CHAPTER V
The Consultant System
William C. Menninger, M.D., Malcolm J. Farrell, M.D., and Henry W. Brosin, M.D.
THE NEED FOR CONSULTANTS
There was mutual agreement among Regular, Reserve, and Army of the United States medical officers in World War II that the development of the consultant system in the Medical Department was one of the most important progressive steps made during the war. Certainly, it was largely responsible for the high professional standards of practice and treatment that existed in every specialty of medicine throughout the Army, both in the Zone of Interior as well as in the theaters of operations. Credit for the vision and initiation of the plan for consultants for service commands belongs to the Director, Medical Consultants Division, Brig. Gen. Hugh J. Morgan, and to the Director, Surgical Consultants Division, Brig. Gen. Fred W. Rankin, both in the Surgeon General's Office.
From the beginning of the plan, neuropsychiatry was recognized as being responsible for a sufficiently large problem to justify a consultant in this specialty, paralleling the consultant in internal medicine and the consultant in surgery. Consequently, throughout the Army Service Forces, in which all medical installations were under the jurisdiction of The Surgeon General, the professional triad of consultants always included the neuropsychiatrist. Later, in several service commands, the orthopedic surgeon was included, and in certain theaters, additional consultants in other fields were appointed. The Army Ground Forces and the Army Air Forces, whose medical activities were not directly under The Surgeon General, in some degree also adopted the consultant system, including the internist, the surgeon, and the neuropsychiatrist in the combat armies, and qualified men in certain specialties attached to the Air Surgeon's Office.
The consultant system, in part, was necessitated because of the size, the geographic distribution, and the organization of the Army. Obviously, it was impossible for a single office, even when at its greatest strength, to supervise and coordinate the professional standards of medicine throughout the Army in its many ramifications. Following the pattern of World War I, the oversea theaters, in most instances, effected plans for and the appointment of consultants before the professional consultant system was organized in the Zone of Interior; the latter plan was entirely new in World War II.
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DEVELOPMENT IN ZONE OF INTERIOR
The plan, as envisioned, called for experienced specialists in each of the three major fields to be specially appointed and commissioned for the purpose of supervising and standardizing the professional work done in all medical installations. It was recognized from the outset that such men in the Regular Army, who might be qualified for such positions, would be assigned to full-time administrative positions. It was intended that professional consultants would have a minimum of administrative responsibility. The duties of each would be primarily professional, as a consultant in his specialty, traveling from one hospital to another, in nearly a continuous fashion. Plans were initiated, early in 1942, to appoint this group of well-qualified and recognized physicians for the purpose of assuming professional supervision over the practice of the three major specialties in service commands.
A letter1 requesting approval and appointment of such consultants to service commands was submitted by The Surgeon General, on 28 May 1942. In this letter, The Surgeon General mentioned that, at the time, there were 209 station hospitals and 71,459 hospital beds in the 9 corps areas (later designated as service commands) of the United States and that the bed capacity would shortly increase to 158,352. He recommended that 27 such specialists (psychiatrist, internist, and surgeon for each corps area) be appointed and commissioned in the grade of lieutenant colonel. He also asked for an increase in personnel allotments to permit such additions.2
In reply, as a first indorsement, dated 1 June 1942, the Director of Military Personnel for the Commanding General, SOS (Services of Supply, later ASF (Army Service Forces)), stated there was no objection to the assignment of these medical officers to corps areas (service commands) but denied an increase in allotment because the number of medical officers on duty was well below the number authorized by the original allotment.
Apparently anticipating some resistance on the part of the corps area commanders to the assignment of three medical officers to their staffs, another letter3 by The Surgeon General requested that an official directive be issued, incorporating the duties and responsibilities of these consultants. No action was taken on the recommendations in this letter, but reference was made to existing directives, especially WD (War Department) Circular No. 59, issued on 2 March 1942, which had established a basis of responsibility and authority for such technical medical activities. The
1Letter, The Surgeon General, to The Commanding General, Services of Supply, 28 May 1942, subject: Coordination of Medical Service (Professional) in Corps Area Installations.
2It should be noted that many service commands utilized military or civilian psychiatrists as informal consultants who visited various posts and stations, as requested, and reported to the service command surgeons.-A. J. G.
3Letter, The Surgeon General, to The Commanding General, Services of Supply, 23 June 1942, subject: Coordination and Supervision of Medical Service in Station Hospitals, with 1st indorsement thereto, Headquarters, Services of Supply, to The Surgeon General, 14 July 1942.
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Surgeon General was also told to 'report further any difficulties beyond his authority to adjust.'
Thus, having obtained approval for the use of consultants, The Surgeon General, on 28 July 1942, sent identical letters to the commanding generals of all service commands, and also to the Commanding General of the AAF (Army Air Forces), informing them of the action taken and referring specifically to the pertinent correspondence emanating from the offices concerned. The main body of this letter, which follows, is quoted because it actually established the policy governing the activities of service command consultants.
* * * * *2. In order to coordinate and supervise the medical service of Army hospitals in accordance with the above authorization, qualified consultants in medicine, surgery, and neuropsychiatry will be assigned in the early future to the staffs of the Fourth, Seventh, Eighth, and Ninth Service Commands. Professional consultants will be assigned to the remaining service commands when, because of the expansion of hospital facilities, their need is apparent or when, in the opinion of the commander of the service command concerned, the needs of the service command warrant the assignment of consultants in one or more specialties.
3. To promote uniformity in supervisory functions, the various fields of medicine and surgery will be assigned to consultants as follows:
Medicine. All medical specialties (except neuropsychiatry), venereal disease, dermatology, dietetics, and clinical pathology.
Surgery. All surgical specialties (including urology), ophthalmology, otorhinolaryngology, radiology, and physical therapy.
Neuropsychiatry. Neurology, psychiatry, and war neuroses.
4. Although consultants will interest themselves especially in the fields designated, it will be deemed appropriate for the consultant in any field to cover all the professional services of a hospital in his inspection when so directed by the commander of the service command.
5.These officers will serve in an inspectoral and consultative capacity, and their activities will cover all fixed Medical Department installations for the care of the sick and injured within the geographical limits of their respective service commands, except Walter Reed General Hospital and the General Dispensary, U.S. Army, Washington, D. C., which for this purpose will be directly under The Surgeon General. Their duties will include the coordination of professional practice by local discussions with hospital staffs of professional subjects in general and such special problems as may present themselves; appraisal of therapeutic and diagnostic procedures and agents, and miscellaneous other duties which may come within their respective specialized professional fields.
6. Each consultant will render a written report concerning his activities at each facility visited. Original reports will be forwarded to the commander of the service command except in the case of Air Corps stations, concerning which original reports will be forwarded directly to the Commanding General, Army Air Forces (Attention: The Air Surgeon, a duplicate in such cases being forwarded to the commander of the service command. In each case a duplicate report will be furnished the commanding officer of the station concerned and another forwarded directly to The Surgeon General.
