Publications
APS Bulletin • Volume 13, Number 2, 2003
History of Pain
Marcia Meldrum, PhD, Department Editor
S. Weir Mitchell: The Early Years
Nancy Cervetti, PhD
Neurologist and novelist S. Weir Mitchell was one of the most prominent physicians of the late 19th and early 20th centuries. Interestingly, many of his most noteworthy contributions were made in his earliest years of practice.
In the 1850s, while in his twenties, Mitchell experimented extensively with animals, publishing 25 accounts and papers in the Proceedings of the Academy of Natural Science of Philadelphia between 1853 and 1870. During Civil War years 1862 to 1864, Mitchell worked as a contract surgeon in the Union Army, treating hundreds of nervous cases at Turner’s Lane Military Hospital in Philadelphia.
Of the many publications resulting from his Civil War work, the two most important were Gunshot Wounds and Other Injuries of Nerves, published in 1864 and co-authored with Drs. George R. Morehouse and W.W. Keen, and Injuries of Nerves and Their Consequences, a more comprehensive work that Mitchell published solo in 1872. Gunshot Wounds quickly became the authoritative work on nerve injuries; it featured the first descriptions of phantom limb, ascending neuritis, and causalgia, the “burning pain,” and discussed various treatment methods such as blistering, leeches, cautery, electricity, and hypodermic injections.
“Father of American Neurology”
As recently as 1965, the American Academy of Neurology reprinted Injuries of Nerves and Their Consequences and referred to Mitchell as the father of American neurology. The preface states that each study “of peripheral nerve injuries incident upon major wars since the American Civil War has drawn upon Mitchell’s account of his own experience. None has had the impact of Mitchell’s” (Gillen et al., 1965).
Mitchell’s early years offer a broader understanding of a life marked by great energy and intellectual curiosity and recorded by a writer gifted with an impressive facility with language. In 1849, Mitchell completed a two-year degree at Jefferson Medical College and left for a year of study in England and France. From Paris, he wrote, “My time here looks only too short for the work to be done” (Mitchell, 1850).
A few months later, he sent this account to his father:
I rise at 7 1/2—and after a cup of coffee go to Velpeau’s clinic—which terminates at 9 1/2 with a lecture—full of original ideas and observations. At 11 every other day I spend an hour and a half with Caudmont in crushing stones practising with the catheter etc. In the afternoons of the same days, I have a lesson on surgical diagnosis from Velpeau’s interne, whilst on the intermediate days I attend the eye clinic of Sechelle and a course on auscultation with the interne of Bouillard. My course on the microscope has just terminated, and some of my leisure time is occupied with that study. I examine all the specimens I can meet with, and when I meet with any thing new to me I draw it. (Mitchell, 1851)
Mitchell returned to Philadelphia with a new $140 microscope (worth about $3,500 in 2002 dollars) and a keen desire to establish a reputation in physiology and neurology. He noted experimenting with opossums, muskrats, pikes, pigeons, frogs, turtles, dogs, guinea pigs, rabbits, ducks, and chickens. His first comprehensive investigation followed the purchase of six rattlesnakes. Initially wanting to assess the value of Bibron’s antidote for snake venom, Mitchell began this investigation in 1858, spending all of his free time on the project. It grew to include the habits of snakes in captivity, their anatomy and physiology, and the toxicology and physiological effects of venom.
In 1860, the Smithsonian Institute published Mitchell’s 145-page monograph entitled Researches Upon the Venom of the Rattlesnake. In the introduction, he discussed the general human aversion to snakes and how such fear and dread have interfered with any comprehensive research on the composition and effects of venom. He also defended his work against the anti-vivisectionists. In his own words, he had destroyed “many animals,” causing snakes to bite pigeons, frogs, rabbits, and dogs and cutting off the heads of live snakes to study their glands and fangs. Later, after another series of rattlesnake experiments, he wrote they had “also been conducted at the cost of a large expenditure of the lives of birds, dogs and rabbits. I have said these few words in apologetic preface, only because I respect the motives of the many ignorant and well meaning persons, who have recently sought to take away from us the chief aid of the modern physiologist” (Rein, 1952).
