Wednesday, May 22, 2013

Could Lincoln have survived his gunshot wound today? A comparison with Representative Gabrielle Giffords assassination attempt

One oft-heard speculation regarding the President Lincoln’s assassination goes something like this: “We have such better medical care now! Lincoln would’ve definitely survived…wouldn’t he?” Just type “would Lincoln have survived today” in any search queue and you will find yourself awash in forums discussing the differences in firepower between now and the 1860’s, myths about Lincoln’s doctors, and assertions that trauma care is so advanced, that Lincoln would have survived and resumed official duties if he had been shot with the same caliber weapon today. Faced with these opinions, tried to use the medical evidence to get to the bottom of this conundrum.

In order to better illustrate what trauma care looks like today, I will use the 2011 shooting of Representative Gabrielle Giffords (D-AZ) as a case study. In the 911 call made just after the shooter fled, those at the scene (some of them doctors) stated that Representative Giffords “had been hit” but that she was breathing and conscious. First responders were at the scene within five minutes, and all victims were quickly evacuated. While medical records are not available to the public, one can assume that Rep. Giffords received standard pre-hospital care, which involves assessment of the airway, respiration, and circulation. She was immediately taken to the University Medical Center in Tucson where Dr. Randall Friese performed the initial evaluation. This is where the story dramatically diverges from Lincoln’s. Rep. Giffords was conscious, could respond to simple commands such as “squeeze my hand,” “hold up two fingers,” and “wiggle your toes,” and could open her eyes spontaneously. All of these signs pointed to the fact that her injury was markedly less severe than President Lincoln’s.

One of the major predictors of recovery from traumatic brain injury is a high score on the Glasgow Coma Scale. This scale measures motor response, ability to open the eyes, and verbal response to quantify consciousness after head trauma. Unlike Rep. Giffords, we have no record of the President’s precise responses. However, the physician who initially evaluated him reported that he was unconscious, with his eyes closed, his breathing intermittent and raspy, and his pulse undetectable. This presentation would lead to a very low score on the Glasgow scale, which is indicative of worse prognosis and higher mortality. Even though his doctors were not trained in modern resuscitation techniques, the fact that the President responded so poorly to stimuli after his injury reveals that he had a slim chance of recovery even in light of medical advances.

Once in hospital, Rep. Giffords underwent a decompressive craniectomy to reduce her intracranial pressure and thus lessen her chances of cerebral herniation. Over the next few weeks, she had further surgeries to fix her shattered eye socket and remove pieces of bone that the bullet had displaced into her brain. She was also put into an induced coma in order to spare her brain from the overwhelming metabolic demands associated with central nervous system injury. The congresswoman was eventually discharged to a rehabilitation facility to undergo intense therapy in the hope that she could regain some of her lost motor and speech abilities. Had Lincoln been shot today, he would most certainly have received the same level of surgical and hospital care.

Another key difference between Rep. Giffords injury and the President’s is that the trajectory of the bullet, as well his symptoms, are disputed within the primary literature. Dr. Leale, the first on the scene, reported that “…the pupil of that eye [Left] was slightly dilated, and the right pupil was contracted; both were irresponsive to light.” However, one of the other physicians on the scene, Dr. Taft, reported the exact opposite. Additionally, the autopsy reports are unclear on where the bullet finally lodged in the President’s brain. Did it stop posterior to the left eye or did it cross the midline and come to rest posterior to the right eye? Doctors present for Lincoln’s autopsy testified to both trajectories. How can we, nearly 150 years after his death, reconcile these stark discrepancies? The fact is we can’t. With testimony from physicians on the scene differing so much about such a crucial fact, we cannot know how the bullet traveled through Lincoln’s brain. This is one of the essential pieces of information that would allow us to judge whether or not the President could have survived the same injury if presented with current medical care. Dr. Blaine Houmes, an ED physician and Lincoln expert, stated that, “…if you only read one or two of the reports, in theory Lincoln could have survived, particularly today with our medical care. But if you read all the others, there's no way he could have survived, due to the severity of the injury.”

