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Chapter 2

Contents

CHAPTER II

The Control of Pain in Men Wounded in Battle

Henry K. Beecher, M. D.

MORPHINE OVERDOSAGE AND POISONING

Early in November 1943, a curious phenomenon was repeatedly observed in the operating tents of forward hospital installations in Italy. Wounded men who were brought into the receiving wards in shock and thoroughly chilled all presented essentially the same appearance and clinical picture on their arrival. Some of them, after they had been warmed and had been treated by standard shock therapy, responded to it in the usual manner. Others, however, after receiving exactly the same kind of treatment, presented profound respiratory depression associated with pinpoint pupils, although neither of these signs had been present before resuscitation. These men, though they had not had morphine since they entered the hospital, were clearly suffering from morphine poisoning. In fact, in the absence of head injuries, and under the circumstances of combat, it was impossible to attribute their condition to any other cause. Alcoholism, chloral hydrate, and the barbiturates, all of which can produce a similar picture, could be excluded, for obvious reasons.

This phenomenon had been observed in patients who were burned in the Cocoanut Grove disaster in November 1942.1 It had also been recorded in the civilian medical literature before it was observed in the Mediterranean Theater of Operations in the fall of 1943.

How frequently the syndrome of morphine poisoning occurred it is not possible to say. Often it was too severe to be overlooked. Occasionally it was fatal. On the other hand, it probably went unrecognized in many instances, because the manifestations were slight or subclinical. When it was serious, it might be misunderstood, but it could not be ignored. In the first 10 days of November 1943, morphine poisoning was recognized in several hospitals. On 11 November, it was discussed at the regular weekly medical meeting of the Fifth United States Army medical officers. Subsequently it was observed and commented on in all the hospitals in the theater.

A consideration of the circumstances of wounding and resuscitation offered an entirely reasonable explanation of what had happened to these wounded men. Early in November 1943, it was cold in the valley of the Volturno, where the fighting was taking place. It rained frequently, and

1The fire in the Cocoanut Grove, a Boston, Mass., night club, occurred on the evening of 28 November 1942. As a result of the disaster, 491 persons lost their lives. The author of part I of this volume was on the staff of the Massachusetts General Hospital, which received 114 of the fire victims within a period of 2 hours.


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snow fell low on the mountainsides. If a man was not wet and chilled before he was wounded, he promptly became wet and chilled after he fell, even if he was picked up shortly after injury. Often he was subjected to further exposure in the course of a difficult litter carry to the receiving hospital. The result was impairment of the circulation in the skin and subcutaneous tissues. Sometimes the impairment was slight, but sometimes it amounted to almost complete cessation of the local circulation.

Under these conditions, it was not likely that the morphine administered as a first-aid measure on the battlefield would be absorbed. That it was not absorbed was proved by the fact that, in many instances, the injection of 30 mg. (gr. ), the amount put up in Army-issue syrettes, brought no relief of pain. A second, and often a third, injection in the same amount would therefore be given over a period of hours, each time with no perceptible effect. These wounded men were often described as "resistant" to morphine. When they were in good general condition and not in serious shock, an active peripheral circulation was promptly restored as they warmed up in the hospital, even if no other measure of resuscitation was employed. The restoration of the circulation caused the rapid, simultaneous absorption of all unabsorbed deposits of morphine, sometimes many hours after the injections had been made. If shock was present, and resuscitative measures in addition to warming were employed, the restoration of the peripheral circulation often led to dangerously rapid absorption. Either course of events was likely to be followed by morphine poisoning.2

It soon became evident that although morphine poisoning was an increased risk in cold weather, it was equally likely to develop, regardless of weather, in the presence of surgical shock, hemorrhage, or any other condition leading to, or associated with, a reduction in the peripheral circulation. It often became evident during anesthesia, in cases in which it was necessary to undertake operation before full resuscitation from shock had been accomplished. The chain of events was as follows: Ether stimulated the respiration. Peripheral vasodilatation then occurred. Morphine, which might have been injected as long as 8 or 10 hours earlier, was rapidly absorbed. When pinpoint pupils and profound respiratory depression developed before the surgical stage of anesthesia had been reached, induction was greatly prolonged, sometimes taking an hour or more.

