History

CHAPTER XIV

Preventive Psychiatry

John W Appel, M.D.

GENERAL CONSIDERATIONS

A history of preventive psychiatry in the Army during World War II should include an account of the mental health of the men in the Army during that period and of the factors which affected mental health, both favorably and unfavorably; and then, specifically, it should contain an account of the attempts by psychiatrists to influence favorably the mental health of Army personnel and the success of these attempts.

This sounds reasonable enough, yet at the outset it must be said that no satisfactory criteria existed then, or now, for appraising mental health. Application of the usual standards for the dichotomies-health-sickness, normal-abnormal-leads only to confusion when applied to mental, as distinct from physical, health. When a man is noneffective for mental reasons, is it due to sickness or to unwillingness? This proved to be a key question during World War II and still remains one which has yet to be answered satisfactorily. In a broader perspective, the history of mental health of the Army during that war period becomes an account of human behavior or, more specifically, an account of the factors which determined behavior, of the types of behavior which were considered desirable and undesirable, and, finally, of how undesirable behavior was labeled. Preventive psychiatry then becomes those actions taken by psychiatrists intended to produce desirable behavior in military personnel.

By the criterion of performance, it can be said that the mental health of the American soldier was good during World War II. The men fought long and well, and they won the war. On the other hand, most psychiatrists would say that the mental health of the average soldier was far from optimum and that the effectiveness of the Army would have been significantly greater if mental health had been better. Here, however, considerable difficulty arises in distinguishing between mental health and motivation to fight the war, which also was not optimum in the American soldier in World War II. Furthermore, it seems evident that the war had an adverse effect on mental and emotional health. By the time the war ended, many, if not most, personnel in the Army were showing signs of emotional wear and tear severe enough to be classified, according to psychiatric criteria, as sickness of at least a mild degree, but sufficient to

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impair performance. This was more marked in men who had served prolonged periods in combat or in isolated outposts overseas. There is evidence that in several battle campaigns, particularly those in the Mediterranean theater, the breaking point of the average man was reached and that most men engaged in frontline duty ultimately broke down psychologically, or would have done so had they not been killed, wounded, or otherwise disabled.

SCOPE OF PROBLEM

The statistical data introduced here pertinent to the appraisal of the various phases of the neuropsychiatric problem deal, broadly stated, with the disqualifications for military service for neuropsychiatric reasons; with the incidence of neuropsychiatric disorders, as reflected in hospital admissions for such disorders; and with discharges for neuropsychiatric disorders. In interpreting the statistical data, specifically those related to admissions, it is important to recognize that they represent only rough indices of the actual incidence of psychiatric disorders in the Army, inasmuch as the criteria by which patients were so diagnosed varied widely during the war, as will be discussed subsequently in detail. The disqualifications for military service are evaluated first.

Rejections for Military Service

It has been estimated that 1,846,000 Selective Service registrants, 18-37 years of age, were classified as of August 1945 as IV-F-unfit for military service because of neuropsychiatric conditions. These disqualifications represented 38.2 percent of all World War II disqualifications for military service, or 11.5 percent of all registrants examined (appendix A, tables 5 and 7). The psychiatric criteria for rejection or acceptance varied considerably during the war. Most psychiatrists now believe that, in general, the criteria applied were too strict and that a sizable proportion of the rejectees could have rendered useful service had they been accepted.¹ Be this as it may, it does seem clear that the marginal segment of the population, those with the 'poorest' mental health, had been screened out. The 11 million who served in the Army represented mainly the healthy young men of the country.

Hospital Admissions Worldwide

During World War II, there were 1.1 million admissions to hospitals for neuropsychiatric conditions-on a worldwide basis, indicating for the

¹As a matter of fact, the psychiatric standards have been liberalized after World War II and fundamental changes have been introduced in the psychiatric screening procedures. See Karpinos, Bernard D.: Qualifications of American Youths for Military Service. Medical Statistics Division, Office of The Surgeon General, Department of the Army, 1962.-A. J. G.

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entire war period a rate of 43.5 neuropsychiatric admissions per 1,000 mean strength per year (ch. IX, table 6). The neuropsychiatric admissions comprised 6 percent of the hospital admissions for all causes, or 7 percent of the hospital admissions for disease. The actual number of patients admitted for neuropsychiatric conditions was naturally smaller, since a certain proportion of these admissions were readmissions. It has been estimated that 960,000 patients were admitted to hospitals for neuropsychiatric disorders. These patients represented approximately 9 percent of all those who served in the Army in World War II.

From the viewpoint of prevention, the most important question to ask is what these data imply relative to the mental health of the other approximately 91 percent of the Army. The inpatients had neuropsychiatric disorders considered serious enough to require removal from duty and admission to a hospital. But, as was gradually realized during the war, a mental and emotional disorder cannot be compared to a clinical entity, such as typhoid, for example, which a person either does or does not have. Rather, such disorders were analogous to nutritional deficiencies and varied, in degree, from completely disabling to relatively minor discomfort. Thus, for every psychiatric case serious enough to require hospitalization, there must have been many more cases of lesser severity among personnel who remained on duty. Therefore, the hospitalization rate was chiefly significant as an index of the mental health of the population in which it occurred.

Diagnostic distribution

Of the total number of admissions (1.1 million) for neuropsychiatric disorders, 15.8 percent were for neurological disorders; 6.1 percent for psychosis; 58.8 percent for psychoneurosis; 10.8 percent for character and behavior disorders, among which the most prevalent was immaturity reaction; 2.6 percent for disorders of intelligence; and 5.9 percent for other psychiatric disorders (ch. IX, table 9). Evidently, the bulk of these disorders consisted of psychoneurosis. There were wide variations in the total admission rates from year to year, and especially from month to month, primarily due to changes in the admissions for psychoneurosis. The admission rates for other diagnostic categories, specifically for neurological disorders and psychosis, remained relatively constant. (See chapter IX, tables 6 and 8 and chart 2.)

Psychoneurosis has been a well-established diagnostic term with fairly well established criteria for its application. It connoted that the person was psychiatrically sick. There is no question that a large proportion of the patients so diagnosed during the war actually did have this condition. Yet, during the war, it was concluded that this term had been widely misapplied throughout the Army and that a large proportion of the personnel admitted to hospitals with this diagnosis actually did not have

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this illness; rather, they were persons whose ineffectiveness was due to faulty attitudes, deficient motivation, or 'poor' character.

Significance of hospitalization

According to Army policy, particularly during the first years of the war, if a person became so ill as to be unable to perform his job satisfactorily, there was no place for him except in the hospital. This, of course, is in marked contrast to the situation in civilian life where, if one has a head cold or a sprained ankle, it is possible for him to take off a couple of days and stay at home. In the Army, a person with such minor ailments had to be hospitalized or, under exceptional conditions, confined to quarters. This hospitalization for minor disorders had a profound psychological effect on personnel in producing gain in illness, which will be discussed subsequently. In the present context, however, it should be clear that although the 1.1 million neuropsychiatric admissions represented personnel sufficiently sick to be ineffective in their jobs, by and large they were not so sick as to require hospitalization as it usually occurs in civilian life.

It would also be a mistake to conclude that the 1.1 million neuropsychiatric admissions represented personnel who had 'broken down' in the service. A significant proportion were soldiers hospitalized as a result of the constant screening process which was carried out throughout the Army, particularly during training. The trainees hospitalized in this process frequently were no sicker than they were before entry into the Army; it had merely been concluded by the examining medical officer, that, according to the current manpower policies, these persons were psychologically unsuited to their current duties and required reassignment or return to civilian life.

Differentials in admissions for neuropsychiatric disorders

Different factors affected the hospital admissions for neuropsychiatric disorders. Those affecting the admissions in continental United States are not the same as those in the oversea theaters, and especially in combat areas. Therefore, these admissions will be discussed separately-first, the admissions in the continental United States will be appraised, and then, those in oversea theaters.

Hospital Admissions in Continental United States

Of the 1.1 million admissions for neuropsychiatric disorders in World War II, on worldwide basis, 679,000 admissions (ch. X, table 14) (or 61.5 percent of all admissions) were in the continental United States and 424,000 admissions (table 22) (or 38.5 percent of all admissions) were in oversea theaters.

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The World War II admission rates were 45.8 in the continental United States (ch. X, table 14) and 40.2 in oversea theaters (table 22)-for 1,000 mean strength for the year. The admission in continental United States included trainees having difficulties in their initial adjustment to Army life, persons being screened out of the Army as unsuited to military service, and soldiers becoming incapacitated while on duty status in the various Army installations in the Zone of Interior.

Of the neuropsychiatric admissions in continental United States, 15.8 percent were for neurological disorders and 84.2 percent for psychiatric disorders, the latter containing 5.6 percent psychosis; 57.5 percent (the majority of the cases) psychoneurosis; 12.1 percent character and behavior disorders; 3.6 percent disorders of intelligence; and 5.4 percent, other psychiatric disorders (ch. X, table 15).

The admission rates in continental United States for neuropsychiatric reasons, specifically for psychiatric disorders, varied widely, from year to year and from month to month. The most striking feature was the sharp increase in the admission rate for neuropsychiatric conditions that occurred in the second half of 1943. The admission rate in continental

CHART 5.-Admission rates for neuropsychiatric disorders, U.S. Army, total worldwide, continental United States, and oversea theaters, by month, 1942-45

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United States, which had fluctuated early in 1943 around 40, rose in August 1943 to a high level of 67.6 per 1,000 mean strength per year-a relative increase of 28 percent. The rate declined abruptly toward the end of the year almost to the earlier lower level (table 23; chart 5). Both this rise and fall reflected changes in policies and criteria for admitting patients to hospitals and, evidently, were in no way related to changes in the actual

TABLE 22.-Admissions for neuropsychiatric conditions, by diagnosis and year, U.S. Army, overseas, 1942-45¹

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

Diagnosis	Total 1942-45		1942		1943		1944		1945
Diagnosis	Number	Rate	Number	Rate	Number	Rate	Number	Rate	Number	Rate
Neurological disorders:²
Epilepsy	3,930	0.4	358	0.6	887	0.5	1,450	0.4	1,235	0.3
Other	63,250	6.0	3,524	6.0	13,551	8.0	22,665	5.9	23,510	5.2
Total neurological disorders	67,180	6.4	3,882	6.6	14,438	8.5	24,115	6.3	24,745	5.5
Psychiatric disorders:
Psychosis	29,818	2.8	1,651	2.8	5,182	3.1	12,125	3.2	10,860	2.4
Psychoneurosis	257,891	24.5	6,559	11.2	43,007	25.4	117,050	30.7	91,275	20.6
Character and behavior disorders:
Pathological sexuality	1,674	0.2	48	0.1	271	0.2	825	0.2	530	0.1
Asocial and antisocial personality types	1,002	.1	15	.0	42	.0	265	.1	680	.2
Immaturity reactions³	16,617	1.6	987	1.7	3,395	2.0	6,275	1.6	5,960	1.3
Alcoholism	16,879	1.6	1,142	2.0	2,972	1.8	5,220	1.4	7,545	1.7
Acute	(12,126)	(1.1)	(910)	(1.6)	(2,146)	(1.3)	(3,705)	(1.0)	(5,365)	(1.2)
Chronic	(4,753)	(.5)	(232)	(.4)	(826)	(.5)	(1,515)	(.4)	(2,180)	(.5)
Drug addiction	218	.0	19	.0	39	.0	100	.0	60	.0
Enuresis	¹NA	¹NA	¹NA	¹NA	¹NA	¹NA	340	.1	280	.1
Total	37,010	3.5	2,211	3.8	6,719	4.0	13,025	3.4	15,055	3.4
Disorders of intelligence	4,514	0.4	271	0.5	1,173	0.7	2,000	0.5	1,070	0.2
Other psychiatric disorders	27,922	2.6	884	1.5	4,648	2.8	11,185	2.9	11,205	2.5
Total psychiatric disorders	357,155	33.8	11,576	19.8	60,729	36.0	155,385	40.7	129,465	29.1
Total neuropsychiatric disorders	424,335	40.2	15,458	26.4	75,167	44.5	179,500	47.0	154,210	34.6

¹See footnote 1, table 6, chapter IX.
²See chapter XVIII, 'Neurology,' table 60, for detailed diagnostic distribution.

