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.