THE USE OF MUSIC IN A NEUROPSYCHUTRIC SERVICE 
BX * 
SOT. H. P. YEAGER, A.U.S. * 
Music is being used at this psychiatric center for two 
principle reasons, (l) There is a possibility that there is 
real theranutic value to be gained from its use and this nossi— 
bility should be thoroughly exploited. (2) Even if the thera- 
peutic value (in the strict sense of the word) is found not to 
exist, the music is at least a palliative agent in the adminis- 
tration of the various other types of therany. 
Our attitude, therefore, has been to provide an optimum of 
oleasure for the oatlent while, at the same time conducting e*- 
nerlnents Assigned to investigate any snecific theraneutic value 
of music. 
The department at present is set up in a newly decorated, 
soundproof room, 54 feet by 17• Half of this is given over to 
a lounge and may be used for large choral grouos or community 
sings. The other half is partitioned Into 2 soundoroof, aircorv- 
ditinned practice cubicles, a larger recording studio and a radio 
control.room. This latter room is also the nerve center of a 
high fidelity public address system which extends to the various 
wards throughout the building. Other items of equipment are 
pianos, band and orchestra instruments and a library of approxi- 
mately 500 recordings. 
Patients are Chosen for various phases of the program by 
referral of the medical officers, the case workers, or his own 
application. Experience has shown that optimum results are 
achieved when the patient participates in the production of the 
music being used. Many, however, are too disoriented for this 
tyne of work and so the program divides itself rather naturally 
into active and passive phases. If, after a period of passive 
listening the patient evinces sufficient interest, he Is given 
private lessons on the instrument of his choice with the possi- 
bility of entering him into a group as the ultimate aim. 
Obviously, careful thought must be given to the type of music 
that ia used in ajj£ phase of the program. It must fct least meet 
the natlent on his wn cultural plane and our experience has borne 
out Altshuler's findings that it must also approximate his emo- 
tional state and motor tempo. 
All the music used must then be classified according to its 
cultural and nhysio-nsychologlcal content. There are, of course, 
no clear-cut border lines, but at any one particular moment music 
nay be said to be acting on either the thalamo-hypothalsmie level 
♦ Vaughan General Hospital, Hines, Illinois. or on the cerebellar or cortical levels. At one extreme we find 
only l r-sp rhythmic resoonse and at the other extreme, music 
that is nroructive of mood changes, connotation and the like. 
It will be seen also that music on widely varying cultural 
Dianes might well have almost identical nhysio-nsycholopical 
characteristics. The Brelude to the Third Act of nTannhausern, 
for eramole, will nroduce aonroximatoly the same thalamic resoonse 
as "Alexander’s Rag-Time Band", Further quantitative and quali- 
tative subdivisions are used but which fry lack of tine will be 
given here in outline form without exolanation. 
Suffice it to say that they were culled from the contemoornry 
literature and changes were freely made on an emoirical basis. 
A, Physiologically Functional 
1) Denressant - Stimulant 
2) Producing Kinesthesia 
B, Psychologically Functional 
1) Deores - Uunhoria 
2) Oonnotative 
3) Plcturesoue 
A) Reoui~in.~ Mentation 
The various ramification* of the active asnect of the nro~ 
fran are as numerout as there are branches of interest in music. 
One nationt asks to be taurrht harmony, another wants to know 
this Classical stuff" is all about, ethers like to sing 
but insist with obvious modesty that they have no voice, A nusw- 
ber of ex-nrofeasional and amateur musicians ask for further in- 
struction on their instrument. 
The nroblem is to take uo all these loose ends and knit 
them together into grouns, large or small. One value of the proun 
lies in the necessity for the individual to adjust his behavior 
(or in this case his nlaying ) to those about him, A second value 
is to be found in the socializing influence of such a grouo. 
Third, the oroduction of music entails bodily rhythm and co-ordi- 
nation olus aesthetic and nopsiuly soiritual affect. All of these 
tend to sublimate instinctual drives, smooth out aggression and 
relieve neuro-muscular tension. 
Here the difficulty arises that to learn an instrument well 
enough to Join a groun takes a longer time than the natients . 
average length of stay. This is answered martially by giving 
groun lesaons on the easier instruments such as the guitar. 
The incentive for these natients to work at their 
ments has been furnished by making neriodic recordings of their 
nrogress. This method has a distinct advantage for Some natients 
'wer nublic It saves many an introverted tyoe from riving un in terror, while those who really desire an audience 
will usually have no trouble in finding one on the wards. Used 
in such a way as to furnish passive listening, music has been 
found to be of ssnecial helo as an adjunct to a number of other 
therapies, Among these is the insulin sub shock therany in which 
the original intention had been merely to nrovide a measure of 
enjoytienf for the patients, Later, with experimentation, it was 
found that music of various types., and played in a nartlcular 
Order produced the following results. 1) The group as a whole 
was quieter and this reduction in tx.e expenditure of energy on 
the part of the patient seemed to result in a smoother reaction. 
2) The patient approached the confusion stage of the treatment 
with considerably less anxiety. xt is interesting to note that 
upon,post-treatment questioning, patients were able to re- 
call selections that were played after they were apparently out 
of touch with realityf and that kinesthesia (that is, tapping of 
the foot, or hand movements in time with -the. musiq) could be 
observed in-otherwise unconscious subjects. ’ !) As a palliative 
agent it helns to divest the patient of any ideas that the treat- 
ment is a form of punishment. 
Music is sent up to the wards by means of the public address 
system. Treatment lasts from diQO AM until 9*45 AM. The first half 
hour of music is taken from the populair files. It consists of 
approximately 8 selections In a depending order of rhythmic value. 
From 8*30 until 9i00 the rhythmic swing is in the opposite direc- 
tion and use is made of symphonic music which has greater elas- 
ticity. From 9»00 AM (which is the peak of the reaction) until 
9i45 the music is again graduated into smoother rhythmic patterns 
and" the content becomes more or less universally famllar. As the 
mtient regain*! consciousness this type of music servts well as a 
stooping stone to a normal reality. 
It is to be understood that the above.observations are mere 
indicat one gathered through the clinical experience of the nurses 
and medical officers attending the treatments, and the nearest 
we have cone to control has been during those tines when, due to 
mechanical difficulties, it has bean impossible'to send'tbs music 
up to the wards. It is then that the nurses report a more dis- 
turbed, group and a lack of the indication* Just reported. 
The use of music during hydrotherapy has also.been produc- 
tive of some interesting indications. Three manic psyehotlcs 
entered the baths at the same time and remain there for one hour. 
On alternate days the treatment is accompanied by music. At the 
beginning of the hour the music approximates the patient*s ex- 
cited mood and overnroductivity, As the treatment progresses 
the music goes downhill in tempo, volums and emotional street. 
It has been found necessary to do this by degrees, however, or 
the resulting tautology will undo whatever depression has been 
effected. These steps might be represented numerically as (8765) 
(6543) (4321) (3211) where 8 is maximum of stimulation and 1 is 
its antithesis. Used under these circumstances the action of music is in the 
nature of a synergism in that it adds more to the efficiency of 
the bath than could be effected by the use «f music alonr. 
here again must be content with clinical observation as there 
seems to be no objective method for measuring the reduction of 
mania. 
Agitated depressed natients may also derive some benefits 
from music during hydrotherapy. • The same method of sten progress 
is used except that the order of graduation is reversed. With 
these natients, however, considerable caution must be used. If 
the music gets too far ahead of the patient in brightness, it may 
serve to deepen his deoression by pointing up the contrast 
between his mod and that of his environment. 
A limited amount of work has been done in conjunction with 
electro—shock. The music used is identical in nature with that 
employed during the terminal stage of the insulin treatment. 
It is administered during the recovery period and seems at times 
to be of value in allaying the feelings of confusion or terror 
that are occasionally experienced. 
CONCLUSIONSi l) Whether or not one wishes to call the aonlioa- 
tion of controlled music a •’tHerapy" depends largely upon the de- 
finitions used. It has, in no wise, been found to be a radical 
therapy for anything. On the other hand, as a synponatic or 
palliative therapy its range and flexibility are remarkable. It 
may excitp or depress physiological functions, xt may sublimate 
instinctual drives into acceptable channels. It may be used as 
an exercise for concentration time or as an agent in’ altering the 
emotional field of the environment. Its uae as an adjunct to otner 
therapies is promising, 2) The type of4 active wortc described is 
best suited' to institutions where patients remain for longer-than 
several months, p) r Further workjrith control groups .in hydrothe- 
rapy, insulin and electroshock therapy is warranted.,-, -4) A thorough- 
roinc study with a large group is needed..to determine the effects 
of music on blood pressure, blood volume, pulse, respiration, mus- 
cular tension, ideation and emotion. 5) Another thorough study is 
needed to classify M.th certainty a large block of music 
into terms consistent with these findings. MUSIC THERAPY - DISCUSSION 
BY 
ESTHER Q0ST2 QILLILAND* 
To those who have observed it in action, music has been re- 
vealed as a potent agsnt in therany, when properly administered. 
The resort of the program at Vaughan General Hospital on the Use 
of Music in a Neuroosychiatric Service outlines a well-planned 
and executed experiment that deserves to be shared in greater 
detail. The graduation of selections according to tempo and 
emotional intensity should prove very helpful to other music tech- 
nicians who need guidance and are.seeking.to amplify their services 
The lack of-a control group is a regrettable weak soot in 
this orogram rhidv'in ell other, phases, is an excellent beginning 
toward the compilation of data. With the'extensive music activi- 
ties in force in many government hospitals, it is to be honed that 
many other renorts be made available, 
Dr. William White’s Prgcnisav-as-a-whole concept is helpful 
‘in understanding the therapeutic properties of music, 'the physio- 
logical, psychological and socialising effects of which have been 
so admirable condensed in this report .on‘short term patients in 
an army hospital. To this I would like to add similar activities 
in a civilian hosnltal where I - studied and worked under the gui- 
dance of Dr. Ira M, Altshuler. Here many psychotic’s :roraain for 
much longer periods and many are permanently institutionalised. 
Group Music Therany makes possible the. treatment of as many 
as thirty patients at one time and is in many ’’'ays more potent 
than the snoken word, certainly less, controversial. Two areas 
not stressed in this oaner are the- most regressed cases and 
patients about ready to be paroled, - those Who haVe reacted favor- 
ably to shock or insulin therany and need to be resodalised be- 
fore beine released. *. : • 
Rhythm activity (the Rhythm Band and Dancing) i® the first 
step in music therapy, through the thalamic approach, when pro- 
perly ‘administered it arouses a large percentage of catatonic* 
and underactives and relievestyoermaniacals. Participation in 
such activities identifies these patients with the group, gives 
emotional relief in a pncially acceptable manner, accomplishes 
ego aggrandisement as well as raonort with the leader. Close 
contact with reality is established and muscular coordination 
stimulated. Attendants are also benefitted and usually are • 
attracted to spontaneous participation,* A very noticeable lift 
in spirits and improvement in cooperation will continue for many 
hours,after music technician has left the ward. 
a well-develooed music program with wisely planned activi- 
ties on the.cultural level of the convalescent can be coordinated 
into the psychotherapy classes to speed recovery, * A very notice- 
able improvement in Posture, initiative, concentration, general 
appearance, self-control and many other personality traits was 
♦Director of liusic, Wilson Br^ 
Chicago City Jr, Colleges “ 107 “ very .evident in ail participate W’the choir ttfhioh I directed. 
Those who'have learned to ; iiiuaid to-advantage: a re better able 
to adjust to home' situations JbecaiUse of* widened interests and 
the tolerance and enjoyment they have ejreSrienoed through group 
activity., . ‘ ' ’ ' ;r ''r * • ’• • * 1 
Those incurables who;ai*8 permanent residents find instiT 
tutional life much more'endurable fAr themselves as well as the 
attendants when their activities include music participation 
on their own level. 
Another group whom music benefits are those whose music 
talents were develooed to a great degree of proficiency before 
the their psychosis. No natter how regressed or with- 
drawn, it has been observed that they retain their musical skill 
if orooerly guided. This one contact with reality can be ex- 
nanded amazingly. Music technicians who are introverts can work 
singly with such very successfully because they undeiv- 
stand Schizonhreni.es, Extroverted technicians get better results 
with groans of course. 
Granted that these and many other musical activities have 
been largly empirical, many of us who have worked and studied in 
this field feel that enough knowledge is at hand to justify an 
extended program of research, if our resources were adequately 
organized. Granted that a foundation with an experimental cen- 
ter adeauptely financed is the ideal goal toward which we long, 
must we sit idly by, waitin' for the dawn? Are there no adventur- 
ous souls among the medical profession who will unite their efforts 
in guiding kindred venturesome spirits among qualified musicians? 
We feel sure that our services will Justify your tine and effort. 
Other sections of the country are providing onoortunities, New 
York University offered a survey course last summer with lec- 
turers by Drs. Bernard Wnrtis, Loretta Bonder, Morris Herman, 
Leida Berg and George Deavor besides an array of Psychologists 
and musicians. Frnm the lan e class of musicians attending, 
suitable personalities were selected to nail* off with psychia- 
trists in order to carry on experiments. 
In Boston, Flagler Fultz has established a course which is 
accredited by the Boston School of Occupational Therapy. His 
trained workers are carefully tabulating results of their efforts. 
Mi-chigar State College has instituted a four year course which 
includes internship at County Board of Institutions at 
Eloise, Iowa State University has been experimenting. Many 
other institutions are contemplating courses of study. 
My Plea is that musicians in this locality be given a like 
opportunity so that music technicians may be trained to apply 
the music prescriptions of psychiatrists intelligently and effec- 
tively, A well integrated personality, successful with groupsj 
sensitive to patient reaction with ability to adjust his technic 
accordingly is most important in dealing with the human equation. RECOMI;ENDkT..0N3-1) That the r enort from Vaughan be extended 
to include details of materials and techniques. 2) That the 
experiences of this technician and many other warrant the estab- 
lishment of courses of study in this locality so that properly 
qualified musicians may be trained to work with psychiatrists, 
both in army and veteran as well as civilian hospitals. 3) That 
further experiments with control groups be encouraged in clinics 
and veterous hospitals throughout this locality. PSYCHIATRY AMD ATOidS 
by 
Francis J, Braceland* 
Captain (MC), US®. 
Chief of Nour©psychiatric Division 
bureau of Medicine and Surgery 
Navy Department, Washington, D, C, 
The small object which was parachuted over Hiroshima on 
■August 6th ushered in an atomic ago which found the world entirely 
unprepared for its advent# tt'hile Einstein, Rutherford, Meitner, 
Fermi, and others had been heralding its approach, their audience 
was limited and few suspected the possibilities in store for us# 
The bomb which announced the success of their efforts may prove 
to be the most catastrophic bit of human audacity since that 
celebrated contretemps in the Garden of Eden. 
Though most of the details are still secret, it appears from 
the published reports that only approximately one-tenth of one per- 
cent of tho potontial nuclear energy in uranium is released when a 
chain reaction bomb is exploded# Professor states that if 
some scheme could be devised for converting to energy as much as a 
few porccnt of tho matter of some common material, civilization 
would have tho means to commit suicide at will," Vfoat is implied, 
1 tako it, is that if somo method could bo dovisod for releasing 
about five percent of a material such as manganese, tho means 
would be at hand for causing many times tho havoc of one August 6th, 
1945, model plutonium bomb. Thus has modern man by his ingenuity 
finally found tho moans by which ho can destroy himsolf and his 
neighbors in wholesale lots. 
In tho newspaper accounts of tho flight to Hiroshima and 
tho dramatic moment immediately after tho bombs away, it was 
stated that one of tho piano's occupants remarked, "Let's got the 
ho11 out of hero." This being good advice and tho pilot being 
forosightod—they did# Now in tho wake of that ominous event as 
I mull over its significance, 1 cm convinced that this is tho best 
bit of advice thus far expressed on tho subject and wo would all do 
woll if wo could follow it# UniiioD tho men in that piano, howovor, 
there is no safe place for us to go, for oxtensivo technological 
advances in aviation havo rondorod all parts of the globo vulnerable 
to attack from tho air. Aftor caroful consideration, it becomes 
apparent that, if wo cannot fight againit or floe from this weapon, 
wo must try to provont all armod conflict in which it might bo used# 
In othor words, wo have to stay and think and work out our problem; 
♦The opinions and assertions contained heroin aro tho private onos 
of tho author and are not to bo construed as official or reflecting 
the viows of the Navy Deportment or tho Naval Sorvico as a whole* that is what psychiatry toachcs us to do anyway. Without being 
unduly lugubrious about it, wo realize that atonic warfare would 
put an awful dent in civilization. If wo fail to prevent it, 
there is grave danger that the nook vrill have no oarth to inherit. 
It would bo idyllic if atonic energy could bo 'controlled for 
industrial use, bvrt i»t s.opms as though this realization is a long 
way off, For various reasons, it appears that it is much simpler 
to blow up the world with atonic onorgy than to novo a ship or a 
loconotivo with it, #von when it can bo harnessed for industry 
at some, futuro tino, it nay st.ill ronain a menace, a Danoolotian 
sword which hangs over an uneasy world, On this point Einstein 
has remarked, "Perhaps it is well that it should bo (a nonaoo). 
It nay intimidate the human raco into bringing order Into its 
intornational. affairs-*whioh, without pressure or fear, it would 
not do* 
At tho,prosent time the heads of several great powers are 
nee'ting to discuss tho control of atonic energy,’ Our own legislators, 
concerned about the problem, have boon seeking expert advice about’it. 
For tho past month chemists and physicists have boon appearing-before 
tho Senate sub-committcc• Their thesis has been tho need for controlling 
atomic energy. One day for a few hours some social scientists woro; 
hoard; their topic was tho nood for controlling oursolvos. 
Physical scientists ono month-social scientists ono day, 
Billions for destruction—littlo thought for tho disciplines which 
might help vis to avoid future wari* To psychiatrists this is a 
frniliar story. It is faintly redolent of millions of dollars 
spent annually for tho custodial caro of tho mentally ill and a 
pittance for research vrhioh might prevent mental illness. 
Tho precipitate arrival of tho atonic ago'will'of necessity 
bring a woltor of books, articles and aftor-dinnor addresses in its 
wake, authors, speakers, teachers, clergymen' and educators will 
toko the opportunity of examining their ovm particular field of endeavor 
in tho light of tho now development and will attempt to forecast its 
future. ?his, as' you nay have suspected, is ny intention; and following 
upon tho erection of a little more scaffolding, I would like simply 
to mention some possibilities for psychiatry of tho future, in an 
atomic ago. , 
Boforo developing my thesis further, I cannot help but note 
certain points of similarity between psychiatrists and tho physicists 
who have pointed up this major problem for us. Heretofore tho 
physicists always seemed to live in a tight littlo world, Thoy 
sconod to bo a group sot apart from thoir colleagues. Idko psychia- 
trists, thoy talked thoir own particular typo of mumbo jumbo, Ualiko tho 
psychiatrists, thoir solorico was usually fifty yoors ahead of its im- 
portant technological application, Tho ossontial unpredictability of the laws of nature made their scientific research a voyage 
into uncharted seas whoso very existence was in doubt. Th0 
essential unpredictability cf ran and his emotional actions 
m.rhcs curs a similar venture. As another point cf similarity, 
in our college days the chemists used to loch at the physicists 
"dth askance—shall v;c say, much like the surgeons look upon 
psychiatrists today? Suddenly this cindorolla-liko science 
presents to its questioning colleagues an accomplishment which 
to some already holds promise cf a fabulous push button age 
but which tc others looms as a Frankenstein which had been 
bettor left undiscovered. Fsychiatry will hardly present the 
world with anything so dramatic, but it dees have a contribution 
to make to some of the problems which face our culture. 
Ono of our difficulties in psychiatry he.c been the tendency 
r.t tir.ee to operate in a vr.cuun. have beer, abl to liavu cur 
Patients adjust and apparently recover in our sanitaria, but they 
frequently have net boon able to held their gains in society* 
-his attitude comes be us naturally, for basically va have been 
physicians charged with the treatment of the mentally ill. The 
present age points up for us a little more sharply the fact that, 
in addition to our basic functions, v.-o need to train our sights 
cn the goal of positive mental health, Positive mental health 
is as dependent upon-inter-personal, ar it is upon intra-personal, 
relationships,In a v;crld in rhlch rapid transportation and communication 
and new weapons have made* nations dependent upon the actions of other 
nations fer their very existence, thoro vdll of necessity be an in- 
crease in social.pressures. There is rood, therefore, for a renewed 
interest on the part of psychiatry in social phenomena, an attention 
to the development cf what be called Social Psychiatry. Because cf 
our particular type of training, there arc several adjustments which 
need to be made before no can expand, for .we all realize that our 
tendencies have been.to-go in the other direction. 
There arc several major promises upon vrhich cur new planning 
may bo based, and the .atomic ago furnishes us with r. good opportunity 
to discuss their.. It is axiomatic in psychiatry that wo believe in 
the efficacy of our influence and treatment in mental and emotional 
diseases. Our treatment, cf course, is predicated upon proper diag- 
nosis of the ailment, Idkowico, if wo arc to bo of assistance in 
the treatment and euro of the ills of the body politic, it is first 
necessary tc believe that they vdll respond to treatment after a 
correct diagnosis is made, It follows that a body of data on social 
psychopathology is required that vdll enable thinking men to arrive 
at a social diagnosis ar.d begin tc remedy the pathologic conditions. 
The frame cf reference in psychiatry heretofore csto.blishcd has 
boon valid for individuals and as such is not necessarily applicable 
to the problems of groups. It is unjustifiable to speak cf a people 
as being schizoid'1 or a nation as being "paranoid," Those are the 
syr.ptof individuals. There is r.o data on record which indicates that wo can transferor s translate our concepts of individual 
psychopathology tc group psychopathology and fomulato a workable 
system. Therefore, a whole now framework of reference and in- 
quiry is required for the background of the social psychiatry 
of the future. 
Gregg I boliovo that in the future "psychiatry will find 
groat extensions of its content and of its obligations. There 
will be applications far beyond your offices and your hospitals 
of the further knowledge you will gain, applications not only to 
patients with functional and organic disease, but to the human re- 
lations of normal people—in politics, national and international, 
between races, between capital and laber, in government, in family 
life, in education, in every form of human relationship, whether 
between individuals or between groups, You will bo concerned with 
optimum performance of human beings as civilized creatures." 
This task requires tho of more than one group of 
specialists, for tho complexities of modern society make its ills 
tho responsibility of exports from deny fields and calls for the 
pooling of their resources. Tho psychiatry of tho present age 
must ally itself with educational disciplines. Its mootings should 
be attended by ether scientists such as economists, sociologists, 
philosophers and cultural anthropologists# Because of our isolation, 
wo have become inbrod and new ideas aro looked upon with suspicion. 
Our mootings aro the occasions to rehash old ideas# 
V/o v.Tito our books for ouo another and not for tho people who 
would profit by reading than. A few years age an excellent book on 
psychiatry in nodical education was writton. * have yet to moot one 
dean or medical educator nf member of a curriculum committee who has 
road the book. In all fairness, I must say that I mot one nan who 
had heard of it, V/ho is at fault? 
"If v/c r.ro misunderstood wo have oursolvos to blwno 
Men sometimes arc mastors of their fatos 
The fault dear Brutus is not in our stars— 
but in ourselves*'* 
It is interesting to note that, having succoodod in releasing 
atomic energy—the no plus ultra of nuclear physics—tho scientists 
arc now discussing tho philosophical aspects of tho problem and the 
othics and morality of atomic bombing. This is encouraging and 
negates the popular idea of tho aloof, cold, rationalistic scientist 
interested only in his calculations and experiments# 
It is an unfortunate commentary on tho present state of our 
culture that the two main categories in which v/o have benefited from 
advances in science have boon tho development of creature comforts 
and instruments of war. It is much easier to got people interested in a new oloctricrd r.pnlinnoo or r.n nutonobilo thnn it is to 
interest then in. socir.1 progress mcl tho welfare of thoir 
follow non, This brings up ny second point, nnraoly, are v/c 
in psychiatry, like our brethren tho physicists, not required 
to pay r. little more attention to tho Heredity end ethics of 
our concepts before releasing then on tho world at largo? 
It scons as though in our present manner of thinking and 
experimenting in this contury thr.t something has been left out 
or forgotten. Too liatlo attention has boon paid to tho ossontial 
virtues, to tho dignity and worth of man, The sano thing has 
liapponod to nations that has happorlod to individuals—lose of 
nutur.l trust anci. loss of a sense of values. In individuals in 
general it scons as though it is not tho basic truths which count 
any norc* arc off on tho periphery and interested in incon- 
sequential things. If it were announced that one of tho eternal 
truths would be discussed tomorrow morning, it would attract but 
little attention, but if it wore announced that a thousand pairs 
of nylon stockings would gc c-n sale in a certain store, they would 
have to.bring out an extra detail of mounted police, * 
It is certain -that wo will have to return again to the principles 
of first things first and a deep sonao of individual responsibility and 
fundamental honesty before 'vie can make strides toward either individual 
or international good will. It is those ordinary virtues which moor 
tho individual securely when the gales are blowing, Every psychiatrist 
knows how difficult it is to treat a person who has no roots and nothing 
to tic to. 
Already the cult of the inane has too groat a hold, and there is 
too much emphasis on the inconsequential and tho insipid. The desire 
for notoriety read tho acceptance of tho smart aleck and smooth operator 
bade cm* culture no good, Thoso things arc tho result of false philoso- 
phies and the lac.1: of a proper sense of values* If any of us in psy- 
chiatry ask the question: Do these things concern: us and aro we justi- 
fied in preaching to our patients? I believe the answer is apparent, 
>1*0 can no more remain the cold, aloof scientists who simply toss off 
our beliefs with no regard for vihoro they fall than can tho physicists 
who now recognize their obligations. 
third point is that ns we outer a now ora it will be wise 
for us to calibrate the instruments upon which wo aro going to defend 
in our operations, Right now tho ranks of psychiatry aro being swelled 
by hundreds of young rum who have soon the possibilities in ouT 
particular specialty. In thoir military service, they saw tho necessity 
for psychiatric understanding and they now seel: fellowships and resi- 
dencies. It is iur pleasure and our duty to soo that they aro well- 
trained, They, too, must learn that psychiatry cannot operate in a 
vacuum, but that it is intimately related to tho general culture, I 
have always believed that tho education of men for work in psychiatry 
is a sacrod trust. I hold for a broader education than is being given 
at tho present time. If non knew ah at had gone on in ages past, it might holp then to avoid falling into old orrors, They might 
realize that sor.ic of tho things which. loot: up ,to thorn as now 
were tried and found wanting centuries ago, It v/culd bo in- 
teresting for then .to ’irow in the light of. interest in psycho- 
somatic nodicinc that John spoke of the mental causation 
of bodily symptoms in-,1761. It might help then to know that 
the background of Jung’s teachings Bay bo. found in Avorrocs, 
and that tho modern naturalism taught by John *Wcy can be 
found in tho teachings of Titus bucrotius,. Those students 
and foilovrs arc going to" deal with, ideas and systems and the 
more they understand about backgrounds tho loss likely arc 
they to fall into orrpr. Bonotajaos one man influences tho 
thirddng of a discipline and of an ago, and it is well'to 
know how ho arrived, at his concepts. 
I an particularly averse to. allowing non to enter tho field 
suporfioia.lly equipped, • It does .not holp our profession or our 
cause to have young non start out with only tho !m v.iodgu of a 
few clinical entities and a mouth full of jaw-breaking jargon, 
T do nett believe that tho training of tho non should bo immediately 
pointed at passing ti oir American Beard examination.but rather at 
a basic understanding of tho whole field on sound promises. They 
can elaborate later as their training proceeds. It night bo wise 
procedure, whoa a nan does cone before an examining board, to havo 
him defend his thesis against his examiners. 
There-ar6 ndny things in psychiatry which wo would have 
difficulty in defending today, “one cf them wo simply assume 
gratuitously. I an fearful that wo might bo hard put to defend 
elonontarisn or atomization as it is found in psychiatry today. 
It originated in a habit of looking for an explanation cf higher 
phenomena among the lower or elementary ones. It has led to tho 
belief that disintegration will bring forth tho constituent ele- 
ments of an object. By blowing up a bridge one does not recover 
nicely separated bricks, concrete, and rivets, VIKat is recovered 
is a mass cf fragments which are definitely not integral parts cf 
the bridge which was destroyed. Ts it permissible to submit the 
postulate that tho same thing can bo said of .most mental crack-ups? 
“hen wo examine each of tho elements of tho illness and analyze 
them carefully, havo wo qny proof that, they really wore integral 
parts of the real whole? If wo wore to state that intollifcoaoo’ 
is a minimum of idiocy, we certainly would bo criticized and tho 
idea characterized as nonsensical. Are we or are we not likewise 
open to criticism when wo :take tho concepts which we have learned 
from the stuc' cf abnormal minds, and without hesitation generalize 
them and apply to normal minds? This is a.not result of atomization 
in our psychiatric thinking, and I am frank to say that I am not 
sure of the logic cf it. 
There is a fourth point which is requisite for tho proper functioning of psychiatry in a new era, *t nust be admitted that 
what is euphoniously'1 known as our public relations has been poorly 
managed, if need any proof, look at the way the public reacts 
to the terns 'I®5” and "psychoneurosis," Or even much worse, how 
they react to consultation with a psychiatrist# Wq must do a better 
job of it this time for the benefit of the people who are to profit 
by our ministrations. 0f the psychiatrists who objected ijo 
our use of the terns "combat fatigue and "operationalnfatigue 
thought we should desensitize the public to the terms HP" and 
psyrehonourosis." They had no answer to the question as to why 
they had not done so in the twenty-five years between wars. 
So badly had things been handled that early in the war we 
developed in psychiatry what has boon called aptly a "state of 
sioge mentality." It was plain that our colleagues and sane of 
the public wore blaming us for the conditions which we were diag- 
nosing. This, of course, is as sensible as blaming the thermometer 
for the weather or tho surgoon for the cancer, Portunatoly the 
excellent work done by tho military psychiatrists in selection and 
treatment has gone far toward dispelling some of tho misinformation 
about psychiatry which had spread about. 
W0 nust be careful of our statements which get into print. 
There is nothing to bo gained by making comments on the mental 
condition of historical or biblical figures nor of analyzing per- 
sonalities from newspaper clippings, Wo know that wo havo something 
of waluo to toach and wo cannot jeopardize our position by ill- 
advisod interviews. 
Tho lest thing I have to say. to you concerns our inter- 
personal relationships, Thoy ore oxtromely important, and it is 
necessary to avoid all displays of onotional immaturity, TkorQ is 
a losson tc bo loarnod from tho fact that tho psychiatrists in the 
Amy, Navy, Public Health and V0torans have gotten along extremely 
well and wore mutually helpful to ono another. Thoro was never any 
cvidonco in tho Sorvicos of tho justifiable lament of Dr, Alan Gregg, 
who spoaking to psychiatrists notod, "Mon who are personally delight- 
ful whon armod with tho sabor of thoir particular belief and clothed 
with tho toga of thoir knowledge bocouo impossible with thoir modical 
brethren," *t is always sad i/hon physicians quarrel and it is in- 
excusable in psychiatrists who arc charged with tho education of tho 
public to emotional maturity. It is hopod that the pleasant, mature 
relationships dovolopod by psychiatrists in tho S0rvioo will continue 
into civilian lifo. 
It is apparent to you now that tho titlo of ray paper was 
sinply r. snaro to attract your attention and to give mo an opportunity 
to air ry views about tho psychiatry of tho re xt decade, When,tho 
ideals for which our non have fought prevail, tho future v/ill offer 
all noil somo dignity and a chance to work out their destiny, I bo- liovo that psychiatry has an important part to play in that 
future, return of our veterans and thb insecurity of an 
onccning atonic age render our ministrations doubly important 
and nocessaryi It will ivo us an unparalleled opportunity , 
to be of service to our fellow citizons. • . i . . 
And finally I Icavo with you those words of Sickens from 
Donboy and Son* », 
"bright and ,blest the morning that shall rise on 
such a 'night, for non, delayed no more .by stumbling 
blocks of their own tanking, which are but spooks of 
dust upon the. path between thou and eternity; will 
then apply themselves like creatures of one common 
origin,"owing one duty to the Father of' one family and 
loading to one common ond—to ar.ko the world a bettor ’ 
place. ... • ' ' •• STUDY OF’ EIECTRCENCEPHALOGRAPHIC FINDINGS IN 209 CASES 
ADMITTED AS HEAD INJURIES TO AN ARMY NEUROLOGICAL - 
NEUROSURGICAL CENTER 
by 
Maurice V, laufer, Capt,, M,C,, ;.US * 
Roy F, Perkins, Capt,, M.C, AUS * 
INTRODUCTION 
the outset, I must state that this is a rather different 
paper than was originally submitted. However, the other night I 
tried the experiment of reading the paper as originally written 
to some colleagues unversed in the intricacies of EEG and not 
particularly partial to a statistical approach. The state of 
manic stupor which was quickly induced was a sufficiently 
severe stimulus to force a last minute revision, leaving cut 
as much statistical and similar material as possible. 
This study was undertaken in an attempt to find out of 
what value electroencephalography had proven in 209 cases ad- 
mitted to our neurological-neurosurgical center as head injuries* 
After clinical evaluation, observation over a period of time 
on our service and various psychometric tests, these cases 
were divided into "organic" of which there were 159 and "func- 
tional" of which there were 50* This was based on the factors 
already mentioned and was independent of EEG findings. The 
"functional" cases were those in which there was no actual 
objective evidence of organic trauma at all or the trauma was 
so minimal and remote in tine as to not merit consideration, 
and there positive indications of an existing neurotic re- 
action. 
' The organic cases were then further sub-divided accord- 
ing to degree of severity of injury, into "mild", "moderate", 
and "marked". This was of necessity a subjective evaluation, 
but based wherever possible on*‘ extensiveness of injury; 
duration of unconsciousness; evidence of actual brain pene- 
tration or destruction; severity and persistence of neurologic 
symptoms and signs; and laboratory aids such as x-ray and 
pneunoencephalogram. The organic cases were also subdivided 
into groups on the basis of time elapsed from date of injury 
to initial EEG. It should be noted that the study is based 
on initial records only and.not on on analysis of consecutive 
EEG1s on the same patients. 
