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Section I, Chapter V

Table of Contents

CHAPTER V

OBSERVATION AND TREATMENT

All patients admitted to the neuropsychiatric wards received a complete physical, psychiatric, and neurological examination and, where indicated, psychological and special laboratory examinations. The following "Guide," prepared by the National Committee for Mental Hygiene, was found helpful in the psychiatric and neurological examinations:

GUIDE TO THE PSYCHIATRIC AND NEUROLOGICAL EXAMINATION OF PATIENTS AND THE RECORDING OF THE OBSERVATION

The following notes are designed to serve as a guide to the psychiatric and neurological examination of patients in the military hospitals of the Government in order to insure uniformity of recording.

PSYCHIATRIC EXAMINATION

In the guide to the psychiatric examination not only the special cases which may be encountered as a result of war, but also all the types of psychoses and neuroses which occur during peace time as well have been considered; in other words, an attempt has been made to cover all possibilities in this outline, but to do it with special reference to the needs of a hospital receiving only military patients.

The different aspects to be looked into in cases with mental symptoms (be they of the nature of definite psychoses or of psychoneuroses) are grouped under several successive headings. It is by no means necessarily the sequence which is best followed in every instance. We have to be guided in this by the condition of the patient, but it is important that all of these aspects should be covered in every case. On the other hand, it should be borne in mind that a given case may be so obviously normal in regard to some of these aspects that that part can be dismissed with a very brief examination.

The examiner should make use of his own knowledge of military life and make constant comparison between the patient's attitude toward the various phases of life in barracks, camp, or the field, and his own observations as to the attitude of other soldiers. The examiner should make the best possible use of the fact that all his patients are soldiers.

I. BEHAVIOR, ATTITUDE, AND EMOTIONAL STATE

Observe first the general demeanor of the patient as he enters the room (the condition of his uniform, his hair, his finger nails, etc.), and his reactions to a few simple questions of the type which a physician would naturally ask, such as questions about the patient's health, comfort, etc. Note also whether he shows evidence of loss of sleep, having been crying, bruises, suggesting fighting or rough handling. Note whether he is mindful or unmindful of the attitude of a soldier with an officer; whether his attitude toward the examiner is respectful, hostile, friendly, puerile. At the end of the examination the preliminary observations should he supplemented (in this part of the record) by a summary of the observations regarding behavior, attitude, and emotional state, which are made throughout the examination. 

A. Accessibility.

(1) Natural, free, alert.
(2) With definite emotional changes.

(a) Depressive: Depressed, gloomy, worried, uneasy, anxious, fearful, etc.

(b) Elated: Satisfied, happy, exuberant, etc.
More complex emotional states: Suspicious, disdainful, perplexed, etc.


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B. Inaccessibility.

(1) Without definite emotion: Apathetic, dull, somnolent.

(2) With more active emotional changes: Depression, anxiousness, uneasiness, tenseness, perplexity, suspiciousness, disdain, etc.

Certain reactions may at once lead naturally into questions as to what is the trouble; e. g., with an evident worry, one would ask, What is it you worry about? or, What can we do for you? and the like.

II. MOTOR CONDITION

A. General motility.

(1) Normal.

(2) Overactivity, excitement.

(3) Diminished activity, such as slowness of motion (constant or inconstant), complete inactivity, possibly with catalepsy, resistiveness.

(4) Queer, bizarre actions.

B. Speech.

(1) Normal in amount.

(2) Increased in amount (talkative, singing, shouting, noisy).

(3) Diminished in amount; slow speech (constant, inconstant), mutism.

(4) Disordered (other than defects suggesting organic trouble), stuttering, "baby talk," explosive, accompanied by facial contortions, movements of hands, etc.

III. STREAM OF THOUGHT

In spontaneous speech or answers to questions.

(1) Clear, logical, relevant.

(2) Jumping from topic to topic but with fairly comprehensible associations.

(3) Retarded.

(4) Irrelevant-incomprehensible, disconnected, with queer ideas.

(5) Fragmentary, often disordered words, paraphasia and difficulty in word finding.

All this may be observed in the patient's spontaneous speech and in answers to questions. If he is not spontaneous, then ask further questions. In this it is best to follow the patient's lead.

IV. CONTENT OF THOUGHT

(1) Content of any worry or anxiety regarding present and past situations, physical complaints; apprehensions about the present and future, etc.

(2) Compulsive ideas, obsessions, phobias.

(3) Delusions, hallucinations, peculiar mental attitudes. Some of these may have come out before. In that case it is best to summarize briefly what has been obtained thus far and then to proceed with recording the further study.

It should be remembered that it is not merely a question of recording the existence of delusions and hallucinations and the like, but a question above all of inquiring into and recording their content. Give patient's own words regarding hallucinations, etc.

If nothing has thus far been obtained and the patient makes, nevertheless, the impression of being psychotic, the following questions may bring important ideas:

Have you had any peculiar experiences?
Have people said things about you?
Does any underhand work seem to be going on?
How do you fit into the company (battery, mess, wardroom)?
Has anyone made queer remarks? Made veiled references to you?
Do things seem natural or unreal?
Do you hear voices? Or, sometimes one may simply ask: What do they say?
Have people done things to you?
Has everyone been kind to you?
Have you had strange dreams?
Have you had visions?


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Sometimes questions about certain topics bring out peculiar mental attitudes or peculiar ideas, such as:

What do you think about electricity, or magnetism, hypnotism, thought transference, wireless telegraphy? etc.

Sometimes the question, Who are you? leads to important answers.

V. ORIENTATION

Does the patient know the day, month and year? Does he know what place he is in, who the persons are about him; or does he understand, at any rate in a general way, the situation?

VI. MEMORY AND THINKING

(1) With regard to old events.

(a) Inquiry into life history before the advent of the psychosis or neurosis as regards the main data (birthday, positions, dwelling places, as well as inquiry about events since enlistment, etc.), with dates. This gives a good idea of the patient's capacity to think and correlate the different facts (look for discrepancies) as well as of his memory.

(b) Calculation-simple tasks are a matter of memory; more difficult ones test the patient's capacity for concentration and thinking.

(c) Writing-spontaneous and to dictation.

(2) With regard to recent events: Such questions as, How long have you been in this place? Where did you come from? What happened yesterday? What did you have for dinner? etc., will be found useful. (Examiner should use freely his own knowledge regarding military routine.)

Definite tests for retention, such as the remembering of a name and address for two or three or five minutes while questions are asked during the time intervening. For span of memory, test the patients capacity to repeat series of 8, 6, or 5 digits.

VII. INTELLECTUAL LEVEL

If it is settled that no interference with the thought processes exists, an attempt should be made to determine this patient's intellectual level. Test especially the general information regarding the patient's habitual environment, as well as the knowledge he is supposed to have gained in his military experience. Refer also to the guide for the examination and determination of mental deficiency.

The mental tests are often of value even when the permanent intellectual level can not be obtained, since the details of functional capacity may prove of diagnostic value if successive spaced examinations are made.

VIII. THE PATIENT'S OWN ACCOUNT OF THE DEVELOPMENT OF HIS PSYCHOSIS OR NEUROSIS

The object here is to trace in detail the origin and development of the condition from which the patient suffers. Even if inaccurate or obviously inconsistent, the patient's account is, nevertheless, important.

In the case of mental disorders, functional or organic, due to the more specific war causes, it is especially important to inquire into:

(1) The patient's mental make-up before enlistment as regards success or failure in life; the extent to which he was able to get along with other people; his capacity for adaptation to new situations; his habitual mood; his habitual reactions to difficulties in life, responsibilities, stress, etc.; special traits, such as fear of thunderstorms, fear of going underground, sensitiveness to seeing blood; his attitude toward the suffering of others, dread of special diseases or modes of death, etc.

(2) The patient's adaptation to the life of a soldier; i. e., his attitude toward the war, his adaptation to training, his adaptation to fighting. Note his first reactions to this (fear, horror, disgust). Inquire how these first difficulties were overcome, if they were overcome. Check up patient's story by reference to officers and comrades (see disciplinary record).


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(3) Details of any fatigue-producing situations, special stress or loss of sleep, etc.

(4) Reaction to fatigue ("jumpiness," irritability, tenseness, poor concentration, etc.).

(5) The first symptoms of failure of adaptation, if indicated by the patient's history, such as the wish of deliverance from the situation (note the special form which such wishes took, such as the desire to be wounded, to be taken prisoner, or the desire for death or the war ending); an increase of nervousness and anxiousness about his own safety; specific fears; the development of feelings of horror about the situation (note special supersensitiveness).

(6) Disturbing dreams (note content).

(7) Causes which led to the definite breakdown:

(a) Direct injury, wind concussion, burial, "gassing," etc.

(b) Witnessing unusually distressing sights; or friction with superiors or refusal of leave, or distressing news from home, etc.

(8) Onset of acute symptoms: Loss of consciousness (note duration); dazed condition; clouding of consciousness with variations in intensity, etc.

(9) History of condition since that time.

(10) History of treatment and its effects; also history of military management of patient's illness and the patient's attitude toward this.

In case of psychoses much regarding the development may already have been brought out, especially under the heading of content of thought. It is here gone into more thoroughly if the patient is thought capable of giving it.

IX. ATTITUDE TOWARD THE MENTAL OR NERVOUS DISORDER

In psychoses this refers especially to the question of whether the patient understands that he is mentally ill.

In the neuroses it refers more to the attitude in general which he takes toward his symptoms, e. g., does he think they are all due to stress or partly to his own failure in adaptation?

NEUROLOGICAL EXAMINATION

Condition of body

Facies, growth, abnormalities in development, glandular trophic and vasomotor phenomena, including variations in weight, growth of hair, amount of fat, asymmetries, etc.

In functional cases it is especially important to notice trophic and vasomotor phenomena such as skin eruptions, pigmentation, pallor, coolness of the skin, edema, cyanosis, increase or diminution of sweating, excessive dryness, peculiar odors and secretions, pulse rate, pain in the head, palpitation, breathlessness on exertion, precordial pains. If unusual trophic or vasomotor symptoms occur it is important to determine whether or not these are the result of the patient's own actions.

General appearance of patient as regards resemblance to some disease.

CRANIAL NERVES

First nerve (olfactory).-Anosmia, parosmia.

Second nerve (optic) - Acuteness of vision and, if impairment, description of same; irritating visual phenomena. Pupils, whether round or irregular; their reactions to light and to movement of eyeballs. Visual fields (note especially in shell-shock cases variations from the normal such as reversion of color fields, etc.). Opthalmoscopic examination; exophthalmos and enophthalmos; irregular size of palpebral fissure.

Third, fourth, and sixth nerves (ocular nerves) - Ptosis or drooping of the upper lid, ocular palsies, description of double vision, convergence.

Fifth nerve (motor) - Muscles of mastication, masseters, temporals, and pterygoids. (Sensory portion.) Note disturbance of sensation for touch and pain and temperature. Pains in face. Loss or impairment of taste in anterior two-thirds of the tongue. Look for parageusia or perversion of taste sense in shell-shock cases.

Seventh nerve (peripheral facial palsy).-Inability to wrinkle forehead, shut the eye, show teeth. With central facial palsy, can wrinkle brow and shut the eye. Note loss of taste on the affected side. Electrical examination to be made if possible.


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Eighth nerve - Cochlear division: Determined degree of deafness by tuning fork or voice and then make a closer examination and determine whether it is due to the destruction of the nerve itself, or the middle ear, or if it is functional. Vestibular portion: Examination should be made by so-called Bįrįny tests either by means of a turning chair or irrigation of the external ear by water.

Ninth nerve - Inability to swallow. If impaired, note degree of inability to swallow food and regurgitation of same. Loss or impairment of taste in posterior third of the tongue. Look for parageusia or perversion of taste sense in shell-shock cases.

Tenth nerve - Movements of vocal cords, character of speech, and whether or not speech and breathing are interfered with.

Eleventh nerve - Action of sternomastoid and trapezius muscles.

Twelfth nerve - Ability to protrude the tongue and its direction and impairment of movement. Atrophy and tremor.

Motor symptoms

Station and gait. Deformities and contractures. Convulsions, local spasms, tics, tremors (coarse or fibrillary), myokymias, etc.

Limbs: Determination of strength by grip and movements, both voluntary and against resistance. Tonicity, atrophy, or hypertrophy, coordination of extremities and trunk (ataxia), cerebellar asynergy.

Reflexes

Cutaneous - Conjunctival, corneal, epigastric, cremasteric, plantar, Babinski, defense.

Tendon - Biceps, triceps, wrist, patellar, Achilles.

Muscle reflexes - Clonus: Wrist, patellar, ankle. Special: Kernig, Trousseau.

Electrical examination

Faradic response.

Galvanic response and nature of the reaction.

Speech disturbances (organic functional)

Organic.-Motor aphasis: Patient knows what he wants to say, understands what is said to him, can read, but is unable to express himself either wholly or in part in spoken words or by writing.

Sensory aphasia: Patient can talk and can write, but neither his speech nor his writing make sense because he is word deaf; that is, he does not understand the meaning of the sound of words.

Sensory motor aphasia: A combination of motor and sensory aphasia, the extent of the disturbance depending upon the completeness of the lesion.

Functional - In functional or shell-shock cases, look for various forms of speech defects such as mutism, stammering, stuttering, and verbal repetition.

Hearing may be lost often with speech. Hyperacusis or extreme sensibility to sound is very common.

