A History of Prosthetics and Amputation Surgery
A History of Prosthetics and Amputation Surgery
Prosthesis is derived from the Greek word meaning ‘addition’ (pros=to, thesis= a placing)
In this article we will attempt to provide an insight to the history of prosthetics and some of the surgical techniques employed, albeit very basic.
All this began at the dawning of human medical thought, the historical twists and turns paralleled with the development of medical science.
Prosthetic science probably began with man’s need for wholeness, artificial limbs were developed for cosmetic appearance, function, and a spiritual sense of being complete, but maybe not in that order.
The patients requirements exist from early times right up to the present. Early prosthetic principles that were developed still exist to this day, and were amazingly efficient in function.
Neolithic man is known to have survived amputation, archaeologists claim that remains of Neanderthal man show evidence of having lived after amputation, although limb loss was probably more likely to be due to accident, punishment or magic rituals rather than any surgical intent
In the three great western civilisations, Greece, Egypt and Rome the first aids to rehabilitation were recognised as prostheses.
There is no record of amputation in the Old Testament, nor do the Egyptian papyri give any account of it.
The dark ages produced prostheses for use in battle and for hiding deformity.
The renaissance emerged and revitalised the development started by the ancients.
Subsequent refinements in medicine, surgery and prosthetics greatly improved amputation surgery and the function of artificial limbs.
The industrial revolution brought about prosthetic advancement, particularly in the U.S.A, fuelled by money made available to amputees following the civil war.
Finally the modern era of prosthetics moved forward in leaps and bounds with technology developed in the two world wars and the use of materials developed for use in the space race.
The earliest evidence of mans recognition of deformity and the need for rehabilitation is difficult to establish, as many ancient civilisations had no written records and historical accounts were orally recorded in songs, poems and sagas.
To discover the beginnings we have to rely on anthropologists to interpret the myths, artwork and remains.
Early evidence has been found in cave paintings, such as those in Spain and France, which are estimated to be about 36,000 years old, which show a negative imprint of a mutilated hand, later paintings have also been found in New Mexico and suggest the practise of self mutilation to appease the gods in a religious ceremony.
The RIG-VEDA, an ancient sacred poem of India, is said to have the first written reference to amputation and artificial limbs, written in Sanskrit, between 3500-800 BC, it recounts a story of the warrior Queen Vishpla, who lost her leg in battle, was fitted with an iron prosthesis and returned to battle. But it is usually considered that the first account of amputation as a purposeful medical procedure is in the Hippocratic “Treatise on Joints”, which had a modern ring about it, as it is concerned with amputation in vascular gangrene.
Some social attitudes towards amputation and amputees remain today, while others have changed. Congenitally deformed babies may have been ostracised or even killed because they may have been judged a liability or unclean. However, King Montezuma II, an Aztec ruler, established a special, but degrading compound for the disabled between the royal zoo and botanical gardens.
Amputation was often feared more than death, in some cultures it was believed that it affected the amputee not only on earth but also in the afterlife, the amputated limbs were buried, and at the time of the amputee’s death, disinterred and reburied with the amputee to ensure a whole eternal life. This is still practised in some religions today.
Many cultures had a very physical existence and any handicap may have affected the amputee’s ability to provide for themselves, their family or contribute to their tribe.
Reasons for amputation in ancient times varied, congenital deformities have always been present, war was often the cause of traumatic amputation, in battle or even when taken prisoner. Amputation was also used as a punishment; theft would sometimes be punishable by the removal of a hand. Depending on the culture, such as the Moche, from Peru, if the thief could prove theft was a motive because of hunger, the village chief would suffer the punishment! A foot would be removed for laziness and both arms for rebellion.
It is believed that ancient cultures also had knowledge of amputation for diseases such as gangrene, tuberculosis and leprosy, and that amputation was advised above the diseased area for healing.
Religion was another cause for amputation, disfigurement may have appeased the gods, show faith or illustrate the altering effect of faith, a ritualised form of this remains today in circumcision.
Surgery was performed with or without anaesthesia, analgesics and advanced tools. For judicial punishment no anaesthesia would be used, and a guillotine technique with an axe was employed. For curative surgery, an ancient surgeon would use plant extracts, such as nepentas, opium, hemp, mandrake, henbane, hemlock, and alcohol. Analgesic plants, such as asperic acid, derived from tree bark, were used to relieve pain. Antiseptics, such as smoke, honey, wine and cautery with hot oil were used.