Clinical manifestations-Pinpoint pupils and slow respiration were the first manifestations of morphine poisoning. Respiratory depression led to anoxia, which was followed, in turn, by circulatory depression. These were the most serious consequences of overdoses of morphine, but less severe manifestations were frequent, and even small doses sometimes produced reactions which complicated treatment. A single injection of morphine might cause anorexia, nausea, and vomiting, which limited the intake of food and fluids by

2The possibility and dangers of morphine poisoning's developing in battle casualties, particularly under cold weather conditions, had been recognized and emphasized in the curricula for officer and noncommissioned-officer students at the Medical Field Service School, Carlisle Barracks, Pa., in the years preceding World War II.


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mouth and increased the fluid loss in vomitus and sweat. The use of morphine even for brief periods was sometimes followed by severe constipation.

Management-The realization that morphine intoxication might have a rather abrupt onset, sometimes many hours after the last injection, was essential in the diagnosis of morphine poisoning. Unless that fact was constantly borne in mind, treatment was likely to be delayed.

The first step in therapy was the application of a tourniquet proximal to the site of injection, to delay absorption. It was loosened at regular intervals. Body heat was conserved. Then the attention was devoted to the chief aim of therapy, which was to prevent anoxia. This was best accomplished by the administration of oxygen, supplemented by artificial respiration, if necessary. Oxygen was preferably given by means of a closed anesthesia apparatus, with carbon dioxide absorption, accomplished by intermittent pressure on the breathing bag. Atropine in doses of 1 mg. (gr. 1/60) by vein, combined with ephedrine in doses of 30 mg. (gr. ), also by vein, was sometimes useful, the latter as a central stimulant and as a support against falling blood pressure. Hypertonic glucose solution was used intravenously for its diuretic effect, to hasten the excretion of morphine by the kidneys.

If coma developed, a gastric tube was inserted at once to eliminate the risk of aspiration of gastric contents. Pulmonary complications were guarded against by frequent changes of position. Supportive treatment was continued until it was apparent that the excess of morphine administered had been largely destroyed in the body.

INVESTIGATION OF PAIN IN WOUNDED MEN

The numerous instances of morphine overdosage and poisoning observed in Italy in November 1943, and in the succeeding weeks, suggested that the routine administration of morphine to wounded men, particularly in large doses, was not a safe procedure. The question also arose whether all wounded men experienced enough pain to warrant the risk attached to the use of this drug, especially in large doses.

To settle this question, a study was made of 225 patients who had sustained major wounds during the prolonged action on the Anzio beachhead and the Venafro and Cassino fronts and, in a few instances, in southern France. The selection was as consecutive as the criteria permitted, the objective being to select patients with major injuries in certain categories who were clear mentally and who were not in shock when they were questioned. Ten of the two hundred and twenty-five men included in the original collection had to be dropped because they were unconscious or not clear mentally. A few others who had been in shock when they arrived at the hospital were not questioned until their status had improved. Included in the 215 patients were 50 with compound fractures of the long bones, 50 with extensive wounds of the peripheral soft tissues, 50 with penetrating wounds of the thorax, 50 with penetrating wounds of the abdomen, and 15 with penetrating head injuries. In most instances, the


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wounds which formed the basis of selection (table 2) represented only the chief wounds. Most of the patients had multiple injuries.

The incidence of pain in the several categories of injuries was arrived at by asking the patients, shortly after their arrival at forward hospitals, several pertinent questions. These questions had been carefully framed, and great care was taken to see that each patient understood their meaning.

The first question was, "As you lie there, are you having any pain?" To it, 69 of the 215 patients (32.1 percent) replied that they felt no pain at all. The 146 patients who had complained of pain were then asked, "Is it slight pain, moderate pain, or bad (severe) pain?" In reply to this question, 55 (25.6 percent of the original 215) complained of slight pain, 40 (18.6 percent) of moderate pain, and 51 (23.7 percent) of severe pain.

These replies were not in accord with the long-accepted generalization that all extensive wounds are associated with severe pain and that the more extensive the wound, the worse is the pain. If it is possible to speak of such a subjective experience as pain in exact terms, it might be said that the generalization held in only about a quarter of all cases and failed partly or entirely in the other three quarters.

Patients who admitted to pain of any degree were next asked if they wished something to relieve it. The use of the term "morphine" was deliberately avoided. Experience had already shown that it was an unfortunate word to use in front of wounded men, who were likely to form the impression that if their condition was serious enough for them to need morphine they must, indeed, be quite badly off. A close parallelism naturally existed between the number of wounded men who complained of severe pain (51 patients, or 23.7 percent of the 215 in the series) and the number desiring medication for relief (58 patients, or 27.0 percent of the total number). In all, 157 of the 215 patients (73.0 percent) desired no medication, and 164 patients (76.3 percent) had no pain or slight to moderate pain. The results of this study seemed to show clearly that the routine injection of morphine was not necessary in forward hospitals.

