Amputation

In this post by our Digitisation Project Intern, we look at our amputation instruments, while referring to the work of Maister Peter Lowe, College founder and 16th century surgeon.

The surgical procedure of an amputation involves the removal of a section of a limb of the body. The volume of tissue removed from the body depends on a variety of factors, including the severity of the patient’s condition.

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Woodcut illustration, 2nd ed. of Lowe’s Chirurgerie (1612)

 

It is uncertain as to how long amputations have been a regular form of surgical treatment, however the term can be traced back to the 16th century. For example, Peter Lowe uses the term “amputation” when describing how to treat a gangrenous limb in his 1597 work The Whole Course of Chirurgerie [1].  Here he explains how the operation should be carried out, referencing the works of previous scholars:

The judgements are, that it is for the most part incurable, and the patient will die in a cold sweat. The cure, in so much as may be, consists only in amputation of the member, which shall be done in this manner, for the patient must first be told of the danger, because often death ensues, as you have heard, either from apprehension, weakness, or loss of blood.”

It has only been within the last 170 years that amputations, and surgical procedures in general, have been performed in a safe manner, e.g. with the patient under anaesthesia. Prior to this, the limb was removed as quickly as possible. A successful and speedy amputation required precision, strength, skill, and a steady hand, as well as a set of sharp amputation instruments!

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Mid 19th century amputation set

 

Within the museum collection are examples of amputation sets from the 1800-1900s.

Several components make up a set, from trephine heads to amputation saws to tourniquets. Each instrument would be used at a different stage of the surgical procedure. Let’s take a look at how a lower limb amputation would be performed.

First of all, the patient would be prepped for the surgery. In the days before pain relief, alcohol was the method used to calm the nerves. The patient would be given some rum or whisky, and then wheeled into the surgical theatre. Most likely the theatre would be structured with the operating table in the centre of the room surrounded by rows and rows of stands for spectators. Spectators would include the students of the chief surgeon involved in the procedure- not only was this a surgical operation, it was also a lesson. Once the patient was placed on the operating table, the chief surgeon would enter the theatre and the operation would commence.

One of the major dangers of amputating a limb is blood loss. Several blood vessels must be carefully salvaged during the procedure in order to limit haemorrhaging [1]. To enable the surgeon to operate on a bloodless area of the body, a Tourniquet was applied proximal to the site of amputation (a couple of inches above the site of incision).

“The use of the ribband is diverse. First it holds the member hard, that the instrument may curve more surely. Secondly, that the feeling of the whole part is stupefied and rendered insensible. Thirdly, the flow of blood is stopped by it. Fourthly, it holds up the skin and muscles, which cover the bone after it is loosed, and so makes it easier to heal.”[1]

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Example of a tourniquet from an amputation set

 

The tourniquet would have been tightened in order to restrict blood flow and reduce haemorrhaging. It would also have reduced sensation to the limb, providing slight pain relief. However, this would also mean that oxygen was restricted. Hence another reason as to why amputations were performed as quickly as possible.

tourniquet-illustration

The initial incision would have been made with a sharp amputation knife. Amputation knives evolved in shape over the years, from a curved blade to a straight blade. Peter Lowe comments on the use of a curved blade for the procedure:

“…we cut the flesh with a razor or knife, that is somewhat crooked like a hook…”[1]

The blade was curved in order to easily cut in a circular manner around the bone (see image from Lowe’s book above) [2]. Amputation blades became straighter as the incision technique evolved. An example of a straight amputation knife is that of the Liston Knife. With a straight and sharp blade, this knife was named after the Scottish surgeon Robert Liston. Liston is best known for being the first surgeon in Europe to perform an amputation procedure with the patient under anaesthesia [3].

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Liston knife, mid 19th century

 

The straight blades enabled the surgeon to dissect more precisely in order to form the flap of skin and muscle that would become the new limb stump.

As one can imagine, bone tissue would not be easily removed by an amputation knife. Instead, an amputation saw was required to separate bone. Amputation saws were similar to those found in carpentry, with sharp teeth to dig into and tear bone tissue for a quick procedure.

