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.

Art, Culture and Patronage in Renaissance Scotland

Last year we were very fortunate to host placements for four undergraduate history students from the University of Glasgow. The placements were undertaken as part of their class ‘Art, Culture and Patronage in Renaissance Scotland, 1406-1625’ and involved working with primary source materials from the collections of either the University’s Archives and Special Collections, the Hunterian Museum, or the Royal College of Physicians and Surgeons. Each student spent time studying a single item from one of these repositories, thinking about how to interpret the source, assessing its significance, and imagining the curatorial possibilities it offers.

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A manuscript rental on a blank page in ‘The workes of the most High and Mightie Prince, James’ (1616)

The students’ work is now available to read on the class blog:

You can read more about the students’ work in other repositories on the class blog: https://glasgowuniscotrenaissance.wordpress.com/.

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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A Unique Impression?

We have recently started a project to match eligible books from the College Library to the English Short Title Catalogue (ESTC). ESTC is a union catalogue of materials printed in English, or in English-speaking counties, up to the year 1800. With the help of a volunteer, we are matching records on our own catalogue to records on ESTC, and submitting reports of our holdings, along with details of copy-specific features such as provenance marks, bindings etc. The aim of this project is to make our collections accessible to a wider scholarly audience. ESTC is well known and widely used, and researchers are much more likely to begin a search there than come directly to our catalogue. Looking at our records one-by-one also helps us to spot mistakes that may have crept in to the catalogue, and allows us to identify rare or potentially unique items.

One such discovery has been made already. The College holds two copies of ‘The English Physitian Enlarged’ by the 17th century physician and botanist Nicholas Culpeper. Both were printed in 1656 and purport to be the same edition, but are in fact different in a few key ways.

The first and most obvious way in which they differ is in their bindings. Copy 1, bearing an older ‘Faculty’ bookplate, is in a rather poor state, barely covered by a binding of limp calfskin. It resides on the shelf in an acid-free phase box to protect it from further damage. Copy 2, with a slightly newer ‘Royal Faculty’ bookplate, is in a more robust, if slightly warped, vellum binding.

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The College’s two different copies of Culpeper’s “The English Physitian Enlarged” (1656)

The remaining differences are a bit more difficult to spot. On the title page of copy 1, the author is described as a gentleman student of “Physick and Astrology“, whereas in copy 2 he is a student of “Physick and Astrologie : Living in Spittle Fields.” The information provided about the printer also varies slightly. Copy 1 is printed by Peter Cole “at the sign of the Printing pres in Cornhil, neer the Royal Exchange” while copy 2 is also printed at “Leaden-Hall”. These minor variations continue throughout rest of the book, particularly in the pages preliminary to the main body of the text. Some of the pages are mis-numbered, but in different ways in each book.

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Title pages of the two different impressions of ‘The English Physitian Enlarged’

Although the same type fount has been used for both impressions, different tools have been used to insert woodcut borders and decorations. The main body of copy 1 opens with a woodcut initial ‘C’ surrounded by fleurs-de-lis. Copy 2 is almost identical, save for the use of thistles in the border instead.

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Different woodcut initials in the two impressions of ‘The English Physitian Enlarged’.

These differences are, of course, relatively minor. They would not have made much difference to the experience of a contemporary 17th century reader. Comparing them today, however, can help us to draw some conclusions about the number of impressions produced of this book, and perhaps even speculate about the practices of the printer.

ESTC currently lists three different impressions or editions of ‘The English Physitian Enlarged’ from 1656, with small but important differences between each. Our copy 1 has been matched to the record with citation number R216330, but copy 2 appears to be a previously unrecorded impression. We have submitted a ‘new item’ report to ESTC and hope to see our possibly unique item appear on the catalogue soon.

**Update 9th May 2016**

The new record is now listed on ESTC with citation number R505380. You can find it here: http://estc.bl.uk/R505380

Glasgow Incunabula Project

Last year we were delighted to welcome Jack Baldwin, project research for the Glasgow Incunabula Project, to the College to view the five incunabula (i.e. books printed before 1501) held in our library. Jack spent a considerable amount of time meticulously poring over each of these books, recording various bibliographic details, including information on their decorations, annotations, bindings, and any imperfections in the copies. We are very pleased to report that records for each of the books, along with Jack’s findings, have now been added to the project website.

The oldest of the five, and thus the oldest in our collections overall, is a 1479 edition of the Liber Aggregatus of Serapion the Younger. This is a medieval medicinal-botany text which, like many early printed texts, enjoyed great popularity in manuscript form before the arrival of the printing press.

Printed in the same year and bound in the same volume as this book is the Breviarium medicinae of Serapion the Elder. Despite the similar names, the two authors are not known to have been related. They lived four centuries apart, but both wrote on medicine and their work was often confused by later readers. Both works were printed at Venice by Reynaldus de Novimagio.

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A page from the younger Serapion’s Liber Aggregatus, with manuscript initials and marginal annotations

Moving forward chronologically we arrive next at the Carmen Medicinale of Quintus Serenus Sammonicus, a Roman physician who died in AD 212. The text in this edition, printed in 1488, gives a series of incantations against illness and does not add much practically to the art of medicine, but does at least provide some insight into ‘popular’ medicine in the ancient world and indeed in the middle ages. This work was actually printed as part of a much larger work, including a number of different authors. The text by Serenus was obviously rebound on its own at some point before its acquisition by the Faculty Library in the early 19th century.

Next, printed in Strasbourg in 1491, is De proprietatibus rerum by Bartholomaeus Anglicus.Early printers often left spaces for large initials at the beginning of a page or paragraph, so that the initials could be filled in by hand and in colour. The College’s copy of De proprietatibus rerum shows plenty of examples of this, albeit with some less than perfect manuscript work.

