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Chapter IX

Contents

CHAPTER IX

Amputations

Throughout the 2 ½ years of land warfare in the Mediterranean Theater of Operations, the attitude toward amputation was one of extreme conservatism on the part of all medical officers in mobile medical units as well as fixed hospitals in rear areas. Because of the tremendous possibilities of modern reconstructive surgery, the operation was almost never performed unless the extremity was damaged beyond salvage or unless, after salvage had been attempted, conditions developed which endangered life or made further efforts to save the limb futile. Severe compound fractures of the heel bone and of the bones of the leg or thigh associated with extensive loss of bone were clearly extremely serious injuries, but they were not, in the absence of other indications, considered indications for amputation. United States practices of conservatism in such severely wounded lower extremities were in some contradistinction to the surgical policies practiced by medical officers of some of the other warring nations.

The theater policy for amputations was set forth explicitly in Circular Letter No. 46, 2 29 August 1944, Office of the Surgeon, North African Theater of Operations. This letter was merely the official statement of a policy which had been in effect for more than a year and the general principles of which had been established earlier in 1943. Details of technique were described in this circular letter, and it was emphasized that casualties who required amputation should be told before operation, whenever their condition permitted, why this procedure was necessary. It was also suggested that, as soon as the patient was surgically comfortable and mentally receptive, an interview with a psychiatrist or chaplain might be useful. These instructions were based on the fact that about 1 in every 5 patients could be expected to exhibit psychic reactions, often depressive in type, a few days after operation.

Particular attention was to be paid in this and other interviews to what the soldier might reasonably expect in the way of aid. He was to be told of the amputation centers which had been established in the Zone of Interior, the prosthetic appliances which were available, and the economic and other aid which he could be assured of receiving. Fortification of this kind before the patient became the target of sympathetic family and friends, the circular letter pointed out, might tip the scales in favor of rehabilitation, while its omission might result in lifelong disability and resentment.

1 The data in this chapter on amputations in United States Army casualties were collected by Maj. Benjamin W. Rawles, MC, 45th General Hospital. The data on amputations in German prisoners of war were collected by Maj. George S. Hopkins, MC, and Capt. C. R. Brott, MC, 2d Auxiliary surgical Team.
2 See appendix, pp. 326-331.


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FIGURE 81. – Destructive injury of entire left leg from land-mine explosion. Note how the foot has been driven halfway up the leg. An injury of this sort is a true traumatic amputation.

INDICATIONS

Amputations were performed either primarily or secondarily. The great majority (p. 269) were performed primarily, at initial wound surgery, and chiefly in forward hospitals.

Indications, which did not differ from the usual indications for amputation except from the standpoint of the degree of trauma, were as follows:
1.  Trauma at wounding (figs. 81, 82, and 83), in which the extremities were blasted off, blown off, torn off, or shot away. In such cases, the surgeon's function was merely revision of an amputation that had already occurred. Damage to the extremity of such a degree that future function was obviously hopeless also warranted amputation. In many cases of this kind, major blood vessels were interrupted, but vascular insufficiency per se was not considered the indication for amputation; the damage to the extremity, aside from vascular damage, was regarded as sufficient indication for the operation.

2.  Vascular insufficiency per se. In this type of case, the reason for amputation was the interruption of a major blood vessel, with resulting impending or actual gangrene. Amputation on this indication was usually performed in fixed hospitals, though in some cases it was a secondary operation in an evacuation hospital.


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FIGURE 82. – Bilateral traumatic amputations of legs resulting from land-mine explosion. Appearance of the injuries before initial wound surgery, which obviously can consist only of completion of the traumatic amputations.

3.  Infection. In this group of cases, amputation was necessary to control infectious processes, usually clostridial myositis, or was indicated because excision of tissue which had become necrotic had been so extensive that the extremity which was left was damaged beyond hope of function. Amputation on this indication was often undertaken to prevent loss of life.

4.  Disease, including malignant tumors, trenchfoot, thrombosis, tuberculosis, and other conditions. Amputation for these causes was uncommon in an overseas theater.

TECHNICAL CONSIDERATIONS

It was the official surgical policy in World War II that the open circular (so-called guillotine) amputation be employed routinely.3  This policy was set forth explicitly in Circular Letter No. 46, Office of the Surgeon, North African Theater of Operations, as already noted.

