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General Topics
Section 1Section 1
Chapter 1
e Interwoven Histories of Amputation
Surgery and Prosthetics
John H. Bowker, MD Charles H. Pritham, CPO
Abstract
Amputation and prosthetics have a long and interwoven history. Changes in these elds
have been unsteady over time, with advancements lost, sometimes for centuries, because of
political, social, and economic forces. e evolutions in amputation and prosthetic design
and the rehabilitation of individuals with upper and lower limb loss is a fascinating and
informative narrative, reecting both the worst attributes of humanity in formulating
weapons intended to inict devastating injuries and the best intentions of humanity in
attempting to aid those aected by limb loss from wars, conicts, accidents, and diseases.
Keywords: amputation; amputee rehabilitation; analgesia;
anesthesia; history; orthopaedic surgery; peg-leg; prosthesis;
prosthetics
Introduction
The distinct but interdependent fields
of amputation surgery and prosthetics
have historical roots back to approximately 1800 bce when, according to
the Rigveda, the Indian warrior-Queen
Vishpla had her leg amputated after a
battle, was fitted with a prosthesis made
of iron, and subsequently returned to
lead her troops. The oldest archaeologic
evidence of amputation dates to 45,000
years ago. A study of a male Neanderthal skeleton found in present-day Iraq
indicated that he had survived to age
40 years with an atrophic right transhumeral amputation.
The topics in this chapter include
the evolution of amputation surgery as
well as the design and use of prostheses,
the socioeconomic forces affecting the
provision of prostheses, amputee rehabilitation, and education and training
in amputation surgery and prosthetics.
Neither of the following authors nor any immediate family member has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or
indirectly to the subject of this chapter: Dr. Bowker and Mr. Pritham.
To present the many changes that have
occurred in these two fields over time,
the developments of prime interest to
the amputation surgeon, rehabilitation
physician, prosthetist, therapists, and
other members of the rehabilitation
team are examined separately. The political, social, and economic forces that
have influenced both advances and
regression in these fields are included
where appropriate.
Indications for
Amputation Surgery
Early surgeons were strongly influenced
by the writings of Hippocrates (460 to
377 bc e), the greatest medical authority of antiquity (Figure 1). In addition
to trauma, he considered gangrene the
only other legitimate indication for amputation. For such cases, he strongly recommended cutting through insensate
necrotic tissue, preferably the knee joint,
Figure 1
bust of Hippocrates in the British Museum. (Reproduced wit h permission from Garris on FH: An
Introduction to the History of Medicine. Philadelphia, PA, WB Saunders, 1929, p 93.)
analogous to débridement, rather than
a definitive procedure. Any attendant
bleeding was controlled by cauterization with hot irons. Battle wounds were,
of course, the most frequent indication
for amputation, leading Hippocrates
to wisely observe that “war is the only
proper school for the surgeon,” because
of the battle surgeon’s extensive exposure to a wide variety of injuries inflicted
by the cutting, piercing, and crushing
weapons used before the introduction of
gunpowder. Although surgeons of that
time could do little for soldiers with
severe wounds of the trunk or head,
they often encountered combatants
with limb injuries whose lives could, at
times, be saved by amputation. Judicial
amputation of criminals’ hands was also
Photograph of a Greek marble
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
3
Section 1: General Topics
Figure 2
tron saint of those with ergotism, with a victim
of the disease, who uses a knee-walker peg-leg
to replace the right foot. The ames emanating
from his left hand symbolize the burning pain
of severe vasoconstriction, or St. Anthony’s re.
(Reproduced with permission from Hans von
Gersdor: Field-Book of Wound Surgery. Strasburg, Germany, 1540.)
Illustration of St. Anthony, pa-
widely practiced, sanctioned by both the
Babylonian Code of Hammurabi (1792
to 1750 bce) and Mosaic law.
The next reference to surgical indications for amputation was by the Roman
writer Celsus (25
bce
to 50 ce). Although
Celsus supported restricting amputation
to cases of gangrene, he recommended
transosseous division at the junction of
viable and gangrenous tissue. He also
advocated hemostasis by wound compression and vessel ligation, which was
introduced by Alexandrian surgeons.
