A revolution in surgery

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Box A: Lister used dressings soaked in carbolic acid on the compound fracture of James Greenlees, an 11-year-old boy, in August 1865, and the wound healed without becoming infected.

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John Snow's work on anaesthetics was significant first because it made anaesthetics safer. After ether was introduced at the end of 1846 and chloroform in 1847, the biggest danger was the dose: too little and the patient woke up, too much and they could die. In 1848 15-year-old Hannah Greener died under chloroform, which made many people afraid of it. Snow, a London doctor, studied anaesthetics scientifically. He designed inhalers for ether and chloroform that controlled the amount of vapour a patient breathed in, and he worked out how to give the smallest effective dose. This reduced the risk of death and helped surgeons trust anaesthetics.

Second, he was significant because of his most famous patient. In 1853 he gave chloroform to Queen Victoria at the birth of Prince Leopold, and again in 1857 for Princess Beatrice. The Queen wrote that the effect was 'delightful beyond measure'. Once her use of chloroform became known, it became much harder for religious critics to argue that pain relief in childbirth was wrong, and it became fashionable among wealthy women.

In the longer term, Snow was significant because he was one of the first doctors to specialise in anaesthesia. He gave anaesthetics in thousands of operations, and his book On Chloroform and Other Anaesthetics was published in 1858, after his death. Anaesthetics later became a specialist branch of medicine. However, his significance had limits: chloroform was still dangerous and was later replaced, and painless surgery was not safe surgery until Lister tackled infection from 1865.

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One similarity is that both aimed to make wounds heal cleanly, without pus, instead of encouraging infection. In the 13th century most surgeons believed that pus in a wound was a good sign, known as 'laudable pus', and some even tried to encourage it. Hugh of Lucca and his son Theodoric rejected this idea and argued that wounds should be kept clean so that they healed without pus. Aseptic surgery in the 1880s and 1890s had the same aim: to stop germs from reaching the wound at all, so that it healed without any infection. In both cases the surgeons saw pus as a sign that something had gone wrong, not as part of healing.

A second similarity is that both relied on cleanliness to achieve this. Theodoric cleaned wounds with wine, removed any dirt or foreign objects and covered them with clean, dry dressings. Wine contains alcohol, which kills germs, although Theodoric could not have known this. Aseptic surgeons took cleanliness much further, because germ theory and Koch's discovery of the bacteria that infect wounds in 1878 showed them exactly what they were fighting. They sterilised their instruments and dressings with steam, scrubbed their hands and arms, and wore gowns, caps and, from about 1890, rubber gloves. In both periods these ideas went against the practice of most surgeons. Many medieval surgeons continued to encourage pus, and in the late 19th century older surgeons were slow to give up their frock coats and adopt gowns and gloves.

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War has been an important factor in the development of surgery, because it produced huge numbers of serious injuries that forced surgeons to find new methods. However, the most important breakthroughs in overcoming pain and infection were made in peacetime, and war usually speeded up and spread developments that depended on science and technology.

There are examples of war encouraging surgery throughout the period. Medieval surgeons gained much of their experience treating battle wounds, such as arrow and sword wounds, and learned to remove arrowheads and stop bleeding with cautery. In the 16th century Ambroise Paré, a French army surgeon, discovered at the siege of Turin in 1537 that a soothing ointment worked better than boiling oil on gunshot wounds, and he promoted ligatures instead of cautery to stop bleeding. In the 18th century John Hunter's experience as an army surgeon informed his work on gunshot wounds.

War had its greatest impact in the 20th century. In the First World War Harold Gillies developed plastic surgery at Sidcup for soldiers with terrible facial injuries, and methods of storing blood were developed so that transfusions could be given near the front line. Mobile X-ray units helped surgeons find bullets and shrapnel. In the Second World War Archibald McIndoe developed new treatments for airmen with severe burns at East Grinstead, and penicillin was mass-produced to prevent infection in wounds. The scale of injuries, and government funding, speeded up these developments enormously.

However, the key breakthroughs of the 19th century happened in peacetime. Ether was first used in Britain in 1846 and Simpson discovered chloroform in 1847 in civilian practice. Lister began using carbolic acid in a Glasgow hospital in 1865, and aseptic surgery developed in hospitals in the 1880s and 1890s. In fact, war sometimes held back new methods: in the Crimean War in 1854 John Hall warned army surgeons against using chloroform.

Science and technology were more fundamental than war. Lister's work depended on Pasteur's germ theory, and the blood transfusions of the First World War depended on Landsteiner's discovery of blood groups in 1901. X-rays were discovered by Röntgen in 1895, by chance, not because of war. After 1945 transplants and keyhole surgery depended on new drugs and technology developed in peacetime. Individuals, such as Simpson and Lister, and government, especially the NHS from 1948, were also important.

In conclusion, war has been an important factor, particularly in the 20th century, when it speeded up the development of plastic surgery and blood transfusion and the use of penicillin. But it has not been the main factor, because the great problems of pain and infection were solved in peacetime by individuals using science, and wartime advances depended on scientific discoveries that had already been made.