This article will go into detail the whole of B3, Surgery which includes surgery and anaesthetics in 19th century, discovery of anaesthetics, understanding infection, Joseph Lister and antiseptics, reactions to Lister's antiseptics, blood loss - controlling and replacing blood, role or war, science and technology in development of surgery, interactions of factors affecting development of surgery and a check-list to make sure you have copied everything in the Surgery History GCSE topic. Phew, that was a lot and it is a lot. However, you are more than welcome to skip to the parts most relevant to you.
Before we get into surgery, let's have a look at a timeline which shows the most important parts to surgery:
- 1846 - Morton used ether to anaesthetise a patient in the USA.
- 1846 -Liston used ether during amputation in Britain.
- 1847 - Simpson used chloroform.
- 1848 -Hannah Greener died while receiving chloroform.
- 1853 - Queen Victoria received chloroform during childbirth.
- 1861 - Pasteur's germ theory.
- 1867 - Lister used carbolic acid.
- 1877 - Lister became Professor of Surgery at King's College Hospital, London, and publicised his ideas about antiseptics.
- 1878 - Koch developed the steam steriliser.
- 1901 - Landsteiner identified blood groups.
- 1905 - Novocaine used as an anaesthetic.
- 1916 - Rous and Turner developed a way of storing blood.
- 1916 - Gilles set up a plastic surgery unit at Aldershot.
- Assistants had to hold the patient still.
- Everyone wore ordinary clothes (unhygienic).
- Had spectators watching the surgery being carried out.
- Patient usually shouts out in agony.
- Sawdust on the floor to soak up the blood.
- A tourniquet (something that is tied around a part of the body to put pressure on a blood vessel and stop the loss of blood) would be around the place of amputation to stop flow of blood in that area.
- Knives and saws were laid out ready for use.
Fascinating Fact - Robert Liston was a very successful surgeon who was proud of his ability to amputate a leg in just a couple of minutes (record was said to be 28 seconds!). In one case, trying to beat his own speed record, he cut off the patient's testicles, and in another operation, he cut off two of his assistant's fingers. The assistant then later died from infection.
Discovery of Anaesthetics
- Sometimes made patients vomit.
- Irritated the lungs of patients so made them cough even when unconscious.
- Highly flammable which was dangerous as the only form of light in the 19th century was from a naked flame.
- Tended to produce a very deep sleep that could last for days.
- Was carried in large, heavy glass bottles which were difficult surgeons.
- Victorians were religious and therefore felt pain relief was interfering with God's plan, especially as the Bible said that God had told Eve that childbirth would be painful.
- Anaesthetics were new and effects were not fully understood so people distrusted them.
- Doctors felt it was easier for a patient to die unconscious than awake and struggling.
- The number of people that died shortly after their operation increased with the use of anaesthetics which seemed to prove that there was something wrong with anaesthetics.
The discovery of an effective anaesthetic was a major breakthrough in surgery since it meant the patient was not in pain, and it was welcomed by many. However, some people were slow to accept the idea of anaesthetics, and there were drawbacks to the use of both ether and chloroform.
- Medical students would come to watch operations.
- The assistants that held the patient down would all be wearing normal clothes.
- Surgeons wore their 'special' clothes which usually were his oldest coat that had large amounts of dried blood and pus on it.
- All instruments and the operating table would be dirty and unhygienic.
To sum up, Surgeons carried out a greater range of operations after the discovery of anaesthetics and they became more willing to carry our internal operations. However, because infection and microbes were not properly understood, the surgeon and his tools were likely to introduce infection into the wound and so the death rate from the operations actually increased.
Joseph Lister and Antiseptics
- Lister tried various methods to encourage wounds to heal cleanly, without infection, but had little success.
- He became interested in Pasteur's work and especially the idea that microbes were responsible for infection in a wound.
- In 1864 he found that carbolic acid was used in the sewage works at Carlisle and it killed parasites.
- Lister thought that carbolic acid could also be used to kill the microbes causing infection.
Though I hardly expected any success I tried carbolic acid on the wound to prevent the formation of pus in the leg. Well it is now eight days since the accident and the patient has reacted just as if there had been no open wound.Because of this, Lister went on to use carbolic acid EVERYWHERE from cleaning wounds to cleaning equipment and bandages. His operations were widely publicised and other surgeons began to copy his methods.
