A Brief Review of the History of Amputations and Prostheses
EARL E. VANDERWERKER, JR., M.D.
The history of man has been accompanied by trauma, war, and congenital I anomalies. Consequently, amputations and deformity have been dealt with, one way or another, throughout the ages. Those with severe injuries either succumbed to their wounds or were disposed of on the battlefield, in the face of the inevitable. Only those with peripheral amputations might have survived.
Congenital anomalies were considered to be an act of retribution by the gods upon the offending parent. Consequently, most societies, up to the present time, disposed of the infant to hide the evidence.
It is believed that amputations were performed in the Neolithic times, from evidence of saws of stone and bone and what appears to be amputated bone stumps in skeletons of the period.
The first recorded instance of amputations and prosthetic replacement ap- pears in the book of the Vedas, written in Sanskrit in India. The oldest of the Vedas is the Rig-Veda, which is believed to have been compiled between 3,500 and 1,800 B.C. It records that the leg of Queen Vishpla was amputated in battle. After healing of the repaired wound, an iron leg was fitted to enable Queen Vishpla to walk and to return to the battlefield.
The author of a treatise "On Joints," probably written in the latter half of the Fifth century B.C., recommends amputation for gangrene of the joint below the "boundaries of blackening" as soon as it is "fairly dead and lost its sensibility." This writer may have been Hippocrates or Herodotus, who was a contemporary of Hippocrates.
Celsus, who lived at the time of the birth of Christ, described amputation for gangrene through healthy tissue: ". . . between the sound and the diseased part, the flesh is to he 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 be left behind. When the bone is reached, the sound flesh is drawn back from the bone and undercut from around it, so that in that part also some bone is bared; bone is then to he cut through with a small saw as near as possible to the sound flesh which still adheres to it, next the face of the bone, which the saw has roughened, is smoothed down, and the skin drawn over it; this must be sufficiently loosened in an operation of this sort to cover the bone all over as completely as possible. The part where the skin has not been brought over is to be covered with lint; and over that a sponge soaked in vinegar is to be bandaged on." Celsus also describes the ligation of vessels at the time of amputation.
Until 100 A.D. amputation had been performed only as a last resort for gangrene. Archigenes and Heliodorus at that time began to use this procedure for ulcer, tumor, injuries, and deformity. Both used circumferential compression above the operative site, amputated through healthy tissue, and ligated vessels. Over the ensuing centuries, through the Dark Ages, there was little change in operative technique other than a return to the use of cautery and hot oil to prevent hemorrhage.
During the 14th century the development of gunpowder, with its proliferation of firearms, multiplied the number of amputation cases that came to the military surgeon. In the mid-l6th century, Ambroise Pare, the great French army surgeon, reintroduced the use of the ligature rather than cautery, made prostheses for both the upper and lower limbs, and introduced the surgical doctrine of site of election.
The development of Morel's tourniquet in 1674 (the Spanish windlass) and . Petit's tourniquet in 1718 permitted adequate control of hemorrhage so that at- tention could be directed to the condition of the stump.
Petit of Paris modified the usual transverse circular incision in 1718. Ic advised a circular incision through skin and fascia followed by section of muscle and bone at a higher level. Hey of England in 1803 described the "triple incision," first dividing the skin and fascia, which were dissected proximally. A second incision was performed through muscle to bone, and then the bone was sectioned at a higher level.
During the Napoleonic Wars the technique of amputation was brought to the peak of perfection, prior to the introduction of asepsis and anesthesia, by Larrey of France and Guthrie of Great Britain. They both advocated primary amputation as soon as possible after injury, rather than waiting the prescribed three weeks after injury for secondary amputation. They found that immediate amputation produced a lower operative mortality, lower incidence of wound infection, and fewer cases of recurrent hemorrhage. Larrey was the first to disarticulate the hip successfully in 1803. Guthrie performed this procedure successfully during the Battle of Waterloo, and reviewed 20 such cases that had a mortality of 85 per cent.
Sites of election for amputation during this period were, for the thigh, just below the lesser trochanter and at midthigh. A four-inch below-knee stump was accepted by both Larrey and Guthrie.
After observing the high mortality from surgery and the poor stumps of the survivors, Syme, in 1845, advocated thigh amputation through the cancellous bone of the condyles or the trochanters.
The introduction of ether anesthesia in 1846, followed by the acceptance of Lister's technique for antisepsis in the latter part of the 19th century, permitted a less hurried attention to the amputation stump. This paved the way for the development of prostheses and stimulated a cooperation between the surgeon and the prosthetist.
The development of prostheses has roughly paralleled the progress of amputation. The first surviving amputee must have wished for a prosthesis. An Italian vase of the Fourth century B.C. shows a lower-limb amputee supporting himself with a wooden pylon. An artificial leg dating to about 300 B.C. was unearthed at Capua, Italy, in 1858. It was made of bronze and iron, with a wooden core, apparently for a below-knee amputee. The prosthesis was destroyed during an air raid on London in 1941.
Marcus Sergius, who lost his right hand in the Second Punic War (218 202 B.C.), was fitted with an iron hand, which he apparently used effectively.
The knights of the medieval days were anxious to replace limb loss with a prosthesis, not only to improve function but also to conceal their deformity and thus their weakness. It is only natural that prosthetic fabrication became a func- tion of the armorers of the day, who were skilled in the use of metal and wood.
In 1550 Pare designed an artificial hand called "le petit Lorrain" that had a fixed thumb but spring-loaded movable fingers. He also devised an above-knee prosthesis with a knee joint that could be released by a thong running to the hip. An upper-limb prosthesis using the trunk and shoulder-girdle muscles as a source of power for flexion and extension of the fingers was designed in 1818 by a German dentist, Peter Ballif. An above-elbow arm, using Ballif's principle to flex the elbow, was proposed by a Dutch sculptor in 1844.
The Civil War, with a resultant multitude of amputees, stimulated the development of more functional lower-limb prostheses by Marks and Hanger. In 1912 Dorrance invented the first split hook which has continued in standard use, with few modifications, to the present day. A suction socket for both arms and legs was invented in 1863 by Dubois Parmelee, 90 years before it received general acceptance.
Although instances of prosthetic replacement are mentioned throughout history, it is doubtful that more than a few per cent of amputees were fitted until after the Civil War period.
With improved materials and miniaturized components available, we are progressing closer to the "ideal prosthesis" that has been sought for centuries.
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