Sensation

Studied in head, trunk, upper and lower extremities with finger tip, cotton-wool, camel's-hair brush, esthesiometers, hot and cold test tubes, etc.

Epicritic sensibility - Superficial touch, light pressure, warmth, coolness, tickling (hairy surfaces), tactile localization, and tactile discrimination.

Protopathic sensibility - Pain sense, extreme heat, extreme cold.

Deep sensibility - Muscular, tendinous, arthrodial.

Sense of position and passive movement, deep pressure. Astereognosis. Asymbolia.

Vesical, rectal, and sexual functions.

Lumbar puncture

Cell count and Wassermann.


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Physical examination

This should be a general physical examination including condition of the heart, lungs, blood pressure, blood for Wassermann, etc.

Active treatment as contrasted with custodial care was emphasized in all neuropsychiatric wards and hospitals. Diagnosis was not considered an end in itself. Individualization of the patient was insisted upon. Patients, in so far as possible, were not permitted to be idle. From the day of his entrance into the hospital an effort was made to see that the patient was kept occupied. In this important procedure the occupational therapy worker was invaluable.

In most of the hospitals the neuropsychiatric staff met daily to consider difficult cases, to discuss the advisability of discharging certain patients, and to review the results of the examination of recently admitted patients. In some of the hospitals a weekly conference was held, to which all the medical officers of the hospital were invited. At these conferences papers on such psychiatric subjects as might be of interest or benefit to the general medical officer were read and patients were presented and discussed. These conferences frequently aroused much interest and were well attended. A further opportunity to familiarize the general medical officer with psychiatric case studies was presented by the regular hospital staff conferences. The neuropsychiatrists took their turn in presenting to the entire staff of the hospital interesting psychiatric material.

The experience of those responsible for the neuropsychiatric work at Walter Reed General Hospital, Washington, D. C., is more or less typical of the experiences elsewhere and is worth recording.

Prior to the World War mental patients at Walter Reed General Hospital were cared for in the basement of the administration building along with the military prisoners. The place was wholly unsuited for prisoners, let alone patients. But the feature which evidently recommended it was that, having been built for prisoners, it was heavily barred and guarded and the insane could not get out. Treatment was impossible and the care in all respects, except possibly food, was about the equal of the county asylum of the old type. Before the end of 1917, however, psychiatry at Walter Reed General Hospital had improved materially. Five neuropsychiatric wards, of wooden construction, were opened. The first ward was built in accordance with the building plan of the neuropsychiatric wards of the base hospitals; that is, a ward divided into three sections so as to provide a better classification of patients. The other wards were dormitory wards similar to the general medical wards. As it was planned to use a section of the first ward for disturbed patients, the rear portion of this ward was screened with iron-wire mesh. The screening was never completed and a part of what had been put up was later taken down.

The five wards at Walter Reed were open wards without bars or mesh, and were comparable in every way with the general medical wards of the hospital. As a matter of fact, it was possible, in showing visitors through the hospital, to take them from the medical to the neuropsychiatric wards without their knowledge of when they had made the change. The same lack of restraint was to be found at Hospital No. 2, Baltimore-no bars, no bolts, no mesh. The ward physically was no different from any other ward in the hospital, except


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the ward for military prisoners. The psychiatrist's difficulty in conducting this kind of a ward was not so much in keeping patients in as keeping patients out. The ward in the early days of the hospital was so much more attractive than the other wards that it was at times difficult to keep other patients from coming over to visit, play the piano, listen to the victrola, or work in the shop.

The standards were equally high at Fort Benjamin Harrison, Fort Sheridan, the Letterman General Hospital, Fort McPherson, Fort Sam Houston, and Fort Des Moines. Each differed somewhat from the others, depending upon local conditions. None were as free of bars and mesh as Walter Reed General Hospital or General Hospital No. 2, at Fort McHenry, Md., but in each these evidences of incarceration were much reduced and further reduction was contemplated, the chiefs of the service being convinced that the bars and the mesh were not only unnecessary but that treatment could be carried out much better without them. As a matter of fact, many wards that had originally been barred or meshed in order to relieve the anxiety of a commanding officer became open wards, with doors unlocked and patients given much freedom.

That the open-ward system was successful there can be no question. The success depended upon a number of things. The spirit of the wards was important. The spirit was distinctly that of a hospital, not that of a jail. The patient was not constantly reminded of his situation by the sight of bars; he realized that at least some one considered him sick and that for that reason he had been brought to a hospital where he was under no greater confinement than other patients in the hospital; at no time was he stung with the humiliation of imprisonment. Incentive to escape was reduced to a minimum; the patient came to regard himself possibly as sick; his ingenuity was not aroused to out-trick his jailers or to create out of nothing instruments to remove bolts and bars. The importance of careful classification of patients was kept constantly in mind.

CARE OF CASES OF NERVOUS DISEASES

The treatment of organic diseases of the nervous system, under which heading epilepsy is classed at this point for convenience, was of little military importance, as these conditions, almost without exception, disqualified for service. Few of them were susceptible of any great degree of amelioration by such treatment as was afforded in our military hospitals.

The hospital history of all the cases of this general class was that they were retained in the service for antisyphilitic treatment, for tonic treatment, or for operation, as the case might be, and then were discharged from the Army. They showed no differences in symptoms, course, or indications for treatment in the military service from similar cases in civil life.

One of the important demonstrations of the war was the great number of men from all walks of life who were conditioned in their practical usefulness by functional nervous disorders of some kind. These came in for dramatic prominence as cases of shell-shock, developing in both front and base sections in France; but still larger numbers were refused entrance into the Army, and many were discharged from the camps on surgeon's certificate of disability.


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The number of neuropsychiatric cases rejected or discharged at home may be divided into two general classes-the psychasthenic, or neurasthenic, and the hysteric. In the former the patient was concerned with a chain of mental difficulties, and was constantly provided with long explanations as to why he did not successfully carry on his military duties. These explanations referred to various purely subjective symptoms, which might come to light when the man was reported as a patient. Under such circumstances he could be found in any of the various medical services, as the symptoms might be referred to any organic system. These cases were especially found in connection with the "effort syndrome," and with the whole group of cardiovascular conditions. Symptoms referable to the stomach and intestines were particularly frequent.

The cases called hysterical were apt to be associated with more definite symptoms, such as paralysis, contractures, abnormal gaits, etc. In this hysterical group, suggestion as a factor in determining the type of symptom was much more evident than in the psychasthenic group; also these patients were frequently noticed to be less intelligent.

The cases returned as neuroses from overseas were so similar to the home cases in their symptoms that it can be said that there appeared to be no fundamental clinical differences between neuroses developing in actual warfare and those which developed in the training period. The probability is also great that there is slight difference, with the exception of some war coloring, between the neuroses of war and those of civil life.

Practically all of the symptoms reported in France were observed in the cantonments at home. But there existed a difference in degree, in that therapeutic efforts to combat functional nervous difficulties could be made more successful in battle areas than could be done in the zone of the interior. This was probably because, on the one hand, the discipline and morale was better near the front, and, on the other, that real war neuroses were more acute conditions, betraying less fundamental character defects, and appearing as the immediate results of trauma, especially of an exhaustion brought about by mental strain, physical over-exertion, exposure to cold and lack of food. The patients, in other words, if taken immediately in hand, could be brought back to normal, or to a point approximating normal sufficiently to enable them to be returned to duty, full or limited.

This relatively favorable prognosis, under proper therapeutic conditions, did not apply, of course, to all of the overseas cases. Most of the patients returned to the United States during the period of active combat presented character defects of a prominence that made cure under any military conditions most difficult, if not improbable. They should have been detected-many of them were, but were not discharged-and eliminated before their organizations were ordered overseas. But even some of these, who had resisted all efforts at cure overseas, could be brought to the point where at least all symptoms disappeared in the home hospital. One enlisted man who had displayed a useless arm in several of the hospitals in the American Expeditionary Forces resumed the use of it at General Hospital No. 2, Fort McHenry, after 48 hours of deprivation of tobacco, combined with kindly suggestion.


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But the treatment of these cases which met with such general success overseas was never tried out in this country. The short duration of the fighting after our entry into the war afforded no opportunity for such a trial here. Had the war progressed further and had the time come when the United States was actually pressed for men, some definite plans would doubtless have been formulated for the reconstruction of war neurosis cases at home. Plans looking to this end were under consideration in the Surgeon General's Office at the time the armistice was signed. It would have required a more elaborate and special organization than any that had been put into effect. Development battalions had been organized, particularly for physical disorders, but they did not provide sufficiently detailed classification to make them serviceable for neurosis cases. Such cases as were assigned to them soon fell out, and so secured their discharge. Because of early discharge it is difficult to draw any very definite conclusions as to the curability of the functional cases which occurred in the home camps.

As it was, the neurotic soldiers could not altogether escape being regarded in a sense as malingerers. An inquiry initiated by the division of neurology and psychiatry1 brought out that the old point of view, that all functional cases were malingerers, had given place to a more rational view; that most Army surgeons, while noticing the numbers of neurotics among the troops, accused few of being so deliberately and with voluntary intention. But in spite of this there was some feeling on the part of Army surgeons that such soldiers did not play the game quite fairly, that they could have done more if they would. In other words, there seemed to be the general conviction that under certain circumstances many of these men could have been made useful for some duty.

OCCUPATIONAL THERAPY

It was the consensus of opinion of the officers who came most closely in contact with the occupational therapy work that to it must be credited much of the success of the neuropsychiatric wards. One element of the success of occupational therapy in the military hospitals was certainly the high standard of qualification insisted upon by the training schools that prepared these workers and later by the Army itself. A second element of success was that from the first the importance of occupational therapy was insisted upon and it was given an independent and important place in the scheme of hospital organization. It was not subordinated to nursing. It was not considered as a part of nursing but as a part of therapy, and, as therapy, it was under the immediate direction of the physician. The worker was responsible not to the nurse but to the physician. Occupational therapy was introduced into the military hospitals by the division of neurology and psychiatry. The first occupational therapy workers employed by the Army were the six women included in the personnel of Base Hospital No. 117.2 So immediate was the success of these women that the demand for similarly trained women grew.

The feasibility of introducing reconstruction procedures into the neuropsychiatric wards as a whole was doubted, in our earlier experience being considered applicable only to the cases which were less disturbed mentally. The


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benefits of occupational therapy became so pronounced, however, and the aides so skillful in their approach after several months' experience, that the work was given to all except the extremely violent. This furnished systematic employment to restless patients, reduced the introspection of neurotics and the delusions of the insane, seemed to shorten the duration of the pręcox or manic episode of the psychoses, and decreased the necessity for restraint in the more disturbed cases.3

Courses were given in bench woodwork, carpentry, painting and staining, machine work, pattern making, automobile mechanics, English, arithmetic, bookkeeping, stenography, typewriting, drafting and designing, geography, agriculture, history, economics, weaving, basketry, printing, lettering, and poster making. Frequent entertainments of various kinds were given, with an effort to have the patients put on their own shows, and a band was organized. One hospital maintained an excellent library of nearly 4,000 volumes, with the leading periodicals and newspapers from the principal cities of the country.4 The library was considered to have been an important factor in the reconstruction work.

PSYCHIATRIC SOCIAL WORK

Expert consultation in other fields was available at all times and was utilized when necessary. In cases in which the diagnosis was not clear for lack of full information, the psychiatric social worker was called upon, and, in most cases, was soon able to place before the physicians a more or less complete history of the patient's life and condition before entrance into the Army. The importance of psychiatric social work, and of social work generally, was first demonstrated at the special hospital for neuroses at Plattsburg. This demonstration was made by the division of neurology and psychiatry of the Surgeon General's Office through the cooperation of the American Red Cross. The success of the work at Plattsburg led to the assignment of from one to three psychiatric social workers (psychiatric aides) to each of the general hospitals maintaining neuropsychiatric wards and later to the assignment of medical social workers to all hospitals. Where patients required continued care after discharge from the Army, the social worker made inquiry in regard to the family conditions to which the soldier would be returned and the possibilities of local care, and made arrangements with the family, the State authorities, or local Red Cross representatives for the reception of the patient.

The activities of the neuropsychiatric social service at General Hospital No. 30, Plattsburg, N. Y., were reported as follows:5

Soon after the soldiers began to return from overseas, it was discovered that many came with reports containing very little medical information. The soldiers sent to the military hospital for war neuroses (United States Army General Hospital No. 30), at Plattsburg Barracks, N. Y., not infrequently came with only a diagnosis. Some presented symptoms which indicated that their condition was probably chronic and had existed for years previous to their entrance into the Army. Others came with a diagnosis of epilepsy, but while in the hospital had no seizures. The medical officers began to feel the need for information other than that secured from the soldier himself, and through Major Hutchings, chief of the neuropsychiatric service of this hospital, a request was made for the appointment of a social worker at Plattsburg. In consideration of the immediate need for this worker, and the firm belief of all in the necessity of the worker's having complete freedom in developing her work,


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the American Red Cross was asked by the Surgeon General to assist the Medical Department of the Army in demonstrating the value of this type of work in military hospitals. The necessity of this request was due to the fact that, under the existing Army provisions, the social worker could be appointed only as a reconstruction aide, giving her a status lower than a nurse. That the success of psychiatric social service in military hospitals would depend largely upon the efficacy of its organization was hardly questioned, but the significance of its establishment directly under the control of the military authorities and the supervision of the medical officers was not appreciated at this time. It was the consensus of opinion, however, that there might be administrative difficulties if the work was placed under the direct auspices of a civilian and nonmedical organization, when the control of the hospital was military. It was also believed that the very character of the work necessitated its organization as a department of the hospital under medical jurisdiction and that dual control would ultimately weaken its effectiveness.

