Stumps Reattachment Management Complications Revision and Care for Limb Fitting

high inflammation, large suppuration, exfoliation of the bone, a tedious cure, and in the thigh particularly, retraction of the muscles, and a sugar-loaf stump, or an incurable wound, was generally the consequence of the common mode of amputation Amputation is the beginning not the end of treatment. Nonsurgical amputations by accidental dismemberment, by ritual, punitive and legal sanctions or those performed in extremis by the trapped victim are usually guillotine divisions of each tissue at...

Bone Cutting Forceps

Woodall advised dismembering nippers or cutters, a form of large pliers with transverse linear blades, for rapid amputation of fingers and toes. Scultetus suggested even larger cutters for amputations as high as wrist and ankle level, almost certainly needing two-handed strength to achieve this (see Fig. 5.1). Garengeot said cutting pliers were best for trimming diseased or fractured bone, and implied the power to amputate through sound flesh and bone was beyond even the strongest surgeon.54 In...

References

In Brothwell D, Sandison AT (editors) Diseases in Antiquity. Springfield Thomas, 1967 648. 2. Withington ET, Jones WHS. Hippocrates, vol 3. London Heinemann, 1938 361. 3. Watson-Jones R. Fractures and Joint Injuries, vol 1. Edinburgh Livingstone, 1943 129. 4. Ackerknecht EH. Primitive surgery. In Brothwell D, Sandison AT (editors) Diseases in Antiquity. Springfield Thomas, 1967 644. 5. Janssens PA. Medical views on prehistoric representations of human hands....

Summary Of An Artificial Limb

It is postulated that mankind's acceptance of amputees is necessary before elective surgical amputations are undertaken. Even so, some societies do not countenance elective surgery, usually for religious reasons, despite the presence of amputees of congenital, traumatic and punitive or legal origin sanctioned by the same societies. Hence, the wish of a patient to live with three limbs than to die with four, even with the acquiescence of a surgeon, carries no weight unless supported by their...

Ritual Punitive Legal and Iatrogenic Causes

In numerous tribes ritual mutilation is widely practised, and yet these tribes generally fail to develop medical amputation or other major surgery. As for gangrene in fractures which undergo greater compression than is opportune, and in other cases of tight bandaging, the intercepted parts come away in many cases More limbs have been lost by the use of tourniquets than have been saved. Removal of limbs or parts of limbs for ritual, punitive and legal reasons serves no medical purpose, yet this...

Knee Disarticulation and Supracondylar Low Femoral Amputation

Disarticulation at the knee received little recognition before Fabry's brief mention in the 17th century54 and Petit's more positive recommendation in the 18th century when he quoted a successful case history.55 Commenting on its negligence in the 19th century, Velpeau described 14 disarticulations of which 13 healed and most walked with a prosthesis.56 Eventually it was judged a rapid, atraumatic procedure for the very ill, associated with a bonus of minimal muscle and no bone damage, which...

Disarticulation at the Shoulder

This major operation developed in the 18th century, promoted by detailed anatomical knowledge, including initial compression of the subcla-vian artery against the first rib, and acceptance of ligatures for major arterial bleeding, achieving great popularity during the Napoleonic wars. According to Ledran, his father performed the first disarticulation before 1731, for a patient with caries involving the humeral neck, achieving a successful outcome.93 French surgeons promoted many methods of...

Femoral Above Knee Amputation

In contrast to the long debate on levels of below-knee amputation, the site of bone section for above-knee amputation has excited minimal discussion. Long recognised as carrying greater risks to life from haemorrhage and infection, which escalated as femoral division approached the hip, most authors amputated at the lowest point possible, in relation to the pathology, but have varied in their approach to techniques and the formation of flaps (Fig. 11.5). Circular, equal anteroposterior, or...

Gunpowder and Wound Dressings

Table Limbs

Although gunpowder reached Western Europe from China by the middle of the 13th century, no significant account of specific injuries caused by gunshot missiles is found before the work of Brunschwig, who illustrated an amputation saw in 149720 (Fig. 5.2). Shortly after, Gersdorff, another wound surgeon from Strasbourg, published further information on gunshot injuries and illustrated, for the first time, a surgical amputation scene (see Fig. 1.5). He also indicated that many contemporary...