Ligatures of cotton fibre, human hair and hemp may have been used in weaving cultures.
Tools, such as stone or bronze axes were the standard surgical instruments, saws with stone set into animal jaws or wood have been shown to amputate limbs within six minutes.
The artificial limbs of ancient cultures began as simple crutches or wooden and leather cups (shown in Moche pottery). This grew into a modified type of crutch or peg leg to free the hands for function.
Open socket peg legs had cloth rags to provide cushioning for the distal end of the stump, and allow a free range of motion. These limbs would have been functional and used many basic principles of prosthetic fitting.
Amputee gods were also identified, from the Peruvian jaguar god, AiaPaec, who was an above elbow amputee, to the Aztec god, Tezcatlitoca, a right foot amputee, and then there was also the Irish Celtic god, New Hah, a left arm amputee, with a four digit silver prosthesis.
The Birth of Science
Roman artificial right leg, dating from the early Christian era, Excavated from Capua and of bronze plates fashioned a wooden core.
With the beginning of the three great civilisations (Greek, Roman and Egyptian), a scientific approach to medicine and, to a degree, prosthetic science developed. Amputation was recorded in myths and plays, although forms of artificial limbs have been found on mummies with traumatic or congenital limb deficiencies, they were considered to be examples of the embalmers art only, as there was no evidence to suggest they were used in life.
In Greek myth, Pelops, grandson of Zeus was killed, cooked by his father, Tantalus, and served to the gods to see whether they could tell the difference between the flesh of man and beast, the goddess of agriculture, Demeter, ate the shoulder of Pelops and then realising her error restored him back to life and made him a prosthetic shoulder form ivory.
In the 5th century BC, Aristophanes wrote a play, The Birds, in which was a part for an actor wearing an artificial limb.
In 424 BC Horodotus wrote about a Persian seer, Hegistratus of Elis who was condemned to death by the Spartans, he managed to escape from the stocks by cutting off his foot, made a wooden ‘filler’ and travelled to Tregea, some 30 miles away, unfortunately he was recaptured and had his head cut off, no prostheses for that!!
A roman prosthesis from 300 BC (during the Samite wars) was unearthed in Capua, Italy about 1858 and made from a wooden core, bronze shims and leather straps, it was however unfortunately destroyed by enemy bombing during world war 2 in London
A first century Roman scholar, Pliny the Elder, (23-79 AD) wrote in ‘Natural History’ of a Roman general, Marcus Sergius who was leading his army against Carthage during the second Punic war (218-210 BC) where he sustained injuries and a right arm amputation, an iron hand was made to hold his shield and he was able to go back to the battle, he was captured and twice escaped, he served as a civil judge, he wanted to become a priest but was denied because to be a priest one needed two normal hands.
Hippocates, in the 5th century BC originally put forward the use of ligatures to tie off ‘bleeders’ and he also advocated application for vascular gangrene.
Celsus, 0 AD, described another amputation technique, going through healthy tissue between the sound and diseased tissue and also described ligation of blood vessels to stop bleeding. There are various references in the Jewish history of the Talmud to amputation.
Heliodus and Archigenes, two roman surgeons, advocated amputation for gangrene and also for injuries, tumours and other various deformities.
The Dark Ages
As the name implies the dark ages were a period in time when little scientific progress was made. The feudal system had divided many regions of Europe into many isolated kingdoms, thus preventing scientific progress because of the lack of any central learning or governmental forums.
Many of the techniques in surgery developed by the Romans and Greeks fell into disuse, as there were less educated people from the various regions who could read, use and experiment and thus record their findings.
At this time the primitive techniques were used, such as crushing the limb, dipping in hot oil and searing with hot irons. The guillotine method was used and the wound was allowed to granulate, most people died of blood loss, those that did not usually perished from infection because of the poor and dirty techniques used. Pus was expected and thought of as an indication of normal healing; these techniques were still in use and finally died out during the late 1800’s.
