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Section I, Chapter II

Table of Contents

CHAPTER II

PERSONNEL

PROCUREMENT AND DISTRIBUTION; TRAINING

PROCUREMENT AND DISTRIBUTION

NEUROPSYCHIATRISTS

After the establishment of the division of neurology and psychiatry the War Work Committee of the National Committee for Mental Hygiene continued to forward applications of medical men with neurological and psychiatric training for commissions as medical officers, but, as the war proceeded, the majority of such applications were passed upon directly in the Surgeon General's Office. Some neuropsychiatrists who were commissioned, without being exempted for neuropsychiatry, obtained special work in the field through their personal applications for transfer from other services; a few, too, requested transfer from neurology and psychiatry to other services. At first many neurologists and psychiatrists hesitated about applying for a commission at all for fear they would be detailed to other duties than those for which they were specially qualified. They were given such assurances as were possible under the circumstances, namely, that they would be used for work for which they were best fitted. It was only under exceptional circumstances that they were detailed to other activities. Some, as in other professional services, who showed ability in administration, were relieved of professional duties and assigned to administrative work.

At first great care was exercised in regard to the qualifications of physicians seeking commissions for the purpose of doing neuropsychiatric work and for transfer thereto. Estimates of qualifications were based, in the first place, on clinical experience in civil life and, later, on the recommendations of superior and commanding officers. When the demand for specialists of this class became too great, especially from the American Expeditionary Forces, the strictness in regard to qualifications was somewhat relaxed, and the average in professional ability suffered a decline. It is now believed that this relaxation in professional requirements was a mistake. It would have been wiser to have refused to accept for special service all who were not sufficiently qualified professionally. At best, specialism is a difficult matter to assimilate within a military organization. In mobile units it may be quite impossible to arrange it, and even in base and general hospitals it constantly meets obstacles. Those who represent specialties, therefore, if they are really to prove themselves as specialists, must be high-grade men in two essential particulars: They must have a clinical familiarity with the classes of patients their specialty calls them to treat or to pass upon, and, in addition, they must possess traits in personality which render a man adaptable and self-reliant-traits which distinguish the


24

capable medical officer quite independently of his professional qualifications. In actual warfare the latter characteristics are indispensable and outweigh the others. If a man is a failure in either particular he injures the general standing of specialists. It is believed, therefore, that the good of the service is better met by leaving the place of a specialist vacant, even when one is urgently needed, than it is by assigning to it any but a well-qualified person.

In general, the officers serving in this division were either psychiatrists or neurologists, although a few had been thoroughly educated in both branches. The psychiatrists were much more numerous and were drawn chiefly from State hospitals. They were, as a rule, men of high moral standards, with excellent experience and ideals in the care of the insane, and were skillful administrators. They were, perhaps, somewhat lacking in aggressiveness, and none too familiar with general medical problems. It was a disadvantage, on the one hand, that men intrusted with so novel an experience as the widespread dissemination of neurological and psychiatrical principles in the Army should be lacking in the insistence which might lead to their early adoption. On the other hand, the fact that psychiatrists reacted to the military situation as a body of trained men rather than as individuals with a message, may have resulted in more good in the end than if they had comported themselves as individual reformers. As has already been said, the military system, in its fundamental construction, is opposed to specialism, and it is well within the range of probability that the psychiatrists, by reason of their State hospital training, were of an adaptability which finally made psychiatry so welcome to the Medical Department of the Army. The neurologists were less homogeneous, as a class, than the psychiatrists, coming nearer to the type of general practitioner. They were more familiar with the world, more aggressive than psychiatrists, and more familiar with border-line types. Few of them were competent to take charge of the insane, although both neurologists and psychiatrists showed great aptitude in making up, during actual service, whatever defects may have existed in their professional education.

At the time of the creation of the division of neurology and psychiatry, about 50 neuropsychiatric officers had been commissioned.1 Five months later, there were 235, of whom 16 were majors, 71 captains, and 148 lieutenants.1 At the time the armistice was signed, there were 430 officers in this country and 263 overseas, making a total of 673.2 Of these there were 2 colonels, 2 lieutenant colonels, 84 majors, 278 captains, and 307 lieutenants.3 After the armistice was signed promotions were stopped for a time and when resumed were given much less freely than previously.

The distribution of commissioned personnel was made, first, for the purpose of establishing neuropsychiatric examinations in the new Army, and, second, to supply neurologists and psychiatrists to base and other military hospitals, in accordance with the plan for detailing officers of the Medical Reserve Corps for duty as specialists in Army camps.4 The assignments of these officers during the autumn of 1918 gives an index to the work accomplished in the execution of this plan:3


25

Assignment of neuropsychiatric officers, autumn of 1918


Sept.
 27

Oct.
 5

Nov.
 6

Sept.
 27

Oct.
 5

Nov.
 6

UNITED STATES

OVERSEAS-continued

Surgeon General's Office

4

4

5

Base Hospitals, France

130

130

c130

Base hospitals, cantonments

39

39

40

Evacuation hospitals, France

40

40

39

Base hospitals at forts

---

---

11

Divisions

38

37

41

Boards, United States Army

109

126

148

Unassigned, A.E.F.

