1. health and fitness

GCSE Paper One – Medicine Through Time Contents – Section A ‐ Section B ‐ Section C ‐ Section D ‐ Public Health (i) From Ancient Greece to the Renaissance (ii) In the Industrial Age (1750‐1900) (iii) Since 1900 Surgery and Anatomy (i) The Ancient World (ii) The Middle Ages and Renaissance (iii) Since 1800 Disease and Infection (i) Ancient World (ii) Middle Ages and Renaissance (iii) In the Industrial Age (1750‐1900) (iv) 1900 to the Present Day Advice on answering exam questions Section A – Public Health This section is worth 26 out of 50 marks in your exam. Public Health is to do with the standard of people’s living conditions. This includes the quality of housing, water and the disposal of waste. Public health is mostly the responsibility of governments. Some governments in the past have done more than others to improve the health of their people. (i) From Ancient Greece to the Renaissance Ancient Greece The Greeks believed in the importance of a balanced and healthy lifestyle. This fitted in with their belief in balancing the four humours. As a result, the advice Greek doctors gave to their patients was:  Do not eat or drink too much  Keep clean by going to the baths regularly  Stay fit by exercising These are all sensible points and there were a large number of bath houses in Greek towns and cities. However, there were still epidemic diseases in Ancient Greece such as outbreaks of plague because the towns were quite cramped and overcrowded with only basic systems for getting rid of waste. Ancient Rome The Romans prided themselves on being practical and using their common sense. They realised that the dirtier parts of towns and cities always had the most diseases. As a result, the Roman government invested a lot of money into public health facilities:  Bath houses were built in every town/city  Reservoirs were created and aqueducts built to transport fresh, clean water to towns and cities. This water was carried through pipes to larger buildings and drinking fountains.  Sewers were constructed to take away human waste from toilets. Most towns had public lavatories which were built over the sewers. The sewers were flushed with water which had already been used in the bath houses. The Romans, therefore, had reasonably good standards of public health (although they were nowhere near as good as nowadays). Like the Greeks, however, ancient Rome also suffered from outbreaks of plague and other epidemics. The larger towns and cities were overcrowded and the poorer areas quite dirty. The quality of Roman roads and transport meant that these diseases actually travelled faster across Europe in the Roman Empire than they had done before. The Middle Ages Public Health declined in the first half of the Middle Ages before recovering towards the end back to around the same standard as the Romans. The Dark Ages (500 ‐1000 AD) When the Roman Empire collapsed around 500 AD, the tribes which took over control of Europe did not have the same knowledge or expertise about public health. Most of the Roman facilities such as bath houses, reservoirs and aqueducts fell into disrepair and were not used. Public health in the Dark Ages was poor, for example in Saxon and Viking England:  Life expectancy was low  Infant mortality was high  Many women died young, particularly in childbirth  There were high levels of bone and joint diseases such as arthritis and rickets  Waste was left in the streets and trodden into the ground  Rivers were used for getting rid of waste but also for drinking water  Animals lived in the same houses as their owners The main reason for this decline is that the rulers during the Dark Ages were not very strong or rich and were constantly fighting for survival. This meant that they spent most of the money they had on warfare rather than public health. The Later Middle Ages (1000 – 1450 AD) Public health began to slowly improve in the second half of the Middle Ages for various reasons:  Houses destroyed by war, e.g. the Norman Conquest in England (1066), were rebuilt to better standards – there were more stone houses; more houses had separate accommodation for animals; more houses had two storeys.  People were starting to make the connection between the dirty conditions in towns and the outbreak of diseases. Kings in the Middle Ages issued several orders to clean up the streets, e.g. Edward III during the Black Death (although these orders weren’t always carried out).  Butchers were ordered to carry out their trade in separate areas of towns.  Teams of ‘rakers’ were employed in many cities to clear up waste on the streets. There were also fines for dropping waste on the streets.  Sewers were built to carry waste and dirty water into the rivers.  Cess pits were lined with brick or stone and emptied fairly regularly.  Wells were dug to get access to cleaner water. There were clear improvements to public health in the second half of the Middle Ages, however, there were some major limitations: ‐ The government was not strong or rich enough to enforce the new laws about keeping streets clean strictly, so many people ignored the laws and carried on throwing waste into the streets. ‐ Life expectancy did not improve that much because people did not know the real cause of disease and little could be done to prevent outbreaks such as the Black Death (1348). The Black Death (1348) and the Great Plague of London (1665) These two events were outbreaks of the same disease – plague –but were over 300 years apart. This fact alone suggests that not a lot had improved between the Middle Ages and the Renaissance in terms of public health. There were some differences in how people reacted to the two outbreaks, although there were many similarities too: Similarities in people’s reaction to the Differences Black Death and the Great Plague of London Natural Approaches Natural approaches  Some people believed that the plague was  There was a more comprehensive system caused by polluted air (miasma) so they of containing the plague in 1665, which is carried around sweet smelling herbs and why it did not spread outside of London: perfumes. ‐ Examiners were appointed to find out the cause of all deaths  The government ordered the streets to be ‐ Houses where someone had died of the cleaned as they realised there was some plague were shut up and marked with a connection between dirt and disease. red cross. The surviving relatives had to live in quarantine for a month.  Some people pressed chickens against the ‐ Watchmen were appointed to make plague sores in order to draw the poison out. sure no‐one left a quarantined house. Other people burst the buboes to get rid of ‐ The dead were buried before sunrise or the disease. after sunset so that as few people as possible came into contact with the Supernatural approaches body. The dead were also buried at least six feet underground.  Some people believed that the plague was ‐ Public entertainment was banned, e.g. sent by God as a punishment and that praying sports, theatres, so that infected people to God was the best way of getting rid of it. could not spread the disease to others.  Some people used magic spells and charms to ward off the plague, e.g. wearing ‘Abracadabra’ necklaces.  Some people believed that the plague had been caused y the position of the planets. (ii) Public Health in the Industrial Age (1750 – 1900 AD) The Growth of Towns and the Problem of Poor Living Conditions Between 1750 and 1900 the size of Britain’s towns and cities grew very rapidly due to the industrial revolution when more and more factories were being built. This rapid urbanisation led to serious public health problems. This was because:  The growth of towns and cities happened so quickly that the government had very little control over it.  The new houses were built by private landlords who were only interested in profits. As a result, they spent as little as possible on the houses and charged people as much rent as they could get away with.  There were no laws concerning the quality of new housing being built. Most people at the time believed it was not the government’s job to get involved with private business and people’s living conditions (this was the ‘laissez‐faire’ attitude). This situation created living conditions which were very bad, for example: ‐ There were no sewers for taking away human waste. Hundreds of people often shared a privy (toilet) which just emptied into a cess pit dug into the ground. ‐ There was no system of refuse disposal, so rubbish just built up on the streets. ‐ Water was often taken from rivers which were used for dumping waste. ‐ Houses were overcrowded. Whole families often lived in just one room. The poorest people lived in cellars which could flood with sewage water when it rained. ‐ Houses were so poorly built that they were often damp. ‐ Streets and courts were so narrow that there was very little ventilation. This led to serious air pollution which caused many lung diseases, e.g. tuberculosis. Cholera The most frightening killer disease of the 1800s was cholera. It spread when water became polluted with the excrement of cholera victims (people did not know this till later in the 1800s). The first cases of cholera in Britain were in 1831/32. The disease killed people through dehydration and was very painful and agonising. At first, people in the 19th century came up with different ideas about the cause of cholera:  The most common explanation was that cholera was caused by miasma (polluted air). This made sense to a lot of people because the worst outbreaks of cholera were in the smelliest parts of towns.  Some people still believed that cholera had been sent by God as a punishment for sinning.  Others believed that cholera tended to affect those who lived an ‘intemperate’ lifestyle, i.e. they drank too much. Many towns did take action to prevent cholera from spreading, although none of these measures would have been effective in preventing the disease:  They ordered that the streets be cleaned.  They set up quarantine hospitals to isolate the victims.  They ordered that barrels of sulphuric acid be opened in the town to purify the air.  They ordered local residents to ‘limewash’ (disinfect) their houses.  Most notoriously, in London, Edwin Chadwick ordered that all of London’s waste be flushed into the River Thames. He thought that this would get rid of the smell (miasma) which was causing the disease. Unfortunately, this act just made it worse because the Thames provided a lot of London’s drinking water. In 1854, Dr John Snow discovered the true cause of cholera (i.e. polluted water). He proved this by:  Removing the handle to the Broad Street water pump in central London. After he did this, there were no more cases of cholera in that area.  By pointing out the case of an old lady who now lived in Hampstead, but who had water from Broad Street sent to her every day because she liked the taste (yuk!). She got cholera but no‐
one else in her neighbourhood did.  Explaining why the brewery on Broad Street had no cases of cholera. Snow pointed out that this was because the brewery had its own water supply which was not polluted. However, Dr Snow found it difficult to convince other doctors and public health officials that he was correct. It was hard to overcome their commitment to the miasma theory. Snow was helped after 1861, when Louis Pasteur proved that germs cause diseases and that germs could be found in water as well as the air. Improvements to Public Health in the 19th century Edwin Chadwick and the 1848 Public Health Act: 1842 ‐ Chadwick wrote a bestselling report into the living conditions in towns. He pointed out that the life expectancy of the richest people in cities was lower than that of the poorest people in the countryside. 1847 ‐ A new Public Health Act, proposed by Chadwick and others, was defeated in Parliament. The MPs who voted against were nicknamed the ‘Dirty Party’. They were against it because:  They did not want to pay higher taxes to fund cleaning up towns.  They believed in the laissez‐faire attitude that it was not the government’s job to interfere in people’s everyday lives.  No‐one was sure of the real cause of disease. The ‘Dirty Party’ argued that they might be wasting their money on measures that wouldn’t work. 1848 ‐ Cholera returned to Britain. This scared a lot of people into supporting the campaign for cleaning up. The Public Health Act was passed by Parliament. It said: 
Local councils could set up a Board of Health if 10% of the richer taxpayers wanted one. 