In general, in discussing the findings, most of the EEG 
classifications will be grouped into the following few categories. 
First is "borderline generalized abnormal* which presumably 
represents the mildest form of abnormality* Next is the 
"narked generalized abnormal." more severe, but os the name 
*Mayo General Hospital, Galesburg, Illinois Implies still involving many different areas of the brain. 
Third is the "focal" classification. .This refers to records 
in which the abnormality is limited to one specific area of 
the brain. Lastly there is "total .amplitude asvmetrv".' 
Amplitude asymmetry refers to a consistent and definite 
difference in voltage between two sides of the brain, either 
entire hemispheres or. specific portion®; such as temporal or 
parietal areas. Before classing a oaso as representing 
amplitude asymmetry, every attempt was made to be certain 
that this did not represent on artifact# This group included 
both otherwise normal and abnormal records• 
x*m 
The first slide is jbo a certain extent a validation of the 
EEG criteria used. . It compares the abnormalities; found in 
the EBG’s from our organic, group of 159 cases >with those 
found by Giftbs in a study cf approximately 100G normal con- 
trol, Thepe figures show that In our group normal roqqrda 
were only 1/3 as frequent as in the control group# Grouping 
the various, abnormalities together, borderline records were 
found to be five times op frequent and narkod generalized 
«hnnr»nnl records. twenty-eight tines as frequent in the head 
injury oases as in tj*) control group#- Fooal.rocords, vhl*h. 
never occurred in the oCrltrols, were present in 8,5% of .our . 
patients, t-••• > 
oamnc cases copamp with rnrnTta-j. 
The next point of interest was "How did the.eases wo called 
functional .compare with those called organic?" The next slide 
visualises this comparison. First, it till bo noted that three- 
quarters at tho entire functional group*had normal records 
while only one•quarter of tho "organic" group had records in 
this category. Moreover, of all tho abnormal records in the 
"functional" oases, three Quarters wore of the mildest form, 
the borderline abnormal.* while in tho "organic" group only 
half fell in this category. * Equally striking Is the fact 
that rally 2% .of all the "functional1* records showed a narked 
abnormality as compared with 20% in the organic eases or 10 
to 1 in favor of tho latter# There wore no fooal rocords at 
all in the "functional" but almost 1056 In tho "organic" 
ensas, again approximtely"10 to 1, There was 4 similar 
striking difference in the incidence of amplitude asymmetry 
which was six times more oomon in tho inthe 
"functional*oases. Thus by all these criteria considering 
tho group os a whole, tho EEG findings correlated with im- 
press! ns derived from other sources. 
CMEttim. jg EEQ. FINDINGS WITH-7TJ1E >ND SEVERITY H ORG/.KIC 
•mEb 
Having found that tho EEG ropults were of value in oca- 
poring organic with functional oases, tho next problem was' 
to find whether the EEG was of any assistance in different-1 iating cases within the organic group,.. These ..records were 
therefore analyzed, correlating- the-EEC findings- with both 
time elapsed and severity of injury, . The next slide is con- 
cerned with findings related to tine since injury, As can be 
seen, as time increased, from injury to initial EEG correspond- 
ingly so did the percentage of normal records found. Similarly 
as time increased the percentage of total amplitude asymmetry 
showed a steady decrease. 
The next chart illustrates what is found when the EEG!s 
are classified according to severity of injury, (tapper loft 
hand comer) The greatest percentage by far of normal records 
is found in the cases with mild injury, A smaller proportion 
is found in the cases with moderate injury and least of all 
in cases of severe injury. Conversely, the greatest percent- 
age of amplitude asymmetry is found in cases of severe injury, 
(Lower middle) Similarly, most of the markedly abnormal records 
occur in tho severe injury group and least in the mild injury 
grouu, This rel-.t Inn ie again borne out when considering the 
focal records whore (lowsr right hand) the greatest number 
occui in cases ol severe injury and none at all aro found 
in the mild injury group* Thus, it was found that within 
the organic group incidence of the EEG abnormality is corre- 
lated with severity of injury, decreasing as tine from injury 
increases. These two findings together suggest that the EEG 
does reflect severity of injury and also parallels clinical 
improvementt, 3peo.ial attention should be directed to the 
focal records which in our snail group at least, did not 
occur in any of the mild injuries and therefore seem to be 
a particularly good indicator. 
CCM?ARISON OF "CLOSED1* VS CASES 
Another approach to the organic group was by classification 
on the basis of type of injury. The next slide shows our find- 
ings in such a comparison. Three categories are listed, "Closed" 
represents all cases of und°ubted head injury'Without |*esult- 
•ing skull fracture, " Open without penetration11, includes; both 
simple skull fracture and skull defeats without penetration 
of the dura, "Open vdth penetration" indicates that some 
foreign body entered the brain substance. 
(Left hand aide,) As can be seen, EEG normality .was great- 
est in the closed cases, next In the cases that were open without 
penetration and least in the cases with penetration, Exactly 
the reverse wap true when considering amplitude asymmetry on 
the right hand side of the diagram. As night bo expected, 
focal Records were most prominent in cases whore the dura had 
been penetrated, . 
■yArom.w #- tmxm masm 
To were impressedby tho repeated appearance of "amplitude 
asymmetry" as possibly a valuable indicator. This led to an 
attempt to determine whether amplitude asymmetry merely re- fleeted the presence of a skull defect. In such a case there 
would be no intervening bone to reduce the voltage of the 
signal received by the EEG machine and the amplitude asymmetry 
would represent merely a mechanical finding. If this explan- 
ation were true, percentage of amplitude asymmetry would nat- 
urally be higher in our markedly severe cases which included 
a larger percentage of skull defects did any other group. 
To test this, the open group of 95 cases was divided into three 
categories; "simple fracture" (those without any skull defects 
at all) "skull defect without dural penetration"; and "skull 
defect with dural penetration" as shown in the next slide. 
This shows an ascending incidence of amplitude asymmetry follow 
ing the order given. 
However, this table also suggests in several ways that 
the presence of amplitude asymmetry is not entirely due to 
skull defects as such. First, almost one-third of the cases 
that showed simple skull-fracture (without any skull defect 
at all) shewed rrrplituclo asymmetry. Second, almost half of 
the cases el sir defect without penetration failed to show 
any ruch cmplitvce asy.vjetry and one would expect all cases 
with skull defect to t-jem amplitude asymmetry if the mechan- 
ical explanation was the only one. Lastly, oven 38$ of the 
skull defect with penetration did not show amplitude asymmetry 
at all. Then there are records in our files of individual 
cases showing amplitude asymmetry in which the s'rull defect 
was on ono side co* the head, the higher voltage on the opposite 
side of the head and the clinical findings correlated with and 
suggested a lesion on the side of the higher voltage. 
In the majority of cases of amplitude asymmetry the voltage 
was higher on the side of injury. In a few cases, however, 
it was lower; and in almost all of these there had been a signi- 
ficant loss of brain tissue at the site of injury suggesting 
that the iotocr voltage was due to a smaller mass of brain 
tissue giving off electrical discharges. 
Thus, our observation suggests that the occurence of 
amplitude asymmetry is a valuable indicator of cerebral trauma 
and an aid in localizing the site of injury. It is found six 
tines as frequently in the organic as in the functional group. 
Its incidence increases proportionately to severity of injury 
and decreases as time elapses from injury. 
CONVULSIVE SEIZURES 
As the next slide shows convulsive seizures wore noted 
in 19 cases or 11$ of our total organic group, occur ing in 
almost equal numbers for each- time period since injury. It 
is interesting to note that of these 19, 3 had completely 
normal records and 7 iad generalized borderline abnormal records; 
thus making on©-half with either no EEG abnormality or only 
mild EEG abnormality, Tkree showed marked generalized abnormal- 
ity and only six out of the entire total had focal records. 
Of these six with focal records, five were found in cases in which more than six months had elapsed since injury. On the 
other hand, wo had seven patients without seizures presenting 
focal records and all these cases had been injured less than 
six months before the initial ££&». These findings suggest the 
possibility that cases without seizures injured less than six 
months before the initial EEG and presenting focal records say 
at a later date develop post-traumatic epilepsy* 
tmmt ?uiss 
In our group, 44 patients had EEG's both before and after 
insertion of tantalum plates over skull defects* It is realised 
that this is an insufficient number on which to base any definite 
conclusions* Nevertheless, some gross findings and their im- 
plications may be of interest* The next slide illustrates the 
affects we found* 
Approximately half of the patients showed no change whatso- 
ever in their record* The majority of this group had abnormal 
records both before and after insertion of a plate, and a small 
number were normal both before and after* As the next bar 
shows, somewhat less than half of the patients had some degree 
of improvement in their EEG*. This improvement was manifested 
by a change from a borderline to a normal record, from a marked 
or focal abnormal to a borderline abnormal, etc* Finally approx- 
imately one-tenth became worse from an ESQ standpoint after 
insertion of the plate* This group represents four cases and 
three of these four became worse by developing a focal type 
of record where before they had a normal nr a borderline record* 
The fourth case may not properly be included in this group as 
the record changed from marked generalized abnormal to a focal 
record and may actually represent an improvements EEG, the gen- 
eralized abnormality clearing up and leaving only focal activity 
at the site of injury* •, 
Two possible reasons for the improvement in almost half 
the cases presents themselves* First is the healing effect 
of time* Second is the role of the plate in restoring cerebral 
hydrodynamics. It is definitely not possible to rule out the 
effect of time on the basis of our data; and this is almost 
certainly a large factor* That it is not the only one is 
suggested by the fact of the 19 oases with the EEG improvement, 
10 showed this improvement in a period of less than a month 
after insert!ti of the plate* It is also of interest that many 
of the patients showing EEG improvement related a coincident 
improvement in various symptoms such as the vertigo, tinnitus, 
syncope and headache* 
TOomiw 
1, EEG abnormalities are apparently a valid indicator 
of brain injury. 
2* The percentage of EEG abnormality increases with 
severity of injury* It is most marked when the dura has boon penetrated, loss in cases of open head 
injury without dural penetration and least in closed 
head injuries. 
4. . The percentage of KEG do creases as time 
elapses from injury* . 
5. Anplitude asymmetry is a guide, to site' of injury and 
an index of EEC improvement. 
6. Focal records wore not found in eases with mild 
injury but wore more frequent with severe injury 
and penetrating wound and in our series occurred 
relatively soon after injury (under six months). 
The presence of focal records without accompany- 
ing convulsions was found almost entirely in cases 
‘ that had been injured less than six months before 
initial EEG« Focal records -and associated con- 
vulsions occurred in cades where the initial 
record was longer than six months after injury. 
This the possibility that bases,with 
focal rooords may eventually develop post -traumatic 
epilepsy though initially asymptomatic• 
7. There ,ib a suggestion that EEQ improvement nay occur 
< after insertion of tantalum plates over skull 
* defects* This nay be dud either to the healing 
'• Influence of tine or to' a specific effect of 
the plate itself* . 
8,- Although the findings here presented hive shewn 
the value of the EEG, they also make It clear 
that GEG reports are valid only on a percentage 
basis.and must still bo regarded as only Bfie 
• laboratory aid in making up the total picture-. Discussion of STUDY OF ELECTROEUCEPHALOGRAPHIC FINDINGS IN 209 CASES 
ADMITTED aS HEAD INJURIES TO AN ARIIY NEUROLOGIC L- 
NEUROSURGICAL CBITTER 
by 
Frederick A. Gibbs, M. D • * 
Captain Laufer and Captain Perkins have squarely faced the central 
problem of the correlation between the electroencephalogram and the 
clinical features of head injury cases. This is a statistical problem 
and boils down to a problem in bookkeeping, but the way in which the 
books are kept, cases classified and electroencephalograms interpreted 
is absolutely crucial. In all respects the authors have done an 
excellent job. They have succeeded in making their figures talk and 
this is the kind of talk we are most interested in hearing. 
It may appear that the total series has bean divided and subdivided 
unr.ecess>- rily, but this criticism is not justified. On the contrary, 
such factors as severity of injury and time after injury must bo 
Included if the data Is to retain its full meaning. This fact is in 
itself of the utmost ;■ mportr-.noo and should bo recognized, not only by 
eloctroor.ropha: ographers but by clinicians. Hoad injury is too amor- 
phous a classification to be of value except for tho, coarsest purposes. 
Precision ana signiflounoo aro obtained only when restricting criteria 
are employed to subdivide tuo total group. Ago is a factor which 
ordinarily needs to be taken into account, but in tho present study the 
age range is so narrow that it can be omitted. 
Not much has been said about tho value of serial electroencephalo- 
grams for extrapolating the recovery curve ut it is obvious from the 
tables on tho relationship between the degree of abnormality and tho 
time after injury tliat such serial studios can give prognostic informat- 
ion. 
Of groat importance is tho finding that the electroencephalograms 
can bo interpreted, evon as regards amplitude asymmotry, in Ijho presence 
of largo skull dofocts and also in tho presence of ft large tantalum 
nlato. 
In certain classes of patient tho present report deals with small 
numbers. The work has boon so carefully done, however, that I am suro 
succooding investigators will accumulate additional numbers and give 
statistical validity to certain of tho relations which tho authors point 
out. In timo a sufficient statistical basis will form to permit expectancy 
tables to bo drawn up, so that precise diagnostic and prognostic inform- 
ation on head injury oases can bo dbtained from the electroencephalogram. 
Army investigators are in a position to make a major contribution in 
this fiold for thoy havo' tho numbers and tho possibility of conducting 
long-time follow-up, studios. 
I wish to congratulate Captain Laufor and Captain Porkins for har- 
ing injoctod a solid mass of concrete into tho oloctrooncophalographio 
foundations. 
♦Illinois Nauropsyohiatrio Instituto, Chicago, Illinois EVALUATION OF PATIENTS WHO HAVE SUSTAINED HEAD INJURY 
D« Bernard Foster, Captain, M.C# 
Percy Jones General Hospital, Battle Creek, Mich* 
The opinion prevails among many physicians that the elic- 
itation of such subjective symptoms as headache, dizziness, 
irritability, intolerance to heat and alcohol, fainting spells 
and loss of memory constitutes an entirely justifiable basis 
for the assumption that parenchymatous brain damage has oc- 
curred from injury to the head, that incapacitating degrees 
of disability from traumatic changes in the cranial cavity 
may exist in the absence of any objective changes in Vie 
commonly employed neurological diagnostic procedures, and that 
traumatic impairment in intellectual function is a permanent 
and irreversible change* To correct these misconceptions, it 
seems desirable to assess the,reliability of our presently em- 
ployed test?, determining the frequency with which positive re- 
sults are obtained in cases of known parenchymato brain damage 
secondary to trauma, and to show that improvement ir intellect- 
ual function may continue for months after an injury* 
Ti es© observations were made in a neurologic c.ca’.r.* In a 
zone of the Interior General Hospital receiving i ’xi nx'bers • 
of combat injuries, usually within throe to eight rioou; after 
injury* The enter:ng patients include military nju-off jetivos 
of. many types, directed to tliis installation booaus© of com- 
plaints or disability due to head injury* To rapidly screen 
and evaluate large groups of these patients with limited numbers 
of r.eurolo£,l cally brained medical personnel; the use of non- 
medi(:3l personnel has had to be exploited to a maximum degree 
consistent with a fair appraisal of the patient. 
On admission the patient receives a history, physical exam- 
ination and ueurologioal examination by the nediodl officer, 
Whether or not organic brain damage is apparent at the ini- 
tial examination, a psychometric examination, electroencephalo- 
gram and appropriate roentgenograms of the skull are ordered 
for further assistance in evaluation; if signs of organic 
brain damage are not apparent or there appear to bo associated 
psychogenic factors, a psychiatric social history is arranged 
for at the same time. The major portion of this information 
is secured by non-medical personnel, A body of pertinent data 
is usually available within 72 hours which permits further 
appropriate management to bo instituted. 
If the Initial examination results show no pertinent 
organic findings, the psychiatrist nay capitalize on the 
negative data to reassure the patient, strengthen the diagnosis 
of the personality reaction and, promptly institute psychiatric 
measures before the symptoms crystallize in the now environment. 
If the findings reyoal evidence of organic nervous disease, 
appraisal of its degree is facilitated by tho additional inform- 
ation, and tho decision for further studies and management can 
bo arrived at in the sane period. Using this general method of study 100 consecutive head 
injuries were employed for analysis of the reliability of the 
diagnostic measures, selection being based upon previous neuro- 
logical examination findings of organic brain damage, previous 
operative observations of brain damage, roentgen evidence of a 
skull fracture in closed head injuries, roentgen evidence or 
operative observation of dural tear in the penetrating head 
injuries, and sufficient cooperation from the patient to make 
formal psychometric examinations reliable* All examinations 
were carried out in the period between one and six months follow- 
ing injury} sub-tentorial penetrating wounds and patients sus- 
pected of previous nervous or mental disease were excluded* 
SLIDE 2. 
For present purposes the clinical neurological examination 
refers to the usual examination of cranial nerves, reflexes, 
motor and sensory systems* 
Our criteria for psychometric evidence of impaired intellect- 
ual function were a decline of eight or more points on the Army 
Wechsler score as compared with the Army General Classification 
Test Score secured at the time of entrance into the Army, a 
Shipley Hartford Retreat Conceptual Quotient below 85, and/or 
an "organic pattern" on the fechslor examination with dispro- 
portionately low scores in the subtests for digit retention, 
object assembly and block design* 
The eloctroonoephalographio criteria are as defined by 
Gibbs and adopted as standard for the army* Borderllng records 
were classified as abnormal in the present group of cases* 
The pneumooncophalograms were conventionally interpreted, 
any bias being ih .the direction of conservatism* 
Table I represents the incidence ‘ of abnormalities present 
on the various examinations in the 100 patients* It nay be 
seen that the clinical neurological examination alone trill re- 
veal abnormalities in to 80% of the oases, the electroencephal- 
ogram in 6/$ and 91% of cases, psychometric examination in 60% 
of cases, and pneumoencephalography in 50 and 85% of oases* 
It is thus evident that any single procedure nay fail to give 
positive results in the presence of known parenchymatous 
cerebral damage* 
ME h 
A combination of neurologic and eleotroencophalographio 
examinations (Table II) gives positive results in 92% and 97/6 
of the cases, but, since EEG abnormalities nay occur in 14 to 
18% of the normal population one is reluctant to depend ex- 
clusively on an isolated abnormal finding, though the increase 
in diagnostic accuracy by 18)6 and 28% makes its value evident* 
A combination of neurologic and psychometric examinations 
increases diagnostic accuracy by 7% and 16)6, Pre-injury psycho- 
metric standards are not always available in the individual case, abnormal psychometric patterns may have antedated the injury# 
such psychometric tests ore notoriously open to psychogenic 
factors and the perfect test for detecting organic brain damage 
has yet to be devised. 
SLIDE A. 
In addition to the help given by electroencephalography in 
localising lesions and suggesting the presence of,convulsive - 
seizures, and the assistance in guidance for the future.offered by 
psychometric examination, the addition of 
icantly increases diagnostic accuracy and ffuble ;• 
All three methods of examination are positive in 32% . 
oases, two out of throe methods give positive results 28% and 36% 
of the time increasing accuracy in 60%*and 83% of oases, the 
fundamentally reliable neurological examination unsupported by 
positive eloctroencephalographic or psychometric results raises 
this average to 76% and 34%, and isolated psyohorwtrlo or elortro- 
abnormalities increase the proportlm of poslUvo 
findings to 96% and .. 
• This high proportion of one or more positive findings in 
the presence of knorm organic brain disease compares very favor- 
ably with the accuracy of diagnostic measures presently in use 
for evaluating disease in such viscera as,the heart and gastro- 
intestinal tract and renders unnecessary (at the period of tine 
following head trauma) exclusive dependence on subjective symptoms 
for the diagnosis of head injury residuals. 
Several features of. the psychometric methods, employed are 
best, illustrated by individual test1 results. 
SLISE..3. 
1, • G, C, (closed head injury from fracture of the left 
frontal bone). Decline of 28 points in Army ffecheler score from 
J1QCT score, scatter on f'eohsler subtest items not corresponding 
to tho typical "organic pattern11 of Weohslor, and C.Q.of 87 or 
a borderline normal, 
The clearest evidence of impaired intellectual‘function and 
of its degree is afforded by tho drop in overall score, with 
equivocal results on tho other two criteria. This illustrates 
the need for multiple standards to secure consistent and reliable 
re suits t Table II shows that the. neurologic and psychometric 
findings agree 64% and 68% of the time•* 
SLIDE 6, 
2, J, B, (penetrating head injury, anterior portion of loft 
temporal lobo). 
Decline of 15 points in overall score on the Weohsler test, 
disproportionately low scores in digit retention, object assembly 
and block design on the aubtost pattern, and a conceptual quotient 
of 59. . Well defined evidence of organic brain danage by all three 
of our criteria is illustrated by these test results. 
SLIDE 7. 
3, D, J, (penetrating head injury, right parietal cortex). 
When tested one following injury there was a decline 
of 20 points on the overall s ?oro, low scores in digit retention 
and block design, and a Conceptual Quotient of 78# When re-tested 
3 months later the conceptual quotient had returned to nornal, 
together with improvement in the pathological subtests# 
This illustrates that abnormal patterns nay disappear with 
the passage of tine, and that impairment in intellectual function 
following head injury is not necessarily irreversible# 
SMEL8* 
A, L. H, (penetrating injury, right frontal lobe). 
As in case throe, elevation of subtost itens on tho 
pattern, reversion of the Conceptual Quotient to nomal, and slight 
inprnvoncnt in total score over a four nonth periodj donate is 
still evident however by the decline in total score from the AOCT 
score, , 
SLIDE 9. 
5. D, 3, (penetrating head injury, inferior portion of 
both frontal lobes)# 
With no AGCT scores available for comparison and a vocabulary 
too lev? to give validity to the Shipley Hartford Retreat Test, 
pathological depression of digit retention and block design on 
the Wcchalcr subtest items supplied evidence for on organic 
deficit; substantial improvement occurred over a, two and one- 
half month period. • 
Tine does not permit elaboration on eleotroonoephalographlo 
data, but our re stilts confirm other observations that abnormal 
patterns tend to improve with the passage of tine following head 
injury# - Mosaic Tess 
Koho block design; Goldstein modification 
Rorschach 
Babcock 
The incidence of "frequent and severe headache” in the 
Cornell Index is 9$; the complaint of headache among a 
constellation of other complaints occurred in 85$ of the 
outpatients in a psychiatric clinic. 
Giving a dependent, neurotic individual the support 
and financial remuneration of an organic disability 
is uneconomic to the government and frequently devast- 
ating to the later social and economic adjustment of 
the individual, frequently closing the door on either 
self-initiated or otherwise motivated psychotherapeutic 
approaches or alleviation of symptoms and disability# 
To separate individuals with neurosis, neurotic reactions, 
psychopathy and defective attitudes from the organically 
handicapped is essential to intelligent management and dis- 
position to the preservation of group morale and to the 
best interests of the individual. 
The selection of psychometric standards was based 
upon: 
1* E asc of administration by relatively untrained 
personnel. 
2, A. quantitative score which can be compared with 
the AGCT score is made available. 
3. a quantitative estimate of degree of impairment 
is made available, 
A. A relatively short tine is required for admin- 
istration and scoring of the test. 
5. Our records and patients are subject to review 
by medical officers and rating physicians in the 
Veterans Administration Facility who arc un- 
familiar with psychometric procedures; limiting 
the tests to the more concrete and quantitative 
tests enables them to grasp the patients problems 
and extenrt of disability more readily. SUMMARY 
From a study of one hundred patients knowito have sustained 
parenchymatous brain damage from head injury, it is concluded that 
the combination of clinical neurological examination, electro- 
encephalography and psychometric examination will reveal positive 
findings more than 95$ of the tino in the period from one to six 
months following injury. Use of this method has permitted the 
rapid and accurate diversion of patients with symptoms following 
head trauma into the proper organic and psychiatric channels. 
Individual psychometric test results are cited to show 
that improvement in intellectual function nay occur following 
traumatic parenchymatous brain damage; the value of comparing 
AGCT scores with post-injury Array Fecholor scores is pointed 
out, and the tendency for pathologic psychometric patterns to 
improve with the passage of tine is exemplified to show the 
limitations of this method of analysis in the late stages follow- 
ing head iijury. Unselocted 
Routine Medical History -- — 
___ „> Psychiatric 
_Electroencephalogram " 'Examination 
entcrxng 
Riysical Examination 
Roentgenograms of skull 
and 
patients 
Neurological Exanination 
Psychometric Examination 
Treatment 
v.lth 
complaints 
referable to 
Psychiatric Social History 
(optionrl) 
head trauma 
\ 
'■-JFurther neurological 
examination (lumbar 
puncture, pneumo- 
encephalography. 
Medical 
Largely nonanedical 
etc-) and treatment 
Medical 
Personnel 
Personnel 
Personnel INCIDENCE OF ABNORMALITIES ON VARIOUS 
OF 1QQ. MrJM .aflffifflS- 
Clinical Neurological 
Examination .'-bnorml 
Closed 
head 
Injuries 
(25 seg) 
Penetrating 
head 
Injuries 
175 
80% 
Elo ctrocncophalogran 
Abnormal 
6^5 
91% 
Psychometric Examination 
Abnormal 
60% 
60% 
Pneunoenccphalogram 
Abnormal 
50* . 
(4 oases only) 
a«5 
(25 oases only)  
Closed 
Penetrating 
head 
head 
Injury 
Injury 
(25 cases) 
(75,ffagsai 
Neurologic Exon 
* 
360 
71* 
EEG 
f 
Neurologic Exam 
KEG 
m 
18* 
t 
...28* 
Neurologic Exan 
k 
n 
EEG 
-M 
92? 
Neurologic Exan 
8* 
3* 
EEG 
Neurologic Exon 
♦ 
M 
530 
Psychonetric Exan 
t 
Neurologic Exan 
• 
16* 
7* 
Psychiatric Exan 
* 
Neurologic Exan 
¥ 
20* 
250 
Psychonetric Exan 
- 
“155 
"IS 
Neurologic Exan 
Psychonetric Exan 
- 
20* 
15*  
Closed 
h$ad 
Injury 
Penetrating 
head 
Injury 
Closed 
head 
Iniurv 
Penetrating 
head 
Injury 
Neurologic Exan • •/ • 
EEG •/ 
Psychometric Exam-/ 
221 
Ll% - 
3256 
ai 
Neurologic Exam • 
EEG. / 
Psychometric Exan - 
& 
2556 
Neurologic Exam / 
Psychometric Exam / 
EEG ' - 
1256 
556 
Neurologic Exan 
Psychonetric Exam / 
EEG -f 
12% 
28? 
656 
36? 
6056 
■ 84* 
Neurologic Exam --/ 
EEG 
Psychometric Exan - 
1656 
136 . 
. V 
7656 
85* 
Neurologic Exan 
EEG / 
Psychonetric Exan - 
16% 
U56 
Neurologic Exan 
EEG 
Psychometric Exan / 
20? 
156 
12? 
9656 
97* 
Neurologic Exan • 
EEG 
Psychometric Exam - 
IS 
3* 
10056 
100* EVALUATION OF 7ATIENTS TOO HAVE SUSTAINED HEAD 
INJURY. 
DISCUSSION: 
Adrien Verbrugghen, M,D,, Chicago, Illinois 
The problem of compensation is an intricate one and it is 
fundamental in human nature to expect some redress from injury* 
Neither the injury nor the compensation need be on a physical 
level, though in law suits it usually is. Evil doers caught red 
handed and those who have a strong desire or urge to continue 
with some plan rarely complain of minor injuries and especially 
those which cannot be demonstrated objectively. Doctors and 
lawyers arc likewise swayed by their subjective perceptions 
and support the subjective complaints of the injured individual. 
In the absence of objective evidence of injury and disability, 
various ill defined conjectural causes of cental and physical 
suffering are offered as reasons for the justice of adequate 
compensation. In no field of injury has this been more con- 
spicuous than in those of the head, Then no objective evidence 
could bo produced on which to base a claim for damages in a head 
injury, such terms us unresolved contusion, post-traumatic state, 
and post concussion syndrome were introduced. Despite the terms, 
objective evidence of lasting damage to the brain was not forth- 
coming, It was customary to assume that impairment to intellect- 
ual function secondary to this invoked but not proved damage to 
the brain, was permanent or at least not likely to improve, at 
least until the suit was settled. 
It is with grgat interest then that v/c turn to an investi- 
gation of patients who have definitely sustained easily demon- 
strable injuries to tho head and study the ’objective evidence 
produced by undisputed trauma, ’ o find that in over 95% of 
patients known to have sustained injury to the brain substance 
there is objective evidence of that injury. The evidence, how- 
ever, depends on using all the available methods of searching 
for abnormalities. The findings then must be correlated and 
evaluated so that proper treatment nay bo instituted. In tho 
absence of objective evidence of damage to the cerebral sub- 
stance, patients are sent to the psychiatrist, for it is from 
him that they are likely to got the most help. It would appear 
that improvement of intellectual function nay occur after de- 
monstrable injur:.'- to the brain, a point which is familiar to 
all neurological surgeons. There nay be purists who fool that 
the word "demonstrable” is a very clastic one, (which indeed, 
it is), and that minute changes in tho blood vessels and nerve 
colls nay be associated with symptoms though hot necessarily 
with signs of brain injury. This may be true, but it is not 
proved. 
Captain Foster has done us a service in taking tho trouble 
to point out so conclusively, the course to be taken in the 
proper investigation of a case of alleged brain injury. Ho 
leaves us with the feeling that where there is damage to tho 
brain substance, objective evidence will bo forthcoming. If bis criteria wore accepted they, would put an.ond to many a suit 
for danages in' head injuries*" Bgt: hfe n«od have ttofoarj’for • 
cost people will still continue to helloVG what it is their 
interest to bclieva* - SURGICAL PROBLEMS IN THE LATE TREATMENT 6F CRANIOCEREBRAL INJURIES. 
AN ANALYSIS OF 170 CASES 
I. JOSHUA SPEIGEL, mSJoR, MEDICAL CORPS* 
High-speed evacuation, meticulous surgery in the forward 
zones by trained neurosurgeons, and planned cheaotheraoy are 
together resoonsible for ©reserving life in many, heretofore 
bootless cases of severe craniocerebral battle injuries. This 
has resulted in the evacuation to the zone of interior of rela- 
tively large numbers of oatients suffering from the late sequelae 
of craniocerebral injuries. 
The chief ©roblems requiring treatment in such a series 
of natlents are, 
1, Skull defects 
?, Infection 
3. Convulsive seizures 
A, The syndrome of treohine, or so-called, post traumatic 
syndrome, 
5, Intracranial foreign bodies and bone fragments 
6. Neurological defects. 
Skull Defects 
Debridement of penetrating head wounds was found to be the 
most frequent cause of skull defect in our series. Next in order 
of frequency were those due to debridement of compound skull frac- 
tures or elevation of depressed skull fractures not due to oena- 
trating wounds (16 patients)* The defects that were repaired 
varied from 2 cms. to l4*cms, in diameter. The average was 5 cms. 
Eight patients had multiple defects. 
Indication for Repair of Cranial Defects 
1. All pulsating defects anywhere in the skull were repaired 
if they were 3 cms. or over in diameter. Regardless of the size, 
all the following defects were repaired. 
?, All disfiguring frontal and fronto-temooml defects. 
3, All defects which were tender to the touch. 
L, All defects which were covered with a thin layer of soar 
tissue (all such scars were excised) 
5, All defects in oatients who complained of the syndrome 
of the trephined, or the so-called, post-cerebral concus- 
sion syndrome. 
* Mayo General Hospital, Galesburg, Illinois 6, All defects in patients rho needed surgical exploration 
for other reasons, such as removal of foreign bodies or 
bone fragments, resection of scar or uncapping of pore- 
cephalic cysts. 
7. All defects in patients who comnlained of a feeling of 
insecurity as a result cf the skull defect. 
The only contraindication to the insertion of a tantalum 
olate in this series has been the presence of infection. Snail 
temporal and suboccipitel defects well protected by muscle were 
not repaired. 
The material used fot* repair of the skull defects has, in 
all our cases, been tartalum — either the .0125 or the ,015 
thickness. Tantalum is an element chemically and electrically 
inert, non-magnetic, and causes a minimal tissue reaction when 
implanted into the living organism. It lends itself easily to 
beading, shaping and swedging, eliminating the necessity for 
casting the metal and limiting the surgical operation, generally, 
to a one-stage procedure. 
There is insufficient time to elaborate on the details of 
the various techniques employed in the preparation of tantalum 
plates. It is sufficient to say that the most satisfactory 
method in our hands, has been the swedging of the olate from a 
plaster mold of the skull defect. 
For the same reason, the surgical technique of insertion 
and fixation of the olates will not be described in detail ex- 
cept to mention that the olates may be fixed in place by acrews, 
tantalum wirept or "glaziers points" of tantalum. 
If possible, at time of cranioplasty, the scalp scar was 
resected If this was not feasible, a musculocutaneous scalp 
flap ras employed. 
At the outset, much fluid developed post-oneratively over 
the larger plates. This complication has been largely circum- 
vented by perforation of the plate to permit absorption and drain- 
age of the for 7.U hours. 
Postoperative Results 
There were no postoperative infections or deaths. All the 
olates have, up till the present, remained firm. With the re- 
finements in technique, perforation of the Plate, and drainage 
for hours, the development of fluid over the plate has been 
reduced to a minimum. One patient, whose plate was not perforated, 
continued to develop small amounts of clear uninfected fluid 
through the incision for months. It finally became necessary 
to remove the Plate, The fluid was the usual type of serosarv- 
guineous fluid without a high sugar content and without evidence 
of infection. The deduction was that this patients tissues could 
not tolerate tantalum. The nlate wnS removed and the wound heal- 
ed in six days without any further development of fluid. A frequent comolaint is that, in very cold weather, the 
elate dan be felt by the patient to be cold and is slightly urv- 
comfortable. There are no complaints in hot weather. In every 
case, satisfactory cosmetic results were obtained, Where terw 
demess oreviously existed, none ©resent nostooenatively. 
The t"xs oatients who felt insecure due to the skull defect, lost 
this feeling. One very real difficulty, which will doubtless be 
encountered as time goes on, is that the tantalum plates, which 
are ooaaue to &-ray, will interfere with adequate visualization 
of the pneumoenceohalogram, should one become necessary. 
