Psychiatry and War

Out of the horrors of Dunkirk and the aimless terror of the raids on London, British psychiatrists learned much about the treatment of war’s mental cases that has application in the practice of psychiatry today. Sometimes by accident, sometimes by inspiration, doctors evolved ways of curing or inhibiting the effects of acute hysteria, reactive depression, loss of memory, and fright paralysis. Dr. Sargant, a fellow of the Royal College of Physicians and chief of the Department of Psychological Medicine at one of London’s great teaching hospitals, was one of those wartime discoverers. This article is drawn from his new book, THE UNQUIET MIND, to be published in the fall by Atlantic - Little, Brown.

IN WORLD WAR I, psychotherapy did very little to help the large number of men who developed chronic war neuroses. It might have been just the same in World War II had new physical treatments not come suddenly to the rescue. The introduction of “front-line” sedation to splint the brain and so prevent further irreparable damage, drug abreaction under the new short-acting barbiturates or ether, continuous narcosis, modified insulin treatment, and the urgent use of shock therapy saved numerous lives and millions of dollars and pounds in war pensions. In Great Britain the chronic war neurotic of World War II is a rarity compared with the many resulting from World War I.

As soon as Hitler’s armies broke into France, and ours fell back on the Channel ports, Belmont Hospital, then called Sutton Emergency Hospital, where I was working as part of the Maudsley Hospital team, became a main military neurosis center, all British hospitals in France having been overrun. We doctors remained civilians, but the hospital had a military registrar and staff. The new arrangements worked very well. The soldiers far preferred being treated by civilian doctors and nurses; and though limited to a meager civilian diet, the doctors retained a personal freedom of action that would have been impossible had we been bound by the etiquette of rank.

Our grounds lay on a railway line between Epsom and London; thus hundreds of mixed medical and surgical cases who had been landed at Dover after the evacuation of Dunkirk came directly to Belmont by rail, for we maintained a military general hospital section as well as the neurotic wards. I shall never forget the arrival of these Dunkirk soldiers in their tin hats and filthy uniforms, some of them wounded, many in a state of total and abject neurotic collapse, slouching along with Belgian and French civilians who had scrambled aboard the boats at the last minute. What the papers termed a great British achievement seemed to us at the time nothing better than a rout. Men swarmed into the hospital, some raging mutinously against their officers for having deserted them in a panic, and others swearing that they would never fight again. So complete a loss of morale was frightening to witness. Many were suffering from acute hysteria, reactive depression, functional loss of memory or of the use of their limbs, and a variety of other psychiatric symptoms which one would see in such abundance only during a war or after an earthquake or railroad accident, when even perfectly normal people are apt to break.

One of my cases accidentally initiated a method of treatment for acute battle neuroses that was to be used throughout the war and is still occasionally used. This soldier came in with a hysterical dumbness, unable to articulate a word, and his hands shook as though he had reached a final stage of Parkinson’s disease. He also had nervous paralysis of his bladder, which was enlarged up to the level of his navel. His pitiable state of terror prompted me to give him an intravenous injection of sodium amytal, a quickly acting sedative which I had kept at hand for experimental use on air-raid casualties

of whom, so far, none had appeared. The effect was startling. His bladder suddenly emptied, his speech returned, his hands stopped trembling, and he became intelligent, articulate, and comparatively normal, at least until the effects of the injection wore off. Even then his symptoms were far less pronounced. We gave injections to other acute hysterical cases. Each time the treatment worked.

The fact was that while I was at the Massachusetts General Hospital I had watched Dr. George Sutherland’s conditioned-reflex experiments on neurotic patients; he had already spent some years at Yale working in the same way on pigs. One of his hysterical patients recovered composure soon after being given sodium amytal, and the patient’s conditioned reflexes were normal as long as she remained under its influence.

Sodium amytal, Pentothal, and other barbiturates seemed admirably suited for “front-line” sedation where the breakdown was recent; they had the power of speedily rectifying behavior disoriented by abnormal stress. Yet the minds of this group of Dunkirk admissions were at first sight so hopelessly disrupted that it was hard to believe that a simple injection of sodium amytal would be of real assistance. Our successes seemed too easy.