Local councils had to set up a Board of health if the death rate was above 33 per thousand 
Local councils had the power to connect houses to sewers; supply clean water; provide public parks; raise local taxes to pay for the improvements. 
A General Board of Health was set up in London with Chadwick as its chairman. The 1848 Public Health Act had some positive impact but was also limited: Positive impact of the 1848 Act Limitations ‐ The Act was permissive not compulsory. In  It was the first time that the government had other words councils could act if they accepted responsibility for the health of the wanted to, but didn’t have to. Many nation. It challenged the laissez‐faire attitude. councils chose to do nothing because they were worried about the cost of cleaning up.  2500 miles of sewers were built in the next 8 Only 1/6 people in Britain were covered by a years. Board of Health by 1853.  Public Health was now considered an important national issue and was kept in the headlines. ‐ Chadwick was a difficult man to work with. He made enemies out of the doctors, engineers and civil servants who he should have used to help him. ‐ Mistakes were made, for example when Chadwick flushed London’s waste into the River Thames which only made cholera worse. The 1875 Public Health Act The 1875 Public Health Act was more effective because it was compulsory. All local councils now HAD to provide clean water, proper drains and sewers and appoint a medical officer of health. There were various reasons why this more effective act was possible in 1875 but not in 1848:  In the summer of 1858, Parliament had had to be evacuated because the River Thames smelt so bad. This forced Parliament to give the go ahead to Joseph Bazalgette to build a new system of sewers for London which was very successful. This proved public health measures worked.  Prominent campaigners, such as Octavia Hill, put pressure on the government to make a firmer law. Octavia Hill herself bought run‐down apartment blocks and renovated them. She then rented them out at reasonable rates to poorer families. She also ran courses on how to run a healthy household.  Louis Pasteur had shown that germs cause disease, so the Dirty Party couldn’t argue anymore that their money might be wasted.  Cholera returned in 1866 which frightened more people into supporting a stronger Public Health Act. (iii)
Public Health since 1900 Poverty in 1900 Despite the improvements which happened in the second half of the 19th century, many people in Britain still lived in poverty. This was revealed around the year 1900 in various ways:  Charles Booth wrote a report into the lives of working class people in London in 1889. He organised a team of researchers to investigate the circumstances of all streets in the city. He concluded that about 30% of people lived in real poverty. He proposed that the government should take more responsibility for the well‐being of the people, e.g. through introducing Old Age Pensions. Some opponents argued, however, that London was unique and other towns weren’t as bad.  Seebohm Rowntree published a report into living condition in York in 1901. He found that 28% of people in York were living below the poverty line, which meant that they did not have enough money to ensure the health of their family. His study proved that it wasn’t just London that had high levels of poverty. Rowntree was friends with David Lloyd George who was a prominent politician in the Liberal Party. Lloyd George agreed something had to be done to help the poorest people in society.  During the Boer War (1899‐1902), 40% of men who volunteered to join up were rejected because they were medically unfit for service. This revealed to the government how poor a lot of people’s living conditions and diets were. The Liberal Social Reforms (1906‐11) The Liberal Party won the election in 1906 and decided to take action to improve the welfare of poorer people in society. The leading figure in the Liberal Party arguing for these changes was David Lloyd George. The reforms included: 1906 ‐ Local authorities were encouraged to provide free school meals for the poorest children. 1907 ‐ School medical checks were introduced to monitor the health of the nation’s children. The first health visitors were appointed to advise new mothers. 1908 ‐ Old Age Pensions were introduced in order to help older people to survive. 1909 ‐ The building of back‐to‐back houses was banned 1911 ‐ The National Insurance Act was passed to provide a scheme for workers to pay into which would give them some money to feed their families if they lost their job or were too ill to work. The workers could also got to see a doctor paid for by the insurance scheme. The reforms were successful, although there were a couple of limitations: ‐ The wives and children of workers in the National Insurance scheme were not covered, so they still had to pay if they wanted to see a doctor. ‐ The Liberals did not do much to improve the existing slum housing which was still in a very bad state. The 1920s and 1930s Between the two World Wars there were some small improvements in public health in Britain but progress was limited. The main problem holding back progress was the economic depression which followed the Wall Street Crash of 1929. This meant that the government had much less money to invest in public health. The main improvements which did happen were:  1919 Housing Act – this provided government money for the first time for the building of council houses. Lloyd George was now Prime Minister and he promised ‘Homes Fit for Heroes’ for the soldiers returning from the First World War. These council houses were of good quality, e.g. with indoor toilets, and were rented out at reasonable rates. By 1930, one million new council houses had been built.  1930 Slum Clearance Act – the government realised that more had to be done for the poorest people who still lived in terrible slums. A fiver‐year programme was started to knock down the worst slums in each city and built better quality but affordable council housing instead. This was a huge job and although progress was made, by 1939, there were still a lot of people living in slum housing. The other main problem which remained was the uneven access to doctors and hospitals. Most people had to pay to go to the doctor or to be treated in hospital. Many poorer people could not afford this, so they still had to rely on basic remedies passed down through the family. 1920s Council Housing The Impact of the Second World War (1939‐45) The Second World War had a positive impact on the attitude of the government to improving people’s health. The government wanted as many people as possible to be fit and healthy to help the war effort. They did various things which made a difference:  Rationing – this actually improved the health of many poorer people because it provided them with a more balanced diet.  Poster campaigns – the government produced a number of posters advising people on how to stay healthy. The most famous slogan was – ‘Coughs and Sneezes Spread Diseases.’  Immunisation – the government organised a national diphtheria immunisation campaign which combated a disease which still affected thousands of people every year.  Evacuation – children from the cities were evacuated to safer countryside areas. The poor health of a lot of these children shocked many people and the government realised that there was still a lot to be done to improve the health of everyone in the country.  The Beveridge Report – the most important thing the government did during the war was ask William Beveridge, a civil servant, to produce a report about how to make Britain a better place after the war. One of his recommendations was for a National Health Service to be set up. He also said that the government should create a Welfare State to support people and keep them out of poverty ‘from the cradle to the grave.’ The National Health Service (NHS) After the Second World War, the Labour Party formed the new government. They were committed to introducing all of the changes proposed by William Beveridge. In 1946, they passed a law stating that they would set up the NHS by 1948. The key thing about the new NHS was that it was to be free for everyone. Surprisingly, they ran into quite a lot of opposition to this plan. Opponents of the NHS included: ‐ Many doctors who were worried because they thought they would be paid less in the NHS than they were earning as private doctors. Many doctors were also worried that they would lose their independence and that the government would tell them what hours they had to work and maybe even where they had to work. ‐ Some richer people who were worried that the new NHS would be very expensive and that would mean they would have to pay higher taxes. ‐ Charities and local authorities who ran most of the hospitals were not very happy that they would have to hand them over to the government. In the end, Aneurin Bevan, the Minister of Health, persuaded most of the doctors to support the new NHS by promising them that they could continue having private patients and work for the NHS at the same time. By the time the NHS started in 1948, 90% of doctors had signed up to join it. The NHS had an immediate positive impact. It treated millions of people in its first year and continues to do so. It is very popular with the majority of people in Britain. Through the NHS, the government provides hospital care, GP services, maternity and child welfare, ambulances and emergency health care, vaccination programmes (e.g. the BCG against tuberculosis), training of doctors and nurses, and government funded medical research. The NHS is now supported by all political parties, but it has not been without its problems: ‐ In 1950, the government was forced to introduce charges for false teeth and spectacles because the cost of the NHS was so high. Aneurin Bevan was so angry about this that he resigned from the government in protest. Since then, other charges have also been introduced, e.g. for prescriptions. ‐ The NHS constantly faces new demands on its budget. New medical technology and new drugs are introduced very frequently and are increasingly expensive. It is very difficult for the NHS to afford all of these treatments. ‐ The problems that the NHS has faced has leant that many people have continued to pay for private healthcare which has led to accusations that healthcare in Britain is still divided between those that can afford private care and those that rely on the NHS. Public Health in the late 20th century Public health has improved hugely since the Second World War. There are many reasons for this. One is the NHS (see above), others include:  1956 Clean Air Act – the government took action to combat the smog which was polluting the air in towns and cities. By 1971, smoke pollution had been reduced by 65%.  