A Medical History of Skin

Scratching the Surface

Kevin Patrick Siena

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9781848934139
• eBook ISBN: 9781317319535
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

Diseases affecting the skin have tended to provoke a response of particular horror in society. This collection of essays uses case studies to chart the medical history of skin from the eighteenth to the twentieth century.

1 Drain, Blister, Bleed: Surgeons Open and Close the Skin in Georgian London

Lynda Payne

... are your olfactory nerves so delicate, that you cannot avoid turning sick when dressing an old neglected ulcer? or, when, in removing dressings, your nose is assailed with the effluvia from a carious bone? If you cannot bear these things, put surgery out of your head, and go and be apprentice to a man milliner, or perfumer.¹

From Mr Peters, a surgeon:²

[On] Dec. 28. 1737. James Channon, aged about 14, was accidentally shot in his Back by another Lad at the Distance of Two Yards from him; so that the whole Load of [Gun] Shot, not having Space to scatter, enter'd like a Ball, by the Edge of the Left Scapula, which it splinter'd ... [it then] pass'd between the two superior Ribs, and fractur'd the Clavicle — with a Touch of the Incision-Knife ... I took out about a dozen shot.³

Mr Peters then bled James and bandaged the wound on his back. A week later, he expressed satisfaction at the development of 'healthy suppuration'. But then the suppurating pus became so copious that 'When the dressings were removed, I frequently made him force a Cough, and try if he could not throw out any Pus by his Mouth; but, instead of passing that Way, it flew out thro' the Wound like Water from a Pump ... and the "Air which was forc'd thro" the Wound by Coughing, would blow out a Candle, which I often experienced — I thought he would die'.⁴

This went on for eight weeks, during which time James coughed up twenty-five gunshots; he became emaciated; his skin was hot and dry. A cannula, or gum elastic catheter, was inserted to drain the wound, but the shivering from the boy's high fever kept causing it to fall out, James waxed and waned over the next few months, occasionally coughing up yet more gunshot and often running high fevers.

In November 1738, nearly a year after the shooting, a frustrated Mr Peters used a caustic — a hot iron — to burn a hole through the scar of the gunshot wound, and then 'kept it open with a large Bean, to try if a Discharge ... might divert the Matter from coming by the Mouth ... [The boy] weather'd out the Winter tolerable well'.⁵ This method of keeping a wound artificially open by inserting a foreign object, such as a pea, bean or bead, created what was known as an issue. In March 1739 James complained of a pain in his side and Peters applied a 'warm Plaister [or poultice] and drew off ten Ounces of Blood ... A few Days afterwards an Abscess formed between the Ribs ... which I opened, and discharged about four Ounces of ... fetid matter, and 18 Shot'.⁶ Excited by the possibilities this new wound offered to drain yet more pus, the surgeon removed the bean from the original gunshot wound and allowed it to heal; he then kept the new wound open with a cannula. But after ten days the matter had stopped flowing, the patient had a high fever, and Peters reported: 'I threw aside the Cannula, and healed the Wound between the Ribs, it answering no End to keep it open longer'.⁷

The patient lingered on, through 1740, 1741 and 1742 — James generally got sick every spring and autumn and coughed up pus and even more gunshot. But the surgeon cheerfully added that `Between these grand fits of Coughing ... the boy would gain Strength, grow fat, and work at his Trade of Glove-Making'. In 1743 James became very ill and coughed up a two-inch bone fragment that was presumed to be part of his shoulder bone. Old pieces of dead bone were known as sequestra and were regarded as indicative of a major infection. Peters admitted James to the local hospital. There he was bled repeatedly, put on a milk diet and confined to bed — and after fifteen months was proclaimed to be 'healthy, strong, and fat'.⁸ Finally in 1745, eight years after being shot in the back by another adolescent boy, James Channon, now aged twenty-two, was discharged from Peters's practice as successfully cured.

The case of James Channon demonstrates several of the tools and techniques used by Georgian surgeons in attempts to heal their patients' wounds — knives, cannula, caustics, issues, poultices and dressings. It validates research that has shown that a lot of surgeons' work in the eighteenth century was the surgery of trauma, especially related to wounds and broken bones. They set simple fractures and amputated for compound or open fractures, with probable mortality rates of 5 per cent and 50 per cent respectively.⁹ Surgeons trephined or drilled into the skull for open and closed head injuries. Most of their surgery went septic, and as in Channon's case, wounds suppurated, resulting in copious amounts of pus.¹⁰ But what the case of James Channon does not demonstrate is the theories behind the choices Mr Peters made in treating the boy's wound.

