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The Base Section Psychiatric Hospital
Lieutenant Colonel Louis L. Tureen (ref 12)
Major Martin Stein (ref 13)
Basic to any military psychiatric program is the knowledge gained by experience in the two world warsthat delay in psychiatric treatment causes a preventable loss of manpower. Thus the nature of psychiatric disorders, as well as the basic task of every military medical installationthe restoration to effective duty of as many soldiers as possiblemakes it imperative that psychiatric casualties be handled quickly and expertly.
With division and army psychiatric centers functioning adequately, the establishment of base psychiatric centers completed the necessary facilities for good psychiatric service in the Mediterranean Theater of Operations. For the operation of a station hospital as a base psychiatric center, an adequate staff of psychiatrists was assigned and provision was made for treatment of 500 psychiatric patients, with allowance for expansion. It was anticipated that the concentration of facilities and personnel in a specialized type of hospital would make possible the investigation of all forms of psychiatric disorders occurring in an active theater of operations, the interpretation of the etiologic factors producing these disorders, and the formulation of standards for evaluating the prognosis and therapy of psychiatric patients.
The primary function of the base psychiatric center was to receive patients originating in the Army Ground Forces in order that most battle-induced neuroses reaching base sections might be cleared through a unit prepared to handle them. Whenever the base section was close to the fighting front this function was realized, but when the hospital was located in a rear base section, or when the front was relatively inactive, the hospital received the entire range of
(ref 12) Formerly chief of Neuropsychiatric Service, 21st General Hospital; psychiatrist, 9th Evacuation Hospital; and chief of Neuropsychiatric Service, 51st Station Hospital.
(ref 13) Formerly psychiatrist, 51st Station Hospital ; psychiatrist, 114th Station Hospital and psychiatrist, Fifth Army Psychiatric Center (601st Medical Clearing Co.).
psychiatric patients appearing in base section or garrison units. Since the two base psychiatric centers in the theater "leapfrogged" each other with changing military demands, each unit received a wide variety of clinical material for study and treatment and was afforded an opportunity for reviewing every type of psychiatric case encountered in this theater. Admissions to the hospital in groups of 25 to 200 were generally by transfer from other hospitals, either in another or in the same base section or from the forward army psychiatric unit. Direct admission through the outpatient department of the hospital also provided a large number of patients.
About 4,000 patients were studied in a period of 10 months. The nature of the clinical syndromes varied widely in different phases of the operations. Virtually all patients received directly from Army Ground Force units, usually via the army psychiatric clearing company, were suffering from acute battle-incurred neurosis. The prognosis in this type of case was excellent, the period of hospitalization relatively brief, the morale high, and disposition almost always to a reclassified form of duty.
On the other hand, when large shipments of patients were received for domiciliary care while awaiting transshipment to the United States, the problem of treating a severe, chronic, therapy-resistant neurotic and psychotic hospital population arose, and this problem became more complex with the progressive rise in this type of patient when poor shipping facilities prevented their transfer.
To appreciate the battle neurosis syndromes as observed in an active theater of operations, it must be remembered that the psychiatrist observes only one phase of a continuously changing series of reactions that begins with the first precipitation of symptoms. Subclinical anxiety affects the majority of soldiers in a theater prior to combat. Special circumstances are, however, required to precipitate the incapacitating clinical symptoms. It is necessary to gain some insight into what the patient was like before the given period of observation and how he is likely to respond to future situations. From the clinical material studied at this hospital it was possible to select groups of patients that represented various, though certainly not all, clinical stages through which a patient may pass. The diagnostic categories were combat-induced neurosis, noncombat neurosis, constitutional psychopathic states, and psychosis.
Customary practice in this theater differentiated between combat-incurred and noncombat-incurred neuroses. The combat-incurred
neurosis was arbitrarily so designated if the symptoms developed in or immediately after combat, or if the condition was directly attributable to combat. These criteria excluded some patients who should have been included, since it was difficult to evaluate the role of combat in causing illness of patients whose symptoms developed in a rest period or were precipitated by some intercurrent illness or accident. In many such patients anxiety and tension had been present or mounting since the combat experience. On the other hand, such a definition included all patients in whom combat-precipitated symptoms aggravated a preexisting neurotic syndrome. This arbitrary classification did, however, serve to designate for statistical purposes the number of men lost from the front as a direct result of psychiatric illness.
These patients were received at base section hospitals within 3 or 4 days of their evacuation from the front. They represented 88 percent of admissions to the base section neuropsychiatric hospitals in its advanced base sections. Patients with acute anxiety states accounted for 75 percent, manifested predominantly by free anxiety; 2.5 percent were diagnosed as conversion hysteria; and the remainder showed a mixture of symptoms, of which anxiety was most pronounced, but to which were added hysterical, hypochondriacal, depressive, or obsessive reactions. On the whole the symptoms were mild and responsive to therapy. The average period of hospitalization was eleven days. In this group morale, cooperation, and eagerness to return to some form of duty were good. Customary terminology in this theater designated patients returnable for general duty as class A, for noncombat duty as class B, and for return to hospitals in the zone of the interior as class C. The disposition of acute cases was as follows: class A, 1 percent; class B, 96.5 percent; and class C, 2.5 percent (table V).
Anxiety states. In the North African campaign the clinical findings of acute anxiety states differed markedly from those seen in the Sicilian and Italian campaigns, and judging all combat neuroses by the North African experiences would, therefore, have led to erroneous conclusions. The overt evidences of anxiety in patients from the Sicilian and Italian campaigns were generally much less severe than in those seen in the Tunisian campaign. Writing of the North African campaign, Grinker and Spiegel (ref 14) state: "By the time these patients reach the hospital the clinical picture is uniformly one of anxiety accompanied by persistent coarse tremors of the extremities. Various degrees of loss of appetite, restlessness, and insomnia are present. The patients feel jittery and apprehensive all the time, and are unable to keep themselves from jumping at the sound of a loud unexpected noise."
(ref 14) Grinker, R. R., and Spiegel, J. P.: War Neuroses in North Africa: The Tunisian Campaign. New York: Josiah Macy, Jr. Foundation, 1943. (Later published as: War Neuroses. Philadelphia: The Blakiston Company, 1945.)
TABLE VIncidence and disposition of combat-incurred and noncombat-incurred neuroses in percent
(ref 1) Unquestionably some of these cases were included with the anxiety
In sharp contrast, most patients admitted to the base section psychiatric hospital in Italy presented relatively benign findings. Since only the most severely neurotic patients evacuated from the front eventually reached the base section psychiatric hospital for treatment, these differences in the clinical findings were remarkable. They were accounted for in part by the changing tactical situation, for conditions in the Sicilian and Italian campaigns were very different from those in the early part of the Tunisian campaign, when unseasoned troops faced by overwhelming air superiority developed severe panic reactions. These conditions were altered when the victorious offenses began in North Tunisia and continued during the Sicilian and Italian campaigns.
Next in importance in accounting for the benign character of the anxiety reactions in the later period was the adequate psychiatric
care provided for the first time in forward areas, reaching its highest efficiency with the establishment of army psychiatric units and the assignment of division psychiatrists. Sedation and rest, provided first at the battalion aid station, were continued through the division clearing station. Patients who could no longer perform in combat were rapidly evacuated through psychiatric channels, under continuous expert treatment. By the time these patients reached the forward army psychiatric unit or the base section psychiatric hospital, their most severe symptoms had been eliminated, and thus the more serious complications were avoided. Anxiety states represented 75 percent of all acute battle neuroses. Free anxiety, the outstanding symptom, was manifested by tension and tremulousness of a relatively mild degree. Coarse tremors were rare, and headache, startle reactions, and irritability were infrequent. Battle dreams and insomnia were the most common complaints. Most of the patients appeared moderately tired and desirous of rest. The exceptional patient with hyperkinetic reactions and jerky or even parkinsonian tremors was free from these symptoms after 24 hours of wet packs.
All these patients adjusted quickly to the hospital environment, were willing to cooperate and follow the routine of activities, and were appreciative of everything done for them. They improved rapidly and within a few days were usually completely symptom free and ready for noncombat duty. Unlike the several weeks required in Grinker's (ref 14) series, the usual period of hospitalization in the majority of these cases was 7 days. The following cases are illustrative of this type of patient.
