CHAPTER XI
General Hospitals
Henry W. Brosin, M.D.
HISTORICAL NOTE
The creation of named general hospitals as permanent installations in the organization of the Army Medical Department is a fascinating story of the long and persistent struggle for improved medical care of patients by means of improvement in standards, training, personnel, equipment, and facilities. The history of this gradual development has been well told in several volumes and need not be reviewed here except as it relates directly to the problems in World War 11.1
The establishment of permanent-type general hospitals where definitive care was available during time of peace mainly occurred during and after the Spanish-American War.2 This started a trend, climaxed in 1920 by WD (War Department) General Orders No. 40, issued on 26 July 1920, which placed the named general hospitals directly under the command of The Surgeon General as class II installations. These hospitals were then much freer to grow as professional medical centers with independent budgets and relative freedom from routine field military duties.
DEVELOPMENT OF PHYSICAL FACILITIES
Before Mobilization
One week after Germany invaded Poland, President Franklin Delano Roosevelt proclaimed a 'limited national emergency,' on 8 September 1939, following which the Congress of the United States and the War Depart?
1(1) Ashburn, P. M.: A History of the Medical Department of the United States Army. New York: Houghton Mifflin Co., 1929, pp. 148, 215-217. (2) The Medical Department of the United States Army in the World War. The Surgeon General's Office. Washington: U.S. Government Printing Office, 1929, vol. I, pp. 23-91 and 384-394. (3) Smith, 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. (4) Medical Department, United States Army. Organization and Administration in World War II. Washington: U.S. Government Printing Office, 1963. (5) Preference has been given to references which are easily available to the reader, especially published or potential volumes in the series 'Medical Department, United States Army,' rather than cite original sources. For a more complete understanding, the reader can now go to these excellent volumes for more data. It is worthwhile for the contemporary student to grasp the fact that the development of the named general hospitals paralleled extraordinary civilian progress and furnished the means for training and maintaining skilled specialists in many departments of various Army hospitals. The notable accomplishments and several unforeseen side effects will be apparent in this chapter.-H.W.B.
2The former Army and Navy General Hospital at Hot Springs, Ark., was the smallest and oldest, having been opened on 17 January 1887. This hospital was closed on 30 November 1959.
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ment made plans for mobilization. At this time, the Medical Department of the U.S. Army was operating seven named general hospitals: Walter Reed (fig. 31) at Washington, D.C. (1909); Army and Navy at Hot Springs, Ark. (1887); Fitzsimons at Denver, Colo. (1918); Letterman at San Francisco, Calif. (1899, named in 1911); William Beaumont at El Paso, Tex. (1921); Tripler at Honolulu, T.H. (1898); and Sternberg at Manila, Philippine Islands (1898). In addition, the Station Hospital, Fort Sam Houston, Tex., served a general hospital function for psychiatric patients; later, 4 September 1942, this hospital was designated Brooke General Hospital (fig. 32). These named general hospitals differed from the 104 station hospitals active at that time in that the latter were directed by Army Regulations (AR 40-580, 29 June 1929, and AR 40-590, 2 February 1942) to limit themselves in their medical practice to serve the local community for relatively minor disease and injuries. General hospitals were empowered to receive patients from a much wider area and to provide more complex medical or surgical care, particularly in those specialized fields demanding special training and equipment, such as thoracic, neurological, plastic, or orthopedic surgery.3
3Army Regulations No. 40-10, 17 Nov. 1941.
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FIGURE 32.-Neuropsychiatric Section, Brooke General Hospital, Fort Sam Houston, Tex.
The seven original named general hospitals varied considerably in their bed capacity, personnel, facilities, and equipment.4 With changing needs, compelled by the progress of the war, this group of general hospitals as well as the 59 which were eventually added often had considerable changes in their mission as determined by the Medical Regulating Unit, controlling admissions, and by ASF (Army Service Forces) administrative policies, particularly regarding methods of discharge.
Mobilization
On 25 September 1940, the War Department authorized the construction of 10 new cantonment-type one-story wooden general hospitals, with a total capacity of 10,000 beds.5 Considerable delays and difficulties were experienced, however, owing in large part to a lack of clear overall planning at top levels of command. However, during 1941, the following general hospitals of the cantonment type were added: Lovell at Fort Devens, Mass., Tilton at Fort Dix, N.J., Stark at Charleston, S.C., Lawson at Atlanta, Ga., La Garde at New Orleans, La., Billings at Fort Benjamin
4(1) Table of Organization 8-507, 25 July 1940. (2) Table of Organization 8-551, 1 Nov. 1940.
5Smith, op. cit., p. 19.
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Harrison, Ind., O'Reilly at Springfield, Mo., Hoff at Santa Barbara, Calif., and Barnes at Vancouver Barracks, Wash. All of them suffered from various defects in spite of The Surgeon General's insistence that his Office exercise advisory supervision over hospital construction. The basic plans prepared in 1935 were known to be unsatisfactory to the Medical Department in 1940.6
The provisions for the care of psychiatric patients were particularly inadequate in both quality and quantity, and this deficit was not totally removed in most cantonment hospitals during the war, thus forcing standards of patients' care to drop below the desired goal of 'definitive care' and reducing the expectancy from the 'maximum benefit of hospitalization' goal enunciated by President Roosevelt and the War Department. However, psychiatrists were not alone in this unsatisfactory situation, and their problems should be viewed in the total context. This situation has been well described by Smith,7 as follows:
Hospitals built on such plans [1941] had sufficient space for some activities and none at all for others. X-ray clinics and laboratories were too small for use in modern medicine. Administration buildings had insufficient space for extensive records required for patients and civilian employees and were cut up into too many small rooms for efficient use. Post dental work required more room than originally expected. General hospitals needed more space for quartermaster activities. Inadequate kitchens and mess storerooms became a source of frequent complaints. Offices for the medical supply officer and the medical detachment commander, recreation buildings for the patients and for nurses, post exchange buildings, ambulance garages, and strong rooms for safeguarding narcotics as required by Federal Law were not included in existing plans. Of equal importance, neuropsychiatric wards for which plans were provided lacked sufficient strength and safety features to prevent patients from attempting escape or suicide.
It is remarkable that most medical officers were sufficiently adaptable to live with these major handicaps and yet make as good a record as they did in the care of patients.
Psychiatric services.-Facilities for the psychiatric patients in the cantonment-type general hospital presented formidable problems in care and treatment, requiring considerable ingenuity and modification to overcome. For example:
The four W-8 type wards intended for use as closed wards had many defects-the window guards, doors, heating, plumbing, and electrical systems had to be entirely rebuilt. The lock and key system was inadequate. Each ward had as many as thirty (30) different keys which made it necessary to install a master lock and key system. These extensive changes required several months and on 25 October 1941, the first closed ward was in operation.8
It is quite understandable that space for various group, recreational, and occupational therapies, including minimal outdoor athletic facilities
6Smith. op. cit., p. 21.
7Ibid., pp. 21-22.
8Turnbull, Helen D.: History of Tilton General Hospital, Fort Dix. N.J. 1941-46, p. 41. [Official record.]
