Prevalence of Major Eye Diseases Among US Civil War Veterans, 1890-1910

 By Frank A. Sloan, PhD; Daniel W. Belsky, BA; Idrissa A. Boly, MA

ABSTRACT
Objectives:  To estimate the prevalence of major eye diseases and low vision or blindness in a national sample of male US Union Army veterans from 1890 to 1910 and to compare these prevalence rates with contemporary rates for the same diseases and visual status.

Design:  Longitudinal histories of 16 022 white Union Army veterans receiving disability pensions from 1890 to 1910 were developed from pension board examination records. Prevalence rates of trachoma, corneal opacities, cataract, diseases of the retina and optic nerve, and low vision or blindness were calculated in 1895 and 1910. Changes in prevalence by age were examined.

Results:  By 1910, 11.9% of veterans had low vision or were blind in both eyes. Prevalence of cataract increased with age, resulting in 13.1% of veterans having had cataract in one or both eyes. Rates of trachoma were 3.2% in 1895 and 4.8% in 1910. Rates of corneal opacity were 3.0% and 5.1%, respectively. Glaucoma was rarely diagnosed from 1890 to 1910, but diseases of the optic nerve were reported in 2.0% of veterans in 1895 and 3.6% in 1910.

Conclusions:  This study documents substantial reductions in the prevalence of low vision or blindness and changes in the composition of eye diseases from an era in which there were few effective therapies for eye diseases to the present.

The 20th century experienced great changes in the treatment of major eye diseases. However, longevity also increased substantially. The US population aged older than 65 years increased from 4.1% in 1900 to 12.4% in 2000, eye disease prevalence often increases with age. Thus, though innovations in treatment should have decreased prevalence, increases in population age may have, at least in part, offset these decreases. Nationally representative historical data documenting trends in prevalence of major eye diseases and low vision and blindness across several decades have been lacking.

Recently, data from a federal program that began in 1862 and paid pensions to Union Army veterans of the US Civil War (1861-1865) became available in machine-readable form. To obtain a pension, veterans had to be examined by a 3-physician panel, which determined whether their illnesses or injuries qualified for compensation. Prior to 1890, only service-connected disabilities were compensated. In 1890, the program was amended to include compensation for non–service-related conditions, which led to a major increase in veterans having examinations to obtain pensions. In 1907, the program was further amended to include old age as an eligibility criterion. Although old age was not recognized by statute as a basis for receiving a pension until 1907, a minimum pension was granted to all those aged 65 years or older from 1890 to 1907, unless the veteran was unusually vigorous.

This was the first major national pension program in the United States to which a large portion of federal expenditures was allocated in the late 19th century. The program covered 85% of Union Army veterans who were alive in 1900 and more than 90% of veterans who were alive in 1910. Only Union Army veterans were eligible.

METHODS
The data were produced by the Center for Population Economics at the University of Chicago. A 1-stage cluster sample of 331 Union Army companies was randomly selected by the Center for Population Economics from more than 20 000 company records stored at the National Archives in Washington, DC. These companies yielded a sample of 39 616 veterans.

The surgeons' certificates data consist of medical records used by the US Bureau of Pensions to evaluate pension applications. Each record contains physical examination findings. Veterans could apply for a pension more than once (they could claim > 1 disability at each application); therefore there were multiple medical records for some veterans. Surgeons' certificates data were classified by the Center for Population Economics into 21 (primarily) organ system–based health screenings.

The total surgeons' certificates sample includes 87 224 examinations of 17 721 veterans. The veterans sample was reduced to 16 022 because of missing information on birth or death dates. Once a veteran's condition was diagnosed, we assumed that the veteran had that condition until death. In any year, the number of veterans in the sample was well below 16 022, because either the veteran had not yet been examined or had died by then. Our analysis focused on 1895 and 1910. The year 1895 was long enough after the statutory change of 1890 that allowed many veterans with non–service-related disabilities to be examined and added to the pension roles. By 1910, 3 years had passed since the statutory change of 1907, an eligibility expansion that classified old age (≥ 62 years) as a disability. Also, by 1910, most surviving veterans were aged 65 years or older. The death rate was high enough that sample sizes were too small to calculate reliable estimates of prevalence a decade or a decade and a half later.

