Part I
INTRODUCTION
CHAPTER I
Army Psychiatry Before World War II
Colonel Albert J. Glass, MC, USA (Ret.)
HISTORICAL NOTE
Awareness of mental disorder as a major military medical problem came about gradually, beginning in the latter half of the 19th century and developing parallel with the evolution of modern psychiatry. Little was written of psychiatric illness as such in the large six-volume official 'Medical and Surgical History of the War of the Rebellion.'1 Only 2,410 cases of insanity were recorded from the several million combat and noncombat casualties of that conflict. However, also included were 5,213 cases of nostalgia defined as 'a species of melancholy, or a mild type of insanity, caused by disappointment, and a continuous longing for the home.'2 In addition, J. M. Da Costa,3 an Army physician in the Civil War, studied so-called irritable and exhausted heart disorders out of which he described functional heart disease, many cases of which were apparently similar to the syndrome of neurocirculatory asthenia of World War I.
With the passing decades came increasing knowledge of mental disorders and greater uniformity of psychiatric nomenclature and classification. Medical officers of various countries noted an excessive prevalence of mental disease in military personnel, particularly in time of war. An increase in mental cases was reported during the Franco-Prussian War, the Spanish-American War, the Boer War, and the Russo-Japanese War.4 Rates of mental illness during these conflicts are given as ranging from 2 to 3 per 1,000 troops per annum. In the Russo-Japanese War (1904-6), an organized program was developed, for the first time, in which mental illnesses of military personnel were treated by specialists in psychiatry. Because the increased mental cases overtaxed the capability of the Russian Army Medical Service, the problem was turned over to the Red Cross Society of Russia which established psychiatric treatment facilities in
1Medical and Surgical History of the War of the Rebellion. Medical Volume. Washington: Government Printing Office, 1870, pt. I, vol. I, p. 639.
2Hall, J. K., Zilboorg, Gregory, and Bunker, Henry Alden (editors): One Hundred Years of American Psychiatry. Published for the American Psychiatric Assoc., by Columbia Univ. Press, New York, 1944, p. 374.
3Medical and Surgical History of the War of the Rebellion. Medical Volume. Washington: Government Printing Office, 1888, pt. III, vol. I, pp. 862-866.
4(1) Neuropsychiatry and the War. National Committee for Mental Hygiene, New York, 1917, p. 140. (2) Read, C. S.: Military Psychiatry in Peace and War. London: H. K. Lewis & Co., 1920.
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cities near the front as well as in rear home areas. Richards5 reported that the fear of the harmless gas bombs of the Japanese produced one form of psychosis. Depressive syndromes, general paresis, and alcoholic psychosis were frequent. Indeed, it was postulated that the development of organic psychoses was hastened or precipitated by the strain of wartime conditions.6
Problems of Diagnosis
It is evident that before World War I the incidence of psychoses mainly was recorded. The concept of neurosis was little appreciated during these years, and thus the diagnosis of psychoneurotic disorders, except for neurasthenia and hysteria, was seldom made. Salmon7 pointed out that these higher rates of insanity in military personnel during war were due in part to the failure to recognize 'the real nature of severe neuroses.' He offered as evidence repeated instances in World War I of many soldiers, suffering from undoubted war neurosis, who were evacuated as psychotic or insane. While such errors in diagnosis are quite probable, particularly in combat when the intensity of acute psychiatric symptoms may temporarily reach psychotic proportions, it is pertinent to note that rates of psychotic disorders of 2 to 3 per 1,000 troops per annum prevailed in World War II and in the Korean War as well as in World War I. This represents only a small increase over rates of psychoses of military personnal during peacetime (between 1 and 2 per 1,000 per annum). A more rational explanation for the relatively modest rise of psychotic disorders during war lies in the high proportion of personnel new to military service. Since the majority of psychotic disorders become evident in the first 2 years of service, whether in peace or war, it is likely that large increments of new personnel were mainly responsible for the somewhat higher figures of wartime mental illness.
Although there is a minor rise in the psychosis rate during any war, a major increase in the incidence of neurotic disorders was observed, starting with World War I. Whether the war neuroses were not recognized in earlier years, owing to lack of psychiatric sophistication, or whether they simply did not occur because of the relatively low destructive power of weapons before World War I, cannot be answered. However, the total psychosocial matrix in any war must be kept in mind. Morale, motivation, and the quality of leadership are always important factors. All armies had deserters, malingerers, defaulters, and 'escapists.' The more modern armies had fewer roads of 'escape' which would permit individual adaptation. Also, stress and strain were more constant and prolonged.
5Richards, R. L.: Mental and Nervous Diseases in the Russo-Japanese War. Mil. Surgeon 26: 177-193, February 1910.
6Neuropsychiatry and the War. National Committee for Mental Hygiene, New York, 1917, pp. 220, 223.
7Ibid., p. 499.
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Army Psychiatry, 1900-17
In the early years of the 20th century, psychiatry in the U.S. Army made slow progress. As in previous decades, cases of so-called insanity were either discharged from the service or were transferred to the Government Hospital for the Insane at Washington, D.C. (now St. Elizabeths Hospital). However, the desirability of having medical officers more equipped to handle such cases was becoming increasingly recognized. Dr. William A. White, the Superintendent of the Government Hospital for the Insane, gave a series of lectures on psychiatry each year to classes of the Army and Navy Medical Colleges. It also became the custom to detail one medical officer each from the Army and the Navy to the Government Hospital for the Insane to study mental diseases for a 2-year period. The incidence of insanity in Army enlisted personnel in the decade of 1901-11 continued at the usual rate of 1 to 2 per 1,000 troops per year.8
Beginning on 1 January 1912, insanity as a diagnostic entity was discarded in favor of 'mental alienation' which included not only dementia praecox and other functional and organic psychoses but also defective mental development, constitutional psychopathic states, hypochondriasis, and nostalgia. Excluded from mental alienation were such neurotic afflictions as neurasthenia and hysteria, also alcohol and drug addiction. A prompt result of this change was an increase in the reported frequency of mental disease (mental alienation) to rates of 3 to 4 per 1,000 troops.9 According to Maj. Edgar King,10 the percentage of disability discharge for mental alienation in 1912 (20 percent) was higher than any other cause and would have been larger if hysteria or neurasthenia were included. It is noteworthy that mental illness has continued to be the leading cause of medical discharge even up to the present writing (1965), with dementia praecox (schizophrenia) as the single most important disease from the standpoint of disability.