Lister's other Achievements
At the time silk was used as stitches to sew wounds closed. But, silk couldn't absorb carbolic spray and therefore couldn't be sterilised and a thread had to be left dangling out of the wound so that the stitches could be pulled out once the wound had healed. Therefore, Lister came up with the idea of using catgut instead.
Catgut can be sterilised reducing the chance of infection and Lister also developed a catgut that would dissolve after several days in the body, so there was no need to leave a thread dangling.
Lister's work in showing the importance of antiseptic (an environment sterile and free from microbes that cause infection) conditions was an important breakthrough in surgery, although it took time to be fully accepted...
Reactions to Lister's Antiseptics
Although Lister's idea were quickly accepted in Germany and the USA, many doctors in Britain were unconvinced at first and joked about 'Mr Lister's germs'. Meanwhile others accepted the basic idea of antiseptics but found the whole procedure too difficult or uncomfortable to put into practice especially as carbolic acid made the skin on their hands cracked and sore.
Opposition to Lister's Ideas
- Some doctors didn't believe microbes caused infection because microbes can only be seen with a microscope.
- Using carbolic acid slowed down the whole operation which could lead to problems such as blood loss.
- Doctors who copied Lister's ideas did not always copy them properly and then, if they did not get an improved survival rate after operations they said Lister's ideas were wrong.
- Lister kept changing his methods in an attempt to improve his work - many doctors though he was not sure of his ideas.
- The equipment was heavy and expensive.
- Some surgeons had already good results without using carbolic acid.
- The nurses resented the extra work caused by this emphasis on hygiene.
This lead to the shift from antiseptic (fighting infection and killing bacteria) to aseptic conditions, where doctors tried to prevent bacteria being anywhere near the wound. The use of masks, sterile equipment and closed operating theatres are all part of aseptic surgery.
So by 1900...
- Nurses and surgeons would wear clean white aprons and shirts.
- Nurses wore hats to keep hair tidy and prevent infection.
- Instruments were laid on clean trays.
- Dirty equipment were placed in bowls so they can be moved away and cleaned afterwards.
Fascinating Fact - Nurse Caroline Hampton, who assisted the American doctor William Halstead, had severe eczema on her hands and carbolic acid was making it worse. In 1890 Dr Halstead asked Goodyear Rubber Company to make rubber gloves for her. A side effect of this was that scientists found out that wearing rubber or latex gloves helped to prevent bacteria being introduced into the wound by the surgeon's hands.
Lister's use of carbolic acid as an antiseptic was an important breakthrough in surgery, and once the idea was accepted, the move was made towards aseptic conditions to prevent infection as far as possible.
Blood loss has always been a major problem in surgery. Bleeding makes it difficult for the surgeon to see what he is doing, but there is also the problem that if a patient loses too much blood, his blood pressure drops, which affects his heart, and then his body cannot function and he dies.
To counter this, during the 17th century, there were experiments into blood transfusion from animals such as sheep as well as from humans. Although patients occasionally survived, in most cases they died and the procedure was banned. Once anaesthetics and antiseptics made it possible to perform complex operations, there was a renewed drive to find a way of dealing with the two problems of blood loss: controlling blood loss and replacing blood.
Controlling Blood Loss
The usual way of dealing with wounds or amputations was to seal the blood vessels by placing a hot iron onto the wound or pouring hot oil over it. This process was called cautery and was extremely painful.
In the 16th century, Ambroise Pare developed metal clips to place on arteries during operation. He also tried using silk thread to tie the blood vessel after amputation instead of using heat to seal them. This was far less painful, but ligatures did not always stop the bleeding if they were not tied properly. Furthermore, this was before Pasteur developed the germ theory and therefore there was no understanding of the way that a surgeon's dirty hands inside a wound increased the chances of infection and led to a higher death rate. For these reasons, cautery continued to be the main way of dealing with bleeding until Pare's idea of silk ligatures was further developed by Joseph Lister in the late 19th century.
Replacing Blood - Transfusions
It had therefore become possible to at least partly control the loss of blood during an operation, but the problem of replacing blood was not solved until after 1901 when Karl Landsteiner suggested that there were different blood types - A, B and O; a fourth group, AB, was added in 1902.
