History

CHAPTER X

Station and Regional Hospitals

Norman Q. Brill, M.D.

ORGANIZATION AND FUNCTIONS

In the station hospitals which were established in the many camps, posts, and stations in the Zone of Interior, psychiatry and neurology was generally a section of the medical service. Actually, in most hospitals with sizable neuropsychiatric programs, the section operated quite independently under its own chief, without the intimate professional supervision which the chief of the medical service gave to other sections of that service.

In some instances, neuropsychiatry did not have even the status of a section (for example, Camp Roberts Station Hospital, Calif.).¹ In such situations, patients with psychiatric disorders were intermixed on the wards of the medical and surgical services except for disturbed psychotic patients who were housed in a closed ward under the supervision of a psychiatrist.

Ordinarily, the neuropsychiatric section was responsible for the admission, treatment, and disposition of all patients with psychiatric and neurologic disorders. In addition, it provided psychiatric and neurological consultations to the rest of the hospital. The number of consultations at times were very great and constituted a responsibility that equaled in importance the operation of the wards. Some hospitals developed formal psychiatric outpatient clinics to which units on the post might refer personnel for consultation-and in which inpatient consultations might be seen. Psychiatric consultations for dependents were usually arranged on an individual basis and, generally, were not considered an integral part of the program.

Menninger² commented on the magnitude of the psychiatric consultation load. He pointed out how a man in civilian life might fail to function effectively with no serious concern to anyone in contrast to the situation in the military:

Unless he becomes a worry to his family or the law, his inefficiency or incapacity may receive no attention. This point is of greater contrasting significance when one recognizes the major adjustment demands which the Army requires of any individual joining it, with his complete loss of free choice about what he does, when and how he

¹Letter, Lt. Col. Malcolm J. Farrell, MC, to The Surgeon General (through Chief, Professional Services), Washington, D.C., 13 Mar. 1944, subject: Report of Visit of Lt. Col. Malcolm J. Farrell, MC, to Ninth Service Command Installations.
²Menninger, W. C.: Development of Psychiatry in the Army in World War II. War Med. 8: 229-234, October 1945.

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does it. Since the tendency in our culture is to retreat into illness when under stress, it is not surprising to find many individuals finding enormous secondary gain by becoming ill in the Army, thus hoping to escape the demands of duty and service.

Unfortunately, the majority of civilian psychiatric patients have to be brought to the psychiatrist by relatives, usually after a long period of 'putting up' with the patient. In the Army, they are 'discovered' more quickly; the officer, the sergeant, the bunkmate, the dispensary surgeon, the aid station surgeon, the flight surgeon, the internist, or the surgeon may refer a man to the psychiatrist.

Where closed-type prison wards existed, they were generally adjacent to the closed-type psychiatric wards and often, in the early part of the war, were under the administrative direction of the chief of neuropsychiatry. In rare instances, prisoners would be admitted to the closed psychiatric ward itself. This was specifically prohibited by later directives.

At the Station Hospital, Fort McPherson, Ga.,³ and probably at other posts near large cities, the psychiatrists assigned to the neuropsychiatric section were detailed for much of their time to the induction station. While the mental hygiene clinics which were developed in the various training centers were ordinarily under the commanding officer of the training center, in several posts (for example, Station Hospital, Camp Kohler, Calif.), the training center mental hygiene clinic was under the commanding officer of the station hospital and was operated by the chief of the neuropsychiatric section.⁴ It was found that hospital admissions were significantly reduced when there were well-functioning outpatient or mental hygiene clinics.

In one hospital (Station Hospital, Fort Dix, N.J.) in 1942, in accordance with a standing order of the post, all alcoholic addicts were admitted to the hospital, and psychiatric examinations were made on all prisoners in the guardhouse.

While examination of military personnel confined in the guardhouse or undergoing trial by court-martial was not done routinely, there were many occasions where psychiatric examination, and at times testimony, was sought from the station hospital psychiatrists. Where mental hygiene clinics existed in training centers, the psychiatrist in that unit provided such service to the training center.

Psychiatric examination was required when board proceedings were undertaken to discharge enlisted personnel for lack of adaptability, inaptitude, enuresis, or undesirable habits and traits of character, including homosexuality. Before rendering such a report, some psychiatrists admitted the person in question to the neuropsychiatric section of the hospital for observation and examination. In other instances, the subject would be examined on outpatient status.

³Memorandum, Lt. Col. Malcolm J. Farrell, MC, for The Surgeon General (through: The Director, Medical Practice Division), Washington, D.C., 18 Feb. 1943, subject: Neuropsychiatric Inspection of Lawson General Hospital, Ga., 28 January 1943; Station Hospital, Fort McPherson, Ga., 29 January 1943; School of Military Neuropsychiatry, Lawson General Hospital, Ga., 27, 28, 29 January 1943; Station Hospital, Fort McClellan, Ala., 30 January 1943; Induction Station, Fort McClellan, 30 January 1943; and the Infantry Replacement Training Center, Fort McClellan, 30 January 1943, by Lt. Col. Malcolm J. Farrell, MC.
⁴See footnote 1, p. 255.

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PHYSICAL FACILITIES

The neuropsychiatric section in the typical cantonment-type station hospital was located in the rear left corner of the hospital. There were closed wards for disturbed psychoses and also for those potentially suicidal depressions and acting out psychopathic disorders which could not be safely housed on open wards. Open wards adjacent to closed wards were for patients with mild psychotic, psychoneurotic, personality, and neurological disorders (including epilepsy).

Closed Wards

The typical closed wards (fig. 29), designated W-8 on the 1920 quartermaster plans which were used for building these hospitals, had a 23-patient capacity and contained 7 single rooms, a 4-bed room, and a ward for 12 patients. A small dayroom was located in the center of the ward. It served as a dining room during mealtime. There was a porch off the dayroom and another off the large ward.

As originally constructed, these wards were very insecure. Patients could break out of the ward through windows and doors almost at will. At some hospitals, the entire closed-ward section and, in others, the individual closed wards were surrounded by a high wire fence with barbed wire often mounted on top of it. It was possible to get the barbed wire removed in some hospitals, but in others, the commanding officers insisted on its retention. The deficiencies of the W-8 wards eventually came to the attention of the Office of the Chief of Engineers in the War Department, and directives were issued which made possible alteration of the wards so that reasonable security was afforded.⁵

There were continuous tubs in a few hospitals, but not in most, and no facilities for occupational therapy were included in the original plans. Recreation and play areas were generally limited to the small space between adjacent wards.

The lack of adequate facilities in closed wards was probably related to the expectation that psychotic patients would be disposed of promptly and not be retained for treatment. This expectation, as will be discussed later, proved to be erroneous. Individual chiefs of sections and their staffs used considerable ingenuity in arranging for additional recreational space and for establishing occupational therapy and gardening areas adjacent to the closed-ward section. The aid of the Red Cross was enlisted in providing arts and crafts and activities on the wards.

⁵Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior, United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956, chs. II and V.

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FIGURE 29.-Floor plan of a typical neuropsychiatric ward.

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Open Wards

The deficiency in closed-ward facilities for disturbed patients was paralleled in some hospitals by the opposite disadvantage of using closed wards for open-ward cases. Apparently, planning of the psychiatric sections of the cantonment-type hospital had been concerned primarily with

TABLE 14.-Admissions for neuropsychiatric conditions, by diagnosis and year, U.S. Army, continental United States, 1942-45¹

[Rate expressed as number of admissions per 1,000 mean strength per year]

Diagnosis	Total 1942-45		1942		1943		1944		1945
Diagnosis	Number	Rate	Number	Rate	Number	Rate	Number	Rate	Number	Rate
Neurological disorders:²
Epilepsy	14,147	1.0	3,757	1.4	5,655	1.1	3,015	0.8	1,720	0.6
Other	93,095	6.2	14,820	5.6	37,085	7.1	23,415	5.9	17,775	5.9
Total neurological disorders	107,242	7.2	18,577	7.0	42,740	8.2	26,430	6.7	19,495	6.5
Psychiatric disorders:
Psychosis	37,824	2.5	9,659	3.6	12,345	2.4	9,775	2.5	6,045	2.0
Psychoneurosis	390,609	26.4	47,374	17.8	156,155	30.1	155,285	28.9	71,795	24.1
Character and behavior disorders:
Pathological sexuality	3,781	0.3	521	0.2	1,550	0.3	1,095	0.3	610	0.2
Asocial and antisocial personality types	1,713	.1	263	.1	455	.1	420	.1	575	.2
Immaturity reactions³	49,838	3.5	6,518	2.5	17,820	3.5	14,670	3.7	10,830	3.6
Alcoholism	25,165	1.7	6,040	2.3	7,990	1.5	6,310	1.6	4,825	1.6
Acute	(18,820)	(1.3)	(4,540)	(1.7)	(5,765)	(1.1)	(4,725)	(1.2)	(3,790)	(1.3)
Chronic	(6,345)	(.4)	(1,500)	(.6)	(2,225)	(.4)	(1,585)	(.4)	(1,035)	(.3)
Drug addiction	1,077	.1	152	.1	520	.1	330	.1	75	.0
Enuresis	¹NA	¹NA	¹NA	¹NA	¹NA	¹NA	220	.1	190	.1
Total	81,984	5.6	13,494	5.1	28,340	5.4	23,045	5.7	17,105	5.6
Disorders of intelligence	24,357	1.6	3,812	1.4	12,940	2.5	5,360	1.3	2,245	0.8
Other psychiatric disorders	36,716	2.5	5,618	2.1	13,400	2.6	8,420	2.1	9,215	3.1
Total psychiatric disorders	571,490	38.7	80,020	30.1	223,180	43.1	161,885	40.7	106,405	35.7
Total neuropsychiatric disorders	678,732	45.8	98,597	37.1	265,920	51.3	188,315	47.4	125,900	42.2

¹The diagnostic nomenclature and classification used for the presentation of World War II data on morbidity, separation, and mortality are those adopted by the Army in 1944 and used for 1944 and 1945 records. Therefore, the data for diseases which in 1942 and 1943 were differently named or classified, or both, were translated and, in effect, reclassified or renamed in equivalent or closely equivalent terms of the 1944-45 diagnostic classification and nomenclature. In certain cases, this involved a major relocation. With respect to psychiatric diagnoses, cases of 'alcoholism,' for instance, while separately identified prior to 1944 as 'alcoholism with psychosis' and 'alcoholism without psychosis,' appeared in the broad class of 'General Diseases' and not in the 'Nervous System' class, where neuropsychiatric disorders have been shown. Under the 1944-45 classification, alcoholism with psychosis was included under 'psychosis,' and the other cases of alcoholism were classified under 'Character and Behavior Disorders,' separately by acute and chronic alcoholism. Similarly, cases of 'Drug Addiction,' previously classified under 'General Diseases,' are shown here under 'Character and Behavior Disorders.' 'Enuresis' presented in this respect a more complex problem, as no distinction was made prior to 1944 between 'enuresis'-a 'habit' reaction symptomatic of immaturity-and 'enuresis'-a symptom of some organic disorder. (Prior to 1944, all cases of enuresis were listed in the 'Genitourinary Disease' class.) The 1944-45 nomenclature provided for such a differentiation, listing 'enuresis' symptomatic of immaturity under 'Character and Behavior Disorders,' and the other type of enuresis under 'General and Miscellaneous Diseases.' Inasmuch as no differentiation could be made with respect to the data on enuresis prior to 1944, all cases of enuresis in 1942 and 1943 were translated to the 1944-45 class of 'General and Miscellaneous Diseases.' (The table carries, therefore, for 1942 and 1943 the symbol NA-not available-for enuresis.) But, even for the 1944-45 data, this differentiation seems to have been of questionable accuracy, showing a much lower proportion in the psychiatric category than has been observed in later experience. As is seen from the table, only 1,030 cases of enuresis were classified in 1944-45 under 'Character and Behavior Disorders.' However, additional 19,055 cases of enuresis were counted during the 1942-45 period under 'General and Miscellaneous Diseases.' Thus, altogether some 20,000 individuals were admitted to treatment facilities with a diagnosis of 'enuresis,' in World War II, indicating an annual admission rate of 0.8 per 1,000 mean strength per year.

²See chapter XVIII, 'Neurology,' table 60, for detailed diagnostic distribution.³This diagnosis includes 105 admissions for 'pathological personality,' not elsewhere specifically classified.

NOTE.-Figures in parentheses are subtotals. The entry .0 indicates a rate of less than .05.

