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Section I, Chapter VII

Table of Contents

CHAPTER VII

DISPOSITION OF MENTAL CASES

ARMY REGULATIONS GOVERNING DISCHARGE OF THE INSANE

Arrangements for the care, treatment, and eventual discharge of insane soldiers in the Army in peace time easily were made, as the number to be cared for was not large. Decision as to disposition in all cases was made in the War Department. Discharge by reason of insanity could be made only on order of the Secretary of War. To facilitate the decision of the Secretary of War, the papers forwarded to Washington in each case were to contain a statement as to whether the disability was or was not incurred in line of duty; and as to whether the patient, if discharged from the service, could be released from military control without danger to himself or others.1 Disposition was made in one of three ways: (1) Soldiers who became insane in line of duty were transferred to St. Elizabeths Hospital in Washington for treatment and eventual discharge; or, (2) if not considered dangerous, either to himself or to others, the soldier could be discharged on a certificate of disability and furnished transportation to his home or the place of his enlistment. If he was transferred to St. Elizabeths Hospital, he was accompanied by a noncommissioned officer.2 If he was discharged to his home, he might be accompanied, but usually was not. Upon arrival at the hospital, he was placed under treatment and discharged from the service, remaining a patient of the hospital; or, if he was permitted to return to his home, he was discharged on leaving his organization; or, if accompanied, upon arriving at his home. (3) Insane soldiers who were regarded as having been insane prior to enlistment, and hence not having incurred the disability in line of duty, were reported to relatives or to the local authorities at their places of residence. If the relatives expressed a willingness to receive and care for them, they were sent with attendants to the places where the relatives resided, placed in charge of the relatives, and discharged from the Army. In case the relatives would not agree to receive them, they were sent to their places of residence, turned over to local officials, usually the police, and then discharged. Certain cases not regarded as incurred in line of duty, such as general paralysis of the insane, were at times also sent to St. Elizabeths Hospital. The above procedure was provided for by the appended paragraphs of the Army Regulations: This procedure applied only to the enlisted personnel of the Army. Commissioned officers who became insane were ordered to appear before a retiring board for the necessary action. If retired, these officers were entitled to admission to St. Elizabeths Hospital for treatment, or they could be cared for in such other manner as their relatives might wish.


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464. The following classes of persons are entitled by law to admission to St. Elizabeths Hospital, Washington, D. C.: (1) Officers, contract surgeons, and enlisted men of the Army who have become insane while in the military service, or within three years after their discharge therefrom, from causes which arose during and were incident to such service; (2) inmates of the Soldier's Home and of the National Home for Disabled Volunteer Soldiers; (3) civilian employees of the Quartermaster Corps who may become insane during such employment; (4) general prisoners; (5) interned persons and prisoners of war, under the jurisdiction of the War Department, who are or may become insane.

The Secretary of War is authorized by law to transfer from any military hospital to the nearest available public hospital for the care of the insane any insane patient who is in need of treatment, preference being given to the hospital nearest to the place of the patient's enlistment. The superintendent of such public hospital has the right to retain the aforementioned class of patients in his hospital in the same manner and to the same extent as now possessed by the superintendent of St. Elizabeths Hospital. The Secretary of War is also authorized by law, during the existing emergency, to transfer to the various public hospitals for the care of the insane, patients of every class entitled to treatment in St. Elizabeths Hospital and that are admitted on order of the Secretary of War. The War Department will from time to time advise department commanders and others concerned of the public hospitals designated by the Secretary of War to receive insane patients transferred under this authority. (C. A. R., No. 64, Dec. 13, 1917.)

464. Applicants for enlistment and drafted men who are found to be insane after arrival at depot, post, or camp, and before the completion of their enlistment by oath, muster in, or otherwise, will be disposed of as follows: (1) Those whose liberation will be unattended by danger to themselves or others will be rejected and disposed of under the regulations governing the disposal of other rejected recruits; (2) those whose insanity is of a type that would probably make their liberation a source of danger to themselves or others will be delivered to the civil authorities authorized by law to apply for the commitment of insane persons, of the place where they applied for enlistment or whence they were drafted. The depot, post, or camp commander will provide the necessary escort for such delivery, and issue the necessary travel orders, transportation, and subsistence (in kind or by commutation as may be most suitable).