WORLD WAR I
From the earliest fighting of World War I, in 1914, there appeared accounts of a new psychiatric disorder termed 'shell shock,' which was of such prevalence as to constitute a major military medical problem.11 It seemed that warfare which had reached new heights of destruction and terror with weapons of high lethal and explosive power, grinding trench fighting, fatigue, and exposure had evoked a novel psychiatric entity. In time, the Allied Medical Services came to understand that 'shell shock' was a psychological disorder and not due to brain injury from the airblast
8Annual Reports of The Surgeon General, U.S. Army. Washington: U.S. Government Printing Office, 1902-12.
9Report of The Surgeon General, 1913.
10Neuropsychiatry and the War. National Committee for Mental Hygiene, New York, 1917, p. 221.11Ibid., pp. 225, 237.
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of high explosives. Concurrently, trial and error treatment efforts by French, Italian, and British psychiatrists and neurologists clearly demonstrated as early as 1915 and 191612 that a majority of the so-called war neuroses could be salvaged for duty by providing care near the front. Conversely, evacuation of such cases to rear hospitals produced fixation of symptoms and chronic disability.
National Committee for Mental Hygiene.-News reaching the United States of the new and dramatic psychiatric syndromes of combat excited much comment and discussion in medical and psychiatric circles. Particularly concerned was the National Committee for Mental Hygiene, a young and vigorous organization composed of prominent laymen, physicians, and psychiatrists and dedicated to the prevention and treatment of mental illness. Under the leadership of Dr. Thomas W. Salmon, who had been appointed medical director in 1915, the Committee made its services available to the Army Surgeon General to aid in planning for the management of psychiatric disorders in the event the United States became involved in the war.13 Members of the Committee visited Army medical facilities mainly at posts along the Mexican border and in Canada and England, to obtain firsthand information on the current status and needs of psychiatry in the U.S. Army and on the experiences of the Allied Medical Services with psychiatric casualties. Based upon these visits, comprehensive recommendations for establishing a psychiatric program for the U.S. Army were made to The Surgeon General, which in the main were accepted.14
With the entry of the United States in the war, the War Work Subcommitte of the National Committee for Mental Hygiene became actively engaged in furthering the military psychiatry effort, which included the recruiting and training of psychiatrists, neurologists, psychiatric nurses and attendants, and social workers. Committee members Dr. Pearce Bailey and Dr. Thomas W. Salmon were commissioned and given responsible psychiatric assignments. Major Bailey in the United States and Major Salmon in the American Expeditionary Forces implemented the organization and operation of the Army psychiatry program at home and overseas. An account of this program and its results has been well documented in volume X of the 'Medical Department of the United States Army in the World War.'
LESSONS OF WORLD WAR I
Much was written of the lessons of psychiatry learned in World War I, particularly during the period of mobilization and early phases of World
12The Medical Department of the United States Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X, pp. 507-512.
13Hall, J. K., et al., op. cit., p. 385.
14The Medical Department of the United States Army in the World War, vol. X, pp. 5-13; 489-496.
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War II. Prominent civil and military medical authorities15 pointed out that World War I had demonstrated the necessity and feasibility of psychiatric screening in eliminating overt and covert mental disorders prior to entry in the military service. Emphasized by these authorities, based upon the experience of World War I, was the inability of emotionally unstable or otherwise psychiatrically vulnerable persons to absorb training profitably, to tolerate stress, or otherwise to make any useful contribution to the military effort. Also cited as further evidence for the thorough screening out of even potential psychiatric problems was the high cost of mental disorders in war that included their deleterious effect on other soldiers, the increased requirements of medical personnel and facilities to care for these problems, disability pensions, and other veterans' benefits.
However, it became evident during World War II that psychiatric screening at the induction level was neither an effective nor practical procedure.16 The incidence of psychiatric disorders in World War II was two to three times that of World War I despite the fact that rejections for psychiatric reasons were five to six times greater than those of World War I.17 It is, therefore, a matter of some historical and professional concern to understand the reasons why psychiatric screening presumably produced such excellent results in World War I and was a failure in World War II. One can argue that the psychiatrists of World War I were more skilled in the techniques of screening than were their counterparts in World War II. But this is an unlikely possibility in view of the advances in psychiatry during the two decades between the wars. Indeed, the increased knowledge and sophistication of the World War II psychiatrists may well have been a crucial factor in accounting for differences in psychiatric screening of the two wartime periods.
Psychiatrists of World War I, mainly trained and experienced in institutional practice and following a model of descriptive or Kraepelinian psychiatry, identified and eliminated individuals who manifested obvious symptoms of mental disease and defect. Only 2 percent of recruits were rejected for neuropsychiatric reasons in World War I, which included epilepsy and organic central nervous system diseases, as well as functional disorders. The neuroses accounted for only 16.5 percent of rejections as compared to 31.5 percent for mental deficiency, 11.4 percent for psychoses,
15(1) Hillman, C. C.: Medical Problems Encountered in Military Service. Ann. Int. Med. 13: 2205-2211, June 1940. (2) Editorial. With Emphasis on the Word Selective. Mil. Surgeon 87: 265-266, September 1940. (3) Bowman, K. M.: Psychiatric Examination in the Armed Forces. War Med. 1: 213-218, March 1941. (4) Sutton, D. G.: Naval Psychiatric Problems. Am. J. Psychiat. 97: 225-275, September 1940. (5) Porter, W. C.: Military Psychiatry and Selective Service. War Med. 1: 364-371, May 1941. (6) Pratt, J. H.: Psychiatric Factors in Medical Examination. War Med. 1: 358-363, May 1941. (7) Davidson, H. A.: Mental Hygiene in Our Armed Forces. Mil. Surgeon 86: 477-481, May 1940.
16Glass, Albert J.: Psychosomatic Medicine. In Medical Department, United States Army. Internal Medicine in World War II. Volume III. Infectious Diseases and General Medicine. [In preparation.]
17Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, pp. 338-347.
