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Section I, Chapter IV

Table of Contents

CHAPTER IV

DETECTION AND ELIMINATION OF INDIVIDUALS WITH NERVOUS
OR MENTAL DISEASE

PRINCIPLES UNDERLYING NEUROPSYCHIATRIC EXAMINATIONS

One of the most important duties of the neuropsychiatrists in the military service during the war was the elimination, at the time of their preliminary examination and before they were actually enlisted or inducted into the Army, of individuals with mental or nervous disease. Many of the purely physical disabilities which were noted and waived by mustering officers, or which disqualified recruits from service, were susceptible of improvement or cure by treatment, or got well of themselves under the favorable conditions of military training. This was rarely the case for any nervous or mental disease. On the contrary, the longer the training period was prolonged, the more pronounced these conditions became; the soldier was more and more constantly reported at sick call, or was suddenly seized with a nervous or mental collapse, or got into trouble by reason of repeated, and often unnecessary, military delinquencies. The strain of actual warfare, particularly of expeditionary warfare, with the unavoidable homesickness, loneliness, and depression-to say nothing of its actual physical dangers and hardships-brought first to the breaking point those whose morale, by reason of a general instability of the nervous system, could not be maintained. While such men usually were ultimately detected and discharged, it was not until after a considerable period of training during which they received pay, maintenance, and equipment, wasted the time of those endeavoring to instruct them, interfered with the training of their brighter or better-adjusted comrades, and occupied hospital beds which often were urgently needed for others. Another unfortunate feature of the acceptance of such men for military service was that many of them, while unable to adjust themselves to the military environment, might be useful citizens if permitted to remain in their accustomed surroundings. Left on the farm or in the factory or store, where their associates were accustomed to their peculiarities, they might prove of material service to the country in time of war.

Furthermore, if men of this type became soldiers, they were almost certain in the future to present a serious economic problem to the country. Under the provisions of the selective service act, which was in force during the period of the war, all soldiers were regarded as physically and mentally sound when accepted for service. If, after a short period in the Army, a soldier was necessarily discharged by reason of mental or nervous disability, be became a beneficiary of the Bureau of War Risk Insurance (later called the United States Veterans' Bureau), and thus was entitled to governmental compensation and hospital care. Nervous and mental disorders constituted a substantial proportion of ultimate disabilities.a Many of the former soldiers discharged by reason

aIn February, 1927, ex-service men with neuropsychiatric disabilities constituted 46.7 Percent of all patients receiving hospital treatment as beneficiaries of the United States Veterans' Bureau. (Hospital Facilities by Coordination Areas for U. S. V. B. Patients, as of Feb. 26, 1927. Issued weekly for administrative purposes by Evaluation Division, Coordination Service, United States Veterans' Bureau. Copy on file, Historical Division, S. G. O.).


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of nervous or mental diseases are drawing compensation from the Federal Government, some with a rating of total permanent disability. A large proportion of these men rendered practically no service to the country, their time in the Army having been spent in base or general hospitals, or under observation for the defect which in a short period after induction or enlistment resulted in discharge.

Before we had entered the World War, the possibility of conditions was appreciated by only a small group of the civil medical profession; it was not surprising, therefore, that they were not accepted at their face value, immediately, by the regular line and medical officers of the Army, who exhibited, perhaps, less indifference and less reluctance to accepting them, in principle, than civil authorities or general medical organizations were in the habit of doing prior to the demonstrations of their practical importance furnished by the war. The introduction of novel and special examinations of so many kinds created great administrative difficulties immediately, as they interfered with established military routine, and it probably was this factor, rather than any lack of open-mindedness as to their usefulness, that was the basis of such opposition as was made to them. Division surgeons complained that specialists interfered with the prompt getting in order of their camps, which was true, and line officers were not hard to find who maintained that if the specialists did not stop eliminating the unfit, there would be no army left. Many medical officers, not distinguishing between physical and mental disorders, halted considerably before they embraced the belief that the training which transformed poor physical specimens into robust fighting men did not have the same effects upon recruits with nervous or mental disabilities. Occasionally line officers, taking things into their own hands, looked over candidates recommended for rejection, decided that, as the men looked all right to them, they probably were all right, and then waved aside the recommendation for rejection or discharge. Ultimately it was discovered, however, that nervously unfit men were a great embarrassment to the American Expeditionary Forces. On July 15, 1918, General Pershing cabled to the Chief of Staff as follows:1

Prevalence of mental disorders in replacement troops recently received suggests urgent importance of intensive efforts in eliminating mentally unfit from organizations new draft prior to departure from the United States. Psychiatric forces and accommodations here inadequate to handle a greater proportion of mental cases than heretofore arriving, and if less time is taken to organize and train new division, elimination work should be speeded.

Upon receipt, by the Surgeon General, of this information, the matter was taken under consideration by the chief of the division of neurology and psychiatry, and the following information, based upon reports made to the Surgeon General by neuropsychiatric examiners, was submitted to the Surgeon General by the chief of the division, with his recommendations:2

1. Apropos of the attached cablegram from General Pershing, the following data are submitted: A survey of the records in this office shows that the divisions that have gone abroad have carried with them the following number of men who had been recommended for discharge as unfit for military service by the psychiatric examiners:


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Division

Number 
of men

Division

Number 
of men

Division

Number 
of men

Division

Number 
of men

4th

48

34th

21

77th

5

85th

45

27th

21

35th

181

78th

208

86th

53

28th

93

36th

138

79th

73

87th

198

29th

166

37th

271

80th

90

88th

29

30th

152

38th

130

81st

3

89th

115

31st

52

39th

244

82d

120

90th

44

32d

32

40th

25

83d

53

92d

70

33d

44

42d

273

84th

38

Total

3,035


2. The men enumerated above are epileptics, dementia pręcox, general paretics, tabetics, psychoneurotics, imbeciles, etc. Because of their condition, these men are totally unfit for military service, and become a burden upon the Government either immediately upon landing, or shortly afterwards. The psychiatric service abroad is equipped only to care for men who become incapacitated in line of duty. Three thousand cases thrust upon this service almost en masse will tax the resources seriously, as it is evident has been done from the cable of General Pershing.

3. Attention is called to the fact that the numbers of cases carried over by different divisions differ markedly. Three divisions (41st, 76th, 91st) carried no men who had been recommended for discharge. The 81st carried 3; the 77th, 5; the 42d, 273; the 37th, 271; the 39th, 244, etc. It is evident, therefore, that the S. C. D. boards in the different camps vary either in the importance they attach to nervous and mental disease, or in the expedition of their work. Complaints have frequently been received on the length of time necessary to discharge men who have been recommended to the boards. An inquiry recently made in a few camps shows the following variations in time:

Camp Dix, average time 5 days.
Camp Jackson, previous to July 1, average time 24 days; since July 1, 12 days.
Camp Fremont, 21 days.
Base hospital, Alexandria, La., 23 days.

4. In order to obviate the difficulties arising in the American Expeditionary Forces, as mentioned by General Pershing, it is suggested that an effort be made to expedite S. C. D. proceedings, and that the importance of excluding recruits who are nervously and mentally unfit for service be drawn to the attention of S. C. D. boards.

REASONS FOR REJECTION OR DISCHARGE

The War Work Committee of the National Committee for Mental Hygiene appointed a subcommittee to study clinical methods and standardization of examinations and reports. The subcommittee soon rendered a report to the War Work Committee, which submitted to the Surgeon General, in July, 1917, a memorandum containing various suggestions pertaining to examinations of recruits, and giving a list of diseases, symptoms, and groups of symptoms which it was thought should exclude from military service, regardless of ultimate diagnosis. On August 1, 1917, the Surgeon General issued general directions to examiners based on these suggestions.3 (See p. 66).

There was little question about clearly defined types. No commanding officer would accept, knowingly, a man who was actively hallucinating, and an epileptic fit which was verified was equivalent to discharge. More important than the patent nervous and mental diseases, for an understanding of the general philosophy of rejection by reason of nervous and mental conditions was a knowledge of the mental states of unstable individuals whose unfitness for service was not on the surface, the advisability of whose rejection frequently was questioned not only by line officers, but by medical officers.


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THE PSYCHOPATHIC PERSONALITY

Viewed from the standpoint of personality, human beings of the group called psychopathic have been so from youth, and produce, under certain conditions, characteristic behavior. At the time of any single examination the symptoms they present (and even these may be put down as conclusions on the part of the overzealous examiner) may be no more definite than irritability, inability to control the passions, suspicion, resentfulness, particularly to discipline, depression, and general egocentric tendencies. These evidences, slight in themselves, gain an additional significance when associated together characteristically, or when, as they usually can be, they are shown as characteristics by which the individual has been conditioned throughout his whole life. The behavior of such persons under military conditions is inconsistent with military efficiency. They are not of the stuff of which soldiers are made-which is the real issue so far as the Army is concerned. They are persons who can not give the service required, and no system yet devised will make them adequate.

The question to be determined, then, at the examination of a recruit, before the Army assumes charge of him, is whether his make-up is such that his behavior, with practical certainty, will be inconsistent with service. These examinations undertake to recognize at the outset, before the Government assumes liability, the type of person which the Army will be forced to recognize sooner or later. The behavior aspect is more likely to be noted than the health aspect, as is shown by the fact that soldiers are so often referred directly to psychiatrists by company commanders. What the psychiatrist attempts to do is to discover immediately and directly what otherwise it might take several expensive months to find out.