The injections had strange side effects, also reported on in England by Stephen Horsley in civilians before World War II; a soldier might suddenly recover suppressed memories of the gruesome experiences that had caused or hastened his breakdown, and relive them before us. After this discharge of pent-up emotions, especially battle terrors and rage against their officers, soldiers would suddenly improve.

ONE case greatly disturbed me. A soldier from the first batch taken off the Dunkirk beach suffered from gross bodily tremors, total paralysis of the right hand, and an almost complete loss of recent memory. An injection of sodium amytal cured the tremor and restored both the use of his hand and his lost memory, but only after a frightening emotional release. He described, with dramatic gestures, how during the retreat he had come across his own brother lying by the roadside with a severe abdominal wound. At his brother’s earnest plea he had dragged him into a field and put him out of his misery with a rifle shot. It was the hand that pulled the trigger that had suddenly become paralyzed. After his confession of grief and guilt, this hand worked again.

Such results were easily obtained only if one could treat the acute hysterical breakdown cases early enough. If too long untreated, the hysterical patterns of behavior newly formed under stress might become embedded in the nervous system and be increasingly difficult to disrupt. A week or two later Eliot Slater and I published an article in the Lancet: the first account of a practical emergency treatment for acute battle neuroses. We hoped that as the war went on, it would guide other doctors who were faced with numerous similar cases; it described our unexpected findings with the intravenous use of sodium amytal and other barbiturates. I quoted the case of my patient who had carried out the mercy killing. It never occurred to me that the Daily Mail might repeat this story; but to my horror it appeared next morning, under large headlines, mentioning Belmont as the hospital where the soldier had been treated. It was being read by patients in his ward; of course, this upset me greatly, and I sent for the soldier at once, apologizing most sincerely for what had happened. No one seems to have guessed who was the protagonist in the tragic story, but its publication had created such an impossible situation for him that I arranged for his immediate discharge from the army. He returned home to the West Country, and I have often wondered how he has since fared. I hope that he has long ago forgiven me my blunder.

Our experiences after Dunkirk taught us the folly of trying to patch up soldiers and then expecting them to face again the same kind of stress that had caused their breakdown. Our first thousand admissions included, for instance, more than one hundred and fifty men with acute hysterical losses of memory, a condition of the utmost rarity in peacetime. Sodium amytal, promptly injected, brought the memory back, often accompanied by overwhelming emotional release and reliving of the forgotten experiences, but we found that if these soldiers were sent back to full duty, fresh battle stresses would at once reproduce the former symptoms. So we arranged for nervously unstable patients to be discharged from the army, hoping that they would make some sort of success in civil life. In less severe cases, we recommended that they should he kept on base-line army duties; and many of these patients rehabilitated themselves without further serious breakdown.

In World War I, neurotics had, as a rule, been kept with the Colors until they broke down completely. Some were shot for cowardice; but the example did the others no good, because mere willpower cannot control the failing functions of a broken-down brain. And under strong or continuous stresses, no threats of exemplary punishment can prevent breakdowns. Chronic shell-shock cases were eventually sent to the hospital, but very few got their discharge until the war had been won, and by that time most of these patients were past cure. I have childhood memories of utterly unemployable human derelicts begging in the streets of London, some of them with Mons medals and decorations for valor.

After World War II, because of our early treatment and quick discharge or recategorization of neurotic cases, these lamentable sights were rare among army and navy ex-servicemen, who seldom reached the point of complete disintegration under threat of being shot for cowardice. We had treated their brains and the rest of their bodies as a single organism; our predecessors had not.

The most important lesson taught us by Dunkirk and the Battle of Britain in 1940 and 1941 was never to let a neurotic pattern of thought remain fixed in the patient’s brain for a minute longer than necessary. It was like the surgical rule which requires that a fractured leg must immediately be put into a splint; we protected the nervous system against further stresses by sedation until the brain was better equipped to cope with the situation.

