Russian Soviet Military Psychiatry 1904-1945 (Cass Series on the Soviet (Russian) Study of War)

Russian/Soviet Military Psychiatry, 1904–1945 Psychiatry, like most professional fields in Russia, gained its legitima...

Author: Paul Wanke

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Russian/Soviet Military Psychiatry, 1904–1945

Psychiatry, like most professional fields in Russia, gained its legitimacy from its ability to serve the Tsar and later the Bolshevik Party. The militarized nature of these governments meant that psychiatry would have to prove its worth to the military. This study covers Russian/Soviet military psychiatry from its first practical experience during the 1904–5 RussoJapanese War to its greatest test during the Great Patriotic War of 1941–5. Throughout this book, the continuity between Russian and Soviet military psychiatry is emphasized. For example, psychiatry’s materialist school dominated throughout the period and Russia’s acceptance that psychiatric casualties would occur allowed them to focus their resources on treatment rather than prevention. This is the first study of the subject to make use of recently declassified Soviet archives, thereby allowing a critical evaluation of the successes and failures of Soviet psychiatrists and psychologists in World War II that was hitherto not possible. The author also draws interesting comparisons with US military psychiatry, clarifying both similarities and differences between military medical practice in the two countries. Making extensive use of Russian and Soviet military medical journals and reports, this study will interest students of both Russian and medical history, as well as military professionals. Paul Wanke is currently an adjunct faculty member at Oregon State University and Lane Community College, Eugene, OR.

Cass series on the Soviet (Russian) study of war Series Editor: David M. Glantz ISSN: 1462-0960

This series examines what Soviet military theorists and commanders learned from the study of their own military operations. 1. Harold S. Orenstein, translator and editor, Soviet Documents on the Use of War Experience, Volume I, The Initial Period of War 1941, with an Introduction by David M. Glantz 2. Harold S. Orenstein, translator and editor, Soviet Documents on the Use of War Experience, Volume II, The Winter Campaign 1941–1942, with an Introduction by David M. Glantz 3. Joseph G. Welsh, translator, Red Armor Combat Orders: Combat regulations for tank and mechanized forces 1944, edited and with an Introduction by Richard N. Armstrong 4. Harold S. Orenstein, translator and editor, Soviet Documents on the Use of War Experience, Volume III, Military Operations 1941 and 1942, with an Introduction by David M. Glantz 5. William A. Burhans, translator, The Nature of the Operations of Modern Armies by V.K. Triandafillov, edited by Jacob W. Kipp, with an Introduction by James J. Schneider 6. Harold S. Orenstein, translator, The Evolution of Soviet Operational Art, 1927–1991: The documentary basis, Volume I, Operational Art 1927–1964, with an Introduction by David M. Glantz 7. Harold S. Orenstein, translator, The Evolution of Soviet Operational Art, 1927–1991: The documentary basis, Volume II, Operational Art 1965–1991, with an Introduction by David M. Glantz 8. Richard N. Armstrong and Joseph G. Welsh, Winter Warfare: Red Army orders and experiences

9. Lester W. Grau, The Bear Went Over the Mountain: Soviet combat tactics in Afghanistan 10. David M. Glantz and Harold S. Orenstein, editor and translator, The Battle for Kursk 1943: The Soviet general staff study 11. Niklas Zetterling and Anders Frankson, Kursk 1943: A Statistical Analysis 12. David M. Glantz and Harold S. Orenstein, editor and translator, Belorussia 1944: The Soviet general staff study 13. David M. Glantz and Harold S. Orenstein, editor and translator, The Battle for L’vov, July 1944: The Soviet general staff study 14. Alexander O. Chubaryan and Harold Shukman, editors, Stalin and the Soviet–Finnish War, 1939–40 15. David M. Glantz and Harold S. Orenstein, editor and translator, The Battle for the Ukraine: The Red Army’s Korsun’-Shevchenkovskii operation, 1944 16. David M. Glantz, The Soviet Strategic Offensive in Manchuria, 1945: ‘August Storm’ 17. David M. Glantz, Soviet Operational and Tactical Combat in Manchuria, 1945: ‘August Storm’ 18. Alexander Hill, The War Behind the Eastern Front: Soviet partisans in North-West Russia 1941–1944 19. Alexander Hill, The Great Patriotic War of the Soviet Union, 1941–45: A documentary history

Russian/Soviet Military Psychiatry, 1904–1945 Paul Wanke

FRANK CASS LONDON and NEW YORK

First published 2005 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Simultaneously published in the USA and Canada by Routledge 270 Madison Ave, New York, NY 10016 Routledge is an imprint of the Taylor & Francis Group This edition published in the Taylor & Francis e-Library, 2004. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” © 2005 Paul Wanke All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Wanke, Paul. Russian/Soviet military psychiatry 1904–1945 / by Paul Wanke. p.cm. Includes bibliographical references and index. ISBN 0-415-35460-9 1. Military psychiatry–Soviet Union. 2. Military psychiatry – Russia (Federation). I. Title. UH629.5.R8W36 2005 616.89'0088'355––dc22 2004011501 ISBN 0-203-00132-X Master e-book ISBN

Contents

List of tables Acknowledgments

viii ix

Introduction

1

1 Russian psychiatry and the emergence of modern warfare

5

2 The Russo-Japanese War

17

3 World War I

30

4 The inter-war years

42

5 The Great Patriotic War – Phase 1: The hurricane

57

6 The Great Patriotic War – Phase 2: The tide turns

70

7 The Great Patriotic War – Phase 3: On to Berlin

83

8 Soviet–US comparison of military psychiatry in World War II

95

9 Conclusion

109

Notes Bibliographic essay Bibliography Index

116 125 128 139

Tables

1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3.1 3.2 4.1 7.1 8.1 8.2 8.3 8.4 8.5

Incidence of mental illness in the Russian Army, 1871 NP casualties in the Russo-Japanese War Admissions to Harbin Central Psychiatric Hospital Ratio of illnesses in Army Treatment Centers, 1904–5 Officers with non-traumatic nervous disorders Officers with traumatic nervous disorders Non-traumatic nervous disorders among enlisted men Traumatic nervous disorders among enlisted men NP casualties on the Northwest Front Data collected by Professor Prozorov’s study, 1926 Psychiatric disorders in Vinnitsa, 1930–3 Sample Soviet medical curriculum, 1945–6 Admissions for NP conditions, US Army, European theater, 1942–5 Outcomes of nervous disorders with proper diagnosis Time until speech recovery following contusion Time until hearing recovery following contusion Length of treatment for neurosis

10 18 19 21 25 26 27 27 34 34 51 92 99 105 106 106 107

Acknowledgments

Playing hockey for years has taught me to appreciate good teamwork and this work is the result of the generous assistance of a wide variety of people and institutions. The central source of information for this study has been the libraries at the University of Kansas and Oregon State University. Brad Schaffner (KU) and Doris Tillis (OSU) did a great job in tracking down rare books and obscure journal articles. The Academy of Science library in St Petersburg, Russia was also very generous helping me in the summer of 2000, finding materials and steering me towards other avenues of research. While I was not granted access to the Military-Medical Museum archives in St Petersburg, the staff there were polite and professional and encouraged me to continue my work. One of the most enjoyable aspects of this study was meeting other historians who were always generous with their time and knowledge. Professor Roger Spiller, Chief Military Historian at the US Army Command and General Staff College, spent time talking to me about the Russo-Japanese War and emphasized the role that culture played when discussing psychiatric casualties. The late Professor John Erickson sent me a copy of the bibliography published in F. Ivanov’s study of reactive psychosis, which proved invaluable while I was in St Petersburg. His kindness and generosity will be missed. The history department at the University of Kansas has been a delight to work with. Professor Anna Cienciala introduced me to the complex and fascinating history of central Europe and also translated Polish journal articles pertinent to my dissertation. Professor John Alexander showed me the continuity of thought in pre- and post-revolutionary Russia. Professor Theodore Wilson sparked my interest to include a comparison of US and Soviet military psychiatric efforts in World War II. Special thanks goes to Professor Jacob Kipp whose excellent questions demonstrated to me how each individual country’s military experience can serve as a mirror to the society as a whole. Finally, Professor Norman Saul provided excellent suggestions for further research and his editing skills were invaluable. He urged me to see the task of writing history as a fine craft, of not only proper research, but also quality presentation.

x

Acknowledgments

Throughout this process I received the support of my wife, family and friends. My parents always encouraged my pursuit of history and my brother introduced me to ice hockey, two pursuits that have enriched my life. And what held it all together was the patience and love of my wife, Jenny. While I hold complete responsibility for the final product, I sincerely thank all involved for improving this work and making it a true learning experience. Transliteration follows the Library of Congress system. Up to February 1918, the Julian calendar was followed which fell behind the modern Gregorian calendar: 11 days in the eighteenth century, 12 days in the nineteenth century, and 13 days in the twentieth century. The Soviet government adopted the Gregorian calendar on 14 February 1918.

Introduction

Upon completion of a tour of Soviet military medical facilities in 1943, Canadian physician Wilder Penfield summarized his conclusions regarding Soviet neuropsychiatric (NP)1 casualties stating that ‘… psychoneurosis is rare in the Soviet Union for they have an ample supply of its specific antidote, i.e. high morale.’ These were bold words indeed. For example, in the period 1942–5, according to the US Army, 234,116 patients were admitted to military hospitals as NP casualties in the European and Mediterranean theaters alone.2 Not just the United States, but all of the major combatants of World War II grappled with the problem of NP casualties. The idea that somehow the Red Army had solved this intractable problem was challenged by many including US Army psychiatrist Lt. Colonel Roy Grinker who questioned Penfield’s observations, writing that ‘… inevitably every man, Russian or British, French or American, has his threshold no matter under what conditions he fights.’3 Military psychiatry, as all of military medicine, has as its goal the care and treatment of personnel in order to maintain military effectiveness. The purpose of this study is to explore Russian/Soviet psychiatry’s response to the individual soldier’s mental health and how their minds were affected by the onslaught of modern industrialized warfare. It will briefly describe the emergence of psychiatry as a distinct medical discipline within Imperial Russian society and then go on to examine the years 1904–45. These years cover the steady increase of industrialized killing, leading to the barbarization of warfare4 as exemplified by the fighting during World War II. This study will then focus on Soviet military psychiatry, especially its role in ground combat during World War II. The origin, prevention, care and treatment of NP casualties were important considerations for all the major powers in the early twentieth century. The answers to these questions were not only reflections of the level of medical knowledge within their countries but also the unique historical and cultural milieux in which they operated. The Soviet Union was no exception. Therefore in order to understand the performance of Soviet military psychiatry during the Great Patriotic War, one must step back and trace the origins of psychiatry in old Imperial Russia and follow it through the revolution and Stalinism, until victory in 1945.

2

Introduction

Certain recurrent themes will appear in this narrative. The first significant thread running throughout these years was the continuity of medical and psychiatric thought. For example, the role of sound organization in proper medical treatment had been a mainstay in Russian thought since the famous military surgeon, Nikolai Ivanovich Pirogov (1810–81), encouraged it after the Crimean War. Also, in terms of origin, Russian and Soviet military psychiatrists stressed the physiological nature of NP casualties over a wide variety of other possible causes, such as those found in Freudian psychology. Although not a Bolshevik, Ivan Petrovich Pavlov (1849–1936) was accepted by the Soviet government because his emphasis on physiology corresponded well with Marxist materialism. The care and treatment of NP casualties, however, did change over the years. The idea of shipping NP casualties across the vast expanse of Russia for further treatment in Moscow, as was done during the Russo-Japanese War, was discarded during World War II. Instead a tiered system of evaluation and treatment was set up with the goal of treating soldiers as close to the front as possible in a military environment. But the greatest and most significant change that occurred over this period was the evolution of diagnostic labels. In short, what constituted an NP casualty? Much of the following discussion will hinge upon the proper definition of terms and perhaps the most basic, yet important, differentiation to be made is between Russian psychiatry and psychology. According to Military Psychology, published by the Soviet Ministry of Defense in 1972, military psychology is involved with the ‘… psychological aspects of training and education of personnel, the patterns of mental activity of men, and the spiritual life of man and the collective … .’5 Military psychiatry on the other hand is more directly involved with the treatment of soldiers who have suffered some kind of mental distress sustained in military service. For Russian psychiatry the essential assumption was that there was some kind of physiological damage suffered by the victim, whether that injury was obvious or not. For example, the idea of shell shock, which was a common diagnosis among all the warring parties during World War I, assumed that the blast waves from artillery caused micro trauma to the brain, resulting in physiological changes affecting the entire organism. Therefore, the true nature of symptoms such as epilepsy or schizophrenia was damage to the brain and/or peripheral nervous system. Russian military psychiatry was strongly grounded in the science of neurology and physiology, whereas Russian psychology was considered a softer discipline, less dependent on scientific observation and experimentation. Differences between military psychiatry and psychology were simple as compared to the wide variety of terms used to describe and diagnose NP casualties. Of course the critical question was what defined an NP casualty. How does the psychiatrist determine if a soldier was suffering from fear so strong that the body reacted physiologically to render the soldier incapable of performing his duties? Or was it simple cowardice? Failure to recognize

Introduction

3

the genuine possibility that a soldier has been rendered incapable of performing his duties while lacking signs of obvious trauma could be disastrous. Such a soldier, returning to the front, could jeopardize his entire unit by failing to perform appropriately under combat conditions. Therefore, it was crucial to get the proper diagnosis as quickly as possible, in order to ensure that the soldier received the proper treatment. A misdiagnosis could send a salvageable soldier, who needs only rest and a good meal, back to a major hospital, thus losing his services for a long period of time. Or a severely traumatized man may be released back to his squad too soon, greatly reducing that unit’s effectiveness. All of the major powers faced this problem, and how they established the criteria for diagnosis would determine the number of NP casualties. This theme will be examined throughout this work. In order to show the continuities of Russian military psychiatry, this study steps back to the sixteenth century and the origins of identification and treatment of mental illness. It then continues up to the beginning of the twentieth century as the Russian military begins to emerge as a world power and the psychiatric profession takes form within the special features of Russian society. Russian military psychiatry faced its first significant task during the Russo-Japanese War but nothing could adequately prepare it, or any nation, for World War I. During World War I, Russian military psychiatry was seemingly offering tangible benefits to the military but the 1917 revolution placed the future of military psychiatry in doubt. Despite a radical change in political ideology, Marxism and Russian psychiatry could find common ground in the general belief of materialism, which went as far back as Ivan Mikhailovich Sechenov (1829–1905). In Reflexes of the Brain (1863), Sechenov wrote ‘… the initial cause of any human action lies outside the person.’6 This theory was carried over through the work of men like Pavlov and V.M. Bekhterev (1875–1927). But this did not mean there was no debate and controversy in Russian/Soviet military psychiatry. By the late 1930s the physiological domination was gradually challenged by social psychology as espoused by men like S.L. Rubinstein (1889–1960), who would eventually win the Stalin prize in 1942. Military psychology attempted to provide an alternative to strict psychiatric treatment of NP casualties but its reputation as a soft discipline continued to hamper efforts at legitimacy. Of course, all the theories and their practical applications would be tested to their limits by the onset of Germany’s ‘Operation Barbarossa’ in 1941. The choices made by Russian/Soviet psychiatry regarding the origin of NP casualties and their proper care and treatment were largely determined by the increasing militarization of their society.7 Psychiatry’s chance for legitimacy depended on their useful service to the Tsar, then following 1917, to the party. Providing psychiatric care to the armed forces best rendered this service. Thus Russian/Soviet psychiatry emerged from a military, not a civilian, background. Also, the fact that Russian/Soviet governments provided resources to the study of NP casualties suggests that they recognized the problem and hoped that military psychiatry could provide solutions.

4

Introduction

This study is not the first of its kind. In fact it follows and hopes to improve upon the previous work of Professor Richard Gabriel, who first addressed the issue of Soviet military psychiatry in the West.8 He too emphasized the Imperial Russian influences on Soviet military psychiatry and also went into great detail regarding Soviet treatment of NP casualties. However, his study was weakened by lack of Russian/Soviet sources, some of which were only recently declassified. This work has incorporated much more information from a wide variety of Russian sources. Several Russian scientific journals, publishing since the beginning of the twentieth century, have provided a continuous narrative covering the issue of military psychiatry. Regarding World War II, the official 26-volume Soviet study, The Experiences of Soviet Medicine during the Great Patriotic War [Opyt sovetskoi meditsiny v velikoi otechestvennoi voine 1941–1945] (OSM)9, especially volume 26, has been invaluable. Still gaps remain. First-hand accounts of both military psychiatrists and soldiers treated as NP casualties are lacking. Soviet statistics have been notoriously suspect and that fact certainly is true regarding the numbers of NP casualties. One can glimpse into the world of Soviet military psychiatry but there still remains a fair degree of speculation. Along with Russian materials, foreign reports and documents have also been used in an attempt to verify or clarify the information drawn from the Russian experience. To begin, it is necessary to provide a brief background concerning the changes in warfare and how they challenged the mental health of the soldiers involved. Russian psychiatry’s response to industrialized warfare was shaped by its intellectual traditions and by the constraints placed upon them by the Tsarist State.

1

Russian psychiatry and the emergence of modern warfare

The fact that slaughter is a horrifying spectacle must make us take war more seriously and not provide an excuse for gradually blunting our swords in the name of humanity.1

Napoleonic mass armies combined with technological advances such as railroads, telegraphs, high explosives and rifled weapons produced a profound change in warfare during the nineteenth century. The battlefield became larger, the confusion of combat greater and the individual soldier fought day and night under increasingly more stressful conditions. These changes occurred rapidly. In 1759 at the battle of Kunersdorf, Frederick the Great’s army of 50,000 attacked a combined Russian and Austrian force of 60,000. Frederick’s casualties amounted to 18,500 (37 percent) while his opponent lost 15,600 (26 percent). Fifty-four years later on 16 October 1813, Napoleon and his army of 175,000 soldiers clashed with a combined force of 325,000 men under Prussian Field Marshal Gebhard von Blucher, Field Marshal Prince Schwarzenberg and Sweden’s Crown Prince Bernadotte. At the end of the day, the allied forces suffered approximately 80,000 casualties (25 percent) while Napoleon’s losses numbered 60,000 (34 percent).2 Within approximately 50 years, armies had grown five or six times and so had their casualties in battle. A great deal of effort was put into controlling and supplying these new mass armies. Many European nations, including Russia, instituted General Staffs to coordinate these efforts and plan for new wars. Much of the General Staffs’ work focused on the proper use of the new weapons of war. The introduction of breech loading and rifled guns and artillery into European armies of the mid-nineteenth century resulted in more accurate and rapid firepower. Infantry weapons increased the killing zone to as far as 1,000 yards while artillery shells tended to force infantry down to the ground. The killing capacity of weapons further increased with the introduction of magazine rifles, machine guns, smokeless powder and an effective recoil system for artillery later in the century. By the beginning of the twentieth century the Polish railroad entrepreneur, Ivan S. Bloch,

6


wrote that the result of these innovations was ‘… an impassable zone of fire deadly in equal degree to both the foes.’3 This left soldiers in a deadly position. How to cross this wall of fire while ignoring the basic principles of self-preservation? The new battlefield often left the individual soldier ‘… unknown often to his closest companions. He loses them in the disorienting smoke and confusion of a battle which he is fighting, so to speak, on his own.’4 The psychological benefits a soldier received by facing combat with fellow soldiers by his side diminished on the modern battlefield. Each Western nation responded to these changing conditions. Russia’s military response reflected its own cultural and historical traditions. Following Russia’s defeat in the Crimean War (1853–6), Russian military reformers, such as Dmitrii Miliutin, aimed at modernizing the armed forces. He sought to improve the military’s administration, produce a large reserve force with short-term enlistments and raise the quality of military education. Russian military officers were grouped in essentially two classes. Elite noble families provided officers for the higher ranks and special units. Lesser nobles filled out the remainder of officer positions. Miliutin’s attempt to establish standard educational requirements for all officers failed as elite officers fought to maintain their privileged status. Regarding battlefield tactics, Russian military theorists, such as M.I. Dragomirov and G.A. Leer, still regarded the idea that national spirit, morale and cold steel could overcome the advances in weapon technology. ‘The bullet and the bayonet do not exclude but supplement each other: the first paves the way for the second.’5 This attitude of spirit over machine was not exclusive to Russia. As late as 1912, the German General Friedrich von Bernhardi wrote ‘… we can assume with certainty that those troops who are not afraid of losses are bound to maintain an enormous superiority over others who are more sparing of blood.’6 At the dawn of the twentieth century, many military officers still maintained that sacrifice, character and national pride could overcome machines. Bloch’s impassable field of fire could be crossed with soldiers possessing a strong body and a firm mind. But there were voices that questioned these assumptions. At approximately the same time that the lethality of war increased, a newly emerging medical discipline also came to light. Psychiatry, designed to treat the illnesses of the mind, stepped warily onto the medical scene in the nineteenth century. In the process of defining its special discipline, psychiatry also sought to be accepted by society and conventional medicine alike. For Russian psychiatry, this search for legitimacy took place within the military. Mental illness has long been recognized in Russia. For much of early Russian history, the church or monastery took care of the mentally ill. This was somewhat formalized by the edict of 1551 when the monasteries were given the task of caring for those ‘… possessed by the devil and those who lost their minds … .’7 While monasteries provided help for the ill, this arrangment also served to keep the healthy safe from possible contamination. What


7

is important to note here is the idea of mental disorders as a force operating outside of the body. By the next century, however, some significant changes occurred. During the reign of Fedor III (1676–82) legislation was carried out limiting the property rights of people such as the deaf, the blind, and fools. This term fool, however, was soon changed, categorizing people exhibiting strange behavior as ill.8 This marked the gradual change from supernatural explanations for mental disturbances to a more scientific model, now suggesting that these unfortunates suffered from some kind of illness. Peter the Great (1682–1725) heralded vast new changes in Russian society. Peter opened Russia to Western ideas that placed a great deal of stress on society. To what extent Peter’s reforms psychologically affected the population is unclear, but Peter encouraged new ideas if he felt they had some practical benefit. Theories regarding mental illness were no exceptions. Here one can find the true beginnings of a mutual relationship between the military and medical services dealing with the mentally ill. In the newly acquired province of Vyborg, bordering on the Gulf of Finland, a prototype for an academic clinic catering to the needs of mentally exhausted soldiers was established in an old Cossack barracks in 1706. Peter’s constant wars led to an identification of soldiers that were suffering from physical and mental exhaustion brought on by combat. Also, incessant warfare established a need for a modern, professional medical service able to stem the tide of deaths and debilitating injuries that occurred while in military service. The first modern Russian hospital was constructed in Moscow in 1706. This served not only as a military hospital but also as the training ground for future military doctors.9 Within 20 years, two more were established in St Petersburg: the Army (1723) and Admiralty (1726) military hospitals. In 1798, a major medical advance was made with the creation of the Medical-Surgical Academy (MKhA), also in St Petersburg.10 Treatment for the newly categorized mentally ill continued to advance. Catherine the Great (1762–96) promulgated a series of reforms throughout her reign. One example was when she reorganized the country according to the Guberniia [Provincial] Reform Act in 1775. The number of Russian guberniias increased in an attempt to make local provincial governments more responsive to the people. One of the provisions of this act was for each guberniia to establish Departments of Public Welfare. These new departments were responsible for providing health care for the majority of Russians living in rural areas. Part of that health care was to provide services for the mentally ill, not through monasteries but in asylums, which were referred to as ‘Yellow Homes.’ The first of these homes was established in Novgorod the following year, while at the same time a 26-bed psychiatric clinic was attached to a Moscow hospital. By 1761, a special psychiatric hospital was built just outside of Moscow. Gradually these psychiatric clinics increased in number, from 14 clinics in 1810 to 43 by 1860.11

8


Regarding these psychiatric clinics, a contemporary account in the Poltava region in 1801 described a scene worthy of Dante’s Inferno. The institution was designed to hold approximately 20 individuals, and living conditions could be best described as primitive. Patients slept on straw covered floors, segregated into violent and quiet individuals, with non-violent patients rewarded 60 days a year by receiving meat with their meals. Therapy was generally punitive in nature, including a ‘dripping machine,’ which dripped water on a patient’s head, 17 rawhide straps and 11 metal chains used for patient restraint. Russia, along with many Western nations, viewed patients with mental illness as threats to the general society and asylums as a place to keep these people safely confined. Therapy and rehabilitation were not high priorities.12 The fact that the major medical educational facility was the MedicalSurgical Academy in St Petersburg meant that the best-trained doctors in Russia by the nineteenth century had a close affiliation with the military. But how did they gradually become involved with the newly evolving medical science of psychiatry? A significant factor in the organization of psychiatry as a field of study at the Academy was the Russian judicial system. From approximately 1775 to 1850 Russian intellectuals referred to a phenomenon called the ‘shame of the courts.’ Mentally ill people brought before the courts for crimes they had committed resulted in the legal system searching for some means of examining these individuals in order to determine their mental competency. Gradually rejecting supernatural reasons, such as witchcraft or sorcery, the courts turned to the Academy to provide some kind of scientific, medical reason for their apparent insanity. By 1832 a department of legal medicine was formed at the Academy with lectures in basic psychology offered through the department. Many offered were based upon one of the first Russian academic dissertations on mental illness by P.P. Pelekhinim, ‘On the Nature of Mental Illness’ (1829). Pelekhinim had studied under Professor S.A. Gromov, who in 1832 wrote ‘Mental Illness in a Legal-Medical Aspect.’ These men were not trained psychiatrists but rather doctors interested in mental illness. They emphasized the biological and bodily processes at work in these disturbed individuals, but perhaps their most significant conclusion was the need for specially trained physicians in mental illness.13 This task was taken up fairly quickly. A new charter was given to the Medical-Surgical Academy in 1835 allowing classes in psychiatry to be offered within the internal medicine and pathology division. The first instructor was P.D. Shipulinskii, a graduate of the Academy’s philosophy department in 1831. For four years he taught classes in psychiatry, six hours a week. The value and quality of his work was recognized when the Academy stated that Shipulinskii ‘… has provided special benefits to students with his classes in psychiatry and his practical instructions for the treatment of the mentally ill located at the second Army hospital.’14 Other schools soon followed and by 1846 a clinic was opened at the second Army


9

hospital for the treatment of psychiatric illnesses in Russian servicemen. This process culminated with the Imperial decree of 29 January 1857, creating a new medical department for mental and nervous disease.15 This seemingly rapid acceptance of psychiatry as a legitimate medical science was not realized, however, outside the academies. To begin with, regular Russian military doctors were poorly regarded. Medicine was not an occupation of the aristocratic officer class. Physicians had a difficult time fitting into the strict structure of Russian society. Their training and intelligence should have placed them high up in the table of ranks but some in the military saw them as upstarts and threats to their authority. Russian physicians had a history of community service but their rank in the social structure was insufficient to make needed changes in the medical system. Thus officers looked down upon doctors as their social inferiors, not much better than barbers, while doctors chafed at the idea that men with limited education made the crucial decisions regarding the medical profession. To make matters worse, doctors were often put at odds with the common soldiers by their duty to examine and certify the health of soldiers before they were to be flogged for some military infraction. In the late nineteenth century, this situation was exacerbated for fledgling psychiatrists because both military officers and other medical specialists felt that psychiatry lacked the validation of scientific research. The solution to this dilemma was twofold. First, Russian psychiatry needed to establish itself as a genuine profession, based on principles of science and medicine. Second, in order to achieve this goal, it would need the resources to carry on proper research into mental illness. Since much of Russian medical research and education was tied to the military, a symbiotic relationship between the military and psychiatry could be extremely helpful to the young medical profession.16 But what could psychiatry offer to the military? The Crimean War (1853–6) offered the first evidence of possible benefits that psychiatry could offer the Imperial Russian military. At this time, the Tsarist army perceived mental illness among its members as shameful, particularly among officers, whose behavior could compromise the honor of an entire unit. During the war, only six soldiers were evacuated based on some kind of ill-defined mental illness.17 However, the poor performance of the Russian military ushered in a series of reforms that also carried over into the medical field. In fact the war brought forth one of the first of a series of important medical reformers in Russia, Nikolai Ivanovich Pirogov. Pirogov was an outstanding researcher, teacher and surgeon. He pioneered the use of ether narcosis and inflexible gypsum bandages but is best remembered as the father of military surgery. His work Foundations of General Military Field Surgery18 was based on his experiences during the defense of Sevastopol in 1854. The chief Russian medical society, founded in 1883, was named ‘The Pirogov Society’ in his honor. But it was his observations regarding shortcomings in Russian military medicine that would

10


play a major part in the future of Russian military psychiatry. In his opinion the greatest shortcoming in Russian military medicine was not lack of surgical skill but the lack of professionalism and organization. His criticism would be repeated 25 years later during the Russo-Turkish War (1877–8), when the general opinion was that the war ‘… brought to light many deficiencies in the system of battlefield organization and medical supply.’19 These observations were not lost on military psychiatry. Soon after the Crimean War in March 1859, the Chief Military-Sanitary Committee that included a psychiatric branch met in order to work on the problems identified in the military medical establishment. Of particular importance was the decision to create a military psychiatric school under the directorship of Ivan Mikhailovich Balinskii. Balinskii had been teaching psychiatry as an independent discipline at the Medical-Surgical Academy since 1857 and had opened the first clinical department of mental illness in St Petersburg two years later. He became involved in the controversy regarding the use of psychiatry in the Russian court system. Considered by many to be the ‘father of Russian psychiatry,’ Balinskii gave military psychiatry a growing sense of respectability. The increased role of military psychiatry can be seen by the distribution of government statistics regarding the number of illnesses and deaths that soldiers from a variety of military districts suffered in 1871. Table 1.1 is an account of this incidence of mental illness in the Russian army in 1871. There are a number of significant points in this study. The

Table 1.1 Incidence of mental illness in the Russian army, 1871 Military district

Mental disturbance

Petersburg Finland Riga Vilnius Warsaw Kiev Odessa Kharkov Moscow Kazan Caucasus Orenburg West Siberia East Siberia Total

Ill 145 10 23 47 45 29 38 74 104 70 158 26 4 10 783

Died 33 0 5 4 8 5 1 6 14 1 7 2 0 0 86

Source: Litvintzev/Kuznetzov (1998), p.26.

