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Saturday, August 6, 2011

Amputation in the Civil War


by Alfred Jay Bollet, M.D.

Despite the long-standing negative reputation of Civil War surgery, there is abundant evidence that the surgeons did quite well for the time, and made continuing efforts to improve their results as the war progressed. The large number of amputations performed has been the main criticism of Civil War medicine. Were many of them unnecessary?

Any discussion of Civil War medicine has to take into account the state of surgery at the time. At the time of the Civil War surgery was still rudimentary, and the most frequent major operative procedure that could be done successfully was amputation. In civilian hospitals as well as military, amputations were the most frequent major surgical procedures. Anesthesia had become universal during surgery, but little else changed until the germ theory was accepted and techniques to prevent infection were adopted late in the 19th century.

Decisions regarding evacuation of wounded soldiers to field hospitals effected the statistics about amputations during the Civil War. Serious head, chest and abdominal wounds could rarely be treated successfully. As a result of the application of triage principles, extremity injuries were preferentially evacuated to field hospitals for surgical treatment, while the more seriously injured generally were given morphine and water, and not moved unnecessarily. As a result the statistics concerning the nature of the wounds treated in hospitals have confused students of the war; for example, the data in the surgical section of the Medical and Surgical History of the War of the Rebellion show that 71% of the hospitalized wounds were in the extremities, almost equally divided between arms and legs, while only 18% of the wounds were in the trunk and 11% in the head and neck. Military historians have tried to explain these figures, assuming they were totals for all the battle injuries, by suggesting that they resulted from men being ordered to shoot low, and that many arm wounds occurred while men were reloading their weapons. There was only one battle in which all injuries were counted, including those for men “killed in battle.” Of the 1,173 injuries tabulated, of those killed (and therefore not evacuated to hospitals) 51% were in the trunk, 42% in the head and neck, 5% in the legs and 3% in the arms. These data contrast with the statistics for wounds treated in hospitals, and tell us why the hospital statistics gave the impression that amputations were excessive, since comparatively, so few other injuries were recorded in the hospital statistics.

Since about 85% of the wounded who were evacuated to hospitals survived, large numbers of men with amputations came home and were seen in public. Most families probably had a son, husband or more distant relative with an amputation. The frequency of amputations and the resulting disfigurement and disability were prominent in the minds of everyone, and that image of the results of Civil War surgical care has dominated the reputation of those surgeons ever since.

Widespread criticism of the surgical treatment of wounds appeared in newspaper reports and letters by wounded soldiers during the first year of the war; members of Congress condemned the surgeons publically. One of the clearest condemnations of army surgeons of the time appeared in the third edition of a textbook of surgery used by Confederate surgeons during the second half of the war; it documents the problems that existed in the both the Confederate and Union armies. Professor J. Julian Chisolm, of Charleston, wrote,

“Among a certain class of surgeons … amputations have often been performed, when the limbs could have been saved, by inexperienced surgeons, over simple flesh wounds. In the beginning of the war the desire for operating was so great among the large number of medical officers recently from the schools, and who were the first time in a position to indulge this extravagant propensity, that the limbs of soldiers were in as much danger from the ardor of young surgeons as from the missiles of the enemy.”

Medical Director Jonathan Letterman of the Army of the Potomac was so disturbed by public criticism of the Army surgeons after the Battle of Antietam in September 1862 that he wrote:

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. [But] it is certainly true that there are surgeons who will favorably compare with the military surgeons of any country….

These criticisms subsequently affected the decisions of surgeons, making them hesitate to perform amputations even when they were necessary. Instead attempts were made to save fractured limbs, even those with compound fractures (where the skin over the fracture is torn, often with bone ends protruding), without amputation -- with some successes. But infection always resulted, whether or not they were operated on, and led to many fatalities or the development of chronic, disabling bone infections (osteomyelitis), that, in many instances, were ultimately fatal.

