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Disabling and Disfiguring Injuries

Chapter 14

DISABLING AND DISFIGURING INJURIES

EDWIN A.WEINSTEIN, M.D.*

INTRODUCTION

AMPUTATION

Behavioral Effects

Phantom Limb

Treatment

SPINAL CORD INJURIES

Neurological Aspects

Behavioral Effects

Personality Factors

Treatment

DISFIGUREMENT

Brain Syndromes

Stresses of Recovery

Coping Mechanisms

Treatment

BLINDNESS

Cerebral Blindness

Visual Phenomenology

Early Reactions

Stresses and Coping Mechanisms

Treatment

CASTRATION AND GENITAL MUTILATION

Behavior

Treatment

SUMMARY

*Consultant in Neurology, National Naval Medical Center, Bethesda, Maryland; Consultant in Psychiatry, Walter Reed Army Medical Center,

Washington, D.C.; and Formerly Chief, Fifth Army Neuropsychiatric Center (World War II)
War Psychiatry

354

Barse Miller Requiem Mass 1944

Barse Miller was an artist for Life Magazine before he enlisted in the U.S. Army in 1943. He served with the

Corps of Engineers before becoming the War Art Leader of the Combat Art Section. In this watercolor,

Miller portrays the interior of a church in World War II that has been converted to a makeshift hospital to

care for combat-injured soldiers. The man in the foreground has sustained wounds to his hands and face,

the two areas most associated with visible expression of emotions. These are among the injuries that

soldiers fear the most—those that leave them permanently disfigured or disabled or both.

Art: Courtesy of US Center of Military History, Washington, DC.
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Disabling and Disfiguring Injuries

INTRODUCTION

This chapter takes up the neurological and physiological disturbances and the behavioral changes

that follow major amputations, spinal cord injury

with paralysis, facial disfigurement from missile

wounds and burns, blindness, and mutilating and

castrating wounds of the external male genitalia.

Changing conditions of warfare and the greater

explosive power of weapons have raised the proportion of some types of wounds, and increased the

incidence of multiple injuries. Improved methods

of evacuation and the development of new surgical

techniques have resulted in the survival of many

men who previously would have died. Whereas the

combat zone hospital mortality rate in World War II

was 3.3%, the rate in Korea was 2.4%, and that in

Vietnam 1.8%.1 The changing nature of future combat actions, to include nation assistance, foreign

internal defense, and operations other than war

(OOTW), broadens the range of patients that may

be seen.

Survivors of disabling and disfiguring injuries

share a number of problems. Along with their

physical limitations, they experience an altered body

image, lowered self-esteem, and changes in their

personal relationships. Some bear the social stigma

associated with crippling and deformity. It is only

since World War II that these features have been

recognized and specialized programs set up for

amputees, paraplegics, and the burned and the blind.

Sustaining a combat wound does not preclude the

development of post-traumatic stress disorder

(PTSD), and depression, denial, and drug abuse

pose major problems in therapy. While the management of each type of disability will be considered separately, overall principles of management

are presented.

AMPUTATION

Amputation of a limb as a result of an injury in

combat has profound and special behavioral consequences. These are the emotional reactions to

the initial trauma, the problems of coping with the

motor disability, the alterations of body image

caused by the loss of a previously healthy arm or

leg, and the neurophysiological and psychological

aspects of phantom limb phenomena.

Lower-limb amputations are much more common than amputations of the upper extremity; in

Vietnam these wounds were caused predominantly

by antipersonnel land mines and booby traps, and

might extend to involve the scrotum, buttocks,

and abdomen. The limbs might be severed by the

injury, or a surgical amputation was carried out,

usually within hours of the initial trauma. In cases

in which attempts were made to preserve a shredded limb the amputation might not be performed

until days or weeks later.

Behavioral Effects

Behavioral disturbances are not usually a problem in the early postoperative period over which

the combating of infection, the maintenance of

metabolic balance, and the management of other

injuries are the paramount considerations. Also,

newly wounded soldiers are apt to be euphoric,

glad to be alive, and thankful that their injuries

were not more severe. Even at this early stage,

however, what the emergency room, surgical, and

ward staff say to the patient (or to each other within

hearing distance) is important even if they think the

patient is unconscious. Depression may follow

elation, but it is mainly when the patient encounters

the stresses of further treatment and recovery, and

begins to realize the extent of his physical and social

limitations, that emotional problems arise. The

physical stresses include surgical revisions of an

infected, often painful, stump, learning to use a

temporary prosthesis, and experiencing the fatigue

caused by alterations in posture, balance, and locomotion. Patients worry how they will be accepted

by their family and community, and whether they

will be able to make a living and lead a normal life.

They are concerned with physical attractiveness

and sexual ability.

Anxiety and Depression

Anxiety and depression are the most common

forms of emotional distress. These states are experienced as feelings of tension, sleep disturbances,

somatic complaints, phobias such as fears of falling

or otherwise injuring the amputation stump, irritability, outbursts of anger, and feelings of worthless-
War Psychiatry

356

ness and social withdrawal. The circumstances of

the initial injury are a factor in that soldiers who

have undergone a particularly traumatic experience involving the death or mutilation of others are

more severely stressed.

Case Study 1: Lord Nelson at Tenerife

Admiral Lord Nelson, England’s greatest naval hero,

had his right arm amputated above the elbow following a

wound sustained in an attack on the Spanish fortress of

Tenerife in 1797. The assault failed with heavy British

casualties, largely because of Nelson’s overconfidence

induced by his contempt for the Spaniards, his faith in

Providence, and his belief in his own magical qualities of

leadership. He was initially elated but several days later

he wrote in left-handed script to his superior, Lord St.

Vincent, “I am become a burden to my friends and useless

to my country. When I leave your command I become dead

to the world; I go hence and am no more seen. I hope you

will give me a frigate to convey the remains of my carcass

to England.”2(p145) The wound healed but Nelson continued to experience phantom pain for the rest of his life.3

Comment: Lord Nelson believed that the phantom

fingers of his amputated arm provided a direct proof of the

existence of the soul.

In World War II it was observed that amputees

who had been injured through their own negligence, or while they were absent without leave

(AWOL), were more apt to be depressed and have

disciplinary problems.4 Some patients deal with

the stresses and boredom of hospitalization by resort to alcohol or other drugs.

Denial

Denial is the most prominent defense mechanism. Patients do not deny the actual loss of a limb

unless there is brain dysfunction such as might

result from an associated head injury, or a toxic or

metabolic encephalopathy. Amputees may deny

phantom sensations for fear of being thought mentally abnormal. Denial may be expressed in dreams

in which the patient sees himself with his limbs

intact or as having sustained some lesser damage

such as a fracture. An occasional patient expresses

the idea that his limb will grow back or that he can

get a transplant. Some have the unrealistic expectation that an artificial limb will allow them to function as well as they did before they were injured.

Most commonly, patients deny concern, depression, and other negative feelings. Some have a

paranoid reaction and blame the staff and hospital

equipment for their less than satisfactory progress.

Amputees may manifest denial by not recognizing

the need for rehabilitative procedures. Others offer

a show of bravado, and boast of their physical and

sexual prowess. They may engage in reckless behavior such as racing wheelchairs down hospital

corridors.5

 Preoccupation with religion may become a form of denial as patients avoid discussion

of their problems by engaging in theological speculations.4,6

Denial appears on both conscious and unconscious levels. It may function temporarily as an

adaptive mechanism but, if continued over time,

poses barriers to treatment. It keeps the soldier

from coming to terms with his loss and prevents the

development of close personal relationships with

other patients and staff; it is often followed by

depression.

Phantom Limb

Phenomenology

The phantom limb, the experience of sensation in

the severed extremity, is virtually universal. The

phantom may be so mild that the amputee is aware

of it only when his attention is directed toward it; in

other cases it is more vivid. The phantom may

originally duplicate the normal limb, but over time

differs in size, sensation, shape, position, and completeness—in the case of an amputation at the shoulder, there may be a gap between the shoulder stump

and the phantom elbow. The foot and hand are felt

most prominently. Sensations range from a not

unpleasant tingling and feelings of warmth, cold,

and heaviness, to cramping, twisting, burning, or

lancinating pain. The phantom usually appears

immediately after amputation, so that patients on

awakening from anesthesia do not believe that the

limb has been removed, but it occasionally comes

on later. Most phantoms begin to fade within weeks,

with sporadic later occurrences over a period of

years.7,8 Fading of the phantom, which is felt more

vividly in the upper extremity, may be associated

with telescoping, the sensation that the fingers or

toes, or hand or foot are attached directly to the

stump. Chronically painful phantoms, however,

do not telescope.

Pain occurs in both the stump and the phantom.

Stump pain is almost always present. It is usually

severe immediately after the operation and

subsides in a few days. If it persists, then there is

likely a problem with the stump, such as infection

or poor blood supply. Recurrence may often be

traced to local abnormalities such as bone spurs,

deficient soft tissue padding, difficulties with the
357

Disabling and Disfiguring Injuries

prosthesis, and alterations in gait and posture.9

Phantom pain is much more variable. Whereas the

phantom itself appears immediately, the pain may

not come on for months or years after the amputation, with disagreeable feelings replacing the original benign sensations.8

 Phantom pain is more likely

to be present in persons who have had pain prior

to operation.10 The pain may be described as similar in type and location to that previously experienced, with even the limb in the same distorted

position.11,12

Somatosensory memories, most of which are

painful, may be multimodal involving not only

pain, but tactile, visual, motor, and even olfactory

components. Riddoch7 described the case of a soldier whose arm was blown off by the premature

explosion of a bomb that he was holding. In the

painful phantom, his hand was still grasping the

bomb. A phantom reported by Henderson and

Smythe8 included the sensation of blood trickling

down the limb. A soldier whose leg was amputated

in the Italian campaign of World War II could still

feel and visualize the fragments of his shattered

bones. Some somatosensory memories are benign

as in the instance of the man who reexperienced the

sensation of a bandage being applied to his wounds,

but most are associated with high levels of anxiety

and emotion.12

Phantoms, painful and nonpainful, may appear

without apparent cause, or they may be brought on

by a wide variety of perceptual, cognitive, or affective experiences. Sensory stimulation of the stump

and elsewhere on the body or face can produce or

accentuate a phantom, as may pain from an arthritic

shoulder or an anginal attack. Visual experiences

can elicit a phantom, as in a case described by

Varna, Lai, and Mukherjee,13 in which a man, after

an upper-limb amputation, would feel his ring on

an absent finger when he saw someone wearing a

ring on the corresponding digit. Micturition, defecation, yawning, and sexual activity may occasionally elicit phantom sensations and images. A

phantom may be evoked by thinking of it, and a

sense of movement created by willing it. Bailey and

Moersch14 reported a patient who related that while

his amputated arm was being burned at his request,

he had felt the ashes gradually dropping from the

phantom. Riddoch7 described an amputee in whom

pleasant excitement caused his phantom to tingle

along with the rest of his body. When, however, his

mind was fully occupied, he was as unaware of the

phantom as he was of the rest of the body. Episodes

of phantom pain can be precipitated or intensified

by emotional stress.

