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 theoperating tents of forward hospital installations in Italy. Wounded men who werebrought into the receiving wards in shock and thoroughly chilled all presentedessentially the same appearance and clinical picture on their arrival. Some ofthem, after they had been warmed and had been treated by standard shock therapy,responded to it in the usual manner. Others, however, after receiving exactlythe same kind of treatment, presented profound respiratory depression associatedwith pinpoint pupils, although neither of these signs had been present beforeresuscitation. These men, though they had not had morphine since they enteredthe hospital, were clearly suffering from morphine poisoning. In fact, in theabsence of head injuries, and under the circumstances of combat, it wasimpossible to attribute their condition to any other cause. Alcoholism, chloralhydrate, and the barbiturates, all of which can produce a similar picture, couldbe excluded, for obvious reasons.
This phenomenon had been observed in patients who were burned in the CocoanutGrove disaster in November 1942.1 It had alsobeen recorded in the civilian medical literature before it was observed in theMediterranean Theater of Operations in the fall of 1943.
How frequently the syndrome of morphine poisoning occurred it is not possibleto say. Often it was too severe to be overlooked. Occasionally it was fatal. Onthe other hand, it probably went unrecognized in many instances, because themanifestations were slight or subclinical. When it was serious, it might bemisunderstood, but it could not be ignored. In the first 10 days of November1943, morphine poisoning was recognized in several hospitals. On 11 November, itwas discussed at the regular weekly medical meeting of the Fifth United StatesArmy medical officers. Subsequently it was observed and commented on in all thehospitals in the theater.
A consideration of the circumstances of wounding and resuscitation offered anentirely reasonable explanation of what had happened to these wounded men. Earlyin November 1943, it was cold in the valley of the Volturno, where the fightingwas 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 andchilled 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 furtherexposure in the course of a difficult litter carry to the receiving hospital.The result was impairment of the circulation in the skin and subcutaneoustissues. Sometimes the impairment was slight, but sometimes it amounted toalmost complete cessation of the local circulation.
Under these conditions, it was not likely that the morphine administered as afirst-aid measure on the battlefield would be absorbed. That it was not absorbedwas 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. Asecond, and often a third, injection in the same amount would therefore be givenover a period of hours, each time with no perceptible effect. These wounded menwere often described as "resistant" to morphine. When they were ingood general condition and not in serious shock, an active peripheralcirculation was promptly restored as they warmed up in the hospital, even if noother measure of resuscitation was employed. The restoration of the circulationcaused the rapid, simultaneous absorption of all unabsorbed deposits ofmorphine, sometimes many hours after the injections had been made. If shock waspresent, and resuscitative measures in addition to warming were employed, therestoration of the peripheral circulation often led to dangerously rapidabsorption. Either course of events was likely to be followed by morphinepoisoning.2
It soon became evident that although morphine poisoning wasan increased risk in cold weather, it was equally likely to develop, regardlessof weather, in the presence of surgical shock, hemorrhage, or any othercondition leading to, or associated with, a reduction in the peripheralcirculation. It often became evident during anesthesia, in cases in which it wasnecessary to undertake operation before full resuscitation from shock had beenaccomplished. The chain of events was as follows: Ether stimulated therespiration. Peripheral vasodilatation then occurred. Morphine, which might havebeen injected as long as 8 or 10 hours earlier, was rapidly absorbed. Whenpinpoint pupils and profound respiratory depression developed before thesurgical stage of anesthesia had been reached, induction was greatly prolonged,sometimes taking an hour or more.
Clinical manifestations-Pinpoint pupils and slowrespiration were the first manifestations of morphine poisoning.Respiratory depression led to anoxia, which was followed, in turn, bycirculatory depression. These were the most serious consequences of overdoses ofmorphine, but less severe manifestations were frequent, and even small dosessometimes produced reactions which complicated treatment. A single injection ofmorphine might cause anorexia, nausea, and vomiting, which limited the intake offood 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 morphineeven for brief periods was sometimes followed by severe constipation.
