Tuesday, July 3, 2007

"Medical Department" Column #5 - "Gettysburg: Then and Now"

As this week marks the anniversary of the Battle of Gettysburg, it seemed like a good time to post another past "Medical Department" column from The Civil War News. This column - first published in the February/March 2001 issue is relevant as it concerns a comparison of treatments: that of a re-enactor accidentally wounded at a Gettysburg "living history" event compared with the treatment given to a casualty during the actual battle, 1-3 July 1863. Enjoy!


"Gettysburg: Then and Now"
by Jim Schmidt
From the February/March 2001 issue of The Civil War News


The subject of this column is a paper in the Journal of the American College of Surgeons, "The Last Confederate Casualty at Gettysburg: A Case Report and Review of Similar Historic Cases" (Volume 191, Issue 2, August 2000, pp. 204-207).

The article, written by Suzanne Shultz and her colleagues at York Hospital, York, Pa., reviews the hospital treatment of a man wounded in the neck at the 135th anniversary reenactment event at Gettysburg in 1998, an unfortunate episode that resulted in a good deal of discussion among the living historian community.

The article includes the patient's account of the wounding, a detailed case report of his treatment at York Hospital, a review of similar cases from the Civil War, and a commentary on the differences of treatment of similar wounds separated by 135 years of advances in medicine. A short list of references provides avenues for additional reading and research.

The article begins with the account, in his words, of the fellow who was injured. After describing his regiment's part in the battle and his place in line as a skirmisher, he recounts that as he advanced he felt a tremendous blow behind and below his left ear. His neck and shoulder were paralyzed from the pain. He put his hand to his neck, felt blood, and realized he had received more than just a powder burn. He tried to yell for help, but could manage only a whisper.

The authors then describe their treatment of the patient. He was evacuated from the scene by helicopter and treated with oxygen en route to York Hospital. Arriving within an hour of being injured on the battlefield, they report that the patient was alert and had recovered his voice enough to give a coherent account of the accident. The patient was submitted to a battery of diagnostic tests, including x-rays, CT scans, and an arteriogram. The tests revealed the path of the projectile, the location of the lodged bullet, and encouraging evidence that there was no complicating vascular injury.

The patient was taken to surgery for operative debridement, placement of drains, and removal of the bullet via an oral approach, using rubber-shod clamps. The patient exhibited no fever after surgery and was able to swallow without difficulty. The wound healed rapidly and he was discharged within a week's time. Antibiotics and pain medication were prescribed to reduce the opportunity for infection and to relieve discomfort.

Recognizing the unique circumstances, especially the historical setting, of the wounding, the authors consulted the Medical and Surgical History of the War of the Rebellion to compare their patient's case with similar cases from the Civil War. None of the cases exactly paralleled the current case, but they did identify a small set of similar cases, allowing them to point to some important changes in medical practice in the last 140 years.

Of particular significance is the speed of removal from the battlefield to the hospital. Times from wound to treatment averaged nearly five days in the Civil war cases they studied, with the longest being 16 days! Minimizing the time between trauma and treatment can result in considerably better outcomes.

The authors acknowledge that their handling of a single reenactment casualty does not compare to the challenge of triaging the thousands of wounded after a major battle, such as Gettysburg. They also discuss the complications caused by the type of ordnance used in the Civil War.
Another significant difference is surgical technique. During the Civil War, gunshot wounds were explored with either a nonsterile probe or equally contaminated finger to remove bullet and bone fragments, and other debris. Modern patients have the benefit of a clean surgical environment as well as non-invasive tests such as CT scans and x-rays.

The accident may have served as a wake-up call to safety practices at reenactment events, but it also allows for a unique then-and-now perspective in the treatment of serious gunshot wounds.


Best Regards,


Jim Schmidt

5 comments:

BlueMassCat said...

The links to the articles is great, but some of us are too poor to subscribe to this particular professional journal site. Any way of maybe persuading the authors to reprint their articles?

BlueMassCat said...

A particular passage in the article summary states:

"Another significant difference is surgical technique. During the Civil War, gunshot wounds were explored with either a nonsterile probe or equally contaminated finger to remove bullet and bone fragments, and other debris. Modern patients have the benefit of a clean surgical environment as well as non-invasive tests such as CT scans and x-rays."

It subtly implies that modern medicine is better than nineteenth century medicine simply because we know about germs &c. I offer a counter argument, based on a discussion we have going on the CW Reenactors Forum -

"Period medicine was a complex field in its own right. The fact that much of it has been improved upon or proven wrong, doesn't mean that individual surgeons were stupid, any more than individual soldiers were stupid for using what we consider obsolete weapons and tactics. Or, for that matter, that modern doctors are stupid for not applying today, discoveries from the 22nd century." Hank Trent

Thusly, I feel the surgeons who wrote their report in the MSH did the best they could, and I feel it is somewhat arrogant to compare our treatments to theirs and feel like we are the winner.

Jim Schmidt said...

Bluemasscat:

Thanks for the great responses. First - I'm also too "poor" to subscribe to the professional journals; I usually ask the author for a hardy copy or e-copy (called a "reprint" in the journal business). I believe the primary author - Suzanne Shultz - can still be reached through York Hospital at: sshultz@wellspan.org

Best Regards,

Jim Schmidt

Jim Schmidt said...

Bluemasscat:

Thanks for the other great response to the blog entry. I think you and I will actually agree on more than you think...I would consider myself part of the "new school" of thought on Civil war medicine advanced by the likes of Jay Bollet, etc. - that is...the Civil War surgeon was not at all "stupid" and indeed did the best they could...what's more, many of their techniques - e.g. the "Letterman System" are still in use today. From what I could tll, the purpose of the "Last Confederate Casualty" article was to take advantage of a unique opportunity to compare and contrast, not to pass judgement.

I hope you'll keep reading...and commenting.

Best Regards,

Jim Schmidt

Anonymous said...

The educated surgeons of the time, including my great-great grandfather, Henry H. Smith, M.D., and Surgeon General of Pennsylvania from 1861- Sept. 1862did know about infections and about trying to maintain sterile conditions. Unfortunately, not many "surgeons" were actually trained in medical schools. I have my ancestors' letters that describe his efforts to communicate and supervise the field hospitals and surgeons and to help impress upon them better methods. He was often frustrated by the bureaucracy of the War Department and by other problems, but they were very aware of the need to maintain better sanitary conditions.

At some point, I'll transcribe all the letters, journals, and his lecture notes--he taught Anatomy and Surgery at The University of Pennsylvania.

Thanks,