During the American Civil War, thousands of soldiers survived gunshot wounds that should have ended their lives. Limbs were saved, bullets removed, scars healed. Yet for some men, recovery never truly came. Long after their wounds closed, a different kind of suffering emerged, one that surgeons could not explain and commanders refused to believe.
Union physician Silas Weir Mitchell, stationed at military hospitals treating nerve injuries, began to notice a disturbing pattern. Soldiers with seemingly healed gunshot wounds described pain that defied all logic: an intense, burning sensation deep within the limb, as if the flesh itself were on fire. Their arms or legs would swell, turn red or pale, shift between extreme heat and icy cold. The lightest touch, a sleeve brushing the skin, a faint breeze, could provoke unbearable agony.
To military officials, these men looked well. There were no open wounds, no infections, no visible damage to justify such suffering. Many were accused of exaggeration or cowardice. Some were labelled hysterical or mentally unstable and discharged without treatment. Pain, when it could not be seen, was assumed to be imagined.
Mitchell refused that explanation.
He meticulously documented these cases, observing the common features: burning pain, hypersensitivity, changes in skin colour and temperature, muscle wasting, and profound functional loss. He recognised that the symptoms followed nerve injuries but extended far beyond what anatomy alone could explain. In 1864, he gave this condition a name, causalgia, derived from Greek words meaning burning pain.
Mitchell’s writings became the first formal medical descriptions of what we now know as Complex Regional Pain Syndrome. Yet recognition did not bring relief. For decades, patients continued to suffer in silence, their pain questioned, minimised, or dismissed as psychological. The disorder remained poorly understood, misunderstood, and frequently misdiagnosed.
Today, CRPS is recognised as a real and severe neurological pain disorder, complex, devastating, and still without a cure. Modern imaging and neurobiology have confirmed what Mitchell observed more than a century ago: this pain is not imagined. It is a dysfunction of the nervous system itself.
The fire that Mitchell described has never truly gone out. But because one physician chose to listen when others doubted, that suffering was recorded, named, and finally believed.
NCLEX-Style Question:
A client is 7 hours post–open reduction and internal fixation of a fractured tibia. The client reports intense, deep pain in the affected leg that is progressively worsening and not relieved by prescribed opioid analgesics. Assessment reveals firm swelling, shiny, taut skin, and increased pain with passive toe movement. Pedal pulses are present but weaker than on the unaffected side.
Which action should the nurse take first?
A. Notify the healthcare provider of suspected compartment syndrome
B. Administer the next scheduled dose of opioid analgesic
C. Loosen restrictive dressings and maintain the extremity at the heart level
D. Apply intermittent ice packs to reduce postoperative inflammation
E. Reassure the client that pain is expected following orthopaedic surgery
Correct Answer: C. Loosen restrictive dressings and maintain the extremity at heart level
Rationales
A. Notify the healthcare provider of suspected compartment syndrome — Incorrect (priority-wise)
While this action will be necessary, the NCLEX requires the nurse to intervene within scope first when an immediate nursing action can reduce harm. Failing to act before calling the provider reflects a delay in nursing judgment.
B. Administer the next scheduled dose of opioid analgesic — Incorrect
Pain that is out of proportion and unrelieved by opioids suggests a developing complication. Treating pain alone masks symptoms and delays appropriate intervention.
C. Loosen restrictive dressings and maintain the extremity at heart level — Correct
This is the highest-priority nursing action. Loosening dressings can immediately reduce compartment pressure, and maintaining the limb at heart level supports perfusion without worsening ischaemia. NCLEX prioritises actions that prevent irreversible damage.
D. Apply intermittent ice packs to reduce postoperative inflammation — Incorrect
Cold causes vasoconstriction and may further compromise tissue perfusion in suspected compartment syndrome. This intervention is inappropriate in the presence of neurovascular warning signs.
E. Reassure the client that pain is expected following orthopaedic surgery — Incorrect
This response ignores red-flag symptoms and reflects failure to recognise a limb-threatening emergency. NCLEX consistently penalises reassurance in the presence of abnormal findings.
Lau, F. H., & Chung, K. C. (2004). Silas Weir Mitchell, MD: The physician who discovered causalgia. The Journal of Hand Surgery, 29(2), 181–187. https://doi.org/10.1016/j.jhsa.2003.08.016
Iolascon, G., de Sire, A., Moretti, A., & Gimigliano, F. (2015). Complex regional pain syndrome (CRPS) type I: Historical perspective and critical issues. Clinical Cases in Mineral and Bone Metabolism, 12(1), 4–10. https://doi.org/10.11138/ccmbm/2015.12.3s.004