A similar procedure will be followed in the case of civilian employees of the Quartermaster Corps who are found to have been insane before the beginning of their employment. (C. A. R. No. 64, Dec. 13, 1917.)

465. (Changed by C. A. R., No. 46, W. D., 1916.) Except as provided in paragraph 467 of these regulations the insane of the military service enumerated in paragraph 464 who require treatment in institutions for the insane will be promptly transferred to the institutions designated to receive them respectively.

No person will be transferred under the provisions of this paragraph except after a critical examination by a board of at least two medical officers, of whom one shall, if practicable, be a specialist in nervous and mental diseases. The examination will preferably be made in hospital, and in the special ward for nervous and mental diseases, should there be one; and the board will not make its report until after the person being examined shall have been observed for a reasonable period of time. The report will give the diagnosis, a detailed account of the medical history of the case, and a statement as to whether the disability was or was not incurred in line of duty; also a statement as to whether the patient, if discharged from the service, can be released from military control without danger to himself or others, and the board's recommendation for or against the patient's transfer for treatment to such designated institution; all papers to be executed in duplicate.

Should the board recommend the patient's transfer for treatment to a designated institution, its report and all papers therewith and the medical certificate required by the Department of the Interior (blank form for which is furnished by The Adjutant General of the Army) properly filled in will be forwarded for the action of the department or division commander, who will, if he approves the transfer, issue the necessary orders therefor, and for such escort, transportation, and subsistence as may be required.


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Commands that are ordinarily exempted from the control of department and division commanders will forward such papers to the commander of the department within the territorial limits of which the command is located, for his action.

The department or division commander will send one copy of the board's report and the medical certificate to the institution to which the patient is transferred, and will forward the second copy of the board's report, etc., with a note thereon of his action, to The Adjutant General of the Army.

If the patient so recommended is an enlisted man, the record, and the report of the board of examining medical officers, will be prepared on the certificate of disability blank form in duplicate, accompanied by the necessary attached papers, and, in the event that his transfer is ordered, he will be discharged from the service on account of disability. (C. A. R., No. 64, Dec. 13, 1917.)

466. (Changed by C. A. R., No. 13, W. D., 1914; No. 22, W. D., 1915; and No. 55, W. D., 1917.) Upon the departure of the insane patient his immediate commanding officer will make and sign an inventory, in duplicate, of his effects, and will send one copy of the inventory, together with his money and other valuables by registered mail, to the superintendent of the institution to which he is transferred, retaining the other copy for the records of the command. The other effects of the patient, such as clothing, will accompany him as baggage. Upon the patient's departure the commanding officer will by telegraph advise the institution thereof and of the time when the patient will be due to arrive. (C. A. R., No. 64, Dec. 13, 1917.)

467. The insane of the military service in the Philippine and Hawaiian Islands, who appear to require treatment in institutions for the insane, except natives, will be sent by the department commanders to Letterman General Hospital, San Francisco, Calif., for observation in that hospital, before action is taken in their cases in accordance with the provisions of paragraphs 465 and 470. The insane in the Canal Zone and among other forces overseas will in like manner be sent to an Army hospital in home country near the suitable home port of the Army Transport Service for observation preliminary to similar action.

Insane natives of the Philippine Islands and Porto Rico serving in the Army of the United States may, under authority of the Secretary of War, be sent to asylums in the Philippine Islands and Porto Rico, respectively, (C. A. R., No. 64, Dec. 13, 1917.)

