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Perspectives
1332
www.thelancet.com
 
Vol 373 April 18, 2009
On June 29, 1864, a military surgeon in the 21st KentuckyInfantry wrote to his wife. “It has been almost one continuedstream of carnage”, he explained, adding that “My hands areconstantly steaped [sic] in blood. I have had them in bloodand water so much that the nails are soft and tender. I haveamputated limbs until it makes my heart ache to see a poorfellow coming in the ambulance…the horror of this war cannever be half told.”The American Civil War was a conflict of utmost savagery.Over 600 000 American soldiers died. 30 000 limbs wereamputated. The new conical bullet or minié proved to bemore damaging to muscle and bone than its predecessors.Made of soft lead, the minié tended to flatten out whenit entered a body, leading one surgeon writing in the
Confederate States Medical and Surgical Journal
in 1864 toargue that soldiers were wrong to fear “cold steel” since“bayonet wounds are almost harmless when compared tothe ploughed tracks which the terrible Minnie [sic] boresthrough the tissues”. Surgeons were right to despair: howcould the “horror of this war” be adequately told?Some military surgeons believed that fiction could be more“true” to the terrors of war than objective medical texts. Lessthan a year after the war was over, a 37-year-old neurologistwho had enlisted with the Union forces published a shortstory that entranced thousands of Americans.
The Caseof George Dedlow
came out in
The Atlantic Monthly
in July,1866. Its author was Silas Weir Mitchell, later to become arenowned neurologist and the inventor of the “rest cure” for“nervous” patients. Because the short story was publishedanonymously, many readers believed that it was theautobiography of its narrator, George Dedlow. Dedlow’s fatewas unusual, but imaginable to readers still reeling from thecarnage of the war. While serving as assistant-surgeon in theSeventy-Ninth Indiana Volunteers, Dedlow had been injured:all of his limbs had been amputated. “Of my anguish andhorror of myself I dare not speak”, he stuttered.In searing prose, Dedlow described how he “screamed,cried, and yelled in my torture” after being first wounded.His arm felt as if it was being “perpetually rasped with hotfiles”. Even without anaesthetic, amputation was a blessing:the “strange lightning of pain” was followed by “instant,unspeakable relief”. Looking at his arm lying on the floor,Dedlow’s first thought was: “There is the pain, and here am I”.Subsequent wounding and a gangrene infection eventuallyled to the amputation of his other three limbs. He lost four-fifths of his bodyweight, becoming, in his words, nothingmore than “a useless torso, more like some strange larvalcreature than anything of human shape”.At this stage in the story, Mitchell uses his fictional characterto muse on the neurological phenomenon of phantom limbs.Phantom limbs had been described in the mid-16th centuryby French military surgeon Ambroise Paré, but very little wasknown about what caused stump neuralgia (in the 1860s, theonly treatments were electrotherapy, leeching, irritation of the surface of the stump, and re-amputation, none of whichwere very successful). In
The Case of George Dedlow
, Mitchellspeculates freely about what caused absent limbs to itchand feel pain. According to him, sensory impressions weretransmitted through nerves to spinal nerve-cells and thento the brain. When a limb was removed, and until the stumphealed, nerves continued to accept sensory impressions andto convey these impressions to the brain. If the stump neverfully recovered, the result was constant irritation or a burningneuralgia. As Mitchell later explained in his famous textbook,
Injuries of the Nerves and Their Consequences
(1872), phantomlimbs made “the strongest man…scarcely less nervous thanthe most hysterical girl”.Phantom limbs were related to broader problems of defining the boundaries of the self. In Dedlow’s words, “Ifound to my horror that at times I was less conscious of myself, of my own existence, than used to be the case”. Itwas, he explained, “a deficiency in the egoistic sentiment of individuality”, as though one half of himself was “absent orfunctionally dead”. In the climax of the story, this atrophy of the self was briefly reversed when, during a spiritualist séance,his legs were physically conjured up. They had been in storageat the US Army Medical Museum in Washington, wherearmy surgeons during the American Civil War had routinelysent amputated limbs for study. “I was re-individualized, soto speak”, Dedlow insisted, and “I arose, staggering a little”
The art of medicine
Silas Weir Mitchell’s
The Case of George Dedlow
 
Return of wounded Confederate prisoners, under a flag of truce, during the American Civil War
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