A Plethora of Dangers to Study
Mitchell’s interest in poisonous snakes would continue for almost 50 years. A second major study was conducted in 1883 in collaboration with Dr. Edward T. Reichert, professor of physiology at the University of Pennsylvania. In an essay entitled “The Poison of Serpents,” Mitchell described this work:
There were half a dozen of these snake cages in our laboratory, and at times they contained a hundred snakes, each genus or species having its own box. If disturbed, the rattlers were apt to start a chorus which was somewhat appalling to strangers. When we desire to collect venom, we use the snake loop. With it a serpent is caught by the neck and lifted up to the top of the box. The lip of a saucer is then slipped into the snake’s mouth. Angry at this liberty, it lifts its fangs, which catch on the inner edge of the saucer, against which the serpent bites furiously again and again. As it does so, a thin yellow fluid squirts out of the perforation near to the needle-like end of the fangs. (Mitchell, 1889)
Mitchell and Reichert’s studies were conducted on the rattlesnake, cobra, water moccasin, and copperhead. The discovery that rattlesnake venom was a compound of two separate poisons was their most noteworthy.
However distasteful the milking of snake venom may seem, it was child’s play compared to what awaited Mitchell as a contract surgeon in the Civil War. Working alongside Drs. Keen and Morehouse at Turner’s Lane Military Hospital, Mitchell treated nervous cases referred from the 25,000 army hospital beds in the Philadelphia area.
Advances in technology made the horrors of this war worse than those of previous wars. Because the traditional smoothbore musket had a maximum range of about 250 yards and an effective range of about 80 yards, close-order formation was necessary to concentrate the firepower of such inaccurate weapons. However, in 1848, Claude E. Minié invented a spinning conical bullet. James H. Burton made a cheaper and better version, and these bullets became the famous “minié balls” of the Civil War rifles (McPherson, 1988).
With a range of 1,500 yards and extreme accuracy at 350 yards or less, a .58 caliber minié ball fired from a Springfield or Enfield musket could penetrate six 1-inch pine boards. Officers on both sides trained in the tradition of close-order infantry assaults were slow to register the significance of these differences in range and accuracy. Casualties multiplied, and injuries worsened. Because the soft lead flattened and broke apart upon hitting the human body, the destruction of tissue, bone, cartilage, and vein was massive. While the entrance wound was the size of a thumb, the exit wound could be the size of a fist. When a soldier was hit in the arm or leg, the ball could shatter the bone from a distance of 6 to 10 inches. The 48 case studies in Gunshot Wounds describe some of the resulting pain and damage:
In the case of William S. Sylvester, a farmer, age 22, a minié ball entered his face an inch below the left eye, passing backward and outward and injuring the eye, ear and jaw. His mouth was locked, an abscess formed at the posterior wound which discharged freely, and he experienced total palsy of the muscles of facial expression, which would continue for the rest of his life. (Mitchell, Morehouse, & Keen, 1864)
David Schively, age 17, enlisted in August 1862. At Gettysburg in July of 1863, a ball entered one inch to the left of the middle line, and one inch above the sternal end of the clavicle. Exit on the posterior part of the right arm, at the middle line, two inches below the axilla. When hit, he thought his arm was shot off. It dropped, the gun fell, and, screaming that he was murdered, he staggered, bleeding freely, and soon fell unconscious. (Mitchell, Morehouse, & Keen, 1864)
More than 620,000 soldiers died between 1861 and 1865, a cost as great as all of the nation’s other wars combined up to and including the Vietnam conflict (McPherson, 1988). One-third died from battle wounds, more than 94% of them caused by gunshot. Approximately 60,000 amputations were performed, as more complex surgery was rarely possible. Nearly 500,000 men were left permanently disabled. (Farrell-Beck & Figg, 1993). In an attempt to capture some part of the carnage and torture, Mitchell wrote the haunting short story, “The Case of George Dedlow” (1866), in which the protagonist loses first an arm, then his legs, and finally his remaining arm, becoming a mere stump. As a symbol of the war’s costs, Dedlow becomes a composite figure for the half million Civil War soldiers who went home disfigured, in pain, and chronically ill.