Neurophysiological Aspects

Observations that could not be explained by current neurophysiological concepts, and the failure of

surgery to help phantom pain more than temporarily, led to the belief that phantom limb phenomena were of psychological origin, and various theories were advanced. One view was that the

symptoms were caused by the amputee’s narcissistic reluctance to accept the reality of his physical

mutilation—in essence a denial. Another was that

the phantom represented mourning for the lost

limb.15 A number of the patients studied by Kolb16

had had a close emotional attachment to another

amputee, and pain was thought to express the

patient’s feelings of hostility and guilt toward persons with whom he identified as mutilated or mutilating, and on whom he was dependent. It was also

believed that amputees who developed phantom

pain had a high incidence of premorbid psychopathology.16–18

Psychological, cultural, and emotional factors

enter into the perception of pain, but recent psychological and neurophysiological investigations have

not yielded evidence that phantom phenomena are

psychogenic. Pain is often precipitated by stress

and associated with anxiety and depression; and,

patients with adjustment problems are apt to focus

on pain as the source of their discontents. In World

War II, amputees referred to a psychiatrist for disturbances in behavior or disciplinary infractions

were more likely to complain of pain than those

who sought help voluntarily.19 Such observations,

however, do not mean that pain, per se, is necessarily of psychogenic origin. Patients with chronic

pain, however, whether of organic or functional

origin, have high scores for “neuroticism” on the

Eysenck Personality Inventory, and are notoriously

difficult to treat.20

Older neurophysiological theories of phantom

limb involved the action of afferent fibers from the

stump on spinal and supraspinal cells and the sending of abnormal impulses to cortical sensory areas.

Most hypotheses focused on pain rather than other

sensory disturbances and, in particular, did not

offer an explanation of telescoping. More recent

formulations have utilized the evidence of brain

plasticity, that is, the manner in which the brain can

modify its connections in response to experience,

and the way in which it can reorganize function

after damage.

In World War II, a study of amputees showed

that the thresholds for two-point discrimination on

the skin of a stump were consistently lower than
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358

those in the homologous area of the sound limb.

This suggested that there had been a central cortical

reorganization of function, in which the stump had

taken on features of the amputated hand or foot.21

Subsequent studies also showed lower thresholds

(ie, finer discrimination for light, touch, and point

localization). Furthermore, accuracy in point localization was significantly influenced by telescoping,

in that it was most efficient in above elbow amputees who perceived their phantom to be within the

stump.22

The work of Merzenich and his associates23–25 has

established a basis for the understanding of the

mechanism of cortical reorganization after peripheral trauma. It was found that after amputation

of a finger in the adult monkey, the cortical area

that had been deprived of its original input could

be activated by touching the adjacent fingers, and

even by stimulation of other points on the body

and face, in the way a phantom in man can be

elicited by a stimulus on the stump and elsewhere.

The perceived length, size, and shape of the phantom may thus be a peripheral marker of the extent

to which input from the stump and other regions

has taken over cortical areas originally driven by

input from the amputated limb. Plasticity of cortical reorganization is also determined by the use of

the digit, paralleling the observation in man that the

length and shape of the phantom changes after

extensive use of the stump. If a stump is surgically

cleft and the two parts used as a forceps, patients

may report a cleft phantom hand.26 Severe pain

prevents the use of a prosthesis, and may contribute

to the failure of telescoping to develop in such

patients.

Phantom-limb phenomena also have a temporal

dimension in that preamputation sensations, particularly painful ones, may be reproduced in vivid

detail. Katz and Melzack12 emphasize that the patient not only remembers that he had pain but has

the direct experience of pain. Pain, or stress, or both

appear to be crucial for the development of somatosensory memories because most of them are painful. The authors suggest that sensitized cells in the

spinal cord activate the structures in the brain which

subserve sensory memories, a process resembling

the flashbacks of PTSD. The highly emotionally

laden features of multimodal phantom representations may relate to the fact that multimodal association areas, rather than the primary unimodal cortical sensory areas, are interconnected with the

paralimbic regions concerned with the affective

coloring of experience.

Treatment

There has been an apparent decline in the incidence of severe and enduring phantom pain since

World War II. Prior literature and reports of observations early in the war described suffering so intense as to lead to serious depression, morphine

addiction, and suicide. A noted neurosurgeon,

James C. White, recommended surgical intervention in amputees with severe phantom pain of more

than 6 months duration before psychic changes

became irreversible.27 Unfortunately, procedures

such as sympathetic block, chordotomy, tractotomy

at medullary and midbrain levels, and cortical parietal ablation failed to provide lasting relief. Revisions of the stump for ulceration, necrosis, and

neuromas might relieve local stump pain but did

not, as a rule, help phantom pain.

More recent studies present a more favorable

picture. A 1955 review of 400 amputees treated at

the U.S. Navy Amputee Rehabilitation Center in

Oakland, California, the majority of whom were

battle casualties, found that 94% were employed

and wearing their prostheses.28 Painful phantoms

were rare among British amputee prisoners of war

(POWs) in Germany in World War II.8 A long-term

follow-up of Finnish amputee veterans of the wars

with the Soviet Union (1939–1946) showed persisting debilitating pain in only 2% of subjects.29 No

painful phantoms were encountered among Vietnam amputees treated at Valley Forge General Hospital in Pennsylvania.6 Two thirds of Israeli amputees of the Yom Kippur War of 1973 had phantom

pain, but in the great majority of cases it decreased

in intensity and disappeared after a few weeks or

months.30

The method of study influences the evaluation of

phantom pain. A 1979 poll of U.S. medical schools,

Veterans Administration (VA) hospitals, pain clinics, and pain specialists found that 58% of respondents who had treated amputees reported no experience with phantom pain.31 A mailed questionnaire,

however, sent by the same investigators to 5,000

U.S. veteran amputees yielded an incidence of pain

in 78%, and 85% of subjects who reported pain

experienced it for 6 or more hours a day. However,

90% of the respondents were able to use their prostheses more than 8 hours a day.32,33

The decline in the frequency of severe chronic

pain may be attributed to a number of advances in

medicine stemming from World War II. These

include the shortening of the period between wounding and hospitalization, better surgical techniques,
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Disabling and Disfiguring Injuries

a broader spectrum of antibiotics and analgesics,

recognition of the special behavioral problems of

amputees with the setting up of amputee centers,

and changes in the attitudes of society toward the

handicapped.

The treatment of an amputee begins prior to

surgery. It is important to control pain and avoid

unnatural positions of the injured limb, and to operate as soon as feasible to diminish the likelihood

of painful somatosensory memories. The patient

should be told what to expect in the way of phantom

phenomena. If there is pain after surgery, its relationship to tension and stress should be discussed

with the patient. Maximum use of his prothesis

should be encouraged. He should be urged to keep

a log, so that any correlation with weather, diet,

alcohol, smoking, or a particular type of stress can

be noted. Sources of referred pain into the phantom—from pathology in the stump, a faulty prosthesis, an arthritic joint or an intervertebral disc

abnormality—should be identified.

In the absence of specific precipitating factors,

treatment of phantom pain can be very difficult,

and none of the numerous methods that have been

employed have been consistently efficacious. In

World War II, Russell34 reported that percussion or

vibration of the stump alleviated pain. Measures

that reduce tension and interrupt the pain-anxiety

cycle, such as biofeedback and relaxation training,

have been suggested.35 An occasional patient benefits from self-hypnosis. Transcutaneous electrical

nerve stimulation (TENS), a procedure based on a

reported concordance between points of tenderness

and skin conductance on the outer ear and pain in

an extremity, is said to have resulted in a moderate

reduction of phantom pain.36

Many medications have been used, and relief

has been reported with the anticonvulsant,

carbamazepine,37 antidepressants used alone or in

combination with other drugs,38,39 phenothiazines,40

and propranolol, a beta-blocker.41,42 Such studies,

however, have been poorly controlled with insufficient data for critical evaluation. Narcotic analgesics usually result in increasing dosage and drug

dependence with poorer and poorer pain control

and depression. Sedatives and hypnotics are not

only ineffective in relieving phantom pain, but tend

to be habit-forming and increase depression.39

The treatment of the amputee goes beyond the

control of pain and extends into the broader behavioral area. In former years the emphasis was on the

promotion of denial as amputees were encouraged

to be optimistic and not give into their fears and

doubts in the interest of maintaining good ward

morale. Frank6 noted that the objective of the hospital staff was to keep the patient so busy with

activities that he did not have time to dwell on his

problems. Staff also tended to give an overly rosy

picture of what the prosthesis could accomplish.

Interest by psychiatrists was discouraged on the

grounds that it would stir up new problems or

reactivate old ones.

Currently, there is more cooperation among surgeons, psychiatrists, nurses, and rehabilitation personnel. The amputee is given a realistic account of

the difficulties he will encounter and asked to participate in his own treatment, as in the care of his

stump. He is allowed to speak openly of his feelings, whether of powerlessness, shame, anger, or

self-blame, and pass through the period of mourning for the dismembered part of his body, which is

essential for the eventual acceptance of loss. Efforts

are made to help the soldier incorporate the prosthesis into his body image, for example, by doing

his exercises in front of a mirror rather than regarding it as a foreign object.

The amputee must acquire a new identity. This

involves not only in some cases training for a new

occupation, but new ways of thinking, feeling, acting, and relating to others. Actions that were once

carried out automatically now require focused attention. The amputee must reevaluate himself and,

if necessary, change old attitudes, notably those

concerning physical attractiveness, masculinity or

femininity, and self-sufficiency. If he persists in the

belief that a physically handicapped person is also

psychologically and socially inferior he is likely to

perceive these attitudes in others.43 The successful

amputee must have qualities of concentration, flexibility, and sensitivity.

SPINAL CORD INJURIES

The systematic study of the behavioral aspects of

spinal cord injuries (SCI) did not begin until World

War II, as in World War I 80% of men with SCI died

within a few weeks of injury.44 Even with the

advances in surgery, antibiotics, and methods of

evacuation in World War II, the majority of patients

arrived at hospitals in the United States suffering

from decubitus ulcers, urinary tract infections, and
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360

malnutrition. It was largely through the work of

Donald Munro and Ernest Bors in America and Sir

Ludwig Guttmann in Great Britain that the humanitarian needs of paraplegics and quadriplegics were

recognized and comprehensive spinal cord injury

centers were established.

