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 communications concentrate on personal experience and case histories, or isolated aspects of the etiology, pathology and indications for or against amputation, and especially on operative techniques, instrumentation, postoperative management, problems of amputation stumps, the fitting and manufacture of prostheses, or the statistics of surgery in relation to operative procedures. Only a few authors mention the possibility of prehistoric limb loss before elective surgical methods developed.28 In particular, no comprehensive account of nonsurgical amputations and amputees has been traced, despite their positive contributions towards eventual surgical methods. In studying the background to earlier as well as recent attitudes and practice, many communications have been examined, although doubtless many sources have been overlooked, especially non-English accounts, for which the writer apologises. As a basis for this study, the following selection of works adopting a more-complete approach to amputation have proved important guides, both in their own right and by means of their bibliographical contribution towards further investigation. The first four items are monographs on surgical amputation which include introductory accounts of its history and evolution. The remaining works are comprehensive book sections, chapters or journal communications noting historical factors.
1. B.A. Watson's A Treatise on Amputations of the Extremities and their Complications of 1885 (Fig. 1.4) is an encyclopaedic volume having origin in the author's experience during the American Civil War of 1861-1866 and later in Jersey City where more railroads terminated than in any other American city; train wheels remain a significant cause of traumatic amputations.29 The first chapter, on the history of elective amputations, commences with conjectures from classical
AMPUTATIONS OF THE EXTREMITIES
SURGEON TO' THE JERSEY CITY CHABXTY HOSPITAL, TO ST. FRANCIS'S, AND TO CHRIST'S HOSPITAL AT JERSTffY CITY, N. J.; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION, PERMANENT MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, HEME EH OF THE N. Y. PATHOLOGICAL SOCIETY, 'MEMBER OF THE X. T. NEUROLOGICAL SOCIETY, MEMBER OF THE HEW JERSEY MICROSCOPICAL SOCIETY, ETC.
UPWARDS OF TV.'O HUNDRED AND F1FTV ENGRA VINGS, AJfB
TWO FULL-PAGE PLATES.
1012 WALNUT STREET.
Fig. 1.4. Title page of a comprehensive treatise on amputations, with a historical appraisal, by B.A. Watson, 1885.29
authors and finishes with details of antiseptic wound management (his book is dedicated to Joseph Lister); much historical material is incorporated into subsequent chapters. If Watson does not refer to ritual or punitive amputations, or to auto-amputation, he provides a detailed study of conditions affecting the results of amputation and on indications, instruments and equipment, and the control of haemorrhage and infection. Watson mentions recent work on germs but displays no knowledge of thermal sterilisation techniques, just starting in Europe. Only one chapter is devoted to operative techniques, well illustrated with 96 graphic engravings. Studies of postoperative wound care and stumps and artificial limbs are extensive. The work terminates with three chapters, virtually a separate treatise, on wound complications, mentioning haemorrhage, fever, pyaemia, septicaemia, erysipelas, gangrene and osteomyelitis at length, with only sparse references to amputation.
2. Leon Gillis' Amputations of 1954 reflects the experience of an orthopaedic surgeon attached to the principal limb-fitting centre in Britain, at Queen Mary's Hospital, Roehampton, where he advised many victims of World War II.30 Gillis commences with definitions and a brief history devoted mainly to developments of saws, knives, artery forceps, tourniquets, anaesthetics, surgical techniques and artificial limbs. His last chapter notes amputations in unusual circumstances, including brief consideration of ritual loss and auto-amputation. Other chapters are devoted to indications, standard and special amputations, and to congenital anomalies and short limbs in children requiring prostheses, to phantom limbs and to after-care. Six chapters consider the problem of painful stumps and their management, a topic which Gillis studied in detail, doubtless due to experience at this special hospital, perhaps the most profitable element of the book. Some reamputated specimens removed by Gillis were presented to the Royal College of Surgeons of England and are now displayed in the Museum of Anatomy and Pathology (see Fig. 12.5). Gillis also wrote a further volume on artificial limbs, to be referred to later.31
3. Miroslaw Vitali, Kingsley Robinson, and Brian Andrews, et al., who wrote Amputations and Prostheses (second edition, 1986), aimed at sur geons, emphasised that amputation and prosthet-ics were not separate entities and postulated union of the stump and prosthesis as a single locomotor unit.32 An introductory historical survey stated Neolithic man survived amputation but found no evidence in the Bible or Egyptian papyri related to amputation, considering "artificial limbs" found with mummies were postmortem additions to replace congenital or traumatic deficiencies. They believed Hippocrates performed dismemberment for gangrene but considered gunshot injuries were the stimulus to elective amputations. The significance of Petit's vital screw tourniquet is understated and Lister's revolutionary contribution is not mentioned. However, a longer section on prosthetic evolution is very helpful and is amplified by a chapter on statistics and trends. Reference is made to other sections of the book later.