On 22 October 1942, Brig. Gen. (later Maj. Gen.) David N. W. Grant, the Air Surgeon, notified The Surgeon General: 'It is the desire of this office that the medical consultants in all Service Command Areas be made
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available to Air Force Station.' The Air Surgeon further stated that a copy of The Surgeon General's letter, just quoted, had been sent to all Army Air Forces Commands and Air Forces.
THE ASSIGNMENT OF PSYCHIATRIC CONSULTANTS
Zone of Interior
The assignment of the service command psychiatric consultants was left very largely to the Chief Consultant in Neuropsychiatry, in the Surgeon General's Office, on the advice of and approval by the Chief of Professional Service, Brig. Gen. Charles C. Hillman, and the approval of The Surgeon General, Maj. Gen. James C. Magee, and later, Maj. Gen. Norman T. Kirk. Despite the influence of the Surgeon General's Office, the appointment and the assignment of these specialists encountered certain difficulties. The job necessarily called for a man of demonstrated professional ability and with a reputation in his field which would command respect. There were relatively few such individuals available, and many who would have, theoretically, been eligible, were occupying positions in civilian life in which they were classified by the Procurement and Assignment Service, of the War Manpower Commission, as 'essential.' It should be stated that many of those in this essential category disregarded it and came into the Army. When the consultant system began in 1942, despite the fact that the Army was growing rapidly, there were some of the smaller commands which hardly justified the full time of so high a caliber of professional man. Because the whole consultant system was new, there was some resistance, and in one instance, there was open hostility to the appointment of a neuropsychiatric consultant.
Despite these difficulties, the first neuropsychiatric consultant in the service commands, Lt. Col. (later Col.) Franklin G. Ebaugh, MC, was appointed on 27 August 1942, to the Eighth Service Command, and Lt. Col. (later Brig. Gen.) William C. Menninger, MC, was appointed on 25 November 1942, to the Fourth Service Command; five more neuropsychiatric consultants were appointed to the various service commands in 1943. The neuropsychiatric consultant to the Fifth Service Command, the last vacancy to be filled, was appointed on 22 August 1944. Neuropsychiatric service command consultants were as follows:
First Service Command:
Maj. (later Lt. Col.) Wilfred Bloomberg, MC, 29 June 1943-21 August 1945.
Col. Lloyd J. Thompson, MC, 4 September-21 December 1945.
Lt. Col. Wilfred Bloomberg, MC, 17 December 1945-12 July 1946.
Second Service Command:
Lt. Col. (later Col.) Douglas A. Thom, MC, 25 March 1943-31 January 1946.
Third Service Command:
Lt. Col. (later Col.) Henry W. Brosin, MC, 15 April 1944-21 December 1945.
Fourth Service Command:
Lt. Col. William C. Menninger, MC, 25 November 1942-10 December 1943.
Lt. Col. Paul L. Schroeder, MC (fig. 15), 13 March 1944-31 October 1945.
Fifth Service Command:
Maj. William H. Dunn, MC, 22 August 1944-15 February 1946.
Sixth Service Command:
Col. William J. Bleckwenn, MC, 5 August 1944-12 December 1945.
Seventh Service Command:
Maj. Garland C. Pace, MC, 1 January-25 September 1943.
Lt. Col. Clarke H. Barnacle, MC, 10 December 1943-10 August 1945.
Lt. Col. John H. Greist, MC, 12 June 1945-15 February 1946.
Eighth Service Command:
Lt. Col. (later Col.) Franklin G. Ebaugh, MC, 27 August 1942-28 May 1945.
Lt. Col. Perry C. Talkington, MC, 20 July-20 September 1945.
Ninth Service Command:
Lt. Col. (later Col.) Lauren H. Smith, MC (fig. 16), 16 October 1943-15 December 1945.
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FIGURE 15.-Lt. Col. Paul L. Schroeder, MC, Neuropsychiatric Consultant, Fourth Service Command.
Oversea Theaters
During World War II, consultants in oversea theaters were valuable, even necessary, and consequently, even before the consultant system was placed into effect in the Zone of Interior, plans were underway and appointments made for neuropsychiatric consultants in the European theater and
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FIGURE 16.-Col. Lauren H. Smith, MC, Neuropsychiatric Consultant, Ninth Service Command.
the Southwest Pacific Area. Lt. Col. (later Col.) S. Alan Challman, MC (fig. 17), was appointed and sent to the Southwest Pacific on 25 May 1942, and on 12 August 1942, Lt. Col. (later Col.) Lloyd J. Thompson, MC, was dispatched to the European theater. After the Mediterranean theater became active, Capt. (later Lt. Col.) Frederick R. Hanson, MC, was appointed for that area. In the Pacific Ocean Areas, Lt. Col. (later Col.) M. Ralph Kaufman, MC, was assigned as consultant in the South Pacific Base Command. A neuropsychiatric consultant, Maj. (later Lt. Col.) John R. S. Mays, MC, was sent to the Burma-India theater in January 1945, and in this same year, an acting neuropsychiatric consultant, Maj. John M. Flumerfelt, MC, functioned in the Middle East theater with his headquarters in Cairo, Egypt. With the exception of the Pacific Ocean Base Command and the Alaska Base Command, all oversea theaters with large troop strength were provided with a neuropsychiatric consultant, as follows:
Southwest Pacific Area:
Lt. Col. (later Col.) S. Alan Challman, MC, 25 May 1942-11 June 1945.
Col. Franklin G. Ebaugh, MC, 12 June-1 December 1945.
Lt. Col. Clarke H. Barnacle, MC, 10 October 1945-23 January 1946.
Maj. Ivan C. Berlien, MC, 26 September 1945-19 January 1946.
Lt. Col. William H. Everts, MC, 7 August-21 November 1945.
European theater:
Lt. Col. (later Col.) Lloyd J. Thompson, MC, 12 August 1942-12 August 1945.
Lt. Col. Joseph S. Skobba, MC, 14 August-22 December 1945.
Mediterranean theater:
Capt. (later Lt. Col.) Frederick R. Hanson, MC, 22 February 1943-July 1945.
South Pacific Area:
Lt. Col. (later Col.) M. Ralph Kaufman, MC, 26 October 1943-20 August 1944.
Lt. Col. (later Col.) Edward G. Billings, MC, 2 November 1943-7 June 1945.
Pacific Ocean Areas:
Lt. Col. (later Col.) M. Ralph Kaufman, MC, 30 August 1944-1 June 1945.
China-Burma-India theater:
Maj. (later Lt. Col.) John R. S. Mays, MC, 26 January-31 October 1945.
Middle East theater:
Maj. John M. Flumerfelt, MC, 29 December 1944-11 July 1945.
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FIGURE 17.-Col. S. Alan Challman, MC, Neuropsychiatric Consultant, Southwest Pacific Area.
