere was
an excess of bloodwhich couldbecured byreleasingsomeblood fromthebody.Correctdiet, bathing,
exercise, sleep andsex would preventillness. Accordingto Hippocrates sexshouldbemorefrequentin
winter and older men should have sex more frequently thanyoungermen.Heconsidered epilepsy was
causedby an excessofphlegm. Hippocrateshowevertellsuslittleaboutinfectiousdiseasesandanatomy
as the dissectionofbodies wastabooasitwasconsidered tobe aviolationof the sanctityofthehuman
body.
The classical era taboo on human dissection led to some quite erroneous views of the human
body.Aristotle consideredtheheartwaswhere the soulwaslocatedandwasthecenterofthought,sense
perception and controlled bodily movements. He considered the brain cooled the heart and the blood.
There washowever abriefperiodinAlexandria wheredue totheancientEgyptianpracticeofembalming
and the more recent Platonic view that the soul and not the body, was sacred, human dissection was
allowed.Herophilus and Erasistratuscarried out dissections that leadthemto discoverthenervesleading
to the brain.They discoveredtherewere two differenttypesofnerves,onedealingwithsenseperception
and the other with body movement. When studying the brain they discovered the cerebrum and the
cerebellumand suggestedtheheavilyfolded humanbrain indicatedhumanshigherintelligencecompared
to animals.Theyconsidered the lungstookin airthatwasthentransferred tothearteries, the veinsheld
blood and the heartworkedlikea bellows. After making significant discoveries thatcouldonlybe made
by human dissection, the taboo against dissection arose again delaying further progress until the 16th
century. Until then, knowledge of the interior of the human body could only be guessed at from its
externalbehaviororbycomparisonwithanimalanatomy.
Twofurthertheories created bytheancient Greekswere the methodictheory and the pneumatic
theory.TheMethodictheory considereddisease tobe caused byadisturbance of atoms inthebodyand
treatment involved manipulating the body by massage, bathing or exercise. The pneumatic theory
consideredbreathtobeacrucialfactorinhumanhealth.
Thehighpointof GrecoRoman medicalknowledgecamewithGaleninthesecondcenturyAD.
Galens two main areas of study were anatomy and physiology. As human dissection was illegal his
anatomical studies were based on dissections of animals, particularlytheBarbaryape.Hedidhowever
havetheassistance of his study of gladiatorswounds, ahumanskeletonhehadseeninAlexandriaandof
human bodies exhumed by natural events, such as floods. Galens work on the bone structure and
muscular system were a significant advance on anything elsein antiquity. His beliefin Aristotles idea
thateverythinghada purposelead himtoassumeeverybone,muscleandorganhadaparticularfunction
and he set out to describe each bone, muscle and organ and their particular function.Hedescribed the
humanskeletonandmuscularsystem with someaccuracy.HeputanendtoAristotlesidea that themind
was located in the heart, locating it in the brain. Galen discovered seven pairs of cranial nerves, the
sympatheticnervoussystemandhedistinguishedbetweenthesensoryandmotornerves.Howeverhealso
found thingsthatdidnot exist.The
rete mirabile(wonderfulnetwork)islocatedunder thebrain ofmany
hoofedanimals butisnot foundin humans. Yet Galens claimthatitexists inhumans wasaccepted for
somethirteencenturies.

Galens physiology, his concept of how the human body worked, began with a vital spirit,
pneuma taken intothebody bybreathing.The
pneumaentered thelungswhereitmetsomebloodbefore
passingintotheleft ventricle oftheheart. The bloodthenflowedintothearteriesandspreadthroughthe
body feeding theflesh.Whenfoodenteredthebody itconvertedintobloodintheliver,someofthe blood
then entered the veins and spreadthrough the body andwasfeedintotheflesh.Otherbloodflowedfrom
theliverintothe right ventricle ofthe heartfromwheresomeoftheblood enteredthelungstoabsorbthe
pneuma
.Some ofthebloodin the rightventricle howeverpasseddirectlyintotheleftventricleandfrom
there flowed into the arteries. One problem for Galen was that he was unable to discover how blood
moved from the right ventricle to the left ventricle, which were divided by a solid muscular wall. He
eventuallyconcluded theremustbetinyholesinthewall,sosmalltheycould not beseenbythehuman
eye. Galens system correctly realized the heart caused blood to flow through the body and that the
arteries containedblood. PreviouslyErasistratus suggestedthearteriesonly containedair, as the arteries
of adead bodydo notcontain blood. Galen didnotrealizethatthebloodcirculatedandhissuggestionof
minuteholesinthewallbetweentherightandleftventriclesoftheheartwaswrong.
Galenspathology,hisconcept ofillness,broughttogetherHippocratestheoryofthefourhumors
and Aristotlesidea ofthefourelements,air,fire,earthandwater. Bloodwasconsideredtobewarmand
moist, yellow bile warm anddry,blackbile coldanddryandphlegmcoldandmoist.Bloodisassociated
with the heart, yellow bile with the liver, black bile with the spleen and phlegm with the brain. The
followingtableshowshowGalenbroughtthetwoideastogether.

Humor

Element

Organ

Qualities

Phlegm

Water

Brain

Cold&Wet

Blood

Air

Heart

Hot&Wet

Yellowbile

Fire

Liver

Hot&Dry

Blackbile

Earth

Spleen

Dry&Cold

Thetable indicates the symptoms ofthedisease,the causeof the disease andthecureforthedisease.If

the patient has the symptom of being hot and perspiring, this is the quality of being hot andwet,this
suggeststhereisanimbalancein theblood, so that bleedingis the cure.Iftheyhaveahotanddryfever,
this suggeststheyellowbileisoutofbalance,sothatvomitinguptheyellowbileisthecure.Thehumors
couldalso affect apersonspersonality. An excessofphlegmwouldmakeonephlegmatic,ofblood,one
wouldbesanguine,ofyellowbile,onewouldbecholericandofblackbile,onewouldbemelancholic.
Animbalance in the humors inparticularorganscouldresult in illness.Excessive phlegminthe
bowels resulted in dysentery and an excess in the lungs caused tuberculosis. Cancer was caused by a
massive imbalance inthehumors.Strokewascausedbyanexcessofblood,jaundicebyexcessiveyellow
bileanddepressionbytoomuchblackbile.


DarkAges

Thefall of theRomanEmpiremarkedthebeginningoftheDarkAgesinEurope.Thelaterstages
of the Roman Empirewereaperiodof epidemicdisease andpopulationdecline.Thepopulationofcities
in particular was to fall and the cities paved roads, drains, aqueducts and public baths soon fell into
disrepair.Thedeclineof thecitieswasaccompaniedbyadeclineinclassicallearningwhich wasopposed
by the new Christian church. In 391 ADa Christianmobset fire tothegreat library of Alexandria and
murdered thepaganphilosopher Hypathia.The lastpaganschooloflearning,theacademyinAthenswas
closedin529ADbyorderoftheEmperorJustinian.
Medicine was not to escape the general decline of learning which accompanied the fall ofthe
Roman Empire and the arrival of Christianity. There was a return to the beliefthatthecause ofmuch
illness was supernatural. IllnesswasapunishmentfromGodforpeoplessins.Thecuringofsuch disease
bymedicalpractices wascontrarytoGodswill. Theonlyappropriatetreatmentwasprayerandpenitence.
Diseases might also becausedby witchcraft, possession bydemons orspellsmadeby elvesandpixies.
Some of the old learning did survive, ironically in Christian monasteries where monks copied and
translated classical writings. Their work mixed superstition and religion with classical learning and
knowledge. Bede, (born 673 AD) an English monk famousforhis
Ecclesiastical History ofthe English
Peopleandoneof the mostlearnedmenof theDark Ages,alsowroteonmedicalmatters.Hereferredto
Hippocrates and the theory of the fourhumorsandprescribedbleeding astheappropriate treatmentfor
hotfevers caused,ashebelievedbyanexcessofblood.Buthealsoconsideredmagicincantationsandthe
wearing of magic amulets as the way to deal with spells made by pixies. There are also stories of
miraculous cures such as a leper sleeping where a saint died and being cured when waking the next
morning.
Not much had changed by the 12th century AD when Hildegard of Bingen began to bring
togetherclassicalmedicalbeliefs with 12thcenturyreligiousbeliefs.Sheconsideredtheimbalanceofthe
four humors resulted from mans ejection from the Garden of Eden. The eating of the forbidden fruit
destroyed the balance of the four humors in the human body. Sin was to cause the imbalance of the
humors and was therefore the cause of disease. Some of her medical beliefs could not be regardedas
scientificorrational. Her cure forjaundice wasto tie alivebat, firstto thepatientsback andthentothe
patients stomach. Failing eyesight, caused by excessive lust, was to be cured by placing the skin of a
fishsbladderoverthepatientseyeswhenhegoestosleep,butithadtobetakenoffbymidnight.

Arabmedicine

TheMoslemprophetMohammed was bornin 570ADandheandhissuccessorsweretoconquer

an empire extending from Spain to India. The early Moslems had a tolerant attitude to Christian and
Jewishminoritieswhowereallowedtofreelypracticetheirreligions.TheoriginsofArabianmedicinelay
withahereticalChristiansect known asthe Nestorians.TheNestorians underthreatofpersecutionfrom
orthodox Christians fled eastwards toward present day Iraq andIran. They broughtwiththem classical
texts from a range of authors including Hippocrates, Aristotle and Galen which they proceeded to

translateinto Arabic.AtthistimetheArabworld had apositive attitude tonew ideas and was happyto
adopttheideasofclassicalscholarslikeAristotleandGalen.
The first great Arab medical authority was Rhazes who was born in854AD. Rhazesbelieved
illness had nothing todo with evil spirits or Godandthatclassical authorities werenotabovecriticism.
He was in frequent disagreement with Galen. He considered Galens cure for asthma consisting of a
mixtureofowls bloodandwine did notworkas he had tried it andfoundittobeuseless.Hequestioned
the belief that disease could be diagnosed by studying the patients urine and was the first medical
authority to understand the differencebetweenmeasles and smallpox.Rhazesgavea full descriptionof
diseases he encountedgiving hisdiagnosis,prognosisandtreatment.His understanding of the workings
ofthehumanbodywerehoweverhinderedbytheIslamicprohibitionondissectionsofthehumanbody.
Arabian medicines second great authority was Avicenna (9801037) whosebookthe
Cannonof
Medicine was to become the leading medical work in both Europe and the Middle East for some 600
years. Avicennas
Cannon includes many of the ideas of Hippocrates, Aristotle and Galen but also
includes many ofAvicennas ownideas. The
Cannondealswitha rangeofdiseasesand describestheir
diagnosis, prognosis and treatment. Avicenna accepted Hippocrates and Galens theory of the four
humors.Treatmentsincludedbleeding, enemasand purges whilediagnosisincludedexaminingthe pulse
and urine. Over 700 drugs were recognized by Avicenna and the
Cannonprovidedinstructions onhow
they were to be prepared,whichdrugs should be usedfor whichillness andtheir effects. Woundswere
dealtwithbycauterizing,atreatmentthatdatesbacktoAncientEgypt.
Surgery intheArabworldwasnotrespectedandsurgeonswereusuallycraftsmen.Oneexception
to this is Albucasis (9361013) who practiced in Cordoba in southern Spain. Alburasis wrote a book
called
Tasrif or the
Collection which provided full accounts of surgery practiced at the time. The
Collection was to become the standard book on surgery during medieval times. The bookprescribes a
range of surgical procedures including trepanning, dentistry, mastectomy and lithotomy and advocates
cauterizationasatreatmentforawiderangeofproblems.

MedievalEuropeanmedicine

European medicine began to moveawayfrom the supernaturalexplanationsofdisease with the

founding of a medical school at Salerno. The school was probably founded in the ninth century and
reached its greatest heights between the tenth and thirteenth centuries. Anatomy was taught atSalerno
based on the dissection of pigs whose internal organs were thought to be similar to those of humans.
Passionarius
, abookwritten by Gariopontus, one oftheteachersat theschool,wasbaseduponclassical
Greek learning while the arrival in Salerno of Constantine the African around 1075 with many Arab
medical works was to greatly improve the medical knowledge at Salerno and eventually all Europe.
Constantinewasto spend the remainderofhislifetranslatingtheArabictextsintoLatinandsobringthe
classicalGreekauthors,uponwhoseworkArabicmedicinewasbased,toEurope.
The translation of Arabic medical textsintoLatin continued inearlymedievaltimes so that the
worksofHippocrates, Aristotle, Galen, Rhazes, Avicenna and Alburasisbecamewellknown.Theysoon
assumed a status of great authorityandtheirinitialimpactwastohelp freemedicinefrom supernatural
and magical explanationsandcures. Their status howeverwaseventuallyto hold backtheimprovement

of European medicineas newideascontrarytothoseoftheGreekandArabwritershadgreat difficultyin

obtainingacceptance.
New medical schools at Montpellier, Bologna, Paris and Paduawerefoundedthatsignificantly
increasedmedicalknowledge.Theknowledgeofanatomyimprovedwiththeoccasionalhumandissection
beingperformedaspostmortemexaminationsforjudicialpurposesandwithoccasionaldissectionsofthe
bodies of executed criminals.Anatomywasalsoimprovedby MondinodeLuzziorMundinuswhotaught
at Bologna. His book
Anothomiabrought anew levelof knowledge ofanatomy,althoughhedidrepeat
manyoftheerrorsofGalen.Mundinushoweverdidmostofhisdissectionshimself,unlikeotherteachers
who sat on ahighchairsomewhat above the bodyreadinga book supposedly describing the dissection,
butprobablyonlylooselyrelatedtoit.Guy deChaulias,theleadingsurgeonofthefourteenthcenturywas
apupilofMundinus.
The most dramatic medical event of the 14th century in Europe was the arrival of the Black
Death.Itoriginatedin China killingup totwothirdsofthepopulationandthenspreadalongtraderoutes
to EuropeandtheArabworld.Itkilled halfthepopulationofCairo andbetweenaquarterandathirdof
thepopulationofEurope.ThemedicalauthoritiesinEurope hadnosolutiontotheBlackDeath.The idea
of a contagious disease was beyond the understanding of medical knowledge in either the Arab or
European world during the 14th century. The Arabs considered the Black Death was caused by evil
spirits, the Europeans blamed everythingfromthe Jewsto Gods punishmentforhumanssins.Jewswere
accused of poisoning wells and entire Jewish communities were wiped out by vengeful Christians.
Flagellants traveled around Europe whipping themselves for theirsinshoping thiswould appeaseGod.
Conventionalmedicineofthetimehadnoanswers, bleeding,cauterizingandcleaningtheairwithincense
were alltriedandfailed.Quarantining workedtosomeextentbutthebestadvicewastorunlikethewind.
The failure of conventional medicine during the Black Death lead to a revival of supernatural
explanationsofdisease.

