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Section II, Chapter II

Table of Contents

CHAPTER II

DIVISION, CORPS, AND ARMY NEUROPSYCHIATRIC CONSULTANTS

In the earliest recommendations for combating war neuroses in the American Expeditionary Forces the greatest emphasis was placed upon the work carried on in the divisions. The experience of the French and British medical services showed, within a very few months after the beginning of the war, that patients with war neuroses improved more rapidly when treated in permanent hospitals near the front than at the base, better in casualty clearing stations and postes de chirurgie d'urgence than even at advanced base hospitals, and better still when encouragement, rest, persuasion, and suggestion could be given in a combat organization itself. It was for the purpose of applying this well-established fact that plans were made to station a medical officer with special training in psychiatry and neurology in each combat division, since the division was to be the great combat unit of the American Army in France. It was deemed impracticable to consider detailing a consultant in neuropsychiatry to a combat unit smaller than the division.

Corps and army consultants in neuropsychiatry ordinarily had merely organizing and supervisory functions. The actual neuropsychiatric work with combat organizations in the theater of operations was done by the division psychiatrist and such enlisted personnel as were assigned to assist him.

DIVISION PSYCHIATRISTS

Immediately after the authorization by the War Department of the assignment of specialists in nervous and mental diseases to tactical divisions, as detailed in Chapter I, p. 273, the chief surgeon, A. E. F., issued the following circular outlining the duties of these medical officers:

CIRCULAR No. 5-DUTIES OF MEDICAL OFFICERS DETAILED AS PSYCHIATRISTS IN ARMY DIVISIONS IN THE FIELD

  HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
  OFFICE OF THE CHIEF SURGEON,
France, January 15, 1918.

1. The following outline naturally does not indicate all the means by which medical officers detailed as psychiatrists in army divisions in the field can be of service in dealing with the difficult problems arising in the diagnosis and management of mental and nervous diseases among troops. These officers are under the direction of the chief surgeons of the divisions to which they are attached, and they must be prepared at all times to render such services as he may require. These officers are not members of division headquarters staff. They are attached to the sanitary train.

2. It is essential for such officers to bear in mind the prime necessity of preserving, or restoring for military duty, as many as possible of the officers and enlisted men who may be brought to their attention. On the other hand, they should recommend the evacuation, with the least practicable delay, of all persons likely to continue ineffective or to endanger the morale of the organizations of which they are a part. This is particularly true in the


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case of the functional nervous disorders loosely grouped under the term "shell shock" but more properly designated as war neuroses. Psychiatrists detailed to this duty have a unique opportunity of limiting the amount of ineffectiveness from this cause and of returning to the line many men who would become chronic nervous invalids if sent to the base. At the same time they can bring to the attention of other medical officers and company commanders individuals who possess constitutional mental defects of a type which make it certain that they will break down under stress.

3. Specific duties which may be performed by psychiatrists in army divisions are as follows:

(a) Examine all officers and men under observation or treatment for mental or nervous diseases in regimental infirmaries, field hospitals, camp infirmaries, and other places, and to advise regarding their diagnosis, management, and disposition.

(b) Examine other mental or nervous cases in the divisional areas when directed to by the chief surgeons or requested to by other medical officers or company commanders.

(c) Examine and give testimony regarding officers and men brought before courts-martial or under disciplinary restraint, when directed or requested by competent authority.

(d) Give informal clinical talks to groups of medical officers in the divisions to which they are attached upon the nature, diagnosis, and management of the mental and nervous disorders peculiar to troops.

(e) Keep careful records of all cases examined.

(f) Make such reports to the chief surgeons of divisions as they require and to make monthly reports of their operations to the director of psychiatry, bringing especially to his attention any matters likely to increase the efficiency of this part of the medical work of the American Expeditionary Forces.

  A. E. BRADLEY,
Brig. Gen., N. A., Chief Surgeon.

Approved:
  By command of General Pershing:
  J. G. HARBORD,
Chief of Staff.

The duties outlined in Circular No. 5 were amplified in certain respects, by Circular. No. 35,a as follows:

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 is 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.

During the spring of 1918, when the combat divisions of the American Expeditionary Forces were engaged in every type of preparation for battle, many procedures were tested among medical organizations which were to serve combat troops. In addition, the weeding-out of undesirable members of the organizations, the selection of those best fitted to perform special duties, and the circulation of useful information, all went on with the utmost vigor.

The reports of division psychiatrists, pertaining to this period, show many interesting and useful activities. In several instances the division psychiatrists not only performed work in their own field, but rendered useful service in practically every type of medical undertaking carried on in a division. Regarded at first, perhaps, as superfluous members of an organization designed primarily for combat, they won for themselves the favorable opinion of their superiors

aFor full text see p. 280.


