Physical Treatments
James Blackman faced an agonising decision. Three weeks earlier, at five o‟clock on a warm Wednesday afternoon in late February, 1848, he had been out riding his master‟s horse in Bridgewater, nineteen kilometres north of Hobart. Blackman‟s right foot suddenly slipped through the stirrup and, frightened by the sudden cry from his rider, the horse reared around. The rider‟s foot was caught and, unable to free himself as the horse struggled frenziedly, both
bones in Blackman‟s lower leg snapped two inches above his ankle.709
Seven years earlier, Blackman, a red-headed farmer‟s labourer from Sussex, had been sentenced to fourteen years transportation as punishment for stealing a jacket and a pair of shoes. Arriving in Van Diemen‟s Land in mid-1842 aged twenty-three, he was first stationed in a probation gang in Victoria Valley, one hundred and one kilometres from Hobart Town. Five year later,
Blackman was assigned to Mr Murdoch in Bridgewater.710 Indeed, on that February afternoon in
709 Tasmanian Archive and Heritage Office, Royal Derwent Hospital: James Blackman (HSD 246/1/6/152). 710 TAHO, Conduct Registers: James Blackman (CON 33/1/20, p. 34).
1848 it may have been Murdoch who helped carry Blackman, his leg and foot painfully unstable, to a boat in the nearby Derwent River. As the day deepened into night and the temperature began to drop, Blackman was rowed towards New Norfolk, twenty kilometres away. After more than ten hours in the boat, soaked with the water thrown back by the oars and shivering with fatigue and shock, Blackman arrived at the Hospital. Fifteen hours after the accident, Dr
Frederick Brock observed Blackman‟s injuries with trepidation. A double fracture of both bones
of the leg was considered to be perhaps the most difficult break to treat.711 Blackman‟s leg
muscles contracted the bones from their natural positions, forcing them violently out through the skin. The sheer physical strength required to wrench the displaced bones back into position and their tendency to slip back was compounded by the dread of infection common to any nineteenth-century surgical procedure.
Brock helped Blackman onto his back and a wardsman – usually a fellow patient – was employed to firmly grasp his thigh so that the leg bent at the knee, forcing the large calf muscle to relax. Brock seized Blackman‟s ankle with both hands and, working by the feel and sound of the broken ends of the bones rasping together as much as by sight, manoeuvred them back into
position.712 To prevent the bones sliding back once Brock and the wardsman released their grip,
two long pieces of wood were positioned on either side of Blackman‟s leg. Straps were bound around the limb to keep it immobile and padded with dressings over the wound, with sheets of
linen rollers wrapped over the top.713
711 E. Lonsdale, A Practical Treatise on Fractures (John Churchill, London, 1838), pp. 473-507.
712 Lonsdale recommended that “a kind of see-saw motion…will unlock the ends of the bone, as well as disentangle
them from the muscles.” He also warned that the fractured ankle is perhaps the most difficult break to reduce, having so little leverage with which to reposition the broken bones (Lonsdale, A Practical Treatise on Fractures, p. 480, p. 485).
Brock‟s concise case notes do not record how his patient coped with the brutal pain of this
treatment.714 It is known, however, that Blackman was not offered the newly-discovered miracle
of ether anaesthetic to dull the agony of this procedure.
Over the next ten days, Blackman‟s condition appeared to steadily improve. His appetite was
healthy, his bowels were regular and he was “free from pain.”715 On the twelfth day, however,
Brock pulled back Blackman‟s coarse blanket to find abscesses spreading from the sole of his
foot, up the ankle and over the lower part of the leg.716 The wound where the bone had pierced
the skin was swollen, and the bandages were growing stiff from increasing quantities of pus discharging from the lesions. Brock dosed his distressed patient with wine, incised the abscesses
to drain away the pus, and ordered the ankle to be rebandaged with clean dressings.717
Blackman spent a restless night, perspiring heavily and waking with little appetite for his arrowroot and milk. For another ten days his condition remained much the same, neither improving nor deteriorating. Three weeks after the accident, on a Thursday in mid-March, the discharge from the wound suddenly increased, with “several small pieces of bone” coming away
with the pus.718 The wound had also expanded in size, allowing Brock to probe further inside
Blackman‟s leg than he had earlier dared. What he found disturbed him. Rather than beginning
714 Doctors accepted that patients varied in the level of their pain tolerance, with sex, age and class also believed to
influence sensibility (S. Snow, Blessed Days of Anaesthesia: How Anaesthetics Changed the World (Oxford University Press, Oxford, 2008), p. 63).
