A town like Tuttlingen

Surgery

I must thank you for your third invitation to me in four years to speak on surgical instruments. On the first occasion I spoke about surgical instrument standards and care, based partly on my own research into the ergonomics of hand function_ applied to surgery. Two years ago I described to you my study tour of five of the nine major surgical instrument makers in the United States. Today my subject is a three week study
tour last February to the United States and Germany, with the main emphasis of my visit on a week with the instrument makers of Tuttlingen, the world centre of surgical instrument manufacture.

The stimulus to this tour was an invitation to me from the Department of Head and Neck Surgery at the Mercy Hospital, Pittsburgh, to take part, as Visiting Professor, in a workshop on microvascular surgery attended by head and neck surgeons from across the United States and abroad. These surgeons, already skilled in using the operating microscope for middle ear surgery, wanted to take up the use of vascularised free flaps for covering defects after excision of large tumours. My role was to speak on two main areas, instruments for microsurgery, and ergonomics applied to microsurgery, comprising mainly the analysis of hand grip, tremor, lighting, and the processes of skill acquisition. However on arrival I found my work expanded to six lectures including one to the theatre staff, some demonstrations, and much discussion.

It seems that here in Australia we are now much more aware of instrument standards and management than many other parts of the world, as you will also see later. For those of you unfamiliar with this work, the papers to this meeting in earlier years have been published in full in the Australian Nurses Journal as well as surgical journals, and back copies may prove interesting to you. However, I will return to the subject of this workshop a little later, after describing two other places of interest for surgeons and for instruments.

San Francisco - the R.K. Davies microsurgical laboratory

My first stop in America was the R.K. Davies Microsurgical Laboratory, at San Francisco, stimulated by the world famous work of a plastic surgeon there called Harry Buncke. At this laboratory, surgeons come to train during courses lasting one or several weeks, and experimental work is carried out. I spent four days with the technical director, Mr. Zoltan Szabo, who is outstanding as an innovator and technician in this field.

Zoltan Szabo has concentrated on perfecting and simplifying microsurgical technique and instruments, and any of you particularly concerned with microsurgery would gain a lot from study of the technical manuals, published by Davis and Geck, to which he has contributed, as well as his laboratory layout. Simple practical points included sets of metal and plastic drawers for holding equipment, a watchmaker's lathe and small instrument workshop bench within the laboratory itself, and a watchmaker's demagnetiser. This is relatively cheap to buy, simple to use, and greatly appreciated when it stops fine needles sticking to instruments.
Sharpening the points of watchmakers' forceps has also been developed very nicely by Zoltan Szabo. This is important for picking up the filmy outer layer of small blood vessels cleanly and reliably. Briefly, the points are closed securely with a small collar of plastic tubing, and the tips ground flat till there is a blunt end about 1 mm wide. This blunt end is then sharpened with two 60 degree cuts on either side. The result is a very fine toothing effect which makes a great deal of difference to the surgical procedure to be carried out.
These few points from a minor aspect of the activity at this laboratory do have one lesson for other fields of surgery. Attention to detail and a deep interest in the work can lead to outstanding results. Of course over-all interest and dedication vary as much as resources from one hospital to another, with a corresponding difference in the quality of work that emerges.

Visit to the Ethicon Company Factory

From San Francisco I flew 3000 miles eastwards at the invitation of the Ethicon company to visit their factory at New Jersey. There I was not able to take photographs as many of the manufacturing processes are commercial secrets which have been expensive to develop, but I had the privilege of seeing these and the methods of quality testing for sutures and needles, as well as viewing and discussing experimental methods of measuring needle sharpness and improving this quality. Some of these techniques are quite similar to methods I have already described and published. In these, the force required to push a needle through tissue or material is measured, using equipment donated to me a couple of years earlier by
the Davis and Geck Company. It seems these studies have a significant future in helping improve surgical materials, as well as providing methods of comparison for us, as we work in hospitals and assess the difference in quality between good equipment and materials and bad, as well as allowing for the individual preferences of surgeons, which can even be measured.

Pittsburgh and a microsurgery workshop

I omit a description of my visit to the Wang Computer factory near Boston, my next stop being Pittsburgh and the Microsurgery Workshop at the Mercy Hospital. This is a large 700 bed hospital with a department of head and neck surgery serving a population of many million people in three adjoining states, and much of the work is the surgical removal of large tumours which require skin grafting. Recent developments by Australian microsurgeons including Ian Taylor and Bernard O'Brien in Melbourne have led to the use of vascularised skin flaps, which requires the joining of blood vessels in the skin graft to the local blood vessels.

