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The word amputation originates from the latin amputare history essay

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Amputation of an irreparable limb is one of the oldest and most traumatising surgeries ever performed. History has moulded the techniques and reinvented surgical instruments into what, is today a safe and effective way of saving a life. In the United Kingdom from April 2006 to March 2007, 4957 amputations were performed(1). Many surgical developments were brought about through the evolution of amputation and today’s modern techniques and instruments all arose through pioneers attempting to make amputation safer and more successful. The word amputation originates from the Latin amputare which means ” to cut off” or ” to prune”(2). In ancient Peru we find drawings and figurines depicting amputated limbs, these amputations would have been performed with a stone knife call a tumi and a saw made from flint or obsidian set into wood or a jawbone(3). In first century Rome, Celsus described amputation of a gangrenous limb(4). He clearly stated that one should cut through the soft tissue at the border between the sick tissue and the healthy tissue until the bone has been reached. Following this the healthy tissue should be pulled back and the bone cut as near as possible to the healthy soft tissue there after the bone is to be polished and the skin sutured over it. The 16th, 17th and 18th centuries are probably the most significant time in the development of limb amputation technique and the evolution of amputation parallels the maturation course of surgery throughout these centuries. A. Paré(1590) made one of the most important steps in the development of a safe method of amputation. He was the first person to make use of ligatures to reduce the amount of blood lost during the amputation. He ligated the bleeding vessels instead of using cauterization as was previously done. He would then apply hemostyptic substances such as vitriol and hot oil(4). The introduction of using a tourniquet some 80 years later, this was brought about by a French barber surgeon Morell who is said to have made use of a tourniquet during the battle of Besancon in 1674(4). Through my reading on the general history of amputations I discovered some interesting facts that needed further researching. The first fact was that painless amputation could have been performed many years before the discovery of anaesthesia and the second that the use of ligatures, whose discovery is attributed to Ambrose Paré, had been around and used by Celsus in first century Rome(5). The aim of this paper will be to look at why these two major discoveries were not made and if they were why they weren’t made use of or why they were forgotten about for hundreds of years before being rediscovered and attributed to someone else. The justification of this study is to use history to identify how new ideas get disseminated.


” History of amputation” term search using JSTOR online catalogue, looked for and selected relevant articles and accessed them through the University online library catalogue.” History of amputation” term search using the Wellcome Library online catalogue and gained access to relevant journals through the University online library catalogue.” History of amputation” term search using University of Liverpool search engine, Discover. Selected and accessed the relevant articles. Term searches using JSTOR online catalogue using the terms ” painless amputation” and ” Discovery of ligatures”. The relevant books and articles were selected.


Amputation without pain: the discovery never discovered

James Cooke’s account of amputation in 1685(6): ” Dismembering is a dreadful operation; yet necessary, that the dead part may not injure the living, nor procure death . . . let one man be at the patients back holding him, and another before him, holding the upper part of the limb; and a third holding that part that must be taken off . . . you are to make strong ligature with broad tape . . . about three inches above the place you intend to incise . . . and let him that has the gripe haul up the muscles tort . . . this done (and the man having had a spoonful of cordial to cherish him), you must with your dis-membring knife, take two large slashes round the part in the form of half rounds, and let one meet the other as evenly as possible, and let them be deep enough. then with your catling divide the flesh and vessels about and between the bones, and with the back of your catling, remove the periostium that it may not hinder the saw, nor cause greater torment in the operation. so saw off the bone at as few stokes as possible, and let him that holds the lower part have a care to hold steady least he break the bone before the saw is quite through.”(6) The pain of amputation was simply accepted as is was believed to be the only option when it came to saving a life from an injured or diseased limb. The only way offered to minimise pain was speed, but no matter how fast the surgery was performed the pain and suffering remained(7). Anaesthesia was not discovered until 1844(8), so what else was on offer before then? Well alcohol for one was widely available but it was never used as anaesthesia. A small amount of alcohol was given before the procedure for fortitude but not for anaesthesia(9). The true reason as to why alcohol was not used for anaesthesia is unclear but most surgeons of the time believed that patients had to be alert and mindful to survive the amputation, ” proceed as soon as possible otherwise the patient may be so exhausted to make it very hazardous and his recovery doubtful.”(10) Another substance available was opium which today is widely used for pain relief following such a painful procedure as amputation but not used all those years ago. Opium for the same reason as alcohol had unwanted side effects that surgeons considered not worthwhile. Opium altered a patient’s state of alertness and caused nausea and as with alcohol these are perceived as unwanted side effects by the surgeon(10). A final reason as to perhaps why opium was not used is because only physicians had licence to use drugs and surgeons were but barbers and will have had no formal training and very little idea of the uses of drugs. Another way that amputation could have been made painless was by making use of a tourniquet to induce limb ischemia, which in turn would lead to anaesthesia in roughly 30 minutes and would rapidly recover following release. So why was, this never used to make amputation painless? The tourniquet had been discovered and was already widely used to control bleeding and when any new method or device is used, all manner of new discoveries is usually made surrounding that method or device. So although the prospect of making the discovery of tourniquet anaesthesia must have occurred, I found little to no mention of it in any recent reviews. There were however; a few ideas that could have lead to its discovery. Notes from William Clowes, in 1637 say, ” the pain of the [haemostatic] binding doth greatly obscure the knife and feeling of the incision.”(11) An account by James Yonge’s 1679 says, ” Nor shall the pain of that operation be comparable to what it would be, were not the member numbed by the Compress.”(12) So as we can see this idea of numbing was not that far away and the technique was there but, why was the link never made? Accidental tourniquet anaesthesia most definitely occurred but it wasn’t noticed by surgeons, as they were more concerned with speed and quick responses than taking notice of the unusual effects. They performed surgeries under great stress at war time and didn’t have the time to stop; think, investigate and interpret this phenomenon. Surgeons of the time were barbers who were called upon during the time of need. Clinical researchers whose life revolves around discovery may have discovered this use of a tourniquet sooner but they were not the ones performing the amputations. Thus this failure to recognise and use a tourniquet to induce anaesthesia was almost an unavoidable consequence of the constraints of the time.

