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Section II, Chapter I
GENERAL VIEW OF NEUROPSYCHIATRIC ACTIVITIES
As early as the summer of 1917 the chief surgeon, A. E. F., had been considering the organization of a group of specialists to direct and coordinate the special medical and surgical professional services in the American Expeditionary Forces. It was realized that, while base hospitals and tactical divisions would be adequately supplied with medical personnel, many of them leaders in medicine, surgery, and the specialties in the civil profession in the United States, professional standards throughout all the activities of an army could not be maintained at a high level, however efficient the medical officers of individual organizations might be, without some provision for the supervision of professional work by consultants in the main branches of medicine. This fact was conclusively demonstrated in the experience of our allies. Elsewhere in this history there is given an account of the organization, in September, 1917,b of such a group of consultants.
ORGANIZATION OF THE NEUROPSYCHIATRIC SERVICE
The beginning of a well-defined neuropsychiatric service in the American Expeditionary Forces may be said to date from December 24, 1917, when a director of psychiatry was appointed. A medical officer, who had been assigned to duty in England to study the treatment of war neuroses, was shortly afterward assigned as assistant in the office of the director of psychiatry.
The newly organized neuropsychiatric service found plenty of urgent tasks. It was apparent that no time could be wasted in providing for neuropsychiatric work in the tactical divisions if the American forces were to escape the heavy toll of casualties from functional nervous disorders that had been borne by the other armies earlier in the field. Although chief reliance had to be placed upon the assignment of a consultant in each tactical division who could help in the task of dealing with war neuroses at their very inception, there was no provision in the military organization for such an extra medical officer. Early in January, however, the War Department approved the plan1 that had been devised in the American Expeditionary Forces for the provision of a divisional neuropsychiatrist,2 thus making it possible to assign to each combat division "one specialist in nervous and mental diseases."1
The instructions in this connection applied to the United States; however, they permitted division psychiatrists to be detached by the commander in chief, A. E. F., upon the arrival of divisions in France, if that seemed to be desirable. It was for this reason that these officers were not included in the tables of organization, a factor which gave rise to some difficulty later on. Fortunately,
there was no disposition on the part of the chief surgeon, A. E. F., to recommend their detachment, although some of the division surgeons felt that, being attached to a field hospital, their work should be confined to such an organization and not be broadened so that they could help, if needed, in every regiment, train, and company. Had it been possible to foresee this handicap, division psychiatrists would have been attached in the first place to the office of the division surgeon, as was done later with practically all divisional consultants by the division surgeons on their own initiative. On September 8, 1918, a communication from the chief surgeon, A. E. F., to all division surgeons directed that divisional consultants "should be attached to the office of the division surgeon as additional assistants,"3 thus confirming a status which, in most instances, had already been granted.
There were in France in January, 1918, five divisions (1st, 2d, 26th, 41st, and 42d).4 All but the 41st were in training areas centering in Chaumont, the location of general headquarters, A. E. F. Neufchateau, headquarters of the professional services, was 40 miles from Chaumont and quite as convenient a center for work in the training areas. The problem was to find psychiatrists for assignment as division consultants. Fortunately, in July, 1917, seven medical officers who had had special training in nervous and mental diseases had been sent to England to observe the treatment of war neuroses in the different British war hospitals. Orders were secured for four of these officers, all of whom were men with high professional and personal qualifications, to report to the divisions then in France. By the middle of January all four had been assigned to duty. The work of division psychiatrists, as they were always termed, from this small beginning until the demobilization of the American Expeditionary Forces, is given in detail in the next chapter.
REORGANIZATION OF THE NEUROPSYCHIATRIC SERVICE
In the latter part of April, 1918, a new plan was put into effect by General Orders, No. 88, G. H. Q., under which the directors were termed senior consultants in the various specialties and the medical and surgical groups were under the general direction of a chief consultant in medicine and a chief consultant in surgery, respectively. The former directors became senior consultants, A. E. F.; consultants, A. E. F., were also provided.
In the division of neuropsychiatry, an assistant director of psychiatry, A. E. F., who had been appointed April 10, 1918, now became consultant in neuropsychiatry, A. E. F. Although the considerations that had led to the establishment of the immense hospital centers in the American Expeditionary Forces were chiefly of an administrative nature (for example, the great amount of material needed in the construction of long sidings for the American hospital trains that brought the wounded from the front), the chief surgeon, A. E. F., had not lost sight of the fact that professional services in the hospitals constituting these centers could be supervised effectively by a consultant in each of the more important specialties. Some of the most distinguished American physicians and surgeons served in this capacity with great advantage not only to the sick and wounded but to the other officers in their specialty who found encouragement to conduct their work on the highest possible level.
By August 1, 1918, neuropsychiatric consultants had been assigned to Base Sections Nos. 1 (St. Nazaire) and 2 (Bordeaux), and to the hospital centers at Bazoilles-sur-Meuse, Paris, Tours, and Vittel-Contrexeville. A station list issued immediately after the armistice was signed showed that consultants in neuropsychiatry were on duty in the following base hospital centers:5 Allerey, Beaune, Bazoilles, Commercy, Limoges, Mars, Nantes, Paris, Tours, Vichy, and Vittel-Contrexeville. Base Sections Nos. 1 (Savenay) and 2 (Bordeaux) were similarly provided for. Although no officers had been designated general consultants for the following centers, each of them had at least one base hospital to which a neuropsychiatrist was attached: Clermont Ferrand, Dijon, Langres, Mesves, and Rimaucourt.5
At the time of the signing of the armistice the administration of the professional services, as far as neuropsychiatry was concerned, was on a very effective and satisfactory basis and could have continued so with a very much larger load of responsibility in all activities. There was considerable difficulty in keeping in touch with different officers assigned to this work, but efforts continually were being made to improve methods of communication. It was planned to have conferences during the winter, in which studies could be made of experiences to date and plans could be prepared for the heavy load that was expected when activities were resumed in the spring.
Immediately after the armistice began, the medical officer who had served since January, 1918, as division psychiatrist in the 2d Division, was assigned to duty as consultant, Base Section No. 3 (Great Britain.)
NEUROPSYCHIATRIC HOSPITALIZATION FACILITIES
DURING THE PERIOD OF ACTIVE HOSTILITIES
The realization of the general hospitalization project of the American Expeditionary Forcesc depended upon many uncertain factors, and it was necessary to scrutinize every new demand for hospital beds with the utmost care. To ask for more than a due share for any special class of patients would be as harmful to the ultimate success of the program as to make requisition for too few to meet the expected load. The minimum provisions to meet the neuropsychiatric needs, if the program decided upon was to be carried through, were a special hospital for war neuroses just behind the front line in the proposed American sector; a psychiatric collecting station for the emergency care of the psychoses in the training area where it would be equally accessible from the front and from the divisions in training; psychiatric wards and, later, a special neuropsychiatric hospital at the principal base port, to facilitate the evacuation to home territory of patients who would not be returned to front line duty or even reclassified for duty in the Services of Supply; neuropsychiatric wards at other base ports; and a few neuropsychiatric departments at the hospital centers which it was proposed to establish at convenient points along the line of communications and which ultimately were destined to provide the major portion of the hospital beds in the American Expeditionary Forces.
Within the first 60 days after a professional service in neuropsychiatry was organized, in other words, by the end of February, 1918, there were 16 base hospitals along the American line of communications, receiving, or ready to receive patients.6 It was not yet possible to determine which of the projected hospital centers would be the best one in which to develop the psychiatric collecting station, but there was organized in Base Hospital No. 66 at Neufchateau a special ward for mental patients to meet the immediate need.7 A medical officer and enlisted men with neuropsychiatric experience were assigned to care for mental patients. As soon as Bazoilles-sur-Meuse was definitely selected as the site for such a center, it was determined to place the main psychiatric collecting station there because of its proximity to the prospective site of Base Hospital No. 117, at La Fauche, and the headquarters of the professional services at Neufchateau and its nearness to the proposed American front. On February 27, the following recommendations regarding neuropsychiatric departments in such centers were made to the chief surgeon, A. E. F., by the director of neuropsychiatry:8
1. Where it has been determined to establish several standard base hospitals in groups (as at Bazoilles and Vittel-Contrexeville) it is obviously more economical of personnel, special equipment, and construction to provide a central neuropsychiatric department which can serve all hospitals in the group than to provide neuropsychiatric wards for each base hospital.
2. An added advantage in the collection of such wards into a unit, is that a classification of patients which will lead to much better therapeutic results can be made. It is not uncommon to find at the same time in a neuropsychiatric ward an excited manic-depressive case, several patients with middle grade mental defect sent in for observation, a case with febrile delirium, and others who have shown no abnormalities of conduct but have slight depressions or neurasthenic symptoms. Satisfactory treatment under such conditions is often impossible. If such wards are grouped, however, each may care for a different general class of patients.
3. It is recommended, therefore, that in each standard base hospital group a neuropsychiatric department be provided, with from 50 to 60 beds.
4. The personnel of such a neuropsychiatric department should be made up in accordance with the suggestions in the appended table. At least one of the medical officers should be a man of sufficient experience to enable him to act as consultant in all kinds of difficult cases; the others could be younger men, capable of doing valuable work under his general direction.
5. The commissioned officers of such neuropsychiatric departments can be furnished from the specialists now in the American Expeditionary Forces and those who will come with base hospital units. The noncommissioned officers, female nurses, and enlisted men can be supplied from those with suitable experience now attached to various hospital organizations and from Base Hospital No. 117 (neuropsychiatric hospital) which is intended to serve partly as a training hospital and replacement center for neurological and psychiatric personnel.