The combination of these techniques
considerably increased the safety of amputation surgery. Celsus considered the
common practice of vessel cauterization
by hot irons to be a last resort. Over the
next half-century, the list of indications
for amputation was further expanded by
two Greek surgeons, Archigenes and Heliodorus, to include chronic leg ulcers,
tumors, and congenital malformations
in addition to trauma and gangrene. The
expansion of indications to include even
semielective disorders was made possible by the application of a tight bandage proximal to the site of amputation.
Larger vessels were controlled with ligatures and smaller ones with compression and torsion. Additional indications
mentioned in the Talmud were leprosy
and other incurable infections. Thereafter, through the influence of the prolific
writings of the Greek physician Galen
(131 to 201 ce), the recommendations of
Celsus were rejected with a return to the
teachings of Hippocrates, including am
putating only through necrotic tissue or
the knee joint, although Galen advised
using ligatures for hemostasis.
Following the decline of Roman
influence during the third and fourth
centuries ce, advances in medicine made
before Galen did not pass into the successive Byzantine and Arabic medical
traditions. Instead, with the rise of Islam, numerous works of Hippocrates
and Galen were translated from Greek
into Arabic by Persian scholars in the
seventh and the eighth centuries ce.
This perpetuated their influence for the
next 1,000 years, aided by belief in their
infallibility on the part of both Muslims
and Christians. Other influences maintaining the status quo included the early
Christian church’s rejection of anatomic
studies, its discouragement of surgery,
and the feuding of rival medical groups.
These factors resulted in widespread
discrimination against surgery and its
practitioners, who were held in low
esteem.
Nonetheless, during the European
Middle Ages (circa 476 to 1453 ce), the
indications for amputation expanded to
include limbs damaged by leprosy or
ergotism. Leprosy, a mycobacterial infection introduced to Europe by returning Crusaders (11th to 13th centuries)
results in loss of protective sensation in
the limbs. Repetitive minor trauma frequently results in painless injury to the
hands and feet, causing ulceration and
deep infection. Ergot poisoning occurs
after ingestion of rye bread contaminated
by the alkaloid ergotamine, produced by
the fungus Claviceps purpurea. In 857
ce, the first of many European ergotism
pandemics occurred among the poor,
for whom rye bread was a staple food.
Ergotism is manifested by the painful
burning sensation of prolonged arterial
vasoconstriction, hence the names ignis
sacer (sacred fire) and St. Anthony’s fire
(Figure 2), resulting in gangrene of the
hands and feet. Autoamputations or surgical ablation of gangrenous hands and
-
feet was usually followed by recovery,
whereas vasoconstriction of mesenteric
arteries was rapidly fatal.
The number of amputations from
battle wounds increased greatly after
the introduction of weapons using gunpowder, particularly with the cannon
at Crécy, France, in 1346 and muskets
at Perugia, Italy, in 1364. The wounds
incurred were so severe compared with
those from cutting or piercing weapons
that surgeons became newly interest
ed in amputation surgery as a worthy
endeavor.
During the Renaissance (14th to 16th
centuries), the original works of Celsus
were rediscovered in cloister libraries
and widely circulated with the aid of the
printing press. Prior to this, European
physicians had only inaccurate Latin
translations of Arabic translations of the
original Greek writings of Hippocrates
and Galen. With the rise of Humanism
and a relative decline in ecclesiastical
authority, Leonardo DaVinci (1452 to
1519) was able to undertake detailed
anatomic studies that refuted some of
Galen’s revered, but incorrect, notions.
Unfortunately, DaVinci’s work was suppressed for another century.
Ambroise Paré (1510 to 1590) (Fig-
ure 3) contributed greatly to the development of modern amputation surgery
by reintroducing Celsus’ principles of
amputation through viable tissue and
the use of ligatures, rather than cauterization, for hemostasis—two ideas lost
-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
Figure 3
to 1590) who reintroduced Celsus’ principles
of amputation through viable tissue and vessel
ligation, rather than cauterization, for hemostasis. (Copyright Association of Friends of the
Historic Site of V ieil Hesdin, France. http: //w ww.
levieilhesdin.org/ambroisepare.php. Accessed
on March 19, 2015.)
Image of Ambroise Paré (1510
for a millennium. Paré also abandoned
the use of boiling oil for cauterization of
wounds contaminated by gunpowder,
which was thought to be poisonous. After he fortuitously ran out of oil during
a battle, an immediate improvement
in his results reinforced his resolve to
abandon this excruciatingly painful
measure. Paré’s other great contribution
was making Vesalius’ monumental anatomic treatise, De Fabrica Humani Corpo-
ris Libri Septem (1543), easily accessible
to his contemporaries by publishing an
epitome in vernacular French.