In view of these facts, no definite decision was made regarding the status of the work, but there was a general understanding between the Army and the American Red Cross that it would be an advantage to have the worker considered as an unofficial adjunct to the medical staff and under military authority.

On September 1, 1918, the social worker began her duties at the military hospital for war neuroses, Plattsburg, N. Y., the American Red Cross having agreed to pay her salary and allow her to be considered a part of the military régime, having no status under the organization of the American Red Cross. She was assigned an office in one of the hospital barracks, accessible to the wards and the administrative offices, and was supplied with sufficient equipment to start her work. Through the courtesy of the military authorities, officers' privileges, such as living in officers' quarters and eating at the officers' club, were extended to the worker.

Her duties were not defined, but she was expected to secure early histories through correspondence to assist the medical officers in the diagnosis of difficult conditions and to help them in reaching a decision as to whether the soldier's condition occurred in line of duty or prior to his enlistment or induction into the Army.

For five months the social work of the hospital was carried on by one worker, with the assistance of enlisted men from the Medical Department, and convalescent patients, who were assigned for messenger and clerical service. The stenographic assistance was provided by the hospital until the 1st of January (1919), at which time the bureau of camp service of the American Red Cross donated the salary of a full-time stenographer. It was extremely difficult to handle effectively the amount of work referred to the department, owing to the lack of professional and clerical assistance. The delay in the appointment of social workers was due to the fact that it was impossible for the American Red Cross and the Army to reach a decision as to the organization under which these workers should be appointed until the latter part of 1918, and it was not until the latter part of January, 1919, that the provisions made by the Surgeon General for the appointment of psychiatric social workers in military hospitals under the status of reconstruction aides became effective. By January 31, 1919, two workers had reported for duty at Plattsburg.

After the establishment of the department, the following divisions of work were developed: (1) Securing early histories; (2) social case work; (3) after-care; and (4) administrative work. The scope of work was limited, owing to lack of assistance, simply to handling the most urgent cases.

SECURING EARLY HISTORIES

The majority of these investigations have been to establish, in the cases referred, the diagnosis of epilepsy, hysteria, or other conditions, prior to the soldier's admission into the Army, in order to decide the Government's liability and the soldier's rights for compensation. In most instances the soldiers have been interviewed by the social worker in her office, and have been questioned regarding their early history. Special emphasis has been placed upon securing the names and addresses of individuals who would be in a position to give the necessary information and encouraging the soldier to give his own statement regarding his illness. Inquiries in general have been addressed to physicians, principals of schools, former employers, and immediate relatives. In 90 Percent of the cases replies have been received, the greatest assistance coming from physicians and employers. The school reports have


98

shown that, in most instances, the health records have been incomplete. The value of the replies can not be statistically given, but in the majority of cases the replies have indicated a past history of nervous instability, if not a definite history of nervous or mental disorders. There have been a number of instances in which soldiers' statements to the medical officers and the social worker have been found untrue, generally in the cases of soldiers who were undoubtedly malingerers, desiring to secure compensation or to avoid military service.

Examples:

Case 1 - The soldier claimed his epilepsy occurred in line of duty. The investigation proved that he had been an epileptic for years; that he had had great difficulty in holding positions, and had not been able to support his family.

Case 2 - A soldier, having definite seizures of epilepsy, grand mal type, at the hospital, claimed he had never had them before entering the Army. The history he gave showed that he had been a wanderer, and had never lived in any place longer than a few months, following many occupations. It was felt that it would be impossible to secure any past history, and that his condition would have to be considered in line of duty. This soldier had never been overseas, and had a record of intemperance in the Army. After considerable questioning the social worker was able to secure the names of a few former employers, and through the interest and assistance of one of our western railroads the diagnosis of epilepsy prior to enlistment was definitely established.

Case 3 - A soldier coming from overseas, with a very meager history and a diagnosis of epilepsy, had no seizures while at the hospital. The investigation showed that he had been an employee in one of our epileptic institutions, having been discharged for larceny, and had had a court record. No history of epileptic seizures was obtained, although the soldier stated that he had had them.

Case 4 - A soldier claimed his condition occurred in line of duty and it was learned from his wife that he had nocturnal attacks of epilepsy.

Owing to the success of the investigations the medical officers, prior to the signing of the armistice, were considering referring to the social worker all overseas cases, classed as epileptics in line of duty, whose histories were inadequate to establish this fact. The cases referred were so numerous that it was impossible for the social worker to handle them alone, and it was necessary on account of the other important types of work to limit the number to those which the medical officers felt could not be decided without further information. The scope of this division of work was therefore considerably limited and has not been developed to the extent of its value.

The foregoing facts seem to indicate the value of investigating cases involving the question of compensation prior to discharge from the Army, as it would seem logical that histories, as described above, would be almost impossible to obtain after the soldier had made a claim for compensation.

SOCIAL CASE WORK

One of the most important functions of the department has been social case work, the assistance rendered the soldiers who have been troubled with personal or family difficulties. The chief complaint has been in relation to their financial circumstances. Many of the overseas soldiers, who had left the United States months ago, having made not only voluntary but compulsory allotments before they went over, returned to find that their families had not received their allotments. The number of soldiers applying for advice and assistance has been so great that it has been impossible to keep track of them. In general, the soldiers have been grossly ignorant concerning the Bureau of War Risk Insurance and its methods of operation. Of all cases investigated the statements of the soldiers regarding the nonpayment of allotments were found to be correct, but it was impossible to secure replies to inquiries sent to the Bureau of War Risk Insurance, except through indirect channels. The reasons given were general and to the effect that the allotments and Government allowances had not been paid owing to faulty execution of the forms in the beginning or that the wrong forms had been used. It was learned through the investigations made by the American Red Cross, at our request, that a great many of our soldiers' families were in serious financial difficulties as a result of this situation, and that the American Red Cross had been obliged to give financial aid. The need for a worker specially trained in handling these problems had been demonstrated in this hospital by the number of cases referred to the social worker for


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investigation, not only by the soldiers themselves, but also by the officers in charge of this branch of work, who, owing to the pressure of work, have been unable to give the personal attention needed to adjust these difficulties.

Another particularly important phase of social case work has been time so-called reeducational, personal talks with the soldiers. Anyone at all familiar with the type of cases which have been under observation and treatment at this hospital realizes that some of the main symptoms have been restlessness and discontent, and a general attitude of lack of sympathy with the Government and Army life. The soldiers' complaints, such as the theft of their personal property, the nonpayment of their allotments, etc., seem to be well founded and have resulted in the feeling that the protection which would have been awarded them in civil life has not been given them in military life. Almost all have had one aim; namely, to get out of the service as soon as possible. The social worker believed that much could be done toward changing this attitude, at least in the men who came to her for assistance of one sort or another, and has made a special effort to give the soldiers a somewhat different point of view than they have had regarding the military system. That the majority of cases treated at Plattsburg showed mental inferiority as well as moral defects is evident. There has been a childlike attitude of the men regarding all phases of their army life and their social tendencies, as well as nervous instability. These reports have been filed with the soldiers' clinical records, and, although they have not, except in a few instances, influenced directly the disposition of the cases, may prove of inestimable value to the Government if claims for compensation are filed. The American Red Cross has been notified of the date of discharge and has rendered any assistance necessary, such as securing employment, medical supervision, and anything which may be required. The assistance given by the American Red Cross can not be overestimated, and the results have been exceedingly satisfactory. It is evident that the interest taken by the local Red Cross chapters in this group of cases will stimulate a keener community interest and appreciation of the mental hygiene movement.

ADMINISTRATIVE WORK

Another division of the work which might have proved of considerable value to the administrative department of the hospital, if it had been possible to have had more assistance, is that of answering inquiries from relatives, friends, and civilian organizations concerning the soldiers' condition and circumstances. The replies to these inquiries must of necessity be very carefully considered, for they must contain enough information to allay anxiety, and at the same time must not divulge any information which might give a false impression or serve as a basis for a claim against the Government. Owing to the fact that the social worker has been asked to answer many of these inquiries, it is reasonable to conclude that this work might be handled effectively by the social service department, whose workers are trained in dealing with problems of this type. The social worker has regretted exceedingly her inability to give information of a medical nature to the American Red Cross, because of their cooperation and interest, and the importance of having this knowledge in order to be able to give more satisfactorily the assistance required.

The social worker has been asked to investigate the need for furloughs in a number of cases where the reliability of the statements was questioned. Requests have also been received to investigate the need for the soldiers' early discharge from the Army because of dependent relatives, serious illness, etc.

The foregoing report shows in a measure time point of view of the social worker regarding the usefulness of social service departments in military hospitals and outlines, in general, the type of organization which seems necessary and the scope of work which might be undertaken. That a department of this type is essential has been established, and the conclusion drawn, namely, that the effectiveness of the treatment in military hospitals depends upon the cooperation and assistance of the community after the soldiers' discharge is undeniably sound and practicable. As to the financial value of such a department, the reports on early histories of the soldiers have conclusively shown that much expense might be saved the Government through the establishment of departments of investigation at the time the soldiers are under treatment in the hospital, rather than after the soldiers have been discharged and have filed their claims for compensation.


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STATISTICAL SHEET

Number of individuals assisted 

820

Sources from which these cases were referred:

(1) Medical officers

558

(2) Soldiers

231

(3) Miscellaneous

31

Classification of cases according to reason referred. (NOTE.-These figures overlap because in some cases all 4 types of work have been done):

(1) Securing early histories 

191

(2) Social case work 

668

(3) After-care

495

(4) Administrative work 

96

Number of letters sent out 

1,428

Number of letters received 

1,166

Number of interviews with soldiers 

960


 

ACTIVITIES OF NEUROPSYCHIATRIC SERVICES

The following accounts of the methods of observation and treatment employed in some of the more typical neuropsychiatric services in base and general hospitals are taken, without comment, from selected reports to which they are credited.

BASE HOSPITAL, CAMP SHERMAN, OHIOb

All cases that could not be decided on at the preliminary survey (mental and nervous examinations of troops) were referred to the base hospital, either to be admitted as patients for observation or to be examined thoroughly at greater leisure. The psychiatrist at the base hospital saw these men, made careful examinations, often spending an hour or two at a time on one patient, applying Binet or other tests where needed. He wrote for information to relatives, employers, or attending physicians; or got information as to the man's behavior from commissioned or noncommissioned officers or privates, with a view of getting such data as might help in the diagnosis of epilepsy, mental deficiency, peculiarities, malingering, etc. It was found very helpful to have a noncommissioned officer go to the patient's company to make inquiries about his general adaptive reactions or about some special incidents.

Besides the cases thus referred by the surveying examiners, there were sent to the base hospital by the line officers patients in whom they suspected evidences of nervous or mental disease. In the camps where psychological surveys were made, the psychologists also referred cases to the psychiatrists. These cases were examined in the same way as those sent by the psychiatric surveyors.

In addition to these, many cases were seen in consultation in the other wards of the base hospital. Many of these were neurasthenics, in whom the question of malingering arose. Sometimes the advisability of operating on a given patient came up, as, for example, in a case of hernia in a defective. If he was too deficient mentally to make a good soldier, operation was advised against.

Another group of cases that came before the psychiatrist was that of the men who had been arrested for various offenses, such as theft, desertion, repeated

bBased on The Work of Psychiatrists in Military Camps, by Maj. E. Stanley Abbott, M. C. American Journal of Insanity 1919, lxxv, No. 4, 457.


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absence without leave, in order to determine their responsibility for their acts, and whether or not they should be brought to trial by court-martial. In one case a man already had been convicted for refusal to be operated on for hernia. Before sentence was passed, however, the question of his mentality was raised, and it was found that he was about 9 years old developmentally. His sentence was not carried out; instead, he was discharged from the Army.

The cases of mental disease arising among the men, such as manic or depressive states, dementia pręcox, acute alcoholism, delirium tremens, had to be taken care of and treated until some adequate disposition could be made of them. It fell to the psychiatrist, of course, to exercise the care of these, as well as of the cases sent for observation or special examination. The psychiatrist had to determine whether the patient should be allowed to go home or should be sent to an institution for the care of the insane; also, whether he should be allowed to go home alone or must be accompanied by one or more persons. And if the patient was sent to a hospital, the psychiatrist prepared and sent adequate records of the case.

BASE HOSPITAL, CAMP DEVENS, MASS.c

The neuropsychiatric service was opened December 4, 1917, for the reception of patients. During the time draft men were being received, this service did all the camp neuropsychiatric work in addition to attending to the ward cases.

The class of patients handled by this service included neurological, psychiatric, feeble-minded, epileptic, and inebriate, and after the return of the overseas men, so-called "shell-shock," and various traumatic neurological cases. Among the psychiatric cases, dementia pręcox, manic-depressive, general paralysis of the insane, and various other forms of psychiatric cases were under observation and treatment.

The treatments as administered, consisted of medicinal therapy, hydrotherapy, electrotherapy, and occupational therapy.

The disposition of the cases was variable; some, not in line of duty, were transferred to the psychopathic hospital, Boston, Mass., and from there to the State in which the patient resided. Other patients, whose disability was incurred in line of duty, were transferred to general hospitals for the insane. Some cases were discharged to duty, either well or improved, and the remaining psychopathic or neuropathic cases were discharged on surgeon's certificate of disability.

