History- Surgery

• In the 1840s patients would only have been given alcohol to help them overcome the pain of operations. Speed was important and the patient had to be held down to stop them moving
• Lots of blood would be lost in operations and blood transfusions were mostly unsuccessful as they used animal blood or blood from another human with a different blood group
• Ligatures were starting to be used to stop blood loss but infection was commen and people would often die after an operation if they managed to survive
• In the 1860s Lister used sterilised cat gut which stopped blood loss and stopped infection getting into the wound. This was not a very practical method however...
• In 1846 Ignaz Semmelweiss found that washing hands after delivering a baby in a chlorinated solution reduced the death rate dramatically
• In 1846 William Morton a dentist, found that using ether gas helped to relieve pain and was a longer lasting anaesthetic than had ever been used before. But it tended to make patients vomit and resulted in fatalities.
• in 1859 Edinburgh James Simpson and his friends inhaled chloroform and realised it did not have any side effects. However Hannah Greener died having an operation on her toe using chloroform
• Lots of Victorians were reluctant to use pain relief as they thought it interfered with God's will
• In 1867 Joseph Lister proved that germs were carried by microbed in the air. He soaked bandages in carbolic acid before placing them on a wouond and found that this helped the would heal.
• 1878 Koch proved that certain bacteria causes blood poisoning and developed a steam steriliser to be used for surgical instruments.
• 1884- it was discovered that cocain could be used for pain relief.

• During the first World War improvements were made to the storage of blood. In 1916 Francis Rous and James Turner found that adding a citrate glucose solution allowed to be stored for longer.
• Until Blood groups were discovered in 1901 by Karl Landsteiner, he suggested that there were 4 different types of blood groups. For the first time surgeons knew it was important to use the correct blood group for transfusions.

Step 1: Laughing Gas (Nitrous Oxide)

Anaesthetics developed partly because of improved knowledge of chemistry. In 1799 Sir Humphrey Davy discovered that laughing gas reduced the pain. He suggested that it could be used in surgery and by dentists. BUT:

• It did not make patients completely unconscious so was not a complete answer to the problem of pain
• An American dentist, Horace Wells became convinced of the value of laughing gas after inhaling it at a fair. However ,when he used it in a public demonstration his patient was in agony. This killed confidence in laughing gas.

Step 2: Ether

In 1846 John Collins Warren, an american surgeon removed a neck tumour using ether as an anaesthetic. A year later, a famous English surgeon, Robert Liston, used ether to anaesthetise a patient during a leg amputation. BUT:

• Ether irritated the eyes and lungs, causing coughing and sickness. It could catch fire if close to a flame and had a vile, clinging smell that took ages to go. Ether also came in a large, heavy bottle that was difficult to carry around

Step 3: Chloroform

James Simpson, a professor at Edinburgh University had used ether but was searching for a better anaesthetic. One evening in 1847, he and several colleagues experimented with different chemical to see what anaesthetic effects they had. Simpson realised that chloroform was very effective and within days started using it to help women in childbirth and in operations. Chloroform as the most effective anaesthetic yet discovered, but that didn't mean it was problem free or that everyone was enthusiastic about pain free surgery.

• In the early 1800s, surgeons prided themselves on how quickly they could operate because speed was the only way of reducing pain. Anaesthetics meant that speed was no longer important.
• Chloroform was untested. No one knew if there would be long-term side effects on the bodies or minds of patients. They did not know what dose to give different patients 
• In 1848, Hannah Greener died whilst being given chloroform during an operation to remove her toenail. This first death from the use of chloroform scared surgeons
• With patients asleep, doctors attempted more complexed operations thus carrying infection deeper into the body and causing more blood loss. The late 1870s were known as surgery's Black Period because of the high death rate. Some surgeons returned to using ether mixed with nitrous oxide.
• Letter to the medical journal The Lancet in 1849 ; 'The infliciton of pain has been invented by Almighty God' Pain may even be considered a belling of the Gospel.
• Some thought pain was good.

Many surgeons followed Simpson's example in using chloroform, but there was still opposition. At least some of this opposition gave way in 1857 when Queen Victoria accepted the use of chloroform during the birth of her 8th child. She publicly praised that blessed chloroform. There were still many improvements to make, but Simpson's use of chloroform was the turning point on they way to pain-free surgery. Adv:

• surgery was pain free. This meant that fewer patients dies of shock
• Surgeons began to take more time over operations and were able to work deeper inside the body developing new operations
• Research began into using chloroform more safely and effectively
• Research led to better Anaesthetics that relaxed muscles as well as simply putting patients to sleep and had fewer side effects. 
• Local Anaesthetics developed

Dis

• it took time for surgeons to find the right doseage
• chloroform made may patients vomits
• surgeons still operated at high speed at first
• With patients asleep surgeons tried risky operations
• the problems of infection and blood-loss continued so surgery was still very dangerous.