The government has passed many laws to ensure – we have clean water; sewage is disposed of safely; toxic waste is controlled; housing is of a good standard; health and safety at work is much better; food is hygienic and carefully labelled.  Recently the ban on smoking in confined public places has led to a decrease in the impact of passive smoking. There are still public health problems which concern the government nowadays. One major one is the increasing level of obesity amongst the population in modern Britain. Another is the high level of use of illegal drugs in this country. The improving situation of public health in the second half of the 20th century has largely been enjoyed by richer western countries. The majority of the world’s population, who live in developing countries or the Third World, do not enjoy such high standards. Section B – Surgery and Anatomy (worth 12 marks) (i) Surgery and Anatomy in the Ancient World The Prehistoric World Surgery ‐ was limited by their knowledge of the human body and the tools they had available, however there is evidence that their procedures were successful:  The would cut a hole in the skull in order to let out bad spirits which were believed to be the cause of severe headaches. This is called trephining (sometimes trepanning). Many patients survived this operation, which is shown by skulls which show evidence that the wound started to heal.  There is evidence that prehistoric people may have used splints in order to stabilise broken bones to allow them to heal naturally.  Recent evidence has suggested that some prehistoric people were able to perform amputations which the patient also survived. This suggests that they were able to control bleeding and infection to some degree. Anatomy – their knowledge of the human body was limited. Some basic knowledge is indicated by:  Cave paintings show animals being speared through the heart which shows an understanding that the heart is an important organ.  Attacks by wild beasts would have caused some serious injuries to people, allowing some knowledge of the inside if the body to be gained. Ancient Egypt Surgery – Ancient Egyptian surgery improved on prehistoric surgery for a few reasons:  Egyptian metal working was better so that surgeons had sharper and stronger tools to work with. They could perform more minor surgery e.g. removing tumours.  Egyptians understood that honey had healing properties and it was used to treat wounds.  They bandaged wounds and kept them clean. Anatomy – Ancient Egyptian understanding of the human body also improved on prehistoric times:  The process of mummification involved the removal of the internal organs of the body in order to preserve the body for the after‐life. This gave them a better understanding of the inside of the body. The Egyptians had names for the heart, lungs, liver etc.  The Egyptians believed the heart was the centre of the body where the soul of a person was to be found and thinking took place. They thought that the heart was connected to the rest of the body through channels.  The Egyptians wrote down their knowledge on papyrus scrolls which allowed future generations to build upon it. However, there were limitations to Egyptians’ knowledge: ‐ Embalmers (who did the mummification) were not doctors and would not have passed on much knowledge about the internal organs. ‐ The internal organs were also preserved in separate jars, so they were not dissected. ‐ Human dissections were not allowed because the whole body was needed for the after‐life. Ancient Greece Surgery – Greek surgery improved on the Egyptians:  The Greeks used wine and vinegar to clean wounds. These would have acted as antiseptics.  Greek metal was even stronger and sharper than Egyptian allowing more precise surgery. Greek surgeons even successfully operated to drain the lungs of a patient suffering from pneumonia.  The Greeks fought many wars and surgery dealing with war wounds improved with this experience, e.g. removing arrowheads, setting broken bones. Anatomy – This was the biggest area of improvement in Ancient Greece:  Aristotle carried out many animal dissections and argued that all knowledge should be based on careful observation.  The city of Alexandria was founded by Alexander the Great in 331 BC. It became the centre of learning based around the university and enormous library. Alexandria was the only place in the Ancient World where human dissections were allowed. The greatest Greek doctor working in Alexandria was Herophilus. He discovered: ‐
it is the brain which controls the body ‐
the difference between arteries and nerves ‐
the different parts of the stomach and intestines ‐
the link between the beat of the heart and the pulse Ancient Rome Surgery – the Romans continued the successful progress of the Greeks:  They used opium as a mild anaesthetic.  The Roman Army developed more and more techniques to deal with injuries suffered in battle. Each major Roman Army camp had a sophisticated hospital. Anatomy –  Galen (who was born in Greece) trained at Alexandria. He travelled to Rome and became doctor to the Roman Emperor. Galen performed live dissections of animals to demonstrate his knowledge of anatomy. Most famously he cut the spinal cord of a pig at different places to show that the nerves control different actions in the body.  Galen wrote many books about anatomy. These were largely based on his dissections of animals. The books contained a lot of useful knowledge but also had some errors as the human body is not the same as other animals. (ii) Surgery and Anatomy from the Middle Ages to the Renaissance The Middle Ages After the fall of the Roman Empire, there was a period of decline in knowledge and understanding of surgery and anatomy during the Dark Ages. After this, the Middle Ages saw a recovery of knowledge. By the end of the period (about 1450 AD) the standard of surgery and anatomy was probably back to Roman levels. Surgery – surgeons were looked down on by other doctors in the Middle Ages. Surgery was not thought to be a proper part of medicine. Most surgeons were barber‐surgeons who learned their trade as apprentices not at university. Compared to the Dark Ages, there was significant improvement in surgery during the Middle Ages:  The large number of wars in the Middle Ages gave surgeons plenty of opportunity to practise operations. Pictures of ‘Wound Men’ show all of the injuries that surgeons learnt to deal with.  John of Arderne was the most famous medieval surgeon in England. He developed new methods based on careful observation and practice, e.g. anal operations.  Surgeons in the Middle Ages made mild anaesthetics using hemlock and henblane. However, surgery in the Middle Ages was still limited in development because:  Surgeons still relied on supernatural beliefs such as consulting a Zodiac chart to work out the best time to operate on a patient. Anatomy – unlike surgery, anatomy was considered to be a proper part of medical training and was studied at the universities where doctors trained. Like surgery, knowledge of anatomy began to improve in the Middle Ages after the decline of the Dark Ages:  At first dissections were banned by the Church which ran all of the universities where anatomy was studied. This was because the body would be needed in the after‐life. Later in the Middle Ages, the Church allowed each university to do one dissection per year on a convicted criminal’s body. These dissections were carried out by an assistant whilst the professor would read out from Galen’s books. If there was a difference between the body and the book, they thought that the body must be wrong. Despite these limitations, these dissections did improve people’s knowledge of anatomy. The Renaissance Surgery – most surgery in the Renaissance stayed much the same as in the Middle Ages. Surgeons mostly only performed three operations – trephining, amputations and removing tumours. One surgeon who did make advances during the Renaissance was Ambroise Paré:  After working as a barber‐surgeon, Paré got a job as a surgeon for the French Army. The traditional method of treating gunshot wounds was to pour boiling oil into the wound to cauterise it (burn it). This was agonisingly painful. Paré ran out of boiling oil during one battle when there were lots of French casualties – he was forced to improvise. He came up with a new ointment using turpentine, which he had read about in a book about Roman surgery. The new ointment worked very well and he never used boiling oil again.  Paré also used ligatures (made of silk thread) to tie the ends of arteries after he had done an amputation. This was instead of the traditional method of cauterising the stump with a hot iron bar. Again, this was better because the patient did not suffer agonising pain. The one drawback with Paré’s ligatures was that he did not know they had to be sterilised, so the wounds often got infected and many surgeons stuck to the old cauterising method. Anatomy ‐ there were certain features of the Renaissance which allowed advances to be made in the knowledge of anatomy:  Reduction in the power of the Church – this meant that universities were not limited to one dissection per year any more. It also encouraged doctors to challenge the work of Galen, who the Church had believed was right about everything.  Scientific study – there was much more interest in the Renaissance about finding out things through observation and experiment rather than just relying on books.  New artistic techniques – much more accurate pictures could be drawn of the human body which allowed doctors to learn more and share their knowledge.  The printing press – books could now be mass‐produced so doctors could circulate their new knowledge much more widely and quickly. Two doctors in the Renaissance who made hugely important breakthroughs were Andreas Vesalius and William Harvey. Andreas Vesalius became Professor of Anatomy at Padua University in Italy in 1537. He contributed a huge amount to the understanding of anatomy in the Renaissance because:  He studied the human body itself and did not just rely on Galen’s books. Vesalius is said to have stolen the body of an executed criminal when he was a student in order to study the skeleton. He performed many public dissections at the university.  He pointed out several mistakes which Galen had made including: ‐
