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Psychiatry at the Army Level
Major Alfred O. Ludwig Medical Corps, Army of the United States
Medical Corps, Army of the United States
This section is based on experience in army psychiatric treatment centers with both the Fifth Army in Italy and the Seventh Army in France and describes the duties and functions of the army psychiatric center, the organization of army psychiatric centers, and the appearance, treatment, and disposition of patients seen at these centers.
THE ARMY PSYCHIATRIST
Military psychiatry is more than a medical problem. It involves important aspects of law and morale as well. Accordingly, it is advisable to have on the staff of the army surgeon a medical officer familiar with all phases of the task. In addition to adequate civilian psychiatric training and experience, the army psychiatrist must possess a detailed knowledge of the special problems of military psychiatry and the variations in treatment and attitude which combat imposes on the practice of his specialty. The army psychiatrist, although he devotes a large part of his time to the care of psychiatric casualties, has many administrative and consultative functions as well. His problem concerns echelons both forward and to the rear of the army center. He should be familiar with the psychiatric work carried on in all these installations, preferably through previous tours of duty in their hospitals. As part of his staff functions the army psychiatrist advises the battalion surgeon of the policies to be followed with psychiatric patients and prepares written directives and informative circulars on the subject for distribution to all army medical officers. He maintains liaison with the personnel section at army headquarters with reference to reinforcements and reassignments, and, in consultation with the judge advocate, formulates policies concerning medicolegal and disciplinary problems.
It is his duty also to supervise the operation of the army psychiatric treatment centers, to provide psychiatrically trained medical officers for such centers, and to further the training of medical officers at these installations. He should keep in close touch with the division psychiatrists and supervise and assist them in their work. It is particularly important to consult with psychiatrists from divisions newly
committed to a combat zone and instruct them in the organization of efficient intradivisional psychiatric programs and in the special problems that may be expected to arise. To insure correct disposition of patients with psychosomatic and psychiatric complaints admitted to the army evacuation hospitals, close contact should be maintained with the hospitals. At intervals the psychiatrist should visit base section hospitals in order to evaluate the earlier care given patients in the army psychiatric centers and to check on errors of diagnosis or treatment.
The psychiatrist must maintain adequate records of the incidence of psychiatric casualties in all army units. Comparative figures of battle casualties, psychiatric casualties, disease, and injury give vital information concerning the state of morale in combat troops, the quality of leadership, and the adequacy of screening of psychiatric casualties by unit medical officers. The report form used in the Fifth and Seventh armies for psychiatric casualties in divisions furnished these data. The figures on duty returns from division clearing stations provided a semimonthly check on the efficacy of the psychiatric policies of each division. The value of these reports and the use made of them to improve efficiency within the division are discussed in the preceding section. From these reports the army psychiatrist may obtain an excellent conception of the condition of the troops which will serve as a basis for the initiation of needed corrective measures.
THE ARMY PSYCHIATRIC TREATMENT CENTER
With well-organized division psychiatric programs the need for a separate army treatment center may well be questioned. It was, however, found essential because: (1) the treatment of psychiatric casualties and those of other types as well is facilitated by such separation, for emotional disorders readily become contagious in hospitalized combat troops and nonpsychiatric patients may become "infected"; (2) the treatment of psychiatric patients is more effective when care is centralized and when hospital atmosphere is minimized; (3) it provides a place for psychiatric patients who cannot be held in division clearing stations that are overcrowded or must evacuate patients because the division is moving; (4) it provides a means for further screening and thus insures that a maximum number of potentially useful soldiers will be retained for service; (5) it provides a meeting place where army and division psychiatrists can discuss mutual problems; and, (6) it furnishes excellent facilities for the instruction and indoctrination of medical officers in the special methods and principles of combat psychiatry.
Organization. In the Fifth Army the Second Platoon of the 601st Clearing Company, 161st Medical Battalion (Sep.), was designated as the psychiatric treatment center. The number of enlisted men provided by the normal T/O was approximately doubled by attaching additional personnel from other units in the battalion. In order to provide adequate facilities to care for 200 patients, allowing for expansion to accommodate 250, additional equipment was added over and above the normal T/E. Four psychiatrists from base hospitals were attached to handle the professional work. The administration of the hospital was left entirely to the assigned medical and medical administrative, or other personnel of the platoon. Additional psychiatrists were added from time to time when an increased case load made it necessary to do so. On the Anzio beachhead the policy of separate treatment of psychiatric casualties was accomplished by designating one evacuation hospital as the receiving station for all such cases. A ward with a capacity of 60 to 80 patients was set aside for this purpose. The service was staffed by the psychiatrist assigned to the hospital and attached psychiatrists from the main Fifth Army center. This unit continued to operate until the two fronts were again joined during the offensive of May 1944, when all patients were again treated in the original center. In the Seventh Army the first center was organized as in the Fifth Army, with the Second Platoon, 616th Medical Clearing Company, so used. When a second center became necessary both platoons of the 682d Medical Clearing Company were used. Both in the Fifth and the Seventh Armies the treatment centers soon became the nuclei for all psychiatric activities. Clinics were instituted to teach the principles and methods of diagnosing and treating combat neuroses to medical officers from divisions and evacuation hospitals. Division psychiatrists maintained close touch with the professional staff of the center and aided greatly in formulating and improving treatment policies. The work also helped to stimulate interest in psychiatry in army medical officers.
Enlisted personnel. Enlisted personnel of the Medical Department who were entirely unskilled in the handling of psychiatric patients were trained by means of short preliminary talks, continued after operations began by suggestions related to current ward patients. Ward attendants were told that psychiatric patients were to be regarded as sick, not "yellow," and the dynamics of the disturbance were explained to them. They were shown the need for a sympathetic but firm attitude, and were instructed to foster a spirit of optimism on the wards, stress ultimate return to duty, discourage undisciplined outbursts of emotion or defeatist trends, and report any unusual
behavior or symptoms to the ward officer at once. Many of our ward attendants developed great skill in handling these often difficult patients, and, owing to their close contact with the patients, were often able to furnish valuable information to the ward officers.
Equipment. Patients were housed in tents throughout the Italian campaign, and, until extreme cold in the winter of 1944-45 forced the use of buildings, in southern France as well. Every effort was made to minimize hospital atmosphere. The installation was often spoken of as a "rest center" and this attitude was fostered. There were no nurses. No sheets, pillows, pillowcases, or pajamas were issued. The men slept between blankets on Army cots. Tents and buildings were adequately heated in winter. Bathing facilities, consisting of portable shower units, were provided when available. A supply of fresh clothing was always kept on hand to replace torn, soiled, wet, and muddy garments. The field soldier, accustomed to extreme discomfort at the front, found these arrangements adequate. It was felt that hospital accoutrements usual at home or in base hospitals were unnecessary and would tend to spoil this type of casualty.
Location. These installations were placed on the same level as the army evacuation hospitals, from 5 to 20 miles from the front, and moved forward with the evacuation hospitals.
Psychiatric Casualties Seen at Army Centers
Sources of cases. When the Fifth Army Center was first organized there were no psychiatric facilities and little or no psychiatric treatment at division level, and patients were therefore received directly from division clearing stations. Although some screening was done by battalion surgeons, many mild cases were then received at the center which in a later period would have been held and treated by division psychiatrists. Patients from corps or army troops were sent directly from unit dispensaries or aid stations. Evacuation hospital commanders were instructed to send patients with psychiatric disorders to the center on admission. If soldiers arrived at the hospital with a nonpsychiatric diagnosis and were later shown to have a psychiatric ailment, they were to be transferred to the center, but, since such cases had been treated in the evacuation hospitals for many months under the supervision of their own psychiatrists, a fair number, especially of soldiers with psychosomatic symptoms, were not transferred to the center. When psychiatrists were assigned to the divisions and facilities for holding and treating such casualties became available to them, the nature of the cases received at the army psychiatric center changed and mild cases were seen less commonly. In the Seventh Army only one of the evacuation hospitals that
participated in the invasion of southern France had an assigned psychiatrist. In this army, circulars issued at the outset directed that all patients whose main problem was psychiatric be screened through the psychiatric center. The army psychiatrist visited the chiefs of medicine of each evacuation hospital to discuss the types of patient to be disposed of in this way. Thus patients with psychosomatic complaints were made subject to psychiatric evaluation and screening after the presence of organic disease had been ruled out by preliminary examination in the hospitals. A check made on patients evacuated from army centers proved that few men were lost to the Seventh Army by improper treatment or disposition. Evacuation hospitals cooperated in this program and welcomed the freeing of their beds and personnel for other casualties.