The technical details of the operation were fully described in this circular letter, the basic direction being that open circular amputation be used routinely and that it be performed at the lowest possible level of viable tissue. The only exceptions to the latter requirement were that proximal amputation

3Circular Letter No. 91, Office of the Surgeon General, U. S Army, 26 Apr. 1943, subject: Amputations.


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FIGURE 83. – Bilateral injuries of lower extremities resulting from land-mine explosion. On the left side, there has been a traumatic amputation through the thigh. On the right side, damage to the thigh and leg is so extensive that only primary amputation is possible.  A. Appearance of injuries before initial wound surgery.  B. Appearance of injuries after initial wound surgery. The right lower extremity has been amputated through the middle third of the thigh by the open circular technique. The stump of the left thigh has been shaped so as to present a similar circular stump.


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might be performed in preference to disarticulation and that such modifications as good judgment dictated were permitted in amputations of the upper extremity.

In practice, amputation at the lowest level of viable tissue not infrequently came into technical conflict with amputation by the open circular technique (fig. 84). These recommendations, in practice, could be applied concurrently only in cases in which the saw line was determined by the level of viability of soft tissue. This was generally true in amputations performed on the indication of vascular insufficiency, as well as in some amputations for clostridial myositis. When trauma was the indication, as it was in the great majority of amputations, especially those performed in forward areas, the extensive compound fractures present almost invariably determined the level of the saw line. Only in the very occasional case was it found expedient to amputate through a long bone which was the site of a proximal fracture. Some viable muscle and skin were, as a rule, present below the level of the fracture or fractures that determined the saw line, and the use of the circular technique necessarily meant their sacrifice. In such cases, therefore, amputations were not performed at the lowest level of viable tissue.

It was not easy, in some instances, to ascertain the true lowest level of viable tissue. This was well expressed in the report of an orthopedic team attached to the 2d Auxiliary Surgical Group, which pointed out that “where to amputate” sounded simple when it was followed by the statement “at the lowest possible level.” In extremities that had been blasted off or undergone extremely severe trauma, the report continued, muscle tissue might be found damaged for a distance of several inches above the site of the wound, and selection of the amputation site might be a matter of considerable difficulty. Often the muscle varied in color from deep red to purple and was congested, swollen, and noncontractile while its blood supply was apparently adequate. In most such cases, it was the policy not to select the higher level of undamaged and clean tissue for the amputation site but to choose, instead, the lower level, where there was no doubt that the muscle, while damaged, was still viable. The risk involved in this policy was overcome by watching the patient very carefully for signs of further necrosis or of the development of clostridial myositis.

That these and other problems were usually solved with discretion and judgment is shown by the infrequency of reamputations in the Mediterranean theater (fig. 85). The conservative attitude expressed in the report just cited was theaterwide, and it is doubtful that any appreciable number of amputations were done at an unnecessarily high level.


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FIGURE 84. – Traumatic amputation of right leg, multiple penetrating wounds of left leg, caused by high-explosive shell fragments.  A. Appearance of wounds in evacuation hospital after removal of emergency splinting and dressings.  B. Appearance of wounds after preparation for initial surgery. Note large posterior flap of apparently viable skin on right leg. The tibia is completely fractured in the mid third.  C. Appearance of stump of right leg after amputation by prescribed open circular technique, with sacrifice of flap of skin seen in view B. The level of amputation approaches the critical level at the junction of the upper and middle thirds of the leg. The salvage of the presumably viable flap of skin might have permitted delayed wound closure and avoided a later undesirable reamputation at a higher level in a Zone of Interior hospital.


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FIGURE 85.- Amputation stump of left forearm, at junction of upper and middle thirds. The severe compound fracture of the lower end of the humerus, associated with the loss of soft tissue, was considered an indication for reamputation just below the middle of the upper arm.

The required technique of circular amputation was as follows:

*   *   * A circular incision is made through the skin at the lowest level compatible with viable tissue and the skin is allowed to retract; the fascia is then incised at the level to which the skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and permitted to retract. At its point of retraction, the deep layers of muscle are cut through to the bone. After the deep muscles have retracted the periosteum of the bone is cleanly incised and the bone sawed through flush with the muscles. No cuff of periosteum is removed as in a closed amputation. Bone denuded of periosteum will sequestrate if infection is present and a ring sequestrum often results when the periosteum has been removed. It is important also that no periosteum be elevated or torn from the bone in the stump by rough handling.

