NLM D00fl?6flo PROPERTY OF THE NATIONAL LIBRARY OF MEDICINE U.S. NATIONAL 1 LIBRARY OF MEDICINE NLM000878802 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN U.C,. .:.u"itieO"w Oeiie^L v )£[-<■-I TShe MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR VOLUME X NEUROPSYCHIATRY IN THE UNITED STATES BY COL. PEARCE BAILEY, M. C. LIEUT. COL. FRANKWOOD E. WILLIAMS, M. C. SERGT. PAUL 0. KOMORA, M. D. IN THE AMERICAN EXPEDITIONARY FORCES BY COL. THOMAS W. SALMON, M. C. SERGT. NORMAN FENTON, M. D. prepared under the direction OF MAJ. GEN. M. W. IRELAND The Surgeon General WASHINGTON : U. sTgOVERNMENT PRINTING OFFICE : 1929 Z\5 A£ nBe 3. Rank order of States from the standpoint of density of population related to the percentage of the total Army enlistments and of the patients of Base Hospital No. 117 from those States________________________________________________ 437 4. Rank order of States from the standpoint of their percentage of foreign-born pop- ulation related to the percentage of the total Army enlistments and of Base Hospital No. 117 patients from those States________________________________ 438 5. Rank order of States from the standpoint of their percentage of males 10 years and over engaged in agricultural work related to the percentage of the total Army enlistments and of the patients of Base Hospital No. 117 from those States---- 438 6. Comparison of distribution of types of occupation of Base Hospital No. 117 patients with certain other groups----------------------------------------- 440 7. Comparison of the 1919-20 follow-up group and the total Base Hospital No. 117 service in regard to physical classification---------------------------------- 44/ 8. A. E. F. physical classification of 1919-20 follow-up group in relation to condition in 1919-20________________________________________________________------ 449 9. Frequency of usage of diagnoses and physical classifications of psychoneurosis cases discharged from Base Hospital No. 117------------------------------------ 451 10. Comparison of the 1919-20 follow-up group and the total population of Base Hospital No. 117 in regard to diagnosis------------------------------------ 452 11. Condition in 1919-20 in relation to diagnosis in France------------------------ 453 12. Condition in 1919-20 in relation to diagnosis and physical classification-------- 454 13. Rank order of diagnoses on the basis of the percentage of those carrying on in civilian life in 1919-20____________________________________________________ 456 14. Ages at hospitalization in France of follow-up group in relation to condition in 1919-20_________________________________________________________________ 458 15. Distribution of cases within the normal, neurotic, fatigued, and disabled groups according to age_________________________________________________________ 459 16. Distribution of cases within each age group according to condition in 1919-20---- 459 17. Family and personal histories (positive and negative) in relation to condition in 1919-20, numbers and percentages_________________________________________ 460 18. Family and personal histories (positive and negative) of follow-up cases compared with 1,000 unselected cases from Base Hospital No. 117, numbers and per- centages _________________________________________________________________ 460 19. Relation of pre-war occupation to condition in 1919-20------------------------ 461 20. Relation of 1919-20 condition to pre-war occupation___________________________ 461 21. Rank order of percentage of men of each occupation of the 1919-20 follow-up group now able to work___________________________________________________ 461 22. Comparison of physical classification in the American Expeditionary Forces and the 1919-20 condition of the follow-up group, arranged so as to show cases dis- charged from the hospital before the armistice and during the armistice______ 463 23. Comparison of the 1924-25 follow-up group and the total Base Hospital No. 117 service in regard to physical classification__________________________________ 465 24. Physical classification of the 1924-25 follow-up group in relation to condition in 1924-25_________________________________________________________________ 466 25. Comparison of the 1924-25 follow-up group and the total population of Base Hospital No. 117 in regard to diagnosis_____________________________________ 467 26. Condition in 1924-25 in relation to diagnosis in France________________________ 468 27. Rank order of diagnoses on the basis of the percentages of those carrying on in civilian life in 1924-25____________________________________________________ 469 28. Ages of follow-up group in relation to condition in 1924-25_____________________ 469 29. Distribution of cases within the normal, neurotic, fatigued, and disabled groups, according to age_________________________________________________________ 470 30. Distribution of cases within each age group according to condition in 1924-25___ 470 31. Family and personal histories in relation to condition in 1924-25--------------- 471 32. The follow-up cases (1924-25) compared with 1,000 unselected cases from Base Hospital No. 117_________________________________________________________ 471 TABLE OF CONTENTS XIII Table Page 33. Relation of occupation (1924-25) of follow-up group and total patients of Base Hospital No. 117 to working capacity_________________________________ 472 34. Relation of condition in 1924-25 to occupation in 1924-25__________________ 472 35. Rank order of percentage of men of each occupation of the 1924-25 follow-up group now normal_________________________________________________ 472 36. Rank order of percentage of men of each occupation of the 1924-25 follow-up group now either neurotic or fatigued_________________________________ 473 37. Direct comparison of physical classification in France and condition in 1924-25 of the follow-up group______________________________________________ 474 list of figures Figure 1. Map showing the locations of army neurological hospitals during the Meuse- Argonne operation__________________________________________________ 326 2. Plan of psychiatric group at Bazoilles hospital center, A. E. F________________ 406 3. Plan of psychiatric clinic group at Savenay hospital center, A. E. F----------- 409 Appendix: A bibliography of American contributions to war neuropsychiatry. By Norman Fenton, Ph. D____________________________________________________ 477 Letter from Pearce Bailey, M. D., Stewart Paton, M. D., and Thomas W. Salmon, M. D., April 12, 1917, to the Surgeon General, United States Army__ 489 The Care and Treatment of Mental Diseases and War Neuroses (''Shell Shock") in the British Army. By Maj. Thomas W. Salmon, M. C______________ 497 SECTION I IN THE UNITED STATES INTRODUCTION Before the United States entered the World War, the attention of both the American medical profession and the public had been attracted by the prev- alence of some apparently new types of mental reactions under the stress of actual campaign. From the earliest days of the fighting at Mons, stories had come to the United States of strange new diseases apparently having their origin in the stress and special horrors of modern warfare and presenting problems in treatment and prevention that baffled the medical organizations of the armies that later were to become our allies. After making all possible allowances for exaggeration and highly colored lay reports of technical and medical matters, it was apparent that some new medical problems had arisen in connection with the reactions of the central nervous system to the new conditions of warfare. It was also apparent that a new type of casualty which might threaten most seriously the manpower of armies existed in the inability of human beings to stand more than a certain amount of exposure to the effects of high explosives, even though they escaped bodily injury. For these reasons the first published reports on the neurological and psychiatric aspects of the war were eagerly read by neurologists and psychiatrists in the United States who realized, even then, that the time might very soon come when they would be dealing with the same problems in troops serving under their own flag. The first impression to receive confirmation by reports from the scene of conflict was that relating to the increased incidence of mental disorders occa- sioned by war. It had been observed that not only in actual war but even in peaceful mobilization, such as that of our own Army along the Mexican border in 1916, there was a higher rate of mental disease among soldiers than in civil life. The discharge rate for mental diseases in the United States Army in 1916 was three times the admission rate for these disorders in the adult male population of the State of New York, one-tenth of all discharges for disability being for mental diseases, mental deficiency, epilepsy, and the neu- roses.1 Out of a group of 1,069 enlisted men discharged from the United States Army in 1912 on account of disability from all causes, more than 200, or practically 20 per cent, were found to be mentally diseased or defective during the year.2 Among the reasons adduced for the excessive prevalence of insanity among soldiers, the peculiar kind of stress which military life imposes upon psycho- pathic individuals was considered the most important. Many people are able to make satisfactory adjustments to life only with the greatest difficulty and under exceptionally favorable circumstances. On account of certain inade- quacies of character or personality, life presents to them complexities of which their fellow men are unaware. By means of fortunate changes in their en- 1 o NEUROPSYCHIATRY vironment, opportune withdrawals from difficult situations, and many other expedients not required by most people, individuals with serious detects in adaptation manage to get along in civil life with fair success. Others, who are able to make adjustments that are only partially successful, escape serious mishaps through a lot of charitable allowances on the part of persons with whom they come in contact and the support of these persons in critical situa- tions. In military life such aid is lacking. The individual who, with much assistance, only barely succeeds in making satisfactory adjustments, is here thrown upon his own meager resources. All kinds of personalities, some of them just able to adapt themselves to life under the best of conditions, must fit into the one iron mold which experience has shown to be best for the stern business of war. The result is a heavy incidence of those varieties of mental shipwreck that we call psychoses and neuroses, and the merciless disclosure of a large number of constitutionally inferior individuals.1 While it was assumed that with actual fighting the rate for mental disease rose sharply, what impressed American neurologists and psychiatrists most was the extraordinary prevalence of the neuroses,—functional nervous con- ditions that came to be known chiefly as "shell-shock," from the apparent association of these conditions with the high explosives used in battle. Accounts reached this country of the queer aura of symptoms that character- ized these cases, and many and varied were the interpretations advanced in the early reports in explanation of the phenomena of "shell-shock," so little understood at the time. There were descriptions of cases with staring eyes, violent tremors, a look of terror, and blue, cold extremities. Some were deaf and some were dumb; others were blind or paralyzed. In general, these con- ditions were associated with the central nervous system and the shock of exposure to the strain of battle under new conditions of warfare. There was much difference of opinion as to whether the causes of "shell- shock" were mainly physical or mental. Some were inclined to look for injuries to the central nervous system as the chief explanation for the production of this condition, others claimed that the disorder was mostly psychological. It was recognized that the appearance of neurological symptoms in certain cases could be accounted for by the physical effects of shell explosion, even without external injury. But there was considerable controversy about that group of "shell-shock" cases among patients exposed to shell fire in whom there may or may not have been damage to the central nervous system but whose symptoms were those of neuroses familiar in civil practice, colored in a distinctive way by the precipitating cause.1 Mott included them in his group of "injuries of the central nervous system without visible injury," holding that some unknown physical or chemical change must underlie such striking disabilities.3 Wilt- shire gave less weight to the factor of physical damage, though still recognizing its existence, and put the emphasis upon psychologic factors in his explanation of the phenomenon.4 There was common agreement upon one point, however, and that was the importance of the constitutional make-up of the individual exposed to shell fire as a contributing factor in shell-shock. IN THE UNITED STATES 3 Numerous observers at the front and in home hospitals noted the absence of "shell-shock" among the wounded. "Among scores of Canadian soldiers returned with severe head injuries," according to Farrar, "most of them shrapnel and gunshot wounds with loss of portions of the skull, symptoms of psychosis or traumatic neurosis have practically never been observed * * * trench neuroses occur usually in unwounded soldiers. " 5 The frequency of mental and nervous affections was remarked by medical writers in every combatant nation, and all agreed that the terrible conditions of modern warfare, with its new methods of fighting—high explosives, liquid fire, tanks, poison gas, bombing planes, the "warfare of attrition" in the trenches—contributed to the creation of a novel disease entity. At first called "shell-shock," this disease came gradually to be recognized as "war neurosis," a condition very similar to the neuroses of civil life, but highly colored by the terrifying influences of new conditions of combat. An American observer wrote that "the present war is the first in which * * * the functional nervous diseases ('shell-shock') have constituted a major medico-military problem. As every nation and race engaged is suffering from the symptoms, it is apparent that new conditions of warfare are chiefly responsible for their prevalence." J The Russians, in their war with the Japanese, developed the first army medical service in which mental cases were treated by specialists, both at the front and upon return to home territory;6 but this service was primarily for insane soldiers, the functional neuroses not being especially significant. It is possible that the neuroses may not have been distinguished from the pyschoses in previous wars. However, Read, who made a very careful study of the prob- lem, had this to say: "* * * war neurotic states have an intimate relation- ship with the conditions under which this great war was fought—the enormously high explosives, special trench warfare, poison gases, and horrors that were not present to any extent in previous wars. It is stated that no war neuroses were observed in the Boer War, where the methods were so different, but some traces were seen in the Russo-Japanese War."7 Though none of the sympto- matic expressions of war neurosis were considered new, all having been noted by the military surgeons in previous wars, still the great frequency of their occurrence in the World War wTas a decided novelty to war-time medical eXperience' REFERENCES (1) Salmon, Thomas W.: War Neuroses ("Shell-Shock"). Monograph, Mental Hygiene War Work Committee of the National Committee for Mental Hygiene (Inc.), New York. (2) Annual Report of the Surgeon General, U. S. Army, 1913, 238. (3) Mott, Frederick W.: Effects of High Explosives upon the Central Nervous System. (Lettsomian Lectures Nos. 1, 2, and 3). The Lancet, London, February 12, 1916, 331-38; February 26, 1916, 441-51; March 11, 1916, 545-53. (4) Whiltshire, H.: Contribution to the Etiology of Shell-Shock. The Lancet, London, June 17, 1916, 1207-12. (5) Farrar, Clarence B.: War and Neurosis. American Journal of Insanity, Baltimore, lxxiii, No. 4, April, 1917, 12. (6) Richards, Robert L.: Mental and Nervous Disorders in the Russo-Japanese War. The Military Surgeon, Washington, 1910, x.xvi, No. 2, 177. (7) Read, C. S.: Military Psychiatry in Peace and War. Lewis, London, 1920, 143. 42705—29----2 CHAPTER I ORGANIZATION PRELIMINARY PLANS UPON WHICH TO BASE ORGANIZATION During the first few months of 1917 it was apparent to the Surgeon General that the Medical Department of the Army was soon to be called upon to assume the performance of enormous tasks, many of them quite unrelated to military duties in time of peace, or even to the latest campaigns in which the United States Army had taken part. In other volumes of this history are to be found accounts of the methods by which plans were made for the mobilization of the medical, sanitary, and nursing resources of the country. Similar preparations were not lacking in the field of neuropsychiatry. Having in mind the desir- ability of being prepared at the earliest possible moment to deal with the new and formidable problem of war neuroses, the Surgeon General, in March, 1917, invited a committee of civilian neuropsychiatrists a to Washington, for a con- ference on the subject.1 This committee was part of a larger group, formed by the National Committee for Mental Hygiene, for the purpose of studying the possible neuropsychiatric needs of the United States Army in the event of our country's entry into the war. Appreciating the importance of mental disorders as a medico-military problem, and aware of the magnitude of this problem among European armies, this group was already at work laying plans for one or more psychiatric hospital units to be placed at the disposal of the United States Government when needed. ON THE MEXICAN BORDER As a result of the Washington conference the Surgeon General requested the committee to visit the Army camps on the Mexican border to study the pro- visions made in the United States Army, as then constituted, for the diagnosis of, and the care and treatment of soldiers suffering from, mental diseases.2 A careful study was made of the whole situation, including inspections of the larger military hospitals at San Antonio and El Paso, Tex., and the military prison at Fort Leavenworth, Kans. The committee was impressed with the high incidence of mental diseases in the Army. These diseases were found to be approximately three times as prevalent among the troops on the Mexican border during the previous summer as, for example, among the civil population of the State of New York.2 The committee noted also the uniformly high standard which characterized pro- visions for the diagnosis and treatment of physical disorders in the base hospitals visited, in contrast with the meager provisions for the care of the mentally « Dr. Stewart Paton, of Princeton University; the late Dr. Pearce Bailey, of the Neurological Institute, New York City; and the late Dr. Thomas W. Salmon, the medical director of the National Committee for Mental Hygiene. 5 6 NEUROPSYCHIATRY ill. It was apparent that special provisions would have to be made to meet adequately the needs that would arise with the participation of the United States in the European conflict. In its report to the Surgeon General (see appendix, p. 491) the committee outlined a plan for a central psychiatric unit of 110 beds to be established in connection with base hospitals near the largest concentration of troops, and a 30-bed unit for base hospitals elsewhere. It was recommended that such units be integral parts of military hospitals and that the psychiatrists and neurologists in charge of them be medical officers of the Army. Diagrams of these units, with a description of buildings, equipment, and personnel, were submitted. The usefulness of a psychiatric service was pointed out in connection with the handling of disciplinary cases, malingering, and other behavior problems among the troops. Such a service was deemed to be indispensable to the morale of a modern fighting organization. IN CANADA In May, 1917, a member of this committee 6 made a trip to Canada in quest of information concerning the management of the numerous problems arising out of the presence of mental and nervous disorders among soldiers. It was believed that valuable lessons could be learned from Canadian experience with neuropsychiatric cases, particularly in view of the similarity in geographi- cal situation between the United States and Canada with regard to the scene of war. The transportation of bodies of troops over the seas presented similar difficulties, and the same problems arising in connection with the reception, classification, and distribution of those invalided home would have to be met by our own Army. Evidence of strong neuropathic trends or mental diseases was found in many of the medical histories of returned Canadian soldiers. The predisposition to nervous and mental diseases or the actual existence of these conditions in slight degree, while readily and quickly demonstrable by a physician accustomed to look for them, usually passed unnoticed by the surgeon. Yet the frequency writh which these disorders occurred, and the certainty of their disabling char- acter, made the enlistment of men so affected a direct blow at the efficiency of the Army and a source of unnecessary expense to the Government and hardship to the soldier. In his report to the Surgeon General 3 the member of the com- mittee emphasized the importance of this phase of recruiting and recommended the assignment of medical officers of the proposed base hospital psychiatric units to duty at Army camps during mobilization. Another member of the committee c about the same time, visited Quebec, to observe conditions among returned Canadian soldiers at the discharge depot there. In his report to the Surgeon General4 he noted certain dispositions exist- ing in each patient prior to enlistment which, under the stress of war condi- tions, were particularly favorable for the development of nervous and mental symptoms, and suggested that it should not be a matter of great difficulty to eliminate from the service, in advance, a large proportion of the cases returned b Dr. Pearce Bailey. ' Dr. Stuart Paton. IN THE UNITED STATES i as "nervous and mental disorders." He also stressed the importance of bring- ing any psychological work in the Army into close union with the activities of the Medical Department, and described the great variety of the nervous and mental disorders found among the returned soldiers. IN ENGLAND In June, 1917, a member of the committee/ through the cooperation of the Rockefeller Foundation, was sent to England to secure, first hand, the most recent information as to the British and French methods of dealing wTith war neuroses in and near the theater of operations, to make observations on these methods, and to confer with medical officers in the British War Office. His report to the Surgeon General5 (see appendix, p. 497) confirmed observations and impressions of other members of the committee concerning neuropsychiatric conditions in the Canadian Army, and contained data that proved of great value in the preparation of plans for dealing with the problem of mental and nervous diseases in the United States Army, abroad and at home. The high rate of mental disorders in the British Army (one-seventh of all discharges for disability had been due to mental conditions), the difficulties in which the Allies found themselves as a result of failure to prepare adequately for the manage- ment of mental and nervous cases developing in combat, and the great problem created by the acceptance of large numbers of recuits who had been in institu- tions for the insane or were of demonstrably psychopathic make-up—these and other significant observations were among the most important factors determin- ing the course of American medico-military preparations. The foremost recommendation contained in this report called for rigid exclusion of all insane, feeble-minded, psychopathic, and neuropathic individuals from the forces which were to be sent to France and exposed to the terrific stress of modern war. Not only medical officers, but the line officers interviewed in England, had emphasized over and over again the importance of not accept- ing mentally unstable recruits for service at the front. As a result of these observations, it was believed to be within the power of the United States Army, by the adoption of an exclusion policy, to reduce very materially the difficult problem of caring for mental and nervous cases in France, to increase the mili- tary efficiency of the expeditionary forces, and to save the country millions of dollars in pensions. The next most important lesson learned was that of preparing, in advance of urgent need, a comprehensive plan for establishing special military hospitals for mental diseases. Here, again, it was declared that the United States could profit vastly by the experience of its allies by having at the disposal of the Army, before it began to sustain mental and nervous casualties, a personnel of specially trained medical officers, nurses, and civilian assistants, and an efficient mechan- ism for treating these disorders in France, evacuating them to home territory, and continuing their treatment, when necessary, in the United States. It was estimated that the annual rate of admissions of mental and nervous cases to British military hospitals at the time of this observer's visit was about d Dr. Thomas W. Salmon. 8 NEUROPSYCHIATRY 2 per 1,000 among the nonexpeditionary troops and about 4 per 1,000 among expeditionary troops, compared with a rate of 1 per 1,000 among the adult civil population of Great Britain. The greatest problem, however, both from the standpoint of the welfare of the individual soldier and of military morale, was that presented by the excessive incidence of war neurosis, a problem which proved to be most serious for all of the allied armies. Of 200,000 soldiers on the pension list of England, it was found that one-fifth were suffering from this condition. Among the chief recommendations resulting from this study were: (1) The establishment overseas of special base hospitals of 500 beds for neuropsychiatric cases, and convalescent camps in connection with these hospitals in the base sections of the line of communications; (2) the provision of special neuropsy- chiatric wards of 30 beds for the observation and emergency treatment of mental and nervous cases in base hospitals in the advance section of the line of com- munications; (3) the assignment of psychiatrists and neurologists from these wards to evacuation hospitals and more advanced stations as opportunities permitted. For the United States the following recommendations were made: (1) The provision of clearing hospitals, and clearing wards in general hospitals for the reception, emergency treatment, classification, and disposition of mental cases among enlisted men and officers invalided home; (2) legislation enabling the Surgeon General to contract with public and private hospitals for the con- tinued care of mental cases prior to discharge; (3) the establishment of recon- struction centers and special convalescent camps for the treatment and reedu- cation of returned soldiers suffering from war neuroses; (4) the appointment of a special medical board to inspect all Government hospitals and reconstruc- tion centers, public and private institutions caring for mentally disabled officers and enlisted men. Descriptive plans for hospital personnel and equipment, together with a diagram showing the scheme of care of the disabled soldier from the field hospitals at the front to his return home, accompanied the report. A concluding observation described the changing point of view in England and France, brought about by the war, with regard to mental and nervous diseases in civil as well as in military life. Whereas mental illness had been almost wholly ignored and the medical advances before the war dealt almost exclusively with physical diseases, the wide prevalence of the neuroses among soldiers was apparently leading to a revision of the medical and popular atti- tude toward mental and functional nervous diseases, and stimulating wide- spread interest in their observation and study. APPROVED PLANS The report of the observations on the Mexican border was promptly accepted and the plans suggested were approved by the Surgeon General who authorized the National Committee for Mental Hygiene e to proceed at once with the organization of the neuropsychiatric units recommended.1 To this end there was formed the Committee on Furnishing Hospital Units for Nervous • The origin and work of the National Committee for Mental Hygiene are described in "a Mind That Found It If" an autobiography, by Clifford W. Beers. Doubleday, Page & Co., New York. IN THE UNITED STATES 9 and Mental Disorders for the United States Government/ composed of repre- sentative neurologists and psychiatrists from various parts of the country. The American Medico-Psychological Association (now the American Psychi- atric Association) appointed a member of the association in each State to work with this committee. The American Neurological Association and the Ameri- can Psychological Association also appointed special committees to cooperate with the National Committee for Mental Hygiene. In Massachusetts the committee for war work in neurology and psychiatry was appointed by the governor with a view of organizing a neuropsychiatric hospital unit of its own for the use of the Government and to cooperate with the National Com- mittee for Mental Hygiene. Soon it became evident that the problem of organizing and equipping hospital units would be but one of a number of problems that would have to be considered, so that the Committee on Fur- nishing Hospital Units for Nervous and Mental Disorders for the United States Government widened the scope of its activities and changed its name to War Work Committee, making provision at the same time for subcom- mittees for the study of particular problems. On the authority of the Surgeon General J the War Work Committee early set about securing for the Medical Department a special personnel, cir- cularizing the medical profession and special hospitals for this purpose. There were received in all 795 applications for commission in the Medical Reserve Corps. After considering the special fitness of the applicants, the papers were forwarded to the Surgeon General, with indications as to the aptitude of the candidates, and with recommendations as to rank, based on professional standing.6 Commissions were granted to 564 such applicants. The committee also, in much the same manner, secured the names of nurses and attendants, and cooperated with the Surgeon General in regard to their induction into the service. It was from plans drawn by this committee that the type of neuropsy- chiatric pavilion for the camps was decided on.1 The committee also dis- tributed special literature and, in some instances, equipment to the neuro- psychiatric units and officers. It contributed $2,500 to enable a committee of psychologists to continue the investigations which resulted in the psycho- logical tests later adopted by the Medical Department of the Army." As the war proceeded, the committee continued to cooperate with the division of neurology and psychiatry of the Office of the Surgeon General and with the civil community. It assisted in making the arrangements by which recruits who became insane prior to or immediately after enlistment would be cared for by their own States; prepared a classified list of State hospitals, showing their standards, medical personnel, and methods of treatment and care of patients; and throughout the war helped in the solution of various professional problems which confronted the Surgeon General. f The work of this committee was first made possible through a generous gift made by Miss Anne Thompson, of Phila- delphia. Later it was financed by the Rockefeller Foundation. » Memoirs of the National Academy of Sciences, Vol. XV. Psychological Examination in the United States Army. Part I. History and Organization of Psychological Examining and the Materials of Examination. Part II. Methods of Examining: History, and Development, Preliminary Results. Part III. Measurements of Intelligence in the United States Army. Government Printing Office, Washington, 1921. 10 NEUROPSYCHIATRY DIVISION OF NEUROLOGY AND PSYCHIATRY, SURGEON GENERALS OFFICE The Surgeon General, appreciating the highly specialized nature of modern medical practice, organized in his office, in addition to the existing divisions, several others to direct and supervise all matters relating to the recognized specialties pertaining to medical science. One of these was the division of neurology and psychiatry,7 of which the section of psychology constituted a part. Later, the section of psychology was made an independent division.8 With the reorganization of the Surgeon General's Office in the latter part of 1918, the division of neurology and psychiatry ceased to exist as such, and became a section of medicine, under the direction and control of the chief of the division of internal medicine.9 Reference is made later to this arrangement. Prior to the organization of the division of neurology and psychiatry there was no neurological or psychiatric organization in the Office of the Surgeon General or in the Medical Department. A social and psychiatric department, organized at the Fort Leavenworth Disciplinary Barracks, had shown the value of psychiatry in relation to crime, delinquency, and disciplinary problem*.10 But no special examinations as to the mental fitness of volunteers were made at recruit depots or recruit depot posts, or of applicants for commission in the Regular Army. There was a small number of medical officers who were recog- nized as having a knowledge of psychiatry, obtained, for the most part, during periods of service to which they were detailed at St. Elizabeths Hospital (Gov- ernment Hospital for the Insane, Washington, D. C). With the exception of service at the Letterman General Hospital, however, the special equipment of these officers was not utilized by the Medical Department of the Army as it would have been had their professional interests been in another direction, as, for example, toward bacteriology. The creation of this division, therefore, opened a new field in the Medical Department, concerning which the following announcement was made by the War Department on February 8, 1918: n Officers with special experience in nervous and mental diseases have been added to the Medical Department of the Army. Such officers are detailed at all base hospitals and with many divisions. Most base hospitals have also special nurses and therapeutic appliances for the care of nervous and mental diseases. The services of these officers and nurses are available, through their superior officers, for consultation in all matters pertaining to such diseases. FUNCTIONS To the division of neurology and psychiatry was assigned jurisdiction over all problems relative to neuropsychiatry. This involved (1) preparing for the examination of recruits in the mobilization camps in order that those unfit for military service because of neuropathic or psychopathic conditions might be discharged; (2) preparing adequate facilities for the observation, treatment, and care of soldiers ill of nervous or mental diseases pending discharge; (3) pre- paring for the treatment of soldiers in the American Expeditionary Forces wTho became incapacitated because of nervous or mental disease; (4) preparino- for the continued treatment and final disposition of soldiers invalided home. The following were special problems to which the division gave immediate attention: (1) Mobilization of the psychiatrists, neurologists, and psychologists IN THE UNITED STATES 11 of the country for service with the Army. (2) Securing the enlistment of specially trained women nurses and male attendants for service in the neuro- psychiatric hospital units. (3) Devising methods of examination whereby large numbers of men could be examined by a few specialists in a comparatively short time. (4) Determining neuropathic and psychopathic conditions which, in the light of the European experience, should exclude from military service. (5) Preparing plans for a standardized neuropsychiatric hospital for Army use. (6) Preparing plans for a special standardized 500-bed reconstruction hospital for nervous and mental cases to be located in France. (7) Preparing plans for 30-bed units to be attached to the base and other military hospitals in France. (8) Standardizing equipment for Army neuropsychiatric hospitals. (9) Standardizing neurological, psychiatric, and psychological examinations for Army use. (10) Preparing special report blanks adapted to military use. (11) Arranging for the systematic collection and utilization of statistical data. (12) Arranging for special intensive courses in war psychiatry and neurology for the additional training of young neurologists and psychiatrists. (13) Collecting information pertaining to the situation abroad for the guidance of those at work upon the problem in this country. (14) The study of disciplinary problems arising in the Army. (15) Developing methods by which the work of the neu- ropsychiatric units could be coordinated with the medical military machinery. (16) Developing plans for the continued treatment in this country of nervous and mental patients invalided home from the American Expeditionary Forces. ADMINISTRATION A small administrative force was maintained in the Office of the Surgeon General, but for the greater number the neuropsychiatrists were placed on duty at the hospitals, camps, cantonments, posts, ports of embarkation, and dis- ciplinary barracks, both in this country and in France. The first efforts of the division were directed toward classifying and exempt- ing for neurosychiatric service the specialists whose applications were received daily in great numbers, in deciding upon assignments for them when commis- sioned, in recommending orders, and in attempting to coordinate its own activi- ties with those of other branches of the professional services. The last was a difficult task. The majority of the officers in the Surgeon General's Office at the time were fresh from civil life, most of them were without military experience, and many were without administrative experience. For a long time there was no officer or machinery to coordinate different interests, and many recommendations were made from all sides which overlapped or conflicted and which could not be carried out successfully. The result was that the different professional divisions in the office operated independently, with much inevitable confusion. Ultimately this was corrected, with the development and correlation of the various professional activities of the office. With the reorganization of the office, in the latter part of 1918, the division of neurology and psychiatry ceased to exist as such, and became a section of the division of internal medicine.9 This was considered by the chief of the neuro- psychiatric service an undesirable change as it interposed between him and the 12 NEUROPSYCHIATRY executive officer of the Surgeon General's Office another officer, who was given authority, but who was not required to possess any special knowledge of nervous or mental diseases, who presented to the Surgeon General recommendations which he did not initiate, and of which he had no first-hand knowledge. The stream of execution was also slowed up, as each interruption of a channel of action involved, even in intraoffice activities, an additional delay of at least 24 hours. Another disadvantage of this arrangement was that by it psychology was placed under medicine,9 when, in reality, it should have been under neuropsy- chiatry. While military psychology is ostensibly concerned with mental ratings and with the detection of mental deficiency—in other words, with a study of the normal mind and of the mind purely defective—it should not be forgotten that it constantly encounters medical problems of a psychiatric nature. Both the findings and the recommendations of psychologists concern psychopathology and consequently should go through the psychiatric officer and not the officer directing internal medicine. Consulting Service No authority was vested in the officers of the division of neurology and psychiatry, Surgeon General's Office except, on occasions of special detail, to make inspections, all inspection duties normally being performed by officers of the division of sanitation, Surgeon General's Office. Certain special inspec- tions, however, which were classed as consultations in reference to professional work, were made by members of the division of neurology and psychiatry. Some of the professional divisions of the Surgeon General's Office appointed officers known as consultants, who were assigned to different geographical regions for the purpose of consulting therein.12 This plan was not adopted by the division of neurology and psychiatry for the reason that it was always possible to secure War Department orders designating an individual officer as a consultant, and it was deemed wiser to use different officers for this purpose as the need arose. For example, when an officer assigned to some particular post developed a particularly successful system of treatment or management of patients or of making examinations, permission for his temporary relief was obtained from his commanding officer, and he was sent to posts in his neighbor- hood to consult with neuropsychiatric officers there, in order that they might benefit by whatever he had to tell them. Contract surgeons also were appointed for consulting purposes when they had special knowledge that would prove use- ful to neuropsychiatric officers on duty in their neighborhood. Practically all the officers detailed to this division were ordered from time to time to make trips to certain hospitals or camps for the purpose of ascertain- ing whether a more or less uniform standard of excellence in the neuropsychiatric services was being maintained. Consultations in California were made by a member of the staff of Mendocino State Hospital.13 This method of consultation in professional matters proved highly successful. Visits from outside officers to officers working at one point invariably resulted in an increase of interest in the removal of any obstacles that may have existed, and in improvement of the standard of professional work. IN THE UNITED STATES 13 Those who acted as consultants in base and general hospitals were assigned to the medical service and wTere usually referred to as neurologists, though in general hospitals in which psychiatric wards were established the consultations were conducted generally by the psychiatrists detailed there. There were many more demands for neurologists to serve in base and post hospitals and at detached points than could be met. They were supplied as freely as possible. They aided greatly in evacuation activities and in facilitating hospital business. When nerve injury cases began to be returned from overseas, neurologists were assigned to the various surgical services. Special Neuropsychiatric Reports The officer in charge of the division of neurology and psychiatry realized that in view of the large number of neuropsychiatric examinations which were to be conducted in the Army, an unparalleled opportunity was at hand for obtaining information concerning a group of diseases of great social importance, the incidence of which was unknown and, further, that, in order to correlate the data derived from the examinations made, certain reports must be prepared and submitted to the Surgeon General for study and compilation by the division. It is true that the examinations conducted in the Army applied only to men of military age, but the statistical data elicited from this source must offer a reliable index to the extent to which disease and defects of this character occur through- out the entire population of the country. It was believed that the time of the neuropsychiatrists should be largely occupied with their professional duties and that any forms adopted for the report of cases must be brief, concise, and practical. Another essential was that the report blank be so devised that the facts contained could readily be reduced to statistical form and made available for study. The following blank forms were adopted and distributed to all stations where neuropsychiatric officers were on duty: h Form 89 Medical Department, U. S. A. (Authorized Sept. 19, 1917.) Record of Neurological and Psychiatric Examination Surname of patient Christian name Rank Company Regiment or staff corps Examiners will record observations in the following sequence: 1 Record historv of syphilis, previous diseases (physical or mental), injuries, alcohol and drugs; chief symptom; duration of present illness; evidence of alcoholic or drug addic- tion- state of nutrition, flesh, hair, nails, skin, and muscles. 2 If paralysis, note distribution, character, and contracture. If tremor or tics, note distribution and character. Note station and gait. Of reflexes, note knee jerks and abdom- inals especially; Babinski. Of eves, note condition of pupils, nystagmus, double vision. If anesthesia, make chart showing distribution and different forms of sensibility affected. Note ataxia, taste, and smell. Note defects not previously mentioned.____________________ * These forms were prepared with the assistance of Dr. Horatio M. Pollock, statistician of the New York State Hospital Commission, whose knowledge and experience in this line of work rendered his advice particularly valuable. 14 NEUROPSYCHIATRY 3. Note behavior, attitude, emotional state, general motor condition; stream of thought, content of thought (compulsive ideas, obsessions, phobias, delusions, hallucinations, peculiar mental attitudes); mood (depressed, gay, suspicious, irritable, sulky, resentful); orientation; memory and thinking (past events, recent events; calculation); intellectual level (always in cases of mental deficiency; in other cases when possible); patient's interpretation of the development of the psychosis or neurosis and attitude toward it. 4. If diagnosis of mental defect i.s made, state method of examination and basis of conclusion. Place Date. Signature of Examiner , 191 Statistical Data Card Surname Christian name Rank Company Regiment or staff corps Diagnosis Nervous disease or injury ._.............______________ Psychoncurosis...............______________________ Psychosis________________________________________ Inebriety________________________________......... Mental deficiency_________________________________ Constitutional psychopathic state___________________ In line of duty? Date of injury or onset of disease________........_, 191 Reason for examination By whom referred? Place and date of examinatio n Age Race yrs._____mos. _________ Nativity Single Marital condition Married Widowed Divorced Legal residence Education None. Grades_____High School______College Home environment Urban Rural Economic condition Marginal Comfortable Previous occupation Army service Arms of service Rank Years Months (In U. S., P. I., Europe, or elsewhere (specify), with time in each) [/. S. Army. Accompanying diseases Wounds in engagements, with dates Injuries not received in engagements, with dates Diseases during army life, with dates and lengths of time in hospital Diseases previous to admission to Army Mental or nervous_____...........___________ Venereal___________________......__________ Others___________________ Abstinent Alcoholic habits Moderate Intemperate Family history Of mental diseases Of nervous diseases Of inebriety Of mental deficiency Other etiological factors Recommendation of examiner Disposition, with date Name and station of examiner Name U. S. Army. Station. Form 90 Medical Department, U. S. \ (Authorized Sept. 19. 1917.) COVER) IN THE UNITED STATES 15 Form 91 Medical Department, U. S. A. (Authorized Sept. 19, 1917.) Report of Completed Neurological and Psychiatric Examinations At----------------From_______________, 191 , to_____________,191 Submitted by______________________________________, Examiner Command, and organizations examined__________________________________ Strength of command Number examined d .5 1 Diagnoses Disposition of Cases Rank eated dispei rosis Inebriety iefi-onal it hie ■a o % A. E. F., that the number of troops then in France, many of whom had sailed before the neuropsychiatric examinations had begun, rendered imperative the services of a director for nervous and mental diseases. Consequently a n^lir«- psychiatrist was ordered overseas as a casual with recommendation that he be placed in charge of these matters—a recommendation which was complied with on his arrival.5 After that, assignments for service with the American Expedi- tionary Forces became increasingly frequent, being made to overseas base hospitals, evacuation hospitals, Base Hospital No. 117 (special hospital for war neuroses), and as casuals and replacements.6 Some younger officers were assigned to the liaison officer in London for the purpose of studying the methods of management of the war neuroses in the English military hospitals. Division Psychiatrists In January, 1918, on the recommendation of the division of neurology and psychiatry, the War Department created the position of division psychiatrist, with the rank of major,7 one for each tactical division. The creation of this position, which was the first recognition in the Army of the utility of specialists for troops in the field, proved of the utmost impor- tance. These positions were filled as fast as divisions were formed. The official detail of each of these officers was to one of the field hospitals of the division concerned, but they were generally given desks in the office of the division surgeons, from which points they could operate most effectively. Being with and a part of a tactical division, they were able to exercise the preventive side of their specialty to the utmost advantage. It was their duty to keep in touch with the mental health of the command and to familiarize medical officers serving with sanitary troops with the methods of neurology and psychiatry. During the training period they were available for all special examining boards. They directed the neuropsychiatric examinations of their divisions, supervised the preparation of the special reports to the Surgeon General, and saw to it that the recommendations of the neuropsychiatric examiners were promptly prepared for forwarding to general disability boards. They visited the regimental infirmaries and held informal conferences from time to time with regimental surgeons and company commanders. They were generally available for consultation and established a satisfactory cooperation with judge advocates, by means of which the mental state of prisoners or of those accused was established as a factor in their delinquency. Reports of the functioning of these officers overseas indicate that they assisted materially in maintaining the integrity of the commands to which they were attached and expedited the elimination of the unfit.8 Without them the prompt treat- ment of functional nervous disorders in the hospitals attached to the combat forces, which practically eliminated "shell-shock" as a military problem in our troops, would not have been possible. The duties of the divisional psychiatrists were to be as follows:9 (1) To examine or cause to be examined all cases of mental and nervous diseases occur- ring in the command. (2) To be available for all special neuropsychiatric examining boards convened from time to time for the purpose of examining IN THE UNITED STATES 27 the command. (3) To ask for the assignment of regimental surgeons to assist in the neuropsychiatric examination of recruits; this latter largely for the purpose of instruction of regimental surgeons. (4) To supervise the making of all reports of examinations in the specialty and the forwarding of them to the Surgeon General. (5) To see to it that the recommendations of neuro- psychiatric examiners were promptly prepared for forwarding to general dis- ability boards. (6) To hold from time to time brief informal conferences with regimental surgeons and company commanders in relation to the general subject of military neuropsychiatry. (7) In cantonments, to be available for consultation with medical officers stationed at base hospitals. (8) To visit frequently regimental infirmaries and, whenever invited, the nervous and mental wards of base hospitals. (9) To cooperate with judge advocates for the purpose of establishing in every division a method of treatment of delin- quents similar to that in successful operation at the disciplinary barracks, Fort Leavenworth. (10) Consultation service in reference to service battalions should such service battalions be established in connection with depot brigades or base hospitals. (11) To cooperate with psychological examiners and, if practicable, to arrange for psychiatric and psychological surveys of troops to take place at the same time and place. Division surgeons were to assist in every way possible to the end that the division psychiatrist should have the necessary facilities for carrying on his work, and especially in regard to desk room, stenographic assistance, and transportation. Contract Surgeons Contract surgeons were employed1 from time to time and proved valuable, as by this means were secured the much needed services of men of exceptional ability who were over age, or who, for other reasons, could not enter the military service for overseas dutv. FEMALE NURSES Second in importance to the mobilization of neurologists and psychiatrists was the recruiting of nursing personnel. The number of female nurses in the country trained for the care of mental and nervous patients was relatively small, compared with the great number of such patients in public and private hospitals, in contrast to the proportion and number of nurses experienced in general hospital care available for the physically sick. Every effort had to be made to conserve the supply of those experienced in neuropsychiatric work for the needs for the special wards and hospitals set aside for mental and nervous cases in the Army. To this end the Mental Hygiene War Work Committee secured the services of the superintendent of nurses of Bloomingdale Hospital, New York, who from the summer of 1917 until she assumed the duties of chief nurse of Base Hospital No. 117,10 the overseas hospital for war neuroses, devoted many months to the procurement of specially trained nurses for service with neuropsychiatric units in this country and overseas. The need for such nurses proved to be very great, and the National Committee for Mental Hygiene used all of its resources and contacts and developed others to stimulate recruiting from civil hospitals for mental and nervous diseases. Working arrangements 2nal discouragement and indifference. "Psychiatric ward," on the other hand, approximated, at least, and in some places largely attained, what the term implies in hospitalization—understanding and professional hope and activity. The "isolation-insane " building was a long rectangular building with windows and doors heavily barred on the outside and heavily screened on the inside, the interior broken into small cell-like structures stoutly maintained.5 The psychiatric wards, as will be more fully described later, were open, bright, airy wards, in some hospitals, without bars or mesh of any kind. The "isola- tion-insane" building was built in connection with the base hospital in a few of the early cantonments.6 The psychiatric ward was built in the majority of the cantonments, and these early wards represent the first step in the transition that took place in the Army. It was considered that each cantonment would need a special ward for nervous and mental patients, and plans designed by the National Committee for Mental Hygiene for psychiatric units of 30 beds were adopted for the cantonment base hospitals.7 The following equipment was proposed and approved for these units:' Electrical: 1 No. 7 galvanic, Faradic, and sinu- soidal wall cabinet, oak or mahogany, with meter, for direct current, 35 inches high, 22 inches wide, 113^ inches deep, with the following ac- cessories : 1 pair No. 649 green and red cords. 1 No. 756 plain handle. 1 No. 757 interrupting handle, style "A." 1 No. 1635 asbestos pad electrode, 5 by 7 inches. 2 No. 728 round asbestos disk electrodes. 1 motor generator set, J^ ampere, 110 volts, for operating wall cabinet on alternating current. 1 Excell high-frequency machine, with hot wire meter, oak or mahogany finish (no accessories). 1 rotary converter for operating Excell high-frequency machine on the direct current. 1 Excell high-frequency portable ma- chine, 10 inches high, 14 inches wide, 10 inches deep (no accessories). therapeutic lamp with plug and inlet cable. pounds lead foil, about 0.008 mm. lengths of 5 feet each No. 653 heavy insulation high-frequency cord. improved auto-condensation chair pad. 1 fulguration handle with set of three electrodes. Electrical—Continued. 1 surface vacuum electrode. 1 vacuum electrode handle and sleeve cap. Hydrotherapeutic: 1 combination douche apparatus, Xo. P-2281, without steam connection. 2 immersion baths, No. P-2108. 1 electric cabinet, type B. Psychological: 1 steel tape. 1 form board. 1 imbecile tests (Knoxj 1 picture memory test. 1 pictorial completion test. 1 construction puzzle A (Healy). 1 construction puzzle B (Healy). 1 aussage test. 1 500-learning test. 1 McCalliss test cards. 1 stop watch. 1 material for Binct-Simon test. 500 record blanks for scoring. 1 material for Yerkes point scale. 500 record blanks. Diagnostic: 2 reflex hammers. 2 stethoscopes (A/4832). 2 stethoscopes (A/4800). 1 blood pressure instrument. 1 hand centrifuge. 1 dozen lumbar puncture needles. 1 Zappaert-Ewing blood pressure count- ing chamber. 2 red blood counting pipettes. 2 white blood counting pipettes. IN THE UNITED STATES 41 Diagnostic—Continued. 1 outfit for taking \\ assermann blood specimens. 2 urinometers. 1 head mirror. 1 head band. 1 microscope. 1 Fuchs-Rosenthal's counting chamber. 2 white blood counting pipettes for spinal fluid. 6 gross slides, 3 by 1 inch. 10 boxes cover glasses, 22 by 22 mm. 200 test tubes, 6 by % inch. 2 alcohol lamps. 1 dozen urine sedimentation glasses. 1 opthalmoscope with electric battery attached. 2 pupil lights. Miscellaneous: 1 salvarsan administration outfit. Canvas camisoles with long sleeves. Protection sheets of canvas. Stretcher cots for transporting short distances the disturbed and delirious patients. Leather straps with buckles, 5 feet (3 straps to each cot). Tube-feeding outfit. Rubber sheets. Fountain syringe. Bed pans and hand basins. Physician's emergency handbag. Hypodermic syringe. Hypodermic tablets of morphia, strych- nia, hyoscine hydrobromate, paralde- hyde, magnesium sulphate, cascara, compound carthartic pills. This new ward was so arranged as to care for any type of patient that might be admitted—one portion, for the much disturbed, equipped with continuous baths, one for the semidisturbed, and another for the convalescent or quiet patients. Each portion was separated from the others; small dormitories were provided in each with rooms for individual patients in the disturbed section. It was intended that a medium iron-wire mesh should be used on the windows of these wards and not bars; through an inadvertence, however, some of the early building plans issued by the War Department called for bars.4 The situation of the local psychiatric officers with proper ideas as to physical standards was thereby made more difficult and in consequence the physical standards of the wards varied, depending upon the standards of the local officer himself, and his ability to convince his commanding officer that hospitals and not jails were being built. For a lieutenant or captain new to military service to convince a commanding officer of the "isolation-insane" school was no small task. But many of them succeeded. There were to be found, therefore, wards heavily barred, wards with bars confined to that part of the building used for disturbed patients, with mesh for the rest of the ward, wards with mesh for the disturbed portion and neither bars nor mesh for the part used by convalescent patients. While the physical standards of the wards varied from camp to camp, there existed almost throughout a uniformly high standard of care and treat- ment. Although some of the wards appeared more like jails than hospitals on the outside, they were hospitals in fact on the inside. The neuropsychiatric wards of the base hospital served a useful purpose. During the early days of the World AVar, they were used chiefly for the exami- nation and observation of recruits referred by the division psychiatrist. Later, they served the mental health needs of the various commands occupying the camps at different times. Since it was the understanding from the beginning that the insane would be discharged from the Army as quickly as possible, the neuropsychiatric wards were intended for temporary care only. Quite fre- quently, however, it was found that patients had to be retained in the wards 42 NEUROPSYCHIATRY for a considerable length of time, due to various unforeseen circumstances. These wards made expert care and treatment immediately available to any soldier becoming ill in the camp. With no more formality than obtained in entrance to the medical or surgical wards, patients could be brought to the ward especially provided for them. Patients who developed nervous or mental symptoms in other wards were transferred without formality to the special wards. Soldiers who, because of a nervous or mental condition, ran counter to the military laws and arrived at the guardhouse were transferred to the special wards. General prisoners, about whose mental condition there was question, were sent to the wards for observation. Recruits found unfit for military service because of mental disease and awaiting discharge were cared for in the neuropsychiatric wards until such time as proper arrangements could be made for their return home. Up to the time of the beginning of the armistice, the neuropsychiatric wards of the base hospitals cared for about 28,000 patients.8 IN GENERAL HOSPITALS The neuropsychiatric wards of the general hospitals of the Army were established in order to relieve congestion in the neuropsychiatric wards of the base hospitals. It had been thought that the neuropsychiatric wards of the base hospitals would be adequate to care for all cases of nervous or mental disease arising in the camps. It was soon found, however, that the rate of admission was such and the delays incident to transfer and discharge so great that further provision would be necessary. It was difficult to maintain an adequate personnel with the requisite experience at so many small units. It was decided, therefore, to use the base hospital wards as clearing houses and for emergency treatment only and to establish additional neuropsychiatric centers convenient to the centers of military population to which patients could be transferred for longer periods of treatment. Two methods for providing these additional facilities were considered: (1) The establishment of special neuropsychiatric hospitals; (2) the establish- ment of neuropsychiatric wards in connection with the Army general hospitals. Both plans obviously had advantages and disadvantages. It would have been easier, no doubt, to staff special hospitals more satisfactorily, as there needed to be assigned to them only officers with neuropsychiatric training. This would have reduced the friction and misunderstanding likely to arise when superior officers were unfamiliar with the professional problems of their juniors. A greater freedom, probably, might have been permitted patients; closer super- vision and direction to the immediate needs of the patients might have been had of the local machinery of reconstruction. On the other hand, had special hospitals alone been provided, professional isolation would have been increased and emphasized. The greatest obstacle to neuropsychiatry in both civil and military practice has been the barrier that tends to separate nervous and mental diseases from all other diseases, and it was thought by some that, in so far as the Military Establishment was concerned, the greatest good, both to the practice of neuro- psychiatry and to the patients who were dependent upon it, would be accom- IN THE UNITED STATES 43 plished if a determined effort were made to break through this barrier and to place the mental patient on a par with patients incapacitated by reason of other diseases. Not until commanding officers and others in authority realized that their responsibilities for the medical, the surgical, and the mental cases were the same was it considered possible to accomplish those things of which the well-trained neuropsychiatric officer is capable. It was thought that the establishment of neuropsychiatric wards in the general hospitals would empha- size this responsibility. Such a course, however, was not without its dangers. As a part of a general hospital the neuropsychiatric ward is a section under internal medicine, and the chief of the medical service has supervision over the neuropsychiatric ward. The success of the ward, therefore, is in part dependent upon the attitude of this officer and the ability of the chief of the neuropsychiatric section to cope with the double opposition that might be met in this officer and the command- ing officer. As a matter of fact, this plan of hospital organization was a hin- drance, in some instances, to the proper conduct of the neuropsychiatric work. On the whole, however, it did not cause the difficulty that might have been expected. In most hospitals the chief of the medical service assumed but a nominal oversight of the neuropsychiatric wards and placed full responsibility in the hands of the chief of the neuropsychiatric section. It is interesting to record, in this connection, that the officer frequently quickest to appreciate the service of the neuropsychiatric officer and to give him heartiest support was the line officer. Officers of the Medical Department of the Regular Army also, in most instances, gave their support. The officers with whom the neuropsychiatrists had most frequent difficulties were the offi- cers of the Medical Reserve Corps, commissioned from the civil medical profession. The significance of this observation lay in the sidelight it threw upon the teaching of neuropsychiatry in the American medical schools. The line officer frequently was faced with problems in personality and conduct that frankly he did not understand. He turned gladly, therefore, to the neuropsychiatric officer when he found that that officer could be of assistance to him. The officers of the Medical Department of the Regular Army for a number of years have been given a systematic course in neuropsychiatry. The larger knowledge manifested itself in a quicker understanding and appreciation of the problems of the neuropsychiatrists. The greater number of the officers in the Medical Reserve Corps, however, had had practically no instruction in neuropsychiatry. In most instances their school instruction had consisted of a few lectures, to- gether with a visit to a neighboring institution, where a few striking and bizarre cases of chronic mental disease had been demonstrated to them. Their expe- rience in practice largely had been limited to the sterile forms of legal commit- ment. Many medical officers, however, were as frank as line officers in admitting their lack of understanding of nervous and mental patients and spent many hours, when possible, in the wards studying patients in an earnest effort to inform themselves upon a subject in which they found a growing interest, and a subject of increasing value to them. Aside from the fact that the estab- lishment of neuropsychiatric wards in the general hospital would be an impor- tant step in breaking down the barrier that tends to isolate mental patients, and that through the presence of these wards the medical officer would come 44 NEUROPSYCHIATRY to a better understanding of the mental patient, the standards, methods of treat- ment, and possibilities of the modern neuropsychiatric clinic, it was realized that expert care would be available for patients on other wards who were show- ing nervous and mental symptoms, and that, on the other hand, expert con- sultation in other fields would be available to the neuropsychiatrists. The plan adopted, therefore, was that of special wards in the general hospitals, and five general hospitals suitably situated geographically were selected for the purpose:9 The Walter Reed General Hospital, Washington, D. C; United States Army General Hospital No. 6, Fort McPherson, Ga.; United States Army Base Hospital, Fort Sam Houston, Tex.; United States Army General Hospital No. 20, Fort Des Moines, Iowa; and the Letterman General Hospital, San Francisco, Calif. United States Army General Hos- pital No. 4, Fort Porter, N. Y., was a special psychiatric hospital opened espe- cially for mental patients returning from overseas, although it received also, at times, patients from neighboring camps.9 United States Army General Hospital No. 13, Dansville, N. Y., and United States Army General Hospital Xo. 34, East Norfolk, Mass., were also neuropsychiatric hospitals, but for over- seas patients, as were the special wards at United States Army General Hospital Xo. 1, Williamsbridge, X. Y. United States Army Hospital No. 30, Plattsburg, X. Y., was established for nervous patients from overseas, although some patients were transferred there from American camps.9 Later, with the more rapid return of patients from overseas, further neuro- psychiatric centers were opened in connection with United States Army Gen- eral Hospital No. 25, Fort Benjamin Harrison, Ind., and United States Army General Hospital No. 28, Fort Sheridan, 111.9 There was also a single neuro- psychiatric ward at United States Army General Hospital No. 2, Fort McHenry, Baltimore, Md.9 The original wards, however, and those designed to serve as a reservoir for the neuropsychiatric wards of the camp base hospitals, were those at Walter Reed, Fort McPherson, Fort Sam Houston, Fort Des Moines, and the Letterman General Hospital. Patients, whether officers or enlisted men, who presented symptoms of mental disease were transferred to these centers for care and treatment in the same manner as other patients. Such transfers were effected as follows- The patient whose symptoms were considered as requiring special observation and treatment was ordered for that purpose to the hospital designated The orders were obtained from The Adjutant General through the Surgeon General, having been first initiated by the commanding officer at the point from which the patient was removed. Thus the patient, whether officer or private, with menta symptoms, was transferred not as an insane person, but as any other patient^ Except m violent or essentially incurable cases the patients were retained in these centers for a period of time not to exceed four months » «vcWSitlPreVentmg ^/een!!stment of "Hie™ who had suffered from tic en er to [—"V * ** COmmanding officers of the neuropsychi- T^Zl^ mentd "^ ^'^ transWd ^ ^ '-t be no'ted on IX THE UNITED STATES 45 By relieving base hospitals of mental cases in this manner, congestion in the general medical services was lessened and a higher standard of care, with a proportionate increase in the ratio and speed of recoveries, was obtained. There was effected an economy of personnel, for even if it had been possible to supply base hospitals generally with a sufficient number of psychiatrists to treat mental cases, it would have been extravagant in the extreme. With the speedy evacuation of all cases presenting mental symptoms, it was possible for the neuropsychiatric work in a base hospital to be performed by one energetic and competent medical officer. As things turned out this arrangement was imperative, for, with the limited number of neuropsychiatrists available, the need of these officers at other points in the medical service did not permit the detail usually of more than one at a base hospital. The suddenness of the armistice brought about a great change in many of the arrangements which had been made for the treatment of nervous cases. Except for a geographical rearrangement of hospitals with reference to the homes of patients, there was no change in the plan of care for mental cases. It was found, however, as will be discussed in greater detail in the following pages, that war neuroses had ceased to exist as a problem, in that the number of cases from the American Expeditionary Forces dwindled, and those under treatment in this country made rapid recoveries. The cases which appeared in the home camps were less influenced by the change in the military situation. At Plattsburg Barracks, N. Y., where a special hospital was established for war neuroses, cases were put back on duty status faster than they were received, and consequently plans for another hospital of 1,000 beds at Carlisle Barracks, Pa., were abandoned. The practical end of the war brought into prominence the advisability, imperfectly realized before, of sending patients who were to undergo continued treatment to hospitals in the immediate vicinity of their homes. This required a rearrangement of hospital facilities for neuropsychiatric cases, especially with regard to the cases of epilepsy, and injuries of the peripheral nerves. It was planned, moreover, that cases of this character, as well as the insane, who required care after discharge from the Army, would be provided for in the vicinity of their homes by the Bureau of War Risk Insurance.10 CLASSIFICATION AND DISTRIBUTION OF OVERSEAS PATIENTS The importance of accurate clinical diagnosis as a basis for the classification and distribution of patients can not be insisted upon too emphatically as an important feature of treatment. From the dressing stations and field hospitals at the front, through the base sections and into the home stations, this principle is cardinal to successful functioning of the medical department of an army. In this country the two most important sorting points were the ports of debarkation at Hoboken, N. J., and at Newport News, Va., and of all the classes of cases returned, perhaps none presented such perplexing clinical problems as the nervous and mental cases. Many, if not most, of these patients were returned without records and without notes, the only indicating sign to the examiners who met them at the ports being a diagnosis written out or initialed on the field card. Then, in the cases of the psychoses and neuroses, a change 4(i NEUROPSYCHIATRY had often come over the patient since he was last examined by a medical officer, so that what may have been a correct diagnosis on leaving France was no longer correct, on arrival. Also, because of the refusal of the Navy, which had charge of all patients at sea, to transport large numbers of mental cases on any one ship, medical officers stationed at the French ports were forced, in order to evacuate their hospitals, to mark some patients as "X" or nervous, when in reality they were mild mental cases. To insure speedy distribution of the neuropsychiatric cases returned from abroad, psychiatrists were assigned to the ports of debarkation at Hoboken and Newport News.11 Cases were classified immediately upon arrival and evacuated to the proper hospitals as soon as possible.11 The following hospitals were designated by the Surgeon General on December 9, 1918, for overseas mental and nervous cases:12 EPILEPTICS AND MENTAL DEFECTIVES Walter Reed General Hospital, Takoma Park, D. C. Letterman General Hospital, San Francisco, Calif. General Hospital No. 1, Williamsbridge, N. Y. General Hospital No. 6, Fort McPherson, Ga. General Hospital No. 25, Fort Benjamin Harrison, Ind. General Hospital No. 26, Fort Des Moines, Iowa. General Hospital No. 28, Fort Sheridan, 111. General Hospital No. 29, Fort Snelling, Minn. Base Hospital, Fort Sam Houston, Tex. General Hospital No. 1, Williamsbridge, N. Y. Walter Reed General Hospital, Takoma Park, D. C. Letterman General Hospital, San Francisco, Calif. General Hospital No. 4, Fort Porter, N. Y. General Hospital No. 6, Fort McPherson, Ga. General Hospital No. 13, Dansville, N. Y. General Hospital No. 25, Fort Benjamin Harrison, Ind. General Hospital No. 26, Fort Des Moines, Iowa. General Hospital No. 28, Fort Sheridan, 111. General Hospital No. 34, East Norfolk, Mass. Base Hospital, Fort Sam Houston, Tex. NEUROSES, FUNCTIONAL General Hospital No. 30, Plattsburg Barracks, N. Y. DRUG ADDICTS AND INEBRIATES General Hospital No. 31, Carlisle, Pa. pitals wrere With the exception of General Hospitals Nos. 4, 30, and 34 these hos- s were chosen for the establishment of special neu^psycMatrif^ first, because they would reduce transportation to the minimum and T the' same time give wide geographical distribution- second becZ? T u enable all cases to be treated in the vicinity of Zlt T- I** WOuM made for the most economical u^t^^^^^ *» ^ IN THE UNITED STATES 47 General Hospital No. 4 was for a time devoted almost entirely to mental cases returned from France.13 As the bed capacity was soon taken up, it was necessary for General Hospitals Nos. 13 and 34 to be taken over for the care of insane cases. As the number of cases returned from abroad decreased and the population of these hospitals diminished, all the cases were transferred to the Soldiers' Home for Disabled Volunteer Soldiers at Hampton, Va., which previously had been Debarkation Hospital No. 51. On May 1, 1919, it was made General Hospital No. 43, for the care and treatment of mental cases. This hospital was used also as a classification hospital for other nervous condi- tions received from overseas through the port of Newport News.14 At the time of the transfer of these cases, General Hospitals Nos. 13 and 34 were closed.13 There was also a neuropsychiatric service in the embarkation hospital at Newport News.14 This service showed a steady increase in mental cases from the local camps from the beginning, augmented by the return of overseas cases. Eventually all mental cases from the American Expeditionary Forces were returned through the port of Newport News and taken directly to the hospital at Hampton, without long travel and with economy of personnel, as the patients were then treated in one hospital instead of three.13 The procedure followed is given below.14 PORT OF EMBARKATION, NEWPORT NEWS, VA. After November 11, 1918, emphasis was placed upon the reception of neuropsychiatric cases from France. This had long been a function of the embarkation hospital where patients were received in small groups; of 100 admissions to the neuropsychiatric ward in August, 1918, for instance, 30 were from overseas. By September 4, 1918, the accommodations at this hospital (for 38 insane and 60 nervous patients) were manifestly insufficient even for the immediate future. At this time it was recommended to the surgeon that 180 more beds be provided, this special need to be merged in the general need of a large debarkation hos- pital. The old Soldiers' Home at Hampton, which was transferred to the War Department by act of Congress, when opened as Debarkation Hospital No. 51, on November 17, 1918, contained 39 beds for the care of acute psychoses and 110 beds for neuroses. In January, 1919, accommodations for 50 more psychoses were provided and 2 wards of 60 beds each were nearly read}'. Before these new accommodations were available the U. S. S. Aeolus docked, on October 13, with 243 cases, divided as follows: Psychoses, 127; feeble-minded, 18; epileptics, 55; neuroses, 39; and 3 cases of organic disease of the nervous system. No warning was given; the force of attendants at embarkation hospital was crippled because of the influenza epi- demic; other ships were due. Under these circumstances special trains were requested to carry these patients directlv inland, and after a day's wait the psychoses and mental de- fectives were sent to Fort McPherson, Ga., and the others to Plattsburg, N. Y. Two patients hung themselves on the ship, one on the last day of the voyage and one while the transfer from boat to train was going on. The ship of necessity carried these patients between decks without lights from sunset to sunrise. The train trips were made without incident. When the debarkation hospital was opened on November 17, its first large group of patients was a convov of 300 nervous and mental cases. Notice had been sent ahead and a psvchiatrist had gone out to meet the ship and classify the patients, but unfortunately the ship'did not stop to take on a pilot. At the pier, a hospital boat was brought alongside, received the patients, and landed them at a dock inside the hospital grounds. One man dove overboard but was rescued unharmed. These patients were successfully transferred to interior hospitals. 48 NEUROPSYCHIATRY Subsequently other ships, each carrying two to three hundred mental cases, were un- loaded and a procedure developed which gave very satisfactory results in the transfer of these patients from ship to hospital wards. In brief this plan was as follows: (1) On advance information the neuropsychiatrist, with a detail of experienced enlisled men, reported at the pier as adviser to the medical superintendent of transports. (2) The medical officer and noncommissioned officer in charge of the detail boarded the ship and secured all possible information regarding the behavior of the patients from the ship's surgeon and attendants. (3) Quarters on the hospital boat or the routes to t he ambulances were inspected and attendants placed at strategic points, gangways, ports, stairways. (4) Patients from whom trouble could be expected were each placed in charge of an attendant and landed first. (5) Milder mental cases were grouped and taken next with several attendants. (6) At the receiving hospital patients were taken off in the same order and thus the more dis- turbed could be placed in the most protected ward and the patients who needed no special care could be admitted to the general medical wards when necessary. The custom of the hospitals with regard to diagnosis of general cases was followed. This meant the filling in before 9 a m on the day following admission of a "Classification for distribution" form, of which a synopsis is here given: 1-2. Name and identification, 3. Diagnosis 4. Classed as— Psychoneurosis. Epilepsy. Psychosis. Mental defect. Convalescent Peripheral nerve injury. Other medical groups; other surgical groups. 5. Ambulatory or bed patients. 6. Individual attendant Special care of litter. 7. Recommendations It was obvious that the future care of patients was dependent to a considerable extent upon the accuracy with which the diagnosis was made prior to entrainment for interior hos- pitals. If conditions were such as to limit the time which the neuropsychiatrist might expend in making the diagnosis the ratio of accuracy would be lowered. After numerous experiences the neuropsychiatrist of the port arrived at the conclusion that while, theoretically, the interests of the patient and the service alike would be best served by allowing more time for making the investigations upon which an accurate diagnosis must rest it was impracticable to secure more time without greatly interfering with general evacuation operations In other words, a port of debarkation, by its very nature can not become a place for scientific niceties of diagnosis. Therefore an endeavor was made to combine speed with accuracy That this succeeded is well illustrated by the experience and experiments described below ' A large group (300) was landed at the hospital dock at 6 p. m.. whence thev were enrolled and sent to the ward with Form 55a made out. The ward surgeons assigned each man to a bed and entered the number of the bed on the 55a slip. Supper was then served. Then four men at a time were taken, from each of the five wards, for delousing. Field cards from over- He^ whl t^W6 WafS ^ W6re matChed With th6 55a formB= alwa^s with s°™ discrepan- cies winch took time to adjust. A neuropsychiatrist stationed himself at the door of each class.' & ?a ' read thG fidd CaPd' 6ntered & diagnosis> »nd checked the appropriate Many diagnoses could be confirmed in a few seconds; epilepsv, for instance bv a historv of convulsions antedating Army service, or undiagnosed psychosis bv the presence of a^- delusional remnant or behavior disorder. It should be remembered'that such a diagno is had lit le of the significance that it had in civil life, merely meaning at the port that th psychotic was going to a hospital with the proper specialists to care for or dtacWe hto Therefore when epilepsy was the term used to describe a disease characterized l- convul^i «h!ch first appeared under shell fire, a change was made to psychoneurosis in orcS t*r.ak IN THE UNITED STATES 49 sure that the patient would receive specialized treatment The diagnosis "constitutional psychopathic state" covered such varied conditions that at first it seemed best to change it; later it was retained and its constituents separated by checking under classification, "psy- chosis, epilepsy, psychoneurosis, mental defect," according to the treatment the patient required. In questions involving mental defect, patients were referred to a psychologist for individual examination. After diagnosis and classification had been made by a specialist, the patient took his papers to the ward surgeon who completed them. The distribution papers were then ready with the papers from other medical and surgical wards for early action the next day after admission; from them were made up the travel orders which caught the patient in a system which landed him at an interior hospital. At times patients would remain several days before entraining, and many valuable clinical notes could be entered on their field cards. Unless an injustice was being done to a soldier, it was found best not to alter his diagnosis, since this meant disarranging complicated travel orders. Hospital trains formed a medical unit separate from the hospitals. For mental patients, however, the hospitals were asked to furnish additional neuropsychiatric attendants. The 35 enlisted men sent to the port by the section of neuropsychiatry, "to escort nervous and mental cases from the port to the general hospitals," were used here, as well as in the transfers from ship to ward and from ward to train. Berths were made without curtains and toilet rooms were specially guarded. Efforts were made to improve this routine. Attention was first centered on the short time allowed for diagnosis in these difficult cases. As stated above, careful consideration made the neuropsychiatrists feel that no increase in time should be asked if such an increase would give mental patients second place in travel arrangements. Next the question of discharging patients at the port was raised in an effort to help clear beds in interior hospitals. Certificates of disability for discharge were made out for 30 epileptics whose convulsions clearly antedated their enlistment and where treatment could not be expected to improve their condition. Contrary to some presuppositions, no difficulty was experienced in getting convincing histories. The result was that these patients were held about a month and then sent under escort to widely separated homes, a procedure which resulted in a multiplication of travel orders and a tying up of many Hospital Corps men in travel. The scheme was abandoned as having no advantage over immediate distri- bution to hospitals near homes. PORT OF EMBARKATION, HOBOKEN, N. J. For a time the neuropsychiatric cases received at the port of New York were debarked at Ellis Island, where they were cared for in special wards until they could be transferred to special hospitals for nervous or mental patients. The stay at Ellis Island was usually brief, the patients being trans- ferred in the course of a very few days. Because of this brief stay, little attempt was made at treatment of cases there, though every effort was made to provide for their care and for such emergency treatment as was required. Later the Messiah Home for Children in New York City was obtained by the Surgeon General for use as a clearing hospital (as part of United States Army General Hospital No. 1) for patients arriving at the port of New York (Hoboken), and the special wards at Ellis Islands wTere given up.15 The neuropsychiatric service at Hoboken was established in July, 1917. A director of neuropsychiatry was appointed by the surgeon of the port of embarkation as his personal representative to direct all the neuropsychiatric activities at the port. The duties of this officer, who had for years previously had charge of the largest psychopathic reception service in the country, were as follows: (1) To advise, assist, and cooperate in the organization of a special hospital for the care and evacuation of nervous and mental cases. 50 NEUROPSYCHIATRY (2) To organize and establish special wards in various hospitals within the port for the brief and temporary care of such cases. (3) To make official visits and act as consultant and to assist and advise with the commanding officers of the various hospitals in the examination, classification, and the general care of nervous and mental patients. (4) To examine and report special psychiatric cases that might arise within the port, including the mental examination of those who were charged with criminal offenses and in whom the question of mental responsibility arose. (5) To advise the personnel officer in the office of the surgeon in the assignment of medical officers having neuro- psychiatric training, to various hospitals as the necessity required. Because of the special and technical character of the work, the relation of the director to the neuropsychiatric service in the port and particularly to the special hospital, ward 55 (Messiah Home), General Hospital No. 1, had of necessity to be very intimate. Owing to the fact that nervous and mental patients were returned in large groups, the accommodations at the special hospital (Messiah Home) proved temporarily inadequate and, at various times, many of the milder cases had to be distributed to other hospitals until evacuated, which complicated the work of the division considerably. Notwithstanding this, in a service which is fraught with danger and where accidents, injuries, abuses, and complaints are apt to be frequent, such occurrences were happily rare. In transferring patients from ocean transports to the debarkation hospitals and from the debarkation hospitals to hospitals in the interior, patients were accompanied by attendants experienced in the transportation of mental and nervous cases. Reports of the elopement of patients and injuries received while in transit were few, and complaints as to condition of patients arriving were almost negligible.9 The following is a description of methods and equipment used in the transportation of mental patients:16 The equipment needed and the arrangements to be made for transporting mental cases will depend to a great extent on the mode of conveyance (train, automobile, steamship, etc.), the distance to be traveled, and the types of cases to be transferred. Under all circumstances, it is of first importance to provide trained attendants and nurses and to have in charge a physician experienced in the management of mental cases. If a large body of patients is to be transferred an effort should be made to classify the cases into groups, according to the severity of the symptoms and the amount of supervision needed. Mild and tractable cases.—These may be transferred by train or ship with little difficulty if their physical condition is good, and if properly supervised by trained attendants very little restriction of their activity is necessary. In railroad cars the doors should be locked and the windows kept down, except when opened for purposes of ventilation, and then they should be guarded by attendants. Suicidal cases.—Careful watching and considerable restriction of liberty on train and ship are necessary. Actively suicidal and disturbed cases must be managed as are excited patients next referred to. Excited and assaultive cases.—Doors must be kept locked and windows closed and blocked Wire screens over the windows (on the inside) may be used to prevent breaking of glass' \ cry disturbed cases should be transferred in a compartment sleeping car so that each patient has a room. In these cases canvas camisoles, with long sleeves, should be used to control destructive tendencies and prevent assaults. Some violently excited cases, or those with self-mutilative tendencies, require to be kept in bed under a protection sheet This can not IN THE UNITED STATES 51 be applied unless an ordinary single bed (hospital style) is available. In transferring excited patients short distances by ambulance, or from hospital to train or ship, stretcher cots should be used and leather straps provided for confining the patient to the cot. Delirious case*.—As these patients are usually seriously ill, they should not be trans- ported long distances unless it is absolutely necessary. They should always be moved on a stretcher cot and placed in bed as soon as possible on train or ship. Other equipment required for the handling of disturbed and uncleanly patients should include plenty of water and hand basins for cleansing purposes. Ample supply of underclothing and bedding, and rubber sheets to be used under unclean patients. A tube feeding outfit, consisting of a rubber tube with funnel attached (tube should be small enough to introduce through the nostril). A physician's hand bag or kit containing the usual emergency outfit, including also hypodermic syringe and tablets of morphia, strychnia and hyoscine hydrobromate; paralde- hyde, magnesium sulphate, cascara and compound cathartic pills should be provided. Foun- tain syringe and bed pans are also needed. STATISTICAL DATA There is no accurate record of the date and number of the first nervous and mental cases returned from the American Expeditionary Forces, but the first mental cases from overseas to be admitted to the first special hospital for such cases (General Hospital No. 4) was in the month of February, 1918, and the first cases of war neurosis were admitted to General Hospital No. 30, in May, 1918.17 The following neuropsychiatric cases had been returned from overseas up to June 30, 1919:17 otal Hoboken Newport News 3,597 2,715 882 504 149 355 416 302 114 762 410 352 2, SSS 1,675 1,213 51 51 6 6 95 95 8,319 5,403 2,916 42705—29---5 Psychoses (insanity)-----.....— Constitutional pyschopathic states Epilepsy.......----------------- Mental deficiency--------------- Psychoneuroses---------.....--- Alcoholism____________....... Drug addiction.......----------- Recovered--------------------- Total____________________ 52 NEUROPSYCHIATRY The following is a list of the mental and nervous patients transferred to general, base, and special hospitals from the ports of Hoboken and Newport News, between April, 1918, and June 30, 1919, with the hospitals to which they were admitted:18 Letterman, San Francisco----------------- Walter Reed, Takoma Park, D. C---------- No. 1, Williamsbridge, N. Y--------------- No. 2. Fort McIIenry, Md________________ No. 3, Colonia, N. J______________________ No. 4, Fort Porter, N. Y------------------ No. 5, Fort Ontario, N. Y----------------- Xo. 6, Fort McPherson, Ga________________ No. 9, Lakewood, N. J---------........---- Xo. 10, Boston, Mass_____________________ Xo. 11, Cape May, N. J------------------ No. 14, Fort Oglethorpe, Ga___......-------- No. 25, Fort Benjamin Harrison, Ind-------- No. 26, Fort Des Moines, Iowa------------- No. 27, Fort Douglas, Utah________________ No. 28, Fort Sheridan, 111_____.....-------- No. 29, Fort Snelling, Minn_______________ No. 30, Plattsburg Barracks, N. Y---------- No. 34, East Norfolk, Mass________________ No. 41, Fox Hills, Staten Island, N. Y_______ No. 43, Hampton, Va_____________________ Camp Bowie, Tex----------------------- Camp Custer, Mich---------------------- Camp Devens, Mass_____________________ Camp Dix, N. J_________________________ Camp Dodge, Iowa______________________ Camp Gordon, Ga_______________________ Camp Grant, 111_________________________ Camp Lee, Va_______________________,— Camp Lewis, Wash---------------------- Camp Meade, Md_______________________ Camp Pike, Ark_________________________ Fort Sam Houston, Tex__________________ Camp Shelby, Miss______________________ Camp Sherman, Ohio____________________ Fort Sill, Okla__________________________ Camp Taylor, Ky_______________________ Camp Upton, N. Y______________________ Post hospital, Jefferson Barracks, Mo------- St. Elizabeths Hospital, District of Columbia. Total. Mental tt v. i Newport Hoboken Ne£s 36 171 94 61 20 152 112 340 3 228 209 6 154 17 3 333 65 190 1 393 2 13 10 33 14 2 3 6 2 2 2 42 1 16 Mental defective Hoboken ^wport Hoboken | Newport Neurosis 2,929 1,161 1,393 7 1 1 16 1,024 3 1,150 A census of mental and nervous patients in military hospitals taken as of June 25, 1919, showred the following: 19 General hospital No. 1____________ No. 2____________ No.4____________ No. 5____________ No. 6......_______ No. 25___________ No. 26___________ Xo. 2S___________ No. 30___________ Xo. 43_____....... Fort Sam Houston. Letterman_______ Walter Reed_____ Total. Total 270 51 125 5 192 186 143 318 205 983 123 116 142 Consti- Psycho-ses Psycho-neuroses tutional psycho-pathic Mental defi-ciency Epilep-tics Others 44 states 18 138 21 18 31 16 15 6 4 3 ; 95 26 3 21 2 2 1 12 1 136 5 3 124 7 11 13 2 29 83 21 11 3 9 M 146 40 13 28 18 3 169 9 2 i; 693 90 72 117 10 i 59 13 12 4 30 54 9 3 28 4 18 100 12 3 3 12 12 1,648 470 165 238 89 249 IN THE UNITED STATES 53 Another census taken on August 12, 1919, showed the following: Hospital Total Psycho-ses Psycho-neuroses Epilepsy Consti-tutional psycho-pathic states Mental defi-ciency Walter Reed.....___ _____________ 123 117 80 40 47 194 132 178 95 117 1,087 67 58 53 21 12 14 89 138 54 73 868 38 29 8 15 24 131 23 15 24 19 23 6 14 1 7 12 9 2 9 37 5 Fort Sam Houston......______ 4 Letterman General____ ... _ 3 General Hospital No. l..._____..... 1 2 General Hospital No. 4_______ General Hospital No. 6...____ 1 12 7 5 9 2 11 8 General Hospital No. 25.....____ ____________ General Hospital No. 26._._. ___ _. . General Hospital No. 2S__. _ _ . ._ .__ _____ (General Hospital No. 43.....____ 11 s 2 59 4 14 135 Total______......._________ 2,210 1,447 349 64 156 194 NEUROSURGICAL CASES In the winter of 1918-19 officers specially experienced in organic neurology were ordered to certain of the general hospitals receiving wounded from overseas with the recommendation to the commanding officer that they be assigned to the surgical service.20 This recommendation was necessary because the organic injuries to the nervous system, although most of them had ceased to be surgical, were being treated in the surgical services. That this great mass of neurological material, approximately 5,000 cases, should have been retained under surgical control was not an altogether happy clinical arrangement from the standpoint of the division of neurology and psychiatry, but it was inevitable in view of the circumstances. The whole question of the proper organization for the care of this class of cases was considered important. Battle injuries of the nervous system are primarily surgical, being associated not only with open wounds but also with fractures. The best clinical arrangement for this class of injuries, at the front, is in surgical hospitals which are staffed as far as possible with the neurosurgeons and neurologists. If neurosurgeons can not be supplied in sufficient numbers the cases must be treated at the front by general surgeons. With the healing of the original wound the injury changes its type in the majority of cases. There are some cases which, when they reach the hospitals in the zone of the interior, still require operation, but these cases are in the great minority. At this stage the spinal cord injuries are hardly operable, some of the brain cases require secondary operations, and perhaps 15 per cent of the peripheral nerve palsies require surgical interference. But with these exceptions, after the original wound has healed, the majority have changed their clinical status and, though primarily surgical, now actually present problems with which a medical officer who is a neurologist by experience and interest is best fitted to deal. Those who have sustained cerebral injuries have been left irritable and subject to various symptoms, which makes personality study necessary before they can be readjusted to civil life; and the cases of peripheral nerve injuries which give promise of spontaneous repair require exact neurological diagnosis and treatment. 54 NEUROPSYCHIATRY Thus, at the close of the surgical wound period, injuries to the nervous system become, as a class, neurological cases. But a change in clinical status would have been difficult to recognize administratively. It was not done in the British medical service and it would have been impossible under the organization which obtained in our Medical Department. The original plan, as devised in the Surgeon General's Office, was that all these cases would be cared for in the United States in one or more special hospitals, under the brain section of the division of head surgery.21 But when these cases began to be returned in so much greater numbers than had been anticipated, it was found that the provisions for their care in the special hospitals established for the purpose at Cape May and Colonia, N. J., were inadequate both as to the number of beds and as to qualified personnel. And, in addition, it was found that civil interests demanded a wider distribution than had been provided for. These patients, like most of all the others, wanted to be somewhere near their homes. It became necessary, accordingly, to increase the hospitals designated for their special care. More than a dozen, geographically well separated, general hospitals were therefore designated for patients of this class on their arrival from overseas, the choice of the particular hospital being made with reference to nearness to the patient's home.21 The division of head surgery, Surgeon General's Office, having so many of its officers overseas, could not expand its personnel to meet this situation, and as there was no neurological service in the hospital organization of the Medical Department, the patients automatically fell to the division of general surgery, to which were assigned such neurologists and neurosurgeons as were available. REFERENCES (1) Annual Reports of the Surgeon General, U. S. Army. (2) War Diary of commanding officer, Letterman General Hospital, San Francisco, Calif., November 12, 1918. On file, Record Room, S. G. O. (3) Army Regulations, 1913, par. 464. (4) Plans on file, Finance and Supply Division, S. G. O. (5) Plan R2 (neuropsychiatric ward, base hospital). On file, Finance and Supply Division, S. G. O. (6) Letter from Pearce Bailey (chairman of the Committee on Furnishing Hospital Units for Nervous and Mental Disorders to the United States Government), to neurolo- gists, May 11, 1917. On file, Record Room, S. G. O. (7) Circular letter, Surgeon General's Office, September 5, 1917. (8) Based on sick and wounded reports sent to the Surgeon General, U. S. Army. (9) Annual Report of the Surgeon General, U. S. Armv, 1919 Vol II 1081-83 (10) G. O. No. 57, W. D., April 30, 1919. (11) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II 1083. (12) List of Hospitals Designated for Overseas Cases, Surgeon General's Office December 9, 1918. (13) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II 1082 (14) History of Embarkation Hospital, Newport News* Va., bv Maj. W c' Rucker U ?■ P. H. S. On file, Historical Division, S. G. O. ' (15) History of the office of the surgeon, Port of Embarkation, Hoboken N J On file, Historical Division, S. G. O. ' (16) Memorandum to Dr. Pearce Bailey, from Dr. George H. Kirby (Manhattan State Hospita ), Ju y 2, 19l,. ,ub?ect: Transport and transfer of insane soldiers. On file, Historical Division, S. G. O. IN THE UNITED STATES 55 (17; Letter from the Surgeon General, U. S. Army, to Hon. Edwin D. Ricketts (concerning shell-shocked and insane soldiers of the late war), August 21, 1919. On file, Record Room, S. G. O., 701.7. (18) Routine reports made by post surgeons to the Surgeon General, U. S. Army. On file, Record Room, S. G. O. (19) Based on reports made by commanding officers, showing the number of neuropsychiatric cases in the respective hospitals, by classification, as of June 25, 1919. (20) Correspondence. On file, Record Room, S. G. O., 210.31-1 (Neuropsychiatry assignments). (21) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1095, 1096. CHAPTER IV DETECTION AND ELIMINATION OF INDIVIDUALS WITH NERVOUS OR MENTAL DISEASE PRINCIPLES UNDERLYING NEUROPSYCHIATRIC EXAMINATIONS One of the most important duties of the neuropsychiatrists in the military service during the war was the elimination, at the time of their preliminary examination and before they were actually enlisted or inducted into the Army, of individuals with mental or nervous disease. Many of the purely physical disabilities wdiich were noted and waived by mustering officers, or which dis- qualified recruits from service, were susceptible of improvement or cure by treatment, or got well of themselves under the favorable conditions of military training. This was rarely the case for any nervous or mental disease. On the contrary, the longer the training period was prolonged, the more pronounced these conditions became; the soldier was more and more constantly reported at sick call, or was suddenly seized with a nervous or mental collapse, or got into trouble by reason of repeated, and often unnecessary, military delinquencies. The strain of actual warfare, particularly of expeditionary warfare, with the unavoidable homesickness, loneliness, and depression—to say nothing of its actual physical dangers and hardships—brought first to the breaking point those whose morale, by reason of a general instability of the nervous system, could not be maintained. While such men usually were ultimately detected and discharged, it was not until after a considerable period of training during which they received pay, maintenance, and equipment, wasted the time of those endeavoring to instruct them, interfered with the training of their brighter or better-adjusted comrades, and occupied hospital beds which often were urgently needed for others. Another unfortunate feature of the acceptance of such men for military service was that many of them, while unable to adjust themselves to the military environment, might be useful citizens if permitted to remain in their accustomed surroundings. Left on the farm or in the factory or store, where their associates were accustomed to their peculiarities, they might prove of material service to the country in time of war. Furthermore, if men of this type became soldiers, they were almost certain in the future to present a serious economic problem to the country. Under the provisions of the selective service act, which was in force during the period of the war, all soldiers were regarded as physically and mentally sound when accepted for service. If, after a short period in the Army, a soldier was neces- sarily discharged by reason of mental or nervous disability, be became a bene- ficiary of the Bureau of War Risk Insurance (later called the United States Veterans' Bureau), and thus was entitled to governmental compensation and hospital care. Nervous and mental disorders constituted a substantial propor- tion of ultimate disabilities.0 Many of the former soldiers discharged by reason • In February, 1927, es-service men with neuropsychiatric disabilities constituted 46.7 per cent of all patients receiving hospital treatment as beneficiaries of the United States Veterans' Bureau. (Hospital Facilities by Coordination Areas for U. S. V. B. Patients, as of Feb. 26,1927. Issued weekly for administrative purposes by Evaluation Division, Coordination service United States Veterans' Bureau. Copy on file, Historical Division, S. G. O.). 57 5S NEUROPSYCHIATRY of nervous or mental diseases are drawing compensation from the federal Government, some with a rating of total permanent disability. A large propor- tion of these men rendered practically no service to the country, their time in the Army having been spent in base or general hospitals, or under observation for the defect which in a short period after induction or enlistment resulted in discharge. . Before we had entered the World War, the possibility of conditions was appreciated bv only a small group of the civil medical profession; it was not surprising, therefore, that they were not accepted at their face value, imme- diately, by the regular line and medical officers of the Army, who exhibited, perhaps, less indifference and less reluctance to accepting them, in principle, than civil authorities or general medical organizations were in the habit of doing prior to the demonstrations of their practical importance furnished by the war. The introduction of novel and special examinations of so many kinds created great administrative difficulties immediately, as they interfered with established military routine, and it probably was this factor, rather than any lack of open-mindedness as to their usefulness, that was the basis of such opposi- tion as was made to them. Division surgeons complained that specialists inter- fered with the prompt getting in order of their camps, which was true, and line officers were not hard to find who maintained that if the specialists did not stop eliminating the unfit, there would be no army left. Many medical officers, not distinguishing between physical and mental disorders, halted considerably before they embraced the belief that the training which transformed poor physical specimens into robust fighting men did not have the same effects upon recruits with nervous or mental disabilities. Occasionally line officers, taking things into their own hands, looked over candidates recommended for rejection, decided that, as the men looked all right to them, they probably were all right, and then waved aside the recommendation for rejection or discharge. Ulti- mately it was discovered, however, that nervously unfit men were a great embarrassment to the American Expeditionary Forces. On July 15, 1918, General Pershing cabled to the Chief of Staff as follows:1 Prevalence of mental disorders in replacement troops recently received suggests urgent importance of intensive efforts in eliminating mentally unfit from organizations new draft prior to departure from the United States. Psychiatric forces and accommodations here inadequate to handle a greater proportion of mental cases than heretofore arriving and if less time is taken to organize and train new division, elimination work should be speeded. Upon receipt, by the Surgeon General, of this information, the matter was taken under consideration by the chief of the division of neurology and psychi- atry, and the following information, based upon reports made to the Surgeon General by neuropsychiatric examiners, was submitted to the Surgeon General by the chief of the division, with his recommendations: 2 1. Apropos of the attached cablegram from General Pershing, the foUowing data are submitted: A survey of the records in this office shows that the divisions that have gone abroad have carried with them the following number of men who had been recommended for discharge as unfit for military service by the psychiatric examiners: IN THE UNITED STATES 59 Division Number of men Division Number of men Division | Number of men Division Number of men 4th---------- 48 34th.....____ 21 181 138 271 130 244 25 273 77th___________ 5 78th.........____ 208 79th......______ 73 80th___________ 90 81st___________ 3 82d___________; 120 83d___________i 53 84th___________ 38 85th___________ 45 27th___________ 21 35th.......____ 28th__________! 93 36th________ 29th----------- 166 37th__________ 29 30th-----------i 152 38th_____ 31st___________ 52 39th 90th___________ 44 32d___________ 32 40th_______ 33d___________ 44 42d___________ Total_____ - 3.035 2. The men enumerated above are epileptics, dementia prsecox, general paretics, tabetics, psychoneurotics, imbeciles, etc. Because of their condition, these men are totally unfit for military service, and become a burden upon the Government either immediately upon landing, or shortly afterwards. The psychiatric service abroad is equipped only to care for men who become incapacitated in line of duty. Three thousand cases thrust upon this seivice almost en masse will tax the resources seriously, as it is evident has been done from the cable of General Pershing. 3. Attention is called to the fact that the numbers of cases carried over by different divisions differ markedly. Three divisions (41st, 76th, 91st) carried no men who had been recommended for discharge. The 81st carried 3; the 77th, 5; the 42d, 273; the 37th, 271; the 39th, 244, etc. It is evident, therefore, that the S. C. D. boards in the different camps vary either in the importance they attach to nervous and mental disease, or in the expedition of their work. Complaints have frequently been received on the length of time necessary to discharge men who have been recommended to the boards. An inquiry recently made in a few camps shows the following variations in time: Camp Dix, average time 5 days. Camp Jackson, previous to July 1, average time 24 days; since July 1, 12 days. Camp Fremont, 21 days. Base hospital, Alexandria, La., 23 days. 4. In order to obviate the difficulties arising in the American Expeditionary Forces, as mentioned by General Pershing, it is suggested that an effort be made to expedite S. C. D. proceedings, and that the importance of excluding recruits who are nervously and mentally unfit for service be drawn to the attention of S. C. D. boards. REASONS FOR REJECTION OR DISCHARGE The War Work Committee of the National Committee for Mental Hygiene appointed a subcommittee to study clinical methods and standardization of examinations and reports. The subcommittee soon rendered a report to the War Work Committee, which submitted to the Surgeon General, in July, 1917, a memorandum containing various suggestions pertaining to examinations of recruits, and giving a list of diseases, symptoms, and groups of symptoms which it was thought should exclude from military service, regardless of ultimate diagnosis. On August 1, 1917, the Surgeon General issued general directions to examiners based on these suggestions.3 (See p. 66). There was little question about clearly defined types. Xo commanding officer would accept, knowingly, a man who was actively hallucinating, and an epileptic fit which was verified was equivalent to discharge. More important than the patent nervous and mental diseases, for an understanding of the general philosophy of rejection by reason of nervous and mental conditions was a knowledge of the mental states of unstable individuals whose unfitness for service was not on the surface, the advisability of whose rejection frequently was questioned not only by line officers, but by medical officers. 60 NEUROPSYCHIATRY THE PSYCHOPATHIC PERSONALITY Viewed from the standpoint of personality, human beings of the group called psychopathic have been so from youth, and produce, under certain conditions, characteristic behavior. At the time of any single examination the symptoms they present (and even these may be put down as conclusions on the part of the overzealous examiner) may be no more definite than irritability, inability to control the passions, suspicion, resentfulness, particularly to discipline, depres- sion, and general egocentric tendencies. These evidences, slight in themselves, gain an additional significance when associated together characteristically, or when, as they usually can be, they are shown as characteristics by which the individual has been conditioned throughout his whole life. The behavior of such persons under military conditions is inconsistent with military efficiency. They are not of the stuff of which soldiers are made—which is the real issue so far as the Army is concerned. They are persons who can not give the service required, and no system yet devised will make them adequate. The question to be determined, then, at the examination of a recruit, before the Army assumes charge of him, is whether his make-up is such that his behavior, with practical certainty, will be inconsistent with service. These examinations undertake to recognize at the outset, before the Government assumes liability, the type of person which the Army will be forced to recognize sooner or later. The behavior aspect is more likely to be noted than the health aspect, as is shown by the fact that soldiers are so often referred directly to psychiatrists by company commanders. What the psychiatrist attempts to do is to discover immediately and directly what otherwise it might take several expensive months to find out. The candidate may have been treated for mental disease and may be sane now; he may have had epileptic attacks but none for a long period; he may have been addicted to the use of a drug and may have discontinued the habit; or he may have none of these serious disabilities and still may have met difficult situations in the past in such an abnormal and unsatisfactory manner—not through lack of "will" but because of a fundamental disorganization of his personality—that he may be counted on to meet those of the future no more satisfactorily. If individuals of this category are not recognized they fail the Army in some of the following ways: By having attacks of mental disease; by the development of neuroses; by reappearance or increase of epileptic attacks; by the kind of delinquency which results from a mental or temperamental inability to adjust to the restrictions of military discipline or to profit by punishment. Perhaps the most frequent and important reaction of the psychopathic personality to the trying exactions of war, or even to life in the Army, is the neurosis—a condition difficult to conceive of dispassionately in actual practice, because the manifestations and complaints of the neurotic seem so closely akin to malingering. A neurosis is the psychopathic means of evading a difficult situation. It may be primarily mental in character (psychasthenia), or it may present symptoms closely simulating those of organic injuries or diseases (hysteria). IN THE UNITED STATES 61 Overseas the neuroses developed in large numbers both in the base sections and at the front. Although the method adopted of treating the acute cases which developed during battle, in the divisional and army hospitals, greatly decreased their numbers, there were still many in whom the symptoms persisted in a disabling way until the armistice was signed, and some in whom they per- sisted after that. These persistent symptoms showed plainly that the persons presenting them were of a psychopathic type and might have been recognized at the time of enlistment, and by whose rejection the Army would have profited. As it must now be conceded that there is a large class of recruits who are bound by neurotic behavior to be a burden instead of an asset to the Army, the only questions that remain are whether these individuals can be recognized beforehand, and what, if any, distinction should be made between them as to possibilities of service. METHODS OF ELIMINATION Owing to the absence frequently of outstanding physical defects, the detection of mental and nervous defects in individuals during the physical examination prior to entry into the Army is frequently rendered most difficult. In times of peace, when enlistment is on a voluntary basis, and the number being examined at any place each day is not large, it is possible for an experienced examiner to detect the majority of applicants of this type. Prior to our par- ticipation in the World War, however, with the Army recruited in this manner, the number of discharges each year on account of neuropsychiatric disease was never large. Following our participation in the World War and the consequent rapid mobilization of men of draft age, it became evident that skilled recruit examiners were not available in sufficient numbers. In order that qualified examiners might be available at all camps, each professional division of the Office of the Surgeon General, as noted heretofore, designated certain of the officers exempted to that division for duty at the camps as examiners in their particular specialt}'. From the beginning of the mobilization the examinations were carried on at officers' training camps, cantonments, recruit depots, and recruit depot posts, and at all points where registrants or volunteers were being mustered into the service. At first two chief methods were employed: Examination of referred cases, and general surveys. By the method of referred cases, only such cases as were referred to the neuropsychiatrist were examined. The references were made by regimental surgeons and company commanders. It soon became obvious that this method was inadequate, as by it only men with evident defects were referred, and then generally after long and unnecessary delay. Further, the officer who made special examinations of referred cases was stationed at the base hospital, and, therefore, not readily accessible. Later, upon the appointment of examining boards at each camp functioning for the examination of all men arriving at the camps, under the general direction of the camp or division surgeon, every man was examined for mental or nervous defect by an officer assigned by the division of neurology and psychiatry of the Surgeon General's Office. The first increments of our Army were not all examined by neuropsychi- atrists and a considerable number of men unfit for military service, because of 62 NEUROPSYCHIATRY nervous or mental condition, were carried overseas. These promptly appeared in the hospitals of the American Expeditionary Forces and, later, in General Hospital No. 30, Plattsburg, the majority of them with a history of illness of from one to five years' duration previous to their entrance into the Army. To meet this situation survey boards composed of two or more neuropsychiatrists were later ordered to examine commands which had been previously accepted for service. Under the method of surveys, the whole command passed before the special officers. On the basis of a brief conversation and observation, and examination for such physical symptoms as tremors, changed reflexes, etc., the recruit was passed, or if not satisfactory, was deferred for a thorough examination. By this method an experienced examiner could dispose of 100 to 150 cases a day with reasonable accuracy. Large boards were sometimes sent by request of generals commanding divisions, to examine the whole division in a short space of time. Neither of these methods being coordinated properly with the physical examinations, it was difficult for special boards to operate when the camps first opened, and later it was difficult to get the recruits together, as they were occupied with their military duties. The examinations did not become ade- quate until they became a part of the routine entrance examination of all recruits. But the great practical difficulty for a time was to obtain action on the recommendations for rejection or discharge. The special examining boards were composed, for the most part, of officers of little or no military training, who, consequently, were ignorant at first of the procedure to be followed to insure action on their recommendations. For example, between two and three hundred privates of the National Guard of New York, examined and found unfit by psychiatrists in New York, were nevertheless sent to Camp Sevier, S. C, with their organizations. It was only after the useless journey to South Carolina that the recommendations found their way to the disability boards, and the men were finally discharged. Once the recommendations reached the disability board they were generally acted on favorably, although the surgeon sometimes disapproved the board's findings, and the discharging authority did not always agree with the surgeon's recommendations. But most of the cases which were retained in the service in spite of the recommendation of the psychiatrists failed to come to the atten- tion of the disability boards for the reasons stated above, or because troops were being moved too fast to make it possible. It was never considered desirable that disability boards be made up ex- clusively of psychiatrists. Composed, as they were, of general medical officers these officers had the advantage of acquiring a familiarity with the methods and importance of the neuropsychiatric work; furthermore, discharges recommended by mixed boards could not be considered as testimonials to the overenthusiasm of specialists. In August, 1918 an order was issued abrogating provisions for separate examining boards for three of the medical specialties, including neuro- psychiatry.^ Following this all the camp examinations for the purpo of examining drafted men, and later for demobilization, were coordinated and placed under the direction of the division of sanitation, Surgeon^ls IN THE UNITED STATES 63 In the beginning there wrere neuropsychiatric examinations of candidate officers at a few of the first series of the officers' training camps, and at many of the second series. In general, however, officers were not examined for nervous and mental conditions prior to being commissioned and, at the majority of camps, were not examined when the neuropsychiatric surveys of the soldiers already in the service were conducted. This was an outstanding defect of the neuropsychiatric service, as many officers were later discovered to have defects of this type rendering their discharge necessary. On the whole the cooperation existing between the neuropsychiatrists and other medical officers, as well as with officers of the line, was harmonious and attended always by a joint desire to detect and eliminate the mentally or nervously unfit from the service. Attention was directed to the importance of the work being done by the neuropsychiatric officers in the following promulgations: 6 7 1. The Surgeon General again invites your attention to his desire that you make every endeavor to recognize and eliminate all cases of mental disease, all mental defectives, and all cases of nervous disease. It is believed that not less than 10 per 1,000 of men now in service are unfit from one of the above mentioned conditions 2. To aid you, orders have been issued making the services of the neurologists and psychiatrists detailed to the base hospitals available for the examination of troops of the division in his specialty. 3. It is desired that you use every effort to arrange with the commanding officer for the inspection of each organization by the specialist medical officer at some time during the training period, to discover those soldiers whose general attitude and appearance suggest the need of special neurologic and psychiatric examination. Each organization will be inspected if possible, details of this inspection being left to you, but it is suggested that they may be made advantageously when organizations are gathered together for such general medical purposes as vaccination, inoculation, physical inspection of various kinds, etc. But if special formations are necessary, you will endeavor to arrange them. 4. You will recommend to the commanding officer that general written instructions be issued confidentially to the officers, to the following effect: (a) Officers commanding companies, troops, batteries, detachments, or other organiza- tions will note each member of their commands for the purpose of forming an opinion as to whether they show evidences suggesting mental disease or defect, or insufficient nervous stability. Organization commanders will require the same observation by their junior officers and by noncommissioned officers, who will be directed to report doubtful cases to them. (6) Those having officers under their command should secure special examination of any officer who seems of doubtful mental integrity or nervous stability. (c) Senior medical officers will require those under their command to be on the lookout for mental and nervous cases. (d) Medical officers serving with regiments or other units, those holding daily "sick call," those making physical inspections of any kind, and ward surgeons will bear nervous and mental disease in mind, and refer suspicious cases for expert examination. (e) Officers commanding places where prisoners, garrison or general, are confined, summary court officers, judge advocates, and assistant judge advocates of courts-martial, and officers who act as counsel for enlisted men, will note the mentality of all cases before them and refer all doubtful cases for proper examination, (/) The observations herein required should be made quietly and unobtrusively so that if possible no officer or enlisted man shall know that his mental or nervous condition is under question This is important. 5. The fact that troops are being mentally examined will be kept from becoming a matter of gossip if possible. 64 NEUROPSYCHIATRY 6. You should require the neurological examinations of all men known to be suffering from syphilis. 7. You will require the specialist medical officer to make, through you, monthly reports to this office of the special work done. Forms S9, 90, and 91 have been prepared for this purpose. The printed copies of these forms will be sent to the cantonments by the field supply depot in a few days. Bulletin No. 4. War Department, Washington, February 7, 1918. ******* Officers with special experience in nervous and mental diseases have been added to the Medical Department of the Army. Such officers are detailed at all base hospitals and with many divisions. Most base hospitals have also special nurses and therapeutic appliances for the care of nervous and mental diseases. The services of these officers and nurses are available, through their superior officers, for consultation in all matters pertaining to such diseases. The foregoing facts are announced for the special benefit of persons that are brought socially in contact with soldiers, as such persons are in a particularly favorable position to witness the early stages of mental disease, and by their prompt and cooperative action may render valuable assistance in preventing nervous breakdowns. Reports from abroad indicate that a large number of the soldiers who break down nervously (shell- shock) had, for several days before their final collapse, given evidence that they were fast approaching the limit of their nervous endurance. It is believed that had something been done for them during those critical days they would have readjusted themselves quickly and gone back to their duty instead of remaining nervous invalids, with little prospect of recovery before the end of the war. Nervous breakdowns often begin by sleeplessness, persistent homesickness, nervousness, depression, self-reproach, unreasonable fear, suspicion of others, feeling of resentment against others, and general complaints of ill health. These signs often show in the man's social conduct, so that he is remarked by his companions as being restless, jerky, inclined to stay by himself, bad tempered, etc.; in other words, his com- panions remark that some change has come over him. The man himself may realize that he is out of sorts, but often he does not realize that he is ill and so does not report at sick call; on the contrary, he often resents the idea that he needs the care and supervision of a phy- sician. Yet a little rest, care, and medicine, such as would be provided if his case were brought to the attention of a medical officer, would in all probability suffice at this time to put the man on his feet again. (700.7, A. G. O.) By order of the Secretary of War: John Biddle, Major General, Acting Chief of Staff Official: H. P. McCain, The Adjutant General. Clinics and lectures were given for other medical officers, and talks of a suitable nature, to officers of the line. The following memorandum was distributed to company commanders: 8 The object of this survey is to find and discharge from the Army such cases of mal- adjustmentto Army duties or discipline as may be shown to have a mental or nervous abnor- "rvev bold "^ ^ CaS6S Sh°Uld ^ S°Ught °Ut and Sent f°r examination byX Cases showing unusual difficulty in learning drill insfrnf.tir.ne Q+^ ± ^ , , on unfamiliarity with the English language. instructions, etc., not clearly dependent Persistent delinquents, irresponsible, morally obtuse individuals Eccentric, seclusive, taciturn individuals, company "butts " Those showing marked emotional instability; i. e., too readily moved to tears aneer or noisv elation. Cdl!!) anger, IN THE UNITED STATES 65 Those indulging in or suspected of abnormal sexual practices. Drug or alcohol addicts. Those having fainting spells or other evidences of possible epilepsy. Persistent bed wetters. Extreme cases of stammering. Chronic ailers showing no evidences of organic disease, hysterical or neurasthenic indi- viduals, suspected malingerers. Apathetic, negligent, untidy, or otherwise seemingly inferior or objectionable individuals. Those who may be on any other grounds suspected of being mentally unfit. It is very desirable that each case sent for examination should be accompanied by a memorandum stating in terms of observed facts or of the soldier's utterances or conduct the reason for the desired examination. (Company commanders and regimental surgeons cooperated in the neuro- psychiatric surveys, as they afforded often the only way of being relieved of problems of administration and discipline arising from the demoralizing effect of the presence in their organizations of mentally unfit individuals. All cases about to be tried by court-martial should receive a competent psychiatric examination to determine not merely their legal responsibility, but also whether the soldier is afflicted with a neuropsychiatric disorder which would ordinarily lead to his discharge on surgeon's certificate of disability. If so affected, generally he should be discharged, rather than tried, and not recommended for reenlistment. Should trial be deemed advisable, no sentence should be imposed which might aggravate his disability—such as confinement with hard labor in a case of epilepsy—but rather forfeiture of pay or dishonorable discharge. INSTRUCTIONS TO EXAMINERS The examinations made by the officers of the neuropsychiatric service may be divided into two general groups. The first comprised the mental and nervous examination of applicants for enlistment and of draftees reporting at camps of mobilization. This examination was completed before the men were actually in the military service and was made with the special object of excluding those who failed to reach the required standards. In the second group fell all examinations made by the neuropsychiatrists after the individuals were actually in the Army. Included here were the examinations of patients in hospitals; of men referred by medical or line officers; the neuropsychiatric surveys of troops which had come into the Army without the special neuro- psychiatric examination, as has been explained previously; and the examination of all men prior to discharge from the service. This latter examination was conducted at the various camps by the camp examining boards referred to above, but the results of the neuropsychiatric examinations at this time were largely negative, as the majority of soldiers of this type had already been detected and disposed of. Examinations made at the disciplinary barracks may be con- sidered as a third group. While a thorough mental examination of the recruit will eliminate a large proportion of undesirables at the outset, a certain number of mental and nervous defectives will slip through. From the nature of the diseases concerned this can not be avoided, and the neuropsychiatrists must be alert at all times to detect ental or nervous disease in those who have shown unusual difficulty in learning 66 NEUROPSYCHIATRY the drill and in following instructions, those who are persistently delinquent, who are seclusive, eccentric, taciturn, or who exhibit other marked peculiarities of behavior. Such men were carefully sought for during the war and properly disposed of when discovered. With the exception of the purely neurological cases the defects to be identi- fied by the neuropsvchiatric officers were more in the sphere of behavior than in that of concrete physical symptoms. The diagnoses were generally made independently of physical symptoms, and sometimes recruits, at the preliminary examinations, were recommended for rejection as mentally unsuitable who had been passed by other medical officers as physically sound in other respects. The methods employed during all these special examinations were those of clinical psychiatry. Under date of August 1, 1917, as noted heretofore, the Surgeon General issued Circular No. 22, which outlined the nervous and mental conditions for which the neuropsychiatric examiners should search, and gave the general grouping which should serve as causes for rejection. This circular was as follows: Circular No. 22. - War Department, Office of the Surgeon General, Washington, August 1, 1917. Examinations in Nervous and Mental Disease 1. For the safety, efficiency, and economy of the military service it is highly essential that, nervous and mental disease be recognized at the earliest possible moment. Nervous and mental diseases may, and frequently do, exist in persons who are strong, active, and apparently healthy and who make no complaints of disability. Such persons are, however, more than useless as soldiers, for they can not be relied on by their commanders, break down under strain, become an encumbrance to the Army, and an expense to the Govern- ment. Disorders of this character are often demonstrable only as the result of a pains- taking and special examination directed toward the mind and nervous system. This circular is published for the special purpose of calling the attention of medical officers to the particular diseases most frequently overlooked on general examination, and the symptoms most impor- tant to their diagnosis, and to certain characteristics in personality and in the behavior which might raise the question of the existence of mental disease. 2. The duties of the examiner are to be familiar with the symptoms and significance of nervous and mental disease and the means of eliciting them, and to recommend for rejection from service all those in whom any of the evidences mentioned in paragraph 4 are demon- strated. He should determine the importance of slight variations from the ordinary normal standard and recommend acceptance or rejection on the basis thereof. He should search for symptoms or tendencies which may be concealed for the purpose of obtaining service, and he should recognize symptoms which are feigned for the purpose of avoiding service'. Organic nervous disease can not be feigned in a way to deceive a skillful and careful examiner' To demonstrate feigned insanity a period of several weeks' observation may be necessary! 3. It is assumed that the examiner is familiar with the current methods of examination in neurology and psychiatry, and that he will make careful employment of them in all cases referred to him for consultation. But in addition to acting as a consultant to whom cases are referred, he must also himself select cases for special examination. To this end he is directed to be present as often as possible when the recruits are gathered together at times of instruction and training and for such general medical purposes as vaccinations inocula- tions, group examinations of the heart, lungs, etc. At such times he should discriminatingly observe the appearance and behavior of the recruits, pass in and out among them converse with them when possible, and report to the camp surgeon the names of anv whom his obser IN THE UNITED STATES 67 vations have led him to consider as requiring a special neurological and psychiatric examina- tion. By thus learning, in a way, to know the recruits personally his special training should enable him now and then to pick out one who might pass the general medical examination and yet whom special examination would clearly prove to be a hazard to the Army. Queerness, peculiarities, and idiosyncrasies, while not inconsistent with sanity, may be the beginnings or surface markings of mental disease. A soldier is too important a unit for such variations from a standard of absolute normality not to be looked into before the recruit who presents them is accepted for service. To aid the neurologist and psychiatrist in these ways the camp surgeon, shall direct all medical officers, dental surgeons, instructors, hospital sergeants, and others who come in close contact with recruits to refer to him (the camp surgeon) all recruits who persistently show any of the following characteristics: Irri- tability, seclusiveness, sulkiness, depression, shyness, timidity, overboisterousness, suspicion, sleeplessness, dullness, stupidity, personal uncleanliness, resentfulness to discipline, inability to be disciplined, sleepwalking, nocturnal incontinence of urine, and any of the various characteristics which gain for him who displays them the name of "boob," "crank," "goat," "queer stick," and the like. The reaction of the pupils to light should be part of every medical examination, and if this is not systematically provided for, the neurologist and psychiatrist should be directed to determine it. This could be done at the time of group inoculations and with the help of a hospital sergeant could be made rapidly. Electric light should be used. It is especially important in the examination of officers and recruits above 25 years of age. It is further recommended to camp surgeons to provide neurological examinations for all cases of syphilis. 4. The following are causes of rejection for military service: A. Organic nervous diseases. B. Mental defect. C. Mental disease and pathological mental states. D. Confirmed inebriety (alcohol or drugs). a. organic nervous disease Certain after effects of organic nervous disease need not be causes for rejection provided (1) that the disease is no longer operative and is not likely to recur, (2) that the effect left by it does not prevent a satisfactory fulfillment of military duties. Examples of such con- ditions are paralysis of a few unimportant muscles following poliomyelitis, slight unilateral hypertonicity as a result of an infantile hemiplegia in a man now robust, and various trau- matic conditions. A history of hemiplegia occurring after infancy should always exclude, even if no symptoms remain. Existent organic nervous disease should always exclude. For example, neuritis, of one or many nerves, while susceptible of recovery without resultant defect, is none the less a cause for rejection as long as it exists. The following organic nervous diseases are mentioned specifically, as they are the ones which frequently present few symptoms and may pass undetected by even the most skillful examiner: Tabes, or locomotor ataxia.—Look for Argyll-Robertson pupil or pupils, absent knee jerks, Romberg symptom, ataxia of hands or legs (especially with closed eyes), hypotonia, anesthetic areas of skin. History is usually that of slow progression, failing sexual power, and pains in the legs or back, often described as rheumatism. In doubtful cases it is required that the Wassermann reaction of the blood be determined and the cerebrospinal fluid be examined as to the Wassermann reaction, cellular and globulin content, etc. Multiple sclerosis.—Look for intention tremor, nystagmus, absent abdominal reflexes, and increased tendon reflexes. The scanning speech may be mistaken for stammering. No history of pain, but sometimes history of urinary disturbance. Progressive muscular atrophies, dystrophies, and syringomyelia.—Look for atrophies in the small muscles of hand and in the muscles of the shoulder girdle, with fibrillary twitchings. These plus anesthesia for heat and cold (scars on hands from cuts and burnings) = syringomye- lia. History usually furnishes little data, although reference may be made to awkwardness. No history of pain. Syphilitic spinal disease imitates these conditions closely. 4270"!—29----6 68 NEUROPSYCHIATRY Epilepsy.—Look for deep scars on tongue, face, and head. The voice is frequently characteristic. If history alone, verify by correspondence with physicians. Hyperthyroidism.—A nervous disease in its effects. Look for persistent tachycardia, exophthalmos, tremor, enlarged thyroid. History of general nervousness. In addition to the foregoing there are certain sets or combinations of symptoms which should exclude from service. They may not by themselves be sufficient for an exact diag- nosis, but they prove beyond cavil that the nervous system is seriously diseased and totally independable for any continuous service. Pupil or pupils—Argvll-Robertson. Nystagmus (in one not an albino), absent abdominal reflexes, intention tremor. Combination of any two should constitute a cause for rejection. Babinski reflex. Disturbances of station or gait. Disorders of speech on test phrases (viz, "Third riding artillery brigade") plus facial tremor or any other one symptom of organic disease. Confirmation by laboratory findings is desirable. Cervical sympathetic syndrome, viz, unilateral narrowing of palpebral fissure, sunken eyeball, flattening of face, unequal pupils. b. mental defect or deficiency Look for defect in general information with reference to native environment, ability to learn, to reason, to calculate, to plan, to construct, to compare weights, sizes, etc.; defect in judgment, foresight, language, output of effort; suggestibility, untidiness, lack of personal cleanliness, anatomical stigmata of degeneration, muscular awkwardness. Consult psy- chometric findings. Get history of school and vocational career and disciplinary report. c mental diseases A definite corroborated history of a mental disease that required hospital treatment or observation serves as a cause for rejection in a recruit mentally normal at the time of examination. The circumstances should, however, be inquired into with great care. Few mental diseases present objective physical signs, but their manifestations are none the less characteristic and dependable. All mental diseases are causes for rejection. In addition to the well-defined clinical types such as paresis, dementia praecox, etc., there are various combinations of psychological symptoms which render those who suffer from them unstable, unreliable in emergency, and subject to attacks of disabling mental illness from slight emotional causes. General paralysis (paresis).—Look for Argyll-Robertson pupil or pupils, facial tremor, speech defect in test phrases, and in the slurring and distortion of words in conversation, writing defects consisting of omissions and distortion of words. Mood is apathetic or de- pressed or euphoric. Memory loss, discrepancies in relating facts of life. Knee jerks may be plus, minus, or normal. In doubtful cases it is required that the Wassermann reaction in the blood be determined and that the cerebrospinal fluid be examined as to Wassermann reaction, cellular and globulin content, etc. Dementia praecox.—Look for indifference, apathy, withdrawal from environment, ideas of reference and persecution, feelings of the mind being tampered with, and thoughts being controlled by hypnotic, spiritualistic, or other mysterious agencies, hallucinations of hear- ing, bodily hallucinations, frequently of electrical or sexual character; meaningless smiles; in general, inappropriate emotional reaction and a lack of connectedness in conversation. There may be sudden emotional or motor outbursts. Get history of family life and of school, vocational, and personal career. Manic-depressive insanity .—Look for mild depression with or without feeling of inade- quacy or mild manic states with exhilaration, talkativeness, and overactivity. Psychoneuroses.—Look for hysterical stigmata, such as cutaneous anesthesias (especially hemianesthesia), contractions of the visual fields, etc., phobias, morbid doubts and fears, anxiety attacks, compulsions, hypochondriasis. Compare complaints with behavior and obtain history as to former nervous breakdowns and vocational career. IN THE UNITED STATES 69 Psychopathic characters.—Homosexuals, grotesque liars, vagabonds. Superficially brifiht oftentimes. These individuals do not last out and never stay at anv one thing long. Frequent military and civil offenders. Get history of personal career. D. chronic inebriety For alcoholism look for suffused eyes, prominent superficial blood vessels of nose and cheek, flabby, bloated face, red or pale,purplish discoloration of mucous membrane of pharynx, and soft palate; muscular tremor in the protruded tongue and extended fingers, tremulous handwriting, emotionalism, prevarication, suspicion, auditory or visual hal- lucinations, persecutory ideas. For drug addiction look for pallor and dryness of skin. If taking drug, the attitude is that of flippancy and of mild exhilaration; if without it, it is cowardly and cringing. There are also, during period of withdrawal, restlessness, anxiety, and complaints of weakness, nausea, and pains in stomach, back, and legs. Distortion of alge nasi. Pupils contracted by morphine and dilated by cocaine. All habitual drug takers are liars. They do not drink, as a rule, and are inactive sexually.6 Most drug takers use needles and show white scars on thighs, arms, and trunk. Heroin takers are mostly young men from the cities, often gangsters. They have a characteristic vocabulary and will talk much more freely about their habit if the examiner in his inquiries uses such words as "deck," "quill," "package," "an eighth," "blowers," "cokie," etc. W. C. Gorgas, Surgeon General, United States Army. Approved by order of the Secretary of War, August 9, 1917. (702 O. D., A. G. O.) STANDARDS OF FITNESS « Circular No. 22, although it set few absolute standards, largely determined the findings of the neuropsychiatric officers throughout the war. In pronounced cases of definite diseases, such as dementia prsecox and epilepsy, it was possible to follow a fixed standard, but many of the mentally and nervously unfit are border-line cases or are types of inadequate personality impossible of absolute classification. The actual symptoms are not always definite, and the reasons for rejection for military service must frequently lie in the judgment of the examiner and his ability to evaluate in terms of personality development or psycho- pathology the social histories of the men. For example, many of the men rejected on account of constitutional psychopathic state would have been accepted had it not been for the special examination by the neuropsychiatrists, as no definite tangible physical symptoms existed which, otherwise, would have been observed. Had these men been accepted for military service the majority of them would have been ultimately discharged as inapt under the provisions of paragraph 1483^, Army Regulations, or for physical disability, or by sentence of a court-martial, after having been convicted for some derelic- tion of duty. In the consideration of mental deficiency, the standard for rejection was not always uniform, although generally understood to be a mentality of or below that of a child of 8 years. It is apparent from reports received in the Office of the Surgeon General that this 8-year standard is too low. b ThjS was proved to be in error. ' A full discussion of physical examinations may be found in Vol. VI, Sanitation, Chaps. XIX, XX, and XXI. 70 NEUROPSYCHIATRY However, it was not always possible to arrive at a scientific determination of the mental age of recruits, as the time required for the necessary examination was often not available. Even if the psychological group tests had been applied for all recruits, the problem would not have been settled, as it was not agreed that psychological rating alone is sufficient to warrant rejection for mental deficiency. Throughout the entire group of neuropsychiatric disorders much latitude was necessarily left to the opinions of the neuropsychiatric examiners, and the recommendations of these officers with reference to the mental or nervous fitness of recruits for the military service came eventually to be quite generally followed. This was true for both rejection from and retention in service. Chronic alcoholism, for instance, was a cause of rejection, yet comparatively few alcoholics were rejected, far less than might have been under the existing standards. The standards of physical requirements placed subjects of drug addiction in the deferred irremediable group, yet a certain percentage of them were accepted for service. During the first period of mobilization the acceptance for limited service of recruits, presenting certain specified neuropsychiatric defects, was authorized and recommendation to this effect was made in a considerable number of cases. With added experience the disadvantages of such a procedure became evident, as has been mentioned, and upon the recommendation of the Surgeon General, recruits presenting neuropsychiatric defects, with a few minor excep- tions, were rejected for all military service. The most important of the excep- tions mentioned was that certain mental defectives, especially negroes, be accepted for limited service in labor battalions. Reports regarding the service of men of this class left considerable doubt as to the wisdom of this policy. The subject of aviation opened up a new and important field of neuropsy- chiatric activity, for it was found that even after the minute and prolonged examinations to which aviators were subjected, there was still room for special investigation of the nervous system. Three neuropsychiatric officers were detailed to the medical research laboratory at Mineola, Long Island, to study the problems peculiar to this branch of special work. Because of the high physical and mental standards of fitness employed in the selection of men for this arm of the service, the neuropsychiatric problem here was different from that associated with the ordinary work of elimination for mental and nervous disease or defect carried on in the other branches of the service. The psychiatric work at Mineola was more than the mere search for pathological conditions through the observation of more or less gross signs or symptoms, or even the more extended examination of men suspected of mental or nervous disease. Because of the superior type of human material needed for the Air Service and the special stresses and strains of aerial warfare, this work took on the character of refined personality studies in which the more difficult and less tangible emotional factors had to be considered and dealt with. Such personality studies were made after the examination of several hundred aviators and after numerous conferences with American officers who had seen service at the front, and with representatives of our allies The IN THE UNITED STATES 71 psychiatrist had three definite objects in view in making these studies: (1) To detect the presence of nervous and mental diseases which would render the aviator temporarily or permanently unfit for service; (2) to form a definite idea as to what extent the aviator could stand the pressure of life at the front; (3) to determine, and as far as possible to compensate for, the existence of any latent tendencies which, under the strain of actual warfare, would become so accentuated as to make the aviator either inefficient, or to increase his danger of nervous and mental collapse. The value of these brief studies in reducing the number of casualties due to preventable causes and in increasing efficiency, it is believed, was clearly dem- onstrated. It was felt that the information obtained had a direct practical bearing in assisting the aviator to maintain his morale and to make a rational effort to direct all of his nerve and brain power, without useless dissipation, to the task of winning the war. The following cases are examples of the advan- tages accruing from a psychiatric service for aviators:9 Case 1.—A typical case of mild manic excitement, marked by motor restlessness, slight but well marked irritability, typical elation and desire to talk, was examined one forenoon and pronounced unsafe for flying. This aviator, although forbidden to fly, disobeyed orders, took the plane up, and crashed on attempting to land. The machine was partially wrecked, and by a miracle neither the observer nor the pilot was seriously injured. Case 2.—One of the best pilots, who had had 300 hours in flying, lost nerve and when ordered to fly refused to go, saying he was sure an accident would follow. This aviator was referred to the neuropsychiatric department for examination, and it was discovered that his sudden loss of nerve was due to an unsolved personal problem which he had attempted to dodge and to forget. After one week's treatment in which assistance was given in settling the difficult situation, his nerve returned and he was practically as efficient as ever. In a number of cases studied the symptoms of mental staleness and mental fatigue were present. These symptoms were characterized by loss of interest in work, a tendency to analyze details and forget the main object in view, and a certain recklessness, the result of defective inhibition. Serious accidents would have followed had these aviators been allowed to fly before they had gained their emotional equilibrium. Many serious accidents occurred as the result of the failure to recognize the importance of the initial symptoms of fatigue and staleness. NEUROPSYCHIATRIC EXAMINATIONS IN CAMPS The following discussion of neuropsychiatric examinations made in camps is based on the reports to which they are credited, without comment as to the findings: IN RECRUITING AND CANTONMENT d The neuropsychiatric work in the cantonment presented special features which were quite different from those in military hospitals. In the latter, neuropsychiatry was similar to that in civil hospitals, or civil practice. In base hospitals one found chiefly obvious disorders, which had been referred for ex- amination and treatment, by the regimental surgeons, who as a rule were not very familiar with such conditions. In the cantonment, cases of the same class * Neuropsychiatry in Recruiting and Cantonment, by Maj. M. S. Gregory, M. C. Archives of Neurology and Psychia- try, 1919, i, No. 1, 89. 72 NEUROPSYCHIATRY were met with, but, in addition, one encountered a special type, which rarely, if ever, found its way to the base hospital, by reason of the fact that the true character of such disorders was not recognized and very frequently they were regarded as entirely foreign conditions, such as malingering, carelessness, shift- lessness, delinquency, and inattention to duty. TYPES OF DISEASES OBSERVED These cases were not dissimilar to those found in civil life, only modified by the natural differences, such as age, sex, climate, geographical conditions, care in selection, etc. One encountered gross organic nervous diseases, such as early tabes, paresis, multiple sclerosis, peripheral neuritis, neurosyphilis, residual from old poliomyelitis, occasional brain tumor, and other conditions, on the one hand, and, on the other, well-developed dementia precox, manic-depressive psychoses, mental deficiency, alcoholism, drug addiction, epilepsy, and well- marked psychoneuroses. Between these two extremes, there was a host of intermediary conditions, such as mild neuroses and psychoneuroses, neurasthenias, anxiety states, hysterias and hysteroid episodes, epileptoid conditions, psychopathic person- alities, inferiors, military misfits, and otherwise near-normal individuals. Cases of this group were, of course, the most baffling and taxed the ingenuity and resourcefulness of the examiner to the utmost. Moreover, they constituted a greater menace to the military organization, by lowering the efficiency and impairing the general morale, than did the obviously diseased types which were readily recognized and without great difficulty eliminated. They were constant sources of annoyance and trouble to the officers, forming the larger number of the absentees, the discontented, the inefficients, the inmates of the guardhouse, and the frequenters of the regimental infirmary. These were the cases which complained of being dizzy, faint, and bewildered at critical mo- ments, while in training or maneuvers. The psychoneurotic formed the largest and most important of this inter- mediary group. As they presented themselves in the cantonment, and based on the duration and mode of onset of their malady, they were classified, for practical purposes, into three groups: The first group consisted of those in whom the disease existed long before their entrance into the Army. These, as a rule, had neuropathic family his- tories and had been unstable and more or less shiftless, long prior to the onset of the neuroses. Curiously enough, many of the neurotics of this type were found among the enlisted men who had been advised, by physicians, to enter the Army with the assurance that the discipline and outdoor life would correct their trouble. Others had enlisted without much advice, although they themselves had entertained the hope that they would derive benefit from mili- tary service. According to their own statements, all seemed to have felt quite improved for a short period immediately after their enlistment However this amelioration was of brief duration. Our experience was that this type of neurotic was quite unfit for military service and that the entrance of such indi- viduals was detrimental to themselves as well as to the Army IN THE UNITED STATES 73 The second group comprised those in whom the disease arose while they were in the Army, following an accident, injury, or some somatic disorder, such as rheumatism, bronchitis, etc. The neurosis was referred to and inti- mately connected with the injury or disease. These men, as a rule, had a better family and personal history than the former group and recovery of a small proportion might be looked for in camp. The third group was made up of men whose antecedents had been appar- ently free from neurotic taint and in whom the hysterical conversion had not been definitely established, remaining latent or just beneath the surface and usually corrigible by educative and environmental influences. METHOD OF APPROACH One hardly expected to be received with enthusiasm when one arrived at a camp to do neuropsychiatric work. There appeared to be, on the contrary, with very few exceptions, a lack of interest or an indifference or a manifest skepticism; not infrequently there was a passive, or even an active, antagonism to any examination of this sort. Strangely enough, the medical officers were the chief passive obstacles and, in the very beginning, very little assistance or cooperation could be obtained from them. So the first effort at a cantonment had to be directed to the officers, especially the medical officers, with the view of demonstrating to them the practical value of such examination in order to enlist their sympathy and cooperation. They had to be made to appreciate the importance of neuropsychiatric examinations. In order to accomplish this, one frequently had to resort to tact, persuasion, or even strategy. In dealing with this situation of passive resistance, it was desirable in the beginning to report as unfit for military service only men with obvious nervous or mental disturbances in whom one could show the disorder in its early phases and point out how the disease influenced the soldiers' conduct and efficiency. For example, the painstaking demonstration of early cases of tabes, of dis- seminated sclerosis, of paresis, of dementia prsecox, or of manic-depressive psychosis, which had been unrecognized and unsuspected, went a great way in rousing the interest and even the enthusiasm of the medical officers. The greatest help to the neuropsychiatrist came, however, from the line officer, and particularly the company commander. It may seem strange, but it is never- theless true, that the line officers appreciated the value of neuropsychiatric examinations much more readily than did the medical officers. The explanation for this was found in the fact that the line officer rated his men in terms of conduct, behavior, and efficiency, which, after all, was equivalent to the standard of the neuropsychiatrist, who estimated conduct from the mental qualities and make-up of the individual. If a company of soldiers be carefully examined from the neuropsychiatric standpoint and the results compared with the reports furnished by the company commander of men in his organization who have been inapt, inefficient, slow, awkward, easily fatigued, delinquent, insubordinate, and difficult to get along with, a striking parallelism will be found between the two sets of observations. Experiences of this character naturally brought the line officer very close to the neuropsychiatrist. The officer eagerly sought counsel and aid, as he at 74 NEUROPSYCHIATRY once recognized that he and the examiner were dealing with similar problems. The neuropsychiatrist might be called on by the commanding officer to give advice in the matter of discipline of the force and even in the rating of the efficiency of his officers. In a hastily formed army like ours, especially under a system of draft, there was a great demand on the individual soldier for a rapid and violent ad- justment. Men without any previous military experience, drawn from every walk of life—from distant parts of the country, from farm and factory, bank and bench, the rich and the poor, the illiterate and the educated—all were thrown together in a heterogeneous mixture and subjected to the same disci- pline, the same regulations, and the same daily routine. It was most astonishing how well and how rapidly they adapted themselves under these most difficult conditions. However, there was a small number in whom this adjustment did not readily take place. It was among this class of men that one observed pathologic reactions in the form of sluggishness, dis- content, inadaptability, lonesomeness, nostalgia, lack of application, lack of initiative and ambition and, therefore, military inefficiency. Some of these, of course1, were of markedly pathologic make-up, but the great majority were men to whom the neuropsychiatrist could be of the greatest assistance. These were the border-line cases, the potential neurotics and psychotics, in whom preventive psychiatry found a most fertile field. Many patients of this kind, although able to get along fairly well in camp, suffered a definite breakdown at some critical time, such as just before em- barkation; others were returned from overseas before they had seen any active service at the front. SUGGESTIONS AS TO PROPER SUPERVISION It was surprising how much the advice, encouragement, assurances, per- sonal contact and attention, and trivial changes in environment would do for these men. That this was not mere theory, but intensely practical, could be readily demonstrated in a military camp or cantonment. The following are a few brief illustrations: The attention of the neuropsychiatrist was called to a soldier who was indifferent, inefficient, lazy, and seemingly lacking in initiative. Examination revealed that he came from a large city, had had a high-school education, had worked as a salesman, and had a salary of from $75 to $100 a week. He was made assistant in the camp to a kitchen worker, who was illiterate, far below him socially, and whose earning capacity had never been more than $12 a week The soldier did not complain of this, nor could he give any conscious reason for the change m his efficiency and conduct, which, however, he acknowledged His commanding officer was advised to place him in another department where his talents would find a better expression. Within a week a striking change had come over his disposition and he was regarded as a most useful energetic worker and a promismg soldier. 8 A soldier serving as a waiter at an officers' mess showed mild mental de- pression. He was regarded as slow, inattentive, and inefficient. He Z^ of insomnia, nervousness, headache, dizziness, and inability to take any interest IN THE UNITED STATES 75 .n things. He was unable to assign any cause for his disability. He was anxious to be a soldier and serve his country. It was further found that he was a recent graduate of a New England college; had been brought up in affluence and comfort, and was socially equal or superior to many whom he attended as a waiter. He consciously did not resent his position, because he felt that it was a part of military life. The commanding officer, on recom- mendation, assigned him to another kind of work more in keeping with his talents and experience. He soon became active, energetic, and efficient. He was regarded as good material for a soldier and was rapidly promoted. These actual cases wrere selected from a large number of records. RESULTS THAT MIGHT BE EXPECTED There were many soldiers who voluntarily sought the advice of the neuro- psychiatrist because of nervousness, dizziness, inability to sleep, poor appetite, indefinite pains, etc., and who, with marvelous rapidity, yielded to treatment by the "nerve specialist" of the camp. The amount of effective effort wThich could be achieved in applied neuropsychiatry' in the Army was limited only by the experience, interest, and ability of the neuropsychiatrist. The neuro- psychiatrist was no longer one who merely selected obvious cases of nervous and mental disease for elimination from the Army, but was one who also healed, repaired, conserved, and reconstructed. He became the guardian of the mental health, just as the sanitary surgeon was responsible for the physical welfare of the military organization. AT CAMP PIKE, ARK.« To the neuropsychiatrists fell the work of eliminating the nervous and mentally unfit among the recruits. This examination was made in connection with and as a part of the regular physical examination. While it is true that in some instances the attempt was made to unduly rush the wrork, and as a result a few men slipped through who should have been rejected, yet, taken in the aggregate, this number was very small and these few cases were generally detected later, since the troops had to undergo another neuropsychiatric test before being accepted for overseas duty. The average neuropsychiatric board consisted of five or six members and, as a rule, worked in two sections. In the course of the regular routine exami- nation the recruit came before the first section of the board where he was given a short neurological and psychiatrical examination, and if there was a suspicion of any abnormality he was referred to the second section, where he was sub- jected to a very careful examination and either accepted or finally rejected. If there was still doubt regarding his case he was sent to the psychopathic ward of the base hospital, where he was closely observed and all necessary tests made to determine his true nervous and mental status. When the draft first began in the fall of 1917 the instructions to the local boards were not very clear and explicit and were sometimes difficult to properly interpret; as a result, a number of recruits were found unfit for service when • Work of the Neuropsychiatrists in the United States Army Camps, by Capt. Hermon S. Major, M. C. Journal of the Missouri State Medical Association, 1919, xvi, No. 11, 377. 7(i NEUROPSYCHIATRY they were examined by the special boards at the camp and consequently were returned to their local boards. As time went on the local board became more critical and did quite a good deal of eliminating at home. As an illustration of this, the following results of some neuropsychiatric examinations, taken from the report of the neuropsychiatric board at Camp Pike, Ark., are given: May 7 to May 26, 1918, number examined, 9,834; number rejected, 199, or 2.02 per cent. May 26 to June 20, number examined, 10,338; number rejected, 165, or 1.59 per cent. June 21 to July 16, number examined, 19,178; number rejected, 190, or 0.99 per cent. July 16 to August 23, number examined, 22,020; number rejected, 173, or 0.79 per cent. August 23 to September 21, number examined, 22,649; number rejected, 123, or 0.54 per cent. The steady decrease in the number of rejections at this one camp would tend to prove that either the local boards were more carefully eliminating the nervous and mentally unfit or that the neuropsychiatric board was more lax in its examinations, but since practically the same board worked at Camp Pike during this time and under the same instructions, this hardly seems plausi- ble, especially in view of the fact that the same conditions obtained with the other special boards at this camp during the above-mentioned time. AT CAMP DEVENS, MASS/ The following is a brief summary of the neuropsychiatric examination of 170,478 soldiers at Camp Devens, Mass. There were rejected for all neuro- psychiatric causes 1,787 men. These examinations were conducted from early in September, 1917, until November 11, 1918. The classification of diseases used is the one furnished by the division of neuropsychiatry of the Surgeon General's Office. The first subdivision is that of nervous disease or injury. Under this head- ing were rejected 389 men. As the accompanying table shows, the majority of these rejections were for epilepsy. The diagnosis of epilepsy is by no means so hard as some imagine, if the patient, on physical examination, presents the characteristic mental symptoms and in addition has scars on various parts of the body and head caused by injuries while in convulsions, or if the tip and sides of the tongue are scarred; the symptoms were considered sufficient for rejection. If the patient stated that he had epilepsy and could show none of these signs, he was observed in the neuropsychiatric wards of the base hospital The orderlies there were trained in the observation of convulsive attacks particularly in disturbances of the tendon reflexes, and whether or not the pupils reacted to light during and after the attacks. In our experience the reaction of the pupils to light is the very best single test in the differentiation between epilepsy and hysteria. So far as we know, the pupillary reflex to light is always absent in an epileptic attack and never is in an hysterical attack. The other subheadings under nervous disease and injury will readily explain themselves. The small number of cases of syphilis of the nervous system is no doubt explained by thej^^ too young tQ shQP tabes I Report of Neuropsychiatric Work at Camp Devens Mass hvTiAnt n„i t -,- •„ ~ B. Hodskins, M. C, Sew York Medical Journal, 1921, cxiii, No. 14, 749 ern°n ggS' M" C" a,ld MaJ" MorSan IN THE UNITED STATES 77 dorsalis, and no doubt most of the frank cerebrospinal cases were rejected by the local draft boards. Under the heading psychoneurosis, 249 were rejected. The cases of stammering were rejected at time of examination. The others were always observed for some time, either in their organization or in the base hospital, before they were rejected. There was a total of 167 rejections under the heading psychosis. Some of these cases were rejected immediately, as they came to camp with a frank psychosis. In others, psychosis developed after the patient had been under military training for some time. A psychotic individual does very poorly in the Army. As soon as he is subjected to military discipline he usually breaks down. Under the heading inebriety there were 57 rejections. These rejections were made after the patients had been under observation for a few days and showed the well-known withdrawal symptoms. The patient listed as a case of drug addiction, opium, was addicted to the use of camphorated tincture of opium. His statement was to the effect that he would take more than a pint of this a day, and he showed well-marked withdrawal symptoms. Forty-five cases were rejected for chronic alcoholism. Under the heading mental deficiency, as one would expect, there was a large number rejected, a total of 813. These men were nearly all returned to their homes. Under the heading of constitutional psychopathic state there were 68 rejections. These men were rejected only after they had been observed in their companies for some time, and had proved themselves so totally unfit for military service that it was necessary to reject them. NEKVOUS DISEASE OR INJURY Epilepsy__________________________ 261 Cerebrospinal syphilis______________ 11 Congenital syphilis with nervous symptoms______________________ 1 Hemiplegia_______________ ------ 7 Paraplegia________________-------- 6 Tertiary syphilis with nervous symp- toms___________________________ 30 Multiple sclerosis_________ - ------ 9 Multiple neuritis_________ -------- 10 Paralysis, facial___________ ------ 4 Enuresis__________________________ 8 Poliomyelitis, chronic-------------- 3 Sciatic neuritis____________________ 3 Chorea___________________________ 13 Migraine___________________------ 1 Myotonia congenita--------------- 2 Spinal meningitis, chronic---------- 1 ('ongenital speech defect----------- 1 Hereditary tremor_________________ 2 Transverse myelitis________________ 1 Tabes dorsalis_____________________ 9 Hereditary ataxia------------------ 1 nervous disease or injury—continued Facial tic_________________________ Nystagmus_______________________ Hyperthyroidism__________________ Brachial neuritis__________________ Destructive lesion of red nucleus---- Total______________________ 389 PSYCHONEUROSIS Hysteria-------------------------- 133 Neurasthenia_____________________ 64 Psychasthenia--------------------- 12 Stammering_______________________ 40 Total______________________ 249 PSYCHOSIS Dementia precox: Hebephrenic------------------ 79 Paranoid_____________________ 31 Katatonic____________________ 11 Simple_______________________ 7 78 NEUROPSYCHIATRY psychosis—continued Psychosis: Manic-depressive__________ Traumatic_______________ Epileptic________________ AJcholic— Acute hallucinosis----- Chronic paranoid______ General paralysis of the insane — Psychosis, toxic_______________ Total_________________ 25 1 1 4 1 6 1 MENTAL DEFICIENCY Imbecile________________________ 258 Moron_________________________ 555 Total. 