The candidate may have been treated for mental disease and may be sane now; he may have had epileptic attacks but none for a long period; he may have been addicted to the use of a drug and may have discontinued the habit; or he may have none of these serious disabilities and still may have met difficult situations in the past in such an abnormal and unsatisfactory manner-not through lack of "will" but because of a fundamental disorganization of his personality-that he may be counted on to meet those of the future no more satisfactorily.

If individuals of this category are not recognized they fail the Army in some of the following ways: By having attacks of mental disease; by the development of neuroses; by reappearance or increase of epileptic attacks; by the kind of delinquency which results from a mental or temperamental inability to adjust to the restrictions of military discipline or to profit by punishment.

Perhaps the most frequent and important reaction of the psychopathic personality to the trying exactions of war, or even to life in the Army, is the neurosis-a condition difficult to conceive of dispassionately in actual practice, because the manifestations and complaints of the neurotic seem so closely akin to malingering. A neurosis is the psychopathic means of evading a difficult situation. It may be primarily mental in character (psychasthenia), or it may present symptoms closely simulating those of organic injuries or diseases (hysteria).


61

Overseas the neuroses developed in large numbers both in the base sections and at the front. Although the method adopted of treating the acute cases which developed during battle, in the divisional and army hospitals, greatly decreased their numbers, there were still many in whom the symptoms persisted in a disabling way until the armistice was signed, and some in whom they persisted after that. These persistent symptoms showed plainly that the persons presenting them were of a psychopathic type and might have been recognized at the time of enlistment, and by whose rejection the Army would have profited.

As it must now be conceded that there is a large class of recruits who are bound by neurotic behavior to be a burden instead of an asset to the Army, the only questions that remain are whether these individuals can be recognized beforehand, and what, if any, distinction should be made between them as to possibilities of service.

METHODS OF ELIMINATION

Owing to the absence frequently of outstanding physical defects, the detection of mental and nervous defects in individuals during the physical examination prior to entry into the Army is frequently rendered most difficult. In times of peace, when enlistment is on a voluntary basis, and the number being examined at any place each day is not large, it is possible for an experienced examiner to detect the majority of applicants of this type. Prior to our participation in the World War, however, with the Army recruited in this manner, the number of discharges each year on account of neuropsychiatric disease was never large. Following our participation in the World War and the consequent rapid mobilization of men of draft age, it became evident that skilled recruit examiners were not available in sufficient numbers. In order that qualified examiners might be available at all camps, each professional division of the Office of the Surgeon General, as noted heretofore, designated certain of the officers exempted to that division for duty at the camps as examiners in their particular specialty.

From the beginning of the mobilization the examinations were carried on at officers' training camps, cantonments, recruit depots, and recruit depot posts, and at all points where registrants or volunteers were being mustered into the service. At first two chief methods were employed: Examination of referred cases, and general surveys.

By the method of referred cases, only such cases as were referred to the neuropsychiatrist were examined. The references were made by regimental surgeons and company commanders. It soon became obvious that this method was inadequate, as by it only men with evident defects were referred, and then generally after long and unnecessary delay. Further, the officer who made special examinations of referred cases was stationed at the base hospital, and, therefore, not readily accessible. Later, upon the appointment of examining boards at each camp functioning for the examination of all men arriving at the camps, under the general direction of the camp or division surgeon, every man was examined for mental or nervous defect by an officer assigned by the division of neurology and psychiatry of the Surgeon General's Office.

The first increments of our Army were not all examined by neuropsychiatrists and a considerable number of men unfit for military service, because of


62

nervous or mental condition, were carried overseas. These promptly appeared in the hospitals of the American Expeditionary Forces and, later, in General Hospital No. 30, Plattsburg, the majority of them with a history of illness of from one to five years' duration previous to their entrance into the Army. To meet this situation survey boards composed of two or more neuropsychiatrists were later ordered to examine commands which had been previously accepted for service.

Under the method of surveys, the whole command passed before the special officers. On the basis of a brief conversation and observation, and examination for such physical symptoms as tremors, changed reflexes, etc., the recruit was passed, or if not satisfactory, was deferred for a thorough examination. By this method an experienced examiner could dispose of 100 to 150 cases a day with reasonable accuracy. Large boards were sometimes sent by request of generals commanding divisions, to examine the whole division in a short space of time.

Neither of these methods being coordinated properly with the physical examinations, it was difficult for special boards to operate when the camps first opened, and later it was difficult to get the recruits together, as they were occupied with their military duties. The examinations did not become adequate until they became a part of the routine entrance examination of all recruits.

But the great practical difficulty for a time was to obtain action on the recommendations for rejection or discharge. The special examining boards were composed, for the most part, of officers of little or no military training, who, consequently, were ignorant at first of the procedure to be followed to insure action on their recommendations. For example, between two and three hundred privates of the National Guard of New York, examined and found unfit by psychiatrists in New York, were nevertheless sent to Camp Sevier, S. C., with their organizations. It was only after the useless journey to South Carolina that the recommendations found their way to the disability boards, and the men were finally discharged.

Once the recommendations reached the disability board they were generally acted on favorably, although the surgeon sometimes disapproved the board's findings, and the discharging authority did not always agree with the surgeon's recommendations. But most of the cases which were retained in the service in spite of the recommendation of the psychiatrists failed to come to the attention of the disability boards for the reasons stated above, or because troops were being moved too fast to make it possible.

It was never considered desirable that disability boards be made up exclusively of psychiatrists. Composed, as they were, of general medical officers, these officers had the advantage of acquiring a familiarity with the methods and importance of the neuropsychiatric work; furthermore, discharges recommended by mixed boards could not be considered as testimonials to the overenthusiasm of specialists. In August, 1918, an order was issued abrogating provisions for separate examining boards for three of the medical specialties, including neuropsychiatry.4 Following this, all the camp examinations for the purpose of examining drafted men, and later for demobilization, were coordinated, and placed under the direction of the division of sanitation, Surgeon General's Office.5


63

In the beginning there were neuropsychiatric examinations of candidate officers at a few of the first series of the officers' training camps, and at many of the second series. In general, however, officers were not examined for nervous and mental conditions prior to being commissioned and, at the majority of camps, were not examined when the neuropsychiatric surveys of the soldiers already in the service were conducted. This was an outstanding defect of the neuropsychiatric service, as many officers were later discovered to have defects of this type rendering their discharge necessary.

On the whole the cooperation existing between the neuropsychiatrists and other medical officers, as well as with officers of the line, was harmonious and attended always by a joint desire to detect and eliminate the mentally or nervously unfit from the service. Attention was directed to the importance of the work being done by the neuropsychiatric officers in the following promulgations:6 7

1. The Surgeon General again invites your attention to his desire that you make every endeavor to recognize and eliminate all cases of mental disease, all mental defectives, and all cases of nervous disease. It is believed that not less than 10 per 1,000 of men now in service are unfit from one of the above mentioned conditions

2. To aid you, orders have been issued making the services of the neurologists and psychiatrists detailed to the base hospitals available for the examination of troops of the division in his specialty.

3. It is desired that you use every effort to arrange with the commanding officer for tile inspection of each organization by the specialist medical officer at some time during the training period, to discover those soldiers whose general attitude and appearance suggest the need of special neurologic and psychiatric examination. Each organization will be inspected if possible, details of this inspection being left to you, but it is suggested that they may be made advantageously when organizations are gathered together for such general medical purposes as vaccination, inoculation, physical inspection of various kinds, etc. But if special formations are necessary, you will endeavor to arrange them.

4. You will recommend to the commanding officer that general written instructions be issued confidentially to the officers, to the following effect:

(a) Officers commanding companies, troops, batteries, detachments, or other organizations will note each member of their commands for the purpose of forming an opinion as to whether they show evidences suggesting mental disease or defect, or insufficient nervous stability. Organization commanders will require the same observation by their junior officers and by noncommissioned officers, who will be directed to report doubtful cases to them.

(b) Those having officers under their command should secure special examination of any officer who seems of doubtful mental integrity or nervous stability.

(c) Senior medical officers will require those under their command to be on the lookout for mental and nervous cases.

(d) Medical officers serving with regiments or other units, those holding daily "sick call," those making physical inspections of any kind, and ward surgeons will bear nervous and mental disease in mind, and refer suspicious cases for expert examination.

(e) Officers commanding places where prisoners, garrison or general, are confined, summary court officers, judge advocates, and assistant judge advocates of courts-martial, and officers who act as counsel for enlisted men, will note the mentality of all cases before them and refer all doubtful cases for proper examination.

(f) The observations herein required should be made quietly and unobtrusively so that if possible no officer or enlisted man shall know that his mental or nervous condition is under question. This is important.

5. The fact that troops are being mentally examined will be kept from becoming a matter of gossip if possible.


64

6. You should require the neurological examinations of all men known to be suffering from syphilis.

7. You will require the specialist medical officer to make, through you, monthly reports to this office of the special work done. Forms 89, 90, and 91 have been prepared for this purpose. The printed copies of these forms will be sent to the cantonments by the field supply depot in a few days.

Bulletin No. 4.