Of those who have attempted to speculate on his potential survival, opinions are split. Nearly all investigators agree that his wound was just too severe for him to have survived in any circumstance. Dr. Houmes explains that, “Today if you treat someone with an injury like Lincoln had, despite all of our advances, despite all of our equipment, despite all the drugs we're able to give, and the procedures available, if you look in the medical literature, the fatality rate is still 100 percent.” In contrast, Dr. Thomas Scalea, of the University of Maryland’s R. Adams Cowley Shock Trauma Center, believes that it would not be out of the ordinary to see people with gunshot wounds like Lincoln’s who survive. “We probably see a dozen gunshot wounds to the head each year where people survive. He had a non-fatal injury by 2007 standards.” This assertion, based on the idea that the bullet stayed on the left side of Lincoln’s brain instead of crossing to the right, makes sense. Even though the number of people who survive such an injury is not high, it is not inconceivable that he would have survived. However, if the bullet crossed the midline and entered the right half of his brain, as Dr. Houmes believes, then his survival would be much less likely.

Retrospective diagnosis or prognosis presents many challenges, including source credibility and agreement. Additionally, it is difficult to interpret medical terminology used in the past, since it isn’t often standardized and very easily could mean something totally different than it does today. Ultimately, we will never know if Abraham Lincoln could have survived his injuries today, and what that would have meant for the country. All we can do is wonder, and see how alternate history buffs tell the story the way it might have happened.

Tuesday, May 21, 2013

The Overlooked Prosthesis: The Use of the Artificial Eye and Orbital Reconstruction during the Civil War

When presented with the notion of Civil War medicine, the minds of most individuals will conjure images of the tireless battlefield surgeon, hurriedly moving between dozens of wounded young men, with neither enough time nor scientific understanding to clean himself or instruments of the blood from his previous patient. While it is argued that the surgeons of the Civil War do not necessarily deserve the reputation of “butchers” that society has seemed to bestow upon them, their lack surgical experience combined with utterly traumatic wounds and the sheer magnitude of patients did cause these physicians to turn to amputation as the primary means of treating wartime injuries. During the course of the war, 70% of the gunshot wounds would be on the extremities, leading to over 60,000 amputations between 1861 and 1865. This never before seen proliferation of amputees would drive the production of prosthetic limbs and eventually lead to the manifestation of the prosthesis industry in America. While much historical literature focuses on the sectors of this industry concerning prosthetic limbs, one aspect of Civil War prosthetics often overlooked is the use of the artificial eye. This however, is unsurprising, as only 49 prosthetic eyes were furnished to soldiers between July 16, 1862 and May 4, 1867, compared to 2,391 arms and 4,095 legs. However, despite the small proportion of prosthetic eyes that were issued to wounded soldiers relative to limbs, the methods of reconstructive and prosthetic work done with regard to orbital injuries during the Civil War were nonetheless monumental and are still reflected in modern ophthalmology.

In the 16th century, French surgeon Ambrose Paré was the first to describe the use of artificial eyes. His descriptions included pieces made to fit in the eye socket, made of silver and gold. Two types of ocular prosthesis he described were ekblphara, worn in front of the eye lids, and hypoblephara, worn under the eyelids. Because enucleation would not become a common ophthalmic procedure until the 19th century, the hypoblephara was typically used over the dysfunctional eye. During this time enamel prostheses were also used. However, despite being aesthetically pleasing, they were not very durable and very expensive. Consequently, German craftsmen in the 1830s developed a prosthetic eye made of cryolite glass that was of a greyish-white color, similar in color to a healthy eye. In Germany and France, the class art technique would soon bloom and these German craftsmen would eventually be coined “ocularists”. These artisans soon toured, among other parts of the world, American cities to fit and fabricate eyes upon request to patients in need of ocular prosthesis. In the United States, it was not uncommon for the newly termed “eye-doctor” to keep drawers full of hundreds of premade eyes, ready to be fit to their patients.

Upon the dawning of the American Civil War, eye hospitals and formal ophthalmic societies in the United States were only beginning to form. Consequently, very few physicians who served during the war had any formal training in ophthalmology. Before 1860, the enucleation procedure was paired with a very high mortality rate and was not yet perfected. Those who did have formal training were typically practicing in major cities or were operating away from the field hospitals, far from where their expertise was desperately needed. During battle, the eyes of soldiers were exceptionally vulnerable to shrapnel, debris, and injury from small arms fire. Also, because of the explosiveness of the Minié ball, those soldiers struck in eyeball by small arms fire nearly always experienced eyelid, orbit, and other secondary facial injuries.