The standard technique for the open circular type of amputation was followed in the theater (fig. 86). Early in the war, some surgeons were inclined to use the so-called meat-cleaver method, but this error was corrected by educational endeavors to demonstrate the proper inverted-cone stump. As experience increased, this error disappeared.

Circular Letter No. 46 directed that the end of the stump be dressed with fine-mesh gauze, so applied that the gauze did not overlap the skin edges. Skin traction was then applied immediately (fig. 87) either by a stockinet cuff attached with ace adherent or by adhesive tape. Traction was best obtained by a light plaster cast with a wire ladder banjo (fig. 88). The cast


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FIGURE 86 – Technique of open circular amputation.  A. Severe injury in region of right ankle, with established infection, for which secondary amputation was performed in a fixed hospital. Note destruction of heel.  B. Lateral view of circular incision through skin, which has retracted. C. Medial view of incision of fascia and muscles at level to which skin has retracted in view B.  D. Incision of periosteum, sawing of tibia, at level to which muscles have retracted in view C. E. Lateral view of section of fibula with Gigli saw at level slightly proximal to stump of tibia. In the open circular technique, no particular effort is made to section the fibula ¾  to 1 inch above the end of the tibia, as is done at definitive reamputation or revision of the stump. F . Open concave circular stump at completion of amputation.  G. Stockinet applied in fixed hospital after dressing of open circular stump. H. Skin traction provided by means of weight attached to rope which passes over pulley and extends from stockinet attached to skin; lower extremity rests on half-ring leg splint. This is the most effective means of traction on the skin following open circular amputation.


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FIGURE 87. – Steps in application of skin traction after amputation of leg.

always incorporated the joint above the amputation; a spica, for instance, would be used after a thigh amputation. Alternatively, if an Army half-ring splint was used in amputations of the lower leg, a posterior plaster-of-paris splint was provided from the mid thigh to beyond the stump, to prevent flexion contracture of the knee. The plasma tubing formerly employed was generally replaced by the elastic cord provided for this purpose in 1944 (fig.89).

Reparative surgery. – Circular Letter No. 46 directed that all amputations in the thigh and all in the leg at or near the site of election should be treated by continuous skin traction after the patient reached a general hospital. Secondary suture or skin grafting of the terminal defect, with or without revision, was forbidden. It was recommended that the cast or splint be removed in the fixed hospital and that 6 to 10 pounds of traction be maintained over a pulley at the foot of the bed. Traction was to be continued for at least 6 weeks, until all layers of soft tissue had been firmly fixed by scar formation.

Traction during evacuation to the Zone of Interior, for which amputees were given priority by air as soon as they became transportable, was provided by stockinet and a banjo plaster.

Closure of wounds in the lower third of the leg, which was well below the site of election, and in the upper extremity was permitted by secondary suture in general hospitals provided that the wound was clean and the operation was done under penicillin protection. If closure was not feasible, skin traction was maintained.

When the reparative-surgery program proved successful in the Mediterranean theater, it was natural that enthusiasm for it should lead to an extension of its principles to the amputation stump. The application of these principles in the management of compound fractures had amply demonstrated that closure of muscles and other soft parts over exposed bones prevented the access of organisms to the deeper tissues and fracture site, reduced scar formation, and simplified as well as shortened the period of healing (figs. 90, 91, 92, 93, 94, 95, and 96). In deference to the recommendations of The Surgeon General and the judgment of surgeons at the amputation centers in the Zone of Interior, an extensive clinical trial of reparative surgery as applied to circular flaps was


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FIGURE 88 – Use of plaster cast incorporating banjo made of wire ladder splint or steel rod, to which elastic traction is provided from stockinet fixed to skin. A and B. Upper extremity. C and D. Lower extremity.

not undertaken. Delayed closure was strictly forbidden in Circular Letter No. 46 in amputations of the thigh and of the leg unless it could be carried out well below the site of election. In amputations of the lower third of the leg arid of the upper extremity, closure by suture was permitted whenever it was surgically feasible. As a matter of fact, as already mentioned, modifications of technique were permitted in all amputations of the upper extremity in order to secure early closure.

