SECT. LXXXIV.—ON AMPUTATION OF THE EXTREMITIES.
Sometimes the extremities, such as a hand or a foot, having mortified, so that the bones themselves are corrupted, either from having been fractured by some external means, or from having become putrid owing to some internal cause, it is necessary to saw them off; before doing which the parts surrounding the bones must be divided. But since, when this is done first, as a considerable time is required for the sawing, there is danger of a hemorrhage taking place, Leonides properly directs us not to divide all the parts at once unless they are completely mortified, but first to cut the part where not many nor very large veins or arteries are known to be situated, down to the bone quickly; then to saw the bone as expeditiously as possible, applying a linen rag to the parts which have been cut lest they be torn by the sawing and occasion pain, and then having cut through what remains, to apply red-hot irons to the vessels and stop the hemorrhage thereby with compresses of lint, and to apply proper bandages with the dressings suitable to suppurations.
Commentary. Hippocrates and Galen recommend amputation to be performed in general at a joint. (De Articulis, Galeni Comment. t. v, p. 650, ed. Basil.) Hippocrates says complete excision may be performed at the joints of the hand and foot, and at those of the wrist and ankle, and generally with safety, unless the patient be cut off by fainting, or continual fever supervene on the fourth day. When gangrene attacks a fractured limb, his rule of practice is to let the parts drop off, and he remarks, many persons thus recover, even when the fracture is seated in the femur. When gangrene comes on without being preceded by fracture, he directs the soft parts, as soon as they have lost all sensibility, to be removed at the nearest joint below, and the surgeon is to wait until the bone also separates. He says he had seen the bone of the thigh thus separate on the eightieth day; in that case the limb below had been removed at the knee on the twentieth day. In a similar case of gangrene of the leg, the bones separated on the sixtieth day. He pronounces gangrene of the extremities to be more formidable in appearance than in reality. He recommends a mild and anti-inflammatory treatment, and that the limb should be laid in an elevated position as long as there is any fear of hemorrhage. Violent attacks of dysentery are apt to come on, but do not generally prove obstinate. (De Artic. 69.) It would appear from Thucydides and Lucretius that it was not uncommon to amputate in cases of gangrene in the days of Hippocrates. (See their Descriptions of the Plague of Athens.)
In cases of gangrene Celsus directs us to make an incision of the flesh, between the sound and corrupted part, down to the bone, which is to be sawed across, and after the asperities have been removed from the end of the bone, the skin is to be brought over the stump. (vii, 33.) He gives us no particular description, however, of amputation of the extremities. We turn, therefore, to the celebrated fragments of the works of Archigenes and Heliodorus, preserved in the collection of Nicetas, published by Cocchius. (Chirurgici Græci, Florent. 1756.)
Archigenes begins by stating the circumstances which require recourse to be had to amputation. They are, the presence of some intractable disease, such as gangrene, necrosis, putrefaction, cancer, certain callous tumours, and sometimes wounds inflicted by weapons, and the like. Before attempting the operation he recommends us to consider well if the patient’s strength will enable him to endure it. The operator must then tie or sew the vessels which pass to the parts; in certain cases a ligature is to be applied round the whole limb, cold water is to be poured upon it, and some are to be bled. Amputation near the joints is not to be attempted. In such as are of a full habit of body, a circular band is to be put round the limb, to draw up the skin with, and to direct the incision. After cutting down to the bone, the tendons are to be retracted, and the bone scraped and sawn. When much blood is discharged, red-hot irons are to be applied, and a double compress laid on the part from which the blood proceeds. Having loosened the band, a cataplasm of leeks, bread, and salt is to be applied to the stump; and the parts about the jaw-bone are to be anointed with cerate of iris and old oil, doubtless in order to obviate the danger from tetanus.
Heliodorus states that a limb may require to be amputated owing to gangrene or any other cause that occasions the death of it. In the extremities, then, he remarks, amputation may be performed with less danger; but above the knee or elbow the danger of hemorrhage from the great vessels being wounded is very considerable. Some, he says, from too great anxiety for despatch, cut through all the bodies (the soft parts?) at one incision, and then saw the bones. But this method of removing the limb is not unattended with danger, as many vessels pour forth blood at the same time. “Wherefore,” he adds, “it appears to me better first to divide those parts of the limb where there is least flesh, as on the anterior part of the leg, and then to saw the bone; and I myself am in the practice of first applying a ligature above the part of the limb which is to be sawn across, and then of operating in the manner described. In sawing the bone the plate of the saw ought to be applied even, in order that the sawing of the bones may be even. When the bones are sawed the other parts which remain undivided are straightway to be cut through with a scalpel, and large pledgets applied along with suitable compresses. External to these, sponges with suitable bandages are to be put on. After the third or fourth day, when all fear of hemorrhage is over, suppuration is to be promoted by suitable dressings.”