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so that patients could at least get out of doors when the weather was good, was not included. Psychiatrists, in 1935, had just begun to implement on a national basis the large active treatment programs, particularly for acute cases, with numerous skilled assistants from various specialties. Although neuropsychiatric outpatient departments were known in a few university centers, they were not required in most psychiatric hospitals until the war demonstrated their feasibility and value. The goal of preventive medicine to keep patients out of hospitals as much as possible by means of skilled ambulatory treatment was not yet well defined in spite of World War I experience. It does seem unfortunate that the 1941 revisions of the 1935 plans did not reflect these improved medical practices, but rather were a hurried emergency response to the demand for speed and economy. The 1941 revisions were made following numerous complaints from civilian and military sources that these buildings were unsafe from the hazards of fire as well as unsatisfactory for professional and administrative purposes. Expediency, however, dictated policy and operations with little regard for the realities of current medical practices.
Wartime Period
After several painful shifts in policy with regard to meeting the need for hospital beds, the War Department approved, on 6 August 1941, the construction of two-storied semipermanent fire-resistant plants for all future hospitals but, before the plans could be completed, the War Department stopped their use. In December 1941, there were 1,686,403 men in the Army, increasing to 6,993,102 in June 1943, which was the peak of the preparatory period.9 Obviously, the country at large as well as the War Department and the Medical Department suffered severe transformation phenomena while preparing to send trained men overseas as rapidly as possible. In December 1941, there were 14 general hospitals with 15,533 beds while about 200 station hospitals had 58,736 for a total of 74,269 beds. The general hospitals added 38,226 beds and the station hospitals 161,279 beds, between December 1941 and June 1943. Thus, as of June 1943, there were 53,759 authorized general hospital beds and 220,015 authorized station hospital beds, which seems to be a remarkable achievement in view of all the other competing activities.10
Semipermanent-type facilities.-Speed and economy were the prime factors in this new building phase, and simplicity of design was sought above all else. Consequently, the War Department, on 29 December 1941, revoked the previous authorization for the two-storied semipermanent plan in favor of the cantonment type for general hospitals, and a modified theater of operations type of construction for station hospitals. Further reduction in quality was contemplated but not effected, for the latter type
9Smith, op. cit., p. 53.
10Ibid., p. 68.
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of hospital was seen chiefly in AGF (Army Ground Forces) maneuver areas.11 On 31 December 1941, however, permission to build some two-storied semipermanent plan hospitals was granted if the cost and time involved were not significantly greater. Five general hospitals of this type were finished: Bushnell, Brigham City, Utah; McCloskey, Temple, Tex., Kennedy, Memphis, Tenn.; Valley Forge, Phoenixville, Pa.; and Shick, Clinton, Iowa. There were also five station hospitals of the same type completed during this time. Finding that the initial cost was 'considerably greater,' the War Department on 16 April 1942 authorized only cantonment-type construction for general hospitals.12
Conversion of existing facilities.-Already, in 1940, there had been consideration of the conversion of existing civilian buildings into Army hospitals, but many difficulties prevented either acquisition or conversion of suitable buildings. However, 28 Army hospitals, 23 new and 5 expanded, were established in converted civilian buildings by the end of 1943.13 Of these 28 hospitals, 10 were general hospitals: Ashford, White Sulphur Springs, W. Va.; Darnall, Danville, Ky.; Deshon, Butler, Pa.; England (later Thomas M. England), Atlantic City, N.J.; Gardiner, Chicago, Ill.; Halloran, Staten Island, N.Y.; Mason, Brentwood, Long Island, N.Y.; Oliver, Augusta, Ga.; Percy Jones, Battle Creek, Mich.; and Torney, Palm Springs, Calif.
Semipermanent, Type A.-During 1942, pressure from the Veterans' Administration to build hospitals which could be converted to postwar use, thereby avoiding another World War I error, and civilian pressure from makers of brick and tile, materials proposed as substitutes for lumber, which was becoming scarce, caused the War Department to authorize a third type of hospital, a one-storied semipermanent type known as Type A. The following 12 hospitals (11 general, 1 regional) of this type were built before the war's end: Battey, Rome, Ga.; Birmingham, Van Nuys, Calif.; Crile, Cleveland, Ohio; Cushing, Framingham, Mass.; DeWitt, Auburn, Calif.; Dibble, Menlo Park, Calif.; Glennan, Okmulgee, Okia.; Madigan, Tacoma, Wash.; Mayo, Galesburg, Ill.; Newton D. Baker, Martinsburg, W. Va.; Northingham, Tuscaloosa, Ala.; and Waltham Regional Hospital, Mass.
During 1943, the Type A hospitals were modified to meet Veterans' Administration postwar needs resulting in the construction of a Type A layout, with five two-storied Veterans' Administration-type buildings substituted for ordinary wards for the McGuire General Hospital, Richmond, Va., and the Vaughan General Hospital, Hines, Ill.
The diversity of facilities called named general hospitals became further apparent when their size was surveyed. The original seven general hospitals were usually about 1,000-bed capacity or less. These capacities
11Smith, op. cit., pp. 68-70.
12Ibid., p. 69.13Ibid., p. 73.
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were expanded, however, to 1,220 at Army and Navy, 4,000 at William Beaumont, and 3,000 at Walter Reed. World War II hospitals, such as
England General Hospital, had a 3,650-bed capacity and Halloran General Hospital, 5,350-bed capacity.
In discussing the neuropsychiatric facilities at these widely varying hospitals, it is apparent that few generalizations will hold: Darnall General Hospital (921 beds) was a State hospital before it was turned over to the Army as a psychiatric hospital, while Deshon (1,774 beds) and Mason (3,032 beds) General Hospitals were converted State hospitals, and all of them were good facilities. The McGuire (1,765 beds) and Vaughan (1,900 beds) General Hospitals likewise were rather good hospitals with satisfactory psychiatric facilities. (All authorized bed capacities quoted here are as of April 1945. See Smith, op. cit., pp. 304-311, table 15.)
PERSONNEL
General Considerations
Planning of tables of organization and equipment did not take into account the enormous growth in medical specialization. While psychiatrists wanted trained psychiatric nurses, social workers, clinical psychologists, trained ward attendants with a military occupational specialty number,14 and recreational and occupational therapists, the other medical services also wanted enlisted men with specialty ratings in several technical branches, as well as civilian dietitians, physical therapy aids, and dental hygienists.
The tables of organization did not provide sufficient men necessary for the job in all categories, including nonmedical officers (branch immaterial), medical officers, and enlisted men, not to mention nurses, psychologists, and social workers, Waacs, and technicians.15 Even after War Department authorization for higher quotas of qualified men and women, such personnel were seldom available in sufficient numbers. It should be remembered that there was considerable civilian pressure against 'aggressive Army recruitment' which was applied by powerful voices in Congress (special subcommittee of the Senate Committee on Education and Labor), by the Office of Civilian Defense, and by the Procurement and Assignment Service for Physicians, Dentists, and Veterinarians of the War Manpower Commission.16 The results of these and other pressures for officers and enlisted men overseas resulted in relatively smaller medical staffs with larger civilian components and Waacs, and with some increase in social
14Later, Neuropsychiatric Technician SSN 1409 by authority of War Department Circular No. 209, 13 July 1946.
15Smith, op. cit., pp. 131-137.
16Medical Department, United States Army. Organization and Administration in World War II, pp. 146-147.