In a great many of these patients, the striking absence of severe pain, and of any pain, could not be explained either by the amount of morphine received or the time at which it was given (table 2). Of the 51 who complained of severe pain, 5 had had no morphine since they were wounded. The other 46 had had an average total dose of 30.5 mg. and had received an average of 24.5 mg. in the most recent injection. Of the 157 who wished no medication when they were questioned, 32 had had no morphine at all. The other 125 had received an average total dose of 27.3 mg. The elapsed time since the last dose was essentially the same in both groups. It was therefore not possible to explain the degree of pain, or its presence or absence, on the basis of the amount of morphine given and the time at which it had been injected.

Only 1 of the 15 patients with penetrating wounds of the head complained of severe pain, in contrast to 6 of the 50 patients with wounds of the thorax, 12 of the 50 with extensive compound fractures of the long bones, and 24 of the 50 with penetrating wounds of the abdomen. Although there was little


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TABLE 2.-Analysis of pain sensation in 215 freshly wounded patients with major injuries1


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difference in the amount of morphine received by the two groups of patients, there were four times as many complaints of severe pain in the group with abdominal injuries as in the group with thoracic injuries. Perhaps the explanation is the spill of blood and intestinal contents into the peritoneal cavity, as well as the role of infection. Be this as it may, these data supported the idea that, in forward areas, it was not necessary to give morphine routinely and that it would be wiser to administer it according to the needs of the individual patient.

RELIEF OF PAIN

Routine for administration of morphine-It became apparent early in the Tunisian campaign that the 30-mg. (gr. ) amounts of morphine put up in Army-issue syrettes were too large for many patients, even when only single injections were used. Some observers attributed the difficulties which arose from overdosage of morphine and morphine poisoning to the fact that medical aidmen, for the first time in United States Army history, were being permitted to administer the drug. This was not the general opinion. It was repeatedly observed that medical officers were much more likely to be at fault in the overgenerous use of morphine than were medical aidmen.

Throughout the war, there was a tendency in all theaters to overtreat wounded men with morphine in an endeavor to relieve pain. The situation in Italy began to improve when the Chief Surgeon, North African Theater of Operations, in December 1943, established the rule that morphine usually was not to be administered in more than gr. (half a syrette) single dose.3 In addition, a vigorous educational program was begun, and this endeavor, together with an increasing appreciation of the disastrous possibilities of delayed morphine poisoning, led to a sharp decline in the excessive use of the drug. It was about this time that the study just described was begun on the Anzio beachhead, and it promptly became clear that severe pain is much less common than was generally supposed in severely wounded men and that if morphine is used at all, it is not necessary to use it in large doses.

Eventually the following routine for the administration of morphine became fairly well standardized:

1. As a general rule, the amount injected in a single dose did not exceed 15 mg. (gr. ). In patients to be transported by air, in whom respiratory depression was particularly undesirable, the amount was reduced to 8 or 10 mg. (gr. 1/8 or 1/6). Maximum analgesic effects could be secured with these dosages, and the undesirable side effects caused by larger doses were seldom apparent.

2. Subcutaneous or intramuscular injection was employed when a gradual, prolonged effect was sought, but this route was avoided when the peripheral circulation was slowed by exposure, hemorrhage, shock, and other causes. Intravenous injection was then a better choice. It was also a better choice

3Circular Letter No. 50, Headquarters, North African Theater of Operations, United States Army, Office of the Surgeon, 30 Dec. 1943, subject: Morphine.


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when the immediate relief of pain was desired or when delayed absorption might prove harmful, as in impending shock. When 8 or 10 mg. (gr. 1/8 or 1/6) were given by this route, the full effect was achieved within a few minutes, and there was no possibility of delayed absorption. If the desired results were not obtained by the first injection, a second could be given, without risk, within 15 or 20 minutes. As a practical matter, it was almost never possible to administer morphine intravenously to a wounded man on the battlefield. Every circumstance conspired to make the continued use of peripheral injections necessary-the extra time which would be required for venous puncture, the urgent need for haste in the face of enemy action, the large numbers of casualties requiring treatment when combat was intense, the frequently collapsed state of the wounded man's veins, the poor physical facilities, and the inexperience of the nonprofessional personnel who gave the treatment. It was therefore the rule to give the injection on the battlefield intramuscularly (not subcutaneously) and to follow it by massage. The injection was made low enough on the extremity to permit the placing of a tourniquet above it to slow down the absorption rate if signs of morphine poisoning should develop. The site of the injection, the time it was given, and the size of the dose were recorded on the wounded man's emergency medical tag.

