J Royal Naval Medical Service 2010, 96.1 34-44

History 200 Years of ‘Legging It’ – A comparison of amputation surgery in 1805 to 2005

T Stevenson

“From the time that man first waged war in 1850 and in it states, “More than thirty years upon, & begun to wound & kill his fellow-men, experience… has enabled me to collect an he has been ready to avail himself of all the extensive record of operations of all classes, knowledge & skill that could be obtained to and among them amputations, of course, form save & cure…” a considerable proportion.”(3) His use of the W. H. Flower - 1859(1) words “of course” implies that he expects the reader to know that amputations indeed made As Introduction up a large proportion of operations at that time. Amputation is the oldest capital operation in With regard to the navy, a source charting the existence, and has been practiced since history of surgery at sea concludes, “…it was Neolithic times for punitive, therapeutic and common practice to hack off broken or ritualistic reasons for many thousands of wounded limbs with merry abandon…”(4). years(2). This paper reviews the indications, This may be an exaggeration however, when contra-indications, surgical procedure, faced with no hospital facilities, little room or morbidity and mortality, rehabilitation and time allowed for a patient to languish in bed to prostheses associated with amputation, recover, perhaps it is understandable that the particularly in the Naval theatre of war around navy surgeon would just remove the limb and 1805, and compared with the modern world of be done with it, enabling the man to be ready medicine and surgery of today. for duty or replacement as soon as possible.

Amputations Of The Past: 1805 Indications (Or Thereabouts!) The operations were performed on patients The first and foremost consideration of who were wide awake and carried a conducting amputation during this time was substantial risk of haemorrhage, infection, both that the patient would be wide awake and fully resulting in death. It was also not unheard of aware of the procedure being done to them. for patients to die of shock during the This meant that all operations needed to be procedure(5). However, with these risks well carried out as swiftly and as (relatively) known, the operation would still be carried out. painlessly as possible. After the discovery and The main indications were trauma and subsequent implementation of general disease. In cases of trauma where fractures anaesthesia, time became a luxury of which occurred, the standard management, particularly the surgeon could take full advantage. in open fractures, was amputation at the joint Amputation was extremely common-place above where the injury had occurred. The two hundred years ago. Many sources discuss thinking behind this practice was to prevent amputation as though it was the most routinely infection of the open bone and subsequent performed procedure by surgeons, for example generalised sepsis leading to almost certain surgeon John Haddy James wrote a book death. Crush injuries, and in the case of military about the causes of mortality after amputations casualties, gun-shot wounds, lacerations from

34 200 Years of ‘Legging It’ – A comparison of amputation surgery in 1805 to 2005 35

swords and bayonets, and cannon ball injuries James’ book on the mortality of amputation, all required amputation. Whilst it may seem mentioned earlier, neatly sums up the traumatic that no attempt was made to save the limb, this reasons for amputations according to each limb: was not the case. John Woodall, the “Father of Sea Surgery” (1569-1643) published a book Fore-arm g gun-shot wound, laceration called “The Surgions Mate” in 1617 and actively by mills discouraged amputation where possible, stating Arm g laceration and crush “over forwardnesse doth often as much hurt as Thigh g wagon crush, mines good.”(6) His idea of management, whilst exploding, jumping [falls] argued against at the time, makes more sense Leg g wagon crush, mines by today’s standard, “Nothing cureth fractured exploding, jumping(8) boane so much as rest.”(7) Indeed amputations were considered by many surgeons the last At sea, reasons for amputation would be battle possible option and done in order to trauma, although in bad weather, accidents preserve life. were common. The following table contains The trauma expected in civilian life information from surviving certificates comprised crush injuries and lacerations from contained in the “Chatham” and “Greenwich” wagons and mills and fractures from falls. John chests – Navy Pension boards, responsible for