Alcohol Ill 206 5 23 36 131 39 34 72 130 47 126 42 44 46 981

Died 0 0 0 0 4 2 1 3 2 1 8 1 2 4 28

Epilepsy Ill 64 0 29 39 115 44 52 44 78 101 189 26 13 3 797

Died 0 1 0 3 0 2 1 2 4 6 8 1 0 0 28


11

first is that in 1871 the Russian military felt that it was important to quantify the number of mentally ill soldiers within its ranks. Recognition of mental illness in the army provided an opportunity for Russian military psychiatry to show what it could offer. The wide array of ailments that are dangerous to the human body led to the specialization of medicine in the eighteenth and nineteenth centuries. Diseases such as cholera and typhus led some Russian physicians into public health while surgery grew more specialized, in part due to the wide variety of wounds that were seen on the battlefield. The acceptance of mental illness as a genuine threat to the effectiveness of the army meant that psychiatry could fill the niche in order to provide diagnosis and treatment to soldiers suffering from a number of mental disorders. Military psychiatry at this time was still in its infancy and the vague definition of mental illness as listed in the 1871 study was indicative of psychiatry’s tenuous grasp of basic psychiatric concepts. Alcoholism and epilepsy were separated from mental illness, but a wide variety of possible symptoms were lumped under a single diagnosis. To meet the demands of Pirogov’s entreaty to improve battlefield organization of the medical services, diagnosis of mental illness would have to be refined in order to determine questions of appropriate treatment and chances of recovery. In order to do this, more work would have to be put into theories behind the origin, prevention, and care and treatment of the mentally ill. These numbers are vague and can be misleading. Without the total number of soldiers present in each district, percentages cannot be determined, therefore the relative presence of mental illness in each district is unavailable. The high numbers present in the Moscow, St Petersburg and Caucasus military districts were probably more an indication of larger concentrations of Russian troops in these areas than a sign that these districts were more prone to mental illness. The source of mental illness in early Russian history was believed to exist in areas such as witchcraft and sorcery. By the nineteenth century theories regarding the origins of mental illness were beginning to change. Russian researchers followed closely the work of Western Europeans as far back as the 1600s when French and German research suggested that hysteria was an illness of the brain or the nervous system. In the next century comparative studies were made between hysteria and hypochondria, with the consensus being that women were prone to hysteria. In 1884 a significant event occurred during the Berlin Medical Conference. Serious questions began to be asked about male hysteria and its tendency to occur in the military. Russian researchers were already beginning to delve into this phenomenon, examining retired soldiers in Siberia for hysteria. Meanwhile, studies were conducted in Germany on 57 hysterical patients, 11 of whom were in the military, while the French researcher Batault examined 105 hysteria cases, including 12 officers and 7 common soldiers.20 Those who studied this problem grappled with the essential question of what caused this mental illness or hysteria with the issue coming down on the relationship of the mind and body.

12


Dualism, the theory that argued that mind was separate from matter, clashed with the opposing theory of materialism claiming that the actions of the mind could be explained through the brain and the nervous system. The materialist theory took root in Russia. One of its earliest and bestrespected advocates was the physiologist Ivan Mikhailovich Sechenov who wrote the outstanding work Reflexes of the Brain.21 An early advocate of Sechenov was V.M. Bekhterev, who would dramatically change Russian psychiatry. Bekhterev was the son of a low ranked government official and grew up along the Volga. He graduated from the Military-Medical Academy, where he was one of approximately 250 graduates from the 1878 class.22 He specialized in functional brain anatomy, experimental psychology, and clinical neurology. His work was prodigious, including publishing over 350 books and articles on neuroanatomy, physiology and psychiatry. Regarding psychiatry, Bekhterev is best remembered for his attempts to humanize the treatment of the mentally ill in Russia. He argued for dispensing with restraints in asylums and changed the whole structure of asylums by advocating the construction of clinics modeled after small homes with a feeling of normality, including kitchens, libraries, pools and research labs on the premises. On 19 November 1897, Bekhterev opened a new clinic in St Petersburg with 26 patients, quickly building room for an additional 20. Here patients were divided between calm and aggressive individuals and were also further classified according to their own unique symptoms. Treatment consisted of trying to bring the patients out of their illness by placing them in an environment as normal as possible. This would include work therapy and more radical therapies, such as radiant X-ray. Along with his partner, I.P. Merzheevskii, Bekhterev developed ideas for the characteristic symptomatology and clinical appearance of mental illness. From this work came the concept of degeneration of the nervous system due to stress, injury, disease or some combination of these factors.23 His work gradually gained the respect of not only foreign scientists but also his own government. This new found respect resulted in the work of other researchers being recognized by the Tsar. For example, Alexander III in 1896 approved the research results of A.V. Timofeev and directed additional funds for the treatment of mentally ill military personnel. Timofeev’s observations included the following: 1) the speed at which acute psychoses advanced depended on the duration of the event that brought about the illness; 2) soldiers suffering from nervous exhaustion responded well to artificial feeding; 3) hysteria among attacking units or those that were surrounded was rare; 4) supervision of mentally ill soldiers required fewer personnel than were currently assigned; and 5) it was rarely necessary to isolate mentally ill patients. These suggestions were forwarded to Bekhterev who sent them to the Military-Medical Academy Studies Committee, and by the end of the year they were distributed to all military-medical hospitals. What effect these guidelines had is difficult to discern since no fully developed strategy


13

was followed to ensure the implementation of these ideas and no attempt was made to prepare Russian military psychiatry for future conflict.24 Still work proceeded. The French psychiatrist Dupanchel wrote Hysteria in the Army (1886) based on his observations of the French Army. He developed six classifications of hysteria, which were accepted by Russian military psychiatry. They included hysteria with muscular contractions that closely resembled epilepsy. Also traumatic paralysis, mutism and stammering were recognized as specific kinds of war related hysteria. Dupanchel’s work mirrored the findings of the Russian psychiatrists such as Tikhomirovum and Borisov who led the 1889 Odessa Military-Sanitary Society conference on hysteria within the military. The conference agreed that war hysteria could be avoided through the use of increased free time for soldiers, clean and sanitary barracks, and nutritious food. These results were put to practical use in places like the Nicholas military hospital in St Petersburg where, in 1890, 16 soldiers suffering from hysteria were closely examined and treated.25 The soldiers’ symptoms seemed to confirm the presence of unique symptoms for specific kinds of mental illness and the possible efficacy of new treatment procedures. Two significant works were published in the next ten years that focused the debate of Russian military psychiatry up to the Russo-Japanese War. The first was published by the Russian psychiatrist A.I. Ozeretskovskii, titled Hysteria in the Military (1891). This work was a fine example of Russian military psychiatry. Ozeretskovskii was well versed in European research, especially that of the Frenchman Charcot. His most important contribution was providing doctors with a clear symptomatology of hysteria or war neuroses as it was beginning to be called. He described 12 major symptoms, including convulsions, muscle contractions, tremors, paralysis, speech and auditory disorders, and exhaustion. Regarding the cause of war neuroses, Ozeretskovskii observed that in many cases of hysteria the individual had a family history of mental disease. This could impact the overall health of the nervous system and increase the incidence and scope of war neuroses. Physical trauma and mental stress all produced a reaction in the brain that could run along a continuum from minor irritability to paralysis. The general health of the nervous system prior to stress and trauma determined where along the continuum the patient would display symptoms. For example, a patient with strong initial nervous constitution prior to trauma might display the most minor symptoms, such as difficulty sleeping, and not even be diagnosed as suffering from a mild form of hysteria. Another patient, who for a variety of reasons has an already compromised nervous system, might display symptoms as severe as communication disorders or muscle contractions/paralysis. The role of family history ran counter to a strict materialistic view of mental illness and was considered by some Russian psychiatrists to be the result of Ozeretskovskii’s acceptance of Western theories. Regardless, Ozeretskovskii’s treatment recommendations of work therapy, sanitary conditions, and nutritious food suggest that by altering the environment

14


and providing the resources for an individual to develop a strong nervous system, war neuroses can be avoided. Such opinions became formalized with the publication of S.S. Korsakov’s Course in Psychiatry in 1901. This was the text adopted by the MilitaryMedical Academy at the turn of the century, written by perhaps the finest Russian psychiatrist of the time. Korsakov (1853–1900) was born in Vladimir province where his father managed a glove factory. He studied medicine at the University of Moscow, graduating in 1875, but over time moved into psychiatry. His principal fields of research included the study of paranoia, psychiatric symptoms of alcohol poisoning, and schizophrenia. Like Bekhterev, Korsakov believed in the ‘no-restraint’ policy for the mentally ill and furthered the idea of treatment taking place in a friendly, natural setting by advocating the use of family care for psychotics. Finally, he also believed strongly in the idea of a professional journal that could disseminate research and findings throughout the empire. His dream was realized a year after his death with the publication of the Journal of Neuropathology and Psychiatry. His multi-volume text, however, included only two pages on war neuroses. This indicates how the problem of war neuroses was seen as compared to psychiatry as a whole. Still, his notes were important. He stated that war always increases the number of mental illnesses, not just among soldiers but in the population as a whole. These are not new illnesses, but rather extreme forms of pre-existing conditions within society. For example, Korsakov pointed out that delusional behavior was not unknown in peacetime and often had a contemporary flavor, but in war the symptoms become exaggerated. So in peacetime patients may cry out that they are Bismarck or Dreyfus, while in times of extreme stress or war, they may claim to be the anti-Christ. Korsakov warned that these claims are not simply attempts to shock doctors or to fake their illness. Rather they are genuine symptoms of delirium or some other kind of mental illness.26 One more strand needs to be added to this story of early Russian military psychiatry and that is the role of the Zemstvo act of 1864. The Zemstvo reforms allowed local government to take some responsibility for public health care. This was not always successful and was highly controversial. Some saw it merely as a way for the central government to shirk its responsibilities, while others saw it as a step for genuine progress. Regardless, the effect it had on psychiatry was a rapid increase in local outpatient clinics, daily treatment for the mentally ill, and the opportunity for family members to care for patients in their homes. By 1892, the Zemstvos administered and supervised 34 psychiatric hospitals, 9,055 beds and approximately 90 psychiatrists, primarily located in Western Russia. The effects Zemstvo reforms had on Russian psychiatry varied. They helped psychiatrists to further advance their occupation. More Russians now knew the contributions that psychiatry could provide society. Yet bureaucratic interference invaded the realm of Russian health care, with the


15

deadly cholera epidemic of 1892–3 being one of the most egregious examples. The result of this interference was the gradual radicalization of the Russian medical profession. Voices spoke out advocating that military medical officers should be given the respect due to their rank and education. The Pirogov Society from 1902–4 declared that it was the moral duty of military doctors to refuse to participate in floggings and other inhumane forms of discipline.27 Such radicalization was certainly not welcome in the conservative Imperial Russian officer class. The 14 March 1904 incident involving Nikolai Zabusov served as an example of the tensions between officers and doctors in the Russian army. Zabusov, chief physician of the Central Asian railroad in Ashkhbad, was summoned without explanation to the headquarters of Major-General Kovalev, commander of the Transcaspian Cossack brigade. There, without reason, Zabusov was beaten, then sent away. An instant furor ensued, and the subsequent trial resulted in Kovalev being let off with a light sentence, which infuriated the medical profession.28 For those in the medical profession, this served as a prime example of the gulf between officers and physicians and the impossibility of reforming military medicine. If chief physicians were treated this way, one can only assume that psychiatrists were certainly not treated any better. This need for reform was not limited to just the Russian military or the medical profession. The 1905 Russian Revolution soon made the call for reform nationwide. By the beginning of the twentieth century, Russian psychiatry was beginning to be accepted by the scientific community as a separate discipline within the medical profession. This acceptance, however, had not carried over into the military sector for a variety of reasons. The concept of mental illness had changed radically from when monasteries were the caretakers of the insane and mental illness was regarded as being caused by supernatural means, with modern explanations at times just as mysterious. Psychoses and neuroses29 were difficult concepts to grasp, especially for military officers accustomed to battlefield casualties such as fractures, cuts and bullet wounds. Also, for many Russian officers, soldiers were to be treated as nothing more than ‘… rows of cattle,’ who readily fake mental illness to avoid military duty.30 Psychiatry itself was at fault for this mistrust. Psychiatric research was highly detailed and seemingly esoteric. Questions of the dualistic or materialistic nature of the mind may have challenged the intellectuals and writers of nineteenth century Russia, but to the military officials of the Russian army these ideas were alien and perhaps dangerous. One reason for difficulty in comprehension was a division within Russian psychiatry itself. Two schools of psychiatric research and thought were emerging in Russian psychiatry, one centered in Moscow, the other in St Petersburg. The Moscow school was concerned with the body’s internal processes and psychopathologies, while in St Petersburg the source of mental disease was seen more in external factors, and treatment focused on psychotherapy and

16


physical rehabilitation. Both schools, however, failed to make a solid case for the validity of their discipline. A surgeon could amputate a leg and prevent gangrene, or set a fracture to allow a soldier to walk again, and the positive results of these procedures were readily observable. By 1900 it was still difficult for a military psychiatrist to understand what was wrong with a soldier and, more importantly, what to do with him. Finally, the degree to which the results of modern psychiatric research had permeated throughout the empire was dubious. Russian history is filled with examples of discrepancies between theory and fact. The infamous ‘Potemkin villages’ warn students of Russian/Soviet history that laws and instructions can pour from the capital but it does not mean that they become reality. Anton Chekhov’s story ‘Ward Six,’ describes the entrance into a small psychiatric clinic during the time of the Zemstvo reforms. Whole mountains of hospital rubbish are piled against the walls and stove. Mattresses, old tattered dressing gowns, underdrawers, bluestriped shirts, utterly useless worn-out boots and shoes – all this litter lying in jumbled, raddled, moldering heaps and giving off a stifling odor.31 Chekhov, a physician by training, did not give his psychiatrist the humanistic ideas of Bekhterev and Korsakov on how to properly treat the mentally ill. Here there were no kitchens, gardens, or family-like environment. While more humane concepts for the treatment of the mentally ill had developed a following in Moscow and St Petersburg, these new beliefs became lost in the rural Russian provinces. The gap between psychiatric theory and practice became significant when war broke out with Japan in 1904. Many of these same rural physicians were placed in charge of psychiatric care in the military. The combination of new military psychiatrists and Russian officers was difficult. For the former, war was an opportunity to gain the respect they felt they deserved and operated as a gigantic laboratory for the study of male hysteria and war neuroses. But in order to prove their worth, military psychiatrists required a fair degree of independence in how they operated. The psychiatrists wanted the money and supplies to support a proper organization designed to diagnose, care and treat NP casualties, but these hopes were dashed in the face of the necessities of war. Officers, with only a limited amount of transport, men and supplies, and who already viewed the medical establishment prior to the war with disdain, balked at the idea of allocating time and resources to an unproven discipline. The forthcoming Russo-Japanese War was a severe test, not only for military psychiatry, but also for the entire empire.

2

The Russo-Japanese War

Our army will inevitably have many cases of mental illness.1

The Russo-Japanese War (1904–5) was military psychiatry’s first significant test of its value and effectiveness to the Russian army. Militarily, the war challenged the new reforms carried out by the Russian high command. It also tested Bloch’s theory of the impassable wall of fire. Machine guns, trenches, wire and high explosives made the Russian soldier dread the order to advance across an open field. In addition, racism blinded the Russian military to the real strengths of the Japanese armed forces. This distant war provided Russian psychiatry a golden opportunity to make its case as a legitimate medical science by directly aiding the military effort. But perhaps the paramount problem facing Russia would be the vast distances that military logistics would have to overcome in order to supply troops. This dilemma would plague Russian military psychiatry and resulted in the inability to organize effective psychiatric help at the front, the very task that Pirogov argued after the Crimean War.2 A fully developed plan to provide supplies and personnel for psychiatric aid was never formulated. For example, in the Zabaikal and Priamur regions no military psychiatric supplies, such as diagnostic books and drugs, were stockpiled. Nor were construction plans available in order to build psychiatric clinics. During mobilization, specialized psychiatrists arrived in Harbin and Chita and were met with blank expressions as their calls for help and personnel were largely ignored. An observer from the second Psychiatric Congress expressed his ‘… surprise, over how greatly the military-medical department managed to fall behind in the organization of psychiatric matters.’ No one in the military seemed to know about these affairs and showed little inclination to alter them.3 In order to provide psychiatric aid without delay, P.M. Avtokratov, the military physician in the Warsaw district and a student of Bekhterev, was sent east to organize the Russian Red Cross and, through it, develop a procedure for dispensing psychiatric aid. In the spring of 1904, the first military hospital was established outside the city of Harbin. It included one small room, holding six

18


beds for the treatment of mentally ill patients. By September, the number of beds grew to 30. Despite the poor conditions, clinics were staffed with capable Russian doctors and psychiatrists, such as E.S. Borishpolskii, G.E. Shumkov, I.D. Ermakov and V.K. Shmidt. Further demand for psychiatric aid was met on 22 June 1905, when the decision was made to establish psychiatric departments in those hospitals in the Priamursk and Siberian regions, along with those in the cities of Harbin, Chita and Irkutsk. The significance of these efforts was that the military hospitals, along with Red Cross facilities, were able to begin the study of functional characteristics of war neuroses, their outcomes, and viable treatment options.4 Statistics regarding NP casualties during the Russo-Japanese War can be elusive for a number of reasons. There was no standardized system of diagnosis and even psychiatric terms were still hazy regarding their definitions. Individual hospitals and clinics kept their own records and there were only limited exchanges of information among the various medical institutions. Still, some numbers were compiled and can be useful as points of discussion to determine how far Russian military psychiatry had progressed by the opening of the century (see Table 2.1). At first glance the difference between these patients and those examined in 1871 (Table 1.1) is the growing sophistication in diagnosis regarding mental disease. While epilepsy was still regarded as a distinct mental disorder, the 1870s concept of mental disturbance was refined to include diseases particular to the brain, spinal cord, and the peripheral nervous system. This reflected the materialistic basis of Russian psychiatry. These distinctions were further refined at the local hospital level, as Table 2.2 based on statistics taken from the Central Harbin Psychiatric Hospital demonstrates. This data further exemplifies the drive to refine diagnoses and clarify the growing specialized nomenclature of psychiatry. There still existed topics of controversy. For example, psychiatric casualties were roughly grouped according to previously existing conditions, those brought on by Table 2.1 NP casualties in the Russo-Japanese War: 1 February 1904–1 January 1906 Forms of disease

No. of patients

Brain disease 396 Spinal cord 220 Brain and spinal cord 113 Peripheral nervous system and paralysis 4278 Hysteria and nervous exhaustion 6225 Epilepsy 1521 Total 12753 Source: OSM, p. 16

Officers

Soldiers

44 61 12

352 159 101

373

3905

2002 42 2534

4223 1479 10219


19

Table 2.2 Admissions to Harbin Central Psychiatric Hospital, 15 December 1904 – 18 March 1906 Admitted Illness

Recovered

Transferred

Died

Officers Men Officers Men Officers Men Officers Men

Epileptic psychoses Hysterical psychoses Nervous exhaustion Degenerative psychoses Manic–depressive psychoses Manic agitation Melancholy Amentia Hallucinations Acute onset dementia Dementia praecox Catatonia Initial imbecility Secondary imbecility Alcohol psychoses Acute alcoholism Periodic psychoses Polyneuritic psychoses Post-infection psychoses Graves’ disease Poisoning psychoses Traumatic psychoses Organic brain disease Progressive paralysis Syphilis Congenital imbecility Malnutrition psychoses Presenile imbecility Unknown Total

13 4 30 18 0 0 3 1 4 0 5 4 11 0 92 15 2 3 5 0 0 8 9 29 0 0 0 1 9 266

292 29 39 28 18 5 17 46 36 15 47 27 38 5 113 26 7 0 51 2 2 34 29 45 2 36 2 0 23 1014

0 2 10 0 0 0 0 0 0 0 0 0 0 0 13 15 0 0 0 0 0 1 0 0 0 0 0 0 4 45

0 0 0 0 0 0 0 0 1 0 0 0 0 0 3 24 0 0 0 0 2 0 0 0 0 0 0 0 4 34

13 2 20 18 0 0 3 1 4 0 5 3 11 0 79 0 2 3 4 0 0 7 4 29 0 0 0 1 5 214

289 29 39 28 18 5 17 74 35 15 47 26 18 5 110 2 7 0 49 2 0 34 23 41 2 36 2 0 10 963

0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 5 0 0 0 0 0 0 7

3 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 2 0 0 0 6 4 0 0 0 0 0 18

Source: Avtokratov (1906), p. 741

direct trauma, those due to environmental conditions inherent in warfare and a more nebulous category which included conditions such as hysteria and nervous exhaustion. For a materialist theory to be viable, these illnesses needed an explanation. But the ability to scientifically examine the

20


nervous system at the level required to determine actual physical exhaustion of nerve cells and fibers called for a technology and methodology not yet available. A better illustration of the confusion existing among Russian military psychiatrists is found in Table 2.3 which looks at a variety of military hospitals that dealt with psychiatric casualties. The diagnostic names remain somewhat consistent but the number of patients treated for identical disorders among the various hospitals have significant differences. At the N-Ussuriiskii military hospital, the grouping of nervous exhaustion, hypochondria and hysteria accounted for 5.3 percent of total patients, but at the Moscow military hospital, nervous exhaustion alone accounted for 24.0 percent. Such a variance might be explained by chance or perhaps some hospitals specialized in different ailments. There is no evidence to suggest that such specialization existed. Two other explanations seem more likely. One is that different psychiatrists at different locations, while examining patients with similar symptoms, came up with different results. The other possibility would fit with the materialistic view of psychiatry popular at the time. This view argued that a patient’s symptoms ran along a lengthy continuum from stuttering to acute paranoia. The etiology of the disease was the same, but a patient’s symptoms depended upon where he was along this continuum. Thus the number of nervous exhaustion patients in Moscow might be explained by a lessening of their symptoms over time as compared to their neurological display at the time of initial hospital admittance. Among the military, the confusion that psychiatrists experienced was even more profound. The biggest obstacle for officers to overcome was the implications of NP casualties for overall military effectiveness. A broken leg or bullet wound through the lung was an obvious impairment that both officer and doctor could agree on. For many officers, nervous exhaustion was simply a sham. The common assumption among officers was that the Russian soldier ‘… never gave up hope, never lost faith, never quit believing that he was stronger than the Japanese.’5 Anything less was cowardice. Considering the gulf that existed between Russian officers and enlisted men, it is difficult to understand how the officers knew what the common soldier was thinking. There were obvious signs of the disconnection between officers and men. Drunkenness, desertion and self-mutilation were not uncommon events in a war where Russian soldiers asked, ‘Why die faraway from home for a piece of Chinese land?’6 Concerned with strategy and tactics, glory and honor, it would not be unusual for Russian officers to have no idea what the feelings of enlisted men were. Though not the first war that identified psychiatric casualties,7 the Russians were concerned enough with the numbers of men displaying such a wide variety of neurological symptoms that they devoted renewed effort and research into the phenomena of psychiatric casualties. Obviously, the most immediate and important task was the care and prevention of these casualties. Prevention in the Russian army revolved


21

Table 2.3 Ratio of several groups of illnesses in Army Treatment Centers, 1904–5 Author (year of study)

Institution name and no. of observations

Lybabarskii, A.V. (1907)

N.-Ussuriiskii military hospital (283)

Illness

Acute paranoia 22% Nervous exhaustion, hypochondria, hysteria 5.3% Borishpolskii, E.S. (1909) Combined data (2373) Alcohol psychoses 19.6% Epileptic psychoses, epilepsy 20.0% Yakubovich, L.F. Harbin military hospital Epileptic psychoses (943) 20.2% Yakubovich, L.F. (1907) Vilenskii military hospital Epileptic psychosis 2.2% (225) Nervous exhaustion 2.8% Hysterical psychosis 1.3% Vladchko, S.D. (1907) Port Arthur military Amnesia 18.1% hospital (38) Melancholy phase of manic-depressive psychoses 16.0% Nervous exhaustion psychoses 10.0% Traumatic psychoses 7.0% Shaikevich, M.O. Moscow military hospital Depressive-stupor 21.2% (1300) Hysteria 2.0%, Epilepsy 8.8% Nervous exhaustion 24.0% Traumatic neuroses 4.8% Epileptic neurosis 0.25% Source: Ivanov (1970), p. 22

primarily around improving the living conditions of soldiers. These improvements were not solely to provide a better psychological environment for the troops. Rather, the army realized that better sanitary conditions made for physically healthier soldiers, and this happened to correspond to ideas developed in Zemstvo psychiatry that also emphasized concepts such as clean living spaces and nutritious food. The ability to raise standards was greatly assisted by General A.N. Kuropatkin, who urged the construction of small trunk lines providing supplies from the main depots along the Trans-Siberian railroad to the immediate fronts.8 Food and military supplies would be the fuels to keep the machine moving. Regarding screening of recruits prior to the Russo-Japanese War, it is difficult to make any conclusions. Based on figures from the Central Harbin Psychiatric Hospital (Table 2.2), some soldiers were admitted into the army with pre-existing conditions. At least 88 officers and men were admitted who were diagnosed with some kind of earlier mental illness or a congenital

22


mental disorder. The chief administrator at the hospital, Professor Avtokratov, stated that he witnessed cases of officers sent to the front who were already in the early stages of partial paralysis brought on by arterial sclerosis. Also it was not uncommon for soldiers, already treated for some kind of mental disorder such as chronic alcoholism, to be sent back to the front three or four times.9 Effective pre-induction screening depended upon qualified personnel in charge of the process. Russian psychiatry was not yet firmly established and was unable to provide an adequate number of qualified psychiatrists to make pre-induction work. Treatment was also haphazard. Owing to the initial disorganization of the psychiatric services, the system never seemed to catch up with the increasing flow of patients. The result was that soldiers who were diagnosed with a mental disturbance and did not recover simply from rest were often shipped across Russia to Moscow for further observation and treatment. Treatment in the Russian army was exemplified by the Central Harbin Hospital. In early 1904, the first psychiatric clinic was attached to the first military hospital and administered by Dr Borischpolski. By December over 400 patients had come through, with the number of admissions that month being six times higher than when it opened in the spring. This overwhelmed their resources, so that on 15 December 1904, the Russian Red Cross, under Avtokratov, established a new 50-bed psychiatric hospital in Harbin.10 A key ingredient for success was prompt psychiatric treatment close to the battlefield. Special ambulances were provided with a psychiatrist, an aufseher (similar to a medic or nurse) and three other men for litter bearing and other physical work. Initial diagnosis was made in the ambulance but the real work began after patients arrived at the hospital. There, they were divided into four groups: officers who were quiet, those who were agitated, and the same two groupings for the common soldiers. An experienced psychiatrist was on duty at Harbin and also at the ever-growing number of clinics, such as those at Mukden, Chita and Irkutsk. The following demonstrates the pace of work at Harbin: 1 2 3 4

Average patient time in the hospital: 15–16 days Average number of patients per day: 43 Average monthly admission: 90 Average monthly transfer to Moscow: 82

The Harbin psychiatric team also recorded the fate of these men. Of the 266 officers and 1,014 enlisted men that passed through the hospital, 79 recovered, 1,177 were transferred to Moscow, and 25 died. Harbin, as with the other psychiatric clinics in the war zone, exemplified the chief distinction of Russian military psychiatry and that was the transfer of over 85 percent of its patients to Moscow. Besides rest, the only other viable treatment option seemed to be a ticket home.11


23

The transfer system was adequately planned but execution was a different matter. The 5,000-mile journey by rail took approximately a month. Needless to say, the transfer of psychiatric casualties for such a long period of time posed a series of problems. In order to offset these difficulties, a number of procedures were followed. Patients were quartered in three railroad cars, one for the officers and two for the enlisted men. The officers, along with the responsible psychiatrist and some nursing sisters, traveled in a second class car, while the soldiers’ cars held only bunks and a small stove. All cars had barred windows. Some space was reserved for agitated or violent cases.12 To ease the long journey and provide more detailed care along the way, small clinics were established at Chita, Krasnoyarsk and Omsk. Each clinic had an experienced psychiatrist in charge and could hold approximately 15–20 patients. Men whose physical health had deteriorated to dangerous levels were left at these way stations in order to recover and continue to Moscow, or to die. These clinics were adequately staffed but contained only the bare necessities such as iron beds with grass mattresses and isolation rooms. During its wartime operation, Harbin made 37 transfers to Moscow, generally two to four times a month. Approximately 30–32 enlisted men and six to eight officers were transported each time, along with some 45 attached personnel. Besides a psychiatrist, two feldshers (army surgeons) and two nursing sisters, attendants and a small guard detachment were also assigned to each journey. But while the planning and organization seemed adequate, physicians who made the trip voiced several concerns. The cars were not properly designed. Ventilation was poor. Patients were able to get up from their beds and move between cars where they could jump to escape or to kill themselves. Since officers and the only physicians were part of second class, they were physically separated from the two cars that held the enlisted men. Delays were frequent along the torturous journey that tended to aggravate the patients even more. This was especially true along those parts of the trip where the distance between satellite clinics was great. For example, it was eight days between Chita and Krasnoyarsk and ten from Omsk to Moscow. Almost surreal situations occurred when inexperienced and uneducated guards began to obey the orders of officers diagnosed as psychiatric casualties. Finally, some soldiers were being released from care in Moscow too soon. An unidentified number were sent back east only to become hospitalized again, while at least one soldier committed suicide soon after his discharge from the hospital.13 Looking at Table 2.2, one can see that substantial effort was placed on differential diagnosis, which has a variety of reasons. The greater the complexity of mental disease or injury from war, the greater the need would be for trained psychiatric professionals. This corresponded closely with the pre-war desire to organize Russian medicine and give legitimacy to psychiatry. Expanding on this idea, the vague etiology and complex syndromes

24


exhibited by soldiers returning from the front made it important to correctly interpret these factors in order to derive a proper treatment protocol. Drawing upon an analogy from general medicine, a doctor needed to know the nature and extent of an injury before prescribing treatment. Therefore, for Russian military psychiatry, the specific nature of these mental disorders had to be investigated and carefully defined. Among Russian military psychiatrists, one of the most surprising signs of mental disorders was the relatively high number (305) of cases with epilepsy. While a detailed history of these patients found some evidence of prior attacks, the vast majority were previously quite healthy. It was generally concluded that fear and physical exhaustion could produce epilepsy in soldiers with no previous history of the disorder. Slight or partial paralysis (paresis) was found in 74 cases. Interestingly, psychiatrists attributed this to prior infection with syphilis, and the war seemed to speed up the process of paresis. Earlier studies noted that paresis may develop from 12 to 20 years after the primary syphilitic sore was discovered. During the fighting, however, paresis developed even though it had been only five to ten years since the initial diagnosis. Battlefield stress speeded up the progression of the disease, leading to a much earlier display of paralysis than it would have in peacetime. A variety of psychoses were identified. Considering the reputation for heavy drinking among Russians, the number of alcohol psychoses was not significantly higher during the war in comparison to peacetime. Assuming that alcohol is a means of self-medication in times of stress, one may venture the conclusion that war stress was not much greater than everyday life for many of these men. Post-infection psychoses were closely tied to typhoid fever, especially in the months of August and September 1905. These cases were mostly stabilized by the time they reached Moscow. Nervous exhaustion and hysteria proved a curious and controversial diagnosis at the time. For many Russian officers, this was simple cowardice even though officers were not immune to these conditions. Cases usually exhibited initial hysterical fear and great bursts of energy but, like an overloaded circuit, would eventually burn out with patients becoming physically and mentally exhausted. For many days patients would often remain unaware as to how and why they were in a hospital. Eventually, after rest and proper food, most soldiers would recover, but it was quickly noted that many would have recurrences of such conditions when returned to combat. Some evidence suggested that individuals who demonstrated such symptoms as hysteria and nervous exhaustion had a previous history of such disorders. Difficulties in getting accurate statistics regarding NP casualties are highlighted by the category of traumatic psychoses. These patients, unlike those with hysteria, suffered some kind of obvious, actual physical trauma that resulted in behaviors not typical of simple tissue or bone damage. These psychoses often developed some time after the initial trauma. Thus the


