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Section I, Chapter III

Table of Contents

CHAPTER III

PROVISIONS FOR CARE OF MENTAL AND NERVOUS CASES

With an army as small and as scattered as ours was before the World War, it was difficult to make proper provisions for the care of the insane. The actual number of cases requiring prolonged treatment at the hands of the Government was not large, not exceeding 200 annually.1 These cases occurred at widely separated points. Native soldiers in our island possessions who became insane were cared for in local institutions, but for others the only hospital facilities provided were at St. Elizabeths Hospital in Washington, D. C. In the United States the only wards maintained at all for the insane in the military service, with the exception of a few beds in the basement of Walter Reed General Hospital, were 50 beds in a building, which also held prisoners, at the Letterman General Hospital, San Francisco,2 and in these 50 beds were collected cases from the Western Department, and especially from the Philippines.

The ultimate destination of all cases in which recovery was not prompt was St. Elizabeths,3 and during the long interval which was required for commanding officers to obtain the necessary authority for transfer, the patients were kept in such quarters as were available at the place of their mental breakdown. Some, as long as they could be regarded as harmless, were retained in the wards of the local hospital, but more frequently they were lodged in prison wards. In certain places portable steel cages were utilized for patients regarded as particularly dangerous. The practical result of this whole system was that weeks, sometimes months, elapsed before efficacious treatment could be employed.

The great increase of the military forces for the World War required a corresponding enlargement of the provisions for the care of the insane. The larger Army demanded many receiving hospitals, or wards, speedier methods of disposal of cases which were not a legitimate charge on the Federal Government, and the establishment of rational and prompt means of treatment for the patients whom the Army would be called upon to maintain. Such a program required changes in the methods of military hospitalization, in respect of admissions to civil hospitals, and in those Army regulations which controlled the evacuation and final disposal of the insane.

IN BASE HOSPITALS

NEUROPSYCHIATRIC WARDS

During the World War, provision was made for neuropsychiatric wards in all camp, cantonment, and department base hospitals. The first plans drawn by the War Department for a building for nervous and mental patients were labeled "Isolation-insane."4 Later, wards in which these patients were cared for were officially designated "Psychiatric wards."a The transition from one to the other was more than a mere change in names.

aSee Vol. V p. 69, for plans of this ward.


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"Isolation-insane" was all the term implies in misunderstanding and professional discouragement and indifference. "Psychiatric ward," on the other hand, approximated, at least, and in some places largely attained, what the term implies in hospitalization-understanding and professional hope and activity. The "isolation-insane" building was a long rectangular building with windows and doors heavily barred on the outside and heavily screened on the inside, the interior broken into small cell-like structures stoutly maintained.5 The psychiatric wards, as will be more fully described later, were open, bright, airy wards, in some hospitals, without bars or mesh of any kind. The "isolation-insane" building was built in connection with the base hospital in a few of the early cantonments.6 The psychiatric ward was built in the majority of the cantonments, and these early wards represent the first step in the transition that took place in the Army. It was considered that each cantonment would need a special ward for nervous and mental patients, and plans designed by the National Committee for Mental Hygiene for psychiatric units of 30 beds were adopted for the cantonment base hospitals.7

The following equipment was proposed and approved for these units:7

Electrical:

1 No. 7 galvanic, Faradic, and sinusoidal wall cabinet, oak or mahogany, with meter, for direct current, 35 inches high, 22 inches wide, 11 inches deep, with the following accessories:

1 pair No. 649 green and red cords.
1 No. 756 plain handle.
1 No. 757 interrupting handle, style "A."
1 No. 1635 asbestos pad electrode, 5 by 7   inches.
2 No. 728 round asbestos disk electrodes.

1 motor generator set, ampere, 110 volts, for operating wall cabinet on alternating current.
1 Excell high-frequency machine, with hot wire meter, oak or mahogany finish (no accessories).
1 rotary converter for operating Excell high-frequency machine on the direct current.
1 Excell high-frequency portable machine, 10 inches high, 14 inches wide, 10 inches deep (no accessories).
1 therapeutic lamp with plug and inlet cable.
2 pounds lead foil, about 0.008 mm.
2 lengths of 5 feet each No. 653 heavy insulation high-frequency cord.
1 improved auto-condensation chair pad.
1 fulguration handle with set of three electrodes.
1 surface vacuum electrode.
1 vacuum electrode handle and sleeve cap.

Hydrotherapeutic:

1 combination douche apparatus, No. P-2281, without steam connection.
2 immersion baths, No. P-2108.
1 electric cabinet, type B.

Psychological:

1 steel tape.
1 form board.
1 imbecile tests (Knox)
1 picture memory test.
1 pictorial completion test.
1 construction puzzle A (Healy).
1 construction puzzle B (Healy).
1 aussage test.
1 500-learning test.
1 McCalliss test cards.
1 stop watch.
1 material for Binet-Simon test.
     500 record blanks for scoring.
1 material for Yerkes point scale.
     500 record blanks.

Diagnostic:

2 reflex hammers.
2 stethoscopes (A/4832).
2 stethoscopes (A/4800).
1 blood pressure instrument.
1 hand centrifuge.
1 dozen lumbar puncture needles.
1 Zappaert-Ewing blood pressure counting chamber.
2 red blood counting pipettes.
2 white blood counting pipettes.
1 outfit for taking Wassermann blood specimens.
2 urinometers.
1 head mirror.
1 head band.
1 microscope.
1 Fuchs-Rosenthal's counting chamber.
2 white blood counting pipettes for spinal fluid.
6 gross slides, 3 by 1 inch.
10 boxes cover glasses, 22 by 22 mm.
200 test tubes, 6 by 5/8 inch.
2 alcohol lamps.
1 dozen urine sedimentation glasses.
1 opthalmoscope with electric battery attached.
2 pupil lights.