The number of cases in which the reparative-surgery program was applied in amputations was far too small to permit any conclusions concerning results. The data from three general hospitals, however, are recorded, for this small group of cases, all handled in 1944, might serve as a reference point should the problem arise in another war.

At the first hospital, 77 of 338 casualties with major amputations (22.7 percent) were submitted to suture of the stump before evacuation to the Zone


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FIGURE 89 – Traumatic amputation of right leg, compound fracture of both bones of left leg, caused by land-mine explosion. A. Appearance of wounds in evacuation hospital.  B. Anteroposterior roentgenograms of both legs before initial surgery.  C. Transportation splinting after initial surgery, which included completion of the traumatic amputation of the right lower extremity by the open circular technique. After the ace adherent used to fix the stockinet to the skin has dried, elastic traction to the wire ladder splint will be provided.

of Interior. Twenty-one of the stumps were covered by skin grafts after fixation of the tissues had been obtained and skin traction was no longer effective. Healing was regarded as satisfactory in all of these cases.

At the second hospital, 39 of 251 amputation stumps (15.5 percent) were sutured, 18 before the 12th day after wounding and 21 after that time. Wound healing was regarded as satisfactory in all of these cases.

At the third hospital, delayed primary suture or skin grafting was carried out in 63 of 129 major amputations (49 percent). The results are unknown in 28 of the 63 cases. In 29 of the other 35 cases, healing was known to be complete; 27 of the 35 were managed by delayed primary suture. It should be understood that failure of healing in the remaining six eases did not imply infection but merely that granulating areas, most of which were inconsequential, were present. The hospital records were incomplete in the 28 cases in which


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FIGURE 90 – Open circular amputation through middle third of forearm.  A. Appearance of stump 7 days later.  Note that sufficient skin is available to justify closure by suture.  B. Appearance of stump after easy closure of skin over stump by interrupted vertical mattresses sutures.  Note absence of tension on suture line.  C. Provision of elastic skin traction, as additional safeguard against tension after suture closure of stump.  
the results are listed as unknown, but such data as could be secured suggested that healing was also likely to be satisfactory in most of this group.

Whenever the stump was closed, skin traction was maintained for 7 to 10 days after amputation, in order to reduce tension on the suture line.

An important point about the cases just discussed and about the other cases in the theater in which delayed primary suture was employed is that there was no known fatality in any of the series. No instance of clostridial myositis or other serious infection was reported, and there was no reported reamputation.

Even though the end results are unknown in so many of the cases in which reparative surgery was employed, the facts which have just been stated are


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FIGURE 91. –  Healed stumps 3½ weeks after amputation by open circular technique. Both patients had sufficient skin available for closure of the wound at reparative surgery 6 days later.

significant. The good results and, more important, the absence of fatalities and of invasive infections, were accomplished under a definite handicap, that the stump after a circular amputation is not plastically adapted to early closure of the skin and soft tissues by suture. For a fair test of the program, it. would have been necessary to preserve normal skin, in the form of short flaps, when the initial operation was performed. This was not permitted. Moreover, as already mentioned, the specified technique of amputation not infrequently required the deliberate sacrifice of normal skin extending below the level of the saw line which had been determined by trauma to the bone.

For these reasons, many surgeons in the Mediterranean theatre were of the opinion that the directive for routine amputation by the open circular technique might well have been somewhat modified. There was no desire to shorten the bone in order to permit the fashioning of flaps. It was merely desired to preserve as flaps all viable skin and soft parts, to facilitate early staged repair without tension.

Traction during evacuation. – Early in the war, the skin traction secured with adhesive tape and the Army half-ring or full-ring hinged splint proved unsatisfactory for transportation. Universal adoption of the banjo traction cast., with stockinet and skin adherent (p.25), greatly improved the situation. Traction was examined just before the casualty was evacuated and was reapplied if necessary. The apparatus also had to be checked at regular intervals during the course of transportation and readjusted if it became displaced. Priority air evacuation to the Zone of Interior was provided for amputees as soon as they became transportable.