Defining and Treating Causalgia
Many of the gunshot wounds Mitchell treated resulted in the burning pain that he would later call “causalgia.” Gunshot Wounds provides the following description of causalgia:
As the pain increases, the general sympathy becomes more marked. The temper changes and grows irritable, the face becomes anxious, and has a look of weariness and suffering. The sleep is restless, and the constitutional condition, reacting on the wounded limb, exasperates the hypersthetic state, so that the rattling of a newspaper, a breath of air, another’s step across the ward, the vibrations caused by a military band, or the shock of the feet in walking, give rise to increase of pain. At last the patient grows hysterical, if we may use the only term which covers the facts. (Mitchell, Morehouse & Keen,1864)
Although the symptoms, intensity, and duration of causalgia varied with each case, there were common signs. There was the “glossy skin,” deep red or mottled in patches, “perfectly free from hair,” and without wrinkles—“skin that shined as though skillfully varnished.” According to Gunshot Wounds, “Nothing more curious than these red and shining tissues can be conceived of” (Mitchell, Morehouse, & Keen, 1864). The nails often became curved and thickened. In one case, body sweat became “copious and intensely acid, so that an odor of vinegar could be smelt at all times in the neighborhood of the man. . .The same unpleasant symptom existed to a less degree in others, while in a single instance the odor of the sweat was disgustingly heavy, and resembled the smells from a bad drain” (p. 86). The slightest jar, touch, sound, exposure to air, presence of light, or advance of the surgeon could cause excruciating pain. Patients frequently mentioned relief could be found from wetting their hands and pouring water into their boots. Many soldiers became demoralized and hysterical, and one patient moaned and wept “incessantly” and “constantly prayed us to amputate the arm” (Mitchell, 1867).
In 1861, S. Johnson enlisted at the age of 18; he was wounded 21 months later by a minié ball in the cheek. The ball had most likely lodged in his spinal column, and he experienced total motor paralysis of the arms and legs. After a couple of months in other hospitals, he was transferred to Turner’s Lane in July 1863. The clinical terms in the following passage cannot blur the horrible image of the emaciated and rigid body and monkey-like hand:
A more wretched spectacle than this man presents can hardly be imagined. He lies in bed, motionless, emaciated to the last degree, and with bed-sores on both elbows and both hips. His hands lie crossed on his chest, perfectly rigid; the fingers extended; the skin congested and thin; the nails curved; false anchylosis of all the joints of the upper limbs; the head and neck rigid, with acute pain in these parts on movement. (Mitchell, Morehouse, & Keen, 1864)
Johnson was treated with massage that was vigorously carried out, despite his pain and his protests to be left alone. By October his appetite was voracious, he had gained weight, and he could voluntarily cross his legs. By January his hands had lost their smooth, shining look, and the nails were less curved. The patient was given electrical treatments and etherized daily, his adhesions were forcibly broken, and the massage continued. By late February he could walk a few steps, and by March 20 he walked well without any aid. After 11 months, he was discharged, slightly shuffling, but with nearly complete use of all his limbs.
Mitchell and his colleagues wrote that no such cases of burning pain “can be successfully treated without the frequent aid of narcotics” (Mitchell, Morehouse & Keen, 1864). They began an article, “On the Antagonism of Atropia and Morphia,” by noting that they made “incessant use” of hypodermic injections “which alone in many instances seemed able to overcome the anguish of certain forms of neuralgic distress. . . In one case half a grain to a grain of morphia was injected thrice a day, and the man finally recovered after having used nearly 400 injections” (Mitchell, Morehouse & Keen, 1864). Mitchell wrote that other remedies “passed successively under trial in our vast experience during the war. For the most part, they may be classed with the therapeutics of despair, the use of narcotic injections having allowed us to dispense with them altogether” (Mitchell, 1872).
In the Turner’s Lane Hospital wards for nerve wounds, it was customary to give hypodermic injections to between 60 and 80 men two or three times a day. The resident surgeons, passing through these wards with their narcotics and hypodermic syringes, would see “anguish and troubled faces before them, and [leave] behind them comfort, and even smiles. The picture is not overdrawn, since, perhaps, few hospitals have ever embraced at one time so many cases of horrible torture” (Mitchell, 1872).
Mitchell felt that some of the opiates given in the form of hypodermic injection might even have a curative effect. However, in cases of organic alteration of the nerve, narcotics chiefly helped by relieving the pain and enabling the soldiers “to bridge over, so to speak, the many months of torture which are needed to bring the nerve back to health again, or to afford time for electrical or other treatment.” In numerous cases, narcotics were “the saving of a number of nerves and of many limbs which otherwise must have been sacrificed for the purpose of relieving unendurable pain” (Mitchell, 1872).
In a letter to his sister, Mitchell commented on the pleasure of helping these men:
No physiology this summer but splendid hospital work and I thank God—heartily such wonderful results that I am sometimes amazed. It is such a pleasure to see men who have drifted hopeless and helpless from Hosp—to Hospital with dead limbs or moveless below the waist to see them walking about and grateful even to tears. I have just cured a charming old naval captain of paralysis from wounds. You never saw a man so pleased. (Mitchell, 1863)
Other interesting aspects of Mitchell’s Civil War work include amputation, phantom limb, and his theory of the mind/body relationship.