468. Army patients committed to institutions for the insane under these paragraphs will, when cured, be released from custody under the laws and regulations governing the release of other cured patients. To obtain the release of an Army patient who is not cured, or his delivery to the care of friends, application must be made therefor to The Adjutant General of the Army, accompanied by the recommendation of the superintendent of the institution. (C. A. R., No. 64, Dec. 13, 1917.)

469. The insane who do not require treatment in institutions for the insane will, unless permanently incapacitated for military service, be retained under military control. If they are permanently incapacitated for service and can be liberated without danger to themselves or others they will be discharged on certificate of disability. In case it is necessary to send a soldier to his home with an attendant he should not be discharged until he reaches his destination. (C. A. R., No. 64, Dec. 13, 1917.)

470. An enlisted man who requires treatment in an institution for the insane by reason of insanity existing before his enlistment is not entitled under paragraph 464 to be cared for at the expense of the United States. Each such case will nevertheless be examined and reported on in the same manner as the cases referred to in paragraph 464. The conclusions of the board being approved by the authority who is to take final action thereon, the soldier will be discharged for disability, and the following procedure had: His immediate commanding officer will communicate with his family or friends, with the civil authorities authorized by law to apply for the commitment of insane persons of the State where he was enlisted or whence he was drafted, and with the like civil authorities of the State which he claims as his home, to ascertain whether they will receive and care for the man at their own expense. Should they agree to do so, the man will be sent under proper escort to the family or friends, or to the local authorities mentioned, as may be appropriate. Should they refuse to take charge of him the soldier will be sent to a designated public hospital for the insane pending


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the determination of what civil authorities are legally required to assume his care and treatment. Upon the soldier's departure his commanding officer will by telegraph advise the hospital thereof and of the time the soldier will be due to arrive.

Whichever action is taken, the effects of the soldier will be inventoried as under paragraph 467; his money and valuables will be secured for disposition as indicated below; and his other effects, such as clothing, sent with him as baggage to his destination. In case his family or friends or the local committing authorities agree to receive him, they will be advised that his money and valuables are subject to the orders of the person legally authorized to receive the same in the insane man's behalf upon presentation of proof of such authority. In case he is sent to a designated public hospital for the insane pending the determination of what civil authorities are ultimately chargeable with his care, his money and valuables will be sent by registered mail to the superintendent of such hospital, accompanied by one copy of the inventory.

Full report of the action taken in each such case will be made to The Adjutant General of the Army. (C. A. R., No. 64, Dec. 13, 1917.)

With the great increase in the strength of the Army following the declaration of war, it was obvious that the procedure formerly followed could not meet adequately the new needs. St. Elizabeths Hospital could not possibly provide for all insane soldiers, and, even if it could, the transportation of large numbers of insane soldiers over long distances was impracticable. The sending of papers in all cases to Washington for decision and an order to discharge from the Secretary of War created, under the circumstances, unsatisfactory conditions in the camps where hospitals were congested with insane soldiers awaiting transfer or discharge. A general order was issued, therefore, which extended authority of discharge to division and departmental commanders.3 Certain other changes to facilitate expedition were likewise made from time to time in the Army Regulations.

In the cantonment two main problems presented themselves: (1) Disposition of soldiers insane in line of duty; (2) disposition of soldiers whose mental condition existed prior to admission into the Army. With a prompt examination of drafted men and volunteers upon their arrival at cantonments and before induction into the service, the question of "line of duty" could be settled with comparative ease. When men were not examined promptly on arrival, but only after several weeks or more of service, the question was not so easily determined; although from the condition of the patient, the nature and degree of his illness, and his previous history fairly accurate judgment could be made. Diagnoses and recommendations could frequently be made more rapidly than transfers or discharges could be arranged. While waiting for transfer or discharge patients were retained (except those who, assigned to quarters, could safely remain with their organizations) in the neuropsychiatric wards of the base hospitals. They were likewise cared for here if discharged until such time as arrangements could be made with relatives or civil authorities to receive them. In other words, insane soldiers were no longer just turned loose. An insane soldier when returned home was always accompanied if his condition demanded it, and in all other cases also if possible.

