CHAPTER XII
Troops in Transit
Morris M. Kessler, M.D.
HISTORICAL NOTE
Historical records from World War I with a neuropsychiatric significance for staging areas, ports, or oversea transports are meager. Lt. Col. Albert B. Kellogg,1 in reviewing these data, dealt principally with certain highly publicized abuses in French ports of embarkation at the end of that war. The two reverse staging areas involved were Brest and Saint?Aignan, France. Poor arrangement of physical plant, improper discipline, and low morale of personnel, plus the fact that somewhere in the chain of command classification of sick and wounded was faulty2 led to serious grievances that became headline stories in American newspapers. One article was captioned 'Say Wounded U.S. Die in Mess Line in France.' The report described how, at Saint-Aignan, mess lines were formed in a disorganized manner and were, consequently, very long; also, that the ground was muddy and unsuitable for negotiation by the ambulant sick and wounded who had to compete with able-bodied soldiers. This resulted in some unfortunate casualties. At the port of Brest, Colonel Kellogg noted an interesting psychological reaction among the soldiers awaiting passage. The men who had no assigned duties would start to line up for the next meal long before the appointed time. It seemed to be a commentary by the troops on the subject of boredom.
Colonel Kellogg also made some personnel observations at Hampton Roads Port of Embarkation where Negro troops were being staged for oversea shipment. Anxiety, based on the proximity of the Atlantic Ocean, led to a heightening of religious fervors. 'Self-appointed preachers were as thick as mushrooms.' Tenseness about the potentially dangerous ocean voyage was partially relieved by rationalizations such as 'Well, that ain't so far' or 'that water ain't very stormy.' It is regrettable that Colonel Kellogg's compiled data did not include any formalized psychiatric observations of clinical cases either at the port of embarkation or en route overseas, so that a comparison might be drawn with the problems of troops in transit overseas in World War II.
1Kellogg, Albert B.: Psychological and Psychiatric Reactions of Troops in Ports of Embarkation During World War I. Prepared in the Historical Section, Army War College, August 1942. [Official record.]
2Note how the same explanation for abuses repetitiously appears in the experiences of World War II.-M. M. K.
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PORTS OF EMBARKATION
Function of the Psychiatrist
In many respects, the practice of neuropsychiatry in the staging area was little different from that found in other phases of military psychiatry during World War II. The staging area psychiatrist performed his duties in a conventional station hospital environment or in an outpatient clinic where, in addition to a consultative function, he carried out psychotherapy. He served the disposition and discharge boards. With regard to his own station complement, his decisions were neither crucial nor overly urgent. It was the crucial matter of making weighty and prompt decisions relative to the oversea shipment of particular individuals that constituted the unique function of neuropsychiatry in the staging area.
In an informative paper, Maj. (later Lt. Col.) Louis S. Lipschutz, MC,3 reported on the special nature of the neuropsychiatric services in a staging area and the type of medical organization which was required for idiosyncratic requirements. He described the staging area as a stress zone where the unstable break down and the last stop before oversea and combat duty. Theoretically, psychiatric services for troops embarking for oversea duty should have been at a minimum if it was assumed that all necessary screening had been accomplished before arrival at the staging area. In this event, all personnel arriving at the staging area would have been fit for combat or general oversea duty. However, this was not always the case. Actually, the efficiency of training of combat troops was tested in the staging area by the extent of their need for medical services, particularly psychiatric consultation.
Organization of medical services
The organization of the staging area of the port of embarkation consisted physically of housing facilities (barracks) located in specific areas of the post. In the medical organization, it was found expedient to create in each of these housing areas a dispensary with relative autonomy from other medical or administrative departments; that is, the dispensaries were fully staffed and kept their own records. The military physicians assigned to these dispensaries had wide latitude in carrying out evaluation and treatment, even in the psychiatric sphere. It became quickly apparent that from 40 to 50 percent of dispensary calls at the staging area involved the emotional sphere.
In the station hospital serving the staging area were conventional open and closed psychiatric wards. The hospital psychiatrist offered a consultation service to the other medical departments as well as to the
3Lipschutz, L. S.: Symposium on Psychiatry in the Armed Forces; Neuropsychiatry in the Staging Area. Am. J. Psychiat. 100: 47-53, July 1943.
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area dispensaries. Decisions had to be made promptly, often from a single consultation, as to whether the oversea bound soldier was to be sent on with his unit or kept for further observation and possible separation from the service. The psychiatrist was regularly faced with this dilemma:
He must not recommend the unwarranted separation of a soldier from his outfit after he had undergone extensive training and had become an integral part of a unit. On the other hand, each fighting man overseas required the services of 5 to 9 men behind the battlelines in addition to large quantities of supplies, so that a useless soldier must not be permitted to make the voyage overseas.
Special programs
Duty-status approach.-Staging area neuropsychiatrists might have been helped in their special functions, somewhat, had they been able to benefit by the experiences of Lt. Col. A. Allen Goldbloom, MC, and Maj. Benjamin A. Schantz, MC.4 These officers studied the maladjusted soldier to determine whether the emotional disorder which mushroomed out in the staging area was an adequate reason for separation from the service. They developed a special program at Camp Kilmer, N.J., where observation of a group of such problem soldiers could be carried out with the men on duty status, quartered in area barracks. Out of 185 patients, they found that 57 had to be discharged from the service under one of three Army regulations, 41 being separated for neurosis (medical discharge). Of the remaining 128, 84 were reclassified to limited service and 44 returned to general military service. Thus, 69 percent of the entire group was returned to duty status. Most of the cases originated from troops awaiting oversea shipments. In these soldiers, an acute psychiatric breakdown was induced by proximity to the port of embarkation. It was found that a high incidence of anxiety began with entry into the service, which remained latent until its florid outbreak in the staging area. Goldbloom and Schantz agreed with other investigators that there was a need for immediate, appropriate decisions in the staging area based on a number of factors, such as reversibility of anxiety, morale of the unit, and the like.