The Napoleonic Era (1792 to 1815)
produced two notable military surgeons;
George Guthrie in Great Britain (Fig-
ure 4, A) and Dominique-Jean Larrey in
France (Figure 4, B). Larrey concurred
with Guthrie that prompt primary amputation on the battlefield resulted in
fewer fatalities than waiting the commonly recommended 3 weeks before
Figure 4
both advocated primary amputation on the battleeld. (Panel A courtesy of Wikipedia: George
James Guthrie. http://en.wikipedia.org/wiki/George_James_Guthrie and panel B courtesy of Wikipedia: Dominique Jean Larrey. http://en.wikipedia.org/wiki/Dominique_Jean_Larrey. Accessed
August 4, 2015.)
Figure 5
ment performing a eld amputation during the battle of Waterloo, painted by James Askew, 2011.
(Copyright The Collection of The King’s Own Royal Regiment Museum, Lancaster, England. Accession Number KO2942/01.)
secondary amputation (Figure 5). To
allow rapid access to the wounded, Larrey introduced “flying ambulances” to
pick up the wounded during battle and
transport them to a forward aid station
(Figure 6). Using this method, Larrey
Images of the British surgeon Guthrie (A) and the French surgeon Larrey (B), who
Illustration depicting a Regimental Surgeon of the 4th Foot, King’s Own Royal Regi-
provided truly expeditious care to the
men of Napoleon’s Imperial Guard.
During one battle, only 43 of 12,000
casualties brought to his aid station
died, a record far better that that of other
French army units.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
5
Section 1: General Topics
Figure 6
to collect wounded men during battle for rapid transfer to a forward aid station. (Courtesy of
Wikimedia, Larrey DJ: Flying ambulance. http://upload.wikimedia.org/wikipedia/commons/1/1c/
Larrey%27s_Flying_Ambulance.jpg. Accessed on March 20, 2015.)
Illustration depicts an ambulance volante (ying ambulance), invented by Larrey
injured soldiers resulted in a refinement
of indications for primary amputation
in both Union and Confederate armies.
These included comminuted open fractures, open joints with fracture, major
nerve or blood vessel injury, extensive
soft-tissue loss, and crush injuries.
In more recent wars, the introduction
of land mines and improvised explosive
devices has resulted in limb trauma of
increasing severity (Figure 7). Positive
developments over time have included
the introduction of aseptic surgery by
von Bergmann in 1891, blood replacement in 1909 by Crile, antibiotic use by
Germany and England during World
War II, primary vascular repair by DeBakey during the Korean War (1950s),
and external skeletal fixation in the
1960s by Ilizarov. These advancements
have been augmented by helicopter
evacuation to well-equipped forward
hospitals and have shortened the list
of absolute indications for amputation
while expanding the indications for
limb salvage. Nonetheless, the list developed during the US Civil War remains
basically valid in many less-than-ideal
circumstances.
Figure 7
or improvised explosive device.
Illustration s hows the lower leg zones of injur y sustained by stepp ing on a land mine
During the US Civil War (1861 to
1865), the severity of limb wounds increased markedly with the introduction
of the French Minié ball, a conical bullet
with a hollow base that expanded as it
left the rifle barrel, splintering bone on
impact. Because wounded men were
considered a greater liability to an army
than those killed outright, the standing
order was to fire at the feet of advancing
troops. The extensive damage to both
soft and bony tissue in thousands of
Advances in Level Selection
Hippocrates recommended amputation
through gangrenous tissue, thereby
averting much of the pain of surgery
and reducing the likelihood of exsanguination. Celsus’ use of ligatures for hemostasis facilitated amputation through
viable tissue, but this technique was lost
for a millennium after the fall of Rome.
Hieronymus Brunschwig (1425 to 1520)
recommended amputation distal to the
knee whenever possible and considered
knee disarticulation the most proximal
level consistent with survival. Within
a half-century, however, Paré’s reintroduction of vessel ligation allowed him
to report the first successful transfemoral amputation. In 1774, the English
surgeon James Kerr was the first to
report the 18-day survival of a patient
after hip disarticulation, at which point
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
the patient succumbed to tuberculosis.