WAR DEPARTMENT,
Washington, February 7, 1918

*  *  *  *  *  *  *

Officers with special experience in nervous and mental diseases have been added to the Medical Department of the Army. Such officers are detailed at all base hospitals and with many divisions. Most base hospitals have also special nurses and therapeutic appliances for the care of nervous and mental diseases. The services of these officers and nurses are available, through their superior officers, for consultation in all matters pertaining to such diseases. The foregoing facts are announced for the special benefit of persons that are brought socially in contact with soldiers, as such persons are in a particularly favorable position to witness the early stages of mental disease, and by their prompt and cooperative action may render valuable assistance in preventing nervous breakdowns. Reports from abroad indicate that a large number of the soldiers who break down nervously (shellshock) had, for several days before their final collapse, given evidence that they were fast approaching the limit of their nervous endurance. It is believed that had something been done for them during those critical days they would have readjusted themselves quickly and gone back to their duty instead of remaining nervous invalids, with little prospect of recovery before the end of the war. Nervous breakdowns often begin by sleeplessness, persistent homesickness, nervousness, depression, self-reproach, unreasonable fear, suspicion of others, feeling of resentment against others, and general complaints of ill health. These signs often show in the man's social conduct, so that he is remarked by his companions as being restless, jerky, inclined to stay by himself, bad tempered, etc.; in other words, his companions remark that some change has come over him. The man himself may realize that he is out of sorts, but often he does not realize that he is ill and so does not report at sick call; on the contrary, he often resents the idea that he needs the care and supervision of a physician. Yet a little rest, care, and medicine, such as would be provided if his case were brought to the attention of a medical officer, would in all probability suffice at this time to put the man on his feet again.

(700.7, A. G. O.)

By order of the Secretary of War:

JOHN BIDDLE,
Major General, Acting Chief of Staff

Official:

  H. P. MCCAIN,
The Adjutant General.

Clinics and lectures were given for other medical officers, and talks, of a suitable nature, to officers of the line. The following memorandum was distributed to company commanders:8

The object of this survey is to find and discharge from the Army such cases of maladjustment to Army duties or discipline as may be shown to have a mental or nervous abnormality. The following types of cases should be sought out and sent for examination by the survey board:

Cases showing unusual difficulty in learning drill, instructions, etc., not clearly dependent on unfamiliarity with the English language.
Persistent delinquents, irresponsible, morally obtuse individuals.
Eccentric, seclusive, taciturn individuals, company "butts."
Those showing marked emotional instability; i. e., too readily moved to tears, anger, or noisy elation.


65

Those indulging in or suspected of abnormal sexual practices.
Drug or alcohol addicts.
Those having fainting spells or other evidences of possible epilepsy.
Persistent bed wetters.
Extreme cases of stammering.
Chronic ailers showing no evidences of organic disease, hysterical or neurasthenic individuals, suspected malingerers.
Apathetic, negligent, untidy, or otherwise seemingly inferior or objectionable individuals.
Those who may be on any other grounds suspected of being mentally unfit.
It is very desirable that each case sent for examination should be accompanied by a memorandum stating in terms of observed facts or of the soldier's utterances or conduct the reason for the desired examination.

Company commanders and regimental surgeons cooperated in the neuropsychiatric surveys, as they afforded often the only way of being relieved of problems of administration and discipline arising from the demoralizing effect of the presence in their organizations of mentally unfit individuals.

All cases about to be tried by court-martial should receive a competent psychiatric examination to determine not merely their legal responsibility, but also whether the soldier is afflicted with a neuropsychiatric disorder which would ordinarily lead to his discharge on surgeon's certificate of disability. If so affected, generally he should be discharged, rather than tried, and not recommended for reenlistment. Should trial be deemed advisable, no sentence should be imposed which might aggravate his disability-such as confinement with hard labor in a case of epilepsy-but rather forfeiture of pay or dishonorable discharge.

INSTRUCTIONS TO EXAMINERS

The examinations made by the officers of the neuropsychiatric service may be divided into two general groups. The first comprised the mental and nervous examination of applicants for enlistment and of draftees reporting at camps of mobilization. This examination was completed before the men were actually in the military service and was made with the special object of excluding those who failed to reach the required standards. In the second group fell all examinations made by the neuropsychiatrists after the individuals were actually in the Army. Included here were the examinations of patients in hospitals; of men referred by medical or line officers; the neuropsychiatric surveys of troops which had come into the Army without the special neuropsychiatric examination, as has been explained previously; and the examination of all men prior to discharge from the service. This latter examination was conducted at the various camps by the camp examining boards referred to above, but the results of the neuropsychiatric examinations at this time were largely negative, as the majority of soldiers of this type had already been detected and disposed of. Examinations made at the disciplinary barracks may be considered as a third group.

While a thorough mental examination of the recruit will eliminate a large proportion of undesirables at the outset, a certain number of mental and nervous defectives will slip through. From the nature of the diseases concerned this can not be avoided, and the neuropsychiatrists must be alert at all times to detect mental or nervous disease in those who have shown unusual difficulty in learning


66

the drill and in following instructions, those who are persistently delinquent, who are seclusive, eccentric, taciturn, or who exhibit other marked peculiarities of behavior. Such men were carefully sought for during the war and properly disposed of when discovered.

With the exception of the purely neurological cases the defects to be identified by the neuropsychiatric officers were more in the sphere of behavior than in that of concrete physical symptoms. The diagnoses were generally made independently of physical symptoms, and sometimes recruits, at the preliminary examinations, were recommended for rejection as mentally unsuitable who had been passed by other medical officers as physically sound in other respects. The methods employed during all these special examinations were those of clinical psychiatry.

Under date of August 1, 1917, as noted heretofore, the Surgeon General issued Circular No. 22, which outlined the nervous and mental conditions for which the neuropsychiatric examiners should search, and gave the general grouping which should serve as causes for rejection. This circular was as follows:

Circular No. 22. WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, August 1, 1917

EXAMINATIONS IN NERVOUS AND MENTAL DISEASE

1. For the safety, efficiency, and economy of the military service it is highly essential that nervous and mental disease be recognized at the earliest possible moment. Nervous and mental diseases may, and frequently do, exist in persons who are strong, active, and apparently healthy and who make no complaints of disability. Such persons are, however, more than useless as soldiers, for they can not be relied on by their commanders, break down under strain, become an encumbrance to the Army, and an expense to the Government. Disorders of this character are often demonstrable only as the result of a painstaking and special examination directed toward the mind and nervous system. This circular is published for the special purpose of calling the attention of medical officers to the particular diseases most frequently overlooked on general examination, and the symptoms most important to their diagnosis, and to certain characteristics in personality and in the behavior which might raise the question of the existence of mental disease.

2. The duties of the examiner are to be familiar with the symptoms and significance of nervous and mental disease and the means of eliciting them, and to recommend for rejection from service all those in whom any of the evidences mentioned in paragraph 4 are demonstrated. He should determine the importance of slight variations from the ordinary normal standard and recommend acceptance or rejection on the basis thereof. He should search for symptoms or tendencies which may be concealed for the purpose of obtaining service, and he should recognize symptoms which are feigned for the purpose of avoiding service. Organic nervous disease can not be feigned in a way to deceive a skillful and careful examiner. To demonstrate feigned insanity a period of several weeks' observation may be necessary.

3. It is assumed that the examiner is familiar with the current methods of examination in neurology and psychiatry, and that he will make careful employment of them in all cases referred to him for consultation. But in addition to acting as a consultant to whom cases are referred, he must also himself select cases for special examination. To this end, he is directed to be present as often as possible when the recruits are gathered together at times of instruction and training and for such general medical purposes as vaccinations, inoculations, group examinations of the heart, lungs, etc. At such times he should discriminatingly observe the appearance and behavior of the recruits, pass in and out among them, converse with them when possible, and report to the camp surgeon the names of any whom his obser-


67

vations have led him to consider as requiring a special neurological and psychiatric examination. By thus learning, in a way, to know the recruits personally his special training should enable him now and then to pick out one who might pass the general medical examination and yet whom special examination would clearly prove to be a hazard to the Army.

Queerness, peculiarities, and idiosyncrasies, while not inconsistent with sanity, may be the beginnings or surface markings of mental disease. A soldier is too important a unit for such variations from a standard of absolute normality not to be looked into before the recruit who presents them is accepted for service. To aid the neurologist and psychiatrist in these ways the camp surgeon shall direct all medical officers, dental surgeons, instructors, hospital sergeants, and others who come in close contact with recruits to refer to him (the camp surgeon) all recruits who persistently show any of the following characteristics: Irritability, seclusiveness, sulkiness, depression, shyness, timidity, overboisterousness, suspicion, sleeplessness, dullness, stupidity, personal uncleanliness, resentfulness to discipline, inability to be disciplined, sleepwalking, nocturnal incontinence of urine, and any of the various characteristics which gain for him who displays them the name of "boob," "crank," "goat," "queer stick," and the like.

The reaction of the pupils to light should be part of every medical examination, and if this is not systematically provided for, the neurologist and psychiatrist should be directed to determine it. This could be done at the time of group inoculations and with the help of a hospital sergeant could be made rapidly. Electric light should be used. It is especially important in the examination of officers and recruits above 25 years of age.

It is further recommended to camp surgeons to provide neurological examinations for all cases of syphilis.

4. The following are causes of rejection for military service:

A. Organic nervous diseases.
B. Mental defect.
C. Mental disease and pathological mental states.
D. Confirmed inebriety (alcohol or drugs).

A. ORGANIC NERVOUS DISEASE

Certain after effects of organic nervous disease need not be causes for rejection provided (1) that the disease is no longer operative and is not likely to recur, (2) that the effect left by it does not prevent a satisfactory fulfillment of military duties. Examples of such conditions are paralysis of a few unimportant muscles following poliomyelitis, slight unilateral hypertonicity as a result of an infantile hemiplegia in a man now robust, and various traumatic conditions. A history of hemiplegia occurring after infancy should always exclude, even if no symptoms remain.