Infection 
Analysis of our series indicates that *he chief cause for 
infection of a craniocerebral wound is inadequate debridement 
or no debridement. In th's series of compound skull fractures, 
9 cases were inadequately debrided, and of these 6 (66.6%) became 
infected. Seven cases were not debrided at all and of these, 4 
became infected, xt is our opinion, therefore, that in- 
adequate debridement is Just as dangerous as no debridement at 
all. Our definition of adequate debridement has been complete 
removal of all dead or potentially infected tissue and foreign 
bodies with an anatomical closure, undrained. 
Of the IP cases adequately debrided more than days after 
injury, only 2 became infected. One patient was not debrided 
until 14 days following the wound and did not develop infection. 
The tine int°rval between injury and debridement appears to be, 
therefore, a vital, but not decisive factor in the prevention of 
infection. 
Besides the infections mentioned above, 3 additional infec- 
tions were encountered. All three were instances of oBteomy&- 
litis of the skull’ with extradural abscesses. Two >of these 
patients had free fascia lata grafta used to repair the dural 
defects, inserted at the time of debridement. The. other patient 
had a free temporal fascia graft similarly employed. All three 
grafts eventually sloughed out. The areas were then debrided 
and plastic repair of the serin and chemotherapy carried out. 
Four weeks later, tantalum elates were inserted without utv- 
toward seouelae. It is our opinion, therefore., that ttee 
fascial transplants for dural defects inserted at the time of 
debridement, although, in general, quite useful, can be 
sible for the nwJhteiBrre of infection in a wound. They should 
be used with that in mino in any potentially infected wound. 
Convulsive Selguree 
Accurate records of the development of donvulsive sei- 
zures are available only from the time the patient received 
his injury to the time of his discharge from Mayo General Hos- 
pital, All patients were instructed to write nr otherwise conw- 
municate with us if seizures occured while at home. It is 
possible that some patients developed convulsive seizures with- 
out bothering to send the information in, It is significant also in the interpretation of these statistics to bear in mind 
that the follow-up period varied from Z years in the earliest 
cases to less than 3 months in the most recent cases. For the 
sake of accuracy in determining the relative orooortlone of 
those with and without seizures, any explosive set of clonic 
contractions, however mild, were labelled convulsive seizures 
regardless of whether or not consciousness was lost. 
Seizures occured, in this series, only in those patients 
where laceration of the dura and brain occured at the tire of 
injury. Thirty-five or (2f$) of the oattents in this series 
developed seizures at one time or another. Seven oatients had 
seizures before cranioplasty was attempted. Of these, 1 had a 
porencephalic cyst ~dth tantalum foil buried in cortical scar 
overlying the cyst. The foil had been used as a dural substitute. 
There were t*»o ether porencephalic cysts with dural defects and 
cortical scar in this group. The remaining four all had dural 
and cerebral lacerations. The three porencephalic cysts were un- 
capped and the cortical scars resected following which the dura 
was repaired by the insertion of feacia lata grafts. 
In this series of cases, there were 4l patients whose dura 
was not repaired at the of debridement and whose skull de- 
fect wap occupied by galeal and neningo-cerebral scar. Of these 
11 developed convulsive seizures at one time or another. 
Twenty-three (?1<) of the remaining 113 Patients whose dura was 
repaired at the tine of debridement developed seizures. 
It would appear that there is ■ somewhat greater chance 
for a patient to develop convulsive seizures if the dura had 
not been repaired at the time of initial debridement. On the 
other hand, our figures indicate, that a dura repaired some 
months after the original injury is no gwarantee against the 
onset of seizures later. 
In this series little or no effort was made to resect cere- 
bral scar, except where the soar presented Itself in the skull 
defect. In the three instances where porencephalic cysts existed, 
a wider exposure was made and the entire scar resected, °n 
exposing the defect at the time of cranioplasty, if an intact 
dura was encountered, it was never opened. It is obvious, there- 
fore, that the percentage of cerebral scars in this series is 
not known. It seems evident, however, that it is pointless to 
routinely resect every meningocerebral scar at the tine of cranio- 
plasty, The procedure of choice seems to be resection of the scar 
when it is easily available on exposure of the skull defect. If 
the scar is not easily available and there is no history of 
epilepsy, it is suggested that simple cranioplasty be performed. 
Resection of raeningocerobral scar with its attendant danger of 
intensification of existing neurological deficit can be performed 
at a later date if clinically indicated. The Pnet-eerebrel anion flyndnae 
or 
■ The Syndroae of., the Trephined 
There was nri- correlation at-all between the sise of the bone 
defect and the development of the ejwJroae, Now was there ftny 
correlation between the onset of the syndrome and the.length of 
unconsciousness, presence or absence or Infection, on the presence 
or absence of a dural defect. 
Of the 27 patients complaining of the-syndrome, 2 had coo- 
Diete relief, 3; had partial relief, and 2 had ho change in their 
symptoms following cranioplasty,. 
Intracranial foreign Bailee -and Bone' Fragment. 
. The ’Tiers conaide to .be indications of the : 
necessity for removal of foreiim h'odles .and bone fragments, ■ 
1, The oresence of foreign bod tea easily accessible with- 
out undue manipulation at the -time of cranioplasty,' - 
7, the presence of depressed or Indriven bone fragments, 
, foreign bodies and sequestra in infected areas. *" i 
3. The presence foreign bodies or bone fragments causing 
neurological symptoms or signs.- 
Removal of a bone fragment of foreign body was considered 
contraindicated if it was deep In the substance of the brain and 
not causing symotoma or infection,' In only one patient was the 
presence of a foreign body considered sufficient indication for 
its removal through a bone flan iNay from the site of the skull 
defect. Immediately following the surgical removal ..of this large 
shell fragment, lodged In the vermis* Just under the tentorium, 
complete relief from incapacitating f!i**iness ensued. In the re- 
mainder of the patients whose metallic foreign bodies and de- 
pressed bone fragments were removed-, although a number showed 
clinical improvement in their neurological deficits,., too much 
time elapsed between the repair'and the Improvement.for any Valid 
conclusions to be drawn, • " • 
*»wta8 
The improvement in .the various neurological deficits me 
remarkable, Of the 36 hemiplegic wbients, all but one 'showed 
sufficient improvement to allow them to be up*end about, nelning 
themselves. • • . ,• 
Of the 21 aphaslc. (varying in severity and type) patients, 
only one, a profound tempro-parietal brain destruction, is still 
unable to adequately express himself.' It ia obvious that neither 
resection of cerebral scar, nor repair of the skull defect, can 
be considered in any way as being responsible for the improvement. Nether "cm. the rer.aVal of fojv 
eiph bodies or 'iahyAdtheraoy, .occuo*- 
ti*nal theraoy, .'rtfsefeh training, encouragement 
ant’ natural recuoerntivc' the' young-seen to N the,i5*- 
oortant factors In, tcmrovenent of Vheae neurological,deficits. 
It ia noteworthy -that in.’the teri caaeiTof; hoaon©nou8 hemianopsia 
in' this series,. none showjed' * -• • • i m . -■;.. j; THa TEaJUPY aND RiSHABILITAIIOH OP i-iiiHJ WITH SIUIH BAMaOJS 
BY John A, Aita, Cept*, M.C* - aUS* 
The overall picture of war casualties pernits some segre- 
gation of anatomical-functional groups, We speak of amputees, 
the blind, the spinal paraplegics-* the plastics end head in- 
jury cases as types requiring special care. The neurological- 
neurosurgical center has among its main problems that of men 
with head injuries, A certain group of these patients have 
severe brp.in injuries, severe to the extent that they are phys- 
sically handicapped or even nontally handicapped. They are 
handicapped sufficiently that they cannot go to advanced re- 
conditioning centers* They must remain under closer super- 
vision of a neurological service because they cannot care for 
themselves outside of hospital wards. Besides impairment of 
cognitive and other personality function, there are also such 
things as hemiplegias, convulsive seizures and hemianopsia 
with which to deal. We are seeing far more cases of severe 
brain injury returned in this war than we did in the last. 
There is a bettor control of infection. We have progressed in 
our knowledge of Intracranial physiology and pathology. Im- 
proved neurosurgical techniques are available. 
Seeing head injury cases arrive at our hospital day after 
day, two to six months after injury, ws are struck by what the 
human brain can take. Yet, in any series of men with head in- 
juries incurred in action there is a definite and by no means 
small group showing mild to severe mental impairment, Respon- 
sibility for evaluating and rehabilitating these men falls on 
the neurological service* 
Here is an example of one of the more severe cases. A 
27 /ear old white male was wounded two months prior to entry 
to this hospital by machine gun bullets which penetrated the 
vertex and right parietal region of his head. He recalls 
being struck end soon after became unconscious for a pro- 
longed period. It was soon evident that he had lost control 
of his left arm and both legs. A massive debridement of his 
skull and brain was necessary. On arrival at this hospital 
he is bedridden with a triplegia. There is cortical sensory 
loss on the left arm and log. Ho has a skull defect 5 X 10 
cns. His mental status'reveals that he is easily moved to 
tears. Bis expression is somewhat fixed. He occasionally 
grins in a sudden, poorly-controlled way, reminiscent of 
patients with Wilson's disease. In coversation, he is 
naive, anxious, child-like and gives evidence of a short- 
ened memory span. Be is carefully worked up, neurological 
examination completed and tracing is obtained. Sven a 
pneumoencephalogram is performed. The neurosurgeon covers 
his skull defect with a plate. He is labeled encephalo- 
pathy, post-traumatic severe. 
♦Mayo General Hospital, Illinois But the proolom is nore than just diagnostic labeling. It 
embraces more than physiotherapy and disposition to homo or 
simple institutional life. There is more to this than just a ; 
patient*with a greater or smaller hole in his brain, with loss 
of brain tissue or cerebral deficit. ' There is more to this 
picture than more Norganic deterioration11 • A condition exists 
which is not static but which calls for active assistance. 
In this group of non with brain-damage, these things are 
found. There is often a disorganisation of personality nark- 
ed by loss of cognitive and intellectual function, Agnosio- 
aprazic disturbances are present, gross or subtle. There is a 
general lapse to a more child-like level of thinking. Higher 
social sensitivities, evaluations and responsibilities are 
gone. Interest and planning are deficient. Mood control is 
unstable or erratic. Bebelliousness and passive acceptance 
of invalidism are common. Yet these overwhelming liabilities 
do not remain regidly set or go unbalanced. Just being alive, 
just living in a ward will serve to change things. In each 
case, a dynamic reaction takes place which is unique and indi- 
vidual. 
The reaction of the total personality to cerebral de- 
ficit depends on sovoral variables. On the 1 hand we haves 
!• The trauma 
&• The extent of the lesion and its surrounding 
* ■ influences* This includes also a considera- 
tion of tho reversibility of the damage* 
b. Tho location of the lesion* 
c* The suddenness of appearance of the de- 
struction* 
On the other hand we have: 
2* The personality whose brain was injured, 
a* Age 
b* Endowment 
c. Life experiences 
d* Situational factors at present, 
e* A powerful force of restitution* 
It is reasonable to believe that there are no two human 
brains quite alike. Lesions in the same*areas of two brains 
do not cause exactly the same symptons because the life expe- 
riences, conditioned reflexes .and delayed reflexes of each 
person have made his own brain unique, end, if anything, un- 
predictable. Much depends on what was in that brain that was 
IsSsMi. 3ut the problem is more diagnostic labeling. It 
embraces more than physiotherapy and disposition to home or 
simple institutional lifa. There is more to this than Just a 
patient with a greater or smaller hole in his brain tissue or 
cerebral-.deficit. There*'is more to this picture than mere 
’’organ-io- deterioration*. A condition exists which is not sta- 
tic but which calls for active Assistance. 
In this group of men with brain-damage, these things are 
found. . There is often a disorganisation of personality mark- 
ed by Ipss of cognitive and intellectual function* • Agnosic- 
apraxie disturbances are' present, gross or subtle* There is 
a general lapse to a more childrlike level of thinking. High- 
er social sensitivities, evaluations and responsibilities are 
gone*- Interest and planning are.deficient. Mood control is 
unstable or erratic. • Rebelliousness and passive acceptance 
of invalidism ere common* Tet these overwhelming liabili- 
ties do not remain rigidly set or go unbalanced* Jpst being 
alive, Just living in a ward will serve to change things. 
In each case, a dynamic reaction takes place which is unique 
and individual. • 
■ The reaction of the total personality to cerebral de- 
ficit depends on several variables. On the 1 hand we have: 
1* The trauma.. * . 
a* The extent of the lesion and its surrounding 
influences* This includes also a considera- 
tion of the reversibility of the damage* 
b* The location of the lesion* 
c* The suddenness of appearance of the destruc- 
tion. 
On the other hand we have I 
2. The personality whose brain was Injured. 
a. Ago *' 
b. .Endowment * 
c. Life expediences 
d. Situational factors at present. 
e. A powerful force of restitution* . 
It is reasonable to believe that there are no two 
brains quite alike. Lotions in'the same areas .of two brains 
do not cause exactly the ease symptons because the life expe- 
riences, conditioned reflexes ahd delayed- reflates of each 
person have made his own brain unique, and, il anytning;un- 
unpredictable. fiuch depends on what was in that Vraia that 
was injured. There arc memories, beaten paths, ruts, conditional reflexes 
nnd associative pc.thwp.y9 that are the sole property of the in- 
dividual involved. 
It is our belief as wo saw increasing numbers of these 
patients thrt many of them could be salvaged from institutional 
care, provided they received careful assistance in re-adjusting 
the wounded and remaining portions of their cerebrum and per- 
sonalities. It was our impression thrt other men besides just 
the aphasic required special care and we should not passively 
discriminate against non with cerebral loss elsewhere than 
Broca* s area. 
Over a period of several mouths, a definite program of 
evaluation and therapy was evolved for men who are Impaired 
because of brain injury. I should like to stress the follow- 
ing 12 needs: 
1. Careful psychological testing. One of the first 
problems which concerns us is the present level 
of baseline of intellectual functioning of the 
patient at hand. Certain other important cogni- 
tive functions may bo tested also if necessary. 
disturbances must be sought. We 
have found it well to evaluate simple reading, 
writing, spoiling and arithmetic ability. Once 
those baselines are established, the patient’s 
present state of deficit con be ascertained and 
progress measured from this point. Some of these 
patients nay eventually take vocational interest 
and aptitude tests to assist in their re-educa- 
tion. 
2. Psychosomatic orientation. Nothing can take the 
place of underat- nding and knowing the patient 
who had the injury. This is fundamental in hand- 
ling men with brain injury. Personality traits, 
attitudes and conflicts nay be important to 
recognize early as the individual strives to re- 
adjust with a wettindod brain. It is well to 
know something of his previous assets, liabili- 
ties and nodes of adjustment. At tines the per- 
sonality and individual brain involved are more 
potent factors affecting recovery than the le- 
sion or its extent. 
3* Red Cross, social service information. An intelli- 
gent, undorstonding social worker can assist great- 
ly in eliciting the patient's previous assets or 
liabilitiosjwhcthar there has been a personality 
change new evident to others; to what type of hone 
situation ho will return; what plane the family has 
In mind and what local resources and assests there 
are in the community which nay continue his re- 
habilitation. The Hod Cross worker on our service 
has a broad contact with those men. They discuss maijy of their problems v/ith her. She is aware of the 
general problem, and hence, able to assist the medical 
officer with additional data concerning mental status* 
anxieties and so on. 
U, A special reconditioning and rc-educational program 
under the supervision of one man. This men is, in 
turn, supervised by the medical officer in charge. 
This man is an instructor with teaching experience. 
Ec has training and experience in psychology and in 
the instruction of intellectually limited individuals. 
He is sensitive to the personality, the limitations, 
interests and aptitudes of each patient. He schedule* 
and coordinates such things as occixpational thorapy, 
physiotherapy, educational movies, exorcises and vari- 
ous instruction and sees to it that each patient attends. 
He teaches certain subjects and assigns patients to 
other instructors (in the reconditioning department) for 
more specialized subjects. He assists the medical offi- 
cer in collecting information about each patient and his 
progress. Subjects taught and goals are practical and 
not academic. They are fitted to the patient and his 
likely vocational choices. They often concern chiefly 
reading, writing, spelling and arithmetic. This ap- 
proa.ch aids materially in an acquaintance with the 
patient which otherwise might depend only on psycho- 
logical test scores. 
5* Earlier interest of the separation classification offi- 
cer who is the employment specialist, this officer 
should know about the patient's discharge several weeks 
before this occurs. Some of the non-confidential infor- 
mation obtained by medical examination, psychological 
tests, Hed Cross notes and instruction of the patient 
should be. efficiently funncled to hiru So will, in turn, 
furnish the medical officer with practical advice con- 
cerning specific jobs and rehabilitation which the 
patient may try on discharge. He knows practical de- 
tails concerning employment possibilities and job classi- 
fication, He has a full batti ry of tests designed to 
indicate skills, aptitudes and interests, Kis interest 
and cooperation are valuable. 
6. Cr.rcful formal.-1 ion -nd explanation to the patient: 
These non want to kiiow how they have been injured and 
what it will nern, They often have many misconceptions 
which they will n,t spontaneously bring out. Some feel 
that head injury will lead to insanity later on. Some 
believe that it can cause a brain tumor. We can give 
then authorititive information and conceptions which 
will help materially. Wo should give them a chance to 
ask questions so that they will not leavo the hospital 
confused or with misconceptions. At least one session soon after arrival in tho hospital and ono prior to 
discharge Is advised* These patients must know that 
they are expected to he able to do certain things. 
Passive concepts of invalidism must not he allowed to 
develop* "I vat injured in the head" must not he pes- 
simism! hypochondriasis or abnormal behavior* 
7* Improved contact with patient*s relatives. Patient*s 
wives, parents and others aro likewise concerned 
about the nature of tho injury and what it moans. 
Their attitudes are exceedingly important in influ* *. 
encing tho patient's future. There is no doubt that 
they aro as much in need of formulation concerning 
theso things as are tho patients. If they cannot 
come to tho hospital,,tho Bod Cross can assist in 
transmitting-concrete, individualized formulations io 
thorn. These things should be done as soon after tho 
patient arrives at the general hospital as possible. 
Otherwise tine is allowed for misconceptions to de- 
velop and sot. 
8. Therapeutic trials at homo. After tho patient is sta- 
bilised and a change of routine is advisable, wo 
found it valuable to send him home for a month or two. 
This helps in several wayst His folks get acquainted 
with him and his handicap. Bo gets reacquaintod with 
his home setting. Plans can bo made in a more practi- 
ced light. Future difficulties can be anticipated* 
When tho patient returns to the hospital, the Bod Cross 
worker immediately gets a report of what transpired 
while he was home. Tho resulting information is ex- 
ceedingly helpful in further planning. 
9* Supervised physiotherapy, exercise and gymnasium ac- 
tivities. Tho medical officer should maintain regu- 
lar chock on physiotherapy and exercise activities. 
Progressive management and tho patient's active par- 
ticipation must he sought. At least once a month, 
a careful objective study of the amount of weakness 
and spasticity of all involved musclos should bo 
tabulated. 
10. Occupational therapy. This is devised to aid in re- 
training nuscle skills and to give tho patient a 
daily sense of accomplishnont. Mental as well as 
physical stimulation is sought. 
11. Ce.se conference. Onoo a week an hour's conference, is 
held with tho re-educational instructor, Bod Cross 
worker, occupational therapist, physiotherapist, 
nurse, psychologist and separation officer. Hero 
individual case problems*of rehabilitation, progress 
and future plans aro discussed. The medical officer learns what everyone 1# acconplishing-arid what progress is 
being made. He, then, directly advises, Instructs, and 
coordinates all of the efforts* 
IS.Tollow through. The management, of these patients oust 
not stop the day they leave the Army general hospital. 
There is a need to carry therapy and rehabilitation 
over into civilian life* His family, hie family doctor, 
local and state agencies, Veteran’s Administration and 
industry must know of this. Of bourse, nothing can take 
the place of a wise, understanding family1. A Job, how- 
ever simple, if it does not tax the patient’s remaining 
assets,,is exceedingly valuable, especially soon 
ing a period of readjustment after discharge. It Is im- 
portant for the family doctor to- continue with a careful 
understanding of tho personality Involved, stressing good 
adjustment to a handicap, and avoiding concepts of inva- 
lidism. 
Merely doing a ’’work-up’l, sending patients to physiotherapy, 
occupational therapy and reconditioning does not comprise suf- 
ficient therapy for these.aep. ' Their wounded personalities 
grope for re-integral ion. They must bo treated as a special 
group needing stimulation and direction* When they are sent 
home, .they, need not lapse into tho status of alcoholics, var- 
iants, village half-wits, or useless invalids. They and 
their families must be given healthy, reasonably optimistic 
conceptions end plans, reelings of hope, usefulness and being 
restored to the community as a respected adult must bo in- 
stilled. * : 
Tho above program also can be carried out while the patient 
is in tho nourosurgical ward for dressings, decubitus ulcers, 
tantalum plate and so on*. , There is no need for time spent in 
tho neurosurgical ward to be lost time. . 
Those men can learn to adjust with what they have loft. They 
can bring new assets and compensations into use. They can be 
ro-oducatcd. Their management calls for hard work and they im- 
prove. - 
The old concepts of organic dementia, deterioration or cere- 
bral deficit are not strictly applicable to those non. Those 
patients arc young and their brains wore healthy* Their le- 
sions and the biological adjustments to those lesions are phe- 
nomena with which medicine and surgery have had little ac- 
quaintance* There is an inherent tendency for 
stabilization aj>d improvement. However, it needs stimulation 
and direction* There is no reason as yet to regard all of 
their deficits as permanent, static or progressive* There 
appear to be many possibilities for re-education, restoration 
and healthy adjustments* There .is reason to bolievo in a re- 
serve of cerebral neurones which can be re-educated* The human personality is versatile in its ability to adjust with 
losses and to losses. Tine does not permit us to cite fully 
illustrations of the interesting progress these men make — in 
physical handwriting, reading, spelling, arithmetic, 
mood stability, poise, solf-confidcnce, and so on. The triplegio 
walks with a cane. The hemipleric drives his father’s tractor* 
They can read again and write enthusiastic letters home. They 
can plan now for tho next 25 to 50 years. They have an under- 
standing about themselves that is wholesome* 
SUMMARY 
We cannot rehabilitate all of theso men to whore they will 
be entirely self-sufficient, steadily omployded and "as good ns 
before," However, we cannot walk through a ward and simply re- 
legate many of them to institutional care as vegetating automatons. 
Ve have yet to see a case where such pessimistic disposition was 
warranted. Wo- have seen recovery of mental and physical function 
that heretofore would bo inconceivable, I have soon only tho 
rare caso whore one could, in a more pessimistic vein, argue that 
tho individual would have boon more fortunate had ho not sur- 
vived, Hut this is exceedingly rare, 1 have yet to soo tho man 
for whom a great deal not bo done in tho way of active re- 
storation and rehabilitation. With proper management now, the 
number who should require relaxation to simple Institutional care 
is small. 
Those men must bo understood as Individuals and individuals 
adjusting to a loss, Thoy must bo kept busy — and I mean busy 
— mentally and physically and socially. Invalidism, apathy, 
stagnation and neurotic adjustments to a handicap must be pre- 
vented, for men with head injuries aro very suscepitible to theso 
things* . 
These non must bo given concepts that they aro expected to do 
and can do certain things, Thoy must bo given every help to 'adjust 
with and to what thoy have left. They must be re-educated in a 
general and practical manner, • 
Those things arc not dono by merely covering a skull defect 
or routine assignment to physiotherapy, occupational therapy or 
reconditioning program. These things arc not dono by a groat 
deal of diagnostic-anatomic workup and then easy relegation to 
institutional care. Tho wounds are fresh and the patient young. 
Vo must deal with both now and not two or five years hence. Lot 
us again seriously consider what constitutes maximum benefit of 
hospital care in those cases. 
VT« found It convenient to divldo tho eases into three groups 
a occluding to intelligence levels. Those XcvoXs wore determined by 
consideration of patient’s previous educational and occupational 
attainments, advancements in tho Array, array. General classification 
tost scores obtained prior to injur/, and duos furnished by psy- 
chological tests given in this hospital. 
XLLTJSmEIVB CaSiitS 1* Dull normal group* 
k SU-year old P7C entered this hospital three months 
after he was wounded in action by small fragments, which lacera- 
ted and penetrated ,the left .posterior paft of his head* There 
was defiriite brain injury, centering particularly around areas 
39, and 19* At operation, there was a tract into the. lateral 
ventricle, k massive debridement was necessary and a few weeks 
later, the patient developed coma and signs of an intracranial 
infection. This was treated and responded Weil', 
On arrival at our hospital,.his only complaints concerned 
a right homonymous hemianopsia, difficulty in reading, writing 
and, to some extent, in expressing himself* Neurological ex- 
amination revealed in addition a minimal fight hemiparesie and 
cortical sensory loss* He demonstrated great difficulty in 
reading perception and written expression. He had moderate 
difficulty with>nominal'expression but during conversation, he 
would proceed without difficulty if kept on a simple level. 
Mental status, revealpd him to be bipad, placid, contended'with 
minimal complaining* Generalised* intellectual impairment vat 
Immediately evident* Head x-rays revealed a large irregular 
bone defect in the left parieto-ooeipital region, 7 cm* 
There were multiple small metallic fragments in the toft tissues 
at the site of the lesion -and many ’located inside of the cranial 
cavity in tho extreme occipital region* There were also several 
small' spicules of bone substance located in cranial cavity ad- 
jacent to the lesion* There were three radiating fracture lines, 
one extending forward through the temporal and frontal bones to 
the sinus; a second extended upward to the superior, sagittal 
sinus, and a third extended downward to the mastoid area* a pneur- 
.moenoephalagram demonstrated a definite enlargement of both.lat- 
eral ventricles* There was a large porencephalic cyst located 
on the left teaporo-pariet&l region* This was slightly irregur- 
ler in outline and measured about 6 Z 8 cm. in diameter* Zt 
oomaunucated with tho loft lateral ventricle as well as the 
subarachnoid spaces* There was no significant displacement of 
the ventricular system* U0 tracings soon after entry into . 
this hospital revealed a borderline, moderately slow* general- 
ised type of tracing with amplitude asymmetry, greater .volt- 
age on the right, noted particularly in the ooeipital region 
of tho hoed* There was no response to hyperventilation* 
Surgery was performed two months after entry hero by Maj. 
1. J* Speigel* k resection of roof of porencephalic cyst, in- 
sertion of facia lata graft in the dura and insertion of tan- 
talum plate to cover skull defoot were performed* The opera- 
tion revealed that as the galea wps retracted in the loft 
parioto-oeoipital region, there was.V defect consisting of 
necrotic brain tissue about 2’em* in diameter* This layer 
was very thin and on incision, the operator found himself in 
the porencephalic cyst cavity, which communicated anteriorly 
through a hole about l/2 on* in diameter with the left lateral 
ventricle* The cyst cavity itself was about the site of a 
email lemon* The lateral ventricle was markedly dilated* Psychological investigation revealed the following* Tho 
patient’s prior Army general classification test score was IV—. 
67. That would place him in the dull normal classification. 
On arrival at this hospital, the complete Wechsler mental 
ability scale 2 gave him the following -Score* His aphasia hin- 
dered performance on verbal parts of the tests, but even so, 
his performance score was significantly lower* Extreme slow- 
ness, combined with trial end error technique were readily 
evident. Even so, ho obtained a mental age equivalent of 9 
years and J months. He could repeat only two digits in in- 
verse. His Binet vocabulary was slightly less than 12 years 
attainment. Pour months admission, the complete 
Wechaler mental ability scale was administered again. At this 
tine the patient had much loss difficulty handling words. Now 
his performance standard score surpassed his verbal standard 
score. Hij mental age equivalent at this time was 11 years. 
The ilorscha-h ink blot tost revealed six of the Piotrowski's 
ten organic signs 3, j* indicated his present intellectual 
functioning at a defective level* There was a paucity of 
associations and a narrowness of content* He gave no indica- 
tions of a personality disturbance other than those involving 
cognitive function. Poor judgment, constriction and a loss of 
organizational, analytical and problem solving ability were 
readily demonstr 1 i;od. An effective responsiveness "and a some- 
what practical, oeryday approach to situations were indicated. 
There was nothing outstanding or unusual about this patient's 
personality otherwise. He was always placid, contented, passive 
and willing to do anything within his range of assets. 
His ‘background revealed that his parents had teen $orn in 
Czechoslovakia. He was the oldest of five siblings. Birth and 
early development wore not unusual. At the age of 15* he grad- 
uated from grammar school with no failures. He attended a tech- 
nical high school for one year, but then left becuase he did 
not like school. After, this, ho worked on many different jobs, 
usually running drill machines, punch presses or lathes. He 
never seemed to stick to any one Job long. Ha had athletic in- 
clinations and played football and baseball. He was always 
more of a follower than a leader and could usually be easily 
swayed. He was sociable but always shy with girls. At 22 he 
married but separated from his wifo six months before entering 
the service. There has been apparently no desire to return to 
living with one another. The present hone situation (parents) 
to which the patient would return is congenial and comfortable. 
While patient was home on his furlough, his family noted no 
gross deviation from his previous personality traits. Mental 
slowness and difficulty remembering things were noted, of course. 
However, the patient was cheerful and his reactions toward fam- 
ily and friends were unchanged. He was able to find his way un- 
accompanied to various persons* houses at distances of many 
blocks. He showed no anxiety or depression. He realized that 
he had to figure out what he would like to do when he was dis- 
charged but he was in no hurry about this. He did not tire 
easily. Aside from a good home setting in a large nid-wesfcern city, 
there was nothing more definite for the patient to return to. 
There wore no definite plans concerning what he would do at 
this time or how he would occupy himself after discharge from 
the Army, 
Soon after arrival at this hospital, the patient Was jput 
on the re-oducatlonal program* ignoalc-apraxic disturbances, 
had to be dealt with as such, but on a general background of 
cognitive end intellectual imperinent. However, he was easy 
to got along with and responded well to the enthusiasm and 
interest of others to advance himself. He iiade rapid progress 
in handwriting and frequently expressed a desire to "learn 
more about words", Simple handwritting and spelling and vocabu- 
lary work interested him and, hence, were started first. It 
was interesting that in "relearning0 he recalled a trick his 
teacher taur.ht him in grammar school! when learning to spell, 
he would repeat "the work, spell it aloud and then write it as 
he spelled it. Later, arithmetic and other grammar school 
subjects were tackled. Definite improvement was noted month 
by month, Four months nftor entry into this hospital, the 
patient was taking a greater interest and activity in group 
discussions He had an almost amazing Interpretation of tho 
G-, I. Dill of Bights, and arguments about it. He became more 
sociable. He always seemed to have a sense of humor which 
carried him over the rough spots. He continued to say that he 
"needed to know a lot more about words and spelling and how to 
say things and how to write them down so that they make sense"• 
Hie arithmetic ability returned fairly Well, More time and 
efi’ort had to be spent in reading, where week by week improve- 
ment was noted. However, it was noted that as he began to un- 
derstand what he was reading, he had difficulty retaining it 
for friy. period thereafter. This was worked on as a special 
problem, His grammar school ability was on a second or third 
grade level on arrival here. He had to be watched and worked 
with becuaeo he became distracted easily, How, five months 
after entry, he has passed all subjects of fifth grade and 
some of sixth grade level. Bis letters home revealed a good 
wit and ability to recall many incidents of the past week. 
He was no problem on the ward. He never complained. He 
helped his share of ward duties. Be had a pustular acne 
of the face which required vigorous deraatiological treatment. 
He was able to take this routine over by himself and carried it 
out dally with care. 
His family was -contacted through, the.: Bqdr.■Cross: and‘helped to 
understand the nature of his disability,- 
He attended the occupational therapy shop daily and took 
part in gymnasium activities and swimming. Ho had two fur- 
loughs hone with no difficulty. Be has now, five months after 
admission here, reached a place where he may be sent to a more 
advanced reconditioning center. Special attention will be given there to his residual egnosic-eprexic disturbances end 
continued re-education and vocational It is no 
longer necessary that he live in a hospital* He is now ready 
for a more active physical and social type of life, such as he 
will have at any advanced reconditioning center* . Simple re- 
education along grander school and trade learning lines will be 
continued/ i<tore definite plans oust be insisted on before he 
leaves the service* if ter a period of rest and readjustment in 
civilian life, he can be occupied at least on a simple level* 
2* Average or high average level* 
•This 23-year old PIC entered this hospital four months 
after ho was wounded in action by shell fragments in the right 
posterior parietal region*' There was deep cerebral injury* He 
was unconscious for seven days* A left hemiplegia was Immedi- 
ately evident* Cerebral herniation developed, Ihero was much 
infection, including abscess formation at the- site and much of 
the right parieto-ooclpital area had to be excised* For ’a long 
tine, ho was desperately ill, bedridden and emaciated* Sis S~ 
rays on arrival a.t this hospital showed an extensive, irregular 
triangular bone defect in the right parieto-occipital region* 
measuring X cm* Some bone fragments appeared to lie in 
the substance of the cerebral cortex* Two linear fracture 
lines could be soon extending into the right occipital bOne 
from this defect* 30 paoumoencephalogran was performed* On 
arrival at this hospital, his scalp wound was still infected and 
draining* This gradually responded to treatment* When this had 
healed end it was certain there was no intracranial, infection re- 
maining, a cranioplasty with insertion of a tantalum plate was 
performed by Maj* I* J. Spotgel* This was performed about six 
weeks after admission here* The cerebral scar was densely ad- 
herent to the dura over a Wide area* The periosteum surrounding 
the defect was incised, separated from the bone -and removed 
•from the dura as carefully as possible* lor about two months 
after entering here the patient was - bedridden* He was extremely 
weak and malnourished* • There was complete lose of function of 
both left, extremities with marked spasticity* A left homonymous 
hemianopsia and a loss of cortical sensibility in both left ox~ 
tremitios were also present* His mental status revealed him to 
bo not only intellectually impaired but also sonowfa&t rebellious, 
Irritable and given to severe bouts of depressed mood* At times 
he refused to eat. and desired to die* Ho had insight into his 
gross disability* He complained bitterly, of prolonged hospital- 
ization without improvement and the .'feeling that surgery was 
just palliative and would not help his hemiplegia* Following 
the surgery described above, he improved physically and was ; 
given more psychotherapeutic attention* With thoaid of physio- 
therapy and general push, ho was gotton out of bed end Into a 
more active routine*; Ho responded well to this* 
lour months after arrival at this hospital, his KBO trac- 
ings showed ohly a borderline, slow, generalized typo of record with higher voltage on the right side and no response to hyper- 
ventilation. Throe months later, there was no essential change 
in tho typo of tracing* 
His prior Army General Classification Test score was 11 - 119. 
which placed him in tho high average intelligence group* 
?Our ninths after this patient came to this hospital, whon 
his mental and physical status wore ouch improved, ho' was given 
the Voshslor mental ability scalo. His performance scores were 
exceedingly low* 3a rated a mental ago "f 11 years, 6 months. 
