1802 - 1871
"The Best Stone Surgeon in the North of Scotland"
William Keith (1802 – 1871) was a notable Scottish surgeon who was born in Aberdeen on 3 November 1802 to John Keith and Mary Donald. He was appointed as surgeon to Aberdeen Royal Infirmary in 1838.
According to Sir Henry Thompson, Keith was the best stone surgeon in the north of Scotland. William Keith was the first surgeon to carry out this new lithotrity in Scotland on 72-year-old Reverend Robert Forbes.
On 23 April 1833, Keith first passed a lithotrite - a Heurteloupe percussor - with the patient on the specially designed Heurteloupe bed to which the percussor was fixed to a vice and then hit with a hammer, thus breaking the stone within the bladder.
The operation took 15 minutes. Keith tried again on 1 May but the Reverend’s bladder couldn’t hold enough water. The procedure was carried out several more times, each operation lasting eight to ten minutes, with Keith crushing from 2-5 stone fragments. The last procedure was on 20 July, following which the patient was stone free. Keith operated on his second lithotrity patient on the 30 July.
William Keith and early audit
After his appointment to the Aberdeen Royal Infirmary, Keith carefully recorded and later published all his surgical stone cases. From 20 March 1838, he recorded every case “whatever the age, or the state of health, or of constitution might be” so his data would be “strictly impartial”.
In his first published series of 2352 patients, admitted to his 56 beds, 42 (1.78%, or as Keith put it, 1 in 54 ¾) were stone cases, only one of these was female. 23 underwent open lithotomy and 16 lithotrity. Three patients requested lithotrity but were not suitable and declined lithotomy, whilst one was not fit for either procedure. Of the 39 operated on, only three died (7.69%), two who had lithotomy (8.69%) and one lithotrity patient (6.25%). The mortality rate for stone surgery in England at that time was 13.9%, whilst in France, according to Dupuytren, it was 23.5%. In patients over the age of fifty years, 20% died in England and one third across France. Of the 19 cases between the ages of 50 and 78 operated on by Keith, only one (5.26%) died. Keith continued to publish his series of Aberdeen stone patients.
William Keith's enhanced recovery programme
William Keith was also a great advocate of preparing the patient fully prior to the major surgery of lithotomy. In young, fit patients, he was prepared to operate soon after admission but, in older, frail or unfit patients, he would spend many days trying to improve their fitness for surgery. On average, in his early stone series, 25 days were spent pre-operatively, 35.5 days were spent on average post-operatively, and his patients spent, on average, a total of 60 days in hospital. Frail, weak patients were given build-up diet, fat and florid patients a reducing diet. Treatment was given to calm down the bladder as much as possible.
We might now recognise this as part of a 19th century Enhanced Recovery Programme.
William Keith and early anaesthesia
The famous Scottish surgeon Sir Alexander Ogstan (1844–1929) was a pupil of Keith in 1862 and he gives, in his memoirs, an excellent picture of surgery in Aberdeen at that time. He states that Keith was the chief opponent of the introduction of chloroform anaesthesia into Aberdeen, and that his students called him, "Old Danger".
Ether anaesthesia was first used in 1846 and chloroform, always a more popular anaesthetic in Scotland, in 1847. According to Ogstan, Keith felt his stone patients did better without it and told them to “Put your trust for a minute in Dr Keith and God”. If this is true, in defence of Keith, the operation of lithotomy usually took two or three minutes without exposing the patient to the considerable dangers of early anaesthetics.
However, Keith had presented a series of cases to the Edinburgh Medico-Chirurgical Society in 1849 in support of chloroform and he is certainly recorded as administering a chloroform anaesthetic on 18 August 1865 to seven-year-old Eliza Shirriffs, whose right arm had been crushed by the wheel of a loaded cart. So, it would appear that Keith was not against chloroform, but perhaps he came to believe his speedy operation of lithotomy was safer without it. Certainly, by the time Ogstan was appointed to Aberdeen as junior surgeon in 1868, he said chloroform had been widely adopted.
William Keith and antisepsis
Ogstan also paints a vivid picture of surgery before antisepsis at Aberdeen in Keith’s time. The theatre had no washing facilities, the instruments lay uncovered on a shelf, the needles, lubricated and ready, pushed into a jar of rancid lard and the sand box to soak up the blood smelling of cat urine (the theatre at Aberdeen was apparently the favoured retiring room for the ward sister’s cats).
Unsurprisingly, all wounds festered and it was with great delight and excitement that Ogstan read Joseph Lister’s 1867 paper on antiseptic surgery. After visiting Lister in 1869, he brought the ideas back to Aberdeen. There was shock from the hospital mangers about the cost of the antiseptic carbolic putty (somewhat more expensive than the red zinc sulphate lotion and rags used before) and indifference plus hostility from the senior surgeons (although Ogstan does not name Keith specifically).
The arguments against antisepsis were not confined to Aberdeen and included the feeling that wound suppuration was a normal part of healing and was indeed necessary. It was supposed that hospital sepsis could be cured by better ventilation of the ward, and that wound infections and subsequent haemorrhage were due to the sloughing of the silk sutures used to secure bleeding vessels. Due to the latter, new techniques were devised such as torsion of the vessels without ligatures (promoted by James Syme (1799-1870)) or acupressure, a system using compressive metal wires (promoted by Syme’s rival James Young Simpson (1811–1870)). It is not clear where William Keith stood on the introduction of aseptic surgery but he did co-author a book with fellow surgeon Professor William Pirrie, on Acupressure in 1867.
William passed away on 5 February 1871, aged 68. The cause of his death is not entirely certain. However, records from the time state that he had suffered from “paralysis with effusion of blood upon the brain”, suggesting that he had suffered from a haemorrhagic stroke. It appears that William Keith may have suffered from a number of strokes towards the end of his life, as it was noted in his obituary that he took a trip to America “with a renewed sense of vigour” following either a stroke or TIA around one year before his death.
Keith’s last 13 stone cases and his careful summaries of the 45 patients who died in his series were published posthumously in the BMJ to ensure the lasting legacy of his complete and accurate audit of the stone cases in Aberdeen.
This Museum item was created with the help of Mr Kamran Raza, Specialist Registrar in Urology at Leicester General Hospital
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