In no other of the Greek medical works which have come down to us is there any description of amputation of the extremities.
Avicenna mentions the operation of sawing off the bones of the extremities, but in such general terms as gives us no information in what manner it was performed. (iv, 4, 4, 10, 11, 12.)
The description given by Haly Abbas is more complete. A limb, he says, is amputated thus. The operation is to commence with first cutting the skin, and then when the bone of a limb is to be sawn, you must not cut through the whole flesh at once, lest an immoderate discharge of blood take place from the veins and arteries so as to occasion the death of the patient and interrupt the process of sawing the bone; except the flesh of the limb be wasted or putrid. But you ought first to divide that part of the flesh where no great arteries and veins are situated, cutting them down to the bone, which is to be sawn across as quickly as possible, the fleshy parts in the mean time being retracted with a piece of linen, lest the saw should tear them and occasion bleeding and pain; when the bone is sawn across, whatever portion of the flesh remains undivided is to be cut, and then the veins and arteries are to be burned. When the bleeding is stopped a pledget with suitable bandages is to be applied. (Pract. ix, 65.)
Albucasis represents amputation as necessary in cases of mortification, as indicated by the smell and discoloration. When the disease is seated in the hand, he recommends us to amputate at the fore-arm; when in the forearm, at the elbow; and if the arm itself be affected, he pronounces the case to be hopeless. In like manner, with regard to the lower extremities, he pronounces all cases incurable in which the disease is seated above the knee. In performing the operation he directs us to apply two bandages around the limb, the one above and the other below the place at which it is to be cut off. These bandages are to be pulled, the former upwards and the latter downwards, by two assistants, so as to put the skin upon the stretch; the fleshy parts are then to be divided with a large scalpel down to the bone, which is afterwards to be cut out, or sawed across, and during this part of the process a piece of linen is to be applied around all the fleshy parts, to prevent them from being injured by the sawing. Should any hemorrhage occur during the operation, he directs us to apply the cautery, or a styptic powder; and after the operation he recommends us to bandage the limb in a suitable manner, until the stump is healed. He relates a case, from which the timidity of his own practice is rendered very apparent. A person who had a spreading mortification in the foot, cut it off at the ankle-joint himself, and was cured for the time. The disease next attacked the hand, upon which he applied to Albucasis, requesting that he would cut it off in the same manner, but this he refused to do, for fear that the man’s strength might not be able to endure the operation. He afterwards learned that the man had cut off his whole hand, and had recovered. (Chirurg. ii, 89.) The history of this case proves decidedly that the operative surgery of the Arabians, in the days of Albucasis, must have been very defective; this he himself frankly confesses, for he declares that all knowledge of this art had been lost, except what vestiges of it had been preserved in the works of the ancient authors, whose descriptions, he complains, had been mutilated and corrupted. (Prefatio.) We mention this, in order that the ignorance which prevailed in his time may not be imputed to all preceding ages, nor may be used as an argument against the genuineness of the extracts from the works of Heliodorus and Archigenes, given above.
Rhases makes some interesting remarks on the sawing of bones. He directs us to stretch the flesh upwards and downwards, with a piece of cloth, so that it may not come in the way of the teeth of the saw. When it is necessary to saw a rib or a bone, near any important membrane or organ, he recommends us to use a plate (tabella), to protect the soft parts from the saw. When the bone connected with a joint is diseased, he directs us to extract it at the joint. When the os brachii, or tibia, is diseased, he recommends us to extract it entire, but forbids to meddle with the head of the femur or the vertebræ. In another place he declares it as his opinion that when a joint is swelled, and the bone diseased, (in cases of white swelling?) it will be impossible to effect a cure unless the whole diseased portion of the bone be cut out. (Cont. xxix.) From these passages it is quite obvious that the ancients practised excision of the bones of joints. See also what our author says on this subject in [the seventy-seventh section] of this book. A Cooper or a Liston could not recommend a bolder plan of treatment in such cases.
Theodoricus, Guy of Cauliac, and the other surgical writers of that age, follow closely in the footsteps of the ancients, especially of the Arabians. When the mortified part is near to a joint, they recommend amputation at it. In other cases they direct us to make an incision between the sound and the dead parts, to saw the bone with a fine saw, and to stop the bleeding with a heated iron. Theodoricus recommends stupifying medicines, such as opium, hyoscyamus, mandragora, or cicuta, before the operation. Ambrose Paré has undoubtedly the merit of introducing the use of the ligature into modern practice in amputations, and, in fact, Archigenes seems to be the only ancient authority who mentions it in such cases. We have shown, however, in another place, that the ligature was freely used by the ancients for stopping bleeding from wounds.