His Binot vocabulary was at a superior adult 11 level* Two 
months later a Horschach tost was performed which indicated tho 
following: Six of Piotrowski's ton sighs were given* Tho 
record also indicated the presence of personality dilturbanco; of- 
a "neurotic" nature* There wore anxity feelings, bated at least 
partially on feelings of personal inadequacy. There wore indica- 
tions of depression and that the pationt withdraws from environ- 
mental contacts of an emotional nature. There was definite indi- 
cation of intellectual impairment* 
S*nc indication of the patient's personality has already 
been given. Since tho day of entry, he had given indication of 
acute awareness of his disability*. As hie mood difficulties 
cleared up, ho demonstrated a groat deal of drive and willingness 
to cooperate in his rehabilitation* Tet he was always somewhat 
child-1iko and petulant* Ho' apparently had always been inde- 
pendent and acutely resented any impression that something was 
being "stuffed down my throat". Those wh" worked with him 
realised that a certain amount of stubbornness, rebelliousness 
and touchiness wore over present* His physical drive was good 
and as time went on, his mrod difficulties disappeared almost 
completely. He was exceedingly proud that ho was a paratrooper 
and often stated that ho had respect only for paratroopsrs* 
However, such an attitude did not prevent the establishment of 
good rapport with othor individuals* During his furloughs homo, 
ho gave no indication of poor sociability* Ho was not martyred 
or hypochondrical* However, he was easily Irritated by any 
"red tape", minor inefficiencies, or fumbling "by the Army, by 
civilians or by tho Bed Cross. He demonstrated occasional out- 
bursts of temper to tho extent that he violently cursed the 
occupational therapist and another time throw bis dinner plate 
to the floor. However, these were not without some justifica- 
tion* 
The patient's family background was not unusual excepting 
that his parents wore separated and his mother working* Ho 
had one older sister who lived in another town with whom he has 
always gotten along very well. Patient's birth and early de- 
velopment were not unusual* Ho always seamed to be la goad' 
health* Ho graduated from high school at 18, but it is admitted 
that some subjects wore difficult for him* He excelled in track sports r.nd was crodited as holding a high school title. Ha 
had many fiiends and got dong well with his teachers, Jor 
two years sifter graduating from high school ho workted for 
one of the large rubber companies in the iSast as a 
Conscientiousness was said to ho one of his notable charao^'J 
toristics. With hotter knowledge of the patient, it became 
evident that ho was estranged from his father. Too while he 
loved and respected his anther, he readily admitted that their 
dispositions were too different and he could not return to 
live with her. Sis sister would seem to provide the logical 
attachment and there appeared to ho a strong mutual attach- 
ment for one another. However, his slater’s husband was over- 
seas and his sister worked full time. It appeared that when 
the patient would return home, he might he left t6 himself 
and his own devices much of the time at least during the 
day. 
When first put on a special re-educational program, he 
was very erratic and stubborn. His main desire was to he 
left alone and he stated he had no interests in studies. The 
pressure was taken off agd after a series of.interviews, his 
attitude greatly and he was able to hold a good dis- 
cussion on current events* fie was (given an opportunity, on 
hie own, to decide that he would lifcs to study typing, mathe- 
matics and to road more. At first, his functioning was at a 
3rd to 5th grade level. Over a period of three months, he 
improved to 4the place that he was handling several high scho- 
ol subjects in an interested and competent manner. On the 
ward, ho was no trouble. Ke learned to handle himself very 
well and required very little nursing care after he was here 
for three months. There were occasional episodes of rebel- , 
liousnoss. He w'mld get very angry at the physiotherapists 
v'hen they would not carry out his physiotherapy in at vig- 
orous a way as he desired. He resented any ■babying'*. He 
would flare up at the occupational therapists, how and then, 
if they tried to boss him too much. • • • 
Both his mother ond his sister were contacted. Careful 
explanations wero given to them concerning his condition and 
his likely future. Three months after his arrival here, he had 
become ambulatory to the extent that he could use a walker. 
A foot brace was ordered to*prevent foot drop. One month later, 
he had graduated to using crutches or walk with someone assist- 
ing him. 7ivo months after his entry into this hospital, he 
started using a cane. . Soon aftler this, it was felt that he 
could take a furlough home, provided someone assisted him. This 
was arranged and his sister quit working teraporairly to be with 
him. The furlough contributed in every way to his improvement. 
Ho socialized well, entered into discussions and showed a mark- 
ed determination to triumph over his handicap. ho did 
demonstrate periods of irritability. At times the family felt 
that he wanted to exert himself too much. Attempts to guide his 
activities wore resentei because he felt that they ware trying 
to baby him. During hia 6th & 7th month at this hospital, he appeared 
more cheerful and stable. His instructor reported hin "still 
stubborn as over,.but his stubbornness now has a purposet he 
will do anything he things will make hioinprovo physically 
or mentally. Hia, judgment for tho noat part ,i». nuch improved. 
Most of "his bitter projudicoe have disappeared and he is 
thinking more clearly and broad nladedly., He -was getting 
around nuch bettor with- a cane, and ho was sent hone again in 
his 8th month for six weeks*' This tine he appeared to be quite 
capable of visiting pld-frlends around town.with great facility* 
It was now learned, that hi.* sister's husband soon expected a 
discharge fron the, armed services* Vhen he arrives home, his 
sister will not need td work and tho patient has a more settled 
hone to»which to return*; ; ■ , 
At present, thp patient has been in the hospital nine 
nonths. With a cane ho gets around slowly. His left forearm 
and hand are1 useful only for gross, coarse movements. His 
nontal function and emotional stability have improved markedly* 
There is no reason, why, after.a period of re-adjustment as a 
civilian,; hb"cannot be at least sedentary job. He 
has a good chance to return to tho rubber company where he 
previously worked, as he has some seniority there* They have 
promised that they find him a job that he can do. 
3. Superior Group 
This 21-year;old Sergeant was'founded in action three months 
prior to cqninghere, by shell fragments which struck him In the 
left fronted region. There was some damage to both :f rental lobes, 
particularly the loft and a penetration into the left lateral 
ventricle. Inhere wgs an almost immediate right hemiplegia and 
oppressive aphasia.. He also incurred a penetrating wound of his 
left log and severe.frostbite with gangrene of the. three fingers 
on his loft hand. On arrival at this hospital, he demonstrated 
a moderately severe, expressive aphasia and a right hemiparesis 
(arm affected more-than leg). He was 'blind in the left eye duo 
to injury to that optic nerve. He showed some urinary inconti- 
nence, which, however, rapidly disappeared. Mental status re- 
vealed him to be in excellent contact and slightly euphoric. 
Ho snilod tpo- readily and excessively. There was a definite 
attitude of f&ootiousnoss* X-rays of the skull .revealed an 
elongated defect in the frontal "bone, which extended from just 
tho right of the nldline around into the left temple. There 
wore long linear fracture* extending posteriorly to the right 
frontal and parietal bones* * Multiple, metallic foreign bodies’ 
were seen in tho floor of the frontal fossa and at least one 
bony fragment in the left.frontal lobe of the brain* The 
skull defect was repaired with a tantalum plate. SKI showed a 
borderline slow record with higher voltage in left occipital 
than the right 'occipital lead. Loft temporal lead showed 
almost a flat tracing. •This, suggested loss of brain substance 
in left temporal area. . This man's prior AGTC score was 1-149. Three months 
after entry to this hospital, it was felt that his aphasia 
had improved sufficiently that a Wechsler Mental Ability 
test was attempted. His performance standard scor* was 
slightly below his verbal standard score, but his total 
mental age was equivalent to that of a normal adult, (AGCT 
equivalent 11-110). His Binet vocabulary placed him at a 
superior adult II level. The Rorschach test indicated 
impaired intellectual control, poor judgment and limited 
functioning intelligence. Inner living was fairly well 
developed with evidence of fantasy and creativity. Reaction 
to emotional situations was apt to be immature. He showed 
intense resistiveness against his conscious wishes and sexual 
preoccupa’? on was indicated. No significont ’’organic" signs 
were present. There were several indications of schizoid 
responses. 
Present personality is somewhat as follows; He is tall, 
well-built. At present facial expression is poorly controlled, 
somewhat like that of a person mildly intoxicated. Ho laughs 
and smiles excessively and inn. par '"or i a to ly. He is energetic, 
good naturod and has a good opinion of himself. His social 
inhibitions are sparse and similar to those of an over- 
confident college freshman. Insight into his present situat- 
ion is only partial and he holds himself intellectually and 
socially aloof from the other patients. He likes to talk 
and argue a great deal but is alleys manageable and friendly. 
Family background is not unusual, Patient's birth and 
oarly dovelopmont wero normal. He was always in good health 
and ms outstanding in high school for athletic and scholastic 
accomplishments. Ho ms in his second year at the university 
studying chemical engineering when ho ontorod tho service. His 
homo situation is congenial. It has boon takon for granted by 
all mombors of the family that tho patient would return to 
tho university. 
Ro-oducational plans woro made around throe difficulties; 
1. Frontal lobo deficit personality changes. 
2. Expressive aphasia. 
3. General intellectual slump. 
Of courso, tho first difficulty was tho most resistive. 
His expressive difficulty oloarod up considerably but ho 
continuod to show a dofinito dysarthria. Ho showed ability 
to mstor high school and collogo subjects of tho typo that 
ho had previously mastered. However, ho showed difficulty 
in learning now matorial. It was difficult to maintain his 
attention nn it. It ms difficult to got him to accept seriously the responsibility of studying although lie always 
spoke of returning to the university in the fell* He had one 
furlough hone hut wo have the impression thrt his family did 
not fully appreciate his limitations* His hemiplegia shewed 
a definite physical improvement* He got ©round quite well 
without a cane or asslstenco. However, his right hand func- 
tioned only for coarse movements, and. ho had to learn to write 
with his left* Physically and mentally, now ho is about ready 
for a more advanced type of reconditioning. Wc believe that 
he is a person with sufficient remaining assets that he is 
worth more training. Consequently, wo plan to send him to an 
aphasia center, whore it is hoped that his speech will bo 
made more distinct. At the same tine there, he can ho more 
constantly under a more concentrated psychological guidance, 
insofar ns his other deficiencies are concerned. 
He he?loves that ho wants to teach mathematics now. How- 
ever, it is likely that an immediate rush hack to the univer- 
sity should not he advised after his discharge. If he does 
not return to, the university, ho has a good opportunity to 
enter his father's retail business. 
H-hlP.BlR f*yJCijS 
1, Amy General Classifiertion Test, Prepared by Person- 
nel Proce,’.ores Section, l.l6 and Plans 
and Train: rn: Branch, adjutant Generali Office, War 
Department, Washington, D,C. 
2. Wcchsler i-lcntal Ability Scale, Porn 3. Manual of di- 
rections rnd scorinr forms# Revised July Pra— 
pe.ro4 by Personnel Procedures Section, Plans and 
Tr. ininr Branch, Adjutant General1s Office, War De- 
pendent, Wash in.'ton, D. C. 
3. Piotrowski, Zygmunt* J. of Nerv. and lent. Dls, 86i 
525-?37. #5. November 1937. REHABILITATION III BRAIN DEFICIT CASES 
Discussion by ’Yard C. Halstead, ll.D., University of Chicago. 
It is a pleasure to op-in the discussion on this valuable 
contribution of Captain Aita. One looked almost in vain for 
contributions 'such as this (on the rehabilitation in brain 
deficit cases) during times of peace. They wore even less 
tc be expected in time of war. For those of us who have been 
associate© with army hospitals in any capacity during this 
war know something of the many adverse pressures against which 
Captain Aitu has been able to carry on his investigations and 
thuraoeutic activities. He has boon especially fortunate in 
his associated team of colleagues at Mayo General Hospital. 
It is a further tribute to the nodical direction of the Sixth 
Service Command that I and various colleagues in the medical 
departments of the University of Chicago hav-., as civilians, 
enjoyed quite similar relations with the staff of Gardiner 
General Hosoital. 
Certain features of Captain Aita's presentation seem to 
mo to demand special comment. (1) Kis comprehensive view of 
th.. total job involv-.d ir the rehabilitation of individual 
brain injured patients. Captain Altars carefully organized 
12-point program finds amplo support in the experience of my 
own laboratory where wu have foliowad the post-operative course 
of individual neurosurgical patients over a period of ten 
years. I can agree with him heartily in his statement that 
"at tin-. o the personality and individual brain involved are 
more- potent factors ff.acting recovery than the lesion or its 
extent." It is this fact which makes all cf the other stops 
in his program so necessary. (2) Ilis emphasis upon careful 
psychological testing. As one who is actively engaged in 
developing testing methods in this field, I can only deplore 
th.. f.ct that better psychological nothods for evaluating 
tv. altered status of brain injured patients were not generally 
■available during the war. That such methods nay soon become 
available in no way alters the fact that Captain Aita made 
skillful us*, of those accessible to him. This is well-illustrated 
in his case histories where the therapeutic result is related 
to a realistically induced level of aspiration in the individual 
patients. The possible exception hero is the patient with left 
frontal lob*: damage who now aspires to teach mathematics. Our 
experience would suggest that while the individual described 
night still have limited ability to teach mathematics, he will 
probably ultimately fail cf adjustment in the kind of environ- 
ment whore mathematics are normally taught. 
(3) 'us emphasis upon psycho somatic orientation. It is 
apparent that this rmraso is more than u shibboleth to Captain 
Aita. Fer t avery point in his program he attempts to rein- 
force the security axis oi tuo patient and to strengthen the 
social vectors of motivation. Her© again, our experience 
supports him—th -se are necessary seeps, for without then, the 
brain injured pati nt-far removed in tine and space fron tones 
of combat-, ay v-t ri\j time experience the catastrophic reaction 
so well described by Grinker .and Spioglo as #,fcKe dissolution of the ego in the face of ovcr-wholning anxiety." The findings 
in our Laboratory indicate that this prononess exists not only 
in c.notional terns, but in an altered neurophysiology ef the 
injured brain as well. 
Vie hero are indebted to Captain Aita as are indeed those 
brain injured soldiers who were fortunate to cone under his 
understanding care. SPEECH THERAPY FOR APHASICS 
Vivian Mowat* 
A little more than a year ago there occured an amusing yet tragic 
incident which led to the beginning ol’ the program of rehabilitation 
for aphasics at Percy Jones. At that tine I was employed in' the Battle 
Crook Schools as a speech correctionist• Ono afternoon my phone rang 
and ono of the remedial reading teachers in the Ann J. Kellogg School 
asked somewhat desperately for help. "I have a soldier here from the 
hospital who ms sent over to learn to read and write and he can’t • 
oven talk] Can you come down to ray room to see him?” I did, and from 
then on began to work with his kind - the brain-injurod who have lost 
their ability to talk, read, write, calgulate, and function socially 
to such a degree tliat they are not acceptable to society. 
Naturally the program had its humble beginning and it has since 
undergone innumerable changes in organization, physical and material 
growth, and personnel, as well as in its aims and objectives. That is 
a story with which anyone who is a part of an Army hospital must be 
familiar, for every program of rehabilitation has proceeded thru similar 
phases of development. 
It is my purpose to present to you a brief sketch of the type of 
program wo have finally succeeded in producing and to attempt to show 
what uo feel we are accomplishing thru such a set-up. 
Any rehabilitation program for aphasias must necessarily bo 
developed with consideration for both the general and specific dif- 
ficulties which hinder the patients. Lot mo review briefly the 
problems which must bo mot and dealt with, for they have determined 
the different phases of the program. 
When the aphasics roach our mrd they.have been thru surgery] they 
are ours to keep as long as we’deem expedient• And oven the several 
months may have elapsed since the onset of aphasia, their problems are 
acute. 
• They my bo unable to speak or road, writo, paloulate, and under- 
stand. In other words thoir communication lines are badly damngod, 
perhaps on both orjds - receiving as well as expressing. The result 
is a sense of frustration which may in turn result in despondency, 
tears, or conploto resignation and apathy. Ropoatod failures earlier 
my have built such burriors as to now inhibit tho return of that 
speech which is possible, And the-individual may have withdrawn so 
far into his shell as to bo almost oblivious to his surroundings and 
associates. Obviously tho need for. social adjustment is tremendous; 
tho need for realization that spoojch is again possible is unquestion- 
able; and tho need for a fooling of success to erase previous failures 
is absolutely essential. An organized attack on thoso problems is 
nocossary. 
Still further problems besot tho poor aphasio. Ho soon becomes 
aware that he can no longer do many simplo things ho onco took for 
granted. Either ho cannot talk-at all - or not wall enough; perhaps 
ho cannot road, cannot writo, cannot do tho simplest arithmetic 
problems, Why, perhaps ho cannot oven hold a pencil because ho is 
paralyzed, lot alone copy or writo spontaneously. Often ho blames 
his paralysis for his inability to \/rito, unaware that evon thr * 
his hand could function ho no longer conooivos form normally. It 
♦Percy Jones General Hospital, Battlo Crook, I!ichigan, is an understatement to say this follow needs to ba given an opportunity 
to rcloarn tho basic skills. 
Evan more sorious difficulties arise from tho usually reduced capacity 
for abstract thinking, from memory defects, from shortanad attention span 
and lack of ability to concontratoor rather lack of ability to overcome 
or ignore distractions and from a general impairment of intellectual 
functions• 
Add to thiso things tho actual personality changes, tho tension, the 
visual defects, the physical weakness, tho convulsive soizuros, tho need 
for rost and sloop, tho anxiotios, or tho contrary euphoric state, tho 
concern about and yot lack of understanding of his condition, tho almost 
complete lack of a sonso of humor, and tho hundred and one additional 
almost freakish neurological defects which nay be involved in individual 
oasos and you have a picture of tho statu of confusion which is typical 
of tho aphasios. I am in no way trying to toll you what aphasia isj 
that you know better than I, I am moroly reiterating and trying to 
group their problems so that you may ov&luato tho therapy I describe. 
For tho tost for any therapy must bo - does it moot tho noed? and 
does it gut the results it should? 
ViTo moved our aphasios to one \rtxrd of Percy Jones, Jo havo had an 
average of approximately twenty at any one time, with a slow, steady 
influx and corresponding reloaso. The ward is an ordinary ono; most 
of the non live in tho ono largo dormitory space, Wo have appropriated 
six of tho small individual rooms and havo furnished them as classrooms 
to suit their particular use. In addition tho day-room and porcli serve 
as other classrooms for larger groups. 
Our patients ar :> referred to us after careful modioal and neu- 
rological studios are made and psychological testing has boon completed. 
It is our task to fit tho man into his propor place or rather to make 
a placo for him. Wo must arrange for tho help ho noods, givo him tho 
classwork ho must havo. 
Perhaps outlining a typical sehodule will show a little hotter 
what wo do. Lot us say that wo tako Walt's **ase. His power of speech 
was lost throo years ago in a Jap prison camp - cuuso undetermined. 
Vfelt has a spoeoh class at 8»15, a reading class at 9x00 (for while ho 
understands somo of what ho roads silontly, ho cannot road aloud.) At 
9:45 ho goes to Occupational Therapy for help in using his loft hand. 
Following his dinner hour (10x45) ho has Physiotherapy at 11x30 and 
thon a poriod of free timo until 12 ;45 when ho joins tho rest in a 
singing class for half an hour. At 1x15 ho goes to class for writing, 
at 2x00 he has an arithmetic class and finally, between 2x45 and 3x45 
ho ha$ an individual speech lesson of 15 to 30 minutes. In such a way 
his day is filled and ho is kept busy with tasks ho wants to do or 
with things ho can accomplish. No brooding idleness horej no long 
strotchus of loneliness. 
Most of the classwork is carried on with small groups assomblod 
on the basis of similar difficulties. Wo have stressed considerable 
group thorapy boeuuso spoeoh is a social function and ‘can best bo 
practiced in normal situations, and booauso tho contact with others 
has therapeutic value in itself. It lossons solf-pity and shtunoj 
it produces q sonso of responsibility and a chance.to holp others 
who are vrorso off in another way. Nothing dc'QB moro good for instance, 
for tho boy who cannot understand what others are saying than to 
become aware that ho can holp to guide an almost blind follow-patient 
about tho ward. Group speech classes usually Consist or five or six members 
with somewhat similar needs as far as speech is concerned. ’To use 
imitation, repetition, and- phonetic- placement, coupling visual, 
auditory and motor images. vWb. capitalize on involuntary speech and 
raise it to a voluntary level.' We stress speaking in normal phases 
and sentences, finding that oft-repeated groups of words are as easily 
said as single words, and promote a natural speech rhythm pattern. Wo 
do, of course, build vocabulary too, choosing to talk about the things 
the fellows need immediately - thdir names-, hone towns, greetings, names 
of families, money, colors, articles to be purchased at the PX, clothing, 
food, sports, cards, etc. 
Reading classes are smaller, \rith two to four persons each. Both 
silent reading (for comprehension) and oral reading (for expression) 
are a part of the work, we find phrased materials and a combination 
•of motor activity and? speech facilitate tho reading*. Wo have made use 
of the Army manuals for illiterate*?, but havo found it necessary to 
create and adapt most of the materials. As fur as wo can ascertain 
there are no materials with adult interests 'Which are- simple enough 
to servo our purpose. 
Writing classes, v;ith a roster of two to four, stress throe things: 
penmanship (especially-for those with a cliunge of hand), .spelling, and 
sentence structure, sc tliat tho patients can write their own letters. 
Outside of a few sets of wooden and metal letters, u blackboard, a list 
of Basic Unglish words, and some spalling books, few mtoriels are 
necessary. • •• 
/.rithnotic is also taught in small groups of two to four. Ofton 
it is necessary to begin with number concepts and -to' rio-tecLohnumbor 
combinations and tho four basic processes in arithmetic• In some cases 
more advanced work must bo taught, depending upon tho .previous training 
and future needs of the patients. • • - 
Individual speech classes stress tho work most noedod whether this 
is learning to produo.j tho sound tiuru imitation, or increasing vocabulary, 
learning the alphabet, etc. Wo use tho taehistoscopo, a mechanical 
device which capitalizes on the aphaslc's inability to ignore distractions. 
It releases, quite suddenly, a given Word, phrase, or.sentence; the patient 
responds involuntarily, then trios to produce tho sane response voluntarily, 
The oral speech and reading involved are coordinated then with spelling 
and \/riting as tho patient uses metal letters arranged on a black table 
to spell the words he pronounces. These same metal letters (which make 
uso rf tho tactile senso, temperature sense as well as motor activity) 
c.ro used for teaching the 'alphabet and numerals, both in and out of serial 
urdor. ' \ • 
Thoso aro the classes, the actual academic reeducation facilities wo 
havo developed. No do vary tho program for tho individual by encouraging 
classes in tho Educational Reconditioning Program in typing, bookfcooping 
or perhaps ovon analytical goonotry, if feasible. Howovor, our own classes 
bear tho burden .if tho most of th’> touching# 
"To attempt to coordinate tho' speech and language training with tho 
work in Occupational Tnorupy and Ihysio-thorupy. ’Jo often confer an tho 
patient's work, ability, noeds, interests and attitudes, as wall as progross* 
Insortod throughout tho ontiro program Is tho element of 
nontal hygiono« Jo aro continually helping tho patient to understand 
aphasia and to realize why ho ca 't say his namo ovon though ho knows it, 
Jo uso drawings of tho brain, sinplo explanations, stories of cthors1 
•eventual success dospito thoir losses. Vfo t.ro busy offering onoourago- nont, jotting rid of fulsc notions, and overcoming disillusionment. Ta 
build c. cheerful working atmosphere with plenty of informality and 
freedom from tension. 7o try to dovolop a sonso of humor, through 
tolling of jokes, pulling littlo pranks, etc. Vfo try to 
help the men look forward to the future with a fooling of pleasant 
anticipation rather than dread - a simple task on paper, but a 
tremendous one in view of their physical and mental handicaps. 
Good social adjustment, the ability.to moot others and act 
freely and comfortably in small groups (and later in largo ones), 
Vfo find that-a kitchen whore vo can gather for an occasional cup of 
coffee,or glass of milk, card games, informal parties which are not 
too demanding, picnics, small gatherings, etc., are all good moans for 
promoting a sense of companionship and friendliness - and, as a by- 
product, good speech. Such activities also play no snail part in 
helping the staff to gain food rapport with each patient* 
I ; I1' I ill ; i (' |w |if ijlli i'lili tin) 1(1111,11 
'ii |i 11 hh !■ lli'ij ii hm |ii>mj(i|fii iij iihiiiII; hill liii f|l lwl(l 
Mhu n'I i | i H||(| Hi llillifj) pull |l||i|i i4| i||'|rl |!iHlii||lli 
home,road nail, straighten nut pay ehebks, gdk sotvttte hibkbHfl; 
keep up insurance forms, etc, Those littlo odd jobs, simple as 
they seem, put the patient at ease and leave him less disturbed in 
an environment which cannot help but be ton dcmandin0 and difficult 
for the brain-injured. 
Of great import:.nco in understanding the men we are working with 
arc the visits and correspondence with members of their families. Vfo 
usually explain to tfn family what aphasia is, hou their boy is affected, 
’./hat handicaps ho must ovorono, what wo will try to do, what results 
can bo expected in general, and how he must bo treated when he c-r.es 
hone, ife provide each family with a copy of the bulletin, naphasia in 
idults" (published by the University of ilichigan Speech Clinic) to 
further their understanding. When members of the family remain near 
the hospital and see the patient frequently v/e make use of them and 
give them actual instructions to follow in working with the patient. 
Still another portion of tho program is the Mfollow-upn which 
is attempted in an effort to holp tho aphasias adjust to civilian 
life or continue necessary reeducation.once they leave tho army 
hospital. By moans of urging further training (either additional 
spooch training or vocational and making arrangements for 
it, and through the media -of correspondence and personal contacts, 
chock is kept on the men who leave. 
Thoso are all phases of cur Spooch Therapy. In this short tino 
I cannot begin to mention all tho details of the programs the typos 
of cases, their causes, the functional cases of stutterers and the 
voice cases and others who wend their way to us for holp. I 
cannot recount all the little things wo find ourselves doing; can- 
not launch into an explanation of how, specifically, to teach a 
nan to say his name, or to teach him to toll right from left, to 
toll time, to feed himself, or to find the correct place to sit on 
a chair when he can no longer understand or interpret sphtial relations and shapes, and v/hon ho has lost his sonso of diroctiin* Thoso 
o.ro tho individual differences which v/o must moot ovory day; thoy aro tho 
things which mako tho scopo of tho program so vory broad and tho staff- 
pationt ratio scon s< largo. 
At host I an afraid I havo only generalized, but thon I sinooroly 
hopo I havo at least a general impression of tho work wo aro trying to 
to, Uo havo folt it worthwhile; some of tho rsoults aro measurable 
enough; others sinply show in tho healthier and happier attitudes of 
th< si who loavo us* 17o fool wo can conclude that wo havo boon ablo 
to hasten the prnooss of reeducation; that wo have pushed it far boyond 
tho level usually attained by tho pationt allowed to drift his own way 
without guidance and directirn and professional oncouragonont; but 
above all wo know that v/o can tako credit for making life a brighter, 
pleasanter and more worthwhile venture for those who onco dreaded its 
very existence* Discussion of 
"SPEECH TE2Ibi?Y FOlt oFIt-SICC” 
by 
Clarence T. Simon, Ih.D.* 
It has boon stimulating e.r.d gratifying; to listen t>- this pro Son- 
tv. ti on of it program (f speech therapy for aphasics, It has boon gratify 
in./ booauso it is tangible ovidenco if ti.o growing belief that r.phasics 
respond to remedial treatment and that timo spent with thon yields 
domonstr? bl > results. 
It has boon gratifying also because if its domnnstrati -n that the 
language rooovory of an ache, sic pe.tiorxt can b •> accelerated by a compre- 
hensive pr gram of speech therapy, Far to< . ft ;n, aph.sios arc n t 
provided with the over-all type < f remedial nr \;r: on thoy nood kut are 
allowed to rocovor slowly, if at all, by ;> pri cess of drifting* After 
tlia initial spurt of improvement following tho occuranoo <f the lesicn, 
to( many patients uro allowed ti lapse into an inactivity which not 
rniy fosters discouragonent and or.otioiial depression, but also interferes 
directly with tho redevelopment of tho language process. An aphasic 
must he.vo spoooh therapy to reach his maximum possible rain in language 
skill* 
I ho paper has been stimulating boor use tho working techniques 
suggested grew out f a concept of aphasia which is in accord -with 
modern thinking in the n.tural and biologic''1 sciences. Fortunately, 
for those nf us interested in the language re-education of aphasias, 
tho structuralistic traditi n fathered by Gall and carried an by 
Broca, Bastian, Wernicke and 'th.rs has boon giving way t( the more 
dynamic concept begun by Flcurens rind o-ntinued by Charcot, Jackson 
und Goldstein. Sc long as the li ealizat lonlsts and dir.gr'. mat is ts 
had their day, wo tend d tr. make c.n atomistic approach of the treatment 
of aphasia which yielded fow satisfactory rosults, V/hon, hnwev.r, wo 
began to interpret aphasia <.s tlio disturbance of pr'-ooss and t‘ think 
of it as involving the language function an a whole, adequate rennlli 1 
teuhnJqn s fe «i n t p aulble. 
3" long as our main intorost in aphasia lay in deciding whether 
It was sensory, notor or nixed, or in determining whether the lesion 
involved Proca’s, TJornioku’s r • thor areas, the structuralistic 
hpprohoh prevented udoquut • language retraining. 
Important as these data may be f - r the nouro-surgoon, they are 
of little if any value for tho speech therapist, iOiy attempt at 
language development on the basis of convent! nal classifications 
of typos of aphasia, ir the basis of the locus rf tho lesirn, 
results In a partial and inadequate program. The spa )oh therapist 
must approach his problem with a funoti’ nal view of aphasia as an 
intarforonoo with a total language process. His tusk is tho redevel- 
opment of this proooss as a •cnpluto periphery t. periphery behavior. 
One other comment rx.y bo nr.de ooncoming tho language involvomont 
in anhasia. Frequently wo hear the nxnrnssion, "langunro loss,” 
‘•‘Speech and i loft ring Clinic, Northwestern University, Evanston, 111. Our definition of that word ”1 <>na'* is Important. Mum accurately wo 
night say that the uj basic presents ■ disturbance of the Ifinf“u^(v* 
function, Ho still has i\ language process, but he performs hia 
language activities in more primitive and roundabout ways. although 
these ways my bo so primitive and roundc.be ut that they aro meaningless 
to us, ho still retains a language process of sorts. It is true that 
ho cannot uso ndstractions and symbols, r employ tho shortcuts which 
wo call thinking, but ho still has a language process; a process which 
is vory roal and meaningful to him. Although wo know that his primitive 
processes are closer to tho intellectual lifo of tho cave man than to 
our own, ho tends to fool that tho difficulty lies in our stubborn 
unwillingness to understand. 
Tho aphasic retains a language process of sorts. Tho speech 
therapist stimulates this process by every moans at his command, work- 
ing always in a total language *aitviation*# As this process is stimulated, 
more and more it dominates and integrates undamaged neural structures 
to make them subserve tho function of language. 
This paper has boon stimulating in its presentation of a modern 
program for aphasics and its indications 'f satisfactory results. In 
our enthusiasm for those service programs, however, wo shall have to 
guard against too broad generalizations concerning our results. The 
speech therapist working in a service hospital deals with patients 
different from *hoio fnunrt in mop-) .1 practice, In the first 
plnof),ftt loemt meet of the pi.tiontn f • unO In « »rvioe hocpituls are 
yovmfi and nut toe f .r from th.ilr learning uciyu they haven't sottlocl 
di-wn to an adequate and comf stable routine of established habits and 
skills. Second, for the most part, they ar*j in relatively vigorous 
health. Third, they are locking forward tc a productive and active 
lifo. Fourth, thoir lesions generally v/oro produced by single incidents 
and thoir neural condition is static and not progressive. 
In contrast to tJvis, the aphasic patient whom wo tend to see in 
general practice is older and therefore further from his useful learn- 
ing days, generally l« m < In thu most robust health, 1* not looking 
forward to many mope years of productive activity und last, and mod 
Important, generally faces a pr»rrosslvo father than a statin prognosis. 
jvii of these dlfferonoeu indicate th t th j ruauits obtained in 
our service hospitals should bo nr ro rapid and more complete than any 
wo have over obtained, or can obtain, in general practice, ./hilo in 
general practice, tho speech therapist must determine which cases 
justify speech therapy and which do not. In tho service hospitals 
relatively few such ducisi' ns must be made. Rather tho issue is 
that of adequate personnel to achieve maximum results before tho 
votora n sinks to tho typical corditon commonly soon in general 
clinics. 
This papor has boon stimulating and pleasing t - hoar. It 
recognizes aphasia for what it is, a disturbanco of a total process 
which rondors tho patient unable to indulge in language behaviors in 
anything like tho normal manner, because of his lesion, he is compel- 
led to carry on language processes in roundabout, primitive and frequently '.r'.ys. It is tho job of the speech 
therapist to rebuild this total' preops s, us inn a wide variety of 
total language situations* . POLYNEURITIS ASSOCIATED WITH CUTANEOUS DIPHTHERIA 
Hawley Sanford, Captain, Medical' Corps* 
Diphtheria of the skin, particularly as manifested by 
wound infections, was rather a common condition during the 
nineteenth century. In mere recent years it has beer men- 
tioned chiefly in reports of medical officers stationed with 
troops in tropical climates. During T’orld Tar I there were 
sporadic outbreaks of cutaneous diphtheria among British 
Soldiers in the tropics. During the recent war it has again 
been found that some of the soldiers in the islands of the 
Pacific who .develop skin lesions referred to as "jungle sores*' 
or "tropical ulcers" have virulent diphtheria organisms in 
these ulcers, the organisms entering as secondary invaders. 