TheRenaissance

Arevolutionwastotake place inmedicine atthetimeof the Renaissance. It wasto involve the

breaking of the stranglehold classical and Arabic thought, especially Galen and Avicenna, had on
medicineanditsreplacement bya beliefin observationandexperiment. Oneoftheprincipalproponents
of the new beliefs was Paracelus who attacked academic learning, especially Galen and Avicenna and
advocated learning from experience. His own ideas however werenot muchof animprovement onthe
classical learning. He rejected the humoral theory, but consideredeverything was madeoutofsulphur,
mercury and salt. Sulphur caused inflammability, mercury volatility and salt solidity insubstances.He
also believed in the doctrine of signatures the idea that assumed plants capable of healing visibly
showed their healing qualities. Heartshaped lilacleaves wouldcureheart diseaseandyellowcelandine
wouldcurejaundice.
However Paracelus interestin alchemylead him tosomesignificant discoveries.He noticed the
anaesthetic effects of ether and tincture of morphine which he called laudanum. He recognised that
particular substances had their own individual qualities and that compoundsincluding those substances
often had some of those same qualities.Heconsidered that each disease neededto be curedby its own

remedy.The mainvalue ofParacelussideas wereinhisiconoclasticattackonclassicalmedicallearning,

which was held in vastly excessive reverence in Paraceluss time. After Paracelus it became easier to
criticiseestablishedmedicallearningandfornewideastobeaccepted.
A contemporary of Paracelus, Fracantorius, suggested contagious disease was caused by tiny
seeds invading thehumanbody.Theseeds wereto smallto be seen with the humaneye andcould find
theirway intothebody fromtheair,frombodilycontactorfrominfectedclothesorbedlinen.Oncethey
had entered the human body theycould multiplycausingpeopletofallill. Fracantoriusalso considered
each disease was caused by its own particular seed leading Fracantorius toclearly distinguishbetween
such contagious diseases as smallpox, measles, the plague, syphilis and typhus. Previously contagious
diseaseswere sometimes consideredtobeversionsofthesamediseasewithvaryingdegreesofintensity.
Fracantoriusstheory isvirtuallyidentical tothe germtheoryof diseasebut inthe16thcentury, without
microscopes,hewas unabletoprove the theory. Physicianspreferredothertheories,suchasthehumoral
theory,whichwhilealsounprovableatleasthadthesupportoftraditionandancientauthority.
Thestudy ofanatomy wasto undergo arevolution atthehandsofVesalius.Vesaliuswasableto
dissect human corpses and this enabledhim toprovidea generallyaccurate picture of the human body.
Previouslyanatomy hadsufferedfromtheprohibitionon humandissectionthatextendedbacktoclassical
times, so that knowledge of human anatomy was based on animal dissections. Before Vesalius the
accepted authority wasGalenwhose anatomicalstudies werebaseonanimal dissectionandwhosework
hadacquiredsuchastatusthattoquestionitcouldinvolveaccusationsofheresy.
Versalius was abletoobtainhuman corpses for dissection,aspublicauthorities werepreparedto
allow the dissection of the corpses of executed criminals.Somephysicianshadpreviouslydissectedthe
corpsesof criminals, butsuchwasthereputationof Galen that theyhadnotnoticed ornotdaredtopoint
out that the dissection of humans showed that much of what Galen had said was wrong. Versaliuss
strength wasthathewaspreparedto relyonhisobservationsandwherethesecontradictedGalenhewas
preparedtosayGalenwaswrong.
Vesaliuss great work was the
De Humani Corporis Fabrica usually called the
Fabrica
. It
consisted of seven books, the first dealing with the skeleton, thesecond withthe muscular system,the
third withtheveinsandarteries, the forthwiththenervous system,thefifthwiththeabdominalorgans,
the sixth with the heartandlungsandtheseventh with the brain. The
Fabrica especiallybooks1and 2
were illustrated with high quality drawings showing the various human parts in considerable detail. In
book 1 Vesalius emphasises that the bones supported the human body, played an important role in
movement and provided protection for other parts of the body. The illustrations in book 2 show the
muscles inthe order inwhicha person dissectingabodywouldseethem.Theupperlayerofmusclesare
shown then the layerbelow themandthen the next layerandsoon. Book3 gives agooddescription of
thearteriesandveinsandbook7describessomeofthestructureofthebrainforthefirsttime.
The bookcorrectedcertain ofGalens errors. ItquestionedGalens suggestionthatblood flowed
from the rightventricle of the heartto theleftventricle. Vesaliusalsoshowed that
the retemirabiledid
notexist,thattheliverwasnot divided intofivelobes,thattheuterushadmultiplechambersand thatthe
pituitarywas directly connectedtothenose. Vesaliuss expose of such errors by Galen resulted insome
criticismofVesaliussworkfromphysicianswhoconsideredanyquestioningofGalentobeoutrageous.
Vesalius did makesomeerrors.Hisdescriptionsof thevisceralorgans(the liver,thekidneyand
theuterus)werebased uponthoseofpigs and dogs.Hefailed tonotice thepancreas,theovariesandthe
adrenal glands. His description of female organs was poor, probably due to there being fewer female

10

bodies available for dissection. Nevertheless the book still represented anenormousadvanceinhuman
knowledgeofanatomy.

CirculationoftheBlood

Classicalphysicianswere aware of the existenceoftheheart,buthadlittleideaofitsfunctionin

thehumanbody.Theyrealisedwhentheheartstoppedbeatinglifewouldstopwhich leadthemtobelieve
theheart had asignificantrole duringandat theendoflife.Theyconsideredtheheartwaswherethesoul
waslocatedwhenapersonwaslivingandthesoulleftthebodywhenapersondied.
Classicalphysicianshadlittleunderstandingoftherelationship betweentheheart andtheblood.
They didnotknow how bloodgot totheheart,howit gotfrom the rightventricle tothe leftventricleor
what happened after it left the heart. They believed the heart providedavital spiritto blood passing
throughthe heart. Theyalso believedthearteriesdidnot contain bloodaswhenapersonoranimaldies,
theheart stops pumping bloodintothe arteries, which then contractanddrivetheirbloodintotheveins.
Thisonly leavesairinthearteriesofadeadpersonoranimalandclassicalphysiciansonlydissecteddead
bodies and soneverdiscoveredbloodinthearteries.Theveinsindeadbodiesarefullofblood, especially
the veins connected to the liver. This lead classical physicians to believe that the liver created blood
whichwaspassedthrough the veins to the restofthebody.Itwas alsobelievedthatthebodysomehow
absorbedtheblood.
Galen, who had the opportunity to observe the internal organs of living human beings while
actingasphysician toinjuredgladiatorshadabetterunderstandingoftheheartand blood.Heunderstood
thearteriescontainedblood inlivingpeopleand that theheart wasapumpwhichpushedbloodfromthe
rightventricleof theheart into thelungswhichthenflowedintotheleftventricleandfromthereintothe
arteries.Thiscirculation fromtherightventricleto the lungsandthen totheleftventriclewasknownas
the pulmonary transit. Galen however still believed that the liver created the blood, but also that it
pumped the blood totherestofthebodyandthat bloodwaspasseddirectly formtherightventricletothe
left ventricle of the heart. The irony is that Galens work on the pulmonary transit, which was atleast
partly rightwaslargely notnoticed,while otherworkwhichwasquiteerroneouslikethehumoraltheory
wastreatedasholywrit.
The idea of the pulmonary transit was revived by the Arab physician Ibn alNatis in the 13th
centurywhenhe suggested that allthebloodwentfromtherightventricletothelungsandthen totheleft
ventricle and nonetravelled directlyfrom the rightventricle totheleft ventricle.In the 16th century the
same idea wassuggestedbyMichaelServetusandacceptedbyRealdoColombo.Colomboalsosuggested
the heart couldactasa pumpanddiscoveredthe presenceofvalves intheveinswhich ensuredthatthe
blood could move only in a single direction from the right ventricle to the lungs and then to the left
ventricle.
The classical ideas concerning the heartandblood werebeginning tobechallenged inthe 16th
century.Ideas ofthepulmonary transit, the heartactingasapump andvalvesin theveinsensuringblood
flowedonlyonewayquestionedtheclassicalorthodoxystilllargelyacceptedinRenaissanceEurope.Into
thisenvironmentWilliamHarveyproposedhisideasofthecontinuouscirculationoftheblood.

11

Harvey had been carrying out dissections on a wide range of living animals and it is fromhis
observations of their living organs that he was able tounderstand how the bloodcirculatesthrough the
humanbody.His book
DeMotuCordis beginsby explaining the structure oftheheartandwhat itdoes.
Theheartconsists oftwoupperparts called theauriclesandtwolower partscalledtheventricles. Theleft
auricle and the left ventricle were separated from the right auricle and the right ventricle by an
impenetrable muscular wall. Thequestionofwhethertheauricles ortheventricles beatfirstwasdifficult
to resolve as hearts would often beat to fast for normal observation to provide an answer. Harvey
answered the question by observing the hearts of coldbloodedanimals like fish which beatslowlyand
then confirmed itby observingtheslowbeatingheartsofdying warmbloodedanimals.Heobservedthe
auriclesbeatfirst,pushingbloodintotheventriclewhichcontractedpushingbloodoutoftheheart.
The classical theory considered bloodwas made bytheliver, flowedthroughthe heartandwas
absorbedbythe body. Harveycalculatedtheamountofblood that flowed throughtheheartofadog.He
calculated the numberof heartbeatsper minute,whichwas the numberoftimestheheartpumpedblood
out into the body. He also calculated the quantity of blood that was pumped with each heart beatand
concluded that theheartpumpedbloodweighing threetimestheweightofthe wholebodyeachhour.The
questionaroseasto wheredidall this bloodcomeformandwherediditallgo.Bloodequivalenttothree
timesa personsbodyweightperhourcouldnotcomefromfoodanddrinkconsumed.Noonecouldeator
drink that much per hour.Nor couldthatquantityof bloodbe absorbed bythebody everyhour. Veins,
arteries and tissues wouldexplode withthatquantityofbloodbeingpouredintothemeveryhour. Harvey
suggested thesolutionto this problem was that blood was notbeingcreatedby the liver or absorbed by
thebody,butthatthesamebloodwasconstantlycirculatingaroundthebody.
Galen had suggested that the blood moved in both directions in the veinsandarteries.Harvey
showedthatvalves inthe veins ensuredthatblood movedinonlyonedirection.Heshowed thatbloodin
theveinsalways moved towardstheheart,by pressing avein,bloodaccumulatedin theveinontheside
of the compression away fromthe heart.Thesideofthecompressionclosetotheheartwouldbeemptied
of blood as the blood flowed to the heart and away from the compression point. When an artery was
pressed the blood built up on the side of thecompression closestto the heart. This indicatedtheblood
flowedinasingledirection,intheveinstowardstheheart,andinthearteriesawayfromtheheart.
The consequences of the blood all flowing in one direction and the same blood constantly be
circulated, without blood being created by the liver or absorbed by the body was a revolution in
physiology. New ideas often receive considerable criticism and Harveys ideaofconstantlycirculating
blood was attackedfordaring todisagreewithGalen. OnerationalcriticismofHarveystheorywasthat
Harvey couldnot show howbloodflowingout of the heartto thearteries couldconnecttotheveins and
flow back into the heart. Harvey suggested tiny connections, to small to be seen with the naked eye,
linked the arteries and the veins but he could not prove their existence. This problem was solved by
MarcelloMalpighi, in1661,when using amicroscope hewasabletoobservetheexistenceofcapillaries
linking the arteries and the veins which allowedblood toflow fromthearteriesto the veins so that the
ideaofthecirculationofthebloodwascomplete.