Neurological Aspects

Spinal cord transections vary in completeness

and are classified according to the level of the lesion

into cervical, thoracolumbar, and cauda equina

types. The wounds are most often caused by shell

fragments or bullets with the foreign bodies piercing the cord directly, or driving bone into the spinal

canal. Blast injuries may produce intramedullary

hemorrhages. Falls and vehicle accidents are other

sources of injury. Alcohol exacerbates the neurochemical and behavioral effects of spinal cord

trauma.45 SCIs are commonly associated with abdominal and chest injuries, and with brain damage,

especially with high cervical cord lesions. Shock,

loss of blood, sepsis, stress hormonal responses,

anoxia from respiratory embarrassment, and the

administration of morphine for pain also contribute

to impairment of brain function. Opioids apparently decrease spinal cord perfusion, and opioid

receptor antagonists can reduce tissue damage following central nervous system trauma.46

There is no immediate intrinsic phenomenological awareness of disability and many patients sustaining acute SCIs initially deny or are unaware of

their paralyses and sensory loss. Such anosognosia

may persist for days or weeks. Heilporn and Noel47

found that only 4 of 40 paraplegics were immediately and spontaneously aware of their deficits.

Others realized that their legs were paralyzed and had

lost feeling when they tried to move them, and some

recognized their disabilities after they were demonstrated on a neurological examination. Anosognosia

is more marked and more enduring in patients who

have been unconscious and who have gone through a

period of amnesia and disorientation. Quadriplegics

show more denial/unawareness because of the more

frequent association with brain damage. Another

factor in early unawareness of paralysis is that

patients may be confused by phantom sensations.

Paraplegics who have had an initial loss of consciousness may have the illusion that the lower part

of their bodies have been amputated.48

As in the experience of amputees, phantom phenomena are common. Bors49 found them in all of the

50 paraplegic veterans of World War II whom he

studied. The most frequent abnormal sensations

were paresthesias in the anesthetic limbs, and feelings that the legs were floating upward from the

bed or frame, extended at the knees or ankles, and

slightly flexed at the hips.50 Other phantoms are

more bizarre. Patients may feel that their legs have

been cut off, and one described the feeling that

blood was oozing from the stumps.51 Another

paraplegic felt as if he had an extra pair of legs that,

at times, were tied up in knots.52 If there is associated brain damage, the patient may have the persistent delusion that he has another pair of arms or

legs.53,54 In the absence of significant brain injury,

phantoms usually disappear in a few weeks, except

those resulting from cauda equina lesions. Unlike

amputees, however, SCI patients do not experience

telescoping, possibly because of inability to move

their legs.

Toxic psychosis caused by sepsis from urinary

tract infections and deep decubitus ulcers are rare

when adequate treatment facilities are available.55

However, brief episodes of delirium and agitated

behavior may be associated with fever or occur after

general anesthesia for operative procedures in the

first few months after injury. Hypoxic episodes occurring during sleep in patients with high cervical cord

lesions may contribute to cognitive impairment.56

Patients with high cervical cord lesions necessitating traction with tongs and neck and head immobilization may show manifestations of sensory deprivation.57 They are lethargic, with little interest in

food or surroundings, and in interviews they keep

their eyes closed. They comprehend and retain

orientation, but respond slowly. Alertness and eye

contact can be restored by a tactile stimulus to the

neck, but they may revert to the previous state until

stimulated again. Hallucinations may occur. This

condition usually disappears when the restraint is

removed and the patient is helped to sit upright.

Loss of spinal cord function produces many

physical problems in addition to the paralysis.

Laminectomy and surgical stabilization of the spine

may be necessary followed by immobilization in a

prone position on a Stryker frame for several weeks

to avoid pressure sores. A study by Jacobson and

Bors58 found decubiti in almost half of men sustaining SCI in combat in Vietnam. There is impairment

of bowel and bladder function, pain, leg spasms

that may be very painful, and defective autonomic

reflexes with reduced capacity for blood pressure

regulation. Genitourinary complications include

irritation from catheters, infection, calculosis,

hydronephrosis, and epididymitis. Complete spinal cord transection may require an orchiectomy

adding to the sense of emasculation. Insomnia may
361

Disabling and Disfiguring Injuries

be a problem because of frequent turning on a frame

and the diminished amount of REM (rapid eye

movement) and deep sleep associated with cervical

cord lesions.56

Behavioral Effects

Patients respond to the loss of control over their

bodies and the overwhelming sense of helplessness

and dependence in a number of ways. Some become childish and demanding while others withdraw and show little emotion. Some are hostile,

others are anxious or depressed. Many express

denial. Several models of the behavioral course of

SCI patients have been offered. Guttmann55 described a first stage of anxiety and regression, sometimes associated with negativistic behavior and

provocative attitudes, followed by denial, and then

by adjustment. Another proposed sequence is one

of initial denial, succeeded by depression with grief

and mourning, with eventual acceptance of disability.59,60 However, not all patients get depressed.

Others become depressed in response to some disappointment such as the failure of a laminectomy to

clear up the paralysis. Patients may or may not

express hostility or denial. Behavioral manifestations such as withdrawal and indifference can be

interpreted as either depression or denial.

Depression

Estimates of the incidence and significance of

depression vary. Some authors believe that it is

normal for a severely disabled person to become

depressed.61 It has been stated that when a newly

paralyzed person does not appear to be depressed

he is denying his loss of function and its social

implications.60 Other observers have not found

depression to be inevitable, and believe that the

incidence has been exaggerated through the expectations of the hospital staff.62 A prospective study63

of 71 civilian patients followed through the acute

and rehabilitative stages found that 14 fulfilled the

criteria of the Diagnostic and Statistical Manual,

3rd edition, of the American Psychiatric Association (DSM-III)64 for major depressive disorder, and

that another 13 had transient periods of depressive

mood. The time of onset of depression was from 3

to 40 weeks after injury. Remarkably, depressive

disorders appeared with comparable frequency in

paraplegics (17%) and quadriplegics (23%). Similarly, Lawson65 showed that the level of cervical

cord injury was not a factor in the incidence or

severity of depression. These observations were

made in civilian hospitals but there is no reason to

believe that there would be different findings in

military personnel. Thom and Von Salzen66 noted

no difference in the incidence or severity of depression in World War II veterans who sustained SCIs in

combat and in those hurt in accidents.

While a period of grief and mourning is helpful

in allowing the patient to work through his feelings

of loss on the way to acceptance, prolonged depression has disastrous effects. Self-neglect is a frequent feature of depression. Such patients present

with either angry, rebellious attitudes, or are withdrawn, indifferent, and overtly self-destructive.67

They do not cooperate with the hospital staff, may

refuse medication or other treatment, refuse to eat

or maintain fluid intake or breathe deeply, and fail

to attend to skin care or manage their catheters.

They may demand unnecessary surgery and have

alcohol or other drug problems.

Suicidal ideation is very common in the first days

after injury but it rarely materializes.55 Suicide,

however, may be a problem later on and Hohmann60

warns that it is a great mistake to assume that

because a patient is disabled his incapacity will

physically preclude his trying to kill himself. Suicidal intent should be suspected in patients with

self-neglect who deny having ever having harbored

thoughts of ending their lives.56 A 20-year followup of veterans of World War II with traumatic

myelopathies revealed suicide to be the third most

common cause of death, ranking behind only renal

failure and secondary amyloidosis.68 The figure

does not include other deaths involving self-destructive behavior such as alcoholism, smoking,

and motor vehicle accidents.

Denial

Unless there is associated brain dysfunction, SCI

does not result in classical anosognosia in the sense

that the patient explicitly denies or is unaware of his

paralysis, forgets that he cannot walk, or represents

the disability in delusional fashion. Brain damage

is produced by the injury, or by a toxic or metabolic

encephalopathy. An investigation of fatal craniocerebral injuries, principally from motor vehicle

crashes, noted that 46% of victims with spinal cord

damage also had brain pathology.69 Wilmot, Cope,

Hall and Acker70 identified four risk factors for

brain dysfunction: (1) quadriplegia following a high

deceleration accident, (2) loss of consciousness, (3)

cortical or brain stem neurological signs, and (4)

required respiratory support at the time of injury.

Of patients with one or more risk factors, 64%
War Psychiatry

362

showed impairment on neuropsychological testing

a median 48 days after injury.

Apart from classical anosognosia, denial is expressed in a number of ways. Unlike the amputee

whose loss is visible, the SCI patient may cling to

the hope that he will regain the function of his limbs

through some new medicine or operation. A form

of denial encountered by Guttmann55 in young soldiers wounded in World War II was a defiant “we

can take it” mentality, with rejection of advice and

instruction by the hospital staff. Some patients are

highly euphoric and joke about their problems. As

amputees do, some engage in reckless behavior

such as the wheelchair racing portrayed in the

Marlon Brando movie, The Men. Others are indifferent and are not motivated to participate in selfcare or rehabilitation. Denial of loss of sexual function may be shown in inappropriate boasting of

sexual prowess and excessive interest in pornography.71 Paranoid forms of denial are shown by patients who charge that newly discovered treatments

are not being made available to them, or who blame

paralysis on being kept on a Stryker frame.

It may be difficult to separate denial from hope

and faith, and in the earliest stages it can be a help

in survival. Denial, while it may make a patient

more comfortable and provide a temporary solution to his problems, is ultimately maladaptive. It

deprives him of the opportunity to grieve, prevents

the formation of intimate relationships, and blocks

rehabilitative efforts. Moreover, the collapse of a

denial system is apt to be followed by depression.

Personality Factors

While no type of premorbid personality has been

found to be predictive of adaptation to SCI, previous experience is significant. Social background,

academic and vocational achievement, quality of

interpersonal relationships, habitual modes of coping with stress, and the values that determine the

meaning of the incapacity are all relevant.

Civilian patients with histories of sociopathic

behavior, poor school and job records, drug abuse,

and painful punishment in childhood were found

to adjust poorly after SCI, with more depression

and disruptive behavior.59,72 Similarly, soldiers who

have had problems with authority may find it difficult to establish a trusting relationship with the

professional staff. Patients who have been well

educated and have developed skills are better able

to occupy themselves productively and plan for the

future than those whose vocational abilities are

limited and involve physical work. A study of the

individual beliefs of SCI patients showed that those

who believe that they exercised control over their

lives and health were less depressed than those who

thought that rewards and punishments resulted

from chance, luck, fate, or the actions of powerful

others.73

The meaning of the disability in terms of the

person’s value systems is highly significant. Some

patients with pain are mainly concerned with what

the pain means in regard to their health and prognosis, and are apt to refuse medication unless it serves

some therapeutic purpose. Others react in terms of

their current suffering and want relief. Patients

who have needed physical activity, such as jogging,

to ease tension, are apt to find the limitation of

mobility particularly difficult to accept. Some feel

that the disability means loss of manhood, and a

loss of sexual attractiveness. Or, they may equate

the incapacity with inferior status as a person, and

a loss of love and respect. A soldier who has had an

authoritarian religious upbringing may perceive in

this injury a manifestation of God’s will, and a

punishment for sin.

Roberts,74 from his experience in a rehabilitative

facility, regards spontaneity, ability to show emotional experience, the holding of conventional but

not fundamentalist or dogmatic religious beliefs,

good contact with reality, and feelings of personal

adequacy as predictive of good adjustment.