During this period in time there were not many prosthetic alternatives available for the unfortunate amputee apart from basic ‘peg’ legs or ‘hook’ hands, only the very rich could afford to have artificial limbs made.
Knights would have their armourers make some form of prosthesis made for use in battle, some of these devices were fairly advanced but invariably cumbersome and heavy and therefore only of use in battle. Arms would be made to hold a shield and legs would be set up to ride, using stirrups; these would not have been any use at all for normal daily uses such as walking. When a knight returned from battle he would probably have used a peg leg or hook hand (depending of course on the amputation site) for daily use.
Limbs at this time would have been more cosmetic than of functional use, usually to hide the disgrace of weakness from defeat in battle. Armourers could sometimes make the prosthesis look like an extension of the original armour. Although they had knowledge of the human body they did not know much about creating a more functional limb. Watchmakers joined the throng later in time to make intricate internal equipment with gears and springs etc.
Many of the recorded amputations were more to do with traumatic injury during battle, but also many were due to leprosy.
The battle of Crecy hailed the use of gunpowder and cannon shot, with this came the end of the age of armour, but it introduced a new and massive cause of trauma and this would have a great impact on future wars and thus on the traumatic injuries.
Agony and surgery were inseparable in the centuries before anaesthesia. This woodcut is dated 1517, a clenched fist close at hand represents anaesthesia
With the renaissance period the scientific and medical practices began by the Greeks and the Romans was reborn.
As the systems of government in Europe became more central cities, then universities began to rise where the sciences and the arts could be recorded and grow.
A German mercenary knight, Gotz von Berlichingen (1480-1562) had an arm made of iron which was an advanced example of prosthetic implements made at this time; he had a reputation as a ‘Robin Hood’ type because he protected the peasants from oppression, he lost his arm in 1508 at the battle of Landshut when friendly cannon fire struck his sword and as it fell, severed his arm, hearing of another knight who used an iron prosthetic hand in battle, Gotz had two made, these for the period where mechanical marvels, each of the joints could be moved separately by using the ‘sound’ hand and then relaxed by spring releases. The hand could pronate and supinate, the arm was suspended by leather straps and although it was not powered by use of the body it was a great attempt at making a functional prosthesis.
There are other accounts of functional limbs, such as the Alt Ruppin hand, ‘fished out’ of the river Rhine around 1858; it was believed to be from around the 1400’s.
During the 16th century an Italian surgeon wrote of his travels to Asia and told of a bilateral upper limb amputee who was able to sign his name, open his purse and remove a hat he was wearing.
There is also a story of admiral Barberossa who fought against the Spaniards about 1512, in Bougie, Algeria; he had an iron hand made for the left hand he lost.
Hans von Gersdoff, during 1517, recommended the use of a tourniquet, made from pig or cow’s bladder, for compression, cautery and dressing using warm, not boiling oil.
The first educated and scientific German surgeon, Wilhelm Fabry, wrote about amputations above gangrenous levels and describes the use of tourniquets, this was circa 1593.
Ambroise Pare (1510-1590) probably provided the greatest contribution to amputation surgery and prosthetic science of this period; he was a barber-surgeon in the French army.
He reintroduced the use of ligatures made of linen first suggested by Hippocrates and Celsus, when he ran out of oils used for cautery during battle surgery. Time was still a limiting factor, a surgeon without the benefit of any anaesthetics, tourniquets or skilled assistants was limited to about 30 seconds to amputate and about three minutes to complete the operation, and this was not much time for a surgeon to ligate major arteries etc and why this usage was abandoned as a method of cautery by the likes of Guillemeau, who was a student of Pare.
It was to be later that use of the tourniquet would be introduced by Etienne J Morel, a French army surgeon in 1674 during the siege of Besancon and that ligation would have a more widespread use, and therefore amputation became more of a life saving technique.
Also invented by Pare was the upper and lower extremity artificial limbs that provided a basic knowledge of prosthetic function.
“Le Petit Lorrain”, a hand operated by catches and springs, was provided for a French army captain which was used by him in battle. Pare also devised an above knee artificial limb which was a kneeling peg leg and foot prosthesis, it had a fixed equinus position, an adjustable harness, control for locking the knee and other features still in use today.
