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Roman Encyclopedist Authored How-to Guide for Gangrene, Amputation

Amputation was a “sad…remedy,” for treating incurable gangrene, confessed Aulus Cornelius Celsus, the famous Roman encyclopedia author.

But he pointed out that the alternative to surgical removal of a diseased limb was sadder. The patient would almost certainly die.

Celsus (c.25 BCE-c.50 CE) authored De Medicina (“On Medicine”), a weighty medical work that is apparently all that survives of an even weightier encyclopedia. De Medicina offers a rare glimpse at pharmacology and medical science in ancient Rome.

Celsus also went down in history for etymology. He translated the Greek word “carsinos” (crab) for a malignant mass into the Latin “cancer,” which also means crab.

A step-by-step guide

Celsus, who lived around the time of Jesus Christ, graphically described the removal of limb infected with severe gangrene.

“Patients often die under the operation either from loss of blood or synocope (passing out),” he conceded. “It does not matter, however, whether the remedy is safe enough, since it is the only one.”

Early treatment was key for patients with gangrene in the time of Aulus Celcus. For gangrene left untreated, surgery was the only option.

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De Medicina included a how-to guide to amputation. Celsus instructed, “…between the sound and the diseased part, the flesh is to be cut through with a scalpel down to the bone, but this must not be done actually over a joint, and it is better that some of the sound part should be cut away than that any of the diseased part should be left behind.”

When the surgeon reached the bone, he was supposed to draw back “the sound flesh…back from the bone and undercut from around it, so that in that part also some bone is bared; the bone is next to be cut through with a small saw as near as possible to the sound flesh which still adheres to it; next the face of the bone, which the saw has roughened, is smoothed down, and the skin drawn over it; this must be sufficiently loosened in an operation of this sort to cover the bone all over as completely as possible,” Celsus wrote.

The section “where the skin has not been brought over is to be covered with lint; and over that a sponge soaked in vinegar is to be bandaged on. The remaining treatment is that prescribed for wounds in which suppuration (the formation or discharge of pus) is to be brought about,” he added.

In explaining limb removal, Celsus failed to “mention vessels, nerves or the use of tourniquet or hot iron cautery, and it is concluded any division of sound flesh was superficial and limited to skin,” wrote John R. Kirkup in A History of Limb Amputation. “However, in a chapter on wounds and haemorrhage [sic], Celsus wrote vessels were to be tied in severe cases, retaining cautery as a last resort.”

Early treatment advised

When Celsus wrote about open fractures, he stressed that flesh wounds to the thigh and upper arm were especially “liable to more severe inflammations and also have a greater tendency to gangrene.” He added that “in the case of the thigh-bone, if the fragments have separated from one another, amputation is generally necessary. The upper arm is also liable to this danger, but is more easily preserved.”

On the other hand, Celsus advised that in its early stages, gangrene was not hard to cure, particularly in young people “and even more so if muscles are intact, sinews uninjured or but slightly affected, and no large joint opened, or if there is little flesh in the part, and so not much to putrefy, and if the lesion is limited to one place; and this mostly happens in a finger.”

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According to Celsus, the doctor should begin with bloodletting, if the patient is strong enough, followed by excising the diseased tissue up to “the sound tissue.”

If the disease was spreading, treatments “which tend to promote suppuration are not to be applied; and therefore not even hot water. Weighty dressings also, although repressant [sic], are unsuitable; but the lightest are needed; and over the parts which are inflamed refrigerants are to be used.”

If the gangrene was not abating, “the part between what is sound and diseased ought to be cauterized; and in such a case especially assistance is to be sought, not only from medicaments, but also from a system of diet; for this malady only occurs in a corrupt and diseased body.”

Thus, until the patient grows dangerously weak, he “should fast; after that he should be given light food and drink to tone up the bowels, and so also the body in general. Later if the lesion has been checked, the same things should be put on the wound which were prescribed for putrid ulceration.”

If the patient improved, he could go on “a fuller diet — foods of the middle class, but only such as dry up the bowels and the body generally; and cold rain-water to drink,” Celsus wrote. On the other hand, baths were out until the doctor was positive “that soundness has returned; for a wound, if softened in the bath, is quickly again affected by the same malady.”

However, if bloodletting, dressings, excisions, fasting, various diets and rain water did not work, “there is one sad by solitary remedy to secure the safety of the rest of the body, that is to cut away the limb which is gradually dying,” he concluded.

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