It was this technique which was of special interest to the surgeons attending the workshop. One week is not long enough for surgeons to develop this skill, but it is sufficient to enable the setting up of practice facilities for microvascular surgery using rats, and to become familiar with the techniques and instruments. As at San Francisco, there was a very strong link between work in the operating theatre and in the animal laboratory. The senior theatre sister, a most remarkable person, would take part in practising and supervising microvascular anastomoses in the animal laboratory, help teach the registrars, personally supervise the selection and care of surgical instruments, and could carry out the actual surgery of the anastomosis as skilfully as many surgeons already experienced in this area.

I should mention the other visitor to the workshop who, with myself, was invited to give lectures, Dr. Sun Lee, who is widely regarded as the father of microvascular surgery. He is now based at San Diego and has many research projects and papers to his credit, as well as a number of surgeons he has trained in this specialty. His skill in this field can only be described as fantastic, in that he demonstrated a heart transplant in a rat carried out single-handed in less than one hour, using only the most simple of instruments and equipment. Of course it is a help if one has twenty years of experience in this field.

The vivid memory of a visit to the United States is that of experienced and expert senior people who are receptive to new ideas. More than in other parts of the world, including our own, Americans are eager to hear of innovations, and if they judge them worthwhile, to try them out and then incorporate
them in their own work. This is the story of penicillin, of television, jet engines, and most recently the new landing system for aeroplanes originated in this country. In my own much more modest field, that of applying ergonomics to surgical instruments and technique, the interest I found in this work was an enormous encouragement, with further invitations to return and speak in other parts of the country. Certainly there is much more money available for new developments and the use of existing technology, but one has the feeling that even with limited resources Americans would be continually striving to modify and improve their working methods.

Tuttlingen

From Pittsburgh I flew to Germany, then travelling by train to reach my destination there about which I should like to speak at greater length. Tuttlingen is a small city of 30,000, a little smaller than my home of Whyalla, but it is the very heart of the world's surgical instrument manufacture, and should be known to all surgeons and to anyone who has some connection with surgical instruments and their care.
Tuttlingen is a most beautiful town with both traditional and modern German building set among hills on the northern edge of the Black Forest, on the Danube river 30 kilometres below its origin. It is an hour or two by road from Lake Constance, the Swiss ski resorts, and seven famous wine-growing districts. In summer it is beautifully green and wooded, and in winter it is covered with a thick blanket of crisp snow. Even more important for our present purpose, it has about 450 surgical instrument factories, ranging from Aesculap with 1500 employees down to the keller-macher" or one-man workshop in the cellar or basement of his house.

Some history

Now Tuttlingen got started in surgical instrument manufacture is difficult to be sure of. in the middle ages it was known for leather-making and for cutlery, based on local farming and iron-ore. In 1803 the town was practically destroyed by fire, and its woollen industry had suffered from competition from textile machinery in the north of England. From here there are several versions as to what happened. One is that a man named Jetter travelled about Europe, visiting the instrument makers of Paris and other parts of Germany, and brought his new skills back to start a factory and teach them to others. He founded the firm of Jetter and Scheerer which later became the Aesculap company.

Another version describes how the new railways of the last century made Solingen, in the north of Germany, a more important centre for cutlery and scissors, and Tuttlingen had to seek a new industry. Yet another account tells of how Johann Storz began his knife-making business in Tuttlingen after four years of training in Paris. Certainly Aesculap was the giant in the area and guarded its position jealously, so that only this century did a number of its employees break away to form their own factories and companies.

Tuttlingen takes instrument making very seriously. Each year about 70 apprentices start their three year training at the local trades school, spending half the week in a factory. At the end of their three years they have to work a further five years before they can take an examination as a master
craftsman, which allows them to set up their own factory to make instruments for export. Many firms in other parts of the world buy instruments made at these factories and then put their own brand name on, while other companies buy partly finished instruments or the raw forgings to process themselves. At the same time the cost of wages has risen so high in Germany that some of the companies have set up subsidiary factories in Spain, Malaysia, and other countries where wages are lower, but where they must maintain their own strict standards and quality control.

I was lucky to arrive in Tuttlingen just one week after the annual Carnival, a week-long celebration of the coining end of winter, because during that time most of the factories are closed. The usually serious-minded and earnest people of Tuttlingen let their hair down during the Carnival, with pageants, feasting, and night-long parties. My host at the Hotel Schlack, Herr Reiner Schlack, was one of the small number of people in Tuttlingen to speak English, and no one could have been more kind or helpful. Any of the visitors to his hotel are from instrument companies abroad, and his hotel lobby has displays of instruments by two of the smaller companies. It is not all hard work, and most nights there is a cabaret in the large cocktail lounge, with a pop group playing till the small hours.

