Therapeutic Revolution

Early Conceptions of Medicine

For centuries, the humoral theory of the Greeks formed the basis of medical thinking.  In essence, the theory attributed sickness to an imbalance of the four basic humors: blood, phlegm, black bile, and yellow bile.(1)  Bleeding, blistering, purging and sweating remained the standard practice, designed to restore the humoral balance and eliminate corrupt humors.(2)  During this period, physicians ardently believed in such depletory regimens and the humoral basis of health and pathology. 

Not based in evidence, these practices were harmful to patients and useless to doctors.  The negative consequences of such practices resulted in an era of nihilism characterized by public distrust of the medical profession.  Medical nihilism was the prevailing attitude that physicians had as much of a chance of hurting patients as helping them.(3)  Thus, many preferred to let nature run its course rather than enlist the help of the medical profession.

“With physicians in short supply and subject to little regulation, folk practitioners and quacks supplied much of medical care, and the quacks undoubtedly contributed to the public suspicion of the medical profession.”(4)

In the early 19th century, the focus of medical research changed from a generalized pathology concerned with bodily humors to a localized pathology concerned with physiology and disease transmission.  This transition, known as the “therapeutic revolution” occurred during the 20th century when research came to focus on specific diseases.  The therapeutic revolution is generally understood as the moment when medicine began to work.

Germ Theory

Medicine underwent a dramatic change in the late 19th century with the advent of the germ theory of disease.(5)  This change began the Western trajectory of biomedicine that continues today. Early proponents of the germ theory of disease included Louis Pasteur, Robert Koch, and John Snow among others.  Pasteur, father of germ theory, unraveled the mysteries of many diseases and contributed to the development of the first vaccines. He debunked the widely accepted myth of spontaneous generation, and set the stage for modern biology and biochemistry.  Pasteur’s colleague and rival, Robert Koch, developed Koch’s Postulates which established a list of criteria to prove bacterial causation of a disease.  John Snow, often called the father of modern epidemiology, is best known for discovering the transmissibility of cholera and preventing an epidemic by removing the handle of the Broad Street water pump in Soho, London.(6)

“Cholera never arises spontaneously. No healthy man can ever be attacked by cholera unless he swallows the comma microbe, and this germ can only develop from its like--it cannot be produced from any other thing, or out of nothing. And it is only in the intestine of man, or in highly polluted water like that of India that it can grow.” - Robert Koch, 1884

These discoveries led to fifty years between the 1870s and 1920s during which the bacteriological paradigm was dominant.  The dominance of the germ-theory of disease was ensured by its impressive research findings: “the decade of the 1870s saw isolation of agents responsible for causing leprosy and anthrax; the 1880s found agents for typhoid, tuberculosis, cholera, diphtheria, and meningococcal meningitis; the 1890s, plague and malaria; and by 1910 pertussis, syphilis, and epidemic typhus.”(7)  The bacteriological paradigm was later joined in the early 20th century by an appreciation for the importance of vector-borne diseases, nutrition, and disease transmission by healthy carriers.

“With the advent of bacteriology came an increased focus on the disease agent, which dominated the epidemiological literature for almost fifty years.  Geographical and social epidemiology continued to survive while the bacteriological paradigm dominated research.  However, under the influence of the doctrine of specific etiology and the philosophy of social Darwinism, the social and geographical approaches lost some of their momentum.”(8)

Effect on Global Health

The therapeutic revolution created a new understanding of disease and illness and began the trajectory of Western biomedicine.  First, diseases came to be seen as specific and separate, rather than caused by vague humoral imbalances. Second, medicine became part of science, taking place in the laboratory alongside traditional sciences.  Furthermore, public health had a new foundation to work from as the germ theory of disease was instilled in the public’s consciousness. 

