U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Appendix

Table of Contents

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 Neurology 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.

Atwill, 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, Louisville, 1920, xxxvi, 193-97.

Bailey, Pearce: Neuropsychiatry and the mobilization. The New York Medical Journal, New York, 1918, cvii, 794-95.

Bailey, Pearce: Prevention of nervous casualties. New Republic, 1918, xiii, 275.

Bailey, Pearce: Psychiatry and the Army. Harpers Monthly, 1917, cxxxv, 251-57.

Bailey, Pearce: Reconstruction in nervous and mental disease. Ungraded, 1920, v, 97-107.

Bailey, Pearce: War and mental disease. American Journal of Public Health, New York, 1918, viii, 1-7.

Bailey, Pearce: War neuroses, shell shock, and nervousness in soldiers. The Journal of the American Medical Association, Chicago, 1918. lxxi, 2148-53.


478

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 rehabilitation. 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, Ill., 1919, x, 97.

Bisch, L. E.: Early recognition of mental disease. The Southern Medical Journal, Birmingham, 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 suffering 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.


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 Insanity, 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, Ill., 1919, x, 60-64.

Campbell, C. McF.: Role of instinct, emotion, and personality 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

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 Association, 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 American Psychological Association (Western Division), July, 1925. Also Psychiatric Bulletin of the New York State Hospitals, Utica, 1926, xxiii, 299.

Fenton, Norman: A survey of war 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. Lippincott 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 Surgical Journal, New Orleans, 1918, lxxi, 191-202.


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 dysthyroidism 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, developing under intensive military training. The Journal of the American Medical Association, 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, lii, 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, xlii, 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.

Kenyon, E. K.: The stammerer and Army service. The Journal of the American Medical Association, Chicago, 1917, lxix, 664-65.

Kiely, 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.

Klopp, H. I.: War neuroses in general practice. The Hahnemannian Monthly, Philadelphia, 1922, lvii, 91-100.


482

Kolb, Lawrence: Bearing of war neuroses on immigration. Archives of Neurology and Psychiatry, Chicago, 1919, i, 317-32.

Leahy, S. R.: An analysis of cases admitted to the neuropsychiatric services of U. 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 Bulletin, 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.

MacDonald, Arthur: Disequilibrium of mind and nerves in war. The Medical Record, New York, 1919, xcv, 727-31.

MacDonald, Arthur: Physical and mental examination of American soldiers. Modern Medicine, Battle Creek, Mich., 1921, iii, 129-33.

MacDonald, V. May: Psychiatric social work for the discharged soldiers. Psychiatric Bulletins 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 Insanity, Baltimore, 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 invertebrates. 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, Ill., 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.


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, Brooklyn, 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, Ill., 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 war 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.


484

Raynor, M. W.: Psychiatry at the front in the American armies. Psychiatric Bulletins of the 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, J. H. 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. War 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, cx, 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. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 849.

Robinson, G. W.: Neuropsychoses of war and peace. Journal Missouri State Medical Association, St. Louis, 1921, xviii, 435-39.

Rogers, J. C.: Residuals of encephalitis lethargica. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 2, 20.

Rosanoff, A. J.: First psychiatric experiences at the national cantonment at Camp Upton. The Medical Record, New York, 1917, xcii, 877-78.

Rosanoff, A. J.: Study of hysteria based mainly on clinical material observed in the U. S. Army Hospital for War Neuroses at Plattsburg Barracks, N. Y. Archives of Neurology and Psychiatry, Chicago, 1919, ii, 419-60.

Salmon, T. W.: American psychiatry and the war. Proceedings of the American Medico-Psychological Association, Utica, 1919, xxvi, 269.

Salmon, T. W.: Care and treatment of mental diseases and war neuroses (shell shock) in the British Army. Mental Hygiene, New York, 1917, i, 509-47.

Salmon, T. 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, Ill., 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. American 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, xli, 674-93.


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. Proceedings 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 Psychiatry, 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.

Skverskv, A.: Lethargic encephalitis in the A. E. F.; a clinical study. The American Journal of the Medical Sciences, Philadelphia, 1919, clviii, 849.

