A History of Limb Amputation

191 Pages·2007·11.442 MB·English

by  John Kirkup MD, MA, FRCS (auth.)

A History of Limb Amputation
Ship’s cook with peg-leg after below the knee amputation.Coloured engraving after drawing by Thomas Rowlandson,c.1789.(© National
Maritine Museum,London,UK)
John Kirkup
A History of Limb
Amputation
John Kirkup,MD,MA,FRCS,Dip Hist Med
Former Consultant Orthopaedic Surgeon,Bath Clinical Area,UK; Honorary Curator,Historical
Instrument Collection,Royal College ofSurgeons ofEngland,London,UK;
Lecturer in Surgical History,Society ofApothecaries,London,UK
British Library Cataloguing in Publication Data
Kirkup,John
A history oflimb amputation
1. Amputation – History 2. Medicine – History 3. Wounds and injuries – Treatment – History
I. Title
617.5′8′059′09
ISBN-13:978-1-84628-443-4
ISBN-10:1-84628-443-0
Library ofCongress Control Number:2006927418
ISBN-10:1-84628-443-0 e-ISBN-10:1-84628-509-7 Printed on acid-free paper
ISBN-13:978-1-84628-443-4 e-ISBN-13:978-1-84628-509-7
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Preface
This book is intended to explain and inform,not to dismay and shock,despite under-
tones of disapproval inherent in the term amputation,so deeply implanted in popular
imagination,as epitomizing cruel and barbaric surgery before general anaesthesia.Yet
many patients accepted this painful last resort in an endeavour to survive with three
limbs rather than die with four,at a time when,we must reflect,no mechanism for effec-
tive pain reliefexisted.It is our knowledge ofanaesthesia and aspirin which distorts per-
ceptions of a very different world when pain acceptance was strongly bolstered by
powerful convictions,often religious in character.Even today,as we shall see,certain
victims entrapped by a limb,alone and remote from assistance,will perform their own
amputations in grim determination to cheat death,despite self-induced agony.Similarly
isolated,you or I would probably react in the same way.
It has been well said that amputation is not the end oftreatment but its beginning,a
long process in which the amputee has to readjust psychologically to their mutilation
and a supportive team has to achieve a healed stump,to provide a functional prosthesis
and to guide the amputee towards maximal rehabilitation.Before safe surgery was estab-
lished,postoperative problems were formidable from secondary haemorrhage,infection
and slow healing with indifferent stump scarring.Iftoday these perils have been reduced,
the fitting of a suitable prosthesis remains an individual problem,yet functional recov-
ery can be remarkable,even among elderly amputees.
Broadly speaking,the evolution of amputation can be divided into five time periods:
(i) that of thousands of years (at least from the Old Stone Age) when amputees were
victims of nonsurgical loss,the result of congenital factors,disease,frostbite,accidents
and ritual or punitive action;(ii) that of tentative surgery in historic times when gan-
grenous limbs were separated at the junction ofdead and living tissues;(iii) that ofelec-
tive but painful surgical amputations,precipitated by gunshot injuries between the 15th
and 19th centuries,aimed to save lives and obtain a healed stump;(iv) that ofpain and
haemorrhage control,aided by anaesthesia after 1846;and (v) that ofpain,haemorrhage
and infection control after 1867,accompanied by sophisticated prosthetic designs,espe-
cially during the 20th century.
As no comprehensive historical study linking these topics has been traced,it is sub-
mitted the subject is ofsufficient significance,socially and medically,to be examined in
more detail.Importantly,before elective surgical amputation,the long period of non-
surgical dismemberment has received little attention;furthermore,until some societies
eventually tolerated amputees in their midst, it is surmised no question of “surgical”
amputation was possible. Related to this toleration are the protean convictions and
v
vi Preface
philosophies of divergent societies,patients and surgeons faced with the dilemma of a
mutilated or gangrenous limb.
The first period described relies on commonsense deductions,information from non-
industrial societies observed by explorers,missionaries and others,mainly in the 19th
century,and a certain amount ofclassical literature.The remaining periods are surveyed
utilising written evidence and,when possible,by quoting recorded patient histories.The
study also focuses on legal amputations,auto-amputation in extremis,iatrogenic sources
and the development of alternative surgical solutions to amputation,all factors which
persist in the 21st century.Surgical publications,and latterly prosthetic publications on
elective amputation,are massive in their extent;hence only a proportion ofavailable lit-
erature has been studied, mainly restricted to English and French communications.
Readers may well conclude my contribution is but an introduction to the subject.Cer-
tainly,much more detail could be added.
