Logistical Factors

As suggested in the preceding chapter, the acceptance of immediate amputation for most compound fractures was strongly influenced by the opinions of military and naval surgeons who, having extensive experience of such injuries, were prepared to advise a similar approach in civilian life. However, not only were gunshot wounds contaminated with much foreign material and necrotic tissues, unlike most open fractures of civilian practice, but the particular circumstances of the battlefield also required consideration. As Petit observed, evacuation of soldiers from the field was often delayed and then followed by a long painful period of transport, with fractures poorly splinted, in a bone-shaking cart before reaching medical facilities. This transit was associated with continuing blood loss, painful movement of the fractures, often exposure to great heat or to great cold, all of which reduced the strength of the injured profoundly and hence their chances of surviving a delayed amputation. Petit and others believed early amputation on the field was essen-tial.35 Even the injured believed immediate operation was best, not least because their courage diminished with time, as Wiseman affirmed:

"And a Walloon earnestly begged of me to cut off his shattered Leg: which whilst I was doing, he cried, 'Depeche vous connous vendrone a terre mous bioran' (Hurry up, when we get ashore we'll have a drink). Also others have urged me to dismember their shattered Lims at such a time, when the next day they have protest rather to die ... Therefore you are to consider well the Member, and if you have no probable hope of Sanation, cut it off quickly, while the Soldier is heated and in mettle."36

But often the numbers of wounded involved and the chaos of a major battle caused insurmountable obstacles to rapid evacuation, as experience confirmed at Waterloo after cessation of fighting on June 18,1815. Among surgeons arriving from Britain to help, as soon as the slow communications of the time permitted, was Charles Bell 11 days after the battle, who noted that although the British wounded were badly off, the French wounded had hardly been evacuated and indeed many were to lie in the woods for a fortnight. In these circumstances, it is impossible to estimate the numbers dying without surgical assistance or who might have survived a timely amputation. Bell paid particular attention to the French, operating almost continuously for 3 days, and commented:

"While I amputated one man's thigh, there lay at one time thirteen, all beseeching to be taken next; one full of entreaty, one calling upon me to remember my promise to take him, another execrating."37

Professor Thomson,from Edinburgh, arrived in Brussels on July 8 and reported that surgeons on the field had been overwhelmed by numbers for it had taken several days to evacuate the 8,000 British injured to hospitals in Brussels and elsewhere. Three weeks after the battle, he found 2,500 wounded in Brussels and many others evacuated to Termonde and Anwterp. Thomson and a colleague took 12 days to make a full examination of the wounded in Brussels and noted many had fevers associated with the marshy countryside and also hospital gangrene.38 Of 500 amputation cases, more than one-third took place before the onset of inflammation and progressed more favourably than the later amputations, recording a future plea for early amputation and more medical staff on the field, because of:

"The hurry, confusion, and uncertainty which occur during a battle, the multiplicity and variety of the cases which demand attention, and the shortness of the time which is left for deliberation in the period which intervenes between the infliction of the wound and the occurrence of inflammation and fever,.. ,"39

Even with sufficient medical arrangements and staff, evacuation might take many days, as proved too often the case during the miserable trench warfare of World War I. Soldiers with open fractures of the femur were marooned in no-mans-land, often for many days, due to enemy fire, as only a stretcher party could extricate them, provided the bearers were not shot in the process. Too often infection and gangrene supervened before the victims reached surgical facilities, the death rate proving severe with or without amputation.40 And although on wooden battleships sailors with gunshot wounds, especially of the lower limbs, were close to surgical assistance, they were reluctant to be put down into a dark airless hold for expectant treatment, conscious their bleeding wounds were liable to be nibbled by rats.41 Many preferred an amputation stump which allowed more mobility than a painful open fracture which, at best, demanded many weeks of dressings confined to a bunk or hammock.

In the 17th century, major injuries of the upper thigh and hip region remained a problem as amputation at hip joint level was considered a step too far, due to the problem of securing major vessels in the groin. Ravaton reported that, in his experience, all men with gunshot injuries of the thigh with an open femoral fracture, when treated conservatively, eventually died. By contrast, gunshot fractures at other levels often did well if carefully managed. For this group of high thigh injuries with poor prognosis, he recommended amputation by disarticulation at the hip joint as the only possibility of saving life.42 Unfortunately, it does not appear he was able to conduct such an operation, for he reported:

"I wished to do this major operation in 1743 on a gendarme of the Guard whose femur was fractured near the trochanter. I communicated my plan to several surgeons of merit, to have authority by their counsel and to be encouraged by their presence; some approved but others rejected my plan such that the patient died within a few days."43

Until the advent of helicopter evacuation, the reality for most military surgeons engaged in major conflicts was a constant struggle to treat the wounded against a background of constant shell-fire, moving battle actions, long lines of communication, a shortage of personnel, drugs, dressings and splints, with poor hospital resources or even none at all.

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