Smith, R. P.: Mental defects found in the Army. Northwest Medicine, Seattle, 1918, xvii, 99-103.

Somerville, W. G.: Shell shock (war neuroses). Memphis Medical Monthly, Memphis, Tenn., 1919, xl, 481-83.

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, 1918, 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.

Steckel, H. A.: War neuroses in combat areas. Psychiatric Bulletins 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, xlii, 48-53.

Stephenson, J. W.: Brief résumé of neurologic and psychiatric observations in a hospital center in France. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 61-67.

Strecker, E. A.: Experience in the immediate treatment of war neuroses. The American Journal of Insanity, Baltimore, 1919, lxxvi, 45-69.


486

Sullenger, T. E.: Shell shock. The Psychological Clinic, Philadelphia, 1919, xiii, 33-50.

Swan, J. M.: Analysis of ninety cases of functional disease in soldiers. The Archives of Internal Medicine, Chicago, 1921, xxviii, 586-602.

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 of Insanity, 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.

Townsend, 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, xli, 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 Psychological Clinic, Philadelphia, 1920, xiii, 222-24.

Walsh, J. J.: Psychoneuroses and the war. International Clinics, Philadelphia, 1919, xxix, series 2, 148-63.


487

War 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 explosions 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, xlv, 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 Surgeon, 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 of the American Medical Association, Chicago, 1918, lxx, 303-08.

Wolfsohn, J. M.: Treatment of hysteria; successful results of a rapid reeducation method. The Journal of the American Medical Association, Chicago, 1918, lxxi, 2057-62.

Worch, Margaret: Psychiatric social work in a Red Cross Chapter. Mental Hygiene, New York, 1922, vi, 312-31.

Wright, H. W.: Postbellum neuroses; a clinical review and discussion of their mechanisms. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 429-34.

Ziegler, L. H.: Group of psychoneurotic ex-service men. Mental Hygiene, New York, 1925, ix, 128-56.


489

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 provisions 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 elements 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 recoveries. 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 constitutional psychopathic conditions who are better out of the Army than in it. Their prompt


490

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 experience 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 furnished 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, Baltimore, 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.


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, N.Y.

Thomas W. Salmon, M. D., medical director, National Committee for Mental Hygiene, 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.
4. Blue print showing typical pavilions in central psychiatric unit.
5. Personnel of central psychiatric unit.
6. Blue print showing general arrangement of smaller unit of 30 beds.
7. Blue print showing typical pavilions in smaller unit.
8. Personnel of smaller psychiatric unit.

Military zones

Military hospitals

Facilities for treating mental diseases

Zone of the interior

Camp hospitals; general hospitals (permanent); hospitals for prisoners of war; convalescent camps; hospital trains; hospital ships (in overseas operations); hospitals at ports of embarkation (in overseas operations.)

Central psychiatric hospital unit (110 beds) attached to camp or base hospital nearest largest concentration of troops; civil institutions; Government Hospital for the Insane (St. Elizabeths Hospital); special wards in State hospitals for the insane; psychopathic hospitals; psychopathic wards in general hospitals.

Zone of communications

Base hospitals (500 beds); evacuation hospitals (432 beds); evacuation hospital ambulance companies.

Psychiatric pavilions (30 beds) attached to base hospitals in favorable locations.

Zone of the advance

Field hospitals (216 beds); ambulance companies; dressing stations; first aid.

Psychiatrist and neurologist attached to each field hospital company.


492

GENERAL ARRANGEMENT 
CENTRAL UNIT OF 110 BEDS


493

TYPICAL PAVILIONS
CENTRAL UNIT IF 110 BEDS


494

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 class1

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.

1 in storeroom.

22 ward attendants (12 day, 8 night, 2 relief).

1 in office.

1 in laboratory.

1 in outside police.

4 in kitchens and mess rooms.

2 supernumeraries.

1 orderly (to Major A).


Recapitulation

Commissioned medical officers

8

Noncommissioned officers, Hospital Corps

8

Enlisted men, hospital corps

35

Total

51

Patients

110

Grand total

161


PERSONNEL OF UNITS ATTACHED TO BASE HOSPITALS, 30 BEDS


Commissioned medical officers

Captain A1

In general charge.