We identified veterans with a visual disability who had diagnosed amblyopia or blindness in both eyes. We examined 5 categories of eye disease: trachoma, corneal opacity, cataract, disease of the retina, and disease of the optic nerve. Trachoma, corneal opacity, and cataract were all easily identified then by basic visual inspection. All were well-known causes of blindness and were considered when determining cause of impairment. Diseases of the retina and of the optic nerve, rather than being specific diagnoses, refer to findings from an examination with an ophthalmoscope. Ophthalmoscopes were reasonably well distributed by the 1890s.

Trachoma was identified by searching responses for trachomawithin a category dealing with the conjunctiva. We identified cases of corneal opacity by searching for items pertaining to the cornea. Cataract was identified from variables for cataract and cataract extraction and was indicated as specific to the left, right, or both eyes. Diseases of the retina and optic nerve were identified by codes for infection or inflammation of the eye.

Few cases were explicitly classified as glaucoma, but glaucoma was also plausibly included in a separate category, diseases of the optic nerve. We included both in the category disease of the optic nerve.

RESULTS
The sample increased by 50% between 1890 and 1895 (Table 1), reflecting the increase in veterans obtaining examinations after the statutory change in pension law in 1890. In 1895, of the 12 144 veterans in the sample, 84.8% were aged younger than 65 years. By 1910, of the 7782 remaining veterans in the sample, only 17.8% were aged younger than 65 years. Most veterans were aged 65 through 74 years in 1910 (66.2%).

Cataract was by far the most common of the study diseases, with prevalence ranging from 4.5% for those younger than 55 years to 15.6% for those aged 75 years and older in 1895 (Table 2). In 1910, prevalence of cataract among those aged 75 years and older had risen to 17.1%. For those aged 65 through 74 years, prevalence of cataract was 8.4% in 1895 and 13.0% in 1910. Corneal opacity affected 3.8% and 4.8% of this age group in 1895 and 1910, respectively. Prevalence of trachoma was similar; that for diseases of the retina and optic nerve was much lower, ranging from just under 1% to 2% in 1895.

Prevalence of diseases of the retina increased between 1895 and 1910, even on an age-adjusted basis, possibly reflecting better detection in the latter year. However, in data for either year, rates of documented retinal disease did not increase with age, as is now typical in elderly populations. Prevalence of disease of the optic nerve did not change appreciably between 1895 and 1910 on an age-adjusted basis, and the patterns of prevalence rates with respect to age are irregular in both years.

In 1895 and 1910, respectively, 7.1% and 11.9% of the white male veteran population had low vision or blindness. The prevalence of low vision/blindness increased substantially with age. In 1895, 6.0% of veterans younger than 55 years and 11.0% aged 75 years or older had this diagnosis. In 1910, 14.1% of veterans aged 75 years or older were recorded as having low vision or being blind in both eyes.

Of those veterans with low vision or blindness, most had diagnosed cataract (Table 3). Corneal opacity and trachoma were present in one-quarter or more of these individuals. Diseases of the retina and optic nerve were documented in 13% to 15% and 8% to 10% of these cases, respectively.

COMMENT
Several major eye diseases and low vision/blindness were highly prevalent at the turn of the 20th century. Prevalence of some major eye diseases, especially cataract, increased substantially with age.