CASE 19. A 24-year old sergeant was admitted to the hospital because of severe anxiety and tremulousness. In the Regular Army for 8 years and overseas 19 months, he had fought with his unit from the time of the invasion of North Africa until he became ill during the march on Rome. He began to get jittery in the early stages of the Italian campaign, but continued on duty until the final break. He participated in the entire Sicilian campaign. Five days before the last battle he had premonitions of being killed in battle. After 3 or 4 days of heavy action, in which many were killed and he was strafed by friendly planes and shot at by friendly tanks, he became anxious and tremulous and cried that he "wouldn't and couldn't go forward." He was "cooled down" by his comrades and evacuated. On admission to the hospital he stated that he "felt fine" as long as he was away from the front. There were no gastrointestinal symptoms and his appetite was good. He showed no tremors. His sleep was poor at first and disturbed by battle dreams. He repeated that he could no longer function in combat. His past history indicated that he had been subject to premonitions all his life, and he was particularly so when overseas. His premonitions about the death of other men in combat had proved correct. He was worried about his child, of whom he had had no news since his wife had asked him for a divorce a year before. He was depressed about his length of service overseas and his "inability to get home." The physical examination was negative. Under routine hospital care he improved rapidly.
In 6 days he was discharged to a replacement depot and reclassified to noncombat duty.
Case 20. A 24-year-old infantry private with five years' service in the Regular Army, had been overseas 19 months. He had fought in Africa, Sicily, and Italy, and had conducted himself well, except for some slight jitteriness, until 5 or 6 days before admission to the hospital, when a "dud" landed near him. Thereafter he shook, prayed, stayed in his foxhole, and could not go on with his unit. "There is a limit to what a man can take," he said. He had been wounded twice in the previous year. He required 6 weeks' hospitalization for shrapnel wounds of the buttocks and 3 months' hospitalization for a wound of the upper extremity. He had made a good social adjustment in the past, though he was a nail biter. On admission to the hospital he was mildly tense and anxious, but not tremulous. He slept well and had no battle dreams. Loud noises brought back "bad memories." Except for anorexia, he had no gastrointestinal symptoms. The physical examination was negative. He made a good recovery and was discharged to noncombat duty.
Conversion hysteria. Conversion hysteria was the diagnosis in 2.5 percent of the group. These patients were notable for their lack of visible anxiety. Many exhibited the "belle indifférence" characteristic of hysteria. From most of them a history of a fugue episode, acute panic reaction, or transient period of amnesia on the battlefield was easily elicited. Subsequently various forms of motor disturbances were evident, including monoplegia, astasia-abasia, and transient weakness. There were also auditory, visual, and speech defects, and more rarely, a persistent amnesia. In contrast to the situation in the North African campaign, patients of this group, from the Sicilian and Italian campaigns, were free of their major conversion symptoms by the time they reached the base section psychiatric hospital. Gastrointestinal symptoms and somatic symptoms referable to injured regions or organs were more persistent. This group of patients was less responsive to treatment by hypnosis and suggestion, but the majority could be assigned to limited duty after a brief period of hospitalization. Cases 21 and 22 are illustrative of the conversion hysteria group.
CASE 21. A 23-year-old infantry private suddenly developed a complete flaccid paralysis of the left side while in combat. He had been very anxious and had felt that he would become ill, but this episode developed after a short sleep. He failed to improve during evacuation, in spite of faradism and suggestion, with and without sodium amytal. On admission he had a complete flaccid paralysis of the left arm and leg, with sensory loss. The reflexes and cranial nerves were normal. He was fairly cheerful. He was given 0.25 gm. of sodium amytal intravenously. His cheerfulness increased and under strong suggestion and persuasion he moved his left shoulder and elbow fairly well. His unconscious resistance was marked in a recurrent slip of speech: "This is worse than I ever was before," meaning that he was better. He expressed some anxiety about his battle experiences and was urged to tell about them. Under hypnosis he moved his paralyzed limbs well, but his general condition was not favorable. He walked well, but did not use his left arm. His attitude was superficially pleasant, but
underlying hostility and resistance were evident. This severe major hysteria was complicated by conscious and unconscious resistance to cure. The patient had been treated by four medical officers, all of whom met with the same general response, though there was some symptomatic improvement. Physical examination was negative. The patient was evacuated to the zone of the interior.
CASE 22. A 32-year-old infantry private, with 7 months' service who had been overseas less than a month, was admitted to the hospital with aphonia, deafness, and a violent body tremor. Three days before admission to the base section hospital an exploding shell had "knocked him out." He was amnesic for 2 days after the explosion, The noise of the big guns had impaired his hearing, and he awoke in the clearing company completely deaf. There, under intravenous sodium pentothal, he became mute and smiled in a hebephrenic manner. While he was in an evacuation hospital his mutism cleared up slightly, and he could whisper on arrival at the base section hospital. His hysterical symptoms were removed under hypnosis, enabling him to talk well and leaving with a residual partial nerve deafness that he had had for many years. The tremor disappeared. His personal history revealed a rather inadequate, emotionally unstable person who was easily upset. He had had an 8th grade education. He stated that he could never tolerate noise before he joined the Army and "knew he would not be able to stand guns." He had spent 3 years in the Civilian Conservation Corps beginning in 1932, and received an "excellent" discharge. He then operated a truck. He stated that he was happily married. He had had malaria in 1939 and afterward was unable to walk for 2 weeks. He believed that his "legs were still weak from it." After treatment by hypnosis and suggestion he improved rapidly, and after 10 days was assigned to noncombat duty.
Anxiety hysteria. Soldiers with anxiety hysteria comprised 9 percent of our patients with acute battle-incurred neurosis. In contrast to those with simple hysteria, who displayed little overt anxiety, this group manifested a great deal of free anxiety. Their anxiety was not as intense as that of patients with anxiety states, nor were their hysterical symptoms as clearly defined as those of patients with conversion hysteria. The history usually showed that panic was the precipitating event. Transient fugues and amnesias occurred simultaneously. Neurocirculatory symptoms were pronounced in some of these patients. The following case typifies the anxiety hysteria group.
CASE 23. A 30-year-old infantry private, 4 months overseas and 10 days in combat, was knocked out for a moment by an exploding shell. For a day he apparently reacted in hysterical fashion. He stated that he was dazed during this time; that he was told, and partly remembered, that he tried to hit everybody. This episode occurred 1 week prior to admission to the hospital. He had previously been treated in an evacuation hospital. Since the onset he had had frequent right-sided headaches, which were worse at night, when he worried about combat or his family. In the hospital he reacted with panic to the sound of gunfire, running wildly and yelling for a friend. He stated that he cried frequently at his memories. Past history revealed a slightly hysterical, emotionally unstable person. He had had a 7th grade education, a fair work history, and a fairly sheltered life. He said that he "would die if anything happened to his wife." Physical examination was negative. After 6 days he was discharged to a noncombat assignment, greatly improved.
Reactive depression occurred as a separate clinical entity in 0.7 percent of the patients with acute battle-incurred neurosis. In the early stages of the anxiety states, however, guilt feelings and reactive depression centering about the soldier's inability to remain in combat were prominent symptoms, particularly pronounced in commissioned and noncommissioned officers with a long period of good service. Men with severe reactive depressions were inclined to be suicidal, and were the least responsive to psychotherapy of any group. The prognosis was usually poor unless electroshock therapy was employed. Differential diagnosis from psychotic depression was established on the basis of the dynamic material elicited by narcoanalysis.
CASE 24. A 24-year-old lieutenant with 2½ years of service had been overseas 10 months. Eight months before admission to the hospital two of his men were killed by a shell that landed close to him. He became tense and depressed, lost spontaneity, and felt that he had to "push himself" all the time. He displayed increasing lack of judgment and difficulty in self-control, particularly when under shellfire. Sleep was disturbed and irritability became pronounced. In the weeks prior to hospitalization he broke down and wept on several occasions. On admission he appeared depressed and discouraged and expressed obsessive thoughts about the men he had lost. His case was unusual in that he improved in the hospital as a result of simple reassurance and in a week was ready for a noncombat assignment.
