During the American Civil War, gunshot wounds were the main cause of injury leading to amputation (75%), with the remainder of the injuries caused by artillery projectiles (fragments or grapeshot).^1,2 By World War I, artillery shell fragments were the most common cause of injury leading to amputation. Artillery and shell fragments were the major cause of injury during World War II, but Hampton³ noted that the prevalence of land mines contributed to the number of patients with limb loss in Italy.

Early in the American Civil War, amputations were recommended under the following conditions: crush injury, nerve or blood vessel injury, gunshot fracture with extensive comminution, a major open joint injury accompanied by a fracture, or extensive soft-tissue injury.^4,5 Surgery was recommended as soon as possible within the primary period of the first day, before the development of sepsis.

By 1863, as surgical techniques evolved and surgeons became more experienced, indications for amputation became more refined. Gunshot fractures of the femur were not always necessarily an indication for amputation. In 1863, Moses⁶ reported a 12.9% incidence of amputation associated with long-bone fractures for the battles near Chattanooga, Tennessee. Hodgen⁷ and Lidell⁸ reported good results in treating gunshot fractures of the lower limbs with Hodgen splints. Hodgen himself, who treated survivors of the long evacuation from the battlefield to a large hospital in St. Louis, Missouri, thought that amputation should be performed only for those patients who had injuries to joints, blood vessels, or nerves. Swinburne⁹ advocated amputation surgery for a partial or complete traumatic amputation, extensive soft-tissue injury associated with nerve or blood vessel injury and denuded bone, the loss of a major blood vessel, or compound fractures of the knee or ankle joint. Most gunshot fractures were managed nonsurgically during the Civil War, and a variety of splints were developed to treat patients with these fractures.^7,8

During World War I, the indications for surgery also changed. Speed,¹⁰ who was with the Base Hospital (Chicago Unit) in France in 1918, reported on 121 amputations. The indications for surgery were severe fractures, gas gangrene, sepsis, secondary hemorrhage, and trench foot. The most common level was transfemoral amputation (58.6%). Speed¹⁰ recommended an open circular amputation with longitudinal skin slits up the side of the residual limb.

Evacuation Hospital No. 8 reported 151 amputations in 4,714 battle injuries (3.2%) from September 13 to November 13, 1918. Of these, 62% were for gas gangrene, 33.7% for trauma, and 10.5% for sepsis. Again, transfemoral amputations were the most prevalent (39%).¹¹

By World War II, the indications for surgery were primarily for the direct effects of trauma, with a partial or complete traumatic amputation being the most common reason for amputation; completion of the amputation was the initial procedure performed. Major vascular repair had not yet been developed, and up to 20% of limb losses were caused by vascular injuries. Infection had declined as a major indication for surgery, possibly because of the widespread use of antibiotics.^3,12,13

Various amputation techniques were reported during the Civil War. The Army Medical Museum recorded 253,142 casualties in the Civil War; 20,559 patients (8.1%) had major limb amputations (those proximal to the wrist or the ankle). In this series, transfemoral amputation was the most common amputation level. The open circular (or flapless) technique was most commonly used. For transtibial amputations, flaps were used in 1,720 patients (58.8%), and the open circular technique was used in 1,206 patients (41.2%). The total overall mortality of these patients was 35.7%.¹⁴

During World War I, various techniques were attempted for amputation surgery. The United States officially declared war in 1917, but the Red Cross had been providing medical units to France since the beginning of the war in 1914. In 1918, a hospital center was established in Savenay, France, with Evacuation Hospital No. 8 as its core unit. An amputation service was established at that hospital to care for people with amputations who would be returning to the United States. The goals of this service were to provide skin traction, wound care, and physical therapy. A program of early ambulation with fitting of a temporary prosthesis, with a design based on the experience of Belgian physicians, also was instituted at Savenay, and approximately 20% of the returning personnel with amputations were initially fitted there.^11,15 Of the 550 individuals with amputations examined at Savenay, 58% were treated using the open circular technique, 30% using the flap technique with delayed primary closure, and 11% using primary or delayed primary closure alone.¹¹ Of the residual limbs that were closed, 25% needed to be reopened because of infection.

