Dorothea Dix

From: totalgettysburg.com

Dorothea Dix was made famous by her role in the American Civil War as the Union's Superintendent of Female Nurses. Prior to her role in the war, she had implemented the first programs in the country to treat those suffering from insanity. Through tireless lobbying with state legislatures, she laid the groundwork for the nations first mental asylums.

As the American Civil War broke out between the North and South, Dorothea felt a call to duty. As Superintendent of Female nurses, Dix set strict guidelines for the women she hired. They were required to be between 35-50 years old and plain-looking. They were to dress in black or brown dresses and were not allowed to wear jewelry of any kind.

Dorothea Dix, Civil War Nurses, Civil War HospitalsDorothea did not want to put any of the women in danger of being exploited by male doctor’s or patients and also looked to avoid flirtatious marriage-minded women from joining her ranks.

She was tough to deal with and would often fight with Civil War doctors, surgeons and army bureaucrats. Many did not want female nurses in Civil War hospitals and she fought for the rights of her women.

There were constant disagreements over the hiring and firing of nurses and she was known to fire many nurses that she did not initially hire. There was a marked improvement of nursing care under her direction however and her service to the Union army was invaluable.

Dix was known to have treated Union and Confederate soldiers equally when providing treatment although many would disagree with her policy of equality. She simply saw men in need regardless of uniform and she saw no reason to favor one side or the other.

After the war ended, Dorothea Dix resigned her position in August 1865 and returned to her life-work of caring for the mentally ill. She will be most remembered however for being the catalyst behind the immeasurable contribution of Civil War nurses.

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Clara Barton: Angel of the Battlefield

From: totalgettysburg.com

Shortly after the start of the American Civil War, Clara Barton, a clerk for the U.S. Patent Office tended to wounded Union soldiers in Washington. She quickly realized the need to get supplies to wounded soldiers on the battlefield and established a system of helping to meet this need. Clara often traveled to the front with army personnel to treat wounded soldiers early on in the war despite lack of support for her efforts.

By the time the conflict broke out, women were not accepted in Civil War hospitals, camps and battlefields and those women offering their assistance faced staunch resistance. Clara persisted and lobbied with U.S. army officials for permission to bring her own medical supplies to the front to treat the wounded and dying.

In August, 1862 Clara received the permission she was looking for and served on the front lines at some of the bloodiest battles for the remainder of the war. Clara quickly became one of the highly-regarded nurses of the Civil War and was appropriately named “The Angel of the Battlefield” for helping thousands of wounded men over the course of the war.

Clara Barton, Angel of the Battlefield, Nurses of the Civil WarIn 1865, President Lincoln appointed Clara in charge of locating missing Union soldiers. Right around this time, a Union solider named Dorence Atwater located Clara and brought some encouraging information. He had been held prisoner at the notorious Andersonville prisoner camp and had copied a list of 13,000 names of those who had died in the camp. Dorence was able to smuggle the names out of the camp when the prisoners were released and he intended on publishing the names so the families would know the fate of their loved ones.

He and Clara made a trip to Andersonville GA following the war, and after honoring the dead, they proceeded to have all the names published in newspapers and sent letters to soldiers’ families. This list would thereafter be known as “The Atwater List”.

Clara toured the country speaking of her wartime experiences as a nurse and her accounts brought great clarity to the important role of Civil War nurses. This helped the women's suffrage greatly in this country and paved the way for women to be viewed as skilled workers in the medical profession.

Perhaps Clara Barton’s largest contribution was to start an American chapter of the International Committee of the Red Cross. After visiting France and being exposed to this organization and their efforts, she lobbied to start a similar organization in the U.S. After seven tireless years of building support for this endeavor, the American Red Cross was founded on May 21, 1881. Barton carried out her duties as acting president with great success before retiring in 1904 at the age of 83. Clara Barton died on April 12, 1912 in Glen Echo, Maryland surrounded by friends.

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Civil War Medicine

From: totalgettysburg.com

Civil War medicine played a large part in keeping soldiers on the field and disease at bay, yet 19th century medicine in America left much to be desired. Civil War doctors were only required to have two years medical training prior to being appointed, and many had even less. In short, at this time in America, Civil War medicine was unable to keep up with the horrors of an industrialized war.

