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Shifting Medical Thought

What causes disease? Most people answer bacteria, or viruses, which are both simply

microorganisms, like fungi spores and mould. However, if you ask a doctor and a different

answer appears: it’s complicated. The number of diseases without a cause or cure, or both, are

rising, in part thanks to the recent shift in medical thought and redefinition of disease. Before the

nineteenth century, multiple medical schools of thought muddled together, confusing medical

practitioners and the causes and treatments of disease. Although the invention of germ theory

spawned revolutionary changes to medicine and prevention by simplifying medical practice into

one holistic view, in disproving the earlier ideas it simplified too far. Now, another change is

taking place from germ theory’s purely biological standpoint to the biopsychosocial model,

which concentrates on not only the biological, but also the individual’s mental health and social

situation. This double paradigm shift shows the difficulty of changing thought models, even in

the world of medicine where one wrong move can cause death; it also shows how more than just

scientific research has influenced the long history of medical thought. Advancements in

technology and overcoming social taboos, like mental illness, are equally important in advancing

the medical field.

Before germ theory, doctors had no consensus on what caused disease or how to treat it,

and any individual doctor believed any combination of the following theories. Thus, for germ

theory to take hold, research had to disprove each theory in turn before people finally accepted it.

Two such theories were humorism and the religious attribution of disease. Humorism laid out

human biology as the balance of the four humours (black bile, yellow/red bile, blood and

phlegm). Everyone had a personal constitution or necessary balance, which resulted in their

personality and health; they were influenced by the seasons, climate, diet, occupation, location,
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astrology, and social class (“Humoral Theory”). Religion could also explain someone’s illness,

especially those associated with sinful acts, like sexually transmitted diseases, or certain

unfavoured ethnic or religious groups (“Concepts of Contagion and Epidemics”). These

connected personality, race, and religion to health, thus someone’s illness directly resulted from

their personal actions and failures and, in some practices, doctors refused patients, citing the

suffering as a punishment they had to accept, especially those on the more religious side.

Moving on to the time’s more scientific theories, spontaneous generation held that tiny

animalcula sprang into existence from nothing onto food, water, or inside certain areas like

swamps, and they hurt humans. The animalcula described through use of early microscopes are

likely germs or cells, which could not be seen clearly (“Germ Theory”). Finally, the most well

known and believed theory was miasma, a word literally meaning “bad air.” Believers in miasma

thought disease rose from rotting plants, animal matter, and general filth and decay (“Concepts

of Contagion and Epidemics”)––think of the black plague doctors, who wore large beak masks

stuffed with flowers and nice smelling things to ward off the plague. This theory’s prevalence

correlates to the difficulty germ theory researchers had in disproving it; bad smelling things, like

rotten food or fecal matter, often could carry harmful diseases, like mould or cholera, and many

diseases do spread through the air, like the flu. Back then, before scientists could see anything as

small as a bacterium, let alone a virus, the idea that scent itself spread disease seemed logical––

close enough to smell it, close enough to get infected. In each theory, a grain of truth exists,

either in the correlations between those catching the disease (ie social class, as poorer people

often consumed contaminated water or food) or in the cause of the disease, as with miasma

theory, therefore germ theory researchers fought an uphill battle.

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It took many scientists producing revolutionary research from the mid 1600s to the mid

1900s to finally prove germ theory and its related sanitation practices to the scientific

community. To begin, Louis Pasteur looked at alcohol fermentation. He discovered the

eponymous method of pasteurisation, wherein heating a food item like milk or wine can kill off

harmful bacteria and prevent spoiling, while leaving non harmful microorganisms like yeast,

which is required for alcohol fermentation. His problem came afterwards: once the food was

germ free, how to stop them from spontaneously generating back into it? After a series of

experiments with swan-neck flasks, he concluded spontaneous generation could not exist; the

flasks’ necks trapped dust and other particles, but not air, from reaching the liquid inside. When

he took off the neck, the liquid became contaminated, indicating that rather than exposure to air

itself, the particles within the air contaminated the substance. Thus, to keep from spoilage after

pasteurisation, such foods only need storage in bottles or other covered containers (Ullmann).