Owing to increased longevity and improved medical knowledge and diagnostic techniques, reported prevalence increased for many eye diseases. Current rates of cataract surgery, a reasonable proxy for cataract prevalence in high-income countries, are well above those for cataract and cataract surgery combined in the Union Army data, especially for populations aged 70 years or older. Data from populations aged 65 years or older in the 1990s indicate a prevalence rate of about 5% for age-related macular degeneration, about 7% for diabetic retinopathy, and close to 8% for glaucoma. The combined rates of 5% and 7% for the retinal diseases are far above the corresponding rates in the Union Army data (considering joint prevalence of both diseases), even allowing for a somewhat higher mean age of the more recent population. Diabetes prevalence among white veterans in 1895 was about 2% and was about 4% in 1910. Judging from recent data, far fewer than half of veterans with diagnosed diabetes would have had retinal disease (< 1% in 1895 and < 2% in 1910). Urinalysis was used during this period to diagnose diabetes. Recent prevalence of glaucoma is also much higher than the rates diagnosed in the Union Army veteran population, even accounting for some differences in age between the comparison and Union Army data.

However, trachoma, which was highly prevalent in the United States around 1900, is now virtually nonexistent in the developed world, which is largely a result of better sanitation, improved personal hygiene, and antibiotics. The disease now exists almost exclusively in low-income countries, where prevalence is similar to that found in our study, though it was sometimes higher depending on the region.

In contrast to increases in reported prevalence of major eye diseases, visual outcomes in the United States have improved dramatically since about 1900. Data from the World Health Organization from indicate that blindness prevalence (defined as visual acuity < 20/400 OU) among those aged 50 years or older in the United States was 0.4%. The Eye Disease Prevalence Research Group (EDPRG) reported a combined prevalence of blindness (defined as best-corrected visual acuity < 20/200 OU) and low vision (defined as best-corrected visual acuity < 20/40 OU) for those aged 40 years or older of less than 3%. Rates for other high-income countries are similar.

Eye disease prevalence in the Union Army veterans data are more similar to reported prevalence in low-income countries, where sanitation and hygiene may be more like that of the United States in the early 20th century. According to the World Health Organization, prevalence of blindness in Africa among individuals aged 50 years or older was 9% in 2002. In Southeast Asia, including Indonesia, Malaysia, the Philippines, and Thailand, prevalence in 2002 was 6.3%. Combined prevalence of blindness and low vision (best-corrected visual acuity < 20/60 OU and > 20/200 OU) among adults in Pakistan and Bangladesh is around 10%. Rates for persons aged 60 to 69 years have been reported at 13% in Malaysia and 8% in Nepal.

Access to affordable, safe, and effective cataract surgery is of primary importance in decreasing prevalence of blindness in the developed world. Cataract is the leading cause of blindness globally, accounting for 47.8% of adult-onset blindness. The EDPRG estimated that among white Americans, cataract caused less than 9% of blindness, even though the US population is proportionally much older than the world as a whole; 7.4% of the global population is aged 65 years or older compared with more than 12% of the US population.

Causes of low vision or blindness cannot be ascertained from the Union Army data; however, prevalence of eye diseases among those with low vision or blindness provide an approximation. These data assign a major role to cataract as causing low vision or blindness. Even with better technology, contemporary estimates of the causes of the 2 conditions in the United States differ appreciably. According to EDPRG's meta-analysis, cataract, for example, accounts for 59.9% of low vision and only 8.7% of blindness among white Americans. Rates are 3.3% and 6.4% for glaucoma and 22.9% and 54.4% for age-related macular degeneration among white individuals with low vision and blindness, respectively. Age-related macular degeneration's prominence in the EDPRG meta-analysis relative to that in the Union Army data (even considering that some diabetic retinopathy would have also been included in diseases of the retina) primarily reflects current knowledge compared with that of a century ago as well as the higher fraction of younger elderly in the veterans' analysis.

Unlike cataract, age-related macular degeneration, and glaucoma, corneal opacities were much more common among those with low vision or blindness in the Union Army sample compared with contemporary populations in both the United States or low-income countries. Corneal opacities accounted for 3% of blindness in the United States and 8% to 12% of blindness in Africa in 2002. Higher prevalence of trachoma, the most important infectious cause of corneal opacity, cannot fully explain this effect. While rates of trachoma in Africa (6%-8%24) are higher than those in our data, the reported effect of corneal opacity on vision is substantially lower. Corneal scarring from war-related trauma is the likeliest explanation for the high rates of corneal opacity among those with visual impairments in the veterans' sample. This explanation is supported by the decline in the prevalence of corneal opacity among those with serious visual impairment as the sample aged and other eye diseases become more common.