Management-The realization that morphine intoxication might have arather abrupt onset, sometimes many hours after the last injection, wasessential in the diagnosis of morphine poisoning. Unless that fact wasconstantly borne in mind, treatment was likely to be delayed.
The first step in therapy was the application of a tourniquet proximal to thesite of injection, to delay absorption. It was loosened at regular intervals.Body heat was conserved. Then the attention was devoted to the chief aim oftherapy, which was to prevent anoxia. This was best accomplished by theadministration of oxygen, supplemented by artificial respiration, if necessary.Oxygen was preferably given by means of a closed anesthesia apparatus, withcarbon dioxide absorption, accomplished by intermittent pressure on thebreathing bag. Atropine in doses of 1 mg. (gr. 1/60)by vein, combined with ephedrine in doses of 30 mg. (gr. ?), also by vein, wassometimes useful, the latter as a central stimulant and as a support againstfalling blood pressure. Hypertonic glucose solution was used intravenously forits diuretic effect, to hasten the excretion of morphine by the kidneys.
If coma developed, a gastric tube was inserted at once to eliminate the riskof aspiration of gastric contents. Pulmonary complications were guarded againstby frequent changes of position. Supportive treatment was continued until it wasapparent that the excess of morphine administered had been largely destroyed inthe body.
INVESTIGATION OF PAIN IN WOUNDED MEN
The numerous instances of morphine overdosage and poisoning observed in Italyin November 1943, and in the succeeding weeks, suggested that the routineadministration of morphine to wounded men, particularly in large doses, was nota safe procedure. The question also arose whether all wounded men experiencedenough pain to warrant the risk attached to the use of this drug, especially inlarge doses.
To settle this question, a study was made of 225 patients who had sustainedmajor wounds during the prolonged action on the Anzio beachhead and the Venafroand Cassino fronts and, in a few instances, in southern France. The selectionwas as consecutive as the criteria permitted, the objective being to selectpatients with major injuries in certain categories who were clear mentally andwho were not in shock when they were questioned. Ten of the two hundred andtwenty-five men included in the original collection had to be dropped becausethey were unconscious or not clear mentally. A few others who had been in shockwhen they arrived at the hospital were not questioned until their status hadimproved. Included in the 215 patients were 50 with compound fractures of thelong bones, 50 with extensive wounds of the peripheral soft tissues, 50 withpenetrating wounds of the thorax, 50 with penetrating wounds of the abdomen, and15 with penetrating head injuries. In most instances, the
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wounds which formed the basis of selection (table 2) represented only thechief wounds. Most of the patients had multiple injuries.
The incidence of pain in the several categories of injurieswas arrived at by asking the patients, shortly after their arrival at forwardhospitals, several pertinent questions. These questions had been carefullyframed, and great care was taken to see that each patient understood theirmeaning.
The first question was, "As you lie there, are you having anypain?" To it, 69 of the 215 patients (32.1 percent) replied that they feltno 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 tothis 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-acceptedgeneralization that all extensive wounds are associated with severe pain andthat the more extensive the wound, the worse is the pain. If it is possible tospeak of such a subjective experience as pain in exact terms, it might be saidthat the generalization held in only about a quarter of all cases and failedpartly or entirely in the other three quarters.
Patients who admitted to pain of any degree were next asked if they wishedsomething to relieve it. The use of the term "morphine" wasdeliberately avoided. Experience had already shown that it was an unfortunateword to use in front of wounded men, who were likely to form the impression thatif their condition was serious enough for them to need morphine they must,indeed, be quite badly off. A close parallelism naturally existed between thenumber of wounded men who complained of severe pain (51 patients, or 23.7percent 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 215patients (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 showclearly that the routine injection of morphine was not necessary in forwardhospitals.
In a great many of these patients, the striking absence of severe pain, andof any pain, could not be explained either by the amount of morphine received orthe time at which it was given (table 2). Of the 51 who complained of severepain, 5 had had no morphine since they were wounded. The other 46 had had anaverage 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 medicationwhen they were questioned, 32 had had no morphine at all. The other 125 hadreceived 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 thedegree of pain, or its presence or absence, on the basis of the amount ofmorphine given and the time at which it had been injected.