In contrast to the service command consultant, however, the theater consultant functioned entirely under the jurisdiction of the theater surgeon, who was largely independent from the Surgeon General's Office. Consequently, the work of the theater consultant varied widely, depending on the opportunities he was given. In some instances, he was entirely free and unhampered; in others, he was greatly handicapped by regulations
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within the theater. Because theater medical organizations were so independent of War Department control, the theater consultant had far more 'staff work' (preparation, documentation, and implementation of policy) to accomplish than did the consultant in the service command. In the latter, the consultant was largely concerned with professional work and with visits to medical installations.
Combat armies.-The combat armies also were included in the total program for professional consultants-the First U.S. Army appointed its neuropsychiatric consultant on 31 December 1943 and the Third U.S. Army followed soon thereafter, on 23 January 1944. During the course of 1944, all but the Sixth U.S. Army availed themselves of the services of a neuropsychiatric consultant.4 The surgeon of the Sixth U.S. Army steadfastly refused to accept the services of such a consultant until June 1945.
FIGURE 18.-Lt. Col. Joseph S. Skobba, Neuropsychiatric Consultant, Fourth and Fifteenth U.S. Armies.
4The actual appointment of a neuropsychiatric consultant to the Fifth U.S. Army was delayed because the tables of organization vacancy had originally been allocated to another section of the Fifth U.S. Army headquarters. Capt. (later Lt. Col.) Calvin S. Drayer began his services as consultant to the Fifth U.S. Army informally as early as December 1943. On 21 July 1944, he was placed on temporary duty in this office, and it was not until February 1945 that it was possible for him to actually be assigned to this position.
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Neuropsychiatric consultants in the armies and their periods of assignment were as follows:
First U.S. Army:
Lt. Col. (later Col.) William G. Srodes, MC, 27 December 1943-14 December 1945.
Third U.S. Army:
Lt. Col. Perry C. Talkington, MC, 23 January 1944-1 July 1945.
Fourth U.S. Army:
Lt. Col. Joseph S. Skobba, MC (fig. 18), 20 August-28 September 1944.
Maj. (later Lt. Col.) Manfred S. Guttmacher, MC, 6 August-2 November 1945.
Fifth U.S. Army:
Maj. (later Lt. Col.) Calvin S. Drayer, MC (fig. 19), 21 July 1944-27 August 1945.
Sixth U.S. Army:
Lt. Col. (later Col.) M. Ralph Kaufman, MC, 1 June-28 September 1945.
Seventh U.S. Army:
Maj. Alfred O. Ludwig, MC, 21 July 1944-10 July 1945.
Eighth U.S. Army:
Maj. (later Lt. Col.) Josiah T. Showalter, MC, 17 June 1944-1 October 1945.
Ninth U.S. Army:
Lt. Col. (later Col.) Roscoe W. Cavell, MC, 20 May 1944-19 September 1945.
Tenth U.S. Army:
Lt. Col. Oscar B. Markey, MC, 10 August 1944-15 October 1945.
Fifteenth U.S. Army:
Lt. Col. Joseph S. Skobba, MC, 28 September 1944-12 August 1945.
FIGURE 19.-Lt. Col. Calvin S. Drayer, MC, Neuropsychiatric Consultant, Fifth U.S. Army.
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One of the examples of the uphill struggle of neuropsychiatry in the Army is exemplified in the regulations and the table of organization laid down for the professional consultants in the field armies. In this table of organization, the neuropsychiatric consultant was listed as the 'assistant medical consultant' with the rank of lieutenant colonel, although the consultants in medicine and surgery were rated as colonel. The Neuropsychiatry Consultants Division, SGO (Surgeon General's Office), over a period of many months attempted to have these officers assigned and titled as 'Consultant in Neuropsychiatry' with the same rank as the other two specialties. Not until nearly the end of the war was concurrence obtained for this change.
GENERAL FUNCTIONS OF THE CONSULTANT
A remarkable feature about the consultant system was the fact that, despite its importance and its prominence in the function of the Medical Department, it was not until almost a year after V-E Day that a circular was issued directing the functions and the responsibilities of the professional consultant. It was not until WD Circular No. 12 was issued, on 12 January 1946, that The Surgeon General was specifically authorized to appoint such consultants, although the details of their responsibilities were never printed in any official Army literature. Despite absence of formalization, the consultant system worked so effectively on the basis of the experience in the practice of clinical medicine, surgery, and neuropsychiatry that specific instructions were not essential. A training program was developed for neuropsychiatric consultants whereby each new consultant coming into the service served with one of the functioning consultants for a month prior to assignment in a service command. Undoubtedly, the neuropsychiatric consultant was regarded initially with more skepticism and was accepted less enthusiastically than was the case with the internist or surgeon; on the other hand, without a single exception in every service command, he succeeded in completely dispelling this skepticism and winning full acceptance.
The functions of the neuropsychiatric and other consultants were officially listed in WD Circular No. 101, issued on 4 April 1946:
* * * * * * *2. As representatives of The Surgeon General, the professional consultants are concerned essentially with the maintenance of the highest standards of medical practice. It is their function to evaluate, promote, and improve further the quality of medical care * * * by every possible means, and to advise in the formulation of the professional policies of The Surgeon General and to aid in their implementation. The proper performance of these functions necessarily involves an appraisal of all factors concerned with * * * the professional care of patients, including particularly the organization and program of professional services in medical installations, the quality,
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numbers, distribution, and assignment of specially qualified professional personnel, the diagnostic facilities including roentgenologic and laboratory procedures, the availability and suitability of equipment and supplies for professional needs, and the nursing care, dietary provisions, recreational and reconditioning facilities, and other ancillary services which are essential to the welfare and morale of patients. The professional consultants exercise their functions by assisting and advising The Surgeon General, the surgeons of major forces and commands, * * * on all matters pertaining to professional practice * * * by providing advice on professional subjects in general and on newer developments in * * * diagnosis, treatment, and technical procedures, by stimulating interest in professional problems and aiding in their investigation, and by encouraging * * * educational programs such as conferences, ward rounds, and journal clubs * * *. The execution of these functions involves periodic visits to medical installations and other types of units concerned with the medical care of military personnel. The functions of professional consultants vary somewhat according to their assignments.
As one of the functions just listed, the service command consultants and, in a lesser degree the theater consultants, acted as a liaison between the Surgeon General's Office and the field. It was primarily through their reports of medical installations that the Surgeon General's Office could keep informed as to problems in the field, and permission was gained early to have free exchange of personal communications between consultants and the Surgeon General's Office. Various members of the Neuropsychiatry Consultants Division, SGO, frequently accompanied the consultant on his visits to medical facilities in his command. This practice also applied to the theaters of operations.
