Surgery

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Advances and problems in surgery by 1840

The three main problems that were affecting surgery in 1840 were pain, infection and bleeding. All these factors contributed to death rate- in 1840, about 40% of patients died. Because of pain, infection and bleeding, all surgical operations had to carried out in the quickest time so that the patient would suffer the least shock.

The most important English surgeons at this time were...

1. Astley Cooper: operated on King George IV and spent years perfecting his operations on hernias. First surgeon to successfully operate on an anuerysm (a ballooning artery which could burst and lead patient to bleeding to death).

2. Robert Liston: known for biting the surgeon's blade between his teeth so he could save time in operations.

Hospitals in London provided operating theatres for the greatest surgeons and operating day was a weekly show for everyone to come and observe, mainly students and the public.

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How did surgeons overcome the problem of pain?

Humphry Davy experimenting with nitrus oxide as a painkiller: From testing out nitrus oxide as a painkiller in 1795, following that in 1800 he wrote a report recording his experiments showing that when nitrus oxide was mixed with oxygen it produced reversible unconciousness. Therefore, he used it on a patient to relieve the pain of an inflamed gum. He suggested to use it in surgical operations but nobody took up his ideas.

1845: Horace Wells (USA surgeon) used nitrus oxide for the extraction of teeth. This failed miserably as the dosage given was too small, meaning the patient was in agony. Niturs oxide got a poor reputation: they also discovered effects of nitrus oxide only lasted around 5 minutes, making it a useless painkiller to use.

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How did surgeons overcome the problem of pain?

Ether

Ether used as a painkiller: American doctor, William Clarke successfully performed an operation where he deduced the amount of pain the patient was when extracting their tooth in 1842. 

News of ether quickly spread to Europe: First use of ether in England was by Robert Liston in Dec 1846, during an amputation. Ether had effects that lasted longer than nitrus oxide and the operation was a success. 

Problems with ether: Ether irriated the lungs, caused many patients to vomit and could knock a patient out for days, which was dangerous.

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How did surgeons overcome the problem of pain?

James Young Simpson and chloroform

James Young Simpson discovered chloroform in 1847.He was a professor or surgery, specialising in midwifery.

He discovered chloroform by one evening taking home some chemicals with his assistants in an attempt to find a decent anaesthetic. By accident, someone knocked over the bottle containing chloroform, knocking Young Simpson and his assistants out into a deep sleep.

Key event in acceptance of choroform: used by Queen Victoria whilst she was in labour. She believed chloroform performed as an effective and successful anaesthetic. With royal approval, it increased chloroform's popularity.

John Snow tackled the problem of overdosing on chloroform by developing a portable inhaler during the 1850's: regulated how much chloroform was given to patients.

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How was the problem of infection dealt with?

Semmelweis: doctor for Vienna General hospital who discovered disease was being spread through not washing your hands. Semmelweis ordered that everyone in the hospital wards should wash their hands in chlorinated water. However, he faced oppostion due to his colleauges not believing that germs caused disease (Germ Theory not discovered yet) and refused to wash their hands as they saw it as a waste of time. They did not agree with his 'bullying' ways to try to get people to wash their hands.

His discovery improved surgery to an extent as it took the death rate of deaths from septiciaemia and other infections from 30% to 1%.

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How was the problem of infection dealt with?

Joseph Lister

Joseph Lister was a head of surgery in Glasgow in 1859, who made the key discovery of antiseptic surgery.

From reading Pasteur's Germ Theory, he was convinced sepsis was being caused by microbes in the air. Therefore, Lister now understood that he needed to get rid of these microbes. He had an understanding of using carbolic acid in treating sewage, he dressed a compound tibia fracture with a bandage soaked in carbolic acid. The patient walked out of the infirmary fully head 6 weeks later.

The experiment was repeated 9 months later and yet again, was a success. Lister wrote up his findings in his medical journal, the Lancet (1867). In addition to this, he went on to develop the 'donkey engine', a steam driven machine that sprayed the operating theatre with carbolic acid.

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How was the problem of infection dealt with?

Joseph Lister

Lister first used his invention the 'donkey engine' in 1877, in an operation and was widely publicised leading to other surgeons copying his methods. In addition to the donkey engine, he also introduced the use of catgut for ligatures: dipped in carbolic acid to sterilise them and developed a form of catgut which would dissolve so no threads would be left dangling outside the body.Criticisms of Lister's methods:

1. Some doctors denied existence of bacteria in the air and thought the use of carbolic acid was unneccessary.

2. Lister kept changing his methods to improve them, however people thought e was changing them as they didn't work.

3. Nurses in operations complained carbolic fumes caused damage to their hands.

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How was the problem of infection dealt with?

By the late 19th century, operations were carried out quite differently in antiseptic conditions...

1. Operating theatres were full of carbolic, and surgeons and nurses worked in clean white aprons and shirts.

2. Instruments were laid out on a clean tray and any used equipment was put in a bowl and moved out the way.

3. Nurses had to wear caps to keep their hair from bringing in infection to the operating theatres.

End of 19th century: antiseptic surgery (GET RID OF GERMS) changed to aseptic surgery (NO GERMS PRESENT AT ALL). Aseptic surgery: hand scrubbing for hygiene, heat sterilisation for instruments, rubber gloves introduced (1894) and face masks (1897). Surgeons were actively pursuing higher standards of hygiene to reduce death rates.

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How has war helped in the development of surgery?

Accelerated surgeons training: WW1 brought surgeons into contact with large number of new wounds. Worked with soldiers in poor conditions. Gained experience and wealth.

New techniques: 75% of wounds caused by shrapnel- learned to soak wound in saline solution and cut away infected tissue, which could solve infections. Brain surgery development: surgeons first time dealing with brain injuries. Harvey Cushing: Us surgeon who developed a glass sucker to remove damaged brain sections and used electromagnets to remove shrapnel from brain.

Plastic surgery: Harold Gillies observed attempts at skin grafting on Western Front and returned to England, setting up a plastic surgery unit in 1917. They completed 11,000 plastic surgery operations on WW1 soldiers. Developed new technique of pedicule tubes where a layer of skin was taken from the body and stitched onto a tube at the other end.

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How has communication helped in the development of

Surgeons wanted their work to be recorded and made notes and had photographs taken. This meant surgeons could improve on their work.

Newspapers reporting surgical news to the public had a role in publicising new techniques. The best example here is when the newspapers reported Queen Victoria's use of chloroform whilst giving birth.

Surgeons and scienctists also travelled and visited each other. For example, Lister travelled around Germany and the USA discussing his ideas with other surgeons. He met with Louis Pasteur in 1892 at a confrence of 2,500 surgeons. Instrestingly, Lister was not informed of the work of Semmelweis.

Many medical and scientific journals were published which allowed ideas to be shared. The Royal College of Surgeons had one which encouraged surgeons to discuss new ideas and problems.

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