In some instances the admission of a soldier to hospital on account of a mental or nervous condition was not necessary. Whenever the peculiar actions of a soldier or his failure to adapt himself to his new environment was noticed by his commanding officer he was referred, either directly or through the regi-


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mental surgeon, to the neuropsychiatric officer who, after a sufficient examination, submitted proper recommendation as to the disposition of the soldier. If necessary, he was admitted to hospital for further observation or treatment, but frequently, in such conditions as mental deficiency, constitutional psychopathic state, and certain of the psychoneuroses, this was considered unnecessary and the soldier was retained with his company or transferred to a development battalion, marked "quarters," and action initiated with a view to his discharge on account of physical disability. The "course of papers" in the camps (as in a regiment, for example) may be described as follows: (a) Regimental surgeon sent patient to hospital for diagnosis and observation. (b) Neuropsychiatric service reported patient "insane-should be discharged." (c) Report was made to commanding officer of hospital. (d) Commanding officer transmitted report to the man's regimental commander. (e) Regimental commander transmitted report to (1) company commander or (2) regimental surgeon. (f) Company commander initiated necessary form (S. C. D.) and sent it to regimental surgeon. (g) Regimental surgeon filled in his part of the form and transmitted it to the regimental commander. (h) Regimental commander made out the necessary papers for final action.

COOPERATION WITH CIVIL AUTHORITIES

Shortly after the mobilization of the World War Army began the Surgeon General communicated with the authorities in the different States inquiring if they would cooperate in relieving the Federal Government of the care and responsibility of recruits in whom insanity existed prior to enlistment, or in whom it was not an incident to service, as it was evident that cases of this character should not be a charge on the Federal Government. On September 20, 1917, the following communication was sent by the Surgeon General to all the States:4

The Surgeon General is called upon to make immediate arrangements for the care of the military insane in whom the insanity was not incurred in the line of duty. There will probably be one of these for every thousand troops mobilized, and the Surgeon General is desirous of making arrangements by means of which the different State hospitals will receive and care for the insane officers and soldiers of the above category from their own States.

It is evident that when the mental disease existed prior to enlistment or was for other reasons not contracted in line of duty, the cost of the care of the patient should not be a charge upon the Federal Government. The cost should be borne by the States. Division surgeons and other commanders will be advised that for each case the question of line of duty is to be carefully considered. All those in whom insanity was not incurred in line of duty will be released from military control on a certificate of disability whenever this can be done without danger to himself or to others. It is for the disposal of patients who can not be released from military control without danger to themselves or to others that the Surgeon General requests your immediate and hearty cooperation.

He directs me to inquire if you will cooperate with him to this end by receiving officers and soldiers of the above class, they being transported and delivered to any point or points named by you. In our reply you are requested to state to what point or points such cases should be sent. A prompt reply will be greatly appreciated.

By the middle of November, 1917, favorable replies had been received from 25 States. The Surgeon General then issued the circular following on the subject for the information of those concerned.


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NOVEMBER 17, 1917.

STATE CARE OF INSANE SOLDIERS

(Subject to amendments and additions)

Authorities of the following States have signified their willingness to receive, care for, and maintain at State expense soldiers from their own State who require institutional care, when the insanity existed prior to enlistment or arose not in line of duty. No patient will be sent to any of the State institutions without assurance having been obtained from the State authorities that beds are available and without the exact point having been indicated to which the patient shall be delivered by the military authorities.

Arizona.-Communicate with medical superintendent, Arizona State Hospital, Phoenix, Ariz.

Connecticut - Communicate with medical superintendent, Connecticut Hospital for Insane, Middletown, Conn.

Delaware.-Communicate with medical superintendent, State Hospital for Insane, Farnhurst, Del.

Idaho.-Communicate with medical superintendent, Idaho Insane Asylum, Blackfoot, Idaho.

