Amputations at the London Hospital 1852-1857

Abstract

Between 1852 and 1857 at the London Hospital, 142 amputations were performed in 136 patients. The most common indication was an injury sustained at work. Overall mortality was 46% and the death rate was especially high for lower-limb amputations. Most deaths were due to postoperative sepsis. Those who received chloroform anaesthesia did worse than those who received ether.

INTRODUCTION

‘Amputation or dismembering is the most lamentable part of surgery... if you be constrained to use your saw, let first your patient be well informed of the imminent danger of death by the use thereof.’ John Woodall (1556-1643)¹

In the nineteenth century, the most common treatment for severe limb injury was amputation. In the days before antisepsis and antibiotics, the mortality from amputation was high. Most of the published work on this subject has a basis in military practice during the eighteenth and nineteenth centuries. In this historical review we look at the incidence of amputations in a major London teaching hospital in the mid-nineteenth century, at the beginning of the anaesthetic era, and compare the outcomes of patients operated on with and without general anaesthesia. We also draw comparisons with surviving civilian records and with experience in the Crimean War (1854-1856), where anaesthesia was first introduced into military practice on a large scale².

PATIENTS AND METHOD

We conducted a retrospective audit of the operating log of the London Hospital, Whitechapel, between 1852 and 1857. The log was a leather-bound ledger designed specifically for the purpose. The note-keeping was of high standard, with entries recording the demographic details of the patient, his or her occupation and the nature of the injury or disease process requiring amputation. The name of the operating surgeon was recorded, together with the type of amputation performed, the anaesthesia used and postoperative notes on the patient's progress. Until 1903 there was only one operating theatre at the London Hospital, so it is likely that all the major operations taking place between 1852 and 1857 were recorded in the operating log (Evan J, personal communication). The records of the Hospital Samaritan Society were also analysed to establish how many prosthetic limbs were paid for by the hospital during the same period.

RESULTS

During the five years from 1852 to 1857, 142 amputations were performed at the Royal London Hospital out of a total of 400 operations recorded in the operating log. Other operations included hernia repair, ligations of major vessels and removal of various tumours. Of the amputations, 121 were performed on men and 15 on women. In 6 cases the sex of the patient was not recorded. 103 (76%) of the 136 patients were male, aged between 11 years and 50 years old. 92 legs and 44 arms were amputated. Of the lower limbs, 50 were amputated above the knee and 42 below the knee. 27 of the arms were amputated above the elbow and 17 below the elbow. Amputations were performed as a result of injury in 84 (62%) of 136 cases. Other common indications included osteomyelitis and septic arthritis (Table 1).

Table 1.

Indications for amputation

	Number of amputations
Indication	Leg	Arm	Total
Trauma	49	35	84
Osteomyelitis	13	5	18
Septic arthritis	18	1	19
Cancer	3	2	5
Gangrene	4		4
Ulcer	2		2
Acute infection	2	1	3
Other	1		1

Occupations of amputees

Of the 84 amputations performed as a consequence of trauma, 72 were necessitated by injuries sustained at work—for instance, ‘being run over by a railway car’, being ‘crushed between two ships’ or being ‘injured by machinery’. The distribution of injury is reflected in the occupations of the male patients, most of whom were labourers, railwaymen, sailors or factory workers (Figure 1). The occupations of female patients were not recorded.

Figure 1.

Occupation of amputees

Mortality

The overall mortality from amputation was 46% (61 deaths out of 136 recorded outcomes). For the amputations performed as a consequence of trauma the mortality was 50% (35 patients of 70). Most of the trauma-related deaths were in patients who required lower-limb amputations (28 of 40 deaths), as opposed to upper-limb amputations (7 deaths in 30 cases). The cause of death was recorded in 54 of the 61 patients. Sepsis (31 cases) and ‘shock’ (11 cases) accounted for 69% of the total recorded deaths.

Eight surgeons were named (in the operating log) as performing the 142 operations. Six of these surgeons accounted for 133 procedures. For those operations where the outcome was recorded, most of the surgeons achieved about the same overall mortality (mean 46%, range 29-56%).

