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Y11 surgery revision booklet


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Y11 surgery revision booklet

  1. 1. Nominated Topic 2009: Surgery c.1850-c.1950 The situation at the beginning of the 19th century In 1800, surgery rarely went beyond setting broken bones, removing growths and performing amputations. However, surgery was beginning to lose its reputation as a “second rate” branch of medicine and well-trained surgeons were emerging from medical schools. The first 15 years of the nineteenth century saw the Napoleonic Wars between France and the rest of Europe, and new surgeons at this time had lots of practice on the battlefield and the quarterdeck. As the first half of the 19th century went by, surgeons began to go a bit further than the traditional operations. From Germany, operations were developed to cure cleft palates and squinting. In America, internal cysts were removed. For example, surgeon Ephraim McDowell removed a 15 pound ovarian cyst from Mrs Todd of Kentucky. The operation lasted 25 minutes, Mrs Todd sang hymns to drown the pain and she lived for a further 31 years! But this was unusual. Mortality rates in surgery were high. In 1800, about 40% of patients died, mostly through post-operative infections. Even surgeons who tried hard to be clean, like Spencer Wells in London, had high mortality rates – Wells’ was 25%. The three main problems causing this death rate were pain, infection and bleeding. This meant operations had to be done in the quickest time possible so that shock, loss of blood and the chance for germs to enter the wound were minimised. In 1824, it took 20 minutes to amputate a leg through the hip joint; in 1834, the same operation was done in 90 seconds. The most important English surgeons at this time were: • John Abernethy, who became Professor of the College of Surgeons in 1814 and placed great emphasis on anatomy, turning surgery from a craft to a science. • Astley Cooper, who operated on King George IV and spent years perfecting his operations on hernias. He was the first surgeon to successfully operate on an aneurysm (a ballooning in a large artery which would burst and lead the patient to bleed to death) after practising on a cadaver in the dead-room next door. • Robert Liston, who was renowned for biting the surgeon’s blade between his teeth so that he could save time in operations. He taught anatomy at Edinburgh Medical School from 1818 and then moved to University College London in 1835. Hospitals in London provided operating theatres for the greatest surgeons and operating day was a weekly show with celebrity surgeons performing before their colleagues, students and the public. However, top surgeons, like Astley Cooper of Guy’s Hospital, earned their vast salaries from performing operations on private patients in their homes.
  2. 2. How was the problem of pain dealt with? Since the times of the Ancient Greeks, surgeons had tried to find ways to deaden the pain during operations. The main products used were alcohol and opium – but experience showed that they were dangerous. For example, alcohol thins the blood, so a drunk patient might not feel much pain but would probably bleed to death during the operation. In 1795, Humphry Davy experimented with nitrous oxide (laughing gas) as a painkiller. In 1800, he wrote a report of his experiments, showing that neat nitrous oxide would kill animals, but when mixed with oxygen it produced reversible unconsciousness. He used it on a human patient to relieve the pain of an inflamed gum and suggested that it might be useful in surgical operations, but no-one took up his ideas. Later, nitrous oxide was used by dentist Horace Wells in the USA for the extraction of teeth. He developed a bellows system to administer the gas and gave a public performance in Massachusetts – which went badly wrong and his patient suffered in agony. Wells lost medical support, grew depressed, became a drug addict and committed suicide whilst in jail for hurling sulphuric acid at prostitutes. The next substance to be tried to deaden pain was ether. This had been discovered in the sixteenth century in Germany and had been used to make people cough up phlegm to balance their humours. An American doctor, William Clarke, used ether to deaden the pain of a patient having a tooth extracted in 1842 and another American doctor, Crawford Long, used ether to remove a cyst from a neck. Both operations were successful. An American dentist, William Morton, then popularised the use of ether in dentistry in the USA. News of ether soon spread to Europe. The first use of it in England was by Robert Liston in December 1846, during an amputation. The newspaper headlines the next day read: “Hail Happy Hour! We Have Conquered Pain!” However, ether had problems. It irritated the lungs and led to long bouts of coughing. It caused many patients to vomit. It was flammable – which was not good in an age of candles and gas lamps. An alternative anaesthetic was needed.