the human jaw is only one bone not two as Galen had said ‐
the septum in the middle of the heart does not have tiny holes in it as Galen had claimed  He wrote a book on anatomy called On the Fabric of the Human Body, which was read across Europe. The book contained many accurate pictures of the human body. William Harvey proved that the heart is a pump and that the blood circulates around the body. Harvey is typical of the Renaissance because:  He challenged Galen’s ideas about the heart and the nature of veins and arteries.  He proved his ideas through careful experimentation, observation and measurements. For example, he dissected live lizards to observe their hearts beating. He tried to force thin rods and liquids the wrong way up arteries to show that the blood circulated in one direction.  He wrote a book about his discoveries.  He faced opposition from other doctors who were unwilling to believe that Galen could be wrong. Conclusion Both Vesalius and Harvey made very important discoveries about anatomy which laid the foundation for future advances. However, during the Renaissance their ideas did not contribute much to improving treatments or surgery. For example, William Harvey continued to use bleeding as a treatment even though he had proved that there is the same amount of blood in the body at all times. Ambroise Paré did improve the treatment of gunshot wounds but this would only have affected a small number of people. (iii) Surgery and Anatomy since 1800 The Nineteenth Century In 1800, surgery was still very dangerous. The death rate during and after surgery was still very high – around 50% ‐ for three main reasons: PAIN, INFECTION and BLOOD LOSS. Over the next century (plus a little bit) these three problems were reduced and surgery became much safer. Pain Many patients died of shock due to the pain of surgery. In the 1840s surgeons became interested in chemicals which could relieve pain, i.e. anaesthetics. The first of these was nitrous oxide (laughing gas) which was especially used by dentists. It was not ideal though because it could not knock out patients sufficiently for major operations. The second chemical tried was ether. This was more powerful but it has some drawbacks – it irritated the patients’ lungs; it made patients vomit; and it was mildly explosive. In 1847, James Simpson decided to try to find a more suitable anaesthetic. He sniffed a range of chemicals until he found chloroform. This was powerful enough to knock out patients without the side effects of ether. He first used small doses to ease the pain of women giving birth. Simpson faced a lot of opposition, for example: ‐
Some religious leaders thought that it was unnatural and against God’s wishes for the pain of childbirth to be reduced. ‐
Some doctors were concerned that it was difficult to decide on the correct dose (this was made worse when one patient died of too much chloroform in 1848. ‐
Other doctors claimed that chloroform might have long‐term side effects which were not yet known. Simpson argued back against all of these objections and he was greatly helped when Queen Victoria used chloroform to help with the birth of her eighth child in 1857. After this, chloroform became widely used for all types of surgery. Anaesthetics were hugely successful in overcoming pain in surgery, however, they actually made the problem of infection worse. This was because surgeons could now take longer over operations as the patient was not writhing around in agony and they could also cut more deeply into the body. Both of these developments meant that more germs could get into the body. Infection In 1864, Joseph Lister read Louis Pasteur’s work on Germ Theory and became convinced that germs were the cause of ‘hospital fever’ (the name for the infection which many patients died of after surgery). Lister decided to look for something which would kill the germs in his operating theatre. He developed carbolic acid as the first antiseptic. He tried it out on a boy called James Greenlees who had badly broken his leg. Normally the leg would have been amputated, but Lister set the leg straight and wrapped it in bandages soaked with carbolic acid. The boy’s leg healed perfectly and he suffered no infection. Lister then developed a carbolic acid spray to disinfect the area around an operation. Later, he soaked all of his tools in the acid too. The death rate for Lister’s operations fell from 50% to 15% in just 4 years. Like Simpson, Lister also faced a lot of opposition, for example: ‐
Many surgeons still did not believe in Germ Theory. They could not accept that something as small as a germ could kill a human. ‐
Lister was not a good public speaker. His speeches were quiet boring and his written notes were very detailed and hard to read. ‐
Lister kept changing his methods to improve them, but some surgeons said this was because they were no good. ‐
Carbolic acid irritated surgeons’ hands and skin. ‐
Operations with carbolic acid became slower and more expensive which put a lot of surgeons off. Lister slowly overcame this opposition when he showed that the death rate in his operations had fallen as low as 5%. He was also helped by the work of Robert Koch who discovered the specific bacteria which causes septicaemia in 1878. Lister could then demonstrate that his carbolic acid could kill the germ which caused blood poisoning. Aseptic Surgery was an improvement on Lister’s antiseptic surgery. In the 1880s and 1890s, surgeons developed new techniques which aimed to prevent germs getting into the area of the operation at all. These new ideas included:  Sterilising surgical instruments with steam. In the 1880s, Robert Koch demonstrated that steam was more effective than carbolic acid at sterilising the tools.  William Halsted, an American surgeon, invented sterilised rubber gloves in the 1890s.  Operating theatres and hospitals were rigorously cleaned. As a result of these improvements new types of surgery could be attempted. The first successful operation to remove an appendix happened in the 1880s and in 1896 the first operation to repair a heart was carried out. The Impact of the First World War Blood Loss Surgeons had tried blood transfusions for many years to try to overcome the problem of excessive bleeding during surgery. However, they could not work out why many patients died after receiving blood from someone else. In 1901, a German doctor (Landsteiner) discovered that there were different blood groups and that you could only give certain types of blood to different patients. After this discovery successful blood transfusions could take place, but there was one major limitation ‐ the person giving blood and the patient receiving it had to be lying next to each other because if they tried to store the blood it would simply start to clot. During the First World War (1914‐18) the need for a better method of blood transfusion became urgent. There were thousands of wounded soldiers whose lives could be saved if a way of storing blood could be discovered. During the war scientists worked together and actually developed two ways of storing blood:  They found that if you separate the blood cells from the liquid part of blood (plasma), the cells could be stored in ice. When they were needed, the blood cells could be rehydrated with saline solution.  Other doctors discovered that by adding sodium citrate to blood it stopped it from clotting Conclusion Between 1840 and 1918, therefore, the three main causes of death during and after operations (pain, infection and blood loss) had been massively reduced. However, surgery in 1918 was still more dangerous than it is in the present day because, throughout the rest of the 20th century and up to the present day, scientists and surgeons have continued to make important breakthroughs in the technology and safety of surgery. X‐Rays X‐rays had first been discovered by a German scientist – William Röntgen – in 1895. He discovered that the rays could pass through human flesh but not bone or metal. X‐ray machines were immediately developed and installed in hospitals. The First World War had a significant impact on the development of x‐ray technology because of the number of wounded soldiers who needed to have bullets or shrapnel removed from their bodies. X‐rays proved very useful in allowing surgeons to accurately locate the metal objects inside the body. During the war the first mobile x‐ray machines were invented. The Twentieth Century The speed of advances in surgery increased dramatically in the 20th century, for example: Plastic Surgery The solution to the problem of storing blood for blood transfusions happened during the First World War (1914‐18) which was in the 20th century. Another advance which was speeded up by the First World War was the development of plastic surgery. Harold Gillies set up the first dedicated centre for plastic surgery in England in 1917. Gillies’ cousin – Archibald McIndoe – continued his work in the 1930s. In 1938, McIndoe was appointed as Consultant in Plastic Surgery to the R.A.F. During the Second World War (1939‐45), Archibald McIndoe operated on many badly burned aircrew. He reconstructed their faces but also recognised that they would need psychological support in order to recover. He called the airmen his ‘Guinea Pigs’ and the Guinea Pig Club still meets today to honour him. The First Transplants In 1954, the first successful kidney transplant was carried out. It was between two twin brothers so they matched perfectly and the transplanted kidney was not rejected. In 1959, doctors discovered the drug imuran which could suppress the immune system and prevent transplanted kidneys being attacked by the patient’s immune system. By 1967, the technology existed for the first successful heart transplant to take place. This was carried out by Christian Barnard. He was able to carry this out due to a number of factors:  He led a team of highly trained anaesthetists and nurses.  