Skin ulcers are rather common in the tropics, particu- 
larly under combat conditions. The factors involved are trauma 
to exposed surfaces as result of living in the Jungle,insect 
bites,, enforced lower standard of hygiene, malnutrition, and 
inter-current disease. Various names have been applied to the 
resulting ulcers; — tropical ulcer, Jungle sore, desert sore, 
veldt sore, Barcoo rot, frontier sore or Magi sore. Any of 
theae ulcere r,&j become infected with Coxynebactcrium diph- 
theriae, either from exposure to cases of faucial diphtheria 
or from carriers. The diphtheritic ulcer most frequently 
occurs on the extremities. It is rounded or oval, may 
vary from a few millimeters to several centimeters in dameter, 
has e rolled, firm edge which is undermined, with a base which 
is as a rule covered with a dirty gray sloughing surface. The- 
ulcer is surrounded by an inflammatory zone which later becomes 
pigmented, Th® ulcers are practically always multiple. After 
healing the of the scar rill be insensitive to pin prick, 
the area of Insensitivity extending for a short distance 
around the margin of the scar. 
(Slide No. 1) 
The important thing in the "treatment of the ulcer is e 
thorough cleansing followed by application of sterile, rarm 
saline dressings or compresses soaked in penicillin solution 
of 250 to 500 Oxford unit? per cubic centimeter. As soon a? 
the diagnosis of diphtheria is made the patient should receive 
20,000 units of antitoxin in an attempt to prevent later com- 
plications such as neuritis. Diphtheritic infections of the 
skin are not confined to ulcers such as those just described, 
but ray also be complications of either surgical or traumatic 
wounds, scratches, insect bites, scabies, impetigo, staphylococ- 
cus, folliculitis,, and epidermonhyton. 
♦Percy Jones General Hospital* 
Battle Creek, Michigan. Diphtheria toxin may affect the nervous sytem in several 
Kays, and there may result delirium, meningitis, or encephal- 
itis. Hemiplegia has been reported as a rare sequela of 
diphtheria, but in this instance the etiological relationship 
is indirect. The diphtheria causes a myocarditis. A mural 
thrombus forms on the rail of the affected heart from which 
a piece breaks off, lodging in a cerebral vessel as an embolus, 
causing the hemiplegia. The most common complication of 
diphtheria is a neuritis. Although it is stated that as many 
as 20% of the cases of cutaneous diphtheria later develop 
polyneuritis, such palsies do not present a numerically im- 
portant problem in the casualties of this war. Of nearly 
one thousand cases seen in our neuropsychiatric section during 
the first nine months of this year, there were A6 cases of 
polyneuritis, of which 2L were associated witn diphtheria. Of 
these only 12 were the results of cutaneous diphtheria. 
The ciliary nerves to have a selective action for 
diphtheria toxin, as a paralysis of accommodation is by far 
the most common neuritlc complication, and is usually the first 
to appear. It makes its appearance about two weeks after the 
acute stage of the infection and persists for about two weeks. 
For some reason the toxin absorbed from cutaneous diphtheritic 
lesions does not effect the peripheral nerves for some time 
after the skin lesions hove heeled. The average latent period 
is two to four months, and one interval of nearly five months 
has beer reported. Regardless of the site of the lesion, the 
lower extremities are usually affected first. Sensory symptoms 
are the first to appear. Numbness of the toes, which spreads 
up the legs is followed by symmetrical ascending paralysis of 
the legs. The arms then become affected in the seme manner, 
resulting in complete paralysis of all four extremities. 
Tendon reflexes are lost, and the muscles become atonic end 
atrophic. The cervical end back muscles may become involved 
to a lesser degree. Paralysis of the muscles of respiration 
has been described, but fortunately has not occurred in any 
of our cases. 
At the height of the neuritis, examination of the patient 
will reveal generalized flaccid paralysis of all four extremi- 
ties, or varying degrees between this and merely weakness of 
certain muscle groups, A foot drop is practically always found. 
Tendon and superficial reflexes are lost. Superficial sensa- 
tion is symmetrically disturbed so that a stocking and glove 
type of anaesthesia is present. Vibratory and position sense 
may be lost distally. Before the strength is entirely lost, 
or as it returns, an incoordination is noted, and the patient 
is ataxic. 
Recovery is slow, the signs and symptoms disappearing in 
the seme order in which they appeared. First the sensory loss 
gradually recedes, then muscle power, substance end tone 
finally return to normal. Lastly the tendon reflexes return. The time from complete paralysis to complete recovery may 
be six months or longer. There is no specific treatment for 
this type of polyneuritis. The usual precautions are taken 
to prevent tendon contractures. Physical therapy in the 
nature of electrical stimulation is used in the early stages, 
exercise in whirlpool baths and remedial exercises as strength 
returns. The patient is given a diet rich in vitamins, sup- 
plemented by vitamin preparations given by mouth and paren- 
terally. 
The polyneuritis associated with cutaneous diphtheria 
is essentially the same as that following the faucial in- 
fection, but there are differences. Paralysis of the palate 
and throat resulting in disturbances of deglutition and 
phonetion is a common complication of faucial diphtheria but 
is rarely seen following cutaneous diphtheria. Thit would 
seem to indicate that in tor.silar infection the toxin is 
absorbed along the perineural sheaths causing a local paralysis. 
It appears that the toxin also circulates through the blood 
stream as the peripheral neuritis usually starts in the toes, 
regardless of the sit© of the lesion. Another difference be- 
tween the neuritides seen in faucial and cutaneous infections 
is that in the first, the neuritis usually follows a few weeks 
after the acute stage of the illness, while in the cutaneous 
form it may be postponed for several months. One might postu- 
late that the skin, the chief anti-biotic organ of the body 
holds the toxin in check for a longer period than does thc- 
mucous membrane of the threat. 
A severe diphtheritic polyneuritis may be clinically 
indistinguishable from another condition; namely, the type of 
polyneuritis which is referred to as infectious neuronitis, 
or the Guillain-Berre syndrome. One of the important diagnos- 
tic criteria of the Guillaln-Barre syndrome is an increase in 
spinal fluid protein not associated with an increased cell 
count; however, this can not be relied upon tc distinguish 
this condition from the neuritis associated with diphtheria, 
for in this illness too the spinel fluid total protein may 
be materially increased. It may be as high ns 400 or even 
500 mg f but in most instances it is 100 mg % or less. In 
cases of Guillain-Berre syndrome the spinal fluid protein 
may be increased to as much as 100C# or more and it is iry 
personal feeling that of the two, the protein in the diph- 
theritic neuritis cases tends to be lower. The differential 
diagnosis in the two disorders will have to rest on the history 
of isolation of diphtheria organisms from the skin, the appear- 
ance of typical insensitive scars on the legs, the history of 
paralysis of accommodation, and evidence of cardiac damage 
particularly as reflected by electrocardiographic evidence soon 
after the onset of the illness. In conclusion, it should be stated that this condition 
will probebly make its appearance in the practices of civilian 
neurologists during the coming year. Troops ere nor being 
returned in great numbers from overseas end most of these 
soldier? are being discharged from the Army p,other promptly. 
Some of the men who hhd diphtheritic infections of the skin 
while- in the tropics rill probably develop neuritis after 
they have returned to diviiian life. 
DISCUSSION OF FOLYNEUF IT IS ASSOCIATED ?ITH CUTANEOUS 
pmirnu 
Discussed by George B, Hassin, M, D,, 
Professor, Emeritfcs, University of Illinois 
As Captain Sanford has so rell shown, the neurologic fea- 
tures of cutaneous diphtheria are similar to those of the 
faucial type. In both the toxin of diphtheria travels from 
the affected area - the throat or the skin - to the medulla 
oblongata, along the fibers of the nervus vagus or to the 
gray substance of the spiral cord, along the spinal nerves. 
If the parts of the medulla or the spinal cord thet are 
connected with the nerves extending from the infected areas 
are emulsified and in;'acted into a dog or a guinea pig, the 
animal either succumbs or develops a paralysis* Nothing 
happens if one injects other parts of the spinal cord or 
medulla or tissues frdm a healthy non-diphtheritic human 
being. It may-thus be assumed that not only the nerve alone 
but the whole neurone — the nerve endings, th,e nerve fibers 
end their centers -- the nerve colls themselves- is involved, 
in short that we deal here with something like a neuronitis. 
This, cf course, differs as, Captain Sanford;.pointed out, from 
the classical Guillain-Parre type., mainly in its: serologic 
characteristics. Much more.does, the clinical picture, es- 
pecially of a protracted,case of,post-diphtheritic paralysis 
resemble that of tabes dorsalis, as evidenced by the loss 
of the terdon reflexes, the presence of sensory anomalies, 
ataxia, incoordination and occasionally of the Hornberg sign. 
Such a wymptomocomplex in connection with a peripheral nerve 
■lesion is classified as pseudo-tabes because of the favorable 
course end prognosis,' Yet, I have seen cases of post- 
diphtheritic paralysis in which loss of the tendon reflexes 
seem to have been a permanent feature. ELECTRO-DIAGNOSIS 
EXAM NATION OF PERIPHERAL NERVE LESIONS 3Y PERCUTANEOUS 
ELECTRICAL STIMULATION 
I* T, Center, Ceotaln, M, 0,, and 
Frank H, Mayfield, Lt Colonel, M, 0, * 
It in often impossible to determine by clinical examination 
Aether Ions of function following peripheral nerve injury is due 
to division or contusion of a nerve. Many nerves that are con- 
tused recover spontaneously. These that are divided require op- 
erative repair. The final result in cases that require suture 
is better if the suture is done early. The need of some diag- 
nostic method that will determine if muscle is neurotired is 
therefore apparent. 
In 1868 Erb described the difference between Normal and 
denervated muscle In response to electrical stimulation. Many 
workers have anolled these principles to clinical diagnosis. 
Partly due to errors of interpretation of this i"ork and partly 
due to incomplete data in some phases of it, errors have been 
perpetuated down through the years without critical examination. 
Mostly because of this, the procedure of examination in common 
use at the outset of this war gave information that was inade- 
quate and misleading. The purpose of this paper is to point out 
the common errors of interpretation and to describe methods of 
proven reliability. The opinions expressed have been elaborated 
from an extensive clinical investigation under way at Percy Jones 
General Hospital since February 1944, No claim to originality 
is made, for the work has been carried out in collaboration with 
and under the supervision of Doctors Pollock and Oolseth and 
thair associates at Northwestern University Medical School. It 
consists of wide clinical application of principles already elaboiv 
ately studied by them in the laboratory and to a lesser extent 
in the human, much of which has already been published. It is 
presented now in elementary and preliminary form, with their full 
permission, that it may bo used in the in sstigation of military 
casualties. Time does not permit presentation of all the data 
from which the conclusions have been drawn, but it is to be em- 
phasised that the data has been verified by gross and micro- 
scopic examination of the surgical specimens* 
Contraction of normal muscle may be induced by percutaneous 
stimulation either throu gh its nerve supply or by direct stimu- 
lation of the muscle. If the nerve is divided, the distal ■end 
loses power of conduction within about fifteen days and stimu- 
lation no longer induces contraction of the muscle. The muscle 
remains capable of contracting if stimulated directly. 
In, general, three types of currant are used for examina- 
tion! A. Feradic, B, Alternating and 0. Galvanic. 
♦ Percy Jones Hospital Center 
Fort Ouster, Michigan. Faradic current! Consista of a rapid series of very short diphasic 
impulses (150-300 per sec) and is usually obtained from an induc- 
tion coil. It has very Hailed application in electrical exanin- 
ation. It is genr ally capable of inducing contraction of muscle 
only when the nerve can conduct impulses. It win always induce 
contraction in normal muscle, or within the first fifteen days 
after injury if the nerve is divided. Faradic response rarely 
returns acre than a few days before voluntary motion. This cur- 
rent has the added objection of oeing Impossible to measure. 
Alternating current! is also a biohasic current (60 cycle oer 
sec) and is that type usually supplied for household appliances. 
The resoonse of muscle to this current is similar to that with 
faradic stimulation. This type, however, is readily measurable, 
and is of great value for use at the operating table, but has 
had little apolication for oercutaneous investigation. 
Galvanic current is a constant nonophasic electrical impulse which 
flows steadily in contrast to faradic or alternating which is 
biphasic and rapidly changing, flowing from positive to negative 
and vice versa. This current nay be obtained from a battery or 
by conversion of alternating current through rectifiers. It is 
capable of inducing muscular contraction either through nerve 
conduction or by direct muscle stimulation. If its nerve supply 
is lost, muscle continues too irritable to Galvanic current, but 
the character of contractions and the amount of current required 
changes. Interpretation of the latter phenomena is the key to 
sound electrical examination. 
Methods of examination 
The terra electro-diagnosis is commonly used to indentify the pro- 
cedure of stimulation of muscles by applying electrodes to the 
skin. The terns bipolar and unipolar examination refer to the 
distance separating active and the indifferent electrodes. If 
the indifferent electrode is placed some distance from the mus- 
cle to be tested, i. e., the proximal part of the limb, the method 
is unipolar. If both electrodes are placed on the muscle in 
question, the method is bipolar. Either method is satisfactory, 
but the unipolar is usually more convenient. 
Contraction of muscles may be recognized by direct observa- 
tion or palpation of the muscle belly -»r tendon or movement of 
the part it supplies. Interpretation, however, depends upon the 
amount of current required to induce contract4on. Therefore, it 
is necessary to establish a fixed degree of contraction ns a 
standard, Thae minimal visible contraction is accented as that 
standard, Laoicoue used the term "Rheobsse" to identify that 
amount of current, necessary to induce such a contraction. 
The terra reaction of degeneration (RD) has gained much atten- 
tion in the literature. It describes a state of progressive change 
in muscle irritability after loss of all or part of its nerve 
supply. It has long been recognized that muscle was more easily 
stiaulated for a short period of time after injury to its nerve, 
thereafter it was believed that with passage of time hither and higher thresholds of current were required to induce contraction, 
until eventually the muscle was. no longer capable of contraction. 
At this period absolute reaction of degeneration (RD) was said 
to have* occured. From thda state, recovery wap considered un- 
likely or impossible,. States short of. complete (RD) were des- 
cribed r s partial (RD) ,• ' 
Pollock et al, demonstrated in experimental specimens in cats 
that denervated muscle would respond to less current than normal; 
and that the threshold became progressively less for approximately 
20—4o days when it leveled off and remained low throughout the 
dernervatdd period. Certain specimens were observed for more than 
300 days. Furthermore, they showed that the threshold .required 
for contraction incr ased very abruptly after about 90 days in 
cases where the nerve wap repaired,. T*>e change occurred when 
axis cylinders reached the muscle, We have since confirmed this 
phenomena in raahy humans. One case was examined 11 years after 
division of the ulnar nerve and another 5 years after Injury, 
The paralyzed muscles.extracted to low thresholds of current, 
yet within;'4 months after suture the amount of current required 
for contraction was greatly increased. It was thought for a 
tine that this phenomena of low threshold would be adequate to 
determine the state of neurotization of muscle. This hope was 
short lived, however, for it wa8 soon apparent that local factors, 
such as edema, changes in the skin, temperature of the part, so 
common with war wounds, influenced the rheobase value sufficiently 
to render it unreliable. 
It has often been reported that muscle contracted only on 
making and breaking of the galvanic current; that during the 
flow of current, the muscle did not contract. Pollock and his 
colleagues have called attention to the fact that either normal 
or denervated muscle may remain in sustained contraction or teta- 
nus durinr the flow 0f current. This phenomena had been observed 
by many workers, but its significance in clinical .study escaped 
attention. It has now been shown that the current required to 
induce tetanus in denervated muscle is much less than in the nor- 
mal or recovering muscle. These workers have introduced the 
term "galvanic tetanus ratio" to sh~w the relation between the 
threshold current required for a minimal visible contraction, 
and that required for a sustained or tetani c contraction. This 
value is relatively uninfluenced by above mentioned local factors. 
Normal muscle requires a certain value of current to produce a 
minimal contraction. From three to six times this value is re- 
quired to produce tetanus. However, denervated muscle responds 
to minimal stimulation by a tetanus contraction, An other words, 
the same amount of current strength that causes minimal contrac- 
tion in the denervated muscle, alao cawfces tetanus. Perhaps 
the often mentioned "worr>-like" response of denervated muscles 
were merely incomplete and unsustained tetanus of this type. 
Galvanic tetanus rat .o !«■ determined by dividing the strength 
of galvanic current in nilliamoeres required to produce a constant 
or tetanic response in muscle by the minimal strength of the sane 
current required to produce a simple perceptible contraction. In 
normal muscle this galvanic tetanus ratio ranges from about 3,5 
to 6,0, In the denervated. muscle it reaches unity or value of 1.0. By this unity ratio is meant, therefore, that in denervated 
muscle the minimal stimulating current is the sane as that re- 
quired to produce tetanus, other words, when the minimal con- 
traction is a tetanus, the ratio is 1, The tetanus ratio changes 
with the state of innervation in this way—normal, 3.5 to 6; de- 
nervrting 6.0 to 1,0; denervated, 1,0 to 1,5; regenerating, 2.0 
to 15 to normal again, (Slide) This ratio will apply to the 
evaluation of peripheral nerve lesions as follows* A ratio of 
1,5 or below, ninety daya or more after injury with a lesion 
(25om) above the motor point, indicates continued denervation and 
an unfavorable outlook for recovery. Similarly, 100 days after 
suture, a ratio of 10,0 would be indicative of successful anas- 
tomosis, and that oerve fibers had reached the muscle. Time 
since injury is an important factor in determining the status of 
a nerve or muscle. The electro—diagnostic findings must always 
be considered in the light of the estimated rate of growth. If 
sufficient tine has not elapsed since injury for re-innervation 
to occur, a denervated picture may be noted even though regenera- 
tion is progressing satisfactorily. 
AH patients with peripheral nerve injuries admitted to the 
Neuro-Jkxrgical Section have received electro-diagnostic examina- 
tions prior to operation, Tn certain instances when electrical 
examination indicated that muscle fiberb were neurotired, opera- 
tion exposed a lesion which was considered incapable of satis- 
factory functional recovery. (Slide 2) 
For a tine this confusing, but following operation when 
resection and suture was done, the galvanic tetanus ratio fell 
to one, usually within 30-40 days. This indicated that certain 
fibers which were reaching the muscle had been removed at ooera- 
tion. Pathological sections of the surgical snecimens have shown 
that axis cylinders were nresent in the- distal end. This confir- 
med our previous exoectations concerning the galvanic tetanus 
ratio, but it also demonstrated the shortcomings of this method 
of examination, have substantial evidence that the galvanic 
tetanus is high or increased -"hen the nerve fibers reaching 
the muscle are too few and too immature to accomplish satisfac- 
tory restoration of function. Indeed it annears likely that in 
general rambling nerve fibers may bridge the gao of a divided 
nerve and produce evidence of neurotization. It follows there- 
fore that a single examination prior to operation cannot usually 
be absolutely relied unless there is evidence of complete 
denervation. Foil OK'ing operation when repeated examinations can 
be done, reliable evidence of regeneration can be determined 
weeks in advance of clihicnl recovery, (Slide 3), 
Our present analysis of electro-diagnosis may be summed up 
in the following way, Faradic stimulation is valuable only as 
a rough screening test. If a muscle response is obtained, no 
further electro-diagnosis is carried out. Failure to respond to 
faradic stimulation does not provide any kind of diagnosis. Ideally, re would like to have the values 
using galvanic current! 
. :^A?UAD 
1, Qal vanio-t - 
2, Strength duration 
L.'Vn 
3, ' Chronaxle • * . ) . r 
4," Response to reodtltJLve of frequencies. 
(Slide 4) All of thaaa values except the galvanic 
tetanus ratio, require apparatus which is used gener- 
ally not available at oresent. (Slide 3) • The galvanic 
tetanus ratio can be-determined on any reliable galvanic 
stimulator rhich is eouitroed *dth a well damned ammeter 
and a current control key r ich makes constant true 
contact. The well danced ammeter eliminates needle 
oscillations, thereby permitting accurate readings. 
The current control key sircld be independent of the 
electrode. (Slide 5) 
groW&HI AKD 0QUCLU3I01I8 
The inaccuracies of interpretation and the misleading use 
of reaction of degeneration studies has been presented, A new 
concent is discussed in clinical galvanic electro-diagnosis, 
that of galvanic tetanus ratio. This ratio nay be very simply 
determined by using any reliable galvanic stimulator. The Quotient 
or number obtained by dividing current strength required for 
tetanus by the current strength required for a minimal visible 
contraction is the galvanic tetanus ratio. The application of 
this galvanic tetanus ratio in determining the necessity for neuro- 
surgery on peripheral nerve injuries is discussed. Other 
values such as chronaxie, strength duration curve and repetitive 
stimuli supplement this procedure, but are not considered in 
detail here. By use of these electro-diagnostic values prognosis 
of the nerve suture may be determined long before sensory or 
motor return. A Study of Seventy-five Cases 
CAUSALGIA 
Captain Jack L, Ulmer, MC* 
and 
Lt, Col. Frank H. Wayficld, MC* 
The term "causalgia" was first used by Mitchell, Morehouse, 
and Keen1* in 186A to designate a bizarre symptom complex oc- 
curring after injury to peripheral nerves. The mein features 
of this symptom complex are severe burning pain and hyper- 
esthesia, in association with trophic and vasomotor changes 
in the injured extremity. Little is known about the funda- 
mental cause of this condition, and the theories advanced to 
explain it are so numerous that no attempt shall be made to 
develop them. Suffice it to say that in certain individuals 
following injury to one or more peripheral nerves a painful 
reflex mechanism is set in motion which is accompanied by ab- 
normal vasomotor activity, varying, degrees of 
vasodilatation or vasoconstriction. Relief cm oe obttmed 
in most instances by surgical interruption of the appropriate 
sympathetic pathways. 
In this paper we present the data from 75 patients who 
showed this symptom complex. Fifteen of these cases have 
previously been reported by Lt. Col, Mayfield with Capt. 
(Slide ;, These 75 cases were encountered in a 
series of 1A77 peripheral nerve injury coses admitted to the 
neurosurgical service of Percy Jones General Hospital from 
January 15» 1943, to May 31, 1945, an incidence of approxi- 
mately 5 pm cent. Three patients were officers and 72 enlisted 
men. The ages ranged from 19 to 39 years. 
(Slide #2), The peripheral nerve injury was incomplete 
in every instance and resulted from penetrating shell fragment 
or bullet wounds. The sciatic nerve was involved in 29 cases; 
the median in 16 cases; the brachial plexus (predeminently the 
lateral and medial cords) in 13 cases; the median end ulnar in 
eight cases; the median, ulnsr, and radial in three cases; the 
tibia1 end peroneal (below the knee) in two cases; the tibia! 
in t-o cases; the median and radial in one case; and the femoral 
nerve in one case. The nerve injury was proximal to the elbow 
or knee in 66 cases (88 per cent) and distal in nine cases 
(12 per cent). No patient had accompanying major vascular 
injuries. 
In 4A of the 75 cases the burning pain developed immedi- 
ately after the injury, in 14 within the first 4.8 hours, end 
in the rest (17) in from 72 hours to two months. The symptoms 
had been present for periods of time ranging from 3i weeks to 
15 months. majority of cases were treated within four 
months from the time of injury. 
♦Percy Jones General Hospital, 
Pattle Creek, Michigan, Symptom? snd_Sjgnf 
Thr cardinal symptom in each case ref burning pain of 
a throbbing or aching character, The pain T’a? always referred 
to the distal part of the involved extremity and was not con- 
fined to the. autonomous zone of the injured nerve though it 
was usually, more intense in that zone. In the hand it was 
referred chiefly to the palms and fingers? in the foot, to 
the instep, sole, and toes. The intaneity varied from lees 
severe states to the unbearable. The pain was continuous 
but subject to exacerbation by the clightest emotional or 
physical stimulus, and most of these patients appeared in a 
perpetual state of defense and went to absurd extremes to 
protect the painful limb. Tbs severity of the pain rendered 
an accurate assessment of the nerve injury impossible in many 
cases. 
The vasomotor manifestations were of two types, vasodila- 
tation and vasoconstriction, and in no cose was there notice- 
able alteration in the type rhiie the patient •■ae under our 
observation. (Slide The skin of those in vasodilatation 
The skin (Slide #5) of those in vasoconstriction ras usually 
cold, thin, end glistening, and sweated profusely. In this 
group there was us\:slly loss of heir, tapering of the digits, 
and trophic changes in the nails. 
Sixty-eight of the seventy-five patients obtained some 
•relief from the application of moisture. Thirty-eight preferred 
where there- was vasoconstriction and cold where there ras 
ye sodlietation, (Slide #C), (This patient inadvertently 
blistered kle hand by submerging it in hot vater to secure 
relief from the burring pain.) 
Most of these extremities shored gradation? of Joint 
stiffness brought on by painful splinting and disuse. This ras 
one of the greatest residuals after the relief cf pain but 
proved amenable to physical therapy if treated eirly. 
In the more severe the patients were usually 
malnourished because of low food-intake. 
Most of these patients were irritable, shut-in, critical 
of attendants, and showed no interest in family or friends even 
though they had beer overseas for many months,* (Slide #7), 
Their faciei expression manifested evidence of anxiety, weari- 
ness, and distress. These findings suggested that the disorder 
might be functional, sc psychiatric examinations were carried 
put in some of our patients before and ?fter opefrticn (Slide 
#8). After relief of the prlr, all appeared essentially stable 
and normal, and without exception they became pleasant, cooper- 
ative, and happy. In our cases there was no evidence of any 
definite predisposing constitutional factor responsible for 
the development of this syndrome. There appeared to be no correlation between the severity 
of the nerve injury end the intensity of symptoms, The nrrve 
lesion was incomplete in each case. 
Method? of Study 
These patients were studied tc correlate subjective 
symptoms and trophic disturbances with blood flow in the in- 
jured part. Blood flow was determined by means of oscillo- 
metric and shin temperature readings in the first 1$ cases and 
by skin temperature readings aiem1 in the rest. Those in 
vasodilatation usually showed skin temperature readings from 
one to four degrees higher than readings of corresponding areas 
of the normal extremity; those in vasoconstriction showed 
readings from two to six degrees lower. 
One patient in vescconstriction devcloped malaria 
(Plasmodium Vivax) and during the periods of elevation of 
temperature ’-as completely of pain. The pain returned, 
however, the malaria was controlled, because of this 
observe tier, artificial fever therapy wos tried in five 
patients, cne whom remained ""ell after three treatments. 
The others received ss many ts five treatments, with relief 
for the period of elevated temperature only. Subsequent sym- 
pathectomy was followed by relief in those four patients. 
X-ray of the painful part was made in 2C cases. Each 
showed some degree of demineralization of the srrr-11 bones of 
the hand or foot •• contracted to the normal. The changes were 
more marked in those in vasodilatation. However, the deminer- 
alization appeared ro more pronounced than in cases of com- 
parable nerve injuries without causalgia. 
Treatment 
Seventy-two of our patients were treated by surgical 
procedures, — seventy by surgical interruption of the sympa- 
thetic chain,.,which included.preganglionic ramisf-ctomy of the 
second end third dorsal ganglia “or the upper extremity end 
removal of the second, third, and fourth lumbar ganglia ftr 
the lower extremity. Sixty-three of the seventy were cured 
by the initial operation. 
Two patients with severe but incomplete lesions of the 
sciatic nerve were treated by resection of the injured segment 
and neurorrhaphy. This procedure relieved the pain in both 
instances. 
In every case, procaine block of the appropriate sympathetic 
ganglia wss done before definitive treatment was carried out. 
This procedure invariably g've immediate and dramatic relief 
of the pein for periods ranging from one to three hours, but in 
most patients it reached its previous intensity in a very short 
time. In c few, partial relief persisted for several days. 
During the period of remission, the pftient became cooperative 
and permitted a more thorough sensory and motor evaluation of tthe involved extremity, whereas examination wa.s unreliable before 
the pain was relieved.' Frequently, where no notor function 
had been observed previously. the patient begm toneve the ex- 
tremity immediately* - This Suggested that in some of the cases 
the pain had initiated a reflex paralysis (Livingston?*), 
Since numerous reports have been made of permanent cures 
from one or more sympathetic blocks, some patients were injec- 
ted four to six times. There was always imediate relief of 
the pain, but no pat.ient obtained complete and permanent relief 
from this procedure. However, the sympathetic block served 
two useful purposes: First, by relieving the pain temporarily 
a more accurate evaluation of the nerve Injury was obtained; 
and second, it established the indication for sympathectomy,. 
In the last .55 cases, this procedure was used for diagnosis 
only. 
Neurolysis was done In five eases and periarterial sym- 
pathectomy at the level of the injury in three cases, but the 
pain was not influenced by these procedures. Later these pa- 
tients were synpathectomised, with relief. 
Discussion 
In each case of this series, symptoms resulted from high 
velocity missile wounds of large nixed peripheral nerves and 
we feel that they represent true cousalgia, Form time it 
was felt that causalgla was a distinct entity, but the under- 
lying disorder is no doubt related to that of a heterogeneous 
group of painful pesttraumatic dystrophies, including Sudeck's 
atrophy, pesttraumatic painful osteoporosis, and other so- 
called mirror causalgia* (Homans *), The chief difference is 
one of degree, perha.ps, varying with the size of the nerve 
Involved, 
The vasomotor disturbance was of two types, vasodilata- 
tion and vasoconstriction, Thirty patients of this group 
were in vasodilatation and 35 in v-soconstrictlon, The sub- 
jective symptoms were identical but the objective signs varied, 
yet interruption of the sympathetic chain relieved the pain 
in both groups. Therefore, it would appear that alteration 
of blood flow was not responsible for the pain. 
In the majority of our cases the intense burning pain 
occurred immediately after the injury, which rules out infec- 
tion and irritative scar formation as significant etiologlc 
factors. In fact, with rare exception the traumatic wounds 
healed without gross infection. 
The trophic manifestations in some cases were essentially 
the same as those seen in conparable nerve injuries without 
causalgia, but the secondary Joint changes with resulting 
fibrous ankylosis were more severe because of voluntary im- 
mobilisation of the painful extremity. Seven patients of this group failed to obtain complete 
relief from the initial operation upon the sympathetic chain. 
Five were patients with wounds involving the sciatic nerve at 
the buttock or above. Removal of the second and third lumbar 
ganglia had been effected in each case. Subsequent removal 
of the first lumbar ganglion in three of these resulted in 
complete cure. In two, removal of the eleventh and twelfth 
dorsal and first lumbar ganglia were required. In the other 
two cases which involved the upper extremity, incomplete sym- 
pathectomy was done at the initial procedure when the fourth 
rib was removed instead of the third. One patient was then 
relieved by neurorrhaplbyof the median nerve. In the other 
case, neurolysis of the eighth cervical and first dorsal roots 
did not affect his symptoms. However, he has since improved 
to the point where no further surgical interference seems 
Indicated. 
Those patients not relieved by the initial sympathectomy 
showed evidence of incomplete sympathetic denervation, not 
only to the area of referred pain, but to the area of injury. 
This was verified by sweating in these areas as shown by 
starch-iodine tests and evidence of lowered skin resistance 
to electrical conduction. This has been more noticeable in the 
eases involving the lower extremity where the injury was high 
in the thigh. 
From these observations, it would appear that the sympa- 
thectomy must include the injured segment of n*=rve. However, 
the possibilities of anomalies of the sympathetic chain must 
be considered. It can be stated that removal of the second, 
third, and fourth lumbar ganglia may be inadequate for lesions 
high in the thigh. In these cases it may be necessary to remove 
the first lumbar as well as the eleventh and twelfth dorsal 
ganglia. For lesions of the upper extremity preganglionic sym- 
pathectomy of the second nnd third dorsal ganglia is necessary. 
The segment of the sympathetic chain removed has been identi- 
fieddpostoperatively by x-ray through the use of a metallic clip 
on the proximal end of the chain when the lumbar opf ration was 
done and by identity of the rib removed when the dorsal opera- 
tion was done. 
Various medical and surgical treatments have been advocated 
for the cure of causalgla but in our experience surgical inter- 
ruption of the appropriate sympathetic ganglia has been the 
most effective procedure. It has provided relief in ep,ch case 
nnd has the advantage of carrying a minimal penalty, in contrast 
to more radical surgical procedures such as regional injection 
of alcohol, rhizotomy, and chordotomy. 
Summary and Conclusions 
The data from 75 cases of causnlgia due to war wounds of 
large mixed peripheral nerves have been presented rnd the 
following conclusions are drawn. 1, The pathologic mechanism is obscure. 
2, Th,e disorder is characterized by burning pain in 
association with vasomotor disturbances In the distal part of 
the extremity. 
3, The vasomotor disturbances- are of two types, vasocon- 
striction or vasodilatation. The possibility that the vasomotor 
state may vary in any case is recognized but has not been observed. 
4. The pain can be relieved by appropriate, sympathectomy. 
The sympathectomy must be complete, horever, and with lesions 
involving the upper portion of the scietie nerve removalcf the 
sympathetic chain as high 'as the eleventh dorsal ganglion may 
be required, For lesions of the bpper extremity preganglionic 
operation is adecuate, - 
Procaine block of the appropriate chain is a necessary 
diagnostic procedure. 
6. Repeated procaine block as a therapeutic agent has not 
been effective in our hands. Certain patients have improved 
with this procedure, but none have been completely relieved. 
7. Resection of the injured segment of, nerve will provide 
relief. Neurolysis and periarterial sympathectomy at the level 
of the injury are ineffective. 
8, .Sympathectomy should be done as-sapn as the diagnosis 
is established, to prevent the psychic trauma of prolonged pain 
and crippling joint stiffness. 
9, :Gausalgia has beer noted only with incomplete nerve 
lesions, • ' 
10, Recovery of function is often rapid after relief of 
pain, Consecuertly, primary neurorrhaphy Ip rarely indicated. 