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Amputation saw, mid 19th century

 

Aside from the major dissecting tools, there are more specialised instruments within an amputation set that we must consider. One of the main risks of an amputation operation was death by haemorrhaging. For years, the letting of blood was used to treat certain ailments according to the ancient teaching of the “Four Humors”. However, in a surgical procedure the major loss of blood was something to be avoided. In order to prevent the haemorrhaging of dissected vessels, the surgeon would have used a Ligature to tie off the vessel and disrupt blood flow. This technique was pioneered by French surgeon Ambroise Paré during the 1500s [4].

Found within our amputation sets are trephine heads with accompanying handles. Rather than being used during an amputation procedure, trephine heads were used to drill into the skull to treat conditions by relieving intracranial pressure. Nowadays, access to the brain via the skull is achieved with the use of electric drills.

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Trephine, mid 19th century

 

Amputation procedures have changed dramatically since the days before anaesthesia and antiseptics, but the risks have remained. Blood loss, sepsis, and infection are factors that can still occur today. Thankfully, their likelihood is much lower than they were 170 years ago.

References

  1. Lowe, P., 1597. The Whole Course of Chirurgerie.
  2. Science Museum, 2016. Amputation Knife, Germany, 1701-1800. Brought to Life: Exploring the History of Medicine. [online] Available at: http://www.sciencemuseum.org.uk/broughttolife/objects/display?id=5510
  3. Liston, R., 1847. To the Editor. The Lancet, 1, p. 8.
  4. Hernigou, P., 2013. Ambroise Paré II: Paré’s contribution to amputation and ligature. International Orthopaedics, 37(4), pp. 769-772.

The College and ‘Clarinda’

Scotland’s national bard Robert Burns had many close and interesting connections with medical men during his short life. The College’s historical collections unfortunately don’t contain a large number of items relating to Burns. Naturally, the library holds William Finday’s 1898 book Robert Burns and the Medical Profession (Paisley: Alexander Gardner), among other 19th century texts on the poet. Burns’s connection to Dr John Moore is well-known, and we can illustrate this with our portrait of Moore, which hangs in College Hall.

A more hidden and subtle connection concerns one of the most fascinating of the poet’s relationships. His affair with Agnes Maclehose in 1787 – 1791 produced a famous, romantically-charged correspondence (in which Maclehose was named Clarinda). ‘Ae Fond Kiss’, one of Burns’s most beloved songs, was written for Maclehose.

Maclehose was born in Glasgow in 1758, daughter of surgeon Andrew Craig, who was a member of the College (then known as the Faculty). She married the lawyer James Maclehose at 18, but left him just before the birth of their fourth child in 1780. She returned to live with her father, then a widower, but he died soon after in 1782. As a dependent Agnes received a pension of £8 from the College. The Minutes of 1782 below show the application for the pension, and its approval.

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College Minutes 2nd September 1782 (RCPSG 1/1/3)

Maclehose moved to Edinburgh, still married but formally separated from her husband. The College minutes throughout the mid 1780s list her as a recipient of the pension, known as the Widow’s Fund.

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College Minutes 22nd October 1783 (RCPSG 1/1/3)

This continued until 1787, the year she was introduced to Burns (who was by now being celebrated in the capital as a literary star, after the publication of his Kilmarnock and Edinburgh editions). Maclehose, a poet herself, was keen to meet Burns, and did so in December 1787. However, in the preceding month there was a change in her personal circumstances. In the Minutes of 6th November 1787, there is an entry stating that the Widow’s Fund committee “submit to the consideration of the Faculty, whether or not Mrs McLehose [and another recipient] are any longer objects of their charity” (see image below).

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College Minutes 6th November 1787 (RCPSG 1/1/3)

Days after, the decision is taken that “instructions as appointed to be given immediately to Mrs McLehose  [and another recipient] that they are struck off the list of Pensioners” (see image below). No further context or explanation is given in the Minutes for this decision. The exact date of this entry is unclear, but it appears to be sometime between 6th and 23rd November 1787.

