The Transformation of Surgery 1845-1918
Question 1 - Study Source A.
What can you learn from Source A about how operations were carried out before the
nineteenth century?
(6 marks)
Source A: An eighteenth century painting
of an operation.
From Source A I can learn that operations in the C19th would have been very painful.
(Inference). This is because the patient is struggling and has to be held down by other people.
(Support from source). This clearly shows it isn’t a pleasant experience.
From Source A I can also learn that operations would not have been very hygienic and the
patient would have most probably died from infection. (Inference). This is because the source
shows there are a large number of people watching the operation in the operating ‘theatre’ and
also all the people involved with the actual operation are in their normal, everyday clothes which
they would wear in the street. (Support from source). Both of these would introduce germs into the
operating theatre and contribute to the poor and dirty conditions, making it more likely for infection
to spread and the patient to die, even though he might survive the actual operation. (Level 3 – 2
inferences given, with support for both from the sources).
Question 2 - Study Source B
What was the purpose of this representation? Explain your answer, using Source B
and your own knowledge.
(8 marks)
Source B: An illustration and caption showing an
operation from ‘Antiseptic Surgery’ written by one of
Lister’s assistants and published in 1882. It is a
representation of Lister’s methods.
Note the distance of the spray from the wound and the
position of the surgeon and assistant. The surgeon should
always have his hands in the spray and the assistant should hand the instrument to the surgeon through
the spray.
The purpose of the illustration and caption in Source B is to show other surgeons how to use
Lister’s antiseptic spray and equipment in an operation to stop infection. (Purpose given). The
source clearly shows the spray pump being used as it is prominent in the foreground of the picture
and the surgeon and his assistants are carrying out the operation in a ‘mist’ of carbolic as the
equipment is spraying the patient and the area in which the surgeon is working. This is instructing
others as to who should be present and how the equipment should be used. (Level 2 – showing
the purpose with some support from the source).
Below the picture there is a caption which is giving very precise instructions for others to follow.
These include the distance from the spray to the wound, where the surgeon and assistants should
be placed as well as what their actions should be to ensure their hands and instruments pass
through the spray to ensure anti-septic surgery methods are being used. (Top of level 2 – content
of source used to support answer).
It was very important that these instructions were followed precisely because many surgeons
didn’t follow them and their patients became infected and died. Since Lister’s development of the
carbolic acid spray to kill germs in 1865, there had been a lot of opposition from other surgeons
about the extra work involved for themselves and their assistants in using antiseptic surgery
methods. This often meant surgeons would be too impatient to wait for the equipment to work fully
or, sometimes didn’t even bother with it at all because it was too much trouble to set up. In
addition, the carbolic acid was an irritant to the skin of the surgeon and assistants and could get in
their eyes as well. Surgeons still wanted to get operations over with as quickly as possible, even
though the patient was now asleep and impervious to pain. Using these methods made it difficult
to achieve this speed and surgeons also feared the patient might die from blood loss if they took
too long as this problem wasn’t solved until the early part of the C20th. Many surgeons didn’t
believe in Pasteur’s Germ Theory and how it affected surgery and as a result weren’t very careful
when doing operations. (Level 3 – purpose of giving these instructions is fully explained by putting
the source into context eg own knowledge used to explain why others weren’t using these
methods or weren’t getting successful results like Lister).
Antiseptic surgery took a long time to catch on and by issuing these instructions it was a way of
getting surgeons to follow them carefully, see how it would make their operations successful, and
then convince them to continue using these methods to save lives. (Summary statement).
Question 3 - Study Source C
Why was the problem of infection so great in the1860s? Explain your answer, using
Source C and your own knowledge.
(10 marks)
Source C: From ‘Lord Lister, His Life and Work,’ by GT Wrench, published in 1913. Here he is
writing about operations in the 1860s and 1870s.
“In the early nineteenth century, only the most urgent operations were carried out. Then
the removal of the dreadful pain which had made an operation such a gruesome thing,
seemed to open a new era for surgery. However, in hospitals the blessing of anaesthetics
also led to its own defeat. More operations were undertaken for smaller problems. As a
result, infection and gangrene swept through the wards with increasing force.”