813 167 inebriety Drug addiction: Morphine___________ Heroine____________ Cocaine____________ Opium_____________ Alcoholism, chronic_______ Total____________ 48 4 4 1 45 constitutional psychopathic state Inadequate personality____________ Paranoid personality_____________ Emotional instability_________ Pathological liar_________________ Sexual psychopathy______________ Criminalism____________________ 102 Total. 48 11 4 1 4 1 69 Total rejections____________ 1, 787 AT CAMP SHERMAN, OHIO" This war brought about many innovations, and among them was a con- sideration of the individuality and of the mental and nervous condition of the prospective soldier. But the line officer did not always appreciate this or know what things to be on the lookout for in order to detect the indications of such abnormal conditions in the men as might be detrimental to the service. So a part of the work of the psychiatrist was to give talks to the line officers, telling them how the various mental and nervous conditions which interfere with the making or the dependability, or the endurance or the efficiency of the soldier, and what types of behavior he should be on the lookout for. Their cooperation in looking for these conditions and sending men for examination or observation was asked for. Some were very much interested and cooperated; others thought it all nonsense; others were indifferent. Such talks had to be arranged for with the regimental commanders. If one wished to talk to the medical officers only, the arrangements were made with the divi- sion surgeon. But it was advisable to talk to the nonmedical officers as well, and even to the noncommissioned officers, for they saw much more of the men than the medical officers did. An important work of the psychiatrist was to make a survey of the whole personnel of the camp. The ideal way to do this would have been to have the recruits on arrival at camp come into special barracks where they could be held before being assigned to any organizations until the various special exam- iners could go over them at reasonable leisure. An approximation to this plan was made by having the recruits very hastily surveyed by the examiners as fast as they came in. The men were stripped and examined by the various specialists. The examinations had to be very superficial when over 1,500 i9i9:^e, xoork4,°;5?yehiatrists ta Miiitary cam^^^*^^ IN THE UNITED STATES 79 men were looked over in a day. Many slipped through with defects which were detected some time later who would have been eliminated In the first place if only half the number were examined in the same period of time. Four neuropsychiatrists were able to make a superficial examination as fast as the other examiners made theirs. Before even this plan was adopted, and wherever it had not been put into practice, a survey of the personnel, regiment by regiment, was made when possible. It was necessary to secure the cooperation of the commanding officer of the regiment for this. It was sometimes easily secured; sometimes he resented it as an interference with his work of training soldiers because it took the men away from their work. Whenever possible it was advisable to make the survey in cooperation with the tuberculosis or other examiners, for example, as it caused much less loss of the soldier's time. After the com- manding officer had given his cooperation, arrangements were made with the regimental surgeon and the adjutant to have the men of a given company remain in barracks or report at the regimental infirmary at a given time. There the psychiatric examiners went over each man, testing pupillary and tendon reflexes, coordination and station, looking for tremors and for scars suggestive of epilepsy, and asking a few questions as to heredity, environment, schooling, convulsions, or nervous breakdowns, meanwhile noticing any peculiarities. Under the most favorable conditions, with a roster of the company and a clerk to check off the names and put down findings, one examiner could make a fairly thorough preliminary survey of from 150 to 200 men a day, according to their quality. But in actual practice that number could not be examined on an average, because of time lost in going from one organization to another, changes in daily orders in the organization, misunderstandings, etc. It was found at Camp Sherman that making allowances for Sundays, holidays, and unexpected interruption, interferences, and delays, one examiner could be counted on to go over about 2,800 to 3,000 men a month. The time available and the size of the command determined the number of examiners needed to complete a survey in a given time. This type of survey was unsatisfactory, for it can never be complete. Men were transferred out from a company that had been examined and men from unexamined units were often put in to fill up the organization, and it was difficult for the examiners to go back and pick up these men. Since the vast majority of the men who were found to have some nervous or mental disease or defect were incapable of making good soldiers, or of enduring without breaking down the stresses of warfare, they had to be discharged. It was part of the work of the psychiatrist to make the recommendations for discharge, giving the diagnosis, and stating how the condition interferred with the man's performing general military service. In some camps the psychiatrist made his recommendation to a general military service of which he might or could not be a member. At Camp Sherman three of the psychiatrists them- selves constituted a disability board. This gave an opportunity to hold con- ferences over the cases, to which the other neuropsychiatric examiners and sometimes other physicians were invited. 80 NEUROPSYCHIATRY Some of the kinds of cases and of difficulties that confronted the psychiatrist can be illustrated by the experience at Camp Sherman: The feeble-minded made up the largest single group of cases. Up to May 1, 1918, 134 out of 468 cases recommended for discharge were of this group. Those measuring 12 years old and over were regarded as suitable material for the Army unless they were of unstable make-up, had shown economic or social inadaptabilities, or had some general physical disability, even though the latter were not sufficient in itself to be a cause for rejection. At Camp Sherman the epileptics formed the next largest single diagnostic group. If the epileptics and organic nervous diseases were grouped together, this whole group was a trifle larger than that of the feeble-minded. Most of the patients could give a characteristic description of the onset of attacks, but in two there seemed to be absolute amnesia for them, and for having had them. One had a typical grand mal seizure, seen and described by a young physician; the other made a suicidal attempt in barracks and later in the hos- pital; no recollection whatever of either attempt could be elicited either by ordinary questioning or when hypnotism was attempted. No other cause for the suicidal attempt could be unearthed than a probable epileptic crepuscular condition. Among the officers referred for examination, manic-depressive depressions predominated, and these were the most frequent of the actual psychoses seen at Camp Sherman. There were many cases of neurasthenia following trauma or severe illness, and it was often a difficult matter to determine whether it was a real or an assumed disability. These cases were usually kept under observation several weeks, and information was sought from physicians who had attended them in civil life. Consultation with the orthopedists or other specialists was fre- quently held. X-ray examinations were usually negative, as were the results of spinal puncture and Wassermann tests. There were other types of neuras- thenia, some with a number of vagotonic or hyperthyroid symptoms, without thyroid enlargement. These were recommended for discharge on the ground that they were not capable of standing the strain of general military service, nor even of domestic service. By searching inquiry one could elicit from almost all men an occasional neurasthenic or fatigue symptom. When a large number of drafted men was received there were always a few cases of alcoholism, delirium tremens, and drug addiction. The confirmed habitues could not be kept in the base hospital long enough to be reconstructed, and once they were in the ranks they could get the drug with comparative ease. There were not many constitutional psychopaths (35 in all), but a few- sexual perverts, paranoid personalities, and inadequate personalities—were found and recommended for discharge. The cases examined with reference to whether they should be brought to trial or not were principally for repeated absences without leave or for desertion. One case was for forgery, another for stealing, and one, dementia prsecox case, for refusing to obey orders. Some were clearly feeble-minded, and proceedings against them were stopped and the men were discharged. Two measured between 12 and 13 years, but had good understanding of what they were doing__ IN THE UNITED STATES 81 desertion in the one case, stealing in the other—and were allowed to stand trial. Another, measuring 14 or 15 years, had a long insane hospital and penitentiary record and was also regarded as being sufficiently developed to stand trial for forgery. The decision in these cases had to be made with different conditions in mind from those which obtain in civil life. There was no indeterminate sentence or probation. It was either full acquittal and return to the ranks, or sentence to the military prison at Fort Leavenworth. A number of cases of persistent enuresis was under observation. Most of these were mental defectives, with rather small bladder capacity (280 to 350 c. c). One was a very intelligent fellow whose father corroborated all the essentials in his claims of never having been able to control his bladder while asleep. He, like the others, was discharged. AT FORT OGLETHORPE, GA.* Recruits were examined as they came up for their physical examination at the local recruiting office, and a number were eliminated who might easily have been passed by the regular examining surgeon. The most satisfactory work done was in the examining of the candidates for the second reserve officers' training camp at Camp Warden McLean. These examinations were held from August 29 to September 4 and were conducted by a large board of medical officers, including the tuberculosis board and the nervous and mental board. The routine examination was to test the pupillary reflexes, the superficial and deep reflexes, the gait and station, look for asymmetries and for scars of the head, face, and tongue, and for tremors, and to quiz them as to epilepsy, insanity, nervous trouble, syphilis, etc. The report on these examinations showed the following facts: (1) Eighty-seven noted as having neurological symptoms. (2) Of that number 25 were disqualified. (3) Each man was given the benefit of any doubt, and only those disqualified, whose symptoms were either pathognomonic of a serious nervous disease, or else of such a kind as to make one reasonably certain that they were unfitted for the service. (4) Thirteen were disqualified for Argyll-Robertson pupils, either with or without other symptoms, on the ground that, unless properly treated, sooner or later they would be entirely unfitted. (5) Ten were found with irregular pupils and 10 with unequal pupils; none of these was disqualified, though if Wassermanns had been done doubtless many of them would have been disqualified. (6) Of the others disqualified, 1 was a probable case of general paresis, 2 were psychoneurotics, 1 a case of hyperthyroidism, 1 an epileptic, and the majority of the remainder showed signs of cerebrospinal syphilis, all of whom were unquestionably unfit for the active duties of an officer. AT CAMP UPTON, N. Y., AND CAMP GORDON, GA.' From May to September, 1918, inclusive, 54,000 recruits were examined at Camp Upton, X. Y. Of this number, 1,050, or 2 per cent, were rejected for » Letter from Capt. D. R. Oilfillan, M. C, base hospital, Fort Oglethorpe, Ga., Sept. 15, 1917, to Dr. Frankwood E. Williams, New York, N. Y. Copy on file, Historical Division, S. G. O. ' Neuro-Psychiatry in Army Camps, by .Maj. George E. McPherson, M. C, Boston Medical and Surgical Journal, 1919, clxxxi, No. 21, 606. 82 NEUROPSYCHIATRY nervous and mental disorders. At Camp Gordon, from July to October, inclu- sive, out of 58,850 men, 1,225, or 2.8 per cent, were rejected for similar disease and conditions. At Camp Upton drug addicts constituted 17 per cent of the rejections for mental disease, while at Camp Gordon they made up 3.27 per cent of such rejections. A survey of 100 drug addicts gave them a mental age rating of 12 years, which is not materially different from that of other soldiers of the same educational-industrial level. As a rule, however, they were unskilled or poorly trained workers whose schooling, in 50 per cent of the men, did not extend above the fifth grade. Only 10 per cent were foreign born, and the 100 were equally divided between two Army drafts—one white, the other black. In both classes the drug addict from a rural community seemed to be a rare specimen. Out of the 100 cases surveyed, 56 had been committed to penal institutions on charges other than drug addiction. Seventy-two men reported 173 unsuc- cessful attempts at a cure. Although not measurably deficient, these men were certainly inferior in fields other than intellectual. One would have supposed that such cases as epileptics would have been well weeded out by various draft boards with less difficulty than obtained in many other classes of registrants. However this may appear, large numbers of epileptics entered camps, later to be discharged when their disabilities came to the attention of the neuropsychiatric examiner. Many men came to camp in the drafts with definite histories of seizures, showing scars on bodies and tongues, while some showed quite marked deterioration. Such were rejected, even on suspicion, some may say, but such a course seemed the common-sense one. There was, of course, no defense against the epileptic who willfully deceived and who showed no evidence of his infirmity. One simply had to wait for his attacks, and fortunately they generally appeared quickly under the ardors of drill. Probably about 3.5 per cent of 1,050 rejections were because of this disease. MENTAL DEFICIENCY Thirty per cent of rejections for nervous and mental disabilities were for mental deficiency, about 0.6 per cent of all cases examined. Such men offered a serious problem, as one had to overcome the disinclination of others to allow rejection of a man who looked healthy and strong. Orders from Washington instructed examiners to consider no man unfit for military service who should grade up to or over 10 years, mental rating. One must also grade 8 years or lower before he was to be considered unfit thereby for domestic duty. It was believed that no other class of men made for so much mischief in the Army as did the feeble-minded. The stories of such soldiers proved the statement that ability to get along in civil life did not, of itself, insure satisfac- tory Army service. Such an idea was not workable, and a large number of cases examined were of just such soldiers who could not get along in a strange and exacting environment. IN THE UNITED STATES 83 Psychological group examinations rendered an important service in calling to attention men who graded low, and that earlier than without such rating. All such were referred to the psychiatrist from the psychological boards, and in many cases were accompanied by a recommendation for rejection. More careful consideration of these men would find some fit for domestic duty, but, on the whole, the low raters did not prove "worth their salt." The defects in fields other than intellectual were generally brought to notice when the higher grades of morons, for instance, failed to fit properly into their several assignments or organizations. Much that was reckoned as criminality or insubordination can be charged to the mental deficiency of these soldiers. PSYCHOTIC CASES The psychoses were limited to relatively few varieties. Manic-depressive psychoses were present in very small numbers, especially while the drafts were coining in. Most of the insane in the camps fell into the schizophrenic group and were generally called dementia prsecox. In practically all of such soldiers it was possible to obtain outside histories which, together with the patients' stories, appeared to indicate that the acute psychotic episodes were but other stages in conditions which had existed for some time, even if below the surface. After worry at home over the draft to come, many men seemed just to go to pieces once they reached camp. The alcoholic psychoses were not numerous. There were few cases of chronic alcoholism. Acute alcoholic hallucinosis was found in but few men. Outside of numerous men who had endeavored to accommodate themselves to too many farewell parties and who came to camp intoxicated and shaky, alcohol did not cause much concern in the examination of recruits. Neurosyphilis contributed many cases for rejection, taken in the aggregate. In one draft of 800, luetic cases amounted to 0.7 per cent of men examined. The cities seemed to furnish a much larger percentage of luetic disabilities than did the country. Experience in camps terminated a bit too early to speak of the toxic- infectious psychoses, of wThich little was seen. CONSTITUTIONAL PSYCHOPATHIC STATES Under this heading one may speak of a large group of men, many of whom were accepted for service only to become very unhappy and a source of great concern to everyone interested. At Camp Upton 50 were discharged during five months, while at Camp Gordon 299 were thrown out in four months. Emotional instability, inadequate personality, and sexual psychopathy pro- vided the subdivisions under which the majority of psychopathies were classi- fied. These three classes just mentioned were found to consist of poor material to begin with, and the demands of war did not help them in their adjustments. 12705—29---7 \ 84 NEUROPSYCHIATRY PSYCHOXKIROSKS One can hardly describe the amazing story of this class of recruits and other men who had entered the service only to fall by the wayside when active duty was undertaken. It is difficult to believe the frequency with which men were turned down for inability to drill or to march. Enuresis, hysteria, neuras- thenia, and stammering furnished a large quota of rejections and discharges. It was interesting to learn the frequency with which other forms of the psy- choneuroses had previously been afflicted with enuresis. Needless to say such men were constantly referred for disposition. RESULTS For the reasons that have been given, not all the soldiers admitted to the Army were examined by neuropsychiatrists, but the large majority of them were examined, by one method or another. Xot all who were examined and found unfit for service were discharged, and not infrequently these came later to at- tention not alone through admissions to hospitals but also in more tragic ways. Prior to February 1, 1919. there had been returned from the American Expeditionary Forces 4,039 cases of nervous and mental disabilites, a small number when it is considered that nearly 2,000,000 troops had been sent over- seas and especially when deduction is made of the 3,1S1 soldiers who were sent overseas in the face of psychiatric recommendations to the effect that they were not fit for military service' of any kind. The insane, suicide, and delin- quency rates in the American Expeditionary Forces were extraordinarily low for an expeditionary campaign. The accuracy of the examinations is attested by the fact that there was substantial agreement in results at different points, that they coincided almost exactly with the results recorded in the reports of the local boards as prepared by the Provost Marshal General of the Army, and by the fact that individuals detected and discharged at one camp were later again detected and discharged from another camp to which they had been sent. Local draft boards did not always take as final the rejection of recruits and when called upon for another increment of men would include in this increment, to be sent to another camp, men rejected at the first camp as nervously or mentally unfit. Records were received in the Surgeon General's Office of men detected and discharged from as many as five different camps, each time by a different group of examiners. One other factor should be considered—a factor already hinted at, which refers less to the good of the Army than to that of the country as a whole. It has become clearly apparent that it is not the Army alone which makes war in these days. The whole country makes war, and like the Army, it, too, has military necessities which must be recognized. It can make use of many individ- uals who would be useless to the Army, and it should have exempted from it those whom the Army might take without being able to use. It seems to be incontestably proved that men who would not become insane in civil life, become insane through the suppression of individualism necessary in military life. If it can be shown that this is equally true for the neuroses and the mili- tary offenders, there will be collected a large class whose members useless to the military, may be counted on for partial service in the civil community IN THE UNITED STATES 85 Partial service under military control is only moderately successful with any class, and in the class of psychopaths, in this country at least, it was a complete failure. The following circular letter was promulgated by the Suigeon General regarding this matter:10 It is the opinion of this office that there are no border-line cases in neuropsychiatry with the exception of certain cases of mental deficiency and drug addiction. The nervous in- stability of the psychoneurotics and those suffering from organic nervous diseases is such that they soon break down even in domestic service, and become a burden to the Army. If they are not fitted for full military service, they are fitted for no military service. Many of the cases of mental deficiency may be found fitted for labor battalions or domestic service. This is particularly true of the negro troops. At present no facilities are available for treat- ing and rehabilitating the drug addicts. The assignment of psychopathic individuals to the development bat- talions was tried but soon given up. It would seem wiser, to leave to the civil community from the beginning these individuals who can not be made into soldiers. In addition to the rejection of recruits, it was considered important to prevent from being returned to duty, or discharged on duty status, those who had suffered from psychoses, even if they had recovered from them in the service. The recommendation was made accordingly by the Surgeon General that cases of this class should be discharged on Form 17, A. (i. O., regardless of any improvement or cure that might have taken place.11 The various types of nervous and mental diseases which disqualify from military service will be discussed elsewhere. They are, with the number of each class rejected as of May 1, 1919: u Number , Per cent 7.910 11 ti, ;ws 9 li, 916 10 4, 805 7 11. 44:-! 17 3, 87K (i 21, S58 31 6,196 9 69, 394 100 REFERENCES (1) Letter from The Adjutant General of the Army, to the Surgeon General, July 22, 191N. Subject: Mentally unfit in replacement troojx. (Transmitting extract from cable- gram No. 14(54, dated July lo, 191S, from General Pershing.) On file, Record Room, S. G. ()., 201.(i (Misc. Div.). (2) Memorandum for Colonel Howard, S. G. ()., from Frankwood E. Williams, major, M. C, division of neurology and psychiatry, S. G. O., August 14, 191S. Subject: Unlisted men recommended by psychiatric examiners for discharge already carried abroad with organizations, despite recommendations to the contrary. Copy on file, Historical Division, S. G. (). ('A) Circular No. 22, S. (!. ()., August 1, 1917. Subject: Examinations in nervous and mental diseases. (.4) Letter from The Adjutant General of the Army to all department commanders; the commanding generals of all divisions, and ports of embarkation; and the commanding officers of all camps, recruit depots, excepted places, August 22, 191S. Subject: Special examiners. I. Psychoses, or mental diseases 2. Epilepsy_______________ 3. Organic nervous diseases 4. Glandular disorders alTecting growth 5. Neuroses, or functional nervous diseases fi. Inebriety (alcohol and drugs).. ~. Mental defect ____________________ v Constitutional psychopathic state_____ 86 NEUROPSYCHIATRY (5) Office Order No. 97, S. G. O., November 30, 191s. On file, Record Room, S. G. ()., Correspondence File 342.15 (Misc. Div.). (6) Letter from the Surgeon General, U. S. Army, to the Division Surgeon (name of division and camp) (undated). Subject: Recognition and elimination of the mentally unfit and of those suffering from nervous disease. Copv on file, Historical Division, S. G. O. (7) Circular Letter from the Surgeon General, U. S. Army, to division surgeons, October 18, 1917. Also: Bulletin No. 4, W. D., February 7, 191S. (S) Mimeographed memorandum for organization commanders, concerning neuropsy- chiatric surveys. (9) Report on Hazelhurst Field, Mineola, L. I., by Maj. Stewart Paton. (10) Circular Letter, S. G. O., undated. (11) Circular Letter No. 95, S. G. O., February 19, 1919. Subject: Disposition of insane. CHAPTER V OBSERVATION AND TREATMENT All patients admitted to the neuropsychiatric wards received a complete physical, psychiatric, and neurological examination and, where indicated, psychological and special laboratory examinations. The following "Guide," prepared by the National Committee for Mental Hygiene, was found helpful in the psychiatric and neurological examinations: Guide to the Psychiatric and Neurological Examination of Patients and the Recording of the Observation The following notes are designed to serve as a guide to the psychiatric and neurological examination of patients in the military hospitals of the Government in order to insure uniformity of recording. psychiatric examination In the guide to the psychiatric examination not only the special cases which may be encountered as a result of war, but also all the types of psychoses and neuroses which occur during peace time as well have been considered; in other words, an attempt has been made to cover all possibilities in this outline, but to do it with special reference to the needs of a hospital receiving only military patients. The different aspects to be looked into in cases with mental symptoms (be they of the nature of definite psychoses or of psychoneuroses) are grouped under several successive headings. It is by no means necessarily the sequence which is best followed in every instance. We have to be guided in this by the condition of the patient, but it is important that all of these aspects should be covered in every case. On the other hand, it should be borne in mind that a given case may be so obviously normal in regard to some of these aspects that that part can be dismissed with a very brief examination. The examiner should make use of his own knowledge of military life and make constant comparison between the patient's attitude toward the various phases of life in barracks, camp, or the field, and his own observations as to the attitude of other soldiers. The exam- iner should make the best possible use of the fact that all his patients are soldiers. I. behavior, attitude, and emotional state Observe first the general demeanor of the patient as he enters the room (the condition of his uniform, his hair, his finger nails, etc.), and his reactions to a few simple questions of the type which a physician would naturally ask, such as questions about the patient's health, comfort, etc. Note also whether he shows evidence of loss of sleep, having been crying, bruises, suggesting fighting or rough handling. Note whether he is mindful or unmindful of the altitude of a soldier with an officer; whether his attitude toward the examiner is respectful, hostile, friendly, puerile. At the end of the examination the preliminary observations should be supplemented (in this part of the record) by a summary of the observations regarding behavior, attitude, and emotional state, which are made throughout the examination. A. Accessibility. (1) Natural, free, alert. (2) With definite emotiorial changes. (o) Depressive: Depressed, gloomy, worried, uneasy, anxious, fearful, etc. (b) Elated: Satisfied, happy, exuberant, etc. More complex emotional states: Suspicious, disdainful, perplexed, etc. 87 OO NEUROPSYCHIATRY B. Inaccessibility. (1) Without definite emotion: Apathetic, dull, somnolent. (2) With more active emotional changes: Depression, anxiousness, uneasiness, tenseness, perplexity, suspiciousness, disdain, etc. Certain reactions may at once lead naturally into questions as to what is the trouble; e. g., with an evident worry, one would ask, What is it you worry about? or, What can we do for you? and the like. II. MOTOR CONDITION A. General motility. (1) Normal. (2) Overactivity, excitement. (3) Diminished activity, such as slowness of motion (constant or inconstant), com- plete inactivity, possibly with catalepsy, resist ivcness. (4) Queer, bizarre actions. B. Speech. (1) Normal in amount. (2) Increased in amount (talkative, singing, shouting, noisy). (3) Diminished in amount; slow speech (constant, inconstant), mutism. (4) Disordered (other than defects suggesting organic trouble), stuttering, "baby talk, " explosive, accompanied by facial contortions, movements of hands, etc. in. stream of thouoht In spontaneous speech or answers to questions. (1) Clear, logical, relevant. (2) Jumping from topic to topic but with fairly comprehensible associations. (3) Retarded. (4) Irrelevant—incomprehensible, disconnected, with queer ideas. (5) Fragmentary, often disordered words, paraphasia and difficulty in word finding. All this may be observed in the patient's spontaneous speech and in answers to questions. If he is not spontaneous, then ask further questions. In this it is best to follow the patient's lead. iv. content of thought (1) Content of any worry or anxiety regarding present and past situations, physical complaints; apprehensions about the present and future, etc. (2) Compulsive ideas, obsessions, phobias. (3) Delusions, hallucinations, peculiar mental attitudes. Some of these may have come out before. In that case it is best to summarize briefly what has been obtained thus far and then to proceed with recording the further stud v. It should be remembered that it is not merely a question of recording the existence of delusions and hallucinations and the like, but a question above all of inquiring into and recording their content. Give patient's own words regarding hallucinations, etc. If nothing has thus far been obtained and the patient makes, nevertheless, the impres- sion of being psychotic, the following questions may bring important ideas: Have you had any peculiar experiences? Have people said things about you? Does any underhand work seem to be going on? How do you fit into the company (battery, mess, wardroom)? Has anyone made queer remarks? Made veiled references to you? Do things seem natural or unreal? Do you hear voices? Or, sometimes one may simply ask: What do thev sov? Have people done things to you? Has everyone been kind to you? Have you had strange dreams? Have you had visions? IN* THE UNITED STATES 89 S mietimes questions about certain topics bring out peculiar mental attitudes or peculiar ideas, such as: What do you think about electricity, or magnetism, hypnotism, thought trans- ference, wireless telegraphy? etc. Sometimes the question, Who are you? leads to important answers. v. orientation Does the patient know the day, month and year? Does he know what place he is in, who the persons are about him; or does he understand, at any rate in a general way, the situation? VI. MEMORY AND THINKING (1) Willi regard to old events. (a) Inquiry into life history before the advent of the psychosis or neurosis as regards the main data (birthday, positions, dwelling places, as well as inquiry about events since enlistment, etc.), with dates. This gives a good idea of the patient's capacity to think and correlate the different facts (look for discrepancies) as well as of his memory. (b) Calculation—simple tasks are a matter of memory; more difficult ones test the patient's capacity for concentration and thinking. (c) Writing—spontaneous and to dictation. (2) With regard to recent events: Such questions as, How long have you been in this place? Where did you come from? What happened yesterday? What did you have for dinner? etc., will be found useful. (Examiner should use freely his own knowledge regarding military routine.) Definite tests for retention, such as the remembering of a name and address for two or three or five minutes while questions are asked during the time intervening. For span of in"liiory, test the patient's capacity to repeat series of S, f>, or 5 digits. VII. INTELLECTUAL LEVEL If it is settled that no interference with the thought processes exists, an attempt should be mule to determine the patient's intellectual level. Test especially the general informa- tion regarding the patient's habitual environment, as well as the knowledge he is supposed to have gained in his military experience. Refer also to the guide for the examination and determination of mental deficiency. The mental tests are often of value even when the permanent intellectual level can not be obtained, since the details of functional capacity may prove of diagnostic value if succes- sive spaced examinations are made. VIII. THE PATIENT'S OWN ACCOUNT OF THE DEVELOPMENT OF HIS PSYCHOSIS OR NEUROSIS The object here is to trace in detail the origin and development of the condition from which the patient suffers. Even if inaccurate or obviously inconsistent, the patient's account is, nevertheless, important. In the case of mental disorders, functional or organic, due to the more specific war causes, it is especially important to inquire into: (1) The patient's mental make-up before enlistment as regards success or failure in life; the extent to which he was able to get along with other people; his capacity for adaptation to new situations; his habitual mood; his habitual reactions to difficulties in life, responsibilities, stress, etc.; special traits, such as fear of thunderstorms, fear of going underground, sensitiveness to seeing blood; his attitude toward the suffering of others, dread of special diseases or modes of death, etc. (2) The patient's adaptation to the life of a soldier; i. e., his attitude toward the war, his adaptation to training, his adaptation to fighting. Note his first reactions to this (fear, horror, disgust). Inquire how these first difficulties were over- come, if they were overcome. Check up patient's story by reference to officers and comrades (see disciplinary record). 90 NEUROPSYCHIATRY (3) Details of any fatigue-producing situations, special stress or loss of sleep, etc. (4) Reaction to fatigue ("jumpiness," irritability, tenseness, poor concentration, etc.). (5) The first symptoms of failure of adaptation, if indicated by the patient's history, such as the wish of deliverance from the situation (note the special form which such wishes took, such as the desire to be wounded, to be taken prisoner, or the desire for death or the war ending); an increase of nervousness and anxiousness about his own safety; specific fears; the development of feelings of horror about the situation (note special supersensitivcness). (6) Disturbing dreams (note content). (7) Causes which led to the definite breakdown: (a) Direct injury, wind concussion, burial, "gassing," etc. (b) Witnessing unusually distressing sights; or friction with superiors or refusal of leave, or distressing news from home, etc. (8) Onset of acute symptoms: Loss of consciousness (note duration); dazed condi- tion; clouding of consciousness with variations in intensity, etc. (9) History of condition since that time. (10) History of treatment and its effects; also history of military management of patient's illness and the patient's attitude toward this. In case of psychoses much regarding the development may already have been brought out, especially under the heading of content of thought. It is here gone into more thoroughly if the patient is thought capable of giving it. IX. ATTITUDE TOWARD THE MENTAL OR NERVOUS DISORDER In psychoses this refers especially to the question of whether the patient understands that he is mentally ill. In the neuroses it refers more to the attitude in general which he takes toward his symp- toms, e. g., does he think they are all due to stress or partly to his own failure in adaptation? NEUROLOGICAL EXAMINATION Condition of body Facies, growth, abnormalities in development, glandular trophic and vasomotor phenomena, including variations in weight, growth of hair, amount of fat, asymmetries, etc. In functional cases it is especially important to notice trophic and vasomotor phenomena such as skin eruptions, pigmentation, pallor, coolness of the skin, edema, cyanosis, increase or diminution of sweating, excessive dryness, peculiar odors and secretions, pulse rate, pain in the head, palpitation, breathlessness on exertion, precordial pains. If unusual trophic or vasomotor symptoms occur it is important to determine whether or not these are the result of the patient's own actions. General appearance of patient as regards resemblance to some disease. CRANIAL NERVES First nerve (olfactory).—Anosmia, parosmia. Second nerve (optic).—Acuteness of vision and, if impairment, description of same; irritating visual phenomena. Pupils, whether round or irregular; their reactions to light and to movement of eyeballs. Visual fields (note especially in shell-shock cases variations from the normal such as reversion of color fields, etc.). Opthalmoscopic examination; exophthalmos and enophthalmos; irregular size of palpebral fissure. Third, fourth, and sixth nerves (ocular nerves).—Ptosis or drooping of the upper lid ocular palsies, description of double vision, convergence. Fifth nerve (motor).—Muscles of mastication, masseters, temporals, and pterygoids. (Sensory portion.) Note disturbance of sensation for touch and pain and temperature. Pains in face. Loss or impairment of taste in anterior two-thirds of the tongue. Look for parageusia or perversion of taste sense in shell-shock cases. Seventh nerve (peripheral facial palsy).—Inability to wrinkle forehead, shut the eve show teeth. With central facial palsy, can wrinkle brow and shut the eve. Note loss of taste on the affected side. Electrical examination to be made if possible. IN THE UNITED STATES 91 Eighth nerve.—Cochlear division: Determined degree of deafness by tuning fork or voice and then make a closer examination and determine whether it is due to the destruction of the nerve itself, or the middle ear, or if it is functional. Vestibular portion: Examination should be made by so-called Barany tests either by means of a turning chair or irrigation of the external car by water. Xinth nerve.—Inability to swallow. If impaired, note degree of inability to swallow food and regurgitation of same. Loss or impairment of taste in posterior third of the tongue. Look for parageusia or perversion of taste sense in shell-shock cases. Tenth nerve.— Movements of vocal cords, character of speech, and whether or not speech and breathing are interfered with. Eleventh nerve.—Action of sternomastoid and trapezius muscles. Twelfth nerve.—Ability to protrude the tongue and its direction and impairment of movement. Atrophy and tremor. Motor symptoms Station and gait. Deformities and contractures. Convulsions, local spasms, tics, tremors (coarse or fibrillary), myokymias, etc. Limbs: Determination of strength by grip and movements, both voluntary and against resistance. Tonicity, atrophy, or hypertrophy, coordination of extremities and trunk (ataxia), cerebellar asynergy. Reflexes Cutaneous.—Conjunctival, corneal, epigastric, cremasteric, plantar, Babinski, defense. Tendon.—Biceps, triceps, wrist, patellar, Achilles. Muscle reflexes.—Clonus: Wrist, patellar, ankle. Special: Kernig, Trousseau. Electrical examination Faradic response. Galvanic response and nature of the reaction. Speech disturbances (organic functional) Organic.—Motor aphasis: Patient knows what he wants to say, understands what is said to him, can read, but is unable to express himself either wholly or in part in spoken words or by writing. Sensory aphasia: Patient can talk and can write, but neither his speech nor his writing make sense because he is word deaf; that is, he does not understand the meaning of the sound of words. Sensory motor aphasia: A combination of motor and sensory aphasia, the extent of the disturbance depending upon the completeness of the lesion. Functional.—In functional or shell-shock cases, look for various forms of speech defects such as mutism, stammering, stuttering, and verbal repetition. Hearing may be lost often with speech. Hyperacusis or extreme sensibility to sound is very common. Sensation Studied in head, trunk, upper and lower extremities with finger tip, cotton-wool, camel's- hair brush, esthesiometers, hot and cold test tubes, etc. Epicritic sensibility.—Superficial touch, light pressure, warmth, coolness, tickling (hairy surfaces), tactile localization, and tactile discrimination. Protopathic sensibility.—Pain sense, extreme heat, extreme cold. Deep sensibility.— Muscular, tendinous, arthrodial. Sense of position and passive movement, deep pressure. Astereognosis. Asymbolia. Vesical, rectal, and sexual functions. Lumbar puncture Cell count and Wassermann. 92 NEUROPSYCHIATRY Physical examination This should be a general physical examination including condition of the heart, lungs, blood pressure, blood for Wassermann, etc. Active treatment as contrasted with custodial care was emphasized in all neuropsychiatric wards and hospitals. Diagnosis was not considered an end in itself. Individualization of the patient was insisted upon. Patients, in so far as possible, were not permitted to be idle. From the day of his entrance into the hospital an effort was made to see that the patient was kept occupied. In this important procedure the occupational therapy worker was invaluable. In most of the hospitals the neuropsychiatric staff met daily to consider difficult cases, to discuss the advisability of discharging certain patients, and to review the results of the examination of recently admitted patients. In some of the hospitals a weekly conference was held, to which all the medical officers of the hospital were invited. At these conferences papers on such psychiatric subjects as might be of interest or benefit to the general medical officer were read and patients were presented and discussed. These conferences frequently aroused much interest and were well attended. A further oppor- tunity to familiarize the general medical officer with psychiatric case studies was presented by the regular hospital staff conferences. The neuropsychiatrists took their turn in presenting to the entire staff of the hospital interesting psychiatric material. The experience of those responsible for the neuropsychiatric work at Walter Reed General Hospital, Washington, D. C, is more or less typical of the experiences elsewhere and is worth recording. Prior to the World War mental patients at Walter Reed Cleneral Hospital were cared for in the basement of the administration building along with the military prisoners. The place was wholly unsuited for prisoners, let alone patients. But the feature which evidently recommended it was that, having been built for prisoners, it was heavily barred and guarded and the insane could not get out. Treatment was impossible and the care in all respects, except possibly food, was about the equal of the county asylum of the old type. Before the end of 1917, however, psychiatry at Walter Reed General Hospital had improved materially. Five neuropsychiatric wards, of wooden construc- tion, were opened. The first ward was built in accordance with the building plan of the neuropsychiatric wards of the base hospitals; that is, a ward divided into three sections so as to provide a better classification of patients. The other wards were dormitory wards similar to the general medical wards. As it was planned to use a section of the first ward for disturbed patients, the rear portion of this ward was screened with iron-wire mesh. The screening was never com- pleted and a part of what had been put up was later taken down. The five wards at Walter Reed were open wards without bars or mesh, and were comparable in every way with the general medical wards of the hos- pital. As a matter of fact, it was possible, in showing visitors throuo-h the hospital, to take them from the medical to the neuropsychiatric wards without their knowledge of when they had made the change. The same lack of restraint was to be found at Hospital Xo. 2, Baltimore—no bars, no bolts, no mesh. The ward physically was no different from any other ward in the hospital, except IN THE UNITED STATES 93 the ward for military prisoners. The psychiatrist's difficulty in conducting this kind of a ward was not so much in keeping patients in as keeping patients out. The ward in the early days of the hospital was so much more attractive than the other wards that it was at times difficult to keep other patients from coining over to visit, play the piano, listen to the victrola, or work in the shop. The standards were equally high at Fort Benjamin Harrison, Fort Sheridan, the Letterman General Hospital, Fort McPherson, Fort Sam Houston, and Fort Des Moines. Each differed somewhat from the others, depending upon local conditions. Xone were as free of bars and mesh as Walter Reed General Hospital or General Hospital No. 2, at Fort McHenry, Md., but in each these evidences of incarceration were much reduced and further reduction was con- templated, the chiefs of the service being convinced that the bars and the mesh were not only unnecessary but that treatment could be carried out much better without them. As a matter of fact, many wards that had originally been barred or meshed in order to relieve the anxiety of a commanding officer became open wards, with doors unlocked and patients given much freedom. That the open-ward system was successful there can be no question. The success depended upon a number of things. The spirit of the wards was important. The spirit was distinctly that of a hospital, not that of a jail. The patient was not constantly reminded of his situation by the sight of bars; he realized that at least some one considered him sick and that for that reason he had been brought to a hospital where he was under no greater confinement than other patients in the hospital; at no time was he stung with the humilia- tion of imprisonment. Incentive to escape was reduced to a minimum; the patient came to regard himself possibly as sick; his ingenuity was not aroused to out-trick his jailers or to create out of nothing instruments to remove bolts and bars. The importance of careful classification of patients was kept con- stantly in mind. (ARE OF CASES OF NERVOUS DISEASES The treatment of organic diseases of the nervous system, under which head- ing epilepsy is classed at this point for convenience, was of little military impor- tance, as these conditions, almost without exception, disqualified for service. Few of them were susceptible of any great degree of amelioration by such treat- ment as was afforded in our military hospitals. The hospital history of all the cases of this general class was that they were retained in the service for antisyphilitic treatment, for tonic treatment, or for operation, as the case might be, and then were discharged from the Army. They showed no differences in symptoms, course, or indications for treatment in the military service from similar cases in civil life. One of the important demonstrations of the war was the great number of men from all walks of life who were conditioned in their practical usefulness by functional nervous disorders of some kind. These came in for dramatic prominence as cases of shell-shock, developing in both front and base sections in France; but still larger numbers were refused entrance into the Army, and many were discharged from the camps on surgeon's certificate of disability. 94 NEUROPSYCHIATRY The number of neuropsychiatric cases rejected or discharged at home may be divided into two general classes—the psychasthenic, or neurasthenic, and the hysteric. In the former the patient was concerned with a chain of mental difficulties, and was constantly provided with long explanations as to why he did not successfully carry on his military duties. These explanations referred to various purely subjective symptoms, which might come to light when the man was reported as a patient. Under such circumstances he could be found in any of the various medical services, as the symptoms might be referred to any organic system. These cases were especially found in connection with the "effort syndrome," and with the whole group of cardiovascular conditions. Symptoms referable to the stomach and intestines were particularly frequent. The cases called hysterical were apt to be associated with more definite symptoms, such as paralysis, contractures, abnormal gaits, etc. In this hys- terical group, suggestion as a factor in determining the type of symptom was much more evident than in the psychasthenic group; also these patients were frequently noticed to be less intelligent. The cases returned as neuroses from overseas were so similar to the home eases in their symptoms that it can be said that there appeared to be no funda- mental clinical differences between neuroses developing in actual warfare and those which developed in the training period. The probability is also great that there is slight difference, with the exception of some war coloring, between the neuroses of war and those of civil life. Practically all of the symptoms reported in France were observed in the cantonments at home. But there existed a difference in degree, in that thera- peutic efforts to combat functional nervous difficulties could be made more suc- cessful in battle areas than could be done in the zone of the interior. This was probably because, on the one hand, the discipline and morale was better near the front, and, on the other, that real war neuroses were more acute con- ditions, betraying less fundamental character defects, and appearing as the immediate results of trauma, especially of an exhaustion brought about by mental strain, physical over-exertion, exposure to cold and lack of food. The patients, in other words, if taken immediately in hand, could be brought back to normal, or to a point approximating normal sufficiently to enable them to be returned to duty, full or limited. This relatively favorable prognosis, under proper therapeutic conditions, did not apply, of course, to all of the overseas cases. Most of the patients returned to the United States during the period of active combat presented character defects of a prominence that made cure under any military conditions most difficult, if not improbable. They should have been detected—many of them were, but were not discharged—and eliminated before their organizations were ordered overseas. But even some of these, who had resisted all efforts at cure overseas, could be brought to the point where at least all symptoms disappeared in the home hospital. One enlisted man who had displayed a useless arm in several of the hospitals in the American Expeditionary Forces resumed the use of it at General Hospital No. 2, Fort McHenry, after 48 hours of deprivation of tobacco, combined with kindly suggestion. IN THE UNITED STATES 95 But the treatment of these cases which met with such general success overseas was never tried out in this country. The short duration of the fighting after our entry into the war afforded no opportunity for such a trial here. Had the war progressed further and had the time come when the United States was actually pressed for men, some definite plans would doubtless have been formulated for the reconstruction of war neurosis cases at home. Plans looking to this end were under consideration in the Surgeon General's Office at the time the armistice was signed. It would have required a more elaborate and special organization than any that had been put into effect. Development battalions had been organized, particularly for physical disorders, but they did not provide sufficiently detailed classification to make them serviceable for neurosis cases. Such cases as were assigned to them soon fell out, and so secured their discharge. Because of early discharge it is difficult to draw any very definite conclusions as to the curability of the functional cases which occurred in the home camps. As it was, the neurotic soldiers could not altogether escape being regarded in a sense as malingerers. An inquiry initiated by the division of neurology and psychiatry x brought out that the old point of view, that all functional cases were malingerers, had given place to a more rational view; that most Army surgeons, while noticing the numbers of neurotics among the troops, accused few of being so deliberately and with voluntary intention. But in spite of this there was some feeling on the part of Army surgeons that such sol- diers did not play the game quite fairly, that they could have done more if they would. In other words, there seemed to be the general conviction that under certain circumstances many of these men could have been made useful for some duty. OCCUPATIONAL THERAPY It was the consensus of opinion of the officers who came most closely in contact with the occupational therapy work that to it must be credited much of the success of the neuropsychiatric wards. One element of the success of occupational therapy in the military hospitals was certainly the high standard of qualification insisted upon by the training schools that prepared these work- ers and later by the Army itself. A second element of success was that from the first the importance of occupational therapy was insisted upon and it was given an independent and important place in the scheme of hospital organiza- tion. It was not subordinated to nursing. It was not considered as a part of nursing but as a part of therapy, and, as therapy, it was under the imme- diate direction of the physician. The worker was responsible not to the nurse but to the physician. Occupational therapy was introduced into the military hospitals by the division of neurology and psychiatry. The first occupational therapy workers employed by the Army were the six women included in the personnel of Base Hospital Xo. 117.2 So immediate was the success of these women that the demand for similarly trained women grew. The feasibility of introducing reconstruction procedures into the neuro- psychiatric wards as a whole was doubted, in our earlier experience being con- sidered applicable only to the cases which were less disturbed mentally. The 96 NEUROPSYCHIATRY benefits of occupational therapy became so pronounced, however, and the aides so skillful in their approach after several months' experience, that the work was given to all except the extremely violent. This furnished systematic employ- ment to restless patients, reduced the introspection of neurotics and the delu- sions of the insane, seemed to shorten the duration of the prseeox or manic episode of the psychoses, and decreased the necessity for restraint in the more disturbed cases.3 Courses were given in bench woodwork, carpentry, painting and staining, machine work, pattern making, automobile mechanics, English, arithmetic, bookkeeping, stenography, typewriting, drafting and designing, geography, agriculture, history, economics, weaving, basketry, printing, lettering, and poster making. Frequent entertainments of various kinds were given, with an effort to have the patients put on their own shows, and a band was organized. One hospital maintained an excellent library of nearly 4,000 volumes, with the leading periodicals and newspapers from the principal cities of the country.4 The library was considered to have been an important factor in the reconstruc- tion work. PSYCHIATRIC SOCIAL WORK Expert consultation in other fields was available at all times and was utilized when necessary. In cases in which the diagnosis was not clear for lack of full information, the psychiatric social worker was called upon, and, in most cases, was soon able to place before the physicians a more or less complete history of the patient's life and condition before entrance into the Army. The importance of psychiatric social work, and of social work generally, was first demonstrated at the special hospital for neuroses at Plattsburg. This demon- stration was made by the division of neurology and psychiatry of the Surgeon General's Office through the cooperation of the American Red Cross. The success of the work at Plattsburg led to the assignment of from one to three psychiatric social workers (psychiatric aides) to each of the general hospitals maintaining neuropsychiatric wards and later to the assignment of medical social workers to all hospitals. Where patients required continued care after discharge from the Army, the social worker made inquiry in regard to the fam- ily conditions to which the soldier would be returned and the possibilities of local care, and made arrangements with the family, the State authorities, or local Red Cross representatives for the reception of the patient. The activities of the neuropsychiatric social service at General Hospital Xo. 30, Plattsburg, X\ Y., were reported as follows: 5 Soon after the soldiers began to return from overseas, it was discovered that many came with reports containing very little medical information. The soldiers sent to the military hospital for war neuroses (United States Army General Hospital No. 30), at Plattsburg Barracks, N. Y., not infrequently came with only a diagnosis. Some presented symptoms which indicated that their condition was probably chronic and had existed for years previous to their entrance into the Army. Others came with a diagnosis of epilepsy, but while in the hospital had no seizures. The medical officers began to feel the need for information other than that secured from the soldier himself, and through Major Hutchings, chief of the neuro- psychiatric service of this hospital, a request was made for the appointment of a social worker at Plattsburg. In consideration of the immediate need for this worker, and the firm belief of all in the necessity of the worker's having complete freedom in developing her work. IN THE UNITED STATES 97 the American Red Cross was asked by the Surgeon General to assist the Medical Depart- ment of the Army in demonstrating the value of this type of work in military hospitals. The necessity of this request was due to the fact that, under the existing Army provisions, the social worker could be appointed only as a reconstruction aide, giving her a status lower than a nurse. That the success of psychiatric social service in military hospitals would depend largely upon the efficacy of its organization was hardly questioned, but the signifi- cance of its establishment directly under the control of the military authorities and the supervision of the medical officers was not appreciated at this time. It was the consensus of opinion, however, that there might be administrative difficulties if the work was placed under the direct auspices of a civilian and nonmedical organization, when the control of the hospital was military. It was also believed that the very character of the work necessitated its organization as a department of the hospital under medical jurisdiction and that dual control would ultimately weaken its effectiveness. In view of these facts, no definite decision was made regarding the status of the work, but there was a general understanding between the Army and the American Red Cross that it would be an advantage to have the worker considered as an unofficial adjunct to the medical staff and under military authority. On September 1, 1918, the social worker began her duties at the military hospital for war neuroses, Plattsburg, N. Y., the American Red Cross having agreed to pay her salary and allow her to be considered a part of the military regime, having no status under the organ- ization of the American Red Cross. She was assigned an office in one of the hospital barracks, accessible to the wards and the administrative offices, and was supplied with sufficient equip- ment to start her work. Through the courtesy of the military authorities, officers' privileges, such as living in officers' quarters and eating at the officers' club, were extended to the worker. Her duties were not defined, but she was expected to secure early histories through cor- respondence to assist the medical officers in the diagnosis of difficult conditions and to help (hem in reaching a decision as to whether the soldier's condition occurred in line of duty or prior to his enlistment or induction into the Army. For five months the social work of the hospital was carried on by one worker, with the assistance of enlisted men from the Medical Department, and convalescent patients, who were assigned for messenger and clerical service. The stenographic assistance was provided by the hospital until the 1st of January (1919), at which time the bureau of camp service of the American Red Cross donated the salary of a full-time stenographer. It was extremely difficult to handle effectively the amount of work referred to the department, owing to the lack of professional and clerical assistance. The delay in the appointment of social workers was due to the fact that it was impossible for the American Red Cross and the Army to reach a decision as to the organization under which these workers should be appointed until the latter part of 1918, and it was not until the latter part of January, 1919, that the provi- sions made by the Suigeon General for the appointment of psychiatric social workers in mili- tary hospitals under the status of reconstruction aides became effective. By January 31, 1919, two workers had reported for duty at Plattsburg. After the establishment of the department, the following divisions of work were devel- oped: (1) Securing early histories; (2) social case work; (3) after-care; and (4) administrative work. The scope of work was limited, owing to lack of assistance, simply to handling the most urgent cases. SECURIXO EARLY HISTORIES The majority of these investigations have been to establish, in the cases referred, the diagnosis of epilepsy, hysteria, or other conditions, prior to the soldier's admission into the Army, in order to decide the Government's liability and the soldier's rights for compensation. In most instances the soldiers have been interviewed by the social worker in her office, and have been questioned regarding their early history. Special emphasis has been placed upon securing the names and addresses of individuals who would be in a position to give the necessary information and encouraging the soldier to give his own statement regarding his illness. Inquiries in general have been addressed to physicians, principals of schools, former employers, and immediate relatives. In 90 per cent of the cases replies have been received, the greatest assistance coming from physicians and employers. The school reports have 98 NEUROPSYCHIATRY shown that, in most instances, the health records have been incomplete. The value of the replies can not be statistically given, but in the majority of cases the replies have indicated a past history of nervous instability, if not a definite history of nervous or mental disorders. There have been a number of instances in which soldiers' statements to the medical officers and the social worker have been found untrue, generally in the cases of soldiers who were undoubtedly malingerers, desiring to secure compensation or to avoid military service. Examples: Case 1.—The soldier claimed his epilepsy occurred in line of duty. The investigation proved that he had been an epileptic for years; that he had had great difficulty in holding positions, and had not been able to support his family. Case 2.—A soldier, having definite seizures of epilepsy, grand mal type, at the hospital, claimed he had never had them before entering the Army. The history he gave showed that he had been a wanderer, and had never lived in any place longer than a few months, following many occupations. It was felt that it would be impossible to secure any past history, and that his condition would have to be considered in line of duty. This soldier had never been overseas, and had a record of intemperance in the Army. After considerable questioning the social wrorker was able to secure the names of a few former employers, and through the interest and assistance of one of our western railroads the diagnosis of epilepsy prior to enlist- ment was definitely established. Case 3.—A soldier coming from overseas, with a very meager history and a diagnosis of epilepsy, had no seizures while at the hospital. The investigation showed that he had been an employee in one of our epileptic institutions, having been discharged for larceny, and had had a court record. No history of epileptic seizures was obtained, although the soldier stated that he had had them. Case 4-—A soldier claimed his condition occurred in line of duty and it was learned from his wife that he had nocturnal attacks of epilepsy. Owing to the success of the investigations the medical officers, prior to the signing of the armistice, were considering referring to the social worker all overseas cases, classed as epilep- tics in line of duty, whose histories were inadequate to establish this fact. The cases referred were so numerous that it was impossible for the social worker to handle them alone, and it was necessary on account of the other important types of work to limit the number to those which the medical officers felt could not be decided without further information. The scope of this division of work was therefore considerably limited and has not been developed to the extent of its value. The foregoing facts seem to indicate the value of investigating cases involving the ques- tion of compensation prior to discharge from the Army, as it would seem logical that histories, as described above, would be almost impossible to obtain after the soldier had made a claim for compensation. SOCIAL CASE WORK One of the most important functions of the department has been social case work, the assistance rendered the soldiers who have been troubled with personal or family difficulties. The chief complaint has been in relation to their financial circumstances. Many of the overseas soldiers, who had left the United States months ago, having made not only voluntary but compulsory allotments before they went over, returned to find that their families had not received their allotments. The number of soldiers applying for advice and assistance has been so great that it has been impossible to keep track of them. In general, the soldiers have been grossly ignorant concerning the Bureau of War Risk Insurance and its methods of operation. Of all cases investigated the statements of the soldiers regarding the nonpay- ment of allotments were found to be correct, but it was impossible to secure replies to inquiries sent to the Bureau of War Risk Insurance, except through indirect channels. The reasons given were general and to the effect that the allotments and Government allowances had not been paid owing to faulty execution of the forms in the beginning or that the wrong forms had been used. It was learned through the investigations made by the American Red Cross, at our request, that a great many of our soldiers' families were in serious financial difficulties as a result of this situation, and that the American Red Cross had been obliged to give financial aid. The need for a worker specially trained in handling these problems had been demonstrated in this hospital by the number of cases referred to the social worker for IN THE UNITED STATES 99 investigation, not only by the soldiers themselves, but also by the officers in charge of this branch of work, who, owing to the pressure of work, have been unable to give the personal attention needed to adjust these difficulties. Another particularly important phase of social case work has been the so-called reeduca- tional, personal talks with the soldiers. Anyone at all familiar with the type of cases which have been under observation and treatment at this hospital realizes that some of the main symptoms have been restlessness and discontent, and a general attitude of lack of sympathy with the Government and Army life. The soldiers' complaints, such as the theft of their personal property, the nonpayment of their allotments, etc., seem to be well founded and have resulted in the feeling that the protection which would have been awarded them in civil life has not been given them in military life. Almost all have had one aim; namely, to get out of the service as soon as possible. The social worker believed that much could be done toward changing this attitude, at least in the men who came to her for assistance of one sort or another, and has made a special effort to give the soldiers a somewhat different point of view than they have had regarding the military system. That the majority of cases treated at Pla'tsburg showed mental inferiority as well as moral defects is evident. There has been a childlike attitude of the men regarding all phases of their army life and their social tenden- cies, as well as nervous instability. These reports have been filed with the soldiers' clinical records, and, although they have not, except in a few instances, influenced directly the dis- position of the cases, may prove of inestimable value to the Government if claims for com- pensation are filed. The American Red Cross has been notified of the date of discharge and has rendered any assistance necessary, such as securing employment, medical supervision, and anything which may be required. The assistance given by the American Red Cross can not be overestimated, and the results have been exceedingly satisfactory. It is evident that the interest taken by the local Red Cross chapters in this group of cases will stimulate a keener community interest and appreciation of the mental hygiene movement. ADMINISTRATIVE WORK Another division of the work which might have proved of considerable value to the administrative department of the hospi'al, if it had been possible to have had more assistance, is that of answering inquiries from relatives, friends, and civilian organizations concerning the soldiers' condition and circumstances. The replies to these inquiries must of necessity be very carefully considered, for they must contain enough information to allay anxiety, and at the same time must not divulge any information which might give a false impression or serve as a basis for a claim against the Government. Owing to the fact that the social worker has been asked to answer many of these inquiries, it is reasonable to conclude that this work might be handled effectively by the social service department, whose workers are trained in dealing with problems of this type. The social woiker has regretted exceedingly her ina- bility to give information of a medical nature to the American Red Cross, because of their cooperation and interest, and the importance of having this knowledge in order to be able to give more satisfactorily the assistance required. The social worker has been asked to investigate the need for furloughs in a number of cases where the reliability of the statements was questioned. Requests have also been re- ceived to investigate the need for the soldiers' early discharge from the Army because of dependent relatives, serious illness, etc. The foregoing report shows in a measure the point of view of the social worker regarding the usefulness of social service departments in military hospitals and outlines, in general, the type of organization which seems necessary and the scope of work which might be under- taken. That a department of this type is essential has been established, and the conclusion drawn, namely, that the effectiveness of the treatment in military hospitals depends upon the cooperation and assistance of the community after the soldiers' discharge is undeniably sound and practicable. As to the financial value of such a department, the reports on early histories of the soldiers have conclusively shown that much expense might be saved the Gov- ernment through the establishment of departments of investigation at the time the soldiers are under treatment in the hospital, rather than after the soldiers have been discharged and have filed their claims for compensation. 42705—29—8 100 NEUROPSYCHIATRY STATISTICAL SH10KT Number of individuals assisted_________________ s-0 Sources from which these cases were referred: (1) Medical officers_______________________ __ 5oS (2) Soldiers_______________________________ 231 (3) Miscellaneous_____________________________________ - - . - --------- 31 Classification of cases according to reason referred. (Note.—These figures overlap lie- cause in some cases all 4 types of work have been done): (1) Securing early histories___________ ________________ - - - — - 191 (2) Social case work_________________ _________________- - ---- litis (3) After-care________________________ ________________ - I'l/i (4) Administrative work_____________ _______---- - - % Number of letters sent out________ .1, I2.s Number of letters received_____ ...... ... _.----- .._._. — 1,166 Number of interviews with soldiers._________ _________ _ — _ _ ---- 960 ACTIVITIES OF NEUROPSYCHIATRIC SERVICES The following accounts of the methods of observation and treatment employed in some of the more typical neuropsychiatric services in base and general hospitals are taken, without comment, from selected reports to which they are credited. BASE HOSPITAL, CAMP SHERMAN, OHIO1 All cases that could not be decided on at the preliminary survey (mental and nervous examinations of troops) were referred to the base hospital, either to be admitted as patients for observation or to be examined thoroughly at greater leisure. The psychiatrist at the base hospital saw these men, made careful examinations, often spending an hour or two at a time on one patient, applying Binet or other tests where needed. He wrote for information to relatives, employers, or attending physicians; or got information as to the man's behavior from commissioned or noncommissioned officers or privates, with a view of getting such data as might help in the diagnosis of epilepsy, mental deficiency, peculiarities, malingering, etc. It was found very helpful to have a noncommissioned officer go to the patient's company to make inquiries about his general adaptive reactions or about some special incidents. Besides the cases thus referred by the surveying examiners, there were sent to the base hospital by the line officers patients in whom they suspected evi- dences of nervous or mental disease. In the camps where psychological surveys were made, the psychologists also referred cases to the psychiatrists. These cases were examined in the same way as those sent by the psychiatric surveyors. In addition to these, many cases were seen in consultation in the other wards of the base hospital. Many of these were neurasthenics, in whom the question of malingering arose. Sometimes the advisability of operating on a given patient came up, as, for example, in a case of hernia in a defective. If he was too deficient mentally to make a good soldier, operation was advised against. Another group of cases that came before the psychiatrist was that of the men who had been arrested for various offenses, such as theft, desertion, repeated » Based on The Work of Psychiatrists in Military Camps, by Maj. E. Stanley Abbott, M. C. American Journal of Insanity 1919, Ixxv, No. 4, 457. IN THE UNITED STATES 101 absence without leave, in order to determine their responsibility for their acts, and whether or not they should be brought to trial by court-martial. In one case a man already had been convicted for refusal to be operated on for hernia. Before sentence was passed, however, the question of his mentality was raised, and it was found that he was about 9 years old developmentally. His sentence was not carried out; instead, he was discharged from the Army. The cases of mental disease arising among the men, such as manic or depres- sive states, dementia prsecox, acute alcoholism, delirium tremens, had to be taken care of and treated until some adequate disposition could be made of them. It fell to the psychiatrist, of course, to exercise the care of these, as well as of the cases sent for observation or special examination. The psychi- atrist had to determine whether the patient should be allowed to go home or should be sent to an institution for the care of the insane; also, whether he should be allowed to go home alone or must be accompanied by one or more persons. And if the patient was sent to a hospital, the psychiatrist prepared and sent adequate records of the case. BASE HOSPITAL, CAMP DEVENS, MASS." The neuropsychiatric service was opened December 4, 1917, for the recep- tion of patients. During the time draft men were being received, this service did all the camp neuropsychiatric work in addition to attending to the ward cases. The class of patients handled by this service included neurological, psy- chiatric, feeble-minded, epileptic, and inebriate, and after the return of the overseas men, so-called "shell-shock," and various traumatic neurological cases. Among the psychiatric cases, dementia prsecox, manic-depressive, general paralysis of the insane, and various other forms of psychiatric cases were under observation and treatment. The treatments as administered, consisted of medicinal therapy, hydro- therapy, electrotherapy, and occupational therapy. The disposition of the cases was variable; some, not in line of duty, were transferred to the psychopathic hospital, Boston, Mass., and from there to the State in which the patient resided. Other patients, whose disability was incurred in line of duty, were transferred to general hospitals for the insane. Some cases were discharged to duty, either well or improved, and the remaining psychopathic or neuropathic cases were discharged on surgeon's certificate of disability. The routine of the staff was as follows: There was a daily morning staff meeting on each case, at which time the diagnosis was made. As the occasions demanded, consultations were held in the medical and surgical wards of the hospital. The enlisted personnel were practically intact from the time of the establishment of the ward, most of the men being experienced in the han- dling of psychopathic cases. The total number of admissions during 1918 was 929. 'Based on History of B;ise Hospital, Camp Devens, Mass., by Maj. W. B. Lancaster, M. C, March 19, 1919. On file, Historical Division, S. O. O. 102 NEUROPSYCHIATRY BASE HOSPITAL, CAMP WADSWORTH, S. C. d The neuropsychiatric work at Camp Wadsworth was begun during the latter part of September, 1917. At first it consisted in the examination of the camp personnel. A number of organizations of the 27th Division had been examined before coming to Camp Wadsworth. The examination of the remainder was completed during January. Scattered cases and men especially referred by the regimental surgeons were gone over in February. Additional troops began to arrive during March and April, therefore, the number of examinations increased. It was not until February 15, 1918, that all neurological cases in the base hospital were concentrated in one ward, ward No. 15. This was a regular ward and, therefore, not suitable for the care of insane patients. From the opening of the hospital psychiatric patients were transferred as soon as possible to special institutions; at first to Kings County Hospital, Brooklyn, X. Y., and St. Elizabeths Hospital, Washington, D. C, after December, 1917, to General Hospital Xo. 6, Fort McPherson, Ga. A special psychiatric ward was constructed and completely equipped. Ward No. 15 contained 36 beds, most of which were constantly occupied. The majority of cases treated were psychoneurotic. Hysteria was especially frequent. Patients with this trouble responded well to suggestive therapy administered through the medium of faradic and sinusoidal electricity. Neu- rasthenic patients did well under rest, forced feeding, massage and salt rubs. Special attention was paid continually to the mental attitude of the patients. Cheerfulness was the rule in the ward. Sympathy and understanding, com- bined with firmness, were maintained. Faulty attitudes and emotional reactions were explained to the patients and they were encouraged to combat them. They were made to realize that a personal interest was taken in their welfare, that things were done for them, and that much was expected from them in return. BASE HOSPITAL, CAMP MEADE, MD.e The personnel of the neuropsychiatric section consisted of 1 officer and 12 enlisted men. Of the enlisted men, 3 were male graduate nurses, 5 men with previous experience in State hospitals for the insane, and 4 orderlies. On February 1, 1918, one ward was assigned for neurological and psychiatric cases. On March 15, one-half of another ward was assigned to this service, and on April 22 the number of cases had increased to such an extent that it was necessary to assign two full wards to this service. Of these wards, one was used for psychiatric, the other for neurological cases. On December 18, it was found again unnecessary to have two wards, owing to the decreased population of the camp, and all cases were concentrated in one ward. The following tabulation shows the movement of patienis on this service for the year: * Based on History of Base Hospital, Camp Wadsworth, S. C, by Maj. W. Barndollar, M. C, undated. On file, Historical Division, S. G. O. • Based on annual report, base hospital, Camp Meade, Md., for 191%, made to the Surgeon General by the commanding officer. On file, Historical Division, S. G. O. IN THE UNITED STATES 103 Total admissions___________________ ---------------------- 952 Average under treatment daily_______________________________ 51 Discharged: Improved___________________ ______________________ 166 Recovered____________________________________________ 65 Unimproved__________________________________________ 630 By transfer___________________________________________ 65 Died_________________________________________________ 5 Remaining Dec. 31, 1918____________________________________ 21 The percentage of various classifications of diseases resulting in discharge from the service follows: Per cent Nervous disease or injury___________________________________ 24 Psychoneurosis____________________________________________ 20 Psychosis________________________________________________ 10 Inebriety_________________________________________________ 9 Constitutional phychopathic state____________________________ 8 It would seem at first glance that the percentage recommended for dis- charge was high; however, it is evident that once a diagnosis of nervous or mental disease was made it was to the best interests of the service, as well as of the individual, to return him to his home, experience having shown that such men would not stand up under the stress of modern warfare. Because of limited space, necessitating the expeditious handling of patients, the insane were transferred to the Government Hospital for the Insane, Wash- ington, D. C, for further observation and treatment. Mildly demented cases which observation showed were not dangerous to themselves, or a menace to society, were sent to their homes in care of an attendant. Of the 952 patients admitted, 80 per cent were admitted from command and 20 per cent transferred from other wards of the hospital. There were no suicides or other serious injuries during the year. From each incoming draft were admitted about 10 cases of drug addiction. These men were immediately discharged from the service, experience having shown that no reliance could be placed on a man so afflicted, and his presence in a company was decidedly detrimental to the morale. It is interesting to note the high percentage of cases of hyperthyroidism from the mountainous districts of adjacent States,, especially West Virginia. There were surprisingly few cases of attempted malingering. The exceptionally low percentage of involvement of the central! nervous system in syphilis in the negroes is also wort try of mention. BASE HOSPITAL, CAMP JACKSON, S. C/ The neuropsychiatric ward was opened in November, 1917. This building was designed and equipped on the lines of the standard base hospital ward for this special purpose. According to the original plans, heavy iron bars on the windows were called for, but were omitted by the War Department upon the request of the chief of the service, it being his belief that such measures for the restraint of patients were antiquated. / Based on History of Base Hospital, Camp Jackson, S. O., from October 22, 1917, to June 1, 1918, by Capt. Martin W. Reidan, M. ('. On file, Record Room, S. G. O., 314.7 (Medical History, Camp Jackson) (D). 104 NEUROPSYCHIATRY The psychiatric portion of the ward was not available for its proper purpose until March, 1918, because the whole building was commandeered for the care of meningitis cases during the severe epidemic of 1917-1H. The growth of the service is shown by the following table for the first four months of 1918, which presents, however, only patients in the neuropsychiatric ward and does not include cases seen in consultation: Number of patients 1st day of month. Admissions______________________ Total number under treatment_____ Daily average_._....._____________ Total number discharged__________ January Ket unary M arch April s is 11 27 21 17 12 48 29 :*■> '>(> 7.:) 14 17 2') 27 11 21 29 48 This department performed two distinct functions: First, as a clearing house through which soldiers who were accepted for service could be passed in order to ascertain their fitness for service or responsibility for misconduct, and, second, as a place where the insane or neurologically afflicted might be helped, cared for, and treated until their discharge papers were complete or the type of service for which they were qualified could be determined. With tin1 return to the special ward it became easy to classify the different groups and to begin such a systematic ordering of work and recreation and rest as to show a dis- tinctly remediable effect upon many cases. The patients were kept occupied at work or games as much as possible. The insane patients were required to do simple tasks wThen their condition permitted. The camisole or other restraint, mechanical or medicinal, was rarely resorted to; usually enough attendants were available to care for such cases. A classification of the various cases follows: Cerebral hemorrhage_________________ 3 Manic-depressive psychosis_______ . __ 19 Dementia prsecox____________________ 9 General paralysis of the insane________ 1 Conscientious objector_______________ 1 Constitutional psychopathic state_____ 5 Psychoneurosis____ _______________ 103 Mental deficiency____________________ 68 Epilepsy____________________________ 45 Tertiary syphilis, cerebrospinal_______ 12 Peripheral nerve lesions______________ 8 Morphine habit______________________ 9 Hyperthyroidism____ _ _____________ 4 The neurasthenias and psychasthenias were almost without exception of long standing, and their detection before acceptance w^ould have saved the Government a large sum of money. The determination of intellectual level in cases of mental deficiency pre- sented great difficulties because of the remarkable degree of illiteracy in the troops, especially the negroes. To apply to these cases any arbitrary method of examination applicable to communities which were literate would have given results almost grotesque. The Yerkes-Bridges point scale, modified by leaving out the questions demanding literacy and adding, to the total of points thus secured, an average credit for these questions which had been elided gave good results. The sense of relative degrees of wrongdoing was very limited, indeed, and it was often a question for deep and ponderous mental debate with them IN THE UNITED STATES 105 whether it were worse to kill a man or to curse. Most whites measuring below s years were, as a rule, poor specimens physically as well as mentally and morally. On the contiary, amongst the negroes a great many who measured imbeciles were excellent workers. These were held for limited service. The experience with drug addicts was interesting. With very few excep- tions all of these men had taken "cures" from one to five times. All, upon discharge, were in much improved condition. There was little doubt that each one resumed the use of his drug soon after return to civil life. These men were unanimous in the belief that the Harrison Act had merely increased the price of narcotics and that any addict could readily secure the "dope," usually by means of doctors' prescriptions; less often by the various under- ground paths worn smooth by the "dope fiend's" shuffling steps. The fact that there was only one case of general paralysis of the insane was noteworthy. BASE HOSPITAL, CAMP GRANT, ILL." The department of neurology and psychiatry was established September 1, 1917. The work of the department consisted of two fairly distinct divisions: (1) Examining of recruits for nervous and mental disease. For this work examiners attached to the camp, as well as those in the base hospital, were used One examiner worked with each general examining board at the time of the initial examinations. Cases considered suspects were sent to another examiner who, with a psychologist, acted as a final deciding board. In examining the last 15,000 recruits it was found that this plan was more satisfactory than the old method of examining only referred cases or the method of making the psychiatric examination after the general examination was completed. (2) Care of patients requiring hospital treatment and examination of referred cases. Only such patients were kept in the psychopathic ward as required treatment or needed more supervision while awaiting discharge than could be given them in their companies. The new form of certificate of disability materially short- ened the stay in the hospital of these cases. Referred cases came from a number of sources, usually from the regimental surgeon but often originally from the company officers on account of inaptitude or peculiarities; cases of misconduct referred for examination preliminary to trial; as a result of letters written by relatives or friends; and hospital cases referred on account of some neurological or mental condition developing or being first observed while under treatment for some physical ailment. A considerable number of conscientious objectors were examined. They were classified as religious, intellectual, and the objector whose scruples were only means to the end of getting out of a situation that was distasteful to him. It was exceedingly difficult to separate the latter from the two former groups. Objectors were classified also as to their mental make-up. The majority were found to be normal both as regards disease and defect, but a certain per cent were psychotic. The mentally abnormal wTere very seldom feeble-minded. They wore usually either hypomanies or paranoid praecoxes, especially the latter. « Based on History of llase Hospital, Camp Grant, III., by Lieut. Col. H. C Michie, M. C. On file, Historical Divi- sion, s. o. o. 106 NEUROPSYCHIATRY Of the psychoses, dementia prsecox of the hebephrenic type was by far the most frequently encountered. Old prsecoxes were especially liable to "blow up in a military environment and were frequently minor offenders. Syphilitic psy- choses were the next most frequent. Of the organic nervous diseases the only one of any great importance, aside from cerebrospinal lues, was epilepsy. Establishing a diagnosis of epilepsy was not always an easy matter, differ- entiation from hysteria often was difficult, and many cases were seen in wdiich there was an isolated fit at the beginning of an acute infection or following typhoid inoculation. Functional nervous diseases were rather frequent—hysteria among the negroes and lower grade of white soldiers, and neurasthenia among the better grade of whites. The custom was to recommend men with functional nervous disease for domestic service and not for discharge from the Army, except in the more advanced and disabling cases. The diseases, then, that were especially to be dealt with were dementia prsecox, cerebrospinal lues, epilepsy, and psychoneuroses. From September 1, 1917, to April 30, 1918, 319 men were recommended for discharge by this department. The above plan worked very well for several months until the camp had increased largely in population so that the number of men who required examination on account of nervous or mental diseases, but who did not require admission to the hospital, became so large as to inter- fere materially with the work of the psychopathic ward itself. Early in July, 1918, the division psychiatrist moved his offices to a building in the camp away from the base hospital, and the psychopathic ward was used only for patients requiring admission. Nervous and mental cases which did not seem to be serious enough to require admission to the psychopathic ward for care or treatment were sent first by their regimental officers to a psychiatric examiner stationed at one of the buildings in a part of the camp more easily accessible to ambulatory cases than was the base hospital. GENERAL HOSPITAL NO. 1, NEW YORK CITY * On November 22, 1918, ward 55 of General Hospital No. 1 was opened for the reception of neuropsychiatric patients arriving at the port of embarkation, Hoboken, N. J., from overseas and also for such cases as developed in the hos- pitals under the jurisdiction of this port. This had formerly been the Messiah Home, maintained for the care of children. The general construction was so good that with but a few alterations it was readily adapted for the class of patients with which we had to deal. The building contained five wards, two of which were devoted to the frank psychoses, one for disturbed patients and the other for quiet, depressed ones. The remaining wards were used for the care of mild mental states, psycho- neurotics, epileptics, constitutional psychopaths, etc. The hospital had a total bed capacity of 220. Of this number the ward for disturbed patients contained 30 beds, the ward for quiet patients 40 beds, and the remaining 3 wards contained 50 beds each. » Based on Report of General Hospital No. 1, Williamsbridge, N. Y., made by Lieut Col P W Oihsnn m r ober IK. 1919. On file TTisrnnVal r>i,-ici™, c n n r' "' "'^son, -M. L., October IS, 1919. On file, Historical Division, S. G. O. IN THE UNITED STATES 107 The staff consisted of an executive medical officer, chief of service, five ward surgeons, a mess officer, a registrar, and a dental officer. As this part of the general hospital functioned as an evacuation unit, urgent conditions only could be treated, but detailed reports were made of all pathologic findings, and recommendations for treatment were written thereon. These reports were then forwarded, with the history of the patient, to his final destination. In view of the fact that the unit was an integral part of General Hospital No. 1, it was possible to arrange for consultation with the members of this staff, and their services were always promptly available. As a result of such an arrange- ment, many patients actually ill with conditions other than mental could be immediately transferred for treatment. The hospital was equipped with a complete hydrotherapeutic outfit, consisting of continuous baths, showers, needle spray, douche, etc. An occupation class under the direction of a trained worker and three assistants completed the therapeutic system. On admission all patients immediately were inspected for louse infestation, venereal diseases and throat infections. Throat cultures were taken on all admissions. Following this procedure, a hot shower was given to all but louse- infested patients, who were given a special tub bath. The clothing of all patients was sterilized by steam. As soon as possible after admission a complete physical and mental exami- nation was made. The cases were classified and reported to the office of the surgeon, Hoboken, N. J., in order that transportation might be arranged. If the diagnosis on the field card accompanying the patient was not concurred in, the patient was presented at a staff meeting, and the consensus of opinion determined the diagnosis. In all doubtful cases, blood and spinal fluid exami- nations were made. In addition, ophthalmic, aural, surgical, and medical examinations were made where there were special indications. Where a diag- nosis of mental deficiency was in doubt, an intelligence test by means of the Stanford revision was made, and in many cases the diagnosis was changed. This cast no reflection on the work of the psychiatrists overseas, as many of these patients presented a far different aspect after reaching this country. The psychoses patients, too, often presented a far different appearance from that previously noted in their records, and although formerly indifferent and depressed, now presented a cheerful, interested aspect. The total number of patients admitted was 2,750, of which 2,126 were overseas and 624 were local cases. The patients admitted to the hospital were classified as follows: Classification of patients with organic nervous diseases Amyotrophic lateral sclerosis------------------------------------- Sydenham's chorea______________________________________________ Acute encephalitis____________________________________ --------- Lateral sclerosis_________________________________________________ Tabes dorsalis___________________________________________________ Multiple neuritis (following typhoid fever, 1; diphtheria, 2; intraven ous administration of arsphenamine, 1; alcohol, 4)--------------- Cerebral syphilis_________________________________________________ Peripheral nerve injury___________________________________________ 1 1 1 2 4 8 33 9 108 NEUROPSYCHIATRY 01 7 3 1 1 1 Gunshot wound of the head------------------------ Head injury without demonstrable fracture of the skull---- General paresis------- Fractured skull------------------ Brain tumor_______________________ Progressive muscular atrophy------------------------------- Myotonia congenita---------------------------------------- Transverse myelitis following intratracheal administration of arsphen amine______________________________________________ Nervous disease undiagnosed------- Total______ ____ -------- 144 It will be seen from the above that 100 of the 144 organic nervous cases were syphilitic diseases of the central nervous system. The cases classified as "Observation for epilepsy" presented no evidence in the accompanying history that a convulsion had ever been observed by a medical officer, and as none occurred at this hospital it was deemed fair to the patient to leave the diagnosis open. Cases of epilepsy and observation for epilepsy Observation for epilepsy____________ 25 Traumatic---------------- 2 Grand mal_______________________ HI Psychosis----------------- .. 2 Petit mal________________________ 9 Equivalents______________________ 1 i Total--------- ------------ 151 Jacksonian___ ------------------ 1 The patients listed under the heading "Recovered" had usually had either a mild depression or excitement of the manic-depressive type, or else had had an actute alcoholic hallucinosis from which they had completely recovered. A number of psychoneurotics appeared to have recovered, in that thev were free from symptoms during their residence and so were placed in this group because it was felt that further hospital residence was unwise and might produce a recurrence of their symptoms. Of the recovered cases the subclassifications were as follows: Classification of recovered cases Psychoneurosis____________________ 17 Psychosis following influenza (infective Alcoholic hallucinosis, acute_____ _ 7 exhaustive)_____________________ 3 Manic-depressive psychosis__________ 9 I ndifferentiated depression__________ 2 Psychosis undiagnosed______________ 1 Gunshot wound of the spinal cord____ 1 Alcoholism, acute___________ _____ 1 ---- Pathologic intoxication_____________ 1 Recovered___________________ 43 Delirium tremens__________________ 1 Mental deficiency and manic-depressive psychoses Mental deficiency with psychosis__________________________ 4 Manic-depressive psychoses: Manic type------------------------------------------ 95 Depressed type_______________________________________ 213 Mixed type__________________________________ 44 Circular type_______________________________ 1 Total 353 IN THE UNITED STATES 109 In the manic-depressive psychoses group, in so far as it was possible to obtain reliable information, 35 had had a previous attack. It must be remem- bered, however, that the number of patients who had had previous attacks was undoubtedly greater, but as many of the patients were entirely inacces- sible, information in regard to this could not be obtained. The depressions predominated. Cases of dementia pracox Hebephrenic___________________________________________________ 256 Paranoid______________________________________________________ 163 Simple____________________________________________ _. ____ __ 111 Catatonic_____________________________________________ _______ 20 Total___________________________________________________ 550 Many of the patients presented a typical schizophrenic history, but were in an apparently normal condition and well adjusted. Some of them gave quite adequate explanations for their upset, such as nostalgia and worry over misfor- tune at home. Others stated that they felt they had been unfairly treated in the Army. The eventual outcome appeared to be problematical. It was felt that the original diagnosis should be left unchanged. Cases of paranoid condition, alcoholic and traumatic psychoses, constitutional psychopathic state, and psychoneuroses Paranoid condition. Psychoses with somatic disease: Following influenza______________ 20 Following mumps________________ 2 Following pneumonia------------- 1 23 Traumatic psychosis (head injury)----- 5 Alcoholic psychoses: Acute hallucinosis---------------- 37 Deterioration____________________ 4 Pathologic intoxication----------- 1 12 Constitutional psychopathic state: Inadequate personality----------- 110 Emotional instability---------- s Paranoid personality------------- 5 Delinquent tendencies------------ 1 Homosexuality___________________ 3 Criminal tendencies-------------- 3 Psychoneuroses: Hysteria_____ Neurasthenia. Psychasthenia rosis) _ _'____ (compulsion neu- Anxiety state_________________ Hyperthyroidism_____._______ Enuresis_____________________ Disordered action of the heart. Traumatic neurosis___________ Stammering__________________ Syphilophobia________________ Hyperthyroidism___________ Somnambulism_______________ Dyspituitarism_______._______ Facial tic______________ ----- 295 2S2 25 22 8 S 5 3 6 2 2 1 1 1 661 130 110 NEUROPSYCHIATRY Of the neurasthenic group 26 per cent of the patients gave a history of having had symptoms of this condition in civilian life, and of the hysteria group 19 per cent gave a history of similar trouble prior to Army service. Cases of inebriety Alcoholism______________________________________________ ------ n Morphine addiction______________________________ --- ------ Heroine addiction_______________________________ -------------- " Heroine and morphine addiction------------ ---- 1 Total___________________________________________________ 125 The small number of drug addictions is nbtable. Cases of mental deficiency, without mental disease and undiagnosed Mental deficiency: Morons_________________________ 225 No mental disease found—Contd. Deviated nasal septum----------- 1 Imbeciles_____________ ___ --- 27 Diphtheria carrier---------------- 2 ---- Malaria, tertian__________________ 1 252 Polyarthritis, rheumatic---------- 1 Gunshot wound of the right arm _ _ 1 No mental disease found: Valvular heart disease____________ 1 Rheumatic fever, subacute-------- 1 Diagnosed as epilepsy but not con- Flat-foot------------------------ 1 curredin. Duodenal ulcer------------------ 1 No phySjCal or mental disease Pulmonary tuberculosis__________ 3 found 13 Syphilitic cirrhosis of the liver____ 1 Gastritis, chronic catarrhal_______ 1 Syphilis, secondary______________ 1 Acute gonorrhea_________________ 1 31 Psychoses undiagnosed_______________ 148 The cases with psychoses undiagnosed were left ungrouped because of the lack of data sufficient to make a differentiation possible. Many of these patients were fearful and refused to answer questions. They were not cata- tonic nor did they attitudinize. Hallucinatory reactions were not osberved. Other patients appeared quite confused and presented a dreamlike, perplexed state. At times they appeared quite distressed. They refused to cooperate on examination. Many of the patients were difficult to differentiate ade- quately, and it could not be definitely decided as to whether they presented a prsecox or manic-depressive reaction. In many cases there was an alcoholic history and coloring which was difficult to evaluate properly. In a few of the cases there were pupillary signs, but the residence was too short to permit of blood and spinal fluid examinations, or else they were too disturbed for such procedures. This part of the United States Army General Hospital No. 1 closed offi- cially on September 10, 1919, but no patients were received after September 1, 1919, so that it was open for the reception of patients for a period of 9 months. and 22 days. None of the cases appeared different from those encountered in civilian life, except that most of them had a military coloring. Of the total number of 2,750 patients, 24 per cent were psychoneurotics, 20 per cent of the dementia IN THE UNITED STATES 111 praecox type, 12 per cent were of the manic-depressive group, 10 per cent mental defectives, 5 per cent had organic nervous diseases, principally of the syphilitic type, 4 per cent were definitely epileptic, and 4 per cent were constitutional psychopaths. There were only 14 cases of drug addiction, or about 0.5 per cent of the total admissions. Many of the cases apparently of the praecox type appeared to be recovered, with excellent insight. Of the neurasthenic group, 26 per cent of the patients gave a history of having had symptoms in civilian life, and of the hysteria group 19 per cent gave a history of similar trouble prior to Army service. A comparison of the group percentages found at this hospital, with the group percentages of the total male admissions for the New York State hospital service during the year 1919, is interesting. During this year the total first admissions were 6,791. Of this number, 3,527 were men. The group per- centages for the male admissions are as follows: Classification of men admitted to the New York State hospitals during 1919 Traumatic psychoses------------- Senile psychoses__________________ Cerebral arteriosclerosis___________ General paresis------------------ Cerebral syphilis_________________ Organic brain diseases (Huntington's chorea, brain tumor, etc.)-------- Alcoholic psychoses_______________ Drug psychoses------------------ Psychoses with somatic disease----- While a strict comparison is not possible, it is interesting to know that there is a close ratio between the percentage of cases of dementia praecox, namely, 20 per cent in the Army and 27 per cent in civilian life, and between the percentage of cases of manic-depressive diseases, 12 per cent in the Army and 9 per cent in civilian life. Dementia praecox in both instances forms the largest group of the psychoses. Comparisons between the other groups is impossible because the civilian State hospitals deal primarily with psychoses occurring at all ages and with unselected population. In 1918, of the total remaining population in the New York State hospitals, 59 per cent were of the dementia praecox group. It will readily be seen, therefore, that our great problem, from the standpoint of psychoses, both civilian and military, was that of the dementia praecox group. All the acute psychoses among the officer patients received at Hoboken requiring close supervision were transferred to the Bloomingdale Hospital, White Plains, N. Y., where the Government reserved a limited number of beds. An Army medical officer was stationed at Bloomingdale most of the time, and in addition, a psychiatrist from United States Army General Hospital No. 1 visited the hospital two or three times a week and supervised the treatment and disposition of the officer patients. The mild and recovered psychoses and psychoneuroses among officers and some organic nervous cases were excellently handled at the private pavilion. Per cent Number of cases 0.5 18 9.0 324 6.0 236 20.0 710 .4 15 .5 19 5.0 204 .16 6 2.0 76 Manic-depressive psychoses----- Involution melancholia_________ Dementia praecox.....--------- Paranoia____________________ Epileptic psychoses___________ Psychoneuroses_______________ Constitutional psychopathic state Psychoses with mental deficiency. Psychoses undiagnosed--------- Not insane___________________ Per cent Number of cases 9.0 352 1.5 56 27.0 1,001 1.5 59 2.7 96 1.0 35 1.6 66 2.5 88 3.9 13H .7 2*< 112 NEUROPSYCHIATRY This place afforded not only very desirable private rooming facilities, with pleasant environment, but also a most up-to-date hydrotherapoutic plant. The treatment of these officer patients consisted in general of hygienic measures, medicinal treatment, special medical and surgical treatment, psychotherapy, and hydrotherapy. As in other hospitals, the importance of the neuropsychiatric department in United States Army General Hospital No. 1 became evident in the summer of 1918, when there were numerous consultations required by other departments in looking over doubtful cases in other medical services. The following tabulation of nervous and mental cases treated at the United State- Army General Hospital No. 1 (exclusive of the Messiah Home), between July 1, 1918, and June 30, 1919, shows diagnosis and disposition. Re to 05 a E o 13 .urned duty c 05 C "c K 56 5 2 3 2 Left hos-pital ^ ;b w C 'a* c .- £ St £> 05 JS> o - -E ~- ^ -4-T So © -S2 r-i a Q fl o i- -05 05 SI 05 "5 ft— CO * 3 cart go p5 4 Dis-charged to custody of re-lative 05 if O 05 c ■O 03 05 b! be 3 CO .a 0 5 Trans-ferred to other hospital D 1 0 ied b 05 E a; "c Re-main-ing or on leave c £ 05 0 .2 E | E O K 10 ; 15 I ___ T 05 a E 139 3 11 76 14 5 5 6 2 14 12 6 otal B 05 Cv "b 414 95 146 72 102 121 12 11 8 2 12 16 05 C5 £ o l l 0 c * o °S - i K § § W 0 ... 68 1 ! 68 3 ' 96 ...I 65 c I £ CO 8i .a E! B c w ..." 4 1. 05 C5 6 0 30 c 05 6 05 c Epilepsy_____ 80 1 271 I 1 21 553 98 146 Mental deficiency 38 22 Constitutional psy-chopathic states. 2 3 6 39 2 1 1 1 1 1 4 ____ 1 Manic-depressive Dementia praecox 1 20 m| 77 6 11s l 19 2 6 , 3 178 135 5 Paranoid states 2 2 3 Paresis ___ 11 2 1 I I 4 1 L.._ 1 4 2 a 1 . 1 ___ Infective exhaustive psychoses____ 5 4 17 10 10 24 22 Psychoses (undiag-nosed)___ 4 3 ... Organic nervous dis-eases_____ 4 5 2 5 5 2 Chronic alcoholism.._ --- ... 30 12 1 Others_____ 1 '____ - --I 4 55 567 1 Total_____ 29 74 2 5 326 144 12 5 4 1 44 31 293 1,011 1,304 GENERAL HOSPITAL NO. 2,' FORT McHKXRY, MD. The neuropsychiatric service at this hospital was opened in March, 1918, but adequate facilities were lacking and it was not until Mav that the patients were moved into the new standard psychiatric building and the real, effective work of the service was begun. Patients were given every benefit of the modern school of neuropsychiatry. The interior of the building was decorated and painted in soft, restful colors, while potted plants and flowers distributed through- out and lace curtains at the windows all combined to make the place as attrac- tive, homelike, and pleasant as possible. In the rear a spacious porch was con- verted into a sun parlor and made an ideal place for the activities of occupa- tional therapy. Divisfon^.G. 0^°°' °f Gen,?ral H°SPital X°- 2' F0,t McHeMy' Md- by Maj- A' R ^Tm. ~C On file, Historic! IN THE UNITED STATES 113 The psychiatric building had its own hydrotherapy room equipped with showers, continuous tub, etc., and the soothing effect of the sedative bath, especially in manic cases, was successfully demonstrated. Full advantage was taken of the hospital's physiotherapy department and nearly all of the neuro- psychiatric patients were sent out daily for some kind of treatment in the more elaborately equipped psychiatric building. No effort was spared to provide every therapeutic benefit to be derived from diversional occupation and recreation for the patients. A reconstruction aide spent her time entirely with these patients, doing all that was possible to keep their minds and hands busy, and splendid results were achieved. In addition, a teacher of calisthenics spent some time each day giving the patients brisk exercises and lively games which were greatly enjoyed. A large pool table, a Victrola, and a well-stocked library were available for use at all times. The patients were treated individually and not collectively. No routine or "system" methods were used in administering to those who were admitted complaining of the many and varied symptoms incident to a nervous or mental disorder. The happy results attending the use of the principal agencies of treatment (hydrotherapy, occupational therapy, psychotherapy), especially in the large group of the functional neuroses and the incipient mental disorders, amply justified the principles of "nonrestraint" which were insisted upon when the department was inaugurated, early in 1918. The neuropsychiatric wards in this hospital were built along the plans of those existing in all of the Army general hospitals at that time. There were no locked doors, barred or screened windows. Patients admitted to the department of neuropsychiatry were always treated as sick individuals. On March 22, 1919, the scope of the service was considerably broadened by making arrangements to care for a number of neuropsychiatric officer patients, and a ward was set aside for their use. In addition to this the Surgeon General gave this service general supervision over a number of neuropsychiatric cases among Army nurses, aides, and others who were sent to the Shepherd and Enoch Pratt Hospital at Towson, Md., and to Henry Phipps psychiatric clinic at Johns Hopkins Hospital. The following is a brief statistical summary of the department: Number of patients admitted during the year 1918------------- 231 Number of patients admitted during the year 1919------------- 388 Number of patients admitted from January 1 to April 31, 1920---- 60 Total number admitted____________________________ Number of patients discharged by surgeon's certificate of disability Number of patients discharged to duty--------------------- Number of patients transferred---------------------------- Number of patients deserted------------------------------ Number of patients died------------------------------ 144 120 403 8 4 Total number disposed of 679 114 NEUROPSYCHIATRY Diagnoses: Nervous disease and injury________...... — — 1 "•> Psychoneurosis__________________ __ _ — —--- !"•' Psychoses_____________ ---------- ---------- l'u Inebriety________________________________ 21 Mental deficiency___________________________ __.._.-.- 79 Constitutional psychopathic state-------------- s<) Other diseases and injuries______________ ------ 19 Total_________________________________ ------------ ■- *>79 Consultations_________ ---------------------------- 345 GENERAL HOSPITAL NO. 6, FORT McPHERSON, GA.' The first collecting wards in the United States to be especially built and equipped for the neuropsychiatric work of the Army were opened to receive patients at Fort McPherson on November 7, 1917. In the suburbs of Atlanta United States Army General Hospital No. 6 was centrally located with regard to a great military population, including many cantonments and all the forts along the southeastern coast. Its grounds contained many medical units preparing for foreign service. Near by, with through train connections, were Camps Greenleaf, McClellan, Sheridan, Wheeler, and Hancock. The main line north tapped Camps Sevier, Wadsworth, and Greene. The neuropsychiatric wards were so placed that the reception and treatment sections had on three sides medical and surgical wards, while the three buildings for nervous and insane cases stretched out toward the woods and away from other structures. Diet kitchens and offices were in the proximal ends of the three buildings for mental diseases and porches made them easily accessible from the general mess hall and from each other. All buildings were new and conformed in appearance to other new hospital structures. They were sunny, well ventilated, with ample porch space, which was screened. The door of the reception section opened into a large room furnished with center table and settees. This was a meeting place for all the activities of the service. On one side was the record room and on the other the physician's office, housing a collection of books on neuropsychiatry, mental hygiene, and military service furnished by the National Committee for Mental Hygiene. Opposite the door were three smaller rooms. The first was for mental examinations, fitted with a table and shelves on which were kept the psycho- logical tests and record blanks. The second contained a high bed for physical examinations and a blood-pressure instrument, an ophthalmoscope, and other clinical apparatus. The third room was fitted as a ward laboratory, with apparatus chiefly for urinalysis and the collecting and examining of blood and spinal fluid. Entering the treatment section by a narrow hall from the reception room, one found in a room on the right electrical apparatus with a high convenient table for a recumbent patient. Across the hall on a cement floor were high tables for massage and packs. In front, in a room of many windows, open on Bis/ofiSfDivisfon!0^ ST"* H°SPital ^ "' ^ McPherSOn' Ga- by CoL Thomas 8- Bnrttan, M. C. On file, IN THE UNITED STATES 115 three sides, with cement floor sloping 3 inches to a central drain, were placed an elaborate combination douche apparatus controlled from the wall and an electric light cabinet bath. In a separate room a Bergonie machine was set up. Special articles of therapeutic and diagnostic equipment were furnished by the National Committee for Mental Hygiene as soon as the buildings were under construction and, because of this generosity and foresight, were at once ready for use. A building adjoining, with small dormitories well separated from each other, was used as an admission ward. At its far end was a large space fitted with con- tinous bathtubs and showers, with inclosed porch in connection. Two other buildings radiated from a common center with this last building. They were arranged to give isolation with a separate porch and bath to varying groups of patients. The chief of neuropsychiatric wards, by consent of the chief of medical service, reported directly to the commanding officer in exclusively neuropsychi- atric matters. Assistant physicians had duties roughly coordinate and inde- pendent. One devoted all his time to teaching enlisted men and to carrying out meningitis therapy in the medical wards. Another physician had charge of physiotherapy, treating patients from all hospital services. He gave instruc- tion in his particular field to enlisted men, who assisted him in turn. The third was a specialist in the use of the Bergonie electrical apparatus, demonstrat- ing its use in selected cases. Other physicians had direct charge of the wards. Each ward for the insane was in charge of a nurse or wardmaster who had adequate psychiatric training; a supervising nurse had general duties in the care of all cases. The neurological ward was in the charge of nurses with general training; it was open, and run as were other medical wards. A sergeant was in charge of occupational activities, being responsible for patients received from the wards for outside work. There was opportunity also to use the occupational classes of the reconstruction department. A sergeant, first class, was in charge of all enlisted men sent here for train- ing, assigning them to duty and keeping track of their work and character; he also had charge of records, with three clerks to help him. Enlisted men were supplied by the section of neurology and psychiatry of the Surgeon General's Office, which selected them because of special experience or fitness. Among them were many attendants with more or less service in hospitals for the insane and many college men who had specialized in psychology or pharmacy. Due to a shortage in experienced personnel, it was necessary to take Hospital Corps men and men without hospital experience and train them for work on the mental wards. A special course was instituted and lectures were given by the ward physicians on the care and treatment of mental diseases. During the fall and winter (1917-18) the wards were crowded with dementia prsecox cases, most of them of long standing. In some cases the conditions of Army life seemed to precipitate mental trouble in persons who might have re- mained normal in civil life. Many were returned to their homes for super- vision. Over 50 were returned to hospitals in their home States, often to hos- pitals where they were well known as former patients. 42705—29---9 116 NEUROPSYCHIATRY As a contrast to this group was one formed by patients from Camp Gor- don, Ga., and the other wards of the general hospital, who complained of headaches, vertigo, pains. Many of these were carried as consultation cases; those not rather promptly relieved by the fitting of glasses, the cleaning of teeth, by baths and packs, were found, in general, resistant to treatment, and, under the diagnosis of neurasthenia or constitutional psychopathic state, usually were discharged. With the spring came a third general group—the organic-appearing cases, which turned out to be functional, and the acute psychoses. Electrical appa- ratus, added to suggestion, made many dumb to talk and many crippled to walk. The diagnosing of different sorts of fits was a difficult problem. The malingerer was rare. Cases of feeble-mindedness were few because they had been sifted out in the cantonments. In treatment physiotherapy was used largely and with good results. Gardening developed nicely in adjoining spaces and provided many mental cases with pleasure and exercise. It was the aim to give most of the patients employment of some kind. During the spring, summer, and fall months, many patients worked on the lawn, grading, seeding, planting, and caring for flowers. Others worked in the vegetable garden. On the wards patients were employed under the supervision of occupational therapists and instructed in basketry, rug weaving, bead work, hammock making, wood carving, etc. A great deal of interest was manifested in the work and much benefit was derived from it. The neuropsychiatric section of the hospital contained, on January 1, 1918, 30 patients, and on December 31, 1918, there were 153 patients. During the year there were 817 admissions. The largest number of patients admitted in any one month was during October, when 174 cases were received. The average monthly admission was 68 patients. Up to October (1918) it had been possible to care for and treat all mental and nervous cases in the buildings desig- nated and built for this class, namely, wards U, V-l, V-2, and V-3. In Octo- ber, however, it became necessary to convert medical wards M and L into psychiatric wards. These gave an additional capacity of 160 beds, making the total capacity of the neuropsychiatric wards 276. About 45 of the admissions to the neuropsychiatric section were psychotic cases. Many of these cases in the early part of the year came from the various camps, but the majority came from overseas. About 25 per cent of the cases admitted were functional neuroses, mostly from overseas; about 10 per cent were mental defectives. Comparatively few organic nervous cases were re- ceived. Constitutional psychopathic states represented 6 per cent of the mental cases admitted. This class seemingly found it difficult to adjust to Army life for any length of time, soon ran counter to the necessarv discipline, and were a source of disturbance and trouble. Only a few drug addicts and epileptics were received. During the year 692 cases were discharged in various wavs Three hun- dred and seventy-nine cases were discharged as recovered or improved- P5 cases were transferred to Government hospitals for the insane; 116 cases were discharged to other public and private hospitals. The death rate was com- paratively low, 5 cases m all, or less than 1 per cent of admissions IN THE UNITED STATES 117 GENERAL HOSPITAL NO. 26, FORT DES MOINES, IOWA* At General Hospital No. 26, Fort Des Moines, Iowa, there were two wards for neuropsychiatric cases. These wards were newly built of the stand- ard type—wards C and D. Ward D was occupied first on May 17; ward C on May 28, 1918. By the early fall of 1918 the hospital had approximately 1,300 patients, with about equal numbers of general medical and surgical (chiefly orthopedic) cases, and some 80-odd mental cases. By October the daily average of mental patients had increased to 130. Patients were received in the neuropsychiatric wards in larger or smaller numbers at a time from Camps Funston, Dodge, Stuart, and Grant, from Forts Bliss and Omaha, and McCook Field, and in August and later from the debarkation hospitals at New York, Newport News, and Boston. Sixteen patients (mental) were discharged by the end of July, but from that time to the middle of October only 20 more were discharged. The diagnoses wore about the same as recorded in the literature for other military hospitals, except that there were not many war neurosis cases—a few epileptics, some manic-depressive cases, some dementia prsecox cases, a number of moron and border-line defectives, a few constitutional psychopaths, and an occasional alcoholic or drug addict. A few cases of post-meningitic condition were admitted for observation. When the orthopedic and other surgical cases began to come in from overseas, many nerve-injury cases were seen. The total number of cases admitted to the mental wards up to December 4 was 220. An equal number were seen in consultation, but not admitted to the wards. In addition to these, a survey was made in August, 1918, of the enlisted personnel, 241 men altogether, of Base Hospital No. 79, which out- fitted and organized at Fort Des Moines. The nursing personnel of the neuropsychiatric wards was adequate in numbers and fair as to quality. GENERAL HOSPITAL NO. 30, PLATTSBURG, N. Y.« Early in 1918 it became evident that more facilities wrould be required for the observation and treatment of psychoneurotic disorders than could be pro- vided in the neuropsychiatric wards of the general hospitals. These wards, as well as the wards of base hospitals, had been relieved by the establishment of a general hospital for psychoses (General Hospital No. 4, Fort Porter, N. Y.), and patients with psychoneuroses had from time to time been transferred there. It was obvious, however, that this hospital could not be expanded to take care of the large number of psychoneurosis cases that would come under treatment, even if this wTere desirable, and it was not considered desirable. It was felt that the two types of patients should be separated. For the successful treat- ment of patients with psychoneuroses in large numbers an organization was required in which could be maintained a spirit of recovery. This meant a hospital to which would be transferred only those patients for whom recovery * Based on History of General Hospital Xo. 26, Fort Des Moines, Iowa, by the commanding officer, Nov. 15, 1918. On file, Historical Division, S. G. O. ' Based on History of General Hospital No. 30, Plattsburg, N. Y., by the commanding officer. On file, Historical Division, S. G. O. US NEUROPSYCHIATRY was reasonably to be expected, and a hospital so located as to be as free as possible from outside distractions, both military and civil, and whore military discipline could be maintained or relaxed as the occasion demanded. The post hospital at Plattsburg Barracks, N. Y., was selected. Medical officers specially trained in neurology and psychiatry wore ordered to Platts- burg during May, 1918, and the first neuropsychiatric patient was received May 23, 1918. Ninety-nine patients were transferred to the hospital during June and other patients were transferred during July, August, and September, although the hospital continued during this period as a post hospital and re- ceived, in addition to the neuropsychiatric patients, patients from the military organizations then stationed at Plattsburg Barracks and from the second of- ficers' training camp of 3,454 candidates. Some neuropsychiatric patients were received also from overseas. September 21, 1918, the original post hospital at Plattsburg Barracks was designated General Hospital No. 30 and expanded to include the entire group of permanent buildings at this post, the Infantry barracks being converted into hospital wards. There were 28 wards, with a capacity of 1,200 beds. The hospital was divided for purposes of administration into four sections. Section 1, for medical and surgical cases, including operating room; eye, ear, nose and throat, and genitourinary cases, with X-ray laboratory. Sections 2, 3, and 4, in the Infantry barracks, contained wards for various classes of neuro- psychiatric cases. The hospital headquarters offices were moved from the old post hospital to the post administration building in the early part of October, this building being centrally located and more convenient for purposes of ad- ministration. Medical officers on duty in the hospital and nurses were assigned to quarters upon the post in buildings set aside for this purpose. During the months of November and December, various buildings com- prising the hospital were connected by inclosed bridges, making in all a com- pact, protected area for the transfer and care of patients. During this time the porches were inclosed and a steam-heating system was installed throughout. Although designated as a hospital for war neuroses and primarily for the reception of patients from overseas, patients with other neuropsychiatric con- ditions, through mistake in diagnosis and the exigencies of the service, were transferred to the hospital or received from overseas. There were later assigned to this hospital, also, at the instance of the division of neurology and psychiatry of the Surgeon General's Office, patients suffering from convulsive disorders (epilepsies) for special study, drug and alcoholic inebriates, and patients with residuals of epidemic cerebrospinal meningitis. The first 1,000 patients had been received by November 16 1918 \ statistical analysis of this group of 1,000 patients (considered typical for the patients received at this hospital) shows the following clinical distribution and disposition: IN THE UNITED STATES 119 OFFICERS Clinical groups Psychoneuroses: Hysteria___________________ 2 Neurasthenia_____________~ ~ ~: 11 Psychasthenia____________~" ~ 2 Other psychoneuroses. ' 1.3 Epilepsy___________________ 2 Psychoses: """1 Manic-depressive____________I 5 Other psychoses____________J 2 >> .= £ T! t 0. JH a "£■= C 3 1 1 10 1 l 1 4 7 2 1 1 -- Clinical groups £ Us 0 • S t£ C Q 1 . 1 0 C o3 c c a 1--- c X Constitutional psychopathic states Inebriety: Chronic alcoholism,.. Traumatic conditions: Concussion 2 1 1 1 2 1 1 Miscellaneous groups: Tic. 1 Epileptiform seizures, isolated- 2 All groups. __ 44 10 j 18 3 13 ENLISTED MEX-DOMESTIC SERVICE Psychoneuroses: Hysteria____________ Neurasthenia_________ Psychasthenia________ Nostalgia______________ Other psychoneuroses. ! 8 Epilepsy---------------------1 8 Psychoses: Manic-depressive___________ 2 Dementia praecox__________j 1 With constitutional inferiority 1 ' Constitutional psychopathic state's 10 Mental deficiency______________[ 8 s Cerebrospinal syphilis: Mesoblastic_______ 3 I Tabes____________________I 1 | Organic nervous disease: 1 Sciatica___________________: 4 Multiple neuritis___________ 3 _ Amaurosis (wood alcohol)____ 1 j. Cerebral embolism.._.....___ 1 j. Facial paralysis____________ 1 46 29 10 22 10 10 3 1 1 2 1 Endocrinopathies: Hyperthyroidism__________ Other endocrinopathies Inebriety: Acute alcoholism_____...... Chronic alcoholism______ Drug addiction_______ . Traumatic disorders: Cerebral concussion__________________, 4 Residuals of cerebrospinal menin- gitis---------------------- Miscellaneous groups: Tic_____________.......... Enuresis_________________ Somnambulism___________ Weakness following nephrec- tomy __________________ All groups. 1 ... "2 >|> 29 !___. 1 !___. i .... I 77' ENLISTED MEN-OVERSEAS SERVICE Psychoneuroses: Hysteria.....____ 1.50 48 8^ 33 dizziness, faintness, and losses of consciousness, and in the tact of these symptoms being especially apt to be brought on by exertion stooping, sudden movements, or exposure to the sun, the post-meningitic con- IN THE UNITED STATES 123 dition closely resembles the well-known condition that persists for years following severe cranial traumatisms. Muscular weakness, as existing independently of the fatigability and of the pains, was shown particularly by feeble hand grips in more than half of the cases. Usually both grips were weakened, but often in an unequal degree. One patient, in other respects having a rather mild case, formerly as "strong as a tiger," was hardly able to turn the faucets in the lavatory. The tendency toward blurring of vision was very common but also variable in degree. It became manifest when patients attempted to read, especially if the print was fine. After a few minutes or half an hour the letters would begin to "run together"; if the patient rested a while he could continue the reading, but unless he had rested an hour or more the blurring would come on again and more quickly than the first time. It would seem that this trouble is due to a weakness of the ocular muscles; in some cases close application would bring on diplopia; the ocular movements, however, as ordinarily tested, as a rule were not impaired. In cases in which the tendency to blurring of vision was most marked there was also a degree of photophobia; at least two of the patients had to wear smoked or colored glasses. In these cases there was sluggishness and limited excursion in the pupillary reaction to light; moreover, on continued exposure to bright light, the initial contraction would soon give way to relaxation; and it may be that the photophobia was dependent at least in part on weakness and fatigability of the concentric muscle fibers of the iridos, with resulting lack of shielding of the retina. The impairment of appetite and sleep, sometimes associated with a state of slight subnutrition, was perhaps a secondary phenomenon. Many of the patients had formerly been leading active outdoor lives but had since been forced by their illness to remain almost wholly without exercise for months. The loss of sleep was almost invariably associated with pain; in some cases the patients had difficulty in getting into a comfortable position for sleep and would toss around for hours before finally falling asleep; others would fall asleep quickly but would wake up in the night on account of pain developing from the strain of being in one position. The cases showed considerable variation in severity of the symptoms and degree of disablement, as compared one with another, but not in the syndrome considered qualitatively. The quantitative variations seemed to depend in part on severity of the original infection, or possibly the patient's resistance to it, and in part on the length of convalescence. The usual course was char- acterized by a very pronounced degree of disablement at the beginning of con- valescence, progressive improvement for about a month or six weeks under rest without special treatment, and from then on an almost stationary residual condition persisting apparently indefinitely—in the cases at Plattsburg from throe months to over a year. Shortly following the admission of these patients to this hospital, they were divided into groups, according to the degree of disablement, and were placed under a regimen of graded marches, hikes, and exercises, such as neck bending and body bending. This was followed by striking and rapid improve- 124 NEUROPSYC1I1ATRY ment in some cases and in distinct though slight improvement in almost all within a month. All cases eventually recovered from the above-described symptoms at least sufficientlv to leave the hospital and resume either duty or their civilian occupations. There remained in some of the cases lingering symptoms, such as stiffness in the spine, pains in back, legs, or head; but these wore present only in slight degree and were in no way disabling. In the course of observation of these cases, the impression was occasionally gained of a psychoneurotic element in the form either of exaggerations of the disability or of addition of manifestations foreign to the typical symptom- complex. It was noted that some of the cases showed rather sudden improve- ment within a few days following the signing of the armistice. The most flagrant case was that of an enlisted man who showed, in addition to the typical post-meningitis symptom-complex, a persistently labored and grotesque gait due to contractures at both knees in a position of partial flexion: "Capt. K. ______- gave me electrical treatment, and after the second treatment I was all cured up." This is merely added evidence of the well-known fact that a purely func- tional mental element not infrequently exists as a complicating factor in organic disease. On the whole the group of post-meningitic residuals presented not only a striking uniformity of symptomatology, but also of course and termination— and that quite regardless of such conditions as prospect of overseas duty, and the signing of the armistice, as may be judged from the fact that of the 31 cases admitted 12 had recovered sufficiently to be recommended for duty prior to November 11; several were among the more recent admissions. The following case record is cited as typical of the group: J. F. B., private, headquarters company, 154th Infantry. Born in Arkansas; white, aged 22; single, former occupation, farmer. Admitted to United States Army General Hospital No. 30, Plattsburg Barracks, N. Y., by transfer from base hospital, Camp Beauregard, La., on July 31, 191S. Transfer card diagnosis: Neurosis, post-meningitic. Family history.—Negative for mental or nervous disease, inebriety, feeble-mindedness, or criminalism, except that one brother died in convulsions in childhood. Personal history.—Had measles, whooping cough, and mumps in childhood; "swamp fever" (malaria?) at 15; recovered fully from all; no other diseases or injuries. He went to school irregularly, as he had to work and did not have much opportunity; reached fourth grade. Then went to work on his fathei's farm, receiving $30 a month and his board. Enlisted June 5, 1917, and was first sent to Fort Logan H. Root, Ark. In September, 1917, was sent to Camp Beauregard, La. He had had no trouble whatever in either place up to the time of onset of his present illness in the latter part of December, 1917. He had drilled and worked well and reported at sick call only twice for minor ailments. Present illness.—About the 18th of December, 1917, he began having frequent chills, felt weak, and lost appetite; he slept well, however. In the evening of the 20th he developed a very severe headache and "a drawing from the back of the head all the way down"; could not sleep that night. Next morning became unconscious and was taken to the base hospital (Camp Beauregard). Has a vague and incomplete recollection of lumbar punctures. Clin- ical history from that hospital states that he had epidemic cerebrospinal meningitis, received intraspinous and intravenous treatment, but did not begin to improve until the latter part of February, 191s. Case note, March 1, 1918, states: "Up; very thin and weak." April 11: " Hook-worm treatment given." On April 26 given a furlough. Returned to camp on June IN THE UNITED STATES 125 20, but was not able to do duty; felt weak and feverish; occasionally had slight headaches; complained of pains in the back and in the back of the head; would have dizziness on stooping or "on the least strain"; when he tried to read his vision, after a while, would become blurred; he had not regained all the weight he had lost. He was readmitted to the base hospital on June 22; about two weeks later he was sent to the convalescent camp attached to the base hospital. Improved somewhat, but did not fully recover and on July 2S, 1918, was ordered transferred to Plattsburg Barracks, N. Y. Examination on admission.—Complains of weakness in the back; states he tires very easily. Eyes are still weak; i. e., on trying to read, vision soon becomes blurred. Upon exertion, the old pain in the back and in the back of the head begins to trouble him again. Upon stooping or exertion becomes dizzy, though not so badly as formerly. Walking fast tires him quickly, but if he takes his time he can walk a good deal. Is somewhat under- weight; weight, 130 pounds in ordinary clothing; height, 5 feet 7 inches; his usual weight in ordinary clothing is 150 pounds. Has scar over sacrum from bedsore. Is unable to touch toes with tips of fingers by stooping over without bending the knees on account of pain and stiffness in small of the back. Patient was prescribed neck and body bending exercises and graded hikes. Note of October 8, 1918, states: "He feels now that he is as well as he was before he had meningitis." Recommended for duty by board of medical officers. DEBARKATION HOSPITAL NO. 51, NATIONAL SOLDIERS' HOME, HAMPTON, VA.m The neuropsychiatric service of Debarkation Hospital No. 51 was organized on or about November IS, 1918. The first large convoy of overseas patients was received on November 20, 1918. This convoy contained approximately 300 mental cases who were placed in wards that were not well prepared for the reception of such cases. Notwithstanding this inadequacy of facilities, how- ever, these patients were handled with only one accident, a minor one, an abortive attempt at self-injury on the part of the patient. Reception of patients was rather slack during the remainder of the month. From about the middle of December, 1918, the debarkation of neuropsychiatric patients went on sporadically, large convoys of patients alternating with small ones. On January 1, 1919, 215 cases arrived and these were handled without difficulty. Up to February 1, 1919, approximately 1,520 mental cases were cleared through this hospital and in this number, psychoneuroses, psychoses, constitu- tional psychopathic states, epileptics and mental defectives were found in the order named, organic disease of the central nervous system being far in the minority. As this hospital functioned only as a debarkation hospital, none of these overseas cases were retained here for treatment. All cases were classified on standard blanks. After the diagnosis and condition of the patient was deter- mined he was transferred to the hospital treating his special condition. Epi- leptics and mental defectives were sent to the camps nearest their homes for demobilization. The psychoneuroses were all sent to General Hospital No. 30, Plattsburg Barracks, N. Y., and this was routine up to March 22, 1919. At that time a letter from the Surgeon General authorized the commanding officer to send to ■» Based on report of the neuropsychiatric service, Debarkation Hospital Xo. 51, National Soldiers' Home. Hampton, Va., by Capt. Nathaniel II. Brush, M. C, May, 1919. On file, Historical Division, S. Q. O. 126 NEUROPSYCHIATRY the nearest camp for demobilization all psychoneurosis cases who had suffi- ciently recovered to need no further treatment. This authority not only relieved the debarkation hospitals of a great burden, but also freed General Hospital No. 30 of many unnecessary cases. A careful record was kept of the various types of cases received from the American Expeditionary Forces, from February 1, 1919, to March 31, 1919. During this period 589 neuropsychiatric cases were received. They were classified as follows: Mental defectives____________________ 39 Organic brain disease_________________ 14 Total_________________________589 Psychoneuroses______________________ 250 Psychoses___________________________ 184 Constitutional psychopathic states_____ 54 Epileptics___________________________ 48 In a general way this classification showed the usual type of cases received at this hospital. Careful and completely tabulated records were kept of the diagnoses in all cases from the opening of the hospital, but through an unavoid- able accident these records were destroyed. The only records left at that time showed the clinical difficulties of the above listed group of 589 cases, but other statistics were available showing that up to April 27, 1919, when it terminated its debarkation activities, a total of 2,419 neuropsychiatric cases had been cleared through this hospital. Early in March, 1919, two representatives of the Surgeon General inspected the hospital with a view to its conversion into a permanent hospital for the continued care and treatment of mental cases exclusively. The lay-out and plant seemed ideal, and almost immediately plans were formulated for the functioning of the hospital in its new capacity. On April 20, 1919, it became United States Army General Hospital No. 43 (q. v.). UNITED STATES ARMY GENERAL HOSPITAL NO. 43, NATIONAL SOLDIERS' HOME, HAMPTON,VA." The hospital being designated to care for mental cases only, it is obvious that the neuropsychiatric service enbraced the greater proportion of the pro- fessional work, but to provide adequate medical and surgical service for the patients it was necessary to continue medical, surgical (including genitourinary and eye, ear, nose, and throat departments), and dental services. The labo- ratory and hydro therapeutic departments also were organized and equipped. This institution was originally the National Soldiers' Home, and not having been built for mental cases, there were no standard wards. Thev varied in capacity from 35 to 200 beds. Some of the barracks were provided with the necessary screening for doors and windows to insure the retention of the irresponsible cases. Continuous baths were installed in three buildings for the treatment of excitable cases who required frequent and continuous baths to control their psychotic episodes. There were 22 wards in all, 8 of which were operated as closed wards. It was the policy to give the patient as much freedom as possible, and many kept in closed wards at night were paroled during the day. JanuanTigTo IL! T^tT ™* ? ^^ Ho8pital X°' ^ '" ^ ^ 1919' b-v the commanding officer, January y, iyjo. On file, Record Room, S. G. O., 319.1-2. IN THE UNITED STATES 127 In the treatment of the mental cases the continuous sedative baths, hot packs, Scotch douches, needle showers, electric heat, occupational therapy, and exercise were the chief methods employed. Special efforts were made to avoid the use of narcotic and sedative drugs and very seldom were they used, and then never for other than temporary relief of an excitable or nervous patient at a time when it was not feasible to resort to the bath or pack. Prob- ably drugs were not used in one-half dozen instances during the period covered by this report. The restraint sheet practically never was used. One section of ward 18 was used for hydrotherapy. Temporary partitions were put in, dividing the room into small compartments for beds and stalls in which the patients disrobed. Ten beds were maintained in this department. The equipment consisted of two Scotch douches, two needle showers, four electric cabinets, and a number of incandescent-light baths for local applica- tion. A qualified masseur was employed in this department and his service in some instances apparently was very beneficial. The more excitable cases were segregated in the wards provided with con- tinuous baths, and the result of these baths in the control of such cases was very gratifying. There was no instance where a patient could not be quieted by the use of the hot pack or continuous bath if handled judiciously and the treatment was repeated at frequent intervals. Patients seldom objected to this treatment and many were glad to return to the baths. Occupational therapy did much to establish confidence in the patient. The prime factor in this work was to obtain the gradual cooperation of the patient in order not to put him at a task that would be repulsive, and thereby make him worse. There was close cooperation between the ward surgeon and the reconstruction aides, and the helpless and irresponsible patients were coaxed to work on the wards. In this work they began with simple tasks, such as the winding of string, the unraveling of burlap, basketry, rug weaving, and knitting. As the patient regained his confidence and the control of his faculties and acquired more responsibility, he was allowed to do a different class of work requiring more physical and mental ability, such as carpenter work, printing work, typewriting, and automobile repairing. Through the medium of exercise the patient's physical condition was kept as near normal as possible. Exercise was also useful in stimulating a desire for food. Care was taken in the selection and grouping of patients for the different exercises, giving them all the benefits of open air during the day. The less responsible patients were taken on walks, while the others were required to take varied calisthenic movements. Through the American Red Cross and other civilian organizations many automobile rides were arranged for the patients. The granting of furloughs was very liberal when the condition of the patient warranted. In many instances a visit home unquestionably benefited the soldier. 128 NEUROPSYCHIATRY On December 31, 1919, 3,206 patients had been treated at this hospital, classified as follows: Dementia paralytica-------------- -- 2 Constitutional psychopaths----- .-_ 229 Mental deficiency (moron)------------ 298 Psychoneurosis______________ - 445 Epilepsy_____________________ ----- 72 General paralysis_____________________ 277 Under observation for mental aliena- tion (no disease)____________________ 6 Nervous disease, undiagnosed--------- 40 Psychosis: Dementia prsecox_________ 703 Undiagnosed______________ - 223 Manic-depressive---------------- 266 Due to drugs, alcohol------------ 158 With cerebral syphilis____________ 23 With arteriosclerosis_____________ 3 Traumatic_______________________ 9 Infectious and exhaustions________ 6 Anxiety__________ ------------- 2 The balance, 444, were not neuropsychiatric patients but transfer cases handled for the port of embarkation, old soldiers, and civilians. There probably has been no institution in this country where the opportu- nities to study unusual mental diseases were so excellent as at this hospital. The material was abundant, and it is unfortunate that the personnel of the hospital had to change so frequently and that the pressure was so steady and the requests so insistent to get cases away to institutions near their homes, or otherwise released from the service. The commanding officer reported that the members of the staff were im- pressed with the large number of mental cases that were diagnosed dementia prsecox and who suggested a typical history of mental deterioration, who later- had their mental faculties return almost to normal and were discharged, cured, or improved to such an extent that they could be released on their own responsi- bility. These cases were depressions of a mixed type which could not be differentiated from dementia prsecox until they had been under observation for some time. They were impressed .also with the large number of cases that developed after the armistice was signed, conditions which could not be accounted for unless the etiological factor was purely anxiety and nostalgia. Many of these soldiers had gone through the worst of the fighting and were apparently normal a long while after the armistice was signed, then became confused and were later sent to hospitals for mental observation. A large number had actually returned to this country and were in the demobilization centers before they had their psychotic episodes. A few cases were difficult to determine in persons who drank heavily in France but had been men of exemplary habits in civil life. In these cases it was the problem to decide whether the psychosis was of alcoholic origin or whether the soldier had become a victim of mental deterioration before he had begun to indulge in alcoholic debauches. LETTERMAN GENERAL HOSPITAL, SAN FRANCISCO, CALIF.- The psychopathic ward, with an authorized capacity of 60 beds, was opened to patients on October 17, 1918. Previously the mental patients were caredJor in the detention ward along with general and garrison prisoners and • Based on War diary, Letterman General Hospital, San Francisco, Calif., November 12, mix Also- History of Letter- man General Hospital, by the commanding officer, June 21, 1920. ,ltoo: Annual report, Letterman General Hospital for uux, by the commanding officer. On file, Historical Division, S. C. O. IN THE UNITED STATES 129 men confined for punishment. The detention ward, with an authorized capacity of 50 beds was much overcrowded, but the more serious objection was the confinement of patients with prisoners behind bars. The opening of the pyscho- pathic ward was, therefore, an epochal event. While the detention ward had a barred entrance, barred windows, barred doors and partitions and "cells," the psychopathic ward had no barred doors or windows, and had "rooms" and "dormitories." This improvement in the surroundings was of great advan- tage in the care and treatment of the insane. The building was well constructed, with many windows and two large air shafts affording good light and, with the aid of a fan system, adequate ventilation. The hallways and offices had good hardwood floors; the other floors were of colored cement. The single rooms and dormitories were located around the outside, hotel fashion. The ceilings were high and the rooms spacious. The general impression was pleasing to both patients and visitors. On the second floor was the reception or sick dormitory, and near it was a screened porch where patients could enjoy the air and a view of the bay and environs. In the basement was the very complete hydrotherapeutic department. (Control table for needly spray, rain douche, Scotch douche, steam douche, perineal spray, liver spray, sitz bath; continuous bath with automatic control; electrohydric bath; electric light cabinet; electric coil cabinet; pack tables; massage tables; blanket warmer; scales, etc.). A large room adjoining the hydrotherapeutic room was utilized as a rest room, where patients were required to lie down for an individually designated time following treatment. The "hydro" nurse and his assistants were kept busy throughout the day, and very beneficial results were effected through their efforts. The nature of the treatment depended upon the individual case. Not only healthy functioning of the skin was secured, but through individual treatment a sedative, restful effect upon an excited, sleepless person and a stimulating effect upon a depressed, retarded patient. Another important form of treatment was occupational therapy. Every patient, unless his physical state absolutely contraindicated, was expected to do some form of work morning and afternoon, the nature and duration of which were carefully regulated in each individual case. It was kept clearly in view that the object was to hasten recovery or at least to improve a chronic state, rather than to accomplish a set amount of work. Accordingly, variation of employment was given to increase interest, and above all the advancement from a simple to more complex tasks. Certain patients were not mentally fit to do regular duty, inside or outside the ward. Much attention was given to such patients in an attempt to draw them out to better results. To that end a large airy room in the basement was used for raffia work, basket weaving, games, or other activities designed to arouse interest and bring the patient into better contact with his environment. The man's former occupation and interest were taken into consideration. He was carefully observed for revival of interest, and wherever indicated he was drawn in that direction to better cooperation and eventually to duties on the ward. Patients wore urged to take a personal interest in the cleanliness of the ward and were held responsible for certain windows, walls, floors, brass work, etc, A record was kept of each man's 130 NEUROPSYCHIATRY activities, and his duties were varied to suit his condition. The man overcharged with energy was given a useful outlet for his activity, thus bringing him into better accord with his environment and hastening recovery. Another class of patients, if allowed to do so, would gradually get out of touch with the world and shut themselves into a little world of their own imagi- nations. Along with this would result a marked dilapidation of personality, untidy appearance, lack of care of person, wetting and soiling, etc. Through proper attention to occupational therapy this deterioration could be prevented in marked degree and the patients held to more normal mental content, more natural appearance, and easier care. Whenever a man's condition permitted he was given outside work in shops, garden, etc., with greater liberty and resultant upbuilding of interest. All patients were benefited through recre- ation inside or outside the ward, such as athletic games, graphaphone concerts, etc. The work of the educational department along these lines was most thorough and commendable. Sharing in importance with the above was the work by the physician with the patient himself, investigating his difficulties, airing them and helping him straighten them out. In order to get best results it was necessary to secure the confidence and cooperation of the patient and to make him feel that the physician was his friend who had his best interest at heart. A careful record was kept of such investigations and interviews with the patient were repeated from time to time as indicated. The psychopathic section of the medical service was extremely busy during the entire period of the war. The construction of the new and modern psycho- pathic ward greatly facilitated the handling of mental cases and enabled proper treatment to be given the patients. Though, as stated above, the ward was designed to accommodate 60 patients, at times it had to accommodate as many as 130, for after the signing of the armistice the hospital began to receive numbers of cases returned from France and from Siberia. REFERENCES (1) Circular letter from the Surgeon General, U. S. Army, December 6, 1917. Subject: Malingerers. (2) History of Base Hospital No. 117, by the commanding officer. On file, Historical Divi- sion, S. G. O. (3) Letter from Maj. Frank E. Leslie, M. C, to Maj. Frankwood E. Williams, M C, March 12 1919. Subject: Observations and suggestions. On file, Record Room, S. authorized by law, during the existing emergency, to transfer to the various public hospitals for the care of the insane, patients of every class entitled to treatment in St. Elizabeths Hospital and that are admitted on order of the Secretary of War. The War Department will from time to time advise department commanders and others concerned of the public hospitals designated by the Secretary of War to receive insane patients trans- ferred under this authority. (C. A. R., No. 64, Dec. 13, 1917.) 464H- Applicants for enlistment and drafted men who are found to be insane after arrival at depot, post, or camp, and before the completion of their enlistment by oath, muster in, or otherwise, will be disposed of as follows: (1) Those whose liberation will be unattended by danger to themselves or others will be rejected and disposed of under the regulations governing the disposal of other rejected recruits; (2) those whose insanity is of a type that would probably make their liberation a source of danger to themselves or others will be delivered to the civil authorities authorized by law to apply for the commitment of insane persons, of the place where they applied for enlistment or whence they were drafted. The depot, post, or camp commander will provide the necessary escort for such delivery, and issue the necessary travel orders, transportation, and subsistence (in kind or by com- mutation as may be most suitable). A similar procedure will be followed in the case of civilian employees of the Quarter- master Corps who are found to have been insane before the beginning of their employment. (C. A. R. No. 64, Dec. 13, 1917.) 465. (Changed by C. A. R., No. 46, W. D., 1916.) Except as provided in paragraph 467 of these regulations the insane of the military service enumerated in paragraph 464 who require treatment in institutions for the insane will be promptly transferred to the institu- tions designated to receive them respectively. No person will be transferred under the provisions of this paragraph except after a crit- ical examination by a board of at least two medical officers, of whom one shall, if practicable, be a specialist in nervous and mental diseases. The examination will preferably be made in hospital, and in the special ward for nervous and mental diseases, should there be one; and the board will not mate its report until after the person being examined shall have been observed for a reasonable period of time. The report will give the diagnosis, a detailed account of the medical history of the case, and a statement as to whether the disability was or was not incurred in line of duty; also a statement as to whether the patient, if discharged from the service, can be released from military control without danger to himself or others, and the board's recommendation for or against the patient's transfer for treatment to such designated institution; all papers to be executed in duplicate. Should the board recommend the patient's transfer for treatment to a designated insti- tution, its report and all papers therewith and the medical certificate required by the Depart- ment of the Interior (blank form for which is furnished by The Adjutant General of the Army) properly filled in will be forwarded for the action of the department or division com- mander, who will, if he approves the transfer, issue the necessary orders therefor, and for such escort, transportation, and subsistence as may be required. IN THE UNITED STATES 141 Commands that are ordinarily exempted from the control of department and division commanders will forward such papers to the commander of the department within the terri- torial limits of which the command is located, for his action. The department or division commander will send one copy of the board's report and the medical certificate to the institution to which the patient is transferred, and will forward the second copy of the board's report, etc., with a note thereon of his action, to The Adjutant General of the Army. If the patient so recommended is an enlisted man, the record, and the report of the board of examining medical officers, will be prepared on the certificate of disability blank form in duplicate, accompanied by the necessary attached papers, and, in the event that his transfer is ordered, he will be discharged from the service on account of disabilitv. (C. A. R., No 64 Dec. 13, 1917.) 466. (Changed by C. A. R., No. 13, W. D., 1914; No. 22, W. D., 1915; and No. 55, W. D., 1917.) Upon the departure of the insane patient his immediate commanding officer will make and sign an inventory, in duplicate, of his effects, and will send one copy of the inventory, together with his money and other valuables by registered mail, to the superin- tendent of the institution to which he is transferred, retaining the other copy for the records of the command. The other effects of the patient, such as clothing, wall accompany him as baggage. Upon the patient's departure the commanding officer will by telegraph advise the institution thereof and of the time when the patient will be due to arrive. (C. A. R., No. 64, Dec. 13, 1917.) 467. The insane of the military service in the Philippine and Hawaiian Islands, who appear to require treatment in institutions for the insane, except natives, will be sent by the department commanders to Letterman General Hospital, San Francisco, Calif., for observa- tion in that hospital, before action is taken in their cases in accordance with the provisions of paragraphs 465 and 470. The insane in the Canal Zone and among other forces overseas will in like manner be sent to an Army hospital in home country near the suitable home port of the Army Transport Service for observation preliminary to similar action. Insane natives of the Philippine Islands and Porto Rico serving in the Army of the United States may, under authority of the Secretary of War, be sent to asylums in the Philip- pine Islands and Porto Rico, respectively, (C. A. R., No. 64, Dec. 13, 1917.) 468. Arm\T patients committed to institutions for the insane under these paragraphs will, when cured, be released from custody under the laws and regulations governing the release of other cured patients. To obtain the release of an Army patient who is not cured, or his delivery to the care of friends, application must be made therefor to The Adjutant General of the Army, accompanied by the recommendation of the superintendent of the institution. (C. A. R., No. 64, Dec. 13, 1917.) 469. The insane who do not require treatment in institutions for the insane will, unless permanently incapacitated for military service, be retained under military control. If they are permanently incapacitated for service and can be liberated without danger to themselves or others they will be discharged on certificate of disability. In case it is necessary to send a soldier to his home with an attendant he should not be discharged until he reaches his destination. (C. A. R., No. 64, Dec. 13, 1917.) 470. An enlisted man who requires treatment in an institution for the insane by reason of insanity existing before his enlistment is not entitled under paragraph 464 to be cared for at the expense of the United States. Each such case will nevertheless be examined and reported on in the same manner as the cases referred to in paragraph 464. The conclusions of the board being approved by the authority who is to take final action thereon, the soldier will be discharged for disability, and the following procedure had: His immediate command- ing officer will communicate with his family or friends, with the civil authorities authorized by law to apply for the commitment of insane persons of the State where he was enlisted or whence he was drafted, and with the like civil authorities of the State which he claims as his home, to ascertain whether they will receive and care for the man at their own expense. Should they agree to do so, the man will be sent under proper escort to the family or friends, or to the local authorities mentioned, as may be appropriate. Should they refuse to take charge of him the soldier will be sent to a designated public hospital for the insane pending 142 NEUROPSYCHIATRY the determination of what civil authorities are legally required to assume his care and treat- ment. Upon the soldier's departure his commanding officer will by telegraph advise the hospital thereof and of the time the soldier will be due to arrive. Whichever action is taken, the effects of the soldier will be inventoried as under paragraph 467; his money and valuables will be secured for disposition as indicated below; and his other effects, such as clothing, sent with him as baggage to his destination. In case his family or friends or the local committing authorities agree to receive him, they will be advised that his money and valuables are subject to the orders of the person legally authorized to receive the same in the insane man's behalf upon presentation of proof of such authority. In case- he is sent to a designated public hospital for the insane pending the determination of what civil authorities are ultimately chargeable with his care, his money and valuables will be sent by registered mail to the superintendent of such hospital, accompanied by one copy of the inventory. Full report of the action taken in each such case will be made to The Adjutant General of the Army. (C. A. R., No. 64, Dec. 13, 1917.) With the great increase in the strength of the Army following the declara- tion of war, it was obvious that the procedure formerly followed could not meet adequately the now needs. St. Elizabeths Hospital could not possibly provide for all insane soldiers, and, even if it could, the transportation of large numbers of insane soldiers over long distances was impracticable. The sending of papers in all cases to Washington for decision and an order to discharge from the Secretary of War created, under the circumstances, unsatisfactory conditions in the camps where hospitals were congested with insane soldiers awaiting transfer or discharge. A general order was issued, therefore, which extended authority of discharge to division and departmental commanders.3 Certain other changes to facilitate expedition were likewise made from time to time in the Army Regulations. In the cantonment two main problems presented themselves: (1) Dispo- sition of soldiers insane in line of duty; (2) disposition of soldiers whose mental condition existed prior to admission into the Army. With a prompt examina- tion of drafted men and volunteers upon their arrival at cantonments and before induction into the service, the question of "line of duty" could be settled with comparative ease. When men were not examined promptly on arrival, but only after several weeks or more of service, the question was not so easily determined; although from the condition of the patient, the nature and degree of his illness, and his previous history fairly accurate judgment could be made. Diagnoses and recommendations could frequently be°made more rapidly than transfers or discharges could be arranged. While waiting for transfer or discharge patients were retained (except those who, assigned to quarters could safely remain with their organizations) in the neuropsychiatric wards of the base hospitals. They were likewise cared for here if discharged until such time as arrangements could be made with relatives or civil authori- ties to receive them. In other words, insane soldiers were no longer just turned loose. An insane soldier when returned home was always accompanied il his condition demanded it, and in all other cases also if possible In some instances the admission of a soldier to hospital on account of a mental or nervous condition was not necessary. Whenever the peculiar actions oi a soldier or his failure to adapt himself to his new environment was noticed by ins commanding officer he was referred, either directly or through the regi- IN THE UNITED STATES 143 mental surgeon, to the neuropsychiatric officer who, after a sufficient exami- nation, submitted proper recommendation as to the disposition of the soldier. If necessary, he was admitted to hospital for further observation or treatment, but frequently, in such conditions as mental deficiency, constitutional psycho- pathic state, and certain of the psychoneuroses, this was considered unnecessary and the soldier was retained with his company or transferred to a development battalion, marked "quarters," and action initiated with a view to his discharge on account of physical disability. The "course of papers" in the camps (as in a regiment, for example) may be described as follows: (a) Regimental sur- geon sent patient to hospital for diagnosis and observation. (6) Neuropsychi- atric service reported patient "insane—should be discharged." (c) Report was made to commanding officer of hospital, (d) Commanding officer trans- mitted report to the man's regimental commander, (e) Regimental com- mander transmitted report to (1) company commander or (2) regimental surgeon. (/) Company commander initiated necessary form (S. C. D.) and sent it to regimental surgeon, (g) Regimental surgeon filled in his part of the form and transmitted it to the regimental commander, (h) Regimental commander made out the necessary papers for final action. COOPERATION WITH CIVIL AUTHORITIES Shortly after the mobilization of the World War Army began the Surgeon General communicated with the authorities in the different States inquiring if they would cooperate in relieving the Federal Government of the care and responsibility of recruits in whom insanity existed prior to enlistment, or in whom it was not an incident to service, as it was evident that cases of this character should not be a charge on the Federal Government. On September 20, 1917, the following communication was sent by the Surgeon General to all the States:4 The Surgeon General is called upon to make immediate arrangements for the care of the military insane in whom the insanity was not incurred in the line of duty. There will probably be one of these for every thousand troops mobilized, and the Surgeon General is desirous of making arrangements by means of which the different State hospitals will receive and care for the insane officers and soldiers of the above category from their own States. It is evident that when the mental disease existed prior to enlistment or was for other reasons not contracted in line of duty, the cost of the care of the patient should not be a charge upon the Federal Government. The cost should be borne by the States. Division surgeons and other commanders will be advised that for each case the question of line of duty is to be carefully considered. All those in whom insanity was not incurred in line of duty will be released from military control on a certificate of disability whenever this can be done without danger to himself or to others. It is for the disposal of patients who can not be released from military control without danger to themselves or to others that the Surgeon General requests your immediate and hearty cooperation. He directs me to inquire if you will cooperate with him to this end by receiving officers and soldiers of the above class, they being transported and delivered to any point or points named by you. In your reply you are requested to state to what point or points such cases should be sent. A prompt reply will be greatly appreciated. By the middle of November, 1917, favorable replies had been received from 25 States. The Surgeon General then issued the circular following on the subject for the information of those concerned. 144 NEUROPSYCHIATRY november 17, 1917. State Care of Insane Soldiers (Subject to amendments and additions) \uthorities of the following States have signified 'heir willingness to receive, care for, and maintain at State expense soldiers from their own State who require institutional care, when the insanity existed prior to enlistment or arose not in line of duty. N o patient will be sent to any of the State institutions without assurance having been obtained from the State authorities that beds are available and withoir the exac' point having been indicated to which the patient shall be delivered by the military authorities. Arizona.—Communicate with medical superintendent, Arizona State Hospital, Phoenix, ' n7"Connecticut.—Communicate with medical superintendent, Connecticut Hospital for Insane, Middletown, Conn. Delaware—Communicate with medical superintendent, State Hospital for Insane, Farnhurst, Del. /da/io.—Communicate with medical superintendent, Idaho Insane Asylum, Blacktoot, Idaho. . . Illinois.—Communicate with medical superintendent of most convenient institution, as follows: Al on State Hospital, Upper Alton; Anna State Hospital, Anna; Chester State Hospital, Menard; Chicago State Hospital for the Insane, Dunning; Elgin State Hospital, Elgin; Jacksonville State Hospital, Jacksonville; Kankakee State Hospital, Kankakee; Peoria State Hospital, Peoria; Watertown State Hospital, East Moline. /0U,a._Communicate with medical superintendent of any of the following State hospi- tals: Cherokee State Hospital, Cherokee; Claiinda State Hospital, Clarinda; Independence State Hospital, Independence; Mount Pleasant State Hospital, Mount Pleasant; State Reformatory, Anamosa. Maryland.—Communicate with Dr. Arthur P. Herring, 406-407 Professional Building, Baltimore, Md., who will designate proper State institution. Massachusetts.—Communicate with medical superintendent, Boston Psychopathic Hospital, Boston, Mass. Michigan.—Communicate with attorney general's department, Lansing, Mich., giving county where soldier was enlisted. Minnesota.—Communicate with Downer Muller, secretary, State Board of Control, St. Paul, Minn. Nebraska.—Communicate with Henry Gerdes, Board of Commissions of State Institu- tions, Lincoln, Nebr. Nevada.—Communicate with Commissions for the Care of Indigent Insane, Carson City, Nev. New Hampshire.—Communicate with medical superintendent, New Hampshire State Hospital, Concord, N. H. New Mexico.—Communicate with medical superintendent, New Mexico Insane Asylum, Las Vegas, N. Mex. New York.—Communicate with E. S. Elwood, secretary, State Hospital Commission, Albany, N. Y. Ohio.—Communicate with E. F. Brown, secretary Ohio Board of Administration, Columbus, Ohio. Oklahoma.—Communicate with medical superintendent, East Oklahoma State Hospital, Yinita, Okla. Oregon.—Send insane soldiers to State institutions as follows: Those from Baker, Crook, Gilliam, Grant, Harney, Hood River, Jefferson, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, and Wheeler Counties, to be sent to medical superintendent, Eastern Oregon State Hospital at Pendleton, Oreg.; those from Benton, Clackamas, Clatsop, Colum- bia, Coos, Curry, Douglas, Jackson, Josephine, Klamath, Lake, Linn, Lincoln, Lane, Marion, Multnomah, Polk, Tillamook, Washington, and Yamhill Counties to be sent to medical superintendent, Oregon State Hospital, at Salem, Oreg. IN THE UNITED STATES 145 Pennsylvania.—Communicate with Frank Woodbury, secretary committee on lunacy, Bulletin Building, Philadelphia, Pa., stating county where soldier enlisted. Rhode Island.—Communicate with medical superintendent, State Hospital for Mental Diseases, Howard, R. I. South Carolina.