25

patients were admitted initially as traumatic wound patients, not psychiatric ones and were usually treated in standard military hospitals. The Harbin psychiatric hospital served as a filter, taking care of the mild cases that required primarily rest, and sending on the more severe cases to Moscow where detailed examination of these casualties occurred and patients were provided slightly more sophisticated forms of treatment.14 Generally within 24 hours of patients arriving in Moscow, diagnoses were re-evaluated and decisions were made regarding their disposition. Those who were no longer hospital cases but were unable to continue service (amputees, the blind, etc.) were quickly discharged. Others, who were determined to be sufficiently recovered from their injuries and able to serve again by the time they reached Moscow, were quickly shipped back east. Only the most severe cases remained in Moscow. These cases were divided into two broad groups: traumatic and nontraumatic injuries. These were further subdivided between officers and enlisted men. A total of 1,350 officers and 25,350 soldiers were observed in Moscow and of those, 404 officers and 1,905 enlisted men were diagnosed and treated for nervous disorders. Among the officers, 225 had suffered a traumatic incident while 179 displayed nervous disorders without apparent trauma. The non-traumatic cases were distributed among the various diagnoses listed in Table 2.4. More accurate patient histories were produced in Moscow that again brought to light the poor pre-war screening process. Those with tabes dorsalis (wasting of the spinal cord), hemiplegia, and myelitis had exhibited symptoms prior to their deployment to the east. Regarding head injuries, 84 were described as cerebral concussions, later termed ‘shell shock’. These were caused by close proximity to exploding Table 2.4 Officers with non-traumatic nervous disorders Diagnosis

Number of cases

Nervous exhaustion Sciatic nerve lesions* Hysteria Epilepsy Alcoholism Traumatic neurosis* Tabes dorsalis (wasting of spinal cord)** Hemiplegia Myelitis Neuralgia Total Source: Richards (1910), p. 190 and Minor (1909) Notes: *no wound evident **usually due to syphilis

108 15 8 2 2 4 7 4 4 25 179

26


shells. Full or partial deafness and severe nervous exhaustion were often associated with such cases. Traumatic cases among officers were also subdivided as shown in Table 2.5. Enlisted men were also similarly divided between non-traumatic (537) and traumatic (1,368) cases (Tables 2.6 and 2.7). Comparison of the two groups at the time yielded two important points. The first was that traumatic injuries to the nervous system were more prevalent around the head, decreasing proportionally towards the feet. The other interesting observation was the higher proportion of non-traumatic injuries to the nervous system among officers (44.4 percent) than among the enlisted men (28.2 percent). Reasons for this disparity were vague. One possibility was that officers received greater care and attention during their examinations, leading to more accurate diagnoses. Another interesting theory was put forward by the American military observer, Capt. R.L. Richards, who suggested that the ‘… difference may be explained by the higher social origin and less resistive nervous system of the officers.’15 This statement is a fine example of the enigma that the Russo-Japanese War posed for Russian military psychiatry. Not only did the war end in a humiliating defeat for Russia, but also revolution broke out throughout the empire in 1905. Calls for reform prior to the war now became strident as Russia became increasingly radicalized. Tensions between conservative military officers and liberal physicians became even more pronounced than before the war. Physicians who wished to be free to do their jobs felt alienated by an officer class that still wanted to control or ignore them. Therefore, when it came time to derive lessons from the Russo-Japanese War regarding psychiatric casualties, few were willing to listen. For the army, the years following the war were devoted to the study of linking theory to practice in military operations. Similar to the West, Russia began preparing for another short conflict with a logistical plan designed to feed the engines of war.16 Military medicine’s role was to prevent losses, primarily through the control of diseases like cholera and typhus and also to treat wounds suffered in combat. Psychiatric casualties, however, still appeared nebulous and insignificant in terms of total numbers. Also, what psychiatry claimed was an ever-increasing sophistication in diagnostic labels appeared as simple confusion to many career officers. Table 2.5 Officers with traumatic nervous disorders Area of injury Head Spinal cord Other portions of nervous system Total

Number 184 16 25 225

Source: Richards (1910), p. 190 and Minor (1909)


27

Table 2.6 Non-traumatic nervous disorders among enlisted men Diagnosis Nervous exhaustion Sciatic nerve lesions Neuralgia Neuritis (nerve inflammation) Hemiplegia Epilepsy Other brain affections Myelitis Hysteria Traumatic neurosis General tremor Facial nerve disorders Sunstroke Total

Number 358 60 29 20 17 14 7 8 8 7 5 2 2 537


This attitude left the army blind to some important lessons learned by military psychiatry. One of its most important conclusions was the need to bring psychiatric care close to the front. For this to work, a standardized approach was established for diagnosis, prognosis and treatment of NP casualties. The mass shipment of casualties to Moscow only served to exacerbate the mental illness incurred by the soldiers. A means to avoid this large transfer was to establish a series of checkpoints along the various stages of the medical evacuation. By the time patients finally reached Moscow, they should have gone through several steps of diagnosis and prognosis. If improvements were noticed along the evacuation process, soldiers could then be stopped at that point, rather then sending them far from the front for treatment. Once their place of hospitalization was established, consistent treatment followed based on the diagnosis. Treatments included Table 2.7 Traumatic nervous disorders among enlisted men Area of injury Head Concussions Facial nerves Other cranial nerves Other non-cranial nerves Total

Number 896 162 25 5 280 1368


28


psychotherapy, work therapy, and pharmaceutical aid. Finally, it was essential to order proper rehabilitation measures, eventually restoring these men to active duty.17 Theoretically these suggestions were sound, but proper implementation required additional work. As always, many of the problems in military psychiatry stemmed from the true nature of NP casualties. The rehabilitative measures followed, the drugs prescribed, the prognosis delivered, all depended upon understanding the origin of mental illness. To make matters worse, questions began to appear after the war suggesting that the problem behind the etiology dilemma lay in the fact that war neurosis was something completely different from that found in peacetime. Russian military psychiatry was not operating in a vacuum at this time and, in fact, was well aware of research being done in the West on psychiatric illnesses in wartime. At the turn of the century, a significant debate in Germany centered on the question of whether NP casualties produced a new and particular kind of psychosis. The German psychiatrist Schaikewicz observed a number of Russian soldiers evacuated to Moscow military hospitals during the Russo-Japanese War. He described patients suffering from nervous exhaustion as lying still for weeks, being hand fed and suffering depression with hallucinations.18 These patients were divided into acute and chronic cases. The acute cases, suffering from depression in combination with hypochondria, confusion, stupor and/or paranoia, tended to recover well with rest and proper treatments. He observed that these conditions often developed in combination with alcohol or some special neuropathy. Schaikewicz concluded that war placed a unique face on mental illness but acted upon only what was there in the individual already. Commenting on the same report, Schaikewicz’s partner, W. Steida, added that combat alone was not able to produce psychoses. The immediate hysteria and confusion often passed in a few days, while general overall mental health remained compromised for weeks. For Steida, the environmental factors of war, hunger, thirst and sleep deprivation, were equally responsible for wartime NP casualties as much as combat itself.19 Russian military psychiatrists dismissed the idea that wartime psychiatric disorders were a new kind of disease. A clinical professor at the Warsaw military hospital, M.I. Astvatsaturov, studied the results from the FrancoPrussian and Spanish-American wars and compared them to the results garnered from the Russo-Japanese conflict. He concluded that all armies observed a gradual increase in mental illness. For the Russians, it ran three percent greater than in peacetime. This increase was not due to combat producing a new disease, nor even higher rates of peacetime diseases. Rather better understanding of mental illness and proper diagnostic techniques made wartime statistics more complete and accurate than in peacetime. Military psychiatry was more effective than civilian psychiatrists in recognizing and diagnosing mental illness. Also, the sharp increase in the number of officers admitted to hospitals with psychiatric disturbances was in direct


29

relation to the duration of the military action. The longer the individual remained in a combat environment, physical exhaustion, hunger and thirst, compounded by fear, would produce a greater number of NP casualties.20 The effect of this research and the general conclusions made about the Russo-Japanese war led to certain assumptions regarding military psychiatry as Russia moved towards war in 1914. Psychiatric casualties were to be expected in the future but on a scale that could be handled with a minimum of disturbance to the military-medical establishment. Wartime neurosis was no different from that in peacetime and combat itself was not the prime catalyst in producing a higher level of psychiatric casualties. Poor food and sanitation provided an environment that produced diseases like typhus and cholera, so too with mental disorders. Combating epidemics had been a major concern of Zemstvo medicine in peacetime and military physicians in war. There was a sense that psychiatric casualties could be handled in a similar manner. This allowed a sense of complacency that would result in Russian psychiatry having to relearn some of the valuable lessons it had already recognized. The Russo-Japanese War set up false hopes. The reforms of 1905 suggested possible new relationships between the government and the people and these hopes were also reflected in the interplay between medical professionals and the military. Despite the initial glow of nationalism in 1914, both sides quickly fell back into mutual distrust and incompetence as the unimaginable intensity and duration of the new war quickly became apparent.

3

World War I

Correct organization of medical aid in the field is the single prerequisite for success in battle.1

World War I proved to be a greater catastrophe than any of the European powers had anticipated. For Russia, success was dependent upon proper organization and mobilization of the armed forces. Preparations for what was believed would be a short war taxed Russian society and as the war progressed, the strain proved to be too much. Combat on the Russian front proved more fluid than the static fighting in the West, but eventually offensives were still bogged down under the killing weight of industrialized warfare. The term ‘shell shock’ entered military vocabulary as the soldiers’ order to attack across barren killing fields clashed with the desire for selfpreservation. The result, for some, was mental collapse. The war machine’s appetite for resources was insatiable. All sectors of the war effort faced shortages of supplies and personnel. Under these conditions, it was important to prioritize limited resources to meet the needs of the military. Russian military psychiatry fell low on the priority list. By the time the full magnitude of the war was felt and military psychiatry implemented the lessons of the Russo-Japanese War, the empire began to dissolve from within. The need for military medicine to be properly organized, an idea recognized well before the war, was not accomplished. Frightful losses on the battlefield, combined with threats of internal revolt, prevented Russian military psychiatry from providing effective assistance to NP casualties.

ORIGINS OF NP CASUALTIES The period from 1905 to 1914 was marked by Russian military psychiatry going beyond the compilation of diagnostic labels and beginning the difficult task of attempting to understand the origins behind wartime psychiatric casualties. Psychiatric labels developed during the Russo-

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Japanese War seemed exhaustive but their practical use remained limited. Without knowledge of the cause of these casualties prevention would remain impossible and treatment would not be tailored to meet specific needs. Work on the etiology of these disorders became an important task for military psychiatry. A variety of theories were examined to answer questions regarding the origins of NP disorders. Even by 1914, many in the Russian officer corps still maintained that NP casualties were simply cowards or men hoping to shirk their duties. Military psychiatry and even some officers rejected this belief. While many significant questions still remained after the RussoJapanese War, careful documentation and record keeping dispelled most beliefs that only cowards suffered from psychiatric disorders on the battlefield. Russian officers themselves witnessed and recognized the psychiatric trauma brought on at times by modern war.2 Two Western theories revolved around the controversy regarding the nature of the mind and body: dualism and materialism. For dualists, those who wished to keep separate the mind and body, the term neurosis was used in conjunction with wartime nervous disorders. Neurosis was defined as ‘… disturbances of sensations and movement which do not follow fever and do not depend on localized damage, yet is detected by the organs, resulting in general suffering.’3 In the early part of the twentieth century this term was refined to include psychoneurosis and was meant to stress the mental factors in the origin and prevention of neurotic disorders, focusing on the functional character of these problems and how they differed from psychosis. Thus neurosis and psychoneurosis became practically synonymous, emphasizing functional illnesses of the nervous system as opposed to organic illnesses which produced actual anatomical destruction. The dualist school was hampered by the lack of empirical evidence to support it. Russian physiology and psychiatry always had a strong materialistic bent, and the definition of neurosis seemed too vague and unscientific. Advances in physiology and neurology were steadily being made by 1914 resulting in a greater understanding of the brain and nervous system. These advances offered hope to be able to identify actual physiological changes brought on in the absence of obvious trauma. Scientific evidence to prove the materialistic basis for Russian psychiatry had many advantages. Such evidence could provide the tools for psychiatrists to use in order to further establish their discipline. Previously unseen trauma might now be examined and psychiatric disorders could be as real as a broken leg. Such evidence would also be helpful to the military. Officers might now have the ability to distinguish cowards or slackers from genuine psychiatric casualties, and the stigma of weakness could be removed from patients with such disorders. This is not to say that the dualist philosophy and view of psychiatric disorders simply gave way to the materialists. In fact, a strong idealistic faction within Russia disagreed with Sechenov’s materialistic views, as expressed in

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his Reflexes of the Brain (1863). Sechenov argued that ‘All psychic acts which occur along reflex lines must be studied entirely physiologically because their beginning, the sensor stimulus, and their end, the motor action, are physiological phenomena.’4 Idealists countered with the possibility of physiological phenomena that did not travel along the paths of nervous reflexes yet produced a functional disorder. And to steal a page from psychiatric research, they were willing to prove this through experimentation. This idealist psychology was strong in the university setting of pre-revolutionary Russia. They were not psychiatrists, because they were not grounded in medical science, but they did call for some measure of experimentation. One of the most significant researchers of this school was Georgii Ivanovich Chelpanov (1862–1936) who founded the Institute of Experimental Psychology in Moscow in 1911. His work, The Brain and the Spirit (1900), was an early attempt to explain the mind–body connection. Along with such research, the idealist school also published an influential journal, Questions in Philosophy and Psychology, which disseminated the results of their work. Through its efforts and the work of men like A.P. Nechalis, chief of the St Petersburg School of Experimental Psychology, and Bekhterev, the experiments of the idealist school were often used to present psychiatric disorders as too complex to be merely attributed to a solidly medical-scientific materialist school of psychiatry. The tools of science were being used to challenge scientific authority.5 These debates were usually held in universities and research institutes, but for psychiatric casualties in World War I they were largely irrelevant. Practice, not theory, was needed on the battlefield. Without a solid foundation regarding the origin of wartime psychiatric disorders, diagnosis and subsequent treatment would still remain in flux.

ORGANIZATION OF PSYCHIATRIC AID Organization was deemed to be the key to success for providing psychiatric aid on the battlefield, though organizational lessons learned from the Russo-Japanese War had largely been ignored. The 1914 pre-planned Russian drives into East Prussia had been rushed in order to help relieve pressure on the French in the West. While many of the European nations began the war without being in a state of full readiness, the early Russian drive into East Prussia further exacerbated their organizational and logistical problems. The subsequent magnitude of the war made the realization of proper organization an elusive goal. In theory, however, proper Russian psychiatric aid was functioning by 1916. There were three stages of evacuation of wounded personnel. The first took casualties from the actual battlefield to the closest corps supply station by road. There casualties were sorted, and the first opportunity for psychiatric screening was available. Nervous exhaustion and hysteria may

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33

remain at this point while more difficult cases, like epilepsy or traumatic neurosis, were evacuated further to the rear. These more extreme cases were transported by train back to a field evacuation point at the army level. A similar diagnostic screening then took place, with the most egregious cases sent by rail to the front hospital. Rail transport was very similar to the system established in the RussoJapanese War. Special psychiatric train cars transferred patients back to the army or front receiving stations. The cars were built with separate rooms with bunks for the patients, holding up to eight in a room. The rooms had internal framed windows and a single one-way mirror for observation. A specific compartment for solitary confinement was also provided for the disruptive or violent patient. A designated train for psychiatric patients generally had three cars with a doctor, six nurses and nine assistants, plus a boiler stoker. It is impossible to determine the exact number of these special cars that existed in the Russian army. It is probable that the number was not adequate to fulfill its mission as many cars departed crammed with patients, leaving other NP casualties at the rail station or in the hospital.6 Regardless of the number of cars or their spartan conditions, shipments of psychiatric patients produced an additional strain on an already taxed logistical and transport system of the army. The chain of command for this system of psychiatric care began at the Main Military-Sanitation Directorate (GVSU) of the Russian armed forces. Within this organization was the Center for Psychiatric Aid, which dealt directly with the various fronts. Each front, in turn, supervised the activities of the various armies under its command. Naturally the chain of command moved down to the corps, division and regimental level. While logical on paper, the system had its problems. First and foremost was the lack of qualified psychiatrists to fill the need the need of trained personnel at each of these various levels. Attempts were made to remedy this situation. For example on the Southwest Front there were 28 psychiatrists available in 1916, but by the next year there were 101. Many of these new psychiatrists came from the civilian sector or were newly graduated from universities and not well equipped to handle military psychiatric cases. This lack of trained personnel led to the second problem, the lack of qualified psychiatric aid available for soldiers as early as possible. Genuine psychiatric aid was rare at the divisional level and practically non-existent below that. Therefore NP casualties could move through at least two levels of evacuation before being properly assessed, thus placing patients who may have stayed and been properly treated at the regimental level to be shipped to army hospitals.7 Who were these patients and what kind of problems did they place on the Russian military effort? Records for World War I are fragmented and sometimes contradictory but some materials are available from the various fronts, providing a glimpse into the workings of Russian military psychiatry (Tables 3.1 and 3.2).

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Table 3.1 NP casualties on the Northwest Front: 1 October 1914–30 September, 1917 Mental illness Period

Total treated

Recovered

Discharged light duty

Evacuation

Died

1/10/14–30/9/15 1/10/15–30/9/16 1/10/16–30/9/17 Total

2394 5814 4699 12907

283 894 385 1562

17 47 34 98

1179 2118 3114 6411

25 131 57 213

Period

Total treated

Recovered

Discharged light duty

Evacuation

Died

1/10/14–30/9/15 1/10/15–30/9/16 1/10/16–30/9/17 Total

15997 24747 28473 69217

7101 10903 11827 29831

1512 579 765 2856

4193 5389 7580 17162

93 157 89 339

Nervous illness

Source: Bondarev (1931), p. 128

The first point to be made from this data is the vague distinction between mental and nervous illness. At this time mental illness was seen as a functional disorder, affecting the soldier’s behavior with no real solid tie to the actual nervous system. Nervous illness however was an organic disease tied Table 3.2 Data collected by Professor Prozorov’s study, 1926 Illness

SW and South Fronts (8509 patients) in %

Schizophrenia Paranoia Infectious psychoses Syphilis Alcoholism Epilepsy Amnesia Psychotic reaction Arterial sclerosis Psychoses w/ brain trauma Psychoses w/ organic brain disease Oligophrenia* Psychopathology Undefined mental illness

12.6 1.0 1.1 5.5 0.9 31.6 10.4 2.8 0.2 6.9 1.9 5.4 3.1 7.1

Source: Bondarev (1931), p. 132 Note: *Mental illness due to faulty development

Venskaya clinic (11,933 patients) in % 15.6 2.1 – 7.3 8.7 3.2 5.7 7.8 0.1 – 4.1 16.4 4.7 14.3

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to the brain or central nervous system, resulting in some level of anatomical destruction. Thus the higher rates of recovery from nervous illness were ascribed to the fact that these disorders, like a broken leg, can be recognized and treated, thus restoring some level of function when the injury has healed. Mental illness, however, may be congenital or due to improper development or some other cause unrelated to the nervous system. The kinds of diagnoses at the front hospitals and other clinics had also changed since the Russo-Japanese War. Schizophrenia, for example, was being identified as a distinct illness, running as high as 12.6 percent of those treated as NP casualties. Also some categories of nervous illnesses during the Russo-Japanese War seemed to be absent in World War I. Various kinds of congenital disorders were absent as compared to a decade earlier. Part of the reason for this was the increasing sophistication and training of psychiatric personnel. Special hospitals were established for ‘war neurosis’, such as the Petrograd Military-District Sanitarium (PVOSU) under Professor N.I. Bondarev.8 The availability of Russian psychiatrists never met the military demand. Attempts were made, however, to provide new doctors with practical skills. The chief course of study was the origin of NP casualties. S.A. Preobrashenskii’s dissertation, published in 1917, was an example of academic and practical research.9 According to his findings, the development of schizophrenia was a slow, gradual process in peacetime. Schizophrenia exacerbated by direct trauma or contusions on the battlefield often produced new symptoms such as delirium and hallucinations. Many of the delirious patients demonstrated a religious or mystical persona. Schizophrenia combined with traumatic psychoses was often difficult to isolate. Many times the underlying schizophrenia did not became apparent until after a period of rest in the rear. Preobrashenskii also argued that manic-depression occurred in patients with a congenital predisposition to mental illness. Thus one old diagnosis merged into a new one. Along with wounds, somatic illnesses and general deprivation often produced manic-depression. Generally the course of this disease was the same as in peacetime, though depression was more common than manic-depression. He did conclude that NP casualties were more often involved in active frontline operations than in rear duties. Even traumatic psychoses were not unique to war according to some researchers. Emphasis was placed on the functional character of the illness and by 1914 a great deal of faith was placed in the idea that contusions from high explosives were the chief cause of traumatic psychoses. The implications behind this theory were that trauma preceded emotion. Disturbances of the nerves produced outward symptoms that may be described as fright. Thus the stigma of hysteria as a sickness of character was removed by attributing actual physical injury as the cause of traumatic psychoses.10 Not everyone agreed with the idea that the war produced nothing new in terms of mental illness. Some psychiatrists noted that new forms of depressive

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World War I

psychoses were being diagnosed. These patients exhibited vivid hallucinations and paralysis without any obvious physical cause. Others fell ill to mental disorders by simply being inducted into the military. Simple nervous exhaustion in conjunction with military life produced a new symptom: amnesia. To explain these new developments, one school of thought felt that the etiology of these disturbances had less to do with emotion and more with the change in the reflexive tone of the nervous system.11 Others claimed that the key to these anomalies was to be found in predisposing factors such as background and genetics. For example, nervous exhaustion may display a wide spectrum of symptoms based on a variety of factors which, properly understood, would affect treatment. Simple nervous exhaustion, similar to that experienced in peacetime, merely required rest, but exhaustion combined with physical deprivation, depression, congenital weakness or motor dysfunction required treatment protocols beyond mere rest. By 1918 it was generally accepted that Russian NP casualties fell into three groups. The first was war psychoses, developed on the battlefield, regardless of heredity or constitutional predisposition. A wide variety of symptoms such as hysteria or mutism may occur but usually they were all associated with nervous exhaustion. The second, trench psychoses, was not associated with the battlefield experience, but rather the inability to adapt to military life in general. This may manifest itself in a wide variety of psychoses but especially dementia and manic-depression. Finally there were those who developed NP characteristics deep in the rear area hospitals. These were patients who developed traumatic psychoses from previous wounds or contusions. Diagnosed originally as a chest wound, a patient may begin to develop traumatic psychoses after evacuation to the rear. The most prevalent kind of traumatic psychoses was epilepsy which some researchers claimed may have reached 4.6 percent (Kashenko) or 8.0 percent (Timofeev) of all mental and nervous casualties.12 While these arguments occupied Russian military psychiatrists, the army was more concerned in developing effective treatments for NP casualties. Treatment in the Russo-Japanese War was primarily limited to rest, better food, hot baths and transport to Moscow. The casualty rates for patients diagnosed with NP disorders in the Russo-Japanese War ranged from two to three per 1000 soldiers, while in World War I the rate ranged from six to ten per 1000.13 The higher rate may be explained by the greater intensity of fighting in World War I or by better diagnostic techniques developed by military psychiatrists. Yet despite the greater rate and number of psychiatric cases in World War I the recovery rate seemed to be much better as compared to the Russo-Japanese War. Again referring to the Southwestern Front in World War I, 12,907 soldiers were treated for mental illness with approximately 8.3 percent recovering and 49.6 percent being evacuated to the deep rear hospitals. Of the 69,217 suffering from nervous illnesses, 43.1 percent recovered, 4.1 percent were discharged to light duty and only 24.8 percent were evacuated deeper into the interior for further treatment. This

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compares to a combined recovery rate of 7.8 percent for nervous and mental illness in the Russo-Japanese War and 88.9 percent being transferred back to Moscow.14 The raw data suggests that the treatment for Russian NP casualties in World War I was substantially better but these numbers deserve closer scrutiny. Treatment options were more varied than a decade earlier but bed rest, proper nutrition, and bath treatments were still the most common. What had changed, however, was the number of psychiatric casualties who were given time to rest at regimental, division and corps aid stations or hospitals, rather than being sent back deep to the rear area. How much of this was a deliberate design by Russian military psychiatry is speculative. The difference in the logistical and transport systems between the two wars was significant. The Russian Far East in 1904 was largely underdeveloped and linked to its supply line by the single track Trans-Siberian railroad that was not yet completed. There was little infrastructure available to provide psychiatric aid stations or hospitals outside of the Central Psychiatric Hospital at Harbin. In World War I, however, the western or European part of Russia was more developed, providing a greater depth of infrastructure and a preexisting road and rail system to already operating hospitals and clinics. The Zemstvo system and the Russian Red Cross were better established here, providing valuable assistance to the military-medical effort. In short, World War I simply provided more opportunities to treat psychiatric casualties closer to the front. Along with logistical considerations, new therapies were also available, which were primarily psychotherapeutic and had their origins in pre-war foreign research in Germany and France. These new psychotherapies revolved around the use of persuasion and suggestion in order to increase morale and give meaning to the sacrifices that the soldiers were making.15 The treatment of mental illness by these methods dated back to the nineteenth century when physicians argued that illness was the result of the interaction between the individual and the environment. Thus the social context, in this case war and military life, and the progress of the illness over time were critical factors to be addressed.16 But how could persuasion and suggestions help alleviate military NP casualties? These were just some tools in the attempt to treat NP casualties prophylacticly and after onset of symptoms. The general theory was to begin viewing the individual as a whole and disease as part of a continuum, not something that an individual gets, which then disappears after treatment. In order to maintain a strong nervous system, the environment, which directly acts upon the nervous system, must be fashioned in such a way as to either enhance, or at the least not destroy, the individual’s constitution. Thus good food, hygienic quarters, meaningful work or training when not actually engaged in combat all provide an environment that can actually benefit the soldier’s nervous system at the physiological level.17 All of this of course was theory, since at this time the ability to actually measure such responses was beyond the available technology. Observations seemed

38

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to bear out that happy soldiers meant effective ones, and such prophylactic measures would strengthen soldiers to withstand the rigors of combat. Yet what is to be done about the battlefield environment? Little can be done once combat is initiated, but those soldiers who became NP casualties did not suddenly become afflicted with this disease. Rather, their nervous systems had become so weakened that their bodies had moved along the continuum to the point where nervous symptoms would become visible. Thus the purpose of post combat treatment was not to eliminate the disease but to strengthen the victim’s nervous system again, placing the symptoms into remission. Persuasion and suggestion did this by increasing morale. Morale for Russian psychiatry was not just a slogan, but a medical means to prevent and/or treat NP casualties. This treatment must be done quickly and continued along every level of evacuation. Psychiatric care should begin at stage one of the evacuation process, lasting from one to five days, before determining whether patients should be sent back to the divisional level or further. Many physicians noted that soldiers suffering from combat induced mental illness, though five to six times greater in number than those with general nervous disorders, did not need to be evacuated to the rear as they recovered very quickly. Morale was restored again by the introduction of a healthy environment, nutritious food, and, if possible, work therapy. Many front area hospitals, containing approximately 200 beds, used physical therapy machines as an integral part of their treatment. Also, work therapy was extremely popular. All of this was designed to alleviate stress, heighten morale and thus restore the proper physiological equilibrium to the nervous system.18 These therapies grew out of the early psychiatric treatment protocols following the Zemstvo reforms of the 1860s.19 The need for quick care at the lowest level possible matched the outpatient or dispensary system of care in peacetime Russia. The idea of work farms was easily transferred to the military, providing non-combat military jobs as a form of therapy. The Russian Red Cross, as in the Russo-Japanese War, served as a valuable adjunct and intermediary between civilian practices and military medicine.20 Perhaps most importantly, persuasion, suggestion, work and other treatment protocols matched the Russian military-psychiatric resources well. These therapies were cheap and easily administered to large groups. Yet there was substantial room to doubt the real efficacy of this system, despite the high recovery rates of World War I. There were a number of observers outside of Russian military psychiatry who described a system that fell far short of the theoretical plan for psychiatric aid to soldiers. Great stress was placed on the correct and timely diagnosis of nervous disorders and to channel them to the proper treatment center. However, cases existed where soldiers were treated with obvious physical wounds and associated nervous afflictions, but they were bandaged, splinted, and quickly returned to their units. The English nurse, Florence Farmborough, while working with the Russian Red Cross,

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39

remembered meeting an old friend with a compound fracture of the arm, incurred during a German artillery attack. He was diagnosed, treated and sent by ambulance to a nearby clinic with no mention of the hand tremors, inability to sleep and depression that the soldier had complained of to the doctor.21 Those who were properly diagnosed and sent on for treatment did not always receive the prescribed care recommended by military psychiatrists. In one example, three patients were treated by an unknown Russian officer who entered the medical tent and provided hypnosis as a means of relaxation. The procedure backfired, as all three displayed violent reactions to the therapy. Finally, the idea of morale as therapy seemed possible in theory but morale often hinged upon trust between the soldier and the military leadership. Proper food, adequate supplies and sound leadership give confidence to the soldier and increase their sense that victory is attainable. In a military hospital setting, morale is sustained and strengthened by the trust a patient has in the ability of the doctor to help. For some Russian NP casualties in World War I, that was not always the case. One Russian doctor stated that ‘Some had received no outward visible wound; their hurt had been afflicted on mind and spirit; and these we were powerless to aid.’22 If the doctor feels that there is little to be done for NP patients, that perception will be transferred to the patient, making recovery even more difficult. Another factor that greatly interfered with Russian military psychiatry’s ability to deal with NP casualties was the increased occurrences of civilian psychiatric problems brought on by the war. The Russian civilian psychiatric system was only just taking shape by 1914. As the need for military psychiatrists became apparent for the war effort, civilian psychiatrists were conscripted into the military. Therefore when civilian refugees began to display ‘… an epidemic of psychiatric abnormalities,’ the system cracked.23 By 1916, the medical staffs of public organizations such as the Zemstvos, Union of Towns24 and the Red Cross shifted their resources to epidemiology and public sanitation, to offset the danger of epidemics. This occurred in part at the expense of the minor civilian psychiatric services that they provided. Russian psychiatrists, such as V.M. Bekhterev, tried to compensate for these losses by establishing a special civilian psychiatric hospital in Petrograd and another 100-bed facility in Moscow.25 To what degree these clinics met the demand of civilian psychiatric care is unknown. However, considering that Russian society by 1915 was geared for war and the military had a very difficult time meeting its medical-psychiatric needs, one can guess that these civilian clinics failed even further in its attempts to treat refugees.26

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World War I

CONCLUSION World War I was the spark that the Bolsheviks and others exploited to eventually end Tsarist rule in Russia. Over the previous 60 years Russian psychiatry had adopted the materialistic view of NP casualties and had prescribed certain treatments, such as rest, good food, and work therapy as effective means to treat such patients. While these theories may not always have been put into practice, they still remained the basis of Russian military psychiatry. Since the Russo-Japanese War, Russian military psychiatry proved to be able to learn from mistakes and provide some valuable service to the empire. By the middle of World War I it had adopted an organization capable of providing psychiatric services close to the front and was making progress in lessening the wastage of NP casualties. The British, French and later American armies adopted a similar three-tiered system of screening and treatment during the war. Going as far back as the Crimean War, N.I. Pirogov demanded rational military-medical procedures. This goal was echoed in psychiatric circles. Zemstvo reforms in the 1860s attempted to decentralize control of psychiatric services to regional levels. Outpatient clinics, mobile dispensaries and work farms were designed to bring services to the people of rural Russia. As Russia industrialized, similar urban organizations like the Union of Towns also provided psychiatric services to factory workers and urban residents. This peacetime psychiatric organization was gradually mirrored within the military but difficult to establish in the distant Russo-Japanese War. With more available infrastructure in West Russia during World War I, a better attempt was made to bring psychiatric care closer to the soldiers. But theory often was not met with practice, as the limited number of trained psychiatrists was not close to filling the numbers required to establish such a system. The need for trained military psychiatrists was not always appreciated. The relationship between physicians and the military was generally poor. Aristocratic officers often looked down upon military medical officers due to class differences and the fear that doctors were superior to them in intelligence. This was exacerbated in psychiatry, a medical field struggling to assert its identity. Perhaps the chief cause of this struggle for legitimacy was Russian psychiatry’s inability to clearly define mental illness in general and, specifically, the origin behind neuropsychiatric casualties in the army. The prevailing theory behind NP casualties, however, was based on the idea that the mind and body were one. While there were dissenting views, a steady line can be drawn from the scientific works of Sechenov and the literary characters like Turgenev’s Bazarov to the St Petersburg Military-Medical Academy in 1914. The source of NP casualties, therefore, was presumed to come from the outside as a result of some kind of disturbance to the nervous system. This disturbance would then result in a functional or organic injury affecting the entire body. This concept was not purely Russian as numerous

World War I

41

researchers, in France and Germany especially, were focusing on this theory. Perhaps it was the harsh Russian environment itself that helped to move Russian psychiatry to the side of materialism. Still, by 1917 the materialist sector of Russian psychiatry was the strongest and this would directly affect the treatment protocols to be used for NP casualties. The military application of psychiatry closely followed the peacetime, civilian experience. Starting from the assumption that environment played a leading role in mental illness, Russian psychiatry offered treatments to offset these environmental factors. To counter the grinding life of the peasantry, rural clinics would claim to offer direct antidotes such as good food, warm baths and hygienic living conditions. A more advanced clinic may even offer a work farm as therapy. The theory, unfortunately, fell far short of reality, based on the observations of many contemporary observers, including the doctor and author, Chekov. Still these treatments fit the Russian army well. They were simple, mobile and ideas like work therapy could even directly aid the war effort by placing wounded soldiers in noncombat positions. It was a treatment regime that fit well the realities of an underdeveloped agricultural and rural society. All this began to dissolve during the course of 1917. The army disintegrated. Respect for officers melted away as they were seen as indifferent to the suffering experienced by the common soldier. The soldiers saw physicians and psychiatrists as no better than their officers. With revolution and the subsequent civil war, military psychiatry fell far behind thousands of more pressing needs. In this new environment the challenge was to hold on to the lessons learned and find a way to serve the new state. Lenin’s victory found practitioners of Russian military psychiatry huddled in small clinics in Petrograd waiting to see what the new day would bring.