Interpretations of Amputation by Society Patients and Surgeons

Medicine, magic and religion are abstract terms, each of which connotes a large group of social processes, processes by means of which mankind has come to regulate his behaviour towards the world around him. it is no small presumption to Dismember the Image of God. amputation should be performed only under circumstances when no other means will avail. The difficulties in determining these circumstances are often very great, and sufficient to perplex even the most experienced practitioner. From...

Foreign Body Contamination

When Was The Screw Invented

Pare and others soon discovered that gunshot wounds were uniquely sinister because, in addition to tissue damage, the depths of the wound were contaminated by in-driven missile material, clothing, armour and other foreign bodies, causing deep suppuration, unless extracted promptly.24 In addition, larger artillery pieces produced cannonballs, chain-shot, and exploding shells which literally tore body and limbs apart, and if not severing limbs completely (Fig. 5.3), rendering them candidates for...

Control of Haemorrhage and Infection

Charles Bell Wounds

Petit's introduction of the screw tourniquet in 171831 (Fig. 5.5) was a major step forward in controlling bleeding from limbs before, during and after surgery. Unhappily, the problem of how best to secure divided arteries remained, for cautery had major drawbacks, yet the alternative of vessel ligatures also had penalties, for unabsorbable silk and wool acted as unsterile foreign bodies to cause infection. One common solution offered was to leave ligature ends long, protruding from the wound,...

Frostbite and Immersion or Trench Feet

From mankind's beginning to the present day, freezing conditions or prolonged exposure to wet conditions compromise the circulation of unprotected feet and hands, leading to spasm and thrombosis of small vessels, damage to the soft tissues and local gangrene. Indeed,young children Fig. 2.2. a. Dry gangrene of foot and lower shin caused by vascular disease, showing early separation of necrotic tissues. (From Spence J, Lectures on Surgery Edinburgh Black, 1875, vol 1, fig. 12.49) b. Arm...

Natural Causes of Dismemberment

Even today chronic ergot poisoning is not unknown in Europe, and is characterised by a chronic gangrene of the extremities leading to loss of the fingers and toes. Despite current preventive measures and sophisticated medical care, natural causes of limb failure remain prevalent and often precipitate gangrene, terminating in operative amputation, a combination of events more evident in elderly populations. It is postulated, firstly, that most natural causes have a prehistoric origin and exerted...

Surgical Levels and Procedures Ad Hoc Amputations

Before the development of elective amputation in response to gunshot trauma, little evidence is available to indicate whether amputation levels were rationalised with a view to fitting a prosthesis. For traumatic loss by animal bite, military action or legal section, surgical treatment was unable to influence the level, as was the case of incomplete amputation, although surgery might improve skin cover. For well-established gangrene, spontaneous separation of the mortified segment was possible...

Venomous Bites and Stings

Although apocryphal tales suggest amputation was a remedy for poisonous bites and stings of the extremities, reports of such action are rare in medical literature. In 1000 a.d., Albucasis recommended amputation of a finger, a hand or even a whole forearm, and as high as the knee for the leg, depending on the site of the sting, for bites of marine scorpions, vipers or venomous spiders he offered no case observations.34 However, De La Motte recorded that a woman's middle finger, bitten by a...

Congenital Abnormality

Grossly deficient or deformed lower limbs are sometimes removed to provide suitable stumps for rapid mobilisation with a prosthesis rather than a series of reconstructive operations, extending over many years, which in any event may require a supporting orthosis. Thus, in the 19th century persistent club feet were sometimes amputated,6 although most are now corrected by reconstructive operations, leaving only occasional skeletally defective cases for inevitable ablation see Fig. 2.1 ....

Rehabilitation

In the sense of a positive programme to assist patients recovering from an injury or a major operation, rehabilitation is essentially a 20th-century concept, spurred on by World War I and its vast numbers of disabled who wished to resume employment despite residual physical defects. Before the 19th century little information is available although, as we have remarked, amputee cooks were often engaged on ships, however, as far as is known, without any rehabilitation programme. In 1885, Bigg gave...

Ankle Disarticulation and Tibiotalar Amputation

Removal of the foot by disarticulation through the ankle joint was undertaken sporadically before the 19th century. In 1796, Bell noted the projecting malleoli of the tibia and fibula made it difficult to obtain adequate skin cover and, even when healed, the long stump proved difficult to fit with a suitable prosthesis, and formal below-knee amputation was advised.31 Farabeuf maintained that Baudens rehabilitated ankle disarticulation in 1841 and, although he did not remove tibial articular...