Other types. Under this designation are grouped the rest of the acute cases. In these patients there was no fixed pattern of symptoms. It was possible to elicit from most of them a history of neurotic symptoms in civil life which had been reactivated and aggravated by combat experience. The chief symptoms were hypochondriacal. There were severe somatic complaints, gastrointestinal difficulties, backache, headache, arthralgias, or any combination of these symptoms, with variable degrees of phobias, tension, anxiety, depression, and emotional instability. These patients were resistant to therapy, but were generally able to perform noncombat duty after a period of hospitalization. Case 25 is representative of the group.
CASE 25. A 32-year-old staff sergeant, who had come to this theater 5 months previously as a squad leader, was on duty with his organization until 4 days before admission to the hospital. He had been exposed to several days of severe artillery fire and gradually became fearful, tremulous, and confused. Aware that he was incapable of killing the enemy and overwhelmed with dread that he himself would be killed, he threw away his rifle and made his way to the aid station. He was a high school graduate and had operated a general store for several years until drafted. He was happily married. He had had many bouts of malaria in civil life, but his medical history was otherwise negative. His mother had suffered from a nervous breakdown ever since he had joined the Army. The patient spoke in a whimpering voice and gave a tearful account of his battle experiences, stating that he was poorly led by his officers and saw the lives of fellow soldiers needlessly sacrificed. He displayed a marked degree of circumstantially and self-pity in his story. His attitude toward duty was poor, but he improved sufficiently in 7 days to be reclassified to a noncombat assignment.
In this large group of patients the clinical findings were intermediate between those of acute and chronic types. Descriptions of the various clinical pictures would be repetitious. These patients, who arrived at the base 10 to 21 days after leaving the front, represented 16 percent of admissions to the base section neuropsychiatric hospital in the rear base section. Anxiety states comprised 81 percent of the cases; conversion hysteria, 7 percent; reactive depression, 2 percent; and other types, 10 percent. Only rarely did cases seem to fall into the anxiety hysteria group. The level of morale in these patients was much lower than in acute cases. Their disinclination to continue on foreign duty was obvious. The hospitalization period averaged 3 weeks, as compared to the slightly more than 1 week for acute cases. Seventy percent were returned to limited duty and 30 percent were evacuated to the zone of the interior. None returned to combat.
This term is applied to a type of reaction in which the patient is so out of contact with reality and his behavior is so bizarre as to give an initial impression of a psychotic process. Although the clinical findings show great variation, there are several distinctive features that qualify the illness for a separate group: the onset is relatively acute; the illness is battle induced, an important difference from a true psychosis; and clinical response to therapy is good, though in our experience few patients were able to continue on foreign duty. Although clinical reports from the army neuropsychiatric center and from other base section hospitals indicated that abreaction was not a useful therapeutic measure for this group, we found that some of the withdrawn, retarded, and catatonic patients responded after barbiturate abreaction and continued to improve after rapport was established. The agitated, restless, and generally disturbed patients were received by us after barbiturate therapy had failed in forward hospitals. They responded dramatically to electroconvulsive treatment. In general the illness most closely resembles catatonic schizophrenia, and this is the erroneous diagnosis most frequently made. The following case illustrates the stuporous type of pseudopsychosis.
CASE 26. A 21-year-old soldier was admitted in a deep stupor, necessitating tube feeding. He assumed an intrauterine position. His transfer diagnosis was catatonic schizophrenia. Under intravenous sodium amytal he regained complete contact with reality, but had a total amnesia for his abnormal behavior. The last thing he recalled was that his sergeant had made derisive remarks about
his abilities as a front-line soldier. He was an intelligent but rather dependent person who had no past history of mental disturbance. He had little abreaction and returned to the stuporous state when the effects of the drug subsided. There was dramatic recovery after 3 electroconvulsive treatments. After a course of 8 treatments he was evidently functioning at about the same level of emotional adjustment as before the onset of the illness.
At the other extreme is the type of patient who is in a state of constant agitation. The movements are diffuse and apparently purposeless, there is complete disorientation, and no response is made to ordinary, simple, factual statements. These patients are hypersensitive to sound and touch stimuli. Recovery is often slower than for the stuporous type, but again the prognosis is poor following a course of electroconvulsive treatment. The patients groan and moan and sometimes mutter, sometimes scream, for an hour at a time. Often they repeat a significant word or phrase such as: "Let's duck!" or "Take cover!"
When the base section psychiatric hospital was operating in an advanced base section, 28 percent of the psychiatric patients evacuated from the front gave a history of premilitary psychiatric difficulties. About half of them were capable of a normal adjustment in the military situation until they were exposed to combat. The combat situation increased their anxiety and neurotic symptomatology to a degree that incapacitated them for further duty. These patients are included in the data on combat-induced neuroses, and are not considered here. In general, tolerance for combat in this group was lower than that of previously healthy soldiers, although in individual instances performance was surprisingly good. The clinical syndromes consisted of the usual symptoms seen in combat neuroses, superimposed on old symptoms (ref 15).
In the rest of this group failure in the combat situation was part of a pattern of failure antedating the combat situation and military duty. In this group the combat situation was not of critical importance in determining hospitalization, and these patients are accordingly classified with the noncombat neuroses. The diagnostic categories were anxiety state, 50 percent; hysteria, 3 percent; and other types, 47 percent. Disposition was class A, 0.5 percent; class B, 90 percent; and class C, 9.5 percent. These patients were more resistant to therapy, but did well symptomatically when reassignment was in prospect. Careful screening would have eliminated many from original assignment to combat organizations.
(ref 15) In many patients the symptoms referable to premilitary neurotic reaction patterns were absent when the patient was first evacuated from his unit and appeared only after the acute combat symptoms had diminished.
When the hospital was operating in a rear base section, this type of patient was drawn primarily from replacement depots. The usual forms of neurosis seen in civil life were represented: passive dependent persons; emotionally immature young soldiers; anxiety states, with neurocirculatory asthenia as the chief manifestation; conversion hysteria; and obsessive-compulsive types. The diagnostic groups were anxiety state, 25 percent; hysteria, 20 percent; reactive depression, 2 percent; and other types, chiefly with hypochondriasis, 53 percent. Disposition was class A, 4 percent; class B, 50 percent; and class C, 46 percent. About half of these patients were not originally suited for overseas duty.
Constitutional Psychopathic States
Soldiers with constitutional psychopathic states constituted 10 percent of admissions when the hospital operated in a rear base section, as contrasted with 1.8 percent in a forward base section. Chronic alcoholism, sex perversion, criminalism, inadequate personality, and emotional instability were represented. Disposition was class A, primarily for separation from the service under the provisions of sec. VIII, AR 615-360 (now AR 615-368 and AR 615-369), 67 percent; class B, 28 percent; and class C, primarily because of concomitant disorders, such as episodes of psychosis or organic illness, 5 percent.
Soldiers with psychoses totaled 13 percent of admissions to the hospital. Dementia praecox comprised 59 percent, of which more than half were of the paranoid type, and manic-depressive psychosis, depressed type, 11 percent. Psychosis unclassified included mental defectives and constitutional psychopathic states with psychosis, and a small group of pseudopsychoses that on further study were established as anxiety states with regression. Toxic psychosis following febrile diseases and drug or alcoholic intoxication was diagnosed in a few patients. Malaria was particularly significant as an etiologic agent in this group. Whether malaria produced an encephalitis with subsequent psychotic reactions, or whether the psychosis was purely toxic in nature, was not clear. Clinically the syndrome was not dissimilar from psychoses following febrile diseases, injuries, or even childbirth in civil life. In most patients there were no neurologic abnormalities. In one patient abnormal plantar reflexes persisted for weeks, and schizophrenic symptoms developed in the acute phase of a malarial attack, but continued for weeks after he had become afebrile and the blood was free of plasmodia. Among the alcoholic intoxications, acute alcoholic furor was most common.
The primary objective of treatment was to restore the maximum number of soldiers to duty as quickly as possible. Disabling symptoms were removed first, and then the patient was assisted in re-establishing himself as a functioning member of a military body. Because the demands on the psychiatric personnel were so great, it became a matter of extreme importance to devise a plan of continuous treatment, even in the face of a relatively brief contact with each patient. Such a plan was successfully effected through a comprehensive program based on the simultaneous and coordinated use of individual and group therapy. Early establishment of rapport between patient and doctor was sought. Further contact was maintained on an individual basis as long as necessary and on a group basis by means of a continuous series of therapeutic and group training activities.