Miscellaneous:

1 salvarsan administration outfit.
Canvas camisoles with long sleeves.
Protection sheets of canvas.
Stretcher cots for transporting short distances the disturbed and delirious patients.
Leather straps with buckles, 5 feet (3 straps to each cot).
Tube-feeding outfit.
Rubber sheets.
Fountain syringe.
Bed pans and hand basins.
Physician's emergency handbag.
Hypodermic syringe.
Hypodermic tablets of morphia, strychnia, hyoscine hydrobromate, paraldehyde, magnesium sulphate, cascara, compound carthartic pills.


This new ward was so arranged as to care for any type of patient that might be admitted-one portion, for the much disturbed, equipped with continuous baths, one for the semidisturbed, and another for the convalescent or quiet patients. Each portion was separated from the others; small dormitories were provided in each with rooms for individual patients in the disturbed section. It was intended that a medium iron-wire mesh should be used on the windows of these wards and not bars; through an inadvertence, however, some of the early building plans issued by the War Department called for bars.4 The situation of the local psychiatric officers with proper ideas as to physical standards was thereby made more difficult and in consequence the physical standards of the wards varied, depending upon the standards of the local officer himself, and his ability to convince his commanding officer that hospitals and not jails were being built. For a lieutenant or captain new to military service to convince a commanding officer of the "isolation-insane" school was no small task. But many of them succeeded. There were to be found, therefore, wards heavily barred, wards with bars confined to that part of the building used for disturbed patients, with mesh for the rest of the ward, wards with mesh for the disturbed portion and neither bars nor mesh for the part used by convalescent patients.

While the physical standards of the wards varied from camp to camp, there existed almost throughout a uniformly high standard of care and treatment. Although some of the wards appeared more like jails than hospitals on the outside, they were hospitals in fact on the inside.

The neuropsychiatric wards of the base hospital served a useful purpose. During the early days of the World War, they were used chiefly for the examination and observation of recruits referred by the division psychiatrist. Later, they served the mental health needs of the various commands occupying the camps at different times. Since it was the understanding from the beginning that the insane would be discharged from the Army as quickly as possible, the neuropsychiatric wards were intended for temporary care only. Quite frequently; however, it was found that patients had to be retained in the wards


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for a considerable length of time, due to various unforeseen circumstances. These wards made expert care and treatment immediately available to any soldier becoming ill in the camp. With no more formality than obtained in entrance to the medical or surgical wards, patients could be brought to the ward especially provided for them. Patients who developed nervous or mental symptoms in other wards were transferred without formality to the special wards. Soldiers who, because of a nervous or mental condition, ran counter to the military laws and arrived at the guardhouse were transferred to the special wards. General prisoners, about whose mental condition there was question, were sent to the wards for observation. Recruits found unfit for military service because of mental disease and awaiting discharge were cared for in the neuropsychiatric wards until such time as proper arrangements could be made for their return home. Up to the time of the beginning of the armistice, the neuropsychiatric wards of the base hospitals cared for about 28,000 patients.8

IN GENERAL HOSPITALS

The neuropsychiatric wards of the general hospitals of the Army were established in order to relieve congestion in the neuropsychiatric wards of the base hospitals. It had been thought that the neuropsychiatric wards of the base hospitals would be adequate to care for all cases of nervous or mental disease arising in the camps. It was soon found, however, that the rate of admission was such and the delays incident to transfer and discharge so great that further provision would be necessary. It was difficult to maintain an adequate personnel with the requisite experience at so many small units. It was decided, therefore, to use the base hospital wards as clearing houses and for emergency treatment only and to establish additional neuropsychiatric centers convenient to the centers of military population to which patients could be transferred for longer periods of treatment.

Two methods for providing these additional facilities were considered: (1) The establishment of special neuropsychiatric hospitals; (2) the establishment of neuropsychiatric wards in connection with the Army general hospitals. Both plans obviously had advantages and disadvantages. It would have been easier, no doubt, to staff special hospitals more satisfactorily, as there needed to be assigned to them only officers with neuropsychiatric training. This would have reduced the friction and misunderstanding likely to arise when superior officers were unfamiliar with the professional problems of their juniors. A greater freedom, probably, might have been permitted patients; closer supervision and direction to the immediate needs of the patients might have been had of the local machinery of reconstruction. On the other hand, had special hospitals alone been provided, professional isolation would have been increased and emphasized.

The greatest obstacle to neuropsychiatry in both civil and military practice has been the barrier that tends to separate nervous and mental diseases from all other diseases, and it was thought by some that, in so far as the Military Establishment was concerned, the greatest good, both to the practice of neuropsychiatry and to the patients who were dependent upon it, would be accom-


43

plished if a determined effort were made to break through this barrier and to place the mental patient on a par with patients incapacitated by reason of other diseases. Not until commanding officers and others in authority realized that their responsibilities for the medical, the surgical, and the mental cases were the same was it considered possible to accomplish those things of which the well-trained neuropsychiatric officer is capable. It was thought that the establishment of neuropsychiatric wards in the general hospitals would emphasize this responsibility.

Such a course, however, was not without its dangers. As a part of a general hospital the neuropsychiatric ward is a section under internal medicine, and the chief of the medical service has supervision over the neuropsychiatric ward. The success of the ward, therefore, is in part dependent upon the attitude of this officer and the ability of the chief of the neuropsychiatric section to cope with the double opposition that might be met in this officer and the commanding officer. As a matter of fact, this plan of hospital organization was a hindrance, in some instances, to the proper conduct of the neuropsychiatric work. On the whole, however, it did not cause the difficulty that might have been expected. In most hospitals the chief of the medical service assumed but a nominal oversight of the neuropsychiatric wards and placed full responsibility in the hands of the chief of the neuropsychiatric section.