As a former surgeon familiar with amputations,principally for trauma and diabetes
mellitus,I lay no claim to all aspects of this rapidly developing branch of surgery and
have to thank various individuals for their advice and assistance.In particular,I am most
grateful to Kingsley Robinson, MS FRCS,Advisor in Amputee Management at Queen
Mary’s Hospital,Roehampton,the UK national centre for amputee problems,who kindly
agreed to enlarge Chapter 13 on artificial limbs with his expertise on recent develop-
ments and future possibilities.I must also thank one of his former colleagues at Roe-
hampton,Brian Andrews,FRCS,for reading Chapter 12 on amputation stumps and for
his assistance in tracing sources.My friend Krishna (Ravi) Kunzru,MS FRCS,a former
surgical registrar at Roehampton,was most helpful with Chapter 4 on ritual causes of
amputation,especially with respect to former practices in India,and my close colleague
Mick Crumplin,FRCS,Honorary Curator ofthe Historical Instrument Collection at the
Royal College of Surgeons of England,kindly corrected Chapter 10 on surgical instru-
mentation and equipment and provided several important illustrations. I am also
indebted to Dr.Jean-Claude Rey for information and to Geoffrey Walker,FRCS,hugely
experienced in orthopaedic management of developing countries,for help in elucidat-
ing the problems of gangrenous limbs following imperfect fracture splintage.Professor
Leslie Klenerman,ChM FRCS,has also been most supportive and helpful in finding my
publisher.Although I have collected works on amputation for many years, inevitably
assistance has been sought from several medical libraries,but I am mostly indebted to
the late Ian Lyle,Thalia Knight,Tina Craig and their staff of the Library at the Royal
College of Surgeons,Lincoln’s Inn Fields,London,for tolerating countless requests for
assistance.I also thank John Carr ofthe Photographic Department ofthe Royal College
ofSurgeons,the Medical Photography Unit ofthe Royal United Hospital,Bath,for several
illustrations, Melissa Morton and Eva Senior of Springer and Barbara Chernow of
Chernow Editorial Services for their helpful guidance and important corrections ofthe
manuscript.
It is hoped this work will interest medical historians,surgeons and nurses responsi-
ble for amputations,prosthetic limb fitters and manufacturers,engineers and scientists
advancing prosthetic design, general historians, the public at large and, importantly,
amputees themselves.
John Kirkup,MD,FRCS
Weston Hill,Bath,UK
December 2006
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
1 Introduction and Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Natural Causes ofDismemberment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3 Accidental Causes for Amputation:Auto-Amputation . . . . . . . . . . . . . . . . . . 23
4 Ritual,Punitive,Legal and Iatrogenic Causes . . . . . . . . . . . . . . . . . . . . . . . . 35
5 Cold Steel and Gunshot Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
6 Elective Amputation:Early Evolution to the End ofthe 17th Century . . . . . 55
7 Elective Amputation:From the 18th Century to 1846 . . . . . . . . . . . . . . . . . . 68
8 Elective Amputation:From 1846 to Recent Times . . . . . . . . . . . . . . . . . . . . . 83
9 Interpretations ofAmputation by Society,Patients and Surgeons . . . . . . . . 96
10 Surgical Instrumentation and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
11 Indications,Timing and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
12 Stumps:Reattachment,Management,Complications,Revision and Care
for Limb-Fitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
13 Artificial Limbs and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
With contributions by Kingsley Robinson
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
vii
1
Introduction and Sources
“...after the loathsome stinch of his putrid limbe was as the latter,suggesting gradual abandonment of
removed...he began to cheere up,and...from day to the term dismembring6 (Fig.1.1).Among earlier
day was refreshed more and more...as a tree refresheth works, no description of limb excision as an
after the dead bowes are pruned off.” amputation has been found before that,in French,
Woodall,16391
ofPare,in 1564,who wrote a chapter headed“Du
“Oh I know,Sir,my leg cannot be saved...I wish it had lieu ou il faut commencer l’amputation” and
been offat first...the sooner the better.” advised “sans delai...couper et amputer” for
A soldier after gunshot wounding,c.18282 gangrene.7
Among alternative expressions,we find the fol-
lowing.Gale wrote in 1563: “...in those wounds
Definitions and Usage
wyche are greate and perilous with shotte,I would
have them straite waye to dismember the patient
Amputatio, the Latin noun from the verb ...”,8without employing the word amputation.In
amputare, to cut off or cut away, derived from 1596,Clowes wrote:“The maner and order of the
amb,about and putare,to prune or to lop,was little taking off a mortified and corrupt legge or arme,
