Apart from obvious complete severance of a limb, it is proposed to include injuries where the tran-section is incomplete yet sufficiently destructive that surgical completion of the severance appears mandatory, to both patient and surgeon. Many crush injuries without an open wound may require immediate amputation, according to surgical opinion, yet this advice is resisted by the patient and relatives who ignore, or fail to understand, the significance of an interrupted blood supply until gangrene develops.
Traumatic amputations of the fingers and toes were probable early examples of complete tran-section, due to the use of stone hand axes and other tools, crushing by rocks or building stone and accidents in mines; a shoeless society was particularly vulnerable to injuries of the feet. Eventually, metal tools and, ultimately, industrialisation with mechanically motivated machinery became major sources of hand injuries. Most accident services are familiar with wood machinists who sustain circular saw amputations; indeed the writer recalls treating a carpenter who had a series of saw injuries over many years and had to retire having, on this occasion, lost his last remaining finger, although he still retained his thumbs; this occurred before reattachment of digits was practised.
Traumatic amputations through the shin, forearm, thigh and upper arm demand severe and well-localised linear violence, for example, by powerful animal bites, by railway train wheels, occasionally by the high impact of a motorcycle collision, and at sea by hawsers snapping under tension or uncoiling rapidly to entrap limbs. In 1678, Yonge described a sailor sustaining a virtual complete amputation in this way:
"John Boddam ... standing in the coyle of an Halcer (hawser), by which the Ship was fastened: he was drawn forward, and griped therin: so that both legs were shattered in pieces,... one of them hung by a tendon or two above the Ancle. In fine, an Amputation was inevitable."4
Similar leg injuries were noted by Woodall in 163 95 and by Boyle working in Sierra Leone, West Africa, in 1831 who recorded the following accident when an emergency anchor was lowered to prevent a ship running aground:
"Whilst this anchor was being dropped from the bow of the boat, one of the men unguardedly allowed his leg to become entangled in a coil of running cable, and in a moment the limb was literally torn to pieces, the only continuity remaining being one or two of the extensor tendons in a greatly lacerated and injured state. The poor fellow was rescued from the additional peril of being dragged overboard by the cable."6
The victim was then transported 18 miles for an immediate formal below-knee amputation from which he eventually recovered. Arms were not immune to this mechanism of injury as De La Motte recounted, in 1711, when a ship's captain trapped his thumb in a cable round a capstan which pulled his arm in to above the elbow; De La Motte saw him 4 days after injury when the arm was gangrenous and undertook amputation close to the shoulder, with a good result.7 To bring this relatively rare but dramatic accident nearer our own time, the recent obituary of a former merchant marine officer recorded that in 1944 he sustained compound fractures of both legs when a rope, mooring a 20,000-ton vessel, parted and the recoil knocked him off his feet. He was in hospital for 3 years and, despite modern treatment with antibiotics and skin- and bone grafting, one leg proved so disabled that eventually it was amputated.8
Arms and legs are also vulnerable to the bites of sharks and crocodiles. Boyle recorded four victims of shark bites involving young sailors swimming or simply dangling their feet in the Sierra Leone River between 1827 and 1830. Of the three who came to amputation, the following patient is remarkable for surviving extensive and severe injuries. Boyle wrote:
"On the 28th September, 1828, I was suddenly called to visit Thomas Corrigle, an apprentice on board the Britannia merchant-ship, (about 17 years old), who, it was stated was dreadfully mutilated by a shark whilst bathing up the river Sierra Leone, where the vessel was employed loading with timber.
On proceeding to examine the injured parts, I found that the left fore-arm had been removed within about two and a half inches of the elbow joint; the joint having been deeply penetrated by the animal's teeth, and the head of the ulna broken off from the body of the bone remaining attached.