Captain B

Ward physician.

Captain C

Do.

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.

1Previous military training required.


495


Enlisted men, Hospital Corps, assigned to duty

1

1 acting cook.

1 orderly (to Captain A).

6 ward attendants (4 day, 2 night, 1 relief).

1 in office.

2 in kitchen and messroom.

1 supernumerary.

GENERAL ARRANGEMENT 
SMALLER UNIT OF 30 BEDS


Recapitulation

Commissioned medical officers

3

Noncommissioned officer, Hospital Corps

4

Enlisted men, Hospital Corps

12


Total

19

Patients

30

Grand total

49

1Previous military training required.


496

TYPICAL PAVILIONS
SMALLER UNIT OF 30 BEDS


497

THE CARE AND TREATMENT OF MENTAL DISEASES AND WAR NEUROSIS ("SHELL SHOCK") IN THE BRITISH ARMY

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 Osler, 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 symptoms 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.

1By Maj. Thomas W. Salmon, Medical Officers' Reserve Corps, U. S. Army.


498

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. Injuries 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 functional 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 commencement 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 opportunity 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 thousand 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 Percent 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 nonwounded expeditionary patients the percentage was about three times that among the nonexpeditionary cases. The rate among officers was only one-third that among men in expeditionary 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


499

the rule in the case of nonexpeditionary troops. It can be estimated, from all the data available, that the annual admission rate is about 2 per 1,000 among the nonexpeditionary troops and about 4 per 1,000 among 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 Army is less at the present time than it was in the first year of the war, and that it has not reached some of 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 much to former 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 Percent of the 1,74 patients admitted1 were found to be suffering from mental diseases and sent to hospitals for the insane. On the other hand, 20 Percent of the 6,755 patients received1 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 functional nervous diseases. On the whole it may be said that medical officers serving with troops are becoming more familiar with the symptoms of functional 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 Victoria 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, exhaustion, 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

1To May 31, 1917.


500

War Hospital), was turned over entirely for this purpose, as was part of the Lord Derby War Hospital at Warrington, which had been the Lancashire Asylum. Later the Belfast District 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 temporary 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 diseases. 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 understand 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 tendency 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 by

1To July 1, 1917.


501

experts to estimate the part played by military service in the causation of mental illness. When relatives and friends are induced to take insane soldiers from the military hospitals the next step is usually admission to the district asylums. During the year ending May 31, 1917, 900 insane soldiers were admitted to the local asylums. 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 May 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 psychoses." 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 psychoses. 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 Percent of patients admitted to the military hospitals for mental diseases are mentally defective. Only such mental defectives as get into trouble or


502

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 system 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 disciplinary 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 beneficial 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 particularly 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 accustomed 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 Percent of the mental cases received in these special hospitals have general paresis. There is convincing evidence that the stress of war accelerates 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 commissioned 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.


503

Manic-depressiveinsanity.-Patients in this group supply about 20 Percent 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 - Soldiers with delirium tremens are admitted to special hospitals for mental diseases if they are stationed near such institutions. This disorder is now confined almost entirely to patients on leave from the front. During the early days 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 possible 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 præcox - Patients with this disorder constitute 14 Percent 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 Percent 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.

OUTLOOK 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 hospitals 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 insane, 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 United 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

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 medicomilitary problem. As every nation and race engaged is suffering severely from these disorders, it is apparent that new conditions of warfare are chiefly responsible for their prevalence. 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 mechanical 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

1These 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, No. 3) contains a résumé 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 contributions of Maj. Frederick M. Mott (71 and 72), Prof. G. 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" (N. Y.) for July, 1917. (The numbers refer to the references in Appendix I.)


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 outcome 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 explosions 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 apparently predominantly organic. It may be that in the latter two groups endocrinitic disturbances 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 causation. 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, neuropathologists 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 psychological situations discovered in individual cases.

These suggestive facts require some elaboration. The high prevalence of "shell shock" among 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

1Analysis of 381,983 casualties between Aug. 4, 1914-Aug. 21, 1915, reported in a statement in Parliament, and 901,534 casualties between July, 1916, and July, 1917.
2References given by Capt. C. B. Farrar.


