Colonial Williamsburg Digital Library

BONING UP ON AMPUTATION

"Amputation, is the cutting off any Limb, or Part of the Body."¹ Amputation, probably the most commonly performed major operation of the 18th century, was performed for a variety of reasons which included gangrene, mortification, bad compound fractures, extensive wounds of the muscles and bones, caries and tumors of the bones, cancer, extensive ulcers, disorders of the joints, and distortions of the limbs. The condition for amputation determined when the operation would be performed. For many conditions the amputation did not take place immediately, but after a period of time had elapsed. For example, when cancer was the diagnosis, the operation was performed only after all medical treatment failed. Immediate operations were only performed when there was no possible chance of recovery, such as the shattered bone that couldn't possibly be repaired. These general rules applied most in private practice; however, the military surgeon did not often have the luxury of time and space, and as a result, amputation was more routinely performed.

In a private practice an amputation was usually performed in the home with the patient laying on a table for a leg and sitting in a chair for an arm amputation. The surgeon's equipment included a variety of bandages and compresses, a tourniquet, retractors, various knives, a saw, sponges and warm water, digestive ointments, and a crooked needle and thread. Four assistants were usually necessary to assist the surgeon, one to hold the limb, two to hold the patient and one to assist with the operation itself. Laurence Heister in 1743 recommended six assistants, three holding the patient, two assisting the surgeon, and the last was available to assist either the surgeon or the patient. The room needed to be well lit, natural daylight was preferred, and excess onlookers were discouraged. If the operation was performed in a hospital operating theater, surgical students and the general public were invited to view the scene. While the operating room was being prepared, the patient was also being prepared. Traditionally the patient was bled and purged before an operation; but, by mid-century bleeding and purging were no longer mentioned in textbooks which described amputation procedures. This may be due to its no longer being practiced or because it was routine and simply not considered necessary to mention. Heister recommended administering wine or cordial before the operation to prevent the patient from fainting during the operation. No form of anesthesia was administered because it did not exist; however, according to Benjamin Bell in 1788, some type of narcotic, especially opium, might be given before the operation "for the purpose of lessening the general sensibility," but opium produced serious side effects and was often not used before the operation but immediately after.

The first step was to tie a piece of tape or rag around the limb to be amputated. This tape acted as a cutting guide. Next a tourniquet was applied above the area of amputation and usually over the main artery that supplied the limb. "The course of the Blood being stopped, you must begin your Incision just below the Linen Roller, on the under Part of the Limb, bringing your Knife towards you, which at one Sweep may cut more than the Semi-circle; then beginning your second Wound on the upper Part, it must be continued from the one Extremity to the other of the first Wound, making them but one line."³ This circular incision was made down to the muscles. The linen roller was then removed and the skin drawn up. Another circular incision was then made at the edge of the previous wound through the muscles down to the bone.

There are some minor variations of the cuts through the fleshy tissue, such as not using a guide tape and pulling the skin taut before the initial cut, however; the most significant variation is the flap amputation. The flap amputation was most commonly performed on the lower leg where the soft tissue is not evenly distributed around the bones. Instead of making a circular cut, a semi-circular cut was made over the shin. From the end points of the semi-circle, a double-edged scalpel was used to cut straight lines leading toward the foot, ending in another semi-circular cut (see Fig. 1). Fig. 1 This cut was to be made in proportion to the size of the limb. In order for the straight cuts to be the same length and eventually meet, it was recommended that the surgeon mark out the flap with ink.

The next step in the amputation was to get through the bone. Before the bone was sawed through, the muscles had to be separated from the bone "and it is easily done by inserting the point of the common amputating knife between them, and carrying it freely round from one side of the limb to the other. This being done, the muscles and teguments must be drawn up as far as the muscles have been separated from the bone."⁴ The retractors used to draw the tissues could be made of a linen rag, slit leather, or iron. The tissues were retracted approximately one inch. The covering around the bone was then divided with a knife directly below the retractor. "At this place the saw should be applied, and with long steady strokes the bone should be divided."⁵ "The Assistant who holds the Leg while it is sawing, must observe not to lift it upwards, which would clog the Instrument; and at the same time, not to let it drop, lest the sight of the Limb should fracture the Bone, before it is quite sawed thro'."⁶

The position of the operator was important and was determined by the part of the limb being amputated. When sawing through the lower leg or forearm, the operator would be on the inside, and when amputating through the upper part of the limb, the operator would stand on the outside. "And thus in one minute or two the Amputation may be compleated."⁷