³This diagnosis includes 145 admissions for 'pathological personality,' not elsewhere specifically classified.

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

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incidence of neuropsychiatric disorders. In May, again in April, and then again in July 1943, memorandums² from the War Department pointed out that too many men with neuropsychiatric disorders were being shipped overseas and ordered that increased efforts be made for their detection and elimination.

On 14 July 1943, WD (War Department) Circular No. 161 eliminated the category of limited service and ordered the discharge of all men who

²(1) War Department Memorandum No. W600-30-43, 25 Mar. 1943. (2) War Department Memorandum No. W600-39-43, 26 Apr. 1943. (3) War Department Memorandum No. W600-62-43, 29 July 1943.

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TABLE 23.-Admissions for neuropsychiatric disorders, U.S. Army, worldwide, continental United States, and oversea theaters, by month, 1942-45

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

Month and year	Total worldwide¹		Continental United States		Oversea theaters
Month and year	Number	Rate	Number	Rate	Number	Rate
1942
January	4,598	30.6	4,194	31.2	404	25.4
February	4,641	30.3	4,212	31.3	429	23.0
March	5,877	31.0	5,282	32.2	595	23.6
April	6,248	30.4	5,661	32.8	587	17.9
May	6,981	30.4	6,123	32.1	858	22.1
June	8,189	33.8	7,053	35.5	1,136	25.9
July	9,498	35.6	8,155	37.9	1,343	26.3
August	10,802	37.0	9,266	39.7	1,536	26.4
September	11,895	38.2	10,150	40.8	1,745	27.9
October	13,544	37.8	11,643	40.6	1,901	26.8
November	14,470	36.6	12,406	39.4	2,064	25.6
December	17,312	38.6	14,452	40.0	2,860	32.8
Total	114,055	35.2	98,597	37.1	15,458	26.4
1943
January	18,413	37.9	15,215	38.9	3,198	33.8
February	18,197	39.2	15,125	40.2	3,072	34.9
March	23,295	42.4	19,295	43.3	4,000	38.4
April	24,940	45.5	20,140	45.8	4,800	44.4
May	26,173	44.9	21,240	46.4	4,933	39.6
June	28,702	50.0	23,130	51.8	5,572	43.6
July	33,798	55.2	26,000	56.1	7,798	52.4
August	38,970	63.5	30,950	67.6	8,020	51.4
September	36,163	60.6	28,285	64.8	7,878	49.2
October	34,842	56.5	26,785	61.1	8,057	45.1
November	30,568	50.9	21,955	53.0	8,613	46.1
December	27,026	43.3	17,800	42.9	9,226	43.9
Total	341,087	49.6	265,920	51.3	75,167	44.5
1944
January	27,030	43.0	17,545	43.9	9,485	41.4
February	24,695	41.6	15,085	41.7	9,610	41.5
March	25,305	39.8	14,575	39.1	10,730	40.8
April	22,960	36.5	13,085	37.4	9,875	35.3
May	27,830	42.0	15,475	43.6	12,355	40.1
June	27,170	42.1	13,965	41.7	13,205	42.6
July	33,150	49.1	14,020	41.3	19,130	56.9
August	31,165	46.3	16,320	49.7	14,845	43.0
September	37,010	56.4	20,055	65.9	16,955	48.2
October	37,595	56.2	17,950	60.9	19,645	52.6
November	37,775	57.9	15,460	57.0	22,315	58.5
December	36,130	54.0	14,780	56.7	21,350	52.2
Total	367,815	47.2	188,315	47.4	179,500	47.0
1945
January	35,780	54.3	14,465	57.6	21,315	52.3
February	29,690	45.1	11,460	48.0	18,230	43.5
March	31,595	47.2	12,230	52.3	19,365	44.4
April	31,205	46.5	11,985	51.1	19,220	44.0
May	29,830	43.5	12,180	51.2	17,650	39.3
June	26,930	40.1	12,155	49.6	14,775	34.6
July	24,985	37.3	12,275	45.7	12,710	31.7
August	22,910	34.6	12,550	43.2	10,360	27.9
September	16,275	25.3	8,880	29.8	7,395	21.4
October	13,470	22.9	7,935	28.8	5,535	17.6
November	10,305	21.4	5,735	25.9	4,570	17.5
December	7,135	19.1	4,050	21.8	3,085	16.5
Total	280,110	37.7	125,900	42.2	154,210	34.7

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

did not meet the minimum standards for induction. By September 1943, the disability discharge rates of enlisted men reached a peak of 35.6 per 1,000 mean strength per year for neuropsychiatric disorders, and a rate of 105.9 for all medical reasons; in other words, these discharge rates increased to such a level that 225,000 enlisted men per year would have been discharged-for neuropsychiatric conditions-or 660,000 enlisted men per year-for all types of medical conditions-had these discharge rates continued throughout the year. (See chapter IX, table 3 and chart 1.)

On 3 November 1943, the War Department temporarily suspended all discharges. This was followed, on 11 November, by instructions (WD

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Circular No. 293) which represented a basic change of manpower policy from that of screening and elimination to one of conservation and utilization. Men with psychiatric disorders were to be kept in the Army if medical officers considered them capable of rendering useful service (pp. 207-213). Their discharge was firmly prohibited. The rise and fall of admission rates in 1944 also occurred as the result of similar policy changes. (For further details, see chapter IX.)

Hospital Admissions in Oversea Theaters

Overall evaluation.-As mentioned before, 38.5 percent of the World War II admissions for neuropsychiatric disorders, or a total of 424,000

TABLE 24.-Percent distribution of admissions for neuropsychiatric conditions, by diagnosis and year, U.S. Army, overseas, 1942-45¹

Diagnosis	Year
Diagnosis	Total 1942-45	1942	1943	1944	1945
	Neuropsychiatric Disorders
Neurological disorders:²
Epilepsy	0.9	2.3	1.2	0.8	0.8
Other	14.9	22.8	18.0	12.6	15.3
Total	15.8	25.1	19.2	13.4	16.1
Psychiatric disorders:
Psychosis	7.0	10.7	6.9	6.8	7.0
Psychoneurosis	60.8	42.4	57.2	65.2	59.2
Character and behavior disorders:
Pathological sexuality	.4	.3	.4	.5	.3
Asocial and antisocial personality types	.2	.1	.1	.2	.4
Immaturity reactions³	3.9	6.4	4.4	3.4	3.9
Alcoholism	4.1	7.4	3.9	2.9	4.9
Acute	(3.0)	(5.9)	(2.8)	(2.1)	(3.5)
Chronic	(1.1)	(1.5)	(1.1)	(.8)	(1.4)
Drug addiction	.1	.1	.1	.1	.0
Enuresis	¹NA	¹NA	¹NA	.2	.2
Total	8.7	14.3	8.9	7.3	9.7
Disorders of intelligence	1.1	1.8	1.6	1.1	0.7
Other psychiatric disorders	6.6	5.7	6.2	6.2	7.3
Total psychiatric disorders	84.2	74.9	80.8	86.6	83.9
Total neuropsychiatric disorders	100.0	100.0	100.0	100.0	100.0
	Psychiatric Disorders
Psychiatric disorders:
Psychosis	8.3	14.3	8.5	7.8	8.4
Psychoneurosis	72.2	56.7	70.8	75.3	70.5
Character and behavior disorders:
Pathological sexuality	0.5	0.4	0.5	0.5	0.4
Asocial and antisocial personality types	.3	.1	.1	.2	.5
Immaturity reactions³	4.7	8.5	5.5	4.0	4.6
Alcoholism	4.8	9.9	4.9	3.4	5.8
Acute	(3.5)	(7.9)	(3.5)	(2.4)	(4.1)
Chronic	(1.3)	(2.0)	(1.4)	(1.0)	(1.7)
Drug addiction	.1	.2	.1	.1	.1
Enuresis	¹NA	¹NA	¹NA	.2	.2
Total	10.4	19.1	11.1	8.4	11.6
Disorders of intelligence	1.3	2.3	1.9	1.3	0.8
Other psychiatric disorders	7.8	7.6	7.7	7.2	8.7
Total psychiatric disorders	100.0	100.0	100.0	100.0	100.0

²See chapter XVIII, 'Neurology,' table 60, for detailed diagnostic distribution.
³This diagnosis includes 145 admissions for 'pathological personality,' not elsewhere specifically classified.

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

admissions, occurred in oversea theaters. Detailed statistical data relating to these admissions for all oversea theaters are presented in table 22, by year and diagnosis; in table 23, by year and month, side by side with those for total (worldwide) and for the continental United States, for comparative purposes (these data are graphically shown in chart 5); in table 24, showing the percent distribution of the oversea admissions by year and diagnosis; and in table 25, presenting the total World War II admission rates for the total (worldwide), continental United States, and oversea theaters, by diagnosis.

These statistical data clearly indicate lower frequencies of neuropsychiatric disorders in the oversea theaters, when viewed in toto. As stated before, the total admission rate for World War II for neuropsychiatric disorders was 40.2 in oversea theaters compared with a rate of

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45.8 percent in the continental United States, per 1,000 mean strength per year. With the exception of few months (December 1943, and June, July, and November 1944), the rates in oversea theaters were definitely lower for each month of the World War II period (table 23, chart 5). It must be realized, of course, that certain screening took place when troops were sent overseas, outside of the fact that certain proportions were weeded out much before oversea assignment. Among the specific diagnoses showing definitely lower admission rates in oversea theaters were immaturity reactions, disorders of intelligence, and to a certain degree psychoneurosis.

TABLE 25.-Admission rates for neuropsychiatric disorders, U.S. Army, worldwide, continental United States, and oversea theaters, by diagnosis, 1942-45

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

Diagnosis	Total worldwide¹	Continental United States²	Oversea theaters³
Neurological disorders:
Epilepsy	0.7	1.0	0.4
Other	6.2	6.2	6.0
Total neurological disorders	6.9	7.2	6,4
Psychiatric disorders:
Psychosis	2.7	2.5	2.8
Psychoneurosis	25.6	26.4	24.5
Character and behavior disorders:
Pathological sexuality	0.2	0.3	0.2
Asocial and antisocial personality types	.1	.1	.1
Immaturity reactions	2.6	3.5	1.6
Alcoholism	1.7	1.7	1.6
Drug addiction	.1	.1	.0
Enuresis	⁴NA	⁴NA	⁴NA
Total	4.7	5.6	3.5
Disorders of intelligence	1.1	1.6	0.4
Other psychiatric disorders	2.6	2.5	2.6
Total psychiatric disorders	36.7	38.7	33.8
Total neuropsychiatric disorders	43.5	45.8	40.2

¹See table 6, chapter IX.
²See table 14, chapter X.
³See table 22.
⁴"Not available." See footnote 1, table 6, chapter IX.
NOTE--.The entry .0 indicates a rate of less than .05.