3. Morphine was not administered in the field to a patient who would be required to walk back to the battalion aid station, nor was it administered at the aid station to a man who would be evacuated to the rear at once as walking wounded. Its use under these circumstances was extremely dangerous. The man might become confused, lie down along the evacuation route, go to sleep, and suffer serious exposure or other untoward consequences. Another reason for withholding morphine from walking wounded was the accumulated evidence that nausea following its use was apt to be much more severe in ambulatory patients than in patients at rest in the recumbent position.

4. It was constantly emphasized to both medical officers and corpsmen that the only justifiable use for morphine was the relief of severe pain. Codeine or aspirin was to be used for mild degrees of pain.

5. In the absence of respiratory depression, morphine could be given in small doses to patients with head or chest wounds.

6. The routine use of morphine was avoided, unless it was required for pain, in the pre-anesthetic medication of seriously wounded patients, in whom anesthesia was usually easy to induce (p. 76).

7. The contraindications for the use of morphine were repeatedly emphasized. It was not to be employed for a sedative effect in nervous, manic, or hysterical patients. It was not to be used to allay fear, to promote sleep, or to control restlessness associated with hemorrhage. It was to be used in these circumstances only if pain was present. Otherwise, phenobarbital or pentobarbital sodium or paraldehyde, all of which were available, met the needs of the patient better than morphine. When pain was present in these conditions, the combination of small doses of morphine and a barbiturate often accomplished better results than large doses of either agent alone.


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Morphine was absolutely contraindicated in patients in shock unless, as was highly unusual, severe pain was also present. The respiratory depression and the increased fluid loss in vomitus and sweat made its use in shock particularly undesirable. Morphine was used with great caution, if at all, in minor degrees of anoxia, such as were present in circulatory impairment. It was not used when the respiration was impaired by pneumothorax, hemothorax, or pleural effusion. It was not used when there was a mechanical obstruction of the airway or when a central depression existed. It was recognized as dangerous in hypothyroid patients or in those with low metabolism from other causes. Finally, it was used with great caution, if at all, in patients with liver disease, such as infectious hepatitis, since it is largely destroyed in the liver.

Relief of pain by other means-Throughout the war, it was necessary to emphasize repeatedly to medical officers and corpsmen that morphine is not the only means of relieving pain. Regional nerve block, for instance, was sometimes useful, particularly in wounds of the chest. Either intercostal or paravertebral block controlled the pain of these injuries quickly and even dramatically, and, at the same time, by making it possible for the patient to breathe normally, this measure helped to restore pulmonary ventilation to normal.

Adequate support of the wound was another simple method of relieving pain. Swelling of the lower leg and foot usually occurred rapidly after fractures of the long bones of the extremity and was often extremely painful if the limb was left unsupported. Adequate immobilization of the wounded part whenever a skeletal injury was known or suspected to exist not only relieved pain but also prevented further local damage and militated against shock. Needless suffering could often be eliminated, without drugs, simply by unlacing and slitting the shoe in fractures of bones of the extremities.

The effectiveness of barbiturate administration, without morphine, is shown in the following case history:

Case report.-A husky 19-year-old soldier was brought into a forward hospital on the Anzio beachhead 5 hours after injury by a mortar shell. He had a wound near the vertebral column, which looked as if it had been made with a meat cleaver, through all the ribs from the 5th through the 12th. He was cyanotic and had lost a great deal of blood. The hemoglobin was 9.5 gm. percent, and the blood was not yet completely diluted. The patient was obsessed with the idea that he was lying on his rifle. He complained bitterly of pain and struggled constantly to get off the litter; three attendants were required to hold him on it. He appeared to be wild from pain, and his wound supported the idea, though examination in any adequate sense was impossible.

The patient had had no morphine for at least 4 hours, but it was decided, instead of giving him more, to give him 150 mg. (gr. 2) of Sodium Amytal by vein. Almost immediately after it was administered, he quieted down and went to sleep. His color improved strikingly, probably, at least in part, because the nasal oxygen tube, which he had repeatedly pulled out, could now be kept in place. His systolic blood pressure also rose from 60 to 80 mm. Hg. Before the barbiturate was given, all who saw him agreed that his condition was rapidly deteriorating. He began to improve as soon as he received it. The dose given could not possibly have controlled pain, and it seemed reasonable to assume that his manic state was not due to pain.


