 Give him another shot of morphine and take him to the surgical tent. Yes, sir. Put on another dressing. Thank you, sir. You'll be all right. He found him in Farks over his back. I guess they had to pull him up. He can't walk. He can't find a spatula. Take a movie of yourself, soldier. What's your name? Shell shock. Evacuate. But over two months after the break, the variety of neurosis which he exhibits is not an unusual one on the battlefield. Many errors have been made in his case. For one thing, his EMT tag is labeled shell shock. The army choice of term is exhaustion. And this term will be used exclusively for all forms of neurosis in echelons forward of the evacuation hospital. The reason is obvious. Soldiers read their tags, and long involved medical terms serve only to confuse an already disturbed mind. Now, placing yourself in the situation of this medical officer at the clearing station, what would you have done for John Clemens? I don't see what else the officer could have done. There seems no point in keeping a patient like this on the battlefield. Any other comments? Major, we're going to be busy out there with patients who are really shot up, and we won't have time to mucky around with guys like that. Major, I'm a surgeon. It looks to me like this is a job for psychiatrists. That soldier must have been a misfit from the start to break down like that. The medical record shows that the soldier was a healthy, normal individual before he underwent the experience that caused his illness. High school graduate played an end on the football team, had a creditable job in a Pittsburgh steel mill after he left school at the age of 18. In brief, he displays the picture of a typical American boy. And now he's sick, and unless we do something for him, he may remain sick for an indefinite period of time. Gentlemen, you are not requested to treat these patients. You are directed to do so. May I equate you with a few statistics from recent campaigns? The size of the problem will startle you. These figures from Italy seem to indicate that 20% of all the non-fatal battle casualties were not wounded. They were suffering from neurosis. In Sicily, the overall figure for the entire campaign was 14.9%. When you add up the easy and the hard days of the Tunisian campaign, you will find that 16% of all the non-fatal casualties were suffering from neurosis. In prolonged engagements, where the going is really tough, we find that 30 to 50% of all men coming under your care in the divisional area are suffering from combat exhaustion. Gentlemen, that means that one out of three or even one out of two of all soldiers coming under medical canvas does not have a drop of blood on him. Now, get the idea that the American GI is the only soldier that develops neurosis. What else statistics of the armies of our allies and enemies show that they are faced with the same problem? You are members of the medical department, and to you is entrusted the care of all the sick. There are no specialists on the battlefield. If you say that you are a surgeon and can handle only the surgically wounded, you have failed in your mission. Out in the mud, you've got to be a medical soldier and meet all comers. In the folder issued to you, you will find a copy of this chart depicting the various forms of neurosis, hysteria, anxiety state, reactive depression, and the terror state. This will act as a guide to us as we visit the wards where we can observe actual cases. Please, man. Will you hold this, please? You let me see it. Good morning, McKenner. How are you feeling now? I don't know, sir. I'm afraid you'll have to give me up as a bad job. I'll never get well. Oh, it isn't as bad as all that, is it? I can't stop from crying like a damn fool, baby. The blues, I guess. You did pretty well before the war, didn't you? I did all right, I suppose. This man has an excellent background. He averaged $400 a month as an automobile salesman in Chicago. Why did they send you here, McKenner? We got stuck out in Casserine Pass. They had to send up reinforcements. The new CO had no use for me. I thought I was a sad sack. I don't blame him. Well, you'll feel better in a week or so. Take my word for it. McKenner went through most of the North African campaign. The death of his CO, plus the loss of many of his friends, plus prolonged physical fatigue, have produced a reactive depression. Well, lots of other fellows have been through this same thing. Maybe a pick and shovel in the little discipline would fix him up. What does usually happen to these cases, Major? Unless properly treated, suicide may occur. These gentlemen are medical officers, Sergeant, and they're interested in your story. Would you mind telling us what's the matter with you? Well, sir, I just can't seem to get my strength back. I feel all in. They get me up for a child, but I can hardly make it to the line. How long has this been going on? Well, I know it's the first on the boat, coming to England. When did you arrive from the States? Well, I