With this narrative in mind, I would like to consider the advice given in hospital surgical training to young apprentices and pupils about — to quote a leading Georgian surgeon — 'the most common business of surgery',¹¹ which was the care of wounded skin. How did a wound heal? What kind of wounds should a surgeon treat, and what should he leave alone as necessarily fatal? What was an abscess? What treatments were available for skin wounds, and what were the challenges and controversies surrounding them? Did early modern surgeons discuss pain control, or is this, as some historians have claimed, a modern concern? And what can all of this tell us about the history of skin? In short, does evidence from clinical encounters support contentions put forward by scholars on the nature of pre-modern skin — that it was 'a sort of porous tissue that could potentially have an opening anywhere',¹² and/or a 'cushion touched from beneath by a delicate webbing of "sensitive" and "irritable" nerve fibers'?¹³

Many of the surgical cases in mid- to late eighteenth-century London came to St Bartholomew's Hospital, one of the English capital's seven teaching hospitals. Patients there often came under the care of Percivall Pott (1714-1788), considered by his peers to be the best practical surgeon of his day. Born in London in 1714, he was apprenticed at the age of fifteen for £200 to Edward Nourse, a surgeon and lecturer at St Bartholomew's Hospital.¹⁴ Despite the nauseating nature of the work, Pott credited his early training in cutting up rancid human body parts to make Nourse's teaching specimens with giving him the dexterity —and the strong stomach — that a surgeon needed.

Pott was a prolific author, and in 1756 he used the recovery time following a riding accident to write his first book, A Treatise on Ruptures, or hernias. It covered one of the most common ailments a surgeon treated, and began a stream of publications that give a glimpse of the workaday existence of a Georgian practitioner of surgery: a second book on ruptures and treatises on head wounds, cataracts, spine curvature and testicular cancer all followed. As a senior surgeon at St Bartholomew's Hospital from 1749, Pott trained hundreds of future surgeons, including the three on whom I focus in this chapter: John Abernethy (1764-1831), Peter Clare (1738-86) and John Heaviside (1748-1828). They in turn became successful surgeons and authors of medical texts and, in the case of Heaviside, anatomy museum owners. At St Bartholomew's Hospital, pupils followed Pott on his ward rounds, wrote up cases, attended lectures on surgery and anatomy, and admitted patients. Michael Crumplin estimates that between 1728 and 1820, 60-90 per cent of all hospital students were surgical trainees.¹⁵ Dressers such as Abernethy, Clare and Heaviside paid extra to obtain ward experience with Pott.¹⁶ In addition to other skills, Pott taught them to open and close the skin. They learnt how to let blood by lancet, fleam or leech, to apply wet and dry bandages, to mix up poultices, to apply heated cups and to make an issue with a pea or a bean to create a persistent sore. Along with the pupils, they observed but also often assisted at operations that generally took place on Saturdays between 11 a.m. and 1 p.m., when the light was presumably at its best.¹⁷

Lectures and publications by Pott and his former dressers, Abernethy, Clare and Heaviside, reveal the theories, practices and fierce arguments behind treating even the simplest of skin wounds. The initial question was how a wound to the skin naturally heals; according to eighteenth-century surgeons, there were three stages involved. The first was called digestion, and to quote Clare from his 1779 treatise on skin ailments, 'digestion involved the formation of a quantity of good pus on the surface';¹⁸ he addressed good and bad pus later in the chapter. The second stage of natural healing was known as incarnation, and here the wound fills up with 'granulations of tender flesh and becomes florid'.¹⁹ Clare referred to this granulation as a fungus, which had to be protected at all costs —perhaps with oil, 'as it is an artificial pus that protects and comforts the tender wound'.²⁰ Cicatrization was the third and last stage, and 'compleats the cure'.²¹ This was the formation of a hard dry scab on the wound.