Illinois.-Communicate with medical superintendent of most convenient institution, as follows: Alton State Hospital, Upper Alton; Anna State Hospital, Anna; Chester State Hospital, Menard; Chicago State Hospital for the Insane, Dunning; Elgin State Hospital, Elgin; Jacksonville State Hospital, Jacksonville; Kankakee State Hospital, Kankakee; Peoria State Hospital, Peoria; Watertown State Hospital, East Moline.

Iowa.-Communicate with medical superintendent of any of the following State hospitals: Cherokee State Hospital, Cherokee; Clarinda State Hospital, Clarinda; Independence State Hospital, Independence; Mount Pleasant State Hospital, Mount Pleasant; State Reformatory, Anamosa.

Maryland.-Communicate with Dr. Arthur P. Herring, 406-407 Professional Building, Baltimore, Md., who will designate proper State institution.

Massachusetts.-Communicate with medical superintendent, Boston Psychopathic Hospital, Boston, Mass.

Michigan.-Communicate with attorney general's department, Lansing, Mich., giving county where soldier was enlisted.

Minnesota - Communicate with Downer Muller, secretary, State Board of Control, St. Paul, Minn.

Nebraska - Communicate with Henry Gerdes, Board of Commissions of State Institutions, Lincoln, Nebr.

Nevada - Communicate with Commissions for the Care of Indigent Insane, Carson City, Nev.

New Hampshire - Communicate with medical superintendent, New Hampshire State Hospital, Concord, N. H.

New Mexico - Communicate with medical superintendent, New Mexico Insane Asylum, Las Vegas, N. Mex.

New York - Communicate with E. S. Elwood, secretary, State Hospital Commission, Albany, N. Y.

Ohio.-Communicate with E. F. Brown, secretary Ohio Board of Administration, Columbus, Ohio.

Oklahoma- Communicate with medical superintendent, East Oklahoma State Hospital, Vinita, Okla.

Oregon - Send insane soldiers to State institutions as follows: Those from Baker, Crook, Gilliam, Grant, Harney, Hood River, Jefferson, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, and Wheeler Counties, to be sent to medical superintendent, Eastern Oregon State Hospital at Pendleton, Oreg.; those from Benton, Clackamas, Clatsop, Columbia, Coos, Curry, Douglas, Jackson, Josephine, Klamath, Lake, Linn, Lincoln, Lane, Marion, Multnomah, Polk, Tillamook, Washington, and Yamhill Counties to be sent to medical superintendent, Oregon State Hospital, at Salem, Oreg.


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Pennsylvania - Communicate with Frank Woodbury, secretary committee on lunacy, Bulletin Building, Philadelphia, Pa., stating county where soldier enlisted.

Rhode Island - Communicate with medical superintendent, State Hospital for Mental Diseases, Howard, R. I.

South Carolina - Communicate with A. S. Johnson, secretary State Board of Charities and Corrections, Palmetto Building, Columbia, S. C., who will give directions.

Uta - Communicate with medical superintendent, State Mental Hospital, Provo, Utah.

Vermont - Communicate with medical superintendent, State Hospital for Insane, Waterbury, Vt.

Virginia - If white soldiers, communicate with J. M. Bauserman, Commissioner of State Hospitals, Woodstock, Va. If colored, communicate with Dr. William F. Drewry, superintendent, Central State Hospital, Petersburg, Va.

Wisconsin.-Communicate with M. J. Tappins, secretary State Board of Control, Madison, Wis.

In March, 1918, the National Committee for Mental Hygiene was requested to take up the matter further with States which had not replied or which sent unfavorable replies. The vice chairman of the committee at once circularlized the governors of all these States and in certain instances followed up the circular with further correspondence. The circular letter referred to is as follows:5

As you are doubtless aware, the Federal Government is prepared to provide care and treatment for the military insane in whom the insanity is incurred in the line of duty in the present war.

But it has been held that the cost of caring for the military insane in whom the mental disease existed prior to enlistment, or was for other reasons not contracted in line of duty, shall be borne by the several States. In order to assure absolute fairness and justice in deciding responsibility for the expense, most careful attention is being given in each instance to the question of line of duty.