The routine of the staff was as follows: There was a daily morning staff meeting on each case, at which time the diagnosis was made. As the occasions demanded, consultations were held in the medical and surgical wards of the hospital. The enlisted personnel were practically intact from the time of the establishment of the ward, most of the men being experienced in the handling of psychopathic cases.

The total number of admissions during 1918 was 929.

cBased on History of Base Hospital, Camp Devens, Mass., by Maj. W. B. Lancaster, M. C., March 19, 1919. On file. Historical Division, S. G. O.


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BASE HOSPITAL, CAMP WADSWORTH, S. C.d

The neuropsychiatric work at Camp Wadsworth was begun during the latter part of September, 1917. At first it consisted in the examination of the camp personnel. A number of organizations of the 27th Division had been examined before coming to Camp Wadsworth. The examination of the remainder was completed during January. Scattered cases and men especially referred by the regimental surgeons were gone over in February. Additional troops began to arrive during March and April, therefore, the number of examinations increased.

It was not until February 15, 1918, that all neurological cases in the base hospital were concentrated in one ward, ward No. 15. This was a regular ward and, therefore, not suitable for the care of insane patients. From the opening of the hospital psychiatric patients were transferred as soon as possible to special institutions; at first to Kings County Hospital, Brooklyn, N. Y., and St. Elizabeths Hospital, Washington, D. C., after December, 1917, to General Hospital No. 6, Fort McPherson, Ga. A special psychiatric ward was constructed and completely equipped.

Ward No. 15 contained 36 beds, most of which were constantly occupied. The majority of cases treated were psychoneurotic. Hysteria was especially frequent. Patients with this trouble responded well to suggestive therapy administered through the medium of faradic and sinusoidal electricity. Neurasthenic patients did well under rest, forced feeding, massage and salt rubs. Special attention was paid continually to the mental attitude of the patients. Cheerfulness was the rule in the ward. Sympathy and understanding, combined with firmness, were maintained. Faulty attitudes and emotional reactions were explained to the patients and they were encouraged to combat them. They were made to realize that a personal interest was taken in their welfare, that things were done for them, and that much was expected from them in return.

BASE HOSPITAL, CAMP MEADE, MD.e

The personnel of the neuropsychiatric section consisted of 1 officer and 12 enlisted men. Of the enlisted men, 3 were male graduate nurses, 5 men with previous experience in State hospitals for the insane, and 4 orderlies. On February 1, 1918, one ward was assigned for neurological and psychiatric cases. On March 15, one-half of another ward was assigned to this service, and on April 22 the number of cases had increased to such an extent that it was necessary to assign two full wards to this service. Of these wards, one was used for psychiatric, the other for neurological cases. On December 18, it was found again unnecessary to have two wards, owing to the decreased population of the camp, and all cases were concentrated in one ward.

The following tabulation shows the movement of patients on this service for the year:

dBased on History of Base Hospital, Camp Wadsworth, S. C., by Maj. W. Barndollar, M. C., undated. On file, Historical Division, S. G. O.
eBased on annual report, base hospital, Camp Meade, Md., for 1918, made to the Surgeon General by the commanding officer. On file, Historical Division, S. G. O.


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Total admissions 

952

Average under treatment daily 

51

Discharged:

Improved 

166

Recovered 

65

Unimproved 

630

By transfer

65

Died

5

Remaining Dec. 31, 1918

21

The percentage of various classifications of diseases resulting in discharge from the service follows:

Percent

Nervous disease or injury

24

Psychoneurosis

20

Psychosis

10

Inebriety

9

Constitutional psychopathic state

8


It would seem at first glance that the percentage recommended for discharge was high; however, it is evident that once a diagnosis of nervous or mental disease was made it was to the best interests of the service, as well as of the individual, to return him to his home, experience having shown that such men would not stand up under the stress of modern warfare.

Because of limited space, necessitating the expeditious handling of patients, the insane were transferred to the Government Hospital for the Insane, Washington, D. C., for further observation and treatment. Mildly demented cases which observation showed were not dangerous to themselves, or a menace to society, were sent to their homes in care of an attendant.

Of the 952 patients admitted, 80 Percent were admitted from command and 20 Percent transferred from other wards of the hospital. There were no suicides or other serious injuries during the year. From each incoming draft were admitted about 10 cases of drug addiction. These men were immediately discharged from the service, experience having shown that no reliance could be placed on a man so afflicted, and his presence in a company was decidedly detrimental to the morale. It is interesting to note the high percentage of cases of hyperthyroidism from the mountainous districts of adjacent States, especially West Virginia. There were surprisingly few cases of attempted malingering. The exceptionally low percentage of involvement of the central nervous system in syphilis in the negroes is also worthy of mention.

BASE HOSPITAL, CAMP JACKSON, S. C.f

The neuropsychiatric ward was opened in November, 1917. This building was designed and equipped on the lines of the standard base hospital ward for this special purpose. According to the original plans, heavy iron bars on the windows were called for, but were omitted by the War Department upon the request of the chief of the service, it being his belief that such measures for the restraint of patients were antiquated.

fBased on History of Base Hospital, Camp Jackson, S. C., from October 22, 1917, to June 1, 1918, by Capt. Martin W. Reidan, M. C. On file, Record Room, S. G. O., 314.7 (Medical History, Camp Jackson) (D).


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The psychiatric portion of the ward was not available for its proper purpose until March, 1918, because the whole building was commandeered for the care of meningitis cases during the severe epidemic of 1917-18.

The growth of the service is shown by the following table for the first four months of 1918, which presents, however, only patients in the neuropsychiatric ward and does not include cases seen in consultation:

January

February

March

April

Number of patients 1st day of month

8

18

14

27

Admissions

21

17

42

48

Total number under treatment

29

35

56

75

Daily average

14

17

25

27

Total number discharged

11

21

29

48


This department performed two distinct functions: First, as a clearing house through which soldiers who were accepted for service could be passed in order to ascertain their fitness for service or responsibility for misconduct, and, second, as a place where the insane or neurologically afflicted might be helped, cared for, and treated until their discharge papers were complete or the type of service for which they were qualified could be determined. With the return to the special ward it became easy to classify the different groups and to begin such a systematic ordering of work and recreation and rest as to show a distinctly remediable effect upon many cases. The patients were kept occupied at work or games as much as possible.

The insane patients were required to do simple tasks when their condition permitted. The camisole or other restraint, mechanical or medicinal, was rarely resorted to; usually enough attendants were available to care for such cases.

A classification of the various cases follows:

Psychoneurosis 

103

Cerebral hemorrhage 

3

Mental deficiency

68

Manic-depressive psychosis

19

Epilepsy 

45

Dementia pręcox 

9

Tertiary syphilis, cerebrospinal

12

General paralysis of the insane 

1

Peripheral nerve lesions 

8

Conscientious objector 

1

Morphine habit

9

Constitutional psychopathic state

5

Hyperthyroidism 

4


The neurasthenias and psychasthenias were almost without exception of long standing, and their detection before acceptance would have saved the Government a large sum of money.

The determination of intellectual level in cases of mental deficiency presented great difficulties because of the remarkable degree of illiteracy in the troops, especially the negroes. To apply to these cases any arbitrary method of examination applicable to communities which were literate would have given results almost grotesque. The Yerkes-Bridges point scale, modified by leaving out the questions demanding literacy and adding, to the total of points thus secured, an average credit for these questions which had been elided gave good results. The sense of relative degrees of wrongdoing was very limited, indeed, and it was often a question for deep and ponderous mental debate with them


105

whether it were worse to kill a man or to curse. Most whites measuring below 8 years were, as a rule, poor specimens physically as well as mentally and morally. On the contrary, amongst the negroes a great many who measured imbeciles were excellent workers. These were held for limited service.

The experience with drug addicts was interesting. With very few exceptions all of these men had taken "cures" from one to five times. All, upon discharge, were in much improved condition. There was little doubt that each one resumed the use of his drug soon after return to civil life. These men were unanimous in the belief that the Harrison Act had merely increased the price of narcotics and that any addict could readily secure the "dope," usually by means of doctors' prescriptions; less often by the various underground paths worn smooth by the "dope fiend's" shuffling steps.

The fact that there was only one case of general paralysis of the insane was noteworthy.

BASE HOSPITAL, CAMP GRANT, ILL.g

The department of neurology and psychiatry was established September 1, 1917. The work of the department consisted of two fairly distinct divisions: (1) Examining of recruits for nervous and mental disease. For this work examiners attached to the camp, as well as those in the base hospital, were used. One examiner worked with each general examining board at the time of the initial examinations. Cases considered suspects were sent to another examiner who, with a psychologist, acted as a final deciding board. In examining the last 15,000 recruits it was found that this plan was more satisfactory than the old method of examining only referred cases or the method of making the psychiatric examination after the general examination was completed. (2) Care of patients requiring hospital treatment and examination of referred cases. Only such patients were kept in the psychopathic ward as required treatment or needed more supervision while awaiting discharge than could be given them in their companies. The new form of certificate of disability materially shortened the stay in the hospital of these cases. Referred cases came from a number of sources, usually from the regimental surgeon but often originally from the company officers on account of inaptitude or peculiarities; cases of misconduct referred for examination preliminary to trial; as a result of letters written by relatives or friends; and hospital cases referred on account of some neurological or mental condition developing or being first observed while under treatment for some physical ailment.

A considerable number of conscientious objectors were examined. They were classified as religious, intellectual, and the objector whose scruples were only means to the end of getting out of a situation that was distasteful to him. It was exceedingly difficult to separate the latter from the two former groups. Objectors were classified also as to their mental make-up. The majority were found to be normal both as regards disease and defect, but a certain Percent were psychotic. The mentally abnormal were very seldom feeble-minded. They were usually either hypomanics or paranoid pręcoxes, especially the latter.

gBased on History of Base Hospital, Camp Grant, Ill., by Lieut. Col. H. C. Michie, M. C. On file, Historical Division, S. G. O.


106

Of the psychoses, dementia pręcox of the hebephrenic type was by far the most frequently encountered. Old pręcoxes were especially liable to "blow up" in a military environment and were frequently minor offenders. Syphilitic psychoses were the next most frequent. Of the organic nervous diseases the only one of any great importance, aside from cerebrospinal lues, was epilepsy.

Establishing a diagnosis of epilepsy was not always an easy matter, differentiation from hysteria often was difficult, and many cases were seen in which there was an isolated fit at the beginning of an acute infection or following typhoid inoculation.

Functional nervous diseases were rather frequent-hysteria among the negroes and lower grade of white soldiers, and neurasthenia among the better grade of whites. The custom was to recommend men with functional nervous disease for domestic service and not for discharge from the Army, except in the more advanced and disabling cases.

The diseases, then, that were especially to be dealt with were dementia pręcox, cerebrospinal lues, epilepsy, and psychoneuroses.

From September 1, 1917, to April 30, 1918, 319 men were recommended for discharge by this department. The above plan worked very well for several months until the camp had increased largely in population so that the number of men who required examination on account of nervous or mental diseases, but who did not require admission to the hospital, became so large as to interfere materially with the work of the psychopathic ward itself. Early in July, 1918, the division psychiatrist moved his offices to a building in the camp away from the base hospital, and the psychopathic ward was used only for patients requiring admission. Nervous and mental cases which did not seem to be serious enough to require admission to the psychopathic ward for care or treatment were sent first by their regimental officers to a psychiatric examiner stationed at one of the buildings in a part of the camp more easily accessible to ambulatory cases than was the base hospital.

GENERAL HOSPITAL NO. 1, NEW YORK CITYh

On November 22, 1918, ward 55 of General Hospital No. 1 was opened for the reception of neuropsychiatric patients arriving at the port of embarkation, Hoboken, N. J., from overseas and also for such cases as developed in the hospitals under the jurisdiction of this port. This had formerly been the Messiah Home, maintained for the care of children. The general construction was so good that with but a few alterations it was readily adapted for the class of patients with which we had to deal.

The building contained five wards, two of which were devoted to the frank psychoses, one for disturbed patients and the other for quiet, depressed ones. The remaining wards were used for the care of mild mental states, psychoneurotics, epileptics, constitutional psychopaths, etc. The hospital had a total bed capacity of 220. Of this number the ward for disturbed patients contained 30 beds, the ward for quiet patients 40 beds, and the remaining 3 wards contained 50 beds each.

hBased on Report of General Hospital No. 1, Williamsbridge, N. Y., made by Lieut. Col. P. W. Gibson, M. C., October 18, 1919. On file, Historical Division, S. G. O.


107

The staff consisted of an executive medical officer, chief of service, five ward surgeons, a mess officer, a registrar, and a dental officer. As this part of the general hospital functioned as an evacuation unit, urgent conditions only could be treated, but detailed reports were made of all pathologic findings, and recommendations for treatment were written thereon. These reports were then forwarded, with the history of the patient, to his final destination. In view of the fact that the unit was an integral part of General Hospital No. 1, it was possible to arrange for consultation with the members of this staff, and their services were always promptly available. As a result of such an arrangement, many patients actually ill with conditions other than mental could be immediately transferred for treatment. The hospital was equipped with a complete hydrotherapeutic outfit, consisting of continuous baths, showers, needle spray, douche, etc. An occupation class under the direction of a trained worker and three assistants completed the therapeutic system.

On admission all patients immediately were inspected for louse infestation, venereal diseases and throat infections. Throat cultures were taken on all admissions. Following this procedure, a hot shower was given to all but louse-infested patients, who were given a special tub bath. The clothing of all patients was sterilized by steam.