don't think you understand, Lieutenant. This man has just arrived from Sicily. Did you see much action, Kosharski? Well, sir, we took a terrible shellacking at Randazzo. I lost a lot of my buddies there. Did you stand up pretty well during that campaign? Well, sir, except having to jitter as once. I stood up as well as anybody else. In what way do you feel your weakness? Well, sir, it's all over. Mostly in my chest, the pains, I get out of breath. Maybe I got TB. Oh, I'll bet a hundred to one against that. This is also a depression. But action on the physical rather than the emotional side is in the first case. Would you mind showing us your foot? It's all healed up, isn't it? Yes, sir. They fixed it up in the surgical ward. Tell us how it happened. I was cleaning my gun in the Bivouac area. And it went off accidentally. That was outside of Troina, wasn't it? Yes, sir. Didn't you try to save one of your men? All of that. That was after we'd landed at Sicily. Our company had to retreat. One of our men couldn't keep up with us, and he was wounded. We lost sight of him. Another fellow and myself asked the CO if we couldn't go back and get him. We got him all right. As we started back, the Jerry spotted us and laid down a barrage of mortar fire that was like all hell breaking loose. We had to leave him behind. What happened to him? He died out there. How soon after that did you have your accident? About a week or so. What shape were you in? Jittery. Couldn't sleep much. I kept thinking about that day. Thank you, Corporal. Is that a common occurrence under pressure, Major? In the battle of Boitzen-Litzen, there were 3,000 cases like that. The commander asked his chief surgeon to investigate. He found that they were self-inflicted. Boitzen-Litzen? That's a German name. Who is the commander? Napoleon. Eddie's, Peters. You're in the air corps, aren't you? Would you mind telling us about yourself? No, sir. Don't mind a bit. You just refused to fly. Were you scared? No, I don't think so, sir. You see, I'm a waste-gunner and a bomber. A bomber's crew is just like a football team. If one fella keeps fumbling the ball all the time, a lot of good guys are on the losing team. Tell us what happened that day you refused to fly. They briefed us to go over Berlin that morning, and I was feeling terribly nervous and shaky. I hadn't slept for about three nights, and when I was going over towards the ship, I felt the butterflies in my stomach worse than ever. So I just told them it didn't make any difference to me whether they busted me or not. A guy in that shape just shouldn't go up. Do you always get butterflies when you go up? No, I think that started when we were shot up over the drink. We ditched out there, and the pilot and the rear-gunner were both killed. Took them about three days before they finally fish us out, and I don't think I've ever been the same since. How do you feel about going back to flying? Well, the eighth means a hell of a lot to me. When nerves clear up, I'll do everything they want me to. But I think I'm washed out now. They'll never let me fly again. Well, let's cross that bridge when we come to it. Sit down, Peters. You may call him a blow-break if you want to, but take a look at this. He's had 20 missions, and he's been decorated four times. This is another form of exhaustion known to the air core as operational fatigue. We now come to an extremely common variety of the anxiety state. At first glance, this patient might appear to have Parkinson's disease, but in reality, he is suffering from exhaustion. Note the rhythmic tremor of his lips, of his hands, of his knees, of his feet. He was pinned down by enemy mortar fire and cut off in an observation post for the better part of four days. He was flown into us this morning from the combat area. Speech is difficult, so we won't burden him with questions. Treatment will begin immediately. Yes, sir. You have a variety of anxiety and neurosis with visceral dysfunction. How is your stomach? I vomited again, sir. At ease, soldier. How long has this been going on? It started when I was in action about six weeks ago. Have you lost any weight? About 30 pounds, so they tell me. We'll soon make that up for you here. Any other complaints? Well, everything seems torn to pieces. My heart beats awfully fast. My stomach, I just can't seem to get over my diarrhea. How do you sleep? It'd be all right if it weren't for those dreams. Do you dream about anything in particular? Terrible stuff. A barrage, strafing, being stuck out in a foxhole. Memories, sort of. There's noise, Bob. I want to jump out of bed every time a plane goes overhead. I've been so nervous and jittery, I can't even write. Look at here. Well, don't worry too much, soldier. You'll be better soon. And now we come to a case of back pain with no organic basis. Just where is the pain? It's right here between my shoulder blades, sir. How long has it been going on? Well, it's been worse for the past couple of weeks since I strain it, living