4

The inter-war years

Most of all, the political moral level of the Red Army soldier, his durable political class consciousness, will enable him to more easily overcome psychotic reactions.1

The Soviet Union was a social experiment that removed the old ruling class and attempted to replace it with a socialist utopia. One of the most important elements of this experiment was the transformation of the Imperial Russian military to a new proletarian force dedicated to the defense of the Soviet State. The party hoped to alter the class-consciousness of the peasant soldiers in order to make them loyal defenders of the revolution. But this change was filled with controversy. Heated debates ensued over whether the armed forces should be based on an expansive militia or a cadre of professional officers. Perhaps the most controversial issue was edinonachalie, which was the desire of military officers to retain sole control over their units without the political interference of political commissars.2 The social class of the Red Army was another issue of great concern. To ensure the loyalty of the peasant class, literacy education, propaganda and promised better living conditions were used to inculcate a proletarian attitude. In return, these soldiers were often used in a variety of projects to assist the state, most importantly collectivization under Stalin. The effect of the collectivization campaign is difficult to judge. Evidence does exist that some soldiers found the task onerous and party commissions were established to monitor their loyalty.3 Stalin’s military purge placed even greater strain on the armed forces. Distrust and fear permeated the Red Army. Once Stalin believed that the Red Army was cleansed of disloyal factions, he began a rapid buildup of forces that suffered from inefficiency, wasted effort and the lack of qualified officers.4 Stalin dragged Soviet society and the military through collectivization and industrialization in order to become a modern industrial state within a decade. His success was costly. In the late 1930s, the author Nadezhda Mandelstam wrote that the Soviet people were ‘…slightly unbalanced mentally – not exactly ill, but not normal either.’5 The civil war and

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Stalin’s rule placed incredible strains on the Soviet population. As Soviet society became more militarized, the distinction between soldier and civilian, even in peacetime, became blurred. Amidst all this pressure and confusion stood a small core of Russian psychiatrists seeking to find its proper place in this new state. Conditions during and immediately following the civil war were grim and the hardships facing the psychiatric section of the Military-Medical Academy were no exception. According to the director, Viktor Petrovich Osipov (1871–1947), daily caloric intake for clinic patients declined from 1,500 in early 1917 to 534 by 1919. This precipitous drop was reflected in the average deaths in the clinic which climbed from 3.2 percent in 1916 to 17.1 percent by 1918. The harsh civil war conditions in Petrograd were manifested by a dramatic increase in the number of psychiatric patients suffering from morphine or cocaine addiction along with patients drinking denatured alcohol. A staff physician, M.I. Shakin, reported that from 20 November 1917 to 21 March 1918, the clinic was partially closed due to lack of water. With temperatures inside the building hovering around 2 degrees Celsius, patients suffered greatly from cold and malnutrition. The clinic received electricity for only one hour a night. The cold and unsanitary conditions led to fears of a cholera outbreak. The immediate danger of cholera passed with the onset of spring and by June 1919 a degree of normalcy returned to the psychiatric clinic at the Military-Medical Academy.6 Conditions within psychiatric facilities in the Soviet Union were not improved by 1924. A microbiology student in Novocherkassk, N.M. Borodin, worked in a nearby psychiatric hospital that locals referred to as the ‘madhouse.’ His description matched that of Chekhov’s ‘Ward No. 6’ as the hospital was overcrowded and filthy, with violent patients often being physically restrained and tied down. He concluded that the majority of them ‘…were insane because their minds were not strong enough to resist the things they saw during the Civil War and the Great Famine.’7 While the Academy and military psychiatry survived the initial ordeal of the civil war, more significant threats loomed on the horizon. As the Bolsheviks solidified their control on the nation, critics of military psychiatry began to express their opinions. Some political leaders and several new Red Army officers questioned the existence of wartime psychiatric casualties. They claimed that Red Cross workers who served in Russian military hospitals during World War I lacked socialist zeal, allowing cowards to shirk their duty under the charade of mental illness. On 18 September 1918, a decree from N.A. Semashko, Commissar of Public Health, placed all psychiatric departments of military hospitals under the control of the neurology department and in 1922–3 the Deputy Commissar E.P. Solov’ev eliminated them.8 The Military-Medical Academy’s psychiatric department was the exception. It survived under the guidance of V.P. Osipov. He joined the department in 1915 as a professor of psychiatry and later chaired the department from 1917 to 1947. Osipov appears to have been a true survivor

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The inter-war years

of the Soviet system. During the period of Lenin’s illness with recurrent strokes, Osipov was called in as a consultant. As party attacks increased on military psychiatry, his department kept a low profile, issuing only two major studies, in 1934 and 1941. Throughout the Bolshevik and Stalinist reorganization of society, the psychiatric department seemed to pay lip service to communist doctrine in order ‘…to retain its scientific potential and not expose itself to reorganization.’9 But these were difficult times for all aspects of Soviet society and psychiatry was no exception, as researchers and psychiatrists attempted to match science with communist ideology. Initially, Soviet research in physiology and neurology seemed to reinforce the materialistic view of mental illness, especially through the work of Ivan Petrovich Pavlov and V.M. Bekhterev. Pavlov was an internationally known scientist and had received the Nobel Prize for medicine in 1904 for his work on circulatory physiology that led to his theory of conditioned reflexes. The son of a village priest, Pavlov was educated at a theological seminary and later at St Petersburg University and the Military-Medical Academy. He became professor of physiology at the Military-Medical Academy in 1897. Religion remained an integral part of his life and he was skeptical of the Bolshevik regime, openly criticizing Bukharin in 1923 over Bukharin’s belief that socialist ends justify the means.10 Yet the Soviet government supported Pavlov’s work on conditioned reflexes because it closely corresponded to the Marxist–Leninist theory of materialism. Following Leningrad’s devastating flood in 1924, Pavlov noticed that the animals that he used for experiments on conditioned reflexes began to show anxiety and fear. This sparked his interest regarding the etiology and treatment of neurosis in traumatized human behavior. Based on his materialistic view of physiology and neurology, Pavlov argued that abnormal human behavior was the product of the interplay between the individual’s first and secondary signaling system and the environment. The first signaling apparatus was the strength, equilibrium and mobility of the nervous system. Nerves either excited or inhibited motion of the body. Proper functioning of the organism, therefore, required that these nerves were operating in equilibrium. These were conditioned reflexes. The second system was the thought process, demonstrated either through language or symbols. These two systems were responsible for guiding individuals through their environment. When these systems were not operating properly, neurosis could develop. Pavlov felt that there were only two kinds of neuroses, nervous exhaustion (neurasthenia) and hysteria. With rest and proper nutrition, allowing the nervous system to strengthen, neurasthenia had a good prognosis for recovery. The hysterical patient had little chance to improve. This was due to the predominance of inhibitory nerves and the weakness of the excitatory nerves. According to Pavlov, hysteria resulted from a nervous system so weakened that it was unable to recover.11 Pavlov’s earlier fame gave this materialistic view of abnormal human behavior a legitimacy that Russian/Soviet psychiatry had not yet achieved.

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45

Pavlov’s theory of conditioned reflexes extended far beyond military psychiatry. It was a case of science reinforcing ideology, explaining human behavior and serving as the foundation of Soviet educational theory and practice. The proper application of Pavlovian science could provide the Soviet system the tools required to produce the new Soviet man. A perfect environment will produce the perfect man. But his theory would be taken to greater extremes through the new science of reflexology, espoused by his colleague V.M. Bekhterev. V.M. Bekhterev was appointed Chair of Psychiatry and Nervous Disorders at the Military-Medical Academy in 1893. He gave up his position in 1913 over frustration with the government, which turned against him after his expert testimony had freed a Jewish suspect, Mendel Beiliss, tried for an alleged ritualistic murder of a Christian child.12 He immediately established the Psychoneurological Institute in St Petersburg, a place that authorities considered a hotbed of revolutionary activity. Here he conducted intensive research in the anatomy and physiology of the brain and central nervous system (CNS), creating a new science, reflexology. According to Bekhterev, ‘Reflexology is based on neurology and the direct study of man’s motor reactions to internal and external stimuli, particularly those stimuli issuing from the social world.’13 Bekhterev took the materialistic base of Russian psychiatry, combined it with recent research by scientists like Pavlov and created a science of human behavior based purely on objective observation and experimentation. He dismissed the work of Freud and Adler and those who wished to attribute human behavior to subconscious desires. Bekhterev stated that the ‘…psycho-analytical method of treatment is easily understood by means of the reflexological doctrine of association-reflex activity.’ Man had been reduced to a biochemical machine whose personal behavior could be understood by fully understanding the physiology of the brain and CNS. Even though it appeared to fit nicely into the materialistic scheme of Marxism–Leninism, strong voices spoke out, arguing that reflexology could not explain the vast array of behavior seen among the mentally ill.14 As the 1920s came to a close, Stalin’s grip grew tighter on all aspects of society and Soviet psychiatry was no exception. Interestingly, the greatest challenge to reflexology and the materialistic view of human behavior came from Soviet psychology, a field treated with disdain by the more scientific-medical psychiatric discipline. During the 1920s, Soviet psychology was seen as unscientific, too subjective in its observations and conclusions. Also, psychology tended to focus on the course of human development among normal, healthy people and on education. Within the military, psychology was used to research topics like vision and how to use camouflage to fool the eye. Additionally, psychology was used for leadership training for military and political officers alike. Still, psychology was generally marginalized and considered too subjective to be a real science.

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The inter-war years

The extreme materialistic explanation for human behavior as espoused by reflexology gave psychology an opening into mainstream science. Following the death of Lenin in 1924, more of his writings were brought to light, including ‘Materialism and Empirio-Criticism’ and his ‘Philosophical Notebooks.’ As the 1930s progressed, adherence to Marxist–Leninist ideology in all fields became quite important. Regarding human behavior, Lenin’s theory of reflection appeared to challenge reflexology and other extreme notions of materialistic psychiatry by positing the position that the mind is the reflection of external reality. Soviet psychologists took this to mean that one could not be limited to studying only man’s objective behavior but rather must constantly examine the interaction between an individual’s experience and his or her mental functioning. The chief proponent of this new Soviet psychology was S.L. Rubinstein whose 1934 article, ‘The Problems of Psychology in the Works of Karl Marx,’ argued for dialectical reasoning in the study of human behavior. His main thesis was that the mind is not only a function of matter, but also a reflection of external material reality. This suggested that the mind, like society, was a product of historical evolution and could also experience revolutionary change. Most challenging to reflexology and strict materialistic psychiatry was the concept that historical forces can change human behavior, thus socialist man is different from capitalist or communist man. Soviet psychology questioned the static diagnostic labels of psychiatry regarding abnormal behavior and countered that psychology was capable of studying behavior that was much more fluid and dynamic than psychiatry suggested. While psychology remained more concerned with changing an individual’s behavior, this new Soviet psychology offered substantial criticisms to the strict materialistic model of psychiatric disorders and sought answers beyond just the individual’s central nervous system.15 However principled these debates may have been, one can deduce additional reasons behind these controversies. Both psychology and psychiatry were fairly new disciplines, both eager to establish legitimacy and scope to their respective professions. Prior to the revolution, both sought scientific and objective criteria to validate their positions. After the revolution, and especially after Stalin’s rise to power, ideological concerns also had to be met. For military psychiatry, however, these theoretical debates were distractions to their main concern, the proper organization and delivery of psychiatric aid to the battlefield. By the 1930s, Soviet military psychiatry was centered at the MilitaryMedical Academy in Leningrad. Under the careful leadership of V.P. Osipov, the Academy stayed clear of theoretical debates and centered its attention on the traditional concern of military psychiatry, proper organization. However, with the dissolution of military hospitals’ psychiatric departments in September 1918, psychiatry became even more closely tied to neurology. Neurological treatment centers sprang up throughout the Soviet Union in the 1920s, including Petrograd (1921), Moscow (1929), Kharkov, Kiev and

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Rostov-on-Don. A product of this close collaboration between neurology and psychiatry was A.I. Iushchenko’s Questions on the Classification, Prevention and Treatment of Traumatic Neuroses (1935).16 Iushchenko’s work contained little new psychiatric information but its effective use of clinical examples to illustrate theoretical principles provided an excellent summary of Russian/Soviet research on traumatic neuroses. The first significant work from the Military-Medical Academy’s psychiatric department was Psychoses and Psychoneuroses in Wartime (1934), which included scholastic studies by Osipov and his colleagues. Stalin provided the official stamp of recognition with his remarks in the introduction that stated that the Soviet Union had advanced from a poor agricultural country to one ‘…capable of producing massive amounts of everything for modern instruments of defense in case of attack from the outside.’17 The militarization of the state was taking place and war was expected. This research was military psychiatry’s answer to preparation for the next war. Osipov’s introduction stressed the importance of military psychiatry in order to prepare the nation for future war with the West. He carefully separated the Soviet State from its Imperial Russian predecessor who he claimed treated soldiers as cattle. Yet he maintained the old Russian tradition of military medicine by stating, ‘Correct organization of medical aid in the field is the single prerequisite for success in war.’18 Osipov then predicted that the next war would be vast in scope and intensity, making psychiatric treatment highly complex, necessitating the need for researchers and military doctors to produce effective and practical treatments for NP casualties. This task had been complicated by the lack of clear distinctions among various psychiatric disorders, such as neuroses, psychoneurosis and psychotic reactions. His conclusion reflected the growing ideological concerns of the 1930s by urging physicians ‘…to take into account the social class character of the individual soldier.’19 S.P. Ronchevskii was given the task of addressing the issue of war psychosis. According to the author, the psychiatrist must concentrate on the pathological signs and symptoms of the patient, such as trauma, rather than the emotional displays. This search for the physiological damage will lead to the true source of the psychiatric damage. This is consistent with traditional Russian military psychiatry but the Soviet addition to this was the observation that the soldier’s spirit, his moral and political consciousness must also be ascertained when diagnosing NP casualties. The difficult conditions that the frontline soldier must endure open him up to nervous exhaustion and the threat of eventual breakdown. And Ronchevskii claimed that proper political indoctrination and high morale could actually have a positive physiological effect on the nervous system, making it stronger and more apt to overcome nervous fatigue. How much of this new twist was genuinely accepted by the Academy is difficult to determine. Osipov’s career as a member of the Military-Medical

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Academy, then later as its director, spanned the years of Nicholas II, World War I, revolution, Stalinism and World War II. This suggests that he was a survivor, capable of using those skills to maintain the independence of the Academy from direct political control. If this meant that at times, sound, fundamental research must also include ideological trimmings, so be it. For Osipov and his team, the construction of a viable organization, capable of providing sound psychiatric care to the Red Army, was the only goal. In order to achieve this goal of proper organization, N.I. Bondarev, a specialist in organizational questions regarding psychiatric care, carefully laid out his plan in chapter 5 of Osipov’s study. Bondarev began with an historical study of Russian military psychiatry. He examined the Russo-Japanese War and concluded that evacuation to the deep rear and eventually Moscow was not only logistically unsound but also counter-productive for the prognosis of NP casualties. World War I was a slight improvement but due to the incredible number of casualties and the breakdown of the military during the 1917 revolution, any real statistical analysis is impossible. Bondarev made two organizational recommendations. The first regarded the evacuation of the mentally ill from the battlefield. This should begin at the regimental level, where the first professional diagnosis would take place. Mild cases would remain at this level, receiving rest, vitamin therapy and shelter before returning to the front. Bondarev did not speculate as to how long this might take. Extreme cases would be evacuated further to the divisional hospital, where a special isolation section was established. How this evacuation would take place was not clear, since no mention of vehicular or rail transport was made which suggests that these men may be transferred in as simple a way as possible. Here, for the first time, a trained psychiatrist would evaluate the NP casualties. Again a simple triage system would be applied with the lighter cases remaining at the divisional hospital, and the more difficult cases being transferred by trucks or hospital vans to the corps level evacuation base hospital. Patient evaluations and transfer of severe cases by train to the army and front hospitals, with the most extreme patients eventually ending up in the deep rear like Moscow or Leningrad, was the preferred plan. Responsible for this system was the Main Military-Sanitary Directorate (GVSU) which directly supervised the center for psychiatric aid in the army. This organization had two department heads supervising psychiatric aid at the front and deep rear. The front psychiatrist was responsible for care starting at the army level, down to the regiment and the entire zone within the front. He was also responsible for manning the various stages of evacuation with professional psychiatrists down to the division, and specially trained physicians at the regimental aid stations. Besides simply laying out an organizational form, Bondarev discussed in his 1934 work the needs and ramifications of such a system. He stressed the importance for trained diagnosticians all along the lines of evacuation. This would require not only a large number of trained psychiatrists and

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other personnel, but they would also have to be familiar with military life and the specialized quality of combat. He harkened back to the experience of World War I and the rapid increase in the number of psychiatrists serving in the military. However, he warned that this increase in number was not matched by an increase in quality care. Civilian psychiatrists were not able to directly enter the military and adequately respond to their new duties because they lacked experience in treating mental illnesses brought on by war. Based on his research, Bondarev argued that in a 12,000 strong division, approximately 18 had some kind of pre-existing psychoses. This might be avoided with proper screening, but lack of personnel or belief in the efficacy of pre-screening left a void in this aspect of psychiatric aid. Finally, divisional psychiatrists needed to direct care at their hospitals and also work closely with medical personnel at the regimental level. These hospitals may contain as many as 200 beds at the front level for the most extreme cases. All this pointed to the need for a large number of highly qualified military psychiatrists. Soviet military psychiatry in 1934 was not capable of fulfilling its role due to the lack of psychiatrists experienced with NP casualties. Bondarev concluded by making general observations regarding the ramifications of the lack of quality personnel. Battle-induced mental illness occurred five to six times more than general mental illness but such combat casualties need not be evacuated deep into the rear, as they recover very quickly with simple rest, food, and a strong military environment. Unqualified diagnosticians who fail to make this distinction reduce combat effectiveness and strain logistics and transportation by sending these patients along the evacuation route until they are properly assessed. Interestingly, Bondarev chose the US Army as an example of a good psychiatric organization that stressed the need for qualified psychiatrists from the division on up.20 Despite the increase in the need for ideological purity, this report did not come out of a vacuum. For example, contrary to the American experience during the inter-war years when military psychiatry was virtually ignored, Soviet military psychiatrists had been working and publishing their results in a variety of forums well before Osipov’s contribution, which served to consolidate information from within the Soviet Union and elsewhere.21 For example, D.A. Krasnov, a member of the neurological department of the Leningrad military district, published a pair of articles in 1933–4. His primary concerns were problems of psychiatric disorders already present in the Red Army. Krasnov observed that the number of military personnel medically discharged due to mental illness had almost doubled between 1927 and 1930. Despite incomplete data coming out of the civil war, Krasnov was able to chart an increase in epilepsy in the Red Army, reaching a total of 1,200 by 1927. This increase he surmised might be due to improper diagnosis and poorly trained medical personnel. Poorly trained military psychiatrists could exaggerate the actual number of mental discharges by

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relieving men who did not have a real mental illness and by allowing recruits with obvious functional disorders to enter into the army during the draft. Treatment, as in the Tsarist army, consisted of physical and occupational therapy along with the Soviet addition of party activities such as those promoted by the Komsomol. Krasnov also wrote of specific disorders such as post-traumatic neurosis and epilepsy. He repeated the importance of proper diagnosis and of searching for the organic cause of the affliction. A correct diagnosis would increase the chance of prompt and proper treatment to relieve the military of costly transport to treatment centers further to the rear. Here again he warned that these numbers might be more reflective of the poor diagnostic skills of the physicians than any real increase. The article concluded by urging for better training of medical personnel, not just psychiatrists, and for neurologists and psychiatrists to work closely to develop efficient diagnostic tools and treatment methods.22 The next year Krasnov followed with a study on the question of drafting soldiers who have pre-existing mental disabilities, either organic or psychological. His study mentioned specific case studies, including one I.N. Nikolaev, who complained of mysterious pains in his legs and arms while stationed at Kronstadt in 1933. Nikolaev’s case clearly illustrated Krasnov’s concerns regarding the problems of misdiagnosis and its complications. Nikolaev’s physician did not recognize that there might be a legitimate organic reason behind what appeared to be a simple case of malingering. The doctor feared, as line officers and medical personnel in all armies, that allowing Nikolaev medical treatment would legitimize his illness and encourage similar complaints by other soldiers. These concerns delayed treatment and Nikolaev’s condition worsened until he was eventually discharged. Krasnov urged the Red Army to recognize the existence of mental illness during peacetime and its potential role in weakening the effectiveness of the Soviet armed forces. The Soviet sense of the inevitability of war with the West was evident in Krasnov’s tone. This emphasis on the peacetime value of military psychiatry contrasted sharply with the US at the time, which lacked the sense of class conflict and the fear of coming war.23 Total numbers of psychiatric disorders in the pre-war Red Army are almost impossible to discover, but some researchers, like I.B. Galant at the psychiatric hospital in Smolensk, provide clues to the nature and extent of mental illness in the army. Out of 335 soldiers admitted to the hospital in 1931, 135 cases were diagnosed with mental illness due to faulty development. Alcohol and syphilis accounted for only four cases, suggesting that methods were taken to curb excessive drinking and unsafe sexual practices. This study was taken in the Belarus military district, an area where any threat to military effectiveness was taken seriously.24 Two years later in 1933, M. Pasherstnik recorded numbers of Red Army personnel suffering from mental disorders at his psychiatric clinic in

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Vinnitsa (Table 4.1).25 Pasherstnik repeated many of the same conclusions as had Krasnov regarding the need for a variety of Red Army personnel to be cognizant of the basics of mental illness. Not only must psychiatrists and neurologists work together but line officers and political officers must also make an attempt to better understand psychiatric casualties. What is most interesting in his article is the diagnostic list of the 261 patients that he saw over the three-and-a-half-year period. The problem of misdiagnosis is illustrated by the fact that 63, or 24 percent, of the patients admitted to his psychiatric clinic were determined as being mentally healthy. The next highest diagnosis was poor mental development. As Krasnov had argued, soldiers were being admitted into the army with pre-existing conditions, thus advocating for better pre-induction screening. At this time, some Soviet theorists challenged the role of heredity in mental illness, but within the military it appears responsible physicians were taking note that perhaps some draftees should not be admitted due to poor early development. Part of the controversy was that some Soviet ideologues argued that the proper Soviet system could overcome such disadvantages. Looking at Table 4.1 Psychiatric disorders in Vinnitsa, 1930–3 Diagnosis Good mental health Mentally underdeveloped Psychopathy Epilepsy Schizophrenia Hysteria Nervous exhaustion Neurotic constitution Encephalitis Progressive muscular atrophy Traumatic neurosis Psychoasthenia* Manic–depression Acute paranoia Chorea** Chronic alcoholism Infectious psychoses Total

1930

1931

1932

First half of 1933

Total

25 15 7 9 3 0 3 0 4 0 0 0 3 0 1 0 1 71

11 8 13 8 5 4 2 6 2 0 0 0 0 1 1 1 0 62

26 12 11 15 11 7 6 6 0 1 3 3 2 1 0 0 0 104

1 4 4 3 6 0 1 2 1 0 0 0 0 0 0 0 0 22

63 39 35 35 25 11 12 14 7 1 3 3 5 2 2 1 1 259

Source: Pasherstnik (1933), p. 896 *nervous affliction characterized by facial twitches ** psychological weakness, easily fatigued, highly emotional

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Pasherstnik’s admittance records, an argument could be made that there was some truth to this. The Russian scourge of alcoholism appears to have been met successfully, a claim that the PUR or political administration of the Red Army would certainly advance. Through literacy programs and political indoctrination, the ‘new Soviet man’ would not succumb to drink but would develop ‘…the discipline of the citizen soldier and selfless devotion to our party….’26 And not only was the problem of alcoholism addressed, but also general sanitation within the Red Army improved, as only one case of psychosis brought on by infection was recorded in three and a half years. It is important to note, however, that even in the early 1930s failure to reach state goals was considered a serious matter. Anything interfering with the proper effectiveness of Red Army units was a threat to military officers and commissars alike. High rates of chronic alcoholism and/or infectious psychoses would cast a poor reflection on the unit’s commanders, thus falsifying psychiatric statistics may have been a means of self-protection. Cooperation among military and political officers with their unit’s physicians and psychiatrists was essential in providing accurate diagnoses but the atmosphere of mistrust at this time in the Soviet Union likely prevented this from happening. This need for close cooperation among military and medical personnel in order to diagnose properly psychiatric conditions was an important theme among military psychiatrists. N.I. Bondarev, who contributed to Osipov’s 1934 study, published comments regarding this question in 1931. He recognized the diagnostic problems faced by the military and gave a number of suggestions. An accurate patient history could provide a great deal of meaningful information for determining the likelihood of a legitimate mental illness. Problems also arose from the difficulties civilian psychiatry had in adjusting to military life. The army did not produce new mental illnesses, yet the military environment was often sufficiently different from civilian life to blur a patient’s diagnostic signs and symptoms. An example was a 22-year-old soldier, a former member of the Komsomol, who complained of mental fatigue in late 1929. By March 1930 he was feeling worse and his condition was difficult to diagnose. Only after receiving a letter from home, providing a better history of the young man, was his diagnosis complete: nervous exhaustion.27 In response to this need for a standardized method of diagnosis, Academician A.I. Iushchenko wrote a text on the classification, prevention and treatment of traumatic neurosis. Though confined only to traumatic injuries, this was still an important advance for military psychiatry, especially as the threats of war seemed to grow. Iushchenko, using Russian/Soviet sources and actual case studies derived primarily from World War I, produced a fairly complete and simplified handbook for diagnosis of traumatic neuroses. Following closely the history of Russian military psychiatry, his classification scheme was strongly based on a