Treatment

The aims of treatment are: (a) managing of the

initial state of impaired awareness, (b) motivating

the patient to participate in self-care and rehabilitation, (c) addressing denial, and (d) dealing with

the problems of pain, depression, and sexual dysfunction.

It is useful to point out to the patient that phantom sensations are normal and do not mean that he

is losing his mind. The staff should avoid fostering

denial unwittingly. A corpsman who might feel sorry

for a soldier should not try to cheer him up by telling

him that he will recover the use of his limbs. Similarly, a physician may believe that if the patient is

given the facts of his situation, hope will be destroyed and that he will have no motive to work in

therapy. Roberts74 is of the opinion that loss of

motivation, over time, is more often due to the

patient’s failure to achieve unrealistic goals based

on misleading information. When should a patient

be told of his prognosis? It should not be in the

acute stage when he may have impaired brain function, or when he is too sick or uncomfortable for the
363

Disabling and Disfiguring Injuries

information to matter. He should be told at the

point at which he is able to retain information and

participate in treatment. He should receive an

explanation of SCI, and be told the reasons why

procedures are being carried out and why it is

important for him to attend to skin care, breathe

deeply, and maintain fluid intake and nutrition.

Pain following SCI is of different types and degrees of severity. Pain in the area of the wound

usually clears in a few weeks. Pain in the shoulders,

elbows, and fingers of paraplegics may be due to

tendinous and articular contracture, often caused

by faulty positioning of the upper limbs following

injury.55 Radicular pain, along with hyperesthesia,

results when damaged nerve roots are encased in an

adhesive arachnoiditis, and is particularly severe,

with a causalgic quality, in cauda equina lesions.

Flexor leg spasms can be painful. Visceral pain that

may be referred to anesthetic areas can occur because of distension or reflex activity of the bladder,

colon, uterus, or ureter. Syringomyelic pain may

develop in chronic cases as a consequence of cavitation in the spinal cord above the level of the lesion.75

Phantom sensations are not usually painful, but

tingling, pressure, and burning sensations in areas

below the level of the lesion are common and may

be perceived as painful. The dysesthesias recede in

most cases, but they can be long-lasting. While such

central pain is not psychogenic, it is affected by

emotional and attentional factors. It is also influenced by fatigue, weather, alcohol excess and other

drug abuse, smoking, and pressure sores.52,76 It is

unlikely that a pressure sore causes pain by direct

neural transmission, but the need to lie in a bed or

on a frame for long periods contributes to depression. Moreover, depression may have led to selfneglect and the development of a bed sore.

Drugs can create problems in a number of ways.

Patients may resort to marihuana and alcohol to

relieve pain and boredom. The cord injury may

exacerbate preexisting drug dependency. Insomnia may lead to excessive use of hypnotics, especially benzodiazepines.

Local pain responds to nonnarcotic analgesics,

but radicular pain and central pain are much more

difficult to treat. Some patients with radicular pain

are helped by carbamazepine (Tegretol) or

phenytoin (Dilantin) but in most chronic cases not

even chordotomy gives permanent relief.52 One

must rely on directing the patient’s attention away

from his symptoms into other activities such as

prevocational training and sports. If possible, the

patient should be taught relaxation techniques and

self-hypnosis. Anxiolytic or antidepressant drugs

may be given if there is evidence that anxiety or

depression is present.

Antidepressant drugs should be used when appropriate with great caution. Depression should be

distinguished from sorrow, despair, and grief. It

should also be differentiated from states of conservation-withdrawal in which patients weakened by

long bed rest, intercurrent infections, and nutritional depletion are apathetic.77 Drugs with anticholinergic effects can compromise the function of

a neurogenic bladder, and those with alpha-adrenergic properties can induce dangerous hypotension.

Tricyclic antidepressants, and especially the

nontricyclic, bupropion, can lower seizure threshold, a significant factor for patients with brain damage. Levin, Burtt, Levin, and Ginsberg78 reported

ventricular fibrillation in quadriplegic patients on

therapeutic levels of imipramine. Of tricyclic antidepressants, desipramine and nortriptyline have

the least alpha-blocking actions and relatively few

anticholinergic effects. However, newer generations of antidepressants (fluoxetine, paroxetine,

sertraline, bupropion) are virtually free of alphablocking, anticholinergic, and antihistamine effects.

In treating psychotic states, haloperidol and piperazine have the fewest anticholinergic effects. They

may, however, require the addition of anticholinergic agents (preferably amantadine) to prevent

extrapyramidal syndromes, such as dystonia,

pseudoparkinsonism, and akathisia. Stewart57 notes

that it is important to avoid drugs such as trazodone

(Desyrel) which have soporific side effects, as vigilance is necessary for self-care. Electroconvulsive

therapy should be considered in severe depression

when rapid action is required. With anesthesia,

muscle relaxants, and oxygenation, the risk of fracture or further cord damage is low.

The effects of spinal cord damage on sexual functions is a serious concern of the recovering patient.

While sexual competence is impaired in ways that

depend on the completeness and level of the lesion,

patients have normal desires, fantasies, and erotic

dreams. The issue should be addressed, and a

physician should overcome whatever inhibitions

he or she may have in the matter. It can be pointed

out that marriage is feasible, that a majority of

males have erections, and that some can consummate intercourse. The therapist can indicate that

other methods of gaining sexual satisfaction are not

necessarily perversions, and that stimulation of

erotic areas other than the anesthetic parts of the

body can be enjoyable. Above all, the need of a

loving relationship to accommodate mechanical

handicaps should be emphasized.
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DISFIGUREMENT

Major disfigurement, involving the face and

hands, occurs mainly as the result of burns, and of

blast and missile wounds. Thermal injuries include

exposure to flames, flash burns from gas explosions, the effects of chemical and high-voltage electrical agents, and smoke and carbon monoxide inhalation. Burns occur principally in tank warfare,

and after vehicle explosions including airplane

crashes and ship sinkings. Burns accounted for

4.6% of all casualties in Vietnam, for 12.5% in the

1973 Yom Kippur War, and for 18% of British casualties in the 1982 Falkland Islands War. It is estimated that 9% of the casualties in the 1991 Persian

Gulf War had burn injuries.79 Facial injuries are

produced by bullet wounds, and by blast from

mortars, mines, and other explosive devices, which

commonly cause other disabilities such as blindness. Survivors of high-velocity missile wounds are

more apt to have had maxillofacial and mandibular

fractures than penetrating orbital injuries, which

are often fatal.

This section focuses on burns because they are

more likely to involve other organs including the

brain, pose the most difficult problems in cosmetic

surgery, and have the most severe and lasting behavioral consequences. The survival rate following

even severe burns is high: more than 50% of patients

15- to 40-years-old with burns covering 75% of total

body surface (TBS) live.79 Life-threatening complications, however, are frequent with burns involving more than 30% of TBS. These involve the hormonal and cell immune systems, heart, lungs, liver,

adrenals, kidneys, gastrointestinal tract, hematopoietic and blood clotting systems, and central nervous system and peripheral nerves.

Brain Syndromes

Delirium

Burn encephalopathies, which develop in the

majority of patients with burns involving 30% or

more TBS, have a number of etiologies. These

include hypoxia, hypovolemia, electrolyte imbalance, notably hyponatremia resulting in seizures,

acidosis, and sepsis. Patients may be awake, alert,

and well-oriented on admission to the hospital, but

within hours or days may become restless, agitated,

disoriented, with fluctuating levels of consciousness, memory lapses, hallucinations, and paranoid

ideation. Fear, pain, terror, and immobilization

contribute, but the more massive the burn, the more

likely the patient is to develop delirium, which is

almost always associated with an abnormal

electroencephalogram (EEG).80 Some patients are

only mildly disoriented, a condition that may be

overlooked. Delirium usually clears in a few weeks

but abnormal behavior may persist for weeks or

months.81

Delayed Manifestations

There are also delayed complications, appearing

weeks or months after the burn and usually associated with sepsis or fluid or electrolyte imbalance.

These include focal neurological manifestations

such as seizures, cranial motor nerve palsies,

hemipareses,82 spinal cord and peripheral nerve

disabilities,83 behavioral disorders including paranoid disorders, hallucinations,84 psychoses,82,85 and

somatic delusional states, notably anosognosia and

reduplicative misidentification syndromes.

Anosognosia and Reduplication

Patients deny or appear unaware of the somatic

manifestations and obvious consequences of their

injuries. If a burned limb has been amputated, its

loss may be denied or represented in delusional

fashion. Thus a patient in danger of losing a severely burned hand developed the idea that the

doctors had removed the hand and was angry at

their delay in putting it back.81 Damage to the body

can be selectively ignored, as in the case of a man

who failed to notice the silver-nitrate–blackened

skin of fellow patients in the burn unit.81 Reduplication of the self was noted in a case described by

Steiner and Clark.86 In an apparently lucid period in

which the patient expressed concern for her status,

she told the staff to débride the sick woman in bed

with her while she and her husband went to have a

cup of coffee in the cafeteria.

Some anosognosic patients are bland and unconcerned, others paranoid or euphoric. A paranoid

form of implicit denial was noted in a man with

burns over 60% of his body. Despite being so weak

that he was unable to raise his head from the pillow,

he threatened to punch his physician in the nose.87

A state of blissful euphoria associated with

anosognosia was described by Hamburg, Hamburg,

and de Goza.88 The patient was a woman with

extremely severe burns necessitating maintenance
365

Disabling and Disfiguring Injuries

on a Stryker frame. She had initially thought that

she would die, following which she claimed that

she had recovered and would be able to go home in

a few days and care for herself and her children. She

died 2 weeks later. The experience at the A.V.

Vishnevskii Institute of Surgery in Moscow is that

euphoria succeeding depression is a grave prognostic sign.82

Neuropathology

Examination of the brains of persons who have

died of burns and their complications has shown

very little. In the great majority of instances no

pathology has been found, although in a few cases

cerebral edema, small infarcts and hemorrhages,

and neuronal degeneration have been noted.89,90

The cause of the delayed onset of symptoms referable to the central nervous system is unclear beyond

that which can be attributed to sepsis or fluid or

electrolyte imbalance, or a vascular complication.

It is likely that burn encephalopathy is relatively

common with many manifestations and few deaths.90

Stresses of Recovery

The surviving patient is subject to a broad range

of stresses throughout the process of recovery. Pain

is exacerbated by debridement, dressing changes,

skin grafts and other plastic surgery, and the need

to exercise burned limbs to avoid contractures.

Gastric stress ulcers are another source of pain. The

patient may have to be isolated until the danger of

infection has passed, and extensive bandaging

further reduces environmental contact. A tracheostomy may interfere with communication. In the

patient’s state of relative sensory isolation all fears

are magnified. If he has facial burns and edema of

the eyelids he worries that he will be blind, and

burns in the genital area cause concern about sexual

function. Insomnia can be a problem. When he is

with other patients, the sight of charred bodies and

the odor of wounds and dressings are distressing.