BELMONT, as well as being on a railway line, lay near the strategic airports at Croydon and Biggin Hill, which made us vulnerable to both day and night bombing during the Battle of Britain. In the course of three months, about sixteen bombs were dropped on the hospital grounds, while we were still entrusted with the cure of some two hundred casualties, mostly acute neurotic cases from Dunkirk and the new blitz. This gave us a wonderful chance of developing the emergency treatments which became standardized in military hospitals for the rest of the war, especially front-line sedation prolonged to a sleep of from twenty-four to fortyeight hours — long enough to disperse many very recent neurotic symptoms. We found that if shock casualties were left for a month or two without such treatment, their abnormal behavior patterns would become firmly stabilized in the nervous system. As a rule, such men would be irreclaimable so far as any military duties were concerned. Moreover, most soldiers or civil defense workers who had put up an honest fight against their mental stresses lost fifteen to twenty pounds in weight before the final breakdown; and it was essential to restore this loss as fast as possible if they were to make a speedy improvement.

The treatment that we developed at Belmont for doing so is now known as modified insulin treatment; it was also used by the American Forces in the European campaign and elsewhere on more than fifteen thousand of their neurotic casualties. We discovered it by a series of accidents. Before the “phony war” period, I had noticed that schizophrenics generally put on a lot of weight while recovering under insulin-coma treatment. And I knew that depressives in the days before shock therapy was invented also would give signs of being about to make a spontaneous recovery by gaining weight; they did so two or three weeks before any other outward sign of improvement appeared. I decided, therefore, to find out whether we might stimulate the recovery of depressives by artificially fattening them up. I tried giving them large doses of insulin, letting them drop into a coma, and as soon as they did so, feeding them a large quantity of sugar by means of a stomach tube. Some certainly put on weight, but their depression noticeably improved in the case of only two out of about twenty patients.

I should have abandoned this treatment as inadequate had I not been summoned by our medical superintendent, Dr. Minski, and told that as there was a war on, and I was using a lot of sugar, the experiment would soon have to stop. But feeling that research must go on even in wartime, I telephoned Dr. Russell Fraser, who had returned to Mill Hill from America, and asked for his advice. “Try potatoes instead of sugar, Will,” he said. “They’re using them at another mental hospital, Warlingham Park, near you.” He explained that the trick was to mince potatoes into a fluid, for feeding patients through a stomach tube. Though their stomachs took a longer time to metabolize the potato starches into sugar, most of the men came out of their insulin coma pretty well.

So I, too, used potatoes instead of sugar. That was when the hospital first came under daylight bombing. Patients undergoing insulin treatment complained that the treatment was all very well, but what about being caught in a coma if a bomb dropped on the hospital? I had to agree with them, though determined not to stop any treatment simply because of German bombs. It then occurred to me: why not give the patients their doses of insulin, and just before they were due to drop into coma, ask them to sit up and eat their potatoes? This would save us the trouble of having to mash the potatoes into a fluid and use a stomach tube. And so was triggered off a treatment now familiar in England as the “modified insulin treatment” and in America as “insulin sub-coma.” Patients were given between thirty and a hundred units of insulin, and left fasting for about two hours. By that time they were sweating and drowsy, and had usually developed ravenous appetites for a plate or two of boiled potatoes. These were never rationed. Often a patient would gain a pound of weight a day, and before long he would put on nearly thirty pounds.

But it soon grew obvious that deep depressives were not doing so well under this treatment as patients suffering from anxiety or acute hysteria, such as the Dunkirk and blitz casualties, so many of whom had lost ten to twenty-five pounds before finally breaking down. The restoration of body weight in this particular group greatly speeded up their recovery and armed them against further stresses. The depressives had not greatly improved under insulin, but had responded later to electric shock treatment; while patients suffering from acute anxiety and hysteria did not respond later to electric shocks, but greatly improved under our new modified insulin treatment.