He used an electrocardiogram (ECG) machine to monitor the heart.  He used X‐rays to monitor the lungs.  Blood chemistry and urine were analysed in a laboratory. Surgery in the Present Day Two significant advances which have been made in recent years are: (i) Keyhole surgery – this is where a very small incision in the patient’s body is made and the surgeon uses fibre‐optic cables to look inside the body and an endoscope which has tiny tools for performing the operations. The advantage of keyhole surgery is that it does not leave a serious wound for the patient to recover from. (ii) Micro surgery ‐ By magnifying the area a surgeon is working on it is now possible to perform operations on tiny nerves and blood vessels. For example, severed limbs or hands can be sewn back on and the feeling restored. Section C – Disease and Infection (worth 12 marks) This section is about how people in the past have tried to explain the causes of disease and infection and how they have tried to prevent and to cure them. (i) The Ancient World The Prehistoric World Evidence about the prehistoric period is limited but comes from two main sources: ‐ Archaeological finds, e.g. bones and the remains of tools and plants ‐ The culture of current peoples whose lives haven’t changed much since prehistoric times, e.g. the aborigines of Australia Based on this evidence, historians can draw some fairly reliable conclusions:  Prehistoric people largely explained disease and infection through the spirits they believed in. A bad spirit could enter the body and cause an illness.  In order to treat illness a patient might be given a herbal remedy by someone in their family.  The patient could also go and see a medicine man who was a half‐priest, half‐doctor figure. The medicine man would put the patient into a trance, use herbal remedies, and chant spells and prayers to get the bad spirits to leave the body. Therefore, prehistoric people had a supernatural approach to disease and infection. Ancient Egypt Egyptians also had a supernatural approach to disease and infection. They had temples of healing and several gods and goddesses to whom people prayed to get better. Sekhmet was a goddess who could cause and cure epidemics and Imhotep was a god of healing. Other Egyptian sources mention people going to see ‘priest‐magicians’ in search of cures. Other supernatural ideas the Egyptians had to prevent or cure disease and infection were:  Wearing magic charms to ward off evil spirits.  Making ointments out of the fat of animals which they believed had healing powers, e.g. cats, crocodiles and snakes.  Bathing in water that had been blessed by a priest.  Swallowing mice whole was believed to cure certain conditions. However, the Egyptians also developed a natural approach to disease and infection. They observed the River Nile and how the irrigation channels from the river brought life to their fields. They developed the theory that the body has channels through which blood, air and water flow. They believed that you became ill when these channels were blocked. One cause of blocked channels they thought of was rotting food. They believed that this is why you are sick when you are ill – your body is trying to get rid of the rotten food. The rotten food could also cause other symptoms such as wind and diarrhoea. Other natural ideas the Egyptians had about how to prevent and cure disease and infection were:  Herbal remedies – many Egyptian medicines contained honey which has been shown by modern science to have anti‐bacterial properties.  Using mosquito nets to keep the insects off the body. The Egyptians had clearly realised that insects could spread diseases.  Keeping the body clean and washing regularly.  Making yourself or the patient sick – this was to get rid of the rotten food blocking the channels. Ancient Greece Some of the Ancient Greeks had a supernatural approach to disease and infection. They believed that illness was caused by the gods and that the only way to get better was to pray at an Asclepion which was a temple built to worship Asclepius, the god of healing. At an Asclepion they would:  Make offerings to Asclepius and his two daughters – Panacea and Hygeia.  Sleep in the abaton – a building next to the temple where they believed that Asclepius would visit them in their sleep and cure their illness.  Asclepions also had baths, gymnasiums and were built in the fresh air of the countryside. These things would have helped people to recover as well, but they believed it was the power of the god that was curing them. Other Greeks rejected supernatural ideas and developed more natural approaches. They used herbal remedies in the same way as the Egyptians had. The best known of the Greeks’ natural approaches is the Theory of the Four Humours which was developed by Hippocrates. This theory said:  The body is made up of four liquids (humours) – blood, phlegm, black bile and yellow bile.  If the humours are in balance then you are healthy, however, if there is too much of one humour then you are ill. The Theory of the Four Humours seemed to be a very good idea because:  It explained the symptoms of many illnesses, for example in the winter when you get runny noses the theory said that you had too much phlegm. If you were sick, your body was trying to get rid of yellow bile. Diarrhoea was a symptom of having too much black bile.  It fitted in with the Greeks’ beliefs about the four elements (earth, air, fire and water) and also the four seasons. Therefore winter was cold and wet, which was why you had too much phlegm in that season. Water which is also cold and wet was the dominant element in winter.  It also fitted in with the Greeks’ belief in leading a balanced lifestyle. They thought that not eating or drinking too much would help to keep you healthy. Hippocrates is a very important figure in the history of medicine because:  He developed the Theory of the Four Humours which was believed for the next 2000 years.  He totally rejected any supernatural beliefs about disease and infection. He insisted that all illness had a natural cause and could only be treated with natural remedies. He said that doctors should carefully observe and record the symptoms of their patients.  He came up with the Hippocratic Oath which set out how doctors should behave, e.g. they should never give patients anything which could harm them and they should keep their patients’ details totally confidential. These are still rules for doctors nowadays.  He wrote many books about his ideas which were still being read 2000 years later. Therefore, Hippocrates is important because he set out the methods which doctors use even in the present day – careful observation and recording; rejecting supernatural beliefs; maintaining high standards of professional behaviour. However, Hippocrates did not come up with many treatments to cure diseases – he could recognise and name many illnesses but he couldn’t effectively cure any. The most common treatment based on his ideas was bleeding, which was done to get rid of excess blood in line with the Theory of the Four Humours. Hippocrates Ancient Rome The Romans had strong supernatural beliefs in the gods. As a result they also had temples of healing and prayed to different gods to cure illnesses. Salus was a goddess of healing. The Romans even built temples to Asclepius as they had heard of his supposed healing powers from the Greeks. The Romans also had natural approaches to disease and infection. They used herbal remedies and because their Empire stretched so far they were able to get hold of a wider range of natural ingredients for their medicines. A Roman medical book lists 600 different herbal remedies. Early on, the Romans were very suspicious of Greek doctors and their theories. The Romans liked to think of themselves as practical people who did not get carried away with fancy ideas. Their attitude towards Greek theories began to change with the arrival of Galen in Rome in AD 161. Galen is important because:  He was trained at Alexandria in the natural ideas of the Greeks including the importance of careful observation and recording and the need to lead a healthy lifestyle.  He introduced the Theory of the Four Humours to ancient Rome.  He added his own Theory of Opposites which explained many more treatments that could be offered based on the theory of the four humours, e.g. giving patients dried pepper to balance out too much phlegm. Galen was enthusiastic about the use of bleeding as a treatment.  He became the doctor to the Roman Emperor which allowed him to spread his ideas quickly.  