Gangrene and Pre Renaissance Practice

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.:

"... even when a portion of the thigh comes away, or of the arm, both bones and flesh, but less so in this case; and when the forearm and leg drop off, the patients readily recover."1

In the 2nd century a.d., Galen also counselled an expectant approach. Even in 1363, Guy de Chauliac confessed, after detailing instructions on how to amputate for gangrene either at joint level or through bone, that he himself never amputated but advised scarification of dead skin followed by the application of arsenic to the mortified area, ensuring healthy tissue was defended against arsenical attack with suitable dressings and, finally, firm bandaging in anticipation of the gangrenous tissues falling away. He concluded:

"... it is more honest for the physician that it falls spontaneously than to amputate it. For if one amputates there is always some rancour or regret, and thoughts by the patient that the limb might have survived."3

Indeed, until general anaesthesia was available, a conservative surgical approach was often favoured for gangrene; in 1824, Astley Cooper remarked:

"Nature adopts the very plan in her amputations which the surgeon pursues; the skin separates the longest, the muscles next, and then the tendons, together with the bones, which are left considerably shorter than the other parts... the bones become covered by skin, and the muscles surround the extremity of the bone."4

Other classical authors provided evidence of more-positive action with the removal of mortified digits and limbs at the demarcation line of dead and living tissues to counter unpleasant-smelling and death-threatening pathology. Celsus argued, in the 1st century A.D.,that amputation for gangrene involved very great risk either from loss of blood or syncope, adding:

"It does not matter, however, whether the remedy is safe enough, since it is the only one. Therefore between the sound and diseased part, the flesh is to be cut through with a scalpel down to the bone, but this must not be done actually over a joint, and it is better that some of the sound part should be cut away than that any of the diseased part should be left behind. When the bone is reached, the sound flesh is drawn back... and undercut... so that in that part also some bone is bared; the bone is then to be cut through with a small

Hand Gangrene

Fig. 6.1. Examples of gangrenous mortification. a. Hand after trauma and amputation through the forearm. b. Forearm with senile gangrene showing clear line of demarcation. c. Foot and ankle following cold exposure, showing final stages of sponta neous separation at the junction of dead and living tissues leading to amputation at a higher level. d. Part forefoot senile gangrene spreading to remainder of the foot. (From Spence J. Lectures in Surgery, vol 1. Edinburgh: Black, 1875: plate III.53)

Fig. 6.1. Examples of gangrenous mortification. a. Hand after trauma and amputation through the forearm. b. Forearm with senile gangrene showing clear line of demarcation. c. Foot and ankle following cold exposure, showing final stages of sponta neous separation at the junction of dead and living tissues leading to amputation at a higher level. d. Part forefoot senile gangrene spreading to remainder of the foot. (From Spence J. Lectures in Surgery, vol 1. Edinburgh: Black, 1875: plate III.53)

saw as near as possible to the sound flesh ... and the skin drawn over it;... The part where the skin has not been brought over is to be covered with lint;"5

In this passage on amputation, Celsus did not mention vessels , nerves or the use of tourniquet or hot iron cautery, and it is concluded any division of sound flesh was superficial and limited to skin. However, in a chapter on wounds and haemorrhage, Celsus wrote vessels were to be tied in severe cases, retaining cautery as a last resort.6 From this, Lister concluded Celsus would have adopted a similar approach to the haemorrhage of amputation,7 an opinion shared by Wangensteen and Wangensteen.8 When Celsus debated open fractures he stated those with flesh wounds involving the thigh and upper arm were grave injuries and observed:

"... they are liable to more severe inflammations and also have a greater tendency to gangrene. And in the case of the thigh-bone, if the fragments have separated from one another, amputation is generally necessary The upper arm is also liable to this danger, but is more easily preserved."9

Celsus continued with a description of conservative management for long bone fractures, including reduction, medicated dressings, splin-tage, diet and general measures, but provided no details of an amputation technique. This author concludes any compound fracture requiring amputation had a grave prognosis being unstable, contaminated and complicated by extensive muscular and vascular damage, amounting to virtual traumatic amputations which were completed by minimal soft tissue severance and saw trimming of prominent bone. For many centuries before this, it is probable crushed, trailing and useless limbs were "amputated" in an act of instinctive common sense, sometimes by the patient. A 20th-century example is recounted by Duhamel during the 1914-1918 War:

"Auger was an engineering sapper. A shell had fractured his thigh and mangled his foot. As the foot was still con nected by a skin remnant, Auger took his pocket-knife and cut the foot free, saying to his comrades who had looked on in horror; 'Well comrades! Nothing much has been lost. Get me out of here.'"10

The distressing spectacle of acute traumatic amputations, domestic, battlefield or punitive in origin, must have encouraged the spontaneous application of coverings and, ultimately, medicated dressings to protect raw stumps, either undertaken by victims or their family. And in the case of transected fingers and toes, acceptable healing often followed, leading to recovery of adequate function, but for amputations above the hand and foot healing was more doubtful, and the best possible outcome often a thin painful scar fixed to bone, with poor residual function. As already observed, cultural and legal amputations recorded within historic times, at least for victims whose survival was anticipated, had their open stumps dressed to encourage healing and survival, perhaps to ensure their stigmatisation as permanent outcasts of society.