I had done this work with the help of Dr. Nellie Craske and had patted myself on the back for making so original a discovery, until one day I found that a famous American physician named S. Weir Mitchell had anticipated me during the American Civil War. In his “Fat and Blood,” published in 1870, he records that soldiers often fighting most gallantly with Sheridan and Grant had become “as hysterical as the veriest woman” while suffering from loss of weight, painful war wounds, fatigue, and exhaustion. He therefore invented a technique of massage to induce the same sort of heavy sweating that we now get more simply with insulin injections, and to increase these poor heroes appetites; this he followed with prodigious platefuls of food. The Weir Mitchell treatment had a long and successful vogue not only in America but in England, especially among neurotically underweight and hysterical women. Only around 1910 when applied inappropriately to other morbid conditions, such as severe depression, did it gradually begin to fall into disrepute. I found in fact that patients who responded in our war to modified insulin treatment were of exactly the same type as those whom Weir Mitchell had clearly described in his own war: namely, underweight neurotic soldiers of good previous character. So ours was a mere rediscovery, except that Weir Mitchell’s treatment had now been simplified by the substitution of insulin for massage.

We also learned to lengthen still more the periods of sedation for restoring the shattered nervous system of war casualties. We would now sometimes keep them drugged and even fed by hand for three weeks at a stretch, after which they would wake up greatly refreshed. And this was a technique borrowed from the Republican doctors, such as Professor Mira, in the Spanish Civil War.

A system of treatment, gradually evolved at Belmont, became standardized as the war went on, especially among the American forces in Europe. A patient fresh from the battlefield would immediately be put to sleep for a day or two. If functional loss of memory or paralysis of limbs was then noted, it would be restored by intravenous injections of sodium amytal, and the patient might also be made to relive his horrifying experiences under such drugs. If he continued anxious and exhausted, we might give him a further week or two of continuous sleep treatment, then put him on modified insulin treatment to restore his normal weight. He might finally be subjected to group reconditioning methods and an assessment of his probable future capabilities for military service. If it then seemed more humane, more practical, and more in the interest of what came under the heading of the total war effort, he was discharged and directed into civil employment. You don’t insist on keeping your brokendown players on the first football team if you want to win the championship.

We were soon allowed to make such decisions on medical grounds without too much interference by service authorities, and as a rule, with their active cooperation. We continually reminded them how disastrous the tough “shoot all cowards” policy of World War I had proved in saddling the nation with a legion of incurable mental cripples. Between 1942 and 1944 it was our task to spend long hours in showing service doctors around the hospital, and explaining how all our various treatments should supplement one another.

IN SEPTEMBER, 1940, the main hospital building at Belmont caught its first direct hit on three wards, one above the other. Most of us doctors were gathered after dinner in a room very close by, and I saw my staid colleagues suddenly revert to the human behavior pattern of a million years ago or more by trying to burrow into the floor. We were all so bomb-shocked that an hour or two passed before any of us could remember exactly why, when the bomb fell, we had been grouped near the sitting room door. Then it occurred to someone that an earlier bomb dropped on the railway line had sent us toward the door just as the fatal one came down. In fact, we were all suffering from the same sort of short-lived functional amnesia for which we were treating so many of our soldiers. I sometimes wish I could give myself an injection of sodium amytal to clear my mind, so that I could recall in detail how we worked until early morning at the wreckage of those three collapsed wards. It still remains a little blurred. We dug patients out unconscious but still alive, after perhaps trampling on their faces in our rescue efforts. We found many others blown to pieces. Sixteen patients were found dead, and many of the survivors had been badly injured. Heroic feats were performed that night by patients who had hitherto seemed helplessly incapacitated neurotics, and most of whom relapsed as soon as the crisis ended.

This experience left me with a neurotic avoidance of the lowest bombed ward; even when the damage had been patched up a year or so later, I could hardly bear to walk through there at night. The ceiling had fallen and killed every patient on one side of the ward, whereas those on the other side had walked out unhurt. The two totally destroyed wards above had housed the civilians evacuated to us from similarly bombed London hospitals. Many of the older patients could not stand the strain of being moved about this way, further and further away from homes and families, and their death rate was high even without their being buried once or twice under a heap of debris.