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providing for the psychotic or closed-ward type of patient. In 1943, the percent distribution of neuropsychiatric patients in the continental United States by closed and open wards was 43 : 57; in 1944, 29 : 71; and in 1945, 23 : 77. (See chapter IX, 'Hospitalization and Disposition,' table 10.) However, psychotic disorders constituted during these years only 5.5, 6.0, and 5.7 percent, respectively, of all psychiatric patients hospitalized in continental United States. For the entire World War II period, the psy?

TABLE 15.-Percent distribution of admissions for neuropsychiatric conditions, by diagnosis and year, U.S. Army, continental United States, 1942-45¹

Diagnosis	Year
Diagnosis	Total 1942-45	1942	1943	1944	1945
	Neuropsychiatric Disorders
Neurological disorders:
Epilepsy	2.1	3.8	2.1	1.6	1.4
Other	13.7	15.0	14.0	12.4	14.1
Total	15.8	18.8	16.1	14.0	15.5
Psychiatric disorders:
Psychosis	5.6	9.8	4.6	5.2	4.8
Psychoneurosis	57.5	48.0	58.7	61.3	57.0
Character and behavior disorders:
Pathological sexuality	0.6	0.5	0.6	0.6	0.5
Asocial and antisocial personality types	.3	.3	.2	.2	.5
Immaturity reactions	7.3	6.6	6.7	7.7	8.5
Alcoholism	3.7	6.1	3.0	3.4	3.8
Acute	(2.8)	(4.6)	(2.2)	(2.6)	(3.0)
Chronic	(.9)	(1.5)	(.8)	(.8)	(.8)
Drug addiction	.2	.2	.2	.2	.1
Enuresis	¹NA	¹NA	¹NA	.1	.2
Total	12.1	13.7	10.7	12.2	13.6
Disorders of intelligence	3.6	3.9	4.9	2.8	1.8
Other psychiatric disorders	5.4	5.8	5.0	4.5	7.3
Total psychiatric disorders	84.2	81.2	83.9	86.0	84.5
Total neuropsychiatric disorders	100.0	100.0	100.0	100.0	100.0
	Psychiatric Disorders
Psychiatric disorders:
Psychosis	6.6	12.1	5.5	6.0	5.7
Psychoneurosis	68.4	59.1	70.0	71.3	67.4
Character and behavior disorders:
Pathological sexuality	0.7	0.7	0.7	0.7	0.6
Asocial and antisocial personality types	.3	.3	.2	.3	.5
Immaturity reactions	8.7	8.2	8.0	9.0	10.2
Alcoholism	4.4	7.5	3.6	3.9	4.5
Acute	(3.3)	(5.6)	(2.6)	(2.9)	(3.5)
Chronic	(1.1)	(1.9)	(1.0)	(1.0)	(1.0)
Drug addiction	.2	.2	.2	.2	.1
Enuresis	¹NA	¹NA	¹NA	.1	.2
Total	14.3	16.9	12.7	14.2	16.1
Disorders of intelligence	4.3	4.8	5.8	3.3	2.1
Other psychiatric disorders	6.4	7.1	6.0	5.2	8.7
Total psychiatric disorders	100.0	100.0	100.0	100.0	100.0

¹Derived from table 14.

NOTE.-Figures in parentheses are subtotals.

choses comprised 6.6 percent of all psychiatric admissions in continental United States (tables 14 and 15). (See chapter IX, table 9, for the corresponding distributions on worldwide basis and for oversea theaters.) Perhaps, the requirement in some station hospitals that closed-type wards be used for psychoneurotic patients may have contributed to the widespread belief in the Army, during World War II, that all neuropsychiatric patients were 'crazy.'

In most hospitals, the large general-purpose wards of the W-1 and W-2 variety (fig. 30), which housed general medical and surgical patients, were used for open-ward patients who generally constituted a mixture of neurological, psychoneurotic, personality, and intelligence disorders. These ambulatory patients moved freely about the hospital and were, therefore, able to participate in the arts and crafts and recreational activities in the centrally located Red Cross building.

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By no means were all open-ward neuropsychiatric patients admitted to the neuropsychiatric section. A large percentage of patients on the medical, orthopedic, and other wards were primarily adjustment problems with symptoms of organic dysfunction, pain, or discomfort which were mainly of emotional origin. Often, patients with such quasi-organic complaints were retained on the ward and service to which they were initially admitted. When clinical investigation revealed no evidence of organic disease and symptoms persisted, neuropsychiatric consultation was commonly requested. At times, such patients were returned to duty without benefit of neuropsychiatric opinion as soon as it was determined that there was no positive evidence of organic disease.

PERSONNEL

Neuropsychiatrists

From the beginning, there was a shortage of trained psychiatrists, neurologists, psychiatric nurses, attendants, aids, social workers, psychologists, occupational therapists, and recreational therapists. Brief training programs in psychiatry were established for general medical officers, and in spite of the monumental accomplishment of these training programs, the shortage of psychiatrists was never relieved during the entire duration of the war.⁶ Graduates of these programs, established by the Surgeon General's Office, were commonly referred to as '90-day wonders.' In addition, psychiatrists and other medical and paramedical personnel from numbered station and general hospital units, assigned to the various posts for training, were also used for varying periods in the psychiatric sections of station and regional hospitals. Also, medical officers without even the benefit of professional training programs, but already stationed at a hospital, were often assigned to assist the psychiatrist in carrying his disproportionate load of hospital patients and consultations. In the main, these 90-day wonders and the psychiatrically untrained medical officers, after a short period of supervision, became quite proficient in their psychiatric work and proved to be invaluable. Many of them were to remain in psychiatry after the war. It was estimated that each psychiatrist had approximately twice the patient load of the surgical and medical specialists.

Dr. Eli Ginzberg,⁷ Director, Resources Analysis Division, SGO (Surgeon General's Office), believed that the gap between psychiatric means and requirements was never fully appreciated.

⁶According to William C. Menninger, "Psychiatry in a Troubled World,' New York: The Macmillan Co., 1948, p. 238, 2,402 was the greatest number of men assigned to psychiatry, of whom 21 were of professional caliber and 401 board eligible or board certified; 1,251 had had little or no psychiatric training or experience before entering the service-A. L. A.
⁷Ginzberg, E.: Logistics of the Neuropsychiatric Problem of the Army. Am. J. Psychiat. 102: 728-731, May 1946.

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FIGURE 30.-Standard open psychiatric ward identical with ward used for medical, surgical, and other nonpsychiatric patients.

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Psychiatric Nurses

Psychiatrically trained nurses were as scarce in the Army as they were in civilian life. Nurses untrained in the care of the mentally ill were assigned to the psychiatric section, many times against their wishes. Some became interested in the challenge and ultimately did outstanding jobs. Others had to be removed and reassigned elsewhere in the hospital. (See chapter XXI, 'The Psychiatric Nurse.')

Psychologists and Social Workers

An occasional enlisted man who had had training in psychology or social work would be assigned to the hospital detachment, but for the most part, psychologists and social workers were not available in the neuropsychiatric section of station hospitals until quite late in the war and, then, only in very small numbers.⁸ When psychiatric social work and clinical psychology were recognized as military occupational specialties, and personnel with these backgrounds identified, such personnel were, for the most part, assigned to the general and convalescent hospitals.⁹

It was left to the Red Cross to provide most of what social work was practiced in the station hospitals. In some instances, a Red Cross social worker would be assigned to the neuropsychiatric section where she would assist greatly in obtaining histories from patients and relatives, in arranging for disposition of psychotic patients, and, often, in administering simple intelligence or psychological tests.¹⁰ Later on, with the development of the convalescent hospitals, social workers and psychologists participated ac?tively in the treatment program, particularly in group therapy.

In 1946, however, Hutt¹¹ found that, of 50 psychologists, only 1 was assigned to a regional hospital and 2 to station hospitals. At the Camp Carson, Colo., Station Hospital, an unusually active psychological testing

⁸Psychiatric social work was formally recognized as a military occupational specialty on 1 November 1943.-A. L. A.
⁹(1) In addition to the psychiatric social work specialty which required a graduate degree in social work from a recognized school of social work or at least 2 years of supervised experience in a private or public agency, a category of psychiatric assistant was established in the WAC (Women's Army Corps) for members of the WAC who had completed 1 year in a recognized school of social work, or who had a college degree or 2 years of college plus 1 year full-time experience in supervised casework. The duties of both types of workers and standards of practice were described in War Department Technical Bulletin (TB MED) 154, June 1945. (2) M. J. Farrell and E. H. Ross, in an excellent review in the Bulletin of the Menninger Clinic (8: 153-158, September 1944, entitled "Military Social Work'), trace the entire history of the use of psychiatric social workers in the Army. (3) War Department Circular No. 270, 1 July 1944, provided for the assignment to general hospitals and station hospitals of 1,000 beds or more of clinical psychologists who were commissioned in the Adjutant General's Department and outlined their duties. TB MED 115, 14 Nov. 1944, and changes issued on 19 Mar. 1945, outlined in more detail the clinical psychological service in Army hospitals. (4) War Department Circular No. 71, 6 Mar. 1945, provided for the assignment of clinical psychologists to convalescent hospitals and other psychiatric facilities-A. L. A.
¹⁰Feldberg, T. M., and Rosenberg, S. J.: The Psychiatric Social Worker in the Army Station Hospital. Ment. Hyg. 28: 586-595, October 1944.
¹¹Hutt, M. L.: Report of Duties Performed by Clinical Psychologists. Bull. U.S. Army M. Dept. 7: 233-237, February 1947.

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program was developed.¹² Studies were performed on the underlying emotional problems of enuretics and patients with rheumatic fever; also, correlations were made between psychological tests and clinical diagnosis of illiterate personnel (including mental and educational deficiencies).

Ward Attendants

The enlisted 'corpsmen' who were assigned to the psychiatric wards as aids or attendants generally had no prior experience working on psychiatric wards. Formal or informal training programs were established in most hospitals to provide them with the basic understanding and techniques that were required to work with mental patients. Many of those men developed into outstanding technicians. It was not until after the war that their special talents were acknowledged by an official military occupa?tional specialty designation.¹³

Clerical Workers

Secretarial help for the neuropsychiatric section, as well as for other sections and services in the hospital, was provided by civilian employees who were generally recruited from the area in which the hospital was located.

CLINICAL PROBLEMS

The psychoneuroses were the most common emotional disorders. This holds true whether the distribution of the psychiatric disorders are viewed on a worldwide basis, or separately by continental United States and oversea theaters. (See chapter IX, table 6, for the admissions and admission rates for neuropsychiatric disorders on worldwide basis, and table 14, this chapter, for the corresponding data in continental United States.) Psychoneurotic disorders composed 69.8 percent of all psychiatric disorders on a worldwide basis, 68.4 percent in continental United States, and 72.2 percent in oversea theaters (chapter IX, table 9).

Next in magnitude were immaturity reactions, closely followed by psychoses. Immaturity reactions constituted 7.3, 8.7, and 4.7 percent of all psychiatric disorders on a worldwide basis, in the continental United States, and in oversea theaters, respectively. The corresponding percentages for psychosis were 7.3 percent, 6.6 percent, and 8.3 percent (chapter IX, table 9).

¹²Greenwood, E. D., Snider, H. L., and Senti, M. M.: A Psychological Testing Program in an Army Station Hospital. Mil. Surgeon 95: 489-495, December 1944.
¹³War Department Circular No. 209, 13 July 1946.

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Psychotic Disorders

Hecker and his associates¹⁴ reported their findings in the 10-month period preceding the onset of the war. Working in a typical 800-bed station hospital in the United States, serving 17,000 troops in training, they found that the majority of patients with psychoses were admitted within the first 6 months of their service. In many cases, excitement and panic were found to be predominant with rapid improvement on hospitalization and, in some cases, seeming complete recovery after discharge.

Observations by other psychiatrists were in wide agreement on both the tendency for early occurrence of psychotic episodes and the better immediate prognosis. Many cases of brief transient psychotic episodes were seen in the Army and reported by various workers.¹⁵ These were not the psychoticlike reactions that were described as occurring in combat.

