Any accidental compound limb fracture may interrupt the distal arterial circulation and almost certainly contaminate the wound. Even without a comminuted fracture, the blood supply can be compromised, and the injured segment becomes pale or blue and cold and, in the absence of reconstruction of the disrupted vessels, gangrenous changes can be anticipated. Almost until the mid-20th century when arterial repair became commonly available, such limbs were subjected to amputation, either immediately or later, depending on the assessment of the surgeon and reaction of the patient. Sometimes the decision to operate was made too late to prevent extension of the gangrene, with or without complicating infection. Despite a good blood supply, crushed and contaminated tissue damage may produce spreading infection which, if not controlled, becomes an indication for amputation. Further, if infection stabilises to reach a chronic state, the patient may take the lead to be rid of a useless and foul-smelling appendage, as a 9-year-old boy demanded in the 17th century. His surgeon Hugh Ryder wrote:
"A Lawyer's Son in Fetter-lane,... having eleven Fistu-laes in his Leg, and Thigh: for about a Twelve-month, had been under the hands ofseveral Surgeons; who at length despairing of his cure, let him off. The Boy calling to mind, that some fouryears before,I had cured him of two Ulcers in his Leg (for this accident was since, and hapned (sic) by a Contusion from a Cart-wheel, hurting his thigh and Leg, from whence afterwards Apostemations and Fistulaes were produced) desired his Father to send to me,... I accordingly went; but found him so discarned, that he was almost a Skeleton, having for twelve weeks been detained by a Diarrhaea. From his Ulcers, and Fis-tulaes flowed a filthy matter, stinking beyond all comparison, his Heel stuck to his Buttock, and his Knee disjoynted; for the head of the Tibia met not with the Os Femoris (which overhung it) by above an Inch, the Ligaments being all eaten asunder, by the matter there contained. I told his Father, I had considered, the circumstances he lay under, were so severe, that I thought, there was no likelyhood ofhis recovery, nor possibility of Cure; to which the Boy very heartily replied, he knew he should be well, if I would cut off his Thigh; and if I would lend him a Knife, he would cut it off himself;"19
Persuaded by the boy, Ryder's high thigh amputation healed well and the boy recovered both health and strength. A similar history is noted by Spence in 1874, concerning a girl of 9 years with her left calf in contact with the thigh due to severe knee contracture, associated with chronic infection of the femur and ulceration, possibly following a fracture. Her hamstrings were divided and bony sequestrae removed but she did not improve as the infection extended towards the hip. Under anaesthesia, hip disarticulation was performed and she did well, returning home on crutches20 (Fig. 3.2).
Much of the debate on whether and when to amputate was fuelled by military and naval surgeons with extensive experience of gunshot trauma who, in general, argued for early amputation. However, we must remember missile injuries were particularly associated with embedded foreign material, a focus of deep infection, which altered the whole basis of management (see Chapter 5). Nevertheless, as a result of this influence (before antiseptic surgical techniques were available), battlefield practice promoted amputation which, until the later 18th century, became almost a routine recommendation for any compound fracture, of any source, even before
gangrene or infection was observed. If the fractures involved a major joint then this alone was an indication for immediate amputation because, before antiseptic surgery, it was believed persistent disabling joint infection would follow.
Interestingly, at least three prominent surgical authors who sustained compound fractures of the shin, two at least caused by their horses, managed to avoid amputation when the climate of opinion was otherwise: Pott in the 18th century, who was thrown from his horse,21 Wiseman in the 17th century,22 and Paré in the 16th century, who was kicked by his horse, and whose detailed record serves to illustrate the complications of such injuries and how amputation was avoided, despite significant illness. Paré (Fig. 3.3) wrote:
.. intending to pass over the Sein (Seine)... I endeavoured to make my horse take boat, and therefore switched him over the buttocks: The Jade madded herewith, so struck at me with his heels that he brake both the bones of my left leg, some four fingers bredth above my ankle. Then I, fearing some worse mischief, and lest the Jade should double his blow, flew back; and as I fled back, the broken bones flew in sunder; and breaking through the flesh, stocking and boot, shewed themselves, whereby I felt as much pain as it is credible a man was able to endure;..."