A strength of the veterans data is that they are fairly representative of middle-aged and elderly white men who were alive around 1900. About half of adult white men in the North fought in the Civil War. Many men whose poor health precluded fighting in the Civil War, owing to, eg, congenital heart disease, probably did not survive to 1895. The pension program covered 85% of all Union Army veterans by 1900 and more than 90% by 1910. Because of the relaxation of regulations in 1890 that allowed pensions to be granted to almost all veterans older than 65 years and the formalization of this policy in 1907, there was a substantial incentive for even veterans without disabilities to apply for pensions. Fogel conducted analyses comparing the examined soldiers with other men of this period, concluding that the veterans sample was representative of the Northern white male population according to geographic distribution, wealth, and cause of death.

We acknowledge several study limitations. Our data only pertain to adult white men and exclude men in states not held by the Union Army until the end of the Civil War. Second, methods of diagnosing and classifying disease and depth of understanding of disease processes differed substantially between the beginning and the end of the 20th century. Diagnostic techniques around 1900 were very limited, the field of ophthalmology was comparatively young, and the physicians performing the examinations were not likely to be familiar with any ocular pathologies besides the very most common. Consequently, misdiagnosis and underdiagnosis were likely to have been more common relative to more recent data. For example, around 1900, the presence of cataracts was typically based on observing a “white pupil” rather than by methods used more recently. Vision loss at the time of cataract surgery today is comparatively mild. Thus, using contemporary criteria, prevalence of cataract in 1895 and 1910 reported in our study is likely to be understated.

However, visual and functional status was observable. Graeff, in his book Das Menschliche Augepublished in 1933, urged those rating severe visual impairment and blindness to classify them based on the conditions' effects on patients' ability to function in their usual activities.

Classification, terminology, and knowledge of disease processes also differed. For example, the 1898 English edition of Fuchs' Text-Book of Ophthalmology, a widely respected reference at the time, defines amblyopia as weak sight or low vision that cannot be corrected by eyeglasses. Similar definitions are found in Alt's 1884 A Treatise on Ophthalmology for the General Practitioner and Higgens' 1888 Ophthalmic Practice. Complete blindness is referred to in these 3 texts as amaurosis. Our analysis considered a diagnosis of amblyopia in both eyes as functional blindness.

There is good support for supposing that a diagnosis of amblyopia, as the term was used then, was associated with severe functional impairment. Wood, writing on the army pension program, stated that “No pension is given for a partial loss of sight or for the partial or complete loss of the field of vision or the muscular functions of the eyes.” Graeff, writing more than 3 decades after Fuchs, Alt, and Higgens, characterized amblyopiaas a historical scientific term for severe visual impairment. He argued that if the criterion of amaurosis had been strictly applied as a basis for admission, 80% to 90% of all residents of institutions for the blind would have been there inappropriately.

Glaucoma provides an example of the lack of understanding of disease processes in the early 20th century. The term glaucoma appeared in ophthalmologic reference books of the period, and it was one of the listed diagnoses the board of surgeons could apply following their examinations of pension applicants; but the consequences of glaucoma were not understood then. There are 2 chief reasons for the rarity of reported glaucoma: (1) The disease was thought to be very uncommon and (2) the relationship between glaucoma and the optic nerve was not well understood. Fuchs wrote in 1898 that glaucoma accounted for less than 1% of all eye diseases. In 1900, Deyl and Sattler’s chapter “Diseases of the Optic Nerve” in Norris and Oliver's System of Diseases of the Eyemade no reference to glaucoma, though some connection with the optic disc was mentioned in Smith’s chapter on glaucoma in the same volume. Fuchs identified excavation of the optic nerve as the cause of blindness in advanced glaucoma but went no further. Both Alt and Higgens discussed glaucoma and the optic nerve separately. However, by the time Graeff’s text was published in 1933, examination of the optic nerve was used to diagnose glaucoma. Although tonometers existed in the late 1800s, in our data, there were more findings of disease of the optic nerve than there were of diagnoses labeled glaucoma. Thus, in our analysis, the latter was combined with the former group.

