Large and Small Knives

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Before the 16th century, amputation knives described in texts are either not illustrated, defectively illustrated, or do not survive in collections and hence remain structurally obscure. Subsequently, illustrated or surviving amputation knives are either large or small, the former for dividing the major soft tissues and the latter for penetrating soft tissues in difficult areas, especially between the tibia and fibula of the shin, and between the radius and ulna of the forearm; in

Britain, small knives with two-edged blades were often termed "catlins" or "catlings," a term which has not been explained but may be related to "cutting."

Gersdorff's amputation scene of 1517 (see Fig. 1.5) and Ryff's of 1545 (see Fig. 9.1) illustrated a single relatively short, straight and strong knife, presumably for undertaking all soft-tissue dissection. By 1545, however, Paré figured a "hooked" amputation knife, that is, of sickle shape with a concave cutting edge (see Fig. 6.4), believed to be applied more rapidly to the convex surface of limbs; that is, a longer section was cut in one sweep of the blade in the technique of guillotine dismembering. Franco, in 1556, also recommended the "culter falcato," or hooked knife (see Fig. 6.2) and, as we shall see, the sickle shape persisted in some hands until the 19th century, although with diminishing degrees of curvature as knives became ever straighter. In the writer's view, sickle-shaped blades, appropriate for guillotine procedures, became recognised as inappropriate for undertaking flap amputations (see Fig. 6.8) which stimulated the rehabilitation of straight knives.

By contrast, Croce employed a large convex-edged blade in 1573, as did Fabry (Hildanus) in 1646, who also illustrated a smaller concave knife in 1646 (Fig. 10.8); in practice, convex blades remained a minority choice. Among those employing concave edges were Woodall, initially

Ryff Amputation
Fig. 10.8. Amputation Instruments, 17th century. fig. 1, concave knife; fig. 2, massive convex bladed knife; fig. 3, bow saw of unusually simple design. (From Fabri de Hilden G. Observations Chirurgiques. Geneva: Chouet, 1669.8)

in 1617 (see Fig. 6.7) and again in 1639 with a reduced degree of concavity (see Fig. 9.2), Sculte-tus in 1653,Verduin in 1697,Purmannus in 1706,37 Garengeot in 1727,38 Sharp in 173939 and Petit in a posthumous work of 1783. In 1743, Heister also featured a large concave knife yet, exhibited alongside this: "... a small-sized straight Scalpel, more commodius for dividing the Skin and Flesh in Amputations than the large crooked one .. .",40 a first criticism of concave-edged knives traced by the writer. Heister offered no explanation for displaying the concave knife in his important textbook. Possibly he comforted those apprentices whose masters still favoured such knives. By the later 18th century, English amputation knives, as represented in museums, retained a moderate concave edge (see Fig. 6.6) and, despite the introduction of long straight narrow blades with slight convex extremities, most English amputation boxes retained one knife displaying minor degrees of concavity until the late 19th century, often with a slight notch on the back and a round blunt termination, described by Brambilla as the "cultrum angli," the English knife (Fig. 10.9). It is under stood these shadowy analogues of the original sickle knives were believed to facilitate rapid guillotine amputations, especially under battlefield conditions.

As early as 1588, Clowes illustrated straight-edged folding or clasp knives for amputation, a century before the introduction of flap procedures; he offered no explanation for selecting this form of knife. Straight blades did not become evident again until 1772 when Perret advertised both concave- and straight-edged knives, indicating the latter were necessary for flap amputa-tions41; Brambilla offered a similar choice in 1782.42 Alanson, who published a remarkably successful series of amputations, advised in 1782:

"... operate with a lesser knife, than that used in common amputations; a catlin of modest size answers the purpose very well, is more handy, cuts with either edge as the turn of the hand directs, and acts more under the immediate view of the eye than a larger knife."43

Benjamin Bell also advised a strong straight-edged knife in 1788. By the 19th century, most amputation knives became essentially straight

Wwi Amputation Knife

Fig. 10.9. Selection of knives, 18th to 20th centuries. From top: concave blade with notch on back, the "cultrum angli"; long transfixion double-edged blade; convex blade of Liston type; slightly concave blade, the final form of the "cultrum angli" of the late 19th century; all-metal knife with convex blade of early 20th century; all-metal scalpel of mid-20th century, perfectly adequate for all amputations under full anaesthesia. (From Private Collection.)

Fig. 10.9. Selection of knives, 18th to 20th centuries. From top: concave blade with notch on back, the "cultrum angli"; long transfixion double-edged blade; convex blade of Liston type; slightly concave blade, the final form of the "cultrum angli" of the late 19th century; all-metal knife with convex blade of early 20th century; all-metal scalpel of mid-20th century, perfectly adequate for all amputations under full anaesthesia. (From Private Collection.)

edged but also much longer and slimmer, technically possible thanks to the availability of cast or crucible steel (see Fig. 10.9). This process produced a blade of uniform structure and hence stronger than earlier shear steel blades which had to be thick to resist breakage. At the same time the transfixion method of amputation was reintro-duced, a method benefiting from narrow blades inserted like a lance (see Figs. 8.2,8.4); these also furthered the technique of foot amputation by disarticulation through the complex of tarsal joints, as suggested by Lisfranc44 (Fig. 10.10). The length of lancelike knives varied to match the diameter of the limb or digit undergoing amputation with choices between 4 inches and 13 inches overall,the longest having a 9-inch blade for hip disarticulation (see Fig. 10.9). Often called Liston's knives, they were sharpened on the back of their tips to act as periosteal elevators and were narrow enough to pass between leg and forearm bones, rendering catlins obsolete.

With the establishment of thermal sterilisation techniques after 1890, all-metal knives became obligatory and, about the same time, knives longer than 11 inches overall disappeared from instrument catalogues. After World War I, surgeons performing nonurgent amputations found simple dissecting scalpels equally effective and less unwieldy in achieving healthy flaps for primary healing and functional stumps. This choice was facilitated by utilising disposable scalpel blades, from about 1920, to provide a choice of sizes and blade edges instantly sharp. However, for emergency amputations, especially under war conditions, long knives continued to be used for rapid guillotine procedures. At the end of the 20th century, British armed services still retained 10-inch Liston knives in emergency surgical kits, although their frequency of use is believed to be virtually nil.45 In practice, small interchangeable, disposable scalpel blades are employed, especially for the slow methodical surgery needed to

Tarsometatarsal Stump

Fig. 10.10. Operative diagram of Lisfranc's tarsometatarsal disarticulation of the foot with plantar flap; his long narrow knives were introduced, c. 1815, to facilitate dissection between the tightly arranged joints of the midfoot. (From Bernard C, Huette C, Precis Iconographique de Medecine Operatoire, Paris: Mequignon-Marvis, 1845, plate 24.71)

Fig. 10.10. Operative diagram of Lisfranc's tarsometatarsal disarticulation of the foot with plantar flap; his long narrow knives were introduced, c. 1815, to facilitate dissection between the tightly arranged joints of the midfoot. (From Bernard C, Huette C, Precis Iconographique de Medecine Operatoire, Paris: Mequignon-Marvis, 1845, plate 24.71)

preserve tissues after traumatic mangling of the foot and lower leg by destructive antipersonnel mines, as Coupland's experience demonstrated (see Fig. 1.7).46 Today, the long knives of the past, intended to shorten the patient's agony, epitomize grisly memorials to horrific and hasty dismembering before anaesthesia.

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