—Communicate with A. S. Johnson, secretary State. Board of Charities and Corrections, Palmetto Building, Columbia, S. C, who will give directions. Utah.—Communicate with medical superintendent, State Mental Hospital, Provo, Utah. Vermont.—Communicate with medical superintendent, State Hospital for Insane, Waterbury, Vt. Virginia.—If white soldiers, communicate with J. M. Bauserman, Commissioner of State Hospitals, Woodstock, Va. If colored, communicate with Dr. William F. Drewry, superintendent, Central State Hospital, Petersburg, Va. Wisconsin.—Communicate with M. J. Tappins, secretary State Board of Control, Madison, Wis. In March, 1918, the National Committee for Mental Hygiene was requested to take up the matter further with States which had not replied or which sent unfavorable replies. The vice chairman of the committee at once circularlized the governors of all these States and in certain instances followed up the circular with further correspondence. The circular letter referred to is as follows:5 As you are doubtless aware, the Federal Government is prepared to provide care and treatment for the military insane in whom the insanity is incurred in the line of duty in the present wrar. But it has been held that the cost of caring for the military insane in whom the mental disease existed prior to enlistment, or was for other reasons not contracted in line of duty, shall be borne by the several States. In order to assure absolute fairness and justice in deciding responsibility for the expense, most careful attention is being given in each instance to the question of line of duty. On September 20, 1917, the Surgeon General sent to the appropriate authorities in your State a letter explaining this matter. A copy of the letter is inclosed. The War Work Committee has been designated by the Surgeon General's Office to handle the correspondence about this mater, and we are in receipt of advices from the Surgeon General that a conference can not be entered into at this time. It would be appre- ciated if you would advise the appropriate authorities of the Surgeon General's advices that a quick decision in this matter is necessary and thaJ a prompt reply at this time is desired to facilitate arrangements to provide for this class of persons. A substantial number of the States hav( already responded favorably, directing which of their institutions will receive such cases and giving the name of the proper authorities with whom to communicate. Your early attention to this important matter in your State would be greatly appreciated. On May 2, 1918, the vice chairman of the War Work Committee, National Committee for Mental Hygiene, reported to the Surgeon General the following results:6 On September 20, 1917, you sent a letter to the boards in control of the institutions for the insane in each State in the Union calling upon them to make arrangements for the care of their military insane in whom the insanity was not incurred in the line of duty. On Novem- ber 30 you wrote me that 25 of the States had replied favorably as follows: Arizona, Con- necticut, Delaware, Idaho, Illinois, Iowa, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Wisconsin. In that same letter (November 30), you stated that unfavorable replies, or no replies, had been received from: Alabama, Arkansas, California, Colorado, Florida, Georgia, Indiana, Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Washington, West Virginia, Wyoming. 146 NEUROPSYCHIATRY In a letter dated March 16, 1918, you asked that the matter again be taken up with the States which had not taken appropriate steps. Accordinglv, on April 5, letters were sent from this office to the governors of all such States calling the matter to their attention and asking them to take it up. Replies from the governors and boards to which they referred the letter have been coming to this office. On the basis of the replies received by you in November, 1917, and the replies received by us in April, 191S, I have compiled an alphabetical list of the States, indicating the action which has been taken by the various States, and am inclosing it herewith.6 * * * I am also writing again to-day to some of the States which have not yet replied. Most of the States thus eventually responded and entered whole-heartedly into the agreement to care for patients for whom the Army could not be expected to provide. The arrangement in general was, with certain variations, depending upon different methods of handling insane persons in the different States, that the military authorities would send patients of the above class to a point designated by the State authorities, and would then release the patient to the State authorities. Commanding officers were furnished lists of the States and the points to which patients wore to be sent. This arrangement was of great assistance to the Medical Department and did not put a very great burden on the States. It worked most satisfactorily when there was a central State board such as a State commission on mental diseases with which all commanders could communicate and which could, in turn, at once indicate the special institution to which the recruit in question should be sent. In States where there were no central boards, correspondence over a considerable period frequently was necessary before it could be determined wdiich of possibly several hospitals should receive the patient. In certain States not provided with committing officers the Medical Department met the moderate fee which was asked by physicians who executed the commitment papers. CARE OF MENTAL CASES IN GOVERNMENT HOSPITALS As the number of soldiers with nervous or mental disease who required treatment, or for whom it was necessary to care pending discharge increased, it was necessary to provide facilities other than those offered by the neuropsy- chiatric wards in base hospitals. To relieve the congestion in these wards and at St. Elizabeths Hospital, a number of neuropsychiatric centers, widely distributed geographically, to which such soldiers could be transferred for treatment or for care pending discharge, were established in various U. S. Army general hospitals.7 Mendocino State Hospital, Talmage, Calif., was designated by the Secre- tary of War to receive patients on the same status as at St. Elizabeths Hospital. This was done with a view of relieving congestion at St. Elizabeths Hospital, and also of avoiding the unnecessary transportation of the insane. St. Eliza- beths Hospital itself was enlarged by 500 beds. The increasing number of Army patients at St. Elizabeths Hospital over- taxedJhej^ortsj)Uliejegular staff on duty there, and medical officers and few 'JSI!|! referred t0 iDClUded comme^W the character of the response made by each State. It showed only a "SI? 'I ,TSe W? UDfavorable or wh0 had failed t0 act "P to that time. Those indicating favorable action were Kansas mZ. m r i™?/ Anzona Arkansas, Colorado, Connecticut, Delaware, Florida, Idaho, Illinois, Indiana, Iowa, Sf™' Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, Xew York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon Pennsylvania Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West VirgiS WiSn IN THE UNITED STATES 147 enlisted men of the Medical Department were assigned to duty at the hospital.8 A detachment was organized and all military records were under the supervision of the commanding officer. A few neuropsychiatrists were assigned to assist the medical staff of the hospital in the treatment of these patients, and certain of the enlisted men were used as orderlies and helpers. There was a marked delay in accomplishing the discharge of the soldiers after their arrival at the hospital, and the detachment of patients was constantly increasing in numbers. To relieve this congestion of patients and in order that only cases of insanity which promised to be of long standing would be sent to St. Elizabeths Hospital, the following circular letter was issued from the Office of the Surgeon General on November 20, 1918:9 disposal of the insane 1. Members of the Military Establishment suffering from general paralysis of the insane and from insanity complicated by epilepsy (insane epileptics) shall be sent from hospitals at ports of embarkation and from other hospitals to St. Elizabeths Hospital, \Yashington, D. C, as provided by paragraph 464, Army Regulations, 191N, as amended by C. A. R., No. 64 December 13, 1917. 2. All other patients in the military service who present symptoms of insanity shall be retained in the military hospitals for necessary care and treatment provided the period of care and treatment shall not exceed four months. 3. All cases of epilepsy which can not be improved by medical or surgical treatment in the military hospitals shall be recommended for immediate discnarge from the service without transfer to other military hospitals. As the war proceeded it was considered desirable to require that all mental cases be treated for a reasonable period in the military hospitals. Directions recommended in June, 1918, sent out November 20, 1918, provided that all except cases which were evidently incurable should be treated in the military hospitals for a period of at least four months, unless recovery took place sooner, before being sent to St. Elizabeths Hospital.10 This provision enabled many patients to leave the Army well, without having been sent to an institution identified with the care of the insane, enabled many patients to pass their period of illness in the neighborhood of their homes, and avoided many unneces- sary transfers. It also seemed to meet the hearty approval of the civil population. The requirements of Army Regulations 470 (as amended), in so far as they pertained to insanity existing before enlistment, were nullified by the provisions of that section of the war risk insurance act which stated that "said officer, enlisted man, or other member shall be held and taken to have been in sound condition when examined, accepted and enrolled for service."11 The interpretation placed on this proviso during the war was that once the officer or soldier was accepted he must be regarded, for purposes of compen- sation and future hospitalization, as having been mentally and physically sound when he came into the Army.12 Therefore, theoretically, insanity could not have existed before enlistment and the soldier must be transferred to a public institution for the care of the insane. After the armstice was signed and demobilization was under way it was possible to determine very closely the number of psychiatric cases which re- 42705—29---11 14S NEUROPSYCHIATRY mained to be disposed of. A census of the hospital accommodations showed that sufficient beds were available in Army general hospitals for the care of all insane cases remaining. In view of this fact and of the crowded conditions at St. Elizabeths Hospital, instructions were issued directing that no more insane soldiers be transferred to St. Elizabeths, but that all be retained in military hospitals pending further orders.13 FUNCTION OF THE BUREAU OF WAR RISK INSURANCE WITH RESPECT TO THE INSANE The Bureau of War Risk Insurance had been charged by law with the duty of providing hospital care for the compensable insane after discharge from the military service. By that time the bureau was well established and was able to provide hospital facilities for all discharged soldiers entitled to such care. Section VII, General Orders, Xo. 57, War Department, April 30, 1919, provided as follows for the future disposition of the insane of the Army: VII. Care of compensable insane (Cir. No. 225, W. D., 1919).—1. The Bureau of War Risk Insurance is charged by law with the duty of caring for the compensable insane of the military service after their discharge from the Army, and has undertaken to provide institu- tional treatment after discharge for cases requiring it. Such cases are to be turned over directly to the care and responsibility of the bureau in such a manner that there will be no interval between discharge from the military service and the commencement of the con- tinued care in hospitals near their homes, which is to be provided by the bureau. 2. In order to accomplish this, the following procedure will be observed: (a) Cases which have been under treatment in military hospitals in this country for four months, and which are considered to be incurable or to require a much longer period of hospi- tal treatment to effect a cure, will be reported in writing by the commanding officer of the post, camp, or station directly to the chief medical advisor, Bureau of War Risk Insurance, Washington, D. C. (attention section of nervous and mental diseases), who will give instruc- tions as to the disposition desired by the Bureau of War Risk Insurance. When reporting cases to the Bureau of War Risk Insurance under this paragraph, the following information regarding the soldier will be furnished: (1) Name, rank, organization, Army serial number, and race; (2) length of service; (3) legal residence; (4) name and residence of nearest relative; (5) diagnosis; (6) brief summary of medical history; (7) prognosis. (b) Upon receipt of instructions from the Bureau of War Risk Insurance, the soldier will be ordered discharged on certificate of disability by the authority designated to order discharge in such cases. The same procedure as to preparation and disposition of records will be followed as outlined in Army Regulations governing the discharge of insane in the military service and their delivery to institutions. The soldier will be delivered to the designated institutions accompanied by necessary attendants, and not discharged until his arrival thereat. When the soldier has been delivered to the authorities of the institution designated to receive him, the senior attendant will ordinarily telegraph the commanding officer authorized to discharge the soldier. Upon receipt of this information the soldier will be discharged and discharge papers mailed to the authorities of the institution to which the soldier was transferred for delivery to the soldier. When a patient is delivered to an institution and discharged the Bureau of War Risk Insurance will be so informed in writing by the commanding officer concerned. 3. The provisions of this order do not in any way amend subparagraph a, Circular No. 188, War Department, 1918, relative to the discharge of a certain class of patients who possess funds or have relatives or friends who can afford them specialized care after discharge. By the provisions of this order the whole question of the disposition of the insane was greatly simplified. After an ample period of observation in military hospitals the insane soldiers were transferred directly to the hospital designated IN THE UNITED STATES 149 by the Bureau of War Risk Insurance, discharged from the Army upon arrival, and their treatment continued under the jurisdiction of the bureau, which in the future was responsible for their care. The United States Public Health Service, charged with the hospitalization of the beneficiaries of the Bureau of War Risk Insurance, opened numerous hospitals throughout the country for the care of the insane. In addition the Bureau of War Risk Insurance made arrangements with the authorities of many States for receiving the ex-service insane in the State hospitals provided for the care of this class of incapacitated. Through these facilities, the Bureau of War Risk Insurance usually was able to send the insane to some institution near their homes, an arrangement which in itself was a source of great comfort to the patient and his relatives. This procedure was most successful, and was continued during the remainder of the period in which the war Army was being demobilized. REFERENCES (1) A. R. 465, 1913 (C. A. R., Nos. 10 and 46). (2) A. R. 467, 1913. (3) G. O. No. 133, W. D., October 11, 1917. (4) Letter from the Surgeon General to the governors of the various States, September 20, 1917, relative to State care of the military insane. Copy on file, Historical Divi- sion, S. G. O. (5) Letter from the vice chairman, War Work Committee, National Committee for Mental Hygiene, New York, to the governors of certain States, April 5, 1918, relative to State care of the military insane. Copy on file, Historical Division, S. G. O. (6) Letter from Dr. Frankwood E. Williams, New York, to Lieut. Col. Pearce Bailey, M. C, May 2, 1918. Subject: State care of military insane. Copy on file, His- torical Division, S. G. O. (7) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1164-1167. (8) Personnel files. Personnel Division, S. G. O. (9) Circular Letter, Surgeon General's Office, November 20, 1918. (10) Circular Letter S. G. O., November 20, 1918. (11) Act of Congress, approved October 6, 1917. (12) Opinions, Judge Advocate General, 1918-19. (13) Circular No. 164, W. D., 1919. CHAPTER VIII OCCURRENCE OF NEUROPSYCHIATRIC DISEASES IN THE ARMY The reports received in the Office of the Surgeon General concerning the occurrence of neuropsychiatric diseases in the Army were of two entirely dis- tinct classes. The first was the report card of sick and wounded (Form 52, Medical Department) which is forwarded for every officer or soldier admitted to sick report. In the second group wore the special reports, required by the division of neuropsychiatry, which will be referred to at greater length in the following chapter. The statistics compiled from the report cards of sick and wounded for all diseases are given in full in Volume XV, Part II, Medical and Casualty Sta- tistics. From those statistics certain facts pertaining to the occurrence of neuropsychiatric diseases are recorded in Tables 1, 2, 3, and 4 below. In Tables 1 and 2 every admission to sick report is considered. The only possible duplication would be that an individual may have been admitted more than once with the same diagnosis. This did not occur in any great number of instances, and the fact that it did occur among all the classes tabulated would tend to equalize the percentage of occurrence for purposes of comparison. Table 2 shows for the following conditions a relatively higher degree of incidence among officers than enlisted men: Encephalitis, locomotor ataxia, apoplexy, neurasthenia, "shell-shock," neuritis, general paralysis of the insane, psychasthenia, psychoneurosis, and manic-depressive psychosis. The inclusion in this group of many of those indefinite functional disorders which usually are placed under the general term of psychoneuroses is of special interest. On the other hand, certain conditions occur much more frequently among the enlisted personnel. The marked preponderance in this respect of epilepsy, enuresis, constitutional psychopathic states, mental deficiency, and dementia praecox is striking. Table 2 shows, also, the higher incidence rate among officers serving abroad than among those in the United States. Further, it is seen readily that while for the total Army the percentage of neuropsychiatric diseases existing among officers was higher than among enlisted men, among those serving in Europe this disproportion was even greater. As noted before, the special neuropsychiatric examination was not given fis a routine to commissioned officers of the Army. This fact readily explains the higher percentage of this type of defect existing among officers and also why this percentage was increased among those serving in Europe. (When neuropsychiatric surveys of troops were made, officers were seldom required to undergo the special examination.) Ordinarily, we would expect a con- siderably lower rate of neuropsychiatric disease among the type of men included in the officer group than in the general type representing the enlisted men. The failure of this corollary to hold true is explained by the elimination of a 151 132 NEUROPSYCHIATRY large percentage of men, suffering from this class of disease, from the enlisted forces as a result of the efforts of the neuropsychiatrists. A comparison of the ratio of these diseases occurring among enlisted men in the whole Army and among those serving in the United States and in Europe shows a much lower percentage for practically all neuropsychiatric diseases among the enlisted men in Europe. This marked reduction in the noneffective rate for this class of disease among the troops abroad is undoubtedly evidence of the efficiency of the neuropsychiatrists in detecting this type of defect before the soldiers had finished their period of training in this country. The general statement made above with reference to enlisted men as a whole applies simi- larly with reference to white and colored troops when considered separately. In a comparison of the occurrence of neuropsychiatric diseases among white and colored troops, Table 2 discloses that the following diseases were recorded proportionately more often in white soldiers: Encephalitis, multiple sclerosis, neurasthenia, neurosis, "shell-shock," chorea, constitutional psycho- pathic state, dementia praecox, psychasthenia, psychoneurosis, alcoholic psy- chosis, and manic-depressive psychosis. The following diseases occurred in a higher ratio among the colored soldiers: Simple meningitis, locomotor ataxia, apoplexy, facial paralysis, paraplegia, epilepsy, Jacksonian epilepsy, enuresis, neurocirculatory asthenia, hysteria, neuralgia, neuritis, defective speech, gen- eral paralysis of the insane, and mental deficiency and malingering. In general, the ratio of occurrence of neuropsychiatric diseases in white and colored troops corresponds for the whole Army—the Army in the United States and the Army in Europe. A comparison of Tables 3 and 4 with Tables 1 and 2 shows a smaller num- ber discharged on certificate of disability than might have been expected for defects of this character. It must be remembered, however, that a certain number died, some remained in hospital, and disposition at the final date included, in the statistics, a considerable number who were regarded as fit for the performance of some military duty and who were retained in the service; an appreciable number, after the signing of the armistice, were discharged upon the demobilization of their organizations who, if the war had not ended, would have been discharged for disability. Table 1.—Neuropsychiatric diseases. Admissions, oflicers and enlisted men (except native troops), in the, United States and Europe (except North Russia), April /, 1917, to December .il, 1919. Absolute numbers Total If. S. Army (excepting native troops) Enlisted men Offi- cers Encephali tis__________________________________ 7 Meningitis, simple___.....____________________ 11 Locomotor ataxia_____________________________| ]9 Multiple sclerosis_____________________________ 5 Spinal cord, other diseases of__________________! 13 Apoplexy......-------------------------------j 24 Facial paralysis_______________________________ 17 Paraplegia^......._____________________________! 3 Paralysis without specified cause______________ 37 Epilepsy_____________......__________________i 52 Jacksonian epilepsy___________________________! 1 Neurasthenia.........._______________________I 891 Enuresis______________________________________ 5 Xeurosis______________________________________' 38 Neurocirculatory asthenia_____________________j 66 Shell-shock (cause not given)__________________[ 239 Chorea________________________________________ 1 Hysteria and results_____.....__________....... 152 Neuralgia_____________________________________ 221 Neuritis_________________________________...... 478 Speech, defective- ___________________________ 2 Nervous system (other diseases of)............ 459 General paralysis of the insane_________.....__ 25 Constitutional psychopathic states____________■ 87 Mental deficiency_____________________________ 12 Malingering___________________________......_ 3 Dementia praecox.____________________________ 50 Psychasthenia________________________________ 111 Psychoneurosis... ... ___________.......___ 403 Psychosis: Alcoholic_____ _______________.....______I 24 Manic-depressive_________________________ 129 Others______________________.............. 156 White 66 393 184 226 564 305 258 60 981 7,523 104 7,559 2,737 743 3,768 3,281 307 5,533 4,594 4,890 184 4,511 245 4,913 11,202 658 5, 793 673 7, 054 539 1,790 2,855 Col- ored 3 63 22 13 39 52 24 9 77 1,047 14 267 241 42 468 27 9 452 529 603 25 364 22 174 1,764 74 349 (I 316 13 119 205 Color not stated 4 39 4 2 10 10 7 5 24 109 202 10 11 74 351 4 105 173 150 1 117 8 Total 73 495 210 241 613 367 289 74 1,082 8,679 118 8,028 2,988 796 4,310 3,659 320 6,090 5,296 5,643 207 4,992 275 5, 146 13,051 7i:i 6, 199 699 7,501 565 1, 939 3,148 Total officers and en- listed men 506 229 246 626 391 306 77 1,119 8,731 119 8,919 2,993 834 4,376 3,898 321 6,242 5,517 fi, 121 209 5,451 300 5, 233 13,063 746 li, 249 810 7, 904 589 2,068 3,304 U. S. Army in United States Enlisted men Offi- cers 502 17 16 18 1 148 2X1 1 384 21 53 4 2 36 66 Col- White ored 37 208 153 206 476 242 132 49 770 6,237 89 5,272 2,383 512 2,335 87 278 3,643 3,499 3,118 163 3,646 194 3,882 9, 947 511 5,016 468 3, 399 367 1,395 1,350 2 35 19 13 35 46 13 7 55 875 12 209 178 38 347 1 9 348 384 482 25 286 16 144 1,618 Total 39 243 172 219 511 288 145 56 825 7,112 101 5,481 2,561 550 2, 682 88 287 3,991 3,883 3, 600 188 3,932 210 4,028 11,565 566 5, 293 475 3, 630 374 1,489 1,392 Total officers and en- listed P. S. Army in Europe (excluding Russia) Enlisted men Offi- cers men 40 6 249 5 186 3 223 1 517 6 301 12 153 9 48 848 14 7,150 10 101 1 5, 983 355 2,561 3 567 21 2,698 50 106 220 288 4,046 96 4,031 69 3,881 190 189 1 4,316 69 231 4 4, 079 31 11,569 3 568 1 5, 329 10 541 39 3,721 308 382 16 1,569 47 1,454 90 143 307 1,434 (i 8 28 51 138 81 13 11 58 57 2 16 84 131 6 13 24 30 159 84 162 421 178 468 Table 2.—Neuropsychiatric diseases. Admissions, officers and enlisted men (except native troops), in the United Stales and Europe (except North Russia), April 1, 1917, to December 31, 1919. Rales per 1,000 per annum Encephalitis________________ Meningitis, simple__________ . 1 locomotor ataxia_________________ Multiple sclerosis_________________ Spinal cord (other diseases of)----- A poplexy.........----------------- Facial paralysis___________________ Paraplegia.. ---------------------- Paralysis without specified cause.. Epilepsy.....------------ -------- Jacksonian epilepsy.....----------- Neurasthenia______________________ Enuresis_______________........... Neurosis___ . _________------...... Neurocirculatory asthenia.....----- Shell shock (cause not given)....... Chorea.._________________________ Hysteria and results_______________ Neuralgia.......---------.......— Neuritis......--------------------- Speech, defective— . ------------ Nervous system (other diseases of). (icneral paralysis of the insane----- Constitutional psychopathic states. Mental deficiency----------..... M alingering_______________________ Dementia praecox........---------- Psychasthenia__________.........-■ Psychoneurosis-------------------- Psychosis: Alcoholic........------------- Manic-depressive______________ Others..................------- Total U. S. Army (excepting native troops) Offi- cers 0.03 .05 .09 .02 .06 . 12 .08 .01 . 18 .25 .00 4.32 .02 .18 .32 1.16 .00 .74 1.07 2.32 .01 2.22 .12 .42 .06 .01 .24 .54 1.95 .12 .63 .76 Enlisted men 0.02 . 11 .05 .06 .16 .08 .07 .02 .27 2.09 .03 2.10 .76 .21 1.05 .91 .09 1.54 1.28 1.36 .05 1.25 .07 1.36 3.11 . 18 1.61 . 19 1.96 . 15 .50 .79 Colored 0.01 .22 .08 .05 . 14 . 18 .08 .03 .27 3. 65 .05 .93 .84 . 15 1.63 .09 .03 1.58 1.85 2.10 .09 1.27 .OS .61 6. 16 .26 1.22 .03 1.10 .05 .42 .72 Total 0.02 . 13 . 05 .06 . 16 .09 .07 .02 .28 2.23 .03 2.07 .77 .20 1.11 .94 .08 1.57 1.36 1.45 .05 1.28 .07 1.32 3. 36 .19 1.60 .19 1.93 .15 .50 .81 Total officers and enlisted men 0. 02 . 12 .06 .06 . 15 . 10 .07 .02 .27 2.13 .03 2.18 .73 .20 1.07 .95 .08 1.53 1.35 1.50 .05 1.33 .07 1.28 3. 19 . 18 1. 53 .20 1.93 U. S. Army in United States Offi- cers o.oi . 05 . II .03 .05 . 10 .06 .02 .19 .31 4.04 .14 .13 .14 .01 .44 1.19 2.26 .01 3.09 .17 .43 .03 .02 .29 .53 .73 .06 Enlisted men . 14 .51 , .64 .81 .50 White Colored 0. 02 0.01 . 11 .24 .08 . 13 . 10 .09 .24 .24 .12 .32 .07 .09 .02 .05 .39 .38 3.17 6.00 .05 .08 2.68 1.43 1.21 1.22 .26 .26 1.19 2.38 .04 .01 .14 .06 1.85 2.39 1.78 2.64 1.59 3.31 .08 .17 1.85 1. 96 . 10 . 11 1.98 .99 5.06 11.10 .26 .38 2.55 1.90 .24 .05 1.73 1.59 .19 .05 Total officers and enlisted men n .69 0.02 . 12 .08 . 10 .24 . 14 .07 .03 .39 3.37 .05 2.60 1.21 .26 1.27 .04 .14 1.89 1.84 1.71 .09 1.86 .10 1.91 5.48 .27 2.51 .22 1.72 . 18 .71 .66 0. 02 . 11 .08 . 10 .23 . 13 .07 .03 .38 3.20 .05 2.68 1.15 .25 1.21 .05 .13 U. S. Army in Europe (excluding Russia) Offi- cers 0.08 .07 .04 .01 .08 . 15 . 12 .19 .14 .01 4.82 .04 .28 .68 2.98 Enlisted men 1.81 1.30 1.80 .94 1.74 2.58 .08 .01 1.93 .94 .10 .05 1.82 .42 5.18 .04 .25 .01 2.38 . 14 .24 .53 1.66 4.18 .17 .22 .70 .64 .65 1.22 "" i " 'hite Colored 0.02 0.01 . 12 .23 .02 .02 .01 .05 .03 .04 .04 .08 .09 .01 .02 .13 . 15 .78 1.27 .01 .01 1.35 .40 .19 .30 .15 .03 .97 .99 2.17 .21 .01 1.21 .75 .62 .96 1.11 .94 .01 .51 .50 .03 .05 .67 .23 .77 1.13 .08 . 11 .45 .47 . 13 .02 2.47 .69 .10 .25 .05 .20 1.30 Total officers enlisted men 0. 02 . 15 .02 .01 .06 .04 .09 .01 . 14 .88 .01 1.41 .20 . 15 1.02 2.24 .02 1.24 .75 1:19 .01 .58 .04 .67 .85 .09 .49 .13 2.41 .10 .26 1.05 0.02 .02 .01 .06 . 05 .09 V, .01 w .14 n .85 w .01 c 1. 56 . 19 Ti .15 ►> 1.01 n 2.27 X .02 •—i 1.24 »*» H 1. 25 .01 .60 .04 .66 .82 .09 .47 .15 2.49 . 11 .28 1.06 Table 3.—Neuropsychiatric diseases. Discharges for disability, officers and enlisted men (except native troops), in the, United States and Europe (except North Russia), April i, 1917, to December 31, 1919. Ahsohttc numbers Encephalitis________________ Meningitis, simple_________ Locomotor ataxia_________ _ Multiple sclerosis___________ Spinal cord (other diseases of) Apoplexy_____________......... Facial paralysis________________ Paraplegia_____________________ Paralysis without specified cause Epilepsy________________....... Jacksonian epilepsy____________ Neurasthenia__________________ Enuresis______________________ Neurosis______________________ Neurocirculatory asthenia... Shell-shock (cause not given) Chorea__________________ . Hysteria and results______ Neuralgia______...... N'euritis_____________._ . Speech, defective______ Mervous system (other diseases of) (leneral paralysis of the insane.. .. Constitutional psychopathic states Mental deficiency_______________ Malingering___________________ . Dementia praecox________________ Psychasthenia___________________ Psychoneurosis__________________ Psychosis: Alcoholic____________________ Manic-depressive____________ Others______________________ U. S. Army in United States Enlisted men White 9 63 101 171 146 1,714 29 487 123 445 160 3, 180 8,549 2 4,481 280 2, 267 143 1,231 742 Col- ored Total officers and Total listed men 284 26 129 28 33 6 30 ," 298 28 233 608 38 7 883 82 641 66 130 19 476 258 38 5 170 I 321 17 26 15 114 1,416 """267" 3 153 2 90 72 V. S. Army in Europe (excluding Russia) 112 181 310 157 39 35 326 841 45 965 707 149 734 38 151 884 30 808 140 471 1(1 76 114 182 314 159 41 35 328 4, 851 45 2,013 707 150 1,737 40 151 1, 895 30 821 14(1 477 182 3, 308 9, 966 2 4, 769 290 Offi- cers White 9 10 15 13 12 1 21 387 3 184 10 4 71 20 3 183 2 17 31 313 Enlisted men Col- ored Total officers and Color en- not Total listed stated ' men I 1 1 ____ 1 1 62 2 1 2 12 5 [ 6 i 3 1 7 3 10 10 16 15 13 3 23 461 3 195 10 4 74 21 3 202 2 59 7 17 34 328 565 869 33 2, 420 2,440 4 128 8 16 152 145 145 28 1 29 1,321 1,349 7 277 26 13 316 811 827 3 177 15 4 196 8 3 10 10 16 15 13 3 24 461 3 202 10 5 75 22 20 34 320 874 37 156 29 323 199 H H M d H o w > W w Oi 1 Table 4.—Neuropsychiatric diseases. Discharges for disability, officers and enlisted men (except native troops), in the United States and Europe (except North Russia), April 1, 1917, to December 31, 1919. Rates per 1,000 per annum C5 Encephalitis--------------- Meningitis, simple---------- Locomotor ataxia ----------- Multiple sclerosis............ Spinal cord (other diseases of). Apoplexy---------.......--- Facial paralysis... ---------- I 'araplegia__________________ Paralysis without specified cai: Epilepsy.. ----- -------- ■ .lacksonian epilepsy---------- Neurasthenia------........... Enuresis___.....---------------- Neurosis____.......-------------- Neurocirculatory asthenia-------- Shell-shock (cause not given)----- Chorea_______*----------------- Hysteria and results-------------- Neuralgia_______________________ Neuritis_________________________ Speech, defective______ --------- Nervous system (other diseases of). (Jeneral paralysis of the insane---- Constitutional psychopathic states. Mental deficiency________________ Malingering........-------------- Dementia prsecox..........-------- Psychasthenia______......---'----- Psychoneurosis___________________ Psychosis: Alcoholic_____................. Manic-depressive............... Others_________...........---- Total U. S. Army (excepting native troops) Offi- cers Enlisted men White Total officers and Colored Total eni!!led men U. S. Army in United States 0.00 .02 .03 .04 .03 .03 .05 .03 .05 .05 .08 .09 .09 .08 .04 . 10 .05 .04 .01 .02 .01 .01 .01 .02 .01 .01 .09 . 10 .10 .09 1.30 2.35 1.38 1.32 .01 .03 .01 .01 .58 .30 .57 .55 .18 .24 .19 .18 .04 .07 .04 .04 .43 .91 .47 .45 .02 .02 .02 .04 .02 .04 .04 .53 .64 .55 .52 .01 .00 .01 .01 .15 1.13 .22 .22 .04 .06 .04 .04 .13 .09 .13 .12 .05 .06 .05 .05 .98 .43 .95 .91 2.52 5.26 2.74 2.60 .00 .00 .00 1.48 1.20 1.48 1.41 .09 .01 .08 .08 .67 .56 .67 .64 .05 .01 .05 .04 .42 .41 .43 .42 .26 .31 .27 .26 Offi- cers 0.00 | 0.01 .02 Enlisted men U.S. Army in Europe (excluding Russia) Enlisted men Total ____ officers j and White Colored Total [enm|ne<1 CHAPTER IX ANALYSIS OF SPECIAL NEUROPSYCHIATRIC REPORTS The neuropsychiatric statistics here considered were prepared with little reference to the number of men examined. In the following pages estimates as to this number are made, but these are merely estimates. Complete reports as to the number examined were not received. The reported total number of men with neuropsychiatric conditions who entered the military service can not be considered the correct number, as it has already been shown that the neuro- psychiatric examination was not given to all of the first increments of drafted men reporting at the camps. Further, many officers and the majority of those who served in the Students' Army Training Corps and the National Guard were not examined. After a careful consideration of all the facts, the total DIAGNOSES NO. CASES PER CENT 5 10 15 20 25 30 MENTAL DEFICIENCY 21,856 31.5 PSYCHONEUROSIS 1 1,443 16.5 PSYCHOSIS 7,910 11.4 NERVOUS DISEASES AND INJURIES 6,916 10.0 EPILEPSY 6,388 9.2 CONSTITUTIONAL PSY-CHOPATHIC STATES 6,196 8.9 ENDOCRINOPATHIES 4,8 05 6.9 DRUG ADDICTION 2,020 2.9 ALCOHOLISM 1,858 2 .7 ^ TOTAL 69,394 100.0 Chart I.—Diagnoses of neuropsychiatric cases (home forces) number who underwent this special examination is placed at approximately 3,500,000. Unless otherwise stated, all percentages given in this chapter refer to the total number of neuropsychiatric cases considered—69,394. For example, as shown in Chart I, of the total number of neuropsychiatric cases identified in the Army in the United States and available for classification, 21,858, or 31.5 per cent, were of mental deficiency, and 11,443, or 16.5 per cent, were of psycho- neuroses. In certain of the tables which have been prepared the statistics established how the different conditions were distributed and, referring to States, for example, the percentage given shows the proportion of any given condition of the total neuropsychiatric conditions found among the residents of the State. As concerns races, the percentage is in reference to the total of neuropsychiatric disorders found among the members of a race, whether American born or foreign born. From the foregoing statements it is evident that such percentages can not be regarded as indicative of the actual frequency of a condition in the total 157 158 NEUROPSYCHIATRY number of men examined or in the representatives of either States or races. Further, as concerns the drafted men of the Army, the neuropsychiatric examina- tions were made only of those men who had been passed by the local examining boards under the provisions of the selective service act. The number of neuropsychiatric cases found among the quotas which arrived at the camps depended upon the thoroughness of the examination by local boards. The character of the examination varied with different boards, and also at different periods of the mobilization, with the changing orders which were issued from time to time relative to the standards for rejection and classification. In order that one may understand in what degree the num- ber of diagnoses of certain conditions made by the neuropsychiatric officers in camps corresponded with the rate of rejections for the same conditions by the local boards in various States, Table 5 was prepared. This table was com- piled from the statistics given in Defects Found in Drafted Men,1 and affords information in respect to a few of the more important clinical groups in which the classification adopted by the Provost Marshal General corresponds with that used herein. Table 5.—Neuropsychiatric defects noted in the total number of men rejected (549,099) by local boards in the different States. Rates per 1,000 Alabama___________ Arizona____________ Arkansas__________ California......__..... Colorado___________ Connecticut.....____ Delaware-.......____ District of Columbia.. Florida____________ Georgia_____........ Idaho_____________ Illinois_____......... Indiana_____........ Iowa______________ Kansas____________ Kentucky__________ Louisiana__________ Maine___......_____ Maryland......_____ Massachusetts______ Michigan__________ Minnesota_________ Mississippi_________ Missouri___________ Montana___________ Nebraska__________ Nevada...........___ New Hampshire...... Men- tal defi- ciency Epi- lepsy 1.99 .95 2.58 3.54 3.27 4.15 1.36 2.78 2.78 2.17 2.12 3.03 4.01 3.55 2.31 3.47 3.44 4.45 6.03 3.74 2.67 2.53 2.50 3.49 1.74 1.96 2.07 3.58 Drug addic- tion 0.05 .35 .01 .64 .20 .16 .27 .07 .11 .14 .06 .06 .06 .03 .10 .10 .12 .23 .09 .06 .16 .02 .15 .05 .10 .21 Con- stitu- tional psy- cho- pathic states 0.08 .09 .07 .22 .07 .06 .28 .14 ,09 .27 .07 .12 .05 .06 .10 .08 .64 .14 .21 .11 .05 .12 Alco- hol- ism 0.01 .38 .07 .26 .14 .14 States Men- tal defi- ciency .06 ."is" New Jersey__________ New Mexico_________ New York__________ North Carolina______ North Dakota_______ Ohio........_________ Oklahoma___________ Oregon_____________ Pennsylvania________ Rhode Island________ South Carolina______ South Dakota_______ Tennessee___________ Texas_______________ Utah_______________ Vermont____________ Virginia____________ Washington_________ West Virginia________ Wisconsin___________ Wyoming......______ Total United States rate per thousand, draft boards and camps___..... United States average.. 6.14 10.52 7.26 14.03 7.61 9.95 9.24 6.55 8.04 13.44 11. 18 11.34 15.32 8.42 5.95 27.13 13.72 6.94 6.84 9.70 2.40 14.45 8.94 Fni- Drug 2.63 2.76 3.92 3.72 2.03 3.99 3.08 2.40 3.55 6.03 2.76 .79 3.36 3.82 2.50 10.18 4.25 2.96 2.59 2.84 5.15 3.29 0.20 .14 .48 .05 .04 .09 .17 .04 .17 1.05 .10 ,15 .14 .31 .10 .10 .49 .03 .03 .54 .16 Con- stitu- tional psy- cho- pathic states Alco hol- ism 0.07 0.21 .20 .30 .18 .04 .01 .14 .07 .19 .10 .04 .01 .04 .18 .13 .33 1.18 .02 .07 .20 .14 .03 .04 .38 .40 .30 .13 .01 .04 .12 .14 .20 .55 .15 In general, a low rate of rejections by local boards corresponds with a small number of cases found at the camps. For example, in the examination of men from Florida, the neuropsychiatric distribution average for mental defect was far below that of most of the other Southern States. This might be explained by the Florida local boards being unusually on the alert for mental defect, thus leaving fewer cases to be detected at the camps. Such was not the IX THE UNITED STATES 159 case, however, as both local boards and neuropsychiatrists reported a below- average of mental defect in Florida. On the other hand, such correspondence between the findings of the local boards and the neuropsychiatrists was not invariable. For example, Nevada, with a none per thousand local board rejection for alcoholism, showed the highest neuropsychiatric distribution average for alcoholism of any State (see Table 42), although the actual number of cases was small. The totals in all tables refer to diagnosis exclusively. The diagnoses form the basis of the statistics quite independently of any recommendation or action affecting the status of the soldier. That is, any individual in whom a diagnosis of neuropsychiatric disease was made and reported on Form 90 M. D. (see p. 14) is considered in the discussion which follows, irrespective of whether he was discharged from, or retained in, the Army. In some of the tables herein, in which the information is discussed in detail under subheads, the totals are not always uniform for the reason that in some of the different items the total of information was not constant. In the consideration of many items, such as family history, preexistence of venereal disease, and alcoholic habits, the information is based upon the answers the enlisted men gave to questions asked them. Whenever possible their statements, especially as to personal history, were verified by correspond- ence with institutions, family physicians, and relatives. The facts as given are regarded as substantially correct. Drafted men, as a class, seemed truth- ful; the motives for deception were not strong, and attempts to deceive could generally be foiled. Again, in dealing with such large numbers, misstatements tend to balance. The compilations of the statistics as they became available at different periods were quite uniform. Thus the percentages established when 600,000 men had been examined were practically identical with those which covered the examination of 3,500,000. Throughout, also, there was a remark- able uniformity of the information obtained by the examiners at different stations. In general it may be said that the present study furnishes many facts hitherto unknown concerning nervous and mental disease and defect occurring in a large group of individuals, or in certain selected smaller groups, all among males of a given age period. The neuropsychiatric disabilities of volunteers and drafted men are compared; of white and colored; of several races, both foreign and native born. Important information is furnished as to the length of service to be expected from men suffering from the different defects; the date of onset of such defects; the family history, age, education, home environ- ment, marital and economic conditions, and alcoholic habits of those under consideration. It must be borne in mind throughout that the cases are discussed as groups and that the facts and conclusions given apply only to the group under consideration. DISTRIBUTION OF CASES (OFFICERS AND ENLISTED MEN) The distribution of the cases considered in this series among officers, candidates for commission, and enlisted men is shown in Table 6. Assuming 3,500.000 as the total number examined, it is found that about 20 out of every 160 NEUROPSYCHIATRY 1.000 were discovered to have some form of mental or nervous disease or defect. The distribution of the cases among the military personnel was: '_'_'___________ 5K7 (»S, 274 Officers___________________ Candidates for commission. Enlisted men_____________ Total____________________________________________ ™<-m OFFICERS AND CANDIDATES FOR COMMISSION It was not possible to make accurate determinations of the number of officers and candidates for commission examined by neuropsychiatrists, except in officers' training camps which were in operation subsequent to the summer of 1917, no routine psychiatric examinations having been prescribed for this class of personnel. The high percentage of defects found among those attending the officers' training camps is startling. These conditions were discovered during the routine examinations conducted at certain of the officers' training camps. A greater number of candidates for commission were eliminated at these few camps by reason of neuropsychiatric disease than among the entire officer personnel throughout the United States. It is certain that if all candidates for commission had been subjected to a thorough neuropsychiatric examination before being ac- cepted many would have been rejected with advantage to the military service. It was probably the outstanding defect of the neuropsychiatric service during the war that so many individuals were commissioned and given positions of military responsibility without a determination of their mental and nervous fitness therefor. Table 6.—Diagnoses of nervous and mental diseases and defects among commissioned officers, candidates for commission, and enlisted men Diagnoses Mental deficiency. Imbecile____________ Moron____.......___ Border-line condition... Degree not determined. Psychoneuroses__________ Anxiety neuroses____ Angioneuredema___ Compulsion neurosis. Enuresis__________ Hysteria__________ Migraine__________ Neurasthenia______ Psychasthenia_____ Stammering_______ Traumatic neurosis.. Undiagnosed_______ Total White Total Commis-sioned officers Candi-dates for commis-sion Enlisted men Colored, total 21,858 17, 803 7 17, 796 4,055 6,817 4,881 11,215 846 861 4,881 11,208 846 861 1,936 13, 242 7 2,027 880 34 919 58 11,443 10,343 166 124 10,053 1,100 89 3 88 3 2 466 3,220 178 3,800 1,079 993 175 339 3 1 1 84 2 2 465 3,180 175 3,659 1,020 991 174 301 1 2 497 3,648 181 3,982 1,118 1,343 1 22 1 90 40 18 2 51 19 2 31 428 3 182 39 350 219 1 44 361 31 22 IN THE UNITED STATES 161 Table 6.—Diagnoses of nervous and mental diseases and defects among commissioned officers candidates for commission, and enlisted men—Continued Diagnoses Traumatic. Senile____ With cerebral arteriosclerosis____________ General paralysis______________________ With cerebral syphilis__________________ With Huntington's chorea........._______ With brain tumor_____________________ With other brain or nervous diseases_____ Alcoholic_____________________________ Drug and toxic________________________ With pellagra_________________________ With other somatic diseases_____________ Manic-depressive________....._________ Involution melancholia_________________ Dementia praecox______________________ Paranoia and paranoid conditions________ With mental deficiency_________________ With constitutional psychopathic inferioriO E pileptic____________________________' Undiagnosed__________________________ Nervous diseases and injuries______ Arteriosclerosis______.......... Ataxia: (a) Friedreich's___________ (6) Marie's______________ Atrophy.......______________ Beriberi______.............___ Brain: Abscess of_______*_______ Tumor of________.......... Chorea_____________________ Combined sclerosis___________ Dercum's disease_____________ Ear disease__________________ Erythromelalgia_____________ Hemiplegia____________....... Hematomyelia_______________ Hemorrhage, cerebral_________ Herpes zoster________________ Hydrocephalus______......___ Injury: (a) Brain________._______ (6) Spinal cord......______ (c) Peripheral nerve_______ Lateral sclerosis................. Little's disease_______.......... Meniere's disease______......... Meningitis.......______........ Multiple sclerosis_______....... Myasthenia gravis____________ Myelitis____________________ Myotonia congenita......_____ Neuralgia___________________ Neuritis......_______________ Neurofibromatosis.......______ Paralysis agitans_____________ Paramyoclonus multiplex....... Paralysis____________________ Paraplegia____________........ Pes planus___________________ Plumbism___________________ Poliomyelitis_________________ Progressive muscular atrophy... Progressive muscular dystrophy. Radiculitis_____________......- Retinitis.....___________..... Raynaud's disease____________ Sciatica______......__________ Syphilis C. N. S..........._____ Syringomyelia_________........ Tabes dorsalis________________ Tetanus_____......_____....... Tetany______________________ Thrombosis cerebral___________ Tics..........________________ Torticollis________......______ Tremor___________............. Vagatonia___.....___________ Undiagnosed_____........----- Total White Total Commis-sioned officers Candi-dates for commis-sion Enlisted men Colored, total 7,910 7, 354 3s 12 4 487 33 1 J 287 36 33 92 1,304 3 4,433 4s 100 64 112 264 14S 71 7,135 556 51 12 4 530 44 1 1 2 17 2 37 5 1 458 29 1 1 2 283 32 33 81 1,214 1 4,394 44 100 57 112 250 13 1 12 2 43 11 1 2 292 45 37 4 2 2 9 4 109 1,385 3 4, 73S 113 8 64 24 3 3 26 15 1 17 81 305 4 13 66 7 131 19 294 12 2 30 6,916 6,116 100 147 5,869 800 41 41 4 4 52 1 8 27 252 3 1 2 1 210 3 16 2 12 245 33 150 21 2 3 242 483 4 27 17 4 213 3 16 3 282 28 22 12 191 58 14 1 1 8 127 2,161 16 294 2 10 14 17 4 4 50 1 8 26 252 3 1 1 1 203 3 15 2 12 240 32 147 21 2 3 239 476 4 27 17 4 207 3 16 3 277 27 22 12 186 56 14 1 1 8 122 2,085 16 256 2 4 4 55 1 9 27 264 3 1 2 1 258 3 17 2 13 337 39 178 24 2 3 279 511 4 32 17 5 222 3 18 3 340 34 23 13 211 61 15 1 I 137 2,462 17 333 2 1 5 200 34 243 16 377 ________ 2 3 1 1 12 1 5 2 48 1 ] 1 3 1 3 2 92 6 28 3 2 4 1 3 37 28 1 6 9 9 3 1 2 5N 6 1 1 4 1 1 1 20 3 1 5 26 10 50 301 1 11 27 39 4 183 27 212 16 352 4 176 26 208 15 311 1 6 1 4 1 29 17 31 12 25 162 NEUROPSYCHIATRY Table t>.—Diagnoses of nervous and mental diseases and defects among commissioned officers, candidates for commission, and enlisted men—Continued Diagnoses Epilepsy...................------ Constitutional psychopathic states Criminalism----------------- Emotional instability________ Inadequate personality------- Nomadism__________________ Paranoid personality--------- Pathological liar_________..... Sexual psychopathy---------- Undiagnosed----------....... Endocrinopathies.......-------- (a) Achondroplasia------..... (6) Adrenal_________________ (c) Gonad__________.....____ (d) Neurocirculatory asthenia. (e) Pituitary________________ (/) Thyroid.....____________ (j) Polyglandular______...... Drug addiction_________________ Alcoholism......._______......... Grand total.......________ Total White Enlisted men Total Commis-sioned officers Candi-dates for commis-sion Colored, total 6,388» 5, 273 9 14 5,250 1,115 6,196 5,941 65 168 5,708 255 323 1,915 2,594 28 388 28 190 730 306 1,835 2,500 28 378 27 171 696 1 21 21 305 1,739 2,446 28 360 26 165 639 17 75 33 80 94 9 1 2 10 9 10 1 4 47 19 34 4,805 4,506 17 52 4. 437 299 2 6 16 50 205 4,501 25 2 6 15 35 186 4,239 23 2 6 15 35 184 4,172 23 1 15 2 50 19 17 262 2 2,020 1,858 1,823 1,834 20 8 1, 803 1,825 197 1 24 69, 394 60,993 533 584 59, 876 • 8, 401 All enlisted men except 3, who were members of the Officers' Training Corps. RATIO PER IOOO MEN 5 10 15 20 25 VOLUNTEERS FOR SECOND O.T.C. 27 VOLUNTEER RECRUITS 25 DRAFTED RECRUITS 17 Chart II—Ratio of neuropsychiatric cases found among volunteers and drafted men examined by neuropsychiatrists ENLISTED MEN The predominance of mental and nervous defects among men who volun- teered as compared with those who were drafted is shown in Table 7 and Chart II. The cases considered were collected from reports which showed definitely the number of men examined in each of the groups referred to, and how many of these had neuropsychiatric defects. While the number here considered is far less than the total, the results are regarded as typical for the entire series. In this connection it is noteworthy that many neurospychiatric patients who might otherwise have entered through the draft had already been sifted out by the local board examinations. Xo such preliminary elimination had occurred among those enlisting voluntarily. Table 7 also shows the distribution of neuropsychiatric disorders among volunteers to be different from that in the Army as a whole. Those applying for voluntary enlistment show proportionately fewer mental defectives and drug addicts, and many more alcoholics. IN THE UNITED STATES 163 Table 7.—Neuropsychiatric cases found among volunteers at recruit depots, and drafted men, by clinical groups Number of neuropsychiatric cases Number of men examined 81, 881 626, 825 Total Mental Psycho-cases deficiency | neuroses Psychoses Nervous diseases or injuries Constitu-1 tional n * sarins* states Alcohol-ism 2,066 413 108 138 6.S2 , 232 4S0 13 10,812 3,952 1,681 453 | 3,356 | 750 i 99 521 Total......________ 708, 706 12,87s 4,365 1,789 591 i 4.038 982 579 534 METHODS OF DISCOVERING CASES The neuropsychiatric cases which comprise the present series came under the observation of the neuropsychiatrist through five sources (Table 8): (1) Dur- ing the routine examination of all men on their arrival at a mobilization camp; (2) reference by other medical officers; (3) reference by commanding officers of organizations; (4) reference by psychologists; (5) reference by a court-martial or in connection with delinquency. More cases were detected by the neuropsychiatrists during the preliminary physical examination than in any other manner, 27,836 cases, or 40.1 per cent of the total number reported, having been discovered in this way. Cases referred by other medical officers are regarded as consultation oases. The cooperation of line officers was generally secured through talks given to them by the neuropsychiatrists. Their attention was invited to those particular traits which might indicate mental abnormality; and they were requested to refer to neuropsychiatrists, men in whom such characteristics were noted, for special examination. The success attending these efforts is indicated in the 16,336 positive cases which came to light through this channel. One of the striking features of Chart III is the small number of cases reported as referred by the psychologists. Several explanations may be offered for this. As the psychological group examinations were conducted after the physical examinations were completed the greater number of cases of mental deficiency were discovered before the psychological examination began. Another explanation is, that many of the soldiers who received low grades in the psy- chological tests were sent to the development battalions where they were given an apportunity to display their ability. If their service was unsatisfactory they were later referred to the neuropsychiatrists by the commanding officers or surgeons of the organizations to which attached. Final recommendations in such cases were made, not alone upon failure to be placed in a particular psychological group, but upon failure to get along properly under training as well. . u , Whenever possible a psychologist was assigned to duty with the neuro- psychiatric board for the purpose of conducting individual psychological examinations of men referred to them by the neuropsychiatrists. Their serv- ices were highly esteemed. Psychological ratings were thereby established, and the time of medical officers was economized. 42705—29---12 164 NEUROPSYCHIATRY Table S.—Methods of discovering neuropsychiatric case Diagnoses Mental deficiency... ...21,858 17.803 7,271 5,046 4, 525 294 Psychoneuroses_______________11, 443 10. 343 3, 540 3, 882 2, 594 38 Psychoses___________________ 7,910 General paralysis Alcoholic......____ Manic-depressive... Dementia praecox__________ 4, 73* Epileptic___.....__________! 131 Other forms______________i 834 Xervous diseases and injuries 0 horea_______________ Hemiplegia Injuries to nervous system Meningitis Multiple sclerosis Neuritis________ Paralysis_______ Poliomyelitis Sciatica____ Syphilis C N. S___________i 2,462 Tabes dorsalis........______j 333 Tic......_________________ 200 Tremor__________________| 243 Other forms Epilepsy_______ Constitutional states________ E ndocringpathies Drug addiction Alcoholism Total.... ...169,39460,99324,230119,652114,454, 440 225| 1,992 8,401 or, i- 1(0 Jog (0>H o «0_l z< (OOO 0O3tt >(V|(OLJ IO 0> Z I _:--Ol- n (M OO 69,394 NEUROPSYCHIATRIC CASES NUMBER OF NEUROPSYCHIATRIC CASES DISCOVERED BY DIFFERENT METHODS Chart III IX THE UNITED STATES 165 DELINQUENCY The number of cases brought to the attention of neuropsychiatric examiners by reason of misconduct was small. Out of the total of 69,394 neuropsychi- atric oases there were only 1,498 (see Chart IV) which were referred by reason of delinquency. So small a representation of misconduct from a group of disorders of which the symptoms are primarly behavioristic contradicts civil experience. This contradiction may be interpreted in two ways. The first is that at the entrance examinations the neuropsychiatric officers detected most of the mentally irresponsible who were likely to turn out to be "bad actors," and succeeded in having them kept out of the Army. Such an interpretation is borne out by the unexpectedly low delinquency rate reported throughout the Army, both in this country and overseas. But even this interpretation Chart IV7 does not altogether account for the low delinquency rate found among the neuropsychiatric cases. The conclusion can not be avoided that more mis- conduct cases would have been identified had there been a more thorough neuropsychiatric examination of all offenders prior to their trails by courts- martial. Such a view is borne out by the fact that of the 1,498 cases of mis- conduct, 575, or more than one-third, were reported from the Fort Leaven- worth Disciplinary Barracks. In other words, the true nature of one-third of those cases was recognized, not as it should have been, at the point where the offense was committed, but at the point to which the individual had been sent after court-martial, for reformation or punishment. With only 923 reported from all mobilized troops, it is evident from all previous experience with delinquency and mental irresponsibility, that many irresponsible soldiers were treated as delinquents. 166 NEUROPSYCHIATRY Table 9. — Delinquency cases in each clinical group Clinical groups Psychoses______......_________ Constitutional psychopathic states________......_________ Mental deficiency_____________ Alcoholism_____................ Drug addiction__________^____. Num- ! ber of Num- Per neuro- ber of cent psychi- delin- delin- ;| atric quent quent cases 5. 1 7,910 404 6, 190 272 4.4 21, 858 633 2.9 1,858 24 1.3 2,020 21 1.0 Clinical groups Num- ber of neuro- psych i- atric cases Epilepsy_______________________j 6. 38s Psychoneuroses......_...........j 11. 443 Nervous diseases and injuries___ 6.916 Endocrinopathies___............ 4, 805 Total...........__________| 69,394 Num- ber of delin- quent Per cent delin- quent CLINICAL CLASSIFICATION The neuropsychiatric examiners were instructed by the Surgeon General to use the following diagnostic terms in reference to classification:" CLASSIFICATION OF DISEASES, INJURIES AND DEFECTS I. Mental deficiency: Imbecile. Moron. Border-line condition. II. Psychoneuroses: Enuresis. Hysteria. Neurasthenia. Psychasthenia. Stammering. Other forms (specify). Undiagnosed. III. Psychoses: In designating the mental disease on the statistical card, the group and type of the psychosis will be given whenever possible. 1. Traumatic psychoses. 2. Senile psychoses. 3. Psychoses with cerebral arteriosclerosis. 4. General paralysis. 5. Psychoses with cerebral syphilis. 6. Psychoses with Huntington's chorea. 7. Psychoses with brain tumor. 8. Psychoses with other brain or nervous diseases (specify when possible). 9. Alcoholic psychoses. (a) Pathological intoxication. (b) Delirium tremens. (c) Acute hallucinosis. (d) Korsakow's psychosis. (e) Chronic paranoid type. (/) Other types, acute or chronic. 1.0. Psychoses due to drugs and other exogenous toxins. (a) Morphine, cocaine, bromides, chloral, etc., alone or combined (to be spec'ified). Metals, as lead, arsenic, etc. (to be specified). Gases (to be specified). Other exogenous toxins (to be specified). (b) (c) (d) 11. Psychoses with pellagra. • The classification of mental diseases is the one adopted in May Association, now the American Psychiatric Association. 1917, by the American Medico-Psychological IN THE UNITED STATES III. Psychoses—Continued. 12. Psychoses with other somatic diseases (specify disease). 13. Manic-depressive psychoses. (a) Manic type. (b) Depressive type. (c) Stupor. (d) Mixed type. (e) Circular type. 14. Involution melancholia. 15. Dementia prsecox. (a) Paranoid type. (b) Catatonic type. (c) Hebephrenic type. (d) Simple type. 16. Paranoia and paranoid conditions. 17. Psychoses with mental deficiency. 18. Psychoses with constitutional psychopathic inferiority. 19. Epileptic psychoses. 20. Undiagnosed psychoses. IV. Nervous diseases and injuries: Abscess— Brain (specify location). Spinal cord (specify location). Arteriosclerosis— Cerebral. General. Spinal. Beriberi. Bulbar palsy. Chorea. Combined sclerosis. Ear disease. Embolism and thrombosis. Eye diseases. Facial palsy. Hemorrhage (specify location). Herpes zoster. Hydrocephalus. Injury (specify kind)— Brain (specify location). Spinal cord (specify location). Peripheral nerve (specify nerve). Lateral sclerosis. Lumbago. Meniere's disease. Meningitis— Cerebrospinal. Tuberculous. Other forms (specify). Migraine. Multiple sclerosis (disseminated sclerosis). Myasthenia gravis. Myelitis— Transverse. Traumatic. Myotonia congenita (Thomsen's disease). Neuralgia (specify nerve). 168 NEUROPSYCHIATRY IV. Nervous diseases and injuries—Continued. Injury (specify kind)—Continued. Neuritis (specify nerve)— Diphtheritic. Multiple- Alcoholic. Traumatic. Other forms. Pachymeningitis cervicalis. Paralysis agitans. Paramyoclonus multiplex. Pes planus. Plumbism. Poliomyelitis. Progressive muscular atrophy. Progressive muscular dystrophies. Sciatica. Syphilis of central nervous system. Syringomyelia. Tabes dorsalis (locomotor ataxia). Tics. Torticollis. Tremor— Chronic progressive. Brain (specify location). Spinal cord. Peripheral nerve (specify nerve). Vagotonia. Undiagnosed. Conditions secondary to other diseases- Aphasia. Bulbar syndrome. Hemiplegia. Jackson's syndrome. Optic atrophy. Paraplegia. V. Constitutional psychopathic states: Criminalism. Emotional instability. Inadequate personality. Nomadism. Paranoid. Pathological liar. Sexual psychopathy. Other forms (specify). Undiagnosed. VI. Epilepsy: Idiopathic. Ja'cksonian. VII. Endocrinopathies: Achondroplasia. Adrenal. Gonad. Neurocirculatory asthenia. Pituitary. Polyglandular. VIII. Drug addiction. IX. Alcoholism. IN THE UNITED STATES 169 The number of cases concerned was so large that the assembled material may be accepted as representing every variety of nervous and mental disease or defect occurring in men in the given age period in the United States. Larger collections of statistics concerning individual conditions exist, but none dealing with the whole subject of neuropsychiatry are known which parallel the present series. They furnish a complete compilation, not only of disorders which affect conduct primarily, such as the psychoses and the constitutional psychopathic states, but also the organic and functional disorders which affect the nervous sys- tem in structure and function. To divide the diagnoses into distinct groups was not difficult, and it is be- lieved that the several groups represent essentially different conditions, not only in regard to origin, but also as to characteristics, management, and other factors. The fringes of each group overlap, observable especially in the merging into each other of such con- ditions as are without definite physical symptoms. Under such circumstances the diagnosis and group assignment were made on the basis of the major disability. There was some question as to the proper group assignment of the 292 cases of alcoholic psychoses. (See Table 6.) These disorders, being induced by alcohol, belong to the alco- holism group, but any discussion of the psychoses must also include them. So they belong to both groups. They are counted with the psychoses in the general clinical classification and in the tables; but in the itemized infor- mation concerning the psychoses and alcoholism, they appear in both places. Similarly there were placed under psy- choses 45 cases of "drug and other toxic psychoses." Of these no further account is made. The numbers finally placed in each group are shown in Table 6. The order of arrangement established in Table 6 is the order followed through- out this chapter. LENGTH OF SERVICE The neuropsychiatric examinations, except those made of the men of the first draft and the men in the National Guard and the Regular Army, were con- ducted eventually as a part of the routine physical examination given the men upon arrival at a mobilization camp. As a result of this system, most of the individuals who were rejected left the service before the Government had pro- ceeded to any great length with their military training. Information as to how long the men of this series were in service prior to discovery was obtained 60 — 50- 5 2.6 •/. LENGTH OF SERVICE OF 66,759 NEUROPSYCHIATRIC CASES (home forces) 40- DATA UNASCERTAINED FOR 263S CASES 1-z y 30-a. u a. 20- 22.1 V. 10- 12.0V 8.3 V. 3.3 V. 1.7 % LENSTH OF SERVICE LESS 1- 3 MONTHS 3-6 MONTHS »-l2 MONTHS 1 - 2 YEARS OVER 2 YEARS NUMBER OF CASES 35123 14770 8019 5512 2168 1167 170 NEUROPSYCHIATRY for all but 2,635 cases. (Chart V.) Of the number for which the data were obtained, 52.6 per cent of all cases were discovered before they had been in the service one month, and 74.7 per cent wore discovered before they had been in the Army three months, 86.7 per cent of all cases wore identified before the expira- tion of six months, which was the average training period before men went over- seas. The period of service for the entire group of cases would have been reduced considerably if the final perfected system of conducting neuropsychiatric examinations had been in operation at the time the first draft went to camp. The men who were not examined immediately were given neuropsychiatric examinations by special boards after their training was started; in some instances the delay reached three months. Eliminating the cases found in this delayed group, which numbered about 13,000, the conclusion that most neuro- psychiatric cases can be found by experienced neuropsychiatrists in one month does not seem to be unreasonable. Table 10.—Length of service of neuropsychiatric cases prior to discovery Diagnoses Mental deficiency. -........------ Psychoneuroses___...........___ Psychoses__________.........---- General paralysis___.......... Alcoholic____________________ Manic-depressive____________ Dementia praecox......______ Epileptic____________________ Other forms........__________ Nervous diseases and injuries_____ C horea______________________ Hemiplegia__________________ Injury to nervous system_____ Meningitis......____________ Multiple sclerosis____________ Neuritis. _.......____________ Paralysis____________________ Poliomyelitis________________ Sciatica_________________ Syphilis C. N. S_____________ Tabes dorsalis_______________ Tic_________________________ Tremor_____________________ Other forms......____________ Epilepsy________________________ Constitutional psychopathic states Endocrinopathies________________ Drug addiction__________________ Alcoholism______________________ Total.........____________ Total 21, 858 11,443 7,910 530 292 1,385 4,738 131 834 6,916 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 c. 3ss 6, 196 4, 805 2,020 1,858 69, 394 White Total 17, 803 10,343 Under 1 month 9,212 4,516 i Over 1 to 3 4 to 6 7 to 12 1 year Over months|months months to 2 2 years years 3, 753 2,510 2,178 1,403 1,320 1,039 377 411 7,354 487 287 1,304 4,433 112 731 6,116 252 210 428 242 483 213 282 191 127 2,161 294 183 212 838 2,522 1,773 1, 299 163 445 1,352 44 219 56 42 315 1,146 34 180 38 11 186 741 11 112 28 23 161 592 9 82 3,312 1,114 5,273 5,941 4,506 1,823 1,834 60, 993 137 118 226 77 313 62 146 129 34 1,199 191 95 155 430 51 40 73 37 76 54 68 31 31 356 39 48 31 179 2,624 2,246 2,994 1,165 1,287 1,363 1,484 722 254 101 29,87s | 13,074 21 22 51 34 36 35 29 15 19 169 12 17 13 81 354 139 102 7, 285 29 16 37 54 26 32 16 10 17 175 18 8 3 59 9 20 78 271 4 53 343 701 227 74 106 5,205 145 294 95 41 90 2,102 Un- ascer- tained 99 209 293 123 5 40 337 15 11 53 11 6 11 6 1 7 108 15 10 f] 35 65 185 133 175 27 >n7 28 122 68 1 MJ 1,107 2,342 IN THE UNITED STATES 171 Table 10.—Length of service of neuropsychiatric causes prior to discovery— Continued Colored Diagnoses Total Under 1 month 2, 496 688 1 to 3 months 781 233 4 to 6 months 7 to 12 months Over 1 year to 2 years Over 2 years Un-ascer-tained Mental deficiency_____________________ 4,055 1,100 438 85 120 49 29 12 19 6 27 556 249 177 47 43 8 14 18 ('■eneral paralysis________.....__________ 43 5 81 305 19 103 22 4 35 138 8 42 13 1 28 90 38 2 1 1 4 Alcoholic____.........._____________ 28 3 7 6 31 1 5 1 6 1 2 3 7 Epileptic----------------- ______________________ Other forms_________________...... 5 1 --"" Nervous diseases and injuries . ... __ ..... 800 520 122 64 43 11 13 27 Chorea.....____.. ________ _________....... 12 48 126 37 28 9 58 20 10 301 39 17 31 64 11 36 80 26 19 2 41 15 182 26 13 25 39 8 23 2 6 3 9 o i 47 2 3 9 1 1 8 3 3 3 2 3 25 2 1 12 Hemiplegia_____________________________________ 1 2 Injury to nervous svstem__________...... 6 5 Meningitis. _ . ... _________________ _ ._ _ ... 1 Multiple sclerosis______________.....______....... 2 2 1 1 1 Poliomyelitis_________ __________________________ Sciatica.______ .._____________________ __...... Syphilis C. N. S________________________........ 23 2 7 : Tic_________......______________________________ Tremor_________________________________________ 1 ---- i i •; 1,115 255 299 197 24 713 151 241 167 20 267 59 39 16 2 74 22 3 1 30 14 7 3 2 1 i 3 3 1 27 4 Endocrinopathies....... .... .. _______ ... 8 10 Alcoholism____________.........-------------------- 1 Total_________________________________________ N. 401 5, 245 1.696 734 307 66 60 293 LINE OF DUTY It appears, as far as the determination by medical officers is concerned, that 96.1 per cent of the cases discovered did not have a disability which arose in line of duty; that is, the disability was not due to service in the Army. In only 2.8 per cent was "in line of duty" established. (See Table 11.) As most of the cases were considered as "not in line of duty" the date of onset of the disease is of little importance from a military point of view, but the records contain important clinical data, especially as to the essential chronicity of nervous and mental disorders. 172 NEUROPSYCHIATRY 90-1 8 0- 70- 60 50- \- Z u u C£ UJ °- 40- 30- 20- 10- 8 4.2% TIME OF ONSET OF DISEASE BEFORE ENTERING SERVICE______ 50,042 NEUROPSYCHIATRIC CASES HOME FORCES DATA UNASCERTAINED FOR 16,6 2 4 CASES 13.1% 0- 8% 0.4% 0.4% TIME UNDER 2 MOS. 2-3 MOS. 3-6 MOS. 6-12 MOS. 1-5 YRS. OVER 5 YRS. CASES 3 85 211 222 526 6567 42131 Chart VI Table 11.— Time of onset of neuropsychiatric disorders—line oj duty White Diagnoses Mental deficiency Psychoneuroses Psychoses_____ ... (ieneral paralysis Alcoholic.-. .Manic-depressive Dementia pnecox Epileptic.. Other form Nervous diseases and injurii Chorea.. Hemiplegia Injuries to nervous system Meningit is ... _ __'____ Multiple sclerosis... Neuritis Paralysi Poliomyelitis. _. Sciatica.. .... Syphilis C. N. S Tabes dorsalis Tic____________ Tremor________ Other forms________ Epilepsy______ ________ . _____ Constitutional psychopathic states Endocrinopathie Drug addiction- Alcoholism Total 00 Table 11.—Time of onset of neuropsychiatric disorders—line of duty—Continued Total 4,055 1,100 556 Total 4,055 1,071 508 •"Jot in line of duty In line of duty after en 6 to 12 months Diagnoses Time of onset prior to entering service Total Under 2 months Time of onse tering service (' nas-cer- Under 2 months 2 to 3 months 4 to 5 months 6 to 12 months 1 to 5 years Over 5 years Unas-cer-tained 2 to 3 months 4 to 5 months 1 to 5 years Over 5 years Unas-cer-tained lained Mental deficiency _ 4,055 668 147 10 7 6 2 4 16 14 177 95 190 242 25 44 9 10 5 3 5 2 1 4 Psychoses.. . .. 1 7 ~ 2 1 16 4 Oeneral paralysis 43 5 81 305 19 103 42 4 76 288 19 79 1 1 2 2 1 9 1 9 50 4 22 9 21 87 5 25 22 2 39 141 8 30 1 1 5 14 1 Alcoholic_____ 1 2 Manic-depressive_______ 2 1 3 7 2 1 1 2 3 1 1 3 1 Dementia pnvcox.. 1 l Epileptic________ _..... 3 1 23 7 4 3 1 8 Nervous diseases and injuries____ 800 762 12 5 10 19 209 323 184 35 6 13 4 7 1 4 3 (' horea_____________......... 12 48 126 37 28 9 58 20 10 301 39 17 31 64 12 47 121 29 28 4 51 18 10 301 39 16 30 56 1 19 49 10 13 2 14 4 3 73 10 21 46 15 9 1 23 12 4 107 15 13 16 31 1 5 13 1 5 1 113 17 1 15 183 89 45 44 8 Hemiplegia_________ _ ... 2 3 2 1 3 8 1 Injuries to nervous system___ 4 6 1 1 1 2 1 2 4 1 2 4 1 1 2 Meningitis___............... 2 Multiple sclerosis____________ Neuritis ..________ ____.. 5 2 1 3 2 2 1 1 1 1 1 " Paralysis .. _______....... 1 3 3 1 1 Sciatica____ _________ Syphilis U. N. S____......... 2 2 ' i 7 i Tic________........ 2 6 6 1 1 1 Tremor______________________ 2 1 1 1 1 1 1 ., 1 - * Epilepsy_____......._________ 1,115 255 299 197 24 1,111 255 299 196 24 ________ 1 i 6 6 163 12 86 34 1 752 154 164 117 15 3 1 1 | 1 Constitutional psychopathic states__________ . ____________ Endocrinopathies___ _________ --1 1 3 1 ----------!---------- Drug addiction__________........ i 1 Alcoholism ...__________________ ------r-.....-|------ i Total........... 8,401 8,281 29 15 1 21 59 777 6,395 985 107 26 26 13 14 5 1 22 13 IN THE UNITED STATES ] 75 RECOMMENDATIONS OF PSYCHIATRISTS AND DISPOSITION OF CASES Table 12 gives in detail the final disposition of the cases. Ninety-nine deaths were reported; 27 cases were absent without leave. These 126 cases RECOMMENDATION LIMITED SERVICE-8.3% 5,783 CASES DUTY 585 CASES 0.8% OBSERVATION & 3.6% TREATMENT 2,509 CASES DISCHARGE 87.2% 60,517 CASES DISPOSITION ✓ _ ' ■ o ? %,1D,ED 99CASES (AW0L27CASES 15.7% RETAINED 10,893 CASES 9.4 % UNREPORTED 6,498 CASES 74.8% DISCHARGED 51,877 CASES RECOMMENDATIONS AND FINAL DISPOSITIONS OF NEUROPSYCHIATRIC CASES Chart VII and the 10,893 cases represented as retained include 2,142 more cases than the number recommended for retention. Adding these 2,142 cases to the 6,498 (unreported) cases upon which no action was taken, it seems probable that 176 NEUROPSYCHIATRY 8,640 cases were retained which were at one time recommended for discharge by the neuropsychiatrists. In other words, 8,640 eases of nervous and mental diseases discovered in the United States were retained in the service while, in the opinion of neuropsychiatric officers, they should have been separated from it. Some light as to the wisdom of retaining cases of nervous and mental dis- eases in the Army, especially among troops destined to go overseas, is shown by the statistics of the nervous and mental cases reported from France. Between the dates of January 1, 1918, and July 1, 1919, the total number of cases of nervous and mental disease occurring in France and evacuated home, passed through General Hospital Xo. 214, A. E. F.2 The total number of them was 8,772, which is close correspondence between the number that the neuro- psychiatrists had recommended unavailingly to be prohibited from going to France. These figures do not include the cases which were treated in hospitals and returned to duty. Table 12.—Recommendations and final disposition of neuropsychiatric cases Disposition Diagnoses Mental deficiency_______________ Imbecile....._______________ Moron______________________ Border-line condition________ Degree not determined_______ Psychoneuroses......____________ Anxiety neuroses_____________ Angioneuredema_____________ Compulsion neurosis_________ Enuresis_____________________ Hysteria_____________.....___ Migraine____________________ Neurasthenia________________ Psychasthenia_______________ Stammering_________________ Traumatic neurosis___________ Undiagnosed____....._........ Psychoses_______________________ Traumatic___________________ Senile_______________________ With cerebral arteriosclerosis. _. General paralysis_____________ With cerebral syphilis________ With Huntington's chorea____ With brain tumor____________ With other brain or nervous dis- eases________________....... Alcoholic_______________...... Drug and toxic__________...... With pellagra________________ With other somatic diseases___ Manic-depressive_____......... Involution melancholia_______ Dementia praecox_____________ Paranoia and paranoid condi tions______________________ With mental deficiency____._ With constitutional psycho pathic inferiority_____ Epileptic___________________"" Undiagnosed___________ Absent without official leave Unre- ported 1,684 425 1,082 55 122 1,011 1 12 1 1 60 2 336 22 1 353 106 f>: 14 39 1,099 6 4 2 41 1 193 "709 IN THE UNITED STATES 177 Table 12.—Recommendations and final disposition of neuropsychiatric cases—Continued Total Total Recomi White Diagnoses nendations Disposition Dis-charge 5,292 Dut 29 Treat-*' ment Lim-ited serv-ice 354 Dier Dis-chargee Absent Re- withou tained' official leave 1,058 ; 4 Unre-ported Nervous diseases and injuries____ 6,916 6,116 441 1 1 28 4,530 496 Arteriosclerosis______ 41 4 4 55 1 9 27 264 3 1 2 1 25* 3 17 2 13 337 39 178 24 2 3 279 511 1 32 17 5 222 3 41 4 4 52 1 8 27 252 3 1 2 1 210 3 16 2 12 245 33 150 21 2 3 242 483 4 27 17 4 213 3 37 3 4 43 1 2 24 234 2 1 1 | 5|------- 1 _______ Ataxia: (a) Friedreich's..... 3 31 0 (6) Marie's_________ i 4 34 1 Atrophy____ Beriberi______ -- 3 " "o 12 i_______ 6 Brain: Abscess of________ 1 6 1 3 1 10 ------1------- ■* [ 2 i 22 2 Chorea. ... 1 Combined sclerosis. 2 1 26 _______ 20 1 Dercum's disease.. Erythromelalgia_____ ----- 1 1 10 1 1 1 24 2 ,-- .. Hematomyelia.. 192 1 13 1 9 3 1 165 13 ---- 2i Hemorrhage, cerebral____ 1 1 Herpes zoster_____ 1 _______ Hydrocephalus______ 9 188 24 99 19 2 3 154 469 3 20 17 3 34 2 24 2 1 1 165 21 74 15 2 1 125 440 3 Injury: (a) Brain__________ 1 1 1 22 26 1 (6) Spinal cord_____..... (c) Peripheral nerve______ Lateral sclerosis.. 57 2 _______ 18 _______I 4 Little's disease. Mfiniere's disease______ 1 88 21 Meningitis_______ 1 1 67 ,\ 1 20 5 6 _______ 23 1 21 Multiple sclerosis______ Myasthenia gravis. ________ Myelitis.. ______ 18 17 3 3 Myotonia congenita_____..... . ... Neuralgia_________ 3 100 1 9 1 Neuritis... ... 100 2 15 3 243 25 18 1 162 56 13 1 1 6 82 2,055 16 288 1 4 3 88 2 16 1 150 Neurofibromatosis_____ 1 Paralysis agitans___________ 18 16 ______1 i Paramyoclonus multiplex______ 3 340 34 23 13 211 61 15 1 1 8 137 2,462 17 333 2 1 200 34 243 Hi 377 3 282 28 22 12 191 58 14 1 1 8 127 2,161 16 294 2 2 Paralysis____________ ._ 3 1 1 35 2 4 3 114 1 5 4 43 5 1 15 5 Paraplegia........._________ Pes planus_____________ 17 Plumbism....... 8 i! 1 11 Poliomyelitis_____ Progressive muscular atrophy... 1 46 12 I 1 Progressive muscular dystrophy. Radiculitis________ .. Retinitis.. Raynaud's disease_________ 7 43 199 1 2 Sciatica_______ _ 9 35 49 9 Syphilis of central nervous sys-tem___________ . . Syringomyelia_______________ 13 , 249 1 1 ' 3 Tabes dorsalis__..... 3 1 """tj::::: 15 1 :«n Tetanus______ __________ 1 Tetany_____ _...... Thrombosis, cerebral__________ 4 183 27 212 16 352 2 156 22 167 12 280 3 3 9 i5 2 2 1 45 1 125 2 Tics_______....... 17 j 43 50 4 15 Torticollis...................... 3 15 40 148 3 ' fi 5 Tremor_____________ 1 Vagotonia.....________...... _______ 14 6 Undiagnosed____............... 24 2 235 38 Epilepsy____________.......... ' 6,388 1 5,273 5,100 15 69 89 4 4,402 338 529 Constitutional psychopathic states... 0. 196 5,941 5,178 96 123 544 6 4,308 , 920 4 ) 703 Criminalism_________________ Emotional instability__ 323 1.915 2. 594 28 388 306 1,835 2,500 28 378 273 1,571 2,197 14 339 24 160 600 IS 14 28 3 11 1 14 11 34 40 9 9 1 1 18 4 216 235 2 19 1 3 64 220 i 1 ' 1,333 4 1.813 35 326 393 5 52 3 11 95 _______ 51 1 174 Inadequate personality______ . 1 i 289 Nomadism___.....___________ 1 15 262 16 130 519 -------1- 8 _______ 61 Pathological liar......_......... 28 27 190 1 171 ______1 8 Sexual psychopathy............. _______i 30 Undiagnosed......___________ 730 -------1- 696 2| 79 178 NEUROPSYCHIATRY Table 12.—Recommendations and final dispositio?i of neuropsychiatric eases ( ontinuca Diagnoses Total Total 4,506 Re commendations Disposition Dis-charge Duty Treat-ment Lim-ited serv-ice Died Dis-charged Absent Re- without Unre-tained official ported leave 4,805 3,927 6 32 541 2 3,545 718'______ 211 2 6 16 50 205 4,501 25 2 6 15 35 186 4,239 23 1 3 14 32 174 3,682 21 1 1 3 12 29 162 3,321 17 1 i______.... 1 2 2 i______i 1 1 2 11 525 1 1 1 2 ______ 1 (d) Neurocirculatory asthenia... (e) Pituitary________________ (J) Thyroid.........._________ (g) Polyglandular____________ 5 1 1 27 1 2 !_....... 4 13 1______ 10 695 ;______1 222 3 ______ 3 Drug addiction.. ..___________ 2,020 1,858 1,823 1,834 1,631 1,650 7 21 163 111 22 ! 52 ____ 1,439 1,503 249 ______ 135 229 ______ 102 Total.......____............. 69,394 60,993 53, 264 552 2,340 4,837 87 45,368 9, 514 24 : 6,000 Colored - Diagnoses Total Recommendations Disposition Dis-charge Duty Treat-ment Lim-ited serv-ice Died Dis-charged Re-tained Absent without official leave Unre-ported Mental deficiency......_.....______..... 4,055 3,366 12 10 667 1 3,043 816 2 193 Imbecile__________________________ 1,936 2,027 34 58 1,754 1,532 27 53 1 11 1 7 2 180 477 5 5 1 1,553 1,446 269 506 34 7 1 113 Moron........... 74 Border-line condition.. Degree not determined________ 44 1 6 Psychoneuroses_________...... 1,100 853 5 62 180 740 276 1 83 Anxiety neuroses 1 31 428 3 182 39 350 44 22 1 22 358 3 150 35 230 39 15 1 22 299 3 126 29 217 34 9 Enuresis........______ 5 9 41 4 84 1 5 Hysteria........_..... Migraine_____........ 24 44 Neurasthenia......... Psychasthenia___..... 5 27 4 118 2 ......----- 7........ 123 _______ 8 L....... 9|... 15 3 Stammering... _ _ --- 2 3 2 Traumatic neurosis.. Undiagnosed. _. .. . Psychoses___________ 556 510 4 36 6 4 425 63 ---- 64 Traumatic...... . 13 43 11 5 9 4 17 81 305 4 13 2 19 30 12 43 10 1 3 4 6 76 298 3 13 2 19 20 1 13 36 10 1 1 4 5 67 245 2 10 General paralysis _ _ _ 2 1 4 6 5 With cerebral syphilis___ 2 1 2 4 Alcoholic__________ 2 Drug and toxic______ With pellagra______. With other somatic diseases. 2 8 4 1 1 1 1 2 1 10 6 1 6 37 Manic-depressive_____ Dementia praecox_____ Paranoia and paranoid conditions 2 With mental deficiency 1 9 With constitutional psychopathic infe-riority_______ 2 Epileptic__________ 19 12 _ Undiagnosed..... 9 1 9 IN THE UNITED STATES 179 Table 12.—Recommendations and final disposition of neuropsychiatric cases—Continued Re comm Colored Diagnoses Total 800 endations Disposition Dis-charge Duty Treat-ment Lim-ited serv-ice Died Dis-charged Re-tained Absent without official leave Unre-ported Nervous diseases and injuries______ 731 9 37 23 5 665 88 42 Atrophv.___........ . 3 1 12 48 1 1 92 6 28 3 37 28 5 1 9 2 58 6 1 1 20 3 1 10 301 1 39 1 1 17 7 31 25 3 3 Brain: Abscess of______ 1 1 1 4 Chorea......______ 11 45 1 1 83 5 25 3 32 28 1 3 11 43 1 1 '4 25 3 28 23 1 1 4 Hemiplegia.......______ 1 Hemorrhage, cerebral_____ Hydrocephalus........... Injury. (a) Brain______ 2 1 3 7 1 12 1 3 3 (b) Spinal cord______ (c) Peripheral nerve... Lateral sclerosis_________ Meningitis____.....___ 1 4 ______ 1 8 2 4 Multiple sclerosis____ Myelitis___________ 5 Neuralgia_______ 1 6 1 47 5 1 1 19 3 1 10 283 1 39 1 1 14 7 30 23 Neuritis________.......... 3 3 1 5 1 4 2 9 Paralysis agitans______ Paralysis___......___ 3 47 5 1 1 19 3 1 9 247 1 36 2 Paraplegia..........___ Plumbism.......... Poliomyelitis......___ 1 1 Progressive muscular atrophy.. Progressive muscular dystrophy_____ Sciatica___________....... 1 Syphilis of central nervous system___ Syringomyelia____________________ 3 10 5 3 27 24 Tabes dorsalis____________..... 1 2 Tetany__________________....... ----- 1 Thrombosis, cerebral____.........___ .......1 1 Tics__________.......____ 1 2 1 14 6 29 21 3 Torticollis_____________ 1 Tremor_____________ 1 1 1 ____ 2 3 Undiagnosed............ 1 Epilepsy__________.......____........___ 1,115 1,079 1 17 18 i 1 983 72 Constitutional psychopathic states.......... 255 234 2 3 16 207 26 22 Criminalism.......__................ 17 80 S4 10 1 19 34 16 73 86 10 1 18 30 1 1 2 15 61 76 9 1 17 28 1 7 12 1 Emotional instability_____.....____ 5 12 Inadequate personality__.....________ 6 Paranoid personality........________ . 1 Pathological liar_____________________ Sexual psychopathy........___________ 1 i 2 Undiagnosed.................._______ 4 ...... 6 Endocrinopathies_____........___________ • 299 266 1 32 250 28 21 Gonad......................_____....... 1 15 19 262 2 1 14 16 233 2 1 11 15 221 2 Neurocirculatory asthenia............. 1 2 29 4 3 21 Pituitary______________.....____..... 1 1 Thyroid____________________________ 20 Pol yglandular............... ________ Drug addiction........_________........... 197 191 3 3 | 1 175 9 12 Alcoholism_________________.......______ 24 23 1 21 1 2 Total______..........______..... 8,401 7,253 33 169 946 12 6,509 1,379 3 498 FAMILY HISTORY Tables 13 to 17 gave details concerning the members of families having a historv of nervous or mental disease, inebriety, and mental deficiency. Tables 18 and 19 summarize information as to family history in the different clinical groups. Table 19 indicates the distribution throughout the nine 42705—29---13 180 NEUROPSYCHIATRY clinicial groups of family history of nervous disease, mental disease, inebriety and mental deficiency in the 39,484 cases classified under these headings. Later in the chapter, for each clinical group an additional summary is made in ac- cordance with disorder and relatives. The number of the classified cases which serves as a basis of this summary is small. The information is interesting but too much weight should not be given to it. 53,508 WHITE CASES 27,487 CASES BAO 6,902 COLORED CASES 26,021 CASES GOOD | 56.3 % J msm it 3,869 CASES 3,013 CASES FAMILY HISTORY OF 60,410 N EUROPSYCHIATRIC . CASES DATA UNASCERTAINED FOR 6,984 CASES Chart VIII Table 13.—Neuropsychiatric cases giving a family history of nervous disease, mental disease, inebriety, or mental deficiency Diagnoses Mental deficiency______________ Psychoneuroses_______________ Psychoses____________________ General paralysis___________ Alcoholic........___________ Manic-depressive___________ Dementia praecox___________ Epileptic__________________ Other forms_______________ Nervous diseases and injuries____ Chorea___________________ Hemiplegia________________ Injury to nervous system____ Meningitis_________________ Multiple sclerosis___________ Neuritis___________________ Paralysis__________________ Poliomyelitis______________ Sciatica__________ Syphilis C. N. S____________ Tabes dorsalis______ Tic_______________________ Tremor___________________ Other forms_______________ Epilepsy_____________________ Constitutional psychopathic states Endocrinopathies______________ Drug addiction________________ Alcoholism___________________ Total______________ Total 21, 858 11,443 7,910 530 292 1,385 4,738 131 834 6,916 264 258 554 279 511 222 340 211 137 ,462 333 200 243 902 6,388 6,196 4,805 2,020 1,858 69,394 White cases Total 17,803 10, 343 7,354 487 287 1,304 4,433 112 731 6,116 252 210 428 242 483 213 282 191 127 2,161 294 183 212 5,273 5,941 4,506 1,823 1,834 Family history of neuropathic taint Posi- tive 6,624 5,486 3,441 137 116 652 2,143 52 341 Nega- tive 8,103 4,187 2,850 263 122 484 1,675 • 33 273 2,164 162 72 140 76 226 56 85 55 36 692 75 89 122 278 2,859 3,108 2,549 648 3,215 78 116 241 145 193 141 173 120 77 ,188 149 72 79 443 1,867 2,188 1,645 967 60,993 : 27,487 26,021 Unas- cer- tained 3,076 670 1,063 87 49 168 615 27 117 737 12 22 47 21 64 16 24 16 14 281 70 22 11 117 547 645 312 208 227 7,485 Colored cases Total 4,055 1,100 43 5 81 305 19 103 12 48 126 37 28 9 58 20 10 301 39 17 31 64 1,115 255 299 197 24 8,401 Family history of neuropathic taint Posi- tive 1,598 577 Nega- tive 1,430 445 232 10 2 31 137 12 40 7 17 52 19 18 3 24 14 4 135 17 11 20 19 714 144 180 66 18 3,889 187 5 27 49 14 7 5 28 5 6 124 15 6 11 34 Unas- cer- tained 1,027 78 137 13 333 70 100 107 5 3,013 41 19 24 1 1,499 IN THE UNITED STATES 181 Table 14.—Neuropsychiatric cases giving a family history of nervous disease Diagnoses Mental deficiency. Psychoneuroses__ Psychoses. General paralysis- Alcoholic________ Manic-depressive. Dementia praecox. Epileptic________ Other forms_____ Nervous diseases and injuries . Chorea_________________ Hemiplegia_____________ Injuries to nervous system- Meningitis______________ Multiple sclerosis________ Neuritis________________ Paralysis_____......____ Poliomyelitis______....... Sciatica_______......____ Syphilis C. N. S_________ Tabes dorsalis___________ Tic____________________ Tremor________________ Other forms_____________ Epilepsy______________________ Constitutional psychopathic states. Endocrinopathies_______________ Drug addiction_________________ Alcoholism______________........ Total. Total 3,456 4,009 1,534 White Num- ber of cases 2,967 3,587 1,438 74 38 294 927 32 169 1,572 129 48 94 62 176 34 71 45 27 458 37 74 110 207 2,036 1,616 1,180 266 224 15, 893 64 36 282 873 27 156 1,389 124 44 71 56 169 33 56 37 25 379 32 68 93 202 1,525 1,535 1,045 239 221 13, 946 Number of relatives with nervous disease Fa- thers 1,025 360 15 6 77 211 10 41 432 394 417 53 43 3,764 Moth- ers Grand- parents 1,542 2,301 37 11 140 485 12 83 21 39 33 83 12 25 18 13 205 18 31 41 82 79 128 52 875 947 1,024 106 102 111 59 85 7 3 8,355 583 Sib- lings 1,419 2,110 27 19 170 420 21 78 643 81 18 29 25 85 23 19 10 13 153 15 34 44 94 1,251 839 78 8,162 Collat- erals 376 402 210 1 4 53 127 7 18 196 395 192 250 25 23 De- nied 11,427 6,015 4,646 337 198 815 2,804 50 442 3,870 113 145 309 160 234 160 202 138 87 1,431 187 95 107 502 3,083 3,611 111 1,321 1,343 35,409 Unas- cer- tained 3,409 759 1,270 53 207 756 35 133 15 21 48 26 80 20 24 16 15 351 75 20 12 134 665 795 350 263 270 Diagnoses Mental deficiency___ Psychoneuroses_____ Psychoses__________ General paralysis. Alcoholic_______ Manic-depressive- Dementia praecox. Epileptic_______ Other forms_____ Nervous diseases and injuries.. Chorea______.....______ Hemiplegia____.....----- Injuries to nervous system. Meningitis_____________ Multiple sclerosis________ Neuritis________________ Paralysis_________.....-- Poliomyelitis___________ Sciatica________________ Syphilis C. N. S.__........ Tabes dorsalis___________ Tic___.................... Tremor____............... Other forms_______....... Epilepsy______________________ Constitutional psychopathic states. Endocrinopathies____..........— Drug addiction___________.....--. Alcoholism_____________________ Colored Num- ber of cases 489 422 Total. "ill 81 135 __3 ry-if" Number of relatives with nervous disease Fa- thers 110 104 Moth- ers 190 138 Grand' parents Sib- lings 399 343 26 166 39 58 16 1 102 40 Collat- erals 139 62 De- nied 2,383 596 19 3 49 175 9 59 Unas- cer- tained 1,183 82 146 ~14 491 7 40 4 70 33 27 4 17 4 7 1 40 3 11 ] 8 175 47 24 10 11 362 41 65 7 1 525 120 145 40 20 1,370 4,634 1,720 182 NEUROPSYCHIATRY Table 15.—Neuropsychiatric cases giving a family history of mental disease Total Wh ite ves witt Diagnoses Num-ber of cases Number of relat mental disease Fa-thers Moth-ers Grand-parents 194 159 Sib-lings Colla-terals Denied Unas-cer-tained 2,855 1,744 2, 146 1,551 353 255 403 292 650 399 972 781 12, 252 7,890 3,405 902 1,855 1,729 357 384 208 561 940 4,427 1,198 42 40 390 1,182 27 174 41 40 373 1,101 23 151 11 8 86 222 7 23 10 10 102 221 3 38 2 3 41 128 5 29 9 14 119 371 5 43 21 24 176 612 17 90 366 195 736 2,625 57 448 80 52 195 707 32 132 653 515 97 102 67 113 309 4,782 819 34 26 53 34 61 19 26 17 11 210 33 22 37 70 33 24 34 24 50 17 20 16 10 149 26 17 30 65 9 2 6 2 10 4 3 3 1 34 7 4 3 9 6 3 4 4 12 1 6 1 2 34 3 6 9 11 6 3 3 2 4 3 2 1 23 5 4 11 7 4 6 6 9 6 1 3 42 6 4 6 13 46 11 16 16 24 7 12 7 7 87 5 12 20 39 200 157 345 196 353 178 237 158 101 1,710 192 143 165 647 19 29 49 22 80 18 25 17 16 Syphilis C. N. S - .....______ 302 76 Tic _____________________ 23 17 126 1,035 1,061 543 177 115 747 999 496 149 113 110 206 75 26 18 181 248 102 29 9 114 123 52 15 8 198 268 116 45 27 357 586 238 87 52 3,745 4,111 3,612 1,417 1,460 781 831 398 257 261 Total........____________ ______ . . 10,038 8,445 1,497 1,750 940 2,377 4,322 43, 696 8,852 Diagnoses Mental deficiency. Psychoneuroses___ Psychoses......... General paralysis. Alcoholic________ Manic-depressive- Dementia praecox. Epileptic-........ Other forms_____ Nervous diseases and injuries.. Chorea__________________ Hemiplegia______________ Injuries to nervous system. Meningitis_______________ Multiple sclerosis_________ Neuritis_________________ Paralysis________________ Poliomyelitis_____________ Sciatica_________.....____ Syphilis C. N. S__________ Tabes dorsalis____________ Tic_____________________ Tremor.......___________ Other forms______________ Colored Num- ber of cases 709 193 Number of relatives with mental disease Fa- thers Moth- ers 113 22 17 | 2 81 19 4 1 23 6 Epilepsy______________________ Constitutional psychopathic states. Endocrinopathies_______________ Drug addiction_________________ Alcoholism____________________ 288 62 47 28 ___2 Total_______........_______........______ 1,593 138 23 Grand parents Sib- lings 264 62 50 240 Colla- terals 432 121 Denied 2,239 826 29 5 45 150 13 50 109 21 17 3 1 184 .56 22 10 21 3 46 13 139 29 27 13 1 729 136 233 144 21 19 25 _1 T659 IN THE UNITED STATES 183 Table 16.-—Neuropsychiatric cases giving a family history of inebriety Total White Diagnoses Num-ber of cases Number of relatives with inebriety Fathers Moth-ers Grand-parents Sib-lings Collat-erals Denied Un-ascer-tained 3,028 1,566 2,630 1,434 1,963 926 55 18 55 68 781 337 446 334 11,810 7,917 3,363 992 1,403 1,326 988 27 45 358 240 4,745 1,276 63 112 215 834 13 166 61 110 206 789 12 148 49 57 153 620 10 99 1 3 19 7 3 8 21 21 47 38 172 5 75 17 22 36 135 1 29 340 119 884 2,897 61 444 86 51 214 747 39 4 6 139 970 822 559 15 25 254 153 4,454 840 43 32 82 23 110 21 40 21 16 402 33 19 29 99 42 26 48 21 103 20 27 14 13 349 30 17 22 90 30 19 30 10 63 18 17 9 9 240 26 16 17 55 1 4 2 1 2 5 1 1 5 6 17 2 16 3 13 10 7 121 11 5 3 35 8 7 12 9 22 3 4 4 10 42 10 2 3 17 187 157 332 198 301 174 228 159 97 1,496 187 140 172 626 23 27 48 23 79 19 27 IS 17 Syphilis C. N. S____________________ 5 3 1 1 5 1 1 6 316 77 Tic __________..........._______ 26 18 Other forms------------------------ 122 894 1,167 737 429 542 681 1,119 675 382 531 599 861 462 247 355 20 32 12 22 18 27 44 23 13 17 210 254 129 134 183 195 219 152 96 116 3,841 4,037 3,451 1,191 1,077 751 785 380 250 226 Total _________ ---.....--- 10,736 | 9,600 6,960 219 317 2,640 1,951 42,523 8,863 Diagnoses Mental deficiency----------- Psychoneuroses________..... Psychoses.............------ General paralysis-------- Alcoholic------.......--- Manic-depressive-------- Dementia praecox-------- Epileptic--------------- Other forms.....----..... Nervous diseases and injuries.. Chorea............------ Hemiplegia________...... Injuries to nervous system. Meningitis_________...... Multiple sclerosis________ Neuritis____.......----- Paralysis..............--- Poliomyelitis-----........ Sciatica.....------.......- Syphilis C.N. S_________ Tabes dorsalis-------..... Tic.............--------- Tremor........---------- Other forms............... Epilepsy.......-----.........---- Constitutional psychopathic states. Endocrinopathies...............— Drug addiction-----......------- Alcoholism_________......------ Colored Number of relatives with inebriety Num- '------ ber of cases i Fathers Moth- ers 398 132 248 96 52 Total. 2 2 9 45 1 18 T48" Grand- parents Sib- Collat- lings erals 196 45 213 48 62 47 11 116 29 36 24 9 104 17 40 20 1,136 679 269 Denied 2,463 879 340 27 3 53 186 15 56 Un- ascer- tained 1,195 9 38 77 30 20 7 42 12 6 197 24 14 24 41 153 212 125 7 5,525 2 4 15 5 1 1 3 1 1 51 12 1 1,740 184 NEUROPSYCHIATRY Table 17.—Neuropsychiatric cases giving family history of mental deficiency Total Num-ber of cases j White Diagnoses * umber of relatives with mental deficiency Fathers Moth- Grand-ers parents Siblings Collat-erals Denied 12,376 9,406 Unas-cer-tained 1,752 84 1,478 34 244 21 243 23 9 8 1,339 190 151 91 3,949 967 307 280 42 53 3 232 89 5,644 1,430 7 1 48 207 12 32 5 1 47 194 10 23 --.. .. 1 3 2 49 134 8 36 2 13 57 3 14 390 231 1,038 3,369 58 558 92 55 s 25 1 8 7 35 1 9 2 1 219 870 44 150 125 89 5 5 4 69 35 5,248 956 6 6 10 2 19 3 4 4 6 31 3 3 10 18 5 5 3 1 14 2 2 4 5 19 1 3 7 18 4 3 2 1 8 1 3 3 4 17 3 6 5 9 2 1 1 6 3 4 9 2 7 222 172 368 198 388 188 254 170 104 1,809 212 155 186 695 25 33 57 43 1 1 1 81 23 26 1 1 1 1 1 1 2 17 is Syphilis C. N. S___________...........- 333 81 Tic 25 19 2 1 127 288 53 165 35 8 208 35 152 33 8 19 81 7 7 1 19 31 8 8 7 7 3 165 167 93 24 4 69 90 21 9 3 4,194 5,003 3,907 1,504 1,512 871 903 447 286 314 Total__________________............. 2,817 2,317 427 390 41 2,282 557 48,596 10,080 Colored Diagnoses Num-ber of cases Number of relatives with mental deficiency Fathers Moth-ers Grand- cihli ' parents blblmes Collat-erals Denied Unas-cer-tained Mental deficiency ... ._________________ 274 50 27 2 32 9 7 36 8 5 3 292 52 21 5 2,535 958 382 27 4 58 213 14 66 606 9 47 81 30 19 7 42 20 9 226 24 16 24 52 909 165 247 175 23 1,246 Psychoneuroses.......______________....._____ Psychoses............____________ General paralysis_____ - ____ 1 52 18 2 126 147 14 Alcoholic___________________________ 1 Manic-depressive____________ ___________ 1 13 2 9 36 1 1 7 5 1 2 1 7 2 fi 24 2 1 1 3 3 1 2 3 2 7 1 2 1 22 Dementia praecox____________________ . Epileptic......_________ _________ 5 3 79 3 Other forms______ ________ 2 4 2 4 2 28 Nervous diseases and injuries_________ 160 2 Hemiplegia_______________..... Injuries to nervous system_______ Meningitis___________ 1 2 1 38 6 Multiple sclerosis________ 1 4 Neuritis______________ ------1----- _ 1 Paralysis__________ _______ .. 14 Poliomyelitis____________ Sciatica....._________ 1 12 2 1 2 Syphilis C. N. S_______ 1 1 2 7 1 63 Tabes dorsalis_____________ 13 Tic______________ ---- 1 Tremor______........ 3 3 |_______ 4 Other forms ________..... 1 2 1 14 Epilepsy.....___________ 80 18 13 2 8 2 1 11 4 79 1 5 2 15 11 8 126 Constitutional psychopathic states .. 72 Endocrinopathies_____ 39 Drug addiction........ 20 Alcoholism________ 1 Total_____________ 500 63 68 9 470 119 5,970 1,931 IN THE UNITED STATES 185 Table 18.—Neuropsychiatric cases giving family history of neuropathic taint. Percentage distribution ° Total cases Per cent of cases ascertained as to family history in each clinical group Family history of neuro-pathic taint Num-ber Per cent Mental defici-ency Psycho-neu-roses Psycho-ses Neuro-logical Epi-lepsy Consti-tutional psycho-pathic states Endo-crino-pathies Drug addic-tion Alco-holism 31,376 29,034 51.9 48.1 46.3 53.7 56.7 43.3 54.7 45.3 41.5 58.5 61.9 38.1 59.0 41.0 61.0 39.0 39.9 60.1 38.4 61.6 Total ascertained..... 60,410 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 « There were 8,984 cases of which the family history of neuropathic taint was unascertained. Table 19.—Family history of principal neuropathic taints among neuropsychiatric cases Cases with each taint Per cent of cases with each specified taint among the total cases with ascer-tained family history in each clinical group Specified neuropathic taint in family Num-ber Per cent Mental defici-ency Psycho-neu-roses Psycho-ses Neuro-logical Epi-lepsy Consti-tutional psycho-pathic states Endo-crino-pathies Drug addic-tion Alco-holism Nervous diseases____________ 15, 893 10, 038 10, 736 2,817 26.3 16.6 17.8 4.7 19.5 16.1 17.1 9.9 37.5 16.3 14.6 .S 22.9 27.6 20.9 4.6 25.9 10.7 16.0 2.1 35.3 17.9 15.5 5.0 29.3 19.3 21.2 1.0 26.4 12.1 16.5 3.7 14.9 10.0 24.0 2.0 13.7 7.1 33.3 .5 Total neuropathic taints. 39,484 65.4 62.5 69.2 76.0 54.7 73.7 70.7 58. 7 50.7 54.5 AGE In Table 20 it is possible to compare the ages of the white with the colored neuropsychiatric cases. This table shows the predominance of neuropsychiatric disorders among colored between the ages 20 and 24 years. There is little difference in the percentages for the other groups, except the colored naturally fall below the whites on account of the increase in the percentage for the colored in the age group from 20 to 24 years. Table 21 summarizes information as to age in the different clinical groups. 186 NEUROPSYCHIATRY 50 40 Z 30 o or. hi o. 20 10 6.3 < 52.6 UNDER 20 20-24 25-29 AGE GROUPS 3 0-34 35 AND OVER AGE GROUPS OF 67,569 NEUROPSYCHIATRIC CASES DATA UNASCERTAJNED FOR 1,8 25 CASES Chart IX IN THE UNITED STATES 187 Table 20.—Ages of neuropsychiatric cases Total White Diagnoses Total Under 20 years 20 to 24 years 25 to 29 years 30 to 34 years 35 years and over Unas-cer-tained Mental deficiency____________ ___________ 21, 858 11,443 17, 803 10, 343 1,685 445 7,878 4,200 5,782 3,962 1,692 1,331 143 242 623 163 Psychoneuroses.................______________ Psychoses_________________......___..... 7,910 7,354 334 2,551 2,694 1, 158 382 235 General paralysis. ________________..... 530 292 1,385 4,738 131 834 487 287 1,304 4,433 112 731 4 2 31 254 10 33 37 33 427 1,781 44 229 158 107 500 1,634 42 253 165 95 220 549 10 119 110 36 84 85 4 63 13 14 42 Alcoholic_______________________ Manic-depressive..........___________ Dementia praecox_______.....________ Epileptic_____________________ Other forms____. ________________ Nervous diseases and injuries_______.....____ 6,916 6,116 184 1,831 2,264 1,171 480 Chorea_______ ........_ .. 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 252 210 428 242 483 213 282 191 127 2,161 294 183 212 838 19 1 11 10 29 7 12 7 45 3 7 1 32 136 71 165 125 168 78 111 107 40 382 29 74 67 278 75 98 172 83 183 76 109 50 55 820 87 74 88 294 20 29 55 19 71 33 37 19 21 589 93 22 48 115 7 9 2 16 13 6 2 8 266 60 3 3 85 Hemiplegia________________ Injuries to nervous system_____,.___ 16 Meningitis____________ 3. Multiple sclerosis____________ 16 Neuritis_______ ___________ 6 Paralysis_______ ________ 7 Poliomyelitis_________________ 6 Sciatica______ .. . _____ 3 Syphilis C. N. S____......__________ 59 Tabes dorsalis__..........______ 22 Tic......_____........._____ 3 Tremor_____ ............ 5 34 Epilepsy_________________ 6,388 6,196 4,805 2,020 1,858 5,273 5,941 4,506 1,823 1,834 358 537 161 12 13 2,383 2,438 2,293 665 131 1,790 1,960 1,545 845 489 497 745 410 238 652 57 174 28 28 513 188 Constitutional psychopathic states.....__________ 87 Endocrinopathies_____________......... 69 Drug addiction___________ 35 36 Total__________________...______________ 69,394 60,993 3,729 24,370 21,331 7,894 2,047 1,622 Total Colored Diagnoses Under 20 years 20 to 24 years 25 to 29 years 30 to 34 years 35 years and over Unascer-tained 4,055 1,100 78 34 2,273 569 1,168 365 353 110 42 8 141 14 556 9 227 216 70 15 19 43 5 81 305 19 103 8 19 3 33 111 10 40 9 2 7 35 1 16 5 2 1 8 35 138 6 40 1 4 1 4 4 9 1 Other forms________________________________ 3 800 7 310 315 138 17 13 12 48 126 37 28 9 58 20 10 301 39 17 31 64 6 26 58 19 13 5 26 8 5 91 11 9 9 24 5 13 46 11 11 4 18 11 4 133 14 6 15 24 1 6 17 6 3 2 2 1 1 3 1 11 1 2 1 1 63 13 1 5 11 Syphilis C. N. S ___________ 1 9 1 4 Tic 1 1 1 4 1 1,115 255 299 197 24 19 5 6 2 598 118 163 54 3 388 90 90 88 12 87 35 36 50 11 5 2 3 2 12 2 2 S. 401 160 4,315 2,732 886 105 203 188 NEUROPSYCHIATRY Table 21.—Ages of neuropsychiatric cases. Percentage distribution Total with as- certained ages Age on enlistment Num- ber Under 20 years___________ 3,889 20'to 24 years_____________ 28,685 25jto 29 years_____________ 24,063 30 to 34 years_____________\ 8,780 35'years and over---------- 2,152 Total cases with as- certained ages---- 67, 569 Per cent 5.8 42.5 35.6 13.0 3.2 100.0 Per cent distribution of ascertained ages in each clinical group Mental defi- ciency 8.4 48.1 32.9 9.7 .9 100.0 Psycho- neuro- ses 4.3 42.3 38.4 12.8 2.2 100.0 Psy- choses 4.5 36.3 38.0 16.0 5.2 Neuro- logical 2.8 31.9 38.4 19.5 7.4 100.0 100.0 Epi- lepsy 6.1 48.2 35.2 9.4 1.1 100.0 Consti- tutional psycho- pathic states 41.8 33.6 12.8 2.9 100.0 Endo- crinopa- thies 3.5 51.9 34.5 9.4 .7 100.0 Drug addic- tion 0.7 36.2 47.0 14.5 1.6 100.0 Alco- holism 0.7 7.4 27.5 36.2 28.2 100.0 Ages unascertained of 1,825 cases. SCHOOLING From the data which were compiled by the division of psychology of the Surgeon General's Office, reasonably accurate information was obtained as to the literacy of the men who made up the Army.3 The statements as to school- ing, which wore given by the men subjected to the psychological examinations, were not verified, and if there is any error it is probable that the facts were overstated by the men, as it is believed there was a general tendency for them to exaggerate their previous training. From the entire group of men tested by the psychologists, about 80,000 records were carefully selected as a fair sample of the men in the Army. (Table 22.) The tabulation upon which the report of the division of psychology is based, is used herein for purposes of comparison. The neuropsychiatric records are perhaps somewhat more accurate in reference to education than the psychological records, because of the oppor- tunities for verification. Each case was personally interviewed by the neuro- psychiatrist, and the records corrected if misstatements were found. Table 22.—Schooling of 80,000 soldiers as determined by psychological examinations Schooling White (per cent) Colored (per cent) None________________________ ________________________________ ... 3.2 75.2 16.6 5.0 13.5 Grades_________________ . ___________________ 76.0 High school___________________....._______ 8.9 College__________________________ ___ 1.6 Total______________ 100.0 100.0 Source of information. Report of division of psychology of the Surgeon General's Office. IN THE UNITED STATES 189 NONE GRADES GRADES HIGH 1-3 4-8 SCHOOL & UNKNOWN COLLEGE SCHOOLING OF NEUROPSYCHIATRIC CASES COMPARED WITH THAT OF OTHER SOLDIERS Chart X 190 NEUROPSYCHIATRY Table 23.—Schooling of neuropsychiatric cases Diagnoses Mental deficiency_______ - .... Psychoneuroses_________ Psychoses_______......._____ General paralysis___..... Alcoholic__.....__________ Manic-depressive__________ Dementia praecox.......____ Epileptic________........_. Other forms______________ Nervous diseases and injuries___ C horea____________....... Hemiplegia______________ Injuries to nervous system... Meningitis____......_____ Multiple sclerosis____...... Neuritis__________........ Paralysis________________ Poliomyelitis_____________ Sciatica_________________ Syphilis C N. S__________ Tabes dorsalis......_______ Tic......_______________ Tremor___________......__ Other forms______________ E pilepsy____________________ Constitutional psychopathic states_____________________ Endocrinopathies_____________ Drug addiction______________ Alcoholism__________________ Total_________________ White 21. S5S 11,443 17,803 10,343 7,910 6,916 7,354 530 487 292 287 1,385 1,304 4,738 4,433 131 112 834 731 6,116 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 252 210 428 242 483 213 282 191 127 2,161 294 183 212 6,388 6,196 4,805 2,020 1,858 69, 394 5,273 5,941 4,506 1,823 1,834 60,993 Grades 5,729 4,974 759 il, 112 5,376 5,716 455 321 493 845 22 52 9 31 58 113 315 549 19 20 70 80 3,857 254 161 641 2,395 39 367 349 575 8 24 8 23 22 56 24 26 28 51 9 15 11 20 12 18 7 19 146 197 17 11 9 20 15 26 33 69 3,437 164 126 218 126 271 112 157 106 61 1,277 152 104 126 437 550 671 I 2,786 3,331 2,683 1,144 469 639 250 454 69 137 84 152 8,752 9,559 29,328 39 16 56 190 8 20 High school College 16 ! 10 | 8 2 525 !106 ,275 254 471 | 296 184 202 73 22 14 10 11 15 16 8 2 2 4 107 67 14 53 76 285 170 33 99 77 3 4 1 1 2 38 33 9 18 28 406 286 65 134 141 72 14 22 10 30 19 26 20 28 14 6 133 15 12 6 65 272 191 154 126 311 2,425 294 174 34 71 37 16 23 408 265 54 163 147 68 21 317 226 52 111 91 25 9 146 56 10 32 33 12 4 87 40 14 15 16 6 2 2,967 1,884 414 993 923 J393 211 3,144 IN THE UNITED STATES Table 23.—Schooling of neuropsychiatric cases—Continued 191 Colored "3 O a a Grades High school College eg Diagnoses CO o CO O > O CO O T3 0} a '3 a> o CO O c= O W 03 a> o CO ■a a> _a '3 05 U 8 H 3 be a $ a be '3 o c 3-3 B.S .2 a CO CJ 3 T3 K 4,055 1,100 2,788 404 877 315 251 312 78 24 4 9 1 9 56 1 4 7 15 556 173 140 160 45 5 2 1 5 1 .... 24 43 81 305 19 103 14 17 93 8 41 12 1 19 85 5 18 8 3 28 85 4 32 4 1 8 27 1 4 1 1 3 2 1 1 1 6 3 2 .... 9 1 .... 1 6 800 238 216 284 24 10 8 -J." 1 3 i^: 1 | 15 12 48 126 37 28 9 58 20 10 301 39 17 31 64 4 13 42 8 10 3 15 4 4 82 17 3 9 24 4 16 38 13 7 2 16 8 2 81 7 3 6 13 301 69 82 30 6 4 16 35 12 10 £ 7 4 112 14 9 13 21 280 105 126 117 10 2 6 2 1 .... 2 i 2 1 1 1 1 1 1 1 1 , - | 1 Syphilis C. N. S___________........_________ 5 1 1 5 25 6 2 ...J 2 | .. 1 10 Tic ____ .... 1 2 1 j----, 1 .... 1 1 3 3 1 2 2 , 1 .... 1,115 255 299 197 24 472 64 74 14 3 8 12 .... 4 11 4 , 7 5 4 14 10 1 1 1 i .... 3 5 3 2 Total .......___.....................- 8,401 4,230 2,036 1,645 222 59 37 5 19 15 , 2 1 130 The facts clearly indicate that the neuropsychiatric cases did not measure up to the educational standards of the average soldier. This may be due to the large number of mental defectives included in the group of neuropsychiatric cases. Further comparisons will be made in the discussion of the different groups of neuropsychiatric cases. ECONOMIC CONDITION In compiling information on the ecomonic condition, the cases were placed into two groups: Those in marginal and those in comfortable circumstances. (See Table 24.) Persons were considered as being in marginal circumstances who were not able to live without working for four months, without becoming objects of charity. This classification does not include "dependents" as the number of dependent men accepted by local boards was negligible. The table shows that 50,181, or 87 per cent of the whites and 8,005, or 97 per cent of the colored neuropsychiatric cases were in marginal circumstances. The facts give no light on the question of whether poverty is the cause or the result of mental disease or defect. They do, however, show a close relationship 192 NEUROPSYCHIATRY and agree with previous statistics, the best of which have been compiled by the New York State Hospital Commission, that neuropsychiatric disorders are relatively more frequent among persons in marginal circumstances. MARGINAL TOTAL 57,491 WHITE CASES COMFORTABLE H H~aTT~%H Mlliiniiirlli 50,181 CASES MARGINAL TOTAL 8,224 COLORED CASES 7,310 CASES COMFORTABLE H~9773~%H ■ 8,005 CASES ECONOMIC CONDITION OF 65,715 NEUROPSYCHIATRIC DATA UNASCERTAINED FOR 3,679 CASES CASES 219 1 Chart XI Table 24.—Economic condition of neuropsychiatric cases Diagnoses Mental deficiency______________ Psychoneuroses_______.......... Psychoses____________________ General paralysis___________ Alcoholic_________________ Manic-depressive___________ Dementia praecox_________ Epileptic__________________ Other forms_______________ Nervous diseases and injuries____ Chorea____.....___________ Hemiplegia____________~~~~~ Injuries to nervous system.. Meningitis______________ Multiple sclerosis_________'_'_ Neuritis_________________ Paralysis_____________'."'" Poliomyelitis___________" Sciatica....... Syphilis C N. S_______ Tabes dorsalis.. Tic__________________'.'....I Tremor____________ Other forms_________........ Epilepsy___________________ Constitutional psychopathic states Endocrinopathies__ Drug addiction_________~~ Alcoholism__________ Total________ Total White Total 21,858 11,443 17,803 10,343 7,910 530 292 1,385 4,738 131 834 6,916 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 287 1,304 4,433 112 731 6,116 252 210 428 242 483 213 282 191 127 2,161 294 183 212 6,388 6,196 4,805 2,020 1,858 5,273 5,941 4,506 1,823 1,834 Mar- ginal 15,865 7,992 5,777 362 233 941 3,654 88 499 Com- fort- able 927 1,901 1,053 32 268 481 13 171 4,618 213 170 325 196 351 135 201 155 91 ,698 190 144 170 579 1,035 34 29 71 33 75 60 65 27 30 313 65 30 28 175 4,355 602 4,801 791 3,567 704 1,602 159 1,604 138 , 394 60,993 ] 50,181 7, 310 Unas- cer- tained 1,011 450 37 22 95 298 11 61 463 5 11 32 13 57 18 16 9 6 150 39 9 14 84 316 349 235 62 92 3,502 Colored Total 4,055 1,100 556 43 5 81 305 19 103 800 12 48 126 37 28 9 58 20 10 301 39 17 31 64 1,115 255 299 197 24 8,401 Mar- ginal 3,951 1,037 38 5 75 266 17 92 Com- fort- able 739 11 44 118 37 26 7 53 18 9 277 36 15 29 59 1,061 233 290 177 24 L nas- cer- tained 1 2 2 5 3 2 1 1 4 1 2 1 14 10 3 2 8,005 35 19 12 10 8 1 10 4 219 177 VENEREAL DISEASE Data on venereal infections at some time previous to entering the service were obtained from statements of the soldiers comprising this series. (See 1 able 25.) \enfications of the statements, being difficult, were not made except m such instances as required Wassermann examinations IN THE UNITED STATES 193 The usual motive for denying the existence of venereal disease did not exist in the Army, and neuropsychiatric examiners were impressed with the frankness with which soldiers spoke of their past life in this respect. The 13,567 CASES ADMITTED COLORED 47,426 CASES DENIED H^H imiiiiimiiiiiii, Wli, | 57.8 °^H 4,856 CASES 3,545 CASES RATIO OF NEUROPSYCHIATRIC CASES ADMITTING AND DENYING VENEREAL INFECTION Chart XII figures here presented must stand by themselves, as the Army statistics relative to venereal diseases refer only to the actual existence of them, not to past ADMITTED 4,54 5 ADMITTED | 2 6.1 % 2.195 CASES 1,076 CASES ADMITTED SYPHILIS WHITE GONORRHEA WHIT E 56,448 CASES DENIE1- r///##jia 6,206 CASES NEUROPSYCHIATRIC CASES ADMITTING AND DENYING SYPHILITIC ANDG0N0RRHEAL INFECTION ■ ^j_^^^B l««^» ///a 3,933 CASES 4,468 CASES Chart XIII histories. It is impossible, therefore, to state how the neuropsychiatric indi- viduals compared with soldiers in general as to a venereal history. Table 25 shows the great predominance of history of preceding venereal infection in the colored cases. 194 NEUROPSYCHIATRY Table 25.—Neuropsychiatric cases admitting and denying venereal infection previous to entering the Army Total White Diagnoses Total Syphilis Gono rrhea De-nied 15, 572 8,483 Other venereal infection Ad-mitted De-nied Ad-mitted Ad-mitted 171 114 De-nied 21,858 11,443 17, 803 10, 343 517 446 17, 286 9,897 2,231 1,860 17,632 10,229 7,910 7,354 640 6,714 1,409 5,945 163 7,191 530 292 1,385 4,738 131 834 487 287 1,304 4,433 112 731 255 35 69 205 2 74 232 252 1,235 4, 228 110 657 159 93 256 752 18 131 328 194 1,048 3,681 94 600 19 11 29 83 2 19 468 276 1,275 4,350 110 712 6,916 6,116 1,669 4,447 1,594 4,522 176 5,940 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 252 210 428 242 483 213 282 191 127 2,161 294 183 212 838 11 26 23 4 16 5 15 6 7 1,345 135 8 22 46 241 184 405 238 467 208 267 185 120 816 159 175 190 792 35 45 79 32 88 35 52 27 26 862 107 29 38 139 217 165 349 210 395 178 230 164 101 1,299 187 154 174 699 3 4 4 2 1 2 5 2 3 102 11 2 7 28 249 206 424 240 482 211 277 1S(1 124 Syphilis C N. S....._______________________ 2,059 283 Tic________............______________....... 181 205 810 6,388 6,196 4,805 2,020 1,858 5,273 5,941 4,506 1,823 1,834 182 360 131 390 210 5,091 5,581 4,375 1,433 1,624 819 1,142 591 847 583 4,454 4,799 3,915 976 1,251 69 117 46 74 39 5,204 5,824 4,460 1,749 1,795 Total......_______................______ 69, 394 60,993 4,545 56, 448 11,076 49,917 969 60,024 Total Colored Diagnoses Syphilis Gonorrhea Other venereal infection Admitted Denied Admitted Denied Admitted Denied Mental deficiency.....____________________ 4,055 1,100 949 240 3,106 860 1,846 506 2,209 594 166 65 3,889 Psychoneuroses__________________________ 1,035 Psychoses.............. _ . _______ 556 145 411 220 336 25 531 General paralysis______ . _____ 43 5 81 305 19 103 31 2 9 58 6 39 12 3 72 247 13 64 17 3 33 117 8 42 26 2 48 188 11 61 5 38 Alcoholic_____ ... . ... ._____ 5 Manic-depressive____________ ____ 4 10 4 2 77 295 Epileptic.__________ ...____ 15 Other forms________________________ 101 Nervous diseases and injuries. _________..... 800 349 451 404 396 39 761 Chorea_______________________..... 12 48 126 37 28 9 58 20 10 301 39 17 31 64 5 20 31 8 9 2 15 6 2 188 30 7 10 16 7 28 95 29 19 7 43 14 8 113 9 10 21 48 3 24 66 9 14 5 32 13 5 153 22 9 24 60 28 14 4 26 7 5 148 12 44 Hemiplegia_______....._____.. 4 Injuries to nervous system______ 5 1 121 Meningitis. _______________ 37 2-1 9 57 20 10 278 Multiple sclerosis_______ _____ Neuritis____ ______ . Paralysis____......_____ 1 Poliomyelitis_________ Sciatica......________ . Syphilis C. N. S___ 23 Tabes dorsalis_________ 2 ' 37 Tic__________ 6 1 11 21 1 10 31 ' 33 1 16 Tremor ____________ 1 , 30 Other forms______ 2 62 Epilepsy_____________ 1,115 255 299 197 24 273 1 842 71 184 85 214 75 122 8 16 557 558 133 122 148 151 112 85 7 17 45 1,070 9 246 Constitutional psychopathic states.. Endocrinopathies.......______ 18 281 16 181 1 23 Drug addiction________ Alcoholism________ Total________________ 8,401 2,195 6,206 3, 933 4, 468 j 384 8,017 IN THE UNITED STATES 195 ALCOHOLIC HABITS Table 20 shows that an almost equal percentage of the white and colored neuropsychiatric cases abstained from the use of alcohol, and that the ratio of moderate drinkers was also about the same. The ratio for the whites exceeded that for the colored in the number who were classed as intemperate. It will be observed that a little less than one-half of the individuals were reported as moderate drinkers. No information is obtainable which might permit a comparison of the alco- holic habits of neuropsychiatric cases with similar habits in soldiers generally; but Table 20 permits of a comparison of the alcoholic habits among the different neuropsychiatric groups. There are noteworthy wide variations between the percentage of "abstinent" and "intemperate" in the various groups. NTEMPERATE ALCOHOLIC HABITS OF 65,326 NEUROPSYCHIATRIC CASES DATA UNASCERTAINED FOR 4,068 CASES Chart XIV Table 26.—Habits of neuropsychiatric cases as to alcohol Total White Colorec Diagnoses Total Absti-nent (i, 873 4.824 Mod-erate In-tem-per-ate Cn-ascer-tain-ed 1,274 424 Total Absti-nent Mod-erate In-tem-per-ate I'n-ascer-tain-ed Mental deficiencv_________________ 21, S5S 11,443 17,803 10.343 8,100 4, 554 1,556 541 4,055 1,100 1,626 522 1,989 470 358 84 82 24 7,910 7,354 2,383 3,102 1,278 591 556 183 261 76 36 General paralvsis ........ . Alcoholic ... ... .. ... ____ 530 292 1,385 4, 738 131 834 487 287 1,304 4,433 112 731 81 446 1,586 40 230 244 14 589 1,914 28 313 121 259 162 603 18 115 41 14 107 330 26 73 ■13 81 305 19 103 12 20 8 4 6 42 3 1 26 105 10 30 40 138 9 54 9 20 Dementia praecox. _ ._ ____ Epileptic_____________________ Other forms_______________ .. 16 3 Nervous diseases and injuries_____ 6,916 6,116 2,010 2. 880 741 485 800 274 395 111 20 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 252 210 428 242 4S3 213 282 191 127 2,161 294 183 212 S3S 141 101 189 129 173 82 125 105 43 371 48 K4 96 323 98 76 181 84 218 93 124 70 62 1,206 142 76 89 361 6 16 31 12 38 29 12 5 8 437 60 10 15 62 17 27 17 54 9 21 " 14 147 44 13 12 92 12 48 126 37 28 9 58 20 10 301 39 17 31 64 5 21 46 21 11 6 15 12 7 79 8 10 10 23 4 25 54 14 12 2 33 7 2 160 22 7 17 36 2 2 19 1 5 1 9 1 55 9 1 Injuries to nervous system____ 1 Paralysis_____________________ 1 1 Syphilis C. N. S______________ Tic Tremor_____......_. ._____ . Other forms____ . . _____ 3 4 1 1 Epilepsv__________________ _______ Constitutional psychopathic states Endocrinopathies_________________ Drug addiction___________________ 6,388 6,196 4,805 2,020 1.S5S 5J 941 4. 506 1,823 1.S34 2, 245 2,186 2,151 567 2,274 2,548 1,930 838 343 913 198 319 1,771 411 294 227 99 63 1, 115 299 197 24 501 91 105 72 525 114 154 100 66 46 34 22 22 23 4 6 3 2 Total_________ ________ 69,394 60. 993 23, 239 26, 226 7,660 3. 868 8,401 3,374 4,008 819 200 ■1270")—29- -14 196 NEUROPSYCHIATRY MARITAL STATUS Table 27 shows the marital status of the neuropsychiatric cases. Therein it is seen that 54,106, or 78 per cent, of the 69,394 neuropsychiatric cases were single, as compared with 89.5 per cent of the draft men (Class I) who were single.4 Marriages in both groups include widowed and divorced. There are NEUROPSYCHIATRIC CASES MARITAL STATUS OF NEUROPSYCHIATRIC CASES COMPARED WITH THAT OF THE MEN PLACED IN CLASS I NOTE: MARRIED INCLUDES ALSO WIDOWED AND DIVORCED. Chart XV several explanations for the excess in the percentages of married men among the neuropsychiatric cases: One was the tendency of the local boards to place in Class I men who had no families to support; another is the probability that Chart XVI some benedicts enlisted on account of domestic troubles, which are frequent among those handicapped by nervous and mental disease or defects. It will be noticed that the number of marriages among the colored exceeds that of the whites, the ratio more than double, and that there is a very slight increase in the ratio of divorces among the colored. IN THE UNITED STATES Table 27.—Marital status of neuropsychiatric cases 197 Total White Colored Di-vorc-ed Diagnoses Total Single Mar-ried Wid-owed Di-vorc-ed Unas-cer-tained Total Sin-gle Mar-ried Wid-owed Unas-cer-tained Mental deficiency.. _______ 21,858 11,443 7,910 17,803 10,343 7,354 15,161 7.882 5,989 1,813 2,062 932 87 56 69 128 131 115 614 212 249 4,055 1,100 556 2,724 670 359 1,158 381 85 21 73 21 15 7 Psychoses.........._. _ __ _ 160 11 8 18 530 292 1,385 4,738 131 834 487 287 1,304 4,433 112 731 322 221 1,018 3,798 86 544 105 31 209 440 19 128 16 7 10 29 27 20 19 35 2 12 17 8 48 131 5 40 43 5 81 305 19 103 26 3 50 201 11 68 14 24 87 7 28 1 1 3 3 1 2 1 1 3 2 Alcoholic___ . . _. ... Manic-depressive___ . Dementia praecox ______ Epileptic.....______ . 3 11 Other forms_____ _ .. 3 2 Nervous diseases and injuries 6,916 6,116 4,553 1,128 69 122 244 800 483 263 23 22 9 Chorea_______________ 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 252 210 428 242 483 213 282 191 127 2,161 294 183 212 838 199 170 316 191 382 161 228 163 89 1,552 186 136 167 613 46 32 83 44 67 40 43 24 29 436 59 36 33 156 3 4 6 3 8 3 3 2 22 3 23 6 10 4 5 70 30 6 7 53 12 48 126 37 28 9 58 20 10 301 39 17 31 64 5 35 71 26 21 4 37 15 9 172 19 8 18 43 6 10 42 11 7 5 18 4 1 105 18 8 9 19 1 2 5 Hemiplegia_______. 1 4 Injuries to nervous sys-tem.. .......... 4 Meningitis........._____ Multiple sclerosis. _____ Neuritis_______________ Paralysis_____ _ ... 1 2 Poliomyelitis.. ________ 1 Sciatica_______________ 35 10 3 68 9 4 2 9 Syphilis C. N. S____ 8 2 1 1 2 12 Tabes dorsalis__________ Tic___________________ Tremor____ _ _ . ... 3 Other forms___________ Epilepsy_____ . .____ 6,388 6,196 4.805 2,020 1,858 5,273 5,941 4,506 1,823 1,834 4,009 4,857 3,570 1,367 1,379 926 803 792 355 282 47 31 21 20 45 68 83 28 41 74 223 167 95 40 54 1,115 255 299 197 24 662 162 197 125 17 420 89 94 66 6 18 2 4 --- 12 2 1 2 1 142 3 Constitutional psychopathic states_______ ... Endocrinopathies .. _. ... Drug addiction..... ... ... Total_______________ 69, 394 60, 993 48, 767 9,093 445 790 1,898 8,401 5,399 2,637 171 52 HOME ENVIRONMENT—URBAN OR RURAL Neuropsychiatric examiners were instructed to classify all places of 2,500 people or over as urban, in accordance with the classification used in the reports of the United States Census Bureau. In the examination of the records of 200,000 selected registrants from urban and rural districts, 21.7 per cent of those from urban districts were rejected, while the rejections from the rural districts were 16.9 per cent.5 In other words, according to the Provost Marshal General, considerable physical advantage accrues to the boy reared in the country.5 Of the general population of the United States, 49 per cent of the whites and 73 per cent of the colored reside in rural districts. Table 28, which shows the home environment of the neuropsychiatric cases during the World War indicates no striking difference between the percentage of white and colored population and the percentage of white and colored neuropsy- chiatric cases living in the urban and rural communities. A slightly higher rate of neuropsychiatric cases is to be found among people living in the cities, but in individual clinical conditions there is more variation as between urban and rural environments. 198 NEUROPSYCHIATRY 58,709 WHITE NEUROPSYCHIATRIC CASES HOME ENVIRONMENT-URBAN OR RURAL- OF 67,050 NEUROPSYCHIATRIC CASES COMPARED WITH THE POPULATION OF THE UNITED STATES. U.S. CENSUS- 1910 Chart XVII Table 28.—Home environment of neuropsychiatric cases Diagnoses Mental deficiency_______________ Psychoneuroses_________________ Psychoses______.....____________ General paralysis____________ Alcoholic____________________ Manic-depressive____________ Dementia praecox____________ Epileptic____________________ Other forms_________________ Nervous diseases and injuries_____ Chorea______________________ Hemiplegia__________________ Injuries to nervous system..... Meningitis__________________ Multiple sclerosis____________ Neuritis_____________________ Paralysis____________________ Poliomyelitis________________ Sciatica________ Syphilis C. N. S_____________ Tabes dorsalis_____ . Tic_________________________ Tremor_____________________ Other forms_________________ Epilepsy________________________ Constitutional psychopathic states Endocrinopathies______________ Drug addiction________________" Alcoholism___________________""" Total___________ Total 21, 858 11,443 7,910 530 292 1,385 4,738 131 834 White Total 17, 803 10, 343 7, 354 487 287 1,304 4,433 112 731 Urban 6,081 5,889 4,228 374 209 800 2,400 55 390 Rural 11,022 4,167 Unas- cer- tained 700 287 Colored Total 4,055 1,100 Urban Rural 2,944 2,759 87 63 438 1,837 49 285 367 26 15 66 196 56 556 216 43 28 S 2 81 24 305 118 19 6 103 38 323 14 3 54 178 13 61 Unas- cer- tained IN THE UNITED STATES 199 STATES OF RESIDENCE AND BIRTH (WITH GAIN OR LOSS FROM IMMIGRATION OR MIGRATION) Table 29 shows the number of residents of each State included in the present series of neuropsychiatric cases. Table 30 shows the State of birth of neuropsychiatric cases. In reference to the occurrence of nervous and mental diseases or defect in the individual States, a question presents itself: Are the cases found among the residents of the State the State's own people? Table 31 shows, by States, the gains or losses of neuropsychiatric cases through foreign immigration and State migration. It will be observed that all but nine States have more cases living in the State than were born there. Table 31 shows in detail whether the problem for each State is one of foreign immigration or is of State migration of either the white or colored. Those interested may ascer- tain how immigration is related to the State problem in regard to any clinical group. For instance, as concerns mental deficiency in Connecticut and Rhode Island, the foreign-born mental defectives constituted about one-half of all the cases. In New York and Massachusetts about one-third of the cases were of foreign birth. In New Jersey, Pennsylvania, Michigan, California, and Washington the foreign-born equaled from one-fourth to one-fifth of the total. In many of the other States the ratios were from one-sixth to one-ninth of the totals. Thus it may be determined in reference to any condition how many cases more or less were residing in the State than were born there. For instance, the residents of Alabama gave birth to 435 of the white and 711 of the colored mental defectives. The same State had only 397 of the whites and 656 of the colored mental defectives living there. In other words, the other States had among their mental defectives 38 whites and 55 colored which were received from Alabama (for which the latter State received 9 in return). The residents of the State of New York gave birth to 814 of the white and 12 of the colored mental defectives, and 412 of the whites came to the State from foreign countries. Deducting the last figure from the total whites, it is found that the State of New York received 45 white and 35 colored mental defectives from the other States. Calculations similar to the ones made in the preceding paragraphs may be made by those interested for each of the different clinical conditions for every State in the Union. The results may be of no great practical value because of the inability to prevent neuropsychiatric individuals from going where they are taken by their parents. The information may prove useful, however, to those who wish to determine the localities that furnish more than their quota of neuropsychiatric conditions. 200 NEUROPSYCHIATRY Table 29.—State of residence of neuropsychiatric ca.- I'ni 3 o 21, s;»S 11, 443 ted States Alabama Arizona Arkansas California Diagnoses 2 1 M — o si ca S I s 17,803 ,4,05.5 10,343 1.100 o 1,053 285 White Black "3 0 18 15 M CD CS 5 1 1 3 "o 615 212 cd 384 184 as s 231 28 "3 0 cu !3 377 2*6 297 a a 397 056 222 63 19 16 3S2 2H7 300 5 Psychoneuroses___------ ------ 1 7,910 7,354 556 179 130 49 22 20 2 100 80 20 3 530 292 1,385 4,738 131 834 487 287 1,304 4,433 112 731 43 5 81 305 19 103 7 2 23 111 9 27 5 2 22 85 7 9 2 .... 26 2 is 1 1 5 12 1 1 4 12 .... 4 .... 4 9 12 56 167 7 49 9 12 56 165 7 48 __ __ 1 23 59 4 10 21 50 2 7 2 9 2 3 -- 2 __ Other forms.. ____ ------- 3 2 1 1 Nervous diseases and injuries---- 6,916 6,116 800 213 109 104 23 22 1 87 63 24 210 208 2 264 258 554 279 511 222 340 211 137 2,462 333 200 243 902 252 210 428 242 483 213 282 191 127 2,161 294 183 212 838 12 48 126 37 28 9 58 20 10 301 39 17 31 64 9 7 52 2 21 7 9 5 3 6 2 16 5 4 4 46 "5 2 2 10 3 3 4 1 5 6 1 33 1 2 2 1 3 3 1 4 5 1 19 1 2 .... 2 .... .... 1 "u 11 7 7 15 14 13 11 5 8 71 14 4 2 28 11 7 15 14 13 11 5 8 70 14 4 2 27 Injuries to nervous system — 2 2 3 2 2 3 .... __ __ 2 7 3 3 .... 4 63 10 7 5 17 3 1 47 16 3 7 2 6 1 2 6 _.__ Syphilis C. N. S 1 Tic 3 3 11 4 2 6 4 4 .... 16 14 2 1 6, 388 6,196 4,805 2,020 1,858 5,273 5,941 4,506 1,823 1,834 1,115 255 299 197 24 174 112 55 14 5 102 1 72 13 14 8 6 5 13 14 8 5 5 .... 132 61 15 24 2 74 56 12 23 2 58 5 3 1 136 218 46 76 91 132 218 46 56 91 4 Constitutional psychopathic 80 44 13 5 32 11 1 20 Total______________________ 69, 394 60,993 8,401 2,090 1,102 988 126 120 6 1,248 878 370 1,746 1,711 35 Colorado Connecticut Delaware Florida G 652 289 eorgia Diagnoses „ ! 0 120 88 70 CD s 120 88 70 a 3 "3 0 169 112 CD 2 163 109 M 0 5 6 3 1 "3 0 36 14 13 2 | M si 3 ____ 1,360 1,196 j 164 Oregon Diagnoses Mental deficiency. Psychoneuroses... 5 s Psychoses_______________________________ 60 ; 60 General paralysis.. Alcoholic.....____ Manic-depressive- Dementia praecox. Epileptic________ Other forms_____ Nervous diseases and injuries. Chorea____________________________ Hemiplegia________________________ Injuries to nervous system------------ Meningitis_________________________ Multiple sclerosis________......------ Neuritis_____________.....---------- Paralysis........-------.....---...... Poliomyelitis_______________________ Sciatica____________________________ Syphilis C. N. S........------------- Tabes dorsalis..........-------------- Tic__________________________________ i 1 Tremor____............---------------------- Otherforms___________________________I 9, 9 27 ! 27 Pennsylvania 1,641 1,522 119 901 861 i 40 643 621 22 56 45 94 353 6 67 170 41 16 6 523 Epilepsy________________________________' 29 I 29 Constitutional psychopathic states---------- 50 50 Endocrinopathies_________________________ 16 , 16 Drug addiction___________________________ 12 8 Alcoholism______________.......----------- 1 1 Total............................-........3(18 304 564 174 294 28 15 31 37 60 22 26 8 9 160 39 16 6 429 32 674 20 556 8 157 17 293 1 5,919 5,636 283 Rhode Is- land South Caro- lina 23 233 223 537 282 318 219 144 138 103 60 South Da- kota 101 101 44 44 43 39 158 36 60 14 6 10 1,281 S3 2 i. 4 i. 20 . 12 _ 49 . 1 . "33 548 305 305 .... 204 NEUROPSYCHIATRY Table 29.—State of residence of neuropsychiatric caso -Continued 1 Te 3 o anessee 1 "exas 1 'tah Ve 3 o 39 rmont Vi rginia 3 m — o sz a '■$■ 5 "I ! 570 501 •a ' « o ^ , « Eh 3S 1 ' 936 19 .... 269 CD £ is 656 174 Diagnoses 3 o Eh 528 288 2 ! x £ ! 2 414 114 3 o H 31 29 £ i § £ i pa 31 .... it CD a 3 1.071 237 2X11 Q5 190 "liTi 4 V 240 2S5 48 x'* __"X 152 25 328 43 28 28 ____ 15 15 ...J 180 133 47 5 1 28 94 2 22 8 4 42 218 6 50 7 1 1 1 10 1 '..J 12 6 1 24 84 3 15 6 24 81 2 17 1 4 13 4 — - 35 195 1 43 7 23 5 7 4 20 4 20 1 ___ 10,.... 111 4 27 4 4 .... 2 2 ;.... 22 152 Nervous diseases and injuries---------- 194 158 36 245 200 45 9 9 -- 12 12 L... 101 51 3 9 16 2 20 4 6 10 3 85 10 3 5 18 2 8 11 20 1 1 5 2 13 26 26 8 7 10 7 2 11 63 7 7 16 42 13 20 21 3 6 8 2 2 9 54 7 4 15 36 3 3 j.... 4 7 15 26 10 4 7 2 2 42 4 9 6 14 3 4 7 19 9 4 4 1 1 24 2 8 5 10 6 5 5 1 2 5 1 I .... 1 1 .... 1 1 ___ 4 ___ 6 !_ — 10 -- 3 3 .... 1 67 9 1 4 15 2 18 1 2 1 3 2 9 ~~3~ 1 6 1 1 1 1 1 1 Syphilis C. N. S-------.....------ .... 2 2 ___ 18 2 2 .--. 2 3 2 3 I.. - ---- 4 156 60 91 51 11 106 51 67 46 10 50 9 24 5 1 299 146 40 71 18 218 143 38 66 18 81 3 2 5 12 20 6 12 5 12 19 6 12 5 .... 10 12 4 10 12 4 .... 140 123 183 20 16 83 107 158 17 14 57 Constitutional psychopathic states----- 16 25 3 -- 3 3 -- 2 2,023 1 1,325 698 1,963 1,622 341 |152 151 1 114 113 1 2,019 1,443 576 Washington Diagnoses Mental deficiency. Psychoneuroses___ Psychoses. General paralysis . Alcoholic________ Manic-depressive- Dementia praecox. Epileptic________ Other forms______ Nervous diseases and injuries. Chorea___________________ Hemiplegia_______________ Injuries to nervous system. Meningitis_______________ Multiple sclerosis_________ Neuritis__________________ Paralysis_________________ Poliomyelitis_____________ Sciatica___________________ Syphilis C. N. S__________ Tabes dorsalis____________ Tic_______________________ Tremor___________________ Other forms___........___ 117 62 78 115 62 78 West Virginia 166 469 153 Wisconsin 364 258 109 10 : 170 363 258 170 36 36 11 11 1 1 1 1 1 1 12 12 Epilepsy--------------------------------- 33 Constitutional psychopathic states________ 42 Endocrinopathies________________________ 41 Drug addiction___________________________ 30 Alcoholism_______________________________ 4 Total______________________________ 443 111 194 15 76 95 190 13 10 157 6 6 2 1 27 7 6 4 1 58 7 6 7 19 Wyoming 10 94 84 170 9 43 92 84 170 9 43 1,294 [1,214 11,349 11,345 10 10 12 11 6 6 3 3 9 9 117 IN THE UNITED STATES 205 Table 29.—State of residence of neuropsychiatric cases—Continued District of lumbia Co-C3 3 United States dependencies State unascer-tained Foreign Diagnoses Total White 3 o Eh White Black 3 o Eh CD ca 3 "3 o Eh 20 23 £ CD 74 26 47 38 48 9 2 6 2 952 323 879 311 73 12 20 L..... Psychoneuroses........................____ --- Psychoses.............._____........______ 39 I 32 7 4 3 1 442 426 16 25 General paralysis______________________ 2 j 2 2 1 2 2 | 2 23 18 1 1 1 9 I 7 2 1 1 28 21 76 244 11 62 26 21 75 236 11 57 2 1 8 Alcoholic......________________________ 1 3 14 1 3 14 Manic-depressive______ _________..... Dementia praecox________........____ 5 2 2 Epileptic_______________ .. ___________ Other forms......___________ ... _____ 2 5 7 7 Nervous diseases and injuries_______.. 35 23 12 4 4 |...... 280 269 11 10 10 6 9 26 6 22 10 8 3 5 85 23 8 8 6 7 24 6 22 10 8 2 5 79 23 8 8 61 Hemiplegia........________________... 1 2 6 4 1 1 4 2 2 2 2 2 2 1 6 1 1 Meningitis......_______________________ Multiple sclerosis______________________ 1 1 Paralysis______________________________ 2 2 2 10 2 1 2 2 8 2 1 2 Poliomyelitis__________________________ 1 6 Sciatica..__________ ________________ . 2 2 2 2 Syphilis C. N. S_______________________ 2 Tabes dorsalis_________________________ 1 Tic__________..........._______________ — .1. 3 2 1 2 | 2 1 fit 2 2 18 16 14 5 4 10 14 10 4 4 8 2 4 1 3 1 3 | 1 290 1 931 281 229 85 42 70 9 2 2 1 12 15 5 7 4 12 15 5 7 4 85 44 71 Total . _______....... 252 161 91 20 19 1 1 2,718 2,592 126 121 121 Table 30.—State of birth of neuropsychiatric cases United States Alabama Arizona Arkansas California Diagnoses Total White OS 3 "3 o CD £ CD 03 3 "3 O CD £ o 03 3 3 o Eh CD £ M CD OS 3 ■3 "o Eh CD £ CD ca 3 19, 605 10, 011 6,771 15, 558 8,914 6,215 4,047 1,097 556 1,146 333 204 435 245 148 711 88 56 2 7 7 2 7 7 -- 577 218 112 392 198 90 185 20 22 181 128 135 180 127 135 1 1 463 247 1,170 4,048 118 725 420 242 1,089 3,743 99 622 43 5 81 305 19 103 8 5 3 6 1 5 1 9 23 73 4 25 1 9 23 73 4 25 30 129 8 29 27 100 6 10 3 29 2 19 3 4 3 4 .... 23 68 5 10 21 59 3 6 2 9 2 4 Nervous diseases and injuries -.---- 6,213 5,415 798 220 110 110 9 9 -- 95 71 24 101 99 2 255 233 500 264 451 188 314 190 112 2,189 295 189 243 185 374 227 423 179 12 48 126 37 28 9 10 9 53 5 23 7 1 4 59 10 6 8 18 7 3 5 19 5 1 3 42 2 2 3 11 3 6 46 3 8 2 3 3 2 6 1 38 2 2 1 17 2 4 1 3 2 2 5 5 1 27 1 2 1 15 "ii" 5 3 9 9 7 6 8 3 2 30 8 1 5 3 9 9 7 6 8 3 2 29 7 1 Injuries to nervous system - --- .... .... 4 .... 256 58 170 20 102 10 1,889 300 257 38 172 17 .... 1 17 8 4 5 7 -- Syphilis C. N. S----------------- 1 1 Tic - -- - 227 1 196 31 806 , 742 64 Other forms______________________ .__- 2 10 10 -- 5,614 4,504 1,110 1SS 129 57 20 11 98 92 46 16 10 90 37 11 4 1 6 9 2 2 6 9 2 2 — - 121 66 25 29 7 73 18 27 7 48 9 7 2 63 98 19 33 38 61 98 19 30 38 2 Constitutional psychopathic states... 5,447 4,423 5, 192 255 4,124 299 .._- 1,890 1,694 196 1,625 1,601 24 3 61. 599 53. 217 S, 382 2, .308 1, 200 1,108 44 44 __ 1,250 933 317 796 787 9 206 NEUROPSYCHIATRY Table 30.— State of birth of neuropsychiatric cases—Continued Colorado Connecticut Delaware Florida — 2 \ a H £ PS 156 136 20 95 i 73 22 Georgia £ TL h P-685 504 299 197 Diagnoses c 70 52 42 CD £ 69 50 42 3 l 2 87 58 53 3 4 S 31 1 6 31 2 1 2 2 3 1 2 1 2 8 2 ■ •* ■s \ 3 S3 , 4 56 ! 2 27 12 17 8 M CD CO 3 10 4 o 5 181 102 53 .---1 14 12 2 74 ' 59 15 235 190 45 3 4 1 4 3 1 i 1 6 4 1 "2 10 1 1 25 ' 11 3 26 176 6 13 249 7 3 21 148 4 169 4 __ 3 I 6 2 1 5 1 .... ""b 28 12 27 12 27 S ___ 31 '___ 53 3 7 61 44 2 6 36 1 6 3 29 2 2 2 5 2 3 29 2 2 2 5 2 .... 4 12 2 4 9 3 6 Nervous diseases and injuries-------------------- 31 2 1 2 2 3 1 2 1 2 8 .... SI) 1 1 3 4 9 1 3 3 1 4 2 1 4 1 3 1 1 3 1 3 5 ~~2 .... 2 13 28 5 18 3 21 30 2 81 6 2 6 32 2 6 15 4 16 3 14 18 1 56 4 1 4 25 __ t .... 1 1 13 1 2 2 2 .... 1 1 .... ' 12 1 Syphilis C N. S. . ......._____________ 6 1 1 1 5 34 23 25 7 289 6 1 1 1 .... .... 6 4 2 22 5 1 2 3 12 5 1 ~~2~ 10 ~~2 1 25 __ .... 2 1 4 2 1 4 1 2 Other forms.-......--------------- ---- 5 ... __ 2 2 __ ' Epilepsy-------------- .----------------------- Constitutional psychopathic states-------------- Endocrinopathies.......-.....- -- ----------- -Drug addiction... ________ ----.....--------- 34 ,..__ 23 .... 25 .... 7 .... 46 49 15 14 93 45 49 15 12 23 1 ~~2 10 9 9 14 6 9 7 9 8 6 1 2 ~6~ 68 40 15 11 38 37 14 9 30 3 1 2 201 197 111 45 11 125 174 85 37 11 76 23 26 t 286 i 3 376 Total.- __________________ ___________ 367 9 113 85 28 520 402 118 2,033 1,492 541 Diagnoses Mental deficiency__________________ 23 23 Psychoneuroses_________... ... ___J Illinois t 3 5. o 676 654 660 16 410 647 ' 7 356 Indiana Psychoses________________________ 14 14 General paralvsis____________ . ______ Alcoholic_____________________________ Manic-depressive__________ ____ 5 5 Dementia praecox__________..... 8 s Epileptic_______________ . ____ 1 I 1 Other forms_______________________I___ 42 24 73 243 41 24 72 239 176 401 352 Iowa Kansas 277 197 275 196 X. — CD M -c p: H p- m 2 207 201 1 ■ 181 172 164 I___ 114 109 18 5 21 106 4 10 18 5 21 106 4 10 14 13 18 17 69 66 2 2 11 11 Nervous diseases and injuries________ 13 , 13 363 159 17 10 359 250 I 247 Chorea_______________________ 4j 4 Hemiplegia___________________________ Injuries to nervous system..... l l Meningitis________________________ Multiple sclerosis__________ ____ 2 1 2 Neuritis______________________________ Paralysis____________________ ____'_____ Poliomyelitis____________________________ ; 12 Sciatica_____________ _ Syphilis C. N. S_______________ 6 i "e" Tabes dorsalis________ Tic______.....________________ ; Tremor____.__________________I V Other forms_______________ "I I 46 18 .... 14 _. 25 _. 5 ... 21 ._ 9 _. 12 12 7 .. 156 3 17 .. 10 .... s 45 i Epilepsy_________________________ 2 Constitutional psychopathic states____ 6 Endocrinopathies______________ J g Drug addiction________________ ] ~, 3 Alcoholism____________....._____~~~ 1 Total_______________________^79~ 12 12 5 5 3 3 6 6 ...- 1 1 .... 2 2 '._-- 50 48 2 10 10 3 3 3 3 11 11 ... 273 319 360 70 195 265 315 359 67 194 132 128 4 84 , 234 233 1 105 152 152 96 23 22 1 34 46 46 -... 30 83 102 96 30 30 80 73 104 97 129 118 46 38 15 , 15 3,321 3,274 j 50 11, 779 11, 753 j 26 1,132 1,121 11 1,000 '944 IN THE UNITED STATES 207 Table 30.—State of birth of neuropsychiatric cases—Continned Diagnoses K( ntucky 2 it Louisiana 1 c Eh 174 48 ilaine Maryland Mass c achusetts 3 O Eh 0 CD 280 268 it 5 338 63 2 174 48 5 0 2 it % 3" 2 it 5 Mental deficiency__________ 939 343 856 300 83 | 618 .... 655 125 374 100 281 25 232 192 229 189 Psychoneuroses _______ ... 3 3 Psychoses_____ ________ ___. 163 151 | 12 133 89 44 25 25 — 101 172 171 9 30 112 1/ 1 General paralysis_________ 12 8 37 74 2 30 12 " i 18 49 3 14 3 1 1 3 8 5 54 2 12 3 '~2 9 9 30 113 Alcoholic__________ 8 34 72 2 ::::i i 3 1 26 2 74 ____ 4 8 -- Manic-depressive_______. 8 25 1 7 5 18 5 18 -- Dementia praecox. .... 63 2 15 -- Epileptic___ __________ Other forms__________ 23 7 | 21 1 1 — 3 13 13 -- Nervous diseases and injuries. 295 258 , 37 112 62 50 22 21 1 - • ~~ijT" 23 83 82 1 ,8 Chorea... ._ _________ . 7 4 23 4 18 5 10 2 6 127 13 10 37 29 7 4 18 3 2 2 — 1 5 4 2 10 3 1 4 2 27 5 1 3 10 6 3 3 6 3 3 Hemiplegia_______________ "5" 1 5 10 8 3 5 7 2 3 4 7 2 4 5 2 2 6 1 1 1 2 4 2 9 8 3 ~T 2 15 4 1 2 7 .... 2 -- Injuries to nervous system___. 2 2 .... -- Meningitis____ .... -- Multiple sclerosis___ 18 2 1 1 2 .... "12" 1 .... 3 6 4 7 1 3 24 2 5 3 16 6 4 7 1 3 23 2 5 3 16 Neuritis________ . .. 5 4 2 6 113 12 ~~6~ -- Paralysis _ . .....______ 4 4 .... -- Poliomyelitis . . ____ -- Sciatica___ _____________ 1 8 1 1 8 1 -'-'- Syphilis C. N. S________ Tabes dorsalis______________ 14 1 51 4 1 4 12 23 2 1 3 6 28 2 1 Tic_______________________ 8 | 2 30 1 7 28 1 Tremor______ _ _______ ... 1 6 | Other forms______ . . ____ 2 2 .... -- Epilepsy___________ _ ___________ Constitutional psychopathic states. Endocrinopathies___... __________ Drug addiction___________________ 202 193 113 38 63 184 188 104 31 55 18 5 9 7 8 279 96 44 26 9 113 76 19 22 9 166 20 25 36 31 2 5 8 36 31 2 5 8 .... 48 98 41 15 17 32 80 35 11 17 16 12 6 4 116 157 25 49 94 115 156 25 1 1 Alcoholism_________ . . ______ 94 .... Total................___________ 2,349 2,127 222 1,648 938 710 351 350 1 1,178 794 384 1,120 1,106 14 Michigan Minnesota Mississippi Missouri Montana Diagnoses 3 0 CD £ it 3 3 c Eh .■= it CD ca 5 Eh 2 it £ 03 £ 3 "3 0 Eh CD £ it CD 3 3 0 Eh CD £ it CD ca 3 427 202 423 201 4 931 231 182 -- 709 324 318 391 207 117 977 446 922 424 55 22 11 12 11 12 1 182 203 202 1 142 142 128 74 54 276 267 9 11 11 21 7 33 131 1 10 21 33 131 1 9 .... 3 5 16 106 1 11 3 5 16 106 1 11 '-'-'-- 8 1 23 69 4 23 5 1 13 43 1 11 3 "w 26 3 12 29 4 46 178 1 18 29 4 46 170 1 17 .... 1 1 !... 1 "s 3 6 "3 :.. 6 1 1 1 Nervous diseases and injuries...------- .. 175 175 .... 96 95 1 165 95 70 322 298 24 12 12 .... 7 2 7 2 30 8 9 3 7 2 7 2 30 8 9 3 :..: 6 3 6 3 11 9 3 3 1 35 1 2 6 3 5 3 11 9 3 3 1 35 .... 10 7 12 15 8 1 13 3 2 65 4 4 4 17 6 4 4 14 6 1 5 1 2 36 2 2 2 10 4 3 8 1 2 ~~8~ 2 ~29~ 2 2 2 7 14 10 20 17 16 5 13 6 3 147 16 12 15 28 14 10 18 16 13 5 12 5 3 133 16 12 14 27 2 1 3 .... 1 1 3 1 3 Syphilis C N. S .. _______________ 67 12 6 3 67 12 6 3 .... 14 4 1 4 1 1 .... 1 1 1 2 1 2 19 19 — 13 13 .... .... 132 188 191 27 38 131 187 189 27 38 1 1 2 79 69 125 30 77 [ 2 69 •-.. 125 |____ 30 .... 238 80 63 28 9 104 59 21 26 8 134 21 42 2 1 832 194 273 249 106 81 2,924 177 264 220 79 75 2,726 17 9 29 27 6 198 9 6 5 2 1 69 9 6 5 2 1 69 __ 30 30 | —.. __ 1,583 1,573 10 984 981 3 1,744 312 208 NEUROPSYCHIATRY Table 30.—Slate of birth of neuropsychiatric cases—Continued Nebraska Nevada New Hamp-shire r2 \ *^> \ it n — cd ■£ J3 , ca e i >■ [ pp 36 ' 36 '-._. 19 , 19 i-.-. 18 [ 18 .... New Jersey New Mexico Diagnoses 3 o 124 94 84 CD £ 124 94 84 2* 03 3 3 o Eh 7 6 2 CD £ 7 6 2 CD CO 5 3 O CD £ M CD CO 5 3 "3 o Eh 207 24 17 White Black 286 279 163 [163 128 125 207 24 17 __ Psychoneuroses__________________________.....-- 10 10 5 2 27 5 12 5 2 26 75 5 12 2 3 12 2 3 .... .... 2 2 4 9 2 4 9 __ 16 52 1 5 16 52 1 5 .... 1 1 1 1 — -- 12 .... __ .... 1 I ___ -- 2 2 -- 65 65 __ 3 3 — 13 13 -- 61 59 2 20 20 3 6 5 7 2 3 6 1 3 6 5 7 2 3 6 1 1 1 .... 5 5 .... 2 2 .... 2 2 4 4 6 3 2 1 1 14 3 2 6 10 114 123 63 41 35 4 4 6 3 2 1 1 13 3 2 6 9 108 122 62 36 35 .... 4 4 1 1 .... ...: 1 3 1 1 3 1 1 1 .... i 1 4 1 4 22 22 3 3 .... 1 1 3 1 6 45 40 55 19 14 3 1 6 44 40 55 18 14 3 1 3 18 17 2 3 3 1 3 18 17 2 3 7 .... l 6 1 1 5 4 29 11 13 4 2 4 29 10 13 4 2 l .... 3 1 3 1 — 1 3 3 Total________............................... 540 538 2 25 25 .... 133 133 ___|l,014 989 25 327 326 1 New York Diagnoses Mental deficiency____________________: 826 814 Psychoneuroses__......______________' 807 I 802 North Carolina 361 Psychoses___________________________' 563 ' 560 General paralysis.........__________ 43 Alcoholic_________________________| 35 Manic-depressive__________________ 119 Dementia praecox.......___________ 322 Epileptic__________________________ 5 Other forms_______________________ 39 Nervous diseases and injuries. Chorea__________________ Hemiplegia______________ Injuries to nervous system- Meningitis_______________ Multiple sclerosis_________ Neuritis_________________ Paralysis________________ Poliomyelitis_____________ Sciatica____________ Syphilis C. N. S__________ Tabes dorsalis_____ Tic______________________ Tremor__________________ Other forms_____________ Epilepsy......___________________ Constitutional psychopathic states. E ndocrinopathies________..... Drug addiction_____________...... Alcoholism_________ Total. 41 35 118 322 5 39 3 19 111 5 17 375 ' 374 17 11 37 10 20 4 24 31 11 114 9 19 10 58 17 11 37 10 20 4 24 31 11 113 9 19 10 58 383 631 272 427 184 375 627 272 416 184 114 22 15 641 256 134 29 140 58 95 11 14 4,468 4, 424 44 1,910 11,434 476 North Dakota 3 ;.. 22 .. i L. Ohio Oklahoma 795 633 28 15 92 186 2 40 778 , 17 1241 616 17 69 360 3 71 27 15 92 185 2 39 18 10 18 4 23 8 11 6 3 151 20 10 25 61 362 18 10 IS 4 23 8 11 6 2 147 20 10 25 60 6 57 51 1 1 3 3 3 6 6 3 3 1 1 4 3 2 2 1 5 5 4 21 1 20 2 2 1 1 1 4 4 73 15 14 10 24 24 19 4 4 11 5 S 1 2 2 239 283 430 92 79 158 [156 2 3,282 229 10 47 42 5 279 4 40 39 1 427 3 26 21 5 86 6 42 , 34 8 78 1 10 ; 10 3,215 67 603 519 84 IN THE UNITED STATES 209 Table 30.—State of birth of neuropsychiatric cases—Continued Oregon Pennsylvania Rhode Island South Carolina Diagnoses "3 o CD £ it CD 03 3 "3 O Eh 1,056 632 505 it CD ca 3 "3 o Eh CD £ it 3 c CD 304 154 56 it 5 Mental deficiency-........._______ 60 33 21 39 32 21 21 1 1,080 645 510 24 13 5 41 31 20 38 31 19 3 1 563 305 104 259 151 4S Psychoneuroses____________________ Psychoses..............._______ General paralysis______........._____ 44 37 73 294 5 57 44 37 73 290 4 57 3 3 3 2 20 66 2 11 3 2 10 34 2 5 Alcoholic______.....__________ 1 3 14 1 3 ... 14 Manic-depressive___________ 4 1 2 13 1 13 1 10 32 Dementia praecox.-______..... Epileptic_________....._______..... Other forms________________ 3 3 2 2 6 Nervous diseases and injuries..____ 19 19 448 438 10 10 9 1 112 57 55 Chorea_________________ _______ 3 3 24 10 26 24 51 17 22 7 4 152 33 16 5 57 24 10 25 24 48 17 22 7 4 147 32 16 5 57 1 1 Hemiplegia_______________ _____ 13 16 3 5 6 9 1 1 32 5 6 12 2 1 5 6 1 1 12 1 7 Injuries to nervous system__________ 1 3 2 1 2 1 Meningitis_________________ 1 1 1 4 Neuritis______................_____ 1 2 1 2 1 Paralysis_________....._______ 1 1 Poliomyelitis______................ Sciatica__________________.......... Syphilis C. N. S_________.......____ 5 2 1 5 2 1 5 1 3 3 Tabes dorsalis__________.....______ 4 Tic______________________________ Tremor___________________ _ .. _ 1 1 1 1 5 16 10 5 Other forms_________ _ _. 4 4 6 Epilepsy_______________________ _ .. 15 38 15 6 3 14 38 15 6 3 1 337 523 437 166 259 325 513 433 154 259 12 10 4 12 14 12 7 9 11 13 12 7 8 11 1 1 170 50 60 13 6 65 42 44 8 6 105 Constitutional psychopathic states. _ ____ Endocrinopathies_____________________ 8 16 Drug addiction________....._________ 5 Total___________............_____ 210 187 23 4,405 4,315 90 155 148 7 1,383 736 647 South Dakota Tennessee Texas Utah Diagnoses 3 o Eh CD £ it 5 3 o Eh CD 623 215 it CD ca 3 "3 o Eh CD CD — 3 3 o Eh CD £ it ca 3 95 41 94 41 l 1,071 262 448 47 534 300 421 246 113 54 36 25 36 24 l 23 22 l 170 139 31 299 258 41 23 23 7 1 28 108 2 24 5 25 88 19 2 1 3 20 5 7 8 42 190 1 51 256 5 8 34 168 1 42 206 2 2 17 2 17 8 22 4 16 4 16 4 3 i 9 3 3 9 24 24 225 175 50 50 9 5 12 17 5 20 5 10 9 4 92 10 3 5 28 4 11 10 2 19 5 8 9 3 65 9 2 5 23 1 1 7 3 1 2 1 27 1 1 5 15 25 22 7 9 8 9 4 14 76 5 9 14 39 15 18 16 5 8 6 4 4 11 62 3 6 14 34 1 3 5 4 1 1 1 3 5 4 1 1 6 2 1 2 5 3 14 2 3 5 1 1 1 1 1 1 1 1 5 5 _____ 1 3 1 _____ 3 _____ 1 4 1 4 10 15 7 10 4 Constitutional psychopathic states------- 18 15 38 2 18 _____ 15 1_____ 38 _____ ill...... 174 81 105 51 15 119 73 74 44 14 8 31 1 294 136 56 93 ■ 21 212 129 48 80 20 82 7 8 13 1 10 15 7 11 4 l Total____________.......-------- 258 256 2 2,154 1,476 678 1,989 1,620 369 140 138 2 210 NEUROPSYCHIATRY Table 30.—State of birth of neuropsychiatric eases—Continued \ "ca rermont -< rirgini a it CD CO 3 Washington We st Vir< CD 370 132 ;inia Diagnoses 2 £ it CD 3 "3 o Eh CD "3 o E-| 42 25 % 5 , £ 42 385 25 '_____I 137 5 37 26 36 i 1 26 |_____ 855 255 575 175 280 80 15 5 15 -15J-- 191 140 51 28 28 _____i 97 _____ 3 _____' 3 _____ 17 _____ 66 _____ 2 89 3 3 16 60 2 5 » 3 3 _____ i 11 3 33 116 1 27 2 26 89 16 4 1 7 27 1 11 1 1 2 18 1 5 1 1 2 18 1 5 4 6 4 '_____ 1 6 6 2 2 = 6 1 12 12 ... 145 102 43 11 11 9K 93 5 3 3 5 9 16 10 11 4 6 3 3 48 3 8 5 14 4 4 8 10 11 4 4 2 2 29 2 7 4 11 J 8 2 1 1 19 1 1 1 3 1 1 1 3 13 5 8 3 3 4 1 35 7 3 3 9 1 3 13 4 8 3 2 4 1 34 6 3 3 8 1 1 1 1 1 1 1 1 1 3 3 |_____ 1 1 4 1 4 Syphilis C. N. S__________________ 3 3 _____ 1 1 Tic_____________________________ 1 1 _____ 1 1 1 1 _____ 1 1 1 7 11 3 11 !_____ 3 1_____ 150 115 134 32 20 82 102 115 18 17 68 13 19 14 3 11 19 17 12 5 11 19 17 10 5 2 70 S2 148 12 7 69 SI 147 11 7 1 Constitutional psychopathic states__--- 1 1 1 4 4 j_____ Total _________ 115 114 i 1,897 1,326 571 170 168 2 1,036 999 37 Diagnoses Mental deficiency____ Psychoneuroses______ Psychoses__________ General paralysis. Alcholic________ Manic-depressive- Dementia praecox. Epileptic_______ Other forms_____ Nervous diseases and injuries. Chorea________________ Hemiplegia_____________ Injuries to nervous system. Meningitis_____________ Multiple sclerosis________ Neuritis___________..... Paralysis_______________ Poliomyelitis___________ Sciatica________ Syphilis C. N. S_________ Tabes dorsalis____ Tic___________________ Tremor________________ Other forms___________ Epilepsy______________________ Constitutional psychopathic states Endocrinopathies__________ Drug addiction____________'.'."'.' Alcoholism__________ Total. Wisconsin Wyoming 317 250 167 12 86 91 155 1,267 317 249 167 12 85 91 155 7 43 1,265 3 3 1 ! 1 District of Col- umbia Unascertained 1,537 1,266 646 575 534 I 504 48 43 23 91 260 24 63 271 71 30 5 35 23 95 273 31 64 12 14 37 58 27 17 25 12 6 140 41 18 158 8 6 498 10 3 424 5 2 368 8 1 133 2 130 62 4,774 12 14 34 34 26 16 20 11 6 121 37 17 s 85 63 447 398 348 127 130 4,236 IN THE UNITED STATES 211 Table 31.—Cain or loss of neuropsychiatric cases resulting from immigration or migration" Total gain or loss State migration Foreign immi- Alabama______________ —211 Arizona___............. +98 Arkansas_____....... . +2 California_____________+1, 223 Colorado . Connecticut... Delaware_____ Florida______ Georgia______ Idaho________ Illinois_______ Indiana______ Iowa________ Kansas______ Kentucky____ Louisiana____ Maine_______ Maryland____ Massachusetts. Michigan____ Minnesota___ Mississippi___ Missouri_____ Montana_____ Nebraska...... +252 +438 +32 +118 -38 +101 + 1,417 + 137 -114 -7 -2SS +10 + 101 +181 +896 +1,033 +381 -131 +171 +259 +16 White +76 — 55 +924 +198 +244 +7 +87 +42 +86 +693 +38 -177 -32 -251 + 19 +42 +87 +448 +558 +201 -42 + 1 +200 -40 Col- eration ored -120 +6 +53 -26 -2 +4 + 12 + 12 -96 +2 +96 +17 +13 -5 -48 -23 +45 +7 +36 +8 -96 +81 +4 +9 +7 +16 +4 +325 +56 +190 +13 +19 +16 + 13 +628 +82 +50 +30 + 11 +14 +59 +49 +441 +439 +172 +7 +89 +53 +47 Total gain or loss State migration Nevada_______________' +48 New Hampshire_______ +37 Xew Jersey___________, +782 Xew Mexico__________, +30 Xew York____________+3,769 Xorth Carolina________ —133 North Dakota_________ +157 Ohio_________________+1,079 Oklahoma____________ +778 Oregon_______________ +130 Pennsylvania_________+2, 514 Rhode Island__________ +154 South Carolina________ -100 South Dakota_________; +75 Tennessee____________, —126 Texas________________ +22 Utah_________________I +28 Vermont______________i +11 Virginia______________! +138 Washington___________ +354 + 298 +233 +102 +111 West Virginia______ Wisconsin.......____ Wyoming__________ District of Columbia. White Col-ored +35 +1 +4 +437 +37 + 17 +4 +1,980 + 117 -39 -99 + 106 _o +555 +103 +677 +80 + 117 -19 + 1,321 + 148 +75 +3 -3 -99 +49 -2 -151 +20 +2 -28 + 13 -1 +117 +5 +273 +215 +43 +80 +2 +80 +2 +65 +29 Foreign immi- +12 +33 +308 +9 + 1,672 +5 +53 +421 +21 +32 +1. 045 + 7fi +2 +2S +5 +48 +16 + 12 + 16 +81 +40 +151 +20 + 17 » Data unascertained for 2,755 cases. RACE Table 32 shows the distribution of neuropsychiatric conditions among the races concerned. From it may be seen the distribution averages attained by the several races. Table 33 furnishes information in regard to the four foreign- born peoples of which the numbers were adequate. This table offers oppor- tunity for comparing the occurrence of neuropsychiatric conditions between the native and foreign born in the four peoples. The results as to the different races classified worthy of notice are sum- marized below. AFRICAN (NEGRO) (Number classified, 8,401) A high distribution rate of mental defect and a low distribution rate of alcoholism is found in this race. The low alcoholic distribution exists in spite of the fact that the alcoholic habits of Negroes are about the same as of whites. From this comparison it appears that the Negro can be practically as intemper- ate as the white man without paying the same penalty for it. On the other hand, he has a higher ratio of venereal disease. (See Table 25.) By reason of this, it would seem that some modification might be made in the views of those who place alcohol as the chief factor in the spread of venereal diseases. A simi- lar, though less marked, resistance to the invasion of the central nervous system by syphilis is shown by the Negro. Among neuropsychiatric patients the pre- vious history of syphilis was more than three times as frequent in the colored as in the whites, but the invasion of the central nervous system was about equal in the two classes. 42705—29- -15 212 NEUROPSYCHIATRY Table 32.—Races of neuropsychiatric ca.- Diagnoses Mental deficiency---------------------- 21' ,?'?2 l'?nn Psychoneuroses________________________ 11,443 1,100 Psychoses General paralysis... 530 Alcoholic________________•----------1 292 Manic-depressive-----------.....- - -1 1. 385 Dementia praecox------------------- 4. 738 Epileptic__________________________I I1*1 Other forms - ----------------- 834 Chorea___ Hemiplegia Injuries to nervous system Meningiti Multiple scler Neurit Paralysis... 'oliomyelitis. Sciatica ... Syphilis C. X. S Tabes dorsalis Tic__________ Tremor Other forms Epilepsy_________ . 6,388 Constitutional psychopathic states... . 6,196 Endocrinopathies Drug addiction_____ .: 2,020 Alcoholism___________.....____________ 1, 858 Epilepsy Constitutional psychopathic states Endocrinopathies Drug addiction Alcoholism Total IN THE UNITED STATES 213 Table 33.—Per cent distribution of neuropsychiatric conditions among four different with comparisons between the American born and the foreign born Race Italians: American born. Foreign born... Scandinavians: American born. Foreign born... Irish: American born. Foreign born... German: American born. Foreign born... Xumber classified 413 2,039 4,068 394 4, 164 187 Mental defi- ciency 33.9 32.5 Psycho- neuroses 13.6 19.0 26.7 15.8 17.8 16.9 21.6 15.0 14.7 15.7 28. 1 2.V 7 17.6 15.5 Per cent of total of each nativity Psy- choses 11.6 9.3 15.4 21.9 10.9 20. 1 12.3 21.4 Xeuro- logical condi- tion Consti- I tutional Epilepsy psycho- I pathic states 6.5 8.0 9. 1 12.6 2.2 15.0 6.6 7. 1 11.6 10.9 8. 2 7.9 9.6 10.7 7.3 8.6 Endo- crinop- athies Drug ad- diction 19.1 2.6 2. 1 1.4 5.4 1.0 Alco- holism 2.4 2. L Table 34.—Races of neuropsychiatric cases. Classification percentage Total classified Per cent of total of each race Race Xum-ber Per cent Mental defi-ciency 48.3 62.9 37.7 26.2 29.2 29.1 28.0 23.8 17.2 21.0 32.7 66.9 23.6 12.4 37.0 28.4 15.3 27.5 33.8 37.3 Psycho-neu-roses Psy-choses Neuro-logical Epi-lepsy 13.3 7.3 10.1 10.4 8.9 10.8 7.4 13.5 7.1 8.2 12.8 11.7 6.8 9.3 6.6 11.9 5.9 8.7 8.8 8.4 Consti tutional psycho-pathic states ____ 3.0 8.9 8. 7 10.1 10.7 8.0 10.0 8.2 15.4 11.1 9.3 3.9 8.4 10.7 10.0 11.0 12.9 9.9 10.2 7.0 Endo-crinop-athies ____ 3.6 2.4 1.4 10.4 8.8 5.8 10.9 5.3 5.6 6.4 3.8 2.3 10.5 10.4 5.7 .9 7. 1 7.2 4.6 7.2 Drug addic-tion Alco-holism African (Xegro)______ S, 401 124 69 328 9,092 941 4,351 281 1,314 4,462 2,452 384 1,256 579 2,474 109 85 23, 604 713 8,375 12.1 .2 .1 .5 13.1 1.4 6.3 .4 1.9 6.4 3.5 .6 1.8 .8 3.6 .2 . 1 34.0 1.0 12.1 13.1 4.8 15.9 14.9 16.5 18.5 17.5 24.9 25.2 14.8 18. 1 4.2 17.6 18. 3 15.3 17.4 18.8 18.4 17.7 13.4 6.6 4.0 14.5 13.1 11.8 10.1 12.7 13.9 14.9 11.7 9.7 4.7 17.3 12.3 14.5 10.1 10.6 12.2 12.3 11.0 9.5 4.0 11.6 11.6 10.0 10.8 9.6 8.9 7.5 11.6 7. 8 5.7 10.1 16.6 7.3 14.7 18.8 10.2 9.1 10.4 2.3 3.2 0.3 2.4 Dutch ... 1.5 1.9 2.7 1.6 .4 6.7 5.0 5.3 .5 1.9 4.7 1.2 3.7 1.2 3.7 1.4 1.7 I.s English____ ___________ 2.2 4 1 2.4 1. 1 . 5 10. 1 .4 3.9) Scotch___ . _________ 5.4 2. 5 I.S Welsh . ____________ 9.4, 2.3- 2.01 3.7/ 69, 394 100.0 31.5 16.5 11.4 10.0 9.2 8.9 6.9 2.9 2.7 With the exception of mental deficiency and epilepsy, the Negro falls below all United States distribution averages. He is especially low in psychoses, constitutional psychopathic states, and alcoholism. In the psychoneuroses, the Xegro presents distinct differences from the white man. He is more prone to hysteria than to neurasthenia, and stammering is nearly twice as frequent with him as is neurasthenia. The psychological mechanism of the disorder is simple, as these conditions in Negroes were identified more frequently by examining and discharging officers. In Negroes the psychoneuroses occurred more frequently in the younger age groups than in the whites. The Negro is given to early marriage, lives more in the country, and contends with especially unfavorable circumstances as concerns education and modern standards of livinp;. 214 NEUROPSYCHIATRY AMERICAN INDIAN (Number classfied, 124) The \mencan Indian is primitive, like the Negro, and exceeds even the latter in mental deficiency. He is not so much below the average in alcoholism or drug addiction as the Negro, but is somewhat below him in epilepsj In other neuropsychiatric conditions the Indian falls below all I nited htutts aVClilVsCconcernsnon-native races, it should be remembered that the information which follows stands bv itself, and is not supplemented by any tacts as to the circumstances of residence of these races in this country, nor as to the causes of their immigration or nature of occupation. There is no information as to whether these individuals are representative of the same races living at home. Comparison can be made also between the native born and the foreign born of the different races given in Table 33. Certain definite variations are noticeable; for example, practically all native born are more addicted to the use of drugs than are the foreign born. The influence of this country seems to arouse a drug inebriety or to-convert an alcoholic inebriety into a drug inebriety. Similarly, foreigners seem to undergo a decrease in insanity from residence in this country. Table 35.—Foreign-born neuropsychiatric cases, by countries of birth Per cent of total of each nativity Country of birth X umber classi- fied Austria-Hungary-------- 462 Canada________________ 337 Denmark, Norway, Swe- den______.....------- 366 England, Scotland, Wales. 323 France________________ 49 Oermanv______________ 187 Greece____________..... 242 Holland_______________ 50 Ireland________________ 394 Italv__________________ 2,039 Poland________________ 331 Russia_____ __________ 1,675 Switzerland____________ 31 Others_________________ 772 Mental defi- ciency 31.8 21.4 Psycho-, Psycho- neuroses ses 15.8 9.3 20.4 25.7 24.0 ls.0 15.0 32.5 43.5 32.1 6.5 28.9 14.9 16.6 16.9 24.5 16.3 15.5 23.1 16.0 15.7 19.0 15.1 21.1 22.0 17.5 19.0 13.4 21.9 12.1 10.2 21.4 15.3 24.0 20.1 9.3 13.0 15.3 25.8 17.2 Neuro- logical 5.6 12.8 Epi- lepsy 11.0 9.2 Consti- tutional I Endo- psycho- I crino- pathic pathies states 12.6 7.1 8.5 12.4 8.4 15.2 24.5 14.3 8.2 10.7 8.6 7.0 9.1 14.5 7.4 4.0 20.0 8.0 10.9 7.9 6.6 8.0 15.0 9.0 6.9 6.9 9.1 7.2 5. 7 11.3 9.7 9.7 6.5 9.5 9.6 11.1 6.5 4.5 9.3 5.0 2.0 7. 5 6.2 8.0 4.8 4.4 4.2 4.4 9.7 3.6 Drug addic-tion holism 1.1 1.3 3.0 9.2 1. 4 3. 1 2. 0 1 6 4 1 0 2 6 3 1 4 6.6 10.2 2.0 2.1 2.0 ls.0 .2 .9 1.5 9.7 I.s DUTCH (Number classified, 328) The Dutch come near the United States average in almost all groups. They drink more than they take drugs, but in both are below the United States averages. They have a few less neurotics and a few more of the other classified disorders, except mental deficiency, alcoholism, and drug addiction. IN THE UNITED STATES 215 ENGLISH (Number classified, 9,092) The English, like the Dutch, approximate the United States average in practically all groups. They are more inclined to drink than to take drugs, and have a slight excess of epilepsy, endocrine disturbances, and constitutional psychopathic states. They just reach the United States average for mental defect. FRENCH (Number classified, 941) The French show rather a high total of inebriety, being above the average in alcoholism, and only a little below it in drugs, their total inebriety percentage being 6.8 per cent as compared with 4.1 per cent for English, and 4 per cent for the Germans. They also exceed the average in psychoneuroses, neurological conditions, and epilepsy. They are considerably below the average in endocrine disorders and constitutional psychopathic states, and are about equal to the United States average for mental defect. The excess of inebriety in the French may surprise many, as the French are said to be a wine-drinking people, and it is a common belief that wine-drinking people do not suffer from alcoholism. As a matter of fact, alcoholism depends more upon the amount of absolute alcohol imbibed than upon the form in which it is taken. If enough wine or beer or any other beverage with comparatively low alcohol content is taken, a person becomes alcoholic. AMERICAN-BORN GERMAN (Number classified, 4,164) In spite of his reputed beer-drinking customs, the native German fails to reach the United States average in alcoholism, and is not much given to drugs. On the other hand, he exceeds, slightly, the United States average in psychoses, psychoneuroses, and constitutional psychopathic states, and by 3.6 per cent in endocrine troubles. He is slightly below United States average in mental defect. FOREIGN-BORN GERMAN (Number classified, 1ST) The foreign-born German shows a much higher rate for insanity than the native born, and one considerably lower in endocrine troubles and mental defect. GREEK (Number classified, 281) The Greeks are very low in inebriety, especially as concerns drugs, but exceed the United States average in epilepsy, the psychoses, and the psycho- neuroses, an excess particularly noticeable in epilepsy and the psychoneuroses. They are well below the average in mental defect and constitutional psycho- pathic states. 216 NEUROPSYCHIATRY HEBREW (Number classified, 1,314) The American-born Hebrew shows a very striking contrast in his habits of inebriety as far as the choice of alcohol and drugs is concerned. The number of Hebrew alcoholics is almost negligible, while the percentage of drug addicts is more than double the United States rate. The Hebrew is also low in neuro- logical conditions, epilepsy, endocrine disturbances, and mental deficiency. The low percentage of mental defect is particularly striking; the only classified races which show less being the Scotch. The Hebrew exceeds, on the other hand, the average representation in the conditions characterized by emotional instability. He is nearly 3 per cent above the United States average for insanity, and is very much above it in the psychoneuroses and the constitutional psycho- pathic states. AMERICAN-BORN IRISH (Number classified, 4,068) The American-born Irish show the most pronounced tendency to inebriety of any racial group except the foreign-born Irish, and their intemperance relates to both alcohol and drugs. Inebriety constitutes 14.8 per cent of all their neuropsychiatric disorders. Although they are less than one-sixteenth of all the neuropsychiatric cases, the native-born Irish contribute more than one- fifth of all the cases of alcoholism identified by the neuropsychiatric examiners and more than one-tenth of all the cases of drug addiction. With the exception of inebriety, neurological conditions, and constitutional psychopathic states, they sink below all United States averages. They are so far below this average in mental defect that they confirm the general law of the incompatibility of alcoholism and mental defect. They also furnish an interesting example of a high distribution of alcoholism with an underaverage of mental disease. It would seem that if alcoholism were an important cause of insanity, one would find an excess of it, instead of an underaverage in a group so given to alcoholic intemperance as this one is. But in this connection it should be remembered that drafted men, as a class, were too young to have developed alcoholic insanity. The Irish offer an interesting comparison with the English. They have more inebriety by 11 per cent and less mental defect by 8.2 per cent. The excess of alcoholism and the lesser amount of mental defect would show them to be a livelier, more excitable race than the English, which is rather borne out by their having a slight excess of constitutional psychopaths than the English. FOREIGN-BORN IRISH (Number classified, 394) The foreign-born Irish have a distribution rate of mental defect 6 6 per cent lower than that for the native. They have also a lower distribution rate of constitutional psychopathic states and endocrine troubles. Insanity and inebriety are much higher among them than among those born in this country Inebriety changes both in extent and in its own distribution. There is a lessened total rate of inebriety by 4.2 per cent among the native, and even a greater falling off m the distribution rate of alcoholism. Nearly one-half of the decrease IN THE UNITED STATES 217 in alcoholism is accounted for by an increase in drug addiction among the native born. It would seem at first sight that the lowering of the distribution rate for insanity among the native-born Irish was to be connected with the lowering of the alcohol rate, but it should be observed that a similar decrease in insanity distribution occurs in the German native born as compared with foreign born, with an increase in alcoholism, and a smaller decrease in insanity among Scan- dinavian native born, with a large decrease in the alcohol rate. AMERICAN-BORN ITALIANS (Number classified, 413) The native Italians present a distribution of neuropsychiatric disorders which indicates a sluggish, backward mentality. As drug addicts they have a much larger percentage than the Jews, and like the Jews are little given to alcoholic inebriety. Some races, such as the Jews and the Irish, seem to be able to surpass the average in drug inebriety, and still, through the low per- centage of other disorders wmich indicate racial backwardness, retain the char- acteristics of nimble-minded people. For example, the Irish, while they are excessive drug users, are more given to intemperance in alcohol than in drugs; and of the two, alcoholic intemperance seems to indicate a more active mentality than does the secret and solitary use of drugs. Both Irish and Jews, while exceeding the average for drugs, are far below it in mental defect. But the Italians make the poorer choice for the satisfaction of their inebriate tendencies; and in addition to that show their racial backwardness by a preponderance of those other disorders which must be accepted as indicative of inferiority. In mental defect the native Italians exceed the United States average rate by 4.7 per cent, but in epilepsy they fall below the United States average by 6.4 per cent. In respect to the distribution of neuropsychiatric defects in general, they manifest a remarkable correlation with the two primitive races, the Xegro and the American Indians. All three have an excess of mental deficiency and are below the average in mental diseases. All these are low in endocrine troubles, and take drugs more than they drink. FOREIGN-BORN ITALIANS (Number classified, 2,039) The foreign-born Italian shows considerable variation from the native in the distribution of neuropsychiatric disorders. The rate for epilepsy and psychoneuroses is much higher among the foreign born, but the rate for drug addiction is higher among the native, as in fact it is among all the native-born European races except the Germans, where the two percentages are equal. MEXICANS (Number classified, 384j Of all the races classified the Mexicans have the highest rate for mental defect, 66.9 per cent. They exceed even the Negroes and American Indians. As all percentages are based on the total neuropsychiatric cases from each race, it is evident that when two-thirds of the total is taken up by a single condition the percentages of the other eight conditions must be low. So it is with the 218 NEUROPSYCHIATRY Mexicans. With the single exception of epilepsy, they are below the Lnited States average in all other neuropsychiatric groups. There was not a single alcoholic among them, and only two drug addicts, as contrasted with 45 epileptics and 2")7 mental defectives. MIXED RACES (Number classified, 23,604) The mixed races include those whose ancestors were of different races. This group, of course, includes most "Americans." The large number (almost one-third of the total cases) makes this group fundamentally important in the establishment of the United States average. AMERICAN-BORN SCANDINAVIANS (Number classified, 890) Native Scandinavians (Norwegian, Danish, Swedish, Icelandic) show an excess of mental disturbances and endocrine troubles. They slightly exceed the United States average of psychoneuroses. They are well below the average in mental defect and in epilepsy. FOREIGN-BORN SCANDINAVIANS (Number classified, 366) The foreign-born Scandinavians show much less mental deficiency than those born here, and, strangely enough, less endocrinopathy. On the other hand, they show an excessive percentage of alcoholism and insanity as compared with the American born. SCOTCH (Number classified, 579) The Scotch exceed the United States average in all groups except that of mental deficiency. The mental deficiency rate is lower than that of any other race and is 16.8 below the United States average. The inebriety is high; but, as in all races which have a low mental-deficiency rate, alcoholism exceeds drug taking. SLAVONIC (Number classified, 2,474) This racial classification includes Bohemian, Bosnian, Croatian, Dal- matian, Herzegovinian, Montenegrin, Moravian, Polish, Russian, Ruthenian, Serbian, Slovak, and Slovenian. The Slavs have a high mental-deficiency rate, in spite of which their inebriety is alcoholic rather than narcotic. Both varieties of inebriety are below the United States average. The comparative infrequency of epilepsy is worthy of remark, especially in view of the high mental deficiency. In spite also of the sluggishness indicated bv the excess of mental deficiency, they have an emotional sphere of some activity, as is shown bv the excess of psychoses among them. IN THE UNITED STATES 219 CORRELATIONS OF NEUROPSYCHIATRIC WITH OTHER CLINICAL CONDITIONS In the following pages, in which the nine different clinical groups are described in detail, it appears that a certain "antagonism" exists between some of the different clinical conditions. That is, where a given condition exists in excess, other conditions vary in a way that can not altogether be explained by the variations inevitable in a method of distribution percentage average of the preponderance on one condition over another. For example, the variations between mental defect and alcoholism are constant: Where one rises, the other falls. With these two this relationship or antagonism is constant as concerns States' populations and native and foreign born races. It is believed that the connections of these two conditions have a certain significance as to the environmental condition, perhaps of the traits of character of the peoples concerned. Drug addiction, the psychoses, and endocrinopathies showed a similar disharmony with mental defect, though not so conclusively as with alcoholism. Efforts to establish correlations between the psychoneuroses and constitutional psychopathic states have been less successful. There seems to be no correlation of symptoms between the psychoneuroses and the endocrine group. The character of epilepsy in this respect is that it so nearly corresponds in both states and races with the United States average. This matter will be considered in more detail below under the separate captions. MENTAL DEFECT The outstanding features in regard to mental defect, as revealed by the statistics herein, are its wide distribution throughout the United States, with an especial excess in the Negro and the American Indian; its apparent antago- nism to alcoholism, in that in the communities and races where it exceeds the United States distribution average, alcoholism falls below it, and vice versa. It is a definite clinical entity, classifiable and distinct from insanity or any other of the different neuropsychiatric conditions, and is a result of a fail- ure of development of the mentality up to a capacity which, as we are dealing only with adults, we may call adult capacity. Among its chief characteristics are lack of initiative, undue suggestibility, and lack of ability in meeting new situations. The distribution of mental deficiency is postulated as an index of general intelligence, because where it is widely distributed the average intelligence can hardly fail to be lowered thereby. The standard of intelligence is lowered not only by the actual mental defectives, but by the number of dull people which the existence of mental defect implies. The standard of mental defect employed in the Army—i. e., a mentality not exceeding that of a child of 8 vears e—implies a degree of incompetency so profound that the individual, whatevei- his race or surroundings, could not be counted on to take care of himself. Such a degree of inferiority is found in only a relatively small number of any race or people, but its occurrence has a direct bearing on the general intelligence and educability of the people in whom it occurs. It is probable that for every case of mental defect of the 8-year-old mentality standard, there are at least 10 cases of backward or retarded mentality. 