Who’s Who in Orthopedics the moment when Lister began tentatively to apply carbolic acid to compound fracture wounds, so that Macewen witnessed in Glasgow Royal Infirmary the birth of an antiseptic system that revolutionized surgery. For 4 years he watched its unfolding, part of which time he was Lister’s dresser.
Macewen graduated as Bachelor of Medicine and Master of Surgery in 1869, just after Lister had left Glasgow to succeed Syme as Regius Pro- fessor of Surgery at Edinburgh. After qualifying, he served as house surgeon and house physician before becoming for a short period superintend- ent of Glasgow Fever Hospital at Belvedere, an appointment notable for Macewen’s introduction of intubation of the larynx through the mouth instead of by tracheotomy or laryngotomy—a procedure that aroused interest at home and abroad whereby he anticipated O’Dwyer’s tubes.
In 1871 he was appointed district medical officer, a post that enabled him to gain experience in prac- tical surgery at the parish hospital in Parliamen- tary Road. Also the same year he became casualty surgeon to the Central Police Division of Glasgow, an office offering him rich experience in emergency surgery and enabling him to con- tribute many original papers to medical journals, one of which drew attention to a valuable diag- nostic sign of alcoholic coma. Macewen had noticed that the pupil of the eye in such a state remained contracted as long as the individual was undisturbed, but under mechanical stimulus such as passive movement of a limb, insufficient to arouse from somnolence, the pupil dilated only to contract again when the stimulus ceased. This sign is sometimes referred to as a “Macewen pupil.”
He proceeded to the degree of Doctor of Med- icine in 1872 and the following year was elected to the important office of dispensary surgeon to the Western Infirmary, from which he resigned within a year on appointment to a similar post at the Royal Infirmary. In 1874 he was elected into the Fellowship of the Faculty of Physicians and Surgeons of Glasgow. Macewen was now well set for a surgical career. He started consulting prac- tice at 73 Bath Street, in the center of Glasgow.
In 1876, when he was only 28 years old, he was promoted full surgeon with charge of wards.
From that date to 1892 marks the period of Macewen’s greatest productivity.
From the beginning, Macewen was attracted to the study of diseases and injuries of the skeletal system, which in turn compelled him to investi- 209
Sir William MACEWEN
1848–1924
Sir William Macewen was one of the most versa- tile of British surgeons. He watched the dawn of antisepsis, grasped its implications and eagerly played a leading part in the romantic expansion of surgery that followed. Many of his widespread contributions were of fundamental importance.
He was born on June 22, 1848, at a house called
“Woodend” on the Port Bannatyne side of Skeoch Wood, Isle of Bute. He was youngest of the 12 children of John and Janet (née Stevenson) Macewen. His father was a marine trader doing business in sailing ships plying from Rothesay, but family fortune ebbed and flowed like the tide.
At one time he was master of the “Breadalbane,”
a yacht that ferried Free Church Ministers to and from the islands of the West Coast of Scotland.
The boy, brought up in a seafaring atmosphere, felt the call of the sea all his life, returning to it whenever he could conveniently flee the city.
Later in life he bought a small estate on the coast of Bute, engaging in experimental farming and yachting.
John Macewen retired to Glasgow in 1860 and William attended the Collegiate School, Garnett Hill. He was a big, bright and lively boy, dis- playing more prowess in the gymnasium than the classroom; skilful with the single stick. Passing on in 1865 to the university, he arrived at a time when the professors in the faculty of medicine were of unusual distinction: there was Allan Thomson in anatomy, Buchanan in physiology, Gairdner in medicine and Lister in surgery. It was
gate the physiology and growth of bone, a pursuit he continued until his latter days. During the last century, many children in Glasgow, as in other industrial centers, suffered from the evils of overcrowding, lack of fresh air and faulty diet;
a social environment that had its reflex in the prevalence of rickets. Macewen became inter- ested in the disease and the pathology of its defor- mities; he found that the epiphysial cartilages of the long bones were much increased, the diaphy- ses softened and prone to bend or increase their natural curve under body weight. He shrewdly suspected some error of diet as the causal agent and recommended cod-liver oil, fresh air and sun- light for these young patients, remarking that poor children in the open Highlands escaped the malady.
When he contemplated the fixed deformities of severe knock-knee or bow-leg, he found that many of them were only capable of correction by operation. The procedure Macewen devised for their cure became the standard operation in surgery; it brought him early worldwide fame.
