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Revision: Transformation of Surgery c1845-1918

Revision: Transformation of Surgery c1845-1918. NAME:. Checklist: Factual Details. Dealing with pain Dealing with infections Dealing with blood loss Role of factors in the development Extent of progress in surgery. Attitudes towards pain relief. Dealing with.

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Revision: Transformation of Surgery c1845-1918

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  1. Revision: Transformation of Surgery c1845-1918 NAME:

  2. Checklist: Factual Details • Dealing with pain • Dealing with infections • Dealing with blood loss • Role of factors in the development • Extent of progress in surgery

  3. Attitudes towards pain relief Dealing with Problems before anaesthetics Problems with anaesthetics Ether Chloroform

  4. Opposition to Lister Early attempts to control Infection Problems of Infection Dealing with Infection Antiseptic Conditions Aseptic Conditions Carbolic Acid

  5. Problems of Blood Loss Dealing with Blood Loss Controlling Blood Loss Replacing Blood

  6. Individuals Factors Affecting Developments Science Technology Communication War

  7. Advantages and Improvements Extent of Progress Within Surgery Hindrances to Progress Disadvantages and Setbacks

  8. Checklist: Evidence Skills • Inference: your ability to work things out from the source, e.g. what can you work out about a situation, the attitude of an author, the message of a cartoon, the purpose of a speech • Analysis of the source: which parts of the sources create a certain impressions, which parts of a source support or challenge an idea of another source • Cross-referencing: checking how far sources agree with each other and considering the overall weight of evidence • Evaluation of Reliability or Usefulness: the use of various checks to see how reliable or useful a source is • Making a judgement: weighing up all the evidence of an issue in order to come to a thoughtful and supported conclusion

  9. Question 1 Mark Scheme Things I have to include or remember for this type of question:

  10. Question 2 Mark Scheme Things I have to include or remember for this type of question:

  11. Question 3 Mark Scheme Things I have to include or remember for this type of question:

  12. Question 4 Mark Scheme Things I have to include or remember for this type of question:

  13. Question 5 Mark Scheme – MARKED ON COMMUNICATION AGAIN Things I have to include or remember for this type of question:

  14. QUESTION 1 EXAMPLE QUESTIONS

  15. From The Age of Miracles by Guy Williams, 1981. Here he is writing about surgery in the mid-nineteenth century. “Very few people who were operated on in the overcrowded hospitals actually survived the dreaded period after surgery. This was because the flesh that had been cut would start, almost inevitably, to develop gangrene. With such a big problem, the surgeons of those days were forced to limit their activities to the performance of emergency operations such as the amputation of limbs and minor repairs to the outer surfaces of the body. Major surgical work on the chest or internal organs was made virtually impossible by the great risk of sepsis.” Study Source A. What can you learn from Source A about problems in surgery in the mid-nineteenth century? (6 marks) …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

  16. Study Source A. What can you infer about the way operations were carried out in the early 19th century? (6 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... A painting from 1817 showing an operation in a patients home in Dublin to remove a tumour from a mans arm pit

  17. From the diary of Gideon Mantell, a surgeon 1 May 1847 Went to Bartholomew’s Hospital and witnessed two operations under the influence of Ether: the first I have seen. The loss of feeling on both occasions was complete: the patient had no consciousness of the operation. But the effect on the patient afterwards was appalling, although brief. Study Source A. What can you infer from Source A about Mantell’s attitude towards the use of ether?(6 marks) …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

  18. Study Source A. What can you learn from Source A about people’s attitudes towards Simpson and the discovery of anaesthetics. (6 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. A statue of James Simpson that were erected in Edinburgh after his death; the money for the statue came from collections from the public

  19. QUESTION 2 EXAMPLE QUESTIONS

  20. Sources for 2a Source A - A painting from 1817 showing an operation in a patients home in Dublin to remove a tumour from a mans arm pit Source C: A photograph of an operation in 1847. It was one of the first to use an anaesthetic. Source B: From a book published by John Leeson in 1927 about his early days as a medical student in 1871. Leeson later worked with Joseph Lister. “I remember the surgeon with his threaded needles hanging from the front of his coat, the silken threads touching the well worn cloth which was blood-stained and dirty. One of our surgeons lectured on anatomy in an old coat. I see it now, faded with age, stained with blood and covered with pus.”

  21. Question 2aStudy Sources A, B and C. How far do Sources B and C support the view of problems in surgical operations given in Source A? Explain your answer, using all three sources (8 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  22. A painting by Henry Tonks, a surgeon and artists, showing a military dressing station in France in 1918. A dressing station was the place were the injured would receive basic treatment before they were sent to hospital for more complicated treatment Sources for 2b

  23. Question 2bStudy Source B. What impression has the artist tried to give of the treatment of wounded soldiers in the First World War? Explain your answer, using Source B. (8 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  24. From a speech by James Simpson to a meeting of doctors in Edinburgh in 1847 In years to come people will look back with sorrow at our reaction to anaesthetics. They will be amazed at the idea of humane men saying they prefer operating on patients who are conscious instead of anaesthetised, and that fearful agonies of an operation should be endured quietly Sources for 2c

  25. Question 2cStudy Source A. How can you tell from Source A that Simpson thought that anaesthetics were an advance in surgery? (8 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  26. Sources for 2d Source B: A painting about the first use of ether as an anaesthetic. It shows an operation carried out in the USA by Dr Warren and Dr Morton in 1846.