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CHART 6.-Admission rates for neuropsychiatric disorders, U.S. Army, worldwide, continental United States, and oversea theaters, by diagnosis, 1942-45

Psychosis indicated a somewhat higher admission rate in oversea theaters than in the continental United States (table 25, chart 6).

The admissions for neuropsychiatric disorders in oversea theaters were distributed by diagnosis as follows: 15.8 percent, neurological disorders; 7.0 percent, psychosis; 60.8 percent (again the largest proportion), psychoneurosis; 8.7 percent, character and behavior disorders; 1.1 percent, disorders of intelligence; and 6.6 percent, other psychiatric disorders (table 25 and chart 6).

Although this overall evaluation of the oversea theaters shows, in general, lower frequencies of neuropsychiatric disorders than in the con-

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CHART 7.-Admission rates for neuropsychiatric disorders, for selected areas, U.S. Army, 1944

tinental United States, it does not hold true when comparison is made in terms of combat versus noncombat areas.

Combat versus noncombat areas.-The broad effects of combat on the incidence of neuropsychiatric disorders are illustrated in chart 7, in which the 1944 admission rates are shown for selected areas. These effects are conspicuously brought out in comparing the admission rates of a non-combat area as the Alaskan Department, with those of a combat theater as represented by the European theater. Not only are the European rates generally higher, but they also increased tremendously with the advent of intensive combat. (Note the high rates of July and November, reaching a peak rate of about 70 per 1,000 mean strength per year. But even these rates are not representative of the actual incidence of neuropsychiatric conditions in combat, since a significant part of the theater strength is made up of noncombat troops. The average annual neuropsychiatric admission rates for combat divisions in the European theater were approximately 250 per 1,000 strength from June to November 1944. The problem is further discussed in subsequent sections dealing with individual theaters of operations.)

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Discharges for Neuropsychiatric Disorders

During World War II, 389,000 persons were separated from the Army for neuropsychiatric disorders, of whom 375,000 were enlisted men discharged on certificates of disability for discharge. These separations represented 43.9 percent of all disability discharges (ch. IX, tables 2 and 4). In addition, 163,000 enlisted men were administratively discharged for inaptitude or unsuitability, and unfitness (ch. IX, table 11). The latter categories included separations for mental deficiency, homosexuality, enuresis, and certain other asocial and antisocial conditions for which, according to Army policy, administrative discharges were given. By combining all these (medical and nonmedical) separations, some 538,000 enlisted men were thus separated from the Army, for which the underlying cause of separation was basically psychiatric.

The principal cause of the neuropsychiatric separations for disability was psychoneurosis, constituting 69.1 percent of all neuropsychiatric discharges, or 79.8 percent of the discharges for psychiatric reasons. Next in order of magnitude was psychosis which accounted for 15.9 percent of all neuropsychiatric discharges, or 18.4 percent of the discharges for psychiatric reasons (table 26).

Table 27 shows the proportion of men discharged medically for neuropsychiatric disorders who had had oversea service. The proportion with oversea service among those discharged medically for all causes is included for comparison.

The limited data in table 27, relating to the distribution of discharges by percent with oversea service, clearly indicate that while the bulk of the discharges in 1943 and 1944 represented training casualties, the 1945 data show that most of the discharged personnel had oversea service, a large proportion of whom had undoubtedly combat service.

NEED FOR PREVENTIVE PSYCHIATRY

Defects in Preparation and Planning

As has been indicated already, psychiatric disorders proved to be a major source of manpower loss to the U.S. Army in World War II. At the beginning of the war, a potential loss of this magnitude was neither expected nor planned for by military authorities in general or the Medical Department in particular. In the Surgeon General's Office, although there was a large department of preventive medicine actively engaged in programs of disease prevention, there was no department of preventive psychiatry. It was not until February 1942 that a psychiatrist was assigned to the Surgeon General's Office, for any reason, and when assigned, his duties were concerned with hospital care and disposition of psychiatric cases rather than with the prevention of psychiatric disorders.

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TABLE 26.-Percent distribution of disability discharges for neuropsychiatric disorders, by diagnosis, U.S. Army, worldwide, 1942-45¹

Diagnosis	Total	Enlisted men
	Neuropsychiatric Disorders
Neurological disorders:
Epilepsy	3.9	3.9
Other	9.5	9.4
Total	13.4	13.3
Psychiatric disorders:
Psychosis	15.9	16.0
Psychoneurosis	69.1	69.1
Character and behavior disorders	.8	.8
Disorders of intelligence	.7	.7
Other psychiatric disorders	.1	.1
Total	86.6	86.7
Total neuropsychiatric disorders	100.0	100.0
	Psychiatric Disorders
Psychosis	18.4	18.4
Psychoneurosis	79.8	79.8
Character and behavior disorders	.9	.9
Disorders of intelligence	.8	.8
Other psychiatric disorders	.1	.1
Total psychiatric disorders	100.0	100.0

¹Derived from table 2, chapter IX.

It was known that psychiatric disorders did occur in warfare, for the World War I experience showed some 106,000 admissions for neuropsychiatric conditions in the Army.³ At the beginning of World War II, however, most military authorities and many psychiatrists, including civilian consultants to the armed services, believed that psychiatric disorders did not occur to a significant extent in 'normal' persons, but arose primarily in the minority population who were 'weaklings' or who had underlying emotional instability that predisposed them to psychiatric illness.

Admittedly, 'psychotics,' mental defectives, psychopaths, and severe psychoneurotics were untrainable, untreatable, disturbing to morale, and,

³The Medical Department of the United States Army in the World War. Statistics. Washington: Government Printing Office, 1925, vol. XV, pt. 2, table 46, p. 90. These admissions include the diagnoses listed under 'V. Nervous system, diseases of (all),' and 'VI. Mental alienation'; 'alcoholism' and 'drug addiction' are given under 'IV. General diseases (other).' (See also appendix A, table 2, footnote.)

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TABLE 27.-Distribution of personnel discharged for neuropsychiatric conditions and for all medical conditions, by percent with oversea service

Period	Discharge by percent with oversea service
Period	Neuropsychiatric conditions	All medical conditions
1943 (May through December)	12	9
1944	35	33
1945 (January through June)	69	66

eventually, expensive liabilities to the Government. It was obvious that such persons were of no use to the service. An attempt should have been made to prevent them from being accepted, and when discovered in the Army, they should have been discharged. Also, it was believed that predisposition to psychiatric illness could be detected in advance. This belief led to the expectation that the psychiatric problem in the Army could be largely solved by establishing a screening process.⁴ Accordingly, extensive arrangements were made to conduct a psychiatric screening examination on each candidate for military service. As previously stated, about 12 percent of the registrants examined in World War II were classified as IV-F for neuropsychiatric reasons, representing 38.2 percent of all disqualifications (appendix A, tables 5 and 7). In addition, procedures were established in training centers, medical installations, ports of embarkation, and elsewhere throughout the Army to detect and discharge those military personnel suffering with, or predisposed to, psychiatric disorders. In 1942, there were 22,000 psychiatric discharges for the entire year, but in September 1943, there were some 18,000 such discharges for that month alone -a rate of 216,000 discharges per year.

Lack of Experience and Methodology

However, even if the limitations of screening had been recognized and the full magnitude of the psychiatric problem foreseen, before World War II, no effective method for preventing psychiatric disorders was known which could have been used. Preventive psychiatry was then a new discipline, if indeed it could be said to have existed at all. Psychiatry had grown rapidly since World War I, and a great deal was known about the causes and nature of mental and emotional illness. However, this knowledge had been applied primarily to the treatment of the sick. Only the beginning of interest in the possibilities of using existing knowledge for prevention had occurred. It is true that a mental hygiene movement had been active for several decades, but this had concerned itself mainly

⁴Porter, W. C.: Military Psychiatrist at Work. Am. J. Psychiat. 98: 317-323, November 1941.

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with standards of care in State hospitals for the insane, although the early treatment of minor psychiatric disorders in children and public education in the principles of mental health had been included in its activities.

The American Psychiatric Association, which represented the psychiatric profession as a whole in the United States, had no section devoted to preventive psychiatry, although it had sections concerned with almost every other aspect of mental illness. Similarly, medical schools and governmental agencies lacked departments of preventive psychiatry. The vast majority of civilian psychiatrists, before World War II, were involved almost exclusively with treatment and care, rather than with prevention, of psychiatric disorders. Consequently, when the fall of France and Pearl Harbor rather belatedly turned their attention to problems of military psychiatry (the 5-day program of the Annual Meeting of the American Psychiatric Association, in May 1942, allotted only a single afternoon to problems of military psychiatry), civilian psychiatrists concerned themselves principally with the problems of induction screening and treatment facilities in the Armed Forces and gave little consideration or encouragement to the development of a preventive program.

Failure of Screening

Not until the war had been in progress for a year and a half was it revealed that psychiatric cases were occurring in large numbers in the Army, despite the screening process. This delay in recognizing the failure of screening was due, in part, to the absence of pertinent and reliable statistical data. At the beginning of the war, the Medical Department had no effective system for obtaining regular reports on the number and types of mental disorders occurring among the troops. Data were available for the number of soldiers being discharged from the Army because of neuropsychiatric disorders, but there was no report on the number being admitted to hospitals. The only available source of information on psychiatric admissions was the WD MD Form No. 52 which was completed when patients were discharged from an Army hospital. Unfortunately, the Medical Statistics Division, SGO, was from 2 to 3 years behind in tabulating and processing statistical data from this source. The principal reporting system (WD MD Form No. 86ab, 'Statistical Health Report') by which the Army kept abreast of the incidence of battle casualties, injury, and disease contained no place for reporting mental or nervous disease.

When, finally, a reporting system was established and data became available in the spring of 1943, they indicated for continental United States some 20,000 admissions for neuropsychiatric disorders per month, and this number climbed and reached a peak number of 31,000 in August of that year. The psychiatric problem looked very serious indeed. At the end of 1943, the data showed a total of 266,000 admissions in the continental United States. (See table 23 and chart 5.) Within the same year, 141,000

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persons were discharged for neuropsychiatric conditions, constituting 40 percent of all medical discharges (ch. IX, tables 2 and 4).

Overseas, the situation was no better. During the last month of the Buna-Gona campaign, the neuropsychiatric admission rate was approximately 60 to 70 per 1,000 troops per year⁵ from the entire Southwest Pacific Area, more than twice as high as the then current admission rate of troops in the United States and four times as high as the average neuropsychiatric admission rate for the American Expeditionary Forces during World War I. (The admission rate for neuropsychiatric disorders of the U.S. Army in Europe in World War I was 17.5 per 1,000 mean strength per year.)⁶ Approximately 40 percent of all casualties being returned to the Zone of Interior from the Southwest Pacific Area were neuropsychiatric cases, as were also 42 percent of those from the South Pacific Area. The size of these losses was great enough to concern not only the Medical Department but also the military authorities.

Psychoneurosis

In the Surgeon General's Office, it was not fully appreciated that such large numbers of psychiatric casualties indicated that psychiatric screening had been useless. Mental defectives, severe psychopaths, and 'psychotics' were still considered noneffective as soldiers and, therefore, not usable by the Army. The issue was, however, that such soldiers with severe overt problems were but a small portion of the total number of psychiatric cases being encountered. The vast majority were cases of psychoneurosis, which constituted almost all the psychiatric cases occurring in combat and most of those who were returned from oversea theaters. Similarly, most of the psychiatric cases admitted to hospitals from troops in continental United States were psychoneuroses.