The metacarpal bones of the right hand were denuded and fractured, whilst the ligamentous attachments of the wrist superiorly were all cut through, and both radius and ulna fractured at their lower extremities. There was also a deep ragged wound in the palm of the hand, exposing the flexor tendons."9
In addition, there were wounds of the right groin, the scrotum and the right thigh which Boyle described as "the most appalling spectacle I had ever seen before in the form of a wound" extending from the hip joint to within 4 inches of the knee; the neck of the femur was marked by the animal's teeth. It was clear the left forearm transection required formal amputation above the elbow and the right forearm was amputated above the wrist; the question of amputating the right leg at the hip was debated but considered too hazardous, and the wound was cleaned and sutured. Boyle concluded: "All this the heroic boy bore without a murmur.. " After 4 days of slight fever, he steadily recovered, the amputation stumps healing gradually, and on December 25 he walked without a limp and took passage for England.10 Sharks continue to be an agent of accidental amputation as well as death, and indeed a growing factor, as the quotation heading this chapter suggests (Fig. 3.1). A recent victim near Brisbane, Australia, aged 21 years, had both upper limbs bitten off and despite being airlifted to hospital died of blood loss.11
Nevertheless, with modern management, survival after severe accidental amputations has improved. In 1971 Johansson and Olerud described the case of a boy aged 10 years sitting on a combine harvester who lost the whole of his right leg and hemipelvis when his foot was caught and the frame of the machine acted as a "blade." Strenuous resuscitation enabled him to survive and eventually walk with a prosthesis.12
Natural disasters such as earthquakes, volcanic eruptions, severe storms and tidal waves were doubtless ancient sources of major limb transec-tions and, as contemporary reports of earthquake and tsunami disasters confirm, continue to be so. During the last century, we can add the innocent civilian amputee victims of warfare, aerial bombardment, minefields and of suicide terrorists. Since its introduction, the heavily laden wagon wheel, especially that of railway traffic, has been a potent cause of limb transection or near-transection. Lucas of Leeds communicated the following observation to Alanson:
"November 27th, 1780, Esther Pearson, aged seventy-three, was admitted my patient at the Infirmary, for an accident she had just received; which had broken both
legs. A heavy coal-waggon had run over them, and shattered the bones of both in such a manner, that one required immediate amputation; the haemorrhage being difficult to restrain ... The amputation was made above the knee... The other leg was so shattered, that it was thought necessary to remove three or four inches of the tibia."
The amputation healed completely in about 6 weeks but the outcome of the other leg is unrecorded.13 Another victim reported by Alanson sustained severe injuries to one leg crushed by two wheels of a coal-waggon; in addition to compound fractures and muscle damage, bleeding was profuse and immediate below-knee amputation was performed with, ultimately, a good result.14 In the mid-19th century, Erichsen remarked that primary amputation is commonly required in civil life for crushing limb injuries due to accidents in mines, on railways and by waggons.15 Spence detailed a number of such accidents in 1882 including the following:
"Alexander R., whilst in a state of intoxication, fell under the wheels of a railway carriage, and sustained a compound comminuted fracture of both legs in the one communicating with the knee joint, whilst the other limb was almost completely cut off below the knee. Amputation of both limbs performed at lower third of femur. Patient never rallied, and died on the third day."16
Similar injuries on modern underground and overground railway tracks are noted in national media reports from time to time.
The arm was not immune to accidental amputation and was an especial hazard for those working with moving unguarded machinery. Spence noted several in his Clinical Cases and Commentaries of 1882, of which the following is an example:
"On the morning of the 9th December 1847, James Watt, millwright at a large paper-mill in the vicinity of Edinburgh, when inspecting the machinery, perceived that a part of it was loose. While engaged in fastening the loose part, the sleeve of his jacket was caught, and the right arm dragged between two wheels and rapidly crushed ... The injured arm presented a frightful appearance; the limb was completely detached from about three inches above the elbow, and the humerus was again broken through obliquely, immediately below the insertion of the deltoid, leaving the attachment of that muscle entire; but on the inner side the fracture had splintered the bone to within an inch of the joint; the middle part of the humerus, together with the soft parts, were hanging in shreds. On the right side of the chest the integuments had been entirely removed to within two inches of the sternum;... Although, from the nature of the injury, and the state of the patient, I had almost no hopes of his recovery, I thought it right to give him the only chance—viz, by amputation at the shoulder joint."17
Operation was performed under chloroform, the full effect of anaesthesia being obtained in 3 minutes. This point is significant as Simpson had introduced chloroform for anaesthesia only a month earlier in November 184718; indeed, Spence observed that this was his first great operation under chloroform. After a few days illness, the patient steadily improved, his wound becoming sound after about 2 months.
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