During the Napoleonic wars, Larrey
(and later Guthrie) performed successful
hip disarticulations on the battlefield.
A consummate anatomist, Larrey was
able to complete an open hip disarticulation within 15 seconds of ligating the
femoral vessels. Before the development
of effective anesthetic agents, the most
sought-after surgeons combined a profound knowledge of anatomy with dexterity and speed to shorten the patient’s
period of intense pain.
Because extreme speed is no longer
a necessity, attention is now focused on
reconstruction of a residual limb that
interfaces comfortably with a modern
prosthesis. For transtibial amputation,
both Larrey and Guthrie preferred a
short tibial segment (8 to 10 cm) to more
conveniently fit the knee-walker peg-leg
then in common use. If only a very short
level could be salvaged, Larrey advocated complete fibular removal.
Several end–weight-bearing amputations that preserved some foot tissue
were developed about this time that
either completely eliminated the need
for a prosthesis or allowed the fitting
of a simplified, less expensive prosthesis. These developments were important because the transtibial amputee
who could not afford a prosthesis that
retained knee function was relegated to
a knee-walker peg-leg. The first of these
procedures was the midtarsal disarticulation described by François Chopart in
1792, followed closely by Jacques Lisfranc’s tarsometatarsal disarticulation
in 1815 and James Syme’s ankle disarticulation with retention of the heel
pad for end-bearing in 1843. However,
Nikolai Pirogoff, a Russian surgeon who
admired Syme’s innovation, was unable
to provide Russian peasant soldiers with
a prosthesis that would prevent instability of the heel pad. In 1854, Pirogoff
reported on stabilization of the heel pad
by fusion of a calcaneal fragment, still
attached to the heel pad, to the distal
tibia, allowing the use of standard work
boots for return to farm labor (Figure 8).
In 1939, the American surgeon Harold
Boyd reported on a similar procedure.
Despite the continuing development of
these distal techniques, the transfemoral
amputation level remained dominant
throughout World War I. In 1914, Blake
reported that 70% of amputations were
at the transfemoral level, and in J.S.
Speed’s series, 58.6% were transfemoral.
Overall, of the total 42,400 lower limb
amputations sustained by the Allied
Forces, 39.6% were transfemoral. The
first successful transpelvic amputation
had been reported by the French surgeon Mathieu Jaboulay in 1895.
Immediately following World War
II, basic research into normal human
gait was begun by Verne Inman and
Howard Eberhart at the University of
California at Berkeley (UCB) under US
government sponsorship. Their studies demonstrated that an amputee’s gait
benefited from the retention of as much
healthy bone and soft tissue as possible.
This conclusion was in sharp contrast to
the traditional practice of amputating at
fixed sites in each limb segment.
Regarding the upper limb, Paré performed the first elbow disarticulation
in 1536, Henri-François LeDran performed the first successful shoulder disarticulation in 1731, and John Cuming,
a British naval surgeon, performed the
first successful scapulothoracic amputation in 1808. The concept of cineplasty as a means to capture the power of
arm and forearm muscles to control a
prosthetic hand was developed in chickens by Vanghetti in Italy in 1896. His
associate Ceci first applied it to Italian
soldiers whose hands had been amputated as punishment while prisoners
of the Ethiopians. With cineplasty, a
transverse tunnel is made in a muscle
and its insertion is severed. After healing
has occurred, the tunnel is kept patent
and a rod is passed through the tunnel
and harnessed to a cable attached to
the prosthetic hand. When the muscle
contracts, it pulls on the cable, thereby
Figure 8
ication of the Syme ankle disarticulation. The
calcaneotibial arthrodesis stabilizes the heel
pad.
Illustration of the Pirogo mod-
activating the prosthetic hand. In 1916,
Ferdinand Sauerbruch and ten Horn refined the procedure by lining the tunnel
with a medially based skin flap. Thereafter, it was used during both World Wars,
but with the widespread availability of
myoelectric prostheses, it is now rarely
performed. This surgery could be useful
in the future to help control prosthetic
hands with multifunctional fingers.