At the beginning of the war before the true magnitude of the war effort became apparent, some surgeons and post commanders regarded psychiatric consultants as intrusive upon their command responsibility because they had been trained to do all jobs themselves.5 This commendable goal was difficult to accomplish with the influx of inexperienced and young officers so that most of them welcomed the manifest help given them, just as some division commanders could accept division psychiatrists without loss of prestige. Initially, the stereotype that psychiatrists were suspect themselves because they were apt to be deviant or queer was a handicap. Also troublesome was the belief that psychiatrists dealt only with psychotics, until the value of psychiatry in other areas was demonstrated. It is gratifying that, with very few exceptions, most psychiatrists won acceptance on their own merits with their nonmedical officers. Another prejudice which needed correction was the bias against educational activities. A medical officer on coming into the Army, according to this view, was fully equipped to discharge whatever duties he was assigned within his rank and military occupational specialty, and efforts to hold case conferences and journal clubs were viewed as a waste of time and a means of evading duty. The support of the Surgeon General's Office and service command authority for better education in professional matters was of tremendous help in improving patient care and officer morale.
5The remainder of this chapter refers mainly to the work of the service command consultant; however, oversea consultants performed in a similar manner.-A. J. G.
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Staff Activities
The consultant in each service command was expected to be a staff officer and assistant to the service command surgeon. As a staff officer in a line organization, he found communications poor regarding some professional matters and very little opportunity for active control, except as the surgeon and the commanding general of the service command agreed to implement an action at the posts and hospitals in the service command. Because the policies and tactical problems were quite different in the nine service commands and the personality of each commanding general and his staff and of each surgeon and his staff varied widely, there is little possibility of accurately summarizing the job specifications and the workload of each of the service command consultants. However, some approximation was possible, and the duties of the psychiatrists in these staff positions have been described in detail by Glass and his associates.6
Professional Activities
By means of the staff advisory activities in headquarters and by direct evaluation, discussion, and stimulation at local stations, psychiatric consultants were in a good position to help medical officers in all installations solve problems of diagnosis, recordkeeping, preparation for boards, technical treatment procedures, and disposition. Uniform interpretation of the policies and directives of the Surgeon General's Office and service command headquarters to medical officers was an important means of making possible more effective work. As a senior with wide experience in civilian and military installations, the consultant could often offer useful suggestions. At the very least, he could offer to the local medical officers and his superiors reassurance that they were doing the best that could be done under the circumstances. In some troublesome cases, he could resolve differences of opinion and seek new solutions from the local command or the service command. Occasionally, he could obtain valuable help in interpretation and operation from the Office of The Surgeon General. At all times, the service command psychiatrist could expect a sympathetic ear from the Neuropsychiatric Section of the Professional Service Division, SGO, which was highly important to all concerned regarding decisions which had to be made when overall Army policy was in doubt.
Field Visits
The psychiatric consultant was especially welcomed in the field when new directives on treatment methods, on the use of psychologists, social workers, and other workers, and on disposition criteria and methods were
6Glass, A. J., Artiss, K. L., Gibbs, J. J., and Sweeney, V. C.: The Current Status of Army Psychiatry. Am. J. Psychiat. 117: 673-683, February 1961.
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issued and studied. Since he had direct access for information to the surgeon and the Professional Service Division, he could help field personnel in their interpretations and planning. He could also assist the service command surgeon in interpreting new directives on professional practice and technical procedures.
Most consultants spent from 50 to 70 percent of their time in visiting installations. The temptation to remain in service command headquarters to work at the ever-present paperwork, that of answering letters from many sources including medical officers in the service command, of writing up reports of the last trip, and of keeping in touch with new developments at the source of power, was great at times. However, most consultants realized that their work in field installations was probably their major contribution, no matter how much influence could be exercised at headquarters.
It was the personal satisfactions received from dealing with the overburdened workers in the field which made the visits of consultants seem worthwhile. After the initial period of acquaintance with consultants' visits during which time post personnel, as well as medical officers, learned that the consultant came to help professionally, and not as an inspector or as an officer to exercise power, the overwhelming majority of Army personnel accepted him for what he was, a physician-consultant, and welcomed him with open arms. There was always much work to do, patients to discuss, and local personnel as well as policy questions to review. Some post surgeons and hospital commanders made much more use of consultants than others, so that the consultant had to budget his time carefully to get to the patients' care level at all. In other installations, the consultant was required merely to make a formal appearance to the post surgeon or the hospital commander and then could spend all of his time with the medical team. Because of his association with them, the consultant, although he had no command function, could assist the surgeon in implementing War Department policies.
Reports
Consultants were required in most cases, particularly during visits in the early war years or where visits were made infrequently, to write reports of their visits to installations. The original report was sent to the surgeon of the service command, one copy was sent to the commanding officer of the station concerned, and another was forwarded directly to The Surgeon General.
These reports were valuable in several ways. They constituted, in many cases, the only record of the number of persons, of their qualifications, and of their assignments on post to both the surgeon of the service command and The Surgeon General. When consultants visited posts, they had the time and the opportunity to evaluate the abilities of medical personnel and were able to advise the local commanding officer and the sur?
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geon about promotions, reassignments, rotation, or similar questions when this advice was requested. Malassignment was quickly detected and usually corrected, if the consultant pointed out inequities. Efficiency in organization and imaginative use of the limited personnel available were encouraged when officers were indecisive. Many consultants did extremely well in recruiting personnel and in improvising facilities for patient care, rehabilitation, occupational therapy, and recreation.
Correction of Local Problems
Occasionally, particularly in the early part of the war, the consultant could assist the medical officer in obtaining better facilities for housing patients, occupational therapy, reconditioning, rehabilitation, and recreation. Some of the consultants who came in early in the war (1943) wrote that a large part of their work at that time was taken up with obtaining reasonably good physical quarters and equipment, whereas later in the war, their work was related to more specific professional problems. At all times, he could aid in helping the neuropsychiatric service or section get more personnel and facilities for the ancillary services. In some service commands, this part of the consultants' survey work was extremely important because the surgeon made judgments based upon this information. It should be noted, however, that the written reports were usually written in neutral language regarding the excellences and deficiencies of a program. The more intimate evaluations were given verbally and with discretion. In this way, highly motivated and well-trained officers with superior abilities could be recognized and rewarded. Differences of opinion on professional matters could either be reconciled or be adjusted so that the climate improved.
The Consultant as a Teacher
There is an old Army adage that every officer is in some way a teacher, and it is true for most officers who deal with troops that they spend much time, energy, and thought about training. This was certainly true for the psychiatric consultant who had to keep alert at all times to the ever-changing regulations, to anticipate changes, to keep abreast of military and civilian progress in diagnosis and treatment methods so that he could discuss them intelligently, and to keep in touch with clinical work sufficiently to be able to help with difficult diagnostic problems, particularly in the neurological or medical fields.