715 TAHO, RDH: James Blackman (HSD 246/1/6/155).
716 This horrific level of infection was common after compound fractures; when the bone breaks through the skin,
the shards permit bacteria to enter the gaping wound. Surprisingly, it was not universally fatal. A case similar to Blackman‟s was admitted to St Bartholomew‟s, with the attending surgeon commenting that the favourable “termination of this case was considered as remarkably fortunate, for in this great and crowded hospital, it rarely happens that a compound fracture does well, or at best, not until a tedious suppuration” (cited in A. Digby, Making a
Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (Cambridge University Press,
Cambridge, 1994), p. 84).
717 Although suppuration and pus was sometimes considered to be a healthy process which allowed the body to
naturally rid itself of toxins and rebalance the humours, in Blackman‟s case Brock does not comment on the „healthiness‟ of his patient‟s discharge. It is probable, therefore, that he considered the pus to be injurious to the healing of the wound (H. Ellis, The Cambridge History of Surgery (Cambridge University Press, Cambridge, 2009), p. 82).
to unite, Brock recorded that the bones of Blackman‟s ankle and leg remained “completely separated.” With “there being no probability of preserving the limb,” he continued brusquely, “amputation is proposed.”
The choice now facing Blackman was stark: consent to the amputation of his leg, with the very real risk of rapid death through loss of blood or a slower demise through infection, or face weeks, even months, of pain as the tissue of his leg slowly putrefied, poisoning his blood and eventually his entire body. While Blackman weighed up his dismal options, Brock consulted with the Principle Medical Officer and as many other surgeons as he could from his isolated location.719
Two hundred kilometres away in a different, although almost equally isolated, colonial town, another doctor had undertaken a radical experiment which would have extraordinary impact upon Blackman‟s treatment. In June 1847, eight months after its first public demonstration in America, Dr William Russ Pugh became the first surgeon in the southern hemisphere to
anaesthetise a patient using ether.720 Nine months later, Blackman was destined to become the
first New Norfolk patient to experience the miraculous effects of the drug. Brock and his
colleagues would have been aware of Pugh‟s innovative and startlingly successful operations.721
They may have seen in Blackman an opportunity to utilise new anaesthetic techniques in a
719 Doctors routinely consulted with a number of colleagues before proceeding with an operation, primarily to
confirm the necessity of surgery, but also to diffuse the responsibility if the procedure proved fatal (M. Cooper, „The Agony – Surgery Before Anaesthesia, The Patient‟s Perspective‟ in P. Richards and P. Ogden (eds.), Anaesthesia:
Awakening the Sleeping Giant (Myola Publishing, Launceston, 2003), p. 39).
720 Sydney dentist Dr J. Belisaro was the first medical practitioner in the southern hemisphere to report using ether
to anaesthetise a patient (see, for example, E. Ratcliff, „The Pugh Oration: A Yankee Dodge for Making People Insensible‟ in Richards and Ogden (eds.), Anaesthesia, p. 7, pp. 10-11; H. Ellis, The Cambridge History of Surgery
(Cambridge University Press, Cambridge, 2009), p. 80; „St. John‟s Hospital – Surgical Operations. The Influence of Ether‟, Courier (12 June 1847), p. 2).
721 It is likely that Pugh would have been interested in Blackman‟s case, as Pugh devoted his MD thesis to the
subject of fractures, and later published a number of articles on various types of amputations (J. Paull, „William Russ Pugh: Not Just an Anaesthetist‟, Australian and New Zealand College of Anaesthetists, at
<http://www.anzca.edu.au/events/asm/asm2008/abstracts/william-russ-pugh-not-just-an-anaesthetist.html>, accessed 25 June 2009).
relatively rare „capital‟ operation, to advance both personal and professional knowledge and
reputation.722 And, of course, to ultimately – hopefully – save a patient‟s life.