Date Sailor/Age/Rank Ship Injury Action

22/11/1801 Judonie Blight – HMS Thistle Lost right eye off coast of Egypt Nil 24 – Able Seaman 01/06/1806 Michael Martin – HMS Jason Received lacerations of the face, No amputation 26 – Able Seaman neck, arms, hands, legs, & feet recorded by explosion of a magazine whilst Developed ulcer taking & spiking 6 guns in an at the wrist enemy battery. 19/02/1807 Charles Kellott – HMS Royal Injury of 2nd finger of right hand Ulceration of wound 31 – Landsman George due to a splinter, in action of led to amputation Sir Thomas Duckworth in passing above the 1st finger the Dardanelles joint 13/08/1807 Owen Hughes – HMS Crush of the big toe of the Toenail fell off, 25 – Ordinary Belligerent right foot so amputated at the Seaman 1st joint 30/07/1810 Robert Daniels – HMS Euryalus Gun-shot wound in right Amputated above the 34 – Sergeant, fore-arm after cutting out elbow Royal Marines a French vessel near Toulon 10/10/1810 Henry Hoskin – HMS Victory Fell from booms into the waist, Nil 26 – Quarter Gunner causing violent concussion of the brain whilst getting foresail ready to be sent aft 24/11/1810 William Thompson – HMS Blake Hurt left foot by capstan bar falling No action taken, 35 – Able Seaman on it, fracturing metatarsal bones, although wound has at Copenhagen whilst conveying caused seaman great along main deck to wash seamen’s distress clothes 10/06/1811 John Tuffnell – HMS Ibis Chime of cask damaged tendons Fingers went to 33 – Able Seaman of the 1st & 2nd fingers of right sleep & afterwards hand whilst doing as Captain of sailor endured the Hold employed & was fully sober. amputation

Table 1 Pension Certificates from the Chatham Chest & Greenwich Chest (9) 36 J Royal Naval Medical Service 2010, Vol 96.1

issuing pension certificates to injured sailors: own red mist to withstand the horror of losing a The amputations performed are highlighted limb to the surgeon’s blade. Other surgeons, in bold just to draw attention to the fact that of such as John Hunter, liked to wait for several this random sample of sick certificates, four hours “until the first inflammation had (possibly five) out of eight cases underwent passed,”(12) as did surgeon John James minor amputation for their injuries. “Secondary amputations in civil practice and The other major indication for amputation, performed under favourable circumstances, both at sea and at home, was disease. were and are, on the whole, attended with less Unfortunately, diseases were not always well mortality than primary”(13). Finally, there were described two hundred years ago, and where surgeons who would remain undecided, and sources have described amputations in these hence found themselves in a dilemma, such a cases, they refer to “Disease Process” or military surgeon John Bell, “When there is a “Infection”. The assumption that by “Disease question about amputating, in a very bad Process” they are referring to what we now call compound fracture, the question is, whether the peripheral vascular disease, ulceration, the patient will consent to lose the leg at once, or consequences of Diabetes Mellitus, Tuberculosis risk the dangers of immediate gangrene and infection or untreated malignancy. By infection, death?”(14) There is difficulty in finding reliable the books tended to refer to “Mortification” or statistics to see which argument may be correct, dry gangrene due to disruption of the blood flow however a senior naval surgeon by the name of (ie not from sepsis) which was common both in Alexander Hutchinson decided to settle the injury, disease and following surgery. Sepsis argument once and for all following the battle of was almost always inevitable in civilian trauma Algiers 1816. He circulated questionnaires to injuries, especially in cities, as the streets were the surgeons of the fleet regarding the number often lined with horse dung, and thus home to and nature of wounds requiring amputation, many forms of bacteria, all able to enter a duration of delay before amputation, mortality wound site following, say, a wagon wheel crush rate and period of survival. His results showed injury or compound fracture(10). surgeons who practiced immediate amputation dealt successfully with more serious injuries and Contra-Indications conducted more amputations per patient with a There were very few contra-indications to mortality rate of 33.3% - significantly lower than amputate two hundred years ago and the only where amputation was delayed (45.8%). Whilst debate was when to amputate. Many today’s epidemiologists may criticise his study, it surgeons would argue that primary won many of his contemporaries over, and amputation, conducted immediately at the Hutchinson went on to make important time of injury led to the greater success. recommendations for further reduction of Others argued that delaying for as long as mortality following amputation(15). possible, and thus performing secondary A converse view was given by surgeon amputation, was advantageous. Stephen Hammick in 1830 who wrote of an Many believed in amputating without occasion where he had a patient whose limb hesitation because of the detriment to the body was prepared for amputation, however the a traumatic injury could cause. For example, a patient’s physician would not allow it, fearing for famous surgeon in his day, John Atkins, the patient’s life, which over-ruled both the published a book “The Navy Surgeon” and surgeon and the patient’s desire for the operation spoke of amputation during battle, “…the heat to go ahead. The patient survived and the limb and surprise in action makes it the properest eventually healed, but the patient “spent five time for amputation, men meeting their years in bed recovering and was utterly misfortune with greater strength and resolution miserable” and never regained full mobility(16). than when they have spent a night under The only other contra-indication I could thought and reflection”(11) suggesting that a discover was where the patient was beyond man steeled for battle would be able to use his saving, so palliative measures were taken to 200 Years of ‘Legging It’ – A comparison of amputation surgery in 1805 to 2005 37