Evolving Techniques
for Bone Coverage
From the time of Hippocrates until the
first century ce, the recommended technique for limb amputation was division
of all tissues at the same level. As these
open wounds healed by secondary intention, the soft tissues contracted, resulting in a conical residual limb with
distal bone prominence. Early in the first
century ce, Celsus advocated cutting the
bone at a higher level than the soft tissues, which allowed the skin to be drawn
distally to cover the end of the bone. This
advancement was lost with the decline
of Rome and rediscovered during the
Renaissance. Several new techniques
based on Celsus’ principle appeared in
the 18th century. During 1717 and 1718,
the contemporaries Jean Louis Petit, Lorenz Heister, and William Cheselden favored making a circular incision through
the skin and fat, pulling these tissues
proximally, and dividing the muscle and
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
7
Section 1: General Topics
Figure 9
transtibial amputation. A, The posterior
myofasciocutaneous ap. B, The completed
amputation. (Reproduced with permission
from Heister L: Chirurgie. Nuremberg, Germany,
1718 .)
Illustration depicts Verduyn’s
bone; this method was termed the double circular incision method. In 1779,
Edward Alanson created a less bulky
residual limb by following the skin and
fat incision with an oblique cut through
muscle from distal to proximal, followed
by division of the bone at the apex of the
muscle cone. The triple circular incision
was introduced by Henri-François LeDran (1731) and Benjamin Bell (1787).
Following successive circular divisions
of the skin and subcutaneous tissue and
a muscle layer, both were pulled proximally to the level of bone division. This
method was used by both Larrey and
Guthrie during the Napoleonic Wars.
Although double and triple circular
incisions remained the most common
methods used to ensure that the bone
remained well covered, other surgeons
were developing flaps for wound closure
beginning in 1679 with James Yonge, a
British naval surgeon. In 1696, Pieter
Verduyn described the first long posterior myofasciocutaneous flap for transtibial amputation (Figure 9). Hugues
Ravaton (1739) and Vermale (1756) reported the first use of sagittal flaps consisting of skin and muscle. In addition,
in 1796 the French surgeon Raphaël Bienvenu Sabatier described a myofasciocutaneous flap raised from the anterior
leg to close a knee disarticulation. Later
major contributions to knee disarticulation surgery included F.W. Wagner’s
1970s description of a gastrocnemius
muscle flap to cushion the femoral condyles closed with sagittal skin flaps. In
1985, the German surgeons Klaes and
Eigler described the use of a posterior
myofasciocutaneous flap, including the
gastrocnemius muscle bellies, to cushion the distal femur, with less risk of
partial skin flap necrosis than in Wagner’s technique.
In 1915, during World War I, Fitzmaurice-Kelly performed emergent
flapless open amputations at the most
distal level of viable tissue to preserve
limb length. He considered this the first
stage of a two-stage procedure, using
skin traction in the interim. The American surgeon Kellogg Speed modified
this technique by incising the skin longitudinally on each side in preparation
for the secondary closure. Using this
method, he found that the wounded
could be moved safely to a rear hospital
1 week after amputation.
Although these incremental improvements to technique tended to produce
marginally better residual limbs, the
underlying bone often became prominent over time as soft-tissue atrophy
occurred, resulting in distal discomfort
and ulceration with use of a prosthesis.
This was especially common after transfemoral amputation if the muscles were
not attached stably over the end of the
femur. After World War II, the German
surgeons F. Mondry and R. Dederich developed widely adopted myoplasty methods in which the distal femur is covered
by suturing opposing muscles over its
end. In 1960, the Polish surgeon Marian
Weiss introduced myodesis, in which the
muscles are reattached to bone or periosteum to restore some of their motor
function. This concept was extended in
1990 by Frank Gottschalk of Dallas, who
demonstrated the value of preserving
the adduction power of a transfemoral
residual limb by performing myodesis
of the adductor magnus tendon to the
lateral femoral cortex. Ample padding
is provided by suturing the quadriceps
muscle over and to the distal femur.
Distal coverage of a transtibial residual
limb with a posterior myofasciocutaneous flap, introduced by Verduyn in 1696,
was reintroduced by William Bickel in
1943, and later was widely promoted by
Ernest Burgess of Seattle.