Though specialized ophthalmic treatments existed, such as cataract removal, irodotomy, compression, and mercury ointments, poor equipment and a lack of ophthalmologic knowledge made it extremely rare for a soldier to be given such treatment. Instead, enucleation would become the most common ophthalmic surgical procedure for injuries to the globe or orbit. Physicians believed that even if the eye did heal correctly, it would eventually deteriorate and the other eye would be exposed the damaged eye’s pathology, thus inclining many physicians to enucleate. Of the 1,190 soldiers reported with isolated eye injuries, the loss of one eye characterized two-thirds of these cases. However, despite the large proportion of enucleation, only 5% of the soldiers with eye injuries lost sight in both eyes or died from their wounds, a statistic that brings great credit to the wartime physicians, especially considering the conditions under which they served and the lack of formal training.

Because of the disparity between limb injuries and eye injuries, the refinement of ocular prosthetics and surgery progressed at a much slower rate than that for amputees. The frequency of eye injuries was so much less than injury to the extremities that need to restore mobility in these veterans vastly overshadowed the need to repair a damaged eye or orbit. Many soldiers would simply wear patches overtheir damaged eye for several reasons. Patches were much more inexpensive than ocular prosthesis, there was a scarcity of glass eyes, and for some, their patch served as a badge of honor, a symbol of their service and sacrifice. Additionally, the destruction of the orbit was often so extensive that it was either inadvisable or impossible to find an artificial eye that would fit properly.

While evolution of ocularistry was slow, some reconstructions did occur which would mark the beginnings of eye and orbital plastic and reconstructive surgeries. For those who underwent orbit reconstruction, materials such as glass, gold, wool, silver, rubber, bone, or aluminum were used. In addition to the French and German-made lead or glass prosthesis, charred human bone was a particularly favorite implant material. Because the bone was charred, the fire had sterilized the material. Additionally, the canals within the bone allowed for the growth of living tissue into the implant, eliminated air pockets and the reducing the possibility of bacterial infiltration. Such materials were used until the 1930s when they were replaced by such materials as sterilized coral and such synthetic materials as plastic and aluminum.

An often overlooked topic within Civil War medicine, the use of ocular prosthesis and orbital reconstruction is nonetheless an area of considerable importance with its regard to its connection to modern day patient care. The topic also brings necessary undue credit to the battlefield physicians who labored under unimaginable conditions and possessed little knowledge of the field of ophthalmology yet were still able to prevent significant mortality among their patients with eye injuries. Current methods of reconstruction and prostheses use can trace its beginnings to the heroics and innovation of these physicians. The Civil War would prove to be a pivotal time in American medicine, and the field of ophthalmology would be no exception.

Forged Under Fire: The History and Future of the American Prosthetics Industry

The American Civil War was a conflict that occupied a very unique time in history.  Occurring at the tail-end of the industrial revolution, the 1860’s in America were a time of great progress, but also a time of great disparity.  While industry and opportunity were booming in the North, Southern economics still relied largely on plantations and slave labor.  As ideas and inventions were patented daily, there was very little progress made in the understanding of disease.  While weapons became exponentially more effective and destructive, tactics remained static and antiquated.  It was this unique set of factors that set the stage for the birth of an entirely new industry that would define the treatment and recovery of soldiers in all future American wars, as well as those around the world.

If I had to identify the one technological advance that had the most impact on the American Civil War, it would be an invention that occurred almost 4000 miles away.  A French army captain, Claude-Etienne Minié invented a new type of ammunition in 1849 that came to be known as the Minié ball. 

This bullet was smaller than the barrel of the rifle, so it could be easily loaded by dropping it in from the end of the barrel.  However, when rifle fired, the hollow base of the bullet expanded to fill the barrel and “grip” the rifling of the barrel.  This gave the projectile spin and somewhat slowed down its ejection velocity.  These two factors made the bullet much more accurate (up to 250 yards) and much more deadly.  First used by the Brits in the Crimean war (they paid him for his design), the Minié ball was so effective that it effectively tripled the power of a single soldier.  “The bullet so improved effectiveness of infantry troops that 150 soldiers using the Minié could equal the firing power of more than 500 with a traditional musket and ammunition.”