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College Minutes, between 6th and 23rd November 1787 (RCPSG 1/1/3)

Less than two weeks after this she met Burns for the first time, sparking a relationship that produced remarkable correspondence, and one of the greatest love songs ever written. Further research into Maclehose’s circumstances leading up to this fateful meeting would be a useful avenue for scholars with an interest in the women who feature strongly in Burns’s life and work.

The manuscript of ‘Ae Fond Kiss’ will be on display at the National Library of Scotland at Kelvin Hall, Glasgow, on 25th January 2017. For more information, see the NLS website.

Maister Peter Lowe and Glasgow

Our first event of 2017 will be an informal gathering in College Hall on Thursday 19th January to hear our Honorary Librarian, Mr Roy Miller, discuss our founder Maister Peter Lowe and the town of Glasgow, c1599.

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We will hear about the background of this intriguing man, his arrival in Glasgow from France in the 1590s, and what compelled him to petition King James VI to set up what became the Royal College of Physicians and Surgeons of Glasgow in 1599. Lowe’s education and surgical training in France, and his writings on the practice of surgery, played a key role in how medicine and surgery developed in Glasgow at this early stage.

The event will take place in our College Hall, which features portraits of our founding members and of James VI. In addition, there will be a pop-up display of historical collections relating to our early history, for example our first Minute Book (1602 – 1688), rare copies of Peter Lowe’s 16th century surgical texts, and a pair of gloves belonging to the founder.

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Detail of first College Minute Book, summarising 1599 Charter (1602)

Our event is part of St Mungo Festival, now in its ninth year, which celebrates the life of St Kentigern, better known as St Mungo, patron saint of Glasgow. Find out more about the Festival and its programme of events at the St Mungo Festival Facebook page.

Here are the details of the event:

Date – Thursday 19th January 2017

Time – 12.30 – 1.30 with refreshments served afterwards

Venue – Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow G2 5RJ

To book – Email library@rcpsg.ac.uk or phone 0141 221 6072. This is a free event but places are limited.

16th Century Surgery & Comic Creation

Origin / foundation stories are so important to an organisation’s identity.  The foundation story should always address the questions – Why do we exist? Why do we do what we do? This theory has been well-used in marketing and branding, from products such as drinks and shoes, to film and literary franchises. We’re lucky at the College to have a very clear link from our foundations in 1599 to our current aims – to set the highest possible standards of healthcare.

Flyer for the event Glasgow's Marvellous Medicine - A comics workshop with Adam Murphy

Yet, there are challenges in how we communicate this. How do you engage audiences with the origins of a 16th century medical and surgical college? In November we worked with leading comic book artist and writer Adam Murphy for a creative workshop with families. Inspired by the 16th century foundations of the College and its enigmatic founder Maister Peter Lowe, Adam led us on a journey of comic creation. Under the gaze of the Maister himself in our College Hall, Adam used Lowe’s 1597 book The Whole Course of Chirurgerie and our 1599 Royal Charter to create graphic stories of surgical and medical improvement.

We invited families along and the event sold out very quickly, mainly through social media promotion and Glasgow event listings. It was important for us to hold the event in our main historical space, College Hall, where portraits of our 16th century founders are on display.

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The workshop kicks off in College Hall

 

Adam kicked things off by setting the scene of a character seeking medical care in the 16th century, and the various options available: the heavy-handed barber-surgeon, the expensive physician, or the unpredictable remedies of folk medicine. Then, via our 1599 Charter, he introduced the idea of surgical training and licencing of practitioners. Never before have the words “Out of the way, losers!” been attributed to the College founder!

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Adam’s initial rough sketches

 

The young people and adults taking part got hands-on instruction on the basics of comic creation, how to build characters, sequence stories, and most importantly, to take risks and make mistakes.

Participants spent some time viewing a pop-up display of our surgical instruments and old medicine cabinets, sketching these and incorporating them into their own stories. The audience chose a large amputation saw as the item for Adam to demonstrate some drawing tips (capturing the impact of the saw’s teeth, for example!).