Hindquarter Amputation

Complete ablation of the lower limb with attached hemipelvis, or most of the hemipelvis, was a heroic procedure before accurate monitoring systems and transfusion developed. According to Peltier, Girard performed it successfully in 1894,71 although it was Gordon-Taylor who perfected the procedure between 1922 and 1950, reporting 50 amputations at one hospital in 1952. The majority of these were for bone and soft tissue sarcomas of the hip region, with an immediate overall mortality of 22 ,...

Flap and Transfixion Amputations Resumed

Hip Disarticulation Amputation

Towards the end of the 17th century, when Yonge and Verduin described the formation of soft-tissue flaps, they anticipated below-knee stumps would heal more rapidly. In the early 18th century, Verduin's operative technique was supported enthusiastically by Garengeot with detailed illustrations including the transfixion technique demonstrated with his left thumb and fingers dangerously handling the blade point Fig. 7.7 . O'Halloran also practised a flap technique in order, he claimed, to avoid...

Traumatic Avulsion at the Shoulder and

An example of forequarter separation at the shoulder Fig. 3.4 was described by Cheselden in 1741 as follows Samuel Wood a miller, whose arm, with the scapula was torn off from his body, by a rope winding round it, the other end being fasten'd to the coggs of a mill. This hap-pen'd in the year 1737. The vessels being thus stretch'd bled very little, the arteries and nerves were drawn out of the arm the surgeon who was first called plac'd them within the wound, and dressed it superficially. The...

Auto Amputation in Extremis

Blue John Canyon Utah

According to recent media reports, this dramatic form of self-amputation is not as rare as may be imagined, although such cases always achieve headline exposure usually as grotesque mutilations, rendered difficult to imagine by most readers, despite the victims intention of preserving their lives when trapped, alone and denied help. Here, it must be emphasised we are discussing auto-amputation performed by the mentally stable, precipitated generally by an accident or by acute pain, and not...

Summary Vigo The Most Excelent Worckes

If surgical excision in the line of gangrenous demarcation hastened natural separation of mortified limbs and reduced suffering, it left a discharging wound which, at best, might heal only after several months to leave a fragile scar, prone to breakdown, and a stump often incapable of bearing an artificial limb. Later, more-aggressive removal of bone promoted closer apposition of skin margins which improved cicatrisation, yet these stumps remained fragile and often unsatisfactory for prosthetic...

Vascular Failure

Frostbite resulting from intense vessel spasm may cause gangrenous loss, especially of fingers and toes, even in the healthy. Until late in the 18th century, enlarging aneurysms, associated with injury by venesection when an artery was wounded or caused by syphilitic damage, were considered indications for amputation above the aneurysm. Increasingly significant today is vascular occlusion of sclerotic arteries affecting the elderly, especially in long-lived Western societies where it is the...

Puncture and Dissection Wounds

Occasionally minor puncture wounds, especially of the hand, produced serious infection, abscesses, general septicaemia or death, rarely avoided by amputation. Anatomy students in the dissection room were particularly vulnerable and several well-known surgeons were also victims. This problem was highlighted by a report on the deaths of 33 Parisian medical students between 1826 and 1846.29 Practitioners were infected particularly after performing postmortem examinations or operations, before...

Alternative Procedures to Amputation

After Waterloo, Larrey, reduced in rank to become Honorary Surgeon to the Hospital of the Old Guard, treated 12 successive compound fractures with local dressings of styrax benzoin , compresses of wine or vinegar and splinting the dressings were changed only once or twice during wound healing.49 Despite these successful conservative measures, avoiding amputation completely, these cases had no perceptible influence on wound care, despite Biencourt's claim in 1873 which concluded Larrey had...

Tarsometatarsal Disarticulation

Disarticulation of the accessible first metatarsal with its toe is pictured in Bell's Illustrations of the Great Operations of Surgery in 1821, but for intermediate metatarsals he found it a struggle to open the tarsometatarsal joints and advised bony division with a small trephine. In 1827, Scoutetten, employing his ovular or elliptical skin incision, a form of racquet, was able to remove intermediate metatarsals whole by dividing the basal ligaments with a fine bistoury.20 Total excision of...