Outpatient approach.-Capt. George E. Poucher, MC,5 the author's associate at Camp Patrick Henry Station Hospital for 2? years during the war, recalls how unreasonably the inpatient facilities were being over-taxed until emphasis was shifted to outpatient services. At one point, 2 psychiatrists were trying to manage 150 inpatients, distributed in 5 neuropsychiatric wards, in addition to conducting an expanding consultation service. With the development of outpatient evaluation and treatment, the number of inpatients was reduced to a more reasonable caseload.
4Goldbloom, A. A., and Schantz, B. A.: The Management of the Emotionally Maladjusted Soldier at a Staging Camp. Psychiat. Quart. 20: 452-469, July 1946.
5Personal communication.
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The size of the workload in this staging area neuropsychiatric outpatient clinic was approximately 300 patient visits per month with peakloads of as many as 1,800 per month during surveys, such as in the routine profiling of troops. This huge caseload was handled entirely by the two regularly assigned neuropsychiatrists.
Professional isolation
The Hampton Roads, Va., Port of Embarkation was one of the eight major American ports under the command of the Chief of Transportation. Although this port facility was located within the geographic boundaries of the Third Service Command, its chain of command went directly to the Chief of Transportation in Washington, D.C. Consequently, the medical facilities within the Transportation Corps were outside the control and supervision of this and other service commands. This was a mixed blessing from the start. The advantages were the autonomy and the ability to function independently, which frequently has its merits in wartime. The disadvantage, however, was the lack of communication with the next higher echelon and with the hierarchy in military psychiatry. This state of relative isolation was particularly disconcerting to the psychiatrist fresh from civilian life, because he had so many problems of adjustment to the policies, procedures, and methodology of the Army in general and to military psychiatry in particular. As a consequence, the psychiatric section or service at the port of embarkation developed its own complicated channels of communication, in addition to contending with the numerous internal problems that beset any organization of men. Communication with the Neuropsychiatric Consultants Division in the SGO (Surgeon General's Office) had to be accomplished through the intermediation of the port surgeon. The chain of medical command at the Hampton Roads port was most cooperative, but simple cooperativeness was no substitute for the direct, on the scene, visit of a psychiatric consultant. For this reason, many problems developed.
One of the problems in the early phase of the war was that general hospitals were not in an advanced stage of construction and thus were not ready to receive patients. Further, the medical sections of the Transportation Corps had no direct access to those general hospitals that were constructed. Initially, the vast majority of psychotic military patients were not considered to be in line of duty. This necessitated their transfer to public mental hospitals in the State of the patient's origin, when and if beds became available. Later in the war, with the change of regulations liberalizing service connection, psychiatric patients requiring further care could be readily transferred to nearby Veterans' Administration hospitals. However, in the early period of the war, before such change, correspondence with the various States concerned on the subject of the transfer of such patients was interminable and seemingly endless. As a result and
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also because such patients could not be transferred to military general hospitals, they accumulated and remained incarcerated in the closed wards of the station hospital at the port of embarkation for months and months, creating crowded conditions and low morale. This state of affairs was further complicated by the fact that during this phase of the war active therapy (electric shock) was not permitted. There were some patients who were dangerous in the sense that they were overtly psychotic or severely psychopathic. Although they were clinically 'insane,' their minds had sufficient clarity for the plotting and organizing of riots. One such disturbance occurred at Camp Patrick Henry which ended only after the use of tear gas.
Finally, permission was granted to the psychiatrist of Hampton Roads Port of Embarkation to discuss the aforementioned problems with the psychiatric consultant to The Surgeon General in Washington, D.C. A solution was reached; namely, to place the medical facilities of the Transportation Corps under the Third Service Command, where regular communication with the supporting echelon proved to be the best answer to the local problems, both current and future.
The psychopathic personality
Major Lipschutz6 found that 3 percent of dispensary patients were admitted to the station hospital and that 5 percent of those hospitalized were eventually transferred to the psychiatric wards. Although he encountered the usual cross section of psychiatric and neurological conditions he found that, in the staging area, the disposition by administrative discharge of pathologic personalities created an unusual difficulty. Apparently, in the press of departure, unit commanders failed to leave the necessary documents which would facilitate administrative discharge proceedings for men with undesirable habits and traits of character. In the author's experience, this problem was handled in routine fashion; patients were not permitted to be detached to the hospital without the necessary written evidence required for administrative discharge.
Maj. John M. Flumerfelt, MC,7 writing on this problem, suggested the use of a-
* * * standard size medical record paper, with one side divided into two halves-one half to contain a paragraph from the commanding officer of the soldier's unit, the other, a paragraph from the medical officer of the soldier's unit.
Once the soldier has 'made' sick call at the port of embarkation dispensary and the medical officer there decides that further information is required, such a form could be forwarded to the soldier's unit, filled out, returned by some other person than the soldier concerned and, altogether, handled in a confidential manner.
* * * Medical tactics would then determine whether the soldier should be ad?
6See footnote 3, p. 326.
