Military | Books, Health and History

By Dr. Michael Robinson, National Army Museum Research Fellow, University of Birmingham (UK), and the Library’s 2024 Paul Klemperer Fellow in the History of Medicine

I spent one month working in the New York Academy of Medicine’s magnificent library and reading room in the autumn of 2024. This residency enabled me to look at a host of materials dedicated to the treatment of mentally ill American Army veterans of the First World War during the Great Depression (1929–1939). I undertook this research hoping to utilise the USA as an important comparative case study on my current research project dedicated to mental illness and British Great War veterans during the 1930s. By examining mental breakdown and psychiatric medical care during this decade, this research seeks to reveal the delayed traumatic after-effects of war service on ex-service personnel and the potential for additional psychosocial determinants to influence mental ill-health.

I first became interested in the American experience of post-First World War disability and mental healthcare owing to its regular appearance in the archival records of Britain’s Ministry of Pensions, the government agency responsible for distributing veterans’ pensions and medical care. During the inter-war period, British policymakers regularly cited the US experience of veteran after-care as a deterrent and a case study to avoid replicating. They actively held up the US system as being unfairly exclusive, costly, and liberal owing to its incremental but costly expansion of veteran rights and facilities. Britain significantly reduced its liability on behalf of veterans during the 1920s and 1930s, including the closure of most veterans’ hospitals. Veterans’ medical care in Britain was primarily outsourced to broader public health facilities, the civilian welfare state, and the charity sector.

By contrast, the US witnessed increased state liability, including a vast financial outlay in funding exclusive Veterans Administration (VA) hospitals and medical facilities. In 1936, owing to the two nations’ inversed approaches to veteran care, one Ministry of Pensions official described the UK and US responses as being of ‘opposite extremes.’¹ The primary purpose of my time at the NYAM was to better understand why the British and US systems were the complete inverse of one another. I also sought to appreciate how these contrasting policy trajectories and medical infrastructures affected the lives of mentally ill veterans.

Portrait of Thomas Salmon, from *History of the Interurban Clinical Club 1905-193*7, edited by David Riesman (1937).

This comparative approach first led me to NYAM records relating to Dr. Thomas Salmon (1876–1927). For those unfamiliar, Salmon was the American Expeditionary Forces’ chief consultant in psychiatry during the First World War. Before this important role, following the country’s entry into the global conflict in 1917, Salmon visited England to study how it dealt with mental wounds during the war to help inform his country’s approach.² As a leading figure in the US National Hygiene Movement before and after his war service, the records of Salmon’s war experience reflect a relatively progressive military medical official. He regularly stressed the environmental causes of soldiers’ breakdown. In short, Salmon was more inclined to blame combat neurosis and stress on the dehumanising and brutalising effects of war service than citing faulty hereditary genetics, as was more apparent amongst British military officials. This more empathetic outlook continued into Salmon’s advocacy on behalf of veterans following his return to America. Unlike the more reclusive and disillusioned Dr. Charles Myers, the British Army’s leading psychiatric official, Salmon advocated for healthcare and welfare on behalf of the mentally disabled First World War veterans during the initial post-war years. Described by his biographer as a successful ‘spokesman for veterans,’ the force of Salmon’s personality and his effective collaboration with the American Legion help explain why the American mentally ill veteran stopped being admitted into larger public mental hospitals.³ Instead, the US Federal Government established exclusive medical facilities for veterans from the early 1920s onwards.

Salmon died unexpectedly whilst sailing near Long Island in 1927. Reflecting his prestige amongst his contemporaries, the National Committee for Mental Hygiene, an advocacy organization founded in 1909 by Clifford W. Beers, set up the Salmon Committee on Psychiatry and Mental Hygiene at the New York Academy of Medicine in 1931.⁴ Regardless, the exclusive medical infrastructure he had helped establish continued to cater to mentally ill First World War veterans into the 1930s. In stark contrast to Britain’s minuscule and dwindling psychiatric infrastructure, the VA provided seventeen neuropsychiatric facilities across its national network of forty-nine hospitals. It offered 10,633 beds for mental ailments, marking a 467% increase over 1921’s availability. The number of beds would be set to increase for the rest of the decade.⁵ With this exclusive federal medical care program for veterans, the VA published its Medical Bulletin journal throughout the 1930s. Pouring through these issues reveals a lively forum of VA medical officials discussing the continued difficulties of treating veterans during this period.

