‘The Camp being broken up, I returned to Paris, with my Gentleman whose leg I had cut off. I dressed him, and God cured him; I sent him to his house merry with his wooden leg, and was content, saying that he had escaped good cheap, not to have been miserably burnt …’.
Ambroise Paré, The works of that famous chirurgeon Ambrose Parey, translated out of Latin, and compared with the French, by Th. Johnson … (London, 1678), p. 697.
Guilhelmus Fabricius Hildanus, Opera quae extant omnia … (Frankfurt, 1682), p. 809.
The technique of tying a piece of thread (suture) around a blood vessel to stop the flow of blood (hemostasis), which is known as a ligature, was described by the Roman writer Celsus in the 1st century AD. This practice appears to have been subsequently forgotten and surgeons stopped bleeding by burning blood vessels closed using boiling oil and cautery, the latter being divided between actual cautery, i.e. red-hot metal instruments, and potential cautery, i.e. caustic material such as vitriol (sulphuric acid). Ambroise Paré (1510-90) re-introduced the ligation of blood vessels thereby greatly improving the surgical technique for amputations.[1]
Speed was of the utmost importance when it came to performing the amputations of limbs given that operations at the time were not conducted under anaesthesia and patients had to be held down and restrained by the surgeon’s attendants. Amputations were carried out almost always by guillotine fashion whereby the skin, muscles, and bone were detached at the same level. The use of cautery allowed much faster control of bleeding compared to the use of ligature, which was much slower to perform. Cauterisation continued to be used by surgeons, therefore, despite the proven effectiveness of ligatures.[2] The famous German surgeon Guilhelmus Fabricius Hildanus (1560-1634), for instance, differed with Paré’s views on the use of ligature for haemostasis in amputation, preferring to use cautery because it was quicker and resulted in less bleeding, although he did use the ligature in certain circumstances.[3] Images 1 and 2 are taken from Worth’s copy of Fabricius Hildanus’ Opera quae extant omnia … (Frankfurt, 1682) and depict a surgeon preparing to amputate below a patient’s knee and the act of amputating respectively. Note the firepot for heating the cauteries is shown in both illustrations. Paré applied the use of cautery for debridement, i.e. removal, of dead tissue in gangrenous wounds.[4] Pierre Dionis (1643-1718) writing on amputations in his textbook Cours d’operations de chirurgie, demonstre’es au Jardin Royal … (Paris, 1707) favoured the use of ligature over cautery because the scars caused by cauterisation, which hindered blood issuing from blood vessels, had a tendency of falling off and blood would flow out as violently as on the day of the operation.[5]
The tourniquet, which is a device that applies pressure to a limb or extremity with a cord or tight bandage in order to control the flow of blood, existed prior to the time of Paré. Sellegren notes that Guy de Chauliac (c. 1300-68) ‘used a tight band above and below the site of amputation to reduce pain and minimize bleeding by compressing the soft tissues against the bone’.[6] Fabricius Hildanus carried out above-knee amputations of the thigh and devised a special tourniquet that was applied to the limb.[7] The French surgeon Jean-Louis Petit (1674-1750) designed a tourniquet in 1718 that consisted of a screw and a leather pad with a circular bandage attached, which applied direct pressure on the major artery of the limb to be amputated and provided effective hemostasis. This greatly simplified the use the ligatures.[8]
Guilhelmus Fabricius Hildanus, Opera quae extant omnia … (Frankfurt, 1682), p. 809.
The writings of Hippocrates taught amputation through devitalized (i.e. dead) tissue rather than through healthy living tissue to avoid the risk of haemorrhage. This left the amputation stumps open to heal by granulation, whereby new connective tissue and microscopic blood vessels form on the surface of a wound. This resulted in a protruding fragment of bone that had to be removed later by saw or bone gnawing surgical instruments known as rongeurs.[9] Paré amputated through healthy tissue proximal to the demarcation line between gangrenous and healthy tissue as his preferred sites for amputations. Celsus described the practise of amputating above the dead tissue and Paré adopted this procedure:
‘As to that which is necessary (say you), to use fire after amputations of the members, in order to consume and check the putrefaction of which is common to gangrene and to mortifications, that in truth hath no place here because the practice is to amputate always the part above that portion which is mortified and corrupted, as wrote and recommended Celsus, to perform the amputation on-that which is healthy, rather than to leave any of the putrefied’.[10]
Paré recommended retracting the skin and muscle proximally before cutting the bone in order to get better stump coverage and advocated the use of delayed closure, which reduced the rate of infections in the stump and hastened the wound healing process.[11] Ellis credits James Yonge (1646-1721) for introducing ‘the flap operation for limb amputation which allowed much more rapid healing than the classical guillotine procedure. Initially, a single flap was used but the operation underwent many modifications and usually a double flap replaced the single flap’.[12]
Pierre Dionis, Cours d’operations de chirurgie, demonstre’es au Jardin Royal … (Paris, 1714), fig. XLVII facing p. 611.
