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During the 5½ years of World War II there was little published information about the earlier stages of combat neuroses, though there was no lack of articles describing these disorders, weeks, and even months, after their initial appearance. Since the maximum benefit from therapy is to be expected in the early stages, a real need existed for accurate and detailed descriptions, not only of the initial reactions of the patient, but also of the circumstances associated with the development and early treatment of these disorders.
Ideally the contrast between the earlier and later stages would be demonstrated by following a single patient from his first appearance in combat, through the development of his neurotic reaction, and then through the psychiatric treatment given him in various echelons from battalion aid station to base section psychiatric hospital. In practice, it was necessary instead to describe typical reactions as they appeared in men treated in the several echelons. In the course of this account it was possible as well to describe the integrated functions of the psychiatric services of a field army during combat.
This symposium was undertaken in February 1943. Psychiatrists with extensive experience in the treatment of psychiatric patients under combat conditions were asked to write on the subjects most familiar to them. Many had worked at several echelons and were thoroughly cognizant of their interdependent problems. Moreover, all these officers knew one another and had had frequent opportunities to discuss their basic principles and opinions. The unity and personal acquaintance of the group proved important, for they made possible a general agreement on all major points and an integration of ideology difficult to obtain in a symposium on a controversial subject. The approach is descriptive rather than explanatorythough the two are in many instances inextricably mixedfor the purpose was to produce a symposium, unobscured by argumentative theory, which would be useful to the nonpsychiatrically trained medical officer called on to treat combat disorders.
The opinions and case material presented were derived from 2½ years of continuous, active combat experience in the Mediterranean Theater of Operations, and reflect the knowledge gained in the campaigns of Tunisia, Sicily, Italy, and southern France. Thus the fighting embraced nearly every type of terrain, weather, operation, and
combat condition, with the exception of the jungle and the Arctic. It seems probable, therefore, that the material is applicable to most of the commonly encountered combat conditions of land and amphibious warfare. As to its applicability in jungle and Arctic conditions, only psychiatrists who have worked under such conditions are competent to decide. No attempt has been made to describe the problems peculiar to the Air Force, since Air Force casualties seldom came under our care.
In any discussion of the neuroses of combat the framework of reference for all abnormal symptomatology and reactions is the symptomatology and reactions of the normal person in combat. To discuss combat neuroses in terms of civil life is to invalidate the inquiry. In civil life, for example, insomnia, recurrent nightmares, tremulousness, and urinary frequency would usually be regarded as indications of pathology. In combat they may be simply manifestations of normal anxiety. The medical officer familiar with the reactions of the ordinary soldier under combat disregards many manifestations that would be considered abnormal in the civilian. The first article of the symposium is devoted to the normal reactions of combat, in order that this altered frame of reference may be understood.
The importance of environmental factors in producing the neuroses of combat warrants equal consideration. It may be tautologic to state that the neuroses of combat arise as a result of combat. Nevertheless, this simple fact is often overlooked. An unstable personality may be a predisposing factor in the development of combat neurosis, but indubitably a man whose emotional stability is normal, or even superior, before entering combat, may become a psychiatric casualty, usually as the result of a series of cataclysmic event or prolonged exposure to the dangers of battle. In short, even the most normal of soldiers may be brought to neurotic decompensation by war. Associated with the powerful emotional stimuli of danger are other, and at times oppositely directed, factors of environmental type, such as physical fatigue, unfavorable terrain and weather, and such social factors as leadership, unit morale, and beliefs. The neuroses of combat cannot be understood unless proper weight is given to environmental factors.
A major feature of war neuroses is the remarkable plasticity and variability of the neurotic reaction, particularly in its early stages, when it may be properly considered amorphous and unfixed. With the passage of time the process tends to become stabilized and fixed. The unfixed nature of the neurosis in its early stages makes possible the successful treatment of the majority of combat-precipitated neuroses. Owing to the variability in speed and type of progression of
the symptoms, an account of the process at any single echelon of observation describes, not combat neuroses in toto, but only a single cross section of the dynamic process. This fact is often overlooked, and the literature is consequently replete with "cross-sectional" observations that purport to be descriptions of the total process of combat neurosis. The present symposium, by describing this process at all levels of observation and treatment within an active theater of operations, purposes to present an understandable and more nearly complete study of the neuroses of combat.
In the treatment of psychiatric disorders in this theater we followed the concept of not seeking perfection for the patient. That is, discomfort was not regarded as synonymous with disability, and the soldier who retained minor but unprogressive complaints and symptoms was compelled to perform his duties. Most psychiatric and psychosomatic patients cannot be made symptom free under combat conditions, but it is quite possible to return the greater number of them to effective combat duty under this principle of limited disability. In civil life the therapeutic value of making reasonable demands on the neurotic patient has long been recognized. This practice has not produced a severe exacerbation of the neurotic process in any significant number of soldiers.
Although most of this material was written in the field, without access to the literature, and it was thus impossible to give credit in the usual manner to the various authors who have contributed to the subject, references to a number of related works have now been added. The symposium is organized into two main sections, of which the first describes the appearance and treatment of soldiers at the various echelons of psychiatric treatment, and the second presents a series of special topics of major interest in the field of combat psychiatry. A third section presents statistical data, the present combat treatment plan, and references.
F. R. HANSON