When the bomb fell, my wife was sleeping in our shelter. She heard an enormous explosion, followed by screams and shouts. Fearing for a moment that our block of flats had been hit and that she might be the only survivor, she rushed out, realized her mistake, and met someone who shouted that the hospital had been hit and nobody was allowed in except regular air-raid personnel. When several hours later, covered with dust and dirt, I stumbled back to reassure her that she was not yet a widow,

I found her fast asleep in a neighbor’s flat. This surprised me very much, even when she rationalized her behavior with “What else could I do? I was in such a state of anxiety, and they would not let me find out if you were alive, so I forced myself to sleep as the most sensible thing to do.” But the reason for her sleep was physiological rather than intellectual.

One of my colleagues and greatest friends, the late Dr. H. J. Shorvon, had been visiting the top ward when the bomb actually dropped into it and exploded. He escaped from the debris and got downstairs — he could not remember how, perhaps by a simple fall — but instinct sent him to find out first whether his brother, a member of our staff, was still alive — he was — and then to visit the rest of us. Alarmed by his characteristic bomb-shock facies—black sunken eyes and ashen gray cheeks — I poured him out half a tumblerful of gin, as there were no other sedatives immediately at hand. A quarter of an hour later he had his normal red face back again, was laughing rather drunkenly at his extraordinary escape, and volunteered to do medical rescue work again. We did not let him join us, although his abnormal pattern of psychological and physiological shock, so often observed in the acute Dunkirk cases, had been suddenly and simply dispelled. He showed us again what could be achieved by immediate front-line sedation.

A tough character, he suffered no aftereffects at all, but if he had been left in that terrible shocked state for even twenty-four hours and been allowed to continue with his work, he would almost certainly have developed persisting aftereffects.

During the long blitz, several very normal members of the hospital staff showed signs of breaking down, but responded to our prescription of immediate deep sedation for a night or two. Their rapid recovery made us realize what patients had had to suffer who had been left for weeks or months without any treatment.

Our nearness to the railway line, and our consequent greater risk of air attack, gave us frequent proof that abnormalities of brain function are initially caused by shock rather than by any subconsciously motivated process. When a bomb dropped near the hospital, a frightened patient might lose the use of his limbs before the ward doctor’s very eyes and be unable to run to the specially prepared shelter. If someone immediately gave him an intravenous injection of sodium amytal, the paralyzed limbs would begin to regain their lost function as soon as the drug entered his bloodstream. He could then escape from his fright paralysis and seek safety.

However, if a patient had been brought back from the battlefields of North Africa to the supposed safety of an English hospital with his paralyzed limbs left untreated, we could not always cure him with a simple amytal injection. But since initial fright paralysis can turn into a motivated illness as its value is recognized by the patient, we had to warn him that he could be discharged from the army only when quite fit again. Meanwhile, he must stay with us, because the government was determined not to turn a great crowd of cripples into the streets. Once he understood that recovery would win him an honorable discharge, his symptoms slowly diminished, or injections of amytal might work again, and he had a good chance of ultimate recovery. One can also, by the way, sufler from motivated piles, useful for procuring discharge! The doctor’s task is to cure an illness before its value becomes recognized by those seeking release from intolerable stress.

Fright paralysis took many forms. It might be simple limb paralysis that would suddenly seize a soldier and allow him to be run over by a tank; or a loss of memory; or hysterical blindness, such as appeared on Adolf Hitler’s medical sheet after his war service in France.

We were obliged to revise most of the doctrines taught us at our hospitals about subconscious motivation and to realize that practically everyone has his neurotic breaking point if the stresses are severe enough. Among our patients was a tough sergeant major who had been ordered by a probably mad officer to encourage his men during the Battle of Britain by standing at attention in the middle of the square at an airfield in Kent, subject to repeated daylight bombing attacks; he finally collapsed. The only treatment he needed was a change of unit and a new commanding officer!

The wards became scenes of complete chaos on air-raid nights. As soon as the sirens sounded, soldiers and civil defense patients would rush madly out to some supposedly safer place. Those whose nerves had originally broken down while they were sheltered by a house would make for the open and often stay out all night, returning almost frozen in the morning. Those, on the other hand, who had been bombed and broken down in the open would take cover in buildings.