It was rare to retain a man in the service who suffered a psychotic breakdown. Regulations and other directives necessitated his discharge even upon recovery.¹⁶ Many patients recovered promptly upon returning to their homes and were able to return to civilian empboyment.¹⁷ It is estimated that 60 percent of all psychotic patients recovered within a period of 2 to 3 months from the time of onset of the illness.¹⁸

In general, the incidence of psychotic reactions was much higher in men with less than a year of military service than in those with 2 or 3 years.¹⁹ Cases of psychosis were apt to manifest themselves early or develop promptly in markedly predisposed individuals. In the series of 48 cases studied by Hecker and his associates, approximately one-third were hospitalized during their first month of service. Similarly, Hitschmann

¹⁴Hecker, A. O., Plesset, M. R., and Grana, P. C.: Psychiatric Problems in Military Service During the Training Period. Am. J. Psychiat. 99: 33-41, July 1942.
¹⁵(1) Porter, William C.: Psychiatry in the Army. In Psychiatry and the War (edited by F. S. Sladen). Springfield: Charles C Thomas, 1943, p. 245. (2) Malamud, W., and Malamud, I.: Sociopsychiatric Investigation of Schizophrenia Occurring in the Armed Forces. Psychosom. Med. 5: 364-375, October 1943. (3) KIow, S. D.: Acute Psychosis in Selectees. Illinois M.J. 83: 125-130, February 1943. (4) Brosin, H. W.: Symposium on Psychiatry in the Armed Forces: Panic States and Their Treatment. Am. J. Psychiat. 100: 54-61, July 1943.
¹⁶Brill, N. Q., and Walker, E. F.: Psychoses in the Army; Follow-Up Study. Bull. U.S. Army M. Dept. 79: 108-115, August 1944.
¹⁷Circular Letter No. 99, Office of The Surgeon General, U.S. Army, 4 Sept. 1942.
¹⁸(1) Menninger, op. cit., pp. 174 and 598. (2) That most patients with acute psychotic disorders probably 'recovered' was a common impression of psychiatrists during World War II. However, no followup studies have been accomplished to determine if the remission of psychotic symptoms was maintained. The studies of Ripley and Wolf relative to similar acute psychotic disorders occurring in a combat theater do not indicate such a benign prognosis: 'A group of 341 patients with acute schizophrenic reactions treated in a combat zone overseas were followed up 5 to 8 years later. Despite removal from the environment in which the illness occurred and discharge from the service, 51 of the patients had to be rehospitalized for their psychosis; 186 of the patients were still considered to be moderately or markedly disabled by their mental illness 5 or more years after the original episode. These findings would appear to contradict the widely held notion that these 'acute battle reactions' are of a relatively benign and transitory nature. In fact, the illness does not seem to differ significantly from schizophrenia encountered in civilian life' (Ripley, H. S., and Wolf, S.: Course of Wartime Schizophrenia Compared With Control Group. J. Nerv. & Ment. Dis. 120: 184-195, September-October 1954) .-A. J. G.
¹⁹Menninger, op. cit., p. 170.

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and Yarrell²⁰ reported that 23 percent of psychotic patients became ill within 2 weeks of starting training in the Army and 70 percent developed their illness in the first 5 months of service.²¹

Officers who were, in general, more carefully screened than were enlisted men had a lower incidence of psychotic disorders²² (table 16). The highest rate of psychosis was in enlisted women who were not screened psychiatrically in the early part of the war.²³ It is not known if the incidence of psychotic reactions was higher in the Army than in civilian life.

TABLE 16.-Admission rates for psychiatric conditions, by rank, U.S. Army, worldwide, 1942-45¹

[Rates per 1,000 mean strength per year, by rank]

Diagnostic category	Total¹	Officers	Enlisted personnel
Psychosis	2.7	1.1	2.9
Psychoneurosis	25.6	15.1	26.7
Character and behavior disorders	4.7	1.7	5.0
Other psychiatric disorders	3.7	2.5	3.8
Total psychiatric disorders	36.7	20.4	38.4

Nonpsychotic Disorders

Other psychiatric problems which often resulted in hospitalization were reactive depressions, homesickness, 'gold-bricking,' situational maladjustments, emotional immaturity, enuresis, somnambulism, and alcoholism. The magnitude of these problems and their military significance have been comprehensively reviewed by Menninger.²⁴ It was commonly observed that the breakdown rate, particularly with psychoneurotic reactions, reached a peak after 3 or 4 weeks of basic training. It was this early period of training at replacement training centers and in tactical units that constituted the first serious hurdle for the new soldier.²⁵ At the Camp

²⁰Hitschmann, M., and Yarrell, Z.: Psychoses Occurring in Soldiers During a Training Period. Am. J. Psychiat. 100: 301-305, November 1943.
²¹In general, it is well documented, even before World War II, that psychotic disorders in military personnel arose early in their military career, usually 50 percent within the first year. However, it should be noted that the findings made herein were related to soldiers new to the service, therefore any psychiatric disorder arising from this newly inducted group would perforce be found to occur early in the service. Thus the appearance of psychosis from these new soldiers was more a characteristic of the group studied than of the disease itself.-A. J. G.
²²There is no evidence to support the implication in this statement that officers were more carefully 'psychiatrically' screened than enlisted men. However, the incidence of psychosis in officers, which has also been a constant finding in peacetime, is most probably related to the screening process relative to requirements for commissioning such as age, intelligence level, and educational background-A. J. G.
²³Author's own impression. There are no available data to support this statement.-A. J. G.
²⁴Menninger, op. cit., pp. 175-190.
²⁵Halloran, R. D.: Problems of Neoropsychiatiy in the U.S. Army. M. Ann. District of Columbia 13: 17-23, January 1944.

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Maxey, Tex., Regional Hospital, most cases were mild neurotics with various somatic manifestations. Sore backs, stomach aches, and headaches predominated.

The inadequate soldier was another outstanding problem. This type of soldier rapidly developed somatic symptoms along with complaints and appearance of weakness.²⁶ Intensive therapeutic interviews and suggestive therapy accomplished very little in changing these patterns.²⁷ The commanding officer of the hospital, commenting on other types of problems encountered, stated:

The psychopaths are a heterogeneous lot and our consciences sometimes hurt when we recommend a discharge for undesirable habits and traits of character, for many of these men are as much out of control as the psychotic. * * * A related problem is the criminal soldier. * * * We are now required to see all the prisoners that come up for general courts-martial. It is our impression that routine punishment and discipline has very little effect on most prisoners whom we see and it is encouraging to note that many more of the men are being sent to reconditioning centers where they may receive skilled help for evaluating their problems.

Another complex group includes the homosexual soldiers. * * * Success [in treating them] is questionable.

The majority of psychotic patients have schizophrenic reactions combined with considerable affect. These reactions are transient and less severe than what we have seen in civilian life.

He also commented on the strong trend so many patients showed to remain in the hospital and stated that the reconditioning annex was a logical attempt toward correcting this strong desire toward remaining ill. He believed that their major accomplishment had been emphasis on outpatient care, working with junior line officers and noncommissioned officers in going over specific problem cases. Their policy was to return the questionable or mild cases to duty and then help the officers in the unit to better deal with these men.

Menninger,²⁸ while agreeing that anxiety reactions were the most common neurotic disorders seen and schizophrenic reactions the most common type of psychosis, emphasized the importance of the problem of mental retardation and the lack of special battalions for persons so handicapped. He also called attention to the common occurrence of clinical pictures rarely encountered in civilian practice-severe nostalgia and enuresis in adults. While true malingering was rare, it was seen (or suspected) more frequently than in civilian life. He observed that individuals with psychosomatic complaints constituted a large portion of the practice in the gastrointestinal, cardiac, and orthopedic services. The so-called neurocirculatory asthenia was observed frequently-but too often regarded as having an entirely organic basis.

²⁶In World War II, such cases were often dubbed the 'PMS (poor miserable soul) Syndrome' because of the persistent clinical picture of multiple and shifting somatic complaints, weakness and overall helplessness, and inadequacy in performing even menial tasks.-A. J. G.
²⁷Annual Report, Regional Hospital, Camp Maxey, Tex., 1944.
²⁸Menninger, W. C.: Psychiatric Problems in the Army. J.A.M.A. 123: 751-754. 20 Nov. 1943.

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Psychosomatic disorders.-The need to recognize and evaluate properly the large number of patients with psychosomatic disorders was stressed by Pignataro.²⁹ Such patients were commonly looked upon by medical officers as 'gold bricks' and were returned to duty 'only to oscillate between their companies and the hospital until, in disgust, their commanding officers sloughed them off or until a medical officer finally discharged them.'³⁰

It was suggested by Menninger that such mistakes were related to emotional problems in the physicians who became irritated, annoyed, and at times vindictive toward the patient.³¹ Too often, there was an attitude that, unless there was some surgical, mechanical, or medicinal treatment, nothing could be done.

Except for special studies in individual installations there were no means of determining the extent to which patients with primary psychogenic disorders were initially hospitalized or observed for 'organic' pathology. A cursory study of consecutive cases observed in the gastrointestinal and cardiovascular services of 7 station and 11 general hospitals in the Zone of Interior in 1944 gave some indication of the probable extent of the problem. Under the 'organic' category were placed those cases that had demonstrable tissue pathology. In the 'functional' category were included those cases with a specific diagnosis of psychoneurosis or a condition believed to be predominantly psychogenic and without demonstrable tissue pathology. Of 1,000 cases in the station hospitals, 35.5 percent were categorized as functional, and of 3,242 cases in the general hospitals, approximately 22 percent were considered functional.³²

Inpatient Workload

In May 1945, the peakload of neuropsychiatric patients in hospitals in the continental United States was 37,640 (see chapter IX, table 10). At that time, 5,871 closed-ward beds and 7,238 open-ward beds were authorized for psychiatry in all the general and special hospitals. In addition, there were 17,000 beds in convalescent hospitals and 6,000 in regional and station hospitals.

During 1942, there were some 99,000 admissions for neuropsychiatric conditions in continental United States; 266,000 in 1943; 188,000 in 1944; and 126,000 in 1945. Altogether, there were in the continental United States some 679,000 admissions for neuropsychiatric conditions (table 14). (For corresponding data on a worldwide basis, see chapter IX, table 6.)

²⁹Pignataro, F. P.: Psychosomatic Medicine in Military Practice. Mil. Surgeon 89: 632-638, October 1941.
³⁰Menninger, W. C.: Psychiatric Problems in Army Hospitals. Bull. U.S. Army M. Dept. 71: 31-42, December 1943.
³¹(1) Menninger, W. C.: Relationships of Neuropsychiatry to General Medicine and Surgery in the Army. Mil. Surgeon 96: 134-138, February 1945. (2) Bauer, W., and Brosin, H. W.: The Importance of Preventive Psychiatry in Psychosomatic Medicine. [Unpublished manuscript.]
³²Annual Report, Neuropsychiatry Consultants Division, Office of The Surgeon General, 1944-45.

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Characteristics of Hospitalized Psychoneurotic Enlisted Men

After the war, a followup study of war neuroses was undertaken as part of the program of studies of the Follow-Up Agency of the National Research Council developed by the Committee on Veterans Medical Problems in cooperation with the Veterans' Administration, the Army, and the Navy.³³ Approximately 1,000 men, aged 18-25, who had been hospitalized for psychoneurotic disorders in the service were studied. From the data obtained, it was possible to reconstruct some of the characteristics of this group which distinguished it from a cross section of the military population.

Those who had been admitted for psychoneuroses were a little older at entry into service, a little more often married because they were older, and, possibly, a little more often from 1 of the 13 largest metropolitan districts of the country. They did not differ as to intelligence, civilian occupation, religion, or race. It was found, however, that men with a lower educational attainment had a greater chance of breakdown. The estimated admission rates for those who completed less than 5 grades was 80 per 1,000 per year, while the rate for those who had completed from 13 to 15 grades was somewhat under 20 per 1,000 per year.

The admission rate for psychoneurosis during the first month of service was double the rate for the average length of service before hospitalization, reaching a low point in the second year and peaking again after 4 years of service.

Fewer psychoneurotics, than the cross section of the Army, served overseas. The relative frequency of courts-martial was about 60 percent higher for the psychoneurotics. As a group, they were AWOL (absent without leave), confined, or incapacitated about 1 percent of the time. Multiple hospital admissions for psychoneuroses were common, and the duration of hospitalization greatly exceeded that of admissions for disease generally (not including wounds).

Stresses such as domestic difficulty, economic hardship, anxiety over entry into the service, homesickness, and fear of impending shipment overseas were perceived as stresses more often in men whose psychoneuroses occurred in the Zone of Interior. Lack of comforts, change in diet, and food deprivation were also factors in some of the early breakdowns, although there is reason to question the objective severity of such stresses in these men.

