War and Surgery

What war did to surgery

On 8 November 1895 Wilhelm Rontgen, working alone in his laboratory at Wurzburg, found that a new kind of ray passed through flesh and not through bone, and within weeks hospitals across Europe were photographing fractures and bullets. In 1901 Karl Landsteiner in Vienna sorted human blood into groups and explained why transfusion had so often killed. Neither discovery had anything to do with war. What war did, from 1914, was to supply the patients, the money and the urgency that turned laboratory findings into routine surgery. The Western Front produced injuries in numbers no hospital had seen: shell fragments carrying mud and cloth deep into wounds, jaws and faces destroyed by shrapnel, thighs shattered by machine-gun fire. The Thomas splint, invented in the 1870s and issued from 1916, cut deaths from a fractured femur from around 80 per cent to around 20. Mobile X-ray cars, some driven by Marie Curie herself, found the metal before the surgeon cut. Sodium citrate, shown in 1914 to stop blood clotting in the bottle, let Oswald Robertson store blood for the Battle of Cambrai in 1917, the first blood bank. And at the Queens Hospital, Sidcup, from 1917, Harold Gillies and his team carried out around 11,000 operations on about 5,000 men whose faces had been shot away, inventing modern plastic surgery as they went. The Second World War repeated the pattern with burns, blood and penicillin, and the peace that followed brought transplants, lasers and keyhole surgery from laboratories and companies rather than battlefields. AQA asks how far war has been the factor behind surgery, and the grade-9 habit is to separate what war invented from what it only accelerated, advance by advance. This module gives you the advances, the dates and figures, and the usefulness, significance, similarity and factor shapes.

Five terms with their dates

Each definition carries the date and the figure that make it usable as evidence, and says whether war or something else produced it, because that distinction is the whole of the factor question.

The advances in order

Put these six developments in the order they happened.

• A German physicist finds rays that pass through flesh and not bone
• Blood is sorted into groups in Vienna
• Stored blood is used for the first time in a battle
• Burned airmen form a club named after laboratory animals
• A surgeon in Cape Town transplants a human heart
• A gall bladder is removed through small incisions using a camera

Why did war speed surgery up?

X-rays, blood groups and skin grafting all existed before 1914, and all became routine surgery between 1914 and 1918. Which explanation best accounts for what war did?

• War supplied what peacetime medicine lacked: patients in numbers, with the same kinds of injury arriving in thousands, so that a surgeon like Gillies could refine a technique on 5,000 faces in four years when a civilian hospital saw a few a decade; money and organisation, since the army built Sidcup, bought X-ray cars and set up blood depots on a scale no hospital could afford; urgency, which swept away the caution that had kept transfusion and grafting experimental; and the removal of the usual objections, because a man with no jaw would consent to anything. What war did not supply was the science, which came from Rontgen, Landsteiner and the chemists before the war and from the pharmaceutical industry after it.
• Army surgeons invented X-rays, blood groups and grafting under fire.
• War did nothing for surgery because it killed so many doctors.
• Britain copied German surgery after the war.

What war produced, and what it did not

The factor question on this key element turns on one distinction, so make it advance by advance: which developments the wars produced or transformed, and which came from science, industry and individuals in peacetime. The last item in each column is the one to use for a judgement.

Question 1: how useful is the source?

Source A: a description of the case records kept at the Queens Hospital, Sidcup, between 1917 and 1921. Each patient has a file with his name, rank and regiment, the date and place of his wound, a note of the injury in medical language, photographs taken before and after each operation, and, for many patients, pastel portraits drawn by Henry Tonks, a surgeon turned artist, showing the face at each stage of repair. The files record more than 11,000 operations on around 5,000 men and note when a man was discharged and to what work. AQA Question 1 asks: How useful is Source A to a historian studying the impact of the First World War on surgery? Tap the TWO details that make it most useful for that enquiry.

• The photographs and portraits at each stage of repair, which show the techniques being developed operation by operation and let the historian see how the tubed pedicle and grafting improved across the four years
• Each file has the name, rank and regiment of the patient.
• The record of more than 11,000 operations on around 5,000 men with their outcomes and discharge, which shows the scale of practice the war provided and allows the historian to measure results rather than rely on the claims of the surgeons
• The portraits were drawn by a surgeon turned artist.
• The hospital was in Sidcup.