18

13

13

Aviation

7

7

7

Hospital trains and replacement units

2

8

11

Disciplinary

7

7

7

In England

16

16

16

General hospitals

48

52

81

Philippines

1

1

1

Ports of embarkation

8

9

11

                          

Total

247

247

253

Training institutions

34

38

26

POSSIBILITIES

Medical officers' training camps

---

6

6

Internes

8

7

7

St. Elizabeths Hospital

7

8

a8
b11

Inactive

6

6

7

Recruit depots

---

---

16

Prospective "Under orders"

51

55

114

                                

Total

263

296

377

Papers received

57

---

---

OVERSEAS

       

Grand total

632

611

758

Headquarters office, medical and surgical consultants

2

2

2

aTraining.
bDuty.
c35 of this number were still in this country on that date.

Perhaps the most important piece of intensive work done by the neuropsychiatrists in the early period of mobilization was in connection with the examination of candidate officers at the officers' training camps. It was not possible to send examiners to many of the first series of training camps, which closed August 1, 1917, although excellent pioneer work was done at some places. At the second series of camps, August 27, to November 26, 1917, valuable service was rendered by specially selected contract surgeons. Contract surgeons were chosen for this service partly by reason of a shortage of competent officers, but especially because the specialists selected were men of mature judgment and long experience, and so better qualified to make successful approaches to the educated men who made up the class of student officers.

It was so important to eliminate unfit officers at the outset of their military career that it is unfortunate that so many commissions were granted-e. g., in the Quartermaster and Medical Corps-without subjecting the candidate to the thorough and exhaustive examinations which, later, were established at all the camps.

It was attempted to make examinations of the National Guard in the armories before they went to the camps, but this was successful in few cases,a by reason of the great confusion which existed in all branches of the service at that time. Examiners were sent later to all cantonments and recruit depots, to all base hospitals, to some general hospitals, and to all disciplinary barracks.2

As soon as circumstances demanded, officers were detailed to the ports of embarkation to make examinations of unexamined men ordered overseas, or to bring before disability boards men recommended for discharge by neuropsychiatrists whose recommendations had not been acted upon.2

aIn the New England States and in the States of New York, New Jersey, Pennsylvania, Maryland, Virginia, North Carolina, and South Carolina.


26

By December, 1917, it was realized in the office of the chief surgeon, A. E. F., that the number of troops then in France, many of whom had sailed before the neuropsychiatric examinations had begun, rendered imperative the services of a director for nervous and mental diseases. Consequently a neuropsychiatrist was ordered overseas as a casual with recommendation that he be placed in charge of these matters-a recommendation which was complied with on his arrival.5 After that, assignments for service with the American Expeditionary Forces became increasingly frequent, being made to overseas base hospitals, evacuation hospitals, Base Hospital No. 117 (special hospital for war neuroses), and as casuals and replacements.6 Some younger officers were assigned to the liaison officer in London for the purpose of studying the methods of management of the war neuroses in the English military hospitals.

DIVISION PSYCHIATRISTS

In January, 1918, on the recommendation of the division of neurology and psychiatry, the War Department created the position of division psychiatrist, with the rank of major,7 one for each tactical division.

The creation of this position, which was the first recognition in the Army of the utility of specialists for troops in the field, proved of the utmost importance. These positions were filled as fast as divisions were formed. The official detail of each of these officers was to one of the field hospitals of the division concerned, but they were generally given desks in the office of the division surgeons, from which points they could operate most effectively. Being with and a part of a tactical division, they were able to exercise the preventive side of their specialty to the utmost advantage. It was their duty to keep in touch with the mental health of the command and to familiarize medical officers serving with sanitary troops with the methods of neurology and psychiatry. During the training period they were available for all special examining boards. They directed the neuropsychiatric examinations of their divisions, supervised the preparation of the special reports to the Surgeon General, and saw to it that the recommendations of the neuropsychiatric examiners were promptly prepared for forwarding to general disability boards. They visited the regimental infirmaries and held informal conferences from time to time with regimental surgeons and company commanders. They were generally available for consultation and established a satisfactory cooperation with judge advocates, by means of which the mental state of prisoners or of those accused was established as a factor in their delinquency. Reports of the functioning of these officers overseas indicate that they assisted materially in maintaining the integrity of the commands to which they were attached and expedited the elimination of the unfit.8 Without them the prompt treatment of functional nervous disorders in the hospitals attached to the combat forces, which practically eliminated "shell-shock" as a military problem in our troops, would not have been possible.

