|background - History and Prosthetics|
|Text der Northwestern University Medical School / Prosthetic Education|
History and Prosthetics
The history of prosthetics and amputation surgery begins at the very dawning of human medical thought. Its historical twists and turns parallel the development of medical science, culture, and civilization itself. Prosthetic history begins with humankind's spiritual and functional need for wholeness. Prostheses were developed for function, cosmetic appearance, and a psycho-spiritual sense of wholeness but not necessarily in that order. These patient needs exist from the dawn of time to the present. Early prosthetic principles that were developed exist to this day and are amazingly efficient in function. In the three great western civilizations of Egypt, Greece, and Rome the first true rehabilitation aids recognized as prostheses were made. The Dark Ages produced prostheses for battle and hiding deformity. The Renaissance emerged and revitalized scientific development begun by the ancients. Subsequent refinements in medicine, surgery, and prosthetic science greatly improved amputation surgery and the function of prosthesis. The industrial revolution brought about prosthetic advancement fueled by money available to amputees following the American Civil War; painting a colorful array of humanitarians, scientists, and charlatans. Finally the modern era of prosthetics arose with quantum leaps in technology developed in two world wars.
What are the historical trends that seem to underlay all of prosthetic science's history? Fundamental proven prosthetic principles are never outdated, only the methods to accomplish them are refined. Ideas are endlessly being recycled from the past. Concepts that may have been impractical at the time of their inception, become possible with developments in materials and technology. Prosthetic science advanced in leaps and bounds when a forum for research and discussion are created with a common goal in mind.
PREHISTORY: Man's Awakening
The earliest evidence of humankind's recognition of deformity and concern for rehabilitation is difficult to determine. Many ancient civilizations had no written records and history was recorded orally in poems, sagas, and songs. To discover the beginning of prosthetic science we must rely on anthropology to interpret artwork, remains, and myths.
The earliest anthropological evidence of an amputee is that of a human skull in the Smithsonian Institution 45,000 years old which shows teeth shaped and aligned in such a way that indicate he was an upper extremity amputee. Other evidence is found in cave paintings in Spain and France, about 36,000 years old, which show the negative imprint of a mutilated hand. Later paintings like these were also found in New Mexico and suggest the practice of self mutilation to appease gods in religious ceremonies. The Rig-Veda, an ancient sacred poem of India, is said to be the first written record of a prosthesis. Written in Sanskrit between 3500 and 1800 B.C., it recounts the story of a warrior, Queen Vishpla, who lost her leg in battle, was fitted with an iron prosthesis, and returned to battle.
Some social attitudes toward amputation an amputees remain to this day, while others have changed. Congenital deformed baby's may have been killed or ostracized because they may have been judged a functional liability or spiritually unclean. However, King Montezuma II, an Aztec ruler established a special, albeit 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 not only affected the amputee on earth, but also in the afterlife. The ablated limbs were buried, and at the time of the amputee's death, disinterred and reburied so the amputee could be whole for eternal life. Many cultures had a very physical subsistence and any handicap might have affected an amputees ability to provide for themselves and contribute to the tribe.
The reasons for amputation in ancient times varied. Congenital deformities have always been present. Especially in Arabic countries where first cousins were encouraged to marry. War was often times the cause of traumatic amputation in battle or when taken prisoner. Amputation was also used as a judicial punishment especially in the ancient Moche culture of Peru. Theft was punishable with the amputation of a hand, but if the thief could prove a motive of hunger, the village chief suffered the punishment. A foot was removed for laziness and both arms were removed for rebellion. In the Arabic countries the right hand was used for eating from a common bowl and the left used for toileting. Theft was punishable by the removal of the right hand, effectively ostracizing the thief from the social group. Ancient cultures also had knowledge of amputating for diseases such as gangrene, tuberculosis, and leprosy and advised amputation above the diseased area for healing. Religious ceremonies were another cause of amputation. Disfigurement alters the worshiper to appease gods, show faith, or illustrate the altering effect of faith. A ritualized form of this exists today in the form of circumcision.