4. George Murdoch and A. Bennet Wilson edited Amputation: Surgical Practice and Patient Management in 1996 to reflect the views of some 35 authors worldwide, focussed firmly on the surgeon who is advised not to amputate without an understanding of the biomechanical and prosthetic factors involved.33 A brief introductory chapter mentions a few historical features including the fearsome immersion of stumps in boiling oil. Tourniquets and anaesthesia are not included but recent developments are prominent; Wilson has written much more fully on these, in a symposium essay "The modern history of amputation surgery and artificial limbs."34
5. Samuel Cooper's A Dictionary of Practical Surgery was first published in 1809 and subsequently in six editions; those of 1822 (fourth) and especially of 1838 (seventh)35 have been consulted, the latter amplified by new material particularly from American practice. Cooper's amputation account is extremely detailed and his bibliography extensive. At the outset he emphasised: "... it is not enough for a surgeon to know how to operate; he must also know when to do it," and then listed conditions which might require solution by amputation. These situations were compound fractures, especially caused by gunshot violence and crushing, lacerated wounds with a damaged arterial supply, limbs partly carried away by a cannonball, mortification, diseased joints, large bony exos-toses and bone necrosis, and cancerous diseases and tumours, a choice somewhat skewed by his military experience in the Waterloo campaign. A detailed history of surgical amputation follows, commencing with the Hippocratic era. Significantly, Cooper believed nature was a guide in confirming, long before written accounts, that gangrenous limbs sometimes separated spontaneously with survival of the patient and hence encouraged early practitioners to resect at the dead and living junctions, carefully avoiding the blood vessels. However, he agreed Celsus and Archigenes performed sectioning through sound flesh for the first time, although he doubted they fully understood how to control haemorrhage; he found Galen and Arabic authors much less adventurous. Noting the introduction of gunshot injuries in the 14th century, Cooper considered an effective surgical response to their destructive damage was delayed until 1517 when Gersdorff demonstrated elective amputation above injury level (Fig. 1.5), combined with skin conservation to secure sound stump healing, as well as to save life. The subsequent history of elective amputation is detailed, ending with the works of Velpeau (1832), Liston (1832), Dupuytren (1834) and Malgaigne (1834); this period is surveyed in later chapters.
6. Alfred Velpeau's Nouveaux Eléments de Médecine Opératoire, first published in 1832, provides a brief historical outline36 with similar conclusions to Cooper in 1822 and a detailed analysis of indications meriting amputation. These indications were partially divided limbs or fingers, established gangrene including traumatic and hospital gangrene, frostbite and severe burns, open fractures, especially due to gunshot, severe bone infection, carious joints, cancer and sarcoma, severe leg ulceration, supernumerary fingers and toes, and rarely exostoses, severe joint contractures, tetanus and hydrophobia. Velpeau mentioned contraindications briefly and outlined his general operative organisation, instrumentation, types of procedure, dressings and complications, before describing specific levels of amputation in great detail37; these are considered in subsequent chapters of this volume.
7. Thomas Longmore's pamphlet Amputation: an Historical Sketch of 1875 is historically sketchy although generally accurate. He emphasised early lack of knowledge to control bleeding, the importance of Petit's tourniquet, and recognised the
significance of hygiene and Lister's antiseptic school. However, as a military surgeon (he was Medical Director of the British Army) he considered antiseptic management very difficult in time of war. He then commented briefly on operative developments.38
8. Joseph Lister's (Fig. 1.6) amputation chapter in Holmes & Hulke's A System of Surgery, edition of 1883, commenced:
"Amputation is often regarded as an opprobium of the healing art. But while the human frame remains liable to derangement from accident or disease, the removal of hopelessly disordered parts, in the way most conducive to the safety and future comfort of the sufferer, must ever claim the best attention of the surgeon." and he added, "It is instructive to trace the history of the improvement of this department of surgery"69
Lister's historical survey forms a major portion of his article. He debated Celsus's views and concluded he advised amputation through sound tissues with ligature of the vessels, a scheme thereafter overlooked, due to Galen's timid teaching, until Pare's reintroduction in the 16th century. Even so, Lister believed subsequent progress was slow until efficient bleeding control emerged with Morel's tourniquet and particularly Petit's screw tourniquet in 1708. After describing instrumentation in detail, he concluded with relatively brief accounts of recommended amputation procedures. Curiously he did not mention his own revolutionary antiseptic system, published in 1867, specifically to reduce the mortality of amputation after compound fractures.40
9. Ernst Gurlt's Geschichte der Chirurgie, volume 3 of 1898, contains a section entirely devoted to the history of amputation from classical times to the end of the 16th century.41 Within this restricted period, Gurlt noted the contributions of surgeons mentioned earlier, and many others, with particular emphasis on their instrumentation and equipment which are illustrated comprehensively; he devoted a long paragraph to limb prostheses.
