The Evolution of Artificial Limbs
The earliest definite reference to prosthetic appliances is that of Herodotus (487 B.C.) who cites the ease of and Elean named Egesistratus, who had inflicted many atrocities upon the Spartans and knew when they finally captured him that he was doomed to die. Closely confined in stocks with one foot bound in iron it was necessary for him to amputate that foot to affect his release. This he did and escaped to Fogea. After the wound healed he procured a wooden foot, which he is reputed to have used. Another reference definitely before the Christian era is by Pliny the younger concerning M. Sergius (167 B.C.) who lost a hand or arm in the second Punic war. An artificial appliance was devised to enable him to hold his shied in battle and later he succeeded in releasing Cremona from siege. It is interesting to note that in spite of his splendid military service, there was an attempt made to bar him from various sacred rites since he was a “mutilated man.”
The oldest artificial leg in existence is now in the Museum of the Royal College of Surgeons in London. It was exhumed with a skeleton form a tomb at Capus, Italy. While its exact age is not known, it is estimated in the following description given by the official catalogue of the Museum: “Roman artificial leg; the artificial limb accurately represents the form of the leg; it is made with pieces of thin bronze, fastened by bronze nails to a wooden core. Two iron bars, having holes at their free ends, are attached to the upper extremity of the bronze; a quadrilateral piece of iron, found near the position of the foot, is thought to have given strength to it. There is no trace of the foot, and the wooden core had nearly crumbled away. The skeleton had its waist surrounded by a belt of sheet bronze edged with small rivets, probably used to fasten a leather lining, three painted vases (red figures on a black ground) lay at the feet of the skeleton, the vases belong to a rather advanced period in the decline of art (about 300 B.C.).”
In addition to the above mentioned specimen and historically dated references there are three illustrations, which may or may not antedate these mentioned. One is a Mosaic in the Cathedral of Iescar (Lower Pyrenees), which portrays an African American whose left leg, lacking the foot, takes its support from the knee from the socket of a wooden pillion similar to those in use at the present time. Some authorities ascribe this to the Gallo-Roman epoch but others to the 12th century. In a collection at the Louvre in Paris is a Graeco-Roman vase upon which is depicted a satyr with a wooden leg. The third illustration is also fin Graeco-roman art and represents a sportsman with an artificial limb.
When it is considered that amputation is one of the oldest surgical procedures (dating as it does from prehistoric times) and that man’s mechanical ingenuity even then was well manifested in other fields, the paucity of these reports can mean but one thing—recovery after amputation was rare. Most probably died from hemorrhage and the majority escaping that fatal issue succumbed to infection. Extreme speed was the sine qua mon of the of the surgeon’s armentarium. Rapid strides in the number and improvement of artificial limbs is noted to begin about 1500, at which time the mortality after amputation was successively reduced by the introduction of the following measures: First, cautery, which in about the 15th century replaced crushing as a means of controlling hemorrhage; secondly, an improvement along the same line was the legation of individual vessels, begun by Pare in the 16th century; thirdly, the use of the tourniquet, first mentioned in the 17th century, was a supplement to the other two; fourthly, in the 19th century, the discovery of anesthesia relieved pain, and lastly in the same century, antisepsis and asepsis controlled infection. The supply of victims constant fighting between the nations of Europe and the New World – and it may be stated here that few wars surpassed our own Civil War in this regard. The recent World War, the establishment of the machine age industry, the popularizing of the automobile and the introduction of air navigation on a eat present furnishing a definite quota forour consideration.
The appliances beginning with the Renaissance were made of iron, steel, cooper, etc., and evidently by mechanics especially interested in the construction of armor. They were generally rather crude affairs (the ancient arm weighing 20 to 30 pounds for instance, as compared with modern ones of 1½ to 2 pounds) and required a long and powerful stump. Some, however, in spite of the weight, were rather ingeniously constructed and examples of some of these will be mentioned.
The hand made for Goetz von Berlichingen, a knight of Nuembery, in 1504 was a complicated clumsy iron structure but buttons and levers could accomplish certain finger movements, enabling him to hold the bridle of his horse or shield to protect his body. With this hand he later fought at the head of an army and is quoted as saying that the artificial hand “has rendered more service in the fight than ever did the original flesh.” This appliance still preserved is further immortalized in Goethe’s poem “Goetz von Berlichingen.”
Another famous hand of that time was one described in 1564 by Pare. It had been constructed for a Huguenot captain whose left arm, shattered at the siege of Fontency, was subsequently amputated. “This iron hand which on the dorsum has the form of a steel quantlet is attached to the forearm by two metal rods and leather straps. The thumb is rigid and the fingers are kept extended by four springs fixed in the palm. When they are flexed they are kept so by rackets worked by metal levers.”