Surgical Analgesia
and Anesthesia
In the fourth century ce, Dioskorides,
a military surgeon under Nero, compiled a Materia Medica, describing the
medical uses of more than 600 plants,
including the anesthetic effects of Man-
dragora and opium for surgical procedures. The Talmud later mentions the
specific use of anesthesia for amputation as well. During the Middle Ages,
the Spongia Soporifica, invented by
Ugo di Borgognoni of The University
of Bologna was widely used for surgical
anesthesia. A sponge was soaked in a
mixture containing, among other ingredients, opium, Mandragora, Hyoscyamus,
and hemlock, providing both narcotic
and atrophin-like effects when inhaled
or swallowed. After drying, the sponge
became easily portable, to be reconstituted with water when needed. For the
next four centuries, however, from the
end of the Middle Ages (circa 1450) until
the mid 19th century, amputations were
performed without the benefit of analgesia, placing a premium on the speed
of the surgeon to reduce the duration of
suffering (Figure 10).
The evolution of modern anesthesia began with two related events;
Humphrey Davey’s description of the
pain-killing effects of nitrous oxide in
1792, and Faraday’s demonstration of
the similar effect of nitrous ether in 1818.
In 1846, the first amputation using ether
anesthesia was performed for tuberculosis of the knee by John Collins Warren
at Massachusetts General Hospital in
Boston. Six weeks later, having heard
of Warren’s success, Robert Liston performed the first amputation using ether
anesthesia in England at the University
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
Figure 10
ly without anesthesia. The assistant on the right compressed the thigh to control hemorrhage. All
tissues were divided at the same level, resulting in a prominent distal tibia with poor soft-tissue
coverage. (Reproduced with permission from Heister L: Chirurgie. Nuremberg, Germany, 1718.)
College of London Hospital. Liston accomplished this transfemoral ablation
with his usual dispatch in 28 seconds.
The necessity for extreme speed was no
longer necessary and was succeeded by a
new luxury: sufficient time to carefully
execute a deliberate surgical plan and
deal with unexpected findings without
the sometimes violent struggles of a patient in extreme pain. The use of ether
anesthesia was quickly adopted in 1847
by both Syme in Edinburgh and Pirogoff in Russia. Chloroform was preferred
by surgeons active during the US Civil
War as a safer alternative to ether on
the battlefield.
Illustration depicts a t ypical 18th century transtibial amputation, performe d swift-
conservatism of Hippocrates and his adherents, who accepted gangrene as the
only proper indication for amputation,
other than trauma, with the transection
performed through necrotic tissue to decrease the chance of fatal hemorrhage.
In addition, because hemorrhage was
more easily controlled by cauterization
or bandaging at distal levels, only transtibial amputation or, at most, knee disarticulation was recommended.
Military surgeons gradually improved the outlook for survival by better
control of blood loss during amputation. Intraoperative hemostasis evolved
over many centuries, beginning with
the popularization of vessel ligation
Mortality After
Amputation Surgery
The earliest records clearly show that
amputation commonly resulted in
death from blood loss during surgery
or some days later from sepsis, often
associated with secondary hemorrhage.
These known risks resulted in the
by Celsus, which was reintroduced by
Paré. A precursor of the tourniquet was
a circular bandage placed proximal to
the amputation site by Archigenes and
Heliodorus in the first century ce. In
1674, the French army surgeon Etienne
Morel introduced the first true tourniquet, tightened with a stick. Because
Figure 11
tourniquet in the early 18th century, a great improvement on Morel’s earlier windlass tourniquet because of its security. (Reproduced with
permission from Heister L: Chirurgie. Nuremberg, Germany, 1718.)
Illustration of Petit’s screw
the stick often obstructed the surgical
site, it was quickly displaced by Petit’s
screw tourniquet circa 1700 (Figure 11).
Nonetheless, mortality rates following
battle wounds remained so high that
Louis XIV (1638 to 1715) complained
that “For my soldiers, the amputation
knife of my surgeons is far more dangerous than the enemie’s (sic) fire.”
Eventually, it was accepted that mortality after amputation for battle wounds
was closely linked to the interval between injury and surgery. Initially, opinion was sharply divided between those
who advocated primary amputation on
the battlefield and those who would wait
2 to 3 weeks until the risks of wound
infection and secondary hemorrhage
had subsided. By delaying surgery, these
surgeons were able to claim a lower surgical mortality rate because most of the
wounded had died of sepsis or hemorrhage while waiting the prescribed
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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Section 1: General Topics
interval. Larrey, during the Napoleonic
Wars, used “flying ambulances” to bring
the wounded directly to his surgical station following primary amputation on
the battlefield. By this means, he markedly decreased both the intraoperative
death rate of the soldiers under his care
and the death rate from wound infection
and secondary hemorrhage. Guthrie’s
experience with British casualties was
similar. During the Crimean War (1853
to 1856), primary amputation resulted
in a 37% mortality rate, compared with
60% for secondary ablation. The Union
Army had the same experience with
20,500 amputations during the US Civil
War, with a mortality of 35.7%. This was
a marked improvement from the Battle
of Fontenay in 1745, when mortality after amputation was 90%.