  3. 3. James Young Simpson had discovered chloroform in 1847. Simpson was a professor of surgery in Edinburgh, dealing specifically in midwifery. One evening, he took home some chemicals with his assistants to try and find a decent anaesthetic. Someone knocked over the chloroform bottle, and when his wife had dinner brought in, Simpson and his assistants were all found asleep. Later, Simpson tried giving half a teaspoon of chloroform on a rag to a woman in labour and was so pleased with the results that another 30 patients were given chloroform that week. The key event in the acceptance of chloroform was its use by Queen Victoria in the birth of Prince Leopold, 7 April 1853. John Snow administered the anaesthetic and the Queen recorded in her journal that the effect of chloroform was “soothing, quieting and delightful beyond measure”. With royal approval, chloroform began to increase in popularity. However, there were protests against its use including: • It was seen as cowardly to have pain relief – men were not real men if they took it • It was seen as anti-religious: the Bible taught that childbirth was supposed to painful • It was possible to kill people by giving them an overdose of chloroform • It actually killed more people in operations – this was true. As the patient was no longer thrashing about, surgeons began to attempt more risky and longer operations, inevitably killing more patients through bleeding and infection. John Snow tackled the problem of overdosing on chloroform by developing the portable inhaler during the 1850s. This now regulated how much chloroform was given to patients. It was accepted that knocking people out entirely was a risk. Surgeons also recognised that not all operations required patients to be totally unconscious. A search developed for substances which would numb a particular area for local surgery – such as the removal of a cyst. Coca leaves were traditionally used in South America for deadening pain and, in 1859, the active ingredient – cocaine – was isolated. By 1885, cocaine was being produced commercially as a local anaesthetic. A few more developments to the problem of pain were made in the twentieth century: • In 1902, anaesthetics began to be injected into the blood stream to control doses even more precisely. • Synthetic substances for local anaesthetics were developed such as ester procaine in 1905. • In the 1930s, artificial respiration was developed which allowed surgeons to use curare – a muscle relaxing drug.
  4. 4. How was the problem of infection dealt with? In the nineteenth century, it was common for a surgeon to operate in an old blood-caked frock coat and to wash his hands only after the operation. The operating theatre would contain a wooden table and sawdust to soak up the blood. All of these things meant germs were rife and sepsis (infections in the blood and tissue) were common. The link between sepsis and cleanliness had already been noted. In 1795, Alexander Gordon had argued that mothers who contracted childbed fever after childbirth had been infected by their doctors or midwives, and had recommended that the operator should wash before coming into contact with the mother. In 1843, American Oliver Holmes had argued that doctors were bringing “germs” into contact with mothers but was overruled by other doctors. The sepsis problem came to a head in the 1840s in Vienna. The Vienna General Hospital had the largest maternity clinic in the world. There were two great wards: in Ward One, childbed fever raged and the mortality rate was at 29%, in Ward Two, childbed fever was rarer and the mortality rate at 3%. An assistant physician, Ignaz Semmelweis, tried to work out what the difference was. He knew that Ward One was handled by the medical students and that Ward Two was handled by midwifery students. Medical students came straight to the wards from the autopsy rooms with soiled hands and instruments; midwifery students didn’t. When the two groups swapped over, Ward Two became the place to die. His suspicions were confirmed when a doctor cut his finger during an autopsy and died of septicaemia (blood poisoning) with the exact symptoms of the