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materialistic, organic, and neurological approach to the question of traumatic neuroses. He also simplified diagnosis by reducing the number of labels, a process that had been ongoing since the Russo-Japanese War. There were three kinds of neuroses, according to Iushchenko: 1) reactive, 2) constitutional, and 3) psychoneurotic. Reactive neurosis was more common in traumatic injuries producing symptoms such as deaf-mutism and other functional disorders. Often these patients would be helped by immediate treatment of the site of trauma, and rest. Constitutional neurosis and psychoneurosis were more difficult to differentiate and often the stress of military life and/or actual combat exacerbated pre-existing conditions. For the military psychiatrist, it was important to get an accurate history before military induction in order to determine susceptibility to future mental illness.28 All of these suggestions required time to properly train and expand Soviet military psychiatry. But time was running out. The official line regarding Soviet military psychiatry again came from V.P. Osipov and his team from the psychiatric department of the MilitaryMedical Academy on the very eve of war.29 Similar to his 1934 work, this new study was a collaborative effort using information not only from the Soviet Union but also from the West. The emphasis was on the fundamental importance of correct diagnosis of NP casualties. Recent military actions with Japan and Finland had given Osipov’s team time to study the ramifications of modern war, with tanks and airplanes, on military psychiatry. Osipov made the point that the Soviet Union was woefully lacking in trained psychiatric personnel, especially with these new weapons of war. While war did not create a new kind of neurosis, civilian psychiatrists, who had been called up to serve in Finland, often misdiagnosed patients, especially traumatic neurosis. These errors were to play a role in difficulties faced by military transport and hospital organization. The authors often repeated what had been said throughout the 1930s, chiefly the need for all specialists to work together. This constant refrain most likely came from a number of incidents where proper cooperation and communication did not occur. The rapid expansion of the Red Army in the late 1930s must have made these incidents more common. While little specific work has been done on the effects of the purges and the rapid expansion of the military on Soviet psychiatric personnel, it would be prudent to suggest that these problems only made things worse.30 With the rapid collapse of France in 1940, Hitler’s eyes began to look east. Therefore, Osipov’s suggestions to prepare Soviet military psychiatry for the inevitable war are important: to begin, every doctor, regardless of their specialty, must be familiar with the basics of neurology and psychiatry; the majority of mental illness will be the result of direct combat but more severe cases, complicated by past mental illness, could emerge further in the rear; these cases are not new forms of mental illness, but rather the same as in peacetime but now occurring in a wartime environment. While great emphasis was placed on correct diagnosis, Osipov wisely argued that doctors who

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The inter-war years

did not specialize in neurology or psychiatry did not need to always correctly diagnose the actual condition. Rather, it was the task of these physicians, who often were the first to treat NP casualties, to simply acknowledge psychiatric symptoms and refer them to specialists further down the evacuation line. At the same time, the primary physicians must make an effort to get a good medical history of the actual means of injury and the background of the patient. A proper history can provide the needed information to determine site of injury where no obvious signs are visible, or other important factors in the patient’s health such as alcohol or drug abuse. Much of this information can come from the commanding officer or political representative of the unit. Finally, Osipov made the very practical observation that while correct diagnosis is very important, it must not concern the primary doctor so much that he forgets to provide basic treatment, such as attention to obvious wounds, rest and proper nutrition when available.31

CONCLUSION Osipov’s report, coming as it did on the eve of the German invasion, was reflective of the entire Russian/Soviet experience in military psychiatry. The inter-war years were formative for the Soviet Union, as the nation grappled with the death of Lenin and his successor, Stalin, who forced collectivization and industrialization on the nation. While implementing these policies, the nation also reeled under Stalin’s paranoid gaze as the party attempted to purge itself and the country of all internal enemies. Military psychiatry seems to have weathered these storms fairly well. A Russian military psychiatrist in 1914 would not feel lost reading Osipov’s 1941 report. The basis of Soviet military psychiatry remained rooted in Russian traditions of mental illness, including the materialistic and organic causes of the majority of psychiatric conditions. Not only was the etiology of NP casualties generally the same during the inter-war years, but treatment also remained constant. Rest, proper nutrition and work therapy were still the dominant methods of treatment. Soviet ideology was not able to overcome centuries of Russian tradition, nor did it need to. The vast expanse of Russia and its primitive economy produced a psychiatric formula of keeping treatments basic and bringing them to the people. Another general theme throughout this period was the military’s need to keep things simple. Soviet military theorists like V.K. Triandofilov and A.A. Svechin predicted the next war to be a massive enterprise, requiring all the resources of the state. Collectivization and industrialization caused chaos in the Soviet economic system, producing shortages and bottlenecks throughout the economy. Psychiatry had to accomplish its goals in the most expedient way. This is not to say that Soviet military psychiatry preferred these simple methods, rather it adapted to the circumstances. Thus the theoretical arguments between researchers like Bekhterev and

The inter-war years

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Rubinstein were not that important to the military. A review of the medical literature of the time clearly points out the differences between academic theory and military practicality. By 1934 Soviet military psychiatry had developed a careful relationship with the Bolshevik party. The materialistic basis for mental illness, espoused by researchers like Pavlov and Bekhterev, found a welcome environment within Bolshevik ideology. There were few theoretical disputes between military psychiatry and the party. In fact, there were areas of political cooperation available. Soviet propaganda, education, and entertainment provided by party representatives within the military were seen as positive measures to prevent NP casualties. When these preventive measures failed, military psychiatry stepped in to provide proper diagnosis and treatment, with the goal of maintaining the mental health of the Red Army. Military psychiatrists gave practical and theoretical support to the Stalinist regime, key ingredients to their survival. Yet one important point is missing from the literature of the inter-war years, namely how much did political concerns interfere with proper psychiatric practice? The members of the Military-Medical Academy’s psychiatric department in 1934 included V.P. Osipov, N.I. Bondarev, V.A. Gorov-Shaltan, S.P. Ronchevskii, V.E. Makarov and others. When war began in June 1941 this core of psychiatrists was still alive and active in their duties to the Red Army. Their survival during the Stalinist purges requires explanation. Early Western studies on the purges emphasized the role of Stalin as the prime instigator of this frightening period of Soviet history. In brief, they argued that without Stalin there would be no purges.32 More recent studies do not discount Stalin but argue that the role of ordinary citizens, peasants and soldiers alike, contributed greatly to the scope and scale of the purges. This group of scholars maintains that one of the key ingredients feeding the terror was the willingness for some victims to denounce others, thus allowing the cancer to spread. In the countryside, it was not unusual for peasants to accuse one another as class enemies, with little prompting from the party. Torture and blackmail were used in the military purges and their effects were the same as in the countryside. As each new victim confessed, a new list of enemies was made.33 I.V. Pavlova provides a more recent Russian critique of these two schools. Pavlova stands firmly behind the idea that Stalin and his revolution from above was the chief motivating force behind the purges. Those Westerners who have minimized the role of Stalin and focused on the revolution from below have placed too much trust in the accuracy of Soviet documents but, more importantly, have failed to place the purges within the context of Russia’s unique historical and cultural experience. Pavlova states that ‘…the central methodological problem in the study of Russian history is the use of conceptual approaches based on alien cultures.’34 The question regarding the survival of military psychiatry must then be placed in the specific context of Russian/Soviet history. Russian/Soviet

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The inter-war years

leadership was hierarchical with expansive visions of the future, from Peter the Great to Stalin. Motivation and change came from above but the details behind grandiose plans were often left unanswered. Stalin’s bold plan was to wrench the Soviet Union from its backward ways into a modern industrialized society before the capitalistic West destroyed it. With such a mindset, large important groups within the country, such as the peasantry and the military, fell under his critical gaze both as a means of revolution and the possible source of counter-revolution. The world of military psychiatry, however, was small and its role in society was quite limited. Its science supported Marxist ideology and its purpose was to help maintain the effectiveness of the Soviet military. For military psychiatry to be seen, it would have to make an effort to become visible. By all accounts, the members of the psychiatric department of the Military-Medical Academy were all professional psychiatrists, intelligent men who understood that their collective security meant that they should remain hidden, waiting for the day when their services were called for. Soviet military psychiatry’s agenda in the 1930s was simple but its implications were significant. Emphasis on organization, correct diagnosis and other technical matters laid a strong foundation for viewing the patients as an abstraction. They were numbers to be moved along the system and returned to duty as soon as possible. This was not unusual in military societies but was exacerbated within the Soviet system. An argument can be made that the Stalinist terror produced an even stronger sense of stoicism among the Soviet people. Such an attitude would have a significant impact on the degree of NP casualties in the coming war. Like Pavlov’s dogs, Soviet society in the 1930s seemingly pre-conditioned the population to accept privations and suffering, all in the name of national security. Yet nothing could prepare the Soviet people for what lay ahead. Similar to the Red Army as a whole, the effects of Stalinism, the purges and the rapid expansion of the military in the short years prior to World War II left Soviet military psychiatry dangerously ill equipped to face the German whirlwind.

5

The Great Patriotic War – Phase 1 The hurricane

The fundamental task of military psychiatry remains unresolved. (M.I. Timofeev, 1942)1

Early in his war novel, Volokolamsk Highway, Alexander Bek told the tale of a young Kazakh Sergeant Barambayev, who was surrounded by Germans, panicked and eventually shot himself in the hand to avoid future fighting. This event occurred early in the war as the Germans were driving rapidly towards Moscow. By the time he made it back to his unit, his hand was bandaged and he was mentally recovered but his company commander would have none of it. Barambayev was executed by the men in his own unit in full view of the entire company. The ferocity of the initial period of war with Germany did not provide time for diagnosis and treatment for NP casualties. Ruthless application of discipline replaced psychiatric theory. The theory and practice of military psychiatry clashed head on in the early months of the desperate fighting and would continue throughout the war as the lines between cowardice and NP casualties were slowly drawn.2 It is impossible to describe the initial chaos experienced by the Soviet Union during the opening weeks of the Great Patriotic War. According to recently declassified Russian sources, on the Soviet Western Front alone during 1941, there were 1,297,954 total casualties, with 328,735 listed as wounds, burns or concussions.3 These enormous casualties overwhelmed all aspects of the Soviet medical system, including military psychiatry. One Soviet physician, I.V. Rebel’skii, claimed that in the early months of the war, up to 70 percent of all wounded and ill who were evacuated from the front lines had some form of psychiatric disability.4 From 22 June 1941 until approximately November 1942, the first period of the Great Patriotic War,5 Soviet military psychiatry sought to establish the psychiatric organization that they had proposed throughout the pre-war years. It quickly became apparent that all aspects of the Soviet military were hopelessly unprepared for the chaos of war. Numerous memoirs recall units lacking fuel, weapons, and basic logistical support. Some Soviet commanders recognized the ruthless speed of the German advance as the

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The Great Patriotic War – Phase 1

perfect conditions for fear and panic, sure signs of psychiatric distress. K.K. Rokossovskii, commander of the 9th Mechanized Corps in the Kiev Military District, was aware of these factors. He went out to the front to examine the troops in their foxholes where he gathered a sense of isolation and could see how the new recruit could be filled with ‘… the constant feeling of alarm and apprehension … .’6 Rokossovskii quickly ordered the foxhole system to be abandoned and replaced by the trench system of defense in order to provide a more supportive environment for the soldiers. Not all remedies for the panic were so benign. On 28 July 1942, responding to the crushing German summer offensive Operation Blau, Stalin issued Order No. 227, prohibiting units from retreating, and establishing the strictest discipline within the military. ‘Panic mongers and cowards should be exterminated on the spot.’7 During the brutal six months of fighting in 1941, the Red Army suffered approximately 360,000 killed in action, 960,000 wounded and over two million Soviet soldiers were listed as missing or POWs.8 Such a hemorrhage could not continue unabated. Soviet military psychiatry now had the opportunity to step into the light and put its pre-war theories and recommendations into practice. Stalin and the Red Army were open to any means of preventing, treating and returning NP casualties to the front, but these desperate times made it difficult for military psychiatrists to implement proper organization and procedure. In the meantime, Stalin chose to use the harshest means to prevent the collapse of the military, with little opposition from his commanders. Prevention of NP casualties in June 1941 was impossible. Nothing could alter the incredible hardships of the front while chaos in the rear prevented any real screening process of recruits. The Soviet surgeon Nikolai Amosov recounted that on the day of the invasion, the induction post commander at Cheraponts said ‘No consultations or analyses. We must mobilize this town in 24 hours.’9 In Baku, N.M. Borodin recalled that his induction screening focused on establishing that he had two eyes, arms, and legs and that he was able to run. Amazed, Borodin asked the medical officer if this was the standard exam. The officer laughed, saying that he spent more time with Borodin than with most. The doctor then remarked that many recruits ‘… were rushed to the front with no medical examination at all.’10 The desperate need for additional troops to offset the initial massive losses meant that psychological standards for the average rifleman were set at only the most obvious and extreme cases of mental illness. As is often the case in military institutions, change came from the top down. Soon after the war began, a special directive from the Main MilitarySanitary Directorate (GVSU) defined psychiatric assistance to Red Army troops. It closely resembled the organizational structure from the highest levels of army command down to the regimental level as previously recommended by the Military-Medical Academy’s research published in 1934 under the guidance of V.P. Osipov. Psychiatric departments were included in military hospitals and civilian psychiatric hospitals were also


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ordered to make room for military personnel in September 1941. At the same time pre-existing special neuropsychiatric hospitals within the People’s Commissariat of Defense (NKO) and the People’s Commissariat of Health (NKZ) fell under the authority of the GVSU. The complex network of civilian psychiatric clinics and hospitals plus the military hospitals provided a framework for rapid expansion of psychiatric care for the army.11 The guidelines for psychiatric care came from above, primarily from the psychiatric department of the Military-Medical Academy in Leningrad. As the Wehrmacht tightened its stranglehold on the city, however, the psychiatric department was transferred to Samarkand in the fall of 1941. There Osipov and his team continued their work with a series of conferences, beginning in the spring of 1942, whose results were published and distributed to the appropriate Red Army medical services throughout the course of the war.12 These conferences tended to concentrate on practical suggestions to front line psychiatrists and physicians regarding diagnosis and treatment. Conference topics included differential diagnosis and criteria to be used for determining the mental fitness of NP casualties. But before these could take place, basic restructuring of the psychiatric system was necessary.13 Restructuring from above began as early as October 1941 when special neuropsychiatric reception points were established at the evacuation centers of every army. By early 1942 trained psychiatrists were at the divisional level and some 30 beds were assigned for NP casualties at many army hospitals. Recovery time was set at 20 days at the divisional level. Those patients whose recovery it was felt would take longer than 20 days were evacuated further to the rear.14 In 1942, as the draft quotas began to fall short, rehabilitation of NP casualties was seen as a potential source of manpower to make up for conscription shortfalls. In March 1942 concrete steps were made to realize the goal of bringing psychiatric aid close to the front with the adoption of psychoneurological aid departments in the Northwest Front. Gradually this was adopted throughout all the fronts. More importantly, specialized rear area hospitals were established for psychiatric aid. These hospitals had four departments: 1) psychiatric, 2) contusions, 3) traumatic damage and illnesses of the central and peripheral nervous system, and 4) recovery. Simultaneously, front areas developed special hospitals exclusively for contusion victims, each divided into three departments: 1) open trauma to the skull, 2) contusions or closed trauma to the skull with pronounced problems to speech and hearing faculties, and 3) contusions with pronounced problems to areas other than the nervous system.15 While all of these changes were simply the application of suggestions that were promoted for years before the war, the most significant change that occurred in the early months of the war was the prevalence of the diagnosis of contusion or barotraumatic illness.16 According to Soviet neuropathologists, contusions were the results of rapid changes in atmospheric pressure due to high explosives. These contusions affected the ‘… regulatory mechanisms of

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the blood and spinal fluid circulation, as well as the cerebral cortex, because of anoxia.’17 Such a total assault on the body led to a wide variety of symptoms, such as hysteria, deaf-mutism, exhaustion and others. The most important point regarding contusions, and what separated them from the more general Western term of shell shock, was that contusions affected the total organism, not just the visibly affected parts. In the first phase of the war, this diagnosis was prevalent. Ninety percent of all neurological injuries, or seven percent of all hospital patients, were diagnosed as suffering from contusions by the end of 1941.18 According to recently declassified figures, total cases of sick and wounded in the Red Army at the end of 1941 were 1,166,615. Assuming that these cases were hospitalized and the percentage of contusion cases was correct, over 81,000 Soviet soldiers were diagnosed with contusion injuries.19 These kinds of injuries had been discussed in the pre-war literature, especially in works regarding World War I, but the degree to which they were diagnosed seems much greater than anticipated. The exact reasons are unclear but a variety of possibilities exist. The most obvious and plausible explanation is that Soviet physicians and psychiatrists believed that contusions were the cause of most NP causalities. This strong physiological reason was consistent with the Russian/Soviet materialistic diagnosis of mental illness. Given the dearth of qualified Soviet psychiatrists, contusions were also a very simple diagnosis that could cover a wide variety of symptoms. These symptoms varied according to the individual patient’s unique neurological makeup, but whether it was deaf-mutism or some kind of reactive psychosis, the root cause was traced back to some kind of high explosive trauma. Regardless of the explanation, Soviet psychiatrists believed that contusions were widespread and they needed to diagnose them correctly, as their treatment protocol was different from other forms of NP casualties. A variety of important symptoms were necessary in order to differentiate correctly contusions from other neurological conditions. For example, patients with emotional shock or hysteria often could not walk and their pupils were dilated, and with specific questioning they often provided a detailed description of the emotional trauma. Contusion casualties, however, presented far different signs and symptoms. Often the body was inert but the muscle tone remained. The patient’s face showed suffering and pain, but questions about what happened were generally unanswered. Most of these patients exhibited some degree of deaf-mutism, poor sight, and a heightened sense of pain. Improper diagnosis during the first phase of the war led to faulty treatment. While cases of hysteria were generally treated through techniques like physiotherapy and organized work parties, contusion patients required quiet and calm and eventual evacuation to the rear. Over time, motor functions tended to return, but the deaf-mutism often degenerated into hysterical fixation, which became more pronounced as days passed. In order to force the patient to speak, a variety of therapies were used: ether-


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narcosis, the prohibition of writing as a means of communication, and refusal to entertain requests by the patients unless they were spoken. Perhaps most effective of all, patients were not allowed to smoke unless they verbally asked for cigarettes.20 Special hospitals were established for contusion victims by early 1942, and they appeared to serve their purpose. Soviet authorities claimed that these hospitals were able to achieve a 93 percent recovery in deaf-mute patients. Those that did not recover were later found to have actual physiological damage to the hearing organs. These casualties were then evacuated to a special otolaryngologic hospital in Moscow. An interesting observation made by Soviet physicians was that often the hysterical fixation came about not because the patients wished to remain deaf-mute, but because they feared to try hard, as it might make the condition worse. Instead, proper treatment required immediate and aggressive means to restore speech and hearing.21 Soviet psychiatry and neurology naturally gravitated to contusion victims, since these injuries were clear examples of their physiological focus of mental illness. But there were numerous NP casualties that were not suffering from barotraumatic injuries. Injuries to the peripheral nervous system, frontline privation and exhaustion and/or a combination of these factors also produced psychological reactions. Soviet psychologists, who had argued against the strict materialistic explanation for mental illness, used World War II as means to expand their discipline. Before the war Soviet military psychology had concentrated on tasks such as improving visual acuity and recognition along with improving officer leadership and troop morale. During the war, however, NP casualties appeared who lacked definite physiological injuries. Military psychology offered an alternative explanation for and treatment of war-induced mental illness. The leading Soviet psychologist at the time, S.L. Rubinstein, wrote that when evaluating NP casualties it was important to look beyond the functional disturbance and to examine the whole individual because ‘… the function of the sense organ itself depends vitally on the general psychological state and tendency of the individual.’22 Therapy was the most important contribution Soviet military psychology provided for NP casualties. Rehabilitation evolved from the work of psychologists like A.R. Luria who labored in the special hospital at Kisigach in the Chelyabinsk oblast. Rehabilitation focused on two primary goals: 1) the return of speech and hearing function and 2) restoration of motor functions of limbs impaired as the result of central or peripheral nerve damage. Their key concept in rehabilitation was not to restore function in its previous form but to reconstruct a new pathway to the brain, thus bypassing the damaged area and recreating the original function. In one specific case, a soldier was wounded in the parietal lobe and other central areas of the brain, creating tremendous speech problems. The patient was unable to speak unless he could see the visual form of the word spelled out in front of

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him. Often the patient would gesture to the researcher that he needed to see the word written before he could speak it. With time and much practice the patient was eventually able to restore part of his speaking ability by simultaneously writing, reading and pronouncing the words or letters he wished to speak. After speech and hearing, the restoration of motor functions was of great importance. Here the goal was to ‘… restore the ability of the soldiers of our Red Army to fight and to work.’23 Much of the research behind the rehabilitation of motor functions belonged to Professor A.N. Leontiev. Leontiev had already been involved in rehabilitation work during the late 1930s at Kourovka in the Sverdlovsk oblast. During the war he worked at the Laboratory for the Psychophysiology of Movement at the Institute of Psychology in Moscow. As with speech and hearing, simple repetitive drills designed to return the limb to its original network of nerves and reflexes did not achieve restoration of motor functions. A new functional reorganization of the nerves that govern the limb’s movements had to be achieved. Success in this endeavor depended on well-planned exercises and proper motivation. One interesting exercise was object-orientated tasks. Leontiev described a clinical experiment where a patient unable to lift his arm to a given point was able to do it later when asked to remove an object from a shelf from the same height. This case demonstrated that patients were more likely to be able to regain some level of functional ability of a stricken limb if the activity was purposeful, such as removing the object from the shelf. This concept was generalized to mean that ‘active participation in meaningful, socially important work both presupposes and produces a change of the patient’s relation to his defect, and at the same time has a curative effect on his whole moral attitude.’24 Simple goal-orientated tasks fit perfectly with the Russian tradition of work therapy and were adapted to provide practical retraining of disabled soldiers to perform non-military jobs. Soviet military psychologists further developed the idea that meaningful work helped to rehabilitate NP casualties by examining the role of duty and responsibility. As a prophylactic against NP casualties, military psychologists sought to ingrain into the individual that what is socially significant, such as defending the nation, is also personally significant. ‘To satisfy his own personal needs, man must make the satisfaction of society’s needs the direct goal of his actions.’25 For Soviet military psychologists, this was more than simply an issue of morale but an actual retraining of the brain to function under adverse conditions. Similar to restoring function in an affected limb with specialized object-orientated tasks, the individual must also be given specific opportunities and jobs in order to restore proper functioning of the whole organism. The Red Army devoted a great deal of energy in providing such opportunities. For example, throughout the war, in the Omsk evacuation hospital, 437 political discussions were held, 9,375 political information bulletins were published, and 156 films were shown with over half on a


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variety of medical subjects such as hygiene and sexual diseases.26 The reason for these activities was to restore purpose to the lives of wounded soldiers and nurture their desire to return to the fight. Soviet military psychology attempted to reduce NP casualties by fostering high morale and providing rehabilitative care to NP patients. Under the strains of war, they served as a complement to the neurophysiological-based Soviet military psychiatry. The clearinghouse for practical advances made by Soviet psychiatrists and psychologists in the care and treatment of NP casualties was the Military-Medical Academy, relocated to Samarkand in the fall of 1941. During the early war years, the staff of the psychiatric department of the Military-Medical Academy consisted of its chief, V.P. Osipov, and his colleagues N.I. Bondarev, N.N. Timofeev, S.P. Ronchevskii, A.S. Chistovich and I.F. Sluchevskii.27 These men, and a large group of other specialists, offered a wide variety of assistance to the Red Army in coping with NP casualties. Perhaps its most important function was the series of conferences held throughout the war on NP casualties. The results of these conferences were widely published and distributed throughout the Soviet military.28 One of the themes of its earliest conference in late 1941 was to re-establish the legitimacy of military psychiatry. For example, the psychiatrist V.A. Gorovoi-Shaltan gave a general historical review of war neurosis.29 Based on his studies of World War I, Gorovoi-Shaltan argued that war neuroses were important to recognize, especially for their potentially debilitating effect on the entire war effort. The etiology for war neurosis was placed not on hereditary factors but on issues of frontline privations and simple exhaustion, factors that could be altered to reduce risk. Gorovoi-Shaltan divided NP casualties clinically into two categories: 1) endogenous or constitutional and 2) exogenous or environmental. The second category is the most prevalent in wartime, as frontline conditions stress the individual’s nervous system beyond its capabilities to cope. He noted that NP casualties fell under neurasthenia (nervous exhaustion), emotional neuroses, hysteria, and traumatic psychoneurosis, and argued that to differentiate among these four types was difficult. He was able to discern certain characteristics that were indicators of each type of NP casualty. Increased irritability, weakness, and disturbances to the heart, stomach and bowels were clear signs of nervous exhaustion. Soldiers with already weak nervous systems due to childhood diseases or poor upbringing may be constitutionally more likely to fall victim to nervous exhaustion. Emotional neurosis occurred when soldiers overreacted to stressful situations, like combat, rendering them incapable of action. A clear indication of emotional neurosis is that it continues after the stressful situation has passed. In fact the neurosis can now be generalized to new situations. Severe depression and a collapse into a vegetative state can be the result of emotional neurosis. Hysteria is described as a somatic

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conversion reaction, such as paralysis or deaf-mutism without any trauma. Interestingly, Gorovoi-Shaltan observed that these reactions were most severe when they occurred in ‘… hereditarily predisposed people.’30 The final category, traumatic psychoneurosis, is similar to shell shock and has an observable traumatic feature to it. Gorovoi-Shaltan concluded his article with specific treatment options. In contrast to many of the earlier arguments regarding organization of psychiatric services, the author wrote that ideally NP casualties should be treated towards the rear, in special neuropsychiatric wards or hospitals. These rear areas should be more prepared for special therapies that were lacking at the front, such as the presence of a wide variety of sedatives, for example bromides and valerian root. Providing an environment that is in stark contrast to the front lines will provide the needed rest and relaxation required to help restore NP casualties. Good work therapy, proper nutrition and morale building programs provided by the party characterized such an environment. Additional therapies included hypnosis, suggestion and electrotherapy when applicable. This does not suggest the viability of psychoanalysis for soldiers. ‘The psychoanalytic method proposed by Freud and Adler was completely useless as applied to war psychoneurososes.’31 During the same conference in late 1941 F.F. Detengov presented a paper suggesting different therapies for traumatic psychosis.32 Detengov’s topic was primarily concerned with injuries requiring surgical care and the need for such treatments to be administered quickly. The chief dangers behind surgery were infection and further stress on the body, both factors that could exacerbate psychological symptoms. Rest, spinal drainage and air injection into the spine were common treatments following surgery. If the patient’s surgery was successful but psychological problems remained, psychotherapy was the preferred treatment method over simple rest or work therapy.33 Following the 1941 meeting with Detengov and Gorovoi-Shaltan, another conference was held in early 1942, whose purpose was also to disseminate the most up-to-date information regarding wartime psychoneurosis to Soviet military medical personnel. A.I. Buneiev addressed the question of whether there truly is something behind traumatic neurosis. He gave a brief survey of opinions from various countries such as Germany, France and the United States. Buneiev challenged the interpretations of these researchers. He dismissed the German notion that traumatic neurosis was merely malingering and an attempt to receive generous pensions from the government. Regarding the French and American viewpoints, Buneiev stressed that usually NP casualties were the result of a combination of factors, both traumatic and psychogenic. Those psychogenic factors were the unusual and stressful conditions at the front and in direct combat. According to Buneiev, the relationship between these two factors was that the organic damage or disturbance served as the foundation for the psychogenic reactions. In terms of treatment, the importance of correct diagnosis was repeatedly emphasized. NP casualties that were purely psychogenic, such as pre-combat fright


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or hysteria, were successfully treated with rest and proper nutrition or vitamin therapy and did not need to be evacuated to army or front hospitals. Organic damage was more serious and might require more sophisticated treatments available further in the rear.34 V.P. Osipov delivered a paper on ‘War Psychoneuroses’ at the conference of 18–20 December 1942 in Samarkand.35 Osipov took an interesting approach to this topic by doing a comparative study of Russian/Soviet NP casualties from World War I, the Russian civil war, the 1939 Finnish war and the current fighting with Germany. His observations were fascinating. During World War I, Osipov discovered, NP casualties were not unusual among privates but among officers the diagnosis was much less common. He concluded that the reason for this was that officers had a better understanding of what the war was about and had a greater personal stake in its outcome. Therefore NP casualties were not only the result of physical injury but also were highly dependent on psychological factors such as fear, homesickness, guilt and others. For Osipov, an examination of the NP casualty rates of these various conflicts justified his conclusions. In World War I for example, neuroses were found in 60 percent of all neuropsychiatric casualties. This percentage dropped during the Finnish war to 40 percent and, despite lacking any real current statistics, the percentage now in war with Germany was even lower. For Osipov, a viable reason for the suffering and sacrifice of war led to lower NP casualty rates throughout the entire spectrum of the Soviet military. The fact that the Red Army was now fighting on Russian soil, and soldiers were, at times, directly defending their homes and families gave the Soviet soldier the required reason to continue fighting and not succumb as easily to psychoneurosis. One additional reason was not offered. The NP casualty rate may have been lower because the Germans or Stalin’s Order No. 227 had already killed many of them. Besides these conferences, there is further evidence that the work of Soviet military psychiatrists extended to the fronts. One prime example was the assignment of Soviet psychiatrists to various armies and fronts. N.N. Timofeev was the chief psychiatrist of the Far Eastern front before the war but when the conflict began he was shifted to the Leningrad front and was assigned in March 1942 as chief psychiatrist of the Red Army. Two months later, Soviet military psychiatrists V.A. Gorovoi-Shaltan and V.E. Makarov were also assigned to front duty. Despite the war, the Military-Medical Academy in Samarkand did not shirk its educational duty and awarded candidate degrees covering a wide range of topics concerned with care and treatment of NP casualties. Makarov completed his dissertation entitled ‘Categorization, Diagnosis, Movement and Treatment of Contusions at the Front,’ in 1941. The next year Gorovoi-Shaltan finished his work, ‘Regarding the Pathogenesis of Morphine Abstinence.’ Both were examples of the most up-to-date and practical information on their topics.