Types of patients. Table I shows the incidence by diagnosis of conditions seen in Seventh Army centers from 15 August 1944 to 1 January 1945.
Incidence of psychiatric disorders in percent
The data show that, in this theater at least, the anxiety state was the most prevalent psychiatric disorder of the combat soldier in World War II. The current diagnostic fashion may account in part for the high incidence of this disturbance. Major psychoses, constitutional psychopathic states, and mental deficiency were rarely encountered, since most of these defects had been screened from combat units earlier. The category "other psychiatric disease" included patients with no psychiatric disorderthe unwilling or poorly motivated soldiers whose symptoms were considered largely volitional. Few patients with concussion were admitted to the centers, because it was army policy to treat such patients in evacuation hospitals, where trained
neurosurgeons and facilities were at hand to deal with intracranial hemorrhages and other cerebral injuries that often complicate this type of trauma. Usually the centers received only patients with mild cerebral concussion in which there was a large overlay of neurosis.
Appearance and behavior of patients. Few observations of combat neuroses shortly after their onset were recorded before World War II. Most of the descriptions of combat neuroses came from base section hospitals, or even veterans hospitals, and dealt with a group whose symptoms were chronic, fixed, and often intractable. Our experience indicates that the combat-induced neurosis is often a progressive disorder that becomes increasingly severe, fixed, and difficult to treat as the soldier is evacuated rearward. It appears that even the soldier whose symptoms are severe enough to preclude further combat benefits greatly from early treatment.
Medical officers often have the mistaken idea that dramatic or violent behavior is usual in soldiers treated at the army level. In general, striking symptomatology was rare in our patients. Five to 10 percent of our patients showed mild tremor or startle patterns at this stage. Not more than 3 percent had severe terror states or other violent manifestations. In the average patient marked fatigue, apathy, and lack of facial expression were the outstanding features on admission. Questions were answered in monosyllables, in a dull, toneless voice. The men sat on benches or on the ground, supported their heads in their hands, and, without previous sedation, often fell asleep sitting, or even standing, as soon as they were left alone. In soldiers who came to us before division psychiatric treatment had been established, the unwashed hands and unshaven faces, the lackluster eyes, the soiled, torn, and often wet and muddy clothing, accentuated their "beat-up" appearance.
Most of these soldiers displayed marked symptoms only under actual combat conditions. On seeing them at the centers lay observers sometimes doubted that they were ill at all. Noise sensitivity was not an important symptom at this stage. When present it was highly specific to gunfire or other explosions. Marked intolerance to nonspecific noises, so frequent in base section hospital patients from Tunisia, was rare in this group. Extreme noise sensitivity was unusual even at Anzio, where the hospital was within enemy artillery range surrounded by the constant noise of our own artillery and antiaircraft batteries, with enemy shells screaming overhead and bursting nearby and occasionally even in the hospital area, and where night air raids were frequent. During air raids a few patients left the ward to seek cover in nearby ditches, but the others showed little increase in symptoms. After the first 2 or 3 days, during which patients were often heavily sedated, new symptoms appeared and progressed rapidly in
severity. The will to return to combat decreased with each succeeding day, discomfort from minor illness or injury was exaggerated, and without vigorous treatment the trend toward invalidism and dependency grew. Increasing gain was derived from illness, which became more fixed as the need for self-justification rose. Early treatment was therefore essential, for without it the soldier was inevitably lost for combat, and rehabilitation for even limited service became difficult.Description of Patients
Severe anxiety states. Certain clinical manifestations, mostly variants of the anxiety state, were seen repeatedly in army center patients. One of the most interesting examples was the violent, disoriented soldier whose behavior was at least temporarily psychotic. Because of the complete loss of contact with reality, the hallucinations and delusions, and the ultimately favorable outcome, we designated these reactions "pseudopsychotic." Case 12 is typical.
Case 12. A 19-year-old rifleman with only a few weeks of combat service was admitted to the Fifth Army Center in a completely disoriented state. He had been found crawling along a road near an aid station. At times he attempted to dig himself in with his fingernails. He was so violent that heavy sedation with intravenous barbiturates was required to control him sufficiently for evacuation. He was hallucinating on arrival at the center. He believed himself still in battle and behaved accordingly. With expressions of terror he cried to his friends to look out for shells. Often he attempted to flee. It was apparent that some of his confusion was the result of repeated heavy sedation, and further drugs were therefore omitted. It was impossible to establish contact with him. He thought himself under fire, screamed, and had to be restrained from running away. Occasionally enough contact could be established to convince him that he was in a hospital, but such periods were short and his violent behavior soon recurred. He was so disturbing to other patients that he was moved to a separate tent, and a ward attendant was kept with him constantly. The attendant was urged to make every effort to reassure the patient and orient him to his surroundings. After 24 hours it was possible with effort to establish contact with him, but conversation with him was repeatedly interrupted by renewed hallucinations, attempts to flee, or terrified questions about when he was to return to combat.
The following story was finally obtained. He had been in a group that was surrounded by the enemy and lay under heavy fire for many hours. Many of his friends were killed or wounded. He recalled that he had escaped by crawling away, but could not say how he had reached the aid station. Further questioning brought out that he had always been close to and dependent on his mother. Some of his dependence had been transferred to the corporal in charge of his squad. He expressed great distrust of medical officers and said that he had been deceived by a line officer who had sent him to the front after promising not to do so. He found it hard to believe that this deception would not be repeated. He became dependent on the attendant who had been with him for several days and often turned to him for reassurance during the interview. He gave the impression of marked regression and behaved like a severely frightened child. At times he burst into tears and clung to the attendant. Again he
smiled in a childish manner. He continued to improved slowly and was eventually evacuated to the rear.
This type of severe reaction occurred almost exclusively in soldiers with past histories of marked inadequacy, dependency, or disabling neurotic symptoms. Many of them broke after brief exposure to combat, usually shortly after their unit had been committed in heavy action. Usually the onset was acute and sudden, and followed some severe psychic trauma. The reaction seemed to be a severe and continued panic state in which the patient remained "fixed" in the combat situation. Even after hospitalization this panic reaction continued in response to the content of the soldier's delusions and illusions or hallucinations. Since in such patients heavy sedation was necessary in division medical installations to facilitate evacuation, it is possible that some of the confusion and disorientation observed in army centers was secondary to oversedation. The general behavior of these patients, however, was not very different when little or no sedation had been used. The chief problem was to re-establish contact and orientation. To do so required a different technique from that used to recover amnesic material in the less severe anxiety states; namely, the use of barbiturate narcosis, under which the patient is encouraged to relive the traumatic experience in order to release tension and recover forgotten material. In the acute stages of pseudopsychotic reactions we found intravenous barbiturates of no value in establishing contact or influencing symptoms. Temporary sleep was produced, but no lasting improvement followed.
