Edging the Competition: Surgical Instruments in the 18th-Century

As I’ve written about in other posts about razors and posture devices, in the second half of the eighteenth century, the introduction of cast steel transformed products for the body. Steel had many physical properties that rendered it very useful across a range of instruments. Unlike its predecessor, blister or shear steel, which was of uneven quality and could be brittle, cast steel was durable and capable of carrying a very sharp edge. It could also be polished to a mirror-like shine, making it very attractive to wear as ‘brilliant’s – imitation diamonds.

Many of the instruments I’ve written about, from razors to spectacles, were things that people bought to use upon their own bodies. But there was another group of instruments that was transformed, but one which people generally did their best to avoid – surgical instruments.

The surgeon’s knife held something of an ambiguous position within medicine. For patients the briefest glimpse of a scalpel or, worse, an amputation knife, was enough to send them into a swoon. Some surgeons argued that people would much rather subject themselves to the dubious ministrations of the quack than to the slice of the blade. Surgeon’s instruments also suffered from the taint of the manual craft. It was argued that almost anyone could wield a knife or a saw, without any need for theoretical knowledge of the body. As such, surgical instruments were little more than tradesmen’s tools.

Nevertheless there was an increasing demand for instruments in Britain in the later eighteenth century. Across Europe numbers of medical students were swelling. In France the numbers of surgeons nearly tripled between 1700 and 1789. By the early years of the nineteenth century, around 300 students per year were enrolling in London hospitals, as well as Edinburgh and Glasgow. As well as the increasing numbers, medical education was changing, especially in the matter of dissection. Before the 1750s, anatomisation was generally a theatrical event where the dissection was carried out by a surgeon, watched over by a crowd of enthralled and doubtless, sometimes, nauseated crowd.

But changes in medical education meant that trainee surgeons were increasingly given access and encouraged to get their hands dirty. Reading books about anatomy was fine as far as it went, but could never replace empirical observation and experience. This was also an age where views of the body were changing, and the human form was likened to a machine. As Thomson’s The Art of Dissecting the Human Body, in a plain, easy and compendious method dissection manual put it, there were only two possible ways to discover the workings of a machine. One was to be taught by its creator…difficult in this case! The other was simply to take it to bits and put it back together again.

Surgical manuals began to set out the requisite kit for the gentleman surgeon. One was to purchase a set of pocket instruments containing the most commonly-used items. The German anatomist Lorenz Heister advocated a pocket set including lancets for opening veins and abcesses, straight and crooked scissors, forceps, probes, a razor and needles. A similar kit was popular in London, containing knives ‘made of best steel’, lancets and scissors, as well as a salvatory and plaster box. Clearly some surgeons were apt to keep buying until they had amassed a huge number of instruments. The surgeon and author Benjamin Bell cautioned against such acquisitiveness, arguing that too many instruments confounded the surgeon under the pressure of the operation.

Image from http://collectmedicalantiques.com/gallery/cased-surgical-sets

The increasing demand for instruments opened up a range of new opportunities for the makers of instruments. Traditionally cutlers had been the mainstay of surgical instrument manufacture. With their experience in making edged tools and of tempering metals to exact requirements, they were the best qualified. But by 1763 the Universal Director, a directory of London trades, was describing surgical instrument manufacture as ‘a distinct branch from the common cutler’. By 1800 the first dedicated surgeon’s instrument catalogues were being produced by prominent makers such as J.H. Savigny of the Strand in London. Savigny’s catalogue contained a wide variety of different instruments from knives and saws to catheters, tourniquets and even apparatus for the recovery of the apparently dead!

Image from Savigny’s instrument catalogue, 1800

Surgical instrument makers were also keen to puff their products in newspapers. The market for these products was fairly narrow and specialised; these were not items marketed for the public. Nevertheless it is noticeable that makers did their best to clothe their advertisements in the language of polite commerce, and include popular and elegant designs in their trade cards. The language of advertisements was all polite puffery. The tone of advertisements for ‘Thurgood’s Surgeon’s-Instrument Manufactory’ in Fenchurch Street was deferential, seeking to reassure ‘any professional gentlemen’ that ‘nothing shall be wanting on his (Thurgood’s) part to render full satisfaction’. Many other adverts were targeting ‘gentlemen of the faculty’ and seeking to encourage their business.

Advertising also offered opportunities for illustration. The trade card of John Chasson of London depicts a variety of amputation knives, saws and other instruments set against an elegant rococo surround. The razor and surgical instrument maker Henry Patten’s card shows a range of instruments, including lancets, hanging from branches of its elaborate frame. Given their associations with manual trades, it is noticeable that advertisements began to pay attention to the form as well as the function of instruments. John Chasson’s instrument cases, for example, could be bought in elegant boxes covered in fashionable shagreen (sharkskin). The handles of knives and saws began to change from traditional wood and bone to more exotic and expensive products like ebony, ivory and tortoiseshell.

