The Surgery Revolution

Twenty-eight seconds

Robert Liston of University College Hospital could take off a leg in 28 seconds, and needed to, because until 1846 the only anaesthetic was speed, and the patient was held down by assistants while he worked. Around one amputation in three or four killed the patient afterwards, of infection nobody could explain. Surgery had three problems: pain, infection and blood loss. Between 1846 and 1900 two of them were solved, in an order that mattered. On 21 December 1846 Liston amputated a leg under ether, the first such operation in Britain, two months after William Morton had demonstrated it in Boston. On 4 November 1847 James Simpson in Edinburgh found chloroform, easier to use and quicker to act. Pain was beaten. Then the deaths rose, because surgeons who could take their time went deeper and took longer, and every extra minute let infection in. It was the discovery of the germ, by Pasteur in 1861, that gave Joseph Lister his idea: on 12 August 1865 in Glasgow he dressed the compound fracture of an eleven-year-old boy with carbolic acid, and the wound did not go bad. His amputation death rate fell from 46 per cent to 15 per cent in five years. Aseptic surgery, the removal of germs before they reached the wound, followed in the 1880s and 1890s with steam sterilisers, gowns, gloves and masks. AQA asks four things on this key element: how useful a source is, how significant a development was, how two developments compare, and which factor mattered most across the whole story. This module gives you the dates, the figures and the chain, and the shapes to argue them in.

Five words the examiners use

Each definition ends with the moment it mattered, because a bare definition earns nothing in an 8-mark answer.

The chain, in order

Put these six developments in the order they happened.

• Liston amputates a leg under ether at University College Hospital
• Simpson discovers the anaesthetic effect of chloroform in Edinburgh
• Queen Victoria takes chloroform for the birth of Prince Leopold and the drug becomes respectable
• Lister dresses a compound fracture with carbolic acid and the wound does not become infected
• Koch shows that steam kills bacteria and surgical instruments begin to be sterilised by heat
• Halsted introduces rubber gloves and the aseptic operating theatre is complete

Why did surgery change so fast after 1846?

For centuries surgery had been speed, strength and prayer. Which explanation best accounts for its transformation in fifty years?

• Science and technology supplied the means: the chemists who made ether and chloroform available, and the germ theory of Pasteur in 1861 that told Lister what was killing his patients; individuals took the risks, Simpson on himself at his dinner table and Lister on a boy in Glasgow against the disbelief of colleagues; communication spread each step within months, Boston to London in two, Glasgow to the Lancet in two years; and chance played its part, since Simpson found chloroform by trying bottles and Lister chose carbolic because Carlisle used it on sewage.
• The wars of the nineteenth century forced surgeons to find better methods.
• The government passed laws requiring anaesthetics and antiseptics.
• Patients demanded painless surgery and surgeons had to provide it.

Each solution and the problem it exposed

The grade-9 habit AQA rewards on this key element: read the three developments as a chain, each step solving one problem and revealing the next, rather than as three separate inventions.

Question 1: how useful is a source?

Source A: a description of a painting made in 1882 by Thomas Eakins, The Gross Clinic, showing the American surgeon Samuel Gross operating on the thigh of a patient in a lecture theatre in 1875. Gross stands in a dark frock coat with a bloodied scalpel in his bare hand; assistants in ordinary clothes hold the wound open; an anaesthetist holds a cloth over the face of the patient; rows of students watch from the benches; the mother of the patient covers her eyes. AQA Question 1 asks how useful the source is to a historian studying the surgery revolution. Tap the TWO details that a top-level answer would use to show what surgery had and had not achieved by 1875.

• An anaesthetist holds a cloth over the face of the patient, showing that pain had been conquered and the operation could be conducted at length before an audience.
• The mother of the patient covers her eyes.
• Gross operates in a frock coat with bare hands and a bloodied scalpel, and his assistants wear street clothes, showing that neither antiseptic nor aseptic practice had reached this theatre a decade after Lister.
• Rows of students watch from the benches.
• The painting was made in 1882.

Opposition to change

Select the THREE statements that correctly describe the opposition each development met.

• Chloroform was opposed on religious and medical grounds: some clergy said pain in childbirth was ordained, some doctors feared patients would die under it, and the death of Hannah Greener in 1848 seemed to prove them right, until Queen Victoria used it in April 1853 and the argument was over.
• Carbolic acid was opposed because most surgeons did not accept germ theory, because the spray was unpleasant and the acid damaged skin, and because Lister kept changing his method, so that London surgeons dismissed him when he arrived in 1877.
• Aseptic surgery was slower to be resisted than adopted, but it needed expensive theatres, sterilisers and trained staff, so poorer hospitals kept older methods into the 1890s.
• Parliament banned chloroform in 1848 after the Greener death.
• The Church excommunicated Lister for using carbolic acid.
• Anaesthetics were accepted at once without any opposition.

Which factor mattered most?

The 16-mark question on the thematic study names one factor and asks whether it was the main one in the development of surgery. The strong answer weighs that factor against the others with dated evidence, and reaches a judgement that answers the question rather than listing everything. Science and technology supplied every means: the chemistry that made ether and chloroform, the germ theory of 1861 without which Lister would have had no idea to test, the steam sterilisers that followed Koch in 1878. The individual turned means into practice: Simpson testing bottles on himself, Lister risking a boy with a compound fracture, Halsted ordering gloves for a nurse whose hands the carbolic had cracked. Communication made each step a movement: Boston to London in two months in 1846, the Lancet in 1867, the medical conferences of the 1880s at which German asepsis reached Britain. Chance opened doors, from the sewage works at Carlisle to the dinner table in Edinburgh, and war waited for the next key element. Government and religion were absent from surgery in this period, which is itself an answer worth writing. This meant that no single factor made the surgery revolution; science made it possible, individuals made it happen, and communication made it general. A judgement that says which of those three was necessary first, and shows with dates that the other two depended on it, reaches the top level.