In these patients sedation should be omitted. The patient should be segregated under the supervision of an experienced attendant, who should make continued efforts to reassure and reorient the patient and establish contact with him. At best, treatment of such patients is a difficult problem in army installations, and they should be evacuated to the nearest base section hospital as rapidly as possible. These highly dramatic manifestations appeared in less than 3 percent of total admissions. All degrees of severity are seen in anxiety states, and no useful purpose is served by subdividing the group into separate diagnostic categories. In some patients marked terror reactions are encountered. Such patients show excessive startle patterns in response to slight stimuli. One such soldier, very confused, answered all questions with a stereotyped reply: "It was too noisy." When his pupils were examined with a light he jumped from the cot and bolted from the tent. In spite of reassurance and explanation of the purpose of intravenous barbiturate narcosis, all attempts to use the treatment were frustrated by his anxious, tearful protests. The sound of a passing truck caused another patient to dive into a coal box.
This man insisted on wearing his helmet in bed because he thought he heard shells exploding nearby. Another soldier sat and stared blankly. He slowly moved his head from side to side and muttered repeatedly: "Shells, tanks, captain killed." Such patients often imagine that they hear shells exploding, and may warn others of the danger. Others show catatonic behavior, with immobility, rigidity, masklike faces, and mutism. Inexperienced medical officers sometimes confused these manifestations with true Parkinsonian states, especially when there was an associated tremor resembling the "pill-rolling" type. Such behavior gives the impression of uncontrolled, catastrophic reaction to fright, varying on minimal stimuli from wild, impulsive flight to "freezing," or primitive protective withdrawal, with stupor, catatonia, or mutism.
Moderate and mild anxiety states. By far the greatest proportion of our cases fell into the category of moderate anxiety states. The stories and appearance of these patients were repeated hundreds of times with monotonous regularity. The following cases illustrate typical reactions.
CASE 13. An infantry soldier who had been in combat for 5½ months was sent to the Center because of recurrent nervous symptoms. He had first noted confusion under shell fire 2 months before. He had recovered without having to leave his unit. On the day before he entered the Center many men were killed or wounded near him during a heavy barrage. Finally he could no longer "see or hear." He wandered around and found himself in a hole with his lieutenant. He was sent back to the company command post for the night and returned to the line in the morning. He was still very shaky and was, therefore, evacuated. At the Center he complained of headache, dizziness, tinnitus, insomnia, urinary frequency, and tremor. He had bitten his fingernails to the quick. On the ward talk about war upset him greatly. He was troubled by noise and wept at the slightest provocation. On examination he was apathetic and showed a coarse tremor of the hands. These symptoms continued, and he was sent to a base section hospital.
CASE 14. An infantry private had been in combat for 4 months, during 6 consecutive weeks of which he had been on the line without relief. About a month before admission he began to get shaky during shelling and when other men were killed. On the morning of the day he came to the hospital a barrage kept up for 2 hours. About noon the men were briefed for an attack. Just as the officer completed his instructions "all hell broke loose." Two officers, a close friend of the patient, and several other enlisted men were killed. The patient became shaky and nervous and did not know what to do. They had been ordered to hold their position, but he could stand it no more. He stood and "just looked around" until someone told him to go to the aid station. Even then he could not make up his mind, and another patient finally helped him to the aid station. Here he was given a sedative and evacuated to the rear. On arrival at the Center he was still quite shaky, but there was no amnesia and he had good insight into his condition. An interesting point in his family history was that he had one brother who had never been able to hold a responsible job and who was rejected for military duty because of "nervousness." Rest,
together with discussion of his problem, restored his self-confidence, and he returned to combat after 7 days.
The mode of onset of these disturbances is discussed in the sections on "The Battalion Surgeon as Psychiatrist" and "Psychiatry at the Division Level." It was common to find a slow, episodic increase of anxiety over a period of time, which culminated in a "break" after some severe psychic trauma. About 20 percent of such patients seen in the Center gave histories of civilian neuroses severe enough to cause them to consult a doctor. The family background was often poor. Although most men with histories of previous inadequacy "broke" relatively early in combat, a large number carried on in severe combat for many months before becoming incapacitated for psychiatric reasons. We found it necessary to modify our conceptions of the potential combat capacity of such apparently predisposed patients. Those who were severely predisposed usually developed severe and intractable symptoms as soon as a disabling exacerbation was produced in combat.
The most common complaints in our patients were anxiety, apprehension, mild depression, emotional lability, headache, dizziness, tinnitus, loss of appetite, urinary frequency, insomnia, and battle dreams. Waking battle "images" disturbed occasional patients in this group. On examination the outstanding signs were tension, tremor, mild apathy, and weeping. Guilt feelings over leaving friends were common. Such feelings led to the need for self-justification and probably played a large part in the increase in symptoms after the first few days. Many of these men strove desperately to convince us and themselves that somatic symptoms were caused by injury or organic disease. In response to their sense of guilt some soldiers insisted on returning to duty, even when they had severe tension and other unrelieved symptoms. If they were returned to combat it was almost invariably necessary to re-evacuate them several days later.
Under the stress of increasing tension at the front a few soldiers resorted to alcohol. One soldier who had been a litter bearer in combat for 6 months found it possible to continue only by means of all increasing daily consumption of alcohol. In others alcoholism appeared for the first time in periods when the division was out of the line or in training periods between campaigns. In one group of medical soldiers the use of morphine followed the onset of anxiety at the front. These men gave no history of previous addiction to drugs or alcohol, nor did they manifest the usual personality traits associated with these disorders in civil life. They used drugs or alcohol to alleviate intolerable anxiety. Nothing is known of the ultimate outcome in such patients, but it is possible that the relief from tension and proper treatment of the underlying anxiety might remove this abnormal need for alcohol or drugs.
The "old sergeant syndrome" represents a chronic moderate anxiety state. At the army centers these men behaved quite differently from most patients. Pride prevented them from losing control of their emotions, and except for apathy, loss of interest in their surroundings, and mild depression they showed no symptoms. They were seclusive and intolerant of the sometimes dramatic emotional outbursts of patients who were less well controlled or suffered from a more severe degree of anxiety. Such old soldiers usually maintained complete control until told that they were not to return to combat; then they would break into tears and immediately afterward express shame at their display of emotion. All had considerable guilt for their breakdown in combat and were eager to return to work that would forward the war effort. When it was possible to reassign them to noncombat positions they often performed in a superior fashion. One must not be misled by the apparent absence of symptoms in this group. As pointed out in an earlier section, though these men willingly return to combat if ordered to do so, their symptoms recur immediately when they are once more exposed to shelling.
In the many patients with mild anxiety evacuated to the Center before division psychiatrists were on duty, extreme physical exhaustion appeared to be an important factor in the disability. The role played by physical exhaustion is discussed elsewhere. It is agreed that it cannot cause an anxiety neurosis but that it may be a potent precipitating factor. We found that a few days of rest and sedation rapidly removed all symptoms, and that many patients asked to be returned to duty after such treatment.
Conversion hysteria. Only true hysterical conversions, without manifestations of anxiety, were diagnosed as such. Impure conversions are seen, and, with or without treatment, complete conversions may be changed into a form in which anxiety predominates. Case 15 illustrates the striking lability of the neurotic patient with conversion hysteria.
CASE 15. A 30-year-old corporal had served with an antiaircraft battery for 5 months. During this time his unit protected divisional artillery and was subjected to repeated enemy counterbattery fire. He was admitted to the Center because he had collapsed on the previous day. He stated that his back had troubled him for a year. One month before, he had entered an evacuation hospital because of gastrointestinal symptoms. These symptoms cleared within a week. When he was about to return to duty his back again began to bother him. On return to his unit his back pain increased. Pain radiated down into his legs, and finally his legs "gave way." He steadfastly denied that he had experienced anxiety under fire. On examination he limped, there was tenderness of the lumbar spine, twitching of the legs, and hypesthesia to pinprick over the anterolateral aspects of the feet. These sensory changes did not coincide with expected root or peripheral nerve distribution. The deep reflexes and
joints were normal. Since he appeared to show hysterial conversion phenomena, he was given 0.4 gm. of pentothal intravenously. During narcosis he wept bitterly and told of increasing tension and conflict over a period of months. He was terrified at the thought of returning home as a cripple, unable to support his wife and small daughter, and felt that he would rather be dead than face such a situation. It seemed that he had successfully concealed these conflicts from himself.