NEUROPSYCHIATRIC DEPARTMENT, STANDARD BASE HOSPITAL GROUP PERSONNEL
dIndicates that special training in the care of mental and nervous cases is required.
The neuropsychiatric department of the base hospital at Bazoilles-sur-Meuse, established in connection with Base Hospital No. 116, became the "Psychiatric Collecting Station," the activities of which are referred to again below.
HOSPITAL FOR WAR NEUROSES (BASE HOSPITAL NO. 117)
Second only in urgency to the provision of a foundation for psychiatric work with troops in the field was the establishment of a special hospital for war neuroses as far forward as possible in the advance section, for it was upon these two resources that chief dependence was to be placed for effective management and treatment of the war neuroses. Fortunately at La Fauche (a tiny village on the main route between Chaumont and Neufchateau) there was one of the camp hospitals with which each training area was to be provided.6 The use of this hospital as a special hospital for war neuroses was recommended in February, 1918, by the director of neuropsychiatry, A. E. F.9 The chief surgeon, A. E. F., approved this plan and a provisional neuropsychiatric personnel immediately occupied it and assisted in its completion.
Its activities soon increased to such an extent that by the end of May it was obliged, because of the great increase in the number of war neuroses and the lack of adequate personnel, to refuse new admissions.10 The special hospital care of these cases was the most urgent need in all the neuropsychiatric activities at that time. Though the permanent personnel for Base Hospital No. 117 had been organized early in the year in the United States, they were still detained at Camp Crane, Pa. War neuroses cases were appearing in increasing numbers in base hospitals throughout the American Expeditionary Forces, where they were treated without special facilities and in accordance with many different clinical points of view. It was by no means easy to arrange for their transfer to Base Hospital No. 117, and thus additional evidence was provided that
dIndicates that special training in the care of mental and nervous cases is required.
some method of directing the evacuation of these men from the divisions must be devised or the problem of controlling the incidence of war neuroses would not be solved successfully in our Army. On June 16 the highly trained personnel of neuropsychiatrists, nurses, and occupational aides for Base Hospital No. 117 arrived at La Fauche and within a few weeks this hospital became an efficiently organized special institution for the treatment of a special type of illness-war neuroses.10 Base Hospital No. 117 rapidly became the center for scientific work and training in neuropsychiatry in the American Expeditionary Forces. Its ability to receive patients thereafter was limited only by its capacity.
By September it was apparent that this hospital would have to be greatly enlarged and so plans were drawn for the addition of a sufficient number of beds to bring the capacity to 1,000. This was accomplished by the time the armistice was signed.10 The necessity for a convalescent camp operated in connection with Base Hospital No. 117 had already been shown by the disastrous results of allowing convalescent patients to go to general convalescent camps when they no longer required hospital treatment. An entirely different point of view as to the nature of war neuroses often prevailed in the general convalescent camps, and the result was a large number of relapses just when the maximum improvement could have been expected. The plan for a convalescent camp at La Fauche was very carefully thought out. It was intended to provide for about 1,000 patients under an environment quite different from that of the hospital or of a general convalescent camp. Drill, including machine-gun and hand-grenade practice, were to constitute an important feature, and it was hoped that a special group of men could be organized into a company of infantry from those most nearly ready to return to duty. This plan, of course, was abandoned with the armistice.
It was apparent that additional hospital provisions for war neuroses would be required if hostilities continued. On September 14, 1918, therefore, the senior consultant recommended a second hospital in the following letter to the chief surgeon:11
1. The number of troops in France makes it necessary now to consider the provision of the second hospital in the S. O. S. for the treatment of war neuroses. In order to have one bed per thousand combatant troops, which is generally agreed to be the minimum required, it is necessary to provide another hospital as large as Base Hospital No. 117. This hospital should be at least as near the front as La Fauche and preferably not more than 60 miles to the west of it in order that a convalescent camp for these cases can be established between them which will be easily accessible from each. Perhaps a nucleus for such a hospital can be found north of Epinal.
2. If next summer, with the enlargement of our Army, a third is necessary, it could be located somewhere in the southern part of France and be used for a special class of cases-the most unfavorable type-those arising in training areas and the S. O. S. and others who have had successive relapses, the other two hospitals being employed exclusively for cases from the front.
3. It seems necessary to look this far ahead in order that this problem may not get beyond our control.
4. I have great hopes of the results to be obtained in such advanced stations for temporary care as those which we have just been able to establish at Toul and Bennoite-Vaux. The work in tactical divisions is becoming much better organized and I think that we may look for a decrease rather than an increase in these cases as our mechanism for dealing with
them at an early point develops. I am quite sure that as a result of this method of management we shall have few of the very intractable cases seen among the British.
5. Has the division of hospitalization an offer of property in the region lying north of Epinal and east of Nancy that I might look at soon and report upon as to its suitability?
Had hostilities continued, the personnel of this second hospital would have been provided by the replacement unit due to arrive in France in October.
After the armistice began, new admissions to Base Hospital No. 117 declined very rapidly and a large number of men were restored to duty who otherwise would have required a considerable period of treatment.10 There was not, however, as has been stated, any very marked change in the character of the war neuroses or in their prognosis. It was simply possible to restore to A or B status some men who would have been classified C or D, had the war continued. By January 9, 1919, the number of patients had diminished to 149,12 and during the following week those remaining were transferred to Base Hospital No. 214, Savenay, which from that time on conducted two departments, one for psychoses and one for psychoneuroses.13 The total admissions from the opening of the hospital were 3,268, 50 per cent of whom were returned to combat duty and 41 per cent for other military duty in the American Expeditionary Forces.10
PROVISIONS FOR MENTAL DISEASES (PSYCHOSES)
Although the total number of American troops in France in January, 1918, was only approximately 203,000,14 the caring for mental patients had already become a problem. It was obvious at the outset that such patients could not be cared for in the individual American base hospitals scattered throughout France, partly because of the lack in some of them of medical officers, nurses, or enlisted personnel who had had experience in the actual care and treatment of patients suffering from acute mental disorders, but chiefly because of the absence of any special facilities for treatment. In order to function as a collecting station the neuropsychiatric department at Bazoilles would have to be provided with an outlet. Therefore, mental patients had been collected as far as possible at Base Hospital No. 8, at Savenay, near the base port of St. Nazaire, where two wards were set apart for their reception and treatment.15 The growth of these two wards into an efficient hospital for mental cases of 1,000 beds, with every modern facility for psychiatric diagnosis and treatment, is described in detail in Chapter VI of this section. Base Hospital No. 66 at Neufchateau already was serving as a temporary psychiatric collecting station for the troops in the training area. Most of its neuropsychiatric patients reported at the time under consideration were mental defectives who had been "weeded out" by the divisional psychiatrists as one of their first tasks.
The following recommendations for the care of mental cases, made by the director of psychiatry to the chief surgeon, A. E. F., February 1, 1918, indicates the general nature of the plans then being shaped:16
1. Mental cases (insanity, mental deficiency, and constitutional psychopathic states) can be expected to furnish a considerable proportion of all soldiers of the Expeditionary Forces who will have to be invalided home. Already these cases constitute 30 per cent of the total number so returned. In the Canadian overseas forces, in spite of the enormous
incidence of disability resulting from battle casualties, about 12 per cent of all soldiers returned during the war have been mental cases.
2. It is apparent from these facts that arrangements must be made for dealing with this problem. If a simple and effective mechanism for treating and evacuating mental cases is devised and put into operation while the number to be provided for is still relatively small, much subsequent difficulty (as well as unnecessary hardships for a class of the sick having very special needs) can be prevented.
3. Any such mechanism must take into account the fact that practically no soldier who has had a psychosis and few other mental cases should be returned to duty in France. It is not meant to imply by this statement that the psychoses common among soldiers are especially unrecoverable. The reverse is the case. It is unwise to return to duty such cases, however, until a considerable period has elapsed after their recovery. This fact and the long period of treatment usually required in mental cases make it undesirable to provide for continued care in France. Provisions here must be considered as simply preliminary to their return to the United States as promptly as possible. Little more can be undertaken here than to make a careful diagnosis in each case and to provide for efficient treatment while waiting for a sailing or getting the patient into condition to make the journey safely.
4. To provide such a mechanism, the following facilities are required: (a) Observation wards in camp hospitals, or in some cases in base hospitals, favorably situated in the training areas where the psychiatrists attached to divisions can examine cases and make recommendations for their disposition. (b) Arrangements for the evacuation to a designated base hospital at a port of all cases requiring emergency treatments, continued observation, or return to the United States. (c) A special psychiatric department in a base hospital at St. Nazaire or Bordeaux (or one at each port if the number of such cases or transportation difficulties should require it.)
Detailed recommendations as to the size, arrangement, personnel, and equipment of such a psychiatric department were inclosed.
By the end of February, 1918, the above general plan of providing for patients with psychoses had been decided upon by the chief surgeon. As has been stated, Base Hospital No. 66 was the first hospital in the training areas to provide a special ward. It was not until July 20 that the neuropsychiatric department at the Base Hospital No. 116 (Bazoilles hospital center) was able to receive patients.17 It operated continuously until April 30, 1919.
The other main resource for the treatment of mental disease was that provided by the neuropsychiatric department of Base Hospital No. 8, at Savenay. By June, 1918, the new ward buildings to constitute the psychiatric department were well under way.
