PROSTHETICS UNDER TRIALS OF WAR

By Carlo FlaschaContributing WriterAccording to Katherine Ott, curator in the Science, Medicine, and Society Division of the National Museum of American History, Smithsonian Institution, “[t]he material and social tales of prosthetics provide a more intimate and compelling history of embodied technology than any postmodern cyborg can account for: from the ivory, leather, and vulcanized rubber in Victorian artificial limbs, to the acrylic parts and power-assisted controls used in limbs of the 1950s and 1960s…” (1) The story of prosthetics would not be so great without the trials of war as the lead antagonist.Throughout the history of prosthetics, war’s economic conditions and war amputees’ practical and subjective needs contribute to the progressive design of body-related technologies. (2) Conflict is a force for change, as Mary Guyatt suggests: “Works such as John Heskett's Industrial Design of 1980, and David Hounshell's From the American System to Mass-Production of 1984, have demonstrated that technology is at least pushed, if not developed in the first instance, by factors outside the world of pure science and engineering.” (3) War and its amputees catalyzed the development of maxillofacial prosthesis, lower-limb prosthesis, and upper-limb prosthesis. The slightly easier challenge of reconstructing the form of the face provided experience for the more significant challenge of reclaiming the function of the leg, which preceded the greater challenge of returning to the function of the arm and hand. But it was the problem of prosthesis for the eye that first emerged in warring society. (4)Up to late 1800s, few techniques existed to defend or heal the eyes of soldiers, which eventually led to the development of artificial eye making. Blunt trauma from blows to the head and face in battle were frequent dangers, such as gun cap shrapnel flying into eyes. Such injuries of the time were often so damaged that physicians resorted to enucleation, or the surgical removal of the eyeball. Physicians believed that, despite the eye recovering fully, the eye would eventually deteriorate and the pathology would inevitably spread to the other, healthy eye. (5) Some soldiers after the American Civil War especially needed an artificial eye to protect painfully exposed portions of their brains. (6)During the 19th century, war indirectly allowed social and symbolic value to merge with medical necessity, as Germany became the main force behind eye design. Ott noted, “Underlying all attempts at artificial eyes was the search for a ‘good fit.’ Since the definition of a ‘good fit’ depended on the availability of materials as well as the interplay of cultural aesthetics and medical practices, the design of artificial eyes has varied across time and place.” (7) For example, 18th-century Italy used glass as the material of choice for artificial eyes, while 19th-century France made theirs of enamel. Ultimately in the 1870s, the German Empire that formed after the Crimean War was able to use its combined resources to produce the advanced science, engineering, and industry behind cryolite glass. This material had the advantage of being easier to work with and could be finished into a more lifelike shine. Such craft experience led to medical necessity factoring into the design of the Snellen eye, shaped like a hollow pillow. Before this “reform” eye, artificial eyes were thin curved shells of glass with edges that cut into surrounding tissue, causing fluid build up. Patients also preferred the Snellen design for reducing the sunken appearance of the face’s orbit and socket area. (8)The fact that Germany was the lead manufacturer of glass and a common enemy of both wars in the early 1900s peculiarly led to the role of war itself in advancing prosthetic eyes. In World War I, glass manufacturers facing dwindling supplies chose not to advance research into perfecting glass eye tubing. Then in World War II, the Nazis forbade the export of glass, leading to glass shortages among the Allies. War left army medical officers with the responsibility to find alternatives. Plastic eyes appeared in the late 1930s, while three army dentists (Milton Wirtz, Stanley Erpf, and Victor Dietz) invented the first acrylic eye in 1943. Eventually, many 20th century ocularists learned the technique of acrylic eye craft in the army during World War II.(9) The use of plastic eliminated any chance of glass edges further damaging the eye socket. War’s initial hindrance led to the compensating advancement of prosthetic technology. Shared materials led to interdisciplinary work in both directions: as the work of dentists led to ocular innovation, ocularists in return learned how to fabricate other facial prostheses such as the jaw and teeth.Historical accounts speak of facial war injuries and corresponding maxillofacial prosthesis during wars as early as the 1800s. (10) The Franco-Prussian War from 1870 to 1871 held the scenario of a French soldier who had nearly his entire face blown off, including both eyes. The injured soldier received from his dentist a mask that included a full palate and complete dentures. The patient also got two false eyes for his hollow eye sockets. Another case from the American Civil War involved a corporal who lost his nose, maxilla, and upper lip in the Battle of Missionary Ridge. In 1864, a dentist from Ohio used the corporal’s face to produce an accurate cast, vulcanized with a connected nose and lip. (11) Both