The average length of service before initial hospitalization for psychoneuroses in those cases that developed in the Zone of Interior was 11.7 months, with 8.1 months served after 'breakdown.' Part of the 8.1 months, however, was spent in hospitals. Of the men with a Zone of Interior breakdown, 72 percent were given a medical or administrative discharge (the latter only rarely), half without ever being returned to duty.

³³Brill, Norman Q., and Beebe, Gilbert W.: A Follow-Up Study of War Neuroses. Veterans' Administration Monograph. Washington: U.S. Government Printing Office, 1955.

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Only 17 percent of the men who were hospitalized while in a training center were ever sent overseas.

Analysis of these followup data revealed that it was the man with a positive history of psychiatric disorder in one or both parents and, in addition, with an excessively strong positive attitude toward his mother who was most apt to break down in the Zone of Interior (if he broke down at all). There were 30 men so classified, and 70 percent of them broke down before going overseas.

Many other variables were studied to determine which preservice characteristics were associated with early breakdowns as contrasted with late breakdowns; that is, in or after combat. Economic status of the individual's parental family, role of religion in the life of the parental family, presence of overt sibling rivalry, parental conflict, parental withdrawal via death or divorce, and order of birth seemed to play no part.

Of those who broke down in the Zone of Interior before any oversea service, 37 percent had strongly positive family histories of emotional maladjustment or illness in contrast to 25 percent with negative family histories.

Not all of those who broke down early gave histories of previous emotional difficulty. As far as could be concluded from careful examination and review, 19 percent of those in the followup sample, who were clinically 'normal' before service, broke down early. Of the men studied who had suggestive or overt neuroses before induction, 60 percent broke down in the Zone of Interior. It must be emphasized that this does not mean that 60 percent of all soldiers with suggestive or overt neuroses before service were hospitalized for psychoneuroses in the Zone of Interior-but of those who did break down, hospitalization was apt to result early in the person's military career if he had a 'positive' past history. Of interest is the fact that a significant number of those with positive past histories were known to have rendered effective service, up to and including combat, before becoming disabled.

Further information relative to the prevalence of neurotic predisposition was obtained from a study made by the Research Branch of the Information and Education Division, War Department, in collaboration with the Neuropsychiatry Consultants Division, of the Surgeon General's Office. This study, which involved a personality survey of a sample of all military personnel in the continental United States, found that the incidence of what had previously been regarded as neuropathic traits (for example, history of bed wetting or thumbsucking) was so high among men performing duty that these traits could no longer be regarded as in themselves highly significant. Similar findings were obtained from battle casualties and men performing combat duty. It is believed that some psychiatrists, not having the benefit of service in combat theaters, medically reclassified

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and discharged many men who could have rendered effective service had they been retained.³⁴

DISPOSITION

Early Policies

During the period of mobilization and in the early part of the war, a psychiatric patient was hospitalized in a station hospital located on or nearest the post where he was on duty. Army policy was to dispose of such patients as soon as a definitive diagnosis was made. In this vein, a directive from the Surgeon General's Office³⁵ stressed that disposition need not be delayed until a highly accurate diagnosis was established by prolonged and detailed study, as follows: 'If an individual is obviously unfit, the psychiatrist should make the best tentative diagnosis and proceed promptly with the necessary action to dispose of the patient.'

The Army was concerned with building and maintaining a healthy and effective fighting force and left the burden of treating noneffectives to the Veterans' Administration and other civilian agencies.³⁶

Early in the expansion of the general hospital system, provision was made for specialist care in general hospitals of surgical and medical cases requiring long-term treatment or special procedures. Psychiatric patients, however, continued to be 'disposed of locally' except in the case of officers and of enlisted men with over 20 years of service and where no psychiatrist was available.³⁷ These were to be transferred to the nearest general hospital.

On 11 March 1942, The Surgeon General announced the opening of Darnall General Hospital in Danville, Ky., a mental hospital leased from the State of Kentucky. It was the first of two general hospitals which were to be used strictly as psychiatric hospitals. (Mason General Hospital, Brentwood, Long Island, N.Y., was the second.) In June 1942, when sufficient other general hospitals had been opened, Darnall General Hospital was designated to receive only certain psychotic patients (nurses and enlisted men) when transfer would place them nearer to their homes than transfer to a nearby hospital.³⁸

Delays in Transfer and Discharge

Up until March 1943, when Public Law No. 10, 78th Congress, granted the status of 'a veteran of any war' to all militarized persons who served

³⁴Annual Report, Neuropsychiatry Consultants Division, 1944-45, pp. 114-117.
³⁵See footnote 17, p. 266.
³⁶Halloran, H. D., and Farrell, M. J.: The Function of Neuropsychiatry in the Army. Am. J. Psychiat. 100: 14-20, July 1943.
³⁷Circular Letter No. 6, Office of The Surgeon General, U.S. Army, 24 Jan. 1942.
³⁸Circular Letter No. 61, Office of The Surgeon General, U.S. Army, 27 June 1942.

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on or after 7 December 1941, psychotic patients could be transferred to Veterans' Administration hospitals only when their illnesses were 'in line of duty.' The vast majority of cases were considered 'to have existed prior to induction' and were therefore not eligible for veterans' hospital care. When in need of continued hospitalization on discharge, application to the various State agencies was required. It was unusual to dispose of a psychotic patient sooner than 2 months after admission to an Army station hospital. Some psychiatric patients were not transferred for more than 3 to 5 months during 1941-43 because their home States refused to accept responsibility for prolonged care. During this time, when active therapy would have been most effective, it was not possible to provide such treatment except that which could be improvised with the existing facilities and with the approval of hospital commanders.

The procedure to dispose of psychotic patients was extremely complex and cumbersome, and often, psychiatrists who were unfamiliar with all the directives and methods encountered marked difficulty and delay in disposing of their patients. Porter³⁹ had called attention to this even before the start of the war and had recommended elimination of the AR 600-500⁴⁰ board, the so-called Army Insanity Board. Patients had to be examined by such boards and also by CDD (certificate of disability for discharge) boards;⁴¹ families had to be contacted and their desires ascertained (that is, if they wished to arrange for further treatment themselves); State agencies had to be written to, and often, no reply was received for weeks. Where efforts to dispose of patients to relatives and State agencies were unsuccessful, commitment boards had to be appointed and convened and application made through channels to transfer patients to St. Elizabeths Hospital in Washington, D.C. This entire procedure is described in detail by Farrell.⁴²

Other factors contributing to the delays in disposition were related to the discharge system. Patients admitted to station hospitals continued to belong to their organizations. The CDD form initiated by the hospital had to be forwarded to and signed by the patient's commanding officer who often was not familiar with the procedure and took an excessive amount of time in returning the form to the hospital. In some instances, the patient's service record was with his unit which had already been transferred to another post or shipped overseas, and this had to be obtained before discharge could be processed.

As a result, there was a gradual accumulation of mental patients in Army hospitals to the point where it constituted a major logistic problem. The problem was further complicated as the war progressed by the need

³⁹Memorandum, Lt. Col. William C. Porter, MC, for Col. Albert G. Love, MC, Assistant to The Surgeon General, 29 Feb. 1940.
⁴⁰Army Regulations No. 600-500, 25 May 1944.
⁴¹Army Regulations No. 615-361, 4 Nov. 1944
⁴²Farrell, M. J.: Military Laws and Regulations Pertaining to Disposition of Neuropsychiatric Casualties. In Manual of Military Neuropsychiatry. Philadelphia: W. B. Saunders Co., 1945, p. 71.

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to care for psychotic prisoners of war. Mason General Hospital which was opened in June 1943 was designated to receive them.⁴³

Elimination of delays.-When transfer to Veterans' Administration hospitals was authorized by law, regardless of line of duty, the long delay that was incident to corresponding with the State agencies was, for the most part, eliminated, and dispositions became more rapid.

In January 1944,⁴⁴ in addition to Darnall General Hospital, Mason General Hospital, Bushnell General Hospital, Brigham City, Utah, and Valley Forge General Hospital, Phoenixville, Pa., were designated as centers for specialized care of psychotic patients and for those neuropsychiatric cases which involved special diagnostic or treatment problems. Such centers had been recommended by Ebaugh⁴⁵ as early as 1941. However, the majority of neuropsychatric patients were still disposed of locally by the station hospitals.

Return to Duty

The extent to which neuropsychiatric patients were returned to duty from Zone of Interior hospitals cannot be determined. Any statistical figure would be of questionable value since there were certain variables affecting the return to duty rate, and these variables were, in part, based on administrative policies rather than on medical criteria. In addition, the increasing use of consultation services for diagnosis and outpatient treatment tended to decrease admissions of personnel who, if admitted to hospitals, would conceivably be returned to duty. However, it is believed that, beginning in the latter part of 1944, the frequency of return to duty increased as a result of directives which stated that the existence of a psychoneurosis was not sufficient reason for discharge but, rather, that discharge should be accomplished only if the patient's illness actually incapacitated him for service. In addition, the increase in facilities for and the emphasis upon definitive treatment throughout 1944 were effective in returning a greater percent to duty than had been accomplished previously.⁴⁶

How many patients were returned to duty was clearly related to the perspective and viewpoint of the psychiatrist responsible for the treatment of the soldier with an emotional or functional disorder. Most psychiatrists carried with them into the service the traditional civilian physician's concern about his patient and his well-being and comfort. What is best for an individual in the service, however, is not always best for the Army. Combat is very unhealthy and often fatal and, if just the patient's immediate welfare were the sole concern of the military psychiatrist, he would prescribe removal from combat for everyone. While this, of course, did not occur,

⁴³War Department Circular No. 214, 15 Sept. 1943.
⁴⁴War Department Circular No. 12, 10 Jan. 1944.
⁴⁵Ebaugh, F. G.: Symposium on Medical Preparedness; Role of Psychiatry in National Defense. J.A.M.A. 117: 260-264, 26 July 1941.
⁴⁶Annual Report, Neuropsychiatry Consultants Division, 1944-45, p. 44.

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many psychiatrists were preoccupied with removing patients with emotional difficulties from stress. They did not always appraise realistically the degree to which psychiatric disorders impaired a person's effectiveness, often underestimating a soldier's ability to render effective service in spite of personality defects. Psychiatrists in combat units were better able to observe the powerful positive effect of good motivation and leadership and more quickly revised their concepts. They were able to observe, firsthand, how individuals with psychoneurotic or personality disorders were able to render prolonged effective service under most intense stress of combat.

TREATMENT

Early Experiences

As late as May 1944, AR 615-360 specifically stated: 'Individuals permanently unfit for Army service because of neuropsychiatric disturbances will not be retained for definitive treatment, but will be discharged and arrangements will be made for further care by the Veterans Administration if such is indicated.' However, due to delay in transfer and discharge and the consequent accumulation of patients, most hospitals, during 1942-43, on their own initiative and with considerable ingenuity, developed activity programs for as many patients as possible. Those patients who could not be quickly transferred often received considerable attention in order to make possible their transfer. However, even though psychiatrists attempted to treat as many patients as possible, they were hampered by the large number of patients they were called upon to see and by the lack of facilities. In a few hospitals, there were no organized therapy programs for either open- or closed-ward patients during the early years of the war.

'Too Little and Too Late'

Individual attention was given to the more seriously ill patients; wet-packs were used to quiet agitated patients, sedation was prescribed when indicated; the occasional patient with a conversion reaction was rendered symptom free through the use of suggestion, often with Sodium Amytal (amobarbital sodium) narcosis. As time went on, ball games and daily calisthenics were arranged; entertainment was brought to the closed wards. In a few hospitals, occupational therapy shops were improvised out of warehouses or unused wards, salvaged material, and equipment which could be purchased with hospital funds. It was generally impossible to obtain sufficient personnel to cover the neuropsychiatric wards, and most of what was done in the way of recreation, entertainment, and occupational therapy through 1943 was possible only because of the assistance and cooperation of the Red Cross or local Gray Ladies.

Electroshock treatment was not authorized until the spring of 1943,

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when its use in selected cases of psychoses was approved.⁴⁷ However, many hospital commanders were reluctant to introduce such 'dangerous' treatment in their hospitals, and equipment for such treatment could not be requisitioned. Furthermore, in many of the smaller hospitals, personnel trained in giving shock treatment were not available.