More men died of disease in the Civil War then fell in battle at a rate of 2 to 1. Diarrhea and dysentery were two of the worst afflictions soldiers faced and took many lives over the course of the war. Typhoid, smallpox, measles, pneumonia, camp itch and malaria ran rampant through the camps. Thousands of men were thrust together in cramped quarters and many had no immunity to the diseases they faced.

Conditions in camps on both sides were often deplorable with feces and rotting food within the camps creating highly unsanitary conditions. The overall knowledge of disease and how it spread was not common knowledge like it is today and mistakes were made that cost many men their lives outside of the field of battle.

Civil War Medicine and Civil War Doctors could not keep up with the horrors of the Civil War.

For the most part medical supplies were manufactured in the north. The Confederates found supplies harder to come by as the were typically either smuggled through the Union blockade, or captured Union stores were utilized to treat troops.

Quinine was widely used by both armies to treat high-fever, namely malaria. It was known that a camp near a swampy area would cause outbreaks of fever, chills, headache and the shakes and this drug that is derived from the South American Cinchona tree could effectively treat these symptoms.

Whiskey was often used as anesthetic when nothing else was available and was utilized to treat wounds as well. It could be ingested prior to amputations to make the patient calmer in a tough situation and acted as a painkiller.

Use of unprocessed opium was popular during the conflict for treating pain and for a variety of other needs. Open bowels were treated with a plug of opium and closed bowels were treated with a mixture of “blue mass” containing mercury and chalk.

Civil War surgery caused many issues as well with few doctors having actual surgical experience prior to the war. Limb after limb would be cut off using the same blade and sterilization of instruments was largely non-existent. It was not often a doctor or Civil War nurses for that matter would even wash their hands before moving on to the next patient, nor did they always have the time.

Civil War medicine evolved over the course of the war and made great advances over time yet many good men died from lack of good medicines, a general misunderstanding of hygienic practices and the lack of practical experience in treating the horrific wounds that evolved through industrial-age warfare.

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Civil War Surgery

From: totalgettysburg.com

The primary form of Civil War surgery was the amputation. The common use of the minie ball, named after co-inventor Claude Etienne Minié in the American Civil War greatly increased catastrophic injuries. Made with soft expanding lead, when the mini ball struck flesh, bones and major organs the injuries were devastating.

A minie ball could be accurately fired from 1,000 yards and the basic line-formation tactics of the Civil War had not adapted to new weaponry. It could easily shatter bones and when faced with these types of injuries, Civil War doctors of this age often had no choice but to amputate.

This may seem archaic but due to the lack of time available to doctors to perform surgery, the high-risk of infection, and the catastrophic destructive power of these bullets, the decision to amputate was typically the right one.

The success rate for amputees was roughly 75% and these odds were good considering the awful nature of the injuries. Many injuries and death were caused by cannonballs, canister shot, shells and bayonets, but the majority of injuries were from bullets.

A woeful 1% of doctors in the Civil War had prior experience as surgeons. Doctors learned as they went and adapted quickly with practice and slowly gained practical experience. Early on there were many mistakes made, and men died from it. But as the war went on the doctors’ skills improved and the care provided increased.

A good surgeon could amputate a limb in under 10 minutes by using a bonesaw and other instruments. Chloroform was used when available to render the patient unconscious and morphine was utilized as a pain-reducer.

The bone was sawed clear through and the limb was disposed of often in a pile of other limbs form previous amputations. Next, the arteries were tied-off with silk, horsehair or cotton thread to stop blood flow to the area. Then the bone would be filed down smooth to prevent the sharp edge from protruding and causing future damage to the area operated on.

Finally, using a flap of skin that was left, it was folded over to create the stump with a hole for fluids to drain. Then the wound was bandaged and the solider was set aside to rest and recover. If infection or gangrene didn’t set in after 48 hours, the chances of survival were greatly improved. When “surgical fevers” did set in, the chance of survival was just over 10%.

Basically the closer the amputation was to the body, the less chance for survival. When a solider came in with a head, stomach or chest wound, they were typically put to the side as they were almost always fatal injuries beyond the help of Civil War medicine. This allowed the Civil War doctors to help the soldiers who had a chance to survive, rather than waste their time on those with a lesser chance.

The skill involved in Civil War surgery developed sharply over the course of the war and the efforts of the doctors really paid off for those lucky enough to survive the terrible injuries suffered on the field of battle.