The duties of the divisional psychiatrists were to be as follows:9 (1) To examine or cause to be examined all cases of mental and nervous diseases occurring in the command. (2) To be available for all special neuropsychiatric examining boards convened from time to time for the purpose of examining


27

the command. (3) To ask for the assignment of regimental surgeons to assist in the neuropsychiatric examination of recruits; this latter largely for the purpose of instruction of regimental surgeons. (4) To supervise the making of all reports of examinations in the specialty and the forwarding of them to the Surgeon General. (5) To see to it that the recommendations of neuropsychiatric examiners were promptly prepared for forwarding to general disability boards. (6) To hold from time to time brief informal conferences with regimental surgeons and company commanders in relation to the general subject of military neuropsychiatry. (7) In cantonments, to be available for consultation with medical officers stationed at base hospitals. (8) To visit frequently regimental infirmaries and, whenever invited, the nervous and mental wards of base hospitals. (9) To cooperate with judge advocates for the purpose of establishing in every division a method of treatment of delinquents similar to that in successful operation at the disciplinary barracks, Fort Leavenworth. (10) Consultation service in reference to service battalions should such service battalions be established in connection with depot brigades or base hospitals. (11) To cooperate with psychological examiners and, if practicable, to arrange for psychiatric and psychological surveys of troops to take place at the same time and place. Division surgeons were to assist in every way possible to the end that the division psychiatrist should have the necessary facilities for carrying on his work, and especially in regard to desk room, stenographic assistance, and transportation.

CONTRACT SURGEONS

Contract surgeons were employed1 from time to time and proved valuable, as by this means were secured the much needed services of men of exceptional ability who were over age, or who, for other reasons, could not enter the military service for overseas duty.

FEMALE NURSES

Second in importance to the mobilization of neurologists and psychiatrists was the recruiting of nursing personnel. The number of female nurses in the country trained for the care of mental and nervous patients was relatively small, compared with the great number of such patients in public and private hospitals, in contrast to the proportion and number of nurses experienced in general hospital care available for the physically sick. Every effort had to be made to conserve the supply of those experienced in neuropsychiatric work for the needs for the special wards and hospitals set aside for mental and nervous cases in the Army. To this end the Mental Hygiene War Work Committee secured the services of the superintendent of nurses of Bloomingdale Hospital, New York, who from the summer of 1917 until she assumed the duties of chief nurse of Base Hospital No. 117,10 the overseas hospital for war neuroses, devoted many months to the procurement of specially trained nurses for service with neuropsychiatric units in this country and overseas. The need for such nurses proved to be very great, and the National Committee for Mental Hygiene used all of its resources and contacts and developed others to stimulate recruiting from civil hospitals for mental and nervous diseases. Working arrangements


28

for the enrollment of neuropsychiatric nurses were made with the Army Nurse Corps and the nursing service of the American Red Cross, through which nurses for the psychiatric units were registered. Many of the nurses with the special training were already enrolled in the Red Cross.

The same difficulty arose in regard to the psychiatric nurses as in regard to the psychiatric officers-proper assignment so that the full benefit of their special training and experience could be obtained, and that the psychiatric nursing needs of the Medical Department of the Army could be met. It was obvious that the psychiatric needs would never be met and little of importance would be gained by commissioning psychiatrists and enrolling psychiatric nurses if these officers and nurses were to be swallowed up, as it were, in the administrative routine and assigned to duties for which they were little or not at all fitted, while others equally unfitted were assigned to work which only the psychiatric officers and nurses were prepared to do excellently. The problem was met so far as the medical officer was concerned, as previously noted, by the plan of exemption to specialized divisions which was early put into effect in the Office of the Surgeon General.

This problem was more troublesome in the nursing service. A psychiatric nurse may be of service upon any ward; a nurse, no matter how excellent her general training may have been, is not only of little use but may even be a handicap to the work on a psychiatric ward unless she has had psychiatric nursing experience. Not only does she not understand, she misunderstands, the problems about her, and creates more difficulty-with the best of intentions-than she appeases. The importance of having available for the psychiatric wards suitably trained nurses was realized and every effort was made not only to recruit these nurses but also to hold them available for psychiatric work, especially in overseas units, but in home cantonments as well. Efforts were made to keep an exempted list both in the office of the Army Nurse Corps and in the reserve list of the American Red Cross, but the plan did not work well. The pressure for nurses upon both the Army Nurse Corps and the American Red Cross was so great that it was frequently impossible, or seemed to be, for either organization to adhere strictly to a policy of exemption as was done successfully with officer personnel.

MALE ATTENDANTS AND NURSES

Efforts were made to enlist male attendants and nurses trained in the care of mental and nervous cases for service with the neuropsychiatric units. These were secured, largely, from the personnel of State hospitals for the insane. During the early period of hospital organization, the policy had been followed of assigning to the psychiatric wards enlisted men of the Medical Department regardless of their lack of experience in such work. Officers who had come from long experience in civil hospitals knew that this would not be satisfactory, but it was not until a number of quite unnecessary, serious accidents had occurred in various psychiatric wards that others were convinced that trained psychiatric attendants were necessary. The number of trained attendants in


29

the country was distinctly limited, and it was necessary that those available to the Army should be conserved. It was known that many had enlisted voluntarily and that hundreds had been called in the drafts. Some of these already were serving in the Medical Department, but on assignments not particularly suited to their training. Others were in different branches of the military service. The problem was to locate these men, more particularly those in the Medical Department, and to make possible their assignment to psychiatric duty. In this, as in the work of procuring officers and female nurses, the Mental Hygiene War Work Committee cooperated with the Surgeon General.

