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Section I, Chapter I

Table of Contents

CHAPTER I

ORGANIZATION

PRELIMINARY PLANS UPON WHICH TO BASE ORGANIZATION

During the first few months of 1917 it was apparent to the Surgeon General that the Medical Department of the Army was soon to be called upon to assume the performance of enormous tasks, many of them quite unrelated to military duties in time of peace, or even to the latest campaigns in which the United States Army had taken part. In other volumes of this history are to be found accounts of the methods by which plans were made for the mobilization of the medical, sanitary, and nursing resources of the country. Similar preparations were not lacking in the field of neuropsychiatry. Having in mind the desirability of being prepared at the earliest possible moment to deal with the new and formidable problem of war neuroses, the Surgeon General, in March, 1917, invited a committee of civilian neuropsychiatristsa to Washington, for a conference on the subject.1 This committee was part of a larger group, formed by the National Committee for Mental Hygiene, for the purpose of studying the possible neuropsychiatric needs of the United States Army in the event of our country's entry into the war. Appreciating the importance of mental disorders as a medico-military problem, and aware of the magnitude of this problem among European armies, this group was already at work laying plans for one or more psychiatric hospital units to be placed at the disposal of the United States Government when needed.

ON THE MEXICAN BORDER

As a result of the Washington conference the Surgeon General requested the committee to visit the Army camps on the Mexican border to study the provisions made in the United States Army, as then constituted, for the diagnosis of, and the care and treatment of soldiers suffering from, mental diseases.2 A careful study was made of the whole situation, including inspections of the larger military hospitals at San Antonio and El Paso, Tex., and the military prison at Fort Leavenworth, Kans.

The committee was impressed with the high incidence of mental diseases in the Army. These diseases were found to be approximately three times as prevalent among the troops on the Mexican border during the previous summer as, for example, among the civil population of the State of New York.2 The committee noted also the uniformly high standard which characterized provisions for the diagnosis and treatment of physical disorders in the base hospitals visited, in contrast with the meager provisions for the care of the mentally

aDr. Stewart Paton, of Princeton University; the late Dr. Pearce Bailey, of the Neurological Institute, New York City; and the late Dr. Thomas W. Salmon, the medical director of the National Committee for Mental Hygiene.


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ill. It was apparent that special provisions would have to be made to meet adequately the needs that would arise with the participation of the United States in the European conflict.

In its report to the Surgeon General (see appendix, p. 491) the committee outlined a plan for a central psychiatric unit of 110 beds to be established in connection with base hospitals near the largest concentration of troops, and a 30-bed unit for base hospitals elsewhere. It was recommended that such units be integral parts of military hospitals and that the psychiatrists and neurologists in charge of them be medical officers of the Army. Diagrams of these units, with a description of buildings, equipment, and personnel, were submitted. The usefulness of a psychiatric service was pointed out in connection with the handling of disciplinary cases, malingering, and other behavior problems among the troops. Such a service was deemed to be indispensable to the morale of a modern fighting organization.

IN CANADA

In May, 1917, a member of this committeeb made a trip to Canada in quest of information concerning the management of the numerous problems arising out of the presence of mental and nervous disorders among soldiers. It was believed that valuable lessons could be learned from Canadian experience with neuropsychiatric cases, particularly in view of the similarity in geographical situation between the United States and Canada with regard to the scene of war. The transportation of bodies of troops over the seas presented similar difficulties, and the same problems arising in connection with the reception, classification, and distribution of those invalided home would have to be met by our own Army.

Evidence of strong neuropathic trends or mental diseases was found in many of the medical histories of returned Canadian soldiers. The predisposition to nervous and mental diseases or the actual existence of these conditions in slight degree, while readily and quickly demonstrable by a physician accustomed to look for them, usually passed unnoticed by the surgeon. Yet the frequency with which these disorders occurred, and the certainty of their disabling character, made the enlistment of men so affected a direct blow at the efficiency of the Army and a source of unnecessary expense to the Government and hardship to the soldier. In his report to the Surgeon General3 the member of the committee emphasized the importance of this phase of recruiting and recommended the assignment of medical officers of the proposed base hospital psychiatric units to duty at Army camps during mobilization.

Another member of the committeec about the same time, visited Quebec, to observe conditions among returned Canadian soldiers at the discharge depot there. In his report to the Surgeon General4 he noted certain dispositions existing in each patient prior to enlistment which, under the stress of war conditions, were particularly favorable for the development of nervous and mental symptoms, and suggested that it should not be a matter of great difficulty to eliminate from the service, in advance, a large proportion of the cases returned

bDr. Pearce Bailey. 
c Dr. Stuart Paton.


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as "nervous and mental disorders." He also stressed the importance of bringing any psychological work in the Army into close union with the activities of the Medical Department, and described the great variety of the nervous and mental disorders found among the returned soldiers.