Image 4 shows the instruments, pledgets (compresses of absorbent material, often lint) bolsters (absorbent pads) and bandages that Pierre Dionis describes as necessary to facilitate an amputation, which were required to be readied prior to the commencement of the operation:
‘This Apparatus comprehends three things; First of all, the Instruments to cut off the Leg; secondly, whatsoever is necessary to stop the Blood; thirdly, whatever is requisite to dress the Patient. For the first, there must be two Bolsters to lay under the Ligatures, viz. a long and a circular one, a double Wrench to close it the better, a very strong Ligature to fix a Finger’s breadth above the place where we intend to make the Incision, a great crooked Knife, which is not to have any Edge on its back, that the Chirurgeon may press upon it with his Left-hand to expediate the Incision, a large Penknife to cut off the Flesh betwixt the two Bones and the Periosteum, in case that the crooked Knife has not done it, a good Saw well fil’d or sharpen’d, and a little greas’d, that it may make quick Dispatch in sawing the Bone. Secondly, to stop the Blood, there must be a Crane’s-Bill Pincers, on which is fixed a noos’d Thread, another pair of Nippers, with a Ring to close it, when it holds the end of the Artery, Needles, wax’d Thread, small Bolsters, Astringents composed of Bole Armoniac, Terra Sigillata, Sanguis Draconis, &c. powder’d and incomporated with the Whites of Eggs, with which Preparation we are to cover the Pledgets, as is with three or four Bottons of Vitriol in case of Necessity. Thirdly, to dress the Patient, we must have three small square Bolsters to lay on the ends of the Vessels, two Pledgets dipt in Spirit of Wine to lay on the Bones which are cut, a numerous quantity of Pledgets charged with Astringents, with which we are to cover the whole Wound, a Stopple made of two about the size of the bottom of a Plate, to take in the whole Stump, and cover’d with Astringents; a Bladder, at the bottom of which are Astringent Powders, and which is cleft to clap the Stump into it, a large Plaister and Bolster cut like a Malthese Cross, four long Bolsters of half an Ell long, and two Fingers breadth broad, a Band roll’d up at one end, another of four or five Ells long, of the breadth of four Fingers, and roll’d up at both ends, in order to make the Bandage which we call the Cap of Maintenance, and several Napkins for necessary Occasions’.[13]
Peter Uffenbach, ed., Dispensatorium Galeno chymicum : continens primo Ioannis Renodaei Institutionum pharmoceuticarum [sic] lib. V. De materia medica lib. III et Antidotarium varium et absolutissimum : secundo Iosephi Quercetani Pharmacopoeam dogmaticorum restitutam … (Hannover, 1631), engraved title page (detail).
Sources
Dionis, Pierre, A Course of Chirurgical Operations, demonstrated in the Royal Garden at Paris (London, 1710). This is an English translation of Dionis’ Cours d’operations de chirurgie, demonstre’es au Jardin Royal … (Paris, 1707). Worth had the 1714 Paris edition.
Ellis, Harold, The Cambridge Illustrated History of Surgery, 2nd ed. (Cambridge, 2009).
Fliegel, O. and S.G. Feuer, ‘Historical Development of Lower-Extremity Prostheses’, Orthopedic & Prosthetic Appliance Journal, vol. 20, no. 4 (1966), 313-324.
Jones, Ellis, ‘The Life and Work of Guilhelmus Fabricius Hildanus (1560-1634) Part I’, Medical History, vol. 4, no. 2 (1960), 112-134.
Paré, Ambroise, The works of that famous chirurgeon Ambrose Parey, translated out of Latin, and compared with the French, by Th. Johnson … (London, 1678). This is an English translation of Paré’s Les oeuures de M. Ambroise Paré … (Paris, 1575). Worth had the 1685 Lyons edition.
Sachs, Michael, et al., ‘Historical Evolution of Limb Amputation’, World Journal of Surgery, vol. 23, no. 10 (1999), 1088-1093.
Sellegren, Kim R., ‘An Early History of Lower Limb Amputations and Prostheses’, The Iowa Orthopaedic Journal, vol. 2 (1982), 13-27.
Simpson, Donald, ‘Pierre Dionis and the Franco-British Dialogue in Surgery’, Australia and New Zealand Journal of Surgery, vol. 73, no. 5 (2003), 336-340.
Text: Mr. Antoine Mac Gaoithín, Library Assistant at the Edward Worth Library, Dublin.
[1] Ellis, Harold, The Cambridge Illustrated History of Surgery, 2nd ed. (Cambridge, 2009), p. 36; Fliegel, O. and S.G. Feuer, ‘Historical Development of Lower-Extremity Prostheses’, Orthopedic & Prosthetic Appliance Journal, vol. 20, no. 4 (1966), 317.
[2] Sellegren, Kim R., ‘An Early History of Lower Limb Amputations and Prostheses’, The Iowa Orthopaedic Journal, vol. 2 (1982), 18.
[3] Jones, Ellis, ‘The Life and Work of Guilhelmus Fabricius Hildanus (1560-1634) Part I’, Medical History, vol. 4, no. 2 (1960), 125.
[4] Sellegren, ‘An Early History of Lower Limb Amputations and Prostheses’, 18.
[5] Dionis, Pierre, A Course of Chirurgical Operations, demonstrated in the Royal Garden at Paris (London, 1710), p. 408.
[6] Sellegren, ‘An Early History of Lower Limb Amputations and Prostheses’, 18.
[7] Jones, ‘The Life and Work of Guilhelmus Fabricius Hildanus (1560-1634) Part I’, 124.
[8] Sellegren, ‘An Early History of Lower Limb Amputations and Prostheses’, 18.
[9] Ibid., 19.
[10] Ibid., 19.
[11] Ibid., 22.
[12] Ellis, The Cambridge Illustrated History of Surgery, p. 41.
[13] Dionis, Pierre, A Course of Chirurgical Operations, demonstrated in the Royal Garden at Paris (London, 1710), p. 410.