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and recreational workers, clinical psychologists, and other specialists, especially MAC (Medical Administrative Corps) officers.17
Neuropsychiatrists
Since there were so few Regular Army psychiatrists in 1939-40, and most of these were assigned administrative duties, the new general hospitals, opened in 1941, were largely staffed by newly inducted civilian psychiatrists, often chosen from the lists provided by the American Psychiatric Association or the National Research Council (p. 42).
Lt. Col. (later Col.) Arthur B. Welsh, MC, in the Surgeon General's Office, did an excellent job in choosing highly qualified men in all medical specialties from civilian life who also were able to meet the manifold demands of the new and strange military life. With very few exceptions, the early staffing of the new general hospitals upheld the traditional goal of the Medical Department to provide 'definitive care' comparable to that of the best civilian hospitals. The newly inducted psychiatrists in general hospitals too often met inadequate physical facilities, personnel, and equipment to do the work which poured in from the beginning of the active mobilization in November 1940. It is curious to reflect that almost all Regular Army medical officers in the field that this author met agreed, during this pre-Pearl Harbor period, that the neuropsychiatric problem would be the major medical problem of the war and consequently should be given much support, but apparently this attitude did not prevail in higher command circles, in spite of the obvious experience of past wars.
The attitude of medical and line officers during this period and throughout much of the war if they did have a psychiatrist was often 'I have no use for psychiatry but we like our psychiatrist.' In the new one-storied wooden cantonment hospitals, the psychiatrist was usually given willing support by his commanding officer, insofar as he was able, to buttress the walls which had been smashed, shield windows with heavier screens, obtain more substantial doors and locks, cover the pipes on the ceiling to forestall hanging, and otherwise protect the electrical and heating systems in the wards for acutely psychotic patients. In time, as the workload increased and treatment and disposition measures became clearer to all concerned, most psychiatrists in general hospitals earned the sincere help of their superiors. As in the field, much of the administrative and repair work done during 1941-42 was done on the personal initiative of the psychiatrist and the commanding officer or his representative on a 'learn as you work' or impromptu basis without tutoring from above.
The number of neuropsychiatrists assigned to a general hospital was never large. In most 1,500-2,000-bed general hospitals, there were usually two or three 'trained' men with one or two young assistants on 'perma?
17Smith, op. cit., pp. 131-137.
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nent' assignment, during the 1941-45 period. Larger general hospitals had proportionately larger staffs, but they were seldom opulent for more than a few weeks at a time even when newly inducted medical officers were assigned for temporary periods of training while awaiting transfer to their permanent posts, or when a numbered station or general hospital was in the vicinity for training. The total number of psychiatrists with various levels (I-IV) of training assigned to general hospitals at any given date was not easily available from existing records, but an approximation would be 285 on V-E Day (8 May 1945) of 1,012 in the Army Service Forces or of a total 1,515 in the Zone of Interior.18
Some highly qualified psychiatrists were assigned to general hospitals, but ofttimes their experience, skills, and leadership were lost to the Army. This was often obvious in general hospitals when the chief of psychiatry was usually junior to the chiefs of other services. During the summer of 1943, this situation was improved when the status of an independent psychiatric service was granted. Professional staffing, however, was not so easily remedied19 as young, relatively untrained psychiatrists constituted over half of the psychiatric staff of the general hospital. Of necessity, these young men were required to assume numerous responsibilities for which they were not professionally equipped.
Nurses
There were relatively few nurses trained in psychiatry in civilian life in 1940, and this lack was most evident in the Army. Even though there were nearly 600 women trained for neuropsychiatric duty in the Army, there was no official recognition of their special skills, and many of them were assigned to other fields of nursing.20 Most general hospitals were pleased to have even one trained psychiatric nurse, and welcomed anyone who had some experience or who showed an interest in the work where she received on-the-job training. If the usual 150- to 250-bed neuropsychiatric section had two or three nurses with experience in psychiatric or neurological nursing, they considered themselves fortunate. Even during 1942-43, before there were large troop movements overseas, there were relatively few trained psychiatric nurses unless there were field units in training nearby. For a better picture of nursing activities, the reader is referred to the chapter on this subject, but tribute should be paid to these women who worked so loyally under many handicaps.
18For total numbers of psychiatrists in the Army, and their classifications, see chapter III, p. 48.
19Farrell and Berlien, in their chapter, 'Professional Personnel,' summarize the acute shortage of psychiatrists and the various steps taken to counteract it.
20Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948. p. 247.
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Clinical Psychologists
The full history of the development of clinical psychologists is contained in the chapter on that subject and need only be touched upon here.21 Clinical psychologists were welcomed by general hospital psychiatrists because they were able to help in the daily clinical load; also, they were able to help with special diagnostic and evaluation tests. Following the precedent established in World War I when clinical psychologists were commissioned in the Sanitary Corps (after the war they were transferred to the Office of The Adjutant General), six clinical psychologists were again commissioned in the Sanitary Corps and assigned to work in the general hospitals22 with psychiatrists. Some enlisted men worked as psychologists, MOS (military occupational specialty) 289, but there was no official approval of their assignment.23 Later, in 1944, a reorganization of these activities by Dr. Walter V. Bingham and Lt. Col. Morton A. Seidenfeld, AGD, resulted in commissioning as second lieutenants, 244 men under The Adjutant General. War Department Technical Bulletin (TB MED) 115, which described the functions of clinical psychologists, was issued on 14 November 1944. The clinical psychologists were later transferred to the Medical Administrative Corps24 to enable them to identify with medicine. They were of enormous help in the general hospitals where they worked as an integral part of the clinical staff.25 Unfortunately, most general hospitals did not have their aid until late 1944 or 1945.
Psychiatric Social Workers
For reasons not immediately obvious, administrative as well as practical considerations delayed the procurement and proper professional utilization of psychiatric social workers, despite their well-established place on the civilian psychiatric team. In October 1943, belated recognition occurred in creating MOS 263 for enlisted men, and in 1944, the Women's Army Corps recruited both social workers and psychiatric assistants. Commissions were not approved for social workers until after V-J Day (TM 12-406, February 1946), although about 50 qualified social workers who could meet basic requirements were commissioned as psychologists in order to bring in at least a few members of this category of critically needed specialists. There were 711 men and women with an MOS 263 or equivalent classification, during August 1945, but this number was not sufficient to fill the need for social workers. Even many general hospitals did not have one until late in the war because of the critical need in con?
21The Medical Department of the United States Army in the World War. The Surgeon General's Office, 1929, pp. 395-405.
22At Darnall, Fitzsimons, Lawson, Letterman, McCloskey, and Walter Reed General Hospitals.-A. J. G.
23Menninger, op. cit., p. 244.
24War Department Circular No. 264, 1 Sept. 1945.
25Menninger, op. cit., p. 245.
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sultation services, disciplinary barracks, and rehabilitation and redistribution centers. There is no doubt that where present they were valuable members of the psychiatric team.26
Psychiatric Attendants
Almost all neuropsychiatric sections in general hospitals gave didactic and informal instruction to ward attendants from the beginning of the mobilization because of the lack of trained men and the absence of any recognized position or training for them. To begin with, there was no selection as such, or in one sense there was even a powerful negative selection in some general hospitals, where enlisted men could not be easily transferred to or from field units. One example illustrates a widespread problem, particularly during the early years of the war. When the commanding officer of a newly opened general hospital surveyed the cadre of enlisted men who had been sent to him from a training center, he found a few intelligent, reliable NCO (noncommissioned) officers and some NCO's of marginal ability, but most of the men were of questionable ability in any specialty. Upon questioning, it was found that undesirable men, including a considerable number for the guardhouse, had been ordered for transfer to the general hospital as one method of disposition. The better men were needed in such responsible positions as surgical assistants, assistants in X-ray and anesthesia, and recordkeeping, while those in the next category of competence were assigned to the medical and surgical wards needing help with the acutely ill. The least competent found their way to the kitchen and police details and the psychiatric wards.