It is interesting to record, in this connection, that the officer frequently quickest to appreciate the service of the neuropsychiatric officer and to give him heartiest support was the line officer. Officers of the Medical Department of the Regular Army also, in most instances, gave their support. The officers with whom the neuropsychiatrists had most frequent difficulties were the officers of the Medical Reserve Corps, commissioned from the civil medical profession. The significance of this observation lay in the sidelight it threw upon the teaching of neuropsychiatry in the American medical schools. The line officer frequently was faced with problems in personality and conduct that frankly he did not understand. He turned gladly, therefore, to the neuropsychiatric officer when he found that that officer could be of assistance to him. The officers of the Medical Department of the Regular Army for a number of years have been given a systematic course in neuropsychiatry. The larger knowledge manifested itself in a quicker understanding and appreciation of the problems of the neuropsychiatrists. The greater number of the officers in the Medical Reserve Corps, however, had had practically no instruction in neuropsychiatry. In most instances their school instruction had consisted of a few lectures, together with a visit to a neighboring institution, where a few striking and bizarre cases of chronic mental disease had been demonstrated to them. Their experience in practice largely had been limited to the sterile forms of legal commitment. Many medical officers, however, were as frank as line officers in admitting their lack of understanding of nervous and mental patients and spent many hours, when possible, in the wards studying patients in an earnest effort to inform themselves upon a subject in which they found a growing interest, and a subject of increasing value to them. Aside from the fact that the establishment of neuropsychiatric wards in the general hospital would be an important step in breaking down the barrier that tends to isolate mental patients, and that through the presence of these wards the medical officer would come


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to a better understanding of the mental patient, the standards, methods of treatment, and possibilities of the modern neuropsychiatric clinic, it was realized that expert care would be available for patients on other wards who were showing nervous and mental symptoms, and that, on the other hand, expert consultation in other fields would be available to the neuropsychiatrists.

The plan adopted, therefore, was that of special wards in the general hospitals, and five general hospitals suitably situated geographically were selected for the purpose:9 The Walter Reed General Hospital, Washington, D. C.; United States Army General Hospital No. 6, Fort McPherson, Ga.; United States Army Base Hospital, Fort Sam Houston, Tex.; United States Army General Hospital No. 26, Fort Des Moines, Iowa; and the Letterman General Hospital, San Francisco, Calif. United States Army General Hospital No. 4, Fort Porter, N. Y., was a special psychiatric hospital opened especially for mental patients returning from overseas, although it received also, at times, patients from neighboring camps.9 United States Army General Hospital No. 13, Dansville, N. Y., and United States Army General Hospital No. 34, East Norfolk, Mass., were also neuropsychiatric hospitals, but for overseas patients, as were the special wards at United States Army General Hospital No. 1, Williamsbridge, N. Y. United States Army Hospital No. 30, Plattsburg, N. Y., was established for nervous patients from overseas, although some patients were transferred there from American camps.9

Later, with the more rapid return of patients from overseas, further neuropsychiatric centers were opened in connection with United States Army General Hospital No. 25, Fort Benjamin Harrison, Ind., and United States Army General Hospital No. 28, Fort Sheridan, Ill.9 There was also a single neuropsychiatric ward at United States Army General Hospital No. 2, Fort McHenry, Baltimore, Md.9 The original wards, however, and those designed to serve as a reservoir for the neuropsychiatric wards of the camp base hospitals, were those at Walter Reed, Fort McPherson, Fort Sam Houston, Fort Des Moines, and the Letterman General Hospital.

Patients, whether officers or enlisted men, who presented symptoms of mental disease were transferred to these centers for care and treatment in the same manner as other patients. Such transfers were effected as follows: The patient whose symptoms were considered as requiring special observation and treatment was ordered for that purpose to the hospital designated. The orders were obtained from The Adjutant General through the Surgeon General, having been first initiated by the commanding officer at the point from which the patient was removed. Thus the patient, whether officer or private, with mental symptoms, was transferred not as an insane person, but as any other patient. Except in violent or essentially incurable cases the patients were retained in these centers for a period of time not to exceed four months.b For the purpose of preventing the reenlistment of soldiers who had suffered from psychoses, it was recommended to the commanding officers of the neuropsychiatric centers to which mental cases were transferred that the fact be noted on the discharge form.

bBy these means, the Army regulations concerning the disposition of the insane were not resorted to until a reasonable time of observation had elapsed. This subject is discussed further in Chap. VII.


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By relieving base hospitals of mental cases in this manner, congestion in the general medical services was lessened and a higher standard of care, with a proportionate increase in the ratio and speed of recoveries, was obtained. There was effected an economy of personnel, for even if it had been possible to supply base hospitals generally with a sufficient number of psychiatrists to treat mental cases, it would have been extravagant in the extreme. With the speedy evacuation of all cases presenting mental symptoms, it was possible for the neuropsychiatric work in a base hospital to be performed by one energetic and competent medical officer. As things turned out this arrangement was imperative, for, with the limited number of neuropsychiatrists available, the need of these officers at other points in the medical service did not permit the detail usually of more than one at a base hospital.