In the spirit of the industrial revolution, both the Confederate and Union armies adopted the Minié ball and rifle as standard issue for all soldiers.  Improved upon and mass produced, this combination redefined the killing power of an infantry unit.  However, the wartime tactics of our country's best-educated military minds lagged behind the technology.  Most of the commanding officers of the day were educated in Napoleonic methods of war at West Point.  Ten or twenty years earlier, heavy cavalry maneuvers and infantry assaults on fortified positions were successful because they could survive an initial volley of shots and then overwhelm the position before they could reload. The Minié bullet allowed soldiers to not only pick off targets much farther away, but now they could reload two or three times before they were overrun.  It took the entire war and over 600,000 casualties on both sides, 90% of which are attributed to the Minié bullet, before military leaders began to realize their mistake.

The massive trauma of the Minié bullet (click to see video) caused not only a massive increase in casualties compared to previous wars, but also injuries never before faced by soldiers and medical personnel.  Its soft lead and slow speed made it cause devastating physical damage upon impact.  Bones were shattered, tissue was shredded, and bullets often did not exit the body, bringing particles of clothing and the environment in with them.  When faced with these types of injuries, Civil War surgeons had little choice but to amputate most peripheral limb wounds to try and save as many lives as possible.  Since 70% of Civil War wounds affected the limbs, this led to a massive amount of amputations; conservative estimates place the number in excess of 70,000 amputations between 1861 and 1865.

This staggering figure earned Civil War surgeons the unfair titles of “butchers” and the nickname “sawbones.” Countless piles of amputated limbs convey the terrible reality of the situation, but amputations were certainly necessary and life-saving.  Especially when compared to the surgeons of the British army, our doctors in fact did quite well.  The History of the British Medical Services in the Crimean War estimates that mortality rates for amputation were around 38-40%.  Comparatively, American surgeons had mortality rates around 28%.  

As a growing number of amputees returned from battle, the US Government quickly realized its obligation to its wounded warriors.  In 1862, only one year after the war began, the government issued what became known as the “Great Civil War Benefaction”: an unconditional guarantee to provide prostheses to all veterans who lost a limb during the war.  The Confederacy offered a similar program initially for its veterans, but costs limited them to only supply compensation for lower limb amputations.

After the war, many entrepreneurs saw an opportunity to capitalize on a new demand for something previously only available to the wealthy.  With the government footing the bill, “American inventors filed more than 80 patents for prosthetics made of wood, cork, rubber, iron, and leather” between 1861 and 1873.  Prosthetics became more functional, less noticeable, and arguably more comfortable.  Utilizing travelling salesmen, mail-order catalogs, prosthetic clinics, and large manufacturers, the leaders of a new prosthetics industry sought to provide customizable appendages to every veteran in need.  Nearly every producer made claims about the unique capabilities and comfort of their prosthetics, but most did not live up to their boasts. In fact, many amputees chose to abandon their prostheses in favor of crutches because of the discomfort. 

This standard persisted until the end of the First World War.  It was only then that the Surgeon General of the United States held a conference to try and create standards for prosthetic development and advancement.  The resulting “American Orthotics and Prosthetics Association” still exists today as the body in charge of the development of ethical standards and research in prosthetic design.

In the 150 years since the Civil War and the birth of the American prosthetics industry, phenomenal advancement has been made.  Both privately and federally funded research and development have introduced new materials, technology, and capability to prosthetics.  Soldiers today who lose even multiple limbs can often regain much of their original functionality (albeit with extensive physical therapy and surgical intervention).  Improvements are currently being made to even regain sensation in lost limbs. These technologies are not just for veterans though.  Amputees from automobile or industrial accidents, illness, or any other cause are benefitting today from what began as a money-making venture in 1861.  These milestones are a tribute to the original commitment that our government made to care for its wounded veterans.

