Under the Knife

Tuesday, August 6th, 2013

I recently mentioned how anesthesia spread rapidly, but antisepsis did not, and Civil War field surgery exemplifies this:

Civil War surgeons almost always had chloroform to anesthetize patients before an amputation. The chloroform was dripped onto a piece of cloth held over the patient’s face until he was unconscious. Although not an exact science, the procedure worked well, and few patients died from overdose. Opium pills, opium dust and injections were also available to control postoperative pain.

The mistaken belief that amputations were routinely performed without anesthetics can be partially attributed to the fact that chloroform did not put patients into a deep unconscious state. Bystanders who saw moaning, writhing patients being held down on the table assumed no anesthetic was being used. As in the case of General Ewell, patients often reacted to the scalpel and bone saw as if in pain, but they did not remember it afterward. After his left arm was amputated (Dr. McGuire also performed that operation), Stonewall Jackson mentioned that he had heard the most beautiful music while under the chloroform. Upon reflection, he said, “I believe it was the sawing of the bone.”

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Early in the war surgeons earned the nickname “Saw-bones” because they seemed eager to amputate. This eagerness stemmed not from overzealousness but from the knowledge that infections developed quickly in mangled flesh, and amputation was the most effective way to prevent it. Those limbs removed within 48 hours of injury were called primary amputations, and those removed after 48 hours were called secondary amputations. The mortality rate for primary amputations was about 25 percent; that for secondary amputations was twice as high, thanks to the fact that most secondary amputations were performed after gangrene or blood poisoning developed in the wound. Surgeons learned that amputating the limb after it became infected actually caused the infection to spread, and patients frequently died. Thus, the patient was much more likely to survive if a primary amputation was performed before infection set in.

[...]

Nonetheless, it is estimated that approximately three out of four soldiers survived amputations. Amazingly, some, like Confederate Brig. Gen. Francis T. Nicholls, endured more than one. His lower left arm was amputated after he was shot at the First Battle of Winchester and his left foot was taken off when he was wounded at Chancellorsville. After the war, Nicholls was a popular Louisiana governor who was said to ask people to vote for “all that’s left of General Nicholls” and to support him for governor because he was “too one sided to be a judge.”

Often, surviving an amputation seemed to be completely random. While some, like Ewell and Nicholls, seemed unhindered by the surgery, others died from what appeared to be rather minor wounds. Two members of Company B, 19th Michigan Infantry, were shot in the index finger in the same battle during the Atlanta campaign. One man treated himself by cutting off the mangled finger with his pocket knife. He wrapped the stub in a handkerchief and waited until the battle was over to have the wound dressed at the field hospital. The other soldier went immediately to the surgeon for a proper amputation. Gangrene set in within days, and the surgeon was later forced to amputate his arm at the shoulder. The soldier died soon afterward. The man who treated himself made a full recovery and lived to a ripe old age.

(Hat tip to Weapons Man.)

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