Tuesday, January 05, 2010

CWL---When Nerves Are Literally Shot: Phantom Pain From Gunshot Wounds

"The Firm: Mitchell, Morehouse and Keen and Civil War Neurology", D. J. Canale, pp. 127-141 with notes in Years of Change and Suffering: Modern Perspectives on Civil War Medicine, James M. Schmidt and Guy R. Hasegawa, editors, Edinborough Press, 2009, $29.95 (hardcover), $13.95 (paper).

As in the case of post-traumatic stress syndrome in Civil War veterans, brilliant and hardworking individuals bring forth a new medical approach to phantom pain and sensations from amputated limbs. Silas Weir Mitchell and co-workers George R. Morehouse and W.W. Kean birthed the American study of neurology. At the outbreak of the war Mitchell declined a commission as a brigade surgeon due to family obligations including assuming his father' medical practice. In a year's time, Mitchell was serving as a contract surgeon at the Filbert Street Hospital in Philadelphia. Recognizing the experience as a unique opportunity to produce scholarly research as well as heal wounded soldiers, Mitchell pursued patients with diseases and injuries to the nervous system.

George Read Morehouse, a colleague of Mitchell, was assigned in 1863 to the Christian Street Hospital and W. W. Keen was assigned to assist Mitchell after Keen served as an assistant surgeon during the First (1861) and Second (1862)Manassas campaigns. Like several other medical discoveries during the Civil War, neurology was developed by the concentration of medical talent in Philadelphia. As the three migrated to the new 400 bed Turner Street Hospital in Philadelphia, it became the first hospital in the United States to develop treatment for neurological injuries and disorders.

The first hand observation of nerve injuries inflicted by gunshot wounds led to a classification system: the pain, paralysis and loss of sensation related to reflex paralysis, causalgia (burning sensation in attached limbs), malingering (feigned symptoms) and the perception that a missing limb is still attached. By 1864 the team wrote and published ground breaking Gunshot Wounds and Other Injuries of Nerves.

The six classifications of injuries to nerve trunks were founded upon detailed case students with the full cooperation of the afflicted soldiers. Self-reporting by articulate suffers and improvement in interviewing techniques of physicians allowed for a breakthrough in interpretation of trends found in case studies. From the 1854 Surgery (Eichsen edited by Briton), the 1861 System of Surgery (Gross) and the 1862 Treatise on Gunshot Wounds (Longmore), Mitchell and colleagues found that there was not therapy for the repairing of damaged nerves.

They successfully explored the degeneration and regeneration of served nerves and the possibility of suturing of divided ends of nerves. Reflex paralysis instigated by shock to nerves or the spinal cord and causalgia (burning sensation) brought about severed and damaged nerves were found to exist in patients. A systematic and thorough interview and collection of information from other soldiers weeded out malingers who feigned pain and disability to avoid duty. Though not systematically studied, data was collected on phantom limb sensation. Mitchell speculated on the phantom limb pain in his noteworthy, in literary terms, short story The Case of Georg Dedlow published in 1866 in the literary magazine The Atlantic .

Mitchell succumbed to exhaustion and withdrew from medicine for 1864, but during the year he travelled to Paris to consult with physicians also studying neurology. With the closing of Turner's Lane Hospital in June 1865, the team broke apart though they worked in Philadelphia at different practices. Mitchell, Morehouse and Keen continued their pioneering work throughout the rest of the 19th century with Mitchell also gaining notoriety for his short stories. Their systematic collection of data, their consistent use of interviewing methods, their collection of patient generated descriptions allowed them to advance neurology and the treatment of gunshot wounds. Surgeons in both World War One and World War Two relied on their discovers and conjectures.

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