Regarding neuropsychiatry—I was struck by how hospital superintendents, nurses, vocational trainers, and social workers regularly articulated a holistic approach to mental healthcare. They cited the psychosocial determinants of health outside of hospital walls. This includes, for example, the detrimental impact of unemployment and poverty on an individual’s mental and bodily health, the emasculating stigma attached to male mental illness, and the potential for harmful self-medication practices such as alcoholism.

*United States Veterans’ Bureau Medical Bulletin* (1931), a collection of articles by VA staff and associates dedicated to all aspects of veteran after-care. These various scans come from volume 7.

The materials I reviewed at the NYAM provide a complex and nuanced picture of the post-war treatment of mentally ill World War One veterans. On the one hand, they give an image of an expansive, caring and financially generous veterans’ system. On the other hand, however, they provide comparatively little insight into the personal perspectives of veteran patients to verify the progressive narrative offered by medical officials. In addition, contemporary medical journals reveal increasing resentment from American citizens regarding the spiralling costs of veteran medical care with little in return in terms of cure and recovery.⁶ This counter-narrative also appears worthy of further research.

Before arriving in New York, I was unsure how exactly the USA would fit into my larger project of Great War veterans during the Great Depression. However, my time at the NYAM proved incredibly rewarding by revealing how fascinating and unique an American case study is. I look forward to continuing this research into 2025.

Notes:

1 Nineteenth Annual Report of the Ministry of Pensions, 1935-1936, 33.

2 For a write-up of Salmon’s observations and recommendations, see Thomas Salmon, The care and treatment of mental diseases and war neuroses (“shell shock”) in the British Army (War Work Committee of the National Committee for Mental Hygiene, 1917).

3 E. D. Bond, Thomas W. Salmon: Psychiatrist (W. W. Norton & Co, 1950), 160.

4 For more information on the Salmon Committee on Psychiatry and Mental Hygiene and its records that are held in the NYAM, see https://www.nyam.org/library/collections-and-resources/archives/finding-aids/ARN-0006.html/ [last accessed 18 November 2024].

5 E. O. Crossman and Glenn E. Myers, ‘The neuropsychiatric problem in the US Veterans’ Bureau,’ Journal of the American Medical Association, vol. 94, no. 7 (1930), 473–478.

6 For example, see the Crossman and Myers article cited above.

Paul Theerman, Associate Director

On April 6, 1917, the United States entered the Great War on the side of the Allied powers. By the following fall, those powers were victorious, in part due to the American presence, adding industrial might and men to the stalled conflict and making up for the Russian withdrawal after the October Revolution.

Combat is the most vivid part of war. Victory often depends, however, on maintaining the military effort, and this meant mobilization, training, logistics, supply, and above all, the “medical front.” Armies had to take the wounded soldier, help him heal, and return him to battle. For World War I, that front was where men’s wounds met the medical machine.

Dupuy-Stretcher Bearer-Fig 134_watermark

From a training book for stretcher bearers. Image source.

How were men wounded in the war? The strain and the boredom of trench warfare are part of our collective memory; the drama of that war comes from two sources: mustard gas and machine guns. The use of chemical weapons and the mechanization of shooting brought horror to men’s lives at the front. Yet they were not the greatest source of casualties. By far, artillery was the biggest killer in World War I, and provided the greatest source of war wounded.

In his book Trench: A History of Trench Warfare on the Western Front (2010), Stephen Bull concluded that in the western front, artillery was the biggest killer, responsible for “two-thirds of all deaths and injuries on the Western Front.”[1] Of this total, perhaps a third resulted in death, two-thirds in injuries. Artillery wounded the whole body. If not entirely obliterated, the body was often dismembered, losing arms, legs, ears, noses, and even faces. Even when there was not superficial damage, concussive injuries and “shell shock” put many men out of action. Of course, shooting—in combat as well as from snipers—was another great source of wounding. Gas attacks were a third. Phosgene, chlorine, mustard gas, and tear gas debilitated more than killed, though many ended up suffering long-term disability. Overall the war claimed about 10 million military dead, and about 20–21 million military wounded, with perhaps 5% of those wounds life-debilitating, that is, about a million persons.[2]

Moving the wounded. Image source.