IN ENGLAND

In June, 1917, a member of the committee,d through the cooperation of the Rockefeller Foundation, was sent to England to secure, first hand, the most recent information as to the British and French methods of dealing with war neuroses in and near the theater of operations, to make observations on these methods, and to confer with medical officers in the British War Office. His report to the Surgeon General5 (see appendix, p. 497) confirmed observations and impressions of other members of the committee concerning neuropsychiatric conditions in the Canadian Army, and contained data that proved of great value in the preparation of plans for dealing with the problem of mental and nervous diseases in the United States Army, abroad and at home. The high rate of mental disorders in the British Army (one-seventh of all discharges for disability had been due to mental conditions), the difficulties in which the Allies found themselves as a result of failure to prepare adequately for the management of mental and nervous cases developing in combat, and the great problem created by the acceptance of large numbers of recruits who had been in institutions for the insane or were of demonstrably psychopathic make-up-these and other significant observations were among the most important factors determining the course of American medico-military preparations.

The foremost recommendation contained in this report called for rigid exclusion of all insane, feeble-minded, psychopathic, and neuropathic individuals from the forces which were to be sent to France and exposed to the terrific stress of modern war. Not only medical officers, but the line officers interviewed in England, had emphasized over and over again the importance of not accepting mentally unstable recruits for service at the front. As a result of these observations, it was believed to be within the power of the United States Army, by the adoption of an exclusion policy, to reduce very materially the difficult problem of caring for mental and nervous cases in France, to increase the military efficiency of the expeditionary forces, and to save the country millions of dollars in pensions.

The next most important lesson learned was that of preparing, in advance of urgent need, a comprehensive plan for establishing special military hospitals for mental diseases. Here, again, it was declared that the United States could profit vastly by the experience of its allies by having at the disposal of the Army, before it began to sustain mental and nervous casualties, a personnel of specially trained medical officers, nurses, and civilian assistants, and an efficient mechanism for treating these disorders in France, evacuating them to home territory, and continuing their treatment, when necessary, in the United States.

It was estimated that the annual rate of admissions of mental and nervous cases to British military hospitals at the time of this observer's visit was about

Dr. Thomas W. Salmon.


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2 per 1,000 among the nonexpeditionary troops and about 4 per 1,000 among expeditionary troops, compared with a rate of 1 per 1,000 among the adult civil population of Great Britain. The greatest problem, however, both from the standpoint of the welfare of the individual soldier and of military morale, was that presented by the excessive incidence of war neurosis, a problem which proved to be most serious for all of the allied armies. Of 200,000 soldiers on the pension list of England, it was found that one-fifth were suffering from this condition.

Among the chief recommendations resulting from this study were: (1) The establishment overseas of special base hospitals of 500 beds for neuropsychiatric cases, and convalescent camps in connection with these hospitals in the base sections of the line of communications; (2) the provision of special neuropsychiatric wards of 30 beds for the observation and emergency treatment of mental and nervous cases in base hospitals in the advance section of the line of communications; (3) the assignment of psychiatrists and neurologists from these wards to evacuation hospitals and more advanced stations as opportunities permitted.

For the United States the following recommendations were made: (1) The provision of clearing hospitals, and clearing wards in general hospitals for the reception, emergency treatment, classification, and disposition of mental cases among enlisted men and officers invalided home; (2) legislation enabling the Surgeon General to contract with public and private hospitals for the continued care of mental cases prior to discharge; (3) the establishment of reconstruction centers and special convalescent camps for the treatment and reeducation of returned soldiers suffering from war neuroses; (4) the appointment of a special medical board to inspect all Government hospitals and reconstruction centers, public and private institutions caring for mentally disabled officers and enlisted men. Descriptive plans for hospital personnel and equipment, together with a diagram showing the scheme of care of the disabled soldier from the field hospitals at the front to his return home, accompanied the report.

A concluding observation described the changing point of view in England and France, brought about by the war, with regard to mental and nervous diseases in civil as well as in military life. Whereas mental illness had been almost wholly ignored and the medical advances before the war dealt almost exclusively with physical diseases, the wide prevalence of the neuroses among soldiers was apparently leading to a revision of the medical and popular attitude toward mental and functional nervous diseases, and stimulating widespread interest in their observation and study.

APPROVED PLANS

The report of the observations on the Mexican border was promptly accepted and the plans suggested were approved by the Surgeon General, who authorized the National Committee for Mental Hygienee to proceed at once with the organization of the neuropsychiatric units recommended.1 To this end there was formed the Committee on Furnishing Hospital Units for Nervous

eThe origin and work of the National Committee for Mental Hygiene are described in "A Mind That Found Itself," an autobiography, by Clifford W. Beers. Doubleday, Page & Co., New York.


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and Mental Disorders for the United States Government,f composed of representative neurologists and psychiatrists from various parts of the country. The American Medico-Psychological Association (now the American Psychiatric Association) appointed a member of the association in each State to work with this committee. The American Neurological Association and the American Psychological Association also appointed special committees to cooperate with the National Committee for Mental Hygiene. In Massachusetts the committee for war work in neurology and psychiatry was appointed by the governor with a view of organizing a neuropsychiatric hospital unit of its own for the use of the Government and to cooperate with the National Committee for Mental Hygiene. Soon it became evident that the problem of organizing and equipping hospital units would be but one of a number of problems that would have to be considered, so that the Committee on Furnishing Hospital Units for Nervous and Mental Disorders for the United States Government widened the scope of its activities and changed its name to War Work Committee, making provision at the same time for subcommittees for the study of particular problems.