women dying of childbed fever. In 1847, Semmelweis ordered that everyone in the wards wash their hand with chlorinated water. Mortality rated plummeted. However, colleagues refused to believe his theories about putrid particles being passed from the medical students to the women – remember this was before the discovery of Germ Theory – and resisted his attempts to clean up. Semmelweis left Vienna for Budapest and introduced chlorine disinfection to the maternity wards at his new hospital. Childbed fever rates fell below 1%, and in 1861, he published a book on childbed fever. However, in 1865, Semmelweis died in a Viennese mental asylum. By this time, antiseptics of a general kind, like Semmelweis’s, were used widely. Iodine was used for bathing wounds, and other substances like bromine, creosote, zinc chloride and nitric acid were used for washing. Florence Nightingale had introduced the idea of spotless hospital environments. Whitewashing walls was common. Surgeons were urged to use soap and it was known that dressings should be changed. But no-one had yet introduced one clear, effective way of limiting infection and got everybody to use it. This was the achievement of Joseph Lister. Lister studied at University College London and became an assistant surgeon in Edinburgh in 1854, before moving on to head up surgery in Glasgow in 1860. In Glasgow, patients were often contracting
  5. 5. sepsis. He began to research where sepsis was coming from, experimenting on frogs. Then he read Pasteur’s Germ Theory in 1865 and became convinced that sepsis was being caused by microbes in the air. Lister now understood that he needed to get rid of these microbes. Normally skin provided the barrier to these microbes – if the skin was open, he would need a chemical barrier instead. Using knowledge of carbolic acid used in treating sewage, he dressed a compound tibia fracture with a bandage soaked in carbolic. The boy, James Greenlees, who had been run over by a cart, walked out of the infirmary fully healed in 6 weeks. The experiment was repeated 9 months later and worked again. From this success, Lister worked out a ritual for operations – antisepsis (killing infections in the wounds by smothering it in carbolic drenched dressings and tin foil) and asepsis (preventing new infections entering the wound by spraying the whole operating theatre with carbolic acid). He wrote up all his findings in 1867 in the medical journal The Lancet and went on to develop antiseptic ligatures for wounds and a “donkey engine”, a steam driven device to spray the operating theatre with carbolic acid. Criticisms of his methods immediately followed: • Some doctors denied the existence of bacteria in the air and said all the carbolic was unnecessary. • Lister kept changing his methods to improve them – but this made people think he was changing because they didn’t work • Carbolic acid slowed down an operation – many people believed that speed was the most important thing • When people tried to copy Lister’s methods and weren’t so careful, they didn’t work. • Nurses and assistants in the operations complained of the carbolic fumes and the damage the acid did to their hands By the late nineteenth century, operations were a strange mix of the old and new. Theatres were full of carbolic, but hands were just rinsed not scrubbed. Operations were still based around setting broken bones, amputating and removing cysts. The old blood-stained coats were still worn. But at the end of the century, as Koch’s identification of germs continued, Lister’s ideas were accepted more and more and his antiseptic (getting rid of germs) surgery began to develop into aseptic (no germs in the first place) surgery. Rubber gloves were worn (1894) and face masks began to be used (1897). Koch’s work showed that heat was more effective than carbolic for sterilising surgical instruments and the spray was abandoned in 1890. By 1910, operating theatres were filled with people wearing sterilised gowns, masks and gloves, using metal furniture and operating under electric lights. Surgeons were actively pursuing higher and higher standards of cleanliness to reduce the death rates.