Predisposition versus stress

Considerable evidence accumulated during the war which indicated that psychoneurosis occurred in a large proportion of soldiers whose past histories were negative for neuropathic traits or characteristics that could be taken to indicate 'predisposition' to psychiatric disorders. In another significant percent of the cases, the histories showed varying degrees of past psychological disturbance; however, it was believed by the examining psychiatrists that the stress of the situation, rather than the weakness of the personality, was of more importance in having caused the presenting disorder.

The myth that only weaklings developed psychiatric disorders was finally exploded completely by reports from the North African theater,

⁵Personally collected data.
⁶The Medical Department of the United States Army in the World War, vol. XV, pt. 2, table 47, p. 115.

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where a particularly careful study⁷ had been made of the problem. It was found that in one campaign the incidence of psychiatric cases was uniformly higher among veteran combat troops than among fresh, inexperienced troops. Months of intensive combat had weeded out all the 'weaklings.' The men who remained had proved the toughness of their underlying personality structure by their mere survival. Yet fatigue and other factors produced more 'psychoneurotics' in this group than in the fresh, untried troops. In short, it became evident that anyone could develop psychoneurosis under certain circumstances. The limitations of screening became obvious. If screening was to weed out anyone who might develop a psychiatric disorder, it would be necessary to weed out everyone.

Screening standards influence discharge standards

Psychiatric screening could weed out only abnormal men. It could not be expected to have any effect in decreasing the rate at which normal men broke down. It further ran the risk of eliminating men who, although having some defects of personality, nevertheless, if properly handled, could render valuable service in the Army. The assumption that a person developing a psychiatric disorder was a weakling led to the policy of discharging anyone who was labeled with a psychiatric diagnoses. The wastage inherent in this policy became evident when it was demonstrated in the North African theater that, if regarded as medical emergencies and properly treated, from 60 to 80 percent of the acute psychiatric casualties were recovered successfully for full combat duty.

Another unfavorable result of the liberal discharge policy soon became evident. Study of the psychiatric cases revealed that, although true malingering was rare, the escape mechanism, through utilizing symptoms of illness, was prominent and, frequently, very close to the conscious level. The policy of discharging all psychiatric patients not only made the escape mechanism more effective and encouraged its use but also constituted a reward for sickness. Knowledge that the diagnosis of a psychiatric disorder led to prompt discharge from the Army became commonplace among troops and was an important stimulus in increasing the number of psychiatric admissions. To circumvent the escape mechanism and remove secondary gain from illness, it became evident that it might be necessary to retain, rather than discharge, known psychiatric noneffective personnel.

It should be recognized that this common statement of 60 to 80 percent successful return to full combat duty cannot be supported by followup studies which indicated that, while a majority of such returnees functioned effectively, there was a significant minority of 30 to 40 percent, similar to

⁷Annual Report, Neuropsychiatry Consultants Division, Office of The Surgeon General, U.S. Army, 1944, pp. 23-24.

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medical and surgical returnees, who were found to be noneffective in battle.⁸

Summary

It thus became clear that the psychiatric problem could not be solved by assuming that psychiatric cases represented weaklings who should not have been accepted by the Army in the first place. It had to be recognized that the various screening and elimination processes, although important, could hardly be called prevention. Prevention began where screening left off. It would be necessary to find out what was causing men to break down and then to attempt to eliminate those causes. The psychiatric problem involved not just the psychopaths, the psychotics, and the marginal segment of the Army; it involved the stresses and strains which affected the mental health of all personnel in the Army.

EPIDEMIOLOGY OF MILITARY PSYCHIATRIC DISORDERS

In seeking the causes of psychiatric disorders in the Army, it was possible to fall back on a considerable fund of existing knowledge of the etiology of psychiatric disorders in civilian life, plus some data on the causes of psychiatric disorders in warfare. From the work of Adolf Meyer and Sigmund Freud had grown the concept of mental health as the product of multiple factors, internal and external, operating upon a person throughout his lifespan. The experiences of World War I,⁹ including the work of Thomas W. Salmon and Abram Kardiner and the memories of such psychiatrists as Arthur H. Ruggles, Frederick W. Parsons, and Edward A. Strecker, who had served in the Army in World War I, gave some glimpse of the application of this knowledge to the military scene.

Nature of Combat Stress

The application of certain principles of epidemiology was found to be useful. For example, when hospital admission rates were determined and studied, it was clear that, although the psychiatric problem was Army-wide, the rates were from 5 to 10 times as high among troops engaged in actual combat as in training centers, or in isolated oversea outposts, or anywhere else in the Army. This knowledge immediately lent perspective to the problem. The height of the rates in combat indicated the relative seriousness of manpower loss in combat. Obviously, priority needed to be given for further study of causes of these combat cases. It was epidemio?

⁸(1) Combat Psychiatry. Bull. U.S. Army M. Dept. (Supp.) 9: 200-204, November 1949. (2) Glass, A. J.: Effectiveness of Forward Psychiatric Treatment. Bull. U.S. Army M. Dept. 7: 1034-1041, December 1947.
⁹The Medical Department of the United States Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X.

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logical studies of hospital admission rates which showed the direct role of physical danger of enemy shellfire in causing psychiatric disorders. Similarly, the steady increase in hospital admission rates with duration of exposure to enemy shellfire represented strong evidence of the role of physical exhaustion in these cases. Such studies were then confirmed by clinical examination of the individual cases.

One of the first and most influential of such studies was that of Capt. (later Maj.) Herbert Spiegel, MC,¹⁰ a psychiatrist who had served as a battalion surgeon in an infantry division during the Tunisia Campaign in North Africa in 1942-43. He testified not only to the role of fear and fatigue in causing psychiatric disorders but asserted also that the morale of the men's immediate organization, the platoon or company, had a vital effect on their mental health; similarly, the quality of leadership, discipline, medical care, and basic motivation to fight were of utmost importance.

Report from Mediterranean theater

These findings were confirmed and amplified by a particularly able group of psychiatrists, serving combat troops during the subsequent campaigns in Sicily and Italy, under the leadership of Maj. (later Lt. Col.) Frederick R. Hanson, MC, the consultant in psychiatry to the Mediterranean theater surgeon. The key members of this group were Capt. (later Lt. Col.) Calvin S. Drayer, MC, Capt. (later Maj.) Alfred O. Ludwig, MC, Capt. (later Maj.) Louis L. Tureen, MC, Capt. (later Maj.) Stephen W. Ranson, MC, and Lt. (later Maj.) Albert J. Glass, MC. These men not only made the epidemiological and clinical studies which laid the groundwork for the development of preventive psychiatry in combat troops but also evolved the treatment program which later became the model for treatment of psychiatric disorders in combat throughout the Army, both in the subsequent campaigns in the European theater and in those in the Pacific areas. An early report made by Major Hanson based on the findings of these psychiatrists in the North African theater reads as follows:¹¹

Precipitating Factors. The precipitating factors in the development of neurosis under battle conditions appear to be the following, listed in order of importance:

a.Length of battle trauma, that is, number of consecutive days in action.

b.Physical fatigue, due to improper sleep, prolonged exertion, irregular eating, weather, and intercurrent illness, e.g., mild dysentery.

c.Unit morale.

d.Explosions in close vicinity.

e.Observation of death and maiming of buddies.

f. Improper training and lack of confidence in unit leadership.

g.The frequently stated belief that 'This is not our War.'

It is important to note that, while cases occurring early in battle generally have an unstable background, those cases occurring later on generally (approximately 70

¹⁰Spiegel, H. X.: Psychiatric Observations in the Tunisian Campaign. Am. J. Orthopsychiat. 14: 381-385, 1944.
¹¹Annual Report, Neuropsychiatry Consultants Division, 1944, pp. 11-14.

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percent) have an essentially normal background and records. Furthermore, the percentage of psychiatric disability is higher among 'veteran' troops of a unit than it is among replacements to that same unit. Among nonbattle neuropsychiatric casualties, the following precipitating causes are listed in the order of their importance:

a. Frustration in work and improper classification.
b. Domestic worries and separation from home.
c. Inability to adjust to difficult living conditions, such as poor quarters and food.
d. Air raids, especially in reclassified cases.
e. Long delays in replacement centers.
f.Prolonged and unnecessary hospitalization.

Attitudes and Beliefs in Enlisted Men and Officers. The following general beliefs and attitudes have frequently been noted in discussions with neuropsychiatric patients in Clearing Stations, Evacuation Hospitals, and in the special Neuropsychiatric Hospital:

a. That they have been expended without consideration for their rest and safety. One of the frequent complaints met with is that veteran troops were given insufficient rest after the Tunisian campaign.

b. That certain troops were doing all the fighting, particularly their own units. This belief was widespread among 1st Division men.

c.There was a deep seated conviction on the part of 1st Division men that they had been promised to be returned to the United States after the Tunisian campaign.

d. That places of recreation were not provided and existing places were put out of bounds in rest areas.

e.That PX supplies were not available in rest areas.

f. That they had frequently been fired on by their own artillery, bombed and strafed by their own planes.

g. That following the Tunisian campaign they did not receive recognition for their efforts, 'heroic deeds.' They noted this especially in the attitude of civilians of nearby communities.

h. A definite fear of replacement centers was frequently noted. The patients dreaded the uncertainty of placement, long periods of inactivity and the inability of replacement centers to handle their cases without undue delay.

i. Many patients entertained the belief that they had been improperly classified originally, and had not been given the work they were best suited to do.

j. That there was undue delay in being paid and delivery of mail.

k. Among officers the most common belief noted was that they had been improperly classified and were doing minor duties which could easily have been handled by officers of lower rank. In addition, recognition and promotions were not available as rewards for duties efficiently performed.

Morale:

a. Many men do not have a clear understanding of what they are fighting for. There is a definite lack of understanding concerning the whole situation and they do not know their role in the war.

b.They do not understand why they are sent overseas while millions of other soldiers remain in the United States.

c.Passive dependent trends have been fostered.

d.Rash promises have been made, or false rumors allowed to spread without denial, etc., that troops would be sent home after combat, especially in Tunisia.

e. There is frequently noted a lack of confidence in unit leadership.

Report from Pacific theaters

From the Pacific theaters came similar reports. For example, in the New Georgia campaign (July through September 1943), the psychiatric

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problem proved to be especially serious in the early and most difficult stages of the campaign, principally in men with temporary symptoms precipitated by fatigue and emotional stress of jungle fighting. The problem was particularly grave in the 43d Infantry Division, involving almost 10 percent of its total strength during July 1943. A study of the records of these psychiatric casualties convinced Col. Clyde M. Hallam, MC, Surgeon, XIV Corps, that incompetent or questionable leadership in small units was operating as a major precipitating factor. The number of men evacuated from each company was found to be in direct proportion to the number of unit leaders evacuated. The analysis prepared by Colonel Hallam stressed the need which each soldier had for such orientation toward his task as only good leadership could provide, and also the importance of both good discipline and physical fitness.