Jennerandvaccination

12

Smallpox goesbackat least to AncientEgyptand wasin Greecein theclassicalperiodandwas

present inAncient China and India.Thesymptoms of the disease weredescribed byAlRazi in910AD
and involved blistersfilledwithpussappearingon the eyes,face,armsandlegs.Twentytoforty percent
of those who caught smallpox died from it and the survivors were covered with disfiguring scars. In
Londoninthe17thand 18th centuriesathird of the people hadsmallpoxscarsandthemajorityofcases
ofblindnesswerecausedbysmallpox.
Ithad beenobservedthatpeoplewhosurvived smallpox didnotusuallycatchitagain.Theidea
developed that if a mild case of smallpox could be produced it would protect a person from future
smallpoxattacks.In the East dustfrom asmallpoxscabwasblownintothenosetoinduceamildcaseof
smallpoxto create immunity fromfutureattacks.In Ottoman Turkeysmallpox material was rubbedinto
small cuts made in a persons arm. These methods of conferring immunity from smallpox were made
knowninEnglandintheearly18thcenturybutwereignored.
Thepracticeofdeliberately givinga personamildcaseofsmallpoxbeganin Englandintheearly
18th century with Lady Mary Montagu. The practice became known as variolationand Lady Montagu
whohadlearntaboutthepracticeinTurkeyhadherowndaughtervariolatedinthepresenceofnewspaper
reporters which ensured substantial publicity. Lady Montaguthen persuadedthe Princeand Princessof
Walestohavetheir childrenvariolated whichensuredevenmorepublicity.Variolationalsotook placein
America where Zabdiel Boylston, a Boston physician, heard of variolation from an African slave and
facedwithasmallpoxepidemicvariolated244peopleofwhomonly6died. Surgeonshowever demanded
patientsgo througha 6weekperiodofbleeding,purginganddietingbeforevariolationwhichlimitedthe
popularity of the practice and resulted in patients being weakened before variolation took place.
Variolation turned out to be quite dangerous with modern estimates that12%of patientsdied,alower
deathratethanthe2040%whomightdieinasmallpoxepidemic,butcertainlynotaperfect treatmentfor
theproblemofsmallpox.
A better treatment was to come with Edward Jenner, whowhiletraining as asurgeon in1768,
heard that milkmaids who had contacted cowpox were immune from smallpox. Cowpox resulted in
lesions on the milkmaids hands, but had no other symptoms. Later Jenner meet aMrFrewsterwho in
1765 had presented a paper to the London medical society on the ability of cowpox to prevent future
smallpox attacks. The paper was neverpublishedbut remindedJennerof whathehadheard of cowpox
from the milkmaids.Cowpoxis part of afamilyofanimalpoxes,includinghorsepox,cowpox,swinepox
and smallpox all caused by the orthopox virus. All the animal pox diseases can infect humans andan
infection from anyone of them will protect people from all the other animalpoxes.InDecember 1789
Jenner began a series of experiments. He inoculated three people including hissonwithswinepox and
later variolated them with smallpox and none of them produced the rash that usually came from
variolation with smallpox. Swinepox seemed to protect them from smallpox. Later in 1796 Jennerput
cowpox into a healthy 8 year old boyand after hedeveloped normalcowpoxsymptoms variolatedhim
withsmallpox.Theboydidnotdevelopanyofthesymptomsthatnormally occurredwithvariolationwith
smallpox. Jennerthentookfluidfromtheboyscowpoxpustleandusedittoinoculatesomemorechildren
and fluid from their cowpoxpustles wasusedto inoculatesomemore children.Twoofthesewere later
variolated with smallpox, but did not develop any of the symptoms that normally occurred with
variolation, confirming the initial experiment. The experiment showed that cowpox could provide
protection againstsmallpoxwithout anyoftherisks ofvariolation.Thepracticeofcowpox inoculations,
whichbegantobecalledvaccination,wassoondonethroughout theBritishEmpire,theUnitedStatesand

13

Europe although there was some opposition to it. The opposition graduallydisappearedandeventually
lateinthetwentiethcenturysmallpoxwascompletelyeliminated.

The discovery of anaesthesia

A vital component of modern surgical operations is the use of anesthesia. Without anesthesia
operations would be excruciatingly painful and as a result many patients chosenot tohaveoperations.
The pain of having limbs amputated could result in patients dying of shock and forced surgeons to
perform operations with extreme speed. The bestsurgeonscouldamputate alimbinlessthan aminute.
Thestateofmindofapersonawaitingsurgerywouldbesimilartothatofaperson abouttobetorturedor
executed. When London hospital was built in 1791, and was to act as a modelforotherhospitals, the
design took into accountthelackofeffectiveanesthetics.Theoperatingroom wasonthetopfloor,partly
to allowsunlightthroughaskylight toilluminatetheoperation,butalsosothe patientsscreamswouldnot
travel through the hospital and could be muffled by extra heavy doors. When an operation was to
commence hospitalstaffwouldgo tothe topfloorandassistinholdingthepatientdownandifnecessary
ingaggingthepatient.
The problem with an effective aesthetic that will allow major surgery is that it mustplacethe
patientin astatewhere the central nervoussystem is depressedto an extentwherepainful stimulicause
no muscular or other reflexes. This is far beyond ordinary sleep as obviouslyperformingsurgeryon a
sleeping person will wake them.Effective surgicalanaesthesia mustplacethepatientina state close to
thatofdeath.
In the past various attempts were made to reduce or eliminatepain during surgicalprocedures.
Dioscorides, a Greek physician in the early RomanEmpire,useddrugs such as henbane and mandrake
root to relieve pain. These drugs continued to be used intomedievaltimes. Arab physicians seemed to
haveused drugssuchasopiumandhyoscyamus.Alcoholwasoftenusedbutwasprobably moreeffective
at making the patient easier to hold down than in relieving pain. Soporific sponges, involving the
inhalationofdrugssuchasopium,mandragoraandhyoscyamuswereused fromaroundtheninthcentury.
However modern experiments with such sponges suggest they hadno aesthetic effectat all.Theuse of
soporific sponges was discontinued in the seventeenth century. It may well be due to the lack of
effectiveness ofpremodernanaestheticsthattheirusewasnotwidespread.Egyptianpapyri andtheCode
of Hammurabi describesurgerywithoutmentionofanaesthetics. OnlyoneChinese surgeon, one Indian
surgeon and a few Greek, Roman and Arab surgeons seem to have made any attempt to relieve pain
during surgery.Premodernattemptsto relievepainduringsurgicaloperationsseemtohavebeenoflittle
ornoeffect.
Thefirst stepin the developmentof modernanaestheticswasthediscoveryofether.In1275,the
Spanish alchemist Raymundus Lullius produced ether by mixing alcohol with sulfuric acid. Paracelus
used ether to relieve pain in 1605 in some of his medical patients but not in surgery as he was not a
surgeon.
Nitrous oxide, soon to be known as laughing gas, was discovered by Joseph Priestly in 1772.
Priestley however did not realise nitrous oxide could act as an anaesthetic. Others however soon
discovered both nitrous oxideandether had an intoxicating effectwhen inhaled andsoonetherfrolics
and laughing gas parties became a popular source of amusement. It was soon observed that minor

14

injuriessuchasbruisesreceived atthefrolics and parties werenot accompaniedby anypain.Inaddition

Humphrey Davy discovered that nitrous oxide relieved the pain of an inflamed gum and jaw and
suggested nitrous oxide could be used in surgery. Similar observations concerning nitrous oxide were
made by William Barton intheUnited States. In 1842etherwasusedtopainlesslyextract atooth,by a
dentist,DrElijaPope,actingonthesuggestionofWilliamClarkachemistrystudentwhohadparticipated
inetherfrolics.
The first use of ether for surgical purposes was by Crawford Long in Georgia, USA in 1842.
Longhadattendedetherfrolicsandhadnoticedbruiseshehadreceivedwhileundertheinfluenceofether
had involved no pain.Realising that etherhadstopped the pain he used it invarioussurgical operations
andinobstetricalprocedures.Hedidnothoweverpublishhisworkuntil1849.
Adentist, HoraceWells, whileattendinganitrousoxide party in1844 noticed apersoninjuring
hislegswithout suffering anypain. Realisingnitrous oxidecouldserveasadentalanaestheticWellshad
one of his own decaying teeth removed by another dentist whilehe was underthe influenceof nitrous
oxide. Wells experienced no pain and was soon performing dentistry using nitrous oxide on his own
patients. Howeverwhenhe attempted apublic demonstration atMassachusettsGeneralHospitalheused
insufficientgasandthedemonstrationwasnotasuccess.
Thepublic demonstration atMassachusetts GeneralHospitalhadbeenarrangedbyWellsformer
dentistry partner William Morton. Morton who had possibly seen Long operate in Georgia, became
interested in ether as an anaesthetic and had discussed it with Charles Jackson, a doctor in Harvards
medical faculty and at Massachusetts General Hospital. Intending topatentthe anaestheticMorton and
Jackson disguised the ether by mixing it with aromatic oils and called it Letheon. Theythen arranged
public demonstrations of the useofLetheon,in 1846, for pullingteeth and for an operationremovinga
tumour froma patientsjaw.Both the dentistryandthe operationwerecarriedoutpainlessly.Jacksonand
Mortonhowever wereforced towithdrawthepatentforLetheonandrevealthatLetheonwasreallyether
bypressure fromthesurgeonsinvolved intheoperations. By the end of1846newsoftheuseofetheras
an anaesthetic had travelled across the Atlantic and in December 1846 it was used in an operation in
London.
Jackson, Morton and Wells allclaimed tobethediscovererofsurgical anaesthesiaandin 1847
the United States Congress became involved in trying to sort out who was the true discoverer of
anaesthesia. Congress eventually dismissed Wells and Mortons claims and decided it was between
Jackson andLong. TheAmericanMedicalAssociation,in1872,gavethecreditto Wells, whilein1913
the electors of the New York University Hall of Fame named Morton as the discoverer of surgical
anaesthesia. The American College of Surgeons, in 1921, decided Long should be credited with the
discovery.
Attemptswere soonmadetouseetherin obstetrics butitwasfoundtobe unsuitable.Etheroften
produced vomiting patients, irritated lungs and a bad smell. Chloroform had been discovered
independently in 1831 by Samuel Gutherie inNewYork, by EugeneSoubeiran inParis and byLiebig.
Initially its anaesthetic quality wasnotrecognisedbutGutheriesdaughterhadbecomeunconscious for
several hours after tasting it. In 1847 Sir James Simpson while looking for an anaesthetic to use in
obstetrics triedchloroformonhimselfandhavingfoundittobeaneffectiveanaestheticbeganusingitin
surgical operations. Its use wassoonextendedtoobstetrics provoking considerableopposition fromthe
CalvinistChurchin Scotlandon the grounds the Bible stated In sorrowthoushalt bring forthchildren
showedwomenmust sufferwhen givingbirth. TheCalvinistchurchoppositiondisappearedwhenQueen

15

Victoriagavebirth toher eighth child undertheinfluence of chloroform.Howeverchloroformwassoon

discovered tohave its ownproblems as it couldcauseliver damageand fivetimesasmany peopledied
underchloroformasdiedunderether.
Themethodofapplicationof the anaesthetic developed overtime.Longhadsimplypouredether
into a towel for his patient to inhale. Mortonusedan inhaler madeupofa round glassbottle with two
holesandamouthpiece.Air passed throughoneholeintothebottlewhichcontainedaspongesoakedin
theether whichwastheninhaled bythepatientthrough the mouthpiecewhichwasattachedtotheother
hole.Mortons inhaler didnotallowtheanaesthetisttohave controlovertheamountofanaesthetic.Soon
John Snow, who had provided the chloroform to Queen Victoria created an improved inhaler which
provideda4% mixof chloroformin air.Joseph Cloverproducedafurtherimprovedinhalerinwhichthe
chloroform and air mixture was prepared in advance and held in an airtight bag. Sir FrancisShipway
created an apparatus which allowed the anaesthetist to control a mixture of varying amounts of
chloroform,etherandoxygenforinhalationbythepatient.
Asignificant improvementintheprovision of anaesthetics occurred withthe introduction of the
anaestheticdirectlyintothewindpipe or trachea. Thiswasfirstattempted byFrederickTrendelenburg,in
1869, who inserted the anaesthetic through a tube he inserted into a hole he had cut into the patients
windpipe. Sir Ian Macewan achieved the same result without cutting into the windpipe, in 1880, by
inserting a metal pipe down the throat and into the windpipe. This allowed the development of
endotracheal anaesthesia which was important for operations on the mouth and the jaw and for many
moderncardiacandpulmonaryoperations.Endotrachealanaesthesiawasfurtherimproved,in1919,when
Sir Ian Magill put tubesthrough theconsciouspatients nose and mouthanddowninto the windpipeby
anaesthetizingthethroatwithcocainebeforeinsertingthetubes.
General anaesthetics were often not necessary for minor operations. A local anaesthetic which
workedona particular partof the body andavoidedthesmallriskofdeathandseveralhoursofrecovery
timeinvolvedwithgeneral anaestheticswassought.PeruvianIndiansknewabouttheanaestheticqualities
of the cocaplantsand in the nineteenth century cocaine wasobtained fromtheplant.In1872Alexander
Bennettobserved that cocainehadanaestheticpropertiesandinthe 1880sCarlKollerexperimentedwith
cocaineusing ittoanaesthetizefrogseyes. Sooncocaine begantobeusedasalocalanaestheticforeyes,
the mouth, nose and throat and intheurethra.Theuse of cocaine wasextendedby injectingitintothe
nerves relatingto the areato beoperatedonandeventuallyintotheepiduralspace aroundthespinalcord
whichallowedalargerareatobe anaesthetized.Theuseofcocaineasalocalanaesthetichasdiscontinued
withitsreplacementbynovocainewhichwassynthesizedasanaestheticafter1905.