Yet, how did this trajectory come into contact with the under-developed, non-Western world?  Germ theory was revolutionary not only for its scientific insights, but also because it changed people’s ideas about the meaning of disease.(9)  For example, prior to the therapeutic revolution, early 19th century people believed that tuberculosis was contracted by individuals who were highly intelligent.(10) The idea was that individuals were infected because they were too beautiful and smart to live.  Koch’s discovery of the microbial nature of tuberculosis destroyed this false conception.  Tuberculosis soon became known as a disease of the poor, associated with filthy living conditions, child labor, etc.  Thus, social reformers used germ theory to give their cause for reform much greater weight.  In global health, germ theory’s major impact was not therapeutics, it was to give public health advocates a new boost and justification for local and global efforts.(11)

In addition, the therapeutic revolution began the globalization of medicine.  The Columbian exchange profoundly altered the arsenal of European medicine as New World herbs and chemicals became prized commodities.  Quinine, one the properties of Cinchona bark (‘Peruvian bark’) became recognized in the treatment of malaria, creating widespread global interest in Cinchona trade. Thus, from the beginning, medicine was portrayed in two contrasting ways: as a commodity and as social good that should be equally accessible to all. The commoditization of drugs meant that market forces determined their availability and distribution. Yet there was a simultaneous realization that the inability to provide available and effective drug treatments to the world presented a moral urgency. 

Conclusion

The therapeutic revolution gave society a faith in medicine. Today, we have a belief in the pills that we take—a sense of security rooted in the knowledge and social structures that emerged during the therapeutic revolution.

Yet in spite of the gains, society lost something. Since the therapeutic revolution, improvements in health outcomes have been increasingly tied to improvements in biomedical technology.  Today’s biomedical paradigm has skewed medicine toward an interventionist, disease-driven model, and it now struggles with diseases that do not fit the mold, such as obesity and asthma.(12)  Confronted by increasing rates of chronic diseases, the western medical world has responded by moving back into biomedical comfort zones—finding drugs to solve diseases, gene therapy, etc.(13)  This tension has created a dichotomy between the social determinants of health and the need for health care delivery(14)—a tension that will be explored later in the course.

Go To Module 4: Eradication Efforts: Malaria vs. Smallpox >>

Footnotes

(1) Rosenberg, Charles. “The Therapeutic Revolution: Medicine, Meaning, Social Change in Nineteenth Century America.” Cambridge: Cambridge University Press, 1992: pp. 9.

(2) Duffy,J. From humors to medical science: a history of American medicine 2nd ed. 1993. Chicago: University of Chicago Press. Urbana, IL.

(3) “Samuel Thomson, a Botanic Healer, Decries the Regular Medical Profession as a Murderous Monopoly, 1822.” In Warner and Tighe, Major Problems in History of American Medicine and Public Health (New York: Houghton Mifflin, 2001): pp. 7

(4) Duffy,J. From humors to medical science: a history of American medicine 2nd ed. 1993. Chicago: University of Chicago Press. Urbana, IL.

(5) Leavitt, Judith W., and Ronald L. Numbers, editors. Sickness and Health in America: Readings in the History of Medicine and Public Health, 3rd Edition. Madison: University of Wisconsin Press, 1997.

(6) Rosenberg, Charles E. The Cholera Years: The United States in 1832, 1849, and 1866. Chicago: University of Chicago Press, 1962, 1987.

(7) Duffy,J From humors to medical science: a history of American medicine 2nd ed. 1993. Chicago:  University of Chicago Press. Urbana, IL.

(8) Ibid.

(9) Pellegrino, Edmund.  "The Sociocultural Impact of Twentieth-Century Therapeutics" (pp. 245-266) in The Therapeutic Revolution (eds. Morris Vogel and Charles Rosenberg). Philadelphia: Univ. Penn Press, 1979.

(10) Tomes, Nancy. The Gospel of Germs: Men, Women, and the Microbe in American Life. Cambridge: Harvard University Press, 1998: Chapter 6.

(11) John B. McKinlay and Sonja M. McKinlay "The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century" in The Milbank Memorial Fund Quarterly. Health and Society, Vol. 55, No. 3 (Summer, 1977), pp. 405-428.

(12) Greene, Jeremy. Prescribing by Numbers: Drugs and the Definition of Disease. Baltimore: Johns Hopkins University Press, 2007. 

(13) Cutler, D., Deaton, A., & Lleras-Muney, A. “The Determinants of Mortality”. Journal of Economic Perspectives, 20(3), 197-120, 2006. 

(14) Brandt, Allan. “Antagonism and Accommodation: Interpreting the Relationship Between Public Health and Medicine in the United States During the 20th Century.” American Journal of Public Health 90 (2000) 707-715.