The guillotine is better known for taking lives in the French Revolution than for saving limbs in World War I.
But in 1914-1918, French army physicians used a variation of the notorious beheading machine to quickly remove the gangrenous arms and legs of soldiers who probably would have died otherwise, wrote Julie Anderson, PhD, a British medical historian, for the British Library’s website. “As traumatic as it was, amputation saved the lives of many men as it often prevented infection.”
Anderson stated, “The First World War created thousands of casualties. New weapons such as the machine gun caused unprecedented damage to soldiers’ bodies. This presented new challenges to doctors on both sides in the conflict, as they sought to save their patients’ lives and limit the harm to their bodies. New types of treatment, organization and medical technologies were developed to reduce the numbers of deaths.”
Evolution of surgery during wartime
The “guillotine amputation” did not always involve an actual guillotine. British and American military surgeons used standard surgical instruments. But the guillotine technique was “definitely established in the World War of 1914-1918,” wrote Maj. Gen. Norman T. Kirk, the U.S. army surgeon general and Lt. Col. Francis M. McKeever of the army medical corps in the April 8, 1944, issue of The Journal of the American Medical Association.
Image: U.S. Army Medical Department Office of Medical History
Kirk and McKeever’s article appeared during World War II. The guillotine amputation was meant to prevent the often fatal effects of gas gangrene by improving drainage from infected or potentially-infected tissues, they explained. Such drainage, they added, “ has always been a fundamentally sound surgical principle … So lethal were the consequences of primary closure of battle wounds that it was necessary for the Surgeon General of the American Expeditionary Forces [in World War I] to issue an order prohibiting the closure by primary suture of any battle wound.”
“Guillotine amputation” was something of a misnomer, according to Capt. Thomas G. Orr, MD, of the army medical corps. “The term ‘guillotine’ as applied to amputations is perhaps not as suitable or as descriptive of the operation that is really done, as the term ‘flapless operation,’ but priority counts for much in medicine and surgery and the word will, no doubt, continue in use,” he wrote in the May 1919 issue of The Annals of Surgery.
A response to gangrene
Orr credited Capt. M. Fitzmaurice-Kelly, MB, FRCS, a British army surgeon, with devising the guillotine amputation. “The early days of the war produced conditions which we had never dreamt of, and these called for new methods,” Fitzmaurice-Kelly stated in 1915 in the British Journal of Surgery.
Fitzmaurice-Kelly recalled that in October 1914, he “had the temerity” to adopt the flapless amputation, which, he confessed, “reverted to the dawn of surgery.” He added that his “method, called the flapless amputation, the guillotine amputation [a bad name], and the amputation en saucisson [a very bad name], has had a curious fate; approval almost unanimous from those at the front, and obloquy almost universal from those at home.” [Author’s note: “En saucisson” translates from French to English as “in sausage.”]
Fitzmaurice-Kelly said he developed the flapless amputation in response to the many cases of gangrene he encountered when he arrived in France. In September 1914, British and French forces had stopped the invading German armies at the Marne River, near Paris. Casualties were heavy on both sides.
“Large segments of the limb, often above the elbow or knee, reached the base hospitals in a totally gangrenous condition, and a large area of the limb was hard and brawny, with the typical brown discoloration, frequently extending to the trunk,” he wrote. “In such cases, amputation seemed hopeless, and I am afraid our first case died without anything being attempted for his relief.”
The next case was a soldier “with gangrene to the middle of the arm.” Fitzmaurice-Kelly decided to amputate the diseased limb.
“I divided the skin a quarter of an inch from the gangrenous margin, and after allowing for retraction, I divided the muscles, then the bone at the level to which the muscles retracted. To my surprise, the patient’s general condition improved at once.”
Thus, Orr wrote, “the [technique] of the guillotine operation as described by Fitzmaurice-Kelly was not a true guillotine in the sense that the extremity was cut squarely off as might have been done with the historic guillotine blade. The skin was divided in a circular fashion, permitted to retract, as it will always do to a certain extent, and the muscles and bone were divided in the plane of the retracted skin.” Nonetheless, he added that “so many modifications of this procedure have been used, depending usually upon the available tissue, that it is probably wiser to include under the guillotine all flapless amputations.”
Flapless amputations sometimes required subsequent surgery to improve the residual limb. But, according to Orr, “quite a large percentage of oblique guillotine amputations of the lower thigh heal and make satisfactory stumps without further operation, and if operation is advisable a good end-covering of the stump with anterior flap can be made with little or no sacrifice of bone.”
Orr lauded the flapless amputation. “Judging from knowledge we have received nothing but praise from the surgeons overseas in handling the amputated. For the most part patients have received good and proper amputations and postamputation treatment. There are, without question, cases that would have healed with flap operations and secondary suture when the guillotine was used, but from the histories we are able to obtain, such cases are very much in the minority, and at the time the amputations were done were probably doubtful or potentially infected cases.”