Interview and psychotherapy. Effective individual therapy in the base section hospital demands a clear understanding of basic purposes. Attempts to treat the military patient by the usual civilian methods are not only time consuming but futile as well. The fundamental purpose of therapy in this milieu is the preparation of the soldier for duty, on as high a plane of effectiveness as possible. All other goals must be subordinated to this one. Individual goals and perplexitieshappiness, difficulty in social relationships, psychosexual disorders, and somatic symptomsmust all be subordinated to the group purpose of defeating the common enemy. In view of this purpose and the usually severe limitations of time and material facilities, as well as the peculiar relationship of the soldier to the Army psychiatrist, treatment is necessarily different from that employed in civil practice. The psychiatrist must be prepared to interview, diagnose, and treat the average psychiatric patient all in a period of 30 to 40 minutes. Some patients must be seen oftener and for longer periods, but their number is necessarily limited and their eventual usefulness is low.
The initial interview is, therefore, as a rule the basic instrument by which the psychiatrist accomplishes all that is possible. During this period he must elicit a history that will permit all adequate estimate of the patient's basic personality and his present illness and make a reasonably thorough physical examination. The physical examination is necessary, not only to eliminate incidental nonpsychiatric disease, but, more significantly, to give a basis for reassurance. During this period the patient should be impressed with the military, yet sympathetic and understanding, attitude of the psychiatrist and with the scientific and thorough conduct of the examination.
This reassurance serves to establish a foundation for active therapy. The patient feels that he has found someone, even though an officer, who understands him, to whom he can express himself naturally and with little restraint, and who will try to help him.
A warning is necessary at this point. In the history, leading questions should be kept to a minimum. It is better to miss an occasional symptom of importance than to suggest a dozen to an anxious patient who is seeking new defenses against his overwhelming anxiety. Similarly, in the conduct of the physical examination, meticulousness, a virtue in civil practice is here definitely an evil. The psychiatrist should be able to make a positive diagnosis of neurosis by his study of the patient's personality and the nature of his symptoms, and he should be able to say with fair accuracy which of the symptoms result from the neurosis. That it is possible to do so is borne out by the experience of forward psychiatrists who were able to make very few elaborate physical examinations but nevertheless had an excellent diagnostic record.
At the base section hospital, therefore, the physical examination should be brief and systematic and directed more toward the detection of common disabling diseases or somatic manifestations of anxiety than toward the searching out of relatively common chronic diseases. The same approach is necessary in laboratory procedures. The detection of malaria and common epidemic diseases or basic structural defects is necessary; but for every patient helped by extensive laboratory work, particularly x-ray studies of the skull and the gastrointestinal tract, great damage is done to scores of neurotic soldiers.
Precision of thinking in the interview permits the omission of many procedures formerly thought necessary for diagnosis. The more purely therapeutic portion of the interview occurs at its close, when, usually in a period of 10 to 15 minutes, the patient is prepared for what faces him. The psychiatrist must first decide what disposition to make of the case. As a rule he can determine rather quickly whether the soldier is fit for return to combat or to limited service or whether he must be evacuated to the United States as a patient. Only a small number of men sent to the base section hospital can be returned to combat. Those evacuated to the zone of the interior are not likely to be military effectives for some time, and then only in a very limited capacity. The second and largest group, those going to limited service, are, therefore, the most important in our scheme of therapy.
Most of us found it desirable to inform patients of their eventual disposition as early as possible. This procedure not only gives the patient an immediate sense of securityif only because the decision is something fixed and definitebut also lays the basis for further therapy.
It impresses the patient with the power of the psychiatrist and allows an effective approach to the removal of hysterical symptoms. The decision is often received with gratitude by the patient, even if it is one he does not consciously desire, so marked are his fear of the unknown, his dislike of the uncertain, and his desire to be commanded and led. These neurotic traits of the patient are useful to the psychiatrist and should be exploited. Many objections to this procedure have been voiced and will be voiced in the future. For example: Is it not possible, by withholding decision, to return more of these men to combat? It is not. If anything, the reverse is true. As the psychiatric services were organized, no patient reached the base section hospital until he had been seen by two experienced psychiatrists in the division and the forward psychiatric center. Those men who were finally culled out for evacuation to the base section were almost without exception no longer fit for combat. No therapy employed on this group of patients, so selected and evacuated, was effective in returning more than a small percent to combat as useful soldiers.
Furthermore, attempts at prolonged therapy, intended to return the neurotic soldier to duties of which he is not capable, have several undesirable results. Symptoms become worse and new ones appear as anxiety becomes intolerable. Concomitantly, conscious hostility appears as a result of anxiety, and in turn reinforces it. When strong hostility appears all attempts at therapy become ineffective, and few patients so affected can be reclaimed even for limited service. Withholding decision concerning disposition also means prolonged hospitalization, which is to be deplored, not only because every hospital day is a dead loss to the Army, but also because it is usually worse than a dead loss to the patient. Long periods of hospitalization reduce the efficiency of any soldier, and in neurotic soldiers prolonged hospitalization for any reason leads to undesired results. Although the psychiatrist lacks authority to authorize final disposition of the patient, since disposition is almost invariably accomplished by a board of officers, the trained psychiatrist, familiar with the administrative policies of his own hospital board and commanding officer and with those of the Department, can in most cases predict the decision of the board and of higher headquarters. In doubtful cases it is wise to explain something of the procedure to the patient and to give him the date on which the board will make a decision.
After the completion of the first step in active treatment, the establishment of a basis of security for the patient in the knowledge of his fate, he must be prepared for the future. Primarily he must be told what his illness is and how it came about. The language used, the depth of the explanation, and the precise approach will depend on the patient's intelligence, his basic attitudes, his degree of insight,
and the severity of his neurosis, as well as the degree of responsibility he will face as the result of the disposition made of his case. Officers and noncommissioned personnel who will go back to positions of command should be given a thorough explanation. All patients must understand certain basic facts: that their symptoms are psychogenic and arise from certain situations or personality difficulties or both, and that there is no important somatic disorder and they are in every respect capable of performing certain duties. With many patients it is advisable to discuss in simple language the relationship of somatic symptoms to anxiety. The acute fear reaction of battle may be cited as an example.
Reassurance should be used freely, though sensibly. There are great advantages to be gained from telling a patient that he will be better, that he has suffered no permanent impairment of his ability to live happily, and that his illness is common and benign. Optimism is advisable when it is justified. It is dangerous, however, to depart from the known facts about neurosis. It is unwise to tell a patient that he will be well in a few days, that there is really nothing wrong with him, or that it is his "imagination." He senses that something is wrong, and this type of reassurance results only in loss of confidence. Guilt feelings should be actively combated, since they may lead to severe disability. The patient must be told that he is going to do a useful job; that he has suffered no disgrace; and that he is being removed from combat, not at his own wish, but because the Army finds him more useful elsewhere.
The final step in active therapy is exhortation. All soldiers with battle neurosis are discouraged, and many are disgusted or hostile as well. Cynical attitudes and confused thinking about the war are often present; they result from and predispose to neurosis. These factors must be combated, not so much by lecturing to the patient as by an extension of the psychiatrist's own attitudes. A proper orientation of the physician himself is required, for no one with a fundamental disbelief in the war effort call be expected to impart an idea of the need for it to others. The personal interview is not the place for orientation, which takes more time than the psychiatrist call afford and is better done in groups.
The four major methods of active individual therapy are, therefore, disposition, explanation, reassurance, and exhortation. All are effective with these patients, most of whom will go to noncombat duty. For the average patient there is neither time nor need for further formal therapy. Abreaction is not included, because it usually constitutes part of the history-taking period. For occasional patients it is an important and useful method. Mild suggestion, combined with reassurance,
has some value, but any considerable degree of it is to be avoided except with hysterical patients. Such formal techniques as free association are generally too time consuming to be practical. The psychiatrist should, however, allow the patient free play in recounting his illness. In cases in which a relatively active technique is unsuccessful, hypnosis or hypnotic drugs are usually used. In the initial interview the patient should be allowed to be as spontaneous as possible and the psychiatrist should direct the interview as passively as he can. Limitations of time modify the possibilities in this respect.