Factory tours - the Aesculap Company

My time was taken up with five days of visiting to twelve factories. On the Monday I began at Aesculap, spending the morning with design and production engineers there discussing instrument standards and care. My work on hand-grips and measurement of instrument stiffness was largely new, but seemed to appeal. In return, I learned much about their developments. Contrary to other advice, they are happy to use strongly alkaline solutions for the cleaning of stainless steel ware. (Recent research has shown that the acid hydrogen ions cause embrittlement of the iron atom aggregates with increased chance of fracture.) They are conscious of the labour, time and cost of instrument cleaning systems, and are developing integrated systems of washing machines and detergents through a national committee which includes other instrument makers.

During the afternoon I was taken on a factory tour. Some of their processes were commercial secrets which had been expensive to develop, and I was not able to take photographs within the factory, though later in the week I was able to see at least one of these processes in use by another company. Unlike the smaller companies, Aesculap had its own forge, which stamped out the rough shape of the instrument from a bar of stainless steel, as the first of several dozen steps in manufacture. Aesculap have a splendid wallchart of these stages available from their local distributors, which would be an interesting asset for instrument care departments in any hospital. Perhaps I should add that lunchtime was also delightful, with a short walk through the snow from the Aesculap factory to a restaurant just 500 years old, with delicious local cooking and wines.

Visit to a small factory

On the second day I spent the morning at a completely different factory employing just 3 people, that of the Rudolf Gimme company. Here the emphasis was on production runs of just one or two instruments, with batches of instruments being processed for each stage. At the time of my visit several dozen raw forgings were being milled, ground, and sharpened into biopsy punch forceps. The cutting edges of the two jaws
are aligned by hand, a true craftsman's job, the edges being shaped with a hardened cutting tool as if it was wood being cut rather than toughened stainless steel, and with occasional measured taps from a hammer. The sharpness of the jaws was checked on tissue paper moistened by the tongue and on hairs from the back of the hand. Later in the week I saw sharpness of microsurgical scissors tested on rubber dental dam, similar to glove rubber, and as I hope to explain, this is a particularly useful material on which to try scissors in general.

Even as simple a tool as a file was used with an expert touch both to shape instruments and to produce an accurate ridged surface on the metal which finally formed the teeth of the jaws. A work bench had vices whose jaws were padded with wood or plastic, and had little hardwood blocks on which to carry out hammering of instruments for a local build-up of metal. Within the same factory other stages of manufacture included grinding, polishing and heat treatment, both to soften the metal to allow it to be worked, and to harden it later on for sharpness and durability.

The Martin Group

That afternoon I visited the head office of the Martin company, which has seven separate factories in the group of which the largest has 250 workers. It was founded in 1923, and its head office is a three story building facing the Aesculap factory across open space half a mile away, rather like being watched over by a big brother. The top floor was a magnificent showroom and reception room which I was to visit again later in the week.

From here I was taken to the factory of Josef Heiss, now run by his son, a strong local tradition. The older man was delighted to meet an Australian visitor, with the help of an interpreter, and was happy to demonstrate the sharpening of a corneal knife. Oil was applied with a brush to the whetstone, and the final edge was so sharp that it slid through chamois leather on the test drum with no more force than the friction
of it weight on the palm of the hand. The skill to sharpen an instrument like this takes a background of generations of instrument making and a lifetime of experience. In a manner which I hoped was half-joking I tried to persuade Mr. Heiss as well as others I met that a subsidiary factory in Australia would have enormous success both for manufacture and for maintenance of surgical instruments, for Australia itself and neighbouring countries.

The Carl Teufel factory at Liptingen

On the Wednesday morning I was driven ten kilometres out of Tuttlingen to the beautiful village of Liptingen, of about 2000 people. Its industries included a dental instrument factory and a forge producing stampings for many of the smaller companies, but my visit was to the factory of Carl Teufel, now run by the son-in-law of the founder, Herr Armin Schweizer, a young man with profound dedication to his craft. Many eye surgeons would consider that he and Grieshaber in Switzerland are the world's best makers of microsurgical scissors. At his desk in the main office, he has a 40 dioptre microscope and two sharpening stones of red carborundum and a square Arkansas stone. Though his work is now that of a manager, he checks samples of instruments made in the factory personally to satisfy himself about their quality. Naturally the Carl Teufel brand is one of the more expensive to buy. He is interested in quality control of his products and is now developing a method of testing scissors for use by the surgeon far in advance of any other method now used. It is interesting that the figures he has arrived at are similar to ones I derived by other testing methods.