Psychiatrists and nurses were forced to work overtime and to exercise constant supervision over these unrestrained, semiliterate men to minimize their crude, aggressive attitudes toward patients. Sooner or later, these men eliminated themselves by AWOL (absent without leave), alcoholism, and even assault and robbery, but their replacements were usually also men of marginal ability. Owing to the wartime pressure to utilize all available manpower, it was difficult to correct this situation. The few industrious and loyal attendants who worked overtime to do the necessary work were vulnerable to transfer, and during the early years, all of them were transferred to cadres of numbered station and general hospitals. Not until experienced psychiatric attendants were given recognition and their duty stabilized was there some correction of this unsatisfactory situation; this was described by Menninger,27 as follows:
After much persuasion a directive [ASF Circular No. 310, 16 Sept. 1944] was published in September, 1944, which allowed the modification of the specialty number of 'medical technician' by placing NP after the number 409, on the records of attendants with psychiatric training and experience. After that, except
26Menninger, op. cit., pp. 245-247.
27Ibid., p. 247.
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under unusual circumstances, these persons could not be taken out of the type of work [War Department Circular No. 209, 13 July 1946, finally established the military occupational specialty 'neuropsychiatric technician (SSN 1409)' pending revision of TM 12-427, 12 July 1944] for which they had qualified.
Ancillary Service Personnel
Medical administrative officers
Medical administrative officers were important to the general hospital system because they were given increasing responsibility as the war went on to relieve medical officers of nonprofessional duties. One general hospital (Tilton) had a total of 85 such officers, including branch immaterial officers, at the peakload. In the large psychiatric centers, they were highly valued colleagues, but they were not available to most of the smaller neuropsychiatric services during the war.28
Women's Army Corps
One of the ways to fight the manpower shortage was the creation of the WAC (Women's Army Corps), in July 1943, formerly an auxiliary unit known as the Women's Army Auxiliary Corps. While Wacs were assigned to many general hospitals, no overall information is available about their activities in neuropsychiatric services. This author does not recall any Wacs being trained as psychiatric assistants, although they were often admirable workers as clerks, administrative assistants, mess attendants, and drivers.29
The American Red Cross
The accomplishments of the American Red Cross are well known. Their quasi-official relation to the Army (called affiliation), apparently based upon traditional relations, gave them status and a well-defined position in the Army, particularly in hospitals. There were '3,853 (31 October 1945) in the United States affiliated with the Medical Department. Nearly 9,000 women were employed in the many other Red Cross activities throughout the Army.'30 Psychiatrists in general hospitals were often entirely dependent upon the Red Cross for social workers and recreational therapists, along with trained leaders in social activities, which were important in treatment programs. There were too many local variations in assignments and duties to make many generalizations but, during the first 2 years, these women did valuable service wherever they were assigned.
28Smith, op. cit., charts 2, 3, 6, 12, 13, 15, and 16.
29Mention has been made that, in 1944, Wacs were recruited as social workers and psychiatric assistants. At Fort Hood, Tex., Station Hospital, two Wacs worked on the neuropsychiatric service in 1945-46 as clinical psychology technicians and did a very commendable job. See also chapter X.-R. J. B.
30Menninger, op. cit., p. 116.
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During this early period, volunteer workers were often useful in writing letters of inquiry to relatives but the quality of work was uneven. The Gray Lady units which were developed to a high level of excellence in many general hospitals, during 1943-45, often were helpful with psychiatric patients.
Clerical workers
For psychiatrists who had a great deal of paperwork (correspondence, preparation of various administrative and medical reports, and the like), the quality of clerical help was of crucial importance. Good clerk-typists and stenographers were eagerly sought and highly prized, but competition with better paid jobs in business and industry did not make recruiting easy. In general, many medical officers will attest to the faithful service of many dedicated women who worked as hard as they could,
Occupational therapists
There were about 900 occupational therapists in the Army who were never commissioned31 although they were often an essential and integral part of the treatment program. All general hospitals had them as nearly as can be determined (see also ch. XXII, 'Occupational Therapy').
Volunteers
Civilian volunteers of various categories, including Red Cross aids, Gray Ladies, church groups, and clubs, played an active part in the treatment program of some general hospitals. In one general hospital (La Garde), a highly developed group music therapy program was developed by a teacher of music. Librarians, sometimes paid, but also those who volunteered, deserve commendation. Representatives of all religious faiths lent their support, rarely as a part of scheduled activities, except that attendance at chapel was encouraged. Recreational therapists as such were not recognized in general hospitals until the large reconditioning and rehabilitation programs were instituted. They were not as prominent a part of the neuropsychiatric treatment program in most of the general hospitals as they were in the convalescent hospitals.
Summary
To summarize this personnel discussion as it relates to the manning of the general hospitals, reference is made to the following statement made by Smith:32
31Commissions were authorized by the Army-Navy Nurse Act of 1947.
32Smith, op. cit., p. 259.
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* * * during the earliest part of the war Army hospitals had larger staffs than they actually needed to maintain a satisfactory standard of care, for the Surgeon General's Office itself was agreeable to some reductions in 1944 when necessity required them.
It is probable that, from the overall national or Army-wide point of view, this statement is correct for the reasons given by Smith, but this does not take into account the genuine hardships endured by many medical officers who carried clinical and administrative duties far beyond any reasonable expectation because of faulty distribution and assignments. Smith's careful documentation of the conflicts and confusion brought about by lack of adequate planning and delineation of authority and responsibility can be used as evidence for some of the areas of short supply, as in neuropsychiatry. This conclusion also fails to take into consideration his own thesis, with which this author agrees, that lack of planning also resulted in faulty use of men during training periods and after, so that, while there may have been an adequate number of medical officers in the total Army during 1941-42, they were not available for clinical work in many of the most active hospitals. In fairness to Smith, it should be added that he also cites the opinion of some medical officers, including some service command surgeons and the chief of The Surgeon General's Hospital Division, who 'believed that medical care suffered as a result of changes in both the quality and quantity of personnel changes assigned to hospital staffs.'33
POLICIES AND CONFLICTS
For a proper appreciation and broad understanding of the problems encountered in the evolution and growth of Army general hospitals during World War II, it is necessary to review some of the leading controversial issues which caused much conflict and fluctuation of policy both within the Surgeon General's Office and between the Surgeon General's Office and other branches of the War Department, particularly the Hospitalization and Evacuation Branch of the SOS (Services of Supply, later renamed Army Service Forces in 1943). These issues with particular reference to neuropsychiatric care and treatment were as follows:
1. The economical use of building material and other supplies, even though this resulted in inferior construction which proved equally expensive in the long run.34
2. The conservation of manpower, both civilian and military, resulting in understaffing in all categories in most of the neuropsychiatric installations except for brief periods.