The patient’s first look at himself in the mirror can

be a shocking experience and should be managed

sensitively.

After survival is assured and the patient is no

longer preoccupied with the issue of life and death

new problems arise. As he is now able to participate

in his own care, he needs less attention from nurses

and other staff members to whom he may have

become attached, and may thus feel betrayed and

abandoned. Although his wounds have healed or

been covered by grafts, he must face the fact of

disfigurement and wonder if he will be socially

rejected or unable to work. Burns of the exposed

parts of the body, the face and the hands, have the

most serious social consequences. The burned soldier must anticipate the reactions of people who

may be horrified, curious, hostile, or pitying. Eventually he must come to recognize that burned faces

may all look much the same, without individuality,

and that his capacity to smile or use other muscles

of expression to convey emotion may be reduced. If

his hands have been severely burned, he is handicapped in using them in gesture. Moreover, posture, which reflects so much of personality and

attitudes, may become rigid and distorted by

contractures about joints.91

Coping Mechanisms

Patients react to disfigurement in various ways.

Some accept their misfortune and cooperate in treatment. Most are depressed and anxious in some

degree. There may be post-traumatic stress disorder with agitation, tremulousness and startle responses, nightmares or flashbacks concerning the

circumstances of the injury, and difficulty in concentrating. Depression is usually self-limiting. It

may come on at any time—on emergence from

delirium, or weeks or even months later. It may be

precipitated by the discovery that grafted skin does

not look quite normal. Serious depression is manifested in feelings of hopelessness and thoughts of

suicide, insomnia, lethargy, and poor cooperation

as in refusal to eat. Suicidal ideation and gestures

are rare during initial hospitalization, but they may

occur following discharge. Some patients react

with anger and bitterness, directing their resentment against the hospital staff. Others show what

has been called regressive behavior, because it suggests a return to childhood attitudes. Such patients

are excessively dependent, demanding, and demonstrative. They are apt to complain a great deal, and

feel neglected or mistreated.

Denial in patients without impaired brain function usually does not involve somatic delusions, but

takes other forms that may be adaptive or maladaptive. It helps the person combat anxiety and depression and may give him hope for the future. On the

other hand, it leads to lack of concern about problems, unrealistic expectations of the future, and, at

best, passive participation in therapy. Many patients seek religious meaning as they struggle to

come to terms with their suffering.92 These have

positive and negative aspects. A person may feel

sustained by God’s presence or by the idea that he
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366

has been purified by fire. Others may see the injury

as a punishment for sin or misconduct, or as some

other manifestation of divine will.

Adaptive—and maladaptive—mechanisms have

been usually formulated in psychodynamic terms,

but organic neurological features must be considered in patients who have severe burns. One of the

effects of such brain damage is a lowered threshold

for the effects of acute environmental stress and the

action of drugs. One of the survivors of the Coconut

Grove fire disaster in Boston of November 1942 was

a woman who showed no evidence of impairment

of brain function until she received the news that

her husband and son had died. She responded to

the news with a state of excitement and paranoid

suspicions that the doctors and nurses considered

her to be a sinful, immoral person.93 A U.S. Army

sergeant, burned in a fire in his apartment, was

ordinarily quiet and cooperative. He would, however, become extremely demanding, critical, and

combative following the recovery of consciousness

after the administering of a general anesthetic for

dressing changes and skin grafting.88 Similarly,

burn patients may be sensitive to drugs used to

control pain, anxiety, and depression.

Treatment

The aims of therapy are the management of delirium, the control of pain, anxiety, and depression,

and the establishing of a social milieu in which the

patient can come to terms with his disability and

participate in his care.

Pharmacotherapy

Treatment of delirium involves the correction

of disturbances of fluid and electrolyte balance,

providing orientation cues such as keeping lights

on at night, and protection of patients from selfinjury. Neuroleptics are the drugs of choice, given

orally if possible, with checking for hypotension.

High-potency neuroleptics with minimal anticholinergic effects and alpha-adrenergic blocking are

preferred.

Pain is especially severe in the first few weeks. If

necessary, morphine or meperidine is indicated as

the danger of addiction is slight. Respiratory depression may be more of a problem. For the control

of acute anxiety provoked by the anticipation of

pain, oral diazepam given one hour prior to the

treatment has been effective, with intravenous (IV)

administration of diazepam or chlordiazepoxide in

more severe cases.94 These drugs can impair cognition and are long-acting. Chronic use can cause

depression. Intramuscular use is contraindicated

because of poor absorption by that route. If major

depression or chronic anxiety states supervene,

antidepressants should be used, as they are effective for both the depression and the anxiety. Doxepin

may be particularly useful for depressed or anxious

patients who also have peptic (stress) ulcers because it is one of the most potent histamine-2 receptor blocking agents, more potent than cimetidine

(Tagamet) in reducing gastric acid secretion. It is

primarily a noradrenergic modifying antidepressant, hence useful in chronic pain disorders as well.

Its anticholinergic and antihistamine effects can, of

course, be detrimental for alertness, bladder function, and vascular reflexes.

Behavioral Management

As soon as the patient’s medical condition permits and he is able to retain information, he should

be given a statement of the extent of his injuries, the

type of and rationales for the treatment that will be

required, and the anticipated length of his hospital

stay. As noted by Kjaer,95 the often heard phrase,

“You’re lucky to be alive,” is rarely helpful. In the

absence of information, rumors and irrational fears

flourish, and it is important for physicians and

nurses to maintain communication with patients

other than that which involves a dressing change or

some other painful procedure.

The belief that the soldier has some control over

his destiny should be fostered. The first self-feeding or unassisted bath should be met with expressions of approval. If possible patients should be

taught self-hypnosis or other relaxation techniques.

These are not only helpful in the relief of pain,

nausea, anorexia, and tension, but provide a sense

of mastery and raise self-esteem. Group therapy

allows for the ventilation of feelings, mutual support, and the building of a common identity. If

there are multiple survivors of the same event,

critical event debriefing may be helpful. Chapter

11, Debriefing Following Combat, discusses several

methods available.

The management of demanding and dependent

patients is difficult, in part because such behavior

brings out resentment in the staff. It is important

to keep in mind that the behavior has an adaptive

function in that many of these patients are dramatizing their problems by taking the role of a child.

Limits should be set, with some choices left to the

patient to enable him to keep some sense of autonomy.
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Disabling and Disfiguring Injuries

Physical and adjustment problems may persist

after the soldier has left the hospital. He may need

further surgery to correct scars and contractures.

While such reconstruction is helpful, the patient

should be cautioned that scarring may never be

entirely eradicated, or a burned face restored completely. Patients who have been disappointed with

the results of surgery may demand further operations that are not medically indicated. Some may

use relatively minor disfigurement as a focus for

their discontents, and blame job failures, inability

to make friends, or domestic difficulties on others’

reaction to their appearance.

Case Study 2: Fall of a Hero

A 24-year-old decorated combat infantry officer sustained fractures of the left zygoma and mandible, multiple

facial lacerations, injury to the left ear canal, and a left

facial nerve palsy in an airplane crash. He was comatose

on admission to the hospital and over the next 2 to 3

weeks he was restless, combative, and feared that he

would be killed. In this state, he reenacted scenes of

battle in Korea. After recovering orientation he complained a great deal of pain in his jaw. Following each of

two corrective surgical procedures he became confused

and hostile. Routine mental status, however, was normal

and he returned to duty 5 months after his injury.

In Korea, he experienced dizziness, diplopia and unsteadiness of gait, was depressed, had nightmares and

flashbacks, and found that he was intolerant of the noise

of grenade and rifle fire. He did not seek medical aid for

these complaints, but rather focused on his disfigurement. He had several scar revisions and was noted

as being unusually sensitive about his appearance. Following a complaint of pain and photophobia in his left eye,

a blepharoplasty was performed. A small foreign body

was found and it was suspected that he had inserted it

himself.

Four years after his initial injury he was referred by his

commanding officer for psychiatric observation because

of disrespectful behavior and for having made allegations,

out of channels, of inefficiency and security violations.

This conduct contrasted with his previously excellent

efficiency reports and his reputation for bravery in combat. Examination showed no evidence of organic brain

damage, neurosis, or psychosis and he was discharged to

duty. His full scale intelligence quotient (IQ) of 115,

however, was considered to represent a fall from his

premorbid level.

Following his resignation from the service, the patient

continued to have difficulties. He attributed his employment and marital problems to his facial disfigurement and

was preoccupied with violence. He carried pictures of his

men who had been killed in combat and made several

suicidal gestures. Following the assassination of President Kennedy, he claimed that he had known Lee Harvey

Oswald, that he had had foreknowledge of the assassination, and feared that he would be set up by the same

conspirators who had murdered Oswald.

Comment: This case illustrates the association of traumatic facial disfigurement with a brain injury (the severity

of which was not recognized), PTSD, and a paranoid

delusional state.

BLINDNESS

fractures, and blew off a leg. Chemical agents

may result in blindness as occurred with mustard

gas in World War I. Ocular trauma from highvelocity fragments is frequently accompanied

by brain injury, and blindness of central origin

results from intracranial wounds involving the visual pathways.

The current battlefield laser rangefinders and

designators produce multiple pinpoint burns on

the retina, where the beam has been focused by the

lens of the eye. This can occur at distances of several

kilometers if the source of the laser is viewed with

the naked eye, and out to many kilometers if viewed

through binoculars, gunsights, or other optics. The

tiny burns are quickly surrounded by edema. While

loss of peripheral vision may go unnoticed, burns in

the fovea produce sudden impairment of vision.

Depending on size and location of the retinal burns,

recovery of vision may take days, and can leave

visual field defects.

Loss of vision is a catastrophic event that thrusts

a soldier into an unfamiliar world, profoundly alters his perception of reality, robs him of mobility,

and ends a way of life. Changing conditions of

warfare have markedly increased the incidence of

eye injuries. In the Civil War ocular wounds made

up 0.5% of surviving casualties. The figure rose to

2.14 % in World War I.96 In Korea the rate was

8.1%,97 and in Vietnam 9% of surviving combat

casualties had ocular injuries.98,99 In Vietnam the

great majority of wounds were generated by fragments from explosive projectile shells, rockets and

bombs, grenades, booby traps, and land mines.

Tank warfare, which requires commanders to expose their upper bodies for better vision, produces

many eye injuries, totalling 25% of all Israeli casualties in the 1967 Arab-Israeli War.100 Most casualties sustain other wounds as well. In Vietnam,

it was not uncommon for a man to be blinded by

the same explosion that caused multiple facial
War Psychiatry

368

Cerebral Blindness

Cerebral or cortical blindness is usually the result of bilateral occipital lobe lesions involving the

striate cortex. It is characterized by failure to see

light or movement, even though the pupils are

dilated and react to light, and in attempted convergence. Blindness may not be total, but as most

patients have mental changes it is sometimes difficult to be certain of the degree of visual loss. Binocular blindness may also be caused by lesions of

the optic chiasm, and by anoxia, such as that resulting from carbon monoxide poisoning. Anoxia may

also result in selective visual impairments such as

achromatopsia, and loss of perception of form and

motion in which the patient tries to identify an

object by color alone.101 Lesions of the visual pathways cause hemianopias in both the vertical and

horizontal planes.