The consultant was expected to be lively and entertaining, as well as informative, because this stimulated interest in both military and professional work. One of the more rewarding aspects of the local visits were the purely educational programs, clinical case seminars, or case conferences, ward rounds, and journal clubs. Often, especially when the visits of the
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consultant were infrequent, he was asked to give lectures on some scientific subject in which he was known to have an interest. The consultant was often able to convince a chief of a neuropsychiatric service, who had only one or two assistants, that an educational program which included nurses, social workers, psychologists, occupational and recreational workers, nurse therapists or other specialists, and psychiatric aids was indeed worthwhile. It was demonstrated repeatedly that, if the medical personnel could retain a strong sense of their professional identity, they were very much happier with themselves and with their work. Many of those unfortunate physicians who, at the outset of their Army experience, believed that they could not practice without a huge laboratory with much special equipment or who practiced medicine by means of rigid schedules learned to their surprise that they were delighted with practicing more of the art of medicine with less dependence upon laboratory procedures. Some gained insight about their use of mechanical, radiological, and chemical methods of 'treatment' as a defense against dealing with the personal problems of the patient. In some of the service commands, the consultants in medicine and surgery were extremely helpful in this regard and were highly skillful and successful in persuading medical officers to practice a better grade of comprehensive medicine.7
Informal programs for on-the-job training of nurses, social workers, psychologists, psychiatric aids, and other specialists were not uncommon in many of the larger post hospitals early in the war because the pressures on medical officers were great and they responded with ingenuity. Later, these informal programs were given much better status and recognition by commanding officers of installations. When reconditioning techniques were being developed, the training of appropriate personnel was officially approved. That the consultant was often able to obtain judgments, data, attitudes, and decisions from the service command surgeon and the Neuropsychiatry Branch of the Professional Service Division enabled him to be a teacher of military policy and directives in these new projects.
The consultant was also a teacher in the sense that he initiated when required, or encouraged when desirable, the use of social workers, psychologists, occupational and recreational therapists, and other useful members of the psychiatric team. Because many of the psychiatrists were young and inexperienced, or came from State hospitals where they were not familiar with the use of ancillary personnel, they had to be helped in the initial stages of building up a team. Most of them learned rapidly and became at ease with this method of functioning instead of the more classic State hospital or private practice techniques.
The introduction of the officers from the Medical Administrative Corps into psychiatric units to perform nonmedical duties was occasionally a difficult problem until the persons concerned learned how they could help
7Bauer, W., and Brosin, H. W.: The Importance of Preventive Psychiatry in Psychosomatic Medicine. [Unpublished manuscript.]
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each other to mutual advantage. Procurement and advantageous use of these and other paramedical personnel was often a task at which the consultant could assist the service command surgeon and commanding officers of installations.
Morale Function
One of the intangible but most valuable functions of the service command consultant was to improve the morale of his colleagues in the field. During the often trying days when personnel was inadequate in quality and quantity and the management of patients was something less than satisfactory because of poor leadership, poor directives, and lack of facilities, the visit of a senior professional colleague from service command headquarters was a welcome change. The consultant brought status and prestige to the clinician who often felt neglected or forgotten. The clinician could express his frustrations and dissatisfactions to the consultant with greater freedom than he could to his own commanding officer. Pressing professional questions could be reviewed with mutual interest and profit. A renewed sense of a professional identity was gained in addition to the military model to which most men were overwhelmingly and scrupulously loyal even though discouraged about their own activities. The consultant could be used as a counselor on delicate personnel problems before more public action was requested.
After service command surgeons and commanding officers of installations learned that they could trust the consultants' discretion, judgment, and common sense about the realities of Army life, they often used them as advisers or informal messengers regarding evaluation and assignment of personnel or for the correction of difficulties. The never-ending series of questions on administrative problems was a constant source of conversation. For many medical officers, the consultant was a significant figure because he was able to convey messages to service command headquarters and to the Professional Service Division, SGO, thus giving them some sense of belonging to a large organization in contrast to being isolated in a tiny ward or clinic in a remote camp. Since many of the men in local installations had exceptional ideas and ability, they did help initiate and encourage new or revised practices which received publicity via the consultants. Such recognition did much to lift the painful anonymity of the isolated post. The consultant brought news, both professional and personal, as well as administrative, regarding friends in other parts of the world which also relieved the monotony and the sense of being out of touch. During the earlier days of the war when directives were few and often ambiguous, the consultant could bring in copies of the War Department or Army Service Forces directives as reissued by the service command. They could also distribute reprints on military subjects such as those provided by the Josiah Macy, Jr.
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Foundation,8 or other pertinent references from the American or British literature.
Summary
In summary, all consultants uniformly reported from their firsthand experience that, although the background and training of the psychiatrists in the Zone of Interior varied widely and though a few were not fitted for military life, with few exceptions, they were exceptionally 'conscientious, loyal, hardworking, and cooperative men who had a genuine concern for the patient's welfare and a high degree of therapeutic intent. They were exposed to much frustration, but they maintained their professional attitudes and sense of responsibility in an admirable fashion.'9
The activities of the medical and psychiatric units of the service commands are described in separate chapters of this volume so no attempt will be made to summarize them here.
PERSONNEL PROBLEMS IN THE SERVICE COMMAND
Inadequate Quantity and Quality of Personnel
It is not feasible nor necessary to further devote additional space to the influence wielded by the commanding generals of service commands or the service command surgeons upon the psychiatric care of patients, by means of directives, instructions, or more subtle pressures, during the trying days of mobilization and the pressures which came with the shocking loss of manpower during 1942-43. An earlier chapter (pp. 41-51) amply outlines the broad picture of the manpower problem together with the policies and operations which affected the mental health of troops and care of psychiatric patients. The pertinent regulations are reproduced in appendix B.
The leadership in the War Department was under the guidance of able and well-intentioned men who had the difficult burden of carrying an unprecedented load of large tasks for which ground rules had to be developed as they went along. They had to satisfy the strenuous demands of their vigorous superiors, often with unclear, inadequate, and even unrealistic directives within a short time, often too short, considering local handicaps. These tasks had to be performed with men in the field who were untrained for their missions for the most part, and many were simply incompetent. This unpleasant fact which is unlikely to receive much space in an official history was another cause of impaired morale since these incompetents,
8Literature was made available by the Josiah Macy, Jr. Foundation, N.Y., distributed through the National Committee for Mental Hygiene.
9Dunn, William H.: History of Neuropsychiatric Activities of the Fifth Service Command, 1 January 1941 to 15 August 1945. [Official record.]