220 NEUROPSYCHIATRY In addition to the lowering of the general intelligence through a high pro- portion of mental defectives, together with the dullards which go along with them, the quality of the general intelligence is further impaired by t he reduction in the chances of the existence of persons of superior intelligence. The significance of a high proportion of distinctly inferior persons in a community becomes apparent when different countries, and especially when different races, are compared. For example, as concerns mental defect, the American Indian presents a distribution rate of more than double, and the Xegro a rate little less than double, that of the rate among whites over the whole United States. This in itself is enough to explain the inability of the two races to compete with the average American. The Mexican living in the United States presents an even higher rate for mental defect (66.9 per cent) but for them, as in fact for all races which may have have immigrated here within recent years, we can draw no such general conclusions as we can for the indig- enous Indian and Xegro. The most that can be said for the foreign races which present a high distribution rate for mental defect, such as the Slavs (37 per cent) and the Italians (32.7 per cent) is that the ones living here now are distinctly below the average United States intelligence. It would be impossible to infer that these races at home present the same degree of mental inferiority. The extreme dissemination of so disabling a condition as mental defect throughout men of military age marks this subject as the most important department of public mental hygiene. The combined totals of the draft and camp examinations shows that it existed to such an extent that the individual was unfit as a soldier in 12.06 out of every 1,000 men examined. There were registered 10,101,506 men between the ages of 21 and 31 years, and the ratio of 12.06 per 1,000 gives for this number 121,824 unfit from mental defect, in this registrant class. The ratio considered above includes only men who were rejected for military service. In addition there must be considered the number who were discharged on this account after they had entered the Army. This number was 10.64N, or a ratio of 2.60 per 1,000. If mental deficiency ran uniformly among persons of all ages and of both sexes there would be, on the basis of 100,000,000 poulation, 1,218,000 mental defectives in the United States. This number would be an understatement, however, because, while the distribution of mental defect in the two sexes is about equal, many defectives die before reaching the age period on which the estimates are based. Also, inasmuch as the standard of rejection in the Armv sXia°i^,r /% Ke71TrreJeCti°n theFe Were aCCePted> without ^stion, • 000 ' ? k ' b0^b?e ^e recruits> * i* easy to see that the figures o oh™™' g;nKeral.dlsuadvantages of ^vmg mental defectives in an army are obvious. Their inability to learn and understand orders interferes wUh th X7«pStr^h-- 7T laCk °f ]Udgment -^ them^Stl^ undevelopedTn e of nLl 7 ^ t0 """* n°rmal Standards and their undeveloped sense of obligation is a constant source of difficulty and frequently IX THE UNITED STATES 221 brings them into the military courts. Of the disciplinary cases reported by neuropsychiatrists 42.3 per cent were mental defectives. When, after the war, disabled ex-soldiers came under the charge of the Bureau of War Risk Insurance, the mental defectives had almost disappeared as hospital inmates. The explanation for this may be that they did not re- quire hospital care, or that they had gone back to wTork for their families, chiefly on farms, or that they lacked the enterprise to request hospitalization. CLASSIFICATION In the classification of the mental defectives discovered in the Army, conventional terms were employed (see Table 6); an imbecile was considered as one capable of guarding himself against common physical danger, but in- capable of earning a living; a moron as one capable of earning a living under favorable circumstances, but incapable of competing on equal terms with his normal fellows. Xo idiot came under the observation of the neuropsychiatric officers, and, among the whites, morons constituted approximately two-thirds of the mental defectives and imbeciles one-third. The negroes showed a higher per- centage of grave defects, as among them the imbeciles constituted 47.7 per cent of the cases and the morons, or higher grades, sank to 50 per cent with 0.8 per cent border-line cases. Of the cases rejected at local boards, as re- ported in the report of the Provost Marshal General, no classification as to mental grade was made. The present statistics refer to a definite group, and so it is not possible to compare the classification derived from them with classi- fications obtained in civil life. METHODS OF DISCOVERING CASES Twenty-eight per cent of the mental defectives discovered were referred by medical officers, and 26 per cent by line officers, notably company command- ers. (See Table 8.) They were referred chiefly because they could not under- stand or learn. These two percentages disclose the satisfactory cooperation that existed between the specialists and the officers of the Army as a whole. As far as medical officers were concerned, any doubt that may have existed in their minds as to the nature of the diagnosis was relieved by the consultation, so that they could proceed confidently to the necessary steps for discharge on account of disability. Hospital beds were thereby relieved. In connection with examinations made of members of the Army by the psychologists, all men falling into the lowest group as a result of the psychological examinations were to be referred to the psychiatrist as suitable for discharge. Information as to the exact number of cases so referred has not been obtainable. Partial reports of the section of psychology of the Surgeon General's Office give the number as 4,7)55 from the examination of 1,147,829 men. If a man was considered unfit for service after receiving a psychiatric examination he was recommended for discharge by the psychiatrist and the case was reported to the Office of the Surgeon General on Forms 89 and 90 Medical Department, from which the statistical data of this study have been compiled. According 999 NEUROPSYCHIATRY to the available records, specific recommendations were made by the psychia- trists on only 936 of the cases referred. Of this number, 175 cases, or 18.7 per cent, were found to be not mental defectives. These 175 cases were diagnosed as follows: Psychoneuroses, 45; psychoses, 2S; constitutional psychopathic states, 26; nervous disease and injuries, 29; endocrinopathies, 23; epilepsy, 22; and drug addiction, 2. LENGTH OF SERVICE PRIOR TO DISCOVERY Prior to the expiration of the average training period, 18,858, or about 86 per cent of the total number of mental defectives, had been identified. (See Table 10.) There were 1,475 mental defectives recorded at Base Hospital Xo. 214, the one central receiving point for such cases in the American Expedi- tionary Forces.1' Many of these probably were border-line cases. Of the 1,47.5 reported as admitted to Base Hospital No. 214 as mental defectives, only 762 reached the ports of the United States under that diagnosis. Many of the others may have been put back on a duty status, after treatment in hospital and subsidence of the reactionary episode—so common among the feeble- minded under strain and excitement—that caused their admission. A higher percentage of colored cases than of white ones was discovered in the first three months and a lower one after the first six months. RECOMMENDATIONS FOR DISPOSITION Table 12 shows that only 206 cases, or 1 per cent of those identified, were recommended for full duty. Mental defect was one of the neuropsychiatric conditions for which limited service was allowable, and 2,791, or 12.8 per cent, such recommendations were made. Labor battalions were regarded as organ- izations where the Negro, for limited service, could do well, and so a higher percentage of Negroes (16.4 per cent) were recommended for limited service than whites (11.9 per cent). The proverbial freedom from physical illness of mental defectives is substantiated by the fact that only 76 cases (0.3 per cent) were retained in the hospital for treatment. DELINQUENCY Of the total number of mental deficiency cases, 562 white and 71 colored men, or 3 per cent, were referred to the neuropsychiatric officers for opinion as to the causes of misconduct. Mental deficiency heads the list of neuropsy- chiatric conditions found among the men tried for military offenses, constitut- ing 40.5 per cent of the white and 64 per cent of the colored. But a larger- percentage of constitutional psychopaths and insane were delinquent than of mental defectives. Mental deficiency was not so frequent among the neuropsychiatric pris- oners at Fort Leavenworth as it was among delinquents in the camps This fact may indicate that the mental defectives are in general the petty offenders and the individuals who commit chiefly misdeameanors. IN THE UNITED STATES 223 Table 36.—Classification of family neuropathic taints among mental defectives, according to disorder and relatives Neuropathic taint in family Nervous disease... Mental disease___ Inebriety-------- Mental deficiency. Total. Nervous disease... Mental disease___ Inebriety_______ Mental deficiency Total....... Number of cases Number of relatives Fathers Mothers g£^ 2,967 2,146 2,630 9,221 709 398 274 1,870 Total, white and colored_______________________I 11,091 « Siblings include brothers and sisters. 6 Collaterals include uncles, aunts, and cousins. Siblings <• White 686 1,542 79 1,419 353 403 194 650 1,963 55 55 781 244 243 9 1,339 3,246 2,243 337 4,189 Colored 110 196 32 399 83 113 52 264 248 18 8 196 32 36 3 292 473 363 95 1,151 3,719 2,606 432 5,340 Collat- erals * 376 972 446 151 1,945 139 432 710 2,655 FAMILY HISTORY The information covering family history is open to the criticism that it was furnished by a class of patients less qualified to be accurate about such matters than most representatives of the neuropsychiatric group. (See Tables 13 to 17.) Mental defectives, when questioned about their forbears, may well be suspected of not having the knowledge that would enable them to give correct answers. They might and probably would know if members of the immediate family had been in an institution, but otherwise would be unaware of the existence of psychiatric conditions. This would be particularly the case for histories of mental deficiency itself which, in certain sections of the country, exists as a family characteristic and so wrould not be remarked by members of the family. This probably accounts for the relatively few instances of mental defect in forbears, as shown in Table 17. About four-fifths of the histories recorded data on these several points. Psychopathic inheritance existed in a little more than one-half of the whites and a little less than one-half of the colored. Table 36 shows the large number of mothers among both the white and col- ored who had nervous diseases; also the large number of inebriates, chiefly alcoholics, among the fathers. Mental disease and defects are about equally balanced between fathers and mothers among both the white and colored. The same table shows the large number of brothers and sisters—listed in the table as siblings—who were victims of nervous disease and mental defect. This appears to be true for both the white and colored. Mental diseases also ran high among the brothers and sisters of the colored mental defectives. The table also shows the small number of mental defectives and the large number of cases of mental disease among collateral relatives. 224 NEUROPSYCHIATRY AGE Relatively few of the colored cases were found to be under 20 years of age, the greater percentage being between the ages of 20 and 25 years. (See Table 20.) As already stated, of the men placed in Class I between the ages of 21 and 29 years, 62 per cent were between the ages of 21 and 24 and 38 per cent between the ages of 25 and 29. The corresponding percentages for the cases of mental deficiency are 59.4 and 40.6. The difference of less than 3 per cent would probably justify the conclusion that between the ages of 21 and 29 there is no difference of significance between the ages of a group of mental defectives and normal individuals. When the ages of mental defectives are compared with the other groups of neuropsychiatric disorders, especially those which had a definite time of begin- ning, different conclusions appear. About 9 per cent of the white mental- deficiency cases were under 20 years of age, which percentage is the largest for any group, constitutional psychopaths and epileptics standing next in order of frequency. The percentage of white mental defectives over 30 years of age was smaller than for any other group except the endocrinopathies. The percentage of white epileptics over 30 was very slightly larger than that of the mental defectives. Among the other groups, the percentages of individuals over 30 years of age ran from 5 to over 50 per cent higher than the percentage for the mental defectives. EDUCATION Mental defectives, as might be expected, made the poorest showing in regard to education of any of the neuropsychiatric groups. (See Table 23.) The subject is best considered in connection with Table 22, prepared from certain selected examinations made by the psychological examiners, which indicates the results of their inquiries into the education of drafted men as a whole. One is struck, first of all, by the great difference between the education given the normal and that given the defective. In considering the disparity between the two, it should be borne in mind that the class here under discussion is composed of the higher grades of defectives, many of whom are, in certain respects, educable. Yet one-third of the whites and two-thirds of the colored had no education at all. No effort, apparently, was made to keep them in school. Fifty-nine per cent of the defectives had had some schooling, but only a small number reached high school, and the only college representatives were found in the officers' training camps. The difference in the efforts at education of the Negroes as compared with the whites is conspicuous. The fact that such a large number of the negroes received no education may account in part for the large number reported by the psychologists as being defective. ECONOMIC CONDITION The numbers of the white and the colored mental defectives in marginal circumstances were larger than the numbers for any other group (See Table 24.) This would be expected, since mental defectives have low earning power and lack ordinary prudence. IN THE UNITED STATES 225 HISTORY OF VENEREAL DISEASES Table 25 shows that there were relatively few instances of preexisting venereal diseases among mental defectives. This corresponds with civil experience as concerns mentally defective males, as the sexual instincts are frequently dormant in these individuals. The rate of admission of the existence of infections of some kind was about four times as high among the colored as among white mental defectives. The rate of syphilitic infection being about eight times and that of gonorrheal infections about four times as high. Among the mentally defective whites the percentage for all venereal diseases was lower than among any other group of neuropsychiatric disorders; for example, it was 12.8 per cent among white defectives and 54.2 per cent among white drug addicts; among the colored the percentage was lower than for any other group of colored except that of alcoholism, of which latter con- ditions the numbers were too small for the computation of rates. The rate of syphilitic infections among the mentally defective whites was relatively low; it was equaled, however, in the endocrine group and was not much smaller than the rates for the epileptics and the psychoneurotics. Among the colored mentally defective the rate for syphilitic infections was lower than for any other group except that of the psychoneuroses. Gonorrheal infections were comparatively infrequent among the white mental defectives; among the colored the rate was higher for mental defectives than those for the groups of alcoholism and psychoses. ALCOHOLIC HABITS There is practically no difference between the white and colored cases of mental deficiency, in so far as alcoholic habits are concerned. (See Table 26.) The percentage of moderate drinkers for both white and colored mental defec- tives is slightly larger than the percentage for all neuropsychiatric cases. The mental defective group ranked sixth in order of frequency as to intem- perance. MARITAL STATUS Including the widowed and divorced, 15.7 per cent of mental defectives were married, which is a slightly higher percentage than that (13.2 per cent) found among the total of Class I men, and a lower percentage than that of neuropsychiatric cases generally, 19.1 per cent. (See Table 27.) The per- centage of marriage was about three times as great among the colored defectives as among the white, but even in them the percentage was smaller than for any other colored group, except alcoholism. As a class, defectives show less matrimonial inclinations than any other neuropsychiatric individuals. This is in contradiction to the common theory that lack of general intelligence is the chief factor in early marriage. Inasmuch as the mental defectives married relatively less than the other neuropsychiatric groups, and groups in which temperamental instability is conspicuous, it wTould seem that the explanation of early marriage would be found in the sphere of the emotions rather than in that of the intelligence. The relative number 220 NEUROPSYCHIATRY divorced among defectives was also lower than for any other group, except the endocrine group, although among Xegro defectives it was higher than that for the group of epilepsy, endocrine disorders, drug addicts, insane, or con- stitutional psychopathic states. HOME ENVIRONMENT--URBAN OR RURAL While 51 per cent of the population of the United States resides in communi- ties of 2,500 or more (United States Census, 1920), only one-third of the mental defectives of the Army came from such urban communities. (See Table 28.) The rate of mental defectives from rural environment is higher among the colored than among the whites. This is accounted for by the excess of rural residence of the former. Of all the neuropsychiatric conditions, mental defect was the only one for which the percentage of cases coming from rural districts exceeded the per- centage of the population residing in rural districts. The general explanation is that the great flocking to the cities, so characteristic of modern times, is a movement carried out by the more progressive of the community. STATE OF RESIDENCE (WITH GAIN OR LOSS FROM IMMIGRATION OR MIGRATION) Among the whites for the entire United States mental deficiency con- stituted 29.2 per cent of all neuropsychiatric disorders. (See Table 37.) In 19 States (Table 38) the percentages are larger than for the United States as a whole. Table 37.—State of residence of mental defectives. Percentages ° State of residence Alabama_____ Arizona______ Arkansas____ California____ Colorado_____ Connecticut... Delaware____ Florida______ Georgia______ Idaho.....____ Illinois______ Indiana______ Iowa________ Kansas______ Kentucky____ Louisiana____ Maine_______ Maryland____ Massachusetts- Michigan____ Minnesota___ Mississippi___ Missouri_____ Montana____ Nebraska____ Nevada______ White Num- ber 397 18 384 377 120 163 21 152 511 44 791 417 239 197 771 275 202 396 400 623 262 30S 922 l.i 125 11 Per cent 36.0 15.0 43.7 22.0 24.8 26.7 22.8 31.1 33.3 26.7 19.9 23.3 25.3 21.6 41.1 28.7 51.5 44.9 25.7 29.2 22.2 35.4 33.8 16.7 25.1 18.3 Colored Num- Per ber cent 656 66.4 1 16.6 231 62.4 5 14.3 6 46.2 15 37.5 15 11.5 141 31.7 60 14 3 11 67 332 319 7 15 1 328 tw 1 1 41.1 32.6 12.5 21.6 38.5 48.3 74.4 33.3 32.6 9.1 44.6 24.4 25.0 9.1 White State of residence New Hampshire______ New Jersey__________ New Mexico_________ New York___________ North Carolina_____ ._ North Dakota. _. Ohio________________ Oklahoma___________ Oregon______________ Pennsylvania_________ Rhode Island_________ South Carolina________ South Dakota________ Tennessee____________ Texas_________ Utah________________ Vermont__________________ Virginia__________________ Washington_______________ West Virginia_____________ Wisconsin________________ Wyoming_________________ District of Columbia_______ State unascertained and others Num- Per ber cent 36 27.7 393 27.6 210 61.2 1 1,271 19.8 651 46.7 101 38. 5 901 23.9 398 55 1,522 65 318 101 570 414 31 38 656 115 469 363 25 26 901 33.3 18.1 27.0 29.2 43.4 333.1 43.0 25.5 20.5 33.6 45.5 26.1 38.6 27.0 21.7 16.1 United States---------------- 17,803 29.2 Colored ew Hampshire, New York, Pennsylvania, Rhode Island, Utah, and Vermont- exceeded m the neuropsychiatric examinations in the camps. CORRELATIONS WITH OTHER CLINICAL CONDITIONS Eighteen States (Table 45) exceeded the United States distribution average or this condition. The excess of the average was 2.2 per cent. In these States the only averages of the other clinical conditions to show changes worthy of note were mental deficiency and endocrine disturbances. These both fell below IX THE UNITED STATES 253 In the classified races (Table 34) the only significant changes referred to the Negro and the Mexican. These two races are conspicuous by low averages in the constitutional psychopathic group. In reference to the foreign-born as opposed to the native (Table 33) both the German and Irish foreign-born show a lower percentage of psychopaths than the native. Table 45.—Per cent distribution of neuropsychiatric conditions in 18 States in which the rate for constitutional psychopathic states exceeded the United States rate of 9.7 per cent State of residence United States... Arizona_______ California_____ Connecticut____ Georgia------- Indiana_______ Kansas________ Maryland_____ Massachusetts... Michigan______ New Hampshire New Jersey...... New York_____ North Dakota- Oregon________ Pennsylvania__ Rhode Island___ Utah__________ Vermont______ Consti- tutional psycho- pathic states 9.7 11.7 12.7 10.3 11.8 14. 5 9. s 10.7 12.2 11.6 12.4 11.2 13.1 10.3 16.4 12.0 9.9 12.6 10.6 Mental defl- Psycho- neuroses 29.2 17.0 15.0 12.5 22.0 16.7 26.7 17.8 33.3 13.0 23.3 20.0 21.6 IS. 2 44.9 13.3 25.7 18.1 29.2 12.0 27.7 23.4 27.6 16.6 19.8 18.3 38.5 14.1 18.1 19.1 27.0 15.3 29.2 18.8 20.5 19.2 33.6 16.8 Psy- choses Neuro- logical condi- tion 12. 1 16.7 17.4 15.9 13.4 8.6 10.4 10.4 14.4 13.5 10.2 13.4 11.6 12.6 19.7 11.0 9.9 is. 5 13.3 10.0 18.3 12.2 7.7 11.5 14.3 13.5 7.6 6.9 10.9 7.3 6.8 8.8 9.2 8.9 9.3 7.2 6.0 10.6 Endo- Epilepsy crin- opathie: 8.6 10.8 10.6 3.1 7.9 6.1 7.5 8.3 6.3 15.4 4.5 4.4 10.4 1.7 8.6 11.2 10.2 1.5 12.6 5.7 10.0 6.3 8.0 3.S 9.5 5.3 7.6 9.9 9.4 4.0 7.9 4.0 S. S 3.5 Drug addic- tion 3.0 4.2 3.3 2.9 2.5 1.6 2.7 1. 1 2.9 3.0 8.4 .4 2.6 2.8 4.9 7.9 Alco- holism 3.0 4.2 5.3 4.9 2.X 2.2 2.5 7.9 2.3 4.4 3.2 3.5 3.1 .3 5.2 6.7 3.3 2.7 ENDOCRINOPATHIES The present statistics furnish only a partial record of the endocrinopathies identified during the mobilization, for the reason that only a portion of these cases came under the special observation of neuropsychiatrists. Many of the cases, it is not known how many, were regarded as medical and were disposed of as such. For this reason the present statistics give only a partial idea of the extent of this problem, especially in the central (lake) and northwest regions of the United States. The importance of the nervous aspects of these troubles, however, is shown by the fact that so many were referred to neuropsychiatrists, and also by the frequency with which a neurotic family history was given. CLASSIFICATION Of the 4,805 cases of endocrinopathies, 4,501, or 93.7 per cent, concerned the thyroid gland primarily, and 205, or 4.3 per cent, concerned the pituitary gland. (See Table 6.) As between the whites and the negroes, the whites had a higher percentage of thyroid involvement, and the negroes a higher per- centage of neurocirculatory asthenia. In view of the classification as given above it seems probable that only the outspoken cases were included in this group. Examiners may have missed some of the less conspicuous evidences of endocrine troubles either classifying them under some more evident disability or passing over the symptoms altogether. 254 NEUROPSY CHIATRY METHODS OF DISCOVERING CASES As shown in Table 8, two-thirds of the endocrinopathies were discovered at the routine examinations—the largest percentage thus discovered in any clinical group. They were medical rather than behavioristic, and with the exception of cases of alcoholism, a smaller percentage of these cases than of any others were referred by commanding officers. LENGTH OF SERVICE PRIOR TO DISCOVERY The nature of the condition rendered the time required for identification short; 92.5 per cent had been identified before the expiration of six months; 97.2 per cent of the colored had been identified in that space of time. (Table 10.) TIME OF ONSET The endocrinopathies were among the cases of longest standing; 97.7 per cent had existed for from one to five years or over before entering the service. (See Table 11.) The percentages were practically the same for both white and colored. Only 28 cases developed after entering the service, and of these 12 developed during the first six months. RECOMMENDATIONS FOR DISPOSITION As endocrinopathies so frequnetly create a partial rather than a complete disability, the percentage of them, 87.3, recommended for discharge, was smaller than that for many other conditions. (See Table 12.) Eleven and nine-tenths per cent were recommended for limited service. Two deaths were recorded. As between the whites and the colored a slightly higher percentage of the latter were recommended for discharge and a slightly smaller percentage of them were recommended for limited service. DELINQUENCY Only 6 cases out of the 4,805 in the endocrine group were reported for examination by reason of misconduct. FAMILY HISTORY Although not generally classified with nervous diseases, the endocrinop- athies gave a high percentage (61.0 per cent) of neuropsychiatric taint in the family being exceeded in this respect by epilepsy alone. (See Tables 13 to 17.) the colored gave a somewhat higher percentage than the whites. Of the neuropsychiatric conditions in the family, the order as to frequency was nervous diseases, inebriety, mental diseases, mental deficiency. The percentage of mental diseases, in the families of endocrinopaths was lower than the average for the other groups. IN THE UNITED STATES 255 AGE The bulk of these cases, both white and colored, were in the age group of the draft. They had a relatively small representation under 20 years and over 30 years. (See Table 20.) It seems probable on the one hand that they did not volunteer, and on the other, that they could not stand the strain of service. (See Table 21.) EDUCATION The white endocrine cases were somewhat below the average white soldier in relation to school and college attendance but above the average of neuro- psychiatric cases. (See Tables 22 and 23.) ECONOMIC CONDITION After the psychoneuroses and neurological conditions the endocrinopathies made the best showing in regard to economic conditions, 15.6 per cent of them being in comfortable circumstances. (See Table 24.) This relatively favorable showing was due to the whites. HISTORY OF VENEREAL DISEASES Table 25 shows the endocrinopathies to have the smallest number of histories of venereal diseases. Of the whites, 2.9 per cent admitted having had syphilis, and 13.1 per cent gonorrhea. The colored percentages were much higher. ALCOHOLIC HABITS The percentage of intemperate men among the endocrinopathies (5.1 per cent) was lower than for any other group, and they furnished the highest per- centage (49.3 per cent) of abstinent men. The colored had higher percentages as to intemperance and moderate drinking, and a lowT percentage in relation to total abstinence. (See Table 26.) MARITAL STATUS Eighty per cent of these cases were single, which was above the average for neuropsychiatric cases. (See Table 27.) The endocrinopaths had the lowest percentage of divorces. HOME ENVIRONMENT--URBAN OR RURAL Somewhat less than one-half of these cases, 44.4 per cent, lived in rural surroundings, a fact which will appear again in the paragraph on State of resi- dence. (See Table 28.) STATE OF RESIDENCE (WITH GAIN OR LOSS THROUGH IMMIGRATION OR MIGRATION) Seventeen States (Table 46) exceeded the United States distribution average of 7.4 per cent for endocrinopathies, the distribution average in these States being 11.4 per cent. These States are chiefly those in the central and north- 25(3 NEUROPSYCHIATRY west part of the United States. The Gulf States were remarkably free. (See Table 29.) For example, the average distribution in Florida, Alabama, Missis- sippi, Louisiana, and Texas was 2.7 per cent as compared with 11.4 per cent in the 17 States which exceeded the United States average. If endocrinopathy, as used herein, corresponds with the classification of "goiter" and "exophthal- mic goiter" as employed by local boards, there is substantial agreement in the results found by draft boards and by the neuropsychiatric examiners at camps. Table 46.—Per cent distribution of neuropsychiatric conditions in 17 States in which the rate for endocrinopathies exceeded the United States rate of 7.4 per cent State of residence United States Idaho______ Illinois_____ Indiana_____ Iowa_______ Kansas_____ Michigan___ Minnesota... Missouri____ Montana..... Nebraska___ Ohio_______ Pennsylvania. South Dakota Virginia____ Washington.. West Virginia Wisconsin___ Endo- crino- pathies Mental defi- ciency 29.2 26.7 19.9 23.3 25.3 21.6 29.2 22.2 33. 8 16.7 25.1 23.9 27.0 33.1 45.5 26.1 38.6 27.0 Psycho- neuroses 17.0 10.3 20.6 20.0 17.8 18.2 12.0 19.5 15.9 16.0 14.7 19.7 15.3 14.4 12.1 14.1 12.6 19.2 Psy- choses 12.1 25.5 13.8 8.8 16.4 10.4 13.5 14.0 8.5 20.8 15.5 11.3 1.0 10.5 9.2 17.7 8.2 12.6 Neuro- logical condi- tions 10.0 8.5 10.7 14.3 9.9 13.5 10.9 10.9 11.4 11.2 12.9 10.9 9.3 12.8 7.0 8.2 9.1 11.6 Epilepsy 7.9 8.3 7.5 8.4 6.3 8.6 7.8 6.3 11.9 7.6 7.7 7.6 6.6 5:8 7.5 6.3 Consti- tutional psycho- pathic States 9.7 6.7 9.1 14.5 9.3 9.8 11.6 7.1 9.4 8.9 9.4 8.6 12.0 3.9 7.4 9.5 7.8 6.2 Drug addic- tion 3.0 1.5 .6 2.6 2.5 1.1 2.2 3.0 3.7 2.6 2.7 2.8 .3 1.2 6.8 1.1 .7 Alco- holism 3.0 6.2 2. H 2.1 2.2 2.3 4.3 3.3 3.0 1.6 2.3 5.2 2.3 1.0 CORRELATIONS WITH OTHER CLINICAL CONDITIONS Seventeen States (Table 46) exceeded the United States distribution rate for endocrinopathies of 7.4, the average distribution percentage in these States being 11.4 per cent. The distribution average in these 17 States for the different clinical conditions showed no marked variations, mental deficiency, alcoholism and drug addiction fell further below the United States average than the others. The United States endocrine average was especially exceeded in the North and Northwest. In most of these States the distribution average for alcohol and drugs was well below the United States average for these two conditions Of the classified races (Table 34) five, namely, the Dutch, English, German, Scandinavian, and Scotch, were all much over average in relation to endocrine troubles. These races showed an under average in mental defect, except the English whose rate just equaled the United States average for mental defect. As between native and foreign born, the foreign born German, Scandina- vian, and Irish have a lower distribution average than the native; with the Italians the reverse is the case. (See Table 33.) DRUG ADDICTION lormfn^^ ad^ ^^^ one who has become so habituated to habit- ormmg drugs chiefly derivatives of opium-that when suddenly deprived of them he falls ill with painful symptoms and can not work. This Lli^n! and inability to work is essential to the definition of drug addiction Many if IN THE UNITED STATES 257 not most, of the habitues, as long as they are supplied with what they have become dependent on, can work and keep in fairly good health. But they go to pieces shortly after withdrawal. It is in this way that the diagnosis of drug addiction is chiefly made—not by direct examination, but by the so-called withdrawal symptoms. The drug addict has always been unpopular with the Army. He can not by any chance make a reliable soldier unless cured of this habit, and the Army has no facilities for curing him, for cure means not only hospital treatment during the period of withdrawal, but a long time of vigilant watching after- ward. Most drug users are proselytors, eager to make others acquire the habit that enslaves them, and so in any community, and especially in a military community, they create a focus which fosters bad morale and disobedience. Before the World War our Army refused to accept applicants for enlistment who were drug addicts. But it could take no such attitude under a draft act because of the danger of drug-taking being feigned as a means to exemption; and also because, if physically sound drug addicts ran into the thousands— no one knew how many there would be—to have rejected all of them would have entailed too great a loss of man power. So, from the beginning, drug addicts were not accepted, but were rejected conditionally, so that if the num- bers of them proved sufficient to justify it, they could be recalled.6 As a class drug addicts were not conspicuous as malingerers. Some recruits brought syringes, etc., with them, and others had punctured their skin for the purpose of giving the impression of being old "needle fiends." But most of these were malingerers pure and simple, and not drug addicts at all. And the number was small. The unbridled stories circulated in the newspapers in the early days, that many young men were acquiring the habit for the pur- pose of evading the draft, were entirely baseless. According to the total draft figures, drug addiction occurred in 0.54 men per 1,000 examined. METHODS OF DISCOVERING CASES By direct examination alone the only positive reliable evidence of habit are scars and abscesses from needle punctures. Failing to find these the most skillful physician can not be sure that addiction exists from any objective examination. In consequence, drug addiction belongs to the class of conduct disorders—the blight becomes evident more from the way the patient behaves than from medical examination. It appears from Table 8 that considerably less than half of the cases were identified by the psychiatrists in routine ex- aminations. This is explained, partly, by the fact that routine examinations did not disclose the condition, and partly because the addict brought to camp with him a sufficient supply of heroin or morphine, or whatever he took, and could carry on for a time. More cases of alcoholism, neurological and endo- crine disorders, and constitutional psychopathic states were found out at the start than of drug addiction. Other medical officers, on the contrary, dis- covered them frequently when they reported to hospital for treatment of symptoms of withdrawal or for independent disorders. Commanding officers also found them frequently. Drug addicts concerned psychologists but little, and few also came to light through the courts-martial or guardhouses. 258 NEUROPSYCHIATRY LENGTH OF SERVICE PRIOR TO DISCOVERY The drug addicts gave the shortest service prior to discovery—84.9 per cent of them were detected before the expiration of three months, and only 3.8 per cent served more than a year. (See Table 10.) This prompt identifica- tion may be explained in part, at least, by the fact that these soldiers could not get drugs in the cantonments and so were forced to disclose themselves. Police regulations for the suppression of the traffic seem to have been effective. TIME OF ONSET Not all those who tamper with drugs acquire the habit, even when the tampering occurs in the social ways by which drug addiction is most estab- lished. Many persons try drug taking, do not like it, and give it up after a short time. Some months are required for the habit to become fixed. But within that time the habit usually does become fixed and the fact that no cases developed in the service indicates definitely that there was not great prevalence of drug taking among troops. Ninety-eight and eight-tenths per cent of the drug addicts (Table 11) had been such for a year or more before they were mobilized. This is in full accord with what was known previously, namely, that the drug habit is a long-standing affair, meriting, on account of its very chronicity, being classed with the other degenerative neurotic con- ditions. The long establishment of the habit in the cases reported, furnishes additional proof that practically no habits were formed for the purpose of evading the draft. RECOMMENDATIONS FOR DISPOSITION Of the drug addicts discovered 90.2 per cent were recommended for dis- charge. (See Table 12.) This percentage was higher for the colored than for the white. One death was reported. The almost complete eradication of drug habitues from our troops is shown by the fact that hospital admissions in the American Expeditionary Forces for this cause numbered but 70 for the years 1917-18-19. DELINQUENCY Only 21 cases of drug addiction were reported for examination as to mis- conduct. This is approximately 1 per cent of the total 2,020 drug addicts. FAMILY HISTORY As a class, drug addicts, both colored and white, were among the more intelligent of the neuropsychiatric cases, and their answers to questions as antecedents have, therefore, a fair chance of being correct. (See Tables 13 to U.) Among them, the distribution of family neuropathic taint was about the same as among alcoholics. It was notably less than in endocrine disturbances and epilepsy. From this it seems evident that while many drug addicts are neurotically predisposed individuals, they, with alcoholics, are less so than the other members ot the neurotically degenerate group. IN THE UNITED STATES 259 Table 47 gives specific information as to which of four specified conditions had existed most frequently in the families of 907 drug addicts. The import- ance of the direct inheritance of tendency to inebriety is shown by the percent- age 24 of history of family inebriety. A similar condition exists among alco- holics (33.3 per cent) and drug addicts share with alcoholics the lowest percent- age of mental disease in the family, of all neuropsychiatric cases. But even then it is found in approximately 10 per cent of all cases. It will be observed that the history of mental disease in the family is much more frequent among negro drug addicts than among whites. Family history of mental deficiency, 2 per cent, is higher than in alcoholism, psychoneuroses, or constitutional psycho- pathic states. Table 48 shows a relative excess of inebriety in fathers. Table 47.- -Family history of neuropathic taints among cases of drug addiction Neuropathic taint in family Total White Colored Number ! Per cent a\ Number Per cent <• Number Per cento Nervous disease_______ . 266 177 429 35 14.9 10.0 24.0 2.0 239 14.8 149 9.2 382 23.7 33 2.0 27 , 15.6 28 ! 16.2 47 27.2 2 1.2 Mental disease___________ Inebriety.......________ . Mental deficiency____________ Total taints__________ 907 50.7 803 ! 49.7 104 60.1 • Percentages are based on the number of cases with each specified taint among the total cases with ascertained family history. Table 48.—Classification of family neuropathic taints among cases of drug addiction according to disorder and relatives WHITE Neuropathic taint in family Number of relatives Number of cases Father ! Mother Nervous disease... Mental disease___ Inebriety___..... Mental deficiency. Total______ 239 149 382 33 53 26 247 7 106 29 22 8 Grand- parents 35 Siblings ■ 45 134 24 Collat- erals b COLORED Nervous disease____________________ ...... _________ 27 _________ 28 .. ______ 47 2 2 4 24 16 4 3 1 4 1 7 3 20 2 2 13 Inebriety_____________________________ Mental deficiency________________________ 11 Total........_______________________ _________ 104 30 23 6 32 26 _________ 907 363 ; 188 41 334 243 <• Siblings include brothers and sisters. b Collaterals include uncles, aunts, and cousins. AGE The two groups, drug addiction and alcoholism, contain the smallest number of individuals under 20 years of age of any of the neuropsychiatric conditions. (See Table 20.) In contrast to alcoholism, the greatest number, 42705—29---IS 260 NEUROPSYCHIATRY 83.2 per cent, of drug addicts were found in the age period of 20 to 30, although negroes averaged somewhat older. Thus, while averaging older than the ages of Class I men, they were much younger than alcoholics. As a disability, drug addiction is established much more rapidly than alcoholism. They are primarily youngsters who congregate together evolving, meanwhile, a special vocabulary of their own, especially necessary since the enactment of laws limiting the use of drugs. The vendor must know the gangs' members. The members of these gangs are almost invariably young men. In the round-ups of addicts which take place from time to time only here and there will be observed anyone more than 30 or 35 years of age. The others are of about the same age as those found in the Army. The fact that drug addicts are so rarely met with after 35 years of age raises an interesting question as to prognosis. What becomes of them? If the current belief that drug addicts are incurable, that they never break the habit, is correct, the only alternative explanation is that they all die. But this explanation is not correct, because there has never been a high mortality among drug addicts. It must be, therefore, that drug addicts, as they grow older, either do break the habit, or else get adjusted to small doses such as it is possible for them to obtain easily, and so keep out of trouble. In either event, it would seem that in their maturer years persons who have taken drugs cease to be much of a burden either to themselves or the community. EDUCATION The information as to this point bears testimony to the comparatively high mental development of drug addicts. (See Table 23.) There were fewer drug addicts (4.2 per cent) without any education at all than in the other groups, and the percentage of those who reached the grades is higher for all other conditions except alcoholism. Few drug addicts, however, reached high school, and a very small percentage, indeed, got to college. This rather abrupt breaking off of the education of drug addicts who were so well represented in the grades, may find some explanation in the succeeding paragraph. ECONOMIC CONDITION Drug addicts (91 per cent), alcoholics (92.2 per cent), and mental defec- tives (95.4 per cent) were in poorer circumstances than representatives from the other neuropsychiatric groups. (See Table 24.) Mental defectives are in poor circumstances because they not only are unable to earn much them- selves, but also because one or both parents are so frequently inferior in wage- earnmg ability The same facts may hold true for both drug addiction and alcoholism, although in the latter the habits alone are sufficient to account for the mdigence. More drug addicts were in comfortable circumstances (9 per cent) than alcoholics (,.8 per cent) or defectives (4.6 per cent). All the other neuropsy- ?K gTPS T*^ 8 high°r Percenta8« m comfortable circumstances ban these three. It would seem that economic condition is to be held to account, to a certain degree at least, for the sudden cessation of education on the part of drug addicts. Economic conditions force them to forego high school and college. IN THE UNITED STATES 261 VENEREAL DISEASES Among drug addicts venereal disease prior to entering the service was more frequent than in any other neuropsychiatric conditions—56 per cent as compared to 38.8 for alcoholism and 18.5 per cent for endocrine disturbances. (See Table 25.) Among the colored cases the percentage was even higher. Twenty-three per cent of all drug cases admitted syphilis. This is higher than in any other group except in the nervous disease group, in which syphilis is included. The history of gonorrheal infection (47.5 per cent) was the highest of all in drug addicts. This frequency of venereal disease among drug addicts brings up an impor- tant consideration as to the action of drugs in the spread of venereal disease. Alcoholic intemperance has always been put down as the chief extraneous factor in the spread of venereal disease. Of course alcoholic intemperance is more widely disseminated throughout the community, and occupies a more especially important position in relation to the spread of venereal disease than drug taking, but as an actual incitant of behavior which results in venereal infection, alcohol seems materially less active than habit-forming drugs. ALCOHOLIC HABITS With the exception of alcoholism, relatively fewer drug addicts were ab- stainers than were found in any other neuropsychiatric group. (See Table 26.) With the exception of the neurological and mental deficiency groups there were proportionately more moderate drinkers among the drug addicts (48.9 per cent). After the alcoholism and the psychoses, they gave the most frequent history of intemperance. MARITAL STATUS The endocrine, mental defective, psychoses and constitutional psycho- pathic groups contain substantially more single men than the others. (See Table 27.) In the remaining group the proportion of single men was about the same throughout. Exceptions to this must be made in the case of the colored drug addicts who had more married men and fewer divorces. Id this connection, however, it should be remembered that the colored drug addicts averaged older than the whites. The married drug addicts did not seem to get along very well domestically, as the divorces among them were more frequent than among any group except the alcoholic and the nervous disease groups. HOME ENVIRONMENT—URBAN OR RURAL Table 28 shows that 91.4 per cent of the drug addicts come from cities having over 2,500 inhabitants. Among negroes the percentage was 95.4 per cent, as compared with 36 per cent of colored neuropsychiatric cases as a whole, and 27 per cent of the colored population as a whole. Drug addiction is the urban variety of neuropsychiatric disorder par excellence, being followed by alcoholism (82.8 per cent), constitutional psychopathic states (63.6 per cent), and nervous diseases (62.1 per cent). This overwhelming preponderance of narcotic drug habits among city dwellers suggests several interesting observa- tions. One of them is the folly of estimating the number of drug addicts in the country as a whole from the numbers found in cities. In the past it has been 262 NEUROPSYCHIATRY inferred that in New York, for example, where drag addicts are registered in accordance with the State law, the distribution rate in New lork might be made to apply for some State, such as Kansas, which has no very large cities. Another inference concerns control. Inasmuch as drug addiction is essentially an affair of large municipalities, its local control, in addition to Federal, should be placed in the hands of municipal authorities. The problem of suppressing it is local, and is essentially a municipal and not a State problem. This point will come out plainly when the different localities are compared, as then it will appear that cities in some sections of the country have a much higher distribution of drug addiction than others. Another inference to be drawn from Table 28 is that drug addiction is essentially a matter of social custom. It is well known that some drug addicts acquire the habit after the administration of morphine or other pain-relieving drugs by physicians. The drugs have been given after surgical operations or during the course of painful diseases. The physician either has been careless in not stopping the medicine soon enough, or the patient has continued the use of the drug without the physician's knowledge, or in spite of it. But such a mode of origin of drug addiction comprises only a small proportion of the cases. This is known to be so from analyses of the histories of individual drug addicts, and would seem to be proven by the great preponderance of drug addiction in cities as compared to rural districts. If maladministration of drugs by physi- cians was a common cause of the habit, we would expect to find the same rate of it in country as in city communities, as country doctors and city doctors treat their patients in very much the same way. But as this is not so, the conclusions seems plain that it is the urban atmosphere which fosters this variety of inebriety through example, imitation, and social associations, in much the same way that alcoholic intemperance is fostered. Table 49.—State of residence of cases of drug addiction State of residence Alabama______ Arizona_______ Arkansas______ California_____ Colorado_____ Connecticut___ Delaware_____ Florida_______ Georgia_______ Idaho_________ Illinois_______ Indiana_______ Iowa_________ Kansas........ Kentucky____ Louisiana_____ Maine________ Maryland____ Massachusetts. Michigan_____ Minnesota____ Mississippi___ Missouri______ Montana_____ Nebraska_____ Nevada_______ White Num- ber Per cent 1.2 4.2 2.6 3.3 2.1 2.9 9.8 2.9 2.5 59 11 25 23 22 24 5 14 42 24 ] 26 27 82 10 ll 1.5 .6 2.6 2.5 1.2 2.5 1.3 1.6 2.7 1.1 2.2 3.1 3.0 27.3 2.6 1.7 Colored Num- ber Per cent 0.1 16.7 .3 57.1 7.7 35.0 2.3 16.7 7.8 2.3 .3 14.3 6.5 10.8 50.0 27.3 State of residence New Hampshire__________ New Jersey_______________ New Mexico______________ New York......___________ North Carolina___________ North Dakota___ Ohio.........._________"" Oklahoma________________ Oregon.......____________ Pennsylvania_____________ Rhode Island_____________ South Carolina___________ South Dakota______........ Tennessee....._______..... Texas________ Utah____________'...'.'.'.'.'.'..'.'. Vermont___________________ Virginia____________________ Washington_________________ West Virginia_______________ Wisconsin__________________ Wyoming________________^__ District of Columbia________" State unascertained and others. United States_________ White Colored Num- ber 4 43 1 541 10 1 101 88 8 157 11 14 1 46 66 12 Per cent 2.9 3.0 .3 8.4 .7 .4 2.7 7.4 2.6 2.8 4.9 1.9 .3 3.5 4.1 7.9 Num- ber 1.2 6.8 1.1 .7 2.6 2.5 Percentages are based on total neuropsychiatric cases of each color from each State. Per cent 12 19.4 20.5 .3 3.5 4.9 100.0 6.0 20.0 2.5 1.1 l.*23 3.0 197 2.3 IN THE UNITED STATES 263 Table 50.—Per cent distribution of neuropsychiatric conditions in 12 States in which the rate for drug addiction exceeded the United States rate of 3 per cent State of residence United States Arizona_____ California___ Delaware___ Mississippi- Montana____ New York... Oklahoma... Rhode Island Tennessee___ Texas______ Utah_______ Washington.. Drug addic- tion 3.0 4.2 3.3 9.8 3.1 3.7 8.4 7.4 4.9 3.5 4.1 7.9 Mental defi- Psycho- ciency neuroses 29.2 17.0 15.0 12.5 22.0 16.7 22.8 12.0 35.4 23.2 16.7 16.0 19.8 18.3 33.3 15.6 29.2 18.8 43.0 14.3 25.5 14.8 20.5 19.2 26.1 14.1 Psy- choses 12.1 16.7 17.4 12.0 9.S 20.8 11.6 11.8 9.9 9.6 17.6 18.5 17.7 Neuro- logical Epi- condi- lepsy tions 10.0 8.6 18.3 10.8 12.2 7.7 14.1 7.6 8.3 10.9 11.2 1.9 8.8 10.0 12.7 6.7 7.2 9.4 11.9 8.0 12.3 13.4 6.0 7.9 8.2 7.5 Consti- i tutional j Endo- psycho- j crinopa- pathic ] thies states 9.7 11.7 12.7 8.7 6.7 8.9 13.1 6.7 12.6 9.5 7.4 6.7 2.7 6.5 2.1 7.9 6.3 4.0 4.0 5.1 2.3 4.0 9.3 Alco- holism 3.0 4.2 5.3 .5 0.6 3.0 3.5 1.9 6.7 .8 1.1 3.3 .9 STATE OF RESIDENCE (WITH GAIN OR LOSS FROM MIGRATION OR IMMIGRATION) Drug addiction constituted 2.9 per cent of the total of neuropsychiatric cases; 3 per cent for the whites, and 2.3 per cent for the colored. (See Table 49.) Among the colored the average of 2.3 per cent was greatly exceeded in the States of Arizona, California, Delaware, Iowa, Massachusetts, Missouri, Montana, Nebraska, New Jersey, Newr York, Oregon, and Rhode Island. Illinois furnished no cases among the colored. Among the whites the following States exceeded the United States average: Arizona, California, Delaware, Mississippi, Montana, New York, Oklahoma, Rhode Island, Tennessee, Texas, Utah, and Washington. (See Table 50.) Of the total, New York furnished more than one-quarter of the cases; and more than half were furnished by the States of New York, Ohio, Pennsylvania, California, and Missouri. These statistics show how essentially local drug addiction is. CORRELATIONS WITH OTHER CLINICAL CONDITIONS In preceding paragraphs on correlation it has been indicated that drug addiction, in common with psychoses and alcoholism, tends to sink below the distribution average in both States and races, when mental deficiency rises above it. How far the converse of this holds true in the States is shown in Table 50, which enumerates 12 States that exceed the United States distri- bution average of 3 per cent for drug addiction. For all these clinical con- ditions named, the converse holds true as far as the average of the whole 12 States is concerned. For example, the average for these States for mental defi- ciency is 25.8 per cent, for drug addiction, 5.6 per cent. The converse does not hold true for every State. As to mental deficiency, Mississippi, Oklahoma, and Tennessee exceed the average; as to psychoses, 6 fall below; as to alco- holism, 5 fall below. Of the classified races (Table 34) six—Indian, Hebrew, Irish, Italian, Scotch, and mixed—exceed the United States distribution rate for drug addiction of 3 per cent. Of these six, all but the Indian and the Italian fall below the mental deficiency average. No foreign-born race reaches the United States average of 3 per cent for drug addiction. 264 NEUROPSYCHIATRY From this it appears that drug addiction is antagonistic to mental defi- ciency, with the tendency to group itself with the conditions which indicate a higher mentality, such as psychoses and alcoholism. This tendency is less marked than in alcoholism. It further appears that those born in America are more prone to drug taking than those born abroad. It might be advisable to consider both alcoholism and drugs under a common title of inebriety. Perhaps the two conditions are interchangeable means of expressing a com- mon mental tendency or predisposition. For example, the foreign-born Irish drink heavily and are little given to drugs; while the native Irish drink much less than their foreign born brothers do, but take drugs more freely. (See Table 33.) There seems to be a distinct tendency for drug taking to become higher in native as opposed to foreign born stock, a fact to be explained, perhaps, by the proselyting traffic in drugs which exists in the large cities in the United States. It may be that drug taking is an expression of a tendency to inebriety which finds particularly favorable conditions here. ALCOHOLISM, INCLUDING THE ALCOHOLIC PSYCHOSES The most noteworthy facts, established as to the distribution of chronic alcoholism among recruits, were the small number found, the excess among volunteers as compared to drafted men, the excess of alcoholism in communities and races low in mental deficiency, and the excess of mental deficiency in com- munities and races low in alcoholism—a fact especially clear as regards negroes. It must be understood that, as used here, the term chronic alcoholism signifies more than intemperance, and the term alcoholic, more than a drinking"man. Alcoholic, as used here, means a person physically sound in other respects, who has become poisoned by alcohol to a degree to be unfit to bear arms. Of the total 69,394 neuropsychiatric cases under consideration, 1,858, or 2.7 per cent, were chronic alcoholics. (See Table 6.) How many intemperate men were accepted for service and made good under military conditions we have no means of knowing; we know only the number of those whose habits had brought about disabilities so serious that the Govern- ment did not think it worth while to try to reconstruct them. These during their brief time of service, caused comparatively little trouble They were quickly identified and discharged. The relatively small number of cases identified raises the question whether all possible ones were included, or if other reasons existed which might explain it. L,fS 1*T ^ ^VY nUmbGr 1'858' aS Siven in Table 6, does not include the 292 cases of alcoholic psychoses. To express fully the effects of alcohol on recruits these 292 cases should be added, making a total of 2,150 camp cases. If the local board cases approximate 1,000 the grand total of aleoho ies for the mobilization of approximately 3,500,000 men examined would be 3,150, or less than 1 per thousand. This result is so small, so far below any estimates that had been made that o^nth "l^lf ?LP°^ °f ^ ^ °f °- ™* had s— to do withit for it is well established that a long period of steady drinking is ^t 2T- and in ouT"! f ^^ * fact Sub^iated * the preset statistic, and m our Army, at least, the average age of alcoholics was shown to IN THE UNITED STATES 265 be above the average age of recruits. In response to this it may be said that approximately one-half of the alcoholics identified were not drafted men, but were volunteers, a group which averaged higher in age than drafted men. If the 1,199 alcoholics who were volunteers are subtracted from the 3,150 total alcoholics, there remain only 1,951 cases of drafted men who were found alco- holic. Even if only one-third of the draft had reached the age most favorable to alcoholism, the above number of them is so small that it is plain that alcoholism can not be considered as affecting to any degree the military strength of the United States. Among negro troops alcoholism practically did not exist—there were only 29 cases, including 5 cases of alcoholic psychoses, as compared with 4,055 cases of mental defect. The great disparity between these two conditions in negroes made it necessary, in constructing United States distribution averages, to leave the negro out of account, and to make the averages on the basis of whites. Table 51.—Per cent distribution of neuropsychiatric conditions in 17 States in which the rate for alcoholism, including alcoholic psychoses, exceeded the United States rate of 3.5 per cent State of residence Alcohol-ism (in-cluding alcoholic psy-choses) Mental defect Psycho-neuroses Psycho-ses Neuro-logical condi-tions Epi-lepsy Consti-tutional psycho-pathic states Endo-crinopa-thies Drug addic-tion United States. _ ___ . 3.5 5.0 6.0 5.7 8.7 7.0 8.8 4.9 3.7 18.3 4.4 3.6 4.3 6.0 7.2 3.9 7.8 3.7 29.2 15.0 22.0 26.7 22. S 19.9 25.7 22.2 16.7 18.3 27.7 27.6 19.8 27.0 29.2 27.0 21.7 16.1 17.0 12.5 16.7 17.8 12.0 20.6 18.1 19.5 16.0 11.7 23.4 16.6 18.3 15.3 18.8 19.2 24.3 23.6 12.1 16.7 17.4 15.9 12.0 13.8 14.4 11.0 21). S 18.3 10. 2 13. 4 U.6 11.0 9.9 12.6 S. 7 19.9 10.0 18.3 12.2 7.7 14.1 10.7 6.9 10.9 11.2 18.3 7.3 6.8 8.8 9.3 7.2 11.6 11.3 14.3 8.6 10.8 7.7 10.6 7.6 8.3 10.4 7.8 11.9 8.3 10.2 12.6 10.0 7.6 9.4 6.8 8.7 6.2 9.7 11.7 12.7 10.3 8.7 9.1 12.2 7.1 8.9 6.7 12.4 11.2 13.1 12.0 9.9 6.2 9.6 8.7 7.4 6.7 2.7 3.1 6.5 9.8 1.7 12.0 7.8 1.7 1.5 5.7 6.3 9.9 4.0 12.6 5.2 6.2 3.0 4.2 California........ ________ 3.3 Connecticut...... _____ __ _ 2.9 Delaware_______ .. .. _________ 9.8 1.5 Massachusetts____________________ Minnesota________________________ 2.7 2.2 3.7 1.7 New Hampshire- . _______________ 2.9 3.0 8.4 2. S 4.9 Wisconsin......___ . ______ ... 0.7 2.6 2.5 CLASSIFICATION The only effort made to classify the different varieties of alcoholism was to separate the alcoholic psychoses from the chronic form of poisoning. As has already been stated, in grouping the whole neuropsychiatric material, the alco- holic psychoses wTere considered as belonging to the psychoses. If they were omitted from an intensive study on alcoholism in troops, the result would be an incomplete picture, and so, in this section on alcoholism, the general statisti- cal information includes the psychoses due to alcohol. METHODS OF DISCOVERING CASES The neuropsychiatric examinations were usually near the head of the list of the camp examinations, and consequently were in a favorable position as regards the prompt identification of conditions which presented physical 206 NEUROPSYCHIATRY symptoms. Of all the neuropsychiatric groups, alcoholism and endocrine disturbances presented more physical symptoms than the others. These two groups, therefore, furnished the highest proportion of cases detected by the routine examinations, 63.9 per cent in the case of alcoholism. (See Table 8). Of the other methods of discovering cases, 26.9 per cent of the cases were referred bv other medical officers, these cases being in large part those requiring treatment for such conditions as delirium tremens. Only 8.9 per cent were referred by commanding officers and only a few cases by the courts martial and by the psychologists. LENGTH OF SERVICE PRIOR TO DISCOVERY The alcoholics were sifted out very promptly. Table 10 shows 71.6 per cent of all alcoholic cases were identified before they had been in service one month, which is the shortest service rendered by any one group. TIME OF ONSET Only five of the cases of alcoholism and six of alcoholic psychoses gave the date of onset after entering the service. (See Table 11.) The large majority of cases whose time of onset was ascertained gave a history of alcoholism for more than five years before entering the service. The essential chronicity of alcoholism which disabled for military service is thereby shown. RECOMMENDATIONS FOR DISPOSITION As the greater number of the cases of alcoholism were of long standing, they were considered as of little value to the service, and 1,844, or 85.8 per cent, were recommended for discharge or rejection, and 306, or 14.2 per cent, for treatment, duty, and limited service. (See Table 12.) Excepting the epilepsies and psychoses, recommendations for discharge and rejection ran higher among the alcoholics than in any of the other groups of neuropsychiatric cases. DELINQUENCY Thirty-one cases of alcoholism were referred for examination as to miscon- duct. These constituted 2.1 per cent of the total neuropsychiatric misconduct cases. FAMILY HISTORY Of the 1,873 cases analyzed under this heading 744, or 39.7 per cent, have a history of some hereditary neuropathic taint. (See Tables 13 to 17.) These figures indicate the clearest neuropathic inheritance of any neuropsychiatric group. The negro cases form an exception. When individual family neuro- psychiatric conditions are investigated, it appears that inebriety takes preced- ence of all others. Family inebriety occurs with a greater relative frequency among alcoholics than among any other group. Alcoholism in fathers appears especially prominent. IN THE UNITED STATES 267 AGE Table 20, which gives the ages of the cases of alcoholism, shows that 36.2 per cent of the cases were between the ages of 30 and 34. The increased ages of alcoholics found in the Army when compared with the statistics relating to the other groups is as follows: Age, 30 to 34: Percent Alcoholism___________________________________________ 36. 2 Nervous diseases and injuries____________________________ 19. 5 Psychoses____________________________________________ 16. 0 Drug addiction_______________________________________ 14. 5 Psychoneuroses_______________________________________ 12. 8 Constitutional psychopathic states_______________________ 12. 8 Mental deficiency_____________________________________ 9. 7 Endocrinopathies______________________________________ 9. 4 Epilepsy_____________________________________________ 9. 4 The ages of alcoholics can not be considered without noticing the condi- tions affecting volunteers and drafted men, a subject referred to elsewhere. EDUCATION Table 23 indicates that 89.6 per cent of the cases did not pass beyond the grades; that 8.2 per cent entered high school, and that an additional 2.1 per cent entered college. When compared with the statistics of the other groups of neuropsychiatric cases, with the exception of mental deficiency, one finds the smallest percentage to enter high school and college among the alcoholics. On the other hand they shared with drug addicts the distinction of being only a little behind the average soldier in having had some schooling. ECONOMIC CONDITION Only 170, or 7.8 per cent, of the alcoholics were in comfortable circum- stances. Not one of the 29 colored alcoholics was in comfortable circumstances. The whites were 4.5 per cent below the average for all neuropsychiatric white cases. With the exception of mental defectives, the percentage in comfortable circumstances is lower than for any other group. Next in order come drug addicts. HISTORY OF VENEREAL DISEASES Venereal infections of all kinds were far more frequent among the white alcoholics than among any other group of neuropsychiatric cases, except the drug addicts and the group of nervous diseases and injuries. Among the colored this did not hold true. (See Table 25.) MARITAL STATUS Marriages were about as frequent among the alcoholics as among the other groups of neuropsychiatric disorders; divorces, however, were twice as frequent among them. (See Table 27.) 26S NEUROPSYCHIATRY HOME ENVIRONMENT--URBAN OR RURAL One thousand seven hundred and one, or 82.8 per cent, were from the urban districts. The percentages for urban residences were largest for alco- holics and drug addicts. (See Table 28.) STATE OF RESIDENCE Seventeen States exceeded the United States distribution average of 3.5 per cent as to alcoholism, viz, Arizona, California, Connecticut, Delaware, Illinois. Massachusetts, Minnesota, Montana, Nevada, New Hampshire, New- Jersey, New York, Pennsylvania, Rhode Island, Wisconsin, Wyoming, District of Columbia. (See Table 51.) When the States exceeding the neuropsychiatric (camp) rate for alcoholism are compared with the States which exceeded the local board rate, as given in Table 5, it is found that a substantial agreement exists between the results of examinations by local boards and at camps. In 11 of the States mentioned— California, Connecticut, Delaware, District of Columbia, Massachusetts, Min- nesota, New Hampshire, New Jersey, New York, Rhode Island, and Wiscon- sin—the average alcoholic rate was exceeded at both draft boards and at camps. One State, Pennsylvania, which exceeded the camp rate, just equaled the local board rate. Of the States in which the camp examinations showed an over- average and the draft board examinations did not, in four—Arizona, Montana, Nevada, and Wyoming—the numbers covered in the camp examinations were too small to be of great significance. In Illinois there was a distinct disagree- ment between the two sets of figures. There were only four States—Maryland, Missouri, New Mexico, and Vermont—in which an excess in the average at draft boards failed to correspond with an excess at the camps. It would seem, therefore, that in general an excess of alcoholism in the population of any State was remarked by both draft examiners and camp examiners. NATIVITY Two hundred and sixty-four, or 12.3 per cent of all cases, of alcoholism were foreign born. This is considerably below the percentage of foreign born in Class I men (17 per cent) and above the percentage (10 per cent) of the foreign born in the whole neuropsychiatric group. CORRELATIONS WITH OTHER CLINICAL CONDITIONS In the discussion of mental defect, attention was drawn to the fact that in btates and races where mental defect was over-average, alcoholism was under- average The converse of this also holds true. Among the 17 States (Table ol) which exceeded the United States distribution average for alcoholism, none exceeded the United States distribution rate for mental deficiency. One only, Rhode Island, equaled it. The others all fell below Further correlations of alcoholism with other clinical conditions show few rates of particular significance except in the cases of psychoses. The latter IN THE UNITED STATES 269 appear to have an excess distribution rate in States high in alcoholism. In explanation of this, two hypotheses are possible: That intemperance increases insanity, or that men of the psychotic group are prone to excess in alcoholic indulgences. The correlation of alcoholism with other conditions in both native and foreign-born races is in agreement with those observed in the States. In other words, among races in which the alcoholism rate is high, the mental- deficiency rate is low, while the rate for psychoses is usually high. (See Table 34.) An exception is to be noted in the case of the Irish, where the alcoholism rate is high, but the rate for psychoses is below the average except for the foreign born. REFERENCES (1) Defects found in Drafted Men. Statistical Information. Compiled from the Draft Records. Washington, Government Printing Office. 1920. (2) Based on: History of Base Hospital No. 214, by the commanding officer. On file, Historical Division, S. G. O. (3) Psychological Examining in the United States Army. Memoirs of the National Academy of Sciences, Volume XV. Washington, Government Printing Office, 1921, 553. (4) Second Report of the Provost Marshal General, to the Secretary of War, on the Opera- tions of the Selective Service System to December 20, 1918. Washington, Government Printing Office, 1919, 118. (5) Ibid., 159. (6) Special Regulations, No. 65, W. D., 1918. SECTION II IN THE AMERICAN EXPEDITIONARY FORCES INTRODUCTION A large part of the neuropsychiatric work in the United States (described in Section I of this volume) had for its objects the maintenance of a successful effort to combat war neuroses in the American Expeditionary Forces and the provision of efficient and humane treatment in France for those of our soldiers who fell victim there to mental disease. In a sense, therefore, this section deals with the continuation of that work and its fruition. After thoughtful consideration in the Surgeon General's Office, certain general principles, based upon the recommendations of the special committee appointed in March, 1917,a were approved. Stated broadly these principles were: First, that it is not only in accordance with the best scientific practice to treat soldiers suffering with war neuroses as early and as effectively as possi- ble but to do so is an important contribution toward the conservation of manpower and military morale; second, that a point of view regarding these disorders based upon a rational conception of their physiological and psychological origin should at all times be maintained and should form the basis for medico-military effort; third, that in neuropsychiatric work, as far as the exigencies of actual service permit, responsibility and leadership should rest in the hands of those who had had special training in this department of medicine. The success attained was due, first, to a clear conception on the part of the highest military authorities of the objectives to be reached and of the general plan to be followed in attaining them; and second, to the cooperation of several hundred specialists in neuropsychiatric work in connection with combat troops, general and special hospitals, courts-martial, camps, classification boards, and prisons. ° The recommendations of this committee are given in full in the Appendix, p. 489. 271 CHAPTER I GENERAL VIEW OF NEUROPSYCHIATRIC ACTIVITIES As early as the summer of 1917 the chief surgeon, A. E. F., had been considering the organization of a group of specialists to direct and coordinate the special medical and surgical professional services in the American Expedi- tionary Forces. It was realized that, while base hospitals and tactical divisions would be adequately supplied with medical personnel, many of them leaders in medicine, surgery, and the specialties in the civil profession in the United States, professional standards throughout all the activities of an army could not be maintained at a high level, however efficient the medical officers of individual organizations might be, without some provision for the supervision of professional work by consultants in the main branches of medicine. This fact was conclusively demonstrated in the experience of our allies. Elsewmere in this history there is given an account of the organization, in September. 1917,6 of such a group of consultants. ORGANIZATION OF THE NEUROPSYCHIATRIC SERVICE The beginning of a well-defined neuropsychiatric service in the American Expeditionary Forces may be said to date from December 24, 1917, when a director of psychiatry was appointed. A medical officer, who had been assigned to duty in England to study the treatment of war neuroses, was shortly after- ward assigned as assistant in the office of the director of psychiatry. The newly organized neuropsychiatric service found plenty of urgent tasks. It was apparent that no time could be wasted in providing for neuro- psychiatric work in the tactical divisions if the American forces were to escape the heavy toll of casualties from functional nervous disorders that had been borne by the other armies earlier in the field. Although chief reliance had to be placed upon the assignment of a consultant in each tactical division who could help in the task of dealing with war neuroses at their very inception, there was no provision in the military organization for such an extra medical officer. Early in January, however, the War Department approved the planx that had been devised in the American Expeditionary Forces for the provision of a divisional neuropsychiatrist,2 thus making it possible to assign to each combat division "one specialist in nervous and mental diseases." x The instructions in this connection applied to the United States; however, they permitted division psychiatrists to be detached by the commander in chief, A. E. F., upon the arrival of divisions in France, if that seemed to be desirable. It was for this reason that these officers were not included in the tables of organization, a factor which gave rise to some difficulty later on. Fortunately, ' Vol. VIII, pp. 20-21. 273 274 NEUROPSYCHIATRY there was no disposition on the part of the chief surgeon, A. E. F., to recommend their detachment, although some of the division surgeons felt that, being attached to a field hospital, their work should be confined to such an organi- zation and not be broadened so that they could help, if needed, in every regi- ment, train, and company. Had it been possible to foresee this handicap, division psychiatrists would have been attached in the first place to the office of the division surgeon, as was done later with practically all divisional con- sultants by the division surgeons on their own initiative. On September S, 1918, a communication from the chief surgeon, A. E. F., to all division surgeons directed that divisional consultants "should be attached to the office of the division surgeon as additional assistants," 3 thus confirming a status which, in most instances, had already been granted. There were in France in January, 1918, five divisions (1st, 2d, 26th, 41st, and 42d).4 All but the 41st were in training areas centering in Chaumont, the location of general headquarters, A. E. F. Neufchateau, headquarters of the professional services, was 40 miles from Chaumont and quite as convenient a center for work in the training areas. The problem was to find psychiatrists for assignment as division consultants. Fortunately, in July, 1917, seven medical officers who had had special training in nervous and mental diseases had been sent to England to observe the treatment of war neuroses in the different British war hospitals. Orders were secured for four of these officers, all of whom were men with high professional and personal qualifications, to report to the divisions then in France. By the middle of January all four had been assigned to duty. The work of division psychiatrists, as they were always termed, from this small beginning until the demobilization of the Ameri- can Expeditionary Forces, is given in detail in the next chapter. REORGANIZATION OF THE NEUROPSYCHIATRIC SERVICE In the latter part of April, 1918, a new plan was put into effect by General Orders, No. 88, G. H. Q., under which the directors were termed senior consult- ants in the various specialties and the medical and surgical groups were under the general direction of a chief consultant in medicine and a chief consultant in surgery, respectively. The former directors became senior consultants, A. E. F.; consultants, A. E. F., were also provided. In the division of neuropsychiatry, an assistant director of psychiatry, A. E. F., who had been appointed April 10, 1918, now became consultant in neuropsychiatry, A. E. F. Although the considerations that had led to the establishment of the immense hospital centers in the American Expeditionary Forces were chiefly of an administrative nature (for example, the great amount of material needed in the construction of long sidings for the American hospital trains that brought the wounded from the front), the chief surgeon \ E F had not lost sight of the fact that professional services in the hospitals' constitut- ing these centers could be supervised effectively by a consultant in each of the more important specialties. Some of the most distinguished American physi- cians and surgeons served in this capacity with great advantage not only to the sick and wounded but to the other officers in their specialty who found encouragement to conduct their work on the highest possible level IN THE AMERICAN EXPEDITIONARY FORCES 275 By August 1, 1918, neuropsychiatric consultants had been assigned to Base Sections Nos. 1 (St. Nazaire) and 2 (Bordeaux), and to the hospital centers at Bazoilles-sur-Meuse, Paris, Tours, and Vittel-Contrexeville. A station list issued immediately after the armistice was signed showred that consultants in neuropsychiatry wTere on duty in the following base hospital centers: 5 Allerey, Beaune, Bazoilles, Commercy, Limoges, Mars, Nantes, Paris, Tours, Vichy, and Vittel-Contrexeville. Base Sections Nos. 1 (Savenay) and 2 (Bordeaux) were similarly provided for. Although no officers had been designated general consultants for the following centers, each of them had at least one base hospital to which a neuropsychiatrist was attached: Clermont Ferrand, Dijon, Langres, Mesves, and Rimaucourt.5 At the time of the signing of the armistice the administration of the pro- fessional services, as far as neuropsychiatry was concerned, was on a very effective and satisfactory basis and could have continued so with a very much larger load of responsibility in all activities. There was considerable difficulty in keeping in touch with different officers assigned to this wrork, but efforts continually were being made to improve methods of communication. It was planned to have conferences during the winter, in which studies could be made of experiences to date and plans could be prepared for the heavy load that was expected when activities were resumed in the spring. Immediately after the armistice began, the medical officer who had served since January, 1918, as division psychiatrist in the 2d Division, was assigned to duty as consultant, Base Section No. 3 (Great Britain.) NEUROPSYCHIATRIC HOSPITALIZATION FACILITIES DURING THE PERIOD OF ACTIVE HOSTILITIES The realization of the general hospitalization project of the American Expeditionary Forces c depended upon many uncertain factors, and it was necessary to scrutinize every new demand for hospital beds with.the utmost care. To ask for more than a due share for any special class of patients would be as harmful to the ultimate success of the program as to make requisition for too few to meet the expected load. The minimum provisions to meet the neuropsychiatric needs, if the program decided upon was to be carried through, were a special hospital for war neuroses just behind the front line in the proposed American sector; a psychiatric collecting station for the emergency care of the psychoses in the training area where it would be equally accessible from the front and from the divisions in training; psychiatric wards and, later, a special neuropsychiatric hospital at the principal base port, to facilitate the evacuation to home territory of patients who would not be returned to front line duty or even reclassified for duty in the Services of Supply; neuropsychiatric wards at other base ports; and a few neuropsychiatric departments at the hospital centers which it was proposed to establish at convenient points along the line of communications and which ultimately were destined to provide the major portion of the hospital beds in the American Expeditionary Forces. < Consult Chaps. XV and XVI, Vol. II of this history for details concerning the hospitals of the American Expedi- tionary Forces. 42705—29---19 276 NEUROPSYCHIATRY Within the first 60 days after a professional service in neuropsychiatry was organized, in other words, by the end of February, 1918, there were 16 base hospitals along the American line of communications, receiving, or ready to receive patients.6 It was not yet possible to determine which of the projected hospital centers would be the best one in which to develop the psychiatric collecting station, but there was organized in Base Hospital No. 66 at Neuf- chateau a special ward for mental patients to meet the immediate need.7 A medical officer and enlisted men with neuropsychiatric experience were assigned to care for mental patients. As soon as Bazoilles-sur-Meuse was definitely selected as the site for such a center, it was determined to place the main psy- chiatric collecting station there because of its proximity to the prospective site of Base Hospital No. 117, at La Fauche, and the headquarters of the professional services at Neufchateau and its nearness to the proposed American front. On February 27, the following recommendations regarding neuro- psychiatric departments in such centers were made to the chief surgeon, A. E. F., by the director of neuropsychiatry: 8 1. Where it has been determined to establish several standard base hospitals in groups (as at Bazoilles and Vittel-Contrexeville) it is obviously more economical of personnel, special equipment, and construction to provide a central neuropsychiatric department which can serve all hospitals in the group than to provide neuropsychiatric wards for each base hospital. 2. An added advantage in the collection of such wards into a unit, is that a classifica- tion of patients which will lead to much better therapeutic results can be made. It is not uncommon to find at the same time in a neuropsychiatric ward an excited manic-depressive case, several patients with middle grade mental defect sent in for observation, a case with febrile delirium, and others who have shown no abnormalities of conduct but have slight depressions or neurasthenic symptoms. Satisfactory treatment under such conditions is often impossible. If such wards are grouped, however, each may care for a different general class of patients. 3. It is recommended, therefore, that in each standard base hospital group a neuropsy- chiatric department be provided, with from 50 to 60 beds. 4. The personnel of such a neuropsychiatric department should be made up in accord- ance with the suggestions in the appended table. At least one of the medical officers should be a man of sufficient experience to enable him to act as consultant in all kinds of difficult cases; the others could be younger men, capable of doing valuable work under his general direction. 5. The commissioned officers of such neuropsychiatric departments can be furnished from the specialists now in the American Expeditionary Forces and those who will come with base hospital units. The noncommissioned officers, female nurses, and enlisted men can be supplied from those with suitable experience now attached to various hospital organizations and from Base Hospital No. 117 (neuropsychiatric hospital) which is intended to serve partly as a training hospital and replacement center for neurological and psychiatric personnel. Neuropsychiatric Department, Standard Base Hospital Group Personnel Commissioned officers . ajor ----------------------------------------------_---------jn generaj cnarge< Captain-------------------------------------------------------- Ward physician. First lieutenant-____________________________ -p» Noncommissioned officers Sergeant, first class-_____ rT. „„____, . . ° ' In general supervision. ^erge. i Mess and kitchen. Sergeant____________ r^ g______________-------------------------------------------- Office. ' Indicates that special training in the care of mental and nervous cases is required. IX THE AMERICAN EXPEDITIONARY FORCES 277 Nurses, female Acting chief nurse -______________________________________________ 1. Ward nurses (day)---------------------------------------------- 4. Ward nurses (night)-------------------------------------------- 2. Ward nurses (relief)-------------------------------------------- 1. Privates and privates, first class Ward attendants (day)----------------------------------------- 7. Ward attendants (night) -_______________________________________4. Ward attendants (relief) -_______________________________________ 2. Mess and kitchen_______________________________________________ 3. Office___________________________________________________________ 1. Recapitulation Commissioned officers_________________________________________________________________ 3 Noncommissioned officers______________________________________________________________ 3 Nurses, female------------------------------------------------------------------------ 8 Privates and privates, first class_______________________________________________________ 17 31 The neuropsychiatric department of the base hospital at Bazoilles-sur- Meuse, established in connection with Base Hospital No. 116, became the "Psy- chiatric Collecting Station," the activities of which are referred to again below. HOSPITAL FOR WAR NEUROSES (BASE HOSPITAL NO. 117) Second only in urgency to the provision of a foundation for psychiatric work with troops in the field was the establishment of a special hospital for war neuroses as far forward as possible in the advance section, for it was upon these two resources that chief dependence was to be placed for effective management and treatment of the war neuroses. Fortunately at La Fauche (a tiny village on the main route between Chaumont and Neufchateau) there was one of the camp hospitals with which each training area was to be provided.6 The use of this hospital as a special hospital for war neuroses was recommended in February, 1918, by the director of neuropsychiatry, A. E. F.9 The chief sur- geon, A. E. F., approved this plan and a provisional neuropsychiatric personnel immediately occupied it and assisted in its completion. Its activities soon increased to such an extent that by the end of May it was obliged, because of the great increase in the number of war neuroses and the lack of adequate personnel, to refuse new admissions.10 The special hospital care of these cases was the most urgent need in all the neuropsychiatric activities at that time. Though the permanent personnel for Base Hospital No. 117 had been organized early in the year in the United States, they were still detained at Camp Crane, Pa. War neuroses cases were appearing in increasing numbers in base hospitals throughout the American Expeditionary Forces, where they were treated without special facilities and in accordance with many different clinical points of view. It was by no means easy to arrange for their transfer to Base Hospital No. 117, and thus additional evidence was provided that 'Indicates that special training in the care of mental and nervous cases is required. 278 NEUROPSYCHIATRY some method of directing the evacuation of these men from the divisions must be devised or the problem of controlling the incidence of war neuroses would not be solved successfully in our Army. On June 16 the highly trained person- nel of neuropsychiatrists, nurses, and occupational aides for Base Hospital No. 117 arrived at La Fauche and within a few weeks this hospital became an efficiently organized special institution for the treatment of a special type of illness—war neuroses.10 Base Hospital Xo. 117 rapidly became the center for scientific work and training in neuropsychiatry in the American Expedi- tionary Forces. Its ability to receive patients thereafter was limited only by its capacity. By September it was apparent that this hospital would have to be greatly enlarged and so plans were drawn for the addition of a sufficient number of beds to bring the capacity to 1,000. This wTas accomplished by the time the armistice was signed.10 The necessity for a convalescent camp operated in con- nection with Base Hospital No. 117 had already been shown by the disastrous results of allowing convalescent patients to go to general convalescent camps when they no longer required hospital treatment. An entirely different point of view as to the nature of war neuroses often prevailed in the general convales- cent camps, and the result was a large number of relapses just when the maxi- mum improvement could have been expected. The plan for a convalescent camp at La Fauche was very carefully thought out. It was intended to provide for about 1,000 patients under an environment quite different from that of the hospital or of a general convalescent camp. Drill, including machine-gun and hand-grenade practice, were to constitute an important feature, and it was hoped that a special group of men could be organized into a company of infantry from those most nearly ready to return to duty. This plan, of course, was abandoned with the armistice. It was apparent that additional hospital provisions for war neuroses would be required if hostilities continued. On September 14, 1918, therefore, the senior consultant recommended a second hospital in the following letter to the chief surgeon:11 1. The number of troops in France makes it necessary now to consider the provision of the second hospital in the S. O. S. for the treatment of war neuroses. In order to have one bed per thousand combatant troops, which is generally agreed to be the miminum re- quired, it is necessary to provide another hospital as large as Base Hospital No. 117. This hospital should be at least as near the front as La Fauche and preferably not more than 60 miles to the west of it in order that a convalescent camp for these cases can be established between them which will be easily accessible from each. Perhaps a nucleus for such a hospital can be found north of Epinal. 2 If next summer, with the enlargement of our Army, a third is necessary, it could be located somewhere in the southern part of France and be used for a special class of cases-the most unfavorable type-those arising in training areas and the S. O. S. and others who have had successive relapses, the other two hospitals being employed exclusively for cases from the 3^ It seems necessary to look this far ahead in order that this problem may not get beyond our control. jo ™rv LI n^^^ l°T °f the feSUltS t0 be °btained in such advanced stations for tempo- re worktn *T Th ™ ^ JUSt ^ aWe t0 establish at Tou] an* Bennoite-Vaux. lol for t 21 trT 1S beC°ming mUCh better 0r^anized and I th^k that we mar look for a decrease rather than an increase in these cases as our mechanism for dealing with IN THE AMERICAN EXPEDITIONARY FORCES 279 them at an early point develops. I am quite sure that as a result of this method of manage- ment we shall have few of the very intractable cases seen among the British. 5. Has the division of hospitalization an offer of property in the region lying north of Epinal and east of Nancy that I might look at soon and report upon as to its suitability? Had hostilities continued, the personnel of this second hospital would have been provided by the replacement unit due to arrive in France in October. After the armistice began, new admissions to Base Hospital No. 117 declined very rapidly and a large number of men were restored to duty who otherwise would have required a considerable period of treatment.10 There was not, however, as has been stated, any very marked change in the character of the war neuroses or in their prognosis. It was simply possible to restore to A or B status some men who would have been classified C or D, had the war continued. By January 9, 1919, the number of patients had diminished to 149,12 and during the following week those remaining were transferred to Base Hospital No. 214, Savenay, which from that time on conducted two depart- ments, one for psychoses and one for psychoneuroses.13 The total admissions from the opening of the hospital were 3,268, 50 per cent of whom were returned to combat duty and 41 per cent for other military duty in the American Expedi- tionary Forces.10 PROVISIONS FOR MENTAL DISEASES (PSYCHOSES) Although the total number of American troops in France in January, 191s, was only approximately 203,000,14 the caring for mental patients had already become a problem. It was obvious at the outset that such patients could not be cared for in the individual American base hospitals scattered throughout France, partly because of the lack in some of them of medical officers, nurses, or enlisted personnel who had had experience in the actual care and treatment of patients suffering from acute mental disorders, but chiefly because of the absence of any special facilities for treatment. In order to function as a collect- ing station the neuropsychiatric department at Bazoilles would have to be provided with an outlet. Therefore, mental patients had been collected as far as possible at Base Hospital No. 8, at Savenay, near the base port of St. Nazaire, where two wards were set apart for their reception and treatment.15 The growth of these two wards into an efficient hospital for mental cases of 1,000 beds, with every modern facility for psychiatric diagnosis and treatment, is described in detail in Chapter VI of this section. Base Hospital No. 66 at Neufchateau already was serving as a temporary psychiatric collecting station for the troops in the training area. Most of its neuropsychiatric patients re- ported at the time under consideration were mental defectives who had been "weeded out" by the divisional psychiatrists as one of their first tasks. The following recommendations for the care of mental cases, made by the director of psychiatry to the chief surgeon, A. E. F., February 1, 1918, indicates the general nature of the plans then being shaped:16 1. Mental cases (insanity, mental deficiency, and constitutional psychopathic states) can be expected to furnish a considerable proportion of all soldiers of the Expeditionary Forces who will have to be invalided home. Already these cases constitute 30 per cent of the total number so returned. In the Canadian overseas forces, in spite of the enormous 280 NEUROPSYCHIATRY incidence of disability resulting from battle casualties, about 12 per cent of all soldiers returned during the war have been mental cases. 2 It is apparent from these facts that arrangements must be made for dealing with this problem. If a simple and effective mechanism for treating and evacuating mental cases is devised and put into operation while the number to be provided for is still rela- tively small, much subsequent difficulty (as well as unnecessary hardships for a class of the sick having very special needs) can be prevented. 3. Any such mechanism must take into account the fact that practically no soldier who has had a psychosis and few other mental cases should be returned to duty in France. It is not meant to imply by this statement that the psychoses common among soldiers are espe- cially unrecoverable. The reverse is the case. It is unwise to return to duty such cases, however, until a considerable period has elapsed after their recovery. This fact and the long period of treatment usually required in mental cases make it undesirable to provide for continued care in France. Provisions here must be considered as simply preliminary to their return to the United States as promptly as possible. Little more can be undertaken here than to make a careful diagnosis in each case and to provide for efficient treatment while waiting for a sailing or getting the patient into condition to make the journey safely. 4. To provide such a mechanism, the following facilities are required: (a) Observation wards in camp hospitals, or in some cases in base hospitals, favorably situated in the training areas where the psychiatrists attached to divisions can examine cases and make recom- mendations for their disposition, (b) Arrangements for the evacuation to a designated base hospital at a port of all cases requiring emergency treatments, continued observation, or return to the United States, (c) A special psychiatric department in a base hospital at St. Nazaire or Bordeaux (or one at each port if the number of such cases or transportation difficulties should require it.) Detailed recommendations as to the size, arrangement, personnel, and equipment of such a psychiatric department were inclosed. By the end of February, 1918, the above general plan of providing for patients with psychoses had been decided upon by the chief surgeon. As has been stated, Base Hospital No. 66 was the first hospital in the training areas to provide a special ward. It was not until July 20 that the neuropsychiatric department at the Base Hospital No. 116 (Bazoilles hospital center) was able to receive patients.17 It operated continuously until April 30, 1919. The other main resource for the treatment of mental disease was that provided by the neuropsychiatric department of Base Hospital No. 8, at Savenay. By June, 1918, the new ward buildings to constitute the psychiatric department wrere well under way. By June 13, 1918, it was possible for the chief surgeon's office to issue a circular letter giving detailed instructions for the care, evacuation, and trans- portation of neuropsychiatric patients in the American Expeditionary Forces. This circular is given in full because its paragraphs indicate not only the facilities available for care but also the standards of humanity which from the very first governed the treatment of this class of sick in the American Expeditionary Forces. Circular No. 35.—The Management of Mental Diseases and War Neuroses in the American Expeditionary Forces American Expeditionary Forces, France, 13 June, 1918. Absence of the auxiliary civil facilities that simplify the management of mental cases in the Army in home territory and the extraordinary incidence of functional nervous disease? IN THE AMERICAN EXPEDITIONARY FORCES 281 in all armies in the present war have made it necessary to provide special facilities and methods of procedure in the A. E. F. These disorders, by their very nature, interfere with the morale and efficiency of troops in war. Their proper management in the hospitals and organizations in which they first come to notice and their wise disposition and reclassification subsequently will not only increase military efficiency, but, in the case of war neuroses, will tend to diminish to a considerable extent their incidence. This circular is issued in order that all medical officers may become familiar with the facilities that have been provided for the diagnosis, transportation, and treatment of soldiers with these disorders. These facilities will be modified from time to time as changing con- ditions necessitate, but the general plan of management here outlined will be followed. I. Mental cases (insanity, mental deficiency, observation cases). (a) Provisions for prompt diagnosis and early care. Tactical divisions: Each tactical division in the A. E. F. and in the United States is provided with a psychiatrist whose duty it is, under the direction of the division surgeon, to examine all mental cases coming to attention in the division and to make recommenda- tions for their evacuation or other disposition. The psychiatrist will be detailed from the division sanitary personnel. Their specific duties are defined in Circular No. 5, C. S. O., A. E. F. They will examine enlisted men brought before general courts-martial as provided by W. D. order of March 28, 1918. They will also examine all other military delinquents brought to their attention, especially those in whom self-inflicted wounds or malingering are suspected. Except under exceptional circumstances, no cases of this kind will be evac- uated to the rear until examined by the division psychiatrists. In the case of prisoners accused of crimes the maximum punishment of which is death, the division psychiatrist should, whenever practicable, have the assistance of a consultant in psychiatry. Base hospitals: A neurologist or a psychiatrist has been assigned to each base hospital or group of base hospitals in the same vicinity. This provision makes it possible for mental cases that first come to attention in such hospitals to receive early diagnosis and treatment and prompt evacuation to hospitals provided with special facilities for their care. (b) Provisions for hospital care. Advance section, S. 0. S.: There has been provided in connection with Base Hospital No. 116 a neuropsychiatric department of 72 beds which will act as a collecting and evacu- ating point for mental cases from other base hospitals, from tactical divisions, and from training areas. When observation cases or patients with frank mental diseases or defect are recom- mended by the division surgeon, upon the advice of division psychiatrists, for transfer to this collecting station, the commanding officer of Base Hospital No. 116 will be notified by telephone or telegraph and will thereupon send a sufficient number of attendants to bring such patients to the hospital in safety. It is necessary, in making such requests, to state the number of patients and the amount of supervision that they will require en route. When practicable, the ambulance service to be established in connection with Base Hospital No. 117 will be employed for this purpose. In all such cases the diagnosis will be "Observa- tion, mental," the type of disease being added in parentheses. It is very important that mental cases be accompanied by records in which the circum- stances under which their condition came to notice are fully stated. It is obvious that, without such information, the medical officers who have the responsibility of dealing with these cases will often have difficulty in arriving at a diagnosis or in making suitable recom- mendations for their disposition. Base hospitals in the advance section will transfer to this collecting station all mental cases except those which can readily be retained until sent for by the psychiatric department of one of the base hospitals at a base port and those in whom complications or other reasons render a transfer undesirable. Effort will be made to provide all base hospitals with several nurses or enlisted men of the Medical Department who have had experience in the care of mental cases. With such attendance it will be unnecessary to place guards in observation or mental wards. Commanding officers will protect these cases from the ridicule to which they are sometimes subjected even in hospitals. 282 NEUROPSYCHIATRY Intermediate section: At least one of the large base hospital centers which it is proposed to establish in this section will ultimately have in connection with it a neuropsychiatry department similar to that at Base Hospital No. 116. Hospitals in this section will in the meantime, evacuate their mental cases to Base Hospital No. 8 in the manner specified in paragraph I (c) of this circular. Base Sections Nos. 1 and 2: A psychiatric department with a capacity of 152 patients has been provided in connection with Base Hospital No. 8. This and a similar one to be established in connection with a base hospital center in Base Section No. 2 will provide the chief facilities for the classification and continued care of mental cases in the A. E. F. Base Section No. 3: Mental cases among American troops serving with British organi- zations will be evacuated to England in the same manner as other sick and wounded from the same organizations. In England a neuropsychiatric department will be provided for the reception, continued care, and classification of cases from British clearing hospitals for mental diseases and from other hospitals in Great Britain. Base Section No. 4: Any mental cases coming to notice in this section will be evacuated to Base Section No. 3. Base Section No. 5: Psychiatric wards will be provided at a base port. These wards will receive only cases which have been classified "Class D" at Base Hospital No. 8 and whose condition is such that they can be transported to home territory with the minimum of care and supervision. This ward will receive no other cases but will provide temporary care for soldiers who are found insane upon their arrival from the United States. Base sections Nos. 6 and 7: Mental cases arising in these sections will be evacuated to a base hospital at the port of Base Section No. 2. French hospitals: Mental cases that have been evacuated from the front into French military hospitals will be transferred as soon as practicable to the most accessible neuro- psychiatric department of an American base hospital center. (c) Transportation. The neuropsychiatric department at Base Hospital No. 116 will send for patients to other base hospitals in the Advance Section, S. O. S. and to tactical divisions and training areas as provided in Paragraph I (b) of this circular. The neuropsychiatric departments of base hospital centers to be established in the Intermediate Section, S. O. S. will send for patients in the same manner. The psychiatric departments of Base Hospital No. 8 and the base hospital center in Base Section No. 2 will send for patients to any base hospital which is nearer to them than to a collecting station. As mental cases of all degrees of severity can be safely and comfortably provided for at these collecting stations, they will be retained until a sufficient number have accumulated so that they can be evacuated in parties, the attendance being provided by the psychiatric department at the base port to which they are sent. Ordinarily, regular passenger trains will be used, but in special instances and where the number of patients warrants it, transfers will be made in a car set aside for this purpose on an American hospital train destined for a base port to which they are to be sent. In this case, as in all others, attendance will be provided by the psychiatric department receiving the convoy. Evacuation to home territory of patients classified "Class D" will be made in accord- ance with special arrangement which it is not necessary to outline in this circular. (d) Disability boards for mental cases. Disability boards for mental cases will be convened at neuropsychiatric departments of base hospital centers and at psychiatric departments at base ports. Other disability boards should not pass upon these cases, but should refer them to one of the points at which such boards are authorized. All mental cases to be transported in France will be given the tentative diagnosis of "Observation, mental," except those transported to their final desti- nation on American hospital trains. Disability boards will be guided by Circular No. 24, C. S. O., 1918, in passing upon mental cases. II. Functional nervous diseases and concussion cases. (a) General consideration. IN THE AMERICAN ENPEDITIONARY FORCES 283 The proper management of these conditions which are commonly included in the desig- nation "shell shock" is regarded by this office as a matter of much importance. This term, which, unfortunately, is being used indiscriminately by medical officers as well as patients, includes a number of different conditions depending upon many different causes and requir- ing for their successful management several entirely different methods of procedure. Many patients in whom severe concussion symptoms following being blown up by shells or buried in dug-outs can be returned to duty, and it is possible to return a much larger proportion of those cases in which purely psychoneurotic symptoms develop under shell fire or in training, if they are skillfully managed. The return of these cases to their own organizations after a short period of treatment has a very favorable effect in lessening the incidence among their comrades of disorders in the second group mentioned. If, on the other hand, a large pro- portion of these patients are evacuated indiscriminately to hospitals in the S. O. S. or to home territory, the effect will be to increase their incidence. For this reason a special hospital for these cases, Base Hospital No. 117, has been estab- lished and an ambulance service has been provided in connection with this hospital by which cases can be received directly from tactical divisions at the front. At this hospital the resources found most useful in the British and French special hospitals for these cases are employed. Success in their treatment depends very largely upon the attitude of medical officers generally toward the special problems in diagnosis and management which they present. For this reason regimental medical officers should guard against making an unfavorable prognosis even in cases presenting severe symptoms. (b) Treatment. Tactical divisions: The advice of the division psychiatrist should be utilized to the fullest extent in the early treatment of these cases in division sanitary organizations and in the selec- tion of cases for evacuation to hospitals in the S. O. S. It will be found advisable, whenever practicable, to receive such cases in special wards in one field hospital and to evacuate cases to hospitals in the S. O. S. only upon the recommendation of the division psychiatrist. This officer will advise with regimental medical officers regarding the management of nervous manifestations when they first come to attention at the front. Hospitals in the S. 0. S. in France: It is expected that a very large proportion of these cases will be admitted directly from their organizations to Base Hospital No. 117 and that relatively few, unless complicated by wounds, gassing or other conditions, will be received in other base hospitals. Other base hospitals will promptly transfer suitable cases to Base Hospital No. 117, except in these instances in which it is thought that they can return directly to duty and those in which the outlook seems so unfavorable, from constitutional neuro- pathic tendencies or other factors, that their reclassification is probable. Cases in which there is some doubt as to whether an organic or functional disorder is present should be transferred to Base Hospital No. 117. No cases having wounds requiring much surgical attention should be sent to Base Hospital No. 117. All cases in which there is doubt as to the best disposition should be brought to the attention of the consultant in neuropsychiatry for the hospital. Hospitals in the S. 0. S. in England: A special hospital for war neuroses will be pro- vided in England which will be organized and conducted upon the same lines and will per- form the same functions as Base Hospital No. 117. American soldiers serving with British organizations will be transferred to this hospital from the British clearing hospital for these cases or from other hospitals in England. French hospitals: American patients with these disorders in French military hospitals will be evacuated to Base Hospital No. 117 or to the nearest neuropsychiatric department of a base hospital center. (c) Disability boards for functional nervous diseases and concussion cases. Disability boards for these cases will be convened at Base Hospital No. 117, neuro- psychiatric departments of base hospital centers, and psychiatric departments of base hos- pitals at base ports. No other disability boards should pass upon these cases. No great difficulties were experienced in putting the provisions of this circular letter into effect except as regards the mental cases. Though medical 284 NEUROPSYCHIATRY officers generally recognized their own lack of experience in the care of mental patients and were willing to transfer them as soon as possible, the transfer of such patients from the forward base hospitals to the hospital center at Savenay presented difficulties not apparent at first glance. In the first place, not only was the number of enlisted men with training in the care of mental patients very limited but only two American hospital trains (converted French trains) were operating until late in the summer. Thus all the transfers to base ports had to be made on French civilian trains. How-ever, by deferring such evacuations until a number of patients had been collected and having each convoy accompanied by a medical officer and several enlisted men with experience in neuropsychiatry, transportation was accom- plished without serious disadvantage to the patients. It is appropriate to record here that during the whole history of the American Expeditionary Forces no patient suffering from a mental disease committed suicide while under treatment, was injured or lost during transportation, and (except in rare instances where methods could not be controlled) no patient being evacu- ated was subjected to mechanical restraint. Secondly, there was never at any time a special vessel designated to return neuropsychiatric patients to the United States. They had to be included in the rather limited space set aside for hospital accommodations on the west- ward trips. Again and again a transport filled its hospital beds with the sick and wounded and found that there was no place left over for neuropsy- chiatric patients. There wras a considerable lack of agreement as to what constituted proper provisions for the transportation of these patients. Another difficulty arose out of the use of the term "neuropsychiatric" to designate patients requiring such widely different types of provision on shipboard as those with acute mental diseases (psychoses), those convalescent from war neuroses, mental defectives, epileptics, insane prisoners, and patients suffering from organic diseases of the central nervous system. The shortage of shipboard facilities was, of course, only for those in the first category, but all were refused. Then, often, unexpectedly a transport would be willing to receive a large number of mental patients and the population of the 300-bed psychiatric department of Base Hospital No. 8 would be quickly relieved. Congestion, however, was the rule. For this reason the provision of a special hospital at Savenay was recommended by the senior consultant on October 28, 1918.18 One of the hospitals in the center finally was set aside and opened Novem- ber 6, 1918, under the designation Base Hospital No. 214.13 At Brest a difficult situation was created by the fact that occasionally a convoy of mental patients which had arrived from Savenay for the sailing of a designated transport from Brest was refused by the medical officer of the transport because of the lack of suitable accommodations for them. In such instances emergency provision had to be made in hospitals at Brest which had no special facilities for their care. The outgrowth was a development of a special department at Base Hospital No. 65, at the Kerhuon hospital center, at this base port.19 This department became one of the most effective and useful neuropyschiatnc resources in France. IN THE AMERICAN EXPEDITIONARY FORCES 285 DURING THE ARMISTICE Just before the armistice was signed the chief surgeon directed the senior consultant to submit a full statement as to the adequacy of existing hospital accommodations for neuropsychiatric patients in the Services of Supply, with a statement of the additional provisions already under construction or agreed upon and any expansion required. This report is given below in full, because it provides an excellent summary of the situation as it existed a few weeks before the armistice was signed:20 SPECIAL HOSPITAL PROVISIONS FOR MENTAL AND NERVOUS CASES IN THE S. O. S. Bazoilles center: Present provisions—■ Psychiatric department of Base Hospital No. 116; in seven buildings, including quarters for nurses and enlisted personnel. Capacity: 72. Serves as collecting station for mental cases from tactical divisions and all hos- pitals in advance section east of Troyes. Disability board for neuropsychiatric cases. Under construction or agreed upon— None. Expansion recommended— Addition of three ward buildings of type known as "general wards" in present department and enlargement of present nurses' quarters. Proposed capacity: 150. La Fauche: Present provisions— Base Hospital No. 117 (for war neuroses) consisting of a standard camp hospital, and a small chateau which is used for officer patients. Village used for billets for medical officers. A dwelling rented for nurses' quarters. Four French barracks, a mile from hospital, constitute convalescent camp. Dis- ability board for neuropsychiatric cases. Capacity: Hospital_____________________________________________405 Convalescent camp___________________________________ 125 Total__________________________________________530 Receives war neuroses from Army neurological hospitals and all base hospitals in American Expeditionary Forces. Under construction or agreed upon— Buildings to bring capacity of hospital to 2,000 beds under construction. Recommendation made to erect buildings for second 1,000 beds on site now used for convalescent camp. Expansion recommended— None after completion of buildings now under construction. Tentage can be added in spring to bring convalescent camp to 2,000. Proposed capacity: Hospital----------------------------- 1,000 Convalescent camp___________________ 1, 000-2, 000 Allerey Center: Present provisions— None. Under construction or agreed upon— Plans for a neuropsychiatric department not of the standard type have been sub- mitted by the Engineer's Department. Recommended that psychiatric depart- ment of Base Hospital No. 116 at Bazoilles center be duplicated here, and the department thus established serve as collecting station for mental cases for the northeastern part of the intermediate section. Disability board for neuropsychi- atric cases recommended. 286 NEUROPSYCHIATRY Allerey Center—Continued. Expansion recommended— Same as for Bazoilles center, when needed. Proposed capacity: 150. Mars Center: Present provisions— None. Under construction or agreed upon— Recommended that a psychiatric department of 250 beds consisting of an adaptation of "A" type base hospital be constructed as soon as possible on site already suggested by center commander. Plan submitted to C. S. O. this date for such a department and for expansion proposed. The fact that large hospital centers and several depot divisions are near this center make it desirable to centralize the work of observation and collection of mental cases which will otherwise have to be done in small observation wards at base hospitals in the neighborhood and at camp hospitals in depot divisions (as at St. Aignan). Disability board for mental and nervous cases recommended. Expansion recommended— Increase of psychiatric department to 500 beds, when needed. St. Aignan-Noyer: Present provisions— Psychiatric wards operated as branch of Camp Hospital No. 26, First Depot Divi- sion, in a convent in St. Aignan. Used chiefly for observation of mental cases. Important when all replacements to American Expeditionary Forces came through the First Depot Division, but less so now. Capacity: 114. Pudcr construction or agreed upon: Disability board for neuropsychiatric cases recommended. Expansion recommended: None. When proposed psychiatric department at the Mars center is ready to receive patients, these wards may be abandoned. Base Section No. 1: Present provisions— Psychiatric department of Base Hospital No. 8 at Savenav, partly in buildings of special design and partly in other wards of hospital. This department receives and "boards" practically all mental cases and many nervous cases who are subsequently returned to the United States. The increase in population is shown by this table: Returned T i Admitted to U. S. July. ---------------------------------------- 4Q5 34g £T k------------------- 588 601 September------------------------------------- 8g7 5g5 l nder construction or agreed upon— Additional buildings being constructed but wards are now widely separated, per- onnelis confused, and the provisions for insane officers are unsatisfactory. It is hosofta unit in T* « t0 ^^ '^ ^ imP°rtant deP^tment as a separate hospital unit in the Savenay center. The center commander has suggested a unit nearmg completion for this purpose. Recommended that a unTt oflOOO siuiliTb: plhiT^ ,G °CCUPled " S°°n aS P°SSible b* P—-1 to b suppl ed by Psychiatric Replacement Units Nos. 1 and 2. The buildines now _„»_rssrdepartment can be used * ad~'««csr Thn^uiadelbnXhOSPital '" -™ *o °e e„,arged only as absolute Although the armistice put an end to battle casualties, thus eliminatine one great mcreasmg demand for hospital beds, the hospita problem" of he Amencan Expedit.on.n- Forces were not immediately reduced in "heir sit IN THE AMERICAN EXPEDITIONARY FORCES 287 or complexity. The necessity for beds for neuropsychiatric patients increased for a time instead of diminished, and congestion of such patients at Savenay hospital center because of delay in transferring them to the United States, became very serious. One of the results of the delay in the transfer of these patients was to imperil recovery in many of the lighter types of depression that had occurred in men exhausted by the severe fighting of the fall. This situation was brought to the attention of the chief surgeon, A. E. F., by the senior con- sultant in neuropsychiatry, in November, 1918.2) A number of the more recent cases showed simple depression, in some instances only slightly beyond phsyiological limits but, nevertheless, accom- panied by painful ruminations and often by suicidal ideas. An intense longing for home was characteristic of this condition. It resembled a set of reactions to which the term "nostalgia" used to be applied and is common in all military expeditions when a period of intense activity is succeeded by an uneventful one. The cessation of hostilities made it necessary to modify plans for the care of neuropsychiatric patients. It was upon the following letter from the senior consultant to the chief surgeon, A. E. F., that the neuropsychiatric work during the armistice, except in the army of occupation, was based: 22 1. The cessation of hostilities and the proposed decrease in the number of expeditionary troops necessitate radical changes in plans for the care of neuropsychiatric cases in the Ameri- can Expeditonary Forces. 2. The most convenient method of presenting these changes is to consider them with reference to the following three groups into which practically all neuropsychiatric cases in the American Expeditionary Forces fall: Injuries to the central nervous system and periph- eral nerves; psychoneuroses, chiefly those termed "war neuroses"; mental diseases (insanity, mental deficiency, etc.). INJURIES The possibility of further admissions to this group terminated with the armistice. In civil accidents—such as will continue in the American Expeditonary Forces—such injuries are very rare. The whole problem of dealing with injuries to the central nervous system and peripheral nerves is their diagnosis and management pending their return to the United States for continued treatment. The neurosurgeons having decided that all such cases should be returned to the United States before operation, it is important that every effort should be made now to see that each patient with a wound in which injury to the brain, cord, or peripheral nerves may exist receives a careful neurological examination and that accurate notes of such examination be made on the clinical records. It is not sufficient to examine only cases brought to attention by surgeons but all cases should be seen. Negative notes will often prove of as much value in the future management of these cases as positive ones. There are many instances in which a functional element, or a "functional overflow of symptoms" as it has been called, complicates cases in whom organic injury exists. To deter- mine the existence and extent of this complication requires a careful examination by one experienced in the diagnosis of functional as well as organic conditions. Neuropsychiatrists in the American Expeditionary Forces have had unusual opportunities of seeing functional disturbances among soldiers. It is important, therefore, that their opinion should be re- corded in all such cases before sending them home. It can readily be seen that neuropsy- chiatrists and neurosurgeons in the United States may be misled by the disappearance or modification of functional symptoms when cases arrive at hospitals at home unless careful examinations and clear records have been made in the hospitals of the American Expedi- tionary Forces. With these considerations in mind, thousands of careful examinations of the wounded have been made by neuropsychiatrists in base hospitals in the American Expeditionary Forces. Now a general survey with reference to neurological injuries is being undertaken. 288 NEUROPSYCHIATRY In every base hospital center this work is being pushed by additional personnel under the direction of the consultant in neuropsychiatry for the center. Not only will positive findings be recorded but in all negative cases the clinical records will be stamped "Neurological examination negative." It is realized that the rapid evacuation of patients toward base ports can not be delayed for such examinations and that many patients will not be reached. To meet this situation a number of young and energetic neurologists have been sent to Savenay, Brest, and Bor- deaux. At these ports, through which all the wounded must flow, efforts will be made to examine all records and as far as possible to examine all cases in which a previous examina- tion was not recorded. Three very experienced officers have been assigned to these ports as consultants in neuropsychiatry to supervise this work. In about six weeks the work outlined above should be completed. The medical officers engaged in it may then be returned to the United States. PSYCHONEUROSES It is estimated that the incidence of these disorders will be decreased not less than 90 per cent through the cessation of hostilities. The remaining 10 per cent will continue to be contributed in the future as they have been thus far, by the factors responsible for psycho- neuroses in civil life. Military experiences other than the hardships and danger of actual warfare will tend to make psychoneuroses not less prevalent in the American Expeditionary Forces than among a body of men of the same age periods in civil life. Accompanying the decreased incidence of the psychoneuroses will be a greatly increased recovery rate among those remaining under treatment. It is estimated that among the 465 cases remaining unclassified at Base Hospital No. 117 on November 25, as many as 410 will be discharged to duty. As nearly as can be estimated, about 200 cases are now in other base hospitals. Steps are being taken to have these cases sent to Base Hospital No. 117 at once. It is very desir- able that they should be restored as soon as possible and not returned to the United States still suffering from functional nervous disorders. Spreading the information that this will not be done has already promoted recovery. It is apparent that Base Hospital No. 117 will have seen less than 200 patients, and that with this number of beds all new admissions to be expected can be provided for. As it is uneconomical to maintain a separate hospital for this number of patients and it is perfectly useless to send these cases to general hospitals, it is recommended that all cases of functional nervous disease be cared for in the neuro- psychiatric hospital considered under the heading "Mental diseases" in this letter. MENTAL DISEASES The elimination of danger, hardship, and exhaustion as causes of mental disease will tend to decrease the number of admissions in this group. The number of mental defectives coming to notice will be diminished on account of the inevitable lowering of standards of mental fitness in troops not required to do combat duty. (Many mental defectives used to come to attention on account of their inability to put on gas masks or perform outpost duty.) To offset the effect of these causes of a substantial decrease in the admission rate for mental cases, are the lengthening period of service and absence from home, disappointment over not returning immediately and the unavoidable impairment of morale that will result when a combatant army becomes one of the occupation. It is predicted that mental cases will continue to be admitted at an annual rate of 3 per thousand enlisted strength—about three times the civil rate for adult males. The present provisions for the insane of the American Expeditionary Forces are inade- quate. The collecting station provided by the psychiatric department of Base Hospital No. 116 at Bazoilles has been of much value. It should be continued as well as the wards now set aside at the Allerey and Mars hospital centers, as these centers are within easy reach of the areas in which the troops are quartered. Mars is a particularly favorable location as it is at the point of divergence for the three base ports. A similar ward should be maintained at Bordeaux and one at Brest for convenience in embarking mental cases and for the collec- tion of new cases from the troops in the vicinity. All these ward* are being adequately staffed from the personnel now available. In addition officers and enlisted men are being congre- IN THE AMERICAN EXPEDITIONARY FORCES 289 gated at the three base ports so that they can be detached to accompany convoys of mental patients home. The chief provision for mental cases should continue to be at Savenay or Nantes. These places are nearest the most convenient port and also nearest to the points from which cases will be collected and afforded temporary care. The problem of caring kindly and skillfully for mental cases from the American Expeditionary Forces will have to be met at one of these points as long as there are troops in France. When the pressure of caring for the wounded submerged everything else it was out of place to dwell upon the kind of care provided for mental cases. Now, however, it would seem that the matter could be taken up seriously. Insanity is not an occasional occurrence among troops but one of the most important diseases in an army in peace as well as war. It should be provided for not as an emergency but as one of the routine tasks of the medical department of an army. Although no country has higher standards than the United States in the care of mental disease, the care of the insane at the present time at Savenay is below that seen in any Brit- ish or French military hospital for mental diseases. Base Hospital No. 214 is a base hospital only in name. It was created by giving this designation to the overcrowded wards already occupied by the mental cases, without any provisions for personnel, administration, or treat- ment being added. The capacity of these wards was rated at 400 by giving up all rooms intended for special patients, for the isolation of special classes, or for day rooms. The enlisted personnel is away from the unit altogether at night although this is a practice full of danger when mental cases are cared for. The personnel on night duty should always have assist- ance at hand in case of emergency. Only 13 nurses are available for the care of 560 patients. Thirty nurses were assigned to this department when the personnel of Base Hospital No. 117 arrived in France in June. Although these nurses were all especially trained in the care of mental diseases, having been enrolled in the United States for that purpose, they have been assigned to other work in other hospitals. The remedy for the conditions under which the insane of the American Expeditionary Forces are cared for is to provide at Savenay or at Nantes a separate neuropsychiatric base hospital capable of caring adequately for all mental cases, with proper classification and provision for the relatively large number of insane officers, and for the psychoneurotic cases after Base Hospital No. 117 has been discontinued. No special provisions other than those which can be extemporized by a staff of the hospital are required. It is necessary, however, that such a hospital should be recognized as a necessity and not a temporary expedient and be permitted to develop the special methods of treatment and care needed even in the short period in which mental cases are provided for here. A very large proportion of the mental cases now coming to light are recoverable. Many can be transported to the United States with much less danger after a short period of treatment here and in not a few the difference between permanent mental disease and prompt recovery will depend upon what is done for them in that short period. The wards at Savenay constitute nothing but a place of deten- tion now. By January 14, 1919, certain further modifications were necessary and Circular No. 35, quoted above, which had provided the official authorization for a large proportion of the neuropsychiatric work in France, was superseded by Circular No. 35-A: Circular Letter No. 35-A American Expeditionary Forces, January 14 1919. From: The Chief Surgeon. To: C. O.'s all base, camp and evacuation hospitals, hospital centers, surgeons of armies, corps, divisions, and sections, and the surgeon, district of Paris. Subject: Mental and nervous cases. MENTAL CASES 1. The directions of Circular 35, O. C. S., June 13, 1918, that relate to the care and evacuation of mental cases (insanity, mental deficiency, epilepsy, observation cases) are modified as indicated below. 290 NEUROPSYCHIATRY 2. Psychiatric departments for the reception, observation, early treatment, and evacua- tion of mental cases are now in operation at the following hospital centers: Hospital center, Bazoilles. Allerey. Mars. Kerhuon, Brest. Savenay. Beau Desert, Bordeaux. District of Paris, Camp Hospital No. 4, Joinville. 3. All mental cases will be sent to the psychiatric department most accessible in the manner indicated in Circular 35. It is important that proper attendance be provided in all cases to prevent accidents during evacuation. Unless special circumstances make other arrangements more advantageous, such attendance will be supplied by the psychiatric department to which patients are being sent. No stigma attaches to admissions to these departments and they should be freely used for observation in all doubtful mental conditions. Fl'NCTIOXAL NERVOUS CASES 4. Patients with functional nervous diseases (psychoneuroses, war neuroses) will be sent, in the first instance, to the nearest base hospital and thence to Base Hospital No. 214, at Savenay, which has a special department for psychoneuroses. Attendance will be pro- vided for these cases only when there is some special reason for it. They will not be sent to psychiatric departments at hospital centers. 5. In Section I, paragraph (b) of Circular 35, O. C. S., June 13, 1918, the following statement is made regarding records of mental cases: It is very important that mental cases be accompanied by records in which the cir- cumstances under which their condition came to notice are fully stated. It is obvious that, without such information, the medical officers who have the responsibility of dealing with these cases will often have difficulty in arriving at a diagnosis or in making suitable recom- mendations for their disposition. These instructions are being generally neglected with the result that the work of the medical officers in the psychiatric departments is unnecessarily rendered more difficult. Mental cases come from divisions with no record except their diagnosis cards. In some cases these patients have had general court charges preferred against them without notations to indicate it. Others have made suicidal attempts or threats, but without any record of these facts they can not be properly classified until observation at the hospital has revealed them. 6. Disability boards will not reclassify mental cases or those with psychoneuroses. This will be done by the neuropsychiatric disability boards which have been established at each psychiatric department and at Base Hospital No. 214 (neuropsychiatric hospital). Walter D. McCaw, Colonel, Medical Corps, Chief Surgeon. PERSONNEL OFFICERS SOURCES When the neuropsychiatric service was organized in the American Expedi- tionary Forces medical officers with neuropsychiatric training were widely scattered among the organizations there; but the names, assignments, and qualifications of those available for professional work in the field had been ascertained by the senior consultant in neuropsychiatry. This was done by examining the personnel records in the chief surgeon's office and by correspond- IN THE AMERICAN EXPEDITIONARY FORCES 291 ence with commanding officers of the base hospitals and with division surgeons. By the end of January, 1918, the location of about 20 such officers had been ascertained and they had been graded into the following three groups with reference to their training and experience: (a) Those who could be intrusted with important duties in their specialty without supervision. (6) Those who, on account of their less thorough training or other reasons, could be utilized as assistants but not placed in charge of the work to be performed independently. (c) Those who had had so little experience and training that it was inadvisable to use them as specialists. The most fruitful sources from which these officers were obtained were base hospitals organized from important medical centers in the United States which had come overseas shortly after war had been declared by us. Each of these hospitals had as a member of its staff a neuropsychiatrist who, in many instances, had been professor of neurology and psychiatry in the university and a director of those services in the teaching hospital at home from which the military hospital had been organized. Other sources were the medical officers studying the treatment of war neuroses in England and those scattered throughout various organizations where special training could not be well utilized. Plans were made at once to have these officers reassigned to posts where they could be most useful. It was from the seven officers on duty in England that the first four division psychiatrists, the first commanding officer of Base Hospital No. 117, and its first medical director were obtained. An effort was made also to secure a roster of nurses and enlisted men who had had experience in the treatment of mental patients. During March, April, and May, 1918, with the advent of many additional base hospitals from the United States and the construction of hospital centers, the organization of the professional services in hospitals in accordance with the general plan which formed the basis for Circular No. 2, chief surgeon's office, A. E. F., November 9, 1917, became necessary.6 It was not difficult to make the reassignments required to provide consultants in neuropsychiatry for nearly all hospital centers. As the personnel to staff new hospitals arrived from the United States the neuropsychiatrist attached to each was communicated with or visited by the senior consultant in neuropsychiatry and the general plan for the care, treatment, and evacuation of mental and nervous patients explained to him. Such officers differed in their special experience and training and reassignments were made so that, in general, younger men could be detached to serve with troops and those qualified for particular tasks could be assigned to them. The personnel was augmented continually from newly arrived tactical divisions and hospital units, each with its attached neuropsychiatric specialists. An unexpected increase in personnel was due to the fact that evacuation hos- pitals arriving after the first of August, 1918, each had a neuropsychiatrist attached.23 Since it was not practicable for such officers to perform very useful work in the evacuation hospitals under the plan of action in the theater of • Consult Chap. XVIII, Vol. II, of the history for full details concerning the professional services, A. E. F. 42705—29---20 292 NEUROPSYCHIATRY operations, they were immediately detached and made available for other duties. All these sources, however, were inadequate to meet increasing needs, consequently there were organized in the United States two neuropsychiatric replacement units of officers, nurses, and enlisted men, all not only with civil experience in neuropsychiatry but, by that time, with a good deal of military training.24 Upon their arrival in France they were immediately distributed to the different stations in most urgent need, thus increasing very greatly the use- fulness of available neuropsychiatric facilities. There were certain losses of personnel, fortunately, however, few through death or illness. In order to meet the need for better care during ocean transportation, officers and enlisted men with neuropsychiatric training were detached from the American Expedi- tionary Forces to accompany home convoys of mental patients. Few of these officers or enlisted men returned. It was also necessary to release a few officers for general work because they had shown lack of aptitude for the highly specialized tasks that they were called upon to perform. On the other hand, the high administrative capacity of many neuropsychiatrists who had held responsible positions in civil life made their services sought after for executive posts in the American Expeditionary Forces. TRAINING The neuropsychiatric work of the American Expeditionary Forces covered such a wide field that it was possible to make assignments with reference to the special types of training and ability which medical officers possessed. In general those whose training had been chiefly psychiatric were assigned to tactical organ- izations and to hospitals and departments established for the care of mental patients, while those whose training had been chiefly neurologic served as con- sultants in general base hospital centers. Although it was one of the outstand- ing features that neurologists and psychiatrists shared each other's duties, responsibilities and point of view to an extent that had never existed in civil life, and that the new terms "neuropsychiatry" and "neuropsychiatric" came to have ample justification for their use, it was true, nevertheless, that rela- tively few medical officers possessed equal qualifications in both these fields. Psychiatrists who had had years of excellent training and experience in dealing with mental diseases, psychoneuroses and conduct disorders did not possess the background of neuroanatomy, neuropathology, and clinical neuroloev required to deal with the organic injuries and diseases of the brain, spinal cord, and peripheral nerves that contributed so many interesting and perplexing questions in diagnosis and treatment in the base hospitals. On the other hand, many neurologists had devoted themselves so exclusively to these subjects that they were insufficiently prepared to care for patients with acute mental diseases unhtwbPP 7 T ^conviction some of the psychological viewpoints upon *hich the treatment and prevention of the war neuroses were largely based. During the strenuous weeks that intervened between the unexpected entry of Ztle ZlZ\r1™ mt°, aCtlVe %hting in Ma^ 1918> and the armisiice, h deSct d r^ t0 t0Tnf medlCal traini1^ Jt was ^tended to remedy this defect during the winter when neurological training would be afforded for IN THE AMERICAN EXPEDITIONARY FORCES 293 psychiatrists and psychiatric training for neurologists. In the specialists arriv- ing late in the summer and fall of 1918, however, there was striking evidence of results of the breadth and soundness of the training that had been carried on in the United States in the courses offered at the various neuropsychiatric centers such as the Michigan Psychopathic Hospital, Ann Arbor, Mich.; Boston State Hospital; Neurological Institute, New York City; Philadelphia General Hos- pital; Phipps Psychiatric Clinic, Baltimore, Md.; Government Hospital for the Insane, Washington, D. C; Manhattan State Hospital, New York City.25 These men were indeed neuropsychiatrists; others would have been had those who came to the American Expeditionary Forces early in its existence had the opportunity during the winter of 1918-19 to avail themselves of similar educa- tional opportunities. Regular courses for medical officers, nurses, occupational aides, and enlisted men were established at Base Hospitals No. 117 10 and No. 214.13 A two weeks' course was arranged at American Red Cross Hospital No. 1 at Paris where, with the cooperation of French neurological clinics, there was an excellent opportunity for the study of brain and peripheral nerve injuries. ASSIGNMENT From the beginning the chief surgeon trusted the senior consultant in neuropsychiatry, as was the case with other senior consultants, to make such recommendations as were needed to use the neuropsychiatric personnel to the best possible advantage. Almost without exception, the recommendations of the senior consultant in neuropsychiatry were promptly put into effect by an official order. There was, unfortunately, one important obstacle—the refusal of commanding officers to grant their approval. Entirely in the interests of harmony and cooperation, the senior consultant had established the custom of asking commanding officers in advance if they would approve his making such recommendations. It was apparent that the special work for which he was directly accountable to the chief surgeon would fail if this custom was con- tinued and if small needs rather than larger issues governed the distribution of personnel. On July 28, 1918, the senior consultant brought this important matter to the attention of the director of professional services,26 whereupon he was given practically free disposition of the neuropsychiatric personnel, and no further difficulties, such as those outlined above, were experienced. PSYCHIATRIC NURSES As explained in Section I of this volume, the National Committee for Mental Hygiene, at the request of the Surgeon General of the Army, secured a large part of the neuropsychiatric nursing personnel for the Army. In the original selection of these nurses, made in the first year of America's participation in the war, only persons were selected for psychiatric nursing service in the American Expeditionary Forces who had had training and experience in caring for nervous and mental cases. Applicants were investigated carefully and only those highly recommended for the service were accepted. After extensive correspondence and other lines of inquiry a group of 46 nurses finally was obtained for duty in the American Expeditionary Forces. 294 NEUROPSYCHIATRY Until June 8, 1918, when the first contingent of specially obtained nurses arrived in France,10 neuropsychiatric nursing in the American Expeditionary Forces was done by a few nurses selected from among the general nursing personnel. These were usually women who had had previous experience in special hospitals for nervous and mental diseases, or in wards for these cases in general hospitals. In addition to the 46 nurses referred to, 20 more were added to the unit at the time it sailed for France. These 66 nurses were assigned for the most part at Base Hospital No. 117, but some were left at Base Hospital No. 8, at Savenay, and others were sent to psychiatric departments of hospital centers throughout France. After the arrival of the unit designated Base Hospital No. 117, neuropsy- chiatric nursing was taken over as much as possible by specially trained nurses. Throughout the summer, the neuropsychiatric nursing personnel was increased in number by the addition of those sent from the United States in two psychiatric replacement units. LIAISON WITH THE DIVISION OF NEUROLOGY AND PSYCHIATRY, SURGEON GENERAL'S OFFICE Liaison with the division of neurology and psychiatry in the Surgeon General's Office was maintained by personal communication in the form of letters and cables between the chief of the division of neurology and psychiatry, in the Surgeon General's Office, and the consultant in neuropsychiatry, A. E. F. This informal method was first approved by the chief surgeon but the restric- tion of censorship was a formidable barrier. One of the most valuable aids which the neuropsychiatric work in France obtained during the war came through the visit made by the chief of the division of neurology and psychiatry in the Surgeon General's Office. His temporary assignment to the American Expeditionary Forces was recommended by the senior consultant to the chief surgeon, A. E. F., on June 18, 1918, in the fol- lowing letter:27 1. The extensive plans being made in the United States for continued care and social and industrial rehabilitation of disabled returning soldiers do not in all cases provide for direct continuity between management here and at home. It is essential that those responsible for h Z "f t^ t* ^^f ^ d°Sely " t0UCh Wlth What is done here -d familiar with lenity Car6 °Ur S°ldierS duHng thG earli6St Phase of their illn^ or dis- disea'se ^n leiTttT^, *T i" ^ "^ °f ^ W" neUr°SeS and °f Some for™ <* ™ntal vouTmen Enlllnd a H r ^ nerV°US "^^ reSUltin* from the ^ar-most of them lone-aiZ the^^n™ ""^ ^ "^ Pr°blemS that wil1 remain unsolved anJTsodal f 7th ■♦ Pr6SenCe °f theSG men in the homes and * the industrial z r/n1 tr itr ^^r^^i^r^the menttheaith of those claiming them The^oi^S „f ^ ?"* ^ "^ treatmGnt' With the ob*ct of re" ^^^s**z :^:^^r^^rbefore they had the *v^o?Z£^ZZt%- t^ ^JV^ Cl0SGSt UaiSOn betW6en this ^ and General's Omcete^TtoZZ^*7 • V^ ?^ ^^ ^^ since the S™&™ have interested Z" the Z? ^ / ^ °ffidal and Un°fficial ^ncies that tnemselves in the various phases of reconstruction work among soldiers It IN THE AMERICAN EXPEDITIONARY FORCES 295 is suggested, therefore, that it be indicated to the Surgeon General that it would be agreeable to have Col. Pearce Bailey ordered to France and England for a short period of observation of neuropsychiatry work in expeditionary troops. 4. It is believed that nothing will contribute more to close cooperation in this field than the personal contact with the actual problems in mental medicine in the American Expedition- ary Forces that such a tour of duty would provide. The medical officer concerned visited England first and spent July, August, and part of September in the American Expeditionary Forces. He was able to visit the French neuropsychiatric hospitals and training centers which the senior consultant in neuropsychiatry, A. E. F., had been unable to see on account of a great pressure of work. The report to the chief surgeon which the chief of the division of neurology and psychiatry rendered, September 5, 1918, on his observations, with his recommendations for the American Expeditionary Forces, is as follows: MANAGEMENT OF WAR NEUROSES BY THE FRENCH Connected with each army the French have a neurological center which has a capacity of from 100 to 200 beds. The capacity should be in the ratio of 1.5 beds to 1,000 troops. This army center is located or should be located with one or two hours motor transport dis- tance from the front. It has three medical officers who have had experience at the front. The patients, transported as promptly as possible after the development of symptoms, are placed first in a receiving ward where they are carefully examined and then sent to differ- ent wards, classified as far as possible in relation not only as to their injury but also as to their personality, the hysterical and malingering types being kept apart from the others. The character of the disabilities varies with the activity of the sector which the center serves. For example in quiet sectors these centers receive large numbers of cases of rheuma- tism, sciatica, etc., while in active sectors the true commotioned cases are in the majority. The method of treatment and management varies with the class of cases. The true commotionne is treated with all sympathy and kindness. He is kept in bed until he feels able to get up, which is generally within a week, and is then treated as a convalescent until he leaves, which is ordinarily within two or three weeks. Quite a different course is taken toward the emotionne, or toward the commitionne who shows signs of developing neurotic symptoms. Such a patient is given to understand at once that such symptoms as trembling, failure to move a limb or portion thereof, deaf mutism, etc., are not symptoms of disease but rather failure in will, a defect in character, that persistence in the demonstration will cause the man to be regarded as a malingerer, which will eventuate in his punishment, perhaps by court-martial. Two forms of punishment are available to the neurologist at the center itself. One of these is the threat that the "permission" or leave, to which every French soldier is entitled after discharge from the hospital, will be taken away from him if he persists in functional symptoms. He will not be allowed to go home, he is told, but will be returned directly to the front. The other form of punishment is solitary confinement. The soldier presenting hysterical symptoms is put in a room by himself, locked in, and is not permitted to read, write, or smoke. He is told that the trouble with him is in his will and that the best way to recover the will is by silently reflecting in the dark. In addition to these means of combating the outbreak of hysterical symptoms, electricity with persuasion is used or the rougher quick method of suddenly turning on strong electric currents in the region of the part showing signs of defaulting function. By these various measures the French maintain that it is not necessary to send many functional cases back to the interior. Certain cases of true commotionne" who do not recover in the army centers are sent to the interior for further treatment or convalescence. All organic cases are evacuated to the interior as rapidly as possible. Different methods are required in the neurological centers of the interior than of the advance. The medical point of view regarding the neuroses is no different, but the patients are under a less rigid control than in the army centers and more easily accessible to their 290 NEUROPSYCHIATRY friends, to civil inspection, etc. The neurological centers of the interior are organized as regional, there being 20 regions in France. These centers are complete neurological hospitals, with wards for organic as well as for surgical cases. In some centers, as at Besancon, the surgical cases are sent to another hospital for operation. In others, as at Lyons, the center has a surgical service of its own. The management of the neuroses in these interior centers varies considerably with the personality of the director. As a rule, while there is no different point of view regarding the neuroses than is entertained in the army centers, the brusque methods employed near the front have been found less practical in the regional centers. Relaxation of discipline, prox- imity of friends, popular disapproval, etc., explain this. Torpillage, or the sudden electri- zation of affected part, is still made use of and is said to produce immediate cure, but may bring the physician who employs it into trouble. The most successful of these interior centers, as far as the neuroses are concerned, is the one at Salins. It is remote. The patients are carefully prepared by various suggestions before they are treated. This stage of preparation is extended for several days or weeks, the patients being kept as much as possible in company with patients who have already been cured. The treatment itself, consisting of persuasion with mild faradization, is completed at one sitting, the sitting requiring from a few minutes to several hours. When the local hysterical manifestation is removed the patients are held in the center for two or three weeks, are daily encouraged and made to do exercises and are also made to do such work as farming and carpentry. The organization at Salins is very carefully thought out and skillfully conducted, but not the least good point about it is the military training which follows the cure. This is conducted at a camp at the foot of the mountain peak where the hospital is located. The camp is under the command of a captain of infantry, wounded and not fit for field service, who is in full sympathy with the physician of the hospital. The patients on coming from the hospital are grouped in accordance with their capacities. About two-thirds are drilled with arms and are trained again for full field service. The balance, who will only see service at the rear again, are given hikes and calisthenics. To the evident advantage of tiaining as an after cure the camp offers the physician the opportunity of seeing his graduates daily, of watching their progress in resuming their military careers, and in immediately becoming cognizant of relapses. These occur not infrequently in the camp and then the patient is taken up on the mountain again and is put in solitary confinement before being re-treated. Second relapses are said to be exceedingly rare. It would seem that the training camp, under the command of a well-selected line officer, offers the only means of accurate classification of cases of neuroses which have been hospi- talized. Unless patients of this class are tried out for several weeks before they are sent to line duty great errors in the evaluation of their capacity are bound to occur. And if they are returned a second time from full duty the chances for their complete restoration are very poor. The French method of handling the neuroses of war has doubtless been of great service not only to the army but also the patients themselves. As far as the army is concerned, a very large percentage has been returned to the line. It is true than many are still to be found in the interior hospitals who have resisted the treatment of the army centers, but these are still in the military service and so even now have a better chance of recovery than if they had been discharged from the army. Even cases of long standing, of two or three years, are successfully treated and returned at Salins. It is not true that these patients recover when discharged from the army, in the sense that the condition was due to a wish to be out contrarT1"" """^ erotics among discharged British soldiers teach quite the SUGGESTIONS FOR AMERICAN EXPEDITIONARY FORCES Everything seems to point to our soldiers developing neuroses to a degree even greater than has occurred among the British unless special means are taken to prevent ^Hon- wheTh°eiTorTe s al " ^ ^ *** & y°Ung ^ SUdde^ takenfrom ™S- L was tarht tha he . S ? 7n W&y' WhGre °bedienCe Was never necessa^ ^here *as taught that he was the equal of every one, suddenly taken from surroundings of that IN THE AMERICAN EXPEDITIONARY FORCES 297 character and forced to obedience, forced also to face all this war has of horror, it would not be surprising if he showed his reaction to the change by developing a neurosis if he were given a chance. French neurologists with whom I have talked have spoken of the excessive nervousness of American soldiers who have been under their care. It would seem then that we should profit as far as we can from the experience of the French in this matter. Check the development of neurosis by denying its existence at the start, Each army should have its own center of a capacity of at least V/2 beds to each 1,000 troops. It should keep its patients two or three weeks if necessary, and should be entirely independent of any hospital of the communication or base. The treatment of the patients should be calmative and restorative and any appearance of such symptoms as tremors, paralysis, etc., should be rigidly discouraged. This idea should run through the whole personnel of the hospital. At first it should be effected by gentle persuasion, but if the patients persist in the production of hysterical symptoms sterner measures should be resorted to. It is not considered desirable to send patients of this class to convalescent camps. It would be better for them to have leaves, and the threat to cut off the leave might persuade many to suppress the self-indulgence which is so often the neurosis and give up his symptoms. Isolation and strong faradization might also be employed with advantage at this stage. Those patients should be held at the army hospital with the greatest tenacity. The chances of their permanent military recovery is reduced the moment they are sent back. It is strongly recommended that none of this class be returned to America until after the war. The influence of the home country would make it extremely difficult to organize a hospital service where these cases could be properly treated, and there would be small hope of ever fitting the patients again for military duty. And the fitting for military duty is the one means of effecting a satisfactory cure. A neurosis which has lasted for a year or more has established a habit which persists, or is prone to, after the cause is removed. This is shown by the numbers of permanently (or apparently permanently) disabled men to-day, discharged from the army in England and Canada. DISABILITY BOARDS Following the promulgation of General Orders, No. 41, G. H. Q., A. E. F., March 14, 1918, which governed the physical classification of the personnel of the American Expeditionary Forces, it proved necessary to have special pro- cedures in the care of officers and men suffering from mental and nervous diseases. Accordingly, on April 23, 1918, the chief surgeon, A. E. F., issued the following circular letter: Circular No. 24 American Expeditionary Forces, France, April 23, 1918. Disability boards passing upon mental and nervous cases under Sec. I, G. O. 41, G. H. Q., A. E. F., March 14, 1918, will, as far as practicable, be governed by the following considerations. general In dealing with these cases, there should be borne in mind their chronicity, the proba- bility of recurrences or acute episodes in constitutional disorders, and the bearing which abnormal mental states have upon questions of responsibility. The special mental stresses of modern warfare and the fact that the safety of many soldiers often depends upon the con- duct of one of their number should be given due weight in considering the fitness of men with mental or nervous diseases for service at the front. At the same time the importance of utilizing, in any safe and suitable way, the services of men partially incapacitated should not be overlooked. The essential question for boards to decide is usually whether, taking all the facts into consideration, the individual before them will be an asset or a liability to the Expeditionary Forces. Whenever possible a psychiatrist or a neurologist should act as one member of a board passing upon mental cases. 298 NEUROPSYCHIATRY PSYCHOSES (INSANITY, MENTAL ALIENATION, MENTAL DISEASES) All officers and enlisted men in whom frank psychoses exist should be marked "D ' and returned to the United States as soon as this can be done without injury or endangering their chances of recovery. It will often be advantageous to hold these cases in the psychiatric departments of base hospitals at base ports until acute and severe manifestations have passed or, in cases of an especially favorable type, until recovery has taken place, but it should not be made the practice to provide extended treatment in hospitals in the American Expeditionary Forces. In exceptional cases where it seems desirable to depart from the rule of returning to the United States soldiers who have or who have had psychoses, the patients may be classified "B," and the special considerations which make a departure from the rule desirable must be noted on the report card. MENTAL DEFICIENCY (FEEBLE-MINDEDNESS, DEFECTIVE MENTAL DEVELOPMENT) The existence of a readily demonstrable degree of mental deficiency should almost invariably be sufficient reason for not classifying soldiers as "A," but it should by no means be regarded as sufficient reason in itself for placing them in class "D." In recommending mentally defective soldiers for duty in labor organization at the rear, especial weight should be given to good physique, emotional stability, and freedom from such delinquent traits as alcoholism, dishonesty, nomadism, and the like. Military delinquents, of whom the mentally defective constitute a large proportion, are a source of almost as much noneffectiveness as illness and it is important that the Expeditionary Forces should not be burdened with their care and supervision. Defective delinquents should always be classified "D." CONSTITUTIONAL PSYCHOPATHIC STATES In making recommendations as to the disposition of soldiers found to have constitutional psychopathic states, the considerations mentioned under the preceding heading should govern. It should be remembered that many individuals with volitional defects are amenable to military control. Conditions which should usually indicate the wisdom of returning these cases to the United States are marked emotional instability, sexual psychopathies (homo- sexuality, etc.), paranoid trends, and specific criminalistic traits. These cases should be classified "D." Excessive fear or timorousness should prevent return to duty at the front. For military reasons it is especially undesirable, however, to return such cases to the United States. They should be recommended for duty in labor organizations and marked "C." EPILEPSY Epileptics should be classed "D," the only possible exceptions to this rule being individuals in robust physical health who have attacks of moderate severity at long intervals and those in whom treatment has had this result. In making the diagnosis of epilepsy the fact should be borne in mind that attacks are likely to be less frequent in the favorable environment of the hospital while observation is being carried on than in the organizations from which patients are received. Great weight should be given to a well-authenticated history of epileptic seizures, especially when witnessed by medical officers or other persons who can give a clear account of their character. While the possibility of malingering should not be overlooked, it should be remembered that attacks similar to those in epilepsy are much more frequently psychoneurotic in their nature than feigned. The high prevalence of epilepsy among soldiers should be remembered. DRUG ADDICTION AND ALCOHOLISM These conditions are essentially curable. Inebriates and drug addicts should not be recommended for return to the United States with a view to their discharge until thev have ailed to respond to adequate treatment. Then, their disposition should depend upon the type of personality presented, the effects of alcohol or drugs in physical deterioration or IN THE AMERICAN EXPEDITIONARY FORCES 299 damage to the central nervous system, and the conditions to which they will be exposed when they are returned to duty. It will often be found that these cases do better at the front than in duty at the rear. PSYCHONEUROSES (HYSTERIA, NEURASTHENIA, PSYCHASTHENIA) These conditions must be dealt with as disorders amenable to treatment under proper conditions. Individuals who fail to benefit from such treatment in the special hospital which has been provided, either because of severe defects in make-up or on account of previous mismanagement, should be returned to the United States for continued treatment unless it seems likely that good results can be obtained from their assignment to duty at the rear. A very large proportion of the severe neuroses seen in war are of the "situation type," rather than psychoneurotic manifestations in persons who have had many previous episodes of the same kind in civil life. These instructions had the effect of amending or at least interpreting General Orders, No. 41. It was one thing to determine upon such a policy, however, and another to put it into effect. On account of misunderstanding what was contemplated, a good many disability boards in base hospitals passed upon the neuropsychiatric patients before evacuating them to the hospital center at Savenay. This was done for several reasons besides misunderstanding the intent of the order. One technical difficulty came from the requirement by the commanding officers of some base hospitals of the approval of a disability board before authorization of the travel necessary to take the patients to the base port. In addition, many mild cases of psychoneuroses recovered in interior hospitals and were deemed fit for class A duty. These could not be discharged to duty without review by a physical classification board, and it seemed unwise to delay it. It is interesting to see how frequently individual opinion tended to govern in these matters and thus defeat a general policy. In one large hospital center the commanding officer formed the apparently fixed opinion that no soldier who had ever developed psychoneurotic symptoms was fit for military duty in any capacity in France. In consequence he had ordered disability boards at that center to classify all such patients D and send them to the hos- pital at Savenay for evacuation to the United States. When it is remembered that a large proportion of all men who broke down at the front and were treated at army neurological hospitals returned to duty without ever having left the theater of operations,28 and that 91 per cent of all patients treated at Base Hospital No. 117 were there reclassified for some type of military duty in France,10 it can be seen how untenable such an opinion was. These difficulties were largely overcome later through the intervention of the consultants for the hospital centers. These consultants interested themselves very actively in the question, served on, or examined cases for, disability boards, or gave opinions which helped to put the provisions of Circular Letter No. 24 into practical effect, At the first replacement depot established at St. Aignan-Noyer by the 41st Division a very large proportion of all reclassified men received in the early activities of the American Expeditionary Forces came before disability board No. I.29 From May 1 to December 31, 1918, 27,437 men appeared before that board, of whom 9,256 were classified A.29 The 41st Division was provided with a division psychiatrist upon its arrival in France, but it soon became apparent that he would require additional 300 NEUROPSYCHIATRY aid as the reclassification work of the division increased. During the summer of 1918 a neuropsychiatrist was detailed as chairman of the disability board and, with several assistants, he organized extremely effective and practical methods of neuropsychiatric examination and reclassification. The following report from the medical officer who was in charge of the neuropsychiatric department of Base Hospital No. 8, dated July 9, 1918, indicates the general principles which from that time on governed the reclassification of neuropsychi- atric patients at that base port:30 I. In accordance with verbal request, the general principle governing this disability board, with respect to line of duty in nervous and mental diseases, is submitted. The following cases are considered not in line of duty: 1. Psychosis in men who have had a well-established psychosis previous to enlistment. 2. Psychosis in men so psychopathic in constitution that the psychosis represents merely an episode in a constitutionally psychopathic individual. 3. Psychoneuroses which were well established before enlistment and did not arise as the result of military service. 4. Epilepsy in men who have had well-established epilepsy previous to enlistment. 5. Mental deficiency. 6. Constitutional psychopathic states in men who have a life history of associated alcoholism, criminal tendencies, and delinquencies. II. Cases considered in line of duty: 1. All psychoses developing since enlistment, presumably as the result of military service, without established histories of previous attacks. 2. Epilepsy, with first history of well-established epileptic seizures, occurring since enlistment and presumably as the result of military service, such as traumatic cases, shock and others. 3. Psychoneuroses (hysterical states, neurasthenia, anxiety states, and others) in which the condition developed since enlistment, presumably as the result of military service 4. Other diseases of the nervous system—such conditions as toxic neuritis, traumatic cases, affecting the nervous system—are considered in line of duty, unless well-established histories indicate their presence previous to enlistment. ^ V/' In a number of cases of syphilis of the central nervous system the board has had difficulty in deciding the question of line of duty. These are cases in which the time of the initial infection « unknown and in which the invasion of the central nervous system occurred since enlistment and where military service may have been an important etiological factor. Instruction is desired as to proper procedure in such cases. IV. The above general principles are followed and applied to each individual case in accordance with the history as established. In acute psychoses the eases are consdered n hne of duty when the history of a previous attack can not be established. The total work of neuropsychiatrists in connection with these boards throughout France was very great and represented an extremely useful con- men""he v!r.S ^ ' ** "*"* * *" ^ °f ^ilitatfng ex-service There was established at Blois, in the summer of 1918 an officers' classi fication and efficiency board 31 Here mamr ™™l* • ?? 0ttlCers classi" .JJ&M^ inters ^es'oS^ fT "*" * ^ ""^ there were cases coming to attention in 2 tn. i T" aPPar6nt *" —ent o. ]udgm/nt, _ack Tjl^t ^TZ*TZ IN THE AMERICAN EXPEDITIONARY FORCES 301 some form of mental disorder. In several instances the suicide of officers occurred after they had been reclassified, usually through demotion, by this board. Accordingly, a medical officer who had had nearly two years' experi- ence in the study of war neuroses in British war hospitals and was at the time serving as division psychiatrist in the 1st Division, was assigned to this board, not as a member but as consultant in neuropsychiatry. He reported for duty in November, 1918, and continued his work until January, 1919. His reports showed that such a detail was well justified and he was able to bring to the attention of the board a considerable number of cases, some of them officers of high rank, in whom there were definite but quite unsuspected evidence of mental or nervous diseases. In not a few such instances the result of the board's investigation was the transfer of officers to neuropsychiatric hospitals and their evacuation to the United States for retirement or discharge on a surgeon's certificate of disability. REFERENCES (1) Letter from The Adjutant General to the Surgeon General, January 12, 1918. Subject: Assignment of neurologists to tactical divisions. Copy on file, Historical Division, S. G. O. (2) G. O. No. 81, H. A. E. F., December 24, 1917. (3) Letter from the chief surgeon, A. E. F., to all division surgeons, September 8, 1918. Subject: Psychiatrists, neurologists, and ophthalmologists in tactical divisions. On file, A. G. O., World Wai Division, chief surgeon's files, 321.62. (4) Outlines of Histories of Divisions, U. S. Army, 1917-1919, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College. (5) Station lists for medical officers assigned to the neuropsychiatric service, A. E. F. (6) Letter from the chief surgeon, A. E. F., to the Surgeon General, February 23, 1918. Subject: Hospitalization data. On file, Record Room, S. G. O., 322.3 (Med. Dept. Units, France). (7) History of Base Hospital No. 66, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O. (8) Letter from the director of neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., February 27, 1918. Subject: Neuropsychiatiic department, standard base hospital group. On file, Historical Division, S. G. O. (9) Letter from the director of psychiatry, A. E. F., to the chief surgeon, A. E. F., February 10, 1918. Subject: Use of Camp Hospital No. 4 for treatment of war neuroses. Copy on file, Historical Division, S. G. O. (10) History of Base Hospital No. 117, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O. (11) Letter from the senior consultant in neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., September 14, 1918. Subject: Second hospital for war neuroses. Copy on file, Historical Division, S. G. O. (12) Weekly bed reports, chief surgeon's office, A. E. F. On file, Historical Division, S. G. O. (13) History of Base Hospital No. 214. A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O. (14) Monthly returns of the American Expeditionary Forces, made to The Adjutant General of the Army. „. (15) History of Base Hospital No. S. A. E. F., by Lieut, L. G. Payson, S. C. On file, His- torical Division, S. G. O. (16) Letter from the director of psychiatry, A. E. F., to the chief surgeon, A. E. F., February 1, 1918. Subject: Recommendations for the care of mental cases. Copy on file, Historical Division, S. G. O. (17) History of Base Hospital No. 216, A. E. F., by the commanding officer of the hospital. On file, Historical Division, S. G. O. 302 NEUROPSYCHIATRY (18) Letter from the senior consultant in neuropsychiatry, A. E. F., to the chief surgeon, A. E. F.. October 28, 1918. Subject: Provisions for mental cases at Savenay. Copy on file, Historical Division, S. G. O. (19) Report of Medical Department activities, Base Section No. 5, A. E. F., undated, compiled under the direction of the base surgeon from official records in his office. On file, Historical Division, S. G. O. (20) Report of special hospital provisions for mental and nervous cases in the Services of Supply, A. E. F., made by the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., October 26, 1918. Copy on file, Historical Division, S. G. O. (21) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., November, 1918. Subject: Return of mental cases to the United States. Copy on file, Historical Division, S. G. 0. (22) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., November 28, 1918. Subject: Modification of plans for care of neuropsychiatric cases. Copy on file, Historical Division, S. G. O. (23) Tables of Organization (Medical Department). On file, Record Room, S. G. O., 320.3-1 (Table Organ). (24) Report of the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., for the period embracing the beginning and end of American participation in hostilities, December 31, 1918. On file, Historical Division, S. G. O. (25) Correspondence. On file, Record Room, S. G. O., 353 (Training neuropsychiatrists). .20) Letter from the senior consultant in neuropsychiatry, A. E. F., to the director of pro- fessional services, A. E. F., July 28, 1918. Subject: Approval of commanding officers for orders, neurologists and psychiatrists. Copy on file, Historical Division S. G. O. (27) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., June 18, 1918. Subject: Observation by Colonel Pearce Bailey, of neuropsychiatric work in France and England. Copy on file, Historical Division, S. G. O. (28) Final report of the chief surgeon, First Army, November 20, 1918. On file Historical Division, S. G. O. (29) Report of the president of Disability Board No. 1, First Replacement Depot No. 1, St. Aignan-Noyers, December 31, 1918. On file, Historical Division, S. G. O. (30) Letter from Maj. Sanger Brown, II, M. C, to the senior consultant in neuropsychiatry, A. E. F., July 8, 1918. Subject: Line of duty, disability board, neuropsychiatric cases. Copy on file, Historical Division, S. G O (31) G. O. No. 131, G. H. Q., A. E. F., August 7, 1918. CHAPTER II DIVISION, CORPS, AND ARMY NEUROPSYCHIATRIC CONSULTANTS In the earliest recommendations for combating war neuroses in the Ameri- can Expeditionary Forces the greatest emphasis was placed upon the work carried on in the divisions. The experience of the French and British medical services showed, within a very few months after the beginning of the war, that patients with war neuroses improved more rapidly when treated in permanent hospitals near the front than at the base, better in casualty clearing stations and postes de chirurgie d'urgence than even at advanced base hospitals, and better still when encouragement, rest, persuasion, and suggestion could be given in a combat organization itself. It was for the purpose of applying this well-established fact that plans were made to station a medical officer with special training in psychiatry and neurology in each combat division, since the division was to be the great combat unit of the American Army in France. It was deemed impracticable to consider detailing a consultant in neuropsychiatry to a combat unit smaller than the division. Corps and army consultants in neuropsychiatry ordinarily had merely organizing and supervisory functions. The actual neuropsychiatric work with combat organizations in the theater of operations was done by the division psychiatrist and such enlisted personnel as were assigned to assist him. DIVISION PSYCHIATRISTS Immediately after the authorization by the War Department of the assign- ment of specialists in nervous and mental diseases to tactical divisions, as detailed in Chapter I, p. 273, the chief surgeon, A. E. F., issued the following circular outlining the duties of these medical officers: Circular No. 5.—Duties of Medical Officers Detailed as Psychiatrists in- Army Divisions in the Field Headquarters, American Expeditionary Forces, Office of the Chief Surgeon, France, January 15, 1918. 1. The following outline naturally does not indicate all the means by which medical officers detailed as psychiatrists in arm}- divisions in the field can be of service in dealing with the difficult problems arising in the diagnosis and management of mental and nervous diseases among troops. These officers are under the direction of the chief surgeons of the divisions to which they are attached, and they must be prepared at all times to render such services as he may require. These officers are not members of division headquarters staff. They are attached to the sanitary train. 2. It is essential for such officers to bear in mind the prime necessity of preserving, or restoring for military duty, as many as possible of the officers and enlisted men who may be brought to their attention. On the other hand, they should recommend the evacuation, with the least practicable delay, of all persons likely to continue ineffective or to endanger the morale of the organizations of which they are a part. This is particularly true in the 303 304 NEUROPSYCHIATRY case of the functional nervous disorders loosely grouped under the term "shell shock" but more properly designated as war neuroses. Psychiatrists detailed to this duty have a unique opportunity of limiting the amount of ineffectiveness from this cause and of returning to the line many men who would become chronic nervous invalids if sent to the base. At the same time they can bring to the attention of other medical officers and company com- manders individuals who possess constitutional mental defects of a type which make it certain that they will break down under stress. 