Amputation: history, causes, procedure

Dr. Utz Anhalt

Amputation: history, causes, procedure

Amputated leg. Walking aids allow a normal life. Image: ottoblotto – fotolia

Removal of limbs
Amputation means to artificially separate a body part from the body, usually surgically, to save a person’s life, or when the severed part cannot heal, or as a punishment.

Origins in the Stone Age

Amputations are among the earliest medical procedures we know of, and Stone Age people were already severing body parts – 10 years ago.000 years.

Amputated leg. Walking aids allow a normal life. (Image: ottoblotto/

In the advanced civilizations of the Near East and in the Old Testament, cutting off the hand was the punishment for theft, which proves that amputations were also common here.

Cornelius Celsus (50 v. Chr. Until 50 n. Chr.) discussed cutting away as a medical method: "We therefore make an incision with a knife down to the bone between the healthy and the diseased tissue (…) taking care that a piece of healthy tissue is cut away rather than that a piece of diseased tissue remains."

Greco-Roman physicians knew various treatments to heal the amputation wound. Thus, Archigenes, the wound surgeon, thought it proper to ligate the limb before amputation and then anneal it with a branding iron.

Scholars argued over whether only the diseased part of the limb should be severed or the healthy part as well. In practice, however, the Romans amputated almost exclusively the diseased section, and this probably led to the wound becoming infected.

In addition, the peoples of antiquity already used prostheses. The shard of a vase from Italy in the 4th century shows that the wound was closed with a branding iron. Jh v. Chr of a man with an amputated lower leg wearing a prosthesis made of wood, and Herodotus wrote of a wooden foot a century earlier. Pliny then reports in 3. Century v. Chr of a soldier who wore a hand made of iron.

Firearms and deadly inflammation

In the Middle Ages, there were plenty of reasons to amputate body parts. Lepers rotted body parts alive, dog bites became infected, gangrene was ubiquitous in wars.

Until the early modern period, physicians in Germany did not know the discussion of antiquity and only cut away the gangrenous tissue. The only instruments used were knives, amputation saws, pliers and chisels. No one knew about the danger posed by viruses or bacteria, and the germ-infested tools drove patients all the more toward exitus. The doctors closed the wound with a branding iron. The heat closed the vessels, but could cause new injuries and inflammations.

Experts in amputations and their treatment became the executioners. Executioners not only had the task of carrying out punishments such as cutting off the hand. Such mutilations, which seem barbaric today, were not arbitrary, but a crime was considered a disturbance of the order intended by God: the punishment was not aimed at the individual, but was intended to restore the divine order.

Therefore, the executioner had to carry out the punishment according to a precisely defined ritual. If he amputated a limb, the wound became infected and the delinquent died, the executioner had committed an outrage that he could hardly make up for.

Executioners were also among the only ones who knew about human anatomy. The learned doctors were forbidden to dissect corpses and was considered blasphemy. The executioners, however, cut up corpses and sold the "magic medicine" extracted from them, and when they applied thumbscrews, dislocated bones or placed weights on the chest body, they had to know exactly how this torture affected the body.

The invention of firearms increased the need for amputations to a great extent. Hans von Gersdorff wrote in 1517 how the amputations of the early modern times proceeded. The victims sat down, they were only given opium and henbane for anesthesia. If the limb had been severed, the doctor pulled the bladder of a cow or pig over the stump.

Except for war casualties, physicians usually amputated only when gangrene had already broken out or the wound had become infected. Most people who underwent amputation died during or after the operation, from blood loss or the gangrenous wound.

Only the wound surgeon Ambroise Pare prevented bleeding to death by blocking the blood vessels with triangular needles. The Swiss physician Fabricius Hildanus also correctly demanded amputation in healthy tissue and sealing the stump with linen. The Englishman Lowdham used a flap of flesh instead of cloth.

Gotz von Berlichingen (1480 – 1562) not only survived the loss of his hand in 1504, but also had an ingenious prosthesis made from iron. Their fingers fixed cogwheels. The robber knight could even adjust the iron hand so that it grasped his sword.

Modern war surgery

The guillotine replaced medieval mutilation and death punishments such as wheeling, quartering, or cutting off hands during the French Revolution. So, while amputation as a punishment did not play any role in Europe, it became one of the essential practices of medicine in the modern material warfare.

Cannons and shrapnel bullets tore bodies apart, completely or half severed arms and legs, hands, feet and faces were the gruesome face of modern times, when masses marched against masses.