In too many installations, the small neuropsychiatric section was looked upon as a necessary evil. Occupational therapy, when finally authorized in August 1943, was approved only for general hospitals in the Zone of Interior, but not for station hospitals where arts and crafts and hobby activities were continued by Red Cross workers. It became increasingly apparent that, if proper treatment were to be given psychiatric patients, they would have to be concentrated in specially designated centers where trained personnel could be used most economically. This eventually came about with the establishment of regional hospitals in April 1944⁴⁸ and the designation of additional general hospitals as neuropsychiatric centers.⁴⁹

Special Programs

It had been recognized for a long time that many persons who were hospitalized for psychoneurotic disorders did not require hospitalization and, in fact, did poorly in hospitals.⁵⁰ Medical officers, however, had no other recourse. If a man were not fit for duty because of a psychoneurosis, the only possible disposition was to send him to a hospital. In civilian life, hospitalization would not even have been considered.⁵¹

Great ingenuity was used by many medical officers, however, in developing treatment programs that were designed to return to duty as many psychiatric patients as possible. For example, Col. Thomas G. Tousey, MC, commanding officer of the Station Hospital, Camp Kilmer, N. J., established a rehabilitation program for men who developed emotional symptoms at the staging area in which his hospital was located. Before establishing this program, Colonel Tousey had determined that, when such men were given medical discharges for psychoneuroses, 69 percent were able to readjust themselves and become gainfully employed almost immediately after returning to civilian life.

By not using a formal diagnosis of psychoneurosis in these cases who 'broke down' just before oversea shipment and by assigning those who could not be returned to duty to the hospital medical detachment, continued medical observation could be carried out while these men lived in barracks and worked in the hospital or were on a nonpatient status. By gradually

⁴⁷Circular Letter No. 88, Office of The Surgeon General, U.S. Army, 23 Apr. 1943.
⁴⁸War Department Circular No. 140, 11 Apr. 1944.
⁴⁹War Department Cirular No. 235, 12 June 1944.
⁵⁰Menninger, W. C.: Problems Confronting Psychiatry in the Army Convalescent Hospital. Am. J. Psychiat. 102: 732-34, May 1946.
⁵¹Farrell, M. J., and Appel, J. W.: Current Trends in Neuropsychiatry. Am. J. Psychiat. 101: 12-19, July 1944.

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increasing their responsibilities and the demands made on them to restore their self-confidence, it was possible to return 83 percent of these patients to general or limited service. A considerable number were assigned directly to task forces departing from the staging area or to other posts to join units that were preparing to go overseas. Only 17 percent had to be discharged. Followup on those who were returned to duty revealed that only five men were hospitalized and three of these again returned to full duty. This program was described in detail by Goldbloom and Schantz.⁵²

Col. Lauren H. Smith, MC,⁵³ Neuropsychiatric Consultant, Ninth Service Command, was impressed with how much individual psychiatrists were able to do in the way of developing treatment programs which, he believed, compared favorably with those of civilian hospitals.

Treatment Officially Directed

Circular Letter No. 168, Office of The Surgeon General, issued on 21 September 1943, prescribed a convalescent reconditioning program for hospitals. Its objective was to return men to duty from hospitals in the best possible physical condition and the constructive use of leisure time in educational pursuits. However, no special provisions for neuropsychiatric patients were included.

In general, little was done previously to develop reconditioning programs in hospitals, and on 10 December 1943, The Surgeon General sent a memorandum to all service command surgeons and commanding officers of all named general hospitals, ordering that reconditioning programs be put into effect at once for all patients regardless of whether or not they were expected to return to duty.

On 1 April 1944, War Department Technical Bulletin (TB MED) 28, the first comprehensive directive on the treatment of psychiatric patients, was issued, and for the first time, it was officially directed that psychiatric patients be treated:

The acute needs for manpower make it imperative that every treatment method available in station and general hospitals for neuropsychiatric patients be utilized to the maximum. The aim is to salvage every possible soldier for further duty. Those patients in whom there is no hope for salvage should be recommended for discharge.

a. An erroneous attitude prevails that neuropsychiatric patients should not be treated, perhaps because of misinterpretation of previous directives. In too many hospitals, neuropsychiatry is merely a matter of diagnosis and disposition. This must be corrected: the soldier receives the best of medical and surgical treatment, and the neuropsychiatric patients should be given the benefit not only of treatment but of the most scientific methods available. 'Those individuals with neuropsychiatric conditions incurred incident to the service who, in the opinion of the medical officer, may, within

⁵²(1) Goldbloom, A. A., and Schantz, B. A.: The Management of the Emotionally Maladjusted Soldier at a Staging Camp. Psychiatric Quart. 20: 452-469, July 1946. (2) See also chapter XII, 'Troops in Transit.'
⁵³Smith, L. H.: Treatment Activities in War Psychiatry. Am. J. Psychiat. 101: 303-309, November 1944.

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a reasonable period be returned to duty within the continental limits of the United States' are to have definitive treatment (AR 615-360, Changes No. 16, 15 December 1943). A high percentage of psychoneurotic patients can be salvaged, if treated, and the possibility of their salvage can be determined only by treatment.

b. There is a tendency to misuse the diagnostic term 'psychoneurosis.' On the other hand, under sufficient stress of a specific type, any individual may develop a psychoneurotic disorder. Consequently, the presence of psychoneurotic symptoms may indicate an extremely difficult situation rather than a 'weak' individual.

c. A widespread attitude prevails on neuropsychiatric wards that admission to such wards is tantamount to discharge. This attitude spreads, with infectious virulence, to new patients. Effective steps must be taken by medical officers and all ward personnel to reverse this attitude through individual and group contacts and segregation.

Many important principles of treatment were outlined, such as:

Psychotic and psychoneurotic patients should not be housed in the same ward, except in those occasional instances where active suicidal trends may be present in a psychoneurotic patient.

Prisoners, unless neuropsychiatric cases themselves, are not to be housed with neuropsychiatric patients, and in no instance is the guard on a neuropsychiatric ward to be armed with a firearm.⁵⁴

Depending upon the number of patients and wards available, all open neuropsychiatric wards, with the exception of one for acute cases and new admissions, might be located in military barracks, with an attempt to divorce the patients from a 'hospital atmosphere.' The patients in such wards should be dressed in uniform or fatigue clothes, and required to do their own police work, take care of the ward, and their own beds and property, and care for themselves.

Obtain the 'permanent' assignment of as many nurses as possible with neuropsychiatric nursing training and/or experience to the neuropsychiatric section.

Exercise care in the selection of ward attendants to the end that-

(1) Neuropsychiatric patients be in charge of intelligent and emotionally stable individuals capable of contributing to their effective therapeutic management.

(2) Individuals with special skills in sports, crafts, games, and music, especially those capable of leadership in such activities, be utilized to the fullest extent.

Enlist as much aid from the Red Cross as possible.

Recreation workers especially can be of major help in the development of an activity program.

Gray Ladies, under the supervision of the Red Cross, can be of such help as instructors, and can assist in the recreation program and provide individual attention.

Enlist the part-time or occasional help of other medical, dental, and medical administrative officers and nurses in the leadership of special classes or group activities in their particular hobbies or interests (chess, photography, aviation, art, etc.).

In general hospitals, full utilization of the gymnasium and the occupational therapy shop should be made. In station hospitals, if no separate space is available, a craft workshop can be established on the porch or dayroom of a ward. Every ward or group of patients (including psychotic) should have an adequate outdoor recreation area, sufficiently large to permit active group games. An area for vegetable or flower gardening is desirable.

Every neuropsychiatric patient should have psychotherapy.

⁵⁴This provision was reinforced by a letter from Brig. Gen. Raymond W. Bliss, Chief of the Operations Service of the Surgeon General's Office, to the service command surgeons, dated 5 June 1944, in which it was directed that prisoners not be confined on neuropsychiatric wards and that members of the medical detachment not be confined or assigned to the neuropsychiatric section for disciplinary purposes (a practice that was followed in some hospitals).

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Group psychotherapy was encouraged. The indications and technique of psychotherapy under sedation with Sodium Amytal and Sodium Pentothal (thiopental sodium) were given. The development of a well-rounded and scheduled occupational-recreational-educational activities program was urged. Authority for the use of shock therapy was restated and utilization of hydrotherapy encouraged.

The publication of TB MED 28 can be attributed to the personal efforts of Brig. Gen. William C. Menninger. Previously, as a neuropsychiatric consultant in the Fourth Service Command, he had urged that neuropsychiatric patients be given every possible benefit of treatment. However, it was this War Department directive which made possible the Army-wide adoption of a treatment program which was to continue to expand during the remainder of the war. The importance of this was described by Thomas⁵⁵ and many others.

Army Service Forces Circular No. 175, issued on 10 June 1944, provided for the extension of the reconditioning program to include the majority of neuropsychiatric patients, as follows:

Experience has shown that the majority of patients with mental and emotional upsets are benefited by the prompt institution of a planned program which prevents apathy, morbid introspection and preoccupation with the somatic manifestations of emotional disturbances. Prolonged hospitalization tends to fix the symptoms rather than alleviate them. In order to achieve the maximum benefit, any patient who has even a remote chance for salvage for additional military service will be given a trial at reconditioning.

As soon as the necessary investigative procedures have been completed, all patients who do not require closed ward care or intensive individual therapy will be assigned to the advanced reconditioning section and housed apart from the hospital wards. Care will be exercised that disturbed or suicidal patients will continue to receive appropriate ward care.

Patients will be organized into separate platoons and placed in duty uniforms, grouped so far as possible on the basis of the degree of their incapacity.

An organized program of physical conditioning, educational reconditioning, occupational and industrial therapy, and active recreation will be planned. Group psychotherapy will be utilized to its full effect.

The reconditioning program for many neuropsychiatric patients will constitute their only treatment in contrast to medical and surgical cases where active therapy has given way to convalescent care. Such reconditioning will include individual and/or group psychotherapy and participation in prescribed activities designed to overcome neuropsychiatric defects. Programs for these patients, therefore, will be formulated and carried out with the approval and active assistance of the psychiatrist.

Convalescent neuropsychiatric patients who have been judged fit to return to duty may be combined, when it is desired, with other trainees in the advanced reconditioning sections.

If it is found impractical to conduct a program of reconditioning for neuropsychiatric patients at a hospital because of the smallness of the group, they may be sent to another hospital or facility at the direction of the service command.

Full use should be made of the treatment program for psychiatric patients outlined

⁵⁵Thomas, H. M., Jr.: Convalescent Care and the Morale of Patients. Mil. Surgeon 93: 453-457, December 1943.

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in TB Med 28, 1 April 1944 * * *. Attention is also directed to the need for proper reclassification and selective assignment to duty which the neuropsychiatric patient may be expected to perform * * *.

The greatest improvement in the treatment of psychiatric patients came about with the establishment of psychiatric centers (in certain general hospitals) and of convalescent hospitals in the spring and summer of 1944. By concentrating all closed-ward cases (originating in the Zone of Interior or overseas) in the centers, it was possible to develop active treatment programs which had not been possible in the station hospitals. Under these conditions, shock therapy (mostly electroshock) was used freely for disturbed or agitated psychoses and depressions; subshock insulin treatment was employed in the more severe psychoneurotic reactions with encouraging results; psychotherapy under sedation called narcosynthesis, which had gained great popularity overseas in the treatment of combat neuroses, was resorted to in patients with residual symptoms of psychoneuroses incurred in combat and in cases of conversion hysteria.

CONVALESCENT HOSPITALS

Purpose

In preparation for the large influx of patients from oversea theaters, 13 convalescent hospitals were activated in August 1944. Of these, 12 had large sections devoted to the treatment of mild psychoneuroses. It was originally planned to treat Zone of Interior and oversea open-ward psychiatric cases in the convalescent hospitals-when traditional hospital care was not required. The number of patients who were returned from oversea theaters turned out to be so large that it became necessary to limit the function of the neuropsychiatric sections of the convalescent hospitals to treating oversea cases, with just a few exceptions.

Apart from the need for beds, there were other considerations which prompted the development of the convalescent hospitals. It was generally accepted that the usual type of hospitalization was not conducive to recovery for the average open-ward patient who was not seriously ill.

Symptoms tended to become fixed, patients became somewhat apathetic, and resistance to return to duty gradually increased. ('Hospitalitis' was a term often used to describe this phenomenon.) It was believed that housing patients in barracks, organizing them into company units, and instituting a planned program of treatment and activities would be productive of much better results. At the same time, the concentration of large numbers of patients would result in economies of personnel. Under the supervision of psychiatrists, it was possible to use clinical psychologists and psychiatric social workers for interviewing and observing patients and in group therapy, in addition to their more usual functions. A greatly expanded activities program of education, physical reconditioning and recrea?

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tion, occupational therapy, and prevocational training could be justified by the large number of patients.