On the authority of the Surgeon General1 the War Work Committee early set about securing for the Medical Department a special personnel, circularizing the medical profession and special hospitals for this purpose. There were received in all 795 applications for commission in the Medical Reserve Corps. After considering the special fitness of the applicants, the papers were forwarded to the Surgeon General, with indications as to the aptitude of the candidates, and with recommendations as to rank, based on professional standing.6 Commissions were granted to 564 such applicants.

The committee also, in much the same manner, secured the names of nurses and attendants, and cooperated with the Surgeon General in regard to their induction into the service.

It was from plans drawn by this committee that the type of neuropsychiatric pavilion for the camps was decided on.1 The committee also distributed special literature and, in some instances, equipment to the neuropsychiatric units and officers. It contributed $2,500 to enable a committee of psychologists to continue the investigations which resulted in the psychological tests later adopted by the Medical Department of the Army.g

As the war proceeded, the committee continued to cooperate with the division of neurology and psychiatry of the Office of the Surgeon General and with the civil community. It assisted in making the arrangements by which recruits who became insane prior to or immediately after enlistment would be cared for by their own States; prepared a classified list of State hospitals, showing their standards, medical personnel, and methods of treatment and care of patients; and throughout the war helped in the solution of various professional problems which confronted the Surgeon General.

fThe work of this committee was first made possible through a generous gift made by Miss Anne Thompson, of Philadelphia. Later it was financed by the Rockefeller Foundation.
gMemoirs of the National Academy of Sciences, Vol. XV. Psychological Examination in the United States Army. Part I. History and Organization of Psychological Examining and the Materials of Examination. Part II. Methods of Examining: History, and Development, Preliminary Results. Part III. Measurements of Intelligence in the United States Army. Government Printing Office, Washington, 1921.


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DIVISION OF NEUROLOGY AND PSYCHIATRY, SURGEON GENERAL'S OFFICE

The Surgeon General, appreciating the highly specialized nature of modern medical practice, organized in his office, in addition to the existing divisions, several others to direct and supervise all matters relating to the recognized specialties pertaining to medical science. One of these was the division of neurology and psychiatry,7 of which the section of psychology constituted a part. Later, the section of psychology was made an independent division.8

With the reorganization of the Surgeon General's Office in the latter part of 1918, the division of neurology and psychiatry ceased to exist as such, and became a section of medicine, under the direction and control of the chief of the division of internal medicine.9 Reference is made later to this arrangement. 

Prior to the organization of the division of neurology and psychiatry there was no neurological or psychiatric organization in the Office of the Surgeon General or in the Medical Department. A social and psychiatric department, organized at the Fort Leavenworth Disciplinary Barracks, had shown the value of psychiatry in relation to crime, delinquency, and disciplinary problems.10 But no special examinations as to the mental fitness of volunteers were made at recruit depots or recruit depot posts, or of applicants for commission in the Regular Army. There was a small number of medical officers who were recognized as having a knowledge of psychiatry, obtained, for the most part, during periods of service to which they were detailed at St. Elizabeths Hospital (Government Hospital for the Insane, Washington, D. C.). With the exception of service at the Letterman General Hospital, however, the special equipment of these officers was not utilized by the Medical Department of the Army as it would have been had their professional interests been in another direction, as, for example, toward bacteriology. The creation of this division, therefore, opened a new field in the Medical Department, concerning which the following announcement was made by the War Department on February 8, 1918:11

Officers with special experience in nervous and mental diseases have been added to the Medical Department of the Army. Such officers are detailed at all base hospitals and with many divisions. Most base hospitals have also special nurses and therapeutic appliances for the care of nervous and mental diseases. The services of these officers and nurses are available, through their superior officers, for consultation in all matters pertaining to such diseases.

FUNCTIONS

To the division of neurology and psychiatry was assigned jurisdiction over all problems relative to neuropsychiatry. This involved (1) preparing for the examination of recruits in the mobilization camps in order that those unfit for military service because of neuropathic or psychopathic conditions might be discharged; (2) preparing adequate facilities for the observation, treatment, and care of soldiers ill of nervous or mental diseases pending discharge; (3) preparing for the treatment of soldiers in the American Expeditionary Forces who became incapacitated because of nervous or mental disease; (4) preparing for the continued treatment and final disposition of soldiers invalided home.