The prosthetic revolution that began in the Civil War has surpassed what we even thought was its terminal point; likely unimaginable 150 years ago (even 20 years ago!), the first successful hand transplant was conducted in 1999.  Last year, in Dec 2012, the first double arm transplantation was done on a soldier who survived the loss of all four limbs in Afghanistan.  Although the surgery seems to be successful thus far, we won’t know for sure for several more months or years. 

So what is the future of prosthetics?  Will the need for prosthetics dramatically decline as limb transplantation progresses?  Or will amputation one day be an elective procedure to replace our "inferior" human limbs with superior prosthetic ones?  Its hard to tell now, but it sure is exciting to think about.

A Night with Venus, a Lifetime with Mercury

There is a saying that dates back to approximately the Civil War era: that a night with Venus leads to a lifetime with Mercury.  This was a pithy warning for a serious set of infections.  At that time, germ theory had yet to be fully developed, sexually transmitted infections (STIs) were not yet well understood (gonorrhea and syphilis were believed to be manifestations of the same illness), and there no effective cures available.  This was the background that the Civil War surgeons had to work against while treating soldiers for STIs. 
Although more soldiers were wounded and infected with other disease, there were a high number of cases of STIs.  Unfortunately, no records exist for the number of Confederate soldiers that were infected with STIs during the war.  For white Union soldiers, 73,382 were diagnosed with syphilis, usually based on the presence of a chancre.  109,397 soldiers were diagnosed with gonorrhea based on presence of pus coming from their urethras.  Gonorrhea diagnoses probably included cases of chlamydia and other STIs that were not yet known to be separate infections.  The diagnosed cases averaged out over the war to be approximately 82 cases/1000 men/year. The highest rates of STI infection were at the beginning and the end of the war. 
Comparable to white soldiers, there were 6,207 syphilis cases and 8,050 gonorrhea cases in black Union soldiers that averaged 78 cases/1000 men/year.  There were 426 hospitalizations of white soldiers, and 136 deaths (32 fatalities reported for black soldiers).  Depending on location, age, and army, STI infection rates could be much higher-the Department of the Pacific at one point reported rates of 461 cases/1000 men/year.  Soldiers who were not actively fighting, young, and stationed near cities were the must likely to become infected and the soldiers of the Department of the Pacific often matched those descriptors. 
Most men contracted STIs from contact with prostitutes also known at the time as “public women”, and surgeons of the day knew this, although some may have also been infected during small pox vaccinations by sharing blood of an infected individual.  As STIs were a widespread problem in the Union army, many commanders looked for various ways to stem the issue as STIs were bad for morale, and were considered detrimental to their army’s performance.  Famously, Union General Joseph Hooker forced all of the prostitutes in Washington, D.C. to be relocated into a single area that was then nicknamed “Hooker’s Division.”  Although this may have cleaned up the city, it is unlikely that this was an effective measure to curb soldier’s visiting the prostitutes’.  In an interesting set of cases, unparalleled in American history, in Nashville, prostitution became so widespread in the city that while under Union army control in 1863, Provost Marshall Lt. Colonel Spalding was given orders to take his men and the local police around the city to capture all the prostitutes, put them on the merchant ship Idahoe, and exile them.  After the ship visited Louisville, Covington, and Newport KY as well as Cincinnati, OH without being able to successfully drop off the prostitutes, the boat was forced to return to Nashville. 
Upon their return, Provost Marshall Spalding designed a system of legalized prostitution, with the aim to reduce new STI cases.  First, all prostitutes were required to have a license to practice.  Second, each week, a prostitute had to have an appointment with a physician to be given a certificate of health.  If a woman was found to have contracted an STI during that examination, she was sent to a special hospital (or ward) for treatment until she was declared healthy.  Finally, each week, each prostitute would pay 50¢ towards the hospital for its support. This system was deemed so successful at reducing troops contracting new cases of STIs in Nashville, that Memphis also adopted it.   
Although these treatments, as discussed above, were not cures, it appears that by quarantining these women when they were likely the most contagious, such as when the syphilis chancre is present during the early stages, was at least somewhat effective in reducing new infections.  This solution accepted that human behavior would continue, while reigning in some of the unwanted effects to improve soldier’s performance in the battlefield. 
Today, soldiers deployed to Afghanistan and Iraq face much lower rates of STI infections, although there does seem to be an upward trend in cases.  Between 2004-2009 case rates of gonorrhea ranged from 5/100,000 to 17.6/100,000 (not separated by gender or race) and chlamydia rates for men were approximately steady at 192.6/100,000 (although it did increase over time).  Rates for syphilis diagnosis were not available.  The current rates are much lower, presumably because of the ability to cure STIs using antibiotics rather than Civil War-era treatments such as mercury, sarsaparilla, and diet alterations as well as more widespread use of condoms than in the civil war era.  However, both the rates during the Civil War and the current wars in Iraq and Afghanistan are probably lower than reality, as STIs are commonly not reported by individuals either due to embarrassment or not being aware of their infection status. Treatments and rates of STIs have improved since the Civil War; however, most likely now just as back then, STI rates are under-represented due to unknown cases. 
Finally, what cannot be quantified, is the lasting impact of these STIs.  The soldiers themselves would have continued to suffer from both diseases, with severe morbidity.  Gonorrhea in some cases can continue to cause pain while urinating.  Persistent syphilis can go on to its tertiary stages (neurosyphilis/cardiovascular syphilis), which attacks the central nervous system or heart and can be fatal.  Some historians estimate that up to one third of the men in veteran’s homes and hospitals that were caring for the soldiers from the Civil War were suffering from STIs at the end of their lives.  Undoubtedly, men went home and infected their wives, who then could also suffer from both neurosyphilis, but also pelvic inflammatory disease (PID) caused by gonorrhea.  Although this was unknown at the time, we now know that PID could have lead to problems with fertility, salpingitis, and tubal pregnancies.  Women could have also passed on the diseases to children in childbirth.  In children, gonorrhea can cause blindness and syphilis is linked to stunted growth.  Unfortunately, despite good treatments and screening programs, many individuals still do not know today whether or not they are infected with an STI, and many of the same results can occur. Although the pathology, knowledge, and treatments of STIs have significantly improved since the Civil War, culture today still suffers many of the same problems from untested STIs.