The suddenness of the armistice brought about a great change in many of the arrangements which had been made for the treatment of nervous cases. Except for a geographical rearrangement of hospitals with reference to the homes of patients, there was no change in the plan of care for mental cases. It was found, however, as will be discussed in greater detail in the following pages, that war neuroses had ceased to exist as a problem, in that the number of cases from the American Expeditionary Forces dwindled, and those under treatment in this country made rapid recoveries. The cases which appeared in the home camps were less influenced by the change in the military situation. At Plattsburg Barracks, N. Y., where a special hospital was established for war neuroses, cases were put back on duty status faster than they were received, and consequently plans for another hospital of 1,000 beds at Carlisle Barracks, Pa., were abandoned.

The practical end of the war brought into prominence the advisability, imperfectly realized before, of sending patients who were to undergo continued treatment to hospitals in the immediate vicinity of their homes. This required a rearrangement of hospital facilities for neuropsychiatric cases, especially with regard to the cases of epilepsy, and injuries of the peripheral nerves. It was planned, moreover, that cases of this character, as well as the insane, who required care after discharge from the Army, would be provided for in the vicinity of their homes by the Bureau of War Risk Insurance.10

CLASSIFICATION AND DISTRIBUTION OF OVERSEAS PATIENTS

The importance of accurate clinical diagnosis as a basis for the classification and distribution of patients can not be insisted upon too emphatically as an important feature of treatment. From the dressing stations and field hospitals at the front, through the base sections and into the home stations, this principle is cardinal to successful functioning of the medical department of an army.

In this country the two most important sorting points were the ports of debarkation at Hoboken, N. J., and at Newport News, Va., and of all the classes of cases returned, perhaps none presented such perplexing clinical problems as the nervous and mental cases. Many, if not most, of these patients were returned without records and without notes, the only indicating sign to the examiners who met them at the ports being a diagnosis written out or initialed on the field card. Then, in the cases of the psychoses and neuroses, a change


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had often come over the patient since he was last examined by a medical officer, so that what may have been a correct diagnosis on leaving France was no longer correct, on arrival. Also, because of the refusal of the Navy, which had charge of all patients at sea, to transport large numbers of mental cases on any one ship, medical officers stationed at the French ports were forced, in order to evacuate their hospitals, to mark some patients as "N" or nervous, when in reality they were mild mental cases.

To insure speedy distribution of the neuropsychiatric cases returned from abroad, psychiatrists were assigned to the ports of debarkation at Hoboken and Newport News.11 Cases were classified immediately upon arrival and evacuated to the proper hospitals as soon as possible.11 The following hospitals were designated by the Surgeon General on December 9, 1918, for overseas mental and nervous cases:12

EPILEPTICS AND MENTAL DEFECTIVES

Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
General Hospital No. 1, Williamsbridge, N. Y.
General Hospital No. 6, Fort McPherson, Ga.
General Hospital No. 25, Fort Benjamin Harrison, Ind.
General Hospital No. 26, Fort Des Moines, Iowa.
General Hospital No. 28, Fort Sheridan, Ill.
General Hospital No. 29, Fort Snelling, Minn.
Base Hospital, Fort Sam Houston, Tex.

INSANE

General Hospital No. 1, Williamsbridge, N. Y.
Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
General Hospital No. 4, Fort Porter, N. Y.
General Hospital No. 6, Fort McPherson, Ga.
General Hospital No. 13, Dansville, N. Y.
General Hospital No. 25, Fort Benjamin Harrison, Ind.
General Hospital No. 26, Fort Des Moines, Iowa.
General Hospital No. 28, Fort Sheridan, Ill.
General Hospital No. 34, East Norfolk, Mass.
Base Hospital, Fort Sam Houston, Tex.

NEUROSES, FUNCTIONAL

General Hospital No. 30, Plattsburg Barracks, N. Y.

DRUG ADDICTS AND INEBRIATES

General Hospital No. 31, Carlisle, Pa.

With the exception of General Hospitals Nos. 4, 30, and 34, these hospitals were chosen for the establishment of special neuropsychiatric services, first, because they would reduce transportation to the minimum and at the same time give wide geographical distribution; second, because they would enable all cases to be treated in the vicinity of their homes; third, this plan made for the most economical utilization of the existing facilities.9


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General Hospital No. 4 was for a time devoted almost entirely to mental cases returned from France.13 As the bed capacity was soon taken up, it was necessary for General Hospitals Nos. 13 and 34 to be taken over for the care of insane cases. As the number of cases returned from abroad decreased and the population of these hospitals diminished, all the cases were transferred to the Soldiers' Home for Disabled Volunteer Soldiers at Hampton, Va., which previously had been Debarkation Hospital No. 51. On May 1, 1919, it was made General Hospital No. 43, for the care and treatment of mental cases. This hospital was used also as a classification hospital for other nervous conditions received from overseas through the port of Newport News.14 At the time of the transfer of these cases, General Hospitals Nos. 13 and 34 were closed.13

There was also a neuropsychiatric service in the embarkation hospital at Newport News.14 This service showed a steady increase in mental cases from the local camps from the beginning, augmented by the return of overseas cases.

Eventually all mental cases from the American Expeditionary Forces were returned through the port of Newport News and taken directly to the hospital at Hampton, without long travel and with economy of personnel, as the patients were then treated in one hospital instead of three.13 The procedure followed is given below.14

PORT OF EMBARKATION, NEWPORT NEWS, VA.