Existent organic nervous disease should always exclude. For example, neuritis, of one or many nerves, while susceptible of recovery without resultant defect, is none the less a cause for rejection as long as it exists. The following organic nervous diseases are mentioned specifically, as they are the ones which frequently present few symptoms and may pass undetected by even the most skillful examiner:

Tabes, or locomotor ataxia - Look for Argyll-Robertson pupil or pupils, absent knee jerks, Romberg symptom, ataxia of hands or legs (especially with closed eyes), hypotonia, anesthetic areas of skin. History is usually that of slow progression, failing sexual power, and pains in the legs or back, often described as rheumatism. In doubtful cases it is required that the Wassermann reaction of the blood be determined and the cerebrospinal fluid be examined as to the Wassermann reaction, cellular and globulin content, etc.

Multiple sclerosis - Look for intention tremor, nystagmus, absent abdominal reflexes, and increased tendons reflexes. The scanning speech may be mistaken for stammering. No history of pain, but sometimes history of urinary disturbance.

Progressive muscular atrophies, dystrophies, and syringomyelia - Look for atrophies in the small muscles of hand and in the muscles of the shoulder girdle, with fibrillary twitchings. These plus anesthesia for heat and cold (scars on hands from cuts and burnings) = syringomyelia. History usually furnishes little data, although reference may be made to awkwardness. No history of pains. Syphilitic spinal disease imitates these conditions closely.


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Epilepsy.-Look for deep scars on tongue, face, and head. The voice is frequently characteristic. If history alone, verify by correspondence with physicians.

Hyperthyroidism - A nervous disease in its effects. Look for persistent tachycardia, exophthalmos, tremor, enlarged thyroid. History of general nervousness.

In addition to the foregoing there are certain sets or combinations of symptoms which should exclude from service. They may not by themselves be sufficient for an exact diagnosis, but they prove beyond cavil that the nervous system is seriously diseased and totally undependable for any continuous service.

Pupil or pupils-Argyll-Robertson.
Nystagmus (in one not an albino), absent abdominal reflexes, intention tremor. Combination of any two should constitute a cause for rejection.
Babinski reflex.
Disturbances of station or gait.
Disorders of speech on test phrases
(viz, "Third riding artillery brigade") plus facial tremor or any other one symptom of organic disease. Confirmation by laboratory findings is desirable.
Cervical sympathetic syndrome,
viz, unilateral narrowing of palpebral fissure, sunken eyeball, flattening of face, unequal pupils.

B. MENTAL DEFECT OR DEFICIENCY

Look for defect in general information with reference to native environment, ability to learn, to reason, to calculate, to plan, to construct, to compare weights, sizes, etc.; defect in judgment, foresight, language, output of effort; suggestibility, untidiness, lack of personal cleanliness, anatomical stigmata of degeneration, muscular awkwardness. Consult psychometric findings. Get history of school and vocational career and disciplinary report.

C. MENTAL DISEASES

A definite corroborated history of a mental disease that required hospital treatment or observation serves as a cause for rejection in a recruit mentally normal at the time of examination. The circumstances should, however, be inquired into with great care. Few mental diseases present objective physical signs, but their manifestations are none the less characteristic and dependable. All mental diseases are causes for rejection. In addition to the well-defined clinical types such as paresis, dementia pręcox, etc., there are various combinations of psychological symptoms which render those who suffer from them unstable, unreliable in emergency, and subject to attacks of disabling mental illness from slight emotional causes.

General paralysis (paresis) - Look for Argyll-Robertson pupil or pupils, facial tremor, speech defect in test phrases, and in the slurring and distortion of words in conversation, writing defects consisting of omissions and distortion of words. Mood is apathetic or depressed or euphoric. Memory loss, discrepancies in relating facts of life. Knee jerks may be plus, minus, or normal. In doubtful cases it is required that the Wassermann reaction in the blood be determined and that the cerebrospinal fluid be examined as to Wassermann reaction, cellular and globulin content, etc.

Dementia pręcox - Look for indifference, apathy, withdrawal from environment, ideas of reference and persecution, feelings of the mind being tampered with, and thoughts being controlled by hypnotic, spiritualistic, or other mysterious agencies, hallucinations of hearing, bodily hallucinations, frequently of electrical or sexual character; meaningless smiles; in general, inappropriate emotional reaction and a lack of connectedness in conversation. There may be sudden emotional or motor outbursts. Get history of family life and of school, vocational, and personal career.

Manic-depressive insanity - Look for mild depression with or without feeling of inadequacy or mild manic states with exhilaration, talkativeness, and overactivity.

Psychoneuroses - Look for hysterical stigmata, such as cutaneous anesthesias (especially hemianesthesia), contractions of the visual fields, etc., phobias, morbid doubts and fears, anxiety attacks, compulsions, hypochondriasis. Compare complaints with behavior and obtain history as to former nervous breakdowns and vocational career.


69

Psychopathic characters.-Homosexuals, grotesque liars, vagabonds. Superficially bright oftentimes. These individuals do not last out and never stay at any one thing long. Frequent military and civil offenders. Get history of personal career.

D. CHRONIC INEBRIETY

For alcoholism look for suffused eyes, prominent superficial blood vessels of nose and cheek, flabby, bloated face, red or pale purplish discoloration of mucous membrane of pharynx, and soft palate; muscular tremor in the protruded tongue and extended fingers, tremulous handwriting, emotionalism, prevarication, suspicion, auditory or visual hallucinations, persecutory ideas.

For drug addiction look for pallor and dryness of skin. If taking drug, the attitude is that of flippancy and of mild exhilaration; if without it, it is cowardly and cringing. There are also, during period of withdrawal, restlessness, anxiety, and complaints of weakness, nausea, and pains in stomach, back, and legs. Distortion of alę nasi. Pupils contracted by morphine and dilated by cocaine. All habitual drug takers are liars. They do not drink, as a rule, and are inactive sexually.b Most drug takers use needles and show white scars on thighs, arms, and trunk. Heroin takers are mostly young men from the cities, often gangsters. They have a characteristic vocabulary and will talk much more freely about their habit if the examiner in his inquiries uses such words as "deck," "quill," "package," "an eighth," "blowers," "cokie," etc.

  W. C. GORGAS,
  Surgeon General, United States Army.

Approved by order of the Secretary of War, August 9, 1917. (702 O. D., A. G. O.)

STANDARDS OF FITNESSc

Circular No. 22, although it set few absolute standards, largely determined the findings of the neuropsychiatric officers throughout the war. In pronounced cases of definite diseases, such as dementia pręcox and epilepsy, it was possible to follow a fixed standard, but many of the mentally and nervously unfit are border-line cases or are types of inadequate personality impossible of absolute classification. The actual symptoms are not always definite, and the reasons for rejection for military service must frequently lie in the judgment of the examiner and his ability to evaluate in terms of personality development or psychopathology the social histories of the men. For example, many of the men rejected on account of constitutional psychopathic state would have been accepted had it not been for the special examination by the neuropsychiatrists, as no definite tangible physical symptoms existed which, otherwise, would have been observed. Had these men been accepted for military service the majority of them would have been ultimately discharged as inapt under the provisions of paragraph 148½, Army Regulations, or for physical disability, or by sentence of a court-martial, after having been convicted for some dereliction of duty.

In the consideration of mental deficiency, the standard for rejection was not always uniform, although generally understood to be a mentality of or below that of a child of 8 years. It is apparent from reports received in the Office of the Surgeon General that this 8-year standard is too low.

bThis was proved to be in error.
cA full discussion of physical examinations may be found in Vol. VI, Sanitation, Chaps. XIX, XX, and XXI.


70

However, it was not always possible to arrive at a scientific determination of the mental age of recruits, as the time required for the necessary examination was often not available. Even if the psychological group tests had been applied for all recruits, the problem would not have been settled, as it was not agreed that psychological rating alone is sufficient to warrant rejection for mental deficiency.

Throughout the entire group of neuropsychiatric disorders much latitude was necessarily left to the opinions of the neuropsychiatric examiners, and the recommendations of these officers with reference to the mental or nervous fitness of recruits for the military service came eventually to be quite generally followed. This was true for both rejection from and retention in service. Chronic alcoholism, for instance, was a cause of rejection, yet comparatively few alcoholics were rejected, far less than might have been under the existing standards. The standards of physical requirements placed subjects of drug addiction in the deferred irremediable group, yet a certain percentage of them were accepted for service.

During the first period of mobilization the acceptance for limited service of recruits, presenting certain specified neuropsychiatric defects, was authorized and recommendation to this effect was made in a considerable number of cases. With added experience the disadvantages of such a procedure became evident, as has been mentioned, and upon the recommendation of the Surgeon General, recruits presenting neuropsychiatric defects, with a few minor exceptions, were rejected for all military service. The most important of the exceptions mentioned was that certain mental defectives, especially negroes, be accepted for limited service in labor battalions. Reports regarding the service of men of this class left considerable doubt as to the wisdom of this policy.

The subject of aviation opened up a new and important field of neuropsychiatric activity, for it was found that even after the minute and prolonged examinations to which aviators were subjected, there was still room for special investigation of the nervous system. Three neuropsychiatric officers were detailed to the medical research laboratory at Mineola, Long Island, to study the problems peculiar to this branch of special work.

Because of the high physical and mental standards of fitness employed in the selection of men for this arm of the service, the neuropsychiatric problem here was different from that associated with the ordinary work of elimination for mental and nervous disease or defect carried on in the other branches of the service. The psychiatric work at Mineola was more than the mere search for pathological conditions through the observation of more or less gross signs or symptoms, or even the more extended examination of men suspected of mental or nervous disease. Because of the superior type of human material needed for the Air Service and the special stresses and strains of aerial warfare, this work took on the character of refined personality studies in which the more difficult and less tangible emotional factors had to be considered and dealt with.