Anosognosia for Blindness

The most striking behavioral abnormality associated with cerebral blindness is anosognosia for visual loss, known as Anton’s syndrome, in which

patients deny or appear unaware of their blindness.

Even though they appear to be totally blind, they

confabulate descriptions of the examiner and their

surroundings. Denial may be incomplete in that a

patient may complain of dim vision, but attribute

it to the darkness of the room, or being kept in a

dungeon. Some patients are cheerful and unconcerned about their deficits; others become angry

and hostile when their claims to vision are challenged.102 Patients may behave in ludic fashion,

joking and clowning. Such apparent emotional

indifference or inappropriateness could contribute

to a mistaken diagnosis of conversion disorder.

Patients are usually disoriented for place and time,

and may have visual hallucinations. They are amnesic, particularly when the injury has resulted in

loss of consciousness, and they confabulate about

their activities and reason for coming to the hospital.

The pathology is bilateral and extensive. When

the occipital lobes are involved, the lesions usually

extend from the ventromedial portions into the

temporal lobes. When blindness is caused by damage to the optic chiasm at the base of the brain there

are commonly lesions of the frontal lobe. Anton’s

syndrome also appears with blindness of peripheral origin provided there is additional cerebral

damage. Recovery from cortical blindness caused

by occipito-temporal lesions may go through various stages of visual agnosias and homonymous

scotomata.103

Case Study 3: Denial of Blindness

A 21-year-old paratrooper, while on maneuvers in

Germany, was thrown from a moving vehicle sustaining a

basilar skull fracture and bleeding from his right ear canal.

He lapsed into unconsciousness, and a subdural

hematoma and necrotic brain tissue was removed from

the right parietal-temporal region. Papilledema developed, followed by optic atrophy and bilateral loss of vision.

On arrival at Walter Reed Army Medical Center in

Washington, D.C. 6 weeks after his injury, the right pupil

was fixed to light and the left reacted sluggishly. Visual

acuity in the better eye was 20/200. The patient was

disoriented for place and date, was amnestic for his injury,

and did not remember that he was married. He denied

anything was wrong with his vision, even though he

identified objects mainly by feeling them. He was cheerful

and uncomplaining; at times he stated that his vision was

dim because the ward was so dark, and that maybe he

should get goggles. There were many references to

vision in colloquial speech, as in reporting on his first

leave. “Well, I got home and seen my uncle, and seen

nearly everybody. I went and got baptized. I went to see

everybody. I seen my aunt and grandmother and everyone else. Seen people I hadn’t seen for a long time.”

Denial of blindness lasted for 3 to 4 weeks by the end of

which period he was completely oriented. He then developed a hysterical tremor of his head.

Comment: The case is of particular interest because it

demonstrates that patients with anosognosia can have

unconscious awareness of their deficits, and that a conversion reaction can be a late consequence of brain injury.

Anosognosia for Hemianopia

Whereas patients with Anton’s syndrome have

other disorders of consciousness, patients with a

homonymous hemianopia from a head injury may

be unaware of their visual loss even though their

mental faculties are intact. Such patients do not see

only one half of space. Because of the phenomenon

of completion, they “fill in” the part of the image

falling in the hemianoptic field, and report a complete circle when a semicircle is presented. Such

patients may not complain of visual loss or they

may have noticed only a slight difficulty in picking

up a line in reading. Although such soldiers might

function well in ordinary surroundings, they are at

serious risk if exposed in a combat situation.

Visual Phenomenology

Visual hallucinations, as distinguished from

mental imagery, may occur during a period of de-
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Disabling and Disfiguring Injuries

lirium, but are rare in traumatic blindness of peripheral origin unless it is associated with brain

damage, drug effects, or extended sleep deprivation. Transient episodes of phantom vision comparable to phantom limb sensations have been described in Vietnam combat veterans following

enucleation of one or both eyes.102 Some had had

brain injuries but all were aware of their blindness.

As in cases of extremity phantoms, the men were

reluctant to report their experiences of seeing out of

an empty socket out of fear of being thought mentally unbalanced. Patients stated that they had seen

clouds, flashing lights, and movement—in one case

the man’s mother—even though they knew that

there was nothing there. The visions appeared

under a variety of circumstances, often while the

patient was relaxed. Phantom vision should be

differentiated from the pseudo-hallucinations of

the Charles Bonnet syndrome. These are wellformed, often of marching soldiers, and are common after cataract extraction in the aged, but rare

after trauma in the young.104 Visual phantoms

should be discussed with patients, not only to allay

fears of being mentally disturbed, but to remove

false hopes that they are a sign of recovery of vision.

There may be a cessation of dreaming for a period after brain injury, but most recently blinded

persons have an active dream life. Many report that

their dreams are more vivid and the colors more

intense since the loss of sight.105 Soldiers in the early

stages are apt to reenact battle experiences or other

trauma, but as nightmares recede, dreams become

more varied. Men may dream that they can see,

while knowing that they are blind. One man would

dream that he could see but not reach the object.

Wittkower and Davenport106 described the case of a

soldier at St. Dunstan’s who dreamed that he could

see his empty sockets in a mirror. When disturbing

dreams do occur, the dreamer, rather than being a

victim, may be a detached spectator of some trauma.

Early Reactions

Soldiers who have been blinded in combat are

not usually unconscious unless they have sustained

a brain injury but, as in paraplegia, they may not be

immediately aware of their visual loss. When they

find they cannot see they react in various ways. In

some cases, they go into in a state of emotional and

cognitive withdrawal. They may believe that the

visual loss is only temporary, and that they will see

when the swelling subsides or the bandages are

removed. Some are in a state of despair, talk of

suicide, and express regret that they were not killed

outright. Some do commit suicide “accidentally” in

such mishaps as falling out of a window.107 Others

are relieved and thankful that they were not injured

more seriously.

Stresses and Coping Mechanisms

As a patient’s condition stabilizes he encounters

the consequences of his blindness—the sensory isolation, the loss of autonomy, and the impairment of

communication. He must attend to countless actions that formerly were carried out unconsciously.

He must learn how to walk again, to wash, bathe,

dress, and feed himself. He must rely to a much

greater degree on the senses of hearing, touch, proprioception, and smell and be able to visualize the

information. He must depend more on his memory.

He must acquire the ability to form visual and

affective images of people he knows only by their

voices, and overcome the handicap of not being able

to see their facial expressions and gestures. If there

is the additional loss of hearing, this interferes with

his ability to judge depth and distance of objects. If

he is also disfigured, the inability to observe the

reactions of people whom he meets may be especially troubling. He must learn to use the aids that

will enable him to be literate again, and acquire new

work skills and modes of recreation. If he has lost

a limb or sustained hearing loss or brain damage

these tasks are more difficult. He must accustom

himself to the fact that he will never drive a car

again, play or watch a baseball game, or see the

faces of his children.

Blindness imposes a loss of status and self-esteem. Many soldiers feel deprived of their manhood and dignity. In the hospital some are too

ashamed or embarrassed to tell people at home

what has happened to them. They are concerned

with whether they can function as a husband or

father and associate with people. As one man noted,

“It’s hard to make friends with people you can’t

see.” They worry about making a living, and being

dependent on the charity or pity of others. Many

feel inferior to and are resentful of the sighted.

Patients respond to these stresses with varying degrees of denial and depression, frustration, anger,

and anxiety and resort to alcohol or other drugs.

Moreover, blindness exacerbates previous emotional and social problems.

Denial and Nonacceptance

Patients do not continue to deny or appear unaware of their blindness unless they have severe
War Psychiatry

370

brain damage, as in Anton’s syndrome, but manifest denial in other ways. They may cling to the

hope that sight will be restored by a transplant or

some miracle. Denial may be expressed by inappropriate cheerfulness and unrealistic plans for the

future. Nonacceptance is indicated by such statements that if the surgeons had performed the right

operation the patient would be able to see. Denial

is also shown in patients’ refusal to use the Hoover

light cane as an aid to spatial orientation and mobility and participate in other training exercises.

Patients who have light perception and some

useful vision within the definition of blindness as

central visual acuity of 20/200 or less in the better

eye, or central visual acuity of more than 20/200 if

there is a peripheral visual field subtending an

angular distance no greater than 20 degrees in the

better eye, have some advantage over the completely blind. They, however, on the whole are less

accepting of their disability and make a poorer

adjustment.106,108,109 The minimally sighted are more

reluctant to enter into rehabilitation training, and

continue to rely on their residual sight which may

provide erroneous information. Whereas the completely blinded have come to terms, once and for all,

with the fact that they will never see, the partially

blinded often retain false hopes and are beset by

fears that they will lose their remaining vision. The

earlier the person accepts his blindness, the more

favorable the behavioral outcome.110 Some patients

show “blindisms,” (ie, vacant stare, grimacing,

overloud voice and failure to look at the person

with whom they are conversing). It has been noted

that men with the grossest “blindisms” are particularly apt to resist training.111

Denial may be unwittingly reinforced by the

attitudes of caretakers. A staff member may give a

patient an assurance that his sight will return in a

well-meant effort to keep up his morale. Physicians

may contribute to denial by their reluctance or

inability to give the patient a definitive evaluation.

Statements such as “one chance in a million” and

“perhaps a miracle will happen” should be

avoided.108 Soldiers are apt to remember such

phrases to the exclusion of everything else they

have been told and become bitter over what they

consider to have been a deception.

Depression

The majority of men blinded in combat are depressed to some degree and feelings of hopelessness and suicidal ideation are common during hospitalization. The experience at St. Dunstan’s, the training center for British soldiers blinded in World War II,

was that 29% of patients were depressed, although

very few were “grossly and patently” so.106 Mainly,

they were withdrawn and moody and dwelled on

the past. Feelings of guilt and self-blame are more

likely to be expressed by soldiers blinded by disease

or in accidents than those wounded in combat.108

Depressed patients regard training as another stress

to be avoided rather than an opportunity to overcome some of their handicaps.

An initial period of depression has been considered to be a mourning process through which the

person grieves for the death of the sighted self in

order to be reborn as a blind man. Cholden112

believed that such depression was necessary before

the patient could accept his loss and that it diminished with time. A blinded veteran recalled:

I think it must have been or was a lot like dying.