In deciding whether to amputate, most Civil War surgeons were guided by the aphorism, “every hour the humane operation [of amputation] is delayed diminishes the chance of a favorable issue.” (This parallels the modern concept of the “golden hour” for trauma patients.) Late in the war, Dr. Henry S. Hewit, the Medical Director of Sherman’s Army during the 1864 Atlanta campaign, reported:

[Delayed] amputations, after osteomyelitis is kindled or fully established, are very dangerous to life, and every moment of delay in the amputations necessitates a greater sacrifice of length [amputation of more of the extremity to get above the zone already infected]. With a full and careful examination and estimate of contingencies, every case must be decided upon its merits, and it is impossible as yet to promulgate a general law. It must, however, be said that the chances for life, preservation of constitution, and prevention of suffering, preponderate in favor of primary [i.e. early] amputation. . . .”

William M. Caniff, a British surgeon who was Professor of Surgery at the University of Victoria College in Toronto, visited the Union army after the Battle of Fredericksburg. He commented that American surgeons were too hesitant about doing amputations: “Although a strong advocate of conservative surgery . . . I became convinced that upon the field amputation was less frequently resorted to than it should be; that while in a few cases the operation was unnecessarily performed, in many cases it was omitted when it afforded the only chance of recovery.”

Chisholm, in the textbook mentioned above, after describing the unnecessary amputations done by inexperienced surgeons, added, “It was for this reason that, in the distribution of labor in the field infirmaries, it was recommended that the surgeon who had the greatest experience, and upon whose judgment the greatest reliance could be placed, should officiate as examiner, and his decisions be carried out by those who may possess a greater facility or desire for the operative manual.”

On October 30, 1862, about a month after the Battle of Antietam, Jonathan Letterman, after only a few months as Medical Director of the Army of the Potomac, issued an order making a number of administrative changes in the medical department of that army. He circumvented many army regulations (with the approval of General McClellan, commander of the Army of the Potomac), changing many of his predecessor’s policies. After describing organizational changes, such as making the divisional hospital the primary unit, rather than the regimental hospital, the order included the following:

“There will be selected from the division, by the Surgeon-in-chief, under the direction of the Medical Director of the Corps, three Medical officers, who will be operating staff of the hospital, upon whom will rest the immediate responsibility of performing all important operations. In all doubtful cases they will consult together, and a majority of them shall decide upon the expediency and character of the operation. These officers will be selected from the division without regard to rank, but solely [italics in original] on account of their known prudence, judgment, and skill. The Surgeon-in-chef of the division is enjoined to be especially careful in the selection of the officers, choosing only those who have distinguished themselves for surgical skill, sound judgment, and conscientious regard for the highest interests of the wounded.”

It is most noteworthy that the selection of the individuals described in this order, as in Letterman’s description of his system, was to be based “solely” on ability “without regard to rank….” The standard army principle of “RHIP,” (“Rank Has Its Privileges”) was suspended for the duration of the war as far as decisions regarding surgery in the Union Army were concerned.

Later, on May 20, 1864, General Order No. 19 of the Eighteenth Corps of the Army of the Potomac also described the system:

“All cases of amputation must either be first designated for operation by the surgeon in charge of the hospital, or be determined upon by a majority vote of a board of at least three surgeons to be detailed by the surgeon in charge, or the corps medical director.”

In the third edition of his textbook, Professor Chisolm, described a similar procedure adopted in the Confederate army, where manpower deficiencies affected the details of the practice: “In the distribution of labor in the field infirmaries, it was recommended that the surgeon who had the greatest experience, and upon whose judgment the greatest reliance could be placed, should officiate as examiner, and his decision be carried out by those who may possess a greater facility or desire for the operative manual.”

Figure 1. Amputation scene at Gettysburg. (National Archivesd and records Admin, 79-T-2265)

This photograph, identified as “amputations scene at Gettysburg,” actually shows the implementation of Letterman’s orders in the Army of the Potomac. The operating surgeon can be seen standing with his knife ready but not in use. This illustrates the controls that were established by late 1862, beginning in the Army of the Potomac; they may have been posed because of the long exposure times necessary with the photographic technology of the time, but the scene obviously depicts actual events.