Blood, X-rays and the Second World War

Select the THREE statements that are accurate about these advances.

• Transfusion became practical in three steps: Landsteiner identified the blood groups in 1901, sodium citrate was shown in 1914 to 1915 to stop stored blood clotting, and Oswald Robertson used refrigerated group O blood at Cambrai in November 1917, so that the science came before the war and the organisation came from it.
• X-rays were discovered by Rontgen in 1895 and used in hospitals within months, but the First World War made them routine before surgery, with mobile units in the field to locate shrapnel and bullets, and the same war showed the danger of the rays to those who operated the machines.
• The Second World War brought the treatment of burns under McIndoe at East Grinstead, the drying and storage of plasma developed by Charles Drew in 1940, the mass production of penicillin from 1943, and the national blood service of 1946 built on wartime depots.
• Blood groups were discovered on the Western Front in 1916.
• X-rays were first used in the Second World War.
• The first heart transplant was carried out on a wounded soldier in 1944.

Question 1: the usefulness method

AQA Question 1 on Paper 2 gives one source and asks how useful it is to a historian studying a stated enquiry, for 8 marks. The marks come from three things used together: content, what the source shows about the enquiry; provenance, who made it, when, for whom and why, and what that does to its value; and own knowledge, used to test what the source shows against what else is known. For the Sidcup records in Source A, the content shows the techniques improving across thousands of operations and the outcomes for the men. The provenance is the strength: the files were made by the surgeons for their own use, to track each case, not to impress the public or the army, so they show what was actually done, including the failures, and the Tonks portraits were drawn as clinical records rather than as art. The limit is that they show one hospital and one kind of injury; the historian learns about plastic surgery and nothing about blood, X-rays or the splint, and nothing about the men treated elsewhere or not at all. Own knowledge tests them: the scale matches what is known, that Sidcup treated around 5,000 men, and the techniques match the tubed pedicle Gillies published in 1920. This meant that the source is very useful for how the war created a specialism and less useful for the impact of the war on surgery as a whole, and a top-level answer says both and uses the provenance to explain why the source can be trusted for what it covers.

Four surgeons, four wars and peaces

Four decisions between 1917 and 1967. Choose what was actually done at each, and notice which were made possible by war and which were not.

• 1917. You are Harold Gillies at Sidcup. A sailor burned at Jutland has lost most of the skin of his face. A skin graft cut free from his chest will die before it takes. What do you do?
• November 1917. You are Oswald Robertson, an American doctor with the British army before Cambrai. Wounded men are dying of blood loss before a donor can be found. What do you do?
• 1940. You are Archibald McIndoe at East Grinstead. Fighter pilots are arriving with hands and faces burned by petrol, and the standard treatment, tannic acid, sets the burns hard and leaves them worse. What do you do?
• 3 December 1967. You are Christiaan Barnard in Cape Town. A young woman has died in a road accident and her heart is healthy; Louis Washkansky is dying of heart failure. No human heart has ever been transplanted. What do you do?

From discovery to routine

Because Rontgen found in 1895 that a new ray passed through flesh and not bone, hospitals could see inside the body, and because the war of 1914 filled men with shrapnel, mobile _____ units made the picture before surgery routine. Because Landsteiner sorted blood into groups in 1901 and chemists found in 1914 that _____ stopped it clotting, blood could be stored, and because Cambrai needed it, the first depot was built in 1917. Because thousands of faces were destroyed by shellfire, the army gave Gillies a hospital at _____ and the practice that produced the tubed pedicle. Because burning petrol did to pilots in 1940 what shells had done to infantry, McIndoe advanced the treatment of _____ and founded a club for his patients. And because transplants, lasers and keyhole surgery came from laboratories and companies after 1945, a judgement on war as a factor must separate the surgery of _____ from the surgery of disease.

The Thomas splint

Before the Thomas splint was issued in 1916, around 80 per cent of soldiers with a fractured femur died. After it, around 20 per cent did. By how many percentage points did the death rate fall?

Question 3: two similarities, marked

AQA Question 3 asks you to compare, for 8 marks: Explain two ways in which the impact of the First World War and the Second World War on surgery was similar. Which answer reaches the top level?