The plan of inducting men into the service and assigning them immediately to psychiatric duty worked well. Thus several hundred excellently trained men were obtained for service that was greatly needed and for which they were specially equipped. The authority to deal directly with local draft boards with the view of inducting men into special branches of the military service was rescinded in June, 1918.11 That such a plan could be abused by individuals having themselves inducted into noncombatant services for which they had no particular fitness is obvious, but such a plan properly safeguarded has the possibilities of great service to the Army. Without such a plan it would not have been possible for the division of neurology and psychiatry to have assembled even a nucleus of trained attendants about which it could build an attendant service out of untrained men supplied by the Medical Department. As the number of trained men available to the division of neuropsychiatry was far below the number needed, it was necessary to call upon the Medical Department for the additional men required. These men were sent, when possible, to St. Elizabeths Hospital, Washington, for training, or to one of the five large neuropsychiatric centers established by the division.

The State hospitals for mental diseases throughout the country cooperated whole-heartedly with the National Committee for Mental Hygiene and the division of neurology and psychiatry in providing the Army with trained attendants and nurses, as well as physicians. These hospitals seldom had the quota of physicians, nurses, and attendants they required, and when to the usual shortage was added the depletion due to personnel entering the Army the situation in many hospitals became serious. There were few complaints, however. Toward the latter part of the war it became evident that few more could be spared from the attendant services without the situation becoming dangerous; it was then suggested that trained attendants and male nurses, called in the draft, claim exemption under section 80; section 81, rule 16; section 88, rule 25; section 89, rule 26, of the Revised Selective Service Regulations.

PSYCHIATRIC AIDES

Special women assistants, termed psychiatric aides,12 were employed, on civilian status, after a course of training at Smith College.


30

TRAININGb

NEUROPSYCHIATRISTS

The shortage of competent neuropsychiatrists in the Army brought to light marked defects in the educational opportunities in America for this important specialty. As far as psychiatry is concerned, little provision was made in the United States before the World War for the proper instruction of undergraduate students in medical schools. A few clinical lectures were given, but the students were not afforded opportunity for sufficient ward work for these lectures to be of any great advantage to them. There were also few provisions for postgraduate instruction. As stated before, practically all the psychiatrists of the country were employees of State hospital systems and had received their education through routine performance of their duties. Their experience was largely confined to institutional patients, and they had had little opportunity to observe the border-line cases, which constituted, after all, one of the real problems of the Army. There were, however, a few important centers for psychiatric instruction, such as the State Psychopathic Hospital, Ann Arbor, Mich.; the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital, Baltimore, Md.; the Boston Psychopathic Hospital; the New York State Psychiatric Institute; and St. Elizabeths Hospital (Government Hospital for the Insane), Washington, D. C.13 The last had been used as a center for the instruction of medical officers of the Army and Navy.

In neurology educational conditions were no better. Practically the only clinical instruction given was on out-patients. Bed services in connection with medical schools were practically unknown, few hospitals had any beds set aside for neurological cases, and in few hospitals did neurological patients have any real representation.

The Neurological Institute, in New York City, received many students, but it had no amphitheater, and the teaching done there, while of high quality, was performed under the greatest difficulty.

The meager educational provisions for these two branches resulted largely from the lack of acquaintance of the medical profession as a whole with the purposes and methods of neurology and psychiatry and its failure to perceive the clinical and economic importance of these specialties. Few medical men, apparently, realized that no clinician ever was great who did not carry into his practice a good working knowledge of mental pathology; few could estimate the wastage to be saved by taking it into account. At the beginning this was true for the medical officers of the Army, but it is believed that the experiences of the war made them more alive to these matters than are civilian physicians.

The almost simultaneous opening of many cantonments in 1917 created so great a press for neuropsychiatrists that it was rarely possible to send them to officers' training camps for military training. A few were ordered to these camps, and some officers detailed at these camps who were discovered to have had neuropsychiatric training were accepted for neuropsychiatric service; but most neuropsychiatrists acquired military knowledge by actual field duty.

It was often found desirable to provide additional instruction in the professional aspects of their work. It was not infrequent to find an officer who

bFor a full discussion of Medical Department training, sec Vol. VII, Training.


31

had had good neurological training but little psychiatric training, or one who had had good psychiatric training but not an adequate foundation in neurology. It was desirable to round out the training of those men and to better equip others whose training in both fields had been limited. Seven institutions, distributed geographically, were asked by the Surgeon General to provide suitable courses of instruction:13 Neurological Institute, New York City; State Psychopathic Hospital, Ann Arbor, Mich.; Philadelphia General Hospital, Philadelphia, Pa.; Mendocino State Hospital, Talmage, Calif.; Henry Phipps Psychiatric Clinic, Baltimore, Md.; State Psychopathic Hospital, Boston, Mass.; St. Elizabeths Hospital, Washington, D. C. All responded cordially. The directors of these institutions were commissioned or served under contract and were given the title of military director.1 The military directors secured the collaboration of many other representative teachers of the medical community, with the result that excellent special neuropsychiatric instruction was provided.1

These courses were usually of six weeks' duration, although not infrequently interrupted by the pressing need for neuropsychiatric officers in the field. Even when courses were not actually in progress there were usually some students left on special detail to profit by the usual clinical routine of the institution. The course of study included lectures, clinics, demonstrations, and laboratory work.1 The fields covered were psychiatry, neurology, psychology, personality problems, serology, neuropathology, with collateral instruction in otology and ophthalmology. In planning the courses, the amount of time which the exigencies of the service would allow to be devoted to the subject was considered, and the rosters and schedules were prepared accordingly.