Background Information: Lister was a surgeon but had a keen interest in the application in Science to medicine. He researched gangrene and infection

Progressive

• Found carbolic acid could be used as a good antiseptic when he saw it being used by sewage workers to cover up the smell5
• Made 3 improvements to his method: hand washing, carbolic spray, antiseptic ligature
• Changed the death rate for amputation from 40% to 15%
• Marked a turning point in history

Regressive

• Surgeons were still convinced speed was essential
• Lister appeared cold, arrogant and aloof
• When some surgeons tried his methods they didn't get the same results

• Despite anaesthetics, surgeons were still convinced that speed was essential. Lister's antiseptic methods seemed to slow everything down.
• Pasteur's ideas had spread very slowly. Trained surgeons found it hard to understand that tiny organisms caused disease
• Lister was not a showman giving impressive public displays. He appeared cold, arrogant and aloof and was sometimes critical of other surgeons.
• When Lister achieved his good results, surgeons reactions were defensive feeling Lister was criticizing them for letting patients down.
• Lister's carbolic spray seemed extreme. It soacked the operating theatre, cracked the surgeons skin and made everything smell. The new precautions caused extra work, they made operations more expensive and less pleasant for surgeons
• Lister constantly changed his techniques to find a substance that would work equally as well as carbolic but without the erosion it caused
• When some surgeons tried Lister's technique they did not get the same results. Other argued that antiseptics actually prevented the bodies own defence mechanisms from working effectively.

Key moment: Carbolic Spray 1864

Surgery before antiseptics: Infection could be carried into the body caused the black period of surgery where there was low success rate.

Main Stages of Development

• hand washing with carbolic- Ignaz Semmelweis 
• Carbolic Spray to kill germs in the air- Joseph Lister
• Antiseptic Ligatures- to tie up blood vessels

Factors explaining breakthrough: science- germ theory, individual genius- Semmelweis, Lister, Pasteur, Technology- chemicals, Chance- Lister happened to be going past a sewage team

Impact of use of antiseptics- Semmelweis cut the number of women who died from childbirth by encouraging hand washing. Before carbolic spray 1864-1866 the death rate was 46% 1867-1870 death rate cut to 15% when carbolic used.

Limitations: carbolic acid spray slowed down operations at a time where they hadn't dealt with blood loss, it soaked the operating theatre and cracked the hands of surgeons, conservatism- new to surgeons so many didn't want to use it, not everyone believed in germ theory, only antiseptic surgery not aseptic surgery 

Reasons for oppositions

• conservatism
• not every surgeon got the same results
• surgeons were still convinced speed  was essential
• Surgeon's thought that Lister was criticizing them
• Lister was arrogant, cold and aloof
• Lister constantly changed his methods, his critics thought this was because they didn't word

Surgery before blood transfusions: People died because there were different blood groups but this was not known, people had to be present to give blood transfusions, only simple operations could be performed.  Main stages of development:

• Landsteiner identify's blood groups
• In 1907 Ruben Ottenberg perform 1st blood transfusion using blood groups
• Large casualty rates in WW1 lead to attempts to store blood for later transfusion
• The 1st blood banks were set up by the British during WW1 after scientists discovered how to prevent blood clotting by using sodium citrate they also realised that blood could be presented using a citrate glucose solution
• Scientists found out how to separate and store the crucial blood cells.

Factors explaining breakthrough: Science- landsteiner and others, War- WW1 accelerated the need to overcome blood loss, Individuals- Landsteiner, Technology

Impact of Blood transfusions: Less people died because of the knowledge of blood groups, casualty rates in WW1 are far lower than they would otherwise have been, this is bcause of blood transfusions

Limitations: Both people would have to be present 

Factors explaining opposition: Attitudes and beliefs- certain religions don't allow blood transfusions, little opposition because its war time.

Science: Science played an important role in the development of surgery, for example, the developments in anaesthetics and antiseptics had a huge impact on surgery as it went deeper into the body and became more complex. Science in the form of carbolic spray also had a huge impact on infection.

Communication : Communication was a key factor, as the publication of ideas meant theories spread faster than before. However it was not always effective, e.g. Semmelweis didn't know about Lister's work.

Technology: Technology played a significant role. The discovery of x-rays made surgeons more confident. X rays were also used to remove bullets and shrapnel and were developed into mobile x rays units during the war. Other examples, carbolic spray, steam sterilizer etc

The work of key individuals e.g. Lister, Simpson, Pasteur, hunter

War

War big effect led to improvements however it focused attention on dealing with wounds and so other progress such as search for bettwe anaesthetics may have been delayed.

Scientific Understanding- chemistry was developing

Germ theory 1861, proved Semmelweis was correct

1878 Robert Kock found bacterium which caused septicemia which boosted Lister's ideas.

Scientists realised how to seperate plasma and corpsecules

blood groups

Marie and Pierre Curie began using radiotherapy 

Fleming discovered Penicilin

New technology- xrays discovered in 1895, 6 months later x-ray machines in hospitals. WW1 led to development of mobile x-ray machine pioneered by Marie Curie.

During the First World War surgeons gained greater experience due to the mass casualties of the conflict. Surgeons gained a great deal of experience in a wide range of injuries and sometimes had to improvise new techniques. War accelerated the training of surgeons.

During wartime there were many 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 solution was the best way of dealing with infection. 

Surgeons found themselves having to make early attempts at brain surgery because of severe war injuries.

At the start of the First World War Harold Gillies set up a plastic surgery unit in the British Army. Before the war the French surgeon Morestin worked on facial surgery. Before the first world war french and German surgeons were developing skin graft techniques, using tissue from another part of the body to repair and injury. Harold Gillies then developed new and advanced techniques of skin graft and plastic surgery.