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FIGURE 92. – Closure of amputation stumps. The 2 soldiers whose 4 amputated lower extremities are shown in these illustrations sustained their injuries at the same time, from the same shell, while they were in the same foxhole.  A. Appearance of granulating stump of upper third of left leg 5 weeks after amputation. Skin traction had been maintained since operation.  B. Healed stump of mid third of right leg in same patient shown 5 weeks after amputation and about 2 weeks after suture.  C. Healed stump of upper third of left leg in second patient 1 month after suture.  D. Healed stump of right thigh in same patient 1 month after suture.  E. Stumps of same patient after revision and conditioning for prostheses in amputation center in Zone of Interior.  F. Rehabilitated patient shown in views C, D, and E after fitting of prostheses .


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FIGURE 93. – Closure of amputation stump.  A. Closed stump of thigh 6 days after amputation by open circular technique and application of skin traction.  B. Completely healed stump 26 days after closure.

Revision of the stump. – It is known that revision of the amputation stump was necessary in the Zone of Interior in 95 percent or more of all amputations. Whether a wider use of closure of the stump by reparative surgery would have reduced this proportion substantially is a matter of speculation. A reduction of any consequence might not have been achieved. Revision of the stump before the fitting of the prosthesis might still have been desirable. The objective of overseas surgery, to accomplish a healed wound before evacuation of the patient to the Zone of Interior, would, however, have been achieved to a greater degree than was accomplished under the directives in effect.


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FIGURE 94. – Closure of amputation stump.  A. Appearance of stump of right leg after amputation just below the middle. The stump had been in traction for 4 weeks. B. Appearance of stump 16 days after closure by suture. Note that healing was complete except for two small granulating areas. There was no sinus formation .

It seemed likely that there would be relative technical advantages at the revision operation if the defects bad been completely healed for several weeks; if scar formation was negligible; if infection was absent; and if skin was ample, in comparison with revision when the scar was firm and when granulation areas were present. The crucial test would have been in revision of amputations at critical levels in the lower femur and upper tibia, when further sacrifice of bone length was undesirable but would have been unavoidable if the end of the stump was covered with scar tissue and if normal skin was not available.

ANALYSIS OF CASES

The data discussed in the next several pages are derived from the following sources:

1.  Two hundred and eighty-three major amputations performed on 271 United States Army casualties in 1943, and 1,096 major amputations performed on 1,000 United States Army casualties in 1944-45, a total of 1,379 amputations performed upon 1,271 casualties.

These cases were secured, without selection, from the proceedings of hospital disposition boards for the years in question. Since disposition boards are created only in fixed hospitals, it is obvious that the cases concern only those amputees who had survived the shock of wounding and who had recovered sufficiently to become transportable to the rear. There were no fatalities in


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FIGURE 95. – Amputation by open-flap technique, with closure of flaps without tension 6 days later, at reparative surgery. Appearance of stump showing complete healing 23 days after wounding.

either the 1943 or the 1944-45 series. Deaths of amputees in fixed hospitals were infrequent, and fatal cases did not reach disposition boards.

2.  After captured German military hospitals came under control of the Surgeon, Fifth U.S. Army, at the end of hostilities in the Mediterranean theater in 1945, 1,389 major amputations were performed on 1,332 German prisoners. As soon thereafter as practical, all prisoners of war who required medical care were collected in a large hospital center previously established by German forces in Merano, Italy. The maximum enemy patient census during the period of United States Army responsibility for medical care was in the neighborhood of 20,000.

The statistics analyzed do not include amputations of the hand distal to the wrist joint or amputations of the foot distal to the junction of the middle and distal thirds of the metatarsal bones. Disarticulations at the ankle, knee, wrist, and elbow were tabulated as proximal amputations, while disarticulations at the shoulder were tabulated as amputations of the upper arm. As in all collected series, many items are lacking in many cases, particularly in the prisoner-of-war series and, to a lesser extent, in the series from 1943 disposition-board proceedings.

Site of amputation. – The site of amputation in both United States and German casualties was usually the lower extremity (tables 28 and 29). The large number of amputations of the lower extremity among United States troops in 1944-45 is to be explained by the increasing use of land mines by the enemy as they retreated up the Italian peninsula in the last year of the war. In the 1943 series (table 30), land mines accounted for about 15 percent of all amputations, while in 1944-45 they accounted for almost 36 percent.


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FIGURE 96. – Amputation through leg near site of election, with preservation of long posterior viable flap of skin. Seven days after amputation, the flap was sutured to the anterior skin margin. Healed stump 24 days after wounding.