The following were special problems to which the division gave immediate attention: (1) Mobilization of the psychiatrists, neurologists, and psychologists 


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of the country for service with the Army. (2) Securing the enlistment of specially trained women nurses and male attendants for service in the neuropsychiatric hospital units. (3) Devising methods of examination whereby large numbers of men could be examined by a few specialists in a comparatively short time. (4) Determining neuropathic and psychopathic conditions which, in the light of the European experience, should exclude from military service. (5) Preparing plans for a standardized neuropsychiatric hospital for Army use. (6) Preparing plans for a special standardized 500-bed reconstruction hospital for nervous and mental cases to be located in France. (7) Preparing plans for 30-bed units to be attached to the base and other military hospitals in France. (8) Standardizing equipment for Army neuropsychiatric hospitals. (9) Standardizing neurological, psychiatric, and psychological examinations for Army use. (10) Preparing special report blanks adapted to military use. (11) Arranging for the systematic collection and utilization of statistical data. (12) Arranging for special intensive courses in war psychiatry and neurology for the additional training of young neurologists and psychiatrists. (13) Collecting information pertaining to the situation abroad for the guidance of those at work upon the problem in this country. (14) The study of disciplinary problems arising in the Army. (15) Developing methods by which the work of the neuropsychiatric units could be coordinated with the medical military machinery. (16) Developing plans for the continued treatment in this country of nervous and mental patients invalided home from the American Expeditionary Forces.

ADMINISTRATION

A small administrative force was maintained in the Office of the Surgeon General, but for the greater number the neuropsychiatrists were placed on duty at the hospitals, camps, cantonments, posts, ports of embarkation, and disciplinary barracks, both in this country and in France.

The first efforts of the division were directed toward classifying and exempting for neuropsychiatric service the specialists whose applications were received daily in great numbers, in deciding upon assignments for them when commissioned, in recommending orders, and in attempting to coordinate its own activities with those of other branches of the professional services.

The last was a difficult task. The majority of the officers in the Surgeon General's Office at the time were fresh from civil life, most of them were without military experience, and many were without administrative experience. For a long time there was no officer or machinery to coordinate different interests, and many recommendations were made from all sides which overlapped or conflicted and which could not be carried out successfully. The result was that the different professional divisions in the office operated independently, with much inevitable confusion. Ultimately this was corrected, with the development and correlation of the various professional activities of the office. With the reorganization of the office, in the latter part of 1918, the division of neurology and psychiatry ceased to exist as such, and became a section of the division of internal medicine.9 This was considered by the chief of the neuropsychiatric service an undesirable change as it interposed between him and the


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executive officer of the Surgeon General's Office another officer, who was given authority, but who was not required to possess any special knowledge of nervous or mental diseases, who presented to the Surgeon General recommendations which he did not initiate, and of which he had no first-hand knowledge. The stream of execution was also slowed up, as each interruption of a channel of action involved, even in intraoffice activities, an additional delay of at least 24 hours.

Another disadvantage of this arrangement was that by it psychology was placed under medicine,9 when, in reality, it should have been under neuropsychiatry. While military psychology is ostensibly concerned with mental ratings and with the detection of mental deficiency-in other words, with a study of the normal mind and of the mind purely defective-it should not be forgotten that it constantly encounters medical problems of a psychiatric nature. Both the findings and the recommendations of psychologists concern psychopathology and consequently should go through the psychiatric officer and not the officer directing internal medicine.

CONSULTING SERVICE

No authority was vested in the officers of the division of neurology and psychiatry, Surgeon General's Office except, on occasions of special detail, to make inspections, all inspection duties normally being performed by officers of the division of sanitation, Surgeon General's Office. Certain special inspections, however, which were classed as consultations in reference to professional work, were made by members of the division of neurology and psychiatry. Some of the professional divisions of the Surgeon General's Office appointed officers known as consultants, who were assigned to different geographical regions for the purpose of consulting therein.12 This plan was not adopted by the division of neurology and psychiatry for the reason that it was always possible to secure War Department orders designating an individual officer as a consultant, and it was deemed wiser to use different officers for this purpose as the need arose. For example, when an officer assigned to some particular post developed a particularly successful system of treatment or management of patients or of making examinations, permission for his temporary relief was obtained from his commanding officer, and he was sent to posts in his neighborhood to consult with neuropsychiatric officers there, in order that they might benefit by whatever he had to tell them. Contract surgeons also were appointed for consulting purposes when they had special knowledge that would prove useful to neuropsychiatric officers on duty in their neighborhood.

Practically all the officers detailed to this division were ordered from time to time to make trips to certain hospitals or camps for the purpose of ascertaining whether a more or less uniform standard of excellence in the neuropsychiatric services was being maintained. Consultations in California were made by a member of the staff of Mendocino State Hospital.13 This method of consultation in professional matters proved highly successful. Visits from outside officers to officers working at one point invariably resulted in an increase of interest, in the removal of any obstacles that may have existed, and in improvement of the standard of professional work.


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Those who acted as consultants in base and general hospitals were assigned to the medical service and were usually referred to as neurologists, though in general hospitals in which psychiatric wards were established the consultations were conducted generally by the psychiatrists detailed there. There were many more demands for neurologists to serve in base and post hospitals and at detached points than could be met. They were supplied as freely as possible. They aided greatly in evacuation activities and in facilitating hospital business. When nerve injury cases began to be returned from overseas, neurologists were assigned to the various surgical services.