After November 11, 1918, emphasis was placed upon the reception of neuropsychiatric cases from France. This had long been a function of the embarkation hospital where patients were received in small groups; of 100 admissions to the neuropsychiatric ward in August, 1918, for instance, 30 were from overseas. By September 4, 1918, the accommodations at this hospital (for 38 insane and 60 nervous patients) were manifestly insufficient even for the immediate future. At this time it was recommended to the surgeon that 180 more beds be provided, this special need to be merged in the general need of a large debarkation hospital. The old Soldiers' Home at Hampton, which was transferred to the War Department by act of Congress, when opened as Debarkation Hospital No. 51, on November 17, 1918, contained 39 beds for the care of acute psychoses and 110 beds for neuroses. In January, 1919, accommodations for 50 more psychoses were provided and 2 wards of 60 beds each were nearly ready.

Before these new accommodations were available the U. S. S. Aeolus docked, on October 13, with 243 cases, divided as follows: Psychoses, 127; feeble-minded, 18; epileptics, 55; neuroses, 39; and 3 cases of organic disease of the nervous system. No warning was given; the force of attendants at embarkation hospital was crippled because of the influenza epidemic; other ships were due. Under these circumstances special trains were requested to carry these patients directly inland, and after a day's wait the psychoses and mental defectives were sent to Fort McPherson, Ga., and the others to Plattsburg, N. Y. Two patients hung themselves on the ship, one on the last day of the voyage and one while the transfer from boat to train was going on. The ship of necessity carried these patients between decks without lights from sunset to sunrise. The train trips were made without incident.

When the debarkation hospital was opened on November 17, its first large group of patients was a convoy of 300 nervous and mental cases. Notice had been sent ahead and a psychiatrist had gone out to meet the ship and classify the patients, but unfortunately the ship did not stop to take on a pilot. At the pier, a hospital boat was brought alongside, received the patients, and landed them at a dock inside the hospital grounds. One man dove overboard but was rescued unharmed. These patients were successfully transferred to interior hospitals.


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Subsequently other ships, each carrying two to three hundred mental cases, were unloaded and a procedure developed which gave very satisfactory results in the transfer of these patients from ship to hospital wards. In brief this plan was as follows:

(1) On advance information the neuropsychiatrist, with a detail of experienced enlisted men, reported at the pier as adviser to the medical superintendent of transports. (2) The medical officer and noncommissioned officer in charge of the detail boarded the ship and secured all possible information regarding the behavior of the patients from the ship's surgeon and attendants. (3) Quarters on the hospital boat or the routes to the ambulances were inspected and attendants placed at strategic points, gangways, ports, stairways. (4) Patients from whom trouble could be expected were each placed in charge of an attendant and landed first. (5) Milder mental cases were grouped and taken next with several attendants. (6) At the receiving hospital patients were taken off in the same order and thus the more disturbed could be placed in the most protected ward and the patients who needed no special care could be admitted to the general medical wards when necessary.

The custom of the hospitals with regard to diagnosis of general cases was followed. This meant the filling in before 9 a. m. on the day following admission of a "Classification for distribution" form, of which a synopsis is here given:

1-2. Name and identification.
    3. Diagnosis
    4. Classed as- 
        Psychoneurosis.
        Epilepsy.
        Psychosis.
        Mental defect.
        Convalescent.
        Peripheral nerve injury.
        Other medical groups; other surgical groups.
    5. Ambulatory or bed patients.
    6. Individual attendant     Special care of litter.
    7. Recommendations

It was obvious that the future care of patients was dependent to a considerable extent upon the accuracy with which the diagnosis was made prior to entrainment for interior hospitals. If conditions were such as to limit the time which the neuropsychiatrist might expend in making the diagnosis the ratio of accuracy would be lowered. After numerous experiences the neuropsychiatrist of the port arrived at the conclusion that while, theoretically, the interests of the patient and the service alike would be best served by allowing more time for making the investigations upon which an accurate diagnosis must rest it was impracticable to secure more time without greatly interfering with general evacuation operations. In other words, a port of debarkation, by its very nature can not become a place for scientific niceties of diagnosis. Therefore an endeavor was made to combine speed with accuracy. That this succeeded is well illustrated by the experience and experiments described below.

A large group (300) was landed at the hospital dock at 6 p. m., whence they were enrolled and sent to the ward with Form 55a made out. The ward surgeons assigned each man to a bed and entered the number of the bed on the 55a slip. Supper was then served. Then four men at a time were taken, from each of the five wards, for delousing. Field cards from overseas arrived at the wards and were matched with the 55a forms, always with some discrepancies which took time to adjust. A neuropsychiatrist stationed himself at the door of each ward, called a patient, read the field card, entered a diagnosis, and checked the appropriate class.

Many diagnoses could be confirmed in a few seconds; epilepsy, for instance, by a history of convulsions antedating Army service, or undiagnosed psychosis by the presence of any delusional remnant or behavior disorder. It should be remembered that such a diagnosis had little of the significance that it had in civil life, merely meaning at the port that the psychotic was going to a hospital with the proper specialists to care for or discharge him. Therefore, when epilepsy was the term used to describe a disease characterized by convulsions which first appeared under shell fire, a change was made to psychoneurosis in order to make


49

sure that the patient would receive specialized treatment. The diagnosis "constitutional psychopathic state" covered such varied conditions that at first it seemed best to change it; later it was retained and its constituents separated by checking under classification, "psychosis, epilepsy, psychoneurosis, mental defect," according to the treatment the patient required. In questions involving mental defect, patients were referred to a psychologist for individual examination.

After diagnosis and classification had been made by a specialist, the patient took his papers to the ward surgeon who completed them. The distribution papers were then ready with the papers from other medical and surgical wards for early action the next day after admission; from them were made up the travel orders which caught the patient in a system which landed him at an interior hospital. At times patients would remain several days before entraining, and many valuable clinical notes could be entered on their field cards. Unless an injustice was being done to a soldier, it was found best not to alter his diagnosis, since this meant disarranging complicated travel orders.