While Mitchell was working at Turner’s Lane, he also maintained an extensive private practice, conducted inspections for the War Department, and continued with his research. The overwork finally took its toll, however, when he broke down, ill and exhausted. In 1864, he resigned his post as a contract surgeon, paying $400 for a substitute. He wrote to W.W. Keen:
I have been ill or should have written before. Just after your traps arrived, per porter, I took a big diptheria (sic) + a double quinsy—a droll mixture—but it nearly ended me. And now here I am at the close of February—just beginning to feel that I shall ever be myself again. There is a great hiatus full of aches and nausiaus (sic) doses—mustard plasters, slow, long, lazy days of convalescence and lots of no work done—my health forced from me a resignation of my nerve hospital. It went hard—you know how hard. (Mitchell, 1865)
When thinking about Mitchell’s animal experimentation, especially with venomous snakes, and his Civil War work with gunshot wounds, causalgia, and narcotics, one is struck by his boldness. No doubt, his real medical training came with his experimentation and Civil War work, rather than the two years of lectures at Jefferson College or the brief studies in London and Paris. While this pioneering work is valuable in its own right, it also laid the foundation for his later treatment of hysteria and neurasthenia and fed his career as a fiction writer.
Mitchell would go on to publish 13 novels, numerous essays and addresses, several books of poetry, and several books on medical topics, such as the best-seller on his famous “rest cure,” Fat and Blood, published in 1877 with eight editions by 1911. Among all these diverse publications, Gunshot Wounds and Other Injuries of Nerves and Injuries to Nerves and Their Consequences are among the finest.
The research for this article was supported by a Fellowship from the Agency for Healthcare Research and Quality and the National Endowment for the Humanities. The author also wishes to acknowledge the College of Physicians of Philadelphia for two Francis Wood Resident Research Fellowships.
References
Farrell-Beck, J., & Figg, L. (1993). Amputation in the Civil War: Physical and social dimensions. Journal of the History of Medicine and Allied Sciences, 48, 454–475.
Gillen, H., Fabing, H., Horenstein, S., McHenry, L., Schmidt, R., & Clarke, E. (1965). Preface. Injuries of nerves and their consequences. New York: Dover Publications. (Original work published in 1872.)
McPherson, J. (1988). Battle cry of freedom: The Civil War era. New York: Ballantine Books.
Mitchell, S.W. Personal communication to Sarah Matilda Mitchell, November, 1850. S. Weir Mitchell Papers, Available from Library of the College of Physicians of Philadelphia, Box 4.
Mitchell, S.W. Personal communication to John Kearsley Mitchell, April 3, 1851. S. Weir Mitchell Papers, Available from Library of the College of Physicians of Philadelphia, Box 4.
Mitchell, S.W. Personal communication to Elizabeth K. Mitchell, August 10, 1863. S. Weir Mitchell Papers, Available from Library of the College of Physicians of Philadelphia, Box 4.
Mitchell, S.W. Personal communication to W. W. Keen, February 8, 1865. S. Weir Mitchell Papers, Available from Library of the College of Physicians of Philadelphia, Box 8.
Mitchell, S.W., Morehouse, G., & Keen, W. (1864). Gunshot wounds and other injuries of nerves. Philadelphia: J. B. Lippincott & Co.
Mitchell, S.W. (1866). The case of George Dedlow. Report in The Autobiography of a Quack and Other Stories. New York: The Century Co., 1900: 115–149.
Mitchell, S.W. (1867). On the diseases of nerves, resulting from injuries. In Contributions Relating to the Causation and Prevention of Disease, and to Camp Diseases; Together with A Report of the Diseases, Etc., Among the Prisoners At Andersonville, GA. New York: Hurd and Houghton, 412–468.
Mitchell, S.W. (1872). Injuries of nerves and their consequences. Philadelphia: J.B. Lippincott & Co.
Mitchell, S.W. (1889). The poison of serpents. The Century Magazine, 38, 503–515.
Rein, D. (1952). S. Weir Mitchell as a psychiatric novelist. New York: International Universities Press.
Nancy Cervetti, PhD, is dean of humanities and associate professor of English at Avila University in Kansas City, MO. As part of her research on the life and writings of S. Weir Mitchell, she has traveled the country to locate and read all of his surviving letters. She can be reached at cervettin@mail.avila.edu.