Another report from a psychiatrist in the South Pacific Area reads as follows:¹²

The ultimate goal of a very high percentage of personnel is to 'get home,' whether or not augmented by the thought 'to get it over, and get home.' Evacuation from an organization is one step to that goal. The overall problem of changing that goal from 'to get home,' to 'win this War' or 'to kill Japs' is a tremendous undertaking and involves changing of viewpoint in all ranks. It involves changing the trend of thinking even in the continental United States. Mail censorship indicates that mail from home does not promote the 'win the war,' 'kill some Japs for me,' 'we're proud of you' note, but tends to increase nostalgia with the 'wish you could be with us,' 'when are you coming home?' theme. Radio programs frequently carry the same note of nostalgic sentimentality. There is a preponderance of sentimental songs and love songs reaching popularity and being publicized and a dearth of good stimulating tunes such as marching songs for men to sing as they perform their duty. There is a great need for more education of the men by means of increased emphasis on orientation lectures. Greater emphasis should be placed on such types of moving pictures as 'Divide and Conquer' and 'Why We Fight.' These latter are considered the best means at hand for education and orientation of the soldier, and their use should be extended and effort made to produce more of these films for showing to officer and soldier audiences. The soldier must know why he is fighting.

Morale is directly in proportion to leadership; incidence of neuropsychiatric casualties is in inverse proportion to morale. Figures of neuropsychiatric casualties are high in units where the leader, be he of commissioned or noncommissioned grade, becomes a neuropsychiatric casualty. In units fighting side by side with this same unit, under the same conditions, be it squad, platoon, or company, in which leadership is good and the leader is not a psychiatric casualty, figures are disproportionately low. Good leadership is considered the most important factor in obtaining and maintaining morale. Continued emphasis is being placed on careful selection of leaders. Emphasis is also being placed upon building 'esprit-de-corps' with the unit as a command function. This must be continually emphasized, as unit commanders are sometimes prone to consider morale building a function of Special Service, which is concerned primarily with recreation.

However, it must also be said, that prolonged service outside the continental United States and in tropical and sub-tropical areas does have a deleterious effect upon some individuals. It is evidenced in this area by decreased vigor or drive, and increased census on sick call due to psychoneurosis and minor complaints of psychogenic origin.

¹²Annual Report, Neuropsychiatry Consultants Division, 1944, pp. 9-11.

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Also related to reduce morale, as finely distinguished from 'esprit-de-corps,' has been a lack of replacement rotation policy to allow men who have been in this area for long periods, to be returned for duty in the continental United States. Allowing these men to remain in a unit until they become psychoneurotic breakdowns, and then evacuated, is not considered advisable. In the past, illness, plus return of small numbers of cadres, has been the only means by which a man could obtain his 'goal' (return to the United States), and thus often illnesses are exaggerated, and the patient uncooperative in taking medication and treatment, in an attempt to be evacuated. It is believed that the recently approved rotation policy for this area, to be initiated in March 1944, will have a healthy and immediate effect. Establishing this method of return and giving the soldier 'something to look forward to,' will be a definitely beneficial morale factor, as well as a means of preventing psychoneurotic breakdown, and increasing unit efficiency.

Multiple Causation

From reports such as these, it became obvious that a number of factors were important in causing psychiatric disorders, both in combat and elsewhere in the Army. Personality structure was merely one of several. Danger, fatigue, leadership, morale, discipline, job assignment, motivation, training, domestic difficulties, and civilian attitudes-each of these might be as important as personality structure in any given case and in combination frequently more so. If psychiatric disorders were to be prevented, it would be necessary to control or modify any or all of these factors. If men were breaking down because they were inadequately motivated, then prevention would have to include means of giving them a clear understanding of the issues at stake in the war. If job assignment were playing a role, then it would be necessary to see if job classification and personnel placement could be improved from a psychiatric standpoint. Similarly, if leadership, morale, discipline, and training were important factors in mental health, then it would be the responsibility of psychiatrists to concern themselves with these problems also.

Reorientation and relocation.-To accomplish this mission in preventive psychiatry would require a radical change not only in the concept of the duties of a psychiatrist in the Army but also in the type of military unit to which he was assigned. In 1943, of the 1,300 psychiatrists in the Army, 957 were assigned to hospitals. Diagnosis, treatment, and disposal could be accomplished more efficiently in hospitals, but here psychiatrists came in contact only with troops who had already broken down. To prevent disorders from occurring, it would be necessary to move psychiatrists out of hospitals, even though they were urgently needed there, and to assign them to field units where they could come in contact with normal men on duty. Psychiatrists would then enter into the everyday life of the Army. If their recommendations concerning rest periods for combat troops, morale, leadership training, and job classification were not to be naive, it would be necessary for psychiatrists to acquire intimate knowledge of the

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Army in all its aspects, particularly knowledge of the everyday problems of unit commanders.

Such a change would require a reorientation on the part of psychiatrists. But if they were to be accepted as useful advisers on leadership, discipline, morale, and personnel policy, a reorientation on the part of military authorities toward psychiatrists and psychiatry would also be required.

For troops in training in the United States, preventive psychiatry was best accomplished by placing psychiatrists on the staffs of the training center commanders with an organization which later came to be known as the Consultation Service. For combat troops, the key position for the psychiatrist was on the staff of the infantry, armored, or airborne division surgeon. At higher echelons, the key positions were on the staff of army, theater, or service command headquarters, and in the Surgeon General's Office.

APPLICATION IN ZONE OF INTERIOR

Early Development

The first beginnings of preventive psychiatry in the Army were made early in the war by psychiatrists at training camps in the Zone of Interior. The extramural activities of these psychiatrists were the basis for the later development of mental hygiene clinics, which became known as Training Center Consultation Services and were established at each of the approximately 30 basic training camps in the Army. The development and history of these Consultation Services has been described in chapter XIII.

It is true that, in their early days, operating under the Army's then current philosophy, the Consultation Services functioned primarily as psychiatric screens to eliminate 'those mentally unstable individuals who are or who may become a distinct liability to military training, discipline and morale during the early weeks of training.'¹³ It was not until later in the war that the possibilities of this area of endeavor in preventive psychiatry were recognized and emphasis placed on it.

In the spring of 1942, several psychiatrists, independently and almost simultaneously, engaged in activities intended to prevent the occurrence of psychiatric disorders. The training camps where these psychiatrists were assigned were receiving large numbers of inductees, fresh from civilian life. It was here that the trainees received their first real contact with Army life, which included regimentation, Army discipline, and the physical and technical arduousness of the military training program.

The psychiatrists assigned to the camp station hospitals saw the inductees who failed in the training program, when these men were admitted

¹³Letter, The Adjutant General, to Commanding Generals, various Replacement Training Centers, 30 Oct. 1942, subject: Assignment of Neuropsychiatrists to Replacement Training Centers.

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as psychiatric patients. Certain of these psychiatrists were alert enough to recognize that a large percentage of these cases represented little more than maladjustment to army life. It appeared to them that many patients could have become satisfactory soldiers if measures had been taken early to help them in their adjustment difficulties, before symptoms assumed a fixed pattern. Showing a considerable degree of resourcefulness, these psychiatrists, each in his own way, proceeded to leave the hospital environment, periodically, and observe the behavior of troops on duty. As long as psychiatrists remained in the hospital, little could be done in the way of prevention, since soldiers were not referred until they had become so maladjusted as to be considered sick. In each case, the psychiatrist gained permission from his superior to observe the trainees on the rifle range, on speed marches, at close order drill, and in battle indoctrination courses. Having thus gained a first hand view of the stresses to which the trainees were attempting to adjust, the psychiatrists proceeded to institute preventive measures.

Mental Hygiene Consultation Services

The activities of these hospital psychiatrists later developed into what were known as Mental Hygiene Consultation Services. They were, essentially, similar to mental hygiene clinics in civilian life, directed by a psychiatrist and staffed by psychologists, psychiatric social workers, other interviewers, and clerks. From an organizational viewpoint, the important feature of these clinics was that they were disassociated from the camp hospital, both geographically and administratively, and were attached instead to the training center headquarters. In this way, they became identified with the viewpoint of troop commanders instead of the hospital atmosphere.

The psychiatrists lived in daily contact with the headquarters staff and with troops in the field. They became known personally not as 'nut doctors,' but as knowledgeable members of the training staff, often providing practical suggestions which were found to be of help in solving personnel and morale problems. In performing their duties, the psychiatrists became acquainted with the daily aspects of camp life. They knew what it was like to go on a 12-mile 'speed march,' and the psychological adjustment required to function effectively in the rifle range became a matter of personal experience. Many of the psychiatrists actually qualified as marksmen, not only with rifles but also with light and heavy machine?guns.

Screening function

As mentioned previously, in their inception and early function, these Mental Hygiene Consultation Services were primarily psychiatric screens

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to catch the mental defectives and the emotionally unstable who had not been rejected at the induction stations. For the first 18 months of their existence, the Consultation Services were considered of value chiefly for this screening function. Training center commanders welcomed any organization which would serve as a means of expeditiously eliminating the seemingly never ending supply of men who were not sick enough to be discharged medically by the hospitals, but who were apparently unable to complete the training program and, consequently, were a constant source of administrative difficulty. Indeed, the Mental Hygiene Consultation Services were kept so busy with diagnosing and administratively disposing of these marginal personnel that it was difficult to find time for even minimal treatment of patients, let alone for any considerable program of prevention. Some of the services saw as many as 1,000 persons a month, the average being from 300 to 600 a month, and even with a staff of interviewers and other assistants, it was evident that a single psychiatrist at any one clinic had his hands full even examining the clinical records of all cases.

In specifying the mission of the Consultation Services when they were initially established in the various training centers, the official directive¹⁴ stressed their screening function. Emphasis was also placed on giving early treatment of 'those normal individuals who may have correctable maladjustment to the Army Service.' However, no mention was made of preventive psychiatry per se in this letter, except for the statement that the training center psychiatrist was to 'develop a liaison with line and medical officers for the purpose of instructing and developing a better understanding of the principles of mental hygiene as applied to the military service (and) to aid in the morale program of the stations (camps) by the use of neuropsychiatrists' specialized training and knowledge.'

Preventive psychiatry initiated

An attempt to emphasize the preventive aspect of the training center psychiatrist's duties was made in the summer of 1943. Then, a letter was sent out over The Surgeon General's signature to each of the training center psychiatrists, drawing their attention to the existence of the Special Services Division (later renamed the Information and Education Division), Army Service Forces, and informing them of the liaison with this division which had been made by the Neuropsychiatric Branch of the Surgeon General's Office. In this letter, The Surgeon General also instructed the psychiatrists to effect a similar liaison with the Information and Education organizations in their own training centers.

Again, in the fall of 1943, eight of the training center psychiatrists who had been most active in pursuing preventive measures were called

¹⁴Letter, The Adjutant General, to Commanding Generals, various Replacement Training Centers, 30 Oct. 1942, subject: Assignment of Neuropsychiatrists to Replacement Training Centers.

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into Washington, D.C., by the chief of the Mental Hygiene Branch, Neuropsychiatry Consultants Division, for a conference. Ways and means of pursuing preventive psychiatry were discussed, and representatives of the Information and Education Division were brought in to describe their facilities and activities concerning morale and motivation through orientation and information programs. Although this conference stimulated interest and clarified methods to some extent, it was evident that the training center psychiatrists were so overburdened with the load of screening and disposal that not a great deal of headway in prevention could be expected.