Anyway I know I went through all the stages of

“dying” that some one who is terminally ill goes

through when he’s told he’s dying. I remember

how strenuously I demanded that the doctors do

everything to restore my vision, even though it was

hopeless. I called them “idiots” and “fools” for not

knowing what to do to help me. I prayed and made

promises to God. But I was blind and no amount of

denial of the fact could change it. I was angry and

resentful for a long time, and I remember how often

I asked, “Why me?” I went through a stage where

I cried a lot and was really depressed. I still feel that

way sometimes but I’ve learned to accept my blindness the best I can. I came to a point where I started

having some good days. Now most of them are

okay.113(p35)

Other observers, however, have not found this

sequence to be necessary or inevitable.114 Some men

are briefly devastated by the news that they will not

see again, but then work vigorously on a rehabilitation program.109,115 Depression may not come on

until after the patient has left the hospital, and some

men are chronically depressed. In the St. Dunstan’s

study, 50% of the patients followed for periods of

from 1 to 4 years were depressed, resentful, or

showed other psychiatric abnormalities.106 If depression is severe or enduring, it should be actively

treated. Along with denial, prolonged depression

poses the greatest barrier to successful adaptation.

Anxiety is manifested in fears of falling, and in

suspicions of being watched by sighted people.

Insomnia may occur, due in part to the absence of

the light-dark cycle, and some patients develop a

fear of the dark. There may be accompanying PTSD

and psychosomatic complaints include headache,

dizziness, gastrointestinal discomfort, and eye
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Disabling and Disfiguring Injuries

strain. Blind men may complain of eye strain after

Braille reading even after both eyes have been

enucleated.106

Adaptation to blindness is determined by the

extent of other injuries, personality and social factors, and the quality of the training program. Patients with concomitant brain damage and deficits

in memory and attention, and those with amputations, marked facial scarring, and hearing loss are at

a disadvantage. Certain premorbid personality features favor the development of denial. Such patients are described as having been compulsive and

perfectionistic, as reluctant to share their feelings,

and as priding themselves on their self-sufficiency.

They had regarded disability as a personal failure

or disgrace.116,117 Patients with a history of dependency, on the other hand, may find it all too easy to

accept any assistance that is offered and be reluctant to work on their own.109 Levels of education

and degree of family support correlate positively

with successful adjustment.118 According to one

combat-blinded veteran (known to the author), who

was active in rehabilitation, macho types see in

blindness a loss of masculinity and have particular

difficulty in enduring the limitations of physical

activity.

Treatment

Modern treatment of blindness resulting from

combat began during World War II and is based on

the principles of orientation and mobilization (O &

M), acceptance of blindness, and the forming of a

group esprit. Despite the experience of World War

I, the U.S. armed services were not fully prepared

for the care of the 1,400 men blinded in World War

II. Soldiers were evacuated to Dibble General Hospital in Menlo Park, California or Valley Forge

General Hospital in Phoenixville, Pennsylvania. U.S.

Navy and Marine Corps personnel were sent to the

Philadelphia Naval Hospital in Pennsylvania, but

the first center devoted exclusively to the rehabilitation of the blind was not set up until June 1944 at

Avon Old Farms, Connecticut. Treatment had consisted of instruction in self-care, posture, and facial

expression; physical exercise and sports activities;

social recreation; and industrial, vocational, and

academic classes. Morale was not good, and over

40% of the men at Dibble General Hospital were

considered by a psychiatrist to be maladjusted.108

The prevailing philosophy at Avon Old Farms

was that the blind could be taught to “see” through

“facial vision.” This was the idea that the person

could perceive obstacles in front of him by changes

in the sensations of touch, pressure, and temperature emanating from the object. The method had

had rare success with the congenitally blind but

was ineffective for the war-wounded. Locomotion

was aided by an ordinary wooden walking cane.

What came to be known as the Hoover light cane

was introduced at Valley Forge by Sergeant Richard

E. “Dick” Hoover119 (who completed medical school

after World War II), and the O & M technique was to

be developed with the collaboration of Russell C.

Williams who had been blinded in the Normandy

campaign, and C. Warren Bledsoe, who had been a

teacher of the blind. Hoover found the conventional cane to be too cumbersome, and devised a

lightweight longer one made of steel—subsequently

aluminum or fiberglass—that the patient swung in

an arc in front of his trailing foot. This extension of

the patient’s arm enabled him to “feel” objects and

gain an appreciation of their qualities through the

transmitted vibrations. The metallic body was a

good sound conductor that gave information about

the presence of walls, open spaces, or changes in

terrain. The cane tip also gave auditory information. Even some bilateral upper limb amputees

could use the cane which was more of a wand and

light enough to be attached to a stump. Hoover and

his associates trained many instructors, and the

technique has spread around the world. The shift

to O & M occurred in the context of a change in

social attitudes toward the blind. An original objection to O & M was that the Hoover cane made the

user conspicuous while “facial vision” disguised

the blind so that they would not upset or offend the

sighted.

A follow-up study (1952–1953) of 1,949 veterans

blinded in World War II and the Korean conflict118

showed a high level of adjustment, considering that

so many men had other disabilities. Of these blinded

veterans, 50% were employed and 82% of these

expressed satisfaction with their jobs. A much

higher employment rate was found in men who had

completed rehabilitation training. Nine of 10 were

reported as coping well with community attitudes

and relating well in their families. The same number expressed themselves fluently, and appeared

orderly in their thinking processes. Eight of 10 did

not appear nervous or depressed during interviews,

and 8 of 10 did not show “blindisms.” As for

manifestations of denial, 30% had unrealistic plans

for the future, 15% were reported as using cheerfulness to mask other feelings, and 32% had retained

hopes of seeing for 10 or more months after their

injuries.118 No comparable study of Vietnam veterans has been published.
War Psychiatry

372

The following do’s and don’ts in dealing with a

blind patient have been suggested:

1. Address him directly rather than his escort.

2. Do not shout unless the patient has a hearing loss.

3. Do not avoid the words “look” and “see”

for fear of embarrassing the blind person.

4. Do not hesitate to ask the person how much

sight he has.

5. Announce when you are entering or leaving

his room.

6. Give specific directions on location of

objects rather than using the vaguer term,

“over there.”

7. Ask the patient to take your arm rather than

taking his and propelling him.

8. Tell a patient you have not guided before

when coming to steps.

9. Walk in line with the patient but in going up

and down stairs keep one step in front of

him.

10. Do not feel offended if the blind person

refuses help.

Wounds of the external genitalia are the most

feared combat injuries. Soldiers in foxholes have

been observed to place their helmets over their

genitalia, and airmen noted to reinforce their seats

with life jackets. While the incidence is low as

compared to other wounds, it has risen over the

years with the change from the static trench warfare

of World War I to more mobile modern tactics.

Wounds of the penis, scrotum, and testicles made

up 2% to 3% of American casualties in Vietnam,120

and comprised from 40% to 67% of all genitourinary

injuries.121–124 The rate was higher before the 1968

Tet offensive because there were more below-thewaist explosions from mines and booby traps than

after Tet when there was a higher proportion of

shell-fragment wounds.122,123 Burns are another

source of genital injuries.

The great majority of genital wounds are associated with other organ damage—to the extremities,

other parts of the genitourinary tract, the abdomen,

and chest—and the greater explosive power of weapons over the years has increased the incidence of

such injuries. Spinal cord damage, amputations,

and even blindness may result. Such extensive

injuries differ strikingly from the castrating and

mutilating genital wounds of civilian life. The latter

are caused mainly by low-velocity bullets, now

commonly used in drug wars, and by knives, razors, and scissors wielded by vengeful lovers or

rivals. Self-castrations are performed by mentally

disturbed persons. Such wounds do not produce

the massive tissue destruction and the extensive

contamination that result from the impact of the

high-velocity particles of combat.

Patients are usually admitted to the hospital in

shock and early attention is directed to life-threatening problems, so that definitive treatment is delayed until their condition has stabilized. Complete

loss of external genitalia was reported as a common

occurrence in the Soviet Army in World War II125

but penile amputation has been encountered much

less frequently by American surgeons.124,126–128 Superficial penile injuries involving the skin and glans

or subcutaneous tissues or both, are much less likely

to be accompanied by other genital wounds and

generally heal without major complications.122 Severe penile wounds with injury to the corpora

cavernosa are apt to be associated with urethral and

testicular damage but partly severed penises can

be reconstituted provided sufficient corpus

cavernosum is retained. Later complications include penile pain and fibrosis, and chordee interfering with erection.

Scrotal-testicular wounds are the most common

external genital injuries. They made up 32.8% of all

genitourinary wounds in a series of 124 patients

evacuated from Vietnam to Japan. It was usually

possible to preserve at least part of a testicle.

Orchiectomy or partial orchiectomy was performed

in 77 of 98 men with unilateral testis injury, and

total bilateral orchiectomy was done in only 5 of 28

patients with damage to both testicles.124 Loss of

one testicle does not interfere with potency or cause

sterility, and does not contraindicate return to

duty. After bilateral orchiectomy, hormone replacement with depo-testosterone maintains potency and

bone density. The course and disposition depends

not only on the severity of the genital wounds but

on the extent of other injuries.

Behavior

There are no published studies of the behavioral

sequelae of combat-incurred genital mutilations.

One reason is that such wounds are relatively uncommon. Another is that because of the frequently

CASTRATION AND GENITAL MUTILATION
373

Disabling and Disfiguring Injuries

associated injuries, patients with genital wounds,

unlike amputees and those with spinal cord damage or blindness, do not form a distinct group with

a training program from which data can be derived.

As noted, it may be some time before the wounded

soldier becomes aware of the extent of his injuries.

The first sight of a mutilating genital wound may be

so distressing that some surgeons perform the first

procedures with the patient under anesthesia.124

While some men react with equanimity, depression

ensues in the great majority of cases. It usually

improves over time but may persist, especially if

the patient is septic or in pain. Patients experience

the emotional problems of the disabled and disfigured, along with those specifically related to sexual

functions. The incidence of impotence associated

with persisting penile deformity is not known, but

the sensitivity to the cosmetic aspects is an important psychological factor. For some, disfigurement

of sexual organs is equivalent to the loss of all

manly qualities. Adding to the sense of alienation

in some cases is the lack of a reference group such as

those with which the amputee, the paraplegic, and

the blind can identify and gain support.

The major behavioral disorders in the chronic

stages are depression, social withdrawal, and substance abuse. Statistical data are lacking so it is not

known if the association of genital wounds with

amputations, spinal cord injuries, and blindness or

facial disfigurement or both adds to the suicide rate

or increases the incidence of behavioral disturbances. Phantoms of the genitals may occur but

have not been reported in the literature of recent

wars. Patients with relatively minor genital injuries

may also have psychiatric problems. A man with a

slight penile deformity may believe he is physically

repulsive and make it the focus of all his personal

problems. A patient with loss of one testicle may be

beset by fears that the other will be damaged or he

may engage in compulsive sexual activity to prove

his potency.

Treatment

Treatment depends on the extent of genital loss

and the nature and severity of other injuries that

determine the patient’s ability to participate in a

rehabilitation program. Unfortunately a man with

a genital injury cannot improve his performance the

way a blind man can become proficient in orientation and mobilization techniques. There should, in

any case, be a doctor-patient relationship in which

feelings of despair, loneliness, anger, and shame

can be expressed. The patient must be assured that

loss of physical capacity does not mean loss of

personal integrity and that all that can be done for

him is being done. Some of the more successful

outcomes have been associated with the initiative

and resourcefulness of surgeons who have followed

their patients over the years and the personal qualities of the patients themselves.