So it was no coincidence that doctors on the battlefields developed amputation further. Authoritative was the chief field surgeon of Napoleon, Dominique Jean Larrey (1766-1842). He operated directly on the spot before the infection set in.

Robert Liston (1794-1847) developed knives that cut skin, tendons, and muscles down to the bone with one incision; the surgeon cut around the entire limb at one time. Liston also used anesthesia – instead of speed.

During the two world wars, the development of prostheses made great progress. Ferdinand Sauerbruch (1875-1951) placed a skin tunnel through the upper arm and pushed an ivory pin through it. This lifted when the muscle tensed and the hand gripped.

Since the 1960s, electrodes have been measuring electrical impulses from the arm muscle and transmitting them to motors that move the fingers. Today, prosthetic hands can even be used for feeling.

In the case of leg prostheses, it is partly possible to couple the artificial parts to the nerves.

What amputations are?

Today, the main causes of amputations are circulatory disorders, injuries and infections – especially arteriosclerosis. The lower part of the legs is most at risk.

We call an amputation above the ankle a major amputation. Legally, however, this is already considered a forefoot amputation.

Minor amputations are amputations below the ankle, especially on the toes.

Scheduled amputations are usually performed for occlusive arterial disease when tissue necrosis heralds sepsis and all other methods fail. Where to amputate depends on the quality of blood flow in the respective parts of the body. The thigh is usually amputated a hand’s width above the knee, the lower leg a hand’s width below it.

Very rarely today doctors amputate in accidents. The goal is always to preserve limbs, and today’s technology makes it possible to reimplant even severed parts of limbs. However, if the corresponding body part is destroyed, doctors can only treat the stump.

Uncontrolled infection of wounds and open fractures of grade IV make amputation inevitable.

Even today, malignant tumors sometimes require the amputation of a limb, usually in cases of bone or soft tissue cancer.

How does an amputation proceed?

A planned amputation is primarily designed so that the stump can be well cared for. The bone must be covered with soft tissue, and the skin incision lies below the amputation on the bone – doctors call this a frog’s mouth incision. Once the bone is cut, the surgeon smoothes the edges of the bone. Muscles then surround the bone stump, and the physician connects the muscles.

After that, the aim is to prevent infections. Occlusive disease and diabetes, the two most important causes of amputations, often lead to problems with the healing of the wound.

The doctor fixes the stump with a special bandage. If the wound heals, the physician applies an elastic sheath, and over this he later attaches the prosthetic socket.

The Krukenberg grasping forceps use radius and ulna for grasping. In the case of amputations of the forearm, these bones "replace" the hand in a makeshift manner.

Special amputations

In the Pirogoff amputation, the foot is amputated, but the calcaneus and parts of the plantar flexure are preserved.

The Gritti-Stokes amputation is an amputation on the thigh in the immediate vicinity of the knee joint. The patella remains intact, the surgeon presses it under the stump, fxes it there and sutures the patella tendon to the knee flexor tendons. The stump becomes long and elastic.

Emergency amputations

Emergency physicians sometimes have to amputate directly at the scene of an accident, especially in the case of burials when no technical rescue is in sight, the victims have trapped limbs and their lives are in danger.

Amputations of "diabetic feet" are relatively common. Image: ittipol – fotolia

The emergency physician ensures that vital functions are maintained, so, for example, places the victim in the lateral position, ventilates or resuscitates him if the situation requires it.

He carefully preserves the severed body part in sterile material. If possible, the amputate is transported in a cool place to keep it in the shape it was in when the accident occurred. To do this, it goes into a plastic bag, and this goes into another bag containing ice. However, the ice should not come in contact with the tissue to avoid frostbite.

Amputation as punishment

Today, cutting off limbs as a punishment exists only under Islamic rule. According to sura 5:38 of the Koran, thieves should have their hand cut off, and according to sura 5:33, the hand and foot should be cut off crosswise for street robbery and fighting against the messengers of God. In historical Islam, judges rarely imposed either punishment, and at the turn of the 20th century. In the 19th century, almost all states abolished these penalties.

Only in Saudi Arabia under Wahhabi rule did amputations continue uninterruptedly. The triumph of Islamists since 1972 brought cutting off hands and feet back into the penal system in Libya, Pakistan, Iran, Sudan, and parts of Nigeria; in Sudan, 120 amputations occurred between 1983 and 1985 alone. The practice continues to this day. (Dr. Utz Anhalt)

Author and source information

Important Notice:
This article contains general information only and should not be used for self-diagnosis or self-treatment. It cannot replace a visit to the doctor.

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