506

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 parties 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 horror, 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 governed 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 compromise. 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 involuntary functions include functional heart disorders, low blood pressure, vomiting and diarrhea, enuresis, retention or polyuria, dyspnoa, and sweating. Disturbances of voluntary muscular functions include paralyses, tics, tremors, gait disturbances, contractures, and convulsive 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 hospitals, 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


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 very low level, will is seriously impaired, and a chronic invalid replaces a temporarily incapacitated soldier. These are matters in the realm of clinical psychiatry and psychopathology and are outside the scope of this report. Space is given to them here only 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 contained the information desired it would be very difficult to state the prevalence of the neuroses 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 præcox 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 or 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 discharge 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 Percent.

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 Edinborough. 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 expeditionary 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

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 institution 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 accommodating 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 departments 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 Percent were evacuated to the base after seven days' treatment and 66 Percent 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 convalescent 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."


509

Leri, working in the neuropsychiatric center of the Second French Army, reports that 91 Percent 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 individual 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 treatment 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 controversy, 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 treatment 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 formulæ 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 understanding 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 crisis-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 importance 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.

1Revue-Neurologiqe (November-December, 1916). 
2Paris medicale, 1:14-20 (Jan. 1, 1916).


510

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 powerful 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 particularly 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 rôle which they actually play in the treatment of functional nervous diseases.


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 functions 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."

OUTCOME

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:

Number

Percent

To military duty

153

20.9

To civil life

476

65.1

To other hospitals

88

12.0

To civil institutions for the insane

7

1.0

Died

3

.4

Deserted

4

.6


Total

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 Percent 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 recoveries. 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

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 knowledge 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 prevalence 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 malingering. 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 hospital 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.


513

RECOMMENDATIONS FOR THE UNITED STATES ARMY

The following recommendations for the treatment of mental diseases and war neuroses ("shell shock") in 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 by 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 treatment, 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 expeditionary 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 Association1 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 duty 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.

1Journal American Medical Association, Vol. LXIX, No. 4, p. 290 (July 28, 1917).


514

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 institution 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 discharge (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 eared for under such contracts to see that adequate treatment 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 neuroses 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 policy 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 continued 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 demonstrates the need for such an institution. Few more hopeful cases exist in the medical services


515

of the countries at war than those suffering from the war neuroses grouped under the term "shell shock" when treated in special hospitals by physicians and nurses familiar with the nature of 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 mismanaged 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 nervous 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 embarkation. If it is possible to secure a site in southern France where outdoor work can be continued 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 population. 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 Percent 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 Percent 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.


516

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. Nonproductive 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, 1½ 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, woodturner's lathe.

Machine shop:
  Electric motor, 8½ 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 require 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 conceivable that submarine activity will interfere so seriously with the evacuation of chronic and nonrecoverable cases to the United States that the special hospital will be overcrowded.


517

Overcrowding will instantly interfere with the success of the work and this will simply 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.

Commanding officer.

Captain

M.C.

Adjutant, surgeon of the command, recruiting officer.

Captain

Q.M.C.

Quartermaster.

Major

M.R.C.

Director.

Major

M.R.C.

Chief neurological division.

Major

M.R.C.

Chief psychiatrical division.

Major

M.R.C.

Chief occupational division.

Captain

M.R.C.

Pathologist.

Captain

M.R.C.

In charge of convalescent camp.

Captain

M.R.C.

In charge of electrotherapy and hydrotherapy.

Captain

M.R.C.

Ward physician (in charge of transportation of patients.)

Captain

M.R.C.

Ward physician.

Captain

M.R.C.

Ward physician.

First lieutenant

M.R.C.

Ward physician.

First lieutenant

M.R.C.

Ward physician.

First lieutenant

M.R.C.

Ward physician.

First lieutenant

M.R.C.

Ward physician.

First lieutenant

M.R.C.

Ward physician.

First lieutenant

San. C.

Psychologist.

First lieutenant

San. C.

Registrar.