used in Roman texts and never,it is believed,to which cometh oftentimes, by reason of wounds
indicate a surgical amputation;however,the verb made with Gunshot,...”and advised:“...make a
amputarewas employed with reference to cutting speedy dispatch to cut offthe member...,”9hence
off the hands of criminals.3 Its deriviative in the excluding both dismembring and amputation.In
English language,amputation,was not assigned to the English translation of Vigo’s Practica in arte
limb excision by surgeons much before the 17th chirurgia copiosa of 1550, a section is headed:
century. One of the first to record the word in “Membres,the division of them,”10 whilst a trans-
English, in a written work, was Lowe in A Dis- lation of Brunschwig’s Buch der Cirurgia of 1525
course ofthe Whole Art ofChirurgerie(1612) when stated:“...after that was ye hande cut of....”11An
he headed a chapter,“The maner ofamputation”4; early 15th-century Middle English account ofThe
he also used the term extirpation, perhaps Cyrurgie of Guy de Chauliac has a paragraph
reflecting his long experience in France,but not headed “The rewle in kyttyng ofofa dede membre”
the word dismembring.Soon after,Woodall enti- (The rule in cutting offofa dead member) and,in
tled a chapter in his Surgions Mate (1617),“Of the adjacent text,only employed the terms cutting
Dismembring or Amputation,”5 although in sub- and sawing.12 In 1750,Dionis suggested employ-
sequent discussion on indications and procedure, ing the Greek word acrotiriasmos,to mean cutting
he referred only to dismembring, including the offthe extremities ofthe body,13but no other ref-
dismembring knife and dismembring saw. In a erence has been traced.
later edition, of 1639, Woodall employed both Despite the introduction of amputation as a
amputation and dismembring,the former as often common descriptive term by 1638, Read still
1
2 1. Introduction and Sources
tionary,dismemberment was employed from the
13th century to describe the lopping or pruning of
tree branches and for human limb destruction or
limb removal by accident,in combat or for legal
reasons. Curiously, in the English translation of
Brunschwig,dismembering is applied to joint dis-
locations;“Ofthe dyslocatyon or dysmembrynge of
every joynt in generall.”16Despite its French origin,
desmembrer has not been traced in French surgi-
cal works which employed,in the 16th and early
17th centuries, phrases such as “extirper les
extremitez du corps,” or “extirper les membres,”17
to extirpate limbs, or words such as débiter or
retrancher, as well as couper, to cut off. Even
in 1811, Sabatier defined amputation as “le
retranchement des membres.”18 In Boyer’s Le Dic-
tionnaire Royal of 1759,démembrer is translated
as to tear offlimbs,to pull to pieces or to divide.19
Two centuries before that date,the prominent and
active surgeons Pare and Guillemeau (Fig.1.2) had
promoted and established amputer and amputa-
tion20in French surgical terminology.Both De La
Charriere in 1692 and Verduin in the French
version of his book Nouvelle Méthode pour
Amputer les Membres of 1697 employed amputa-
tion exclusively for limb excision.21 Importantly,
Verduin’s small monograph was one of the first
devoted exclusively to surgical amputation
(Fig.1.3).
Later commentaries by medical historians on
early publications usually transcribe, whether
from a foreign language or English,all reference
FIG.1.1. Title page of John Woodall’s treatise on gangrene,a sec- to limb excision as amputation,perhaps to com-
tional part of his The Surgeon’s Mate,1639.6 municate more readily with modern readers.
Apart from the occasional use of dismembering,
the writer intends to pursue a similar course,in
mentioned dismembring to the exclusion of studying the protracted evolution of limb loss or
amputation,14 whereas later 17th-century British limb removal.We must also note the description
authors Cooke and Wiseman only employ ampu- “disarticulation,” also known as “amputation in
tation.15In more-recent times,the expression limb contiguity,”indicating removal through an articu-
ablation has been employed,more particularly to lation or joint,such as the knee or shoulder,that
extirpate malignant bone tumours by amputation. is without dividing bone. In addition, complete
Dismember, in the sense of limb excision, is transections with sword or axe, cutting the skin
derived from Old French desmembrer, now and bone at the same level,are now called guillo-
reduced in Modern French to démembrer, from tine amputations, even when these took place
the original Latin membrum,a limb.As suggested before the word guillotine originated in 1791
in works already mentioned,dismemberment pre- (after Dr.Guillot,who devised a bladed machine
ceded amputation as a description of surgical for beheading during the French Revolution).In
limb excision, perhaps for half a century or so. 1833,Mayor described the guillotine procedure as
Before that,according to the Oxford English Dic- tachytomie,derived by him from the Greek tachy