  6. 6. How was the problem of bleeding dealt with? The idea of blood transfusions had started back in the 17th century. Here, doctors had tried to pump animal blood into patients but with no success. In the 19th century, human to human transfusions had been tried, but no-one could explain why they sometimes worked and sometimes didn’t. In 1901, Karl Landsteiner discovered blood groups. He noted that when patients died during a transfusion it was because their blood was clotting. Looking carefully at the blood cells under a microscope, he found that they were surrounded by different types of tiny cells which he called antigens. The first type of blood he called Group A and the second Group B. When the antigens of the patient matched the antigens of the transfused blood, all was well. If they didn’t match, the blood would clot and the patient would die. As he continued to test this theory, he discovered some blood cells had no antigens (so he called them Group O) and some blood cells had two types of antigens (so he called them Group AB). Other blood groups were discovered and Landsteiner received a Nobel Prize for his work in 1930. He went on to discover positive and negative blood types in the 1940s. Landsteiner’s work made it possible to have a successful transfusion every time. The problem was that a donor was needed on the spot. When WW1 broke out and thousands of soldiers were dying of gunshot wounds in the trenches, it was not possible to have donors on the spot. The war drove doctors to find an answer and in 1914, it was found that sodium citrate stopped blood clotting when it came into contact with the air. From this, doctors began to experiment with mixing blood with these anti-clotting agents so that it could be transported to the Front. In 1916, this was achieved and led to the British Army setting up the first blood depot. As people saw WW2 approaching in the 1930s, blood banks were set up in readiness for the carnage. In 1940, American doctor Charles Drew worked out a way to separate the blood cells from plasma and found that separately, these products did not clot. They could be kept and transported anywhere in the world before being put together again when needed in an operation. During WW2, it became possible for civilians to receive blood transfusions. As surgeons returned from WW2 with expertise in using blood banks, they began to demand that they have the same facilities for patients in peace times and national blood banks were set up permanently. Britain still has the National Blood Transfusion Service.
  7. 7. What has happened to surgery since these breakthroughs? As surgery became safer, surgeons began to become more adventurous in the types of operation they would attempt. In the late 19th century and early 20th century, surgeons began digging further into the body, treating bowels, the pancreas, the liver and the abdomen. Cancers were cut out, gallstones removed. People began to operate on the heart, lungs and brain. Surgery grew in popularity and people began to see surgery as the way to treat all ills. For example, William Arbuthnot Lane argued that lengths of gut should be removed to cure constipation. Certain operations became fashionable such as the removal of children’s tonsils in the 1920s and hysterectomies in the 1930s. WW1 decisively advanced skin transplants. Shells caused horrific facial injuries. Harold Gillies set up a plastic surgery unit in Aldershot and dealt with 2000 cases of facial damage after the Battle of the Somme. Skin from other parts of the patient’s body was used to cover facial damage and to encourage facial skin to grow back again. Gillies’ cousin, Archibald McIndoe, joined the work in the 1930s, and then treated 4000 airmen from the battle of Britain in WW2. McIndoe called his work reconstructive surgery as he took years and many operations to slowly give men back their hands and faces. These advances marked a shift in people’s thinking about surgery – no longer was it just about “cutting things out” but now began to be about restoring and replacing what was already there. Reasons for changes: new technology and scientific understanding The following technology and knowledge moved surgery along: • Ophthalmoscope – 1851 – allowed the interior of the eye to be seen • Louis Pasteur’s Germ Theory – 1864 – allowed Lister to make his link to antiseptics • Oesophagoscope – 1868 – allowed foreign objects in the gullet to be seen and removed • Robert Koch’s heat sterilisation – 1890 – ended the use of carbolic to sterilise operating theatres • Rectoscope – 1895 – to see up the rectum • Gastroscopes – late 1890s – to see into the stomach • Microscope used directly on the body – 1899 – to see the cornea • Cardiograph – 1903 – keeps the beating of the heart monitored during an operation. • Fibre-optic endoscopes – 1930s – to see into the stomach with greater ease and less pain • Karl Röntgen’s X-rays – 1895 – allowing the inside of the body to be seen without opening it up • Karl Landsteiner’s antigens – 1901 – allowing blood groups to be discovered • Marie Curie’s radiation treatments – 1904 – burning diseased cells away • First microsurgery – 1921 – doing an operation looking through a microscope • Ultraviolet microscope – 1925 – allowing viruses to be seen due to 2500x magnification. • Electron microscope – 1934 – revealing cell structure due to 7000x magnification. • Catheterization – 1940 – placing tubes in a patient to drain off fluid • Heart-lung machine – 1940s – to keep the body working whilst in an operation • Ian Donald’s ultrasound – 1950s – for assessing foetal development