in GI cancer. But I've had this trouble. Ever since I was about eight years old, and I fell off a wagon and hurt my back. And my heart is bad. It gives me a lot of trouble. And my nerves are bad, too. How do you feel about going back to duty? I don't know, sir. My back doesn't get any better. And my heart still gives me trouble. And you can see my nerves are no better. All right, soldier, that's all. Thank you. No organic basis has been found for his complaint. Gentlemen, this is a type of constitutional inadequacy in which there is a fixed somatic complaint in addition to diffuse anxiety symptoms. He has brought his complaint with him into the Army. His chances of rehabilitation are slight, and he should be weeded out as quickly as possible because he would be one of the first to break down in combat. If you will look at your chart, you will find that we have dealt with the various forms of reactive depression and the anxiety state. There are other types of combat exhaustion. The terror state of panic and stupor and the hysterical state of amnesia are seldom met with in hospitals this far from the front. However, we do have an interesting patient in the ward who went through an episode of hysterical amnesia with wandering or fugue, as it is called. Sit down, Kelly. Would you mind telling these medical officers something about that lapse of memory you had? Oh, you mean a time I went over the hill down in Africa and didn't know anything about it? Yes. Weren't you wounded down there? Oh, that was long before that near my turf. The Jerry Sniper got me in the arm. That's right. They patched you up in the hospital and sent you to an outfit near my turf. What shape were you in? Did you feel fit? Hell, no. I was jittery and couldn't get my strength back. But the African campaign was over. So we just hung around doing problems and stuff like that. And now tell us what happened on that problem when they were using live ammunition. Well, we were out on a problem and moving to take a hill. They were shooting 105 and some of them fell short. They were busting right over us. Enough to give anyone the jitters. Then one busted right over my head. I ducked. Next thing I remember, I found myself on the side street in Al Jaze several days later. I looked at myself and looked like I'd been on three-week drunk. I was pretty dirty so I ducked into a barbershop. Got a shave and a brush up. Then I called on the MPs. And what did the MPs do? Well, nobody believed my story. So they tossed me in the clean. Well, I was out and let a cloth to sew high jump down with so they shipped me here. Although nobody would believe his story, you may bet on it as a true one because it is so typical of what is encountered on the battlefield. Rather strange, don't you think? He went through a half a dozen battles and then broke down on a maneuver. And now we come to the case that was under discussion in the classroom. John Clemens. May I have his record? He represents another of the hysterias, the conversion type. Since no definitive treatment has been given him, you will find that his clinical condition has not changed between the time he left combat and his arrival here a few days ago. And now, Clemens, we want to see you walk. Yes, sir. Only I'll have to have some help, sir. Will you help him, Sergeant? Now walk down that way. I think you can walk by yourself, Clemens. Try it. Go ahead. That's it. Now back. That's it. Come along. All right. Now bend forward as far as you can. Is that as much as you can bend? Yes, sir. Now bend back. Is that as far as you can bend? I'm afraid so, sir. Careful diagnostic studies have been made on this patient. No orthopedic or neurologic disease is present. X-rays are negative. This is a conversion phenomenon known as camptochormia, which is Greek for bent back. Good chair, Sergeant. And now, Clemens, will you tell these gentlemen all you can remember of the way this started? There's not much I can remember, sir. I was on the side of a mountain laying wire one night when Jerry opened up with everything he had. So I dove for the nearest foxhole. And then, I don't know, it's all hazy. I was scared. I'm sorry, sir. I just can't think of much more. And suddenly, I felt people pulling me out. I was all twisted up. Oh, yes. You told us about the medics pulling you out. And that's all of his story that he remembers. And now, gentlemen, we come to the subject of treatment. The other patients you have just seen will be treated by prolonged deep sleep or narcosis therapy. And we are going to treat this patient with chemical hypnosis. This should restore his normal posture. Chemical hypnosis produces a state of semi-sleep, or twilight state, in which suggestibility is increased, as it is in true hypnotism. By using this suggestibility and by inducing ab reaction, a cure of his condition can be brought about. If you will follow me, the treatment of this patient will be demonstrated. Will you take over, please? Yes, sir. While we are waiting for the patient, let