Actual Heated Cautery

The application of heat by iron cauteries is noted by Hippocrates, principally as a method of counter-irritation against internal diseases, or to dry up ulcers and wet gangrene, to destroy tumours and to treat haemorrhoids he does not describe heat coagulation of bleeding vessels. Celsus in the 1st century a.d.15 and Archigenes in the 2nd century a.d.16 give early references to the application of heated cauteries to control haemorrhage this is mentioned again by Paul in the 7th century a.d.17...

Haemostatic Artery Forceps

Artificial Artery

After 1847, general anaesthesia liberated patients from the pain of amputation, affording additional operative time for surgeons to combat haemorrhage carefully, enabling small vessels as well as large to be located and ligated. Nonetheless, the threat of infected ligatures and secondary haemorrhage persisted until antiseptic and aseptic techniques were established. In the meantime, the concept of haemostatic closure of vessels evolved, following research by Jones proving all except major...

Surgical Stump Management

Approximation Stump

For surgical guillotine amputation,it was accepted practice to spiral a bandage around the stump, from the root of the limb towards the wound, to manipulate the skin and soft tissues over the bone end to promote healing, although this was often imperfect. Despite the slow healing of guillotine section, this form of amputation is still advised, especially as an emergency on the battlefield or, similarly, to save a trapped victim in a dangerous situation, although today the section is revised...

Primitive Weapon and Cold Steel Injuries

Native Primitive Tribal Wars

It can be supposed disagreements at a personal level and between various opposing groups ending in violence, have a long history, at least as far back as the Old Stone Age, although we have no clear prehistoric facts. Today's newspapers and televi sion programmes confirm such disputes are part and parcel of civilisation, which is not to say the participants concerned are aiming to achieve amputations, for other forms of maiming and mayhem are much easier to attain. Manually inflicted injuries...

Disarticulation at the Wrist and Forearm Amputation

Wrist Disarticulation

Wrist disarticulation was considered an acceptable procedure, especially for those who could not afford a prosthesis, as forearm rotation was preserved and, if the carpus was retained, it possessed some carrying capacity. In 1866, Gross expressed its virtues forcibly as follows Disarticulation at the wrist should always be preferred to amputation of the forearm whenever it is practicable, inasmuch as the mutilated extremity affords a much longer lever which afterwards may be used with great...

Massive Benign and Malignant Tumours

Before modern operative surgery, certain benign bony tumours proved so massive, painful and crippling that painful and slow radical amputation was acceptable to patients Fig. 2.5 .47 Today, control of infection may be decisive. Diabetic gangrene is a complex condition in which major occlusive arterial disease, lesions in small vessels, and sensory neuropathy may each play an important part.45 benign tumours would be excised before reaching intolerable proportions. Malignant tumours of the...

The Control of Infection

Autoclave Von Bergmann

Cleansing wounds with water, wine, balsams and other herbal lotions has a long history and is comprehensible with respect to fresh, dirty wounds which doubtless encouraged, long before any knowledge of the causes of putrefaction, instinctive distrust of obvious foreign material. Any effect of cleansing is uncertain for even macro-scopically clean wounds became infected, and was accepted by many as inevitable and, indeed, a necessary requirement for healing and recovery, leading to the...

Reported and Illustrated Prostheses

The Socket Artificial Limb

We have already commented on the apparent escape of Hegesistratus from imprisonment in the 5th century B.C. see Chapter 4 , who in the process lost or removed his chained and perhaps gangrenous foot which he replaced with a wooden substitute of unknown construction.1 If limb substitutes were introduced for prehistoric amputees, it seems probable most efforts were concentrated on crippling lower limb loss, as unilateral upper limb amputations were generally accommodated by opposite upper limb...

Elbow Disarticulation and Upper Arm Amputation

Pare undertook a disarticulation of the elbow, but according to Malgaigne this technique remained forgotten until the 19 th century when it was resuscitated by Dupuytren who claimed 10 or 12 successful disarticulations. However, Malgaigne noted the statistics of Salleron who had 5 deaths of 26 disarticulations.88 Gross strongly supported disarticulation as a safe easy operation which, generally, healed promptly, leaving a useful stump.89 Farabeuf's enthusiasm for this procedure was associated...