ensure as much comfort was given as perform amputations at the patient’s home, in possible, rather than putting them through the their own home, or in the case of the navy agony of an amputation that would only hasten surgeons, on ships at sea. As a consequence, their demise, as recounted by John James: they would carry their own instruments “He [the patient] dies with the system being wherever they went. conscious of some irreparable injury.”(17). In Surgeons in the cities might have access to these instances, although never official, a large hospitals with teaching theatres or minority of surgeons were rumoured to have been liberal with the administration of opiates, particularly opium (laudanum), to ease the passing of the stricken patient.

Surgical Procedure Notes taken by an anonymous student on May 6th 1814 on a lecture about amputation delivered by a Mr Cooper (probably Samuel Cooper) give guidance on the procedure: “Make your incision… below the patella… 8 inches from patella… the posterior & anterior Tibial artery require tying… Keep the limb cool after amputation.”(18) To take a step back, let us look review the Fdiegs 1ig nSautregde owna Wrd ilslipaamce B. eatty’s Amputation Set conditions in which operations would take (Royal College of Physicians and Surgeons of place. The surgeon of old would typically Glasgow)

Fig 2 Operating Theatre of the 1800’s 38 J Royal Naval Medical Service 2010, Vol 96.1

The situation for the surgeons at sea was With regard to the procedure, Turnbull far less luxurious. The conditions were well wrote of 4 main steps to bear in mind: described by navy surgeon Tobias Smollett in “The first [step] is the prevention of his assumed autobiography “Roderick haemorrhage… by a full command of the Random” where he writes of after being tourniquet… and a minute application of the press-ganged into the HMS Thunder what tenaculum afterwards… The second important awaited him in the sick bay – “about fifty step… is the separation of the nerves… in miserable distempered wretches… huddled order to prevent the symptoms of pain & one upon another… and deprived of the light spasm… The third important step… is the of day as well as of fresh air; breathing nothing proportion of the stump, which should be no but a noisome atmosphere of the morbid more than completely to cover the denuded streams exhaling from their own excrements parts, and not so much as to lap over and and diseased bodies, devoured with vermin endanger the formation of matter… The last hatched in the filth that surrounded them.”(19) circumstance regards the after treatment; and William Turnbull, famous surgeon and here the great object is to obviate former navy surgeon, wrote a handbook for inflammation… and afterwards to check any navy surgeons in 1806 and in it definitively excess of discharge, which might reduce the covered everything the young surgeon would constitution of the patient .”(21) need to know about amputation. He began The following paragraph describes with the instruments: amputation of a hand, written by surgeon William Northcote. “For amputation of the hand, three assistants placed thus. One… should stand behind him [the patient] to hold the body; another on the side of the affected arm, which he is to hold fast; a third assistant must hold the hand about to be amputated. Then proceed to fix the tourniquet with a compress on the brachial artery… [The skin is pulled taught and surgery begins] Having divided the skin, order the same [second] assistant to draw it up as much as possible; then cut through the flesh to the bones circularly, close to the edge of the retracted skin, & divide the intermediate skin and ligament between the bones by the catlin, with which we also separate the periosteum a little, both from the radius & ulnar to prevent its being lacerated by the teeth of the saw, which we must next apply on the outer side of the arm; ordering the assistant to draw up the flesh as much as possible to open a passage to the bones, that they may be cut off a little higher than the incision, and that the flesh may afterwards wrap over them… and thus the flesh and skin being longer than the bone, and folding over the stump, with greatly hasten the cure. Work the saw upon the both bones after they have been partly entered by the teeth and cut Table 2 – A list of instruments according to the through them as speedily as possible, but be New Regulations for navy surgeons(20) 200 Years of ‘Legging It’ – A comparison of amputation surgery in 1805 to 2005 39