Ligatures: A method of controlling bleeding

Ambroise Paré(1510-1590) a French barber surgeon is the person accredited with the discovery of ligatures(3), however there are numerous accounts made hundreds of years before him of the use of ligatures. So why is it that the techniques of those before him were forgotten for so many centuries? It was during these times that cauterization was the accepted method of arresting haemorrhaging. Amputations performed in the earliest of times were done so by only removing dead tissue as Celsus described in first century Rome(4). The reason for doing so was that early surgical techniques could not control the haemorrhaging that occurs from cutting healthy blood vessels. So surgeons in ancient Greece and Rome solved this problem by using the technique of ligating the bleeding blood vessels. Hippocrates(born c. 460BC died c. 375BC) notes that bleeding may be stopped by position, fainting, lint dressing, bandaging and obstructing the blood(5). This obstructing of the blood clearly points to another method distinct from bandaging, however; there is much dispute surrounding this so we cannot be certain Hippocrates knew of or used ligatures. Celsus in his chapter on wounds informs us, ” Take up the bleeding vessel, and, having tied it in two places, to divide between them.”(5) Albucasis(936AD-1013AD) note of four ways to stop haemorrhaging; 1. Cauterisation; 2. The entire section, of the bleeding vessels, its ends then contracting and retracting into the surrounding tissues; 3. The ligature; and 4. The clot which forms in a cut vessel(5). Albucasis is one of the most celebrated surgeons of all time and is considered to be the greatest of all medieval surgeons to have appeared from the Islamic world. So why, was his use of ligatures, detailed some 600 years before Ambroise Pare, not taken up? No definitive answer can be given. Perhaps it is because his literature was written in Arabic and the language of choice used in medicine was Latin. The more likely answer is that Albucasis himself says that neither method is better than the other and that it is the safer option to perform amputation using a red-hot knife(5). Following this period, the priesthood had forbid the shedding of blood in the Council of Tours 1163, apart from the journeymen butchers whom acted under them(5). The journeymen butchers however did not leave evidence of how bleeding should be stopped, so one can speculate that ligatures during this period left out of use as cauterisation was the accepted method to stop bleeding. It takes until 1275 for William of Salicteos to ignore the veto of the Council of Tours 1163 when he writes about haemorrhaging from wounds and reopens the documenting of bleeding control by surgeons. During the period following this through the 13th, 14th and 15th centuries’ cautery was again the favoured method of controlling haemorrhage. John de Vigo, chief surgeon to Pope Julius II in the sixteenth century tell of how amputation should be performed and offers several methods of arresting haemorrhaging including the use of ligatures, thus reigniting its use(5). The great Italian physician Alphonsus Ferrius published a book on wounds in 1534 states, ” When there is bleeding from a wound, stop it with caustics; if they fail, use the ligature.”(5) Still many preferred to use cautery. Come forth Ambroise Paré the future champion of the ligature. Paré arrives in Paris around this time and joins the Barber-Surgeons Company. He goes into the field with the French army on numerous campaigns where he shows an aptitude for surgery and gains much experience from those surgeons around him. Paré soon discovered that in the military cauteries were not as readily available as they were in civil practice, ” In the assault of a city, where diverse soldiers have had arms and legs shot off by bullets, cutlasses, or other instruments of warre, if you should use hot irons to stay the fluxe of blood, it would be needful to have a forge and much coals to heat them.”(5) Influenced by this and having studied John de Vigo’s book he adopted the plan of using ligatures instead of cautery. On his return to France he advocated the use of ligatures over cautery and give the following instructions for amputating a limb, ” Drawing the muscles upwards to the sound parts, let them be tied with a straighte ligature a little above that place of the member that is to be cut off with a strong and broad fillet, like that which women use to tie up their hair withall. This hath a twofold use: first, it holds up the muscle with the skin; second, it prohibits the fluxe of blood. When you have made your ligature, cut the flesh even to the bone with a sharp and well cutting knife; when you shall come to the bone, you shall nimbly divide it with a little saw. When you have taken away the member, the ends of the vessels lying hid in the fleshmust be drawn with this instrument (a forceps) forth of the muscles; and when you have so drawn them forth, bind them with a strong double thread.”(5) So why is Paré accredited as the discoverer of the ligature and not those before him? He had no proof of it being better than cautery but he had experience, which he put to use when demonstrating his technique on the amputation of an ulcerated leg of a man, to John Charbonell, Master Barber-Surgeon of Paris. It was this significant demonstration that brought the heads of colleges down on him and persecuted him for being ignorant and knowing nothing of the subject as he was not well versed in Latin. It was at this point he turned on his persecutors and said, ” Have I not studied long in the hospitals? Have I not been in many battles, and shut up with many wounded men in besieged towns? And how dare such a man as you, who have never made surgery a partof your study, talk of teaching me?”(5) All this attention he received is most likely the reason he is now considered the champion of the ligature as he, more than anyone else is documented to have used the ligature and particularly the documentation of his demonstration for John Charbonell is the first unique mention of ligatures being applied to amputation. Why Paré received this title and those before him did not is open to discussion. In my opinion I think that a combination of language barriers, the fact that surgeons for the most part of history were merely technicians who didn’t have any formal training, and perhaps the most important component was all the negative attention Paré brought upon himself.