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Anesthesia's Evolution: Satanic Influence to Saving Grace

By Cristin O'Keefe Aptowicz, September 26, 2014 4:56 PM

Cristin O'Keefe Aptowicz, author of the new novel "Dr. Mutter's Marvels," released today. She contributed this article to Live Science's Expert Voices: Op-Ed & Insights. 

Dr. Thomas Dent Mütter was a pre-Civil War plastic surgeon who performed radical surgery on the severely deformed in a time before anesthesia. During his life and career, the American medical community saw enormous leaps forward when it came to innovations and discoveries — but in writing a nonfiction book about Mütter's work, I was amazed at how his story, and the parallel story of the development of anesthetics, illustrates the sometimes chaotic and furious path of scientific discovery. ['Dr. Mütter's Marvels' (US 2014): Book Excerpt ]

I had always assumed that medical science — so rooted in provable facts — would embody that clean upward line of success. But science, like life, is far more complicated.

An age before anesthetic
It is hard to imagine, as a person living in the twenty-first century, agreeing to surgery without hope of anesthesia. And yet, prior to the discovery of ether anesthesia in 1846, all surgeries — from minor to major or absolutely radical — were performed on people who were wide-awake, oftentimes held down on the operating table by men whose only job was to ignore the patients pleas, screams and sobs so that the surgeon could do his job.

Dr. Mütter lived and worked in this world, and spent the first half of his career developing and implementing strategies that he hoped would "alleviate human suffering" when it came to surgery — not only in the operating room, but before and after surgery, as well.

He would spend days massaging the faces or limbs of patients on whom he was slated to operate, to desensitize them to the touch of his hands and instruments, and improved his ambidextrousness so that he could perform his surgeries twice as quickly. [The Macabre Dr. Mutter's Freaky Medical Marvel]

When the news of the first successful ether-aided anesthesia surgery exploded across the American medical world, Mütter was the first to embrace the new drug, performing Philadelphia's first ether anesthesia surgery just one month after the first one ever was performed in Boston. Within weeks of Mütter's successful ether surgery, the drug was banned in several Philadelphia hospitals for years.

Why?

Anesthesia's slow start
One would have assumed that once ether anesthesia was introduced, the surgical world would be overjoyed and embrace this transformative innovation with widespread immediacy. But the journey that ether anesthesia took was not that easy … and the reasons were surprisingly logical and diverse.

First, one must understand the mindset of mid-19th century surgeons. It was not just for the entirety of their careers that the norm was to perform surgeries on fully-conscious patients — the practice spanned the entire history of surgery. Speaking with, and attaining permission from, the patients on which they were operating had always been a part of the surgical process. To remove that interaction by using anesthesia seemed utterly foreign to them — like removing one of their senses.

Additionally, anesthesia was discovered in a time before standardized medicine. While the use of pharmacists was growing in popularity (doctors were less reliant on mixing their own medicines), there was no guaranteed quality when it came to medicine during this time period. Surgeons couldn't fully trust the ether they were using. Sometimes the mixture was too weak, and the patients wouldn't lose consciousness (or perhaps more horrifically, would regain consciousness mid-surgery). Other times, the mixture would be too strong, and the patient would die on the table from an overdose.

And lastly — and most compellingly for me — anesthesia was discovered before germ theory became understood as scientific fact. Physicians and surgeons during that time period still debated about whether the thorough washing of hands and tools prior to surgery was even necessary. Because of the lack of cleanliness in the operating room, deaths from surgeries were often not from bleeding out on the table, but from the horrific infections which would overcome the body once the surgery was completed.

The discovery of ether anesthesia certainly opened bold new possibilities when it came to the art of surgery, but without the antisepsis practices that would be embraced by later generations of doctors, the mortality rates for ether surgeries were not terribly different from the surgeries where the patient was thrashing on the table.

It was because of those factors, and other lesser ones, that the American medical community struggled to accept the leap in innovation that anesthesia promised. While doctors like Mütter embraced it — understanding that while it was not perfect, the positives far outweighed the negatives — other doctors were not convinced. For years after its discovery, hospitals and medical schools would continue to ban its use in their operating rooms.