Surgery was performed with or without anesthesia, analgesics, and fairly advanced tools. For judicial punishment no anesthesia was used and a guillotine technique with an ax was used. For curative surgery an ancient surgeon used plant extracts such as nepentag, opium, hemp, mandrake, henbane, hemlock, and alcohol. Analgesic plants such as asperic acid from tree bark was used to relieve pain. Antiseptics such as smoke, honey, wine, niter, and cautery with hot oil were used. Ligatures of cotton fiber, human hair, hemp, or ant jaws may also have been used in weaving cultures. Tools such as bronze or stone axes were the standard surgical instruments. Saws with stone set into wood or animal jaw bones have been shown to amputate limbs within six minutes.
The prosthesis of the ancient cultures began as simple crutches or wooden and leather cups shown in Moche pottery. This grew into a type of modified crutch or peg to free the hands for functioning. An open socket peg leg had cloth rags to soften the distal tibia and fibula and allow a wide range of motion. These prostheses were very functional and incorporated many basic prosthetic principles.
Amputee gods can also be identified. The primary Peruvian jaguar god, Aia Paec (Ai Apec), was an above elbow amputee. Tezcatlitoca, the Aztec god of creation and vengeance was a right foot amputee. The Celtic Irish god, New Hah, was a left arm amputee with a four digit silver prosthesis.
BIRTH OF SCIENCE: Egypt, Greece, and Rome
With the birth of these three great civilizations, came the development of the scientific approach toward medicine and subsequently prosthetic science. Amputation is recorded in myth and plays, and actual prostheses from this era have been found.
Prosthetic limbs made of fiber have been found in the wrappings of Egyptian mummies which were probably the creation of the burial priests rather than a functional device. In a Greek myth Pelops, grandson of Zeus, was killed and cooked by his father, Tantalus, to be served to the gods to see if they could differentiate between flesh of man and beast. Demeter, goddess of agriculture ate Pelops' shoulder, but recognizing her error restored him to life and made a prosthetic ivory shoulder.
Aristophanes from the 5th century B.C. wrote a part in his play, "The Birds" for an actor wearing a leg prosthesis. Herodotus (424 B.C.) writes of Hegistratus of Elis, a Persian seer, who was to be condemned to death by the Spartans. He escaped from the stocks by amputating his foot, making a wooden filler, and traveling 30 miles to Tregea. Unfortunately he was captured at Zaccynthius and had his head amputated. A Roman Prosthesis from the Samite Wars (300 B.C.) was unearthed in Capau, Italy in 1858 and was constructed of a wooden core, bronze shim, and leather straps. Unfortunately it was destroyed during a bombing of London in World War II. Pliny the Elder (23-79 A.D.), a first century Roman scholar writes in "Natural History" of Marcus Sergius, a Roman general who led his legion against Carthage (presently Tunis) in the Second Punic War (218-210 B.C.). He sustained 23 injuries and a right arm amputation. An iron hand was fashioned to hold his shield and he was able to go back to battle. He was captured and escaped twice and served as Praetor Urbanis or civil judge. He was denied a chance to be a priest because one needed two normal hands.
The use of ligatures to tie off bleeders was originally put forth by Hippocrates in the 5th Century B.C. and he also advocated a method for amputation for gangrene. Celsus (0 A.D.) described another technique of amputation through healthy tissue between sound and diseased tissue, and also describes ligation of blood vessels to stop bleeding. There are repeated references to amputation in the Jewish history of the Talmud. Two Roman surgeons, Archigenes and Heliodous advocated amputation not only for gangrene but tumors, injuries, and other deformities.
THE DARK AGES: The Age of Armor
The Dark Ages were, as their name implies, a time in which there was little scientific illumination. The feudal system effectively divided all regions of Europe into many tiny isolated kingdoms. This prevented the scientific process from occurring because no central forum of government or learning existed. Many of the surgical techniques developed by the Greeks and Romans fell into disuse as there were less and less educated people from each region to read, use, experiment, and record their findings. At this time primitive techniques such as crushing the limb, dipping in hot oil, or searing with hot irons were used. The guillotine technique was used and the limb surface was allowed to granulate. Speed was of the essence. Most people died of blood loss and those who didn't usually succumbed to infection from the dirty surgical techniques. Pus was not only expected but thought of as an indication of normal healing. These techniques did not die out until the mid to late 1800's.
