Feature Christmas 2012: Yesterday’s World

Surgical thimbles

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8447 (Published 17 December 2012) Cite this as: BMJ 2012;345:e8447
  1. William H Isbister, retired professor of surgery
  1. 1Hangstrasse 4, Feucht-Moosbach 90537, Germany
  1. Correspondence to: W H Isbister wisbister{at}t-online.de

William H Isbister discusses the usefulness of the humble thimble and its derivatives in a variety of surgical situations

As a child, Christmas meant good food, especially nuts and chocolate, lots of presents, and party games. We often played “hunt the thimble,” and sometimes the thimble was hidden behind my father’s pile of brown paper wrapped, unopened BMJs.

By 1975 I was married with three children. Our Christmases still involved fine food and presents but my wife had become a thimble collector and instead of hunting the thimble I was “gifting the thimble.” Over the next years, as I travelled to meetings and conferences, I had the opportunity to seek thimbles out from all over the world, and over time I too became interested in them. I have devoted my retirement to the hobby of thimble collecting and thought that, as a surgeon, close to Christmas, it might be interesting to review the use of the humble thimble in surgical practice.

Searching for thimbles

I searched the BMJ archive for the word “thimble” and searched on Google for “surgical thimble.” I excluded thimbles mentioned as foreign bodies in the oesophagus or trachea and non-surgical uses of thimbles. Of 113 articles identified in the BMJ archive, 11 detailed the use of surgical thimbles or thimble shaped instruments.

The many uses of thimbles

Although surgeons used thimbles for sewing in the past,1 with the advent of needle holders this is no longer the case. Thimbles or thimble derivatives, however, are used in other surgical situations.

Cardiac surgery

In the 1950s, a cardiac surgeon, William Glenn,2 described the use of a tailor’s thimble to dilate or split the mitral valve during open heart surgery.

In patients with severe mitral valve stenosis needing surgery, the cusps of the valve are sometimes tightly stuck together. They can be separated by pushing a finger through the valve to break down the adhesions or by sharp dissection, although this may result in valvular insufficiency postoperatively. Glenn described how a thimble, worn on the first finger of the operator’s hand, can facilitate and standardise this process. To prevent the thimble becoming stuck in or below the valve, tapes were looped around the thimble under the surgeon’s glove (fig 1). If it was difficult to extract the thimble or finger, an assistant pulled on the tapes. In his first series, Glenn reported 250 patients in whom this system had been used with good results.

Figure1

Fig 1 System used to dilate the heart valves during open heart surgery2

Ear, nose, and throat surgery

Finger protectors (fig 2) can prevent accidental biting injury during intraoral procedures. They might also have been used by staff trying to secure an oral airway during a fit in patients with epilepsy.

In 1906, Cresswell Baber developed metal thimbles for the left forefinger and thumb to facilitate making cotton wool mops for use in ear, nose, and throat surgery (fig 3).3 The thimbles were flattened and had several shallow and one deeper groove on the opposing surfaces, where the metal was dull rather than polished. According to Baber, “with a little practice mops of any size can be rapidly made.” The thimbles fitted on to a metal stand and could be boiled before use to reduce the risk of infection. The handles were for lifting them off the stand.

Figure3

Fig 3 Metal thimbles for the left forefinger and thumb to facilitate making cotton wool mops3

The Millard surgical hook retractor is used in fine work such as rhinoplasty. The thimble may be worn on the thumb (fig 4) or other finger. Small hooks have been attached to a tailor’s type open thimble (fig 5) to create a retractor; several versions are available.

Figure4

Fig 4 Millard surgical hook retractor

Figure5

Fig 5 Different types of retractor based on the tailor’s type open thimble

General surgery

In 1842 Velpeau lectured on his method of ligating varicose veins.4 The trunk of the vein was raised with the fingers and a pin passed below the ends of the fingernails and underneath the vein. The finger was protected from the pin by a thimble. A ligature was wound around the pin and drawn tight. This process was repeated for every dilated vein, so from eight to 15 pins may have been needed between the ankle and the knee. The ligatures and pins were not removed until the vein had become necrotic (around 12 days). If the eschar had not detached by this time it was removed. Velpeau claimed to have used this method in private and public practice and that only one patient died after the procedure.