From the windows and balcony of our flat my wife and I could see the panorama of London stretched out before us: an awe-inspiring sight during the blitz when so many houses and whole street areas might be on fire at the same time during bad raids. We never went up at night, until at last, banking on the improbability that the Germans would bomb London on Christmas Eve, we visited the West End that night together for the first time since September. Later on as intensity of the blitz lessened, we ventured up more often, to dance in nightclubs and hotels or find other distractions from our harrowing hospital work.

London then seemed the most wonderful place in the world. Almost everyone without a real job had escaped to the country, and our friends who stuck it out seemed all vitally preoccupied with what they were doing. In 1941, the year of my election to the Savage Club, I tried to spend every Wednesday evening there, after working at my outpatient clinic at the West End Hospital for Nervous Diseases. Our wholly uninhibited wartime conversations at the Savage dinner table have never since in my experience been equaled; and on the night of a crucial parliamentary debate about our merchant fleet losses from German submarines, when England’s survival seemed highly problematical, the First Lord of the Admiralty (later Lord Alexander) sat at the Club piano jocosely playing hymns to a group of fellow Savages. Hitler’s high opinion of the English nation might well have been shaken had he witnessed this semi-official response to his threat of starving us out.

AT BOSTON CITY HOSPITAL before the war, there had been an active young neurologist named Dr. Howard Fabing. After his training there he had worked in Cincinnati, where I had met him first, and he was now an American army major charged with instructing his front-line medical colleagues how to treat acute neurotic casualties. First, of course, he had to build up an efficient treatment center and stabilize a method for dealing with the large crop of military neuroses which the Normandy invasion was bound to produce. Fabing visited me at Belmont soon after his arrival in England. We were dining together in our flat on the first night when a bomb fell very near, but not quite near enough to cause any practical anxiety, so my wife and I did not let it interrupt the conversation. This was a new experience for Fabing. “Please stop for a moment, Will,” he said. “Was that a bomb? I’ve never heard one before.” We told him, yes, that was a bomb; so, taking the cue from us, he too continued calmly with the conversation. Another American doctor who had just arrived invited me to dinner in London one evening. The air-raid siren wailed, he insisted on going to an air-raid shelter, and though no near-bombing followed, he simply could not understand how, long before the All Clear sounded, we went out to meet my wife, who was waiting at Victoria Station to return ot Sutton with me by local train. Basic differences in temperament show up clearly in war conditions; it was marvelous to hear him, a few weeks later, recounting our supposed mutual valor in what had become for us a very ordinary blitz experience.

Major Fabing was so impressed by our use of drug abreaction, continuous sleep treatment, modified insulin treatment, and front-line sedation that he borrowed all these methods for use on a very large scale at his U.S. Stafford army psychiatric training center. Whereas I, for instance, could use modified insulin in my ward only on fourteen patients at a time, he was able to plan on such a massive scale that something like a belt system of treatment was ready for the Normandy invasion, and used to the full.

Just before it was due to start, we were suddenly informed that in the emergency Belmont would be turned back entirely into a general hospital for the ordinary wounded. Neurotic casualties would be taken up to Southport or elsewhere in the north of England; which meant that we should have to move there as soon as the balloon went up. This typically absurd decision, which contradicted all recent findings about the need for early treatment, aroused our intense anger, especially now that we had our whole treatment routine planned to a nicety. As a result of our violent protests we were eventually allotted a center for the treatment of acute battle neuroses at Graylingwell Hospital, Chichester. This satisfied us because we could there receive cases in even earlier and more acute states of neurotic disturbance.

Our Graylingwell center taught us a great deal. For a while, patients were treated at front-line casualty stations on the Normandy beachhead, and we got only their failures. But when these stations became too full, many acute neurotics were landed by boat at Chichester Harbor and were brought to Graylingwell as speedily as our early patients from Dunkirk had been. On the suggestion of Major Harold Palmer, who, while serving with our forces in the Middle East, had used ether as an inhalant to make soldiers relive traumatic war experiences, we often substituted this method for our intravenous injections of barbiturates. Ether produced far greater excitement in the patient, and we found that the intenseness of emotion was more important in a cure than a recovery of the experience itself.