Only 1 of the 15 patients with penetrating wounds of the head complained ofsevere pain, in contrast to 6 of the 50 patients with wounds of the thorax, 12of the 50 with extensive compound fractures of the long bones, and 24 of the 50with penetrating wounds of the abdomen. Although there was little
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TABLE 2.-Analysis of pain sensation in 215freshly wounded patients with major injuries1
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difference in the amount of morphine received by the twogroups of patients, there were four times as many complaints of severe pain inthe group with abdominal injuries as in the group with thoracic injuries.Perhaps the explanation is the spill of blood and intestinal contents into theperitoneal cavity, as well as the role of infection. Be this as it may, thesedata supported the idea that, in forward areas, it was not necessary to givemorphine routinely and that it would be wiser to administer it according to theneeds of the individual patient.
RELIEF OF PAIN
Routine for administration of morphine-It became apparent early in theTunisian campaign that the 30-mg. (gr. ?) amounts of morphine put up inArmy-issue syrettes were too large for many patients, even when only single injections were used. Some observers attributed the difficulties which arose fromoverdosage of morphine and morphine poisoning to the fact that medical aidmen,for the first time in United States Army history, were being permitted toadminister the drug. This was not the general opinion. It was repeatedlyobserved that medical officers were much more likely to be at fault in theovergenerous use of morphine than were medical aidmen.
Throughout the war, there was a tendency in all theaters to overtreat woundedmen with morphine in an endeavor to relieve pain. The situation in Italy beganto improve when the Chief Surgeon, North African Theater of Operations, inDecember 1943, established the rule that morphine usually was not to beadministered in more than ? gr. (half a syrette) single dose.3 In addition, avigorous educational program was begun, and this endeavor, together with anincreasing appreciation of the disastrous possibilities of delayed morphinepoisoning, led to a sharp decline in the excessive use of the drug. It was aboutthis time that the study just described was begun on the Anzio beachhead, and itpromptly became clear that severe pain is much less common than was generallysupposed in severely wounded men and that if morphine is used at all, it is notnecessary to use it in large doses.
Eventually the following routine for the administration of morphine becamefairly well standardized:
1. As a general rule, the amount injected in a single dose did not exceed 15mg. (gr. ?). In patients to be transported by air, in whom respiratorydepression was particularly undesirable, the amount was reduced to 8 or 10 mg.(gr. 1/8 or 1/6). Maximum analgesic effects could be secured withthese dosages, and the undesirable side effects caused by larger doses wereseldom apparent.
2. Subcutaneous or intramuscular injection was employed when a gradual,prolonged effect was sought, but this route was avoided when the peripheralcirculation 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 absorptionmight prove harmful, as in impending shock. When 8 or 10 mg. (gr. 1/8or 1/6) were given by this route, the full effect was achieved withina few minutes, and there was no possibility of delayed absorption. If thedesired results were not obtained by the first injection, a second could begiven, without risk, within 15 or 20 minutes. As a practical matter, it wasalmost never possible to administer morphine intravenously to a wounded man onthe battlefield. Every circumstance conspired to make the continued use ofperipheral injections necessary-the extra time which would be required forvenous puncture, the urgent need for haste in the face of enemy action, thelarge numbers of casualties requiring treatment when combat was intense, thefrequently collapsed state of the wounded man's veins, the poor physicalfacilities, and the inexperience of the nonprofessional personnel who gave thetreatment. It was therefore the rule to give the injection on the battlefieldintramuscularly (not subcutaneously) and to follow it by massage. The injectionwas made low enough on the extremity to permit the placing of a tourniquet aboveit to slow down the absorption rate if signs of morphine poisoning shoulddevelop. The site of the injection, the time it was given, and the size of thedose were recorded on the wounded man's emergency medical tag.