Additional sources reviewed:


Sunday, May 19, 2013

Post-Operative Care and Consequences during the American Civil War

Surgical techniques became a priority for early medicine because there was such a high prevalence of limb and bodily destruction during the American Civil War. The regimental surgeon at the battlefield frontlines triaged more serious cases to be transported via ambulance to the field hospital in the rear of the battlefield, and here, a medical team would explore the wound and make the decision to resect or amputate, a decision often based on resources. While hemorrhage and loss of blood were common causes of death prior to surgery, infection control, pain management, and rehabilitation of veteran back into society determined post-surgical outcomes.

Of the 29,980 successful and reported amputations between 1861 and 1865, Union medical officials documented that 21,753 amputees survived (Jordan 2011). Despite the seemingly high amount of amputations during the Civil War, early nineteenth century physicians preached and practiced “conservative medicine." Based on this philosophy, they refrained from treating the patient when there was evidence that the disease or injury could have a favorable outcome without active interference (Figg and Farrell-Beck, 1993). While conservative medicine seems to contraindicate the necessity of amputations, surgeons believed that amputation was an end to a means, and that removal of the limb prior to infectious reaction would result in a more favorable outcome for the patient. Primary surgery, federally defined as surgical intervention within forty-eight hours of the injury, intervened prior to the onset of infection, but secondary surgery, intervention following the thirtieth day post-injury, was protocol for all injuries with expected inflammation (Figg and Farrell-Beck, 1993). Those that did not receive amputations by primary surgery were believed to be worse off in terms of morbidity and mortality, and the main source of these complications was infection as a result of operative inference.

