Tuesday, October 23, 2007

Civil War Medicine's "Spookier" Side - Part II - "Phantom Limbs"

Continuing the theme of the very "spooky" (and yet, very real) side of Civil War medicine, I'm pleased to post another older Civil War News "Medical Department" column...this on on the phenomenon of "phantom limbs"

"The Case of George Dedlow"

by Jim Schmidt

from the August 2002 issue of The Civil War News

In July 1866, readers of the popular magazine, The Atlantic Monthly, were treated to an interesting story of a soldier’s Civil War experience, written in the first person by one George Dedlow. George Dedlow’s training as a surgeon was interrupted by the war and he entered the Union Army as an Assistant Surgeon. He was shot by musket in both arms, resulting in the amputation of one at the shoulder. After rehabilitation, Dedlow returned to the battlefield, only to lose both legs at mid-thigh and subsequently the remaining arm to infection.

The account was so convincing that readers accepted it as the description of a real case. Money was collected in several places to assist Dedlow, and caring persons even visited hospitals to find him and offer aid. Unbeknownst to the magazine’s readers, however, the story was actually a fictional account penned by Silas Weir Mitchell.

Mitchell had written the story for his own amusement, and did not intend for it to appear in print. He lent the manuscript to a friend, who then sent it to the Rev. Edward Everett Hale. Hale offered it to The Atlantic, and to Mitchell’s surprise, he received a check from the journal. The story was inserted as a leading article without his name.

Mitchell gained fame as a physician, literary figure, and one of the fathers of American neurology. During the Civil War, he served as a contract army surgeon, and at Mitchell’s prodding, his friend Surgeon General William Hammond opened a center specializing in the treatment of injuries to the nervous system at Turner’s Lane Hospital in Philadelphia. There, Mitchell and his colleagues, especially William W. Keen and George Morehouse, performed important clinical research on nerve injuries.

The Dedlow tale is the subject of Dr. D.J. Canale’s excellent paper, "Civil War Medicine From the Perspective of S. Weir Mitchell’s ‘The Case of George Dedlow,’" published in the Journal of the History of the Neurosciences (March 2002, Vol. 11. No.1, pp. 11-18).

Over the years, the Dedlow story has become a classic of American literature and medicine. "The story is a ‘classic,’ and of interest to medical historians, mainly because of the detailed clinical description of both ‘causalgia’ and ‘phantom limb’ syndrome in a popular magazine before they were widely recognized in the medical literature of the day," Dr. Canale told me.

In the story, George Dedlow is ambushed by Confederate guerillas and shot. The bullet passed through the left biceps into the right arm below the shoulder. The right arm became cold and was without sensation. Within a short time, Dedlow felt a terrible burning in his right hand: "It [the pain] increased…until I felt as if the hand was caught and pinched in a red-hot vise." Only by wetting his hand was Dedlow afforded with some temporary relief.

Dedlow was describing symptoms of "causalgia." Causalgia is pain in an extremity, often very intense, associated with skin changes caused by a peripheral nerve injury. Mitchell, Morehouse, and Keen provided a complete description of this syndrome in their book Gunshot Wounds and Other Injuries of the Nerves, a landmark study which they described several important neurological injuries, including causalgia, for the first time. Dr. Canale points out that wet dressings continued to be the most effective treatment until 1930.

Later in the story, Dedlow explains that he was promoted to captain, and returned to his regiment. During the great battle at Chickamauga, Dedlow was wounded again when the enemy began to "bowl round-shot at us," and he was hit in the legs by a bouncing cannonball. The surgeons felt it necessary to amputate, and when Dedlow awoke from the anesthesia, he felt a sharp cramp in his left leg. He tried to get at it to rub it, but finding himself too weak, Dedlow hailed an attendant and asked him to rub it:

"Calf?" said, he, "you ain’t none, pardner. It’s took off."

"I know better," said I. "I have pain in both legs."

"Wall, I never! Said he. "You ain’t got nary a leg."

Dedlow did not believe him, and when the attendant threw off the covers, Dedlow saw with horror that both his thighs had been amputated very high up.