7Flumerfelt, John M.: Psychiatric Problems in Military Personnel at Ports of Embarkation and En Route Overseas. In Military Medicine Notes. Army Medical Service Graduate School, 1951. sec. C. pp. 1-11.
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mitted to the station hospital or its equivalent in the staging area, or whether the specialist examination should be conducted on an outpatient basis. As far as psychiatric examinations are concerned, there is no question but that an outpatient examination is indicated in all except acute psychotic disturbances and the most severe of the neurotic panic states.
Morale and Psychiatric Workload
The experiences of World War II demonstrated that the efficiency of both the training process and the medical screening in the prestaging operations was extremely variable. In addition, or perhaps in connection with the training phase, morale was a very important factor. Certain units were in such a high state of morale that it was well-nigh impossible to pry one soldier loose from his unit for even the most commendable of reasons. In other groups, morale conditions were reversed, and occasionally, it became necessary for command to declare a whole unit unfit or not ready for oversea duty. The experience of the neuropsychiatrist in the staging area could thus be described as feast or famine; either the pressure of his work was great or it was just average. More than the pressure of a workload, the staging area psychiatrist felt the onus of responsibility for his decisions to remove men from oversea shipments. He had to decide from clinical data how seriously sick the individual was and, then, to evaluate the degree of incapacity in relation to wartime needs for personnel. Frequently, a difficult and tenuous decision had to be made whether the morale of a unit would be better served by keeping the individual with his outfit or by removing him. It is true, the psychiatrist could obtain help in these decisions by conferences with unit commanders or by presenting the problem to a medical disposition board; however, in actual practice, it was his decision to make, and too often it was rendered on an emergency basis.
Personal experiences.-The following personal experiences illustrate the relationship of morale to the incidence of emotional disorders:
The hospital at Camp Patrick Henry was activated in December 1942. Medical officers arriving at the hospital just before Christmas were drafted immediately to aid in processing an emergency shipment of combat troops for overseas. It was a difficult time, and some of the wards in use did not even have heat. Yet, such was the pressure of the war, at the time, that the medical staff had to make do with unfinished facilities. Soon after this initial experience, a full combat division, battle ready and with high morale, was staged directly from the camp for an invasion onto the island of Sicily without restaging in Europe or Africa. As usual, it was found that such organized combat units with keen training and high morale offered no problem to the neuropsychiatrist. Very few men of this division were presented for psychiatric consultation, and almost all of them desired to remain with their units.
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By contrast, another division came through the staging area en route to immediate combat activity. In this group, morale was at a low ebb. Previously, the division had been inspected several times to determine combat readiness but, in each instance, had been returned for further training. Finally, the division was declared combat ready and proceeded through the Hampton Roads Port of Embarkation for duty overseas. Yet, something was still wrong. The officers were dispirited. Many neurotic, including hysterical, personnel came to the clinics daily, but unit commanders refused to let these men be detached, and thus removed from the division. Many of the officers were fearful of certain 'psychopaths' in their units who had threatened to shoot them 'in the back' at the first opportunity which presented itself. The contrast between the two units was striking; it illustrated the extremes in morale which affected the workload of the psychiatrist.
The court of last appeal.-During one period of the war effort, a large group of combat troops was passing through Camp Patrick Henry. These men had had long periods of training and were considered ready to enter combat directly as replacement troops. On the day after their arrival, from the consultation room window, a group of men was seen on the roadway that led in front of the hospital area, presenting the strangest agglomeration of humanity that one could possibly imagine. Incredible as it may seem, there were men actually in wheelchairs pushed by others who limped and who apparently had something askew with their backs. There were men using crutches and improvised supports hobbling along the edge of the road. Those who were not crippled were bedraggled and unhappy. The group numbered well over 50, and it was only a few minutes later that it was discovered they were at the clinic for psychiatric consultation. No organic reasons were found for the apparent disabilities of these men, and it was readily ascertained that these subjects were mainly hysterical neurotics with longstanding histories of emotional illness. One or two, however, were seriously disturbed. The striking thing to bear in mind about this group of men was that they had been sent to the port of embarkation as combat ready. It became the task of the screening psychiatrist not only to keep such men from shipment overseas but also to bring this matter to the attention of the commanding officers of the staging installation for executive action. This entire shipment of men was eventually reentrained to the prestaging installation, and no doubt, some disciplinary action was taken against the responsible commander.
Operational Differences, Camp Kilmer versus Camp Patrick Henry
It is interesting to contrast some available workload statistical data between two comparable East Coast staging areas. This cursory study8
8Annual Report, Surgeon, Camp Kilmer, N.J., 1944, and notes by Capt. George E. Poucher, MC, the author's associate at Camp Patrick Henry, Va.