Occasionally a question arises concerning the extent to which a patient should be exposed to a discussion of his battle experiences. It may be answered by the explanation given by Kardiner and others; that the patient contains his own safety valve. When the facts are intolerable he forgets them or refuses to discuss them; and in general it is best to respect this amnesia or reticence in first interviews, but it is always permissible, and even advisable, to ask the soldier what happened at the front and to allow him to carry on from there, at an emotional level that may be barely tolerable to him. In most patients this aspect of treatment is not difficult. Amnesias offer an important problem only if they are severe and are then best approached with the aid of hypnosis or drugs. Mild amnesias for 1 or 2 hours are fairly common. They are of no great significance and need not be intensively treated if the patient is otherwise reasonably fit to leave the hospital. Only if the amnesia is disabling and associated with marked anxiety does it demand treatment. Its chief significance is as a symptom of anxiety, and the underlying anxiety is the disabling factor.
Gross hysterical symptoms, particularly disabling sensorimotor phenomena, require a somewhat different technique. They present an emergency and should be treated actively and intensively. Primarily, the symptom should be cleared up, and then the basic anxiety should be treated as in the typical anxiety state. A few hysterical symptoms may be removed in a simple interview by suggestion and reassurance alone, but most hysterical patients who reach the rear echelon require more strenuous measures. The severe anxiety states, generally seen in those with chronic personality disorders, and associated with depression, compulsive traits, and certain antisocial or schizoid phenomena, may require repeated interviews, largely for the sake of keeping the patient reasonably comfortable and happy. Most of these patients are returned to the zone of the interior. In such cases, too, immediately notifying the patient of his disposition is likely to be helpful. The interview examination and treatment of psychotic soldiers, whether the disorder is acute or chronic, are not very different from these procedures in civil practice.
Hydrotherapy. Tepid or cold wet packs are a useful form of therapy in certain types of case; for example, for patients with acute pseudopsychotic battle neuroses, those with severely disturbed anxiety states, and as in civil practice, for acutely disturbed psychotic patients. This method was of most value for the acutely disturbed or disoriented soldier who entered the base section hospital within a week of the onset of illness and demonstrated confusion, marked irritability, hallucinatory phenomena, and a cloudy sensorium. Patients who exhibited coarse tremors or similar adventitious movements reacted almost as well. The patient was placed in the pack, preferably in the disturbed ward, within a few hours of admission to the hospital. At the same time he was reassured and informed that he was safe and would not be sent back to the front, a promise that could safely be given in all these cases. Packs were continued for 2 to 3 hours and were given as often as three times daily. They were continued until the patient improved to the extent of regaining an intact sensorium and some degree of comfort, usually 1 to 3 days. This type of patient rarely if ever objected to the pack. Failure to improve, at least to some degree, was also rare.
When the patient had established good contact and became able to verbalize or to erect the common neurotic defenses against his anxiety, packs were no longer effective and were discontinued. Wet packs were not successful in the treatment of irritability, insomnia, and nightmares in patients in whom the disorder was more than 2 or 3 weeks old. Patients with chronic, fixed hysterical symptoms reacted to them badly or not at all. It was possible to replace drug sedation almost entirely by wet packs in the treatment of severe acute battle neuroses, with definite improvement in results. Good nursing care and supervision were necessary. Untoward reactions, such as hyperpyrexia, did not occur. They should be watched for, however, particularly in those few patients who struggle. The same methods and indications for wet packs were used as are in effect in civil institutions.
Narcoanalysis, the interviewing and psychotherapy of the patient while he is under the influence of a hypnotic drug, has been accepted as a useful tool in treating battle-induced anxiety states and hysterias.
Grinker and Spiegel (ref 16) developed this technique for use in combat cases as "narcosynthesis." The technique is simple. One of two drugs, sodium amytal or sodium pentothal, is generally used. Sodium amytal, 0.5 gm. in 5 cc. of water, is given intravenously over a 5- to 10-minute period. Occasionally the patient becomes confused or sleepy in the course of the injection. It is then discontinued
(ref 16) Grinker, R. R., and Spiegel, John P.: War Neuroses. Philadelphia: The Blakiston Company, 1945, pp. 78-86. Also: Men Under Stress. Philadelphia: The Blakiston Company, 1945, pp. 389-406.
before complete emptying of the syringe. Sodium pentothal, 1.0 gm. in 20 cc. of water, is given slowly until a light sleep is induced. The usual precautions for the intravenous use of barbiturate drugs should be observed. When the patient becomes too sleepy to cooperate, the intravenous injection of 0.5 gm. of caffeine sodiobenzoate is usually effective in restoring enough cooperation to allow continuation of the interview.
Various methods are employed after the narcosis is established. Some psychiatrists favor a dramatic technique, in which the patient is told that he is in the battle situation again and appropriate suggestions and noises are employed. If the method is successful the patient acts out a battle situation, often the one that included the traumatic incident. He dodges shells, recognizes fellow soldiers, and cries out in fear, while the psychiatrist takes the part of someone in the battle or a protective person or friend. Another technique, which we used more commonly, is essentially a continuation of the initial interview, obtained from the patient while he was conscious. The hypnotic drug serves to remove or dull the patient's anxiety temporarily, makes possible the discussion of many factors too unpleasant to deal with in the completely conscious state, and brings to consciousness feelings and memories repressed because of their power to produce anxiety. Hostility and guilt often appear on the surface, and the patient's resentments may be far more openly expressed than in the conscious state.
In conversion hysteria the technique is slightly different. In this instance the technique is used largely to dispose of some gross hysterical symptom, such as paralysis. In favorable cases the drug suffices to overcome the patient's resistance to cure, possibly by temporarily dulling the underlying anxiety. Occasionally dramatic relief of paralysis and mutism is effected. In all patients the technique is useful for the rapid elucidation of underlying dynamics. It is frequently possible to outline the structure of a neurosis in an hour, a task that might otherwise require many sessions. Thus the psychiatrist dealing with a severely ill patient is enabled to make a decision rapidly and with some accuracy and also to gain some clues concerning further therapy.
The usefulness of narcoanalysis as an investigative measure and a means of clearing up conversion symptoms is undeniable. It is rapid, harmless, and fairly reliable. Whether it aids in the relief of anxiety states, however, is much less certain. It has been used for the treatment of both chronic and acute anxiety states resulting from combat. In a certain number of patients it brings about some relief of anxiety or other symptoms, but the course of the disease is rarely influenced significantly.
Although patients who are incapable of duty are rarely made capable of it by narcoanalysis, those who are improving slowly may experience some increase in the rate of improvement. The method aids indirectly in increasing the psychiatrist's understanding of the patient. It does not furnish insight to the patient, since there is an almost complete amnesia for the session. (ref 17) The procedure is of value in the diagnosis of psychoses, particularly in catatonic and mute patients, since it is possible to obtain an idea of the patient's thought content. In conducting sodium amytal or pentothal interviews with these patients, excited, even violent, reactions should be anticipated. When the initial interview is complete and the patient's progress is unsatisfactory, narcoanalysis should be employed. It should be used in all cases of conversion hysteria that do not clear promptly with reassurance and suggestion. In general, repetition of the narcoanalytic session has not been found useful, except in hysteria. It is best avoided altogether in anxiety states of mild or moderate degree in which the residual anxiety does not interfere with prompt disposition on a limited duty status.
Hypnosis. The indications for and results of treatment by hypnosis are similar to those described under narcoanalysis. In skilled hands hypnosis is equally effective, particularly in hysteria, and posthypnotic suggestion is occasionally useful in relieving such symptoms as insomnia. The process of abreaction or ventilation under hypnosis is also similar to that under narcoanalysis. Not all patients can be hypnotized. Although some patients develop considerable resistance to the technique after the first two or three sessions, in patients requiring active therapy hypnosis may be worth a trial. The technique is similar to that used in civil practice.