By June 13, 1918, it was possible for the chief surgeon's office to issue a circular letter giving detailed instructions for the care, evacuation, and transportation of neuropsychiatric patients in the American Expeditionary Forces. This circular is given in full because its paragraphs indicate not only the facilities available for care but also the standards of humanity which from the very first governed the treatment of this class of sick in the American Expeditionary Forces.
CIRCULAR No. 35.--THE MANAGEMENT OF MENTAL DISEASES AND WAR NEUROSES IN THE AMERICAN EXPEDITIONARY FORCES
AMERICAN EXPEDITIONARY FORCES,
Absence of the auxiliary civil facilities that simplify the management of mental cases in the Army in home territory and the extraordinary incidence of functional nervous diseases
in all armies in the present war have made it necessary to provide special facilities and methods of procedure in the A. E. F. These disorders, by their very nature, interfere with the morale and efficiency of troops in war. Their proper management in the hospitals and organizations in which they first come to notice and their wise disposition and reclassification subsequently will not only increase military efficiency, but, in the case of war neuroses, will tend to diminish to a considerable extent their incidence.
This circular is issued in order that all medical officers may become familiar with the facilities that have been provided for the diagnosis, transportation, and treatment of soldiers with these disorders. These facilities will be modified from time to time as changing conditions necessitate, but the general plan of management here outlined will be followed.
I. Mental cases (insanity, mental deficiency, observation cases).
(a) Provisions for prompt diagnosis and early care.
Tactical divisions: Each tactical division in the A. E. F. and in the United States is provided with a psychiatrist whose duty it is, under the direction of the division surgeon, to examine all mental cases coming to attention in the division and to make recommendations for their evacuation or other disposition. The psychiatrist will be detailed from the division sanitary personnel. Their specific duties are defined in Circular No. 5, C. S. O., A. E. F.
They will examine enlisted men brought before general courts-martial as provided by W. D. order of March 28, 1918. They will also examine all other military delinquents brought to their attention, especially those in whom self-inflicted wounds or malingering are suspected. Except under exceptional circumstances, no cases of this kind will be evacuated to the rear until examined by the division psychiatrists. In the case of prisoners accused of crimes the maximum punishment of which is death, the division psychiatrist should, whenever practicable, have the assistance of a consultant in psychiatry.
Base hospitals: A neurologist or a psychiatrist has been assigned to each base hospital or group of base hospitals in the same vicinity. This provision makes it possible for mental cases that first come to attention in such hospitals to receive early diagnosis and treatment and prompt evacuation to hospitals provided with special facilities for their care.
(b) Provisions for hospital care.
Advance section, S. O. S.: There has been provided in connection with Base Hospital No. 116 a neuropsychiatric department of 72 beds which will act as a collecting and evacuating point for mental cases from other base hospitals, from tactical divisions, and from training areas.
When observation cases or patients with frank mental diseases or defect are recommended by the division surgeon, upon the advice of division psychiatrists, for transfer to this collecting station, the commanding officer of Base Hospital No. 116 will be notified by telephone or telegraph and will thereupon send a sufficient number of attendants to bring such patients to the hospital in safety. It is necessary, in making such requests, to state the number of patients and the amount of supervision that they will require en route. When practicable, the ambulance service to be established in connection with Base Hospital No. 117 will be employed for this purpose. In all such cases the diagnosis will be "Observation, mental," the type of disease being added in parentheses.
It is very important that mental cases be accompanied by records in which the circumstances under which their condition came to notice are fully stated. It is obvious that, without such information, the medical officers who have the responsibility of dealing with these cases will often have difficulty in arriving at a diagnosis or in making suitable recommendations for their disposition.
Base hospitals in the advance section will transfer to this collecting station all mental cases except those which can readily be retained until sent for by the psychiatric department of one of the base hospitals at a base port and those in whom complications or other reasons render a transfer undesirable. Effort will be made to provide all base hospitals with several nurses or enlisted men of the Medical Department who have had experience in the care of mental cases. With such attendance it will be unnecessary to place guards in observation or mental wards. Commanding officers will protect these cases from the ridicule to which they are sometimes subjected even in hospitals.
Intermediate section: At least one of the large base hospital centers which it is proposed to establish in this section will ultimately have in connection with it a neuropsychiatric department similar to that at Base Hospital No. 116. Hospitals in this section will, in the meantime, evacuate their mental cases to Base Hospital No. 8 in the manner specified in paragraph I (c) of this circular.
Base Sections Nos. 1 and 2: A psychiatric department with a capacity of 152 patients has been provided in connection with Base Hospital No. 8. This and a similar one to be established in connection with a base hospital center in Base Section No. 2 will provide the chief facilities for the classification and continued care of mental cases in the A. E. F.
Base Section No. 3: Mental cases among American troops serving with British organizations will be evacuated to England in the same manner as other sick and wounded from the same organizations. In England a neuropsychiatric department will be provided for the reception, continued care, and classification of cases from British clearing hospitals for mental diseases and from other hospitals in Great Britain.
Base Section No. 4: Any mental cases coming to notice in this section will be evacuated to Base Section No. 3.
Base Section No. 5: Psychiatric wards will be provided at a base port. These wards will receive only cases which have been classified "Class D" at Base Hospital No. 8 and whose condition is such that they can be transported to home territory with the minimum of care and supervision. This ward will receive no other cases but will provide temporary care for soldiers who are found insane upon their arrival from the United States.
Base sections Nos. 6 and 7: Mental cases arising in these sections will be evacuated to a base hospital at the port of Base Section No. 2.
French hospitals: Mental cases that have been evacuated from the front into French military hospitals will be transferred as soon as practicable to the most accessible neuropsychiatric department of an American base hospital center.
The neuropsychiatric department at Base Hospital No. 116 will send for patients to other base hospitals in the Advance Section, S. O. S. and to tactical divisions and training areas as provided in Paragraph I (b) of this circular. The neuropsychiatric departments of base hospital centers to be established in the Intermediate Section, S. O. S. will send for patients in the same manner.
The psychiatric departments of Base Hospital No. 8 and the base hospital center in Base Section No. 2 will send for patients to any base hospital which is nearer to them than to a collecting station.
As mental cases of all degrees of severity can be safely and comfortably provided for at these collecting stations, they will be retained until a sufficient number have accumulated so that they can be evacuated in parties, the attendance being provided by the psychiatric department at the base port to which they are sent. Ordinarily, regular passenger trains will be used, but in special instances and where the number of patients warrants it, transfers will be made in a car set aside for this purpose on an American hospital train destined for a base port to which they are to be sent. In this case, as in all others, attendance will be provided by the psychiatric department receiving the convoy.
Evacuation to home territory of patients classified "Class D" will be made in accordance with special arrangement which it is not necessary to outline in this circular.
(d) Disability boards for mental cases.
Disability boards for mental cases will be convened at neuropsychiatric departments of base hospital centers and at psychiatric departments at base ports. Other disability boards should not pass upon these cases, but should refer them to one of the points at which such boards are authorized. All mental cases to be transported in France will be given the tentative diagnosis of "Observation, mental," except those transported to their final destination on American hospital trains.
Disability boards will be guided by Circular No. 24, C. S. O., 1918, in passing upon mental cases.
II. Functional nervous diseases and concussion cases.
(a) General consideration.
The proper management of these conditions which are commonly included in the designation "shell shock" is regarded by this office as a matter of much importance. This term, which, unfortunately, is being used indiscriminately by medical officers as well as patients, includes a number of different conditions depending upon many different causes and requiring for their successful management several entirely different methods of procedure. Many patients in whom severe concussion symptoms following being blown up by shells or buried in dug-outs can be returned to duty, and it is possible to return a much larger proportion of those cases in which purely psychoneurotic symptoms develop under shell fire or in training, if they are skillfully managed. The return of these cases to their own organizations after a short period of treatment has a very favorable effect in lessening the incidence among their comrades of disorders in the second group mentioned. If, on the other hand, a large proportion of these patients are evacuated indiscriminately to hospitals in the S. O. S. or to home territory, the effect will be to increase their incidence.
For this reason a special hospital for these cases, Base Hospital No. 117, has been established and an ambulance service has been provided us connection with this hospital by which cases can be received directly from tactical divisions at the front. At this hospital the resources found most useful in the British and French special hospitals for these cases are employed. Success in their treatment depends very largely upon the attitude of medical officers generally toward the special problems in diagnosis and management which they present. For this reason regimental medical officers should guard against making an unfavorable prognosis even in cases presenting severe symptoms.
Tactical divisions: The advice of the division psychiatrist should be utilized to the fullest extent in the early treatment of these cases in division sanitary organizations and in the selection of cases for evacuation to hospitals in the S. O. S. It will be found advisable, whenever practicable, to receive such cases in special wards in one field hospital and to evacuate cases to hospitals in the S. O. S. only upon the recommendation of the division psychiatrist. This officer will advise with regimental medical officers regarding the management of nervous manifestations when they first come to attention at the front.
Hospitals in the S. O. S. in France: It is expected that a very large proportion of these cases will be admitted directly from their organizations to Base Hospital No. 117 and that relatively few, unless complicated by wounds, gassing or other conditions, will be received in other base hospitals. Other base hospitals will promptly transfer suitable cases to Base Hospital No. 117, except in these instances in which it is thought that they can return directly to duty and those in which the outlook seems so unfavorable, from constitutional neuropathic tendencies or other factors, that their reclassification is probable. Cases in which there is some doubt as to whether an organic or functional disorder is present should be transferred to Base Hospital No. 117. No cases having wounds requiring much surgical attention should be sent to Base Hospital No. 117. All cases in which there is doubt as to the best disposition should be brought to the attention of the consultant in neuropsychiatry for the hospital.
