Sewing Back an Arm

"When I saw this kid coming down the street, sobbing, I thought he'd been in a fight," said Norman Woodside, a paper-company foreman of Somerville, Mass. "But then I looked at his right hand--he was holding it awkwardly with his left--and I saw it was reversed." Foreman Woodside could not see what was inside the bloody right sleeve of Everett Knowles Jr., a twelve-year-old Little League pitcher. Woodside ran to phone the police, he called to Alice Chmielewski. a shipping-room clerk: "There's a boy here with a broken arm." Mrs. Chmielewski tried to put on a tourniquet above the break. She was puzzled to find an empty space. She stuffed this with rags to stop the bleeding. Then the police ambulance sirened up and rushed the boy to the emergency room of Massachusetts General Hospital in Boston. There, when his long-sleeved shirt was removed, the full extent of Ev Knowles's injury became clear: his right arm was completely severed from the shoulder.

It almost seemed as if the many surgical specialists of Mass General had been waiting for him for ten years. For all that time, they had been sure of their ability to put a severed human limb back in place, with bones, blood vessels, nerves, muscles and skin all reconnected--but they had never had a suitable case. In most accidental amputations, the limb is too badly mangled, and the patient's general condition too poor. Ev Knowles was different.

He had been in perfect health until that afternoon when he was slammed against a bridge abutment while riding a freight train. The arm was not mangled, although its upper part was torn. Duty surgeon Dr. L. Henry Edmunds promptly spotted a chance for a historic operation. He started giving the boy two pints of blood, to combat shock, and antibiotics and tetanus shots to guard against infection. Then Dr. Ronald A. Malt, chief resident surgeon, gave the go-ahead order that called in all the specialists who would make the operation a major team effort.

Flush the Arteries. Even before the boy, already under anesthesia, was hustled to the operating theater, his arm was put in a tub of chipped ice. The doctors dared lose no time in this effort to cut down the tissues' need for oxygen and thus delay the onset of rigor mortis in the muscles. Ev Knowles's shoulder joint was intact. The break in the humerus (the only bone in the upper arm) was between two and three inches below the joint. Says M.G.H. Spokesman Dr. Robert Shaw: "It was as though the arm had been laid on a bar and whacked with a sledge into multiple fragments." About an inch of the bone had been destroyed, mainly on the outer side.

Dr. John Herrmann took the arm to the operating room. To guard against clots, he flushed out the whole artery-vein system with a special saline solution combined with antibiotics, an anticoagulant and a radiopaque dye. X rays promptly showed that the arterial tree was open all the way to the fingertips. Relieved, Dr. Herrmann picked up the arm, carried it carefully to the operating table on which Ev Knowles had just been wheeled in, all draped except for his torn and bloody shoulder.

The many-surgeon team agreed that the most urgent job was to restore the arm's circulation. Specialists in blood-vessel repair first made sure the blood would have a way to get out. With neat and delicate sutures, they stitched the arm's two main veins to their extensions in Ev's shoulder (see diagram). Next, they opened a way for the blood to get in by rejoining the major (brachial) artery. Says Dr. Shaw: "When we took off the clamps from the artery above the break, we rejoiced at the pinking up of the arm as the blood ran through it." It was just 3 1/2 hours since Ev Knowles's arm had been severed.

Single Stitches. Lying on the operating table beside its owner, the arm was still attached only by suture threads. To fix it firmly, an orthopedic surgeon drove a stainless-steel rod into the broken upper end of the humerus, through its squishy marrow center, until the end of the rod projected into the shoulder. He fitted the broken bone ends together, pushing the rod down into the marrow of the undamaged lower bone. If new bone grows well enough to make a solid union, the rod may later be withdrawn; otherwise it will be left in place.

The most delicate and difficult part of such restoration surgery is to rejoin the nerves so that they will resume their task of controlling the muscles. Neurosurgeons usually prefer to wait for weeks or months after the original operation before they attempt the job. The M.G.H. surgeons identified the three main nerve bundles in Ev Knowles's shoulder and arm, drew them together, and rejoined each with a single dacron stitch--a holding operation so that the nerves will not shrink.

Only after all this, which took four hours, did the plastic surgeons get around to what they usually do first: guard against gangrene by clearing both sides of the wound site of all tissue, mostly muscle, that is crushed or deprived of its blood supply. In this case, they delayed because it was more urgent to restore the circulation promptly. At last, they stitched together four major muscles and as much skin as was left around the fracture. It was not enough, but the rest of that job had to wait.

For Ev Knowles also had some injuries to his left hand. The surgeons encased the boy's trunk and right arm in a cast that held the arm in a bent position, as though to ward off a blow. Still anesthetized, the boy was wheeled to a second operating theater. There, surgeons straightened out his battered left hand and sewed up its skin wounds. Ev Knowles received four more pints of blood during the multiple operations, which lasted eight hours.

Exercise the Right. Within two days, the sturdy young patient was taking regular meals. He now feeds himself with his left hand. After five days, his temperature was normal, and the wound showed no sign of infection. But this meant no respite. Last week the plastic surgeons took Ev back to the operating room, pared big patches of half-thickness skin from his right thigh, and grafted the patches onto the raw areas near his armpit.

Though similar operations have succeeded in animals--at the Tufts-New England Medical Center, also in Boston, dogs are running around on severed and resewn legs--it is too early to tell how well the surgeons succeeded with Ev Knowles. "The greatest danger," said Dr. Shaw, "is of infection in an artery. If that developed, the arm would have to be sacrificed to save the patient from the danger of possibly fatal hemorrhages." The most nearly comparable U.S. case ended in failure after seven months, when California surgeons had to amputate the resewn leg of Mechanic Billy Smith (TIME, Nov. 9, 1959) because of a deep bone infection.

"It will take two or three years of hard work on our part and his if this boy is to regain the use of his arm," said Dr. Shaw. "If it is completely numb, it will be only a dangling decoration, and no triumph." To ward off that grim possibility, even in advance of nerve surgery, physiotherapists are already teaching Ev Knowles to use his fast-healing left hand to work the joints of his pink but nerveless right.

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