Anatomical and physiological descriptions of the skin were limited in lecture and in print. In 1789 James Moore discussed some aspects of the skin in a prize-winning treatise on wounds. The cutis or outer layer of the skin was described as growing hair and being full of 'eminences', named papillae, which ran in waving rows, triangles or whorls (fingerprints, in modern parlance). Under the cutis lay the rete-mucosum, which appeared furrowed on dissection from the papillae above it. The rete-mucosum could be white, yellowish, brown or black, and so gave colour to the skin. Moore explained that scars were whiter in white men because they were less vascular than the original cutis had been, but 'in negroes the reverse takes place, their scars being generally blacker than other parts, owing to a darker rete-mucosum forming'.²² Scars were unable to grow hair or create papillae because these were only 'formed in the first organization of the body, and are never afterwards produced'. Moore added that anatomists and surgeons were joined in the opinion that papillae were the source of feeling in the skin, and therefore the lack of them was why scars had no feeling.²³

With this analysis in place, what skin wounds could be treated? Surgeons attempted to provide guidelines on when it was worth trying to save a patient's life and when it might be futile. Pott instructed his students that wounds to the brain, the heart and major thoracic vessels 'may be fairly reckoned as fatal, while chest and abdomen wounds were 'not necessary fatal but always attended with some hazard' to treat, and wounds to the extremities were usually not fatal.²⁴ However, as Abernethy lectured in 1810, 'People will die under trivial Operations — even in opening a common Abscess they will lie down & die — (and) we should (always, therefore) give a doubtful prognosis'²⁵

This brings us to one of the most common and problematic skin issues treated by Georgian surgeons, namely the 'common' abscess. Clare described an abscess as 'a collection of matter betwixt the muscles and the skin and their formation was usually attended with great pain and fever'.²⁶ The matter he referred to resulted from the process of inflammation. When inflammation first occurred in any injury to the skin, it was called the adhesive type. A buff-coloured membrane, generally believed to be made up of lymph, filled up a wound. Blood vessels then grew through the cavity made by the wound, resulting in what was known as 'healing by first intention'. Many surgeons theorized that if the wound was exposed to air, this somehow deprived the blood of the power to unite the parts by first intention;²⁷ therefore they covered an exposed wound with plasters and/or stuffed it with lint in order to absorb any blood and enable the wound to form a hard dry skin on top of the cavity. But this practice was a matter of debate:

Mr. Potts would not advise as a great many of our Practitioners do, to cram the wound with Lint, as it hinders the parts from coming together ... A Farrier will stick his knife into an abscess of a Horse let out the matter dressing it superficially &: the Horse gets well.²⁸

If the wound did not heal by first intention within two to three days, the second and final stage of inflammation developed, known as the suppurative.²⁹ This was known to be hard on the body, but beneficially could expel foreign bodies from wounds. Pott gave the following directions in lectures on how to treat gunshots:

The method I make use of, after, having enquir'd what kind of fire arms the wound had been inflict'd with and in what position he was in & likewise what the piece was load'd with, you are then carefully to extract all extraneous bodys ...

He continued that the wound may have to be enlarged to grasp the shot with forceps, and if it had entered the body 'violently' a counter opening could be necessary. Pott recommended using a very soft dressing:

free from any irritable quality, the digestive bals.m of Barth,w Hosp.l, cover'd with a soft cooling Cataplasm will prove the most serviceable and must be continu'd for some time.³⁰

Pott firmly warned his audience of eager young men not to rush to get the ball out unless it was visible to the eye and not entangled in bones or near a large vessel. They should wait until suppuration is established — 'when one of two things undoubtedly will happen it (the shot) will unite with Callus or come away with suppuration'.³¹ This method was all too clearly used in the case of James Channon.

Essentially, suppuration was the process of forming thick pus to fill a cavity; if it developed in a cavity with no external opening, a cyst or abscess developed. Surgeons recognized suppurative inflammation through several cardinal signs —hot flushed skin, pain, rigours and cold fits:

The discharge from a wound during this period is principally, the putrid serum and crassamentum; this is soon mixed with a thin serous secretion formed on the wounded surfaces. This discharge by degrees, acquires a whiter colour and thicker consistence; and about the fourth or fifth day, pure pus is discharged, an...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Contributors
• List of Figures and Tables
• Scratching the Surface: An Introduction
• Part I: The Emerging Skin Field
• Part II: Skin, Stigma and Identity
• Part III: Skin, Disease and Visual Culture
• Afterword: Reading the Skin, Discerning the Landscape: A Geo-historical Perspective of our Human Surface
• Notes
• Index