Prestigious doctors and dentists would publish damning op-eds referring to the drug as "satanic influence," and decrying those doctors who supported its use by saying they had been "seduced from the high professional path of duty into the quagmire of quackery by this will-o'-the-wisp." And patients, in operating rooms and dentist's chairs across the country, would suffer unimaginably as the debate raged on.

Anesthesia becomes the norm
The true success — and the full acceptance — of anesthesia surgeries happened after so many other factors beyond its control aligned. Once germ theory was proven — and doctors insisted on sterilized environments, tools and hands in surgical settings — post-operative fatality rates plummeted. After the U.S. Food and Drug Administration was created and new legislation required pharmaceutical standards, doctors could feel more confident in the drugs they were administering. And once the old generation of doctors who knew no other way than performing on fully conscious patients died out, the principal voices of dissent were removed.

Science is often messier than people think — and scientific process can be even more messy. Anesthesia's path to acceptance reminded me of an illustration about the messy path of progress. One panel, "How People Think Success Happens" shows a humble line navigating a clean path upwards from a point marked "Obscurity" to a point marked "Success." The second panel, "The Reality of How Success Happens" contains the same two data points, but there is more line than paper, as the scribbled path is not clear at all, and for every hopeful rise there is a near-instant arch backwards and down.

It's important to remember that even if it takes time, progress does happen. And more often that not, it's a group effort. Every new discovery is just another piece of a larger puzzle that helps society create the platform for innovations yet to come.

From: news.yahoo.com

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An Irony of War

By Paul E. Stepansky, Ph.D.

“There are two groups of people in warfare – those organized to inflict and those organized to repair wounds – and there is little doubt but that in all wars, and in this one in particular, the former have been better prepared for their jobs” (Milit. Surg., 38:601, 1916).  So observed Harvey Cushing, the founder of modern neurosurgery, a year before America’s entry into World War I.  Cushing’s judgment is just, and yet throughout history “those organized to repair wounds” have risen to the exigencies  of the war at hand.  In point of fact, warfare has spurred physicians, surgeons, and researchers to major, sometimes spectacular, advances, and their scientific and clinical victories are bequeathed  to civilian populations that inherit the peace.  Out of human destructiveness emerge potent new strategies of protection, remediation, and self-preservation.  Call it an irony of war.

Nor are these medical and surgical gifts limited to the era of modern warfare.  The French army surgeon Jean Louis Petit invented the screw tourniquet in 1718; it made possible leg amputation above the knee.  The Napoleonic Wars of the early nineteenth century brought us the first field hospitals along with battlefield nursing and ambulances.  The latter were of course horse-drawn affairs, but they were exceedingly fast and maneuverable and were termed “flying ambulances.”  The principle of triage — treating the wounded, regardless of rank, according to severity of injury and urgency of need – is not a product of twentieth-century disasters.  It was devised by Dominique Jean Larrey, Napoleon’s surgeon-in-chief from 1797 to 1815.

The American Civil War witnessed the further development of field hospitals and the acceptance, often grudging, especially among southern surgeons, of female nurses tending to savaged male bodies.  Hospital-based training programs for nurses were a product of wartime experience.  Civil War surgeons themselves broached the idea shortly after the peace, and the first such programs opened  in New York, Boston, and New Haven hospitals in 1873.  The dawning appreciation of the relationship between sanitation and prevention of infection, which would blossom into the “sanitary science” of the 1870s and 1880s, was another Civil War legacy.

And then there were the advances, surgical and technological, in amputation.  They included the use of the flexible chain saw to spare nerves and muscles and even, in many cases of comminuted fracture, to avoid amputation entirely.  The development of more or less modern vascular ligation – developed on the battlefield to tie off major arteries extending from the stumps of severed limbs – is another achievement of Civil War surgeons.  Actually, they rediscovered ligation, since the French military surgeon Amboise Paré employed it following battlefield amputation in the mid-sixteenth century, and he in turn was reviving a practice employed in the Alexandrian Era of the fourth century B.C.