Hospital trains formed a medical unit separate from the hospitals. For mental patients, however, the hospitals were asked to furnish additional neuropsychiatric attendants. The 35 enlisted men sent to the port by the section of neuropsychiatry, "to escort nervous and mental cases from the port to the general hospitals," were used here, as well as in the transfers from ship to ward and from ward to train. Berths were made without curtains and toilet rooms were specially guarded.

Efforts were made to improve this routine. Attention was first centered on the short time allowed for diagnosis in these difficult cases. As stated above, careful consideration made the neuropsychiatrists feel that no increase in time should be asked if such an increase would give mental patients second place in travel arrangements.

Next the question of discharging patients at the port was raised in an effort to help clear beds in interior hospitals. Certificates of disability for discharge were made out for 30 epileptics whose convulsions clearly antedated their enlistment and where treatment could not be expected to improve their condition. Contrary to some presuppositions, no difficulty was experienced in getting convincing histories. The result was that these patients were held about a month and then sent under escort to widely separated homes, a procedure which resulted in a multiplication of travel orders and a tying up of many Hospital Corps men in travel. The scheme was abandoned as having no advantage over immediate distribution to hospitals near homes.

PORT OF EMBARKATION, HOBOKEN, N. J.

For a time the neuropsychiatric cases received at the port of New York were debarked at Ellis Island, where they were cared for in special wards until they could be transferred to special hospitals for nervous or mental patients. The stay at Ellis Island was usually brief, the patients being transferred in the course of a very few days. Because of this brief stay, little attempt was made at treatment of cases there, though every effort was made to provide for their care and for such emergency treatment as was required. Later the Messiah Home for Children in New York City was obtained by the Surgeon General for use as a clearing hospital (as part of United States Army General Hospital No. 1) for patients arriving at the port of New York (Hoboken), and the special wards at Ellis Islands were given up.15

The neuropsychiatric service at Hoboken was established in July, 1917. A director of neuropsychiatry was appointed by the surgeon of the port of embarkation as his personal representative to direct all the neuropsychiatric activities at the port. The duties of this officer, who had for years previously had charge of the largest psychopathic reception service in the country, were as follows: (1) To advise, assist, and cooperate in the organization of a special hospital for the care and evacuation of nervous and mental cases.


50

(2) To organize and establish special wards in various hospitals within the port for the brief and temporary care of such cases. (3) To make official visits and act as consultant and to assist and advise with the commanding officers of the various hospitals in the examination, classification, and the general care of nervous and mental patients. (4) To examine and report special psychiatric cases that might arise within the port, including the mental examination of those who were charged with criminal offenses and in whom the question of mental responsibility arose. (5) To advise the personnel officer in the office of the surgeon in the assignment of medical officers having neuropsychiatric training, to various hospitals as the necessity required.

Because of the special and technical character of the work, the relation of the director to the neuropsychiatric service in the port and particularly to the special hospital, ward 55 (Messiah Home), General Hospital No. 1, had of necessity to be very intimate.

Owing to the fact that nervous and mental patients were returned in large groups, the accommodations at the special hospital (Messiah Home) proved temporarily inadequate and, at various times, many of the milder cases had to be distributed to other hospitals until evacuated, which complicated the work of the division considerably. Notwithstanding this, in a service which is fraught with danger and where accidents, injuries, abuses, and complaints are apt to be frequent, such occurrences were happily rare.

In transferring patients from ocean transports to the debarkation hospitals and from the debarkation hospitals to hospitals in the interior, patients were accompanied by attendants experienced in the transportation of mental and nervous cases. Reports of the elopement of patients and injuries received while in transit were few, and complaints as to condition of patients arriving were almost negligible.9 The following is a description of methods and equipment used in the transportation of mental patients:16

The equipment needed and the arrangements to be made for transporting mental cases will depend to a great extent on the mode of conveyance (train, automobile, steamship, etc.), the distance to be traveled, and the types of cases to be transferred. Under all circumstances, it is of first importance to provide trained attendants and nurses and to have in charge a physician experienced in the management of mental cases.

If a large body of patients is to be transferred an effort should be made to classify the cases into groups, according to the severity of the symptoms and the amount of supervision needed.

Mild and tractable cases - These may be transferred by train or ship with little difficulty if their physical condition is good, and if properly supervised by trained attendants very little restriction of their activity is necessary. In railroad cars the doors should be locked and the windows kept down, except when opened for purposes of ventilation, and then they should be guarded by attendants.

Suicidal cases - Careful watching and considerable restriction of liberty on train and ship are necessary. Actively suicidal and disturbed cases must be managed as are excited patients next referred to.

Excited and assaultive cases - Doors must be kept locked and windows closed and blocked. Wire screens over the windows (on the inside) may be used to prevent breaking of glass. Very disturbed cases should be transferred in a compartment sleeping car so that each patient has a room. In these cases canvas camisoles, with long sleeves, should be used to control destructive tendencies and prevent assaults. Some violently excited cases, or those with self-mutilative tendencies, require to be kept in bed under a protection sheet. This can not


51

be applied unless an ordinary single bed (hospital style) is available. In transferring excited patients short distances by ambulance, or from hospital to train or ship, stretcher cots should be used and leather straps provided for confining the patient to the cot.

Delirious cases - As these patients are usually seriously ill, they should not be transported long distances unless it is absolutely necessary. They should always be moved on a stretcher cot and placed in bed as soon as possible on train or ship.

Other equipment required for the handling of disturbed and uncleanly patients should include plenty of water and hand basins for cleansing purposes.

Ample supply of underclothing and bedding, and rubber sheets to be used under unclean patients.

