GRAPHIC Surgeon's Dilemma: Amputation vs. Excision

lelliott19

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"Of the varieties of gunshot wounds, none are more terrible in their effects than those that are produced by the peculiar bullet invented by M. Etienne Minié, of Paris….the effects are truly terrible; bones are ground almost to powder, muscles, ligaments, and tendons torn away, and parts otherwise so mutilated, that loss of life, certainly of limb, is almost an inevitable consequence."
The .58 caliber conical minié ball weighed just one ounce and had a circumference of about ½ inch. It might have been small, but it caused major destruction. It was made of soft lead and designed to spread or flatten, on impact. As a result, the minié ball caused profound damage to soft tissue and often shattered bones 3 or more inches either side of the actual impact site.
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Proximal portion of a right humerus with a comminuted fracture held together with wires and springs; from an unidentified man shot during the Civil War.
Because of the number of amputation being performed, Civil War surgeons faced harsh criticism from all sides. Citizens and the press condemned the practice of amputation, without understanding its necessity. Medical officers on both sides tried to change perceptions of medical services by initiating more conservative approaches instead of amputation. One alternative to amputation was “excision.” If a damaged joint was excised, Confederate surgeons called the procedure a “resection,” but the terms were often used interchangeably.
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Surgeons were much more likely to consider excision instead of amputation when operating at general hospitals located in the rear. They had fewer emergency patients and more time. At field hospitals located near the battlefields, amputations were preferable because of the relative speed with which they could be performed – about 10 minutes. With so many wounded men to attend to, surgeons at field hospitals could treat and save many more lives through amputation. Waiting to operate often resulted in infection, and infection often resulted in death. It is no wonder then, that three of every four surgical procedures performed during the Civil War was an amputation.

If the surgeon had the benefit of time, excision was deemed appropriate when one of the long bones of the leg (femur, tibia, fibula) or arm (humerus, ulna, radius) was comminuted, without damage to nerves or blood vessels. The ends of the fractured bone were cut proximal and distal to the comminuted section and all the fragments were excised. Rigid wooden splints secured and immobilized the shortened extremity, allowing the bone ends to unite.
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After recovery, the results were varied. Some excisions resulted in a limb that was slightly shortened but near normal. Other soldiers might have little or no use of the extremity at all. Results were dependent upon the severity of the injury; the elapsed time between wounding and surgery; and the skill of the surgeon in avoiding collateral damage during surgery.
Sources:
Image 1: Amputation. Samuel Irwin, 67th Pennsylvania Volunteers, had his right arm amputated at the shoulder joint.
Image 2: Excision. Private Francis Furber had the lower third of his humerus bone removed after it was shattered by a minié ball.
Images 1 & 2 from https://www.dailymail.co.uk/news/ar...orrifically-maimed-American-battlefields.html
Image 3: Fractured Right Humerus- Proximal Portion, due to Gunshot Wound, Warren Anatomical Museum, Harvard Medical Library https://collections.countway.harvard.edu/onview/items/show/6128
Image 4: Forearm after excision in the lower third of the radius for shot injury. The Medical and Surgical History of the War of the Rebellion. (1861-65.), Part 2, Volume 2 (Washington, DC: Government Printing Office, 1876), page 938.
Image 5: Double Incline Leg Splint; Illustration from Civil War Medicine by C. Keith Wilbur.
http://www.archivingwheeling.org/blog/founding-physician-and-civil-war-surgeon/scan0002
 
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MillBillyBub

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Historian here at Chickamauga says vast majority of amputations were done at the Field Hospitals. Some got special treatment, but they were few.
Ive read over some of the journals that disclose various procedures and recorded cases. Dr. Lewis Dyer Surgeon of the 81st Illinois Inf'ty. ran about a 75% loss in amputation. And it appeared the patient had a better outcome when he was able to use the flap procedure....Ironically in the most horribe way, during the occupation of Vicksburg and in the act of defending a black man when two Federal soldiers saw it fit to try and take the mans horse...One of the men pulled a dirk from his boot and stabbed Dr. Dyer through the mouth leaving a gaping slough under hia jawline/chin area....some time after the war had ended, the 64 year old physician had no choice but to try and file a disability..he couldnt keep patients for the horrendous wound/scar and the constant salivation that tended to drain out of it...
 

DBF

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I wonder how far medicine progressed during and after the war when all these surgeries and injuries became more the "norm" (not that the was a good thing) and yet it certainly created an industry (and a positive one) for James Edward Hanger. If not for his crippling war injury, he never would have worked to develop an artificial limb and his company is still around today. I would hope the surgeons also learned a few things as well.
 

lelliott19

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After the amputation, how was the wound closed? Stitches, cauterization, etc.?
Thanks for everyone's interest in this thread. In this post, Ill just explain the basic amputation procedure and the instruments used. Since everyone seems to be interested, Ill do some follow up threads to thoroughly cover the different procedures - circular amputation, flap amputation, and excision. Different knives were used for cutting the skin, depending on which amputation procedure was being used (circular or flap) so Ill cover the "cutting" in a separate thread. Since the closing was done differently depending on which amputation procedure was being used, Ill do them separately too. And Ill cover excision in a completely separate thread.