Next, the operator needed to stop the bleeding and close the wound. By the 18th century the established method of closure was with the crooked needle and thread. "The retractors should now be taken off; and the trunk of the femoral artery being drawn out with the tenaculum, a sufficient ligature should be made upon it before the tourniquet is loosened: But as the muscular branches of this artery cannot be discovered as long as any compression remains upon them, the screw should be immediately untwisted so far as to remove it entirely. All the clotted blood should be now removed from the stump with a soft sponge soaked in warm water; and every artery that can be discovered should be secured with a ligature, care being taken to leave the ends of the threads of a sufficient length to hang out without the lips of the wound."⁸

Different types of wound dressings, from styptics to protective cerates, would now be applied. The lips of the wound would be held in place by adhesive plasters. Soft compresses were then used to cushion the stump before a long roller bandage was applied to secure the whole area.

The patient was then put to bed. His diet and regimen were regulated, and medications for pain and fever were administered as necessary. "When anodyne, or antiphlogistic medicines become necessary, after any of the preceding operations, they are to be exhibited according to the nature and urgency of the symptoms which are seldom exactly alike in any two cases."⁹

The wound dressings were changed more frequently at first. As the wound healed and the ligatures fell off, the dressings were changed less often. "In renewing your Dressings, it is chiefly necessary for you to observe, that your Wound be well and gently cleansed from all foul Matter with Lint, of which tha[t] next the Wound should be armed with some digestive Ointment, and the rest applied dry."¹⁰ "As soon as the sore is observed to be perfectly clean, with granulations sprouting up in different parts of it, as the pain and tension will now be quite removed, we may with safety venture to complete the cure, by drawing the edges of the wound together by adhesive plasters."¹¹

How long should the cure of the stump take? In 1743 Heister suggested for an amputated forearm about two months. In 1788 Bell writes about the amputation of the thigh, "By this management, even the largest stumps will for the most part be healed in three or four weeks; often in less. But it must be remarked, that although we may in general depend on this in private practice, when every circumstance that can conduce to the welfare of the patient will meet with attention, and where especially we may always obtain a well-ventilated apartment and proper diet; yet in public hospitals, where those points cannot be duly attended to, and where the patient often suffers more from the bad air which he breaths, than from the operation itself, the success attending it will not in every case be so great."¹²

Success rates are hard to determine. There are very few eighteenth-century reports noting the success or failure of the procedure once it had been performed. In 1752 Monro I. reported a mortality of only 8 percent for the Royal Infirmary of Edinburgh.¹³ This is an extraordinary record in view of nineteenth century pre-antiseptic reports of 48 to 50 percent mortality. Whether the eighteenth-century "standard" mortality rate was 8 percent or closer to 50 percent, the eighteenth-century surgeon performed remarkably well without anesthesia or antisepsis.

BIBLIOGRAPHY

• Alexander Monro I., "Remarks on the amputations of the larger extremities." Medical Essays & Observations, 4th ed., Edinburgh, 1752.
• Bell, Benjamin. A System of Surgery. vol. VI, Edinburgh: printed for Charles Elliot, C. Elliot & T. Kay, and G. G. J. & J. Robinson, 1788.
• Gooch, Benjamin. Cases and Practical Remarks in Surgery. London: printed for D. Wilson and T. Burham, 1758.
• Heister, Laurence. A General System of Surgery. London: printed for W. Innys, C. Davis, J. Clark, R. Manby, and J. Whiston, 1743.
• Jones, John. Plain Concise Practical Remarks, On the Treatment of Wounds and Fractures. Philadelphia: printed by Robert Bell, 1776.
• Le Dran, Henry Francis. Observations in Surgery. London: printed for J. Hodges, 1739.
• Muzell, Frederick. Medical and Chirurgical Observations. London: printed for A. Linde, 1755.
• Quincy, John. Lexicon Physico-Medicum: or, A New Physical Dictionary. London: printed for Andrew Bell, William Taylor, and John Osborn, 1719.
• Sharp, Samuel. A Treatise on the Operations of Surgery. London: printed for J. and R. Tonson, 1761.
• Warner, Joseph. Cases in Surgery with Remarks. London: printed for J. and R. Tonson and S. Draper, 1754.
• White, Charles. Cases in Surgery with Remarks. London: printed for W. Johnston, 1770.