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]

tourniquet

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].

liston-knife

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.

amputation-saw

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.

trephine1

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.

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.

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.

hr-kit-7

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.

kirstys-tools

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.

 

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.

 

A trepan with other instruments for the head - Copy

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.

A large missile lodged in the face

Whilst researching our former President, Professor Thomas Gibson (1915-1993), for a display marking 100 years since his birth, I came across an entry in our museum catalogue for a 20-mm Cannon Shell. Tom Gibson was a renowned plastic surgeon and this seemed like quite an unusual item to be linked to him. After a little more digging around, I found that the cannon shell had actually been removed in surgery by Gibson during WW2 – Gibson had been Captain of a Royal Army Medical Corp maxillofacial surgery team.

What made this find even more interesting was that the cannon shell linked to an article Gibson had written for The Lancet in 1946, a copy of which we hold in the College Library. This article featured a photograph of an x-ray showing the shell lodged in the face of a Gunner.

20-mm cannon shell beside article in The Lancet

20-mm cannon shell beside article in The Lancet

Remarkably, the soldier was unaware that it was even there! He thought a bullet had just grazed his face. The 20-mm cannon shell measures 85mm in length and weighs 147.3g!

In his article, Gibson states that:

“The most interesting points in this case seem to be (1) the large size of the missile, the first of its kind we have seen; and (2) the fact that such a mass of metal could be accommodated in a compact vital structure … and cause so little disability.”1

The College archive houses a collection of Gibson’s case histories, publications, photographs and correspondence.

  1. The Lancet. 1946 Jan 5;1(6384):13. Large missile lodged in the face; with minor clinical disturbance. Gibson T