He wrote many books which eventually became the most important medical textbooks in medieval Europe 1000 years later and were still being read in the Renaissance. (ii) The Middle Ages and the Renaissance The Dark Ages in Europe (500 – 1000 AD) The Roman Empire collapsed around the year 500 AD. The period that followed is called the Dark Ages because there is not that much information about it. During the Dark Ages the standard of medical care and knowledge declined. People relied more heavily on supernatural approaches to medicine and did not continue the Greek and Roman interest in finding out more about the human body. In the Dark Ages, Europe was taken over by warlike tribes. This led to a decline in medicine because:  The rulers spent far more money on soldiers and weapons than on medical progress and universities.  War disrupted the normal channels of communication which meant that medical ideas could not be shared as easily.  Many books were destroyed or hidden during the Dark Ages, for example the books of Hippocrates and Galen. As a result most people relied on prayer and religion to explain and cure illness. They would still have used herbal remedies passed down through families but not a lot of other natural treatments. The Islamic Empire (700 – 1450 AD) Whilst Europe was in a period of decline during the Dark Ages, the Islamic Empire in the Middle East was far more advanced and civilised. There was one strong ruler – the Caliph – who was able to invest money in universities and hospitals because he did not have to spend as much of his money on war. The best example of this is the new university and hospital built next to each other in Baghdad in about 800 AD. At the same time a centre for the translation of Greek and Roman books was set up. This centre translated the work of Hippocrates and Galen into Arabic. Al‐Razi (Rhazes) The first great Islamic doctor was Al‐Razi. Following the ideas of Hippocrates, he stressed the importance of careful observation and recording. Using this method he was able to identify the difference between smallpox and measles. He became the first director of the new hospital in Baghdad. Al Razi was a great admirer of Galen but he also prepared to criticise him where he thought Galen was wrong. Ibn Sina (Avicenna) The second great Islamic doctor was Ibn Sina. He wrote a million‐word encyclopaedia called ‘The Canon’. In it he summarised the whole of medical knowledge up to the year 1000, including Hippocrates, Galen and Islamic doctors. Ibn Sina was an expert on drugs and he listed the properties of 760 different drugs, some of which are still in use today, e.g. camphor and laudanum. Ibn Nafis This Islamic doctor identified that Galen had been wrong about the heart. He showed that the heart did not have tiny holes in the middle for blood to pass through as Galen had described. Unfortunately, Ibn Nafis’ book was not one that was translated into European languages and read there, so doctors in Europe continued to accept Galen’s mistake about the heart until the 1600s. Conclusion Islamic medicine was more advanced than European medicine during the Middle Ages. This was something the Crusaders discovered when they invaded the Holy Land in the 11th and 12th centuries. This was due to the continuation of Greek and Roman knowledge in the Islamic Empire which had been lost in Europe. However, there were limitations on the advances of the Islamic Empire: ‐ Islamic beliefs prevented the dissection of human bodies ‐ Most Islamic doctors did not believe it was right to dabble in surgery ‐ The Islamic Empire suffered as much from the Black Death as medieval Europe did The Middle Ages in Europe(1000 – 1450 AD) The Middle Ages were dominated by the Church, which was the most powerful and wealthy international organisation. The Church controlled all of the universities and therefore the training of doctors. The Church helped medical progress in some ways but hindered its development in others. The Church helped by: ‐ setting up universities where doctors could train, e.g. Salerno, Padua. After the Dark Ages, the books of Galen and Hippocrates were slowly rediscovered and doctors could study these. ‐ running and paying for hospitals. These were often part of monasteries or cathedrals and offered some medical care by the monks or nuns who had some skill with herbal remedies. The Church hindered medical progress by:  Banning dissections because it was believed that the whole body would be needed in the afterlife. (This ban was relaxed a little in the 14th century when each university could do one dissection per year)  Encouraging people to believe that God caused diseases and to pray or go on pilgrimages to cure illnesses. This meant that most people in the Middle Ages had a supernatural approach to illness.
The Church also hindered progress by: 
Insisting that Galen was right about everything. The Church liked Galen because he said the human body is like a perfectly interconnecting machine. This fitted in with their belief that God had designed the human body. This attitude prevented doctors from challenging some of Galen’s mistakes. If a body being dissected was different from Galen’s book, they said that the body was wrong not Galen. Doctors in the Middle Ages Doctors in the Middle Ages had both natural and supernatural approaches to disease and infection. Their natural approaches included:  Following the Theory of the Four Humours and using treatments like bleeding based on the theory.  Using herbal remedies  Inspecting the urine of patients to diagnose their illnesses (although some doctors relied on this so much they didn’t actually bother to meet their patients) Their supernatural approaches included:  Consulting Zodiac charts to find out what was wrong with their patients. The Black Death In 1348, the Black Death struck western Europe. It had already swept across Asia and the Middle East killing millions of people. The disease was the bubonic and pneumonic plagues which killed 90% of people who caught within about five days. The people of medieval Europe were desperate to avoid catching the plague and to cure it if they got it. They tried both natural and supernatural methods: Their natural approaches included:  Cleaning up streets because they believed that the bad smells (miasma) spread the disease  Bleeding or purging (being sick) the body because the humours were out of balance  Burning herbs to take away the bad smells (miasma)  Blaming Jews for poisoning the water supply. Hundreds of Jewish people were murdered because of this belief during the Black Death outbreak. Their supernatural approaches included:  The belief that the plague was caused by the position of the planets  Praying to God to take the plague away because he had sent it as a punishment for people’s sins. One group of people – the flagellants – whipped themselves as they walked through towns and villages to show God how sorry they were for sinning.  Saying magic spells and wearing charms to keep the plague away The Renaissance (1450 – 1700 AD) The Renaissance was very different from the Middle Ages because the power of the Church was reduced. This meant that the restrictions on dissecting bodies at universities were slowly lifted and that doctors could now challenge Galen’s ideas openly. One good example of a Renaissance doctor is Paracelsus, he is a good example because:  He burned Galen’s books in public to show that he thought they were wrong. (It is important to remember that Galen got a lot of things right but he did make some mistakes)  He chose his name because it means ‘Better than Celsus’. Celsus was a famous Roman doctor and Paraclesus believed that his new ideas were better than the old ones from Rome.  He came up with new ideas of his own, e.g. that diseases should be treated with medicines made from chemicals. He used mercury in several of his medicines which is unfortunately poisonous.  He gave lectures in German rather than Latin so everyone could understand them. However, Paracelsus’ influence was limited because he was regarded as a bit of an eccentric – some of his ideas were very supernatural. For example, he believed that God had sent messages about the medicinal qualities of plants through their shape. He claimed one type of orchid was shaped like testicles so it should be used for treating sexually transmitted diseases. His books also contained stories of fairies and nymphs curing illnesses. Overall, the Renaissance was a period of significant advances in the understanding of anatomy (Vesalius and Harvey) but there wasn’t much progress in the understanding of the causes of disease or discovering effective cures. Supernatural approaches continued alongside natural ones. Most doctors continued to believe in the Theory of the Four Humours. Paracelsus