There are a number of reasons why the problem of infection was so great in the 1860s. From
Source C we can learn that one of these problems was the number of operations undertaken,
along with the use of anaesthetics. In addition there was an increase in the types of operations
being carried out as well as a lack of understanding about germs causing infection.
As quoted in Source C, “the blessing of anaesthetics also led to its own defeat”, meaning that the
conquering of pain made operations much more dangerous than before. Anaesthetics made
operations pain-free and this led to surgeons performing more operations than before. In preanaesthetic days, patients had to be desperate to have surgery due to the pain and so very few
operations were carried out in the first place. These operations were usually only undertaken on
the outside of the body such as those to remove obvious boils or cysts or, the more serious
operations, such as the amputation of a damaged limb. Surgeons knew that the risk of infection
was very high for every operation, but if they attempted to do an operation deep inside the body,
the infection risk was even greater. In addition, with the patient squirming around to avoid pain
from the surgical knife, it was very dangerous as the surgeon could easily cut and damage a major
internal organ. As a result, such operations didn’t happen as they were far too risky. When
anaesthetics were used, surgeons were able to do many more operations and for much smaller
problems such as the removal of an in-growing toenail. As operations were performed much as
before in very unhygienic conditions, except the patient was asleep, the problem of infection was
still very large. (Explanation of 1 main reason for the problem of infection connected to Source C).
As a result, the period of time between the discovery of anaesthetics and the use of Lister’s
antiseptic spray is called the ‘Black Period’ of surgery. More and more surgeons would take
advantage of the extra time and the unconscious state of the patient to undertake much more
complex operations which often meant going deep inside the body, eg to remove tumours and
cysts, cutting out of kidney stones and the removal of bullets and sharp objects. By doing these
types of operations surgeons were introducing infection deep into the wound with no chance of
getting rid of it. (In the past if a wound on the arm or leg was infected, the infected part would be
removed, but this wasn’t possible inside the body). (Explanation of 2nd reason – increase in types
of operations undertaken). Surgeons themselves were often responsible for the introduction of
infection through wearing outdoor clothes, not washing their hands and instruments, and using
dirty bandages. This is because infection and its cause weren’t fully understood at this time. It
was not until Pasteur had published his Germ Theory in 1861 and Koch had linked the germs
found on the surgeons to the germs found in the wounds of the patients (1878) that surgeons were
convinced that germs caused infection. As a result, more patients died in the 20 or so years
between the discovery of anaesthetics and the discovery of antiseptics due to more and more
operations being carried out and more complex operations being done also. (Explanation of 3rd
reason – lack of understanding of infection)
The main reason for the problem of infection being so great in the 1860s was this lack of
understanding of infection and germs. Surgeons were very slow to believe in the Germ Theory
and even if they agreed with it, they didn’t then put Lister’s antiseptic ideas into practice which
would have helped to save more lives as the only problem to be solved then would that of blood
loss. This is supported by both Source D when it says “The germ theory maybe correct but nine
out of ten surgeons did not much care whether it is or not” and also by Source F when it says “Tiny
germs seemed to have no relevance to practical work”. (Level 3 – 3 explained reasons with
support from stated source, C, other sources on paper, D and F AND good use of own
knowledge.)
Question 4 - Study Sources D and E.
How reliable are Sources D and E as evidence of the success of Lister’s antiseptic
methods? Explain your answer, use the Sources and own knowledge (10 marks)
Source D: From an article written by the editor of ‘The Lancet’ in 1875. The Lancet is a
medical journal.
“Many of the most successful surgeons have given Mr Lister’s plan a trial and then given it
up. They have returned to using previous methods. The use of the antiseptic system is
certainly not more successful than the use of ordinary methods. It is said to be more
unsuccessful. The germ theory may be correct, but nine out of ten surgeons do not much
care whether it is or not. Their concern is only to cure their patients and reduce deaths to
the lowest possible number.”
Source E: From ‘The Times’ newspaper, published in 1913. It was written shortly after
Lister’s death.
“The opponents of Lister were not all stupid. In 1865 no one could have seen how
successful Lister’s work would be. Disagreement arose because only a few people
believed in the germ theory and accepted the views of Lister and Pasteur. Lister’s early
methods did not always work. Statistics showed conflicting results. There was a need for
more knowledge. Meanwhile, improvements were made without using carbolic acid. All
these things led to resistance and arguments.”