In 1900 Karl Landsteiner, a Viennese pathologist and immunologist, first described the ABO system of blood groups, founding the field of immunohematology.  As a result, World War I gave us blood banks that made possible blood transfusions among wounded soldiers in the Army Medical Corps in France.  The First World War also pushed medicine further along the path to modern wound management, including the treatment of cellulitic wound infections, i.e., bacterial skin infections that followed soft tissue trauma.  Battlefield surgeons were quick to appreciate the need for thorough wound debridement and delayed closure in treating contaminated war wounds.  The prevalence of central nervous system injuries – a tragic byproduct of trench warfare in which soldiers’ heads peered anxiously above the parapets  – led to “profound insights into central nervous system form and function.” The British neurologist Gordon Holmes provided elaborate descriptions of spinal transections (crosswise fractures) for every segment of the spinal cord, whereas Cushing, performing eight neurosurgeries a day, “rose to the challenge of refining the treatment of survivors of penetrating head wounds” (Arch. Neurol., 51:712, 1994).  His work from 1917 “lives today” (ANZ J. Surg., 74:75, 2004).

No less momentous was the development of reconstructive surgery by inventive surgeons (led by the New Zealand ENT surgeon Harold Gillies) and dentists (led by the French-American Charles Valadier) unwilling to accept the gross disfigurement of downed pilots who crawled away from smoking wreckages with their lives, but not their faces, intact.  A signal achievement of wartime experience with burn and gunshot victims was Gillies’s Plastic Surgery of the Face of 1920; another was the founding of the American Association of Plastic Surgeons a year later.  After the war, be it noted, the pioneering reconstructive surgeons refused to place their techniques at the disposal of healthy women (and less frequently healthy men) desirous of facial enhancement; reconstructive facial surgery went into short-lived hibernation.  One reason reconstructive surgeons morphed into cosmetic surgeons was the psychiatrization of facial imperfection via Freudian and especially Adlerian notions of the “inferiority complex,” with its allegedly life-deforming ramifications.  So nose jobs became all the rage in the 1930s, to be joined by facelifts in the postwar 40s. (Elizabeth Haiken’s book Venus Envy: A History of Cosmetic Surgery [1997] is illuminating on all these issues.)

The advances of World War II are legion.  Among the most significant was the development or significant improvement of 10 of the 28 vaccine-preventable diseases identified in the twentieth century (J. Pub. Health Pol., 27:38, 2006);  new vaccines for influenza, pneumococcal pneumonia, and plague were among them.   There were also new treatments for malaria and the mass production of penicillin in time for D-Day.  It was during WWII that American scientists learned to separate blood plasma into its constituents (albumin, globulins, and clotting factors), an essential advance in the treatment of shock and control of bleeding.

No less staggering were the surgical advances that occurred during the war. Hugh Cairns, Cushing’s favorite student, developed techniques for the repair of the skull base and laid the foundation of modern craniofacial surgery by bringing together neurosurgeons, plastic surgeons, and ophthalmic surgeons in mobile units referred to as “the trinity.”   There were also major advances in fracture and wound care along with the development of hand surgery as a surgical specialty.   Wartime treatment experience with extreme stress, battlefield trauma, and somatization (then termed, in Freudian parlance, “conversion reactions”) paved the way for the blossoming of psychosomatic medicine in the 1950s and 1960s.

The drum roll hardly ends with World War II.  Korea gave us the first air ambulance service.  Vietnam gave us Huey helicopters for evacuation of wounded soldiers.  (Now all trauma centers have heliports.)  Prior to evacuation, these soldiers received advanced, often life-saving, care from medical corpsmen who opened surgical airways and performed thoracic needle decompressions and shock resuscitation; thus was born our modern system of prehospital emergency care by onsite EMTs and paramedics.  When these corpsmen returned to the States, they formed the original candidate pool for Physician Assistant training programs, the first of which opened its doors at Duke University Medical Center in 1965.  Vietnam also gave us major advances in vascular surgery, recorded for surgical posterity in the “Vietnam Vascular Registry,” a database with records of over 8000 vascular wound cases contributed by over 600 battlefield surgeons.

The medical and surgical yield of recent and ongoing wars in the Persian Gulf will be recorded in years to come.  Already, these wars have provided two advances for which all may give thanks:  portable intensive care units (“Life Support for Trauma and Transport”) and Hem-Con bandages.  The latter, made from extract of shrimp cells, stop severe bleeding instantaneously.