While it was realized that the instruction given in neurology should be and was largely clinical, it was deemed essential to give some didactic and semididactic instruction in neuroanatomy, neurophysiology, and neurological medicine. The outlines were planned, therefore, to include a limited amount of this work.

Physiology of the nervous system, especially as concerns cerebral, spinal, and peripheral localization, received particular attention, and an effort was made to follow clearly the outlines, physiological teaching by the presentation of clinical cases illustrating the subjects taught. Organic neurology was taught by systematic demonstration of organic symptomatology illustrated by cases which were made to cover a wide range in most of the schools. Many cases of tabes and other forms of sclerosis, syringomyelitis, organic hemiplegia, and other organic nervous diseases were demonstrated. The differentiation of such conditions as hemorrhage, thrombosis and embolism and their separation from focal lesions, like tumors and abscesses, were amply illustrated. Moving-picture demonstrations were used whenever possible. Instruction in syphilis of the nervous system and epilepsy were emphasized. Lectures on war neuroses were given. Pathology of the cerebrospinal fluid and neurohistology were thoroughly gone into. Electrodiagnosis and electrotherapeutics were covered, including a description of the various forms of electrical apparatus. Close attention was given to those phases of ophthalmology which are associated with neurological work. Instruction in neuro-otology included detailed instruction in the Bárány tests.


32

The plan for the course of instruction in psychiatry was based on suggestions contained in Medical Department Circular No. 22, Office of the Surgeon General, Washington, D. C., dated August 1, 1917.c However, the instruction given was not confined to those suggestions, and full advantage was taken of the very large and varied amount of clinical material available.14

As an illustration of the manner of execution of the plan of instruction the course given at the psychopathic hospital, Ann Arbor, Mich., is reproduced here in full:

THE COURSE IN NEUROPSYCHIATRY FOR MEDICAL OFFICERS OF THE ARMY, CONDUCTED AT THE PSYCHOPATHIC HOSPITAL OF THE UNIVERSITY OF MICHIGAN

Soon after the organization of the War Work Committee of the National Committee for Mental Hygiene, plans were perfected for the instruction of medical officers assigned to neuropsychiatric service in the Army. It was planned that this instruction should be given at various neurological and psychiatric hospitals which were adequately equipped for carrying this through.

In accordance with this plan such a course was organized at the psychopathic hospital of the University of Michigan in the latter part of July, 1917.

As the period of assignment of officers for instruction would necessarily be brief, it was essential that the instruction should be as intensive as possible and also be broad enough in scope to meet the practical needs of a neuropsychiatric medical service. To this end instruction was provided in those medical subjects that might form a background for neuropsychiatric training and would have a practical application in neuropsychiatric diagnosis and treatment.

The instruction was arranged to follow out a definite weekly schedule which was planned to furnish a well rounded out course to be completed in six weeks.

As officers were continually coming and going, owing to exigencies of the Army requirements, it was found impossible for each man to follow a prescribed schedule closely. Some were in attendance for only two weeks, while others remained longer than the six weeks' period. Repetitions of the course made it possible to meet these irregularities.

By the time the course was organized it was known from the medical experiences of the war what special training was needed, and the course was shaped to meet these requirements.

The following schedule shows the arrangement of the instruction:

9-10

10-11

11-12

1.30-2

2-3

3-4

4-5

5-6

Monday

Doctor Camp Clinical neurology

Doctor Barrett Psychiatric clinic

Tuesday

Doctor Barrett Psychiatric conference

Clinical psychiatry Hospital staff conference

Doctor Barrett and Doctor Gurd Neuralpathology

Wednesday

Doctor Slocum Neurological disorders of the eye

Doctor Barrett and Doctor Gurd Neuralpathology

Doctor Camp Neurological clinic

Thursday

Doctor Jones Psychometric tests

Doctor Barrett Psychiatric conference

Doctor Barrett and Doctor Gurd Neuralpathology

Friday

Doctor Camp Clinical neurology

Doctor Barrett Psychiatric conference

Doctor Barrett and Doctor Gurd Neuralpathology

Saturday

Doctor Furstenberg Neurological disorders of the ear

cThis circular is quoted in full in Chap. IV.


33

The detailed instruction as given in the various divisions of the course was as follows:

PSYCHIATRY

Psychiatric instruction was given at the psychopathic hospital by Doctor Barrett and the medical staff of the hospital, Dr. Earl Palmer, Dr. B. L. Jones, Dr. Raymond F. Wafer, and Dr. James Stanton. The following subjects were covered:

1. General survey of the problems of mental disorders in their military relations. Two hours.

2. Discussion of the organization for neuropsychiatric work; of the schemes and methods for diagnosis and recording of data. Two hours.

3. General psychopathology. Didactic lectures, with clinical demonstrations. Ten hours.

4. The functional mental disorders of the present war. Survey of the experiences published in the German, French, and British literature. Four hours.