Following this emotional release his legs and back improved and he was able to walk normally as he left. On the following day reinterview brought out that he felt only slight residual stiffness of the legs and back. He complained, however, that soon after the pentothal treatment he began to feel anxious and shaky and that he had been unable to sleep. Examination showed tremor of the hands. He spoke with a tremulous voice. None of these symptoms or signs had been present before pentothal narcosis. He gave the following additional history: In the past 3 months he had felt increasingly depressed, tired easily, and found it difficult to do his work. Since he felt negligent in his duty he asked to give up his rating. This request was refused by his officers, and he was kept in charge of a gun section. Although this patient showed good insight into his symptoms, their severity and his underlying anxiety led us to evacuate him to the rear.
This patient's anxiety symptoms became conscious as soon as the protective conversion was removed. The interplay of hysterical symptoms and his recovery in the evacuation hospital from what was apparently a mild gastroenteritis were of further interest.
The total number of patients with pure conversion symptoms was only 2 percent of total admissions. The most common manifestations of this type were paralyses, aphonias, deafness, and partial or total blindness. Conversions referable to the back, with camptocormia, were seen occasionally. A few patients had hysterical convulsive seizures. For the inexperienced, differentiation of these patients from those in whom there is some organic disease may present difficulties, but observation and examination should suffice to demonstrate the hysterical character of the disturbance. The reaction to pentothal narcosis often clinches the diagnosis. We also saw patients with imperfect conversions, with concomitant anxiety symptoms. In them the hysterical phenomena were usually easily cleared, often by suggestion, sometimes by enlisted personnel on the wards. Since these hysterical symptoms are easily fixed, it is important not to overtreat them. New symptoms and fixations are easily produced in these highly suggestible persons, and it is, therefore, better to omit painstaking sensory examinations unless there is a definite indication for them. The mechanism of symptom production should be explained to such patients. When diagnosis and treatment are prompt, salvage for combat is possible in most mild cases.
Although at this level most hysterical conversion symptoms are quickly and easily relieved by suggestion or pentothal narcosis,
we saw a few patients in whom it was impossible to easily relieve these symptoms by any method. Usually such men refused to admit any fear, either in or away from combat, and thus they were in dire need of justifying themselves for leaving the line. They often begged to be allowed to return to combat in spite of completely disabling conversion symptoms. It is possible that the underlying mechanism in such reactions was furnished by strong guilt feelings, in addition to marked personal pride that forbade any admission of weakness or recognition of the true situation. Occasionally such men had been notorious toughs or bullies, prize fighters, or night club "bouncers" in civil life. Clearly their façade of toughness served only to protect a fundamentally inadequate personality. They were prone to break in combat and to show severe hysterical symptoms that were exceedingly difficult to treat.
Psychosomatic symptoms. Patients with psychosomatic symptoms are one of the most important groups seen by combat medical officers and constitute the largest potential and actual leak in the psychiatric program in forward areas. Some such men were evacuated with diagnoses of organic illness and were subjected to prolonged study and treatment. Such a policy leads to fixation of symptoms and loss of manpower. The majority of these men showed signs of anxiety. Their somatic symptoms, which might be referred to any part of the body, were usually precipitated or exacerbated by battle stress. Fixation was often seen in areas of the body previously involved by disease, wounds, or injuries, and these men continued to suffer pain or other discomfort out of all proportion to the physical signs.
Men with previous medical illnesses developed chronic and lingering symptoms when the time approached for return to duty. Old injuries, such as back strain, were rekindled under combat stress, but skeletal or neurologic pathology adequate to explain the symptoms could not be demonstrated. These manifestations provided the patients with a successful and apparently unassailable rationalization and justification for not continuing in combat. Since anxiety symptoms were almost invariably present, these patients were given a diagnosis of anxiety state. We regarded the somatic manifestations as physical expressions of the anxiety rather than as conversion phenomena. The following cases illustrate some of the problems encountered.
CASE 16. An infantryman was admitted to the Center after a syncopal attack. He had been on his feet continuously for 4 days and nights. His duties had involved constant climbing in mountainous terrain. Just before his attack he had carried two men down to an aid station. When he regained consciousness he found himself weeping, but protested against evacuation. At the Center he was shaky and tense. He said that he had had temper tantrums in childhood. He had used alcohol to excess in the past. His father had died of heart disease
and his mother had suffered from cardiac symptoms. He himself had always feared that he might develop heart disease. He had experienced attacks of chest pain and had fainted several times while in Africa. In Tunisia, after some physical exertion, he had developed anxiety symptoms that had improved without treatment. After he had had a few days of rest his heart was examined carefully and to be normal. He was shown that his fears were groundless, and the nature of his symptoms was explained to him. All symptoms cleared rapidly and he was returned to duty.
Many cases of this type were seen. Patients frequently developed hypochondriacal fears in response to anxiety associated with somatic symptoms. In the soldier described above, severe exertion and lack of sleep may have been sufficient in themselves to account for his reactions, but, his past history and his underlying fear of heart disease rendered him unusually vulnerable to localization of complaints in this organ, and had extensive study and treatment been directed toward the heart his symptoms might easily have become severe and fixed.
CASE 17. An infantryman with 3 months of combat was admitted complaining of insomnia of several weeks' duration. He had been troubled by headaches for several months and just prior to entering the Center after exposure to heavy shelling, they had become severe. At that time he lost control of himself, developed a panic reaction, and feared that the noise would "do something to his head." His father had been an alcoholic. In 1941 the patient had been struck in the head by a baseball. He had been unconscious for an hour. One month later he was again knocked unconscious for a short period. Since that time he had suffered from headache, sensitivity to heat, dizziness, and occasional syncopy. He gave the impression of having used these symptoms to avoid responsibility in civil life. Headache recurred after his first exposure to an air raid. The symptom continued during the Sicilian campaign. Examination showed no evidence of cerebral concussion. The symptom was uninfluenced by either sedation or dehydration, and the patient was evacuated for further treatment.
While this soldier had probably suffered a cerebral concussion in civil life and may have had a postconcussion syndrome, much of his subsequent reaction was on the basis of a posttraumatic neurosis, which under combat stress became exacerbated to the point of complete disability.
CASE 18. A rifleman was admitted because of back pain and nervousness that had developed after a mine explosion that killed two soldiers nearby. The patient fled in a panic and fell from a bank. He stated that he had had symptoms in his back and had been nervous ever since falling from a scaffold 2 years before. At that time he wore a plaster cast and back braces for 4 months. He had been apprehensive even in precombat training. Since joining the Army he had felt tired and had frequently had his back taped. Previous examinations, including roentgenograms, of the back, had shown it to be normal. Examination at the Center failed to show any evidence of significant injury to the back. After several days of rest the patient still complained of pain and showed marked tension. It was necessary to evacuate him.
In this man a moderately severe civilian posttraumatic neurosis became worse after psychic battle trauma and a possible mild back injury. He showed evidence of a moderately severe anxiety state and used the site of the previous injury as a neurotic protective mechanism against further danger.
The soldier with low back pain may present difficult diagnostic problems, for it is not easy to prove or disprove the existence of true significant structural pathology in such patients. The involved parts of the body should be examined sufficiently to convince both doctor and patient of the absence of disease or injury. When such evidence is absent and the findings indicate a neurosis, such patients should be treated psychiatrically. The use of analgesic drugs and strapping or other therapy directed toward the back should be minimized or omitted altogether. When the symptoms are neurotic in origin such measures do no good and merely strengthen the patient's conviction that he has a serious disease or injury.