After patients were stabilized, they were evacuated to the United States. In the continental United States, five hospitals were designated as amputation centers to consolidate the resources of surgeons, prosthetists, physical therapists, and nurses. The team approach, which is currently used, had its origin at these specialty centers during World War I.¹⁶

Kirk,¹⁷ who became the US Army Surgeon General during World War II, wrote about his experiences in caring for personnel with amputations at two hospitals, where he treated approximately 1,700 patients. He advocated the open circular technique for war casualties for two reasons: (1) its simplicity and (2) preservation of the maximum residual limb length, both of which allowed wide drainage to manage infection and enabled earlier transport of the patient. Surgical procedures were staged, and definitive surgical closure was performed when the patient
was stable and in a stable environment. Kirk¹⁷ noted that at least 95% of the patients who arrived from overseas with open residual limbs needed additional care before prosthetic fitting. Most residual limbs were edematous and had unhealed areas. Other problems included bony protrusion and infection (most often from Streptococcus, Staphylococcus, Proteus, and Klebs-Löffler bacillus species).¹⁷

Early in World War II, military surgeons relearned the lessons from previous conflicts. Patients who did not have skin traction after open circular amputations experienced bony protrusion and needed reamputation, with the resultant loss of residual limb length. Amputations in which the skin had been closed were seldom successful because of infection. After the attack on Pearl Harbor, Hawaii, amputated limbs managed with delayed primary or primary closure became infected and required amputation at a higher level (LT Peterson, MD, unpublished data, 1946).

Early in World War I, because of his experience, Kirk was instrumental in developing policies to care for personnel with amputations. In 1942, the lack of success with early wound closure led Kirk¹⁸ (before becoming Surgeon General) to reemphasize the open circular amputation technique. The technique at this time was characterized by amputating at the lowest level of viable soft tissue, allowing the skin to retract, and successively cutting layers of muscle and bone more proximally to produce a concave residual limb. The open residual limb permitted wide drainage to prevent infection. Postoperatively, the patient was to be maintained in continuous skin traction to prevent the retraction of soft tissues. A repair or plastic closure of the residual limb was then performed for patients with an adherent scar. In a later article, Kirk and McKeever¹² emphasized that the open circular technique was a two-stage procedure that required a second surgery for wound closure.

There was no standardized prosthetic fitting or rehabilitation for Civil War soldiers with amputations. Minor¹⁹ recommended that the artificial limb should have the following characteristics: the same size and shape as the limb being replaced; constructed of light, strong, and durable materials; and “well fitting to the residual limb.” Minor¹⁹ thought that the Anglesey and Bly legs (patented in 1805 and 1858, respectively) were most appropriate because both had an ankle joint. Palmer legs (created by Benjamin Palmer in 1846), which had a solid ankle, also were popular. It is not known how many soldiers used prostheses because many people with lower limb amputations walked with ambulatory aids, such as crutches, rather than wearing a prosthesis. During the Civil War, Otis and Huntington¹⁴ reported that 40 to 60 patients with knee disarticulations were fitted for a prosthesis.

During World War I, several improvements were made in the care and prosthetic fitting of soldiers with limb loss. First, a program of early fitting with a plaster temporary prosthesis was tried in France.¹⁵ Wilson,¹⁵ who was in charge of the amputee service at Savenay where a limited program of early walking was instituted for people with lower limb amputations, believed that if the wound was clean, a patient could begin ambulating after 2 to 3 weeks. At this time, the patient was fitted with a temporary prosthesis consisting of a socket and a frame. The frame could be prefabricated and needed a minimum of fitting, and the socket was generally made from plaster of Paris and molded to relieve wound pressure. Wilson¹⁵ believed that early ambulation promoted wound healing, caused residual limb shrinkage, improved morale, and decreased the time to permanent prostheses. For upper limb amputations, body-powered grasping hooks were developed and used.^17,20,21

Before World War II, no national research program, either military or civilian, existed to investigate the quality of artificial limbs. Initially, the military believed that such a program was the responsibility of the Veterans Administration, which had long-term responsibility for personnel with amputations. However, the Veterans Administration procured nearly all its prostheses from commercial manufacturers and therefore lacked its own experienced prosthetists and engineers.

At the request of the US Surgeon General in February 1945, the National Research Council established a Committee on Artificial Limbs. Paul E. Klopsteg of Northwestern University in Evanston, Illinois, chaired the committee. The goals of the committee were to assist the Army, the Navy, and the government in procuring the best prostheses to meet the demands of World War II personnel.^22,23 In addition, the committee sponsored studies on the mechanical behavior of both normal and artificial limbs; studied existing prostheses; and directed research toward improving, simplifying, and standardizing artificial limbs as much as possible. This included investigating potential new materials to manufacture limbs, studying the art of limb fitting, and training the patient in its use. These studies and research resulted in improvements in upper limb prostheses, including improvements in the use of plastics; the testing of many different joints; and the use of rubber, fabric, and bonding methods that were recommended by the National Bureau of Standards.^22,23,24

At the University of California, basic research was conducted on gait and the use of muscles to power an upper limb prosthesis; the latter was known as a cineplastic operation. Lower limb studies focused on identifying the elements of normal gait, principles that are still in current use. This research, started during World War II, was ongoing for several years and led to substantial improvements in prostheses.^{22,23,24,25,26}