Now, of course, with another century of war under our belt and the ability to play computer-assisted war games, we are better able to envision the horrific possibilities of wars yet to come.  In the years leading up to World War I, American surgeons – even those, like Harvey Cushing, who braced themselves for war – had no idea of the human wreckage they would encounter in French field hospitals.  Their working knowledge of war wounds relied on the Boer War (1899-1900), a distinctly nineteenth-century affair, militarily speaking, fought in the desert of South Africa, not in trenches in the overly fertilized, bacteria-saturated soil of France.  Now military planners can turn to databases that gather together the medical-surgical lessons of two World Wars, Korea, Vietnam, Iraq, Afghanistan, and any number of regional conflicts.

Military simulations have already been broadened to include political and social factors.  But military planners should also be alert to possibilities of mutilation, disfigurement, multiple-organ damage, and drug-resistant infection only dimly imagined.  Perhaps they can broaden their simulations to include the medical and surgical contingencies of future wars and get bench scientists, clinical researchers, and surgeons to work on them right away.  Lucky us.

From: adoseofhistory.com

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Second Opinions: What Caused the Death of Stonewall Jackson?

by Jim Schmidt
from the October 2007 issue of The Civil War News

When it comes to "second opinions," few Civil War personalities have been poked and prodded as much as Stonewall Jackson, especially as regards conclusions about what really caused his death after his friendly-fire wounding at Chancellorsville. By turns, several hypotheses have been put forward, including an abscess of his lung, pneumonia, or a pulmonary embolism. A few of the more recent reports include:

Albin MS, "The wounding, amputation and death of Thomas Jonathan "Stonewall" Jackson: Some Medical and Historical Insights," Bull Anesth Hist, 2001 Oct;19(4):1, 4-7, 15-6.

Haines JD, "What killed Stonewall Jackson?" J Okla State Med Assoc, 1998 Jul;91(4):162-5.

Layton TR, "Stonewall Jackson's wounds," J Am Coll Surg, 1996 Nov;183(5):514-24.

Recently, two more physicians have thrown their hat into the ring with a new hypothesis. In a recent paper, “Chronic gastrointestinal symptoms of Thomas ‘Stonewall’ Jackson following Mexican-American War exposure: a medical hypothesis,” (Military Medicine, Jan 2007, Vol. 172, No. 1, pp. 6-8), Drs. Timothy R. Koch and Joseph B. Kirsner offer a new explanation, namely Jackson's complications from chronic peptic ulcer disease.

It's an interesting hypothesis, made even more interesting in that the authors tie it to their experience in treating veterans of the Persian Gulf War, many of whom exhibited symptoms of chronic heartburn or dyspepsia and were diagnosed with infections of Helicobacter pylori, a bacteria that infects various areas of the digestive tract and is a contributing factor to peptic ulcers, gastritis, and even cancer.

The authors note that “Stonewall” Jackson was born and raised in an area of what is now West Virginia that has a high prevalence of H. pylori. Jackson suffered symptoms of chronic dyspepsia, especially after his service in the Mexican-American War. For relief, he tried various remedies, including what would become known as the “Sippy diet” – a regimen of foods (cereals, eggs, and crackers) and fluids (milk and cream) intended to neutralize gastric acid.

On Saturday, May 2, 1863, Jackson received a bullet wound to the left arm at the battle of Chancellorsville; he underwent amputation of the left arm below the left shoulder and died a week later with a diagnosis of pleuropneumonia. But, since the records of Jackson’s post-surgical course are incomplete, the door has been open to a number of possible theories. Drs. Koch and Kirsner believe that Jackson’s chronic dyspepsia - and his death – might be related to chronic ulcers caused by H. pylori.

Both doctors are experts in the field of gastroenterology. Dr. Kirsner received his medical degree more than seventy years ago and is about to celebrate his 98th birthday. He still goes to work daily at the University of Chicago, where he has been teaching since 1935. Dr. Kirsner served as an Army surgeon in Europe and the Pacific during World War II. Dr. Kirsner is recognized internationally as one of the leading figures in the modern development of the field of gastrointestinal medicine.

Dr. Koch received his medical degree at the University of Chicago – where he studied under Dr. Kirsner – and completed his training in gastroenterology at the Mayo Clinic in Rochester, MN. He is a professor of medicine at the Georgetown University School of Medicine, and his special interests involve micronutrients and anti-oxidants in gastrointestinal disorders. He is the author of more than a hundred scientific papers, presentations, and book chapters in his field, and was kind enough to answer some of my questions to cast further lights upon his research and conclusions.

