War Surgery and Medicine
First World War
First World War
It can be realised how important amputation must have been in the past when at the beginning of the First World War practically all patients with fracture of the femur died. It must have seemed reasonable at that time to amputate many of these cases. The frequency of gas gangrene in France made it necessary to carry out rigorous and ruthless excision of muscle and also led to the performance of many amputations, especially of the lower limbs.
Free drainage was essential following operation, and with the introduction of the Carrel-Dakin treatment continuous irrigation of the stumps was carried out.
The simplest form of amputation that would preserve the maximum amount of healthy limb was undertaken, and the circular type of amputation, with the wound left wide open, was therefore done. The nerves were generally pulled “down and cut very short and at the same time crushed and tied, and often alcohol was injected into the end of the nerve. This was done to prevent the development of neuromata in the stump. The fibula was cut across one inch higher than the tibia, and the crest of the tibia rounded off. page 303 At first the muscles were often sutured over the ends of the bone, but this was later given up as it tended to make the stumps clumsy, and in any case the muscle atrophied later.
Often in traumatic amputations the limb was simply cut across and the bone trimmed. This led to the term' guillotine amputations', a most unfortunate term, as it has ever since led to misunderstanding. The ordinary amputation undertaken in the 1914–18 War was not a guillotine amputation, but a circular amputation with the muscle and bone cut across at progressively higher levels. If no traction was applied to the skin, there would be inevitable retraction of the soft tissues and the end of the bone would protrude beyond them. A ring sequestrum would then form at the end of the bone, and there would be slow healing by granulation and scar, with the end of the scar fixed to the bone. This sequence has led to the extreme unpopularity of circular amputation in a wide circle of surgeons, and the name guillotine is just as popular with them as it was with the Royalists at the French Revolution.
The circular amputation, however, as normally carried out, and with efficient skin extension from the beginning, did function very satisfactorily in the treatment of infected cases. Drainage was free, the minimum of tissues was traumatised and opened up, and the end-results in the stump were generally good, the bone being well covered. A cut-down Thomas splint with a ringed broad end was used for the extension in the lower limbs, and a straight-arm Thomas for the upper limbs. Secondary suture of the stump was also commonly carried out in the latter part of the war, thereby shortening the period of healing considerably. The type of amputation performed varied considerably. Commonly, a maximum length of bone was left, there being no attempt to lay down sites of election. In the arm the circular type of amputation was most common, though flaps were sometimes formed, and the amount and position of skin available for covering the stump often dictated the position of the flaps. In the thigh the transcondylar or Stokes-Gritti amputations were usually performed if conditions admitted. The circular amputation was most often carried out in the leg, but again depending on the skin available. Syme amputations were performed if possible, and partial amputations of the foot were also carried out. Amputations were carried out through the knee joint, but were not found to be very satisfactory, except as a temporary life-saving measure in severely ill cases.
Considerable attention to the stumps was needed not only because of infection, but also because of the length of the stumps and the presence of bulky or scarred ends. Refashioning to get smooth snug stumps, without adherent and weak scars, was commonly carried page 304 out. Many of the stumps had to be shortened because of poor circulation, often associated with eczema and even ulceration of the skin.
It was found that about seven inches was the ideal length for below-knee stumps and that two inches was about the minimum which would allow of fitting a below-knee limb with knee movements. Limbs were fitted to through-knee amputations, but with considerable difficulty because of the bulkiness of the stump and the altered level of the joint, and re-amputations were generally carried out. End-bearing stumps were not popular. Neuromata gave trouble and were frequently removed, but often with recurrent symptoms. The phantom limb disturbance persisted often for a long time, but generally finally passed away. Removal of neuromata and more radical measures did little, if any, good. With the weight taken in below-knee amputations by the tuberosity of the tibia, there was frequently a development of pressure sores or sebaceous formations in the skin in this area. Gradually the weight was transferred to the ischial area of the thigh either in whole or in part.
In New Zealand the artificial arms proved to be of little use and were worn by fewer than 5 per cent of the amputees. It would seem that the only useful kind of arm is one that is definitely indispensable for a man's work and livelihood, and that this must be fitted and used for its special work as soon as possible after the limb is lost. Otherwise it is a waste of money to fit an artificial arm, and the money could be better used for extra pension or other benefit.
The lower limb is quite a different matter. Locomotion is essential to living, quite apart from working. And the most efficient artificial leg is worth everything to the amputee, and he must also have a spare limb in case of emergency and when repairs are necessary.
Fortunately very good limbs were made available for the First World War men, both in Britain and also in New Zealand, where a limb factory under private management was set up in Wellington. As far as the lower limb was concerned, our New Zealand factory utilised the British limbs; but, for the arms, the McKay arm invented by one of our own amputees proved quite as satisfactory as the British types. The four main hospitals also developed splint workshops which were able to carry out the minor repairs. The First War amputees were well looked after by this means.
It was found that lower limb amputees were liable to circulatory disturbance with blood pressure and cardiac changes, and provision had to be made for war disability and old age pensions at an earlier age than is usual in many cases.page 305