(iii) The Industrial Age (1750‐1900) During the Renaissance and after, the training of doctors at universities increasingly focused on using a scientific approach based on careful observation and recording of patients’ symptoms and on carrying out experiments to test new ideas and theories. One doctor who used this scientific method to make an important breakthrough was Edward Jenner. Edward Jenner and Smallpox Through his work as a doctor in a countryside area of Gloucestershire, Jenner came across several famers who rejected the offer of being inoculated against smallpox, an horrific killer disease. They did this because they believed they were already protected having suffered from the much milder illness, cowpox. Jenner decided to test this idea out scientifically:  Jenner observed and took careful records of milkmaids who had suffered from cowpox. None of those he examined had ever caught smallpox.  Jenner then decided to test his theory. An 8‐year‐old boy called James Phipps was given cowpox by Jenner. After this disease had passed, Jenner then gave him a dose of smallpox but there was no reaction – it appeared that the boy was now immune to smallpox.  Jenner tried this out a further 23 times and each time the patient did not develop smallpox. Jenner called his discovery ‘vaccination’ after the Latin for cow – ‘vacca’. He published his findings but immediately faced a lot of opposition. People were concerned about vaccination because: ‐ Many people were uneasy about new ideas in general but especially one that involved giving humans and animal disease. ‐ Jenner could not explain how vaccination worked which worried some people. ‐ Doctors who made a lot of money out of the old method of inoculation were against vaccination because it would put them out of business. ‐ Vaccination was not totally safe and some doctors did not take as much care as Jenner. Their patients’ cuts became infected or they went on to catch smallpox anyway. Jenner was helped in overcoming this opposition by support from the government and other prominent people:  Parliament granted him £30,000 to set up a vaccination clinic in London  Thomas Jefferson, President of America, promoted vaccination in the USA.  Napoleon had all of his soldiers vaccinated in 1805 In 1852, the British government made vaccinations compulsory. Some people resented being told what to do by the government and refused to be vaccinated, however, by 1900 smallpox had nearly died out in Britain as a result of Jenner’s work. Smallpox was eventually eradicated completely from the world in 1980 as a result of a mass vaccination programme organised by the World Health Organisation. Louis Pasteur and Germ Theory Since the 17th century scientists had used basic microscopes to observe tiny micro‐organisms invisible to the naked eye. They had observed that there were more microbes on matter that was rotting and wondered why. The most popular explanation for a long time was called spontaneous generation. This theory said that as matter rotted or decayed it turned into the microbes. Therefore, they thought, germs were the result of disease and decay. Some scientists disagreed. They thought that germs were the cause of disease and decay. This idea was called Germ Theory. One scientist who believed this was Louis Pasteur and he was able to prove it by:  In the 1850s, He was asked by the French wine industry to investigate why their wine sometimes went off. He observed through his microscope that there seemed to be a lot of the same germs in the wine that was off. He found that if you heated the wine the germs died and then it would stay fresh. He had shown that the germs were the cause of wine going bad.  In 1864, He entered a competition to show that Germ Theory was correct and spontaneous generation was wrong. He took samples of air in two glass containers. He heated one container until the germs were dead and then sealed it – it stayed fresh. The other container was not heated and the germs began to grow in it until they were visible.  In the second half of the 1860s, he was asked by the French silkworm industry to find out why some silkworms were dying. He observed that all of the dead silkworms seemed to have the same bacteria in them. He and his assistants then tested all the other silkworms and separated the ones with the germs from the healthy ones. The disease stopped spreading in the healthy silkworms. Pasteur had shown that the germs were the cause of the silkworm disease. Pasteur suffered a stroke in the late 1860s which prevented him from following up his work. He had shown that germs cause decay in liquids, and also disease in silkworms. The next step was to show that germs could cause human diseases too. Robert Koch Koch was the first scientist to identify a specific bacteria which caused a specific human disease. The bacteria he identified was anthrax in 1878. He did this by:  Extracting what he thought was the anthrax bacteria from a dead sheep.  Injecting the bacteria into a mouse which then died of anthrax.  Extracting the bacteria from the dead mouse and injecting it into another one.  Repeating this process 20 times after which he still had the same bacteria which he started with. Koch had successfully identified the anthrax bacteria. Robert Koch went on to identify the septicaemia bacteria later in 1878. Using his methods other scientists also discovered typhus, tetanus, pneumonia, meningitis and plague. Koch also developed agar jelly as a better medium for growing and observing bacteria. He also invented a way of staining bacteria using chemical dyes and photographing them through a microscope. Louis Pasteur vs Robert Koch Pasteur and Koch became great rivals. France and Germany had recently been at war and there was still ill‐feeling between them. The French and German governments gave Pasteur and Koch large sums of money and created huge research teams for them in order to make the next breakthrough and claim the glory for their country. Pasteur came out of retirement to try to surpass Koch’s achievements: 1879 ‐ Pasteur discovered how vaccinations work. One of his assistants had left a petri dish of chicken cholera out over the summer holidays. When they came back to the lab, Pasteur injected a chicken with these germs but it did not die. When they injected the same chicken with a fresh batch of cholera it still did not die. Pasteur made the connection that maybe the chicken had been accidentally vaccinated by the weakened form of the disease which had been left out. 1881 ‐ Pasteur now understood how vaccinations work – a weakened form of a disease allows the body’s immune system to learn how to fight off the infection. He developed a new vaccine for anthrax and demonstrated it in public. He vaccinated 25 sheep and left another 25 alone. Two weeks later he gave all 50 sheep a deadly dose of anthrax. The 25 vaccinated sheep survived and the 25 others died. This experiment made front page news all over the world. 1882 ‐ Koch identified the tuberculosis bacteria 1883 ‐ Koch identified the cholera bacteria 1886 ‐ Pasteur tried out a new vaccine for rabies successfully. He had spent four years developing the new vaccine which was very difficult because the rabies bacteria is very small. A boy who had been bitten by a rabid dog was brought to him. The boy was certain to die, so Pasteur tried out his vaccine – it worked because the disease was not yet full‐blown in the boy. This also became famous around the world. Conclusion By 1900, therefore, scientists had discovered the true cause of disease – a massive breakthrough. They also now understood how vaccines worked and had produced several new ones. However, no‐one had yet invented a cure for a disease that had already taken effect in a person’s body. Improvements to Nursing Florence Nightingale Florence Nightingale was from a rich family and was not expected to work but due to her strong religious beliefs she was determined to work as a nurse and improve hospital care. Her opportunity came during the Crimean War (1854‐56) when she persuaded a contact of her family in the government to allow her to travel to the Crimea with a team of nurses. Nightingale struggled to get the Army doctors to let her implement her ideas but she was a very strong and persuasive personality. Eventually she introduced changes which reduced the death rate in the military hospital from 42% to 2%. She achieved this through:  Introducing wards for soldiers with similar diseases, which reduced cross‐infection  Insisting on high standards of cleanliness (Nightingale did not know about Germ Theory yet)  Keeping careful records of medicines given and patients’ progress  Installing beds for all patients  Providing 24 hour care (hence the nickname ‘Lady with the Lamp’) Nightingale became a national heroine for her work in the Crimea but she was determined that this should be the start rather than the end of her work. On returning to Britain she transformed the nursing profession from a very low‐status and unskilled job to a highly respected and professional occupation. She did this by:  Writing a book on nursing which became a best‐seller  Setting up a training school for nurses which insisted on the highest standards  Advising new hospitals on how to set out their buildings Mary Seacole Mary Seacole was the daughter of a Scottish army officer and a Jamaican woman. She had some knowledge and skill at nursing and wanted to help out in the Crimea just like Florence Nightingale. In the Crimea, she set up a ‘British Hotel’ which offered medical care and a shop for troops. She was rejected as a nurse by Florence Nightingale due to the colour of her skin. Mary Seacole was also celebrated after the war for her work with injured soldiers and was given a medal for her service. However, a few years later she was largely forgotten and she did not have the huge impact which Nightingale had back in Britain. Reasons for this are:  She was black and society in Victorian Britain was racist  She was not from a rich and well‐connected family like Nightingale The stories of Nightingale and Seacole are a good example of the factor of war in the history of medicine as well as the influence of other factors such as race and wealth on the impact an individual can have. The First Female Doctors Throughout the history of medicine, women have played a prominent role in providing care for their families. However, in many societies women’s access to the medical profession has been restricted. This was especially the case during the Middle Ages in Europe and in the centuries which followed. In the 19th century, some very strong women were determined to break into the male‐dominated medical profession. The two most prominent of these women were: Elizabeth Blackwell Elizabeth Blackwell was the first woman to qualify as a doctor in the United States in 1849. She visited Britain 10 years later giving a series of talks. She inspired other women in Britain to follow her example. One such woman was: Elizabeth Garrett Anderson 1860s ‐ Elizabeth Garrett Anderson worked as a nurse and attended lectures at Middlesex Hospital 1870s ‐ She passed all the exams to qualify as a doctor but was refused membership of the Royal Colleges of Surgeons, Apothecaries and Physicians. She took the College of Apothecaries to court and won her case for membership. 