We were now developing a progressively higher degree of technical skill, and attempting emergency treatments that we would hesitate to repeat today. At one point we had around thirty or more patients in a large hall, all being given a combination of deep-sleep treatment and modified insulin therapy at the same time; in some cases both treatments had to be maintained for a fortnight or longer; and only the remarkable nursing skill and experience that we had built up allowed us to combine these really separate and potentially dangerous methods. Psychiatrists will appreciate the risks we ran, but in fact, none of the cases we treated ever came to any harm.

ON MY way to Southport soon after the Normandy invasion, I had stopped for a few hours at Stafford to visit Major Howard Fabing at the American neuropsychiatric hospital, where I had helped him to plan his streamlined treatment unit for acute psychiatric casualties, now going into active operation. Fabing had just read Pavlov’s Conditioned Reflexes and Psychiatry, recently translated by W. Horsley Gantt in America. He advised me to read it at once. This series of lectures had been delivered not long before Pavlov’s death in 1936, when he was already over eighty, but was not published in English translation until 1941 — when, unfortunately, most of the British edition was destroyed in the London blitz. Fabing immediately recognized that Pavlov’s years of scientific observations on the incidence of treatment of experimental neuroses in animals would greatly assist our study of the neurotic behavior patterns occurring in human beings subjected to abnormal wartime stresses.

Many of our new physical treatments, developed by mere trial and error, seemed to have been anticipated by Pavlov during his prolonged research on dogs. The Russians tended to scoff at the unprovable philosophic theories of Freud, Adler, and others, so popular in the Western world, where the Russians were sometimes equally despised for daring to suggest that human beings had any psychological affinities with dogs. Yet our acute war neuroses and some of the canine neuroses studied by Pavlov showed such pronounced points of similarity that I found it harder than ever to swallow the current Western psychoanalytical theories about the origin of abnormal behavior patterns in human beings — unless it were conceded that Pavlov’s dogs, too, had their own little subconscious minds, their own psyches, egos, superegos, and ids.

American psychiatrists, with a few notable exceptions, had ignored Pavlov’s work, though he was a Nobel Prize winner. And we British, too, found Pavlov’s experiments sometimes repugnant because the notion of causing animals experimental suffering upsets our sensibilities, as is right and natural. Moreover, the religious tradition that animals have brains but no souls — was even Tobit’s dog, despite his frequent appearance on medieval stained-glass windows, admitted into Heaven by the archangel Raphael? — makes any comparison between the psychological behavior of men and animals hard to accept.

Notwithstanding, therefore, the clear light thrown by animal experiments on the workings of heart, kidney, liver, and all other human organs, it is not surprising that the general Western attitude, when Pavlov began comparing the brain functions of his animals with those of human beings, was often critical; and this most important phase of his work had often passed unnoticed outside Russia. However, the desperate need to foster new approaches to psychiatric research in wartime Britain had helped to make our approach more realistic. Physical methods of treatment that directly affected brain function had shown such uncontradictably good results in the treatment of acute war neuroses that the then existing separation between treatments of the mind and the body had at last started to break down.

My reading of Pavlov’s book in 1944 — while coping with a mass of acute Normandy casualties, at Southport and Chichester — coincided with the discovery of important new facts about our abreactive treatment. We found that abreaction might be encouraged, not by the patient’s being made to relive a particular traumatic war experience, but by his discharging strong basic emotions not necessarily derived from such an experience. Thus we invented fearful and dangerous situations and suggested them to the patient under drugs, though carefully relating these planned emotional blowoffs to the patient’s actual war experiences.

For example, we might excitedly tell a member of the Royal Tank Corps who had broken down in battle that he was trapped in his burning tank and must fight his way out. Though this situation had not, in fact, happened to him, the fear that it might do so might have dominated his mind for months, making him wonder how he would face such a disaster, so that this unfulfilled fear was a probable contributory cause to his eventual breakdown.

