The Foundations of Pathology in The United Kingdom continued
A painting which was stolen from the Royal College of Surgeons some years ago {Figure 16} shows how amputation of a leg was performed. Two ligatures were applied. The "anaesthetic" was administered by a number of strong assistants. The surgeon cut through the soft tissues and then cut the bone with a saw. For many years, the standard method for producing haemostasis was to plunge the amputation stump into boiling oil.
Figure 16
For many centuries, amputation of the leg was the recommended treatment for traumatic injury. Without treatment, a compound fracture of the leg resulted in death from sepsis. The mortality from amputation must have been high, too, but there was a better survival rate following amputation. The inevitable complication following this operation was osteomyelitis. John Hunter had a number of examples of amputated femurs showing the periostitis, sinuses, sequestra and involucra (new bone formation around the original bone shaft). {Figure 17}. He also had a number of specimens of primary osteomyelitis which showed similar appearances. [Figure 18].
Figure 17 and Figure 18 right
Most of the old museums in Europe contain similar specimens which show the effects of chronic osteomyelitis following amputation. A very famous specimen in the Museum of the Armed Forces Institute of Pathology in Washington, USA, shows the right leg of General Daniel Sickles. On July 21, 1863, in the final hours of the Battle of Gettysburg during the American Civil War, while he was riding his horse, his right lower leg was shattered by a cannon ball. He quieted his horse, dismounted, and under the shade of a tree had a mid thigh amputation. When he recovered, he presented the fractured tibia and the cannon ball to the Army Medical Museum (now the Armed Forces Institute of Pathology) {Figure 19}.
Figure 19
For many years he paid an annual visit to the Museum to see his leg. In due course, the proximal half of the femur was "reunited" with his tibia {Figure 20}. It shows the characteristic features of Chronic Osteomyelitis. John Hunter's best remembered contribution to technical surgery was his introduction of a method for treatment of aneurysms of the popliteal artery by partially occluding the femoral artery proximal to the aneurysm. This caused thrombus within the aneurysm which then decreased in size and the collateral circulation developed. The post mortem specimen of the first aneurysm he treated in this way is P275. It belonged to a 45 year old cab driver. Cabs in those days were small, horse drawn carriages rather like the Fortnam and Mason replica seen outside their store in The Strand in London in 2001. {Figure 21}.
Figure 20
Figure 21
The Museum Catalogue records John Hunter's clinical case notes. The man presented in December 1785 with a swollen left foot and leg. The pulsating popliteal aneurysm was easily defined on the posterior aspect of the thigh, pushing aside the tendons of the hamstring muscles. The patient first noticed it three years before. It had slowly enlarged. Hunter made an incision in the leg and placed four ligatures around the femoral artery proximal to the aneurysm. The lumen of the artery was partially occluded which allowed clotting to occur in the aneurysm. The ends of the ligatures were brought out through the wound. The wound was then closed by sticking plaster and bandaging. {Note - there was no anaesthetic, no antibiotics, no aseptic technique, no sutures, but opiates were available for pain relief}. The patient remained in hospital for six weeks. There was no infection, the aneurysm decreased in size and the swelling of the leg subsided. He left hospital and returned to his job. There were a few episodes of abscess formation at the site of operation. Pieces of ligature were discharged from these abscesses. 15 months after the operation, during the winter, he died of pneumonia. Permission to obtain the specimen of the artery by post mortem examination was obtained with some trouble, and considerable expense. The aneurysm was much smaller than it was at the time of operation and it was filled with laminated blood clot. {Figure 22}
Left to right Figure 22, 23 and 24
Specimen P1205 {Figure 23} is another example of this condition. This may have been about the size of the aneurysm from the previous patient at the time of operation. Syphilitic aneurysms of the arch of the aorta were fairly common in Europe at this time. Figure 24 shows one of Hunter's specimens. His case notes record that the patient was a 55 year old soldier who complained of chest pain. Two years later the aneurysm began to protrude through his anterior chest wall. A year after this he died from rupture of the aneurysm. For comparison, Figure 25 shows a wax model of a syphilitic aneurysm eroding through the anterior chest wall of a famous French actor in the early 19th century. This preparation is in the Musee Dupuytren, Ecole de Medicine, Paris. In the year 2000, the College celebrated its 200th year.
Figure 25
During the past ten years the College has adapted to the rapid changes that have occurred in Surgery. A great deal of money has been spent in creating new, modern, teaching and practical training facilities which will equip it to move into the new millennium. The College Council decided to upgrade its public museums to make them more accessible for a wider educational audience. For this purpose, they have raised two thirds of the three million pounds they estimate will be required for this. The plan is to amalgamate the historical Hunterian Museum which now has 3 500 of HunterŐs original specimens with the Odontological Museum (10 000 specimens). Ever since its first opening in 1813, the Museum has made time for members of the public to visit. This policy continues, and conducted tours occur every week.
The two teaching museums, Anatomy (600 specimens) and Pathology (2 500 specimens), housed elsewhere in the College, were merged in 2001 as a single resource. This museum is used for the education of surgeons and other categories of health workers and is not available to the public. For pathologists, it is extremely heartening to see that the Royal College of Surgeons of England values its anatomical and pathological specimens, and acknowledges that they are still useful teaching aids. In many parts of the world, undergraduate medical courses are downgrading the importance of pathology (and anatomy, too) in their curricula. Pathology Museums are being downsized and closed. Hopefully, initiatives taken by such a prestigious organisation as the Royal College of Surgeons of England will help to turn the tide of opinion, and influence medical administrators to reassess the importance of pathology in medical education, and to appreciate Museum collections for what they are - priceless and irreplaceable teaching resources.
Robin Cooke
Information for this article was kindly provided by Miss Elizabeth Allen, recently retired Conservator of the Hunterian Collection and Stella Mason the current Keeper of the College Collections. All except three of the photographs in this article were taken by the author. Permission to use photographs of the specimens from the Royal College of Surgeons of England was kindly given by Professor Sir Peter Morris, President of the College. Permission to use photographs of the William Hunter book "The Anatomy of the Pregnant Uterus" and of the terracotta models was given by the Royal College of Surgeons and Physicians of Glasgow and the Department of Anatomy, University of Glasgow respectively. Permission to use the photograph of the specimen from the Musee Dupuytren was given by the Curator. Permission to use the photographs of the leg of General Sickles was given by Dr Florabel Mullick, Principal Deputy Director, AFIP, Washington. The author is extremely grateful to all of the above people.
References:
"Descriptive Catalogue of the Pathological Series in the Hunterian
Museum of the Royal College of Surgeons of England" Volumes 1 and
11 (1966). E&S Livingstone Ltd.
"The Royal College of Surgeons of England - 200 years of History at the Millennium" (2000) John P. Blandy and John S.P. Lumley, Editors; Published by the Royal College of Surgeons of England and Blackwell Science Ltd.
{A further article on British Pathology will be published in a future edition of the News Bulletin}.