By André B. Sobocinski, Navy Medicine Historian
It has become popular to decry a diagnosis of psychiatric illness with the argument that each patient is an individual so different that standard labels cannot be applied. This point of view ignores the fact that in psychiatry as well as in all medical disciplines, accurate diagnosis is the keystone of appropriate treatment and competent prognosis.
~Capt. George Raines, MC, USN,
Chairman of the APA Committee of Nomenclature and Statistics (1948-1952)
Long before there were psychiatrists Navy physicians tried their best to classify mental health disorders.
In the age of sail, Navy surgeons frequently diagnosed their patients using broad terminology from classical and heroic medical traditions. If you were to look through Navy hospital case reports and ship medical logs from the 19th century you will find terms such as hypochondriasis, hysteria, melancholia, nostalgia, mania, dementia praecox, paranoia and even the ever-nondescript – “Insanity”. (1) These diagnoses were often subjective and based on individual experiences, educational backgrounds and patient load. In today’s medical practice many of these terms are curious relics. They do more to mask the actual environmental, occupational conditions and neurological disorders unknown to military physicians of our past.
With the advances in neurology in the 1880s, the Navy gradually replaced its broad classification “structure” with a more defined vocabulary. According to the Instructions for Medical Officers of the U.S. Navy (1886)the standard terminology for mental disorders followed the classification system established by the Joint Committee of the Royal College of Surgeons in England (see figure 1). Psychiatric disorders were categorized together with everything from seasickness (Nausea Marina) to epilepsy, tetanus and also included new disorders such as “neurasthenia”. (2)
First coined by Dr. George Miller Beard (1839-1883), a former Navy physician, neurasthenia was a condition marked by “nervous exhaustion” attributed to “modern day stressors”. (3) During the age of steam and steel, neurasthenia was not an uncommon diagnosis. From 1880 to 1900, almost 500 Sailors and Marines were diagnosed, which accounted for more than 8,000 sick days. During the Spanish-American War (1898), the condition reached a peak diagnosis of more than 90 cases and almost 2,100 sick days. (4) Today neurasthenia is considered a forerunner to post-traumatic stress disorder (PTSD).
At the turn of the century, several Navy physicians began exploring the causes of mental illnesses and paid greater attention to psychiatric diagnoses. In 1910, Past Assistant Surgeon Heber Butts, (1877-1939) considered the rank, rate, age, and the cause of abnormal condition of Sailors and Marines undergoing treatment at St. Elizabeths Hospital in Washington, D.C.(5) He identified alcoholism, heat/sunstroke/tropical climate and syphilis as the leading causes of mental disorders, including “hardships of war”, “mental strain”, “mental stress”, “worry” and “moral shock” as separate contributing factors. Although not listed in standard Navy terminology, Butts recommended reclassifying the diagnoses of “acute mania” and “acute melancholia” as “manic-depressive psychosis.”(6) According to his study, Butts established that coal passers, firemen and seaman suffered the highest rate of mental illness in the Navy while Marine privates accounted for the largest number of psychiatric patients – 125 out of 528.(7)
In 1913, the Navy reclassified mental disorders as “Diseases of the Mind” (Class XI and after 1922, Class XV). The new classification model followed the Bellevue Hospital Nomenclature of Diseases and Conditions (published in 1911) with “some changes deemed desirable for naval use.”(8) Alcoholism and drug addiction, formerly categorized under dietary diseases and poisons were now listed as types of psychoses (i.e., “psychosis, intoxication”).
Beginning in 1927, the Navy expanded its standard psychiatric language, by patterning it on three different classification models: Standard Nomenclature of Diseases and Pathological Conditions (1919), (published by the Bureau of the Census, 1919); Nomenclature of Diseases and Conditions, U.S. Public Health Service (1921) and Standard Terms for Diagnosis (U.S. Army, 1922).(9) In a little more than a decade these new models would be considered obsolete and the armed services would make strides to establish a standard system of nomenclature.