Such personality studies were made after the examination of several hundred aviators and after numerous conferences with American officers who had seen service at the front, and with representatives of our allies. The


71

psychiatrist had three definite objects in view in making these studies: (1) To detect the presence of nervous and mental diseases which would render the aviator temporarily or permanently unfit for service; (2) to form a definite idea as to what extent the aviator could stand the pressure of life at the front; (3) to determine, and as far as possible to compensate for, the existence of any latent tendencies which, under the strain of actual warfare, would become so accentuated as to make the aviator either inefficient, or to increase his danger of nervous and mental collapse.

The value of these brief studies in reducing the number of casualties due to preventable causes and in increasing efficiency, it is believed, was clearly demonstrated. It was felt that the information obtained had a direct practical bearing in assisting the aviator to maintain his morale and to make a rational effort to direct all of his nerve and brain power, without useless dissipation, to the task of winning the war. The following cases are examples of the advantages accruing from a psychiatric service for aviators:9

Case 1.-A typical case of mild manic excitement, marked by motor restlessness, slight but well marked irritability, typical elation and desire to talk, was examined one forenoon and pronounced unsafe for flying. This aviator, although forbidden to fly, disobeyed orders, took the plane up, and crashed on attempting to land. The machine was partially wrecked, and by a miracle neither the observer nor the pilot was seriously injured.

Case 2 - One of the best pilots, who had had 300 hours in flying, lost nerve and when ordered to fly refused to go, saying he was sure an accident would follow. This aviator was referred to the neuropsychiatric department for examination, and it was discovered that his sudden loss of nerve was due to an unsolved personal problem which he had attempted to dodge and to forget. After one week's treatment in which assistance was given in settling the difficult situation, his nerve returned and he was practically as efficient as ever.

In a number of cases studied the symptoms of mental staleness and mental fatigue were present. These symptoms were characterized by loss of interest in work, a tendency to analyze details and forget the main object in view, and a certain recklessness, the result of defective inhibition. Serious accidents would have followed had these aviators been allowed to fly before they had gained their emotional equilibrium. Many serious accidents occurred as the result of the failure to recognize the importance of the initial symptoms of fatigue and staleness.

NEUROPSYCHIATRIC EXAMINATIONS IN CAMPS

The following discussion of neuropsychiatric examinations made in camps is based on the reports to which they are credited, without comment as to the findings:

IN RECRUITING AND CANTONMENTd

The neuropsychiatric work in the cantonment presented special features which were quite different from those in military hospitals. In the latter, neuropsychiatry was similar to that in civil hospitals, or civil practice. In base hospitals one found chiefly obvious disorders, which had been referred for examination and treatment, by the regimental surgeons, who as a rule were not very familiar with such conditions. In the cantonment, cases of the same class

dNeuropsychiatry in Recruiting and Cantonment, by Maj. M. S. Gregory, M. C. Archives of Neurology and Psychiatry, 1919, i, No. 1, 89.


72

were met with, but, in addition, one encountered a special type, which rarely, if ever, found its way to the base hospital, by reason of the fact that the true character of such disorders was not recognized and very frequently they were regarded as entirely foreign conditions, such as malingering, carelessness, shiftlessness, delinquency, and inattention to duty.

TYPES OF DISEASES OBSERVED

These cases were not dissimilar to those found in civil life, only modified by the natural differences, such as age, sex, climate, geographical conditions, care in selection, etc. One encountered gross organic nervous diseases, such as early tabes, paresis, multiple sclerosis, peripheral neuritis, neurosyphilis, residual from old poliomyelitis, occasional brain tumor, and other conditions, on the one hand, and, on the other, well-developed dementia pręcox, manic-depressive psychoses, mental deficiency, alcoholism, drug addiction, epilepsy, and well-marked psychoneuroses.

Between these two extremes, there was a host of intermediary conditions, such as mild neuroses and psychoneuroses, neurasthenias, anxiety states, hysterias and hysteroid episodes, epileptoid conditions, psychopathic personalities, inferiors, military misfits, and otherwise near-normal individuals. Cases of this group were, of course, the most baffling and taxed the ingenuity and resourcefulness of the examiner to the utmost. Moreover, they constituted a greater menace to the military organization, by lowering the efficiency and impairing the general morale, than did the obviously diseased types which were readily recognized and without great difficulty eliminated. They were constant sources of annoyance and trouble to the officers, forming the larger number of the absentees, the discontented, the inefficients, the inmates of the guardhouse, and the frequenters of the regimental infirmary. These were the cases which complained of being dizzy, faint, and bewildered at critical moments, while in training or maneuvers.

The psychoneurotic formed the largest and most important of this intermediary group. As they presented themselves in the cantonment, and based on the duration and mode of onset of their malady, they were classified, for practical purposes, into three groups:

The first group consisted of those in whom the disease existed long before their entrance into the Army. These, as a rule, had neuropathic family histories and had been unstable and more or less shiftless, long prior to the onset of the neuroses. Curiously enough, many of the neurotics of this type were found among the enlisted men who had been advised, by physicians, to enter the Army with the assurance that the discipline and outdoor life would correct their trouble. Others had enlisted without much advice, although they themselves had entertained the hope that they would derive benefit from military service. According to their own statements, all seemed to have felt quite improved for a short period immediately after their enlistment. However, this amelioration was of brief duration. Our experience was that this type of neurotic was quite unfit for military service and that the entrance of such individuals was detrimental to themselves as well as to the Army.


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The second group comprised those in whom the disease arose while they were in the Army, following an accident, injury, or some somatic disorder, such as rheumatism, bronchitis, etc. The neurosis was referred to and intimately connected with the injury or disease. These men, as a rule, had a better family and personal history than the former group and recovery of a small proportion might be looked for in camp.

The third group was made up of men whose antecedents had been apparently free from neurotic taint and in whom the hysterical conversion had not been definitely established, remaining latent or just beneath the surface and usually corrigible by educative and environmental influences.

METHOD OF APPROACH

One hardly expected to be received with enthusiasm when one arrived at a camp to do neuropsychiatric work. There appeared to be, on the contrary, with very few exceptions, a lack of interest or an indifference or a manifest skepticism; not infrequently there was a passive, or even an active, antagonism to any examination of this sort. Strangely enough, the medical officers were the chief passive obstacles and, in the very beginning, very little assistance or cooperation could be obtained from them. So the first effort at a cantonment had to be directed to the officers, especially the medical officers, with the view of demonstrating to them the practical value of such examination in order to enlist their sympathy and cooperation. They had to be made to appreciate the importance of neuropsychiatric examinations. In order to accomplish this, one frequently had to resort to tact, persuasion, or even strategy.

In dealing with this situation of passive resistance, it was desirable in the beginning to report as unfit for military service only men with obvious nervous or mental disturbances in whom one could show the disorder in its early phases and point out how the disease influenced the soldiers' conduct and efficiency. For example, the painstaking demonstration of early cases of tabes, of disseminated sclerosis, of paresis, of dementia pręcox, or of manic-depressive psychosis, which had been unrecognized and unsuspected, went a great way in rousing the interest and even the enthusiasm of the medical officers. The greatest help to the neuropsychiatrist came, however, from the line officer, and particularly the company commander. It may seem strange, but it is nevertheless true, that the line officers appreciated the value of neuropsychiatric examinations much more readily than did the medical officers.

The explanation for this was found in the fact that the line officer rated his men in terms of conduct, behavior, and efficiency, which, after all, was equivalent to the standard of the neuropsychiatrist, who estimated conduct from the mental qualities and make-up of the individual. If a company of soldiers be carefully examined from the neuropsychiatric standpoint and the results compared with the reports furnished by the company commander of men in his organization who have been inapt, inefficient, slow, awkward, easily fatigued, delinquent, insubordinate, and difficult to get along with, a striking parallelism will be found between the two sets of observations.

Experiences of this character naturally brought the line officer very close to the neuropsychiatrist. The officer eagerly sought counsel and aid, as he at


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once recognized that he and the examiner were dealing with similar problems. The neuropsychiatrist might be called on by the commanding officer to give advice in the matter of discipline of the force and even in the rating of the efficiency of his officers.

In a hastily formed army like ours, especially under a system of draft, there was a great demand on the individual soldier for a rapid and violent adjustment. Men without any previous military experience, drawn from every walk of life-from distant parts of the country, from farm and factory, bank and bench, the rich and the poor, the illiterate and the educated-all were thrown together in a heterogeneous mixture and subjected to the same discipline, the same regulations, and the same daily routine.

It was most astonishing how well and how rapidly they adapted themselves under these most difficult conditions. However, there was a small number in whom this adjustment did not readily take place. It was among this class of men that one observed pathologic reactions in the form of sluggishness, discontent, inadaptability, lonesomeness, nostalgia, lack of application, lack of initiative and ambition and, therefore, military inefficiency. Some of these, of course, were of markedly pathologic make-up, but the great majority were men to whom the neuropsychiatrist could be of the greatest assistance. These were the border-line cases, the potential neurotics and psychotics, in whom preventive psychiatry found a most fertile field.

Many patients of this kind, although able to get along fairly well in camp, suffered a definite breakdown at some critical time, such as just before embarkation; others were returned from overseas before they had seen any active service at the front.