A tube feeding outfit, consisting of a rubber tube with funnel attached (tube should be small enough to introduce through the nostril).

A physician's hand bag or kit containing the usual emergency outfit, including also hypodermic syringe and tablets of morphia, strychnia and hyoscine hydrobromate; paraldehyde, magnesium sulphate, cascara and compound cathartic pills should be provided. Fountain syringe and bed pans are also needed.

STATISTICAL DATA

There is no accurate record of the date and number of the first nervous and mental cases returned from the American Expeditionary Forces, but the first mental cases from overseas to be admitted to the first special hospital for such cases (General Hospital No. 4) was in the month of February, 1918, and the first cases of war neurosis were admitted to General Hospital No. 30, in May, 1918.17

The following neuropsychiatric cases had been returned from overseas up to June 30, 1919:17

Total

Hoboken

Newport News

Psychoses (insanity)

3,597

2,715

882

Constitutional psychopathic states

504

149

355

Epilepsy

416

302

114

Mental deficiency

762

410

352

Psychoneuroses

2,888

1,675

1,213

Alcoholism

51

51

---

Drug addiction

6

6

---

Recovered

95

95

---


Total

8,319

5,403

2,916


52

The following is a list of the mental and nervous patients transferred to general, base, and special hospitals from the ports of Hoboken and Newport News, between April, 1918, and June 30, 1919, with the hospitals to which they were admitted:18

Mental

Mental defective

Neurosis

Hoboken

Newport News

Hoboken

Newport News

Hoboken

Newport News

Letterman, San Francisco

36

14

10

---

7

2

Walter Reed, Takoma Park, D.C.

171

41

54

1

11

1

No. 1, Williamsbridge, N.Y.

94

37

62

16

35

9

No. 2, Fort McHenry, Md.

61

42

4

1

---

14

No. 3, Colonia, N.J.

---

---

---

---

---

2

No. 4, Fort Porter, N.Y.

784

340

1

---

57

36

No. 5, Fort Ontario, N.Y.

3

3

1

---

14

6

No. 6, Fort McPherson, Ga.

277

228

86

10

22

1

No. 9, Lakewood, N.J.

1

---

---

---

12

15

No. 10, Boston, Mass.

---

1

---

---

---

1

No. 11, Cape May, N.J.

---

---

---

---

---

9

No. 14, Fort Oglethorpe, Ga.

20

---

---

---

1

---

No. 25, Fort Benjamin Harrison, Ind.

152

209

38

8

3

---

No. 26, Fort Des Moines, Iowa.

112

6

29

---

7

7

No. 27, Fort Douglas, Utah

---

---

---

---

1

1

No. 28, Fort Sheridan, Ill.

154

65

30

---

23

1

No. 29, Fort Snelling, Minn.

17

---

8

---

---

16

No. 30, Plattsburg Barracks, N.Y.

3

---

3

---

1,161

1,024

No. 34, East Norfolk, Mass.

333

190

---

---

---

---

No. 41, Fox Hills, Staten Island, N.Y.

---

1

---

---

---

3

No. 43, Hampton, Va.

393

---

48

---

---

---

Camp Bowie, Tex.

2

---

---

---

---

---

Camp Custer, Mich.

13

---

---

---

1

---

Camp Devens, Mass.

10

---

1

---

4

---

Camp Dix, N.J.

33

---

---

---

8

---

Camp Dodge, Iowa

14

---

3

---

---

---

Camp Gordon, Ga.

2

---

---

---

---

---

Camp Grant, Ill.

3

---

2

---

---

---

Camp Lee, Va.

6

---

---

---

---

---

Camp Lewis, Wash. 

2

---

1

---

---

---

Camp Meade, Md.

2

---

1

---

---

---

Camp Pike, Ark.

2

---

---

---

---

---

Fort Sam Houston, Tex.

42

---

24

---

13

---

Camp Shelby, Miss.

1

---

---

---

---

1

Camp Sherman, Ohio

16

---

---

---

1

---

Fort Sill, Okla.

---

---

1

---

---

---

Camp Taylor, Ky.

8

---

1

---

---

1

Camp Upton, N.Y.

47

---

4

---

11

---

Post hospital, Jefferson Barracks, Mo.

9

---

---

---

1

---

St. Elizabeths Hospital, District of Columbia

61

11

---

---

---

---

Total

2,929

1,188

412

36

1,393

1,150


    A census of mental and nervous patients in military hospitals taken as of June 25, 1919, showed the following:19