Depressive reactions. The more severe types of depression associated with psychoses are discussed elsewhere; these remarks are limited to the relatively mild neurotic depressions that followed combat experiences. When depression was the outstanding feature in such a patient, reactive depression was diagnosed. Depression of this kind was seen most often in soldiers who had lost several close friends or a particularly well-liked officer in combat. Breakdown rapidly followed such an event. At the center these men showed apathy, depression, weeping, and seclusiveness. A few showed mild agitation. Ordinarily the severity of these reactions did not approach that of endogenous depression. The patient did not lose contact with his environment, and the risk of suicide was not great. The disturbance seemed to be an exaggeration of the normal mourning reaction that follows the loss of a close relative. Undoubtedly the combat soldier transfers many of his former emotional ties to a few close friends or officers, often to one. Such figures seem to exert an enormous psychic protective influence on combat soldiers. When these friends are wounded or killed the soldier reacts with depression, helplessness, and a feeling of being utterly lost. It is likely that strong guilt feelings may also play a part in the psychodynamics of such reactions, but we were unable to investigate this point. A few men with mild depressions were returned to their own units, because it was felt that they might recover more readily in an environment where they had other friends to replace those they had lost.
Obsessive-compulsive states. Though well-established obsessive-compulsive states with elaborate rituals or phobias were seldom encountered, a certain number of men evidenced some degree of compulsive
thinking. Of special interest were soldiers of this type who, because of superior intelligence, conscientiousness, and meticulous attention to duty, had been given commissions or ratings. Such men were usually excellent garrison soldiers but poor combat leaders, because of their indecisiveness, conflicts about aggression, and repressed hostility. Unable to maintain the cool objectivity essential to making quick decisions in combat or to face the strain of assuming responsibility for men under their commandsome of whom must inevitably become battle casualtiesthey soon develop intolerable anxiety, guilt feelings, and depression. Marked schizoid trends, commonly of a parnoid type, appeared in a few who seemed to be on the verge of a true psychosis.
Concussion. The relation of cerebral concussion to the development of combat neurosis has long been a controversial matter. Some authorities believe that concussion plays a major rolean opinion supported by the demonstration of abnormal electroencephalograms or pneumoencephalograms in patients with combat neuroses. While there may be evidence of cerebral damage, it is unsound to assess the importance of such damage in causing combat neuroses until careful control studies are made on normal groups and on wounded soldiers who do not present psychiatric symptoms. In the army centers a diagnosis of concussion was considered only when there was a history of bleeding from the ears, nose, or mouth, the coughing of blood, chest or abdominal soreness or pain, or true unconsciousness at the time of the injury, with amnesia for the flash and sound of the explosion. Further criteria were objective neurologic signs, such as cranial nerve paresis or paralysis or sustained nystagmus, and roentgenologic evidence of blast changes in the lungs.
The incidence of unconsciousness was studied in a group of 100 men who sustained battle wounds of sufficient severity to require evacuation to the zone of the interior. Although almost all these wounds were the result of shell explosions, and it seemed reasonable to assume that the men who sustained them were close to the detonation when wounded, only 9 percent of the patients questioned said they were unconscious at the moment they were wounded, and in most instances the period of unconsciousness was very short. Most of the men with battle neuroses gave a history of having been "knocked out" by an exploding shell. When closely questioned almost all said they remembered clearly both the flash and sound of the explosion before losing consciousness. Patients with true concussion rarely if ever remember the sound, and only occasionally the flash of the detonation, and regain consciousness at or near the place occupied before the explosion. Those with anxiety states "came to" at a site far
distant from their original position. With pentothal narcosis it was usually possible for the patient to recover memory of the events that took place during this interval, and it often transpired that the patient had fled in a panic state. The memory loss associated with concussion cannot be influenced by narcosis.
Changes in the ear drums are said to be helpful in confirming a diagnosis of concussion, but we did not find them so. We found abnormalities in the eardrums and auditory canals of all soldiers who had been near explosions or firing artillery pieces. Hyperemia of the canal wall, especially on the posterior aspect, and of the vessels of the drum, over the ossicles, and in the region of Shrapnell's membrane were among the abnormalities found. Occasionally small ecchymoses were seen on the drum. Acute perforation may occur also. Such changes were found also in combat soldiers who were not hospitalized. Most soldiers with definite cerebral concussion were sent to evacuation hospitals. At the army centers we saw only mild cases, often with superimposed anxiety states. Men with mild concussions sometimes developed anxiety states of moderate severity after several days of rest and after concussive symptoms had subsided. Inexperienced battalion surgeons occasionally fell into the error of diagnosing concussion in soldiers with acute anxiety reactions when they gave histories of "unconsciousness." Such patients avidly clung to such an organic diagnosis and used it to resist psychotherapy. Such impressions should be corrected and the true nature of the disturbance explained to the patient.
Special cases. A number of men without definite evidence of psychiatric disorder found their way to the army centers. They were primarily unwilling soldiers who were afraid and lacked the will to suppress fear. A few became panic-stricken in an initial action. This group showed no symptoms or signs of anxiety. There was no tension, and food intake and sleep were normal. Those with normal fear reactions were rested briefly, reassured, and returned to duty. Those who were unwilling or had given way without adequate reason were often found to be inadequate men who had avoided responsibility in civil life and accustomed themselves to taking an easy way out. Many were dependent on their mothers and leaned on them when confronted with difficulties. In childhood and adolescence they had resorted to temper tantrums to achieve their will. One of the important functions of the psychiatrist, and indeed of all medical officers in combat areas, was to recognize that such men had no true psychiatric disability that entitled them to evacuation. Such reactions were usually encountered in enlisted men, but on rare occasions were seen also in officers, as in case 19.
CASE 19. A 24-year-old infantry lieutenant had been in combat for 3 months. The spoiled son of rich parents, he had always had his own way. After a heavy action he felt tired and applied at an aid station for evacuation, which was denied when it was recognized that he was not ill. He then went to the rear and was tagged at an evacuation hospital and sent to the army center. He said that only 14 men were left in his company. They had been ordered to build a bridge, but he had felt that the men were not in condition to do so. When ordered to proceed to another position he felt unable to go and reported to the aid station. At the center he showed no evidence of physical or psychiatric disease. He complained constantly of various symptoms for which no basis could be found. He was told that he had left the division without authority and was returned with a letter explaining the circumstances. He was charged with being AWOL, but these charges were later dropped when he distinguished himself to such a degree that he was awarded the Silver Star.
This officer, no more tired than his men, showed no evidence of disease, and committed a flagrant breach of discipline in leaving. Such conduct is not to be tolerated, especially in an officer. Cases of this kind are a command responsibility and should not be allowed to continue in a medical evacuation channel. By firm handling this man was able to redeem himself sufficiently to merit decoration.
Constitutional psychopathic states. The psychopath was rarely a good combat soldier. Intolerant of discipline and lacking a sense of responsibility, he disrupted the morale of his combat unit. Punishment was of no avail. Such men were too often sent to combat units as a punitive measure. Often they were transferred from unit to unit because line officers were ignorant of the correct administrative disposition (under AR 615-368 and 615-369) or were unwilling to take the trouble to institute proceedings. Such men were sometimes evacuated through medical channels in an effort to dispose of them easily, despite the fact that medical evacuation was not permissible unless there were complications that made such disposal valid. Occasionally the troublesome, aggressive psychopath who had been a thorn in the side of his officers and noncommissioned officers in the training period, and guilty of frequent infractions of discipline, performed exceptionally in combat, when his aggression was finally channeled toward a temporarily useful goal against the enemy. A few such men were seen in army centers, where they appeared with mild anxiety states. After a short rest they were eager to return to combat, which they appeared to enjoy. They usually resumed their disruptive behavior when the unit was relieved from the line.