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and 8.9 percent for constitutional psychopathic states.18 The modern concept of personality development was not widely known or accepted at that time, although Salmon and others were familiar with the teachings of Sigmund Freud.
Conversely, psychiatrists in World War II, and indeed the prevailing culture, were much more conversant with neurotic disorders and the probability of this or that vulnerable personality becoming decompensated or disabled when exposed to stress. Thus, it may be said that psychiatric screening in World War I accomplished, in the main, elimination of overt mental disease and defect. In World War II, however, the screening procedure involved the rejection of covert or potential emotional problems in individuals with so-called character neurosis or other personality weaknesses, as well as with the more obvious psychiatric disorders. Unfortunately, this procedure proved to be inaccurate and impractical for predicting which type of personality would succumb to 'stress,' particularly when performed by a rapid examination.
There are other considerations which bear upon this question. First, data of World War I do not demonstrate the validity of the screening process despite the strong convictions of Bailey, Salmon, and other World War I psychiatrists. Second, in World War II, military personnel were exposed to weapons of greater destructive power and to more severe environmental and other deprivations over a longer period of time than in World War I. Morale factors including quality of leadership, training, and basic motivation from home or indoctrination acquired in the Army may also have played an important role. In effect, the conditions of the two wars were different in both quantity and quality of hardship and terror. Despite the foregoing, one cannot escape the conviction that the lesson of psychiatric screening of individuals learned in World War I may have been sound; namely, that gross or overt mental disorder or defect can and should be eliminated at induction.
PSYCHIATRY, 1920-30
The experiences of psychiatry in World War I had a lasting effect on Army medical practice. Following the cessation of hostilities and the return of the Army to a small peacetime force, psychiatric treatment facilities which had been established during World War I were maintained and became a regular component of military medical care. These clinical facilities, consisting of open and closed wards, consultation services, and outpatient activities, functioned as a section of the medical services at Walter Reed General Hospital, Washington, D.C., Letterman General Hospital, San Francisco, Calif., William Beaumont General Hospital, El Paso,
18(1) The Medical Department of the United States Army in the World War, vol. X, p. 157. (2) Appendix A, 'Disqualifications and Discharges for Neuropsychiatric Reasons, World War I and World War II (A Comparative Evaluation),' p. 761.
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Tex., and Fitzsimons General Hospital, Denver, Colo.; at the Station Hospital, Fort Sam Houston, Tex.; at Sternberg General Hospital, Manila, P.I.; and at Tripler General Hospital, T.H. As before the war, selected career medical officers were assigned to St. Elizabeths Hospital for 2 years of psychiatric training. In the first decade after World War I and to a lesser extent in the following years, the psychiatric sections of Army hospitals also served as receiving and treatment facilities for veterans with acute mental illness.
Incidence of Mental Disorders
Rates of hospitalization for mental disorders in Army personnel during the postwar period (1920-30) ranged from 11 to 12 per 1,000 men per year.19 These rates included admissions for 'mental alienation' (dementia praecox, manic depressive psychosis, general paresis, alcoholic and other organic psychoses, mental deficiency, constitutional psychopathic states, hypochondriasis) and various neurotic disorders (hysteria, neurasthenia, psychasthenia, psychoneurosis, neurocirculatory asthenia). The incidence of psychotic disorders during this period was from 2 to 3 per 1,000 per annum. Excluded from the preceding mental disease categories were admissions for neurological diseases, drug addiction, and acute and chronic alcoholism. Admissions for alcoholism alone during this 10-year period were from 7 to 8 per 1,000 per annum, a marked decrease from rates of approximately 16 per 1,000 per annum for alcohol admissions in the decade prior to World War I (1907-16) before the establishment of the National Prohibition Act. That mental disorders constituted a major medical problem in the postwar era is indicated by the following data:
1. Suicide was the leading cause of death in military personnel in this decade (over 0.5 per 1,000 strength per annum).
2. Mental disorders as a class were the largest cause for medical discharge with a rate of 6 to 7 per 1,000 strength per annum, which indicated that more than one-half of the admissions eventuated in discharge.
3. Dementia praecox was the leading single disease cause for medical discharge (2 to 3 per 1,000 strength per annum).
4. In general, mental disorders, excluding alcoholism and drug addiction, were first as a cause for discharge, fifth or sixth as a cause for hospital admissions, and third or fourth in producing loss of duty time for medical reasons.
5. Mental disorders were the leading cause for medical evacuation from oversea stations.
19Annual Reports of The Surgeon General, 1921-31.
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Psychiatric Screening
Army medical authorities were well aware that nervous and mental disorders constituted a large and important segment of military medical workload. Annual reports of The Surgeon General during this period made frequent references to the extent and seriousness of mental disorders and manpower loss presented by this group. Major emphasis for the existence of the problem was placed upon errors in the recruitment of mentally unfit soldiers as follows:
Nervous diseases alone caused a loss of more than one-third of the total days [lost], averaging 71.8 days per case. When one considers the cost of enlisting, transporting, equipping, feeding, hospitalizing, and paying such men, the majority of whom probably rendered little if any efficient military service, and many of whom no doubt when not in the guardhouse or hospital were an actual liability rather than an asset to their organization, the very great expense entailed by the enrollment of them is apparent.20
* * * * * * *It is extremely regrettable that the lessons learned during the war regarding neuropsychiatric conditions are not being used in the selection of recruits. That this is not being done is evidenced by the large number of candidates with neuropsychiatric conditions which are passed by recruiting officers.21
It is evident that there existed then, as later in the World War II era, a conviction that the proper screening of the mentally unfit at induction or recruitment was the basic solution for eliminating the psychiatric problems of military service. This is illustrated by a notation in the Annual Report of The Surgeon General of 1926 which stated that a board of officers was appointed at Fort Leavenworth, Kans., to study recruiting problems of enlisted persons who shortly thereafter were found to be mentally deficient or suffering from some form of psychosis which caused their discharge and that 'studies are now underway and it is hoped that in the near future some system may be put into operation which will materially reduce the number of mentally unfit recruits who are accepted for enlistment.'22 Only occasionally was there a comment in The Surgeon General's annual reports recognizing that mental illness might be difficult to detect at the time of recruit examination. Apparently, the ease of identification of mental disorders, sufficiently symptomatic as to require hospitalization, created widespread belief that such individuals could be readily recognized at recruitment even though at a different time and under other circumstances.