Like others in this industry, Armin Schweizer had trained and personally worked as an instrument maker for several years as a younger man, and had also travelled to work in American instrument factories. Typically his grandparents had been at school with the member of the Storz family who had started the American company by that name. Among his thirty workers or so, up to one-fifth might be apprentices; more than that would be too difficult to supervise for the quality of their work.

Other factories

On Thursday, the fourth day, I spent the morning visiting several of the 27 factories in the Medicon group. At the first of these, owned by the Bacher brothers, I saw the manufacture of flexible biopsy forceps for gastroscopes and of bone snips. The elder brother himself had a work-bench at which he carried out some of the hand-work, as well as managing the factory.

At the second factory the manager was yet another Herr Bacher, and he specialised in scissors for the Medicon group, with a large range of different designs and sizes. Even his wife was able to take part in the work of the factory with knowledge and skill.

That afternoon I visited an independent company called Christian Diener, a relatively small factory now run by the son of the founder, a very pleasant and hospitable man. His regret was that he had daughters and no son, but even though they were quite young, he expected that in time one of them might marry an instrument maker to carry on the tradition. Diener was the first maker to introduce tungsten carbide inserts for needleholders and forceps some twenty years ago, and today, like some of the other German makers, his instruments are sold to companies abroad which brand them with their own name. However, they can be recognised by the stamping of an 0 or a D on the inside of the handle near the joint, as well as by their excellent quality. He was not keen on ultrasonic cleaning for instruments because after several hours damage could occur to the pin of box joints which was made of a softer metal, the rest of the instrument having been hardened. As well as the usual range of forceps he had started making a Kirschner wire cutter which was proving popular with orthopaedic surgeons.

On the Friday morning I returned to the Martin office after a very happy dinner with their production executives the previous evening, and was taken over their largest factory. Here I saw many of the same processes as before, together with an ingenious oven for the automatic heat treatment of the finished instruments, as well as electropolishing and the manufacture of dental forceps. At another part of the same factory I saw the assembly of the latest model of surgical diathermy machine, a completely different branch of manufacture. Here the emphasis was on nodular construction and circuit boards to simplify construction and improve reliability and ease of servicing if this proved necessary. Here most of the work was electronic, along the same lines as making other electrical goods.

Later the same morning I fulfilled an invitation to speak to the executives of the Martin group. Few of them understood English, but an interpreter translated each sentence, and many of the slides spoke for themselves. It seems that throughout the world these days there is relatively little feedback of information from surgeons to instrument makers, and hardly any discussion at all about instrument standards. Through the interpreter questions and discussion flew thick and fast, and it is interesting to anticipate what changes there might be in the making or assessment of instruments following this visit.

My last afternoon in Tuttlingen was spent with an independent entrepreneur called Ulli Storz, who was able to fulfil my wish to visit some of the "keller-macher" or one-man factories situated in the basement of the family house. These men are hard workers starting early every morning and take few holidays. They are pre-occupied with their handwork, and the few I met could hardly be described as talkative and indeed
were quite shy. To a large extent they specialise in the making of just one or two instruments, but even so have engineering equipment costing many tens of thousands of dollars.

Was it worthwhile? YES!

I left Tuttlingen the next day, by train to Stuttgart, and then by Aerobus to Frankfurt, to catch the Lufthansa jumbo back to Sydney and then home, half a world away. In just five busy days I had had the enormous privilege of visiting the heart of the world's surgical instrument industry, the pleasure of meeting many dedicated craftsmen, and the delight of a storybook picture of southern Germany under snow.

Several results are following from this tour. First, I am able to tell you about Tuttlingen and its activities today. Next, it is easier to see possibilities and the problems in getting large quantities of instruments for hospitals, and to improve feedback from surgeons and others generally to the makers of instruments. Third, this forms part of a continuing study of instrument standards and care. Last, it is an inspiration to have seen craftsmen at their best, fulfilling themselves through the excellence of their work, and carrying on a tradition of many generations in their families and their towns. I am grateful to the instrument makers of Tuttlingen!

-o0o-

A town like Tuttlingen

Michael Patkin FRCS, FRACS
Honorary Surgeon, The Whyalla Hospital, South Australia

Address to the Central Sterilising Research Council, Gateway Inn, Adelaide, 18 Jun 1978

-o0o-