Certain of Pavlov’s observations suggested to us that if we could raise the crescendo of a patient’s outburst to a grand finale of rage or terror, the necessary collapse would follow. A patient might well be helped. He would suddenly fall inertly back in bed exhausted by his emotional discharge, and on recovering, would tell us calmly that he felt quite himself again. If, however, little emotion had been released, and his war experiences had been relived only intellectually and not to the point of emotional collapse, we would have failed. What surprised us was finding that an implanted suggestion might produce a greater emotional discharge and be even more effective than the memory of a real event; and that we should, if possible, not lessen the emotional stress, but heighten it to the point of exhaustion.

So we developed a successful technique of deliberately inducing collapse by stimulating emotions of anger or fear in our semi-drugged patients, which was helped by our studying Pavlov’s experiments. For instance, he had reported a particular incident in 1924, when his dogs were almost drowned by the great Leningrad flood. A group of dogs conditioned by some months of patient work were trapped in their cages by the rising waters of the Neva River. A laboratory attendant found them swimming about at the top of their cages, with the water close to the roof, a terrifying situation which sent many of them after rescue into a stupor. Their individual nervous systems being incapable of coping with the shock, they had temporarily succumbed to “protective transmarginal inhibition” of the brain. The aftereffects of this emotional experience had been remarkable: when the severe inhibitory phase had passed off and left the dogs ready for new testing, Pavlov found that the ones which had switched over into stupor and collapse had lost the conditioned behavior patterns he had forced on them. This discovery greatly excited him. For years he had been learning how to implant these patterns of behavior in the dogs’ nervous systems, but he had much less idea of how to undo his work. The answer might lie here. And now we were watching the same phenomenon in human beings who, after severe emotional disturbances carried to the point of temporary emotional collapse, were freed by us of recently implanted behavior patterns and reverted to their more normal selves.

Pavlov had also spent many years showing what might happen when dogs’ brains were stimulated psychologically or physiologically beyond their tolerance of stress. Once this limit was passed — it might vary from animal to animal, as it does in human beings — a state of increasing and uncontrolled excitement supervened, whereupon the brain would develop varying degrees of “protective inhibition,” which might profoundly change its behavior. Before the final phase of stupor and collapse, three cumulative phases of protective brain inhibition under stress were noted. The first was the “equivalent” phase, when all stimuli, lesser or larger, produce the same result, just as with human beings who, if utterly exhausted, display no more pleasure on receipt of a ten-dollar bill than on that of a dime. The second phase was a “paradoxical” one: lesser stimuli produce greater responses than larger ones, now serving only to inhibit the brain function still further. Here a dime may give, as it were, greater pleasure than $5000. The third phase was an “ultraparadoxical” one, when positive conditioned patterns suddenly become negative, and vice versa. Thus small things often upset an exhausted man to the point of passion, though he may smile at an almost overwhelming disaster. And the ultraparadoxical phase, where Pavlov’s dog began to hate his beloved master and fawn on people whom he had previously shunned, is paralleled in the sudden complete switchovers from one strong human emotion to a diametrically opposed one. Pavlov showed how such changes could result from great stresses imposed on the nervous system; and also that hypnotic or hypnoidal behavior could be induced by the same means, especially by loading his dogs’ nervous systems with a batch of conflicting problems; we found this to be equally true of our acutely ill but previously normal patients in World War II.

The front-line treatment of combat neuroses has now become standard practice and is being very effectively used, when necessary, in Vietnam. But in peacetime and in sporadic combat, one rarely sees people reduced to these states of extreme anxiety, hysteria, or depression.

By introducing the new antischizophrenic, antidepressant, and tranquilizing drugs, by modifying the lobotomy operation, and by encouraging early admission to state hospitals (90 percent of all admissions to British state mental hospitals are now voluntary), we have made the early treatment of mental illness much easier. There is also a greater insistence that all treatments be used, both physical and psychological, that can help any single patient to get well. In British mental hospitals, one locked ward for males and one for females now are generally all that are needed, as a result of the progress which has been made through this total approach to treatment.

An opportunist and empirical, rather than a doctrinaire, approach to treatment has always paid the biggest dividends in general medicine. It has also proved to do so in British psychiatry, during World War II and since.