The Transformation of Surgery

Laughing gas (nitrous oxide)

Anaesthetics developed partly because of improved knowledge of chemistry. 1799 Sir Humphry Davy suggested that it could be used by surgeons and dentists.

BUT

It did not make patients completely unconscious so was not a complete answer to the problem of pain.

An American dentist used it in a oublic demonstration his patient was in agony. This killed confidence in laughing gas as an anaesthetic. 

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.

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 other collagues experimented with different chemicals 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. He wrote articles about his discovery and other surgeons started to use it in their operations.

Why did some people oppose the use of chloroform?

• In the early 1800's, 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 any long tem side effects on the bodies or minds of patients. They did not know what dose to give to different patients.
• In 1848, Hannah Greener died whilst being given chloroform during an operation to remove her toenail. The first death from the use of chloroform scared surgeons.
• With patients asleep, doctors attempted more complex operations, thus carrying infections deeper into the body and causing more blood loss. The 1870's were known as surgery's Black Peroid because of the high death rate. Some surgeons returned to using ether mixed with nitrous oxide.
• Believe pain was invented by God and some considered it a blessing.
• Believed pain in childbirth improved the religious and moral character of women.

Chloroform

1857 Queen Victoria accepted the use of chloroform during the birth of her eighth child.  She publicly praised 'that blessed chloroform'.

HOWEVER

• It took time for surgeons to find the right dosages.
• Chloroform made many patients vomit.
• Surgeons still operated at high speed at first.
• With patients asleep, surgeons tried more risky operations, leading to more deaths.
• Still problems of infection and blood-loss so surgery was dangerous.

Chloroform

Steps to the future

• Surgery was pain free. This meant that fewer patients died of shock.
• Surgeons began to take more time in operations and worked deeper into the body, developing new operations - saving lives.
• 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 had fewer side effects than chloroform.
• Local anaesthetics were developed.

Carbolic Acid

Before - surgeons still operated with old, pus - stained clothes, did not wash their hands, did not sterlise equipment.

Joseph Lister used Louis Pasteur's germ theory to develop caarbolic spray.

What did Lister do ?

• He first experiemented by treating people with compound fractures where the bone breaks through the skin. Infection often developed in these open wounds. Lister applied carbolic acid to the wound and used bandages soaked in carbolic. He found that the wounds did not develop gangrene, saving many lives.
• He then did the same with amputations, covering the wound in carbolic soaked bandages.

Before carbolic sparay in 1864 and 1866 - death rate of 46%, and between 1867 and 1870 (antiseptic surgery) - death rate of 15%.

Carbolic Acid

Improvements

• Handwashing with carboli before operations to avoid the suregon introducing infections into wounds.
• A carbolic spray to kill germs in the air around the operating table.
• An antiseptic ligature to tie up blood vessels and prevent blood loss.

Where did the idea of using carbolic come from ?

Used carbolic acid on sewage and it prevented the smell and killed the parasites on cattle, so he decided to test carbolic spray on open wounds.

Carbolic Acid - Opposition

• Lister's carbolic spray seemed very extreme. It soaked the operating theatre, cracked the surgeon's skin and made everything smell. The new precautions caused extra work, making operations more expensive and less pleasant for surgeons.
• Despite anaesthetics, surgeons were still convinced that speed was essential. Lister's antiseptic methods just seemed to slow operations down.
• When some surgeons copied Lister's methods, they did not acheive the same results. This was because they were less systematic but they still critised Lister. Others argued that antiseptics actually prevented the body's own defence mechanisms form working effectively.
• Pasteur's ideas had spread very slowly. Even trained surgeons found it difficult to accept that tiny micro-organnisms caused disease.
• For centuries, surgeons had lived with the fact many patients died. When Lister said he acheived good results there was disbelief. Then they were defensive, feeling that Lister was critising them for letting their patients down.
• Lister was not a showman giving impressive public displays. He appeared cold, arrogant and aloof and was sometimes critical of other surgeons, he was regared by some as a fanatic.
• Lister constantly changed his techniques to find a substance that would work equally as well as carbolic, but without the corrosion it caused. His critics said he changed his methods because they did not work.