NOTF: Our series of causelgia cases treated by sympathectomy 
now total 102 cases es of .October 31, 1945, and the. results and 
conclusions remain tha same. For the some period 2205 cases of 
peripheral nerve injurisa,were admitted. 
Sslgrgpg.gr 
1, Mitchell, S, ?,, Morehouse, G.R., and Keen, F.H.i 1864 
* Gunshot founds and Other Injuries of Nerves, Philadelphia, 
J.B, Llppincott Co, J 
2, Mayfield, Prank H., and Devine, Jphn f.i Surg,, Gyn,, and 
Obat.: 1945» 0O» 631. 
3. Tinel, J. Rev. Neuro., Paris, 1919, 26» 521-526. 
4. Livingston, f.K, Pain Mechanism, 1943, The Maollillan Co, 
5. Homans, John. Ann. Surg., 1941, 113i 932, THE POSITION OF THE PSYCHOLOGIST ON THE PSYCHIATRIC TEAM 
let Lt. Bernard D. Rein* 
2d Lt, lilliam Brown* 
2d Lti Maynard Allyn* . 
It is the purpose of this paper to describe the role and 
functions of the clinical psychologist in a psychiatric team. 
Until the end of 1942, there were only six psychologists in 
the Medical Service of our Army, It was not until 1943 that 
clinical psychologists were being used as such in several of 
the general hospitals and some mental hygiene clinics, With 
the expansion of the Neuropsychiatric Service as presented in 
a Tar Department Bulletin 3 Augustl944» the clinical psycholo- 
gists were made pert of a psychiatric team with specific duties. 
In this directive it states Mthe combined efforts .of psychia- 
trists, psychiatric social workers, clinical psychologists, 
occupational therapists, instructors in arts and skills and 
reconditioning officers and instructors ore needed to make 
the program succeed.* 
The present organizational plan of the ncuropsychiatric 
section of the Convalescent Hospital is that of a regiment 
with four battalions. Each battalion is further broken down 
into four companies, each with a capacity of 100 patients. 
Hence, at maximum capacity, there would be 1600 patients in 
the neuropsychiatric section. There are 11 commissioned psy- 
chologists end 10 enlisted psychologists allotted to assist the 
psychiatrists in the diagnosis and treatment of a possible 
1600 patients. 
At the regimental level there is a chief clinical psycholo- 
gist who is the psychological consultant to the commanding 
officer of the regiment. The commanding officer is also the 
Chief of the neuropsychiatric service of the Convalescent 
Hospital, The duties of the Regimental Psychologist are 
primarily to supervise and coordinate the psychological pro- 
gram for the four battalions. He holds weekly meetings in ’ 
which each psychological unit of each battalion may express 
itself as to improving the psychological services. Results 
of techniques and methods used by the different psychological 
units are discussed and modifications may be made to attain 
the best ones so that the psychologist will make a maximum 
contribution to the psychiatric team. He puts into effeet 
policies and plans bearing on psychological work that the 
chief of neuropsychiatric service may request. 
The Regimental Psychologist has the secondary but major 
duty of also being the Regimental Officer which places him in 
the position of coordinating the program for the regiment. 
♦Percy Jones Convalescent Hospital 
Port Custer, Michigan, Since the daily activities made available to the patients ore 
a large component part of the treatment given the neuropsy- 
chiatric patient control by the professional staff is essential. 
The psychologist is able to aid the chief psychiatrist in seeing 
that at all times, the several aspects of the daily program are 
observed for their effect upon the neuropsychiatric patient, 
Frecuent meetings with the chief psychiatrist result in certain 
types of films being censored, extreme types of physical re- 
conditioning being barred, rhereas general athletics are 
encouraged, more time is made available for group and individual 
therapy, 'Also os regimental operations officer, a close liaison 
is kept with the occupational therapy and educational and physical 
reconditioning sections of the Convalescent Hospital, 
At the battalion level, there are Usually two commissioned 
and two enlisted psychologists in each battalion. It is at this 
level that the real psychological work is done. The battalion 
psychological unit performs three main functions! one, psycho- 
metric ej two, individual and group therapy; three, vocational 
counselling and placement. All three functions are closely, 
coordinated with the psychiatrist and the psychiatric social 
worker. 
The commissioned psychologists In each battalion are \ 
experienced and well-trained in the administration and inter- 
pretation of a variety of tests. Many of the enlisted personnel 
are equally capable. No longer is the psychologist limited to 
determining on I,C,» measuring the educational achievement, and 
discovering the vocational interests or aptitudes of a men. 
Of greater importance are the methods and tests used cs diagnostic 
aids and personality evaluators. The psychologist's armamentarium 
includes: The Rorschach Psychodiagnostic, the Bender Gestalt, 
Sentence Completion Teat, the Shipley-Hartford Test for Mental 
Deterioration, The Bellevue-Wechsler Intelligence Scale, The 
Kudcr Vocational Preference Test and others. 
Many of our psychiatrists, particularly in the early stages 
of the program, were unfamiliar: with the teste used by the psy- 
chologists and the value of the interpretations. However, the 
psychologists have done a good job of selling and propagandizing 
the psychiatrists. Today our psychiatrists appreciate the 
assistance of the psychological units, and what is more, they 
know exactly which tests to request for the specific information 
desired. Some have reached the point of confidence in the 
psychologist at which they request information ancl let the 
psychologist decide his methods end means of arriving at the 
answer, 
Tests ere usually administered only upon the request of 
the peychiatriet with the exception that all men who received 
a Grade V ecore on the AGCT are given the Bellvue-Wecheler • 
Intelligence Scale, The reeulte and interpretation of the 
teste are written up and become part of tke medical chart. The results of the teste plus the case histories made by the 
psychiatric social worker give the psychiatrist a most complete 
personality configuration when added to his own observation. 
All new patients, in the course of their processing, are 
seen by the psychologist. If at this time the psychologist 
notes any man to be unfit for an immediate furlough he con- 
sults with the psychiatrist and psychiatric Social worker 
regarding him. The psychologist is aided in his estimate of 
the patient by quick screening devices such as 
Gestalt and Sentence Completion tests. Occasionally we will 
get men who don’t want furloughs or are frightened about 
going home even though they may have been away from home for 
two years or more. They feel the stigma of being ’’nervous" 
is more than they can stand among family and friends. Here 
the psychologist does much to reassure the man, renew his 
confidence in himself and prepare him for a really good time 
while on furlough. Now that the war is over and there is no 
need to return ,cen to duty, the patients are urged to use at 
least part of their furlough time for making post-army plans. 
Once a neurotic starts planning and knows there is a job 
waiting fer him upon discharge, many of his anxieties and 
tensions disappear. However, this creates another problem 
upon their return. They feel that they are completely well 
and should be discharged immediately. When this is not poss- 
ible, their tendons and anxieties start all over again. This 
makes for a good therapeutic setting during which you can point 
out to the man what he allows to happen when he meets frustration. 
When he returns from furlough, the man is guided into the 
school program from which he will derive the most benefits both 
vocationally end therapeutically. This will be discussed more 
fully in a later paper. Those who have absolutely no plans, 
no skills or training, or those whose vocational or job prob- 
lem calls for greeter industrial contact then we have, are 
referred to the vocational section of the convalescent facility. 
In the treatment field the psychologist has been able to 
make a good contribution. Under supervision of the battalion 
psychiatrist he has been able to carry a full load of group 
therapy. The psychologist has been especially well adapted 
to the preparing of topics and carrying on group therapy. As a 
therapist he is well able to present an elementary discussion 
of the anatomy and physiology of the nervous system. He can 
discuss the symptomology of the group. He can intelligently 
present the concepts of fear, emotions, personality, mental 
conflicts, the unconscious and many others. 
Whenever an individual can not derive benefits from group 
psycho-therapy and can be helped with individual therapy, the 
psychologist can be of assistance to the psychiatrist. In many 
cases the psychologist is well qualified in giving insight to 
individual problems. With his knowledge of learning he can 
help a patient develop confidence and a sense of security*. 
Fine*3 he is able to place men in the Convalescent Hospital 
program he can integrate the patients activities toward his 
getting well.  PSYCHOLOGIST 
Discussed by Captain Ray S. Miller, 
Armed Forces Induction Station 
Chicago 
To anyone wh£ has observed the activities of the Con- 
valescent Hospital at Percy Jones it is evident that the 
authors of this paper have done an excellent piece of work 
in delineating carefully the functions of the clinical 
psychplogist on tfce psychiatric team. Since the paper also 
serves to lay the groundwork for other papers which follow 
it, we should try to avoid emphasizing at this time specific 
problems in diagnosis or therapy which will be considered in 
later papers or discussions. 
As one reads the paper it is well to keep in mind some 
problems of a general nature with which the members of the 
team have to contend in carrying out a program of this kind: 
1, Censorship of films at the.regimental level, Wien 
we consider the individual quirks of a neuropsychi- 
atric patient we see what a problem it is to provide 
censorship whiah will accommodate an entire group. 
2, There is the problem of the general athletic program 
which mvst now be adapted to winter weather and 
carried on largely indoors. 
3, The authors mention "selling and propagandizing the 
psychiatrists" on the use and value of tests. Since 
this discussant is not a clinical psychologist in 
the technical sense of the word it is in order to 
suggest that the psychiatrist has been sold first of 
all on the skill and efficiency of the clinical 
psychologists who have been assigned to work with 
him. The effectiveness of the team work outlined in 
this phper probably depends more upon the individuals 
of the team than upon the tools with which they work. 
4, To some extent, the therapeutic program must take 
into Account problems in connection with the patient*s 
free time, e.g., his evenings or weekends. 
5,, There is alao the problem of how much time shall be 
spent in the enlightenment of the patients1 families. 
Undoubtedly many families would prefer to see their 
sons come home "heroes" rather than patients in what 
they might call a "mental" hospital. 
6, At die point in the paper the psychologist as a group 
therapist is mentioned as presenting "an elementary 
discussion of the anatomy and physiology of the nervous 
system". There is the possibility that this type of discussion, although elementary and non-academic, 
might require a group of better than average in- 
telligence and thet seme therapists might achieve 
equally satisfactory results without mentioning these 
organic backgrounds* V 
7. To what extent bas e shortage of ti*# been a problem? 
. These team members must have pressures from the 
• patient1s home community or froi* ’the patient him- 
self which would tempt them towtop short of' a satis- 
factory reconditioning. 
8, That were the results* if any, of the announcement 
of the cessation of hostilities on V-J Day? In this 
connection we will recall the reports of the sudden 
clearing of some hysterical conversions immediately 
after the Armistice, in November of 1918. 
9* And finally, those of us who have spent a considerable 
amount of time in Induction Stations can not refrain 
from asking bow many of the patients are war casualties 
in the real sense, and how many of them should never 
have been Inducted in the first, place? 
Certainly all of ua hope that the team work outlined in 
this'paper demonstrated the value of coordinating the activities 
of se many professional interests and that such team work will 
be carried over into our institutions and industrial organisa- 
tions in civilian life. ‘ EDUCATIONAL VOCATIONAL RECONDITIONING* 
Lts. J. j, Lasky, F. Kobler, and U, K, Vfineberg, A.U.S. 
This paper will discuss first, tho objectives of a convalescent 
hospit 1 school program for paychoneurotics, second, a description of the 
courses offered and third, an evaluation of the benefits of such .a progjv'xi. 
The tern. Educational Reconditioning, is intended to mean a process of. 
stimulating the ;.iinds of convalescent patients through education and infor- 
mation in an effort to encourage mental attitudes conducive to health ;nd 
norrrl activity. This general air. is accomplished through -tho- media of.an 
extensive school system, vocational - educational guidance, and orientation 
talks on current topics, . The educ .tionr.l-vocntional reconditioning phases 
of the convalescent program in the J-teuropsychiatric regiment of Percy Jones. 
Hospital Center at Fort Custer, JfiLohigan, .occupies approximately, of. 
tho patients' treatment time, • • ‘ 
Tnis program is somewhat unique in its application and purpose. The 
experiences gained during the past 13 months are offered for consideration * 
in bui3.ding efficient and practical group treatment programs for psychiatric 
patients in the future, ' ' - ■ . . 
Initially, the patient is occupied for <n entire day after his conval- 
escent furlough in becoming oriented to the program. During the rooming he. 
is informed of the opportunities offered by the educational program, ,.Ke 
then uses.the latter half of the orientation day in taking a conducted tour 
through representative schools. In this way, the patients gain an overall 
first-hand picture of the program before, they, are required to make a1 specific 
selection. The patient is encouraged to interest himself in; the educational 
phases of the program for the following four reasons or objectives. 
First, .It offers trial introductory training 3* taohnleal skills that 
may either explore capacities, skills, and aptitude*’or may further lead to 
successful rehabilitation and useful employment. The basis of the instruc- 
tion offered is intensely practical .and devoid of pedantic-impedimenta. 
The beginner is permitted to make definite progress toward further civilian 
education or job training. The’ course nay serve as a refresher for other 
/non with some experience in order to get back the feel of nld terns 
and practices, It will enable advfineed students to progress from whatever 
achievement they nay have made to higher levels in their particular fields. 
For the undecided, the course may be exploratory. A definite appeal may be 
discovered, or tho discovery of the lack*of such an aptitude in.a particular 
field may save a man tine and money later. 
Secondly, it redirects the soldier's thoughts away from a narrow "sick" 
concept to a realistic attitude of being useful, capable and independent, 
Tho convalescent hospital is the last stop ir> a long hospital chain,' Up to 
this point, the patient has been in a formal hospital setting for a period 
of several ; vonths. A frequent complaint from these neurotic patients is that 
the inactivity often attendant with formal hospitalization breeds tension and 
ennui. Here, in an nmy comp sotting, the patient is given useful -and . 
appropriate mental stimulation similar to that he will encounter in his 
community. 
*Percy Jones Convalescent Hospital 
Fort Custer, Michigan Thirdly, it provides opportunities for general education which will 
enable individual soldiers to continue educational pursuits interrupted 
by entry into the ar;ied forces. The United States Arried Forces Institute 
correspondence courses on high school and college levels offer excellent 
instruction in the iaore academic studies. The near-high school graduate 
can refresh or complete his high school credits and perhaps investigate 
freshnan college subjects. Itie college stuaent can earn college credit 
while still in the aniy. On a lower academic level, there are classes 
for illiterates in elementary reading and writing. If an individual ex- 
presses interests not included in the school program, he nay be assigned 
to study in the library or be encouraged to use his own materials in an 
adequate study room. 
Fourthly, it maintains liaison with public and civilian agencies 
charged with the rehabilitation and the adjustment of the soldier to 
civilian life. One course of study covers Civil Service opportunities and 
exa'iines sample Civil Service tests. Through the orientation program the 
patient will cover a selection of topics taken from the provisions of the 
G. I, Bill of Rights, from publications of the Veterans Administration, th! 
United States Employment Service, and various state and local agencies. 
After the patient's day of orientation, he visits the psychologist and 
■~iakes an educational selection or vocational alternative. The guidance by 
the psychologist, like the balance of the therapy, is based on a study of 
the total individual in a total setting. Such factors as current vocational 
opportunities, illness of the pptient, personality factors, intellectual 
capabilities, and the anbitions and interests of the patient are weighted. 
This information is gained frou clinical observation, study of the previous 
clinical history, and noting current labor trends or opportunities. 
Patients requiring nore intensive guidance my be given personality, voca- 
tional and/or intelligence tests in order to arrive at nore reliable and 
useful vocational and educational guidance. Initial guidance and selection 
nay be modified to suit the changing interests and capabilities of the 
patient at any tine during the patient's stay. Modifications are based on 
-addition*!.! clinical experience gained in therapeutic interviews, further 
vocational study, and actual try out in specific courses. 
1*10 patient nay choose courses from three areas of study; pro-techni- 
cal, pro-cultural, and pre-professional. The courses, in order of patient 
popularity, are as follows: Auto; active, Typing, Welding, Carpentry, Machine 
Shop, Agriculture, Business Administration, United States Arned Forces 
Institute correspondence courses, Hadio, Mechanical Drawing, Photography, 
Motorcycle, Salesmanship, Commercial Art, Plumbing, Business Law, Printing, 
and Fine Arts, 
In a study based on 441 men from each of the five battalions in the 
regiment it was determined that of patients tested believed that the 
school program contributed in making them feel better. 
One patient expressed himself by saying, 'When I do something I like 
I forget myself and become interested in what I’m doing. This makes me feel 
better after I’m through with it,” Another nan states that, »!7hen a nan nakes an object that he 
takes hone to his wife or to his nother and she sees and admires it, 
he feels that he has "done something that’s of some use and that builds 
him up." 
Another good effect of the program expressed by the patients is that 
it acted as a socializing influence. Observing a group busily engaged 
seemed to be a spur to engage in cooperative constructive activity. 
Attacking this problem from another direction, instructors were inter- 
viewed and the following are some representative statements. 
An Occupational Therapy instructor stated that, "Self-creativity is 
built up in a nan who has been pushed around and doesn't have any con- 
fidence in himself." 
It is interesting to note that nixing psychoneurotic patients with 
physically disabled patients, as is done in a few of the courses, resulted 
in greater interest and better morale, /nother Occupational Therapy in- 
structor stated, "When we nixed the groups fron the two regiments, the 
cheerfulness of the ones in the second regiment (physically disabled) 
influenced those in the first regiment (psychoneurotics) and they took 
after then and began to work harder at what they were doing after a while,” 
Thus far we have been considering; the opinions of the 5U% who feel 
that the educational program is aiding in their recovery. Incidentally, 
the instructors believe that 50 to 705S of the students benefit from the 
instruction offered. 
It would appear that not every patient and instructor feels that 
school participation is necessary. There are at least nine such groups 
of patients. 
First, there are thos-e who are returning to occupations they left 
prior to induction. The value of off-duty hobbies and recreation through 
the arts and crafts is emphasized to this type of individual. It is known 
that this type of neurotically predisposed individual will materially 
benefit fron the interest and relaxation such pursuits afford in the 
civilian adjustment period. 
A second group insists that they are unable to attend school because 
of disinterest, lack of concentration, and restlessness. The therapeutic 
benefits of regained interests, goals, planning for the future and purpose- 
ful activity is emphasized to this patient and he is carefully followed up. 
Occupational therapy, with its more personalized instruction and individual 
projects is often a good solution for this type pfitient. 
A third group, men who are older than the average, are at first 
reluctant to "go back to school" again. These individuals are told that 
the school is a school in name only. It is primarily an integral part of 
his treatment program and its benefits are explained to him. In a fourth group are a few individuals who have psychopathic 
tendencies and have adjusted with difficulty during most of their lives. 
Because of their resistance as reflected by absenteeism and attitudes, 
alternative jobs more in line with their personalities are selected. In- 
cidentally, the motorcycle school with its outdoor work has been very 
valuable in releasing the aggression this type of individual exhibits. 
A large fifth group of men are represented by the soldier who stated, 
"The essence of the natter is that sono soldiers feel that they went and 
fought a war, now they want to get home, They see this schooling as an 
interruption in getting hone,'• The reality of the situation is presented 
to these nen. They are told they will be here for treatment and observa- 
tion because they have been upset in the past. If they were perfectly 
well they wouldn't have been sent to us, A large part of their conval- 
escent recovery and future health depends on attitudes and mental set 
during their stay here. 
A resistant sixth group strongly dislikes the army and ail things 
connected with the army. It is not the province of the educational system 
at this level to treat specific adjus.ti.iont and attitudinal problens. This 
work is better handled in group and individual psychotherapy sessions* It 
is felt that when anxieties and agressions are relieved, attitudes are 
nore amenable to reason. 
A seventh group are the tally dull who are well adjusted on the 
lowest vocational levels. Such men willingly engage in such constructive 
activity as*barracks orderly, supply helper, charge of quarters, etc. 
An eighth group aro those few men who arrive at this hospital in 
need of no further hospital treatment. Any further delay would be point- 
less and irritating so these men are dispesitioned prorptly. 
Ihe ninth group of patients who don*t seen to benefit fron the 
progran are those whoso min conflict areas center around unsolved domestic 
and hone problens that demand their personal intervention. Such nen are 
properly dispositioned as rapidly as possible. 
It appears that the majority of the patients who feel they don't 
benefit by the school program are in need of further explanation and under- 
standing as to the purposes and values of the educational system. 
In summary, the educational reconditioning program assists in taking 
the emphasis off a sick individual in a hospital setting and centering his 
focus on healthy ego ideals, his future job, his independence, and self- 
sufficiency by means of mental stimulations and socialization. The good 
results obtained from this type of program indicate that it is a necessary 
component of an adequate treatment program for psychiatric patients. DISCUSSION 
Educational Vocational Reconditioning 
Dr, Richard 1U Pago, Chicago, 111. 
I an certain that it is not poesible to convey in a paper a clear 
and adequate conception of the operation and benefits of as broad a progran 
as the one' described by Lieutenants Lasky, Kobler, and Wineberg. To appraise 
the'*plan intelligently, one should have an opportunity to actually visit the 
school, observe the classes, and talk with the teachers and with1the student- 
patients. 
Lacking this opportunity, the listener is still very favorably impressed 
by the general description, and finds gratification in learning that our men 
in need of rehabilitation are being offered such excellent opportunities of 
finding mental health through education. 
A program such as the one described has,.of course, ample theoretical 
as well as practical support. It is unnecessary to defend the soundness 
of educational, occupational, or recreational work as therapeutic procedures. 
In giving detailed consideration to the paper, however, several points 
appear concerning which one night wish for more information. 
One point which strikes the listener as being open to question is the 
apparent imposition of authority and pressure upon the patient in some 
phases of the program. It was reported, for example, that patients are 
required to make a selection of courses after just one half day of orienta- 
tion. This would appear to be a rather short time for some patients to be 
able to find thexiselves, and oven with psychological guidance, there night 
appear to be some hazard involved of forcing a premature decision, • 
One also gains the impression that the counseling itself nay be highly 
directive or even coercive in character. It is described as '’guidance, , 
based on a study of the total individual in a total setting.” If there is 
provision for the development_of independent insight on the part of the 
patient, such provision is at least not made clear. In fact, some reference 
is made to "patients who require more Intensive guidance," which appears to 
emphasize the coercive aspect of the counseling. 
The handling of six, types out of the nine types of patients who do 
not accept the therapy willingly also indicates varying degrees and types 
of pressure upon th§ patient to conform to the program. 
Broadly speaking, the program is constructive, wholesome, and pro- 
gressive. In view of the mass demands that are made upon it, and in view 
of the special problems entailed by the military setting, the entire project 
is most gratifying. The question still remains, however, whether less 
directive techniques could not bo worked out in the psychologist's contri- 
bution to the program. AN ANALYSIS OF THE USES OF TOE SHIP LEY-HARTFORD RETREAT SCALE 
FOR MEASURING INTEUECTUAL IMPAIRMENT 
Joseph W. Goodrich, 1st Lt,, AGD* 
Raymond A« Thurow, 1st Lt,, Ord, Dept* 
Frank Kobler, 2nd Lt., MAC* 
You have been told southing about the role of the psychologist in 
a convalescent hospital. You have heard a review of some of the psycho- 
logical techniques which are utilized in our work. Ihis afternoon I want 
to describe in more detail the uses we have made of one particular tost, 
the Shipley-Hartford Scale for measuring intellectual impairment. 
Ihe Shipley-Hartford was designed as an aid in detecting mild degrees 
of intellectual impairment. It may also be used as a rough- measure of 
intelligence. It is a simple paper and pencil test made up of two parts, 
vocabulary and abstractions. It is based on the clinic©-experimental 
observation that in mental deterioration and other conditions involving 
mental impairment, vocabulary is relatively unaffected, but the capacity 
for abstract (conceptual) thinking declines rapidly, This scale, then 
measures the extent to which the individual’s level of abstract thinking 
falls short of his vocabulary level. This difference is expressed conven- 
iently in the C.Q. or conceptual quotient. It is the ratio of the patient’s 
vocabulary age to his abstraction age. The conceptual quotient in itself 
tells nothing of the permanency of impairment. In some conditions the 
impairment will be transitory, in others, especially deterioration, it 
will be permanent or progressive. 
This scale may be administered individually or in groups. It requires 
no personal attendance for each case. The directions are self-explanatory. 
It consists of two parts, each of which must be answered in a maximum of 
ten minutes, but the final analysis of the results is not dependent entire- 
ly on the number of parts answered. The tost is based on an analysis of 
the vocabulary level as compared with the power of abstract judgment. The 
first portion of the test consists of forty words, for each of whifth are 
given -four words from which one appropriate synonym must be chosen and 
underlined. For example: Permit: allow, sew, cut, drive. The second 
portion of the test consists of twenty questions, all based on abstract 
reasoning. Each question consists of a variable number of words, phrases 
or letters which have some common characteristic which must be discovered 
to complete the answer. For example: Complete the following: white black, 
short long, down , 
Ihe scale was standardized on 1500 normal and psychotic individuals 
and from the results tables were evolved from which can be calculated or 
read the C.Q., vocabulary, abstraction and mental ages. Of the results, 
the most important is the C»Q, which assumes parity in the development of 
the vocabulary level and abstract thinking levels in adults, A quotient 
of 90 or above is considered to be ’’normal”, A quotient between 85-90 
is considered "slightly suspicious,” 80-85 "moderately suspicious,” 
*Percy Jones Convalescent Hospital, 
Fort Custer, Michigan 75-80 “quite suspicious*, 70-75 “very suspicious*, and below 7t is 
“probably pathological". Furthermore, a quotient of 90 does not 
necessarily signify mental normality. It simply indicates that the 
patient’s ability to think abstractly in the testing situation has not yet 
become seriously impaired. The available evidence Indicates that the C.Q. ' 
obtained from subnormals are not valid. Feebleminded and borderline cases 
tend to earn low quotients, ■ For this reason extreme caution must be 
observed in interpreting quotients from individuals with vocabulary scores 
below 23. 
At the Convalescent Hospital of Percy Jones Hospital Center a number 
of psychoneurotic patients were admitted with a history of blast concussion. 
The severity of their symptom' led some of the doctors to* believe that 
their condition might bo duo to organic rather than emotional factors, 
Iheee patients were given the Shipley-Hartford scale to determine whether 
or not any mental deterioration was present. They showed low C.Q.'s, 
usually in the “probably pathological" group. The fact that deterior- 
ation was indicated on the tost substantiated the belief that some organic 
pathology was present in these patients. They were then referred to the 
neurology clinic for checkup and electro-encephalogram. In no case was 
organic pathology found. This led to the feeling that the lack of mental 
functioning found in these patients was due to some condition other than 
organic. 
In order to study the problem further, 500 psychoneurotic patients 
were selected at random and the results of their tests were studied. It 
was found that 78 per cent of them made C.Q.'s below hormal. Furthermore, 
26 per cent of the group had C.Q.'s below 70 which placed them in the 
“probably pathological” group, A study of their clinical records showed 
few if any'to have a history of organic brain damage. Even though the 
author of this scale states that the vast majority of psychoneurotics 
studied earned normal C.Q.’s we found that of the psychoneurotic patients 
at the Convalescent Hospital less*than 30 por cent receive normal quotients. 
It was thought that if this lack of mental efficiency is due to 
impaired emotional functioning then one should find an improvement after 
a period of convalescent treatment. The problem then was to determine 
whether or not the Shipley-Hartford scale measures any effective change 
in the patient while at the Convalescent Hospital, , The answer to this 
question was pursued by selecting 109 psychoneurotic patients at random. 
They were given the test upon rCadraission into the hospital after furlough. 
On the average of fifty-two days later they were retested end the follow- 
ing results were found,The average C.Q, was 87.0' on the first test and 
95.5 on the retest,’ The group'showed an 8*5 increase in their conceptual 
quotients. This improvement or increase has been treated statistically 
and found to be due to factors other than chance. 
Just where did the improvement occur—oh the vocabulary, on the 
abstractions or on both portions t)f the teat? It was found that on the 
abstractions section of the test the average score for the original test 
was 20,0 and on the retest the average was 25,3, This is a statistically 
significant difference or increase. On the vocabulary section the average score on the first test was 26.5 and 27.6 on the retest. Here, 
as was expected, the increase is slight and when treated statistically 
is insignificant and due to chance factors. In other words, the patients 
showed little or no improvement on the vocabulary test after a period"of 
convalescent treatment, but a significant improvement on the abstractions. 
An identical study was conducted in another battalion using a group 
of fifty psychoneurotic patients selected at random. For this group 
the average C,Q. on the original test was 76,3 and 86,4 on the retest. 
Hero the increase is 10 points. On the abstractions the original average 
score is 15,1 and 23,4 on the retest with an increase of 8,3 points. On 
the vocabulary the averages are 26,4 and 26,9 with an increase of five 
tenths of a point. 
Wc have then a scale which gives us an index of change. Apparently, 
the psychoneurotic patient has a reduced mental efficiency at the tine of 
admission to the convalescent hospital. However, this efficiency is 
usually restored after a period of convalescent treatment. 
SUMMARY: A statistical analysis of the Shipley-Hartford Scale 
administered to psychoneurotic patients at the time of admission to the 
Convalescent Hospital and again approximately eight weeks later shows an 
increase in their ability to think abstractly. From these studies it 
appears possible to reach a generalization that in psychoneurotic patients 
one finds a reduction in mental efficiency which improves after a period of 
convalescent treatment. 
This scale gives a rough index of change in patients who come to 
the Convalescent Hospital and improve. It is a simple measure of intell- 
ectual impairment, but a valuable addition to our present diagnostic methods 
of investigation. ' 
DISCUSSION 
Frances C, Perce* 
This paper was read with real interest since civilian clinicians, 
as well as those in the army, have been concerned with the study of 
impairment of mental functioning. Chose of us who work with disturbed 
children as well as with adults, feel the need of a valid instrument to 
estimate the true or innate ability when organic or functional disturbances 
cloud the picture. To what extent traumatic experiences have affected the 
mental capacity of the patient, is a question often asked of the psychologist,' 
Shipley has accepted two premises in the selection.of test material, 
1) that vocabulary is a reliable measure Of true, unaffected ability, and 
2) that the level of abstract thinking (based on 20 questions) is a 
reliable measure of mental efficiency. Research by Shakow, Hiurstone and 
others would lead us to question the reliability of the first premise, and 
the work of Goldstein and Sheerer would suggest the need for further inves- 
*IlUnois Institute for Juvenile Research tigation of tho second. However, if the test results give a rough, 
quick estimate of the presence of mental deficit, then those patients 
with low C.Q.'s might be studied more intensively. 
The results of the first use of the test reported by the authors 
were those found on patients with a history of blast concussion. Since 
these patients showed low C.Q.'s and "no organic pathology was found," 
it would have been interesting if a follow-up study had been made to 
ascertain whether convalescence effected any changes in their scores on 
tho Shiplcy-Hartford Scale, 
Twenty-six per cent of the group consisting of 500 psychoneurotics, 
wore found to have C.Q.'s below 70, placing them in the "probably patholo- 
gical group," V/hy did these patients obtain such a low score, since 
Shipley found that tho majority of his group of psychoneurotics earned 
normal C.Q.'s? Was the army group comparable to that of Shipley's? Did 
the classification of psychoneurosis in the army delineate the same type of 
disorders as the Shipley group, or was one group more selective? 
Before accepting the test-rotest results on the 150 selected patients 
as indicative of improvement of mental efficiency, further questions 
should be raised, Did practice effect influence the patient's ability to 
do better on the abstractions? Was there more improvement manifested among 
those patients having the longest period of hospitalization? Was the 
improvement greatest among having the highest vocabulary score and, 
therefore, considered the nor-, intelligent, or among certain types of 
psychoneurotics? The group of 100 p.uients obtained an average C.Q. of 87 
on tho first test, which, according to Shipley, would classify then as 
"slightly suspicious", One would wonder whether or not there was real 
intellectual impairment, considering the probably error of the scale. The 
smaller group of 50 patients who' were retested did secure an average C.Q. 
of 76 which would classify them as "quite suspicious". However, in both 
of these groups, the vocabulary averages wore only 26 and as indicated by 
the authors, vocabulary scores below 23 suggest that caution should be 
observed in interpreting bne quotients. In viow of the snail discrepancy 
between the earned vocabulary saores and minimum of 23, there is a suggestion 
that there were a number of patients included in the group whose intelligence, 
as revealed by the vocabulary, was limited. One more question could be 
raised: were there disccrnable clinical differences in adjustment dttween 
those patients who made a high score on the abstract tests and those who 
made a low one? 
It would seen to have been worth the effort if the authors had 
followed this quick and simple evaluation of mental impairment with further 
investigation, using the techniques of Golditeln, Vigotsky and others, and 
also had chosen a Control /'roup of patients with whom no therapy was under- 
taken, or a group of normal individuals and retested then after tho same 
period of tine had elapsed, Moreover, clinical evaluations of degree of 
improvement then night have been compared with the test findings. 
Thu authors have made an excellent start in the investigation of a 
difficult problem by searching for scales which will attempt to measure 
quantitatively the Impairment of mental functioning. Psychoneuroses offer 
a rich field for psychological study and investigation of the effect of 
emotions upon intellectual functioning. It is hoped that the authors will 
continue their interest in this field. S0i._E GENERAL COHSIDSRATIOHS ON THE RORSCHACH TgST IN AN 
ARMY GENERAL HOSPITAL 
By Lieutenant Samuel Pearlman, MAC* 
and 
T/4 E. J. Lotsof* 
The status of the clinical psychologist as a member of the 
psychiatric team has been emphasized at a.number of points in 
the present discussions. His specific functioning within the 
team framework has net been a new development, certainly, but 
it has served in some part to ueet the needs ,of. the army for 
more adequate coverage of neuropsychiatric patients, and thus 
from the broader viewpoint to set off his role in a less fore- 
shortened perspective, It was the apparent intention of the 
higher army headquarters to fix the locus of operation of* the 
clinical psychologist at general and station hospiials of 1000 
beds or more, but it took less than a year for the assignment 
range to be broadened to include such other types of military 
installations as training centers and disciplinary barracks. 
No matter where he has been sent, however, the clinical 
psychologist has boon accorded a heartier welcome if he in- 
cluded within his psychological arsonal an ability to handle 
projective-test techniques. It was not that psychiatrists 
favored any ono instrument over another or that personality 
tosts wore thought of as furnishing now royal roads to diagnosis 
and therapy. It was simply fait that the ability to apply pro- 
jective methods implied greater psychological capabilities and 
more extensive clinical experience on the part of the nowly 
assigned individual, and in addition offered greater prospects 
of developing the personality dynamics of nouropsychiatric 
patients in a prossuro-izod army atmosphere. 