This study documents substantial reductions in the prevalence of low vision/blindness and changes in the composition of eye diseases from an era in which there were few effective therapies for eye diseases to the present. Comparisons of major eye diseases over the course of 100 years reveal substantial improvements in visual function. The appreciable reductions in the prevalence of low vision/blindness reflect such technological changes as innovations in the treatment of cataract and glaucoma and economic growth, which provided funds for developing capacity and financing provision of services. Other improvements, such as a reduction in the prevalence of trachoma, reflect improvements in environmental and public health, which is largely a byproduct of a country's level of economic development.

The burden of chronic eye disease is substantial and is reflected by (1) the resources devoted to its diagnosis and treatment and (2) the losses in productivity and quality of life it can cause. Both are important components of the total burden. Around 1900, when therapeutic options were limited, the burden of such disease and disability was largely borne outside the health care system. But nevertheless, particularly as reflected in high rates of low vision/blindness, this burden was substantial and much greater than it is now.

From: archopht.jamanetwork.com

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The Nashville Experiment: Prostitution is Legalized

By  William Moss Wilson

Emaline Cameron was among the thousands of refugees who poured into occupied Nashville, Tenn., in 1863. While the strains of war may have contributed to her flight from her native Smithville, about 50 miles to the east, Emaline crossed Union lines to distance herself from an imploded marriage. James Hayes, known as Toy, had divorced her on the grounds that he was not the father of their eldest child. She admitted as much in court: while growing up Emaline had worked as a chambermaid at the Smithville Hotel, which was run by her parents. After a boarder left the 15-year-old pregnant, they quickly married her off to the naïve Toy.

When Emaline came to Nashville, where there were many opportunities to clothe, feed and entertain the garrison of Union soldiers, a demand for labor that far outstripped the city’s prewar population. Family history reports that Emaline chose the last sector: sometime after her arrival, she “operated a house of prostitution.” If true, my great-grandfather’s great-grandmother participated in the first licensed and regulated sex trade in the United States.

Like other radical developments during the war, Nashville’s experiment with legalized prostitution evolved as a practical solution to a military problem. Nearly one in 10 Union soldiers were reported to have contracted gonorrhea or syphilis during the war; rates were even higher for troops garrisoned in and around cities.

While these sexually transmitted diseases were hardly fatal, they increased demands on an already strained medical system. In Nashville, schools, hotels, storefronts and even factories had been refashioned into hospitals to accommodate the thousands of wounded soldiers returning from the front. After the Battle of Stones River, federal hospitals were so overwhelmed that Brig. Gen. Robert Mitchell allowed wounded Confederate prisoners to be treated in the homes of known secessionists. Men with sexually transmitted diseases were an unnecessary added burden.

By June 1863, the large numbers of soldiers hospitalized in Nashville for venereal diseases led surgeons and regimental commanders to “daily and almost hourly” petition Brig. Gen. R.S. Granger, a local commander, “to save the army from a fate worse than… to perish on the battlefield.” The first solution was to rid the city of its prostitutes. Deportation would prove no easy task; nearly every structure along the four blocks between Capitol Hill in downtown Nashville and the river wharves, known as “Smokey Row,” was a house of prostitution, and other brothels were scattered about town.

In early July, the case was assigned to Provost Marshal Lt. Col. George Spalding, who led soldiers and police officers on a raid of the city’s brothels, “heaping furniture out of the various dens, and then tumbling their disconsolate owners after.” Under military escort, several hundred women were dragged onto requisitioned steamboats. Capt. John Newcomb of the Idahoe received his passengers only after vigorous protest. Newcomb feared for the reputation of his vessel, and correctly so — the Idahoe soon become known as the “Floating Whorehouse.”