Surgeons having achieved the limits of speed and precision for controlling blood loss and reducing pain in the amputation of limbs still needed attentiveness to improve the most traumatic of surgeries. They needed attentiveness to see the problems with amputation and those problems being; 1. The excruciating pain the patient went through and 2. The uncontrolled blood loss, had these problems been identified sooner countless lives could have been spared. These problems were not solved due to the lack of independence from clinical constraints. Clinical advancement only arises when there is time for reflection and experimentation and this underlines the customs and methods of clinical research which differ to those of clinical practice. The gap between research and practice has narrowed but it is still there and if it were not then the retrospective discovery of ligatures, the use of alcohol and opioids for pain and anaesthesia and tourniquet anaesthesia would have been discovered sooner, when it mattered. Further research would more than likely reveal other techniques or developments that were missed like those of opioid and alcohol or tourniquet anaesthesia that hovered on the fringes and were never discover. Further research would also make us aware of things that had once been forgotten, like the use of ligature which were used, as evidence suggests, as early as first century Rome. Further research may also reveal something of great importance to medicine or surgery today, but it has simply been lost in history. We can learn a lot from history, as history has a tendency to repeat itself and as George Santayana (December 16, 1863 – September 26, 1952) said, ” Those who cannot learn from history are doomed to repeat it.” On reflection this paper has shown me the importance of disseminating information correctly and as widely as possible. The spread of information in today’s medical community is far easier than it has ever been before, with the internet at the finger tips of most people around the world one can access the latest and most up to date information on treatments, surgical techniques and research in the medical community. Through technology and the internet even language barriers are no longer a problem as most of today’s information is translated into many different languages and to add to this English is the mostly widely understood language in the world and thus those barriers have been overcome.


There were a few limitations that I encountered whilst doing this article. Firstly I was not able to access all of the articles that I found using the Wellcome Library online catalogue as some of them were not available through the University library catalogue. My second limitation was that some of the original source information was in Latin or French and as I do not read or speak Latin or French they were of little help to me.


1. database NAs. The Amputee Statistical Database for the United Kingdom 2006/07 2009 [cited 2013 28/01/2013]. http://www. limbless-statistics. org/documents/Report2006-07. pdf. 2. Mavroforou S, Fafoulakis F, Balogiannis I, Stamatiou G. The evolution of lower limb amputations through the ages. International Angiology; Dec 2007: 385. 3. Magee R. Amputations through the ages: the oldest major surgical operation. New Zealand Journal of surgery 1998: 675-8. 4. Sachs M, Bojunga J, Encke A. Historical evolution of limb amputation. World Journal of Surgery 1999; 23(10): 1088-93. 5. A. M. Edwards. A Sketch Of The History Of The Surgical Means For Arresting Bleeding From Arteries. British Medical Journal 1860; 1(170): 241-5. 6. Lewis T. The Blood Vessels of the Human Skin and Their Responses. 19277. Moore J. A Method of Preventing or Diminishing Pain in Several Operations of Surgery. 17848. Goldsmith D. The discovery of anesthesia. Anesthesia progress 1974; 21(6): 174-80. 9. Magee R. Amputation through the ages: the oldest major surgical operation. ANZ Journal of Surgery 1998; 68(9): 675-8. 10. Robinson KP. Amputation surgery from 1800 to the present. The evolution of orthopaedic surgery 2002: 175-90. 11. Northcote W. The Marine Practice of Physic and Surgery. 1777. 12. Stanley P. For fear of pain. British surgery 1790-1850.
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