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is presented because of certain findings which may be helpful in the organization of staging areas in any future wars. In 1944 and 1945, Camp Kilmer, N.J., of the New York Port of Embarkation functioned with a neuropsychiatric service, consisting of two specialists, as did Camp Patrick Henry, at the Hampton Roads Port of Embarkation. Camp Kilmer managed with the use of two psychiatric wards, one open and one closed. While such inpatient facilities were occasionally sufficient for the workload at Camp Patrick Henry, more often, in that period, one closed ward and two or three open wards were required. At Camp Kilmer, the psychiatric inpatient consultations averaged 50 per month, and outpatient consultations numbered 175 per month. At Camp Patrick Henry, the inpatient consultations were from 70 to 140 per month and the outpatient load was approximately 300 consultations per month. As already noted, one month at Camp Patrick Henry, during a survey of embarkation groups, 1,800 consultations were carried out in the neuropsychiatric clinic.9
Explanations.-There is no factual or logical explanation accounting for this large difference in psychiatric workload between the two staging areas, but speculation is possible on a few known variables. At Camp Kilmer, Goldbloom and Schantz (p. 327) conducted a program of rehabilitation for psychoneurotic-type patients, observing in particular a group designated as the emotionally maladjusted which were followed in clinic visits and finally disposed of by discharge from the service, by transfer to a general hospital, or by reassignment to duty. This program was mostly conducted outside the hospital wards. At Camp Patrick Henry, however, although psychoneurotic patients participated in a general rehabilitation program according to War Department directives, the policy of command relative to this group was undoubtedly different from that at Camp Kilmer, at least according to the author's recollection. Officers in charge of reassignment had little success in placing these patients and, after a brief period, urged the psychiatrists to make more and more definitive dispositions of such soldiers, other than transfer or reassignment. The result was that the patients in the rehabilitation group were either discharged from the service or returned to duty. With a larger number of men being recommended for discharge, the population of wards increased, which may account, in part, for the larger inpatient service at Camp Patrick Henry during the 1944-45 period of the war in comparison with that at Camp Kilmer.
Accounting for the larger difference in outpatient clinic consultations between these two staging areas is even more speculative. Information
9It is pertinent to note that no formal psychiatric program for staging areas was employed in the Korean War. Only an occasional psychotic was removed from troops in transit and at the port of embarkation; all others were shipped. This removed the necessity for psychiatrists to make impossible decisions for determining the eventual combat effectiveness of individuals from symptoms exhibited during this transit period. Moreover, it avoided the all too frequent World War II practice of unit commanders attempting to discard problem soldiers at the port of embarkation, many of whom later exhibited effective combat performance-A. J. G.
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available from the book 'The Road to Victory'10 is to the effect that the staging area at Camp Patrick Henry processed for oversea shipment only eight full size Army divisions during 1943 and 1944. Usually, Camp Patrick Henry was occupied with the processing of casual or replacement troops whose esprit de corps was at a low ebb rather than with organized units of high morale. Accordingly, the number of referrals for psychiatric consultations from these casual groups was very high. These men were seen as outpatients, and many were found to be psychoneurotic. It was assumed that the presence of such psychoneurotic disorders must have been known to command at previous stations. Thus, if the men were considered to be of sufficient value to complete training up to a port of embarkation, then it was also considered that they were deemed capable of proceeding overseas with their units even with psychoneurotic conditions. Of course, many of the more severe psychoneurotic individuals had to be detached from their units despite this general policy. In any case, the result was that the psychiatric clinic at Camp Patrick Henry became overloaded and the conclusion drawn was that the overload was due to the nature of the units passing through the port of embarkation. It was assumed that Camp Kilmer dealt more with organized divisions whose personnel had less motivation for separation at the port of embarkation. It has been generally conceded since the war that morale was generally better in units that had trained together than in newly formed units or individual replacements (p.335).
Another factor affecting the large psychiatric caseload at Camp Patrick Henry was that, during the period of comparison with Camp Kilmer, the Station Hospital at Camp Patrick Henry also served as a regional hospital. This led to an unusual admission of patients from many nearby posts and stations for observation, study, and possible discharge from the service. With the increased patient load in the hospital for general medical and surgical reasons, the neuropsychiatric service received an added increment of cases.
The grand total of embarkations of all types at Hampton Roads Port of Embarkation was approximately 772,000.11 It can be assumed that Camp Kilmer exceeded this number considerably, since it was associated with the largest East Coast port, New York, and was the embarkation area for the larger European theater. Hampton Roads served principally the smaller Mediterranean and Middle East theaters. For this reason, the disparity in the neuropsychiatric caseload is even more striking, notwithstanding the possibility that the available statistical data are derived from unequally weighted premises.
Recommendations.-Even though this attempted comparison of two East Coast embarkation facilities may not withstand close scrutiny by
10Wheeler, William Reginald (editor): The Road to Victory. New Haven: Yale University Press, 1946.
11Ibid.
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statistical analysts, its purpose was to establish that there were operational differences. It is believed that service personnel who are, as a rule, older and replacement troops, who are less highly motivated, present a greater problem to the psychiatric staff in a staging area than troops of organized divisions. Accordingly, it is believed that if one particular staging area will in some future war serve largely replacement troops and service personnel it should be provided with a very special organization in its neuropsychiatric service to meet an unusually large workload.12 The department might be larger in staff and have more varied personnel and facilities.
TROOPSHIPS EN ROUTE OVERSEAS
Psychiatric Breakdowns
Little data are available on psychiatric breakdowns occurring en route overseas. Major Flumerfelt personally studied a British soldier after a suicidal attempt aboard ship. The case seemed to be a reaction to frustration; the soldier involved had had long service in Africa and, just when he expected shipment to his home, had found that he had been reassigned to the Near East. Major Flumerfelt also quoted a personal communication from Maj. Walter Musta, MC, who found that the less stable troops were more subject to seasickness. Maj. Theodore P. Suratt, MC, who was the 44th Division psychiatrist, did not recall any outstanding problem with the division troops en route overseas. Lt. Peter J. Brdar, who, while in service, was an officer of the Medical Administrative Corps but later became a psychiatrist, reminisced about a passage overseas on a Liberty Ship, as follows:
The tiers of bunks were so close to each other that they brought out latent claustrophobic tendencies in troops. Seasickness in one or two men seemed to precipitate waves of mal de mer among the ranks.