NONCOMMISSIONED OFFICERS

Sergeant, 1st class

H.C.

General supervision.

Sergeant, 1st class

Q.M.C.

Quartermaster sergeant.

Sergeant, 1st class

H.C.

Office.

Sergeant, 1st class

H.C.

In charge of detachment and detachment accounts.

Sergeant, 1st class

H.C.

In charge of mess and kitchen.

Sergeant, 1st class

H.C.

General supervision, convalescent camp.

Sergeant, 1st class

H.C.

In charge of shops.

Sergeant, 1st class

H.C.

In charge of garden and grounds.

Sergeant

H.C.

Hydrotherapy rooms.

Sergeant

H.C.

Electrotherapy rooms.

Sergeant

H.C.

Massage rooms.

Sergeant

H.C.

Shops.

Sergeant

H.C.

Gymnasium.

Sergeant

H.C.

Mess and kitchen.

Sergeant

H.C.

Storerooms.

Sergeant

H.C.

Office.

Sergeant

H.C.

Office.

Sergeant

H.C.

Outside police.

Sergeant

H.C.

Wards.

Sergeant

H.C.

Wards.

Sergeant

H.C.

Wards.

Sergeant

H.C.

Wards.

Sergeant

H.C.

Wards.

Sergeant

H.C.

Wards.

Sergeant

H.C.

Transportation of patients.

FEMALE NURSES (N.C.)

Chief nurse

1

Assistant to chief nurse

1

Dietist

1

Ward nurses

43

46

ENLISTED MEN (H.C.)

14 acting cooks.

115 privates, 1st class, and privates, distributed as follows:

Ward attendants-

 

Neurological division

22

 

Psychiatrical division

26

 

Convalescent camp

4


52

Shops

10

Electrotherapy rooms

4

Hydrotherapy rooms

4

Massage rooms

6

Laboratory

2

Kitchens and mess

14

Office

5

Storerooms

6

Orderlies

4

Outside Police

4

Supernumeraries

4


115

CIVILIAN EMPLOYEES

Instructors:

Outdoor occupations

1

Indoor occupation

1


2

Assistant instructors:

Carpentry and wood carving

1

Cement work

1

Metal work

1

Leather work

1

Gardening

1

Printing

1

Gymnasium

2

8

Stenographers

4

Photographer

1

Laboratory technician

11


16


RECAPITULATION

Commissioned officers

19

Noncommissioned officers

24

Female nurses

46

Enlisted men

129

Civilian employees

16


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 professional 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, encouragement, 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 work is more exacting than that which will fall to the physicians and chief lay employees in such a hospital. Success in treatment depends chiefly upon each person'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 resourcefulness 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 member 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 highly efficient personnel that it will be able to contribute one-third of its medical officers and trained workers to the next similar base hospital to be established, filling their places from those on its reserve list. This should be repeated a second time if necessary and thus a uniform standard of excellence and the same general approach to problems of treatment assured in each special base hospital organized in France.


520

(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 contributed, 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 determining 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 treatment 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


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 recommendations 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 in 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 discharge, 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 treatment 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 permit 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 reference 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 day's journey 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 clearly that they shall be made only with institutions possessing facilities for treatment laid down by the Surgeon General. The contract hospitals should be required to devote an


522

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. Many 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 Percent of all discharges from the British Army are unrecovered cases of mental diseases and war neuroses. Quite aside from financial considerations, however, 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 facilities 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-


523

lescents from wounds or other diseases are very harmful to neurotic cases. Here much that has been accomplished in special hospitals by patient, skillful work is undone. Therefore special convalescent camps similar to those recommended for the Expeditionary Forces in France should be established within convenient reach of the reconstruction centers.

The special board, recommended for the final disposition of mental cases, should deal with cases of functional nervous diseases.

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 will undoubtedly prove sufficient for dealing temporarily with mental cases developing in 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 by the neuropsychiatric wards of divisional hospitals and that of the special board by the board of survey 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 Percent 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.

1Burton-Fanning, F. W. Neurasthenia in soldiers of the home forces. Lancet (London). 1907-11 (June 16, 1917)

RETURN TO TABLE OF CONTENTS