SPECIAL NEUROPSYCHIATRIC REPORTS

The officer in charge of the division of neurology and psychiatry realized that in view of the large number of neuropsychiatric examinations which were to be conducted in the Army, an unparalleled opportunity was at hand for obtaining information concerning a group of diseases of great social importance, the incidence of which was unknown and, further, that, in order to correlate the data derived from the examinations made, certain reports must be prepared and submitted to the Surgeon General for study and compilation by the division. It is true that the examinations conducted in the Army applied only to men of military age, but the statistical data elicited from this source must offer a reliable index to the extent to which disease and defects of this character occur throughout the entire population of the country.

It was believed that the time of the neuropsychiatrists should be largely occupied with their professional duties and that any forms adopted for the report of cases must be brief, concise, and practical. Another essential was that the report blank be so devised that the facts contained could readily be reduced to statistical form and made available for study.

The following blank forms were adopted and distributed to all stations where neuropsychiatric officers were on duty:h

            FORM 89
MEDICAL DEPARTMENT, U. S. A.
    (Authorized Sept. 19, 1917.)

RECORD OF NEUROLOGICAL AND PSYCHIATRIC EXAMINATION

Surname of patient                      Christian name                     Rank                 Company                         Regiment or staff corps

Examiners will record observations in the following sequence:

1. Record history of syphilis, previous diseases (physical or mental), injuries, alcohol and drugs; chief symptom; duration of present illness; evidence of alcoholic or drug addiction; state of nutrition, flesh, hair, nails, skin, and muscles.

2. If paralysis, note distribution, character, and contracture. If tremor or tics, note distribution and character. Note station and gait. Of reflexes, note knee jerks and abdominals especially; Babinski. Of eyes, note condition of pupils, nystagmus, double vision. If anesthesia, make chart showing distribution and different forms of sensibility affected. Note ataxia, taste, and smell. Note defects not previously mentioned.

hThese forms were prepared with the assistance of Dr. Horatio M. Pollock, statistician of the New York State Hospital Commission, whose knowledge and experience in this line of work rendered his advice particularly valuable.


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3. Note behavior, attitude, emotional state, general motor condition; stream of thought, content of thought (compulsive ideas, obsessions, phobias, delusions, hallucinations, peculiar mental attitudes); mood (depressed, gay, suspicious, irritable, sulky, resentful); orientation; memory and thinking (past events, recent events; calculation); intellectual level (always in cases of mental deficiency; in other cases when possible); patient's interpretation of the development of the psychosis or neurosis and attitude toward it.

4. If diagnosis of mental defect is made, state method of examination and basis of conclusion.

(figure)

Form 89 was intended as a clinical record of individual cases. Thousands of these completed forms were received in the Office of the Surgeon General and contained material of great clinical interest and value, but were too extensive for a thorough statistical study. Form 90 M. D., known as the statistical data card, contained a complete summary of the facts essential in a study of neuropsychiatric cases. These forms, as received in the Office of the Surgeon General, furnished the basis of the statistics quoted in this volume and discussed in detail in the following chapters. Form 91 M. D. was the monthly summary of the work done at each station.

At the end of each month the complete forms were forwarded by the officer who prepared them, through the senior medical officer of the camp or hospital, to the Surgeon General. In the Surgeon General's Office the reports were studied and classified and from time to time reduced to statistical form.


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The following instructions were issued as a guide in the preparation of the reports:

    WAR DEPARTMENT,
                                                        OFFICE OF THE SURGEON GENERAL,
             Washington, February 15, 1918.

Memorandum.

INSTRUCTIONS TO DIVISIONAL PSYCHIATRISTS AND OTHER MEDICAL OFFICERS IN CHARGE OF NEUROLOGICAL AND PSYCHIATRICAL EXAMINATIONS RELATIVE TO THE PREPARATION OF STATISTICAL DATA

In order to secure uniformity in the statistics of nervous and mental disease and defect the divisional psychiatrists and other medical officers who are in charge of the examinations will submit their reports on Forms 89, 90, and 91, Medical Department, specially provided for this purpose.

Form 89 is for the record of neurological and psychiatric examinations.

Form 90 the statistical data card will be used in submitting data relative to each person examined who is found to have nervous or mental disease or defect.

Form 91 is the monthly summary of the work done at the station.

These reports will be sent in at the end of each calendar month unless the work at the station is completed before such time. All reports will be addressed to the Surgeon General and sent to him by the divisional psychiatrist or other medical officer through the senior medical officer in charge of the station.

The following instructions for the preparation of data will be carefully studied and scrupulously observed.

All data will be clearly written in black ink, or preferably typewritten.

The data called for by every item on the report blank will be supplied if possible. If the information can not be obtained, leave the space blank, but enter a capital "U" (symbol for facts unascertained).

Do not use the interrogation point.