3. The urgency of constructing and expanding medical facilities to obtain needed medical beds for the rapidly expanding Army, and the need
33Smith, op. cit., p. 260.
34Ibid., pp. 13-26.
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to obtain priorities in competition with other essential activities, encouraged the continued use of the patently inadequate 1935 plans or the inadequate 1941 revision even though their defects were well known.35
4. The use of simplified administrative methods of either returning men to duty or separating them from the service expeditiously in order to free hospital beds for those who needed them most. The pressure to free beds was a matter of grave concern to higher Government officials including President Roosevelt and Secretary of War, Henry L. Stimson, and this was reflected in the fluctuations in policy.
5. The strong desire to standardize all hospital building, facilities, equipment, and personnel practices in order to simplify administration conflicted with the obvious fact that the medical requirements for hospital beds vary considerably from time to time and that medical services are distinctive functions which can operate best where the local commanding officer has some margin for exercising his ingenuity and judgment.
6. The conflicting goals of retaining manpower in the Army at all costs when the war effort seemed to demand it versus the liberal policy of permitting, and even encouraging, the use of the CDD (certificate of disability for discharge) to control the size of the Army when the tactical situation changed were reflected in ambiguous or even contradictory directives by the War Department.
7. The disagreement about assignments for professional men and the failure to utilize special skills properly.
8. The disagreement about the methods and value of reclassification, reassignment, and the limited-duty concept.
9. The disagreement about the meaning of 'maximum hospitalization' and treatment, particularly in several surgical specialties and in neuropsychiatry.
10. The lack of adequate means of returning psychotic patients during the early years of 1941-43 to a hospital near their homes.
11. The lack of agreement about the definition of 'mental illness' as a cause for hospitalization and discharge which did not reach reasonable solution until 1944.
12. The lack of adequate delineation of the responsibility and authority of the Surgeon General's Office following the reorganization of the War Department in March 1942, when three new major commands (Army Air Forces, Army Ground Forces, and Services of Supply (Army Service Forces)) were created to operate in the Zone of Interior. The Services of Supply was responsible to the General Staff for the corps areas and the technical and supply services, such as the Medical Department and the Quartermaster Corps, together with some administration and personnel functions. In the new organization, The Surgeon General was merely an adviser to the Commanding General, SOS, Maj. Gen. (later Gen.) Brehon B. Somervell, and the extent to which he could discharge his responsibilities
35Smith op. cit., pp. 13-37.
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depended primarily upon the degree to which General Somervell accepted his recommendations relative to (1) SOS medical matters as the basis for command decisions and (2) Army-wide medical matters as a basis for action or advice to the Chief of Staff. So far as hospitalization and evacuation in particular were concerned, it depended-partially, at least- upon the role of a medical section in SOS headquarters.36
Role of the Surgeon General's Office
In general, the Services of Supply favored decentralization in many areas while the Surgeon General's Office favored more central control. While there were no spectacular resolutions, even after the Wadhams Committee37 final report which had been submitted on 24 November 1942, The Surgeon General, during 1944, was gradually able to regain many of his former responsibilities as a staff officer to the General Staff. This progress culminated, apparently with the help of civilian pressure, in WD Circular No. 120, issued on 18 April 1945, with the reassertion of the principle that The Surgeon General was the chief medical officer of the Army and the chief adviser to the Chief of Staff and the War Department, particularly on health matters of an Army-wide scope.38
By the time the war was over, The Surgeon General had won back most of the responsibilities of this office which had prevailed before the March 1942 reorganization. It is worthwhile noting that the Ground Forces Surgeon (Col. (later Brig. Gen.) Frederick A. Blesse, MC) had equal status with The Surgeon General, but worked in harmony with the Surgeon General's Office. The Chief of the Medical Division of the Inspector General's Office, Brig. Gen. (later Maj. Gen.) Howard McC. Snyder, as a member of the War Department Special Staff, was actually on a higher level, yet 'no serious friction developed.' These men never took a position that they were entitled to a medical service independent of the Surgeon General's Office, as did apparently the Hospitalization and Evacuation Branch, ASF, and the Medical Division of the AAF (Army Air Forces). It is interesting to note that, while the original members of the Hospitalization and Evacuation Branch insisted that they were the superior agency to which The Surgeon General must report and defer, their successors reversed this opinion and reduced the branch to a section in April 1943, removed its operational functions entirely in November 1943, and abolished it in February 1944.39 This occurred after Col. (later Brig. Gen.) Robert C. McDonald, MC, had come into this office (6 February
36Smith, op. cit., p. 55.
37The Wadhams Committee was a civilian committee appointed by the Secretary of War in September 1942 to make a thorough survey of professional, administrative, and supply practices of the Medical Department. Although it called itself the Committee to Study the Medical Department, it became better known as the Wadhams Committee from the name of its chairman, Col. Sanford Wadhams, MC, USA (Ret.).
38Medical Department, United States Army. Organization and Administration in World War II, p. 329.
39Smith, op. cit., pp. 159 and 172.
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1943). Colonel McDonald was able to negotiate with the new Surgeon General, Maj. Gen. Norman T. Kirk, who had been appointed on 1 June 1943, without difficulty.
These early circumstances of lessened control by The Surgeon General helped compound the normal difficulties and delayed smooth operation of the general hospital system for several years. Taken all together, these issues furnish a colorful background for the confusion which existed over some of the medical policies and operations until 1945. It would be a mistake to try to visualize the activities of an abstract typical general hospital. In spite of some similarities in organization and function, if not in location, size, and facilities, the differences in mission together with the wide variation in operations in response to the many pressures mentioned resulted in widely varying practices at many levels of administration, medical treatment, and disposition, often reflecting the energy, ingenuity, and bias of the local hospital commanders and their staffs.
In spite of these handicaps, however, the philosophy of the general hospital system in the Zone of Interior seemed sound, causing the War Department to authorize the ratio of general-hospital type beds to the total strength of the Army to be 1 percent. Total hospital beds authorized was 4 percent of troop strength. Eventually, there were 61 named general hospitals, 4 camp general hospitals, 1 prisoner-of-war general hospital.40 The changes in bed capacity of the hospitals due to various wartime needs from 1941-46 are too numerous to follow in detail, but several large trends, such as mergers of adjacent station hospitals with general hospitals, use of general hospitals as receiving, embarkation, and debarkation centers, designation of special treatment centers, and growth of regional and convalescent hospitals, will be discussed later. At this time, it is important to point out that after the war was over and special needs disappeared, the named general hospital system, having proved its worth, was stronger than ever and continued to be the backbone of the professional medical work.
Summary
In retrospect, it can be stated that there were many complex pressures and motivations in conflict at many steps of the process of building sufficient hospital beds for Zone of Interior troops, and many changes in plans, until the actual changes in the war overseas eliminated the need for more building. Some of the differences of opinion between the various branches of the War Department were never reconciled. While such conflicts were inevitable, and even necessary at times, it seems that many of the disputes following the reorganization of the War Department in March 1942, with the steadily diminishing authority and responsibility of The Surgeon General for the health of troops and care of the sick and wounded, could probably have been obviated with better mutual understanding.
40Smith, op. cit., pp. 304-313.