Misapplied Fracture Splints and Bandages

Tight Plaster Gangrene

Misuse of bandaging is one of the commonest reported complications of surgical management and must have an early history lost in the mists of time it was certainly known to Hippocrates, as a quotation at the head of this chapter confirms. In 1676, Wiseman provided several instances of this complication, stating Of Gangrenes from strict Bandage you may see several Instances in this Book the cause may be so easily removed by the loosening of the Bandage. I shall give you one Instance here of a...

Hand Saws

It is likely that the earliest saws for elective amputation were borrowed from butchers, carpenters and other craftsmen those pictured by Brun-schwig in 1497 see Fig. 5.2 and Gersdorff in 1517 see Fig. 1.5 certainly suggest affinity with butcher's hacksaws. However, Ryff's of 1545 has decorative features on the handle and also has a blade tension adjustment screw see Fig. 9.1 , suggesting manufacture specifically for surgery. Franco Fig. 6.2 , Pare Fig. 6.4 and Croce Fig. 6.3 illustrated even...

Instrumental Vessel Occlusion and Ligatures

Ligation of major vessels was advised by Celsus,15 Archigenes27 and Galen28 and, later, by Albucasis if cautery failed, although he expressed reservations about ligatures which, at that time, were not absorbable and often provoked secondary infection and haemorrhage.18 No further reference to ligation is observed before Par questioned heat cauterisation in the 16th century, suggesting liga-tion was more secure and humane. Par drew out vessels with crow's-beak forceps and tied double threads or...

Finger and Hand Amputations and Disarticulations

Conservation of surviving fingers and part hands must have been an objective within historic times, but little is recorded before Woodall illustrated curved chisels, a mallet and a pair of cutters or nippers removing a finger through a phalanx in 1639 see Fig. 9.2 and Scultetus illustrated similar instruments for removing a hand in 1653 see Fig. 5.1 . Such guillotine sections would have healed slowly and with sensitive terminal scars at best. In 1731, Garengeot criticised these methods of the...

Bandages and Tourniquets

Esmarch Tourniquet

Firm compressive bandaging of wounds probably stimulated the concept of controlling bleeding with bandages also termed ligatures above and below a wound or a site chosen for amputation. In the 2nd century a.d., Heliodorus advised compressing the vessels as far as possible with a bandage above the amputation site.5 Albucasis said tight ligatures bandages should be applied above and below the site, enabling an assistant to exert soft-tissue traction during surgery.6 In 1364, Guy de Chauliac also...

Circular Operative Techniques

Amputation Stumps

Early in the 18th century, an innovative amputation technique was introduced, the so-called circular or double incision, with the intention of promoting better stump healing Fig. 7.4 , although dispute surrounds its origin. Petit's posthumous surgical treatise, reprinted in 1783, claimed he was the first to incise the soft parts in two phases to gain adequate cover for the bone and sound healing12 Dieffenbach stated Petit introduced this double incision in 1718. On the other hand, Cheselden...

Crushing Injuries and Compound Fractures

Amputation was commonly indicated for crushing injuries often associated with vascular interruption and severe soft-tissue damage leading to gangrene, and for open fractures which more often than not became infected and might also have vascular problems and become gangrenous. Open wounds with tissue damage can be contaminated with tetanus and gas gangrene organisms, and before modern treatments, amputation was often a last desperate remedy. Today such limbs can be decompressed and drained,...

Response to Gunshot Trauma

Bowsaw Wordpress

Evolution towards more-active surgery owes much to the inventions of printing and gunpowder. Despite the appearance of cannon and presumed gunshot wounds at Crecy in 1346, the first known surgical notice of these injuries in Europe is 1460, by Pfolspeundt, when he refers to methods of removing gunpowder from wounds without offering further management on the specific problems of these new injuries21 thus, he does not mention amputation. It was another German wound surgeon, Brunschwig of...

Flap Amputations

Below Knee Amputation Instruments

A significant advance in technique was recorded by Yonge in 1679, in a letter added to his treatise in praise of turpentine as a wound dressing,46 entitled A new Way of Amputation, and a speedier convenient Method of curing Stumps, than that commonly practised. This method aimed to heal stumps in 3 weeks, instead of many more weeks or months, by constructing a long flap of skin and fascia to cover bone ends, to accommodate a drain, and to allow insertion of four or five sutures without tension....