There was not very many prosthetic alternatives available to the amputee at his time except basic peg legs and hand hooks. Only the rich could afford to have prostheses made. Knights had prostheses made by their armorers for use in battle. Some of these devices were fairly advanced but were usually heavy, cumbersome, and functioned only in battle. Arms were set to hold shields at all times and legs set to ride in stirrups, but not for daily function such as walking.
When the knight returned home, he usually wore peg legs or hand hooks for daily function. Prostheses were more cosmetic than functional; they were meant to hide the disgrace and weakness of defeat from other battles. Armor makers made the prostheses appear as extensions of the knit's original armor. Although they had a great knowledge of the human body, they knew little about creating a functional prosthesis. Watchmakers also joined in later to make more intricate internal functions with springs and gears.
Although most of the recorded amputations have to do with traumatic battle injury, many amputations were due to leprosy and erotism. Ergot was a medicinal rye plant that deadened the limbs' senses and in some cases caused gangrene. The use of gunpowder and cannonshot at Crecy, in 1346 came the beginning of the end for the Age of Armor, but introduced a new cause of trauma that would have a great impact in the wars and traumatic injuries to come.
RENAISSANCE: Age of Enlightenment
The Renaissance signaled a rebirth of science and rediscovery of medical practices begun by the Greeks and Romans. As the governing systems of the European countries centralized, cities and universities arose where science and art could grow and be recorded.
The iron arm of the German mercenary knight Gotz von Berlichingen (1480-1562) is amazingly advanced example of prostheses made at this time. Gotz gained a reputation as a Robin Hood, protecting the peasants from their oppressors. In 1508 he lost his right arm in the Battle of Landshut when friendly cannon fire struck his sword which fell and severed his arm. Learning of another warrior who used a prosthetic iron hand in battle, Gotz had two made for himself. These were mechanical masterpieces. Each joint could be moved independently by setting with the sound hand and relaxed by a release and springs. The hand could pronate and supinate and was suspended with leather straps. Although not body powered, it represented a great attempt at functionality.
Other accounts of functional prostheses exist such as the Alt-Ruppin hand, fished from the Rhine in 1858 and dated to the 1400's. A 16th century Italian surgeon recorded in his travels to Asia, a bilateral upper limb amputee able to remove his hat, open his purse, and sign his name. Also a story of a left iron hand made for Admiral Barbarossa who fought the Spaniards in Bougie, Algeria for a Turkish Sultan in 1512.
In 1517 Hans Von Gersdoff of Straussburg recommended the use of a tourniquet with compression from a cow or pig bladder, cautery, and a dressing with warm, not boiling oil. Wilhelm Fabry, the first educated and scientific German surgeon, wrote of amputation above gangrenous level and also described a tourniquet in 1593.
The greatest contribution to amputation surgery and prosthetics sciences of this time is by Ambroise Pare (1510-1590), a French army barber-surgeon. He reintroduced the use of linen ligatures originally put forth by Celsus and Hippocrates when he ran out of cautery oil during battle surgery. Time was still a limiting factor. A surgeon working with no anesthesia, tourniquet, or skilled aid hand was limited to about 30 seconds to amputate and 3 minutes to complete the operation. This is a very small amount of time for a surgeon to ligate major arteries and is why many, such as Guillemeau, Pare's student, again abandoned this method for direct cautery. It wasn't until later with the introduction of the tourniquet in 1674 by Etienne J. Morel, also a French Army surgeon, during the Seige of Besancon, that ligation would have more widespread use. Hence amputation became more of a lifesaving technique. Pare also invented upper and lower extremity prostheses that show knowledge of basic prosthetic function. "Le Petit Lorrain" was a hand operated by springs and catches for a French Army Captain, which he then used in battle. He also invented an above knee prosthesis which was a kneeling peg leg and foot prosthesis. It had a fixed equinas position, adjustable harness, knee lock control, and other engineering features used today.