Anaesthesia

Chloroform is recorded as having been used in 30 amputations out of a total of 136 operations. 17 of these patients died and 12 survived (outcome not recorded in one). We assume that, if no specific anaesthetic agent was mentioned, they used ether—standard practice in most hospitals at the time.

17 patients were recorded as undergoing amputation for the consequences of injury under chloroform anaesthesia. 12 (70%) patients in this group died, whereas only 23 (43%) of 53 patients died in the group undergoing amputation without chloroform anaesthesia (Table 2).

Table 2.

Mortality according to anaesthetic agent

Operation/anaesthesia	Total	Died	Survived	Mortality (%)
Trauma/chloroform	17	12	6	70
Trauma/ether	53	23	30	43
Elective/chloroform	13	5	8	38
Elective/ether	40	17	19	43

Prosthetic limbs

Over the period 1852 to 1857, the Samaritan Society at the London Hospital issued a total of 49 prosthetic limbs—25 legs and 24 arms.

DISCUSSION

Most of the surviving records of amputations in the eighteenth and nineteenth centuries record the experience of military surgeons in the wars fought between the European powers during that time. Few civilian series have been reported in any detail, despite the fact that amputations constituted a substantial part of the workload for civilian surgeons.

The operating log of the London Hospital devotes 80 pages (from a total of 190 pages in the ledger) to the procedure. Today the great majority of amputations are performed on elderly patients, to deal with the end stages of peripheral vascular disease, whereas in the nineteenth century most amputations were done on young people after trauma. The distribution of limbs removed also differs: in the modern era the upper limb is seldom amputated whereas in this series it accounted for one-third of all amputations².

In the middle of the nineteenth century, the East End of London was at the centre of developments arising from the industrial revolution. With its proximity to the docks on the Thames and the growth of the railways, it is no surprise to see sailors and railwaymen well represented in the population of patients undergoing amputation as a consequence of industrial accidents. Women, being less likely to be involved in heavy industrial labour, represent a smaller proportion. Many of the patients would perhaps have been in a poor general state of health as a consequence of malnutrition, which was rife among the working classes at the time. Major outbreaks of cholera were commonplace, owing to overcrowding and poor sanitation^3,4. There are several entries in the records of the Samaritan Society of surviving amputees being granted money to go to Clacton (an Essex seaside town) for ‘sea air and a wholesome diet’.

The frequency with which amputations were performed in the eighteenth and nineteenth centuries was a reflection of the known consequences of attempting limb salvage with compound fractures. John Bell, a British army surgeon writing in the eighteenth century, noted that ‘If all limbs be kept, many must gangrene; if no amputation be performed all the shattered stumps must gangrene, then the sloughing stumps and gangrenous limbs... must infect the whole...’⁵.

Before the advent of Listerian antiseptic surgical principles in the 1870s, amputation was the safest treatment for compound limb injuries, since overwhelming sepsis was the likely sequel of conservative management. The figures from the London Hospital illustrate that, even after amputation, the hazards of sepsis accounted for most of the postoperative mortality (31 of 54 recorded deaths). Despite the known risks of sepsis developing from compound fractures, by the beginning of the nineteenth century a fashion for ‘delayed amputation’ had developed among military surgeons. The practice arose from the idea that the patient needed to recover from the shock of the initial injury before being subjected to the additional trauma of an amputation. Although circulatory physiology and the effects of haemodynamic shock were not understood at that time, the move towards secondary amputation probably reflects the observation that a resuscitated patient (even if the resuscitation was with brandy and tea) often did better than one who was acutely hypovolaemic from blood loss. However, the risk of sepsis from delayed amputation outweighed the risks from hypovolaemia, and Guthrie was able to show a marked benefit in survival with early amputation in his series following the battle of Toulouse in 1814⁶, later stating that ‘When a limb cannot be saved it is to be amputated without delay’⁷. American surgeons working during the Civil War in the 1860s confirmed this observation, although they preferred to delay amputation for 12-24 hours after injury, to allow a degree of resuscitation of the patient⁸.

The overall mortality from amputations at the London Hospital performed as a consequence of trauma was 50%. Not surprisingly, upper limb amputations carried a better prognosis (22% versus 70% for lower limbs). These figures are comparable to those reported by Malgaigne from Paris in 1842. They show a higher mortality than reported by Erichsen from University College Hospital in 1851, but the UCH series may have included elective cases (Table 3). The mortality rates for the different surgeons operating at the London Hospital during this period are remarkably similar, indicating that factors other than surgical expertise were responsible for determining the eventual outcome.