• One similarity is that both wars turned a small specialism into a large one by supplying patients in numbers: Gillies treated around 5,000 disfigured men at Sidcup from 1917 and worked out the tubed pedicle on them, and McIndoe treated hundreds of burned aircrew at East Grinstead from 1939, founding the Guinea Pig Club in 1941, because each war produced one kind of injury in thousands that peacetime never had. A second similarity is that both wars organised blood on a national scale from a pre-war discovery: Landsteiner had found the groups in 1901, but it was the First World War that produced the Cambrai depot of 1917, and the Second that produced dried plasma under Charles Drew in 1940 and the national transfusion service of 1946, because armies needed stored blood where hospitals had managed with live donors. In both cases the science came before the war and the scale came from it.
• Both wars helped surgery because there were lots of wounded soldiers.
• The First World War produced plastic surgery but the Second World War produced penicillin.
• Both wars had X-rays, blood, grafts, splints, burns, penicillin and hospitals.

Question 2: significance, marked

Question 2: Explain the significance of the First World War for the development of surgery. At the time, the First World War was significant because it turned three pre-war discoveries into routine practice within four years. X-rays, found in 1895, became the standard preliminary to surgery once mobile units under Marie Curie were finding shrapnel in French field hospitals; blood, whose groups Landsteiner had identified in 1901, could be stored once citrate and refrigeration were combined, and Oswald Robertson built the first blood depot for Cambrai in November 1917; and the Thomas splint, issued from 1916, cut deaths from a fractured femur from around 80 per cent to around 20. This meant that a wounded man in 1918 had a far better chance of surviving surgery than in 1914, because the war supplied the patients, the money and the urgency that peacetime hospitals had lacked. In the longer term the war was significant because it created a specialism: Harold Gillies persuaded the army to open the Queens Hospital at Sidcup in 1917, carried out around 11,000 operations on about 5,000 men, and invented the tubed pedicle that made large skin grafts survive, so that plastic surgery existed as a discipline by 1921 and could be extended to burns by McIndoe in the next war and to civilian reconstruction after it. The limit of the significance is that the war discovered nothing: Rontgen, Landsteiner and the chemists who found citrate were working in peacetime laboratories, the war added scale and organisation to their findings, and the surgery of disease, transplants, lasers and keyhole methods, came after 1945 from laboratories and companies with no war involved. The First World War matters most as the event that turned the science of 1895 to 1914 into the practice of the twentieth century, and for the treatment of injury rather than of illness. What earned the marks: significance at the time with dated examples and a figure; significance in the longer term, distinguished from the first and traced forward; the limit stated plainly with evidence; and a closing judgement that says what it matters most for. That three-part shape, at the time, longer term, limit, is what the 8-mark significance question rewards.

Question 4: the factor judgement

Has war been the main factor in the development of surgery in Britain since 1895? Explain your answer with reference to war and other factors.

• State your judgement in the first sentence and keep to it
• Make the case for war with evidence: Sidcup and Gillies, the Thomas splint, the Cambrai blood depot, East Grinstead and McIndoe, each with a date or a figure
• Set other factors against it: science and technology in Rontgen, Landsteiner, the laser and fibre optics; the role of individuals such as Barnard; the pharmaceutical industry in cyclosporin; government in the NHS and the blood service
• Use a link phrase such as "this meant that" to show how each factor changed surgery, not just that it existed
• Reach a judgement on a stated criterion, for instance whether war invented or only accelerated, or whether the surgery of injury and the surgery of disease had different main factors, and say which factor mattered most and why

Question 4: the judgement, tested

A student has argued that war was the main factor because the First World War produced plastic surgery, the blood bank and routine X-rays, and the Second World War produced burns treatment and mass penicillin. Which is the strongest point to set AGAINST that judgement, in the way the top level of Question 4 requires?

• Every one of those advances rested on a discovery made in peacetime by science: Rontgen in 1895, Landsteiner in 1901, the citrate chemists, Fleming in 1928 and the Oxford team by 1940, and Gillies had already learned grafting from French and German surgeons before 1914; the wars organised and scaled what science had found, and since 1945 the largest advances, the transplant of 1954 and 1967, cyclosporin in 1983, the laser and keyhole surgery of the 1980s, have come from laboratories, companies and the NHS with no war at all, so that war was the main factor only for the surgery of injury and only until 1945, and a judgement across the whole period should weigh science and technology as the factor the wars themselves depended on.
• War was the main factor because wars have so many casualties.
• War did nothing for surgery because it killed people.
• The role of the individual was the main factor because Gillies was a genius.