Britain: Health and the people c1000–present

War has been an important factor in the development of surgery because it created huge numbers of casualties and an urgent need for new techniques. However, I do not think it has been the main factor. The most important breakthroughs in surgery, solving the problems of pain and infection, came from science and technology and the work of individuals, and war mainly speeded up developments that had already begun¹.

War has driven surgical change throughout the period. In medieval times, surgeons such as John of Arderne² gained experience treating wounds on campaigns during the Hundred Years' War and developed new techniques as a result. In the Renaissance, the French army surgeon Ambroise Paré found, when he ran out of boiling oil to cauterise gunshot wounds, that a soothing ointment worked better, and he used ligatures to tie off blood vessels instead of cauterising them. War's impact was greatest in the twentieth century. The First World War produced injuries on an enormous scale, so surgeons had to innovate quickly. Harold Gillies developed new techniques of plastic surgery to rebuild faces, opening the Queen's Hospital at Sidcup in 1917. The Thomas splint, used from 1916, kept broken legs still and is estimated to have cut deaths from compound leg fractures from around 80% to around 20%³. Blood transfusion became practical because sodium citrate was used to stop blood clotting, so blood could be stored in blood depots near the front, as at Cambrai in 1917. In the Second World War, the need to treat infected wounds led the British and US governments to fund the mass production of penicillin, so that millions of doses were ready by D-Day in 1944⁴.

However, science and technology, and the individuals who used them, were more important because they solved the three main problems of surgery: pain, infection and bleeding. Before 1847 surgeons had to work very fast on conscious patients. James Simpson discovered the anaesthetic properties of chloroform in 1847 in Edinburgh, which was accepted much more widely after Queen Victoria used it in childbirth in 1853. Pain was solved in peacetime, through scientific experiment, not war.⁵ Similarly, infection was tackled after Louis Pasteur published his germ theory in 1861. Joseph Lister read Pasteur's work and in 1865 began using carbolic acid to clean wounds and instruments, which greatly reduced deaths after operations. This led to aseptic surgery in the 1890s, with sterilised instruments and gowns. These changes affected every patient, in peace as well as war, and without them the wartime developments of the twentieth century would not have been possible⁶.

Other factors also played a part. Chance was important: Alexander Fleming only discovered penicillin in 1928 because mould contaminated a culture dish he had left out. Government was also important, especially after the NHS was created in 1948, which made surgery free at the point of use and paid for new technology such as hip replacements and, more recently, keyhole and robotic surgery.

In conclusion, war has not been the main factor in the development of surgery. War speeded up change, as with penicillin, where war turned a laboratory discovery into a mass-produced drug, and it encouraged new techniques such as plastic surgery. But the most fundamental developments, anaesthetics and antiseptics, came from science and determined individuals in peacetime. War acted as a catalyst that accelerated science⁷, rather than being the driving force behind surgery itself.

John Snow's work was significant at the time because it gave strong evidence that cholera was spread by contaminated water rather than by miasma (bad air)¹. During the 1854 outbreak in Soho, London, Snow plotted the deaths on a map and found they were clustered around the water pump in Broad Street. He also noticed exceptions that supported his theory: workers at a nearby brewery², who drank beer and water from the brewery's own supply, did not catch cholera, and nor did most inmates of a workhouse that had its own well. He persuaded the local authorities to remove the handle of the pump, and new cases soon stopped, although the outbreak was probably already declining by then. This was significant because it was one of the first times statistical evidence had been used to identify how a disease was spreading.

However, its significance in the short term was limited.³ Snow could not explain what in the water caused cholera, because germ theory had not yet been published, so many doctors and officials continued to believe in miasma. The handle was replaced after the outbreak, and when the government acted on London's sewage after the 'Great Stink' of 1858, it was mainly because of the smell⁴, which people believed spread disease, rather than because of Snow's evidence.

In the longer term, Snow's work was very significant. After Pasteur published his germ theory in 1861, and Robert Koch identified the cholera bacterium in 1883⁵, Snow's conclusion that cholera was spread through water was proved correct. His work helped to support the case for clean water supplies and proper sewers, such as Joseph Bazalgette's London sewer system, which ended major cholera outbreaks in London, the last being in 1866 in an area not yet connected. It also strengthened the argument for the government to take responsibility for public health, leading to the Public Health Act of 1875⁶, which made local councils provide clean water and drainage. Today Snow is often seen as a founder of epidemiology, the study of how diseases spread, so his methods are still significant in public health.