Psychoses. Aside from the temporarily psychotic patients with anxiety states already described, psychoses were rarely seen at the army level. Doubtless most of these patients were screened from units before combat. Of the few psychotic soldiers admitted to the army center from combat units, several turned out to be men with longstanding schizophrenic reactions who had remained undetected and
had performed satisfactorily until their symptoms became incapacitating or dangerous to others. Some were hospitalized after medicolegal consultation had been requested for some breach of discipline. In the schizophrenic group the paranoid reactions were most frequent. A few manic-depressive pychoses were seen in the violent manic phase. All these patients were evacuated to general hospitals at the earliest possible moment.
Treatment and Disposition
General principles. Since the primary function of the Medical Department is to preserve maximal fighting strength, the medical officer must subordinate to that end his traditional interest in the individual patient. During the war we learned that the criteria for returning to duty men who had suffered minor psychiatric breaks in combat, or manifested neurotic symptoms in civil life, were misunderstood and required modification. We came to realize that more could be expected of such men than was formerly considered possible by the civilian psychiatrist. The most important points in the management of psychiatric casualties are (1) correct early diagnosis, (2) holding and treating such men as far forward as possible, and (3) relief of symptoms at the earliest possible time. These principles should be followed by all medical officers who see the patient. The important function of the battalion surgeon, who sees him first and is, therefore, the most important medical officer in the entire program, has been discussed. After the organization of services, the effective screening and early treatment practiced during the war at aid stations, division clearing stations, and army centers almost eliminated the loss from combat units of salvageable psychiatric casualties and of soldiers who had no true psychiatric disorder and thus had no claim to be evacuated.
Terminology. It was our policy to use the term "exhaustion" for psychiatric casualties. This diagnosis was the only one permissible to use on emergency medical tags forward of army level. This term was, frankly, a euphemism and its use constituted an evasion. However, it served to emphasize the important precipitating role of physical exhaustion and to imply rapid recovery after a short period of rest. It also avoided giving the impression that incurable mental illness was present, an impression still conveyed to the average layman when technical psychiatric terminology is used. In our experience in the Italian and French campaigns it was rare for patients to refer to their disorder as "shell shock." Although other terms, such as "psycho", were current, most patients referred to their condition as "exhaustion." Thus despite the defects of the term it was valuable in fostering a proper attitude in patients.
General routine of treatment. Some of the means employed to provide a proper atmosphere in the centers have been described. Every effort was made to maintain discipline and morale and to emphasize to patients that they were still soldiers and members of a military organization. On admission patients were interviewed briefly by a medical officer, who ascertained the nature and severity of the disorder and ordered appropriate treatment and sedation. The patient was reassured briefly and then put to bed. All patients were allowed 1 to 3 days of rest in quiet surroundings, with or without sedation. Adequate rest, always one of the mainstays of treatment, was particularly important in the period before divisional treatment facilities were available and the Fifth Army Center still received many patients with mild anxiety states associated with marked physical exhaustion.
All patients were required to shave and wash daily. Frequent bathing was encouraged when proper facilities were available. Soiled, torn, or other unserviceable clothing was replaced. Neatness of appearance and dress was required. Adequate intake of food was stressed. Many of these men had subsisted on insufficient or cold rations for some time before admission. In the hospital prodigious appetites were the rule even when these patients were under heavy sedation. All patients, except those who were seriously ill, were asked to get up for meals. They served themselves in a "chow line" and washed their own mess gear. On the wards they made their own beds, policed the tents or rooms, and assisted in necessary routine work about the hospital. During morning rounds the neatness of the wards and patients was checked, minor complaints were investigated and treated, and sedation orders were reviewed and changed as needed.
After the first few days of rest patients were kept out of bed as much as possible. There was then much discussion of combat experiences among patients. Such "war talk" annoyed a few men, but in general it provided a useful means of verbalizing emotion and alleviating anxiety. When these discussions became too heated they were usually curbed by the patients themselves. Occasionally the ward personnel had to exercise further control, but there were few disciplinary infractions in this group. Motion pictures were shown once or twice a week. In the Seventh Army Center short orientation talks by assigned medical officers, and occasionally by visiting press correspondents, proved helpful. The patients were encouraged to participate.
Sedation. When the Fifth Army Center was first opened sedation was given as follows: 0.6 gm. of sodium amytal or 0.3 gm. of
pentobarbital sodium were given by mouth on admission. If the soldier had been sedated adequately in a forward installation, the dose was lowered. Thereafter 0.4 gm. of sodium amytal or 0.2 gm. of pentobarbital sodium were given by mouth at 9 a.m. and 2 p.m., and 0.6 gm. of sodium amytal or 0.3 gm. of pentobarbital sodium were given at 8 p.m. This routine was continued for 2 days. The dose was varied when indicated. It was the aim to produce a complete nights sleep for 2 days. During this time patients were still required to wash and shave daily and to get up for meals. Under this program most patients showed some ataxia, thickness of speech, and mild confusion. After 6 months of this routine we came to believe that such heavy sedation was unnecessary. One-half the previous dosage was then given with equally beneficial results and without complications. Even with the heavy doses there were no serious difficulties or dangerous complications. Patients were closely watched for possible respiratory embarrassment. In the later periods of operation it was necessary to employ the larger doses only occasionally, when patients were treated in areas close to artillery fire. The advisability of omitting sedation in severely disturbed anxiety states (pseudopsychotic reactions) has already been mentioned.
Ward care. Certain special problems were encountered on the wards. Patients with severe symptoms who were noisy, tearful, or otherwise disturbing and exerted an adverse effect on others were segregated in separate tents. Since our facilities did not permit adequate care for many patients of this type they were evacuated to the rear as soon as possible. The firm handling of men who appeared to be exercising too little control over their symptoms, or whose symptoms were largely volitional, benefited other patients. Such men occasionally attempted to assuage their guilt feeling with voluble and tearful requests to return to the front. Such behavior undermined morale and had to be discouraged. The dramatic relief of severe symptoms with intravenous barbiturates, given on the ward, often reassured and encouraged patients who witnessed it. The management of officer patients presented some difficulties. At first they were treated in a separate ward, but under these conditions there was sometimes lack of restraint and indulgence in self-pity, and some demoralized officers with severe symptoms who reacted in all exaggerated and dramatic manner produced unfavorable effects on enlisted patients in an adjoining tent. We then treated officers in the same wards with enlisted men. This procedure gave officers all incentive to exercise self -control and set a good example. In some instances officer patients ready to return to combat encouraged enlisted men of their command to return to duty also.
Psychotherapy. The hospital routine and atmosphere, rest, and sedation all helped to rehabilitate our patients. Psychotherapy as such was conducted during the interview held with patients on the third or fourth day, when the effects of sedation had usually disappeared. Interviews were held in separate tents. The patient was questioned briefly about family history relating to nervous disorders or alcoholism and about his own childhood neurotic traits. His school and civilian work record and the adequacy of his civil and military adjustment were reviewed. Leading questions about symptoms were avoided in dealing with these highly suggestible patients. Physical and neurologic examinations were performed in sufficient detail to insure that no significant disease or injury was overlooked.
The patient was given a detailed explanation of the mechanism of symptom production and was told that it is normal to be afraid in battle and to experience certain emotional and physical responses. His symptoms were interpreted as exaggerated reactions that had temporarily passed beyond his control. The transitory nature of these symptoms was stressed, and the soldier was assured that they would not lead to insanity or other permanent disability. Technical psychiatric language, which often gives rise to misconceptions and misunderstandings, was used as little as possible. Words with which the soldier was familiar and whose meaning he understood proved more effective. Poorly motivated soldiers who were to return to duty were indoctrinated briefly. The importance of the war and the consequences of defeat to them and their families were stressed, and appeals were made to their sense of duty, pride, and loyalty to comrades, unit, and country.