Age of Exploration and Invention
The Growth of Modern medicine,
From the 1600 to the 1800’s there were great refinements in surgical and prosthetic techniques previously developed during the renaissance, the invention of the tourniquet, anaesthesia, analeptics, blood clotting styptics and disease fighting drugs brought medicine into the modern era and also made amputation surgery an accepted curative measure as opposed to a last ditch effort to save life. The surgeon hence had more time to make the residual limb (stump) more functional and therefore allow the prosthetist to make a more appropriate prosthesis.
An English surgeon, Edward Alanson, suggested in 1782 an amputation technique in which tissue was cut in a hollow conical manner, using skin flaps.
Napoleons personal surgeon, Dominique-Jean Larrey, made use of ambulances that would pick up the wounded immediately, he also tried using refrigeration as a local anaesthetic and is said to have carried out over 200 amputations in 24 hours!
A physician, Crawford Long from Athens, Georgia, USA, was the first to use sulphuric ether for anaesthesia, and William Morton, a dentist from Massachusetts proclaimed its use. In 1847 Chloroform was discovered by Pierre Jean Marie Flourens.
Chief of surgery at the University of Glasgow, Scotland, James Syme performed his first innovative ankle disarticulation in 1842 and was followed by a Russian surgeon, Pirogoff, with his own version in 1854. Rocco Gritti of Milan, Italy, in 1857 described a knee disarticulation technique using the patella as a protective “flap”.
Styptics such as Alum, Vitriol, Turpentine and oil were used to clot blood, but oil may have been used, unknowingly, as an antiseptic. But with all these advancements the patient was still susceptible to infection. In 1842 hospitals in Paris, France, were said to have a mortality rate 62%, and it was even higher for amputation patients, even for a digit amputation! Surgeons seemed to lack the cleanliness valued in everyday life, it is said that it was safer to have a limb amputated by gunfire rather than a surgeon!
As late as 1880, surgery assistants held sutures in their mouths.
Reacting to studies of English surgeons, Monro (1752) and Alanson (1782), Joseph Lister, son in law of James Syme, and now surgeon in chief at the university of Glasgow, experimented with antiseptic surgical techniques in 1865, the results were not published until 1867, subsequently these results were taken to the USA, but not until 1877 by a Captain Gerrard, so it was only a 129 years ago that doctors in the USA started washing their hands. Lister also advocated using cat gut as a suture alternative since silk and hemp could cause inflammation and severe haemorrhage since the body was unable to absorb it.
1600-1800’s – Development of Prostheses
Many of the prostheses developed early during this period were merely refinements of earlier, armour type of devices, they were heavy and bulky, but over a period of time gradually became more functional.
A number of examples of artificial limbs are housed in the Stibbert museum in Florence, Italy. Some of these devices show contributions from other craftsmen such as woodworkers and watchmakers, they show more functionalism than anything else and sacrifice aesthetics, thus indicating more common use.
In 1696 a Dutch surgeon, Pieter Andriannzoon Veduyn introduced the first non locking below knee prosthesis, it showed a striking similarity to today’s knee joint with corset type prosthesis, like the present type of limb it had external hinges and a leather ‘cuff ‘ which bore the weight, the socket was lined with leather and had a copper shell and a wooden foot. In 1800 James Potts of London designed a prosthesis that consisted of a wooden shin and socket, a steel joint and an articulated foot that was controlled by catgut tendons from the knee to the ankle. It was subsequently used by the Marquis of Anglesey who had lost his leg during the battle of Waterloo, and it became known as the Anglesey leg. Flexion of the knee caused the foot to dorsiflex and extension of the knee caused the foot to plantar flex, it has also been referred to as the ‘Clapper Leg’ because of the noise it made with the wooden ‘foot stops, or the ‘Cork Leg’ because it was widely used in county Cork, Ireland. In 1839 William Selpho introduced the Anglesey limb to the USA.
Dr Benjamin F. Parker, a patient of Selpho, was granted a patent in 1846 for his leg which was improved upon the Selpho leg by adding an anterior spring, smooth appearance and concealed tendons. It was honoured at the London world fair in 1851, it was said to have ‘imparted a life like elasticity and firmness in the step’.