Thegermtheoryofdisease

Thefirst person toseemicroorganismswasAnthonyLeeuwenhook(16321723)aDutchdraper

who wasanexpertmakerofmicroscopes.Hismicroscopesgave adegreeofmagnificationwhich wasnot
exceeded until the 19th century.Heusedhismicroscopes for observing awidevarietyofphenomena.In
1675 and 1676helooked atdropsofrainwater and found tiny animalswithin the water. Thoseanimals
wouldhaveincludedwhatwenowcallbacteriaandothermicroorganisms.In1683Leeuwenhooklooked
at plaque from his own teeth and found it contained largenumbers of small animals. Later samples of

16

plaquedidnot containthesmall animals,whichLeeuwenhooksuspectedwasbecausehisdrinkingof hot

coffeekilledthelittleanimals.Leeuwenhookalsolooked atscrapings fromhistonguewhenhe wassick
and atthedecayin the rootsofarottentoothhehadremoved.Inbothcaseshefoundvastnumbersofthe
littleanimals. Thepresence of these animalsin such greatnumbersin places of illnessanddecay raised
the question as to whether the animals arose from the decay or whether they were attracted to it or
whether they caused the decay.Thequestion ofwhetherthesmallanimalswerespontaneouslygenerated
from decaying materials or were attracted to it was the subject of much controversy. Francesco Redi
(16261698) kept boiled meat in sealed containers and when maggots failed to appear suggested this
showed there wasno spontaneousgeneration. However in1748JohnNeedhamrepeated the experiment
and found small animals in the meat which he considered proved spontaneous generation. Lazzaro
Spallanzoni suggested Needham had failed to seal his containers properly so that the small animals
arrived on themeat through theair, ratherthanbeingspontaneouslygeneratedbythe meat.Supportersof
spontaneous generation argued that sealingthecontainerspreventedsome gaseoussubstance,necessary
for spontaneous generation, from reaching the meat and so preventing the generation of the living
organisms.
Whether microorganismscausedthe diseasestheywere sooftenfoundwithwasinvestigatedby
AgostinoBassi. In 1835he showed that the silkworm disease, muscarine, was causedbybacteria.When
he inoculated healthy silkworms with the bacteria, he produced the sickness in the silkworms. This
suggestedthatotherdiseasesmaybecausedbybacteria.
Thequestionsofspontaneousgenerationandwhethermicroorganismsplayedanyroleincausing
disease wereeventuallysettledbyLouis Pasteur.Hewasto showthatfermentationinwine,putrefaction
of meatandinfectioninhumandiseaseallinvolvedthesame processandwereallcausedbytheactivities
of microorganisms. The microorganisms were generated not by decayingmatter but werecontinually
present intheairand whenthey werepresentin greatnumbers and wereofunusualstrengththeycould
causemattertodecayandhumanbeingstofallill.
Pasteur began with fermentation in wine. At the time chemists such asWohler andJustus von
Liebig suggestedfermentationwassolelyachemicalprocesswithlivingorganismsplayingnoroleinthe
process.Fermentationin winewas aproblemassometimesthefermentation wentwrong andsouredthe
wine. Pasteur showed that fermentation was caused by microorganisms in yeast and that round yeast
cells produced good wine, but long yeast cells created lactric acid which caused the wine to go sour.
Pasteurshowedthatifthewinewasheateditwouldkilltheyeastandstopanyofthewinegoingsour.
Pasteur next began to investigate putrefaction in meat with an experiment that allowed air to
reachboiled meatviaanundulating ushaped tube. Themeat did notputrefyandPasteur consideredthis
wasbecause thedust particlescontainingthemicroorganismswerecaughtonthelowbendofthetubeas
they couldnot travelup the tubeduetogravity.Themicroorganisms didnotreachthemeateventhough
it wasexposedto airsothemeat didnotputrefy.Thisshowed itwasnotairthatcausedputrefaction,but
microorganismsintheair.
Pasteur then began to investigate diseases in living organisms, first with silkworms and then
anthrax which effects sheep and cattle and occasionally humans. Pasteur showed the disease killing
silkworms were two different sorts of microorganisms which caused two different diseases in the
silkworms.Inrelationto anthraxitwasalreadyknownthatthebloodofcattlewhohaddiedfromanthrax
contained microorganisms and that these microorganisms were the causeofthedisease.RobertKoch
had discovered the anthrax bacteria, had cultured it and injected it into animals who had immediately

17

died. He also found that anthrax microorganisms could sometimes form spores, which were tiny
organismsresistanttoarange ofenvironmentalconditions.Thesporeswereformedwhenthetemperature
was right and oxygen was present. Once the spores were formedtheycould survivefora considerable
timeandreinfectotheranimals making thediseasedifficulttocontrol. Pasteur,withsomedifficulty, then
produce an anthrax vaccine which he used to inoculate sheep whowere later injectedwiththeanthrax
bacteria.ThesheepdidnotdevelopanthraxandPasteurhadfoundavaccineforanthrax.
Pasteurslastgreat achievement was todiscover avaccine forrabies. Rabies normallyoccursin
humans after they have been bitten by a rabid dog with thesymptomsappearingbetween 10 daysand
several monthsafter thedogbitestookplace.Pasteurstudiedthetissuesofrabid dogsbutcouldnotfinda
microorganismthatcould havecausedrabies. He decidedtheorganismwastosmalltobedetectedwith
a microscope.Pasteurconsidered the microorganismenteredthebody throughthebitewoundandover
timemovedtothebrain,explainingtheperiodoftimebetweenthebiteandthearrival ofsymptoms.After
some time Pasteur was able toproducea vaccine for rabies whichwasable tobe injectedin the period
afterthedogbiteandbeforetheonsetofsymptoms.
Pasteursworkhadfollowed alogical path. He hadfirst shown that fermentation was causedby
microorganisms,thatthosemicroorganisms originatedintheair ratherthanfromthefermentingmatter
and that microorganisms also caused putrefaction and infectious disease. He then showed how the
diseasesin both animalsand people couldbecured byvaccination. Pasteursworkestablishedthegerm
theoryofdiseaseandputanendtoothertheoriesofdiseasesuchasthehumoraltheory.
Robert Koch, after isolating the anthrax bacteria, began using an improved microscope with a
light condenser and an oilimmersion lens.Thisenabled him to see bacteriathathadpreviouslybeen to
small to be seenevenwiththebest microscopes available.He alsousednewanilinedyeswhichhelped
himto distinguish between differenttypesofbacteria.Kochalsofound awayofproducingpurecultures
of different types of bacteria by placing the bacteria on a solid culture medium, in place of theliquid
culture medium then currently used, which only worked well with bacteria that moved in the blood
stream. Withhis improved microscopeandbetter techniquesfor creating pure culturesofbacteria Koch
beganto searchfora tuberculosis bacteriainthetissue of humans who had diedoftuberculosis.Usinga
microscope equipped with the oil immersion lens and condenser that was five times as powerful as
Leeuwenhooksmicroscopeshewas abletofindatinybacteriawhichhecalledthetuberclebacillus.The
tubercle bacilluswasmuch smallerthan theanthraxbacteriaandwastosmalltobefoundwithouttheuse
of his new improved microscope. To prove the tubercle bacillus caused tuberculosis Koch needed to
isolate it inapurecultureandtoinjectitintovariousanimals.Ifitproducedtuberculosisinthoseanimals
thatwouldprovethetuberclebacilluswas the causeof tuberculosis.After somedifficultyhewasableto
produce apureculture ofthetuberclebacilli.He then injectedthisintoanimalswhichsoonbecamesick
and whenheexaminedtheirdiseasedtissueshefoundtheyhadtuberculosis.Kochhadfoundthecauseof
tuberculosisgivinghopethatacurewouldeventuallybecomepossible.
IfPasteurestablishedthegermtheoryofdisease,itwasKochwhowastoturnbacteriologyintoa
science. Koch formalizedthemethodsforstudying microorganisms andproving theirrelationship with
particular diseases. To prove an organism was the cause of a disease Koch proposed the following
criteria,whichcametobeknownasKochspostulates:

1.Theorganismmustbepresentineverycaseofthedisease.
2.Itmustbepossibletoprepareapureculture,maintainableoverrepeatedgenerations.

18

3.Thediseasemustbereproducedinanimalsusingthepureculture,severalgenerationsremoved
fromtheorganismoriginallyisolated.
4. The organism must be able to be recovered from the inoculated animal and be reproduced
againinapureculture.

Clearly thethirdandfourthpostulates canonlyapply todiseaseswhich applytoanimalsaswell

as humans and the postulates were not able to be applied to all microorganisms for example viruses.
Nevertheless the postulates provided asetof proceduresfortheinvestigation of diseases which wereto
establish the causes ofarangeofdiseaseswhichopenedupthepossibilityoffindingcuresandtreatments
forthediseases.Between1879and1906themicroorganismscausingmany
diseases
were
discovered. Thediseasesinvolved includedgonorrhoea(1879),typhoidfever(1880),suppuration(1881),
glanders (1882), tuberculosis (1882), pneumonia (1882 and 1883), erysipelas (1883), cholera (1883),
diphtheria (18834), tetanus(1884),cerebrospinalmeningitis (1887),foodpoisoning(1888),softchancre
(1889), influenza (1892), gasgangrene (1892), plague (1894), pseudotuberculosis of cattle (1895),
botulism (1896), bacillary dysentery (1898), paratyphoid fever (1900) syphilis (1905), and whooping
cough(1906). The discovery of the microorganismcausingthediseasedidnot alwaysresultineffective
treatments.

Antiseptics

Theincreasein surgery producedby the useofanaestheticssimplyhighlightedanotherproblem,

the death of large numbers of patients due to infection. Patients dying from infection had long beena
problem both in obstetrics and surgery. It wasin obstetricsthat the firstunderstandingof the causes of
infectionarose,butitwasinsurgerythatthesolutiontotheproblemwasachieved.
Some doctors and surgeons sensed that a lack of cleanliness may be the cause of infection.
CharlesWhitein1773 inManchestersuggestedthecleaningofthe surgeryroom,clothingandarticlesin
contact with the patients but did not refer to cleansing of surgeons and others involved in operations.
Alexander Gordon (17521799) suggested infection was carried from infected patients to uninfected
patients. He suggested thecleansing ofsurgeonsbut did notrealise that infected matterwas involvedin
thespreadofdisease.
In the mid nineteenthcenturyIgnaz Semmelweis was workingatthe maternityclinic atVienna
General Hospital. He noticed that the section of the hospital used for training medical students in
obstetrics had amuchhigherrateofmortality,around13%thanthesectionusedtotrainmidwives,which
wasaround 23%.Explanations consideredforthevariationsinthemortalityratesincludedthatthepoor
singlemothersandprostitutesinthehospitalwerelessembarrassedwhentreatedbywomen.Semmelweis
noticed that thepuerperal fever which killedmany of the women immediatelyaftertheyhadgiven birth
seemed to be the same disease that hadkilledthesurgeon Jakob Kolletschka whodiedaftercuttinghis
finger in a post mortem. Later Semmelweis realised that medical students goingto theirsection ofthe
maternity clinic came from anatomy classes involving dissections and the handling of diseased body
parts. Little attempt was made to clean up between the anatomy classes and the work done in the
maternity clinic. Semmelweis suspected the students coming from the anatomy classes were bringing

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infectionintothematernityclinic so he ordered students towashandscrubina chlorine solutionbefore

enteringthematernityclinic. Withina monththemortalityrateinthestudentssectiondroppedto2%the
same as for the midwives section. Despite his success Semmelweis became very unpopular with the
medical students, his immediate superior and even the patients who felt he was suggesting they were
dirty. Semmelweis leftViennaforahospitalinBudapestwhereheinstitutedsimilarhygienicreformsand
again the mortality rate dropped dramatically. He published a paper on his discoveries, which was
ignored, and thena bookwhich was alsoignored. Semmelweis then began tobehave erraticallywriting
angry letters tothose whocriticised hiswork. He was sooninduced or forcedto entera mentalhospital
andwithintwoweekswasdeadincircumstancesthatmayhaveamountedtomurder.
Joseph Listerwasa surgeonin Glasgow who noticedthatthe mortality rate for compound bone
fractures wherethebone was exposedtotheairwere muchhigher thanforbroken boneswhere therewas
no exposure to the air. Broken bones exposed to the air often developed gangrene which was usually
blame on miasma or bad air. Listerdid some experimentsonfrogslegs andconcludedthatgangrene
was a form of rotting, involving the decomposition of organic material. He also read Pasteurs work
whichsuggestedthatputrefaction was therotting of organic material caused bybacteriaintheair.Lister
acceptedPasteursideathatitwasnottheairthatcausedthegangrenebutbacteriaintheair.
Thequestion was how todestroythebacteria both intheair and inthewounds.Carbolicacidor
phenolhadbeenisolated inthe1830s throughcoal tardistillation. It wasusedtocleansewersandafter
various experimentswithcrude carbolic, whichkilled tissue, Listerbegantousecarbolicacid.Hewould
dress wounds in lint soaked with carbolic acid and sprayed theair in the operatingroomwithcarbolic
acid.Lister published his work in1867 inapaperentitled
On the AntisepticPrincipleinthePractice of
Surgery
. Themortalityrates fromListers amputation operations fellfrom 45% to15%, butdespite this
somedoctorsstillrefused tobelievethatbacteriaexistedorcouldcauseinfection.Howevertheresultsof
usingListers methods soonbecameobviousand theybegantobeused throughoutEurope.Overtimehe
refined his procedures getting rid of the carbolic spray and putting greater emphasis on using heat to
sterilize dressings and instruments. There was also a move from antiseptic measures whichdestroyed
germs in wounds to aseptic measures which ensures that everything that touches the wound such as
instruments and the surgeonshandsarefree fromgerms. Towardstheendofthe19thcenturysterilized
gowns,masks,capsandrubbergloveswereintroducedforsurgicaloperations.

Antibiotics

Scientists experimentingwithbacteria had onvarious occasions noticed that penicillinandother

biological organisms could inhibitthegrowth of bacteria. In1875JohnTyndall had observed penicillin
had killed bacteriainsomeofhistesttubes. In1877Pasteurhadnotedanthraxbacilligrewinsterileurine
buttheadditionofcommonbacteria stopedthegrowth.In1885ArnaldoCanterinotedcertainbacterial
strains killed tubercle bacilli and reduced fever in the throat of a tubercular child. In 1896 a French
medical student noted that animals inoculated with penicillin and a virulent bacteria did better than
animals inoculated with the virulent bacteria only. In 1925 D A Gratia noted that penicillin couldkill
anthraxbacilli.