  27. Question 2dStudy Source B. How has the artist shown the importance of this first use of ether? Explain youranswer, using Source B. (8 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  28. QUESTION 3 EXAMPLE QUESTIONS

  29. Source D: From an article by Joseph Lister in 1867. Here he is writing about the impact of the ideas of Louis Pasteur on his own work as a surgeon. It had been shown by the researches of Pasteur that the septic* nature of the atmosphere was not a result of miasma but was the result of tiny organisms suspended in the air. It occurred to me that gangrene in the injured limb might be avoided by applying as a dressing some material capable of destroying the life of these tiny organisms. *septic = infected Source E: From The Greatest Benefit to Mankind by Roy Porter, 1999. Lister saw the effectiveness of using carbolic acid to reduce infection among cattle and on sewage farms. He became convinced that it was necessary to cleanse the wound and keep out further infection, and tried various ways to do so. His first trial was on a boy with a broken leg who had been run over by a cart; Lister used a dressing soaked in carbolic acid. The dressing remained in place for four days and the wound stayed infection-free; the boy walked out of the hospital after six weeks. Sources for 3a

  30. Question 3aStudy Sources D and E. Is Source D more useful than Source E to the historian studying the methods ofJoseph Lister? Explain your answer, using Sources D and E. (10 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  31. Source D: A report in a medical newspaper about the use of chloroform, December 1849 A Welsh girl had to undergo a very painful operation, the removal of an eyeball. The surgeon administered about one-third of the quantity of chloroform he ha given to other patients. It had, however, such an effect on her that she had a fit and died. Source E: From For Fear of Pain: British Surgery 1790-1850 by Peter Stanley, 2003 It is possible that surgeons only used chloroform in the 1850s because patients demanded it. It kept patients from pain Sources for 3b

  32. Question 3bStudy Sources D and E. Which source is most valuable for telling you about people’s reactions to the use of chloroform? (10 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  33. Source C: From the Boston Daily Evening newspaper, 1st October 1846. NEW AND VALUABLE DISCOVERY Dr Morton has discovered something which can reduce the sufferings of those who need painful operations in dentistry and surgery and make the operation easier for the surgeon to carry out. He can make the patient unconscious and any operation can then be performed without causing pain. We are told by a gentleman of the highest respectability that he witnessed an experiment carried out by Dr Morton last week. A bad tooth was taken out without giving the patient the slightest pain. He was put into a kind of sleep by inhaling this preparation. The sleep lasted less than a minute, just long enough to extract the tooth. This discovery is destined to make a great revolution in surgery and dentistry. Sources for 3c Source D: From A Brief History of Medicine by Paul Strathern, 2005. Here he is writing about the introduction of anaesthetics. A newspaper headline announced ‘We have conquered pain!’ but people remained unconvinced. There was widespread opposition on religious grounds, especially about the use of anaesthetics during childbirth. According to the bible, God had said childbirth would be accompanied by pain. More serious objections came from medical opposition to ether. It was found that this could damage the lungs, and occasionally cause vomiting which, if it happened during an operation, could lead to the death of the patient.

  34. Question 3cStudy Sources C and D.How far does Source D support the impression given in Source C that the use ofanaesthetics was an important breakthrough in surgery and dentistry? (10 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  35. QUESTION 4 EXAMPLE QUESTIONS

  36. Source F: From the British Medical Journal, reporting on an international meeting of medical experts in Paris in 1878. Professor Joseph Lister gave a speech in response to the criticisms made of his antiseptic methods. Professor Lister was greeted by the whole assembly with the greatest enthusiasm. When he rose to make his speech the whole assembly rose to their feet. With deafening and repeated cheers, and waving of hats they hailed the distinguished Professor time and time again. This continued for some minutes until Professor Donders shook his hand and said: ‘Professor Lister, it is not only our admiration which we offer you; it is our gratitude and the gratitude of all our nations’. Sources for 4a

  37. Question 4aStudy Source F. How does the author of this article suggest that Lister’s work was important in thedevelopment of surgery? Explain your answer, using Source F. (8 marks) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  38. Source E: From a letter from Lister to Pasteur in 1874 …give thanks for having, by your brilliant researches, proved o me the truth of the germ theory. You furnished me with the principle upon which alone the antiseptic system can be carried out Sources for 4b Source F: A table based on Lister’s own records, showing the death rate among amputation cases before and after the use of carbolic acid

  39. Question 4bStudy Sources E and F. Which is more useful to the historian who is investigating the ideas behind Lister’s use of carbolic acid? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  40. Source E: An operation in the late eighteenth century This cartoon shows an amputation. It was drawn in 1793. Sources for 4c Source F: A painting of the great German surgeon, Theodor Billroth performing an operation. It was painted in 1890. Theodor Billroth (1829-1894) was Professor of Surgery in Vienna from 1867. He was described at the time as one of Europe’s best and most trusted surgeons.. He developed many new surgical procedures. This painting recognises the importance Billroth gave to the training of surgeons.