Organization and Function

The organization of the convalescent hospital was outlined in TB MED 80, issued on 3 August 1944. The neuropsychiatric section constituted just one part of it. In most of these hospitals, the psychiatric patients were organized into their own battalion or regiment but, in at least one hospital, medical, surgical, and neuropsychiatric patients were randomly intermixed without reference to disease category.

The treatment program in the convalescent hospitals, as it ultimately evolved, included scheduled psychotherapy, generally group, from 3 to 5 times a week; occupational therapy, 3 to 5 times a week; and daily physical reconditioning in the form of calisthenics, walks, or gymnasium work coordinated with the recreational activities, such as competitive sports, swimming, fishing, and boating when available.

A daily educational hour was included in which were given such courses as foreign languages, motor mechanics, business administration, agriculture, radio, and typing.

Prevocational training was coordinated with occupational therapy and educational activities in such fields as carpentry, mechanics, metalwork, welding, and radio, and a free period was provided for elective activities such as photography, arts, music, rehearsal for shows, band practice, stamp collecting and other hobbies.⁵⁶ A special directive on the use of music in reconditioning emphasized its importance in the treatment of neuropsychiatric patients.

Location

During the peak period of hospitalization, convalescent hospitals, caring for psychoneurotic patients, were established at the following locations:

Camp Edwards Convalescent Hospital, Camp Edwards, Mass.
Camp Upton Convalescent Hospital, Long Island, N.Y.
Fort Story Convalescent Hospital, Fort Story, Va.
Camp Pickett Convalescent Hospital, Camp Pickett, Va.
Welch Convalescent Hospital, Daytona Beach, Fla.
Camp Butner Convalescent Hospital, Camp Butner, N.C.
Camp Atterbury Convalescent Hospital, Camp Atterbury, Ind.
Fort Custer Convalescent Hospital, Fort Custer, Mich.
Fort Logan Convalescent Hospital, Fort Logan, Colo.
Fort Sam Houston Convalescent Hospital, Fort Sam Houston, Tex.
Mitchell Convalescent Hospital, Campo, Calif.
Madigan Convalescent Hospital, Fort Lewis, Wash.
⁵⁶(1) Davis, J. E.: Recreation in the Mental Hospital. Ment. Hyg. 26: 85-91, January 1942. (2) Davis, J. E.: The Importance of Physical Training in a Rehabilitation Program in Mental Hospitals. Psychiatric Quart. (suppl.) 14: 159-167, 1940. (3) Barton, E. E.: Occupational Therapy. In Manual of Military Neuropsychiatry. Philadelphia: W. B. Saunders, 1945, p. 604.
⁵⁷War Department Technical Bulletin (TB MED) 187, 26 July 1945.

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In some of the convalescent hospitals which had a total bed capacity of 5,000, there were as many as 1,900 psychiatric patients on the roster at one time.

Description of Treatment Program

An excellent description of the operation of the Neuropsychiatric Service of the Percy Jones Convalescent Hospital was given by Lt. Col. Fred F. Senerchia, MC, at a Sixth Service Command Neuropsychiatric Conference held in Chicago, Ill., on 16-17 November 1945. He stated, as follows:

The advent of the convalescent hospital brought into focus many problems. We no longer had wards but companies and battalions. We no longer had ward masters and nurses, but first sergeants, company clerks, duty non-coms, company commanders, and battalion commanders. Since almost all of our patients came directly from overseas, it was necessary to handle these patients at as near a general hospital level as possible if professional standards of care were to be maintained. Therefore, from the beginning we made plans for the rendering of a general hospital type of professional care in a setting of barracks, companies and battalions. To more effectively accomplish this, we had to coordinate the purely administrative services with professional services, so that the two could be welded into an organizational whole and make for a smooth running unit. By borrowing from the experiences of the consultation services and mental hygiene clinics, from the experimental developmental training units set up under the provisions of ASF Circular No. 40, 5 February 1944, and from TB MED 80, we were able to set up such an organization.

Apart from the officer patients, the neuropsychiatric service is organized as a regiment. The regiment is quartered in an excellent area of Fort Custer. The patients are housed in newly reconverted two-storied barracks with a central heating plant and inside latrines and showers. The area has its own Post Exchange, Red Cross Recreation Building, Red Cross Professional Building, occupational therapy shops, conference rooms for orientation and group psychotherapy, athletic fields, and many company dayrooms.

At regimental level are found the regimental commander who is chief of the neuropsychiatric service and the regimental headquarters staff who are the coordinators for the various professional and nonprofessional services rendered the patients from within the regiment. It is also at this level where liaison is maintained with the auxiliary nonregimental services, such as educational and physical reconditioning, separation classification, personal affairs, and the Red Cross. Briefly then, regimental headquarters consists of the commanding officer who is also chief of the neuropsychiatric service, a branch immaterial executive officer who supervises and coordinates the purely administrative functions of the regiment; a chief clinical psychologist who supervises and coordinates the psychologists of the regiment and in addition, maintains liaison with separation-classification and educational and physical reconditioning as operations officer; a chief psychiatric social worker who supervises and coordinates the work of the psychiatric social workers and maintains liaison with personal affairs and the Red Cross; and a sergeant major and clerks.

In order to bring the maximal amount of individualized professional care to the patient, the regiment was organized into five battalions of 400 beds each. Each battalion is headed by a battalion commander who functions, in addition, as its senior psychiatrist. He is the focal point of what is in reality, a self-contained psychiatric unit. He has at Battalion Headquarters level coordinators similar to those at regimental level, namely a branch immaterial executive officer, a chief psychologist, and a chief social service worker. In addition, the Battalion Headquarters or psychiatric

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unit is staffed by the company neuropsychiatrists and social service workers, clinical psychologist, clinical records clerks, civilian medical stenographers, and a sergeant major.

The battalion, in turn, is organized into four companies of 100 patients each, comparable to four one-hundred bed wards. Assigned to each company is the company neuropsychiatrist whose duties are comparable to a ward officer even to the making of ward rounds. Assisting him in the discharge of his professional duties are the assigned company social worker and the battalion clinical psychologists. There is thus established a continuous doctor, social worker, psychologist, patient relationship from the moment the patient is admitted to his company or ward until the time the patient is dispositioned. In the diagnosis and treatment of the patient, in addition to the psychiatric team approach and individual and group psychotherapy, the medical officer avails himself of the service of other medical and surgical specialties when the need arises. Also functioning at company level are branch immaterial company commanders, first sergeants, duty noncoms, and company clerks.

The officer section had assigned to it two neuropsychiatrists in addition to a commissioned clinical psychologist. The section was housed in a professional building which it shared with the officer surgical section. The patients were under the administrative control of the commanding officer of the officer patients battalion. This section had a reconditioning program of its own.

The neuropsychiatric service from its inception saw in consultation patients referred from the medical and surgical service. This consultation service was coordinated through the office of the chief of the neuropsychiatric service.

The patients are admitted through the admission and disposition office to the receiving division of the convalescent hospital. There they are examined by a physical examination team, two members of which are neuropsychiatrists. At this level, those cases felt to be too ill for convalescent hospital care are screened out and sent to the neuropsychiatric service of the Percy Jones General Hospital Annex at Fort Custer. In addition to the physical examination, histories are taken and routine laboratory work and chest X-rays are done where necessary. Following this the patients are admitted directly to one of the neuropsychiatric battalions. Here a battalion file is opened on the patient and it is at this level that the neuropsychiatric processing is done by the neuropsychiatrists, psychologists, and psychiatric social workers. In addition to a mental status by the psychiatrist, a psychiatric social summary is obtained by the social worker, and an initial evaluation is made by the psychologist for placement in the educational reconditioning program or for psychometry. When this has been completed and clearance given by the psychiatrist, the patient is ready for furlough if he has come directly from a debarkation hospital. The entire processing from admission to furlough takes an average of less than 5 days. Upon return from furlough, the patient enters the treatment program and is followed up by his company neuropsychiatrist, company social worker, and clinical psychologist. During the course of his treatment the clinical record is completed and when the patient has received maximum hospital benefit, in general between 6-8 weeks after return from furlough, he is brought before a neuropsychiatric staff conference consisting of the battalion commander, who is the senior psychiatrist, the psychiatrist presenting the case and one other medical officer. This staff conference functions also as the disposition board. Here final diagnosis is made, line of duty is established and disposition recommended if it is felt that the patient has received maximum hospital benefit.

Neuropsychiatric Treatment Program: In a discussion of treatment for the convalescent hospital neuropsychiatric patient, in addition to the definitive individual and group psychotherapy, one must include the therapeutic benefits which accrue from the ancillary services. These services include educational and physical reconditioning, occupational therapy, orientation, company commanders discussion hours, individual services, special services, the Red Cross, and the administrative services rendered by the company commanders and cadre. Passes and furloughs are considered therapy.

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Every patient, unless specifically excused (usually for an intercurrent illness), is a participant in the daily program which carries on 5 days a week from 0800 until 1630. The morning program in general consists of physical reconditioning, orientation, and group psychotherapy; while the afternoon program consists of educational reconditioning (the school program) or occupational therapy, ward rounds and, weather permitting, a retreat parade once a week. Individual interviews do not follow any set schedule. Individual Therapy: Because of the excellent facilities offered by the neuropsychiatric section of the Percy Jones General Hospital Annex at Fort Custer, all cases requiring hydrotherapy, Sodium Amytal or pentothal narcosynthesis, insulin therapy or closed ward care were referred to it rather than establish a special treatment section in the convalescent hospital. The more severe cases not requiring the above forms of therapy for proper management were rostered for individual therapy at the Convalescent Hospital level.

At Convalescent Hospital level, the approach was a team approach (psychiatrist, psychologist and psychiatric social worker). The individual therapy given by the non-medical members of the team was primarily along counseling lines. In general, the individual therapy given by the psychiatrist was not tuned to relieving profound personality problems of longstanding duration, but rather to help the soldier gain insight into the psychosomatic dynamics of his syndrome. Means were offered to ease the symptomatic discomfort by sublimation and rationalization together with straight forward common sense psychiatric orientation.

Group Psychotherapy: Group psychotherapy was conducted for several reasons.

(1) To provide daily contact between the patient and the members of the clinical team which time limitations made impossible on an individual level.

(2) Because there was value in discussion of mutual personal problems on an impersonal group level.

(3) Group discussion made the patient realize that his problem and complaints were not unique but were shared by others.

(4) It allowed for release of aggression.

(5) It gave the clinical team an opportunity to evaluate the total program from the attitude of the group. (Observations obtained by all members of the clinical team were shared for the benefit of the total program.)

Administration: All patients took part in group psychotherapy which was conducted by the psychiatrists, the clinical psychologists, the psychiatric social workers and through the media of selected movies. Groups were conducted on two levels; large group therapy and small group therapy.

Large group therapy was part of the regularly planned program and four 1-hour periods per week were scheduled. The time was divided by all the members of the clinical team. The large groups were company size (maximum 100 patients) and all patients attended large group sessions.

Due to the difficulty of handling large groups and because some patients needed more personalized therapy, small group therapy was given to selected individuals. It was found that the best therapy could be accomplished when the group consisted of 5-10 men, sometimes slightly larger. Patients were selected for small group therapy which was conducted by the clinical psychologist or psychiatrist in different ways: (1) Patients were referred for small group therapy by the psychiatrists and the social workers. (2) Patients were selected by the psychologist and psychiatrist on the basis of the clinical picture which made for a homogeneous group. (3) In one battalion all new patients were handled in small groups. The length of the group sessions usually varied between 45 minutes and 1 hour. No rigid time limit could be set. The meeting was concluded when interest lagged or restlessness was noted.

The atmosphere of the group meetings was informal. Everything possible was done to break down the traditional barrier that existed between officer and enlisted

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men. While the therapist had a prearranged plan there was no prearranged text for the meeting. A prearranged text invariably resulted in a health talk which had to be avoided. Occasional straying from the subject caused no great concern. An opportunity for release of aggression was valuable and had to be encouraged.

Educational Reconditioning: Educational reconditioning was considered adjunct therapy. In order to place this activity on a doctor-patient relationship it was coordinated in our battalions through the clinical psychological sections which were under the supervision of the medical officers. As a result, our patients were given assignments by individuals who had understanding of the emotional problems involved and whose progress in the particular studio, shop or classroom was followed from a psychological point of view. The school and shop program aided materially in stimulating a reawakening of interest and combating apathy which was initially present in many of our patients. It helped restore confidence in our anxious patients, particularly those showing preoccupation, restlessness, impaired concentration and inability to sustain attention over long periods of time by proving to them through personal performance, that they could cope with their deficiencies. For those exhibiting 'startle reaction,' the more noisy shops permitted them to make adjustments to occupational noises.