5. Shell shock and the psychoneuroses. Two hours.

6. Psychoneuroses; neurasthenia; anxiety neuroses; hysteria; compulsion neuroses. Didactic lecture and clinical demonstrations. Four hours.

7. Manic-depressive insanity. Didactic lecture and clinical demonstrations. Two hours.

8. Dementia præcox. Didactic lecture and clinical demonstrations. Four hours.

9. Syphilitic mental disorders. Didactic lecture, clinical and anatomical demonstrations. Four hours.

10. Epileptic mental disorders. Didactic lecture and clinical demonstrations. Two hours.

11. Psychopathic personalities. Didactic lecture and clinical demonstrations. Four hours.

12. States of mental defectiveness. Two hours.

13. Feeble-mindedness and mental subnormalities. Didactic lecture and clinical and anatomical demonstrations. Two hours.

14. Psychometric tests. Didactic lecture and practical work in making examinations of defectives and delinquents. Six hours.

15. Mental disorders of organic brain diseases. Arterio-sclerotic mental disorders; mental disorders with tumors of the brain and brain injury. Didactic lecture and clinical demonstrations. Two hours.

16. Serological diagnostic demonstrations. Technique and interpretation. Two hours.

17. Attendance at the psychiatric clinic in the medical school at the university. One and one-half hours each week.

18. Practical work in study of cases and preparation of histories on the wards of the hospital.

NEURALPATHOLOGY

A systematic course in the pathological anatomy of mental and nervous disorders was given by Doctor Barrett and Dr. Adeline Gurd, pathologist at the psychopathic hospital. This course covered 14 periods of two hours each. The schedule followed in this course was as follows:

1. Embryological development of the central nervous system. Surface topography of the brain.

2. Study of gross fiber arrangements, and ganglia of brain.

3. Histology of the nerve cell, nerve fiber, neuroglia and cortical architecture.

4. Histoloy of the spinal cord.

5. Neuronic arrangements of the nervous system. Fiber paths.

6. Localization of nervous function. Correlation of structure and function. Diaschisis. Theoretical consideration of aphasia and apraxia.

7. General pathology of the nervous system. Malformations. Diseases of the membranes of the nervous system. Pathological changes in nerve cells. Pathological changes in nerve fibers. Secondary degeneration.


34

8. Inflammation, repair, and reactive processes in the nervous system.

9. Syphilis of the nervous system. Gummatous formations. Meningitis. Vascular lesions. Histological process of general paralysis.

10. Circulatory disorders of the nervous system. Arteriosclerosis. Haemorrhagic softening.

11. Tumors of the nervous system.

12. Pathology of the spinal cord. Myelitis. Poliomyelitis. Progressive muscular atrophy. Amyotrophic lateral sclerosis.

13. Tabes. Friedreich's ataxia.

14. Pernicious anemia. Multiple sclerosis. Syringomyelia. Hydromyelia. Peripheral neuritis.

NEUROLOGY

The instruction in neurology was given by Dr. Carl D. Camp, associate professor of nervous diseases in the University of Michigan Medical School, in the neurologic wards of the general hospital.

The course in neurology was divided into three parts:

A. A lecture course designed to cover the subjects systematically.

B. Clinical demonstrations in which the officer was assigned to a case and allowed one hour to examine, his examination and conclusion being criticized by the instructor before the whole section, and free discussion was encouraged.

C. A series of formal clinics in neurology, the same as given to the senior medical students in the University of Michigan, with special emphasis on the military aspects of the cases under discussion.

OPHTHALMOLOGY

Instruction in this subject was given by Dr. George Slocum, instructor of ophthalmology in the Medical School of the University of Michigan. The subjects covered were as follows:

A

1. A review of the anatomy of the eye as an optical instrument.

2. Physiology of the accommodation and physiologic optics.

3. Anatomy and nerve supply and physiology of the eye muscles, with binocular vision and fusion, and including the deep origin, relation, and course of the third, fourth, and sixth nerves.

4. Muscular anomalies such as manifest and latent spastic strabismus, including heterophoria.

5. Diplopia and extraocular paralysis and nystagmus.

6. Nerve supply and physiology of the pupillary reflexes including miosis, mydriasis, hippus, and Argyle-Robertson pupil.

7. Anatomy and physiology of the retina, optic nerve, chiasm, primary visual ganglia, optic tracts and cortical visual centers.

8. Mechanism of production of choked disc and significance.

The foregoing subjects were taught with the aid of drawings, specimens, and anatomical models.

B

1. Diagnosis of optic neuroses and malingering.

2. The eye manifestations of wounds of the motor and sensory nerve of the eye and of the optic nerve, tracts, radiations, and centers.

3. Visual fields and hemiopia.

4. Eye symptoms produced by intracranial lesions with particular reference to trauma.

5. Eye symptoms of brain tumor, meningitis, multiple sclerosis, myelitis, locomotor ataxia, superior polioencephalitis, general paralysis, exophthalmic goiter, including the various signs associated with exophthalmic goiter, chorea, migraine, and herpes zoster of the eye.


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OPHTHALMOSCOPY

1. Direct and indirect methods, including examination of the ocular media with the ophthalmoscope.

2. Ophthalmoscopic appearance of the fundus and the diagnosis of syphilitic, albuminuric, diabetic, leukemic lesions of the fundus and other lesions of the fundus dependent upon general diseases.