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FUNCTIONS AND OPERATIONS
General Considerations
In the preceding descriptions of some of the phases of the organization and administration of the Medical Department which affected the operations of the general hospitals in the Zone of Interior, and in the survey of facilities and personnel, there are both explicit and implicit data and interpretation regarding the operation of these hospitals. The basic concept of a general hospital system was, and is, a sound one, and the prewar and postwar organization and administration were, and are, apparently satisfactory for peacetime needs. Wartime needs altered the actual working goals and functions considerably so that it is doubtful if any 3 of the 65 general hospitals (plus 1 prisoner-of-war hospital) were really similar in most of their activities for the entire war period. As special urgent missions diminished or disappeared, general hospital functions and methods of operation became less idiosyncratic and more uniform in consonance with the growing body of explicit directives from the War Department and the Surgeon General's Office. All officers serving in general hospitals, during 1941-43, will recall the repeated, and often heated, consultations with command and colleagues about the meaning of existing regulations in terms of new directives and the realities of the local situation. Telephonic or letter requests to service command headquarters for clarification were not infrequent during periods of transition. Even at higher echelons, reinterpretations or reversals of judgments were not unknown within a 48- to 72-hour period. Consequently, any relatively condensed statement about operations will necessarily be overly simplified, but it is the hope of the author and the editor that these will not be misleading.
Tables of organization indicated the conventional chain of command and the number of persons assigned to the new general hospitals. However, there were no standard 'manning tables' for the original seven general hospitals, nor was there any standard guide beyond an old Army regulation (AR 40-590, 21 November 1935) which 'gave hospital commanders much discretion in both fields [organization and administration] and lacked detailed instructions for inexperienced officers to follow.'41 To meet the foregoing immediate need for reliable information, an entire issue of the Army Medical Bulletin of October 1940 carried an article on the subject of organization and administration. This article was revised and issued as WD Technical Manual 8-260, in July 1941.42
Perhaps the single most important factor which increased decentralization and uniformity, with patent advantages and disadvantages, was, in 1942, the placing of all general hospitals except Walter Reed under service
41Smith, op. cit., p. 26.
42Ibid.
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command control. These hospitals remained under such command until 18 April 1945 when WD Circular Letter No. 120 restored them to the control of The Surgeon General; also restored were some of The Surgeon General's pre-1941 responsibilities. The lack of planning discussed earlier, and the lack of adequate information available at any level as problems arose, caused many conflicts and attendant delays.
Psychiatric Services
Except in a few general hospitals, where there were larger psychiatric services, neuropsychiatry during 1941-43 was a section of the medical service. In most of the general hospitals, the neuropsychiatric section was either too large or too active to permit close personal supervision of individual cases, although the chief of the medical service and the commanding officer usually participated actively in the interpretation of regulations, making decisions regarding LD (line of duty), and reviewing unusual cases, particularly those involving the retirement of officers. During 1942-43, many psychiatric sections were given independent status as a service by general agreement.
In addition to the large inpatient population, most general hospitals had a large consultation service both for soldiers and for their dependents.
Many general hospitals housed prisoners in the closed wards, but this was specifically prohibited after June 1944.43 Local usage varied about sending alcohol addicts and prisoners for psychiatric examination preliminary to court-martial, but this was not the major problem in general hospitals. It was a problem in some station and regional hospitals where the intensive preparatory work and the time lost while at the trial took a medical officer away from other urgent duties.
Psychiatrists were also required to write a report when enlisted personnel were subject to the Army 'Sanity Board' (AR 600-500) and to the board proceedings preliminary to administrative discharge for lack of adaptability, inaptitude or undesirable habits or traits of character, enuresis, or homosexuality. During 1941, psychiatrists were sometimes asked to appear personally but, later, this duty was frequently waived because of the time consumed. Ordinarily, this was a small percentage of the total clinical load in general hospitals.
Training obligations to all components, medical officers, nurses, ward attendants, psychologists, social workers, and specialists in various types of group therapy were constant duties throughout the war in most general hospitals. The chapter on training and references to these activities in other chapters will give the reader a broader view of the psychiatrist's activities in helping his colleagues become effective members of his team.
43Letter, The Surgeon General, to Commanding General, ASF, and Commanding Generals, all service commands, 6 June 1944, subject: Confinement and Assignment of Personnel to the NP Sections for Disciplinary Purposes.
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When general hospitals had a large pool of medical officers or nurses, formal didactic courses were given, as well as on-the-job training.
This brief review does not include the many other activities of psychiatrists, such as advising their commanding officers in numerous matters not directly related to psychiatry; being responsible for the transportation of psychotics; holding informal consultations with field officers; maintaining liaison with visitors from service command headquarters and the Surgeon General's Office; and establishing working relations with the service command consultant who was usually looked to for information, interpretations, and direct help when local resources seemed inadequate. A word of commendation should be said also for the local civilian neurologists and neurosurgeons who, when available, were often a great help in difficult diagnostic or therapeutic cases.
Mission
The historic mission of the general hospitals was to provide definitive care to the sick and injured patients transferred from other posts and station hospitals over a wide area. By virtue of having trained specialists and adequate equipment to provide treatment for the more obscure and difficult patients, the general hospitals were given this major mission, but a number of general hospitals also acquired other functions, as necessitated by local needs. For general hospitals near ports, one such function was the acceptance of soldiers in embarkation or debarkation when other facilities were not available, and 'during the emergency period he [The Surgeon General] had used general hospitals near ports-Tilton for New York, Stark for Charleston, La Garde for New Orleans, and Letterman for San Francisco-to receive and care for patients brought in on ships."44 Many of such patients were disturbed neuropsychiatric cases requiring much emergency help. If the number of neuropsychiatric cases was too large to absorb, preparations for their transfer inland were carried out, usually with unexpected efficiency. The practice of granting bed credits to ports continued during the war until the Medical Regulating Unit, SGO, was established in May 1944, when better control of beds became possible.45
Some general hospitals acted as the receiving hospital for as many as 12 varied installations, many of them sending in emergency cases. This meant that general hospitals could not keep patients for definitive care, particularly if this required prolonged hospitalization, nor were sufficiently skilled experts in all fields available in all general hospitals to provide such care. The daily pressure for beds was growing during 1942, and more of the best medical specialists in the Army were going overseas. Consequently, following preliminary planning during 1942, the Surgeon General's Office, in March 1943, designated some general hospitals as centers
44Smith, op. cit., p. 114.
45lbid., p. 180.
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for specialized treatment.46 Only gradually, as the war situation stabilized and more beds became available in the Zone of Interior was there a possibility for conducting more consistent, sustained treatment programs. Gradually, 26 of the 65 general hospitals were designated as neuropsychiatric centers. Darnall General Hospital opened in March 1942 as an exclusive neuropsychiatric center, receiving only emotionally disturbed (psychotic) patients. Mason General Hospital opened in July 1943 as an exclusive psychiatric center. (As of April 1945, the authorized bed capacity was 921 for Darnall General Hospital and 3,032 for Mason General Hospital, as already mentioned (p. 303).) The volume and character of the patients varied with tactical needs in the other hospitals.
Patient Workload
For much of the first 2 years of the war, the number of patients treated in general hospitals in the Zone of Interior was undoubtedly smaller than the number cared for in station and regional hospitals. The ratio, however, changed sharply as troops moved overseas and with the addition, in 1943, of 24 new named general hospitals.