“My interest in the Helicobacter pylori stomach bacterium was raised when I had a chance to meet with Dr. Barry Marshall from Australia,” Dr. Koch told me. “He discovered this organism by culturing the germ from patients with peptic ulcers; then he swallowed it in his attempt to show its importance in formation of peptic ulcers.” In doing so, Marshall reversed decades of medical doctrine which held that ulcers were caused by stress, spicy foods, and too much acid; he received the Nobel Prize in Medicine in 2005 in recognition of his research.

According to Dr. Koch, his paper on Jackson arose from his interest in whether “history repeats itself.” “Many individuals seen for upper intestinal problems at the Clarksburg, WV, Veteran’s Administration (VA) hospital after Persian Gulf War exposure were found to have the H. pylori organism,” Dr. Koch said. “Thomas Jackson still has family members living there and H. pylori infection is a common diagnosis in the area.” He added that published studies suggest that West Virginia may have one of the highest rates of infection in the country.

“Since Thomas Jackson grew up in Clarksburg, it is likely that he was exposed to the H. pylori bacterium,” Dr. Koch told me. When he visited the Stonewall Jackson Shrine off of Interstate 95, south of Fredericksburg, VA, Dr. Koch saw that the “official” explanation – as described at the Shrine - is that Jackson died essentially of an abscess adjacent to the lung caused by a fall from his horse “Little Sorrel.” “His symptoms and clinical course are not consistent with this diagnosis and certainly many other authors have already stated this point,” he added.

Dr. Koch noted that Stonewall Jackson’s personal surgeon – Dr. Hunter Holmes McGuire – was "not just another country doctor." Indeed, McGuire is a founding father of modern medicine in the state of Virginia and the VA medical center in Richmond, VA, is named after him. Still, Dr. Koch wanted to know more about McGuire’s major professional interests, so he and his daughter, Kristina, obtained reader passes from the Library of Congress.

“You can imagine our excitement when we found that the Rare Books Collection at the library contains a short textbook written by Dr. McGuire after the Civil War,” Dr. Koch told me. “The book was brought up in an elevator from the deep vault by a librarian. When we carefully examined the book, we found that Dr. McGuire's main medical interest is in the field of death rates caused by open abdominal wounds compared to closed abdominal wound, in other words gunshot or stabbing wounds (open) as opposed to perforations of the intestine or ulcers,” he added.

Dr. Koch noted that there was minimal specialization in gastroenterology at that time, but peptic ulcers were identified by autopsy in the 1850’s, well before the onset of the Civil War. “It seems unlikely that Dr. McGuire ignored the potential diagnosis of a closed abdominal wound in Stonewall Jackson,” he told me, but, absent accepted surgical remedies, there was not much McGuire could do to intervene.

Dr. Koch said that gastric disease is an ongoing concern for soldiers deployed around the world today. “Our ongoing concern is that individuals can bleed from peptic ulcer disease without any advanced symptoms as a warning,” he told me. Drugs – such as ibuprofen – are routinely taken for “aches and pains,” but they also have risks of stomach ulcers which could present as a massive internal bleeding.

“Out in the field, it is likely that many soldiers are using these medicines and are not aware of the risks of taking these drugs,” Dr. Koch said. The doctors also propose that military personnel who have lived in a region with a high prevalence of H. pylori should be routinely tested before they are deployed.

The article has very interesting details on Jackson’s early bouts with gastric disease and a spirited defense of the doctors’ hypothesis on the disease’s implications following Jackson’s wounding at Chancellorsville. The story of Dr. Marshall is further witness to the fact that medical theories change with time and new evidence. The doctors round out the article with some good advice for today’s military.

For Dr. Koch, the most interesting aspect of this story is that it remains difficult for us to learn from historical lessons. As his hypothesis strays farthest from the “conventional wisdom” of what ultimately killed “Stonewall” Jackson, it might seem that he has a greater burden of proof. Still, Dr. Koch made a very good point in telling me, “Why would we not think that we could suffer health problems similar to those of our distant relatives?”

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Antebellum Life Insurance: “A Matter of Life and Death”

by James M. Schmidt
The Civil War News – “Medical Department” February/March 2014

Imagine for a moment that you are a life insurance agent sitting in your office in early 1861…the day’s mail includes a piece of correspondence from one of the brave Union soldiers garrisoned at Fort Sumter, with a very serious question:

“I am desirous to be informed whether, in case we are attacked by the forces of South Carolina, and I lose my life in the defense, the Company will pay the amount of the policy to my family.”