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One issue that pre-war military psychiatry did not take into account was the psychological trauma placed on the civilian population. Much of pre-war Soviet military theory envisioned an initial battle on the frontier, then eventual Soviet counterattack, bringing the war to the enemy’s territory. One such tragic example of this miscalculation, the siege of Leningrad, can serve as a microcosm for the difficulties faced by Soviet military psychiatry in the first year of war. From 8 September 1941 to January–February 1942, German and Finnish troops isolated Leningrad from the rest of the Soviet Union. That winter a nightmare descended upon the city as approximately 250,000 civilians died from cold and/or starvation. Prior to the war, Leningrad was one of the chief research centers both for military psychiatry, centered at the Military-Medical Academy, and for military psychology, at the V.M. Bekhterev Institute. Despite the presence of these two institutions, psychiatric services for the city were scarce. The Bekhterev Institute was a clear example of the distinction between military psychiatry and psychology, as their chief focus of research was on camouflage. Military psychology dealt with issues regarding the improvement of already normal human senses such as hearing or sight or how to fool them through the use of camouflage. Both of these institutions were highly valued by the Soviet military, thus they were both evacuated to Samarkand, as the situation within Leningrad became desperate by the end of the year. In Samarkand, the Military-Medical Academy psychiatric department continued its work on military psychiatry while the Bekhterev Institute began to focus on the functional maladies caused by contusions.36 Not all facets of psychiatric help left the city. A neurological clinic remained in Leningrad during the siege, under the supervision of V.V. Skal’skaia and A.E. Sedol, as well as a pharmaceutical laboratory under B.A. Bastuzhev. Along with providing psychiatric care, Skal’skaia also conducted research regarding problems with psycho-sensory disturbances, with additional work done on the psychological effects of the siege on the civilian population. True to their materialistic basis for mental illness, researchers in Leningrad focused on the role of starvation and its effects on the nervous system, leading to mental illness.37 Eight psychoneurological dispensaries also provided psychiatric care to the soldiers and civilians of the besieged city. The efficacy of this care, however, was probably quite limited. As elsewhere in the Soviet Union, the number of casualties simply overwhelmed the psychiatric care system. City and military hospitals lacked adequate amounts of food and medicine and by October the hospitals often were without electricity, heat or water.38 Still, attempts were made to provide psychiatric services under the most difficult and dangerous of circumstances. In fact, one of the Military-Medical Academy’s psychiatrists, S.P. Ronchevskii, was killed in a German bombing raid on his train outside of Leningrad in 1941.39


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CONCLUSION During the first period of the Great Patriotic War, the Red Army was driven into chaos by the initial speed and ferocity of the German attack. Any discussion of Soviet NP casualties must, therefore, bear in mind that statistics and information from this period have great potential for distortion. Also, with the Soviet penchant for secrecy, it is very difficult to even come up with specific totals for NP causalities. The work that comes closest to providing actual numbers is from a team headed by G.F. Krivosheev, which includes a category ‘wounded, concussion and burn cases etc.’ in describing overall Soviet casualties for the war.40 Despite these difficulties, some general conclusions can be made regarding the efforts of Soviet military psychiatry during the first phase of war. In all likelihood, the number of NP casualties was grossly underestimated. In its basic definition, an NP casualty was one who exhibited some neuropsychiatric or psychological disorder when he arrived at the closest aid station. The important point to remember is that only the soldiers who arrived at a medical aid station would have been counted, assuming they were diagnosed correctly in the first place. Many never made it. The number of POWs and missing in action during the first phase of war was staggering. For example, on the Soviet Southwestern Front alone in 1941, 607,860 were listed as POWs or missing in action. Assuming that only 10 percent of these men, when captured or disappeared, were suffering from some kind of neuropsychiatric disorder, approximately 60,000 of them would have been diagnosed as NP casualties had they made it to Soviet medical treatment. That would be in addition to the 128,973 men listed as suffering from wounds, burns or concussions (shell shock).41 Finally, all the combatants found it difficult to quantify the difference between killed in battle and a NP casualty. A soldier, who after days of non-stop combat, snaps and engages in a suicidal activity such as leaving his trench and charging German tanks or dropping his weapon and turning his back to the enemy is a casualty of war. But is his death the result of German fire or a nervous system broken by combat? Other elements also precluded an accurate count of NP casualties in the early phase of the war. Stalin’s Order No. 227, in July 1942, created penal battalions and barrier detachment units. The first were designed to punish cowards and malingerers, while barrier detachments, consisting of up to 200 men, were placed behind frontline units and were ordered to kill ‘… panic mongers and cowards on site in the event of panic and disorderly withdrawal … .’42 The extent to which these orders were carried out and its effectiveness is controversial. Isaak Kobylanskiy, a veteran of the 300th Rifle Division, claims that the blocking detachments certainly existed but at times they were needed to prevent complete collapse. He does feel, however, that their role has been exaggerated.43 Soviet military psychiatric pre-war literature stressed the idea that hysteria and fear, without any real organic damage, was easily remedied by rest

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and proper nutrition. The desperate fighting in 1941 did not allow these soldiers the opportunity to rest and recover. In order to stem panic, examples were made and there is no doubt that many who died because of Order No. 227 were NP casualties who may have been salvaged. As for all aspects of the Soviet military, the psychiatric field was hopelessly unprepared for the war with Germany. The gap between theory and practice is a recurrent theme in Russian/Soviet history and this was evident early on in the war. According to Red Army manuals, the standard rifle division from April 1941 should include a medical battalion consisting of 253 men with 49 trucks.44 The opening days of the war revealed a different story. Surgeon Nikolai Amosoff described how horses initially drew the mobile field unit hospitals and not until December 1941 did they receive their first trucks. The wounded often walked from three to five days to the closest first aid station.45 Exhausted when they arrived, there was little time for rest or treatment, as rapid German advances could soon place the aid stations behind German lines. Such stress also affected the physicians, and Amosoff’s first experience with neuropsychiatric disorders was a fellow surgeon operating while appearing psychotic!46 The staggering speed of the German advance and the crushing casualties suffered by the Red Army resulted in the rapid loss of any lessons learned from previous wars regarding the care and treatment of NP casualties. This need to relearn the lessons of old conflicts and to bridge the gap between theory and practice, between research and clinical experience, was the reason behind the topics chosen for discussion during the early wartime psychiatric conferences in Samarkand, Tbilisi, Omsk and elsewhere. A major theme of these early conferences was the history of military psychiatry. Many papers dealt with topics that had been discussed for years prior to the war but needed to be introduced again to the Red Army medical department. Why? Two reasons stand out. The first was that many Soviet physicians were working outside their main field of expertise. Obstetricians and gynecologists were quickly retrained to provide medical care more appropriate to the military and this included psychiatry. Thus the historical traditions of Russian/Soviet military psychiatry enabled these students to be more qualified to treat NP casualties. Secondly, the massive but still inadequate pre-war expansion of the Red Army resulted in combat units short of required medical personnel. In order to compensate for this, medical students were rushed through their studies and quickly brought into military service. Even during the war this was true. In 1942 the desperate need for trained psychiatrists resulted in the Military-Medical Academy offering only 12 hours of practical training and no lecture classes in neurology/ psychiatry for their general medical students.47 The importance of these hastily trained physicians/psychiatrists was crucial for the smooth operation of the military medical system. Many of these new doctors would be placed close to the front, where they would serve as gatekeepers for the entire system. Their prompt and accurate diagnosis and


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treatment could result in an efficient operation or a logistical nightmare with soldiers being improperly placed throughout the evacuation process. Therefore it was important that these new doctors understood the basics of military psychiatry and perhaps even more significant they had to believe themselves that NP casualties were as real as gunshot wounds or typhus. The Russian winter of 1941–2 and the German retreat from Moscow at the same time allowed Soviet military psychiatry to catch its breath and plan for the future. These plans were simple. The mission of the MilitaryMedical Academy’s psychiatric department and all others involved with NP casualties was to put into place the psychiatric organization that had been discussed as early as 1934. Psychiatric care had to be timely and offered as close to the front as possible. Correct diagnosis was crucial to make sure that soldiers were evacuated to the proper point along the evacuation chain and there received the appropriate treatment. This required standardization of diagnosis and treatment. Fortunately, both topics had also been discussed for years prior to the war. Soviet military psychiatry’s job was not to create a new system but rather install the one that had been planned for years. The second phase of the war was a struggle to put these practices into place. But the savagery of the Great Patriotic War created new problems that even the pre-war planners had not anticipated.

6

The Great Patriotic War – Phase 2 The tide turns

Were the Germans in Maloiaroslavyets – There is no one in Maloiaroslavyets. Let’s go home mama.1

The second phase of the Great Patriotic War witnessed the strategic initiative turning the tide from the Germans to the Red Army. Beginning with the 1942–3 winter struggle at Stalingrad and continuing with the 1943 German summer offensive that was crushed at Kursk, the Soviet Union began to relearn many of the valuable pre-war lessons it had lost during the purges. Soviet military psychiatry was no exception as it steadily began to implement the psychiatric organizational plans espoused as early as 1934 by N.I. Bondarev. A clear example of this gradual positive change was the case of V., a 21year-old soldier who was sent to the front on September 1942. According to the psychiatric researcher A.M. Sviadoshch, V. suffered a contusion blast in December 1942 and was unconscious due to the blast and loss of blood. He did not exhibit psychiatric conditions such as deafness, mutism or stammering but he did not return to the front until April 1943. In August 1943, after four days of continuous fighting, he arrived at the regimental aid station (PMP: Polkovoi Meditsinskii Punkt), suffering from multiple wounds to his face, head and hands. His pulse was 98, his eyes were closed, and he did not respond to questioning. Damage to his head and peripheral nerves, along with his lack of response to stimuli, led to a diagnosis of reactive neuroses. After receiving an intravenous solution of calcium chloride, he slowly began to awaken and asked where he was. By the next day, he talked about his ‘slight concussion’ and within a few days wished to return to his old unit and the front.2 This brief description provides a clear example of the belated implementation of proper psychiatric organization and aid in the Red Army. V.’s first visit to the medical system resulted in the vague diagnosis of contusion and his treatment was not described. Most likely he was shuffled around and gradually, through rest and proper nutrition, he recovered. The ambiguous diagnosis of contusion left doctors providing equally vague treatment such


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as simple rest. Within approximately nine months, the situation had changed. A better evaluation of the patient was made including level of consciousness, pulse and other vital signs. The preliminary diagnosis was reactive neuroses that suggested a specific kind of treatment. The intravenous treatment was applied quickly, right there in the regimental aid station. This suggests that aggressive treatment close to the front was gradually being implemented and that the PMP now had personnel and supplies to offer more appropriate and sophisticated assistance to NP casualties. Increased supplies and the creation of a medical infrastructure were important additions to military psychiatric conditions. By spring 1943 specialized frontline neuropsychiatric hospitals were established for NP casualties. These hospitals were staffed with an increasing number of qualified and experienced personnel. Also, they contained adequate supplies to provide surgical, chemical and psychothereauptic aid to patients. With the onset of Soviet offensive operations in the spring and summer of 1943, special teams of neuropathologists and otolaryngologists were combined to follow the advancing fronts, providing psychiatric aid as soon as possible during the rapidly moving offensives.3 Gradually the seven-step evacuation process also came into effect for the entire Red Army medical forces. The regimental aid station (PMP) remained the first step in the process but by the second phase of the war, succeeding steps became more defined. Battalion, brigade and corps medical stations were assigned and staffed properly. Mobile field hospitals with designated psychiatric departments were developed to keep up with rapidly changing fronts. NP casualties whose conditions warranted greater treatment than was available at the PMP were now regularly evacuated to army, front or special neuropsychiatric hospitals.4 With increased supplies, personnel, and infrastructure, new theories and therapies were also developed for the treatment of NP casualties. The chief example of the evolving views regarding the etiology of NP cases was the issue of contusions. While pre-war Soviet literature discussed contusions, the degree to which they surfaced during the Great Patriotic War was unexpected. By the second phase of the war, more neuropathologists argued that the damage to the cortex and vegetative areas of the central nervous system due to contusions had been underrated. The need to address this damaged tissue became more the focus of military psychiatrists and neurologists. Treatments now became varied and aggressive. Initial treatment often included intensive sleep therapy, placing the patient under through ether, insulin or a variety of barbiturates. This provided the required time for the nervous system to rest, while intravenous feeding supplied all the needed nutrients. Intensive psychotherapy, especially under work-like conditions, often followed. The use of anesthesia and alcohol to limit the spread of the damage was often prescribed. Finally, in drastic situations, surgical removal of the injured brain tissue was done. The value of these treatments may be judged by Soviet claims that up to

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90 percent of contusion victims finished their treatment in specialized army and front hospitals with very few needing to be evacuated further to the rear. No mention is made whether these victims could return to the front as combat soldiers or to some other kind of military work.5 New therapeutic information was disseminated through medical conferences and meetings that took place throughout the country during the war years. Again the psychiatric department of the Military-Medical Academy under Osipov made substantial contributions. While the first phase of the war saw many works published, introducing the topic of NP casualties to the large number of new physicians in the Red Army, the second phase concentrated on more concrete and practical research. N.I. Bondarev presented a significant paper in his 1943 article describing the required psychiatric organizational plan to enhance treatment for the Red Army. Certainly this must have been frustrating for Bondarev, as the organizational scheme he presented in 1943 was practically the same that he published in 1934. Specific suggestions were given on how to implement his ideas for close treatment at the front, careful diagnosis, and the importance of directing the NP casualty to the appropriate level of evacuation.6 The informational guidelines to provide correct and standardized diagnoses was provided by V.P. Osipov in his 1943 article describing psychotic conditions that may be encountered by Red Army doctors. The most important point that he provided in this article was the observation that war ‘… does not create new clinical forms of mental illness but rather new unconventional manifestations …’ not seen in peacetime.7 Conclusions such as these could only have had a positive effect on Red Army physicians as they tended to keep psychiatric diagnosis simple and more familiar. More research regarding practical treatment was also published by psychiatrists like V.E. Makarov and M.S. Glekel’ who respectively looked at differentiating among several kinds of contusion injuries and the importance of prescribing drugs on an individual basis. An outside observer of these changes was the British-AmericanCanadian Surgical Mission to the Soviet Union in the summer/fall of 1943. On a prearranged tour of Soviet military hospitals, the Allied contingent found that the Soviet surgical effort was ‘… well organized, efficient, modern.’8 They were conducted on a visit to frontline hospitals in the Viaz’ma area of the Western Front. The primary author of the report, Professor Wilder Penfield from the National Research Council of Canada, gave a brief description of the Soviet process for handling the wounded. The first point of real professional care was the regimental aid station and if needed transfer on to mobile hospitals which he referred to as either Medical Sanitary Battalions or Evacuation Hospitals. These hospitals were generally located some 6–8 km from the front and the first surgical operations took place here. Further to the rear, as far as 30 km, were hospitals specializing in the treatment of injuries such as hip joint fractures, open and closed skull fractures, and shell shock among others.


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Regarding shell shock or contusions, Penfield reported that 0.2 percent of hospital beds at the front and 0.1 percent of beds in the rear area hospitals were set aside for shell shock. Penfield’s observations provide a unique view of the organization of medical care in the Red Army. One of his first stops was an evacuation hospital, containing approximately 3,000 beds and staffed by 70 doctors, 200 nurses, and 530 additional staff. The buildings were well constructed and camouflaged. Casualties were first washed and provided with clean clothing when they arrived and their initial diagnosis was rechecked. Women were a common sight, working not only as nurses, but also as carpenters and artisans. The evenings often had some kind of folk music, dancing, and, perhaps for their Western guests, jazz. This evacuation hospital was at the army level, some 15–20km from the front. Penfield does not provide enough information regarding quality of care, especially regarding NP casualties, to make any firm judgments concerning the effectiveness of the Soviet military-medical system. His observations do suggest that the hospital was well staffed and carefully planned in terms of construction and location. The entertainment activities he witnessed coincide with the Soviet belief in the importance of high morale. Also at the army level, Penfield examined a mobile field hospital for thoracic surgery. It had a 5m by 10m dressing tent with windows and was powered by a small gas generator. Attached to the dressing tent was the surgical tent, 5m by 5m with two operating tables. A wood burning autoclave and a small blood bank dug into the cellar was also present. Located approximately 20 km from the front, these specialized hospitals were designed to move forward towards the fighting, providing specialized care. While this field hospital specialized in thoracic surgery, the literature cites the existence of mobile units like this specializing in the care of NP casualties.9 Penfield then returned to Moscow where he visited a base hospital for injuries too severe for the army level facilities. Over 90 percent of the staff were women, including 70 physicians and 49 nurses. Student nurses studying at the Second Medical Institute provided additional help. Penfield noted that patients were not only segregated based on their diagnosis but also based on rank, with officers separated from the rest of the men. At the base hospital more sophisticated treatments were available such as oxygen therapy, blood and plasma transfusions, including potassium phosphate. While he does not specifically mention NP casualties at the base hospital, it would be here that severe mentally ill patients would be treated with therapies such as shock treatment or various kinds of chemical intervention.10 The base hospital had previously been a spa, located in a quiet wooded area. Patients seemed genuinely happy and were treated to treatments such as diathermy,11 short wave and hydrotherapy. Physical exercise classes of 55 minutes each were provided under the supervision of gymnasts and physicians, and sports such as volleyball were quite popular. Also in Moscow was a hospital for the lightly wounded. These were designed to serve those patients whose recovery was coming along well and

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who no longer needed to be in the rear hospitals for severe injuries. They helped to relieve congestion in the specialized hospitals and were often a transit point for patients to be returned to the front or discharged. Regarding NP casualties, they came here after their traumatic damage had been diagnosed and addressed medically. For example, patients who had been successfully treated for deaf-mutism or some kind of reactive psychosis were transferred to such hospitals for rehabilitation, such as work therapy.12 The 1943 British-American-Canadian Surgical Mission was well orchestrated. It is unlikely the mission saw anything their Soviet hosts did not wish them to see. Still, Penfield’s observations agreed with the Military-Medical Academy’s directives regarding the proper organization of medical assistance to the army, including psychiatric aid. How much this organization existed outside these carefully chosen hospitals is difficult to say, but all the proper conditions as outlined by psychiatrists like N.I. Bondarev were present in Penfield’s report, including the multi-step evacuation process and a wide variety of therapies, especially those designed to heighten morale.13 It is also important to note that Penfield and his colleagues misinterpreted what they saw. Penfield’s description of Soviet shell shock victims suggests that he was not cognizant of Soviet psychiatric nomenclature. While both the Western powers and the Russians in World War I used the imprecise term ‘shell shock,’ the West changed this diagnostic label to combat or battle neurosis by World War II. The Soviets discarded shell shock but did use the term ‘contusions’ as a specific kind of NP casualty caused specifically by high explosives which left clear organic damage. The confusion may have been a result of language difficulties or a sense of scientific/cultural superiority by Penfield and his Western colleagues over the seemingly less advanced level of Soviet military psychiatry. While organizational reforms were becoming apparent in Soviet military psychiatry by 1943, new problems arose. Prior to the war, Stalin and the party attempted to mobilize the entire nation to face the threat of war with the West. The line between soldier and civilian began to blur even in peacetime. Pre-war planning by Soviet military psychiatry focused on its duty to provide effective and timely medical care to the Red Army but failed to prepare itself to treat the civilian component of the militarized state. Soviet propaganda predicted that after the initial attack by the West, the Soviets would quickly respond and bring the war to the enemy’s territory.14 This miscalculation had tragic consequences, including a large number of civilian psychiatric casualties who had only the Red Army to provide treatment.

CIVILIAN PSYCHIATRIC CASUALTIES ‘They will all die. They will all be murdered.’15 The 14-year-old girl continually muttered these words three weeks after entering the pediatric department of the Kashchenko Hospital in Moscow in 1943. Kashchenko


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was one of the largest psychiatric hospitals in the Soviet Union at the time and it handled many of the most extreme psychiatric cases during the war, both civilian and military. The young girl, from a small village to the west of Moscow, had seen several of her neighbors executed by the Germans. Later, she and other members of the village were herded into a hut that the Germans then set on fire. Somehow she survived, but she had no memory of her escape. While in the hospital, she suffered from frequent crying spells, tension, restlessness and depression. This story and clinical picture was repeated throughout the Soviet Union as Red Army troops began to liberate Russian villages from the Germans. Soviet survivors of German occupation were to strain the already taxed psychiatric resources of the state. G.E. Sukhareva, Director of the Children’s Clinic at the Central Institute of Psychiatry, conducted a study of 858 cases of psychological disturbances among children in 1943 in the pediatric department of the Kashchenko Hospital in Moscow.16 Kashchenko contained 220 beds with seven separate divisions, four male and three female. The children ranged in age from eight to 16 years old and were divided among the seven divisions based on their individual mental condition and sex. The results of this study were presented at the Conference of the Central Institute of Psychiatry in Moscow in April 1944. The research on psychiatric disorders among children during wartime was greatly influenced by the strong materialistic, physiological base of general Russian/Soviet psychiatry. One of the primary results of their research is an example of this influence. When comparing adult and child NP casualties, Soviet psychiatrists stressed that children were less stable under wartime conditions. This was due primarily to the fact that their immature nervous systems were more susceptible to infections and toxic reactions. Also, their nervous systems were poorly developed in their cortical functions and their rational functioning was not as advanced as in adults. Neuropsychiatric diseases among children almost doubled between 1940 and 1943. In 1940, Kashchenko Hospital recorded the number of reactive psychoses among children resulting from a traumatic experience at 7.5 percent of the hospital’s total population. By 1943 it had doubled to 15 percent of the hospital’s population, a direct result according to psychiatrists of the brutal experience of German occupation. E.A. Osipova, the Director of the Central Polyclinic of the Health Bureau in Moscow, also noted this increase in reactive psychosis due to German occupation. At her clinic, reactive cases increased from 15.6 percent among children prior to the war to 24.2 percent in 1943. Psychoses from infections and traumatic brain disease also doubled during the same time period. In accordance with their theory of mental illness, Soviet psychiatrists were not surprised that younger children suffered more than older ones. For example, among pre-school children at Osipova’s clinic, the number who demonstrated psychiatric disturbances went from 19.4 percent in 1940 to 31.6 percent of the total population in 1943.17

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The most prevalent psychiatric disturbance among children was reactive psychoses and these were most pronounced among children who were under German occupation for prolonged periods. Many of these children were simply shattered. Sukhareva noted that, ‘they lived in constant fear and anxiety and witnessed the torture and executions of relatives and neighbors and the death of their loved ones.’18 Their reactions generally were based on fear and subsequent autonomic disturbances. Often they sat and stared as if in an alcoholic stupor. Gradually this acute phase faded and was replaced by heightened anxiety and apprehension. A common fear was that the Germans would return and punish them for leaving their villages. Physically and mentally, the children often were plagued by enuresis, sleep walking, migraines, fainting spells and involuntary movements. Speech disturbances were another common diagnostic tool when examining these children. Stuttering, lisping, and the complete loss of speech were not unusual.19 One seven-year-old boy, living with his mother, had been completely mute for over a year after retreating Germans attempted to tear the boy from his mother’s arms. Long-term psychiatric disturbances were beginning to show in 1943 among children who had been under German occupation since summer and fall of 1941. After passing through a variety of stages of reactive psychoses, these children exhibited classic signs of nervous exhaustion. They were in deep depression and their thought patterns were quite slow. They grew tired easily and their memory was poor. This led to irritability and a general lack of self-control. Interestingly, over time the children became less inclined to talk about their experiences. The prognosis for these young victims was seen as positive. Once they were placed in an environment that offered them care, stability and safety, the disturbances dissipated and they returned to their normal behavior. While under occupation, if they also suffered traumatic injury and/or physical exhaustion, these disturbances were aggravated and extended. Following reactive psychoses, the most prevalent form of mental disease was psychiatric complications of infections and of toxemia. These disturbances were characterized by a dual etiology, physical exhaustion leading to infection. Sukhareva recorded a case of a 16-year-old girl who was admitted to the hospital in a psychotic state after complaining of a minor infection that had been going on for over six months. The infection took hold in a child mentally and physically exhausted by ten months of German occupation. She witnessed the murder of her brother, sister and grandfather while her father was publicly flogged. In her own home, children accused of being partisans were hanged. When the Germans were forced to retreat, her home was destroyed and her family lived among the ruins. When she arrived at the hospital, she was completely exhausted. Her skin was pallid and she had a distended abdomen and a rapid pulse. Her red blood cell count was 3,200,000, a great deal short of the average count of 4,700,000 for women, resulting in decreased oxygen for her body.20 Despite her adolescence, her


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sexual development was retarded. Initially she was disorientated and incoherent. Later she became asthenic, easily fatigued and indifferent. For two months the asthenia continued but gradually she became acclimated to her new environment and began to show signs of a normal 16-year-old-girl. Restorative therapy and good nutrition restored her physical strength while her positive and patriotic surroundings alleviated her mental state. T.P. Simson, who looked at the behavior of children who survived German occupation in the Moscow, Tula and Kalinin oblasts, supported Sukhareva’s work.21 Simson’s work concentrated more on the behavior and treatment of these young victims and described how the behavior pattern of children changed after being admitted to the hospital. While under occupation, children were extremely restrained in their behavior, fearing to draw any attention from the Germans. They were tense and tired. One five-yearold child, Galia P., always asked her mother to keep her younger sister from crying because she feared the noise would bring the Germans, months after they had threatened to throw the infant out the window. This need for quiet often became extreme, resulting in children developing complete mutism for hours or days. From a physiologist’s perspective, Simson noted that the children’s reactions to events like landmine explosions or fires were linked to the primitive vegetative nervous system. They would become pale or flushed, perspire heavily, shiver and complain of nausea. Bodily functions would be compromised, such as loss of bladder and/or bowel control. Exposed to irritative factors, children tended to respond in two ways. One response was to withdraw and remain silent. Simson observed a child who hid under a table or on the floor, lying there silently for hours in response to some sight or sound that triggered his memory of a traumatic event. Another child, however, may react to painful memories by screaming and panicked movements. Stuttering and facial tics were not unusual products of the child’s exposure to traumatic memories. In some cases, children would drop into an epileptic seizure though they never had a history of epilepsy before.22 Behavior patterns changed after the children were admitted to the hospital. After weeks of treatment, heightened excitement, irritation and an explosive temper replaced restraint. Mothers complained that their children were now stubborn and inclined to anger and violence yet would overreact to any admonishment, often setting the child to crying. One interesting observation regarded the willingness of children to talk of their experiences. When left alone from adults, the children would often remember what happened to them and relate their stories with the other children. Hospital staff witnessed these conversations. However, when interviewed by physicians, the children became withdrawn and quiet. When they did talk, the conversations were in whispers and often the children reverted back to behaviors that they followed while under occupation. Gradually psychiatrists and psychologists found that this restraint could be overcome if a feeling of anger or aggression was produced in a child.

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Simson described a four-year-old boy who was restrained and taciturn during an interview. When asked if he wanted a gun, the boy burst out with ‘I’m going to shoot the Germans with the gun or else they will shoot me’23 and from that point the child flooded the interviewer with his experiences. For those whose disturbances were of a psychogenic nature, lacking any real physical trauma, fear took on great significance. Introduction of any stimuli that reawakened old fears of German occupation created panic in these children. Air raid alarms, backfiring automobiles or the sight of airplanes made children go pale, perspire and exhibit tremors. Nausea, diarrhea and enuresis were common. Researchers pointed out the interesting phenomenon that while under occupation the hyperkinesis, stuttering or epileptic fits were uncommon. They argued that fear was the inhibiting factor preventing the nervous system from producing these kinds of reaction psychoses. However, weeks after the children were safely in Moscow, these symptoms emerged.24 Children who suffered these kinds of psychogenic reactions in conjunction with physical deprivation such as starvation also produced unique symptoms. They showed an obsession for food. Often they demanded bread to be given to them before they went to bed. They then would hide the food in their mattress. A three-year-old girl who came to the hospital two months after her liberation always consumed three servings of soup and one time ate one kilogram of bread and 400 mg of butter by herself. She was unable to go to sleep unless she had a piece of bread hidden under the covers. Treatment for these children was quite similar to that which was prescribed to military NP casualties. Children who attempted to deflect any discussion of their traumatic experiences were the slowest to recover. Thus it was essential to get these children talking. The primary tool for this task was to provoke the child into remembering by giving him or her toy guns, planes, or tanks. These prompts often led the children to talk about their experiences. Once they started talking, Simson then recommended that they be quickly given reassurance. For example, tell the child that the Germans are not coming back and that ‘the Red Army men will drive them out.’25 This technique broke down the child’s protective walls, releasing their restraint, and allowed for a quicker recovery. As was true for the psychiatric treatment of soldiers, children’s psychiatry also needed proper organization. Institutions had to be prepared to meet both the physical and mental needs of these young victims. Good food, and exercise combined with appropriate psychotherapy, can heal the whole organism. Correct diagnosis is extremely important in order to match the child with the correct therapy and physician. Under the strain of war, however, the need for trained psychiatrists for the military superseded the needs of the civilian population, resulting in fewer psychiatrists available to treat civilian NP casualties. The tremendous increase in psychiatric patients, both military and civilian, coupled with the vast destruction of western Russia, left the field of


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Soviet psychiatry strained to breaking point. During the Great Patriotic War, all people and resources were mobilized and the line between civilian and military became blurred. Agencies like the GVSU (Main Military-Sanitary Directorate) quickly coordinated with other groups like the NKO (People’s Commissariat of Defense) and the NKZ (People’s Commissariat of Health) in order to pool their resources and talents. By 1943 these efforts were beginning to provide positive benefits, especially in terms of the organization of psychiatric aid to the army and civilians. One last piece of the puzzle must be addressed and that is the increased variety and efficacy of treatment. The twin pillars of therapy for Soviet NP casualties were prolonged sleep and meaningful work. Sleep therapy was based largely on I.P. Pavlov’s work on conditioned reflexes. The chief theory he worked on was protective inhibition. Simply stated, Pavlov argued that a state of depressed or suspended nervous activity has an important restorative effect on the nervous system.26 A variety of methods were used to produce prolonged sleep. Perhaps the most popular and easy to administer was sodium amytal, which was first used extensively during the Great Patriotic War. This was a drug that was relatively stable, safe and reliable, a fine combination of factors for use by physicians not familiar with psychiatric aid. Often used in conjunction with sodium amytal was caffeine. The theory behind the treatment was strict Russian/Soviet emphasis on physiological mechanisms behind mental disturbances. The sleep induced by the sodium amytal would release psychomotor functions deep in the sub-cortical or vegetative areas of the brain. In essence, the healing of psychiatric disturbances should begin deep in the center or more primitive areas of the brain and travel out. Caffeine would stimulate the cortical areas of the brain that would now have the benefit of rested and restored sub-cortical functions.27 Variations of this treatment abounded. The advantage of these alternatives was that numerous substances could produce the same effect, thus the lack of sodium amytal would not mean that treatment was unavailable. Evipal, magnesium solutions and, in extreme circumstances, alcohol were used to induce sleep at the front. Evipal was a recent drug whose chief recommendation for its use was its fast action. Alternative means to stimulate the brain after rest included the use of insulin shock, induced fever and electric shock therapy. Sleep therapy was the obvious choice of treatment for nervous exhaustion and some kinds of hysteria. It was also recommended for treatment of shock, peripheral nerve damage and post traumatic mutism. Sleep therapy was not, however, seen to be a cure by itself. Soviet emphasis on treating the whole organism meant that a combination of treatments designed to address the physical, physiological and psychological disturbances to the body must be used.28 Work therapy was just the next step to restoring the body to its original functioning. As sleep therapy addressed the physiological root of NP casualties, work therapy was aimed at the psychological basis. According to S.L. Rubinstein,

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‘For us man is defined primarily not by his relationship to his possessions, but by his relationship to his work.’29 Before the war, occupational outpatient clinics were available on a limited basis. These provided civilian psychiatric care and vocational therapy for patients during the day, then they returned home. Part of this was due to the belief that psychiatric care should be given in an environment as close to normal as possible and probably due also to limited resources and finances available to these clinics. Psychiatrist M.S. Kogan addressed the problem of inadequate resources. He argued that district psychiatric clinics must have the ability to offer work therapy and vocational placement for patients who are succeeding in therapy. One suggestion was to attach vocational workshops to the clinics. Before the war, Moscow had three clinics set up with these workshops and by 1948 there were 12. One clinic, the ‘Day Center of Work Therapy’ in Moscow, was established in late 1942. Patients admitted to the program were there for approximately three to four months. The work was therapeutic and designed to provide individuals with skills that could be translated into meaningful work. The normal workday was seven hours with three specially designed meals and additional time for providing the individual patient with all their medicines and physical and mental therapy. In addition to work, educational activities such as movies, lectures and library visits were available. This center had special shops for sewing, bookbinding, shoe repair and carpentry.30 NP casualties prompted the increase of such institutions. At the Penza psychiatric hospital, all of the patients who were part of the labor colony worked. Just what that meant is unclear. Patients were involved in agricultural work in order to provide food for themselves. They also repaired a sewage system and cut over 3,000 cubic meters of wood. At the Kostrova hospital, patients were put into library work, bookkeeping and accounting. These work and vocational opportunities for NP casualties were well established by 1944.31

CONCLUSION By autumn 1943, the Soviet Union moved onto the strategic offensive. Despite the initial crushing defeats of 1941, the Red Army gradually relearned the pre-war concepts of ‘deep battle’ and adjusted their tactical and operational policies to meet their goals. By the July battle of Kursk in 1943, Soviet commanders such as G.K. Zhukov and K.K. Rokossovskii were putting into practice the ideas of pre-war theorists A.A. Svechin and V.K. Triandafillov. Necessity proved to be an effective teacher.32 Along with changes in military doctrine, Soviet military psychiatry struggled to rediscover and implement an organizational structure that would provide adequate psychiatric care to the military. Much of what was becoming standard practice in Soviet military psychiatry by 1944 had already been


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addressed by the psychiatric department of the Military-Medical Academy a decade earlier. Following the chaos of the first phase of the Great Patriotic War, a slow but steady learning process occurred and N.I. Bondarev’s organizational scheme came to fruition. The most noticeable change from the early days of the war was the implementation of a seven-step evacuation plan for NP casualties. Psychiatric aid was now available at the regimental level where a screening process began to diagnose then place NP casualties according to their individual requirements. Special neuropsychiatric hospitals were established to handle difficult cases such as reactive psychoses and deaf-mutism. By the summer of 1943, all the fronts were steadily instituting these procedures and by 1944 were generally standardized. Beginning with the simplest cases of nervous exhaustion at the regimental level to the most complex and difficult patients that were sent to hospitals deep into the rear, Soviet military psychiatry was learning quickly under the duress of war the best means of caring for NP casualties. This care was becoming increasingly more sophisticated as the war progressed. While many of their therapies were simple and traditional in theory, they were being implemented by more effective means. The need to return NP casualties to the front rapidly or to some other worthwhile wartime activity put a premium on speed when treating them. Sleep therapy, for example, was made more effective by 1943 with the use of forced narcosis, primarily through drug intervention. This was in addition to good food, hygiene and political and educational instruction designed to treat the whole individual and not just his immediate symptoms. Once these symptoms were under control, work therapy and occupational training followed with the goal of restoring as many men as possible to active duty. The ability to do this reflects the Soviets’ increased logistical abilities. Hospitals and clinics were receiving adequate and appropriate supplies, and increased mechanization meant that casualties were receiving proper medical care more quickly. While Soviet military psychiatry was successfully adjusting itself to fulfill its duties, new, unexpected problems arose in this period. Civilians who suffered under German occupation were also complaining of symptoms quite similar to those that soldiers were experiencing from frontline fighting. Children especially were exhibiting all the clinical signs of NP casualties including reactive psychoses, deaf-mutism, epilepsy and others. Due to the destruction of the pre-war psychiatric infrastructure of Western Russia, most of these civilian victims could initially rely only on military medical help. This, however, could only be a stopgap measure. As the Soviets continued westward into Eastern Europe and eventually Germany, the military had to transfer these patients over to civilian care. Old hospitals and clinics that were previously corps or army installations were often transferred over to civilian use. The priority for psychiatric medical personnel and supplies remained with the army.