careful to have both bones divided at the once (if two) & divided at as few strokes as same time without splintering them. The limb possible… the nearer you come through, the being thus amputated, order the assistant to easier to move, lest the bones should relax a little the tourniquet, that by starting splinter .”(23) forth of the blood the ends of the arteries may From these two accounts, one can see a be discovered, which must be secured by big similarity in how to conduct the operation. ligature with a crooked needle and waxed And from both accounts we can also draw the thread, made pretty broad to prevent it from conclusion that the surgeon’s biggest worry cutting through the coats of the artery, which was haemorrhage. This was assisted is thus intercepted by passing the needle considerably by the introduction of Petit’s twice round and securing the ligature by the screw tourniquet. surgeon’s knot. ”(22)

Fig.3 Right Arm Amputation – A surgeon with Fig.4 Above-Knee Amputation – note the screw his assistants bracing the patient tourniquet & linen retractor This detailed account seems to hold true Morbidity & Mortality the same principles used today and to Amputation as we have already seen was a demonstrate similar procedure for another dangerous business. And the mortality was limb, the following is a generalised method indeed high. The chances of developing with which to conduct an amputation at any infection were significant. Much depended on level, from John Atkins’ The Navy Surgeon: luck and some of the surgeons were able to “In this operation, the first thing we ought publish figures of low mortality, such as to have in intention is the stopping of the Hammick: “During my service, I have blood… There are 3 methods in practice: the performed 287 amputations, of which 16 have 1st by medicines astringent or styptick; the died.”(24) That works out at about a 5% 2nd by cauteries, actual or potential; & the 3rd mortality rate. by a deligation of the artery… The turniket is The causes of mortality after amputation put in, & twisted to a degree sufficient to went as follows – shock & exhaustion, and check or interrupt the course & motion of the pyaemia (secondary infection) with the shock blood… Guide it [the knife] for a smooth & exhaustion being twice as frequent as circumcision… bringing it at once as near the pyaemia(25). Other causes were sepsis, bone as you can, & as far round… also, you gangrene, and tetanus, often found in horse are to separate the flesh… and clear it for the manure on the streets, and so able to freely saw… The saw is to be set on both bones at enter traumatic wounds. Unfortunately it was 40 J Royal Naval Medical Service 2010, Vol 96.1

difficult to find many statistics for the different floor, surgeons would happily wear their causes of death, although below are a series aprons which were stiff with blood without of tables documenting the mortality rates ever washing them (a stiff apron was the sign following amputation in hospitals: of a good surgeon) and in one case attributed So here, out of 300 cases performed by to Robert Liston, where in his haste to remove one surgeon over 33 years, 43 died (approx a leg, he also removed the patients testicles, 14%) with amputations at the thigh providing two fingers from an assistant and the coat tails the larger death rate and amputation at the of an observer. The observer promptly fore-arm the lowest. dropped dead of shock fearing he had been A far more severe death rate occurred in cut. The patient and assistant both went on to Paris at 65%. Presumably the conditions of develop gangrene and both died, so it became the hospital had an effect on whether or not the only operation on record with a 300% the patient would develop sepsis or gangrene. mortality rate!(28) Or perhaps the varying death rates came Figures at sea for mortality were just as from surgeons’ idiosyncrasies, for example an variable. Strangely, the death rate due to American Surgeon, Samuel Gross, would touch infection at the Battle of Trafalgar was only his knife on the sole of his boot and then use it 10%. Either the conditions were inhospitable for the whole operation. Sponges would be re- for the growth of bacteria, or perhaps the used between operations, merely dipped in surgeons were being a little more water if soaked in blood or dropped on the conscientious about their cleanliness: “ [John]

Table 3 – Devon & Exeter Hospital 1816-1849 Mortality rates of 300 amputations(26)