1876 ‐ the government passed a law opening all medical qualifications to women. The opening of the medical profession to women was progress in the history of medicine as it allowed many talented people to contribute to medical advances. It is a good example of the role of determined individuals in bringing about change. (iv) 1900 to the Present Day The First Cures Paul Ehrlich and Salvarsan 606 Ehrlich had been a member of Robert Koch’s research team. He had used the method of staining bacteria to observe them more easily. He thought that he could find a chemical which both stained bacteria but also killed them. If it could kill the bacteria then this would be the first cure. He nicknamed this idea ‘magic bullets’ because the chemical would seek out the bacteria and kill them without harming anything else. Ehrlich and his team painstakingly tested hundreds of different chemicals on syphilis bacteria (a sexually transmitted infection). In 1909, Ehrlich became convinced that chemicals based on arsenic would be the most effective. The 606th arsenic compound which they tested seemed to work. Even then they only spotted it when they were double checking every test. They called the chemical Salvarsan 606. This was the first ever cure – a very important breakthrough BUT Salvarsan 606 only worked on the syphilis bacteria and not on any other diseases. Also, because it was derived from arsenic it proved to be too dangerous to be used widely as a drug. When the First World War broke out more money was invested in other types of medicine especially surgery and Ehrlich’s work was not developed for a while. Gerhardt Domagk and Prontosil In the 1920s and 30s, another German scientist – Gerhardt Domagk – decided to try to find another chemical cure like Ehrlich had. In 1932, he tested the chemical dye, Prontosil, on mice and found that it had an effect on the bacteria which caused blood poisoning. One day, Domagk’s daughter cut herself by accident in his lab and developed a severe case of blood poisoning. She was likely to die, so Domagk decided to try out Prontosil on her. It worked. He had found the second cure. In the 1930s, a new electron microscope had been invented. This allowed scientists to analyse chemicals like Prontosil to discover what the active ingredients were. They discovered that the active ingredient in Prontosil was a sulphonamide. Sulphonamides are found in coal tar. It turned out that there are lots of different types of sulphonamides and that some of them were useful in curing other diseases. Drugs companies invested huge amounts of money into researching sulphonamides and soon cures existed for scarlet fever, meningitis, gonorrhoea and pneumonia. The Development of Penicillin 1928 ‐ Alexander Fleming was a British scientist researching bacteria in the 1920s. One day in 1928 he was tidying up his lab and noticed that in one petri dish there was a circle where the bacteria had been killed. When he looked closer he found that a spore of penicillin had got into the dish and had killed the bacteria. He thought the penicillin must have blown in through the window. 1929 ‐ Fleming published a research paper about his discovery of penicillin but he lacked the funding to continue his research any further. It was very difficult to grow and harvest enough penicillin to make a useful drug. 1937 ‐ Two scientists working at Oxford University – Howard Florey and Ernst Chain – read Flemings paper on penicillin and decided to try to develop it as a drug. 1939 ‐ With the outbreak of the Second World War, the British government was prepared to put more money into research for drugs which could save soldiers’ lives. Florey and Chain were given money to develop penicillin. They did this by:  Using new freeze‐drying technology and some milk bottles to grow and harvest some penicillin.  Testing the small amount they had harvested on eight mice. All the mice were given deadly microbes. Four mice were then given penicillin and survived, the other four mice died. 1941 ‐ By now Florey and Chain had just about enough penicillin to test it on a human patient. One patient in the hospital was seriously ill with an infected head wound. They gave the man penicillin and his condition improved. They had so little of the drug that they even recycled the penicillin which passed out of the patient in his urine. The man was getting better but they ran out of penicillin and he died, however, they had proved that it worked on humans. 1942 ‐ The USA entered the war and also wanted a drug which would save soldiers’ lives. Florey and Chain moved to America where they were safe from German air‐raids, but also where there were huge drugs companies with the money and technology to develop mass‐production of penicillin. The American government provided $80 million for this. 1944 ‐ By the time of D‐Day in June 1944 there was enough penicillin to treat all of the wounded Allied soldiers in France. 1945 ‐ By the end of the war the US Army was using 2 million doses of penicillin a month. It is estimated that another 15% of wounded Allied soldiers would have died without penicillin. The Fight Against Disease and Infection since 1945 The Discovery of DNA In 1953, Francis Crick and James Watson, discovered the ‘double‐helix’ structure of DNA. They also discovered how DNA can ‘un‐zip’ and make copies of itself. They were able to do this using the latest x‐
ray photography technology developed by Maurice Wilkins. Since 1953, scientists have gained more and more understanding of how DNA holds the genetic code to the human body. This has led to some very important developments in medicine, for example:  A gene which is damaged by liver cancer has been discovered. The drug Oltipraz has been shown to protect this gene from the disease and stop people from developing cancer. This has been particularly important in China where many people suffer from liver cancer due to a mould which grows on rice.  Genetic screening of parents and babies can lead to early identification of hereditary diseases which can now be treated much earlier, giving the child a better chance of survival.  Genetic screening of embryos can allow the birth of ‘saviour siblings’ who are born as a perfect genetic match to an older brother or sister who has a serious illness. Stem cells from the younger sibling can be used in the treatment of their older brother or sister. Genetic engineering is a controversial subject and there are several objections raised by different groups in the modern world: ‐ Religious groups are concerned that genetic engineering is messing with God’s creation. ‐ Other people worry about the unknown long‐term side effects of tampering with the DNA of plants, animals and humans. For example, there are worries about the impact of genetically modified crops on the environment. ‐ The cost of developing drugs based on genetic information is a problem. The Development of New Drugs Since the Second World War there has been an explosion in the development of new drugs. Large drugs companies invest huge amounts of money into developing new medicines. Most of these new drugs are very effective at curing diseases. However, there have been problems: ‐
A few drugs have had very bad side effects. The most famous is the drug Thalidomide which was given to pregnant women to ease morning sickness in the 1950s. Unfortunately, many of the babies these women gave birth to had seriously deformed arms and legs. ‐
The cost of new drugs is a problem for the NHS but also for poorer countries in the Third World. This means that many people struggle to get hold of drugs which could save their lives. ‐
The over‐use of antibiotics has led to the evolution of ‘superbugs’ such as MRSA which are resistant to modern drugs. The World Health Organisation (WHO) and the Fight Against AIDS In 1980, the WHO announced that smallpox had been wiped out across the world. This was a massive success for the vaccination programme which the WHO had run in the Third World for many years. Since the Second World War the WHO has played a leading role in combating diseases which kill people all over the world. One of the biggest campaigns the WHO is involved with in the present day is the fight against AIDS. This disease is a very international problem and the fight against needs an international organisation to try to defeat it. The WHO co‐ordinates efforts to educate people in the Third World about safe sex and tries to persuade drugs companies and governments in rich nations to allow poorer countries access to the drugs which can slow AIDS down (although there is still no cure). Alternative Medicine Alternative medicines are ways of healing illness without using artificial or chemical drugs. These methods aim to help the body’s natural immune system fight of diseases. For example:  Homeopathy – this is a belief that ‘like cures like’. These medicines use plants and herbs which produce symptoms similar to the illness. For example, colds make your eyes run and so do onions. The homeopathic treatment for colds is a tablet with a little bit of onion in.  Acupuncture ‐ this is an ancient Chinese treatment which uses needles pushed into the body at certain places which are meant to stimulate the body’s natural energy and teh immune system.  Hypnosis – patients are hypnotised and problems solved. This is sometimes used to help women in childbirth.  Herbal remedies – more and more people use herbal remedies nowadays partly because they are worried about some of the side effects of modern drugs. Modern science has shown that about 20% of herbal remedies from Roman times actually have a positive effect. Alternative medicines are becoming more popular nowadays for several reasons. One is that some people don’t like the idea of taking artificial, chemical drugs. Another is that many celebrities endorse alternative medicine.