3. Specific duties which may be performed by psychiatrists in army divisions are as follows: (a) Examine all officers and men under observation or treatment for mental or nervous diseases in regimental infirmaries, field hospitals, camp infirmaries, and other places, and to advise regarding their diagnosis, management, and disposition. (6) Examine other mental or nervous cases in the divisional areas when directed to by the chief surgeons or requested to by other medical officers or company commanders. (c) Examine and give testimony regarding officers and men brought before courts- martial or under disciplinary restraint, when directed or requested by competent authority. (d) Give informal clinical talks to groups of medical officers in the divisions to which they are attached upon the nature, diagnosis, and management of the mental and nervous disorders peculiar to troops. (e) Keep careful records of all cases examined. (/) Make such reports to the chief surgeons of divisions as they require and to make monthly reports of their operations to the director of psychiatry, bringing especially to his attention any matters likely to increase the efficiency of this part of the medical work of the American Expeditionary Forces. A. E. Bradley, Brig. Gen., N. A., Chief Surgeon. Approved: By command of General Pershing: J. G. Harbord, Chief of Staff. The duties outlined in Circular No. 5 were amplified in certain respects, by Circular No. 35,a as follows: They will examine enlisted men brought before general courts-martial as provided by the.V Z V n 19i8- ThGy WiU alS° eXmIne aU °ther miUtar>' delinquents brought to their attention, especially those in whom self-inflicted wounds or malingering is suspected. ^t7exaUmtc,eXbCTh°H ClrCUmst\nces'.no ««. of this kind will be evacuated to the rear until examined by the division psychiatrists. In the case of prisoners accused of crimes the cThl^r PTS^ef °f WMCh " death' thG divisi0n P^hiatrist should, whenevepraS- cable, have the assistance of a consultant in psychiatry. ^uever practi Exne^iZ'11^815^ °f 1918' WhGn thG C°mbat divisions of the American Expeditionary Forces were engaged in every type of preparation for battle, SfSST rV*Td T°* medlCal °*«ri»tions which were to serv combat troops In addition, the weeding-out of undesirable members of the Z^on ^IW °f t" b?!St fitt6d to ^m ^ ^ties ^ the circulation of useful information, all went on with the utmost vigor inte ^IT^mTT^'^^ PertaininS to this period, slow many mteresting and useful activities. In several instances the division psychiatrists no only performed work in their own field, but rendered usefulservce in nra ticaUy every type of medical undertaking carried on in a division Regarded £t^^-^^73^nr orbgratio11 d« « ---------!____^^^^emselve^ favorable opinion of their superiors 1 For full text see p. 280. IN THE AMERICAN EXPEDITIONARY FORCES 305 and demonstrated their capacity for usefulness. This had its value later when it became necessary for them to have greater responsibility in connection with the evacuation of sick and wounded, when the divisions to which they were attached were engaged in battle. During the time under consideration, the 32d, 3d, and 77th Divisions arrived in France.1 Each was provided with a competent division psychiatrist who had served with the division in the training camp in the United States, directed the neuropsychiatric examination of the personnel and, in each instance, established excellent working arrangements not only with the other medical officers, but also the organization commanders of the division.2 The division psychiatrists of new divisions arriving in France were pro- vided with Circular No. 5, chief surgeon's office, A. E. F., and informed of the general plans for neuropsychiatric work in the American Expeditionary Forces. Parts of eight other divisions arrived during May J but too late to take part in the plan of training that had been employed for the first four and, in a modified way, for the others that had come in April. There was available, by the end of May, 1918, a good deal of practical neuropsychiatric experience, for by this time practically all the neuropsychiatric problems of a division in action had been dealt with experimentally. In this experience it had been found that many difficulties arose unless the division psychiatrists scrutinized closely the flow of exhausted, concussed, and emotion- ally disturbed soldiers from the front and controlled, to a certain extent, their evacuation. Had there been time to do so, these experiences would have led to the establishment of methods certain to avert what happened a little later when a number of our divisions, unprepared by similar experience, were sud- denly thrown into battle. No such opportunity came, however, for the military situation had become critical following the German offensive of March 21, 1918,3 and because of the pressing demand for troops for combat their training had to be considerably curtailed.4 Preparations for imminent battle conditions quickly replaced all other activities. The deficiencies in the organizations of the work of division psychiatrists were to be revealed by further experiences before they could be remedied. In our earlier combat activities, our divisions served as a part of the French forces.3 With the plan of evacuation through American channels abandoned, while our divisions were serving with the French,5 and corps and army medical organizations were only partially effective, it was natural that a combat division should seek only to free itself of its sick and wounded in the quickest way. Experience already had shown the necessity for making separate provisions for gassed cases by designating a divisional field hospital as a gas hospital,6 but with the large number of casualties and the fairly rapid advance of troops, it did not seem possible to designate a field hospital to receive exhaustion, con- cussion, and neurotic cases, much less to set one aside for their exclusive use. It is not surprising, therefore, that many of our soldiers evacuated from the front during the early months of our participation in active warfare were neither wounded nor gassed, the majority of whom could have been returned to their divisions, had the opportunity been provided, after a few days of rest, encouragement, and psychotherapy.7 The subsequent careers of these men were 306 NEUROPSYCHIATRY determined by the hospitalization conditions that existed to the rear of the combat divisions rather than within them. In this connection it is appropriate to state here that, during the German advance in March and April, 1918, the French had lost all their evacuation hospitals, totaling approximately 45,000 beds.8 Behind the retiring lines of the French, with whom the American divi- sions were now fighting, there was insufficient hospitalization to care for the French wounded as well as American; therefore, it was necessary for us to take charge of the medical service to the rear of our divisions. Since the number of our evacuation hospitals at this time was far below the authorized quota, and as the sector originally selected for occupation by American troops was that facing Lorraine, about 160 miles to the east of Meaux, our stationary hospitals had been concentrated largely in that area and to its rear. In consequence, many hundreds of men suffering from exhaustion, concussion neurosis, fear, and other emotional states found themselves, within a few days after leaving their organizations, in hospitals a hundred miles or more away from the front. Very few of these men ever returned to active duty. The value of these experiences lay chiefly in the demonstration of the fact that American divisions (even after a careful selection, with the elimination of many psychopathic, mentally defective, and unstable men) were capable of furnishing a large number of war neurotics under battle conditions, and that these patients were as resistant to treatment at points distant from the line as those in the armies of the French and British, upon whose experience our plan had been based. Fortunately, there were some noteworthy activities that indicated marked progress. For example, during the Aisne operation, the division psychiatrist, 3d Division, effected the establishment of a field hospital for mental patients, and the return of a large proportion of his cases to their own organizations without the necessity of their leaving divisional control.9 During the Aisne- Marne operation, the division psyciatrist, 4th Division, by stationing himself in the triage, and having set aside a field hospital about 6 miles farther to the rear, was able to divert from the evacuation hospitals a large number of men suffering from conditions likely to result in war neuroses, and to return many of them to the front.10 In most of the other divisions engaged, however, it was found or thought to be impracticable for division psychiatrists'to station themselves in triages. No effort was possible, therefore, to distinguish between exhaustion, concussion, fear, and neurosis, and the diagnosis "shell shock" was indiscriminately used when men seemed to be suffering from any of these conditions. The result was that such cases were evacuated to base territory Ten American divisions (the 35th, 82d, 33d, 27th, 4th, 28th, 80th, 30th, ''th, and 78th) were designated to operate at one time or another, with the British m northern France and in Belgium.1 There it was impracticable even to attempt to put into effect a plan which had been devised originally for an American sector. Patients suffering from psychoneuroses were evacuated from those divisions along British lines of evacuation and most of them reached England within a relatively short period of time. Here they were treated at first m special British hospitals for war neuroses, where American medical officers often took an important part in their management and, later, in American IN THE AMERICAN EXPEDITIONARY FORCES 307 base hospitals in England where their treatment conformed to the principles that are described elsewhere in this volume. (See p. 398.) The importance of more adequate medical organization to care for neuro- psychiatric cases at the front was brought to the attention of the director of professional services, A. E. F., by the senior consultant in neuropsychiatry in the following letter, dated August 6, 1918: u 1. The recent severe fighting has resulted in a very large number of soldiers with war neuroses being evacuated to hospitals in the S. O. S. Base Hospital No. 117, on account of lack of provision, has been obliged to decline to receive cases by transfer from other base hospitals. Until the results of telegraphic inquiry recently sent out are known, it is impos- sible to say how many of these cases are in the hospitals of the S. O. S. The fact that no less than 350 were present a few days ago in the hospitals in Vittel and Contrexeville and 135 in Base Hospital No. 115 indicates that a considerable part of our hospitalization is devoted to their care. 2. Such a high incidence of these disorders after a brief period of active fighting gives some idea of the efforts that must be made in the A. E. F. if we are to deal with the problem of the war neuroses in an effective way and prevent serious wastage from this cause. 3. It is desired at this time to invite attention to only one phase of the problem—the urgency of affording divisional psychiatrists an opportunity to pass upon these cases when- ever practicable before they are evacuated to the S. O. S. It has been reported to me that many of the cases received in base hospitals are not suffering from any kind of psychoneu- rosis or from the effects of concussion by high explosives. Many of them are cases of physical exhaustion who would have been entirely fit for duty after a short period of rest without hospitalization had their condition been recognized. Most of the cases, not a few of whom I have examined myself, express great surprise that they should be sent to hos- pitals and their chief desire is to join their organizations as soon as possible. 4. The importance of checking this source of wastage of man power can not be over- estimated. I directed attention to it in a report rendered to the Surgeon General in July, 1917, and in many communications since that time. In division psychiatrists our Army has a most effective means of determining what cases shall be evacuated to the S. O. S. It is very unfortunate that services of these officers, many of whom were specifically trained for their duties in reference to this particular task and all of whom are fully aware of what must be done, are not utilized most effectively in the tactical divisions. I believe that every effort should be made, now that actual experience has demonstrated the validity of previous recommendations, to provide them with facilities for their work. To meet the needs of specialists with divisions at the front, the chief surgeon A. E. F., sent to all division surgeons a communication concerning the duties of certain specialists, the sections of which that deal with neuropsychiatrists being given below, those dealing specifically with other specialists being omitted: American Expeditionary Forces, France, September 8, 1918. From: Chief Surgeon. To: All Division Surgeons. Subject: Psychiatrists, urologists, and orthopedists in tactical division. There is apparently some misunderstanding among division surgeons relative to the duties and status of specialists assigned to divisional formations for duty. During the recent activities one division surgeon assigned the psychiatrists to dressing the slightly wounded. While he was engaged at this work, several hundred cases of slight war neurosis were evacuated that would never have left their division if they had been examined by a trained psychiatrist. 42705—29----21 30S NEUROPSYCHIATRY The above instance is cited to show the importance of properly utilizing the services of these trained specialists with a view in this instance of avoiding a repetition of the expe- riences during the recent activities when a total of nearly 4,000 cases of slight war neurosis were evacuated to base hospitals that should never have left their divisions. i. general status and duties Orthopedists, urologists, and psychiatrists are attached to tactical divisions solely to aid in dealing with the medical and surgical problems of the divisions. Their activities have two objects: (a) to keep the fighting strength of the division at the highest possible point, and (b) to bring about the prompt elimination from the division of those who become unfit for duty. These three branches of medicine and surgery are represented because they are concerned with those diseases and injuries which experience shows contribute most to noneffectiveness of individual soldiers and troops in general. The function of these specialists is to help the division surgeon in the clinical work of the division in much the same way that the sanitary inspector does in sanitation and the assistant to the division surgeon in administration. They should be attached to the office of the division surgeon as additional assistants. In no other way can they render most efficient seivice. Their permanent assignment to an}- subordinate sanitary formation of the division inevitably curtails their usefulness. In periods of stress, however, they should be stationed by division surgeons in the post in which they can work to the best advantage (c. g., orthopedists and psychiatrists in triages, the urologists in surgical hospital during combat). They should not be regarded as consultants representing an organization outside divi- sional control but as integral parts of the division sanitary personnel, wholly concerned with the medical work of the division to which they are attached and directly under the supervision of the division surgeon. Psychiatrists Division in training or rest: 1. Elimination of insane, feeble-minded and epileptic (especially among replacements). 2. Mental examination of general prisoners in accordance with sections 11, G O 56, C. S. 3. Instruction of medical officers regarding diagnosis, early management, and pre- vention of war neuroses ("shell shock"). Division in combat: 1. Examination and sorting of officers and men returned to advanced sanitarv posts for exhaustion, concussion by shell explosion, and war neuroses in order to "control their evacuation. 2. Treatment of light cases of exhaustion, concussion, and war neuroses in divisional sanitary formations so as to preserve the greatest number possible for duty 3. Mental examination of general prisoners and men suspected of having self-inflicted injuries. (Signed) M. W. Ireland, Major General, Medical Corps, Chief Surgeon. T,heVhAAme^n E_xPeditionary F^ces plan for caring for psychiatric casualties had been definitely realized and was in actual operation the following circular letter from the office of the senior consultant in neuropsychiatry was issued under date of September 25, 1918 (section dealing with army neurological hospitals and supervision omitted). IN THE AMERICAN EXPEDITIONARY FORCES 309 Arrangements for Care and Evacuation of Nervous and Mental Cases i. divisions 1. Each division in the area has a division psychiatrist who will be stationed at the triage when his division is engaged. There he will sort all nervous cases, returning directly to their organizations those who should not be permitted to go to the rear and resting, warming, feeding, and treating others, particularly exhausted cases, if there is opportunity to do so, He will recommend all others for evacuation as follows: (a) To a field hospital if all or part of one can be devoted to the care of cases likely to return to their organizations within two to five days. (b) To Neurological Hospital No. 1 at Benoite Vaux or Neurological Hospital No. 3 at Nubecourt if a field hospital can not receive or care for such cases. Under these circumstances evacuations to the neurological hospitals will be direct; otherwise only cases unsuitable for or unimproved by treatment in a field hospital will be evacuated to them. 2. The advantages of these provisions for dealing with war neuroses and allied conditions in the divisions are: (a) Control over the evacuation of cases presenting no psychoneurotic symptoms. (6) Speedy restoration and return to their organizations of those in whom exhaustion is the chief or only factor. (c) Cure of mild psychoneurotic cases by persuasion, rest, and treatment of special symptoms at a time when heightened suggestibility may be employed to advantage instead of being permitted to operate disadvantageously. (d) Prevention or removal of hysterical symptoms (such as mutism, paralyses, etc.) so that, even if the patient has to be evacuated, his subsequent treatment will have been ren- dered easier and his recovery more prompt. (e) Effective management of severe concussion cases during the first 24 hours, thus short- ening their convalescence. (/) Creating in the minds of troops generally the impression that the disorders grouped under the term "shell shock" are relatively simple and recoverable rather than complex and dangerous, as the indiscriminate evacuation of all nervous cases suggests. The military organization for the care of war neuroses in the field had the merit of simplicity. No complex scheme could have succeeded. The division psychiatrist was stationed at the advanced field hospital, or triage, and his range of activity extended forward to the ambulance dressing stations and beyond as far as he cared to go and backward as far as the rear field hospital, which was the unit treatment center. The triage, or sorting station, was apt to be anywhere from 2 to 9 miles, or more, from the front line, and the treatment field hospital 4 to 7 miles farther removed. The former was usually an aban- doned strong barn; and the latter, generally under canvas, capable of caring for about 150 patients in five or six large tents. At the treatment field hospital the division psychiatrist was generally able to count on one enlisted man, Medical Department (usually without any nursing knowledge), to care for each 15 patients. The necessary medical assistance at the treatment field hospital was rendered by ward officers who were without psychiatric training. In some divi- sions the authority, as to the management of neurosypchiatric cases, was practically absolute, or, at least, could be readily made so. The fact that the war neuroses presented such unusual problems to commanding officers of field hospitals, who were unfamiliar with their genesis, type and treatment, and who wished to have these problems solved, made it possible in some organizations for the psychiatrist to obtain all necessary cooperation. In other organizations, however, where the commanding officers were hostile to the retention of such cases at' the front, the division psychiatrist worked under great handicaps. 310 NEUROPSYCHIATRY Thus, the work of the division psychiatrist was of such a nature that it required unusual skill in psychotherapy, courage, good nature, and sociability, which a few who were assigned to this work did not have. An assistant divisional specialist would have proven a valuable adjunct. It is true that even with an active combat division there were times when there was scarcely enough work to keep the division psychiatrist occupied; yet these periods were succeeded by days or weeks of stress and strain in connection with some important military operation when the services of a trained assistant would have been invaluable. The small "pool" of neuropsychiatrists under the control of the corps or army consultant proved to be a useful means of meeting this need. The character of battle activity determined to some extent the number of psychiatric cases occurring in a division. Fighting which obliged men to remain expectantly in trenches or reserve positions under heavy bom- bardment for considerable periods of time produced many nervous and exhaus- tion cases. Open warfare, with the men in action and on the move, alert, and watching the enemy, produced fewer cases, although exhaustion was frequent. Artillery fire, with the weird whistling of the approaching shells, the terrific detonations, and the mutilations produced by exploding shells, unnerved many men. On the contrary, rifle and machine-gun fire were not important factors in the production of nervous disorders. In fact, there were practically no cases in which rifle or machine-gun fire was the upsetting factor. The production of exhaustion cases followed days of constant fighting, with insufficient or no sleep, food, and water. The soldier always started into action with a full canteen and two days' reserve rations. He almost invariably kept his canteen, gun, and ammunition, but everything else in the way of equipment, including his rations, was cast aside as soon as it encumbered him. Conse- quently, not infrequently men were without food or water for several days at a time. The long-continued fighting, lack of rest and food, together with having to he out in shell holes all night in the cold and rain, frequently overcame the most courageous of men. Then a shell exploding near them, knocking them over or possibly killing or wounding a comrade, was often the last straw. A high percentage of men evacuated from the front line as "gassed" were really cases of fatigue, exhaustion, and emotional disturbance. It was neces- sary, therefore, that from this group the fatigued and exhausted be sorted out or treatment in one of the field hospitals. Of the medical cases reaching the triage the most common diagnoses were "bronchitis," "influenza," and "diar- rhea, In many cases the most important factor was fatigue. These cases were also sorted out and retained for treatment in the divisional field hospital. In the last group there were the neuroses with tremors, speech and hearing disorders ataxia,, and stupors. The severe cases were evacuated as promptly as possible to the army neurological hospitals, while the milder cases were deteimLT^ tv. re™ t° duty. The proportion retained was usually determined by the exigencies of the campaign thev^irod'T 0ffC°nCUSSi011 flm°St invariably asked not to be evacuated, as call rhi vt V Pr0mP% t0 thGir °Wn or^ni-tion. In the less severe cas.es. tins was done. IN THE AMERICAN EXPEDITIONARY FORCES 311 Aside from the milder cases of exhaustion, sorted out from among the gassed and medical groups, the largest number of psychiatric cases was the exhausted with nervous symptoms. Men who were worn out, upon seeing their comrades killed or injured, and possibly being knocked over themselves by an exploding shell, lost their nerve, cried, shook all over and felt afraid, crouched and put up their arms as if to protect themselves each time they heard a shell coming or exploding. These responded promptly to treatment at the front. The sick and wounded were tagged either by a medical officer or, as gen- erally was the case, by enlisted men of the regimental sanitary detachments, indicating in a general way that the man was wounded, gassed, sick, or nervous.' The sanitary personnel had all been instructed to use only the term "N. Y. D. (nervous)" for the latter group of cases. This was an important matter, as it was surprising to see with what tenacity men clung to a diagnosis of "shell shock" or "neurosis" even though the tag had been made out by one of the enlisted sanitary personnel. Sometimes soldiers would wander into dressing stations and cheerfully anounce that they were "shell shocked." By using the term "N. Y. D. (nervous)" they had nothing definite to cling to and no sug- gestion had been given to assist them in formulating in their own minds their disorder into something which was generally recognized as incapacitating and as warranting treatment in a hospital, thus honorably releasing them from combat duty. The patients were therefore open to the explanations of the medical officers and to the suggestion that they were only tired and a little nervous, and that with a short rest they would be fit for duty again. It is worth while in this connection, as an example of neuropsychiatric work at the front, to review briefly the military history of the work of the division psychiatrist of the 26th Division,12 and to observe how the curve of neurosis incidence followed the activities of the troops, rising during active campaign and falling again after comparative quiet had been restored. Obviously in times of severe strain the need for a medical assistant to the division psychiatrist was very real. Between February 5 and 8, 1918, the division entered the line north of Soissons, in the famous Chemin des Dames sector, where we remained until March 21. Only about 18 psychopathic cases were evacuated during this time. The reason for this low incidence was t hat the sector was a comparatively quiet one, there was not much heavy shelling, the troops were fresh and eager, and we were brigaded with a veteran French division, thus relieving our own:-men of much anxiety and responsibility. Beginning April 1, 1918, we relieved the 1st Division in the "Boucq" sector, northwest of Toul. The stay of the division in this sector was marked by several serious encounters with the enemy, where considerable forces were engaged. There were furthermore almost nightly encounters between patrols or ambush parties, and the fire of the artillery on both sides was very harassing. On April 10, 12, and 13 the lines were heavily attacked by the Germans. At first the enemy secured a foothold in some advanced trenches which were not strongly held, but sturdy counterattacks succeeded in driving him out with serious losses, and our line was entirely reestablished. Fifty-two cases resulted. April 20 and 21 the Germans made a second raid on our lines about and in the town of Seicheprey and Remieres Woods, supported by exceptionally severe artillery fire. Forty-three cases developed from this attack. A tliird raid was launched on June 16 at the village of Xivray-Marvoisin, but failed to get within our defenses. As if in retaliation for the decisive check the enemy had suffered, he delivered throughout the day exceedingly severe artillery fire on the battery positions and rear areas. Thirty-six cases followed the bombardment. 312 NEUROPSYCHIATRY On July 4 we relieved the 2d Division in the line just to the northwest of Chateau Thierry, taking over the hotly contested and hard-won line from Yaux-Bouresches—Bois de Belleau— to the vicinity of Bussiares. With no system of trenches or shelters, there was great exposure to enemy machine-gun and artillery fire; the woods and villages on the line were drenched with gas; a vigilant and aggressive enemy allowed no rest. The men were tired. They had been in the line almost continuously since February 4. The great German drive southward between Compiegne and Rheims had reached the Marne River. For the moment it had been stopped, but a renewal of the attack was to be expected. The long-distance guns were dropping shells in Paris, 40-odd miles behind us; the Germans were desperate and promised to reach Paris at the next thrust. The morale of our troops was not topnotch and it was thought that many of them would break if anything serious occurred. These expectations were fulfilled a few days later. On July 12 and 13 the enemy made a vigorous thrust at our positions in Vaux, but was beaten back with equal vigor. Seventy-one cases resulted. On July 18 the attack of the division, as part of the general operation to reduce the Chateau-Thierry salient, and thereby avert the threatened danger to Paris, was begun. The villages of Belleau, Torcy, and Givry were taken; Hill 193, behind Givry, was twice won, but had to be abandoned because the French on our left had not been able to make rapid enough progress to secure the position. Heavy opposition was encountered, the enemy employing many machine guns and well-placed artillery fire. Sixty-eight cases occurred on July 18 and 74 on July 19. On July 23, with thorough artillery preparation, the division attacked again, endeavoring to penetrate and clear up Trugny Wood, Epieds, and the woods behind it. Although stubbornly opposed and in spite of severe losses, our troops went forward steadily. Forty-nine cases developed. On July 25 we were relieved. About September 5 we took over the "Rupt" sector. Until September 12 the sector remained quiet. On that date, however, began the great attack in force on the St. Mihiel salient by the American First Army. * * * The piincipal defense of the Germans was machine guns, well placed in concrete "pill boxes"; but there was very little artillery response, * * * Only 26 cases resulted, probably because of little artillery fire from the enemy. On September 26, the division was given the mission of executing a heavy raid against the German positions at Marcheville and Riaville, as a diversion in the general attack of the American First Army, which was to start on that date on the whole Meuse-Argonne front. Similar raids were to be executed by the other divisions of the corps at the same hour, the orders being to penetrate the enemy lines, make prisoners, and occupy the position throughout the day, withdrawing under cover of darkness. Heavy enemy resistance and counterattack resulted in six cases of acute mental disturbance. Shortly afterward we concentrated in and near Verdun. On October 16 we took part in an attack for the purpose of obtaining possession of the Bois d'Haumont, supported by tanks. The tanks failed utteily and heavy casualties resulted. Twenty-one cases resulted. During our stay in this (Neptune sector) conditions were very severe. Influenza was prevalent; the rain was almost continuous; shelter was insufficient. The enemy occupied positions of great natural strength, and was backed bv a numerous artillery He valued these positions highly and hung on with bulldog tenacity. Gas was constantly thrown into the valleys and harassing artillery fire was heavy. Attacks were made daily from October 23 to 27 inclusive, in conjunction with the 29th Division against the Rvlon d Etrayes-Bois Belleau-Hill 360 positions, which won for us a considerable advance, in spite of our heavy losses. Thirty-five cases occurred. The next few days passed without anv action save vigorous and successful patrolling to make prisoners divisSn pvppTh" 7' ^ *** general axis of advances changed from east to southeast, the Ch li F?l V SeC°^ \T\°n " Wlde fr°nt t0Ward the Jumelles d'°™e beyond the Finafiv at in VI wJ ^ WM reMWed daUy UP to and includinS November 11. to a collusion '' °n °f h0StUitieS br°Ught the active operations of the division IX THE AMERICAN EXPEDITIONARY FORCES 313 EMERGENCY TREATMENT AT THE FRONT Stationed, as the division neuropsychiatrists were, in combat areas, all their work being confined to field hospitals, where patients were held only from 3 to 10 days, depending upon military operations, the experience of these officers with the treatment and final outcome of the cases was limited chiefly to the milder forms of the neuroses. The more obstinate and chronic cases, of neces- sity, were evacuated to the rear areas. To the treatment hospital at the front the neuropsychiatric patient was sent after he had taken the first important step on the road to recovery. At least no one was sent there until a determined effort had been made to convince him that he could be cured. Of course, there was necessarily a constant and fairly large residuum of refractory cases, but these were not permitted to nega- tive the atmosphere of optimism which existed. Although situated in the field within the range of artillery fire, and subject to the military necessity of moving at an hour's notice, it was still possible to approximate suitable hospital con- ditions. The first difficulty which presented was the lack of nurses. The group of enlisted men who were selected had in the beginning nothing more than the doubtful merit of curiosity concerning the "shell-shocked" soldiers. Until it was possible to inculcate a certain degree of nursing morale it was necessary to deal with them from the point of view of military discipline. Certain orders were given, and failure to* obey them was considered a punishable infraction of a military command. The few simple rules and suggestions utilized at first (in one division) are here quoted: RULES FOR PSYCHONEUROSIS WARDS 1. Each patient on admission to have a hot drink. 2. Each patient to have three full meals a day unless otherwise ordered. 3. Do not discuss the symptoms with the patient. 4. Be firm and optimistic in all your dealings with these patients. 5. No one is permitted in these wards unless assigned foi duty. 6. The rapid cure of these patients depends on food, sleep, exercise, and the hopeful attitude of those who come in contact with them. From such an elementary beginning there gradually developed among the enlisted men, who acted as nurses, a high degree of interest and efficiency and a generalized and successful effort to intelligently maintain certain thera- peutic principles without which success would not have been possible. Classification was an important function of this hospital. Generally speaking there was an effort to keep the mild cases in one tent, the more severe in another, the physical problems separate, and the recovered awaiting return to the front apart from the others. Soldiers with obstinate symptoms were segregated. The physical needs of the patients were constantly borne in mind. Hot, abundant meals were provided; exercise, amusements, and work were utilized, not haphazard fashion, but with a certain object in mind. One finds in current reports on the therapy of war neuroses indefinite allusions to an intangible and mysterious therapeutic influence termed "atmos- phere." By this is meant, presumably, the general feeling and understanding which existed among all those who came into medical contact with the war neu- 314 NEUROPSYCHIATRY roses, and which sought to provide an urge or incentive for the soldier to return to his duty on the firing line. This was necessarily developed at every point in the American Expeditionary Forces where nervous and mental casualties were grouped for treatment. However, it should not have been permitted to remain at a vague and undefined stage, nor should its growth and direction have been left to mere chance. As a matter of fact, it was a thing which could be deliberately created and shaped into a definite and valuable therapeutic agent. As employed in the type of hospitals under consideration, it was sepa- rated roughly into positive and negative elements, the first being concerned with the advantages of returning to the front, and the second with the disad- vantages of evacuation to the rear. Constantly, and in every conceivable fashion, were emphasized the glory and traditions of the division, of the regi- ment, and of the company, and the very important part which each soldier played in contributing his share. Further, the personal relation which so fre- quently existed between officer and soldier was in a sense filial, just as the inti- mate feeling between man and man was fraternal. In the field with combat troops, where close association under dangerous conditions made for the relax- ation of certain features of rigid military discipline, such as ordinarily obtains in a cantonment, or camp, and also erased social barriers, it is exceedingly probable that what might be termed an artificial familial instinct was often developed and replaced in a measure the one of which the individual was at least tem- porarily deprived. This factor, too, could be utilized as a powerful means for obtaining a healthy therapeutic atmosphere. On the other hand, evacuation to the rear was painted in gloomy colors. The patients came to realize that leaving the division, or unit, meant probably the opportunity forever lost of having a part in its present victories and con- sequently in future honors and rewards. It involved a total separation from the paternal officer and brother soldier, and finally becoming that most un- happy of mortals, a lone casual. It was in a sense a desertion, since it left comrades to "carry on" alone. It w^ould be impossible to enumerate all the methods employed to foster and stimulate such impressions. The following sample will serve: Informal talks to groups of soldiers, the announcing and publishing of bulletins recounting the gallant advance of this or that unit, or the exploits of some well-known officer, or soldier, of the division, the reading and discussing of citations which had been received, rumors of a big offensive which was imminent, or of a well-earned rest which soon would be officially ordered, and the relating of incidents and episodes, "gossip" with a personal flavor which had come back by word of mouth from the front. Xo incidental opportunity was neglected. For instance, during the Meuse-Argonne opera- tion, columns of German prisoners frequently passed the tents. The patients were urged to view the procession, always a stirring event, which often suc- ceeded in evoking an exhibition of satisfaction and even patriotic fervor It is doubtful whether anyone who has not been an actual witness can appreciate the value of even such simple measures. The whole plan was far from being an uncertain proposition which could be expected to appear and act spon- taneously, but was based on an estimate of what emotions and feelings were to be activated and what degree of stimulation was needed to gain the desired object. IN THE AMERICAN EXPEDITIONARY FORCES 315 It is difficult to understand why such a personal and concrete thing as the attitude of the psychiatrist toward each of his patients had to be is so often described in such general terms. It was by far the most important feature of practically any form of treatment. Taking its cue chiefly from personality and intellectual capacity, it had to be rapidly defined in the mind of the physician so as to meet the needs of the individual under consideration. Further, fre- quently it had to be varied from time to time in the same case. It affected every phase of treatment, often dictating the mode in which specific symptoms were removed, modifying the explanation of the neurosis and governing the methods utilized in the final rehabilitation of the soldier before his return to the front. The particular methods of treatment utilized may be roughly divided into those which were applied to all the patients, or to fairly large groups, and those which had an individual application. The former is largely dependent for its effect on the creation and maintenance of the right kind of military atmosphere, which seeks to produce and encourage a desire to return to the front. In this respect the following observations may be of interest: A certain type of soldier, often of a moderately high intellectual grade, not infrequently pre- sented a curious psychological paradox as the time for his return to the front approached. He had made a good symptomatic recoveiy, had a considerable degree of insight into the mechanism of his neurosis, may have expressed a wish to go back to his regiment, and yet found a marked difficulty in taking the final step. This was not due to the fact that he was distinctly unwilling to return to duty, for he would have been as much or even more troubled by a decision which would have evacuated him to the rear. Apparently, there was in these cases a temporary volitional paresis. This condition was observed in a small percentage of all the neuroses. Experiments along the lines of logical reasoning and appeal to the individual had little result, and it was decided to try the effect of another plan. When a sufficiently large group had been col- lected, they were gathered together in a tent and given an informal talk, which was little more than an effort to reach and sway the emotions. Beginning with a recital of the situation at the front with reference to the division, and particularly to the various units which were represented by the soldiers present, it emphasized the acute need for every available man, and the fact that com- rades were suffering because of their absence, and finally came to a climax by a dramatic request for volunteers for immediate service. The result was always highly gratifying, and the spontaneous enthusiasm showed that these men were actuated by something more than mere deference to the wishes of an officer. In another group of patients who had made a fairly good symptomatic recovery, or who persistently retained a few insignificant symptoms, the ques- tion of volitionally withheld cooperation arose. Two courses were open. The power of the military machine might be invoked to force action, reducing the matter to a choice between front line duty or court-martial. Such a procedure was not employed. Its permanent value is not only questionable, but it is open to objections on ethical grounds. However, it had to be recognized that the problem was no longer strictly a medical one. Without using undue severity and with no trace of malice, such men soon found that an invisible barrier had 316 NEUROPSYCHIATRY been erected between them and the other patients. They were denied certain privileges and had to do most of the distasteful work, such as policing the grounds, digging latrines, etc. No one was permitted to impugn their motives, yet on every side they were confronted by a questioning attitude. Always the opportunity was afforded, and was indirectly encouraged, to talk over the situation with one of the physicians; always there was the invitation and the temptation to change their status to a happier and more honorable one. About 90 per cent of this group were eventually reached by such a simple method. For the attack on individual symptoms resort was had to various forms of suggestion which have been described in detail by various authors. When- ever there was a choice between two methods, the simpler was always pre- ferred. Complicated procedures seemed unnecessary. Often nothing more elaborate than passive relaxation of flexion and tension plus appropriate sug- gestion was needed to remove tremors; indeed, many of them disappeared spontaneously. If a paralysis responded at all to passive movement which gradually became active by the imperceptible withdrawal of the assisting hands of the physician, electricity was not employed. If an hysterical depriva- tion could be reached by suggestive persuasion or argument, such "tricks" by means of the stethoscope, tongue depressor, mirror, etc., as wTere in vogue were avoided. There were, of course, times when a degree of mystification was necessary, but it was never the first resort and was usually reserved for more refractor symptoms. Hypnotism was never used. As a preliminary to the consideration of the individual symptoms, there was an estimate of how much of the symptom was real and how much was only apparent. A change of position to one making for greater physical comfort, the removal of con- stricting clothing or of an external source of irritation, a hot drink, and a reassur- ing word or two were sometimes in themselves sufficient to decrease materially the range of tremors, to improve an exaggerated posture or movement, or to reveal a seeming paralysis as only a paresis. The amount of amnesia, partic- ularly, always appeared greater than it really was. Before any intensive attempt was made to treat it as a symptom its extent was carefully gauged. A simple and brief series of questions and answers often strikingly diminished its proportions. The selection of a route to gain access to any sign or symptom which presented in a patient was much influenced by the attitude which the psychiatrist had decided on as best suited to meet his needs as an individual. When more refractory symptoms were to be dealt with, that which seemed the most obvious thing to do was attempted first. Strict segregation had a wholesome effect on obstinate tremors or convulsive movements. Every advantage was taken of possible modifications of classification. A patient with a persistent difficulty would be placed for a short time in the midst of a small group of recovered soldiers awaiting transportation to the front. Occa- sionally some one who had made a particularly striking recovery was kept for a few days as a sort of hospital "pet" for the sake of the effect on difficult cases. He was taken into the confidence of the psychiatrist and instructed as to what was expected of him. Now and then a "chronic" patient was made to observe the removal of some symptom in a recent case. Sometimes the physi- cian planned to have his conversation and opinions overheard by this or that IN THE AMERICAN EXPEDITIONARY FORCES 317 individual. At times, when dealing with troublesome symptoms, it seemed advantageous, after the soldier's curiosity had been aroused, to postpone the final seance a number of times. A few elaborate consultations were staged wholly for their psychic effect. Such instances as the above might be endlessly multiplied; they merely served to intensify suggestion and were therefore useful. The employment of simple procedures had several advantages. They needed no elaborate paraphernalia and did not demand lengthy preparation. In the field space and time had to be carefully conserved. Further, it must be remembered that the patients, as they came to the triage, were like closed books. The soldier himself was frequently the only source of information available, and consequently there were many gaps in the history. When dealing with an individual whose potentialities were largely unknown it seemed the part of wisdom to restrict oneself, if possible, to things which could do no harm. Some of the more complex forms of technique depend largely for their suggestive value on the veil of mystery which surrounds them. Unless absolutely necessary, in some unusual instances, their exhibition ought to be avoided. They are apt to prove embarrassing when the time comes to give the patient the explanation of his neurosis, when, of all times, the physician needs to be sure of his ground. This explanation, too, must be as simple as possible. However high the educative and intellectual standard of the enlisted men in our Army might have been, it did not reach the point where an involved discussion of psychopathological mechanism could be appreciated. Even primary ideas and illustrations had to be used with caution, and the test of their efficacy rested on whether they were easily comprehended by the patient and satisfied his needs. Of 400 war neuroses, embracing all types and occurring in different opera- tions at the front, approximately 65 per cent were returned to front line duty after an average treatment period of four days. During the second half of the Meuse-Argonne operation, the recovery rate amounted to about 75 per cent; earlier, along the Ourcq, it had dropped to as low as 40 per cent. This fluctuation was governed by military necessity. In other words, there were four separate hospital-evacuation orders which affected about 70 patients who had had less than 36 hours' treatment. It is reasonable to assume that at least one-half of this number would have recovered if it had been possible to retain them 48 hours longer. After the armistice was signed an effort was made to determine the number of times a second attack had appeared. Only nine recurrences were found—less than 4 per cent of the total returned to duty. It is possible, of course, that a few cases may have passed through the triages of other divisions. However, these would necessarily have been restricted to troops on the flanks of the line and their number therefore could not have been significant. The recovery rate was influenced by certain factors. From the type of symptom presenting one could often predict the ease or difficulty which would attend its removal. Generally speaking, symptoms which occurred in condi- tions where there had been a definite trauma, or emotional insult succeeded by a stao-e of relaxed consciousness, responded readily. They were frequently of 318 NEUROPSYCHIATRY a hysterical variety. On the other hand, those which belonged to states which had been evolved in the plane of consciousness were not so accessible. They were apt to have a neurasthenic or psychasthenic coloring. Anxiety symptoms of various kinds presented the knottiest problems, and a relatively high percentage of these had to be evacuated to the rear. When time is necessarily limited the rapidity with which contact can be established between patient and physician is an important consideration. The degree of inaccessibility in the make-up of the soldier will be reflected in the therapeutic failures recorded in the field. The responsibilities of the psychia- trist were clear. He had to return as many men as possible to duty, and during times of great activity it was not always feasible to give each patient the full amount of attention his condition deserved. In this way, and at these times, the individual whose personality involved careful and extended study in order that his neurosis might be reached, sometimes had to be neglected as a matter of military economy. The intellectual status of the patient was not without its effect. The relatively ignorant soldier was usually softer clay in the physician's hands than was the one in whom learning and training had sharpened the habit of question- ing, scrutinizing, and weighing in the balance. Of course, these two of ten devel- oped different types of neuroses, but, given the same condition in both, the former could be handled with far greater rapidity and more surety of success. Finally, the recovery rate fluctuated in response to extraneous and wholly accidental factors. It was appreciably higher at periods when the division was about to be relieved, and it was lowered at the beginning of what promised to be a long campaign. During the three or four weeks preceding the armistice, when victory followed victory on every front and definite success seemed assured, it reached its apex. The psychological effect of such incidental happen- ings, of course, was complex; but in general they lessened the activity and the need of close surveillance on the part of the preservative instinct by the intru- sion of new and attractive possibilities; the anticipation of rest and pleasure in different surroundings under safe conditions in the former instance, and in the latter the prospect of an early return to the United States as a member of a victorious fighting division, and a resumption of all those pleasant relations from which the soldier had been cut off by the war. A statement of experiences with the war neuroses would be incomplete without some reference to gas hysteria and its treatment. A striking instance occurred during the Aisne-Marne operation, when the 3d Division was in the neighborhood of the Vesle River. One morning a large number of soldiers were returned to the field hospital diagnosed as gas casualties. The influx continued for about eight days, and the number of patients reached about 500. The divisional gas officer failed to find any clinical evidence of gas inhalation or burning, and the psychiatrist was given an opportunity to act as consultant. The patients presented only a few vague symptoms. There were, perhaps, tour or five instances of aphonia, but in the average case the symptoms pre- sented were a feelmg of fatigue, pain in the chest, slight dyspnea, coughing, husky voice, an assortment of subjective sensations referred to the throat, varying from slight tingling to severe burning, and some indefinite eve symp- IN THE AMERICAN EXPEDITIONARY FORCES 319 toms. Physical and neurological examination was practically negative, and the mental findings were inconclusive; if anything there was an undercurrent of mild exhilaration. Most of the patients had the fixed conviction that they had been gassed and would usually describe all the details with convincing earnest- ness and generally with some dramatic quality of expression. Careful inquiry elicited the information that these soldiers came from areas in which there was some desultory gas shelling, which, however, never reached serious proportions. The amount of dilution was practically always great enough to provide an adequate margin of safety. It was further developed that these conditions were always initiated in about the same way. Either following the explosion of a gas shell, or even without this preliminary, a soldier would give the alarm of "gas" to those in his vicinity. They would use their masks, but in the course of a few hours a large percentage of this group would begin to drift into the dressing stations, complaining of indefinite symptoms. It was obvious on examination that they were not really gassed. Further, it was inconceivable that they should be malingerers. They came from battle-tested troops, veterans of the severe action on the Marne and the early hard fighting in the Aisne region. It is exceedingly probable that a number of factors which existed at that time acted together with the general effect of lowering morale and reducing inhibition to a state where any suitable extraneous opportunity was apt to be utilized by many as a route to escape from an undesirable situation. It differed from the manifestation of the personal preservative instinct in that it was in a sense a mass reaction and a subconscious rejection of a situation which, although decidedly uncomfortable, yet was not sharply threatening from the standpoint of physical danger. The troops were more or less inactive, practically merely holding a position, and the small amount of activity which occurred was more irksome and irritating than highly dangerous. Following on the heels of the advance at Chateau Thierry and the first rush in the Aisne region it was com- paratively monotonous and lacked all those stirring and dramatic qualities which even in modern warfare attend more important military operations. Further, instead of a definite, easily understood objective such as they had been accustomed to, the minor activity which was not taking place seemed to the soldiers indefinite, uncertain, and apparently not aimed at a clear-cut objective. Again, too, for some time there had been a wide-spread feeling that the division was soon to be relieved and given a well-earned rest. When the day came on which the order for relief was expected, and wTord arrived that it was to be indefinitely postponed, the feeling of expectation and optimism gave way to disappointment and dissatisfaction. The relative inactivity gave abundant opportunity for endless thought and discussion among the men by which the mental unrest and uncertainty was rapidly disseminated and intensified. Finally the troops were beginning to feel the physical strain of four weeks' exertion under the most exposed and trying conditions. When these factors, no one of which was sufficiently strong to act alone, accumulated and combined they were evidently powerful enough to produce a wholesale effect. The problem demanded immediate and energetic attention. It was obvi- ously impossible to deal with each patient from the personal angle and give him extended individual attention. The drain on man power was being felt, and 320 X E UROPSYCHIATRY there was a request from military superiors asking that these men be returned to the line as quickly as possible. Each man on admission was examined, assured that his symptoms were not serious, and given some simple suggestive treatment followed by hot food and a brief rest, Some hours later he was again examined, encouraged to feel that the treatment had had the desired effect, complimented on his improvement, reassured about his condition, and convinc- ingly told that he would be able to return to duty on a certain day at some specified hour. From this point on symptoms were practically ignored. The patient now passed to a second tent where the conditions were rigidly military. Soldiers were usually required to wear their uniforms, and to observe all mili- tary courtesies, and they were under strict discipline. There was a round of duties to be performed under the supervision of a noncommissioned officer. In short, the hospital lacked about the only desirable features which were to be found at the front, namely, a relaxation of certain elements of military rule and routine duty. The method was successful. Only an occasional case proved refractory and required more intensive action. The basic idea was an attempt to impress on the patient's conscious mind that his ailment was not serious, and on his subconscious mind that the situation in which he now found himself probably offered no greater advantages over the one which he had recently left. No harshness was permitted, but no opportunity was given to lose contact with the life, duties, and responsibilities of a soldier. The wave of gas "hysteria," as the line officers insisted on designating it, receded from day to day, and ceased spontaneously at the end of eight or nine days. When hostilities ceased, there was some doubt as to whether the services rendered by division psychiatrists were sufficiently valuable to justify their retention in the divisions. In the army of occupation, where there was a pos- sibility that divisions might again be engaged in combat or at least be liable to a long period of service on foreign soil, no such question was raised. The other divisions, however, went back into areas previously used for training, and as rapidly as possible were sent to various concentration centers in preparation for their return to the United States. During this period of waiting for return to the United States a great many policies which were considered of importance during the period of combat were reversed. For instance, it was unwise to conduct too vigorous a search for mentally defective psychopathic individuals in organizations about to return to the United States, as their discharge from the Army in any case was only to be a matter of several weeks. The mentally sick, of course, were sent, as before the armistice, to Base Hospital No. 214, at Savenay, for return to home territory, there to be hospitalized further or discharged from the service on sur- geon's certificate of disability. The war neuroses had ceased to be a problem. CORPS NEUROPSYCHIATRIC CONSULTANTS As soon as the medical service of the corps became sufficiently well organ- ized to require the services of corps consultants in psychiatry these were ap- pointed. These consultants proved a valuable addition to the work of dealing with war neuroses m advanced formations. As it was impossible for a division psychiatrist to care for all the cases coming under his observation under condi- IN THE AMERICAN EXPEDITIONARY FORCES 321 tions of unusual stress, it was found feasible to attach to the corps, as tem- porary assistants to the corps consultant in psychiatry, additional medical officers with neuropsychiatric training. These he could dispose of as exigencies required, and in several instances an unusual flow of exhausted, frightened, and nervous men from the front was checked in triages by the extra officers who were available on this account to examine them and make recommendations as to treatment or other disposition. The corps consultant in psychiatry served an extremely useful purpose and his presence helped to insure the carrying out of a definite policy with reference to the care and evacuation of neuropsychiatric patients during combat. During quiet periods his services were likely to be fully occupied hi working out a better organization for the next period of activ- ity, helping in dealing with the medico-legal situations, questions of morale, and psychiatric problems which arose among troops themselves. The following report of the consultant to the First Army Corps, dated November 25, 1918, covers a period commencing in July, 1918, and ending with November 11, 1918:13 FIRST ARMY CORPS When the consultant in neuropsychiatry joined the First Army Corps in the latter part of July, 1918, its territory embraced all the area of combat in the Chateau Thierry sector. Two divisions were at that time on the front line—the 28th and 42d. Shortly afterwards the Third Army Corps was organized and part of the sector placed under their command. There were no precedents to help or hinder, but the needs of the situation were obvious. A series of divisions were coming into the corps, taking up front-line positions, after a time withdrawn and replaced by others. Each division had its psychiatrist. Some of them had been with the division for a considerable period and had their duties well in hand and ade- quate opportunity to carry them out. In other instances, the work was not well organized and the psychiatrist was called upon to spend his time in doing duties that might be carried on by other medical officers while the duties that only he could perform most satisfactorily were left in abeyance. This all depended on the conception held by the division surgeon of the usefulness and responsibilities of the divisional neuropsychiatrist. The chief surgeon of the corps held a high opinion of the importance of the work of the neuropsychiatrist, and always insisted that they be given every opportunity to do their work. A fine group of men like these officers needed only the opportunity in order to make them- selves most useful. The corps consultant found, therefore, as his chief duty during the period of advance, frequent visiting of the divisions, surveying of the lines of evacuation, and the points at which the psychiatrist could work most effectively, and advice and encouragement to them as various problems came up. Owing to difficulties in getting about over the coun- try, this apparently simple duty required a great amount of time, and until individual means of transportation were available it was frequently impossible to function with even normal speed. In the St. Mihiel and Meuse-Argonne operations the First Army Corps was given three neuropsychiatrists, who might be moved from unit to unit as one division was replaced by another. It was excellent experience for men who were to become division neuropsychia- trists. Since they were always in active divisions, it tested admirably their ability to stand a long period of stressful activity. It also gave them the benefit of working with several more experienced officers in succession. At times these extra men worked with the division psychiatrist at the triage. In other instances a division might maintain two triages, and then the two officers divided these triages between them. In periods when the corps was not engaged in active combat these officers were withdrawn from the division and assigned to other duties. The Army corps comprises a number of organizations aside from the divisions. It was highly important that these troops should be known to the corps neuropsychiatrist and that the medical officers and commanders of these troops should know where they could obtain 322 NEUROPSYCHIATRV help on neuropsychiatric problems. This matter was dramatically illustrated by the case of the 53d Pioneers, an organization comprising a huge number of men unfit for military duties, a considerable number of them because of mental defect. "Whenever time permitted, the corps neuropsychiatrist or one of his extra officers devoted some time to examining men in these organizations. The First Army Corps developed in the Meuse-Argonne operation an institution known as the rest camp. The purpose of this was to take care of men who did not need actual hospi- talization but were in need of a period of rest. In such a place there were always patients with mental problems. It is believed that a medical officer with neuropsychiatric training would be of great service in a rest camp. For a few days only was it possible to make such an arrangement, because of the exigencies of the service in the division. A difficulty encountered was in the matter of evacuating the psychoneurotic patients in the right direction. During active hostilities it is quite impossible to control this matter to one's entire satisfaction, unless the so-called neurological hospital is near a group of hos- pitals so that ambulances are discharging all patients from a certain area at points from which they may be distributed. However, by following the matter as frequently as possible. we probably got a larger number of psychoneurotic patients into Army Neurological Hospital No. 3 than would have gone there otherwise. Attention was given also to the problem of getting back patients from the neurological hospital for active duty as soon as possible. The work of the corps neuropsychiatrist was certainly no more taxing than that of the division oflicers, and probably less so. There were many satisfactions connected with it. It was often possible to give material assistance to the work of division consultants. If the campaign had lasted longer, it would have been possible to hold a larger proportion of neurotic cases in the rest camp, in division field hospitals, and in the field hospital of the Army corps; so that evacuations to the S. O. S. would have been fewer. ARMY NEUROPSYCHIATRIC CONSULTANTS Shortly after the organization of the American First Army, on August 10, 1918,14 it was decided that the Army surgeon should have consultants, including one for neuropsychiatry, but no such assignment was made until October 19, 1918, when the corps consultant for the Third and Fifth Corps was appointed consultant in neuropsychiatry, First Army. On the same day, a consultant in neuropsychiatry was appointed for the Second Army. After the armistice was signed, a consultant was appointed for the Third Army. Army consultants in neuropsychiatry served too short a time to make avail- able many records of their experiences, but the following summary of the con- clusions reached as to the services that can be performed by such a medical officer in a field army is of interest. It represents the joint views of the two officers who served in this capacity in the American Expeditionary Forces:0 THE WORK OF AN ARMY CONSULTANT IN NEUROPSYCHIATRY The army consultant needs some executive ability and preferably a considerable execu- tive experience. His work is no more taxing than that of the consultant in the division or Army corps, but since the projects with which he deals are more numerous and more varied considerable training in hospital and organization activities will not come amiss. There are in the army a number of well-organized units-the divisions-each with a consultant. The army consultant during active operations had to visit these divisions from time to time and to ascertain whether the division psychiatrist had opportunity to function to the best of ^ ability and whether he was provided with the information that he needed in order to fulfill his duties. The hospital^and other facilities that were afforded him, the Col 'johnny Rh?inZSrcki™ " °" Wf ?Ppointed cM^ * neuropsychiatry, First Army, Oct. 19,1918; Lieut. Col. John H. W. Rhein, M. C, was appointed consultant in neuropsychiatry, Second Army, on the same date.-Ed. IN THE AMERICAN EXPEDITIONARY FORCES 323 obstacles, if any, to his handling of such cases as can be properly treated in the division hos- pitals, the direct evacuation to the most favorable point of those who must leave the organi- zation, were problems that required attention. Division psychiatrists sometimes have to leave their organizations for adequate reasons, and it is imperative for the army psychiatrist to obtain early information of such changes in order to provide substitutes to fill such vacancies. If in the army there was an army corps that had a consultant in neuropsychiatry, the relation of the army consultant to him was somewhat similar to that with the division psy- chiatrist. During active operations a very useful arrangement was found to be the placing of some additional psychiatrists in the army corps. These men could be sent from division to division and located at other strategic points in the corps organization according to the need for them in order that all troops might be able to receive the attention of a psychiatrist. Furthermore, these men were trained in this way for taking posts of independent respon- sibility themselves later. The army consultant bore direct responsibility for psychiatric matters in troops that are not included in divisions. This was often a taxing and time-consuming duty, for such troops whether attached to the corps or to the army were scattered and not always easy to locate. Until the acquaintance of their regimental surgeons has once been made, such troops may be sadly neglected, allowing conditions to arise that present a very important element of danger. This may be the case in any branch of medicine. Men have been found in critical military positions suffering from advanced pulmonary tuberculosis, having grave deformities, or serious cardiac disease. Failure by them to carry out military duties might be precipitated by no fault of the man but with considerable embarrassment to his comrades. Likewise, in the mental field, feeble-minded men, unable to tell the right hand from the left, have been intrusted with rifles and put on guard duty, endangering their whole organization through their inability to understand and carry out commands. These situations were quickly relieved by the atten- tion of a medical officer with some knowledge of mental disorders. Furthermore, there were many prisoners to be examined, and this duty fell to the army psychiatrist, except in so far as he could arrange through the chief surgeon to bring the cases to the attention of division or corps psychiatrists. To the army consultant falls the duty of seeing that prisons are surveyed occasionally, and also the duty of examining general courts-martial prisoners or arranging for their examina- tion by psychiatrists who happen to be located in the neighborhood. Arrangement ought to be made by which a report of the name and location of all such prisoners will be sent to the chief surgeon of the army. These lists will then receive the attention of the army consultant in neuropsychiatry. Another set of important duties and responsibilities had to be with the hospital organiza- tions of the army. At convenient points neuropsychiatric units were established. 'Without these the psychiatric problems and in many instances organic neurological problems would not have received the attention that they deserved. Convenient buildings and satisfactory equipment were of some importance, but of far greater importance was trained personnel. Experienced medical officers and enlisted men can convert almost any type of building into a place suitable for the handling of mental problems. Two tendencies had to be combatted: (1) the tendency through lack of understanding to minimize the importance of these organiza- tions and, therefore, not to transfer to them the patients with mental difficulties; and (2) the tendency to take away from these units the very capable personnel and assign them to other duties, important perhaps, but as readily performed by others without special training in neuropsychiatry. Fortunately, when these units were once established there was no question about their continuance or their usefulness. Their value became apparent to the whole medical organization and to the judge advocate's department and the General Staff. It is nevertheless necessary for the army consultant to make rather frequent visits to these hospital units and ascertain if they are permitted and encouraged to function at their highest point of efficiency. The army consultant had important functions in connection with the problem of evacua- tion. He had to be on the watch to see that the patients who by temporary treatment could 42705—29----22 324 NEUROPSYCHIATRY soon be returned to duty, were not sent to hospitals at such distant points that return to their organizations would be delayed and the patients' symptoms become fixed through improper handling. This matter was largely one of routes of ambulance evacuation. He had to know about the routing of hospital trains in order to arrange suitable times for the evacuation of patients by the carload or more to neuropsychiatric centers at points distant from the army area. Unless this was done, considerable numbers of neuropsychiatric patients were unloaded in hospital centers that were not equipped to provide for them. This caused much loss of time and delay in the hospital service itself. REFERENCES (1) Outlines of Histories of Divisions, U. S. Army, 1917-1919, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College. (2) Reports of Medical Department activities of the 32d, 3d, and 77th Divisions, prepared under the direction of the division surgeon concerned. On file, Historical Division, S. G. 0. (3) Final Report of Gen. John J. Pershing, commander in chief, A. E. F. (4) Report of the assistant chief of staff, G-5, G. H. Q., A. E. F., on the operations of G-5, made to the chief of staff, A. E. F., June 30, 1919. On file, General Headquarters, A. E. F., Washington, D. C. (5) Report of the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., for the period embracing the beginning and end of American participation in hostilities, December 31, 1918. On file, Historical Division, S. G. O. (6) Report of the Medical Department activities, 1st Division, 1917-18, prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. 0. (7) Letter from the senior consultant in neuropsychiatry, A. E. F., to the director of pro- fessional services, A. E. F., August 6, 1918. Subject: Preventing evacuation of cases of war neuroses. Copy on file, Historical Division, S. G. O. (8) Report of the Medical Department activities of the 3d Division, A. E. F., prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. 0. (9) Report of the neuropsychiatric activities of the 3d Division for the month of August, 1918, made by Maj. E. G. Zabriskie, M. C, to the senior consultant in neuropsy- chiatry, A. E. F. Copy on file, Historical Division, S. G. O. (10) Report of the neuropsychiatric activities of the 4th Division for the month of August, 1918, made by Maj. Samuel Leopold, M. C, to the senior consultant in neuro- psychiatry, A. E. F. Copy on file, Historical Division, S. G. O. (11) Letter from the senior consultant in neuropsychiatry to the director of professional services, A. E. F., August 6, 1918. Subject: Preventing evacuation of cases of war neuroses. Copy on file, Historical Division, S. G. O. (12) Report from the division psychiatrist, 26th Division, to the senior consultant, neuro- psychiatry, A. E. F., on the activities of the division psychiatrist. Copy on file, Historical Division, S. G. O. (13) Report of the activities of the corps consultant in neuropsychiatry, First Corps, A. E. F., July, 1918, to November 11, 1918, by the corps consultant in neuropsychiatry, November 25, 1918. Copy on file, Historcial Division, S. G. O (14) G. O. No. 120, G. H. Q, A. E. F., July 24. 1918. CHAPTER III ARMY NEUROLOGICAL HOSPITALS Early in the medical history of the American Expeditionary Forces, as pointed out in Chapter I, the conclusion was reached that success in dealing with the loss of man power and the menace to morale caused by the war neuroses could not be attained in the American forces unless division psychiatrists had close behind them special hospitals in which could be received cases that promised well for recovery but obviously required longer care than could possibly be given in divisional hospitals. Both the British and French had recommended the establishment of some type of advanced special hospital for the treatment of psychoneurotic reactions among combat troops. For example, Leri,1 who had conducted work in an advanced French neurological center at Nubecourt, reported excellent results in these cases when several weeks' treatment could be instituted within the zone of active military operations. Working in the neuropsychiatric center of the second French Army, he reported that 91 per cent of the cases received from July to October, 1916, were returned to the fighting line. Roussy and Boisseau,2 describing the work of an army neuropsychiatric center, said the results obtained after six months showed that a neuropsy- chiatric center could render incontestable services to an army from both a medical and a military point of view. For functional nervous cases it avoided sojourns (more dangerous the more they were prolonged) in the hospitals at the rear, where these patients were generally lost. It allowed of the treatment of other nervous or mental cases that were quickly curable and for the direct evacuation to the special centers in the interior of those more seriously affected. This idea was confirmed by English observers.3 A psychiatrist wdio had the opportunity of working in a casualty clearing station of the British Expedi- tionary Force in France reported that of 200 nervous and mental cases which passed through his hands in December, 1916, 34 per cent were evacuated to the base after 7 days' treatment and 66 per cent returned on duty on the firing line after the same average period of treatment. Four of these cases reappeared at the same casualty clearing station. During the latter part of August, while the St. Mihiel operation was being planned, all medical and surgical arrangements for the care of men at the front were carefully reviewed in terms of the experience of the previous four months of active participation by American troops in the fighting in France. Up to that time American troops had always operated in the British and French organizations,4 which had naturally determined the type of many medical procedures. Now came the opportunity for putting into effect some American plans of work in the field. The beginning of these operations was the first favorable time, therefore, for inaugurating this new type of hospital. Con- 325 326 NEUROPSYCHIATRY sequently, it was decided to establish at that time a short distance behind the field hospitals, neurological hospitals for the care of war neurosis patients who required more than a few days rest in the field hospitals, and who at the same Fig. l.-Map showing the locations of army neurological hospitals during the Meuse-Argonne operation suffic'ifnllv^to11 ^ T^ ^^^ would recover, within 2 or 3 weeks, sufficiently to permit them to be returned to their organizations Three such hospitals were established.5 gamzauons. inree IN THE AMERICAN EXPEDITIONARY FORCES 327 ARMY NEUROLOGICAL HOSPITAL NO. 1, FIRST ARMY" The hospital at Benoite Vaux, Army Neurological Hospital No. 1, which previously had been used by the French as an "ambulance" for venereal dis- eases, consisted of 150 beds. The advantages of taking over this hospital for use with neuropsychiatric patients was brought to the attention of the corps surgeon, First Corps, by the senior consultant in neuropsychiatry on August 26, 1918.° It was first suggested that a corps field hospital be stationed at Benoite Vaux with its own commanding officer, adjutant, and personnel, securing the special medical personnel from a "pool" of neurologists and psychiatrists collected at Base Hospital No. 117 for emergency service with advanced forma- tions.6 This proved not to be feasible on account of the medical and surgical needs of corps troops. The hospital was turned over to the First Army before the end of August, 1918, and on September 2, 1918, an advanced neuro- logical hospital was established there.7 It being impossible to detach the per- sonnel of a corps field hospital, as was originally suggested, five commissioned officers and eight enlisted men, stationed at Base Hospital No. 117, proceeded to Benoite Vaux for temporary duty.7 The commanding officer at Base Hos- pital No. 117 furnished a truck for transportation, and on the morning of Sep- tember 3 the detachment arrived and proceeded to prepare the hospital for the reception of patients. Seven other enlisted men were secured, and on Septem- ber 6, it was possible to send the following memorandum to the chief surgeon of the First Army:8 1. The hospital at Benoite Vaux which has been designated Neurological Hospital No. 1, First Armj-, is ready to receive patients, the officers and enlisted men being on duty there and all supplies including rations on hand. 2. The hospital at Toul which might be designated Neurological Hospital No. 2, First Army, if you approve, will have the personnel by tomorrow and will be ready to receive patients by Sunday. 3. Staffing these hospitals has greatly depleted Base Hospital No. 117, which will be called upon to care for at least 1,000 patients, the overflow at Rimaucourt being only 500. 4. It is therefore necessary for the hospital at La Fauche to receive 28 men from your personnel from the special training battalion as soon as convenient. 5. I believe that with these advanced facilities it will be possible to establish a very different record in the loss of effectives from nervous conditions, which, unfortunately, we were compelled to be content with during the last period of extensive fighting. 6. For several days I will be at Toul and in the divisions in that vicinity. Benoite Vaux, a tiny French village, consisted of 45 houses, with a popula- tion of not more than 75 civilians. In the village was a church, an abbey, and a few little shops. The abbey, supplemented by some frame barracks across the road, had been used by the French Army as a hospital for nervous diseases. During the recent active operations carried on by the French, the village had been used as a rest area. The location of Neurological Hospital No. 1 was particularly well adapted for the purpose to which it was to be devoted. The main evacuation center for <■ Except as otherwise indicated, the following statements concerning Army Neurological Hospital No. 1, First Army, are based on "History of Army Neurological Hospital No. 1, First Army," by the commanding officer of that hospital. Copy on file, Historical Division, S. Q. O. 328 NEUROPSYCHIATRY the Verdun front was Souilly, 1x/i miles away, which was also the site of a number of evacuation hospitals.9 An excellent road connected Benoite \ aux with the main route between Verdun and St. Miliiel, while only 9% miies to the west was the main route between Verdun and Bar-le-Duc, upon which route a little later the neurological hospital at Nubecourt was to be established. At the time of the commencement of the St. Mihiel operations, the front line was 5)4 miles away. The hospital consisted of 10 French barracks and a number of small out- buildings, which were little more than huts. One barrack was used both as the admission ward and as a ward for officer patients. It was divided into several rooms accommodating one to four patients each with an additional small ward for six patients. Eight other barracks were used for patients who were enlisted men. Each contained 25 cots. These barracks were arranged in three rows of three each. The first two rows were connected by an inclosed corridor. One of the barracks was used for bathing purposes and one for a storehouse. The office of the commanding officer was a small two-room barrack adjoining this group of buildings. The hospital personnel were quartered in several small buildings which surrounded the group of barracks to the west and to the north. The kitchen was in the rear of the group. Cooking facilities consisted of French brick stoves, and wood was used for fuel. During the French occupa- tion of this hospital, gardens had been planted in which onions, carrots, and lettuce were growing in sufficient amounts to provide fresh vegetables for at least one meal a day for the entire hospital. On September 20, orders were issued to 5 officers and 15 enlisted men, who were stationed at Neurological Hospital No. 2 at Toul, to report for duty at Army Neurological Hospital No. 1 at Benoite Vaux. Accordingly, on the night of September 21, these officers and 30 enlisted personnel traveled in ambulances, arriving at 3 o'clock in the morning. The original 4 officers and 30 enlisted men were synchronously transferred on September 22 from this hospital at Benoite Vaux to Neurological Hospital No. 3 at Nubecourt. The newly arrived officers and enlisted men remained for the purpose of operating this hospital. During the month of October, this hospital continued its activities while the Meuse-Argonne operation was under way, the number of cases admitted being 608.10 Of this number, there were 44 officers, 10 of whom were returned to duty, 1 was transferred to Base Hospital No. 116, 31 to Base Hospital No. 11/, and 2 to medical centers. During the month of November the admissions were considerably less than during the previous month, or even during September.11 This was due to the change in character of the fighting (while battle activities continued), to the tact that the distance between the hospital and the front line was constantly increasing and to the cessation of hostilities or November 11. The number admitted during November was 152. Army Neurological Hospital No. 1 operated under considerable physical disadvantages^ There was no laundry connected with the hospital until the latter part of October. Until then, the laundry was sent to near-by American hospitals. It was done sometimes at the Gas Hospital at Rambluzin, and at IN THE AMERICAN EXPEDITIONARY FORCES 329 other times at Evacuation Hospital No. 6 at Souilly. By the end of October, a laundry was constructed on the grounds, a large fireplace was built for boiling clothes, and a mammoth tub was constructed in the workhouse of the hospital. Tubs were also put in place for rinsing, and convalescent patients were detailed to attend to this work. The average output a day was approximately 900 pieces. Transportation here, as elsewhere in the American Expeditionary Forces, was a source of great difficulty. To get supplies of fuel, water, and rations it was necessary to go to Souilly, a distance of 7^2 miles. The evacuation of patients to trains, to organizations, and to the rear still further embarassed the transportation facilities. Upon every occasion when transportation was needed, a request had to be sent to the transportation officer at Souilly that a truck be sent for this purpose. Since a truck was not always available at the time it was needed, this arrangement was very unsatisfactory. Later, about the middle of October, a truck was assigned from Souilly, to be used conjointly with Neu- rological Hospital No. 3 at Nubecourt, about 15 miles distant. This plan proved to be more satisfactory. An ambulance was also assigned to the hospital and was used largely for evacuating patients to Souilly. Sometimes, when the truck was not available, it was used to obtain supplies. Except on very few occasions, it was not difficult to obtain a sufficient supply of clothing for the patients. The majority of the men, upon being returned to their organizations, were equipped with completely new outfits with the exception of rifles. In the latter part of the month of October a workshop was put in operation. A reconstruction aide was detailed from Base Hospital No. 117 to conduct this department. Over 60 per cent of the patients admitted to Army Neurological Hospital No. 1 were restored within an average of 10 to 14 days to a state of apparent stability. By this is meant a condition in which they acknowledged that they felt well, in which they expressed themselves as willing and anxious to return to their organizations, and in which to all appearances they seemed to be able to do so. The plan employed to bring about these therapeutic results included every psychotherapeutic device, but emphasis was placed chiefly upon persuasion, suggestion, and a simple, practical psychological reeducation. The officer of the day admitted all patients. It was his duty to explain to the soldier in the receiving ward upon admission the exact nature of his condition, and to reassure him as to the prognosis. There was discernible almost immediately a relaxa- tion of the tension characteristic of practically all the patients. The soldier was relieved of a good part of his anxiety. He was then bathed, fed, and put to bed; whereupon he usually fell into a profound slumber which lasted 36 to 48 hours. Then, after a careful examination of the patient by the ward neuro- psychiatrist, it was the duty of the latter to talk to the soldier, explaining the mechanism of his condition and treating by suggestion or persuasion such symptoms as were present. The next step in the therepeutic procedure was an interview by the commanding officer. The latter took the patient into a room by himself, went carefully with him over the history of his troubles, explained 330 NEUROPSYCHIATRY the nature of his symptoms in a way that robbed them of any residue of horror or mystery, and finally gave reassuring suggestions. After a brief period of rest under these conditions, usually lasting three or four days, the patients were put on a schedule which occupied the whole day. This included periods of rest, of exercises and calesthenics graduated according to the condition of the patient, and of recreation, which included games and group singing. In from 12 to 14 days from 60 to 75 per cent were fit for front-line duty. Sometimes, unfortunately, it was not possible to evacuate the patients at once as they should have been when their recovery had reached this point, due to the difficulty in obtaining transportation, inability to locate the head- quarters of their organizations, or other similar reasons. As a result of this delay, in a small number of cases, vague hypochondriacal phenomena developed which became more fixed the longer the patients remained in the hospital. In handling the enlisted men it was originally planned to have an admis- sion ward and then graduate the patients through a series of wards as they improved, the end ward being occupied by recovered cases awaiting transpor- tation to duty. With the pressure of case admissions (which not infrequently ran more than 30 a day, the hospital at times containing more than 100 cases over its normal capacity) this plan was found impracticable. And so cases were admitted to each ward, with the exception of one reserved for ready-for- duty cases. An added advantage in this procedure was that the ward physician saw his patient all the way through. The patients on admission were seen by the officer of the day and obviously unsuitable (medical and surgical) cases were sent to evacuation hospitals near by. "Exhaustion" was the label of most of the medical cases and often it required a day's observation before a definite diagnosis could be made and transfer effected. Many of the cases as they were seen in the admitting office presented coarse tremors and tics and other hysterical symptoms, and it was soon learned that much therapeutically could be done immediately by simple suggestion and explanation and reassurance in the admitting office. Not infrequently a well-marked coarse tremor of the extremities would be cleared up before the patient had his routine admission bath. The majority of cases on admission were tired out, and at least a day in bed was a routine necessity, the beneficial effect of which was very striking. As soon as possible afterwards the patient was gotten up and about and assigned to routine duties. Since the number of hospital enlisted personnel was small, and there was so much of the routine hospital fatigue duty to do, the patients were never at a loss for occupation, as far as needed work was concerned. Drills and practice marches were used at first under the charge of an officer patient, but these later were superseded by work detail, with an initial daily setting-up exercise under a sergeant. There was a variable percentage of work dodging, but on the whole the patients were fairly industrious and idleness was not the problem here that it was in many of the base hospitals. Latterly an occupation shop was started under the supervision of a trained worker, and the activities were mainly with wood and metal work; it proved of considerable interest to the patients, and was valuable, especially for the cases with tremors and difficulty in concentration. IN THE AMERICAN EXPEDITIONARY FORCES 331 The general treatment of the war neuroses, summed up, was the following: Rest when indicated, persuasion, suggestion, work, and psychological reeduca- tion. In dealing with the cases fresh from the line, after one's experience with the older cases, it was most striking how much more suggestible the former were seen to be. Hysterical symptoms that might require hours of treatment in a base hospital could frequently be cleared up by suggestive therapy in a few minutes in a fresh case. It was the policy of the hospital not to transfer cases deemed unsuitable for immediate front-line service to Base Hospital No. 117 as long as gross objective, hysterical symptoms persisted. This suggestibility worked both ways, and unless the therapeutic side was pressed the symptoms tended to become rapidly fixed. But the advantage was with the physician. Upsetting battle dreams were likewise easier to clear up in the fresh cases. These battle dreams were among the few symptoms that seemed to be as marked in the fresh neuroses as in those longer from the line, and they were the most common complaint. (They were frequent in fresh wounded cases as well.) Some patients would stay awake night after night to avoid them. Usually simply explaining the dream mechanism and urging the patient to ventilate and mentally assimilate his affect-charged battle experiences rather than "to keep them out of the mind" during waking hours was quite sufficient therapy; very rarely were hypnotics required. One of the most valuable assets in the treatment of the neuroses was the creation of a ward atmosphere of cure. The patients were quite observant of one another, and a cured case which they had seen from the beginning was a most useful asset. Once the atmosphere of cure was created a part of the therapy became automatic. The ward atmosphere depended almost entirely on the ward surgeon, and it was most striking how quickly the efficiency of the doctor was reflected in the therapeutic results of his ward. Certain members of the staff had had the advantage of training at Base Hospital No. 117 under the stimu- lating influence of the medical director there. In every soldier probably there was some degree of mental conflict between, on the one hand, the instinct of self-preservation and, on the other hand, the more socialized "carry-on" urge and desire for social esteem, with regard to front-line service. There were three possibilities: First, the "carry-on" driving force predominated, which was the condition of the normal soldier, and of not a few neurotic individuals. Secondly, if the "carry-on" force was weak or absent, a neurosis might not develop because the conflicting forces were too unequal and there was little tendency to symptom fixation. These were the fear cases, and certain of them were very honest individuals in their "I can't stand the gaff" attitude. Thirdly, when the two opposing forces were approx- imately evenly balanced, a soldier might perform his duties fairly well until some environmental factor, such as a shell explosion, upsetting emotional experience, fatigue, or minor trauma, disturbed that balance in favor of self- preservation, and a neuroses developed. The symptoms of the neurotic, while out of proportion to the more immediate upsetting event, were usually not out of harmony with it; for example, the relationship between a slight hip trauma and a subsequent functionally paralyzed leg; between a somewhat thin concussion experience and a headache and tremor, or, perhaps, deafness; 332 NEUROPSYCHIATRY between an upsetting emotional experience and the development of an anxiety state, etc. Undoubtedly many soldiers carried on after the same sort of experiences as sent most of the neurotics to hospitals. The cumulative effect of these upsetting experiences must have been large and in time might break men of good balance and make-up. A number of cases held on until their divisions were relieved from the line and then snapped when the sustaining power of action was removed. Life itself being represented by a series of adjustments and compromises between the individual and his environment, the war neuroses furnished no exception. At one extreme was the pure concussion group, and allied to this were the cases in which trauma and exhaustion played the most prominent part; at the other extreme were the fear cases, in which the personal element predominated. Between these extremes fell the bulk of the neuroses, the environmental and personal factors participating in varying proportions, seizing and fixing on the most available experience, as shell explosion, fatigue, trauma, upsetting emotional event (killed comrades, etc.). Neurotic symptoms were quite natural after many of these experiences, and consciousness probably played a very minor part, if any, in their incipiency. But into the maintenance of the neuroses, the conscious factor entered to a greater extent. Any doubt as to this was removed by the decidedly ameliorating effect of the armistice on the majority of the cases. The fear-group cases were largely conscious of the difficulty all the way through, but these were not cases of malingering, because there was no conscious simulation. There may have been a degree of malingering in some of the neuroses, but pure malingering undoubtedly was rare. In civilian cases of neuroses, along with changing the patient's attitude toward himself, it is nearly always possible to modify the environment in which the neurosis arose. The problem of the war neuroses was simpler and more difficult—simpler to the extent that the conflicting forces were less obscure, and more difficult in that the aim of treatment was to enable the patient to be sent back to the same precipitating environment, i. e., the front line. The soldier's neurosis was his reaction and adjustment to an unbearable situation, and it had a double-barrelled potency: To get him out of the situation and keep him out of it. This last factor probably accounted for the tendency later to symptom fixation, and this was the more immediate therapeutic problem. A simple mechanistic explanation of the neuroses was helpful to the patient But more valuable from a therapeutic standpoint was the effect of a definite attitude on the part of the ward surgeon that the goal of treatment of the war neuroses was return to duty. There were three avenues for the disposal of patients from the army neurological hospital: Return to duty; transfer to Base Hospital No. 117, the special base hospital for the neuroses; and transfer of the medical, mental, and surgical cases to other hospitals where more appropriate care and super- vision could be given them. F to dJ^ P>r^y-fTCti°n °f the Jh°Spital WaS t0 return as ma^ cas<* ^ possible to dutj with their divisions, and in as short a time as possible. The average IN THE AMERICAN EXPEDITIONARY FORCES 333 duty case was in condition to go back within 10 days, although there were exceptions. It is impossible to estimate from the length of stay in the hospital the time required for recovery because most of the recovered cases would have to wait over in the hospital, sometimes for several weeks, until a particular division could be reached. The hospital received most of its cases from the north and east of Verdun, and the delay in return to duty was more marked when the divisions moved from sector to sector. Just before the armistice was signed, arrangements were made to return the duty cases to corps replacement camps rather than to their divisions, and this facilitated matters greatly. The question of return to duty was complicated by the possibility of relapse. On the 532 cases returned to duty, 15 cases were known to have come back to the hospital with relapses; none of them lasted more than one day under fire. Soon after the opening of the hospital 22 cases were returned to duty in one group and within 24 hours 11 of them (included in the above 15) wore sent back with an assortment of hysterical symptoms. They had spent the night in a village that was heavily shelled. This experience made one more cautious in the selection of line-duty cases. When a division was in a large area and participation in heavy fighting followed recoveries were more durable. The relapses were all cases of hysteria and hyperemotivity (fear), and these were the two groups that presented the main problem in selection for duty. With the exception of certain of the concussion cases, there was in the general attitude of the patients in the hospital a distinct absence of any keenness of desire to return to front-line service. The question before the hospital staff with nearly half of the hysteria and fear cases was: Which is wiser from the standpoint of army efficiency, to send these men back to the front line on the chance that they will carry on or to send them to Base Hospital No. 117 to be reclassified as labor troops? One's first impulse was to carry out the former alternative, especially if one were dealing with a plain case of fear. There was another point of view to consider, however, and that was the line officer's. Even if the hysterical and fear cases were not contagious in the front line, the chances were that they would not be individually dependable. There were exceptions, of course. Furthermore, at a time when every available bit of transportation was needed for wounded men, a seat in an ambulance for a relapsed nervous case seemed rather superfluous. Before troops went into the front line for the first time it was a hazardous proposition to predict which individuals would develop "shell shock." Men who had been visibly "on edge" often carried on well, and vice versa. The front line itself was the only test. There was a history of neuropathic make-up or neuropathic stock in about 40 per cent of the cases of war neuroses admitted. In 100 case records selected at random the family history was positive in 38 and the personal history in 40. Much depends on the criterion for the term neuropathic. This 40 per cent included the cases with any definite history of nervous or mental anomalies whatever in stock or make-up. Certain of the ward surgeons went into this question carefully, others more casually; so the 40 per cent is only an approximation. The average American soldier's attitude toward "shell shock" had a large proportion of tolerance and curiosity in it. An attempt was made to abolish 334 NEUROPSYCHIATRY the term. Although this could be done in official communications, it was mani- festly impossible in ordinary speech. Much more profitable was the dissemina- tion of information among the troops as to just what "shell shock" meant. The divisional variation in the number of such cases was very striking—it occurred in inverse ratio to the morale. Among the patients themselves there were two main attitudes. The first was to this effect: "You're a long time getting it; but once you get it, it's got you"; and the second: "It's easy to get and easy to get over." The majority of them agreed on one point—they were unfitted for future front-line service. This attitude was one of the main problems to combat in the neuropsychiatric hospitals. It was essentially the unfavorable type of neurosis that was evacuated to Base Hospital No. 117; that is, unfavorable at least as far as any immediate return to front-line duty was concerned; and so the army hospitals made the work at Base Hospital No. 117 more difficult in this way but operated favorably through having exposed these patients early—often a few hours after their breakdown became noticed—to a psychiatric point of view. A number of cases were sent to Base Hospital No. 117 to be reclassified, inasmuch as only class A duty was possible from the army hospitals. The general level of in- telligence of the neurotic patient was certainly not below the average, and the vast majority of those who were unfit for front-line service were quite efficient workers in the base sections. The officer patients, 66 in number, were included in the figures already discussed. On the whole they presented distinctly less favorable material for return to duty than did the enlisted men. There was one feature common to nearly all of them on admission—fatigue. Seventeen of the 66, or 25 per cent, were returned to duty as compared with 61 per cent of the enlisted men. Another factor entered into the selection of duty cases here, for if an enlisted man relapsed it was more or less of an individual problem; while in the case of relapse of an officer during the prodromal period, his wavering might affect more than himself. However, with most of them there was small choice; they were unfit for return to front-line commands. The following is a summary of officer cases: Hysteria_______________________ Neurasthenia___________________ Hyperemotivity (state of anxiety; funk)_______________________.. Exhaustion neurosis______________ Traumatic reurosis_______________ Anxiety neurosis_________________ Psychasthenia___________________ Concussion by explosion___________ Duty Trans -fer Total 1 14 15 5 8 13 3 5 8 3 5 8 1 3 4 0 3 3 0 3 3 2 0 2 Observation, mental___ Exhaustion___________ Concussion neurosis___ Neuritis (musculospiral) Pneumonia___________ Influenza____________ Gas neurosis__________ Psychoneurosis_______ No disease____________ Duty Trans - fer Total There were but two pure concussion cases among the 66 officers and both returned to duty, as did the single case of simple exhaustion. The hospital stay of these three cases, in which the causative factor was so acute and stren- uous, ranged from three to seven days. IN THE AMERICAN EXPEDITIONARY FORCES 335 Hysterias and neurasthenias predominated and there was a distinct "can't- stand-the-gaff" attitude among these and the majority of the other cases of neuroses among the officer patients. Some of the crudest cases of hysteria in the hospital were found among the officers. More striking differences existed in neurasthenia and psychas- thenia; the former was five times as frequent among the officers as among the men, and of the latter, three of the four cases seen were officers. The following list is a comparative percentage list of the neuroses as they occurred among the officers and enlisted men: Officers Enlisted men Officers Enlisted men Hysteria________....._____________ Per cent 22 20 12 12 6 Per cent 30 4 13 6 11 Per cent 4 4 1.5 0 Per cent Neurasthenia..______________...... 1 Hyperemotivity (state of anxiety; funk). 6 Exhaustion neurosis________________ 2 Traumatic neurosis_______________ The following tabulation summarizes the disposal of cases, by months: September, 1918. October_______ November_____ Total____ Return to duty To Base Hospital No. 117 To other hospitals ... ______________ 22 17 226 96 15 _________________t 230 67 2S0 42 . ' 532 339 124 In addition to these there were 5 desertions and 3 deaths, making a total of 1,003 cases. The 124 cases which were transferred to other hospitals (med- ical, surgical, and mental observation) may fairly be eliminated as being com- plications in a hospital that had for its special problem the emergency treat- ment of the war neuroses. Of the cases which may properly be included under the term war neurosis, 61 per cent were returned to front-line duty. CLINICAL ASPECTS OF CASES b During the period from September 26 to November 11, 1918, 1,003 cases passed through Neurological Hospital No. 1 at Benoite Vaux. These patients were relatively fresh cases, admitted usually within 24 hours after they were sent from their divisions. The more favorable cases—those which could be returned to duty within a few days, especially cases of exhaustion—were treated by division psychiatrists in the field hospitals as far as possible. Consequently, few cases of pure exhaustion were received in Army Neurological Hospital No. 1. & Rased upon a report made by the commanding officer, Army Neurological Hospital No. 1, First Army, to the senior consultant in neurology, A. E. F., undated. Copy on file, Historical Division, S. G. O. 336 NEUROPSYCHIATRY Clinical summary of 1,003 cases admitted War neuroses____________________________________________________ 818 Concussion by explosion______________________ ___________________ 10 Gas_______._______________________________ _____________ .-- 2 Gunshot and shrapnel wounds______________ ___________________ 3 Psychoses, observation_____________________ ____________________ 52 Epilepsy, observation_____________________ __________________ 22 Neuritis_________________________________________________________ 10 Organic nervous disease______________________ ___________________ 1 Belladonna poisoning c____________________________________________ 13 Acute infections__________________________________________________ 52 Miscellaneous____________________________________________________ 20 Total______________________________________________________ 1, 003 There were five cases of gunshot or shrapnel wounds altogether, and two of them were too slight to require surgical dressing. One of the remaining three had a finger wound (gunshot, right fourth finger). This was the only possible self-inflicted wound case admitted and there was no corroborative evidence here. Another case had multiple shrapnel wounds and was trans- ferred immediately; and the last case sent in as an epileptic, proved to have a shrapnel fragment in the right parietal region. The common observation that wounded men do not develop "shell shock" was well borne out. The 74 cases which were psychiatric or epileptic, were evacuated as speedily as possible to a special hospital (Base Hospital No. 116, at Bazoilles) for further mental observation. The 10 neuritis (unwounded) cases showed the following involvement: Facial, 3; musculospiral, 1; ulnar, 1; multiple (post-diphtheritic), 5. Included among the acute infectious diseases were one case of epidemic cerebrospinal meningitis and two cases of acute anterior poliomyelitis, one of the latter possibly syphilitic in origin. There was one case of organic nervous disease (an early amyotrophic lateral sclerosis), and this, together with one uncomplicated case of mental deficiency that passed through the hospital, speaks well for the efficiency of the neuropsychiatric weeding out in the camps in the United States. A small number of other mental defectives was admitted, but they were all neurotic as well. The acute infections were admitted mostly as cases of "exhaustion." This was especially true of the pulmonary cases, eight of which proved to be lobar pneumonia. There were three deaths in all in the hospitals; two from lobar pneumonia, and one case (an Austrian prisoner) died on the day following admission, from gas poisoning, probably phosgene. The 10 cases of concussion by explosion were differentiated from the war neuroses because they showed no neurotic feature whatever, and from their histories there was no reason to believe that any factor entered into their causation other than concussion. Of these 10 cases, 8 were returned to duty. The other two were transferred to a surgical hospital—one because of the possibility of a fractured skull and the other because of a complicating super- ficial abscess of the right temporal region. admS i^ty^tS SuT **"" * "^ ^^ *"*■ ^ ta "» ™^ ™* * ^ — *-« IN THE AMERICAN EXPEDITIONARY FORCES 337 There was no evidence of organic nervous disease in any of these cases, and most of them were convalescent when admitted. The diagnosis depended largely on the history, the patient's condition, and the absence of neurotic features. The following case is an example: Pvt. J. C, 4th Infantry. Age, 26; civilian occupation, locomotive engineer. The patient's family and personal history were negative and his make-up was normal. He was drafted in May, 1918, went to France the following August, and was sent with replacements to the 3d Division in September. He carried on well and showed no undue reaction to shelling. On October 10 he was knocked down by a shell but was not unconscious, and continued his duties. On October 21, during a barrage, he remembered vaguely running for a shell-hole. "There was a kind of puff and I didn't know any more until I came to and it was dark"—evidently an initial period of unconsciousness lasting some hours. He had a violent headache and was dizzy, weak, and shaky. He remembered vaguely being carried on a stretcher and remembered the triage on the following morning. He lost con- sciousness again for several hours at the triage. Two days later he was admitted to the neurological hospital in a semicomatose condition, from which he gradually emerged on the following day. His memory from the time he left the triage until his arrival at the hospital was very hazy. He was in fair physical condition and there was no sign of organic neuro- logical disease. His main complaints were headache, dizziness, weakness, and shakiness, the last being more subjective than objective, although he had well-marked coarse hand tremor. He was up and about the third day in the hospital, and by the sixth day his com- plaints had cleared up entirely, with no especial treatment. He was anxious to return to his outfit, and this was done 10 days after his admission to the hospital. As stated above, of the 1,003 cases admitted, 818 were classified as war neuroses. The classification followed was essentially that formulated by the medical director of Base Hospital No. 117. (See p. 355.) Aside from the value of this classification (inasmuch as about one-third of the cases were evacuated to Base Hospital No. 117) it was very helpful to have a common language. This was primarily a working classification which conformed to the Medical Department diagnosis requirements, and was not merely an attempt to pigeon- hole the cases. It was fully understood by all that it lacked many of the requirements of accurate psychiatric work. November .1 Total Transfer Duty Transfer Duty Transfer 0 14 0 54 1 24 13 3 27 27 8 29 3 51 11 8 40 7 91 15 1 0 1 1 1 93 103 41 157 140 14 9 13 22 28 8 6 3 1 6 11 18 3 0 4 20 3 0 1 0 4 3 0 1 0 5 6 0 0 0 7 40 43 24 71 64 Concussion syndrome________ Concussion neurosis__________ Exhaustion neurosis_________ T raumatic neurosis__________ Gas neurosis________________ Hysteria____________________ Neurasthenia________________ Hypochondriasis_____________ Anxiety neurosis....._________ Psychasthenia_______________ Effort syndrome_____________ Anticipation neurosis.......— Hyperemotivity, state of anxiety (funk) September Oct Duty Transfer Duty 19 0 0 0 0 2 0 0 0 0 0 0 0 1 0 0 0 0 6 1 0 2 0 1 1 0 21 14 22 51 1 52 13 0 1 0 0 0 28 lk)_______ 338 NEUROPSYCHIATRY The following list shows the percentages of the various neuroses returned to front-line duty (based on the preceding table): Concussion syndrome_____ Traumatic neurosis________ Exhaustion neurosis......___ Hysteria_________________ Hyperemotivity—state of (funk)_______.......____ Concussion neurosis_______ anxiety Num- Percent- ber of age returned to duty 55 0.98 106 .86 62 .82 297 .53 135 .52 54 .50 Gas neurosis......____ Neurasthenia_______ Hypochondriasis..... Anxiety neurosis____ Psychasthenia______ Effort syndrome____ Anticipation neurosis. Num- ber of cases Percent- age returned to duty 0.50 .44 .35 .16 .0 .0 .0 It is evident that the more clearly exogenous the precipitating factors the better were the prospects of return to front-line duty. Concussion syndrome was a term applied to cases in which the concussion factor was the predominant one, but not so exclusive as in the concussion by explosion group. The distinction is not a sharp one and it had to be largely from the history of the case; it arose from a desire not to preface the undoubt- edly pure concussion cases with the term "psychoneurosis" on the field medical card. The following case is illustrative of the concussion syndrome group: Pvt. A. B., 4th Inf. Age 21; civilian occupation, coal miner. There was nothing abnormal in the patient's family or personal history or make-up. He enlisted in June, 1917, and came to France in April, 1918. He served with the 3d Division at Chateau Thierry and in the Argonne, and had no nervous symptoms. On October 22, after 21 days in the sector north of Verdun, he was returning to his company after taking some prisoners back. The shelling became hard and he took refuge near a bank. A shell was heard coming and that was the last he remembered until he pulled himself out of some dirt. He was dazed and had a headache and was nervous, reported to the first-aid station, and was sent to the rear. On Octob3r 25 he was admitted to the hospital as a walking case. He complained of headache. Physical and neurological examinations were negative. His attitude was good, and he returned to his outfit on November 4. In the next group, the concussion neurosis, there was a history of a con- cussion experience, but it was much less definite and the outstanding feature was that the usual post-concussion complaints—headache, dizziness, general aching, tremor, and weakness-showed a tendency to become fixed and often to be elaborated. In other words, a neurosis had developed. The following is an illustrative case and it might well be termed hysteria: f ,thprgh^'HR"v ^ PiT,ei*Inf' AgG 23; CiYilian occuPation> father worker. The patient's father had diabetes The personal history was negative. He was earning $24 a week at he ChaW T^nhStmen;;n ^ 1917- He -me to France in July, 1918, and served in hook uo ' Ind 7Za>+ . "^rCt°rS- ThC firSt time Under fire he "was nervous and shook up, and couldn t sleep, and was shaky that night. The other men laughed at him. s"lX 26 a H G "* ^^ He ^ With WS re*iment in the Verdu/sector from Mptunbu 26 and was very nervous when the shells hit close. Finally, on October 22 he ™Zt; a^ heT ^ ^7 ^ °f ^ ^ He ™ ^ ** explode and t^ nTpiS and ''felt df 1 vV^""1 ^ &nd l0St consciou-ess. He came to in a Lter (October 24 £ * , ^""^ had headache, and was shaky." Two davs ' I fee di zv Ld Lt 7,1 ^ !° thG neurol°gical hospital. His complaints were: He seemed to beofauZT Z ' ^? ^ head'' Physical exam^ion was negative. t^Z^I ffiKr ^mle^ lC918.and ^ P™ *' ™ IN THE AMERICAN EXPEDITIONARY FORCES 339 There were 65 cases in which the history and examination left no doubt that shell concussion was the dominant factor: Concussion by explosion, 10; concussion syndrome, 55. As has been said, two of these cases were trans- ferred because of surgical complications. All but one of the remaining 63 cases returned to front-line duty. Of the concussion neurosis cases—in which the concussion history was less clean-cut and the subsequent fixation symptoms were pronounced—only half the cases were returned to front-line duty. One can not avoid the conclusion that the more dominant and clean-cut the con- cussion factor, the more likelihood there was of the case being returned to duty. In this connection the individual make-up had to be taken into consideration. The genuine concussion cases were found, on the whole, to be individuals of superior stamina and attitude, compared with the others. Most of them would probably have carried on after a less clean-cut history of concussion, such as one obtained from the concussion neurosis. A shell is no discriminator of the individual make-up. The main thing is the individual's reaction to the situation. One's estimation of the importance of the concussion factor had to be made largely from the history and the way it was told, and in most of the cases it offered no especial difficulty. When objective findings, such as unconscious- ness and unsteadiness, were present, the diagnosis was greatly facilitated. There was one apparently comatose case that offered some doubt as to diag- nosis—until he tried to bite the examiner. Usually the real cases had been carrying on well and there was a history of sudden loss of consciousness, with a rather hazy memory for the immediate concussion setting. As a rule the patient did not remember hearing the explosion clearly, but this condition was not invariable. It seems probable that the better the man's fiber the more tenacious he is of consciousness. It was striking, on the wards, how quickly these concussion cases began to improve and ask for activity and duty. This request was not observed particularly in any other type of case in the hospital. Between the concussion neuroses and the hysterias the distinction is a sliding one. Undoubted cases of hysteria may be precipitated by a concussion experience, although it is usually a fairly safe one. The term hysteria was used in a rather restricted sense and included such symptoms as paralyses, anesthesias, aphonias, stammering, blindness, tremors, tics, gait disorders, amnesias, and fits. A history of loss of consciousness was rather common in the hysterical cases, but on questioning it was evident that previous symptoms had shown themselves and that the way had been prepared for the final concussion experi- ence. The stories of the explosion in these cases were vivid in detail, and consciousness was usually regained suddenly. In most of them the factor that determined the symptom picture could be elicited, i. e., being thrown on one hip, followed by paralysis of that leg; functional deafness following the sound of an explosion; and arm and shoulder tic developing after a rifle carried on that side had been struck by a piece of shrapnel, etc. The following case of hysteria was interesting because a longitudinal section of the patient's experience in the American Expeditionary Forces was known, as well as the cross section condition that he presented on admission, 42705—29---23 340 NEUROPSYCHIATRY and which necessarily had to be the chief criterion in sizing up so many of the cases: Sgt. L. F., P. W. E. Co. 89, First Army. Age 23. The family history was negative. The patient was graduated from high school at 16, and had been in the Regular Army since 1913. He went to France in June, 1917, and saw much service with the 1st Division. He gave a history of a slight wrist shrapnel wound in October, 1917, and some months later was gassed in the Toul sector. He was treated at Base Hospital No. 15 for this, and was discharged from the hospital in February, 1918. On June 10, 1918, he was blown up, with loss of consciousness, at Chateau Thierry, and was sent to a French hospital, where his chief complaints were headache and abdominal pain. He protested to a passing American officer that he was receiving no treatment from the French and was then transferred to an American hospital. The surgeon in charge decided that he had appendicitis and determined to operate. The patient refused operation and charges were preferred against him for this, and he was brought to Base Hospital No. 117 in this status. (This is largely the patient's own story.) At Base Hospital No. 117 his principal complaint was headache, and he was very solicitous in his attitude, and at times emotionally unstable. (One of his brothers in his own outfit had been killed shortly before.) The headache persisted unimproved for some weeks, and it was difficult to get the patient interested in occupation. It was learned that he was quite fond of horses, and so he was given some light duties in connection with the stables. Within a very short time his neurotic symptoms cleared up (there never w-as any evidence of organic disease), and he was discharged to class A duty July, 1918. While awaiting assignment at the replacement camp at Is-sur-Tille, a charge of dynamite exploded near him and he became shaky and upset, and when readmitted to Base Hospital No. 117 a few- days later he presented coarse tremors of the arms and legs and a very marked stammer. These symptoms were cleared up easily with suggestion. It was felt that he would be unfit for any sort of line service, and so he was reclassified C-l and sent to back-area duty in September, 1918. He was assigned to a prisoner-of-war escort company, and the next seen of him was on November 17, 1918, when he was admitted to the neurological hospital, presenting coarse tremors, a dodging head tic, and a bad stammer. In the rapid American advance during the week before the armistice was signed, his duties took him close to the retreating Germans, and on November 8 he was caught in a barrage, became shaky and weak, and the above symptoms developed. He "shook like a leaf, wanted to run, and didn't know what he was doing." He remained in a dugout for some days, until dis- covered by passing soldiers. Under the influence of the armistice and suggestion he cleared up rapidly, and was returned to duty a few days after his admission to the hospital. The anticipation neuroses were cases which developed the various war neurotic symptoms before getting anywhere near the front line. They were essentially cases of hysteria, but less respectable, and very tenacious of their symptoms, and prone to relapse. They took few chances At the instance of the commanding officer of the hospital, the term trau- matic neurosis was applied to a somewhat heterogeneous group. In these cases there was a history of a precipitating trauma, separated from the con- cussion neuroses, because there was no history of associated loss of consciousness. These cases also showed a much smaller tendency to symptom fixation than did the concussion neuroses, and the percentage returned to duty was relatively high (86 per cent). Most of them might be considered as hysteria of a better class. The following case is an example: i*V: ^' K,'' l°2d Inf' Age 24- Interior Painter. His mother was "verv nervous- S* '° f^ V '-, ^ PerS°nal hist°ry was negative a'side from s°™e alcoholic excess. I AH £ H m P ; 91* WGnt t0 FranCG in June> and Was with the 26th Division in the during h^ ^7: g°nne ?erati0ns" 0n 0ctober 25 he was very nervous and shakv during a barrage, but he managed to carry on. On October 27, he said, a machine-gun bullet IN THE AMERICAN EXPEDITIONARY FORCES 341 Went through his legging and that same day a shell exploded near him and he was knocked against a tree. He did not lose consciousness but "lost his nerve''; his comrades told him he was "crying and carrying on and shaking." His memory was rather vague at the time. He was admitted to the neurological hospital on October 29, complaining of pain in his back (lumbar region) and under his knees. He was also troubled with insomnia. His physical examination was negative and he appeared to be of fair stuff. His complaints cleared up rapidly, and he was returned to his outfit on November 4, 1918. As has been stated above, cases of pure exhaustion were nearly all sent back to duty from their divisional hospitals. The exhaustion neuroses com- prised the cases in which the fatigue symptoms became more fixed, and between this group and the neurasthenias the distinction was a relative one, depending on the intensity of the precipitating fatigue and on the consequent degree of fixation of the fatigue symptoms. The former was less marked and the latter was more marked in the neurasthenics. These cases usually gave histories of fatigue reaction in the line that was disproportionate and not acute; more than half of the neurasthenic cases were not returned to line duty because of their tendency to symptom-clinging. The following case is of the neurasthenic type: Pvt. H. C. 102d Trench Mortar Battery. Age 25; occupation in civil life, assistant libra- rian. The patient's mother "has trouble with her heart and nerves and is ven- excitable." He himself had been subject to "palpatation of the heart" for several years. He enlisted in June, 1917, and went to France one year later. His first line experience was in the Verdun sector and he "was much frightened and nervous all the while in action. Shivered and couldn't stop." He "never could hike very well"—his "heart would beat fast." On October 15, after a hike, he "fainted away," and was very weak afterwards. On the follow- ing day he was sent to the field hospital, and on October 19 to the neurological hospital. "1 don't feel strong at all and have headaches." There was no evidence of organic nervous or heart disease. His pulse rate would increase from 72 to 120 per minute after exercise. Mentally he was "not a strong character." His complaints of weakness persisted and he was transferred to Base Hospital No. 117 on November 8. He seemed to be quite a potential effort symdrome case, but his subjective symptoms were not fixed on his heart—as yet. The role of fatigue in the vast majority of all admissions was an important one. Nearly all the cases came into the hospital in much the same condition in which they left the front line, and their common denominator was fatigue. It is quite probable that many neuroses developed because a patient's resistance was lowered by fatigue, just as sometimes a long argumentative speech is successful for the same reason and not because of any increase of potency in the argument. If fatigue, however, were the only factor, then there wTould be no disproportionate symptom fixation. One could frequently see just as tired-looking soldiers hiking with their divisions. Many of the cases of exhaus- tion were associated with the diarrhea that was so prevalent during the Meuse- Argonne operation. The following case is typical of the exhaustion type: E. M., corpl., 101st Field Signal Btn. Age 21; electrician. The patient's family and personal history were negative. He enlisted in April, 1917, and went to France in June, 1918. He was with the 26th Division during the St. Mihiel and Argonne operations, and showed no undue reaction to shell fire. He had been under fire continuously for nine days previous to his admission to the hospital on October 31, and had had diarrhea for a week. Finally he "fell over and was helped back to the first-aid station." He had had little rest and limited food and heavy work and was "all in," and this was his main complaint on admission. Physically, aside from a slender build and tired-out appearance, he presented no anomaly. He'made a quick recovery, and was returned to duty on November 4, 1918. 342 NEUROPSYCHIATRY The gas neuroses were by no means the problem during the Meuse-Argonne operation that they were in certain of the earlier and less important operations. This was possibly due, in part at least, to the increased gas morale in the divi- sions, and perhaps also to the development of gas hospitals. But two of these cases were seen at this hospital. The gas-neurosis symptoms were to the lungs what effort syndrome was to the heart. Visits to gas hospitals by the senior consultant in neuropsychiatry and the corps consultants in neuropsychiatry were helpful means of providing gas medical officers with the psychiatric point of view toward these men. There were but five cases of effort syndrome altogether among the thousand patients admitted. This low number was rather surprising at first because at Base Hospital No. 117, where the patients filtered from other hospitals, it was not unusual at times to find 5 cases of effort syndrome in a ward of 40 patients; all of which emphasized the role of hospitalization as a culture medium for effort syndrome. These cases required special treatment of graded activities and were evacuated with the recommendation that they be sent to our special con- valescent camp for effort syndrome at Liffol Le Grand. The hypochondriases, anxiety neuroses, and psychasthenias were of the same type as those seen in civilian life; they were persistent in character, and this was reflected in the low proportion returned to duty. A final group was labeled "hyperemotivity" and "state of anxiety." In nearly all of these cases the funk element was predominant and the common attitude was "I can't stand the gaff." The term hyperemotivity was included in the field card diagnosis of these cases at the suggestion of the commanding officer of the hospital. This term was used in reference to the exaggerated jump and emotional reaction shown and occasionally such phenomena as tachy- cardia and increased sweating, and slight cyanosis of the extremities. There was no definite evidence of thyroid enlargement in any of these cases." The state of anxiety was a much more modified picture of anxiety than is seen in a typical anxiety neurosis where the cause of the condition is not so clear to the patient. In these fear cases the anxiety was with reference to the future, especially as it concerned return to front-line duty, for these individuals did not have the symptom alibi of an hysteric or neurasthenic. The jumpiness to noises, while frequently seen in the other types of neu- roses, especially the concussion neuroses and hysterias, was more prevalent in the fear group. Certainly it was much less marked in the true concussion cases. On the whole, there was considerably less of this jump reaction among the fresh war neuroses than among the older cases at Base Hospital No. 117. There was quite a tendency among many of the patients who showed it, not to try to control their jumpiness. It was regarded as demonstrable proof that they were genuinely "shell shocked," and the self-styled "shell-shock" cases fell mostly in this group. <■ The number of enlarged thyroid glands among the war neuroses as a whole was insignificant. This was in con- trast to one's experience with the British "shell-shock" cases, in which signs of thyroid enlargement were found some- times in as high as 10 per cent. Most of the British soldiers had had repeated experiences in the line, while the Americans were relatively fresh. It suggests that thyroid enlargement may be secondary to the emotional reaction and not primary. It is possible, too, that the contrast was increased by the elimination of individuals with enlarged thyroid glands at the training camps in the United States. The facial expression of horror which was not infrequently seen in the British -shell-shock" cases, particularly those with repeated exposure, was seen in just one case at the neurological hospital. This patient proved to be hysterical and recovered within a week. IN THE AMERICAN EXPEDITIONARY FORCES 343 Many of these state-of-anxiety cases gave a story of concussion, but it was more than doubtful. Upsetting emotional experiences—companions killed, etc.—were common and probably very potent factors as the "last straw" in the development of the condition; sometimes such experiences were the "first straw." Fifty-two per cent of this group were returned to front-line duty. The following case is typical: C. S., private, 61st Infantry. Age 21; drug clerk. A maternal aunt was insane. The patient was "sickly" until 2 years of age, had enuresis until 8, and was regarded as a "nerv- ous child." He finished high school at 18. In July, 191S, he was in a quiet sector, but in September, 1918, during the St. Mihiel operation, he was under fire for two days and became "unnerved and fearful." Beginning October 10, in the Verdun region, his sleep became poor, and he was bothered by battle dreams, horrible sights, etc. October 12 he lost his company (a not infrequent occurrence among these cases) and said he scarcely remembered what he was doing. He remembered, however, wandering about among the organization of the 30th and later the 7th Infantry. Toward night he saw a soldier stagger from the woods, and started to give him first aid when a shell exploded and cut the man in two. The patient dropped his gun and ran terrified until exhausted. He was picked up and sent to the neurological hospital on October 17, complaining mostly of "nervousness, poor sleep, and upsetting dreams." His deep reflexes were increased, but there was no evidence of organic disease anywhere. He asked for work in the rear of the front line and said he could never stand shell fire again. There was some emotional instability; he wept easily; and he was terrified at the prospect of front-line service. He seemed to get a better grip on himself, and was returned to duty several weeks later. The armistice precluded a probable relapse. ARMY NEUROLOGICAL HOSPITAL NO. 2, FIRST ARMY Neurological Hospital No. 2, established at Toul, September 7, 1918, became a part of the Justice Hospital Group and occupied one of the series of buildings which had formerly been a French barrack.12 The building was a four-story, stone structure with a capacity of approximately 800 beds. In addition to this building, there were available one small building, which had been employed previously by the French as an infirmary, with facilities for 40 patients, and two other small buildings. Of the latter, one contained three rooms, two of which were used as officers' quarters, and the third, a good-sized room, as a recreation room for officer patients; the other building, situated at the gate, contained seven small rooms which were used as quarters for the female nurses. Since the buildings were not in fit condition to receive patients, it was necessary to employ a number of French women, who, with the nurses and enlisted personnel, proceeded to clean up the buildings. In less than a week's time and quite in time for the St. Mihiel operation, which began on the 12th of September, 600 beds were ready for patients. The St. Mihiel operation lasted about four days, that is from September 12 to 16, and the number of war neurosis cases admitted was suprisingly small, owing to the character of the operation. The rapid retreat of the Germans, the comparatively small amount of exposure to high-explosive shells, and the brevity of the operation which eliminated in a large part the element of exhaus- tion, were the factors responsible for this small number of cases. During the month of September, 325 cases werea dmitted to this hospital. Of this number, 44 per cent were returned to duty, 35 per cent were evacuated 344 NEUROPSYCHIATRY to Base Hospital No. 117, 15 per cent were evacuated to Base Hospital No. 116, and 6 per cent to other hospitals. During the month of October the number of cases admitted was 116, being an average admission of about 4 per day. Of this number 101 were returned to duty. The sources of admissions were other hospitals where the patients had remained various lengths of time. The average duration of the stay in the hospital for these patients was 21 days. This was due to the fact that many of the cases developed acute influenza and other conditions which required modifications of the treatment established for cases of war neuroses. This hospital was abandoned on November 5, when part of the personnel was transferred to Neurological Hospital No. 1 of the Second Army and others returned to their proper stations.12 ARMY NEUROLOGICAL HOSPITAL NO. 3, FIRST ARMY When preparations were being made for the Meuse-Argonne operation il was thought that the two neurological hospitals already organized would be insufficient to provide for cases which were expected to develop as the result of this operation. The hospital at Toul was too far removed from the seat of operation to be available. The hospital at Benoite Vaux could not receive men who were evacuated from the American front along the road leading south to the east of Souilly, or admit patients from divisions in the rest area along that road. The senior consultant in neuropsychiatry planned, therefore, to establish a third neurological hospital somewhere in the neighborhood of Souilly, where a group of evacuation hospitals was located. The hospital at Benoite Vaux was then about 15 miles behind the front line. It was the plan to establish Army Neurological Hospital No. 3 somewhere farther to the west and approxi- mately the same distance from the front lines. Thus evacuation from the front could be made directly from field hospitals to Army neurological hospitals with- out first unloading patients at evacuation hospitals. The Army neurological hospitals were situated parallel to the evacuation hospitals and were within easy reach of the field hospitals by ambulance. The site chosen for the third neurological hospital was Nubecourt.13 Army Neurological Hospital No. 3 was established in buildings which had been occupied by the French as a neurological unit. This was known as Ambulance 8/V, during the French occupation of the Verdun section. The building con- sisted of a 12-room dwelling house, 2 barrack wards, and several outbuildings, making possible a total capacity of 220 patients. By the addition of tentage the hospital was further enlarged to a capacity of 400 patients. Army Neuro- logical Hospital No. 3 was situated on the main road from Clermont-en-Argonne to Bar-le-Duc. It was also about 6 miles from Souilly, and thus connected with the road from Verdun to Bar-le-Duc. This unusually favorable situation of the hospital greatly facilitated the evacuation of soldiers from the front areas. In accordance with verbal orders of the representative chief surgeon of the First Army, on September 22, 1918, this unit was placed in operation.13 Four medical officers were transferred to it from Neurological Hospital No. 1. Thirty enlisted men were transferred from Army Neurological Hospital No. 1; of this number 20, including two sergeants, were on temporary duty from Base Hospital IN THE AMERICAN EXPEDITIONARY FORCES 345 No. 117, while the remaining 10 belonged to Evacuation Hospital No. 10. Supplies were obtained from the advance medical dumps at Souilly. This hospital, from the moment of its establishment, began to operate actively. As many as 242 cases were admitted during the first eight days of its existence, when the Meuse-Argonne operation began. Of this number, 229 came directly from field hospitals and were transferred by ambulance or trucks directly from the front. This number represented the personnel of 16 different units, of which 12 were divisions. The memorandum which follows, sent September 30, 1918, by the senior consultant in neuropsychiatry to the chief surgeon of the First Army, is signifi- cant as indicating the value and success of this new type of hospital:14 The inclosed table shows the divisions from which patients have been admitted to Neurological Hospital No. 3 at Nubecourt up to noon to-day. It is seen that the 35th Divi- sion contributed nearly 60 per cent of all admissions. This is due to the fact that the division psychiatrist was not permitted to retain nervous cases in the divisional hospitals on account of the refusal of the divisional officer having charge of evacuations. The only other two divisions which showed a large number of admissions (37th and 91st) had accidents to their triages which somewhat upset the place. The significance of this table is that 7 officers and more than 100 effective men were needlessly lost to their division at a time when every officer and man was of the utmost value. Nearly all the cases received at this hospital from the 35th Division were of the type which in other divisions are being returned directly to their command after a few days' rest and treatment. No action is required in this matter on account of the cooperation which has been secured with the division surgeon. I am bringing it to your attention simply as an illustra- tion of the advantage of the plan which you have approved. If all the divisions engaged had contributed an equal number of cases more than 1,000 men would have been lost within the last 5 days from this controllable cause of noneffectiveness. This is certainly important from a military point of view, but more important still is the bearing which the evacuation of such cases has upon morale and the prevalence of these disorders. During the month of October the activities of this hospital were very great, owing to the character of the Meuse-Argonne operation, and it was necessary to increase its personnel in order to cope with its work.15 The report made by the commanding officer showed, on November 1, an increase in the personnel, consisting of 6 medical officers and 17 enlisted men.15 During the month of October, 868 patients were admitted to this hospital from 32 different organi- zations, of which 20 were divisions in the line. Of this number, including 242 patients who were held over from the last month's report, 561 were returned to duty and 307 were evacuated to the rear. Of those sent to the rear, 203 were sent to Base Hospital No. 117. The latter were cases that had not recovered during a period of two weeks and required further treatment and observation. The total number of cases treated at this hospital from September 25 to Xovember 19 was 1,169. Of this number, there were 852 cases which could be diagnosed as psychoneuroses. Of these 852 cases, 614 were discharged as recovered. Of the cases received at this hospital to which the diagnosis of psychoneurosis was made, which did not include the cases of exhaustion from exposure or from overexertion and influenzal conditions, the total percentage of cases returned to duty was 73.12 per cent, the length of stay in the hospital was 10.4 days. 346 NEUROPSYCHIATRY The same psychotherapeutic principle which governed treatment in the divisions and at Neurological Hospitals Nos. 1 and 2 were employed. The methods by which they were put into effect at this hospital can be seen best by quoting from a report made by the commanding officer to the senior consultant in neuropsychiatry, as follows: 16 As to the description of methods of treatment and management employed, the following may be said: The simplest form of therapeusis, consisting largely of hygienic measures, sufficed in the great majority of cases. These included such measures as food in an easily assimilable form, a hot bath, clean clothes, and absolute rest in bed for a period of from 24 to 72 hours after admission. In the cases exhibiting active motor symptoms, semisequestra- tion, by such means as screening or use of single rooms for a period of one to four days, was found adequate for the removal of these phenomena. During this time of forced rest in bed the patients were not permitted to leave the inclosure, even for brief periods. No intercourse with other patients or with ward masters was allowed except as necessary in the routine of ward management. In no case was this unsuccessful. After a period of primary physical rest had been secured, the patient was provided with a clean outfit of clothing, including a properly fitting uniform. He then engaged in light forms of occupation (for a period of one or two days more), such as assisting in the sanitary care of the ward. At the end of this time he was sent for more advanced treatment into a workshop supplied with tools and materials for woodworking and such metals as tin, copper, brass, and iron. The capacity of the shop wras 50 men. It was under military control, and activity in one or more of its departments was insisted upon. Constant supervision, instruction and aid being afforded by instructors. The ward surgeon designating certain patients for this form of therapeusis specified "whole" or "part-time" occupation for them. Each afternoon, weather permitting, the patients designated by the w-ard surgeon were assembled in military formation and conducted in charge of a commissioned officer on an easy march for a distance of from 3 to 6 kilometers. Verbal orders for the discontinuance of the unit and the return to the supply stations of material were issued by the chief surgeon, First Field Army, American Expeditionary Forces, on November 19, 1918. The patients were disposed of and the material returned as ordered. The unit handed over to the French authorities the material which had been left by the French Ambulance 8/V when Neurological Hospital No. 3 was organized. The personnel was sent to Base Hospital No. 117 except for a section of 3 officers and 10 enlisted men, who were directed to report to Evacuation Hospital No. 6 for temporary duty in accordance with directions of the chief surgeon, First Field Army, American Expeditionary Forces, dated November 19, 1918.16 PSYCHOSES OBSERVED AT THE FRONT « The following observations relative to psychoses seen at the front are pertinent: There was observed in a small number of the cases admitted to the First Army neurological hospitals situated at the front, mental states analogous in their coloring to certain recognized psychoses, but which did not present the complete clinical picture or follow the same evolution of these diseases. The statement is frequently seen in literature that war does not create any special type of psychoses. To a certain extent this is true. The cases of actual psychoses observed in psychiatric units in the Army fall into groups which ' Based on: Psychopathic Reactions to Combat Experiences in the American Army, by John H. W Rhein M D. American Journal of Insanity, Baltimore, 1919, lxxvi, 71. IN THE AMERICAN EXPEDITIONARY FORCES 347 include manic-depressive psychosis, dementia praecox, paresis, epileptic insan- ity, and alcoholic psychoses. These are, in the main, conditions which are not peculiar to war. But there are mental states which are seen in soldiers exposed to combat experiences, and who are admitted to the hospitals at the front, which mav be considered directly related to war. These have already been described by French, Italian, and Russian observers. They occur in small numbers, only at the front; the symptoms are on the whole of short duration; they are directly related to the severe emotional and exhaustive front-line experiences; they show certain well-defined characteristics, and represent abnormal reactions in the sphere of the psychic, due to severe emotional experiences. One of the forms of these mental states which were observed in a few cases was that described by Chavigny as aprosexia, or an inability to fix the attention. In this condition the soldier is unable to concentrate his attention upon the questions of the examiner, his eyes constantly move from the face of the medical officer to one or the other side, at times as if he saw some object of a frightful character, making no reply to questions and apparently oblivious to the pres- ence of the examiner. These symptoms persist a few hours to a few days as a rule and finally disappear entirely. A fairly common type observed was a state of mental confusion associated with what has been termed oneiric delirium, symptoms which were associated with a history of concussion and exhaustive experiences. These symptoms were at the same time susceptible of cure in a short time. A third form which was observed consisted of a state of stupor associated with negativism and some catatonic phenomena suggestive of dementia prsecox. In some cases the symptoms recall the paranoid variety of this disease. This type has been referred to by Davidenkof, who described states of hallucinatory mental confusion with pseudohebephrenic manifestations without the true picture of dementia prsecox. The following cases are interesting as illustrating some of these features: A. B., private. Aged 31. In civil life a teacher by occupation. His father had suffered from a nervous collapse at the age of 47. The patient had been a stammerer and had suffered from three nervous breakdowns in 1900, in 1903, and in 1915. He enlisted in September, 1917, went to France in July, 1918, and had been in the post office of Dieulard since Septem- ber 15, 1918, where he had been exposed to shell fire, though none burst nearer than 70 yards. The shelling had upset him and made it difficult for him to concentrate on his work. Two weeks prior to admission an agent for the Stars and Stripes gave him some candy which he later threw away because he believed there was poison on it. Again, a week later, a soldier borrowed his canteen and when he returned it the patient noticed a peculiar taste in the water when he drank from it, and he concluded that his companions were giving him some poison to make him erotic. On admission he complained of "being worn out," of a sense of tension on both sides of his head and the back of his neck, and a tingling in the arms and legs. He was apathetic, suspicious, uneasy in his manner, indifferent, and showed delusions of perse- cution. There were no hallucinations of sight or hearing. The symptoms improved some- what during his stay in the army neurological hospital, but he was evacuated to the rear for further treatment. This case represented a reaction which suggested the paranoid form of dementia prsecox. 348 NEUROPSYCHIATRY J. J., private. Aged 24. Was employed as a locksmith in civil life. He entered service in February and went to France in May, 1918. He was evacuated to the army neurological hospital from the Argonne front. On admission he refused to give any data regarding his family or previous history, nor would he discuss any of his war experiences. He was reticent, suspicious, and his answers to questions were so unsatisfactory that it was possible to obtain only a meager portion of the trend of his thoughts. He was evidently a victim of a con- spiracy which had been formed for the purpose of blocking the workings of the Government. He had been in communication withThomas Edison, but due to the spy system the work in this line had been interfered with. He said that everyone with whom he had come in contact had attempted to do him harm. Because of his persecutory trend he refused to discuss the details of his mental state, believing that the examiner was in league with the gang, who had persistently interfered with his ability to do good work for the United States Govern- ment. He was evacuated to the rear after three days' treatment, during which his symptoms had improved to a certain extent. This case illustrated again a paranoid reaction suggestive of dementia prsecox. G. C., private. It was impossible to obtain the family or previous histories, or any information relative to the origin of his present condition. He was evacuated to the army neurological hospital from the Argonne front. He appeared to be constantly in a confused state, and refused to make any replies to questions put to him. He occasionally would mumble some words in Polish which were evidently of a religious character, assuming at the same time an attitude of prayer. He was rather emotional and would weep without provoca- tion. He lay quietly on his bed showing no interest in his surroundings. Frequently his lips were observed to move as though praying. He was dull, stolid, and stupid in his manner, frequently put his head on the table and wept, occasionally nodded his head in reply to a question but would not talk. When asked why, he pointed to his larynx. He was evacuated to the rear in two days showing no change in his mental state. His condition was one of confusion associated with some negativism and depression. J. K., corporal, aged 27. In civil life an oiler and coal breaker. The family history was negative. He had arrived at the 5th B grade and had never been sick in his life. He enlisted in April, 1917, and went to France, May, 1918. He went through the Aisne and St. Mihiel operations without mishap. On the Verdun sector he carried on under shell fire for three nights and two days. He then believed that his sergeant had induced him to mal- adjust his gun, which resulted in the death of three American soldiers. He looked upon the sergeant as either a German sympathizer or a German spy. He was somewhat confused but adhered to this statement over and over again. He complained of a heavy feeling in his head on admission and was unable to recall everything that had transpired previous to his admission. He was very much depressed, the depression centering around the death of his companions which he believed he had caused. The physical condition was negative out- side of some stammering. At the end of three days he cleared up entirely. L. M., private, aged 36. In civil life a railroad worker. The family and previous histories were negative. He enlisted April, 1918, went to France July 12, 1918, and was in the Toul and Verdun sectors. He was sent back from the Argonne front during the opera- tion in October. He believed that he had gotten in bad in the camp from which he had come, and that several of the men were going to kill him. There was a plot going on in the ward also to kill him, and he heard the conspirators planning to make away with him before he went to sleep. He said he had come to the hospital because he did not want to "be shot like a dog. I want to go in some other outfit and get killed for my country." There was some concern and feeling about his situation, but on the whole he lacked insight. He was quite tense, did not understand why his enemies had it in for him, and feared he would be killed or court-martialled. He was evacuated to the rear in four days, somewhat improved. The manic-depressive reaction was probably seen more frequently than any of the mental states under discussion. As a result of some intense emotional IN THE AMERICAN EXPEDITIONARY FORCES 349 trauma a soldier suddenly became wildly excited, associated with tremendous physical agitation and oneiric delirium, a condition suggesting mania, These cases were seen in small numbers in field hospitals, where they required packs and hypodermic injections of morphine, the excitement subsiding in large part before they arrived at the army neurological hospital. The following cases illustrate more particularly a mild manic reaction characterized by excitement, and associated with partial amnesic states: R. D., sergeant, aged 27. In civil life an assistant sales manager. His father died of cancer, but otherwise the family history w^as negative. He was more or less disturbed by the sight of blood and the killing of animals, but in other respects his previous history was negative. He had spent two years in college. He was drafted in September, 1917," and went to France, May 31, 1918. He w-as with the British at Arras and then went to the Verdun sector on September 26, where he was obliged to do the work of his sergeant major, who had been killed. He was worried and disgusted by the lack of blankets, lack of artillery support, and the lack of ambulances at this time. Shells made him nervous previously and his nervousness continued to increase until finally a shell killed the adjutant, wounded another man, and threw dirt on himself. He became wild, crying and shaking in an uncontrollable manner, and was evacuated. On admission he presented evidences of fatigue, some tremor, and was physically restless. He recovered entirely and returned to duty at the end of two weeks. L. B., private. In civil life a clerk. The family and previous histories were negative. He entered the service April 25, 1917, and went to France March 22, 1918. He had been under shell fire at St, Mihiel and gave a good account of himself during this operation. At the Argonne front he had been under shell fire a few days when he was blown over by a shell which killed two of his companions. He was dazed and lost complete control of him- self, ran about in an aimless and excited manner, and was so violent and difficult to manage that the medical officer gave him a hypodermic of morphia. Upon admission he complained of tremulousness and nervousness and would start upon hearing sudden, unexpected sounds. He slept with difficulty and dreamed of war scenes. He also complained of a feeling of insufficiency, but otherwise the examination was negative. He returned to duty in three weeks. A. H., aged 24, private. In civil life a contractor. The family history was negative, except that one sister was nervous and excitable. The patient had finished the first year at high school and presented a negative history, except that he was a bed wetter until 10 years of age, had always been easily frightened, and had suffered from nightmare. He enlisted May, 1917, went to France May, 1918, and to the front in June. Shell fire had always made him a little nervous, and he gave a history of very little rest and not much to eat. In October on the Verdun front a shell landed 25 feet from him. He began to "shake, pant, and sweat," felt chilled, "went wild," and ran around in an excited, confused state, and did not know what he was doing. On coming into the hospital he complained of weak- ness and headaches. He presented, on examination, a neurotic make-up, cleared up under rest, and returned to duty in a few- days. E. W., private, aged 27. In civil life a laborer in a steel mill. He attended school until 13 years of age, and was able to read and write. His mother was nervous and one sister had "falling spells." He himself had had nightmares and had walked in his sleep. He was drafted in September, 1917, and w-ent to France May 30, 1918. He was in the Elbert sector in the trenches 10 days, went to Verdun September 26 and was blown over October 24. He stated "that the whole thing had practically demoralized him." He was in a shell hole when two shells struck near him. Shortly afterwards he remembered that he was running away greatly excited, yelling and crying. He went to the first-aid station and was evacu- ated. Upon admission he had recovered largely from his excitement and in a few days was practically well. L. P.", private, aged 23. In civil life a farmer. The family history was negative until June 3, 1917, when he was kicked in the thigh by a horse and was in a hospital for weeks, 350 NEUROPSYCHIATRY since which time he was easily startled, fearful, and apprehensive. He entered the service April 1, 1918, and went to France June 27, 1918. He was sent to the Argonne front in Octo- ber, where he encountered his first experiences under shell fire. He was there for eight hours and got along very well, being under heavy fire nearly all the time. He saw several of his officers and men killed and became more and more nervous, until finally was unable to carry on any further and was taken to a dressing station. Here he was very much excited, tremulous, and nervous, and "would become crazy when he heard the explosions." On admission to the neurological hospital he was excited and tremulous, started at unexpected sounds, and could not sleep. He improved greatly under treatment, but was sent to the base neurological hospital for further rest and treatment. There is a small number of cases belonging to this group, on the other hand, in which the symptoms took a depressive coloring. Usually the picture was one of simple depression associated with preoccupation and sometimes with hallucinations and depressive delusions. J. B., French Canadian, private, aged 31. In civil life a laborer. One brother, an alcoholic, died insane. The patient had an attack of some mental disorder of unknown character in 1911. He was drafted in June, 1918, went to France in September, 1918, and went at once to the Argonne front, where he passed through Clermont and Montfaucon. While helping to bring in food, he said, God's voice said to him, "Leave this place at once before something happens." He started to run and though he heard a sentry say "stop," the voice urged him on, and he ran in spite of the bullets from the sentry's gun, one of which gave him a flesh wound in the left arm. He stayed in the woods one night but was captured the next day, and ran away a second time, on the following day. On admission to the army neurological hospital he appeared to be a simple-minded French Canadian who was in a state of religious excitement in relation to delusions of persecutions and auditory hallucina- tions. He frequently repeated, "I don't feel quite right, I haven't done right, I didn't keep my promise to the priest to take 10 sacraments when I w-as sick last time." He believed he would not be pardoned. He improved considerably in a few days but he was sent to the rear, as it seemed advisable to give him a longer treatment than was practicable in the hospital at the front. C. R., private, aged 2.5. In civil life a potter. One paternal uncle was insane. The patient had finished the fifth grade. He had always shown fear of the sight of blood and the dead. He confessed to have been depressed on numerous occasions in the past. He was drafted May 18, went to France July, 1918, and went to the Argonne front in October of the same year. Shells did not bother him until he saw many of the boys blown to pieces, when he began to get nervous. He was caught in a barrage and became very excited. Finally, at the end of two days a shell exploded near him. He was unable to tell what happened after that, but he believes he became unconscious He reached a kitchen, but does not remember how he got there. On admission he was depressed, showed auditory and visual hallucinations, and was retarded in thought and action. He was emotional about his mother being home alone and could not understand why he did not get mail from her. His memories for events previous to the front-line experiences were good, but memories for the front-line experiences were hazy. He sat or lay in bed with his hands folded in his lap, silent, pre- occupied, took no interest in his environment, and was somewhat disoriented. He improved considerably, but was evacuated to the rear for further treatment, T. R., corporal. In civil life a carpenter's helper. Both father and mother died of tuberculosis. One brother was reported killed two days before he was admitted to the hospital. Otherwise the family history was negative. Outside of the fact that he was a bed wetter until 12 years of age and walked in his sleep, his previous historv was negative. He enlisted m July, 1917, went to France in June, 1918, and went to the Alsace and Verdun sectors. He was very much exhausted by his first shell-fire experiences. He went to Verdun on October 8, and carried on well until October 10, when he heard of his brother's death from a triend. which upset him very much. He was in a trench when a German barrage was put o^er, some of the shells landing near him, none of which made him unconscious, however, IN THE AMERICAN EXPEDITIONARY FORCES 351 but he became flighty, nervous, and w-eak. On admission his expression was strained, his brows wrinkled and he was very much depressed. His depression centered largely around the death of his brother about which he was emotional. His insight was good and he was coopera- tive. He recovered in 10 da}\s' time and returned to the front. The front-line experiences which are practically similar as to exhaustion, commotional and emotional factors in all cases which show a reaction in the sphere of the nervous system, gave rise to a variety of reactions. These con- sisted in some cases of simple hyperemotivity which in itself incapacitated, in others it resulted in the occurrence of actual neuroses, and finally in a small number there occurred symptoms which presented a psychotic coloring. The cause of this variety of reactions to identical experiences offers an extremely interesting field for speculation. Seemingly, it is due to the mental make-up of the individual. When the individual's balance is upset by certain conditions the reactions take one of a number of directions, the type of the reaction depending upon that particular quality of the mental make-up which predominates. We observe these reactions appearing in civil life in individuals who respond under stress more or less within normal limits. We see individuals who are considered normal, who under strain become depressed, excited or paranoid, conditions which may be looked upon as indicating the character of the mental make-up of the individual. These conditions may be regarded as mild transient psychotic states, peculiar to war, though the possibility of their occurrence in civil life, if the stress is sufficiently great, is not to be denied. ARMY NEUROLOGICAL HOSPITAL, SECOND ARMY The consultant in neuropsychiatry for the Second Army reported for duty with that army soon after its organization on October 10, 1918.17 18 Plans were immediately projected to organize a neuropsychiatric service for this army, which included the establishment of an army neurological hospital to provide for the cases of war neurosis which, it was anticipated, would arise as a result of a military operation scheduled to begin in the latter part of October. The army neurological hospital was organized and established, therefore, on November 5, 1918. It was located at Varvinay,17 an advanced position, within 3^2 miles of Mobile Hospital No. 39 and near Field Hospital No. 117, which had been at Commercy, but had been moved in a day from this location to a site on the out- skirts of Varvinay. Varvinay was about 7^ miles behind the front line and near the roads which connected St. Mihiel, Commercy, and Toul with the front areas. There were on this site, when it was taken over, three structures consist- ing of a small German barrack, a small French barrack, and a third building which had been partly destroyed by fire. The latter was at once repaired and was used for storing medical supplies. In addition to these buildings, two tents were erected on the level ground adjoining these buildings. Above this site, on a hill, were three large wooden structures which had been occupied by a French machine gun battalion, and three cottages. These buildings, before the St. Mihiel operation were occupied by the Germans. Two of the large struc- tures were used to house the enlisted personnel, another served as a mess hall, while the cottages were for officers' billets. The hospital had an electric lighting system. On the hill was a spring which afforded an abundant supply of good water to all buildings occupied by the hospital. 352 NEUROPSYCHIATRY The temporary personnel came from Field Hospital Xo. 117. This was augmented by men from Neurological Hospital Xo. 2, First Army, at Toul, upon the abandonment of the latter hospital, as recorded above. At this time two sergeants and six privates, Medical Department, attached for permanent duty to°Neurological Hospital No. 2, First Army, were ordered to the neurolog- ical hospital of the Second Army for temporary duty. Since military operations of the Second Army ended with the signing of the armistice on November 11, just a few days after they had begun,19 the activities of this hospital were likewise brief. The total number of admissions amounted to 12, and these were admitted on November 9. Of this number, 9 were returned to duty and 3 evacuated to the Base Hospital No. 117. All of these cases came from the 33d Division which was operating to the north of Varvinay.20 The hospital was closed on November 23, 1918. REFERENCES (1) Led. Andre: Reforme, Incapacites, Gratifications dous Ies Neuroses de Guerre. Revue neurologique, 1916, xxix, 763. (2) Roussy, Gustave, and Boisseau, J.: Un centre de neurologie et de psychiatric d'Armee. Paris, medical, 1916, No. 1, 14-20. (3) Salmon, T. W.: The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army. Mental Hygiene, New York, 1917, i, No. 4, 509-547. (4) Final Report of Gen. John J. Pershing, Commander in Chief, A. E. F. (5) Report of the activities of the section of neuropsychiatry, A. E. F., made by Col. Thomas W. Salmon, M. C, senior consultant, neuropsychiatry. On file, Historical Division, S. G. O. (6) Letter from the senior consultant in neuropsychiatry, A. E. F., to the corps surgeon, First Corps, August 26, 1918. Subject: Establishment of neurological hospital at Benoite Vaux. Copy on file, Historical Division, S. G. O. (7) Report of Medical Department activities, Base Hospital No. 117, A. E. F., prepared under the direction of Maj. W. J. Otis, M. C, commanding officer, undated. On file, Historical Division, S. G. O. (8) Memorandum from the senior consultant in neuropsychiatry, to the chief surgeon. First Army, September 6, 1918. Subject: Neurological Hospital No. 1, First Army. Copy on file, Historical Division, S. G. O. (9) Final report of the chief surgeon, First Army, upon the St. Mihiel and Meuse Argonne offensives, undated. On file, Historical Division, S. G. O. (10) Letter from the commanding officer, Neurological Hospital No. 1, A. E. F., to the senior consultant, neuropsychiatry, A. E. F., November 10, 1918. Subject: Report for the month of October. Copy on file, Historical Division, S. G. O. (11) Letter from the commanding officer, Neurological Hospital No. 1, A. E. F., to the senior consultant, neuropsychiatry, A. E. F., November 30, 1918. Subject: Report for the month of November. Copy on file, Historical Division, S. G. O. (12) History of the Justice Hospital center, prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O. (13) Letter from the commanding officer of Neurological Hospital No. 3, to the senior consultant, neoropsychiatry, A. E. F., October 1, 1918. Subject: Resume of opera- tions of this unit. Copy on file, Historical Division, S. G. O. (14) Memorandum for Colonel Garcia from the senior consultant, neuropsychiatry, A. E. F., September 30, 1918. Subject: Character of cases admitted to neurological Hospital No. 3. Copy on file, Historical Division, S. G. O. (15) Letter from the commanding officer of Neurological Hospital No. 3, to the senior con- sultant, neuropsychiatry, A. E. F., November 1, 1918. Subject: Resume of opera- tions of this unit. Copy on file, Historical Division. S. G. O. IN THE AMERICAN EXPEDITIONARY FORCES 353 (16) Letter from the commanding officer of Neurological Hospital No. 3 to the senior con- sultant, neuropsychiatry, A. E. F., November 30, 1918. Subject: Report of opera- tions. Copy on file, Historical Division, S. G. O. (17) Report of Medical Department activities. Second Army, A. E. F., by Col. C. R. Rey- nolds, M. C, chief surgeon, Second Army, undated. On file, Historical Division, S. G. O. (18) G. O. No. 175, G. H. Q., A. E. F., October 10, 1918. (19) Major operations of the American Expeditionary Forces in France, 1917-18, prepared in the Historical Section, the Army War College. On file, Historical Section, the Army War College. (20) Outlines of Histories of Divisions, U. S. Army, 1917-18, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College. CHAPTER IV HOSPITAL FOR WAR NEUROSES (BASE HOSPITALINO. 117) ORGANIZATION AND ADMINISTRATION The most important base hospital in connection with the care of war neuroses in the American Expeditionary Forces was the special one, Base Hos- pital No. 117, at La Fauche. The plan for this hospital was outlined in the report of the neuropsychiatrist detailed to study the care and treatment of mental diseases and war neuroses in the British Army.0 As soon as the definite plans for this special base hospital, as outlined in this report, had been accepted by the War Department, efforts were begun at once in the United States to recruit and to organize the necessary personnel.1 The director of the National Committee for Mental Hygiene made a careful search among the various State and private institutions for nervous diseases throughout the country, in the effort to obtain men and women whose training and experience qualified them for this branch of the service. The medical officers thus obtained were sent to special hospitals in the United States and England for intensive training in neuropsychiatry until such time as the hospital in France had begun to oper- ate. The enlisted men and nurses were assigned to duty in neuropsychiatric wards in military hospitals in the United States until March, 1918, when the unit was mobilized.1 Pending the arrival of this unit in France the senior consultant in neuro- psychiatry made preparations there for the organization of this special hospital. The following memorandum was sent by him, February 9, 1918, to the chief surgeon, A. E. F. (the letter and inclosure which accompanied the memorandum are also given):2 1. If the attached recommendation for the establishment of a hospital at La Fauche for the treatment of war neuroses is approved, it is recommended that a cabled request be sent to the United States to transfer to that hospital, for duty, all medical officers, female nurses, and enlisted men, attached to Base Hospital No. 117, now on active duty in the United States and awaiting assignment to duty in France. 2. The commanding officer of that organization should be directed to bring all special hydrotherapeutic and electrical equipment in his possession, which is now ready for shipment. It is believed that all other equipment and supplies can be obtained from the medical supply depot here. 3. The medical personnel of Base Hospital No. 117 is made up of specially trained medical officers, female nurses, and enlisted men, and the number is much smaller than that of a military hospital of the same bed capacity, for the reason that patients will be employed extensively. The products of the shops can be used in other hospitals in France. 4. A copy of this memorandum, with inclosures, has been forwarded to the chief surgeon, L. O. C, through the chief surgeon, advance section, L. O. C, for his information. • This report is reproduced in full in the Appendix, p. 497, et seq. 42705—29----24 355 3f)0 NEUROPSYCHIATRY Office of the Director, Division of Psychiatry, A. K. F., A. P. O. <31, February 10, 1918. From: Maj. Thomas W. Salmon, director, division of psychiatry. To: The chief surgeon, G. H. Q., A. E. F. Subject: Use of Camp Hospital No. 4 for treatment of war neuroses. 