It was not until 3 June 1931 that AR (Army Regulations) 600-750, 'Personnel: Recruiting for the Regular Army,' was revised. Paragraphs 16 and 17 of this regulation are recorded here because they pointedly exhibit one drastic effort made to compel recruiting officers to exercise
20Annual Report of The Surgeon General, 1924, p. 10.
21Ibid., p. 313.
22Annual Report of The Surgeon General, 1926, p. 209.
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better caution in accepting applicants for enlistment. This regulation remained in force until superseded on 10 April 1939.
(Par.) 16. Improper acceptance-proceedings of board.-a. Upon arrival at a place designated for enlistment of an accepted applicant he will be examined with the least practicable delay, with a view to enlistment or rejection. b. If in the opinion of the commanding officer of the post, camp, or station the disqualification of any rejected applicant be of such a character that it should have been discovered by the recruiting officer who accepted and forwarded the applicant to the place of enlistment, the commanding officer will convene a board of three officers, one of whom will be a medical officer, to examine into the case and report whether the disqualification should have been discovered by the recruiting officer. * * *
(Par.) 17. Stoppage of pay for improper acceptance or enlistment.-Recruiting officers will be held to a strict accountability for accepting and forwarding men who may be found unfitted for the service, and officers who enlist such applicants will be held to a like accountability. If a man after having been enlisted at a military post or accepted at a recruiting station and forwarded to the designated place for enlistment be discharged or rejected, and it appears that the enlistment or acceptance was carelessly made or in violation of these regulations, the expenses incurred in consequence of the enlistment or acceptance of the man may be stopped against the pay of the officer responsible.
Psychiatric Practice
The practice of military psychiatry at large Army hospitals during this decade was similar to the diagnostic and treatment procedures in comparable civilian institutions. Letterman General Hospital noted, in 1922, that 'practically all neuropsychiatric cases in this hospital were under the direct charge of medical officers who had had special training in this line of work. * * * the importance of the neuropsychiatric conditions and their definite relation to other medical and surgical conditions is rapidly becoming more appreciated. Many requests for consultations were received.'23 William Beaumont General Hospital reported the successful treatment of psychoneurotic disorders with hysterical manifestations noting that 'some of these cases after years of invalidism have been cured through the efficient handling of a skillful psychiatrist.'24
A good deal of emphasis was placed upon the use of hydrotherapy, also recreational therapy and physiotherapy in selected cases. Thus, in 1923, Letterman General Hospital reported:
One of the most desirable features of ward No. 19 is the complete hydrotherapy plant in the basement of this building. During the past year the availability of qualified enlisted men to take charge of this work has made this department a decided success. Hydrotherapy administered in a scientific manner has been made use of day and night during the entire year with most satisfactory results.25
In 1927, Walter Reed General Hospital reported that its physical
23Annual Report of The Surgeon General. 1923, p. 226.
24Annual Report of The Surgeon General, 1927, p. 396.
25Annual Report of The Surgeon General, 1924, p. 314.
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facilities were improved with four closed wards, two open wards, and one neurological ward. Malarial treatment for cerebrospinal syphilis and general paresis was used in 19 cases. The use of restraints, both chemical and mechanical, was reduced to a minimum.26 In 1930, Walter Reed General Hospital had no facilities for the treatment of insane women. However, the neuropsychiatric staff reported favorably on the continuation of therapeutic malarial treatment and the use of pneumoencephalography for diagnosis, noting its curative effects on 'obscure epileptics.'27
During the years, there were the usual complaints of insufficient personnel, both officer and enlisted, to handle the heavy workload in psychiatry and neurology.
Aviation Psychiatry
In 1921, the School of Aviation Medicine was established at Mitchel Field, N.Y. It later moved to San Antonio, Tex. (Randolph Air Force Base). At the inception of the school, a department of neuropsychiatry was established which was concerned with the problems of psychiatry in aviation medicine, particularly personality study with a view toward selection of suitable candidates for pilot training. Instruction was given which included clinical psychiatry and paid special attention toward performing an adequate psychiatric examination for flying candidates.28 In 1928, the Department of Neuropsychiatry of the School of Aviation Medicine announced a research program focused upon securing better methods of performing the neuropsychiatric portion of the flying examination and the evaluation of flying proficiency. 'There is no subject more baffling than that of personality, and that happy combination of qualities which enter into the personality make-up of the successful flyer remains undiscovered.'29
Instruction in psychiatry at the Army Medical School, Washington, D.C., as before World War I, consisted of a series of lectures which placed emphasis on recognition and elimination of the mentally unstable applicant for the military service and on techniques of diagnosing mental cases occurring among military personnel.30
PSYCHIATRY, 1930-40
Incidence of Mental Disorders
In the decade before World War II (1930-39), social and economic changes, in addition to the growing threat of war, markedly influenced
26Annual Report of The Surgeon General, 1927, p. 330.
27Annual Report of The Surgeon General, 1930, p. 336.
28Annual Report of The Surgeon General. 1924, pp. 264-269.29Annual Report of The Surgeon General, 1928, p. 325.
30Ibid., p. 317.
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both the frequency and the nature of military psychiatric problems. Beginning in 1930, traumatic injury from automobile accidents replaced suicide as the leading cause of death in Army personnel. This change took place despite increased suicide rates during this period. The lowest suicide rate of the Army after 1900 occurred during World War I with a frequency of less than 0.2 per 1,000 enlisted strength. After 1918, there was a steady upward trend which reached a peak of over 0.5 per 1,000 strength in the severe depression years (1931-34) but never attaining the high rate of suicide before World War I (over 0.6 per 1,000 strength per year). From 1935, the suicide rate declined, and in 1939, the rate of 0.29 per 1,000 strength was the lowest suicide record of the previous 10 years.31
For reasons not explainable, admissions for alcoholism, acute, chronic, and with psychosis, except for 1 year (1931) decreased steadily in an irregular fashion from 7.2 per 1,000 strength in 1930 to 3.3 in 1939. This decline was even accelerated after the repeal of prohibition in 1933.32 It is probable that several factors were involved in the reduction of alcohol admissions, including an improved quality of enlistees; policy changes which discouraged the hospitalization of uncomplicated acute alcoholism, a major source of alcohol admissions; and greater psychiatric sophistication than hithertofore which fostered diagnoses of personality, neurotic, or psychotic disorders for many individuals whose alcohol excesses were found to be a manifestation of mental abnormality or disease.