Here, Dedlow was describing the interesting phenomenon of "phantom limbs," the sensation, after amputation, that the absent part is still present. "Phantom limb had been only briefly described in incidental cases before Mitchell's reports," Dr. Canale told me. "Mitchell's description in the Dedlow story is the first clear and definitive description of phantom limb. It was based on studies of a large number of cases at the Turner’s Lane Hospital," he continued.

In his article, Dr. Canale goes beyond Dedlow’s descriptions of causalgia and phantom limbs, which he admits others have done before him. Dr. Canale also suggests, for the first time, that Mitchell’s real purpose was to "describe the many important medical consequences of the American Civil War." In the second part of his article, Dr. Canale shows how Mitchell accomplished this goal through the clever device of Dedlow’s fictional narrative. For example:

At the very beginning of the tale, Dedlow is able to secure an appointment as an Assistant Surgeon, even though he has not completed his studies, "underscoring the acute shortage of surgeons in the army at the outbreak of hostilities."

During the narrative, Dedlow comments that he was treated with great kindness by Confederate surgeons at a hospital in Atlanta. Dr. Canale notes that: "the wounded, with few exceptions, were treated with equal care on both sides."

The emphasis on amputations throughout the narrative is also logical. Even though there are no recorded triple or quadruple amputations during the Civil War, Dr. Canale notes that it was the most common major surgical procedure performed.

Finally, Dr. Canale wonders if Mitchell may have had a deeper purpose in writing the story with an assistant surgeon as its major character. He notes that Mitchell felt that the army surgeons on both sides were "unrecorded heroes," and were generally unrecognized.

Dr. Canale has had a distinguished career as a surgeon and a medical historian. He graduated from the University of Tennessee College of Medicine in 1955, and performed postgraduate training and internships in neurosurgery at Henry Ford Hospital in Detroit. He served three years in the United States Air Force as a Flight Surgeon.

Dr. Canale served as president of the Memphis and Shelby County medical societies, was recently president of the American Osler Society, and is currently historian of the Southern Neurosurgical Society.

In the past few years, Dr. Canale has devoted particular attention to studying Civil War medicine. "My interest was the result of a tour of battlefields and historical sites associated with Stonewall Jackson with a group from my church about three years ago," he told me. He has also been on a similar tour studying Robert E. Lee.

As a surgeon himself, it’s probably not surprising that he counts several Civil War medical personalities among the men that he admires, including Mitchell, Keen, Hammond, and Confederate surgeon Dr. Hunter Holmes McGuire. Dr. Canale’s current project is studying gunshot wounds to the brain during the Civil War.

***

Mitchell’s colleague at the Turner’s Lane Hospital, W. W. Keen, is the subject of an excellent biographical sketch, "A Man for All Seasons: W.W. Keen," by Drs. R.L. Rovit and W.T. Couldwell, recently published in the journal Neurosurgery (Jan 2002, Vol. 50, No. 1, pp. 181-90).

William Williams Keen was a moving force behind the advent of neurosurgery in the United States. During the Civil War, Keen collaborated with Mitchell in studying injuries sustained to the nervous system, and was a contributor to the 1864 publication Gunshot Wounds and Other Injuries of the Nerves. Keen’s most monumental accomplishment was being the first surgeon in the United States to successfully remove a primary brain tumor (in 1887), and have the patient survive for more than 30 years.

3 comments:

Zach Willard said...

Cool!

Teagan Oliver said...

Thank you for an interesting article. I am curious as to what method of treatment would have been given at that time to try to relieve the pain?

Ashley E said...

Hi, I'm wondering if there's any possible way that you could send me the original story by Mitchell. I know that I'm years behind on my comment, but I hope that you still see it.
The reason that I'm so interested is that I have causalgia, (now called Complex Regional Pain Syndrome), and Mitchell was the first to document and do a bit of research about the condition. Yet even now, in 2014, it is severely misunderstood and there is not much research available. The current treatments are just to minimize the symptoms, and there is no cure.
In just curious what Mitchell found during civil war times.
If you want, please email me at ashtpiano at gmail dot com.
Thanks so much.

Ashley