Occupational Therapy: This was utilized for our more severe anxious patients and those with poor intellectual endowment who were on psychiatric grounds not ready for the more formal school and shop program.

Physical Reconditioning: It was found that maximal therapeutic benefit was derived from competitive games and athletics at inter and intra company, battalion and regimental levels. This approach made for spontaneous participation and, in addition to restoring physical fitness, aroused enthusiasm and a feeling of 'belonging' on the part of the patient for the first time since he was lost to his unit overseas and remained lost in the hospital evacuation chain. This rebirth of enthusiasm and feeling of 'belonging' made for good patient morale which was essential for effective, more formal psychotherapy.

Special Projects:

Company for Psychopaths: Due to the large number of psychopaths being admitted despite directives, it was imperative that something be done to prevent the undermining of morale of the other patients and sabotaging of the program by these military delinquents. At the suggestion of Maj. Nils B. Hersloff, MC, a special company was activated. This type of patient was processed rapidly and returned to duty to be handled administratively by the line. In time, the company became known as the special treatment platoon to which were sent, in addition to the aggressive psychopaths, those patients who were awaiting courts-martial principally for AWOL and those who were sentenced to restrictions by courts-martial.

Trial Furloughs: When it became apparent that the symptomatology of a small number of patients was aggravated and accentuated by anxieties relative to civilian adjustments and rehabilitation, Major Nils B. Hersloff instituted the policy of trial furloughs. After maximum hospital benefit had been attained and prior to final disposition, this group of patients were given furloughs of from 5 to 10 days. Inasmuch as they were definitely aware of their ultimate disposition, they were enabled to establish their families, obtain employment and accustom themselves to the routine of civilian living. In some instances it was necessary to repeat these furloughs in order to dissipate the accumulated anxiety. Approximately 8 percent of the patients dispositioned by Major Hersloff's board have required and requested such procedure and as a result benefited immeasurably.

Duty Company: The duty company was established at the suggestion of Capt. Willard Z. Kerman after an exhaustive study in order to effect a physical separation between patients who were likely candidates for duty and those who warranted separation from the service. Mingling of duty prospects with those who should be separated

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from the service blocked adequate therapeutic endeavors. All duty prospects in the regiment were transferred to this duty company as soon after return from convalescent furlough as possible. At this level orientation and psychotherapy programs were conducted with a return to duty as a key note as opposed to adjustment to civilian life.

This company was of necessity created since the policy of higher authority prevented the medical officers from informing the patient of his ultimate disposition. However, shortly after its establishment this policy was relaxed and the company disbanded.

In a staff evaluation of the program we were unanimously of the opinion that the majority of patients whom we have returned to civilian life have been adjusted to the point where once again they can take their places in the community as useful citizens. There is no single factor responsible for this. The professional approach used, utilizing the psychiatrist, psychologist, and psychiatric social worker as a team was in no small way responsible for the results achieved. While everything done for the patient constituted treatment including company management, the contributions of the professional team in terms of group and individual psychotherapy were the backbone of the treatment program. The therapeutic contributions made in the form of educational and physical reconditioning service were very important adjuncts. We were very fortunate in having at our disposal an unusually fine educational system. The shops, classrooms, and stations were well-equipped and excellently staffed. The agricultural school and its farm was an outstanding project. For the physical reconditioning program we had more than our share of playfields and recreational areas. With the coming of winter there were bowling alleys, new gymnasiums and an indoor swimming pool.

The atmosphere of the convalescent hospital provided an effective framework for the treatment program. The usual hospital ward routine was lacking and in its place was substituted a modified type of garrison living. While it is true that discipline was maintained yet our patients were given considerable freedom. The patient was free to do as he wished after five o'clock and could get weekend passes for the asking providing there had been no breach of discipline. They were in a sense on their own again; and for many of the patients this was so for the first time in many months. The self-imagined stigma of an N.P. ward, even though an open one, had been removed. This simple fact was of untold therapeutic value in that it gave support to damaged egos and restored self-esteem and self-confidence. Most of our patients lived within a distance of 200-300 miles of the hospital, and consequently most of them spent their weekends at home. As a result, many civilian problems surfaced during this period. Fortunately, since the patient was still under military control, he had available the help of his doctor, psychologist, and social worker, who as a team helped him resolve his newly acquired anxieties. This benefited not only the soldier returning to duty, but also the one to be discharged. The latter in essence was being prepared for a return to civilian life. His exposure to it was gradual and controlled rather than abruptly from hospital ward to civilian status.

With this approach we felt that a majority of the patients discharged needed no particular followup in the community. Most of the patients in this group had made plans for the future and many had already secured employment by the time they were ready to be discharged. A small percentage were found however, who although they had received maximum hospital benefit, could profit from further psychiatric followup. Upon discharge these were referred directly by their doctor or through the Red Cross followup service to psychiatric clinics in or near their communities.

We of the Convalescent Hospital staff have always been extremely enthusiastic about the program and its effect on our patients. Since we have no followups, our assessment of the program is based entirely on prognostication by the staff and may for that reason be biased. Be that as it may, we are convinced that the approach used was psychiatrically sound. We shall go one step further and state that for the milder neuropsychiatric casualty, the management of choice is at a convalescent hospital level.

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Results

Although each of the convalescent hospitals had psychiatric patients with essentially the same severity of disorders and in the same type of treatment program, there was great variation in the criteria which were used for discharge or return to duty. The disposition of psychiatric cases from 11 hospitals during the period from 11 May to 29 June 1945 was determined from statistical health reports (WD MD Form No. 86ab) which the hospitals submitted to the Office of The Surgeon General. Whereas Welch Convalescent Hospital returned 59.4 percent of its psychiatric patients to duty, Camp Edwards Convalescent Hospital returned only 1.7 percent of its psychiatric patients to duty (table 17).

These results merely emphasize that a medical discharge in itself was no indication of the degree of disability that an individual had upon discharge.

After a visit to the Fort Story Convalescent Hospital, Lt. Col. (later Col.) Henry W. Brosin, MC,⁵⁸ Third Service Command neuropsychiatric consultant, reported that 80 percent of the medical discharges during the first 4 months of 1945 were for psychiatric reasons: 'Very few of the neuropsychiatric patients have been sent to duty [because] it is difficult to get assignments for these patients. Another hazard is the delay in getting

TABLE 17.-Disposition of neuropsychiatric cases from convalescent hospitals, 11 May-29 June 1945

Convalescent hospital	Number returned to duty	Number discharged on certificate of disability	Percent of men returned to duty
Welch, Fla.	530	363	59.4
Camp Butner, N.C.	169	117	59.1
Fort Sam Houston, Tex.	129	737	14.9
Camp Upton, N.Y.	143	806	15.1
Camp Carson, Colo.	54	520	9.4
Camp Pickett, Va.	69	707	8.9
Mitchell, Calif.	19	226	7.8
Percy Jones, Mich.	85	1,052	7.5
Fort Story, Va.	24	507	4.5
Camp Atterbury, Ind.	39	1,025	3.7
Camp Edwards, Mass.	23	1,299	1.7
Total	1,284	7,359	14.9

NOTE.-Men discharged to duty for administrative discharges may be included in the 'duty' figures. Transfers to other hospitals or dispositions other than duty or certificate of disability for discharge have not been included. Percentage of men returned to duty is based only on the 'duty' and 'certificate of disability for discharge' figures.

⁵⁸Letter, Lt. Col. Henry W. Brosin, MC, 9 May 1945, subject: Report of Neuropsychiatric Consultant's Visit to Convalescent Hospital and Infirmary, Fort Story, Va.

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them to a permanent assignment which often vitiates the results of treatment.' Colonel Brosin also reported:

One of the most gratifying aspects of the therapeutic program [at Fort Story] is the prominence given to group therapy and the excellent work which is being done by the medical officers and the MOS 263's [psychiatric social workers]. In addition to the general directions given in TB MED 103, more complex relations are being utilized by the therapists. The more experienced men are able to manipulate the individual expressions of the men so that they have both a general group value and a specific individual meaning. * * * The men are led successively step by step in a coherent fashion to understand their own relations and those of their fellows to authority, to the hospital, to the Army and to the country in a simple straight-forward manner which does much to diminish their tension level. * * * It is estimated that at least 90 percent of the men receive some benefit and that the large majority become reasonably well adapted to the hospital setting with absence of complaints and symptoms. It is noteworthy that the men who retain neurotic action patterns as expressed by undue hostility, guilt, depression, somatic symptoms, passive dependency, etc., have upon examination, deep seated neurotic trends in these directions. It would seem as if the military situation merely gives them an opportunity to exploit previous habit patterns. It might be well for medical officers to examine systematically the thesis that 'war neurosis' or 'combat reactions' or 'fatigue reactions' are caused by adequate exposure to genuine hardship or combat experiences in a relatively stable person with gross acute symptoms which diminish or disappear with treatment.

Maj. Irving L. Turow,⁵⁹ reported on his experience with this problem at the Percy Jones General Hospital in Battle Creek, Mich. In reviewing the records of 1,521 neuropsychiatric patients treated at that hospital from February 1943 to September 1945, 1,104, or 73 percent, first manifested emotional symptoms in the Zone of Interior or noncombatant area. The remaining 417, or 27 percent, first manifested acute disabling symptoms in combat. He concluded:

Although investigation of individual records of the 1104 patients was not thoroughly made, * * * indications are that these patients in the main had neuropathic traits prior to induction into the service. It is not to be assumed that frank neuroses do not occur under Army stress without previous healthy psychiatric history, but the incidence is relatively low.

Turow emphasized the need to differentiate neuroses from neurotic reactions to severe stress.

GROUP PSYCHOTHERAPY

The shortage of psychiatrists and the large number of patients made it impossible to give individual psychotherapy. For this reason, the treatment of patients in groups was encouraged⁶⁰ and ultimately widely utilized.

⁵⁹Turow, I. L.: Neurosis, Neurotic Reaction, and Motivation. In Proc. Neuropsychiatric Conference of the Sixth Service Command, Chicago, III., 16-17 Nov. 1945, pp. 26-30.
⁶⁰(1) War Department Technical Bulletin (TB MED) 84, 10 Aug. 1944. (2) War Department Technical Bulletin (TB MED) 103, 10 Oct. 1944.

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Methodology

Different techniques were developed by the various therapists. In some places, a lecture-discussion method was used, which included series of talks on such subjects as orientation to the hospital, types of nervousness, causes of nervousness, body-mind relations, and the role of dependency, insecurity, and inferiority. In others, a question-answer technique was used. The method most widely adopted was to have patients tell the histories of their illnesses in front of the group and then, to have group discussion of his situation and illness, with some guidance from the therapist. By specific example, it was possible to demonstrate mental mechanisms-the relationship between present symptoms and behavior and emotional patterns which were developed and fixed in childhood. Some therapists undertook analysis of dreams by individuals in front of the group, with good results.

While the early explorations in the use of group psychotherapy tended to be carried on in the general hospital psychiatric centers (for example, Lt. Col. Samuel Paster, MC, at Kennedy General Hospital in Memphis, Tenn., and Maj. Jules V. Coleman, MC, at Lawson General Hospital in Atlanta, Ga.), psychiatrists like Maj. Donald A. Shaskan, MC, utilized group therapy in station hospitals. Some of the most gratifying results were obtained at the Fort Knox Rehabilitation Center where group therapy was included in the daily schedule of activities of the men who were confined there as a result of conviction by general courts-martial. As far as could be determined, this work was begun by Maj. Alexander Wolf, MC, and later developed by Lt. Lloyd W. McCorkle, MC, and his assistants, and by Capt. Joseph Abrahams, MC. Many other psychiatrists throughout the country took part in this early work of using group techniques.

It was recognized in the Neuropsychiatry Consultants Division, SGO, that, if the mass of psychiatric patients were to be treated, they would have to be treated in groups. In planning the convalescent hospitals which later were to treat the majority of soldiers who were returned from overseas because of psychoneurotic disorders, provision was made for group treatment. This was done as much out of necessity as out of the conviction that group treatment had advantages over individual treatment. It was almost a matter of group treatment or no treatment.