Image courtesy of Wellcome Images

Perhaps the most surprising claim made by some makers, however, was that their products lessened pain and improved the experience of patients. In 1778, J. Savigny advertised his newly-invented lancets to the faculty. Stressing his metallurgical skills, Savigny argued that they were ‘wrought to such a degree of accuracy, as will greatly lessen the pain of the patient, and totally remove all apprehension of disappointment in the operator’. In another, he argued that the ‘extraordinary degree of accuracy’ in their edge would lead to the ‘approbation of the patient and reputation of the phlebotomist’. It’s interesting to note that the patient comes first. Many surgeons agreed that speed was of the essence in any surgical technique, and that this could only be achieved by keeping instruments maintained since, as Benjamin Bell noted, they were ‘injured with every use.

The late eighteenth century, then, was something of a golden age in the manufacture of surgical instruments. As the medical faculty sought desperately to separate itself from accusations of quackery and establish itself as an learned profession, the need for new instruments, based on the latest scientific and philosophical principles, was key. Likewise, with an expanding market and greater opportunities to promote their products, surgical instrument makers were continually engaged in developing and refining their products. Whether it would be of any comfort to a poor patient to know that the knife about to saw their leg off was made of the latest cast steel, however, is a moot point!

Name and Shame: performance and reputation in early modern medicine

Last week the issue of the performance of surgeons came under scrutiny. The health secretary, Jeremy Hunt, threatened to ‘name and shame’ any surgeons who refused to publish their performance data, including mortality rates, in league tables. http://www.bbc.co.uk/news/health-22899448 Surgeons have raised many objections to the plans including potential stigmatisation of those seen as under-performing (an issue that is itself problematic say some authorities), the potential for misleading figures and, no doubt, a dent to professional pride.

The measurement of performance  – at least in terms of quantitative measurement and aggregation – together with the publication of results are a modern phenomenon in the medical profession. It is interesting to consider the issue of performance, and of public perceptions of medical practitioners in the past.

In the early modern period, for example, reputation was most certainly a central factor in people’s choice of medical practitioner. They wanted at least some reassurance that the man about to lance their boil or cut for the stone was not some cack-handed amateur who would leave them bleeding to death on the kitchen table. But reputation worked at a deeper level than this. In rural communities, for example, people effectively became healers by reputation; once a cure had been attributed to them, word of the power of the healer would spread and a position cemented. This was generally the way that so-called ‘cunning folk’ and ‘irregular’ healers gained prominence.

It is interesting to consider early-modern perceptions of ‘performance’ though. If we were to apply a modern measure to seventeenth-century practitioners, what sorts of figures would emerge? For many reasons we have no means of accurately measuring the ‘figures’ for early modern doctors. Beyond parish registers there were no official figures for causes of death outside London (if we include the Bills of Mortality) and nothing like today’s patient records from which to infer case histories. Some physicians did keep case books, and these can often reveal interesting stories, but not enough to aggregate.

What does seem likely though is that, at least by modern measures, 17^th-century doctors were probably highly inefficient. Mortality rates, at least for surgeons, were undoubtedly far greater than today. Major surgery (such as opening the chest cavity) was seldom done due to the overwhelming risk of losing the patient. Before anaesthetic, any surgical intervention was risky whether due to hypovolemic shock caused when the body loses too much blood, the physical trauma caused by the pain and wound infliction or, perhaps even more so, the risk of secondary infection after surgery due to unwashed hands and instruments, and dirty conditions. Even relatively minor procedures such as bloodletting carried the risk of introducing infection, and a certain amount of deaths must surely have been attributable to blood poisoning or infection caused in this way.

All of this begs the question of why, if it was so risky, did people elect to visit surgeons at all? Why did some surgeons, especially into the eighteenth century, gain prominence and even fame if they stood a fair chance of killing their patients? Surely people would not have given such people the time of day if it were proved that they responsible for the deaths of far more people than they saved?

The answer is that people simply had a different expectation of what medicine and surgery could do for them. This was a world of sickness in which the patient, while by no means powerless, relied on an array of defences to support them in their fight to return to health. These included domestic medicine, family and friends, books – if they were literate, and also medical practitioners. Rather than one consultation with one general practitioner, as today, people commonly consulted many healers until they found one they were happy with. They might combine treatments and seek the opinions of several, whilst still falling back on their own tried and trusted remedies.

But did they expect practitioners to heal them? They certainly hoped that they would, but also understood that they might not. Let’s imagine for a moment that an early-modern person learned that the mortality rate amongst the patients of their prospective surgeon were in excess of 70% A surgeon with those sorts of rates in today’s league tables might well not last long on the register. But a seventeenth-century person might well view things a bit differently. Whilst acknowledging the potential danger, they could well view this as a risk worth taking – as a last-ditch effort to make them well again.

This explains why people went to doctors at all, and brings us back to reputation. If a practitioner had healed at least some people then they were potentially worth visiting. The fact that many people died under their ‘care’ was not necessarily viewed as their fault; it was an artefact of living in what everyone acknowledged were dangerous times for the sick. Therefore, doctors who had had at even some success were a potential lifeline. More than this, they could be held up as figures of approbation, despite what might be seen as a good record of not curing! What they did, however, was offered some degree of hope where otherwise there might be none. In that case, half a loaf was better than none.

Performance, even today, relies on much more than bare statistics. The reputation of practitioners is still important; we would all ideally want to see the ‘best’ specialist or the most eminent surgeon. It is worth considering how statistics can only tell part of the story though, and the ways in which our perceptions of reputation have shifted over time.