As soldiers lay dying all around them and others awaited attention – some screaming, some in shocked silence – the surgeons in blood-splattered clothes went to work, sawing through bone. Their task was to sever the pulverized limbs and shattered bones of those who had been hit by deadly bullets shot from the barrels of rifled muskets. Amputations conducted on such a large scale had never been seen before.
If the evidence of apparently amputated bone stumps and saws made of stone are anything to go by, amputations have been practiced since Neolithic times. It is during periods of war, however, that the greatest leaps in this surgical procedure have taken place – simply because of the sheer numbers of amputations required in wartime. During the American Civil War (1861–1865) – a conflict in which over 70 percent of recorded wounds were to the extremities – an astonishing 50,000 amputations were performed.
It was largely down to the use of a new bullet called the Minié ball – a slug which tore through tissue like no equivalent ammunition seen before – that three quarters of all surgeries carried out on the Civil War battlefield were amputations. Large, heavy and made of soft lead, the Minié ball tended to expand upon impact, splintering and crushing bone. Yet while the number of fatalities increased as limbs were smashed to smithereens, so too did the number of amputations undertaken to combat the mortality rate.
Although gunshot wounds to the abdomen from these lethal rounds invariably resulted in death, with injuries to the arms and legs of troops, there was at least another option. Indeed, so mangled were the limbs of those who had been shot that the medic usually had little choice but to perform an amputation. It was either that or leave the stricken soldier to face the likelihood of a fatal infection.
The surgical conditions during the Civil War were appalling by today’s standards. However, that’s hardly surprising given the relative lack of medical knowledge at the time – the idea of a sterile environment was not yet recognized – and the chaos of battle, which would have been felt by one and all.
One surgeon stated: "We operated in old blood-stained and often pus-stained coats, we used undisinfected instruments from undisinfected plush lined cases. If a sponge (if they had sponges) or instrument fell on the floor it was washed and squeezed in a basin of water and used as if it was clean". After the limb had been cut through with a saw, the amputated limbs were often simply thrown outside the surgical tent into ever-mounting piles – then it was on to the next patient.
Because of the tremendously unsanitary conditions, a heavy mortality rate arose from so-called "surgical fevers". These were conditions like pyemia (a particularly virulent form of blood poisoning) and tetanus – both of which killed around 90 percent of those afflicted – as well as other diseases such as the now extinct “hospital gangrene.”
Surgeons barely rinsed their instruments between operations, much less washed their hands before they got to work on patients – such was the septic state of surgery during the American Civil War. In the heat of battle, with countless patients needing to be treated, time was of the essence – and cleanliness an afterthought – as the surgeon toiled over his operating table for hours on end.
After seeing to the wound with a wet cloth and probing with a filthy finger for bits of bone or the bullet, the surgeon would make a call on whether or not to amputate the limb. Scalpels or knives were then used to slice through the skin and muscle, and bone saws employed for the work their name implies – hence the Civil War surgeons’ nickname: “Sawbones.”
Upon completion of the procedure, the operator would tie off the blood vessels with horsehair or cotton thread, scrape the bones smooth, and then sew up the skin around the site of the amputation, with opening left to allow fluid to drain. Finally bandages were applied to the stump.
Anesthesia was in its infancy during the time of the Civil War but was nonetheless in widespread use – doubtless to the welcome relief of those being operated upon. At least the surgeons generally had a rag soaked in chloroform to help relieve the patient’s pain – at least for the time it took to perform the surgery – before the tourniquet was applied above the site of the wound and the business of slicing and sawing began.
Amputations were over with quickly – they could take as little as ten minutes in some cases – but they had to be: the mortality rate doubled for those performed more than 24 hours after the injury was inflicted, and yet the wait for treatment could easily be a day or two.
Indeed, the death rate was high in the best of cases, with one in four patients dying anyway after a typical amputation, and surgical fevers pushing the mortality rate up to as high as one in two.
This man, wounded in 1864, looks at the point of death, but a surgeon removed a bone in his leg that had become necrotic and apparently the stricken officer showed signs of improvement.
The hand belonged to Corporal William Brown, who had been shot in the forearm and developed gangrene. Even then, and during the hell that was war, it seems doctors attempted to document what they could of the procedures carried out for other physicians to learn from.
Pictured here, Private Jacob Dilley had his forearm removed after fighting in the Battle of Weldon Railroad, Virginia.
The surgeons did a heroic job in abominable circumstances with what little in the way of tools and knowledge they had at their disposal. Many of the operators had to learn on the job. Out of 11,000 Northern physicians, for example, only 500 had done surgery; in the Confederacy, just 27 out of 3,000.
Thirty-eight year old Private Julius Fabry in 1870 after his fifth operation, when Dr. George Otis successfully re-amputated Fabry's leg at his hip. Note the removed diseased bone on the table to his left.
The therapies and techniques used to treat wounds improved during the course of the American Civil War – in no small part to the amount of amputations that were carried out. It’s also worth noting that this was the last war in which deaths due to filthy instruments and generally septic operating conditions were unavoidable due to lack of knowledge. In 1865, British surgeon Joseph Lister developed the germ theory of disease, which advocated cleaning instruments, hands and linens to avoid infection.
Not only were amputation techniques advanced by the Civil War but so too the development of more practical prosthetic devices – sometimes through the ingenuity of the patient himself in the aftermath of the fighting. In this photo we see Private Samuel H. Decker, who designed his own prosthetic devices. The information provided says: "He receives a pension of $300.00 per year, and is a doorkeeper at the House of Representatives... With the aid of his ingenious apparatus he is enabled to write legibly, to pick up any small objects, a pin for example, to carry packages of ordinary weight, to feed and clothe himself, and in one or two instances of disorder in the Congressional gallery has proved himself a formidable police officer."