As soon as possible after admission a complete physical and mental examination was made. The cases were classified and reported to the office of the surgeon, Hoboken, N. J., in order that transportation might be arranged. If the diagnosis on the field card accompanying the patient was not concurred in, the patient was presented at a staff meeting, and the consensus of opinion determined the diagnosis. In all doubtful cases, blood and spinal fluid examinations were made. In addition, ophthalmic, aural, surgical, and medical examinations were made where there were special indications. Where a diagnosis of mental deficiency was in doubt, an intelligence test by means of the Stanford revision was made, and in many cases the diagnosis was changed. This cast no reflection on the work of the psychiatrists overseas, as many of these patients presented a far different aspect after reaching this country. The psychoses patients, too, often presented a far different appearance from that previously noted in their records, and although formerly indifferent and depressed, now presented a cheerful, interested aspect. The total number of patients admitted was 2,750, of which 2,126 were overseas and 624 were local cases.

The patients admitted to the hospital were classified as follows:


Classification of patients with organic nervous diseases

Amyotrophic lateral sclerosis 

1

Sydenham's chorea 

1

Acute encephalitis 

1

Lateral sclerosis 

2

Tabes dorsalis 

4

Multiple neuritis (following typhoid fever, 1; diphtheria, 2; intravenous
administration of arsphenamine, 1; alcohol, 4) 

8

Cerebral syphilis 

33

Peripheral nerve injury 

9

Gunshot wound of the head 

2

Head injury without demonstrable fracture of the skull 

7

General paresis 

61

Fractured skull 

7

Brain tumor 

3

Progressive muscular atrophy 

1

Myotommia congenita 

1

Transverse myelitis following intratracheal administration of arsphenamine 

1

Nervous disease undiagnosed

2

Total 

144


108

It will be seen from the above that 100 of the 144 organic nervous cases were syphilitic diseases of the central nervous system.

The cases classified as "Observation for epilepsy" presented no evidence in the accompanying history that a convulsion had ever been observed by a medical officer, and as none occurred at this hospital it was deemed fair to the patient to leave the diagnosis open.

Cases of epilepsy and observation for epilepsy

Observation for epilepsy

25

Traumatic 

2

Grand mal 

111

Psychosis 

2

Petit mal 

9

Total 

151

Equivalents 

1

Jacksonian 

1


The patients listed under the heading "Recovered" had usually had either a mild depression or excitement of the manic-depressive type, or else had had an acute alcoholic hallucinosis from which they had completely recovered. A number of psychoneurotics appeared to have recovered, in that they were free from symptoms during their residence and so were placed in this group because it was felt that further hospital residence was unwise and might produce a recurrence of their symptoms.

Of the recovered cases the subclassifications were as follows:

Classification of recovered cases

Psychoneurosis

17

 

Psychosis following influenza (infective exhaustive)

3

Alcoholic hallucinosis, acute

7

Undifferentiated depression 

2

Manic-depressive psychosis 

9

Gunshot wound of the spinal cord 

1

Psychosis undiagnosed 

1

Recovered

43

Alcoholism, acute

1

Pathologic intoxication 

1

Delirium tremens

1


Mental deficiency and manic-depressive psychoses

Mental deficiency with psychosis 

4

Manic-depressive psychoses:

 

Manic type 

95

Depressed type 

213

Mixed type 

44

Circular type

1

Total 

353


109

In the manic-depressive psychoses group, in so far as it was possible to obtain reliable information, 35 had had a previous attack. It must be remembered, however, that the number of patients who had had previous attacks was undoubtedly greater, but as many of the patients were entirely inaccessible, information in regard to this could not be obtained. The depressions predominated.

Cases of dementia pręcox

Hebephrenic 

256

Paranoid

163

Simple 

111

Catatonic 

20

Total

550


Many of the patients presented a typical schizophrenic history, but were in an apparently normal condition and well adjusted. Some of them gave quite adequate explanations for their upset, such as nostalgia and worry over misfortune at home. Others stated that they felt they had been unfairly treated in the Army. The eventual outcome appeared to be problematical. It was felt that the original diagnosis should be left unchanged.

Cases of paranoid condition, alcoholic and traumatic psychoses, constitutional psychopathic state, and psychoneuroses

Paranoid condition

4

Psychoneuroses:

Psychoses with somatic disease:

Hysteria 

295

Following influenza

20

Neurasthenia 

282

Following mumps

2

Psychasthenia (compulsion neurosis)

25

Following pneumonia

1

Anxiety state

22

23

Hyperthyroidism

8

Traumatic psychosis (head injury)

5

Enuresis

8

Alcoholic psychoses:

Disordered action of the heart

5

Acute hallucinosis

37

Traumatic neurosis

3

Deterioration

4

Stammering

6

Pathologic intoxication

1

Syphilophobia

2

42

Hyperthyroidism

2

Constitutional psychopathic state:

Somnambulism

1

Inadequate personality

110

Dyspituitarism

1

Emotional instability

8

Facial tic

1

Paranoid personality

5

661

Delinquent tendencies

1

Homosexuality

3

Criminal tendencies

3

130


110

Of the neurasthenic group 26 Percent of the patients gave a history of having had symptoms of this condition in civilian life, and of the hysteria group 19 Percent gave a history of similar trouble prior to Army service.

Cases of inebriety

Alcoholism 

111

Morphine addiction 

7

Heroine addiction 

6

Heroine and morphine addiction 

1

Total

125


The small number of drug addictions is notable.

Cases of mental deficiency, without mental disease and undiagnosed

Mental deficiency:

No mental disease found-Contd.

Morons

225 

Deviated nasal septum

1

Imbeciles

 

27

Diphtheria carrier

2

252

Malaria, tertian

1

No mental disease found:

Polyarthritis, rheumatic

1

Rheumatic fever, subacute

1

Gunshot wound of the right arm

1

Flat-foot

1

Valvular heart disease

1

Duodenal ulcer

1

Diagnosed as epilepsy but not concurred in

1

Pulmonary tuberculosis

3

No physical or mental disease found

13

Syphilitic cirrhosis of the liver

1

31

Gastritis, chronic catarrhal

1

Psychoses undiagnosed

148

Syphilis, secondary

1

Acute gonorrhea

1


The cases with psychoses undiagnosed were left ungrouped because of the lack of data sufficient to make a differentiation possible. Many of these patients were fearful and refused to answer questions. They were not catatonic nor did they attitudinize. Hallucinatory reactions were not observed. Other patients appeared quite confused and presented a dreamlike, perplexed state. At times they appeared quite distressed. They refused to cooperate on examination. Many of the patients were difficult to differentiate adequately, and it could not be definitely decided as to whether they presented a pręcox or manic-depressive reaction. In many cases there was an alcoholic history and coloring which was difficult to evaluate properly. In a few of the cases there were pupillary signs, but the residence was too short to permit of blood and spinal fluid examinations, or else they were too disturbed for such procedures.

This part of the United States Army General Hospital No. 1 closed officially on September 10, 1919, but no patients were received after September 1, 1919, so that it was open for the reception of patients for a period of 9 months and 22 days.

None of the cases appeared different from those encountered in civilian life, except that most of them had a military coloring. Of the total number of 2,750 patients, 24 Percent were psychoneurotics, 20 Percent of the dementia


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pręcox type, 12 Percent were of the manic-depressive group, 10 Percent mental defectives, 5 Percent had organic nervous diseases, principally of the syphilitic type, 4 Percent were definitely epileptic, and 4 Percent were constitutional psychopaths. There were only 14 cases of drug addiction, or about 0.5 Percent of the total admissions. Many of the cases apparently of the pręcox type appeared to be recovered, with excellent insight. Of the neurasthenic group, 26 Percent of the patients gave a history of having had symptoms in civilian life, and of the hysteria group 19 Percent gave a history of similar trouble prior to Army service.

A comparison of the group percentages found at this hospital, with the group percentages of the total male admissions for the New York State hospital service during the year 1919, is interesting. During this year the total first admissions were 6,791. Of this number, 3,527 were men. The group percentages for the male admissions are as follows:

Classification of men admitted to the New York State hospitals during 1919

Percent

Number of cases

Percent

Number of cases

Traumatic psychoses

0.5

18

Manic-depressive psychoses

9.0

352

Senile psychoses

9.0

324

Involution melancholia

1.5

56

Cerebral arteriosclerosis

6.0

236

Dementia pręcox

27.0

1,001

General paresis

20.0

710

Paranoia

1.5

59

Cerebral syphilis

.4

15

Epileptic psychoses

2.7

96

Organic brain diseases (Huntington's chorea, brain tumor, etc.)

.5

19

Psychoneuroses

1.0

35

Alcoholic psychoses

5.0

204

Constitutional psychopathic state

1.6

66

Drug psychoses

.16

6

Psychoses with mental deficiency

2.5

88

Psychoses with somatic disease

2.0

76

Psychoses undiagnosed

3.9

138

Not insane

.7

28


While a strict comparison is not possible, it is interesting to know that there is a close ratio between the percentage of cases of dementia pręcox, namely, 20 Percent in the Army and 27 Percent in civilian life, and between the percentage of cases of manic-depressive diseases, 12 Percent in the Army and 9 Percent in civilian life. Dementia pręcox in both instances forms the largest group of the psychoses. Comparisons between the other groups is impossible because the civilian State hospitals deal primarily with psychoses occurring at all ages and with unselected population. In 1918, of the total remaining population in the New York State hospitals, 59 Percent were of the dementia pręcox group. It will readily be seen, therefore, that our great problem, from the standpoint of psychoses, both civilian and military, was that of the dementia pręcox group.

All the acute psychoses among the officer patients received at Hoboken requiring close supervision were transferred to the Bloomingdale Hospital, White Plains, N. Y., where the Government reserved a limited number of beds. An Army medical officer was stationed at Bloomingdale most of the time, and in addition, a psychiatrist from United States Army General Hospital No. 1 visited the hospital two or three times a week and supervised the treatment and disposition of the officer patients.

The mild and recovered psychoses and psychoneuroses among officers and some organic nervous cases were excellently handled at the private pavilion.


112

This place afforded not only very desirable private rooming facilities, with pleasant environment, but also a most up-to-date hydrotherapeutic plant. The treatment of these officer patients consisted in general of hygienic measures, medicinal treatment, special medical and surgical treatment, psychotherapy, and hydrotherapy.

As in other hospitals, the importance of the neuropsychiatric department in United States Army General Hospital No. 1 became evident in the summer of 1918, when there were numerous consultations required by other departments in looking over doubtful cases in other medical services.

The following tabulation of nervous and mental cases treated at the United States Army General Hospital No. 1 (exclusive of the Messiah Home), between July 1, 1918, and June 30, 1919, shows diagnosis and disposition.

(figure)

GENERAL HOSPITAL NO. 2,i FORT McHENRY, MD.

The neuropsychiatric service at this hospital was opened in March, 1918, but adequate facilities were lacking and it was not until May that the patients were moved into the new standard psychiatric building and the real, effective work of the service was begun. Patients were given every benefit of the modern school of neuropsychiatry. The interior of the building was decorated and painted in soft, restful colors, while potted plants and flowers distributed throughout and lace curtains at the windows all combined to make the place as attractive, homelike, and pleasant as possible. In the rear a spacious porch was converted into a sun parlor and made an ideal place for the activities of occupational therapy.

iBased on History of General Hospital No. 2, Fort McHenry, Md., by Maj. A. P. Herring, M. C. On file, Historical Division, S. G. O.


113

The psychiatric building had its own hydrotherapy room equipped with showers, continuous tub, etc., and the soothing effect of the sedative bath, especially in manic cases, was successfully demonstrated. Full advantage was taken of the hospital's physiotherapy department and nearly all of the neuropsychiatric patients were sent out daily for some kind of treatment in the more elaborately equipped psychiatric building.

No effort was spared to provide every therapeutic benefit to be derived from diversional occupation and recreation for the patients. A reconstruction aide spent her time entirely with these patients, doing all that was possible to keep their minds and hands busy, and splendid results were achieved. In addition, a teacher of calisthenics spent some time each day giving the patients brisk exercises and lively games which were greatly enjoyed. A large pool table, a Victrola, and a well-stocked library were available for use at all times.

The patients were treated individually and not collectively. No routine or "system" methods were used in administering to those who were admitted complaining of the many and varied symptoms incident to a nervous or mental disorder.

The happy results attending the use of the principal agencies of treatment (hydrotherapy, occupational therapy, psychotherapy), especially in the large group of the functional neuroses and the incipient mental disorders, amply justified the principles of "nonrestraint" which were insisted upon when the department was inaugurated, early in 1918.

The neuropsychiatric wards in this hospital were built along the plans of those existing in all of the Army general hospitals at that time. There were no locked doors, barred or screened windows. Patients admitted to the department of neuropsychiatry were always treated as sick individuals. On March 22, 1919, the scope of the service was considerably broadened by making arrangements to care for a number of neuropsychiatric officer patients, and a ward was set aside for their use. In addition to this the Surgeon General gave this service general supervision over a number of neuropsychiatric cases among Army nurses, aides, and others who were sent to the Shepherd and Enoch Pratt Hospital at Towson, Md., and to Henry Phipps psychiatric clinic at Johns Hopkins Hospital.