3. Morphine was not administered in the field to a patient who would berequired to walk back to the battalion aid station, nor was it administered atthe aid station to a man who would be evacuated to the rear at once as walkingwounded. Its use under these circumstances was extremely dangerous. The manmight become confused, lie down along the evacuation route, go to sleep, andsuffer serious exposure or other untoward consequences. Another reason forwithholding morphine from walking wounded was the accumulated evidence thatnausea following its use was apt to be much more severe in ambulatory patientsthan in patients at rest in the recumbent position.
4. It was constantly emphasized to both medical officers and corpsmen thatthe only justifiable use for morphine was the relief of severe pain. Codeine oraspirin was to be used for mild degrees of pain.
5. In the absence of respiratory depression, morphine could be given in smalldoses 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 whomanesthesia 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 hystericalpatients. It was not to be used to allay fear, to promote sleep, or to controlrestlessness associated with hemorrhage. It was to be used in thesecircumstances only if pain was present. Otherwise, phenobarbital orpentobarbital sodium or paraldehyde, all of which were available, met the needsof the patient better than morphine. When pain was present in these conditions,the combination of small doses of morphine and a barbiturate often accomplishedbetter results than large doses of either agent alone.
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Morphine was absolutely contraindicated in patients in shock unless, as washighly unusual, severe pain was also present. The respiratory depression and theincreased fluid loss in vomitus and sweat made its use in shock particularlyundesirable. Morphine was used with great caution, if at all, in minor degreesof anoxia, such as were present in circulatory impairment. It was not used whenthe respiration was impaired by pneumothorax, hemothorax, or pleural effusion.It was not used when there was a mechanical obstruction of the airway or when acentral depression existed. It was recognized as dangerous in hypothyroidpatients or in those with low metabolism from other causes. Finally, it was usedwith great caution, if at all, in patients with liver disease, such asinfectious hepatitis, since it is largely destroyed in the liver.
Relief of pain by other means-Throughout the war, it wasnecessary to emphasize repeatedly to medical officers and corpsmen that morphineis not the only means of relieving pain. Regional nerve block, for instance, wassometimes useful, particularly in wounds of the chest. Either intercostal orparavertebral block controlled the pain of these injuries quickly and evendramatically, and, at the same time, by making it possible for the patient tobreathe normally, this measure helped to restore pulmonary ventilation tonormal.
Adequate support of the wound was another simple method ofrelieving pain. Swelling of the lower leg and foot usually occurred rapidlyafter fractures of the long bones of the extremity and was often extremelypainful if the limb was left unsupported. Adequate immobilization of the woundedpart whenever a skeletal injury was known or suspected to exist not onlyrelieved pain but also prevented further local damage and militated againstshock. Needless suffering could often be eliminated, without drugs, simply byunlacing and slitting the shoe in fractures of bones of the extremities.
The effectiveness of barbiturate administration, without morphine, is shownin the following case history:
Case report.-A husky 19-year-old soldier was brought into a forwardhospital on the Anzio beachhead 5 hours after injury by a mortar shell. He had awound near the vertebral column, which looked as if it had been made with a meatcleaver, through all the ribs from the 5th through the 12th. He was cyanotic andhad lost a great deal of blood. The hemoglobin was 9.5 gm. percent, and the blood was not yet completelydiluted. The patient was obsessed with the idea that he was lying on his rifle. He complained bitterly of painand struggled constantly to get off the litter; three attendants were requiredto hold him on it. He appeared to be wild from pain, and his wound supported theidea, though examination in any adequate sense was impossible.
The patient had had no morphine for at least 4 hours, but itwas decided, instead of giving him more, to give him 150 mg. (gr. 2?) of SodiumAmytal by vein. Almost immediately after it was administered, he quieted downand 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 bekept 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 wasrapidly deteriorating. He began to improve as soon as he received it. The dosegiven could not possibly have controlled pain, and it seemed reasonable toassume 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 hewas taken to the operating room an hour later. In the meantime, a fullexamination had revealed that eight ribs had been cut in two. He had alsosustained an open pneumothorax, lacerations of the lower lobe of the lung fromthe fractured costal end, and a laceration of the diaphragm. Catheterization,which had previously been impossible, revealed grossly bloody urine, which wasfound at operation to be due to a wound of the kidney.