General hospital

Total

Psychoses

Psycho-
neuroses

Constitutional psychopathic states

Mental deficiency

Epileptics

Others

No. 1

270

138

44

18

21

18

31

No. 2

51

16

15

6

4

3

7

No. 4

125

95

26

2

2

---

---

No. 5

5

1

3

---

1

---

---

No. 6

192

136

21

5

12

3

15

No. 25

186

124

7

11

13

2

29

No. 26

143

83

21

11

3

9

16

No. 28

318

146

40

13

28

18

73

No. 30

205

3

169

9

2

5

17

No. 43

983

693

90

72

117

10

1

Fort Sam Houston

123

59

13

12

4

5

30

Letterman

116

54

9

3

28

4

18

Walter Reed

142

100

12

3

3

12

12

Total

2,859

1,648

470

165

238

89

249


53

Another census taken on August 12, 1919, showed the following:17

Hospital

Total

Psychoses

Psycho-
neuroses

Epilepsy

Constitutional psychopathic states

Mental deficiency

Walter Reed

123

67

38

6

7

5

Fort Sam Houston

117

58

29

14

12

4

Letterman General

80

53

8

7

9

3

General Hospital No. 1

40

21

15

1

2

1

General Hospital No. 2

47

12

24

---

9

2

General Hospital No. 4

194

14

131

1

37

11

General Hospital No. 6

132

89

23

12

---

8

General Hospital No. 25

178

138

15

7

11

7

General Hospital No. 26

95

54

24

5

8

4

General Hospital No. 28

117

73

19

9

2

14

General Hospital No. 43

1,087

868

23

2

59

135

Total

2,210

1,447

349

64

156

194


NEUROSURGICAL CASES

In the winter of 1918-19 officers specially experienced in organic neurology were ordered to certain of the general hospitals receiving wounded from overseas with the recommendation to the commanding officer that they be assigned to the surgical service.20 This recommendation was necessary because the organic injuries to the nervous system, although most of them had ceased to be surgical, were being treated in the surgical services. That this great mass of neurological material, approximately 5,000 cases, should have been retained under surgical control was not an altogether happy clinical arrangement from the standpoint of the division of neurology and psychiatry, but it was inevitable in view of the circumstances.

The whole question of the proper organization for the care of this class of cases was considered important. Battle injuries of the nervous system are primarily surgical, being associated not only with open wounds but also with fractures. The best clinical arrangement for this class of injuries, at the front, is in surgical hospitals which are staffed as far as possible with the neurosurgeons and neurologists. If neurosurgeons can not be supplied in sufficient numbers the cases must be treated at the front by general surgeons. With the healing of the original wound the injury changes its type in the majority of cases. There are some cases which, when they reach the hospitals in the zone of the interior, still require operation, but these cases are in the great minority. At this stage the spinal cord injuries are hardly operable, some of the brain cases require secondary operations, and perhaps 15 per cent of the peripheral nerve palsies require surgical interference. But with these exceptions, after the original wound has healed, the majority have changed their clinical status and, though primarily surgical, now actually present problems with which a medical officer who is a neurologist by experience and interest is best fitted to deal. Those who have sustained cerebral injuries have been left irritable and subject to various symptoms, which makes personality study necessary before they can be readjusted to civil life; and the cases of peripheral nerve injuries which give promise of spontaneous repair require exact neurological diagnosis and treatment.


54

Thus, at the close of the surgical wound period, injuries to the nervous system become, as a class, neurological cases. But a change in clinical status would have been difficult to recognize administratively. It was not done in the British medical service and it would have been impossible under the organization which obtained in our Medical Department. The original plan, as devised in the Surgeon General's Office, was that all these cases would be cared for in the United States in one or more special hospitals, under the brain section of the division of head surgery.21 But when these cases began to be returned in so much greater numbers than had been anticipated, it was found that the provisions for their care in the special hospitals established for the purpose at Cape May and Colonia, N. J., were inadequate both as to the number of beds and as to qualified personnel. And, in addition, it was found that civil interests demanded a wider distribution than had been provided for. These patients, like most of all the others, wanted to be somewhere near their homes. It became necessary, accordingly, to increase the hospitals designated for their special care. More than a dozen, geographically well separated, general hospitals were therefore designated for patients of this class on their arrival from overseas, the choice of the particular hospital being made with reference to nearness to the patient's home.21 The division of head surgery, Surgeon General's Office, having so many of its officers overseas, could not expand its personnel to meet this situation, and as there was no neurological service in the hospital organization of the Medical Department, the patients automatically fell to the division of general surgery, to which were assigned such neurologists and neurosurgeons as were available.

REFERENCES

(1) Annual Reports of the Surgeon General, U. S. Army.

(2) War Diary of commanding officer, Letterman General Hospital, San Francisco, Calif., November 12, 1918. On file, Record Room, S. G. O.

(3) Army Regulations, 1913, par. 464.

(4) Plans on file, Finance and Supply Division, S. G. O.

(5) Plan R2 (neuropsychiatric ward, base hospital). On file, Finance and Supply Division, S. G. O.

(6) Letter from Pearce Bailey (chairman of the Committee on Furnishing Hospital Units for Nervous and Mental Disorders to the United States Government), to neurologists, May 11, 1917. On file, Record Room, S. G. O.

(7) Circular letter, Surgeon General's Office, September 5, 1917.

(8) Based on sick and wounded reports sent to the Surgeon General, U. S. Army.

(9) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1081-83.

(10) G. O. No. 57, W. D., April 30, 1919.

(11) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1083.

(12) List of Hospitals Designated for Overseas Cases, Surgeon General's Office, December 9, 1918.

(13) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1082.

(14) History of Embarkation Hospital, Newport News, Va., by Maj. W. C. Rucker, U. S. P. H. S. On file, Historical Division, S. G. O.

(15) History of the office of the surgeon, Port of Embarkation, Hoboken, N. J. On file, Historical Division, S. G. O.

(16) Memorandum to Dr. Pearce Bailey, from Dr. George H. Kirby (Manhattan State Hospital), July 2, 1917. Subject: Transport and transfer of insane soldiers. On file, Historical Division, S. G. O.


55

(17) Letter from the Surgeon General, U. S. Army, to Hon. Edwin D. Ricketts (concerning shell-shocked and insane soldiers of the late war), August 21, 1919. On file, Record Room, S. G. O., 701.7.

(18) Routine reports made by post surgeons to the Surgeon General, U. S. Army. On file, Record Room, S. G. O.

(19) Based on reports made by commanding officers, showing the number of neuropsychiatric cases in the respective hospitals, by classification, as of June 25, 1919.

(20) Correspondence. On file, Record Room, S. G. O., 210.31-1 (Neuropsychiatry assignments).

(21) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1095, 1096.

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