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under stress of wartime demands, reflected their unhappiness in all directions and used up the energy of their capable neighbors to help themselves avoid prison, psychosis, or some less drastic, but no less destructive, chronic adaptation. As stated by Millett-
The service commands tended to be the dumping ground for all the field grade officers whom the Army Ground Forces found unsatisfactory. This produced a difficult personnel situation and helped to explain why some of the technical services and perhaps even the Army Air Forces distrusted the service commands. General Somervell and the commanders of the service commands could only make the best of a troublesome situation.10
Millett's statement regarding field officers appeared also to be true for other ranks down to private in all branches and lent a special flavor to the work done by the service commands and the Medical Department. The Doolittle Board pointed out the shortsightedness and the wastefulness of the methods of assignment and probation of officers. It also recognized the tragedy of keeping noneffective officers in the service, especially in field grades or higher, because disposition methods were extremely cumbersome. Reclassification in a genuine sense was almost impossible, and grossly incompetent officers were merely sent from job to job or post to post, sometimes with greater responsibilities while the health of all concerned suffered.11
Relationship to Psychiatry
It must be remembered that neither line officers nor medical officers, with few exceptions, understood or had any experience with modern psychiatry with its emphasis upon psychotherapy and activation of patients by numerous methods, including chemical, electrical, or mechanical devices. The Regular line and medical officers also had no indoctrination in field psychiatry which had proved useful in the prevention of neuropsychiatric disorders and treatment of soldiers under stress in training overseas. The civilian psychiatrists who came into the Army in 1941-42 for the greatest part had no experience with either the Army or in dealing with large groups as such. Many of those who did come in were relatively young and were unable to gain the attention of their superiors even if they had good ideas. Many of the older and more experienced men were highly biased in favor of a private practice schedule where they expected to see relatively few patients for private interviews each day. They were sometimes not easily transposed to a busy dispensary, mental hygiene clinic, or a crowded ward, although most of them were remarkably good natured while they gained a new identity as Army medical officers. Those medical officers who
10Millett, John D.: The Organization and Role of the Army Service Forces. United States Army in World War II. The Army Service Forces. Washington: U.S. Government Printing Office, 1956, p. 371.
11Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, p. 527.
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had served in large institutions were not accustomed to the concept of being responsible for the health of a large group of men, and they had to learn the new medium of preventive psychiatry for large populations. Incidentally, contrary to the popular jokes about the mysterious jargon of psychoanalysis, their presumed obsession with sex and the couch, most psychoanalysts in the Army did outstanding work and earned the high regard of their colleagues and superior officers. If one remembers that there were fewer than 500 analysts in the United States in 1940 and that most of them were more than 45 years old and often in responsible positions, their record for military performance is little short of remarkable.
An unforeseen result of the influence of psychoanalytic teaching with its emphasis upon psychotherapy was that there was an unprecedented demand for psychoanalytic training by the young medical officers upon their discharge from the Army. This overload continued well into the 1950's. While it is not easy to know all the reasons for this phenomenon, one can name two factors; namely, the leadership of Brig. Gen. William C. Menninger, MC, Chief Neuropsychiatric Consultant in the Surgeon General's Office, and the daily experience of psychiatrists who saw the value of psychodynamics in understanding the characteristic defenses and physical symptoms of people under pressure, whether they be called psychoneuroses, inadequate or undesirable personalities, or some psychosomatic disorder which probably was emotionally triggered. The latter two groups, particularly the psychosomatic population, are not usually cited in the statistics of morale failure due to lack of proper motivation and similar circumstances, but all officers were aware that this was only another facade of the problem of the effective use of manpower.
Because most of the 2,400 psychiatrists in the Army were relatively young, untrained, and inexperienced in Army psychiatry, it is small wonder that there were occasional dissatisfactions expressed by other medical and line officers. The amazing fact is that, although most critics expressed some skepticism about psychiatrists as a group, they were very friendly with the particular psychiatrist with whom they worked. This is a curious phenomenon deserving study. There were a few incompetent psychiatrists, while others did a passable job only in a protected hospital setting. Remarkably few were incapacitated by personal problems of their own as far as can be shown by a review of the record either in the Zone of Interior or overseas, although the canard occasionally persists that this was a problem.
PROBLEMS OF NEWLY INDUCTED PHYSICIANS
The use of technical experts including physicians on a part- or full?time basis was not new in the Army, but the scope of their activity was greatly increased by the fact that this was a much larger Army, with
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10,420,000 individuals serving in the Army alone.12 The rate of growth of this Army between November 1939 from its slow beginning to its peakload in May 1945 with over 8 million persons on active duty was another factor which made some type of technical assistance highly desirable during the turbulent mobilization period. Some service command surgeons were happy to have this help because they had far too many responsibilities to evaluate and supervise technical work or to become familiar with many of the hundreds of new medical officers under their command. Even consultants could only visit installations once in 3 or 4 months in the large service commands.
There was insufficient time for conventional specialty training in 30-day courses in 'Field Medicine' such as had been given to groups of physicians at Carlisle Barracks, Pa., for a time after 1 January 1941. The Surgeon General's Office realized early that even this was neither feasible nor necessary for those officers who would not be serving troops. The Medical Field Service School, at Carlisle Barracks, was first established on 1 September 1920 and was a substitute 'West Point' for Regular Army medical officers. Now called the Army Medical Service School, after its transfer to Fort Sam Houston, Tex., in 1945, it 'is dedicated to the task of preserving the lives and health of American soldiers'-in the words of its motto, 'To Conserve Fighting Strength.'13
Again, it would be of interest to know if the lessons of World War II regarding earlier wars and troop command are being taught here and in other service schools in a manner which will be effective in the next war. At West Point, there is now a Department of Psychology and Leadership which supplements the other training in this area. The author (Brosin) can speak from experience that during his indoctrination at Carlisle Barracks, in April 1941, he learned nothing about field psychiatry; furthermore, the only psychiatrist, Lt. Col. A. Murray DeArmond, MC, on the staff, was an experienced, competent man who had been assigned to the teaching of map reading and was kept at this job most of the year.
Formal Psychiatric Training
In order to indoctrinate newly inducted Army physicians with little or no psychiatric experience who were to be assigned to neuropsychiatric services, they were sent to a newly created (1942) School of Military Neuropsychiatry at Lawson General Hospital, Atlanta, Ga., under the direction of Col. William C. Porter, MC. From December 1943 until December 1945, 3-month courses were given at the Mason General Hospital, Long Island, N.Y.14 Exactly 1,000 medical officers attended as students and were
12The Army Almanac. 2d edition. Harrisburg: The Stackpole Co., 1959, p. 614. (In the Navy, there were 3,883,520; Marines-599,693; Coast Guard-241,093; for the period 7 Dec. 1941-31 Aug. 1945.)
13Ibid., p. 190.
14Menninger, op. cit., pp. 27-28.
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classified and assigned as neuropsychiatrists. Hundreds of others with some neuropsychiatric experience were sent to active general hospital pools where they had some training for brief periods before being permanently assigned.
Informal Psychiatric Training
Education and training in military neuropsychiatry through necessity had to be a continuing process in both administrative and clinical fields. Less than half of the neuropsychiatrists in the Army had attended one of the formal courses given at the three schools, and more than half of these had no training other than the 90-day course (p. 55). Therefore, the neuropsychiatric consultants were in the ideal position not only to foster and encourage inservice teaching but to participate themselves.15
Many medical officers with some neuropsychiatric experience were sent to active general hospital pools where they had some training before being permanently assigned.