It was not until the late fall of 1943 and the spring of 1944, with the reversal of Army policy from screening to conservation of manpower, that the training center psychiatrists were able to function effectively in preventive psychiatry. As long as the Army policy was to get rid of noneffective or marginal personnel, the training center psychiatrist could really do very little else. When, however, the Army reversed its policy and made it perfectly clear that, henceforth, manpower must not be wasted but must be conserved and utilized at any cost, then Army commanders gradually began to view psychiatrists in an entirely new light. Instead of being utilized mainly for disposition of personnel, psychiatrists were found to be of value as sources of advice for effectively utilizing marginal personnel.

Gradually, commanders began more and more to turn to their psychiatrists for advice on problems of personnel, morale, discipline, AWOL (absent without leave), and training schedules. The process was helped by War Department Circular No. 48, issued on 3 February 1944, which specified the commander's responsibility for developing the mental health of trainees and officially designated the mental hygiene lectures to be given to officers and enlisted men by psychiatrists at all training camps.

Elevation of psychiatry, late in 1943, to a division on a level with surgery and medicine in the Surgeon General's Office gave increased standing and prestige to the training center psychiatrists. It was shortly thereafter that Lt. Col. (later Brig. Gen.) William C. Menninger's leadership began to be felt in the field. A full-time supervisor for the Mental Hygiene Branch, Maj. (later Lt. Col.) Manfred S. Guttmacher, MC, was appointed to the Surgeon General's Office in the spring of 1944. His regular inspection of all the Mental Hygiene Consultation Services not only increased the general efficiency of their operations, thus freeing time of personnel for preventive work, but also established Major Guttmacher's status as a representative from Washington, enabling him to accomplish a great deal in interpreting to the local commanders the current and potential function of the psychiatric services. Further recognition came to training center psychiatrists as a result of a request in the spring of 1944 by the Office of the Secretary of War that they study the training programs in all basic training centers in the country and recommend measures for their improve-

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ment from a psychiatric viewpoint. The consolidated report¹⁵ of these studies, covering such subjects as leadership, training methods, and orientation, was widely read by training center commanders and their staffs. This report impressed them both with the psychiatrists' practical insight into personnel training problems and with the fact that higher authority was interested in psychiatrists' opinions on these subjects.

Preventive psychiatry officially established

At the end of a 3-day conference of all the Mental Hygiene Consultation Service psychiatrists held at Aberdeen Proving Ground, Aberdeen, Md., in January 1945, the general consensus¹⁶ was as follows:

Whereas the treatment and disposition of individuals suffering from psychiatric disorders must be continued, it is evident that the chief military value of a training center psychiatrist can be in the prevention of psychiatric disorders. * * * At the present time, limitation of assisting personnel barely permits the psychiatrist time to handle his heavy caseload of treatment and disposition. Assumption of duties in regard to prevention must be gradual and depend upon the possibility of adding further trained personnel to the consultation staff.

Representatives of both the Army Ground Forces and Army Service Forces were present at this conference, and shortly thereafter, the responsibility of mental hygiene clinics for preventive psychiatry was, for the first time, stated specifically in official directives issued by Army Service Forces and Army Ground Forces headquarters. Also, in WD Circular No. 81, dated 13 March 1945, the training center psychiatrist's position as a staff officer to advise command on policy and procedure concerned with mental health was clearly authorized.

Hospital Psychiatrists

As mentioned previously, psychiatrists in hospitals were not in a position to function effectively in preventive psychiatry. They were too far away from the scene of action, so to speak, and were concerned mainly with problems of treatment and disposition. This was particularly true of the general hospitals, both in the Zone of Interior and overseas. Station hospital psychiatrists, in certain instances, did come to have some contact with troops in training and, occasionally, did give the mental hygiene lectures prescribed for by WD Circular No. 48. Actually, had these psychiatrists been given adequate assistance, they could have done more in preventive psychiatry than they did.

¹⁵The full text of this report is given in chapter XIII, pages 357-359.-A. J. G.
¹⁶Annual Report, Neuropsychiatry Consultants Division, 1945, exhibit B thereto.

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PREVENTIVE PSYCHIATRY IN COMBAT THEATERS

Combat Stress and Psychiatric Breakdown

The incidence of psychiatric disorders was intimately related to the intensity of combat. In chart 8, the rates for battle injuries and psychiatric casualties among three infantry divisions have been compared in index form, for a 7-week period of combat. The rates have been expressed as index numbers, having as a base the average rate for the period in each case. This was done to facilitate comparison of the two sets of rates which, of course, are of different magnitude.

The direct relationship is evident. The rate of battle injuries which is presumed to be an index of intensity of combat is shown by this chart

CHART 8.-Relation between trend of battle injury and neuropsychiatric admissions, selected divisions, Fifth U.S. Army

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to have a remarkably direct relationship with the rate of psychiatric casualties. Roughly, one psychiatric casualty to four or five wounded in action prevailed in troops in combat. Admission rates of infantry (or armored) divisions in combat, although of a high order, were still, as already indicated, not fully representative of the effects of combat, since even in combat divisions only men engaged in frontline duties, such as riflemen, were exposed to continuous and high degree of danger. In infantry battalions, where a much higher proportion of the men were directly exposed to combat, psychiatric admission rates as high as 1,600 to 2,000 per 1,000 troops per year¹⁷ were observed in some instances for short periods.

The 'breaking point'

These rates were so high as to indicate that the breaking point of the average man was being reached. In many circumstances, particularly in the prolonged campaigns of the Mediterranean theater, most men exposed, beyond a certain point in time, to frontline combat, ultimately broke down psychologically, or would have done so had they not been killed, wounded, or otherwise disabled.

Mediterranean theater.-One of the first studies¹⁸ suggested that the breaking point of most men was in the range of 200 aggregate days of frontline combat exposure. The study was based upon the clinical and epidemiological findings of key psychiatrists in the North African (later the Mediterranean) theater, as follows:

The key to an understanding of the psychiatric problem is the simple fact that danger of being killed imposes a strain so great that it causes men to break down. This fact is frequently not appreciated and cannot be fully understood until one has either seen psychiatric cases just out of the lines or himself has actually been exposed to bombing, shell and mortar fire. One look at the shrunken, apathetic faces of psychiatric patients as they come stumbling into the medical station sobbing, trembling, referring shuddering to 'them shells' and to buddies mutilated or dead is enough to convince most observers. Anyone entering the combat zone undergoes a profound emotional change which cannot be described. Each man 'up there' knows that at any moment he may be killed, a fact kept constantly before his mind by the sight of dead and mutilated buddies around him. To one who has been 'up there' it is obvious that there is no such thing as 'getting used to combat.' Each moment of it imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot or shrapnel wounds in warfare. Prevention can be thought of only in terms of preventing needless waste of manpower. All other 'causes' of psychiatric disorders must be thought of only as factors which weaken a man's resistance to the single important cause, namely danger.

Of all branches, the infantry is most affected by danger. Battle casualty rates are so much higher in rifle battalions than in any other type of ground unit

¹⁷Personally collected data.
¹⁸Memorandum, The Surgeon General, for the Assistant Chief of Staff for G-3, (through: Commanding General, ASF), 16 Sept. 1944, subject: Prevention of Manpower Loss From Psychiatric Disorders.

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that these troops should be considered as a separate group just as are flying combat personnel in the air force. For this reason, the loss of manpower from psychiatric cases is also highest in infantry units. In the North African theater during the Tunisian, Sicilian and Italian campaigns, neuropsychiatric casualty rates of 1,200-1,500 per 1,000 strength per year have not been uncommon in rifle battalions, whereas in corresponding units of all other types, including artillery, engineers, rear area and service troops, rates above 20-30 were rarely encountered. In general, 15-25 percent of the total nonfatal combat casualties were neuropsychiatric.

Of more significance, however, is that in the North African theater practically all men in rifle battalions not otherwise disabled ultimately became psychiatric casualties. Although only 1-3 percent of the combat strength was lost from this cause during any single offensive, apparently the intensity and duration of the continued campaign were such that the limit of endurance of the average soldier was reached. Just as a 2?-ton truck becomes worn out after 14,000-15,000 miles, it appears that the doughboy became worn out; he either developed a frankly incapacitating acute neurosis or else became so hypersensitive to shellfire, overly cautious and jittery, that he was ineffective and demoralizing to the newer men.

The point at which this occurred has not been clearly established, but it appears to have been in the region of 200-240 aggregate combat days. The number of men still on duty after this is small and their value to the unit negligible. The first indication of this appeared in the clearing station of the old divisions (the 3d, 34th, 36th, and 45th Infantry Divisions) and the 601st Clearing Company, which handled all psychiatric cases evacuated in the Fifth Army. From the Sicilian Campaign onward, it was noted that an increasing number of the psychiatric patients being sent back from the lines were not weaklings who had merely broken down after a short exposure to combat, but experienced veterans, strong men with excellent combat records, often including decorations. Most of them were noncommissioned officers: squad, section, and platoon leaders. By the spring of 1944, following the Volturno, Rapido, and Cassino actions, more of these old men than new men were coming in as psychiatric patients. Finally, the statements begin to be heard: 'I'm the last old man left in my platoon.' 'There's only two of us old men left, and they're no better off than I am. You'll be seeing them soon.' The frequency of these statements made it difficult to doubt their credibility.

In the light of these findings it was decided to investigate the matter further. Accordingly, a survey was made of Battalion and Regimental Surgeons, of Division Psychiatrists and experienced combat unit commanders. Particular emphasis was placed on obtaining the opinion of company grade commanders, since they had the most direct contact with troops. It was found that both the medical and line officers were in unanimous agreement that, by the time a man had served 200-240 aggregate days of combat in a rifle battalion, he was noneffective. He was worn out. If he hadn't frankly 'cracked-up,' he was so jittery under shellfire and overly cautious that in addition to being noneffective he was a demoralizing influence on the newer men. Actually, many of the line officers were emphatic in stating that the limit of the average soldier was considerably less than 200-240 aggregate combat days. Most men were noneffective after 180 or even 140 days. The general consensus was that a man reached his peak of effectiveness in the first 90 days of combat-after this his efficiency began to fall off and from this time he became steadily less valuable until he finally was useless. They agreed that actions such as the Rapido and Cassino accelerated this process, that men who had survived these actions were never the same again. They stated, however, that even relatively light successful actions such as were experienced by certain units in the Rome push cannot be considered light in their effect on the infantryman.

Individuals developing psychiatric disorders after less than 200 combat days can and have been successfully returned to full combat duty by the excellent frontline

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treatment developed in the North African theater. The 'worn out' soldier on the other hand is through. At least 6 months would be required to make him effective again for combat though he still may be very useful in noncombat assignment.

The 'life' of the average infantryman before he wears out and becomes non-effective appears to depend to a great extent on how continuously he is used. The British, for instance, estimate their riflemen as good for 400 aggregate combat days, a period almost twice as long as ours. This difference they attribute to the policy of never keeping infantrymen on the line more than 12 days at a stretch, alternating 4 days rest with each 12 days combat. The American doughboy, on the other hand, was usually kept in 20-30 days, frequently 30-40 and occasionally as high as 80 days without relief. This has been necessitated by tactical requirements although the fact that a man wears out under combat has perhaps been incompletely recognized by the command.

European theater.-Another study based on experience in the European theater gave similar results:¹⁹

It was found that after 4 months of continuous combat, riflemen and particularly key noncommissioned officers, through the process of normal wear and tear began to exhibit less initiative, lower efficiency, and decreased ability to lead troops into battle. This was even more marked at the end of 6 months of combat. Several divisions found that only 3 percent of the riflemen who had been in combat for 180 days still remained in the division. Those who did remain were key men and, in general, repeatedly decorated. These divisions estimated that half of this group had become useless for combat in the same manner that equipment may be worn out to the extent that it is of no further service.