  41. Question 4cStudy Sources E and F. How useful are these sources in explaining how surgery has changed over time? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  42. QUESTION 5 EXAMPLE QUESTIONS

  43. Source A: From The Age of Miracles by Guy Williams, 1981. Here he is writing about surgery in the mid-nineteenth century. Very few people who were operated on in the overcrowded hospitals actually survived the dreaded period after surgery. This was because the flesh that had been cut would start, almost inevitably, to develop gangrene. With such a big problem, the surgeons of those days were forced to limit their activities to the performance of emergency operations such as the amputation of limbs and minor repairs to the outer surfaces of the body. Major surgical work on the chest or internal organs was made virtually impossible by the great risk of sepsis. Sources for 5a Source C: A photograph of an operation in 1847. It was one of the first to use an anaesthetic. Source D: From an article by Joseph Lister in 1867. Here he is writing about the impact of the ideas of Louis Pasteur on his own work as a surgeon. It had been shown by the researches of Pasteur that the septic* nature of the atmosphere was not a result of miasma but was the result of tiny organisms suspended in the air. It occurred to me that gangrene in the injured limb might be avoided by applying as a dressing some material capable of destroying the life of these tiny organisms. *septic = infected Source G: From The Lancet, a medical magazine. This article is reporting ideas held by some surgeons in 1875. 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 less successful.

  44. Question 5aStudy Sources A, C, D and G and use your own knowledge.‘The work of Lister was the main factor in solving the problem of infection aftersurgery.’How far do you agree with this statement? Use your own knowledge, Sources A, C, Dand G and any other sources you find helpful to explain your answer. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  45. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………......................... ……………………………………………………………………………………………………………………………………………………..

  46. Source D: From A Brief History of Medicine by Paul Strathern, 2005. Here he is writing about the introduction of anaesthetics. A newspaper headline announced ‘We have conquered pain!’ but people remained unconvinced. There was widespread opposition on religious grounds, especially about the use of anaesthetics during childbirth. According to the bible, God had said childbirth would be accompanied by pain. More serious objections came from medical opposition to ether. It was found that this could damage the lungs, and occasionally cause vomiting which, if it happened during an operation, could lead to the death of the patient. Sources for 5b Source A: An eighteenth century painting of an operation before anaesthetics were used. Source G: An account of the death of Hannah Greener, aged 15, in 1848, published in a medical journal. She was the first person to die under chloroform. Her operation was for the removal of a toenail. ‘She inhaled a teaspoonful of chloroform from a handkerchief. In about half a minute, when she was unconscious, I requested Mr Lloyd to begin the operation. She gave a kick, which made me think the chloroform had not had sufficient effect. I was giving her more chloroform when her lips suddenly became pale and she spluttered. I threw down the handkerchief, threw cold water in her face and gave her some water to drink, without any effect. The whole process of inhaling, operation and death, could not have taken more than two minutes.´

  47. Question 5bStudy Sources A, D and G and use your own knowledge.‘Surgery in the 19th century improved significantly with the use of anaesthetics.’How far do you agree with this statement? Use your own knowledge, Sources A, Dand G, and any other sources you find helpful. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

  48. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………......................... ……………………………………………………………………………………………………………………………………………………..

  49. Sources for 5c Source E: A photograph of Walter Yeo, showing his face after (left) and during the tube pedicle reconstruction of his face (right). Walter Ernest O'Neil Yeowas a sailor during WWI, and is thought to be the first person to benefit from advanced plastic surgery, namely a skin graft Source F: A painting by Henry Tonks, a surgeon and artists, showing a military dressing station in France in 1918. A dressing station was the place were the injured would receive basic treatment before they were sent to hospital for more complicated treatment Source G: Cathy Warren and Nigel Bushnell, Medicine and Surgery, 2010 In 1915, the American doctor Richard Lewisohn found that adding sodium citrate stopped blood from clotting. This meant that that the donor did not have ot b present and therefore more transfusions could be carried out. Although it was found that the blood was not used soon afterwards, this discovery still saved the lives of thousands of wounded soldiers

  50. Question 5cStudy Sources E, F and G and use your own knowledge.‘The First World War led to major improvements in surgical methods and techniques’.How far do you agree with this statement? Use your own knowledge, Sources E, Fand G and any other sources you find helpful to explain your answer. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….........................

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