Following surgery, soldiers and the medical staff were plagued with a road to recovery that involved pain management, infection control, and rehabilitation. Fortunately for Union troops, the United States Sanitary Commission, composed of laypeople and physicians, was established and approved on June 13, 1861 (Gilchrist 1998). Despite this safeguard to standardize medical treatment for military troops, two-thirds of amputees died during the first week following surgery (Watson 1985). While recurrent hemorrhage, gangrene, and erysipelas were of concerns, septicemia as a result of operative intervention was the worst fear of infections because it had a 100% mortality rate and did not manifest until after surgery (Watson 1985). Lint covering limb stumps was made by scraping woven linen and was then added to a wet compress of old muslin cloth and applied to the wound. However, water that was used to soak these compresses was often tainted with bacteria (Gilchrist 1998). Maggots were used to clean wounds because they ate dead tissue that provided a breeding ground for such bacteria. Additionally, potassium permanganate, sodium hypochlorite and nitric acid were used on wound treatment, particularly for gangrene (Gilchrist 1998). Staphylococcus aureus and Streptococcus pyogenes were the cause of the majority of post-surgical infections, and Streptococcus pyogenes was known to cause specifically hospital gangrene, an infection that was transmitted during the recuperation period following amputation (Gilchrist 1998). Furthermore, hospitals located in stable areas were ideal locations for the transmission of tetanus because Clostridium spores flourished in the manure-covered floors (Gilchrist 1998). Even with these treatment attempts, microbes killed more men during the Civil War than rifles and cannons because of poor sanitation.

Anesthesia use began during the 1840s and, thus, was poised to be a key factor in Civil War medicine. The major anesthetic agents were chloroform and ether administered with the help of a cloth formed into a cone-shape with a small sponge in the apex or with inhalers such as the Morton Ether Inhaler (Albin 2000). Additionally, chloroform and ether were often used in combination to attenuate the cardio-respiratory excitatory effects of chloroform, the decrease in flammability, and the stimulatory responses associated with ether, resulting in a mortality rate of 2.6 out of every 1000 patients (Albin 2000). Only about one-fourth of amputees received anesthesia during their surgery based on the records in the Medical and Surgical History of the War of the Rebellion. Both North and South experienced supply shortages that affected their ability to use anesthetics and distribute pain management. Northern troops had abundant supplies but their chaotic medical organization led to poor distribution of what was available. On the contrary, Southern troops experienced shortages due to Union naval blockages, resulting in less Confederate soldiers receiving anesthesia in comparison to Union soldiers. Additionally, the shortage of sponges in the South led them to use cotton rags and raw cotton as well as horse’s tail hair for surgical procedures. Southern surgeons were forced to boil cotton and the horse’s hair to remove dried blood from rags and make hair pliable for use in ligatures which inevitably reduced the spread of infection during surgery (Gilchrist 1998). Despite being at an increased disadvantage due to supplies shortage, Southern surgeons realized the potential of surgical sterilization prior to its full understanding.

Post-operative pain was controlled with opioids, specifically morphine. Morphine effectively managed pain but also heightened pain sensitivity, aggravated already existing pain problems, particularly in soldiers with previous amputations, and immunosuppressed soldiers creating additional infection control issues (Albin 2000). Despite its effective use, morphine use led to addiction that was known as “Army Disease,” which often led to increased crime, drug addictions, violence and unemployment among veterans (Dean 1991). It is hypothesized that many soldiers masked possible psychiatric and stress conditions related to their amputations under the guise of excessive morphine misuse.

As a result of the rise in amputations during the Civil War, the manufacturing field for prosthetics, artificial limbs, and other supportive devices exploded during the nineteenth century. Between 1846 and 1861, thirty-four patents for new or improved artificial limbs, crutches, and invalid chairs were recorded, and between 1861 and 1873, this number grew to one hundred thirty-three (Figg and Farrell-Beck 1993). While there were one and a half times more men that survived the War with upper extremity amputations than lower extremity amputations, there were more limbs and devices patented for the lower extremities (Figg and Farrell-Beck, 1993). Manufacturers sought to make their products strong, light, and durable for ease of gait and comfort but also quiet, non-corrosive, and realistic to help veterans assimilate into society despite their deformities. Despite such a crude appearance, these devices allowed veterans to return to their normal lives following the War.

Overall, the federal government provided little social or occupational rehab for disabled veterans prior to the War. In 1862 Congress began a general law pension system that allowed pension for soldiers with permanent bodily injury as a direct result of military duty following March 4, 1861 (Figg and Farrell-Beck, 1993). Starting in 1864, invalid veterans received a monthly pension for each disability, and each year this system increased payments and provided additionally for disabilities. Veterans were also eligible for an additional allowance to cover artificial limbs, which ranged in average cost of fifty to seventy-five dollars between 1863 and 1864. The Congressional Acts of 1866 and 1867 provided free transportation to and from artificial limb fittings and guaranteed replacement of these limbs every five years (Figg and Farrell-Beck, 1993). Through these implementations, the federal government sought to help Civil War amputees to assimilate into daily life and demonstrate its appreciation for their service.