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The patient could be roused, but he did not move of his own volition until he was taken to the operating room an hour later. In the meantime, a full examination had revealed that eight ribs had been cut in two. He had also sustained an open pneumothorax, lacerations of the lower lobe of the lung from the fractured costal end, and a laceration of the diaphragm. Catheterization, which had previously been impossible, revealed grossly bloody urine, which was found at operation to be due to a wound of the kidney.

Sodium Amytal was given to this patient, and to others treated in the same period, not from choice but because it was the only barbiturate then available. Pentobarbital sodium would have been used if it had been at hand. The small dosage of barbiturate employed in this case should be emphasized. Depleted, bled-out men, in shock, appeared extraordinarily sensitive to these agents, and the usual rule was that a single dose of 60 mg. (gr. 1) was the maximum amount permitted at any single injection.

THIRST

Three factors were usually of major importance in the suffering experienced by wounded men; namely, actual pain, mental distress, and thirst. Pain and mental distress were commonly encountered in men in good general condition, who were not in shock. In well-established traumatic shock, such suffering as was experienced was usually not from wounds or from anxiety, but from thirst. This was borne out by the men who were investigated from the standpoint of pain. They were not in shock, and they did not complain to any extent of thirst, of which men in shock usually complained bitterly.

It was not possible, of course, to alleviate thirst by oral administration of fluids in patients soon to be anesthetized. Its correction required restoration of the depleted blood volume, which could best be achieved by intravenous fluid therapy. While the fluid balance was thus being restored, the patient's lips were moistened frequently, and he was permitted to rinse out his mouth. In view of the amount of suffering which can be caused by thirst, it is remarkable that so little attention has been paid to it and to measures for relieving it.

PSYCHOLOGIC PREPARATION FOR OPERATION4

A consideration of certain psychic and emotional factors may throw some light upon the relatively small incidence of severe pain after wounding, as evident in the investigation conducted in the Mediterranean theater. The psychologic preparation for operation was quite as important as the physical preparation, and it is unfortunate that under the stress of combat conditions less attention was paid to it than it should have received.

Most wounded soldiers were young, and their reactions were correspondingly immature. The natural emotional instability of youth had been exaggerated by the harrowing experiences they had undergone. They had suddenly been released by their wounds from an exceedingly dangerous environment filled with fatigue, discomfort, fear, anxiety, and real danger of death.

4The wide experiences of Chaplain (Maj.) M. I. English and Maj. Douglas Kelling, MC, were drawn upon for this section.


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Many men in the confusion of the first hours after wounding became euphoric. Euphoria was probably more often an early postoperative manifestation, but it was by no means unusual to observe it in the preoperative ward. It was probably based on the overwhelming realization that, no matter what happened in the future, the war was suddenly over for this particular wounded man. His wound, in effect, had furnished him with a ticket to the safety of the hospital. With that thought, he overcompensated and became euphoric, with the further result that this emotional release blocked the pain which he might otherwise have felt. If there are other, more valid, explanations for the absence of pain in the study conducted in Italy, they did not become apparent.

The early euphoric reaction was often followed by profound depression. Psychiatrists repeatedly commented on this sequence, which was particularly notable in men who required amputation.

Before wounding, as has just been mentioned, the soldier had lived under circumstances of anxiety and emotional stress. He had been grieved by the wounding and death of friends. He was naturally fearful for his own safety. These emotions were likely to be exaggerated by the sights and sounds of prolonged combat, coupled with the physical discomforts of exposure to bad weather, inadequate food and fluid intake, loss of sleep, and exhaustion, as well as pain. Then, in addition to these considerations, the wounded man suddenly had to face the consequences of his own wound: If his arm was injured, would he lose it? If there was blood about the genitals, would he become impotent? This was a possibility about which there was always great anxiety. Would he lose his sight? Would he be disfigured? Would the chest wound or the abdominal wound he had sustained kill him?

This inner turmoil was manifested in various ways. Sometimes the man lay quietly, seemingly asleep, until a casual question brought out, in a rush of words, the indications of great mental stress. Other men showed their turmoil by restlessness or, occasionally, by manic behavior. Patients who were described as writhing in pain and who had been given large doses of morphine were sometimes found to be suffering from restlessness caused by cerebral anoxia, or from excitement caused by fear and apprehension, which could be overcome by sedation with barbiturates. Morphine was never indicated in these circumstances.