Officers of all ranks were often kept in such pools from 1 to 4 months to learn both the clinical and the administrative problems of the station they were in and the techniques developed by the Army for handling them. In general, most physicians came to appreciate the need for specified Army procedure and the relative economy of the operations compared to equally complex civilian institutions, in spite of complaints which might give the opposite impression. In fact, with the simplifications in procedures which came in the year after Pearl Harbor, there were very few procedures which could be called unnecessary or wasteful. In some general hospitals, informal courses were held to review Army procedures for admission, transfer, preparation of various board procedures, and correspondence with Army and civilian agencies. Because of the specialized nature of these transactions, workbooks with concrete samples and copies of pertinent regulations were developed and highly prized, particularly by physicians with the rank of major or above who had the responsibility for such procedures. In some cases, officers from other sections of the hospital attended classes and requested copies of such workbooks to assist them in their duties.
Other officers went directly to their assignments in station hospitals, regional hospitals, general hospitals, or induction stations without benefit of any military or professional orientation. Once assigned, however, their training began usually through the chief of the neuropsychiatric service or section under the auspices of the neuropsychiatric consultant. Some chiefs of service or sections distinguished themselves as teachers and greatly eased the path of the new officer who had no preparation for working in a busy wartime Army.
The neuropsychiatric consultant performed his teaching and training
15Medical Department, United States Army. Internal Medicine in World War II. Activities of Medical Consultants. Volume I. Washington: U.S. Government Printing Office, 1961, pp. 102-109, 366-372.
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duties in various individual ways but generally followed an established and accepted pattern. In his periodic visits to the various installations in his service command or theater, he either held ward rounds or discussed specially selected problem cases which were presented to him by members of the neuropsychiatric staff. These cases were evaluated as to diagnosis; also, the administrative aspects of each case were discussed.
The neuropsychiatric consultant frequently arrived with new or changed directives concerning neuropsychiatry and was always ready to explain their purpose and use. Among the various professional, administrative, and social reasons why consultants were welcomed was their possession of and knowledge about new directives from the War Department or the service command level. Because of a frequent change of policy at these levels, the necessary vagueness of the wording of the regulations, and their contradictory nature during 1942-44 since manpower policies were not stabilized, consultants were eagerly sought to help interpret and suggest practical implementation of directives. Some consultants also brought with them material for clinical pathological conferences with involved problems of a neurological and psychiatric nature.
On some field trips, the neuropsychiatric consultant was accompanied by a prominent civilian consultant who was an outstanding teacher. The civilian consultant actively participated in the local program prepared for him, and he usually had a message of importance or a particular topic of interest to present. At times, original professional papers were also presented by members of the hospital neuropsychiatric staff. At other times, a 'journal club' meeting was arranged to discuss new and provocative psychiatric literature that had been recently published. As a rule, the entire hospital staff was invited to attend these and other meetings with the neuropsychiatric consultant.
The neuropsychiatric consultant conferred with both the chief of the neuropsychiatric service or section and the commanding officer of the unit. By such conferences and from his own observations and impressions, he was able to evaluate the efficacy of the service or section and the capabilities and potentialities of members of the staff. He was then able to advise on present and future assignments of the neuropsychiatric medical officers. In conference with the hospital commander, he could not only discuss the professional activities of his neuropsychiatric personnel but could also point out personnel inequities and needs as well as such administrative procedures as pertained to bed and equipment requirements.
Papers prepared for presentation at meetings or for publication were often reviewed by the neuropsychiatric consultant so that he could expertly assist and advise the author. Occasionally, he would recommend and encourage the preparation of a paper on a particular subject, and he himself contributed to its development.
Thus, the neuropsychiatric consultant in World War II was the stimulating and directing influence in the promulgation of an enduring informal
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teaching and training program. Many of these consultants had already served 'unofficially' in this capacity either in the Army at different stations or as civilians.
CONSULTANT CONFERENCES
In order to enhance the functioning of the consultant system, on three occasions, conferences were held with the service command consultants in the Surgeon General's Office (figs. 20, 21, and 22). The first such conference occurred on 22 October 1943, at which time there was a joint meeting of the medical and neuropsychiatric consultants. By that date, only four service command neuropsychiatric consultants had been appointed.
The second meeting was held on 12 May 1944, at which time seven of the service command neuropsychiatric consultants had been appointed.
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On 21 April 1945, a third conference was held, at which time all nine service command neuropsychiatric consultants had been appointed, and this meeting was attended also by the civilian consultants.
At these conferences, mutual problems were discussed in much detail, plans laid, changes recommended, and experiences exchanged. The consultants were thus able to gain much more of the total perspective of the neuropsychiatric situation, and the neuropsychiatric staff of the Surgeon General's Office could learn firsthand the problems from the field. At the last conference, committees were formed for the purpose of recommending future action, and their recommendations are of special historical significance because here, in the waning months of World War II, a group of senior military psychiatrists condensed their experiences in the form of recommendations (appendix C). Although some of these recommendations may seem irrelevant in future operations, it is considered that these expres?
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sions of policy, born of intimate contact with the problems, could be of great value in some future conflict to prevent repetition of errors.
CIVILIAN CONSULTANTS
Early in the military effort, provision was made for the appointment of civilian experts as consultants to the Secretary of War on medicine, surgery, and neuropsychiatry. This authority was extended from year to year by the military appropriations acts. It allowed The Surgeon General to utilize, on a part-time basis, the services of highly qualified experts-who were exempt from civil service or classification laws-to provide professional scientific or technical advice, or opinion, in the field of some special knowledge or training. Thus, these services were made available to the Neuropsychiatry Consultants Division.
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Early in 1944, the director of the division requested that The Surgeon General approve the appointment of civilian consultants in the field of neuropsychiatry (fig. 23). In order that there would be some direct relationship to the organized group of civilian psychiatrists, the American Psychiatric Association was approached to appoint a committee to act as consultants representing that organization. Utilization was made of an
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already standing committee known as The Special Committee on Psychiatry in the Armed Forces, composed of Drs. Arthur H. Ruggles, Edward A. Strecker, Frederick W. Parsons, and Karl M. Bowman. Drs. Strecker and Parsons had been appointed as such in August 1943 for other special projects which were at that time under consideration. The committee representing the American Psychiatric Association was officially appointed to counsel with the Neuropsychiatry Consultants Division. To this number was added Dr. Edwin G. Zabriskie, on 10 May 1944, as a representative of the American Neurological Association, of which he at that time was president. On 24 June 1944, Dr. Frederick A. Gibbs was appointed as a special consultant in electroencephalography. On 16 April 1945, Dr. Alan Gregg, of the Rockefeller Foundation, was appointed as a consultant in neuropsychiatry to the division.
This group of consultants met on call of the director of the division to consider special problem or problems concerning neuropsychiatry in the Armed Forces. Their opinion and guidance was solicited and freely given. This group met first on 7 April 1944; again, on 28 June 1944, on 23 August 1944, on 25 January 1945, and on 19 July 1945. The final meeting was held on 19 February 1946. Periodic reports were made by them to the American Psychiatric Association and these were printed in the official journal, American Journal of Psychiatry.