AGE OF INVENTION AND EXPLORATION: Growth of Modern Medicine
From the 1600's to the early 1800's, we see great refinements of the prosthetic and surgical principles put forth in the Renaissance. The invention of the tourniquet, anesthesia, analeptics, blood clotting styptics, and disease fighting drugs brought medicine to the modern era, but also made amputation an accepted curative measure rather than a last ditch effort to save life. The surgeon had time to make residual limbs more functional, and therefore allowed the prosthetist to make better prostheses.
In 1782, Edward Alanson, an English surgeon suggested an amputation in which tissue was cut in a hollow conical manner using skin flaps. Dominique-Jean Larrey, Napoleon's personal surgeon, utilized ambulances that picked up the wounded immediately. He also tried to use refrigeration as a local anesthetic and is said to have performed over 200 amputations in 24 hours. Crawford Long of Athens, Georgia was the first physician to use sulfuric ether for anesthesia and William Morton, a Massachusetts dentist, proclaimed its use. Pierre Jean Marie Flourens discovered chloroform in 1847. James Syme, Chief of Surgery at the University of Glasgow, Scotland performed his first innovative ankle disarticulation in 1842 and was followed by a Russian surgeon, Pigoroff, with his own version in 1854. Rocco Gritti of Milan described knee disarticulation using the patella as a protective flap in 1857. Styptics such as alum, vitriol, turpentine and oil where use to clot blood, but oil may have been used unknowingly as a antiseptic. Still with all the advancement, a patient was susceptible to infection. In 1842 Paris hospitals were said to have a mortality of 62%. It was even higher for amputation patients; even for a digit amputation. Surgeons seemed to lack cleanliness respected even in everyday life. It is said that it was safer to have a limb amputated by gunfire, than by a surgeon. As late as 1880, surgery assistants held sutures in their mouths. Acting on studies of Englishmen, Monro (1752) and Alanson (1782), Joseph Lister, son-in-law of James Syme and now Chief of Surgery at the University of Glascow, experimented with antiseptic surgical techniques in 1865. His results were not published until 1867. These were not brought to the U.S. until 1877 by Captain Gerard. So it was only 114 years ago that doctors started washing their hands in the U.S. Lister also advocated using catgut as a suture alternative since silk and hemp caused inflammation and severe hemorrhage because the body could not absorb it.
DEVELOPMENT OF PROSTHESES: 1600 to 1800's
Many of the prostheses developed during the 1600's were merely refinements of earlier armor type devices. They were bulky and heavy, but gradually gained more function. A number of pieces are housed in the Stibbert Museum, Florence, Italy. Some of these devices show contributions of other artisans such as watchmakers and woodworkers. They exhibit more functionalism and sacrifice aesthetics indicating more common use.
In 1696, Pieter Andriannszoon Verduyn (verduuin), a Dutch Surgeon, introduced the first non-locking, below knee prosthesis. It bears a striking similarity to today's joint and corset prosthesis. Like the joint and corset, it was made of external hinges and a leather cuff that bore weight. The leg cuff socket was lined with leather and had a copper shell and had a wooden foot.
James Potts of London designed a prosthesis in 1800 that consisted of a wooden shank and socket, a steel knee joint and an articulated foot that was controlled by catgut tendons from the knee to the ankle. It was used by the Marquis of Anglesey after he lost his leg in the Battle of Waterloo and become known as the "Angelesey Leg". Flexion of the knee caused dorsiflexion of the foot and extension of the knee caused plantar flexion of the foot. It has also been referred to as the "Clapper Leg" because of the noise it made with wooden foot stops or the "Cork Leg" since it was widely used in County Cork, Ireland. William Selpho then brought the Anglesey Leg to the U.S. in 1839.
In 1846, Dr. Benjamin F. Palmer, a patient of Selpho, obtained a patent for his leg which improved on the Selpho leg by adding an anterior spring, smooth appearance, and concealed tendons. It was honored in 1851 at the London World's Fair: "It imparted a life-like elasticity and firmness to the step."