Psychiatrists were always in too short supply and were too much occupied with other matters to participate very often in the preparation of the wounded man for surgery. Psychologic preparation for operation therefore had to be the concern of other members of the medical staff and the chaplain. Medical officers carried heavy responsibilities, and in their involvement in them, they were sometimes inclined to disregard mental and emotional considerations in the wounded men under their care. It is unlikely that any deaths occurred as a result, but only the future will reveal what effect disregard of these considerations will have on these men's later lives. In any preoperative ward, thoughtful discussion of their condition with wounded men showed how important these


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considerations were and how much needless suffering was caused when they were ignored.

The surgeon's first approach to the wounded patient was the most important. Ideally, he represented the trusted family physician. He was cheerful but never casual. His confidence in his own ability, which could further be built up by the chaplain, was transferred to the patient.

Consultations were always avoided in the patient's presence; they were likely to make him think he was worse off than he really was. His questions were answered carefully. Hope was held out in all correctible lesions. If the lesion was not correctible, the man was told frankly that he might have to lose an arm or a leg. He was assured that everything possible would be done to save the limb, and it was stressed that many men who had undergone similar experiences had been able to live normal, useful lives afterward. Whenever possible, the patient who needed an amputation was told of it before operation; failure to do so was likely to lead to lack of confidence in his future care.

Certain uncorrectible lesions, such as great facial disfigurement, loss of the genitalia, and paraplegia, were difficult to discuss. If the outcome could not be foretold, it was usually best to assure the man that everything possible would be done for him. The proper psychologic management of patients in this group presented a fruitful field for study, which was not gone into during World War II.

Neglect of these emotional problems also had military implications. The patient's permanent outlook on his Army duties might be powerfully and lastingly influenced by it. The casual, lighthearted statement by a medical officer that the patient, now that he was wounded, could go home, could do untold damage if it later proved untrue. It might be impossible, in fact, to reestablish in the healed patient the qualities of a good combat soldier. If a patient's condition was called exhaustion in his hearing, a good response to treatment was likely to be obtained. If it was called shellshock, he was likely to be incurable. The early hours after wounding were thus important for establishing in the patient a point of view that would facilitate his early return to duty.

The chaplain-The commanding officer or the medical officer directly in charge of a wounded man was often inclined to appraise the value of the chaplain in terms of his own need, or lack of need, for religious support, rather than in terms of what the man himself might want. A fair minority of seriously wounded men were not at ease mentally until they had received spiritual attention. They suffered without it. It was an error for the medical officer to take the position that there was nothing the chaplain could do for a wounded man that a good physician could not accomplish. It was frequently observed, in fact, that the physician who assumed that he was good at handling such matters was actually very bad at them.

The enlisted man, in the combat zone, at least, was often more religious than might be expected. Even if he had grown away from his religion through carelessness, he, like the man who had continued to follow his religion, had confidence in the help the chaplain could give him, and he wanted it in this


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crisis. Medical officers presented a different problem. Members of this group sometimes actively rejected religion for intellectual reasons, or felt superior to it on grounds of logic, or were merely indifferent. The best medical officers, however, were the ones who recognized in an able chaplain an intelligence equal to their own and who acted on the assumption that he had something to offer the wounded man, even if they could not put into words just what it was.

The chaplain who cared properly for the wounded needed a great deal of understanding and sympathy. He had to grasp the fact that the soldier had been torn from his familiar life and thrown into a strange milieu, where old standards of conduct were ignored or were deliberately escaped. Animal spirits might have led him into adventures that his early training and standards had taught him were wrong. Then he was wounded and suddenly faced with the possibility of death. He was frightened and spiritually confused, and the chaplain who could deal with his feelings of guilt and who could help him to acquire serenity was heartily welcomed.

It was essential, of course, that the chaplain be brought into the case matter of factly. It was a serious error to project religious care abruptly upon the wounded man, no matter what his beliefs. Invariably this mode of approach convinced him of the gravity of his wound, whether or not that was true. On the other hand, the presence of the chaplain was essential to wounded men whose religious faiths embodied a ritual of departure. To men of these beliefs, the administration of the Last Sacraments was not alarming. Experienced chaplains and experienced psychiatrists alike insisted that it was sometimes desirable to tell a wounded man that he was going to die. Even medical officers who did not share his religious beliefs often saw anguished hope give place to tranquillity when once the wounded man knew that for him the end was not far away.

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