1. It is recommended that Camp Hospital No. 4 be designated as "Base Hospital No. 117," to be used entirely for the treatment of functional nervous diseases and that it be staffed by the neurological section of the personnel of this hospital upon their arrival in France. 2. It is recommended that, pending the arrival of the permanent personnel, this hospital be used for the treatment of cases of functional nervous diseases now in various hospitals and for the observation of mental cases from the training area. A temporary personnel of experienced medical officers and noncommissioned officers can be provided from members of the American Expeditionary Forces already enrolled for work in this type of hospital. The buildings can be used temporarily as indicated in the attached table and diagram. 3. The functional nervous diseases (hysteria, neurasthenia, psychasthenia) and other conditions to which the term "shell shock" has been applied in the British Army are respon- sible, in the present war, for a large wastage of otherwise effective men. Three per cent of all casualties and 20 per cent of all discharges for disability from the British Army have resulted from these disorders. Although they are most frequent in soldiers exposed to shell fire, they are not uncommon among officers and men in training. A number of cases among officers and men are now under treatment in hospitals in theAmerican Expeditionary Forces and 4.5 per cent of all officers and men already returned to the United States for discharge have been invalided for these diseases. 4. These diseases are not only curable in the great majority of instances but their inci- dence among American troops will be determined very largely by the type of management employed. If they are regarded as incurable, except in special hospitals in the United States, and are all returned for treatment or discharge, several thousand more cases will result through the influence of this suggestion upon soldiers predisposed to these disorders than if they are efficiently treated and cured in France. In certain British "shell-shock" hospitals where the average period intervening between the onset of the disease and admis- sion to a special hospital is about five months, less than 20 per cent are returned to duty of any kind. On the other hand, where these cases receive skilled attention in France, more than 60 per cent recover in an average period of treatment of only a few weeks. In the French neuropsychiatric centers established near the front, the percentage of recoveries is even larger. 5. These facts make it imperative for us to provide facilities for the treatment of this class of cases at the earliest possible date in order to check their incidence and to establish a sound method of management. Failure to do so is certain to open a serious source of wastage for the Army. 6. With this need in mind, a special hospital (Base Hospital No. 117; for the treatment of these cases and to serve as a clearing hospital for mental cases has been organized in the United States. This hospital has a very carefully selected personnel, nearly all of the medi- cal officers having studied the war neuroses in special British military hospitals and all the female nurses and enlisted men having had experience with mental and nervous cases in civil institutions. Arrangements are being made for the attachment of the psychiatric sec- tion of this personnel to Base Hospital No. S upon their arrival in France, there to serve as a clearing hospital for the insane and mentally defective. This psychiatric section has a personnel of 7 medical officers, 6 female nurses, 7 noncommissioned officers, and 37 enlisted men. The remainder of the personnel constitutes the neurological section referred to in paragraph 2 of this lettter. 7. Camp Hospital No. 4, at La Fauche, the location of which is indicated in the attached map, is particularly suited for the special purposes of a hospital for the treatment of the war neuroses for the following reasons: IN THE AMERICAN EXPEDITIONARY FORCES 357 (a) It is in the advance section of the line of communications, providing ready access from the front and insuring the absolutely essential impression among patients that their disability is temporary and curable and that they are not going into a long invalidism or necessarily en route to the United States. (b) It is isolated from other hospitals and from military training camps but near enough to a hospital center (Bazoilles) to permit the ready transfer of organic cases and other patients admitted through errors of diagnosis. (c) It is on the outskirts of a village of about 20 houses, large enough to provide billets for part of the personnel if needed in future expansions and small enough to be free from the undesirable features of a large town. (d) It adjoins a small chateau with extensive gardens and a swimming pool, both essen- tial in the occupation and physical training which constitutes an important feature in the treatment of these cases, and providing a separate hospital for officers when operating at full capacity. (e) It is surrounded by level fields, providing the ample space needed for drills and exercises. s. It is recommended that the village of La Fauche be placed out of bounds for any other military purpose to permit the most effective development of this special hospital. 9. It is recommended that the observation ward in Base Hospital No. 66 be discon- tinued as soon as this hospital is ready to receive patients. Thomas \Y. Salmon, Major, M. R. C, U. S. A. Arrangement of standard camp hospital for use as neuropsychiatric hospital (capacity ivith temporary personnel 80; ivith permanent personnel 300) I'se of buildings in standard camp hospital Use of buildings in neuropsychiatric hospital Same. Same. Same. Same (electrical treatment in operating room). Same. Administration. _. _______________ Officers' quarters_________________ Clinic___________________________ Operating room, X ray, laboratory Patients' mess___________________ Bath house and disinfecting_______ Mess, officers and enlisted men____. . .1 Same Barracks, enlisted men____________ Ward A (30 beds)_______________ Ward C (30 beds)_____________ . Ward E (30 beds)____ __________ Ward G (30 beds)___________ ! Ward for 10 officers. Ward I (30 beds)____________________I Ward for 25 acute cases. Ward K (30 beds)_________________ J Ward for 30 convalescent cases Same. Same. Nurses' dormitory. Ward for 15 acute cases requiring close supervision. Shops and gymnasium. All the remaining buildings will be occupied when the arrival of the permanent personnel from the United States permits the hospital to be operated at full capacity. The suggestions outlined in this correspondence were approved by the chief surgeon, A. E. F., and construction of the hospital was begun at once. It was ready for occupancy by the end of February, and since it was highly desirable to place it in use as soon as possible, recommendation was made to this effect, by the senior consultant, as indicated in the following letter from him to the chief surgeon, A. E. F.: 3 1. In view of the desirability of receiving patients at Base Hospital No. 117 at the earliest possible moment, in order that soldiers with psychoneuroses now in other hospitals 358 NEUROPSYCHIATRY may receive special treatment and the precedent of returning such cases to the United States may be avoided, it is recommended that this hospital be opened with a temporary personnel pending the arrival of the regular personnel from the United States. 2. It is recommended that Maj. George B. Campbell, M. R. C, who has been ordered to report at Neufchateau for duty in the division of p.sychiatry be assigned as commanding officer of this hospital upon his arrival. 3. It is also recommended that the following commissioned medical officers, noncom- missioned officers, and enlisted men of the Medical Department be relieved from duty at the stations set opposite their names and ordered to report to Maj. Thomas W. Salmon, M. R. C, for duty at Base Hospital No. 117: Capt. R. W. Hall, M. R. C__________ Division of psychiatry, Neufchateau. First Lieut. E. McConnelly, M. R. C__ Red Cross Military Hospital No. 1, Paris. Sergt. Hugh J. Rice_________________ Base Hospital No. 66, Neufchateau. Pvt, Pearl I. Wiley________________ Do. Pvt. Louis H. Tetu________________ Do. Pvt. Richard O'Brien______________ Do. Pvt. Curtis Senior_________________ Do. 4. It is recommended that an experienced mess sergeant and 20 enlisted men of the Medical Department, one of whom is an experienced cook, be ordered to report for duty at this hospital. 5. The object of the above recommendations is to prepare the hospital so that patients may be received as soon as the necessary equipment arrives, to protect property, and to com- mence the cultivation of gardens and a farm, in order that this important feature of occupa- tional therapy to be employed later may be successful. 6. It is recommended that all these orders be communicated by telegraph. The following letter from the director of psychiatry to the chief surgeon, A. E. F., March 19, 1918, gives the main facts in the establishment of Base Hospital No. 117 and the early orders to transfer cases there: 4 1. Confirming our telephone conversation of to-day, Base Hospital No. 117 (Camp Hospital No. 4) is prepared to receive cases of functional nervous diseases, a small, temporary personnel being on duty. 2. A rough draft is inclosed for a letter to be sent by your office to commanding officers of base hospitals regarding the transfer of suitable cases. 3. As it is practicable to care for only 30 patients at the present time, it is suggested that this letter be sent now only to Base Hospitals Nos. 15, 18, 23, 36. 4. As soon as the personnel for this hospital arrives, which will probably be about the middle of April, patients can be received up to its full capacity of 350, including 50 officers. At that time similar letters should be sent to all division surgeons as well as to commanding officers of all base hospitals. 5. It is requested that this office be furnished a copy of the letter in the form in which it is sent out. 1. Base Hospital No. 117 at La Fauche, a special hospital for functional nervous diseases (hysteria, neurasthenia, and the conditions commonly termed "shell shock") is ready to receive patients by transfer from base hospitals. As the full personnel for this hospital has not yet arrived in France, only a limited number of cases can be admitted 2. You are authorized to transfer to this hospital patients likely to profit by the special treatment Provided It is important not to send mental cases (including not only the insane and feeble mmded but patients in whom these conditions are suspected), epileptics, or cases of organic nervous diseases. Patients in whom there is doubt as to whether a nervous S^IT?^ or organic should be transferred to this hospital. Cases requiring surgical care should not be transferred. «+p„ Si'n +t>.iS0desire71-to ^P1"*^ the fact that this hospital is not intended to serve as a otK«£J hv I™/°.i °l n-erV,?US Cases v° >me territ°ry- It was established and will be SSorin^tnfSi K y /a+lned Personnel for active curative treatment with the object of af the front milltary dut^ as many cases as possible, especially acute neuroses developing 4. Until provisions for officers have been made only enlisted men can be received. IN THE AMERICAN EXPEDITIONARY FORCES 359 The early period of the hospital's service, from March 1 until the middle of June, 1918, is of minor interest. The total personnel consisted of 4 officers and 10 enlisted men.1 Admissions during March totaled 6; during April, 25: and during May, 51. The Base Hospital No. 117 unit arrived in La Fauche, France, June 16, 1918, and then the history of the hospital as an organization really began. When the American troops were sent to the front in great numbers early in the summer of 1918, the needs of the hospital greatly increased. In con- sequence, the hospital rapidly grew in capacity, finally having a total capacity of about 1,000 beds.1 The necessity for facilities other than those afforded by the main group of buildings soon became apparent. The first addition to the hospital was a country house (the "officers' chateau") in a wood about a quarter of a mile away.1 This was opened early in June as a ward for officer-patients who had recovered but who needed a short period of convalescence before return to duty. In this more restful milieu, away from the acute cases which filled the barracks-wards at the central group of buildings, these officers could get better hold of themselves and regain the composure and self-confidence which are so imperative for one again to assume responsibilities. Some deserted French barracks across the meadows about one-half mile from the hospital were taken over early in August, 1918, and converted into a convalescent camp.1 The capacity of this place was originally 125. Patients who had recovered from their symptoms were assigned there before being sent back to duty. Its routine consisted of daily calisthenics and drills. Any man whose symptoms developed again was returned to the hospital ward from which he came. The purpose of this place, like that of the "officers' chateau," was to give the men an opportunity to get hold of themselves and to fall back into military routine, before being returned to their organizations or assigned to duty elsewhere. The work was of such importance that at the time the armistice was signed the chief surgeon, A. E. F., had approved an increase in size to 1,000 beds. But the signing of the armistice put an end to further additions. The patients were all discharged from this hospital by January 12, 1919, and the hospital ceased to function then. The personnel and records were transferred elsewhere, and the hospital was abandoned on January 31, 1919. NURSING" Previous to the arrival of the unit, June 16, 1918, there had been no female nurses on duty at Base Hospital No. 117. The arrival of the chief nurse and her staff was followed shortly by the organization of systematic daily routine on the wards. Careful and orderly case records were kept, and the direction of the wards took on the same qualities that would be found in the best neuro- psychiatric hospitals in the United States. In order to familiarize the nursing personnel with the special clinical and therapeutic features of war neuroses, the medical director of Base Hospital No. 117 arranged a series of lectures by members of his staff. It was his purpose » The statements of fact appearing herein are based on a report of nursing at Base Hospital No. 117, made to the senior consultant in neuropsychiatry, A. E. F., by Chief Nurse Adele S. Poston, U. S. Army. Copy on file, Historical Division, S. O. O. 360 NEUROPSYCHIATRY to make plain to these nurses, who were unfamiliar with war neuroses, the nature and types of these disorders. The lectures included information regard- ing the general conception, classification, and clinical aspects of the war neuroses. Emphasis was placed upon the more common methods of treating these cases and the part of the nurse in their care and equipment. Nurses fresh from hospital experience with civilian cases were unfamiliar with the war neuroses and this plan enabled them to get an understanding quickly of the point of view toward war neuroses which had been developed by the American Expeditionary Forces medical personnel. The nursing done at Base Hospital No. 117 was not nursing as one usually conceives it. There were few cases requiring bedside care. Patients who entered in such a condition were usually up and about shortly. The first day or two of the patient's stay in the hospital were critical ones. It was important, above all, that he receive no false impression regarding the nature of his disa- bility and that those erroneous ideas of it which he held be corrected as soon as possible. The ward surgeon, of course, began to treat him, but it was also very essential to have the nursing personnel alert to the problem of overcoming his difficulties. The primary requirement for good nursing and successful treatment was not merely the individual attitude of nurse to patient or ward surgeon to patient, but the social atmosphere of the ward was all important. An atmosphere of cure was necessary in order successfully to cope with the patient's mental attitude. It was essential that the patient realize that his condition was amenable to treatment and that recovery of sufficient degree to return to duty was the customary outcome of the hospital's therapy. Patients were never allowed to settle into a too comfortable situation at the hospital, but were always kept aware of their responsibilities as soldiers. To maintain the "return-to-duty" attitude in each man on the ward was the primary nursing problem in caring for war neurotics. A severe ward routine was maintained. This consisted of regular hours for rising, military inspection by the commanding officer and staff each morning, prompt response to kitchen and other details, and other military assignments made by the medical officer of the ward. In some cases the details took the patients out as early as 4 a. m. Competition developed among the various wards, not only in the matter of decorations and good housekeeping, but in ward morale. The daily nursing routine of the ward was roughly as follows: As soon as the patients were out of bed, dressed, and had been to mess, if ambulatory, they were assigned to some form of employment. The assignments consisted, as mentioned before, of duties on the wards or in some other department of the hospital, or assignment to the workshop (occupational therapy hut), an impor- tant therapeutic center. The kind of work done by the patients was deter- mined, of course, by the ward surgeon's opinion of his condition. Work on the wards was directed by nurses and attendants and that in the shops by recon- struction aides. The more arduous physical tasks, such as road building, were overseen by enlisted personnel. The ratio of nurses to patients during the day was 3 to 35 and at night 1 to 3o. It was important not to over-nurse a neurosis case, but rather to encourage the patient to do everything he possibly could for himself. The IN THE AMERICAN EXPEDITIONARY FORCES 361 success of the nursing personnel, of course, depended upon the individual personality of the nurse. There was a great deal of difference between wards. So much depended upon the morale of the ward that it was not unusual for cases to be assigned to special wards because the staff felt that they could not "hold on to a tic or coarse tremor" on a certain ward, the general attitude of the patients on that ward being such as to discourage the presence of that type of hysterical symptoms. The type of nurse that accomplished most with war neurotics was one who was understanding, cheerful, impartial, and patient. It was necessary for her to strike a happy medium between severity and exces- sive sympathy. Elements of both kindness and firmness were necessary, but in the right proportions. It has been said that the major problem in caring for war neuroses was the morale of the ward. This was, indeed, a difficult thing to manage. For on the one hand it was the duty of the nurse to be sympathetic and to listen to the patients' complaints and yet at the same time to counteract their worries and anxieties with firmness and decision. The nurse had to realize that any too sympathetic attitude on her part, any questioning of the successful out- come of treatment, was liable to render the patient unfit for further military duty. Another duty of the nurse was her aid in giving the ward surgeon information of service in determining a diagnosis and military classification. Being with the patients on the wards so great a part of the day, the nurse had a better opportunity to study the patient than did the medical officer in charge of the ward. Indeed, the main problem, from the military standpoint, of these cases was their future army usefulness, and for the determination of this for the patients on her ward the nurse gave the ward surgeon his most valuable information. OCCUPATIONAL THERAPY « The importance of the occupational therapy that was carried on at the Base Hospital No. 117 at La Fauche lies in the fact that it was the first time that this form of treatment was put into effect in a military hospital under what must be considered forward-area conditions, as in the early days of June, 1918, this hospital was about 30 miles from the front line. The further signifi- cance of the workshop in this hospital is associated with the kinds of patients that were treated there. The character of the cases and the fact that an attempt was made to treat them with all the methods that were in vogue in the best- equipped hospital in the rear and in the home area formed the two striking features of the use of a form of therapy which up to that time had been reserved for hospitals at base ports or for those forming a part of hospital centers. In describing the methods that were carried out there, it must not be forgotten that Base Hospital No. 117 had a particular problem to solve in a medical way and that the necessity for a proper solution of this problem was never permitted to escape the minds and interests of the medical and nursing staff or the reconstruction aides who managed the workshop. • The statements of fact appearing herein are based on a report of occupational therapy at Base Hospital No. 117, A. E. F., by Chief Aide Meta Anderson. On file, Historical Division, S. G. O. 362 NEUROPSYCHIATRY In Base Hospital Xo. 117 the use of work as a curative agency sprang, in the first place, from the necessities of the hospital in the early phase of its development. Before the regular staff had arrived and before the equipment had been brought over from the United States, when the hospital was simply an old field hospital with a few wards and a few medical officers, it received about 50 cases of what were afterwards called anticipation neurosis. These were soldiers who had never seen active service and had never been anywhere near the front lines but had developed neuroses either in America before sailing or en route to France. They presented a very unfavorable type of case, as may well be imagined. They were not war neuroses in the real sense of the term, never having been exposed to the traumata of warfare, but they presented syniptomatically all the evidence of the most severe types of this condition. Treatment was extremely difficult because there was little either in make-up or temperament upon which to build. They represented as a whole the so- called neuropathic types of soldiers, the kind that were not at all adapted to the conditions of warfare. They would have been excluded from the Army if there had been in force the methods of elimination adopted later. The hospital was much handicapped on account of the lack of roads and pathways between the rows of huts. It had been built on a field, and the wet and rainy winter had left it in a condition that prevented traffic of almost any kind reaching it. The first essential, then, was to build a road through the hospital connecting with the well-made French road leading from the highway to the village of La Fauche. Patients of all sorts were put to work breaking up stone and carrying it to make a foundation for a macadam road. The use of the stone-breaking hammer and the carting of the stones to the roadbed employed these patients for a number of weeks until the road was completed some time in May. The road was a model in its way and showed its value when the hospital grew to a capacity of 1,200 beds. There were, of course, in this use of occupational therapy none of the refinements that were afterwards developed, and no attempt was made to emphasize the localization of therapeutic effort. It was occupational therapy in the broadest sense, and it had its effect on the patients simply because it gave them something to do and showed to those with paralysis and tremors that it was possible for them to carry out coordinated movements and to make use of their movements in the production of tangible results. From this very crude beginning the therapeutic workshop personnel, when they arrived for duty, found that the principle of work had already been established. The value to t^ie individual patient was difficult to establish, as with this class little in the way of permanent improvement could be expected. Some of them did show rather good effects, and it was interesting to note that very few of them objected to this rather monotonous and tiresome form of work. The breaking of stone gives a good deal of opportunity to train coordination, and the use of a certain amount of skill is necessary in order to prevent injury to the hand holding the stone to be broken. The evidence of effort could be measured by the increasing pile of material, and the fact that this work was supplying a very practical need of which the finished portion of the road was the witness, formed the essential elements upon which the efficacy of any work scheme in treatment is based. IN THE AMERICAN EXPEDITIONARY FORCES 363 It accentuated further the fact that the type and kind of work are not of im- portance, nor is the output, either in quantity or quality. The things that count, however, are the physiological and psychological features that result from effort to overcome resistance. The crude and primitive employment of breaking into small fragments a bit of stone in order to build a road may be taken as an ex- ample upon which to base the principles of a work therapy on a more extensive scale. The very primitiveness of the intruments used and the use of the product suggest that something inherently deep down in man's make-up is touched in this performance. Road making is an ancient calling, and the soldier responded to this as he perhaps might not have to a more intricate task. In its therapeutic effect, work is based upon very simple elements and these simple elements should always be thought of in planning its application to any individual. If the performance of breaking rock for the making of a road is examined, it will be found that certain necessary elements enter into it, and if a more intricate kind of work is studied, it, too, will be found to represent only modifications of these very primitive elements. If the problem of work therapy is studied as far as the neuroses are concerned, there appear certain requirements that must be met. These features are of two kinds: One is primarily mental or psychological; the other is physiological or mechanical. These features apply also to the two sorts of persons with war neuroses that benefit from work treat- ment. One needs it because there is some defect in coordination in a broad sense, and the other, because there is some psychological readjustment that demands attention. The exercise in coordination is found in the precision that is essential in using the hammer and in carrying out the necessary maneuvers in preparing and in handling the crude material. There is added to this an additional element that tends to produce precision of motion, and that is the danger of hurting the hand if the blow is not struck right. This makes for con- centration and attention and brings into play the use of the eye at first to a great extent, and then develops an automaticity of movement that overcomes the excessive muscular activity that is associated with tremors and ataxic conditions. The development of strength, that is, muscular power, comes with the practice necessary to perform a definite task. There is, too, a certain amount of noise associated with breaking stones which was found to be a benefit to such cases as complained of being sensitive to sounds. This had to be overcome, and it was often found that the sound of the hammer against the stone was the best method of training this type of case to the usual hospital noises. The evidence of the productivity of effort could be measured by the pile of stone that grew up by each patient. The evidence of utility was the road itself, which the patient saw grow under his eyes. The psychological phase of this kind of work was found in the proof to the patient that a defect in muscular power must be only an evanescent one, if a muscle group that is not acting right is capable of carrying out effectively so complicated a type of movement as handling a ham- mer. The evidence of sufficient muscular strength was there to be seen. The conviction was forced upon the patient, therefore, that his defect was not only a temporary one, but that it was easily curable by the simplest of procedure— that is, use. The emotionally overloaded state that so many of these patients were in could be easily lightened by giving them a muscular outlet or rather an 364 NEUROPSYCHIATRY effort outlet. Through their hands and fingers the emotional hypertension was sidetracked or exploded. In such routine work as this, automatic as it became afterwards in most instances, there was given to the patient an opportunity to face his own experiences,if he had any,or to face his present situation as it was interpreted to him by his medical officer. He could use his intelligence at the same time that he was carrying on his task. This feature of this kind of employment therapy was used effectually in the material that came to the hospital later, when the more definite type of war neuroses, fresh from the combat area, arrived. The emphasis on this simple type of wTork therapy is given because it underlies so much of the philosophy of reeducation and it opens the way for the proper appreciation of just what can be expected from treatment in the more exacting sorts of work that were afterwards used. What was lacking, of course, was the effect of the shop spirit as a whole, developed in a well organized shop, and the personal effect on the patient of skillful reconstruction aide or teacher. These elements can be supplied only by the presence of trained workers. In the month of June the arrival of the complete staff at La Fauche and the increase in the number of available beds brought the hospital face to face with the duty it had been organized to carry out. Numbers of patients began to come, many of them showing the most severe symptoms of the war neuroses, and many of them comparatively fresh from the active fighting areas. The therapeutic problem was focused upon the cure of these patients as promptly as possible, and the return to active duty of as high a proportion of them as possible. From early in June until the end of the war nearly 3,000 cases of war neurosis passed through the hospital. A large proportion of these took part in some kind of work in the workshop as part of their treatment. It was pos- sible to judge, therefore, with a fair approach to accuracy, just what this sort of work was able to do for them, and how necessary a part of the hospital for the neuroses is a workshop. The base hospital unit contained a group of reconstruction aides who soon took over the task of running the workshop. Thus the occupational therapy became an established part of the routine treatment of Base Hospital No. 117, of which ward surgeons might avail themselves. Owing to lack of room the workshop was set up at first in an unused part of a hut that had been a storeroom. A few tables were found, benches were made; and in a few hours patients had been assigned to the shop for treatment. Some weeks later a special Red Cross hut was furnished to the hospital and here the permanent quarters of the shop were established with increased equip- ment which was as satisfactory as could be expected in view of the difficulties in the way of transportation of such supplies. The evolution in work therapy from that of stone breaking and road build- ing to the craftsmanship that soon developed in the shop was a surprising and interesting thing. The shop, as a shop, began to have an influence on the patients in addition to the individual therapeutic effect of a specialized kind of work. It soon became a place where patients liked to be sent, and in its busy atmosphere the patients passed many hours during which they felt relief. During the whole period of the hospital's existence other types of work were IN THE AMERICAN EXPEDITIONARY FORCES 365 continued, not only as a therapeutic method, but because the hospital could not have functioned without them. The policing of the hospital in the military sense of the term, that is, cleaning up the wards, kitchens, roads, etc.,' was done by the patients; and the road was kept in repair by them. The chopping of wood and the cultivation of the farm land surrounding the hospital were always considered a part of the patient's duty. They were told that in so doing these things they were carrying out in a practical way the prescriptions of the physicians who were treating them. About 85 per cent of the total sick population of the hospital were always engaged in work of some kind, most of it being prescribed by ward surgeons. The workshop was considered a sort of specialized therapy directed to a more definite end, planned to treat some definite symptom or to meet some special indication, while the other work was regarded as a kind of therapeutic background underlying the whole scheme of curative effort, The physiological and psychological needs were met by the use of muscular effort in the produc- tion of tangible articles. The handling of the tools and the various movements of sawing, nailing, screwing, and hammering, and the finer and more coordinated movements of wood carving, metal work of various kinds, weaving, and tinning, as well as much more delicate and more emotionally inspired technique of painting, sketching, and printing, supplied the essential training that the paralysis, tremors, and other symptoms needed. In a sense all of these defects were due to an intricate psychological process in which disassociation of function was a predominant mechanism. The patient could not properly innervate a muscle group because there was a defect in the proper utilization of that group. The result was often exaggerated movements in which the inhibitive control and the habituated minimum of effort were lacking. In the same way tremors were primarily defects in motor control, as were purposeless and ataxic move- ments of the choreiform types. Motor reeducation, at first conscious and then automatically carried out, was required. The handling of tools awakened a dormant muscle control, shocked out of consciousness for the time being, and tended to restore the normal and habitual pathways long ago acquired. The familiar grip of a chisel, the friendly feel of a hammer or a saw, reestablished the proper integration and the proper tonal balance in antagonistic muscle groups. These, as symptoms, were acting without any psychological law or purpose. The product that was being worked at gave the necessary interest and permitted the proper concentration. The movements were allowed to fix themselves in the proper channels and the emotional block which stood in the way was for the time being lost sight of and the individual used his hands much in the way that was customary with him. The evidence that this was possible was before him, an evidence that no amount of persuasion or explanation alone could at times accomplish. It must not be forgotten that a large proportion of American soldiers had used tools and implements before in their civilian life, and the traditional pathways, so to speak, were present and only temporarily out of action as a result of their condition. No effort was made to select the kind of work from any other point of view than that of the immediate requirement in muscle defect that was present. 366 NEUROPSYCHIATRY The novelty of producing something that the patient had perchance never thought of doing himself lent an added interest to the carrying out of the job, but further than this no special effort was made to arouse any unusual interest in the thing itself. There was in this way a certain lack of rigidity in the shop that was one of its main features. Patients were sent there not to be amused or to pass the time away, but to be cured; often the therapy was directed to the local defect of the patient and the effort was planned for that symptom and for nothing else. To some of the patients the workshop was a place where they were exposed to a more invigorating influence than was present in the ward. This was particularly so in cases of depression and of apathy; and likewise in cases in which the prominent symptom was amnesia. In such cases the type of work and the product were of no importance whatever, nor was there a question of muscle training or education. Here the attempt was made to reassociate the separated bits of the patient's memory stream, and the stay in the shop was an extension of the effort of reassociation carried out in the medical treatment rooms by the several methods used in the hospital. The social element in the mingling with men and the doing of the bits of accus- tomed things, the talk and the noise of a shop, the familiar surroundings, all helped to that end. The automatic arousing of interest in the things that went on about him was an important element in the restoration of the patient to his normal condition. The facing of the situation, a method which implies that the patient is told not to forget, but to remember past experiences and thus learn to com- promise with them instead of dodging them, may be most successfully worked out if the patient is set to sketching or drawing the details of his experiences in the front lines, particularly those that preceded or accompanied the occasion when he was shocked or traumatized. A number of such instances were found among the patients at Base Hos- pital No. 117, and the therapeutic result was very encouraging. These patients soon learned that it was the turning of their emotionally laden memories of terrifying experiences into pictures and sketches that gave them a definite feeling of relief, and that there was nothing in this kind of exercise that was at all in opposition to the work therapy. It was only a different way of arriving at the same result that was sought each day in their interviews with the medical officers who treated them. Of course, these drawings had a definite meaning and significance and they needed no interpretative mechanism to render them clear and distinct. As a contrast are the artistic productions of the insane which are often symbolically expressed and which act so often as a screen to the real meaning. Whatever the psychical mechanism may be and whatever the place that emotion in relation to events may have, it is true that emotional states are relieved by muscular expression, if this expression is tangibly directed by the patient. In this truth lies undoubtedly one of the great therapeutic agencies in work. The need of the articles which a shop could turn out was so great in the neuropsychiatric hospitals of the American Expeditionary Forces and the tendency on the part of those benefiting by these products to judge the value IN THE AMERICAN EXPEDITIONARY FORCES 367 of the shop by its production, made it difficult to always keep in mind the fact that the occupational work was a means of treating patients rather than a means of turning out a factory product. The trained occupational worker, however, was able to organize the work in such a manner that activities and tasks were assigned to patients for their therapeutic value alone. It was the duty of the workers in charge of the shop to apply the pressure for production in such a way that it would be a therapeutic agent. It appears to be good evidence that the medical officers believed thoroughly in the efficacy of occupational therapy when they extended the experiment to a hospital in the forward area with all the conditions and limitations which that implies. Although the experiment lasted but two weeks, the medical director reported that because of the establishment of the workshop with its aid in the treatment of the men, he had been able to send back to duty some men who had been on the list to be sent to base hospitals for further treatment. REFERENCES (1) History of Base Hospital No. 117, A. E. F., by Maj. Frederick W. Parsons, M. C, com- manding officer, January 22, 1919. On file, Historical Division, S. G. O. (2) Memorandum for the chief surgeon, A. E. F., from the director of the division of psychiatry, February 9, 1918. Copy on file, Historical Division, S. G. O. (3) Letter from the director, division of psychiatry, to the chief surgeon, A. E. F., Febru- ary 26, 1928. Subject: Temporary personnel for Base Hospital No. 117. Copy on file, Historical Division, S. G. O. (4) Letter from the director of psychiatry to the chief surgeon, Advance Section, A. E. F., March 19, 1918. Subject: Transfer of patients to Base Hospital No. 117. Copy on file, Historical Division, S. G. O. CHAPTER V WAR NEUROSES AS A MEDICO-MILITARY PROBLEM War neuroses as a medico-military problem present three important as- pects for consideration, each of which necessitates some special notice. First, there is the military aspect of the problem. This concerns itself with the important fact that, in most instances, the soldier with a war neurosis is physically intact and very often in splendid physical condition. His symp- toms of disease are disturbances due to an intricate physical mechanism of defense based primarily on the primitive instinct of self-preservation. He ob- viously can not be classified as mentally unfit; no more can he be regarded as physically disabled, yet he is incapable in this state of acting the part of a soldier. The fact that at times he has only a limited power of volition over his disability removes him from the class of malingerers. As many of these patients have been good soldiers, judgment as to their potential ability for further military life must be suspended. Where to place such ah individual, and what to do with him, are questions that present themselves immediately. A soldier physically fit, mentally not affected, in every outward aspect a good fighting type, not a coward, often wanting to get back to the lines but held in the grip of a mechanism which negatives his soldierly impulses, presents a problem that again and again has mystified an officer who has at heart the best interests of the men under his command. Where the number of such cases increases to such an extent as to seriously threaten man power, then more than ever do the war neuroses assume the dignity of military importance. There- fore, no statement of the problem of the war neuroses can be made without considering from the very beginning its military significance. Many of the errors made in attempting to solve the problems of the war neuroses among soldiers might have been avoided if at all times the military point of view had been kept in mind. This point of view might be expressed as the effort toward returning such a patient to his former status as a soldier with the basic assump- tion that this is a thing possible to accomplish. The second aspect is purely clinical. A traumatic incident or a series of them acting on the human organism, causes that organism to respond function- ally by sets of abnormal reactions which, becoming fixed, stereotyped, and organized as symptoms, gives the picture of disease called war neurosis. Ob- viously, the thing to do is to classify these appearances into types, to designate them in some way, differentiate them from similar types seen in other condi- tions, and to devise some adequate means by which they can be treated and managed. The significant thing is that the war neuroses are essentially reac- tions to the varying incidents of war and that usually there is present a known set of etiologic factors. There is, further, a varying effect from the etiologic incident, and a therapeutic aim, which has as its chief incentive the return of the subject of war neurosis back to the conditions which, in the first instance, caused them to appear. 370 NEUROPSYCHIATRY The third phase of the statement of the problem is the definition of mecha- nism. For it is necessary to know something of the processes which activate the clinical syndrome, as the surface symptoms are more a result of this deeper- lying, but not readily understood process. These must first be appreciated before anything really tangible can be done for the victims of war neurosis. Incidentally, it is this emphasis upon the underlying mechanism and not on symptomatic expressions, this apparent indifference, in fact, to specific symp- tomatology, which differentiates war neurosis from almost every other clinical problem. MECHANISM AND CLINICAL EXPRESSIONS The conception of war neurosis as a defensive mechanism or as a part of a system of physiologic or bodily conservation may be approached with less difficulty if it is made clear just what is implied by these terms. It is neces- sary, also, to appreciate the fact that the defense meant here is not conscious, but automatic and probably altogether outside of volition. There exist in all living organisms, sets of factors which work toward saving them from destruction. There exists, likewise, in each important function of that organism, a mechanism for preventing the function from becoming ex- cessive and for preventing injury to it as a whole or to its respective elements. Living would be impossible if this did not exist. The protection may be purely automatic and adjustable to mechanical factors, as, for instance, the hyper- trophy of the heart. It may be chemical, as in the immunity defense. It may be various combinations and mixtures in which polyglandular activities come into play. It may be physiologic in respect to functional adjustments and physical when deeper and more intricate activities of consciousness are at work. The latter may be termed physiologic, but for convenience it is better to consider it a definite psychogenic mechanism. This principle of organic defense appears to be fundamental, touching on the innermost principles of living things. Naturally this principle has long been recognized and, by whatever term it has been designated, it has been an admitted fact to be considered always in the attempts to understand the phenomena of life. When the mechanism of defense, whatever its nature is, becomes inactive or less efficient, the living organism may be said to approach destruction, or, if it fails completely, the organism dies. It is possible, perhaps, to divide the defense mechanism into two classes, one acting to prevent the mechanical using up of the living tissue—the wear and tear of the machinery of life—the other acting to resist and modify the exogenous factors of a destructive kind to which every living thing is ceaselessly exposed. It is obvious that, even if no sharp line of demarkation can be said to separate these two, yet the adjustability of the defense shows, in either instance, a difference in the quality of promptness and speed with which it can be put into action. The mechanically incited defensive organization is apt to be slow and cum- bersome, taking place gradually according to the progress which the changed conditions of the mechanism itself necessitates, while the other must be capable of meeting quickly and decisively the immediacy of an oncoming event. Therefore, the latter type of defense must possess a certain power of selection or adaptability, because events or experiences are in their very nature dissimilar IN THE AMERICAN EXPEDITIONARY FORCES 371 and varied. This seems to be true of the neuroses in general, and of the war neuroses in particular. If they are studied from such point of view as this they show the characteristics of an exquisitely adjustable and often complicated piece of psychical machinery, adequately and, in a sense, personally fulfilling the purpose of protecting the individual against reexperiencing a series of destructive events to which he recently has been exposed. The analogy between the organically activated or sensitized probably goes no further than this, and the comparison has served its purpose if the fact has been made clear that the neuroses defensively considered are a part of a mechanism so fundamental for the preservation of life, as a physical phenomenon, that their existence can not well be doubted. There is nothing new in this conception. Freud long ago, and others before him, had seen in the neuroses something more than a collection of symptoms simulating organic diseases. Many students of the neuroses have been impressed with the apparent needless overemphasis of symptoms in face of slight degrees of possible determining factors, and they must have seen in this, or dimly felt at any rate, that some other incentive was at work than merely processes of reaction on the part of the organism. It was in this zone of overresponse that the explanation was to be found. With the appearance, in the early nineties, of Freud's Abwehr-Neurosen, the conception of the neuroses as defense mechanisms began to make slow headway among the neurologists. To many of them the rest of the Freudian psychology was not convincing. That conception, however, was so helpful and clarifying that it gained the support and belief of many to whom anything else coming from that school would not have been acceptable. The war neuroses have given the opportunity to test out this aspect of the Freudian psychology by furnishing thousands of cases in which a well known, and more or less constant, etiology was always to be found, and in which the resulting reactions might be studied, divorced completely from the cloud of etiologic sexual entanglements which so confuse the attempt to understand the peace neuroses. With this conception of the neuroses in mind there remains to study them as they show themselves clinically in varied disease pictures, and to attempt to understand what these pictures mean and how they came about. The test of the accuracy of this conception is to be found in the light that it can throw on origins and mechanisms and the use that can be made of it in appreciating why the thing has happened. A further test will be shown if the facility by which symptoms can be treated and the patient restored to the condition he was in before is increased. The war neuroses show themselves clinically in a variety of confusing types. Classification seems almost impossible because the same symptoms are represented by types that are obviously distinct. In a group of a hundred acute cases, for example, there will be many symptomatic types, such as frank hysterias, anxiety groups, pure sensory disassociation forms, individual over-reactions, concussion forms, episodal and transient mental states. 42705—29---25 372 NEUROPSYCHIATRY Two ways are open in facing so complex a clinical demonstration. I he first is to regard classification as of little consequence, but merely to find some few labels grossly descriptive of large groups and then to think of them as a whole and approach the therapeutic task by some mass form of treatment. The other way is to attempt a grouping, not based on clinical appearances alone, but on mechanism and the most immediate of the etiologic factors concerned. The former method has been adopted by most of the English and French neurologists. It has a certain advantage, chiefly in the avoidance of intimate study of individual types, and in supplying a ready means of avoiding difficult and controversial questions in regard to terminology. For example, it would be perfectly feasible to say that all war neuroses belong to one of two groups—neurasthenia or hysteria—implying that those showing primary fatigue elements belong to the former, those showing paralyses, sensory anomalies, convulsions, etc., to the latter. A third group might be made up of the concussion types. Some of the very best therapeutic results have been obtained by those to whom a further effort seemed useless. It should by no means be inferred because no effort is made to classify or carefully group cases, that the work is unworthy of praise. It seemed, however, in our own experience, that in the long run the more minutely the cases were studied the more effective the therapeutic methods became. The first and essential step was to disintegrate the mass into groups. The smaller groups made easier an intensive study of mechanisms forming, by comparison with other groups, a standard of measurement. Furthermore, the various groups which sprang up almost automatically as a result of this tendency to analyze the material, became centers about which clustered specially developed therapeutic methods, prognostic experiences, disability classification questions and characteristic sets of mechanisms. All of this lent to their study a surprisingly increased amount of interest. A common differ- ential diagnostic language grew up, at first limited to the staff at Base Hos- pital No. 117, which later spread to the forward areas and became, in a measure at any rate, the means by which neuropsychiatrists could communicate with others about their cases. Therefore, the attempt to classify or group the war neuroses seems to be justified by the use which was made of the grouping and by the impulse it gave to a closer scrutiny of individual cases as they fitted themselves into this or that class. It must be understood that a grouping of this kind is of value only if it fulfils the test of utility. If it does not, it deserves to be given up without further argument. That it did seem to stand this test, at least in the experience of Base Hospital No. 117, is the reason for its description here. The following groups were recognized as diagnostic entities at Base Hos- pital No. 117: 1, neurasthenia; 2, psychasthenia; 3, hypochondriasis; 4, hys- teria; 5, anxiety neurosis; 6, anticipation neurosis; 7, effort syndrome; 8, exhaustion; 9, timorousness or state of anxiety; 10, concussion—(a) syndrome, (6) neurosis; 11, gas—(a) syndrome, (b) neurosis; 12, malingering. In order that the mechanism of automatic defense may be set to work, the average soldier must undergo a series of events which tend to weaken what may be roughly and rather inexactly termed his ordinary self-control. By IN THE AMERICAN EXPEDITIONARY FORCES 373 this is meant that he must be put temporarily in a condition where his normal mechanism of inhibition is seriously weakened. By inhibition in this sense is meant the totality of his power to control the natural exhibition of the phe- nomena of fear, terror, nervousness, horror, etc. To this must be added the positive factor which strengthens the inhibitory impulses—the military quality which keeps alive and ever present in consciousness the recently acquired traditions and customs of a soldier. This is an element of morale. The mental process by which this is accomplished is suppression or repression. Inhibition is merely a larger and more physiologic way of expressing it. The important circumstances which tend to weaken this faculty are: Exhaustion; fatigue (the more chronic phase of exhaustion); and then, in succession, sleeplessness, lack of food or water, worry, responsibility, and incidents of a particular, horrifying or unaccustomed kind, loneliness, strange- ness, ill-treatment, etc. The list of these incidents might be endlessly multi- plied, but enough has been set down to indicate their character. The im- portance of incidents like those mentioned and others of a similar kind lies in the fact that they tend, each of them or in combination, to weaken the indi- vidual and to prepare the way for the reception of the final traumatic incident. They create in the soldier a favoring terrain; they further tend to develop in him a soil of receptivity, in which the neuroses, given the proper setting, can easily develop, become fixed and chronic. In opposition to these, the soldier, according to his peculiar personal make-up, struggles either forcibly or feebly, according to the measure to which he has surrendered himself to his career as a soldier. Back of all this lies, no doubt, many an emotionally-tinged impulse, leading straight back to his former nonmilitary existence. Among these may be mentioned the mass effect of discipline, or morale, the grip of idealism which led him to offer himself as a fighter, his experience with the Army as an antag- onist, the memory of killed friends or comrades, his love for his officers, the honor and reputation of his regiment; all of them or some of them are present in the make-up of every soldier. They form the counterflow against the on- rush of factors which center about the condition called fatigue or exhaustion. It is to be noted that in whatever stage of fatigue the soldier now happens to be, he is still in possession of consciousness and a knowledge of himself. In no way has he departed from the condition of a consciously controlled human being. No matter how feebly the inhibitory impulse is asserting itself, it is still to some degree active, and to that extent the soldier is aware of himself as a soldier, perfectly responsible and responsive to the demands of his position. It may be argued that in the extreme stages of fatigue, the condition of autom- atism may be reached, but even if this were so, its approach is too gradual to permit the neurosis structure instinctively fortified by the necessity of self- preservation, to take complete hold of him. At this stage there comes into play a very important and significant psychologic element in fatigue. This is a very unusual and possibly suddenly developed state of suggestibility. This extraordinary state of receptivity not only to outside things, but also to ideas, memories, and emotions of endogenous origin, form, perhaps, the most favoring circumstance for the development of the neurosis which at this moment is awaiting an opportunity to enmesh the individual in its defensive system. 374 NEUROPSYCHIATRY From this point on two sets of things may happen. Both of them have a precipitating effect and both tend to act in a positive and dynamic fashion equally effective in the production of the first and necessary phase of a war neurosis. One set of incidents has to do, in a certain proportion of cases, with the purely mechanical results of a shell explosion in the immediate neighbor- hood of the soldier by which he is shocked to a greater or less degree, so that there is momentary loss of consciousness, or it may extend over some hours, as the case may be. As a rule, he either falls or is thrown to the ground, or wan- ders about in a confused way, and immediately enters into a state in which conscious inhibition is for the time being totally in abeyance. The other set of incidents has to do, not with a mechanically working factor, but with the appearance on the scene of some sudden, unusual or terrifying experience which, emotionally overloaded, tends to produce exactly the same condition. The question of concussion, around which so much controversy has arisen, was not an important cause of dispute in the early years of the war. Even as late as 1917 and up to June, 1918, the most common etiologic factor in a case of war neurosis was that of shell explosion and the resulting concussion, but, as the fighting on the Western Front began to open up, the importance of this factor tended to lessen, though not enough to make it take a secondary place in the list of causative moments. In the earlier days of the war the explosive incident was often combined with a burial experience; that is, the soldier was not only thrown in the air but was covered with trench debris of all kinds, the two forming a twin traumatic incident which often had important conse- quences in the symptomatic sequence which followed. In the experience of the American Expeditionary Forces burial incidents were infrequent, a fact which decreased by so much the emotionally laden incident, which later became one of the most important of the fixation mechanisms. The very constant reports in a soldier's history, as given by himself, of a shell explosion experience led the British Expeditionary Force medical service to inquire more exactly into its accuracy. For a time shell shock could be diagnosed only if there was documental evidence by witness of a shell explo- sion near enough to a soldier to produce a concussion effect. In some instances the soldier's recollection of what happened was not supported by the reports that came from the front. How large the error finally turned out to be is not known, but that the doubt was sufficiently important to warrant the effort of investigation is of importance here. No attempt, as far as is known, was made in the American Expeditionary Forces to obtain exact statistics on this sub- ject, and all that can be relied on is the account given by the soldier as far as he could remember, and on the symptomatic sequence of events which he presented. These, as a rule, are unmistakable and can scarcely be imagined by the average soldier. Whatever may be the percentage of shell concussion experiences in cases of war neuroses, concussion still remains, in a large series of cases, the most important of the immediately working traumatic incidents. It was so important a factor that at one time concussion and its resultant neu- roses became from a percentage point of view a very important, perhaps, all things considered, the most important group in the entire classification. IN THE AMERICAN EXPEDITIONARY FORCES 375 Whatever the immediate factor may be, a period of unconsciousness, con- fusion, or a dazed condition appears to be one of the most significant and almost necessary preliminary states favoring the development of a neurosis. Such a condition offers to the protective mechanism the opportunity to work, unaffected by the ordinary control of the touch with reality, which is implied when consciousness remains undisturbed. It is true that a neurosis can de- velop without an intermediary state, but in these instances the mechanism at work is of a much slower and more complicated kind, leading to approximately the identical condition through endogenous processes largely activated by emotional hyperreactions, breaking through consciously acting repression. Considered as a process, and nothing else, evidently a state is reached by the soldier going into a neurosis when, for the time being, his conscious control is weakened or lost; at that period the instinctive reaction takes possession of him, and, uncontrolled by anything that he can at that moment interpose to counteract it, opens the way for the self-preservation instinct to obtain its fullest influence. At any rate, he remains under its control until one of two things happens: One leads back directly to the restoration of himself in his soldier capacity, in which instance no neurosis develops; the other, further and further away from his normal soldier self into something totally unlike and alien to the thing that he was, and then he begins to show one of the many types of the war neurosis. In the course of this process another important element in the mechanism comes into play, especially during the period of transportation to a hospital and in the early days of the soldier's stay there. The process by which the initial symptoms become either temporarily fixed or tend to further elaboration has been described by various terms, none of them very satisfying. What happens is that there is given an opportunity for more complete concentration and introspection, so that the individual removed from contact with his accus- tomed environment and away from the external influences of military discipline, easily surrenders himself to his neurosis, which automatically tends to further elaboration and intensification of symptoms. If this is not counteracted by intensive medical intervention skillfully planned, and, above all, promptly put into effect, the war-neurosis subject falls under the complete sway of his neurosis and the picture becomes wholly that of a well-developed and chronic type. That there is more at work in this stage than pure automatism and unconscious impulses must be admitted. That there gradually develops a fairly active desire not to get well, but to remain in the apparently safe grip of the neurosis instead of facing a return to conditions which led to its production, seems also evident. There are seen here also the beginnings of another process, that is, a struggle between the innate desire to return as a soldier and the automatic persistence of the preservative tendency previously alluded to. Cases left untreated, neglected, or contemptuously handled rapidly develop into this state, and as a result form the most difficult subjects for subsequent treatment. Before venturing to classify these cases, or rather to label them when grouped, it was necessary to redefine such terms as had been used before and to define the terms that were new. This implied in some instances a rather new, or at least a novel point of view, and a departure from some of the cherished 376 NEUROPSYCHIATRY landmarks of our old neurology. Two factors necessarily influenced all the conceptions in classification. One was that the war neuroses were essentially war-born conditions, and that etiologic incidents were all colored by this fact. The other was the conception of the defensive or protective character of the neuroses frequently referred to in this chapter. A classification which implies a theory may seem artificial and dogmatic and applicable only to a limited series of differing conditions. This and other objections more vital might be advanced. For example, this classification is confusing because three things are considered in the grouping and given unequal prominence: Etiologic trau- matic incidence; symtomatic expression; and what may appear at first sight to be an arbitrary selection of psychologic mechanisms. It appears necessary to point out these defects for the reason that classi- fications are so often the objects of needless controversy and too much emphasis is often placed on them—an emphasis by no means justified in this instance when the modest origin of these attempts is considered. If this attempt at grouping, then, served the purpose of usefulness, it might take its place as a pragmatic constituent of the work done at Base Hospital No. 117. There is a condition to which much that has been described above does not apply. It is mentioned here because it occurs very largely in the officer class, and may or may not have as an etiologic factor the acute traumatic incidents seen so frequently in the soldier types. The anxiety neurosis has a mechanism which is more complicated than the other neuroses and in which the defensive element is obscured by the presence of an intense and persistent conflict. This conflict has its origin in the necessity, which an officer at all times is conscious of, to conceal from the men under him and from himself too, every evidence of emotional stress he may be passing through. This he does by the use of repres- sion. The repressed material of his experiences, notably those in which emo- tional loading is strongly present, activate the conflict between his desire to maintain and follow the tradition and training of an officer and the strongly intrenched but completely unacknowledged instinct to save himself. The essential difference between his reaction to the sequence of traumatizing events, just described, and that existing in the case of the soldier, lies chiefly in the fact that there is an ethical element at work which intensifies the conflict and causes him, in many instances, a great degree of mental distress, suffering, and self-accusation. This produces the state of anxiousness which is sometimes the chief and often the only evidence, externally at least, of his neurosis. It is not to be inferred from this that only the officer class can be afflicted with this type of neurosis. Any soldier, especially one of some education or in whom there exists a well-developed ethical sense capable of introspective attention, may show this type of neurosis. The anxiety type of neurosis presents a much more highly developed, Pure, psychologic defense than the other forms. Its relation to physical factors is often much more difficult to demonstrate. In fact, it is often found devel- oping after a rather long sequence of physically acting traumas showing mark- edly insidious progress and evidently originating from insignificant and not easily demonstrable beginnings. Its defensive character is chiefly in the fact that it renders the officer incapable of positive action, reducing him to a state IN THE AMERICAN EXPEDITIONARY FORCES 377 of neutrality. In this condition he becomes, one might almost say, the pris- oner of his conflict and remains inert, without energy, without initiative, con- trolled almost wholly by the emotional stress engendered by the conflict going on within him. He is frequently unaware that such a conflict is present, the repressing mechanism working automatically to keep out of his waking con- sciousness all evidence of a thing of this sort. What he is aware of, and that very acutely, is his own mental distress and the physical expression of the emotional strain he is under. These external signs of fear, worry, etc., are dissociated in his own consciousness from the sources to which they owe their origin, and he is thus as much a puzzle and mystery to himself as he is often to the neurologist under whose care he may happen to be. Several bits of qualification must be added to much of what has been written in this attempt to state the clinical problem of the neurosis from the point of view of its underlying mechanisms. It is necessary to appreciate the fact that in trying to trace the sequence of happenings which a soldier passes through on his way to a neurosis an average of such experiences was recorded, something that might be accepted as a plan of a physiologic experi- ment if the soldier could be made into a laboratory problem. There is no thought of making this entirely applicable to every case of war neuroses, or, in fact, is it certain that anyone ever passes through just the things that were described. Of all things in the world the war neurosis lends itself least to dogmatic statements, but what has been set down appears to be a reasonable explanation based on an analysis of many hundreds of cases. The expression "his neurosis" has been used frequently in this chapter. The purpose of this was to hint at the very personal character of these defense systems, and any serious study of such cases will show the interesting fact that to each war neurosis subject the symptoms do become personalized, unique, and individual. Thus in attempting to describe them expressions hav- ing the touch of ownership appear to be warranted. The clinical problem of war neuroses, then, may be summarized in some such way as this: There is a set of determining factors sensitizing the individual to one of or the set of direct causative incidents. These, as a whole, are capable of being set down in the order of their assumed importance. The immediately determining factor has a definite traumatic quality, either mechanical, as in the case of shell explosions, or emotionally directive, as in the case of unusual or terrifying experiences. A certain degree of initial disturbance of conscious- ness appears to be either necessary or a very favoring circumstance for the development of the neurosis structure itself. The disturbance may be any- thing from a slightly dazed condition, associated with some degree of con- fusion, to complete loss of consciousness lasting several hours. Associated with the disturbance of consciousness there develops some degree of automa- tism, or a stage in which conscious inhibition is so lost or weakened that the individual becomes a primitive organism reacting to the primitive processes of instincts. In this state the instinct of self-preservation asserts itself. Instead of instinctive flight or concealment taking place, a manifestly impossible con- dition in most instances, there develops the manifestation of various forms of the neuroses which replace them. These take such form as may be modified 378 NEUROPSYCHIATRY by the peculiar circumstances in which the individual finds himself at that time and also according to his make-up. From the temporary fixation of symptoms the rest of the clinical manifestations of the neurosis tend to unroll themselves, influenced by the peculiar mechanism which was then set in action. The neurosis tends to elaborate, become fixed and stereotyped after the initial stage according to the individual experience of the soldier, his surroundings, the kind of hospital he may be in, the character of his medical treatment, the attitude of his nurses and doctors toward him, and other circumstances of a similar kind. At first the neurosis is entirely automatic, the product of a mechanism entirely out of the control of the individual. Later, there enters into the problem some measure of responsibility for the further maintenance of the neuroses. At this place in its development a cure must be effected, if the patient is to be restored to his former condition. As was previously stated, the attempt to classify such cases as came to Base Hospital No. 117—and their number amounted to 3,000—was made for the purpose of so grouping them that more exact study would be possible, and that the mechanism underlying their production could be more effectively inquired into preparatory to a more direct method of treating them. It was apparent almost from the start that there were cases that semed to corre- spond almost exactly to types met with in civilian neuroses and to these the terms commonly used there could be applied. What appeared to be necessary, however, was a new definition to meet the conditions which the stress and strain of war implied so that the designa- tion, war neuroses, might be justified. NEURASTHENIA There was a group of cases in which the chief evidence of disease was a manifest and intense condition of fatigue, the chief neurosis element of which was a marked subjective sensation of tiredness. Fatigue was an essential accompaniment of all muscular and mental effort, as it was of all special sense activities. In such cases it was possible to demonstrate the presence of a fatigue reaction, which can briefly be described as an overresponse to a minimal stimulus, or rather an overeffect to the resultant of a minimal stimulus. To such cases it seemed that the designation neurasthenia might be given. In this group, a very small one by the way, all the presenting symptoms were interpreted and analyzed as depending on the factor of fatigue, and this factor was amplified further by its subjective incidence. In other words, the primary experience was carried over into the neuroses as a fixed and powerfully acting preventive toward any moderate muscular or mental effort. The emotional background secondarily produced was that of a state of simple depression, with a con- comitant fact of irritability. The protective quality of a state such as this is clearly evident and needs no further emphasis. Such patients presented all the symptomatic evidences of a typical neurasthenic of civilian life, with this difference—they did not show the physical appearances so commonly met with in the usual neurasthenic types. When they did it was certain they were not war neuroses alone, but the development of war neuroses on conditions that had existed prior to enlistment. IN THE AMERICAN EXPEDITIONARY FORCES 379 Two types could then be recognized: (1) A neurasthenia differing in no impor- tant way from the neurasthenia of civil life, and (2) an acute, acquired neuras- thenia—that is, a definite clinical variety of war neurosis. The distinction became the more obvious when it was noted that the acute cases presented few, if any, of the organic characteristics of the old neurasthenia, very few of the vasomotor disturbances, such as sleeplessness and cardiac irritability. Some of the extreme cases eventually did, but as a rule the evidence of neuras- thenia was centered rather about the subjective sensation and its controlling power on the patient's activities than on the physical reaction due to disturb- ances of an internal kind. What appeared to determine the presence of the neurasthenic type of war neurosis was the effect of a previous state of exhaustion, an acute experience which led to its further elaboration as a neurosis. That out of this could and did develop the typical neurasthenia was likewise true. Of all types of neuroses, perhaps the neurasthenia cases gave the poorest prognosis and resisted treat- ment most stubbornly. The absence of previous symptoms of neurasthenia in many of these cases, except the congenital type, led to the attempt to place them in a special class and very quickly they came to be recognized as charac- teristic but not common clinical pictures. Another part of this picture was the fact that there was nothing mysterious to the patient about his symptoms, their cause or their significance. No conflict of any kind seemed to develop. Its mechanism was automatic but wholly and completely conscious. A typical case follows: A., L. J., pvt., Co. L., 30th Inf. Born in .Massachusetts; age, 20 years; race, white; date of admission, August 8, 1918; source, Base Hospital No. 13; occupation, worked in woolen mill, common laborer; alcohol, moderate. Family history: Mother dead—growth on neck; father, alcoholic, quick tempered. Schooling, first year high school. Always in good health; enlisted in August, 1917, at Syracuse until October, Camp Greene, N. C, until March, 1918; did well in camp. (Started to get dizzy when in a mill, gave it up and worked on farm, but it did not do any good.) Venereal disease denied. History of present condition: Arrived in France, in April, 1918; to the front in May, 1918. Chateau Thierry, June 6; not under shell fire until July 14, and was able to carry on for about 11 days afterwards. Shells at first only made him a little nervous, but he kept constantly getting worse. Had been working pretty hard, and states had little to eat and drink. Finally while "digging in" amidst heavy barrage lost consciousness and remembers "coming to" in hospital about five hours later; here felt weak, dizzy, very shaky, and had pains in eyes. Subjective symptoms: Condition on admission, heavy headache all the time; gets dizzy; sleeps well, eats well; "gets winded quick." "Not very strong." Not much energy- neurasthenic type? Objective symptoms: Condition on admission, body clean; temperature and pulse rate normal; weight, normal, 144; present, 144. General condition—good; left ear not as good as right; three scars, pale, over left shoulder. Glandular system: Very slight enlargement of thyroid. Heart: No murmurs. Station good; tremors very slight. Report of disability board, August 20, 1918: Disability did not exist prior to entry into service. Nature of duty recommended—duty in the line of communications. Disposition: Duty, Class C-2, August 22, 191S. Final diagnosis: Psychoneurosis, neurasthenia, L. O. D. Condition on completion of case: Improved. Postwar history: In 1919-20, he was working at his old job and was getting along very well. The work was done in a large airy room and he found it very agreeable. It was the same work he did before the war. 380 NEUROPSYCHIATRY In August, 1924, he wrote: "Since I came home, the firm I worked before the service, they have promoted me to examiner on cloth, which was not my position before entering the service. I feel nervous at times, but not as much as when I returned. I think that probably my work does it as I am responsible for everything that goes through my hands. N o diseases or operations since discharge, or before entering service. Weight 170 pounds when I returned home; after three months reduced to 120 pounds. Stopped work for a while and felt better; weight now is 165 pounds and feeling pretty good." PSYCHASTHENIA The second group of cases which early differentiated themselves were those in which doubt was a prominent symptom. In such instances there was little evidence of fatigue, or not at all after a short period of rest, or indeed, without it. Such patients were capable of considerable mental and physical effort, but they complained chiefly of doubt, hesitation, and an almost complete incapacity of choice. To this group, not a very large one, the term psychas- thenia was given, chiefly because the symptoms corresponded accurately to the psychastenic condition of civilian neuroses. Here two types began to show themselves; one, the typical psychasthenia of other days—the congenital scrupulous type, the exaggerator of small differences, the individual incapable of making decisions owing to the conflict of differences; fear as a consequence of choice preventing decision. The type is too well known to warrant any further description in this place. The other was an acquired state similar to this without a previous history of this kind. If the condition of psychasthenia is reduced to its simplest expression, incapacity of the function of choice appears to be its primary departure from the normal. It is the fear of the consequence of choice through • experience or through the anticipation of what the choice may bring about, that creates the static condition which is the chief characteristic of the psychasthenic's attitude toward events which tend to focus on him. The term in Janet's sense seems to have too broad an application for the type which develops among the war neuroses. Here it is seen more as an evidence of the peculiar twist which the neurosis in its defensive adaptation causes. Perhaps, as is often the case, the type that the neurosis finally develops into depends on some congenital peculiarity of the individual or on some expe- riences in his past life, which are awakened and are set again into activity by the more recent emotionally-tinged traumatic incidents. An attempt to con- nect up the acute psychasthenic symptoms in war neuroses with events long past and forgotten with the purpose of proving this point was not successful. A case history of a psychasthenic patient is the following: D. E. R., pvt., Co. D, 101 Ammunition Train, 26th Div. Born in Maine; age, 25; race, white; date of admission, April 6, 1918, transferred from Base Hospital No. 15; motor- man; alcohol, moderate. Family history: Father 45, living and well, moderately alcoholic; patient's grandmother 85, had some sort of nervous trouble; uncle, suicide by hanging at 55; father had one attack of nervous trouble at 35; good recovery; nature of trouble not known, not nervous now. Left school at 16—2 years in high school, good progress; five years motor- man at Lynn, Mass.; had rheumatism at 23, back and legs; pretty healthy; was struck by lightning (or rather schoolhouse was) at 12; scared of thunderstorm since; pretty even tempered; sociable; no especial fears. Was overcome with heat, July, 1917, just after being called out in Massachusetts; sick 2 weeks; no loss of consciousness. Always easily startled, especially after a hard stretch of work—"jumpy." Always dreamed scary dreams, mostly of fire. IN THE AMERICAN EXPEDITIONARY FORCES 381 History of present condition: Enlisted May, 1917; had heat prostration in July (see personal history); came to France October, 1917; well up to present illness and efficient; present illness, went up the line with the 26th Division the beginning of February and carried on normally till March 23 at Soissons; nerves all right till then. Town wras shelled and shells were striking all around; one fell about 50 yards away; patient was not knocked down; he was scared and commenced to shake all over; after this, appetite and sleep poor; patient was jumpy and trembling and weak. He was accidentally hit on the head with a rifle about 10 days before and after this shelling his head ached on the hit (left) side of his head; head- ache better now; easily startled, any noise makes him jump; spontaneous, jumpy movements came on a day or so later, movements not localized. No change; has been at Base Hospital No. 15 three days; condition about the same. No work from March 23 (date of shelling) up to admission to Base Hospital No. 15. Subjective symptoms: 1. "Jumping"—"any noise startles me and makes me jump." 2. Not much sleep (average 4 to 5 hours). Dreams much of bombardments (one recurring dream especially, being bombarded in a cellar, patient not hit). Difficulty is in getting to sleep and then wakes with a start. 3. Legs getting weak from lack of exercise. 4. Occa- sional headaches (chiefly left-sided). Cooperates well in examination, talks in rather quick jerky way. Jumps with small noises. No mood disturbance or outstanding anxiety features. Objective symptoms: Big chap, 6 feet 2, weight 250 pounds at enlistment, 185 pounds now. Well developed and nourished. Mucous membranes fair color. He has several dime-sized skin infections on his face and some hair follicle pimples over his body. Special senses normal. There are frequent, usually several per mintue, involuntary twitching move- ments, small excursion, more marked in neck and shoulder muscles, occasionally in face and legs. Bilateral and tielike. Glands not enlarged; throat clear. Heart not enlarged, sounds normal, pulse 76 regular. Lungs normal, genito-urinary system normal. Pupils active, no especial tremor. Deep reflexes hyperactive. No Babinski. Gait, station, sensation normal. Diagnosis on transfer card: Psychoneurosis, psychasthenia. Progress: April 11, patient is easily disturbed by whistling and chimes; get trembling and jerky; excited last night by excitement of another patient, made threats to "get the ward men." Calmed down and slept fairly. April 22, loud-mouthed and easily startled. Works fitfully, but gets a fair amount done. May 11, 1918, returned to labor duty, class C, to-day. On the whole, in practically same state as on admission. Works fairly and will be useful. May get a grip on himself later on, but it is doubtful. Doubtful stuff for the front in any case. Report of disability board, May 10, 1918: Unfit for full duty because of psychoneurosis, psychasthenia. Disability did not exist prior to enlistment and did not originate in the line of duty. Nature of duty recommended: That he be placed in class C and used for general labor. Condition, unimproved. On September 22, 1919, he wrote that he was not working at former employment. Unable to do anything at present. Feels "pretty rocky." Present condition poor. On July 24, 1924, he wrote that he was sick in bed and under a doctor's care and receiving compensation from the Government. He had not worked since his discharge. HYPOCHONDRIASIS The next group is the third of the consciously produced neuroses, and to this the term hypochondriasis was given because it so exactly fulfilled the con- dition on which such a diagnosis would have been made in neuroses in civil practice. This group was also a small one, having the smallest percentage of incidence of any of the groups. Indeed, it is questionable whether a pure hypochondriasis can develop de novo from war experiences alone. In almost all cases in which this diagnosis was made a previous history of this condition could be discovered. Hypochondriasis is perhaps the most perfect type of a 382 NEUROPSYCHIATRY defensive neurosis because it touches a fundamental and primitive tendency found among all peoples; that is, the automatic release from duty, responsi- bility, and work in the presence of disability or sickness. The mechanism consists of two intimately related things. First, there is evidently present in these patients an abnormally low level to receptive impres- sions from the external world; that is, the skin and special sense mechanisms are capable of transmitting a greater bulk and variety of sensory impressions and having them perceived as impressions, than is found among normal indi- viduals. This lowering of the sensory level is also found in the receptive mechanism having to do with sensations arising from within the body, probably through the autonomic system. This intensification of the sensory margin has its chief effect in developing an increased capacity of attention—the hypo- chondriacal individual has not only a capacity to become aware of a flood of unusual and strange sensations arising externally and internally, but also has his capacity of attention sharpened to their perception when received. By that very sharpening of attention the facility of final interpretation of such sensations is increased. He thus becomes aware of a constant inrush of sensory impres- sions which tend more and more to occupy his field of consciousness. This mass of wrongly interpreted and wholly new and strange sensations is the crude material out of which the neurosis is fabricated. This fabrication takes on the picture of disease which becomes more and more definitely personalized as the process goes on. Naturally the experience with, or knowledge of, disease, together with the suggestions obtained from observation, rumor, and surround- ings, influences the variety and dramatic quality of the particular disease in question. The collection of ideas concerning disease tends to occupy more and more the patient's field of active consciousness so that he lives practically con- trolled by them. When he responds to a constellation of this kind more than he can possibly do to the world about him, when his mental life spins eternally about this or that picture of disease, which at all times fills his field of conscious- ness, the complete picture of hypochondriasis may be said to have developed. This completed picture should be sharply differentiated from what may be called a hypochondriacal attitude. This latter is very common among soldiers, but only as a temporary state which quickly disappears with rest and improve- ment. The true case of hypochondriasis shows no change under either condition and apparently is uninfluenced by treatment of any kind. It has been said that true hypochondriasis is rarely found as an acute or acquired type of the war neuroses. This is in a measure true, but it is quite possible for a clinical state closely resembling this to develop on the foundation of a slight and often insignificant or passing trauma or condition, insignificant in proportion to the more dramatic kinds of traumas so frequently mentioned in this chapter. For example, it was sometimes found that a soldier who had been operated on previously for appendicitis, under the influence of a series of traumatizing events, would develop a neurosis of this hypochondriacal type which appeared to center about the operation or the scar remaining as an evidence of it. Previ- ous to such an experience the whole appendicitis incident had been completely forgotten, but suddenly there developed a complete picture of postoperative adhesions, pains, and a widespread area of scar tenderness. From such a IN THE AMERICAN EXPEDITIONARY FORCES 383 beginning the whole picture tended to spread, involving neighboring organs, until the patient was entirely in the grip of an everspreading collection of disease ideas. It is of some significance that in such cases the therapeutic outlook was more encouraging than in the type previously mentioned. It is necessary to emphasize once more that the hypochondriacal tendency is often found entirely dissociated from the true neurosis, but even in its partly developed form, the essential mechanism as described could easily be demon- strated; that is, the increased capacity for automatic attention and the lowered threshold of sensory receptivity. In hypochondriasis, again, the neurosis is consciously determined and thus belongs to the group of which neurasthenia and psychasthenia are members. These three, then, form the first subdivision, the consciously originating neuroses. This does not at all imply that they are either wilfully or designedly produced, but that they play themselves out in the upper zones of consciousness and awareness. A case history of this type is the following: D., H., pvt., Co. K, 109 Inf. Born, Pennsylvania; age, 25; race, white; date of admis- sion, August 11, 1918; service, 4 months; team driver, shipyard. Alcohol, total abstainer. Family history: Mother died, cancer of breast; father living and well; 1 brother, stomach trouble, constipation; maternal aunt, nervous. Previous personal history: Indigestion (chronic constipation), History of present condition: Inducted, March 10; France, April 2; front, July 15; left, July 16. "We were getting ready to make a counterattack. I asked for a drink of water, they handed me a canteen; as I made to get it I fell flat. We were in woods, shells flying pretty thick." One burst about 20 feet away, one hit apple tree and knocked patient down, and dirt flew all around; patient up all right as runner for captain. Another man tells of shell exploding right in back of him when he fainted away. This observer says patient was all blue and they thought him dead. Taken to regimental infirmary, then evacuation 6— to Base Hospital No. 30—here. Subjective symptoms evacuation hospital: 1. Pains in head, also across back and in legs; 2, patient was shaky, legs and arms; 3, sleepless. Now: 1, stomach, gas, belching; constipation; 2, head; 3, can't lie on broad of back or left side because of smothering or punching of heart; 4, shortness of breath at night; 5, spells of vomiting; patient had stomach trouble previous to war—probably a severe case of concussion, delayed several hours before overcoming. C, of patient's platoon, says company hadn't eaten for 14 days, been under severe bombardment, patient asked for drink, shell landed 20 feet away, patient "keeled over," French Red Cross man fixed him up and C. took him to first-aid station, 100 yards away. Patient wouldn't let himself be carried, was in a pretty bad fix; "shell might have scared him; he just fainted." Objective symptoms: Ambulatory. Weight, normal, 133; present, 128. General con- dition, good; skin and mucous membranes, healthy; blood pressure, 110. Heart: Loud systolic murmur over base. Diagnosis: Hypochondriasis. Report of disability board, September 26, 1918: Dis- ability did not exist prior to entry into service. L. O. D. Nature of duty recommended: Return to ordinary duty. Classification A. Condition: Improved. On December 8, 1919, patient reported that since returning from France he had worked for two months but could not keep it up. Not working at present. Has pains in back and chest. Had not put any claim in for disability as yet. A letter received on July 31, 1924, indicated that this man had been receiving vocational training ($100 a month) from Decem- ber, 1921, and studying to be a stationary engineer. In January, 1921, he was operated upon for gastric ulcer at the Philadelphia Navy Yard. He said that he was not feeling very well. 384 NEUROPSYCHIATRY HYSTERIA By far the most striking of all the war neuroses, clinically, at any rate, is hysteria, as anxiety neurosis is the most subtle and intangible. These two are taken together, in so far as etiology and primary reaction are concerned, because both represent unconsciously produced neuroses, and both are types of a dis- sociation process. The one shows itself by dissociation of motor, sensory, special sense functions, and in some instances of the function of memory; the other, by purely psychical forms. The one—hysteria—showing no evidence of conflict; the other—anxiety neurosis—arising out of a conflict with a strong moral or ethical component. Hysteria was regarded as being in a sense a type of cortical dissociation, very often almost anatomic in its demonstration; the other has to do with much deeper and more illusive qualities of conscious- ness touching more closely on the factors concerned in personality. Another striking difference lies in the reaction to therapy. Hysteria was the most easily cured of all the neuroses, anxiety the most difficult. A curious and interesting point of difference was found in the fact that in hysteria there was little relation to pre-war conditions or experiences. In the anxiety neurosis analysis often led back directly to pre-war conflicts in which the same or similar elements could be demonstrated. They did not necessarily give rise to a neu- rosis then because the repressive mechanism sufficed to tide the patient over, but it was often easy to appreciate how definitely the stage was set, by virtue of the patient's former experience with conflict processes of less intense form. Hysteria, then, is to be considered as a type of war neurosis caused by the mechanism of dissociation, by which functional activity in either its motor, sensory, or physical capacity is blocked from consciousness and conscious con- trol. If an organ of special sense is involved the dissociation process tends to separate out one or more of its coordinating functions from the control of the complete mechanism. The part, or parts, in either instance divorced from consciousness can maintain itself in one of three ways. It can cease to act at all; it can act abnormally, that is, in a qualitative sense; or it can hyperact, that is, in a quantitative sense. In other words, there can be paralysis, unco- ordinated or perverse forms of action or convulsivelike movement. This same thing is found naturally in the sensory and special sense fields. The dis- sociation process is most frequently set in activity by a somewhat sudden emo- tional or physical shock and, if in the latter instance, the precipitating factor is most often the effect of a shell explosion or some type of trauma associated with some degree of violence. The type of reaction in hysteria in respect to both localization and function bears a definite relation to the local effect of the trauma. Blindness is often the result of the acute blinding sensation of an explosion, deafness due to momentary loss of hearing. For the same reason, sensory disturbances are due to numbing of areas of skin following disturbance of atmospheric pressure in the zone of an exploding shell, etc. The emotional precipitating factors have the same curious localizing tendency, with the excep- tion that here suggestion or imitation seem to show a more active influence. It is necessary to point out that in hysteria, particularly the acutely established types, is shown less clearly the characteristic protective defense than in some other types of neuroses, and it must be admitted th*t in some instances it is IN THE AMERICAN EXPEDITIONARY FORCES 385 only after the primary disturbance has manifested itself, whatever its nature may be, that the defensive mechanism is set to work and then chiefly in the direction of fixing it and making it more permanent. A sudden shock having a positive degree of physical incidence may throw out of activity a certain function or a part of it, certainly too rapidly for any kind of physical mechanism to be set going. In such instances the instinc- tive action of self-preservation arises later, automatically making that loss of function fixed, thus establishing it as a neurosis of the war type. Such a conception of hysteria is a departure from the usual thinking on this subject and naturally differs essentially from the theory of Babinski so much in vogue in the literature on war neuroses, but it seems impossible to escape from some notion of this sort, in the face of the almost instant appear- ance of symptoms after an explosion incident and the tendency to fixation and elaboration of the symptoms following the slow return of consciousness. What- ever role suggestion plays, it surely can be regarded as only part of a much more complicated mechanism and not the only factor at work. Among the most interesting phases of hysteria in its war neurosis coloring are the amnesias, which may be regarded as pure types of dissociation in the purely psychical sphere, and they obey apparently the same sequential rule as the cruder forms of response. The single and most reliable diagnostic evidence of hysteria is found in the presence of the dissociation process. 'When the symptom is capable of being described as due to that, and if it meets the necessary require- ments of a hysterical symptom, not necessary to mention here, the diagnosis of one of the many forms of hysteria found in the war neuroses can be made. Another characteristic of a hysterical symptom is that in its disappearance it may pass through any one or a combination of the three forms which have been described. Complete paralysis often recovering through the phases of tremors, exaggerated movements, etc., aphonias recovering through the phase of stammering, etc. The synthesis with consciousness very often is not direct and immediate, but indirect and incomplete. Two cases of this group are the following. 0. C, sgt. Co. F., 362 Inf. Born, Illinois; age, 25; race, white; date of admission, September 10, 1918; source Base Hospital No. 75; farmer; alcohol, moderate. Family history: Father died, Bright's. Mother, stomach trouble; 1 sister, nervous breakdown, 7 years ago. Influenza, 1917. Pyemia. Always nervous. History of present condition: Drafted September, 1917. Overseas, July 5, 1918. Has never been to front. April, 1918, while in hospital for influenza had hysterical attacks occurring 3 to 4 a day for 3 to 4 days. No more attacks until rifle practice, after a few strenuous days again developed and then after coming to France during hand grenade prac- tice a man in patient's platoon pulled the pin from grenade but became too excited to throw it and let it drop, he warned his men and they managed to get away unhurt. But he became much excited and that night after taps had an attack in which his whole body shook, was nervous and had queer numb sensations over body, profuse perspiration, was not uncon- scious, no tongue biting, no incontinence, did not fall. Subjective symptoms: Complains of pain around heart, trembling of entire body. Soldiers call him "shakes".) Poor stuff. Hysteria. Class C. Objective symptoms: Ambulatory. General condition, good; skin and mucous mem- branes, healthy. 386 NEUROPSYCHIATRY Diagnosis: Psychoneurosis, hysteria. Report of disability board, October 4, 1918: Disability did not exist prior to entry into service. Disability is in line of duty. Nature of duty recommended: Labor in the line of communication. Disposition: Class C—1. Final diagnosis: Psychoneurosis, hysteria. On December 13, 1919, he wrote that he had improved wonderfully in the last three weeks. Not working as yet, as he was discharged only a short time ago, but plans to do so in a short time. Is to be given a chance at his old work. Feeling quite well and has had a very good rest. Just came back from farm where he got back into shape. In the summer of 1924, he wrote that he was still nervous in time of excitement or exertion, but otherwise, normal except for "pains around the heart at times." He was working as an indexer of crankshafts and making 50 cents per hour. He received compensation of $20 a month for eight months. This was cut to $8 for three months. B., F. E., corpl., Co. I, 102 Inf. Age, 19 years; race, white; born, Connecticut; date of admission, June 15, 1918; transferred from Base Hospital No. 1. Accountant; alcohol, moderate. Family history: Father, 42, gets tired very easily; very nervous temperament; excitable; two paternal aunts nervous; one has St.Vitus's dance; another was paralyzed in an arm and again in a leg—all cleared up. Previous personal history: Left school, 17; had two years at high school and two years at agricultural school; pneumonia, twice; grip, likely; last attack, 1916; followed by 3 weeks of pain in back, similar to present; no neuropathic history; variable mood. History of present disease: Came to France October, 1917. Was not up in Soissons in February. Was in hospital with pains in right abdomen. (Old appendix, 1915, operation.) Went up to Toul with 26th Division, April 1. "Not at all nervous." Was on duty until April 21; all right except for diarrhea, which was getting worse (began in January). Was sent down from the line because of "exhaustion"—poor sleep; stomach upset because of diarrhea, and he couldn't eat. Says he was knocked down by a shell on the above date, but he kept on running; was paralyzed after; shakiness developed later in hospital; weakness was most striking thing; feels better now; pain in back came on in bed at Base Hospital No. 18. Subjective symptoms: Present complaints—1, diarrhea, 1 to 5 times a day; some abdominal pain before stool; bowels loose; no blood; bowels apt to move at any time during day; 2, pain in back—comes and goes; 3, some pains around old appendix operation; 4, flat feet; sleeps all right; appetite all right; composed. Tells glibly how his abdominal adhesions were turned down by the S. C. D. Board. Says he wants to rejoin his outfit. Possible class A. Rather juvenile, bumptious type. " Will it be long before I can go back to duty?" (hopefully). Objective symptoms: Body, clean; weight, normal, 165; present, normal. General condition: Well nourished and husky. Glandular system: Slight exopthalmos; positive von Graefe. Vascular system: Pulse 88, regular. Good looking appendix operation scar; nothing objective made out of abdomen. Nervous system: Coarse finger tremor not marked. Diagnosis—transfer card: 1, psychasthenia; 2, spondylitis, chronic, 8th and 9th dorsal vertebrae. Diagnosis of ward surgeon: 1, psychoneurosis, hysteria, line of duty; 2, spondylitis, chronic, 8th and 9th dorsal vertebrae, existed prior to entry into service, not L. O. D. Progress: July 3, 1918, apparently recovered, except a slight recurrent pain in back. Disposition: Returned to duty, class A, July, 1918. Final diagnosis: Psychoneurosis, hysteria, line of duty; 2, spondylitis chronic, 8th and 9th dorsal vertebra?, existed prior to entry into service, not in line of duty. Condition on completion of case, cured. On September 20, 1919, he stated that he was a cost accountant before enlisting. Expects to take position in same work. His health is excellent but exceptional loud noises, such as a band, a blast, a factory whistle, a passing train, or particularly a thunderstorm will set his nerves aquiver for periods ranging from five minutes to three hours. Is trying gradually to gain control of himself and thinks he will succeed IN THE AMERICAN EXPEDITIONARY FORCES 387 On July 22, 1924, he wrote: I am feeling fair only. I am very nervous but through power of will am able to keep it in check with the exception of organic trouble. For several months I have been troubled with stomach trouble and my physician lays the blame to nervousness wholly. Of the old troubles, my worst day of the year is the 4th of July and secondly those in which thunder- storms occur. , 4. L^ very stronS Physically, being 5 feet 7 inches in height and weighing 180 pounds, but this does not keep me from tiring easily. I can stand only a small amount of manual labor and my other labors must not be too monotonous if I am to work the whole day at the same job. Exercise in the form of games does not tire me and gives me the sleep which I would not get otherwise. ANXIETY NEUROSIS It is in anxiety neurosis that the most complete example of psychical dis- sociation is met with, that is, a dissociation unaccompanied by anatomically expressed loss of function. Anxiety neurosis has to do with a more general process and reaches down more deeply into personality than the more super- ficially located mechanism seen in hysteria. Something of the etiology and the primary reaction has already been touched on in the consideration of hysteria above. There remains to describe progress and final clinical results. The subject of an anxiety neurosis must be thought of as an individual in whom the repression faculty is well developed. This may come about as a personal characteristic, or it may be due to the position of authority given by his mili- tary status. Naturally the officer falls most easily into this class and it is in the officer class that the majority of instances of anxiety neurosis are found. Next would come certain types of the noncommissioned officers, chiefly such as have received their commissions recently, and then soldiers who by virtue of education and the development of higher standards are inclined to react easily to ethical considerations. While this may be the general type which develops this form of neurosis, there are always found exceptions which appar- ently do not fit into the conditions as set down. Such exceptions are probably insufficiently studied or understood. In the typical case—for the purposes and necessary limits of this discus- sion only such can be considered—there is present, almost from the beginning, the essential elements of the mechanism of an anxiety neurosis. These are conflict, repression, not only of the memory of the experiences themselves, but also of the expression of the emotional reaction associated with them, and a certain degree of what may be called the ethical point of view in the presence of the antagonism between what is regarded as the right thing to do and the natural innate tendency toward self-preservation. These, of course, form only the basic groundwork of the process, indicating enough of the mechanism to warrant grouping these cases in a class by themselves. In almost all instances an officer very early in his career, very likely even in the training camp, feels the necessity of repressing his dislike or objections to discipline, obedience, authority, and many of the other essential phases of military life. His repressive mechanism not only has to do with the ideas themselves, but also with the external evidence of his attitude toward them; that is, his conduct must depart in no way from the correct military form. For these, and indeed for most of the experiences associated with actual combat duty, the repressive function is amply sufficient to keep the officer from ever approaching the territory of the neuroses. 42705—29----26 388 NEUROPSYCHIATRY The repression faculty has a well-known tendency to become automatic and to act entirely without the intention of the individual. As the officer advances in his training as military life grips him more and more intensely, and as military discipline forms him into a silent part of the big army machine, he is less and less in need of any active manifestation on his part of this faculty or repression which was so much a part of the mental discipline of the earlier days of his training. It must not be forgotten that in the American Expedi- tionary Forces the professional class of officers was necessarily a small one and that most of the nonprofessional officers were taken out of civilian pursuits of various kinds in which no trace of military atmosphere, and certainly none of active combatant duty, were to be found. Therefore, there was no important set of military or officer traditions to which the future officer had long ago accustomed himself. Therefore, it should be appreciated that in our Army the traditions of of conduct in general, and particularly those associated with active military life, had been very recently acquired, so recently that they were only super- ficially grafted on the officer's personality. There was need, then, to exercise, whether consciously or not, that form of inhibition called repression in order to maintain such traditions under circumstances of difficulty. This was espe- cially necessary when the officer met front-line conditions, for the first time, when he had not only himself to keep in hand, but also the added responsibility of men under him for whose fortunes in the stress of trench or open warfare he held himself in a measure responsible. In addition to this he realized that the technical side of his profession, a most difficult and intricate thing, was also but recently and often most laboriously acquired and had now to withstand the actual and often bitter test of real combatant conditions. Notwithstanding these heavy burdens, very few officers, it must be acknowledged, even under the adverse conditions associated with front-line duty, developed neuroses. Those who did had to face peculiar sets of circumstances which tended to break down the inhibitory processes which held them together in their capacity as leaders of men. Under the strain of fatigue, exhaustion, worry, and some of the many incidents that have been before alluded to, and as a result of shell explosion with a concussion sequence, the faculty of conscious inhibition was temporarily lost and the officer acted for the time being as a primitive instinc- tive piece of human machinery and during the period of semi-automatism, con- fusion, or haze, the beginning of the neurosis of the anxiety type was laid. If some of these things did not happen in an acute manner, then a series of smaller and less important incidents brought the officer in exactly the same condition. From this time on, the conflict began to assert itself, coupled with the dormant repressive tendencies, which again came into activity as the reality of the situation became more and more apparent. It is this antagonistic rela- tion of conflict to repression that tends toward the separation of emotion from experience. This supplies the mechanism of dissociation alluded to before. There results then the clinical picture of a state of intense anxiety with the external evidences in the way of facial expression, depression, apathv, loss of sleep, dreams, and even the objective appearance of fear, tremor, rapid pulse, vasomotor reactions, in the face of the complete unawareness and lack of under- standing on the part of the patient, of what really is at the basis of his discomfort. IN THE AMERICAN EXPEDITIONARY FORCES 389 The battle experiences repressed and in a sense partially forgotten, tend to express themselves by freeing their emotional content or by spinning themselves out in dramatic and terrifying dreams. There is present, then, the evidence of fear, and even terror, without being related to either actual experiences themselves or even to the actual memories of such experi- ences. In this state there develops a series of conflicts which must be regarded as being hardly conscious in some instances and wholly so in others. These seem to have been the more usual: (1) The conflict between the desire to go back to the front and the negative desire or wish for self-preservation. (2) The conflict arising between tradition and training of an officer and the desire to escape front line conditions. (3) The conflict between the desire to avoid the dangers and discomforts of the front, and previous ideas of duty, valor, etc., and family, social, personal, and class standards. (4) Conflict between the desire to escape and the feeling of inadequacy, in a military sense, of the respon- sibility of an officer in command of men. (5) Conflict between the impulse to go forward and the wish, expressed or not, to go back to former conditions in the United States. (6) Conflicts which had reference to events or similar types of conflict in pre-war experience. Naturally there are many other kinds of conflicts, but these were so common in the cases seen in Base Hospital No. 117, that some of them were predicted in certain individuals and were actually found to be present. Enough has been said of anxiety neurosis to indicate at least what is believed to be its fundamental mechanism, and to establish the fact that such a group of cases exists characterized by this mechanism. A case history illustrating this condition follows: A. P., pvt., Co. 95, 6th U. S. M. C. Age, 19; race, white; service, 1 year; date of admis- sion, July 11, 1918; source of admission, transfer Base Hospital No. 17; born, New York; mechanic; abstainer. Family history: Mother and sister had had "nervous breakdowns." No alcoholism; paternal uncle insane. Exanthemata. High school: Normal progress. Had headaches relieved by glasses; formerly somnambulist; afraid of thunderstorms until 14. History of present disease: Enlisted June, 1917; France September, 1917. While in training camp did not like the instructors, but was not unhappy and not sorry he enlisted. After coming to France he liked it. Went into front line during March and April. Shelling did not bother him. Shelling was constant, "but it didn't amount to much because we had dugouts." During May was in rear. Became rather digusted with excessive drilling; thought his outfit should have been given rest. Went into front lines at Chateau Thierry in June and welcomed the opportunity of getting some open warfare. For first four days he rather enjoyed it and although under shell fire and seeing a goodly number of casualties, he was not conscious of any fear, merely wondered whether one of the shells would "get him." June 5, his company advanced under fire to relieve French. He saw many French dead, with heads shot off and others staring at him. He was detailed to assist in burial. This digusted and horrified him because he never could bear to touch a corpse. He then began to realize for the first time what shell fire was. For several nights he could not sleep because the dead Frenchmen would be constantly before him. At the same time shells began to terrify him. He began to tremble under fire but tried to conceal his fear and to carry on. His condition was exaggerated by the fact that his own artillery was not working very efficiently. June 14, while under heavy shelling in open, and after position of company had been changed several times, he began to tremble, became weak and had to go to dressing station. He quieted down as soon as he was in quiet hospital. For first few weeks had terrifying dreams. Dreams have been absent for weeks. Subjective symptoms: Condition on admission—Says he feels fine now. Knows that he will not continue to feel so well if kept in hospital. Other patients make him nervous. 390 NEUROPSYCHIATRY They shake and jump at every little noise. He says he was always unable to look at people who were shaking, or to listen to people who were stammering. Does not think that he is unusually susceptible just at present. Wants to go back to company. Objective symptoms: Condition on admission—Good. Weight, normal, 150. General condition good. Diagnosis on transfer card: Anxiety neurosis. Diagnosis of ward surgeon: Anxiety neurosis (mild). Any duty in line of communication for at least two months. Disposition: Class B-l. Final diagnosis: Psychoneurosis, anxiety form, mild, L. O. D. Condition: Improved. On October 1, 1919, he stated he was not working at all at present. Upon discharge he started to drive a truck but could not continue to do so. He saw a doctor who ordered him to be quiet and do no work until he gave him permission. He says he is all right mentally. On January 5, 1920, he wrote that he had received $7.50 a month compensation, and that he was in the same condition he was in except rheumatism bothers him more and more. In the summer of 1924 he wrote that he was a teacher of industrial subjects receiving $2,200 for 10 months. He said: I feel pretty good but can not stand any sudden and loud noises as on July 4. My breathing bothers me quite a bit. The United States Government gave me a two-year teacher training course at Buffalo State Normal under the Veterans' Rehabilitation Board; also compensation at $13.50 per month at present. ANTICIPATION NEUROSES The anticipation neuroses were so named because they represented reactions not to actual experiences in battle but to the anticipation of such experiences. The neuroses, therefore, acted not as protections against the repetition of events already lived through, but as protection against initially experiencing them. As a whole, they probably were patients who had shown symptoms of the neuroses in training camps at home, the manifestation of which had most completely developed. On the way over or after they reached the con- centration camps in France, the symptoms became manifest again, and under the spur of immediacy rapidly took on the characteristics of a well-defined neurosis picture. The anticipation group was never a very large one and rapidly declined after active fighting began. Since they formed less than 10 per cent of the total material, evidently most of them were excluded by the neurological examinations made in the home training camps. Any of the clinical types of neurosis could be found in the anticipation group. This appeared to show that the memory of a past experience, imitation, suggestion, rumor—if emotionally intensified sufficiently—could arouse, in given instances, the defensive instincts to take the form of a neurosis, in the presence of a suffi- cient degree of receptivity and expectancy on the part of the individual. The anticipation neuroses are not war neuroses in the narrow meaning of the term, but it was found necessary to include it in a classification and to place in it such cases as had never been at the front, as well as a few patients who developed the attitude of anticipation toward reexperiencing former experi- ences. They reacted similarly to the group for whom the anticipation neuroses were at first devised. The history of such a case, as fell automatically in the latter group, is as follows: G., A. F pvt., Co. 2, Trench M. B. Born, Illinois; age, 23 years; race, white; date of admission, July 25, 1918; source, Base Hospital No. 6; drove mule in mine, $3 19 per day- alcohol, moderate; finished fifth grade at 14; at 15 began working in mines and has con- tinued ever since. Always healthy. Enlisted March 29, 1916, Jefferson Barracks- went to LI Paso (15 months), then to Gettysburg, Pa., 7 months. IN THE AMERICAN EXPEDITIONARY FORCES 391 History of present condition: Came to France January 8, 1918. Went to the front March 12, 1918, Verdun, then to Chateau Thierry in May. Was never afraid when shells broke around him, but rather enjoyed them; had never been in hospital. On June 29, 191S, at 11.30 p. m., several shells burst near, and finally one burst and killed two men and wounded two others. Jumped up and started running toward woods and fell in ravine. Began to shake all over; knew everything that was going on around him, but couldn't control his nerves. From field hospital went to Base Hospital No. 6, July 3, 1918, until coming here. Subjective symptoms: 1. "Nervous, shake all over, any little noise, can't stand it." 2. "Never afraid of anything, but now whenever anything drops I jump." 3. "Short of breath, sometimes I can't breathe." 4. "Can't sleep well, the least little noise wakes me up." Appetite good. Objective symptoms: Body clean; weight, normal, 168, present, 158; general condition good; blood pressure, systolic 125, diastolic 95; heart tachycardia 94; abdomen, slight pro- trusion clue to muscle weakness over each inguinal region; nervous system, quite marked general bodily tremors; pupils, regular, good reaction; knee jerks, slightly increased; osseous system, slight lateral curvature of spine to left about 10-12. Diagnosis on transfer card: Psychoneurosis of war. Report of disability board, August 24, 1918: Nature of disability—psychoneurosis, anticipation neurosis; disability did not exist prior to enlistment in service; disability is in line of duty; classification B-2; condition, improved; nature of duty recommended, labor in the lines of cummunication. On September 20, 1919, he wrote that he was back at home and at work as a salesman. He was feeling fine and doing well. On July 22, 1924, he wrote that he was working in a paper mill, salary 40 cents per hour. He was feeling fairly well, though a little nervous sometimes. He was receiving compensation at the rate of $9 per month at the time of writing. EFFORT SYNDROME Very little will be said about the effort syndrome in this place. So much has been written about this condition and there is still so much controversy on the subject that nothing can be added toward clearing it up from the point of view of its place in a list of war neurosis types. It was common enough in the material at Base Hospital No. 117, and formed so distinct a picture that it was one of the most easily classified. From the point of view of its defensive quality it is a typical neurosis, associated with the exhaustion types, but has a more definite localizing quality. It frequently followed gas poisoning, being the most persistent perhaps of its after effects. Its close association with emotion and the emotional reactions of the cardiac and respiratory functions seems to justify its position among groups of a functional defense system. Clinically, it is too well known to describe here, and it is mentioned because, mechanistically con- sidered, it ought to have a place in any classification of the neuroses. The fol- lowing case illustrates this condition: D. P., pvt., Co. G, 104 Inf. Age, 26 years; race, white; born, Michigan; date of admis- sion, July 27, 191S; source, Base Hospital No. 30; rubber-tire salesman and repairman; alcohol, moderate. Family history: Father, 50, neurosis-invalid type; rheumatism. Pre- vious personal history: Left school at 14, seventh grade; at 8, in bed six months, infected, broken ribs below left axilla. "Heart trouble right along," always short of wind; easily startled; nervous with excitement. History of present disease: Came to France October, 1917; up to the line February, 1918. Had hard times sometimes keeping up on account of shortness of breath. Carried on till July, 1918. Going over top, first time, dropped from exhaustion. As he arose a shell exploded near by and he remembers no more till he woke up at the dressing station. Shaky; blinded (not gassed). "My lungs have been weaker than they ever were." Feels a little better; not much. 392 NEUROPSYCHIATRY Subjective symptoms: Present complaints—1. "Heart and lung trouble"—"nervous. "I seem to get all my breath on the right side. At night I have to jump out of bed sometimes to get my breath and on a hike I have to drop out to get my breath. Nervous; body shakes. When I am walking I get weak-kneed." Headache for two days; appetite fair; tastes sometimes after eating. Ward surgeon's note: Rather hypochondriacal attitude and manner. Some grandstand rapid breathing. General tremor, moderate. Objective symptoms: Condition on admission—body, clean; weight, normal, 158, general condition, fair; two scars of old rib operation in lower axilla-left. Pulse, 100; regular; variable rate. Too much muscle tenseness. Nervous system: General tremor, moderate. Deep reflex is difficult to get because of muscle rigidity. Diagnosis on transfer card: Psycho- neurosis, hysteria. Diagnosis of ward surgeon: Psychoneurosis, effort syndrome. Progress: September 10—hard time breathing when doing strenuous work; difficult to take long breath; always been short-winded; pain in side and in heart; cough; head-shake tic; some stammer; appears quite neurotic; says always been some nervous; when in camp seemed like he couldn't last out in hikes. Gets upset in excitement. Does little detail work. Many hypochondriacal complaints. Pulse from 80 to 156; tremors of fingers; flushing of face; cough; respiration rapid. Probable Class C. Desires work in garage. Report of disability board, October 9, 1918: Psychoneurosis, effort syndrome. Dis- ability did not exist prior to entry into service. Classification, B-2. Nature of duty recom- mended: Labor in line of communication. On September 29, 1919, he was in the U. S. P. H. S. Hospital, Waukesha, Wis., and not doing very well. On July 28, 1924, he wrote that he was feeling fairly well and after receiving vocational training had obtained a satisfactory position. EXHAUSTION Exhaustion has its place in a classification of war neuroses because it connotes defense of a chemical or polyglandular kind. These patients came into the hospital in some numbers at first, but with the establishment of the forward- area hospitals fewer were seen. They represented a large percentage of the material seen in the triages and a considerable number of those seen in the advanced hospitals. In the earlier months of fighting they were often mistaken for and designated as war neuroses. As forming the foundation on which the neurasthenia type of war neurosis often developed, they deserve some mention here. TIMOROUSNESS, OR STATE OF ANXIETY Timorousness, or a state of anxiety, was a term given to a small group of individuals who frankly admitted that they were afraid to face conditions at the front, and deliberately gave way to this fear, refusing to accept or develop any compromise between themselves and what they had to do as soldiers. These are the true and only types of cowards. In them no repression of the kind mentioned here exists. This is not a neurosis, of course, as the whole mechanism is entirely too open and frank. At first sight such cases ought to be dealt with outside of a hospital, but in the case of a soldier the condition was so strange and departed so much from the usual conduct of a soldier that such an individual was not considered normal enough to be handled from the mili- tary side alone. They would belong probably in the same class as conscientious objectors, the difference being in respect to the kind of thing that interfered with their willingness to act the part of a soldier. The foilowing is a case history of this condition: IN THE AMERICAN EXPEDITIONARY FORCES 393 B., W. C, pvt., Co. B, 12th R. R. Engrs. Age 24 years; race, white; service, 1 year; born, Montana; date of admission, October 18, 1918; transferred from Neurological No. 1; railroad machinist; alcohol, moderate. Family history: Father and mother living and well; sister had epilepsy. Previous personal history: Went two years to high school; never was sick. Venereal, none. History of present disease: Enlisted October 17, 1917; France, May 14, 1918; front July 17, 1918. July 18, on Chateau Thierry front was wounded by shrapnel in left thigh; was in hospital five or six weeks. Returned to front September 9; became nervous over shells and airplanes; could not work at his railroad work on account of shells making him nervous. Dropped tools or whatever he had in hand when explosion came. Asked for work farther back, as could not stand shells. Present complaint: Complains of weakness and nervousness. Soreness in old wound in thigh; noise causes him to become nervous and to have headache; dreams some of shells and airplanes. Impression: A man of fair intelligence, but of rather weak, neurotic tendencies; was wounded by shrapnel and when returned to front was afraid of noises; is able to do all kinds of railroad machine work. Recommended for work in railroad shops in S. O. S—not com- batant stuff. Objective symptoms: Nervous; weakness; weak leg. Weight, normal, 114; present, 130. General condition, fair. Vascular system: Pulse 80; after slight exercise, 92; full and regular. Knee-jerks active; pupils react normally; coarse generalized tremors. Diag- nosis of ward surgeon: Psychoneurosis, state of anxiety. Progress (later report): Very much improved; still has little tachycardia; says feels good but not as strong as formerly. Composed. Fearful of returning to shell fire. Sure he would go to pieces again. Com- plains of cough sometimes at night; pulmonary examination negative. O. K. for duty Class A since armistice. Report of disability board: Disability did not exist prior to entry into service. Return to duty, Class A. Diagnosis: Psychoneurosis, state of anxiety, November 16, 1918. On December 16, 1919, he was back at home and claimed to be bothered by a wound eceived July 18, 1918. Was working at old trade as machinist but could not do the work. Is doing much more inferior work. On July 22, 1924, he wrote: "At present I am taking a degree course in mechanical engineering under Section No. 2 Training. Not nervous at present time. When I first got back I was somewhat nervous but I am not bothered with it at present or none within the last three and one-half years." GAS AND CONCUSSIONS Under gas and concussion were included cases in which the primary symp- toms of a concussion or gas experience were elaborated into the structure of a neurosis by the mechanism of fixation and defense. In the concussion neurosis the headache, vertigo, amnesia, temporary blindness, instead of passing away in a few days, as they normally do, begin after a comparatively free interval, to become apparent again, with a definite degree of persistence and exaggera- tion which had all the characteristics of a definite neurosis. In the gas neuroses the hoarseness, difficulty in breathing, pain in swallowing or talking, pressure sensation in the chest, dyspnea, etc., show exactly the same tendency until th,ere develops a chronic picture of gas poisoning long after the acute symptoms have any right to be present. In gas, too, the actual pain of a skin burn per- sists as a widely spread burning and parasthesia, long after the primary burn has healed and all trace of it has completely disappeared. The syndrome of these types is included here, because at times such patients were sent down to the hospital either through a mistake in diagnosis or on account of transportation necessities. 394 NEUROPSYCHIATRY The following cases illustrate these conditions. The first two are gas syn- drome and gas neurosis; the third and fourth, concussion syndrome and concus- sion neurosis: A., O. E., pvt., Co. A, 6th Engineers. Age, 41 years; race, white; born, Washington; source of admission, Cas. Off. Dept. Blois; carpenter; alcohol, very little. Family history: Negative, except that one son has a paralysis, subsequent to "grip." Previous history: Common-school education. No neurotic irregularities in make-up or history. No gunshot wounds or other casualties. Gassed, October 16, 1918. Venereal denied. History of present disease: Enlisted, April 8, 1917. France, June 28, 1918. Front, Chateau Thierry, July 14, 1918. Carried on very well until gassed (Verdun) on October 16; mustard and chlorine, he was told; carried on anyway until sent out by his officer on October 21; in hospitals until sent to Blois, November 24. Sent from there here, December 3, 1918, for reclassification. No history suggestive of a neurosis; possibly an exhaustion with a rather persistent bronchitis following gassing. He had night sweats and loss of weight. Patient does not appear at all a neurotic type. Subjective symptoms, condition on admission: Complains of cough and pain in front of chest and easy fatigability. Impression: Some exhaustion, associated with chronic bronchitis following gassing. Objective symptoms, condition on admission: Ambulatory. Weight, normal, 156; present, about 140. General condition: Rather tall and spare; looks a little emaciated, but has a good color. Skin and mucous membranes, as above; also a little tendency to hyperi- drosis. Vascular system: Radials a little thickened; rate, 100. Blood pressure: Subnormal by palpation. Lungs: Right upper chest in back rather duller and percussion and breath sounds less clear than right; but no persistent rales. Pupils: Left a little irregular, larger than right, but both react normally. Deep reflexes all increased, equally on the two sides. Right face a little weaker than left. Otherwise regular. Disability board, December 9, 1918. Diagnosis: Gas neurosis. Disability did not exist prior to entry into service. Nature of duty recommended, return to United States. January 6, 1920, he was getting along pretty well, although he had a hard time of it at first. Is doing well at present. On July 25, 1924, he reported that he was in vocational training studying to be a shoe repair man. He had worked as a carpenter for about one year, but had suffered from tuberculosis. He had been sent to Arizona, where he was at Whipple Barracks, Prescott. At the present time he is feeling well, though occasionally suffering from nervous troubles. S., J. C, pvt., 1st CI. Co. 2, M. P. Born, Pennsylvania; age, 20 years; race, white; date of admission, October 2, 1918; source, Neurological Hospital No. 1; millwright helper; alcohol, very moderate. Family history: Father, 56, alive and well (except for rheumatism); mother, 48, alive and well, one sister and two brothers, alive and well; one brother nervous; left school at 16—8th grade; always healthy, usual diseases of childhood; "had spasms until 6 years old." Well ever since; rheumatism two years ago; never nervous. History of present case: Enlisted April, 1917. France, May, 1918; went to front July 14, Chateau Thierry. Under heavy shell fire for about three days, becoming more and more nervous. A shell broke about 12 feet away, and he remembers nothing until waking up in a field hospital. Says other men told him he was gassed with chlorine and a little mustard gas. Very nervous and shaky; went to various base hospitals and finally put on M. P. duty at Nixville. Sent to Verdun front. Didn't mind the barrage, but couldn't stand the shells bursting near him. Stayed two days; got more and more nervous and fell down. Awoke in Neurological Hospital No. 1 and hence here. Dreams continually of battle, hears the whizzing of the shells, but "they never light." Sleeps very poorlv. Savs he is all right here, but couldn't stand the shells at the front. Subjective symptoms: Insomnia—battle dreams. Very good material, somewhat nervous in make-up. Talks freely and frankly of condition and doesn't think he will be able to stand shells again. Probably Class B-2. Objective symptoms: Good—rather nervous. General condition: Good. Glandular system: Small maxillary gland palpable. Vascular system: Impalpable. Heart: Normal in size and position; no murmur heard. Lungs: Nothing of note. IN THE AMERICAN EXPEDITIONARY FORCES 395 Diagnosis: Psychoneurosis, gas syndrome. Report of disability board, October 23, 1918: Disability did not exist prior to entry into service. Disability is in line of duty. Nature of duty recommended: Labor in the line of communications. Disposition: Class B-l. October 29, 1918. Final diagnosis: Psychoneurosis, gas syndrome. On August 8, 1919, he wrote that he was doing different work from his pre-war occupa- tion; working in a steel factory. It is too hot there for him, as he works with hot steel. Gets a pain over his heart every day at work and feels as if he would fall over any minute. On July 18, 1924, he wrote that he was earning $175 a month as a bottom maker—had received no compensation from the Government and was feeling fine. A., A., pvt., Co. L, 102d Infantry. Age, 21 years; race, white; born, Massachusetts; date of admission, May 31, 1918; source of admission, transfer Base Hospital 18; machinist; alcohol, moderate; family history negative. Previous personal history: Good health; left school at 14—9th grade; steady worker; no neuropathic history. History of present condition: Came to France October, 1917. Was at Soissons with division in March, 1918. Nerves all right; went up to Toul, beginning of April, all right till about April 15, when he was on his way up to join his company. A shell landed about 6 feet away. Didn't hear it. First he knew the explosion lifted him off the ground. Partly buried. Stunned—not unconscious. While he lay there a second one rolled him over again. He got up and was helped to aid station; he felt nervous and weak and was shaking all over. Was at Field Hospital No. 101 about 10 days; felt all right and returned to duty about May 1. Upset by a thunderstorm, and the batteries near him would keep him awake. Became jumpy. Could not sleep; headaches. Stayed on duty about two weeks. Came to hospital about the middle of May. Subjective symptoms: Present complaints: Weak spells and headaches. "I'll be feel- ing fine and all of a sudden I get dizzy. I have to sit down." Last an hour. Headaches come and go—sharp, frontal; dreams a great deal—war coloring; sleep broken. "When there is a lot of noise I get nervous." Appetite and bowels fair. Patient is of limited intelli- gence; speaks in a low, rather quick, tense voice; restless with hands. Slight nodding, jerking of the head; feels quite a bit better; may be fit for line duty again. Objective symptoms, condition on admission: Very slight generalized tremulousness more marked in hands, variable; body clean; weight, normal, 140; present, slightly under- weight; general condition fair; eye grounds normal; skin and mucous membranes: on fore- head, pea-sized reddish area: some pustular and some scab covered. Acne. Vascular system: Pulse 100; regular. Blood pressure: Systolic 110, diastolic 75. Nervous system: No sign of organic lesion; finger and lip tremor; no ataxia. Diagnosis on transfer card: Psychoneurosis, anxiety form. Findings in this case at Base Hospital No. 18, neurological examination: Early develop- ment fairly normal; never very bright, but has gotten along well. Was doing well in his company until he was blown up, April 15, 1918. Sent to Field Hospital No. 101. Neuro- logical status: Negative, except for coarse, jerky tremor. Diagnosis: Psychoneurosis, anxiety form. Recommendation: Transfer to Base Hospital No. 117 for further treatment. Summary of case at Base Hospital No. 117: Admitted May 31, 1918. April 15, 1918, was blown up by a shell explosion, stunned, weak and shaky. After 10 days in the hospital he returned to duty, and about May 1, 1918, was upset by a thunderstorm and a barrage; became jumpy and developed sleeplessness and headaches. He came to the hospital about the middle of May. His chief complaints on admission here were weak spells, headaches, and being easily startled. He was a little tense and restless and had a slight nodding head tremor. He was negative physically aside from a bad facial acne. He showed good improve- ment while in the hospital. Disposition: Return to duty B-l. July 3, 1918. Final diagnosis: Psychoneurosis (concussion neurosis). Postwar history, 1919-20: Present condition, poor. Is bothered with slight headaches and at times has dizzy spells. Has returned to his old work but does not like it, as it is in a cotton mill and he can not stand it. Is a yarn boy now; was formerly a fixer of machines. Has not worked a week steadily since his return. 396 NEUROPSYCHIATRY In the summer of 1924 the patient wrote: I feel fair. I still am nervous. I do not sleep well. The least bit of excitement makes me feel faint. I get tired quick at night but can not sleep sound. At present I am working one week and loafing a week. While out in the air I feel good, but while working inside I am all in at night. If I had a job outside I would feel a lot better. I have had three years of vocational training and it was a failure in my case, as I was knocked about and did not have a chance to learn enough to make a living at it. It is a long story and if you so desire 1 will write you later about my training career. If it is so in your power, I would like a hearing on my case. I had one hearing, but the persons involved did not have the least interest in the hearing. The American Red Cross sent this report under date of March 12, 1925: Mr. A. filed his claim on December 15, 1919, claiming as his disability shell shock. He was discharged from service on May 9, 1919, and was examined on January 19, 1920, and was given a diagnosis of neurosis, traumatic. He was considered to be disabled to a degree of 5 per cent with regard to vocational handicap. The report from the office of The Adjutant General of the Army shows treatment April 15, 1918, for psychosis, traumatic acute due to exhaustion of concussion of high explosives in action in line of dutv May 19 to July 3, 1918. He was given training on May 10, 1920, for one year as a cabinet maker. On May 12, 1920, he entered training at the Lowell Vocational School, Lowell, Mass. On August 16, 1921, he changed from training in the vocational school to placement training in cabinet making. On December 6, 1921, he was examined by the bureau doctor, and at that time he wanted to change his training from cabinet making to either telegraphy or plumbing. There was some question at that time whether the man would succeed in any work which required the skillful use of tools. The requirements for telegraphy were beyond his limited educational background. On May 15, 1923, he was rehabilitated as a cabinet maker, and was examined by the bureau examiner in the Veterans' Bureau on May 7, 1923. The diagnosis was traumatic neurosis mild. His case was rated on June 7, 1923, and he was given a 10 per cent rating on this neuropsychiatric condition and was considered competent. A follow-up visit was made by the Employment Service and it was found on March 21, 1924, that the man was employed at the------ Textile Co., assisting in the packing room and inspecting cloth. He was getting $21.26 a week. He has been working for this concern since the date of rehabilitation with the exception of one week and his work was considered satisfactory, although there was no future as far as promotion was concerned. It is interesting to note that he has never worked as a cabinet maker, although rehabilitated as such. He was examined again by the Veterans' Bureau on May 28, 1924, and his disability was considered of a noncompensable degree due to service. B., J. H., pvt., Co., M, 168 Inf. Born, Iowa; date of admission, July 25,1918; source of admission, Base Hospital No. 66. Drug store clerk; alcohol, abstainer. Previous personal history: No neuropathic history; left school at 17; third year high school; good health; operation for undescended testicle July, 1917. "When I take a long hike it leaves me pretty stiff the next day." History of present disease: Came to France December, 1917; up the line in March, 1918; got on all right until July 14, 1918; was in trenches fixing an automatic rifle; doesn't remember anything, unconscious for about three hours; came to an infirmary; gradual emergence. Wasn't himself until next day; had bad headache; "not so shaky at any time." Was gassed at time; "lungs were sore"; short windedness is better now; headache some better; upset by air raid and thunderstorm July 15, the night he arrived at C. H. 13. Subjective symptoms: Present complaints: 1. "Dull headache all the time. I don't shake much but I am a little nervous." Easily startled; shooting pains in forehead and back of head. 2. "My wind isn't what it always has been." "Takes a long time to get to sleep." Some war dreams; dizzy on stooping; feels fairly strong; appetite and bowels all right. Composed—good stuff; anxious to return to duty. Objective symptoms: Condition on admission—body clean; weight, normal 130; present, normal. Wax in ears. Pulse, 88, regular. Right testicle half descended. Moderate fine finger tremor. Diagnosis on transfer card, shell shock. Diagnosis of ward surgeon psycho- neurosis (concussion syndrome). Report of disability board: Did not exist prior to entry into service. Duty in line of communications. IN THE AMERICAN EXPEDITIONARY FORCES 397 Disposition: Returned to duty B-2, August 14, 1918. Final diagnosis: Psychoneurosis, concussion syndrome. Line of duty. Condition on completion of case: Improved. Post-war condition: September 29, 1919, "Back at work and feeling fine. Keeping books at present." On July 23, 1924, he wrote: My condition at the present time is a great deal better than when discharged and the only time that I can notice any trace of nervous trouble is upon being excited over some happening or some loud noise at an unexpected time. I can see no reason why my compen- sation should have been discontinued, as I have one bad lung at the present time which gives me some trouble. I really think if the proper authorities were advised that I would be given a just examination and no doubt would be entitled to some adjustment. If anything can be done it would be greatly appreciated. I drew compensation from the time I was discharged in 1919 until the fall of 1922, when it was discontinued. Don't know just why it was dropped as the disability which I had besides the nervous trouble still exists and have been unable to get any satisfaction from the bureau at this time. I was in the Samaritan Hospital in Sioux City, Iowa, in 1920,1 think. Also the Veterans' Bureau in Des Moines, Iowa, a number of times the dates I can not remember. In the spring of 1923 I was in the Veterans' Hospital at Jefferson Barracks in St. Louis for about five weeks and discharged from that place with a discharge marked "condition unchanged." GENERAL SYMPTOMS COMMON TO WAR NEUROSES The classification or grouping has shown that the different types depend rather on certain sets of distinctive mechanisms and on certain almost specific traumatizing experiences than on symptomatology or on the final clinical picture. It is, therefore, necessary now to describe some of the more general symptoms common to many of these types and then to touch on some of the more general of the mechanisms. Three are selected for description under the latter head, noting (1) what may be called, by analogy with general medical description, the reactions of the organism as a whole; (2) the fixation process, especially in its initial stage; and (3) the convalescent conflict. There are certain symptomatic reactions of the organism to emotionally effective traumas, which represent its protective response as a whole and furnish the symptomatic background of the neurosis. As has been shown, such symptoms are capable of elaboration, fixation, and stereotype, according to the type of mechanism set in activity. For this reason some or all of those about to be mentioned may be found in any of the groups which have just been described. They may be regarded either as instantaneous reactions taking place at the moment of traumatic impact, or arising afterwards as a result of the emotional responses accompanying the traumatizing incident. These are, in the main, primary fear reactions, such as tremor, dyspnea, tachycardia, sweating, and sense of muscular weakness, and the resultant condition of head- ache, restlessness, and insomnia. All of these may be regarded as vasomotor in origin and purely physiologic in expression. They appear to be so closely associated with hyperemotional states seen in other than war experiences that they must be looked on as very general types of reaction with no specific war incidence at all. For this reason they are found as a kind of symptomatic background to almost all of the severer types of neuroses. The majority of the cases showed headache, and considerably more than one-half had insomnia. In most of the latter the insomnia was of brief duration, the headache was often very persistent. The headache in cases of concussion is somewhat differ- 398 NEUROPSYCHIATRY ent, approaching closer to a specific symptom. Even in the development of the neurosis out of the concussion experience the headache had a more per- sistent character, a more definite localization, and appeared to produce more discomfort than those found in the other conditions. The characteristic headache was one of the most insignificant items in the diagnosis of concussion neurosis. It is apparent, then, that there are in the war neuroses, more or less sharply defined clinical groups, sufficiently characteristic to warrant giving to them separate neurological designations. The first six of them have a more or less characteristic mechanism; the gas and concussion neuroses are separated out because of a definite etiologic sequence, the others are questionable neuroses but should be included in a classification in use at a neurological hospital in the war zone. TREATMENT No adequate statement of the treatment developed in a special hospital such as Base Hospital No. 117, can be given without describing the history and growth of the place, its spirit and purpose, and the individuals composing its staff. Therefore, the merest outline of methods used can be mentioned here. Each staff member was encouraged to work out and develop his own particular notion as to the best way to treat these cases; in this way, while many personal therapeutic technical methods were developed, often to a remarkably high pitch of efficiency, nothing new or original can be said to have been discovered. Whatever unusual facility there might have been developed in the handling of these cases came more from the importance attached to the study of the mechanism than to emphasis on symptoms. The cases at Base Hospital No. 117 represented, on the whole, the very severe types of war neuroses, particularly so in the earlier and later months of its activity. In the beginning, evacuations were made indirectly to Base Hospital No. 117. After the St. Mihiel operation the forward screening was perfected enough to keep all but severe cases from reaching the rear areas. The therapy found effective in the acute cases (it was from these that the tech- nique was developed) was found effective in the chronic types. But it took longer for the symptoms to disappear. The result with chronic cases was not as good as in the acute cases. The first principle of the hospital was to cure the soldier and send him forward. If this was not possible he was to be fitted for military service in the Services of Supply with the hope that he would soon reach the front-line status. Very few cases were to be sent to the United States; therefore, recommendation to this effect was permitted only in the absolutely hopeless cases, and these chiefly on account of some undercurrent organic malady or previously undis- covered organic lesion of the nervous system. After the armistice began, how- ever, the hospital received a great many cases from other places. These were chronic, defective, and other types, representing the unsuccessfully treated residue of hospitals, camps, and division back areas. As an offset to this the percentage of higher classification during the armistice increased likewise, so that the balance was maintained and perhaps ran to more cured cases than at any other time in the hospital's history. Very few cases of war neuroses devel- IN THE AMERICAN EXPEDITIONARY FORCES 399 oped de novo after November 11. The therapeutic problem after that time became much simpler and required much less effort and time. The second general therapeutic principle was that a patient's stay at the hospital was to be as short as possible—the average in the whole hospital was slightly above three weeks. This included the officer material which required long treatment, and also included delays in getting patients out due to trans- portation difficulties and all other sources of block incident to a hospital oper- ating at the time of active fighting. The third general therapeutic principle was that all attempts made to cure a patient should be instituted as promptly as possible—within 48 hours if it could be arranged. Associated with this was the idea, also, that when the attempt was made it should be followed through to a finish at one sitting. This, of course, refers only to the hysterical symptoms. The fourth principle was that the war neuroses were caused by a mecha- nism not under the patient's control in its initial phases, but subsequent to that, in two to four weeks, there might be a contributing factor in the retention of symptoms through the desire or wish of the patient to remain protected by his neurosis. At least this possibility was kept in mind, so that if a cure was not effected within that time the question of the patient's cooperation was brought up. The fifth principle was that work of some kind was one of the most impor- tant aids in effecting symptomatic cures, so that always more than 80 per cent of the patients were engaged in work of some sort. This work was of a varied sort, work in the fields in season, road making, wood chopping, and work in a special shop—a therapeutic workshop carried on by reconstruction aides. The only novel feature in this was that it was carried on in a hospital to meet war conditions within a comparatively short distance from the front areas. Of the more general and usual methods of treatment of cases of this kind nothing will be said, such as rest for exhausted cases and isolation for excited or markedly tremulous cases. Such things form a necessary part of every hos- pital, and it will be taken for granted that such methods were carried out as effectively as they could be in a hospital equipped under the handicaps existing in France at that time. Such methods as presented an individual therapeutic view were to be found naturally in the hysterias and in the anxiety neuroses, and a description of what was tried out and found of value will be set down, rather to indicate the general trend of therapeutic effort than completely to describe them. The point in view in hysteria was that the symptoms were the result of a promptly acting shock-dissociation process, either materially or emotionally produced. If in the former it was not in any sense due to definite organic changes in the brain but to some sort of preorganic thing, possibly of a molec- ular or circulatory sort—anything which does not preclude the possibility of an equally prompt restoration to the normal. It was further appreciated that there was a mechanism of fixation of symptoms from which the neurosis tended to develop and become elaborated, so that if the emotionally fixed objective symptom could be removed thoroughly, the rest of the neurosis structure would rapidly disintegrate. 400 NEUROPSYCHIATRY Inasmuch as hysteria was thought of as a mechanism of unconscious origin, coming into activity without the patient's awareness and often with- out his subsequent knowledge, its symptoms were regarded by the patient as be- ing mysterious and strange. He himself, then, neither understood what they were, why he had them, nor to what they were due. The first logical step, therefore, was to attempt to explain to the patient something about the mechanism that had been at work in making of him an hysterical type of war neurosis. The second was to assure him both of its unconsciousness and of the possibility of rapid disappearance provided he gave his cooperation, chiefly by developing a condition of receptivity as far as he was able to do so. The next step was the acquirement of an attitude of expectancy. Then followed the use of the many methods of suggestive symptomatic treatment designed to remove as quickly and thoroughly as possible, symptoms in the order of their importance to the patient. This, in turn, was followed by after- treatment aimed to emphasize the fact that the symptoms had disappeared, and furthermore, to fix the notion of the mechanism originating the symptoms and then to fix the mechanism of their disappearance. The last step was an at- tempt to so increase automatic inhibition that the symptoms could not re- appear. This last was still in process of development when the war ended. In the phase of explanation only very simple methods were used, de- pending much on the intelligence and understanding of the patient. With an understanding and belief in a definite mechanistic production of hysteria, it was not difficult to impart such belief to the patient. Without such be- lief and knowledge it would have presented great difficulties. The attitude of receptivity and expectancy grew up in the patient's mind automatically, as his belief and faith in his physician took hold of him, or it arose from his eagerness to get rid of an embarrassing or handicapping group of symptoms. It was possible in many instances to increase the attitude by maneuvers de- signed to stimulate his desire for treatment. The use of apparent indiffer- ence, delay, etc., often caused an increased state of eagerness in the patient to get well. There were developed many devices to increase these essential preparatory qualities to the attack on the symptoms themselves. Some of the staff developed, to a high degree, what was called ward morale. This meant the influence of the cured cases and cases cured of a similar set of symp- toms, on the individual about to be treated. It also had reference to a rather mysterious thing called ward atmosphere. This was a reflection of the attitude of the nurse, physician, and patients to a patient who showed neither aptitude nor inclination to meet the cooperative demands which his case warranted. It is rather difficult to describe in a few words. In certain wards patients were cured quickly and remained so. It was not customary in these wards for patients to show symptoms for more than a little while after admission. It is of interest that this aspect of ward morale did not simply happen, but was consciously and carefully worked out by the physician and nurse. The immediate attack on the symptoms was carried out by means of one or more of the suggestive methods in vogue throughout all the neurological services m all the armies. The suggestive treatment was either intensive— in which case, as a rule, the faradic current was used—or it was gradual, being IN THE AMERICAN EXPEDITIONARY FORCES 401 given at intervals. In some instances the battery was not used at all, per- suasion and command, argument and reasoning being all that was required. In other instances, again, some other material type of suggestion w-as employed, as tuning forks or stethescopes in deafness, and tongue depressors in aphonias. Whatever method was used, great care was always taken to convince the patient that the results attained were only intensifications of what he was perfectly able to do himself. The faradic current, for instance, used to stimu- late a muscle in a case of paralysis, was only a means of demonstrating the functional capacity of the muscle, so that the idea of its paralysis, engendered by the process dissociating it for the time being out of consciousness, was negatived. The personal modifications of the technique of intensive suggestion, developed by members of the staff at Base Hospital No. 117, was used in every type of hysteria and in all its various manifestations. It was very generally effective in causing these symptoms to disappear. Tremors of all kinds, choreiform movements, fixed position, all types of paralysis, blindness, aphonias, deafness, etc., were daily cured, often in a few minutes, seldom taking as much as an hour. There is nothing surprising in this, especially if one considers that a certain percentage of these disappeared of themselves. Of more im- portance and of greater interest was the surprising degree of individual technique which grew up about each of the more expert therapeutists of the staff. The hysterical amnesias as a rule were treated differently, although in some instances much of the same technique as the above was followed. More often, however, these cases were treated by various associative exercises leading back to the event for which the amnesia existed and for which it exercised its protective influence. By bringing into full consciousness this event and forcing the patient to face, and square himself with it, the path of reassociative memory was found, and the amnesic block gradually grew less and finally disappeared. It was either complete, leaving the thread of memory without a break, or some small remnant of block still persisted. In the latter instance it might be left as a perfectly harmless amnesic islet, as it was termed, or dissipated by putting the patient under a very mild degree of hypnosis. In this condition, no great difficulty was found in reestablishing the flow of consciousness again. A small series of amnesias was treated from the start by hypnosis. The therapy of the anxiety neuroses was a much more difficult thing to develop and apply. The condition itself presents a much more complicated form of neuroses than the cruder reactions of hysteria. The anxiety neurosis, as has been said, dips down deeply into the personality and touches on factors that are associated with the make-up of the individual. It has a strongly ethical character, presenting conflicts of various kinds. This dissociation has very little direct material expression and presents, for this reason, little oppor- tunity for a direct therapeutic attack. An anxiety neurosis case takes a great deal more time both to develop and to treat, and the individual who is capable of having it has reacted to it much more deeply than a hysteria case ever does. Besides this, he is apt to be more intelligent, therefore, more suspicious and very much less suggestible than the hysteria case. A certain amount of study must be given to past experiences, to his former life, to his career in the 402 NEUROPSYCHIATRY Army, and to the succession of events which brought him into the hospital. It is necessary to acquaint the patient at first-hand with the causes that led to the condition, the nature of the condition. He must be instructed as to the nature of conflict, his in particular, and as to the function of repression. Above all, he must be taught to face the whole matter as a section of experience which has come into his life, and which will remain as a part of himself as long as he lives or until the memory of it becomes fainter with the piling up of those of more recent origin. The therapeutic aim in the anxiety neuroses had formerly been to encourage the patient to forget his experiences and to aid by his own effort the automatic repressive tendency already existing. The new point of view was to attempt to train the patient to face, and to face daily as a matter of course, the experi- ences he had been through, no matter how uncomfortable or terrifying they happen to have been. It was in a sense a modified psychoanalytic procedure adapted to a war-born condition, divorced from a good deal of the technical complications of the method used in peace times. A patient was encouraged to talk about his experiences, to go over the emotional states which accompanied them, and to examine himself as critically as he could in reference to them. It is one thing to face a past event and to measure oneself in the light of that event; it is quite a different thing to try to forget an event and thus allow the criticism, so to say, to go on unconsciously and the resulting emotion to remain as the only conscious evidence of the con- flict going on sublimated and beyond reach. The former state of mind was encouraged in the patient, the latter was to be avoided. The chief conflicts found in the anxiety neuroses were analyzed out in some such manner as this. The technique differed according to the individual ther- apeutists. None found it necessary, however, to employ any more complicated technique than that of question and answer. A perfectly frank account of experiences, with the proper narrative sequence of events, together with the critical comments of the physician, was all that was required in many instances to prepare the way for a successful therapy. The knowledge of such cases acquired by the therapeutists led to the proper emphasis of the points he was trying to make, much in the way that a trained psychoanalyst in the Freudian sense indicates to his patient the line of associative events he desires to bring up into active consciousness. In the peace neuroses this is frequently a matter of great difficulty on account of the patient's unwillingness to face the embarrass- ing nature of the conflict from his point of view. In the war neuroses the con- flict is formed out of simpler elements and, since the whole thing is more recent, the repressive function has had much less opportunity to bury them deeply in the lower levels of consciousness. Furthermore, the conflicts were so frequently conventionalized and so often found repeated in different individuals that it was an easy matter to present them to the patient with only a little assistance from him. In this way the rapport between patient and physician was not difficult to establish, because it was found that there was little to conceal and less possibility of deception. The favoring element therapeutically was, of course, the central motive underlying all efforts of treatment, that is, the duty and necessity of fulfilling his obligation as a soldier—the return to duty Only IN THE AMERICAN EXPEDITIONARY FORCES 403 in exceptional cases was this ever a matter of argument or even of doubt. There could be little weighing of contending motives in such a situation. The duty of a citizen may present many points of conflicting interests, that of a soldier none. That is, none, if the point is reached, when he is brought face to face with the definite reality of his military position. Although the methods of treatment and the general therapeutic attitude toward a patient with anxiety neurosis can be set down in so simple a manner as this, the implication does not follow that the procedure was an easy one or that it was always successful. Such certainly was not the case, for no condi- tions in the war neuroses were so difficult to handle or required so much effort. Comparatively few men ever acquired the knowledge, patience, tact, insight and firmness to treat such cases adequately. In Base Hospital No. 117, and no doubt in other places, too, there developed among the staff a few- men who became in a way anxiety neurosis specialists. The contrast to hysteria in this respect was marked. Almost anyone after a little instruction could treat the ordinary hysterical case successfully, whereas only a few ever qualified as good therapeutists for the anxiety cases. The therapeutic methods in use in the other types of the war neuroses need scarcely be mentioned in detail. Apart from the usual symptomatic treatment, the conventional hospital manner of handling the daily discomforts of a ward full of patients, there was little to distinguish this hospital from any other. Drugs were given as seldom as possible, and then only to meet the simple complications of an average patient in a hospital. Bromides, hypnotics, and analgesics were given with the greatest reluctance, and for the most part the patient did better without them. It was necessary at all times to combat the natural desire of a patient for some more tangible evidence of treatment, but this the nurses were for the most part able to do. Therapeutic use was made of many other agencies not usually mentioned in describing methods of treatment. All of them had to do with strengthening the patient's morale, and forcing on his attention at all times, the necessity of getting out of the hospital and back to duty. The hospital chaplain, approached this through wisely and cleverly de- signed sermons touching on the spiritual phase of courage, loyalty, devotion, and patriotism. The sermons and religious exercises were planned in part toward this end, as were the weekly talks by members of the staff and some- times by visitors to the hospital. In other ways the military atmosphere was kept alive by every means possible. The decorations in the recreation huts were all planned to keep the military atmosphere in the minds of the soldiers through stirring posters and scenes of actual war conditions. The walls were covered by sketches drawn for the most part by patients, of men going over the top, artillery going into action, airplane fights, etc. Sympathy in the ordinary meaning of the term had little place in this hospital; intelligent insight and appreciation of the mechanism of the war neuroses in a measure took its place. The military necessity was accentuated and kept constantly in mind, but notwithstanding a certain grimness in the hospital's attitude to its patients, not the slightest suggestion of harshness or 42705—29---27 404 NEUROPSYCHIATRY severity was ever permitted. The war neuroses were regarded as temporary conditions into which a soldier might fall and thus become a subject for medical treatment. The treatment was found to fail unless the efforts made to help him met with the cooperation of the patient and a desire on his part to get well. The hospital was planned and equipped for the purpose of returning him to duty and, given his support, in most cases, this was accomplished. If expressing his recent experiences by talking, writing, or even, as was done in some cases, by the most lurid drawings, was an aid to this end, such efforts were encouraged by whoever might happen to be at the time helping on his case, be it chaplain, civilian aid, nurse, or some other specially qualified member of the hospital personnel. CHAPTER VI THE CARE AND DISPOSITION OF CASES OF MENTAL DISEASE COLLECTING STATION In Chapter I of this section explanation was made of the fact that, in gen- eral, it was planned by the Medical Department not to return to duty in France soldiers who had been admitted to hospital with psychoses or other mental diseases, but to return all such soldiers to the United States for further treat- ment. In carrying this plan into effect a collecting station for cases of mental disease was established for the forward area, at Base Hospital No. 116, an inte- gral part of the hospital center at Bazoilles.1 Provisions also were made in other hospital centers, and at most base hospitals not connected with hospital centers, for suitable care of neuropsychiatric cases pending their collection at base ports with the view of their return to the United States. For present purposes it will suffice to state briefly, except in so far as the base ports are concerned, the activities of the neuropsychiatric department of the hospital center at Bazoilles. NEUROPSYCHIATRIC DEPARTMENT, BAZOILLES HOSPITAL CENTER" This department began to function on July 20, 1918, as a part of Base Hospital No. 116. Though nominally under the administrative supervision of the commanding officer of the base hospital, the neuropsychiatrist in charge of the department was permitted to exercise all necessary latitude in the opera- tion of his department. The buildings provided for the neuropsychiatric department consisted of six wooden demountable barracks, of the same character as those used through- out the center for wards and general purposes. These were 100 feet in length. They were located on relatively high ground, to the rear of Section IX of the hospital center, occupied by Base Hospital No. 81. Four of the buildings were used for patients, with a total normal bed capacity of 80. One building was used for administrative purposes as well as barracks for the enlisted personnel on duty in the department; another was used for kitchen and mess hall. After some months of operation, a building of standard width and 50 feet long was added to the group as a dormitory for nurses, thus permitting housing them at a convenient distance from the wards wherever they were on duty. At times, the patient capacity of the department was inadequate, thus necessitating using an additional ward of Base Hospital No. 116. From three to five medical officers were on duty in this department during the greater part of its existence. The enlisted detachment consisted of 4 non- » The statements of fact appearing herein are based on the "History of the Bazoilles Hospital Center," prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O. 405 406 NEUROPSYCHIATRY commissioned officers, 2 cooks, and 14 privates first class and privates. Ten nurses were required for the efficient service of the department, and their number usually was maintained at this figure. Trained personnel was furnished not only for conducting incoming patients to this hospital, but also for convoys of cases of mental disease proceeding hence to the hospital center at Savenay. W 3 Vi\. ^± FLOOR PLAN - DISTURBED CASE BUILDING FLOOR PLAN -GENERAL TY PE OF WARD-N03. I 1 2 ./.V JK. -y 2 1 1 1 In view of the great amount of moving from State to State the figures for the birthplace of the men are less significant than those for home addresses in drawing inferences regarding the social background of the war neurotic group. STATE OF RESIDENCE AND OCCUPATIONAL ENVIRONMENT The States which the enlisted men who were patients of Base Hospital No. 117 gave as their homes were compared with the percentages of enlistments in the Army as a whole coming from the same States. It must be remembered in interpreting such a comparison that a determining factor in the incidence of psychoneurosis in various divisions of the Army is the severity and duration of the campaigns in which the troops in question were used. There is, of course, no assurance that soldiers from the various States were subjected to similar severity of military stress. Yet the coefficient of correlation by the rank methodc between the percentage of Base Hospital No. 117 patients from each State and the percentage of the total Army enlistments by States is plus 0.841 (P. E. +0.0297). This correlation would indicate that from the standpoint of proportionate representation from the States our selection of cases is in general tendency adequately representative of the constitution of the Army as a whole. Significant interpretations regarding the types of localities from which these men came are obtained from the consideration of the precentage of urban and rural residents, density of population, percentage of foreign born, and number of males 10 years of age and over engaged in agricultural work in the various States. Tables 2 to 5 give the results of this tabulation. When either the 10 highest ranks are compared with the 10 lowest (by the addition of the percentages) or the 24 highest with the 24 lowest for the above-mentioned four considerations, the data are all similar in tendency. The States in which there were the highest percentages of native stock, of rural residents and of agricultural workers, and the least density of population, gave much smaller quotas of psychoneurosis patients than did the States high in density of popu- lation, urban residents, foreign born, and nonagricultural workers. Or viewed from another angle, these facts are further defined by the coeffi- cient of correlation by the rank method between Base Hospital No. 117 percent- ages ranked for the four qualities under study and the rank order of per- centage of enlistment in the total Army. Rho is positive for density of popu- Calculation with Spearman's formula: Rho=l- 6^' and the P. E. =0.7063 l-Rho2 IN THE AMERICAN EXPEDITIONARY FORCES 437 lation (plus 0.609, P. E± 0.123), for percentage of urban residents (plus 0.464, P. E. ±0.079), for percentage of foreign born (plus 0.104, P. E. ±0.090), and negative for percentage of males 10 years and over engaged in agricultural work (minus 0.507, P. E. ±0.072). Table 2.—Rank order of States from the standpoint of percentage of urban residents'1 related to percentages of the total Army enlistments and of Base Hospital No. 117 patients from those States Rank 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 State District of Columbia. Rhode Island______ Massachusetts_____ New York_________ New Jersey.....____ California__________ Illinois____________ Connecticut________ Pennsylvania_______ Ohio______________ 10 highest ranks___ New Hampshire____ Michigan.......____ Maryland......____ Washington________ Delaware__________ Indiana____________ Oregon-------...... Colorado___________ Utah______________ Wisconsin.......___ Missouri___________ Minnesota_________ Maine_____________ Florida____________ Total.....________ Per cent B. H. No. 117 0.39 .87 7.57 12.80 4.28 1.66 5.39 3.17 14.70 5.74 (56. 57) .95 4.08 1.43 1.15 .16 1.92 .32 .63 .32 4.49 2.77 1.27 1.27 .33 77.66 Per cent of Army 0.42 .45 3.53 9.79 2.80 2.98 6.68 1.33 7. 93 5. 35 (41. 24) .24 3.61 1.25 1.20 .20 2.83 .80 .92 .46 2.61 3.42 2.64 .65 .89 62.96 Rank State 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 Arizona________ Louisiana______ Kansas________ Texas__________ Montana_______ Nebraska______ Vermont......... Wyoming........ Virginia_______ Idaho............ Oklahoma______ Kentucky........ Tennessee______ West Virginia___ Georgia________ Alabama......._ Nevada________ North Carolina.. New Mexico____ South Carolina... Arkansas_______ South Dakota___ North Dakota___ Mississippi_____ 10 lowest ranks. Total_________ Per cent B.H. No. 117 0.08 .59 1.19 3.05 .59 1.11 .47 .16 1.98 .32 1.39 1.11 .79 1.27 1.07 1.31 .08 .67 .24 .87 .59 .12 .63 .52 (6.10) Per cent of Army 20.20 0.28 1.76 1.69 4.29 .97 1.27 .25 .30 1.94 .51 2.13 2.00 2.02 1.48 2.28 1.99 .14 1.94 .33 1.42 1.62 1.44 (12.64) d Obtained from Abstract of the Fourteenth Census of the United States, Government Printing Office, 1920, page 75. Includes District of Columbia and omits Iowa, rank 25. Table 3.—Rank order of Statese from the standpoint of density of population related to the per- centages of the total Army enlistments and of the patients of Base Hospital No. 117 from those States Rank State 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 District of Columbia. Rhode Island...... Massachusetts----- New Jersey---...... Connecticut__..... New York_________ Pennsylvania.....— Maryland----...... Ohio______________ Illinois_____________ 10 highest ranks___ Delaware............. Indiana____________ Michigan------..... West Virginia_______ Kentucky......----- Virginia____________ Tennessee......----- South Carolina------ North Carolina------ Missouri___________ (Jeorgia________ New Hampshire . Wisconsin------ Alabama_______ Total. Per cent B.H. No. 117 0.39 .87 7.57 4.28 3.17 12.80 14.70 1.43 5.74 5.39 (56. 34) .16 1.92 4.08 1.27 1.11 1.98 .79 .87 .67 2.77 1.07 .95 4.49 1.31 Per cent of Army 0.42 .45 3.53 2.80 1.33 9.79 7.63 1.25 5.33 6.68 (39.41) .20 2.83 3.61 1.48 2.00 1.94 2.02 1.42 1.94 3.42 2.28 .24 2.61 1.99 67.39 Rank 26 27^ 27^ 29 30 31 32 33 34 35 36 37 38 39 40 State 41 42 43 44 45 46^ 463- 48 49 Louisiana____ Vermont...... Mississippi-._ Arkansas____ Minnesota___ Oklahoma____ Maine_______ California____ Kansas______ Washington.... Texas________ Florida------ Nebraska...... North Dakota . Colorado_____ South Dakota.. Oregon_______ Utah........... Idaho________ Montana_____ New Mexico____ Arizona________ Wyoming______ Nevada________ 10 lowest ranks. Total_________ Per cent B. H. No. 117 0.59 .47 .52 .59 1.27 1.39 1.27 1.66 1.19 1.15 3.05 .35 1.11 .63 .63 .12 .32 .32 .32 .59 (2. 86) Per cent of Army 18.08 1.76 .25. 1.44. 1.62 2.64 2.13 .65 2.98 1.69 1.20 4.29 . S9 1.27 .69 .92 .46 .51 .97 .33 .28 .30 .14 (5. 50) 29.00 « Obtained from Abstract of Fourteenth Census of the United States, page 22. Includes District of Columbia and omits Iowa, rank 25. 43S NEUROPSYCHIATRY Table 4.—Rank order of States ' from the standpoint of their percentage of foreign-born population related to percentage of the Army enlistments and of Base Hospittd .\o. 117 patients from those States Rank State 1 Rhode Island____ 2 i Massachusetts___ 3 \ Connecticut_____ 4 | New York______ 5 ! Arizona_________ 6 ! New Jersey----- 7 | California_______ 8 i Nevada_________ 9 '• New Hampshire. 10! 2 Minnesota_______ 10 highest ranks 104; North Dakota-... 12 ; Michigan________ 13 Washington_____ 14 j Illinois__________ 15 | Wisconsin------- 16 | Montana________ 17 j Pennsylvania___ 18 Maine----------- 19.4 Wyoming_______ 1941 Oregon__________ 21 Utah__________ 22 South Dakota___ 23 Colorado _____ 24 Vermont__ ____ Totals________ Per cent B.H. No. 117 0.87 7.57 3.17 12.80 .08 4.28 1.66 .08 .95 1.27 (32. 73) .63 4.08 1.15 5.39 4.49 .59 14.70 1.27 .16 .32 .32 .12 .63 .47 67.05 Per cent of Army 0.45 3.53 1.33 9.79 .28 2.80 2.98 .14 .24 2.64 (24. 18) Rank .69 3.61 1.20 6.68 2.61 .97 7.93 .65 .30 .80 .46 .79 .92 .25 52.04 26 274 274 29 30 31 32 33 34 35 36 37 38 39 40 41 42 131, 13}. 434 45 46 47 State Nebraska_________ Iowa........_______ Idaho........______ Delaware_________ New Mexico......... Texas_____________ Maryland.....----- District of Columbia Kansas----------- Florida----------- Missouri__________ Indiana___________ West Virginia______ Louisiana_________ Oklahoma_________ Virginia___________ Kentucky_________ Alabama__________ Arkansas---------- Tennessee_________ Georgia___________ Mississippi-------- South Carolina_____ North Carolina---- 10 lowest ranks___ Totals-............ Per cent B. H. No. 117 1.11 2.14 .32 .16 .24 3.05 1.43 .39 1.19 .33 2.77 1.92 1.27 .59 1.39 1.98 1.11 1.31 .59 .79 1.07 .52 .87 .67 (10. 30) 27.21 Per cent of Armv 1.27 2.63 .51 .20 .33 4.29 1. 2."i .42 1. 69 .89 3.42 2.83 1.48 1.76 2.13 1.94 2.00 1.99 1.62 2.02 2.28 1.44 1.42 1.94 (18.76) 41.75 ! Obtained fromAbstract of Fourteenth Census of the United States, p. 103. Includes District of Columbia and omits Ohio, rank 25. Table 5.—Rank order of States ° from the standpoint of their percentage of males 10 years and over engaged in agricultural work related to the percentage of the total Army enlistments and of the patients of Base Hospital No. 117 from those States Rank State Mississippi____ Arkansas______ North Dakota _. South Carolina. South Dakota. _ Georgia_________ North Carolina-__ Alabama________ Tennessee_______ Idaho___________ 10 highest ranks. Kentucky_______ Oklahoma_______ New Mexico_____ Texas___________ Nebraska_______ Louisiana. Iowa_____ Montana. Kansas... Virginia. _. Minnesota- Vermont. __ Wisconsin. Florida___ Totals... Per cent B. H. No. 117 0.52 .59 .63 .87 .12 1.07 .67 1.31 .79 .32 (6. 89) 1.11 1.39 .24 3.05 1.11 .59 2.14 .59 1.19 1.98 1.27 .47 4.49 .33 Per cent of Army Rank 1.44 26 1.62 27 .69 28 1.42 29 .79 30 2.28 31 1.94 32 1.99 33 2.02 34 .51 35 (14. 70) 36 2.00 37 2.13 38 .33 39 4.29 40 1.27 41 1.76 42 2.63 43 .97 44 1.69 45 1.94 46 2.64 47 .25 47 State Oregon______ Wyoming____ Utah________ Colorado_____ Indiana______ Maine_______ Arizona______ West Virginia. Washington.._ Nevada______ Delaware_______ Michigan_______ California______ New Hampshire. Maryland______ Ohio.......... Illinois______ Pennsylvania. New York___ Connecticut _ _ New Jersey-------- Massachusetts______ Rhode Island_______ District of Columbia. 10 lowest ranks____ 26.84 40.10 Totals.. Per cent B. H. No. 117 Per cent of Army 0.32 0.80 .16 .30 .32 .46 .63 .92 1.92 2.83 1.27 .65 .08 .28 1.27 1.48 1.15 1.20 .08 .14 .16 .20 4.08 3.61 1.66 2.98 .95 .24 1.43 1.25 5.74 5.33 5.39 6.68 14.70 7.93 12.80 9.79 3.17 1.33 4.28 2.80 7.57 3.53 .87 .45 .39 .42 (56. 34) (39. 51) 70.39 55.60 » Obtained from Abstract of Fourteenth Census of the United States, p. 501. Agricultural work as the term used in the census tabulations also included forestry and animal husbandry. Includes District of Columbia and omits Missouri, rank 25. IN THE AMERICAN ENPEDITIONARY FORCES 439 When the draft quotas were being filled, it was found that the different parts of the country varied in physical readiness and vitality. Ayres,17 after presenting the official statistics for the physical fitness of the various States as expressed in the percentage of men accepted of all those called for national service, says: "In general, it is noteworthy that the best records are made by those States that are agricultural rather than industrial and where the num- bers of recently arrived immigrants are not large." It should be observed, while noting the striking similarity for these data and those of Ayres, that there need not necessarily be any relationship between the percentage of physical defect among recruits and the percentage of neuropathic tendency among those selected after an examination for physical fitness has eliminated the unfit. Another aspect of the problem, which should be considered in attempting a definition of the gross environment factors from which the war neurotics were recruits, is occupation. This has already been touched upon from one angle (agricultural work). In Table 6, the Bureau of the Census data on occupations are compared directly, for each type of work, with the occupations given by the Base Hospital No. 117 patients (officers and enlisted men) in their clinical records. Several items, viz., mining, manufacturing, trade, and public service, involving about 50 per cent of the group, were similar in proportion in both sets of data. It is noteworthy, however, that whereas the percentage of males over 10 years in the United States in employment of some kind who were doing agricultural work was 29.8 per cent in 1920, only 11.5 per cent of the hospital patients gave agricultural work as their occupation when questioned at the hospital. On the other hand, the professional quota in the census is 3.4 per cent, while in the total hospital groups it is 7.2 per cent; likewise, the percentage of men in clerical work in the country at large was 5.11 per cent, while among the hospital groups it was 15.91 per cent; work related to transportation took in 13.8 per cent of the hospital groups and but 8.6 per cent of the males of the country at large. There were fewer (2.5 per cent) of the hospital group engaged in domestic work than the quota for the country at large (3.7 per cent). The last might be accounted for by alien exemptions and the ages of men engaged in domestic work. While recognizing the obvious tendencies of the data, it should also be remembered that 293 patients gave their occupation as "labor" and 124 were students. These cases, comprising 15.50 per cent of the group, are not used in the computations in Table 6 because of the indefiniteness of description and the inability to allocate them in terms of the Bureau of the Census classifi- cation. The data taken in comparison with the census figures unmistakably indicate that so far as occupational milieu was concerned men who were engaged in clerical, professional, or transportation work were liable to develop war neurosis in greater proportion than their quota in the total male population would warrant. 440 NEUROPSYCHIATRY Table 6.- -Comparison of distribution of types of occupation of Base Hospital No. 117 patients with certain other groups Type of work defined by 1920 census Base Hospital 117 total group 1920 Census a Enlisted men in A. E. F.s Enlisted men, Base Hospital No. 117 patients Number Per cent Number Per cent Number Per cent Number Per cent 261 53 789 313 253 45 163 57 339 11.5 2.3 34.7 13.8 11.1 2.0 7.2 2.5 15.9 9,869, 030 1, 087,359 10, 888,183 2, 850, 528 3, 575,187 748, 666 1,127,391 1,217, 968 1, 700, 425 29.8 3.3 32.9 8.6 10.8 2.3 3.4 3.7 5.1 161,975 12, 239 151,429 70,231 36,816 18, 099 34, 748 4,535 51,429 29.9 2.3 28.0 13.0 6.8 3.3 6.4 0.8 9.5 257 52 780 312 214 26 117 57 319 12.1 2.5 36.6 14.7 10.1 1.3 2. Extraction of minerals. ...___ 3. Manufacturing and mechanical trades__________ 4. Transportation_____________ 5. Trade_________________ 6. Public Service....... 7. Professional______ _____ 8. Domestic Service_______ 2.7 14.5 9. Clerical__________..... Total i_________ 2,273 100.0 33, 064, 737 100.0 541, 501 100.0 2,134 100.0 1 Does not include 4,937 of American Expeditionary Forces given as "education, extent of" and 37,034 given as "laborer" (total, 7.2 per cent). Likewise for Base Hospital No. 117 total group, 293 who gave occupation of laborer and 124 as students are omitted (total, 15.50 per cent). 2 Fourteenth Census of the United States, 1920, iv, 3. 3 Personnel System of the U. S. Army, Vol. I, U. S. Government Printing Office, 1919, i, 213-216. There are available some occupation statistics on over half a million enlisted men of the American Expeditionary Forces, which are useful for com- parison with our own. These data are arranged in Table 6 according to the census categories for the purpose of comparison. As indicated in the footnote to Table 6, two groups are omitted as inadequately descriptive and incapable of being fitted into this classification. Otherwise the group totals 541,501. As one would expect, these figures show that the enlisted men of the Army in France were not a perfect sampling of the occupational cross section of the male workers of the country; especially is the variation from the census notable in professional and clerical work, domestic service, transportation, and trade. Only in the agricultural figures are the two sets of facts practically identical. When the enlisted men of the Base Hospital No. 117 patients are compared with the American Expeditionary Forces, figures for occupations of enlisted men, we find certain items in disagreement. The quotas of patients, especially for agriculture, and also for public service and domestic service are considerably less than expectation, whereas the quotas for manufacturing and mechanical trades, clerical work, and trade, are greater than expectation. The most striking difference is again in the small percentage in the agricultural group, while the greater proportion in clerical and domestic work and in trade are the most significant differences in the other direction, namely, toward a greater representation among the psychoneurosis patients than their proportional quotas. There is a slightly smaller percentage of the patients in professional work than the proportion of the American Expeditionary Forces, soldiers. This difference may be accounted for by errors in the collection of the American Expeditionary Forces, data; the very small number who gave the occupation student" being indicative of a possible exaggeration of occupational status bv these individuals into the professional ranks. In general, the tendency is for the patients to be engaged in bookish, indoor, commercial work in greater propor- tion than the Army m general and to have a lesser proportion of men engaged in agricultural work. Unfortunately these data on the Base Hospital Xo 117 IN THE AMERICAN EXPEDITIONARY FORCES 441 group do not lend themselves to interpretation by any of the occupational scales now obtainable. In the succeeding chapter this problem will be reviewed in the light of more adequate data. For the present, however, it may be noted that the war neurotic group, which is high in the trade and clerical types of work and low in agricultural work when compared with the enlisted men of the American Expeditionary Forces, is probably at least the equal of the latter in general occupational rating. REFERENCES (1) History of Base Hospital No. 117, A. E. F., prepared by the commanding officer of the hospital. On file, Historical Division, S. G. O. (2) Ayres, L. P.: The War with Germany. Washington, Government Printing Office, 1919. (3) Mott, F. \Y.: War Neuroses. British Medical Journal, 1919, i, 439. (4) Wolfsohn, Julian M.: The Predisposing Factors of War Psychoneuroses, Journal American Medical Association, 1918, lxx, No. 5, 303-308. (5) Hurst, Arthur F.: Hysteria in the Light of the Experience of War. Archives of Neurology and Psychiatry, 1919, ii, 563. (6) Pollock, Lewis J.: An Analysis of a Number of Cases of War Neuroses. Illinois Medical Journal, 1920, xxviii, No. 3, 209. (7) Salmon, Thomas W.: The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army. Mental Hygiene, New York, 1917, i, No. 4, 509-547. (8) Rhein, John H. W.: Neuropsychiatric Problems at the Front during Combat. Journal of Abnormal Psychology, 1919-20, xiv, No. 1, 1. (9) Weygandt, W.: Versorgung der Neurosen und Psychocen im Felde. Medizinische Klinik, 1914, x, No. 39, 1503. (10) Schwab, Sidney I.: The War Neuroses as Physiologic Conservations. Archives of Neurology and Psychiatry, Chicago, 1919, i, No. 5, 525-653. (11) Viets. Henry: Neuroses and Psychoses in Base Hospital No. 33. Albany Medical Jour- nal, 1919, xl, No. 1, 17. (12) Kiely, Charles E.: Five Hundred Cases of Shell-Shock. Ohio Medical Journal, 1919, xv, No. 11, 711-718. (13) Bowman, K. M.: Report of the Examination of the----Regiment, U. S. A., for Nerv- ous and Mental Disease. American Journal of Insanity, 1919, lxxiv, 555-6. (14) Jones, D. W. Carmalt: War-Neurasthenia, Acute and Chronic. Brain, New York and London, 1919-20, xlii, October, 176. (15) Lepine, Jean: Troubles mentaux de Guerre, Paris, 1917, Mason et Cie. (16) Read, C. Stanford: Military Psychiatry in Peace and War. H. K. Lewis & Co., London, 1920, 34. (17) Avers.----: Op. cit. 21. CHAPTER IX A POSTWAR STUDY OF A TYPICAL GROUP OF WAR NEUROSES CASES IN 1919-20 AND 1924-25 THE 1919-20 STUDY Reference was made in the beginning of the preceding chapter to the fact that in 1919 and 1924 studies were carried on, in the United States, of the post- war condition of certain of the war neurotic patients of Base Hospital No. 117, A. E. F. Plans for these studies were begun shortly after the armistice was signed, when the statistical work on clinical records at Base Hospital No. 117, A. E. F., was extended to include other purposes besides the definition of the nature of war neuroses and the make-up of patients. The preparation of an address list and the tabulation of supplementary data were undertaken to make possible a later study of these typical cases following their return to the United States. The purpose of the study made in 1919-20 was to determine the condition of a typical group of bona fide war neurosis cases after their return to civilian life in America. Basically it was a search for tendency data concerning the war neurotic's readaptation to the condition of civilian life. Though adequate clinical conclusions for a medical definition of war neurosis or its aftermath could not be drawn from these data, because they are social rather than medical in bias, they nevertheless furnish certain practical insights into the problem of neurosis which may prove of value in directing attitudes toward the problems and difficulties which confronted the war neurotic in his attempts at readap- tation. The point of view used in organizing the data for purposes of summary is entirely a practical one. The former patients of the hospital are classified herein according to the type of civilian readjustment they have made and the extent to wmich they were able to be self-supporting. This point of view is similar to that underlying the military classifications used by the Army in France as definitive of the man's future military usefulness at the time of his discharge from the hospital." The problem was to find out how well or poorly these men were getting along in civilian life; whether they were working or not, or how much, if they were; whether ill or well, etc.; and to attempt to relate these facts to such data as were available about them individually and as a group. As a matter of fact, neuroticism seems to be best defined in terms of the total situation—the patient and his environment. Especially is this important "All individuals in the American Expeditionary Forces were in one or another of the following physical classifications: Class A, all officers and enlisted men fit for combat service; class B, officers and enlisted men temporarily unfit for combat service but physically fit for other duty and restorable to a class A status within a period of six months after classification as B; class C, officers and enlisted men permanently unfit for combat service but capable of performing service in the Services of Supply; class D, officers and men unfit for any duty within the American Expeditionary Forces. 443 444 NEUROPSYCHIATRY in cases where the persistence of the symptoms depends so largely upon envi- ronmental factors of the patient's life. A war neurotic who shortly after his discharge tries his old work in a machine shop and "goes to pieces," and who later leaves the city, works on a farm, and gets rid of his symptoms, would be considered finally cured, in so far as present purposes are concerned. Many of the men of the Base Hospital No. 117 group gave just such a history upon returning to America. Though a return to their old work doubtless would bring on a recurrence of their former troubles, judged from this more inclusive social viewpoint the men are now cured and are listed below in our classification as "normal." In discussing the neurotic the dual fact of personality and environment must be considered, for, according to Southard,1 not only must the patient be refitted to his entourage, but the entourage must be refitted to a returned "shell-shocker." So likewise in discussing the readaptation of the Base Hos- pital No. 117 group in 1919-20 and in a later follow-up group, 1924-25, con- sidered more at length below, categories are used in terms of social status and ability to work and be self-supporting, as the following discussion attempts to bring out. EXPLANATION OF THE CATEGORIES FOR PRESENT CONDITION OF THE WAR NEUROTIC GROUP NORMAL The first category to be used in discussing these cases is "normal." Under this come those men who, upon return home, went back to work and readjusted themselves to civilian life, or have been able to support themselves and their families. Many of them note certain novel tendencies in themselves, such as tendencies to become angry or excited easily, some little nervousness, restless- ness, forgetfulness, and occasional slight headaches or dizziness (seldom enough to incapacitate them from work), and other like mild, neurotic symptoms. Yet the general health of these men is good; they are able to be self-supporting and are normally happy. NEUROTIC The second group, called "neurotic," consists of those who made partial readjustments to their old way of living, yet continued to suffer from one or more rather severe nervous difficulties. Most of these men were under a physician's care, or else had at least consulted one about their condition. They were able to work fairly well, but their own personal lives were unhappy because of these neurotic troubles. Some were assigned to lighter and easier work in their old places and were very sensitive about their lowered status. One finds among them the residue of symptoms shown in France—occasionally, fine tremors and tics, more often speech defects, weakness, insomnia, jumpiness, distressing inability to concentrate, memory disorders, and "spells" of all sorts. One case, that of a man with combined concussion and gas neurosis, working IN THE AMERICAN EXPEDITIONARY FORCES 445 as an express helper, fainted in a railroad station when a nearby locomotive puffed suddenly. A great many minor injuries and several serious accidents were reported by men in this group as the result of their nervous condition. The men of this group tended also to lose considerably in weight upon working hard, especially during the summer. In all men who carried over symptoms to civilian life there was a marked reaction to changes of weather, especially damp weather, which called out moods and depression, seriously handicapping them. In this "neurotic" group there were many men who upon return home tried their former work in machine shops or factories but could not control themselves and became nervous and tired. As one man put it: "I used to work a pneumatic drill but I can not any longer; the constancy of action is so much like a machine gun. I tried my best but could not stick it out. I had a semibreakdown." In the cases of some of the men when gas or ideas of gas were involved, indoor work was difficult. Many of these men, especially during the warm summer months, took positions as salesmen, farmers, sailors, laborers— any position which would give them outdoor work. This change in many cases w-as the basis of cure, for some later wrote that their new work agreed with them and they were gradually getting back to themselves. With difficulty in standing indoor work came the same inability to remain in noisy places, espe- cially machine shops or factories. Also some men who were in school or college reported that they found it very difficult to concentrate upon their work and that their memories were bad. FATIGUED Third comes the group called "fatigued." Most of these men can not work regularly without suffering and being confined to bed. The symptoms here are ready fatigability, severe headaches, lack of ambition and depression (general neurasthenic coloring). Whereas the "neurotic group" are able to work, though with much discomfort, this group can work only on the average about one-half of the time. Some of them are fortunate in having easy jobs or considerate employers and so manage to support themselves after a fashion. In some cases where the men are married, their wives also are working to meet the expenses of living. DISABLED The fourth group consists of those at the time of the follow up (1919-20) actually rehospitalized for psychoneurosis or reporting a "nervous breakdown" or some incapacitating medical disease, such as tuberculosis. One wTould anticipate many physical disorders occurring as an aftermath of the conditions to which the men were exposed in France, and indeed, many of the men have had some difficulty as a result of these experiences. There may also be some men in the "fatigued" group outlined above who have disabilities of an organic nature. A study like the present one made by correspondence naturally can not make adequate clinical differentiations. 446 NEUROPSYCHIATRY PSYCHOTICS Fifth is the psychotic group, including such conditions as dementia praecox, psychopathic personality, and epilepsy. An interesting commentary is the infrequency of psychotic outworkings among the former patients of Base Hos- pital No. 117 as a group. In the 1919-20 study, only one suicide was reported —a man of poor stock and make-up, never at the front, who entered the hos- pital after the armistice was signed and was evacuated with the diagnosis "neurasthenia." Otherwise there were relatively few men (10, or about 1 per cent) whose condition had changed by 1920 from the psychoneurosis diagnosed at the hospital to a psychosis. By 1925 four deaths had been reported as suicides. Twelve were definitely psychotic, 14 were returned as either "in hospital; parents uncertain of address," or "lost" with a psychopathic coloring attaching to their disappearance. For instance, one man enlisted in the Navy under his brother's name, causing the family considerable trouble when he later deserted. The outside total of possible psychotics was 28 cases diagnosed psychoneurotic in France, or 3.4 per cent of the group. This is striking evidence favoring the psychological conception of war neuroses, for the mere possibility of insanity developing in 830 men over a period of seven years would probably not be less than this total. In viewing the 1919-20 civilian status of these men in relation to their physi- cal classification in France, when discharged from Base Hospital No. 117, sev- eral significant considerations arise. First of all, the American Expeditionary Forces physical classification was a practical estimate of future Army usefulness. It took into consideration such matters as health, strength, and endurance. Obviously these are factors which would be of significance in both Army and civilian life. Therefore, if the classifications were adequately made, then some positive correlation should exist between them and the 1919-20 conditions of the men. Second, it should likewise be appreciated that the ability of a man to return to the front calls upon factors in him differing from those that would be called forth in his attempting to get back, for example, to clerking or to farming in civilian life. .Military conditions facing the man in France were obviously very different from civilian circumstances upon his return home. It is quite possible for Army misfits to be normal and even very successful in civil life. Third, the Army estimate of the value of a man before the armistice, when further battle service was under consideration, and during the armistice would be based on different factors; the latter would more nearly accord with the criteria of civilian usefulness. Consequently, throughout this discussion figures are given separately for the two groups of cases, those discharged from Base Hospital No. 117 before the armistice and those discharged during the armistice. The total figures are likewise used when the group as a whole is under consideration. The data on military classification are presented in several tables, and the conclusions from each of them are given in order. IN THE AMERICAN EXPEDITIONARY FORCES 447 Table 7.- Comparison of the 1919-20 follow-up group and the total Base Hospital No. 11', service in regard to physical classification11 Column 1 Column 2 Column 3 Column 4 Physical classification Totals for follow up Totals for hospital _ "'" """ 142 366 508 Percent-age of follow up Percent-age of all cases at B. H. No. 117 A __________________________________________________________1 36 152 8.2 47.6 21. S 9.7 32.6 188 19.6 B........ .. ____________ 210 68 696 316 47.9 21.0 47.4 28. 1 278 1,012 36.6 39.2 c_____________ __________ 171 51 54S 276 39.0 15.9 37.4 24.6 222 824 29.3 31.8 D_____________________ --------------- 11 46 32 139 2.5 14.4 2.2 12.4 57 171 7.5 6.6 T»____________...... ____________ 10 3 48 27 2.3 1.0 3.3 2.4 13 4:w (57.8) 320 (42.2) 75 I.S 2.9 Total___________ ______________ ---------- 1,466 (56.7) 1, 124 (43.3) 100.0 100.0 100.0 100.0 758 (100.0) 2, 590 (100.0) 100.0 100.0 • In each group of figures, the upper figure indicates cases discharged before the armistice; the second, cases discharged during the armistice; and the third (below the line) the total number or per cent. » Transferred to another hospital, unclassified. Table 7 is concerned with the problem of the adequacy of sampling of the follow-up group as compared with the total hospital group from the stand- point of physical classification. The selection of cases used in this study is a good one, especially in reference to the proportions before and during the armis- tice, i. e., 57.8 per cent compared to 56.3 per cent and 42.2 per cent to 43.3 per cent (see totals in columns 1 and 2). Furthermore, the percentages of each class of the follow-up group and of each class of the total hospital group are also indicative of a good sampling (see the figures below the line, lowest figures of each group of three in columns 3 and 4; i. e., 24.6 per cent compared to 19.6 per cent, 36.6 per cent to 39.2 per cent; 29.3 per cent to 31.8 per cent; 7.5 per cent to 6.6 per cent; 1.8 per cent to 2.9 per cent). Likewise, the per- centages of each class in the pre-armistice group of the follow up and of the hospital service (given on the top line in each grouping in columns 3 and 4) are nearly identical, i. e., 8.2 per cent compared to 9.7 per cent; 47.9 per cent to 47.4 per cent; 39.0 per cent to 37.4 per cent; 2.5 per cent to 2.2 per cent; 2.3 per cent to 3.3 per cent. There is more variation in the armistice figures (given in the middle of three in columns 3 and 4) than in the others; but it is, however, a fair sampling from the standpoint of the proportions of each class in the total hospital group (i. e., 47.6 per cent compared to 32.6 per cent; 21.0 per cent to 28.1 per cent; 15.9 per cent to 24.6 per cent; 14.4 per cent to 12.4 per cent; 1.0 per cent to 2.4 per cent). 448 NEUROPSYCHIATRY Several other facts are to be ascertained upon inspection of the data on Table 7. First, the military fact is apparent from the totals at the bottom of column 2 that there were almost as many cases discharged from the hospital during the armistice as before it. The sudden ending of the war just after the United States had thrown our great Army into it, the population of Base Hos- pital No. 117 at the time of the signing of the armistice, the use of Base Hospital No. 117 as a reclassification center for war neurosis cases after the armistice was signed—these facts are the explanation for the nearly equal figures for dis- charges before and after the armistice began. Second, another military fact, it is notable that there was considerable difference in the percentage usage of the different classes before and during the armistice; namely, in class A the difference between its use in 10 per cent of the cases before the armistice and 33 per cent after the armistice had begun. The infrequency before the armistice of the physical classification A indicates that the members of the hospital personnel were only willing to send back to the front immediately 1 man in 10 of the dis- charged psychoneuroses cases, whereas during the armistice one in three were sent out class A to full duty in an army at peace. From Table No. 8 we are able to get some idea of the actual prognostic value of military classification for readjustment in civilian life. The difference between the two tests of fitness, that of civil life and earning a living, that of army life and withstanding the hardships of battle conditions, are obvious. Yet there are enough similarities to justify an expectation of a positive correlation between the facts. Reviewing the figures, we find in the column for class A that 68.1 per cent of the patients reached were carrying on in civilian life in 1919-20; i. e., 45.2 per cent were "normal" according to our categories and 22.9 per cent "neurotic." Of those given class B, 64.8 per cent were carrying on, of whom 41.8 per cent were "normal" and 23 per cent were "neurotic." Of those given class C, 55.4 per cent were carrying on, 33.3 per cent were "normal," and 22.1 per cent "neurotic." Of those given class D, 40.3 per cent were carrying on, of whom 21 per cent were "normal" and 19.3 per cent were "neurotic." The T group is too small and indefinite for drawing inferences; usually the neurotic condition was complicated by other medical considerations. The class B men of before the armistice are as a group readjusting them- selves better to civilian life than the prearmistice class A group. Of course, some of the class A group got back to the front again (several were wounded, a few killed in action), others had "relapses" and were returned to Base Hospital No. 117, whereas, since the war ended so soon, few of the B class patients were used again in battle. There is a corollary to this last in that although about 1 in 2 of the discharged psychoneurosis cases were sent out before the armistice as class B, only 3 in 10 were so classed after the armistice began. The 47 per cent in class B before the armistice indicated a general optimism that a short time out of the hospital and back among other soldiers would cause these men to become suitable as members of combat units. The 37 per cent class C before the armistice indicates that it was not practical with three-eighths of the men to try to so groom them for front-line duty. The C class discharges dropped from 37 per cent before the armistice IN THE AMERICAN EXPEDITIONARY FORCES 449 to 21 per cent afterwards. The increase in class D after the armistice had begun is due to clearing out uncured cases and sending them to hospitals at the ports for further treatment or for return to the United States. Table X. -American Expeditionary Forces, physical classification of 1919-20 follow-up group in relation to condition in 1919-20 a Class A Class B Class C Class D Class T » Total Num-ber Per-centage Num-ber Per-centage Num-ber Per-centage Num-ber Per-centage Num-ber Per-centage Num-ber Per-centage 15 70 41.7 46.1 94 22 44.9 32.8 55 19 32.2 37.3 2 10 18.2 21.7 5 3 50.0 100.0 171 124 39.0 38.7 85 45.2 116 41.8 74 33.3 12 21.0 8 61.5 295 38.9 8 35 22.2 23.0 47 17 22.4 25.0 41 8 23.9 15.7 2 9 18.2 19.6 98 69 22.4 21.5 43 22.9 64 23.0 49 22.1 11 2 11 19.3 167 22.0 4 28 11.1 18.4 32 13 15.1 19.4 29 12 17.0 23.5 18.2 23.9 67 64 15.3 20.0 32 17.0 45 16.2 41 18.5 13 22.8 131 17.3 8 19 22.2 12.5 37 16 17.6 23.8 42 10 24.6 19.6 5 15 45.5 32.6 3 30.0 95 60 21.7 18.6 27 14.3 53 19.1 52 23.4 20 35.1 3 23.1 155 20.4 1 2.8 4 2 2.3 3.9 2 20.0 7 3 1.6 1 2.2 .9 Total ____ 1 .5 6 2.7 1 2.2 2 10 3 15.4 10 1.3 36 152 100.0 100.0 210 68 100.0 100.0 171 51 100.0 100.0 11 46 100.0 100.0 100.0 100.0 438 320 100.0 100.0 188 100.0 278 100.0 222 100.0 57 100.0 13 100.0 758 100.0 0 The upper number in each group indicates cases discharged from Base Hospital No. 117 before the armistice; the second number, cases discharged during the armistice; and the number below the line, total. b Transferred to another hospital, unclassified. Lastly, Table 8 showTs (figures in the "Totals" column) that the recoveries or nonrecoveries from war neuroses of the group studied in relation to military classification gives percentages about the same for those discharged before and those discharged during the armistice. In the two largest groups, i. e., "normal" and "neurotic," the percentages before and during the armistice are nearly identical (39 per cent and 38.7 per cent and 22.4 per cent and 21.5 per cent, respectively). The chances that a man discharged in class A, for instance, would be normal in 1919-20 were about equal for him whether he was discharged before or during the armistice. In other words, the prognostic value of military classification for the group of men discharged from Base Hospital No. 117 before and during the armistice is about the same in terms of civilian read- justment. By way of conclusion it may be said that the data on 1919-20 condition are a verification of the military classification. If the data were to run other- wise than as they do above, it might reflect seriously upon the categories of potential value used by the hospital personnel. The tendency of the data indicates that the medical staff in France gave a good practical consideration 450 NEUROPSYCHIATRY of the make-up and potential value of a soldier before launching him forth with a physical classification to the replacement centers for further utilization of his services by the army. DIAGNOSIS IN FRANCE IN RELATION TO 1919-20 CONDITION Diagnosis in mental disease, especially with the psychoneuroses, is less absolute and clean-cut than in many of the physical diseases. At Base Hos- pital No. 117 there were 12 possible diagnoses under the general head of psycho- neurosis. It is obvious that in making a diagnosis among these categories there would be found considerable overlapping of symptoms and many diffi- culties in accurately differentiating symptom groupings. The list of these diagnoses is given above in Chapter V, page 372. It must be appreciated that the diagnoses referred to, which were devised for the psychoneurosis cases at Base Hospital No. 117, were not used with entire uniformity by the medical officers. Hysteria might be given as the diagnosis by one, whereas the same symptoms drew the diagnosis concussion neurosis from another. These variations were chiefly attributable to officers assigned to the hospital for temporary duty or for training. On the whole, however, the diagnoses were similarly used, for the majority of the cases were diagnosed by a small group of men, the original staff (or others under their supervision), whose notions of the different types of neuroses for the most part coincided. Thus, the great majority of the diagnoses follow the scheme of classification used at the hospital, and the error, above mentioned, though it does enter, plays but a minor part. Our first inquiry into the question of diagnosis and its relation to present condition is in regard to the selection of cases in the follow up. Table 9 gives the frequency of usage of the various diagnoses at Base Hospital No. 117 in France; Table 10 gives the frequency of their occurrence in the follow-up group compared with the total hospital group. Inspection of the percentages for totals in Table 10 for each diagnosis (given below the lines) shows that the follow up is a good sampling of the total hospital group. For instance, hysteria occurs in 27.6 per cent of the cases in the hospital service and 25.9 per cent in the follow up; concussion neurosis occurs in the relative proportions 22.1 per cent and 22.9 per cent; neurasthenia 12.1 per cent as compared to 14.4 per cent; others run 2.8 per cent to 3.8 per cent; 5.1 per cent to 5.4 per cent; 2.1 per cent to 2.2 per cent; 8 per cent to 6.7 per cent; etc. IN THE AMERICAN EXPEDITIONARY FORCES 451 Table 9.—Freeiuency of usage of diagnoses and physical classifications of psychoneurosis cases discharged from Base Hospital No. 177a Diagnosis Physical classification Totals A B c D T » 3 6 30 93 119 92 208 98 19 49 379 338 123 211 306 68 9 717 17 112 236 79 64 38 0 17 9 1 326 247 129 315 102 17 10 573 14 15 69 18 95 56 0 37 9 1 1S7 127 29 87 151 41 18 37 5 16 10 0 0 314 2 4 10 1 58 39 6 11 59 21 0 97 13 28 49 30 7 9 1 0 2 0 72 67 41 79 16 1 2 139 3 3 17 7 0 3 1 3 2S 8 ' 12 29 6 25 19 3 4 57 4 14 55 24 55 15 2 3 2 0 US 56 18 79 70 5 2 174 42 37 112 30 11 1 7 0 15 3 181 " 79 142 18 1 is 25S 3 2 4 2 is ; 2 1 0 28 2 6 12 5 6 20 8 1 40 1 11 3 6 11 15 2 1 3 0 20 33 12 9 26 3 3 53 0 1 4 0 18 2 0 2 0 22 ' 1 4 20 o 2 29 2 11 11 13 s 0 0 0 21 3 3 30 13 24 11 3 0 51 0 1 2 6 1 0 0 1 3 8 1 8 1 1 !______ 11 1 0 1 0 1 0 0 1 1 0 4 1 1 1 1 1 1 5 10 34 4 3 1 ______1 2 ........ 11 19 53 44 i U 4 13 72 142 366 696 316 54S 32 48 27 1,466 276 | 139 1. 124 508 1,012 824 171 75 2. 590 • The upper number in each group indicates the cases discharged from Base Hospital No. 117 before the armistice; the second E discharged during the armistice; and the number below the line, the total. <> Transferred to another hospital, unclassified. 42705—29----30 452 NEUROPSYCHIATRY Table 10.—Comparison of the 1919-20 follow-up group and the total population of Base Hospital No. 117 in regard to diagnosis" ... - -■ Diagnosis Totals for follow up 101 95 Totals for hospi-t al group 379 338 Percent-age of follow up Percent-age of hospital group 23.1 29.7 25.9 30.1 J' 196 717 25.9 27.6 98 76 326 247 22.4 23.7 22.2 22.0 174 573 22.9 22.1 63 46 187 127 14.4 17. S 14.4 11. :i 109 314 14.4 12.1 . 12 9 58 39 2.8 3.9 2. 8 ' 3. 4 21 21 17 97 72 Ii7 2.8 4.8 5.3 3.8 4.9 5.9 38 10 6 139 28 29 5.1 2.3 1.7 5.4 1.9 2.6 16 40 21 57 118 2.1 9.1 2.2 S. 1 56 6.7 4.9 61 174 1 8.0 6.7 53 19 1S1 12.1 5.9 12.4 6.9 72 258 9.5 10.0 . 8 28 12 1.8 1 1.9 2. 2 1. 1 15 40 2.0 1.6 13 4 20 2.9 33 1.3 1.4 2.9 17 53 2.2 2.0 12 0 22 ; 2.8 7 | 0.0 1.5 0.6 12 29 | 1.6 1.1 5 10 21 30 1.1 3.1 1.4 2.7 15 51 1.9 1.9 1 0 3 8 0.2 0.0 0.2 0.7 1 11 0.1 0.4 0 0 4 1 0.0 0.0 0.3 Gastric neurosis. _ _____ __________ . _. ._ _____________ 0.1 0 5 0.0 0.2 Post-operative neurosis.. _. _ _ _______________ . ... 1 10 19 i 0.2 1.2 No disease found_______.....______________________ __________ 53 3. 1 i 4.7 11 72 1.4 2.8 Total........_________________............ 438 320 1,466 1,124 100.0 100.0 100. 0 100. 0 ' 758 2,590 100. 0 100.0 " The upper number in each group indicates the cases discharged from Base Hospital No. 117 before the armistice; the second, cases discharged during the armistice; and the number below the line, the total. IN THE AMERICAN EXPEDITIONARY FORCES 453 Table 11 gives the relationship of disgnoses to condition in 1919-20. the psychotics are combined with the organic group; individual statistics for those classed psychotics here are to be found in Table 12. Some of the diag- nostic groups are very small. They are included in part for the sake of com- pleteness, for, since they are a representative sampling of the total hospital service, their proportionate size is a just index of their frequency of occurrence in Base Hospital No. 117 in France. Table 11.—Condition in 1919-20 in relation to diagnosis in France " Normal Neurotic Fatigued Disabled and psychotic Total Num ber Per-centage Num ber Per-centage 2S. 8 18.9 Num ber Per-centage Num-ber Per-centage Num ber Per-centage Hvsteria.. 26 34 25.7 35.8 29 18 20 20 19.8 21. 1 26 23 25.7 24.2 101 95 23.1 29.7 60 30.6 47 24.0 40 20.4 49 25.0 196 25.9 Concussion neurosis 44 29 44.9 38.1 28 17 28.6 22.3 8 18 08.2 23.7 18 12 18.4 15.8 98 76 22.4 23.7 73 41.9 45 25.9 26 14.9 30 17.2 174 22.9 Neurasthenia. __ 27 9 42.8 19.6 10 9 15.9 19.6 15 15 23.8 32.6 11 13 17.4 28.2 63 46 ---- 14.4 14.4 36 33.0 19 17.4 30 27.5 24 22.0 109 14.4 Concussion syndrome 29 9 54.7 47.3 53 19 6 31.6 1 5.3 3 15.8 12. 1 5.9 38 52.8 12 16.7 10 13.8 12 16.7 72 9.5 Anxiety neurosis_____ 17 9 42.5 42.9 13 7 32.5 33.3 4 4 1.0 19.0 6 1 15.0 4.8 40 21 9. 1 6.7 26 42.6 20 32.9 8 13.1 7 11.4 61 S. 0 Exhaustion neurosis. _ 11 8 52.4 47.0 0 4 0.0 23.5 4 1 18.6 5.9 6 4 28.6 23.5 21 17 5.3 19 50. 0 4 10.5 5 13.2 10 26.3 38 5.1 3 4 25.0 44.4 1 2 8. 3 22.2 2 0 16.6 0.0 6 3 50.0 33.3 12 9 2.8 7 33.3 3 14.3 2 9.5 9 42.8 21 2.8 Psychasthenia_________ 3 2 37.5 28.6 0 2 0.0 28.6 12.5 28.6 4 1 50.0 14.2 8 7 1.8 2.2 51 33.3 2 13.3 20.0 5 1 1 33.5 15 2.0 Oas neurosis______________.....______________ 1 6 20.0 60.0 2 2 40.0 20.0 20.0 10.0 20.0 10.0 5 10 1.1 3.1 7 46.8 4 | 26.6 13.3 2 13.3 15 1.9 4 0 33.3 0.0 4 1 33.3 0 | 0.0 8.3 0.0 3 0 25.0 0.0 12 0 2.x 0.0 4i 33.3 4 | 33.3 8.3 3 25.0 12 1.6 Effort syndrome____________________________ 1 4 10.0 66.7 3 1 30.0 16.7 0.0 16.7 6 0 60.0 0.0 10 6 2.3 1.7 5 | 31.2 4 25.0 6.2 6 37.5 16 2.1 Timorousness_________________ ....... 5 1 38.5 3 ! 75.0 8 j 47.1 2 0 15.4 0.0 7.7 0.0 5 1 38. 5 25.0 13 4 2.9 1.3 2 j 11.8 1 5.9 6 35.3 17 2.2 (■as syndrome__________________ ______ 1 "1""" ........ 100.0 0.0 ... 1 0 0 2 0.0 1 I 1 100.0 1 1 ' No disease found______________________...... 0 7 0.0 71.0 0 1 0.0 10.0 0.0 10.0 1 1 100.0 10.0 1 10 0.2 3.1 7 1 63.7 1 1 9.1 9.1 2 18.2 11 1.4 0 The upper number in each group indicates the cases discharged from Base Hospital No. 117 before the armistice; the second, cases discharged during the armistice; and the number below the line, the total. Table 12.— Condition in 191,9-20 in relation to diagnosis and pliysical classification A Normal Neurotic Fatigued Organic Psyc hot ic Total. B C D 3 T" ... To-tal 26 34 A 3 11 B 9 3 C 16 2 D 1 2 3 ____ 1 Ta TO-1 tal _.. 29 ... 18 ... 47 _. 2x ..- 17 ... 45 A "Y 7 B 5 4 9 7 4 11 5 3 C 14 5 19 D 1 4 5 T' To-tal 20 20 40 8 18 26 15 15 A B 0 D T> To-tal A B C D T> To-tal A B C 1) T» Grand Total Hysteria: I'reannistiee_____ During armistice. 2 9 j 15 IS 7 j 6 20 16 | 21 4 j 35 5 23 3 1 27 | 38 6 2 | 11 13 4 ___' 4 ~~7~ 7 "(T 6 ____ 4 5 n 14 3 3 7 10 1 1 22 22 44 16 12 1 1 — 3 1 4 1 1 — 1 1 4 1 5 6 43 27 19 62 17 5 16 1 1 ] 1 1 101 95 Total_______ . 3 L 60 | 14 44 3 29 1 11 12 ! 18 17 5 49 46 73 13 86 25 6 79 21 196 Concussion neurosis: 2 2 ____ 1 20 2 22 == i 5 3 X 5 1 1 13 14 ~~3~ 2 2 8 53 61 2 10 16 ____ 4 6 20 | 6 33 1 2 16 14 98 During armistice.. 9 5 1 1 = 4 !___ 15 5 =l= 4 ' 6 2 5 2 2 1 4 --- 76 Total 73 14 .. : 28 174 Neurasthenia: 27 9 ~~2 10 9 1 4 ... 11 12 63 During armistice____ ... 5 ... 1 1 46 Total.. _____________ 6 11 i 17 1 1 1 36 : 2 6 : 6 4 1 5 ... 19 3 8 14 5 --- 30 9 1 10 1 6 11 5 2 23 1 -= 1 1 1 12 7 9 16 31 49 | 16 1 109 Concussion syndrome: 2 fi 21 4 3 .... 1 29 9 1 2 6 6 8 | 8| 3 ___1 7 3 5 X 3 11 1 36 9 45 19 5 24 5 1 1 .... 6 1 4 53 During armistice_____ . 4 8 1 1 19 -- -----]— -- 2 —,— - — 1 1 Total 8 24 4 jJl 1 38 ' 3 17 1 9 5 26 6 1 12 8 -> ' -- — Anxiety neurosis: 1 5 1 10 [ 5 3 ! 5 1 6 6 1 7 1 --13 1 1 1 2 2 2 4 4 4 ____ 1 ~~2~ 3 3 6 1 6 4 3 11 14 16 3 1 i 1 1 ' 1 40 During armistice 1 2 7|__-. 1 1... 21 — 1 ___i__ 1 1 ___ X 3 4 2 3 -- - — — - — — -- Total 6 13 5 ...| 20 1 19 1 2 2 61 14 3 ....... 7 3 ... 21 6 .... 1 I 1 8 2 1 4 4 2 12 «,.__ Kxliaustioii neurosis: 4 2 6 1 6 1 3 3 9 4 11 S 19 4 4 3 2 4 7 21 During armistice. 2 2 4 | 1 2 17 I Total.. ____ ? 2 4 ' 1 4 2 7 2 6 1 1 2 3 10 6 3 9 11 1 :iv 1 1 = 1 1 2 ___ _ Hypochondriasis: I'rearmistice_____ During armistice 2 3 4 1 ? 2 1 1 2 12 i ■ 3 1 1 1 1 S ... 3 2 _.L i i --_ == == __' 1 Total.. . _ 2 7 3 2 1 2 3 3 == 21 1 1 ' 3 =f l'sychasthenia: 1 1 | 1 1 1 2 2 4 2 1 5 2 During armistice i ________ 1 I-..J 3 2 2 9 1 1 |__. -- — - — 1 1 — 1 -- — - - — -- — 2 2 -- -- ___lU_jl 4 ' 114;:. 53 ___ --------. . ' ■ --.--.- ---— Gas neurosis: Prearmist ice 1 2 3 1 6 .... 1 1 1 2 1 2 2 4 1 1 1 4 1 3 1 1 5 During armistice . 3 3 1 1 1 | 1 6 10 . 1 -- — — 1 Total ... 1 7 1 1 1 ... 2 6 7 2 15 Anticipation neurosis: Prearmist ice. -. 4 4 -- 1 3 4 1 -- 1 2 3 2 10 12 During armistice Total_____ 4 4 1 -- 1 3 1 4 3 1 1 — 1 1 4 2 1 3 6 1 2 7 2 10 2 1 12 = = = = = — — === -- 1 ^^ -- Effort syndrome: Prearmist ice. _ 1 2 1 10 During armistice-. - 1 2 1 4 .... 1 2 1 6 Total-- . 1 1 3 2 1 1 5 '== 3 1 2 4 2 = 1 = 1 4 1 _ — 1 4 1 6 5 1 1 9 3 10 1 2 1 16 __ = = 1 = == == === == __ ______ Timorousness: Prearmistice. __. "~3~ 3 2 5 3 8 1 3 2 13 During armistice______ 4 1111 3 __._ 2 Total__________ 2 2 1 ~ 1 .... 5 6 4 -- 11 .... 2 17 1 = = — = = === Gas syndrome: Prearmistice. _ _ 1 1 During armistice Total ... 1 = 1 1 = = = -- T = 1 1 ~ = === = No disease: Prearmistice i ... ... 1 8 9 1 1 During armistice 5 5 1 1 1 1 7 7 1 1 1 1 1 1 i 1 1 10 1 " Total_______ . 2 2 1 1 11 --- Totals: Prearmistice______ During armistice... 15 70 85 94 55 22 1 19 2 10 5 3 171 1?4 8 , 47 35 17 41 8 49 2 9 11 = 98 69 167 4 28 32 32 1 29 13 14 45 I 43 2 11 13 - 57 , 8 66 19 133 1 57 37 16 53 42 10 52 5 15 20 3 3 95 60 155 1 ... 4 2 fi ... 1 2 2 7 3 10 36 152 188 210 68 ?78 171 51 222 11 46 10 3 438 320 Total__________ 116 74 I 12 8 M5 1 43 1 fid 1 57 13 758 Transferred to another hospital, unclassified. 456 NEUROPSYCHIATRY If we combine for each diagnosis the normal and neurotic groups, that is, the patients of the hospital who were engaged in some pursuit in civilian life in 1919-20, and compare the various diagnoses on the basis of percentage working and percentage disabled (fatigued, disabled, or psychotic) some inter- esting data come to the surface. For instance, if we rank the various diagnoses on the basis of the percentage of those reached in 1919-20 who were working in civilian life we get the following figures: Table 13.—Rank order of diagnoses on the basis of the percentage of those carrying on in civilian life in 1919-20 Diagnosis Per cent Diagnosis Per cent 1. Anxiety neurosis________ 2. Anticipation neurosis. ... 3. Gas neurosis. _____ ___ 75.5 (N-61) 75.0 (N-12) 73.4 (N-15) 72.5 (N-11) 69.5 (N-72) 67.8 (N-174) 60.5 (N-38) 8. Timorousness__________ 58.8 (N-17) 56.2 (N-lfi) 10. Hysteria_______________ 11. Psychasthenia__________ 12. Neurasthenia..... _____ 54.6 (N-196) 53.3 (N-15) 5. Concussion syndrome___ 6. Concussion neurosis_____ 50.4 (N-109) 47.6 (N-21) 7. Exhaustion neurosis_____ Thus it is seen that the typical war neuroses—notably the concussion, gas, and anxiety types—rank very high in percentage of successful readapta- tion, while the more pronounced constitutional types rank lower. A commen- tary of no little interest here is that the conclusions offered by these data approach very nearly the prognoses made by the medical staff of the hospital, while the men were still in France, as to the future well-being of the various types of these cases. The exhaustion, concussion, and anxiety cases were given the best prognosis, the effort syndrome cases, the cases of neurasthenia, psychasthenia, and hypochondriasis the worst. Hysteria was placed in between these groups. And no one predicted any marked number of psychotic outworkings from these symptoms. These facts are in the most part borne out by the above figures. The fact that the true battle neuroses—the concus- sion cases, for instance—are readjusting themselves better proportionately than the timorous, neurasthenic, or hypochondriacal types is interesting, showing, as it does, how incorrect are the popular notions of war neuroses. Men who developed nervous symptoms in the cantonments at home are usually viewed with suspicion by ordinary persons and regarded almost as malingerers by many. The facts here indicate that the hypochondriasis, psychasthenia, neurasthenia, and timorousness groups, due perhaps to the long continued nervous state before the onset of symptoms, often playing upon constitutional susceptibility, do not readjust themselves nearly so well as the actual concussion cases; in other words, many men who never saw action have a more serious aftermath in symptoms than those who were actually in the thick of it, and were concussed by exploding shells or driven into an anxiety state by the fearful conditions and terrible sights at the front. Among the cases of hysteria, the majority are having difficulty getting along in civil life, and, though earning their own living and seemingly carrying on their work, still they are constantly unhappy because of neurotic residues in the form of headache, insomnia, jumpiness, speech disorders, and often tics. On*the whole, the men who had hysteria retain enough of their old condition IN THE AMERICAN EXPEDITIONARY FORCES 457 to handicap them seriously in their personal lives, though not always directly in their business activities. A little more than one-half of them are able to earn their living and ask financial aid of no one, but the great majority are nevertheless constantly seeking advice from physicians. The symptoms in France were usually so gross and vivid that one may believe they probably tended to lay stronger habit foundations than any of the other symptom groupings. An interesting point in reference to neurosis aftermath applicable to nearly all neurosis types, is derived from a physiological truism to which Mott? refers in discussing psychoneurosis: "Consciousness of the existence of an organ or structure interferes with its normal automatic or habitual action." War neurotics, who were sensitive for months to every change in their bodily feelings, who were keenly introspective and analytic of the existence of the various organs and structures of the body, are guilty of continuing even now this search for symptoms in themselves. And it is rare indeed that this search is unre- warded; for example, anyone can produce a headache by introspection of the contents of the cranium continued over several minutes. These men are slow to recognize the feeling of well being, quick to note any signs of possible ill being. This morbid practice may be the basis of many of their present diffi- culties. The effort syndrome cases also tend to be seriously and permanently affected by their symptoms. The great cause for the persistence of symptoms among these cases is that the facilities for treating the men in France were not adequate for the needs. Time and special care, both vital factors in these cases, could not be offered at a hospital where beds were constantly in demand and where there was no room for chronic cases requiring lengthy treatment. The result was that these patients were for the most part sent to light duty in the Services of Supply. Unfortunately, the officers assigning men to duty at replacement camps as a rule did not consider the mental condition of the men so much as their physical appearance. Many men, not only in this group but in all groups, were sent to duty too soon. The group diagnosed as state of anxiety or timorousness show a great number as being permanently affected by their condition in France. The explanation in this case, as in some of those diagnosed hypochondriasis, rests in the make-up of the individuals. These were men who as a group were of inferior intelligence, dull normals, or even morons. The cure of a neurosis in an intellectually inferior person is usually very difficult. The men diagnosed as "Psychoneurosis, no disease found," were an anom- alous group, and generally some other medical diagnosis followed this one. Base Hospital No. 117 being only for psychoneurosis cases, that diagnosis in some form had to be given on the patient's discharge slip when transferred to another hospital for treatment. The percentage of successful readjustment among members of this group represents cures from diseases other than psycho- neurosis. 45S NEUROPSYCHIATRY PHYSICAL AND MENTAL CONSIDERATIONS IN RELATION TO CONDITION IN 1919-20 AGE AT TIME OF HOSPITALIZATION The follow-up group under consideration is a good sampling of the entire group of patients at Base Hospital No. 117 in the matter of age. This is shown bv the fact that the median age for the follow-up group is 24.46 years, while that for the total hospital population is 24.66 years. The numbers for each age are given in Table 14. Table 14 — \ges at hospitalization in France of follow-up group in relation to condition in 1919-20 Age Normal Neurotic Fatigued Disabled Psychotic Totals 0 I) 2 13 15 28 37 37 40 22 27 12 15 9 3 9 3 3 2 1 0 1 0 2 10 7 13 19 26 13 16 13 9 6 6 5 8 4 1 1 0 1 1 0 0 2 7 10 2 15 16 16 14 9 5 10 4 6 3 3 0 0 1 0 1) ' 0 l) 0 2 0 s 3 6 0 8 | 1 1 0 8 41 38 '- 15 15 24 12 12 6 3 2 s 0 0 1 0 0 0 2 1 1 86 94 94 64 27...........________........... til 32 36 30.............._______...........-- 22 23 8 1 0 6 i 0 1 | 0 0 i 0 28 16 33 ....................._______........___ 5 34 . . ____........_____________________ 3 35 ............_____________________ 0 0 1 1 1 0 3 36 ..........._________............- 1 2 1 2 2 1 1 2 1 1 0 1 0 2 1 2 1 1 3 1 1 0 48 _ .___________ . 0 49 . . .............. 0 1 1 N______________________________________________ = 283 165 125 140 10 | 723 = 24.25 24.38 23.69 | 24.69 26 | 24.46 Q._ .. _ _. ._ __ = 2.125 j 2.625 2 32 (Median for total hospital group, 24.66 years.) In so far as these data are significant, the factor of age enters but little in relation to the type of social readjustment of the Base Hospital No. 117 group of war neurotics in 1919-20. The median of the "fatigued" group is a little over one-half a year less than that of the "normal" group, and the median for the "disabled" group almost one-half a year above the "normal" group median. The median is 24.47 years for the combined "normal" and "neurotic" groups (that is, for those who were carrying on in civilian life in 1919-20) and 24.68 years for the combined "fatigued" and "disabled" groups. Thus, a comparison of medians indicates a slight tendency for younger men to be doing better in civil pursuits than the older men. When distributions for the groups are studied IN THE AMERICAN EXPEDITIONARY FORCES 459 from the standpoint of dispersion on the basis of the percentage of men 21 years of age and under, and the percentage of men 36 years of age and over in the various groupings of present condition, as Tables 15 and 16 show, there is also indication of a slight tendency for the younger men to be readapting themselves better than the older men. Table lo. -Distribution of cases within the normal, neurotic, fatigued, and disabled groups according to age Age 1 Normal Neurotic Fatigued Disabled Number Per cent Number Per cent Number Per cent Number Per cent 21 years and younger_______________ . 22 to 35 years (inclusive)_________ 36 years and older________________ 58 ! 20.5 220 77.8 5 | 1.7 33 127 5 18.2 78 8 3.0 21 102 2 16.8 81.6 1.6 24 112 4 17.1 81). 7 2.2 Total_________________ . .. 283 ! 100 165 100 125 100 140 100 Table 16.—Distribution of cases within each age group according to condition in 1919-20 Condition Normal. . Neurotic. Fatigued. Disabled. Total. 21 years and younger 22 to 35 years (inclusive) 36 years older Number 1 and Number Per cent Number Per cent 'er cent 58 33 21 24 42.7 24.3 15.4 17.6 220 ' 39.2 127 . 22.7 102 1 18.2 112 ; 19.9 5 5 2 4 31.25 31. 25 12.5 25 136 100 561 100 16 | i 100 PERSONAL AND FAMILY HISTORY (SEPARATELY AND COMBINED), PRIOR TO HOSPITALIZATION, RELATED TO CONDITION IN 1919-20 Often the opinion is expressed that those wdio, after the war, were not fully recovered from war neuroses were for the most part men of inferior stock and make-up. In other words, persistence of symptoms is supposed to be related primarily to neuropathic make-up. The accompanying data tend to confirm this opinion. In the matter of personal history prior to hospitalization as shown in Table 17, there are 56.4 per cent of those who are now normal who gave a negative history; 47.5 per cent of the neurotic group and 47.6 per cent of the fatigued group who were negative; and 45.4 per cent of the disabled group. For family history, likewise, the normal group has the highest percentage of negative cases; i. e., 52.8 per cent; the neurotic 46.8 per cent; fatigued 44.8 per cent; and disabled 45.5 per cent. When family and personal history are combined the same tendency is present; for Table 17 also shows that 42.2 per cent of the normal group, 31.2 per cent of the neurotic and of the disabled, 32.2 per cent of the fatigued group were negative. There is thus a definite tendency for those of good stock and make-up to readapt themselves better to civilian life than those in whom personal or familial taint is found; still, many war neurotics are now disabled who gave a good history, and a number are now carrviii"- on who were of poor stock and make-up. Thus, evidently, according to these data, stock and make-up alone, though significant, do not afford a sufficient basis for the prognosis of civilian readaptation. 460 NEUROPSYCHIATRY Table is shows that on the whole the follow-up group are an adequate sampling of the hospital group from the standpoints of family stock and personal make-up. Table 17.—Family and personal histories (positive and negative) in relation to condition in 1919-20, numbers and percentages " Family histor y uive Personal history Combined family and personal history Positive Neg Positive ! Neg *tive Per cent Positive Negative Num- Per Num-ber ; cent ber Per cent Num- Per Num-ber cent ! ber Num-ber 159 110 84 96 Per Num- Per cent ber i cent Normal___________ _____________ Neurotic__________ _._ _________ Fatigued____________ - __________ Disabled_____________________________ 127 ' 47.2 142 84 53.2 74 69 55. 2 56 78 : 54. 5 65 52. 8 46.8 44.8 45. 5 117 43.6 82 52.5 65 52.4 77 ; 54.6 151 74 59 64 56.4 47.5 47.6 45.4 57.8 68. 8 67.8 68. 1 116 42.2 50 ! 31. 2 40 32.2 45 ! 31.9 Total___________________________ 358 51.5 337 48.5 341 49.5 348 50.5 449 64. 1 251 i 35.9 <• Exclusive of psychotic cases, the number of which is too few (eight) for comparative purposes. Table IS.—Family and personal histories (positive and negative) of follow-up cases compared with 1,000 unselected cases from Base Hospital No. 117, numbers and percentages Family history Personal history Combined family and personal history Positive Num- Per ber j cent Negative Positive Negative Positive Negative Num- Per Num-' Per ber cent ber 1 cent Num- Per ber cent 488 ! 48.1 348 ' 50. 5 Num-ber Per cent Num-ber Per cent One thousand unselected cases... ... Follow-up . ___ _ ... _ __ . 508 1 50. 2 358 51. 5 505 49.8 527 51.9 337 48. 5 341 | 49. 5 1 643 449 63.5 64.1 370 251 36.5 35.9 SOCIAL STATUS IN RELATION TO PRESENT CONDITION PRE-WAR OCCUPATION The first question that arises regarding occupation is the adequacy of sampling of the follow-up group when compared with the total hospital service. Using the categories of the Bureau of the Census, the totals column of Table 19 shows that a somewhat greater proportion than the expected quota an- swered of those engaged in agricultural (15.5 per cent compared to 11.5 per cent) and professional work (10 per cent to 7.2 per cent) and that the propor- tion of replies from those engaged in trade (8.6 per cent to 11.1 per cent) and clerical work (12.7 per cent to 15.9 per cent) was slightly less than quota. On the whole, the sample was a representative one, for the other items used in the United States census, the differences were less than 1 per cent from expec- tation in terms of the total hospital group, namely, 2.2 per cent compared to 2.3 per cent; 33.3 per cent to 34.7 per cent; 13.5 per cent to 13.8 per cent; 2.1 per cent to 2 per cent; 2.1 per cent to 2.5 per cent. IN THE AMERICAN EXPEDITIONARY FORCES 461 Table 19.—Relation of pre-war occupation" to condition in 1919-20 Normal Neurotic Fatigued Agricultural____ Mining____ . __. Manufacturing. . Transportation . Trade_________ Public service. _. Professional_____ Domestic service. Clerical________ Total. Num- Per Num- Per ber cent ber cent 34 13.9 14 10.4 4 1.6 2 1.5 79 32.3 51 37.8 24 9.8 20 14.8 26 10.6 8 5.9 3 1.3 4 3.0 29 11.9 16 11.8 5 2.1 2 1.5 41 16.5 18 13.3 22.5 1.8 31.5 17. 1 4.5 0.9 8.1 3.6 9.9 245 100.0 l 135 100.0 111 100.0 Disabled • Psychotic Total of Total fr.H/.vL-.... I hospital Num- Per Num- Per ; follow-up | service _ ber cent ber cent 16.8 2 33.3 3.8 1 16.7 32.8 1 16.7 3.8 6.9 1.5 7.6 100.0 97 15.5 261 14 2.2 53 209 33.3 789 85 13.5 313 54 8.6 253 13 2. 1 45 63 10.0 163 13 2. 1 :t. 80 12.7 339 628 100.0 2.273 11.5 2.3 34.7 13.8 11. 1 2.0 7.2 2. 5 15.9 100.0 0 Exclusive of 51 who gave occupation "labor" and 42 who gave "student" (12.9 per cent). * Exclusive of 293 classed as "labor" and 194 as "student" (15.5 per cent). Table 20.—Relation of 1919-20 condition to pre-war occupation " Agricultural Mining Manufacturing Transportation Ti Numbe ade Number Per cent 1 Number Per cent Number Per. ent ".8 (.4 i. 7 1.6 1 5 Number Per ce It 2 5 4 9 ■ Per cent Normal_______________ Neurotic______________ Fatigued________ _____ Disabled______________ Psychotic_____________ 34 35.0 14 14.4 25 25.8 22 1 22. 7 2 2.1 4 2 2 5 1 28.6 14.3 14.3 35.6 7.2 79 51 35 43 1 3 2 1 2 24 20 19 22 28. 23. 22. 26 8 5 13 2 48.1 14.8 9.3 24.1 3.7 97 i Total____________ 100.0 14 100.0 209 100.0 85 100.0 54 100.0 Public service Professional Domestic service Clerical Number Per cent Number Per cent Number Per cent Number Per cent Normal____ ... ... ____ 3 4 23.0 30.8 38! 5 29 16 9 9 46.0 25.4 14.3 14.3 5 2 4 2 38.4 15. 4 41 18 51.2 22.5 1 5 30.8 : 11 15.4 ! 10 13.8 12.5 Total........ 13 100.0 63 100.0 13 100.0 80 100.0 » Exclusive of 51 who gave occupation "labor" and 42 who gave "student" (12.9 per cent). Table 21.—Rank order of percentage of men of each occupation of the 1919-20 follow-up group now able to work " Rank order Occupation Clerical_______ Professional--- Trade________ Manufacturing. Public service.. Number 54 209 13 73.7 71.4 62.9 62.2 53.8 Rank order Occupation Domestic_____ Transportation. Agriculture____ Mining_______ Number : Per cent 13 53.8 85 51.7 97 49.4 14 42.9 " Combined "normal" and "neurotic" groups in Table 19. Tables 19 and 20 bring out the general facts of tendency. The significance of the data is conclusively shown in Table 21 which gives the rank order of the percentages of men in various occupations now able to carry on. The ranks are arrived at by adding together the percentages of "normal" and "neurotic" for each occupational group as given in Table 20. With the exception of mining 402 NEUROPSYCHIATRY (X-14) and domestic and public service (X-13 in both), the groups are all large enough to draw significant comparisons. From these figures it is evident that the clerical and professional groups are making the best readjustment of all the occupational groups. Trade and the mechanical and manufacturing trades come next, and at the bottom are transportation, agriculture, and mining. Lastly, it is to be noted that, in general, men from the higher types of occupations, those requiring somewhat more intelligence for performance, are in better shape proportionately than men from some of these occupations demanding less intelligence for successful participation. COMPARATIVE FIGURES FOR THE 1919-20 CONDITION OF THE GROUP AS A WHOLE RELATED TO THEIR CONDITION AT DISCHARGE FROM BASE HOSPITAL No. 117 In comparing the civilian value of this group of men in terms of our cate- gories of readjustment, with their military worth based upon the hospital's classification, an estimate is obtained of the social value of the group of men reached in the follow-up in two different social situations; first, the Army at war and during an armistice, and second, civilian life in America in 1919-20. Tendencies regarding these facts may be noted by comparing those classified A upon discharge with those now reporting themselves "normal," the B class with the "neurotic," C class with "fatigued," and D and T combined with "disabled" and "psychotic" combined. Furthermore, the class A and class B groups may be combined and compared with the "normal" and "neurotic" figures. Table 22 gives us a summary of the 1919-20 condition of members of the group on whom we have data. Practically 61 per cent, the combined "normal" and "neurotic" groups of the men located in 1919-20, were self-supporting in civil life or sufficiently strong and well to be on active duty in the Army or to be attending school or college. Of this 61 per cent, there were 22 per cent in the "neurotic" group who were able to support themselves, though, from a health standpoint, they were by no means well. The remaining 39 per cent in the "fatigued," "disabled," and "psychotic" groups were either in hospitals when last heard from or were having difficulties of various sorts. The "fatigued" group were the only ones of those last mentioned who were able to work at all, and they could work, on the average, only two or three days a week. Table 22 is, in effect, a comparison of the military classification of useful- ness to an army of a group of neurotics, as a group, with their civilian value in terms of usefulness to society and to themselves a year or so later, after return- ing home. It is a striking fact to be gathered from the table that whereas there are almost twice as many of the follow-up group proportionately who are "normal" and of full usefulness in civil life as there were those who were class A and presumably of full use to the Army, still, when one gets the sum of per- centages of those of full use (class A) and of prospective full use (class B) and compare with it the sum of those "normal" and those "neurotic," the figures are practically identical (i. e., 61.4 per cent as compared to 60.9 per cent). There are about the same proportions who are now (1919-20) partially or wholly disabled, and drags on society, as there were of men who were almost, or actually, useless for combat service. IN THE AMERICAN EXPEDITIONARY FORCES 463 Table 22.—Comparison of physical classification in the American Expeditionary Forces and the 1919-20 condition of the follow-up group, arranged so as to show cases discharged from hospital before the armistice (upper figures of each group) and during the armistice (loiver figures of each group) Physical classification Number Per cent 1919-20 condition of follow-up group Number Per cent A _______..... ........__________ 36 152 8.2 17.6 Normal________________________ Neurotic........______ Fatigued.______________________ Disabled, psychotic. ____________ 171 124 295 39.0 38.7 188 24.8 38. 9 B_______________ _______________ 210 68 47.9 21.0 98 69 22.4 21.5 278 36.6 167 22. 0 C_________________________.....- 171 51 39.0 15.4 67 61 15.3 20.0 222 29.3 131 17.3 D (and unclassified)_______________ 11 46 4.8 15.4 102 63 22.3 19.6 57 9.3 165 21.7 When individual items in Table 22 are compared, though the same tenden- cies hold, the discrepancies are greater. For instance, the proportion of class A of the prearmistice group compared with the proportion of "normal" of the prearmistice group gives 8.2 per cent class A and 39.0 per cent "normal." On the contrary, for the armistice group there are 47.6 per cent class A and only 38.7 per cent "normal." In class B, the figures are reversed, the "neurotic" group of the prearmistice discharge from the hospital contain 22 per cent of the cases whereas class B comprised 47.9 per cent of those discharged before the armistice; the percentages of class B and "neurotic" are identical for the armistice group. And the proportions of Army and civilian disabled in the two groups for the armistice group are practically identical. A general conclusion which may be drawn from the above facts is: When the civilian status of an unselected group of 800 war neurotics returned to civilian life, is estimated in 1919-20 with the five categories used here, "normal," "neurotic," etc., and the proportions of each status compared with the esti- mates of Army usefulness (military physical classification) made in France in 1918, we find that although there is a tendency for a greater proportion to be first-rate citizens (normal) than first-rate front-line material (class A), still, by and large, the group is as great a weight upon society b as it was upon the Army in war times in France. At first sight, for 39 per cent of a hospital's service to be disabled in later life would seem to be a very high figure. And, indeed, in the case of an ordi- nary hospital, it would be so. For if, of every 100 adults who were in a hospital for "operations and diseases during 1918, two-fifths were still to be disabled, healthy and fit men would be at a premium. These figures loom large forjthe " . In attempted ex^aUo^TThe^rioTis carry-over of symptoms by the men of the follow up it is necessary to In attempted exp. significance of the pension issue in relation to present condition. Psychoneu- .nc hide, o course a consriera Wt e Government compensation. An estimate of the rela- a^Z^ee^veZfconaition of the former patients of Base Hospital No. 117 and exaggerated desire for Gov eZSSSTextremely difficult of definition and beyond the scope of this study. 464 NEUROPSYCHIATRY Base Hospital Xo. 117 service, but small in terms of the total American Expe- ditionary Forces cases. The Base Hospital Xo. 117 admissions were of two strains: First, more or less "chronic" cases sent from other nonpsychiatric hospitals in France; and second, cases from the advanced neurological hospitals. The former cases were usually inadequately treated in some way or other, with consequent fixation of symptoms. Of the latter we have more definite knowl- edge. They represent approximately 15 per cent (the severe, resistive cases) of the total neuroses so classified during the St. Mihiel and Meuse-Argonne operations. For every 100 war neurosis cases which developed during the St. Mihiel and Meuse-Argonne operations, 15 were sent from the forward area hospitals to Base Hospital Xo. 117. If nowT, of those 15, two-fifths are dis- abled, it means that at least 6 out of every 100 cases developed during this period referred to were unable to carry on in civil life in 1919-20. It is a fair statement to make that the cases discharged from the forward area hospitals as class A, and ready to return to the front, which amounted to Nf) out of every 100, would be probably much superior in potential civilian well-being to the class A patients of Base Hospital Xo. 117. Therefore since 67 per cent of the A cases at Base Hospital No. 117 are now carrying on in civilian life, it follows, if our premise is adequate, that at least two-thirds, or 57 of the 85 admitted to these forward-area hospitals and sent out class A, would be carrying on in civil life. Our estimates, therefore, would be that of 100 cases of war neuroses which developed at the front, at least 57 of the advanced hospital service, and 9 more of those sent from this service to Base Hospital Xo. 117, or 66 in all, are now carrying on in civil life. The prob- ability which may be sustained by future research is that when the war neuroses were handled by specialists at the front the percentage of cure and of later civilian readjustment is much greater than is found here to be the case for the Base Hospital Xo. 117 service, where some of the men were hospitalized else- where before admission, and those from the special service at the front were especially severe cases and evacuated to the rear for that purpose. THE 1924-25 STUDY The purpose of this study was identical to that of the 1919-20 study described above. Table 23 is concerned with the problem of the adequacy of sampling of the follow-up group as compared with the total hospital group from the stand- point of physical classification. The selection of cases of the follow up is in general a good one from the standpoint of physical classification. While there are variations in the relative size of prearmistice and armistice figures, yet the totals of prearmistice and armistice cases for each classification are usually close in both sets of data. For example, the totals of class A are 23.5 per cent for the follow-up group and 19.6 per cent for the total hospital group, IN THE AMERICAN ENPEDITIONARY FORCES 465 for class B, 39.2 per cent and 39.1 per cent, respectively, class C, 29.3 and 31.8 per cent, class D, 5.9 per cent and 6.6 per cent, etc. (fable 24.) For the total groups likewise the prearmistice and armistice selections are good samplings (00.5 per cent of the follow up are prearmistice, compared to 56.3 per cent of the total hospital group and 39.5 per cent are armistice compared with 43.3 per cent of the total hospital group). Thus, the 1924-25 follow-up group are a representative sampling of the hospital's service from the standpoint of phys- ical classification. Table 23.—Comparison of the 1924-25 follow-up group and the total Base Hospital No. 117 service in regard to physical classification a Totals for follow up Total for hospital Physical classi-_____________________________ ______ fication j Number Per cent Number Per cent D_____________ 8 1.7 32 [ 2.2 36 12.0 139 | 12.4 44 5.9 171 6.6 6 2 1.3 0.7 48 27 3.3 2.4 8 1.5 75 2.9 Totals 462 301 60.5 39.5 1,466 1,124 56.3 43.7 763 100.0 2,590 100.0 « In each group of figures, the upper figure indicates cases discharged before the armistice, the lower, cases discharged during the armistice, the figures below the line, total. 6 T—cases transferred to another hospital, unclassified. From Table 24 we are able to determine the prognostic value of physical classification for civilian readjustment in 1924-25. Although in a period of seven years there have been many ups and downs, fortunate events, and also difficulties and discouragements, to change the mood and outlook of these men, we still find a positive correlation between physical classification and civilian readjustment, despite all the circumstances that would enter to impair such a relationship. In the column for class A we now note 83 per cent carrying on (40.7 per cent normal, 42.3 per cent neurotic); of class B, 85.9 per cent are carrying on (39.1 per cent normal, 46.8 per cent neurotic); of class C, 73.9 per cent are carrying on (30 per cent normal, 43.9 per cent neurotic); of class D, 72.7 per cent are carrying on (40.9 per cent normal, 31.8 per cent neurotic). Members of class B, as a group, are adjusting themselves better to civilian life than class A. Though a slightly smaller per cent of class B are normal, the 4.5 per cent greater number of class B now neurotic makes the total of men able to carry on (i. e., either normal or neurotic) for class B 2.9 per cent greater than for class A. Class C and class D are smaller in percentage of recoveries than class A and class B. Thus, the hospital estimates of potential military value are again found to be of some significance for the group as a whole as prophecy of future civilian readjustment. Physical classi- Totals for follow up Total for hospital fication Number Per cent Number Per cent 9.7 32.6 A_____________ 35 154 7.6 51.1 142 366 189 23.5 508 19.6 B ____________ 241 58 52.1 19.2 696 316 47.4 28.1 299 39.2 1,012 39.2 C ____________ 172 51 37.2 16.9 548 276 37.4 24.6 223 29.3 824 31.8 466 NEUROPSYCHIATRY Table 24.—Physical classification of 1924-25 follow-up group in relation to condition in 1924-25 * Class A Class B CI Num-ber 48 19 .ssC Per cent Cls Num-ber 2 16 iss D Per cent Num-ber r» Totals Num-ber Per cent Num-ber Per cent Per cent \iiin- Per ber cent Normal___________________ 18 59 51.4 38.3 94 23 39.0 39.7 27.9 37.2 25.0 44.4 2 0 33.3 0.0 161 35. .5 117 38.9 77 40.7 117 39.1 67 30.0 18 40.9 2 25.0 281 36. 9 Neurotic_______ .._________ 11 69 31.4 44.8 113 27 46.9 46.5 79 19 45. 9 37.2 3 11 37.5 30.5 2 1 33.3 50.0 208 127 45.0 42.2 80 42.3 140 46.8 98 43. 9 14 31.8 3 37.5 335 43. 9 Fatigued__________________ 3 15 8.6 9.8 20 4 8.2 6.8 27 2 15.7 4.0 1 1 12. 5 2.8 2 0 33.3 0.0 53 22 11.5 7.3 18 9.5 24 8.0 29 13.0 2 4.6 2 25.0 75 9.8 Disabled__________________ 3 6 8.6 3.9 12 3 4.9 5.2 17 9 9.9 17.6 0 8 0.0 22.2 0 1 0.0 50.0 32 27 6.9 8.9 9 4.7 15 5.0 26 11.7 8 18.2 1 12.5 59 7.7 Psychotic................. 0 5 0.0 3.2 2 1 0.0 1.7 1 2 0.6 4.0 2 0 25.0 0.0 1.1 8 2.7 5 2.6 3 1.0 3 1.4 2 4.6 13 1.7 Totals______ 35 154 100.0 100.0 241 58 100.0 100.0 172 51 100.0 100.0 8 36 100.0 100.0 6 2 100.0 100.0 462 301 100.0 100.0 189 100.0 299 100.0 223 100.0 44 100.0 8 100.0 763 100.0 ° The upper number in each group indicates cases discharged from Base Hospital No. 117 before the armistice: the second number, cases discharged during the armistice: and the number below the line, the total. b T = Cases transferred to another hospital, unclassified. DIAGNOSIS IN FRANCE IN RELATION TO CONDITION IN 1924-25 In attempting to learn what relationships prevailed in 1924-25 between the various diagnostic groups and civilian readjustment, our first question again is concerned with the selection of cases. Table 25 gives the frequency of usage of the various diagnoses in the total hospital service, with their occurrence in the follow-up of 1924-25. It shows that the follow-up group is a good sam- pling of the total hospital service from the standpoint of diagnosis; for example, the percentage of cases of hysteria in the follow-up is 27 and in the total hospital group 27.6. Concussion neurosis is even closer to exactness, 22.2 per cent of the follow up and 22.1 per cent of the total hospital group; neurasthenia is 12.5 per cent of the follow-up and 12.1 per cent of the total hospital service. Table 26 gives the relationship of diagnosis to present condition; the psychotics are combined with the disabled group. Some of the diagnostic- groups are small, yet since this smallness is representative of their actual pro- portional number, their inclusion is desirable. If we combine for each diag- nosis the normal and neurotic groups (that is, the patients who were self-sup- porting in civilian life in 1924-25) and compare the various diagnoses on the basis of percentage carrying on and percentage, unable to carry on (fatigued, disabled, or psychotic) significant features of the data are brought to light. In Table 27 the various diagnoses are ranked on the basis of the percentage of those reached in 1924-25 who were carrying on in civilian life. IN THE AMERICAN EXPEDITIONARY FORCES 467 Table 25.—Comparison of the 1924-25 follow-up group and the total population of Base Hospital No. 117 in regard to diagnosis Diagnosis Totals T?^ls Per ! cent for i 2™ cent of of follow-, ™s~ f0How- hos- UP !gProui UP Pital group Hysteria. 379 338 25.8 28.9 Concussion neurosis. 206 717 27.0 Diagnosis Totals r"'; Per cent for , ."^ cent of of follow-] ""s" follow- hos- group1 UP IPital B p ; group up 25.9 30.1 27. 6 II Psychasthenia. 326 247 20.2 25.6 22.2 22.0 170 573 22.2 22.1 Neurasthenia____.....___ 56 39 187 127 12.1 13.0 12 8 11.3 95 314 12.5 12.1 Hypochondriasis___..... 10 1 12 | 58 39 2.1 4.0 3 9 3.4 22 31 19 97 2.9 3.8 Exhaustion____________ 72 67 6.7 6.3 4.9 5.9 50 139 6.6 5.4 Effort syndrome. 1.9 0.7 1.9 2.6 11 | 40 12 57 1.4 2.2 118 56 8.7 4.0 8 1 4.9 52 174 6.9 6.7 Concussion syndrome________ 61 20 181 77 13.2 6.6 12.4 6.9 81 258 10.6 10.0 Timorousness (state of anxi- ety)----------.....______ Anticipation neurosis. Gas neurosis. Gas syndrome <•. Traumatic neurosis________ Gastric neurosis, postopera- tive ___......_______..... No disease. Totals. 7 3 28 12 1.5 1.0 1.9 1.1 10 40 1 1.3 1.6 10 5 20 33 2.1 1.6 --- 1.4 2.9 15 53 1.9 2.0 6 0 22 1.3 0.0 1.5 0.6 6 29 0.8 1.1 10 9 21 30 2.1 3.0 1.4 2.7 19 51 2.5 1.9 5 2 3 8 1.1 0.7 0.2 0.7 7 11 0.9 0.4 3 1 4 1 0.7 0.3 0.3 0.1 4 5 0.5 0.2 2 13 19 53 0.4 4.3 1.2 4.7 15 72 1.9 2.8 462 301 1,466 1,124 100.0 100.0 100. 0 100.0 763 2,590 100.0 100.0 (The upper number in each group indicates the cases discharged from Base Hospital No. 117 before the armistice, the second, cases discharged during the armistice, and the number below the line, the total.) 0 The discrepancy in total hospital and follow-up statistics is due to the fact that gas syndrome was used a few times as subsidiary diagnosis. Again the typical war neurosis, such as gas syndrome, exhaustion, con- cussion, anxiety, show the best recovery, except for gas neurosis (X-19); whereas the more pronounced constitutional types (neurasthenia, psychasthenia, effort syndrome) rank lower. There are, as one might expect, some significant changes in rank among the 1924-25 group as compared with the 1919-20 group (given in Table 13); for example, exhaustion neurosis goes from rank 7 to rank 2, with 48 of the 50 men, or 96 per cent, carrying on. In this con- nection, it is surprising, in view of the nature of their difficulties in France, that they did not rank higher in 1919-20; however, the fact that by now- 48 out of 50 of them have been able to return to the position of being self-sup- porting is a significant proof of diagnosis exactitude in the hospital service. Likewise, that the concussion and anxiety cases have made a good readapta- tion is a justification of their diagnosis and the general opinion of their condi- tion held by the Base Hospital Xo. 117 staff in France. On the other hand, that the effort syndrome group is still in difficulty was well nigh predictable, as functional heart conditions are liable to chronicity. Hypochondriasis, neurasthenia, psychasthenia, are about at the relative rank predicted by the 42705—29---31 468 NEUROPSYCHIATRY medical experts of the hospital. The best insight into the meaning of war-time diagnosis is found by comparing the percentage of recovery in 1924 25 from Table 27 with the same facts for 1919-20 in Table 13. At once it is apparent that practically all of the diagnostic groups show a higher percentage of readap- tation at the later date. Gas neurosis, no disease, and effort syndrome have not shown an improvement from a percentage standpoint. Only anticipation neurosis (which forms a small group of six cases) has shown a decrease in percentage of men with that diagnosis able to carry on. Table 26.—('audition in 1924-25 in relation to diagnosis in Franc Normal Neu Num-ber rotic Fatigued Disabled and psychotic To Num-ber tals Num-ber Per cent Per cent Num-ber Per cent Num-ber Per cent Per cent Hysteria______________ 32 33 19.6 28. 1 60 33 29.0 25.9 15 8 28.9 36.4 12 13 32.4 38.2 119 87 25.9 29.0 65 23.2 93 27.9 23 31.1 25 35.2 206 27. 1 Concussion neurosis_____ 42 31 25. 8 26.4 39 35 18.9 27.8 10 6 19.2 27.3 2 5 5.4 14.7 93 77 20.3 25.7 73 26.0 74 22.1 16 21.6 7 9.8 170 22.4 Neurasthenia__________ 16 13 9.8 11.1 26 18 12.6 14.1 8 2 15.4 9.1 6 6 16.2 17.7 56 39 12.2 13.0 29 10.4 44 13.2 10 13.5 12 16.9 95 12.5 Concussion syndrome--- 20 6 12.3 5.1 28 12 13.5 9.4 9 0 17.3 0.0 4 2 10.8 5.9 61 20 13.4 6.7 26 9.3 40 11.9 9 12.2 6 8.3 81 10.7 19 5 11.5 4.2 17 3 8.2 2.3 1 2 1.9 9.1 3 2 8.1 5.9 40 12 8.3 4.0 24 8.6 20 6.0 3 4.1 5 7.0 52 6.9 Exhaustion neurosis----- 16 11 9.8 9.3 13 8 6.3 6.3 2 0 3.9 0.0 31 19 6.8 6.3 27 0 3 9.6 21 6.3 2 2.7 50 6.6 Hypochondriasis_______ 0.0 2.5 8 6 3.0 4.7 2 3 5.4 8 8 10 12 2.2 4 0 3 1.1 14 4.2 5 | 7.0 22 2 9 ___ Psychasthenia_________ 3 2 1.8 1.6 1 1 .5 .8 I 1.9 0.0 2 0 5.4 0.0 7 3 1.5 1.0 5 1.8 2 .6 1.3 2 i 2.9 10 1.3 3 4 1.8 3.3 4 3 1.9 2.3 1 1.9 0 0.0 2 i 5.4 2 | 5.9 10 9 2.2 3.0 7 2.5 7 2.1 1.3 4 | 5.8 19 2. o Anticipation neurosis____ 3 0 1.8 0.9 1 0 .5 0.0 0 1.9 0.0 1 0 2.7 0.0 6 0 1.3 0.0 3 1.1 1 0.3 1.3 1 1.4 6 0.8 Effort syndrome. ______ 2 1 1.2 2.5 3 0 1.4 0.0 1 , 1.9 1 1 4. 5 3 8.2 0 0.0 9 2 1.9 0.7 3 1.1 3 0.9 2 2.7 3 | 4.3 11 1.5 5 3 3.1 1.7 3 1 1.4 0.8 2 0 3.8 0.0 10 5 1 5.9 1.7 8 2.8 4 1.2 2 2.7 1 | 1.4 15 | 1.9 Gas syndrome__________ 2 1 1.2 0.9 3 1 1.4 0.8 | 5 2 ____1____ 0'.7 3 1.1 4 1.2 |_________i... 7 0.9 No disease___ ... __ .. 0 4 0.0 3.4 1 6 . 5 4.7 1 3 1.9 13.6 f 2 1 13 0.4 4.3 ___ 1 4 1.4 ' 2.1 4 5.5 ________ i 1 15 1 1 9 1 1-a (The upper number in each group indicates the cases discharged from Base Hospital No 117 before trip nrmicti.*- thp lower, cases discharged during the armistice, and the number below the line, the total.) ••> 1 1 7 9 21 21 33 34 35 21 24 19 8 11 14 5 I 1 2 12 18 20 21 52 46 34 26 34 19 20 12 8 9 2 2 2 1 1 1 1 3 23 ________________________________ 1 1 5 9 7 8 20 8 4 6 4 4 2 2 2 4 24__________________________..... 20 '">-, II 4 3 9 6 5 3 3 4 2 4 2 2 1 1 i 38 26 ________________________________ 1 57 ■>7 53 28 ________________________.......___ 1 2 3 97 2>i __________________________ 111 30 _ ______________ .. ______ 86 31 __________________________ 56 32 __________________________ 67 1 1 1 46 37 28 36 . ___________ ___ ... -- 33 18 1 9 Vi-------------------------- __________________ 5 1 4 4 1 5 1 9 1 1 "---------------------------------------------:::::::::::_________________ 1 2 2 i i 2 i;,- --------------------------......:::::::::::::::__________......i.... 5 1 3 1 8 280 i 30. 39 347 1 39.06 93 29.80 62 30.58 11 30.67 793 30.93 470 NEUROPSYCHIATRY Table 29.—Distribution of cases within the normal, neurotic, fatigued, and disabled groups, according to age Normal Neuro Num-ber tic Per cent 21.3 70.0 8.7 Fatigued Disabled Age Num-ber Per cent Num-ber 23 56 14 Per cent 24.7 60.2 15.1 Num-ber 17 35 10 Per cent 27 years and younger____________________ 28 to 35 years (inclusive)_______________ _. 60 185 35 21.4 66.1 12.5 74 243 30 27.4 56.3 16. 3 Totals___________________________ 280 100.0 347 100.0 93 100.0 62 100. n Table 30.—Distribution of cases within each age group according to condition in 1924-25 Condition Normal____ Neurotic___ Fatigued _.. Disabled___ Total. 27 years and younger 28 to 35 years (inclusive) 36 years _ Number Per cent i Number Per cent Number 35 30 14 10 60 74 23 17 34.5 42.5 13.2 9.8 185 243 56 35 35.7 46.8 10.8 6.7 174 100.0 519 100.0 89 Per cent 39.2 33.7 15.7 11.3 100.0 FAMILY AND PERSONAL HISTORY (SEPARATELY AND COMBINED), PRIOR TO HOSPITALIZATION, RELATED TO CONDITION IN 1924-25 The data in Table 31 indicate that, in so far as they apply to this group, pre- vious family and personal histories are not in themselves very significant deter- miners for present condition. In fact the group now classed as normal herein gives a poorer personal history than the neurotics, and a poorer combined per- sonal and family history than the neurotics and fatigued. Of course, not all the cases are included, as the data were missing on some cases from the clinical histories written in France. Furthermore, all data on family and personal history are apt to be unreliable unless collected for specific purposes and undei definite directions, which is in many cases not true of these data. But from the data available family and personal histories, as previously shown in the 1919-20 study, are not very significant in themselves in relation to civilian readaptation. Whereas in the 1919-20 group a slight tendency existed for a better readjust- ment to be made by those giving negative histories, by 1924, this tendency has decreased almost to insignificance. Table 32 shows that on the whole the follow-up group are an adequate sampling of the hospital group from the standpoint of family stock and personal make-up. IN THE AMERICAN EXPEDITIONARY FORCES 471 Table 31.—Family and personal histories in relation to condition in 1924-25 Normal___ Neurotic... Fatigued. _ Disabled. _ Total Family history Positive Num- ber 128 141 36 21 Per cent 56.6 53.0 58.1 42.0 Negative Num- Per ber cent 43.4 125 47.0 41.9 58.0 53.9 278 Personal history Combined family and J nersonal historv personal history i Positive | Negative Positive Negative Num- Per- Num-! Per Num- Per Num- ber cent ber j cent ber cent ber 112 124 64 24 51.6 105 48.4 149 47.1 139 52.9 163 52.5 58 47.5 81 52.2 22 47.8 32 68.0 i 70 62.4 98 67.9 ! 38 68.1 i 15 50.0 324 50.0 I 425 65.8 221 Per cent 32.0 37.6 32.1 31.9 34.2 Table 32.—The follow-up cases (1924-25) compared with 1,000 unselected cases from Base Hospital No. 117 Family history Personal history ! Combined family and 1 personal history Positive Negative Positive Negative 1 Positive Negative Num-1 Per Num-ber ! cent i ber 508 i 50.2 505 326 53.9 278 Per cent Num-ber Per-cent Num- Per Num-ber | cent ; ber Per cent Num-ber Per cent Total Base Hospital No. 117 patients_____ 49.8 46.1 527 324 51.9 50.0 488 48.1 643 324 50.0 ; 425 63.5 65.8 370 221 36.5 Lastly, it is a rather interesting commentary on the whole conception of "neuropathic" taint that there are so many men (over four-fifths) now able to carry on in this group of men, and (by comparison with the findings in 1919-20, which was about three-fifths) an increasing number and proportion who give a neuropathic (i. e., war neurotic) history. Smith and Pear 3 have expressed very well the looseness and inadequacy of all explanation of nervous or mental disease in terms of so-called "neuropathic" taint. It is noteworthy that this group shows no very significant relationship between these factors of make-up and the capacity of readaptation to civilian environment. SOCIAL STATUS IN RELATION TO PRESENT CONDITION PRESENT OCCUPATION Again the adequacy of sampling of the follow-up compared to the hospital service is important. It must be realized at once that when only the present occupation is considered, the psychotic and disabled patients will automatically be excluded, for they are not at work. Likewise many of those reported at work were doing things described in a way difficult to allocate with the Bureau of the Census categories. Taking the 562 cases which remain in the 3 groups, and comparing them with the proportions of the total hospital group, we find (in Table 33) that the sampling is a selected one in the divisions of transporta- tion (7.7 per cent of this follow-up group instead of 13.8 per cent in the total hospital figures), trade (18.1 per cent instead of 11.1 per cent), public service (5.5 per cent instead of 2 per cent), clerical work (11.2 per cent instead of 15.9 per cent), though upon inspection of the other categories (agriculture, mining, manufacturing, professional) it is noted that the sampling is a good one. 472 NEUROPSYCHIATRY Table 33.—Relation of occupation " (19.24-2-') oj follow-up group and total patients of Base Hospital No. 117 to working capacity Fatigued Total of follow- up l Number Agriculture_____ Mining.......... Manufacturing-. Transportation.. Trade.._______ Public service__ Professional____ Domestic service Clerical________ Total. 243 Per cent Number; Per cent Number Per cent! Number Percent 3.7 3.7 32.5 6.6 20.9 6.6 9.5 4.1 12.4 14 13 7 132 17.0 1.4 32. 9 8 7 17.0 4.9 4.5 2.4 11.1 10 32.3 10 32.3 2 6.4 2 6.4 1 3.2 16. 1 3.2 100.0 100.0 100.0 68 13 184 43 102 31 36 22 63 12. 1 2.3 32. 8 is! 1 5.5 6.4 3.9 11.2 562 100.0 Total of hospital service Number, Per cent 261 53 789 313 253 45 163 57 339 11.5 2.3 34.7 13. 8 11.1 2.0 2. 5 15.9 2,273 ■ Exclusive of those who were "disabled" or psychotic at time of writing, who were by definition out of work. 6 Exclusive of 293 classified as "labor" and 194 as "student" (15.50 per cent). Tables 34, 35, and 36, give the facts of occupation related to present con- dition in the Bureau of the Census categories of general types of work. Again, as in the 1919-20 followup (i. e., Tables 19, 20, and 21), those engaged in agri- cultural work and those in transportation are making the poorest readaptation. Mining is too small a group (X-13) to be significant, but those reporting show the highest percentage as normal. The professional group are making the next best readaptation. Then come public service and trade, then manufacturing, transportation, and last of all agriculture. These facts are given in a rank-order presentation in Tables 35 and 36. In Table 36 the same facts are given for those now reporting themselves as neurotic or fatigued. The percentages are of course the complement of those in Table 35, since the two tables include the total number of men now at work in each occupation. Table 34.—Relation of condition in 1924-25 to occupation in 1924-25 Agricul-ture M ning Manu-factur-ing Trans-porta-tion Trade Public service Profes-sional Domes-tic service Clerical t, ^ ^, t. [ « i- i +_. ,_ i ^ ^ ^ ^ ^ a 8 ( 2 P % 1 o & c x> a ._- a> .Q ._ £ ^ s u F o £ w z. O ~ - 3 Z Ph Z ] Ph Z : fc Z Ph 16 37.2 Z Ph 51 50 Z 16 Ph Z Ph z 10 p. Z __. Normal____ _ _____ 9 13.2 9 69.2 79 42.2 51.6 23 63.9 45.4 30 47.6 Neurotic.____ _. ... 49 10 72.1 14.7 4 30.8 95 10 51.5 5.4 25 ! 58.1 2 4.7 49 48 14 45 1 13 36.1 7 5 31.8 22.7 Fatigued__________ 2 2 1 3.2 1 16 Total_________ 68 100.0 13 100.0 184 100.0 43 100.0 102 100 31 100.0 36 100.0 22 100.0 63 | 100.0 Table 35.—Rank order of percentage of men of each occupation of the 192.^-25 follow-up group now normal Rank order Occupation Mining_____ Professional... Public service Trade_______ Clerical_____ Num- Per Rank ber cent order 13 69.2 6 36 63.9 7 31 51.6 8 102 50.0 9 63 47.6 Occupation Domestic service Manufacturing.. Transportation.. Agriculture...... Num- ber 22 184 43 68 Per cent 45.4 42.2 37.2 13.2 IN THE AMERICAN EXPEDITIONARY FORCES 473 Table M.—Rank order of percentage of men of ea-h occupation of the 1924-25 follow-up group now either neurotic or fatigued Rank order Occupation Agriculture____ Transportation, _ Manufacturing... Domestic service- Clerical.....____ Num-ber Per ' cent i Rank order Occupation Num-ber Per cent 68 43 86.8 62.8 57.8 54.6 52.4 6 8 9 Trade_________________ Public service__________ 102 31 50.0 48.4 184 22 63 Professional__________ Mining_________ 36 13 36. 1 30. 8 Since our comparison in Tables 35 and 36 is practically between the normal and the neurotic group (there are so few cases comparatively in the fatigued group), we also get a suggested estimate of what line of work a former war neurotic is now able to engage in as a normal healthy person, and in what general kinds of work he is able to carry on though still somewhat more nervous and unhealthy than the ordinary workman in that line of work, so far as we know. This last might suggest an answer to the question: In what lines of work can a psychoneurotic, still suffering from mild but quite annoying symp- toms, be able to get along and be independent? The answer is agriculture far above all others, then transportation, clerical work, trade and the various lines of manufacturing. It is noteworthy in this connection that the histories of some of the men are in line with this. Many who had difficulty working at manufacturing trades in towns or cities have been able to make a fairly success- ful readaptation in agricultural work. Some have even so improved as to be entirely self-supporting and gradually losing all their symptoms. PRESENT CONDITION OF THE GROUP AS A WHOLE The five years intervening since 1919-20 saw the development of good improvement in the Base Hospital No. 117 group. Whereas in 1919 the per- centage of those reached who were able to carry on (that is, normal or neu- rotic), was only 60.9; by 1924-25 this had grown to 80.8 as shown in Table 37. The fatigued group who were able to work but half the time amounted to 9.8 per cent as compared with 17.3 per cent in 1919-20, and the disabled or psy- chotic who were practically unable to work at all, amounted to 9.4 per cent instead of 21.7 per cent in the previous study. When further comparison is made of the military value and civilian use- fulness of these men, we find 62.7 per cent of good actual or potential military value (classes A and B) and 80.8 per cent of good civilian usefulness (normal and neurotic). There is a greater proportion (36.9 per cent) who are of full value as civilians (normal) than who were immediate front-line material (23.5 per cent) in France (class A) but almost equal proportions (38.2 per cent) of poten- tial front-line material (class B and somewhat nervous individuals (neurotic) of not quite full civilian efficiency (43.9 per cent). The 1924-25 follow-up group is of much more usefulness to society now than they were to the Army at the time of discharge from the hospital. This is a very significant improve- ment over the conditions in 1919-20 of a similar-sized group of war neurotics reached at that time who were as much a burden to society as they were to the American Expeditionary Forces. 474 NEUROPSYCHIATRY Table 37.—Direct comparison of physical classification in France and condition in 1924*25 of the follow-up group Classification Military classification Classification Present condition Number Per cent Number Per cent A 35 154 7.6 51.1 164 117 35.5 38. 9 189 23.5 281 36.9 B 241 58 52.1 19.2 208 127 45.0 42.2 299 39.2 335 43.9 C_____................. _____ 172 51 37.2 16.9 53 22 11.5 7.3 223 29.3 75 9.8 D and T..._........__________ 14 38 3.0 12.7 37 35 8.0 11.6 52 7.4 72 9.4 (The upper number in each group indicates the cases discharged from Base Hospital No. 117 before the armistice, the second, cases discharged during the armistice, and the number below the line, the total.) There are once more discrepancies in individual items in this comparative study as shown in Table 38. The proportion of class A of the prearmistice group was 7.6 per cent, but 35.5 per cent of the armistice group were normal in 1914. On the other hand, the armistice class A amounted to 51.1 per cent and only 38.9 per cent of this group are now normal. The prearmistice class B amounted to 52.1 per cent but the prearmistice cases now neurotic are only 45 per cent; the armistice, class B were 19.2 per cent and the armistice neu- rotic 42.2 per cent. Both the prearmistice and armistice proportions of "fatigued" cases are considerably smaller than the class C cases. And lastly, those of the prearmistice group now seriously handicapped constitute 8 per cent of the group as compared with only 3 per cent of D and T discharges before the armistice. These figures show a marked tendency for improvement among the men of the follow-up group as a whole in the interim of five years since the study made in 1919-20. What the causes are that underlie the improvement is a difficult problem for complete analysis. A few that might be cited are the vis medica- trix of nature in that length of time, the improvement of business conditions, offering more opportunities for civilian reestablishment, and, perhaps most essential of all, the various governmental and social agencies focussed upon the problem of soldier after care. At any rate, whatever the causes of improve- ment, the hospitalized war neurotics of the American Expeditionary Forces have now become more of a social asset in civilian life than they were in 1919-20 and considerably less of a problem as a group to themselves, to their families and to the American people. REFERENCES (1) Southard, E. E.: Shell Shock and After. The Shattuck Lecture. Boston Medical and Surgical Journal, 1918, clxxix, No. 3, 73. (2) Mott, F. W.: War Neuroses. British Medical Journal, 1919, i, April 12, 439 (3) Smith, G. Elliot, and Pear, T. H.: Shell Shock and its Lessons. 2d Ed Longmans Green & Co., 1917, 88. APPENDIX 475 APPENDIX A BIBLIOGRAPHY OF AMERICAN CONTRIBUTIONS TO WAR NEUROPSYCHIATRY Abbot, E. S.: Work of psychiatrists in military camps. The American Journal of Insanity, Utica, 1919, lxxv, 457-65. Adler, H. M.: The broader psychiatry and the war. Mental Hygiene, New York, 1917, i, 364-70. Adler, H. M.: Disciplinary problems of the Army. Mental Hygiene, New York, 1919, iii, 594-602. Adler, H. M.: Some observations on disciplinary psychiatry in the Army. Archives of Neu- rology and Psychiatry, Chicago, 1920, iii, 210-212. American Legion National Rehabilitation Committee: The American Legion at work for the sick and disabled. Report, October, 1922. Ames, T. H.: War shock, its occurrence and symptoms. The Journal of Nervous and Mental Diseases, New York, 1918, xlvii, 43-47. Anderson. M. L.: Mental reconstruction through occupational therapy. The Modern Hospital, St. Louis, 1920, xiv, 326-327. A twill, Dorothy: Psychiatric social service for ex-service men. Committee Social Mental Hygiene, 11th Annual Report, 1918-19, 20-24. Auer, E. M.: Phenomena resultant upon fatigue and shock of the central nervous system observed at the front in France. The Medical Record, New York, 1916, lxxxix, 641-44. Auer, E. M.: Some of the nervous and mental conditions arising in the present war. Mental Hygiene, New York, 1917, i, 383-88. Bahr, M. A.: Importance of a neuropsychiatric examination of registrants for military service. Indianapolis Medical Journal, Indianapolis, 1918, xxi, 211-16. Bailey, Pearce: Applicability of the findings of the neuropsychiatric examinations in the Army to civil problems. Mental Hygiene, New York, 1920, iv, 301-11. Bailey, Pearce: Care and disposition of the military insane. Mental Hygiene, New York, 1918, ii, 345-58. Bailey, Pearce: Care of disabled returned soldiers. Mental Hygiene, New York, 1917, i, 345-53. Also, Pacific Medical Journal, San Francisco, 1917, lx, 608-15. Bailey, Pearce: Incidence of multiple sclerosis in United States Troops. Archives of Neurology and Psychiatry, Chicago, 1922, vii, 582-83. Bailey, Pearce: Malingering in U. S. Troops, Home Forces, 1917. The Military Surgeon, Washington, D. C, 1918, xlii, 261-75, 424-49. Bailey, Pearce: Mental deficiency; its frequency and characteristics in the United States as determined by the examination of recruits. Mental Hygiene, New York, 1920, iv, 564-96. Bailey, Pearce: Nervous and mental disease in U. S. Troops. The Medical Progress, Louis- ville, 1920, xxxvi, 193-97. Bailey Pearce: Neuropsychiatry and the mobilization. The New York Medical Journal, New York, 1918, cvii, 794-95. Bailev Pearce: Prevention of nervous casualties. New Republic, 1918, xiii, 275. Bailey, Pearce: Psychiatry and the Army. Harpers Monthly, 1917, cxxxv, 251-57. Bailev Pearce: Reconstruction in nervous and mental disease. Ungraded, 1920, v, 97-107. Bailev Pearce: War and mental disease. American Journal of Public Health, New York, 1918, viii, 1-7. Bailev Pearce: War neuroses, shell shock, and nervousness in soldiers. The Journal of the American Medical Association, Chicago, 1918. lxxi. 2148-53. 477 478 NEUROPSYCHIATRY Bailey, Pearce: War's big lesson in mental and nervous disease. National Committee for Mental Hygiene, New York, 1919, 10. Ball, C. R.: Neurology and psychiatry in the war. The Lancet, 1920, xl, 207-12. Banguss, J. B.: Drug addiction. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 2, 24. Barker, L. F.: War and the nervous system. The Journal of Nervous and Mental Diseases, New York, 1916, xliv, 1-10. Barnes, F. M., Jr.: Out-patient neuropsychiatric clinic as a factor in vocational rehabilita- tion. Journal of the Missouri State Medical Association, St. Louis, 1924, xxi, 43-46. Bassoe, Peter: Report of neuroses in soldiers, with presentation of cases. The Journal of Nervous and Mental Diseases, New York, 1919, 1, 170-75. Beall, C. C: Functional diseases of nervous system in soldiers and civilians. The Journal of the Indiana State Medical Association, Fort Wayne, 1922, xv, 75-78. Beck, R. J.: Parkinsonian states of infectious origin, with case reports. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 835. Benton, G. H.: Some evidences of inadaptability in ex-service psychoneurotics. The Southern Medical Journal, Birmingham, Ala., 1922, xv, 992-1000. Benton, G. H.: War neuroses and allied conditions in ex-service men, as observed in the U. S. Public Health Service Hospitals for psychoneurotics. The Journal of the American Medical Association, Chicago, 1921, xxvii, 360-64. Billings, Frank: Leaving too soon; the disabled soldier should remain in the hospital for full restoration, phsycial and mental. Carry On, S. G. O., Washington, D. C, i, No. 5, 8-10. Billings, Frank: Physical and mental rehabilitation of disabled soldiers of the United States Army. Transactions of the Congress of American Physicians and Surgeons, New Haven, 1919, xi, 105-116. Also, The Institution Quarterly, Springfield, 111., 1919, x, 97. Bisch, L. E.: Early recognition of mental disease. The Southern Medical Journal, Bir- mingham, Ala., 1919, xii, 538-41. Bisch, L. E.: Eliminating the epileptic from the Navy. United States Naval Medical Bulletin, Washington, 1919, xiii, 5-15. Bloedorn, W. A.: Hysteria in the naval service. United States Naval Medical Bulletin, 1921, 515-21. Bowers, P. E.: Psychoneuroses. Santa Clara County Medical Society Bulletin, 1921, ii, No. 4, 4-7, No. 5, 3-6. Bowman, K. M.: Analysis of case of war neurosis. The Psychoanalytical Review, Lancaster, Pa., and New York, 1920, vii, 317-32. Bowman, K. M.: Relation of defective mental and nervous states to military efficiency. The Military Surgeon, Washington, 1920, xlvi, 651-69. Bowman, K. M.: Report of the examination of the_____Regiment, U. S. A., for nervous and mental disease. The American Journal of Insanity, Baltimore, 1919, lxxiv, 555-67. Boyd, W. A.: Epilepsy: Differential diagnosis and treatment. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 165. Brewster, G. F.: Commitment of insane beneficiaries to U. S. Veterans' Bureau Hospitals. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 249. Briggs, L. V.: Massachusetts Committee for the state care and treatment of soldiers suffer- ing from nervous and mental diseases (letter). The Boston Medical and Surgical Journal, Boston, 1917, clxxvi, 922. Briggs, L. V.: A plea for more psychiatrists and neurologists for war service. Proceedings Alienists and Neurologists, 1917, vi, 31. Briggs, L. V.: War neuroses; environment and events as the causes. The American Journal of Insanity, Baltimore, 1920, lxxvi, 285-94. Briggs, L. V.: Mental conditions disqualifying for military service. The Boston Medical and Surgical Journal, Boston, 1918, clxxviii, 141-46. Briggs, L. V. and Hodskins, M. B.: Report of neuropsychiatric work at Camp Devens, Mass. The New York Medical Journal, New York, 1921, cxiii, 749-50. Brophy, J. W.: Social adjustment of psychotic patients. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 1046. APPENDIX 479 Brown, L. M.: Drug addiction. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 691. Brown, M. W., and Williams, F. E.: Neuropsychiatry and the war; a bibliography with abstracts. National Committee for Mental Hygiene, New York, 1918, 292. Brown, M. W., and Williams, F. E.: Neuropsychiatry and the war; Supplement I, October, 1918. National Committee for Mental Hygiene, New York, 1918, 117. Brown, Sanger II: Nervous and mental disorders of soldiers. The American Journal of Insan- ity, Baltimore, 1920, lxxvi, 419-36. Brown, Sanger II: Nervous symptoms in ex-soldiers. The Journal of the American Medical Association, Chicago, 1921, lxxxvii, 113-16. Brownrigg, A. E.: Neurospychiatric work in the Army. The Boston Medical and Surgical Journal, Boston, 1919, clxxxi, 458-62. Burrier, W. P.: Constitutional psychopaths. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 684. Caldwell, C. B.: Notes on Army neuropsychiatry. The Institution Quarterly, Springfield, 111., 1919, x, 60-64. Campbell, C. McF.: Role of instinct, emotion, and personailty in disorders of the heart. The Journal of the American Medical Association, Chicago, 1918, lxxi, 1622-26. Carlisle, C. L.: Interpretation of inadequate behaviour through neuropsychiatric symptoms. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 230. Carr, B. W.: Occupational therapy for psychotics. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 362. Cohn, A. E.: The effort syndrome. War Medicine, Paris, 1918, ii, 761-66. Report to Research Society, American Red Cross in France. Covey, C. B.: Speech defects in psychoneurotics. U. S. Veterans' Bureau Medical Bulletin Washington, 1925, i, No. 6, 10. Crouch, E. L.: A preliminary study of occupational therapy for the deteriorated psychotic. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 1, 18. Cushing, Harvey: Neurological surgery and the war. The Boston Medical and Surgical Journal, Boston, 1919, clxxxi, 549-52. Cushing, Harvey: Some neurological aspects of reconstruction. Archives of Neurology and Psychiatry, Chicago, 1919, ii, 493-504. Davis, T. K.: Status lymphaticus; its occurrence and significance in war neuroses. Archives Neurology and Psychiatry, Chicago, 1919, ii, 414-18. Dearborn, George Van Ness: An aid in the diagnosis and the prognosis of mental disease, The British Journal of Medical Psychology, London, 1927, vii, No. 3, 315-320. Dearborn, George Van Ness: Psychiatry and science. The Journal of Mental Sciences, London, lxxiv, 305 (April, 1928), 203-223. Dearborn, George Van Ness: Psychology in medicine and psychiatry. Americana, New York, 1919, xviii, 584-587. Dearborn, George Van Ness: Psychometric methods. U. S. Veterans' Bureau Medical Bulletin, Washington, iv, No. 5, 426-432; iv, 6 (June, 1928), 539-544; iv, No. 7, 610-615; iv, 8 (August, 1928), 684-691. Dearborn, George Van Ness: The determination of mental regression and progression. The American Journal of Psychiatry, Baltimore, vi, No. 4, 725-741. Dercum, F. X.: So-called "Shell Shock": the remedy. Archives of Neurology and Psychiatry Chicago, 1919, i, 65-76. de River, J. P.: Some important ophthalmic signs in diseases of N. S. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 3, 26. De Schweinitz, G. E.: Concerning the ocular phenomena in psychoneuroses of warfare. Archives of Ophthalmology, New York, 1919, xlviii, 419-38. Dickerson, D. G.: Neurological studies in psychotic cases. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 233. Dishong, G. W.: War psychoneuroses. Nebraska State Medical Journal, Norfolk, 1919, iv, 238-43. 480 NEUROPSYCHIATRY Drysdale, H. S. and Gardner, J. S. S.: Hysterical hemiplegia; report of a case resulting from a shrapnel wound of the scalp and presenting interesting clinical features. The Journal of the American Medical Association, Chicago, 1919, lxxiii, 1258-82. Eaton, R. G.: Treatment of excited states in the mentally ill ex-soldier. U. S. Veterans' Bureau Medical Bulletin, Washington, October, 1926, ii, No. 10, 932. Engleton, D. F., and Riley, W. J.: Preliminary report, treatment of neurosyphilis with tertiary malaria. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 757. Ernest, F. J.: Standardization of treatment of neurosyphilis. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 5, 13. Fenton, Norman: Bibliography, in Southard, E. E., "Shell Shock." Leonard, Boston, 1919, 905-82. Fenton, Norman, and Schwab, S. I.: The factor of anticipation in war neuroses. Proceedings American Neurogical Association, May, 1919. Fenton, Norman: Anticipation neurosis and army morale. Journal of Abnormal Psychology, Boston, 1925, xxxii, 282-93. Fenton, Norman, and Thom, D. A.: Amnesias in war cases. Proceedings of the American Medico-Psychological Associaiion, Utica, N. Y., May, 1920. Also, The American Journal of Insanity, Baltimore, 1919, lxxiv, 437-38. Fenton, Norman: Civilian readaptation of A. E. F. war neurotics. Proceedings of the Ameri- can Psychological Association (Western Division), July, 1925. Also Psychiatric Bulletin of the New York State Hospitals, Utica, 1926, xxiii, 299. Fenton, Norman: A survey of wai neurosis and its aftermath. A Thesis. Library of Leland Stanford Junior University, 1925, 324. Fenton, Norman: Shell Shock and Its Aftermath. C. V. Mosby, St. Louis, 1926, 173. Foley, T. K: The limp as a manifestation of malingering. International Clinics, J. B. Lip- pincott Company, Philadelphia, 1929, ii, series 29, 164-70. Foster, F. A.: Social work in the Veterans' Bureau. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 17. Frost, L. C: Treatment in relation to the mechanism of shell shock. The Military Surgeon, Washington, D. C, 1919, xliv, 350-60. Gordon, Alfred: The problem of "neurotics" in military service. The Medical Record New York, 1918, xciii, 234-37. Gregory, M. S.: Neurosychiatry in recruiting and cantonment. Archives of Neurology and Psychiatry, Chicago, 1919, i, 89-94. Grimberg, L. E.: War traumas of the spinal cord; some clinical features. The Journal of Nervous and Mental Diseases, New York, 1919, xlix, 115-29. Hadley, E. E.: Mental symptom complex following cranial trauma. The Journal of Nervous and Mental Diseases, New York, 1922, lvi, 453-77. Hamilton, S. W.: Standard neurosychiatric veterans' hospitals. National Committee for Mental Hygiene, New York, 1925. Hammond, G. M.: Neurological and mental examination of state troops of the National Guard. The New York Medical Journal, New York, 1917, cvii, 764. Harrington, M. A.: Mental disease in the field. Mental Hygiene, New York, 1918, ii, 407-15. Harvey, J. G.: Social work as an aid to psychiatry. U. S. Veterans' Bureau 'Medical 'Bulletin Washington, 1926, ii, 962. Heldt, T. J.: Some important factors in the hospital treatment of psychoneurotic ex-service men. American Journal of Psychiatry, 1923, ii, 647-63. Henry, H. B.: Syphilis as a factor in mental disease. U. S. Veterans' Bureau Medical Bulletin Washington, 1925, i, No. 4, 32. Hill, D. S.: Valid uses of psychology in the rehabilitation of war victims. Mental Hygiene New York, 1918, ii, 611-628. Hoch, August: Recommendations for the observation of mental disorders incident to the war. Psychiatric Bulletin of the New York State Hospitals, Utica, 1917, ii, 377-385. Hodes, R., and Pinto, N. W.: Studies of traumatic psychoses. U. 's. Veterans' Medical Bulletin, Washington, 1925, i, No. 3, 44. Holbrook, C. S.: Shell-shock; psychoneuroses of war. The New Orleans Medical and Surqical Journal, New Orleans, 1918, lxxi, 191-202. APPENDIX 481 Hollingworth, H. L.: Psychological service in reconstruction. Columbia University Quarterly, 1919, xxi, 200-26. Hollingworth, H. L.: Psychology of the functional neuroses. Appleton, New York, 1920, 259. Hoppe, H. H.: The source of error in neuropsychiatric diagnosis. U. S. Veterans' Medical Bulletin, Washington, 1926, ii, 745. Howland, G. W.: Neuroses of returned soldiers. The Medical Fortnightly, St. Louis, xlix, 97-100. Also American Medicine, New York, 1917, xxiii, 313-19. Huddleson, James H.: Psychotherapy in two hundred cases of psychoneurosis. The Military Surgeon, Washington, 1927, xl, No. 2, 161. Huddleson, James H., and Bailey, M. Prentiss: The incidence and characteristics of dys- thyroidism as an ex-service disability. Archives of Neurology and Psychiatry, Chicago, 1922, vii, 332. Hulbert, H. S.: Gas neuroses syndrome. The American Journal of Insanity, Baltimore, 1920, lxxvii, 213-16. Hulbert, H. S.: Military value of psychiatry. Journal of the American Institute of Criminal Law and Criminology. Chicago, 1920, x, 612-14. Humes, C. D.: War neuroses. The Journal of the Indiana State Medical Association, Fort Wayne, Ind., 1919, xii, 123. Hunt, J. R.: Exhaustion pseudoparesis; a fatigue syndrome simulating early paresis, develop- ing under intensive military training. The Journal of the American Medical Asso- ciation, Chicago, 1918, lxx, 11-14. Hyslop, G. H.: Relation of compensation to neuropsychiatric disability. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 2, 14. Hutchings, R. H.: Hysteria as manifested in the military service. Psychiatric Bulletin of the New York State Hospitals, Utica, 1919, iv, 293-300. Inman, T. G.: Some comparisons between war neuroses and those of civil life. California State Journal of Medicine, San Francisco, 1920, xviii, 184. Ireland, G. O.: Neuropsychiatric ex-service man and his civil reestablishment. American Journal of Psychiatry, 1923, ii, 685-704. Ireland, M. W.: Care of Army's mental defectives. The Journal of Nervous and Mental Diseases, New York, 1920, Iii, 537. Jacoby, A. L.: Disciplinary problems of the Navy. Mental Hygiene, New York, 1919, iii, 603-08. Jacoby, A. L.: Psychiatric material in the naval prison at Portsmouth, N. H. United States Naval Medical Bulletin, Washington, 1918, xii, 406-13. Jarrett, M. C.: Social work as war service. Bulletin of the Massachusetts Commission on Mental Diseases, Boston, 1918, ii, No. 1, 25-29. Jarrett, M. C: War neuroses after the war; extra-institutional preparation. National Conference Social Work, 1918, 8. Johnstone, E. K.: Notes on shell shock. The Military Surgeon, Washington, D. C, 1918, xiii, 531-38. Kefauver, H. J.: Agriculture as occupational therapy in a neuropsychiatric hospital. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 592. Kellum, H. J.: The infection, exhaustion and toxic psychoses. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 369. Kennedy, Foster: Clinical observations on shell shock. The Medical Record, New York, 1916, lxxxix, 338. Kennedy, Foster: Nature of nervousness in soldiers: The Journal of the American Medical Association, Chicago, 1918, lxxi, 17-21. Kenvon, E. K.: The stammerer and Army service. The Journal of the American Medical Association, Chicago, 1917, lxix, 664-65. Kielv C. E.: Five hundred cases of shell shock. The Ohio State Medical Journal, Columbus, 1919, xv, 711-18. Kindred J. J.: Neuropsychiatric wards of the United States Government; their housing and other problems. American Journal of Psychiatry, 1921, i, 183-92. KIodd H I ' War neuroses in general practice. The Hahnemannian Monthly, Philadelphia, 1922, lvii, 91-100. 482 NEUROPSYCHIATRY Kolb, Lawrence: Bearing of war neuroses on immigration. Archives of Neurology and Psychi- atry, Chicago, 1919, i, 317-32. Leahy, S. R.: An analysis of cases admitted to the neuropsychiatric services of I . S. Army General Hospital No. 1 (Columbia War Hospital, N. Y.). Archives of Neurology and Psychiatry, Chicago, 1920, iv, 191-97. Leahy, S. R.: Neuropsychiatric services of the U. S. A. General Hospital No. 1. The Journal of the Nervous and Mental Diseases, New York, 1920, li, 454-56. Lorenz, W. F.: Delinquency and the ex-soldier. Mental Hygiene, New York, 1923, vii, 472-84. Lorenz, W. F.: War psychoneurosis. The Wisconsin Medical Journal. Milwaukee, 1920, xviii, 506-11. Love, A. G., and Davenport, C. B.: Defects found in drafted men. Government Printing Office, Washington, 1920, 1663. Love, A. G., and Davenport, C. B.: Defects found in drafted men. Statistical information compiled from the draft records. Government Printing Office, Washington, 1919, 359. Love, A. G., and Davenport, C. B.: Physical examination of the first million drafted recruits. Government Printing Office, Washington, 1919, 54. McAllaster, B. R.: Hysterical disorders observed in American soldiers in France. Bulletin of Iowa State Institutions, Des Moines, 1921, xxiii, 98-101. McConnely, E.: Care and treatment of drug addicts. U. S. Veterans' Bureau Medical Bul- letin, 1926, ii, 844. MacCurdy, J. T.: Mental hygiene lessons of the war. Psychiatric Bulletins of the New York State Hospitals, Utica, 1920, v, 205-20. MacCurdy, J. T.: Psychology of war. Luce, Boston, 1918, 85. MacCurdy, J. T.: War neuroses. Cambridge (England) University Press, 1918, 132. Also, Psychiatric Bulletins of the New York State Hospitals, Utica, 1917, ii, 243-54. McDaniel, F. L.: Report of the psychiatric division on recruits entering incoming detention camps. United States Naval Medical Bulletin, Washington, 1919, xiii, 854-58. Mac Donald, Arthur: Disequilibrium of mind and nerves in war. The Medical Record, New Yrork, 1919, xcv, 727-31. MacDonald, Arthur: Physical and mental examination of American soldiers. Modern Medi- cine, Battle Creek, Mich., 1921, iii, 129-33. MacDonald, V. May: Psychiatric social work for the discharged soldiers. Psychiatric Bul- letins of the New York State Hospitals, Utica, 1919-20, v, 148-51. MacFarlane, Andrew: Neurocirculatory myasthenia; a problem of the substandard soldier. The Journal of the American Medical Association, Chicago, 1918, lxxi, 730-33. MacPherson, D. J.: Neuropsychiatric experiences at Vichy and Savenay. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 215-18. McPherson, G. E.: Neuropsychiatry in Army camps. The Boston Medical and Surgical Journal, Boston, 1919, clxxxi, 606-11. Also, The American Journal of Insantiy, Balti- more, 1919, lxxvi, 35-44. McPherson, G. E., and Hohman, L. B.: Diagnosis of "war psychoses." Archives of Neurology and Psychiatry, Chicago, 1919, i, 207-24. Major, H. S.: Work of the neuropsychiatrists in the U. S. Army camps. Journal of Missouri State Medical Association, St. Louis, 1919, xvi, 377-79. Massonneau, Grace: Social analysis of a group of psychoneurotic ex-service men. Mental Hygiene, New York, 1922, vi, 575-91. Mayer, A. G.: On the nonexistences of nervous shell shock in fishes and marine inverte- brates. Proceedings of the National Academy of Sciences, Baltimore, 1917, iii, 597. Mayer, C. E.: Report of a case of sensory aphasia in a soldier. The Institution Quarterly Springfield, 111., 1919, x, 50-52. Meagher, J. F. W.: Prominent features of the psychoneuroses in the war. The American Journal of the Medical Sciences, Philadelphia, 1919, clviii, 344-54. Meagher, J. F. W.: Nervous and mental diseases in the war; a comparison of the results of the examination of recruits in two Army camps. The Journal of Nervous and Mental Diseases, New York, 1919, 1, 331-37. APPENDIX 483 Meyer, E. W.: Notes on the work of the neuropsychiatric corps. Pacific Coast Journal of Homeopathy, San Francisco, 1920, xxxi, 55-58. Mills, C. K.: War neurology; an introduction to shell shock and other neuropsychiatric problems, by E. E. Southard. Leonard, Boston, 1919, 5-18. Moore, G. S.: Introduction to study of neuropsychiatric problems among negroes. U. S. Veterans' Bureau Medical Bulletin, 1926, ii, 1042. Neyman, C. A.: Some experiences in the German Red Cross. Mental Hygiene, New York, 1917, i, 392-96. Nichols, C. L.: War and civil neuroses; a comparison. Long Island Medical Journal, Brook- lyn, 1919, xiii, 257-68. Norbury, F. G.: Relation of defective mental and nervous states to military efficiency. The Military Surgeon, Washington, D. C, 1920, xlvii, 20-39. Norbury, F. P.: Mental hygiene and the war. The Journal of the Iowa State Medical Society, Clinton, 1919, ix, 299-315. Norbury, F. P.: Mental mechanisms of war neuroses. The Medical Herald, St. Joseph, Mo., 1920, xxxix, 109-13. Norbury, F. P.: The National Committee for Mental Hygiene and its war work committee. The Institution Quarterly, Springfield, 111., 1917, viii, 34. Norbury, F. P., and Norbury, F. G.: War neuroses and psychoses; their aftercare and treatment. The Illinois Medical Journal, DeKalb, 1920, xxxvii, 232-37. O'Brien, J. F.: Epilepsy or hysteria, a study of convulsive seizures and unconscious states in one hundred ex-service men. The Boston Medical and Surgical Journal, Boston, 1925, clxxxviii, 103-107. Oppenheimer, G. S., and Rotschild, M. A.: Psychoneurotic factor in the irritable heart of soldiers. The Journal American Medical Association, Chicago, 1918, lxx, 550-54. Parsons, F. W.: War neuroses. Atlantic Monthly, 1919, cxxiii, 335-38. Patrick, H. T.: Remarks on examination of recruits of nervous and mental disorders. The Journal of Nervous and Mental Diseases, New York, 1918, xlvii, 450-53. Patrick, H. T.: War neuroses. The Journal of the Indiana State Medical Association, Fort Wayne, 1919, xii, 33. Payne, C. R., and Jelliffe, S. E.: War neuroses and psychoneuroses. The Journal of Nervous and Mental Diseases, New York, 1919, xlviii, 246-53, 325-32, 385-94; xlix, 50-57, 142-48, 234-38, 1, 359-68, 464-67. Pederson, T. E.: The psychiatric nurse in the Veteran's Bureau. U. S. Veteran's Bureau Medical Bulletin, Washington, 1926, ii, 889. Penhallow, D. P.: Mutism and deafness due to emotional shock cured by etherization. The Boston Medical and Surgical Journal, Boston, 1916, clxxiv, 131. Perde, N.: Endocrinopathic constitutions and pathology of war. Endocrinology, 1919, iii, 329-41. Piersol, G. M.: Cardiovasular phenomena associated with war neuroses. The Pennsylvania Medical Journal, Pittsburgh, 1920, xxiii, 258-63. Pilgrim, C. W.: The State hospitals and the war. State Hospitals Bulletin, Utica, 1918, iii, 223-4. Pollock, A. J.: An analysis of a number of cases of wrar neuroses. Illinois Medical Journal, DeKalb, 1920, xxxviii, 208-12. Pollock, H. M.: Mental diseases in New York State during the war period. Mental Hygiene, New York, 1919, iii, 253-57. Price G. E. and Terhune, W. B.: Feigned amnesia as a defense reaction. The Journal of the American Medical Association, Chicago, 1919, lxxii, 565-67. Prince, Morton: Babinski's theory of hysteria. The Journal of Abnormal Psychology, Boston, 1919, xiv, 312-24. Prince Morton: Prevention of so-called shell shock. The Journal of the American Medical Association, Chicago, 1917, lxix, 725-26. Ratliffe T. A.: Constitutional inferiority in the Navy. United States Naval Medical Bulletin, Washington, 1919, xiii, 728-33. Also, Government Printing Office, Washington, 1919, 9. 42705—29----32 484 NEUROPSYCHIATRY Ravnor, M. W.: Psychiatry at the front in the American armies. Psychiatric Bulletins of (he New York State Hospitals, Utica, 1919, iv, 301-06. Rhein, J. H. W.: Neuropsychiatric problems at the front during combat. The Journal of Abnormal Psychology, Boston, 1919, xiv, 9-14. Rhein, H. J. W.: Psychopathic reactions to combat experiences in the American Army. The American Journal of Insanity, Baltimore, 1919, lxxvi, 71-78. Rhein, J. H. W.: Preventive measures in relation to war neuroses in the Army cantonments in America, irar Medicine, August, 1918, ii, 47-51. Rhein, J. H. W.: War neuroses as observed in Army neurological hospital at the front. The New York Medical Journal, New York, 1919, ex, 177-80. Roberts, R. S.: Use of psychological and trade tests in a scheme for the vocational training of disabled men. Journal Educational Psychology, 1920, xi, 101-08. Robertson, R. C: Epilepsy. U. S. 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W.: Neurology and psychiatry in the Army. Proceedings of the New York Neurological Society, November 13, 1917. Salmon, T. W.: Psychiatric lessons from the war. Transactions of the American Neurological Association, June, 1919. Salmon, T. W.: Some new problems for psychiatric research in delinquency. Journal of the American Institute of Criminal Law and Criminology, Chicago, 1919, xx, 375. Salmon, T. W.: Future of psychiatry in the Army. The Military Surgeon, Washington, D. C, 1920, xlvii, 200-07. Salmon, T. W.: Insane veteran and a nation's honor. American Legion Weekly, January 28, 1921, 5-6. Salmon, T. W.: Outline of American plans for dealing with war neuroses. War Medicine, Paris, 1918, ii, 34. Salmon, T. W.: On shell shock. The Institution Quarterly, Springfield, 111., 1919, x, No. 4, 105-6. Salmon, T. W.: Recommendations for the treatment of mental and nervous diseases in the United States Army. National Committee for Mental Hygiene, New York, 1918, 22. Reprint from Psychiatric Bulletins of the New York State Hospitals, Utica, 1917, ii, 355-76. Salmon, T. W.: Some problems of disabled ex-service men three years after the armistice. Mental Hygiene, New York, 1922, vi, 1-10. Salmon, T. W.: Urgent need of adequate provision for medical care of insane soldiers. Ameri- can Red Cross, New York County Chapter News, February, 1921, 3-8. Salmon, T. W.: Use of institutions for the insane as military hospitals. Mental Hygiene, New York, 1917, i, 354-63. Salmon, T. W.: War neuroses and their lesson. The New York Medical Journal New York 1919, cix, 993-94. Salmon, T. W.: War neuroses ("shell shock"). National Committee for Mental Hygiene, New York, 1918, 20. Also, The Military Surgeon, Washington, D. C, 1917, xii, 674-93! APPENDIX 485 Salmon, T. W.: The wounded in mind. Carry on, S. G. O., Washington, D. C, i, No. 10, 3-6. Sands, I. J.: The problem of mentally defective ex-service men. U. S. Veterans Bureau Medical Bulletin, Washington, 1926, ii, 32. Sands, I. J.: Relation of trauma to neuropsychiatric diseases. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 3, 32. Seymour, W. Y.: Veronal psychosis. U. S. Veterans' Bureau Medical Bulletin, Washington, December, 1926, ii, 1159. Schwab, S. I., and Fenton, Norman: The factor of anticipation in war neuroses. Proceed- ings of the American Neurological Association, May, 1919. Schwab, S. I.: Influence of war upon concepts of mental diseases and neuroses. Modern Medicine, Battle Creek, Mich., 1920, ii, 192-98. Also, Mental Hygiene, New York, 1920, iv, 654-69. Schwab, S. I.: Experiment in occupational therapy at Base Hospital 117, A. E. F. Mental Hygiene, New York, 1919, iii, 580-93. Schwab, S. I.: Mechanism of the war neuroses. The Journal of Abnormal Psychology, Boston, 1919, xiv, 1-8. Schwab, S. I.: War neuroses as physiologic conservations. Archives of Neurology and Psychia- try, Chicago, 1919, i, 579-635. Sheehan, R. F.: Comment on rehabilitation methods from the neurologic viewpoint. The Military Surgeon, Washington, D. C, 1920, xlvi, 636-45. Sheehan, R. F.: Neurologic service in naval hospitals. The Military Surgeon, Washington, D. C, 1920, xlvii, 295-302. Sims, R. F.: Problems of the U. S. Veterans' Bureau. The Boston Medical and Surgical Journal, Boston, 1924, cxci, 189-93. Sims, T. R.: The psychiatrist and his patient. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 568. Sisson, C. E.: The receiving service of a neuropsychiatric hospital. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 485. Skversky, A.: Lethargic encephalitis in the A. E. F.; a clinical study. The American Journal of the Medical Sciences, Philadelphia, 1919, clviii, S49. Smith, R. P.: Mental defects found in the Army. Northwest Medicine, Seattle, 191S, xvii, 99-103. Somerville, W. G.: Shell shock (war neuroses). Memphis Medical Monthly, Memphis, Tenn., 1919, xl, 4S1-83. Southard, E. E.: Shell shock and after (Shattuck lecture). The Boston Medical and Surgical Journal, Boston, 1918, clxxix, 73-93. Southard, E. E.: Shell shock and other neuro-psychiatric problems, presented in five hundred and eighty-nine case histories, 1914-1918, with a bibliography by Norman Fenton. Leonard, Boston, 1919, 982. Stearns, A. W.: The classification of naval recruits. California State Journal of Medicine, San Francisco, 1919, April. Stearns, A. W.: The psychiatric examination of recruits. The Journal of the American Medical Association, Chicago, 1918, lxx, 229-31. Stearns, A. W.: The history as a means of detecting the undesirable candidate for enlistment, with especial reference to military delinquents. United States Naval Medical Bulletin, Washington, 191S, xii, 413-15. Stearns, A. W.: Importance of a history as a means of detecting psychopathic recruits. The Military Surgeon, Washington, 1918, xliii, 652-61. Steekel, H. A.: War neuroses in combat areas. Psychiatric B ulletins of the New York State Hospitals, Utica, 1919, v, 44-56. Stein, A. H.: Case of shell shock in civil life. Albany Medical Annals, Albany, 1921, xln, 48-53. . . , .. . Stephenson, J. W.: Brief resume of neurologic and psychiatric observations in a hospital center in France. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 61-67. Strecker, K. A.: Experience in the immediate treatment of war neuroses. The American Journal oj Insanity, Baltimore, 1919, lxxvi, 45-69. 486 NEUROPSYCHIATRY Sullenger, T. E.: Shell shock. The Psychological Clinic, Philadelphia, 1019, xiii, 33-50. Swan, J. M.: Analysis of ninety cases of functional disease in soldiers. The Archives of Internal Medicine, Chicago, 1921, xxviii, 5X0-602. Swift, H. M.: Neurologic and psychiatric work at Savenay. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 213-15. Swope, S. D.: Psychoneurosis incident to war experiences. Southwest Medical Record, Houston, 1926, vi, 26-28. Taylor, E. C: Types of neurological and psychiatric cases common in the Navy. United States Naval Medical Bulletin, Washington, 1920, xiv, 191-200. Taylor, J. M.: Types of men as observed among recruits. The Boston Medical and Surgical Journal, Boston, 1918, clxxix, 646. Taylor, W. S.: A hypoanalytic study of two cases of war neurosis. The Journal of Abnormal Psychology, Boston, 1922, xvi, 344-55. Terhune, W. A.: The war neuroses. The Journal of the American Medical Association, Chicago, 1918, lxx, 1369-73. Thom, D. A., and Fenton, Norman: Amnesias in war cases. The American Journal oj In- sanity, Baltimore, 1919, lxxvi, 437-48. Thom, D. A., and Singer, H. D.: Care of neuropsychiatric disabilities among ex-service men. Mental Hygiene, New York, 1922, vi, 23-38. Thom, D. A., and Singer, H. D.: Care of neuropsychiatric; some general considerations and recommendations. Government Printing Office, Washington, 1922. Also, United States Public Health Reports, 1921, xxxvi, 2665-77. Thomas, J. J.; Types of neurological cases seen at a base hospital. The Journal Nervous and Mental Diseases, New York, 1916, xliv, 495-502. Tindall, W. F.: Reconstruction work in the U. S. Army Hospitals. Medicine and Surgery, St. Louis, 1921, xlviii, 48. Tompkins, Ernest: Stammering in connection with military service. The American Journal of Public Health, New York, 1917, vii, 638-40. Towmsend, J. G.: Government rehabilitation of the ex-service personnel of the World War. The Military Surgeon, Washington, D. C, 1921, xlviii, 127-39. Treadway, W. L.: Activities of the War Risk Insurance Bureau and U. S. Public Health Service relative to the mentally disabled ex-military men. The American Journal of Insanity, Baltimore, 1920, lxxvi, 349-56. Trentzsch, P. J.: Postwar observations of neuropsychiatric cases. The Medical Record, New York, 1922, ci, 369-71. Tullidge, E. K.: Shock neuroses and psychoses in the present war. The Pennsylvania Medical Journal, Pittsburgh, 1916, xix, 778-82. Turck, F. B.: Wound and shell shock and their cure. The New York Medical Journal, New York, 1918, cviii, 901-03. Viets, Henry: London war hospitals. The Boston Medical and Surgical Journal, Boston, 1917, clxxvi, 222-23. Viets, Henry: Three types of spinal cord injuries in warfare. Journal of Nervous and Mental Diseases, Lancaster, Pa., 1921, liii, 18. Viets, Henry: Shell shock; a digest of the English literature. The Journal of the American Medical Association, Chicago, 1917, lxix, 1779-86. Viets, Henry: Notes on war injuries of the frontal lobe. Albany Medical Annual, Albany, 1920, xii, 14. Visher, John W.: A study in constitutional psychopathic inferiority. Mental Hygiene, Albany, 1922, vi, 729. Visher, John W., and Tartar, J.: The neurotic goal in post war neuroses. Mental Hygiene, New York, 1926, x, 355-61. Viteles, M. S.: Case of loss of psychomotor control, suspected of malingering. The Psycho- logical Clinic, Philadelphia, 1920, xiii, 222-24. Walsh, J. J : Psychoneuroses and the wrar. International Clinics, Philadelphia, 1919, xxix, series 2. 148-63. APPENDIX 487 \\ ar surgery of the nervous system; a digest of the important medical journals and books published during the European War. Government Printing Office, Washington, 1917, 360. Weisenburg, T. H.: Military history of American Neurological Association. Archives of Neurology and Psychiatry, Chicago, 1919, i, 1-13. Weisenburg, T. H.: Traumatic neuroses in war and in peace. The Journal of the American Medical Association, Chicago, 1919, lxxiii, 596-99. Welch, W. H.: Medical problems of the war. Johns Hopkins Hospital Bulletin, Baltimore, 1917, n. s. xxviii, 154-58. White, W. A.: The state hospital and the war. Mental Hygiene, New York, 1917, i, 377-82. Williams, F. E.: Anxiety and fear. Mental Hygiene, New York, 1920, iv, 73-81. Williams, F. E.: Treatment of mental patients in the general hospitals of the U. S. Army. Proceedings of the American Medico-Psychological Association, Utica, 1919, xxvi, 271-86. Williams, F. E.: Organization and scope of the neuropsychiatric unit. American Journal of Nursing, Philadelphia, 1918, xviii, 1010-21. Williams, F. E.: War neuroses. The Journal of Nervous and Mental Diseases, New York, 1919, xlix, 35-42. Williams, F. E., and Brown, M. W.: Neuropsychiatry and the war; bibliography with abstracts. National Committee for Mental Hygiene, New York, 1918, 292. Williams, F. E., and Brown, M. W.: Neuropsychiatry and the war; Supplement I, October, 1918. National Committee for Mental Hygiene, New York, 1918, 117. Williams, T. A.: Diagnosis of the lesions of the nervous systems produced by violent explo- sions in close proximity without external lesions. The Boston Medical and Surgical Journal, Boston, 1919, clxxxii, 27-34. Williams, T. A.: Management of hysteria in war. The Military Surgeon, Washington, D. C, 1919, xiv, 549-559. Williams, T. A.: The emotions and their mechanism in warfare. The Journal of Abnormal Psychology, Boston, 1919, xiv, 15-26. Williams, T. A.: So-called shell shock in the great war. Modern Medicine, Battle Creek, Mich., 1920, ii, 121-23. Williams, T. A.: The military prognosis of some neuropsychiatric affections. The Military Surgeon, Washington, D. C, 1920, xlvi. Williams, T. A.: Tremor following explosions. The Journal of Abnormal Psychology, Boston, 1920, xiv, 393-405. Woods, L. C: What is to become of the psychoneurotic? U. S. Veterans' Bureau Medical Bulletin, 1925, i, No. 5, 17. Wolfe, Samuel: Mental instability in ex-service men; how acquired; how remedied. The Military Surgeon, Washington, D. C, 1922, li, 44-46. Wolfe, Samuel: Military neuroses, general and fundamental etiology. The Military Sur- geon, Washington, D. C, 1921, xlix, 272-76. Wolfsohn, J. M.: The predisposing factors of war psychoneuroses. The Lancet, London, 1918 177-180. Also The Journal oj the American Medical Association, Chicago, 1918, lxx, 303-08. Wolfsohn, J. M.: Treatment of hysteria; successful results of a rapid reeducation method. The Journal oj the American Medical Association, Chicago, 1918, lxxi, 2057-62. Worch, Margaret: Psychiatric social work in a Red Cross Chapter. Mental Hygiene, New Yrork, 1922, vi, 312-31. Wright, H. W.: Postbellum neuroses; a clinical review and discussion of their mechanisms. Archives oj Neurology and Psychiatry, Chicago, 1920, iii, 429-34. Ziegler, L. H.: Group of psychoneurotic ex-service men. Mental Hygiene, New ^ork, 1925, ix, 128-56. New York City, April 12, 1917. Maj. Gen. W. C. Gorgas, Surgeon General, U. S. Army, Washington. Sir: In accordance with the plan agreed upon in our recent conference with you in Washington relative to supplying psychiatric hospital units for the Army, we have visited Base Hospital No. 1, Fort Sam Houston, Base Hospital No. 2, Fort Bliss, and the military prison at Fort Leavenworth. All the officers of the Medical Corps whom we met treated us with great cordiality and kindness and we wish especially to express our appreciation of the courtesies extended to us by Colonel McCaw, Lieutenant Colonel Ireland, Lieutenant Colonel Straub, and Captain King. These officers devoted much of their personal time to us, answered all our inquiries, and placed much valuable information at our disposal. From the information thus gained, together with that which we had already gathered regarding the occurrence of mental and nervous diseases among soldiers, we desire to bring to your attention the following considerations: 1. Need and purposes of psychiatric hospital unit.—The excessive prevalence of mental disorders in military life, as compared with civil life, is borne out by statistics drawn from various sources. Mental diseases were approximately three times as prevalent among the troops on the Mexican border last summer as among the adult civil population of the State of New York. The excess among soldiers is still higher under war conditions. In our own Army the insanity rate rose during the Spanish-American War from 8 per thousand to 20 per thousand; in the German troops during the Boxer Rebellion the rate reached 50 per thousand. The statistics available regarding the incidence of mental diseases in our own troops indicate that an army of 500,000 may be counted upon to furnish 1,500 insane patients a year in peace and not fewer than 4,500 a year in war, or even perhaps at times of rapid mobilization. In other words, the number of insane patients coming to notice from such an army under the conditions which prevailed on the Mexican border last summer is certain to exceed the entire number of men admitted annually to all public institutions for the insane in the State of California. Having in mind the high incidence in armies of such a serious and disabling disorder as insanity, it is evident that some special provisions should be made for the diagnosis and care of such patients. Without special provisions it is unavoidable that mental cases will, for the most part, be maintained in prison wards. This method of dealing with mental diseases is obsolete. It excludes scientific management and deprives the patients of even fresh air, exercise, and occupation. We were much impressed by the uniformly high standard of pro- visions for the diagnosis and treatment of all purely physical diseases in the base hospitals which we visited. The provision existing for the mentally ill, however, presented a sharp contrast. We believe special hospital wards conducted by alienists would not only facilitate more rapid and more complete recovery from psychoses but would remove disturbing ele- ments from the general wards, assist in making important decisions regarding discharges and retirement, and release the regular medical officers for duties for which their training has more specifically fitted them and which they all say are more congenial. In addition to cases of insanity and mental deficiency, all armies have to deal with considerable numbers of soldiers with hysteria and neurasthenia. The prevalence of these disorders increases greatly during war and at times of large mobilization. If, even in civil life, such cases are treated in general hospital wards, they show little tendency to recovery. The suggestions of physical illness inseparable from hospitals often fix their symptoms. When, on the other hand, such patients are cared for where such suggestions can be eliminated and some special methods of treatment can be employed they frequently make rapid recov- eries. A recent report from a French military neuropsychiatric unit states that many soldiers, after a neurotic invalidism lasting for months in the general hospital, were returned to the colors in from two to three weeks when treated in these units. Physicians experienced in psychiatry could also be of service to the Army in making early diagnoses of mental disease when other issues than those of treatment are concerned. Such early diagnoses should be especially helpful in disciplinary cases. Many military as well as civil offenders are in reality beginning cases of mental diseases or persons with con- stitutional psychopathic conditions who are better out of the Army than in it. Their prompt 489 490 NEUROPSYCHIATRY recognition by experts would often do not a little for the morale of troops. The experts connected with a psychiatric unit could often aid very materially in cases where malingering is suspected but can not easily be established. 2. General plan.—We believe that a psychiatric unit of 110 beds should be attached to the base hospital nearest the largest concentration of troops and that smaller units of 30 beds each should be attached to base hospitals elsewhere, as required. The central unit as well as each smaller unit should be a part of the base hospital and directly under the medical officer in command. To these units should be admitted not only well-recognized cases of mental disease and mental deficiency but cases for observation, hysterics, disciplinary cases, and, in short, soldiers presenting any condition in which diagnosis can best be made and treatment carried on by experts in this branch of medicine. 3. Personnel.—The psychiatric units can serve the purposes which have been indicated only if they are integral parts of military hospitals and the alienists are medical officers of the Army. The central unit of 110 beds will require eight medical officers, assigned to duty as follows: One in general charge, one as chief of medical service, six as ward physicians. It is essential that the medical officer in charge should have training and practical ex- perience in medico-military duties. He should be responsible for all reports, correspondence, and property, and should assign the duties of all medical officers, noncommissioned officers, and privates. The smaller units of 30 beds would each require three medical officers. It would seem proper, in view of their long special training and their responsibility, that the medical officer in charge of the central unit should have the rank of major and the other officers that of captain. The success of these units will depend largely upon having as nurses skillful men with long training in the treatment of mental diseases. If provision can be made for enlistment for the duration of the war, the services of nurses in responsible positions in some of the best hospitals for mental diseases in the country can be secured. The attached table shows the personnel which will probably be required for the central unit and for each of the smaller units. 4. Buildings.—The pavilions used in the base hospitals along the Mexican border could be very well adapted for use in these units in all except the most severe climate. Attached are sketch plans showing a scheme of general arrangement, a typical pavilion for general cases, a reception pavilion, and a pavilion for disturbed patients. Plans showing a scheme of general arrangement for a smaller unit and of the two pavilions constituting such a unit are also attached. 5. Equipment.—Assuming that beds, bedside stands, and other standard articles of equipment can be supplied by the Government, the following special equipment will be fur- nished by the committee organizing the units: Hydrotherapeutic outfits, electrical outfits, special diagnostic instruments, including psychological apparatus, typewriters, books. 6. Organization of committee.—For the purpose of expedition in correspondence and executive work, the National Committee for Mental Hygiene, 50 Union Square, New York City, has appointed as a committee on furnishing hospital units for nervous and mental disorders to the United States Government and the following men have been asked to serve as additional members: Pearce Bailey, M. D., New York City. Mr. Otto T. Bannard, treasurer, National Committee for Mental Hygiene, New York City. Lewellys F. Barker, M. D., president, National Committee for Mental Hygiene, Balti- more, Md. Albert M, Barrett, M. D., medical director, State Psychopathic Hospital, Ann Arbor, Mich. G. Alder Blumer, M. D., superintendent, Butler Hospital, Providence, R. I. Owen Copp, M. D., physician in chief, Pennsylvania Hospital, Philadelphia, Pa. Walter E. Fernald, M. D., superintendent, Massachusetts School for Feeble-Minded, Waverley, Mass. George H. Kirby, M. D., clinical director, Manhattan State Hospital, New York City. August Hoch, M. D . director, New York State Psychiatric Institute, New York City/ APPENDIX 491 Adolf Meyer, M. D., director, Phipps Psychiatric Clinic. Baltimore, Md. Stewart Paton, M. D., Princeton, N. J. William L. Russell, M. D., medical director, Bloomingdale Hospital, White Plains, Thomas W. Salmon, M. D., medical director, National Committee for Mental Hvgiene New York City. " ' Elmer E. Southard, M D.; director, Boston Psychopathic Hospital, Boston, Mass William A. White, M.D, superintendent, St. Elizabeths Hospital, Washington, D C Through the generosity of Miss Anne Thomson, daughter of the late Frank Thomson of Philadelphia, we have now on hand $15,000, an amount sufficient to defray the expenses of equipping the central unit of 110 beds in accordance with the list given. " Doubtless funds will be forthcoming to supply the smaller units as they are required. We are prepared to get the central unit together at once, both as to personnel and equipment. Will you kindly inform us at your early convenience if the initial unit is acceptable to the Government and, if so, at what date it is needed and also kindly give us all information necessary to organize in a way to meet all Army requirements? Doctor Salmon holds himself in readiness to come to Washington in this connection at any time. Respectfully, Pearce Bailey, M. D. Stewart Paton, M. D. Thomas W. Salmon, M. D. ENCLOSURES 1. Outline of facilities for treatment of mental disease in military and civil hospitals. 2. Blue print showing general arrangement of central psychiatric unit of 110 beds. 3. Blue print showing typical pavilions in central psychiatric unit. Blue print showing typical pavilions in central psychiatric unit. Personnel of central psychiatric unit. Blue print showing general arrangement of smaller unit of 30 beds. Blue print showing typical pavilions in smaller unit. Personnel of smaller psychiatric unit. Military zones Zone of the interior. Zone of communications. Zone of the advance___ Military hospitals Camp hospitals; general hospitals (perma- nent); hospitals for prisoners of war; con- valescent camps; hospital trains; hospital ships (in overseas operations); hospitals at ports of embarkation (in overseas opera- tions. Base hospitals (500 beds); evacuation hospitals (432 beds); evacuation hospital ambulance companies. Field hospitals (216 beds); ambulance compa- nies; dressing stations; first aid. Facilities for treating mental diseases Central psychiatric hospital unit (110 beds) attached to camp or base hospital nearest largest concentration of troops; civil insti- tutions; Government Hospital for the In- sane (St. Elizabeths Hospital); special wards in State hospitals for the insane; psychopathic hospitals; psychopathic wards in general hospitals. Psychiatric pavilions (30 beds) attached to base hospitals in favorable locations. Psychiatrist and neurologist attached to each field hospital company. 492 NEUROPSYCHIATRY A OFFICES B OFFICERS 8 PATIENTS NO PATIENTS DISTURBED CASES___ 8 PATIENTS GENERAL RECEPTION GENERAL G GENERAL 16 PATIENTS H GENERAL 16 PATIENTS NO PATIENTS I GENERAL KITCHEN & STORE ROOMS GENERAL ARRANGEMENT CENTRAL UNIT OF 110 BEDS APPENDIX 493 D-F-G-H-l GENERAL PIAZZA- 6 FEET WIDE 1 ROOM ATT. S . R. S. R. WARD DAY WA R D 1 CLO. S . R. S. R. SHOWER Of & TOILET OOOl OC R E CE PTION S. R AT T. DAY ROOM D AY ROOM AT T. S . R. WARD WA RD CLO. CLO. e S. R >. R. o SHO o WER 81 Ot J© fo P TYPICAL PAVILI ON S CENTRAL UNIT OF 110 BEDS 494 NEUROPSYCHIATRY PERSONNEL OF CENTRAL UNIT, 110 BEDS Commissioned medical officers Major A1____________________________________ In general charge. Captain B, M. R. C_____________________________ Chief of Medical Service. Captain C, M. R. C_____________________________ Ward physician. Captain D, M. R. C_____________________________ Do. Captain E, M. R. C_____________________________ Do. Captain F, M. R. C_____________________________ Do. Captain G, M. R. C_____________________________ Do. Captain H,1 M. R. C____________________________ Do. Noncommissioned officers, Hospital Corps Sergeant, first class !_____________________________________ Acting first sergeant, in general supervision of the hospital and in charge of medical property and records; acting quartermaster sergeant. Do.1_____________________________________ In charge of mess and kitchen. Do______________________________________ In charge of hydrotherapy. Do______________________________________ In charge of reception ward. Sergeant_____________________________________ Ward master. Do______________________________________ Do. Do______________________________________ Do. Do______________________________________ Do. Enlisted men, Hospital Corps, assigned to duty 1 2 acting cooks. 22 ward attendants (12 day, 8 night, 2 relief). 1 in laboratory. 4 in kitchens and mess rooms. 1 orderly (to Major A). 1 in storeroom. 1 in office. 1 in outside police. 2 supernumeraries. Recapitulation Commissioned medical officers______________________________ 8 Noncommissioned officers, Hospital Corps_____________________ 8 Enlisted men, hospital corps_______________________________ 35 Total___________________________________________ 51 Patients______________________________________________ 1X0 Grand total_______________________________________ 161 PERSONNEL OF UNITS ATTACHED TO BASE HOSPITALS, 30 BEDS Commissioned medical officers Captain A l--------------------------------------------- In general charge. Captain B---------------------------------------------- Ward physician. Captain C_________________________________________ Da Noncommissioned officers, Hospital Corps Sergeant, first class1------------------------------------- Acting first sergeant. Sergeant------------------------------------------------ In charge of mess and kitchen. Do-------------------------------------- In charge of Ward A. Do-------------------------------------- In charge of Ward B. 1 Previous military training required. APPENDIX 495 Enlisted men, Hospital Corps, assigned to duty * 1 acting cook. i 1 orderly (to Captain 6 ward attendants (4 day, 2 night, 1 relief). I 1 in office. 2 in kitchen and messroom. | i supernumerary. OFFICES NO PATIENTS PAVILION PAVILION B ENTS| <0 1-z UJ < Q. KITCHEN AND MESS GENERAL ARRANGEMENT SMALLER UNIT OF 30 BEDS Recapitulation Commissioned medical officers_____________________________________ 3 Noncommissioned officers, Hospital Corps__________________________ 4 Enlisted men, Hospital Corps______________________________________ 12 Total_____________________________________________________ 19 Patients_________________________________________________________ 30 Grand total_______________________________________________ 49 ' Previous military training required. 496 NEUROPSYCHIATRY PAVILION A - FOR OBSERVATION CASES S.R. NURSE CLOSET S.R. WAR D DAY ROOM WARD S.R. EXAM. ELECTRO THERAPY SHOWE R Of TOILET. °t OOOl Ot PAVILION B - FOR INSANE CASES S.R. S.R. DAY ROOM DAY NURSE S.R. S.R. HYDRO-S E S WA R D D 1 STURBED CA ROOM CLO. THERAPY S.R. S.R. S.R. S.R. 0 SHO 0 WER ol o| Of K> 1° __& TYPICAL PAVIL IONS SMALLER UNIT OF 30 BEDS THE CARE AND TREATMENT OF MENTAL DISEASES AND WAR NEUROSIS (" SHELL SHOCK ") IN THE BRITISH ARMY i Introduction No medico-military problems of the war are more striking than those growing out of the extraordinary incidence of mental and functional nervous diseases ("shell shock"). Together these disorders are responsible for not less than one-seventh of all discharges for disability from the British Army, or one-third if discharges for wounds are excluded. A medical service newly confronted like ours with the task of caring for the sick and wounded of a large army can not ignore such important causes of invalidism. By their very nature, however, these diseases endanger the morale and discipline of troops in a special way and require attention for purely military reasons. In order that as many men as possible may be returned to the colors or sent into civil life without disabilities which will incapacitate them for work and self- support, it is highly desirable to make use of all available information as to the nature of these diseases among soldiers in the armies of our allies and as to their treatment at the front, at the bases, and at the centers established in home territory for their "reconstruction." England has had three years' experience in dealing with the medical problems of war. During that time opinion has matured as to the nature, causes, and treatment of the psychoses and neuroses which prevail so extensively among troops. A sufficient number of different methods of military management have been tried to make it possible to judge of their relative merits. My visit to England was for the purpose of observing these matters at first hand so that I could contribute information which might aid in formulating plans for dealing with mental and nervous diseases among our own forces when they are exposed to the terrific stress of modern war. acknowledgments I wish, at the outset, to record my appreciation of the many courtesies which enabled me to use the limited time at my disposal to the best advantage. The Army Council, upon the request of Ambassador Page, agreed to place at my disposal every facility for studying mental and nervous diseases. The medical officers of the special hospitals for mental and nervous cases gave me opportunities to observe the work of the institutions under their charge. Others actively engaged in dealing with various administrative and clinical phases of these problems not only gave me valuable information but very kindly offered suggestions as to practical means by which our Army might profit by the experience of British medical officers. I would mention especially Lieut. Col. William Aldren Turner, the principal advisor to the Government in these matters; Lieut. Col. Sir John Collie, president of the Special Pension Board on Neurasthenics; Sir William Osier, under whose direction work is carried on in the special hospital for functional disorders of the heart; Dr. C. Herbert Bond, of the Board of Control; Dr. Henry Head, who represented the Medical Research Committee in the conference upon nervous diseases among soldiers held in Paris in April, 1916; Dr. H. Crichton Brown, who has prepared a thoughtful memorandum on the subject for the war office; Lieut. Col. Sir Robert Armstrong-Jones and the American liaison officers in London— Brigadier General Bradley and Lieutenant Colonel Lyster of the Army and Surgeon Pleadwell of the Navy. Dr. William Morley Fletcher, secretary of the Medical Research Committee, which from an early period in the war has directed attention to the importance of nervous diseases, presented me with a motion-picture film showing some of the more common symp- toms in soldiers suffering from the neuroses. Dr. John T. MacCurdy, associate in psychiatry at the New York State Psychiatric Institute, who was studying the war neuroses in special hospitals in London, very kindly visited the Moss Side Military Hospital at Maghull and the Craiglockhart Hospital for Officers near Edinboro and furnished me with reports on the facilities for treatment at these institutions. i By Maj. Thomas W. Salmon, Medical Officers' Reserve Corps, U. S. Army. 497 498 NEUROPSYCHIATRY SCOPE OF REPORT I have omitted entirely any account of the treatment of organic nervous diseases or of injuries to the central nervous system or the peripheral nerves. Organic nervous diseases are not especially frequent and seem to present no special military problems. Injuries of the central nervous system are frequent and severe. Those that do not prove fatal very quickly are well cared for at first in general surgical wards where the services of neurologists and neurological surgeons are available and later in special hospitals or special hospital wards. A very serious difficulty in dealing with destructive brain and cord lesions is that the patients sooner or later pass from hospitals in which special care and nursing are provided to their homes or to poorly equipped auxiliary hospitals in which many soon get worse or die. In- juries to the peripheral nerves are frequent and important, in fact there are few extensive injuries to the extremities in which important nerves escape. With neurological advice, the surgeons deal with these cases successfully in the base hospitals and their after-treatment is well carried on in the "reconstruction centers " for orthopedic cases Neither of these classes of injuries concerns especially the treatment or military management of mental and func- tional nervous diseases except for the fact (to be commented upon later) that the treatment of the war neuroses might be carried out advantageously in home territory in cooperation with orthopedic reconstruction centers. Although the problems presented by mental and functional nervous diseases have many clinical and administrative features in common and although these disorders should be dealt with by medical officers with the same kind of special training, it seems desirable to consider their treatment in England separately in this report. My observations as to the nature of the neuroses met with in war are based partly upon the very extensive literature upon this subject which has come into existence since the com- mencement of the war, but chiefly upon personal conversation with medical men engaged in treating these cases in England. It is almost needless to say that during a short period largely spent in securing information regarding facilities for treatment and administrative methods of management and in examining special hospitals for the care of these cases, I had no oppor- tunity to make original clinical observations, although I saw and examined superficially many cases of all degrees of severity. Mental Diseases (Insanity) prevalence For many years war military life has been called the "touchstone of insanity " on account of the high prevalence of mental diseases in armies even during peace. Medical statistics of the present war are as yet untabulated and so it is impossible to state the rate per thou- sand for mental diseases. The only means of estimating their incidence is by considering the number of cases diagnosed officially as "insane" in the military hospitals at a given time. On March 31, 1917, about 1.1 per cent of all patients in military hospitals of Great Britain were officially diagnosed as insane. The percentage among expeditionary patients was 1.3 and among nonexpeditionary patients 1.1. The enormous prevalence of wounds in patients from the expeditionary troops reduces the percentage of all other conditions and so the excess of mental cases among expeditionary cases is much greater than is apparent. Among non- wounded expeditionary patients the percentage was about three times that among the non- expeditionary cases. The rate among officers was only one-third that among men in expedi- tionary patients and about the same in nonexpeditionary patients. This has an important bearing upon the fact that the rate for the war neuroses ("shell shock") among officers is five times as high as among men. About 6,000 patients are admitted annually from both the expeditionary and nonexpeditionary forces to the special military hospitals for the insane. As one such hospital with a large admission rate is a "clearing hospital" and distributes its patients to other special hospitals, some patients are obviously counted twice in the only statistics available. To offset this is the fact that a much larger number of mental cases do not go to special military hospitals at all, but are discharged to friends, with or without an official diagnosis of insanity, or are sent directly to local institutions for the insane. This is APPENDIX 499 Ivan-Wp fW+Ka8e nionexPeditionary troops. It can be estimated, from all the data Z!T„H^ . , annlfLanmiSSi°n mte is ab0ut 2 Per i'000 amonS the nonexpeditionary nonlt ?°n \P*Vim0 amonS expeditionary troops. The rate in the adult male civil population of Great Britain is about 1 per 1,000. There is statistical evidence which indicates that the insanity rate in the British Armv is less at the present time than it was in the first year of the war, and that it has not reached some oi the high rates reported in recent wars. The high and constantly increasing rate for the war neuroses suggests that the latter disorders are taking the place of the psychoses in modern war. How much this phenomenon is due to an actual change in incidence and how ™ f°rmer errors in diagnosis can not be stated accurately. There is a strong suspicion that the high insanity rate in the Spanish-American War and the Boer War was due, in part at least, to failure to recognize the real nature of severe neuroses, similar to those grouped under the term "shell shock" in this war. This may account for the remarkable recovery rate among insane soldiers in the two wars in question. It is certain that in the early months of the present war many soldiers suffering from war neuroses were regarded as insane and disposed of accordingly. When one remembers that the striking manifestations seen in these cases are unfamiliar in men to physicians in general practice, it is not surprising that some of the severer disturbances should have been interpreted as signs of insanity. The benign course and rapid recovery of many of these cases upon their return to England, together with increasing familiarity with the symptoms of functional nervous diseases, soon enabled the medical officers serving with troops to recognize their real nature. Even at the present time, however, it is by no means rare for soldiers with functional nervous diseases to be sent to England as insane or for insane soldiers to be sent to hospitals for the war neuroses. This is shown by the records of the Red Cross Military Hospital at Maghull, a hospital for the treatment of war neuroses. Since this hospital was opened, 10 per cent of the 1,74 patients admitted 1 were found to be suffering from mental diseases and sent to hospitals for the insane. On the other hand, 20 per cent of the 6,755 patients received 1 from France since the commencement of the war at "D Block" of the Royal Victoria Hospital, at Netley, a clearing hospital for mental cases, were subsequently sent to hospitals for func- tional nervous diseases. On the whole it may be said that medical officers serving with troops are becoming more familiar with the symptoms of functiona1 nervous diseases and that fewer such errors now occur. treatment The return to England of considerable numbers of mental cases, commencing early in the war and steadily continuing, soon led to rather difficult questions as to their disposal. Before the war, the army maintained a small department for the insane at the Royal Vic- toria Hospital, at Netley. This department which is known as"D Block" and constitutes practically an independent unit, accommodated only 125 men and 3 officers. For years the annual admission rate averaged 120. The only cases received were soldiers who had served at least 10 years in the regular army or those with shorter service whose insanity seemed clearly to be due to such causes arising in line of duty as head injuries, tropical fevers, exhaus- tion, wounds, etc. As it was manifestly impossible to care for more cases at Netley, the insane soldiers who were first sent home from the expeditionary forces, as well as those from the home forces, were "certified" (i. e., legally committed) and sent to the local "county lunatic asylums" as they are called, unless their relatives and friends took them off the hands of the Government and disposed of them otherwise. The appearance of soldiers from the front in the district asylums, where they were burdened by the double stigma of lunacy and pauperism, aroused public disapproval that speedily made itself felt in Parliament. About this time arrangements had been made to take over 1 county or borough asylum in each group of 10 in the United Kingdom for use as a general military hospital for medical and surgical cases. This made it possible to establish special war hospitals for mental cases. A department of the Middlesex County Asylum (renamed the Napsbury War Hospital) was opened for mental cases, and the District Asylum at Paisley, Scotland (renamed the Dykebar i To May 31, 1917. 42705—29----33 500 NEUROPSYCHIATRY War Hospital), was turned over entirely for this purpose, as was part of the Lord Derby V\ ar Hospital at Warrington, which had been the Lancashire Asylum. Later the Belfast Dis- trict Asylum in Ireland was taken over as the Belfast War Hospital, and still more recently the Perth District Asylum was taken over as the Murthley War Hospital, both being used entirely for the insane. A pavilion at the Richmond District Asylum, Ireland, accommodates 100 and a small hospital in London (Letchmere House) cares for about 84 officers. An annex in connection with the Dykebar War Hospital has recently been opened so that there are now about 3,400 beds in strictly military hospitals available in Great Britain and Ireland for insane soldiers. No attempt has been made to care for the insane in France, the policy of the War Office being to send all cases to the clearing hospital at Netley and then to the special institutions named as soon as possible. There are available in France only 125 beds, all for the tem- porary detention of mental cases. Of the 21 asylums and similar institutions in Great Britain and Ireland which have been converted into military hospitals,1 3 are used wholly or in part for functional nervous dis- eases. In spite of the fact that the names of all these asylums were changed when they were taken over for their new use, a suspicion apparently exists among the public that soldiers with mental or nervous diseases are still being sent to district asylums as "pauper lunatics," the official designation of such patients. It is not easy for us in America to under- stand the importance of this aspect of the question for in most States our State hospitals enjoy a reputation which would no more stigmatize insane soldiers than it does their sisters or daughters when they require treatment obtainable only in these institutions. In England, however, insanity and pauperism have been closely linked, and it is the latter which is very largely responsible for the stigma attached to these institutions. The Government was obliged, therefore, early in 1915 to announce that it has adopted the policy of sending to the district asylums only the following groups of cases from the expeditionary forces: 1. Patients with general paralysis of the insane. 2. Patients with chronic epilepsy. 3. Patients with incurable mental diseases and those giving a history of insanity before enlistment. There is power to apply the pension of the soldier toward this support in these cases, and he is thereby prevented from coming "on the rates." The separation allowances are discontinued when the pension is commenced. All insane soldiers from the nonexpeditionary forces are certified and sent to the district asylums unless it can be shown that the disease was caused or aggravated by military service, The results of these arrangements are not wholly satisfactory. There is a strong tend- ency to adopt an entirely different attitude toward insane soldiers than the wonderfully generous one which the nation has adopted toward the wounded and those suffering from physical disease. In the latter, the Government readily admits its responsibility and makes liberal provisions for treatment, pension and industrial reeducation, while in the former every effort is made to place the burden of responsibility and of support upon the patient or his relatives by magnifying alleged constitutional tendencies and minimizing the effects of military service. It is quite apparent that the conditions of actual service have much to do with the development of mental disease. Even in the case of general paralysis of the insane it is by no means certain that a young soldier with a positive Wassermann test would have developed general paralysis if he had not been exposed to the supreme ordeal of service at the front. This official attitude toward mental disease results in an average period of treatment far shorter than is required in even the most benign psychoses in civil life. It is evident that mental cases are insufficiently treated in military hospitals. During 1916, the number of mental cases passing through the 3,400 beds available for their care in Great Britain and Ireland was about 6,000. The recovery rate in military cases is much higher than in the mental cases admitted to civil hospitals, but the rapid movement of population results chiefly from the custom of "passing on" these cases. Insane soldiers of the nonexpeditionary forces are sent almost invariably directly to district asylums from general hospitals without even going to "D Block," where an inquiry could be made bv ' To July 1, 1917. APPENDIX 501 experts to estimate the part played by military service in the causation of mental illness. U hen relatives and friends are induced to take insane soldiers from the military hospitals i m Tnnn P " USUaUy admission to the district asylums. During the year ending May 31, 1917, 900 insane soldiers were admitted to the local asvlums. A considerable proportion of the insane, even from the expeditionary forces, sooner or later find their way into the institutions out of which Parliament was intent upon keeping them. The disposition of mental cases is well illustrated by the following table showing what was done in the case of 5,473 patients admitted from September 1, 1914, to Mav 31, 1917, at "D Block," Netley, a clearing hospital for mental diseases: DISPOSITION OF CASES ADMITTED TO "d BLOCK," NETLEY, FROM THE BEGINNING OF THE WAR TO DECEMBER 31, 1916 To institutions for the insane: Lord Derby War Hospital, Warrington_____________________________________ 1; 424 Murthley War Hospital, Perth_____________________________________________ ' 210 Dykebar War Hospital, Paisley____________________________________________ 611 Shorncliffe (Canadian Clearing Mental Hospital)____________________________ 147 District asylums_____________________________________________ 128 Dartford (for insane prisoners of war)______________________________________ 3 To war hospitals for functional nervous cases: Moss Side Hospital, Maghull______________________________________________ 509 Springfield War Hospital, London__________________________________________ 680 To hospitals for organic nervous diseases and injuries: Queen Square____________________________________________________________ 4 Maida Vale (for pensioners)_______________________________________________ 2 To Royal Victoria Military Hospital, Netley (recoveries and nervous diseases)______1, 007 To almshouses________________________________________________________________ 2 To Canadian hospitals or returned to Canada___________________________________ 5 To Australian hospitals or returned to Australia_________________________________ 33 To other hospitals and institutions_____________________________________________ 204 Discharged to relatives and friends_____________________________________________ 258 Died_________________________________________________________________________ 21 Furloughed___________________________________________________________________ 110 Returned to duty_____________________________________________________________ 58 Remaining in hospital_________________________________________________________ 57 Total__________________________________________________________________ 5,473 CLINICAL TYPES OF MENTAL DISEASES AMONG SOLDIERS Contrary to popular belief and to some medical reports published early in the war, no new clinical types of mental diseases have been seen in soldiers. There are no "war psy- choses." The clinical pictures familiar in civil life have been seen, colored often by the experience at the front, but for the most part unchanged in their symptomatology, outcome, and course. The distribution of the different psychoses has been strikingly different than in civil life, but this has been chiefly due to the different age periods represented in patients for the army. The absence of the organic mental diseases of the later decades of life, which play so large a part in civil statistics, has resulted in abnormally high percentages for other psvchoses. Although no statistics for the whole number of admissions in a single year are available nearly a thousand admissions from expeditionary troops to the Dykebar War Hospital during 1916 have been tabulated by Maj. R. D. Hotchkis. This series of cases is large enough to make some of the findings significant. They are borne out by observation made by Lieut. David K. Henderson at the Lord Derby War Hospital at Warrington, which received 2,042 mental cases during the year ending April 30, 1917. Mental deficiency.