 

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A page from Bartholomaeus ANglicus’s De Proprietatibus Rerum, featuring 12 red initials supplied by hand

Bartholomaeus, the original author of the work, was a 13th century Franciscan scholar, and his text here can be seen as a medieval precursor to the encyclopaedia. The text itself remains valuable today as it provides modern scholars with a picture of the state of knowledge during the life of the author.

Finally, there is Practica, seu Lilium medicinae by Bernard de Gordon. Bernard was a French doctor of the 13th/14th centuries, and this is a copy of what is arguably his most important work, giving lists and descriptions of diseases thought to be contagious. This particular edition was printed in Venice in 1496 or 1497. Glasgow University Library also holds a copy of this edition, a part of the Hunterian bequest of 1807. These two copies appear together on the project website, and one can see the differing ways in which supposedly identical books can appear to modern users. The books both feature their own annotations, are bound in different styles, and show evidence of the different paths they have taken from owner to owner until reaching their present location.

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The woodcut title page of Bernard de Gordon’s Lillium Medicinae

The Glasgow Incunabula Project website now includes all 1,060 incunabula held by Glasgow University, the 5 held by the College, and 1 held by Strathclyde University, and records are now being added for items held at the Mitchell Library. You can find out more on the project website and follow progress on the project blog.

 

Emergency Surgery – The Trephine

Trepans and trephines have been used to treat head trauma and other conditions for thousands of years. Our current exhibition A History of Emergency and Trauma Surgery contains a display case dedicated to trephination (as well as illustrations of head injury procedures). Practical Cases and Observations in Surgery (1751) by Percival Potts reports successful use of trephination to treat serious head injury caused by a kick from a horse, a common and very serious injury. Potts’s Chirurgical Works (1779) contains an illustration of trepan procedure on a patient (who looks understandably anxious).

Another variant of the trepan can be seen in the 2nd edition of College founder Peter Lowe’s book The Whole Course of Chirurgerie (1612) . In its Sixth Treatise, Chapter 10, ‘Of Woundes in the Head’, Lowe expresses caution in the use of the instrument, which at the time was quite commonly used to relieve pressure on the brain resulting from depressed fracture. In line with the general focus of his book, Lowe is concerned about unskilled surgeons carrying out the procedure. Looking at the array of instruments illustrated below, it is easy to see why.

 

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From The Whole Course of Chirurgerie (2nd edition) (1612) by Peter Lowe

 

Our exhibition also features our 18th century trephine set (below). The set was made by Edward Stanton of Lombard Street, London, between 1738 and 1744. The difference between the trepans as shown above, and the trephine below, is described by John Woodall in his book The Surgeon’s Mate (1639). Woodall claimed to have invented the modern trephine, outlining the improved features of the new instrument. The trephine handle was t-shaped rather than a two-handed brace-and-bit, meaning the tool could be used with one hand. Next, the cutting head was cone shaped, making it easier to extract the disc of bone from the skull. Also, to improve cutting, spiral grooving and spiral cutting teeth were used.

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As well as the four trephines of different sizes and handle, the set contains a perforator, a double ended elevator, raspatory, lenticular, extracting forceps, and a brush, used to clean the trephine teeth.

Similar instruments were used well into the 20th century. The illustration below from a 1950s edition of Surgical Instruments and Appliances used in Operations by Burrows and Raven shows a very similar instrument to that in our set.

 Our exhibition is in the College’s Crush Hall until the end of April 2015. To visit please get in touch by emailing library@rcpsg.ac.uk or calling 0141 221 6072. Alternatively, pop in on a Monday afternoon between 2pm and 5pm.

H.T. Hamblin: Ophthalmologist and Mystic

The latest addition to the library catalogue is a book we found during a recent spot of tidying up around the office. Hamblin’s Ophthalmological Diary and Year Book, 1935 (11th ed.) combines quick reference material for ophthalmologists practising in the UK with a week-to-view diary for 1935 and an illustrated catalogue of ophthalmological instruments.

It’s quite a high quality production, with a padded leather cover and some rather nice marbling on the endpapers. But it doesn’t seem to be a book that many other libraries have held on to. Searches on Worldcat and Copac return no other copies of this particular edition, and only 1 copy of any other edition can be found, in the library of the University of New South Wales (2nd ed., 1926, with a slightly unhelpful spelling mistake in the catalogue record).

Marbled endpapaers from Hamblin's ophthalmological diary and year book, 1935

Marbled endpapers

The preface states that few alterations have been made to the text in its 11th edition, claiming that “[t]he absence of criticism either constructive or destructive, or of suggestions for alteration in the choice of material evidences the continued approval of the Ophthalmic Profession generally.” One wonders if it could simply be that the ophthalmic profession took little notice of the publication.

The diary is published by Theodore Hamblin Ltd, which was a manufacturer and seller of spectacles and various types of optical and ophthalmological equipment, with a number of branches throughout the UK. The firm later became part of the opticians Dolland & Aitchison Ltd, which in turn was merged with Boots Opticians in 2009. It was founded by Henry Thomas Hamblin (1873-1958), a curious character who worked as a successful optician and businessman for much of his life, but eventually became better known as a mystic and proponent of the ‘New Thought’ movement. He authored several books on this subject as well as founding and contributing to a monthly magazine, The Science of Thought Review. His work in this area is kept in print today by the Hamblin Trust.

Our museum collection includes a large number of ophthalmological instruments, and instrument catalogues such as this are always helpful when attempting to identify and describe older medical instruments. This book certainly has an unusual story attached to it, but it should also be a worthwhile and practical addition to our collections.