These few items of information on the subject are very meager, considering the vast numbers of troops conveyed by ship to oversea theaters during World War II. The climate for the passage by ship should have been ideal for precipitating emotional breakdown. The ships were overcrowded, they were blacked out for security reasons, and there was the ever-present fear of submarine attack. A likely conclusion is that this phase of war medicine was not deemed valuable for intensive scientific
12It is unlikely in future wars that the pressure of logistic demands would permit separate and exclusive staging areas for processing casual, or replacement, troops as distinguished from organized troop units. However, it has been repeatedly demonstrated in the past that the motivation of troops organized and trained together as a unit under good leadership is far superior to that of casual replacement troops, which have no such identity, thereby leading to fewer medical and administrative problems. It is for this reason that the Royal British Army has for the past century or more extolled the virtues of regimental banners and endeavored to promote individual pride in unit identity-A. L. A.
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study and recording because a certain percentage of emotional breakdown was to be expected under the existing circumstances.13
MoraleCasual troop replacements.-Lt. Col. (later Col.) M. Ralph Kaufman, MC, Neuropsychiatric Consultant, U.S. Army Forces, South Pacific Area, while en route overseas had an opportunity to conduct a questionnaire survey on a group of 800 casual troops sent abroad as replacements.14 Although the replies to this questionnaire revealed a number of interesting aspects of the soldiers' attitudes toward their training and shipment to the Pacific Area, Colonel Kaufman made the following conclusions:
Casual troops sent abroad as replacements present various differences from troops shipped as part of a well-integrated unit. Lacking a permanent organization and having no officers assigned to them, except casual officers who themselves are in the process of being shipped, the troops seem to lack an 'esprit de corps.' This reflects itself in their general morale. It is the impression of those who have to deal with them aboard ship, that, as a rule, they are more difficult and less amenable to the necessary discipline and routine aboard a crowded ship.
This experience with casual replacements has been mentioned so frequently that whole unit replacements should be the logical choice.
TRANSPORTATION OF MENTAL PATIENTS TO ZONE OF INTERIOR
Abuses Encountered
Lt. Col. Malcolm J. Farrell, MC,15 Assistant Director, Neuropsychiatry Consultants Division, SGO, recorded an important chapter for the history of medical events in World War II by compiling some of the correspondence
13Experiences of most psychiatrists en route overseas by troopship in World War II are similar to these just described. In fact, rarely were psychiatric problems presented for treatment aboard ship. The reason for this relative absence of psychiatric cases may very well be that neurotic gains in illness were inappropriate under these circumstances. Ships would not turn back, as everyone was aware. Here was a situation where psychological symptoms had no value whatsoever. In fact, sickness or other incapacitation would place a restriction on the few possibilities for recreation that were available and possibly decrease the chances of survival in the event of enemy attack. It is an interesting commentary upon the fact that the manifestation of psychiatric symptoms of a neurotic type are strongly influenced by external circumstances. Thus, there were very few psychiatric cases that demonstrated themselves during the first day at Pearl Harbor. Here again, there was no gain in illness. Navy psychiatrists report few psychiatric casualties at the time that ships are engaged in action. Again, gain in illness is impossible under these circumstances.
Nothing in the foregoing should leave the impression that personnel en route overseas during wartime did not suffer from anxiety, depression, and other psychological and psychosomatic symptoms. Almost everyone was under some personal or external pressure, and such discomforts were quite common. Seasickness, for instance, was frequent but here socially acceptable and certainly not gain producing.-A. J. G.
14Questionnaire Survey of Casual Troops (At Sea), 12 Oct. 1943, by Lt. Col. M. Ralph Kaufman, MC, Consultant Neuropsychiatrist, Headquarters, U.S. Army Forces, South Pacific Area, in collaboration with Lt. Col. Gordon M. Johnson, Cav., Code Commander, and Maj. John F. Carey, TC, Transport Command, with assistance of Capt. Bernard J. Goldman MC.
15Farrell, M. J.: Evacuation of Mental Patients by Surface Ships. [Unpublished manuscript.]
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which was conducted by the Neuropsychiatry Consultants Division with the consultants in two service commands, with the Chief of Transportation, and with the surgeons in command of oversea theaters on the subject of transportation of mental cases by surface ship to the United States. The steplike progress, from the spotlighting of the abuses to the recommendations for correction resulting finally in the issuance of orders covering the procedures to be followed, make for fascinating reading.
The abuses uncovered by Colonel Farrell in early 1943 may be summarized as follows:16
1. Inadequate accommodations aboard ship for long ocean voyages particularly through tropical weather.
2. Lack of qualified personnel, both officer and enlisted.
3. Difficulties in proper classification.
4. Problems specifically related to the closed-ward patients.
a. Returning Army transports carried most of the mental cases and the latter were relegated to an undesirable section of the ship which was poorly lighted and ventilated, or quickly constructed and improvised when mental patients were to be embarked.
b. Poorly informed general medical officers had a tendency to classify all psychiatric patients in one group, regarding them all as dangerous to themselves and to others.
c. Fundamentals of care such as nutrition and water balance were neglected.
d. Morphine was used as a sedative.
e. Violent patients were placed in metal cages measuring 6 by 3 by 3 feet.
Recommendations.-As a result of these abuses, Colonel Farrell, in a memorandum of 11 February 1943 to the Medical Practice Division, SGO, submitted the following recommendations relative to the abuses encountered:
1. Removal of physical hazards from rooms in which the mentally disturbed are quartered.
2. Judicious use of sedative drugs such as paraldehyde and the barbiturates along with adequate attention to fluid intakes, nourishment, and vitamins.