This same explanation may hold for the slightly higher proportion of lower-extremity amputations in United States as compared with German troops. The land mines which the Germans used so extensively as defensive weapons often played havoc with United States troops, but some Germans were also injured in their own minefields (table 31).

The 1,096 amputations performed on 1,000 United States soldiers in 1944-45 represented 927 amputations of single limbs, 84.6 percent of the total number. There were 73 double amputations (146 limbs) and 23 second-level amputations (reamputations). In the German series of 1,389 amputations, there were only 57 double amputations (114 limbs), representing 4.1 percent of the total number. In addition, one German soldier suffered the loss of three limbs; both forearms had to be amputated, and one leg was amputated at the thigh. There was no similar instance in the United States Army series, and there were no quadruple amputations in either series.

Numerous other serious injuries complicated the wounds for which amputation was required in the 1944-45 United States Army series (table 32). The majority of injuries, fortunately, were limited to the skeletal system and could be treated by ordinary methods of fracture management. In 12 instances, the additional fracture was in the same extremity as that in which amputation was necessary. Comparable data were not available for the 1943 United States Army series or for the prisoner-of-war series.

Causative agents. – There were only 5 amputations for disease in the combined United States Army series (table 30), 2 of them in the same patient, for trenchfoot. This is about what would be expected, since soldiers with


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TABLE 28 – Sites of amputation in 1,379 separate operations on United States Army troops


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TABLE 29. – Sites of amputation in 1,389 separate operations on German prisoners of war

recognized diseases are not sent into a combat zone. There were 29 amputations for disease in the German prisoner-of-war series (table 31). No details concerning these operations were available.

In both the United States Army and the German series, the great majority of amputations were performed for trauma, and most of the trauma was battle incurred (tables 30, 31, and 33). Although the number of United States Army troops in the theater was smaller in 1943 than in 1944-45, the proportion of accidental injuries was larger (table 30), a fact which can be explained in two ways: In North Africa, where most of the early fighting occurred, supply lines were long, and extensive travel by train and motor vehicle was necessary. This was also a period of extensive training for combat, and the number of soldiers injured by accidental explosions of live ammunition might be expected to be greater than in a period of more active combat.


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TABLE 30 –  Agents of wounding and causes of amputation in 1,271 United States Army troops  

The explanation of the slightly larger proportion of amputations caused by shell fragments and similar agents in the German prisoner-of-war series, than in the United States Army series, is probably heavier United States Army fire. The effect of land mines has already been mentioned. The larger proportion of injuries from small-arms fire in German prisoners of war is perhaps to be explained by the strafing from United States planes which the German troops suffered while they were retreating in the last months of the war.

Except for the category of trauma, all these groups are small, and the statistical differences are not significant. On the other hand, personal observa-


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tions indicate that most of the explanations which have just been advanced are valid.

Indications. – When the indications for which individual amputations were performed are considered (tables 33, 34, and 35), certain differences between German and United States surgical practices suggest themselves.  To consider only the operations for which indications are known in the United States Army series (table 33), 1,027 amputations--more than three-quarters of the total number--were performed for trauma, both combat connected and accidental. In the German prisoner-of-war series (table 35), the corresponding figure was 874 operations, not quite two-thirds of the total number. In the United States Army series, 195 operations (14.5 percent) were performed for

TABLE 31. – Agents of wounding and causes of amputation in 1,332 German prisoners of war 1

TABLE 32. – Complicating injuries in 1,000 United States Army amputees, 1944-45


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TABLE 33. – Indications for amputation in 1,344 of the 1,379 operations following wounds or injuries in United States Army troops 1

TABLE 34. – Indications for 843 primary and 243 secondary amputations in United States Army troops, 1944-45 1

vascular insufficiency. In the German series, the number of operations performed for this reason was 82, not quite 6 percent. The differences in the proportions of cases performed on the indication of infection is striking. In the United States Army series, 122 operations, about 9 percent, were performed on this indication; in 86 instances the infection was clostridial myositis. In the German prisoner-of-war series, 403 operations, almost 30 percent of the total number, were performed for infection. All 86 primary operations performed on the indication of infection were for clostridial myositis.