On September 20, 1917, the Surgeon General sent to the appropriate authorities in your State a letter explaining this matter. A copy of the letter is inclosed.

The War Work Committee has been designated by the Surgeon General's Office to handle the correspondence about this matter, and we are in receipt of advices from the Surgeon General that a conference can not be entered into at this time. It would be appreciated if you would advise the appropriate authorities of the Surgeon General's advices that a quick decision in this matter is necessary and that a prompt reply at this time is desired to facilitate arrangements to provide for this class of persons.

A substantial number of the States have already responded favorably, directing which of their institutions will receive such cases and giving the name of the proper authorities with whom to communicate. Your early attention to this important matter in your State would be greatly appreciated.

On May 2, 1918, the vice chairman of the War Work Committee, National Committee for Mental Hygiene, reported to the Surgeon General the following results:6

On September 20, 1917, you sent a letter to the boards in control of the institutions for the insane in each State in the Union calling upon them to make arrangements for the care of their military insane in whom the insanity was not incurred in the line of duty. On November 30 you wrote me that 25 of the States had replied favorably as follows: Arizona, Connecticut, Delaware, Idaho, Illinois, Iowa, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Wisconsin.

In that same letter (November 30), you stated that unfavorable replies, or no replies, had been received from: Alabama, Arkansas, California, Colorado, Florida, Georgia, Indiana, Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, New Jersey, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Washington, West Virginia, Wyoming.


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In a letter dated March 16, 1918, you asked that the matter again be taken up with the States which had not taken appropriate steps. Accordingly, on April 5, letters were sent from this office to the governors of all such States calling the matter to their attention and asking them to take it up. Replies from the governors and boards to which they referred the letter have been coming to this office.

On the basis of the replies received by you in November, 1917, and the replies received by us in April, 1918, I have compiled an alphabetical list of the States, indicating the action which has been taken by the various States, and am inclosing it herewith.b * * * I am also writing again to-day to some of the States which have not yet replied.

Most of the States thus eventually responded and entered whole-heartedly into the agreement to care for patients for whom the Army could not be expected to provide. The arrangement in general was, with certain variations, depending upon different methods of handling insane persons in the different States, that the military authorities would send patients of the above class to a point designated by the State authorities, and would then release the patient to the State authorities. Commanding officers were furnished lists of the States and the points to which patients were to be sent. This arrangement was of great assistance to the Medical Department and did not put a very great burden on the States. It worked most satisfactorily when there was a central State board such as a State commission on mental diseases with which all commanders could communicate and which could, in turn, at once indicate the special institution to which the recruit in question should be sent. In States where there were no central boards, correspondence over a considerable period frequently was necessary before it could be determined which of possibly several hospitals should receive the patient. In certain States not provided with committing officers the Medical Department met the moderate fee which was asked by physicians who executed the commitment papers.

CARE OF MENTAL CASES IN GOVERNMENT HOSPITALS

As the number of soldiers with nervous or mental disease who required treatment, or for whom it was necessary to care pending discharge increased, it was necessary to provide facilities other than those offered by the neuropsychiatric wards in base hospitals. To relieve the congestion in these wards and at St. Elizabeths Hospital, a number of neuropsychiatric centers, widely distributed geographically, to which such soldiers could be transferred for treatment or for care pending discharge, were established in various U. S. Army general hospitals.7

Mendocino State Hospital, Talmage, Calif., was designated by the Secretary of War to receive patients on the same status as at St. Elizabeths Hospital. This was done with a view of relieving congestion at St. Elizabeths Hospital, and also of avoiding the unnecessary transportation of the insane. St. Elizabeths Hospital itself was enlarged by 500 beds.

The increasing number of Army patients at St. Elizabeths Hospital overtaxed the efforts of the regular staff on duty there, and medical officers and

bThe list referred to included comments upon the character of the response made by each State. It showed only a few States whose response was unfavorable or who had failed to act up to that time. Those indicating favorable action were given as follows: Alabama, Arizona, Arkansas, Colorado, Connecticut, Delaware, Florida, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin.