If the information is negative, enter "no" or "none." Do not use the (-) dash for unascertained or for negative.

Give exact data whenever possible. Avoid the use of the term "many" or "several." State information approximately if exact data can not be obtained. In determining the age of subjects, accept figures ending with 5 or 0 only after close questioning. Give the age in years and months when possible.

Avoid ambiguous abbreviations. Designate items on the reports by underscoring. Do not cross out items or use check marks. If the space in connection with any item on the front of the report blank is too small for a complete statement, mark the blank "over" and enter the data in the blank space on the back of the blank.

The following instructions and information relate to Form 90. The other blanks are self-explanatory:

CLASSIFICATION OF DISEASES, INJURIES, AND DEFECTS

Each case reported will be placed with appropriate specific designation under one of the following general heads:

I. Nervous diseases or injuries.
II. Psychoneuroses.
III. Psychoses.
IV. Inebriety.
V. Mental deficiency.
VI. Constitutional psychopathic states.


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The terms given in the following classifications will be used whenever applicable to specify the particular disease, injury or defect.

I. NERVOUS DISEASES AND INJURIES

Abscess:  
        Brain (specify location). 
        Spinal cord (specify location).
Arteriosclerosis: 
       Cerebral. 
        General.
        Spinal. 
Beri beri.
Bulbar palsy.
Chorea. 
Combined sclerosis. 
Ear diseases. 
Embolism and thrombosis. 
Endocrinopathies (specify disorder): 
        Adrenal.
        Thyroid. 
        Pituitary. 
        Other ductless glands (specify glands).
Epilepsy: 
        Idiopathic.
        Jacksonian. 
Exophthalmic goiter. 
Eye diseases. 
Facial palsy. 
Hemorrhage (specify location). 
Herpes zoster. 
Hydrocephalus. 
Injury (specify kind). 
        Brain (specify location).
        Spinal cord (specify location).
        Peripheral nerve (specify nerve). 
Lateral sclerosis.
Lumbago. 
Ménière's disease.
Meningitis: 
        Cerebrospinal. 
        Tuberculous. 
        Other forms (specify). 
Migraine. 
Multiple sclerosis (Disseminated sclerosis).
Myasthenia gravis.
Myelitis:
        Transverse.
        Traumatic.
Myotonia congenita (Thomsen's disease).
Neuralgia (specify nerve).
Neuritis (specify nerve).
        Diphtheritic.
        Multiple-
           Alcoholic.
            Traumatic.
        Other forms.
Pachymeningitis cervicalis.
Paralysis agitans.
Paramyoclonus multiplex.
Pes planus.
Plumbism.
Poliomyelitis.
Progressive muscular atrophy.
Progressive muscular dystrophies.
Sciatica.
Syphilis of central nervous system.
Syringomyelia.
Tabes dorsalis (locomotor ataxia).
Tics.
Torticollis.
Tremor, chronic progressive.
Tumor:
        Brain (specify location).
        Spinal cord.
        Peripheral nerve (specify nerve).
Vagotonia.
Undiagnosed.
Conditions secondary to other diseases:
        Aphasia.
        Bulbar syndrome.
        Hemiplegia.
        Jackson's syndrome.
        Optic atrophy.
        Paraplegia.
        

II. PSYCHONEUROSES

Enuresis. 
Hysteria. 
Neurasthenia. 
Psychasthenia.
Stammering.
Other forms (specify).
Undiagnosed.

III. PSYCHOSES

The classification of mental diseases given below is the one adopted by the American Medico-Psychological Association in May, 1917.

In designating the mental disease on the statistical card the group and type of the psychosis will be given whenever possible.


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1. Traumatic psychoses.
2. Senile psychoses.
3. Psychoses with cerebral arteriosclerosis.
4. General paralysis.
5. Psychoses with cerebral syphilis.
6. Psychoses with Huntington's chorea.
7. Psychoses with brain tumor.
8. Psychoses with other brain or nervous diseases (specify when possible).
9. Alcoholic psychoses:

(a) Pathological intoxication.
(b) Delirium tremens.
(c)
Acute hallucinosis.
(d)
Korsakow's psychosis.
(e)
Chronic paranoid type.
(f)
Other types, acute or chronic.

10. Psychoses due to drugs and other exogenous toxins.

(a) Morphine, cocaine, bromides, chloral, etc., alone or combined (to be specified).
(b) Metals, as lead, arsenic, etc. (to be specified).
(c) Cases (to be specified).
(d) Other exogenous toxins (to be specified).

11. Psychoses with pellagra.
12. Psychoses with other somatic diseases (specify disease).
13. Manic-depressive psychoses:

(a) Manic type.
(b) Depressive type.
(c) Stupor.
(d) Mixed type.
(e) Circular type.

14. Involution melancholia.
15. Dementia præcox:

(a) Paranoid type.
(b) Katatonic type.
(c) Hebephrenic type.
(d) Simple type.

16. Paranoia and paranoic conditions.
17. Psychoses with mental deficiency.
18. Psychoses with constitutional psychopathic inferiority.
19. Epileptic psychoses.
20. Undiagnosed psychoses.