3. Review of the procedure for giving hydrotherapy along with a recounting of its attendant dangers.
4. Recommendations for diversional activities for mental cases.
5. Review of the proper restraint procedures.
Despite early awareness of serious abuses in the care of mental patients being returned to the Zone of Interior and the recommendations
16(1) Report, Port Surgeon, New York Port of Embarkation, to The Surgeon General, 19 Jan. 1943. (2) See footnote 15, p. 335.
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for the correction of such abuses, improvement was only gradually accomplished.
Use of cages for psychiatric patients
One of the important grievances in the transportation of neuropsychiatric cases to the United States was the use of cages on ship wards. These cages were made of wire mesh, were 6 feet long in a horizontal direction and, otherwise, approximately 3 by 3 feet in girth and height. With the mattress that it contained, there was insufficient headroom for the patient to sit up so that actually the use of the cage was quite inhumane. Maniacal patients had no freedom of movement. The nursing problem with regard to excretions was most difficult. It was quickly advised that these cages be abolished.17 However, there were variant views on this subject, particularly from some ship surgeons and at least one port commander who believed that not all cages should be abolished but that a few should be left on each ship; otherwise, the transportation of this type of patient, understood so little and feared so much, would be too difficult a problem for medical and other attendant personnel. Finally, to control disturbed patients, orders were issued to place shock machines for electroconvulsive therapy on board these transports, and the medical officers in charge were given training in their use.18 Specific recommendations were given about other types of psychiatric management of disturbed patients: Judicious use of exercise on the decks of ships, hydrotherapy, drug therapy, and the proper use of restraints. Although it could not be implemented during the war, it became almost a universal recommendation that ships transporting medical casualties as well as neuropsychiatric casualties should be air conditioned. Authorities were also of the opinion that the best mode of transporting the very sick mental patients was by air, for then time in transit would be brief and, thus, the use of heavy sedation rarely a great danger.
Improper classification of mental cases
The next reform concerned the removal of the stigma created by the letters 'NP' on patient identification tags.19 Apparently, fellow soldiers on transports looked upon men so designated as social pariahs to the consequent grief and consternation of the psychiatric patients. An order20 was then issued providing that only a letter of the alphabet signifying the
17Circular Letter No. 35, Office of Chief of Transportation, U.S. Army, 1 Mar. 1943.
18(1) Memorandum, Chief, Neuropsychiatry Consultants Division, Office of The Surgeon General, for Medical Liaison Officer. Office of Chief of Transportation, 25 June 1945, subject: Electroshock Therapy Aboard Hospital Ships. (2) Letter, Chief, Movements Division, Transportation Corps, to Commanding Generals, Ports of Embarkation, 28 June 1945, subject: Electroshock Therapy Aboard Hospital Ships.19Memorandum, Director, Neuropsychiatry Consultants Division, Office of The Surgeon General, for Lt. Col. John C. Fitzpatrick, MC, Transportation Corps, 27 June 1944.
20Transportation Corps Circular No. 50-31 (revised), 17 July 1944.
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medical classification of the patient, according to a prescribed code, appear on the debarkation tag.
Proper coding21 of mental cases involved the use of letters A, B, and C. The letter A was assigned to the patients who required locked-ward care either in hospitals or during transportation. The letter B designated the patients who might be cared for in open wards of a hospital but whose condition might not be adaptable to open-ward care on board ship. The letter C was for open-ward care in land hospitals or on ships.
It was found that faulty classification was purposely carried out to gain passage for closed-ward cases where such accommodations aboard ship were filled and open-ward spaces were still available. The transport surgeons then found, when the ship was at sea, that they had extremely difficult problems on their hands.
Accordingly, orders22 went out demanding strict compliance with classification requirements for mental cases. Following this, efforts were made to provide psychiatric training in hospitals for officer and enlisted personnel (ship's complement) during their stay ashore. Unfortunately, according to the author's recollections, the initials 'NP' were still on identification tags as late as 1945.
Deaths of psychiatric patients in transit
How hazardous the transportation of disturbed psychiatric patients could be is illustrated by the following statistics: The Port Surgeon of the San Francisco, Calif., Port of Embarkation reported on a period from April 1944 through October 1944. During that period, 2,980 mental patients had been debarked from the Pacific. In this group, there were 19 deaths of which all but 1 occurred in psychotic cases and that one was diagnosed neurosis. Of this psychotic group, nine were drowned (usually by jumping overboard while being exercised under supervision on deck), one died as a result of hanging, one died of diphtheria, three died of cardiac conditions, one died of malnutrition, one died of pyelonephritis, and two died of unknown causes. Of these deaths, 14 were on Army transports which carried the vast majority of Army cases and 5 were on Navy vessels.
Summary
In retrospect, it seems unconscionable that such abuses and inhumanities, as have already been enumerated, could occur in the first place;
21(1) 'Compilation of Instructions Pertinent to Hospital Ships,' issued by Charleston Port of Embarkation, Charleston, S.C., 13 Feb. 1945. (2) See footnote 15, p. 335.
22(1) Letter, Commanding General, Army Service Forces, to Surgeon, Headquarters, North African Theater of Operations, U.S. Army, 10 Aug. 1944, subject: Transportation of Neuropsychiatric Patients From Overseas Theaters. (2) Teletype (73304), Lt. Col. John C. Fitzpatrick, MC, for Lt. Col. Donald E. Farr, Transportation Corps, 28 July 1944, subject: Accommodations of Open Ward Mental Patients En Route.