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Alexander Fleming was experimenting with bacteria in 1928 when he observed bacteria inhis
petri dish had been killed by the
Penicillium mould.Flemingbeganexperimenting with the mouldand
soon isolated the substance that killed the bacteria. He called the substance penicillinandthen tested its
effectiveness againstother bacteria. He found penicillincould killarangeofbacteria buttherewassome
bacteria it did noteffect.Heinjected itinto animalsand foundthatitdidnotdothemanyharm.Fleming
then published his results in 1929 and then in a briefer report in 1932. Flemings work was largely
ignoredandhethenturnedhis researchinterestselsewhere.Theprevailingscientificviewatthetimewas
that antibacterial drugs would not work against infectious disease and would be to toxic to use on
humans.Thisbeliefwastochangeafter1935 whenitwasfoundthatProntosilcoulddestroystreptococcal
infection when given intravenously. Research on penicillin only beganagain in1940,in Oxford, when
Howard Florey andErnestChaindiscoveredthat penicillinwasan unstable simple molecule.Theywere
able tostabilizeitby freeze dryingitina watersolution.Thisproducedapowderthatwastestedonmice
and didnotharmthemand curedthemof streptococci.Itwasalsodiscoveredthat penicillincouldtravel
through the body to attack infections wherever theywere.Theirresultswere published inAugust1940
and Florey, Chain and their colleagues began to manufacture penicillin as fast as possible. The first
human test of penicillin was on abadly ill policeman. Thepolicemanimproved until heseemedon the
verge oftotalrecoverywhenthesupplyofpenicillin ranoutandthepolicemanrelapsedanddied.More
penicillin was manufacturedandtestedonhumans and was foundtoregularlycleanupinfections.Itwas
found tobe effectiveagainst mostformsofpus formingcocciandagainst tetanus, anthrax,syphilisand
pneumonia.ThemanufactureofpenicillinwasgreatlyexpandedwhentheUnitedStatesbegantoproduce
it and new manufacturing techniques involving deep fermentation were developed. This involved
submerging the mouldbelow the surfaceoftheculturemedium.Eventuallysemisyntheticpenicillinsand
penicillinsthatcouldbeswallowedwereproduced.
Eventuallyasystematicsearchbeganforotherantibiotics.HowardFloreyoutlinedthe procedure
to be followed which involved the investigationof microorganismstofindout which onesproduced an
antibacterial substance, the isolation of that substance, testing the substance for toxicity, testing it in
animal experiments and then testing it on people. The search for new antibiotics was to produce a
substantial number of new antibiotics including streptomycin developed in 1944 which was effective
against tuberculosis. Chloramphenicol, developed in 1949, was effective against typhoid fever.
Antibiotics were eventually found thatcould act againstevery bacteriathatcausesdiseasesin humans.
Some of those bacteria are now developing resistance to antibiotics and the development of new
antibiotics is inhibited by the extreme cost, running into hundreds of millions of dollars,of obtaining
United States government approval for the drugs. Nevertheless antibiotics have saved hundreds of
millionsoflives.

MedicalStatistics

The use of statisticsin medicine to determine thecauseofdisease or the success of atreatment

has arelatively shorthistory.In the pastthecausesof diseaseandthe success oftreatmentswereusually
decided by physicians personal experience with patients, which, assuming that physicians had similar
experiences,lead toacceptedbeliefsastotheefficacyoftreatmentsandthecausesofdisease.Thebeliefs
would be recorded in authoritative medical texts and would in many cases become a sort of medical

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dogma. Disputing the dogma could involve accusations of unorthodox opinions that could lead tobad
practicesthatcouldendangerpatientslives.
The idea of doing trials to test the effectiveness of medical treatments were suggested by the
scientist,Johannes vanHelmontandthephilosopher George Berkeley.Thefirstknowntrialtoassessthe
cause ofa diseaseseems tohave been doneby JamesLindinanattempttodiscoverthecauseofscurvy.
Scurvy was killing large numbers of sailors on long sea voyages. Lind took 12 scurvy sufferers and
dividedthem into6 groups of 2andeachgroupwasgivenadifferentdietarysupplement.Thetwosailors
given oranges and lemons rapidly recovered and the others did not. Lind eventually published his
findings, and although there remained some confusion for sometime, eventually lemon juice became
standardonlongseavoyages.
One question, much debatedin the 18th century,waswhethersmallpoxinoculation was agood
thing. In England inoculation was generally favoured, in France it was opposed. Various calculations
were made as tothedeath rate fromsmallpoxwhich was consideredto bearoundonein ten,excluding
fatalities ofthoseunder2 years old.Othercalculationswere1in12and1in7.Thiswascomparedtothe
deathratefrom inoculation whichJamesJurin,secretaryoftheRoyalSociety, calculatedat1in91.The
Swiss mathematician, Daniel Bernoullicalculatedthatinoculationincreased the averagelife expectancy
by two years. Afurtherproblem was that people inoculated with smallpox couldspreadit toothers and
this wasnottaken into accountincalculating deathratesfrominoculation.Ifpeoplewhowere inoculated
couldbe isolatedforaperiod,thenthefiguremightnotbetohigh,but thenifpeoplewhogotsmallpox
naturally were isolated that would reduce the death rate from normal smallpox.Anadditional problem
was that the rate of smallpox infection varied considerably from large cities where nearly everyone
would, sooner or later get smallpox and the small towns and villages where most people in the 18th
century lived,andmanypeoplecould live theirliveswithoutgetting smallpox.Modernestimatesofthe
deathratefrom inoculation areashighas12%,notmuchbetterthanthedeath rate fromnormal smallpox
infection.
The difficulty in calculating accurate death rates for inoculation and for normal smallpox
infection,howto introduceinto the figures people whocaught smallpoxfromthosewhowereinoculated
and how todeal with the widelyvaryingrates ofsmallpox infection between urbanandruralareasgives
someideaof thedifficultyinworkingoutwhetherinoculationwasagoodthingorabadthing. Thewhole
debate eventually became irrelevant when vaccination with cowpox,a quite safeform ofimmunization
becameavailableattheendofthe18thcentury.Afurther illustrationoftheproblemofaccuratestatistical
analysis of medicaltreatmentsiscontainedintheworkof Pierre Louisinthefirst half of thenineteenth
century. Louis conducted several trials to test bloodletting as a treatment for various inflammatory
diseases. He concluded from his trials that bleeding resultedin patientsrecovering earlier, thanifthere
was no bleeding and that if bleeding is done, patients bleed earlier during the course of the disease
recoveredmorequicklythanthosebleedlater. However theway Louisconductedthetrialwasnotideal.
Those bleed earlier during the illness were on average 8 years and5months younger than those bleed
later,which couldexplain the fasterrecovery.A furthercriticism of Louiss study wasthatthenumbers
involved inhistrial wereinsufficientsotherewasa widemargin of errorin his resultssotheywerenot
reliable.
A more successful use of statistics to discover the cause of disease occurred in the mid 19th
century when John Snow discovered the cause of cholera. Cholera was like many infectious diseases,
assumed tobecausedbymiasmaorbadaircaused byputrification.Snowsuspectedthatcholeracouldbe

22

transmitted by personal contact and through polluted water supplies. He examined the sources of the
water supplies in London and compared it to mortality rates from cholera. Areas with clean water
supplies,dueto waterbeing taken fromthe Thamesabovesewageoutfalls,orwithfilteredwater,orwith
water passed through settlement ponds, showedmuch lowerrates ofcholerathanareas usingunfiltered
and unpondedwater taken frombelowsewageoutlets. Areaswithcleanwater had adeath rateof10per
10,000fromcholera,areaswithpollutedwaterhadadeathrateof110per10,000fromcholera.
Snow also investigated the cholera levels for households in the same areas, where the water
suppliescamefrom two separate companies,oneof whichsuppliedclean waterto its customersandthe
other which supplied polluted water. Those customers obtaining clean water had 5 cholera deaths per
10,000,thoseobtaining polluted waterhad71choleradeathsper10,000.The5choleradeathsper10,000
couldhave beencausedby visiting houses,pubsandcafeswithpollutedwater andpeoplewhohadfallen
sickwithcholera.
Snowsfinalstudyconcerneda smallareaaroundBroadStreetinLondonwhere500peopledied
of cholera intendays. Snowsuspected awaterpumpsupplyingdrinking waterin the centreof the area
couldbe responsible so heasked the localauthoritytoremovethehandlefromthepump.This wasdone
and the cholera outbreak ended. Moreparticularly Snowshowedcertain groups withintheBroad Street
area,people in aworkhouseand thoseworkinginabrewerywhodidnotusewaterfromthepumphadan
unusually low cholera death rate. Healso showedthatcertainindividualsfrom outsidetheBroad street
areawhodrankwaterfromthepumpalsodiedofcholerawithinthetendayperiod.
Snows three studies provided powerful evidence that polluted water caused cholera but his
findings were initially rejected. Two inquiries considered cholera still came from bad air and another
study which concluded that the death rate from cholera rose asonemovedfrom highlands tosea level
alsosuggested badairwasto blame.Eventually,whenmiasmictheoriesofdiseaselostcreditabilitywith
theriseofthegermtheoryofdisease,Snowsexplanationofcholerawasaccepted.
The first truly scientific randomised control test was that conducted onthedrugs streptomycin
and PASasatreatmentfortuberculosis.Tuberculosiswasinthemidtwentiethcentury,themostcommon
fatalinfectiousdiseasein thewesternworld.Its cause,thetuberclebacillus,hadbeenidentifiedbyRobert
Koch in 1885, but no effective treatmenthad beenfound for it.Antibiotics like penicillin did notwork
againstit,asithadanimpermeablewaxycoatthatprotecteditfromantibiotics.
Anewdrugcalledstreptomycin had been discoveredinAmerica in1944whichseemedtowork
against tuberculosis germs. It inhibited the growth of tuberculosis bacillus on ager plates and was
successful at curing tuberculosis in guinea pigsand whentriedon ahumanpatientwithfive courses of
treatment between November 1944 and April 1945, cured the human patient. A second drug which
showed promise as a tuberculosis treatment was PAS. It had been noted that Aspirin resulted in the
tuberculosis bacilli absorbing increased amounts of oxygenanditwasconsidered that asimilar drug to
Aspirinmight blockthesupplyofoxygento the tuberclebacilli.PASwas tried andwasshowntocause
animprovementintheconditionoftuberculosispatients.
Immediately after World WarII Britainwasshort of money and couldaffordonlya very small
amount of streptomycin. The Tuberculosis Trial Committee, encouraged by one ofits members Austin
BradfordHill,recognisedtherewasnotenoughstreptomycintoprovide toall patients,decidedtoconduct
a random controltest with thestreptomycin, providingstreptomycintoonesetofpatientsandcomparing
theresults with another set ofpatients notreceiving the drug.Therewasenoughstreptomycintoprovide
to 55 patients and the results of the treatment were compared with 52 patients who receivedtheusual

23

treatmentprovidedfor tuberculosispatients.Whichpatientsreceivedthestreptomycinandwhichreceived
theusualtuberculosistreatmentwasdecidedcompletelyatrandomtoavoidanyconsciousorunconscious
biasintheallocationofpatientstoeithergroup.
Six monthsafter the trialhad begunit wasfound that onlyfourpatientshaddiedfromthegroup
given streptomycin while fourteen had died from the group receiving the conventional treatment.
Streptomycin seemedto be aneffective treatmentwithsignificantlyfewer deathsinthegroup receiving
thestreptomycin.Howevera followup investigationthree years later revealed32 ofthegroupusing the
streptomycin had died compared to 35 in the group notreceiving the drug.Afterthree yearsthegroup
usingthestreptomycinwasonlyslightlybetterofthanthegroupnotusingit.Whathadhappenedwasthat
over the period of treatment some of the tubercle bacilli had become resistant tothestreptomycin and
whenthishappenedpatientswhoinitially seemed tobegetting better, worsenedandoftendied.The test
revealed that not only did streptomycinnot work inthelonger termbutthattherewasa problem of the
bacilli becoming resistant to the streptomycin which, if it could be over come could mean that
streptomycin couldstillbeaneffectivetreatment for tuberculosis.Ifthedrugshadsimplybeprovidedto
doctorsfortreatingpatientsitwouldhavetakenmuchlongertoworkoutwhyitwasnotworking.
A further trial was conducted which combined streptomycin with PAS with the aim of
overcoming the problem of resistance from the tubercle bacilli. In the second trial resistance to
streptomycin developed in only 5 patients comparedto 33in the firsttrial. Thecombination of the two
drugsproved tobe aneffectivetreatmentfortuberculosisandsurvivalratesfortuberculosispatientswent
upto80%.Eventuallyother drugssuchasisoniazidandrifampicinwereintroducedanditwasfoundthat
combiningthreedrugsresultedinsurvivalratesapproaching100%.
Randomcontrolledtrialswerealsofoundtobeeffectivein provingthecausesof certaindiseases.
AfterWorldWarIIthegreat majorityoftheadultpopulationsmokedandlungcancerdeathswererapidly
increasing.BradfordHill, EdwardKennaway,Percy StockandDr RichardDollwereaskedtoinvestigate
whether smoking was a cause of the increasing number of lung cancer deaths. Smoking wasonlyone
possible explanation, others such as increased air pollution especially from motor vehicles were
considered to be as likely or more likely the cause ofincreasedlungcancer deaths, thansmoking.The
asphalting of roads was considered to be another possible cause of the escalating lung cancer deaths.
Given that most adults smoked it was difficult to find a suitable control group of nonsmokers. The
investigationwas conductedby creatingadetailed questionnairewhichpatientssuspectedofhavinglung
cancer completed.Thequestionnairewas alsocompleted bypatients whohadothercancersandalsoby
patientsinhospital for reasons other thancancerto act astwocontrolgroups.Itwas foundthat99.7% of
the lung cancer patients smoked against 95.8% of the control group patients. This was not a great
difference but it was also found that 4.9% of the lung cancer patients smoked 50 cigarettes a day as
opposed to only 2% of the control group patients. The lung cancer rate amongst those smoking 50
cigarettes a day was over double for lung cancer patients than for the control group.Themorepeople
smokedthegreatertheirchancesofgettinglungcancer.
The study conducted by Doll and Bradford Hill had looked at lungcancer patientsandlooked
backintime attheir smokinghabits.Theythendecidedtodoastudyofhealthypeopleinvestigatingtheir
smoking habits and then observing how their health developed in the future. Doll and Bradford Hill
decidedtodothe study ondoctors,40,000of whomfilledinandreturnedtheirquestionnaire.Twoanda
halfyearslaterenoughdoctorshad died for DollandBradfordHill tobeableto show that themorethe
doctors smoked the greater the likelihood they had died of lung cancer. It was eventually found that

24

doctors smoking 25 cigarettes per day were 25 times as likely to develop lung cancer compared to
nonsmokers.
Thesuccessoftherandomcontroltestsonstreptomycinand inshowingthatsmokingcausedlung
cancer lead to random control tests becoming standard practice to test new drugs and to identify the
causes of disease. The testing hashaditsundesirable sidewiththetestingcosts runningto hundredsof
millionsof dollars and so discouragingtheproductionofnewdrugsandsomestudiesofdiseaseshowing
a relationshipbetween environmentalfactorsandthediseasewithoutgivinganyrealindicationofacause
andeffectrelationship.