10. L.-H. Farabeuf concentrated most of his Précis de Manuel Opératoire of 1885 (Masson) to amputation, providing an extremely detailed account of operative developments in the 19th century illustrated with 414 figures mostly drawn by himself.42 Whilst not aiming to write amputation history, he cannot be ignored for his exhaustive review of procedures in the 19th century,most of which were overlooked by others, and are now forgotten; reference to these appears later. A similar view applies to P. Huard's Etudes sur les Amputations et Desarticulations des Membres of 1940, which concentrates on surgical techniques, reviewing progress through the nineteenth and early twentieth centuries, principally from a French viewpoint. Huard also gives prominence to M. Duval, who in 1849 counselled precise methodical amputations, then possible under anaesthesia, when colleagues still operated in reflex haste, as if the patient remained conscious, with poor results.42 As late as 1960, the author, then an apprentice surgeon, was reprimanded for lack of speed during an amputation; today a meticulous approach is demanded.
11. Owen Wangensteen, Jacqueline Smith and Sarah Wangensteen's substantial communication, "Some highlights in the history of amputation reflecting lessons in wound healing," of 1967, details the preanaesthetic and preantiseptic challenges of haemorrhage control and especially wound care based on historical accounts of amputation management.43 Particular attention is paid to the evolution of bleeding control with cautery, caustics, vessel ligatures and tourniquets, to wound care by primary or delayed primary suture or by open methods and to applications including wine, turpentine, water, silver nitrate and finally carbolic acid. American experience is emphasised, including the bitter schism over Lis-terian antisepsis summed up in the words of B.A. Watson as late as 1883:
"The great objections come not from those who have tried Listerism, but from those who are willing to raise their hands and thank God that they have neither witnessed its application nor used it."u
The authors quote experience from the two World Wars and the Korean Wars which reinstated open circular amputations and primary suture as mandatory for gunshot wounds, confirming former preantiseptic practices. They concluded:
"Historical appraisals of accomplishment in a technical discipline may be heightened when complemented by an assessment including the realistic and chastening lessons of experience that only active participants in such disciplines can provide."15
12. Peter Alden and William Shaw's paper "The evolution of the surgical management of severe lower extremity trauma" of 198646 postulated: "The evolution of extremity trauma surgery reflected the development of surgery as a speciality," without indicating why the upper extremity was ignored in subsequent discussions. As specialists in plastic surgery, they argue that from routine high amputations emerged regional amputations which conserved length, followed by flap reconstructions, wound debridements, vascular repairs, limb replantations, and the current concept of reconstruction. Their detailed historical appraisal of lower limb wound care is divided into the ancient era, the Middle Ages, Pare and the beginning of modern trauma surgery, later refinements in amputation, the effect of anaesthesia, the American Civil War, antisepsis, both Great Wars and recent advances. In particular,Aldea and Shaw outline the gradual rise of reconstructive techniques which have reduced many indications for amputation. They also emphasised the surgeon's predicament in counselling prolonged complex surgery when this might not surpass the functional results of immediate amputation and prosthetic fitting. Finally, they remind us of the words of Samuel Gross voicing the ancient dilemma of, if and when to operate, in 1862:
"The cases which may reasonably require and those which may not require interference with the knife are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious apprehension ... that, while the surgeon endeavours to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have been promptly amputated."47
13. Kingsley Robinson's comprehensive chapter in "The Evolution of Orthopaedic Surgery" of 2002, edited by Leslie Klenerman, traced "Amputation surgery from 1800 to the present."48 Attention is drawn to the dominance of immediate amputation in military practice during the
Napoleonic period and the development of flap procedures in the 19th century. Anaesthesia, antisepsis and accurate haemostasis are recognised factors improving primary stump healing, although the role of asepsis is excluded. The evolution of standard amputation levels is described, followed by that of prostheses, an important section on immediate fitting of pros-theses and on recent advances, stump pain and secondary surgery, ending with a discussion of limb reimplantation.