Outcomes depended on getting treatment quickly. Evacuation and triage became watchwords of the war-wounded. For the British Army, for example, the Royal Army Medical Corps developed an extensive system to move the wounded from the front to the rear, with triage at each step. Stretcher bearers evacuated the wounded to Regimental Aid Posts (RAP)—or at least those that they had the means to move, for when stretcher-bearers were few, the worst cases were left on the field of battle.

The path from the front to the hospital. Image source.

In one report of a man severely wounded in the abdomen, “Since ‘death awaited him with certainty . . . I gave him a hypodermic of morphia and we propped him up as comfortably as we could’ and left him there.”[3] Behind the RAPs were Advanced Dressing Stations, then further back Main Dressing Stations, and finally, Casualty Clearing Stations. Each move to the rear—always challenging in itself—was based on an assessment of the injury and the chances of survival. The lightly wounded—those likely to recover quickly—and the “moribund”—those likely to die—were kept, and the others sent on. Each station provided stabilization and immediate care, with some basic surgeries, such as amputation, at Casualty Clearing Stations. More advanced treatment occurred at hospitals, either back in Britain or in France. As the war wore on, more of the wounded were kept in France, at hospitals far back from the lines. This was to use less transport and to maintain military morale, with the goal of returning the men to the front as quickly as possible. And indeed, American medical entry into the war came first in the form of hospitals. “The first six [mobile hospitals] to arrive in France took over British General Hospitals and provided hospital level care for the British. Other American hospitals arriving later in the summer of 1917, remained assigned to the American forces.”[4] The Allied pattern of medical triage and evacuation became the model for American efforts.

The fracture ward; the term “machine shop” likely refers to the frames and power belts that characterized such shops at the turn of the last century. Image source.

How well did the system work? “War is a matter of expedients.”[5] The medical operation was persistently understaffed and under-resourced. In the latter part of the war, as the static front changed to a dynamic one, some medical units had difficulty achieving the mobility needed. And inevitably, given the need continually to evaluate the severity of wounds, and the difficulty of transport, some men ended up in the wrong place, some facilities were too crowded, and others were underused. Finally, in 1918 the medical system began to be overrun with influenza cases. Overall, though, the magnitude of the challenge needs to be kept in mind. In just the American experience, for an army that numbered almost 2 million men in France at the end of the war, 1.2 million men passed through the medical system, with about quarter million military wounded.[6] That is an astounding number for which to provide medical services under severe stress.

Souttar_Surgeon in Belgium-p22_watermark

Surgery in a Belgian field hospital. Image source.

References:
[1]“Krilling for Company.” Mud Feud [Review of Trench: A History of Trench Warfare on the Western Front, by Stephen Bull (Osprey Publishing 2010)]. Papyrocentric Performativity. Published July 14, 2014. Accessed March 21, 2017.
[2] The total number of killed from the Allied Powers exceeded that of the Central Powers by over a million; the total wounded exceeded by perhaps 4 million. Accurate statistics are hard come by; these are based on Antoine Prost. War losses. 1914-1918-online: International encyclopedia of the First World War. Published August 10, 2014. Accessed March 21, 2017.
[3] Carden-Coyne A. The Politics of wounds: Military patients and medical power in the First World War. Oxford: Oxford University Press; 2014. P. 65.
[4] Jaffin J. Medical support for the American Expeditionary Forces in France during the First World War. Published 1990. Accessed March 31, 2017. Pp. 95–96.
[5] Helmuth Karl Bernhard Graf von Moltke. Wikiquote. Published October 7, 2006. Updated September 1, 2016. Accessed March 31, 2017.
[6] Jaffin J. P. 166.

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Researching Neuropsychiatry and Veterans Hospitals During the 1930s at the New York Academy of Medicine

War Wounded