Going further, Ignaz Semmelweis studied a postpartum infection called puerperal fever, and the

resulting mother and infant mortality rates. He proposed the women and babies with the illness

had something which transferred to the doctors who delivered them, then the doctors spread the

illness when moving to the next woman. Semmelweis proved this by having the doctors wash

their hands, resulting in a significant drop in mortality and infection rates compared those who

continued not washing their hands. Generally, he upset the other doctors by suggesting they hurt

and killed their own patients, so they kept him out of practice for insisting this was the case

(Zoltán). Similarly, John Snow, mapped out the worst London cholera outbreaks in the mid

1800’s, tracing it back to a single contaminated water pump and noting cholera’s communication

cholera. Although the government removed the pump and infection rates immediately declined,

they considered it an emergency measure. Nobody believed his evidence for germ theory or
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sanitation advice, such as suggesting cholera was a single celled organism or that drinking water

should be boiled (“John Snow”).

Finally, the strongest research for germ theory came after the microscope’s popularisation

in the late 1800s. Anton van Leeuwenhoek developed and used the first microscope powerful

enough to see microorganisms (Ford). Although microscopes helped the scientific community,

they remained unused for studying diseases until long after they could see bacteria. Casimir

Davaine used them to look at anthrax in sheep, noting rod-shaped bacteria present in any infected

animal’s blood and the absence of it in healthy ones; he also noted transfusing infected blood to a

healthy animal resulted in the animal developing anthrax. His work inspired Robert Koch, who

figured out how to grow the bacteria on a slide, called culturing, which grew spores that could be

used up to years later to infect a host. This lead Koch developing his four postulates, laying the

groundwork for germ theory:

“1. The microorganism or other pathogen must be present in all cases of the disease.

2. The pathogen can be isolated from the diseased host and grown in pure culture.

3. The pathogen from the pure culture must cause the disease when inoculated into a

healthy, susceptible laboratory animal

4. The pathogen must be reisolated from the new host and shown to be the same as the

originally inoculated pathogen” (Stevenson).

He further isolated the bacteria which caused tuberculosis and cholera, proving to the scientific

community that a specific microorganism caused a specific disease. Although he failed to realise

viruses and asymptomatic carriers existed, scientists continue using his postulates today to

identify diseases, albeit not every disease fits each postulate perfectly––all science builds on the

shoulders of others.
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Overall, the shift to germ theory revolutionized the medical and sanitation fields, but the

shift relied on more than only experimental research. The advancement of technology, as in the

microscope, germ culturing equipment, and other precision tools were needed for the

experiments. Additionally, with the newfound understanding of germs, disease became

something controllable, and the government stepped in to enforce public health policies like

quarantining, inoculation (the predecessor to vaccines), sanitation, and doctoral licensing, coined

the “Great Sanitary Awakening” (“A History of Public Health”). In fact, the Great Sanitary

Awakening created the idea of public health, as the state took responsibility for keeping

communities clean and healthy, including spreading information, like boiling drinking water or

washing hands, and building more public hospitals and care facilities (“A History of Public

Health”). Generally, cleanliness became associated with health and disease was seen as

preventable and treatable.

However, many scientists today argue germ theory is too simplistic of a medical view.

Overall health depends on more than just germs and sanitation, so around 40 years ago, the

biopsychosocial model was created. Although young, the biopsychosocial model gained

popularity quickly thanks to the faster spread of information in the modern era compared to 100

years ago. It follows George Engel’s philosophy, an American psychiatrist, who said “the

appearance of illness results from the interaction of diverse causal factors, including those at the

molecular, individual, and social levels” (Borrell-Carrió et al). By this, he distinguished the

biological factors, such as germ theory, diet, and exercise; the psychological factors, such as

mental health; and sociological factors, such as the impact of others’ views and actions on the

individual. His model criticises germ theory’s separation of the body and the mind; germ theory
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focuses on the body because its diseases are seeable, whereas the mind’s diseases are not. Engel

argued their invisibility makes the mind’s disease no less valid or worthy of treatment.

Today, there are fewer stand-out scientists as there were centuries ago; instead,

anonymous groups perform and collect observations to create a new model and to legitimise the

new diseases the biopsychosocial model creates. The new evidence follows: germs and physical

defects do not cause all diseases, such as (some causes) obesity. Further, some disease

symptoms, like a heart attack, can have causal effects as well, as one increases the likelihood of

another (Borrell-Carrió et al). However, there has also been more study into mental health and

disorders, like depression, which is not always caused by a physical defect, but could also be

caused by poor diet, lack of exercise, poor social relationships, abuse, and many other situations

(“Causes of Depression”). Germ theory might argue depression is always caused by an

imbalance of brain chemicals or hormones caused by physical defects or microorganisms; the

biopsychosocial model acknowledges the other possibilities.