Addendum

During final evaluation of this book, news emerged of a possible solution to infection at the junction between osseointegrated titanium implants and cutaneous tissues. By studying how the antlers of deer grow through overlying skin, it was observed the bone structure at the skin margin was porous into which the living dermis penetrated. For some osseointegrated amputees, the introduction of a metal flange perforated with small holes and in contact with the bone extremity where the titanium...

Midtarsal Disarticulation

Lisfranc Chopart Amputation

Disarticulation of the forefoot from the midfoot, through the talonavicular and calcaneocuboid joints, was performed by Chopart before 1792, preserving the talus in the ankle mortise and the calcaneum24 Fig. 11.1 . Originally performed with a long plantar flap, other approaches attempted equal dorsal and plantar flaps championed by Chelius, the medioplantar flap by Sedillot and the dorsal flap by Baudens.25 These operations are modified by preserving the navicular and or cuboid, often by...

Forequarter Amputation

Resection of the arm with attached scapula and clavicle was first performed by Surgeon Cuming in the Royal Naval Hospital at Antigua in 1808 on a sailor hit in the shoulder by a cannon ball he made a good recovery.100 Velpeau remarked that pull-off injuries of the arm see Chapter 3 and shoulder disarticulations combined with part of the scapula, followed by healing, may have encouraged such surgery. and by 1840 he was able to report several cases, mainly for malignant disease.101 Surprisingly,...

Punitive and Legal Amputations

Moche Ceramics

Differentiation between punitive and legal grounds for amputation is not always clear. Pure and simple punishment of prisoners of war, obvious when victorious opponents attack the defeated whether injured or not, as happened in the Dark Ages, may result in severed limbs Fig. 4.4 . However, many prisoners may be subjected to a form of legalised amputation based on the whim of a king or official, or on religious grounds, yet hardly determined by a fair trial supported by a legal representative....

Surviving Historical Prostheses

An Egyptian mummy buried in 1550-700 B.C. was found with a wooden toe substitute for an absent or amputated great toe, probably a ceremonial addition after death, for even today a working prosthesis at this level is unnecessary provided the victim retains functioning lesser toes and wears a firm-soled shoe, although the power of running would be impaired. Another mummy, of the Ptolemaic period, had been fitted with a symbolic artificial arm after a forearm amputation, said to ensure the victim...

Stump Preparation for a Prosthesis

Stump Crutch

Before the 20th century, very little is recorded on stump care with the object of moulding the tissues, strengthening stump muscle control, preventing contractures and certainly not immediate mobilisation with a temporary prosthesis or pylon. Understandably, before anaesthesia, antisepsis and asepsis, efforts were concentrated on preserving the amputee's life, threatened daily by serious hazards of haemorrhage and sepsis, perhaps for months after surgery, and on attempting to ensure a...

Society

Amputation Instruments

We have argued see Chapter 2 that various societies recognised and accepted nonsurgical amputees long before surgical amputation was considered or attempted, although not all societies have undertaken amputation, as Harley indicated when studying the Mano tribe in remote Liberia surgery is limited to bone-setting, blood-letting by shallow incisions, circumcision and scarification by tribal marks on the skin instruments are ordinary household utensils . . .4 among the Burmese the surgeon, even...

Patients

Above Knee Amputation

The victims of congenital deficiencies, acute accidental limb severance and of punitive, legal and many ritual amputations have no opportunity to express their wishes in the matter, in contrast to the majority of patients faced with less concrete situations where there is opportunity to debate their future with surgeons, relatives and friends. By contrast, victims who are trapped alone and without communication or aid have to make a choice for or against amputation without advice, relying only...

Developments in the 20th Century

1912 Aluminium Made Prosthetic

Most sockets were made of block leather tightened by lacing or carved in wood until Marcel Desoutter, an above-knee amputee as a result of an aeroplane accident, was stimulated to manufacture, in cooperation with his brother Charles, an aeronautical engineer, a lighter prosthesis of sheet aluminium in 1912, the first successful light metal prosthesis Fig. 13.13 .31 This design was followed by the Hanger aluminium limb for above-knee prostheses, leading to their almost universal adoption in...