Convinced that experience with group therapy was sufficiently successful to warrant its recommendation for widespread use in the Army, TB MED 103, 'Group Psychotherapy,' was issued on 10 October 1944. The material for this bulletin had been prepared in the Neuropsychiatry Consultants Division to assist most of the psychiatrists who had had little or no experience with this technique. From the time TB MED 103 was issued, increasing use was made of group techniques, and by the end of the war, group therapy was employed in practically every hospital where psychiatric patients were being treated in large numbers.

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Dynamic Mechanisms

While the dynamic mechanisms of group treatment were not known, it seemed clear that certain therapeutic forces were operative. The phenomena of group loyalty and group identification were universally observed. Upon the insistence of the group, patients were more apt to regard their behavior objectively than upon the suggestion of a psychiatrist in a private interview. Patients who were concerned solely with their own problems were obliged to consider the group and its problems because of loyalty and fairness which the group demanded. Interestingly, some patients were able to express themselves more easily in a group setting. An occasional therapist believed that some repressed material was verbalized with less difficulty under group therapy conditions.

It has been postulated that the group represents symbolically a family of siblings held together by a common therapeutic need under the guidance of a nonhostile understanding parent. Some therapists have observed patients striving as children to compete with one another for praise and approval, acting out unsolved conflicts of their childhood.

In general, as a result of encouragement by the presence of the group, patients were able to express their hostile aggressive feelings toward the Army and to officers much more easily than would have been possible in individual interviews. This was extremely important since resentment played an important role in so many of the cases the psychiatrists were called upon to treat. Individual patients accepted the group solution to this problem much more quickly than they would have from the psychiatrist who to them was an officer representative of the very thing they were trying to get away from.

In addition, personal problems were minimized and seen in a broad perspective. Guilt feelings concerning failure and incapacity without visible organic disease to justify such failures were partially relieved by the recognition that others had similar disorders. Any insight which was gained by a patient was to a degree available to the entire group.

Airing of symptoms in a group setting helped to demonstrate the universality of individual problems and to relieve feelings of isolation. The need to solve the problem was stimulated by reason of the person's inability to conceal the problem from society any longer. A patient's attitude toward his experiences may be greatly influenced when he observes that the group reaction to it is different from his own; for certain individuals whose difficulties arise from egocentricity and self-indulgence, their obligations to society and need for change can be better emphasized by the group.

Results

It is unfortunate that no carefully controlled study was made, comparing the results of individual and group therapy. The techniques which

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were used varied so much, and the personalities of the therapists were so different, that such statistical data, even if available, would be difficult to interpret.

Careful followup studies of the results of group therapy were not possible in the Army for other reasons. One was not dealing with the simple situation of a sick patient seeking treatment. The fact that a patient was returned to duty was no indication that he was well. It merely meant that he was believed well enough to perform duty. On the other hand, when getting well carried with it the secondary gain of a discharge from the Army, as it did in many of the Army hospitals in the United States, a motivating force, such as is not ordinarily present in a psychotherapeutic situation, had to be considered. Then, there were the difficulties of trying to trace a man after discharge from a hospital and of obtaining a reliable and objective report on his condition.

Therefore, the results of group therapy, as it was used in the Army, can be evaluated only in terms of subjective impressions of the men who used this technique and by the relatively few detailed reports which were submitted to the Surgeon General's Office. There was almost unanimous opinion among those who worked with group therapy that it was effective. Many were quite enthusiastic and insisted that group therapy had decided advantages over individual therapy-apart from the economy of time.

It is believed that the Army experience with group psychotherapy has helped confirm the results of the civilians who did the pioneer work in this specialty. This experience should serve as a stimulus to further efforts to perfect and standardize the technique and to clarify its dynamics. Group treatment may be the answer to the need for a more efficient and economical method to cope with the ever-broadening horizon of psychiatry.

FINAL POLICY

Presidential Interest

In December 1944, President Roosevelt expressed some concern about the condition of men upon their discharge from the Army, in the following letter to the Secretary of War:

DECEMBER 4, 1944

My dear Mr. Secretary:

I am deeply concerned over the physical and emotional condition of disabled men returning from the war. I feel, as I am sure you do, that the ultimate ought to be done for them to return them as useful citizens-useful not alone to themselves but to the community.

I wish you would issue instructions to the effect that it should be the responsibility of the military authorities to insure that no overseas casualty is discharged from the armed service until he has received the maximum benefits of hospitalization and convalescent facilities which must include physical and psychological rehabilitation, vocational guidance, pre-vocational training and resocialization.

Very sincerely yours,
(Signed) FRANKLIN D. ROOSEVELT

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This letter served to focus the attention of the War Department on what treatment was being given to patients and led to further emphasis of the policy which directed that psychiatric patients be treated.

The Secretary of War sent this reassuring reply to the President:

DECEMBER 20, 1944

My dear Mr. President:

I have received your letter of December 4th concerning the physical and mental condition of disabled men returned from the war. I entirely agree that everything that is humanly possible must be done to return them as useful citizens. In fact, I have made it one of my principal duties when I have been able to get away from Washington to visit the hospitals and rehabilitation centers in order to gain a personal knowledge of what is being done. As you doubtless know, only a portion of this task under our present laws and regulations limiting Army activities falls upon the War Department. A portion of it is handled by the Veterans' Administration.

The War Department since the beginning has followed the principle that no oversea casualty be discharged from the Armed Services until he has received the maximum benefits of hospitalization and convalescent care. The only exceptions are the men who are permanently insane or the tuberculous patients. These men are early transferred to their families or to the Veterans' Administration hospitals for definitive care. Reconditioning, physical, educational and psychological, is begun early during hospitalization and is continued through convalescence. In addition to physical reconditioning, this includes orientation, prevocational guidance and self-teaching courses under the United States Armed Forces Institute, occupational therapy both functional and diversional and recreation. This program is provided for the mentally ill as well as the physically disabled until such time as medical judgment has determined that the expected maximum improvement has been obtained.

Under the present troop strength allotment, the Army cannot undertake pre-vocational trade school training except during that period required for physical or mental treatment of the patient, nor can it indefinitely extend the period of attempted resocialization. Pre-technical training and vocational guidance are provided in the convalescent hospital program now being established.

As you know, under the existing law the Veterans' Administration is charged with the responsibility of vocational training, education, and hospitalization of all discharged service men. The War Department has worked and will continue to coordinate very closely with the Veterans' Administration so that continuity of action may remain assured.

I recently visited several convalescent hospitals in Florida and was much pleased with the care with which reconditioning was being carried on. I also on the same trip witnessed the reorientation which was being given at a redistribution center to unwounded men who were returning on rotation. I deem it of the utmost importance that all of these men, both those disabled and those unwounded who are returning from the long stress of battle experience in the many difficult theaters of this war, should receive such intelligent and faithful care as to not only give them the best possible preparation for their future life but also to completely assure them of their country's interest in their welfare. I enclose several pictures taken during my visit to one of the hospitals in Florida.

I also enclose one of the pamphlets which was given to some of the convalescent patients in the Army hospitals.

Faithfully yours,

HENRY L. STIMSON,

Secretary of War.

The President

The White House

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Secretary Stimson followed up this letter with another, on 28 February 1945:

My Dear Mr. President:

In your letter of December 4, 1944, you expressed concern over the physical and emotional condition of disabled men returning from the war and emphasized that no overseas casualty be discharged from the armed service until he had received the maximum benefits of hospitalization and convalescent facilities.

In addition to the Army program I outlined in my reply of the 20th, comprehensive studies have been made on the subject of psychoneurosis during the past few months both insofar as it affects the soldiers returned from overseas as well as those who have not yet had such service. These studies were conducted by War Department personnel, aided by five of the Nation's outstanding civilian psychiatrists.

Specifically, the field of psychoneurosis insofar as the Army is concerned may be divided into two broad groups. First, those men who entered the Army as normal well integrated individuals whose type of psychoneurosis or maladjustment is a result of military service. The majority of such cases have developed as a result of the severe strains of actual combat. Second, those men who brought with them from civilian life inherent weaknesses such as emotional instability or inadequate personality traits. The majority of these cases appear among the maladjusted, inadaptable and inapt soldiers who cannot qualify physically for oversea service. Both groups include cases ranging from mild to severe, from cases correctible within the means available to a field commander to those requiring hospitalization and the most expert medical treatment.

The soldier who is emotionally sick will, as in the past, receive maximum hospital benefit and treatment. To this end facilities have been enlarged and training provided to increase the medical and other personnel required. In general, the treatment principles are based on well founded experiences gained in this war and in the last, and on sound medical judgment. Every effort is made to treat the combat case early, when treatment is most effective-even within the sound of the guns. As a result a majority of these cases recover and return to full combat duty. Another significant proportion can be salvaged for continued duty in rear areas. Cases that cannot be restored to duty in this manner are returned to the United States where they are treated by special psychiatric techniques which have been found to be both practical and effective. Cases developing in this country are also treated in this manner. No soldier who is emotionally sick will be discharged until every effort has been made toward maximum improvement. When discharge is required it will be through medical channels.

Too often in the past the soldier who is inapt or inadaptable has been classed as a psychoneurotic. Usually this group adjusted fairly well in civil life in spite of their deficiencies, but due to certain mild psychoneurotic tendencies or to an inadequate personality are unable to adapt to military life. Every effort is made through treatment, leadership, education, orientation, motivation and training to enable them to perform satisfactorily, in the military service. Should this not be successful and there is no medical reason for a disability discharge, these men will be released through administrative channels without mention of psychoneurosis.

A related problem is created by those soldiers returned from overseas who find it difficult to readjust to life in the United States. These men are not acutely ill nor do they require hospitalization in the usual sense but their problems are no less real. Here readjustment is a matter of psychiatric treatment, leadership, education, proper motivation, and placement in a job where their ability and training may be constructively utilized. Proper jobs will be provided by shipping overseas all qualified soldiers who have not had such service. In the education and proper motivation phase all

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resources will be utilized. By following this procedure we will be able to better prepare these soldiers for their ultimate return to a gainful civil life. Those who are unable to readjust to Army life in the United States will be returned to civil life without the label of psychoneurosis.

It is significant that the general term psychoneurosis will be discontinued in medical records and a more definitive diagnosis used such as anxiety reaction or other accepted term. It is believed the use of such terms will alleviate much of the disadvantage resulting from the overworked term psychoneurosis.

Extensive studies on the subject of psychoneurosis have been made and are continuing in the European Area. Specialists in this field will conduct additional studies in the Pacific Area. These studies are primarily concerned with the preventive phase of the problem.

Knowing your intense interest in the matter, I am forwarding to you this information, as I am confident that the above policies will be of benefit to the soldiers and are in furtherance of your desires.

Respectfully yours,

(sgd) HENRY L. STIMSON,

Secretary of War.

Psychiatric Treatment Made Mandatory

As an outgrowth of this correspondence and a report of the Inspector General's survey of the diagnosis, treatment, and disposition of psychoneurotics, AR 615-361, on medical discharges, was revised (Changes No. 2, 1 March 1945) so that the retention for treatment, on patients with psychoneuroses severe enough to require hospital treatment, was authorized, and it was made clear that other psychiatric cases would receive appropriate treatment while awaiting disposition.

On 28 May 1945, to clarify whatever misunderstanding that still existed regarding treatment (and disposition) and policies (of all patients) The Surgeon General, in a letter to all service commands, stated (regarding psychiatric patients): 'All patients except those with chronic psychoses were to be retained until maximum hospital improvement had been achieved.'

Another pertinent directive was issued several months later.⁶¹ It stated: 'In no case will individuals with psychoneuroses who are too ill to be at home be discharged from the service and permitted to return home without having been offered the opportunity of further treatment in a Veterans Administration hospital.' In addition, individuals with psychoneuroses resulting from oversea service, severe enough to require hospitalization, were not to be discharged from the service until they had reached a point of maximum improvement in a convalescent hospital.⁶² This policy was to continue in effect for the duration of the war and the postwar period. It represented a radical change in thought and practice in the Army and was a far cry from the 'no treatment and the rapid disposition' days earlier in the war, and it came about not without the

⁶¹War Department Circular No. 162, 2 June 1945.
⁶²Bull. U.S. Army M. Dept. 4: 358, July 1945.

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overcoming of much resistance on the part of those who were reluctant to change either their attitudes or methods of treatment of patients with psychiatric disorders.

Conclusion

Criticism was occasionally leveled at The Surgeon General and his staff by civilian psychiatrists for what they considered inadequate treatment of psychiatric patients, but considering the obstacles that had to be overcome, the shortage of trained personnel, and the tremendous load that they had to carry, the accomplishments have been referred to by others as one of the most outstanding of the war.

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