Fragmentary evidence from Archigenes, at the beginning of the 2nd century a.d., is more specific than Celsus and heralds a radical approach to amputation. He wrote:

"The operator must then tie or sew the vessels which pass to the parts; in certain cases a ligature is to be applied round the whole limb, cold water is to be poured upon it, and some are to be bled ... a circular band is to be put round the limb, to draw up the skin with, and to direct the incision. After cutting down to the bone, the tendons are to be retracted, and the bone scraped and sawn. When much blood is discharged, red-hot irons are to be applied, and a double compress laid on .. ,"11

This description suggests major blood vessels were exposed and tied as a preliminary step, presumably above the level of section. At the same time, the "ligature" applied round the limb indicated a form of tourniquet whilst cold water encouraged vessel constriction; and yet ,he added, some were to be subjected to additional blood loss by venesection? Plainly, upward traction of the soft tissues assisted periosteal elevation and bone sawing, as high as possible above the soft tissue section, after which heated cautery was employed to bleeding points? If the details of these events and their sequence are not entirely clear, Archigenes confronted the dangers of haemorrhage rationally and offered several practical control measures which,for some commentators,is considered to be amputation through sound tissues above diseased or injured parts, even if he did not specify this operative technique unequivocally. Sadly, Archigenes added no explanatory case histories.

These instructions of Celsus and Archigenes were ignored or overlooked for many centuries, and it was not until the Renaissance before elective section, through sound tissues employing arterial ligature, returns to surgical texts. Hence, Paul of Aegineta in the 7th century a.d. limited comment to established gangrene, after the manner of Hippocrates and Galen, but was prepared to assist section at the line of demarcation. He wrote:

"Sometimes the extremities, such as a hand or foot, having mortified, so that the bones themselves are corrupted, either from having been fractured by some external means, or from having become putrid owing to some external cause, it is necessary to saw them off."12

Paul required heated cauteries and compresses to dry up discharge and to stimulate suppuration to obtain healing. From the 9th century a.d. onwards, Arabic authors also emphasised the application of cautery but, apart from Haly Abbas and Albucasis, were extremely conservative about amputation. Haly Abbas advised that less vascular tissues, such as the front of the leg and outer thigh, should be cut first, then bone sectioned before cutting the most vascular tissues last; this almost suggests the fashioning of soft tissue flaps to obtain easier stump cover, but this concept is not mentioned in his text.13 Albucasis in his treatise on surgery and instruments, about 1000 a.d., not only recommended amputation for congenitally superfluous fingers and for gangrene but also to forestall death from spreading poison caused by:

"... the bite of some dangerous reptile such as the marine scorpion, viper, or venemous spider, and so on. If the disease or bite be at the tip of the finger, cut off the finger, giving the disease no opportunity to spread to the rest of the hand. Similarly, if it attacks the hand, cut it off at the wrist... if it attacks the forearm, cut it off at the elbow through the joint itself. If the disease passes onward... by no means cut the shoulder, for that will be the death of the patient;"1*

Albucasis described similar instructions for bites of the lower limb, emphasising that patients diseased above the knee should resign themselves to death for amputation was perilous above knee joint level. He applied ligatures [bandages] around the limb, both above and below the amputation site, to tense the soft tissues during section which were then protected by linen dressings to avoid saw injury; haemorrhage was controlled with cautery and styptic powders; vessel ligatures are not mentioned. Albucasis recounted the history of a patient which fails to shed light on his amputation technique and, paradoxically, underlined his obstinate refusal to assist, despite the presence of gangrene and the patient's pleadings for dismemberment of his foot, and later a hand, which, it is suggested, the patient undertook himself15; one is left wondering if Albucasis actually performed major amputations. Earlier, in ancient India, the threat of ascending complications and death from infected thorns embedded in hands and feet was recognised by Sushruta Samhita, for which he recommended amputations as high as the wrist and ankle.15

Reporting on surgery in Anglo-Saxon Leech Books, Payne submitted amputation was limited to gangrene when the blackened part had no feeling. Nevertheless, one contemporary practitioner recognised that cutting through healthy tissues promoted easier healing, for it was recorded:

"If thou must carve or cut off an unhealthy limb from an unhealthy body, then carve thou not it on the edge of the healthy body; but much more cut or carve on the whole or living body; so thou shalt better and readier cure it."16

On gangrene in the 13th century, Theodoric advised similarly:

"... you should cut down to the healthy areas and leave no part of the putrid flesh, but take away some part of the live and healthy flesh. Indeed, you will effect a cure better and more quickly in this way."17

Theodoric also suggested pain relief during operative surgery by inhalation of a mixture of drugs, including opium, hyoscyamus, mandragora, and hemlock, by means of a soporific sponge. To revive the patient, another sponge soaked in vinegar was applied to the nostrils.18 Later commentators stated this early form of anaesthesia had dubious efficacy, indeed was akin to poison for, sadly, patients often slept well enough but failed to wake up; use of "spongia somnifera" is not recorded beyond the medieval period.19

Between 1130 and 1247, decrees of the Catholic Church, especially that of Tours (1163), "Ecclesia abhorret a sanguine" (The church rejects bleeding), discredited surgery and surgeons, and excluded the contributions of interested priests and university trainees, to leave matters in the hands of empirics and barbers; patient care deteriorated and barber-surgery became limited, it is said, to minor wound-surgery and venesection. Medieval neglect of surgical management was characterised by delayed introduction of artificial limbs, already known to Herodotus and Pliny, according to Garrison who wrote:

"In the Middle Ages, there was an enormous loss of limbs due to the mutilating effect of anaesthetic leprosy and of ergotism, to wounds from cannon-shot (introduced at Crecy in 1346) and half-pound shot (Perugia, 1364), and to gruesome judicial punishments. The stumps were commonly bound up in splints. Crutches and wooden legs, afterwards so familiar in the works of Callot and Brueghel (fig. 12.1), are mentioned in the 'Acta Sanctorum' and other medieval chronicles and frequently appear in the sacred frescoes of the time. The iron hand is first seen in a picture of 1400."20 (see Fig. 13.3).

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