Although these studies are important, especially to the development of elective amputation, none considers in any detail the long presurgical period contributing towards ultimate yet relatively recent surgical action and, also, they overlook many advances in general surgery, derived directly from pioneering amputation techniques. Additional historical sources are indicated in the reference list.49
To comprehend more fully the eventual development of surgical amputation, examination of natural, accidental, ritual, punitive and legal dismemberment is rewarding, not only for technical reasons but for social implications, vital to acceptance of a mutilating procedure performed under horrendous circumstances, before the introduction of general anaesthesia. In addition, in various societies ancient beliefs, taboos and religious convictions were important influences determining whether elective amputation was accepted or, as in the case of Islamic teaching, rejected or accepted with difficulty. The circumstances of acceptance was also significant; for example, during the 16th and 17th centuries in Western Europe,both patient and surgeon were encouraged to go to mass, or to pray earnestly before operation: "For it is no small presumption to Dismember the Image of God."50 At the same time, the surgeon was constrained to perform amputation in the morning and to avoid the day of the full moon! If not always expressed, the fears of cruel operative pain, of death from bleeding or from subsequent sepsis, and anxieties about the quality of the stump to bear weight, and future rehabilitation weighed heavily in the calculations of both patient and surgeon who was encouraged to transmit these to relatives, as Clowes advised his surgical readers in 1596:
"... have ministered unto them some good exhortation, concerning patience in adversitie, to be made by the minister or preacher. And you shall likewise advertise the friends of the patient, that the worke which you go about is great, and not without danger of death."51
Even when elective amputation was accepted as a branch of surgical management for gunshot wounds, it continued to pose many technical problems which, by degrees, stimulated remedies. Hence, the major drawbacks of pain and blood loss, followed by stump sepsis and failed healing, generated many attempts to counter them. Stump infection or the threat of infection provoked a torrent of mostly unhelpful applications and dressings, until Lister's antiseptic prophylaxis with phenol transformed the management of compound fractures, hitherto a source of dangerous infection with or without amputation. His publications on this method, in 1867,heralded the birth of safe elective surgery which, eventually, revolutionised all surgical practices permanently.
Before the assistance of anaesthesia, a persistent search for more-effective instruments, aimed to speed amputation, resulted in significant advances in their design aided by new materials and sophisticated manufacture, frequently with benefit to other surgical operations. In addition to improvements in the efficiency of arterial forceps and tourniquets, blades became slimmer and straighter, hacksaws and tenon saws became smaller or, in some instances, were replaced by narrow or chain saws, and methods of vessel ligature and skin suture were refined employing tenacula and needle-holders.
Not all surgeons and few patients were comfortable with radical solutions and by the 18th century, a more-conservative approach to gunshot fractures became evident, particularly following the monograph of Bilguer translated as A Dissertation on the Inutility of the Amputation of Limbs in 176452 (see Fig. 1.3). Eventually, alternatives to amputation were found including joint excision for disease, ligature for expanding aneurysms, decompression of bone abscesses, improved fracture splintage, antiseptic and aseptic wound care, and the applications of X-ray diagnosis, arterial reconstruction, blood transfusion, open debride-ment, antibiotic therapy, bone tumour excision and prosthetic replacement, and intensive emergency care, including evacuation by helicopter. The evolution of alternative procedures continues to the present and forms a section in Chapter 7. Unfortunately, such measures have their limitations, especially for injuries caused by ever more sophisticated weaponry of increasing velocity and destructiveness, especially the indiscriminate dispersal of antipersonnel mines, deliberately manufactured to maim by irremediable destruction of the feet, rendering surgical amputation at a higher level the only option, when patients accept this advice. Such acceptance depends as much on patients as the society in which they live, for society's approval has always been desirable if surgeons are to advise and patients accept dismemberment with confidence. Yet some societies have been and remain opposed to such surgery in
principle, regarding loss not just as a mutilation but an assault on the completeness and sanctity of the physical corpus. Coupland, who has recent experience of gunshot and mine injuries in Red Cross hospitals (Fig. 1.7), confirmed the persistence of this cultural attitude in 1992, stating:
"The patients may prefer a useless limb to a functioning prosthesis, whilst many others may prefer to die from their wounds rather than suffer amputation. Such views must be accepted and accommodated in decision making."53
This enigma is addressed in Chapter 9, where the concepts of society and the undeniable fears of patients as well as the numerous concerns of surgeons are examined in more detail.
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