Landsteiner showed that blood transfusions had to be between people with the same blood group or else the patient died. However, even with this breakthrough, there was still the problem that a donor needed to be present to provide blood whenever it was needed. This was not very practical and therefore his work id not have a big immediate effect on surgery.
As many soldiers died from blood loss in the trenches of the First World War (1914-1918), there was an emphasis on the search for a way to store blood for use at a later date:
- In 1915, an American doctor called Richard Lewisohn found that adding sodium citrate stopped blood clotting. This meant that the donor did not have to be present and therefore more transfusions could be carried out. Although it was found that the blood cells would deteriorate if the blood was not used soon afterwards, this discovery still saved the lives of thousands of wounded soldiers.
- Richard Weil found that this blood could then be stored in refrigerated conditions.
- In 1916 Francis Rous and James Turner found that adding a citrate glucose solution allowed blood to be stored for longer. This meant that when an attack was planned, the army could ask for donations of blood from the public, so that they were available for transfusion to treat the wounded.
- The first blood depot was established in 1917 for the Battle if Cambrai using blood group O, which can be safely given to all patients, whatever their blood type.
Overcoming the problem of blood loss was an important stage in the development of surgery. It depended on increased scientific knowledge but its development was also accelerated by the casualties of war.
The Role of War in the Development of Surgery
Did war between c1845-c1918 speed up or slow down the development of surgery? We will have to look at the roles of various factors to consider what effects they had.
In the First World War (1914-1918), often treated wounded soldiers close to the front line of fighting where the difficult conditions and large numbers of injuries put them under immense pressure. Surgeons therefore gained a great deal of experience in a wide range of injuries and sometimes had to improvise new techniques. In this way, war can be said to have accelerated their training.
New Developments in Surgery
- The use of explosive weapons meant that many soldiers suffered deep wounds, and when fragments of clothing entered the wound, it caused infection. Surgeons found that cutting away infected tissue and soaking the wound with a saline (salt) solution was the best way of dealing with this (although they still could not deal with serious infection as antibiotics were not developed until later).
- Surgeons also found themselves having to make early attempts at brain surgery because of the nature of some injuries received in the war.
- At the start of the First World War, the New Zealand doctor Harold Gilles asked for permission to set up a plastic surgery (surgery carried out in order to change the appearance of the patient) unit in the British army.
- Before WW1, French surgeon Morestin worked on facial surgery. Also, French and German surgeons were developing skin graft techniques, using tissue from another part of the body to repair an injury.
- Gilles was aware of these developments and asked permission to set up a plastic surgery unit in the British army.
- Gilles began to experiment with ways of reconstructing facial injuries and paid particular attention to the attempt to create a normal appearance.
- A narrow layer of skin was lifted up from the body and stitched into a tube at one end.
- The other end was still attached to the body and this meant blood continued to circulate and helped healthy skin to develop.
- When the tube had grown long enough, the free end was attached to the new site.
- Once the skin graft was in place, the pedicle tube could be cut free at the base.
Between 1914 and 1921 over 41,000 men in the British armed forces lost a limb. Advances in prosthetic limbs included the use of the light metal alloys and new mechanisms, but there were long waiting lists for these to be fitted and patients then needed training to use them properly.
War had a big effect on surgery and led to much progress being made. However, it also had the effect of focusing attention on dealing with wounds, and so progress in other areas of surgery, such as the search for better anaesthetics, may have been delayed as a result.
Role of Science and Technology in Development of Surgery
Science played an important role in suggesting ways of improving surgery, but technology was needed to put these ideas into practice.
Chemistry played an important part in developing anaesthetics and antiseptics. These developments then made surgeons willing to try more complex operations, for example removing tumours. They also began to deal with internal obstructions such as the hard 'stones' inside the gall bladder formed from cholesterol or pigments from blood cells (an extremely painful conditions). In the 1880s operations to remove gallstones and the gall bladder became routine as a result of better anaesthetics and antiseptics. This also led to other procedures being developed to deal with internal problems, for example, the removal of the appendix. Chemistry was also important in the development of a suitable technique to store blood until it was needed for transfusion.
Infection was controlled by using Lister's carbolic spray, sterilising the instruments, wearing rubber gloves and using sterilised catgut for ligatures. In the move to aseptic surgery, gowns and face masks were also used and the operating theatre was a closed environment. This was all based on Pasteur's work on the germ theory, an understanding of chemistry and biology, and the development of the new science, bacteriology.