Throughout 1944, consultant help was gained from Mrs. Elizabeth H. Ross, then the Secretary of the War Service Office of the American Association of Psychiatric Social Workers, jointly sponsored by the American Association of Psychiatric Social Workers and the National Committee for Mental Hygiene, with headquarters in Philadelphia. From this office, Mrs. Ross graciously and generously advised the division with regard to psychiatric social work. Late in 1944, for lack of funds, her office was threatened with closure, and in order that the Army might continue to have her services, she was officially appointed on 16 December 1944, as Consultant to the Secretary of War in Psychiatric Social Work, in which capacity she continued to serve as a consultant throughout 1945 and in the early months of 1946.
Other kinds of civilian consultants were appointed for specific hospitals. A shortage of capable, older psychiatrists and neurologists had always existed in the Army. On the other hand, there were many civilian physicians who, although they had been declared essential in their civilian jobs, were nonetheless anxious to contribute to the war effort. In order to meet in some degree the shortage of psychiatrists and neurologists in the Army, and to take advantage of the assistance offered by the civilians in this group, arrangements were made whereby outstanding men could be appointed within a service command to act as consultants and teachers to a specified hospital.
On 30 January 1945, the Director of the Neuropsychiatry Consultants
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Division, in a memorandum to Brig. Gen. Raymond W. Bliss, set forth the request for this plan, which was approved:
1. Regardless of the number of medical officers that may be assigned to us for use in neuropsychiatry, we shall be hard pressed. We have utilized civilian psychiatrists in induction centers with fair success. We recognize many handicaps in the attempt at utilization of civilian psychiatrists in other positions, and yet believe that many could give some very valuable service. The matter has been discussed with our civilian consultants and with our service command neuropsychiatric consultants, all of whom question the success of such utilization, but feel that we should establish the machinery for such.
2. I wish to make the following recommendations:
a. That the service command neuropsychiatric consultants, under the authority and with the approval of the service command surgeons, be authorized to appoint one or more civilian psychiatrists, the number to be determined by the men available, the need and the facilities for utilization of such men.
b. That such civilians be under the supervision and assignment of the service command neuropsychiatric consultants.
c. That such individuals appointed might be employed up to a maximum of one-half time, though it may be anticipated that some will be used only a few days a month, some only periodically.
d. The possible duties might include:
(1) Regular assigned therapeutic work in convalescent or general hospitals, out-patient department, mental hygiene consultation service, or redistribution center.
(2) Regularly assigned diagnostic work in any of these installations.
(3) Special jobs such as teaching, ward rounds, counseling regarding diagnostic or treatment measures, and consultation on special cases.
Not many men were so appointed, chiefly because of the inherent difficulties of attempting to use civilians who had had no military experience in a military hospital. Many of the knottiest problems confronting the military neuropsychiatrists were concerned with military policy and practice, and in this field, the civilian consultants could be of no help. It was an uphill task for military psychiatrists everywhere to gain the confidence and respect of many of the oldtime Regular Army officers. It was believed that in some hospitals a civilian consultant might be regarded as an intruder. Despite the many obstacles, this plan worked excellently in a few hospitals.
RECOMMENDATIONS AND CONCLUSIONS
It is unrealistic to make recommendations for the corrections of errors which may never be made again. There is no doubt that some effective corrective measures have occurred. It seems unlikely that the next war will be similar to the last one and therefore energy should be devoted to anticipating the needs of the next war in its various forms. Because past experience may be of value to those with planning responsibility, the following recommendations are offered from the experience of many of our consultants, although not all of them would concur in all topics:
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1. Manpower should be conserved as far as feasible by good prewar planning to match the record of procurement and supply.
2. Health and morale are functions of command.
3. The consultant system, unanimously approved, deserves continuance from a central office in the Professional Division, Office of The Surgeon General, to consultants in the field. More outstanding middle-aged specialists should be encouraged to take these positions.
4. It would be well for the military medical services to develop sufficient regular medical officers to serve as consultants. Even the most experienced civilian consultant must go through a transition when assigned in a military setting, in order to be aware of the various operational problems of the military milieu, the military organization, the channels of transmission, even the assimilation of military language. This takes time and mistakes may be made. The Regular Army medical consultant because of his past contacts and experience could better establish liaison and easier accessibility with other medical or tactical agencies. During peacetime, the Regular Army consultant could insure that the lessons learned in previous wars would not be lost by means of establishing and continuing proper policies in regulations, technical manuals, and training doctrines.
5. It was found advisable to have conferences with the service command consultants. Any future program should provide for regular established meetings of the group in the Surgeon General's Office to develop and maintain the close contact with their own professional divisions as well as all other services and divisions in the Surgeon General's Office.
6. A more effective system of selective service should be developed.
7. Consideration should be given to a preliminary trial of inductees analogous to the period of 'boot-training' in the Navy.
8. Neuropsychiatric specialists might work with profit with line officers in maneuvers to develop the best methods of caring for soldiers with 'battle fatigue.' Medical officers must earn the right to help in field activities.
9. Realistic instruction regarding the psychology of leadership, morale, and 'the ineffective soldier' should be added to the already splendid indoctrination received by line officers in special service schools. Brief academic consideration, no matter how well taught or received, will not replace some actual experience. An analogy might be drawn to the necessary clinical experience received by medical students, interns, and residents. Methods or prevention and rapid treatment suitable to large groups should be developed systematically.
10. Better methods for the selection, assignment, transfer, promotion, and separation of Medical Department personnel are essential. This is especially true for the separation of the ineffectual officer.
11. Better communication between all echelons are essential for efficient service.
12. The W-8 type of hospital ward must be replaced by a new design.
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New hospital construction should conform to the best civilian standards with facilities for adequate outpatient care, and ample usable space for the newer laboratories and treatment.16
13. Better methods of statistical reporting of local hospital admissions to the service command headquarters would permit the surgeon to control such admissions and to distribute them more judiciously.
14. Improved methods of administrative discharge of the ineffective soldier as well as better methods of dealing with homosexuals, prisoners, and the antisocial persons are necessary. Since World War II, much progress has been made in this area.
15. Insofar as feasible with military requirements, make provisions for a more stable cadre of nurses and other paramedical personnel in at least the larger hospitals in order to permit these small teams to do good work. The neuropsychiatry sections were usually at a disadvantage as compared with the medical and surgical services, because the more unstable or undesirable nurses or aids were assigned to the neuropsychiatric section, sometimes with the justification that they would receive closer supervision.
16. Public relations methods should be developed to improve morale.
17. While the responsibility for psychological welfare is not ours, it seems obvious that this area in which some work is being done needs development.17
16Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956.
17Dyer, Murray: The Weapon on the Wall; Rethinking Psychological Warfare. Baltimore: Johns Hopkins Press, 1959.