The following is a brief statistical summary of the department:

Number of patients admitted during the year 1918 

231

Number of patients admitted during the year 1919 

388

Number of patients admitted from January 1 to April 31, 1920

60

Total number admitted 

679

Number of patients discharged by surgeon's certificate of disability

144

Number of patients discharged to duty 

120

Number of patients transferred 

403

Number of patients deserted 

8

Number of patients died 

4

Total number disposed of 

679

Diagnoses:

Nervous disease and injury 

175

Psychoneurosis 

129

Psychoses 

170

Inebriety 

21

Mental deficiency

79

Constitutional psychopathic state 

86

Other diseases and injuries 

19

Total 

679

Consultations 

345


114

GENERAL HOSPITAL NO. 6, FORT McPHERSON, GA.j

The first collecting wards in the United States to be especially built and equipped for the neuropsychiatric work of the Army were opened to receive patients at Fort McPherson on November 7, 1917. In the suburbs of Atlanta United States Army General Hospital No. 6 was centrally located with regard to a great military population, including many cantonments and all the forts along the southeastern coast. Its grounds contained many medical units preparing for foreign service. Near by, with through train connections, were Camps Greenleaf, McClellan, Sheridan, Wheeler, and Hancock. The main line north tapped Camps Sevier, Wadsworth, and Greene.

The neuropsychiatric wards were so placed that the reception and treatment sections had on three sides medical and surgical wards, while the three buildings for nervous and insane cases stretched out toward the woods and away from other structures. Diet kitchens and offices were in the proximal ends of the three buildings for mental diseases and porches made them easily accessible from the general mess hall and from each other.

All buildings were new and conformed in appearance to other new hospital structures. They were sunny, well ventilated, with ample porch space, which was screened. The door of the reception section opened into a large room furnished with center table and settees. This was a meeting place for all the activities of the service. On one side was the record room and on the other the physician's office, housing a collection of books on neuropsychiatry, mental hygiene, and military service furnished by the National Committee for Mental Hygiene. Opposite the door were three smaller rooms. The first was for mental examinations, fitted with a table and shelves on which were kept the psychological tests and record blanks. The second contained a high bed for physical examinations and a blood-pressure instrument, an ophthalmoscope, and other clinical apparatus. The third room was fitted as a ward laboratory, with apparatus chiefly for urinalysis and the collecting and examining of blood and spinal fluid.

Entering the treatment section by a narrow hall from the reception room, one found in a room on the right electrical apparatus with a high convenient table for a recumbent patient. Across the hall on a cement floor were high tables for massage and packs. In front, in a room of many windows, open on

jBased on History of General Hospital No. 6, Fort McPherson, Ga., by Col. Thomas S. Bratton, M. C. On file, Historical Division, S. G. O.


115

three sides, with cement floor sloping 3 inches to a central drain, were placed an elaborate combination douche apparatus controlled from the wall and an electric light cabinet bath. In a separate room a Bergonie machine was set up.

Special articles of therapeutic and diagnostic equipment were furnished by the National Committee for Mental Hygiene as soon as the buildings were under construction and, because of this generosity and foresight, were at once ready for use.

A building adjoining, with small dormitories well separated from each other, was used as an admission ward. At its far end was a large space fitted with continuous bathtubs and showers, with inclosed porch in connection.

Two other buildings radiated from a common center with this last building. They were arranged to give isolation with a separate porch and bath to varying groups of patients.

The chief of neuropsychiatric wards, by consent of the chief of medical service, reported directly to the commanding officer in exclusively neuropsychiatric matters. Assistant physicians had duties roughly coordinate and independent. One devoted all his time to teaching enlisted men and to carrying out meningitis therapy in the medical wards. Another physician had charge of physiotherapy, treating patients from all hospital services. He gave instruction in his particular field to enlisted men, who assisted him in turn. The third was a specialist in the use of the Bergonie electrical apparatus, demonstrating its use in selected cases. Other physicians had direct charge of the wards.

Each ward for the insane was in charge of a nurse or wardmaster who had adequate psychiatric training; a supervising nurse had general duties in the care of all cases. The neurological ward was in the charge of nurses with general training; it was open, and run as were other medical wards.

A sergeant was in charge of occupational activities, being responsible for patients received from the wards for outside work. There was opportunity also to use the occupational classes of the reconstruction department.

A sergeant, first class, was in charge of all enlisted men sent here for training, assigning them to duty and keeping track of their work and character; he also had charge of records, with three clerks to help him.

Enlisted men were supplied by the section of neurology and psychiatry of the Surgeon General's Office, which selected them because of special experience or fitness. Among them were many attendants with more or less service in hospitals for the insane and many college men who had specialized in psychology or pharmacy. Due to a shortage in experienced personnel, it was necessary to take Hospital Corps men and men without hospital experience and train them for work on the mental wards. A special course was instituted and lectures were given by the ward physicians on the care and treatment of mental diseases.

During the fall and winter (1917-18) the wards were crowded with dementia pręcox cases, most of them of long standing. In some cases the conditions of Army life seemed to precipitate mental trouble in persons who might have remained normal in civil life. Many were returned to their homes for supervision. Over 50 were returned to hospitals in their home States, often to hospitals where they were well known as former patients.


116

As a contrast to this group was one formed by patients from Camp Gordon, Ga., and the other wards of the general hospital, who complained of headaches, vertigo, pains. Many of these were carried as consultation cases; those not rather promptly relieved by the fitting of glasses, the cleaning of teeth, by baths and packs, were found, in general, resistant to treatment, and, under the diagnosis of neurasthenia or constitutional psychopathic state, usually were discharged.

With the spring came a third general group-the organic-appearing cases, which turned out to be functional, and the acute psychoses. Electrical apparatus, added to suggestion, made many dumb to talk and many crippled to walk. The diagnosing of different sorts of fits was a difficult problem. The malingerer was rare. Cases of feeble-mindedness were few because they had been sifted out in the cantonments.

In treatment physiotherapy was used largely and with good results. Gardening developed nicely in adjoining spaces and provided many mental cases with pleasure and exercise. It was the aim to give most of the patients employment of some kind. During the spring, summer, and fall months, many patients worked on the lawn, grading, seeding, planting, and caring for flowers. Others worked in the vegetable garden. On the wards patients were employed under the supervision of occupational therapists and instructed in basketry, rug weaving, beadwork, hammock making, wood carving, etc. A great deal of interest was manifested in the work and much benefit was derived from it.

The neuropsychiatric section of the hospital contained, on January 1, 1918, 30 patients, and on December 31, 1918, there were 153 patients. During the year there were 817 admissions. The largest number of patients admitted in any one month was during October, when 174 cases were received. The average monthly admission was 68 patients. Up to October (1918) it had been possible to care for and treat all mental and nervous cases in the buildings designated and built for this class, namely, wards U, V-1, V-2, and V-3. In October, however, it became necessary to convert medical wards M and L into psychiatric wards. These gave an additional capacity of 160 beds, making the total capacity of the neuropsychiatric wards 276.

About 45 of the admissions to the neuropsychiatric section were psychotic cases. Many of these cases in the early part of the year came from the various camps, but the majority came from overseas. About 25 Percent of the cases admitted were functional neuroses, mostly from overseas; about 10 Percent were mental defectives. Comparatively few organic nervous cases were received. Constitutional psychopathic states represented 6 Percent of the mental cases admitted. This class seemingly found it difficult to adjust to Army life for any length of time, soon ran counter to the necessary discipline, and were a source of disturbance and trouble. Only a few drug addicts and epileptics were received.

During the year 692 cases were discharged in various ways. Three hundred and seventy-nine cases were discharged as recovered or improved; 125 cases were transferred to Government hospitals for the insane; 116 cases were discharged to other public and private hospitals. The death rate was comparatively low, 5 cases in all, or less than 1 Percent of admissions.


117

GENERAL HOSPITAL NO. 26, FORT DES MOINES, IOWAk

At General Hospital No. 26, Fort Des Moines, Iowa, there were two wards for neuropsychiatric cases. These wards were newly built of the standard type-wards C and D. Ward D was occupied first on May 17; ward C on May 28, 1918. By the early fall of 1918 the hospital had approximately 1,300 patients, with about equal numbers of general medical and surgical (chiefly orthopedic) cases, and some 80-odd mental cases. By October the daily average of mental patients had increased to 130.

Patients were received in the neuropsychiatric wards in larger or smaller numbers at a time from Camps Funston, Dodge, Stuart, and Grant, from Forts Bliss and Omaha, and McCook Field, and in August and later from the debarkation hospitals at New York, Newport News, and Boston.

Sixteen patients (mental) were discharged by the end of July, but from that time to the middle of October only 20 more were discharged.

The diagnoses were about the same as recorded in the literature for other military hospitals, except that there were not many war neurosis cases-a few epileptics, some manic-depressive cases, some dementia pręcox cases, a number of moron and border-line defectives, a few constitutional psychopaths, and an occasional alcoholic or drug addict. A few cases of post-meningitic condition were admitted for observation. When the orthopedic and other surgical cases began to come in from overseas, many nerve-injury cases were seen.

The total number of cases admitted to the mental wards up to December 4 was 226. An equal number were seen in consultation, but not admitted to the wards. In addition to these, a survey was made in August, 1918, of the enlisted personnel, 241 men altogether, of Base Hospital No. 79, which outfitted and organized at Fort Des Moines.

The nursing personnel of the neuropsychiatric wards was adequate in numbers and fair as to quality.

GENERAL HOSPITAL NO. 30, PLATTSBURG, N. Y.l

Early in 1918 it became evident that more facilities would be required for the observation and treatment of psychoneurotic disorders than could be provided in the neuropsychiatric wards of the general hospitals. These wards, as well as the wards of base hospitals, had been relieved by the establishment of a general hospital for psychoses (General Hospital No. 4, Fort Porter, N. Y.), and patients with psychoneuroses had from time to time been transferred there. It was obvious, however, that this hospital could not be expanded to take care of the large number of psychoneurosis cases that would come under treatment, even if this were desirable, and it was not considered desirable. It was felt that the two types of patients should be separated. For the successful treatment of patients with psychoneuroses in large numbers an organization was required in which could be maintained a spirit of recovery. This meant a hospital to which would be transferred only those patients for whom recovery

kBased on History of General Hospital No. 26, Fort Des Moines, Iowa, by the commanding officer, Nov. 15, 1918. On file, Historical Division, S. G. O.
lBased on History of General Hospital No. 30, Plattsburg, N. Y., by the commanding officer. On file, Historical Division, S. G. O.


118

was reasonably to be expected, and a hospital so located as to be as free as possible from outside distractions, both military and civil, and where military discipline could be maintained or relaxed as the occasion demanded.

The post hospital at Plattsburg Barracks, N. Y., was selected. Medical officers specially trained in neurology and psychiatry were ordered to Plattsburg during May, 1918, and the first neuropsychiatric patient was received May 23, 1918. Ninety-nine patients were transferred to the hospital during June and other patients were transferred during July, August, and September, although the hospital continued during this period as a post hospital and received, in addition to the neuropsychiatric patients, patients from the military organizations then stationed at Plattsburg Barracks and from the second officers' training camp of 3,454 candidates. Some neuropsychiatric patients were received also from overseas. September 21, 1918, the original post hospital at Plattsburg Barracks was designated General Hospital No. 30 and expanded to include the entire group of permanent buildings at this post, the Infantry barracks being converted into hospital wards. There were 28 wards, with a capacity of 1,200 beds.

The hospital was divided for purposes of administration into four sections. Section 1, for medical and surgical cases, including operating room; eye, ear, nose and throat, and genitourinary cases, with X-ray laboratory. Sections 2, 3, and 4, in the Infantry barracks, contained wards for various classes of neuropsychiatric cases. The hospital headquarters offices were moved from the old post hospital to the post administration building in the early part of October, this building being centrally located and more convenient for purposes of administration. Medical officers on duty in the hospital and nurses were assigned to quarters upon the post in buildings set aside for this purpose.

During the months of November and December, various buildings comprising the hospital were connected by inclosed bridges, making in all a compact, protected area for the transfer and care of patients. During this time the porches were inclosed and a steam-heating system was installed throughout.

Although designated as a hospital for war neuroses and primarily for the reception of patients from overseas, patients with other neuropsychiatric conditions, through mistake in diagnosis and the exigencies of the service, were transferred to the hospital or received from overseas. There were later assigned to this hospital, also, at the instance of the division of neurology and psychiatry of the Surgeon General's Office, patients suffering from convulsive disorders (epilepsies) for special study, drug and alcoholic inebriates, and patients with residuals of epidemic cerebrospinal meningitis.

The first 1,000 patients had been received by November 16, 1918. A statistical analysis of this group of 1,000 patients (considered typical for the patients received at this hospital) shows the following clinical distribution and disposition:


119

(figure)


120

Disposition of cases

Percent

Discharged on surgeon's certificate of disability

53.8

Returned to duty 

27.0

Transferred to other hospitals 

3.7

Still in the hospital

15.4

Died by suicide 

.1


The disposition of cases as shown above is as of January 1, 1919. The cases discharged on surgeon's certificate of disability were practically all not in line of duty, and the same was true of a good many of those transferred to other hospitals or who remained under treatment at Plattsburg. These officers and men were unfit for military service. Their induction into the service was of no benefit either to the Government or to them. It was possible in almost all of them to obtain readily a history of the existence of their disability for a greater or lesser length of time prior to enlistment, and it would have been possible to obtain such a history at the time of induction into the service.

The cases returned to duty had recovered sufficiently from their more acute manifestations to be able to be of some service; but in most of there there remained behind, of course, the neuropathic constitution on the basis of which their nervous breakdown had occurred. They were at best fitted for limited service.

Some contrasts are to be noted in the above tabulations between the respective groups of cases represented in them.