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Viewing and sketching museum collections in the Lower Library

Wild ideas and the creative imagination took over, and participants let loose with a whole range of comic strip stories, all of which retained a link to the medical and surgical foundations of the workshop. Adam captured some of these ideas – particularly the introduction of a unicorn character which gets its horn cut off by a careless barber-surgeon.

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Adam capturing some audience ideas

The event was a great way to engage a completely new audience with our early history. Participants left knowing much more about the College’s place in Glasgow’s history and in Scotland’s medical history. And our feedback shows that many went home to draw more comics! We look forward to developing further creative events to open up our heritage and collections to a wider audience.

Find out more about Adam’s work at www.adammurphy.com.

The event was kindly supported by Scottish Book Trust’s Live Literature Scotland scheme.

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Macewen on wounds

We have had a lot of interest in our collection of the papers of Sir William Macewen recently, particularly the material relating to his early position as Police Surgeon in Glasgow (1871 – 1875). This relatively small part of the collection represents a short, formative and under-researched part of his distinguished career. It nevertheless contains fascinating material that provides some insight into the early work of the great surgeon. The focus of this post is on Macewen’s treatment of and research on wounds during this period.

The Private Journal (of surgical cases) covering 1872 – 1875 contains notes on a wide range of Police Office cases. Possibly the most common type of case is the treatment of wounds, usually penetrating wounds caused by assault or accident (the example above shows notes and illustration of a head wound). Macewen was interested in both the effective treatment of wounds via investigative surgery, and research into the specific causes of wounds for forensic purposes. These interests resulted in two notable articles in the Glasgow Medical Journal.

1876 saw the publication of his article ‘Wounds in relation to the instruments which produce them’ (Glasgow Medical Journal, viii, 1876). In the article title (above) he was listed as Casualty Surgeon, and also Lecturer in Medical Jurisprudence at the University. In addition to its original purpose as an aid to accurate wound diagnosis, this extraordinary article provides a detailed catalogue of the clinical results and context of (mainly) violent crime in the city at a specific period. Detail includes the range of weapons used, and the context of the wounds caused by assault and accident (many involving alcohol). The image below shows how Macewen presented this data, and the eclectic range of instruments identified as causing the wounds.

tablesIn the article’s introduction, Macewen sets the context of these cases with an intriguing commentary before beginning his rigorous analysis:

The observations in the present paper were made on the living, as accident in part, but mainly the physical expression of human passion […].”

In addition to his move into forensic medicine, this period also saw Macewen challenge the conventional wisdom of surgical textbooks (and their esteemed authors). In 1872 and 1873 he noted several cases of treatment of wounds, particularly of the lungs, for example a case involving a 12 year old boy with a life-threatening knife wound. By adopting a bold, investigative approach (which was not at the time recommended when treating damage to the lungs), Macewen was able to locate a fragment of the knife in the lung. He then removed the fragment, using the antiseptic approach developed by his ex-teacher Joseph Lister. The page from the journal below records this case.

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Private Journal of Surgical Cases (RCPSG10/9/12)

His resulting article ‘Penetrating wounds of thorax and abdomen treated antiseptically’ (Glasgow Medical Journal, vii, 1875) was explicit in its criticism of the contemporary textbook approach to the lung. In his remarks on the case, he challenges the assertion made in recent surgical literature that the surgeon “should throw aside all direct or manipulative modes of investigation.” Instead, he boldly asserts that –

If, without complicating the original injury, an investigation is enabled to be made into the nature of such wounds, and an intelligent treatment thereby adopted instead of groping in the dark, an advance in surgery has been made.”

It is worth bearing in mind that at the time of writing, Macewen was still only in his mid-20s, and employed in one of the most junior surgical positions available.

In addition, he emphasised the adherence to Lister’s antiseptic approach to treating the wounds. In return, Lister wrote Macewen a note, congratulating him on the successful removal of the fragment of pocket knife specifically. This is among a number of items of correspondence between Macewen and Lister in our collections.

The semi-flexible gastroscope

In her latest blog post, Digitisation Project Intern Kirsty Earley looks at the technology behind a mid 20th century gastroscope.