Attitude of the psychiatrist. The attitude of the medical officer or psychiatrist who deals with these cases is of the greatest importance. The necessity of seeing within a short time large numbers of disturbed, unstable, and sometimes demoralized soldiers places him under great strain, but he must make every effort to maintain an objective point of view. He must avoid identifying himself with the patient or displaying excessive sympathy, but it should be remembered that kindness and understanding are not inconsistent with a realistic approach. Browbeating and outbursts of temper do only harm. With the proper approach and adequate explanation most patients accept the necessary decisions.
Intravenous barbiturate narcosis. Much has been written about the efficacy of intravenous barbiturate narcosis in treating combat neuroses, but many of the observations concerning its use were made on patients in rear areas. The method was valuable, but sharply limited in usefulness, with definite indications and contraindications.
It was most successfully employed in (1) severe anxiety states with stupor or marked regression; (2) anxiety states with prolonged periods of amnesia; (3) severe hysterical conversion phenomena, such as convulsions, aphonia, blindness, deafness, or paralyses; and (4) certain cases involving acute tics or repetitive movements. Patients with these conditions represented about 5 percent of the total admissions to army centers. The method was of no value in the ordinary moderate anxiety state, and may even be harmful in severe anxiety states with pseudopsychotic reactions. The use of barbiturate narcosis as an aid in the diagnosis of malingering is discussed elsewhere.
We eventually evolved a procedure that proved successful in the majority of properly selected cases. The intravenous sodium amytal used at first was later supplanted by pentothal, which we found much more satisfactory. It was easier to administer, less time consuming, appeared to produce a higher degree of suggestibility and better emotional release, and its after effects were of much shorter duration than those of sodium amytal. The patient was brought to the treatment tent and asked to lie down. If responsive and able to understand, he was told that he was to be given a drug that would make him sleepy and permit him to remember some of the things he had forgotten, and that this recollection would greatly hasten his recovery. Beginning with the start of intravenous administration, he was asked to count slowly backward from 100. Injection was continued until counting stopped or became grossly inaccurate, or until the patient fell sleep. Some experience was needed to judge correctly the amount of drug and the speed of injection for each patient. When the patient had reached the proper degree of narcosis, strong suggestion was begun.
In the early stages of the treatment the object was to recall to the patient the original traumatic situation in battle. He was told that he was again on the battlefield, and the statement was reinforced by loud warning, such as "Look out," or "Watch those shells," or "Duck," or by whistling to mimic approaching shells and jarring the cot. Usually the patient responded with a dramatic startle pattern, cowered on the couch, sought cover, and at times jumped to the floor to dig in or take flight. He then relived his battle experiences and talked to the therapist as if he were some officer or comrade who was with him at the time. Such recitals, highly realistic and dramatic, were often accompanied by a great outburst of emotion and expressions of resentment, hatred, or previously suppressed fear. Usually the incident that had precipitated the break was recalled. At such times the mechanism of symptom production was pointed out. By further suggestion the patient was then "brought down" from the battlefield to the hospital, and an effort, was made to reconstruct and recover all
amnesic material. At this stage strong suggestion was employed to convince the patient that his symptoms were no longer needed and would disappear. When such disposition was indicated, he was told that he would not return to combat again. He was then awakened and asked if he recalled what had happened during the treatment. The material was again discussed, with further use of suggestion and explanation of mechanisms.
In a successful treatment the patient had usually recovered to a marked degree by this time. He was relaxed and frequently commented on the disappearance of his former tension. Patients who had been stuporous often sat up and rapidly regained normal speech, and their faces, formerly blank and expressionless, became more animated. Even in severe cases patients were often able to return to their wards without assistance and soon joined in normal activity and conversation. In general, the greater the emotional release, the better was the end result. Patients were seen again on the following day, when further efforts were made to remove residual symptoms. The effects of this method are probably best explained on the basis of the marked abreaction and emotional release that takes place. Amnesic material is recovered and assimilated, proper orientation is established,and behavior can be rationally adjusted to the now safe environment. The achievement of these results is aided by strong suggestion, which is facilitated by the lowering of conscious and unconscious inhibitions under narcosis.
The method proved successful in about 95 percent of the patients on whom it was used. Those soldiers for whom we found it necessary to employ intravenous narcosis proved not to be good risks for return to combat. Their emotional reaction to battle had been so overwhelming, or their premilitary personalities so inadequate, that they were unfit to resume duty in battle. Only a few patients so treated could be returned to the front. Intravenous barbiturate narcosis is of the greatest value in beginning the rehabilitation of patients who are to be evacuated farther to the rear. The disorder is then attacked at the most favorable time, shortly after its onset. The method has little place in medical installations forward of army level, though in rare instances it may be necessary to use it in forward stations to control violent symptoms and facilitate evacuation. It would be a gross misconception to assume that its widespread use as a therapeutic method in aid stations or division clearing stations would salvage for combat many patients with severe symptoms.
Treatment of psychiatric complications in other casualties. Because of the prevalence of psychosomatic disorders, it is essential that all medical officers practicing combat psychiatry be well grounded in internal medicine and skilled in the differential diagnosis of organic
and neurotic symptom complexes. If psychosomatic patients are properly treated from the psychiatric point of view and the disturbance is of recent and acute origin, it should be possible to return a high percent of them to duty. In those who have had long-standing symptoms in civil life the outlook for return to combat is poor, and eventually rehabilitation even for limited service is difficult. Knowledge of psychiatric treatment principles is necessary also for medical officers who deal with patients who leave combat with wounds, disease, or injury. Such patients may develop neurotic complications when removed to safe and comfortable hospitals in the rear. Symptoms referable to the site of the wound or illness may persist unreasonably or become exaggerated. The period of hospitalization should be kept to the minimum time consistent with the restoration of combat efficiency. Physical and mental rehabilitation should begin at once. Inactivity should be avoided as much as possible. Soldiers who returned to combat after hospitalization for minor wounds or illness were more vulnerable to subsequent psychiatric breakdown. Their psychic protective mechanisms appeared to have been weakened and their feeling of invulnerability impaired, and relatively minor psychic trauma would then produce the final break soon after return to combat.
Rehabilitation of patients evacuated to the rear. The army center played an important role in the rehabilitation of soldiers deemed unfit for further combat. Whenever possible severe symptoms were removed completely. Combat neuroses are highly labile and are most easily influenced shortly after onset. At this stage, motivations for the elaboration of symptoms or for deriving secondary gain from the disorder do not present themselves. Many of these patients were able to do any type of work except full combat duty, and most of them were eager to work, partly to alleviate guilt feelings and partly because they soon became aware that activity alleviated their anxiety. Prolonged rest and inactivity in comfortable hospital surroundings are the greatest menace to ultimate recovery. They provide opportunity for brooding, tend to fix neurosis, assist in the deteriorating process of self-justification, and hasten the onset of demoralization and invalidism. Patients whose severe symptoms necessitated evacuation to the rear were told that they would not be returned to combat. They were reassured, their symptoms were removed by the various methods described, and they were informed that the best means to achieve rapid recovery was to make every effort to return to useful, active work at the earliest moment.
Such an approach is entirely rational in view of the structure of the combat neurosis. One of the primary personality changes effected by this disorder is an inability to adapt further to the stresses of
combat. A secondary loss of adaptability follows and may make adjustment even to the ordinary responsibilities of life difficult. This change is accompanied by feelings of insecurity, loss of self-confidence, distrust in authority, and depression. Rehabilitation must aim to strengthen the ego and restore self-confidence and normal adaptability. In overseas theaters this purpose was best accomplished by urging rapid return to duties that tangibly furthered the war effort. Patients were told that their recovery depended largely on their own strength of will, and that their symptoms, which would probably recur when they were faced with difficulties, could best be overcome by continuing at work.