The other major cause of death after
amputation was septicemia. Although
Hippocrates recommended that surgeons clean their hands and fingernails
and use boiled water for wound cleansing, this basic principle of asepsis was
rarely heeded, either on the battlefield
or in hospitals. Early attempts at wound
lavage with purported antiseptics included the use of wine by Avicenna (980
to 1037) in the Middle Ages and turpentine by Paré during the Renaissance.
The concept of asepsis progressed with
Ignaz Semmelweis’ 1848 report of the
reduction in puerperal sepsis mortality
from almost 10.0% to 1.3% simply by
enforced hand washing in a solution of
calcium chloride for all personnel before
any patient contact.
In 1865, Joseph Lister, appalled by
the high mortality rate associated with
open fractures and thoroughly familiar
with the work of Louis Pasteur, began
treating open fracture wounds with
carbolic acid dressings in an attempt to
sterilize them, rather than performing
primary amputations. Following the
successful salvage of several limbs using
this method, Lister applied the principle
of antisepsis to his surgical cases. This
included preoperative washing of hands
and instruments as well as intraoperative spraying of wounds with a carbolic
acid solution. Using this form of antisepsis, he was able to reduce his surgical
mortality rate of 48% for amputations
performed from 1864 to 1866 to 15%
for amputations performed from 1867
to 1870. Antisepsis introduced a new era
of safety for elective surgery, as well. By
1877, antisepsis was widely accepted by
most surgeons, including American military surgeons. Antisepsis still remains
applicable for lavage of contaminated
wounds, as exemplified by the continued use of Carrel-Dakin solution and its
various successors.
The progression from antisepsis to
asepsis was also based on the work of
Pasteur. Ernst Von Bergmann, a prominent surgeon during the Franco-Prussian
war (1870 to 1871), introduced steam
sterilization of surgical instruments in
1886. In 1891, he began the gradual introduction of asepsis as known today,
including sterile gowns and gloves and
the use of masks. During World War I,
British, French, and American surgeons
achieved an overall amputation survival
rate of 85%, using a combination of extensive wound débridement, early open
amputation, and wound irrigation with
Carrel-Dakin solution. The availability
of sulfonamides from the beginning of
World War II and the introduction of
penicillin in 1943 marked the beginning
of the antibiotic era.
Education and Training
in Amputation Surgery
From ancient times, the place of surgery
and surgeons in society has been dictated by forces that directly or indirectly
affected its advances and declines. In
Rome, the role of physicians seems to
have included surgery, especially for
those with military experience. During
the Middle Ages, Avicenna, the leading
Islamic medical scholar of that era, put
forth two doctrines that became institutionalized by both the Christian
church and the universities through
the influence of Latin translations of his
voluminous writings. The first doctrine
was that methodical and logical reasoning (ratiocination) was better than firsthand experience and investigation in
medical treatment. The second doctrine
was that surgery is a separate and inferior branch of medicine. Thus, university
medical education in the Middle Ages
became purely theoretic, leaving practical treatment of illness and injury to
nonacademically trained “popular physicians,” barbers, surgeons, bath-stove
attendants, and assorted quacks.
France gradually led the way out of
this morass during the 13th to 18th
centuries. The first attempts to legitimize surgery and raise the status of
surgeons occurred circa 1250 through
the political influence of Jean Pitard, the
personal barber-surgeon to the king.
With royal support, Pitard founded a
surgeon’s guild called the College of St.
Cosmas. To ensure that applicants to
the new college had an acceptable level
of knowledge and experience, Pitard
organized a 4-year apprenticeship that
encompassed not only practical surgery
but also theoretic lessons, taught for the
first time in the French language. After
passing an examination, the apprentices
were called master surgeons and entitled
to enter the College, open an office, and
train their own apprentices.