Hospitals in the S. O. S. in England: A special hospital for war neuroses will be provided in England which will be organized and conducted upon the same lines and will perform the same functions as Base Hospital No. 117. American soldiers serving with British organizations will be transferred to this hospital from the British clearing hospital for these cases or from other hospitals in England.
French hospitals: American patients with these disorders in French military hospitals will be evacuated to Base Hospital No. 117 or to the nearest neuropsychiatric department of a base hospital center.
(c) Disability boards for functional nervous diseases and concussion cases.
Disability boards for these cases will be convened at Base Hospital No. 117, neuropsychiatric departments of base hospital centers, and psychiatric departments of base hospitals at base ports. No other disability boards should pass upon these cases.
No great difficulties were experienced in putting the provisions of this circular letter into effect except as regards the mental cases. Though medical
officers generally recognized their own lack of experience in the care of mental patients and were willing to transfer them as soon as possible, the transfer of such patients from the forward base hospitals to the hospital center at Savenay presented difficulties not apparent at first glance.
In the first place, not only was the number of enlisted men with training in the care of mental patients very limited but only two American hospital trains (converted French trains) were operating until late in the summer. Thus all the transfers to base ports had to be made on French civilian trains. However, by deferring such evacuations until a number of patients had been collected and having each convoy accompanied by a medical officer and several enlisted men with experience in neuropsychiatry, transportation was accomplished without serious disadvantage to the patients. It is appropriate to record here that during the whole history of the American Expeditionary Forces no patient suffering from a mental disease committed suicide while under treatment, was injured or lost during transportation, and (except in rare instances where methods could not be controlled) no patient being evacuated was subjected to mechanical restraint.
Secondly, there was never at any time a special vessel designated to return neuropsychiatric patients to the United States. They had to be included in the rather limited space set aside for hospital accommodations on the westward trips. Again and again a transport filled its hospital beds with the sick and wounded and found that there was no place left over for neuropsychiatric patients. There was a considerable lack of agreement as to what constituted proper provisions for the transportation of these patients.
Another difficulty arose out of the use of the term "neuropsychiatric" to designate patients requiring such widely different types of provision on shipboard as those with acute mental diseases (psychoses), those convalescent from war neuroses, mental defectives, epileptics, insane prisoners, and patients suffering from organic diseases of the central nervous system. The shortage of shipboard facilities was, of course, only for those in the first category, but all were refused. Then, often, unexpectedly a transport would be willing to receive a large number of mental patients and the population of the 300-bed psychiatric department of Base Hospital No. 8 would be quickly relieved. Congestion, however, was the rule. For this reason the provision of a special hospital at Savenay was recommended by the senior consultant on October 28, 1918.18
One of the hospitals in the center finally was set aside and opened November 6, 1918, under the designation Base Hospital No. 214.13
At Brest a difficult situation was created by the fact that occasionally a convoy of mental patients which had arrived from Savenay for the sailing of a designated transport from Brest was refused by the medical officer of the transport because of the lack of suitable accommodations for them. In such instances emergency provision had to be made in hospitals at Brest which had no special facilities for their care. The outgrowth was a development of a special department at Base Hospital No. 65, at the Kerhuon hospital center, at this base port.19 This department became one of the most effective and useful neuropyschiatric resources in France.
DURING THE ARMISTICE
Just before the armistice was signed the chief surgeon directed the senior consultant to submit a full statement as to the adequacy of existing hospital accommodations for neuropsychiatric patients in the Services of Supply, with a statement of the additional provisions already under construction or agreed upon and any expansion required. This report is given below in full, because it provides an excellent summary of the situation as it existed a few weeks before the armistice was signed:20
SPECIAL HOSPITAL PROVISIONS FOR MENTAL AND NERVOUS CASES IN THE S. O. S.
Base Section No. 1:
Although the armistice put an end to battle casualties, thus eliminating one great increasing demand for hospital beds, the hospital problems of the American Expeditionary Forces were not immediately reduced in their size
or complexity. The necessity for beds for neuropsychiatric patients increased for a time instead of diminished, and congestion of such patients at Savenay hospital center because of delay in transferring them to the United States, became very serious. One of the results of the delay in the transfer of these patients was to imperil recovery in many of the lighter types of depression that had occurred in men exhausted by the severe fighting of the fall. This situation was brought to the attention of the chief surgeon, A. E. F., by the senior consultant in neuropsychiatry, in November, 1918.21
A number of the more recent cases showed simple depression, in some instances only slightly beyond physiological limits but, nevertheless, accompanied by painful ruminations and often by suicidal ideas. An intense longing for home was characteristic of this condition. It resembled a set of reactions to which the term "nostalgia" used to be applied and is common in all military expeditions when a period of intense activity is succeeded by an uneventful one.
The cessation of hostilities made it necessary to modify plans for the care of neuropsychiatric patients. It was upon the following letter from the senior consultant to the chief surgeon, A. E. F., that the neuropsychiatric work during the armistice, except in the army of occupation, was based:22
1. The cessation of hostilities and the proposed decrease in the number of expeditionary troops necessitate radical changes in plans for the care of neuropsychiatric cases in the American Expeditionary Forces.
2. The most convenient method of presenting these changes is to consider them with reference to the following three groups into which practically all neuropsychiatric cases in the American Expeditionary Forces fall: Injuries to the central nervous system and peripheral nerves; psychoneuroses, chiefly those termed "war neuroses"; mental diseases (insanity, mental deficiency, etc.).
The possibility of further admissions to this group terminated with the armistice. In civil accidents-such as will continue in the American Expeditionary Forces-such injuries are very rare. The whole problem of dealing with injuries to the central nervous system and peripheral nerves is their diagnosis and management pending their return to the United States for continued treatment.
The neurosurgeons having decided that all such cases should be returned to the United States before operation, it is important that every effort should be made now to see that each patient with a wound in which injury to the brain, cord, or peripheral nerves may exist receives a careful neurological examination and that accurate notes of such examination be made on the clinical records. It is not sufficient to examine only cases brought to attention by surgeons but all cases should be seen. Negative notes will often prove of as much value in the future management of these cases as positive ones.
There are many instances in which a functional element, or a "functional overflow of symptoms" as it has been called, complicates cases in whom organic injury exists. To determine the existence and extent of this complication requires a careful examination by one experienced in the diagnosis of functional as well as organic conditions. Neuropsychiatrists in the American Expeditionary Forces have had unusual opportunities of seeing functional disturbances among soldiers. It is important, therefore, that their opinion should be recorded in all such cases before sending them home. It can readily be seen that neuropsychiatrists and neurosurgeons in the United States may be misled by the disappearance or modification of functional symptoms when cases arrive at hospitals at home unless careful examinations and clear records have been made in the hospitals of the American Expeditionary Forces.
With these considerations in mind, thousands of careful examinations of the wounded have been made by neuropsychiatrists in base hospitals in the American Expeditionary Forces. Now a general survey with reference to neurological injuries is being undertaken.
In every base hospital center this work is being pushed by additional personnel under the direction of the consultant in neuropsychiatry for the center. Not only will positive findings be recorded but in all negative cases the clinical records will be stamped "Neurological examination negative."
It is realized that the rapid evacuation of patients toward base ports can not be delayed for such examinations and that many patients will not be reached. To meet this situation a number of young and energetic neurologists have been sent to Savenay, Brest, and Bordeaux. At these ports, through which all the wounded must flow, efforts will be made to examine all records and as far as possible to examine all cases in which a previous examination was not recorded. Three very experienced officers have been assigned to these ports as consultants in neuropsychiatry to supervise this work.
In about six weeks the work outlined above should be completed. The medical officers engaged in it may then be returned to the United States.
It is estimated that the incidence of these disorders will be decreased not less than 90 per cent through the cessation of hostilities. The remaining 10 per cent will continue to be contributed in the future as they have been thus far, by the factors responsible for psycho-neuroses in civil life. Military experiences other than the hardships and danger of actual warfare will tend to make psychoneuroses not less prevalent in the American Expeditionary Forces than among a body of men of the same age periods in civil life.
Accompanying the decreased incidence of the psychoneuroses will be a greatly increased recovery rate among those remaining under treatment. It is estimated that among the 465 cases remaining unclassified at Base Hospital No. 117 on November 25, as many as 410 will be discharged to duty.
As nearly as can be estimated, about 200 cases are now in other base hospitals. Steps are being taken to have these cases sent to Base Hospital No. 117 at once. It is very desirable that they should be restored as soon as possible and not returned to the United States still suffering from functional nervous disorders. Spreading the information that this will not be done has already promoted recovery. It is apparent that Base Hospital No. 117 will have seen less than 200 patients, and that with this number of beds all new admissions to be expected can be provided for. As it is uneconomical to maintain a separate hospital for this number of patients and it is perfectly useless to send these cases to general hospitals, it is recommended that all cases of functional nervous disease be cared for in the neuropsychiatric hospital considered under the heading "Mental diseases" in this letter.