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Seeing the destruction wrought by the Germans on civilians did have a psychological effect on the Red Army. While political indoctrination and education can be powerful tools to increase morale, revenge became a powerful prophylactic against wartime neuroses. In 1943, a Soviet officer, David Dragunskii, was hospitalized for the third time and was recovering far from the front. There he recognized a fellow patient as someone from back home. Dragunskii however received bitter news as his friend told him of the murder of his family by the Nazis. Dragunskii later wrote, ‘After what I heard and felt I could no longer remain at the invalid home. My duty to the Party and my country, my mother’s last appeal, the sufferings of million of people … ordered me irresistibly to be where my country’s destiny was being decided … .’33 Current research suggests that people fight not for an idea or nation, but for their immediate comrades. Many Soviet survivors today remember that the war was not fought for Stalin or the motherland but, for example in the case of Leningrad, ‘I think I was fighting for my city.’ Hatred of Hitler, not love of Stalin, drove the Red Army forward.34 The second phase of the war pulled back the curtain of German occupation and the picture was horrible. The second phase was no different from the first in that it is very difficult to get specific information regarding total numbers of NP casualties and the reality of how they were treated. The penal battalions and holding companies were still in operation. How many NP casualties that were ‘treated’ by their special therapies is unknown. Also, while Russian civilian casualties were being treated for wartime psychological trauma, Stalin was producing similar traumatic experiences for his own citizens. The forced deportation of minorities such as Chechens, Ingush and others, whom Stalin accused of collaborating with the Germans, was an additional psychological blow.35 Yet Stalin was also clever enough to emphasize Russian patriotism and the need to defend Mother Russia, emotions designed to bolster the fighting spirit of the Red Army. The last phase of the war focused on refining the process that was being employed by Soviet military psychiatry. But the dynamics of the war would produce new problems for the Soviets. As the Red Army moved west, supply lines were stretched and the huge consumption of military supplies needed to sustain the massive Soviet offensives of 1944 had an effect on military psychiatry. While advancing into Eastern Europe and Germany, Red Army soldiers also experienced the difference in material wealth between the West and the Soviet Union, leading some to question the truth behind Stalin’s propaganda. But, like all the warring nations, as the conflict wound down, questions regarding the future of NP casualties in the post-war world became increasingly important.

7

The Great Patriotic War – Phase 3 On to Berlin

We never cried, we were fighting Hitler, and there was no time to think about pain.1

Militarily, the final phase of the Great Patriotic War featured the refinement of Soviet operational theory, exemplified by the 1944 summer offensive, ‘Operation Bagration,’ which resulted in the destruction of German Army Group Center. Soviet military psychiatry also reached its highpoint in the organization of psychiatric aid to the battlefield. Bondarev’s vision of the proper organizational scheme for military psychiatry was realized in the summer of 1944. The 5th Mechanized Corps of the 6th Guards Tank Army during the Jassy-Kishinev operation in Ukraine can serve as an example of the medicalpsychiatric organization of the Red Army by August 1944. The 5th Mechanized Corps consisted of three mechanized and one tank brigade. Among these units each company of a mechanized battalion had a senior medic and three regular medics. Auxiliary personnel supplemented these medics: five or six for each battalion, ten to 12 for each regiment/brigade and 30 at the corps level.2 Medics gave the first care for wounded on the battlefield. It was not unusual for the trained medics to be women and the auxiliaries to be men, as they often served primarily as stretcher-bearers. By the summer of 1944 medical-sanitary platoons for mechanized units often traveled in trucks or half-track vehicles in order to keep up with rapidly advancing Soviet forces. Their responsibility was to be the first response to traumatic injury on the battlefield. A typical response to wounded personnel was to engage in triage, treating those who had the possibility of survival. Controlling blood loss, setting fractures and treating for tetanus were common procedures. Regarding psychiatric care, these medics were important because they were the first step on the paperwork trail, leading the wounded to the next stage of medical evacuation. Not only did they provide the names, age, rank and unit numbers of the wounded, they provided the first information regarding the nature and cause of the wounds and the initial treatments. In terms of

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training, however, medics received only the minimal amount of education regarding psychiatric illness and their primary job in this respect was to identify cowards or malingerers. After January 1944 the 233rd Tank Brigade of the 46th Guards division had a senior doctor, two surgeons and a medical platoon for a total of 38 people. Three trucks and three American half-tracks transported the medical personnel and equipment. These people and materials were the nucleus of the brigade medical station (BgMP). All told, the 233rd Tank Brigade had three battalion medical stations (BMP), a BgMP and a regimental medical station. It was at the regimental level that the possibility existed of wounded personnel being seen by a trained psychiatrist. The medicalsanitary battalion (MSB) was found at the corps level. It was made up of a medical company, a sanitation platoon, an evacuation-transport platoon and a supply platoon. In theory, the MSB could process 450–1,500 sick and wounded in a 24-hour period.3 Most medical/psychiatric organizational changes had been advocated as early as the 1930s, but this does not mean that Soviet psychiatric development followed a rigid pattern. By the last 18 months of the war, new ideas for medical/psychiatric aid had been developed. One important change was the transfer of medical equipment, personnel and supplies from higher levels of medical service, such as the Front or Army level, to those medical stations closer to the front, such as the mobile field surgical hospital (KhPPG), which was often deployed at the brigade level. This unit was staffed with a neuropathologist and otolaryngologist for immediate treatment of contusion victims during offensive operations.4 On paper, by the summer of 1944, Soviet military psychiatry’s organizational theory had become reality. How well the system worked is more difficult to determine. Quality care for NP casualties in the first phase of the war was practically non-existent. The number of NP victims captured by the Germans, summarily executed for cowardice by the Red Army or placed in punishment battalions can only be imagined. By the spring of 1942 specialized neuropsychiatric care was established but the level of treatment was suspect. Still, there are examples from the official records that provide clues as to how changes in organization affected psychiatric care. The following cases came from medical records of soldiers suffering from reactive neurosis early in the war. An intense mortar attack on the Leningrad front shook a young Soviet partisan, P., in December 1941. He was taken under observation where a cursory examination described him as physically exhausted, pale, with a rapid pulse, shaky hands and exaggerated reflexes. No obvious organic damage was seen to his central nervous system. The report stated that after two weeks P. returned to the front. Also in Leningrad, N. was drafted in May 1942 and put to work in a factory. By the end of May he was in the hospital diagnosed with scurvy. He began to regain weight and improve when on 24 June N. received word that his mother and son


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had died. He cried and became hysterical, running from the hospital ward. After two weeks he too was deemed well enough to return to the front.5 Both of these cases were treated in Leningrad, home of the psychiatric department of the Military-Medical Academy. While the Military-Medical Academy staff was evacuated to Samarkand, a special neuropsychiatric clinic remained open even throughout the siege. If quality psychiatric care existed anywhere in the Soviet Union, Leningrad would have been the most likely place. Yet in both cases, diagnosis, care and treatment seemed rudimentary at best. Other than age, little patient history was provided. During the diagnostic stage, only obvious physical symptoms were recorded such as skin color and shaking. While the pulse was taken, other vital recordings were not, such as blood pressure or body temperature. No specific diagnosis was given, nor were any treatments described. The only conclusion that can be made is that the patients were given the opportunity to rest and receive adequate nutrition. By August 1943 the situation was different. A certain 21-year-old soldier, V., was admitted to his regimental aid station (PMP) on 12 August, 1943.6 An adequate patient history was taken, which revealed that V. had suffered a contusion in December 1942 that was not considered serious and he was released to the front in April 1943. The immediate reason for V.’s return to the PMP was a wound to his arm and the subsequent physical decline to the point where he was diagnosed as suffering from a reactive psychosis, being unable to speak and having tremors. A physical examination included taking his pulse, blood pressure and temperature. An IV solution of calcium chloride was administered, resulting in V. opening his eyes and asking, ‘Where am I?’. By the next morning V. was aware of where he was and could communicate verbally, though in a quiet tone. He still was not sure how he got there but he thought that it might be because of his previous contusion in December 1942. After rest and proper nutrition, V. returned to the front within days.7 In March 1944 patient F. had a similar experience with the steadily improving Soviet military psychiatric system. The 23-year-old F. had not been wounded or received a concussion. Rather he was caught in a massive artillery and mortar barrage after only three weeks on the front lines. Despite having no apparent physical injuries, F. reacted to this experience by adopting an almost comatose state. He moved along the evacuation chain, eventually arriving at the army level hospital. There he received a general physical exam, consisting of his pulse, blood pressure and temperature. These signs were in normal parameters and no obvious damage was seen to his central nervous system. F., however, was unable to answer questions. He was given food and liquids through his mouth, which he could hold but was unable to swallow. To break F. out of his condition, he was given an IV solution of calcium chloride that resulted in him opening his eyes, and he began to answer questions quietly and in monosyllables. He could correctly answer the year and month but some of his memories were

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still impaired. After three days of restful sleep and several physical daytime activities, he was able to answer questions in greater detail and assurance. He could remember that he was in battle but was unable to tell when and how he got to the hospital. Nor was he able to remember what he ate that morning or the names of some family members. That evening he slept poorly and dreamed of the battlefield incident. He remembered being covered with earth from the tremendous artillery barrage and felt himself gasping for air. He woke in fear. After four days he answered questions about the incident and his face became full of life. He became completely cognizant of his surroundings but some memories remained vague. Five days later he was feeling better and at that point he was placed under hypnosis to get at the root of his problems. Under hypnosis, F. remembered the attack beginning at 9am with a heavy artillery barrage on his trench. The sound and sight of bursting shells were all around him and his comrades died before his eyes. At some point he lost consciousness. He awoke to find himself being cleaned and transported by vehicle to the hospital. While under hypnosis, his face appeared fearful and his body trembled. Following hypnosis, he could not remember what had happened while hypnotized. But days after the treatment, F. began to recover and within two months he was considered completely recovered.8 Comparisons of these case histories suggest that Soviet military psychiatry had made significant improvements in actual care of Red Army personnel and that organizational changes led to better patient care. The cases from 1943–4 clearly state the existence of facilities that provided psychiatric care, such as the regimental aid stations (PMP) and army hospitals located further in the rear. One rear area rehabilitation hospital was described as a ‘… lovely, quiet place, a refuge amid the storms of war … .’9 More significant for this study is the fact that basic psychiatric care was available close to the front at the PMP. Cases prior to 1943 were poorly described. It was often unclear exactly where they were treated, whether close to the front or somewhere further back, in the army or front hospitals. This was due to the early rapid German advances that often placed army or front hospitals close to the battlefield as in the examples of those patients treated in Leningrad during the winter of 1941–2. As the Soviets began to stabilize their fronts and to wrest the strategic initiative from the Germans by the summer of 1943, psychiatric care and diagnosis became available at the PMP close to the battlefield. When deemed appropriate, cases unable to be treated at the regimental aid stations were transferred further to the rear, as in the case of F. Patient transfer also indicated marked improvement for NP casualties. In 1941–2 many NP casualties became POWs or partisans, while others simply disappeared. NP casualties that did make it to a medical treatment station often arrived on foot. Deep German penetrations resulted in rear area hospitals, such as those in Leningrad, serving as frontline care facilities. In the early months of the war, NP casualties often made it to


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appropriate medical facilities through sheer luck as much as design. By the spring of 1944 however, transfer to psychiatric facilities improved dramatically. The Red Army was on the offensive and moving through territory badly damaged by actual combat and German occupation. Therefore, the most advanced psychiatric services were the Red Army’s own medical department, since many psychiatric institutions in previously occupied German cities were destroyed. As Bondarev recommended in the 1930s, patient evacuation to rear area hospitals was by motor vehicle. Interestingly, F. described his evacuation via motor transport and also noted the care they gave him along the trip. Once at their respective treatment centers, improvements in Soviet military psychiatry since the early phase of the war became more apparent. Despite being one of the pre-war centers of military psychiatric research, Leningrad provided little more than bed rest and adequate food for NP casualties in 1941–2. Within a year, more psychiatric treatment options were available even at the regimental level. Both V. and F. were given IV solutions of calcium chloride, which had the effect of breaking through their reactive neurosis rather quickly. This made them more amenable to further treatments. Rest and proper nutrition were still standards of care for NP casualties and that, plus chemical intervention, was enough for V. who returned to the front straight from the PMP. F.’s case proved more difficult, resulting in his transfer to the army hospital for more advanced treatment. Along with chemical treatments, F. was placed under hypnosis where he relived his traumatic experience. Together with proper nutrition, rest and organized activities, his recovery rapidly progressed after the hypnosis treatment. These new modalities allowed the Red Army to recover NP casualties more quickly with the use of treatment procedures like chemical shock therapy and to restore soldiers with even more profound psychiatric disorders through the use of therapies like hypnosis. The tremendous losses of Red Army personnel were becoming more and more difficult as the war dragged on, thus the rapid salvaging of NP casualties took on more importance by the final phase of the war. The effectiveness of these new treatments was documented by a variety of sources in the Red Army. The Soviet psychiatrist I.V. Pavlov gathered clinical data from a selected number of front level neuropsychiatric hospitals for three years. Reactive psychoses, often brought about by poor initial treatment of NP casualties, stood at 10.9 percent of all nervous disorders in 1942. By 1943 this number declined to 5.6 percent then rose again to 7.4 percent in 1944–5.10 Soviet psychiatrists attributed the decline in reactive psychoses to better organization, diagnosis, and treatment of NP casualties. They were vague in explaining the increase in 1944–5 except to say that NP casualties tended to rise during rapid offensive operations that characterized Soviet campaigns into Eastern Europe and Germany. Other possible reasons include more recognition of NP casualties as psychiatrists gained more experience, and as Soviet troops advanced into foreign territory, the strength that Soviet soldiers derived from defending the motherland began to dissipate.

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Soviet military psychiatrists could take pride in their rapid recovery from the chaos of the opening months of the war. Fortunately, they had a solid blueprint for proper wartime neuropsychiatric aid developed by researchers Osipov and Bondarev. Yet their recovery was not due to a slavish copying of their pre-war recommendations. In fact, Soviet military psychiatry made a number of wartime observations to match changing or unforeseen conditions. Perhaps the most interesting observation was the early recognition that soldiers would still be feeling the effects of NP trauma for years after the war. Concern for post-war NP problems came from both researchers and frontline psychiatrists. Psychiatrist V.V. Skal’skaia, who was actively engaged in providing psychiatric care during the siege of Leningrad, defended his dissertation to the Military-Medical Academy regarding problems with psycho-sensory disturbances due to trauma. Later he concentrated on similar disturbances that appeared some time after initial damage to the brain. His research and clinical experience resulted in his conclusion that NP disorders persisted even after the organic damage appeared to be healed.11 Psychiatrists serving with the Red Army, like V.A. Giliarovskii and G.E. Sukharev, also warned about ‘… the possibility of delayed psychiatric manifestations or emerging emotional stress of somatic disorders … .’12 The implications of post-war psychiatric problems brought on by military service were significant. The existence of soldiers who exhibited NP disorders after the war without discernable organic damage was a direct challenge to the Soviet materialist school of psychiatry. Psychiatry responded by vigorously returning to I.P Pavlov’s school of conditional reflexes and a closer alliance among psychiatry, physiology, and neurology. This return to orthodoxy had the additional consequences of negating the small advances Soviet military psychology had made in the war for treating NP casualties. The most tragic result was that Red Army soldiers who maintained that they still suffered from psychiatric disorders after the war without apparent organic damage were denied medical benefits, as their illnesses were considered imaginary or attempts to defraud the state.13 These issues were drowned out by the rapidly advancing climax of the war. By May 1945 the Soviet flag hung over the German Reichstag and in August 1945 Soviet advances against the Japanese were rendered moot by the atomic attack against Hiroshima and Nagasaki. Soviet military psychiatry quickly turned to analyzing and evaluating the experience of the Great Patriotic War and how these lessons may be applied to future conflicts.

LESSONS FROM THE GREAT PATRIOTIC WAR Soon after the war a flurry of books and articles appeared in Soviet scientific literature regarding the role of Soviet military psychiatry during the


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war. In March 1946 the government called for the publication of an official multi-volume work, ‘The Soviet Medical Experience in the Great Patriotic War 1941–5,’14 eventually consisting of 26 volumes. Volume 26 was dedicated to NP disorders with specific chapters on contusions, reactive neurosis and hysteria. All praised the efforts of Soviet military psychiatry during the war and wished to disseminate the knowledge gained from the war throughout the Soviet Union and to use these new ideas and techniques for all Soviet citizens in the post-war world. Post-war literature confirmed the materialistic school’s theory behind the cause of mental illness and NP casualties during wartime. Following the long line of Russian/Soviet psychiatrists and neurologists like Bekhterev, Pavlov and Osipov, the wartime experience appeared to confirm the importance of organic damage to the body and the consequent neurological and psychological responses. The brief flirtation with competing theories espoused by psychologists like S. Rubinstein was firmly rejected for the materialistic model of mental illness. Contusions were the prevalent diagnosis behind NP casualties and this was indicative of the belief that the underlying cause of exhaustion, reactive neurosis or hysteria was actual damage to the nervous system.15 Post-war psychiatrists now largely dismissed even the role of congenital predisposition to mental illness, which was a significant part of the debate regarding Russian NP casualties in World War I.16 During a centenary address in honor of I.P. Pavlov’s birth, the Soviet psychiatrist N.I. Grashchenkov spoke of the need to dismiss harmful idealistic concepts of mental illness. Only a complete understanding of the nervous system will lead to ‘… a truly materialist theory on the nature of mental disorders, the theory that will lead to the development of effective preventive and therapeutic methods.’17 Thus the care and treatment of NP casualties during the Great Patriotic War followed closely the advice of Soviet psychiatry steeped in the materialist tradition. In order to provide the proper diagnosis and therapies for NP casualties, it was essential to develop a proper organization to dispense psychiatric care. According to the official history of Soviet medicine during the war, the institution of specialized neuropsychiatric hospitals for NP casualties in early 1942 was the first important step to realize the dreams of men like N.I. Bondarev and N.N. Timofeev.18 These men had argued in the 1930s that the most important goal of military psychiatry was proper organization. Correct organization ensured that all NP casualties, from the regimental aid station to hospitals in the deep rear, had the greatest possible chance of either returning to the front or providing some kind of assistance to the war effort. Following the war, Soviet military psychiatrists accepted the need for psychiatric aid as close to the front as possible. Many of the case studies in the official history described how patients were screened and then received basic psychiatric care at the regimental aid station were they either remained for the duration of their treatment or were sent further back for

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more specialized treatment.19 These special neuropsychiatric wings or hospitals were frequently discussed in the post-war literature. In general, they were seen as positive components of the psychiatric organization. The major complaint regarding these treatment facilities was that a mistake in diagnosis could result in a patient with a mild psychiatric disorder being mistakenly sent further to the rear for treatment. This exacerbated their condition as they felt that they truly were worse than they believed. These mistakes were considered minimal, however, and the success that these hospitals had in treating difficult psychiatric disorders more than compensated for these diagnostic errors.20 Post-war researchers heavily scrutinized the treatment options utilized during the war. The first five-year plan following the war gave a general review of the efficacy of the care given to NP casualties.21 The standard procedures of rest, good nutrition and appropriate work were considered to be the best treatments for the vast majority of NP casualties. For example, these treatments were practically 100 percent effective in treating nervous exhaustion. One observation made was that these options were even more important for the effective treatment of nervous exhaustion in children who suffered under German occupation. According to the physiologist I.P. Pavlov, the nervous system has not yet firmly established itself in children and any assault on these newly forming nerves could have grievous long-term consequences. Rest, proper nutrition and work had a long tradition as effective therapies in Russian/Soviet psychiatry. This tradition matched the relatively poor resources of the Russian/Soviet State and these simple procedures could provide adequate care for a large number of psychiatric cases, especially in wartime. The Soviet push to modernize the country, especially in the 1930s, provided new treatment methods for psychiatry. Generally these new options were only in the army, front or rear area hospitals where more qualified psychiatrists were stationed and more difficult cases were sent. One option was hypnosis, used for patients with reactive neuroses, in an attempt to discover the exact cause of the disorder and bring it to the surface so the patient may recognize it and begin to move beyond it. The five-year plan argued that hypnosis had been neglected and could provide future help in dealing with patients suffering from toxic or infectious hallucinations.22 Other therapies after the war included the use of drugs and electrotherapy. Diverse substances were used during the war, with varying degrees of success, to shock the body out of reactive neuroses such as comas or deafmutism caused primarily by blast concussions. Insulin and calcium chloride were commonly used for this form of shock therapy. The effectiveness of these procedures was enough to warrant further investigation, according to the Academy of Medical Sciences. In addition, the process for recovery of nervous exhaustion cases advanced with the introduction of vitamins, and a variety of stimulants such as caffeine and blood transfusions. At the same


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time, cases also responded positively to induced sleep therapy by the introduction of narcotics or barbiturates such as Phenobarbital.23 Soviet factories, such as the one located in Baku, produced a great deal of the pharmaceutical products used in such therapies. Production, however, scarcely met demand, which led to corruption and a black market, especially for valuable drugs such as penicillin.24 Neurosurgery was an additional and drastic therapeutic strategy for treating NP casualties. The vast number of open and closed head injuries during the war provided a great deal of knowledge regarding the destruction of certain areas of the brain and its effects on behavior. Thus the Academy of Medical Sciences urged further research into the use of lobotomies and sympathectomies.25 All of these treatment procedures were viewed with great pride by Soviet military psychiatry. The high percentage of NP casualties that were returned to their units or retrained to provide other important wartime services were critical elements in the Soviet victory, according to the psychiatrists. Though no actual numbers were given, official Soviet medical sources stated that during the war neuroses accounted for 26.6 percent of all disorders to the nervous system. The varieties of neuroses were divided into a number of groups including hysteria (45.2 percent), nervous exhaustion (29.5 percent), reactive neuroses (23.4 percent) and mental weakness (1.9 percent).26 Success in treating these patients was largely defined by the ability to restore them to either active duty or some kind of work to further the war effort. Regarding hysteria, 20 percent of patients recovered completely and 53.3 percent were judged as improved after treatment.27 A complete recovery implied a return to active duty at the front, while improvement often meant reassignment to rear service duties. Similar success was recorded for other forms of NP casualties. Perhaps the most effective treatment of all and the leading preventative against NP casualties was high morale, according to post-war studies. Here the lines between psychiatry and psychology blurred. Late in the war, the Soviet psychologist Samuel Rubinstein wrote that one of the great tasks of psychology was how to educate the individual soldier to ‘… rise above the merely personal to the socially important, and how the socially important becomes personally important for him … .’28 Rubinstein argued that proper socialist education could better prepare the Soviet soldier to withstand the rigors of war. On the surface, his remarks seem to merge closely with Soviet military psychiatry. Psychiatrists believed that proper and healthful surroundings could provide an environment where an individual’s nervous system can reach its full strength. After the war the intellectual climate changed and Rubinstein and his theories were taken to task for their reliance on idealism and metaphysics. Rubinstein found himself on the wrong side of Marxist ideology. This was another signal that the strict Pavlovian neurological theories regarding mental illness had regained their preeminence in Soviet psychiatry.29

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The official Soviet history of medical services emphasized the physiological and neurological aspects of psychiatric care during the war. Morale was factored in when discussing the effects of rest, better nutrition and positive work therapy on the overall health of the individual. Though not explicitly stated, the inference was that the restoration of the individual’s nervous system to proper working order would produce high morale. For Soviet military psychiatry, this had the effect of legitimizing their profession, especially in comparison to psychology, while also demonstrating their scientific superiority over the West in the treatment of wartime NP casualties. Soviet military psychiatrists were not content with simply resting on their success during the Great Patriotic War. Within the framework of a materialistic basis for NP casualties, there still remained some genuine questions about the future of military psychiatry. One issue that was addressed after the war was the need for better preparation for the next conflict. According to both researchers and clinicians, the answer to this question was better education of future medical personnel in the field of psychiatry. Medical instruction in the Soviet Union was revamped in 1945 under the auspices of the Academy of Medical Sciences (AMN), founded in 1944. This academy operated under the People’s Commissariat of Public Health and was given the task of ‘… planning, coordinating, controlling and promoting the medical activities of the nation.’30 When he addressed this body in December 1944, V.P. Osipov explained how Soviet military psychiatry should advance in the coming years. He argued for better diagnosis and earlier treatment of NP casualties, especially in specific disorders such as reactive psychoses and nervous exhaustion. He felt the need for a greater integration of neurology and physiology with psychiatry, without losing psychiatry’s unique identity. Soviet mental health facilities needed to be expanded coupled with an increase in popular education and mental health activities.31 The Soviet Five-Year Medical Plan running from 1946 to 1950 attempted to address these concerns. Despite the destruction of medical facilities, schools and libraries throughout the areas that fell under German occupation, the Soviet Union still planned on a medical school enrolment of 1550 students for the 1945–6 school year. General medical education included courses and instructional time pertinent to military psychiatry (see Table 7.1). Table 7.1 Sample Soviet medical curriculum, 1945–6 Course Physiology Military medicine Neurology Psychiatry

Lecture hours

Practical hours

164 62 62 64

114 118 76 36

Source: Michael B. Shimkin, ARSM, February 1947, p.273


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New research evolved under the five-year plan. Theory and practice were strongly encouraged, especially in the field of psychiatric trauma to pilots. While the precise origin of NP casualties remained unknown, the effects of wartime malnutrition and the emotional and physical strains of war were now subjects of intense scrutiny. All of the post-war psychiatric research had a strong Pavlovian basis, especially the work of Leon Orbeli, the Director of the Pavlov Institute of Physiology in Leningrad and former pupil of Pavlov. Finally, warnings were given regarding the continuance of neuropsychiatric disorders even after the conclusion of the war. On 23 December 1946 the Soviet military psychiatrist V.A. Giliarovskii wrote that ‘Experience has shown that after great wars, nervous and psychic diseases increased.’32 Giliarovskii noted that as of yet this increase had not been noticed, in part, he believed, because of the relative popularity of the war among the Soviet people. However he did warn that there was no room for complacency. This was in tune with his conclusion regarding psychiatry and its role in the post-war Soviet Union. He stated that psychiatry in Russia and the Soviet Union had development in several phases. Its early years in Imperial Russia were a protective phase, where the newly emerging science was careful to protect its sphere of influence and expertise. Next came curative psychiatry, when psychiatry became more confident in its ability to offer viable care and treatment. This phase carried through the war years, and the Red Army’s successful rehabilitation rate of NP casualties demonstrated the success of psychiatric care. Now a new phase of prophylactic psychiatry coul begin when, with the aid of psychiatric concepts, a new society could be built where psychic strains are limited and mental illness could be prevented.33 Post-war Soviet scientific literature praised the role of military psychiatry in the victory over Nazi Germany. It does not require a careful look to see that many aspects of Soviet military psychiatry and its role in the war remained unexamined or hidden. A prime example of this phenomenon was military psychiatry’s chaos in the early months of the war. On 22 June 1941 the entire Soviet military was dangerously unprepared for war. The fact that the psychiatric services rebounded relatively quickly considering the massive damage inflicted upon the Soviet Union in 1941 was in part a tribute to the work done in the 1930s by men like Osipov and Bondarev. Still, Soviet military psychiatry failed its basic responsibility in providing proper psychiatric care to Soviet soldiers at a time when it may have been needed most. The failure of Soviet military psychiatry in the early months of the war led to other means of dealing with possible NP casualties. Perhaps the most insidious and least commented upon was the role of coercion and threats to return these men to the front. No mention was made in the post-war literature of penal battalions, the NKVD or the infamous Order No. 227 and their role in dealing with soldiers who might later have been treated as NP casualties suffering from hysteria, reactive neuroses or nervous exhaustion. The psychiatric health of returning POWs was also a subject ignored by the

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Soviets. Certainly Giliarovskii’s concern over the continuation of NP disorders among veterans after the war was warranted, yet no word was made of Soviet POWs who suffered severely at the hands of their German captors. The fact that many of these returning Soviet soldiers would find themselves quickly transferred to the gulags made them nonentities to psychiatric researchers. Closely related to the fate of Soviet POWs was that of certain ethnic groups, such as Chechens and Ingush, who were accused of collaborating with the Germans. A great deal of study had been done on the deleterious psychiatric impact of German occupation on Soviet civilians. No mention was made of the psychiatric effects of forced exile on the Chechens and Ingush, among others, who were relocated to distant eastern lands by the Soviet government.34 Finally, possible interference between political officers and psychiatrists regarding treatment and discharge of NP patients is not mentioned. Perhaps most tragic of all was the fate of veterans after the war. The Soviet Union lay devastated physically and emotionally. Cities and villages had been destroyed. A significant percentage of young people were growing up without a father or mother. Demobilization records record approximately two million invalids among recently returning soldiers. Of these, some 450,000 had lost at least one limb. Despite the call to provide psychiatric services to post-war veterans, the Soviet Union was simply unable and unwilling to provide such services and psychiatric aid became a low priority. It fell to an interesting post-war phenomenon, so-called tavern democracy, located in innumerable pubs and cafes, often referred to as ‘Blue Danubes.’ It was here amidst alcohol and cigarette smoke that scarred veterans could find some degree of help that the state could not or would not provide. The author, Viktor Smirnov, wrote, ‘How many of these holes-in-the-wall, snack bar, pavilions and taverns, these blue Danubes, were opened by the wrecked and half-destitute country in order to comfort and warm the returning soldiers … .’35 Still, these places could not offer the degree of services that these veterans needed. Only the state had any chance of providing the help required but it responded by making many of them disappear. In a matter of days in 1948, one veteran remembered, ‘All cripples and invalids vanished. They were rounded up and transferred … in the far north of European Russia. So there was nothing to spoil the beautiful picture of Soviet life.’36 Not for 40 years, until the arrival of glasnost and perestroika, would there be a greater appreciation of the psychological damage suffered by the Soviet Union during its Great Patriotic War.

