History

The Battalion Surgeon as Psychiatrist

Major Raymond Sobel (ref 9)
Medical Corps, Army of the United States

The surgeon of an infantry battalion in combat must combine the skills of an auto mechanic, chaplain, platoon leader, engineer, military policeman, and doctor. The health and hygiene of the battalion and the heavy burden of conserving its fighting strength rest on him. Every man who leaves the unit for other than tactical or administrative reasons passes through his aid station. With the battalion commander he is responsible for maintaining a sufficient number of fighting men on the line. He is called upon to plan routes of evacuation, construct litter trails, and command detachments.

Although the large number of men returned to the line by the battalion surgeon and the contribution he makes toward maintaining the morale and fighting spirit of the infantryman do not appear in the record, the evacuation rate of a regiment directly reflects the medical discipline of its battalion surgeons. If the surgeon is too lenient in his evacuation policy many men who need only reassurance to remain on the line are lost to the battalion. If he is too harsh and considers all anxiety a manifestation of cowardice, the AWOL rate will mount.

How much psychiatry does the battalion surgeon have occasion to practice? In rest periods psychosomatic complaints, particularly gastric disturbances, account for about one-half of those reporting on sick call, according to the estimate of eight battalion surgeons of at least 6 months of combat experience. Failure to recognize the true nature of these cases results in loss of manpower for the battalion and loss of prestige for the surgeon. Men evacuated for minor psychosomatic complaints tend to remain in hospitals for long periods, only to return with a "reclassification complex, "despite negative laboratory and clinical findings.

In combat relatively few psychosomatic patients were evacuated and a large number of battle neuroses, resulting from the tactical situation, lack of confidence in command, climatic conditions, and a host of other factors, were seen. Of all the men entering battalion aid stations in combat, it was estimated that 40 to 75 percent, inclusive of

(ref 9) Formerly division psychiatrist, 34th Infantry Division.

men wounded in action, presented behavior problems of one kind or another. This fact was little known outside the infantry battalion, for only about one in five was evacuated from the aid station. If, however, the battalion surgeon was over lenient, a large number might arrive at the clearing station. One instance was seen in the battles of the Volturno River, when over 50 cases of "exhaustion" were evacuated from one battalion in 2 days. Every battalion surgeon at some time forestalled panics by giving reassurance and exercising authority. In light combat, psychiatric cases made up a large proportion of the patients seen. In heavier combat, when men representing borderline cases were busily engaged in attack or counterattack and could not return to the aid station until the technical situation was more stable, such cases were seen less frequently.

In combat one of the surgeon`s main tasks was screening psychiatric casualties. As a rule he had little time to spend with any one case, and he learned to distinguish at a glance the incapacitated soldier from the one who was still effective. Treatment forward of the division clearing station was most effective. Experience proved that the transition from the battalion area to the clearing station produced resistance to treatment, that good results were more easily produced at the battalion level than farther to the rear, and that the rate of return to duty diminished with successive echelons of treatment. At the battalion level the psychiatric difficulties commonly seen were anxiety states, hysterias, malingering, and constitutional inadequacies. Psychotic men were rarely seen and when seen were quickly recognized and evacuated.

The anxiety states seen at the battalion level differed little from those encountered in the rear, except that the patterns showed a startling similarity at this early stage, when the neurosis was amorphous and unfixed. Coarse tremor, with repeated jerking motions, was common and might easily be overvalued by the surgeon. Four signs were found most reliable in determining whether the soldier should be returned to duty: his degree of accessibility, his degree of physical fatigue, his willingness or unwillingness to return, and the tactical situation. If the soldier was uncommunicative, withdrawn, and seclusive, the chances of returning him to effective duty were unfavorable. The more accessible he was, the better was his response to reassurance and suggestion. The greater the soldier`s physical fatigue, the greater was the possibility of returning him quickly to the line. It was astonishing how rapidly a rifleman recuperated when physical fatigue played the preponderant role in his anxiety state. Paradoxically, these soldiers who were most willing to return to their company were often most ill, while those who said flatly that they

could not "take it`" and showed no objective symptoms of anxiety were much better handled in battalion zone than in an evacuation hospital. With respect to the tactical situation, it was not difficult to return a soldier with a mild anxiety state to his company if it was known that he would be in reserve the next day. True concussion, as described in the literature, was rarely seen; most purported cases proved to be anxiety states. It is well to ask every man who reported at the aid station with a history of a near miss or of being blown up by a shell whether he was actually unconscious or merely dazed. All soldiers with "concussions" that showed no signs of organic injury, e.g., wounds, perforated eardrums, or hemoptysis, or of severe anxiety should be retained and treated at the aid station.