Chemotherapy. During the early stages of the North African and Sicilian campaigns heavy sedation, generally by barbiturates, was used in both forward and rear areas for treatment of acute anxiety states. The results obtained in base section hospitals did not justify the continuation of this practice. It then became our policy to give sedatives to neurotic patients only in rare emergencies. Wet packs were found more effective in the treatment of acutely disturbed or pseudopsychotic patients. Sedatives were ineffective in treating insomnia and irritability in the more chronic neuroses, and their effects were often pernicious. After several weeks of treatment with barbiturates patients often demanded more drugs, and there were occasional cases of habituation and drug stealing. Sedation has a limited place
(ref 17) Editorial note: Most of us do not agree with this statement. We have found that a complete amnesia for the session is unusual. (See discussion in the section on "Psychiatry at the Army Level.")
in the treatment of acute neuroses in forward areas but may be discarded entirely as a routine treatment in rear areas. Patients who have not received sedatives before will not ask for them, and those who have had them before should be informed promptly that these drugs are no longer useful and will not be prescribed. To a less extent the same principle holds for all symptomatic therapy. Such analgesics as aspirin and acetophenetidin are of little value in the headaches experienced in battle-induced neuroses, and their use as placebos is rarely indicated. Furthermore, the reasons for withholding medication should be explained to the patient.
Certain treatments were found useful in special cases. In headache or confusion following injury to the brainrather rarely seen in our hospitaldehydration afforded temporary relief of symptoms. It was accomplished by administering 30 gm. of magnesium sulfate by mouth for one dose and 0.25 gm. of caffeine sodiobenzoate hypodermically at half-hour intervals for six doses. This procedure was never effective for neurotic headaches. It may therefore be of some value in differential diagnosis. In establishing a diagnosis when epilepsy was questionable it was sometimes considered desirable to produce a seizure if possible. A hydration procedure was employed, requiring repeated doses of pitressin and water over a 36-hour period. Reactions were unpleasant but not dangerous, and occasionally definite help in diagnosis was obtained by the precipitation of a grand mal seizure.
Amphetamine sulfate was given in selected cases of neurosis. Our observations do not justify any definite statement concerning its therapeutic value, except that severely anxious patients occasionally tolerated large doses of the drug. In the treatment of certain acutely disturbed patients, particularly those suffering from acute alcoholic furora form of pathologic intoxication not uncommon in the Armyparaldehyde or sodium amytal, administered intravenously, was found very useful. This drug was given promptly but slowly in sufficient quantity to produce sleep. The results were uniformly good. The patient recovered in a few hours, with good contact and normal behavior. These drugs were used when necessary for the handling of severely disturbed psychotic patients on admission or when they had to be transported some distance and restraint could not be applied. Dauerschlaf, prolonged sleep under profound drug narcosis, was not used.
Electroshock therapy. The use of electroshock therapy, begun at our hospital in January 1944, proved to be one of the most useful instruments in military, as in civilian, psychiatry. The treatment of psychoses, schizophrenia, and the affective states was one of the major problems of the base section psychiatric hospitals. Facilities for
handling severely disturbed psychotic patients were rarely adequate in overseas hospitals, particularly on a mobile front, and these patients often had to be transported long distances. Moreover, owing to inevitable delays in evacuating patients to zone of interior hospitals, specific treatment was sometimes unduly delayed. Electroshock treatment largely solved these problems and revolutionized treatment of psychotic patients in the theater of war. The technique used was that described by Kalinowsky. (ref 18, 19, 20) The Offner machine which furnishes a high frequency current, 7,000 cycles, of up to 800 ma. was used. Ordinary American generator current (alternating 100 to 120 volts) was used. It was also found possible to employ small portable generators that furnished a similar voltage. Foreign, high voltage current, such as the British and Italian, could not be used. The machine proved to be simple and reliable in operation and was thoroughly satisfactory.
A team of 8 to 10 enlisted men and one nurse assisted the physician in administering the treatment. Six enlisted men held the patient, two each at legs, hips, and shoulders, to prevent excessive movement of the body, while the physician held the lower jaw in place over a rubber gag. A bed with a fracture board and mattress and a pillow under the small of the back made up the rest of the equipment. Patients were started routinely with 500 ma. for 0.3 see., but a few required up to 800 ma. for 0.5 sec. When petit mal seizures occurred the patient was given a second shock immediately. If the second shock was ineffective the current was increased 50 to 100 ma., and a third shock was given. In every case a grand mal seizure was produced before the patient left the table. It was found that convulsions could be produced with 500 ma. for 0.1 to 0.15 sec.
Treatments were given three times weekly to most patients, but oftener if they were excited, suicidal, or destructive. For these seriously disturbed patients it was found useful to produce two or three grand mal seizures within the first 24 hours and to continue daily treatments until the acute emergency had subsided. The usual routine of triweekly treatments was then followed. This procedure was particularly effective in avoiding suicide, self-mutilation, and injury to personnel and equipment. The number of treatments given varied with the type of disease and the patient's progress. Schizophrenic patients were treated as long as they remained in the hospitalrarely more than 4 to 6 weeksfor a total of 12 to 20 grand mal seizures.
(ref 18) Kalinowsky, L. B.: Electric Convulsive Therapy in Psychoneuroses, M. Ann. District of Columbia, 14: 70-75, Feb. 1945.
(ref 19) Kalinowsky, L. B.: Experience with Electric Convulsive Therapy in Various Types of Psychiatric Patients, Bull. New York Acad. Med., 20: 485-494, Sept. 1944.
(ref 20) Barrera, S. E. and Kalinowsky, L. B.: Electric Shock Therapy in Mental Disorders, M. Physics, pp. 335-340, 1944.
Depressed or manic patients were given up to 8 treatments if there was symptomatic relief. Otherwise treatments were continued thrice weekly. Patients with other psychoses, reactive depression, or neurotic states were given 6-8 treatments, or less if the symptoms disappeared.
Certain requirements and safeguards are essential. Treatments must be given by a psychiatrist who is thoroughly familiar with the electroshock technique. Patients must have had a careful physical examination and the required x-ray of the spine and an electocardiogram, and should be approved for treatment by the chief of the neuropsychiatric service. In our group of several hundred cases no physical contraindications to treatment were found, except for one soldier with recent fractures of the forearms sustained before admission to the hospital. Malaria, under control of atabrine or quinine, does not interfere with therapy. Heart disease and chronic bony pathology were encountered so rarely in overseas personnel that they offered no problem in our series. Almost all patients, therefore, who required treatment on psychiatric grounds could be treated without fear of complications. Except in cases of organic psychoses, all suicidal, destructive, excited, or seriously confused psychotic patients were treated. The group suited to treatment included catatonic and paranoid schizophrenic, manic, and severely depressed patients. All such patients were treated promptly and intensively.
Most schizophrenic patients were given electroshock treatment, particularly if the symptoms were of recent onset or if such symptoms as refusal to eat and soiling were present. All patients with psychotic depressions were treated. Those with unclassified psychoses were treated if they failed to improve after a week or two of observation, unless the illness was associated with all organic disease that in itself constituted a contraindication. Patients with organic or toxic psychoses were treated only if they were suicidal or excited to a degree that endangered themselves and others. Reactive depressions of a neurotic type were treated if there was a danger of suicide. Only a small proportion of patients with combat-induced neuroses were given electroshock treatment; that is, only those severely ill patients who continued to have severe depression, marked abnormalities of behavior, paranoid trends, or severe hallucinatory phenomena. A few patients with rigidly fixed hysteria were also treated.
The results were highly satisfactory. Severely disturbed patients showed the most dramatic improvement. Two to 5 treatments resulted in marked improvement in almost every patient with restoration of general health and normal behavior and loss of confusion and suicidal trends. Many patients who had entered the hospital severely disturbed and required restraint could be transferred to open wards a
week following admission. There was no need for tube feeding, restraint, or sedation. Table VI summarizes the improvement for one 30-day period. Results in the treatment of psychotic depressions were equally good. After 3 to 8 treatments the mood and behavior of these patients became reasonably normal. Immediate relapses were unusual. In most paranoid schizophrenic patients results were good, but not so spectacular as in the more acutely disturbed patients. Their behavior improved and the more bizarre symptoms generally disappeared, but there were no complete remissions in the relatively brief period of observation. Patients with neuroses varied in their response to electroshock therapy. As a rule those with severe reactive depressions improved rapidly. Up to a point there was rapid improvement in those who had severe neuroses, with abnormalities of behavior or schizoid characteristics, after 4 to 8 treatments. These patients lost their paranoid trends, hallucinations, and bizarre behavior, but retained sufficient anxiety and irritability to render them unfit for duty in the theater of operations. All these patients became well enough to be treated on open wards.