DiagnosticTechnology

Thetwentieth centuryhasseenthedevelopmentofaseries ofnewtechnologiesthathaveenabled

physicians to see inside the human body. The technologies began withXRays, and then CT scanners,
PETscanners andMRI scannerswere developed. Thesetechnologiesallallowedphysicianstoseeinside
the body fromtheoutsidewhile othertechnologiessuchasendoscopy allowedphysiciansto invade the
bodywithtinycamerastoobservethestateoftheinteriorofpatientsbodies.
XRayswere firstdiscovered byWilhelmRoentgenin1895.Roentgenwasexperimentingwith a
Crookes tube, a glass tube with the air removed to create a vacuum and with electrodes to allow the
production ofan electriccurrent withinthe tube. The electric current, consistingof astreamofelectrons
known as cathode rays, would cause phosphorescent material within the tube to glow. When
experimentingwitha Crookestube,theGermanphysicist,PhillipLeonardhas noticed that cathoderays
couldtravelthrough an aluminiumsheethehadplaced over awindowintheCrookestubeand turnslips
of papercovered with bariumplatinocyanidesalts,fluorescent. LenardsentaCrookestube toRoentgen
for Roentgen tostudy the cathoderays.Roentgen repeatedLenardsexperiments andfoundthecathode
rays were escaping from theCrookes tubejustasLenard hadfound. Roentgenthought that the cathode
rays might be passing through the wallsoftheCrookestubeas well asthrough the aluminiumcovered
window in the tube. When conducting the experiment Roentgen noticed a screen coated with barium
platinocyanide, a yard away from the Crookes tube, turned fluorescent. This could not be caused by
cathoderayswhichonlytravel afewinches in theair.Roentgenmovedthe screenfurtherawayfromthe
Crookestubeand the screenstillturnedfluorescent whenheturnedontheelectriccurrentintheCrookes
tube. Roentgenplaced objectslikea bookanda deckof cardsbetweentheCrookestubeandthescreen
andthescreenstilllitupwhenheturnedonthecurrentintheCrookestube.Furtherexperimentsrevealed,
that the ray causing the screen to lightup, couldpenetrate awide rangeof materialssuchaswoodand
flesh. Roentgen had no idea whattheraywassohecalleditanXray.Whenahuman handwasplacedin
front of a photographic plate and exposed to Xrays, the plate showed the bones in the human hand.
HowevertheXraysdidnoteasilypassthroughmetalsandcouldnotpassthroughleadatall.
Xrays were found to have a number of uses such as in crystallography, astronomy and in
microscopicanalysis, buttheirmostimportantusehasbeeninmedicine.Xrayscanprovideaphotograph
of the inside of the human body. Xrays have a shorter wave length than light so they can penetrate
materials opaque to light. XRays can more easily penetrate materials of low density such as skinand
muscle,butcannotpenetratematerialsofhigherdensity,suchasbone,bulletsandkidneystones.

25

Theuse of xraysinmedicinewasgreatlyextendedbytheemploymentofcontrastingmediasuch
as barium salts and iodine solutions. Barium makes it possible to obtain xrays of the largeandsmall
intestineandthestomachandtheesophageus.Iodine allowsan xray pictureof the kidneysandbladder
and also the carrying out of angiographs.Angiographyprovides aview ofthebloodwithin the arteries
and veins which will disclose blockages and other problems within the arteries and veins. The use of
cathetersallowscontrastmaterialstobeinjectedintotheheartallowingxraysoftheinternalstructuresof
theheart.Xrayscanbeusedtodetecttumours,cancersandcysts.
Afurther enhancementofxraytechnologycamewiththedevelopmentofCT orCATscanners.
TheCT scanner uses xrays,photon detectorsandcomputerstocreatecrosssectionimagesortomograms
of the human body. In 1963 Allan Cormack invented an improved xray machineusingcomputers, an
algorithm and tomograms. In 1972 Godfrey Hounsfield invented the CT or computerized tomography
scanner. It allowed many xraysto be taken,frommultipleangles ofthin slicesof thehumanbody and
detectors opposite the xray tubes would collect the data, whichwasconverted into digitaldata,which
wasthenconvertedby analgorithm,asetofmathematicalinstructions,byacomputerintoxraypictures.
TheCT scanner couldgivethreedimensionalviewsofthebodyandprovidesmuchbetterresolutionthan
ordinary xray images. It can show soft tissues and liquid parts of the brain and can showtumoursas
small as one or two millimetres in size. CT scanners have gone through a series of improvements
involving various different generations of scanners. In the earlier scanners the xray beam lacked the
width and the number of detectors to cover the complete area of interest requiring multiple sweeps to
produce a suitable image. In subsequent scanners a wider xray beamand more detectors wereusedto
shortenscanningtimes.
Endoscopy, also known as laproscopy, involves inserting an instrument into the body either
throughthe bodiesnatural entrancesorthroughasmallholesurgicallycutinthebody.Theinstrument is
usedto observetheinternal structures ofthebodyandcan alsobeusedforsurgerywithtinyinstruments
attheendoftheendoscopebeingmanipulatedbythesurgeonthroughtheendoscope.
Endoscopy goes back to the late nineteenth century but was not widely used as the views it
provided of the interior of the body were to poor for practical use. HaroldHopkins, aphysicist,heard
aboutthe problemswithendoscopesandrememberedthatalthough light normallytravelled inastraight
lineitcouldincertaincircumstancesbemade totravelaroundcornersbytheuseofcurvedglass.Hopkins
considered that tensof thousandsof flexibleglass fibresoperatingtogethermay beabletocauselightto
go around corners. He made an experimental endoscope and published his results in 1954. Basil
Hirschowitz,aSouthAfrican,workingintheUnitedStates,readaboutHopkinsideasandcreatedhisown
endoscope. Several hundred thousand fibres were wound together and to stop light jumping from one
fibre to another which could cause the lose oftheimage atechniqueofcoating eachfibrewitha glass
coating was developed. The endoscope allowed investigation of much of the interior of the body and
somesurgeryontheinteriorofthebodywithouthavingtomakesubstantialincisionsintothebody.
Photographythrough an endoscope wasnotverysatisfactory due toinadequate illuminationand
because the optical system was not good enough. Hopkins investigated the problem and found thatan
endoscopeconsistingof aglasstubecontainingthinlensesofairgaveimproved lighttransmission around
eighty times stronger than conventional endoscopesmadeofanair tube containing thinlensesofglass.
This allowed the taking of photographs through the endoscope and allowed greatly expanded surgical
possibilitiesthroughthe endoscope.Endoscopy can be used for surgery byinstruments such as lasersor

26

wireloopcauterydevicesattachedtotheheadoftheendoscopeandcontrolled bythesurgeonthroughthe
endoscope.

ModernSurgery

Surgery,before the introductionof anaestheticsand antiseptic andasepticpractises,waslimited

to a narrow range of operations, of which limbamputationwas by far the mostcommon.Thequickest
operationsonly werepossiblewithout anaesthetics and the mortalityratesfrominfectionwereenormous
before antiseptic practices were introduced. The introduction of gowns, masks, rubber gloves and the
sterilizationofinstrumentsdramaticallycutthedeathrateinsurgery.
Abdominal surgery only became possible with anaesthetics and antiseptics. Christian Billroth
(182994)pioneered operations inthisarea.Operations toremovetheappendixand toclosea perforated
gastric ulcer began to be performed in the late 19th century. Brain surgery began with Sir William
Macewan (18481924) in Glasgow and Macewan also developed operationsto dealwithbone diseases
suchasrickets.
Plasticsurgerywastomakegreatprogressinthe20thcentury,twoNew ZealandersHarold Gilles
and ArchibaldMcIndoeleadingtheway.Plasticsurgerydatesbacktoancienttimesandwaspracticedin
preBritish India and Renaissance Europe when it was usedto dealwiththeterrible damagecausedby
syphilis. During World War I Harold Gillescarriedout plasticsurgeryon the badlydisfigured faces of
soldiersandsailors.Hedevelopedanoperation wherebya skinflap was sliced fromtheupper arm,one
end of the flapremainingattachedtothearmand theotherendwas mouldedoverthenoseandthensewn
down. After severalweeks the skinsewntothefacewouldtakeandtheskinattachedtothearmcouldbe
cutandsewn intoplaceontotheface.Whentheinjured had no facialskin atall Gilles took the flap of
skin fromtheabdomen rollingitoverthechestandsewing oneendtotheface.Holeswouldbecutinthe
skin for the nose, eyes and mouth. When that end had taken Gilles cut the end still attached to the
abdomen and then sewed that into place on theface.This systeminvolved twooperation asifthe skin
was completly removed from the donor areabeforeit had taken onthefaceit woulddiedueto lackof
blood supply. These techniques were further developed by Archibald McIndoe while operating on air
forcepilotsinjuredinWorldWarII.
Organtransplant hadbeen firstexperimentedwithby AlexisCarrelearly inthe20thcentury.He
carried out various transplant operations on animals discovering the problem of rejection where the
transplanted organ was rejected by the receiving animals body. The problem of rejection was
investigatedby PeterMedawarwhenhe observed skindrafts takenfrom adonor wouldlastfortendays
beforerejection,whileasubsequent skindraftfromthesamedonorwasinstantlyrejected.Whenthebody
suffersaninfectionfrombacteriaorvirusesinitiallyittakestimetoidentifytheinvadingorganismbefore
the immune system attacks the invading organism. In the event of a subsequent attack by the same
organism the organism is immediately attacked because the immune system recognises it as foreign
materialdue toits previouscontact with the virus orbacteria.The wayin which thefirstrejectiontakes
sometimebuta secondrejection of the samematerialoccursimmediatelyleadMedawartorealisethatit
was the immune system rejecting the transplant in the same way as it attacked invading bacteria and
viruses.

27

Organtransplant required apractical surgicaltechniquewhich was developed byJosephMurray

who improved ontechniquesexperimented withbyAlexisCarrelonanimals.Thetechniqueinvolvedthe
sewing together of small blood vessels which allowed the attaching of the transplanted organs blood
supply to those of the recipient so that it could receive the receipts blood. The first attempts at organ
transplant were kidney transplants. This was because humans had two kidneys, but only need one so
living donors werereadily available.Kidneytransplants werealso relativelystraightforward operations
themainjobbeingtoconnectthetransplantedorgansbloodsupplytotherecipientsbloodsupply.
Kidney transplants did however require the priorinventionof the kidneydialysismachine. The
dialysis machine was invented by Wilhelm Kolff, a Dutch physician in 1941. The dialysis machine
performs the work of thekidneyswhen the kidneysfail.This mainlyinvolves removingwastematerial
from the blood. The dialysis machine is needed during transplants to keep people alive before the
operation and foraperiod oftimeafterthe operation,oftentendaysorso,untilthedonated kidneybegins
towork.
A workable surgical technique and the dialysis machine allowed kidney transplants to be
performedand thefirstoperationwasperformedin 1954by Joseph Murray ona patientwhoseidentical
twinsuppliedthedonatedkidney.The operationwas asuccesswithnorejectionproblemsasthedonated
kidneycamefrom an identicaltwinsothattherecipients immunesystemdidnottreatthedonatedkidney
as foreign material. When howeverkidney transplantswere attemptedusingcloserelativesasdonors,the
donatedorganswererejectedbytherecipientsimmunesystemresultinginthedeathoftherecipient.
A drug known as 6mp had been developed by George Hitchings and Gertrude Elion as a
treatment for leukaemia. 6mp worked by stopping the cancer cell from dividing by appearing tobea
chemical necessary for the cancer cells division, but which was slightly differentsothatitstopped the
cancer cell from dividing and so killed the cancer cell. 6mp was tried to stop the immune system
rejecting transplantedorgansbystopping thedivision of cells intheimmunesystem.6mpwastriedon
rabbits and found to stop the rabbits immune system attacking foreignmaterial, butleaving therabbits
immunesystemotherwiseworking. Hitchings andElionalsodevelopedanewdrugazathioprinethatwas
animprovedversion of 6mp.Azathioprine was tried onpeoplebutwithpoor resultsuntilhighdosesof
steroids in short bursts were given to patients with the azathioprine. This had the desired effect of
preventing the immune system attacking the transplanted organ while still leaving the immune system
able toworkagainst ordinaryinfections. Eventuallyanotherdrugcyclosporinewas developedwhichhad
thesameeffectand transplantoperationsforotherorganssuch asthelungs,liver,bonemarrowandhearts
weredeveloped.
Improvementsinmedicineandsanitationleadtopeoplelivinglongerandanincreasingexposure
to the diseases of old age. Arthritisbecamemuchmorecommoninthetwentiethcenturythanpreviously.
Arthritis of the hip was particularlya problem causingconstantandserious painto patientsandgreatly
reducing mobility.The painwas caused bytherubbingofboneagainstboneinthehipduetotheerosion
ofcartilagebetweenthebones.
Some attempts had been made to provide artificial hipsin the 1930sand 1940s butnone had
beenparticularly successful. Amajordifficulty wasthatthehiphastomaintaintheweightofthebodyas
well as being completely mobile. John Charnley looked at the problem and came up with three
innovations that were to lead to a practical artificial hip. He redesigned the socket, he cemented the
artificialhip totheboneswithacryliccementand helubricatedthejointfirstwithTeflon andthenwhen

28

that failed with polyethylene. Charnleys new artificial hip was an outstanding success and the hip
replacementoperationwastobecomeacommonoperationinthelate20thcentury.
The heart is the most complex organ in the body andforthefirst half of the twentiethcentury
surgeons did not touch it believing that to do so would kill their patient. In the 1930s and 1940s
operations were carried out on the aorta and the pulmonary artery to ease symptoms caused by heart
problems, but the heart itself was not touched.In the late 1940s surgeons began towiden heartvalves
throughaholecutinthe walloftheheartwhiletheheartwasstillworking.However,muchheartsurgery,
known as openheart surgery, was only possible with the heart beingstopped. If theheart wasstopped
some means of maintaining the blood supply to the bodywas necessary orthe patient woulddie.John
Gibbon and his wife Mary Hopkinsbeganworkon amachinethatcould perform the work ofthe heart
and lungsin the 1930s.Themachine neededto beable toaddoxygenand removecarbondioxidefrom
the blood and to pump the blood through thebody.Themachine neededvalves toensuretheblood all
flowed in one direction and hadtouseglasstubesasplastic had yet tobeinvented.The SecondWorld
War delayed progress, but a heartlungmachine wascreated intheearly1950s. Early results werenot
promising but the machine was taken over and improved by the Mayo Clinic. Donald Melrose, in
England, andVikingBjork,inSweden,also builtsimilarmachinestoallowopenheartsurgery.Theresult
wasto beaneffective heartlung machinethatcould takeoverthefunctionsofthe heartandlungsduring
operationssoastoallowsurgeryonthehumanheart.