The discovery of X-rays by Wilhelm Roentgen in 1895 made surgeons more confident about internal operations. Roentgen did not take out a patent on his discovery, which meant people were free to copy his ideas. As a result, the use of X-rays spread very quickly - the London Royal Hospital had its first X-ray machine in 1896. X-rays also made it possible for surgeons to extract bullets and shrapnel without having to dig around in a wound, and this reduced the problems of bleeding and infection. The importance was quickly recognised by surgeons, and mobile X-ray units were developed for use during the First World War for the benefit of surgeons working in the front line.
Developments in surgery are closely linked to improvements in scientific knowledge, for example discoveries about germs, anatomy, X-rays and chemicals However, the role of technology is also very important. When chloroform was first administered, it was usually done by pouring some drops onto a handkerchief for the patient to inhale. As you have seen, it was difficult to get the dosage right and chloroform affected the heart, leading to the death of some patients. Dr John Snow developed an inhaler that was much safer.
Other important example of technology helping surgery to advance are the carbolic spray, the steam steriliser, the X-ray machine and the hypodermic needle (invented in 1853 by Alexander Wood) used in blood transfusions.
Science played an important role in suggesting ways of improving surgery, but technology was needed to put these ideas into practice.
Interaction of Factors Affecting the Development of Surgery
Spread of Ideas
The emphasis on scientific methods during the 17th and 18th centuries had led scientists to publish their ideas and details of their experiments. During the 19th century many scientific and medical journals, such as the journal produced by the Royal college of Surgeons, encouraged the publication and discussion of new ideas and problems. For example, the death of Hannah Greener from chloroform was reported in the medical journal The Lancet.
The reason why surgeons were able to make use of X-rays so soon after Roentgen's discovery was because he published his work and did not take out a patent to prevent other people from copying his ideas.
Surgeons often wanted their work to be recorded. We have both photographs and artwork of several key events, such as the first use of ether, field surgery in the First World War and the work of Gilles in plastic.
The public were also interested in developments in surgery, so the papers reported the first use of anaesthetics, Queen Victoria's use of chloroform and the removal of King Edward VII's appendix.
Sometimes surgeons and scientists would travel to visit each other or to meet for conferences. Lister travelled through Germany and around the USA discussing his ideas. He met Pasteur in Paris in 1892 at a conference of 2,500 scientists, when Lister paid tribute to the importance of Pasteur's work. Nevertheless, communication was not always effective. Lister did not know about the work of Semmelweiss, and Morestin was unwilling to share his ideas on plastic surgery with Harold Gilles.
Some of the developments you have studied would probably have happened anyway. The use of ether had been such a breakthrough in surgery that when people realised the problems involved in using it, they did not want to abandon anaesthetics - they just wanted to find a better one. Simpson set out to discover a new anaesthetic, but if he had not discovered chloroform, someone else probably would have done. However, the fact that Queen Victoria's doctor was a friend of Simpson perhaps led to its use on royalty, which then convinced many other people that it was an example of progress.
In the same way, someone else might have discovered how to use carbolic acid instead of Lister, but the fact that he kept careful records, publicised ideas, tried different methods and was prepared to keep on with is ideas even when he was ridiculed all helped to get his ideas accepted (Remember that when Semmelweiss tried to improve hygiene, he was unsuccessful).
Various factors were involved in developments in surgery, often interacting with each other, so that war, science, technology and communications all contributed to developments such as blood transfusions.
The key factual themes throughout Surgery in History GCSE are:
- Dealing with pain, for example the importance of the discovery of anaesthetics, the problems in using ether and chloroform, the work of Simpson, and changing attitudes towards anaesthetics.
- Dealing with infection, for example Lister's use of carbolic acid, the reaction of other doctors, and the development of antiseptic and aseptic conditions.
- Dealing with blood loss, for example the use of ligatures and the importance of the development of transfusions.
- The role of factors in these developments, for example showing the importance of scientific knowledge and technology, communications, changing attitudes, wars, etc.
- The extent of progress within surgery, for example weighing up the advantages of anaesthetics against the problems caused when surgeons began to do more internal operations without a proper understanding of germs and the need for antiseptics.