Late Stump Complications and Revision

Boy Amputees Stumps

Following surgery, amputation stumps may prove suitable for provision of satisfactory prostheses, or may not, because of a variety of established conditions. Earlier authors were especially concerned about continued suppuration, failure to heal, sugar-loaf formation with bone protrusion, painful scars and overlong below-knee stumps which prevented efficient use of a kneeling peg-leg. Poor or failed healing necessitated permanent bandaging to protect fragile tissues from further damage and also...

The Control of Pain

Joseph Lister

The acceptance of ether inhalation anaesthesia in 1846 is a watershed in the history of medicine, assuring patients the balm of pain relief and providing surgeons more time to perform operations accurately. Its success spread like wildfire, on a worldwide scale, in contrast to the halting application of antisepsis and asepsis,equally important to the development of safe surgery, to be debated later. No attempt is made to detail the development of general anaesthesia, a major subject in its own...

Developments in the 21 Century

Limbimplantation

Prosthetic advances continue in various fields with energy-storing spring feet, multiaxial ankles, silicon sleeves with ratchet peg attachments, improved suction sockets, knee mechanisms controlled by computer, gas or hydraulic power, and electric battery-powered hands, wrists and elbows. In particular, the concept of attaching prostheses directly to the bone of the stump is receiving significant attention, especially for transfemoral and upper limb amputees, and ultimately perhaps for...

Subtalar Disarticulation and Transtalar Amputation

Syme Amputation

Hancock stated subtalar disarticulation was suggested by Lignerolles, first performed by Textor in 1841 and promulgated by Malgaine in 1846 Fig. 11.2 .28 Lateral, medial, posterolateral and posterior flaps were attempted to ameliorate results but retention of the talus proved troublesome, usually causing an equinus attitude and pressure of the talar head against foot prostheses. In 1864, Hancock excised the talar head and applied a sliver of cancellous calcaneum see Fig. 11.2, D , Fig. 11.2....

Gas Gangrene and Related Sepsis

Bacterial infections, including gas gangrene, are considered natural causes capable of precipitating amputation, although it is pertinent to recall these infections usually gain hold on tissues previously damaged, that is, by accidental or deliberate trauma, factors reviewed in more detail in subsequent chapters. Before Welch and Nuttall discovered the anaerobic bacterial origin of gas gangrene, identifying clostridial infection in 1892,28 it is believed this condition was not separated...

Compound Fractures and Severe Soft Tissue Wounds

Hip Disarticulation Amputation

Any accidental compound limb fracture may interrupt the distal arterial circulation and almost certainly contaminate the wound. Even without a comminuted fracture, the blood supply can be compromised, and the injured segment becomes pale or blue and cold and, in the absence of reconstruction of the disrupted vessels, gangrenous changes can be anticipated. Almost until the mid-20th century when arterial repair became commonly available, such limbs were subjected to amputation, either immediately...

Gangrene and Pre Renaissance Practice

Hand Gangrene

Remembering the word surgery is derived from the Greek for hand-work, it is probable that early surgical treatment for gangrenous limbs comprised the manual application of ointments, dressings and bandages to counter suppuration and unpleasant odour, in the hope mortified segments would detach themselves at the demarcation line with living tissues Fig. 6.1 and induce spontaneous healing. That such gangrenous separations supervened is confirmed in the Hippocratic writings of the 4th century B.C....

Limb Reattachment

Bilateral Amputation

Reattachment or replantation of traumatically severed limbs, developed over the last halfcentury, is most favourably performed with a clean division of structures, that is, a guillotine section causing minimal damage to the stump and detached limb. Perhaps the concept of reattachment crossed the minds of earlier practitioners long before the necessary technology evolved in Chapter 3 we noted a young boy who, in all innocence, urged the surgeon to put his leg back before confessing the accident...

Tibial Below Knee Amputation

Tibial Amputation Technique Myoplastic

Tibial or below-knee amputation was the first amputation to be estimated in terms of its stump length, the so-called site of election, to accommodate the only satisfactory prosthesis available, that is, a peg-leg on which the amputee kneeled if too much tibial length was conserved, this projected prominently and uncomfortably backwards see Figs. 2.4 and 12.1 . As noted earlier in this chapter, Pare determined the level of section accurately, recommending tibial division five fingers- breadths...