The psychoses constituted 15.9 Percent of all admissions in officers and only 4.5 Percent of all admissions in enlisted men. No significance is probably to be attached to the higher percentage of psychoses among officers, as officers with psychoses were frequently sent to this hospital in preference to a hospital for the insane, while enlisted men were regularly sent to hospitals designated for the treatment of psychoses.

For reasons that are perhaps sufficiently obvious, there were no cases of mental deficiency among officers, and there were also none of cerebrospinal syphilis, although the number of officer patients is too small to be significant. In a larger group of cases a certain percentage of cerebrospinal syphilis would undoubtedly be found, although it seems probable that such percentage would be lower than in enlisted men owing to greater caution about exposure to the infection, more through prophylaxis, and more prompt and thorough treatment in case of infection.

The tabulations show that endocrinopathies-for the most part hyperthyroidism-are more than six times as frequent, relatively, in the home than in the overseas cases. It would seem clear from this that these endocrinopathic cases are so manifestly unfit for military duty that even in the hasty selection of men for overseas service they were almost completely eliminated; those cases which had passed the local board and first cantonment examinations came to light in the course of their training. Thus is explained the fact that endocrinopathies represent 3.9 Percent of all home cases admitted and only 0.6 Percent of all overseas cases.

Residuals of epidemic cerebrospinal meningitis are represented in the home cases by no less than 17.3 Percent of all admissions; in the much larger


121

number of overseas cases no instance of that condition was observed. The underlying fact is that all epidemic infections and, of course, any sequelę or residuals, with the possible exception of influenza, were far more prevalent in the home cantonments than among the troops overseas. The reasons for this fact are well known and require no discussion here.

Epilepsy is represented to the extent of only 4.5 Percent of all home cases and no less than 43.2 Percent of overseas cases. This remarkable contrast, as far as it has a bearing on the relative incidence of epilepsy in troops in the home and overseas service, is more apparent than real. The bulk of all cases of epilepsy discovered in home cantonments were disposed of there by discharge on surgeon's certificate of disability. No such disposition could be made of cases discovered in overseas service; they all had to be sent to hospitals in the United States for final disposition. The figures show merely that in examination before local boards at time of mustering in and at time of selection of troops for overseas service epilepsy was often either overlooked or, if known to exist, ignored, and that eventually the necessity arose for these cases to be sent to hospitals and disposed of by discharge on surgeon's certificate of disability.

RESIDUALS OF EPIDEMIC CEREBROSPINAL MENINGITIS

An instructive series of cases studied at Plattsburg were those with residuals of epidemic cerebrospinal meningitis. In the period from December, 1917, to February, 1918, a number of cases of epidemic cerebrospinal meningitis developed at Camp Beauregard, La. The patients were treated with specific serum administered both intravenously and intraspinally, and a number of them made uneventful recoveries from the infection. After a four or five weeks' period of convalescence in the base hospital at the camp, as a rule, they were granted a 60-days' furlough at home. On return from their furlough some of the men were found still to have certain residuals, owing to which they were unable to go back to duty. Others did go back to duty but were found within a few days to be unable to perform it. Therefore all such patients were readmitted to the base hospital. After a further period of from five to eight weeks' treatment and rest in the hospital they were still not in condition to go back to duty, and 18 of them were transferred on July 29 to General Hospital No. 30, Plattsburg Barracks, N. Y.

At various other times and from other camps 13 other post-meningitic patients were received at this hospital, and thus an unusual opportunity presented itself of studying the residuals of epidemic cerebrospinal meningitis.

In the decade previous to 1917 a great deal had been published on the subject of epidemic cerebrospinal meningitis; but these publications dealt almost exclusively with the acute phases of the disease, its bacteriology, modes of transmission, prophylaxis, and specific therapy, and not with the residuals.

The cases that thus came to the attention of the medical officers on duty at General Hospital No. 30 presented a striking and fairly uniform syndrome made up of the following elements, given here in the order of their frequency: (1) Limitation of flexion of the spinal column; (2) undue fatigability; (3) pains in back, legs, and head; (4) tendency toward dizziness and faintness; (5)


122

muscular weakness; (6) tendency toward blurring of vision, associated with photophobia; (7) impairment of appetite and sleep, associated with a state of undernutrition.

The limitation of flexion of the spinal column was shown in all cases by inability to stoop over far enough to touch the toes with the tips of the fingers without bending the legs at the knees. One or two of our patients, on arriving at the hospital, were able by special effort to come within 6 inches, but most of them could not come within a foot, and one could stoop but very slightly. All said that prior to the attack of meningitis they had been able to do this, and some had been able to stoop far enough to place the palms of the hands on the ground.

The limitation of flexion was further shown in the cervical region by the patients, in the majority of cases, being unable to flex the head on the trunk so as to touch the sternum with the point of the chin-which most people normally can do. Some of the patients could not come within 2 inches of touching.

Undue and unwonted fatigability was present in all cases, although it varied a good deal in degree. In one case, going up a flight of stairs or a short distance up a hill or a few blocks even on level ground resulted in getting out of breath, palpitation, weakness, trembling, aches in the back and legs, and a feeling of exhaustion. In another case the fact of undue fatigability was to be noted only by comparison with former endurance or with the endurance of other men in the organization.

Pains in the back, legs, or head were present in all cases. In some cases it was constant and so severe as to make it impossible to maintain with comfort any position for more than a few minutes. In other cases it was slight or only occasional, or developed only on stooping or exertion. The favorite locations were, in order of frequency, the small of the back, the back of the head and upper part of the neck, the legs behind the knees, and the back between the shoulder blades. In some cases there was tenderness to deep pressure, and in one case the head was so sensitive that laying the hand lightly on the top of it caused an increase of pain. In two cases there was great soreness in the tip of the coccyx, the patients having to sit on either one buttock or the other.

A tendency toward dizziness and faintness was present in almost all the patients, but also varied in degree. In some cases any sudden movement started things whirling or caused black spots to come before the eyes, while severe or prolonged exertion caused the patient to become faint, lose consciousness, and fall; one patient came with a transfer card diagnosis of "epilepsy following meningitis." In the milder cases even severe exertion would bring on only slight or momentary dizziness. Stooping more than other movements would excite this symptom. Arising from bed in the morning would often bring it on. It developed more readily in the unshaded sunlight, especially on a warm day.

In the headaches, dizziness, faintness, and losses of consciousness, and in the fact of these symptoms being especially apt to be brought on by exertion, stooping, sudden movements, or exposure to the sun, the post-meningitic con-


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dition closely resembles the well-known condition that persists for years following severe cranial traumatisms.

Muscular weakness, as existing independently of the fatigability and of the pains, was shown particularly by feeble hand grips in more than half of the cases. Usually both grips were weakened, but often in an unequal degree. One patient, in other respects having a rather mild case, formerly as "strong as a tiger," was hardly able to turn the faucets in the lavatory.

The tendency toward blurring of vision was very common but also variable in degree. It became manifest when patients attempted to read, especially if the print was fine. After a few minutes or half an hour the letters would begin to "run together"; if the patient rested a while he could continue the reading, but unless he had rested an hour or more the blurring would come on again and more quickly than the first time.

It would seem that this trouble is due to a weakness of the ocular muscles; in some cases close application would bring on diplopia; the ocular movements, however, as ordinarily tested, as a rule were not impaired. In cases in which the tendency to blurring of vision was most marked there was also a degree of photophobia; at least two of the patients had to wear smoked or colored glasses. In these cases there was sluggishness and limited excursion in the pupillary reaction to light; moreover, on continued exposure to bright light, the initial contraction would soon give way to relaxation; and it may be that the photophobia was dependent at least in part on weakness and fatigability of the concentric muscle fibers of the irides, with resulting lack of shielding of the retina.

The impairment of appetite and sleep, sometimes associated with a state of slight subnutrition, was perhaps a secondary phenomenon. Many of the patients had formerly been leading active outdoor lives but had since been forced by their illness to remain almost wholly without exercise for months. The loss of sleep was almost invariably associated with pain; in some cases the patients had difficulty in getting into a comfortable position for sleep and would toss around for hours before finally falling asleep; others would fall asleep quickly but would wake up in the night on account of pain developing from the strain of being in one position.

The cases showed considerable variation in severity of the symptoms and degree of disablement, as compared one with another, but not in the syndrome considered qualitatively. The quantitative variations seemed to depend in part on severity of the original infection, or possibly the patient's resistance to it, and in part on the length of convalescence. The usual course was characterized by a very pronounced degree of disablement at the beginning of convalescence, progressive improvement for about a month or six weeks under rest without special treatment, and from then on an almost stationary residual condition persisting apparently indefinitely-in the cases at Plattsburg from three months to over a year.

Shortly following the admission of these patients to this hospital, they were divided into groups, according to the degree of disablement, and were placed under a regimen of graded marches, hikes, and exercises, such as neck bending and body bending. This was followed by striking and rapid improve-


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ment in some cases and in distinct though slight improvement in almost all within a month.

All cases eventually recovered from the above-described symptoms at least sufficiently to leave the hospital and resume either duty or their civilian occupations. There remained in some of the cases lingering symptoms, such as stiffness in the spine, pains in back, legs, or head; but these were present only in slight degree and were in no way disabling.

In the course of observation of these cases, the impression was occasionally gained of a psychoneurotic element in the form either of exaggerations of the disability or of addition of manifestations foreign to the typical symptom-complex. It was noted that some of the cases showed rather sudden improvement within a few days following the signing of the armistice. The most flagrant case was that of an enlisted man who showed, in addition to the typical post-meningitis symptom-complex, a persistently labored and grotesque gait due to contractures at both knees in a position of partial flexion: "Capt. K.--- gave me electrical treatment, and after the second treatment I was all cured up."

This is merely added evidence of the well-known fact that a purely functional mental element not infrequently exists as a complicating factor in organic disease.

On the whole the group of post-meningitic residuals presented not only a striking uniformity of symptomatology, but also of course and termination- and that quite regardless of such conditions as prospect of overseas duty, and the signing of the armistice, as may be judged from the fact that of the 31 cases admitted 12 had recovered sufficiently to be recommended for duty prior to November 11; several were among the more recent admissions.

The following case record is cited as typical of the group:

J. F. B., private, headquarters company, 154th Infantry. Born in Arkansas; white, aged 22; single, former occupation, farmer. Admitted to United States Army General Hospital No. 30, Plattsburg Barracks, N. Y., by transfer from base hospital, Camp Beauregard, La., on July 31, 1918. Transfer card diagnosis: Neurosis, post-meningitic.

Family history - Negative for mental or nervous disease, inebriety, feeble-mindedness, or criminalism, except that one brother died in convulsions in childhood.

Personal history - Had measles, whooping cough, and mumps in childhood; "swamp fever" (malaria?) at 15; recovered fully from all; no other diseases or injuries. He went to school irregularly, as he had to work and did not have much opportunity; reached fourth grade. Then went to work on his father's farm, receiving $30 a month and his board. Enlisted June 5, 1917, and was first sent to Fort Logan H. Root, Ark. In September, 1917, was sent to Camp Beauregard, La. He had had no trouble whatever in either place up to the time of onset of his present illness in the latter part of December, 1917. He had drilled and worked well and reported at sick call only twice for minor ailments.

Present illness - About the 18th of December, 1917, he began having frequent chills, felt weak, and lost appetite; he slept well, however. In the evening of the 20th he developed a very severe headache and "a drawing from the back of the head all the way down"; could not sleep that night. Next morning became unconscious and was taken to the base hospital (Camp Beauregard). Has a vague and incomplete recollection of lumbar punctures. Clinical history from that hospital states that he had epidemic cerebrospinal meningitis, received intraspinous and intravenous treatment, but did not begin to improve until the latter part of February, 1918. Case note, March 1, 1918, states: "Up; very thin and weak." April 11: "Hook-worm treatment given." On April 26 given a furlough. Returned to camp on June


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20, but was not able to do duty; felt weak and feverish; occasionally had slight headaches; complained of pains in the back and in the back of the head; would have dizziness on stooping or "on the least strain"; when he tried to read his vision, after a while, would become blurred; he had not regained all the weight he had lost. He was readmitted to the base hospital on June 22; about two weeks later he was sent to the convalescent camp attached to the base hospital. Improved somewhat, but did not fully recover and on July 28, 1918, was ordered transferred to Plattsburg Barracks, N. Y.

Examination on admission - Complains of weakness in the back; states he tires very easily. Eyes are still weak; i. e., on trying to read, vision soon becomes blurred. Upon exertion, the old pain in the back and in the back of the head begins to trouble him again. Upon stooping or exertion becomes dizzy, though not so badly as formerly. Walking fast tires him quickly, but if he takes his time he can walk a good deal. Is somewhat underweight; weight, 130 pounds in ordinary clothing; height, 5 feet 7 inches; his usual weight in ordinary clothing is 150 pounds. Has scar over sacrum from bedsore. Is unable to touch toes with tips of fingers by stooping over without bending the knees on account of pain and stiffness in small of the back.

Patient was prescribed neck and body bending exercises and graded hikes. Note of October 8, 1918, states: " He feels now that he is as well as he was before he had meningitis." Recommended for duty by board of medical officers.

DEBARKATION HOSPITAL NO. 51, NATIONAL SOLDIERS' HOME, HAMPTON, VA.m

The neuropsychiatric service of Debarkation Hospital No. 51 was organized on or about November 18, 1918. The first large convoy of overseas patients was received on November 20, 1918. This convoy contained approximately 300 mental cases who were placed in wards that were not well prepared for the reception of such cases. Notwithstanding this inadequacy of facilities, however, these patients were handled with only one accident, a minor one, an abortive attempt at self-injury on the part of the patient.