During December 1941, general hospitals had approximately 10,000 beds available with over 80 percent occupancy, and station hospitals had approximately 58,000 beds with perhaps 40,000 occupancy. In June 1943, general hospitals had about 48,000 available beds with approximately 33,000 occupancy. For this same period, station hospitals reported about 175,000 beds available, with about 135,000 beds occupied. For the period June 1944-December 1946, the following hospital data47 indicate the magnitude of service rendered in general hospitals as compared with station, regional, and convalescent hospitals:
As of June 1945, general hospitals had 152,971 authorized beds with 81.4 percent occupancy, whereas station hospitals (both AAF and ASF) had 51,561 beds with 67.1 percent occupancy; regional hospitals (both AAF and ASF) had 50,078 beds with 73.4 percent occupancy; and convalescent hospitals (both AAF and ASF) numbered 59,978 beds of which the AAF had 11,600 beds with 47.7 percent occupancy and the ASF had 48,378 beds with 74.8 percent occupancy. In short, the general hospitals had almost half of the total number of beds (314,588) with the highest bed occupancy and the highest number of patients reported per 100 beds, namely 122; whereas AAF station hospitals reported 55 patients per 100 beds and ASF station hospitals reported 77 patients per 100 beds. This huge increase in general hospital patient load came relatively late in the war as 10 new hospitals were activated in 1944 and 4 in 1945.
The influence of the general hospitals, however, extended far beyond their patient population, because they were the models which were emu-
46(1) Smith, op. cit., pp. 116 and 304-313. (2) War Department Circular No. 235, 12 June 1944.
47Smith, op. cit., pp. 211-213.
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lated. For definitive care in some areas of internal medicine and surgery, this example was splendid. it is worthy of note that some of the newer specialties-thoracic, plastic, ophthalmologic, and neurologic surgery-and dermatology were not strong in most of the Army general hospitals.
At the beginning of the war, the psychiatric sections under medicine were not well prepared for the enormous workload which occurred, and treatment facilities as well as qualified personnel were inadequate. Most large Army hospitals, including the general hospitals, had active treatment programs involving group, recreational, occupational, and art or music therapies fairly well started in 1942, but not until 1944 did the larger rehabilitation programs get underway. (See chapter X, 'Station and Regional Hospitals.')
Because of a shortage of psychiatrists and because most of them, particularly in hospitals during 1941-43, were so busy with routine preparation of histories and examination of patients, formal reports and board proceedings, consultations, and involved disposition methods requiring voluminous letter writing, there was relatively little time and energy left for sustained individual treatment procedures even where these were applicable for the period of hospitalization. Administrative decisions at high levels actually determined admission, treatment, and disposition policies for the most part, as described by Brill (chs. IX and X) and by Farrell (ch. VI).
Expediency with regard to local problems usually governed decisions within the meaning and intention of the regulations, since the primary mission of the Army Medical Department was to support the field units. On the whole, almost all patients were furnished some type of treatment during their stay in the general hospitals, if it was at all possible, and often received careful attention to their total problem at a level which would have brought commendation in civilian hospitals. It is also commendable that most station hospitals also had active treatment programs utilizing specialized workers and outpatient services, even though these were not authorized by the War Department. Even electroshock therapy was utilized in a few hospitals, late in the war, in spite of restrictions placed upon this method of therapy.
Disposition of psychotic patients.-One of the most troublesome sources of administrative conflict, relative to the shortage of psychiatric beds during 1941-42, was the lack of places to transfer psychotic patients after they had received 'maximum benefit' of hospitalization in a general hospital, although regulations, until 1944, pointedly emphasized discharge rather than treatment. During this time, a 'psychotic' soldier could be discharged from a general hospital only after his LD status, Army Sanity Board (AR 600-500), and CDD board proceedings were approved by service command headquarters and if he could be received by legally responsible relatives, or a recognized civilian hospital. Usually, these procedures could not be readily accomplished. Such processing often
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required a minimum of 6 to 8 weeks even if the psychiatrists were extremely prompt and accurate in the execution of necessary procedures. Most psychiatrists became experts in these phases of Army psychiatry because of the constant pressure to empty beds. The regulations during 1941-42 permitted psychotic patients to be discharged to Veterans' Administration hospitals if the LD was 'Yes,' but not if the LD was 'No.' These LD-No patients requiring further care could only be discharged to State hospitals, but during 1941, most States were reluctant to accept them except under pressure, and it was due to this barrier that the patient's transfer was often delayed from 3 to 5 months, except for a few States, notably New York, New Jersey, and Illinois.
The barrier to more rapid discharge of psychotic patients to a hospital near their homes was finally lifted in March 1943 when Congress authorized the Veterans' Administration to care for patients regardless of their LD status.48
TREATMENT
Type of Patients
By tradition and planning, the patients in general hospitals should have been principally those who presented the more unusual administrative and diagnostic problems, or those who could benefit by treatment facilities in such hospitals, not available elsewhere, particularly if this treatment was a prolonged procedure. To some extent, this was true in most of the general hospitals, although a number of large station and regional hospitals had excellent professional staffs in the medical and surgical specialties and, during 1941-43, were as well equipped in both personnel and equipment to give definitive treatment. This was particularly true in general medicine, general surgery, and orthopedic surgery in the better station and regional hospitals. After the peakload in 1943, the general hospitals became much more the treatment centers they were intended to be rather than having a majority of cases which required principally diagnosis and disposition. This was particularly true for the neuropsychiatric section or service during 1941-43, when the pressure for beds was as great as in station hospitals and general hospital treatment facilities were limited. Even though facilities for occupational therapy or active group therapy were not authorized in station hospitals early in the war, a number of those hospitals were permitted by local commanders and encouraged by service command consultants to establish these programs to do the most they could for their patients. It was soon obvious, in 1941, that, if station hospitals did not do this and thereby return a man to duty on the post, transfer to a distant general hospital away from his organization gave
48Public Law 10, 78th Cong., 17 Mar. 1943.
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the patient a large secondary reward together with a high expectancy of discharge. It is regrettable that valuable manpower was lost this way, but it took all components concerned a long time to learn that the best way to keep a man with minor emotional problems or 'occupational' maladaptation in the Army was to treat him as near to his company area as possible within the framework of a high expectancy of a return to active duty. Early in the war when manpower seemed plentiful and the widespread occurrence of psychosomatic disorders and somatic complaints associated with emotional conflict were not sharply delineated, many 'obscure' cases including so-called organic neurological disease, dyspepsia, epilepsy, bowel distress, cephalalgia, and arrhythmia were transferred to general hospitals for diagnosis and treatment which could have been much better treated at the station hospital through an outpatient department or through a mental hygiene center. Partly acting in accordance with civilian prejudice that they brought with them into the Army that most if not all these behavioral disorders were organic, and partly in compliance with urgent requests by field officers to relieve them of their responsibilities, patients were transferred to general hospitals from which they often expected a CDD or they learned to use somatic symptoms to evade duty while undergoing prolonged diagnostic studies. For a more complete discussion of the patients diagnosed as psychoneurotic, the followup study by Brill and Beebe is recommended.49
Policies and Methods
In reviewing old records and in conversation with general hospital psychiatrists, it was gratifying to note that most of these medical officers remembered that they were physicians with an obligation to help sick people and therefore tried to do some type of individual therapy in selected cases, even though the time available for this purpose was very limited. There was little official encouragement to do therapy as the needs for beds increased as shown by Circular Letter No. 99, Office of The Surgeon General, 4 September 1942, and AR 615-360, of 25 May 1944, which stated that psychiatric patients 'will not be retained for definitive treatment, but will be discharged * * *." Menninger has given an excellent account of the obstacles to good treatment which is worth reading.50
Psychosis.-Most disturbed psychotic patients became more controlled within a few days in the 'neutral' hospital environment. Many psychiatrists have commented on the rapid subsidence of what came to be called a 'thirty-day schizophrenia,' in some circles.51 Warm and cold packs for
49Brill, Norman Q., and Beebe, Gilbert W.: A Follow-Up Study of War Neuroses. VA Medical Monograph Series. Washington: U.S. Government Printing Office, 1955.