The elimination of danger, hardship, and exhaustion as causes of mental disease will tend to decrease the number of admissions in this group. The number of mental defectives coming to notice will be diminished on account of the inevitable lowering of standards of mental fitness in troops not required to do combat duty. (Many mental defectives used to come to attention on account of their inability to put on gas masks or perform outpost duty.) To offset the effect of these causes of a substantial decrease in the admission rate for mental cases, are the lengthening period of service and absence from home, disappointment over not returning immediately and the unavoidable impairment of morale that will result when a combatant army becomes one of the occupation. It is predicted that mental cases will continue to be admitted at an annual rate of 3 per thousand enlisted strength-about three times the civil rate for adult males.
The present provisions for the insane of the American Expeditionary Forces are inadequate. The collecting station provided by the psychiatric department of Base Hospital No. 116 at Bazoilles has been of much value. It should be continued as well as the wards now set aside at the Allerey and Mars hospital centers, as these centers are within easy reach of the areas in which the troops are quartered. Mars is a particularly favorable location as it is at the point of divergence for the three base ports. A similar ward should be maintained at Bordeaux and one at Brest for convenience in embarking mental cases and for the collection of new cases from the troops in the vicinity. All these wards are being adequately staffed from the personnel now available. In addition officers and enlisted men are being congre-
gated at the three base ports so that they can be detached to accompany convoys of mental patients home.
The chief provision for mental cases should continue to be at Savenay or Nantes. These places are nearest the most convenient port and also nearest to the points from which cases will be collected and afforded temporary care. The problem of caring kindly and skillfully for mental cases from the American Expeditionary Forces will have to be met at one of these points as long as there are troops in France. When the pressure of caring for the wounded submerged everything else it was out of place to dwell upon the kind of care provided for mental cases. Now, however, it would seem that the matter could be taken up seriously. Insanity is not an occasional occurrence among troops but one of the most important diseases in an army in peace as well as war. It should be provided for not as an emergency but as one of the routine tasks of the medical department of an army.
Although no country has higher standards than the United States in the care of mental disease, the care of the insane at the present time at Savenay is below that seen in any British or French military hospital for mental diseases. Base Hospital No. 214 is a base hospital only in name. It was created by giving this designation to the overcrowded wards already occupied by the mental cases, without any provisions for personnel, administration, or treatment being added. The capacity of these wards was rated at 400 by giving up all rooms intended for special patients, for the isolation of special classes, or for day rooms. The enlisted personnel is away from the unit altogether at night although this is a practice full of danger when mental cases are cared for. The personnel on night duty should always have assistance at hand in case of emergency. Only 13 nurses are available for the care of 560 patients. Thirty nurses were assigned to this department when the personnel of Base Hospital No. 117 arrived in France in June. Although these nurses were all especially trained in the care of mental diseases, having been enrolled in the United States for that purpose, they have been assigned to other work in other hospitals.
The remedy for the conditions under which the insane of the American Expeditionary Forces are cared for is to provide at Savenay or at Nantes a separate neuropsychiatric base hospital capable of caring adequately for all mental cases, with proper classification and provision for the relatively large number of insane officers, and for the psychoneurotic cases after Base Hospital No. 117 has been discontinued. No special provisions other than those which can be extemporized by a staff of the hospital are required. It is necessary, however, that such a hospital should be recognized as a necessity and not a temporary expedient and be permitted to develop the special methods of treatment and care needed even in the short period in which mental cases are provided for here. A very large proportion of the mental cases now coming to light are recoverable. Many can be transported to the United States with much less danger after a short period of treatment here and in not a few the difference between permanent mental disease and prompt recovery will depend upon what is done for them in that short period. The wards at Savenay constitute nothing but a place of detention now.
By January 14, 1919, certain further modifications were necessary and Circular No. 35, quoted above, which had provided the official authorization for a large proportion of the neuropsychiatric work in France, was superseded by Circular No. 35-A:
CIRCULAR LETTER No. 35-A
AMERICAN EXPEDITIONARY FORCES,
From: The Chief Surgeon.
To: C. O.'s all base, camp and evacuation hospitals, hospital centers, surgeons of armies, corps, divisions, and sections, and the surgeon, district of Paris.
Subject: Mental and nervous cases.
1. The directions of Circular 35, O. C. S., June 13, 1918, that relate to the care and evacuation of mental cases (insanity, mental deficiency, epilepsy, observation cases) are modified as indicated below.
2. Psychiatric departments for the reception, observation, early treatment, and evacuation of mental cases are now in operation at the following hospital centers:
3. All mental cases will be sent to the psychiatric department most accessible in the manner indicated in Circular 35. It is important that proper attendance be provided in all cases to prevent accidents during evacuation. Unless special circumstances make other arrangements more advantageous, such attendance will be supplied by the psychiatric department to which patients are being sent. No stigma attaches to admissions to these departments and they should be freely used for observation in all doubtful mental conditions.
FUNCTIONAL NERVOUS CASES
4. Patients with functional nervous diseases (psychoneuroses, war neuroses) will be sent, in the first instance, to the nearest base hospital and thence to Base Hospital No. 214, at Savenay, which has a special department for psychoneuroses. Attendance will be provided for these cases only when there is some special reason for it. They will not be sent to psychiatric departments at hospital centers.
5. In Section I, paragraph (b) of Circular 35, O. C. S., June 13, 1918, the following statement is made regarding records of mental cases:
It is very important that mental cases be accompanied by records in which the circumstances under which their condition came to notice are fully stated. It is obvious that, without such information, the medical officers who have the responsibility of dealing with these cases will often have difficulty in arriving at a diagnosis or in making suitable recommendations for their disposition.
These instructions are being generally neglected with the result that the work of the medical officers in the psychiatric departments is unnecessarily rendered more difficult. Mental cases come from divisions with no record except their diagnosis cards. In some cases these patients have had general court charges preferred against them without notations to indicate it. Others have made suicidal attempts or threats, but without any record of these facts they can not be properly classified until observation at the hospital has revealed them.
6. Disability boards will not reclassify mental cases or those with psychoneuroses. This will be done by the neuropsychiatric disability boards which have been established at each psychiatric department and at Base Hospital No. 214 (neuropsychiatric hospital).
WALTER D. McCAW,
When the neuropsychiatric service was organized in the American Expeditionary Forces medical officers with neuropsychiatric training were widely scattered among the organizations there; but the names, assignments, and qualifications of those available for professional work in the field had been ascertained by the senior consultant in neuropsychiatry. This was done by examining the personnel records in the chief surgeon's office and by correspond-
ence with commanding officers of the base hospitals and with division surgeons. By the end of January, 1918, the location of about 20 such officers had been ascertained and they had been graded into the following three groups with reference to their training and experience: (a) Those who could be intrusted with important duties in their specialty without supervision. (b) Those who, on account of their less thorough training or other reasons, could be utilized as assistants but not placed in charge of the work to be performed independently. (c) Those who had had so little experience and training that it was inadvisable to use them as specialists.
The most fruitful sources from which these officers were obtained were base hospitals organized from important medical centers in the United States which had come overseas shortly after war had been declared by us. Each of these hospitals had as a member of its staff a neuropsychiatrist who, in many instances, had been professor of neurology and psychiatry in the university and a director of those services in the teaching hospital at home from which the military hospital had been organized. Other sources were the medical officers studying the treatment of war neuroses in England and those scattered throughout various organizations where special training could not be well utilized. Plans were made at once to have these officers reassigned to posts where they could be most useful. It was from the seven officers on duty in England that the first four division psychiatrists, the first commanding officer of Base Hospital No. 117, and its first medical director were obtained. An effort was made also to secure a roster of nurses and enlisted men who had had experience in the treatment of mental patients.
During March, April, and May, 1918, with the advent of many additional base hospitals from the United States and the construction of hospital centers, the organization of the professional services in hospitals in accordance with the general plan which formed the basis for Circular No. 2, chief surgeon's office, A. E. F., November 9, 1917, became necessary.e It was not difficult to make the reassignments required to provide consultants in neuropsychiatry for nearly all hospital centers. As the personnel to staff new hospitals arrived from the United States the neuropsychiatrist attached to each was communicated with or visited by the senior consultant in neuropsychiatry and the general plan for the care, treatment, and evacuation of mental and nervous patients explained to him. Such officers differed in their special experience and training and reassignments were made so that, in general, younger men could be detached to serve with troops and those qualified for particular tasks could be assigned to them.
The personnel was augmented continually from newly arrived tactical divisions and hospital units, each with its attached neuropsychiatric specialists. An unexpected increase in personnel was due to the fact that evacuation hospitals arriving after the first of August, 1918, each had a neuropsychiatrist attached.23 Since it was not practicable for such officers to perform very useful work in the evacuation hospitals under the plan of action in the theater of
operations, they were immediately detached and made available for other duties. All these sources, however, were inadequate to meet increasing needs, consequently there were organized in the United States two neuropsychiatric replacement units of officers, nurses, and enlisted men, all not only with civil experience in neuropsychiatry but, by that time, with a good deal of military training.24 Upon their arrival in France they were immediately distributed to the different stations in most urgent need, thus increasing very greatly the usefulness of available neuropsychiatric facilities. There were certain losses of personnel, fortunately, however, few through death or illness. In order to meet the need for better care during ocean transportation, officers and enlisted men with neuropsychiatric training were detached from the American Expeditionary Forces to accompany home convoys of mental patients. Few of these officers or enlisted men returned. It was also necessary to release a few officers for general work because they had shown lack of aptitude for the highly specialized tasks that they were called upon to perform. On the other hand, the high administrative capacity of many neuropsychiatrists who had held responsible positions in civil life made their services sought after for executive posts in the American Expeditionary Forces.