By early on that cloudy March afternoon, both doctors and patient had reached their decisions. Amputation was scheduled for four o‟clock that day, allowing Blackman as little time as possible
to dwell upon his impending surgery.723 As the day lengthened, Brock arranged his equipment
close to the wooden table on which the operation would be performed, being sure to keep it out
of Blackman‟s sight.724 Retractors, tourniquets, ligatures, and dressings were laid out alongside a
wide-toothed saw and the long, curving amputation knife.725 Dr John Meyer arrived to assist in
the operation as Brock assembled his ether truss. As Blackman lay on the table, positioned close to the windows to take advantage of what little light filtered through the clouds, Brock dripped a tiny amount of ether onto a cloth and held it over Blackman‟s mouth and nose. The pungent odour of ether often caused patients to cough and gasp, although Brock does not record that Blackman experienced any respiratory distress. In fact, quite the reverse – after half an hour of administering the ether, his patient still appeared fully conscious, in control of all his limbs and faculties. Brock records despondently that, “as it was becoming late and the Evening dull, it was determined on to defer the operation untill [sic] tomorrow morning.” Both patient and doctors were disconcerted by the apparent failure of the miracle of anaesthesia, but were determined to have a second attempt on the following day.
The second endeavour proved more entertaining, although still without the intended outcome. After Blackman had resumed his position upon the scrubbed wooden operating table, Brock administered a slightly more audacious dose of ether. All present watched apprehensively as the
722 See the Glossary of Terminology for explanation of terms.
723 Cooper, „The Agony‟ in Richards and Ogden (eds.), Anaesthesia, pp. 39-40.
724 It was widely believed that patients should not see operating equipment prior to surgical procedures, lest it induce
panic (T. Wakley (ed.), „Lectures on Surgery Delivered by Mr Wardrop‟, The Lancet, vol. II (1833), p. 593.
725 Amputation saws had widely-spaced teeth to prevent them from becoming clogged and blunted with bone and
moments passed. Suddenly, Blackman began to giggle. “Instead of insensibility,” Brock wrote soberly, the ether produced a “state of Hysteria the Patient laughing and becoming much
excited.”726 While Blackman enjoyed this unexpectedly hilarious interlude from the pain of his
traumatised leg, Brock and Meyer solemnly pondered the possible reasons for the failure of the ether to induce unconsciousness. “Again Postponed,” wrote Brock dejectedly in Blackman‟s case notes.727
Later the same day, the ether was given a third trial and, reports Brock triumphantly, “Finally the
limb was removed.”728 This time, under the influence of the ether, Blackman‟s concentration
became impaired; his speech slurred and became disconnected. Soon his movement became
inhibited and sensibility decreased.729 Cautiously, Brock removed the ether-soaked cloth from
Blackman‟s face and picked up his knife.
As Meyer secured the tourniquet to compress the tibial artery behind Blackman‟s knee, Brock grasped the skin of Blackman‟s leg just below the knee and drew it taut before sinking the blade
into his patient‟s skin and sweeping it around the leg.730 . As the skin shrank away from the
incision, Meyer quickly positioned retractors in the gaping wound. Brock made a second and third cut through the layers of fat and muscle as Meyer forcibly pulled the flesh away from the bone using the retractors. Laying down his knife, Brock began securing the arteries in the stump. Painstakingly knotting a fine length of silk thread, he trimmed one end close to the ligature and let the other to hang out of the incision, to allow it to be removed when – if – the
726 TAHO, RDH: James Blackman (HSD 246/1/6/162). 727 TAHO, RDH: James Blackman (HSD 246/1/6/162). 728 TAHO, RDH: James Blackman (HSD 246/1/6/162).
729 J. Pereira, The Elements of Materia Medica and Therapeutics (3rd ed., Blanchard and Lea, Philadelphia, 1852), p. 239. 730 W. Fergusson, A System of Practical Surgery (2nd ed., Lea and Blanchard, Philadelphia, 1845), p. 162.
wound healed.731 Directing Meyer to loosen the tourniquet, both doctors watched as the blood resumed coursing through Blackman‟s veins and arteries.
Satisfied that the ligatures would hold, Brock picked up the saw. Supporting the instrument on his left thumb nail to prevent it slipping, he began to cut into Blackman‟s exposed leg bones, moving slowly at first, then increasing his pace until carefully making the last few sweeps to
prevent the bones splintering.732 In less than three minutes Blackman‟s right foot was lying in
the sawdust on the floor. Having earlier approximated a few inches of skin to cover the exposed bone and flesh, Brock now set to work “forming a posterior flap” and supporting it with a
bandage. 733 Over this he wrapped calico dressings, and had “a Cloth wet with cold water applied
to the part for 1½ hours.”734Of Blackman‟s state of consciousness, of his level of pain or
distress, Brock records tantalisingly little, stating simply that “The Man bore the operation pretty
well.”735 Whatever his experiences, he passed “a pretty good night” and awoke the day after the
operation hopeful of an uneventful recovery.736