Statistical analysis.-Beebe and Appel,²⁰ after the war, made a study based upon the individual records of 2,500 frontline infantrymen selected on a sample basis from all the principal infantry divisions committed in the Mediterranean and European theaters. They found that, for each aggregate 10 days of frontline combat, from 3 to 10 percent of the men who still remained on duty broke down and were admitted to the hospital. At these rates, the breaking point of the average soldier was estimated to have been in the range of 80 to 90 aggregate days of combat. None of the 50 infantry companies studied in the Mediterranean theater had less than 90 aggregate days of combat, which corresponds to the point at which about half of the men would be expected to have broken down. Half of the companies studied had more than 131 aggregate days of combat, and at this point on the stress scale, an estimated 70 percent of men would have broken down. An estimate developed for all infantry rifle companies which had been committed in the Mediterranean theater suggested that half had 85 or more aggregate days of combat; by day 85 on the company combat scale, almost half of the men would have broken down, according to the calculations made. The answer seems plain then, that in the campaigns of the Mediterranean theater there were many company size combat units from which half or more of the personnel would have become psy?

¹⁹After Action Report, Third U.S. Army, 1 August 1944-9 May 1945.
²⁰Beebe, G. W., and Appel, J. W.: Variation in Psychological Tolerance to Ground Combat in World War II. Final Report, Contract DA-49-007-MD-172, for Medical Research and Development Board, Office of The Surgeon General, 10 Apr. 1958.

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chiatric casualties had not so many emerged as battle casualties or as nonbattle casualties due to injury or disease.

Nonbattle Stress and Psychiatric Breakdown

Southwest Pacific Area

It was not only combat per se which caused high neuropsychiatric rates in World War II. This is readily appreciated from table 28 and chart 9 which compare admission rates in 1944 by theaters of operations. The Southwest Pacific Area especially illustrates the complexity of the problem. Although combat in this area was by far less intense during this time than in the Mediterrean theater (as evidenced by the admission rates for battle injuries), the admission rates for neuropsychiatric disorders were relatively higher in the Southwest Pacific Area than in the Mediterranean theater. While it is believed that the prolonged combat and deficiency of motivation were the primary factors in the higher neuropsychiatric incidence in oversea theaters, there were other factors which were also related. Causal factors which stand out in the Southwest Pacific

CHART 9.-Admissions for battle injuries and neuropsychiatric conditions, World War I and World War II (1944), by theaters of operations

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TABLE 28.-Admissions for battle injuries and neuropsychiatric conditions, World War I and World War II (1944), by theaters of operations

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

Period and theater of operations	Battle injuries	Neuropsychiatric conditions
World War I	¹214	²26
World War II (1944):³
European theater	160	52
Southwest Pacific Area	34	48
Mediterranean theater	131	43
Pacific Ocean Area	31	27
Middle East and Persian Gulf Command	1	25
China-Burma-India theater	18	20
Total	102	43

¹The Medical Department of the United States Army in the World War. Statistics. Washington: Government Printing Office, 1925, vol. XV, pt. 2, table 105, p. 1017.

²The Medical Department of the United States Army in the World War, vol. XV, table 47, p. 114.

³'Morbidity and Mortality in the United States Army, 1940-1945,' Medical Statistics Division, Office of The Surgeon General, 1948.

Area were the tropical climate, lack of normal social and cultural environment, monotony of the jungles, and lack of adequate rotation policy. In addition, the large numbers of troops in base areas who were not fully occupied felt a sense of purposelessness in their sacrifices.

Far East Air Forces

The deleterious effect of such environmental conditions on the efficiency of personnel is further illustrated by the data in table 29, relating to Far East Air Forces; namely, the 38th Bombardment Group. These data clearly indicate the enormous increase in medical care and in the increasing loss of man-days with increasing length of service. (Compare, especially, the indexes of morbidity between 'under 18 months' and 'over 18 months' length of service.)

A comment²¹ on the data just cited was as follows:

Figures similar to these would hold true for practically every Air Force unit with a similar length of service in the forward area. Unit surgeons have utilized every possible means to convey this information to higher headquarters: Sanitary reports, special reports, and subject letters, and this material has been transmitted from this Headquarters in reports of Essential Technical Medical Data and by a special report of the operations analysis section.

It is believed that these important figures dealing with a situation closely related to the problems of morale, neuropsychiatric disease and operational efficiency should be considered of sufficient importance for transmission to The Adjutant General.

²¹Essential Technical Medical Data, Far East Air Forces, for January 1945, dated 1 Mar. 1945.

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TABLE 29.-Indexes of morbidity, by length of foreign service¹

Index of morbidity	Sick days per 100 men, by length of service
Index of morbidity	6 to 9 months	15 to 18 months	Under 18 months	Over 18 months
On sick call	30.5	46.1	33.6	78.2
Sick in quarters	17.3	5.8	15.0	11.2
Sick in hospital	51.2	94.2	59.9	91.5
Total	99.0	146.2	108.5	180.9

¹Derived from data in: 'Essential Technical Medical Data, Far East Air Forces, for May 1944, dated 15 July 1944.' 'Under 18 months' included 516 men: 410 men with 6 to 9 months, 2 men with 10 to 14 months, and 104 men with 15 to 18 months of service. 'Over 18 months' included 518 men.

Division Psychiatrists

It was not until the late fall of 1943, after reports had been received from the Tunisia and Buna Gona Campaigns, showing the seriousness of psychiatric casualties as cause of manpower loss in combat, that authorization²² was finally obtained to assign one psychiatrist to each combat division. This represented the most important organization for preventive psychiatry since it was in combat divisions that the highest rate of psychiatric casualties occurred.

Instruction in preventive psychiatry

It is true that the primary purpose in assigning psychiatrists to divisions was to insure prompt treatment of casualties and to 'maintain a constant screening process for the purpose of detecting and promptly eliminating individuals emotionally unfit for military service.' However, the official statement of the duties of the division psychiatrist, as contained in WD Circular No. 290, specified:

Not only is he to screen out the mentally unfit, but to make available his professional knowledge for the everyday problems of discipline and morale. * * * advise in all matters pertaining to the mental health of the command * * * assist in the program of preventive psychiatry, especially in its relationship to discipline and morale, through educational programs and informal discussions with line officers and others who may seek his advice. * * * help in the proper assignment of military personnel, and keep * * * constantly oriented to the changing psychiatric problems during the training, pre-combat and combat periods, with a view toward the development of the mental toughness essential to combat troops.

In a 3-day conference held in Washington, D.C., in November 1943, to instruct 60 newly appointed division psychiatrists in their duties, considerable emphasis was placed on preventive psychiatry, although here,

²²War Department Circular No. 290, 9 Nov. 1943.

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also, the primary function was seen to be in treatment and screening. The conference program included an hour's presentation, on prevention, by the chief of the Mental Hygiene Branch, Neuropsychiatry Consultants Division. One of the more experienced training center mental hygiene psychiatrists presented a talk on 'Psychiatrists' Relationship With Line Officers.' Maj. Gen. Howard McC. Snyder, from the Inspector General's Office, emphasized the need for division psychiatrists to attempt to conserve manpower as well as to screen out misfits. An entire afternoon of the conference was devoted to a presentation of the work of the Morale Services Division, ASF, on ideological and informational programs as it pertained to mental health. Maj. (later Lt. Col.) Frederick R. Hanson, MC, fresh from the battlefields of North Africa and Sicily took a prominent part in the proceedings and was able to impress the group of the urgent need for, and the practical applicability of, preventive psychiatry in combat.

Evolution of preventive psychiatry

Although the duties of division psychiatrists concerning prevention were thus fairly clearly specified officially, a great many of these officers found, on reporting for duty at their division headquarters, that their mission in this regard was not clearly understood nor sympathetically received either by the division surgeons who were their immediate superiors or by the division commanders and their staffs. Psychiatrists, here, as in the training camps in the early days of the war, were viewed with suspicion and resentment. They were considered 'nut pickers' who properly belonged in lunatic asylums with their patients and had no proper place in a fighting outfit composed of 'redblooded' American soldiers. Many psychiatrists had a long uphill struggle in this regard and, not infrequently, were forced to work as general medical officers, leaving psychiatry functions for shorter or longer periods.

As the divisions entered combat, however, and psychiatric cases began to pour into the aid stations by the hundreds, sometimes even by the thousands, the picture changed rapidly. Psychiatrists came to have a real place on the fighting team. They were looked upon not merely as a means of providing skilled treatment to mentally sick men, but also as a source of urgently needed advice on how to prevent this manpower loss. They became known personally to the responsible regimental and battalion commanders, frequently worked closely with the division personnel section (G-1), with the Judge Advocate General's Office, with the Information and Education Office, and in many divisions conferred regularly with the chief of staff, and, sometimes, with the commanding general of the division.

The division psychiatrist's work in this regard was hindered by the fact that although he was on the division surgeon's staff, and thus in a staff position, by tradition and practice, particularly during combat, he

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functioned at the division clearing station in the treatment of patients. It was not customary in the Army for medical officers to both treat patients and function at an advisory policy level which was required in preventive activities. War Department Circular No. 81, however, which was issued in March 1945, stated specifically that, in divisions as well as in training centers, psychiatrists were to be 'regarded as having a staff function in advising the command on policies and procedures which affect mental health and morale.'

Formal establishment of preventive psychiatry

In the final statement of the division psychiatrist's duties, written to incorporate the lessons learned during the course of the war and issued on 28 June 1946 as Changes No. 1 to WD Medical Field Manual 8-10, his status as a staff officer was made quite clear and his responsibilities for preventive psychiatry set forth specifically:

The division neuropsychiatrist is assigned to the staff of the Division Surgeon. He has a dual function. As a staff officer he assists the surgeon in advising command on matters of policy and procedure which affect the mental health and morale of troops. As a professional consultant he supervises and assists in the treatment and disposition of neuropsychiatric disorders occurring within the division.

1. Prevention. The division neuropsychiatrist keeps constantly informed on all matters which affect the mental health of the troops and takes such action as is indicated to correct conditions that have an adverse effect in this regard.

(a) Since the majority of the factors which determine mental health of troops fall within province of command, the main job of preventive neuropsychiatry must be done by commanding officers of the line. The division neuropsychiatrist acts as a source of professional neuropsychiatric knowledge on this problem. He will maintain close liaison with responsible officers of the regimental and division commands, cooperate closely with personnel officers concerning matters of assignment, consult with the judge advocate in regard to medicolegal problems, cooperate closely with and assist other agencies important to the mental health of troops: the information and education officer, the Red Cross, the special services officer, and the chaplain.

(b) To keep informed on matters affecting mental health he will continually study the current attitudes and morale of divisional personnel, and the psychological stresses to which divisional personnel are exposed, both in and out of combat. He should follow closely such matters as training schedules, furlough policies, disciplinary procedures, need and opportunity for rest and recreation.

(c) He will conduct a continuous educational program by formal lecture and informal discussion designed to instruct enlisted personnel in the principles of mental hygiene and officers in the maintenance of mental health of troops.

* * * * * * *

He will maintain adequate current records pertaining to the mental health of the command. During combat he will keep informed as to the incidence of neuropsychiatric disorders in all units of the division in order that he may be able to advise the surgeon and command as to preventive measures that may be indicated. He will prepare such reports as are required by higher authority.