accounts show how maxillofacial prosthetics delivered prompt, unique, and ingenious designs for the facially wounded soldiers of this era, but innovations would not advance further without a challenge.In late 19th-century America, many soldiers believed that artificial limbs were of little practical use, but still rallied for their subjective use, prompting massive expansion of the country’s artificial limb-making industry. Confederate and Yankee surgeons performed an estimated total of 60,000 amputations during the course of the American Civil War. Consequently, there was an overwhelming demand for artificial limbs in the Confederate states. But many felt these prosthetic legs and arms were bulky, noisy, and uncomfortable. Some veterans were unable to wear Hanger-manufactured legs during the war because army surgeons left too much bone near the surfaces of their stumps. Others did not get their needed artificial limbs at all, as supply failed to keep up with demand. Eventually, the Virginia General Assembly passed over 20 laws designed to give artificial limbs to Confederate veterans who needed them from 1867 to 1894. (12)The start of World War I marked the start of a revolutionizing era of artificial limb making in Britain. Up to the Great War, Europe and America shared similar use of materials and manufacturing methods; towards the end of the 19th century, most legs essentially derived from the basic model of the Angelsey wooden leg. This device had a willow exoskeleton covered in rawhide, metal mechanisms, and a foot with a rubber sole. By 1914, there were about a dozen specialist manufacturers and numerous leather workers producing lower limbs. (13) The Ministry of Pensions showed the demand for artificial limbs in Britain with the following statistic: “Of the estimated 300,000 newly amputated ex-servicemen worldwide, around 41,000 were British.” (14) In Brighton, hundreds of men walked about on crutches, many having lost one or both legs. The spectacle motivated many private individuals to join established limb-makers in devising and patenting prosthetics. For example, one Londoner patented a leg made of paper-mache.(15) These simple developments in the craft of lower-limb prosthetics only hinted at the more significant innovations to come.World War I, with its destructive explosives, higher quantities of soldiers, and higher resulting injuries of disfigurement raised the standards for maxillofacial prosthetics, and the United States responded accordingly. Horrors of war never before witnessed left medical staff unprepared for such patients. To cope for these shortcomings, American sculptors made masks for these injured soldiers around the world. Some used pre-injury photographs to make accurate reproductions of missing parts while using a variety of materials like metal and soft rubber. In the end, sculptors painted all these masks to match the skin colors of respective soldiers. However, these efforts were easily overshadowed by the American genius of Dr. Varaztad Kazanjian, hailed as ‘The Miracle Man of the Western Front.’ Kazanjian combined the disciplines of dental prosthetic appliances and plastic surgery with remarkable results.War and its economic conditions necessitated major expansion and reconfiguration of Britain’s existing limb-making industry, which led to the establishment of Roehampton Hospital as an early research center. Founded in 1915, the hospital invited various limb-makers to demonstrate their products to its committee, which awarded contracts and workshops in the hospital grounds to the companies that impressed them. (16) The practice could be compared to a prosthetic Renaissance, where the patron hospital financially supported the most artful lower-limbs, in terms of subjectivity and practicality, so that the art of artificial limbs would advance as a whole. Roehampton Hospital worked closely with the Ministry of Pensions, which had an economic incentive to reduce the welfare bill and recover able bodies for post-war reconstruction. (17) Over the next ten years, 21 different manufacturers were based in the hospital grounds. Thanks to the collaboration of surgeons, patients, and limb-makers under one complex, Roehampton Hospital earned a worldwide reputation for excellence in the treatment of amputees. (18) Still, even in an institution with such a renowned reputation, the technology behind upper-limb prostheses had to catch up to its lower-limb counterpart.Before World War I, orthopedics and its corresponding upper-limb prosthetics garnered little attention. In the early 1900s there were two main models of artificial arms: the “Sunday arm” and the “work claw.” A Sunday arm, named for its common use on Sundays and holidays, was a cosmetic prosthesis carved from lightweight wood, modeled after the human arm, and incapable of movement. On the other hand, a work claw consisted of a metal hook or clamp attached to the end of a leather casing, which was then slipped over the stump, thus enabling the wearer to hold objects. (19) The former prosthesis catered to subjective needs, while the latter catered to practical needs. But no model at the time could achieve both aspects. Even the most advanced models from the United States, such as the popular Carnes arm, only heightened their resemblance to the human hand without its practicality.Ideologies geared toward improving economies during World War I shaped the goals of rehabilitation while directing the design of artificial upper