8

Soviet–US comparison of military psychiatry in World War II

Soldiers of the Red Army were under constant psychological pressure, which was unprecedented in the history of warfare. Fatigue and psychic exhaustion exceeded all imaginable limits.1

Penfield’s remarks in 1943 regarding Soviet NP casualties were based on a series of assumptions that need to be explored. The first part of his statement that ‘psychoneurosis is rare in the Soviet Union …’ was based on the belief that the definition of psychoneurosis in the West and the Soviet Union was similar enough to make valid comparisons. Second, the reason psychoneurosis was rare in the Soviet Union was due to the high morale of the Red Army. Both of these assumptions will now be examined using the US Army experience in World War II as a means of comparison.2 Prior to World War II both Soviet and US military psychiatry grappled with the problem of NP casualties. Psychiatry in both countries at the start of the twentieth century was seeking to legitimize itself as a genuine medical science. The source of legitimacy in Russia/Soviet Union was the state, and the best proving ground regarding the effectiveness of psychiatry was the military. In contrast, American psychiatry sought its legitimacy in the private sector, expanding psychiatric services outside the hidden asylums and into the general public. The US military’s first real attempt to provide psychiatric care to its soldiers was during World War I, 58 years after the establishment of a military psychiatric school in St Petersburg, Russia. Under the leadership of Colonel Thomas Salmon, the chief psychiatrist for the American Expeditionary Force, the US Army adopted a three-tier psychiatric care and treatment system similar to those in the French and British armies. The system stressed accurate diagnosis and treatment in a military environment close to the battlefield, an organizational plan that closely mirrored the Russian model.3 The primary classification of NP casualties was shell shock, a vague term that covered a wide variety of symptoms. After World War I, military psychiatry in both the US and the newly formed Soviet Union was not satisfied with the shell shock diagnosis and spent the inter-war years trying to further clarify the nature of NP casualties.

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Soviet–US comparison of military psychiatry in WWII

The military background of Russian/Soviet psychiatry made it adaptable to the rigors of world war and civil war. Psychiatry’s value as a medical science was further enhanced by helping to prepare the Soviet Union for possible future war with the West. Research and clinical studies, often headed by the Military-Medical Academy’s psychiatric department in Leningrad, worked to clarify the definition of NP disorders and to provide an effective organizational structure of psychiatric care for the Red Army. Soviet military psychiatry remained true to its materialist roots and found favor and legitimacy in the Soviet army. American military psychiatry, on the other hand, fell into neglect after World War I. Like other aspects of the American military, the psychiatric branch was reduced in manpower and money. This was not unusual, as American psychiatry grew out of the private sector, and it was here, not in the army, that American psychiatry sought to make its mark. Some, such as Colonel Thomas Salmon, called for cooperation between military and civilian psychiatrists. To treat them as different disciplines would only ‘… impair the solidarity which the whole medical profession must possess if it is to serve humanity in accordance with its opportunities in war as well as in peace.’4 His call was left unanswered. In 1927 the Handbook for the Medical Soldier, produced by the US Army, argued that future psychiatric casualties would be weeded out during the induction process. Ten years later the second edition of the US Army’s Military Medical Manual devoted only one page of the 685-page work to mental health in the armed forces. Part of the reason for the lack of interest in American military psychiatry was the current research coming out of the private sector. While I.P. Pavlov’s research further validated the Soviet psychiatry’s strong materialistic basis for NP disorders, researchers like Sigmund Freud and Adolph Meyer heavily influenced the US. Meyer was especially important as he argued that the individual plus the situation equals performance. Each individual’s background, character, and physical makeup were major determinants behind a person’s mental health. The US Army applied this theory to its experience in World War I in an attempt to explain why some individuals broke down in combat while others did not. Their conclusion was that those who became NP casualties already had some pre-existing problems that made them more susceptible to mental breakdown.5 The result was a strong emphasis on preinduction screening in order to identify potential NP casualties. The Soviet view of NP casualties differed considerably from that of the Americans. According to the Soviets, all people have within them the potential for mental disease or disorders. Good health, proper nutrition, adequate rest, and high morale all help to keep the nervous system healthy and prevent NP casualties. For the Soviets, pre-induction screening or testing would do nothing to reduce NP casualties. Soviet and American military psychiatry did share some common views regarding the diagnostic terms used in describing NP casualties. Neuroses and psychoses were terms that both psychiatric communities understood in


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the same way and were grouped under the term of psychiatric disorders. Neurosis was the less serious of the two mental disabilities. It produced psychological and physical disturbances but did not fundamentally change the personality of the victim. Nervous or combat exhaustion was a prime example of a neurosis. Psychosis, however, was more serious, producing psychological and physical reactions so severe that a drastic change in personality became evident. A prime example of psychosis was schizophrenia. Psychoneurosis was essentially a synonym for neurosis. Another broad category of NP casualties was neurological disturbances, and these were strictly organic in origin, such as toxic or infectious neurological disorders.6 While both sides recognized the same general types of psychiatric disorders during the war, each placed special emphasis on some rather than others based in large part on cultural or historical background. For example, the US Army placed categories of character and intelligence disorders under NP diagnoses. These were founded on the more individually orientated American psychiatric approach based primarily on the civilian psychiatrist’s experience with mental illness. American psychiatry had a greater emphasis on pre-existing conditions or vulnerable personalities, which explains the American military’s emphasis on proper pre-induction screening in order to remove likely NP casualties before they were sent overseas. Soviet military psychiatry, however, believed that heredity and prior experiences played a minor role behind NP casualties in combat.7 On the other hand, the Soviet Union expended a great deal of care in order to prevent disease outbreaks, such as typhus, considered to be major contributors to neurological disorders during wartime. This was a direct response to the Russian/Soviet military’s influence on the evolution of psychiatry in Russia. Military psychiatry and sanitation often worked closely together during the Russo-Japanese War, World War I, and the Civil War when fighting, famine, and poor sanitation created conditions that fostered the outbreak of highly infectious diseases.8 While diagnostic labels may have been similar, the US and the Soviet Union differed significantly regarding the causes of NP casualties. Psychiatry and psychology both emerged in the nineteenth and early twentieth centuries as new disciplines centered on mental development and disease. Often they appeared as rivals. The rivalry between psychiatry and psychology in the US resulted in both disciplines playing a significant role in the care and treatment of mental illness. While psychiatry in the US did have a strong physiological emphasis regarding the origin and treatment of mental illness, psychology remained a key player regarding these issues. Psychologists like Freud and Adolph Meyer had a much greater influence in the US regarding the source and proper treatment of mental illness than their equivalents in the Soviet Union. Meyer’s simple formula that the individual plus the situation equals performance helped to explain for American military psychiatry why only some people experiencing the same combat situation developed psychiatric disorders.9 The person who cracked had

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some predisposing condition or experience that made him vulnerable to becoming a NP casualty. Soviet military psychiatry, heavily influenced by physiologists like Pavlov and Bekhterev, did not completely dismiss the role of predisposing conditions in NP casualties but for them, actual physical trauma, like contusions, was a much greater source of NP casualties. The result was that prior to World War II American and Soviet military psychiatrists had distinctly different ideas regarding prevention of NP casualties. For the American military, proper pre-induction screening would greatly reduce the number of potential NP casualties in the next war. This hope was quickly shattered during the Tunisian campaign in the winter of 1942–3. Following battles such as Kasserine Pass, 20–34 percent of all non-fatal battlefield casualties were psychiatric and of those, only three percent returned to combat duty.10 Obviously pre-induction screening was not totally successful. A variety of reasons for this failure were offered, including not enough qualified psychiatrists at the screening centers and the excessive speed behind the buildup of US forces. It became painfully aware to US psychiatrists at the front that every man had a breaking point and NP casualties should be viewed ‘… as inevitable as gunshot and shrapnel wounds in warfare.’11 Following the Sicilian campaign in 1943, greater emphasis in the US Army was placed on treating NP casualties than on preinduction screening, and psychiatry began to play a more prominent role than psychology in the war effort. Soviet military psychiatry, on the other hand, placed little emphasis on pre-induction screening. Only the most obvious mental disorders could be effectively filtered out at the induction centers, according to pre-war theory. The best form of prevention was morale. Morale however was an ambiguous term. Here the role of Marxist–Leninist ideology may have played a role in military psychiatry. In 1934, as Stalin’s grip on Soviet society tightened, V.P. Osipov wrote that proper morale could be defined as having a durable political class-consciousness. Soldiers possessing such morale were more easily able to overcome psychotic reactions.12 Still, while Osipov’s psychiatric team made reference to proper party ideology, the bulk of their 1934 study reiterated the general themes of standard military psychiatry going back to the Russo-Japanese War. Soviet military psychiatry acknowledged the changing political realities but remained true to its earlier Russian traditions. Once it became apparent to the American army in the European theater that large numbers of NP casualties were occurring, proper treatment of these men became essential. In order to do this, the US had to relearn the lessons of proper psychiatric care that they had established in World War I. These lessons included a multi-tiered system that provided psychiatric care close to the front in a military environment. Rest, good food and emotional support were sufficient for most cases. More difficult cases were withdrawn to divisional hospitals where other treatment modalities where available such as hypnosis or chemical intervention. The most extreme cases were evacuated to army hospitals for intensive treatment and possible release


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from military service. These lessons were lost during the inter-war years but were quickly rediscovered by late 1943.13 Table 8.1 illustrates the scope of the problem facing the US Army during the war. One of the first lessons relearned by the US was the need to treat NP casualties close to the front. US Brigadier General Elliot Cooke observed the behavior of NP casualties being evacuated from North Africa back to the States. He was surprised to see that the sullen, depressed men he saw in North Africa become revitalized at sea and their attitude was that of relief, as, in their minds, their war was over.14 Very few of those evacuated across the Atlantic returned to combat duty. Soviet military psychiatry was aware as far back as the Russo-Japanese War that the further NP casualties were removed from the front, the less likely it was that they would return.15 The problem of long distance evacuation of American NP casualties was accentuated by the nature of US combat in the European theater. From 1942 to 1944, the US launched a series of amphibious landings against North Africa, Sicily, Italy and Normandy. Until they were established on these invasion sites, NP casualties often had to be evacuated across the water the invasion had crossed in the first place. This violated a central tenet of proper psychiatric care by removing the soldiers from the front. By the summer of 1943, American military psychiatry established an organizational scheme designed to deliver proper care to NP casualties. Special neuropsychiatric wings or hospitals established on the Italian Front brought psychiatric treatment close to the battlefield. In these treatment centers the lessons of World War I were applied along with treatment advances such as

Table 8.1 Admissions for NP conditions, US Army, European theater, 1942–5 Diagnosis

1942–5 Number

Neurological 20557 disorders Psychosis 8369 Psychoneurosis 111265 Character disorders 13307 Intelligence 1837 disorders Other 5604 Total psychiatric 140382 disorders Total 160939 neuropsychiatric disorders

1942

1943

1944

Number Number

1945

Rate

Number

Number

4.9

659

1648

7780

10470

2.0 26.5 3.2 0.4

200 768 220 57

759 3202 887 255

4140 58790 4585 975

3270 48505 7615 550

1.3 33.4

8 1253

356 5459

3070 71560

2170 62110

38.3

1912

7107

79340

72580

Source: Mullins (1973), p. 1015. Rate expressed as number of admissions per 1,000 mean strength per year

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insulin shock, electric shock and chemical intervention. As the number of patients steadily grew, group therapy was instituted in order to maximize the efforts of the limited number of combat psychiatrists.16 The Soviets followed a different path in order to arrive at an organizational system designed to provide effective treatment to NP casualties. Like the Americans, a pre-war organizational plan for the treatment of NP casualties existed, designed in large part by the researchers at the Leningrad Military-Medical Academy. The strong physiological–neurological path that Soviet psychiatry took during the inter-war years meant that competing theories about the nature of mental illness by men like Freud and Meyer did not interfere with planning for psychiatric aid to the Red Army in the next war. Unfortunately, the planning was not reflected by the reality of the situation by June 1941. When Barbarossa began on 22 June 1941, the Red Army was still in the midst of a massive buildup and restructuring of forces, made even more difficult by Stalin’s purges of top military officers starting in 1937. Considering the deficiencies in strategy, tactics, training and equipment, it is no surprise that proper organization for psychiatric aid to the Red Army was a low priority. The amphibious nature of American combat in Europe up to the summer of 1944 led to mistakes in the treatment of NP casualties, especially regarding the evacuation of these soldiers far from the active front. For the Soviets, geography also played an important role in the early phase of the war and its effects on military psychiatry. The crushing victories of the Wehrmacht in 1941 resulted in a tremendous loss of Soviet personnel and placed the Germans in control of many of the major centers of political and economic life in the Soviet Union. Many of the available psychiatric facilities in the western Soviet Union were lost to the Germans. In short, it was a desperate time for the Red Army. The chaos of the initial onslaught and the massive losses forestalled any attempt to set up a rational organization of psychiatric aid to the battlefield. Only after the German advance was stopped outside Moscow in December 1941, and the subsequent Soviet counter-offensive, was enough space and time made available to put the psychiatric aid plan into effect. Even with this respite, the desperate times resulted in a variety of draconian measures with Stalin’s Order No. 227 in July 1942 being the most infamous. The number of NP casualties and the effectiveness of psychiatric aid to American and Soviet soldiers was closely monitored. Unfortunately, the Russian historical tradition of secrecy makes comparison difficult and it is this tradition that makes Penfield’s observations in 1943 suspect. During the late 1930s Penfield was the chief of the Montreal Neurological Institute (MNI), a world famous center for neurosurgery. Penfield’s view of mental illness closely corresponded with the Soviet model and its strong emphasis on the neurological and physiological aspects of mental disorders. Penfield was proud of ‘… the cooperation and teamwork of neurologists and neurosurgeons which, in the Montreal Neurological Institute, we find of such


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mutual advantage.’17 Penfield’s mission to the Soviet Union in 1943 lasted only three weeks and all the pre-arranged visits were either in Moscow or in areas close by.18 Thus, they saw only what their hosts wished them to see.19 An even more difficult hurdle to overcome regarding comparisons between the US and Soviets was the Soviet policy to report NP casualties as percentages of overall casualties without giving actual total numbers. Rates therefore can be compared but total figures are not yet available. Even the most recent and detailed study of Soviet casualties during the Great Patriotic War, published in 1997, provides only a vague reference to NP casualties. Under the category of sick and wounded, a reference is made to concussion cases but they are joined with general wounded and burns.20 Despite these obstacles, some broad comparisons and general observations can be made regarding the experience of Soviet and American military psychiatry during World War II. It is impossible to determine with any certainty the total number of NP casualties suffered by either the US or Soviet army. While their diagnostic labels, terminology and definitions were similar enough to make some meaningful comparisons, total numbers are dubious. While the US did provide total numbers of NP casualties, they really only represent those soldiers that made it to the aid station or hospital and were correctly diagnosed. The number of soldiers who were victims of NP disorders at the moment of their capture or death will never be known. The much greater number of casualties suffered throughout the war, especially in the opening campaigns when Soviet records were often just a guess, only magnifies this problem on the Soviet side. Still, a rough estimate for the total of Soviet NP casualties can be derived from the available data. According to official US Army records, there were 2,943,714 hospital admissions in the European theater from 1942 to 1945. These included 20,557 neurological and 140,382 psychiatric disorders, for a total of 160,939 NP casualties. The other admissions included patients with diseases, battle wounds and non-battle injuries and wounds. Therefore, based on these statistics, neurological disorders made up 12.8 percent and psychiatric disorders 87.2 percent of NP casualties. Regarding total casualties, neurological conditions were 0.7 percent and psychiatric disorders were 4.8 percent of total hospital admissions.21 Soviet casualty figures for the war against Germany were a total of 18,319,723. If we were to assume that the rate of NP casualties was similar between the US and the Soviets, then the Red Army suffered approximately 880,000 psychiatric and 130,000 neurological disorders, for a total of 1,007,585 NP casualties.22 A closer look at these numbers reveals more problems in comparing the two countries. Regarding the definition of neurological disorders, the Soviet and US views were quite similar. Both sides saw disorders such as epilepsy or organic damage to the head or peripheral nerves as neurological. Under neurological disorders, however, the Soviets placed greater emphasis on neurological problems brought on by disease such as typhus or infections. Psychiatric disorders were also similar. Nervous exhaustion, hysteria and

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reactive psychoses were familiar to both sides. The Americans did include diagnoses such as mental deficiency or constitutional psychopathy, neither of which was recognized in Soviet military psychiatry. Finally, the Americans also diagnosed some soldiers as psychotic, where a profound and lasting change in their personality was observed. The closest diagnosis to this severe disorder among Soviet military psychiatrists was reactive psychosis. A classic example of this was the soldier unable to speak, hear or walk, yet who had no apparent organic damage to the nerves. One chance for a direct comparison between the Soviet and US experience is in the amount of neuroses (hysteria, nervous exhaustion, etc.) found as a percentage of total NP casualties. Assuming a rough equivalence between the Soviet and American definitions of neuroses (often referred to by both sides also as psychoneuroses), 69 percent of all American NP casualties in the European theater during 1942–5 were neuroses.23 This compares to the Soviet figure of 26.6 percent. Within this Soviet group, hysteria was the prevalent diagnosis, at 45 percent. The leading cause behind NP casualties for the Red Army was contusions, in 69.4 percent of all psychiatric disturbances. Soldiers who were severely wounded, with a great deal of tissue damage, were also prone to NP disorders but the cause was generally due to neurological complications resulting from infection.24 Based on these raw numbers, it appears that Penfield’s observations regarding the rate of NP casualties in the Red Army was substantially lower than in the US Army. This of course tells us nothing about the total numbers of NP casualties suffered by the Soviets. It says nothing of the Soviet NP casualties who were captured during the huge German pincer operations in the summer and fall of 1941. Nor does it mention the possibility of Soviet NP casualties that may have been executed by Order No. 227 or placed in penal battalions and eventually lost. There is no doubt that the numbers of Soviet NP casualties, even by their own definitions, were underreported. In short, despite attempts by Soviet authors to compare Western and Soviet psychiatric performance during the war, the military-medical records are simply too incomplete to draw conclusions about the rate and total number of Soviet NP casualties.25 Penfield’s other remarks involved the role of morale as a prophylactic and treatment for NP casualties. Both the Americans and Soviets recognized the role of good morale in the psychological health of soldiers. American and Soviet soldiers were provided films, lectures, entertainment and other diversions designed to increase morale and provide reasons for them to do their duty. But differences in how morale was perceived and how to improve it provide additional clues into the contrast between the US and Soviet armies. In 1943 the war correspondent Ernie Pyle wrote to his wife from Sicily lamenting, ‘The war gets so complicated and confused in my mind; on especially sad days it’s almost impossible to believe that anything is worth such mass slaughter and misery.’26 Far from home, with little immediate threat to one’s family or friends, many American soldiers found it difficult


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to understand the meaning and reason for the horror that was all around them. To compound this problem, US soldiers were in the war for the duration. As casualties mounted and young recruits became old veterans in a matter of months, soldiers often became fatalistic, sensing that soon their number would be up. In fact, researchers validated this feeling by determining that the average soldier reached his peak of effectiveness in the first 90 days of combat and after 180 days was so worn out that he was rendered useless and unable to return to military service.27 Within this environment, military psychiatrists discovered that American soldiers fought not for God or country or out of hatred for the enemy. Rather the primary reason that GIs fought was for their immediate group of comrades. This realization had significant ramifications for military psychiatrists. Strong group loyalty had a profound impact on the psychological health of the individual. Anything that an individual did that hurt or endangered the group led to a profound sense of guilt among many soldiers, whether they were officers, NCOs or enlisted men. Therefore, over time American military psychiatrists understood that maintaining or raising group morale was the key to preventing individual NP casualties. It was ironic that American society, which fostered the importance of the individual, found itself, under the strains of war, recognizing the importance of the group. This was a concept readily understood in the Soviet Union.28 As Penfield noted, morale was a major topic in the Red Army. Like the US Army, the Soviets’ view of morale and how to foster it also changed over the course of the war. The ferocity of the German assault staggered both the Army and the Communist Party. With the very existence of the Soviet Union at risk, Stalin loosened the reins on society and the war against Germany quickly became one to defend what was familiar, not some abstract idea like socialism. One veteran remarked after the war, ‘I think I was fighting for my city. I don’t think the motherland really featured.’29 Another veteran, the writer Vyacheslav Kondratev, wrote that, ‘We felt that in our hands is the fate of the homeland.’30 Neither cites Stalin or socialism, despite the years of propaganda prior to the war and the continuing socialist education soldiers received through films, pamphlets or meetings with their unit political officers. For the Americans, the lack of an immediate threat led them to question the need for their sacrifices and American soldiers looked for support and strength from the men that were part of their small unit. From the atrocities committed in countless small Russian villages to large-scale executions like those that occurred at Babi Yar, the Germans provided ample stimulus for the Red Army to continue the fight. ‘We were fighting fascism, it was a fight for survival.’31 The American soldier who shrugged off his duty or felt the crushing weight of combat on his shoulders, turned to his ‘band of brothers,’ which provided him the resolve to overcome fear and exhaustion in this horrific war on foreign soil. Soviet soldiers need only to look around and see the effects of German occupation to understand why they were fighting. A Red Army recruit could have

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answered Ernie Pyle’s question regarding whether anything was worth this much suffering: their family and friends. German barbarity provided the Red Army the psychological strength to keep fighting. It is obvious that Penfield’s observations were too brief and general and lacked sufficient evidence to sustain his conclusions that the Soviets had solved the problem of NP casualties through high morale. Based on the amount of research and literature generated during and after the war regarding NP casualties, it is safe to conclude that the Red Army determined that the number of these casualties was significant and could pose a threat to the proper effectiveness of future military operations. This work neither denied the existence of NP casualties nor placed much emphasis on preventing it through pre-war screening of recruits. Instead, the main thrust was the origin of NP casualties and its proper treatment. It was widely concluded that the source of these casualties was physiological in nature, a theory with a long tradition in Russia. It was the treatment of these soldiers that was the greatest source of pride for Soviet military psychiatrists. According to Soviet studies, 75.3 percent of NP casualties completely recovered or improved to a point where they could render effective military service beyond the frontlines. Regarding only psychiatric cases, complete recovery was observed in 59.3 percent of cases.32 A final, and perhaps most worthwhile, comparison is the effectiveness of treatment by American and Soviet military psychiatrists. When the number of NP casualties far exceeded expectations by American psychiatrists, who had been convinced that pre-war screening would prevent them, emphasis initially began to shift to the origin of these disorders. However, as manpower demands increased, all American medical facilities were pressured to stem the wastage of personnel. For military psychiatrists, therefore, proper treatment, with the goal of returning these servicemen to military duty, became their chief responsibility. Two armies will be examined to get a sense of the effectiveness of American military psychiatry, the First US Army (6 June–31 December 1944) and the Seventh US Army (1 January–24 May 1945). The First Army admitted 28,475 NP casualties during this period and 14,788 (51.9 percent) were returned to duty, while the remainder were evacuated to the rear army hospitals. The Seventh Army admitted 4,497 NP patients and they returned to duty 1900 (42.3 percent). The Seventh had subdivided their total admissions between those who were in combat areas (3,777) and those in the rear (720). Forty percent of those cases brought on by direct combat returned to duty while 52.6 percent of non-combat cases returned to duty.33 The differences in these numbers reflect the contrast in the nature of combat between these two areas. The highest monthly total for the US First Army was in July when the bitter fighting in the hedgerow country by a determined enemy exacerbated combat conditions. Once they broke out and began the race across France, the number of NP casualties dropped dramatically, from a high of 9,101 in July to October’s low of 1,944.34 Interestingly, the number of


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NP casualties did not dramatically increase during the German Ardennes offensive in December. One American psychiatrist suggested that by December individual soldiers recognized that this was no longer a game and hatred for the Germans became palpable. By December 1944, the average GI on the line was beginning to feel the same hatred toward the Germans as their Soviet allies. The Seventh Army meanwhile was facing less determined opposition as they anchored the southern end of the front facing Germany. By 1944 the US Army’s organization and treatment plan for NP casualties was essentially in place. American military psychiatry had a three-tiered system, providing treatment as close as possible to the front. Difficult cases were further evaluated and evacuated further to the rear if it was deemed appropriate. Treatment included the standards of the time, including rest, good food and work therapy in a military environment. American psychiatric organization and treatment plans were very similar to the Soviets. Some differences were present, notably in terms of treatment. The greater wealth of the US and the lack of destruction to the US economy allowed the US to provide treatment modalities more generously than the Soviets. Drug therapy was more prevalent, like insulin shock or induced sleep through narcotics. Shock therapy was available on a much greater basis. Despite these differences, however, the US was only able to return approximately half of NP casualties to duty. The Soviets could not afford such waste. According to official Soviet sources, over 70 percent of NP casualties returned to some kind of military duty.35 Table 8.2 breaks down the recovery rate of NP casualties based on their diagnosis. According to Soviet psychiatric theory, in those cases where damage to the nervous system was of a transitory nature, such as exhaustion of the nervous system resulting in some kind of neurosis, a great deal of success can be realized through proper treatment. In those cases where damage was considered permanent, such as a stroke, epilepsy, or the aftermath of a disease like typhus, treatment may slow down or stop the damage but cannot reverse it. Therefore

Table 8.2 Outcomes of different nervous disorders with proper diagnosis (in percent) Illness Hysteria Other neuroses Infectious disease Vascular Epilepsy Peripheral nervous system Other diseases Total nervous diseases Source: OSM, p. 32

Recovered 20.0 30.9 10.2 8.4 2.4 35.4 20.8 25.7

Improved

Other outcomes

53.3 56.0 39.3 42.0 21.2 56.2 51.4 51.5

26.7 13.1 50.5 49.6 76.4 8.4 27.8 22.8

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these cases may not be recoverable. This table demonstrates that the Soviet military psychiatrists were quite successful in salvaging patients who were correctly diagnosed and treated. For example, mutism or deaf-mutism was considered to be a very common form of reactive psychosis but one that, if properly diagnosed and treated, was easily reversible. Tables 8.3 and 8.4 illustrate Soviet success with this malady. For Soviet psychiatrists, hearing and speech loss following contusions but with no apparent organic damage was regarded as a form of hysteria. The barometric trauma would weaken the nervous system, which in turn would react by shutting down speech, hearing or both. The treatment for this diagnosis was classic Soviet procedure: rest, induced by narcotics if need be, for the nervous system to regain its strength. Within ten days such rest was able to restore speech in a quarter of cases while 62 percent recovered their hearing within 15 days. Soviet military psychiatrists expected eventual recovery; the real task during the war was to speed up the rate of recovery in order to return men to the front as quickly as possible. The success in speeding up recovery time among NP casualties during the war was a result of the organizational setup of Soviet military psychiatry (Table 8.5). Over the course of the war, treatment time for certain disorders, like hysteria, was reduced by up to 12 days by 1945. On average it took little more than a month for all forms of neuroses to be treated successfully (that is, able to return to some kind of military duty). Research conducted by the Military-Medical Academy along with clinical observations made by psychiatrists throughout the medical system was disseminated throughout Red Army hospitals, gradually leading to a standardization of diagnosis and treatment. The acceptance of the inevitability of NP casualties during war allowed the Soviets to concentrate their efforts and limited resources on the proper treatment and eventual return of victims to military duty. It took some time for the US to recognize NP casualties as a given, like rifle wounds, and therefore they were somewhat behind in the learning curve as compared to the Soviets in salvaging NP casualties. Table 8.3 Time until speech recovery following contusion No. of days after contusion

1–5

6–10

11–15 16–20 21–25

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