SUGGESTIONS AS TO PROPER SUPERVISION

It was surprising how much the advice, encouragement, assurances, personal contact and attention, and trivial changes in environment would do for these men. That this was not mere theory, but intensely practical, could be readily demonstrated in a military camp or cantonment. The following are a few brief illustrations:

The attention of the neuropsychiatrist was called to a soldier who was indifferent, inefficient, lazy, and seemingly lacking in initiative. Examination revealed that he came from a large city, had had a high-school education, had worked as a salesman, and had a salary of from $75 to $100 a week. He was made assistant in the camp to a kitchen worker, who was illiterate, far below him socially, and whose earning capacity had never been more than $12 a week. The soldier did not complain of this, nor could he give any conscious reason for the change in his efficiency and conduct, which, however, he acknowledged. His commanding officer was advised to place him in another department where his talents would find a better expression. Within a week a striking change had come over his disposition and he was regarded as a most useful, energetic worker and a promising soldier.

A soldier serving as a waiter at an officers' mess showed mild mental depression. He was regarded as slow, inattentive, and inefficient. He complained of insomnia, nervousness, headache, dizziness, and inability to take any interest


75

in things. He was unable to assign any cause for his disability. He was anxious to be a soldier and serve his country. It was further found that he was a recent graduate of a New England college; had been brought up in affluence and comfort, and was socially equal or superior to many whom he attended as a waiter. He consciously did not resent his position, because he felt that it was a part of military life. The commanding officer, on recommendation, assigned him to another kind of work more in keeping with his talents and experience. He soon became active, energetic, and efficient. He was regarded as good material for a soldier and was rapidly promoted. These actual cases were selected from a large number of records.

RESULTS THAT MIGHT BE EXPECTED

There were many soldiers who voluntarily sought the advice of the neuropsychiatrist because of nervousness, dizziness, inability to sleep, poor appetite, indefinite pains, etc., and who, with marvelous rapidity, yielded to treatment by the "nerve specialist" of the camp. The amount of effective effort which could be achieved in applied neuropsychiatry in the Army was limited only by the experience, interest, and ability of the neuropsychiatrist. The neuropsychiatrist was no longer one who merely selected obvious cases of nervous and mental disease for elimination from the Army, but was one who also healed, repaired, conserved, and reconstructed. He became the guardian of the mental health, just as the sanitary surgeon was responsible for the physical welfare of the military organization.

AT CAMP PIKE, ARK.e

To the neuropsychiatrists fell the work of eliminating the nervous and mentally unfit among the recruits. This examination was made in connection with and as a part of the regular physical examination. While it is true that in some instances the attempt was made to unduly rush the work, and as a result a few men slipped through who should have been rejected, yet, taken in the aggregate, this number was very small and these few cases were generally detected later, since the troops had to undergo another neuropsychiatric test before being accepted for overseas duty.

The average neuropsychiatric board consisted of five or six members and, as a rule, worked in two sections. In the course of the regular routine examination the recruit came before the first section of the board where he was given a short neurological and psychiatrical examination, and if there was a suspicion of any abnormality he was referred to the second section, where he was subjected to a very careful examination and either accepted or finally rejected. If there was still doubt regarding his case he was sent to the psychopathic ward of the base hospital, where he was closely observed and all necessary tests made to determine his true nervous and mental status.

When the draft first began in the fall of 1917 the instructions to the local boards were not very clear and explicit and were sometimes difficult to properly interpret; as a result, a number of recruits were found unfit for service when

eWork of the Neuropsychiatrists in the United States Army Camps, by Capt. Hermon S. Major, M. C. Journal of the Missouri State Medical Association, 1919, xvi, No. 11, 377.


76

they were examined by the special boards at the camp and consequently were returned to their local boards. As time went on the local board became more critical and did quite a good deal of eliminating at home. As an illustration of this, the following results of some neuropsychiatric examinations, taken from the report of the neuropsychiatric board at Camp Pike, Ark., are given: May 7 to May 26, 1918, number examined, 9,834; number rejected, 199, or 2.02 Percent. May 26 to June 20, number examined, 10,338; number rejected, 165, or 1.59 Percent. June 21 to July 16, number examined, 19,178; number rejected, 190, or 0.99 Percent. July 16 to August 23, number examined, 22,020; number rejected, 173, or 0.79 Percent. August 23 to September 21, number examined, 22,649; number rejected, 123, or 0.54 Percent.

The steady decrease in the number of rejections at this one camp would tend to prove that either the local boards were more carefully eliminating the nervous and mentally unfit or that the neuropsychiatric board was more lax in its examinations, but since practically the same board worked at Camp Pike during this time and under the same instructions, this hardly seems plausible, especially in view of the fact that the same conditions obtained with the other special boards at this camp during the above-mentioned time.

AT CAMP DEVENS, MASS.f

The following is a brief summary of the neuropsychiatric examination of 170,478 soldiers at Camp Devens, Mass. There were rejected for all neuropsychiatric causes 1,787 men. These examinations were conducted from early in September, 1917, until November 11, 1918. The classification of diseases used is the one furnished by the division of neuropsychiatry of the Surgeon General's Office.

The first subdivision is that of nervous disease or injury. Under this heading were rejected 389 men. As the accompanying table shows, the majority of these rejections were for epilepsy. The diagnosis of epilepsy is by no means so hard as some imagine, if the patient, on physical examination, presents the characteristic mental symptoms and in addition has scars on various parts of the body and head caused by injuries while in convulsions, or if the tip and sides of the tongue are scarred; the symptoms were considered sufficient for rejection. If the patient stated that he had epilepsy and could show none of these signs, he was observed in the neuropsychiatric wards of the base hospital. The orderlies there were trained in the observation of convulsive attacks, particularly in disturbances of the tendon reflexes, and whether or not the pupils reacted to light during and after the attacks. In our experience the reaction of the pupils to light is the very best single test in the differentiation between epilepsy and hysteria. So far as we know, the pupillary reflex to light is always absent in an epileptic attack and never is in an hysterical attack. The other subheadings under nervous disease and injury will readily explain themselves. The small number of cases of syphilis of the nervous system is no doubt explained by the ages of the men examined. They were rather too young to show tabes

fReport of Neuropsychiatric Work at Camp Devens, Mass., by Lieut. Col. L. Vernon Briggs, M. C., and Maj. Morgan B. Hodskins, M. C., New York Medical Journal, 1921, cxiii, No. 14, 749.


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dorsalis, and no doubt most of the frank cerebrospinal cases were rejected by the local draft boards.

Under the heading psychoneurosis, 249 were rejected. The cases of stammering were rejected at time of examination. The others were always observed for some time, either in their organization or in the base hospital, before they were rejected.

There was a total of 167 rejections under the heading psychosis. Some of these cases were rejected immediately, as they came to camp with a frank psychosis. In others, psychosis developed after the patient had been under military training for some time. A psychotic individual does very poorly in the Army. As soon as he is subjected to military discipline he usually breaks down.

Under the heading inebriety there were 57 rejections. These rejections were made after the patients had been under observation for a few days and showed the well-known withdrawal symptoms. The patient listed as a case of drug addiction, opium, was addicted to the use of camphorated tincture of opium. His statement was to the effect that he would take more than a pint of this a day, and he showed well-marked withdrawal symptoms. Forty-five cases were rejected for chronic alcoholism.

Under the heading mental deficiency, as one would expect, there was a large number rejected, a total of 813. These men were nearly all returned to their homes.

Under the heading of constitutional psychopathic state there were 68 rejections. These men were rejected only after they had been observed in their companies for some time, and had proved themselves so totally unfit for military service that it was necessary to reject them.

NERVOUS DISEASE OR INJURY

PSYCHONEUROSIS

pilepsy

261

Hysteria

133

Cerebrospinal syphilis

11

Neurasthenia

64

Congenital syphilis with
nervous symptoms

Psychasthenia

12

Hemiplegia

7

Stammering

40

Paraplegia

6

Total

249

Tertiary syphilis with nervous svmptoms

30

PSYCHOSIS

Multiple sclerosis

9

Dementia pręcox:

Multiple neuritis

10

Hebephrenic

79

Paralysis, facial

4

Paranoid

31

Enuresis

8

Katatonic

11

Poliomyelitis, chronic

3

Simple

7

Sciatic neuritis

3

Manic-depressive

25

Chorea

13

Traumatic

1

Migraine

1

Epileptic

1

Myotonia congenita

2

Alcoholic-

Spinal meningitis, chronic

1

Acute hallucinosis

4

Congenital speech defect

1

Chronic paranoid

1

Hereditary tremor

2

General paralysis of the insane

6

Transverse myelitis

1

Psychosis, toxic

1

 

Tabes dorsalis

9

Total

167

Hereditary ataxia

1

INEBRIETY

Facial tic

1

Drug addiciton:

Nystagmus

1

Morphine

48

Hyperthyroidism

1

Heroine

4

Brachial neuritis

1

Cocaine

4

Destructive lesion of red nucleus

1

Opium

1

Total

389

Alcoholism, chronic

45

Total 

102

MENTAL DEFICIENCY

CONSTITUTIONAL PSYCHOPATHIC STATE

Imbecile

258

Inadequate personality

48

Moron

555

Paranoid personality

11

Total

813

Emotional instability

4

Pathological liar

1

Sexual psychopathy

4

Criminalism

1

Total

69

Total rejections

1,787


AT CAMP SHERMAN, OHIOg

This war brought about many innovations, and among them was a consideration of the individuality and of the mental and nervous condition of the prospective soldier. But the line officer did not always appreciate this or know what things to be on the lookout for in order to detect the indications of such abnormal conditions in the men as might be detrimental to the service. So a part of the work of the psychiatrist was to give talks to the line officers, telling them how the various mental and nervous conditions which interfere with the making or the dependability, or the endurance or the efficiency of the soldier, and what types of behavior he should be on the lookout for. Their cooperation in looking for these conditions and sending men for examination or observation was asked for. Some were very much interested and cooperated; others thought it all nonsense; others were indifferent. Such talks had to be arranged for with the regimental commanders. If one wished to talk to the medical officers only, the arrangements were made with the division surgeon. But it was advisable to talk to the nonmedical officers as well, and even to the noncommissioned officers, for they saw much more of the men than the medical officers did.

