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October 2002
Volume 66 |
Number 10
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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.
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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).
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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.
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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… "
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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.
References
1. Redding JS, Matthews JC. Anesthesia during
the Civil War. In: Davis DA, ed. Historical Vignettes of Anesthesia.
Philadelphia: FA Davis Co; 1968:2-18.
2. Schoenberg E. The Turner's Lane Military
Hospital – Birthplace of Scientific Pain Control. Wood
Library-Museum of Anesthesiology Fellowship; 1995.
3. Phantom Limb and Causalgia: The Tragic
Enigmas, Relief of Pain and Suffering Web site exhibit, . John C. Liebeskind History of Pain Collection, History & Special Collections,
UCLA Louis M. Darling Biomedical Library; 1998.
4. Canale DJ. Civil war medicine from the
perspective of S. Weir Mitchell's "The Case of George
Dedlow." J Hist Neurosciences. 2002; 11:11-18.
5. Leriche R. The Surgery of Pain. Baltimore:
Williams and Wilkins; 1939 (translated by Archibald Young).
6. Livingston WK. Pain Mechanisms: A Physiological
Interpretation of Causalgia and Its Related States. New York:
MacMillan Co; 1943:1-253.
Acknowledgement:
The author wishes to thank Maurice S. Albin, M.D., for contributing
the Civil War military medicine photograph and the librarians
of the Wood Library-Museum of Anesthesiology, Patrick Sim
and Karen Bieterman, for their invaluable research help in
preparing this article.
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Doris
K. Cope, M.D., is Professor of Anesthesiology and Critical
Care Medicine, University of Pittsburgh Medical Center
(UPMC), and Clinical Director of UPMC St. Margaret Pain
Medicine Center, Pittsburgh, Pennsylvania. |
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