In 1921 De C Wheeler, vice president of the Royal College of Surgeons, Ireland, reported that a thimble was “of great assistance in making a suprapubic opening for drainage in cases of septic peritonitis.”5 He said that “Before the primary wound is closed, the finger guarded with the thimble is introduced into the abdomen and seeks the interval between the recti muscles just above the pubes. With the thimble as a guide a stab wound is rapidly made, dividing all the tissues down to the peritoneum. The latter is pushed forward and is opened by a nick of a sharp pointed knife between the bars carrying the round knob. A drainage tube (Keith’s glass tube for preference) is fitted to the top of the thimble and is guided with great ease to the bottom of Douglas’s pouch (fig 6).” He adds: “If the unguarded finger is used as a guide, the peritoneum stretches itself over the rubber glove and it is troublesome to separate one from the other.” Surgeons must avoid cutting too boldly on an unguarded finger in the presence of septic peritonitis.

Figure6

Fig 6 Device for introducing a pelvic drain5 6

A similar technique has been used for draining axillary abscesses after mastectomy. In 1938 the same technique was described using an ordinary sewing thimble.7

Surgeons operating in deep cavities sometimes use the index finger of the non-dominant hand to guide the tip of a needle into the correct position. During this process the guiding finger may be injured. Accidental finger stick injuries can occur during normal suturing, as can scalpel cuts during dissection. Because of the risk of HIV infection and hepatitis, surgeons usually wear two pairs of gloves and some also wear a thimble on the index finger under the glove. A more complex type of thimble, which is worn outside of the glove and held in place with a malleable handle, has recently been described (fig 7).

Figure7

Fig 7 Thimble for protecting against finger injury

Thimbles modified with a “pushing rod” can be used to facilitate knot tying in deep cavities with not enough room to tie a normal knot. The first throw of the knot is tied outside the cavity and then slid down one of the suture ends until tight using a pusher. The next throw is similarly tied and then pushed down to tighten. Many other simple pushing devices are also in use, so the thimble pusher is not very popular.

Obstetrics

In 1875 Gordon described an “obstetric thimble” for rupturing the amniotic membranes.8 The thimble, which fits on the index finger, had a sharp point that curved over the free edge of the nail and which facilitated the rupture the membranes.

In obstructed labour with a dead fetus, it may be necessary to decapitate the fetus to facilitate vaginal delivery. A special thimble has been devised that allows the fetal neck to be encircled with a wire saw (Blond Haidler saw). The saw has ball ends and the thimble has a small opening in one side with a hole at its end (fig 8). The saw ball is inserted into this opening and the thimble is worn by the obstetrician. The thimble bearing finger is introduced into the vagina and passed around the fetal neck. The saw handles are attached after removal of the thimble.

Figure8

Fig 8 Thimble and wire saw for use in obstructed labour with a dead fetus

In 1903 a cocoa butter and cocaine thimble was used to rapidly dilate the cervical os during the first stage of labour.9

Ophthalmology

Ophthalmologists have used a thimble with an extension to facilitate the eversion of the upper eye lid (fig 9). This technique was not widely used and these thimbles are rare.

Figure9

Fig 9 Thimble with an extension to facilitate the eversion of the upper eye lid

Orthopaedic surgery

In the 1930s Nordenbos used fibular bone to stabilise femoral neck fractures in much the same way as Küntscher nails were used later.10 A thimble was placed over the end to prevent the graft from shattering as it was hammered into the drilled out track between the greater trochanter and the femoral head.

Thimble splints have been used to immobilise fractures that are confined to the distal phalanx.11 A plaster of Paris thimble enclosing the whole digit provides adequate immobilisation. Aluminium thimbles have also been used for this purpose (fig 10).

Plastic surgery

Breast plastic surgery often involves extensive finger dissection to separate breast tissue from surrounding structures, and a thimble has been devised to facilitate this process.

Urology

Thimbles have been used to fix the testes in the scrotum after surgery for undescended testis. Usually a loop suture is placed in tissue adjoining the testis and brought out through the scrotal skin. To prevent the tied suture from cutting through the scrotal skin, the suture is tied over something more substantial. Special buttons, pieces of rolled gauze, and even thimbles have been used.

Dental applications

In 1971, a pair of thimbles was patented that facilitated the use of dental floss (fig 11). The thimbles clamped the floss to the fingers by friction, thus avoiding the need to wrap the floss around the fingertips. Floss was held in a container and fed between the finger and thimble and out through an aperture in the top of the thimble.

Figure11

Fig 11 Pair of thimbles for facilitating the use of dental floss

Concluding remarks

Thimbles have been part of my life at Christmas for many years, but surprisingly I have never used a thimble in a surgical procedure myself. The BMJ archive is testimony to the many uses of thimbles in surgery over the years, and this article attempts to illustrate many of them.

Notes

Cite this as: BMJ 2012;345:e8447

Footnotes

  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References