Wednesday, November 12, 2014

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.



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