Improvement in a 30-day period after use of electroshock therapy
Electroshock treatment accomplished much beyond its benefit to the individual patient. Thus it made possible the treatment of psychotic patients with reasonable safety without elaborate physical facilities. It cut destruction of property and injury of patients and personnel to a minimum. It made evacuation of patients far easier. It markedly reduced the use of drugs and restraints. Its use enhanced the efficiency and morale of ward personnel, for it demonstrated to personnel untrained in psychiatry, and often indifferent to it, the possibilities and favorable results of specific treatment.
Complications were rare and unimportant. No deaths could be ascribed to the treatment. Dislocation of the jaw, easily reducible, occurred twice. There were no fractures of the extremities, and spinal fractures were never clinically evident. Muscular pains were frequent but unimportant. Because of the temporary amnesia associated with
the treatment, patients developed no fear of it and often spontaneously expressed their sense of benefit. After a prolonged series of treatments mild memory defects occurred, but they were reversible and never severe. The favorable emotional response to the treatment was ascribed to our policy of avoiding petit mal reactions, which do cause fear and discomfort associated with therapy.
Training program. The smooth operation of a large psychiatric hospital in which the majority of patients are ambulatory requires the coordination of all departments toward a unified therapeutic effort. Of primary importance is the morale of the patients. The very nature of the disorders that result in the patient's hospitalization contributes to discouragement, selfishness, insubordination, and irresponsibility. These attitudes are contagious. Close association of a group of patients tends to infect all with the discontent of a few. Resentment toward authority must be understood by the staff as symptomatic of psychiatric disturbances. Manifestations of hostility require a tactful approach by hospital personnel. Facilities for isolation for limited periods are therefore important in the treatment of these patients.
In group therapy a series of educational and rehabilitative activities were provided for all patients. The commanding officer of the detachment of patients was in charge of the program, which was developed in collaboration with the chief of the psychiatric service. Activities were conducted in sections devoted to physical conditioning and educational recreation. All patients were assembled each morning after ward rounds. At 9 a.m. they were marched to a parade ground where calisthenics, close order drill, and competitive sports occupied the next 2 hours. Between 11 a.m. and 2 p.m. their time was their own. A rest period after lunch was encouraged. Formation was at 2 p.m., after which the section was divided into smaller groups for special activities: handicrafts and art classes; lectures by members of the hospital staff on cultural and current topics, given at scheduled periods; hobbies, dramatic or musical; and physical activities and competitive sports. The usual orientation lectures and films were provided through the information and education officer. The Red Cross conducted a weekly town hall forum. Periodically groups supervised by the chaplain were taken on sight-seeing tours to points of interest in a nearby city.
Participation in the actual work of the hospital was considered a part of each patient's treatment. An employment service was maintained to select and assign patients to various departments of the hospital, according to their skills and interests. The patient's efficiency at work was used as an index of his rehabilitation and preparedness
for assignment. An effort was made not to prolong the hospitalization of a patient merely because of his usefulness in the work program. The desirability of shortening the hospitalization period of each patient was constantly stressed. Our data indicated that a period of 1 to 2 weeks in the base section hospital was sufficient to render fit for limited duty a patient capable of quick recovery. Most patients who could not improve sufficiently to be ready for assignment within this period were sick enough to require evacuation to the zone of the interior. There were not many such men in the group who had acute combat-induced neuroses.
Psychotherapy. The group activity program led to experiments in group psychotherapy. Since no one technique was considered better than another, each psychiatrist devised his own. Our interest in group therapy was first stimulated by experiences in the North African campaign, when acute psychiatric battle casualties were treated in an open ward of an evacuation hospital in full view of 20 other patients. There was no privacy during the examination interview or any phase of narcoanalysis. Any abreaction produced in the patient produced a response in all the other patients, who were attentively observing the procedure. There were no unfavorable reactions in any of these patients who were involuntary participants in the proceedings.
Patients were introduced to group orientation in psychodynamics shortly after admission to the hospital through a series of four lectures given by the psychiatric staff on "What is psychoneurosis?" "How does nervousness cause physical symptoms?" "Attitudes: how do they affect patients?" and "What adjustments must the soldier make?" Each lecture, together with a question period, generally exceeded an hour. Meeting in this way, the men identified themselves with one another in that all were patients with similar types of illness and most had had similar military and battle experiences. In simple language they were given an interpretation of their illness, the prognosis for it, and methods of treating it. The patients' responsibility in the treatment program and their role as soldiers in a war theater were emphasized. This type of orientation showed immediate results in the response of patients to demands made on them and improvements of their response to individual therapy from the ward psychiatrists. The general program of hospital activities and procedures was outlined and the reasons for them were explained.
Subsequently each psychiatrist gave informal lectures to his own group of patients, with whose histories he was familiar and with whom he had already established a therapeutic relationship on an individual basis. The lectures were in the nature of discussions extending the material previously presented. Psychoneurosis and the dynamics of its production were explained in some detail. The examples were
limited essentially to hysteria, anxiety states, and the development of various psychosomatic illnesses. The talks were illustrated by examples taken directly from the group. Discretion was used to avoid embarrassing a patient, and material from previous hospital cases was used freely. The lectures were followed by forums. The interest stimulated by the group could be gauged by the number of questions asked. Some forums were devoted to catharsis of the great amount of repressed hostility in these patients, which was clearly manifested by their irritability and tended to become diffuse and displaced and to give rise to psychosomatic complaints. Expression and examination of this emotion in a group proved beneficial. The desire of the patient to become well was stimulated when he saw himself as one of a group of neurotic patients, with whom he freely discussed the nature of the neurosis, and when his attention, like that of the others, was diverted to the psychic origin of his complaints.
Another technique of group therapy was developed in art classes conducted in small groups. An instructor furnished by the Red Cross supervised the classes. The psychiatrist, working with selected groups of patients, asked them to draw or paint as they chose, and afterward discussed the production of each patient in the presence of the others. Using a free association technique, he was able to elicit material representative of the dynamics underlying the patients symptoms. This method led to free group discussion, with obviously beneficial results. The work of the American Red Cross, though its primary function was to provide recreation, comforts, and personal social services, had important therapeutic value as well. The arts and crafts program was directly supervised by the recreational worker, who secured supplies from many sources and acted as instructor. Such programs as community sings, quiz programs, theatrical productions, and playing in a band, in all of which the patients participated, helped them to extravert themselves. The Red Cross facilities, used at times that did not conflict with scheduled classes, kept patients out of their wards and beds.
The social service worker also assisted in a therapeutic capacity. At all times we emphasized treatment and rehabilitation of patients while they awaited evacuation to the zone of the interior. The morale of these men, faced with readjustment to their new status as failures being removed from the theater of operations or soldiers discharged from the Army because of psychiatric disabilities, was generally low. They were preoccupied with the problem of what lay ahead of them and how to accept it. They needed preparation to face their families and friends and to readjust to civil life in the event of a medical discharge, as well as information concerning rehabilitation programs available to them in and out of the Army. The social worker
assisted with these problems. Armed with information about facilities in the States and the provisions of the "GI bill of rights," she was in a position to advise them. More important, in informal gatherings in the Red Cross Club she was able to discuss with patients their prospects, attitudes, fears, resentments, and needs. Since she was a civilian talking to soldiers, there was in these discussions none of the constraint often felt between patient and medical officer. The value of this phase of group therapy was unquestionable.
Regardless of the approach or technique in such a hospital, some form of group organization and approach is necessary. Through the group sessions it was possible to strengthen the doctor-patient relationship. The number of patients and the limited time available for therapy made it impossible to see the patients individually as often as might be wished. Group therapy was one way of overcoming these limitations. It enabled us to maintain continuous contact with large numbers of patients being returned to the zone of interior in whom interest might otherwise have been lost or who might have been neglected while awaiting evacuation.