Lorrain, a French locksmith, was one of the most famous makers of artificial limbs at that time. This work was done under the suggestions of Pare, to whom probably much of the credit should be given. One of Lorrain’s important contributions was an attempt to substitute leather and paper –and-glue in the place of the heavy iron. Pare himself devised an apparatus with a knee joint, which, while usually fixed, could be move by means of a thing running to the hip.
An excellent collection of early artificial limbs is in the Stibbert Museum in Florence, and has been ably described recently by V. Putti.
A little later Father Sebastian, a Carmelite monk, produced of sheet tin and springs and arm capable of many articulations, but not very practical, as it was too dependent upon the firmness of the stump tissues which invariably will shrink.
Peter Lowe shows several forms of artificial limbs used in the 16th and 17th centuries in the “Discourses on the Whole Art of Chirurgery”. It might be mentioned here also that many artificial legs could only be used in the sitting or knee flexed position, and were evidently intended to afford support and conceal the disability of a mounted soldier.
A Dutch surgeon, Verduyn (1690), constructed an artificial leg consisting of a wooden foot and a hollow copper cylinder lined with chamois and strengthened with steel splints into which the stump was fitted. There was a hinge joint at the knee. The apparatus was attached to the thigh by means of a broad band. His principle of using the thigh as a support was an excellent one but the leg he devised was so unsatisfactory that the old custom of using the head of the tibia for support continued to be in vogue.
In 1755 H. Ravaton constructed an artificial limb by means of which a cavalryman was able to continue his field service. It consisted of a laced leather boot filled with horsehair and bearing a joint at the ankle, operated by a spiral spring. Charles white, a surgeon, constructed a prosthetic apparatus for amputation below the knee. It consisted of a jointed foot attached to a leather covered tin cylinder, fastened with leather straps below, and with a steel bow above the knee.
Gavan Wilson of Edinburgh towards the end of the 18th century constructed arms by which a knife and fork could be held and on the first and second fingers of which and apparatus was attached for holding a pen. His arm is evidently passed on the one invented by Father Sebastian, but improved by employing harder leather and covering ther arm with colored sheep skin so as to bear the appearance of human skin, and to render the deception still more complete, he made the nails of white horn, and painted them so as to represent nature. Wilson also made legs for amputation above and below the knee, modeled on the apparatus of Ravaton they were fastened to the body by a strap running over the shoulder of the opposite side. Only the knee joint was movable.
In 1810 Johann George Heine, the founder of German orthopedics, constructed a complicated leg for both high and low amputations, introducing a ball joint at the ankle. The leg was fastened about the trunk by means of a corset.
In 1812 Pierre Baillif, a Berlin dentist, constructed an artificial arm in such a manner that the fingers moved synchronously with motions of the elbow. The hand though of lead weighed only one pound. Later this same principle was utilized by Caroline Eichler (1836) who devised artificial arms with which the wearer could sew, write, braid hair, or play the Violin.
The war in 1812-1815 aroused new interest in the construction of artificial legs. The apparatus constructed by James Potts for the Marquis of Anglesea (1816) was made of two hollow cones of weed, one for the stump of the thigh, the others to replace the leg. The moveable knee joint was of steel, the joint of wood, both reinforced with steel, anteriorly and catgut posteriorly. Gay, Potts’ successor, still makes a leg similar to the “Anglesea leg” with a special modification for horse back riding, consisting of a tick leather pad where the leg touched the saddle.
Dornbluth (1826) constructed an apparatus for amputation in which the stump of the leg had assumed a right angle position. An artificial knee-joint was introduced below the knee-joint proper.
Verduyn’s attempt to make the thigh the main joint of support instead of the knee, was revived by Serre (Montpellier 1826). Goyraud (Aox, 1831) first used the tuberischii as a point of support, even in apparatus for asramalleolar amputations. This was an important advance as was also the new principle introduced by f. Martin and Charriere (1842) who displaced the artificial knee-joint behind the axis of the limb. Goyraud’s modification involves the use of a heavy apparatus and is necessary only in double amputations or where the wearer must be on his feet constantly. For other cases a smaller apparatus, using as a point of support the thigh, tibial tuberosities or edge of patella, is still preferred. In the latter group belongs the leg made by Dr. B. Frank Palmer for himself. This apparatus consists of wood and has wooden joints, the knee-joint being eccentric. The entire apparatus is held straight by an endless chain of strong catgut. If the knee has been bent it automatically resumes its position through the action of a spiral spring. The same device is employed at the ankle joint. This was the only apparatus to receive honorable mention at the London Exposition in 1851. Palmer was a rather interesting character. W. Selphe, an Englishman and protégé of Potts left England and came to America in 1839, and introduced the Anglesea leg into this country. He may be considered the first manufacturer in America who obtained prominence. He made an artificial leg for Palmer, then a young man but of an inventive turn of mind. Palmer sought to improve the Selphe leg and in 1846 obtained from the United States government the first patent issued in this country on artificial limbs. In 1849 he improved the leg and obtained his second patent.