Source D is very reliable because it says that Lister’s antiseptic methods were ‘not more
successful than ordinary methods’. This shows that some surgeons had used the new methods
by 1875 and found that Lister’s methods weren’t very successful and so surgeons returned to
other methods which they had used previously. (Use of content of Source D). It is true that there
were problems with Lister’s methods but these mainly came from the carelessness of the
surgeons and assistants who didn’t apply the methods very well such as not having the correct
distance of the spray from the patient; spraying at the start of the operation only instead of
continuing as it made it difficult to see what was happening and even failing to clean the surgical
instruments before use. (Own knowledge to support content). Source D also points out that
Lister’s methods are based on the Germ Theory which is also correct as Pasteur came up with the
theory in 1861 and so helps the source to be reliable.
To further support the reliability of Source D, the source comes from a surgeon writing at the time
of the use of these new methods and he is publishing his article in a well-known medical journal.
This surgeon would have been able to gauge the feelings of the other surgeons at the time and he
would know who was using the new methods and who had abandoned them. The article is
published in a respected and reliable medical journal which was read by many medical
professionals who could easily refute what he was saying if it wasn’t based on facts. (Provenance
of source D). However, this source can only tell us about the success or not of the new methods
in the short-term as it was printed in 1875, which is only about 10 years after Lister’s methods
were first introduced and so the surgeon isn’t really in a position to comment on the success of the
methods in the long-term. (Evaluation of authorship, questioning the position of the author to
know about the success or otherwise).
(Level 2 up to this point as the answer has assessed for reliability based on both the content of the
source – tested against own knowledge – and the provenance of the source BUT, this has only
been done for one of the 2 sources in the question. For Level 3, this must be repeated for Source
E).
Source E is also very reliable because it points out that there were problems in analysing the
success of the new methods because ‘statistics showed conflicting results’. Some arguments did
arise between surgeons because some had seen good results when using the methods whilst
some hadn’t. This is further supported in E by saying that some surgeons believed in the germ
theory and others didn’t. It is true that Lister’s first attempts didn’t work properly and he found it
very difficult to explain his work to others. (Content of Source E) Indeed he was often made fun of
by others who couldn’t believe that tiny germs, which could not be seen, could cause infection and
often death in their patients and they joked about Lister having to ensure he closed the door to
stop germs entering the room. Surgeons found it difficult to believe that they themselves could be
responsible for causing infection through dirty instruments, dirty clothes and bandages and even
their own hands. (Own knowledge used to support content).
To further support the reliability of Source E, the source has come from a newspaper article written
just after Lister’s death in 1913. This means it has the benefit of hindsight, looking back at times
when the methods weren’t that successful in the short-term, but very successful in the long-term
and it can gather statistical evidence to support this success. If the article was published to
celebrate the life of Lister, just after his death, then it would have been very easy to just write good
things about him and his work and make out that he had been 100% successful, but because it
mentions that he wasn’t always successful, then the source can be seen as being reliable.
(Provenance of the source + evaluation based on nature and time of source)
(Level 3 as the answer has assessed for reliability based on both the content both sources –
tested against own knowledge – and the provenance of both of the sources).
Question 5
Source F suggests that the main reason for opposition to Lister’s methods was that
surgeons could not believe that germs caused infection. How far do you agree with
this interpretation? Explain your answer, using your own knowledge, Sources D, E
and F and any other sources you find helpful.
Source F: From ‘Lister’ by W Watson Cheyne, published in 1927. Cheyne had been one
of Lister’s assistants.
“It was difficult to convince surgeons those tiny objects about 0.001 mm in size could be
the cause of infection. The surgeons of that day were interested in keeping up with
developments in anatomy and in working faster in operations. Tiny germs seemed to have
no relevance to practical work.”
Source F says, “It was difficult to convince surgeons that tiny objects about 0.001 mm in size could
be the cause of infection,” and “Tiny germs seemed to have no relevance to practical work.” This
suggests that the main reason for other surgeons to oppose Lister’s methods was because they
didn’t believe that germs were responsible for infection. To some extent, this is true but there are
other reasons for opposition which include the problems of implementing the methods, the lack of
conclusive evidence to prove the new methods were successful (especially in the short-term), the
poor communication of his ideas by Lister himself and the general conservatism of the surgeons
who were opposed to most new ideas at the time.