Table 3.

Mortality from amputations in the nineteenth century

Series	Mortality in upper limb amputations (%)	Mortality in lower limb amputations (%)
Spain 1813 (Guthrie)	39	58
Brussels 1815 (Guthrie)	30	42
Paris 1842 (Malgaigne)	56	70
UCL 1851 (Erichsen)	17	58
Royal London 1852-1857	22	70
Crimea 1854-1855	33	65
American Civil War 1864-1865	22	36

The introduction of anaesthesia around this time is worthy of note. Ether anaesthesia had been used first in Boston in 1846, and the practice spread rapidly throughout America and Europe. Before then, patients had either been awake and restrained or intoxicated with alcohol. The archive of the London Hospital contains a bell which, in the eighteenth century, hung in the operating theatre. When a patient was about to be operated on, the bell was rung to summon the porters to hold the patient still during the procedure.

Despite the revolution in surgical practice brought about by the discovery of ether, it was far from ideal as an anaesthetic agent, being both volatile and flammable. Induction of anaesthesia was also difficult to achieve. The discovery of the anaesthetic effects of chloroform in 1847 by James Young Simpson, in Edinburgh, provided a more versatile agent. Simpson pioneered the use of chloroform on women in labour, and other surgeons, such as James Syme, used it with success in elective surgical cases⁹. While chloroform rapidly superseded ether anaesthesia in many hospitals in the UK, in London opinion was divided on its use. Several doctors, both in civilian and in military practice, were concerned at the ‘depressant effects’ of chloroform, especially in the case of trauma patients. In an article in The Lancet documenting the use of chloroform in treating the wounded during the Paris Revolution of 1848, the French surgeon Velpeau highlighted the dangers of using the anaesthetic in the shocked patient¹⁰. Such reports had considerable influence in England and Dr John Hall, Principal Medical Officer of the Expeditionary Force in the Crimea, issued an official directive cautioning Army medical officers about the depressant effects of chloroform, summing up his concerns by writing, ‘the smart of the knife is a powerful stimulant; and it is much better to hear a man bawl lustily than to see him sink silently into the grave’¹¹. Hall came in for considerable public criticism for writing this order, which was reprinted in the Illustrated London News and he was much vilified for the medical shortcomings during the Crimean campaign. Despite his instructions, chloroform was used extensively by medical officers in the conflict, both in the hospital in Scutari and in the field. At the end of the war it emerged that, while chloroform anaesthesia at Scutari had been largely trouble-free, its use in the field on acutely wounded men had directly resulted in several deaths. James Mouatt, a leading surgeon in the Army Service in the Crimea, later wrote of cases in which patients anaesthetized with chloroform in the field had died immediately after operation despite having bled very little during the procedure¹². It is possible, however, that this difference was due to the fact that Scutari hospital was several days' travel from the battlefields of the Crimea and a degree of ‘self-selection’ would have taken place with the more severely wounded dying in transit. Injured soldiers who arrived at Scutari alive were less likely to be hypovolaemic from acute blood loss, and more likely to withstand the depressive effects of chloroform than patients anaesthetized on the battlefield.

The figures from our study of amputations for trauma at the London Hospital during the same period seem to support the views of Hall and Mouatt that chloroform anaesthesia in the severely wounded patient was hazardous, since the mortality of the patients anaesthetized with chloroform was much higher than in those anaesthetized with ether. The mortality rates for non-trauma cases were identical irrespective of the anaesthetic agent used.

Perhaps the most poignant note made in the hospital records from this period is a paragraph in the notebook of the Samaritan Society dated 9 August 1852. The clerk writes:

‘I call your attention to the number of expensive instruments... furnished to patients on the recommendations of the surgeons. As applications for that description of aid are still on the increase and must, if they proceed in the same ratio exceed the ability of the society to meet the expense, I am desired to request that in future you will confine your recommendations as much as possible to such aids as without involving extravagant expenditure...’.

After 150 years, the relationship between surgeons and hospital administrators seems to have changed little.