Wounds, Ammunition, and Amputation
Originally published in Winter 2007 in the Surgeon’s Call
Just prior to the Civil War, a new type of rifled musket and bullet were developed that increased the severity of the injuries to the soldiers. The old style smooth-bore musket had a limited range and fired a round ball of lead that usually broke the skin and fractured any bone it hit. The new musket had a rifled barrel and fired a conical bullet with a hollow grooved base, called the Minié ball. The new rifled muskets had a much longer range and better accuracy, and the projectiles traveled faster than those from the smooth-bore muskets. Additionally, when a Minié ball struck a soldier the top of the cone flattened out, resulting in massive damage to tissue and splintering of bone.
The vast majority of wounds documented during the Civil War were caused by the Minié ball, while the rest were from grapeshot, canister or other exploding shells. Few men were treated for saber or bayonet wounds and even fewer for cannon ball wounds.
Over two-thirds of the shot injuries were to the arm or leg. For most of the projectile injuries, the exit wound was often much larger than the entrance wound. Ricocheting or flattened bullets could create even larger lacerations and could carry foreign material into the wound. The extensive damage done by the Minié ball, plus its tendency to contaminate the wound, caused a dramatic increase in the development of infection.
If the injury caused little or no damage to the bone, the wound was often treated conservatively, with intervention limited to the removal of the missile, foreign substances and bone splinters. But if the bone was badly damaged, Civil War surgeons quickly learned that the best chance of survival was through the use of amputation. The limb was lost, but the soldier had less chance of developing life-threatening complications like gangrene, bone infection, blood poisoning, and the dangerous Streptococcus infection erysipelas. Excisions–the removal of a section of damaged bone–were also done, but the overall mortality rates were higher than in both amputations and conservative treatment. Also, since the excision procedure took much longer it was not considered practical in the often overwhelmingly-crowded field hospitals.
Unfortunately for the soldiers and the surgeons, the Civil War was fought just years before the widespread acceptance of the Germ Theory and the understanding of antisepsis and the sterilization of instruments and equipment. The Civil War surgeons performed their work as best they could, but did not have the knowledge of the role germs played in causing infection. While some antiseptic substances like iodine and bromine were used, the reason for their effectiveness was unknown. The discovery of antibiotics was still decades in the future.
The principal surgical procedure performed during the Civil War was amputation, accounting for three out of every four operations. When estimates from both the Confederate and Union sides are combined about 50,000 amputations were done throughout the war, which left the surgeons open to harsh criticism and earned them the reputation of butchers. However, the poor physical condition of their patients, the large number of wounded awaiting treatment after a battle, and the severe nature of the wounds caused by the Minié ball made amputation the practical procedure to follow.
Amputations were classified into three categories based on how soon after an injury they were performed: primary, intermediary, and secondary. Primary amputations were done within forty-eight hours of the injury, intermediary amputations took place between three and thirty days after the wounding, and secondary amputations were performed more than thirty days after the injury. In general, primary amputations had the highest survival rate and were preferred by the surgeons for this reason. Intermediary amputations were the most dangerous because they were often done when the inflammation of the wound was at its greatest and the patient was suffering from its effects.
Surgeons of all ranks, including civilian contract surgeons, performed amputations and other operations. On October 30, 1862, Jonathan Letterman, Medical Director of the Army of the Potomac, issued a circular outlining the preferred organization of operating teams at the field hospitals. Each hospital was to have three medical officers chosen to be responsible for performing all major operations. They were selected by skill and sound judgement rather than rank. Three additional medical officers were assigned to each member of the operating staff, with one assistant selected to administer anesthetic to the patients. This last duty was important, since 95 percent of operations performed during the Civil War were done with the patient under some form of anesthesia, usually chloroform or ether.
The most common amputation sites on the body were the hand, thigh, lower leg, and upper arm. The likelihood of surviving an amputation depended on the distance of the operation site from the trunk of the body, in addition to how long after the injury the surgery was performed. Generally, mortality rates dropped as the distance from the trunk of the body increased. For example, amputations at the wrist joint had a 10.4 percent death rate, while amputations at the shoulder joint had a 29.1 percent death rate.
Circular amputation, made by a direct cut through the limb, leaving a raw open stump which healed gradually. From The Illustrated Manual of Operative Surgery and Surgical Anatomy, 1861.
Flap amputation, done by creating a flap of skin to cover the stump, which healed more quickly but was slightly more prone to infection and took longer to perform. From The Illustrated Manual of Operative Surgery and Surgical Anatomy, 1861.
Left femur of Private John Draker, fractured by a Minié ball. Remarkably, the ball passed through his right thigh before hitting his left thigh. Courtesy of the Otis Historical Archives.
About the Author
Terry Reimer is presently the Director of Research the National Museum of Civil War Medicine in Frederick, Maryland. Previous work includes over twenty years of experience in historical archaeology and research, specializing in 17th, 18th and 19th century American sites. She holds a B.A. in Anthropology from the University of Maryland and did graduate work in anthropology and folklore studies at George Washington University. She is the author of two books, One Vast Hospital: the Civil War Hospital Sites in Frederick, Maryland after Antietam and Divided by Conflict, United by Compassion: The National Museum of Civil War Medicine, and the co-author of two other books, Bad Doctors: Military Justice Proceedings Against 622 Civil War Surgeons and Caleb Dorsey Baer: Frederick, Maryland’s Confederate Surgeon.