Table 4 – Extract of all Primary Amputations in Paris for Traumatic Lesion 1836-1846 (From Malgaigne) (27) 200 Years of ‘Legging It’ – A comparison of amputation surgery in 1805 to 2005 41

Atkins practiced scrupulous cleanliness, anti- 75% of the patients being over 65 years old, sepsis and thorough debridement of and 65% of the patients being men (2003)(31). wounds… [which] included methodical Most limbs can be saved following trauma, so planning, with clean, polished instruments laid why are amputations carried out now? out in order on a linen cloth, threaded needles, The main indications for amputation now ample clean water and an antiseptic solution, are shown below in table 5: two sea chests as operating tables covered with clean clothes and a receptacle for dismembered limbs. ”(29) Atkins’ mentor, Indication percentage James Yonge, senior surgeon at Plymouth, also Peripheral vascular disease 85% practiced extreme cleanliness which was said to be the key factor of his success. Trauma 10% The varying mortality rates would continue Tumours 3% to remain pretty high until the discovery of Infection <1% Joseph Lister’s carbolic acid spray. When that was implemented, the morbidity and mortality rates of all operations, not just amputation, Table 5 – Main indications for amputation in began to drop. the UK(32) Amputation through the lower limb Rehabilitation & Prostheses accounts for 85% of all amputations(33). One The sailors of the Chatham Chest received a of the main causes for all these amputations is generous annual pension for their injuries. But diabetes. Diabetics are 15 times more likely to what was the future in store for an amputee? suffer amputation than someone without. The stereotypical image of the peg-legged The indications for a below-knee pirate was probably quite accurate. amputation are gangrene, ischaemic ulcer, Prostheses were simple wooden ‘pegs’ or, for advanced unreconstructible ischaemia, acute the slightly wealthier, a crafted wooden leg, or chronic infections (including osteomyelitis) The prostheses would depend on where severe enough to preclude healing at a distal the amputation had occurred. With regard to level(34). These indications are perhaps not all post-operative pain, it was considered much that different to those in 1805, but we easier to fit a below-knee amputee with a understand them a little better, and are able to comfortable prosthesis, as recounted by do more to prevent these conditions reaching Hammick, “ Let me urge you very strongly, the need for amputations. whenever you possibly can… take off the limb From a trauma perspective, the standard below instead of above the joint; its managements of compound fractures is now advantages are very great! ”(30) reduction and fixation, with every attempt With regard to rehabilitation, there is made to restore 100% functionality to the almost nothing in the literature. It obviously limb. Amputations still have their place, for had to happen somehow, as so many people example, severe crush injuries, war injuries underwent amputations and there are plenty such as bomb blasts and mines, and also of accounts of how surgeons saw patients severe burn injuries. Most of the disease several years later when they were back to processes bring about the need for amputation normal and pain free. surgery by affecting the circulation at whatever level, as the figures suggested in table 5. Modern Day Amputations: 2005 (Or Thereabouts!) Contra-Indications The first thing to say about amputation is how The universal contra-indications for modern day much less common it is than it used to be. amputation are gangrene, ischaemia, or Approximately 5,500 amputations are infection of such severity as to preclude performed annually across the entire UK, with healing at the level of desired amputation(35). 42 J Royal Naval Medical Service 2010, Vol 96.1