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enlisted men of the Medical Department were assigned to duty at the hospital.8 A detachment was organized and all military records were under the supervision of the commanding officer. A few neuropsychiatrists were assigned to assist the medical staff of the hospital in the treatment of these patients, and certain of the enlisted men were used as orderlies and helpers. There was a marked delay in accomplishing the discharge of the soldiers after their arrival at the hospital, and the detachment of patients was constantly increasing in numbers. To relieve this congestion of patients and in order that only cases of insanity which promised to be of long standing would be sent to St. Elizabeths Hospital, the following circular letter was issued from the Office of the Surgeon General on November 20, 1918:9

DISPOSAL OF THE INSANE

1. Members of the Military Establishment suffering from general paralysis of the insane and from insanity complicated by epilepsy (insane epileptics) shall be sent from hospitals at ports of embarkation and from other hospitals to St. Elizabeths Hospital, Washington, D. C., as provided by paragraph 464, Army Regulations, 1918, as amended by C. A. R., No. 64 December 13, 1917.

2. All other patients in the military service who present symptoms of insanity shall be retained in the military hospitals for necessary care and treatment provided the period of care and treatment shall not exceed four months.

3. All cases of epilepsy which can not be improved by medical or surgical treatment in the military hospitals shall be recommended for immediate discharge from the service without transfer to other military hospitals.

As the war proceeded it was considered desirable to require that all mental cases be treated for a reasonable period in the military hospitals. Directions recommended in June, 1918, sent out November 20, 1918, provided that all except cases which were evidently incurable should be treated in the military hospitals for a period of at least four months, unless recovery took place sooner, before being sent to St. Elizabeths Hospital.10 This provision enabled many patients to leave the Army well, without having been sent to an institution identified with the care of the insane, enabled many patients to pass their period of illness in the neighborhood of their homes, and avoided many unnecessary transfers. It also seemed to meet the hearty approval of the civil population.

The requirements of Army Regulations 470 (as amended), in so far as they pertained to insanity existing before enlistment, were nullified by the provisions of that section of the war risk insurance act which stated that "said officer, enlisted man, or other member shall be held and taken to have been in sound condition when examined, accepted and enrolled for service."11

The interpretation placed on this proviso during the war was that once the officer or soldier was accepted he must be regarded, for purposes of compensation and future hospitalization, as having been mentally and physically sound when he came into the Army.12 Therefore, theoretically, insanity could not have existed before enlistment and the soldier must be transferred to a public institution for the care of the insane.

After the armistice was signed and demobilization was under way it was possible to determine very closely the number of psychiatric cases which re-


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mained to be disposed of. A census of the hospital accommodations showed that sufficient beds were available in Army general hospitals for the care of all insane cases remaining. In view of this fact and of the crowded conditions at St. Elizabeths Hospital, instructions were issued directing that no more insane soldiers be transferred to St. Elizabeths, but that all be retained in military hospitals pending further orders.13

FUNCTION OF THE BUREAU OF WAR RISK INSURANCE WITH RESPECT TO THE INSANE

The Bureau of War Risk Insurance had been charged by law with the duty of providing hospital care for the compensable insane after discharge from the military service. By that time the bureau was well established and was able to provide hospital facilities for all discharged soldiers entitled to such care. Section VII, General Orders, No. 57, War Department, April 30, 1919, provided as follows for the future disposition of the insane of the Army:

VII. Care of compensable insane (Cir. No. 225, W. D., 1919).-1. The Bureau of War Risk Insurance is charged by law with the duty of caring for the compensable insane of the military service after their discharge from the Army, and has undertaken to provide institutional treatment after discharge for cases requiring it. Such cases are to be turned over directly to the care and responsibility of the bureau in such a manner that there will be no interval between discharge from the military service and the commencement of the continued care in hospitals near their homes, which is to be provided by the bureau.