Incidence Rates Versus Quality and Quantity of New Accessions
Admissions for mental disorders were also fewer than those of the previous decade, ranging from 7 to 9 per 1,000 strength in 1930-39, as compared to 11 to 12 per 1,000 strength in 1920-29. In part, at least, a cause for this decline was the widespread economic depression which made available more qualified recruits than in previous years. It is pertinent to note that decreased psychiatric admissions began in 1931 rather than at the beginning of the depression. Indeed, The Surgeon General reported that notwithstanding the large amount of unemployment there was little improvement in the character of recruits during the year 1930.33 However, an improvement was noted in 1931 when it was reported that because of the increase in the number and quality of the applicants 'the recruiting service has among other things insisted upon a higher mental standard, the score of the intelligence test having been raised to a minimum of 50 from 44.'34
Another concurrent circumstance during this period which contributed to the decreased frequency of psychiatric admissions involved a lessened
31Annual Reports of The Surgeou General, 1931, pp. 44-46; 1940, pp. 66-68.
32Annual Report of The Surgeon General, 1940, pp. 51-52.33Annual Report of The Surgeon General 1931, pp. 3, 63, 406.
34Annual Report of The Surgeon General, 1932, p. 307.
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input of personnel new to military service. It has been a common observation that discharges for medical reasons mainly occur from men in their first enlistment. This is particularly true for nervous and mental disorders. Thus, in 1931, The Surgeon General reported: 'In 52 percent of the men who were discharged for disease of the nervous system, the condition became apparent during the first year of service, in an additional 15 percent during the second year, and in 7 percent during the third year, a total of 74 percent during the first term of enlistment."35 These findings indicate that a decreased proportion of recruits in the troop population could favorably influence the incidence of mental disorders. Such circumstances prevailed in 1931, 1932, and 1933, when new enlistments comprised 10 to 14 percent of the total enlisted strength. During this period, psychiatric admissions declined to 7.4 percent in 1933, the lowest rate of the post-World War I era.36 However, as stated previously, also operative during this period was the depression which produced an availability of well-qualified recruits. It is therefore reasonable to conclude that two conditions will contribute toward reducing the rate of psychiatric admissions: (1) Well-qualified recruits from the standpoint of intelligence or educational level, and (2) a stabilized military force with only a small number of accessions each year.
From 1934 to 1939, the increasing size of the Army and a corresponding rise in the percentage of new enlistments, along with a gradual lessening of the economic depression, reversed the favorable conditions of the previous several years. The psychiatric admission rate rose to 8.5-9 per 1,000 strength per annum.37 The lesson that can be learned from the aforestated data indicates that in any mobilization period, with its large numbers of new inductees, a significant elevation of the incidence of psychiatric disorders should be expected.
Renewed Emphasis on Psychiatric Screening
Despite the foregoing evidence of the importance of personnel input in determining the incidence of psychiatric disorders, there continued to be in this decade as well as the previous 10 years a constant reiteration relative to the need for more effective psychiatric screening of recruits. In 1931, it was again stated:
Mental and nervous diseases are of increasing importance as a cause of military unfitness. Since the World War they have caused 44 percent of all discharges for physical or mental unfitness among the white enlisted men serving in the United States, which is more than three times as great as prior to the Spanish-American War, and more than twice as great as between that war and the beginning of the World War. This should not, however, be considered as evidence of the increasing prevalence of
35Annual Report of The Surgeon General, 1931, p. 5.
36Annual Reports of The Surgeon General, 1932-34.37Annual Reports of The Surgeon General, 1935-38, 1940.
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such conditions in our population, but rather chiefly as an indication of the unsatisfactory results of our present system of the physical examination of applicants for enlistment, and to a lesser extent to refinements in diagnosis.38
Various corps and department surgeons repeated this criticism of unsatisfactory recruit examination and argued against assignment to the recruiting of any available medical officer, usually retired, and often a civilian physician. They recommended placing recruits on a probationary period and then for a board of especially qualified and trained medical officers to pass on their eligibility. Enlistment would be completed only when the probationer had been demonstrated to be free from disqualifying defects. It was further suggested that only Regular Army medical officers perform the examinations of applicants rather than civilian doctors unaccustomed to Army requirements.39 The School of Aviation Medicine also maintained considerable interest in the area of selection. Research efforts were continued toward the development of objective tests to be used in connection with personality studies in selecting candidates for flying.40
With the foregoing preoccupation with elimination of psychiatric problems at the induction level, there were occasional references that situational stress could produce emotional disability. Thus, a medical board after a 4-year study found that, after 2 years of service in the Philippine Islands, the mental and physical efficiency of officer personnel was impaired. It was recommended that a tour of service prolonged beyond 2 years be considered inadvisable.41
Psychiatric Practice
The practice of Army psychiatry was similar to that of the previous decade, but in the early years of the depression there was a good deal of comment relative to the shortages of personnel. The Veterans' Administration in the latter part of 1932 began to withdraw patients from Army hospitals.42 In 1933, veteran patients of all types had been curtailed from 2,000 to 457. Also, in 1933, the Civilian Conservation Corps was established which produced a demand upon Army hospitals for their care and treatment.43
On 1 July and 30 December 1930, Walter Reed General Hospital placed into operation new buildings for the open- and closed-ward treatment of psychiatric patients with a capacity of over 200 beds. With pride and approval, various built-in safety features were described, such as baths set in the wall, toilets of one piece flushed by a button insert, and showers which utilized cone-shaped projections from the wall precluding the possi?
38Annual Report of The Surgeon General, 1931, pp. 4-5.
39Ibid., p. 402.
40Ibid., p. 359.
41Ibid., p. 274.42Annual Report of The Surgeon General, 1933, pp. 3, 151-152.
43Annual Report of The Surgeon General, 1934, pp. 139, 141.