There is little doubt that of all the personality instruments 
in use within the army, no ono has achieved the samo high dogroo 
of acceptance as the Rorschach. N0 statistics are available to 
compare tost usages vdthin this category, but the general hospital 
oxporionco of my colleague and mysolf may roll illustrate tho point 
that is being made, Early this year monthly referrals for Rorschach 
analyses could bo counted on the fingers of both hands, and woro 
almost altogether made by a single psychiatrist. H0qU0Sts for other 
tosts v/oro somewhat higher in number. Passage of a half year saw a 
rise of nearly 1000?* in tho Rorschach referrals, and thoso wore now- 
being rccoivod from every one of tho staff members, Considerably 
loss stross was placed on rolatod tests, Tho sharp increase was duo 
not only to the marked rise in tho patient load, but also to tho 
growth of understanding of tho doctors of the potentialities of this 
particular instrument and to tho quality and accuracy of tho intor- 
*vaughan General Hospital, Hines, Illinois. protn.ti.ons, Probably all factors combined in small or largo 
dogr-o to build up a working atmosphoro favorable to tho 
Rorschach technique. 
Frequent mention has boon made of the inadaptability of the 
Rorschach to most army situations, because of the time-consuming 
aspects of its administration and analysis* lino of reason- 
ing was that very fow army stations wore adequately manned, '/.dth 
personnel shortages moro clearly evident in the psychological 
specialties than in most others* the circumstances to 
allot a minimum of two hours to t. Single tost on a single patient 
was to dovoto a disproportionate hUtiber of professional manhours 
to a single thski Admittedly* the Rorschach was a refined per- 
sonality tool, but if it could not bo adjusted to an assembly- 
lino procedure, then its practical military uses had to bo 
severely circumscribed* was felt that the group Rorschach 
only partially mot the demands for the mass handling of non, 
since it discriminated with less speed and facility than other 
screening devices* 
The logic of this development, howovor, does not rolato to 
tho situation normally encountered in the army general hospital 
of tho zone of the interior, The rush and bustle of tho induc- 
tion station, rocoption, cantor, training comp, or overseas 
medical unit arc not typical of this typo cf installation. In 
almost every instance the patient has boon passed on from hos- 
pital to hospital, and has gono through a number of psychiatric 
screenings prior to his arrival. He has boon diagnosed and rc- 
diagnos.d, and has perhaps undergone various forms of high-spood 
therapy, %s admission to a general hospital in this country is 
oxpoctod to lead to a final disposition, involving either a return 
to duty status or a separation from tho armod forces. Of 
necessity his handling will be characterized by more careful 
management, moro extended specialized treatment, and deeper 
probing into the personality structure and background,The tine 
factor, while still ccnsidorod, is not tho essential olomont 
it war previously, and the time devoted to the individual 
Rorschach examination under those loss strained circumstances 
is moro thrx repaid by tho largo number of resulting psychiatric 
loads. Indeed, it has proved possible to repeat tho testing on 
small groups of individuals as a measure of improvement and-a 
guide to further therapy. 
To re-emphasize a sonsoful cliches a test is no bettor than 
the clinician who uses it, and mi otherwise valuable tost may be* 
rondored ineffective by careless administration and naivo inter- 
pretation, Tho Rorschach is not an easy instrument to work with 
when roal depth of interpretation and analysis is required. It 
may or may net bo a point of derogation, but tho fact is that 
relatively few of the raon and women comnissionod by tho Army in clinical psychology were "exposed" to projective techniques prior 
to their array service. This is a far cry from the experiential 
prerequisites widely accepted for active Rorschach practice. There 
is no desire here ot4 at any other point to belittle their com- 
petency in their oWh special field of operation or their capacity 
to adjust to new psychological demands and procedures. As a matter 
of fact, many within the gVoup have managed to acquire a goodly 
measure of facility and flexibility in the application of the 
Rorschach technique. But the development has often been a strained 
one, comparable at its start with' a. plunge into ice-cold water, 
and has involved many pitfalls4 Recognition by the Army of the 
clinical gap has led to the incites ion of a substantial number of 
leoture-ond-praotioe hours- on projective methods in the course 
on clinical psychology at The Adjutant General’s School*. This 
has beoxi by no weans tho definitive solution to the problem* 
It certainly did not supply all that was necessary to cope with ‘ 
situations in the field. 
There has been much controversy over tho comparative values 
of tho different Rorschach scoring systems. At least two major * 
schools of scoring methodology are in existence in this country,* 
and almost as many minor schools as thoro aro clinicians using 
tho Rorschach, At our own unit we have gone through various 
phases of scoring development, only to arrive at tho conclusion 
typically reached by many psychologists that tho precise tabula- 
tory method is not of itself crucial, but rather the basic clinical 
capacity of the psychologist to remain sensitive and receptive . 
to pattern development and deviant tost behavior. 
One of tho handicaps oncouxvtcrod by the clinician at the 
general hospital is the-lack or sketchiness of psychological data 
in patients’ records rocoivod from other installations. Hxterials 
from zono of interior units usually roach us in good order, evon 
if condensed and brief, significant dearth is to bo found, 
however, in tho reports from overseas,, is easy to make 
allowances for tho clinical personnel in combat or roar-echolon 
areas, but it is still grievously disappointing to find an 
individual*s case papers containing no psychological work-up at 
all or at best a half-sontonco impression, when tho patient him- 
self indicates a tost experience with tho Rorschach. It may bo 
well to note, as an aside, that Rorschach reports have been re- 
ceived by us only frem about four 0£ five"medical stations abroad 
(plus one from a replacement depot down under"). 
Opportunities for Rorschach research are numerous multiple 
7/ithin the general hospital set-up, Vaughan General Hospital is 
the Service Command Center for the treatment of the more severely 
disturbed patients, and has a wido enough rango of psychiatric 
typos to afford a base for clinical test projects* An attempt is 
being made at prosont, for exmplo, to gauge tho relationship of Rorschach forecasts to the actual responsiveness of patients 
in group-psychothorapy mootings. somo long-rangp work is 
also being done on pre-and post-inoulin-shock records, ®no 
of the doctors has recently asked us to establish a standard 
operating procedure for the Rorschach handling of those of 
his patients undergoing hypnotherapy. Ambitious projects 
all, to say the least, but gravely circumscribed by a shortage 
of trained personnel. 
DISCUSSION OF: SOinE CKNSKAL CONSIDERATIONS ON THE RORSCHaCH TEST 
IN AN ARnY GENERAL HOSPITAL 
Discussed by* «J. Rock, Rh»D, 
Michaol Rooso Hospital 
Chicago, Illinois* 
This paper describes the Rorschach tost situation in the army 
general hospital. Ac a description it hardly offers much material 
for disagreement, Iboso of us \fho uso the test aro naturally in- 
terested in what is happening in the sotting reported by the authors. 
This is the more true for these who aro using it in the civilian 
general hospital. 
Tho one point on which I do want to comment is in respect 
to what, as reported by the authors, is happening in scoring the 
tost responses; particularly the conclusion typically reached by 
many psychologists that the precise tabulatory method is not of 
itself crucial, but rather the basic clinical capacity of tho 
psychologist to remain sensitive and receptive to pattern develop- 
ment and deviant tost behavior. 
The question is here raised to vrhc.t extent does this oonclu- 
sion" amount to disregard for the formal structure found in a 
Rorschach test record, This formal aspect vras recognized and ac- 
cented by Rorschach as essential in use of his tost, is always 
the first point of departure for interpretation in personality toms, 
— tho objective result that gives the examiner a visible projection 
of the human psycho in throe dimensions* tho Intelloctual, affective, 
and unconscious spheres* 
As such an objective picture it is no stronger, psyohothorapouti- 
cally, than tho factors that comprise it, - those that enter into tho 
"precise tabulatory method" which aro reported as being looked upon 
as not crucial. These component factors that pattern out tho struaturo 
aro represented by certain, now well-known, scoring symbols. They are valid only insofar as they arc experimental end verifi- 
able factors objectively delved out in accordance with usual 
scicintific method. prerequisites in regard to these 
Rorschach tost factors differ net at all from those for 
psychological tosts generally. From tho history of these 
tests wo know that ovory psychological test is likewise an 
experiment, tho Rorschach tost differs from others in psy- 
chology only in that it consists of a number of tosts lor 
experiments) in one; about 14, I should say, — this being 
tho number of variables into which wo break up a Rorschach 
record as wo use tho test in Michael Reese Hospital, When 
tho summary has boon so constructed, i.o,, out of objectively 
valid synbols, wo have Rorschach's essential formal pattern* 
Not until then does the examiner's clinical experience cone 
into play. 
An example will clarify ray point, A patient gives a 
Rorschach record in which *./c find (a) groy«black shock; (b) 
heavily saturated color responses; (c) notable noro than the 
normal amount of white space associations; (d) aggression 
inplcncnts in tho content. From the grey-black shock wo 
conclude to anxiety of deep character force; from tho satur- 
ated color, energetic, but not well-controlled, feeling contact 
with tho world; from tho white spaces, the opposition attitude; 
from the aggression implements, ccr.bativenoss. But how do wo 
knew that there is actually in this record grey-black shock, 
saturated color, much white space, aggression content? 
cannot know this unless wo compare our patient's response record 
with a normative sphere of reference. In regard to grey-black 
shock wo know how many seconds are usually roquirod for tho first 
response to Figures IV, VI, V, VII, — quantitative measure. 
We can recognize too whether tho patient quantitatively varies 
in these figures in respect to P plus, **» P, among other factors. 
Similarly, we know how rauch color to oxpoct in an individual of 
our patient's level, normally; how much white space; about what 
kind of content, S0 wo know from what he does that ho is or is 
not deviating from tho norm. This is the essential, prerequisite, 
quantitative, and objective approach to any Rorschach record. 
From such factors, themselves referable to a stable sphere of 
reference, we construct a formal pattern, which is tho Rorschach 
personality representative. 
Then, and only then, dees our clinical sense enter; but 
then too it becomes a sine gun- non. In tho patient exemplified, 
we can say he is in rebellious attitude (s), has hostile thoughts 
(content), is liable to be carried qway by his impulses (color), 
honcc his anxiety (grey-black shock); — as a self-saving measure. 
It can be soon then that the clinical insight becomes equally im- 
portant with tho objectivity on which tho test rests. It is in 
this way that tho understanding of personality on tho one hand; 
and on tho other, objective foundation fer tho Rorschach tost, 
interlocks, He instrument can do any measuring, or inspecting in 
itself; it can only bo as good as tho person who usos it. USE OF PSYCHOMSTRY IN EVALUATING PERSONALITY 
Lt. Fred Y. Billingslea, MAC 
Lt. William Karp, MAC^ 
In dealing with the physical area of the individual, the 
physician is constantly searching for new instruments that 
will help raise his analysis of an organic condition out of 
the realm of guess-work. Certain of these instruments are 
complicated laboratory procedures; others are rapid and appli- 
cable on the spot. The physician has a feeling of security 
in using the findings from such procedures that is in keeping 
with the degree of reliability of the tests, lie in psychology 
have attempted to develop similar instruments to objectively 
measure the mental and emotional areas of the individual; i.e., 
to reduce us much as possible the guess-work in the analysis 
of those areas. Theso instruments, too, have their limitations 
of reliability, but when adequately administered, their results 
give the clinician the some feeling of security that the phy- 
sician has when the laboratory report comes back negative or 
positive. 
In the convalescent hospital, wo are constantly faced 
with the necessity of objective evaluation in the following 
sub-areas» 
A. Mental Area 
1. Level of intelligence. 
2. Intor-oranial organic pathology. 
3. Mental inefficiency or deterioration. 
4. adequateness of recent or past memory. 
5. Special skills, abilities, or areas of interests. 
6. Adequateness of reasoning and judgment. 
B. Binotional Aroa. 
1. Personality dynamics. 
2. Diagnostic classification or label. 
3. Social adjustment. 
4. Evidence of soxual maladjustment. 
5. Screening out the emotional deviates from the normals. 
6. Evidence of dissociation or degree of contact wth 
reality. 
Wo employ various tests to meet this need with varying 
degrees of success. These are some more frequently used* 
Rorschach, Thematic Apperception Tost, Bonder-Gestalt, . 
Modified Bornrouter, Minnesota Multiphasic Personality In- 
ventory, Bellovue-Weohsler, Wochslor-Memory, series of army 
intelligence and aptitude tests. Ruder and Cloeton blanks, 
Shiploy-Hartford, Sentence Completion, Goldstoin-Schoro's 
battery for organics. Serial "7" Subtraction, Draw a man and 
woman, and other individual units that have been collected 
over a period of years. 
♦Percy Jones Convalescent Hospital, Port Custer, Michigan Perhaps some of our experiences with these tests will 
be of interest to you. ' The ihcflvldudl RbrseliaCh"continues to 
be one of our best aids. Its findings consistently substantiate 
tho clinical symptoms evidenced by the patients, and have been 
often used to throw tho weight of opinion either to or away 
from psychosis. It has proven particularly useful in organising 
personality dynamics, giving evidence of dissociation, pointing 
out sexual madadjustnont, and in estimating prognosis. It has 
helped us in suggesting tho presence of inter-cranial organic 
pathology and post-traumatic syndromes. Finally, it is spec- 
tacular upon occasion when it has been the stimulus for causing 
a patient to bring forth traumatic battle incidents which ho 
has heretofore suppressed. On the other hand, the tost has 
occasionally failed us, too. This is especially true of the 
multiple-choice modification, which has 
proved ineffective in our situation. 
From the Thematic Apperception Test and our own selection 
of pictures, we have been able to got the usual suggestions of 
personality dynamics, but employ it more to supplement the 
Rorschach by obtaining references to definite situations; i.e., 
parental rejections or dependencies, asocial attitudes, and 
strong identifications. War traumatic situations have been 
revealed by those pictures, and they have been found further 
thorapcutioully helpful by so selecting tho cards that the 
patient builds his stories around increasing age levels, thus 
reviewing his life and attitudes in retrospect without having 
to toll tho examiner that this is what he is doing. Maso- 
chistic doprossivos have been greatly helped by this method. 
Little has yet boon published on the Bender-Gestalt 
drawing test. Lt. Max Hutt has been responsible for its dis- 
semination among tho army clinical psychologists. It is com- 
posed of nine geometrical drawings shown individually on 
separate cards. The examinee is given a pencil with an erasure, 
sheets of 8” x 10-1/2" paper, and is told to copy tho drawings 
in any fashion ho sees fit. It takes about five minutes. Tho 
drawings are interpreted in terms of norms for such things as 
anxiety, emotional lability or flattening, intellectual level, 
regression, sexual maladjustment, oompulsivity, persovorativo 
tendencies, constitutional psychopathic state characteristics, 
withdrawal behavior, and others. Four syndromes of those fac- 
tors have already been organized; i.e., mental deficiency, or- 
ganic brain pathological involvement, psyohonourosis, and 
psychosis. In the short time we have employed it, it has often 
been the moons of picking out hidden organic intor-pranial prob- 
lems, and of pointing tho way to further investigation of hidden 
sex problems. , It promises well to be the fad of the immediate 
future, but much standardizing work needs to be done, first. 
Draw a man and a woman test is op tho same order as the 
Bender-Gestalt, but is even loss well standardized £or personality 
dynamics interpretation. There appears to be a positive re- 
lationship, however, between tho manner in which tho hands and 
arms are placed and sexual interests, between the differences 
in ability to draw tho two sexes and tho individual’s identifi- 
cation with a certain sex, and between the elaborateness of the details of the drawing and mental efficiency level. It does 
well in supplementing other tests. 
The Sentence Completion tost is being employed more and 
more. If the right constructs are offered, it can often be 
used to take the place of the autobiography, since it quickly 
indicates areas of conflict, and neurotic characteristics, 
and is a means of establishing rapport and orientation for 
future interviews. 
Those are the purely non-structured and serai-structured 
projective techniques that we find helpful. By that, we mean 
the test’s stimuli have not been so organized as to evoke a 
predetermined response on the part of the examineej his re- 
sponses are fashioned by his own personality pattern, how he 
is set to interpret or perceive his environment. The modified 
Benrouter and the Minnesota Multiphasic Personality Inventory 
are two fully structured personality tests which we employ. 
That is, the stimuli, printed question, are so selected as to 
be answered by either "true", "false", or "cannot say". The 
modified Bonreuter is less needed now, but it is excellent to 
about 80# reliability fur a quick screening of the neurotics 
and constitutional psychopaths from a group, and suggests to 
some extent the degree of abnormality present. We are frequently 
using the Minnesota Multiphasic Personality Inventory because 
it gives us a diagnostic label and it can be administered 
without taking up too much tine of the examiner. It gives 
a profile of behavior classifications plus an estimate of their 
validity, and it can be easily specially scored for unusual 
responses to any key questions the examiner may select. We 
have followed the author’s suggestion and reduced the 550 
cards to 354, thus saving the patient’s time and patience, 
and reducing the scoring time. We are also in the process of 
trying the total profile method developed by Schmidt for the 
constitutional psychopathic state, sexual constitutional psycho- 
pathic state, psychoneurotic, and psychotic. So far these 
have helped in a more accurate labeling in approximately 68# 
of the cases evaluated. They are not useful in detecting the 
dynamics involved, however. 
We have been employing the Army-Vfechsler for' an individual 
tost of intelligence because it attacks u variety of skills with 
greater validity than our paper-pencil tests, and permits 
clinical qualitative judgment of the patient while he is 
operating in these situations. Lately, however, wo have sub- 
stituted the Bollovuo-Wechslor because of its greater validity 
and reliability and because wo feel more secure in the inter- 
pretation of the sub-score scattergram. Besides I.Q.'s in 
the verbal and performance skills areas, this test tolls us 
much for diagnostic labeling and gives us many suggestions 
toward the individual’s basic dynamics. Wechsler’s own tech- 
niques have been helpful, but those being developed in tho 
psychological section of the Iteminger Clinic are most productive. 
A measure of tho mental efficiency level and mental deterioration 
is easily obtainable on the test, too. Use of the individual  has been extremely helpful for investigating 
specific problems such as recent memory, organic brain 
involvement, and vocabulary level. 
Tho Shipley-Kartford t.est pf mental deterioration has 
become widely us-od in'the Army when title Is limited, Wo find 
it to have fairly good*Validity in the middle I.Q. ranges 
when correlated against tho Bellcvde-Wochsler. It gives a 
mental age level, too.- This mental ago, however, is not too 
accurate, and the index of deterioration does not adquatoly 
toll us whether the lowering of the mental level is simply 
emotional inefficiency, impairment, or progressive pathological 
deterioration. ’ • 
One of our therapeutic ..devices at the hospital is to give 
the patient vocational counseling; when he. requests it. We utilise 
JCuder's or Oleeton*s interest inventories plus information from 
various army abilities tests as interview orienting devices, 
and then combine this knowledge with our understanding of his 
©motional difficulties in an effort to help him take positive 
Steps toward adequately solving his future vocational problems. 
Wo do not attempt to advise him in obtaining a specific job. 
This is the overall picture of our psychometric program 
at the Pepcy .Jones Convalescent Hospital. In mny ways we 
have found opr efforts worthwhile in helping the patient to 
adjust himself, and in our undorstanding cf his difficulties. 
More adequate pse of our available tools is still greatly 
needed. Now devices and bettor standardization of our present 
ones arc a "must." We are attempting to add o\yr bit, in that 
phase of tho work, with validating studies of,tho Shipley- 
Hartford, Bander-Gestalt and ro-evaluation of seme of the 
Rorschach interpretations * ... r 
Pi sous siou of Use of Psychonetry in Evaluating Personality 
Eva Ruth 3aIkon, Ph.D. 
Division of Psychiatry, 
University of Chicago. . 
. • 1 v 
The paper rnpsontod by "Lieutenant 3illingsle* covers so 
much .ground that one does not really know where.to boingy 
what;points tc emphasize and at the sano time, give it the 
consideration which it commands. ■ 
So starting from.the ond, it may bo noted that the 
authors are unnecessarily apologetic and modoat whejv they 
understate the value of their contribution. ' Their, selection 
cf a battery. Including the Rorschach* ’ the TLt» the■Qoldstein- 
Schore’s battery for organics; the Beuder-Gostjalt, cpid-tho 
drawing of a man and a WDimn - and ,theyWooh8lerr3ollovue as 
well -.indicates a, basic appreciation of the mixny problems in- 
volved in tho evaluation- of personality, .anyone who can evaluate 
the findings with tho Bender-Gestalt and tho drawing* of a man 
and a woman so as to detect organic brain involvement and- 
hidden sex problems must have an understanding and intuition • of the many implications of the body-image. The authors 
probably are acquainted with a study in which the drawing of 
nan differentiated prisoners committed for homosexuality and 
those who were committed for other offenses. It will be a 
long time before such devices can be standardized, before the 
drawings will be more than drawings to these who do not fully 
appreciate the importance of investigating the body-imago. 
Lt. Billingslea* s experience with the self-administering 
tests is what is to be expected. They serve a valuable purpose 
in screening. But in the investigation of the dynamics and 
structure of an individual personality they yield little in- 
formation of immediate value. They roly too much on the in- 
dividual's own congitive appraisal of his attitudes towards 
his experiences. This is not too apparent if the examiner 
himself does not stay with the individual subject while he is 
filling out the forms or assorting the cards or if the examiner 
has not had extensive experience in group testing. If the 
examiner stays with his subjoct-or even his group-it is sur- 
prising how many nuances of che personality are revealed 
which ordinarily arc obscured in percentile ratings or in diagnostic 
labels, at. obsessive-compulsive, for example - and hero it may 
cetsgor;cally stated that his psychic ego is over-developed 
is apt to place all his experiences, all his reactions in an 
eithor-or category. So when confronted with a third possibility 
- cannot say - his aoubt is accentuated and he often underlines 
the true, false, or cannot say without too much -if any- consid- 
eration for the content of the questions. Regarding the content, 
as one boy, suff ring from an examination neurosis, put it - 
it would be "intollectually dishonest” for him to commit himself 
on so many vaguely formed issues. 
But even more important with regard to self-administering 
tests is the emotional sotting. The soldier in tho convalescent 
hospital, now, more than ever before needs the guidance and 
comfort which are afforded by tho presence of the examiner. 
For over and beyond tho ravages wrought by his war-time ox- 
perisnees, he carries a further emotional burden - that involved 
in making the transition from on organized, group life in which 
the decisions so vital for tho moment were made for him and 
in which he derived emotional support from the other members 
in his group. General speaking, as Dr. Benodek shov/s in her 
forthcoming book on the Individual in the VJar - Before and 
After, there must be many among tho soldiers in the convalescent 
hospital whose dependent needs were brought to the fore, by the 
fact of war-time experiences in general and by the fact of 
physical injury and disablement in particular. While such men 
are going through the process of learning to adjust to thoir 
new self and of accepting their new body-imago, exposing then* 
to self-administering tests may merely reinforce their feelings 
of helplessness. Certainly the scores of such tests will add 
little information concerning the dynamics and mechanisms of 
this emotional state. 
This leads us to the Rorschach and tho TAT. Here it seems 
to me that the authors have over-stressed the importance of traumatic experiences encountered in the war. I have the feeling 
that a similar finding would be obtained with soldiers who re- 
turned to civilian life with their psychic and'physical health 
presumably "intact". A soldier cannot merely take war in his 
stride; every soldier must have had some experience or experiences 
in and out of battle which were more or less disturbing and 
these will not have been completely assimilated into his total 
personality Just because he has finally returned to the United 
States soil. The elation of the point-happy soldier will cer- 
tainly be revealed through these techniques as well as the 
subsequent let,down feeling when he finds that he has to wait 
and wait for passage home. So the important thing to discover 
in the case of the convalescent soldier is not the trauma or 
traumas of war, but the pattern of the experiences underlying 
these - to see. how he handles the anxiety, fears, guilts or 
hostility roinvoked by his disablemorft - bo it physical or 
psychical. In many cafires, I believe, the fantasies will shpw 
that these' affects and attitudes are projected into the future 
and will be related to the soldier's apprehension concerning 
his future adjustment within his family and within his community. 
The problem of the psychologist is not so much to create 
new devices but rather, as Lt. Billingslea intimates, for an 
enrichment in the use of the available repertoire of tests. 
The Rorschach for example, is really incomplete without the TAT 
and vice versa. The Rorschach reveals and delineates how the 
individual acts when ho is confronted with situations which 
stir up dooply-buriod experiences, many of which are closely 
related to the body-ego and many Of which have never really 
reached the level of verbalization. The TAT delineates how 
the individual reacts when confronted with situations which 
more or less correspond or approximate actual experiences in 
life. It may bo said to delineate the defenses; but this is 
only partly true since many subjects will arrange those situations 
- the Rorschach and the TAT - in' much the some manner as they 
do life situations. One claustrophobic for example insisted 
upon making an analysis tost of the Rorschach, and at almost 
every stop further Insisted that no two people would react 
alike, whereas ho was sure everybody would respond alike to the 
TAT. In other words, he had rearranged the testing situation 
so as to avoid temptation and fear Just as.in real life he 
had devised many means - including inability to ride in 
elevators - to master his fear. - : 
I have always been accustomed to asking the subject how 
he liked or felt about the test given him - oven in the-case 
of intelligence tests. The subject’s aid is thus onlistod in 
helping the psychologist evaluate how the subject evaluates 
his experiences and attitudes. In the easo of the Rorschach 
and the TAT - given in this sequence two other questions are 
addedj which of the two was easier and which was preferred? 
The answers are found to be differentially diagnostic end 
delineativo. Generally speaking, the neurotic prefers the TAT 
but finds it harder than tho Rorschach - ho prefers tho TAT be- 
cause ho prefers reality to Concentrating on a fantasy life; 
he finds it more difficult because ho is aware of-how much ho 
reveals himself in it. The more seriously emotionally disturbed usually find the Rorschach very difficult and the TAT easier 
and preferable; they have not learned to build up defenses 
against the irruptions of their inner life whereas they are 
unaware that they arc giving full expression to their fantasies 
in the TAT, that they are not really subscribing to tho rules, 
as it were, of tho latter. As a 17 year old referred for so- 
litary drinking bouts put it, telling stories was "fun", but 
the Rorschach was "brain work". In other words, his defenses 
were not adequate to dealing with tho unconscious content evoked 
by the ink-blots, which was deeply regressive in tho repeated 
expression of wanting to bo a new-born babe again, whiTe he 
had no anxiety or guilt and did not hold himself responsible 
for his stories which dealt with murder, fear, and disparagement 
of women, all of which were a cover up for his anger over having 
boon abandoned. Some subjects break tho answer to those two 
questions even further. One, for example, found the main part 
of the Rorschach very easy, but reacted to tho inquiry as though 
it were an ordeal. Tho inquiry took about throe times longer 
than the main part. Tho questions "how" and "where" seemed to 
express to him that tho examiner was questioning his honesty 
in tho main part and this plus tho weakness of his defenses 
merely accentuated his doubts and ho seemed to bo lost in a 
mate from which he could not extricate himself-ovon with tho 
examiner's help. 
In a similar fashion, tho inquiry nay be related to 
immediate memory. Many subjects respond to it as though it were 
another tost, an entirely now situation. Obviously, if viewed 
from this point, the inquiry will throw added light upon the 
personality of the organics and of tho feebleminded or low in 
intelligence as well as upon that of others. 
Going even further, it has been found fruitful to devise 
h categorizing test out of tho Rorschach. After the test is 
completed, tho subject is asked to make three assortments into 
two piles each, they need not be equal. First on any basis at 
all; second on the basis of which easier, and third on tho basis 
of which ho liked more. And each time ho is asked tho reason 
for his assortment. Sometimes the answers overlap, more often 
they do not-but again one obtains additional information without 
much added work upon how the individual handles his conflicts, 
on how ho reacts to life situations. One subject, for example, 
whose Rorschach was devoid of color responses, the some subject 
who found tho inquiry such an ordeal, made his assortments on 
the basis of color. His reasons revealed that he had learned 
to see all colors as gradations of black and white. It can be 
easily inferred why ho was finding the biological sciences so 
uncomfortable and why ho was in need of treatment. So much 
emotional and mental energy was being used to see all situations 
as oithor-or that ho was easily often taken off-guard in his 
actual handling of them. 
The authors indicate tho need for a re-evaluation of tho 
interpretations of the Rorschach scorings. Long and varied 
experience with personality investigative techniques seems 
always load to this realization. I an finding that M should be scored in the sense as originally defined by Rorschach 
himself. It may then be related to identification, per- 
haps even to the body image as delineated by the Bender- 
Gestalt and the Goodunough test. The small n, as defined 
by Piotrowski, may be interpreted as a projection on to the 
outside world of inner sensations. The depth responses seen 
to indicate the presence or absence of a tendency to correct 
or realistically test the identifications and projections by 
assaying the fantasy element in thorn. The integrated personality 
should give a certain number of depth responses to balance the 
M’s. Further, it scorns that the texture responses may differentiate 
between the hysteric and the obsessive-compulsive patterns of 
reaction. Some confirmation of the reinterpretation of M is 
gained from the doctorate thesis of A. Rieger, here a high corre- 
lation was found between the number of M’s and the number of 
persons interpolated into the fantasies. 
Only one point seems unclear in this presentation; namely, 
the rationale in the selection of pictures and the type of 
pictures used. Both those aspects are, of course, a function 
of the problem investigated, in this case, presumably the ways 
in which the soldiers have reacted to and assimilated or failed 
to master their experiences in war and also the ways in which 
they almost consciously expect to face their future civilian 
life. Both the rationale and the typo of pictures have to be 
empirically determined; they cannot bo decided on ITpriori. There- 
fore, it seems to mo that they should not bo exclusively oriented 
towards the system in which the soldier had to adjust during 
the war. They should highlight pictures vrhich easily and 
sharply define displacement and oven depersonalization, the latter 
in the sense of the unconscious getting ahead of the conscious. 
I would like to spend more time on tiie TAT, largely because 
it is one of the most malleable of techniques. The course of 
the emotional readjustment can bo delineated by using the TAT 
from time to time. Such use will also define the reactions of 
the subject, bo he soldier or civilian, to the treatment or 
counseling situation. In the case of a boy of 17, for example, 
his fantasies showed that he felt impelled to return to a situation 
which ho really did not want and at the some time, they revealed 
that ho might bo restrained from any untoward, impulsive act in 
this direction by the psychiatrist who appeared in his stories 
as a kind-hearted detective who took him under his wing. In 
another case, a young boy's fantasies on the are of a tonsiloctomy 
revealed many fears and much hostility which wore greatly di- 
minished in u later series obtained a short time after the operation. 
Obviously, us Lt. Billingslea intimates, the use of psycho- 
nctry in evaluating personality must be thoroughly and cautiously 
evaluated before the role of the psychologist in counseling and 
in psychotherapy can bo dofinod. Those interested in fundamental 
research us well as those interested in psychoduagnostics will 
eagerly await the publication in detail of the results of the 
authors' extensive and intensive experience. RED CROSS PSYCHIATRIC SOCIAL SERVICE IN A MILITARY HOSPITAL 
ESTHER QLICKMAN, AMERICAN RED CROSS 
The specialized function of the Red Cross psychiatric so- 
cial worker in military installations for patients depends on 
the following three factors* 1, Her professional equipment 
in terms of training, experience and interests? 2, The par- 
ticular needs and functions «f the military installation to 
which sne is assigned, Aether it is screening or treatment 
or evaluation and disposition? 3. The attitude of the psy- 
chiatrist toward the service she offers and the use which he 
wishes to make of her skills. 
The major cart of this paper, therefore, was based on the 
individual experience of this worker located at an observation 
and disposition center of an army hosnitnl in a large city. The 
largest pa't of the work was in conjunction with the psychia- 
tric in the wor.. -up of the patient. The part played by the 
social worker in this study of the patient wap to secure a diag- 
nostic social history t.Jcen directly from the patient and supple- 
mented, whenever indicated and feasible, by information secured 
from other :.nformants, The diagnostic social history, which in- 
cluded subjective material from the patient himself, was found 
to be more useful and revealing than the outside history secured 
from the relatives thr-'urh chanter resources, Hie latter his- 
tory was helpful largely in giving factual information of the 
patient's life story. On the other hand, a diagnostic social 
history, taken from the patient himself, and emetines from 
relatives, res geared tn ascertain*the kind of a person the 
patient had been in civilian life as well as during his army 
service, prior to the onset of the present disturbance. Early 
personal history end family relationships, as well as the 
patient's own expressed attitude toward tnese experiences could 
point aut dynamics of personal behavior which helped the psychia- 
trist evaluate whether or not the patient’s problem was predonirv- 
antly ra deep-seated one or something in reaction to a current 
situation, If it apoeared to be a deep-seated problem, then the 
diagnostic social' study should supply information as to how the 
patient managed his neurosis previous to the current disturbance 
and the extent to which it disabled him in civilian life. This 
account aided the psychiatrist in evaluating what could be ex- 
pected in the -"ay of adjustment to further army service. If the 
history pointed up that the disturbance was more, in the nature of 
a reaction to a current situation, the picture of the patient’s 
earlier adjustment helped the psychiatrist determine what could 
be expected of the patient in terms of handling the present 
disturbance. 
♦ Psychiatric Casework Supervisor, Gardiner General Hospital, 
Chicago, Illinois, The social study should also include information to answer 
such questions as to how well did the patient previously meet 
emotional strain-, disanpointments and other difficult situations. 
What type of defenses had he built up during civilian life to 
secure him against anxieties and other neurotic manifestations, 
and had these defenses been broken down by the army situation, 
thereby releasing a* disabling neurosis? It was found that such 
a social history grefttly facilitated the work of the psychiatrist 
and thereby helped to meet the increasing demands oh his tine. 
It was soon learned also,' that *his kind of information could 
frequently be* secured from the natient by the psychiatric social * 
worker more readily than by the psychiatrist, as the social worker 
does nothnve military statue , which sonetimea proved, a barrier • 
in securing frankness and cooperation the natient. In some 
instances, it was found that the patient could talk more easily 
to a woman Most, frequently the psychiatric social worker was 
able to gi/e more’ time the natient than was the psychiatrist, 
and if allc were . -killed in vnterviewing, she could help the 
napient elaborate more extensively in an unhurried situation. 