An important work of the psychiatrist was to make a survey of the whole personnel of the camp. The ideal way to do this would have been to have the recruits on arrival at camp come into special barracks where they could be held before being assigned to any organizations until the various special examiners could go over them at reasonable leisure. An approximation to this plan was made by having the recruits very hastily surveyed by the examiners as fast as they came in. The men were stripped and examined by the various specialists. The examinations had to be very superficial when over 1,500

gThe work of Psychiatrists in Military Camps, by Maj. E. Stanley Abbot, M. C., American Journal of Insanity, 1919, lxxv, No. 4, 457.


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men were looked over in a day. Many slipped through with defects which were detected some time later who would have been eliminated in the first place if only half the number were examined in the same period of time. Four neuropsychiatrists were able to make a superficial examination as fast as the other examiners made theirs.

Before even this plan was adopted, and wherever it had not been put into practice, a survey of the personnel, regiment by regiment, was made when possible. It was necessary to secure the cooperation of the commanding officer of the regiment for this. It was sometimes easily secured; sometimes he resented it as an interference with his work of training soldiers because it took the men away from their work. Whenever possible it was advisable to make the survey in cooperation with the tuberculosis or other examiners, for example, as it caused much less loss of the soldier's time. After the commanding officer had given his cooperation, arrangements were made with the regimental surgeon and the adjutant to have the men of a given company remain in barracks or report at the regimental infirmary at a given time. There the psychiatric examiners went over each man, testing pupillary and tendon reflexes, coordination and station, looking for tremors and for scars suggestive of epilepsy, and asking a few questions as to heredity, environment, schooling, convulsions, or nervous breakdowns, meanwhile noticing any peculiarities. Under the most favorable conditions, with a roster of the company and a clerk to check off the names and put down findings, one examiner could make a fairly thorough preliminary survey of from 150 to 200 men a day, according to their quality. But in actual practice that number could not be examined on an average, because of time lost in going from one organization to another, changes in daily orders in the organization, misunderstandings, etc. It was found at Camp Sherman that making allowances for Sundays, holidays, and unexpected interruption, interferences, and delays, one examiner could be counted on to go over about 2,800 to 3,000 men a month. The time available and the size of the command determined the number of examiners needed to complete a survey in a given time.

This type of survey was unsatisfactory, for it can never be complete. Men were transferred out from a company that had been examined and men from unexamined units were often put in to fill up the organization, and it was difficult for the examiners to go back and pick up these men.

Since the vast majority of the men who were found to have some nervous or mental disease or defect were incapable of making good soldiers, or of enduring without breaking down the stresses of warfare, they had to be discharged. It was part of the work of the psychiatrist to make the recommendations for discharge, giving the diagnosis, and stating how the condition interferred with the man's performing general military service. In some camps the psychiatrist made his recommendation to a general military service of which he might or could not be a member. At Camp Sherman three of the psychiatrists themselves constituted a disability board. This gave an opportunity to hold conferences over the cases, to which the other neuropsychiatric examiners and sometimes other physicians were invited.


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Some of the kinds of cases and of difficulties that confronted the psychiatrist can be illustrated by the experience at Camp Sherman:

The feeble-minded made up the largest single group of cases. Up to May 1, 1918, 134 out of 468 cases recommended for discharge were of this group.

Those measuring 12 years old and over were regarded as suitable material for the Army unless they were of unstable make-up, had shown economic or social inadaptabilities, or had some general physical disability, even though the latter were not sufficient in itself to be a cause for rejection.

At Camp Sherman the epileptics formed the next largest single diagnostic group. If the epileptics and organic nervous diseases were grouped together, this whole group was a trifle larger than that of the feeble-minded. Most of the patients could give a characteristic description of the onset of attacks, but in two there seemed to be absolute amnesia for them, and for having had them. One had a typical grand mal seizure, seen and described by a young physician; the other made a suicidal attempt in barracks and later in the hospital; no recollection whatever of either attempt could be elicited either by ordinary questioning or when hypnotism was attempted. No other cause for the suicidal attempt could be unearthed than a probable epileptic crepuscular condition.

Among the officers referred for examination, manic-depressive depressions predominated, and these were the most frequent of the actual psychoses seen at Camp Sherman.

There were many cases of neurasthenia following trauma or severe illness, and it was often a difficult matter to determine whether it was a real or an assumed disability. These cases were usually kept under observation several weeks, and information was sought from physicians who had attended them in civil life. Consultation with the orthopedists or other specialists was frequently held. X-ray examinations were usually negative, as were the results of spinal puncture and Wassermann tests. There were other types of neurasthenia, some with a number of vagotonic or hyperthyroid symptoms, without thyroid enlargement. These were recommended for discharge on the ground that they were not capable of standing the strain of general military service, nor even of domestic service. By searching inquiry one could elicit from almost all men an occasional neurasthenic or fatigue symptom.

When a large number of drafted men was received there were always a few cases of alcoholism, delirium tremens, and drug addiction. The confirmed habitués could not be kept in the base hospital long enough to be reconstructed, and once they were in the ranks they could get the drug with comparative ease.

There were not many constitutional psychopaths (35 in all), but a few-sexual perverts, paranoid personalities, and inadequate personalities-were found and recommended for discharge.

The cases examined with reference to whether they should be brought to trial or not were principally for repeated absences without leave or for desertion. One case was for forgery, another for stealing, and one, dementia pręcox case, for refusing to obey orders. Some were clearly feeble-minded, and proceedings against them were stopped and the men were discharged. Two measured between 12 and 13 years, but had good understanding of what they were doing-


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desertion in the one case, stealing in the other-and were allowed to stand trial. Another, measuring 14 or 15 years, had a long insane hospital and penitentiary record and was also regarded as being sufficiently developed to stand trial for forgery. The decision in these cases had to be made with different conditions in mind from those which obtain in civil life. There was no indeterminate sentence or probation. It was either full acquittal and return to the ranks, or sentence to the military prison at Fort Leavenworth.

A number of cases of persistent enuresis was under observation. Most of these were mental defectives, with rather small bladder capacity (280 to 350 c. c.). One was a very intelligent fellow whose father corroborated all the essentials in his claims of never having been able to control his bladder while asleep. He, like the others, was discharged.

AT FORT OGLETHORPE, GA.h

Recruits were examined as they came up for their physical examination at the local recruiting office, and a number were eliminated who might easily have been passed by the regular examining surgeon.

The most satisfactory work done was in the examining of the candidates for the second reserve officers' training camp at Camp Warden McLean. These examinations were held from August 29 to September 4 and were conducted by a large board of medical officers, including the tuberculosis board and the nervous and mental board. The routine examination was to test the pupillary reflexes, the superficial and deep reflexes, the gait and station, look for asymmetries and for scars of the head, face, and tongue, and for tremors, and to quiz them as to epilepsy, insanity, nervous trouble, syphilis, etc. The report on these examinations showed the following facts: (1) Eighty-seven noted as having neurological symptoms. (2) Of that number 25 were disqualified. (3) Each man was given the benefit of any doubt, and only those disqualified, whose symptoms were either pathognomonic of a serious nervous disease, or else of such a kind as to make one reasonably certain that they were unfitted for the service. (4) Thirteen were disqualified for Argyll-Robertson pupils, either with or without other symptoms, on the ground that, unless properly treated, sooner or later they would be entirely unfitted. (5) Ten were found with irregular pupils and 10 with unequal pupils; none of these was disqualified, though if Wassermanns had been done doubtless many of them would have been disqualified. (6) Of the others disqualified, 1 was a probable case of general paresis, 2 were psychoneurotics, 1 a case of hyperthyroidism, 1 an epileptic, and the majority of the remainder showed signs of cerebrospinal syphilis, all of whom were unquestionably unfit for the active duties of an officer.

AT CAMP UPTON, N. Y., AND CAMP GORDON, GA

From May to September, 1918, inclusive, 54,000 recruits were examined at Camp Upton, N. Y. Of this number, 1,050, or 2 Percent, were rejected for

hLetter from Capt. D. R. Gilfillan, M. C., base hospital, Fort Oglethorpe, Ga., Sept. 15, 1917, to Dr. Frankwood E. Williams, New York, N. Y. Copy on file, Historical Division, S. G. O.
iNeuro-Psychiatry in Army Camps, by Maj. George E. McPherson, M. C., Boston Medical and Surgical Journal, 1919, clxxxi, No. 21, 606.


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nervous and mental disorders. At Camp Gordon, from July to October, inclusive, out of 58,850 men, 1,225, or 2.8 Percent, were rejected for similar disease and conditions.

At Camp Upton drug addicts constituted 17 Percent of the rejections for mental disease, while at Camp Gordon they made up 3.27 Percent of such rejections. A survey of 100 drug addicts gave them a mental age rating of 12 years, which is not materially different from that of other soldiers of the same educational-industrial level. As a rule, however, they were unskilled or poorly trained workers whose schooling, in 50 Percent of the men, did not extend above the fifth grade. Only 10 Percent were foreign born, and the 100 were equally divided between two Army drafts-one white, the other black. In both classes the drug addict from a rural community seemed to be a rare specimen.

Out of the 100 cases surveyed, 56 had been committed to penal institutions on charges other than drug addiction. Seventy-two men reported 173 unsuccessful attempts at a cure. Although not measurably deficient, these men were certainly inferior in fields other than intellectual.