Sodium Amytal was given to this patient, and to otherstreated in the same period, not from choice but because it was the onlybarbiturate then available. Pentobarbital sodium would have been used if it hadbeen at hand. The small dosage of barbiturate employed in this case should beemphasized. Depleted, bled-out men, in shock, appeared extraordinarily sensitiveto 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 thesuffering experienced by wounded men; namely, actual pain, mental distress, andthirst. Pain and mental distress were commonly encountered in men in goodgeneral 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 thestandpoint of pain. They were not in shock, and they did not complain to anyextent of thirst, of which men in shock usually complained bitterly.
It was not possible, of course, to alleviate thirst by oraladministration of fluids in patients soon to be anesthetized. Its correctionrequired restoration of the depleted blood volume, which could best be achievedby intravenous fluid therapy. While the fluid balance was thus being restored,the patient's lips were moistened frequently, and he was permitted to rinse outhis mouth. In view of the amount of suffering which can be caused by thirst, itis remarkable that so little attention has been paid to it and to measures forrelieving it.
PSYCHOLOGIC PREPARATION FOR OPERATION4
A consideration of certain psychic and emotional factors maythrow some light upon the relatively small incidence of severe pain afterwounding, as evident in the investigation conducted in the Mediterraneantheater. The psychologic preparation for operation was quite as important as thephysical preparation, and it is unfortunate that under the stress of combatconditions less attention was paid to it than it should have received.
Most wounded soldiers were young, and their reactions were correspondinglyimmature. The natural emotional instability of youth had been exaggerated by theharrowing experiences they had undergone. They had suddenly been released bytheir 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. DouglasKelling, MC, were drawn upon for this section.
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Many men in the confusion of the first hours after woundingbecame euphoric. Euphoria was probably more often an early postoperativemanifestation, but it was by no means unusual to observe it in the preoperativeward. It was probably based on the overwhelming realization that, no matter whathappened in the future, the war was suddenly over for this particular woundedman. His wound, in effect, had furnished him with a ticket to the safety of thehospital. With that thought, he overcompensated and became euphoric, with thefurther result that this emotional release blocked the pain which he mightotherwise have felt. If there are other, more valid, explanations for theabsence of pain in the study conducted in Italy, they did not become apparent.
The early euphoric reaction was often followed by profounddepression. Psychiatrists repeatedly commented on this sequence, which wasparticularly notable in men who required amputation.
Before wounding, as has just been mentioned, the soldier had lived undercircumstances of anxiety and emotional stress. He had been grieved by thewounding and death of friends. He was naturally fearful for his own safety.These emotions were likely to be exaggerated by the sights and sounds ofprolonged combat, coupled with the physical discomforts of exposure to badweather, inadequate food and fluid intake, loss of sleep, and exhaustion, aswell as pain. Then, in addition to these considerations, the wounded mansuddenly 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 becomeimpotent? 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 theabdominal wound he had sustained kill him?
This inner turmoil was manifested in various ways. Sometimes the man layquietly, seemingly asleep, until a casual question brought out, in a rush ofwords, the indications of great mental stress. Other men showed their turmoil byrestlessness or, occasionally, by manic behavior. Patients who were described aswrithing in pain and who had been given large doses of morphine were sometimesfound to be suffering from restlessness caused by cerebral anoxia, or fromexcitement caused by fear and apprehension, which could be overcome by sedationwith barbiturates. Morphine was never indicated in these circumstances.
Psychiatrists were always in too short supply and were too much occupied withother matters to participate very often in the preparation of the wounded manfor surgery. Psychologic preparation for operation therefore had to be theconcern of other members of the medical staff and the chaplain. Medical officerscarried heavy responsibilities, and in their involvement in them, they weresometimes inclined to disregard mental and emotional considerations in thewounded men under their care. It is unlikely that any deaths occurred as aresult, but only the future will reveal what effect disregard of theseconsiderations will have on these men's later lives. In any preoperative ward,thoughtful discussion of their condition with wounded men showed how importantthese
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considerations were and how much needless suffering was caused when they wereignored.