IV. INEBRIETY

Alcoholism.
Drug addiction (specify drug).

V. MENTAL DEFICIENCY

Imbecile.
Moron.
Border-line condition.

VI. CONSTITUTIONAL PSYCHOPATHIC STATES

Criminalism.
Emotional instability.
Inadequate personality.
Nomadism.
Paranoid personality.
Pathological liar.
Sexual psychopathy.
Other forms (specify).
Undiagnosed.

IN LINE OF DUTY

In answering this question examiners will be guided by instructions given in paragraph 448, page 141, of Manual for the Medical Department.

DATE OF INJURY OR ONSET OF DISEASE

An exact date will be specified if possible. If the exact date can not be ascertained, give approximate date.

REASON FOR EXAMINATION

It will be determined whether the examination was to determine (a) fitness for Army service, (b) responsibility for misconduct, or (c) nature of incapacity or illness.

AGE

The age of the soldier will be stated in years and months. If the exact date can not be ascertained the examiner should estimate the age as closely as possible and mark "est." after the number given.


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RACE

In reporting the race of the soldier use the list given below, which is a condensed form of the list adopted by the United States Immigration Service.

African (black).i 
American Indian. 
Armenian. 
Bulgarian.
Chinese.
Cuban.
Dutch and Flemish.
East Indian.
English.
Filipino.
Finnish.
French.
German. 
Greek.
Hebrew. 
Irish.
Italian (includes "north" and "south"). 
Japanese. 
Korean.
Lithuanian.
Magyar.
Mexican.
Porto Rican.
Portuguese.
Rumanian.
Scandinavian (Norwegians, Danes, and Swedes).
Scotch.
Slavonic.i
Spanish.
Turkish.
Welsh.
Other peoples.
Mixed.
Race unascertained.

NATIVITY

The State or Territory of birth of those born in the United States will be given. Enter "U. S." only when the State can not be ascertained.

The date of nativity of those of foreign birth will be based on the classification given below.

Africa. 
Asia.k
Atlantic Islands.
Australia. 
Austria.
Belgium.
Bohemia.
Canada.l
Central America.
China.
Cuba.
Denmark.
England.
Europe.
Finland.
France.
Germany. 
Greece.
Hawaii. 
Holland.
Hungary.  
India. 
Ireland.
Italy 
Japan.  
Mexico. 
Norway.  
Philippine Islands.
Poland. 
Porto Rico.
Portugal.
Rumania.
Russia.
Scotland.
South America.
Spain.
Sweden.
Switzerland.
Turkey in Asia.
Turkey in Europe.
Wales.
West Indies.m
 Other countries.
 Born at sea.

LEGAL RESIDENCE

The legal residence is the place in which the home of the soldier is located. If he has no home his place of residence at the time of enlistment will be given.

iDo not say "colored."
j"Slavonic" includes Bohemian, Bosnian, Croatian, Delmatian, Herzegovinian, Montenegrin, Moravian, Polish, Russian, Ruthenian, Servian, Slovak, Slovenian.
kNot otherwise specified.
lIncludes Newfoundland.
mExcept Cuba and Porto Rico.


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EDUCATION

Report education as none if the soldier could neither read nor write previous to onset of his disease. After the words "grades," "high school," and "college," insert number of years completed.

HOME ENVIRONMENT

Report places of residence with a population of over 2,500 as "urban"; and all other places as "rural." Care should be taken to ascertain whether the actual environment of the subject previous to entering the Army was that of country or city life. Even though the post office address given be that of a place with a population of over 2,500, if it appears that the soldier lived in the open country, the environment will be designated as "rural."

ECONOMIC CONDITION

The economic condition of the soldier will be designated as "marginal" or "comfortable." "Marginal" includes those who live on daily earnings but who have not accumulated enough to maintain themselves without employment for four months. "Comfortable" includes those who have accumulated enough to maintain themselves without employment for four months or more.

PREVIOUS OCCUPATION

Indicate in every case the kind of work done or character of service rendered. State the occupation of the soldier, not that of his employer.

ARMY SERVICE

The rank and time of service in the various arms of the service will be given accurately. In case the soldier has rendered different kinds of service the facts should be definitely stated.

ACCOMPANYING DISEASES

Every important disease present at the time of examination and not included under the heading "Diagnosis" will be specified.

WOUNDS IN ENGAGEMENTS, WITH DATES

"Wounds" include only injuries received in engagements. Specify part of body injured and extent of injury.

INJURIES NOT RECEIVED IN ENGAGEMENTS, WITH DATES

Those include all injuries of importance received in the Army service not included under wounds. State whether injury resulted through accident or was self-inflicted.

DISEASES DURING ARMY SERVICE

Important facts in the hospital record of the soldier will be given.

Venereal diseases contracted during Army service will be noted whether subject entered the hospital or not.

DISEASES PREVIOUS TO ADMISSION TO ARMY

Care will be taken to report venereal disease, tuberculosis, or any disease or injury that would have bearing on soldier's present condition.

