Now all roads lead to France and heavy is the tread
Of the living; but the dead returning lightly dance.
Edward Thomas, Roads

Sunday, September 3, 2017

From the Civil War to the World War: Dealing with Amputations

Advances in medicine toward the end of the 19th century profoundly affected the number and nature of the wounds of surviving soldiers. While the discovery of anesthesia in 1846 had benefited the wounded of Civil War battles, anesthesia had no effect on mortality rates following surgery. It took until 1867, two years after the end of the Civil War, for Joseph Lister to publish “On the Antiseptic Principle of the Practice of Surgery” and more than a decade before the germ theory of disease started to affect army medicine.  World War  I was fought over soil that had been rich farmlands infested with bacteria, and many wounds from exploding artillery rounds caused what one observer called an “unprecedented riot of infection”, but by the time America entered the war, military physicians had learned how to cope with battle infections.

Amputees at Walter Reed Hospital

Allied military surgeons had already learned that the first several hours after injury were critical to preventing contamination of a wound. They learned that, if they cut away all foreign objects and applied antiseptic properly, mortality rates would plummet. As a result, World War I stands in sharp contrast to the experience of the Civil War:

Only 25 percent of the cases of compound fractures are now—during World War I—fatal instead of 66 per cent as in the [Civil War]. Four out of five amputations are due to infection. Our victory over infection is the reason for the greatly diminished number of amputations in the present war. Moreover, the mortality of amputations in our armies is low; in some series every one has recovered. Of the wounded, 80 percent are soon able to return to the fight. (1918 Report)

Table 7.4 shows the distribution of amputations comparing the experiences of World War I and the Civil War. During the Civil War, 11 percent of all “gunshot” wounds resulted in amputations. During World War I, less than 3 percent of “gunshot, shell, shrapnel and hand grenade” wounds resulted in amputations. 

In the years before World War I, American surgeons paid little attention to the “general principles of prosthesis.” Moreover, as Brackett, noted, the surgical methods of the battlefield that had been “found so necessary and advantageous in counteracting the dangers of infection required an entirely different character of after treatment from the customary amputation of civil life.” As a result, while the troops of the AEF were training in Europe, the Medical Department formed a “special amputation service” and started to train its own surgeons in what it called “this special type of work”.   The training took place at the bureau of artificial limbs of the American Red Cross in Paris and at facilities at amputation centers in England, Belgium, France, and Italy.  Special amputee services were established at base hospitals in Chateauroux and Savenay in France.

The amputation centers in France were unique because they provided not only the usual surgical services but also prosthetic services and the advanced physiotherapy that would be the hallmark of the Army’s Walter Reed Medical Center almost a century later. The centers incorporated lessons they had learned from the Belgian Medical Corps, which demonstrated the beneficial effects of early weight bearing in the treatment of lower-limb amputations. Through the good offices of the American Red Cross in Paris, simple prosthetic devises were designed and procured, which made it possible to get patients out of bed and walking without other support very shortly after amputation. The amputees were fitted with “provisional legs” with plaster of Paris sockets. With these temporary artificial legs, the men were put through stump drills to strengthen weak muscles and teach balance. Reconstruction aides administered massage and exercise to the bed cases. This was beneficial because it promoted healing, hastened stump shrinkage, prevented muscle atrophy, improved the patient’s morale, and decreased the time before the permanent artificial limb could be fitted.

Some British WWI Prostheses 

In one way, the Army was well equipped to handle what it expected to be an onslaught of amputations. The United States was the world leader in the production of artificial limbs because of the government’s program to provide them to Civil War veterans. In addition, a byproduct of the industrialization after the Civil War was a steady stream of industrial accidents and amputations. One supplier, the Winkley Artificial Limb Company, even had a standing contract with a railroad company to provide “adjustable slip socket legs,” noting that “a man can do double the amount of work upon a perfectly fitting leg”. When the United States entered World War I, the artificial limb industry had already been supporting increased demands from the Allies for artificial limbs, and the Army estimated that “the industry as a whole, with its existing equipment, could [still] produce a thousand limbs per month in addition to the number required for civilian needs”. Fortunately, that number was never needed.

Sources: Providing for the Casualties of War: The American Experience Through World War II,
Bernard Rostker, by the Rand Corporation for the Office of the Secretary of Defense; Illustrated First World War


  1. Fascinating, actually surprised by the number of amputations. I expected more. Great article.

  2. Interesting that the medical profession learned so much from the Civil War where the military leadership did not.

  3. The special amputee center at Chateauroux was staffed by Base Hospital #9, the New York Hospital unit. My father was on the surgical staff. The National Library of Medicine has an extensive collection of photos online of the reconstruction aids at work. Early weight bearing on temporary prostheses has had a rocky course in the past 100 years. I published work in 1970 supporting the immediate fitting of a prosthesis after amputation. Getting civilian surgeons to follow the technique had proven to be challenging.
    Bob Schrock

  4. Fascinating article -- thanks for pulling together and sharing this research.