3. Differential diagnosis of ocular lesions of the choroid, retina, and the optic nerve with especial reference to their differentiation from those lesions associated with general diseases.

4. Ophthalmoscopic appearance and diagnosis of glaucoma.

Throughout the whole course from one-third to one-half of the time was devoted to the study of cases with the ophthalmoscope with demonstration of the ophthalmic changes peculiar to ocular and general diseases, with especial reference to their practical differentiation.

OTOLOGY

A course of lectures and demonstrations of disorders of the ear in their neurological relations was given by Dr. Carl Furstenberg, instructor of otolaryngology in the medical school. These were given once each week for two hours. The subjects covered were:

1. Functional examination of the internal ear. Disorders of the cochlear portion of the eighth nerve. Vestibular nystagmus.

2. Tests for detecting simulation of deafness.

3. Diseases of the internal ear. Ménière's disease. Arteriosclerosis of the internal ear. Injuries to the internal ear. Syphilis of the internal ear. Hysterical deafness. Occupational deafness.

SEROLOGY

This course was given by Dr. Sobei Ide, serologist to the hospital, and included:

1. Technique of lumbar puncture.

2. Clinical diagnosis of the pathology of the cerebrospinal fluid, Wassermann and gold solution tests.

There were assigned to the Ann Arbor course 78 medical officers. In general it seemed that the plan followed worked out quite satisfactorily. The chief difficulty encountered was the marked difference in knowledge and neuropsychiatric experience for such special training in those assigned to the course. While a considerable number had been actively engaged at some previous time in neuropsychiatric practice, others had no more qualifications for this special training than those of the general practitioner. There was, however, an earnest interest shown by all in attendance and the comments made later by those who had been in active service definitely showed that the plan followed was of great value.

The student officers ordered to the neuropsychiatric schools were on duty status. Between two and three hundred were given this opportunity of acquiring or perfecting neuropsychiatric knowledge.14

ENLISTED PERSONNEL

The enlisted personnel for the care of nervous and mental cases were made up, as stated, as far as possible from attendants who had had experience in State hospitals. They were assigned to the division of neurology and psychiatry, in some cases by orders, when already enlisted, and in others, by induction into the service, and were sent first, as far as possible, to a training camp.

The shortage of enlisted men experienced in the ward care of mental cases, due in part to the exigencies of the selective service draft, which diverted many such men to other branches of the service, and also to the pressing need for attendants in civilian hospitals for the insane, produced a situation which could


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be met only by the utilization of enlisted men of the Medical Department who were not trained in neuropsychiatric work, and in many cases were without hospital experience of any kind. Whenever possible, these men were sent to various centers for a period of training before assignment to duty in neuropsychiatric services.

Conditional to some extent upon the varying supply of special and general hospital personnel, immediate nursing needs, and uncertain time quantities, the training courses gave the attendant an idea of what was expected of him in later service and added new things to his stock in trade. They also allowed a report upon each individual's personality and training to go in to the Surgeon General's Office; on the basis of these reports, groups were selected to man other neuropsychiatric services at home or abroad-groups which had their preliminary adjustment and which could be fitted out with noncommissioned officers who knew them.

PSYCHIATRIC AIDES

The advisability of placing specially trained psychiatric social workers in military hospitals for soldiers suffering from mental and nervous diseases was considered informally, shortly after the outbreak of the war, by the Surgeon General and the National Committee for Mental Hygiene. Many neuropsychiatrists and social workers, who had followed the progress of the mental hygiene movement in this country, had watched with interest the rapidly changing events in the evolution of the comparatively new field of social psychiatry, and especially the work accomplished by social workers at the neurological and psychiatric clinics of general hospitals and at institutions for nervous and mental diseases. It was realized that in a few years a new group of social workers had developed who served ably as assistants to neuropsychiatrists in the various phases of their work. They secured personal and family histories from the patients, relatives, and others, which proved of considerable value to the physicians in the diagnosis of difficult mental conditions; and their personal work in assisting the patients in the adjustment of their social difficulties supplemented the therapeutic treatment of the physicians and thereby achieved more effective results. Their services were appreciated by the administrative departments of the hospitals which formerly had been called upon to perform duties of an essentially social-service character. It was believed, therefore, that there would be as great a need for the service of these workers in the military hospitals as in the civilian hospitals, and that psychiatric social workers could be used as aides to the psychiatrists, to relieve them of duties which could be effectively dealt with by individuals, not physicians, trained along the lines of social psychiatry. The work was still in the experimental stage of its development at the time of our entrance into the war, but the increasing demand, by neuropsychiatrists, hospital executives, and State welfare departments, for social workers experienced in dealing with nervous and mental cases showed that these workers were making a definite contribution in this field of medicine, and were finding a permanent place in the hospital régime.


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It was decided, therefore, to arrange for the appointment of a number of psychiatric social workers (psychiatric aides) to be placed in reconstruction hospitals under the jurisdiction of the division of neurology and psychiatry of the Surgeon General's Office.12 Unfortunately the pressure of work in the Surgeon General's Office at this time (1917) prevented an immediate decision regarding the matter, and not until the early spring of 1918 was the subject taken under official consideration.