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nevertheless, it is gratifying to know that organized authority was alert and sensitive to these defects and corrected them as rapidly as possible. Civilian pressure from newspapers and magazines upon military authorities probably contributed to the alacrity of correction in 1944 when returning soldiers made their complaints known.
Refinements in the humane care of mental cases kept appearing throughout the war. One such improvement concerned bringing class A and B patients up on deck if their emotional status and the weather conditions warranted it.23 Another included an orientation of such patients to their return home. A third recommended a specified recreational program following certain military technical bulletins on the subject.
Hospital Ships
Psychiatric facilities
A medical history report24 of the 211th Hospital Ship Complement aboard the U.S. Army Hospital Ship Emily H. M. Weder for 1944 is a classic for describing the imperfections of the existing hospital ships.
23Letter, Chief, Movements Division, Transportation Corps, to Commanding Generals, Ports of Embarkation, 21 Sept. 1944, subject: Sea Evacuation of Mental Patients.
24Sands, H.: Neuropsychiatric Nursing Aboard USAHSEmily H. M. Weder. [Official record.]
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This intimate annal of the war came to the author's attention through Maj. Matthew Levine, MC.25 His principal service was on this large hospital ship which made important voyages in the Mediterranean and in the Pacific areas. His chief nurse in the neuropsychiatric section was Lt. Helen Sands, ANC. In her report, she traced the group's progress from its activation at Camp Kilmer to its real testing as a professional unit in a run from the Philippines to New Guinea with a full-bed capacity of class A psychiatric casualties (figs. 33 through 37).
Lieutenant Sands described lectures in basic theory and principles involved in normal and abnormal behavior given by Major Levine during the group's indoctrination period at Camp Kilmer. She elaborated at
25Levine, Matthew, M.D.: Personal communication to author. Major Levine surmises that he was one of the few Board-qualified neuropsychiatrists stationed on a hospital ship.
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FIGURE 35.-Nurses admiring what their patients had accomplished aboard ship.
length about their adaptation to the physical appurtenances of the ship, in general, and the neuropsychiatric section, in particular. They devoted a great portion of their spare time to making their dayrooms (one of these rooms was originally a cargo hold) homey and attractive. She wrote:
Both rooms are furnished with leather chairs and settees. We engaged in a ceaseless hunt for suitable pictures, and spent hours arranging them on the bulkheads; walls to you landlubbers. We decided that a bright spot was necessary; the gals came through with a bright red bookcase, hand painted. * * * it proved to be just what the room needed. * * * Our efforts are amply repaid whenever a patient enters the room, and with a wide-eyed stare exclaims, 'Oh, brother, it's a long time since I've seen a room like this * * *."
Lieutenant Sands gave an interesting, detailed record of the nursing care afforded a practically mute psychiatric casualty with personalized attention from a few members of the group. The day-to-day progress report indicated how worthwhile it all was. One of the principal contri?
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butions to therapy of the disturbed patients evacuated in the South Pacific was the effective occupational therapy and judicious companionship given by the nursing personnel. It led to a comment by Major Levine: 'That's one of our best methods of treatment, giving the patient pleasant women to talk to.'
What was stressed in the report, however, was the absence of adequate ventilation and this was particularly underscored with regard to neuropsychiatric patients. It was pointed out that locked-ward cases could not use the decks at any time and that when the psychotic patients became disturbed, the problem became even more difficult because then their body temperatures rose. If, in addition, restraints had to be instituted, this increased the body heat and led to water loss. Also, as might be expected, disturbed patients refused to take the proper amounts of fluid, and this compounded the injury. It was charged that the average ward air temperature during a 14-day trip was between 105? and 110? F. Some of the wards were without portholes. One of the wards was near the hospital laundry which was operated 24 hours a day, adding greatly to the heat and humidity. With the terrible environmental heat, recreational and occupational therapy programs could not be carried out. In the latrines, the increased humidity added to the disturbance by the high temperature. Dermatitis became aggravated by the extreme heat, and this complicated the problems of the neuropsychiatric patients and the medical personnel
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FIGURE 37.-Articles made of leather in the Arts and Crafts Exhibit.
in charge. All disturbed patients seemed to run temperatures. Working in an almost impossible environment produced an adverse effect on the morale of the nurses and ward attendants.
The report listed other defects in the physical appointments of the disturbed ward section (fig. 38). Overcrowding was a problem. Frequently, disturbed patients had to be kept together in confined quarters, and this made it extremely difficult if one of them suddenly became suicidal. The cells for individual care aboard ship were too few. There was a lack of soundproofed bulkheads. The panels enclosing cells for disturbed patients were not secure enough and were frequently broken through. The restraining sheets provided were not tailor made to the bunks found in hospital ships. Washroom facilities were inadequate. However, the most important thing stressed about the difficulties in hospital ship transportation was the matter of ward temperature and ventilation and, what was particularly recommended, was to have the hospital area air conditioned.
Hospital ship fatigue
The annual report from the U.S. Army Hospital Ship Wisteria for 1944 described an interesting syndrome among the personnel of the ship. It was called 'hospital ship fatigue.'
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FIGURE 38.-A ward on the U.S. Army Hospital Ship Emily H. M. Weder.