Whe- natients h-ve been referred from other medical services 
in the .h< s.rtbal for pcyohiatric consultation, the psychiatrist 
referred tnese patients first to the social worker for a history 
as descrJted.. A cony of the social history was then attached 
to the rt-oort of the psychiatrist, which was forwarded to the 
referring medical officers. Several chiefs of medical services 
had.since referred some of their patients directly to the psy- 
chiatric social worker for a history Of personal and social ad- 
justment before deciding on referral to the psychiatrist. These 
medical officers would then use this social study as another 
clinical device in’ determining the Presence and extent of emotion- 
al elements in physical complaints.' If the social history helped 
to confirm such factors, the medical officer would then refer 
the patient to the psychiatrist for evaluation and recommendation. 
The social history’then reached the psychiatrist who used it as 
a guide in hie examination of the patient,* 
* . seemed inevitable that when .the patient was discussing 
emotional material .with the worker, she found him to be obvious- 
ly in need of. help right then with his disturbance. However, 
such treatment was hot felt to be the responsibility of the worker 
nor.was it th.e ;purpose.of the interview,': Yet it hardly seemed 
constructive to open naihful areas necessitated by the history, 
and.thereby leave the patient feeling nore disturbed than before. 
We believe that a .circumscribed type of treatment could be used 
In this situation by the psychiatric social worker. In the be- 
ginning she tried to be careful not to open uo painful areas 
which were not pertinent, and ever! relevant material was guard- 
ed In this#respect, First, if the natient were helped to express 
his feelings without too much probing, he owiild gain some meas- 
ure of relief by doing so, after he was helped in ex- 
pressing negative feelings, such ae hostility, fear, grievances, 
etc,, with a sympathetic reception, could he be given a dynamic reassurance which stresses the positive factors in his situation. 
Our contacts usually consisted of one or-two interviews, as it 
was that more-valid history material could be secured in 
the second interview, after the "ice Is broken", Sometimes:sub- 
sequent interviews were undertaken when the oat lent indicated a 
need of discussing hie feelings about a social problem or an ob- 
jective matter. In s .oh instances the discussion was limited to 
the immediate situation and was related to the objective problem. 
Such interviews were aimed to help the patients think out loud 
and thereby gain a better perspective. At times, a series of iiv- 
teryiew was undertaken with a patient to give him a sUnxortive 
relation snip, Ahis wps f~und most useful with patients returned 
from c'-obat, who were tense and jittery end who complained of a 
feeling of strangeness toward civilians, even their immediate 
family, and were anxious about their inability to relate to them 
emotionally. In talking apout his combat experiences, which were 
highly charged with emotion, to a Red Cross worker, who herself 
was a civilian located in a military, setting, the patient was 
frequently helped to bridge the gap emotionally between hie military 
associations and his civilian relationships. * ?hls *»s achieved 
only in a small:mensure but it seemed like the beginning .of the 
way back for the patient. 
An important phase of the Red Cross worker’s responsibility 
is she service to families-of the patients, while securing histor- 
ies from relatives who visited the hospital, an attempt was made 
to give them reassurance and some interpretation of the patient's 
emotional and mental Illness. Such, service was also given famil- 
ies who lived at a distance, by sending information to local Red 
Cross Chapters for interpretation. Preparation of the foully for 
the patient’s and in arranging for civilian hospital 
care, as indicated, was effected in s similar manner. 
Beyond the specialized function described above, the psychia- 
tric social worker of the Red Cross in military hospitals iacoanait- 
ted to aertain definite services similar to those rendered by Red 
Cross throughout the hospital, program. According to army regulation, 
these universal functions consist of the personal services such 
as loans and grants, health and welfare reporta regarding patients 
to their failles, social investigations of hone conditions idiich 
are troubling the soldier patients, and any other personal or fami- 
ly problem in the patient’s social situation. In addition, social 
histories required in the evaluation of the psychiatric oatlent, 
especially needed for corroboration of factual material, are se- 
cured from the family and other sources through the Red Cross 
chanter service located in the vicinity where the family lives. 
In addition the Red Cross psychiatric social worker also 
attempts to guide the recreafon and the arts and skills worker 
in planning their diversions! activities for psychiatric patients. 
For this purpose she gives the recreation worker in general terma 
the kind of information ab'-ut the patient's condition that will 
help in Planning diverslonal activities according to the oatlent'a 
needs* and the difficulties wuich nay cc anticipated, the 
psychiatric patients of this hospital were almost entirely ambula— tory and the psychiatrist wished that they participate in the gen- 
eral recreation orograa of the hospital rather than be set apart, 
no extensive recreation program was planned especially for them 
as at psychiatric services in other military hospitals. Another 
function of the Red Cross psychiatric social worker is to help 
the arts and skills worker in her individual approach to the 
psychiatric patient, It was found that a patient was more readi- 
ly interested in creative and diversional activity if it was re- 
lated to something emotionally close to him. For this reason the 
psychiatric social worker gave the arts and skills worker a descrip- 
tion of the patient’s family ties, previous interests and occupa- 
tion, as well as his present condition. For instance, the fol- 
lowing use was made of information passed on to the arts and 
skillr worker. Upon learning that a patient was tense, anxious, 
worr and unset because, upon return from overseas service, he 
found he eruld not relate himself to his family including his 
fiftet. ths old son, of whoa he was very fond, the arts and 
skil’s woi.*-er, using this information as a guide, interested him 
in making attractive toys for the child. This soon engrossed the 
patient and helped him find his way back emotionally to his family. 
Incidentally these toys are so inrenious that they are plaiced on 
display among the exhibits at this meeting. Another example was 
of a depressed ratient, whose life-long ocoupation and interest 
was farming, and who was greatly attached to his parents whose 
large farm he had managed. When tnis background in- 
formation wps given to the arts and skills worker, she was able 
to interest the Patient in making building plans of a house, and 
other buildings op a farm near his Parents, to which he expected 
to return after his discharge, 
Another service rendered by the Red Cross psychiatric social 
worker was that of assisting the patient at the time of his 
discharge from the army, when plans for civilian adjustment were 
discussed and assistance rendered in connection with them. At 
the same time, he was helped, in filing a claim for compensation 
if he wished to do so. We found that suggestions for post-dis- 
charge could not ue too specific as the patient was still at a 
loss as to wnat to expect upon return to civilian life after an 
absence of some years. Sometimes the patient did not even know 
what he wanted to do nor did he know what is available. Resources 
in the community as to where he could get pertinent information 
to help him work out his own plans were given him, according 
to his general interests. Referral to the local Red Croaa Chap- 
ter was made, if he wished, for guidance in this. Information 
regarding resources in the community for psychiatric help was” ' 
also given hin, either unon specific recommendation by the psy- 
chiatrist or when the patient expressed a need or an interest 
in such nelo. In many cases, as indicated, it was suggested to 
the patient that he might expect ouch spontaneous improvement 
uoon release from the strains of army life. However, it was 
further suggested that should he not be satisfied with his own 
adjustment after a reasonable length of :ime in the community, 
it might help him to know the kind of treatment he cduld ob- 
tain and "'here it might be secured. Great care was taken not to give the patient an idea that there wr>uld be magic in nay- 
chiatric treatment which would.solve all of hip difficulties. 
Freaucntly this discharge Interview **ith the psychiatric patient 
c~uld be uaed to mitigate pons of hip anxieties about the label 
of ,,opychonemr*slsn as formerly uaed, by interpreting it in 
terms of hip symptoms which "ere familiar to him, such as the 
"nervous, stona'ch" he had had for yearsj or by pointing up for 
example, that many-other5-individuals in the general public have 
similar nervous conditions, yet function adeauately in the com- 
munity, It was further suggested that many prominent and capa- 
ble individuals in civilian life would be incapable of carrying 
on in a military capacity. 
the military installation referred to in this paper 
is located in a large nid-Veatem city where there are no through 
trains, it caused admission to this hospital of many soldiers 
passing through the city on their way to their costs. This af- 
forded a wide variety of clinical pictures. The hospital is lo- 
cated near a large university and the latter selected this cen- 
ter for the field work training of a unit of graduate students 
in psychiatric and medical social work where they have an un- 
usual o') ortunity to observe many different psychiatric problems 
as mentioned. This has added stimulation to the work as well as 
having aided in the preparation of more workers for the future 
needs of ex-servicemen as anticipated. DISCUSSION OF RED CROSS PSYCHIATRIC SOCIAL SERVICE IN A 
MILITARY HOSPITAL _ 
BY 
CHARLES 0. STUJWEVANT, CAPTAIN, M.C. 
GARDINER GENERAL HOSPITAL. CHICAGO. ILLINOIS 
The development of psychiatric adjunctive services has been a 
military necessity productive of many varied and useful devices 
which have nermitted broader utilization of psychiatry. This 
paper illustrates how a circumspect, qualified psychiatric social 
worker may apply her talents in serving the multiple psychiatric 
needs in e general hospital. There are a number of Interesting 
special functions mentioned here which I believe merit emphasis. 
It is a safe guess that othershere have experienced a sense of 
frustration in wading thru a long and detailed factual history in 
search of information of practical value in appraising the patient. 
This is understandable when we realize that many histories obtain- 
ed thru Red Cross channels come from all over the country and are 
often reported by untrained individuals. But we have seen beauti- 
fully constructed histories reflecting training and experience, 
which seem to have lost their purpose in adherence to rote and com- 
position, Miss Glickman has attempted to remedy this fault in what 
she has designated here as a diagnostic social history, a psychia- 
tric history which is concerned ?lth dynamics of behavior at vari- 
ous levels in the individuals adjustment rather than a mere chroni- 
cle of.events and relationships. This type of history is the out- 
growth of certain needs in the evaluation of re tients in the mili- 
tary setting. The psychiatric social worker whose efforts are 
closely integrated with those of the psychiatrist soon becomes aware 
that disposition of patients is always a primary function which de- 
mands an answer to specific questions. The diagnostic history is 
designed to help thru ascertaining individual resources, how the 
individual has adjusted in the oast and, based on this knowledge, how 
he is likely to adjust in the future. This becomes the background 
for further psychiatric evaluation, recommendations for disposition 
and is the initial step in therapy, The patients attention is direc- 
ted toward an evaluation of himself and painful material is encoun- 
tered which lead to questions demanding immediate interpretation. 
How much of this may be done by the social worker depends upon her 
particular insight and how well her efforts are correlated with those 
of the psychiatrist. It should be pointed out that interpretations 
of psychiatrists and social workers may be at variance and that 
even psychiatrists do not always agree. At least the patient should 
have the benefit of a uniform approach upon which to build his 
understanding of himself. 
In addition to this work with patients in the neuropsychiatric 
section this program includes direct consultation with physicians on 
other services. I am sure that Miss Glicknan has found herself in 
the role of interpreter and teacher of the intricacies of psychoso- 
matic relationships on many occasions. It should be emphasized 
that the type of history developed about the presents inr problem and which strives to evaluate emotional factors and 
distinctly correlate then in the total picture of the disease is 
of particular importance when working with medical officers not 
too well founded in the conolexitiea of osychogenesis. 
I should like to commend the intern reting job done in olarv- 
ning an individualized occunational. therapy orogram, Kiss Olick- 
aan has worked closely with the occunational therapist in an 
attempt to reach natients with some tyne of occupational or re»- 
creational activity which would permit a constructive use of in- 
dividual interest In working out emotional difficulties. In some 
of the paintings we navo been able to trace the progress toward 
recovery. In one individual the strangeness felt toward his fami- 
ly and children became the basis for a Program of toy building and 
resulted in considerable alleviation of depression, I am sure this 
has been one of the most interesting and gratifying experiences in 
the osychotheroeutic effort of this hospital. MILITARY PSYCHIATRIC SOCIAL T/ORK 
lit All army mmn 
t/3 Robert Tf. Cruscr* 
When the aeuropsychiatrio soction of Percy Jongs Conva- 
lescent, Hospital was first activated in Septenbcr 1044, the 
role of the psychiatric social worker received careful consideration 
The object was to set up within tho military framework tho some 
coordination of psychiatry, psychology, and social work that * 
has for decades operated so well in civilian clinics.- For each 
company of one hundred patients there was to be a psychiatrist 
and a social worker; for each battalion of four companies, 
a chief psychiatrist, a chief social worker, and a clinical 
psychologist with one or more assistants. This basic pattern 
has required little modification as the section grow from 
battalion to regimental size. V/hon, in Juno 1945, the War 
Department issued Medical Technical Bulletin No. 154, en- 
titled Psychiatric Social Work, we were gratified to find that 
no changes of program or policy wore needed, and that we were 
already carrying on all of tho functions outlined in tho 
bulletin. 
In a paper as brief us this the early development of 
the program cannot bo outlined in detail, but a description 
of present social-work functions on the regimental, battalion 
and company levels will show how it eventually crystallized. 
The regimental psychiatric social worker is responsible 
directly to tho regimental connanding officer end chiof psy- 
chiatrist for tho professional quality of social work in the 
regiment. He supervises the battalion psychiatric social 
workers and delegates to them tho supervision of tho company 
psychiatric social workers. In consultation with the regi- 
mental and battalion commanders and the battalion psychiatric 
social workers, he establishes useful standard practices, 
makes arrangements for tho training of new workers and recommends 
suitable duty assignments. Ho coordinates and participates 
in a program of in-service training and is responsible for 
keeping the social workers oriented to their basic responsibilities 
and to changes of regimental program and policy. 
The battalion psychiatric social worker is responsible 
primarily to the battalion commanding officer and chief 
psychiatrist, and secondarily to the regimental psychiatric 
social worker, for two duties* (a) supervising social work in 
the battalion, and (b) actively participating in the battalion 
group therapy program. As cuso-work supervisor, he is re- 
sponsible for tho quality of social work in the battalion and 
for the professional development of workers on the job. In 
group therapy, he coordinates his activities with tho psychiatrists 
and psychologists, and conducts some of the meetings himsolf, 
or arranges for another qualified social worker to do so. In 
actual practice, most of the battalion social workers were also 
♦Chief Psychiatric Social Vfcrkor, First Regiment, Neuropsychiatric 
Section, Convalescent Hospital, Percy Jones Hospital Center, Fort 
Custer, Michigan. responsible for the social work of one company. 
The company psychiatric social worker functions as 
assistant to the psychiatrist in a specified company of the \ 
battalion, and his primary responsibility is to that psychia- 
trist. However, because the social workers in the battalion 
must frequently work as a pool, and because of the need for 
coordination, training, and establishment of standard prac- 
tices, he is also under the supervision of the battalion \ 
psychiatric social worker. Duties of tho company psychiatric 
social worker include* interviewing newly arriving patients 
individually, and evaluating and recording their social ad- 
justment; obtaining medical histories when previous records 
heed amplification; obtaining psychiatric social histories 
in oases specified by the psychiatrist; conducting a company 
counseling service along case-work lines; observing and re- 
porting on the adjustment of patients to their program; 
liaispn work between tho company and other agencies, such as 
the Rod Cross and the Personal Affairs Office; fostering 
the company cadre’s understanding and awareness of patient’s 
problems; occasional special assignments, as in group therapy; 
and, in general, working to define and improve standard's of 
case-work practice within the regiment. 
As the patient enters the battalion, ho is interviewed 
by each of the three members of the olinioal team. Tho social 
worker sees him first, and outlines tho local program and tho 
different functions of the professional staff. Vocational and 
classification matters and scheduling of tho regular daily 
program, a? well us psychological testing, are handled by the 
psychologists; medical matters are of course referred to the 
psychiatrist, but almost any other questions, except these 
handled routinely by tho company administration, can bo-cleared 
by tho social worker in his capacity as a company counselor. 
This is explained to tho patient, and in tho course of tho 
interview ho frequently brings up problems that can bo cleared 
up by administrative manipulation of the local environment, 
by giving information, or by referral to an appropriate agency 
such as Hed Cross or Legal Assistance. 
After this initial processing (which is briefly recorded), 
the patient goes on a convalescent furlough, in jno.st cases, 
and returns to his convalescent treatment program.-. The base, 
worker remains available for counseling, and fulfills among 
other duties some of the functions of tho Personal- Affaire 
counselors in non-psyohiatrlo sections of tho hospital. Psy- 
chiatric social histories are taken at the doctor’s request,_ 
and progress notes are recorded whenever there is a significant 
contact. Tho psychiatrist takes tho worker’s evaluation Into 
account in his final summary for the disposition board, and 
in many instances the worker attends the board. Throughout the, 
patient’s stay of perhaps two months there is a continuous 
coordination of tho three services for treatment and disposition* 
with fToquont brief, informal professional conferences, 1 
k wealth of case material lies in the completed records. Our experience has shown that the groat majority of case-work 
problems fall into two groupst those that can be quickly 
managed on a simple environmental basis or by referral, 
and those that are open or thinly disguised expressions of 
anxiety about dispositions. Underlying neurotic patterns 
group themaolvos around the duty-or-discharge insecurity 
so massively that any attempt to doal with other aspects of > 
the life situation often seems—irrelevant and trifling. Thus 
both military necessity and the patient’s own drives have 
oriented the professional services, including case work, toward 
settling the main questions of potential usefulness to the 
Army, and meanwhile furnishing an environment in which in- 
dividual strength are carefully fostered. • 
At first the social workers were all men, most of whom 
had spent at least a yoar in some other military occupation* 
Then the VJACs began coming, a few in December 1944, a group ' 
of fifteen in March 1945. From then on the sexes were about 
equally represented. Early misgivings about the effectiveness 
of ITACs with patients who lived in a barracks rather than a 
ward proved groundless, and they fitted into the professional 
organization very satisfactorily. Men and women have had the 
same type of work. 
Qualifications varied greatly, both in academic background 
and experience. Only four or five of the social workers had 
both a Master’s degree and several years’ experience in psy- 
chiatric social work. One or two lacked a bachelor's degree, 
but had had close contact with psychiatric patients for many 
years on a semi-professional level. Of the remaining twenty- 
odd, the typical social worker had had some graduate courses 
in social work and a fow years of experience with a public 
agency* 
The program of in-service training for social workers 
was kept to a minimum expense of time; we wore too busy to 
attend many mootings. Psychiatrists and case-work supervisors 
taught the newer and less experienced workers on the Job. A 
guide was prepared to outline standard procedures and practices, 
such as initial processing, and preparing psychiatric social 
histories. (Care was taken, however, not to carry standardi- 
zation to the point of hampering professional ability.) These 
measures still fell short in one way. Many of the workers, 
although skilled interviewers, needed to know more about some 
aspects of psychiatry in order to take more useful histories, 
a series of lectures and discussions was started, with all the 
workers in the regiment mooting for two one-hour periods each 
week. One of the battalion commanders. Captain Alexander 
Hirschfeld, lectured on psyohodynamios for one hour; the other 
hour was a discussion of case-work applications by Mrs. Margaret 
Schilling, Field Director of the American Red Cross at Percy 
Jones and formerly on the faculty of the University of Michigan. 
V/e feel that it has contributed notably to the effectiveness of 
our group. Group psychotherapy by social workers has intentionally 
boon kept to a definite) content. Tho worker led discussions 
on topics connected with tho social welfare of tho patients. 
Tho 6.1. Bill of Rights, National Service Life Insurance, 
Rconploynont Rights of Selective Service, Veterans * Preferences 
in Civil Service, location and function of state and federal 
veterans' agencies, of civilian psychiatric clinics, of social 
welfare agencies, and so on. Those discussions afforded an 
opportunity to stimulate healthy attitudes toward numerous 
questions of social adjustment. This led into the field of 
mental hygiene, the enunciation of whose principles became an 
important feature of tho social worker*s contribution. V/hen 
discussion verged on specific nodical problems, the workers' 
could better clarify the potential usefulness of a psychiatrist.. 
In intense givo-and-tako of those mootings there was often 
plenty of hostility worked off. . At tho same tine the worker 
had ah enlightening contact with ncralo problems of tho 
patients as a group. • 
This paper is written just after the- collapse of Japan, 
when both social workers and patients' are sharply confronted 
with post-war adjustment. Tho social workers have little to 
fear. Demand for their services cun bo expected to keep upj 
and they have lost nothing, except financially, by their military 
experience. Thoy have hud the unique opportunity to work in 
an authoritative sotting with largo groups of patients with 
neurotic or less serious diagnoses, most of whom have.been 
reasonably woll adjusted as civilians and as soldiers until 
the stress of combat led to a breakdown. The psychiatric social 
workers at Percy Jones agree that theih experience in the army 
has been valuable. In another papei* a'few impressions gained 
from this experience will bo presented. REFLECTIONS OF THE MILITARY PSYCHIATRIC SOCIAL 70RKER 
APPLIED TO CIVILIAN-CASE ViDRK PRACTICES 
Private First Class Vincent Garoffdem- 
and 
Corporal Howard Book* 
At the neuropsychiatric section of the Percy Jones Convalescent 
Hospital, the enlisted military psychiatric social workers have inter- 
viewed and recorded data on a large number of men who have been treated 
and discharged for psychiatric conditions. These men have been veterans 
of overseas service as well as, in the majority of cases, men with front- 
line combat experience. We have thus had an unusual opportunity to 
develop a body of observations and knowledge regarding the attitudes, 
conditions, and needs of these men. 
The enlisted military psychiatric social worker is in no ordinary 
relationship to the neuropsychiatric patient at Percy Jones. T'e live in 
the same barracks with them, share the same mess halls, use the same 
recreational facilities, and wo often become their intimate friends, VJe 
sometimes know more about them than appears in their clinical charts. Hence, 
we believe that our knowledge and understanding of these men has a complete- 
ness that is not to be found in the orthodox case worker relationship. Also, 
as members of the clinical team (psychiatrist, clinical psychologist, psy- 
chiatric social worker), we have participated in the evaluation of the 
patient's convalescence and, ultimately, his disposition. 
In this paper, our comrjents are restricted to that NP patient whose 
symptomotology, condition, and apparent needs were most frequently and, 
we believe, most characteristically present. It is this NP casualty that 
civilian agencies will need to be most knowledgeable about. This NP 
patient's condition corresponds to the clinical entity, the combat syndrome. 
This clinical picture was described yesterday in a paper by two neuropsy- 
chiatrists, Major Kersloff and Captain Brodsky, of the nouropsychiatric - 
section at Percy Jones, 
It is our general impression that, for the majority of men we inter- 
viewed, previous adjustmental history did not signify any notable dispo- 
sition to breakdown. Childhood, school, family, marital and employment 
adjustments were, for these men, reasonably effective. Those with 
strong neurotic backgrounds were, we feel, in the minority, and represent 
broadly those to whom we refer as the "usual social agency client". We 
did find and we did learn that their condition was almost wholly related 
to the nature of their military experience and the severity of their combat 
duty. 
Our experience has shown that these men assimilated and developed 
bewildering preoccupations with hone and family problems. This engrossment 
with family economic and health conditions became attached to an entangled 
in their anxiety state. Absence, idealizations, their lack of confidence. 
#Percy Jones Convalescent Hospital 
Fort Custer, Michigan their generalized sense of insecurity, all make current hone situations 
something which requires thoughtful and neticulous guidance. The burden 
of this work will fall almost entirely upon the civilian case-worker. 
The effectiveness of the military worker in dealing with these problems 
was limited, both by the feeling on the part of the patient that these 
problems would best be taken care of by an army discharge, and by the 
fact that the patient was still removed from the actual situation. 
These problems were discussed with the patient by all members of the 
clinical team and possible courses of action suggested. The civilian 
case-worker will have to take over from that point, in the specific sit- 
uation in which the veteran lives, with due regard both to the uniqueness 
of that situation and the individuality of the veteran. 
This, then, is, in general, the NP patient whom we know best and 
about whom we have developed certain conceptions for their further rehab- 
ilitation. Now for more specific suggestions. 
It would be a great saving of the discharged patient’s time and 
endurance, if civilian case-workers, and others were able to utilize the 
medical and psychiatric clinical records of these patients. Here are 
detailed accounts and chronological histories of hospitalization, of 
therapeutic measures, of response and of the sequence of treatment. If 
the civilian worker is forced to ignore this material.and, of necessity, 
t* proceed independently to prepare routine case data from this NP patient, 
the consequent waste will be only incidental to the Linediate hostile and 
uncooperative response of the patient. 
In many ways, these men have been ’’processed1’ into a state of unyield- 
ing infuriation. They have filled out countless forms and answered count- 
less questions and they have had to tell their story over and over again; 
their answers have become stereotyped. As the social work interview began, 
there was the unfailing and not unvehement, "What, again?" V/e too learned 
that by skilled use of their overseas records, we could avoid partly, at 
least, some of their impatience with the dizzying duplication of record- 
taking, history-taking, question-asking and guidance-giving, V/e can only 
hope that steps will be taken to make this information more accessible to 
the civilian agencies responsible for the handling of the veterans problems. 
Along with our recommendation for the use of these records, a word 
or two about the evaluation of one section, namely the military adjustment. 
Part of our work was to evaluate the patient's adjustment in view of a 
possible return to military duty. Under such circumstances the military 
adjustment of the patient was of paramount importance. In a civilian 
setting the veterans military adjustment should take on less importance 
than we were forced to give it. The case-workers evaluation of the 
individuals potential possibilities for adequate future social and economic 
adjustment should not be influenced too strongly by apparent irregularities 
during military service. In the day to day life of these men as civilians 
the stresses and strains which they will now face will not be as severe or 
as strange as th*se which they experienced in the Army, Bit these exper- 
iences should not be completely overlooked and the civilian social worker 
will be faced with the problem of evaluating the military adjustment of a 
veteran. The actual information will be meager in most cases and it would 
be a serious mistake to try to secure detailed information by prolonged questioning. The chance to forgot about arny experiences was, alnost 
without exception, an inextricable part of the "get out of the Arny" 
feeling which dominated these nen when we talked to then. 
A pertinent exanplo should help in clarifying this discussion of 
evaluation. It often happens that a soldier with a conplotely satisfactory 
and even praiseworthy military record is never advanced in rank even after 
two or three years service. There arc a multitude of reasons for this, 
none of which reflect upon the soldier. He is often resentful over this 
and in fact, disappointments concerning promotions has been recognized 
as one of the contributing factors leading to war neuroses. At all times, 
in dealing with this problem, it should be remembered that the veterans 
own evaluation of his military experiences will change as he becomes 
further removed in time, from these experiences, and the case-worker 
should keep pace with those changes. 
On first contact nany veterans will face the civilian worker with an 
attitude reflecting a type of distrust. Ho expresses this attitude in the 
statement "No natter what they do, the GI will be left holding the bag 
sooner or later," A cold factual comparison of present legislation with 
veterans legislation of the last war will do little to change this attitude. 
It can be changed best by action, action which is of immediate tangible 
assistance, to the veteran. Most efforts, hewever skillful, to present 
a morale building sales talk on any legislation now in force will have 
the opposite effect and will confirm his suspicions. Those opportunities 
which do exist in veterans legislation should be explained factually and 
related specifically to the veterans individual needs. Then, if he can 
qualify and receive direct benefit, that fact, in and of itself, will be 
sufficient to induce some revision of his distrust as to what happens to 
the ex-soldier. 
We too, learned that, if a patient needed advice or help from his 
legal assistance officer; or information about badk pay, awards, decora- 
tions; or advice regarding medical care, for his family; or his rights 
under the G,I, Bill—that it was not enough to tell him to see somebody 
else, in a certain building,‘blocks away, and then forget about it. We 
tried to get the answer ourselves. If we didn't have, or know the answer, 
we arranged for his appointment to get the answer. Then we made certain 
that the appointment was kept and that he returned to discuss with us 
what he had learned and what he had decided to do about it. In this way, 
the social worker participated in the developing adjustmental process as 
well as reinforcing his total relationship with the patient. 
Civilian case-workers must add a new tern to their conceptual appa- 
ratus. This is; "To sweat out." It is at once a penetrating concept of 
amy life as well as a critical description of a soldier's reaction to 
virtually all orders, all promises and, ultimately, his total predicament. 
It is a concept of resignation; but as a civilian this resignation is apt 
to become, instead, instantaneous aversion if the patient senses himself 
in a situation which represents a "sweating-out process," There is, 
already, some evidence of where this is most likely to occur. It is what 
can only be designated no "The Referral Run-around", and it is a practice 
which is guaranteed to delay as well as obstruct the rehabilitation of the 
discharged NP casualty. We believe it to be n matter of the first import- 
ance that this .referral run-around bo entirely absent in any casework with 
these nen. The real problems of Job-placement, medical care, Jiousing and family understanding nust be effected in terns of the patient’s total 
needs, uirectly. and not in any loose, indiscriminate referral manner. 
It nay appear that we have overemphasized the "let the veteran alone" 
approach in our concern about over-questioning, and his sensitivity along 
stated lines. In reality we have set the stage for another important 
suggestion, We believe it would be advisable to allow the veteran to "set 
his own pace" in the solution of his problems. The civilian worker will 
have one advantage which was absent in most situations when we interviewed 
the patient. That is, the veteran will have assumed the initiative in 
seeking assistance from the social agency. In our set-up he entered our 
initial interview as an apathetic if not unwilling participant. Subsequent 
appointments that suggested, unavoidably, a military order were rarely 
conducive to genuine spontaneous conversation. 
In the civilian environment the social and economic adjustment of 
the veteran will be his primary concern; he will have assumed some res- 
ponsibility for the solution of his own problems; and he will discuss 
these problems with more spontaniety than when he phrased answers in terms 
of "what effect v/ill what I say now have upon my discharge?" 
Allowing the veteran to "set his own pace" is, we think, basic to 
the important problem of restoring self-confidence. As the veteran sees 
the solutions to his varied problems being worked out with him on his 
own schedule he will develop insight and self-confidence far more effect- 
ively than if he felt himself "pushed" or "forced" to accept a solution. 
This practice nay be more time consuming, during the actual solution 
process, but we believe it will be worthwhile in the over-all picture of 
the veterans rehabilitation. CONCLUDING HikARKSi 
Colonel William U. Bleckwexln* If the attendance record 
is a criterion I am certain you will agree our meeting has been 
a real success. Vie have had a total of 702 individuals register 
in the two-days, Yesterday, by actual count, there were 450 
people In the auditorium. 
Ifcvy I express my personal appreciation for the remarkable 1 
cooperation of all who participated in this program? fool mqre 
than repaid for the. effort of arranging the program and details 
of the conference, The generous and constructive discussion of 
our distinguished guests has boon inspirational. I fool that 
this joint conference with all groups interested in post war 
carb of our nouropsychiatrically disabled will send us on our 
way with renewed hope and determination for the future. 
declare the conference officially adjourned. LIST OF DISCUSSALS OF PAPERS 
Dr. Franz Alexander, Chicago, Illinois 
Director, Chicago Institute for Psychoanalysis 
Eva Ruth Bal’cen, Fn.D., Chicago, Illinois (University of Chicago) 
Assistant Professor of Psychology in Department of Psychiatry 
Samuel J. Beck, ?h.D., Chicago, Illinois 
Michael Reece Hospital 
Major Nathaniel J. Berkwritz, Chicago, Illinois. 
Psychiatrist, Gardiner General Hospital 
Captain Francis J. Braccland (LC) USJiR, 'Washington, D. C. 
Chief, Division of Neuropsychiatry, Bureau of Medicine & Surgery 
Dr. Hugh T. Carmichael, Chicago, Illinois 
Associate Professor cf Psychiatry, University of Illinois 
Dr, Loyal Davis, Chicago, Illinois 
Professor of Surgery, Northwestern University Medical School 
Dr, Francis J. Gerty, Chicago, Illinois 
Professor and Chnirtion of Department of Psychiatry, Univ. of Illinois 
Dr. Frederick A. Gibbs, Chicago, Illinois 
Illinois Keuropsychiatric Institute 
Esther Goetz Gilliland, Chicago, Illinois 
Director of !£usic, Vfilson* Branch, Chicago City Junior Colleges 
Dr. Maxwell Gitelson, Chicago, Illinois 
Director cf Psychiatric'Service, Michael Reese Hospital 
Dr. hard C, Halstead, Chicago, Illinois 
Department of Psychiatry, University' of Chicago Medical School 
Dr. Ralph C. Haraill, Chicago, Illinois 
Associate Professof PsydHiatry, Rush Medical College 
Dr. George B. Hassin!, Chicago, Illinois 
Professor Emeritus, University of Illinois College of Medicine 
Lieutenant Commander R. S. Lourio, (l.C) USNR 
U. S. Naval Hospital,’ Great Lakes, Illinois 
Dr. John J. Madden, Chicago, Illinois 
Professor and Chairman, Department of Neuropsychiatry, Loyola Univ. 
Dr, L. J. Hoduna, Chicago, Illinois 
Associate Professor of Psychiatry, University of Illinois (List of Discussants - continued) 
Captain Ray S. Hiller, Chicago, Illinois 
Psychologist, Araed Forces Induction Station 
Dr, Clarence A, Neymann, Chicago, Illinois 
Associate Professor of Psychiatry, Northwestern University 
Dr, Eric Oldborg, Chicago, Illinois 
Professor of Neurology £ Neurological Surgery, University of Illinois 
Richard H. Page, Ph.D., Chicago, Illinois 
Psychologist, - Ho.ll & Lilas. 
Frances C, Pcrco, Chicago, Illinois 
Institute of Juvenile Research 
Dr, Lewis J. Pollock, Chicago, Illinois 
Chairman of Department of Nervous cl Mental Diseases,Northwestern 
Comnandor C, L, Reynolds (i:C) (JSNR, Groat Lakos, Illinois 
Chief of Neuropsychiatry, U, 3. Naval Hospital 
Clarence T. Simon, Ph.D., Evanston, Illinois 
Director, Speech end Hearing Clinic, northwestern University 
Dr. David Slight, Chicago, Illinois 
Professor of Psychiatry, University of Chicago Medical School 
Dr. Alfred P, Solomon, Chicago, Illinois 
Associate Professor of Psychiatry, University of Illinois 
Dr, Adrien H. Vcrbrugghon, Chicago, Illinois 
Clinical Associate Professor of Neurological Surgery, 
University of Illinois College of Modicino (Rush) 
Dr. Ra’TT’.ond VJ. '.'aggoner, Ann Arbor, Michigan. 
Director, The Hour©psychiatric Institute (Michigan) and 
Professor of Psychiatry, University of Michigan