In the meantime, in order to prepare for the increasing need for such workers in anticipation of the early return of mental and nervous cases from France, and to be ready for the work of rehabilitation and readjustment, plans were formulated for courses of training in psychiatric social work. For several years before the war there had been a demand for psychiatric social workers that could by no means be met. Yet no training courses existed, except an apprentice training given by the social service of the Boston Psychopathic Hospital to half a dozen students at a time. The director of this hospitald and the chief of its social service, believing that soldiers suffering from war neuroses would require the same treatment as civilian patients, planned to give an emergency training course at the hospital. A large number of students could be admitted by the use of other institutions for practice work. The permanent charity fund of Boston contributed a sum of money to make the course possible. By chance it was learned that Smith College wished to use its equipment during the summer for some educational war work, and was already considering a course for some type of mental hygiene worker. At the same time the National Committee for Mental Hygiene, facing the problem involved in the rehabilitation of returned soldiers suffering from nervous and mental disorders, was convinced of the need of training lay workers to assist physicians in the care of neuropsychiatric cases, and a committee was appointed to consider the matter.

A combination with the Boston group was effected, by which the training course for psychiatric social workers was given by Smith College under the auspices of a committee of psychiatrists appointed by the National Committee for Mental Hygiene, with the director of the Boston Psychopathic Hospital as chairman.15

Thus was the first course for the training of psychiatric social workers established in this country. Within a month 63 students assembled at Smith College to take the course. They represented 21 States and 20 colleges. Thirty-eight previously had been engaged in other occupations, 12 as teachers, 16 as social workers, 3 as librarians, 3 as secretaries, and 4 in miscellaneous forms of work. The students for training were distributed among four cities, Baltimore, Philadelphia, New York, and Boston, for six months of practical case work. The term of practice work was made as short as possible because the graduates would be needed in the military hospitals even before they were ready.

The object of the course was to prepare social workers to perform three functions, if necessary, or any one of the three that might be required: (1) To secure the social history essential to medical diagnosis by interviews or correspondence with informants, or by interviewing patients; (2) to assist the physician in psychotherapy by such means as encouragement, explanation, reeducation;

dThe late Dr. Elmer E. Southard.


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(3) to promote the social adjustment of patients upon discharge. The technique of social case work, taught by lecture and practice, was the basis of the course. It was recognized that an eight months' course in a subject dealing with something so complex as human personality must be very superficial at best. But the aim was to drill the student in the fundamental habits of mind required for future development in her work, a professional attitude, adaptability, the habit of observation, and the psychiatric point of view.

The graduates of this first course for the most part carried out their purpose, working in military hospitals until these hospitals were taken over by the United States Public Health Service, when they continued in them under the American Red Cross. Some of them took up work in State hospitals, in social agencies, and in mental hygiene societies.

REFERENCES

(1) Semiannual report, Division of Neurology and Psychiatry, S. G. O., January 2, 1918. On file, Record Room, S. G. O., Weekly Report File.

(2) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1080-83.

(3) Personnel Files, Personnel Division, S. G. O.

(4) Circular Memorandum, from the Surgeon General, U. S. Army (on recognition of sections representing specialists), October -, 1917.

(5) Confidential Order No. 128, W. D., November 22, 1917, detailing Major Thomas W. Salmon, M. R. C., to duty overseas. On file, Personnel Division, S. G. O. (Personal Report File).

(6) Report of the consultant in psychiatry to the chief surgeon, A. E. F., by Col. Thomas W. Salmon, M. C., undated. On file, Historical Division, S. G. O.

(7) Letter from The Adjutant General to the Surgeon General, U. S. Army, January 12, 1918. Subject: Assignment of neurologists to tactical divisions. On file, Record Room, S. G. O., 210.3 (Assignment).

(8) Annual Report of the Surgeon General, U. S. Army, 1918, 372.

(9) Circular letter to division surgeons from the Surgeon General, January 25, 1918. Subject: The duties of the divisional psychiatrists.

(10) Letter from Frankwood E. Williams, National Committee for Mental Hygiene, to Miss Dora E. Thompson, Supt., Army Nurse Corps, July 25, 1917. Subject: Miss Adelle S. Posten. Copy on file, Historical Division, S. G. O.

(11) G. O. No. 58, W. D., June 22, 1918.

(12) Assignment of psychiatric aides. On file, Record Room, S. G. O., 231 (Reconstruction Aides).

(13) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1079.

(14) Semiannual report, Division of Neurology and Psychiatry, January 2, 1918. On file, Record Room, S. G. O. Also: Correspondence. On file, Record Room, S. G. O., 353 (Training Neuropsychiatrists) (Boston, Mass., New York City, N. Y., Philadelphia, Pa., Baltimore, Md., Washington, D. C., Ann Arbor, Mich., Talmage, Calif. (F).)

(15) Release to the press, June 4, 1918, concerning War Emergency Training School for Workers to assist Soldiers with Nervous and Mental Diseases, by Frankwood E. Williams, M. D., Associate Medical Director, the National Committee for Mental Hygiene. On file, Historical Division, S. G. O.

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