Following the Civil War, the sheer volume of Union veterans’ claims led to absorption of substantial amounts of national resources. In fact, the federal government spent more funds on veterans between 1865 and 1870 than it had in the preceding eighty years (Gilchrist 1998). Veterans had to submit evidence and photographs of their injuries from physicians and affidavits of witnesses to the Pension and Records Division. Reviewed evidence was submitted for a decision from the Congressional officials (Gilchrist 1998). By the end of the nineteenth century, veterans received benefits that included incidental medical and hospital treatment for all injuries and benefits that covered their widows and dependents (Figg and Farrell-Beck, 1993). While the federal government’s provisions were vast for Union soldiers, they did not provide for former Confederates. Confederate amputees did not receive artificial limb assistance until 1864 when the Association for Relief of Maimed Soldiers provided them with benefits.

Armed with artificial limbs and support from the government, most soldiers who returned home were praised by both nurses and civilians. Their injury served as a symbol of courage and their survival was perceived as a form of pride (Figg and Farrell-Beck, 1993). While many returned to duty even after amputation, many found it difficult to return to work. Former generals initially found it easier to find occupations outside of the War because of their prestige, but the majority of veterans returned to farmlands. Both North and South government provided land for veterans to encourage farming endeavors. Additionally, the federal government passed Section 1754 in 1865 to grant preference to disabled veterans for civil service jobs. For example, the Lincoln Institute, an early predecessor of the Veteran’s Affairs, trained the disabled in telegraphy, typewriting, and bookkeeping (Figg and Farrell-Beck, 1993). The severely wounded often were used during the War as the Union’s Invalid Corps, men who worked as clerks, watchmen, cooks, and attendants due to the shortage of nurses.

Despite the federal government’s help in returning veterans to society, many veterans struggled psychologically with amputations and surgery on the battlefield. Some surgeons pioneered the idea of “irritable heart” or “trotting heart,” which were conditions that essentially defined stress, such as paralysis, diarrhea, and headaches. Such symptoms were often attributed to overexertion or sunstroke (Dean 1991). In fact, the Union Army did not recognize insanity as grounds for discharge, and surgeons had to send soldiers to the Military Hospital for the Insane in Washington to diagnose them. Even so, symptoms of stress short of total breakdown were still viewed as cowardice in society, and most veterans suffered the stress of warfare and amputation quietly (Dean 1991). Despite having survived the war and the complications of amputation surgery, many veterans still suffered in post-Civil War life. Through the consequences of both Civil War medicine and postoperative care during the Civil War, history suggests that the road to amputation was one of both physical and mental strife.

Works Cited

Albin, Maurice S. "The Use of Anesthetics during the Civil War, 1861-1865." American Institute of the History of Pharmacy 42.3/4 (2000): 99-114. JSTOR. Web. 14 May 2013. <>

Dean, Eric T., Jr. ""We Will All Be Lost and Destroyed": Post-Traumatic Stress Disorder and the Civil War." The Kent State University Press 37.2 (1991): 138-53. JSTOR. Web. 14 May 2013. <>

Figg, Laurann, and Jane Farrell-Beck. "Amputation in the Civil War: Physical and Social Dimensions." Journal of the History of Medicine and Allied Sciences 48 (1993): 454-75. JSTOR. Web. 14 May 2013.

Gilchrist, Michael R. "Disease and Infection in the American Civil War." The American Biology Teacher 60.4 (1998): 258-62. JSTOR. Web. 14 May 2013. <>

Jordan, Brian M. ""Living Monuments": Union Veteran Amputees and the Embodied Memory of the Civil War." The Kent State University Press 57.2 (2011): 121-52. JSTOR. Web. 14 May 2013. <>

Watson, James R. "Resuscitation and Surgery for Soldiers of the American Civil War (1861-1865)." World Association of Emergency and Disaster Medicine 1.1 (1985): 76-85. JSTOR. Web. 14 May 2013.