Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Pain and Related Phenomena Including Causalgia
Pain and Related Phenomena Including Causalgia
Pages 311-340
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From page 311... ...
Its name we apparently owe to Silas Weir Mitchell (54) , as he wrote: "Perhaps nothing can better illustrate the extent to which these statements may be true than the cases of burning pain, or as I prefer to term it, causalgia, the most terrible of all the tortures which a nerve wound may inflict." These three physicians, while in charge of nerve injuries at a military hospital near Philadelphia during the War Between the States, emphasized that the peculiar burning, 311
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From page 312... ...
that the causalgic syndrome was still present in a few, and that severe burning pain, not related to psychological stimuli but to thermal changes and use of the part, was often a cause of long-continued incapacity and suffering. Weir Mitchell and his colleagues stressed the peculiar emotional factors which characterize the causalgic state, citing the increase in pain which is manifested by the victims with a multitude of psychic stimuli: the stirring music of a military band, jarring noises in the war, even the rattling of a newspaper.
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From page 313... ...
Injuries to certain nerves are far more likely to result in causalgia than others. In the 64 cases we have been able to study in detail there has been the following numerical incidence: Median 33 Ulnar 2 Sciatic 17 Posterior tibial 10 Peroneal 2 It is possible that the incidence of causalgia following ulnar and peroneal nerve injuries is somewhat higher than the figures given above, as there are 11 combined median and ulnar lesions in this series which have all been included under the median and 2 combined posterior tibial and peroneal lesions listed under the tibial nerve.
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From page 314... ...
After the arm was amputed for pain, its dissection showed the median nerve involved in a neuroma. Other examples were recorded by John Abernethy, who described a case following venisection and mentioned an earlier description of the pain by Percival Pott, which followed partial division of a nerve.
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From page 315... ...
Neither of these men derived any benefit from extensive neurolysis of the brachial plexus or from resection of a portion of the axillary artery, but both responded in a most gratifying manner to upper thoracic sympathectomy. In World War II Mayfield found an incidence of causalgia of somewhat over 5 percent in nerve injuries treated at the Percy Jones Army Hospital.
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From page 316... ...
The cervicothoracic or stellate ganglion should be infiltrated when the arm is involved, the lumbar chain for causalgia in the lower extremity. When the pain follows a wound of the sciatic nerve high up in the thigh or buttock care must be taken to carry the infiltration upwards to include the first lumbar and lowest thoracic ganglia.
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From page 317... ...
This represents the incidence amongst a much larger number of peripheral nerve injuries, and it is questionable whether all of these men had typical causalgia.
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From page 318... ...
. Lasting relief following repeated blocking of sympathetic ganglia 6 1 9 2 Relief following excision of neuroma and suture 2 0 Failures: Inadequate sympathectomy 1 1 No sympathetic block, or test preceding ganglionectomy failed to give significant relief 1 t 2 0 Excision of neuroma and suture ...
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From page 320... ...
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From page 321... ...
Diagnosis of causalgia is questionable and pain not well relieved by procaine block.
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From page 327... ...
i 2 g •o § ftI u .a & e s ~ -- •".
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From page 328... ...
We have encountered only one failure for which there is no certain explanation (case 56) , a man who had characteristic pain, a good response to diagnostic block, and removal of the lumbar chain through the first lumbar ganglion for a wound of the sciatic nerve in the midthigh.
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From page 329... ...
The nervous apprehension caused by this procedure resulted in such severe throbbing pain that it was necessary for a hospital corpsman to drip lukewarm water over the lower arm and hand while the needles were being inserted in his back. However, within a minute of the time the infiltration of procaine began the discomfort disappeared, and a few minutes later the cold extremity became warm and dry.
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From page 330... ...
The missile, which entered his axilla, partially divided the axillary artery and ulnar nerve, and severed the median. Severe causalgic pain developed immediately throughout his entire hand.
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From page 331... ...
The cold weather has little effect other than the usual stiffness in my fingers." He also experiences a moderately annoying degree of gustatory sweating in the sympathectomized side of his face when he eats spicy foods. There has apparently been little recovery following the extensive neurolysis, transposition, and suture of his ulnar nerve, although there has been useful recovery of the median following the neurolysis and resection of the lateral neuroma.
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From page 332... ...
Albans he had a cold hand without any radial pulse, the characteristic signs of median and ulnar paralysis, and severe ischemic fibrosis of the flexor muscles in his forearm. On August 21, 1945, a week after his admission, following temporary relief obtained by paravertebral procaine block, his moderately severe causalgia was relieved by preganglionic sympathectomy.
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From page 333... ...
This was made definitely worse by cold weather, but was not related to emotion. We regarded this as a somewhat atypical case of causalgia, but we obtained satisfactory relief by diagnostic procaine block.
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From page 334... ...
Albans he suffered from moderately severe burning pain and hyperalgesia in the ulnar area of his hand, aggravated by cold and the usual psychological factors. The first attempt to block his upper thoracic sympathetic ganglia resulted in vasodilatation, but failed to produce satisfactory drying of the skin or any Horner's sign; furthermore, his pain was not relieved.
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From page 335... ...
Spontaneous pain is considered to be constant or intermittent pain in the injured limb, present even at rest. It is often particularly annoying in damp or cold weather.
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From page 336... ...
The raw data concerning the unpleasant sensory and related sequelae of nerve injury may be summarized as follows among the 2,962 nerve injuries with some follow-up: Number Nature of complaint of nerves A No complaints 228 B
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From page 337... ...
Perhaps because the series is small, especially after subdivision by center, extensive soft tissue damage, requiring plastic repair, is not reliably associated with persistent pain. An associated injury to bones or joints appears to be of little or no importance in determining whether persistent pain will follow a nerve injury, except in the case of the median nerve, where such complaints are somewhat more common in men with complex wounds of this type.
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From page 338... ...
Table 196. -- Prevalence of Painful Phenomena and Agent of Injury, Median an I Ulnar Sutures l Complaints Agent Gunshot Cutting instruments Total Percent 34. 4 Percent 18.4 Per.rnt 32.7 Spontaneous pain Paresthesia 44.
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From page 339... ...
Of patients complaining of spontaneous pain or overresponse, 51 percent had this motor complaint. In the absence of sensory complaints, only 23 percent complained of easy fatigability.
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From page 340... ...
Table 198. -- Relationship Between Motor and Sensory Complaints Following Complete Suture, All Centers and All Nerves Combined Number of lesions Percentage with sensory complaint Motor complaint None 97 62 9 Anv 1,877 92 7 Total 1,974 91.2 Complaints of pain and related abnormalities bear no discernible relationship to return of sensation as judged by the British Summary. It was necessary to seek further for correlation between overresponse and sensory recovery, since absence of overresponse is a criterion of good sensation in the British Summary.
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