The following weeks revealed the limitations of the eviction policy. Armed guards in Louisville and later at Cincinnati refused to allow the female passengers of the Idahoe to disembark, and after the same scene was repeated at smaller ports, Newcomb had no choice but to return to Nashville. Moreover, the day after the Idahoe departed for Louisville, The Nashville Daily Press complained that the only immediate effect of the removal was that black prostitutes had filled the void left by their white colleagues:

Unless the aggravated curse of lechery as it exists among the negresses of this town is destroyed by rigid military or civil mandates, or the indiscriminate expulsion of the guilty sex, the ejectment of the white class will turn out to have been productive of the sin it was intended to eradicate … No city … has been more shamefully abused by the conduct of its unchaste female population, white or black, than has Nashville…for the past eighteen months … We trust that, while in the humor of ridding our town of libidinous white women, General Granger will dispose of the hundreds of black ones who are making our fair city a Gomorrah.

Once deportation proved a failure, Granger and Spalding initiated a second, more radical solution. On Aug. 20, 1863, the Spalding released orders that required all of Nashville’s prostitutes to register with the military government, which would in turn issue each woman a license to practice her trade. In exchange for a weekly fee of 50 cents, these women would receive a regular medical checkup, and if healthy, issued a certificate. Infected prostitutes would be hospitalized and treated at no additional charge. Failure to register would be penalized with a 30-day sentence in a workhouse.

Shockingly, legalization did not draw the same vitriol from the press that had accompanied deportation. The City Council delivered de facto endorsement of military regulation on Aug. 24, when Nashville’s aldermen voted to “postpone indefinitely” legislation banning prostitutes “from riding in hacks with soldiers.”

Nashville’s prostitutes embraced the new scheme. More than 300 licenses were issued in the first six months. By August 1864, Spalding had included black prostitutes in the program; of the 500-plus licensed prostitutes in Nashville, 50 were black women. Women took pride as they flashed their credentials and prominently displayed their health certificates. Observers also noted a decrease in street walking in favor of less-risky brothel work. Part of the licensing surge was attributed to an influx of prostitutes from Northern cities who perceived the increased safety and better working conditions provided by regulation.

Two hospitals were dedicated to treating sexual infections in Nashville: Hospital 11, for soldiers, and Hospital 15, also known as the Pest House, for prostitutes. The head surgeon, Robert Fletcher, claimed that after the first six months of regulation, when 92 women had been diagnosed with S.T.D.’s, only 13 of the nearly 31,000 soldiers admitted to Hospital 15 had contracted their infections in Nashville. Dr. William Chambers, charged with medical inspections of the women, noted that regulations led to improvements in hygiene in addition to the decrease in new infections.

Chambers’s work led him to a discovery that challenged the conventional wisdom of the day, which held prostitutes solely to blame for spreading sexual infection. In February 1864, a substantial spike in new visits to Hospital 15 accompanied the thousands of re-enlisted soldiers returning from furlough. The following days brought a surge of new female patients to the Pest House. Chambers concluded that the returning soldiers must have brought the S.T.D.s with them and then infected his female patients.

Chambers’s insight proved as fleeting as the wartime program, which did not survive his resignation in May 1865. Though the Union command at Memphis had borrowed from the Nashville experiment for a similar program in his city, civilian government in both cities quickly abandoned regulation of the sex trade at the close of hostilities.

While the Nashville experiment may not have had lasting social repercussions, it is possible that improved conditions in the dangerous profession delivered women like Emaline through the hardships of war. Emaline survived her time in Nashville to return to Smithville, where she lived out her days in the home of her son.

William Moss Wilson teaches history at the University School of Nashville.

From: opinionator.blogs.nytimes.com

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Urological Injuries in the Civil War. (Abstract)

By H.W. Herr

PURPOSE:
This study compiles all cases of urological injuries reported in the Civil War (1861 to 1865).

MATERIALS AND METHODS:
Using original sources largely assembled in army surgeon reports urological injuries documented and treated during the Civil War were recorded as to frequency, type, site and outcome.