The following cases are illustrative of some of the

features that have been presented.

Case Study 4: Of Arms and the Man

On Friday, 13 October 1967, a 17-year-old machinegunner in Vietnam was struck by a high-velocity missile

that pierced his left flank and exited from the right, destroyed his left kidney and one half of his right one,

damaged extensive areas of bowel and penetrated the

cauda equina. At an evacuation hospital where he arrived

within 15 minutes of his injury, a surgical team performed

a left nephrectomy, a right heminephrectomy, multiple

bowel anastomoses and a colostomy, and inserted drains

in the pelvic area. In Japan, the patient was noted to be

paraplegic and underwent a lumbar laminectomy after

which he developed a bloody pleural effusion and contracted a severe urinary tract infection. At a hospital in the

United States to which he was admitted 1 month after his

injury he was still paraplegic, had large decubiti over the

sacrum and other pressure points, and had osteomyelitis

of the lumbar vertebrae and pelvic bones. To protect what

was left of his remaining kidney from infection, an ileal

conduit was constructed. The patient was confused and

lethargic as a result of his sepsis, was in constant pain,

became addicted to several drugs, and was deeply depressed. He tolerated food poorly and his weight had

dropped to 57 pounds.

At this point his physician, recognizing the noxious

effects of his pain-racked, functionless, septic lower body,

conceived of a translumbar hemicorporectomy, an operation that had been performed on patients with advanced

cancer of the bladder and pelvis. Following the procedure, the patient’s condition improved remarkably. He

was free of pain, came off drugs, and was no longer

depressed. He entered a rehabilitation program, developed great arm strength, and was able to use and transfer

himself from a wheelchair. One year after his injury he

was discharged to his home and, with the support of his

family and the community, has led an active life. He

operates a small-engine repair shop, drives a number of

vehicles, and serves as a member of a radio emergencyaction communication team. He collects guns, target

shoots, hunts with a rifle and crossbow, and fishes. He

was fitted with a prosthetic trunk and legs but has discarded these, as he finds it easier to ambulate on his

hands which he does without embarrassment. He cares

for his personal hygiene and handles his colostomy and

ileal bags successfully.129

In a 1993 interview, the veteran reported that he had

had no emotional problems. For several years after his

return home from the hospital he drank heavily but stopped
War Psychiatry

374

after he put on a great deal of weight. He has not been

depressed and never thought of suicide. He recalled that

he had been immediately aware of his paralysis after

being wounded in Vietnam, and that in the hospital there

he had been terrified during shelling because of his

immobility. He since has had no symptoms of PTSD. He

has experienced a phantom of his right lower extremity

with a sensation of dull pain from his knee upward, but no

genital phantoms. He has had no sexual sensations,

desires or imagery, and no erotic dreams. When asked

how he sees himself in dreams, he replied that he does not

visualize himself, only others. He states that he does not

regret not having gotten married and having children, and

that he regards his nephews as his sons. He is not bitter

over his war experience, but rather, he is proud of having

served his country as his father and brother have, and is

grateful to the doctors for saving his life.

Comment: One can only marvel at the superb medical

care he received and the patient’s survival skills.

Case Study 5: Against All Odds

An 18-year-old combat engineer was injured in Vietnam in 1968 when his helicopter was struck by rocket fire

and crashed into a mountain. Both legs were sheared off

above the knees on impact, his right little finger was

amputated, there were fractures of both arms, and he had

facial and genital wounds. There was penetration of the

left orbit into the frontal lobe necessitating enucleation of

the left eye and injury to the right eye left only light

perception. The right eye was subsequently enucleated.

The genital wounds consisted of penile lacerations closed

by primary repair, and a damaged right testicle requiring

orchiectomy. He later had a craniotomy for an infected

frontal sinus, reparative upper-limb procedures, a number

of revisions of his amputation stumps, and in 1972

exenteration of his right hip joint for osteomyelitis.

The veteran was interviewed 20 years after his injury

when he was located by his surgeon, Dr. Kenneth Swan.

He recalled that he had been unconscious only briefly, but

that it was not until several days later, and then only after

he had been told by a fellow soldier, that he discovered he

could not see, and that he had lost his legs. He stated that

he was not depressed or concerned over his condition

while in Vietnam. He thought that he would be able to get

along fine with wooden legs, and that his remaining vision

would suffice. Following a craniotomy in Japan, he had an

episode of delirium lasting 4 months, over which time he

was agitated and hallucinatory, reexperiencing combat.

This was followed by long periods of lethargy and depression that improved after the removal of his infected hip

joint. Subsequent depressive episodes associated with

aggressive behavior have appeared mainly in response to

frustration. He recalled that the first time he struck his wife

was when he was having difficulties with college courses.

He also has had problems of drug abuse, but gave up

drinking after a grand mal seizure. Symptoms of PTSD

appeared in 1972, 4 years after his injury, and anniversaries of traumatic experiences such as the 1968 Tet offensive have been associated with emotional distress.

He had been told during his last military hospitalization that he would be sterile; subsequently he engaged

in excessive sexual activity after discharge. He later

married and fathered two children. He is potent except

for brief periods when he is under stress. He remains

totally blind and navigates from a wheelchair with the aid

of a sonar path sounder. He has experienced phantoms

of both lower extremities with sharp pains that may last up

to 24 hours. He has not had phantoms of the missing

testicle or little finger. Since enucleation of the right eye,

there has been phantom vision in which he “sees” bright

lights.

In the late 1980s, the veteran’s wife suffered a nervous

breakdown, an episode of depression brought on by his

social withdrawal, his abusive behavior, and her inability

to cope with the management of the household. The

couple went into counseling and the veteran feels he has

been able to resolve his feelings about the war and his

own experiences as an abused child. Although he states

that he is making a better adjustment at home, he still finds

it difficult to be comfortable with people in public.

Comment: One factor contributing to the worse adaptation of the this second patient is the brain injury that he

suffered.

SUMMARY

Amputation, spinal cord injury, facial disfigurement from wounds and burns, blindness, and mutilating and castrating genital injuries have a number

of features in common. Each involves the loss of a

major function of the body that is largely irreparable. The injuries are frequently associated in that

a mine explosion may blow off one or more limbs,

damage a testicle, and blind a soldier. Following

the initial shock and the undertaking of life-saving

measures, most patients must endure a long hospitalization, often with complications necessitating

arduous and painful surgical procedures. Psychologically, there is a profound alteration of body

image, a loss of self-esteem and, for many, the end

of a way of life. Injuries may be associated with

PTSD, depression, and denial as prominent behavioral features, and brain dysfunction is common.

Brain dysfunction occurs in a number of ways. It

may result from direct impact as in spinal cord

injuries, notably cervical cord lesions, and from

penetrating head wounds in blinded patients. Brain

abnormalities can also be caused by anoxia, sepsis,
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Disabling and Disfiguring Injuries

and metabolic abnormalities. Sensory isolation consequent to head immobilization for cervical cord

injuries may bring on behavioral disturbances.

Phantom-limb manifestations were once regarded

as psychogenic, but current findings suggest that

the phenomena are the result of reorganization of

denervated cortical sensory areas. Burn encephalopathies are manifested in initial delirium and occasionally in delayed focal neurological signs and

psychotic reactions. Among the organic mental

syndromes subsequent to severe burns that have

been reported are depressive-withdrawn and paranoid-aggressive states, anosognosia in which the

patient denies or appears unaware of his bodily

deformities, and delusional misidentifications. In

patients without overt behavioral disorders, brain

damage lowers thresholds for stress and increases

the complications of drug therapy. Psychoses in the

absence of evidence of brain dysfunction are rare.

A wounded soldier may not be spontaneously

and immediately aware of the loss of a limb or of

paralysis, blindness, or disfigurement. The duration of such anosognosia depends on the state of

brain function and the degree of interaction in the

environment. Later manifestations of denial include unrealistic expectations of the future, faith in

a miracle cure, and a defiant “we can take it” attitude. Blind patients may persist on relying on an

inadequate fragment of remaining vision and refuse

training to help them compensate for the loss of

sight. Denial may take a paranoid form in which a

patient may angrily blame his incapacity on improper treatment. In the early stages denial may

detach a patient from the catastrophic reality and

help him preserve a sense of identity, but it is

ultimately maladaptive. It deprives the patient of

the opportunity to grieve, hinders the development

of group relationships, and blocks rehabilitative

efforts.

Depression at some stage is almost universal.

While a period of grief and mourning is helpful in

allowing a patient to come to terms with his loss,

prolonged depression with dwelling on the past has

disastrous effects. It leads to noncooperation in

treatment and to self-neglect. Suicide is a danger

even in severely incapacitated patients, especially

those with self-neglect who deny ever having harbored thoughts of ending their lives.

Although disabling and disfiguring injuries

present a variety of problems, there are some common principles of treatment. The staff should avoid

statements and attitudes that reinforce denial. Patients should be told of their prognoses and given

the rationale for their treatment as early as they can

retain and evaluate information and cooperate in

self-care. The development of a new identity should

be facilitated by acceptance of a handicapped status

and by participation in a rehabilitative training

program. Feelings about disability should be shared

in group sessions and the patient should be helped

to understand how his feelings about himself affect

his perceptions of the attitudes of others. Depression, aggression, and pain should be managed with

both behavioral and pharmacological measures.

ACKNOWLEDGEMENT

The author is pleased to acknowledge the assistance of the following people:

C. Warren Bledsoe, formerly Chief Blind Rehabilitation, Physical Medicine and Rehabilitation

Service, Veterans Administration; Don Garner, Director Blind Rehabilitation Service, Department of

Veterans Affairs; Frank La Piana, M.D. Col M.C., Chief Ophthalmology Service, Walter Reed Army

Medical Center; David G. Mc Leod, M.D. Col M.C., Chief Urology Service, Walter Reed Army Medical

Center; Thomas H. Miller, Director of Governmental and Community Affairs, Blind Veterans

Association; Basil A. Pruitt Jr., M.D. Col M.C., Commander and Director U.S. Army Institute of

Surgical Research, Brooke Army Medical Center, Fort Sam Houston, TX; Stuart M. Selikowitz, M.D.,

Section of Urology, Department of Surgery, Department of Veterans Affairs, White River Junction,

Vermont; Kenneth Swan, M.D., Professor of Surgery, University of Medicine and Dentistry of New

Jersey, New Jersey Medical School; Paul F. Vinger, M.D., Associate Professor of Ophthalmology, Tufts

University Medical School; John N. Wettlaufer, M.D. Col M.C., Department of Urology, Madigan

Army Medical Center, Tacoma, WA; and Russell C. Williams, formerly Chief Blind Rehabilitation,

Veterans Administration.
War Psychiatry

376

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