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bility of a patient's suspending himself from them.44 This improved facility permitted a greater number of patients to be treated, and it was noted in the following year that the neuropsychiatric building was highly satisfactory. The use of malaria in the treatment of general paresis and central nervous system syphilis was continued and also implemented in selected cases of dementia praecox but 'the experience was too small to warrant any opinion as to its value.'45
Letterman General Hospital reported that if personnel were available the full time of one medical officer could be taken up with consultations alone, since such were frequently asked for, not only by medical officers but also by the local office of the Veterans' Administration. Most Army psychiatric hospitals regretted that there were inadequate facilities for the hospitalization of insane officers, or for tuberculous patients who were mentally disturbed.46
In general, during this period, diseases of the nervous system continued to be first as a cause of discharge with dementia praecox being the leading single cause for medical disability, eighth as a cause of admissions, fifth as a cause of time lost, and remained first in medical evacuation from oversea stations. In 1938, the category 'mental alienation' was discarded in favor of the general terminology 'mental disease and deficiency.' Schizophrenia was adopted officially for the first time in place of dementia praecox.47
MOBILIZATION PERIOD
As the threat of war in Europe grew and finally became a reality in 1939, the leisurely pace of Army expansion, which began in 1935, quickened into the heightened activity of mobilization. Although our primary concern here is in military psychiatry, it is pertinent to note that medical mobilization planning was far from efficient. During the prewar period, medical planning was formulated apparently without even consulting The Surgeon General. For example, the 1938 Protective Mobilization Plan prescribed that maximum use be made of Army hospitals under the control of corps area commanders and further directed the corps area commanders to make surveys of the normal average number of vacant beds in Veterans' Administration facilities, U.S. Public Health Service hospitals, and Indian Medical Service hospitals, whose location was such as to make their use feasible for the hospitalization of Army personnel. These provisions were not well considered for the following reasons:
1. The parceling out of Army patients in driblets to fill the empty
44Annual Report of The Surgeon General, 1931, p. 364.
45Annual Report of The Surgeon General, 1932, p. 263.
46Ibid., pp. 270, 288.
47Annual Reports of The Surgeon General, 1938, p. 56; 1939, pp. 57, 109, 135.
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beds of hospitals not under military control was administratively unsound and insufficient to meet the expected needs of mobilization.
2. The data which the corps area commanders were directed to secure by surveys were readily available at the respective headquarters of the Veterans' Administration, the U.S. Public Health Service, and the Bureau of Indian Affairs, in Washington, D.C.
3. The Protective Mobilization Plan had completely forgotten one of the most successful and notable lessons of World War I: the formation of military hospitals by civilian medical institutions (hospitals and medical schools).48
It was well after the publication of the 1938 Protective Mobilization Plan that, in March 1939, The Surgeon General reminded the War Department General Staff of the outstanding success of the volunteer hospitals in World War I and requested approval for the sponsored system of general, evacuation, surgical, and station hospitals. On 3 August 1939, the Secretary of War approved the organization of affiliated reserve units as recommended by The Surgeon General.49
Psychiatric Planning for War
In contrast to the endeavors of The Surgeon General in planning for the medical and surgical problems of mobilization, there was no comparable effort in the sphere of military psychiatry. Such an omission is all the more surprising because the experience of even the peacetime Army after World War I had demonstrated the prevalence of psychiatric disorders of such magnitude as to be the subject of repeated comment in the Annual Reports of The Surgeon General since 1920. Moreover, as indicated previously in this chapter, there was clear evidence that the induction of large numbers of newly mobilized personnel would significantly increase the incidence of psychiatric disorders. Further and most important, there was the documented history of World War I, as well as accounts from other previous wars, which provided abundant evidence that combat would produce large numbers of psychiatric casualties. Indeed, World War I experience indicated that for every four men wounded there would be one psychiatric battle casualty.50
Despite the foregoing data that were available to responsible authorities, there was no effective plan or real preparation for the utilization of psychiatry by the Army in World War II. The Army had no criteria or procedure for the induction of a large fighting force. Facilities for the care and treatment of psychiatric cases were only barely sufficient for the small peacetime Army. Even the value of the division psychiatrist which
48Kreidberg, Marvin A., and Henry, Merton G.: History of Military Mobilization in the U.S. Army. 1775-1945. Washington: U.S. Government Printing Office, 1955. (DA Pamphlet 20-212.)
49Annual Reports of The Surgeon General, 1939, p. 179; 1940, p. 177.
50Menninger, op. cit., p. 11.
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had been so clearly demonstrated in World War I was forgotten. With the reorganization of combat divisions in 1941, in a move toward economy of personnel, the psychiatrist was dropped from the divisional medical staff, which deletion was apparently agreed to by medical officers in charge of plans and training in the Surgeon General's Office at that time. According to Overholser,51 the civilian psychiatrists who were endeavoring to offer help in Army planning were apparently unaware of the fact that division psychiatrists were omitted from War Department Table of Organization No. 8-21, 1 November 1940. It was not until November 1943 that they were reinstated.52
Career Military Psychiatrists
From the standpoint of career military personnel, there were relatively few trained psychiatrists in the Regular Army. Although the Army (and the Navy) had been sending medical officers to St. Elizabeths Hospital for psychiatric training since 1909, there were only a scant number during this period (fewer than 20) on active duty status who had received psychiatric training.53 In 1940, although there were 35 medical officers of the Regular Army Medical Corps assigned to psychiatric positions, 'only four were certified by the American Board of Psychiatry and Neurology, and many of the others had had no formal specialized psychiatric training.'54 In addition, psychiatry occupied a subordinate role, functioning as a section under the medical service in Army hospitals and having little influence in policy decisions at the level of the Surgeon General's Office.
During the expansion of mobilization and at the onset of hostilities, the vast majority of Regular Army psychiatrists, like other career medical officers, were transferred to command and administrative assignments. Only Col. William C. Porter, MC, remained throughout the wartime period in a purely professional psychiatric position. Col. Ernest H. Parsons, MC, commanded an oversea psychiatric hospital, and Col. Cleve C. Odom, MC, succeeded to the command of two Army general hospitals (Darnall and Mason General Hospitals) which were exclusively devoted to the care and treatment of neuropsychiatric patients. Thus, the practice of psychiatry in the Army during World War II became the responsibility of newly inducted physicians with little or no military experience. In brief, as in World War I, Army psychiatry in World War II was fated to be primarily a civilian psychiatric effort. For this reason, it is appropriate to consider
51Overholser, Winfred: Early Steps in Psychiatric Mobilization. [Unpublished manuscript.]