Having crossed the river in absolute agony he pleaded treatment from a fellow surgeon, Richard Hubert:
"... that he would stretch my foot straight out, and if the wound was not sufficiently wide, that he would enlarge it with his Incision-knife, that so he might the more easily set the broken bones in their due place; that he would with his fingers (whose judgement is far more certain than the best made instruments) search, whether the splinters which were in the wound were quite severed from the bone, and therefore to be taken forth;..."
Paré submitted to this management and, after the fractures were reduced and splinted, he was taken home and bled 6 ounces from an arm. He continued to control his treatment and decided to eat little, only 12 stewed prunes, 6 morsels of bread and sugared water daily! Becoming constipated, he took soap suppositories. On the 11th day he developed a fever and an abscess in the wound causing muscle spasms and loosening of the splints, with displacement of the fracture and increased pain. After 7 days fever and discharge of
Fig. 3.3. Portrait of Ambroise Paré, aged 45 years. Frontispiece in his Anatomie Universelle, du Corps Humain, Paris: Le Royer, 1561.51
infected matter, he suddenly improved. He ordered various wound applications and took a diet rich in the "tendinous and gristly parts of beasts" which he considered helped bone union. He concluded:
"Simple fractures of the leg are usually knit in fifty days, but through the occasion of the Wound... and other accidents which befel me, it was three whole Moneths before the fragments were perfectly knit, and it was also another Moneth before I could go upon my Leg without the help of a Crutch.'2
It is probable many surgeons, including Paré, would have suggested early amputation in such circumstances, if treating a patient with similar pathology. Another form of equine injury which produced an amputation is recorded by Wiseman in 1676:
"A Gentleman aged 54 years, of an ill Habit of body, passing in the Street by a Coach, one of the Horses snapt off the end of his Finger with the Glove."24
After a period of infection, the stump healed with difficulty. It is probable such a stump proved tender for a long period and easily broke down after minor trauma. A more-extensive injury to a youth of 17 years is recorded by Spence in 1882:
"While leading a horse by the bridle the animal seized the forearm with his teeth, and inflicted a compound comminuted fracture. He was under treatment for ten days previous to being sent to hospital. Conservative measures were tried, and a fortnight after admission several pieces of bone were removed. Under the prolonged discharge from the wound, and from the ulcers which formed over the sharp prominences of the condyles, his general health became impaired. The inflammatory action extended towards the wrist, and in the fourth week suppuration ocurred within the joint. Under such circumstances there could be no hesitation in removing the limb. The operation was performed below the middle of the arm by a long external and short internal flap formed by transfixion. Recovered."25
In general, falls from a height sufficient to compromise the limbs severely are more likely to produce death from a head injury. However, Spence reported the following about 1882:
"P.L. fell down a height of thirty-five feet, and was brought to hospital suffering from a compound comminuted fracture of the femur, communicating with the knee joint, and a similar fracture of both leg bones. Amputation at middle of thigh. Cured."26
The fact that the knee joint was opened and fractured was a convincing indication for amputation before antibiotics were available. Wangen-steen and Wangensteen complained:
"One looks in vain in textbooks of surgery or monographs on fractures in the late eighteenth to mid-nineteenth century for factual accounts of the outcome of treatment of open fracture. It is as though the great surgeons of that period were in collusion not to expose their tragic results."27
However, in 1802, Crowther reported the healing of 28 consecutive compound fractures without amputation when he applied wood tar to the wounds (see Chapter 7).28 By 1867, Lister offered detailed histories of open fractures as pivotal cases to prove his antiseptic system and, after 1871, Spence published many similar observations. Antisepsis and asepsis greatly improved results, only diminished by gunshot compounding associated with embedded foreign bodies and, in the 20th century, injudicious attempts to stabilise fractures with metal implants before antibiotics were available.
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