Hysterias present no great problem at this level. The more striking symptoms usually developed farther to the rear. Gastrointestinal symptoms, usually attributed to C or K rations and, therefore, given little attention, and mild pareses of the legs, called "fox hole bends" or "fox hole legs," were the most frequent complaints. The infantryman`s insight into the part emotion played in the development of these symptoms was fairly acute.

Malingering. The volitional element in psychosomatic disease must be evaluated subjectively, but it is unlikely that the battalion surgeon will miss the true malingerer. The simulator is seldom seen in heavy combat. He is usually AWOL. The tendency of all soldiers to try out new medical officers should be anticipated and circumvented.

Constitutional inadequacies. Men of poor moral fiber constitute one of the main problems of the line officer and the battalion surgeon. Such men, in total disregard of other soldiers on the line, would coolly announce to the surgeon that they could not "take it any more" or were "too nervous to stand all them shells." Because of insufficient time for examination, this type of soldier was often evacuated. It must be remembered that in combat most men have anxiety. The level at which it becomes incapacitating, not its mere presence, is the criterion for evacuation. The best way of dealing with such men is to adopt a standard procedure prohibiting a soldier from reporting to the medical officer without the explicit permission of a line officer or the first sergeant. This measure prevents such men from leaving the line in large numbers in the hope that the battalion surgeon will evacuate them. Usually they will not argue long when told succinctly that they must return to their companies without delay.

Criteria for evacuation. There is no set rule as to which psychiatric cases should be retained and treated at the forward aid station and which should be evacuated. Practice showed be governed in part by the tactical situation. In a rapidly moving advance an aid station

may change its location three to five times in 24hours. In other situations it may remain stabilized for 3 or 4 weeks. The length of time available to hold patients, therefore, determines the amount and scope of treatment that can be given at the station. In general, however, the psychiatric cases that must be evacuated as soon as possible are the psychoses, the severe anxiety states manifested by panic and intense emotional instability, and severe manifestations of hysteria, such paralysis, fugues, or complete amnesia. A written note from the company commander, describing the soldier`s behavior on the line and requesting evacuation, is often an aid to decision. The battalion surgeon must, however, be wary lest this device be abused and medical channels be used to rid the company of psychopaths and constitutional inadequates who are command problems. New and inexperienced line officers should be cautioned against in discriminate referrals of this type.

BATTALION TREATMENT OF PSYCHIATRIC CASUALTIES

Treatment at the forward aid station must be short. The battalion surgeon must avoid using such terms as "shell-shock"` and "crack-up," or implying that the soldier is mentally ill. A quick decision should be made as to which patients are to be evacuated without delay. Such patients should be tagged, sedated if necessary, and put in a safe place to await evacuation. All soldiers who are to be evacuated should be told so immediately and reassured that they will get rest and sleep in the rear. No mention of reclassification or reassignment should be made. The impression should be given that these men will sometime rejoin the battalion. It is not always possible to separate the patients to be evacuated from those to be treated, but it should be done whenever possible. After screening those who obviously require treatment at the clearing station, the battalion surgeon must take care of those to be held in the battalion area.

The cornerstones of forward treatment in combat are sedation, explanation and reassurance, suggestion, and exhortation.

Sedation. A quick-acting barbiturate is imperative. It is useless to use phenobarbital or any other slow-acting drug when an immediate effect is necessary. All patients should be given 0.2 gm. of sodium amytal immediately on arrival at the aid station to lower irritability and distractibility. This initial dose never produces somnolence in a tense and apprehensive soldier, but considerably reduces his tension. When the battalion surgeon calls him in for questioning he is usually more relaxed and reassurance is more likely to be accepted. Whether prolonged sedation can begiven depends on the ability to hold the patient, and thus, in turn, on the tactical situation. Large initial doses should be avoided, and no more than 0.4

gm. should be given at one time. Soldiers who are to be evacuated should be sedated just before evacuation, but reassurance of going to the rear will in most instances alleviate anxiety. If evacuation is held back by the lack of transportation or shelling of routes, most patients will require 0.2 gm. at 4-hour intervals. Good judgment must be used. No man should be made a litter patient unnecessarily. If return to duty within 6 to 8 hours is contemplated, the dosage must be lessened accordingly. All medication should be oral. Morphine or intravenous sodium amytal are contraindicated, for they make a litter patient of an otherwise ambulatory patient. Oversedation also delays treatment by the division psychiatrist, who must wait until the patient has recovered from the effects of the drug.

Explanation and reassurance. When the ground has been prepared by preliminary sedation and brief inquiry into the symptomatology, the patient should be assured that he has a common type of transient emotional reaction. When there is mild anxiety, reassurance should be confined to saying that the symptoms are a manifestation of fear, that everyone has fear, and that fear is a normal thing in combat. In certain cases it is necessary to explain to the soldier that his symptoms are slight and that there are many men still on the line who are as nervous as he, or more so. If the battalion surgeon is respected and has gained a reputation for fairness, this type of reassurance is successful.