Dr Douglas Bly of Rochester, NY, USA, invented and patented ‘Dr Bly’s anatomical leg’ in 1858, he called it ‘ the most complete and successful invention ever attained in artificial limbs’, he is said to have introduced the first curved knee joint.
The prosthesis also provided inversion and eversion of the foot by means of an articulated ankle: a polished ball in a socket of vulcanised rubber, however Dr Bly did recognise that his invention had its limitations: “Though the perfection of my anatomical leg is truly wonderful, I do not want every awkward, big fatted or gamble shanked person who always strided or shuffled along in a slouching manner with both his natural legs to think that one of these must necessarily transform him or his movements not specimens of symmetry, neatness and beauty as if by magic- as Cinderella’s rats were turned into coachmen.
The Anglesey leg became known as the American leg when an A A Marks in 1856, gave it knee, ankle and toe movements and an adjustable articulation control.
Peter Ballif in 1881, a Berlin dentist first gave the upper extremity limb prehension control by means of a shoulder harness and with a chest strap, this same principle was used in 1884 by a Dutchman, Van Peeterson, for elbow flexion. In 1867 Comte de Beafort illustrated and published an elbow flexion lever device mounted on the chest that he developed in 1855.
The Age of Entrepreneurship – The American Civil War
The American civil war 1861-1865 marked the first example of modern warfare and with the post-war industrial revolution began the age of entrepreneurship. It was fuelled by the ‘Great Civil War Benefaction’ by the US government which produced competition by providing artificial limbs to veterans of the war. This was a government’s first commitment to supply limbs to veterans and whose support is still important today. New designs of prosthesis were being constantly developed. Extraordinary claims were being made in the name of attracting business and veterans’ money. Many of the ideas were only superior to a select number of patient cases; no real system of prosthetic prescription was as yet devised.
Shysters and charlatans abound in history at this time. There was a great amount of amputations (30,000 in the Union army) In 1862 the US government guaranteed artificial limbs for the veterans who had lost limbs during the war. A southern soldier J E Hanger, who had lost a leg in 1861, replaced the then used catgut tendons of the ‘American Leg’ with rubber bumpers to control plantar and dorsiflexion, he also used a ‘plug fit’ wooden socket, he subsequently opened a clinic in Richmond, Virginia USA, his son later set up the firm of J E Hanger & Co in England after the first world war.
Later a rubber foot, the fore runner of the SACH foot came into use and eliminated the articulated and complicated ankle of the Bly leg
In 1863 Dubois D. Parmlee devised an advanced artificial limb which had a suction socket, polycentric knee joint and a multiaxial articulated foot.
In 1868 a Dr August Gustav Hermann of Prague, suggested the use of aluminium instead of steel.
In 1885, Heather Bigg wrote a pioneering book on amputation and prostheses, in it he detailed instructions on placing the prosthetic knee joint posterior to the anatomical knee centre and emphasised the importance of correct alignment.
During this time with governmental money a great number of clinics opened in the USA. In 1917 there were about 200 clinics and a skilled workforce of about 2000.
At this time many extraordinary claims were being made, such as the Bly leg. Many of the manufacturers were amputees themselves and thought their inventions would be a ‘cure all’, in reality it would fit only themselves and a small select patient group.
Around 1912 with the infant aviation technology, an English aviator, Marcel Desoutter, who had lost his leg in an aeroplane accident made the first aluminium prosthesis with the aid of his brother, Charles, an aeronautical engineer. This was followed by similar advancements by Hanger.
Other inventions by Desoutter and Hanger, such as the development of the pelvic suspension rather than shoulder suspension provided a more stable and efficient way of operating the prosthesis and provided a more direct control of the knee, this led to more advanced knee control systems such as the knee brake.
In St Thomas hospital, London, which could be taken as a snapshot of the country as a whole, during 1913, just before World War I, out of 5,483 major operations only 34 were amputations, a ratio of 1:161, in that year too the Royal surgical Aid Society, responsible for all types of appliances, not only in London but also the provinces, supplied only 529 artificial peg legs and arms out of 41,483 appliances, in short as an industry limb manufacturing was on the periphery
A display of new limbs from Bigg and Grossmith from the Great International Exhibition at St Thomas’s Hospital in 1862
With the onset of the First World War, prosthetists were a ‘varied lot’; some were at times unconcerned for the patient’s needs but more for their own pride and greed. Surgeons were reluctant to confide with them because they were frequently ‘ambulance chasers’, sort of shysters preying on the amputee. This though set the stage for leaps in technology of the two world wars and into the modern era.