Dr. Douglas Bly of Rochester, New York invented and patented "Doctor 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 first introduced the curved knee joint. The prosthesis also allowed for inversion and eversion through the use of an articulated ankle: a polished ivory ball in a socket of vulcanized rubber. However, Doctor Bly does admit that his invention has 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 frogs were turned into sprightly coachmen.
The Angelesy leg became known as the American leg, when A.A. Marks in 1856 gave it knee, ankle, and toe movements and an adjustable articulation control. In 1818, Peter Ballif, a Berlin dentist, first gave the upper extremity prosthesis prehension control with a shoulder harness with and a chest strap. This same principle was used in 1844 by a Dutchman, Van Peetersen for elbow flexion. In 1867 Comte de Beafort published and illustrated an elbow flexion lever device mounted on the chest that he had developed in 1855.
THE CIVIL WAR: The Age of Entreprenuership
The American Civil War (1861-1865) marked the first example of modern warfare and the post war industrial revolution began the age of entreprenuership. It was fueled by the "Great Civil War Benefaction" by the U.S. Government which fueled competition by providing prostheses to veterans. This was a government's first commitment to supply prostheses to veterans and whose support plays a major role to this day. New designs of prostheses were constantly being made. Extraordinary claims were 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 systematic prosthetic prescription was as of yet devised. Shysters and charlatans dot the history at this time.
There were a great many amputations (30,000 in the Union Army). In 1962 the government guaranteed prostheses for veterans who lost them in the war. A southern soldier, J.E. Hanger, who lost his leg in 1861 replaced the catgut tendons of the American leg with rubber bumpers to control dorsiflexion and plantarflexion and he used plug fit wood socket. He then opened a clinic in Richmond, Virginia. Later the rubber foot, the forerunner of the SACH foot, came into use and eliminated the complicated articulate ankle of the Bly leg.
In 1863, Dubois D. Parmlee invented an advanced prosthesis which had a suction socket, polycentric knee, and multiarticulated foot. In 1868 Dr. August Gustav Hermann of Prague suggested using aluminum instead of steel.
In 1885 Heather Bigg wrote a pioneering text book on amputations and prostheses. In it he details instructions to place the knee joint of prosthesis posterior to the anatomical knee center and emphasizes the need for correct alignment.
During this time with government money a great many "clinics" opened. At 1917 there were about 200 clinics and 2000 skilled workmen. Many extraordinary claims were made at this time such as the Bly leg. Many of the manufacturers were amputees themselves, and thought their invention was a cure all. But in reality, it fit only themselves and a select patient group.
Around 1912 with the budding aviation technology, an English aviator, Marcel Desoutter, who lost his leg in an airplane accident, made the first aluminum prosthesis with the aid of his brother, Charles, an aeronautical engineer. This was followed by a similar advancement by Hanger. Other inventions developed by Desoutter and Hanger such as the development of pelvic suspension rather than shoulder suspension, provided a more efficient and stable way of operating the prosthesis and direct knee control. This led to knee control systems such as the knee brake.
As World War I began, prosthetists were a varied lot. They were at times unconcerned for patients needs or concerns rather than their own greed and pride. Surgeons were reluctant to confide with them because they were frequently ambulance chasers "sort of shysters preying on the amputee." This set the stage for leaps in technology of the two World Wars into the modern era.
WORLD WAR I, DEPRESSION, AND WORLD WAR II
As World War I (1914-1918) began, American prosthetists remained a very independent, competitive group; rarely working with surgeons let alone each other. Amputee casualties in the U.S. (4,403) were much smaller than the British (42,000) and European armies (100,000). This resulted in European prosthetists jumping ahead in experimentation of their American counterparts.
Recognizing the lagging of care for amputees in America, The Surgeon General of the Army invited the U.S. prosthetists to Washington, D.C. to discuss prosthetic technology and its development in this county. From this meeting arose the present day American Orthotics and Prosthetics Association. This development as one historian writes "contributed more to the development of the science of prosthetics than any other occurrence in its history." Though this forum prosthetists could develop ethical standards, scientific programs, educational programs, and build better relationships with other health professionals.