Some evidence in Sources D, E and F would suggest that surgeons did oppose Lister’s methods
because they weren’t convinced that germs did cause infection. Source D says “The germ theory
maybe correct, but nine out of ten surgeons did not much care whether it is or not.” Source E
supports this when it says “Disagreement arose because few people believed in the Germ Theory
and accepted the views of Lister and Pasteur.” This is further supported by the fact that surgeons
didn’t understand the idea of germs as shown by the jokes many surgeons made about ‘shutting
doors to keep Mr Lister’s germs out’ or, at the start of an operation using Lister’s antiseptic
methods, ‘Let us spray’. This would suggest that the reason given in Source F is correct and
surgeons didn’t believe germs caused infections. (Level 2 – answer uses sources and own
knowledge to support the statement that surgeons didn’t believe that germs cause infection)
However, the sources also suggest there were other reasons why Lister’s methods were opposed.
Source D mentions that surgeons preferred their own old methods which they had always used,
proving that most surgeons were very conservative and didn’t like any kind of change. This had
also been evident when anaesthetics were first introduced to some extent. Source F says
surgeons were more interested in anatomy and working faster (possibly to cut down the amount of
blood lost during operations as reliable blood transfusions had yet to be practiced as different
blood groups had not been identified). Source E adds that surgeons were not convinced because
the new methods did not bring immediate success as the “Statistics showed conflicting results”
and “there was a need for more information”. All of this evidence shows that surgeons weren’t
prepared to accept these new methods and still used their old methods until they had more proof
of success.
Another reason for opposition was Lister’s poor communication of his ideas. He published his
work for all to read but his way of working often changed and so it made it difficult for others to
follow his methods. This can clearly be seen in Source B as Lister has to give out very precise
instructions for others to follow, suggesting that others haven’t been doing this and so weren’t
getting successful results. It is further supported by the date when it was written (1882) showing
that it was 20 years after antiseptic surgery was first introduced and instructions have to still be
issued. It is also noticeable that this book was written by one of Lister’s assistants and not by
Lister himself who found it difficult to communicate his ideas. In addition, his methods were not
always successful, as, according to Source E, “Statistics showed conflicting results”, and “Lister’s
early methods didn’t always work”. In the short-term, this was indeed true, but after Koch could
prove a direct link between germs which caused infection and the germs on the hands, clothes,
instruments and the air surrounding the operation, Lister’s methods became more accepted, but
this wasn’t until after 1878. (Level 3 – balanced answer given – using sources and some own
knowledge to show there were other reasons as well as the one in the question).
The main reason for opposition to Lister’s methods, however, is the problem of implementing the
new methods. Surgeons resented the extra work needed to implement them such as the setting
up of the pump spray, the carbolic acid, the preparation of the instruments and bandages, and the
washing of the wounds of the patient and the hands of the surgeons and assistants before the
operation even begun. This extra work was vital if infection was to be killed off, but if surgeons
didn’t follow the methods exactly, then the patient could die from infection due to their
carelessness. As successful results using the methods could not be guaranteed, and then it
seemed pointless in doing the extra work in the first place if the patient was going to die anyway.
In addition, the spray was a diluted carbolic acid liquid which was an irritant to the skin of the
surgeons and the patients. However, it was clearly of more concern to the surgeon and his
assistants when they were covered in it during the operation. It got on their clothes, hands and
faces and in their eyes. Many suffered in silence, but it was a major problem for them to work in
such conditions. Indeed some were allergic to the acid and came out in a rash! (Lots of own
knowledge to argue that the practical implementation of the new methods was a more important
reason for surgeons to oppose the new methods).
Overall, in the short-term surgeons did oppose the new antiseptic methods because they didn’t
understand how infection was caused by germs, even after Pasteur’s Germ Theory. It was the
work of Koch which proved the link between wound infection and germs by identifying which
germs actually caused the infection that finally convinced them in the longer-term. However, the
practical implementation of the new methods and the general opposition to any new ideas were
the main reasons for opposition to Lister’s new methods for antiseptic surgery. (Level 4 –
balanced argument using reasons given in question and others found in sources and from own
knowledge to show a range of reasons why Lister’s methods were opposed by surgeons).