The development of gastroscopy and endoscopy evolved during the 19th century. Philipp Bozzini in the early 1800s is regarded as the first to attempt to see inside the body using a light source – at this stage candlelight and mirrors. The use of electric light in the later 19th century advanced the procedure. In 1868 Adolph Kussmaul tested a rigid gastroscope on a sword-swallower to establish the line from mouth to stomach.

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Rigid gastroscope in Mayer & Meltzer catalogue, c1914

Prior to any form of recording technology, visualization of the gastrointestinal tract could only be achieved via rigid gastroscopes. These were essentially long telescopes through which the physician could view inside of the patient’s stomach (see illustration above and below).

gastroscope-illustration

Due to the limitations on flexibility, the patient had to be positioned in order that the gastroscope could simply slide down the oesophagus towards the stomach. It would then be rotated to visualize all areas of the stomach. Not the easiest of procedures. For gastroscopy to advance, something had to be done to the gastroscope itself.

Rudolf Schindler (1888-1968) was a German doctor who specialised in gastroenterology. Considered the “father of gastroscopy”, Schindler made incredible efforts to promote the use of gastroscopy as a diagnostic technique for gastrointestinal conditions [1].

Schindler was the brains behind the first ever semi-flexible gastroscope, created in 1931 [2]. He constructed the gastroscope in such a manner that the distal end could be rotated, while the proximal end remained stationary (see image below). This allowed easier access to all areas of the stomach. But how did he test his design? Often, his instruments were tested on his own children, especially his daughter Ursula as she had a strong gag reflex [3].

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One of our mid 20th century gastroscopes

To ensure that procedures were being carried out safely, Schindler trained practitioners in how to use his gastroscope as a diagnostic tool. He argued for many years that gastroscopy should not become a specialised field of medicine, but an examination technique performed by any level of practitioner.

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Detail of mid 20th century gastroscope

Ultimately, the gastroscope was replaced by fiberoptic endoscopes [4]. Instead of a flexible distal end, the entire length of the fibreoptic endoscope was flexible. This allowed the patient to be in a more natural position, e.g. sitting up, during the examination, [5].

Gastroscopy today involves examining components of the gastrointestinal system by inserting a wire-like endoscope down the patient’s throat. The endoscope contains a camera and light, and is controlled by the physician performing the examination. The images from the camera are then fed to a monitor screen for visualization.

References

  1. Gerstner, P., 1991. The American Society for Gastrointestinal Endoscopy: a history. Gastrointestinal Endoscopy, 37(2).
  2. Olympus, date unknown. Olympus History: VOL 1 The Origin of Endoscopes. [online] Available at: http://www.olympus-global.com/en/corc/history/story/endo/origin/.
  3. Schindler Gibson, U., 1988. Rudolf Schindler, MD: living with a Renaissance man. Gastrointestinal Endoscopy, 34(5).
  4. DiMarino, A.J., and Benjamin, S.B., 2002. Gastrointestinal Disease: An Endoscopic Approach. Slack Incorporated: New Jersey.
  5. Hirschowitz, B., 1961. Endoscopic Examination of the Stomach and Duodenal Cap with the Fiberscope. The Lancet, 277(7186).

Old and new surgical tools

Our Digitisation Project Intern expands on the previous post about Dr Harry Lillie’s medical bag.

The recent donation of a medical bag belonging to Dr Harry R.Lillie, a medical officer aboard whaling ships during World War Two, revealed some interesting stories. It also highlighted fascinating insights in the development of basic surgical instruments.

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Dr Lillie’s surgical kit

Within the bag, one item drew much attention- a set of surgical tools (above). These tools drew attention not because of their scarcity, or obscurity, but because of their profound similarities to modern tools used today.

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1939 or 2016?

A set of modern dissection tools was located and compared with the surgical tools found in Lillie’s surgical case. The designs of the tools are very similar, as are their materials. Modern dissection tools are made of stainless steel, as are Lillie’s. Most surgical instrument makers adopted stainless steel since its popularity grew in the 1930s. Even the canvas bags are remarkably similar.

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2016 or 1939?

Apart from some signs of wear and tear, it is hard to believe these two surgical kits have over 75 years between them.