Suggestion. Evacuation should never be mentioned for men destined to return to their companies. The soldiers should continually be assured that his tenseness will pass away and that he will be able to return to his unit after a few hours of sleep. This type of suggestion should be reinforced at frequent intervals, depending on the holding time. As far as possible, the aid station personnel should participate in such suggestion.

Exhortation. Exhortation ranges from an appeal to the soldier concerning the necessity of aiding his comrades on the line to a form of plain talk in which he is asked whether he has actually gone so far as to abandon them. The latter measure should be used sparingly and judiciously, for it may exacerbate an anxiety state. As in all psychotherapy, common sense and judgment are the most important tools at hand.

When these methods were used about 50 percent of all men presenting themselves for relief of anxiety were returned to duty within 1 to 6 hours.

THE PROBLEM OF 24- AND 48-HOUR TREATMENT

When obviously unsalvageable soldiers have been evacuated and those who require brief treatment have been returned to duty, a fair number will remain who can be returned after 24 to 48 hours of

sedation and rest. The treatment given will depend on the frequency with which the aid station makes tactical moves. If it is known that the station will not move for 24 hours or more, a small number of soldiers, after sedation with 0.4gm. of amytal, can be rested in the vicinity of the station. A house or a good defilade will provide space for rest under supervision when there is not room in the station. Heavier sedation can be used when it is known that no advance will be made for 48 hours. It is impracticable to attempt to hold sedated soldiers when moves are frequent. If the aid station is moving continuously, several alternatives are possible: rest at a rear aid station, duty in a zone of less anxiety, or, as a last resort, rest in the kitchen area.

The best treatment, rest at a rear aid station, where control and supervision are available and the soldier`s return to his outfit is assured, can seldom be arranged. When a soldier is sent to a rear aid station, a note should accompany him explicitly stating the period of his stay. No mention should be made of evacuation. Each man should report to the forward aid station before returning to duty. Moving a soldier one zone to the rear for a short time often relieves anxiety. The average rifleman feels that the area in which his company command post is located is much safer than the one where he is fighting, since it is to the rear. This type of thought exists throughout a division, and although any particular zone may not be safer at the moment than one farther forward, it nevertheless symbolizes a zone of lesser anxiety. The zones correspond to the successive echelons of command, beginning with the patrol and continuing with the company command post, the battalion command post, and so on back to the division rear echelon. Soldiers with mild anxiety taken out of the outposts and placed in the company command post as runners for a 24-hour period are content with such duty. Though in the long run it may be more dangerous than that of rifleman, the soldier feels safer, since he is one step back to the rear. Actually, the transition is one of attitude. The soldier has gone back one "anxiety zone." Because of this attitude, men from battalion headquarters are more difficult to treat in the aid station than are men from the rifle companies, for they have not been removed from their customary zone of anxiety.

Men should be rested in the kitchen area only as a last resort and then only when strict control of the area is assured. Unless there is a responsible noncommissioned officer detailed to return patients to duty after a specified time, the kitchen should never be used for rest and sedation. Without such control it becomes a straggler depot. After a soldier has been treated for 24 to 48 hours it is imperative that he be seen again before he returns to the lines. Strong suggestion of

the type already described should be given, and the soldier should then be returned to duty in the company of another, since loitering on the route back to their companies is usual in such cases, particularly if there is shelling nearby.

GENERAL FACTORS

Repeaters are given longer rest periods, or, if rest periods are unavailable, are evacuated. In some divisions a reserve company is kept for such men, who are sent back to this company for periods ranging from 3 to 14 days. Since the company isunder the command of an infantry officer, return to duty is facilitated. No man should be evacuated directly from the reserve company. He should first have a trial on duty and then, if evacuation proves necessary, he should be cleared through the battalion surgeon. Unless such precautions are taken medical control is lost and the reserve company becomes a dumping ground for soldiers who would ordinarily be returned to combat. During combat, psychosomatic complaints are usually ignored by the battalion surgeon, particularly during difficult attacks or advances. The soldier must be incapacitated by his illness to be evacuated. Men presenting themselves with mild illnesses are reassured briefly and told that they have no serious disease. Most infantrymen learn that they must "sweat out" mild illnesses during combat. One, therefore, sees a flood of patients with psychosomatic complaints on sick call following relief from the line. Most of these men have been carried along on promises of one sort or another during combat. If their illness is sufficiently severe they are evacuated immediately on withdrawal from battle.

