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Combat Amputations: The Cost of an Armand a Leg in the Civil War

By Joe Dacanay

“The surgery of these battlefields has been pronounced butchery.”

This quote by Union Army Medical Director Doctor Jonathan Letterman, written a day after the grueling battle of Antietam, was penned in response to public outcry regarding the high use of amputations during the height of the Civil War. Letters and stories of injured soldiers were making their way back to distressed families, and the information spread like bacteria on an open wound. Descriptions of makeshift operating rooms like Dunker Church at Antietam horrified both sides of the conflict. Amputated extremities would be discarded out the windows and piled up outside. Accounts like these formed a lasting scar on the surgical profession that has still not yet healed.

I imagine that the general American public views historical amputations as a brutal operation, where Civil War soldiers would be given some whiskey and a belt to bite on as the knife came down. However, that depiction could not be farther from reality. Analysis of preserved records show that three out of six surgical procedures were amputations, and with such volume of operations came constant opportunities for research and improvement. The process of surgery during the Civil War was extremely well-documented, and based on this information, we now know that past surgeons utilized many standard procedures that physicians still use today.

How Amputations Were Performed

The bloody beginnings of amputations began with those who held a morbid curiosity about the world: Greek philosophers. With time, more and more curious people would take their own crack at refining amputations, and the skill base widened by the century. This diffusion continued up to the start of the Civil War.

The people who stepped up to become combat surgeons in the war were, for the most part, educated with the most up-to-date medical knowledge. Although the requirement to enter medical school was as simple as paying a hefty fee, those who wished to practice medicine must have attended university to become a doctor. For the Union, educated personnel was common. On the other hand, the Confederacy lacked trained doctors who served on the field. The majority of the Confederate surgical staff were volunteers and “medical officers”, soldiers who were trained to complete certain procedures like amputations, which did not require extensive anatomical knowhow. Both armies had similarly structured hierarchies for their medical staff, with the “surgeon general” rank standing at the top of the heap. By the end of the Civil War in 1865, there were about 15,000 doctors who served in total.

A Union surgeon’s best reference for medical guidance was the 1807 book The Practice of Surgery by Englishman Samuel Cooper. This book detailed many early medical practices, including the act of amputation. The high risk for wound infections on the battlefield as well as grievous injuries caused by bullets and cannonballs tended to make amputations favorable to prevent common conditions like gangrene. Gangrene, which is the necrosing of tissue after blood supply is impeded, was a priority to be removed before it spread from the wound. Before the procedure, it was advised that a surgeon use the chemical chloroform to sedate the patient to minimize pain. This was one of the first instances of anesthesia in American history. Afterward, the surgeon would utilize a tourniquet, a strap that tightened around the damaged limb using a screw mechanism. This tool cuts off blood circulation to the limb, preventing excessive blood loss. The tourniquet would then be placed closely above the incision point, in an effort to preserve as much limb as possible. Finally, the surgeon would use a variety of scalpels and a saw to cut through the tissues and bone in a circular motion. This technique was particularly efficient because it allowed surgeons to cut with the shape of the bone. The procedure would finish with covering the site with clean dressings. The entire process would take under 10 minutes. After they had adequately recovered, these soldiers were discharged from service and returned home with their lasting injuries.

Similarities From Past to Present

With the exception of disinfection and maintenance of a sterile field with their tools, the process of amputating a limb has evolved mostly in technology but not so much in technique. In place of the screw tourniquet, we have upgraded to a spinning windlass design. Windlasses ensure higher enhanced mechanical advantage than the screw design, as the windlass mechanism does more work than the user. Think of Civil War tourniquets as having to vertically drive a screwdriver down to secure a screw and windlasses as re-tightening the lid of a pickle jar; it allows a more comfortable hand placement, and is therefore faster. The iconic bone saw was replaced by a gigli saw, which consists of a single sharp wire that can efficiently cut in a circular motion as opposed to the stiff saws used in the Civil War. Our ability to anesthetize has also evolved immensely, and chloroform has been replaced with safer alternatives. Nitrous oxide is another colorless gas that fulfills the roles of anesthesia and sedation without causing the toxic or cancerous complications associated with chloroform use. Masks used to deliver anesthetics guarantee that the patient receives the appropriate dose of the anesthetic, rather than the Civil War method of soaking a sponge with chloroform and having a patient breathe in the fumes. Other than those three safety and technological advancements, the essentials of amputation have remained the same because they work well. It is still ideal to remove as little of the limb as possible, as this practice significantly decreased the rate of mortalities during the conflict. When applied together, these ideas saved lives back then, and continue to do so today.

What Happened Afterward?

After saving the lives of soldiers, what was to come of them back home? Loss of a limb would not only disrupt the activities of their daily lives, but would cause intense mental duress as well. Fortunately, the call for assistance was answered when the first federal pension system was formed in 1862 to help veterans by providing a small amount of financial aid. Disabled Union soldiers and the families of soldiers killed in action were eligible for reimbursement. However, Confederate soldiers were not able to receive benefits from the government on account of their opposition. In addition to this pension, soldiers who had suffered a loss of limb could receive prosthetic limbs, and with the introduction of these prosthetics came a corresponding evolution in prosthetic limb design. Early leg prosthetics were found to be uncomfortable and stiff, so veterans created their own prosthetics and shared their improved versions with others. Confederate soldiers, despite not receiving such aid, fundraised their own programs to provide prosthetics to veterans. Today, our disabled veterans can receive free artificial limbs and other related services to make the transition back to civilian life easier. Even with such progress, what unfortunately remains timeless is the pain and suffering caused by combat wounds. Watching a loved one return home without a hand to hold is debilitating, and anger at the cause is a just reaction. Amputations may be misunderstood as “butchery,” as Doctor Letterman referenced, but that outcry of emotion does not detract from the life-preserving benefits the procedure has. Still, with time, I hope that victims of war, both past and present, are able to recover and understand the decision that surgeons make to save their lives, albeit with the sacrifice of an arm or leg.

“The surgery of these battlefields has been pronounced butchery. Gross misrepresentations of the conduct of medical officers have been made and scattered broadcast over the country, causing deep and heart-rending anxiety to those who had friends or relatives in the army, who might at any moment require the services of a surgeon. It is not to be supposed that there were no incompetent surgeons in the army. It is certainly true that there were; but these sweeping denunciations against a class of men who will favorably compare with the military surgeons of any country, because of the incompetency and short-comings of a few, are wrong, and do injustice to a body of men who have labored faithfully and well. ” — Dr. Letterman