@Mike Serpa for your specific question, the short answer is stitches.

For for both kinds of amputation (circular and flap) they retracted the flesh above the incision and used a bone saw to cut through the bone. A bone saw looks kind of like a hack saw.
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Once the bone was cut and the limb was removed, the next step was to fish out the blood vessels using a tenaculum and tissue forceps (tweezers.) The tenaculum looks like a dental pick and with the hook end, the surgeon was able to pull out the cut ends of the veins and arteries. Next, the surgeon "tied off" the cut blood vessels using silk thread.
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For both the circular amputation and the flap procedure amputation, the surgeon next needed to remove the sharp protruding edges of the bone. They used an instrument called a ronguer to even out the bone by snipping away any sharp edges - kind of like wire cutters, but for bone.
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Next, the surgeon used a bone file to really smooth away all the roughness on the edges of the cut bone. A bone file is like a thick metal nail file....heavy enough to file bone.
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Finally, the flaps of skin were closed using sutures. The specific method of closing depended on whether the circular or flap method had been used.
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In both cases, the surgeon might leave an opening for drainage. Then the stump was bandaged.
EDIT TO ADD: Even though some of the images above show gloved hands, civil war surgeons did not wear gloves. They didn't know about germs and rarely even washed their hands. Usually, they just wiped off the blood from the previous patient on their apron, before moving on to the next.
Images from www.civilwarmed.org and http://www.campsiteartifacts.com/surgicalbonefile.html
 
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lelliott19

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Wow !

I would have guessed cauterization.

But then again, you're the expert here & my limited knowledge is from watching movies.

Seriously @lelliott19, great thread !
Thanks 7th. Surgeons may have used the cautery for some smaller blood vessels (capillaries) when performing amputations, but they used "ligatures" to "tie off" major blood vessels - arteries and veins. Cautery was mostly used for trying to "burn out" infected tissue and gangrene, treating venereal disease (dont ask:nah disagree:), and to control minor bleeding.
 
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Mike Serpa

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Thanks for everyone's interest in this thread. In this post, Ill just explain the basic amputation procedure and the instruments used. Since everyone seems to be interested, Ill do some follow up threads to thoroughly cover the different procedures - circular amputation, flap amputation, and excision. Different knives were used for cutting the skin, depending on which amputation procedure was being used (circular or flap) so Ill cover the "cutting" in a separate thread. Since the closing was done differently depending on which amputation procedure was being used, Ill do them separately too. And Ill cover excision in a completely separate thread.

@Mike Serpa for your specific question, the short answer is stitches.

For for both kinds of amputation (circular and flap) they used a bone saw to cut through the bone. A bone saw looks kind of like a hack saw.
View attachment 297723

Once the bone was cut and the limb was removed, the next step was to fish out the blood vessels using a tenaculum and tissue forceps (tweezers.) The tenaculum looks like a dental pick and with the hook end, the surgeon was able to pull out the cut ends of the veins and arteries. Next, the surgeon "tied off" the cut blood vessels using silk thread.
View attachment 297726View attachment 297727

For both the circular amputation and the flap procedure amputation, the surgeon next needed to remove the sharp protruding edges of the bone. They used an instrument called a ronguer to even out the bone by snipping away any sharp edges - kind of like wire cutters, but for bone.
View attachment 297719

Next, the surgeon used a bone file to really smooth away all the roughness on the edges of the cut bone. A bone file is like a thick metal nail file....heavy enough to file bone.
View attachment 297739
Finally, the flaps of skin were closed using sutures. The specific method of closing depended on whether the circular or flap method had been used.
View attachment 297744
In both cases, the surgeon might leave an opening for drainage. Then the stump was bandaged.
EDIT TO ADD: Even though some of the images above show gloved hands, civil war surgeons did not wear gloves. They didn't know about germs and rarely even washed their hands. Usually, they just wiped off the blood from the previous patient on their apron, before moving on to the next.
Images from www.civilwarmed.org and http://www.campsiteartifacts.com/surgicalbonefile.html
Thank you Laura for your informative reply.
 

Mike Serpa

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Wow !

I would have guessed cauterization.

But then again, you're the expert here & my limited knowledge is from watching movies.

Seriously @lelliott19, great thread !
I thought that they used a torch and just held it to the limb while the wounded patient had a pint of whiskey and a piece of leather crammed in his mouth so he wouldn't bite his tongue when he screamed.
 

Mr. King

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Lt. General Richard Ewell had a lot of problems with his stump. 3 or 4 months after his amputation, he slipped on some ice in Richmond and broke off a short piece of the bone at the end of it, requiring another surgery to snip and file the end of it again. And he had problems with the bone cutting through the skin, I think. (if I remember correctly)

I have always been fascinated with amputations.
My cousin fell off a tractor she was riding with my Uncle when we were kids, and she got ran over by the bush hog. Luckily, she fell into the same hole that cause the tractor to dip and make her fall, and all that was cut off by the bush hog blades was one of her legs right at the knee. She made it to the hospital in about 15 minutes, and made a full recovery. She was walking on a prosthetic within a few months, and today she walks so normally that you probably wouldn't notice. Heck, we rarely even acknowledged her fake leg after that. She literally took it in stride.