To make these various methods of treatment effective there must be close cooperation between the battalion surgeon and the line officer. When there is no give and take between the medical officer and the company commanders the battalion surgeon finds himself handicapped on all sides. One of the first lessons learned by the battalion surgeon is that line officers have only a limited number of easy assignments available for the weaker members of their companies, and for that reason often refer a soldier for evacuation on the ground of psychoneurosis when the difficulty is actually constitutional inadequacy or mental deficiency and should be handled administratively. It is well to have a good rapport in regard to such cases. Company commanders should be instructed not to send a psychiatric battle casualty directly to the kitchen, reserve company, or rear aid station before he has been seen by the medical officer. Otherwise the battalion surgeon will find a large number of men bypassing his aid station who would ordinarily have been returned to the line. In one division such an outcome was prevented by a strict rule that no

patient would be accepted at the clearing station with a diagnosis of" exhaustion" unless the tag was personally signed by the surgeon of his battalion. Some regimental surgeons required all patients tagged "exhaustion" tobe sent through the regimental aid station.

Neither the battalion aid station nor the surgeon is protected from flying shell fragments by the Geneva Convention, nor are the medical officer and his personnel immune to physical and mental strain in combat. After two weeks of grueling combat the battalion surgeon himself is likely to develop some degree of anxiety. His state is usually reflected in one of two ways: either the exhaustion rate goes sky-high or it ceases altogether. In the first instance the medical officer has identified himself with the battle neurotic and says to himself, in effect, "If I can’t get out, at least you can." This type of symbolic self-evacuation accounted for one occasion when over 50 cases were evacuated from a battalion in two days of light defensive combat. The opposite reaction, causing the exhaustion rate to cease altogether, is that of overreaction, symbolized by the thought, "If I can’t get out, you can`t either." The only answer to this problem lies in frequently rotating battalion surgeons to collecting and clearing companies.

THE BATTALION SURGEON IN BIVOUAC

Following the relief and withdrawal of an infantry division from the line, the battalion surgeon is confronted with a host of problems. The first and most important is psychosomatic disease. Many soldiers are relieved of their symptoms by the cessation of combat, but others continue to suffer from various aches and pains that are obviously not organic. Treatment varies greatly, but the single most important factor in therapy at the battalion level is a thorough history and physical examination. Interest in the condition of the individual man will in itself improve many of the milder cases. When a complete examination is given, the soldier is satisfied that the surgeon`s statement is correct. The infantryman resents cursory physical examinations and histories and the routine administration of treatment. He is usually quite willing to accept the fact that his ailments have an emotional basis if he feels that his case has been adequately investigated.

The more severe psychoneurotic manifestations should be referred to the division psychiatrist, but every infantry medical officer should familiarize himself with methods of explaining the emotional nature of symptom production. Such phrases as, "It is all in your head," and "This is all in your imagination, "should never be used. They prevent cure and amelioration of symptoms and antagonize the patient as well. Sick call can make or break a soldier`s morale.

While in bivouac the battalion is busily engaged in reorganization, training programs, and the assimilation of replacements. The battalion surgeon should playa role in the training program. Particular attention should be given to new replacements without combat experience. Short talks to these men concerning the manifestations of fear and the means of controlling them will prove of great value when the unit returns to combat.. The fact that every man is afraid and develops "the shakes" at one time or another should be stressed, along with the normality of anxiety in battle. Sick call can be greatly reduced if the men are informed of the nature of psychosomatic disease in a rational, lucid, nontechnical lecture. As a rule they will have already experienced" battle gastritis" and recognized it as emotionally based, and as a result they can be readily educated regarding other such manifestations.

Another important phase of the battalion surgeon’s work in bivouac is the instruction of company officers in the handling of fear and panic reactions in combat. The fact that psychoneurosis depletes company strength often brings these officers to conclude that all psychoneurotic soldiers are "yellow and cowards. "Instruction in the etiology and symptomatology of the anxiety state, given at informal gatherings, in nontechnical terms, will correct such misconceptions and assure some preliminary screening by those able to observe the soldier on the line, and so will materially reduce the number of constitutionally inadequate soldiers reaching the aid station in battle.

THE ARTILLERY AND ENGINEER BATTALION SURGEON

The surgeon of an artillery or engineer battalion has a large daily sick call, since his aid station is easily available to the men. In engineer companies a tour is usually conducted during combat, and sick call is held at fairly specific hours of the day. The surgeon, therefore, has more time to spend with each patient, psychosomatic disease can be investigated more fully, and more time can be spent with those suffering from mild anxiety. The mildly neurotic patients may be treated at the service battery or company of the battalion under supervision of an aid man. The problem of the moving aid station hardly presents itself. Severe traumatic neuroses are relatively rare, despite the many casualties suffered in counterbattery fire. The essentials of treatment are the same as for the infantry battalion.

SUMMARY

In the prevention and treatment of the psychiatric casualties of combat the battalion surgeon plays a crucial role. When the medical discipline of a division is high, the problem of neuropsychiatric disease will be well controlled.