The surgeon's first approach to the wounded patient was the most important.Ideally, he represented the trusted family physician. He was cheerful but nevercasual. His confidence in his own ability, which could further be built up bythe chaplain, was transferred to the patient.
Consultations were always avoided in the patient's presence; they were likelyto make him think he was worse off than he really was. His questions wereanswered carefully. Hope was held out in all correctible lesions. If the lesionwas not correctible, the man was told frankly that he might have to lose an armor a leg. He was assured that everything possible would be done to save thelimb, and it was stressed that many men who had undergone similar experienceshad been able to live normal, useful lives afterward. Whenever possible, thepatient who needed an amputation was told of it before operation; failure to doso was likely to lead to lack of confidence in his future care.
Certain uncorrectible lesions, such as great facial disfigurement, loss ofthe genitalia, and paraplegia, were difficult to discuss. If the outcome couldnot be foretold, it was usually best to assure the man that everything possiblewould be done for him. The proper psychologic management of patients in thisgroup presented a fruitful field for study, which was not gone into during WorldWar II.
Neglect of these emotional problems also had military implications. Thepatient's permanent outlook on his Army duties might be powerfully and lastinglyinfluenced by it. The casual, lighthearted statement by a medical officer thatthe patient, now that he was wounded, could go home, could do untold damage ifit later proved untrue. It might be impossible, in fact, to reestablish in thehealed patient the qualities of a good combat soldier. If a patient's conditionwas called exhaustion in his hearing, a good response to treatment was likely tobe obtained. If it was called shellshock, he was likely to be incurable. Theearly hours after wounding were thus important for establishing in the patient apoint of view that would facilitate his early return to duty.
The chaplain-The commanding officer or the medicalofficer directly in charge of a wounded man was often inclined to appraise thevalue of the chaplain in terms of his own need, or lack of need, for religioussupport, rather than in terms of what the man himself might want. A fair minority of seriously woundedmen were not at ease mentally until they had received spiritual attention. Theysuffered without it. It was an error for the medical officer to take theposition that there was nothing the chaplain could do for a wounded man that agood physician could not accomplish. It was frequently observed, in fact, thatthe physician who assumed that he was good at handling such matters was actuallyvery bad at them.
The enlisted man, in the combat zone, at least, was often more religious thanmight be expected. Even if he had grown away from his religion throughcarelessness, he, like the man who had continued to follow his religion, hadconfidence 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 groupsometimes actively rejected religion for intellectual reasons, or felt superiorto it on grounds of logic, or were merely indifferent. The best medicalofficers, however, were the ones who recognized in an able chaplain anintelligence equal to their own and who acted on the assumption that he hadsomething to offer the wounded man, even if they could not put into words justwhat it was.
The chaplain who cared properly for the wounded needed a great deal ofunderstanding and sympathy. He had to grasp the fact that the soldier had beentorn from his familiar life and thrown into a strange milieu, where oldstandards of conduct were ignored or were deliberately escaped. Animal spiritsmight have led him into adventures that his early training and standards hadtaught him were wrong. Then he was wounded and suddenly faced with thepossibility of death. He was frightened and spiritually confused, and thechaplain who could deal with his feelings of guilt and who could help him toacquire serenity was heartily welcomed.
It was essential, of course, that the chaplain be brought into the casematter of factly. It was a serious error to project religious care abruptlyupon the wounded man, no matter what his beliefs. Invariably this mode ofapproach convinced him of the gravity of his wound, whether or not that wastrue. On the other hand, the presence of the chaplain was essential to woundedmen whose religious faiths embodied a ritual of departure. To men of thesebeliefs, the administration of the Last Sacraments was not alarming. Experiencedchaplains and experienced psychiatrists alike insisted that it was sometimesdesirable to tell a wounded man that he was going to die. Even medical officerswho did not share his religious beliefs often saw anguished hope give place totranquillity when once the wounded man knew that for him the end was not faraway.