During the course of the war a total of 29,980 amputations were reportedly done on Union soldiers with an overall fatality rate of 26.3%. The closer to the trunk the amputation was done, the higher the fatality rate. During the Crimean War only about one-tenth as many amputations were done (a total of 1,177), but the mortality rate was higher than those for the Civil War armies at every site (except the forearm and hand, where fatalities were very few in either army). Although definite conclusions cannot be drawn from these figures, it seems fair to state that, despite the enormous numbers of wounded needing care, the results of the efforts of Civil War surgeons were respectable when compared international standards of the era.

Civil War surgeons, looking back many years later, felt they had performed too few amputations rather than too many. William W. Keen participated in the Civil War as a Union medical cadet before graduating from medical school; after graduation he became an Assistant Surgeon. Later in the 19th century he became Professor of Surgery at Jefferson Medical College in Philadelphia, one of the leaders in American surgery, and a founder of the field of neurosurgery. “The popular opinion that the surgeons did a large amount of unnecessary amputating may have been justified in a few cases,” he wrote in 1905, “but taking the army as a whole, I have no hesitation in saying that far more lives were lost from refusal to amputate than by amputating.” He added, “Conservative surgery was practiced too much and the knife not used enough.”

The condemnations of Civil War surgeons for performing too many amputations that arose during the war have changed very little since. Criticisms of the bad practices early in the war were widely publicized, but the improvements in care that occurred never made it into the newspapers or into debates on the floor of Congress. Because of the huge numbers of casualties in the major battles of the war, men with amputations were seen frequently on the streets and in homes, but the results of failure to amputate remained unseen, buried.

References

This article is based on information in A. J. Bollet, Civil War Medicine, Challenges and Triumph, Tuscon, AZ, Galen Press, 2002., as well as G. Damman and A. J. Bollet, Images of Civil War Medicine, A Photographic History. New York, NY, Demos Medical Pub, 2008.

i Barnes, JK, Medical and Surgical History of the War of the Rebellion, Washington, DC, GPO, Surgical Section, vol 3, p692, 696.

ii Chisolm JJ: A Manual of Military Surgery for Use of the Surgeons in the Confederate Army. 1st ed. Columbia, SC: Evans and Cogswell, 1861.
Republished: Dayton, OH: Morningside Press, 1992, pp. 370.

iii Letterman, J. in Official Records Series I, vol. xix/1, p 113.

iv Riley, H.D., Jr.: Confederate Medical Manuals of the Civil War. J. Med. Assoc. Georgia 1988; 77(2):104-8.

v) Official Records of the War of the Rebellion (OR)., Series I, Vol. XXXVIII/2, p. 524.

vi Caniff W: Surgery of the Federal army. (Letter to the editor) Lancet. February 28, 1863;1:251-2.

vii Ibid p 409

viii Letterman, J. Medical Recollections of the Army of the Potomac. Knoxville, Tn Bohenian Brigade Pub, 1994 (orig. pub 1866), p 60.

ix Official Records, General Orders No. 19.May 20, 1864.

x Chisolm JJ: A Manual of Military Surgery for Use of the Surgeons in the Confederate Army. 3rd ed. Columbia, SC: Evans and Cogswell, 1864. Republished: Dayton, OH: Morningside Press, 1992, p.409.

xi Keen WW: Surgical reminiscences of the Civil War. Transactions of the College of Physicians of Philadelphia. 3rd Series, 1905;27:95-114.

Alfred J. Bollet, M.D. is the author of the comprehensive and widely acclaimed Civil War Medicine: Challenges and Triumphs.He attended New York University School and Medicine and has been practicing medicine for more than 60 years.

2 comments:

At the time of the Civil War treatment was still general, and the most typical operative process that could be done effectively was amputation. In private hospitals as well as military, amputations were the most regular major surgery processes.

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