52War Department Circular No. 290, 9 Nov. 1943, recreated and authorized the position of division psychiatrist and outlined his duties.
53Brig, Gen. Eugen G. Reinartz, Col. Walter A. Carlson, Col. Rawley E. Chambers, Col. (later Brig. Gen.) Sidney L. Chappell, Col. Frank H. Dixon, Col. Walter S. Jensen, Col. Edward J. Kendricks, Col. John M. Caldwell, Col. Harry E. Hearn, Lt. Col. George E. Hesner, Col. Francis E. Weatherby, Col. Emmett B. Litteral, Col. Patrick S. Madigan, Col. Cleve C. Odom, Col. Ernest H. Parsons, Col. William C. Porter, and Brig. Gen. William L. Sheep.
54Menninger, op. cit., p. 14.
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the state of readiness, preparation, and participation of civilian psychiatry during the mobilization period before World War II.
MOBILIZATION OF CIVILIAN PSYCHIATRY
When it became increasingly clear that the United States might be drawn into the war, individual psychiatrists and psychiatric organizations became concerned with the role of psychiatry in mobilization and made preparations to advise the military services in their special sphere. In June 1939, Dr. William C. Sandy, president of the American Psychiatric Association, appointed a committee on military mobilization 'to be devoted to preparation for emergencies and to confer with other Services as to needs and as to available personnel.'55 The committee was headed by Dr. Harry A. Steckel who had served as a division psychiatrist in World War I and included Drs. Francis H. Sleeper, Appleton H. Pierce, Walter J. Otis, and Samuel W. Hamilton. Committee members met with representatives of the Surgeons General of the Army and Navy on 16 October 1939, and as a result surveyed civilian psychiatric personnel by questionnaire and prepared a list of available psychiatrists. The committee also conducted a roundtable discussion on military psychiatry at the annual meeting of the association in May 1940, made an inspection trip of the Canadian Army, and participated in conferences with selective service officials. These efforts of the American Psychiatric Association were considered mediocre by some contemporary observers. Menninger56 stated that the committee members 'worked hard but met with lukewarm interest on the part of Army authorities.' More critical was Deutsch, who wrote: 'It must be said, in truth, that the steps taken by the Association to give leadership and direction to the psychiatric aspects of military mobilization were at first marked by hesitation and uncertainty of purpose. * * * the American Psychiatric Association seemed content to offer its services to the appropriate authorities and patiently wait to be called.'57
At the May 1942 meeting of the American Psychiatric Association, it was the opinion of the association that the Army and Navy were not utilizing psychiatric facilities and personnel effectively and that these resources were being 'shockingly unappreciated in spite of the lesson learned from the last World War.' A resolution was passed authorizing the appointment of 'a well chosen committee with power to act in making forceful representation of this status of affairs.' Drs. Arthur H. Ruggles, Edward A. Strecker, and Frederick W. Parsons, who composed the committee, later were appointed as consultants to The Surgeon General.58
55Overholser, op. cit.
56Menninger, op. cit., p. 10.
57Deutsch, A.: Military Psychiatry, World War II. In One Hundred Years of American Psychiatry. Published for the American Psychiatric Assoc., by Columbia Univ. Press, New York, 1944, p. 420.
58Overholser, op. cit., p. 10.
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However, Menninger stated that 'not until 1944 did the Neuropsychiatry Consultants Division of the Surgeon General's Office request consultation with these men regularly.'59
One of the first groups advocating psychiatric mobilization was the William Alanson White Psychiatric Foundation of Washington, D.C. In October 1939, a committee of the foundation was constituted to aid in 'the more effective utilization of psychiatry in the national defense.'60 Through the efforts of its president, Dr. Harry Stack Sullivan, the foundation, by the publication of articles and speeches, vigorously urged greater psychiatric participation in planning for mobilization. Particularly emphasized was the need for adequate psychiatric screening of draft registrants.
Another important influence for psychiatric screening was the Federal Board of Hospitalization which, on 16 July 1940, adopted a resolution regarding additional hospital beds which might be required in a national emergency. One provision of the resolution stated: 'The Board also finds that clearly associated with this problem is the careful physical examination of men upon entry into military service in order to eliminate as far as possible later potential claims against the Government arising out of disabilities existing at the time of induction into service.' The resolution was given weight in the psychiatric sphere by an extensive memorandum requested by the Board from Dr. Winfred Overholser, Superintendent of St. Elizabeths Hospital, also a member of the Board, which, while dealing with the additional hospital beds that would be required for men discharged from the Armed Forces for nervous and mental disease, placed particular emphasis upon the need for thorough psychiatric screening of inductees prior to entry into the service. Both the resolution and the memorandum by Dr. Overholser were favorably received by President Roosevelt on 17 September 1940 and transmitted to Mr. Frederick H. Osborn, Chairman of the National Advisory Committee on Selective Service, who, impressed by the importance of psychiatric screening, forwarded the recommendations to the Medical Division of the National Headquarters of the Selective Service.61
Psychiatry and Selective Service
As a result of the foregoing events, on 24 October 1940, the Director of Selective Service, Dr. Clarence A. Dykstra, representatives from various divisions of the War Department, and Drs. Overholser, Steckel, and Sullivan conferred and made plans for placing a psychiatrist in each of the 660 medical advisory boards. Medical advisory boards in the selective service organization were composed of civilian specialists in the various fields of medicine on whom the medical examiner of the local draft board could call
59Menninger, op. cit., p. 10.
60Deutsch, op. cit., p. 421.61Overholser, op. cit.