Reception of patients was rather slack during the remainder of the month. From about the middle of December, 1918, the debarkation of neuropsychiatric patients went on sporadically, large convoys of patients alternating with small ones. On January 1, 1919, 215 cases arrived and these were handled without difficulty.

Up to February 1, 1919, approximately 1,520 mental cases were cleared through this hospital and in this number, psychoneuroses, psychoses, constitutional psychopathic states, epileptics and mental defectives were found in the order named, organic disease of the central nervous system being far in the minority.

As this hospital functioned only as a debarkation hospital, none of these overseas cases were retained here for treatment. All cases were classified on standard blanks. After the diagnosis and condition of the patient was determined he was transferred to the hospital treating his special condition. Epileptics and mental defectives were sent to the camps nearest their homes for demobilization.

The psychoneuroses were all sent to General Hospital No. 30, Plattsburg Barracks, N. Y., and this was routine up to March 22, 1919. At that time a letter from the Surgeon General authorized the commanding officer to send to

mBased on report of the neuropsychiatric service, Debarkation Hospital No. 51, National Soldiers' Home, Hampton, Va., by Capt. Nathaniel H. Brush, M. C., May, 1919. On file, Historical Division, S. G. O.


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the nearest camp for demobilization all psychoneurosis cases who had sufficiently recovered to need no further treatment. This authority not only relieved the debarkation hospitals of a great burden, but also freed General Hospital No. 30 of many unnecessary cases.

A careful record was kept of the various types of cases received from the American Expeditionary Forces, from February 1, 1919, to March 31, 1919. During this period 589 neuropsychiatric cases were received. They were classified as follows:

Psychoneuroses

250

Mental defectives 

39

Psychoses 

184

Organic brain disease 

14

Constitutional psychopathic states 

54

 

Total

589

Epileptics

48


In a general way this classification showed the usual type of cases received at this hospital. Careful and completely tabulated records were kept of the diagnoses in all cases from the opening of the hospital, but through an unavoidable accident these records were destroyed. The only records left at that time showed the clinical difficulties of the above listed group of 589 cases, but other statistics were available showing that up to April 27, 1919, when it terminated its debarkation activities, a total of 2,419 neuropsychiatric cases had been cleared through this hospital.

Early in March, 1919, two representatives of the Surgeon General inspected the hospital with a view to its conversion into a permanent hospital for the continued care and treatment of mental cases exclusively. The lay-out and plant seemed ideal, and almost immediately plans were formulated for the functioning of the hospital in its new capacity. On April 20, 1919, it became United States Army General Hospital No. 43 (q. v.).

UNITED STATES ARMY GENERAL HOSPITAL NO. 43, NATIONAL SOLDIERS'
HOME, HAMPTON, VA.n

The hospital being designated to care for mental cases only, it is obvious that the neuropsychiatric service embraced the greater proportion of the professional work, but to provide adequate medical and surgical service for the patients it was necessary to continue medical, surgical (including genitourinary and eye, ear, nose, and throat departments), and dental services. The laboratory and hydrotherapeutic departments also were organized and equipped.

This institution was originally the National Soldiers' Home, and not having been built for mental cases, there were no standard wards. They varied in capacity from 35 to 200 beds. Some of the barracks were provided with the necessary screening for doors and windows to insure the retention of the irresponsible cases. Continuous baths were installed in three buildings for the treatment of excitable cases who required frequent and continuous baths to control their psychotic episodes. There were 22 wards in all, 8 of which were operated as closed wards. It was the policy to give the patient as much freedom as possible, and many kept in closed wards at night were paroled during the day.

nBased on report of professional work at General Hospital No. 43, for the year 1919, by the commanding officer, January 9, 1920. On file, Record Room, S. G. O., 319.1-2.


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In the treatment of the mental cases the continuous sedative baths, hot packs, Scotch douches, needle showers, electric heat, occupational therapy, and exercise were the chief methods employed. Special efforts were made to avoid the use of narcotic and sedative drugs and very seldom were they used, and then never for other than temporary relief of an excitable or nervous patient at a time when it was not feasible to resort to the bath or pack. Probably drugs were not used in one-half dozen instances during the period covered by this report. The restraint sheet practically never was used.

One section of ward 18 was used for hydrotherapy. Temporary partitions were put in, dividing the room into small compartments for beds and stalls in which the patients disrobed. Ten beds were maintained in this department. The equipment consisted of two Scotch douches, two needle showers, four electric cabinets, and a number of incandescent-light baths for local application. A qualified masseur was employed in this department and his service in some instances apparently was very beneficial.

The more excitable cases were segregated in the wards provided with continuous baths, and the result of these baths in the control of such cases was very gratifying. There was no instance where a patient could not be quieted by the use of the hot pack or continuous bath if handled judiciously and the treatment was repeated at frequent intervals. Patients seldom objected to this treatment and many were glad to return to the baths.

Occupational therapy did much to establish confidence in the patient. The prime factor in this work was to obtain the gradual cooperation of the patient in order not to put him at a task that would be repulsive, and thereby make him worse. There was close cooperation between the ward surgeon and the reconstruction aides, and the helpless and irresponsible patients were coaxed to work on the wards. In this work they began with simple tasks, such as the winding of string, the unraveling of burlap, basketry, rug weaving, and knitting. As the patient regained his confidence and the control of his faculties and acquired more responsibility, he was allowed to do a different class of work requiring more physical and mental ability, such as carpenter work, printing work, typewriting, and automobile repairing.

Through the medium of exercise the patient's physical condition was kept as near normal as possible. Exercise was also useful in stimulating a desire for food. Care was taken in the selection and grouping of patients for the different exercises, giving them all the benefits of open air during the day. The less responsible patients were taken on walks, while the others were required to take varied calisthenic movements. Through the American Red Cross and other civilian organizations many automobile rides were arranged for the patients.

The granting of furloughs was very liberal when the condition of the patient warranted. In many instances a visit home unquestionably benefited the soldier.


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On December 31, 1919, 3,206 patients had been treated at this hospital, classified as follows:

Psychosis:

Dementia pręcox

703

Dementia paralytica

2

Undiagnosed

223

Constitutional psychopaths

229

Manic-depressive

266

Mental deficiency (moron)

298

Due to drugs, alcohol

158

Psychoneurosis

445

With cerebral syphilis

23

Epilepsy

72

With arteriosclerosis

3

General paralysis

277

Traumatic

9

Under observation for mental alienation (no disease)

6

Infectious and exhaustion

6

Nervous disease, undiagnosed

40

Anxiety

2


The balance, 444, were not neuropsychiatric patients but transfer cases handled for the port of embarkation, old soldiers, and civilians.

There probably has been no institution in this country where the opportunities to study unusual mental diseases were so excellent as at this hospital. The material was abundant, and it is unfortunate that the personnel of the hospital had to change so frequently and that the pressure was so steady and the requests so insistent to get cases away to institutions near their homes, or otherwise released from the service.

The commanding officer reported that the members of the staff were impressed with the large number of mental cases that were diagnosed dementia pręcox and who suggested a typical history of mental deterioration, who later had their mental faculties return almost to normal and were discharged, cured, or improved to such an extent that they could be released on their own responsibility. These cases were depressions of a mixed type which could not be differentiated from dementia pręcox until they had been under observation for some time.

They were impressed also with the large number of cases that developed after the armistice was signed, conditions which could not be accounted for unless the etiological factor was purely anxiety and nostalgia. Many of these soldiers had gone through the worst of the fighting and were apparently normal a long while after the armistice was signed, then became confused and were later sent to hospitals for mental observation. A large number had actually returned to this country and were in the demobilization centers before they had their psychotic episodes.

A few cases were difficult to determine in persons who drank heavily in France but had been men of exemplary habits in civil life. In these cases it was the problem to decide whether the psychosis was of alcoholic origin or whether the soldier had become a victim of mental deterioration before he had begun to indulge in alcoholic debauches.

LETTERMAN GENERAL HOSPITAL, SAN FRANCISCO, CALIF.°

The psychopathic ward, with an authorized capacity of 60 beds, was opened to patients on October 17, 1918. Previously the mental patients were cared for in the detention ward along with general and garrison prisoners and

°Based on War Diary, Letterman General Hospital, San Francisco, Calif., November 12, 1918. Also: History of Letterman General Hospital, by the commanding officer, June 21, 1920. Also: Annual report, Letterman General Hospital for 1918, by the commanding officer. On file, Historical Division, S. G. O.


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men confined for punishment. The detention ward, with an authorized capacity of 50 beds was much overcrowded, but the more serious objection was the confinement of patients with prisoners behind bars. The opening of the pyschopathic ward was, therefore, an epochal event. While the detention ward had a barred entrance, barred windows, barred doors and partitions and "cells," the psychopathic ward had no barred doors or windows, and had "rooms" and "dormitories." This improvement in the surroundings was of great advantage in the care and treatment of the insane. The building was well constructed, with many windows and two large air shafts affording good light and, with the aid of a fan system, adequate ventilation. The hallways and offices had good hardwood floors; the other floors were of colored cement. The single rooms and dormitories were located around the outside, hotel fashion. The ceilings were high and the rooms spacious. The general impression was pleasing to both patients and visitors. On the second floor was the reception or sick dormitory, and near it was a screened porch where patients could enjoy the air and a view of the bay and environs.

In the basement was the very complete hydrotherapeutic department. (Control table for needly spray, rain douche, Scotch douche, steam douche, perineal spray, liver spray, sitz bath; continuous bath with automatic control; electrohydric bath; electric light cabinet; electric coil cabinet; pack tables; massage tables; blanket warmer; scales, etc.). A large room adjoining the hydrotherapeutic room was utilized as a rest room, where patients were required to lie down for an individually designated time following treatment. The "hydro" nurse and his assistants were kept busy throughout the day, and very beneficial results were effected through their efforts. The nature of the treatment depended upon the individual case. Not only healthy functioning of the skin was secured, but through individual treatment a sedative, restful effect upon an excited, sleepless person and a stimulating effect upon a depressed, retarded patient.

Another important form of treatment was occupational therapy. Every patient, unless his physical state absolutely contraindicated, was expected to do some form of work morning and afternoon, the nature and duration of which were carefully regulated in each individual case. It was kept clearly in view that the object was to hasten recovery or at least to improve a chronic state, rather than to accomplish a set amount of work. Accordingly, variation of employment was given to increase interest, and above all the advancement from a simple to more complex tasks. Certain patients were not mentally fit to do regular duty, inside or outside the ward. Much attention was given to such patients in an attempt to draw them out to better results. To that end a large airy room in the basement was used for raffia work, basket weaving, games, or other activities designed to arouse interest and bring the patient into better contact with his environment. The man's former occupation and interest were taken into consideration. He was carefully observed for revival of interest, and wherever indicated he was drawn in that direction to better cooperation and eventually to duties on the ward. Patients were urged to take a personal interest in the cleanliness of the ward and were held responsible for certain windows, walls, floors, brass work, etc. A record was kept of each man's


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activities, and his duties were varied to suit his condition. The man overcharged with energy was given a useful outlet for his activity, thus bringing him into better accord with his environment and hastening recovery.

Another class of patients, if allowed to do so, would gradually get out of touch with the world and shut themselves into a little world of their own imaginations. Along with this would result a marked dilapidation of personality, untidy appearance, lack of care of person, wetting and soiling, etc. Through proper attention to occupational therapy this deterioration could be prevented in marked degree and the patients held to more normal mental content, more natural appearance, and easier care. Whenever a man's condition permitted he was given outside work in shops, garden, etc., with greater liberty and resultant upbuilding of interest. All patients were benefited through recreation inside or outside the ward, such as athletic games, graphaphone concerts, etc. The work of the educational department along these lines was most thorough and commendable.

Sharing in importance with the above was the work by the physician with the patient himself, investigating his difficulties, airing them and helping him straighten them out. In order to get best results it was necessary to secure the confidence and cooperation of the patient and to make him feel that the physician was his friend who had his best interest at heart. A careful record was kept of such investigations and interviews with the patient were repeated from time to time as indicated.

The psychopathic section of the medical service was extremely busy during the entire period of the war. The construction of the new and modern psychopathic ward greatly facilitated the handling of mental cases and enabled proper treatment to be given the patients. Though, as stated above, the ward was designed to accommodate 60 patients, at times it had to accommodate as many as 130, for after the signing of the armistice the hospital began to receive numbers of cases returned from France and from Siberia.

REFERENCES

(1) Circular letter from the Surgeon General, U. S. Army, December 6, 1917. Subject: Malingerers.

(2) History of Base Hospital No. 117, by the commanding officer. On file, Historical Division, S. G. O.

(3) Letter from Maj. Frank E. Leslie, M. C., to Maj. Frankwood E. Williams, M. C., March 12, 1919. Subject: Observations and suggestions. On file, Record Room, S. G. O., 730 (Neuropsychiatry).

(4) History of General Hospital No. 30, Plattsburg, N. Y., by the commanding officer, April 14, 1919. On file, Historical Division, S. G. O.

(5) Report on neuropsychiatric social service at General Hospital No. 30, Plattsburg, N. Y., March 1, 1919, by Margherite Ryther. On file, Record Room, S. G. O., 730 (Neuropsychiatry) (General Hospital No. 30) (K).

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