us review some of the drugs used in narcosis therapy and chemical hypnosis. The drugs of choice are the barbiturates. The most practical one for producing and maintaining narcosis is this one, sodium ametal. There is an ample supply of it in your number 2 chest. On the average, 9 to 12 grains will produce adequate narcosis for from 7 to 8 hours. When he wakes up, the patient can be fed and taken to the latrine. This dose of ametal may then be repeated, and the narcosis thus continued as long as necessary. Patients with fully developed varieties of combat exhaustion will require a minimum of 24 hours of continuous narcosis. Some will require 48 to 72 hours. A second barbiturate with an action almost identical with that of sodium ametal is nembutal. 4.5 to 6 grains every 7 or 8 hours. You will note that in combat exhaustion massive doses of these drugs are needed in therapy. A third barbiturate is the familiar drug phenobarbital. Tablets are 1.5 grain. 4.5 grains will usually produce adequate narcosis, but on occasion, 6 grains may be necessary. You can expect sleep for longer periods than with sodium ametal or nembutal. Its action may be estimated at 10 to 12 hours, after which you may proceed as with the first two drugs. Another drug available to you is sodium bromide. Its use is suggested only when others cannot be obtained. Dosage is extremely variable. Its action is inconstant, and it tends to pile up in the bloodstream so that toxic states may develop. In an emergency, inhalation anesthetics such as ether may be used to put a struggling, panicky patient to sleep quickly. Drugs may also be used intravenously. A 10% solution of sodium ametal may be administered with orthodox technique. The rate of administration is 1 cubic centimeter a minute. The average patient will go to sleep after the administration of 5 to 8 cc's and will remain asleep for 7 to 8 hours. In our case, however, we will use another intravenous drug, pentathal. Lieutenant, will you prepare this? Pentathal is not a good drug for narcosis therapy. It will put your patient to sleep quickly and effectively, but its action is extremely short. For our purposes, the chief value of pentathal is in producing chemical hypnosis, a form of semi-narcosis or twilight state. We will use a 2% solution of pentathal. Pre-medication with atropine has been given. Our patient is ready now. Clemens, this medicine will relax your muscles completely and help your back. The rate of administration is 2 cc's per minute. Major, will you keep time, please? You'll feel the prick of the needle now. Ready? Off. Do you feel any effect? No, sir. Only my head's swimming a bit. One minute? We continue the administration at the rate of 2 cc's per minute. How do you feel now, Clemens? You're getting kind of drunk. Like a cheap jag. Don't you mind? One of the early effects of pentathal administration is this feeling of well-being. Two minutes? Now say Methodist Episcopal for me, Clemens. Methodist? Impassable. You will notice the slurring of speech. He is beginning to have difficulty with enunciation. This shows that the drug is having effect. Three minutes? We have now injected 6 cc's of the solution. How are you feeling? I'm beginning to feel awful drunk, sir. Don't let that bother you. That just shows it's taking effect, doesn't it? Yes, sir. This is great stuff for your back. It'll help you straighten out. Four minutes. We have now almost reached the level of chemical hypnosis. What the hell does that mean? That means we're really going to fix you up. There is a very simple test for the determination of the optimum level of chemical hypnosis. We'll have the patient count backward from 100. And when he becomes confused, we'll know he is at the right stage. And tomorrow he won't remember having counted at all. At this level, he will be extremely suggestible. Five minutes. Are you getting off from sleeping? I think I'm going to pass out. Hey, don't you go to sleep on me. I want you to count backwards. Count backwards from 100. 100? 99, 98, 87, 86. Now we can remove the needle. Let's straighten him out of his bed, put him on his back. This gentleman was the phenomenon of ab reaction. Sometimes it is necessary to coax the patient to relive the emotional stresses of the events which produced his hysteria, but it is more common for it to happen spontaneously as it did here. Now he has it off his chest. And this is the time for suggestive therapy. Remember that pentathlon increases the suggestibility. Your back is straight and strong. Your back is fine and straight. Really? Of course. Let's sit up. Well, I can't, sir. We'll help you. Of course you can. There you are. But it hurts. That's only those muscles you haven't used for a long time. Let's bend forward. Way down. There you are. It is better. Of course. Now backward. Well, you do it as well as any of us. Wouldn't you like to see how well you can walk? But I'll follow, sir. Oh, no, we'll help you. Your back's all right now, yourself, soldier. What's happening? We're