limbs. Much like the goals pursued by the Ministry of Pensions decades later, German rehabilitation aimed to return soldiers to professional work for the good of the nation. German orthopedists also wanted to preserve the social status of the disabled. (20) Thus, Germany aligned its objectives for practical and subjective needs. This led to the realization that Germany could not rely on its existing prosthetics of Sunday arms and work claws, which achieved one objective or the other. Engineers and orthopedists reacted by releasing a series of new artificial arms, each tailored for specific classes. Designs first differentiated themselves by general occupational fields such as agricultural work or heavy industrial work. Doctors eventually developed job-specific arms that boosted worker efficiency. (21) Dominated by practical necessity, World War I modified humans into productive machines. Only electronics could extend such a transformation.Postwar efforts pursued electric or compressed gas-powered upper limbs, a stepping-stone for the development of sensory feedback and closed-loop control. Spurred by national recovery efforts after World War I, Germany developed the first powered hand components. (22) This reaction is similar to Germany’s aforementioned development of the Snellen eye after the Crimean War. However, such powered limbs used simple control methods, like switches, which made users feel like they were using foreign appendages instead of their personal appendage. (23) This outcome advised innovators to seek natural control schemes such as manipulating the nervous system. Unfortunately, the internal powering of a prosthesis, known as cineplasty, did not physically manifest before 1950, but at least the idea surfaced as early as the Italian and Abyssinian War of 1897-1898, when historians noted that soldiers with amputated hands had intact and functional forearm muscles. (24) In contrast, externally powered components gained momentum after World War II with the Valduz hand. This myoelectric prosthesis used muscle bulge as an input to position servomechanisms on the hand, granting the amputee some sense of finger position with respect to the hand’s framework. (25) This mechanism is still being modified and experimented with hand prosthetics today.Economic conditions under war and the practical and subjective needs of war amputees made prosthetics essential to the evolution of technologies in human form. In modern times, world-renowned engineer Dean Kamen is working with the Veterans Administration of America to develop the culmination of upper-limb prosthetic technology, the bionic arm. Ott upholds a common historical perspective on prosthetics as “a type of body-machine interface emblematic of modern culture. What, after all, could be a greater expression of modern anomie than the worker or soldier who, after losing his or her arm to modern warfare or an industrial accident, gets a replacement limb fabricated of synthetic materials?” (26)Works Cited(1) Katherine Ott, ‘The Sum of its Parts’, in Artificial Parts, Practical Lives: Modern Histories of Prosthetics, ed. by Katherine Ott, Stephen Mihm and David Serlin (New York: New York University Press, 2002), pp.1-42 (p.3-4)(2) Ott, pp.1-42 (p.5).(3) Mary Guyatt, ‘Better Legs: Artificial Limbs for Veterans of the First World War’, Journal of Design History, 14 (2001), 307-325 (p.308).(4) As early as 1579, Ambroise Paré, an ingenious French physician, produced one of the first usable artificial eyes known as the ekblepharon.(5) Katherine Ott, ‘Hard Wear and Soft Tissue’, in Artificial Parts, Practical Lives: Modern Histories of Prosthetics, ed. by Katherine Ott, Stephen Mihm and David Serlin (New York: New York University Press, 2002), pp.147-170 (p.147, 149).(6) Jennifer David McDaid ‘How a One-legged Rebel Lives’, in Artificial Parts, Practical Lives: Modern Histories of Prosthetics, ed. by Katherine Ott, Stephen Mihm and David Serlin (New York: New York University Press, 2002), pp.119-143 (p.122).(7) Ott, pp.147-170 (p.151).(8) Ibid., (p.151-154) .(9) Ibid., (p.155-156, 159).(10) One account very early in this century occurred during the Napoleonic wars in 1806. A soldier lost his entire lower jaw to a cannon ball. Prostheses for such an injury took the form of a silver chin with a sponge behind it to collect saliva.(11) Malvin Ring, ‘The History of Maxillofacial Prosthetics’, Plastic and Reconstructive Surgery, 87 (1991), 174-184 (p.176).(12) McDaid, pp.119-143 (p.121-124).(13) Guyatt, pp.307-325 (p.309, 311).(14) Ministry of Pensions, Artificial Limbs and Their Relation to Amputations, HMSO, 1939.(15) Guyatt, pp.307-325 (p.311).(16) Ibid.(17) Julie Anderson, ‘Paraplegia, Rehabilitation and Sport at Stoke Mandeville’, Journal of Contemporary History, 38 (2003), 461-475 (p.462).(18) Guyatt, pp.307-325 (p.311-312).(19) Heather Perry, ‘Re-Arming the Disabled Veteran’, in Artificial Parts, Practical Lives: Modern Histories of Prosthetics, ed. by Katherine Ott, Stephen Mihm and David Serlin (New York: New York University Press, 2002), pp.75-101 (p.79).(20) Ibid., (p.83-84).(21) Ibid., (p.84).(22) Dudley Childress, ‘Closed-Loop Control in Prosthetic Systems: Historical Perspective’, Annals of Biomedical Engineering, 8 (1980), 293-303 (p.298).(23) Ibid.(24) Reuben Eldar and Miroslav Jelíc, ‘The Association of Rehabilitation and War’, Disability and Rehabilitation, 25 (2003), 1019-1023 (p.1021).(25) Ibid.(26) Ott, pp.1-42 (p.3).Photo Courtesy of Cambodia Trust