This is perhaps countered by a ‘watch-and- mortality of lower limb amputation and found wait’ policy with appropriate patients, or by that in 97 patients, 122 amputations were short-term and aggressive treatment with performed including 45 above (AKA) and 77 antibiotics, or if delay is impossible, then to below (BKA) knee amputations, with a amputate at a more proximal level. conversion rate from below to above knee In some cases, particularly now that the amputation of 14%; in 65 of those patients 107 average age of an amputee being much older, it complications occurred (67%); the incidence of may be a simple case of the patient being unfit wound infection was 10% in the BKA group for surgery, and where it is just not appropriate and 2% in the AKA group; and finally the to either patient or family to start removing hospital mortality for BKA was 9% and for AKA limbs. These contra-indications show a stark 18%. Long-term survival was 62% at 1 year, similarity to those two hundred years ago. 50% at 2 years and 29% at 5 years(37), showing a still-high mortality figure. Surgical Procedure Another major problem leading to high The procedure has changed very little from post-operative mortality is age. An American that used two hundred years ago. The main study looking at survival following lower limb differences now lie with the conditions under amputation in an elderly population found that which operations are conducted. For a start, mortality risk increased with advanced age, the discovery of anaesthesia and sterile more proximal amputation level, and renal and techniques have offered an entirely different cardiovascular disease particularly after the first environment in which to operate and so have year(38). allowed the surgeon the opulence of as much Recommendations are now to provide time as he needs to operate. The typical specialist care to patients with predictors of amputation of, say, above the knee lasts about long-term mortality and try and reduce figures 20 minutes, although is subject to lengthening in this way. if any complications arise during surgery. Scrupulous cleanliness is now a must, with Rehabilitation and Prostheses surgeons and staff changing into clean clothes Aftercare of a modern western world: this has specific to the theatres, and applying sterile been revolutionised over the last 200 years, gowns and gloves in which to conduct the with patients able to expect a full multi- operation, to maximise the reduction in risk of disciplinary approach geared towards helping infection. them adjust and adapt to ‘life without limb’. With regard to anaesthetic, amputation can With dedicated orthotics and prostheses be performed under general anaesthetic, or in departments in hospitals, at least 90% of the cases of patients unfit for that, spinal patients with a transtibial amputation will anaesthetic or epidural. So some patients are successfully use prosthesis in contrast to a still awake, just like two hundred years ago, success rate of 25% of geriatric transfemoral only now they cannot feel a thing! dysvascular amputees(39). The main factor to account for this difference is that there is a Morbidity and Mortality hugely increased energy requirement to walk For all the advancements made over the last on an above-knee prosthesis. two hundred years, amputation still carries a While they face the problems of stigma substantial risk of morbidity and mortality and embarrassment in public, people without following operation. Infection is still a relative limbs today are well cared for and have a vast problem, with a recent study showing that amount of opportunities open to them. So limb amputation shows the highest rate of long as they are well provided for, rehabilitation surgical site infection at 14.3% of cases and prostheses for amputees will only improve compared to eight other categories of in the future, especially with the advancement surgery(36). of myoelectrics, the computerised limbs that A Norwegian study looked at morbidity and move on command. 200 Years of ‘Legging It’ – A comparison of amputation surgery in 1805 to 2005 43