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TABLE 35 – Indications for 962 primary and 427 secondary amputations in German prisoners of war

It should be pointed out again that vascular insufficiency was considered to be the indication for amputation in primary operations when the records indicated that the limb would have survived if the blood supply had not been interrupted. This group of operations, therefore, includes all instances of gangrene, including wet gangrene with superimposed infection, and all instances of infection in which the infection followed the interruption of a major artery.

In the United States Army series, the proportions of amputations done on various indications changed in the following manner as the war progressed:

In 1943, trauma of all kinds was responsible for 174 amputations, slightly under two-thirds of the total number of operations (283) (tables 28 and 33). In 1944-45 the proportion had risen to more than three-quarters (853 of 1,096 operations) (tables 28 and 33).

In 1943, injury to a major artery was responsible for just over 19 percent of all amputations (54 of 283) (tables 28 and 33). In 1944-45, the proportion was 12.9 percent (141 of 1,096 operations) (tables 28 and 33.)

Infection was responsible for about the same proportion of amputations in both series, 9.2 percent (26 of 283 operations) (tables 28 and 33) in 1943, and 8.8 percent (96 of 1,096 operations) in 1944-45 (tables 28 and 33).

The increasing proportion of amputations in which trauma was the indication and the decreasing proportion in which vascular insufficiency was the indication may fairly be assumed to reflect the better judgment and increased skill of United States Army surgeons as their experience increased. With increased experience in the management of vascular injuries, the limb was undoubtedly saved in some of the later cases in which, if they had been observed earlier, amputation would have been performed. The decrease in this category of indications may also be attributed to better control of infectious processes after initial surgery became more competent, penicillin had become available, and the practice of liberal blood replacement had become general.


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One not too speculative explanation for the disproportionately large number of amputations for infection in the German prisoner-of-war series is that the quality of United States Army medical care was better. An extremely important part of the explanation is that all of these German wounded were managed under the adverse conditions of wholesale retreat and surrender, when medical care can never be on a high professional level.

Timing. – More than three-quarters of the United States Army casualties who required amputations were operated on primarily, with trauma as the chief indication (table 34). Trauma was also the principal reason for about 20 percent of the secondary operations (44). In almost two-thirds of the secondary amputations for infection, the indication was clostridial myositis.

In the German series (table 35) the proportion of casualties operated on primarily was somewhat less than in the United States Army series (table 34), and the proportion of cases in which infection was the indication for immediate amputation was considerably larger. In the cases in which secondary amputation was performed, infection was responsible for a considerably larger proportion of cases than vascular insufficiency, which is the reverse of the situation in the United States Army series.

Multiple amputations.  – In the 85 multiple amputations in the combined United States Army series (table 36), there are 8 separate combinations of operation. In 74 cases, however, the amputations were both on the lower limbs, and in all but 2 of the remaining cases one of the amputations was also on a lower limb.

TABLE 36. – Combinations of levels in 85 multiple amputations in United States Army casualties

Primary amputations were performed on the indication of trauma in 147 of the 170 limbs, and 6 limbs were removed secondarily for the same reason. One amputation was done primarily for clostridial myositis, and seven of the secondary operations were done for this cause. All of the remaining operations were performed secondarily, 3 for other varieties of infection, 4 for gangrene following trenchfoot, and the other 2 for vascular insufficiency.


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In the German prisoner-of-war series, the indications for the 114 multiple amputations were trauma in 68 limbs, infection in 28, and vascular insufficiency in 7. The causes in the remaining 11 operations are unknown.

Seventy-six of the eighty-five double amputations in the United States Army series (90 percent) were required by combat-incurred trauma, shell fragments and land mines being responsible in all but one case. The comparable figures for the German series of multiple amputations are 54 cases (94.7 percent) with shell fragments (30) and land mines (22) responsible for all but 2 of the cases.

Reamputation. – Reamputation was necessary at a higher level in only 23 of the 1,096 amputations performed in United States Army hospitals in 1944—45. All but two were on the lower extremity. The majority of the secondary operations were for infection (16), chiefly clostridial myositis (13), which was usually superimposed upon the trauma for which the first amputation had been done. The original trauma had been caused by mines in 15 cases and by shell fragments in 7. In the remaining case the trauma was accidental.

Details on reamputations are not available in the 1943 United States series nor in the prisoner-of-war series.