Macewen’s Osteotomy
Subcutaneous osteotomy was introduced by Langenbeck in 1852, when, by cutting the neck of the femur, he corrected a flexion ankylosis of the hip joint. The first subcutaneous osteotomy performed in England was by Stromeyer Little in 1865 at the Royal Orthopedic Hospital when, using a mallet and chisel, he corrected a knock- knee deformity. Richard von Volkmann of Halle, the most powerful advocate of Listerian prin- ciples in Germany, was the first to perform osteotomy under antiseptic precautions when, in 1874, he corrected flexion ankylosis of the knee joint. Macewen, after reading von Volkmann’s description of the operation, repeated the proce- dure in 1875 for a similar condition. Two years later he operated for knock-knee, removing some bone from the inner condyle. On May 10, 1878, he performed linear osteotomy for the first time for correction of genu valgum, using a mallet and chisel. The same year, in a paper in the Lancet entitled “Antiseptic Osteotomy,” he described this classical operation: “When the limb is extended a point is taken slightly above the level of the upper margin of the patella . . . a more fixed point would be the uppermost part of the external border of the patellar articular surface which can easily be felt
beneath the skin, a line drawn about half an inch above this would represent the incision in the bone, the chisel being inserted straight across the femur in that line. When the limb is extended a longitudinal incision is made in front of the tendon of the adductor magnus, the middle of the incision corresponding to the transverse line just spoken of. The length of the incision is slightly greater than the largest chisel to be used.” Over two-thirds of the thickness of the femur should be incised before fracture of the bone was attempted.
Occasionally a wedge of bone was removed.
Macewen soon found that the chisel bevelled on one side was unsuitable for the straight cutting of bone. He therefore devised an instrument, wedge-shaped at the cutting end, which a skilled craftsman made for him, meticulously tempering it for its purpose; of the instrument he said: “The borders of the blade are marked with half inches, the figures being extremely light. The figures point out the depth to which the instrument has penetrated and thus serve as a guide. They are finely polished, not for appearance, but, because the finer the surface the less opportunity will organic matter have of becoming adherent and afterwards decomposing.”
In making the osteotome an all-metal polished piece, Macewen departed from the customary bone-handled or wooden-handled surgical instru- ment, but it indicates that his mind was already moving towards aseptic surgery. The osteotome has so completely captivated the orthopedic surgeon as a bone-cutting instrument that the chisel is entirely neglected and its use forgotten.
Yet for the controlled shaving and molding of bone, as in sculpture, the chisel is incomparably the better tool; the osteotome was never intended by its originator for anything but straight fissuring.
Macewen in 1880 published his experiences in a small book, which became a classic, entitled On Osteotomy: with an enquiry into the aetiology and pathology of knock-knee, bow-leg and other osseous deformities of the lower limbs. It was translated into several languages. At the Interna- tional Congress of Medicine held at Copenhagen in 1884, he delivered an address on “Osteotomy for Genu Valgum.” He was able to report upon 1,800 osteotomies without septicemia or fatal wound complication. These results were received with acclamation and astonishment. They also helped to vindicate antiseptic principles in surgery for which Lister was pleading.
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Transplantation of Bone
Some of the best and most abiding work done by Macewen was in connection with the study of the growth and grafting of bone. John Hunter, after much patience, had wonderfully succeeded in transplanting a human tooth to a cock’s comb.
Some scanty success was gained by others in the transference of bone from one lower animal to another. But Macewen in 1879 was the first to transplant bone in a human being successfully. It was a great pioneer achievement for at once it opened up a new field in bone surgery. The work was described in a communication to the Royal Society in 1881 entitled “Observations concern- ing transplantation of bone. Illustrated by a case of inter-human osseous transplantation, whereby over two-thirds of the shaft of a humerus was restored.” This paper is a landmark in surgery; it received the enthusiastic commendation of Pro- fessor T.H. Huxley, secretary of the Society, who clearly saw the significance of successful human bone grafting.
Macewen carried out many successful bone transplantations after his first classic case. In 1903 he succeeded in restoring the transverse ramus of one half of the jaw by transplantation of bone in a girl 15 years of age who had the horizontal ramus of the lower jaw on one side extirpated for a diseased condition several years previously. He was particularly gratified with the result, for the girl had been restored to her natural good looks from what was a hideous saliva-pouring disfigurement.
The Growth of Bone
Macewen, by his extended researches in the phys- iology of bone, greatly advanced our knowledge of its growth. He proved that bone was a living tissue capable of transplantation; he believed the graft played a vital part during the process of incorporation. In his operative and experimental work he was impressed by the efficacy of multi- ple small grafts. They provided a greater surface than the massive graft, each forming a center of ossification that threw out osteoblasts from its whole periphery. Herein he displays a remarkable insight, for this seems to provide an explanation of the quickened osteogenetic power of small medullary bone grafts, which have found such favor in this last decade.
The growth of a long bone occurred at the dia- physis, for he believed that the cartilaginous growth disc belonged to the diaphysis and not to the epiphysis. He showed experimentally that the disc was only concerned with the growth of the shaft. He also believed, contrary to Duhamel and Ollier, that the periosteum had no osteogenetic power; it was purely a limiting membrane giving direction to bone growth but taking no active part in it. He excised bone shafts with the epiphyses in dogs but left the periosteum intact and found that there was no periosteal reproduction of the shafts. In another animal a flap of periosteum was lifted from a radius, detached at its lower end, brought around some muscle fibers and reat- tached to the intact periosteum, but the strip produced no bone. Again he removed part of a radial shaft and inserted a glass tube between the remaining segments to exclude the periosteum, and found that osseous tissue invaded the tubes from the severed ends. “The potency of the periosteum as a limiting membrane is seen when, in cases of fracture, it is torn up and stretched across the fractured surface of one of the frag- ments. It here forms an effective barrier against osseous union, the ossific formation being absolutely limited by the periosteum and fibrous union results.” On the other hand, stripping or tearing of periosteum in a fracture allows out- pouring of osteoblasts from broken surfaces into the gap between the bones and into the surround- ing tissues to form binding osseous deposits.