The neuropsychiatric work of the American Expeditionary Forces covered such a wide field that it was possible to make assignments with reference to the special types of training and ability which medical officers possessed. In general those whose training had been chiefly psychiatric were assigned to tactical organizations and to hospitals and departments established for the care of mental patients, while those whose training had been chiefly neurologic served as consultants in general base hospital centers. Although it was one of the outstanding features that neurologists and psychiatrists shared each other's duties, responsibilities and point of view to an extent that had never existed in civil life, and that the new terms "neuropsychiatry" and "neuropsychiatric" came to have ample justification for their use, it was true, nevertheless, that relatively few medical officers possessed equal qualifications in both these fields. Psychiatrists who had had years of excellent training and experience in dealing with mental diseases, psychoneuroses and conduct disorders did not possess the background of neuroanatomy, neuropathology, and clinical neurology required to deal with the organic injuries and diseases of the brain, spinal cord, and peripheral nerves that contributed so many interesting and perplexing questions in diagnosis and treatment in the base hospitals. On the other hand, many neurologists had devoted themselves so exclusively to these subjects that they were insufficiently prepared to care for patients with acute mental diseases and to apply with much conviction some of the psychological viewpoints upon which the treatment and prevention of the war neuroses were largely based. During the strenuous weeks that intervened between the unexpected entry of the American divisions into active fighting in May, 1918, and the armistice, little time could be given to formal medical training. It was intended to remedy this defect during the winter when neurological training would be afforded for
psychiatrists and psychiatric training for neurologists. In the specialists arriving late in the summer and fall of 1918, however, there was striking evidence of results of the breadth and soundness of the training that had been carried on in the United States in the courses offered at the various neuropsychiatric centers such as the Michigan Psychopathic Hospital, Ann Arbor, Mich.; Boston State Hospital; Neurological Institute, New York City; Philadelphia General Hospital; Phipps Psychiatric Clinic, Baltimore, Md.; Government Hospital for the Insane, Washington, D. C.; Manhattan State Hospital, New York City.25 These men were indeed neuropsychiatrists; others would have been had those who came to the American Expeditionary Forces early in its existence had the opportunity during the winter of 1918-19 to avail themselves of similar educational opportunities. Regular courses for medical officers, nurses, occupational aides, and enlisted men were established at Base Hospitals No. 11710 and No. 214.13 A two weeks' course was arranged at American Red Cross Hospital No. 1 at Paris where, with the cooperation of French neurological clinics, there was an excellent opportunity for the study of brain and peripheral nerve injuries.
From the beginning the chief surgeon trusted the senior consultant in neuropsychiatry, as was the case with other senior consultants, to make such recommendations as were needed to use the neuropsychiatric personnel to the best possible advantage. Almost without exception, the recommendations of the senior consultant in neuropsychiatry were promptly put into effect by an official order. There was, unfortunately, one important obstacle-the refusal of commanding officers to grant their approval. Entirely in the interests of harmony and cooperation, the senior consultant had established the custom of asking commanding officers in advance if they would approve his making such recommendations. It was apparent that the special work for which he was directly accountable to the chief surgeon would fail if this custom was continued and if small needs rather than larger issues governed the distribution of personnel. On July 28, 1918, the senior consultant brought this important matter to the attention of the director of professional services,26 whereupon he was given practically free disposition of the neuropsychiatric personnel, and no further difficulties, such as those outlined above, were experienced.
As explained in Section I of this volume, the National Committee for Mental Hygiene, at the request of the Surgeon General of the Army, secured a large part of the neuropsychiatric nursing personnel for the Army. In the original selection of these nurses, made in the first year of America's participation in the war, only persons were selected for psychiatric nursing service in the American Expeditionary Forces who had had training and experience in caring for nervous and mental cases. Applicants were investigated carefully and only those highly recommended for the service were accepted. After extensive correspondence and other lines of inquiry a group of 46 nurses finally was obtained for duty in the American Expeditionary Forces.
Until June 8, 1918, when the first contingent of specially obtained nurses arrived in France,10 neuropsychiatric nursing in the American Expeditionary Forces was done by a few nurses selected from among the general nursing personnel. These were usually women who had had previous experience in special hospitals for nervous and mental diseases, or in wards for these cases in general hospitals. In addition to the 46 nurses referred to, 20 more were added to the unit at the time it sailed for France. These 66 nurses were assigned for the most part at Base Hospital No. 117, but some were left at Base Hospital No. 8, at Savenay, and others were sent to psychiatric departments of hospital centers throughout France.
After the arrival of the unit designated Base Hospital No. 117, neuropsychiatric nursing was taken over as much as possible by specially trained nurses. Throughout the summer, the neuropsychiatric nursing personnel was increased in number by the addition of those sent from the United States in two psychiatric replacement units.
LIAISON WITH THE DIVISION OF NEUROLOGY AND PSYCHIATRY, SURGEON GENERAL'S OFFICE
Liaison with the division of neurology and psychiatry in the Surgeon General's Office was maintained by personal communication in the form of letters and cables between the chief of the division of neurology and psychiatry, in the Surgeon General's Office, and the consultant in neuropsychiatry, A. E. F. This informal method was first approved by the chief surgeon but the restriction of censorship was a formidable barrier.
One of the most valuable aids which the neuropsychiatric work in France obtained during the war came through the visit made by the chief of the division of neurology and psychiatry in the Surgeon General's Office. His temporary assignment to the American Expeditionary Forces was recommended by the senior consultant to the chief surgeon, A. E. F., on June 18, 1918, in the following letter:27
1. The extensive plans being made in the United States for continued care and social and industrial rehabilitation of disabled returning soldiers do not in all cases provide for direct continuity between management here and at home. It is essential that those responsible for this work in the United States be closely in touch with what is done here and familiar with the views of those who care for our soldiers during the earliest phase of their illness or disability.
2. This is particularly true in the case of the war neuroses and of some forms of mental disease. In their thousands of chronic nervous invalids resulting from the war-most of them young men-England and Canada have medical and social problems that will remain unsolved long after the war has ended. The presence of these men in the homes and in the industrial and social life of the community cannot fail to affect unfavorably the mental health of those who are in daily contact with them. The gravity of this situation is now being recognized and the Military Commission of Pensions in England and the Military Hospitals Commission in Canada are making belated efforts to bring again under treatment, with the object of reclaiming them, the thousands of soldiers who were discharged from the army before they had received adequate treatment and who in consequence remain unrecovered.
3. These considerations indicate the need for the closest liaison between this office and the division of neurology and psychiatry in the United States, especially since the Surgeon General's Office has become the rallying point for the many official and unofficial agencies that have interested themselves in the various phases of reconstruction work among soldiers. It
is suggested, therefore, that it be indicated to the Surgeon General that it would be agreeable to have Col. Pearce Bailey ordered to France and England for a short period of observation of neuropsychiatry work in expeditionary troops.
4. It is believed that nothing will contribute more to close cooperation in this field than the personal contact with the actual problems in mental medicine in the American Expeditionary Forces that such a tour of duty would provide.
The medical officer concerned visited England first and spent July, August, and part of September in the American Expeditionary Forces. He was able to visit the French neuropsychiatric hospitals and training centers which the senior consultant in neuropsychiatry, A. E. F., had been unable to see on account of a great pressure of work. The report to the chief surgeon which the chief of the division of neurology and psychiatry rendered, September 5, 1918, on his observations, with his recommendations for the American Expeditionary Forces, is as follows:
MANAGEMENT OF WAR NEUROSES BY THE FRENCH
Connected with each army the French have a neurological center which has a capacity of from 100 to 200 beds. The capacity should be in the ratio of 1.5 beds to 1,000 troops. This army center is located or should be located with one or two hours motor transport distance from the front. It has three medical officers who have had experience at the front.
The patients, transported as promptly as possible after the development of symptoms, are placed first in a receiving ward where they are carefully examined and then sent to different wards, classified as far as possible in relation not only as to their injury but also as to their personality, the hysterical and malingering types being kept apart from the others.
The character of the disabilities varies with the activity of the sector which the center serves. For example in quiet sectors these centers receive large numbers of cases of rheumatism, sciatica, etc., while in active sectors the true commotioned cases are in the majority.
The method of treatment and management varies with the class of cases. The true commotionné is treated with all sympathy and kindness. He is kept in bed until he feels able to get up, which is generally within a week, and is then treated as a convalescent until he leaves, which is ordinarily within two or three weeks. Quite a different course is taken toward the emotionné, or toward the commitionné who shows signs of developing neurotic symptoms. Such a patient is given to understand at once that such symptoms as trembling, failure to move a limb or portion thereof, deaf mutism, etc., are not symptoms of disease but rather failure in will, a defect in character, that persistence in the demonstration will cause the man to be regarded as a malingerer, which will eventuate in his punishment, perhaps by court-martial. Two forms of punishment are available to the neurologist at the center itself. One of these is the threat that the "permission" or leave, to which every French soldier is entitled after discharge from the hospital, will be taken away from him if he persists in functional symptoms. He will not be allowed to go home, he is told, but will be returned directly to the front. The other form of punishment is solitary confinement. The soldier presenting hysterical symptoms is put in a room by himself, locked in, and is not permitted to read, write, or smoke. He is told that the trouble with him is in his will and that the best way to recover the will is by silently reflecting in the dark. In addition to these means of combating the outbreak of hysterical symptoms, electricity with persuasion is used or the rougher quick method of suddenly turning on strong electric currents in the region of the part showing signs of defaulting function. By these various measures the French maintain that it is not necessary to send many functional cases back to the interior. Certain cases of true commotionné who do not recover in the army centers are sent to the interior for further treatment or convalescence. All organic cases are evacuated to the interior as rapidly as possible.