Analysisoftheorderofdiscoveryinthehistoryofmedicine

Thequestion oftheoriginofinfectiousdiseasewasindispute for thousands ofyears,thematter

notbeing settled until the late19th century.Theearliestculturesandcivilizationsconsideredthecauseof
diseases to be supernatural and the appropriate remedies to be appeals to the Gods and magical
incantations. Such beliefs were perfectly reasonable based upon the knowledge available to our
prehistoric ancestors and to early civilizations. They had no awareness of bacteria, viruses or other
microscopicorganisms. Given that beliefs inGodswere usedtoexplainothermysteriousevents,suchas
earthquakes,stormsandvolcanic eruptions,theGodswereanobviousexplanationofdisease.Givenalso
thatdiseasescankillhumanbeings,itwouldbereasonabletoassume theyarecaused bypowerfulbeings,
likeGodsor powerfuldemonsandevilspirits. As thebodyautomatically tendstorepairitself,duetothe
immune system, it must have appeared to our prehistoric ancestors that on occasions the magical
incantationsandappealsto the Gods had worked.Whenthepatientdiedthedeathcould beputdownto
thecapriciousnessoftheGodsorthe greatpoweroftheevil spirit,rather thantherebeinganythingwrong
withthetreatmentused.
In the west, from the time of Hippocrates, natural causes of diseases, such asthefourhumors
theory, were the favored explanation, although supernatural explanations continued to findacceptance.
The samesituation existedin China with naturalcauses of diseasesuchasinadequate orimbalanced Qi
and Yin and Yangbeingconsideredtobethecausesofdisease.AsimilarsituationexistedinIndiawhere
a balance of the three elements, air, bile andphlegmwas required for goodhealth. TheGreek, Chinese
and Indianexplanationsofdisease arequite similar allinvolvingimbalancesinbodilysubstancesandall
acquiredastatusthatmadethemimpervioustocriticismandablockoninnovation.

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The presence of blood, urine, vomit and diahorrea clearly shows the body has many internal
fluids.Vomit anddiahorreaparticularly seemtobepresentattimes ofsicknessandrecoveryoftenoccurs
after vomiting and diahorrea so that it wouldappear thatgettingridof fluidsfrom thebody couldcure
sickness. Evenbleedingwasoftenfollowedbyrecoveryfrom injury so that alimited lossofbloodcould
beseenaspromoting recovery.Itisbecause thehumanbody hasthesefluids and becausegettingridof
the fluids with vomiting, diahorrea and bleeding seemed to cure sickness and injury, ideas such as an
imbalance of fluids caused ill health arose in Western, Chinese and Indian cultures. This gave rise to
theories such as Hippocrates and Galens four humors theory and to remedies such as bleeding and
purging. TheChinesetheoryofanimbalancebetweenYinandYangcausingdiseaseappears tobeamore
abstract version of the same idea. Given the knowledge of nonscientific societies these theoriesmake
good sense.Atheorythatmicroorganisms,invisibletothenakedeye,causediseaseishardlycrediblefor
societies that have noevidenceoftheexistence ofthemicroorganisms.On the other handbodilyfluids
plainly do exist and their removal from the human body seems to be associated with recovery from
diseaseandinjury.
The medicine ofHippocrates andGalendid not just relateto the fourhumors. It alsodealt with
qualitiessuch ashot, cold,dryandwet. Thisis becausemany of the symptomsofdiseaserelatetothese
qualitiesforexample if apersonhas atemperatureor fever,they arehot, if theyare perspiring,theyare
wet.Iftheydonothaveatemperaturetheyarecold,iftheyarenotperspiringtheyaredry.Galens theory
wasbuiltup fromtheway thehumanbody acts,bothwhenitissickandwhenitishealthy.Ifthehuman
body functionedin adifferent wayitwould have ledto adifferenttypeofmedicaltheory.Ifforexample
thehumanbody changedcolorwhenitwassick,ratherthanchangingtemperature,medicaltheorywould
likely involve explanations andtreatmentsthatinvolvecolors with the aim of restoringthe patienttohis
orhernormalhealthycolor.
The traditional Chinese theoryofmedicinehas considerable similarities totheclassical theories
of Galen. The western idea of
pneuma
, a vital spirit taken into thebody bybreathing,issimilar tothe
Chinese concept of
Qi
. Galens theory of the four humors considers much sickness is caused by an
imbalance inthe bodyfluids.TheChinesetheory alsodealswithbodyfluids,knownas
JinYe
.Ahealthy
person will have the body fluids in balance, but if the body fluids are deficient, or if there is an
accumulationof fluids, sicknesscan result.A furthersimilarity betweenGalenshumoral theoryandthe
Chinese theoryis that the Chinese theoryof Yin and Yang,likethehumoraltheoryconsiderssicknessis
causedby imbalances withinthebody.TheChinesetheoryofbloodalsoemphasizesthatimbalancescan
cause sickness.GiventhatYinandYang,bodyfluidsandbloodshouldallbeinbalancetoavoidsickness
in Chinesemedicaltheory, it hasconsiderablesimilaritieswithGalenshumoral theorywhichconsiders
sicknessiscaused by imbalancesin the fourhumors. Inboththehumoral theoryandtraditionalChinese
medicinetheweathercouldcause imbalancesin bodyfluids.AfurthersimilaritybetweenGalenstheory
and traditional Chinese medicine concerns the elements.Galenstheoryuses the ideaofthefour Greek
elements,air,fire,earth and water. Eachelementisassociatedwithaparticularorgan,aparticularhumor
and with the qualitiesofhot,cold,dryandwet.Waterforexampleisassociatedwiththeorgan,thebrain,
the humor phlegm and the qualities of cold and wet. Traditional Chinese medicine uses the Chinese
elements of fire, earth, water, wood and metal. The elements are each associated with organs, one of
which isaYinorgan andthe othera Yangorgan.Waterforexample is associated with the bladder and
thekidney, whileearth isassociatedwiththestomachandthespleen.Theelementsareallinterconnected
sothatifone of the organs and its elementis inastateofimbalance,itwillaffectthe otherelementsand

30

theirorgans.Thiscouldaffecttheindividualsfacialcolorandemotionalstateaswellas thefunctioningof
therelevantorgans.TheWestern andChinesetheories of medicine weresosimilaraseachwerederived
from the same source. The source was the humanbody and the environment thatcouldaffectthehuman
body.Ifthehumanbodyandtheenvironmentweredifferentthetheorieswouldbedifferent.
The naturalistic and supernatural explanations of disease coexisted for thousands of years,
sometimeswithonedominant and other times with theotherbeingthemorepowerful. Neitherwasmore
convincing than the other, in that both sometimes appeared to work and that both sometimes failedto
work.Whentheyfailed towork,boththe supernaturalandnaturalistictheoriesprovidedexplanationsfor
thefailure.Ifthe human bodydidnothaveanimmunesystem,sothatifa persongotsicktheyinevitably
died and the incantations to the Gods and the treatment provided by doctors never worked, then the
supernatural and naturalistic explanations of disease and the treatments they gave rise to would never
have existed. It is only because the human body fights against disease, often successfully, that the
incantationsto the Godsand doctors treatments often appeared tobesuccessfulwhichsuggested thatthe
explanations of disease were true and the treatments provided were sometimes working. Both the
supernatural andnaturalisticexplanationsofdisease couldhave been provedwrong with moderndouble
blind testing, but such testing was not done in the past because itrequiredknowledge of sophisticated
statistical techniques that only became available in the last 400 years. Even in the 18th century the
English and French were unable toagree as towhether smallpoxinoculationwasdesirable whilein the
firsthalf ofthe 19thcentury Pierre Louisconductedtrialswhichshowedbleedingwasausefultreatment.
Even today, drug trials sometimes produce contradictory results. Even if testing had been done the
theorieswouldprobablyhavesurvivedduetothelackofseriousalternatives.
Itwasnot until the late 19th century with the developmentofthegermtheoryofdiseasethatthe
question of the origin of infectious disease was settled in favor of a naturalistic theory, but a theory
completely different fromany of the naturalistic theoriespreviouslyaccepted.WhenFracantoriusin the
16thcenturysuggestedcontagious diseasewas causedbytinyseedsinvadingthehumanbody,thetheory
wasquitereasonablynot acceptedastherewasno evidenceoftheexistenceofthetinyseedsorthatthey
caused disease. Fracantorius theory was almost identical to the germ theory of disease and the germ
theory was only accepted inthelate19thcenturywiththeworkof PasteurandKoch.Leeuwenhookhad
discovered microorganismsinthelate17thcenturybutthatdidnotmeanthattheycauseddisease.Infact
thevast majority of microorganismsdonotcausediseaseinhumans.Itwasonlywiththemorepowerful
19thcenturymicroscopes that Pasteur and Kochwereabletodiscoverparticularorganismswhichcaused
particular diseases in humans. Theywere ableto show theorganisms werethecausesof thedisease by
isolating the organisms and by preparing a pure culture of the organism, which in the case ofanimals
wouldthenbeinjectedintoananimalcausingthediseaseintheanimal.This procedureknownasKochs
postulate established the germ theory of disease and was able to show which particular germs caused
whichdisease.
Theexplanationsofinfectiousdisease werebasedupon the knowledgeavailabletoasocietyata
particular time.Whenthatknowledge changed(thediscoveryofmicroorganisms and thediscoverythat
someof them causedisease) the explanations of diseasechanged. Societies thatconsideredtheactivities
ofsupernaturalbeingsasexplainingotherwiseinexplicablephenomenausedsupernaturalexplanations for
the cause of infectious diseases. Supernatural explanations and naturalistic explanations of disease
coexisted for thousands of years. Eachwasasconvincing as the other until the germ theoryofdisease
arosein the late 19thcentury.Naturalisticexplanationsofdiseasewere baseduponthenaturalworld,and

31

in particular, onthehumanbodyitself.Bodyfluids,organsandtheelementsofthenaturalworldallhada
prominent role in both Western and Chinese naturalistic explanations of disease. The Chinese and
Western explanations of disease were similar because they had similarknowledge ofthe natural world
and of the human body, so they developedsimilar theoriesto explain the origin ofdisease.Ifthenatural
world and the human bodyweredifferent,thenthetheoriesexplainingdiseasewouldhavebeendifferent.
When human knowledge of the natural world increased, with the discovery of microorganisms inthe
17thcenturyandthediscoveryinthelate 19thcentury thatsomeofthosemicroorganismscauseddisease
in humans,thetheoriesexplainingthecausesofdisease changed.Thegermtheoryof diseasebecamethe
acceptedexplanationofinfectiousdiseasethroughoutthewesternworld.

Thepractice of immunization(themodern namefor vaccination, alsoknownasinoculation)has

been one of the most successful medical practices in history. It has been responsible for anenormous
reduction inhumansuffering andhas savedan enormous numberof human lives. The injection ofdead
bacteria or their toxins, or dead or weakened viruses into the human body to create immunity against
disease, has eliminated or controlled a considerable range of diseases. Immunization has been used
successfully against anthrax, bubonic plague, chicken pox,cholera,diphtheria,Haemophilusinfluenzae
type B, mumps, paratyphoid fever, pneumococcal pneumonia, poliomyelitis, rabies, rubella (German
measles),Rocky Mountain spotted fever,smallpox,tetanus,typhoid,typhus,whoopingcough andyellow
fever.
Immunization worksbecause the bodiesnatural defences againstinfection areable toremember
dangerous bacteriaandviruses they have already had contactwithandareabletoreactmorequicklyand
more strongly to later infections from thesameorganism.Whenaninfectionoccurs certain cellsin the
body respond by moving to destroy the invading bacteria or viruses. In order to destroy the invading
bacteria orvirusesthebodysimmunesystem, acollectionoffreemoving cells,has torecognisewhich
materialsin thebody are foreign invadersandwhatispartofthe body. Itdoesthisbymatchingtheshape
of receptorsonthe surfaceofdefendingcells totheshape of the surface oftheinvadingorganism andif
they fit together the defendingcellsrecogniseaninvadingorganism. Oncerecognitionofaninvaderhas
takenplaceotherdefending cells willattackanddestroytheinvading organisms.Thedefendingcellscan
also produce memory cells which, in the event of afutureinvasion bythesameorganisms,areable to
immediately clone large numbers of the appropriate defending cells to attack the invading organism,
withouthavingtogothrough the process of recognisingtheinvadingorganism. This makestheimmune
systems responsetoinvading organisms, which it hasrecognised before, muchstronger,fasterandmore
effective.Thisprocessknownastheamplificationof the response,isthebasisforimmunization.Adead
or greatlyweakened infectious organismisinjectedintothehumanbodysothatthedefendingcellswill
remember the organism, so that in a future attack the immune system doesnothave togo throughthe
recognition process and can immediately attack the invading organisms with large numbers of cloned
defendingcells.
If the body did not work in this manner,forexample if itdid notproduce memorycellswhich
instantly recognise invadingorganisms,theprocessofimmunization wouldnotwork. This would mean
that the wide range of diseases immunization is effectiveagainst wouldstillbekillingvast numbersof
people.
Smallpox was thefirst infectious diseasetobetreatedwithimmunization,partlybecause it was
one of the worstandmost persistentdiseasesinhistoryandpartlybecause natureprovidedareadymade