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Hospital Psychiatrists

Of all hospital psychiatrists in oversea theaters, those who did the most preventive psychiatry were in the 'Exhaustion Centers' which functioned in the Army zone just behind the combat divisions. These psychiatrists frequently were able to maintain close contact with the division psychiatrists, whose cases they received, and to keep tight the evacuation screen which was so important in preventing epidemics of combat psychiatric disorders. When too many cases were being received from one division, they were able to bring this to the attention of both the Army consultant in psychiatry and the division concerned, so that steps could be taken to remedy the situation. In certain exhaustion centers, other preventive measures were taken. For example, in February 1944, the group of psychiatrists²³ in the 601st Clearing Company, Separate, 1st Platoon, serving as the exhaustion center of the Fifth U.S. Army, in Italy, submitted a report to the Surgeon, Fifth U.S. Army, recommending as preventive measures that infantry replacements be sent forward in groups who had been trained together rather than as individuals. They also pointed out that faulty leadership, excessive periods of duty in battle, and lack of training of infantry replacements were important causes of psychiatric casualties. It is evident that exhaustion center psychiatrists under the field Army headquarters could have done a great deal more along this line if their role in preventive psychiatry had been officially recognized and encouraged and if they had learned more of the skills necessary for staff work.

Theater and Army Consultants

By the end of the war, psychiatrists were on duty as consultants in each major oversea theater and in all but one of the armies. These were key positions, from an organizational standpoint, for the prevention of psychiatric disorders. For the most part, however, these men were so occupied with the supervision and administration of hospitalization and disposition of psychiatric casualties that they had little time for practicing preventive psychiatry. It is also generally true that the possibilities and responsibilities for preventive activities were not so clearly recognized either by these psychiatrists or by their headquarters, as were their functions in other respects.

Theater consultants

Preventive measures were attempted to some extent by several of the theater consultants. As early as the late fall of 1943, Major Hanson, the psychiatric consultant in the Mediterranean theater, submitted a

²³Capt. (later Lt. Col.) Calvin S. Drayer, Capt. (later Maj.) Stephen W. Ranson, Capt. (later Maj.) Alfred O. Ludwig, and Capt. (later Maj.) Walter L. Ford.

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memorandum which called attention of the high command to the direct relationship between the rate of psychiatric casualties and the length of time infantrymen were kept in the line without rest. Later, Major Hanson attempted, although unsuccessfully, to have a preventive psychiatry section with adequate personnel set up as such in the theater surgeon's office.

Col. Lloyd J. Thompson, MC, Consultant in Psychiatry in the European theater, also submitted several memoranda recommending preventive measures involving replacement policies, training, rehabilitation, rest periods, and the like, to his theater command headquarters.

Similarly, Lt. Col. (later Col.) M. Ralph Kaufman, MC, Consultant in Psychiatry in the South Pacific Area, made attempts to study the morale and attitudinal factors producing psychiatric casualties in base areas among combat troops and to recommend the measures necessary for their modification.

Army consultants

Compared to the oversea theater consultants, the field army consultants in psychiatry were in a particularly advantageous position to pursue preventive psychiatry. They were free of the time-consuming difficulties inherent in supervising the large rear area general and station hospital neuropsychiatric services. They were recognized as staff officers of the Army headquarters with a voice in the Army's policy; still, they were close to the scene of action. Frequently, they were able to visit the various ongoing field and combat activities and to observe the factors which were producing psychiatric casualties. The degree to which the psychiatrists in these positions actually functioned to prevent psychiatric disorders varied considerably in the different field armies; much depended upon the individual psychiatrist's own interest and vision, in this respect, as well as upon the encouragement he received from his immediate superiors. It is probably true that, when these officers were first assigned as Army consultants in psychiatry, few of them recognized their potential role in the prevention of psychiatric disorders, and no formal instructions in this respect were issued either by Army or theater headquarters or by the War Department.

An example of the type of preventive activities engaged in by Army psychiatric consultants was furnished by Lt. Col. (later Col.) William Srodes, MC, Consultant in Neuropsychiatry, First U.S. Army. Colonel Srodes, in 1944, was instrumental in having army and corps rest camps established for combat troops and, also, in having a policy adopted for the routine sending of men to these camps. He made certain that the rest policy pertained to battalion commanders and company grade officers as well as to enlisted men. When, in July 1944, one of the combat divisions (90th Division) was in a state of low morale, Colonel Srodes induced the 'Stars and Stripes' to give the division 'a big play and buildup.' He

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maintained close liaison with the Army Quartermaster General to insure that frontline troops in the First U.S. Army obtained shoepacks, overcoats, ponchos, and other supplies essential for their morale as well as for their well-being. The division psychiatrists in the First U.S. Army, as a result of Colonel Srodes' leadership, were particularly active in preventive psychiatry.

In the Fifth U.S. Army, as a result of the neuropsychiatry consultant's efforts, Lt. Gen. Lucian K. Truscott, Jr., the commanding general, personally attended a conference with the division and evacuation hospital psychiatrists to discuss leadership, AWOL, discipline, and problems allied to psychiatric casualties. From the mutual understanding that developed as a result of this conference, it is evident that much more could have been done in this line of endeavor by Army psychiatric consultants had the possibilities for such efforts in preventive psychiatry been earlier recognized and encouraged.

ARMY AUTHORITIES AND PSYCHIATRY

The attitude of Army authorities toward psychiatry changed during the course of the war. The premise that the mental health of the men in the Army depended upon morale, leadership, and personnel policies was new to them, and that psychiatric knowledge could be useful in these matters was not readily apparent. The thinking of Army authorities on the subject in the early part of the war was vividly, if somewhat informally, described by a member of the General Staff subsequently assigned to investigate the psychiatric problem in the Army.²⁴

If the War Department General Staff was alarmed over the large number of men who were being discharged from the Army for psychiatric disorders, their confusion concerning this problem is perhaps shown even more clearly by the fact that in the spring and summer of 1943 they issued a series of directives which resulted in discharging even more men.²⁵

These three directives pertained only to psychiatric cases, but about the same time, WD Circular No. 161 was issued (14 July 1943). This directive eliminated the category 'limited service' in the Army and ordered the discharge of all men suffering from any type of disorder which prevented them from doing full combat duty.

However, psychiatrists in the Surgeon General's Office were not consulted by the authorities at this time. The directives were issued by the War Department General Staff, mainly the Assistant Chief of Staff for Personnel, G-1, over the psychiatrists' ineffective protests. In any event, as a result of these directives, more and more men began pouring out of the Army. It soon became evident that the situation was getting out of

²⁴Cooke, Elliot D.: All But Thee and Me. Psychiatry at the Foxhole Level. Washington: Infantry Journal Press, 1946, p. 7.
²⁵(1) War Department Memorandum No. W600-30-43, 25 Mar. 1943. (2) War Department Memorandum No. W600-39-43, 26 Apr. 1943. (3) War Department Memorandum No. W600-62-43, 29 July 1943.

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hand and that drastic action was needed to prevent the Army from being decimated. Urgent telegrams were dispatched calling an abrupt halt to all discharges, and for a period, no man was discharged from the Army for any reason, pending the preparation and publication of new discharge criteria. War Department Circular No. 293, issued on 11 November 1943, completely reversed the discharge policy. Then, for the first time, psychiatrists were permitted to participate in formulating a policy of discharge for psychiatric reasons. This appeared as Circular Letter No. 194, Office of The Surgeon General, and was issued on 3 December 1943. The directive stated: '* * * a man will not be separated from the service merely because he has or has had a psychoneurosis or similar psychiatric disorder,' Each case was to be evaluated individually and disposition made on the basis of clinical judgment as to the 'individual's potential value to the service.'

Although the War Department General Staff now accepted the fact that further screening was not the answer to the psychiatric problem, it still did not provide a solution. Instead, considerable correspondence was generated not only in Washington but also in the oversea theaters relative to this problem, and the Inspector General was ordered to investigate.²⁶

SUMMARY

In the beginning of World War II, military authorities, both lay and medical, believed that psychiatric disorders occurred only in predisposed individuals-weaklings. This led to the endorsement of and the reliance upon the policy of psychiatric screening. As the war progressed, these authorities discovered that most mental disorders occurred in 'normal' men and that screening was ineffective in preventing the occurrence of such conditions. Then, thinking ultimately changed. Instead of screening and elimination, the policy changed to conservation and utilization of manpower and to the acceptance of psychiatric knowledge for the purpose of prevention. The culmination of this policy change came with the publication of WD Circular No. 81, issued on 13 March 1945, which was one of the chief accomplishments of preventive psychiatry in World War II. This directive not only restricted the use of the generic term 'psychoneurosis' as a diagnosis but also contained a very important section which is quoted as follows:

Utilization and prevention.-The majority of the factors which determine the mental health of military personnel are functions of command. In other words, the

²⁶(1) Memorandum, Assistant Deputy Chief of Staff, for the Assistant Chief of Staff, G-1, 28 Sept. 1944, subject: Psychoneurotics. (2) Memorandum, Assistant Chief of Staff for Personnel (G-1), for Chief of Staff (North African Mediterranean theater) subject: Psychoneurotics. (3) Memorandum, Assistant Chief of Staff, G-1, for Commanding General, ASF, 12 Oct. 1944, subject: Psychoneurotics. (4) Report, The Inspector General, to Assistant Chief of Staff, G-1, 17 Dec. 1944, subject: Psychoneurotics. (5) Memorandum, Assistant Chief of Staff, G-1, for Deputy Chief of Staff, 4 Feb. 1945, subject: Psychoneurotics.

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main job of preventive psychiatry must be done by commanding officers of the line. It is a responsibility of command to obtain maximum utilization of manpower by providing proper incentive and motivation, and such reclassification, reassignment, rest, relaxation, and recreation as exigencies of the military service permit. The psychiatrist acts as adviser to the command. In training centers or in Army divisions as a member of the division surgeon's staff, he is to be regarded as having staff function in advising the command on policies and procedures which affect mental health and morale. In certain divisions and in some commands there appear to be excellent morale and splendid accomplishment which are in part due to an ideal relationship between the psychiatrist, the surgeon, and the responsible officers of the commander. It is the responsibility of the psychiatrist to be alert to the situational factors which are precipitating psychiatric disorders and to recommend the measures necessary to alleviate or remove these factors. He should survey the training program from a psychiatric viewpoint, advise concerning schedules, the method of conditioning troops to battle situations, and adjustment to extremes in climate. He should pay close attention to such matters as the furlough policy and the handling of AWOL cases. Through collaboration with the personnel classification officer he should be able to prevent many psychiatric disorders by bringing a medical viewpoint to bear in the job assignment problems. He should be alert to evidence that troops are approaching the limit of their endurance and in need of rest. Equally, he should be alert to untoward effect of boredom from excessive idleness. He should advise other agencies which are important to the morale and mental health of the troops: the Information and Education officer, the Chaplain, the Red Cross, and the Special Services Officer.

Additional measures were also studied and developed in the preventive psychiatry program. These included WD Circular No. 48 (3 Feb. 1944), TB MED's 12 (22 Feb. 1944) and 21 (15 Mar. 1944), the combat treatment plan, the tour of combat duty, the Infantryman's Badge, the point system of discharge from the Army, the 'Why We Fight' films, and 'Army Talks' system, and certain other measures. Through these various measures, an acute awareness was finally developed in the benefits to be derived from a planned preventive psychiatry program, and the important role that it could play.

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