This was a definite entity characterized by insomnia, anorexia, irritability, slackness in work, and extreme persistent fatigue. Certain individuals with neurotic tendencies and social maladjustment were prone to attack. All personnel, however, experienced a certain degree of hospital ship fatigue which was usually arrested by time ashore. Up to the end of 1944, however, only one person had been put ashore with this diagnosis. Hospital ship fatigue was no different from the maladjustment to confinement and boredom found elsewhere. Apparently, it was not nearly so severe as the so-called 'Arctic stare' seen in Greenland.
A convoy under attack
Capt. Jacob Sirkin, MC, in a letter communication, touched on many of the points of grievance mentioned elsewhere in this chapter; namely, the defects of a hospital ship; the faulty classification of closed-ward-type cases; and the transportation, without guards, of 30 general prisoners, convicted of various crimes, ranging from murder to desertion, on the neuropsychiatric wards. One of his experiences aboard the Santa Maria with a medical hospital ship platoon merits recording:
We were traveling in convoy from England in December 1944 with about 60 'closed ward' patients. One night, there were a series of depth charges being exploded around us by the escorting vessels. This obviously meant to all of us that there might be a submarine in our vicinity. We were all rather jarred by the thought of the ship
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getting torpedoed. I went to the closed ward to see how things were going. To my astonishment, I found that the doors were all open, with my corpsmen standing by. It seems that the patients had become agitated over the fact that they might be caught in a position where escape would be impossible because of locked doors if the ship were struck, and a quick agreement had been made by them and the corpsmen that they would stay where they were if the doors were left open, so that escape would be possible. To me, it was a magnificent display of good and quick thinking on the part of the corpsmen.
DEBARKATION OF MENTAL PATIENTS
From Ship to Hospital Train
The careful inspection by a service command neuropsychiatric consultant26 of a ship-to-hospital train transfer of 171 neuropsychiatric patients resulted in a number of weaknesses in procedure being highlighted. He then initiated the type of communication at the command level that eased many of the stress points. Lt. Col. (later Col.) Henry W. Brosin, MC, made such an inspection at Hampton Roads Port of Embarkation. His recommendations pointed out the faults and suggested the antidote, as follows:
a. It is essential that the medical officers in charge of these convoys assign qualified medical officers, nurses, and enlisted men for the care of psychotics. The responsible medical officer should make an estimate of the situation upon arrival at the port, personally inspect and prepare the patients for transfer to the train, and personally supervise such transfer. He should also deploy his personnel in a most efficient manner and give specific instructions regarding the concrete problem of transporting psychotics. Irresponsible or indifferent corpsmen cannot be tolerated in movements of this kind for they will be the source of much criticism.
b. All officers agree that a thorough 'on the job' training course is essential for enlisted men * * *. Trained enlisted men can make the trip a pleasure for themselves and the patients instead of a fearful, irksome job.
c. If feasible, an officer of the N.P. Staff should supervise transfers of psychotic patients from the ship to the * * * [general hospital of destination]. Where this does not seem feasible * * * the general medical officer can be coached relative to his duties with N.P. patients.
d. There has been a mistaken impression that the hospital cars are provided with leather anklets and wristlets for restraint. These could not be found by the responsible officers. The canvas camisoles which were present are not very useful. The hospital authorities are able and willing to provide the leather restraints in the future * * *.
e. A medical kit should be provided containing an arm board, syringes for intramuscular and intravenous use, Sodium Amytal and similar barbiturates for intravenous use, paraldehyde, bandages, antiseptics and stimulants such as coramine, caffeine, * * * and aphedrine for use in case of respiratory failure.
Staging Becomes Debarkation
Toward the end of the war in Europe, the status of the Station Hos?
26Report of Neuropsychiatric Consultant's Visit to Hampton Roads Port of Embarkation and McGuire General Hospital on 1-2 September 1944.
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pital, Camp Patrick Henry, changed, as did the medical facilities in other staging areas. It was now to serve as a debarkation hospital for sick, wounded, and emotionally disturbed soldiers. Just before this change, the port of embarkation had served as a juncture point where hospital trains would meet the incoming shipments of casualties (fig. 39) and convey
FIGURE 39.-The U.S. Army Hospital Ship Larkspur, arriving at Charleston, S.C., 1944.
them directly to a general hospital. At the general hospital after a brief evaluation, casualties were classified for shipment to specialty hospitals. However, in 1945, the various general hospitals utilized for such screening were filled with their own specialty patients, which necessitated that classification procedures be done elsewhere. It was for this reason that the Camp Patrick Henry Station Hospital became a debarkation hospital, the chief function of which was to receive the shipment of casualties and to reclassify them, after a brief stay, for transfer to the appropriate specialty hospital.
One shipment came into this installation which consisted almost entirety of psychiatric casualties. Information was received some few days before debarkation that the shipment had 1,700 psychiatric patients. With a staff of only two trained psychiatrists, even the briefest type of screening was impossible for such a large number of patients. It was known
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beforehand that the housing for these patients would have to be managed largely in area barracks and that only very special cases could be placed on the hospital wards. Accordingly, every available military psychiatrist, from nearby military hospitals, was recruited and deputized for this screening procedure. In addition, a number of other medical personnel were coached on a method of brief psychiatric screening. These men were to work in teams, each team under the leadership of a psychiatrist who would be available to review any particular case. The reception, feeding, and bedding down of this large group of psychiatric patients went off smoothly, and very few psychotic cases were housed in the closed wards. Every patient in the shipment was interviewed within a few hours of arrival. The average stay of such patients was 5 days, after which they were transferred to the appropriate specialty hospital.