RESULTS:
A total of 1,497 cases of injury involving the genitourinary organs were documented, representing 0.61% of all battle wounds, 22% of gunshot wounds of the abdomen and pelvis, and 47% of wounds restricted to the pelvis. Of these men 342 died (22% of all urological injuries and 37% of fatal pelvic wounds). Half of the kidney, bladder and prostate injuries were fatal, whereas men with injuries of the urethra, testes and penis generally recovered. Urethral wounds were often complicated by traumatic fistula and stricture.

CONCLUSIONS:
Wounds involving genitourinary organs and their consequences had a significant impact during the Civil War. As the war progressed, despite the limited means at their disposal surgeons learned how to better treat devastating urological injuries, resulting in improved survival and fewer severe complications.

Image: Gemrig urology surgical instruments

From: ncbi.nlm.nih.gov

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Pelvis Under Fire: Urological Injuries during the American Civil War

By Josh Knight

During the American Civil War, soldiers risked life and limb for their countries. Unfortunately, most would not escape the war unscathed. More than 620,000 or 2% of the total American population died while in service (http://www.pbs.org/civilwar/war/facts.html). This account fails to consider those who would later succumb to their injuries, both physical and psychological, after the war. Despite the fact that most deaths were a result of disease, consider first that a percentage of this total may have died from post-surgical intervention, though as the war progressed these procedures yielded better outcomes. Nevertheless, soldiers who sustained gunshot wounds, artillery shrapnel or bayonet injuries would still undergo surgeries to remove the .58 caliber lead bullet, any shattered bones or pieces of clothing to help the soldier recover and potentially return to the field of battle. In particular, while most abdominal injuries or “gutshot” were typically fatal and not worth operating, soldiers sustaining urological injuries surprisingly recovered (Urological Injuries in the Civil War: Herr). Keep in mind that the term recovery back then simply referred to not dying on the operating table or soon after surgery. These soldiers still dealt with substantial pain and suffering during the war and long after; many would sadly perish in part due to these injuries or complications such as infected wounds, dehydration or pneumonia, including the famous Union general Joshua Chamberlain (Urological Injuries: Herr).

Most of the records on urological injuries are from Union army surgeon reports and pension records. Thus, the following statistics all refer to Federal soldiers as the medical records for the Confederate army were lost in the fire that destroyed Richmond on April 3rd, 1865 (Urological Injuries: Herr) (Corrected from April 2nd as that was when the fire actually begun). Also consider that these documented cases are an understatement as the numbers only consider those soldiers who sought medical treatment, thus failing to account for soldiers who were killed on the battlefield or never went to the hospitals.

A total of 3,159 pelvic shot wounds were documented. Of these, urological injuries constituted 1,497 or nearly half (Urological Injuries: Herr). As mentioned before, any damage to abdominal organs yielded a poor prognosis. Injuries to the kidneys, stomach, intestines and spleen were thought of as fatal so surgeons would typically leave these soldiers to die, though some were still able to make recoveries despite not receiving treatment. One injury in particular to focus on involves the bladder and urethra. Reports indicate a total of 185 cases of bullet wounds to the bladder and 105 cases of urethral injury (Urological Injuries: Herr; Urethral injuries in the Civil War: Herr). In both instances, the primary goal was to remove the bullet and other debris that may cause secondary infection.

The next step involved “facilitating rather than obviated urinary infiltration” (Urological Injuries: Herr). Surgeons had three methods to accomplish this goal. First was to insert a catheter into the penis to gain access to the bladder. The current literature at the time detailed that immediate insertion of a catheter was necessary while also maintaining caution and “delicacy of manipulation” (Medical and Surgical history of the War of the Rebellion Part III Volume II). The catheter would be used to “realign the urethra, restore continuity” between bladder and urethra and “drain urine” (Urological Injuries: Herr). Reports show that 40% of soldiers who were instantly catheterized recovered normal voiding (Urethral Injuries: Herr). Understand that these catheters were extremely primitive. They were either metal or gum-elastic, which was “silken thread covered in a gum resin called copal” (Urethral Injuries: Herr). Obviously these were not ideal instruments, yet they served an important purpose. While complications associated with catheterization, like creating false passages, did exist, the surgeons understood that the major cause of morbidity and death was due to “sepsis from urinary infiltration into the surrounding soft tissue” (Urethral Injuries: Herr). Catheters were heavily used and some surgeons would even try other techniques to drain extravasated urine.