Despite these advances, real progress was stymied throughout much of
the Middle Ages because of the rivalries
among the university medicine faculties,
the master-surgeons guild, and the barber-surgeons, characterized by constant
bickering and ever-shifting alliances as
each group sought to control the others. The result of this divisive turmoil
was a delay in the application of new
knowledge such as Michael Servetus’
discovery circa 1550 of the pulmonary
(lesser) circulation and William Harvey’s of the systemic (greater) circulation
in 1628, advances characteristic of the
rise of scientific medicine.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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A few foresighted physicians, however, found their theoretic education
useless for rendering aid on the battlefield, so they went to the best-regarded
barber-surgeons for further training.
On becoming physician-surgeons, they
returned to the universities to teach surgery. Three physician-surgeons of the
period, Henri de Mondeville, Guy de
Chauliac, and Lanfranc wrote surgical
texts. Lanfranc, who is considered the
founder of surgery in France, sought
to bring the opposing camps together,
teaching that “no one can be a good
physician who has no idea of surgical
operations, and that a surgeon is nothing if ignorant of medicine.” Cardinal
Richelieu, the Prime Minister of Louis XIII, helped raise the standards and
social status of army surgeons by making them members of the College of St.
Cosmas. Surgical education, at least in
France, was finally brought to the same
academic level as university medicine
in the mid 1700s with the founding of
the Royal Academy of Surgery by Mareschal, the personal surgeon of Louis
XIV. In England, the development of
surgery lagged behind that of France,
but surgeons and barbers finally became differentiated, culminating in the
1800 founding of the Royal College of
Surgeons of London and later the Royal
College of Surgeons of England.
The first two illustrated books that
discussed amputation were written by
experienced military surgeons from
Strasbourg who had learned the art
of amputation surgery while treating
wounded combatants. The first was The
Book of Wound Surgery by Hieronymus
Brunschwig in 1497, followed by Hans
von Gersdorff’s Field-Book of Wound
Surgery in 1517, which contained the
first illustration of an amputation (Fig-
ure 12). Both books dealt with wounds
caused by firearms. Other books dealing
with amputations followed. One book
by Paré described the first designs for
a “wooden leg for the poor.” In 1815,
George James Guthrie, the great British
Chapter 1: The Interwoven Histories of Amputation Surgery and Prosthetics
Figure 12
ing o), the rst known illustration of amputation surgery. Note the hemorrhage despite the
tight bandages above and below the incision.
The scalpel lies in the foreground. The gure
behind the patient wears the Tau cross of St.
Anthony, indicating that he may have lost the
ngers of his left hand from ergotism. (Reproduced with permission from Hans von Gersdor: Field-Book of Wound Surgery. Strasburg,
Germany, 1517.)
surgeon of the Napoleonic Wars, published six editions of an epoch-making
Illustration of “Serratura” (saw-
Figure 13
wooden hallux prosthesis found on a female
mummy circa 1000 bce. Note laced leather band
around the forefoot. (Reproduced with permission from Nerlich A, Zink A: Eine zehenprothese
an einer altae gyptischen mumie. Med Or th Tech
2002;122:32-33.)
Photograph of a cosmetic
the construction and custom-fitting of
prostheses.
treatise, Gunshot Wounds of the Extrem-
ities Requiring Amputation. Formal education in amputation surgery, however,
did not materialize in the United States
until after World War II.
Evolution of Prosthetic Design
The earliest example of a prosthesis for
which visual evidence exists is a cosmet-
ic hallux fitted in Egypt circa 1000 bce
(Figure 13). Another historical example
History of Prosthetics
Introduction
Whether a result of conflict, accident,
disease, or judicial decree, amputations
have always been a part of human experience, as has been the desire to replace
the lost part for functional, cosmetic,
and/or protective reasons. The word
prosthesis, the proper name for an artificial limb, is derived from Greek, meaning “to place an addition;” prosthetics
is the professional field that deals with
is a Roman transtibial prosthesis circa
300 bce that had a wooden socket rein-
forced with bronze sheets. In addition,
a mosaic found in Lescar, France, from
the Gallo-Roman era depicts a Moorish
hunter pursuing game on a knee-walker
peg-leg (Fi g u r e 14). Prostheses made
by armorers for officer-amputees had
the additional benefit of concealing the
warriors’ deficits from enemies. The iron
hands of the Roman Marcus Sergius and
the Teutonic mercenary knight Goetz
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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