In the shoes of the surgeons

Four decisions between 1847 and 1889. Choose what was actually done, and notice what each choice changed.

• November 1847. You are James Simpson in Edinburgh. Ether works but it irritates the lungs, takes time to act and catches fire. You have a cupboard of chemicals. What do you do?
• August 1865. You are Joseph Lister in Glasgow. You have read Pasteur on germs in the air, and a boy with a compound fracture of the leg lies in your ward; such fractures usually end in amputation or death. What do you do?
• 1877. You are Lister, newly appointed in London, where the surgeons doubt germ theory and laugh at the spray. What do you do?
• 1889. You are William Halsted in Baltimore. Your theatre is aseptic in every respect but one: the carbolic used to scrub hands has cracked the skin of your head nurse so badly she cannot work. What do you do?

From cause to consequence

Because ether and then _____ let a patient sleep through an operation, surgeons could work slowly and deeply for the first time after 1846. Because longer operations let more germs into the wound, death rates rose in the years historians call the _____ period. Because Pasteur showed in _____ that germs cause decay, Lister could reason that a germ-killer would protect a wound, and carbolic acid cut his amputation deaths by two-thirds. Because carbolic burned skin and treated the wound only after germs had entered, surgeons turned to _____ methods that kept germs out with steam, gowns and gloves. And because _____ was the one problem none of this solved, the next step waited for the discovery of blood groups in 1901.

Lister by the numbers

Before carbolic acid, 46 per cent of the amputation patients of Lister died between 1864 and 1866. After it, 15 per cent died between 1867 and 1870. By how many percentage points did the death rate fall?

Question 3: in what ways were they similar?

AQA Question 3 might read: Compare the work of Simpson and the work of Lister. In what ways were they similar? Explain your answer with reference to both. It is marked on similarities explained with support from both, for 8 marks. Which answer scores in the top level?

• Both applied a chemical from outside medicine to a surgical problem and tested it on a living person before they understood it fully: Simpson inhaled chloroform at his own dinner table in November 1847 and used it in childbirth within a week, and Lister put carbolic acid, a sewage treatment, on the fracture of a boy in August 1865. Both then met opposition from colleagues that only evidence overcame: the deaths under chloroform were answered by royal use in 1853, and the mockery of the spray by the fall in amputation deaths from 46 to 15 per cent that Lister published.
• Both were surgeons who made surgery better.
• Lister used carbolic acid and cut deaths from 46 to 15 per cent, which was a great advance.
• They were different because Simpson worked on pain and Lister on infection.

Question 2: significance, marked

Question 2: Explain the significance of the work of Joseph Lister in the development of surgery. The significance of Lister was that he turned a theory into a practice that could be measured. Pasteur had shown in 1861 that germs cause decay, but nobody had applied that to the operating theatre until Lister, reasoning that a germ-killer should protect a wound, dressed the compound fracture of a boy with carbolic acid on 12 August 1865 and saw it heal. This meant that surgery had, for the first time, a method against infection with numbers behind it: his amputation death rate fell from 46 per cent in 1864 to 1866 to 15 per cent in 1867 to 1870, published in the Lancet in 1867, so that the argument could be won by evidence rather than authority. The longer significance is that his antiseptic method was itself replaced: the spray of 1871 was unpleasant and the acid damaged skin, and the German surgeons who adopted his principle moved on in the 1880s to keeping germs out with steam and gowns rather than killing them with carbolic. Lister mattered because he proved the germ theory mattered in surgery, which made asepsis, blood transfusion and every later operation possible, even though almost nothing of his own technique survived him. What earned the marks: significance explained at the time (a measurable method), with dated and quantified support; the link phrase this meant that; and significance explained over the longer term, including what was superseded and what endured. Both timescales, tied together, are what reach the top level of the 8-mark significance question.

Question 4: the 16-mark factors judgement

Has the role of the individual been the main factor in the development of surgery in Britain since c1800? Explain your answer with reference to the role of the individual and other factors.

• One paragraph on the role of the individual, with at least three dated examples: Liston, Simpson, Lister, Halsted or others, and what each actually did
• At least two paragraphs on other factors from the AQA list, each with dated support: science and technology (germ theory, chemistry, steam sterilisers), communication (the Lancet, conferences), chance, or war for the twentieth century

Question 4: the judgement, tested

A student has argued that the role of the individual was the main factor in the surgery revolution. Which is the strongest point to set AGAINST that judgement, in the way the top level of Question 4 requires?

• The individuals were indispensable but not sufficient: Lister could not have thought of carbolic without the germ theory Pasteur published in 1861, Simpson could not have found chloroform before the chemists had made it, and neither could have changed surgery beyond one hospital without the Lancet and the conferences that carried their results, so science and technology supplied the possibility, communication supplied the spread, and the individual supplied only the moment, which means the role of the individual was the visible factor and not the main one.
• It was all luck, so no factor was the main one.
• War was the main factor because it forced surgeons to improve.
• Lister was a genius, so the individual was the main factor.