straightening your back for you. See? You're walking straight. Turn around. Hold back your shoulders. Now, let's see you walk like a soldier. Gee, treatment is not complete in this case. Clemens will now go through a general reconditioning program, which will give him confidence, and which will complete what we started here this morning. Okay. What kind of treatment will he get, Major? That question can best be answered by giving you a summary of the operational plan of this hospital. It is divided into three sections. Admission, treatment, and rehabilitation. Shortly after his arrival, each patient is given a complete physical examination in order to ascertain the cause of his illness. This includes dental survey and any necessary laboratory studies. These are followed by intelligence tests and complete mental examinations. If necessary, specialized psychiatric studies such as the Rorschach technique or other personality tests are made. After careful summary of these findings, treatment is based upon the physical and psychological background of the patient and the symptoms he presents. Narcosis therapy or continuous sleep treatment have proved of great value in a large series of cases. Many patients showing marked anxiety, tension, inability to sleep, chronic fatigue, or emotional instability respond to this treatment. By giving them sodium amatol or other barbiturates, the patients are kept to sleep 18 to 20 hours per day for several days. In other words, Narcosis and modified insulin therapies are combined. Insulin is given in the morning and Narcosis is carried out in the afternoon and evening. As we're Mitchell found in the American Civil War, soldiers with combat exhaustion almost invariably suffered great loss of weight. The insulin treatment consists of the administration of from 40 to 100 units each morning before breakfast. With this chemical stimulation of appetite, the patient eats on an average 12 and a half pounds of food per day, which is more than twice the amount normally consumed. By means of this combination of therapies, symptoms of acute tension are relieved and the restoration of weight can be expected at the rate of a half to one pound per day. Careful attention to diet is an important part of the therapeutic program. Balanced meals are planned for high caloric value and proper vitamin content. Patients who show marked symptoms of reactive depression may be given electrical shock treatment in addition to the combination insulin and Narcosis therapy. As previously demonstrated, narcoanalysis and hypnosis are used to eliminate amnesic symptoms. Suggestion, either direct or in the form of hypnosis or narcosuggestion is employed in conversion hysteria. During the therapeutic period, patients go through a program of exercises designed to maintain physical fitness. Individual or group reeducation is undertaken so that patients may understand the cause of their illness. After patients have completed their treatment, they are placed in a training company. Here they live in a barracks and are given a review of military training. Nom nos pos Short hikes, detailed work, sensible occupational therapy projects leading to constructive ends and the type consistent with the job of a field soldier, Sports are included for physical hardening, coordination of muscle, and the fostering of team spirit. During the training company period, a series of discussions is undertaken to review for the soldier the reasons why we fight. All serve to rehabilitate the soldier, observe him under military conditions, prepare him once more for army life, and ultimately return him to active duty. Are there any questions? What percentage of cases are you returning to active duty from this hospital? Major, we're all impressed with what we've seen. You've got a slow setup here, everything you need. Yes, but what about us in the combat area with our hands full and not a thing to work with? I was coming to all that, gentlemen. Early treatment in the combat zone does not require elaborate facilities and would eliminate most of our setup here. We in the communication zone, despite all the facilities, can return only a very small percentage of patients to actual combat duty, whereas you, out in the forward area, can, by getting at them early, send 70 to 80 percent back to duty in the front line. You have been shown around this hospital in order to acquaint you with the principles underlying the treatment of combat exhaustion. Treatment in the forward area is based on identical principles, modified to meet the tactical demand. When patients arrive at the clearing station, it is of primary importance to separate the exhaustion cases from the physically injured. Hey, you soldier, you're in a protected area. Where's the MC tag? Modest! Can't you hear him? Welcome, Exorcist. Take him to 10-5 right away. We'll get the rest of the information after he's high-treatened. Nothing will hurt you now. We'll take care of it. Travel-hold him. He'll be quiet now. Better put him