Timing

Determination of a precise indication to amputate also involves selection of a suitable time to amputate. Immediate amputation would be self-evident for most trapped victims and was also the rule in the early centuries of gunshot wounding, especially during the heat of battle. In the 18th century, Bilguer maintained he amputated rarely for gunshot wounds, recommending conservative care, fortunately having at his disposal hundreds of hospital beds.11 Others suggested delay to assess the victim's progress and, hence, possibly save a limb which otherwise would be amputated.

Delay might mean as soon as "shock" settled and haemorrhage control was achieved or, alternatively, at some days or even weeks distant when local infection had settled, assuming the patient survived. Unfortunately, the latter methods were often completely impractical when massive numbers of wounded presented, as for example during the major battles of the Napoleonic era, the American Civil War, and especially those wounded by invasive shrapnel and shell fragments which dominated World War I battles and some of those of World War II. Delays were certainly common during these conflicts, often up to a week, as a consequence of physical problems in evacuating the wounded, especially from no-mans-land, to surgical facilities.12 Since World War II more rapid transport systems, particularly the use of helicopters, and basic protective inoculations, antibiotics and modern resuscitation methods combined with arterial reconstruction and skin and bone grafting have saved many limbs formerly amputated.

For many conditions in civil life, a more-measured approach is possible, so that patients are carefully assessed, in particular, the elderly with arterial deficiencies, gangrene, infections or diabetes, or for others, often younger, with malignant lesions to consider secondary deposits and conduct surgery under the best possible circumstances.

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