Similarly to germ theory, the biopsychosocial model faces opposition, but unlike germ

theory, the obstacles are social taboos and legal issues. The model’s biggest issue in many

countries across the world is the stigma against seeking help for mental health problems. Further,

many diseases germ theory cannot independently solve, like depression, are chronic; meaning the

expense of the necessary medication and services, such as counselling, also deter many people

from seeking regular care, especially as many health care insurance plans do not cover or

undercover mental health needs. In the United States, although the current Affordable Care Act

does assure mental health care to those receiving insurance directly through the government,

such as through Medicaid, those provided with insurance through their business may not be so

lucky. As well, with the current administration, funding for Medicaid and the Affordable Care
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Act itself is insecure. Worse, things are even more uncertain within individual states, as the state

can decide whether or not to accept the governmental aid and how to disperse it (“Barriers to

Mental Health Care”). Although the biopsychosocial model may not be considered a full

paradigm shift in its own right, as it continues to envelop the previous mindset, the opposition it

faces socially and legally in some aspects of the model does require a true shift in public thought.

In conclusion, shifting medical thought takes more than just a better idea or model. It

takes numerous scientists––some named, some anonymous––doing revolutionary research and

observation to disprove a preexisting thought model. Before germ theory, doctors correlated

behaviour and personality with health, thus doctors could only help with symptoms and attempt

prevention through moral behavioural advice. Germ theory revolutionised the paradigm,

connecting disease to the presence of outside microorganisms and not the patient’s personal

failures. Thus, medicines and more biological preventions were possible, such as through

sanitation and sterilization, like boiling dirty water, better sewage removal, bathing and washing

one’s hands frequently, and cleaning dirty surfaces. However, health and certain diseases are

connected to behaviour, and framing health as a fight against a foreign enemy within the physical

body ignored other important aspects of health, like mental and social health. Just like germ

theory, the biopsychosocial model faces opposition, as mental health facilities are either

underused or underfunded, but times are changing and the acceptance of such facilities grows

with each generation. Hopefully, the biopsychosocial model will win out over germ theory, just

as germ theory won out over its opposers, to normalise the idea of chronic treatment and the lives

of many people.
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Works Cited

“A History of the Public Health System.” National Center for Biotechnology Information. U.S.

National Library of Medicine, 1988. www.ncbi.nlm.nih.gov/books/NBK218224/

“Barriers to Mental Health Care.” Unite for Sight. 2015. www.uniteforsight.org/mental-health

/module6

Borrell-Carrió, Suchman, and Epstein, Ronald M. “The Biopsychosocial Model 25 Years Later:

Principles, Practice, and Scientific Inquiry.” National Center for Biotechnology

Information. U.S. National Library of Medicine, Nov 2, 2004. Doi: 10.1370/afm.245

“Causes of Depression.” Webmd. 2016. www.webmd.com/depression/guide/causes-depression#1

“Concepts of Contagion and Epidemics.” Contagion: Historical Views of Diseases and

Epidemics. Harvard University Library Open Collections Program, 2017. ocp.hul.harvard

.edu/contagion/concepts

Ford, Brian. “Antony van Leeuwenhoek (1632-1723).” University of California. 2016.

www.ucmp.berkeley.edu/history/leeuwenhoek.

“Germ Theory.” Contagion: Historical Views of Diseases and Epidemics. Harvard University

Library Open Collections Program, 2017. ocp.hul.harvard.edu/contagion/germtheory

“Humoral Theory.” Contagion: Historical Views of Diseases and Epidemics. Harvard University

Library Open Collections Program, 2017. ocp.hul.harvard.edu/contagion/humoraltheory

“John Snow.” BBC. 2014. www.bbc.co.uk/history/historic_figures/snow_john

Stevenson, Lloyd Grenfell. “Robert Koch, German Bacteriologist.” Encyclopedia Britannica.

2017. www.britannica.com/biography/Robert-Koch

Ullmann, Agnes. “Louis Pasteur: French Chemist and Microbiologist.” Encyclopedia Britannica.

2017. www.britannica.com/biography/Louis-Pasteur/Spontaneous-generation
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Zoltán, Imre. “Ignaz Semmelweis: German-Hungarian Physician.” Encyclopedia Britannica.

2017. www.britannica.com/biography/Ignaz-Semmelweis