Validity of statistics. Conclusions drawn from statistical data of hospitalized cases must take into account the location of the hospital and its functional relationship to other hospitals at any particular time. Acute cases, including many with relatively good prognosis, are received in advanced base sections; chronic cases, with a high incidence of those with poor prognosis, reach rear base sections. It is impossible to deduce conditions in one base section from those in another. Statistics must be interpreted with great care, for data of this type depend upon a large number of variables, including the conditions prevailing within the base section and also those prevailing in the echelons ahead and behind it, personnel policies, transportation facilities, and theater demands, as well as the immediate tactical situation.
Morale is relatively high in acute cases occurring in fresh troops. It tends to be low in veterans who have seen much fighting, particularly when their symptoms have reached a chronic state. Lack of orientation to the war is a serious factor. An appallingly large number of soldiers had no sense of unity with their national group or even with their immediate military organization. This lack in the first instance was usually caused by inadequate indoctrination, and in the second by poor discipline and command. Lacking both a sense of responsibility with regard to war objectives and the security that comes from identification with a company or regiment, the more dependent soldier in times of stress can turn only to home as a source
of security. Nostalgia is, therefore, not merely the result of the drive for secondary gain, but, even more, an integral manifestation of the neurosis itself. An interesting and clinically significant behavior disorder, which we called "psychopathic reactions due to poor morale," appeared in 2 percent of all types of convalescent patients. These patients, who had previously exhibited good adjustment and attitudes in civil and military life, during hospitalization after long combat showed psychopathic traits of irresponsibility, selfishness, insubordination and indifference to the war effort. This reaction was seen also in many neurotic patients awaiting shipment to the United States.
Recurrent cases. Few patients who reached the base section hospital ever again successfully performed in combat. Arbitrary reassignment of such patients to combat almost invariably resulted in a recurrence of their symptoms. Such recurrences constituted 12 percent of admissions to the base section psychiatric hospital in an advanced base section. Analysis of the amount of duty these patients performed after leaving the hospital the first time indicated that those returned from the advanced army psychiatric unit remained in combat for about 6 weeks before they were incapacitated by recurrent symptoms. Those returned from base section hospitals remained with their units an average of not more than 3 weeks, most of which was spent in noncombat situations. In the rear base sections recurrent cases were chiefly soldiers who had failed to perform limited duty in a noncombat area. These recurrences developed when: (1) unassignable patients were sent to replacement depots and developed exacerbations of symptoms while awaiting assignment; (2) unit commanders were unwilling to tolerate the decreased efficiency and adaptability of such soldiers; and (3) there was a recrudescence of symptoms under provoking circumstances, such as improper assignment or exposure to unanticipated dangers.
Organic disease. Reluctance to make a diagnosis of neurosis until all organic disease has been ruled out results in lengthy hospitalization and preoccupation with detailed studies and laboratory reports. Internists are likely to forget that psychiatric diagnosis should be made on positive evidence rather than by exclusion. Particularly is this true in functional gastrointestinal disturbances. Many of our patients reported that they had been subjected to repeated gastrointestinal x-ray series, proctoscopic examinations, and even gastroscopy. Numerous studies in this theater indicated the nature of functional gastrointestinal syndromes; usually, a differential diagnosis of peptic ulcer, for example, could have been made on clinical observations alone. Similarly, in anxiety states with neurocirculatory symptoms electrocardiographic studies supplied no useful information but tended to fix the somatic pattern in the neurotic patient.
Patients with backaches and motor disturbances of the extremities were subjected to unnecessary physiotherapy for weeks, with deleterious effects on their neurotic disorder. All such procedures tend to crystallize fixed, hypochondriacal reactions in psychoneurotic patients. Far more harm is done to them than to those rare patients whose organic conditions are missed by limiting laboratory studies to a minimum. Of all patients in the base section psychiatric hospital, 6 percent were eventually given a diagnosis of organic disease, such as muscular atrophy, cerebral concussion, herniated intervertebral disk, sciatica, and arthritis. Total figures indicated that 2.5 percent of all patients were erroneously diagnosed as psychoneurosis. Considering the demands on hospitals to evacuate patients at the height of a campaign, this incidence of error is inconsequential. The major function of all military medical installations is to return patients to duty in the shortest possible time.
Advantages. The base section psychiatric hospital has the advantage that: (1) it provides greater efficiency in handling a large influx of acute battle casualties, (ref 21) (2) it provides better segregation of patients, making for formulation of a uniform program and less emphasis on hospital atmosphere, (3) it can react quickly and smoothly to changes in policies laid down by higher commanders and consultants, (ref 22) (4) close association of a group of specialists is important in the field of psychiatry since this facilitates exchange of ideas and experiences, (ref 23) (5) the psychiatrically oriented hospital disposition board can act promptly and efficiently, with good insight into the prognosis of psychiatric casualties, (6) there is proper orientation of such accessory agencies as the special services, the Red Cross, and the information and education program the functions of which can be coordinated by a single administrative officer such as the commanding officer of the detachment of patients, (7) better liaison with the replacement command is provided since the function of the psychiatrist, more than that of any other medical officer, does not end when the patient leaves the hospital, (ref 24) (8) since it is smaller and does not require massive equipment, it can be moved within the theater much more freely than a general hospital with an equal number of psychiatric beds, and (9) the large number of psychiatric patients available provides an opportunity for research (ref 25).
(ref 21) It was demonstrated that the base section psychiatric hospital could dispose of 1,500 patients a month. Few general hospitals could efficiently dispose of 200 neuropsychiatric patients.
(ref 22) Making similar changes throughout the neuropsychiatric sections of general hospitals in a base section requires more time and is much more cumbersome.
(ref 23) Observation of the methods and results of others stimulates self-criticism, curiosity, and flexibility. It is possible also to share such techniques as hypnotism, the Rorschach test, and electroshock.
(ref 24) Knowledge of replacement needs, opportunities, and policies is necessary in making appropriate disposition of patients. Specific recommendations for reassignment of a practical type can be furnished by the hospital disposition board through close liaison with the replacement command. Advice of a professional type offered to the replacement command may assist the command in formulating its policies with reference to reclassified replacements. These activities materially reduce the recurrence rate.
(ref 25) Some of the studies undertaken at this hospital dealt with the testing of the validity of the Rorschach test and the Cornell selectee index test. Studies were made of hysterical amblyopia, the effects of amphetamine sulfate on neurotic patients, the value of electroshock therapy in various conditions, and the usefulness of hydrotherapy in acute battle neuroses. Experiments in the techniques of group therapy were undertaken, and the value of treating soldiers awaiting evacuation to the zone of the interior was demonstrated.
Policy. A clear-cut policy concerning the function of the base section psychiatric hospital must be formulated. It must be flexible enough to permit adaptation to changing tactical conditions. Its primary function is to treat all soldiers with battle-induced psychiatric disorders who reach the base section. Its optional functions are to treat psychotic patients; to operate all outpatient department, with particular reference to reclassification of personnel; and to institute a training program (school of military neuropsychiatry) for personnel. Decision as to final disposition of patients should be a function of the professional staff of the hospital.
Echelon of evacuation. Patients should reach the base section psychiatric hospital directly from corps or army psychiatric units without first passing through station or general hospitals.
Administration. The base section psychiatric hospital should be an independent unit with sufficient mobility to move when necessary to the most advanced base section. If it is attached to a general hospital, the attachment should be for administrative and professional purposes not supplied by the unit itself, and sufficiently loose to permit mobility.
Close liaison with the replacement command is necessary in order to keep the hospital informed of current replacement policies and to keep the psychiatric problem clearly before the replacement command.
The regular staff should be able to care for 500 to 750 patients. A supplementary staff should be available for expansion when necessary. The supplementary staff need not be psychiatrically trained, for training call be given during the working period. A medical consultant is needed. Other consultants are optional, depending on the availability of general and station hospitals for consultative purposes. If the psychiatric hospital is attached to a general hospital, x-ray, laboratory, and dental facilities can be furnished by the general hospital. Enough line officers to direct a training program should be provided. The Red Cross should have trained psychiatric social service workers on the staff. An occupational therapist is desirable.