in a pact, though, in case he's excited when he wakes. Take him and put him in the end space over there. Sit him down on this litter. Bring him some soup. Campbell, put seven-and-a-half grains of sodium amethyl in the syringe. Sit on this chest, soldier. Take off your pack. What's your trouble, soldier? I'm all tired of my headaches. I ain't going over. Are you wounded anywhere? No, sir. It's just it. I never was a Goldberg. Now I don't even want to clean out my gun. I can't understand it. Oh, you're from that outfit that had hell shot out of it a while back? Yes, sir. That's your trouble. You're just worn out. What you need is some rest and some food. Bring me 12 grains of amethyl, Campbell. That's right. Take them all. That's fine. You feel better now. Bring him some soup and some blankets. Pick up your pack, soldier. Put him in the third space. Drink that soup, soldier. Get some sleep and you'll be all right. Now we can take care of you. Just lie back, soldier. Roll up your sleeve, Campbell. Swab off his honor. What I want you to realize is that you're exhausted. The strain has worn you down. This strain causes muscle tension. It's this muscle tension that makes you shake like that. Don't worry about that. I'm going to inject some medicine that will work through your entire body. Relax your muscles. When the muscles are relaxed, the shakes will be gone. Don't move now. You feel a little sticky. You can breathe easier now. Take a deep breath. Try it. That's it. Look at your hand. It's not shaking anymore. That's because the muscles are relaxed. I'll give you the rest of the medicine and you will go sound asleep. When you wake, the shakes will be gone. You will feel well. You hear me? The shakes will be gone. You feel well. You feel perfectly well. He's asleep now. You can cover him up. Just a minute, Pat. How are you feeling? The pain in my chest seems gone, sir. I feel a little dizzy, though. That pain is gone. The dizziness will wear off in an hour or two. How are the shakes? Let's see your hands. Put on your helmet. Let's go outside. No, Pat. I'd like to find something for you to do until we get transportation back to your outfit. Okay, I'll do what I can. Good. Come with me. Sergeant, when are you pulling out? This afternoon, sir. Need some help with the loading? Yes, sir. Good. Here's your man. Report back to me when you've finished. I'll find something else for you to do. Yes, sir. That'll be all. Soldier, good afternoon, sir. Don't get out. How are you feeling? Fine, sir. I haven't had any more trouble with my hand. It's good to know. But I keep on wondering why it went bad on me. It doesn't hurt. Well, here's one way it could have happened. When the bomb struck, your hand was buried in the dirt. You couldn't move it. You made the mistake and thought it was injured. I believe you're right, sir. That sounds kind of fishy, doesn't it? Not at all. When you're scared, and we all get scared on the battlefield, you imagine a lot of things. Then too, when your mind is tired, you're entitled to make mistakes. That's what happened to you. You've had treatment in your hand as well. You're ready to return to duty now. I'm sure glad of that, sir. Good. There's an outfit going up in just a few minutes near where your old outfit is. Think you can make it? I'll be with you in a moment, sir. Get your stuff. How long, Major? Just a second, Lieutenant. You're going forward. I've got a passenger for you. We'll have to hurry. The old man wants me. Report immediately to the disposition tent. The driver is in a few minutes. After that, report to Sergeant Knight. Yes, sir. He's an exhaustion case, isn't he? Yes. That's why I want you to pay special attention to him. See that he gets an even break. Too often, line officers confuse cowardice with fear. That's true. Keep an eye on him. See that he gets his old assignment without preferential treatment. Good luck. Thanks. Sir Lieutenant Burke. All right, Lieutenant. Yes, sir. Ready to leave now. Now, that's an important job out there, especially right now. I guess you know the tactical situation. Yes, sir. I've just been to S3. Good. The thing I want to go over with you is the fact that those troops up there have been driving hard for a long time now and are beginning to show evidence of combat exhaustion. I want you to catch them before this develops. The prodromal stage is the time to treat these men. Watch for the early signs. The most prominent of these are poor physical coordination, slowing of mental processes, excessive reaction to noise, inability to relax or rest even when there is opportunity, and outbursts of temper over trivial matters. Sir, what's the trouble, soldier? I'm fed up with the whole damn thing. Been getting in sleep lately? You can't sleep around here. You have the facilities of sedation and reassurance. Use them. See that he gets a wash, a hot meal, a good night's rest. Such treatment prevents casualties from combat exhaustion, prevents long evacuation, and preserves fighting strength.