How do you reply?  That very note came into the offices of New York Life in February 1861.  For months – anticipating a crisis – the company principals had debated how they would handle war claims, but here – in their hands – was the impetus needed to make a final decision.  They wrote back to the soldier; first, admitting that the risk of war was not legally covered, but then vowing:

“[Should] any of the brave men now doing duty at Fort Sumter…fall in its defence…we doubt not but that there is patriotism enough in our Trustees to waive the legal question…and pay the amount insured.”

The history of life insurance in America, from its origins in the early 1800s up to and including the Civil War, is the subject of an interesting and award-winning book: Investing in Life: Insurance in Antebellum America (Johns Hopkins University Press, 2010; softcover reprint, 2013). The author, Sharon Ann Murphy, Ph.D., is an associate professor at Providence College, Providence, Rhode Island, with special interests in 19th-century U.S. social, economic, and business history. The book won the Hagley Prize in business history in 2012.

I received a review copy from JHU Press and enjoyed the book very much, indeed.  I was especially interested in reading the book as it represents a unique intersection of so many of my own interests in 19th-century history, all in one volume - corporate history, slavery, the Civil War, and – of special interest to readers of this column: medicine and health.

The book is a very thorough examination of the birth and growth of the life insurance industry in America from the early 1800s through the Civil War. The author's research is exceptional: in addition to period newspapers, published company histories, and other secondary literature on the insurance industry in the 1800s, she made special use of a few collections of America's earliest insurance companies, at least one of which included correspondence to and from the company, so one gets both a customer and a corporate perspective.

The beginning of the book was interesting as it explained how the American companies had very little in the way of actuarial or mortality information for the United States and had to make assumptions by adapting British mortality and premium tables instead. It was interesting to learn that the insurance companies pressed for changes to the census questionnaire.

The book then describes the evolution of the major companies (some still in business to this day, such as New York Life, MetLife – which started as the National Union Life and Limb Insurance Co. – and others), the development of agency/agent system, the moral and religious arguments for and against life insurance, the grim - but interesting - involvement of some companies in insuring the lives of slaves, and – finally - the role of firms in insuring the lives of soldiers during the Civil War.  The author also challenges some conventional wisdom on the history and evolution of the life insurance industry in America.

As I hinted at above – and this should not be surprising given the subject matter – there is a considerable amount of material in the book related to 19th-century medicine which should appeal to readers of the column. This includes:

Physicians: Just as many do today, the antebellum insurance companies required a medical examination of potential customers to determine possible risk factors.  One firm required all agents to “select a physician of experience, and one in whose character entire confidence can be placed.  His opinion will be taken in every case.” (p. 66) Insurance firms were very conscientious about the credentials of the examining physician, disallowing eclectics and other "non-traditional" schools of medicine. The examining physicians were asked to assess the applicants’ specific health condition, an opinion on their potential life span, and advice on whether an additional premium should be charged.

Geography: Presumed and demonstrated differences in disease patterns across the continent also played strongly into assessing health risks and premiums.  As a general rule, living or traveling in the Deep South was either prohibited or engendered increases in premiums or limits on policy values.  William Bard – president of New York Life & Trust – declared that he “declin[ed] altogether insurances for the whole year in New Orleans or in other Southern or particularly unhealthy places.” (p. 35).  The firms were also very cautious about insuring persons in California.

War Risks: Policies had almost always included military service and war exclusions but most companies excused these limits and added a modest “war risk” premium of a few percent on soldier and sailor policies, in no small part because they felt it their public and patriotic duty.  But many actuaries and insurance businessmen quickly realized that the real problem was not in the easily intuitive risk of death on the battlefield, but rather from disease.  As one insurance executive warned, “[T]he losses by battle are small in comparison to what they are estimated to be by disease contracted in camp or by exposure.” (p. 270).

In short, this excellent book provides a look at matters of life and death in the Civil War era in a way that you may not have considered before.

It also provides an interesting connection between ourselves and our antebellum and wartime ancestors: there’s a chance that the life insurance company you use today may be the same as the one they used!

Image: St. Louis (MO) newspaper - 12 August 1851

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