Controlling Haemorrhage

Charles Bell Amputation

In 1708, Dionis rejuvenated Par 's work to prevent lethal haemorrhage by vessel ligation and strongly endorsed this over red-hot cauteries and astringents, which he considered not only more painful but more uncertain. He recalled the two methods proposed by Par , either to isolate and pick up bleeding vessels accurately, for which Dionis advised the crow's-beak forceps, self-holding when closed by a spring or sliding ring, combined with a ligature beyond the forceps tip Fig. 7.1 or, Fig. 7.1....

Developments in the 19th Century

Left Syme Amputation

The Napoleonic wars resulted in a flood of amputees, proving a stimulus to more sophisticated and functional prostheses, at least for the wealthy. Thus,the Earl of Uxbridge,later Marquess of Anglesey, whose right leg was amputated above the knee at the Battle of Waterloo see Fig. 5.4 , was in a position to criticise his initial clapper leg and to commission an improvement from Potts, a leading London limb-maker, at his own expense. The resultant prosthesis evolved with knee and ankle movements...

Large and Small Knives

Wwi Amputation Knife

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...

Complete or Near Complete Transections

Amputee Boating Accident

Apart from obvious complete severance of a limb, it is proposed to include injuries where the tran-section is incomplete yet sufficiently destructive that surgical completion of the severance appears mandatory, to both patient and surgeon. Many crush injuries without an open wound may require immediate amputation, according to surgical opinion, yet this advice is resisted by the patient and relatives who ignore, or fail to understand, the significance of an interrupted blood supply until...

Ergot and Other Toxins

Ergot Poisoning

Epidemics of ergot poisoning are especially associated with the Middle Ages when ergot entered the diet as a contaminant of bread made of rye infested with the fungus Claviceps purpurea. Rye bread was a staple of the poorer classes, who were the main victims of what was called ignis sacer sacred fire , ignis infernalis infernal fire or St Anthony's fire Fig. 2.3 . Garrison stated that St. Martial, St. Genevieve and St. Benedict were also regarded as patron saints of ergotism.20 However,...

Ritual Amputations

Yubitsume Right Hand Fingers

Amputation of the fingers for ritual reasons is well known to us from South and North American Indians. The custom seems even more widespread in Africa and Oceania. In an excellent survey, Lagercrantz mentions no less than fourteen tribes in black Africa practising ritual finger mutilation. Soderstrom gives almost the same number for Oceania.4 The discovery of mutilated human hands outlined in paint on the walls of prehistoric caves in France and Spain suggested, initially, these were paintings...

Arteriosclerosis and Vascular Failure

Degenerative arterial disease leads to vessel narrowing, irregularity, ulceration, thrombus formation, aneurysmal weakness or combinations of these, its morbidity increasing with age. Any of these complications, especially in the lower limb, may precipitate acute failure of the arterial circulation leading to gangrene Fig. 2.1b and a high rate of amputation or, alternatively, a chronic state of ischaemia, characterised by painful claudication on activity, with only some 10 ending in...

Congenital Absence or Near Absence

Congenital Absence The Fibula

Absence of one or more fingers and toes at birth is not uncommon today, resulting in minimal functional disturbance, rarely needing reparative Fig. 2.1. Upper. Congenital absence of the fibula with short tibia, only two foot rays and a foot remnant in non-weight-bearing attitude. Treated at 1 year by amputation and prosthesis. Lower. Gangrenous second toe resulting from poor blood supply and local trauma. Treated by local amputation. From author's cases. Fig. 2.1. Upper. Congenital absence of...

Previous Work on Amputation History

Cross Amputation

Cumulatively, published accounts and studies of both nonsurgical and surgical amputations available in surgical literature, in the press and other media, and even general literature, and in many languages, are immeasurably extensive. Complete monographs are few, but most early surgical textbooks contain comprehensive chapters on amputation, some with a historical sketch, whilst many monographs and university theses are limited to particular aspects of this subject. Countless lesser...

Definitions and Usage

Surgical Amputation 1750

Amputatio, the Latin noun from the verb amputare, to cut off or cut away, derived from amb,about and putare,to prune or to lop,was little used in Roman texts and never, it is believed, to indicate a surgical amputation however, the verb amputare was employed with reference to cutting off the hands of criminals.3 Its deriviative in the English language, amputation, was not assigned to limb excision by surgeons much before the 17th century. One of the first to record the word in English, in a...