One would have supposed that such cases as epileptics would have been well weeded out by various draft boards with less difficulty than obtained in many other classes of registrants. However this may appear, large numbers of epileptics entered camps, later to be discharged when their disabilities came to the attention of the neuropsychiatric examiner. Many men came to camp in the drafts with definite histories of seizures, showing scars on bodies and tongues, while some showed quite marked deterioration. Such were rejected, even on suspicion, some may say, but such a course seemed the common-sense one. There was, of course, no defense against the epileptic who willfully deceived and who showed no evidence of his infirmity. One simply had to wait for his attacks, and fortunately they generally appeared quickly under the ardors of drill. Probably about 3.5 Percent of 1,050 rejections were because of this disease.

MENTAL DEFICIENCY

Thirty Percent of rejections for nervous and mental disabilities were for mental deficiency, about 0.6 Percent of all cases examined. Such men offered a serious problem, as one had to overcome the disinclination of others to allow rejection of a man who looked healthy and strong. Orders from Washington instructed examiners to consider no man unfit for military service who should grade up to or over 10 years, mental rating. One must also grade 8 years or lower before he was to be considered unfit thereby for domestic duty.

It was believed that no other class of men made for so much mischief in the Army as did the feeble-minded. The stories of such soldiers proved the statement that ability to get along in civil life did not, of itself, insure satisfactory Army service. Such an idea was not workable, and a large number of cases examined were of just such soldiers who could not get along in a strange and exacting environment.


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Psychological group examinations rendered an important service in calling to attention men who graded low, and that earlier than without such rating. All such were referred to the psychiatrist from the psychological boards, and in many cases were accompanied by a recommendation for rejection. More careful consideration of these men would find some fit for domestic duty, but, on the whole, the low raters did not prove "worth their salt."

The defects in fields other than intellectual were generally brought to notice when the higher grades of morons, for instance, failed to fit properly into their several assignments or organizations. Much that was reckoned as criminality or insubordination can be charged to the mental deficiency of these soldiers.

PSYCHOTIC CASES

The psychoses were limited to relatively few varieties. Manic-depressive psychoses were present in very small numbers, especially while the drafts were coming in. Most of the insane in the camps fell into the schizophrenic group and were generally called dementia pręcox. In practically all of such soldiers it was possible to obtain outside histories which, together with the patients' stories, appeared to indicate that the acute psychotic episodes were but other stages in conditions which had existed for some time, even if below the surface. After worry at home over the draft to come, many men seemed just to go to pieces once they reached camp.

The alcoholic psychoses were not numerous. There were few cases of chronic alcoholism. Acute alcoholic hallucinosis was found in but few men. Outside of numerous men who had endeavored to accommodate themselves to too many farewell parties and who came to camp intoxicated and shaky, alcohol did not cause much concern in the examination of recruits.

Neurosyphilis contributed many cases for rejection, taken in the aggregate. In one draft of 800, luetic cases amounted to 0.7 Percent of men examined. The cities seemed to furnish a much larger percentage of luetic disabilities than did the country.

Experience in camps terminated a bit too early to speak of the toxic-infectious psychoses, of which little was seen.

CONSTITUTIONAL PSYCHOPATHIC STATES

Under this heading one may speak of a large group of men, many of whom were accepted for service only to become very unhappy and a source of great concern to everyone interested. At Camp Upton 50 were discharged during five months, while at Camp Gordon 299 were thrown out in four months. Emotional instability, inadequate personality, and sexual psychopathy provided the subdivisions under which the majority of psychopathics were classified. These three classes just mentioned were found to consist of poor material to begin with, and the demands of war did not help them in their adjustments.


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PSYCHONEUROSES

One can hardly describe the amazing story of this class of recruits and other men who had entered the service only to fall by the wayside when active duty was undertaken. It is difficult to believe the frequency with which men were turned down for inability to drill or to march. Enuresis, hysteria, neurasthenia, and stammering furnished a large quota of rejections and discharges. It was interesting to learn the frequency with which other forms of the psychoneuroses had previously been afflicted with enuresis. Needless to say such men were constantly referred for disposition.

RESULTS

For the reasons that have been given, not all the soldiers admitted to the Army were examined by neuropsychiatrists, but the large majority of them were examined, by one method or another. Not all who were examined and found unfit for service were discharged, and not infrequently these came later to attention not alone through admissions to hospitals but also in more tragic ways.

Prior to February 1, 1919, there had been returned from the American Expeditionary Forces 4,039 cases of nervous and mental disabilites, a small number when it is considered that nearly 2,000,000 troops had been sent overseas and especially when deduction is made of the 3,181 soldiers who were sent overseas in the face of psychiatric recommendations to the effect that they were not fit for military service of any kind. The insane, suicide, and delinquency mates in the American Expeditionary Forces were extraordinarily low for an expeditionary campaign.

The accuracy of the examinations is attested by the fact that there was substantial agreement in results at different points, that they coincided almost exactly with the results recorded in the reports of the local boards as prepared by the Provost Marshal General of the Army, and by the fact that individuals detected and discharged at one camp were later again detected and discharged from another camp to which they had been sent. Local draft boards did not always take as final the rejection of recruits and when called upon for another increment of men would include in this increment, to be sent to another camp, men rejected at the first camp as nervously or mentally unfit. Records were received in the Surgeon General's Office of men detected and discharged from as many as five different camps, each time by a different group of examiners.

One other factor should be considered-a factor already hinted at, which refers less to the good of the Army than to that of the country as a whole. It has become clearly apparent that it is not the Army alone which makes war in these days. The whole country makes war, and like the Army, it, too, has military necessities which must be recognized. It can make use of many individuals who would be useless to the Army, and it should have exempted from it those whom the Army might take without being able to use. It seems to be incontestably proved that men who would not become insane in civil life, become insane through the suppression of individualism necessary in military life. If it can be shown that this is equally true for the neuroses and the military offenders, there will be collected a large class whose members, useless to the military, may be counted on for partial service in the civil community.


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Partial service under military control is only moderately successful with any class, and in the class of psychopaths, in this country at least, it was a complete failure. The following circular letter was promulgated by the Surgeon General regarding this matter:10

It is the opinion of this office that there are no border-line cases in neuropsychiatry with the exception of certain cases of mental deficiency and drug addiction. The nervous instability of the psychoneurotics and those suffering from organic nervous diseases is such that they soon break down even in domestic service, and become a burden to the Army. If they are not fitted for full military service, they are fitted for no military service. Many of the cases of mental deficiency may be found fitted for labor battalions or domestic service. This is particularly true of the negro troops. At present no facilities are available for treating and rehabilitating the drug addicts.

The assignment of psychopathic individuals to the development battalions was tried but soon given up. It would seem wiser, to leave to the civil community from the beginning these individuals who can not be made into soldiers.

In addition to the rejection of recruits, it was considered important to prevent from being returned to duty, or discharged on duty status, those who had suffered from psychoses, even if they had recovered from them in the service. The recommendation was made accordingly by the Surgeon General that cases of this class should be discharged on Form 17, A. G. O., regardless of any improvement or cure that might have taken place.11

The various types of nervous and mental diseases which disqualify from military service will be discussed elsewhere. They are, with the number of each class rejected as of May 1, 1919:11

Number

Percent

1. Psychoses, or mental diseases

7,910

11

2. Epilepsy

6,388

9

3. Organic nervous diseases

6,916

10

4. Glandular disorders affecting growth

4,805

7

5. Neuroses, or functional nervous diseases

11,443

17

6. Inebriety (alcohol and drugs)

3,878

6

7. Mental defect

21,858

31

8. Constitutional psychopathic state

6,196

9

Total

69,394

100


REFERENCES

(1) Letter from The Adjutant General of the Army, to the Surgeon General, July 22, 1918.
Subject: Mentally unfit in replacement troops. (Transmitting extract from cablegram No. 1464, dated July 15, 1918, from General Pershing.) On file, Record Room, S. G. O., 201.6 (Misc. Div.).

(2) Memorandum for Colonel Howard, S. G. O., from Frankwood E. Williams, major, M. C., division of neurology and psychiatry, S. G. O., August 14, 1918. Subject: Enlisted men recommended by psychiatric examiners for discharge already carried abroad with organizations, despite recommendations to the contrary. Copy on file, Historical Division, S. G. O.

(3) Circular No. 22, S. G. O., August 1, 1917. Subject: Examinations in nervous and mental diseases.

(4) Letter from The Adjutant General of the Army to all department commanders; the commanding generals of all divisions, and ports of embarkation; and the commanding officers of all camps, recruit depots, excepted places, August 22, 1918. Subject: Special examiners.


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(5) Office Order No. 97, S. G. O., November 30, 1918. On file, Record Room, S. G. O., Correspondence File 342.15 (Misc. Div.).

(6) Letter from the Surgeon General, U. S. Army, to the Division Surgeon (name of division and camp) (undated). Subject: Recognitions and elimination of the mentally unfit and of those suffering from nervous disease. Copy on file, Historical Division, S. G. O.

(7) Circular Letter from the Surgeon General, U. S. Army, to division surgeons, October 18, 1917. Also: Bulletin No. 4, W. D., February 7, 1918.

(8) Mimeographed memorandum for organization commanders, concerning neuropsychiatric surveys.

(9) Report on Hazelhurst Field, Mineola, L. I., by Maj. Stewart Paton.

(10) Circular Letter, S. G. O., undated.

(11) Circular Letter No. 95, S. G. O., February 19, 1919. Subject: Disposition of insane.

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