PRIVATE PAIN AND PUBLIC DISPLAY: THE YOM KIPPUR WAR
In October 1973, Syria and Egypt attacked Israel and there was a brief, violent war. Dr Carlen from Canada and Dr Noordenbos from Holland and I decided to study a complete sample of Israeli soldiers who had suffered a traumatic amputation during that war. We examined 73 amputees from days to months after their injury. Their mean age was 2,6 and ranged from 19 to 45 years. This study of the subsequent history of amputees in or out of pain was possible because all Israeli amputees attended a single rehabilitation hospital at Tel Hashomer outside Tel Aviv. On questioning about their first sensation at the time of injury, the great majority clearly described their sensations with neutral words such as 'bangs', 'blows' and 'thumps'. Not one described a flash of pain which then died down. These men uniformly expressed their surprise at not feeling pain, often beginning with 'Doctor, you won't believe it but. ..'. A minority had felt pain from the first moment.
With Beecher's reasoning in mind, we began to enquire about the precise circumstances of their wounding. The scene at Anzio was evidently one of unremitting horror and terror, continuing night and day, with the common soldier adjusting to some passive tactic which he hoped would end in survival. For those of us fortunate enough not to have been in battle, we perhaps imagine that painless injuries could occur only in the heat of combat when the 'blood was up' and the victim was engaged in some intense action. But far from this picture of continuous intensity, the Yom Kippur War was often intermittent, scattered with abrupt short violence. Some of the men had suffered in road accidents as they raced at night with lights out on unfamiliar roads. Some had been asleep in a quiet area when they were hit by an unexpected long-range shell. Others had been hit suddenly by the accidental firing of weapons from their own side. It was evident that painless injury could occur in men who were in no unusual state of mind. The episode appeared to begin precisely with the impact and did not depend on some prior expectation.
Our team, which included fluent Hebrew speakers, very tentatively and diplomatically explored the question of whether any of these men greeted their injury as welcome. There was never a hint that anyone adopted the Darwinian approach that being wounded increased their chance of survival. No soldier reported even a fleeting sense of relief that they had escaped alive from the killing fields. Elsewhere, I spoke to a man from another army who had shot off one of his own toes in order to get out of action. He said it hurt badly and immediately. Yet the overwhelming reaction of these 73 soldiers to their wound was anger. Surprisingly, often it was directed at themselves: 'If only I had not gone into that house' or 'If only I had not climbed out of the trench.'
I found the most bizarre story of this kind to come from a man who had lost three fingers from one hand. He had been standing head and shoulders out of a tank turret when he saw an Egyptian wire-guided anti-tank missile streaking towards him. He dodged down leaving his hands on the rim of the turret so that he lost his fingers when the missile exploded. He said: 'What a fool I was. If I had time to get my head out of the way, I certainly had time to move my hands.' Next to themselves, they blamed officers and, only low on the list, the enemy, who had, after all, really been responsible.
We can leave the topic of emergency painless injury as a fact that we must accept and explain without reverting to ad hoc attempts to explain it as a very special case, as Beecher did, or by using meaningless terms such as 'shock' - the victims had clear minds and were behaving rationally. We have all witnessed one such episode on television. President Ronald Reagan was shot with a 9-mm bullet which entered his chest as he walked from a Washington hotel. He was slammed roughly into his car by the Secret Service men. He and the others in the car did not know he was wounded. He began to feel unwell, and there was a discussion about the possible damage to him when he hit the car door. On the anniversary of the shooting, Reagan appeared on a CBS documentary and said, with his wondrous command of English: 'I had never been shot before except in the movies. Then you always act as though it hurts. Now I know that does not always happen.'
So much for the men's reports of their immediate sensations. What was their sensory state after some weeks when we saw them? Within 24 hours of their amputation, 65 per cent experienced a 'phantom limb', a name given by the American Civil War physician Wier-Mitchell to the clear sensation that the missing limb is still present. The remaining 35 per cent all felt a phantom limb within a few weeks. Pain in the phantom was experienced by 67 per cent, who described it using the words 'jabs', 'strong current', 'pins and needles', 'burning', 'knife-like', 'pressure', 'cramps', 'crushing' and 'vice-like'. In addition, many had pain in their stumps, with or without phantom pain as well. On careful examination of the stumps, it was found that every man had at least one area of intensely painful hypersensitivity. At the time these men were examined, in 1973 and 1974, 80 per cent had stumps that appeared perfectly healed with no signs of infection. It is particularly sad to report that when this same group of men were examined fifteen years later, even though all signs of infection had gone and all stumps appeared perfectly healed, the pain reports were identical to those we had reported soon after the war.
Now we have three new problems to absorb and explain. What can be the explanation of the common report of no pain at the time of the injury, but pain within a day? Second, some of the pains appeared to the victims to be located in a lost limb. And third, some of the pains persisted even when there seemed to be complete healing of the remaining damaged tissue.