RSD and Its History

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From: <NOBR>byrd45</NOBR> (Original Message) Sent: 6/15/2005 10:16 AM

Volume 66 Number 10


Phantom Limb and Causalgia Pain in the Three Great Wars

Doris K. Cope, M.D.
Committee on Pain Medicine


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Silas Weir Mitchell, M.D. (1829-1914). Photo courtesy of Library of the College of Physicians of Philadelphia.





In any armed conflict throughout the ages, it has always been the foot soldier, the common man, who bore the brunt of the battle. The physician treating these soldiers has always had a front-row seat in observing the trauma and outcomes of injury in his or her patients. From the tragedies of wars have sprung advancements in medical knowledge and treatment based primarily on the keen observations of individual physicians. Three physicians: Silas Weir Mitchell, M.D. (1829-1914); René Leriche, M.D. (1879-1955); and William K. Livingston, M.D. (1892-1966), helped to shape our understanding of the concepts of phantom limb pain and causalgia over the course of three great American wars.

Civil War (1861-1865)
There have been few conflicts in history as bloody as the American Civil War, where technology in the form of rifled muskets able to fire up to eight aimed shots a minute at a killing range of 500 yards were employed by soldiers of both sides while still using outmoded "close-order drill military tactics more appropriate to Revolutionary War technology."1 The "butcher's bill" was high, and not surprisingly, a plethora of amputations both surgical and traumatic resulted. A young U.S. Army contract physician, Silas Weir Mitchell, M.D., recorded his keen observations of peripheral nerve injuries and postamputation, or phantom pain, which he termed "sensory hallucination." It was notable that he even attempted description and differentiation of these types of pain; this went against the prevailing wisdom of the time. This is reflected in an 1822 statement from Charles Bell, M.D., the Scottish anatomist and neurosurgeon who surmised that the study of neurological injury was impossible due to "endless confusion" and "too great irregularity for legitimate investigation or reliance."2

But Dr. Mitchell was confronted with real patients in pain, and so he carefully documented their presenting symptoms and course of illness. He described the "hallucinations," which we now call phantom limb pain as "the sensorial delusions to which persons are subject in connection with their lost limbs."3 He collected his wartime observations in a monograph published in 1864 as Gunshot Wounds and Other Injuries. He went beyond the purely anatomical injury and discussed the emotional sequelae of amputation and resultant phantom limb pain in "The Case of George Dedlow," the lead article published in the Atlantic Monthly in July 1866. This fictitious account of a U.S. Army surgeon who suffered causalgia and phantom limb pain after a series of war injuries and treatments describes the human cost of trauma, amputation and the debilitating effects of long-term pain. Through multiple military theaters and medical interventions both on the field and at more structured sites, the tortured patient travels until he finally ends up at the Philadelphia "Stump Hospital" on South Street (Turner's Lane) as a "useless torso." The theme of suffering that resulted from traumatic neurological chronic pain continued throughout Dr. Mitchell's career and is seen in his full-length novel, In War Time (1884).




Casualties of War
Outside Union Field Hospital at Fredericksburg, Virginia, 1864. Note the nurse-attendant sitting in the doorway among the wounded soldiers of the Army 3rd Corps, most of whom suffered extremity injuries. Photo courtesy of Maurice S. Albin, M.D.




The trauma and dangers of war were never forgotten by Dr. Mitchell, who experienced it firsthand at the casualty stations as well as through the experiences of his patients. Military medicine was hazardous duty: in the Army of the Republic alone, 51 surgeons were killed outright, and 281 died by a disease or explosion.4 These tragic circumstances helped to shape the beginnings of our current understanding of phantom limb pain and complex regional pain syndrome.

World War I (1914-1919)
Another military physician, René Leriche, M.D., a surgeon, treated many World War I soldiers who also sustained peripheral nerve damage. He observed the classic vasomotor changes of complex regional pain syndrome, which prompted him to attempt pain relief through periarterial sympathectomy:

A few months previously I had unexpectedly encountered one of these cases. I was struck by the resemblance which the condition had to that of a sympathetic disorder: the cyanosis, the sweating, the paroxysmal nature of the pains, the effect on the general mental state, the reference of painful phenomena to a distance – all pointed in that direction. And, remembering that the sympathetic, in its distribution to the limbs, follows the course of the arteries, I asked myself whether, in those case of nerve injury complicated by arterial wounds, it was not the injury to the sheath of the vessel that determined their painful and trophic features – the wound of the sympathetic… Starting from this point, I asked myself whether, by acting upon the perivascular sympathetic, I might be able to succeed in modifying the causalgia.3

In the following case study, he discusses the beneficial effect of his novel treatments:

I saw the patient on the 20th June: the upper limb was completely paralyzed – arm, forearm, hand and fingers… [D]ominating everything, was an intense burning pain, concentrated particularly in the palm of the hand and on the pulp of the finger-tips… On the 27th August I exposed the brachial artery, which I found small and contracted. I removed its adventitia for a distance of 12 cm… By the next day it was obvious that the patient had less pain.3

He went on to contrast his experimentation in treating painful stumps and phantom limb pain with reoperation, neurectomy and neuroma resection. He finally concluded that "novocain infiltrations of the paravertebral sympathetic chain" was a new and effective treatment for this type of pain. Again, he was haunted by the nerve pain these brave soldiers endured, and in 1937 he wrote his classic work on the "surgery of pain," La Chirurgie de la Douleur.5

"It is unfortunately true that sometimes the crucible of fire is required for gold to emerge. Through the pain and suffering of valiant soldiers of past wars, new medical knowledge was offered up… "




World War II (1941-1944)
During World War II, William K. Livingston, M.D., was a Lieutenant Commander physician assigned to the Oakland Naval Hospital where he was responsible for soldiers who had sustained peripheral nerve injury and were in chronic pain. In his landmark book, Pain Mechanisms: A Physiologic Interpretation of Causalgia and Its Related States, Dr. Livingston describes "a vicious circle" of pain as similar with vasoconstriction and atrophy, comparing this pain to "circus movements in heart muscle."6

He also describes the "mirror images" of pain or sympathetic pain in which the limb contralateral to the injury becomes sympathetic. We now know this concept to be true; modern research has delineated interneuron connections that not only ascend and descend the pain pathway but result in abnormal neurotransmission to the contralateral side as well.

Additionally, Dr. Livingston's work is remarkable in that he suggests that the then-current concept of receptor specificity with only four modalities of cutaneous sensitivity (i.e., touch, pain, heat and cold) was much too simplistic and therefore inadequate to explain pain syndromes such as phantom limb pain and causalgia. He defines pain sensation as being modulated by higher cortical centers and emotional factors. Thus, he described all pain as a psychic perception with a marked psychological component. This understanding contributed to our current appreciation of chronic pain as a complex multifactoral phenomenon.

It is unfortunately true that sometimes the crucible of fire is required for gold to emerge. Through the pain and suffering of valiant soldiers of past wars, new medical knowledge was offered up to those who had eyes to see and ears to hear. Let us pray for more peaceful means to advance our medical knowledge in the future.





Hi Everyone,

I thought it might be interesting to read about and comment on the history of RSD. It might have been named by a different name(causalgia),but the pain that was felt by all those soldiers was very much the same pain. I wonder to myself that how come if this has been documented since the civil war why people are still suffering without a cure. That makes me sad, but hopefully through the awareness activities of many and the research being done at this very moment we will live to see a painfree tomorrow!Anyhow I found it interesting researching this and hope you enjoy reading this as well! Any comments and thoughts as always are appreciated. You can add them to this post.

Robyn