32

immunizing material, in the form of cowpox, which saved people from having to identify, isolate and
produce a safe vaccine. The high mortality rate from smallpox andthe observationthatsurvivors were
protected fromfutureattacks,whichcouldonlybeobserved withadiseasewhichwascontinuallyoroften
present made smallpox the obvious disease to immunize against. A disease which came and then
disappearedoftenfor centuriesisalessurgentcasetoimmunizeagainst asitmaywellnotcomebackfor
centuries making immunization unnecessary. Given that smallpox was often or continually around it
made sense toimmunize againstit.Italso made it more easilyobservablethatsurvivorswereprotected
against future attacks. This wasnot so easilyobservable with diseases whichinvolved major epidemics
and then disappeared for long periodsoftime,sotherewere nofutureattacksfromwhichthevictimsof
earlier attacks couldbe shownto beimmune.However earlyattempts atvariolation weresodangerous,
thatitisnotsurprisingthatitneverreallycaughton.
Thereasonwhysmallpoxwasthefirstdiseaseeffectivelytreatedwithimmunizationwasbecause
nature provided, in cowpox, a ready made vaccination material which was not dangerous to human
beings.To produce effectivevaccines for other diseases itwasnecessarytodiscoverthebacteriaorvirus
involved, to isolate it and to reproduce it. This process enunciated in Kochs postulates could only be
done with bettermicroscopesthanwasavailableinthe18thcentury.Italsoneededtheunderstandingthat
germs cause infectious disease which was not established until late in the 19th century byPasteurand
Koch. This understanding was notneeded forsmallpox,whereitcould beempiricallyobserved,evenby
milkmaids, that the natural vaccine, cowpox, prevented smallpox. With the other diseases it was
necessaryto understandthegermtheoryofdiseaseandthentoartificiallyproduceavaccinebeforeit was
possible to immunize against those diseases. The process of immunizing against smallpox was a lot
simpler than the process of immunizing against other diseases, so immunization against smallpox
occurredbeforeimmunizationagainsttheotherdiseases.

Thetaboo onhumandissection appliedinmost humansocieties,exceptIndia,AncientEgyptand

Europe since the Renaissance. The resultwassubstantiallyerroneous beliefs concerninghuman anatomy
and physiology. Beliefs that the heartwas the centre of thought,sense perception andcontrolledbodily
movements, while the brain cooled the heart and blood held by Aristotle resulted from the taboo on
humandissection. When thetaboowasnotpresent,suchasinAlexandriaduringthePtolemaic era,itwas
discovered that the brain dealtwithsenseperceptionandbodilymovements.Furtherprogressinanatomy
and physiology was delayed until the Renaissance when some dissections of the corpses of executed
criminals was allowed. This eventually resulted in the anatomical discoveries of Versalius and the
circulation of the blood by Harvey.Manyfuturedevelopments inmedicine,especiallyinsurgery,were
dependant upon the newknowledge of anatomyandphysiology obtainedfromtheliftingofthetaboo on
humandissection.
Progress in surgery was also dependent on the discovery of anaesthesia and antiseptic and
aseptic practices. There were two main consequences from the discovery of anaesthesia.Thefirst was
thatsurgerybecamefarmorecommonaspatientsnolongertriedto avoidit.Thesecondwasthatsurgical
operationsbecamea lotlongerwithemphasisbeingonprecisionandaccuracyratherthanonspeed.With
increasing time being spent on operations more intricate and complex operations could be performed
which greatly widened therangeofoperationsavailable. Withmuch longeroperationsandtheneed for
anaestheticsandanaesthetiststhecost ofoperationswent upas didthestatusofsurgeons whowerenow

33

able to do so much more for their patients. Surgery became a practical solution to many medical
problems.
The idea that cleanliness was important to stop infections in surgery and obstetrics was only
accepted after Pasteur had established the germ theory of disease which showed thatbacteria intheair
caused infections. Prior to the germ theory of disease being accepted suggestions that cleanliness was
important,were ignoredasthere seemed tobeno reason whycleanlinesscouldstopinfection or lackof
cleanliness could cause infection. Thediscoverythatinfectionwascausedby bacteriaintheair, lead to
the antiseptic idea of killing the bacteria to stop infection and then to the aseptic idea of sterilising
everythingthatcameincontactwiththepatient.
Theendingofthetaboo onhumandissection resultedin vastlyimprovedknowledgeofanatomy
and physiology,this,andthediscoveryofanaesthesiaandtherealisationof theimportanceof aseptics,
formed the basis of modern surgery. Only when these developmentscametogether, wasit possible for
modernsurgery,withitssophisticatedandintricateoperations,tobecomeareality.
Thislead tonew types of surgery whichhadneverbeforebeendevelopedsuchasabdominaland
brain surgery. Plastic surgery, which had been practiced crudelyin thepast, improved enormouslyand
later lead to cosmetic surgery. Hip replacement operations were developed after the invention of a
practical artificalhip.Organtransplants began whensurgicaltechniquesweredevelopedforjoiningsmall
blood vessels and when the problem of rejection of donated organs was solvedby the developmentof
appropriatedrugs.Kidneytransplantsdevelopedrapidlyaftertheinventionofthekidneydialysismachine
as it is a relatively simple operation and because there is a bettersupplyof donatedkidneys as human
beings have two kidneys and only need one so as to allow transplants from living donors. Open heart
surgery and heart transplants were developed after the invention of theheartlungmachinetokeepthe
patientaliveduringsurgery.
Theuse of antibiotics inmedicineis only possible becausenature providessuchorganismsthat
inhibit the growth of bacteria and allows the production of synthetic compoundsthatachieve the same
result. If nature did not provide these organisms, or allow such compounds,therewouldhave beenno
antibioticsusedinmedicine.Withoutantibiotics,medicinesincethe1940s, wouldhavebeenmuchless
effective and hundreds of millions,whowerecuredof infectionswouldhavedied. Thediscoveryanduse
of antibioticswasimpossiblebeforethedevelopmentofmicroscopescapableofobservingbacteria.Only
whensuchmicroscopesexisted was it possible toobserve that certain organisms werecapableofkilling
or inhibiting bacteria. Anumberofsuchobservationswere madein the late 19th andearly20thcentury
and eventually it was realised that penicillin, a substance taken from one of those bacteria killing
organisms, could be used against infectious disease. When penicillin was proved to be effective, a
systematic search was made for other antibiotics which resulted inthe discovery ofa numberof other
antibiotics.However it was only becausenature hasprovidedtheantibiotics,thatwe havethemandwe
haveonlyhadthemsinceweacquiredtheknowledgeoftheirexistenceandofhowtousethem.
Theuse of statisticsin medicine hasbeen of enormous usein showingthecausesofdiseaseand
in assessing the effectiveness of treatments. Yet statistics are never ableto providea perfect answerto
questions of drug effectivenessandthecausation ofdisease. Theymayshowa corelationbetweentwo
variables,forexamplepeoplelivingclosetotheseahavehigherratesofcholera,thanpeoplefurtherfrom
thesea. This does nothowever mean that proximitytotheseacausescholera.Corelationdoesnotprove
causation asthe correlatedvariable may be caused byathirdfactor,suchaspollutedriverwaterwhichis
more common closer to the sea. The third factor, often called a lurking variable, may well not be

34

consideredinthedatasonoeffortismadetocomparecholeraratesamongpeople drinkingpollutedwater
close to the sea with those drinking clean water close tothesea.Ifthecomparisonwasmadeitwould
show that it was the quality of drinking water rather than proximity to the sea that was the important
variable concerning cholera rates. When trying to discover the cause of increasing lung cancer after
World WarII,air pollutionandasphaltingofroadswereconsideredlikelycausesasbothwereincreasing
at the time lung cancer rates were increasing. Working out which variable to study when trying to
discoverthecausesofdiseasecanbeverydifficult.
Afurther problem concernstryingtoensurethechosensampleisrepresentativeofthepopulation
whichisbeing studied. Pierre Louis concludedbleeding wasa usefultreatment,butoneofthegroupshe
studied was substantially younger than another group. The sample must also be of sufficient size or
simple coincidence and high margins of error may provide misleading results. Pierre Louis study of
bleedingwascriticisedforhavinginsufficientnumbersinhissample.
Given the difficulties of doing good statistical studies it is not surprising that the causes of
diseases and the effectiveness of treatments were never accurately assessed until recently. Modern
statistical methods were only developedin the17th,18thand19thcenturiesand arosefromprobability
theory. It was only with the development of modern statistical methods that it has been possible to
identify the causes of many diseases andtoevaluatetheeffectiveness of treatments. Even with modern
statistical methodsthecauses of some diseases,forexamplesomecancers, are still difficult topinpoint.
Often different studies of the same phenomena will produce different results.Inthesecircumstancesit
was impossible for people in the past to discover the effectivenessoftreatmentsand the real causes of
diseaseuntilthediscoveryofmodernstatisticalanalysis.
Modern diagnostictechnologybeganwiththediscoveryofXrays. Xrayshowevercouldnotbe
discovered until certain earlierdiscoverieshadbeen made.Xrayswere discoveredthrough the useofa
Crookestubewhichrequiredpriordiscoveriesofanefficientairpumptocreateanearvacuuminthetube
and theability tosendanelectriccurrent throughthetube.Onlywhenthesediscoverieshadbeenmade
wasitpossibletodiscoverXrays.TheuseofXrayswaseventuallyimprovedandextendedbytheuseof
contrastingmediaandeventuallybyCTscannersaftertheinventionofcomputers.
Xraysarea formofelectromagneticenergyandareusefulduetotheirpropertyofbeingableto
pass through matter of low density but not matter of high density. This allows Xrays to be used to
produce photographsoftheinteriorof thehumanbody,whichiswhyXraysare so usefulinmedicine.It
isonlybecausenaturehasprovidedsuchaformof electromagneticenergythatwehaveXraysavailable
to be usedfor medicaldiagnosis.If naturehadnotprovidedelectromagneticradiation withthatproperty
wecouldnothavetheabilitytoseeinsidethehumanbodyformedicalpurposesbymeansofXrays.
Endoscopy only becamepractical when HopkinsandHirschowitzdiscoveredapracticalmethod
to make light travel around corners. It was only becausesucha method existsthatweareable to have
modernendoscopy, and modernendoscopycouldnotexistuntilthediscoveryofhowtomakelighttravel
around corners. Endoscopy was further enhanced when Hopkinsdiscovered that thin lenses of airgave
much greater light transmission than thin lenses of glass, so as to allow much better endoscope
photography. If such lenses did not provide improved light transmission, then endoscope photography
mightstillnotbepractical.

Our brief examination of the history of medicine has shown how the environment relevant to
medicine has effected the historyof medicine.The relevantenvironmentincludes the human body, how

35

the human body works, the diseases that attack the human body, how the materials in the environment
effect the human body and how the body reacts todiseaseand injury.Ifthe human bodywas different
then the history of medicine would have been different. If, for example,therewasno immune system,
then a lot of the confusion concerning the effectiveness of treatments used in the pastwould nothave
existed. When patients treated with prayers, incantations, herbs, medicines, moxabustion and bleeding
recovered, itlooked asthough the treatmenthadworked. Ifpatientsdiedallthe time,astheywouldhave
ifthere wasnoimmunesystem,itwouldhave beenclearallthesetreatmentswerefailingandtheywould
have been abandoned. If there was no immune system then modern treatments such as immunization
wouldnot work andwouldnotbeavailable.Ifthehumanbodywasdifferent,thetheoriesastowhatwent
wrong with it when people got sick would have beendifferent.Galens humoral theoryandtraditional
Chinese theorieswerebased onthehumanbodyandhowitbehavedinsicknessandinhealth.Ifthe body
wasdifferentthenthosetheorieswouldhavebeendifferent.
Anaesthesiawasonlypossibleasmaterialsinthehumanenvironmenthadthepropertyofmaking
peoplesounconsciousthat theycouldnotfeelpain.Xrayswereonlypossibleaselectromagneticenergy
of acertainwave length willpass throughmatter of low densitybut not matterofhighdensity.Modern
endoscopy is only possible because light can be made to travel around corners and thin lenses of air
provide excellent light transmission. The use of antibiotics is only possible due to bacteria killing
organisms existinginthehumanenvironmentandtheability tocreatecompounds that will killbacteria.
Theproperties ofmaterialsandmatterandformsofenergyintheenvironmentdeterminewhatispossible
inmedicine.
Whenknowledge of the environment relevanttomedicinechanged,thisresultedinnewtheories,
such as the brain being the centre of thought and emotions rather than theheart, the circulationof the
blood and the germ theory of disease. These ideas werethelogicalexplanationsofthenew knowledge
that human beings had acquired, just as the previous theories were the logical explanations of the
knowledge humans possessed at those times. Increasing knowledge of the environment relevant to
medicine also lead to the development ofnew treatments such as anaesthetics and newdrugs.Thenew
theories and treatments inevitably had significant social and cultural consequences,such asgreater life
expectancy, reduced suffering and different attitudes concerning religious beliefs, all of which would
themselvesresultinfurthersocialandculturalconsequences.
Where taboos existed against the acquisition of new knowledge, such as the taboo on human
dissection, then the acquisitionofnew knowledgewillbedelayeduntilthetabooisremoved.This,inthe
case of medicine,meanterroneous ideas ofhumananatomyand physiology continued for as long asthe
taboo remained in place. Only after the taboo was lifted was it possible to make the anatomical
discoveriesofVersaliusandforHarveytodiscoverthecirculationoftheblood.

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