The value of this method was demonstrated by an experiment with three provisional companies made up entirely of men reclassified for psychiatric reasons in the Italian campaign. They were put to work in depots that provided supplies needed on the Cassino front. The work was of direct help to their former comrades. During the 2 months of operation the discipline and performance of the men in these units was excellent and their attendance at sick call infrequent. When such soldiers have been reassigned it is important that they be treated as normally as possible by their fellows and officers. Too often military or medical officers in base section units regard them as sick and give them special privileges or, more rarely, subject them to unnecessarily harsh discipline. A high unit morale, with good unit pride and loyalty, provides the best environment for rehabilitation. Medical officers dealing with these men must aid them by reassurance, encouragement, and, when indicated, by judicious prodding. Unless it is absolutely necessary they should not be returned to hospitals when their symptoms reappear, for hospitalization serves only to convince them of their inability to carry on. In army centers the ordinary methods of occupational therapy, as employed in civil mental or general hospitals, were impracticable and of little value. It was usually difficult if not impossible to interest our patients in such activity.
Disposition of patients is the responsibility of the medical officer. The decision should not be left to the patient. He is unable to make it, and he cannot honestly be said to wish to return to combat if there is an honorable alternative. When the medical officer decides that a soldier is fit to return to duty he should be so informed with firm conviction. Temporizing or evading the issue does much harm. The desired purpose is not achieved by such statements as: "We will rest you a little longer and then see you again," or "Don't you think you can make it up there again?" or "Try it again; if you can't make it, ask your company commander to send you back." Such statements
imply that the medical officer doubts the ability of the soldier to do combat duty. They undermine the soldier's morale and weaken his will to continue. Once a decision has been made it should not be reversed unless there are good reasons for doing so.
Criteria for return to duty. The final indication for returning a soldier to duty is his ability to perform the duty. The criteria mentioned in the section on "Psychiatry at the Division Level" should be followed in army centers as well. One must remember that patients evacuated from a division have already been seen by both the battalion surgeon and the division psychiatrist. Their opinion of the case, based on close observation shortly after the onset, should have weight in making disposition at army level. Opinions or requests for reclassification forwarded by a soldier's commanding officer should also be considered carefully in the final evaluation.
Factors favoring return to duty or evacuation
All the following criteria should be used in arriving at a decision concerning disposition. In the history: the length of time spent in combat, the duration of the symptoms, the presence of premilitary neuroticism or inadequacy, and previous hospitalization for combat neurosis are important. In the examination: the nature and severity of the disorder, the response to treatment, the presence and degree of residual symptoms, and the soldier's attitude are determining factors. The impression the patient makes on the psychiatrist is perhaps the best index for final evaluation, but only extensive experience in observing and treating combat neuroses enables him to interpret these impressions correctly. Table II shows some of the criteria for determining whether the soldier should be returned to duty or evacuated. Table III shows the types of patient returned to duty and those evacuated. These are merely rough guides. Only careful clinical judgment can be relied on as a sound basis for disposition of the individual patient.
Types of patient returned to duty or evacuated
A few additional points should be kept in mind in relation to criteria for return to duty. Our experience indicated that the family history was not of much value determining the soldier's fitness for duty. A history of familial neuropathy was given by many soldiers who performed well in combat for long periods. As pointed out elsewhere, a history of civilian neurosis is also less important in determining poor performance in combat than was formerly thought. In the Seventh Army the following policy was established for the disposition of officers with psychiatric disorders: If in officer was suffering from a true cerebral concussion, a psychosis, or a severe, combat-induced neurosis that had appeared after long and faithful service, he was treated according to the criteria for disposition set up for enlisted men. Moderate or mild anxiety states in officers were likewise treated and disposed of according to these criteria. If, however, the officer broke down after limited exposure to combat stress or after mild combat stress and gave evidence of preliminary neuroticism or inadequacy, he was returned to his unit for administrative reclassification. Officers who deliberately shirked or evaded duty were referred for court martial.
It is essential that combat troops have superior leadership. An officer who does not possess leadership qualifications or who may endanger the lives of his men by his nervous instability should not be allowed to lead troops in combat. An officer with a history of instability or inadequacy should not have been commissioned, for such traits preclude the ability to give adequate leadership. Medical evacuation of such officers rewards their failure, for it often leads to their promotion to a safe position in the rear, a procedure that greatly damages the morale of combat troops. When reclassification of an officer is considered, the welfare of the troops is paramount and must outweigh sympathy for the officer concerned.
Results. From 21 December 1943 through 15 June 1944 the Fifth Army Center returned to full duty 31 percent of all admissions. From 15 August 1944 through 1 January 1945 Seventh Army Centers returned to combat duty 24 percent of admissions. Early in March 1944 the center, operating in an evacuation hospital in the Anzio beachhead campaign, returned 10 percent of its admissions to combat. The number of patients who can be returned to duty from an army center varies widely. When experienced psychiatrists are working in divisions with long combat exposure, screening is highly effective, and the number who can be returned after evacuation to an army center will be very low. With new and inexperienced divisions screening is often less effective, and a greater number of patients evacuated to the army center will be returned to duty. The army center furnishes additional screening facilities and insures the maximum salvage for psychiatric casualties.
At Anzio the poor results were probably accounted for by the exposed location of the hospital, which was situated literally on a target surrounded by artillery. Under such circumstances treatment of combat neuroses was highly unsatisfactory.
Recurrences. Soldiers whose psychiatric symptoms recurred after return to duty were re-evacuated to army centers. In this way the efficacy of treatment and the validity of criteria for return to combat could be estimated. The data may be inaccurate, since it is possible that some men with recurrences were sent to other hospitals with nonpsychiatric diagnoses. In the Fifth Army, from 21 December 1943 through 15 June 1944, 13 percent of the cases returned to duty were evacuated a second time. In the Seventh Army, from 15 August 1944 through 1 January 1945, 28 percent of the patients returned to duty were re-evacuated. Many of the recurrences in the Seventh Army were in soldiers who had no psychiatric disease but were merely poorly motivated or unwilling. They had probably achieved evacuation by persistent attendance at sick call held by inexperienced medical personnel who were unaware of correct diagnostic criteria. Of the Seventh Army recurrences 17 percent were sent to duty a second time. Of this group a majority were thought to have no psychiatric disease.
The difference between the recurrence rates in the Fifth and Seventh Army Centers may also be attributable in part to the fact that the Fifth Army Center operated for 2½ months before a divisional psychiatric program was re-established. During this time the center probably received a higher proportion of mildly psychoneurotic patients, who were good risks for return to duty, than they received at a later date. The Seventh Army received many patients from old divisions that had had long combat experience and were staffed with experienced medical personnel. The material received from such units was well screened and little salvage was possible at the army center. In the Seventh Army the policy of sending all psychiatric patients to the centers, even if they were admitted to evacuation hospitals with erroneous diagnoses, was carefully observed by these installations. It is probable, therefore, that the data on recurrence in the Seventh Army are more nearly complete than those for the Fifth Army.
A study was made of recurrences in the Seventh Army to determine the length of duty in combat units before readmission. The results are given in table IV. The majority of these patients were readmitted within 10 days after their return to combat. Of the total number, however, 30 percent remained on duty for a month or longer before they became incapacitated. Many of these soldiers had been treated in the Fifth Army Center or in general hospitals during the Italian campaign.
Period of combat duty of psychiatric casualties between return to duty and recurrence
It is possible to salvage a large proportion of psychiatric casualties for combat, provided they are seen and treated soon after the onset of the disorder. In those unfit for further combat early treatment greatly hastens rehabilitation. Combat fitness can be estimated accurately only by past performance in combat. Soldiers with poor family backgrounds or past histories of civilian neuroses sometimes perform adequately in combat for long periods. Knowledge of diagnostic criteria is essential for all medical officers operating in combat areas if true psychiatric disorders are to be differentiated from normal fear reactions, poor motivation, and mere unwillingness. To achieve maximum salvage for duty all medical officers must apply correct treatment principles in the management of both psychiatric and nonpsychiatric patients.