Charriere, Mathieu and Bechard constructed for the opera singer Rogers’s artificial arms that were very ingenious. Charriere’s prosthesis was capable of pronation and supination by means of springs; in Mathieu’s flexion and extension were conducted by movements of the shoulder of the sound side through the media of straps and rings. These arms were used successfully in his histrionic gesticulations.
To make artificial arms available to the poor, Count de Beaufort made them of sole leather with wooden hands. By connections to the elbow and shoulder with strings the hands were moved with these larger joints. If amputation was done above the elbow the thumb was connected by a string with the hip, forward motions of which flexed the thumb. The apparatus was a fairly serviceable one and cost but twenty-five francs.
Oscar Dalisch (Berlin 1877) manufactured hands that, by complicated intrinsic mechanism, permitted finger movements more or less delicate. These hand mechanism have been largely abandoned, however, and replaced by simple, but shapely form of wood, or better of rubber – the latter allowing adjustments of the fingers to positions of flexion or extension. These hand forms are removable from the rest of the prosthesis when it is desired to replace them, by a simple movement, with a hook, a tooth brush, or a tool, these latter being the “working hands” of mathieu.
An advance in artificial legs was shown in the apparatus devised by Dr. Douglas Bly, of New Y9oork. It was characterized by a freely moving ball in the ankle joint, movement being limited by leather straps about the joint. Soft rubber is used in all the joints to prevent jarring. The artificial leg of W. Busch-Eschbaum of Bonn introduces an artificial Achilles tendon consisting of a strong rubber band running from knee to ankle. The apparatus of Bechard offers no essential modification.
The ball principle of Bly was also used in the artificial leg made by Esmarch-Beckmann (kiel, 1865).
Russheim (described by Hermann, Prague, 1860) used the tuber ischii as a point of support, also reintroducing fixation of the apparatus by a strap running over the shoulder of the opposite side. Motion in the knee joints is limited and takes place at the point three inches below the true position of the joint.
Herrmann (1865) substituted aluminum for steel on account of its lightness. He also made the axis of the leg alone inch anterior to that of the thigh to give the patient the impression of walking on the whole foot instead on the heel.
The apparatus made up to the middle of the last century was clumsy, noisy, a torture to the wearer and a disturbance to others. It was to the energy and skill of three early American manufacturers, in particular, Selphe, Palmer, and Marks, the credit is chiefly due for those refinements in mechanism and material that have made the modern American prosthesis as acceptable as it is. The furnishing of artificial limbs at government expense to Civil War veterans furnished a great demand. The labors of these and other men have placed us well in the van in this field. England has made little advance on the Angesea leg; France adheres to the productions of Charriere and Mathieu, and Germany to the historic arm of Berlichingen and the leg of the Verduyn pattern.
One modification of recent times is too important to pass by. In 1860, A.A. Marks became convinced that the ankle joint was a source of weakness in the apparatus, and he cast about for a firm material that could be used instead of wood for the foot. Goodyear’s process of curing rubber, just then accomplished, supplied this material, and Marks articulated a rubber foot to the wooden leg. A few years later (1867) at a time when the Count de Beaufort leg – a simple affair of wood in which the leg was immovably attached to a “semblance of a foot”, a rocker sole was attraction much attention. Marks fastened his rubber foot immovably to the leg. Aside from all other considerations, the rubber foot takes from the stump much of the shock and jar of the walking. It must be remembered too, that we used or ankles but little in level walking, and the sacrifice of a freely moving joint at that point is not so great as might appear at first blush.
Oscar Dalisch also made the ankle joint immovable, but he employed a hollow foot of hard rubber, within which was a mechanism whereby the other movements of the foot were simulated.
This brings us to a consideration of the present day. While the artificial limb is now light, useful, ornamental, and far better than any in the past, there is still room for improvement in the treatment of this subject surgically, mechanically and socially. The advances have been made by the manufacturers and not by the surgeon. Most of us have a definite understanding regarding the desirable sides of amputation and most suitable type of stump. Too few of us know enough about artificial limbs to be able to criticize a fit or suggest modifications. Better co-operation with the manufacturer will help him, us, as well as the one most concerned, the patient. The social importance of the question is a growing one. Putting a cripple back to work ranks next to saving a life. When it is considered that men with two artificial legs have learned to skate and ride bicycles and that telegraph operators have learned to send code with the movements of an artificial arm, no case appears hopeless. The proper preparation of stumps and inspection of prosthetic appliances is our duty; the providing of funds (temporarily or otherwise) for the purchase of suitable limbs is an obligation for the various publicly financed lay organizations. In our enthusiasm to help the traumatic cases, let us not forget the child born with congenital defects or crippled later by disease. Artificial limbs can often aid those cases cosmetically as well as functionally.