Different methods are required in the neurological centers of the interior than of the advance. The medical point of view regarding the neuroses is no different, but the patients are under a less rigid control than in the army centers and more easily accessible to their
friends, to civil inspection, etc. The neurological centers of the interior are organized as regional, there being 20 regions in France. These centers are complete neurological hospitals, with wards for organic as well as for surgical cases. In some centers, as at Besancon, the surgical cases are sent to another hospital for operation. In others, as at Lyons, the center has a surgical service of its own.
The management of the neuroses in these interior centers varies considerably with the personality of the director. As a rule, while there is no different point of view regarding the neuroses than is entertained in the army centers, the brusque methods employed near the front have been found less practical in the regional centers. Relaxation of discipline, proximity of friends, popular disapproval, etc., explain this. Torpillage, or the sudden electrization of affected part, is still made use of and is said to produce immediate cure, but may bring the physician who employs it into trouble.
The most successful of these interior centers, as far as the neuroses are concerned, is the one at Salins. It is remote. The patients are carefully prepared by various suggestions before they are treated. This stage of preparation is extended for several days or weeks, the patients being kept as much as possible in company with patients who have already been cured. The treatment itself, consisting of persuasion with mild faradization, is completed at one sitting, the sitting requiring from a few minutes to several hours. When the local hysterical manifestation is removed the patients are held in the center for two or three weeks, are daily encouraged and made to do exercises and are also made to do such work as farming and carpentry.
The organization at Salins is very carefully thought out and skillfully conducted, but not the least good point about it is the military training which follows the cure. This is conducted at a camp at the foot of the mountain peak where the hospital is located. The camp is under the command of a captain of infantry, wounded and not fit for field service, who is in full sympathy with the physician of the hospital. The patients on coming from the hospital are grouped in accordance with their capacities. About two-thirds are drilled with arms and are trained again for full field service. The balance, who will only see service at the rear again, are given hikes and calisthenics. To the evident advantage of training as an after cure the camp offers the physician the opportunity of seeing his graduates daily, of watching their progress in resuming their military careers, and in immediately becoming cognizant of relapses. These occur not infrequently in the camp and then the patient is taken up on the mountain again and is put in solitary confinement before being re-treated. Second relapses are said to be exceedingly rare.
It would seem that the training camp, under the command of a well-selected line officer, offers the only means of accurate classification of cases of neuroses which have been hospitalized. Unless patients of this class are tried out for several weeks before they are sent to line duty great errors in the evaluation of their capacity are bound to occur. And if they are returned a second time from full duty the chances for their complete restoration are very poor.
The French method of handling the neuroses of war has doubtless been of great service not only to the army but also the patients themselves. As far as the army is concerned, a very large percentage has been returned to the line. It is true than many are still to be found in the interior hospitals who have resisted the treatment of the army centers, but these are still in the military service and so even now have a better chance of recovery than if they had been discharged from the army. Even cases of long standing, of two or three years, are successfully treated and returned at Salins. It is not true that these patients recover when discharged from the army, in the sense that the condition was due to a wish to be out of the war. The many disabled neurotics among discharged British soldiers teach quite the contrary.
SUGGESTIONS FOR AMERICAN EXPEDITIONARY FORCES
Everything seems to point to our soldiers developing neuroses to a degree even greater than has occurred among the British unless special means are taken to prevent. The conditions of American life have been such that a young man suddenly taken from surroundings where he more or less always had his own way, where obedience was never necessary, where he was taught that he was the equal of every one, suddenly taken from surroundings of that
character and forced to obedience, forced also to face all this war has of horror, it would not be surprising if he showed his reaction to the change by developing a neurosis if he were given a chance. French neurologists with whom I have talked have spoken of the excessive nervousness of American soldiers who have been under their care.
It would seem then that we should profit as far as we can from the experience of the French in this matter. Check the development of neurosis by denying its existence at the start. Each army should have its own center of a capacity of at least 1˝ beds to each 1,000 troops. It should keep its patients two or three weeks if necessary, and should be entirely independent of any hospital of the communication or base.
The treatment of the patients should be calmative and restorative and any appearance of such symptoms as tremors, paralysis, etc., should be rigidly discouraged. This idea should run through the whole personnel of the hospital. At first it should be effected by gentle persuasion, but if the patients persist in the production of hysterical symptoms sterner measures should be resorted to. It is not considered desirable to send patients of this class to convalescent camps. It would be better for them to have leaves, and the threat to cut off the leave might persuade many to suppress the self-indulgence which is so often the neurosis and give up his symptoms. Isolation and strong faradization might also be employed with advantage at this stage.
Those patients should be held at the army hospital with the greatest tenacity. The chances of their permanent military recovery is reduced the moment they are sent back. It is strongly recommended that none of this class be returned to America until after the war. The influence of the home country would make it extremely difficult to organize a hospital service where these cases could be properly treated, and there would be small hope of ever fitting the patients again for military duty. And the fitting for military duty is the one means of effecting a satisfactory cure. A neurosis which has lasted for a year or more has established a habit which persists, or is prone to, after the cause is removed. This is shown by the numbers of permanently (or apparently permanently) disabled men to-day, discharged from the army in England and Canada.
Following the promulgation of General Orders, No. 41, G. H. Q., A. E. F., March 14, 1918, which governed the physical classification of the personnel of the American Expeditionary Forces, it proved necessary to have special procedures in the care of officers and men suffering from mental and nervous diseases. Accordingly, on April 23, 1918, the chief surgeon, A. E. F., issued the following circular letter:
CIRCULAR No. 24
AMERICAN EXPEDITIONARY FORCES,
Disability boards passing upon mental and nervous cases under Sec. I, G. O. 41, G. H. Q., A. E. F., March 14, 1918, will, as far as practicable, be governed by the following considerations.
In dealing with these cases, there should be borne in mind their chronicity, the probability of recurrences or acute episodes in constitutional disorders, and the bearing which abnormal mental states have upon questions of responsibility. The special mental stresses of modern warfare and the fact that the safety of many soldiers often depends upon the conduct of one of their number should be given due weight in considering the fitness of men with mental or nervous diseases for service at the front. At the same time the importance of utilizing, in any safe and suitable way, the services of men partially incapacitated should not be overlooked. The essential question for boards to decide is usually whether, taking all the facts into consideration, the individual before them will be an asset or a liability to the Expeditionary Forces. Whenever possible a psychiatrist or a neurologist should act as one member of a board passing upon mental cases.
PSYCHOSES (INSANITY, MENTAL ALIENATION, MENTAL DISEASES)
All officers and enlisted men in whom frank psychoses exist should be marked "D" and returned to the United States as soon as this can be done without injury or endangering their chances of recovery. It will often be advantageous to hold these cases in the psychiatric departments of base hospitals at base ports until acute and severe manifestations have passed or, in cases of an especially favorable type, until recovery has taken place, but it should not be made the practice to provide extended treatment in hospitals in the American Expeditionary Forces.
In exceptional eases where it seems desirable to depart from the rule of returning to the United States soldiers who have or who have had psychoses, the patients may be classified "B," and the special considerations which make a departure from the rule desirable must be noted on the report card.
MENTAL DEFICIENCY (FEEBLE-MINDEDNESS, DEFECTIVE MENTAL DEVELOPMENT)
The existence of a readily demonstrable degree of mental deficiency should almost invariably be sufficient reason for not classifying soldiers as "A," but it should by no means be regarded as sufficient reason in itself for placing them in class "D." In recommending mentally defective soldiers for duty in labor organization at the rear, especial weight should be given to good physique, emotional stability, and freedom from such delinquent traits as alcoholism, dishonesty, nomadism, and the like. Military delinquents, of whom the mentally defective constitute a large proportion, are a source of almost as much noneffectiveness as illness and it is important that the Expeditionary Forces should not be burdened with their care and supervision. Defective delinquents should always be classified "D."
CONSTITUTIONAL PSYCHOPATHIC STATES
In making recommendations as to the disposition of soldiers found to have constitutional psychopathic states, the considerations mentioned under the preceding heading should govern. It should be remembered that many individuals with volitional defects are amenable to military control. Conditions which should usually indicate the wisdom of returning these cases to the United States are marked emotional instability, sexual psychopathies (homosexuality, etc.), paranoid trends, and specific criminalistic traits. These cases should be classified "D." Excessive fear or timorousness should prevent return to duty at the front. For military reasons it is especially undesirable, however, to return such cases to the United States. They should be recommended for duty in labor organizations and marked "C."
Epileptics should be classed "D," the only possible exceptions to this rule being individuals in robust physical health who have attacks of moderate severity at long intervals and those in whom treatment has had this result.
In making the diagnosis of epilepsy the fact should be borne in mind that attacks are likely to be less frequent in the favorable environment of the hospital while observation is being carried on than in the organizations from which patients are received. Great weight should be given to a well-authenticated history of epileptic seizures, especially when witnessed by medical officers or other persons who can give a clear account of their character. While the possibility of malingering should not be overlooked, it should be remembered that attacks similar to those in epilepsy are much more frequently psychoneurotic in their nature than feigned. The high prevalence of epilepsy among soldiers should be remembered.