50Menninger, op. cit., pp. 293-319.
51(1) Brosin, H. W.: Panic States and Their Treatment. Am. J. Psychiat. 100: 54-61, 1943. (2) Ripley, H. S., and Wolf, S.: Course of Wartime Schizophrenia Compared With Control Group. J. Nerv. & Ment. Dis. 120: 184-195, September-October 1954.
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sedation were valuable aids in those hospitals which had no continuous tubs. The latter were being installed in some hospitals, as late as 1943, although medical officers had to be sure that, to avoid accidents, reliable persons were in charge of operating the tubs. Chemical sedation often fell short of being satisfactory, so that medical officers were compelled to exercise personal supervision much of the day and night. 'Dauerschlaf' (prolonged deep sleep) and deep insulin therapy were not practical in most places, because of the lack of trained nurses. Subshock insulin was not used until later in the treatment centers. It is noteworthy that, in spite of all these handicaps, most of the severely ill psychotics, not excluding the acute cases with rapid recovery, became amenable to treatment during the 3- to 4-month period of enforced waiting for transfer to another hospital.
Electroshock therapy was not authorized in general hospitals until Circular Letter No. 88, Office of The Surgeon General, April 1943, was issued; nevertheless, this therapy was not used in most general hospitals even after that date because of the lack of equipment, lack of training in its use, or a bias against it. However, when the treatment centers were established, it was used freely for depressed and agitated patients.
Neuropsychiatric Treatment Centers
Because of the lack of adequate facilities and of sufficient trained personnel and large treatment programs in many general hospitals, WD Circular No. 12, issued on 10 June 1944, authorized the establishment of psychiatric treatment centers at Mason, Bushnell, and Valley Forge General Hospitals, in addition to the one already at Darnall General Hospital. Psychotic prisoners of war were sent to Mason General Hospital, as provided by WD Circular No. 214, 15 September 1943.
Because of the increased number of patients, regional hospitals were established in April 1944 (WD Circular No. 140, 11 April 1944), and 22 general hospitals were designated as treatment centers in June 1944 (WD Circular No. 228, 7 June 1944).
Reconditioning Programs
Until the large convalescent reconditioning programs for hospitals were authorized by Circular Letter No. 168, Office of The Surgeon General, issued on 21 September 1943, there were no official directives encouraging active programs other than one of August 1943, Circular Letter No. 149, Office of The Surgeon General, 12 August 1943, which authorized personnel and equipment for occupational therapy departments in all general hospitals in the Zone of Interior. Although not authorized for station hospitals, these hospitals usually had active programs carried out by Red Cross workers and civilians. Recreation therapies of various kinds, includ?
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ing athletic programs, bibliotherapy, group discussions, and music therapy, were carried on from the beginning of the war in accordance with the talent of the persons available, particularly among civilians and Red Cross workers.
Reconditioning programs received another boost when Circular Letter No. 203, Office of The Surgeon General, was issued on 10 December 1943. By this directive, all service command surgeons and commanding officers of all named general hospitals were ordered to establish reconditioning programs at once for all patients regardless of whether or not they were expected to return to duty. This theme became much more prominent later in the war, perhaps in response to civilian pressures, for the rehabilitation of returnees.52
During the period of acute need for manpower early in 1944, TB MED 28, issued on 1 April 1944, specifically directed, the first time, that psychiatric patients, including psychoneurotic patients, be treated. The bulletin also contained a comprehensive description of the methods available.
While most of the general hospitals had substantial programs, TB MED 28, in many instances, helped clarify the legitimacy of the work of the psychiatrist. The reconditioning programs were extended in scope by ASF Circular No. 175, issued on 10 June 1944. Provision was made for the transfer of suitable patients to an active program by the service command if the group at a hospital was too small.
Special Treatment Techniques
Hypnosis was used relatively little except by a very few men with some interest in this procedure. Most psychiatrists had no proficiency in it, probably because of the civilian attitude that it was not genuinely useful in most neurotic processes.
Interviewing patients with the aid of Sodium Amytal (amobarbital sodium) or Sodium Pentothal (thiopental sodium) was not uncommon in many hospitals, particularly in the hysterical amnesias and paralyses, and occasionally in criminal cases, since this was common practice in civilian hospitals after the introduction of the drug by Loevenhart, and Lorenz and its clinical utilization by Bleckwenn, in about 1927.53 Later in the war, it was rarely used for abreaction in the manner commonly employed by overseas psychiatrists; rather, a refined technique was developed, called narcosynthesis.54
52Menninger, op. cit., pp. 293-300.
53Bleckwenn, W. J.: Narcosis as Therapy in Neuropsychiatric Conditions. J.A.M.A. 95: 1168-1171, 18 Oct. 1930.
54(1) Grinker, Roy R., and Spiegel, John P.: War Neuroses in North Africa. New York: Josiah Macy, Jr. Foundation, September 1943. (2) Grinker, Roy R., and Spiegel, John P.: War Neuroses. Philadelphia: The Blakiston Co., 1945. (3) Grinker, Roy R., and Spiegel, John P.: Men Under Stress. Philadelphia: The Blakiston Co., 1945.
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Subshock insulin became popular in some psychiatric treatment centers as sedation for severely neurotic patients.
Group therapy of a more organized type in which selected patients would discuss their own and others' problems under the supervision and leadership of dynamically informed psychotherapists was comparatively scarce though it was encouraged by consultants. Many psychiatrists assigned to this duty developed methods which were suitable to their own interests and abilities including the question and answer techniques, didactic lectures on personality problems, types of maladaptation, therapeutic resources of the hospital and the Army, importance of attitudes in human relations, psychosomatic relations (with charts), and problems in the dynamics of living such as feelings of inferiority, dependency, projection, somatization, and 'acting out.' Following the success of TB MED 28, Col. (later Brig. Gen.) William C. Menninger, MC, was able to secure approval for further instructions in group therapy.55
In the final phase of the war, with thousands of oversea returnees and with civilian pressure which stimulated the interest of President Roosevelt and Secretary of War Stimson, a number of regulations and directives emphasized treatment of all levels for all neuropsychiatric patients, except those with chronic psychotic illness.56
55(1) TB MED 84, 10 Aug. 1944. (2) TB MED 103, 10 Oct. 1944.
56(1) Army Regulations No. 615-361, 1 Mar. 1945, Changes No. 2. (2) War Department Circular No. 162, 2 June 1945. (3) Bull. U.S. Army M. Dept. 4: 358, July 1945.