The second most common procedure was called perineal urethrotomy where a small incision is made through the skin posterior to the scrotal sac in order to gain access to the membranous urethral. This technique creates an artificial fistula from the urethra to the surface so urine can escape. It was not until later in the war when surgeons realized that this practice resulted in infection and other complications like urethral fever. Consequently, surgeons started performing suprapubic cystostomy, which involves placing a catheter directly into the bladder superior to the pubic symphysis. Now this procedure is the most popular technique in modern military practices (Urethral Injuries: Herr). Doctors would also advise medical and supportive measures to “avert inflammatory complications incident to urethral injury” (Urethral Injuries: Herr). One example was saline laxatives to increase water excretion and decrease absorption.

Injuries to the penis and testis also occurred, though surprisingly less frequent than one might imagine since these are both external structures. There were a total of 309 shot wounds to the penis and one bayonet wound. Only 41 were fatal injuries, though the rest obviously detrimental in their life. There was even one case where the surgeon reported removing a bullet from the corpora sighting that had the soldier not have a “virile organ of extraordinary dimensions,” the bullet might have spared him. (Urological Injuries: Herr). Soldiers with penile injuries were advised to “shun lascivious thoughts” (Medical and Surgical History).

One of the greatest stories during the American Civil War is that of a theology professor from Maine named Joshua Chamberlain. He suffered numerous injuries during the war, but none greater than one that should have ended his life. Around Petersburg, VA on June 18th, 1864, he was struck by a Confederate bullet through his right greater trochanter and lodged behind his left acetabulum. He tried leading his men after sustaining the wound, yet eventually collapsed due to blood loss. Once back at the field hospital 3 miles to the rear, surgeons underwent a rare open wound exploration, which led to them realize that he would die of the fatal injury. However, Chamberlain insisted they continue the operation, which concluded with surgeons making a “fistulous opening of the urethra.” He did eventually die as a result of this injury, when he was 85 (The Lion of the Union: The Pelvic Wound of Joshua Lawrence Chamberlain: Harmon). His story is proof that while pelvic wounds may be thought of as fatal just like abdominal ones, surgeon’s were able to improve soldier’s lives though one may argue the lifetime of discomfort and pain is unimaginable. Still, these surgeons had a positive impact for these soldier’s especially this brave professor from Maine.

Overall, considering the complexity of pelvic injuries ranging from removal of bone and bullet, ligation of blood vessels, and extravasation of urine, these surgeons unknowingly set precedent for medicine as a whole for generations to come. Their methods of trail and error to establish the best techniques treated soldiers of their physical pain and attempted to minimize the “traumatic and devastating consequences beyond the wound itself” (Urological Injuries: Herr). Given the circumstances that these surgeons were dealing with, their remarkable accomplishments deserve recognition regardless of what the statistics indicate.

Image: Catheters and sounds from a Tiemann Civil War military urology set

From: gucivilwarmed.blogspot.com

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Post-Operative Care and Consequences during the American Civil War

By Adrienne Bruce

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.

From: gucivilwarmed.blogspot.com

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A Night with Venus, a Lifetime with Mercury

By Julia Carlson

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.

From: gucivilwarmed.blogspot.com

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

By Paul Elsbernd

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 benefiting 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.

From: gucivilwarmed.blogspot.com.

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Could Lincoln Have Survived his Gunshot Wound Today? A Comparison With Representative Gabrielle Giffords Assassination Attempt

By Leslie Rutherford

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.

From: gucivilwarmed.blogspot.com

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