DRUG ADDICTION AND ALCOHOLISM
These conditions are essentially curable. Inebriates and drug addicts should not be recommended for return to the United States with a view to their discharge until they have failed to respond to adequate treatment. Then, their disposition should depend upon the type of personality presented, the effects of alcohol or drugs in physical deterioration or
damage to the central nervous system, and the conditions to which they will be exposed when they are returned to duty. It will often be found that these cases do better at the front than in duty at the rear.
PSYCHONEUROSES (HYSTERIA, NEURASTHENIA, PSYCHASTHENIA)
These conditions must be dealt with as disorders amenable to treatment under proper conditions. Individuals who fail to benefit from such treatment in the special hospital which has been provided, either because of severe defects in make-up or on account of previous mismanagement, should be returned to the United States for continued treatment unless it seems likely that good results can be obtained from their assignment to duty at the rear. A very large proportion of the severe neuroses seen in war are of the "situation type," rather than psychoneurotic manifestations in persons who have had many previous episodes of the same kind in civil life.
These instructions had the effect of amending or at least interpreting General Orders, No. 41. It was one thing to determine upon such a policy, however, and another to put it into effect. On account of misunderstanding what was contemplated, a good many disability boards in base hospitals passed upon the neuropsychiatric patients before evacuating them to the hospital center at Savenay. This was done for several reasons besides misunderstanding the intent of the order. One technical difficulty came from the requirement by the commanding officers of some base hospitals of the approval of a disability board before authorization of the travel necessary to take the patients to the base port. In addition, many mild cases of psychoneuroses recovered in interior hospitals and were deemed fit for class A duty. These could not be discharged to duty without review by a physical classification board, and it seemed unwise to delay it. It is interesting to see how frequently individual opinion tended to govern in these matters and thus defeat a general policy. In one large hospital center the commanding officer formed the apparently fixed opinion that no soldier who had ever developed psychoneurotic symptoms was fit for military duty in any capacity in France. In consequence he had ordered disability boards at that center to classify all such patients D and send them to the hospital at Savenay for evacuation to the United States. When it is remembered that a large proportion of all men who broke down at the front and were treated at army neurological hospitals returned to duty without ever having left the theater of operations,28 and that 91 per cent of all patients treated at Base Hospital No. 117 were there reclassified for some type of military duty in France,10 it can be seen how untenable such an opinion was. These difficulties were largely overcome later through the intervention of the consultants for the hospital centers. These consultants interested themselves very actively in the question, served on, or examined cases for, disability boards, or gave opinions which helped to put the provisions of Circular Letter No. 24 into practical effect. At the first replacement depot established at St. Aignan-Noyer by the 41st Division a very large proportion of all reclassified men received in the early activities of the American Expeditionary Forces came before disability board No. 1.29 From May 1 to December 31, 1918, 27,437 men appeared before that board, of whom 9,256 were classified A.29
The 41st Division was provided with a division psychiatrist upon its arrival in France, but it soon became apparent that he would require additional
aid as the reclassification work of the division increased. During the summer of 1918 a neuropsychiatrist was detailed as chairman of the disability board and, with several assistants, he organized extremely effective and practical methods of neuropsychiatric examination and reclassification. The following report from the medical officer who was in charge of the neuropsychiatric department of Base Hospital No. 8, dated July 9, 1918, indicates the general principles which from that time on governed the reclassification of neuropsychiatric patients at that base port:30
I. In accordance with verbal request, the general principle governing this disability board, with respect to line of duty in nervous and mental diseases, is submitted.
The following cases are considered not in line of duty:
1. Psychosis in men who have had a well-established
psychosis previous to enlistment.
II. Cases considered in line of duty:
1. All psychoses developing since enlistment, presumably
as the result of military service, without established histories of previous
III. In a number of cases of syphilis of the central nervous system the board has had difficulty in deciding the question of line of duty. These are cases in which the time of the initial infection is unknown and in which the invasion of the central nervous system occurred since enlistment and where military service may have been an important etiological factor. Instruction is desired as to proper procedure in such cases.
IV. The above general principles are followed and applied to each individual case, in accordance with the history as established. In acute psychoses the cases are considered in line of duty when the history of a previous attack can not be established.
The total work of neuropsychiatrists in connection with these boards throughout France was very great and represented an extremely useful contribution which was not without its effect in the work of rehabilitating ex-service men after the war.
There was established at Blois, in the summer of 1918, an officers' classification and efficiency board.31 Here many perplexing problems were dealt with. The officers who came before this board had had no charges preferred against them nor had they been suspected of any mental or physical disability. They had been judged unfit for combat duty, and they were to be reclassified and assigned to duty in the Services of Supply. It was soon apparent that there were cases coming to attention in which the only explanation of serious impairment of judgment, lack of self-control, or decrease in efficiency was
some form of mental disorder. In several instances the suicide of officers occurred after they had been reclassified, usually through demotion, by this board. Accordingly, a medical officer who had had nearly two years' experience in the study of war neuroses in British war hospitals and was at the time serving as division psychiatrist in the 1st Division, was assigned to this board, not as a member but as consultant in neuropsychiatry. He reported for duty in November, 1918, and continued his work until January, 1919. His reports showed that such a detail was well justified and he was able to bring to the attention of the board a considerable number of cases, some of them officers of high rank, in whom there were definite but quite unsuspected evidence of mental or nervous diseases. In not a few such instances the result of the board's investigation was the transfer of officers to neuropsychiatric hospitals and their evacuation to the United States for retirement or discharge on a surgeon's certificate of disability.
(1) Letter from The Adjutant General to the Surgeon General, January 12, 1918. Subject: Assignment of neurologists to tactical divisions. Copy on file, Historical Division, S. G. O.
(2) G. O. No. 81, H. A. E. F., December 24, 1917.
(3) Letter from the chief surgeon, A. E. F., to all division surgeons,
September 8, 1918.
(4) Outlines of Histories of Divisions, U. S. Army, 1917-1919, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College.
(5) Station lists for medical officers assigned to the neuropsychiatric service, A. E. F.
(6) Letter from the chief surgeon, A. E. F., to the Surgeon General, February 23, 1918. Subject: Hospitalization data. On file, Record Room, S. G. O., 322.3 (Med. Dept. Units, France).
(7) History of Base Hospital No. 66, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.
(8) Letter from the director of neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., February 27, 1918. Subject: Neuropsychiatric department, standard base hospital group. On file, Historical Division, S. G. O.
(9) Letter from the director of psychiatry, A. E. F., to the chief surgeon, A. E. F., February 10, 1918. Subject: Use of Camp Hospital No. 4 for treatment of war neuroses. Copy on file, Historical Division, S. G. O.
(10) History of Base Hospital No. 117, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.
(11) Letter from the senior consultant in neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., September 14, 1918. Subject: Second hospital for war neuroses. Copy on file, Historical Division, S. G. O.
(12) Weekly bed reports, chief surgeon's office, A. E. F. On file, Historical Division, S. G. O.
(13) History of Base Hospital No. 214, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.
(14) Monthly returns of the American Expeditionary Forces, made to The Adjutant General of the Army.
(15) History of Base Hospital No. 8, A. E. F., by Lieut. L. G. Payson, S. C. On file, Historical Division, S. G. O.
(16) Letter from the director of psychiatry, A. E. F., to the chief surgeon, A. E. F., February 1, 1918. Subject: Recommendations for the care of mental cases. Copy on file, Historical Division, S. G. O.
(17) History of Base Hospital No. 216, A. E. F., by the commanding officer of the hospital. On file, Historical Division, S. G. O.
(18) Letter from the senior consultant in neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., October 28, 1918. Subject: Provisions for mental cases at Savenay. Copy on file, Historical Division, S. G. O.
(19) Report of Medical Department activities, Base Section No. 5, A. E. F., undated, compiled under the direction of the base surgeon from official records in his office. On file, Historical Division, S. G. O.
(20) Report of special hospital provisions for mental and nervous cases in the Services of Supply, A. E. F., made by the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., October 26, 1918. Copy on file, Historical Division, S. G. O.
(21) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., November, 1918. Subject: Return of mental cases to the United States. Copy on file, Historical Division, S. G. O.
(22) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., November 28, 1918. Subject: Modification of plans for care of neuropsychiatric cases. Copy on file, Historical Division, S. G. O.
(23) Tables of Organization (Medical Department). On file, Record Room, S. G. O., 320.3-1 (Table Organ).
(24) Report of the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., for the period embracing the beginning and end of American participation in hostilities, December 31, 1918. On file, Historical Division, S. G. O.
(25) Correspondence. On file, Record Room, S. G. O., 353 (Training neuropsychiatrists).
(26) Letter from the senior consultant in neuropsychiatry, A. E. F., to the director of professional services, A. E. F., July 28, 1918. Subject: Approval of commanding officers for orders, neurologists and psychiatrists. Copy on file, Historical Division, S. G. O.
(27) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., June 18, 1918. Subject: Observation by Colonel Pearce Bailey, of neuropsychiatric work in France and England. Copy on file, Historical Division, S. G. O.
(28) Final report of the chief surgeon, First Army, November 20, 1918. On file, Historical Division, S. G. O.
(29) Report of the president of Disability Board No. 1, First Replacement Depot No. 1, St. Aignan-Noyers, December 31, 1918. On file, Historical Division, S. G. O.
(30) Letter from Maj. Sanger Brown, II, M. C., to the senior consultant in neuropsychiatry, A. E. F., July 8, 1918. Subject: Line of duty, disability board, neuropsychiatric cases. Copy on file, Historical Division, S. G. O.
(31) G. O. No. 131, G. H. Q., A. E. F., August 7, 1918.