Conclusion 9. For the Sick & Wounded Sailors of His Majesty’s Amputations were carried out far more Royal Navy – The Chatham Chest (Also with frequently in Napoleonic times for much certificates from The Greenwich Chest ) 1802 – broader indications and although the procedure 1813 Unpublished, handwritten, [MS.5994] has changed remarkably little, it used to be Wellcome Library for the History and carried out far more swiftly. Both periods Understanding of Medicine, London UK afforded good operational success, the 10. Magee, R. p.678 principal difference being mortality from 11. Atkins, J. (1742) “The Navy Surgeon” J Hodges, infection in the post operative phase. London UK As we are now into the 21st century, we 12. Hunter, J. (1794) “Treatise on the Blood, can only expect further advancement in Inflammation and Gun-shot Wounds” John surgery, medicine and technology. Richardson, London UK The asymmetric nature of the recent 13. James, J.H. p.10 conflict in Afghanistan has shown that 14. Watt, Sg Adm Sir J. (2002) “The Age of Sail: amputations still have a major place in a Naval Surgery in the Time of Nelson” Volume 1, military environment and there is still the Conway Maritime Press, UK p.28 potential for it to face the Naval Surgeon at 15. Bell, J. (1795) “Discourses on the nature and sea, be it in a conflict scenario or a trapped cure of wounds. I. Of generals. II. Of particulars. limb. However although the techniques are III. Of dangerous wounds of the limbs. IV. Of the very similar, fortunately surgical conditions, question of amputation.” Bell & Bradfute, facilities and the long term outcome have Edinburgh UK, p.54 improved markedly. 16. Hammick, S.L. (1830) “Practical Remarks on Nonetheless when one considers the Amputations, Fractures, and Strictures of the conditions at sea in Napoleonic times with no Urethra” Longman, London UK, p.109 anaesthetics and the inevitability of post 17. James, J.H. p.14 operative infection, the successes achieved in 18. Anonymous Medical Student (06/05/1814) “Lecture amputation were remarkable. Notes on Amputation Surgery – Delivered by Mr Cooper” Unpublished, handwritten, [MS.7588] Wellcome Library for the History and References Understanding of Medicine, London UK 1. Flower, W.H. (1859) “On the importance of a 19. Smollett, T. Ed Rose, T. (1841) “The knowledge of the elements of practical surgery Miscellaneous Works of Tobias Smollett” Henry to Naval & military officers” Journal of the Washbourne, London UK, p.56 United Service Institution vol. iii, p1 20. Turnbull, W. (1806) “The Naval Surgeon” Richard 2. Magee, R. (1998) “Amputation through the ages: Phillips, London UK, p.300 The oldest major surgical operation” Australia & 21. Ibid, p.303 New Zealand Journal of Surgery, 68:675-678, p.675 22. Northcote, W. (1770) “The Marine Practice of 3. James, J.H. (1850) “Causes of Mortality After Physic & Surgery” Richardson, London UK Amputation of the Limbs” Deighton & Co., 23. Atkins, J. p.124-6 Worcester UK, p.2 24. Ibid 4. Druett, J. (2000) “Rough Medicine: Surgeons at 25. Sansom, A.E. (1859) “The mortality after Sea in the Age of Sail” Routledge, New York operations of amputation of the extremities & USA, p.18 the causes of that mortality” John Churchill, 5. James, J.H. p.15 London UK, p.20 6. Woodall, J. (1617) “The Surgions Mate” 1st 26. James, J.H. p.30 – 50 Edition, Laurence Lisle, London UK, as cited by 27. Ibid Druett (2000) in “Rough Medicine: Surgeons at 28. Magee, R. p.676-678 Sea in the Age of Sail” 29. Watt, Sg Adm Sir J. p.26-28 7. Ibid 30. Hammick, S.L. p.109 8. James, J.H. p.20-30 31. Surgical Tutor (undated) Amputations [online] 44 J Royal Naval Medical Service 2010, Vol 96.1

available at http://www.surgical- Picture References tutor.org.uk/home/vascular/amputations.htm Fig.1 Courtesy of Mick Crumplin (Accessed April 2006) Fig.2 Courtesy of Mick Crumplin 32. Ibid Fig.3 Courtesy of James Beaton, Royal College of 33. Canale, S.T. (1998) “Campbell’s Operative Physicians & Surgeons of Glasgow Orthopaedics – Part 4 – Amputations” 10th ed. Fig.4 Courtesy of Lt Cdr J Scivier, Commanding Mosby, UK, p.575 Officer HMS Victory 34. Barnes, R.W., Cox, B. (2000) “Amputations: An Illustrated Manual” Hanley & Belfus, Special thanks to: Philadelphia USA, p.67 • Mick Crumplin, Honorary Curator, Museum of the 35. Surgical Tutor [online] Royal College of Surgeons, Lincoln-Inn Fields, 36. Coello, R., Charlett, A., et al. (June 2005) London “Adverse impact of surgical site infections in • Tina Craig, Library of the Royal College of English hospitals” Journal of Hospital Infection. Surgeons, London 60(2):93-103 • Jane Wickenden, Institute of Naval Medicine, 37. Ploeg, A.J., Lardenoye, J.W., et al. (June 2005) Alverstoke, Gosport “Contemporary series of morbidity and mortality • Staff & Crew, HMS Victory, HM Historic after lower limb amputation” Journal of Vascular Dockyards, Portsmouth & Endovascular Surgery. 29(6):633-7 • Royal Naval Museum Library, HM Historic 38. Mayfield, J.A., Reiber, G.E., et al. (June 2001) Dockyards, Porstmouth “Survival following lower-limb amputation in a • Archives & Manuscripts, Wellcome Institute for veteran population” Journal of Rehabilitation, Medicine, London Research and Development. Volume 38, Issue 3, • Mr Aaron Sweeney & Vascular Team, Lewisham Pages 341-345 Hospital, London 39. Canale, S.T. p.575 40. Engstrom, B., Van der Ven, C. (1999) “Therapy for amputees” 3rd ed. Churchill Livingstone, London UK

Surgeon Lieutenant T Stevenson General Duties Medical Officer