In 1918, Dr. Martin described the Belgian prosthesis, which emphasized the anatomy and physiology of the leg. This prosthesis was an improvement on the standard American leg. It could reproduce the natural static and anesthetic appearance of the lower limb and was made from measurements and a modified cast of sound and residual limb.
Because of the relatively low amount of amputees in World War I and the economic depression, prosthetics advanced very little to the beginning of WW II. Many of the European advances had not yet reached America.
As World War II waged on, the American amputee casualty list was much greater. These veterans found the current technology (which had not changed all that much since the 1800's) inadequate. In response, Normal Kirk, Surgeon General of the Army, requested that the National Academy of Sciences investigate the prosthetic state of the art. Originally it was thought only a few designs and studies were necessary. But it soon became apparent, when the Surgeon General brought in a team of engineers and surgeons to Europe in 1946, that the U.S. lagged far behind. At this time the orthotists joined the American Limb Manufacturers Association making it the Orthopaedic Appliances and Limb Manufacturers Association. In 1950 the name was again changed to the American Orthotics and Prosthetics Association or A.O.P.A.
MODERN ERA: Research and Development
This research launched a quantum leap for prosthetic science. The Artificial Limb Program was sponsored by the Veterans Administration, H.E.W., and the Armed Services by establishing a number of research laboratories. The University of California at Los Angeles for upper limb study. Similar research was carried out by the Navy at Oakland Naval Hospital, U.S. Army Air Force at Wright Field, Northup Aviation, Catranis, and New York University. Socket designs such as the quadrilateral and P.T.B. were investigated and refined further at this time. Materials also improved. Northrup Aviation introduced the use of thermosetting resins to form custom fit socket and structural components. This also led to the development of the SACH foot. Total contact now became possible along with clear check sockets. Prosthetic knees such as the Mauch S-N-S system were developed.
Educational seminars for these new techniques and components began in 1947 and pilot courses sponsored by the University of California at Berkeley in prescription, fabrication and alignment of the Above Knee prosthesis. These courses were followed up by workshops by Veterans Administration and the Orthopedic Appliance and Limb Manufacturers now AOPA.
The American Board for Certification was created in 1949 to evaluate and certify prosthetists who met its standard. The 1950's continued this educational growth. In 1952 UCLA began offering 6 week short courses and on a regional basis from 1953 and 1954. About 140 VA and civilian teams were created. In 1956 UCLA began offering formal A.K. prosthetics courses. Because UCLA could not answer the countries growing prosthetic educational needs, the VA established a prosthetic post graduate educational program at New York University in 1956. The office of Vocational Rehabilitation (now Rehabilitation Services Administration) of H.E.W. sponsored the establishment of a prosthetic program at Northwestern University at Chicago in 1959.
1956 marked the development of the SACH foot from the University of California and in 1959 the PTB prosthesis was created at University of California at Berkeley. 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 prosthesis. Different prosthetic procedures resulted when prosthetists began working with surgeons. Marian Weiss of Poland experimented with immediate post surgical fittings in 1963. That same year, Guy Fajal of France developed the PTS or PTB SC-SP and also New York University unveiled a BS degree in Prosthetics and Orthotics. 1964 brought prepatory fitting to the U.S. from Dr. Burgess of Seattle. 1967, Carlton Fillaur of Chattanooga refined Dr. Gotz-Gerd Kuhn's B.K. Prosthesis and brought it to Chattanooga Tennessee as the removable wedge. 1970 marked the inaugural year for the international Society for Prosthetics and Orthotics. 1971 Endoskeletal components, became available with a soft form cover. 1974 to 1976 the STAR, Hosmer and ROL rotational units were developed and in 1980 the SAFE foot (one of the first "energy storing feet") was developed.
Other types of devices were also added such as external power and other techniques. Some work was done in Germany, but it was IBM who first developed it in 1949. 1958 a Russian external power was controlled from muscle contraction flexors and extensors. Otto Bock Orthopedic industry has since refined this to a commercial product.
Many products and events are beyond the scope of this study. However their development and prosthetic history as a whole gives the understanding of our origins and to which we may draw conclusions about the future.