Bone deprived of periosteum will live and grow.
Growth and reproduction are an inherent property of the osseous elements themselves. The result of 30 years’ clinical and experimental investigation was in 1912 published in a book, The Growth of Bone: Observations in Osteogenesis. This was followed in 1921 by another work, The Growth and Shedding of the Antlers of the Deer. The casting of the antlers in early spring followed by the growth of a new pair provided him with the opportunity of closely studying rapid massive osteogenesis in nature.
Macewen was a dresser to Lister at Glasgow Royal Infirmary and saw the effect of the appli- cation of antiseptic principles in the treatment of compound fractures, the impressive lowered mor- tality and the hastened healing of wounds. From that time onwards he became an ardent supporter of Lister, employing in his practice antiseptic lotions and the carbolic spray for several years.
But by the middle 1880s he was already using
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Who’s Who in Orthopedics
instruments forged from a single piece of steel and was boiling his gauze. By 1890 he had installed in the hospital a steam sterilizer for dressings after the Schimmelbusch pattern; was boiling his instruments in a fish kettle, wearing a gown and had discarded the spray. He adopted an aseptic technique. Like Lister, he experimented a great deal with catgut and at last succeeded in making a completely reliable and absorbable suture material, which he continued to make to the end of his life.
Macewen was about the earliest pioneer of cerebrospinal surgery (neurosurgery). In 1879 he operated upon a patient for the relief of subdural hemorrhage with hemiplegia and the same year removed a brain tumor in a girl 14 years of age.
Both made a good recovery. Another great advance was his recognition that middle-ear disease was a common cause of cerebral abscess.
This induced him to design and perfect an opera- tion for mastoid disease. By 1893 he had gathered such a wide experience of this new branch of surgery that he was able to publish an authorita- tive work entitled Pyogenic Infective Disease of the Brain and Spinal Cord. This work was acclaimed all over the world and became a classic. The same year he published another work, Atlas on Head Sections, in the fine production of which he spared neither labor nor expense.
Macewen was also one of the first to open the chest and operate upon its contents. He had some experience in dealing with penetrating wounds of the thorax before he attempted a direct attack on the lungs. In 1895 he was asked to see a patient who was desperately ill, emaciated and toxic from extensive active tuberculous disease of the left lung with secondary pyogenic infection and abscess formation. He performed total lobectomy followed later by thoracoplasty. The man recov- ered his health completely and afterwards was actively engaged in earning his livelihood for many years.
In 1892 Macewen became Regius Professor of Surgery at Glasgow University, a post that entailed a good deal of teaching and transference of his surgical work to the Western Infirmary. He held the chair until his death. In 1895 he was elected a Fellow of the Royal Society. He was also elected an Honorary Fellow of the Royal Colleges of Surgeons of England and of Ireland;
several universities conferred honorary degrees upon him, and he received recognition from leading surgical societies abroad. Soon after the outbreak of war in 1914, he was commissioned as
Surgeon-General in Scotland, serving in the Navy with the rank of Surgeon Rear-Admiral. In addi- tion to the onerous duties of this post, he threw himself with great energy into organizing the Princess Louise Hospital for Limbless Soldiers and Sailors at Erskine, the counterpart in Scotland of Roehampton. In 1922 he was elected President of the British Medical Association on its visit to Glasgow in that year. In 1923 he was elected Pres- ident of the International Society of Surgeons and later the same year experienced something of a triumphal tour in New Zealand and Australia when he went out to the Australasian Medical Congress at Melbourne. He received the honor of Knighthood in 1902, was made a Companion of the Bath in 1917 and was appointed Surgeon to the King in Scotland in 1909. He died of pneu- monia on March 22, 1924. He married in 1873 Mary Watson, daughter of Hugh Allan of Crosshill, Glasgow, and had three sons and three daughters.
Macewen was a man of independent outlook, relying more on his own experience and observa- tion than on the accepted teaching of others. His personality was forceful; he was possessed of immense energy and driving power, prosecuting his work as a scientific surgeon with consuming zeal. His individualism and temperament pre- vented him from easily cooperating with others in a team; he was entirely happy working alone and work was the breath of his life. He was tall, had a commanding figure and was gifted with a clear, resonant voice, all of which enabled him to hold and often sway any audience he addressed. He was born at a fortunate hour and took full advan- tage of the opportunities that were presented, turning all his talents to such development of surgery as Lister had made possible. William Macewen’s contributions were so varied and of such a quality that he must be regarded as one of the greatest surgeons of all time.
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