Anyway, every time I see an amputation on TV, I call BS on their methods. On the Walking Dead, they amputated a guy's leg with a hatchet.... Then on World War Z, Brad Pitt chopped off that girl's arm with a machete.... Yes, those methods will separate the limb from the patient, but you will require more than an ace bandage to survive. Bone filing, flap closure, arterial ligatures..... come on, people....
 
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Ive read over some of the journals that disclose various procedures and recorded cases. Dr. Lewis Dyer Surgeon of the 81st Illinois Inf'ty. ran about a 75% loss in amputation. And it appeared the patient had a better outcome when he was able to use the flap procedure....Ironically in the most horribe way, during the occupation of Vicksburg and in the act of defending a black man when two Federal soldiers saw it fit to try and take the mans horse...One of the men pulled a dirk from his boot and stabbed Dr. Dyer through the mouth leaving a gaping slough under hia jawline/chin area....some time after the war had ended, the 64 year old physician had no choice but to try and file a disability..he couldnt keep patients for the horrendous wound/scar and the constant salivation that tended to drain out of it...
Welcome, enjoy
 

Zack

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pint of whiskey and a piece of leather crammed in his mouth

I'm not sure how it began, but giving a Civil War soldier a pint of whiskey and hacking away is a myth. Anesthesia was widely used during the war. In fact, there are instances of surgeries being delayed due to a lack of anesthesia. https://www.civilwarmed.org/anesthesia/
https://www.civilwarmed.org/anesthesia-2/
https://www.civilwarmed.org/anesthesia-3/
https://www.historynet.com/the-truth-about-civil-war-surgery-2.htm

Also a friendly reminder that Jonathan Letterman is one of the unsung heroes of the war - https://www.civilwarmed.org/quick-facts/letterman/

Anesthesia came in 3 forms at the time - chloroform (the most commonly used by a mile), ether, or a mixture.

When a patient is administered an anesthetic, they pass through a number of stages. (https://www.ncbi.nlm.nih.gov/books/NBK557596/) Today, they are classified as follows:

Stage 1 - initial administration of the anesthesia leading to disorientation and eventual loss of consciousness. If you've ever been under general anesthetic, this is the part where the doctor asks you to "count back from 100" or something and you slowly but surely become less and less coherent until you are unconscious.

Stage 3 - surgical anesthesia. Patient is unconscious and feels no pain. This is the ideal stage.

Stage 4 - overdose. Death.

You'll notice I skipped Stage 2. That's because it is the most interesting. Stage 2 is known as the "excitement" phase. The patient may thrash around, scream, shout things, even vomit. However, they are completely anesthetized at this stage. They will feel no pain and won't remember any of this when they wake up.

Modern anesthesiologists spend a ton of time in school in order to know exactly how much anesthesia to administer to reduce the time in stage 2 as much as possible or skip it altogether.

But in the Civil War, they did not have that level of precision. They were likely to err on the side of caution, since an overdose was never ideal. This led to surgeries being started or conducted while the patient was in Stage 2. A random observer passing by would see a soldier thrashing about, screaming, calling out names and pleading while the surgeon's assistants are trying to hold them down. It would be easy to come to the wrong conclusion that the patient was being operated on while conscious. I'm not 100% sure whether doctors would wait out Stage 2 or attempt surgery during it. It probably depended on the doctor and the quantity of casualties.

As for biting the bullet - introducing a small object to the mouth of someone likely to be screaming in pain is a great way to cause a choking death. One of the links I provided above says that bullets with teeth marks are likely the result of gnawing pigs, not humans. A leather strap or a large piece of wood are better, but in the latter case you have to worry about splinters falling into the windpipe.

The below video shows a recreation of an amputation during the Napoleonic Wars. This was prior to the widespread use of amputation, so the patient is shown (correctly) as being conscious, but the basic procedures of how the leg was removed remain largely the same. I will note, it appears the performance of surgeries with the patient in a vertical position was not really practiced during the Civil War, most likely because of anesthetics (warning graphic)

As a general rule, administering alcohol before a surgery is a bad idea. It's a blood thinner and reduces clotting, which is not good when you're about to cut through arteries. The above video shows the doctor denying the soldier whiskey before the surgery but allowing it afterwards. I have not been able to find any reliable sources as to the extent to which doctors understood the risks of letting soldiers drink before a surgery.

Anyways - great post @lelliott19

It also highlights the reality that medical understanding was much further advanced than we give credit for at the time, but oftentimes the sheer number of casualties forced surgeons to resort to simple operations such as amputations. I read that, prior to the war, medicine in the 19th Century took a conservative approach - they wanted to avoid removing limbs or performing complex surgeries if it was at all possible. It was the volume of casualties combined with the utter brutality of the bullets used that led to mass amputations during the Civil War.

Final thought - in the video I posted the surgeon is shown inserting their finger into the wound. This was still practiced during the Civil War and can quite possibly even be seen in this famous photo (graphic):
n-photograph-Virginia-Savages-Station-June-30-1862.jpg

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