World War I, Depression and World War II
As the First World War began 1914-1918, prosthetists remained an independent and competitive group, more so in the USA, they rarely worked with surgeons let alone each other.
Amputee casualties in the US (4,403) were much smaller than the British (42,000) and the European armies (100,000) this resulted in the European prosthetists jumping ahead of their US counterparts in the experimental stakes.
Recognising this lack of care for amputees in the US, the Surgeon General of the army invited prosthetists to Washington DC to discuss prosthetic technology and its development within the country. From this meeting arose the present day A.O.P.A. (American Orthotic and Prosthetic Association).
This development, wrote one historian, “contributed more to the development of the science of prosthetics than any other occurrence in its history”. Through this forum prosthetists could develop ethical standards, scientific programmes, educational programmes and build better relations with other health professionals.
In 1918 a Dr Martin described the Belgian prosthesis, which emphasised the anatomy and physiology of the leg.
This prosthesis was an improvement on the standard ‘American Leg’, it could reproduce the natural static and aesthetic appearance of the lower limb and was made from measurements and a modified cast of the sound and residual limb.
Because of the relatively low amount of amputees from World War I, and the economic depression, prosthetics advanced very little to the beginning of World War II, many of the advances made in Europe had not yet reached the USA.
As World War II raged on the American amputee casualty list grew, these veterans found that the current technology (that had not changed much since the 1800’s) inadequate. In response to this Normal Kirk, the surgeon general US army requested that the National Academy of Sciences investigate the prosthetic situation.
It was originally thought that only a few designs and studies were necessary, but it soon became apparent, when the surgeon general bought in a team of engineers from Europe in 1946, that the US lagged a long way behind. It was during this period that the orthotists joined the American Limb Manufacturers Association, making it the Orthopaedic Appliances and Limb Manufacturers Association, in 1950 the name changed to A.O.P.A
Modern Era: Research and development
The research launched a quantum leap for prosthetic science. The artificial limb programme in the USA was sponsored by the Veterans Administration (VA) H.E.W, and the armed services by establishing a number of research laboratories. Research was also carried out by the Navy at Oakland Naval hospital, US army air force at Wright Field, Northup Aviation, Cantaris and New York University.
Socket designs such as PTB and the quadrilateral were investigated and refined further at this time. Materials also improved, Northup aviation introduced the use of thermosetting resins to form custom fit sockets and structural components. This led to the development of the SACH foot. Total contact fit sockets now became possible along with clear check sockets. Prosthetic knees such as the Mauch S-N-S system were developed.
Educational seminars for new techniques and components began in 1947 and pilot courses in prescription, fabrication and alignment of the above knee prosthesis were run.
1956 marked the development of the SACH foot from the University of California and in 1959 the PTB prosthesis was developed at the University of California Berkley.
In 1960 the Stewart-Vickers hydraulic leg became available and was improved with the Hensche-Mauch S-N-S systems. In 1968 the modern hydraulic Hensche-Mauch S-N-S knee was developed when it became apparent that hydraulic support in swing was not adequate. The Thalidomide tragedy also resulted in additional impetus for more advanced prostheses.
Different prosthetic procedures resulted when prosthetists began working with surgeons. Marian Weiss of Poland experimented with immediate post operative fittings in 1963, in the same year Guy Fajal of France developed the PTS or PTB SC-SP.
1964 brought prepatory fittings to the US from Dr Burgess of Seattle. In 1967, Carlton Fillauer from Chattanooga refined Dr Gotz-Gerd Kuhn’s BK prosthesis and was known as the ‘Removable Wedge’.1970 marked the inaugural year for I.S.P.O, (international society for prosthetics and orthotics)
1971 saw the introduction of endoskeletal components with soft form covers (fairings)
Since then many new techniques and components have become available but it is beyond the scope of this study (at the present!) The above is only a brief outline of the numerous advancements made throughout the world. The surgeon and prosthetist are working in a field which can draw upon the past but also advance steadily into the future.
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