2. In order to accomplish this, the following procedure will be observed:

(a) Cases which have been under treatment in military hospitals in this country for four months, and which are considered to be incurable or to require a much longer period of hospital treatment to effect a cure, will be reported in writing by the commanding officer of the post, camp, or station directly to the chief medical advisor, Bureau of War Risk Insurance, Washington, D. C. (attention section of nervous and mental diseases), who will give instructions as to the disposition desired by the Bureau of War Risk Insurance. When reporting cases to the Bureau of War Risk Insurance under this paragraph, the following information regarding the soldier will be furnished: (1) Name, rank, organization, Army serial number, and race; (2) length of service; (3) legal residence; (4) name and residence of nearest relative; (5) diagnosis; (6) brief summary of medical history; (7) prognosis.

(b) Upon receipt of instructions from the Bureau of War Risk Insurance, the soldier will be ordered discharged on certificate of disability by the authority designated to order discharge in such cases. The same procedure as to preparation and disposition of records will be followed as outlined in Army Regulations governing the discharge of insane in the military service and their delivery to institutions. The soldier will be delivered to the designated institutions accompanied by necessary attendants, and not discharged until his arrival thereat. When the soldier has been delivered to the authorities of the institution designated to receive him, the senior attendant will ordinarily telegraph the commanding officer authorized to discharge the soldier. Upon receipt of this information the soldier will be discharged and discharge papers mailed to the authorities of the institution to which the soldier was transferred for delivery to the soldier. When a patient is delivered to an institution and discharged the Bureau of War Risk Insurance will be so informed in writing by the commanding officer concerned.

3. The provisions of this order do not in any way amend subparagraph a, Circular No. 188, War Department, 1918, relative to the discharge of a certain class of patients who possess funds or have relatives or friends who can afford them specialized care after discharge.

By the provisions of this order the whole question of the disposition of the insane was greatly simplified. After an ample period of observation in military hospitals the insane soldiers were transferred directly to the hospital designated


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by the Bureau of War Risk Insurance, discharged from the Army upon arrival, and their treatment continued under the jurisdiction of the bureau, which in the future was responsible for their care. The United States Public Health Service, charged with the hospitalization of the beneficiaries of the Bureau of War Risk Insurance, opened numerous hospitals throughout the country for the care of the insane. In addition the Bureau of War Risk Insurance made arrangements with the authorities of many States for receiving the ex-service insane in the State hospitals provided for the care of this class of incapacitated. Through these facilities, the Bureau of War Risk Insurance usually was able to send the insane to some institution near their homes, an arrangement which in itself was a source of great comfort to the patient and his relatives. This procedure was most successful, and was continued during the remainder of the period in which the war Army was being demobilized.

REFERENCES

(1) A. R. 465, 1913 (C. A. R., Nos. 10 and 46).

(2) A. R. 467, 1913.

(3) G. O. No. 133, W. D., October 11, 1917.

(4) Letter from the Surgeon General to the governors of the various States, September 20, 1917, relative to State care of the military insane. Copy on file, Historical Division, S. G. O.

(5) Letter from the vice chairman, War Work Committee, National Committee for Mental Hygiene, New York, to the governors of certain States, April 5, 1918, relative to State care of the military insane. Copy on file, Historical Division, S. G. O.

(6) Letter from Dr. Frankwood E. Williams, New York, to Lieut. Col. Pearce Bailey, M. C., May 2, 1918. Subject: State care of military insane. Copy on file, Historical Division, S. G. O.

(7) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1164-1167.

(8) Personnel files. Personnel Division, S. G. O.

(9) Circular Letter, Surgeon General's Office, November 20, 1918.

(10) Circular Letter S. G. O., November 20, 1918.

(11) Act of Congress, approved October 6, 1917.

(12) Opinions, Judge Advocate General, 1918-19.

(13) Circular No. 164, W. D., 1919.

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