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for assistance in questionable cases. Thus, when the draft began in November 1940, the process of induction included psychiatric assistance, if needed, as part of the physical examination.62
At this time, medical examination of draft registrants consisted of a double screening process. Medical examiners of local draft boards rejected individuals with obvious defects. Doubtful cases were referred to the medical advisory board. Successful registrants from this initial phase were sent to the Army induction station for the final physical and psychiatric examination.63
To implement the psychiatric aspects of the induction program, Dr. Harry Stack Sullivan was appointed as psychiatric consultant to Selective Service. In October 1940, a committee of the William Alanson White Psychiatric Foundation had prepared a plan for the psychiatric examination of draft registrants. Through the influence of Dr. Sullivan, this plan became the basis for the Selective Service System's Medical Circular No. 1, issued on 7 November 1940. The purpose of the circular, entitled 'Minimum Psychiatric Inspection,' was to aid the medical examiners of the 6,403 local draft boards in detecting disabling mental and personality disorders of draftees.64 In addition, Dr. Sullivan, with the aid of prominent civilian and military psychiatrists, conducted 2-day seminars in nine major cities, during the period from January to July 1941, to assist psychiatrists serving with medical advisory boards and Army induction stations.65 On 12 March 1941, The Surgeon General issued Circular Letter No. 19, to supplement and amplify the Selective Service System's Medical Circular No. 1. This circular was designed to supply medical examiners at Army induction stations with the same type of psychiatric orientation as had been given the medical examiners of local draft boards.66
As time and events proceeded, complications soon arose with the psychiatric portion of the induction process, particularly as the tempo of military mobilization increased. Col. Leonard G. Rowntree, MC, who had been appointed medical director of Selective Service in 1941, and Maj. Gen. (later Lt. Gen.) Lewis B. Hershey, who had succeeded Dr. Dykstra as Selective Service Director, were 'somewhat discouraged to learn that despite this psychiatric screening, considerable numbers of men were subsequently being discharged from the Army because of mental derangement.'67 Also, after Pearl Harbor, the rapid acceleration of the draft process, to supply the needs of the vastly expanded Army, forced abandonment in January 1942 of the preliminary local draft board examination in favor of a single screening examination procedure at Army induction centers under Army supervision. This change was opposed by Dr. Sulli?
62Menninger, op. cit., p. 268.
63Deutsch, op. cit., p. 422.
64Ibid.
65Menninger, op. cit., p. 269.
66Deutsch, op. cit., p. 422.
67Menninger, op. cit., p. 269.
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van, and many other psychiatrists, and was protested editorially in the American Journal of Psychiatry.68 Other differences of opinion between Dr. Sullivan and General Hershey developed which led eventually to the resignation of Dr. Sullivan as psychiatric consultant. Dr. Raymond W. Waggoner was appointed psychiatric consultant to the Selective Service in the fall of 1943.
National Research Council
Another organization concerned with psychiatric mobilization was the National Research Council. In October 1940, a committee on neuropsychiatry of the National Research Council was constituted to aid the Surgeons General in neuropsychiatric problems pertaining to national defense. This committee was headed by Dr. Overholser and included Drs. Franklin G. Ebaugh, Foster Kennedy, Adolf Meyer, Tracy J. Putnam, Harry A. Steckel, and John C. Whitehorn.
Through appropriate subcommittees on personnel and training, neurology, psychiatry, and neuroses, the National Research Council endeavored to advise the Surgeons General on military problems of neurology and psychiatry. The Subcommittee on Personnel listed and rated all available civilian psychiatrists and neurologists which was stated by Dr. Overholser to have been found useful by The Surgeon General. Another early task was the revision of the Army's standards of physical examination during mobilization, better known as MR (Mobilization Regulations) 1-9. Many recommendations were not followed, or were only acted upon after a considerable period of time had elapsed. Thus, in June 1941, the committee recommended that a Division of Psychiatry be set up in the Surgeon General's Office and a psychiatric consultant be assigned to each corps area. This proposal was declined by the Army 'as not being in accordance with the present policy.' Also, in June 1941, the committee recommended that clinical psychologists be taken into the Medical Department to work with psychiatrists, but a military liaison with clinical psychology was not effected until much later. In February 1941, the committee recommended that inductees be held as long as 5 days at induction stations for observation, if necessary. However, such a procedure was never really implemented. In 1942, the committee recommended setting up civilian training courses for psychiatry, but the Surgeon General's Office did not see the desirability at that time, although in 1944 such training was accomplished.69
Conclusions
In looking back over the efforts of civilian psychiatry during the mobilization and early phases of World War II, it can be fairly stated that
68Overholser, op. cit.
69Ibid.
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its accomplishments were modest when compared to the more effective work of the National Committee for Mental Hygiene in World War I. There are several circumstances that could account for the difference in the psychiatric participation of the two wars. During the era before World War II, there was little or no enthusiasm for war in contrast to the excitement and high morale of World War I. The lack of martial songs in World War II was evidence of the general pessimistic attitude of the population.70 It is also highly likely that Dr. Salmon's group was better received by Army authorities in World War I than their counterparts in World War II. In this writer's opinion, another reason lay in the major premise of both civil and military psychiatry groups which placed disproportionate emphasis upon screening at induction as the solution to the psychiatric problem. Forgotten was the fact that Dr. Salmon and his group prepared plans and argued for both selection and treatment; were concerned with the construction of psychiatric treatment facilities and the procurement of psychiatric personnel, including nurses and ward attendants; insisted upon the staffing of combat divisions with psychiatrists; and provided for special psychiatric hospitals in the combat zone. It was inevitable that, after World War II, Brig. Gen. William C. Menninger, Chief Psychiatric Consultant in the U.S. Army, wrote:
We expected too much from induction center screening and fell in with the overselling of what psychiatry could accomplish at this level * * *.
Initially we were blind to the needs and ignorant of the methods of preventive psychiatry.71
It may be concluded that an important lesson to be learned from the trials and experiences of psychiatric mobilization in World War II is the error in placing emphasis upon psychiatric screening to the exclusion of prevention and treatment. In war, psychiatric casualties will surely occur as new personnel enter military service and encounter the stress of training, oversea service, and combat. A study of these problems will inevitably lead to possibilities for early treatment and prevention. As Mira has stated from his experiences in the Spanish Civil War 'to prevent or detect early exhaustion in an overworked commander is much more important than to make a fair classification of one hundred inductees.'72
70Menninger, op. cit., p. 88
71Ibid., p. 41.
72Mira, Emilio: Psychiatry in War. New York: W. W. Norton & Co.. 1943.