ALCOHOLIC HABITS

Report as "abstinent" those who do not use alcoholic liquors at all, as "intemperate" those who become intoxicated or show physical or moral deterioration from the use of alcohol or who have committed unsocial acts while under the influence of alcohol. All others who use liquors will be classed as "moderate." In case the habits of the subjects in respect to alcohol have changed, the fact will be stated.


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FAMILY HISTORY

Report separately the family history of the soldier in respect to (a) mental diseases, (b) nervous diseases, (c) inebriety, and (d) mental deficiency.

OTHER ETIOLOGICAL FACTORS

Under this heading will be stated every specific cause of the soldier's disease or condition not previously indicated. Indefinite or doubtful factors will not be given. As causes of nervous and mental diseases are often multiple, it is important that a full statement be given.

RECOMMENDATIONS OF EXAMINING OFFICER

Under this heading will be given the recommendations of the examiner relative to the treatment or disposition of the soldier.

DISPOSITION WITH DATES

State if the soldier is discharged from the Army or sent to a civil hospital or institution, or held for treatment in the camp hospital, or if death ensues. In disciplinary cases, state action taken.

If the case is not disposed of at the end of the month when the statistical data cards are sent in, the final disposition of the case will be reported by letter supplemental to the monthly report.

The records of the cases (Form 89) were of immediate practical assistance to the medical officers on duty in the Office of the Surgeon General in rendering opinions on special cases which were constantly being referred for comment by The Adjutant General of the Army, by the Bureau of War Risk Insurance, and by Members of Congress. They further made it possible for The Adjutant General to furnish the States with information concerning the nervous and mental conditions of rejected recruits and discharged soldiers who required State care, an opportunity of which many States availed themselves. In most instances the information recorded on the special forms was more definite and complete than that contained in the general medical records of the War Department.

In addition to the medical and statistical importance of the records, they enabled the division to keep in close contact with the work being done in the field, to arrive at conclusions, and to form opinions as to the quality and amount of work. The character of the reports and the promptness and manner with which they were rendered, assisted the division in computing the ratings which formed the basis of promotion for these officers. It seemed at first that these forms, which were supplemental to those which were still required by the War Department, might be regarded as an additional burden and would be made out unwillingly. Such, however, was not the case. The officers seldom complained of having to render Forms 89 and 90; on the contrary, many expressed satisfaction at thus being kept in professional touch with the central agency particularly interested in their work. The special forms showed also where the services of specialists were most needed. This was useful information as the demand for services of this character always exceeded the supply.


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REFERENCES

(1) Correspondence. On file, Record Room, S. G. O., 169005 and 183231 (Old Files).

(2) Report to the Surgeon General, U. S. Army, April 12, 1917, by Pearce Bailey, M. D., Stewart Paton, M. D., and Thomas W. Salmon, M. D. On file, Historical Division, S. G. O.

(3) Report to the Surgeon General, U. S. Army, May 12, 1917, by Dr. Pearce Bailey, of visit to Ottawa, Canada, with reference to the management of mental cases among Canadian soldiers. On file, Historical Division, S. G. O.

(4) Report to the Surgeon General, U. S. Army, June 9, 1917, by Stewart Paton, M. D. On file, Historical Division, S. G. O.

(5) Report to the Surgeons General, U. S. Army, undated, by Dr. Thomas W. Salmon:
The Care and Treatment of Mental Diseases and War Neuroses (" Shell Shock ") in the British Army. On file, Historical Division, S. G. O.

(6) Letter from the Surgeon General, U. S. Army, to the National Committee for Mental Hygiene, June 11, 1917. Subject: Applications of psychiatrists for the Reserve Corps. On file, Record Room, S. G. O., 169003 (Old Files).

(7) S. O. No. 166, W. D., July 19, 1917, par. 137. Also: Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1079.

(8) Fifth indorsement, W. D., A. G. O., to the Surgeon General, U. S. Army, January 19, 1918. On file, Record Room, S. G. O., 702 (Psychological).

(9) Office Order No. 97, S. G. O., November 30, 1918. On file. Record Room, S. G. O., 024.17 (Section of Neuropsychiatry).

(10) Report of the work of the class in disciplinary psychiatry, at the U. S. Disciplinary Barracks, Fort Leavenworth, Kansas, to the Surgeon General, U. S. Army, January and February, 1919. On file, Historical Division, S. G. O.

(11) Bulletin No. 4, War Department, February 7, 1918, Par. V.

(12) Memorandum from Brig. Gen. T. B. Lyster, M. C., to the Surgeon General, U. S. Army, August 28, 1918. Subject: Consultants. Approved by the Surgeon General. On file, Record Room, S. G. O. 211 (Consultants).

(13) S. O. No. 214, W. D., October 16, 1917, Par. 59, and S. O. No. 58, W. D., March 11, 1918, Par. 47, detailing Contract Surgeon Robert L. Richards to duty as consultant in neuropsychiatry.

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