—About 18 per cent of patients admitted to the military hospitals for mental diseases are mentally defective. Only such mental defectives as get into trouble or 502 NEUROPSYCHIATRY develop acute psychotic episodes of one sort or another gain admission to these hospitals. It is impossible, therefore, from the point of view of the hospitals for mental diseases, to draw any conclusions as to the relation of mental deficiency to military service. The low grade of many cases received in the special hospitals is very striking and shows an amazing indifference on the part of recruiting officers to this type of disability. It is said that the worst types got in during the first rush of recruits under the voluntary sysytem and that, since then, more pains have been taken to exclude them. Of the 151 mental defectives admitted to the Dykebar War Hospital, 37 were sent there simply because they had been giving trouble to other hospitals where they had been treated for wounds or diseases. Most of these soldiers were defectives of the restless, criminalistic type, many of whom had been civil offenders before entering the army. It is believed that they represented but a small part of cases of this type in the military service, the majority being dealt with from a disciplin- ary standpoint without regard to existence of mental defect, thus following the precedent which, unfortunately, is so firmly established in civil life. The remaining 114 defectives sent to Dykebar had been able to earn their own livelihood before entering the army. They had no criminalistic traits but had proved quite valueless in actual fighting. Sometimes these men were actually dangerous to their comrades and were permitted to load their rifles only when an attack was made. The very specialized activities of modern fighting discloses such individuals who under former military conditions would not have come to light. It is said that in the Boer War many boys from the special classes of the Birmingham and London schools made good soldiers, but apparently the military usefulness of the mentally defective has disappeared under the conditions of modern warfare—an exceedingly important point for the consideration of a nation engaged in raising a new army. Among the defectives received in the military hospitals for mental cases are many in whom attention has been directed to their disability by episodes of confusion or excitement. The outlook is very favorable in such cases, the quiet routine of the hospital having a bene- ficial effect in a remarkably short period of time. Mental defectives develop war neuroses, in spite of statements to the contrary, but with striking infrequency. The generally high standard of intelligence among the patients in the "shell-shock" hospitals is noticeable. There is much difference of opinion as to whether or not men known to be mentally defective should be recruited for any military service. In favor of their acceptance it is said that they can be assigned to certain kinds of work at the bases for which they are par- ticularly fitted and thereby release soldiers of more intelligence for duty at the front. When one remembers that not only the army but the whole nation is at war it seems better, even for military reasons, to leave defectives at work in an environment to which they are accus- tomed than to try the experiment of even a special kind of military service. Certainly the army now has no means of assigning its work with reference to the limitations of such a special group. Moreover, when the army knowingly accepts mentally defective recruits it assumes a liability for their protection which it can hardly be expected to meet in all the exigencies of war. Much injustice is done in the army by punishing mental defectives for military offenses which would have been condoned had the real mental condition of the offenders been appreciated. There are sufficient grounds for excluding all mental defectives from the military forces except when the last available man power must be utilized. When this is the case it will doubtless be found that their most effective service will be rendered at the base under the supervision of noncommissioned officers who have been especially trained in their management. Syphilitic psychoses.—About 2 per cent of the mental cases received in these special hospitals have general paresis. There is convincing evidence that the stress of war accel- erates the progress of this disease. As older men enter the army the proportion of paresis rises. In the navy, which has been largely augmented by the enlistment of older men in the Naval Reserve, general paresis has attained a rate quite unknown in time of peace. Examinations to determine the prevalence of syphilis in recruits are extremely important and the experience of the British Army and Navy shows that no person presenting the slightest suspicion of syphilis of the central nervous system should be enlisted or commis- sioned for any military duty. In view of the social distribution of this disease and the generally higher age of officers, paresis is to be borne in mind especially in the examination of candidates for officers' commissions. APPE.NDIX 503 Manic-depressive insanity.—-Patients in this group supply about 20 per cent of all admissions to military hospitals for mental diseases. The great proportion of those with depressed phases is very striking. Delusions and hallucinations are almost invariably colored by military experiences. Alcoholic psychoses.-Soldievs with delirium tremens are admitted to special hospitals for mental diseases if they are stationed near such institutions. This disorder is now con- fined almost entirely to patients on leave from the front. During the early davs of the war it was most frequently seen among those who had just entered military service and found their supply of alcohol restricted. The delusional types of alcoholic psychoses are found in older men stationed at bases who have the opportunity to continue life-long habits of drinking to excess. Attempted suicides are very common among alcoholics seen in military service. Alcoholics should not be accepted for military service even if it is pos- sible to prevent them from securing alcohol at the front. Furloughs furnish opportunities for drinking, and the time and effort spent in training men are lost through attacks on such occasions. Dementia praecox.—Patients with this disorder constitute 14 per cent of those admitted. The histories of these cases show that in most instances symptoms were manifested shortly after entering the military service. It is apparent that many of them had been psychotic before enlistment. There seems to be no special modification of symptoms on account of military service. Epilepsy.—Seven per cent of cases received at Dykebar War Hospital were suffering from epilepsy. With one exception, all had had the disease before enlistment. Constitutional psychopathic states.—A very large number of these cases are received in the special military hospitals for mental diseases. They probably represent but a small proportion of such soldiers in the army, for the percentage is large in the various disciplinary groups. Unfortunately, the nomenclature used in the British Army did not permit the use of any term applicable to these cases until February, 1916, when the War Office authorized the addition of "mental instability" to the list of mental diseases. Many of these cases are now being reported under this heading. The occasion of their admission is usually an acute psychotic episode or a medico-legal situation. OULTOOK IN MENTAL CASES There are no statistics available to show the outcome in the mental diseases treated in military hospitals. Discharge is much more likely to be regulated by administrative considerations than by clinical ones. Acute conditions seem to recover very quickly. Few return to "first-line duty." The statistics indicate a much larger proportion than is actually the case. The number of those who go back to the colors is made up for the most part of patients who have recovered from delirium tremens and those with war neuroses who have been incorrectly admitted to institutions for the insane. Infective-exhaustive psychoses are much more likely to be regarded as "shell shock" than as mental disorders. The hos- pitals for mental diseases fail, therefore, to get these very recoverable cases and the recovery rate in such institutions suffers correspondingly. SUMMARY Sorely pressed to meet the tremendous medical problems of war, England first used her existing civil facilities for caring for mental diseases among soldiers. Public disapproval, based chiefly upon a mistaken attitude toward the insane and toward the local institutions for their care, forced a different method of management. The military hospitals for the in- sane created without exception by converting civil institutions for mental diseases, failed to do much more than provide places for receiving mental cases and giving temporary care, the clearing hospital is woefully inadequate in size and personnel to determine the important issues which should be determined there, and a solution to the problem presented by mental diseases among soldiers in England does not seem to be in sight. For the LTnited States, this experience carries important lessons. More important than all others is the result of careless recruiting. The problem of dealing with mental diseases 504 N E U RO PS YCHIATRY in the army, difficult at best, has been made still more difficult by accepting large numbers of recruits who had been in institutions for the insane or were of demonstrably psychopathic make-up. The next most important lesson is that of preparing in advance of an urgent need, a comprehensive plan for using existing civil facilities for treating mental disease in a manner which will serve the army effectively and at the same time safeguard the interests of the soldiers, of the Government, and of the community. War Neuroses ("Shell Shock") Although an excessive incidence of mental diseases has been noted in all recent wars, it is only in the present one that functional nervous diseases have constituted a major medico- military problem. As every nation and race engaged is suffering severely from these dis- orders, it is apparent that new conditions of warfare are chiefly responsible for their preva- lence. None of these new conditions is more terrible than the sustained shell fire with high explosives, which has characterized most of the fighting. It is not surprising, therefore, that the term "shell shock" should have come into general use to designate this group of disorders. The vivid, terse name quickly became popular and now it is applied to practically any nervous symptoms in soldiers exposed to shell fire that can not be explained by some obvious physical injury. It is used so very loosely that it is applied not only to all functional nervous diseases but to well-known forms of mental disease—even general paresis. Such a situation is most unsatisfactory and at the present time an attempt is being made to improve the nomenclature of the nervous disorders which prevail so extensively among soldiers. Discussion of clinical features of the war neuroses is not within the scope of this report, which deals with treatment and military management.1 It is impossible, however, even to define the problem with which we are dealing without a few general observations on the nature of the disorders which are grouped under the name "shell shock." The subject can be clarified a little by dividing the different conditions now included under the term "shell shock" into some clinical and etiological groups. First should be considered cases in which the patients have been actually exposed to the effects of high explosives. 1. There are a number of cases, just how many it is quite impossible to say, in which exploding shells or mines cause death without external signs of injury. Apparently death in these cases results from different kinds of causes, among them damage to the central nervous system. 2. In another group of cases severe neurological symptoms following burial or concussion by explosions appear in characteristic syndromes suggesting the operation of mechnical factors. The studies of Major Mott indicate that concussion, aerial compression and the rapid decompression following it, "gassing" from the drift gases (carbon monoxide and nitric oxide) generated by the explosion and other purely mechanical effects of shell explosion may result in transitory or permanent symptoms of a type unfamiliar in the neuroses. There can be no question of the propriety of supplying the term "shell shock" to these two groups of cases if a specific term is required. 3. Another group of cases among those exposed to shell fire includes patients in which there may or may not be damage to the central nervous system but in which the symptoms are those of neuroses familiar in civil practice even though colored in a very distinctive way by the precipitating cause. In this group of cases in which there is possibility but no proof of damage to the central nervous system, the symptoms present which might be attributable to such damage are quite overshadowed by those characteristic of the neuroses. It is about these cases that much controversy exists. Mott includes them in his group of "injuries of the central nervous system without visible injury," holding that a physical or a chemical change at present unknown to us must underlie such striking disabilities. Others i These extraordinarily interesting medical problems of the war are dealt with in a rapidly expanding volume of special literature. The July number of" Mental Hygiene" (Vol. 1, Xo. 3) contains a resume' of this literature. One hundred and forty-one references in English are given in Appendix I of this report. Attention is directed particularly to the contribu- tions of Maj. Frederick M. Mott (71 and 72), Prof. O. Elliot Smith (108), Capt. Charles S. Myers (74), Capt. Clarence B. Farrar (32), Capt. M. D. Eder (28), and to the extensive report by Dr. John T. MacCurdy in the " Psychiatric Bulletin" IN. Y.) for July, 1917. (The numbers refer to the references in Appendix I.) APPENDIX 505 give less weight to the factor of physical damage and yet recognize its existence and reconcile the wide range of neurotic symptoms with the very minute amount of damage which may exist by terming these cases "traumatic neuroses." Others again feel that psychogenetic factors determine not only the continuing neurosis but even the initial unconsciousness and special sense disturbances. 4. There is a fourth group of cases in which even the slightest damage to the central nervous system from the direct effects of explosions is exceedingly unlikely or impossible, the patients being exposed only to conditions to which hundreds of their comrades who develop no symptoms are exposed. In these cases the symptoms, course, and outsome correspond with those seen in neuroses in civil practice. If all neuroses among soldiers were included in these groups the use of the term "shell shock" might be defended. But many hundreds of soldiers who have not been exposed to battle conditions at all develop symptoms almost identical with those in men whose nervous disorders are attributed to shell fire. The nonexpeditionary forces supply a considerable proportion of these cases. To state that, in the cases included in the last two groups of cases in which shell explo- sions play a part, the mechanism is that of a neurosis by no means excludes the operation of physical causes. Very little is known, however, regarding the physiological basis of the disorders in this group or even in those in the first two groups in which the issues are appar- ently predominantly organic. It may be that in the latter two groups endocrinitic disturb- ances are important. Minute injuries of the cord may exist and factors such as exposure, exhaustion, vascular disequilibrium and disorders of metabolism may enter into their causa- tion. Treatment directed along the lines suggested by such an etiology has thus far proved quite ineffective, however, and there is only the most slender basis of experimental work to show that such factors are important. This is a fertile field for research. It is earnestly hoped by all those consulted in England that the United States Army, coming freshly into contact with this problem, will organize a working party of psychiatrists, neurologists, neuro- pathologists and internists and try to clear up some of these issues. It is the opinion of most psychiatrists and neurologists who have been studying and treating "shell shock" in the British Army that the fourth group is the largest and most important and that, whatever the unknown physiological basis, psychological factors are too obvious and too important in these cases to be ignored. In support of this view there is much evidence, some of which it may be worth while to give. 1. The excess of war neuroses among officers. The ratio of officers to men at the front is approximately 1 to 30. Among the wounded it is 1 to 24.1 Among the patients admitted to the special hospitals for war neuroses in England during the year ending April 30, 1917, it was 1 to 6. 2. The rarity of war neuroses among prisoners exposed to mechanical shock.2 3. The rarity of war neuroses among the wounded exposed to mechanical shock. 4. The clinical resemblance of the war neuroses to the neuroses of civil life in which the element of mechanical shock is lacking while the psychological situations are somewhat alike. 5. The fact that severe war injuries to the brain and spinal cord are not accompanied by symptoms similar to those in "shell shock," in which injuries of less degree are assumed. 6. The success attending therapeutic measures employed with reference to the psycho- logical situations discovered in individual cases. These suggestive facts require some elaboration. The high prevalence of "shell shock" anong officers corresponds with the distribution of the neuroses, with reference to education and social grouping, in civil life. Soldiers who are wounded and those who are taken prisoners in battle are exposed to wind concussion and rapid decompression and other mechanical factors in the same degree as their comrades who suffer from neuroses. One must conclude from the fact that they escape that, being wounded or being captured, provides them with something which the neurosis provides for others. The symptoms exhibited usually bear a more direct relation to the existing psychological situation than they could possibly bear to 1 Analysis of 3*1,983 casualties between Aug. 4, 1914-Aug. 21, 1915, reported in a statement in Parliament, and 901,534 casualties between July, 1916, and July, 1917. s References given by Capt. C. B. Farrar. 506 NEUROPSYCHIATRY the localization of a neurological injury. Thus, a soldier who bayonets an enemy in the face develops a hysterical tic of his own facial muscles, abdominal contractures occur in men who have bayoneted enemies in the abdomen. Hysterical blindness follows particularly horrible sights, hysterical deafness appears in those who find the cries of the wounded unbearable, and men detailed to burial paities develop anosmia. The psychological basis of the war neuroses (like that of the neuroses in civil life) is an elaboration, with endless variations, of one central theme, escape from an intolerable situation in real life to one made tolerable by the neurosis. The conditions which may make intolerable the situation in which a soldier finds himself hardly need stating. Not only fear, which exists at some time in nearly all soldiers and in many is constantly present, but hor- ror, revulsion against the ghastly duties which sometimes must be performed, emotional situations resulting from the interplay of personal conflicts and military conditions, all play their part in making an escape of some sort mandatory. Death provides a means which can not be sought consciously. Flight or desertion is rendered impossible by ideals of duty, patriotism, and honor, by the reactions acquired by training, or imposed by discipline or by herd reactions. Malingering is a military crime and is not at the disposal of those gov- erned by higher ethical conceptions. Nevertheless, the conflict between a simple and direct expression of the instinct of self-preservation and such factors demands some sort of com- promise. Wounds solve the problem most happily for many men, and the mild exhilaration so often seen among the wounded has a sound psychological basis. Others with a sufficient adaptability find a means of adjustment. The neurosis provides a means of escape so convenient that the real cause of wonder is not that it should play such an important part in military life but that so many men should find a satisfactory adjustment without its intervention. The constitutionally neurotic, having most readily at their disposal the mechanism of functional nervous diseases, employ it most frequently. They constitute, therefore, a large proportion of all cases, but a very striking fact in the present war is the number of men of apparently normal mental make-up who develop war neuroses in the face of unprecedentedly terrible conditions to which they are exposed. One of the chief objections to the use of the term "shell shock" is the implication it conveys of a cause acting instantly. The train of causes which leads to the neurosis that an explosion ushers in is often long and complicated. Apparently in many military cases mental conflicts in the personal life of the soldier which are not directly connected with military situations influence the onset of the neuroses. Thus, men who have been doing very well in adapting themselves to war develop "shell shock" immediately after receiving word that their wives have gone away with other men during their absence. Approached from the psychological viewpoint, the symptoms in the war neuroses lose much of their weird and inexplicable character. Most of them can be summed up in the statement that the soldier loses a function which either is necessary to continued military service or prevents his successful adaptation to war. The symptoms are found in widely separated fields. Disturbances of psychic functions include delirium, confusion, amnesia, hallucinations, terrifying battle dreams, and anxiety states. The disturbances of involun- tary functions include functional heart disorders, low blood pressure, vomiting and diarrhea, enuresis, retention or polyuria, dyspnoea, and sweating. Disturbances of voluntary mus- cular functions include paralyses, tics, tremors, gait disturbances, contractures, and con- vulsive movements. Special senses may be affected producing pains and anesthesias, mutism, deafness, hyperacusis, blindness, and disorders of speech. In all of these the soldier is afflicted with more or less incapacity without obvious expansion. This is a condition involving grave dangers. His condition is degrading, and is often rendered more so by the punishment or ridicule to which he is subjected. For this reason, immediately after the onset of the symptoms of the neurosis, the patient passes through a very critical period. Improper management may add to the primary neurological disability—which is largely beyond our power of preventing—secondary effects which go even further in producing nervous invalidism. Long-continued treatment in general hos- pitals, confusion of the neurosis present with the organic nervous diseases, unintelligent management, all tend to produce the chronic "shell-shock" cases which are so familiar in the special hospitals for these disorders. Symptoms which were at one time quite easily APPENDIX 507 removable become fixed and refractory or new ones are constantly produced. The mental attitude—the patient's morale as a soldier and his attitude toward his disorder—reaches a 'cr> low level; will is seriously impaired, and a chronic invalid replaces a temporarily inca- pacitated soldier These are matters in the realm of clinical psvchiatrv and psvchopathology and are outside the scope of this report. Space is given to them here onlv because of their very important bearing upon treatment and military management, PREVALENCE The medical statistics of the war are as yet untabulated. Even if the records con- tained the information desired it would be very difficult to state the prevalence of the neu- roses on account of the defective nomenclature employed. It is doubtful if there is another group of diseases in which more confusion in terms exists. Nervous or mental symptoms coming to attention after the soldier has been exposed to severe shellfire are almost certain to be diagnosed as "shell shock," and yet when such patients are received in England well- defined cases of general paresis, epilepsy, or dementia praecox are often found among them. This source of confusion tends to swell the number of cases reported under the term "shell shock," but there are many other errors which tend to diminish the apparent prevalence of the war neuroses. Chief among these is reporting the neuroses under the name of the most prominent somatic symptom. The largest group of cases in which this is done is made up of patients diagnosed officially as having disordered action of the heart ("D. A. H."). Where the only symptoms are cardiovascular ones of neurotic origin a legitimate question of medical nomenclature exists, but one sees in the wards 01 hospitals given over to functional heart disorders patients with hysterical paralyses, tics, tremors, mutism, anxiety states, and other severe neurotic symptoms. Another source of error is the practice, made mandatory by a recent order, of returning these cases (when occurring in soldiers engaged in actual fighting) as "injuries received in action." With a view to discovering the prevalence of the neuroses and insanity, Sir John Collie, president of the Special Pension Board on Neurasthenics, made an analysis of 10,000 dis- charge certificates for disability, interpreting the diagnoses given in the light of his very large experience. He found that of these 10,000 consecutive cases the neuroses constituted 10 per cent. The number of cases treated in the special hospitals in England give some idea of the prevalence of these disorders, but the fact that the number of troops in the expeditionary and nonexpeditionary forces is confidential makes it impossible to give the rates for the two great divisions of the British Army. During the year ending April 30, 1916, approximately 1,300 officers and 10,000 men were admitted to the special hospitals for "shell shock" and neurasthenics in Great Britain. The 1,800 beds in these special hospitals constitute less than half the total provisions in Great Britain for such cases as neurological departments exist in the large territorial general hospitals and in the Royal Victoria Hospital in Edin- borough. Moreover, a constantly increasing number of these cases are being treated in France. The recoveries in the hospitals there diminish, to an unknown degree, the number of cases received in the hospitals in Great Britain. It is the belief of those who have made an effort to ascertain the prevalence of the war neuroses that the rate among the expedi- tionary forces is not less than 10 per thousand annually, and among the home forces not less than 3 per thousand. TREATMENT General arrangements.—When soldiers suffering from functional nervous disorders began to arrive in England from the expeditionary forces in September, 1914, no special civil or military hospitals existed for their reception. In the case of mental diseases it was an easy task to convert "D Block" at the Royal Victoria Hospital into a clearing hospital and to utilize civil institutions for the insane for continued care, but in England, as in the United States there are no public civil hospitals that are engaged exclusively in the work of treating the neuroses. The special civil hospitals for organic nervous diseases were soon filled with patients suffering from severe neurological injuries and were able to do very little on behalf of those with functional nervous disorders. 508 NEUROPSYCHIATRY For a short time it was necessary to care for all such cases in general military hospitals for medical and surgical conditions. The rapid increase in the number of such cases during October and November, 1914, led to the detail of a special medical officer to ascertain their special needs and to prepare a plan for meeting them. The recommendation of this officer that special institutions be provided for functional nervous diseases was approved and when, in December, 1914, the Moss Side State Institution, at Maghull, was turned over to the war office, the first military hospital for functional nervous diseases was available. This institu- tion was particularly suitable for this purpose. It had been completed but not opened for the care of mental defectives of the delinquent type and consisted of detached villas accom- modating 347 patients. The number of these patients was so great, however, that general hospitals were still called upon to deal with them. The establishment of neurological depart- ments in these hospitals partly met the situation until additional special hospitals could be provided. The second such hospital was secured by using a detached portion of Middlesex County Asylum in London. This hospital, accommodating 278 additional patients, was renamed the Springfield War Hospital. The foresight of Sir Alfred Keogh and his advisors thus enabled England to make provision for these cases in special military hospitals at an early period in the war. With more than one hospital available it was possible to make different provisions for different classes of patients suffering from war neuroses. A clearing hospital was therefore established early in 1915 at the Fourth London Territorial General Hospital. The Maudsley Hospital, a psychopathic hospital for the County of London, was nearing completion at this time and, as it adjoined the Kings College Hospital, which formed the larger part of the Fourth London Hospital, it was utilized as a nucleus for this clearing station. The Maudsley Hospital accommodates 175 men and 20 officers; the neurological section—"the Maudsley extension"—accommodates 450 men and 80 officers. Thus, by the spring of 1915 England was provided with a clearing hospital for war neuroses and two special institutions for their continued care. Notwithstanding this provision, by far the greater number of cases were cared for in general hospitals in England and no special provision for continued treatment existed in France. The disadvantages of attempting to treat functional nervous disorders in general hospitals was very apparent, and so neurological sections were established in territorial general hospitals in England, Scotland, and Wales, and in the Royal Victoria Hospital at Netley. Other special hospitals have been provided since. * * * When the submarines began sinking hospital ships indiscriminately last year, a great deal of the medical work previously done in England was undertaken in France and so special provisions for functional nervous cases were made at Havre, Ireport, Boulogne, Rouen, and Etaples. Formerly little more than establishing the diagnosis was done in France. It is likely that the work of caring for these cases will be turned over more and more to the special hospitals in France, as the results of treatment there have been, on the whole, much more successful than in home territory. A recent extension of treatment is that of providing care nearer the front. The striking results obtained in casualty clearing stations and similar advanced posts in the French Sanitary Service (postes de chirurgie d'urgence) are confirmed by many observers. Capt. William Brown, a psychiatrist who has recently had the opportunity of working in a casualty clearing station of the British Expeditionary Forces, reports that of 200 nervous and mental cases which passed through his hands in December, 1916, 34 per cent were evacuated to the base after seven days' treatment and 66 per cent returned to duty on the firing line after the same average period of treatment. Four of these cases reappeared at the same casualty clearing station. Capt. Louis Casamajor, of the United States Army, neurologist to Base Hospital No. 1, British Expeditionary Force, says in a recent letter: "It is a mistake to send these cases to England. We need an intermediate step between the general hospital and the con- valescent camp. Of course, they never should get into general hospitals at all, but should be sent from casualty clearing stations direct to neuropsychiatric hospitals. * * * I hope our army will have a psychiatrist in each casualty clearing station to weed these cases out and send them to their proper places, and not have them knock around from one general hospital to another, being pampered into hard-set neuroses." APPENDIX 509 Len, working in the neuropsychiatric center of the Second French Armv, reports that 91 per cent of the cases received from July to October, 1916, were returned "to the fighting line. Marie reports that the neuroses are less frequently met with in Paris, now that they are treated immediately upon their appearance in the army neuropsychiatric centers.1 Maj. Frederick W. Mott says: "I regard this matter of preventing the fixation of a functional paralysis as of supreme importance both in respect to the welfare of the indi- vidual and from the economic point of view of the state." Roussy and Boisseau2, describing the work of an army neuropsychiatric center, say: "The results obtained after six months show that a neuropsychiatric center can render incontestable services to an army both from a medical and a military point of view. For functional nervous cases it avoids sojourns (more dangerous the more they are prolonged) in the hospitals at the rear where these patients are generally lost. It allows of the treat- ment of other nervous or mental cases that are quickly curable and the direct evacuation to the special centers in the interior of those more seriously affected." General principles.—Methods of treatment employed in different special hospitals are described in Appendix III. With so much about the war neuroses the subject of contro- versy, it is not surprising that different methods of treatment have come into existence. The Royal Army Medical Corps has seen fit to leave these matters largely to the specialists in charge of the different hospitals and so the treatment in each reflects, to a certain degree, the conception of the nature of war neuroses held by the medical officer in charge. Certain general principles regarding treatment may be stated. The experience of the British "shell-shock hospitals" emphasizes the fact that the treat- ment of the war neuroses is essentially a problem in psychological medicine. While patients with severe symptoms of long duration recover in the hands of physicians who see but dimly the mechanism of their disease and are unaware of the means by which recovery actually takes place, no credit belongs to the physician in such cases and but little to the type of environment provided. In the great majority of instances the completeness, promptness, and durability of recovery depend upon the insight shown by the medical officers under whose charge the soldiers come and their resourcefulness and skill in applying treatment. The first step in treatment is a careful study of the individual case. There are no specific formulae for the cure of mutism, paralyses, or tremors or other manifestations of war neuroses. These are symptoms of the disorders and the patient must be treated as well as his symptoms. As in all other psychiatric work, efforts must first be made to gain an under- standing of the personality—the fabric of the individual in whom the neurosis has developed. His resources and limitations in mental adaptation will determine in a large measure, the specific line of management. The military situation is most striking, but the problem which life in general presents to the individual and the type of adaptation which he has found serviceable in other emergencies are of as much importance as the specific causes for failure in the existing situation. The disorder must be looked at as a whole. The incident which seems to have precipitated the neurosis—whether shell explosion, burial, or disciplinary crjsis—must receive close attention but not to the exclusion of other factors less dramatic but often more potent in the production of the neurosis. It has often been said that some of the symptoms of hysteria are the work of the physician and are created—not disclosed— by neurological examinations. This is apparently true, but the question whether analgesia can exist until the pinprick demonstrates it is somewhat like the question whether sound can exist without an ear to receive it. It is not only true but a fact of great practical import- ance that a skillful, searching, psychological examination often constitutes the first step in actual treatment. In the analysis of the situation, as well as in the subsequent management of the patient, the medical officer's attitude is of much importance. He must be immune to surprise or chagrin. Although understanding sympathy is nearly as useful as misdirected sympathy is harmful, he must always remain in firm control. i Revue-Neurologiqe (November-December, 1916). 2 Paris medicale, 1:14-20 (Jan. 1,1916). 510 NEUROPSYCHIATRY The resources at the disposal of the physician in treating the war neuroses are varied. The patient must be reeducated in will, thought, feeling, and function. Persuasion, a power- ful resource, may be employed directly backed by knowledge on the part of the patient as well as the physician of the mechanism of the particular disorder present. Indirectly, it must pervade the atmosphere of the special ward or hospital for "shell shock." Hypnotism is valuable as an adjunct to persuasion and as a means of convincing the patient that no organic disease or injury is responsible for his loss of function. Thus in mutism the patient speaks under hypnosis or through hypnotic suggestion and thereafter must admit the integrity of his organs of speech. The striking results of hypnotism in the removal of symptoms are somewhat offset by the fact that the most suggestible who yield to it most readily are par- ticularly likely to be the constitutionally neurotic. In such cases we are using to bring about a cure, a mental mechanism similar to that which produced the disorder. Recovery within the sound of artillery or at least "somewhere in France" is more prompt and durable than that which takes place in England. For severe cases and those which through mismanagement have developed the unfortunate secondary symptoms of "shell shock" and in whom long continued treatment is necessary, a rural place is best. Reeducation by physical means is a valuable adjunct to treatment in recent cases, but particularly in chronic cases who have been mismanaged and in those who are recovering from long-continued paralyses, tics, mutism, and gait disorders. While drills and physical exercises have their specific uses, occupation is the best means. Nonproductive occupations should be avoided. Occupations are conveniently classified as: 1. Bed. 2. Indoor. 3. Outdoor. 1. Basket making and net making are good bed occupations for cases with extensive paralyses, as are making surgical dressings and various minor finishing operations (sand- papering, polishing, etc.) on products of the shops. All occupations, and especially those which are carried on by patients seriously incapacitated, should be regarded as only steps in a process of progressive education. Every effort must be made to prevent skill acquired in them from being considered as a substitute for full functional activity. Herein is an important difference between the "reeducation" of neurotic and orthopedic cases. In the latter the purpose is often to make the remaining sound limb take on the functions of one which is missing or permanently disabled. The function held in abeyance through neurotic symptoms must never be looked upon as lost. It can and must be restored, and if another function is developed as its surrogate the day of full recovery is thereby postponed. Bed occupations, therefore, must always be regarded as the first steps in a series which is to culminate in full activity. Progress through achievements constantly more difficult is the keynote of reeducation in the war neuroses. 2. A wide variety of indoor occupations should be provided, including at the minimum, carpentry, wood carving, metal work, and cement work. Printing, bookbinding, cigarette making, electric wiring, and other work should be added as opportunities permit. 3. Farming, gardening, and building operations are desirable outdoor occupations. Where possible, wood sawing and chopping are very desirable, as is the care of stock not requiring much land (squabs, guinea pigs, rabbits, game, and frogs). Before even the simplest occupation can be engaged in it is sometimes necessary to reeducate paraplegics and ataxics in walking and coordination. Just as soon as possible exercises should be replaced by productive occupations which will accomplish the same results more quickly and more satisfactorily. The same is true of gymnastic exercises, which in the early steps of treatment constitute a valuable resource but which should be replaced by specially devised useful tasks. Swimming has a unique place in the treatment of gait disturbances, paralysis, and tics. One of the first pieces of construction undertaken by the outdoor patients at a reconstruction center should be that of building a large concrete swimming tank. Hydrotherapy and electrotherapy have a distinct value when they are applied with absolute sincerity and full realization on the part of patient and medical officer of the role which they actually play in the treatment of functional nervous diseases. APPENDIX 511 The experience in English hospitals has demonstrated the great danger of aimless lounging, too many entertainments, and relaxing recreations such as frequent motor rides, etc. It must be remembered that "shell-shock" cases suffer from a disorder of will as well as function and it is impossible to effect a cure if attention is directed to one at the expense of the other. As Dr. H. Crichton Miller has put it, "shell shock produces a condition which is essentially childish and infantile in its nature. Rest in bed and simple encouragement is not enough to educate a child. Progressive daily achievement is the only way whereby manhood and self-respect can be regained." It was impossible for me to discover the end results of treatment. The following table shows the disposal of 731 discharges from the Red Cross .Military Hospital at Maghull during the year ending June 30, 1917: To military duty________________ To civil life......._______________ To other hospitals______.......... To civil institutions for the insane. Died____......._________________ Deserted........._______________ Total______________________ Number i Per cent 153 20.9 476 65.1 SS 12.0 / 1.0 3 .4 4! .6 731 100.0 It is the opinion of the commanding officer of this hospital that few men (of the severe or chronic type there received) can be sent back to military duty at the front. More could be returned to duty at the base but for the fact that after having been in a "shell-shock hospital" they are regarded as being poor material, and little effort is taken to train them for their new duties. Under such conditions the men become discouraged and soon show signs of relapse. Those discharged to civil life have done satisfactorily, as might be expected when one bears in mind the genesis of the neuroses in war. At the Granville Canadian Special Hospital, at Ramsgate, upward of 60 per cent of the patients admitted were returned to the front. The experience of this hospital is of special value to us because the cases treated are those which seem likely to recover within six months. All others and those who do not improve quickly at Ramsgate are sent to Canada. It would be wise for the United States Army to adopt a similar policy. In the special wards established in France the recoveries are still more numerous. It is evident that the outcome in the war neuroses is good from a medical point of view and poor from a military point of view. It is the opinion of all those consulted that with the end of the war most cases, even the most severe, will speedily recover, those who fail to being the constitutionally neurotic and patients who have been so badly managed that very unfavorable habit reactions have developed. This cheering fact brings little consolation, however, to those who are chiefly concerned with the wastage of fighting men. The lesson to be learned from the British results seems clear—that treatment by medical officers with special training in psychiatry should be made available just as near the front as military exigency will permit and that patients who can not be reached at this point should be treated in special hospitals in France until it is apparent that they can not be returned to the firing lines. As soon as this fact is established, military needs and humanitarian ends coincide. Patients should then be sent home as soon as possible. The military commander may have the satisfaction of knowing that food need not be brought across to feed a soldier who can render no useful military service, and the medical officer may feel that his patient will have what he most needs for his recovery—home and safety and an environment in which he can readjust. Looking at the matter from a military point of view alone, one might ask whether it is not desirable to send home all "shell-shock" cases, in whom so much effort results in so few re 'overies Such a decision would be as unfortunate from a military as from a humanitarian standpoint Its immediate effect would be to increase enormously the prevalence of the 512 NEUROPSYCHIATRY war neuroses. In the unending conflict between duty, honor, and discipline, on the one hand, and homesickness, horror, and the urgings of the instinct of self-preservation on the other, the neurosis; as a way out, is already accessible enough in most men without calling attention to it by the adoption of such an administrative policy. MEDICO-LEGAL RELATIONS The sudden appearance of marked incapacity without signs of injury in a group of men to whom invalidism means a sudden transition from extreme danger and hardship to safety and comfort quite naturally gives rise to the suspicion of malingering. The general knowl- edge among troops of the more common symptoms of "shell shock" and of the fact that thousands of their comrades suffering from it have been discharged from the Army suggests its simulation to men who are planning an easy exit from military service by feigning disease. It is therefore of much military importance that medical officers be not deceived by such frauds. On the other hand, especially before the clinical characters and remarkable prev- alence of war neuroses among soldiers had become familiar facts, not a few soldiers suffering from these disorders have been executed by firing squads as malingerers. Instances are also known where hysterics have committed suicide after having been falsely accused of malinger- ing. Mistakes of this kind are especially liable to occur when the patients have not been actually exposed to shell fire on account of the idea so firmly fixed in the minds of most line officers and some medical men that the war neuroses are due to mechanical shock. The diagnosis between neuroses and malingering may sometimes be extremely difficult but usually it is easy when the examiner is familiar with both conditions. The difficulties arise from the fact that in both a disease or a symptom is simulated. As Bonnal says, "The hysteric is a malingerer who does not lie " The cardinal point of difference is that the malingerer simulates a disease or a symptom which he has not in order to deceive others. He does this consciously to attain, through fraud, a specific selfish end—usually safety in a hos- pital or discharge from the military service. He lies, and knows that he lies. The hysteric deceives himself by a mechanism of which he is unaware and which is beyond his power consciously to control. He is usually not aware of the precise purpose which his illness serves. This is shown by the fact that, in many cases, all that is necessary for recovery is to demonstrate clearly to the patient the mechanism by which this disability occurred and the unworthy end to which, unconsciously, it was directed. There are a number of distinctive points of difference between hysteria and malingering, two of which it may be interesting to mention: 1. The malingerer, conscious of his fraudulent intent and fearful of its detection, dreads examinations. The hysteric invites examinations, as is well known to physicians in civil practice. When he has the opportunity he makes the rounds of clinics and physicians, especially delighting in examinations by noted specialists. 2. The hysteric, in addition to the symptoms of which he complains, often presents objective symptoms of which he is unaware. The malingerer, unless of low intelligence, confines his complaints to the disease or symptom which he has decided to stimulate. Malingering may follow or prolong a neurosis. This is not infrequently the case when mutism is succeeded by aphonia. In such cases the clinical picture presents changes very apparent to the experienced psychiatrist but it must be remembered that malingerers (like criminals in civil life) are often very neuropathic individuals. The gravity of malingering as a military offense in an army in the field justifies the recommendation that no case in which the possibility of a neurosis or psychosis exists shall be finally dealt with until the subject is examined by a neurologist or psychiatrist. If neuropsychiatric wards are provided in base hospitals in France as well as in the United States, such an examination will be feasible in practically all cases without causing undue delay. The knowledge that malingerers are subjected to such expert examination will tend to discourage soldiers from this practice. APPENDIX 513 Recommendations for the United States Army .« h^iheJ0l!0'ning recommendations for the treatment of mental diseases and war neuroses ( shell shock ) m United States troops are based chiefly upon the experience of the British Army in dealing with these disorders, as outlined in the foregoing report. The advice of British medical officers engaged in this special work has aided greatly in formulating the plans presented. At the same time conditions imposed bv the necessity of conducting our military operations 3,000 miles away from home territory have been borne in mind. It seems desirable to consider separately, in these recommendations, expeditionary and nonexpeditionary forces. It is necessary to deal separately with mental and nervous diseases in the United States but not in France. While facilities existing at home can be utilized for the treatment of mental diseases it is necessary to create new ones for the treatment of the war neuroses. In France, where all facilities for treatment must be created by the medical department, the distinction between psychoses and neuroses need not be drawn so closely. Consequently simpler and more effective methods of administrative management can be devised. The importance of providing, in advance of their urgent need, adequate facilities for the treatment and management of nervous and mental disorders can hardly be overstated. The European countries at war had made practically no such preparations and they fell into difficulties from which they are now only commencing to extricate themselves. We can profit by their experience and, if we choose, have at our disposal, before we begin to sustain these types of casualties in very large numbers, a personnel of specially trained medical officers, nurses, and civilian assistants and an efficient mechanism for treating mental and nervous disorders in France, evacuating them to home territory and continuing their treat- ment, when necessary, in the United States. Although it might be considered more appropriately under the heading of prevention than under that of treatment, the most important recommendation to be made is that of rigidly excluding insane, feebleminded, psychopathic, and neuropathic individuals from the forces which are to be sent to France and exposed to the terrific stress of modern war. Not only the medical officers but the line officers interviewed in England emphasized over and over again the importance of not accepting mentally unstable recruits for military service at the front. If the period of training at the concentration camps is used for observation and examination it is within our power to reduce very materially the difficult problem of caring for mental and nervous cases in France, increase the military efficiency of the expe- ditionary forces, and save the country millions of dollars in pensions. Sir William Olser, who has had a large experience in the selection of recruits for the British Army and has seen the disastrous results of carelessness in this respect, feels so strongly on the subject that he has recently made his views known in a letter to the Journal of the American Medical Asso- ciation ! in which he mentions neuropathic make-up as one of the three great causes for the invariable rejection of recruits. In personal conversation he gave numerous illustrations of the burden which the acceptance of neurotic recruits had unnecessarily thrown upon an army struggling to surmount the difficult medical problems inseparable from the war. It is most convenient to summarize the recommendations as follows and then to discuss each one somewhat in detail: Summary of Recommendations for the Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the Expeditionary Forces overseas 1. Base section of line of communications.—(a) A special base hospital of 500 beds for neuropsychiatric cases, located at the base upon which each army (of 500,000-600,000) rests These special base hospitals to be used for cases likely to recover and return to active dutv within six months. Other cases to be cared for while waiting to be evacuated to the United States. (b) One or more special convalescent camps in connection with (and conducted as part of) each special base hospital. i Journal American Medical Association, Vol. LXIX, No. 4, p. 290 (July 28, 1917). 514 NEUROPSYCHIATRY 2. Advanced section of line of communications.—(a) Special neuropsychiatric wards of 30 beds in charge of three psychiatrists and neurologists for each base hospital having an active service. These wards to be used for observation (including medicolegal cases) and for emergency treatment of mental and nervous cases. (b) Detail of a psychiatrist or neurologist attached to the neuropsychiatric wards of base hospitals to evacuation hospitals or stations further advanced as opportunities permit. united states 1. Mental (insane).—(a) One or more clearing hospitals for reception, emergency treatment, classification, and disposition of mental cases among enlisted men invalided home. (b) Clearing wards (in connection with a general hospital for officers or private institu- tion for mental diseases) for reception, emergency treatment, classification and disposition of mental cases among officers invalided home. (c) Legislation permitting the Surgeon General to make contracts with public and private hospitals maintaining satisfactory standards of treatment for the continued care of officers and men suffering from mental diseases until recommended for retirement or dis- charge (with or without pension) by a special board. (d) Appointment of a special board of three medical officers to visit all institutions in which insane officers and men are cared for under such contracts to see that adequate treat- ment is being given and to retire or discharge (with or without pension) those not likely to recover. 2. War neuroses ("shell shock").— (a) Reconstruction centers (the number and capacity to be determined by the need) for the treatment and reeducation of such cases of war neu- roses as are invalided home. Injuries to the brain, cord, and peripheral nerves to be treated elsewhere. (b) Special convalescent camps where recovered cases can go and not be subject to the harmful influences for those cases which exist in camps for ordinary medical and surgical cases. (c) Employment of the special board of medical officers, recommended under "1(d)," to visit all reeducation centers and convalescent camps in which war neuroses are treated to see that adequate treatment is being given and to retire or discharge (with or without pension) those not likely to recover. Expeditionary Forces 1. overseas The plan herein suggested for dealing with mental and functional nervous diseases in the Expeditionary Forces overseas presupposes that all sick and wounded soldiers who are not likely to be returned for duty in the fighting line within six months will be evacuated to home territory. The same considerations which led to the adoption of this policj by the Canadian Army are equally valid in the case of American troops. If large numbers of the sick and wounded who are not likely to return to active duty have to be cared for in France during long periods of disability, the amount of food and other supplies which must be sent overseas for them and for those who care for them will diminish the tonnage available for the transportation of munitions required for successful military operations. The great auxiliary hospital facilities available in the United States can not be utilized and, in the case of the severe neuroses, fewer recoveries will take place. If submarine activities seriously interfere with the return of disabled soldiers to the United States and it is necessary to provide con- tinued care, chronic cases should be evacuated to special hospitals established in France for this purpose. It is very desirable to maintain an active service in base hospitals that receive cases from the front. This is especially true in the case of the war neuroses. (a) Base section of line of communications.—The base upon which each army rests should be provided with a special base hospital of 500 beds for neuropsychiatric cases. Three years' experience in treating these cases in general hospitals in England and France amply demon- strates the need for such an institution. Few more hopeful cases exist in the medical services APPENDIX 515 of the countries at war than those suffering from the war neuroses grouped under the term sneu shock ivhcn treated in special hospitals by physicians and nurses familiar with the nature oj functional nervous diseases and with their management. On the other hand, the general military hospitals and convalescent camps presented no more pathetic picture than the mis- managed nervous and mental cases which crowded their wards before such special hospitals were established. Exposed to misdirected harshness or to equally misdirected sympathy, dealt with at one time as malingerers and at another as sufferers from incurable organic ner- vous disease, "passed on" from one hospital to another and finally discharged with pensions which can not subsequently be diminished, their treatment has been a sad chapter in military medicine. As one writer has said, "they enter the hospitals as 'shell shock' cases and come out as nervous wrecks." To their initial neurological disability (of a distinctly recoverable nature) are added such secondary effects as unfavorable habit reactions, stereotypy and fixation of symptoms, the self-pity of the confirmed hysteric, the morbid timidity and anxiety of the neurasthenic and the despair of the hypochondriac. In such hospitals and convalescent homes inactivity and aimless lounging weaken will and the attitude of permanent invalidism quickly replaces that of recovery. The provision of special facilities for the treatment of "shell shock" cases is imperative from the point of view of military efficiency as well as from that of common humanity for more than half these cases can be returned to duty if they receive active treatment in special hospitals from an early period in their disease. British experience indicates that about 100 of the beds in each such special base hospital would be occupied by mental cases and the rest by those suffering from war neuroses. It is not necessary to make this division arbitrarily in advance, however, as both classes of cases can be cared for in the type of hospital to be proposed and redistribution of patients can be made from time to time as circumstances require. It should be the object of these special base hospitals to provide treatment for all cases likely to recover and be returned to active duty within six months. Practically all mental cases, even those who recover during this period, as well as functional nervous cases presenting an unfavorable outlook or which are unimproved by special treatment, should be evacuated to the United States as rapidly as transportation conditions will permit. Each such hospital should be located with reference to its accessibility to other hospitals along the line of communications of the army which it serves. This will necessitate its being on the main railway line down which disabled soldiers are evacuated from the front. It should also be within convenient reach of although not necessarily at the port of embarka- tion. If it is possible to secure a site in southern France where outdoor work can be con- tinued during the winter many important advantages will be gained. Gardening and other outdoor occupations are so valuable that the amount of ground adjoining each base hospital, or contiguous to it, should be not less than 1 acre for every 6 patients of one-third its popula- tion. Thus, at least 30 acres are required for a hospital with 500 beds. The type of general hospital adopted by the American Army for cantonment camps could be used, with certain interior changes, but it would be more advantageous to secure a large hotel or school and remodel it to perform the special functions of a hospital of this character. The living arrangements in these special hospitals are simpler than in general hospitals for medical and surgical cases. About 5 per cent of the bed capacity will have to be in single rooms. This percentage will be somewhat greater in the psychiatric division and less in the neurological division. Less than 3 per cent of the population will be bed patients. A sufficient number of rooms in both the neurological and psychiatrical divisions should be set aside for officers—the higher proportion of officers among patients with neuroses being taken into consideration in planning this department. It is necessary to allow liberally for examining rooms, massage, hydrotherapy, and electrotherapy and to provide one large room which can be used for an amusement hall. When the patients and staff have been suitably housed attention should be directed to the highly important features of shops, industrial equipment, gymnasium, and gardens. If no suitable buildings close to the hospital can be secured, perfectly adequate facilities can be provided in cheaply constructed wooden huts with concrete floors. A gymnasium can be erected more cheaply than an existing building can be adapted for this purpose unless a large storehouse, barn, or factory is available. 42705—29----34 516 NEUROPSYCHIATRY Hydrotherapeutic equipment should include continuous baths, Scotch douche, needle baths, and a swimming pool. The latter is exceptionally valuable in the treatment of functional paralyses and disturbances of gait which disappear while patients are swimming, thus often opening the way for rapid recovery by persuasion. Electrical apparatus is necessary for diagnostic purposes and also for general and local treatment. Second in importance only to the general psychological control of the situation in functional nervous diseases is the restoration of the lost or impaired functions by reeducation. None of the methods available for reeducation are so valuable in the war neuroses as those in which a useful occupation is employed as the means for training. Reeducation should commence as soon as the patient is received. Thought, will, feeling, and function have all to be restored, and work toward all these ends should be undertaken simultaneously. Non- productive occupations are not only useless but deleterious. The principle of "learning by doing" should guide all reeducative work. Continual "resting," long periods spent alone, general softening of the environment, and occupations undertaken simply because the mood of the patient suggests them are positively harmful, as shown by the poor results obtained in those general hospitals and convalescent homes in which such measures are employed. The industrial equipment needed is relatively simple and inexpensive. It is very desirable to begin with a few absolutely necessary things and to add those made by the patients themselves. When this is done every piece of apparatus is invested, in the eyes of the patients, with the spirit of achievement through persistent effort—the very keynote of treatment. The fact that it has been made by patients recovering from neuroses will help hundreds of subsequent patients through the force of hopeful suggestion. The following list gives the equipment for the shops which is necessary at the beginning: Smiths' shop: Forges, tools, etc., for 10 men. Fitting shop: One screw-cutting lathe; 1 sensitive drill; 1 polishing machine; 1 electric motor, l}/2 horsepower; swages; and tools for 8 men. Leather blocking room: Sewing machine; eyeletting machine; tank; galvanized iron; and tools. Tailors' shop: Three Singer machines, tools for 10 men. Carpenters' shop: Selected tools for 15 men, bench screws and special tools not for general use, wood- turner's lathe. Machine shop: Electric motor, 8^ horsepower, with shafting, brackets, etc. Cement shop: Metal molds, tools for 12 men. Printing shop: Press and accessories. General: Drilling machine, grindstone, screw-cutting lathe, fret-saw workers' machine and patterns, circular-saw bench. Practically all gymnasium apparatus can be made in the shops after the hospital is opened. Each special base hospital should be able to evacuate patients who, although not quite able to return to active duty, no longer require intensive treatment. For this purpose one or more convalescent camps within convenient distance by motor truck from the main institution should be established. Each of these convalescent camps should not exceed 100 in capacity. It will requiie only 1 medical officer, 1 sergeant, 3 female nurses, an instructor, and 3 or 4 Hospital Corps men, as the patients will be able to care for themselves and in a short time return to duty. One camp may have to be established for the care of another type of cases. It is conceiv- able that submarine activity will interfere so seriously with the evacuation of chronic and nonrecoverable cases to the TJnited States that the special hospital wrill be overcrowded. APPENDIX 517 Overcrowding will instantly interfere with the success of the work and this will simplv mean that men who otherwise might recover and return to military duty at the front will fail to do so. Such a calamity can be averted by transferring chronic and nonrecoverable cases to a camp organized upon quite simple lines under direct control of the main hospital and near enough to utilize its therapeutic resources. The beds which such patients would otherwise occupy in the special base hospital can be made available for the use of fresh, recoverable cases. Such developments might better be made naturally as circumstances require than provided for by any formal arrangements made in advance. Each base hospital should have the personnel enumerated in the following table: Personnel for Special Base Hospital for Neuropsychiatric Cases commissioned officers Major______________ M. C___ Captain___________ M. C__ Captain___________Q. M. C Major_____________ M. R. C Major_____________ M. R. C Major_____________ M. R. C Major_____________ M. R. C Captain___________ M. R. C Captain___________ M. R. C Captain___________ M. R. C Captain___________ M. R. C Captain___________ M. R. Captain___________ M. R. First lieutenant_______ M First lieutenant_______ M First lieutenant_______ M. R. First lieutenant_______ M. R. First lieutenant_______ M. R. First lieutenant_______ San. C First lieutenant_______ San. C C. C. R. C_ R. C. C. C. C. . _ Commanding officer. ._ Adjutant, surgeon of the command, recruiting officer. ._ Quartermaster. ._ Director. . _ Chief neurological division. . _ Chief psychiatrical division. . _ Chief occupational division. ._ Pathologist. .. In charge of convalescent camp. . _ In charge of electrotherapy and hydrotherapy. . _ Ward physician (in charge of transportation of patients.) . _ Ward physician. . _ Ward physician. . _ Ward physician. . _ Ward physician. . _ Ward physician. . _ Ward physician. . _ Ward physician. . _ Psychologist. .. Registrar. Sergeant, 1st class_____H. Sergeant, 1st class_____Q. Sergeant, 1st class-----H. Sergeant, 1st class-----H. Sergeant, 1st class_____H. Sergeant, 1st class-----H. Sergeant, 1st class-----H. Sergeant, 1st class-----H. Sergeant_____________ H. Sergeant_____________H. Sergeant_____________ H. Sergeant_____________H. Sergeant-------------H. Sergeant-------------H. Sergeant-------------H. Sergeant-------------H ■ Sergeant-------------H- Sergeant-------------H. Sergeant-------------H. Sergeant-------------H. noncommissioned officers C______ General supervision. M. C___ Quartermaster sergeant. C______ Office. C______In charge of detachment and detachment accounts. C______In charge of mess and kitchen. C______ General supervision, convalescent camp. C______ In charge of shops. C______ In charge of garden and grounds. C______ Hydrotherapy rooms. C______ Electrotherapy rooms. C______ Massage rooms. C______ Shops. C______ Gymnasium. C______ Mess and kitchen. C______ Storerooms. C______ Office. C______ Office. C______ Outside police. C______ Wards. C______ Wards. 51S NEUROPSYCHIATRY Sergeant___________ H. C_____ Wards. Sergeant___________ H. C_____ Wards. Sergeant____________ H. C______ Wards. Sergeant_____________ H. C______ Transportation of patient. female nurses (n. c.) Chief nurse___________ Assistant to chief nurse. Dietist_______________ Ward nurses__________ enlisted men (h. c.) 14 acting cooks. 115 privates, 1st class, and privates, distributed as follows: Ward attendants— Neurological division_______________________________________________ 22 Psychiatrical division_______________________________________________ 2(5 Convalescent camp_________________________________________________ 4 Shops_____________________________________________________________________ Electrotherapy rooms_______________________________________________________ Hydrotherapy rooms______________________________________________________ Massage rooms_______________________________________ Laboratory________________________________________________________________ Kitchens and mess__________________________________________________________ Office_____________________________________________________________________ Storerooms___________________________ Orderlies________________________________________________________ Outside Police____________________________________________ Supernumeraries_____________________________________________ civilian employees Instructors: Outdoor occupations________________________________ ___________ \ Indoor occupations__________________________________________ j Assistant instructors: Carpentry and wood carving________________________________ j Cement work______________________________________ 1 Metal work_______________________________________ Leather work_____________________________________ Gardening____________________________________ Printing____________________________________ Gymnasium_____________ Stenographers_______ Photographer________ Laboratory technician APPENDIX 519 RECAPITULATION Commissioned officers________________________________ -.q Noncommissioned officers_____________________________________ 24 Female nurses_________________________________ ,. Enlisted men______________________________ ..-,Q Civilian employees____________________________ 7fi 234 The commissioned medical officers should all be men with excellent training in neurology and psychiatry. The neurologists should have a psychiatrical outlook and the psychiatrists should be familiar with neurological technique. Of importance almost equal to the pro- fessional qualifications of these officers is their character and tact, and no man who is unable to adjust his personal problems should be selected for this work. There is no place in such a hospital for a "queer," disgruntled or irritable individual except as a patient, Men who are strong, forceful, patient, tactful, and sympathetic are required. It is better to permit a medical officer not having these qualifications to remain at home than to assign him to one of these hospitals and allow him to interfere with treatment by his failure to establish and maintain proper contact with his patients. The resources to be employed include psychological analysis, persuasion, sympathy, discipline, hypnotism, ridicule, encour- agement, and severity. All are dangerous or useless in the hands of the inexperienced, as the records of "shell shock" cases treated in general hospital testify. In the hands of men capable of forming a correct estimate of the make-up of each patient and of employing these resources with reference to therapeutic problem presented by each case, they are powerful aids. The female nurses should have had experience in the treatment of mental and nervous diseases. Character and personality are as important in nurses as in medical officers. A large proportion of college women will be found advantageous. The enlisted men who perform the duties of ward attendants and assistants in the shops, gardens, and gymnasium should include a considerable number of those who have had experience in dealing with mental and nervous diseases. The civilian employees who act as instructors should all have had practical experience in the use of occupations in the treatment of nervous and mental diseases. The instructor for bed occupations should be a woman and she should train the female nurses to assist her in this kind of work. No wrork is more exacting than that which will fall to the physicians and chief lav- employees in such a hospital. Success in treatment depends chiefly upon each per- son's establishing and maintaining a sincere belief in the work to which he or she is assigned. No hysterical case must be regarded as hopeless. The maintenance of a correct attitude and constant cooperation between physicians, nurses, instructors, and men in the face of the tremendous demands which neurotic patients make upon the patience and resource- fulness of those treating them soon brings weariness and loss of interest if opportunities for recreation do not exist. Therefore, it should be the duty of the director to see that the morale and good spirits of all are kept up. His recommendations as to the transfer to other military duties of medical officers, nurses, instructors, or men who prove unsuited for this work should be acted upon whenever possible by the chief surgeon under whom the hospital serves. A man or a woman may prove unadapted to this work and yet be a valuable mem- ber of the staff of another kind of hospital. This subject is mentioned so particularly because of its great importance. The type of personnel will determine the success of this hospital and hence its usefulness to the Army in a measure which is unknown in other military hospitals. It does not greatly matter whether the operating surgeon understands the personality of the soldier upon whom he is operating or not. Whether or not the physician treating a case of "shell shock" understands the personality of his patient spells success or failure. The first special base hospital established for neuropsychiatric cases should have such a h' hi efficient personnel that it will be able to contribute one-third of its medical officers and t ' d -orkers to the next similar base hospital to be established, filling their places from ,, ., , rescrVe list. This should be repeated a second time if necessary and thus a uniform H d of excellence and the same general approach to problems of treatment assured in each IpedaTbase hospital organized in France. 520 NEUROPSYCHIATRY (b) Advanced section of line of communications.—The French and the British experience shows the great desirability of instituting treatment of "shell shock" cases as early as possible. So little has been done as yet in this direction that we do not know much about the onset of these cases and just what happens during the first few days. Such information has been con- tributed, however, by the few neurologists and psychiatrists who have had an opportunity of working in casualty clearing stations or positions even nearer the front indicates that much can be done in dealing with these cases if they can be treated within a few hours after the onset of severe nervous symptoms. There are data to show that even by the time these cases are received at base hospitals additions have been made to the initial neurological disability and a coloring of invalidism given which frequently influences the prospects of recovery. It is desirable, therefore, to provide neuropsychiatric wards for selected base hospitals in the advanced section of the line of communications. Other base hospitals can send cases to those which possess such wards. The plan of providing such sections, in charge of neurologists and psychiatrists, for divisional base hospitals in the cantonment camps in the United States has been adopted by the Surgeon General. If it is found practicable to make similar provisions in France, these units can accompany the divisions to which they are attached when they join the Expeditionary Forces in the spring of 1918. In the meantime it is essential that each base hospital should have on its staff a neurologist or a psychiatrist. Provision for the care of mental and nervous cases nearer the front, along the line of communications, can best be developed after the first special base hospital for neuropsychiatric cases has been established by detaching from its staff individual officers as actual circumstances require. It is undesirable to formulate plans for providing this kind of care still nearer the fighting line until a more careful study has been made of the results obtained by the English and French medical services in this undertaking. 2. IN THE UNITED STATES (a) Mental diseases (insanity).—If the policy is adopted of caring in France for mental cases likely to recover and evacuating all others to the United States at once or at the expiration of six months' treatment, we may expect to receive at the port of arrival in the United States not less than 250 insane soldiers per month from an expeditionary force of 1,000,000. We may assume that a plan will be adopted for the reception and the distribution of soldiers invalided from France such as proposed by Major Bailey. Well-organized facilities for dealing with mental disease exist in the United States which can be utilized by the Government without the necessity of creating expensive new agencies. It is obvious that the first facts to be determined in the case of soldiers reaching the United States while still suffering from mental disorders or who have been invalided home after recovery from acute attacks, are: 1. The cause of the disorder, with special reference to military service. 2. The probable outcome. 3. The probable duration. 4. The special needs in treatment. It is quite impossible to ascertain any of these facts by casual examination and so it will be necessary to provide "clearing hospitals" for noncommissioned officers and enlisted men where patients may be received and studied upon their arrival with the view of determin- ing these questions. With an average annual admission rate of 3,000 patients, a clearing hospital of 300 beds would permit an average period of treatment of 36 days. This would seem to be sufficient as the Boston Psychopathic Hospital, during an average period of treat- ment of 18 days, not only determines similar questions but provides continued care for a considerable number of recoverable cases. Such clearing hospitals should be established near the port of arrival and should be essentially military hospitals, with directors who are not only well trained in medical duties but familiar with the requirements of military life and with the institutional provisions in the United States that can be utilized for continued treatment. With such an active service as a clearing hospital will have, the number of medical officers should be not less than 10 and there should be an adequate clerical force to care for APPENDIX 521 the important administrative matters which would require attention. The organization of civil psychopathic hospitals in this country affords data for determining the proper size of the ward and domestic services. After a period of observation and treatment the director of such a hospital should be prepared to furnish the special distributing board with information and definite recom- mendations as to the further disposal of each case. Some patients will be found at the clearing hospitals to have recovered. Although, as a matter of military policy, these patients will not be available for duty again in France, they are still of military value to the Government. Such soldiers should be returned to duty iii the United States by the special distributing board in a category which would prevent them being exposed again in the fighting line but which would indicate precisely the work for which they are suited. We can conceive of many such soldiers who are likely to break down again under the stress of actual fighting but who are quite likely to remain in good health if they are not so exposed. These men will have had valuable military experience and could render efficient service as instructors in training camps or in the performance of other military duties in the United States. Others who have recovered will give evidence of possessing such an unstable or inferior mental make-up that no further military life, even in the United States, is desirable In such cases recommendations should be made by the directors of the clearing hospitals to the special distributing board to discharge them to their homes, with or without pensions as the circumstances demand. There will be found others who have not been benefited at all by treatment in France and who suffer from mental disorders with an extremely unfavorable outlook for recovery. When this conclusion seems justified, the directors of the clearing hospitals should recommend these cases for transfer to a suitable public or private institution in the States from which they enlisted and their discharge from the Army, with or without pension as the circumstances demand. Another group of cases will be made up of those suffering from psychoses which are probably recoverable. It is equally to the advantage of the Army, the community, and the patient that such soldiers be given continued treatment. Facilities for the care of mental diseases vary so greatly in many of the States that neither the Army nor the patients can receive any assurance that proper treatment will be afforded if such soldiers are discharged to the public institution nearest their homes. In such cases the important question of dis- charge, with or without pension, should be deferred until every facility has been given, during a reasonable period of time, for recovery to take place. It is recommended, therefore, that these cases be retained in the Army until their recovery or until the end of the war and ordered for treatment to State hospitals with which the Secretary of War has made contracts. A Government hospital for the insane would be the most suitable for carrying out such treat- ment but the present excellent institution in Washington has reached the size of 3,135 beds and can care for few additional military cases. It is highly desirable that the Government should now establish a military hospital for mental diseases for the Army and Navy and per- mit the Government hospital to devote all its resources to its civil duties. It would be impossible, however, to have such an institution ready within two years. If it were possible to construct such a new Government hospital in shorter time, it would still be necessary to provide for treatment by contract for such an institution would probably have to care for not more than 1,500 military cases during peace. A much larger number are be expected during the war. It is wiser to care for insane soldiers during the war under contract at 10 or 12 first-class hospitals with fully adequate facilities for treatment than to distribute them solely with refer- ence to the location of their homes. This will involve a certain hardship through making it difficult for such men to be visited by their relatives and friends,but it is possible to distribute the contract hospitals over the country in such a way that there would be few cases more than a dav's iournev from their homes. The primary object is to insure recovery in all recoverable cases. This should outweigh all other considerations. The legislation permitting the Secretary of War to make such contracts should state l 1 ' that thev shall be made only with institutions possessing facilities for treatment laid i h r the Surgeon General. The contract hospitals should be required to devote an 522 NEUROPSYCHIATRY entire building of approved construction to military cases or to erect temporary structures meeting the necessary requirements for this purpose. In order that the Army may be able to discharge mental cases cared for under contract promptly upon their recovery or upon ascertaining that recovery is unlikely, it is desirable that a special board of three medical officers should be established to visit the institutions constantly and act as a board of survey. If two medical officers in each contract hospital were appointed in the Medical Reserve Corps and assigned to the duty of caring for Army patients they could serve as members of such a board when convened at their hospital and make it possible for the three general members to cover a good deal more ground. The headquarters of this board should be in the clearing hospital at the principal port of arrival. Clearing wards for officers should be established to serve the special purposes indicated in the description of the clearing hospital for enlisted men. Such wards should provide for reception classification, and treatment in cases likely to be of short duration. It might be established in connection with a general hospital at the port of arrival or in connection with a very efficient private institution for the insane in which full military control of this department could be secured. It is equally important to provide for the continued treatment of officers and not leave this question, in which the Army has so great an interest, to choice or geographical convenience. Arrangement similar to those for the continued care of enlisted men in public contract hospitals could easily be made with the best endowed private institutions for the insane, such as Bloomingdale Hospital, White Plains, N. Y.; Butler Hospital, Providence, R. I.; Hartford Retreat, Hartford, Conn.; McLean Hospital, Waverley, Mass.; Sheppard and Enoch Pratt Hospital, Towson, Md.; Henry Phipps Psychiatric Clinic, Baltimore, Md.; and the Pennsylvania Hospital for the Insane, Philadelphia, Pa. (b) War neuroses ("shell shock").—It is not necessary here to outline the organization of reconstruction centers for the treatment of war neuroses in the United States. The general principles in treatment described in the foregoing report and in the plan recommended for France should be a guide in the development of those centers. It might be desirable to follow the plan in the United States which has been so successful in the Granville Canadian Special Hospital at Ramsgate of treating the war neuroses in a center which also cared for orthopedic cases in which peripheral nerve injuries exist. These latter types of patients constitute a very hopeful group of cases and many of the resources for reeducation which are needed in their treatment are equally useful in the cases of hysterical paralyses, tremors, and disturbances of gait. It should be remembered that if the policy recommended of evacuating to the United States only the neuroses which fail to recover in six months in France is adopted some very intractable cases will be received. For the most part these will be patients with a constitutional neuropathic make-up—the type most frequently seen in civil practice. Manv of these cases will prove amendable to long continued treatment and much can be expected from the mental effect of return to the United States. It is very important not to fall into the mistake made in England of discharging these severe cases with a pension because of the discouraging results of treatment. To do so will swell the pension list enormously, as can be seen by the fact that 15 per cent of all discharges from the British Army are unrecovered cases of mental diseases and war neuroses. Quite aside from financial considerations, how- ever, is the injustice of turning adrift thousands of young men who developed their nervous disability through military service and who can find in their home towns none of the facili- ties required for their cure. It is recommended, therefore, that no soldiers suffering from functional nervous diseases be discharged from the Army until at least a year's special treatment has been given. Furloughs can be given when visits home or treatment in civil hospitals will be beneficial but the Government should neither evade the responsibility nor surrender the right to direct the care of these cases. A serious social and economic problem has been created in England already through the establishment in its communities of a group of chronic nervous invalids who have been prematurely discharged from the only hospitals existing for the efficient treatment of their illness. So serious is this problem that a special sanitarium— "The House of Recovery"—the first of several to be provided, has been established in London and subsidized by the War Office for the treatment of such cases among pensioners. It is highly important not to permit convalescent cases of this kind to be cared for in the ordinary type of convalescent camp or home. The surroundings so suitable to conva- APPENDIX 523 lZTelnZowZ-is7-otherdirasesareveryharmfultoneuroticcas-- «<«™*««* special conv,l P + m SPeC1&1 h°SpitalS by patient' skiUful ™rk is ™done. Therefore Franc should W t ITf/"^ ^ ^ reC°mme"ded for *he Expeditionary Forces h trance should be established within convenient reach of the reconstruction centers wi^Kss t:~^j:t the final disposition of -ntei—-»»'<• «- Nonexpeditionary Forces Facilities for the treatment of neuropsychiatric cases at the camps in the United States have been approved by the Surgeon General and are now being "provided These wl undoubtedly prove sufficient for dealing temporarily with mental cases developing m the nonexpeditionary forces. Their final disposition should be made by means of the same mechanism recommended for expeditionary patients who are invalided home except that the functions of the clearing hospitals for mental diseases can be performed bv the neuropsy- chiatric wards of divisional hospitals and that of the special board by the board of survev composed of the neurologists and psychiatrists stationed at the camps. Neuroses are very common among soldiers who have never been exposed to shell fire and will undoubtedly be seen frequently among nonexpeditionary troops in this country In England nearly 30 per cent of all men from the home forces admitted to one general hospital were suffering from various neuroses.1 Most of these were men of very neurotic make-up. Most of these cases had had previous nervous breakdowns. Fear, even in the comparatively harmless camp exercises, was a common cause of neurotic symptoms. Heart symptoms were exceedingly common. The same experience in our own training camps can be confidently predicted. The responsibility of the Government in such cases is obviously different from that in soldiers returning from duty abroad. In the neuropsychiatric wards of divisional hospitals the important and difficult question of diagnosis can be well determined. Most such cases should be discharged from the service. Some can be treated at the reconstruction centers for, unfortunately, there are scarcely any provisions in the United States for the treatment of the neuroses except in the case of the rich. It is freely predicted in England that the wide prevalence of the neuroses among soldiers will direct attention to the fact that this kind of illness has been almost wholly ignored while great advances have been made in the treatment of all others. In civil life one still hears of detecting hysteria, as if it were a crime, and although the wounded burglar is carefully and humanely treated in the modern city hospital, the hysteric is usually driven away from its doors. To-day the enormous numbers of these cases among some of Europe's best fighting men is leading to a revision of the medical and popular attitude toward functional nervous diseases. 1 Burton-Fanning, F. W. Neurasthenia in soldiers of the home forces. Lancet (London). 1907-11 (June 16, 1917) INDEX Activities: Page in army, corps, and divisions, in the Army of Occupation___________ ___ 407 neuropsychiatric, A. E. F., general view of__________ _________ ~ ^73-302 of neuropsychiatric services, in the United States_____________ ' 100 Base Hospital, Camp Devens, Mass____________________ __ 101 Base Hospital, Camp Grant, 111____________________________ 105 Base Hospital, Camp Jackson, S. C_________________________"^ __ 103 Base Hospital, Camp Meade, Md_____________________________ __" 102 Base Hospital, Camp Sherman, Ohio__________________________~ ~______ 100 Base Hospital, Camp Wadsworth, S. C_________________________ ______ 102 Debarkation Hospital No. 51, National Soldiers' Home, Hampton, Va_ _ . 125 General Hospital No. 1, New York City_______________________ __ __ 106 General Hospital No. 2, Fort McHenry, Md_________________ __ ____~__ 112 General Hospital No. 6, Fort McPherson, Ga____________________ _ " 114 General Hospital No. 26, Fort Des Moines, Iowa________________ _____ 117 General Hospital No. 30, Plattsburg, N. Y_____________________________ 117 General Hospital No. 43, National Soldiers' Home, Hampton, Va_________ 126 Letterman General Hospital, San Francisco, Calif_______________________ 128 Addiction, drug. (See Drug addiction.) Administration: division of neurology and psychiatry, Surgeon General's Office________________ 11 organization and, hospital for war neuroses (Base Hospital No. 117)___________ 355 African (Negro), analysis of special neuropsychiatric reports______________________ 211 Age: alcoholism, including the alcoholic psychoses________________________________ 267 analysis of special neuropsychiatric reports_________________________________ 185 at time of hospitalization, typical group of war neuroses cases_________________ 458 constitutional psychopathic states_________________________________________ 251 drug addiction___________________________________________________________ 259 endocrinopathies_________________________________________________________ 255 epilepsy_________________________________________________________________ 247 mental defect____________________________________________________________ 224 psychoneuroses__________________________________________________________ 234 psychoses__________________________------------------------------------- 241 Ages for a typical group of war neuroses compared with those for the Army at large.. 429 Aides, psychiatric: procurement and distribution---------------------------------------------- 29 training_________________________________________________________________ 36 Alcoholic habits: analysis of special neuropsychiatric reports---------------------------------- 195 constitutional psychopathic states------------------------------------------ 252 drug addiction_______---------------------------------------------------- 261 endocrinopathies--------------------------------------------------------- ^55 epilepsy----------------------------------------------------------------- 248 mental defect____________________________________________________________ j£l psychoneuroses_____--------------------------------------------------- 235 psychoses----------------------------------------------------i~~ Y~r —-lu Alcoholic psychoses, alcoholism, including the, correlations of neuropsychiatric with other clinical conditions----------------------------------------------------- 264 Alcoholism: 9R. including the alcoholic psychoses------------------------------------------- *** age------------------------------------------------------- 2fiti classification----------------------.---------------------------------- ff£2 correlations with other clinical conditions------------------------------- ^o» delinquency---------------------------------------------------------- jf*L economic condition--------------------------------------------------- ^D < education. 266 family history---- -------------------------------------------------- historv of venereal diseases-------------------------------------------- jv< home environment, urban or rural------------------------------------- £>* length of service prior to discovery------------------------------------- fob marital status-------------------------------------------------------- -b7 525 526 INDEX Alcoholism—Continued. including the alcoholic psychoses—continued. Pagf methods of discovering cases____________________________ 26.) nativity________________________________________________ 20s recommendations for disposition____________________________ —*"»*"> State of residence____________________________________________________ 268 time of onset______________________________________________ --- 266 typical group of war neuroses__________________________________ ---- 435 American Expeditionary Forces, neuropsychiatry in the_______________ .. 271-474 American Indian, analysis of special neuropsychiatric reports------------ ----- 214 American-born: German, analysis of special neuropsychiatric reports---------------- ....... 215 Irish, analysis of special neuropsychiatric reports----------------------------- 216 Italians, analysis of special neuropsychiatric reports--------------------------- 217 Scandinavians, analysis of special neuropsychiatric reports_____________________ 218 Amnesia, Base Section No. 1___________________________________________________ 41 s Analysis of special neuropsychiatric reports____________________________________ 157 269 age_______________________________________________________________________ 1 So alcoholic habits____________________________________________________________ 195 clinical classification________________________________________________________ 166 correlations of neuropsychiatric with other clinical conditions__________________ 219 delinquency________________________________________________________ ... 163 distribution of cases (officers and enlisted men)_______________________ ____ 159 economic condition_________________________________________________________ 191 family history___________________________________________________ ___ 179 home environment, urban or rural________________________________________ 197 length of service___________________________________________________________ 169 line of duty________________________________________________________________ 171 marital status______________________________________________________________ 196 methods of discovering cases________________________________________________ 163 race______________________________________________________________________ 211 recommendations of psychiatrists and disposition of cases_____________________ 175 schooling__________________________________________________________________ INS States of residence and birth, with gain or loss from immigration or migration__ 199 venereal disease____________________________________________________________ 192 Anticipation neuroses, war neuroses as a medico-military problem__________________ 390 Anxiety, state of, or timorousness, war neuroses as a medico-military problem_______ 392 Anxiety neurosis, war neuroses as a medico-military problem_______________________ 387 Approach, method of, neuropsychiatric examinations in recruiting and cantonment___ 73 Approved plans for organization, in the United States_____________________________ S Armistice, neuropsychiatric hospitalization facilities, A. E. F., during the___________ 285 Army: corps and divisions— activities in, in the Army of Occupation_________________________________ -127 neuropsychiatric consultants, A. E. F____________________________________ 303 occurrence of neuropsychiatric diseases in the______________________________ 151-156 of Occupation, neuropsychiatry in the_____________________________________ 423-428 activities in Army, corps, and divisions__________________________ _______ 427 clinical observations________________________________________________ _ _ _ 428 Army Neurological Hospital: No. 1, First Army------------------------------------------------------- 327. 335 No. 2, First Army______________________________________________________ ' 343 No. 3, First Army__________________________________________________ _ 344 340 Second Army____________________________________________________ 351 Army neurological hospitals, A. E. F_______________________________________ 325-353 Army neuropsychiatric consultants, A. E. F_____________________________ 322 Army Regulations governing discharge of the insane_________________________ 139 Aspects, clinical, of cases, Army Neurological Hospital No. 1, First Army."_________ 335 Assignment, personnel for neuropsychiatric service, A. E. F____________.______ 293 Attendants and nurses, male, procurement and distribution_____________________ 2s Base Hospital: Camp— Devens, Mass., activities of neuropsychiatric services_____________________ 101 Grant, 111., activities of neuropsychiatric services_________________________ 105 Jackson, S. C, activities of neuropsychiatric services______________________ 103 Meade, Md., activities of neuropsychiatric services_____________________ 102 Sherman, Ohio, activities of neuropsychiatric services___________________ 100 Wadsworth, S. C, activities of neuropsychiatric services_________________ 102 No. 117, hospital for war neuroses_____________________________________ 277 355-367 index 597 Base hospitals: p neuropsychiatric wards in____________________________________ 39 provisions for care of mental and nervous cases in on Base Section No. 1: dy clinical summary__________________________ 41o amnesia___*___________________________ " ^ constitutional psychopathic state..... ~ _ _ _L ~ 4j's encephalitis of undetermined type._ _ ,iq epilepsy_______________ * _ Vrl mental deficiency_____________________ "" V.L organic nervous "diseases_______________ "... V\Q psychoneuroses_______________________ *zt psychoses_________________________ ^rj? war psychoses___________________________~ \\\ special treatment hospitals_________________ 4A0 Base Section No. 5, special treatment hospitals_~r"IIII~Z 40J Bazoilles Hospital Center, neuropsychiatric department ... ". _ 401 Bibliography of American contributions to war neuropsychiatry 477-487 Birth and residence, States of, with gain or loss from immigration or migration, analysis of special neuropsychiatric reports____________ _________ _ '.199 Birthplace, typical group of war neuroses___________________~_\ _" 435 Boards, disability, in the American Expeditionary Forces__________________ 297 Bureau of War Risk Insurance, function of the, with respect to the "insane 148 Camp: Devens, Mass.— Base Hospital, activities of neuropsychiatric services_____________________ 101 neuropsychiatric examinations at.. 1__________________ _________ 76 Gordon, Ga., and Camp Upton, N. Y.— constitutional psychopathic states at___________________________________ 83 mental deficiency at_____________________________________________ S2 neuropsychiatric examinations at_______________________________________ 81 psychoneuroses at_______________________________________________ S4 psychotic cases at____________________________________________________ 83 Grant, 111., Base Hospital, activities of neuropsychiatric services_______________ 105 Jackson. S. C, Base Hospital, activities of neuropsychiatric services___________ 103 Meade, Md., Base Hospital, activities of neuropsychiatric services_____________ 102 Pike, Ark., neuropsj-chiatric examinations at___I___________________________ 75 Sherman, Ohio, Base Hospital, activities of neuropsychiatric services__________ 100 Upton, N. Y., and Camp Gordon, Ga., constitutional psychopathic states at____ 83 mental deficiency at__________________________________________________ 82 neuropsychiatric examinations at_______________________________________ 81 psychoneuroses at____________________________________________________ 84 psychotic cases at_____________________________________________________ 83 Wadsworth, S. C, Base Hospital, activities of neuropsychiatric services__________ 102 Camps, neuropsychiatric examinations in________________________________________ 71 Canada, organization in_______________________________________________________ 6 Candidates for commission, officers and, distribution of cases______________________ 160 Cantonment and recruiting, neuropsychiatric examinations in_____________________ 71 Care: and disposition of cases of mental disease, in the American Expeditionary Forces. 405-422 collecting station_____________________________________________________ 405 special treatment hospitals________________________________________---- 409 and treatment of mental diseases and war neuroses ("shell shock") in the British Army________________________________ ______________________________497-523 of cases of nervous diseases, in the United States---------------------------- 93 occupational therapy__________________________________________________ 95 psychiatric social work________________________________________________ 96 of mental and nervous cases, in the United States, provisions for--------------39-55 of mental cases in Government hospitals------------------------------------- 146 Case histories of a typical group of war neuroses, study of------------------------429-441 Cases: . clinical aspects of, Army Neurological Hospital No. 1, First Army------------- 66b disposition of, recommendations of psychiatrists and-------------------------- 175 methods of discovering----------------------------------------------------- 163 alcoholism, including alcoholic psychoses________________________________ 265 constitutional psychopathic states-------------------------------------- 250 drug addiction-------------------------------------------------------- 257 endocrinopathies------------------------------------------------------ 254 epilepsy --------------------------------------------------------- 246 mental defect--------------------------------------------------------- jf>- nervous diseases and injuries---------------------------.-------------- 245 528 INDEX Cases—Continued. methods of discovering—continued. Page psychoneuroses____________________________________________ — 233 psychoses______________________________________________________ 239 of mental disease, care and disposition of, A.E. F------------------------- 405-122 officers and enlisted men, distribution of--------------------------------- 159 Categories for present condition of the war neurotic group, explanation of the------ 444 Cerebrospinal meningitis, epidemic, residuals of, General Hospital No. 30, Plattsburg, N. Y_________________________________________________________ 121 Civil authorities, cooperation with, in disposition of mental cases---------------- 143 Classification: and distribution of overseas patients___________________________________ 45 neurosurgical cases_______________________________________________ 53 Port of embarkation, Hoboken, N.J__________________________________ 49 Port of embarkation, Newport News, Va______________________________ 47 statistical data__________________________________________________ 51 clinical— alcoholism, including alcoholic psychoses______________________________ 265 analysis of special neuropsychiatric reports____________________________ 166 constitutional psychopathic states__________________________________ 250 endocrinopathies_________________________________________________ 253 epilepsy________________________________________________________ 246 mental defect___________________________________________________ 221 nervous diseases and injuries_______________________________________ 244 psychoneuroses__________________________________________________ 232 psychoses__________________________________________________________ 238 Clinical aspects of cases, Army Neurological Hospital No. 1, First Army__________ 335 Clinical classification, analysis of special neuropsychiatric reports________________ 166 Clinical expressions and mechanism, war neuroses as a medico-military problem____ 370 Clinical observations in the Army of Occupation______________________________ 428 Clinical summary, Base Section No. 1_______________________________________ 413 Collecting station: care and disposition of mental disease___________________________________ 405 neuropsychiatric department, Bazoilles Hospital Center____________________ 405 Comparative figures for 1919-20 condition of typical group of war neuroses cases as a whole related to their condition at discharge from Base Hospital No. 117______ 462 Concussions and gas, war neuroses as a medico-military problem_________________ 393 Condition: at discharge from Base Hospital No. 117, typical group of war neuroses cases, comparative figures for the 1919-20 condition of the group as a whole_______ 462 economic— alcoholism, including the alcoholic psychoses__________________________ 267 analysis of special neuropsychiatric reports___________________________ 191 constitutional psychopathic states__________________________________ 252 drug addiction__________________________________________________ 260 endocrinopathies_________________________,_______________________ 255 epilepsy-------------------------------------------------------- 248 mental defect________________________________________________ 224 psychoneuroses_____________________________________________ 234 psychoses_______________________________________________ 241 in 1919-20, typical group of war neuroses cases— as a whole, related to their condition at discharge from Base Hospital No. 117, comparative figures for the________________________________ 462 diagnosis in France in relation to_______________________________ 450 personal and family history, prior to hospitalization, related to___________ 459 physical and mental considerations in relation to___________________ 458 in 1924-25, of war neuroses cases— diagnosis in France in relation to, typical group______________________ 466 family and personal history prior to hospitalization, related to_____"_""""" 470 physical and mental considerations in relation to______________________ 469 present, typical group of war neuroses cases— of the group as a whole____________________________________ 473 social status in relation to___________________________________ 471 Conditions, clinical, correlations of neuropsychiatric with other________________~_~ 219 . . 229, 231, 235, 236, 243, 245, 246, 249, 252, 253, 256,"263~264 268 Constitutional psychopathic states___________________________________ ' 249 age-------1-------------------------------------------llll"" 251 alcoholic habits_____________________________________________ 959 at Camp Upton, N. Y., and Camp Gordon, Ga_______________________~~~ §3 Base Section No. 1____________________________________________ 410 clinical classification. 250 INDEX 529 Constitutional psychopathic states—Continued. Page correlations with other clinical conditions______ .,-., delinquency__________________ ~'?~ economic condition. II""" ."-, education_______________ -'?- family history."_______________I_________I _ _ 11 o-j history of venereal diseases_____________________I______ """ 9-2 home environment, urban or rural_________________I """ Tfy, length of service prior to discovery______________ 9't-n' marital status____________________'_________________ "" ~_ ?£.-, method of discovering cases______________________ 2^(1 recommendations for disposition______________________I..I _ 251 State of residence, with gain or loss from immigration or migration" 2V? time of onset.._____________________________ 2^n Consultants, neuropsychiatric, in the American Expeditionary"Forces""aivision"cores" and army___________________ ' one? 09. army;_________________IIIIIIIIIIIIIIIIIIIIH"I------------------- 399 corps---------------------------------------------- 020 division_____________________________________ oqq Consulting service, division of neurology and" psychiatry,"Surgeon General's" Office""" 12 Contract Surgeons, procurement and distribution____________________________ 97 Cooperation with civil authorities in disposition of mental cases_____. 143 Corps: army, and division, neuropsychiatric consultants, A. E. F_________________ _. 303 divisions, army and, activities in, in the Army of Occupation__________________ 427 Corps neuropsychiatric consultants, in the American Expeditionary Forces_________ 320 Correlations of neuropsychiatric with other clinical conditions____________________ ? 19 229, 231, 235, 236, 243, 245, 246, 249, 252, 253, 256, 263, 264, 268 Crime groups, intelligence ratings in the, United States Disciplinary Barracks, Fort Leavenworth, Kans__________________________________________________________ 134 Debarkation Hospital No. 51, National Soldiers' Home, Hampton, Va., activities of neuropsychiatric services_____________________________________________________ 125 Defect, mental. (See Mental defect.) Deficiency, mental: Base Section No. 1________________________________________________________ 418 correlation of, with other clinical conditions_________________________________ 229 Delinquency________________________________________________________________ 131-138 alcoholism, including the alcoholic psychoses_________________________________ 266 analysis of special neuropsychiatric reports__________________________________ 165 constitutional psychopathic states__________________________________________ 251 drug addiction____________________________________________________________ 258 endocrinopathies__________________________________________________________ 254 epilepsy___________________________________________________________________ 247 mental defect_____________________________________________________________ 222 nervous diseases and injuries_______________________________________________ 245 psychoneuroses____________________________________________________________ 234 psychoses_________________________________________________________________ 241 Detection and elimination of individuals with nervous or mental disease----------- 57-86 methods of elimination_____________________________________________________ 65 neuropsychiatric examinations in camps-------_----------------------------- 71 principles underlying neuropsychiatric examinations-------------------------- 57 results____________________________________________________________________ 84 Diagnosis in France in relation to condition: in 1919-20, typical group of war neuroses cases------------------------------ 450 in 1924-25, typical group of war neuroses cases------------------------------ 466 Disabillity boards, in the American Expeditionary Forces------------------------- 297 Disabled, category for present condition of the war neurotic group----------------- 445 Discharge: . of the insane, Army Regulations governing----------------------------------- -Lay or rejection, reasons for---------------------------------------------------- 59 Discovering cases, methods of--------------------------------------------------- 163 alcoholism, including the alcoholic psychoses--------------------------------- ^65 constitutional psychopathic states------------------------------------------- 250 drug addiction------------------------------------------------------------- 257 endocrinopathies----------------------------------------------------------- ^f epilepsy------------------------------------------------------------------- ;**? mental defect-------------------------------------------------------------- ffV nervous diseases and injuries------------------------------------------------ ^45 psvehoneuroses------------------------------------------------------------ *«« psychoses------------------------------------------------------------- Z6y 530 INDEX F&SG Discovery, length of service prior to: alcoholism, including alcoholic psychoses---------------------- .. ... -60 constitutional psychopathic states---------------------------- ------------ 25U drug addiction_________________________________________________ ------- 258 endocrinopathies__________________________________________________--------- 254 epilepsy_____________________________________________________----- - ■ - - 2^/. mental defect________________________ ------------- ------------ -- --- nervous diseases and injuries------- ----------------------------------- 24.. psychoneuroses_________________------------------------------------------ 233 psychoses__________________________--------------------------------------- 239 Diseases: mental (psychoses), provisions for, A. E. F--------------------------------— 2..) nervous and injuries, correlations of neuropsychiatric with other clinical conditions. _244 nervous, or mental, detection and elimination of individuals with---------------- 57-86 neuropsychiatric, occurrence of, in the Army------------------------------- 151-156 organic nervous, Base Section No. 1----------------------------------------- 419 types of, observed, neuropsychiatric examinations in recruiting and cantonment. 72 venereal, alcoholism, including the alcoholic psychoses------------------------ 2(57 analysis of special neuropsychiatric reports------------------------------- 192 constitutional psychopathic states--------------------------------------- 252 drug addiction--------------------------------------------'------------ 261 endocrinopathies____________________________________________ --------- 255 epilepsy_______________________________________________________________ 248 mental defect—------------------------------------------------------- 225 nervous diseases and injuries----------------------------------- ... - - 245 psychoneuroses_________________________________________________________ 235 psychoses______________________________________________________________ 241 Disposition: and care of cases of mental disease, A. E. F-------------------------------- 405-422 of cases, recommendations of psychiatrists and-------------------------------- 175 of mental cases___________________________________________________________ 139-149 Army Regulations governing discharge of the insane______________________ 139 care of mental cases in Government hospitals_____________________________ 146 cooperation with civil authorities---------------------------------------- 143 function of the Bureau of War Risk Insurance with respect to the insane___ 148 recommendations for— alcoholism, including the alcoholic psychoses_____________________________ 266 constitutional psychopathic states_______________________________________ 251 drug addiction_________________________________________________________ 258 endocrinopathies_______________________________________________________ 254 epilepsy________________________________________ ______________________ 247 mental defect________________________________ ________________________ 222 nervous diseases and injuries__________________ ________________________ 245 psychoneuroses_________________________________________________________ 233 psychoses______________________________________ ______________________ 240 Distribution: classification and, of overseas patients________________________________________ 45 of cases (officers and enlisted men)___________________________________________ 159 enlisted men___________________________________________________________ 162 officers and candidates for commission___________________________________ 160 procurement and— female nurses___________________________________________________________ 27 male attendants and nurses______________________________________. _ 28 neuropsychiatrists______________________________________________________ 23 training, personnel______________________________________________________ 23 psychiatric aides________________________________________________________ 29 Division: corps, and army neuropsychiatric consultants, A. E. F______________________303-324 of neurology and psychiatry, Surgeon General's Office_________________________ 10 administration__________________________________________________________ 11 functions_______________________________________________________________ 10 liaison with____________________________________________________________ 294 Division psychiatrists__________________________________________________________ 26, 303 Divisions, corps, and army, activities in, in the Army of Occupation________________ 427 Drug addiction__________________________________________________________________ 256 age------------------------------------------------------------------------ 259 alcoholic habits_____________________________________________________________ 261 correlations with other clinical conditions_____________________________________ 263 delinquency_________________________________________________________________ education_______________________________________________________________ INDEX 531 Drug addiction—Continued. Paee economic condition. _ 9,fn family history____________II IIIIIII I ------ 9=0 home environment, urban or rural______ 9?? marital status. u 258 length of service prior to discovery_____________________ method of discovering cases____________________ _ oe- recommendations for disposition______ "" O?o State of residence, with gain or loss from immigration or migration " 26^ time of onset____________________________ _ _____ _ —8 typical group of war neuroses_________ II...I___ 90c venereal diseases_____________________________ 261 Dutch, analysis of special neuropsychiatric reports, raceIII__I_I___I~" 214 Duty, line of, analysis of special neuropsychiatric reports____________ 171 Economic and social status, typical group of war neuroses. 4Q5 Economic condition: " alcoholism, including the alcoholic psychoses________________ 267 analysis of special neuropsychiatric reports_______________ _ _ _ "" 191 constitutional psychopathic states_______________________ 252 drug addiction____________________________________ 260 endocrinopathies________________________________ 255 epilepsy-------------------------------1111111111111111 248 mental defect_______________________________________ 224 psychoneuroses__________________________________________ 234 psychoses____________________________________________ 241 Education: alcoholism, including the alcoholic psychoses_____________________________ 267 constitutional psychopathic states_________________________________ 251 drug addiction_______________________________________________ 260 endocrinopathies_______________________________________________ 255 mental defect______________________________________________________ 224 psychoneuroses_____________________________________________________ 234 psychoses__________________________________________________________ 241 Effects of gassing, typical group of war neuroses______________________________ 434 Effort syndrome, war neuroses as a medico-military problem____________________ 391 Elimination: detection and, of individuals with nervous or mental disease________________ 57-86 methods of, of individuals with nervous or mental disease__________________ 61 Emergency treatment at the front_________________________________________ 313 Encephalitis of undetermined type, Base Section No. 1________________________ 419 Endocrinopathies_______________________________________________________ 253 age--------------------------------------------------------------- 255 alcoholic habits_____________________________________________________ 255 classification_______________________________________________________ 253 correlations with other clinical conditions-------------------------------- 256 delinquency________________________________________________________ 254 economic condition__________________________________________________ 255 education__________________________________________________________ 255 family history______________________________________________________ 254 history of venereal diseases___________________________________________ 255 home environment, urban or rural------------------------------------- 255 marital status______________________________________________________ 255 length of service prior to discovery------------------------------------- 254 methods of discovering cases.----------------------------------------- 254 recommendations for disposition--------------------------------------- 254 State of residence, with gain or loss from immigration or migration----------- 255 time of onset_______________________________________________________ 254 England, organization in------------------------------------------------- 7 English, analysis of special neuropsychiatric reports, race----------------------- 215 Enlisted men: distribution of cases------------------------------------------------- 162 officers and, distribution of cases--------------------------------------- 159 Enlisted personnel, training----------------------------------------------- 35 Environment: home, urban or rural— alcoholism, including the alcoholic psychoses__________________________ 268 analysis of special neuropsychiatric reports___________________________ 197 constitutional psychopathic states-------------------------------------- 252 drug addiction-------------------------------------------------- 261 endocrinopathies------------------------------------------------ 255 42705—29----35 532 INDEX Environment—Continued. constitutional psychopathic states—continued. Page epilepsy____________________________________________________ 219 mental defect_________________________________________________ 220 psychoneuroses__________________________________________________ 235 psychoses_______________________________________________________ 212 occupational, and State of residence, typical group of war neuroses___________ 436 Epidemic cerebrospinal meningitis, residuals of, General Hospital No. 30, Plattsburg, N. Y________________________________________________________________ 121 Epilepsy_______________________________________________________________ 246 age_______________________________________________________________ 247 alcoholic habits_____________________________________________________ 248 Base Section No. 1___________________________________________________ 417 clinical classification_________________________________________________ 246 correlations with other clinical conditions________________________________ 249 delinquency________________________________________________________ 247 economic condition__________________________________________________ 248 education__________________________________________________________ 248 epilepsy____________________________________________________________ 248 family history_______________________________________________________ 247 home environment, urban or rural______________________________________ 249 length of service prior to discovery______________________________________ 247 marital status_______________________________________________________ 248 method of discovering cases___________________________________________ 246 recommendations for disposition_______________________________________ 247 State of residence, with gain or loss from immigration or migration__________ 249 time of onset_______________________________________________________ 247 venereal diseases___________________________________________._■________ 248 Examinations: group, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans_________________________ 133 individual, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans_________________________ 134 neuropsychiatric— in camps_______________________________________________________ 71 principles underlying_____________________________________________ 57 psychological, report of, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans_____________ 133 Examiners, instructions to, methods of elimination of individuals with mental or nervous disease------------------------------------------------------- 65 Exhaustion, war neuroses as a medico-military problem________________________ 392 Explanation of the categories for present condition of the war neurotic group_______ 444 disabled___________________________________________________________ 445 fatigued___________________________________________________________ 445 neurotic___________________________________________________________ 444 normal____________________________________________________________ 444 psychotics__________________________________________________________ 446 Facilities, neuropsychiatric hospitalization, in the American Expeditionary Forces__ 275 Family and personal history, typical group of war neuroses_____________________ 431 prior to hospitalization— related to condition in 1919-20_____________________________________ 459 related to condition in 1924-25_____________________________________ 470 Family history: alcoholism, including the alcoholic psychoses______________________________ 266 analysis of special neuropsychiatric reports_______________________________ 179 constitutional psychopathic states_____________________________________ 251 drug addiction______________________________________________________ 258 endocrinopathies____________________________________________________ 254 epilepsy--------------------------------------------------------'_'/_'_ 247 mental defect_______________________________________________________ 223 psychoneuroses______________________________________________________ 234 psychoses__________________________________________________________ 241 Fatigued, category for present condition of the war neurotic group_______________ 445 Female nurses, procurement and distribution_________________________________ 27 First Army: Army Neurological Hospital— No. 1---------------------------------------------------------- 335 No. 2---------------------------------------------------------- 343 No. 3---------------------------------------------------------- 344 INDEX 533 FldSseSlanda_rdS °f' methods of elimination of individuals with nervous or mental Foreign-born: ~~ ~ 69 PHsTanafv^/i8 °f ^Cial neu™Psychiatric reports, race________ 215 Italians S °- Sp,6Clal .neuroPsychiatric reports, race____ 216 ScanSn»JSfJyS1S ° S]^C1f ^^psychiatric reports, race.... 217 Fort: ' analysls of sPecial neuropsychiatric reports, race. . 1111111111111 218 ^■en^rth0^?6^ ^Y *£■■ 2?. activities of neuropsychiatric services. 117 partment ' ' Disciplinary Barracks, neuropsychiatric de- 5?EnMS %SSik^f*?iH?: 2-a^iv"itie"s"of" "neurop-sycniat-ric" "s"ervice"sl I 112 (Wlethnr^' r?"' General Hospital No. 6, activities of neuropsychiatric services 114 Oglethorpe, Ga., neuropsychiatric examinations at SI _trench, analysis of special neuropsychiatric reports, race ok Front: wi0 emergency treatment at the__________________ oio psychoses observed at the, Army Neurological Hospital Nol ~3, First Armv "" 346 function of the Bureau of War Risk Insurance with respect to the insane ' 148 Functions, division of neurology and psychiatry, Surgeon General's Office " 10 Gain or loss from immigration or migration: State of residence with— constitutional psychopathic states___________________________ 252 drug addiction_______________________________ 263 endocrinopathies___________________________________ 255 epilepsy-----------------------------------IIIIIIIIIIIIIIIII 249 mental defect_____________________________________ 226 psychoneuroses________________________________________ 235 psychoses______________________________________________ 242 States of residence and birth, with, analysis of special neuropsychiatric reports___ 199 Gas and concussions, war neuroses as a medico-military problem__________________ 393 Gassing, effects of, typical group of war neuroses_____________________________ 434 General Hospital: Letterman, San Francisco, Calif., activities of neuropsychiatric services________ 128 No. 1, New York City, activities of neuropsychiatric services________________ 106 No. 2, Fort McHenry, Md., activities of neuropsychiatric services____________ 112 No. 6, Fort McPherson, Ga., activities of neuropsychiatric services___________ 114 No. 26, Fort Des Moines, Iowa, activities of neuropsychiatric services_________ 117 No. 30, Plattsburg, N. Y — activities of neuropsychiatric services________________________________ 117 residuals of epidemic cerebrospinal meningitis_________________________ 121 No. 43, National Soldiers' Home, Hampton, Va., activities of neuropsychiatric services__________________________________________________________ • 126 General hospitals, provisions for care of mental and nervous cases in..:____________ 42 General symptoms common to war neuroses____________________..____________ 397 General view of neuropsychiatric activities, in the American Expeditionary Forces. 273-302 disability boards_____________________________________________________ 297 liaison with the division of neurology and psychiatry, Surgeon General's Office____ 294 neuropsychiatric hospitalization facilities___________________-_j___________ 275 organization of the neuropsychiatric service______________________________ 273 personnel___________________________________________________________ 290 reorganization of the neuropsychiatric service----------------------------- 274 German: American-born, analysis of special neuropsychiatric reports, race_____________ 215 foreign-born, analysis of special neuropsychiatric reports, race_______________ 215 Germany, neuropsychiatric organizations in---------------------------------- 424 Government hospitals, care of mental cases in-------------------------------- 146 Greek, analysis of special neuropsychiatric reports, race------------------------ 215 typical, of war neuroses cases in 1919-20 and 1924-25, a post-war study of a___ 443 war neurotic, explanation of the categories for present condition of the________ 444 Group examinations, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans----------------------- 133 Groups, crime, intelligence ratings in the, United States Disciplinary Barracks, Fort Leavenworth, Kans---------------------------------------------------- i34 Habits, alcoholic: . . analysis of special neuropsychiatric reports------------------------------- 195 constitutional psychopathic states-------------------------------------- 252 drug addiction------------------------------------------------------ ^1 endocrinopathies---------------------------------------------------- ^Ja 534 INDEX Habits, alcoholic—Continued. PaBe epilepsy___________________________________________________________________ 248 mental defect______________________________________________________________ 225 psychoneuroses_____________________________________________________________ 235 psychoses__________________________________________________________________ 241 Hampton, Va.: Debarkation Hospital No. 51, National Soldiers' Home, activities of neuropsy- chiatric services__________________________________________________________ 125 United States Army General Hospital No. 43, National Soldiers' Home, activities of neuropsychiatric services_______________________________________________ 126 Hebrew, analysis of special neuropsychiatric reports, race___________________________ 216 Histories, case, study of, of a typical group of war neuroses________________________429-441 History: family— alcoholism, including the alcoholic psychoses______________________________ 266 analysis of special neuropsychiatric reports________________________________ 179 constitutional psychopathic states--------------------------------------- 251 drug addiction_________________________________________________________ 258 endocrinopathies_______________________________________________________ 254 epilepsy_______________________________________________________________ 247 mental defect__________________________________________________________ 223 psychoneuroses________________________________________________________ 234 psychoses______________________________________________________________ 241 prior to hospitalization, related to condition in 1919-20___________________ 459 prior to hospitalization, related to condition in 1924-25___________________ 470 family and personal, typical group of war neuroses____________________________ 431 epilepsy_______________________________________________________________ 248 endocrinopathies_______________________________________________________ 255 constitutional psychopathic states_______________________________________ 252 of venereal diseases— alcoholism, including the alcoholic psychoses_____________________________ 267 mental defect__________________________________________________________ 225 nervous diseases and injuries____________________________________________ 245 psychoneuroses________________________________________________________ 235 psychoses______________________________________________________________ 241 Hoboken, N. J., Port of Embarkation, classification and distribution of overseas patients_____________________________________________________________________ 49 Home environment, urban or rural: alcoholism, including the alcoholic psychoses_________________________________ 268 analysis of special neuropsychiatric reports___________________________________ 197 constitutional psychopathic states___________________________________________ 252 drug addiction_____________________________________________________________ 261 endocrinopathies___________________________________________________________ 255 epilepsy___________________________________________________________________ 249 mental defect______________________________________________________________ 226 psychoneuroses_____________________________________________________________ 235 psychoses__________________________________________________________________ 242 Hospital, for war neuroses (Base Hospital No. 117)_________________________ 277, 355-367 organization and administration_________________________________________ 355 General. (See General Hospital.) Hospitalization: age at time of, typical group of war neuroses cases____________________________ 458 family and personal history prior to, related to condition in 1924-25, typical group of war neuroses cases_______________________________________________ 470 personal and family history prior to, related to condition in 1919-20, typical group of war neuroses cases_______________________________________________ 459 Hospitalization facilities, neuropsychiatric, A. E. F________________________________ 275 Hospitals: army neurological, A. E. F________________________________________________ 325-353 base— neuropsychiatric wrards in_______________________________________________ 39 provisions for care of mental and nervous cases in________________________ 39 general, provisions for care of mental and nervous cases in_____________________ 39 Government, care of mental cases in_________________________________________ 146 special treatment, care and disposition of cases of mental disease_______________ 409 Hostilities, active, neuropsychiatric hospitalization facilities during the period of____ 275 Hypochondriasis, war neuroses as a medico-military problem_______________________ 381 Hysteria, wrar neuroses as a medico-military problem______________________________ 384 INDEX 535 Imot?SD?ct/aTn^.,migrati(?nJ ^ates of residence or birth, with gain or loss from, analysis ui special neuropsychiatric reports .. i qq constitutional psychopathic states ---- 2I2 drug addiction. £%% endocrinopathies "" 9„ epilepsy------------ ~" £?£ mental defect____________ I" 111""" I 226 psychoses_____________ _" 240 In the Army of Occupation______IIIIIIII.IIIIIIIIIIIIIIIII I~" 423-428 Indian, American, analysis of special neuropsychiatric reports, racelllll 214 individual examinations, in survey of prisoners, by neuropsychiatric "department, t United btates Disciplinary Barracks, Fort Leavenworth, Kans_______ 134 Individuals with nervous or mental disease, detection and elimination of__ . _ 57-86 injuries, nervous diseases and, correlations of neuropsychiatric with other clinical conditions__________________________ 244 Insane: discharge of the, Army Regulations governing________________________________ 139 function of the Bureau of War Risk Insurance with respect to the_____________ 148 Instructions to examiners, methods of elimination of individuals with nervous or mental disease__________________________________________________ 65 Intelligence ratings in the various crime groups, in survey of prisoners, bv neuropsychia- tric department, United States Disciplinary Barracks, Fort Leavenworth, Kans... 134 Intelligence record, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans__________________________ 133 Irish: American-born, analysis of special neuropsychiatric reports, race______________ 216 foreign-born, analysis of special neuropsychiatric reports, race_________________ 216 Italians: American-born, analysis of special neuropsychiatric reports, race_______________ 217 foreign-born, analysis of special neuropsychiatric reports, race_________________ 217 Length of service: analysis of special neuropsychiatric reports__________________________________ 169 prior to discovery— alcoholism, including the alcoholic psychoses_____________________________ 266 constitutional psychopathic states______________________________________ 250 drug addiction________________________________________________________ 258 endocrinopathies______________________________________________________ 254 epilepsy________________________________________________________ --- 247 mental defect_________________________________________________________ 222 nervous diseases and injuries------------------------------------------- 245 psychoneuroses________________________________________________________ 233 psychoses_____________________________________________________________ 239 Letter to the Surgeon General, with plans for neuropsychiatric hospital units-----489-496 Letterman General Hospital, San Francisco, Calif., activities of neuropsychiatric services_____________________________________________________________________ 128 Liaison with the division of neurology and psychiatry, Surgeon General's Office----- 294 Line of duty, analysis of special neuropsychiatric reports-------------------------- 171 Loss or gain from immigration or migration: State of residence, with— constitutional psychopathic states-------------------------------------- *o* drug addiction-------------------------------------------------------- 263 endocrinopathies------------------------------------------------------ ~^ epilepsy------------------------------------------------------------- z *j mental defect_________________________________________________________ zri psychoneuroses-------------------------------------------------------- 249 OSVOllOSGS ____________________________________________________________ States of residence"or birth,"with, analysis of special neuropsychiatric reports.... 199 Make-up, mental and physical, typical group of war neuroses--------------------- *jy Male attendants and nurses, procurement and distribution------------------------ *° Marital status: 267 alcoholism, including the alcoholic psychoses--------------------------------- *«' analysis of special neuropsychiatric reports---------------------------------- ™ constitutional psychopathic states------------------------------------------ 261 drug addiction----------------------------------------------- 255 endocrinopathies------------------------------------------- 248 epilepsy------------------------------------------- 235 psychoneuroses---------------------------------------------- 242 psychoses---------------------------------------- 369-404 Medico-militarv problem, war neuroses as a----------------------------------- 0™ MechanSm and clinical expressions, war neuroses as a medico-military problem.. 370 536 INDEX Page Meningitis, epidemic cerebrospinal, residuals of, General Hospital No.30,Plattsburg,N. Y_ 121 Mental and nervous cases, provisions for care of_______________________________— 39-55 Mental and physical considerations in relation to condition: in 1919-20, typical group of war neuroses________________________________ 458 in 1924-25, typical group of war neuroses____________________________________ 469 Mental and physical make-up, typical group of war neuroses__________________ 429 Mental cases: care of, in Government hospitals____________________________________________ 146 disposition of, in the United States________________________________________ 139-149 Mental defect__________________________________________________________________ 219 age._______________________________________________________________________ 224 alcoholic habits______________________________________________ _____ 225 clinical classification________________________________________ _ 221 correlations w*ith other clinical conditions____________________ ... _ 229 delinquency________________________________________________ ------- 222 economic condition_________________________________________________________ 224 education_____________________________________________________ _____ 224 family history_____________________________________________________________ 223 history of venereal diseases_______________________________________ ..... 225 home environment, urban or rural_________________________________ . _ . _ 226 length of service prior to discovery__________________________________________ 222 marital status_____________________________________________________________ 225 methods of discovering cases________________________________________________ 221 nativity___________________________________________________________________ 229 recommendations for disposition____________________________________________ 222 State of residence, with gain or loss from immigration or migration_____________ 226 Mental deficiency, Base Section No. 1___________________________________________ 418 Mental disease, care and disposition of cases of, in the American Expeditionary Forces. 405-422 Mental diseases (psychoses), provisions for, in the American Expeditionary Forces___ 279 Mental or nervous diseases, detection and elimination of individuals with____________57-86 Method of approach, neuropsychiatric examinations in recruiting and cantonment.. 73 Methods: of discovering cases— alcoholism, including the alcoholic psychoses_____________________________ 265 analysis of special neuropsychiatric reports_______________________________ 163 constitutional psychopathic states_______________________________________ 250 drug addiction_________________________________________________________ 257 endocrinopathies_______________________________________________________ 254 epilepsy--------------------------------------------------------------- 246 mental defect__________________________________________________________ 221 nervous diseases and injuries_________________________________ _______ 245 psychoneuroses________________________________________________________ 233 psychoses_____________________________________________________________ 239 of elimination of individuals with nervous or mental disease___________________ 61 instructions to examiners_______________________________________________ 65 standards of fitness____________________________________________________ 69 Mexican border, organization on________________________________________________ 5 Mexicans, analysis of special neuropsychiatric reports, race________________________ 217 Migration or immigration: State of residence, gain or loss from— constitutional psychopathic states_______________________________________ 252 drug addiction_____________________________________________________ 263 endocrinopathies___________________________________________________ 255 epilepsy-------------------------------._________________I _ _. 111____II. 249 mental defect____________________________________________ 226 psychoneuroses____________________________________________ 235 psychoses____________________________________________________ 242 States of residence or birth, with gain or loss from, analysis of special neuropsy- chiatric reports____________________________________'______________ 199 Mixed races, analysis of special neuropsychiatric reports___________________________ 218 National Soldiers' Home, Hampton, Va.: Debarkation Hospital No. 51, activities of neuropsychiatric services____________ 125 United States Army General Hospital No. 43, activities of neuropsychiatric services______________________________________________________ __!__ 126 Nativity: alcoholism, including the alcoholic psychoses_________________________________ 268 mental defect______________________"_____________________________________ 229 psychoneuroses___________________________________________________________ 235 psychoses________________________________________________________________ 243 INDEX 537 Negro. (See African.) Page Nervous and mental cases, provisions for care of_________________________________ 39-55 Nervous diseases: and injuries______________________________________________________________ 244 clinical classification__________________________________________________ 244 correlations with other clinical conditions_______________________________ 245 delinquency__________________________________________________________ 245 history of venereal diseases____________________________________________ 245 length of service prior to discovery____________________________________ _ 245 methods of discovering cases__________________________________________ 245 recommendations for disposition_______________________________________ 245 care of cases of___________________________________________________________ 93 organic, Base Section No. 1________________________________________________ 419 Nervous or mental disease, detection and elimination of individuals with___________ 57-S6 Neurasthenia, war neuroses as a medico-military problem_________________________ 378 Neurological hospitals, Army, in the American Expeditionary Forces_____________ 325-353 Neurology and psychiatry, division of, Surgeon General's Office___________________ 10 Neuropsychiatric activities, in the American Expeditionary Forces, general view of. 273-302 Neuropsychiatric conditions, correlations of, with other clinical conditions__________ 219 Neuropsychiatric consultants, in the American Expeditionary Forces: army______________________________________________1_____________________ 322 corps____________________________________________________________________ 320 division, corps, and army__________________________________________________ 303 Neuropsychiatric department: Bazoilles Hospital Center__________________________________________________ 405 United States Disciplinary Barracks, Fort Leavenworth, Kans________________ 131 survey of prisoners___________________________________________________ 132 Neuropsychiatric diseases, occurrence of, in the Army-------------------------- 151-156 Neuropsychiatric examinations: in camps_________________________________________________________________ 71 at Camp Devens, Mass_______________________________________________ 76 at Camp Pike, Ark_________________________________________ --------- 75 at Camp Sherman, Ohio____________________________________ 78 at Camp Upton, N. Y., and Camp Gordon, Ga--------------- ------ 81 at Fort Oglethorpe, Ga_____________________________________ --- --- 81 in recruiting and cantonment-------------------------------- 71 method of approach------------------------------------------ 73 suggestions as to proper supervision---------------------------- <_* principles underlying-------------------------------------------- - - - 57 Neuropsychiatric hospitalization facilities, in the American Expeditionary lorces--- 275 during the armistice__________________________________________________ - ■ - 285 during the period of active hostilities--------------------------------- --- jj& Neuropsychiatric organizations in Germany--------------------------- - --- 4-4 Neuropsychiatric reports, special: analysis of______________________-------~—" ."n"*-------------- i? division of neurology and psychiatry, Surgeon General s Office---------------- ia Neuropsychiatric service, in the American Expeditionary Forces: ^ organization of the---------------------------------------------------- 274 reorganization of the----------------------T - - - —---------------- inn Neuropsychiatric services, in the United States, activities ot---------------------- X"J Neuropsychiatric wards, in base hospitals--------------------------------------- Neuropsychiatrists: 23 procurement and distribution---------------------------------------- 3Q training------------------------------------------------------------------ Neuropsychiatry: 271-474 in the American Expeditionary forces------------------------------------ 1-269 in the United States------------------------------------------- Neuroses: ,. .... , ,__, 390 anticipation, war neuroses as a medico-military problem---------------------- war— __ 369- as a medico-military problem-----------v ~ ~ VrT.~rT ~orT ~ ~ y iqo!~:->V -Un- cases, a post-war study of a typical group of, in 1919-20 and 1924-25.. - 443 general symptoms common to--------------------------------- ""'?77"355- hospital for (Base Hospital No. 117)---------------------------- - '499-441 study of case histories of a typical group ot------------------------ Vnnrnsis anxietv, war neuroses as a medico-military problem-------------------- n1 -.wnreieal cases, classification and distribution of overseas patients------------ NVtc category for present condition of the war neurotic group explanation of- n! York Citv, General Hospital No. 1, activities of neuropsychiatric services Newport News! Va., Port of Embarkation, classification and distribution of over- seas patients-------------------------------------------------------- 538 INDEX Page Normal, category for present condition of the war neurotic group; explanation of----- 444 Nurses: and attendants, male, procurement and distribution__________________________ 28 female, procurement and distribution______________________________________ 27 psychiatric, in the American Expeditionary Forces___________________________ 293 Nursing, hospital for war neuroses (Base Hospital No. 117)________________________ 359 Observation and treatment, in the United States________________________________ 87-130 activities of neuropsychiatric services________________________________________ 100 care of cases of nervous diseases_____________________________________________ 93 Observations, clinical, in the Army of Occupation-------------------------------- 428 Occupation: Army of, in the__________________________________________________________ 423-428 present, typical group of war neuroses cases__________________________________ 471 pre-war, typical group of war neuroses cases---------------------------------- 460 Occupational environment and State of residence, typical group of war neuroses______ 436 Occupational therapy: hospital for war neuroses (Base Hospital No. 117)----------------------------- 361 in the care of cases of nervous diseases_______________________________________ 95 Occurrence of neuropsychiatric diseases in the Army_____________________________ 151-156 Officers: and candidates for commission, distribution of cases__________________________ 160 and enlisted men, distribution of cases_______________________________________ 159 for neuropsychiatric service in the American Expeditionary Forces_____________ 290 sources________________________________________________________________ 290 Onset, time of: alcoholism, including the alcoholic psychoses__________________________________ 266 constitutional psychopathic states___________________________________________ 250 drug addiction_____________________________________________________________ 258 endocrinopathies___________________________________________________________ 254 epilepsy___________________________________________________________________ 247 psychoneuroses_____________________________________________________________ 233 psychoses... ______________________________________________________________ 240 Organic nervous diseases, Base Section No. 1_____________________________________ 419 Organization: and administration, hospital for war neuroses (Base Hospital No. 117)__________ 355 of neuropsychiatric service— approved plans for_____________________________________________________ 8 in Canada_____________________________________________________________ 6 in England____________________________________________________________ 7 in the American Expeditionary Forces___________________________________ 273 in the United States___________________________________________________ 5-22 on the Mexican border________________________________________________ 5 preliminary plans upon which to base____________________________________ 5 Organizations, neuropsychiatric, in Germany_____________________________________ 424 Patients, overseas, classification and distribution of________________________________ 45 Personal and family history, typical group of war neuroses_________________________ 431 prior to hospitalization, related to condition— in 1919-20________________________________________ 459 in 1924-25_____________________________________________________________ 470 Personality, the psychopathic____________________________________________________ 60 Personnel______________________________________________________________________ 23-38 enlisted, training___________________________________________________________ 35 for neuropsychiatric service in the American Expeditionary Forces_____________ 290 assignment____________________________________________________________ 293 officers________________________________________________________________ 290 psychiatric nurses______________________________________________________ 293 training--------------------------------------------------------------- 292 procurement and distribution; training_______________________________________ 23 Period of active hostilities, neuropsychiatric hospitalization facilities, during the____ 275 Plans: approved, for organization___________________________________________________ g preliminary, upon which to base organization_________________________________ 5 Plattsburg, N. Y., General Hospital No. 30, activities of neuropsychiatric services___ 117 Physical and mental considerations, typical group of war neuroses, in relation to condition: in 1919-20_______________________________________________________________ 458 age at time of hospitalization____________________________________________ 453 in 1924-25____________________________________________________________II] 469 INDEX 539 Physical sti^t^f makrUp' typical SrouP of ™r neuroses_________ ^5 pSrt^Emtt gF0UP °f ^ neUr°SeS--------------------" 434 NewDort'Nf>'.vJ;'^assifcatipn and distribution of overseas patients____________ 49 PostwarSvn ' . ' ° asSLficatlon &nd distribution of overseas patients_______ 47 Present coSon U?Z\? gr°UP<°f War neur0ses cases in 191&~20 and 1924-25... 443-474 rresent condition, t\ pical group of war neuroses: explanation of the categories for_______ 444 of the group as a whole____________ " Jjt social status in relation to. _ ... I 460 4"1 Present occupation, typical group of war neuroses " ' 471 Rre-war occupation, typical group of war neuroses. _ "" 460 Unnciples underlying neuropsychiatric examinations________ 57 reasons for rejection or discharge_____________ _______________ 59 Prisoners survey of, by neuropsychiatric department, United" "States" Di"s"cipl"inarv Barracks, Fort Leavenworth, Kans._ . __ _ _ " 132 Procurement and distribution: female nurses______________________________ 27 male attendants and nurses__________________________I____II 28 neuropsychiatrists______________________________ 23 psychiatric aides________________________________________________ 29 training, personnel__________________________________________ 23 Provisions: for care of mental and nervous cases, in the United States____________________ 39-55 in base hospitals______________________________________________________ 39 in general hospitals___________________________________________________ 42 for mental diseases (psychoses), in the American Expeditionary Forces_________ 279 Psychasthenia, war neuroses as a medico-military problem________________________ 380 Psychiatric aides: procurement and distribution______________________________________________ 29 training------------------------------------------------------------------ 36 Psychiatric nurses_____________________________________________________________ 293 Psychiatric social work in the care of cases of nervous diseases____________________ 96 Psychiatrists: division— in the American Expeditionary Forces__________________________________ 303 procurement and distribution__________________________________________ 26 recommendations of, and disposition of cases________________________________ 175 Psychiatry, division of neurology and, Surgeon General's Office____________________ 10 Psychological examinations: in recruiting and cantonment, results that might be expected_________________ 75 report of, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans___________________________ 133 Psychoneuroses_______________________________________________________________ 231 age______________________________________________________________________ 234 alcoholic habits___________________________________________________________ 235 at Camp Upton, N. Y\, and Camp Gordon, Ga______________________________ 84 Base Section No. 1________________________________________________________ 416 clinical classification_______________________________________________________ 232 correlations with other clinical conditions____________________________________ 235 delinquency--------------------------------------------------------------- 234 economic condition-------------------------------------------------------- 234 education_________________________________________________________________ 234 family history------.------------------------------------------------------ 234 history of venereal diseases------------------------------------------------ 235 home environment, urban or rural------------------------------------------ 235 length of service prior to discovery_________________________________________ 233 marital status------------------------------------------------------------- 235 methods of discovering cases----------------------------------------------- 233 nativity_________________- -.---------------------------------------------- 235 recommendations for disposition-------------------------------------------- 233 time of onset-------------------------------------------------------------- 233 Psychopathic personality, the-------------------------------------------------- 60 Psychopathic states, constitutional--------------------------------------------- 249 ' at Camp Upton, N. Y., and Camp Gordon, Ga------------------------------ 83 Base Section No. 1-------------------------------------------------------- 418 540 INDEX Pago Psychoses_____________________________________________________________________ 236 age_______________________________________________________________________ 241 alcoholic, alcoholism, including, correlations of neuropsychiatric with other clinical conditions_______________________________________________________________ 264 alcoholic habits____________________________________________________________ 241 Base Section No. 1_________________________________________________________ 414 clinical classification_______________________________________________________ 238 correlations with other clinical conditions____________________________________ 243 delinquency_______________________________________________________________ 241 economic condition________________________________________________ _______ 241 education_________________________________________________________________ 241 family history_____________________________________________________________ 241 history of venereal disease__________________________________________________ 241 home environment, urban or rural___________________________________________ 242 length of service prior to discovery__________________________________________ 239 marital status_____________________________________________________________ 242 mental diseases, provisions for, in the American Expeditionary Forces__________ 279 methods of discovering cases, psychoses______________________________________ 239 nativity___________________________________________________________________ 243 observed at the Front, Army Neurological Hospital No. 3, First Army_________ 346 recommendations for disposition____________________________________________ 240 State of residence, with gain or loss from immigration or migration____________ 242 time of onset______________________________________________________________ 240 war, Base Section No. 1____________________________________________________ 414 Psychotic cases at Camp Upton, N. Y., and Camp Gordon, Ga____________________ 83 Psychotics, category for present condition of the war neurotic group_______________ 446 Race, analysis of special neuropsychiatric reports_________________________________ 211 African (Negro)___________________________________________________________ 211 American Indian___________________________________________________________ 214 American-born— German_______________________________________________________________ 215 Irish__________________________________________________________________ 216 Italians_______________________________________________________________ 217 Scandinavians_________________________________________________________ 218 Dutch_____________________________ _ . _ .__-.-_._ 214 English___________________________________________________________________ 215 foreign-born— German_______________________________________________________________ 215 Irish__________________________________________________________________ 216 Italians_______________________________________________________________ 217 Scandinavians_________________________________________________________ 218 French________________________________________________________ ___ ... __ 215 Greek_____________________________________________________________________ 215 Hebrew___________________________________________________________________ 216 mixed races_______________________________________________________________ 218 Mexicans__________________________________________________________________ 217 Scotch____________________________________________________________________ 218 Slavonic__________________________________________________________________ 218 Races, mixed, analysis of special neuropsychiatric reports__________________________ 218 Ratings, intelligence, in the various crime groups, United States Disciplinary Barracks, Fort Leavenworth, Kans___________________________________________'__________ 134 Reasons for rejection or discharge_______________________________________________ 59 Recommendations: for disposition— alcoholism, including the alcoholic psychoses_____________________________ 266 constitutional psychopathic states_______________________________________ 251 drug addiction_________________________________________________________ 288 endocrinopathies_______________________________________________________ 254 epilepsy_______________________________________________________________ 247 mental defect__________________________________________________________ 222 nervous diseases and injuries____________________________________________ 245 psychoneuroses________________________________________________________ 233 psychoses_____________________________________________________________ 240 of psychiatrists and disposition of cases, analysis of special neuropsychiatric reports__________________________________________________________'_______ 175 Recruiting and cantonment, neuropsychiatric examinations in______________________ 71 Rejection or discharge, reasons for_______________________________________________ 59 Report of psychological examinations, in survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth,Kans______ 133 INDEX 541 Reports, special neuropsychiatric: Page analysis of---------------------------- 157-VQ division of neurology and psychiatry, Surgeon General's"6ffice"" "l3 ResEc^ ^ neuroP^vchiatric service, in the American Expeditionary" Fo"r"c"esI 274 and birth, States of, with gain or loss from immigration and migration, analysis ot special neuropsychiatric reports________________ __ __"_ _99 State of and occupational environment, typical group of "war "neuroses 436 with gain or loss from immigration or migration.._ 226, 242 249 25_<> -\55 -?63 268 Residuals of epidemic cerebrospinal meningitis, General Hospital No.' 30, Plattsburg" ' Results-""" 121 detection and elimination of individuals with nervous or mental disease._______ 84 that might be expected, neuropsychiatric examinations in recruiting and canton"- ment_________________________________________ ye San Francisco, Calif., Letterman General Hospital, activities" of "neuropsychiatric services____________________________________________ _28 Scandinavians: American-born, analysis of special neuropsychiatric reports__________ ._ ._ 218 foreign-born, analysis of special neuropsychiatric reports, race_________________ 218 Schooling, analysis of special neuropsychiatric reports_____________________________ 188 Scotch, analysis of special neuropsychiatric reports, race__________________________ 218 Second Army, Army Neurological Hospital____________________________________ 351 Service: length of— analysis of special neuropsychiatric reports______________________________ 169 prior to discovery, neuropsychiatric conditions___________________________ 222 233, 239, 245, 247, 250, 254, 258, 266 neuropsychiatric, in the American Expeditionary Forces— organization of the____________________________________________________ 273 reorganization of the__________________________________________________ 274 Services, neuropsychiatric, in the United States, activities of______________________ 100 Slavonic race, analysis of special neuropsychiatric reports_________________________ 218 Social and economic status, typical group of war neuroses_________________________ 435 Social status in relation to present condition, typical group of war neuroses_________460, 471 Social work, psychiatric, in the care of cases of nervous diseases___________________ 96 Sources of officers, for neuropsychiatric service, in the American Expeditionary Forces. 290 Special neuropsychiatric reports, division of neurology and psychiatry, Surgeon General's Office______________________________________________________________ 13 Special treatment hospitals: Base Section No. 1________________________________________________________ 409 Base Section No. 5________________________________________________________ 421 care and disposition of cases of mental disease in the American Expeditionary Forces__________________________________________________________________ 409 Standards of fitness, methods of elimination of individuals with nervous or mental disease______________________________________________________________________ 69 State of anxiety, or timorousness, war neuroses as a medico-military problem________ 392 State of residence: alcoholism, including the alcoholic psychoses_________________________________ 268 and occupational environment, typical group of war neuroses__________________ 436 with gain or loss from immigration or migration— constitutional psychopathic states-------------------------------------- 252 drug addiction-------------------------------------------------------- 263 endocrinopathies------------------------------------------------------- 255 epilepsy_______________________________________________________________ 249 mental defect--------------------------------------------------------- 226 psychoses------------------------------------------------------------- 242 States, constitutional psychopathic, correlations of neuropsychiatric with other clinical conditions------------------------------------------------------------ 249 States of residence and birth, with gain or loss from immigration or migration, analysis of special neuropsychiatric reports--------------------------------------------- 199 Statistical data, classification and distribution of overseas patients----------------- 51 Stigmata, physical, typical group of war neuroses--------------------------------- 434 Status: alcoholism, including the alcoholic psychoses----------------------------- 267 analysis of special neuropsychiatric reports------------------------------ 196 constitutional psychopathic states-------------------------------------- 252 drug addiction-------------------------------------------------------- 261 endocrinopathies------------------------------------------------------ 255 542 INDEX Status—Continued. marital—continued. Page epilepsy______________________________________ _________ 248 mental defect_______________________________I________________________ 225 psychoneuroses_________________________________I______________________ 235 psychoses__________________________________________ ______________ 242 social and economic, typical group of wrar neuroses___________________________ 435 social, in relation to present conditions, typical group of war neuroses________460, 471 Study: a post-war, of a typical group of war neuroses cases in 1919-20 and 1924-25. .. 443-474 of case histories of a typical group of war neuroses_________________________429-441 mental and physical make-up__________________________________________ 429 social and economic status_____________________________________________ 435 the 1919-20, of a typical group of war neuroses cases_________________________ 443 the 1924-25, typical group of war neuroses cases_____________________________ 464 Suggestions as to proper supervision, neuropsychiatric examinations in recruiting and cantonment_________________________________________________________________ 74 Summary, clinical, Base Section No. 1___________________________________________ 413 Supervision, proper, suggestions as to, neuropsychiatric examinations in recruiting and cantonment_____________________________________________________________ 74 Surgeon General's Office, division of neurology and psychiatry____________________ 10 Surgeons, contract, procurement and distribution_________________________________ 27 Survey of prisoners, by neuropsychiatric department, United States Disciplinary Barracks, Fort Leavenworth, Kans____________________________________________ 132 intelligence ratings in the various crime groups_______________________________ 134 intelligence record_________________________________________________________ 133 Symptoms, general, common to war neuroses_____________________________________ 397 Therapy, occupational: hospital for war neuroses (Base Hospital No. 117)____________________________ 361 in the care of cases of nervous diseases, in the United States__________________ 95 Time of onset: alcoholism, including the alcoholic psychoses_________________________________ 266 constitutional psychopathic states___________________________________________ 250 drug addiction____________________________________________________________ 258 endocrinopathies__________________________________________________ 254 epilepsy---------------------------------------------11111.111111111111 247 psychoneuroses_________________________________________________ 233 psychoses________________________________________________ 240 Timorousness or state of anxiety, war neuroses as a medico-military problem_______ 392 Training: personnel for neuropsychiatric service—■ in the American Expeditionary Forces__________________________________ 292 in the United States-------------------------------------------- 23 30, 35, 36 I reatment: emergency, at the front________________________________________ 313 observation and, in the United States_____________________________!___ _ " 87-130 wrar neuroses as a medico-military problem_____________________II_____" 398 Treatment hospitals, special, care and disposition of cases of mental disease, A. E.F 409 types of disease observed, neuropsychiatric examinations in recruiting and canton- ment ______________________________________ 72 United States, neuropsychiatry in__________________________ " 1-269 United States Army General Hospital No. 43, National"Soldiers'" Home""Hampton", Va., activities of neuropsychiatric services______________ ______________ 126 United States Disciplinary Barracks, Fort Leavenworth, KansI," "neuropsychiatric ucp&ri. incut —_____— — —___ 101 survey of prisoners__________________________IIIIIIIII 132 Venereal diseases: alcoholism, including the alcoholic psychoses__________________ 267 analysis of special neuropsychiatric reports____________________ "__ 192 constitutional psychopathic states__________________________ 252 drug addiction____________________________________" 261 endocrinopathies__________________ ______________ 2^ = epilepsy---------------------------_____ 248 mental defect_________________________________________________ 225 nervous diseases and injuries__________________________________________ 245 psychoneuroses___________________________________________________ 935 psychoses_____________________________________________________ ____" 24i INDEX 543 War neuroses: Page as a medico-military problem_____________________ _______________369-404 anticipation neuroses____________________________________________ 390 anxiety neuroses_______________ _ . _ _________________ 387 effort syndrome_________________ . . _ ________________________ 391 exhaustion_____________________________________________________ 392 gas and concussions______________________________________________ 393 general symptoms common to_____________________________________ 397 hypochondriasis_________________________________________________ 381 hysteria_______________________________________________________ 384 mechanism and clinical expressions_________________________________ 370 neurasthenia___________________________________________________ 378 psychasthenia__________________________________________________ 380 timorousness or state of anxiety____________________________________ 392 treatment__________________ ___________________________________ 398 hospital for (Base Hospital No. 117)______________________________277, 355-367 study of case histories of a typical group of____________________________429-441 War neuroses cases, a post-war study of a typical group of, in 1919-20 and 1924-25. 443-474 War neurotic group, explanation of the categories for present condition of the______ 444 War psychoses, Base Section No. 1________________________________________ 414 War Risk Insurance, Bureau of, function of the, with respect to the insane-------- 148 Wards, neuropsychiatric, in base hospitals___________________________________ 39 Wounds, in a typical group of war neuroses__________________________________ 434 o __ Bridgeport -_<"__!_ National Lfc_3£J Bindery, Inc. T AUG. 1983^] "Bound to Last" NATI0N-.1 LISMRY Of MEDICINE NLM 000A7flfi0 E