How did Lister and antiseptics change surgery?

Antiseptic surgery - There are germs in the operating theatre but surgeons use methods, such as carbolic spray, to stop open wounds being infected.

Aseptic surgery - Cleaning and sterilising methods prevent there being any germs in the operating theatre to infect wounds.

By the late 1890's Lister's antiseptic methods had developed into aspetic surgery. To ensure absolute cleanliness:

• Operating theatres and hospitals were rigorously cleaned.
• From 1887, all instruments were steam-sterilised.
• Surgeons stopped operating in their ordinary clothes and wore surgical gowns and face masks.
• In 1894, sterilised rubber gloves were used for the first time.

With 2 basic problems of surgery now solved, surgeons attempted more ambitous operations.

Doctors first attempted to give blood to humans from dogs, sheep and cows until the practice was banned in the 1670's. The first human-to-human transfusions started in the 1790s in America.

James Blundell successfully transfused blood from twin brothers in 1827.

How was the problem of blood loss overcome?

Stage 1: Landsteiner identifies blood groups

Karl Landsteiner identified blood groups and demonstrated that some blood groups were incompatible with others. Landsteiner showed that each blood cell had antibodies which would react with those from a different blood group, meaning blood tranfusions would only ok if there was no reaction.

In 1907 in New York, Reuben Ottenberg performed the first blood transfusion using blood typing. However the patient and the donor had to be in the same place. When doctors tried to store blood it clotted and could not be used for transfusions.

Stage 2: Storing blood for later transfusions

BT needed an emergency to make it more commonly used and to solve the problem of storing blood for later transfusion. WW1 - high casualty rates and the impact of high explosives and machine gun bullets made the need for blood tranfusion greater.

Scientists discovered sodium citrate could be added to blood to prevent it clotting. They also realised that a citrate glucose solution allowed blood to be stored for several days after it had been collected. This led to the first blood banks being set up by the British for use during the war.

Scientists also discovered how to seperate and store the crucial blood cells. The cells could be bottled, packed in ice and stored where they were needed. The cells only had to be diluted with a warm saline solution and then usable blood was ready. This discovery helped save many lives both in trenches and on the operating table and made possible the huge blood banks that supply today.

Effective blood transfusions

Sodium citrate and the discovery of how to seperate and store blood cells prevented blood from clotting. This led to the first blood banks being set up by the British for use during the war and as a result many lives were saved.

The development of X-rays

Developed by scientist Wilhelm Rontgen in 1895. Within months of Rontgen publishing his discovery the news had spread world-wide and the first X-ray machines were being used in hospitals.

WW1 had a major impact on the common use of X-rays. Surgeons needed to locate bullets and shrapnel lodeged deep within wounded men. Govs. ordered the making of many more X-ray machines and they were installed in all major hospitals on the Western Front. 

Fighting infection

Many wounds were very deep and bullets carried fragments of clothing, carrying bacteria deep inside the body. This caused deep infections. Gradually, through practice and trying out new methods during the war, surgeons learned how to cut away the infected tissue and protect it with a saline solution.

The development of plastic surgery

The terrible injuries in WW1 led to a rapid improvement in techniques, especially the use of skin grafts. Injuries were mostly from bullet and shell damage. Surgeons carried out over 11,000 plastic surgery operations, increasing their experience and learning from each other. Harold Gillies in 1917 in a new hospital in Sidcup specialising in reapiring facial injuries developed many more plastic surgery techniques.

The development of brain surgery

As the war progressed, new treatments such as use of saline for shock and blood transfusions kept the patients alive and it became possible to operate on severe head injuries. Surgeons developed new techniques and improved their skills as they were faced with large numbers of casualties suffering from severe head wounds. For example, Harvey Cushing developed a surgical magnet during WW1 to extract bullets from the heads of wounded soldiers.