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and demonstrated their capacity for usefulness. This had its value later when it became necessary for them to have greater responsibility in connection with the evacuation of sick and wounded, when the divisions to which they were attached were engaged in battle.

During the time under consideration, the 32d, 3d, and 77th Divisions arrived in France.1 Each was provided with a competent division psychiatrist who had served with the division in the training camp in the United States, directed the neuropsychiatric examination of the personnel and, in each instance, established excellent working arrangements not only with the other medical officers, but also the organization commanders of the division.2

The division psychiatrists of new divisions arriving in France were provided with Circular No. 5, chief surgeon's office, A. E. F., and informed of the general plans for neuropsychiatric work in the American Expeditionary Forces. Parts of eight other divisions arrived during May1 but too late to take part in the plan of training that had been employed for the first four and, in a modified way, for the others that had come in April.

There was available, by the end of May, 1918, a good deal of practical neuropsychiatric experience, for by this time practically all the neuropsychiatric problems of a division in action had been dealt with experimentally. In this experience it had been found that many difficulties arose unless the division psychiatrists scrutinized closely the flow of exhausted, concussed, and emotionally disturbed soldiers from the front and controlled, to a certain extent, their evacuation. Had there been time to do so, these experiences would have led to the establishment of methods certain to avert what happened a little later when a number of our divisions, unprepared by similar experience, were suddenly thrown into battle. No such opportunity came, however, for the military situation had become critical following the German offensive of March 21, 1918,3 and because of the pressing demand for troops for combat their training had to be considerably curtailed.4 Preparations for imminent battle conditions quickly replaced all other activities. The deficiencies in the organizations of the work of division psychiatrists were to be revealed by further experiences before they could be remedied.

In our earlier combat activities, our divisions served as a part of the French forces.3 With the plan of evacuation through American channels abandoned, while our divisions were serving with the French,5 and corps and army medical organizations were only partially effective, it was natural that a combat division should seek only to free itself of its sick and wounded in the quickest way. Experience already had shown the necessity for making separate provisions for gassed cases by designating a divisional field hospital as a gas hospital,6 but with the large number of casualties and the fairly rapid advance of troops, it did not seem possible to designate a field hospital to receive exhaustion, concussion, and neurotic cases, much less to set one aside for their exclusive use. It is not surprising, therefore, that many of our soldiers evacuated from the front during the early months of our participation in active warfare were neither wounded nor gassed, the majority of whom could have been returned to their divisions, had the opportunity been provided, after a few days of rest, encouragement, and psychotherapy.7 The subsequent careers of these men were


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determined by the hospitalization conditions that existed to the rear of the combat divisions rather than within them. In this connection it is appropriate to state here that, during the German advance in March and April, 1918, the French had lost all their evacuation hospitals, totaling approximately 45,000 beds.8 Behind the retiring lines of the French, with whom the American divisions were now fighting, there was insufficient hospitalization to care for the French wounded as well as American; therefore, it was necessary for us to take charge of the medical service to the rear of our divisions. Since the number of our evacuation hospitals at this time was far below the authorized quota, and as the sector originally selected for occupation by American troops was that facing Lorraine, about 160 miles to the east of Meaux, our stationary hospitals had been concentrated largely in that area and to its rear. In consequence, many hundreds of men suffering from exhaustion, concussion neurosis, fear, and other emotional states found themselves, within a few days after leaving their organizations, in hospitals a hundred miles or more away from the front. Very few of these men ever returned to active duty.

The value of these experiences lay chiefly in the demonstration of the fact that American divisions (even after a careful selection, with the elimination of many psychopathic, mentally defective, and unstable men) were capable of furnishing a large number of war neurotics under battle conditions, and that these patients were as resistant to treatment at points distant from the line as those in the armies of the French and British, upon whose experience our plan had been based.

Fortunately, there were some noteworthy activities that indicated marked progress. For example, during the Aisne operation, the division psychiatrist, 3d Division, effected the establishment of a field hospital for mental patients, and the return of a large proportion of his cases to their own organizations without the necessity of their leaving divisional control.9 During the Aisne-Marne operation, the division psychiatrist, 4th Division, by stationing himself in the triage, and having set aside a field hospital about 6 miles farther to the rear, was able to divert from the evacuation hospitals a large number of men suffering from conditions likely to result in war neuroses, and to return many of them to the front.10 In most of the other divisions engaged, however, it was found or thought to be impracticable for division psychiatrists to station themselves in triages. No effort was possible, therefore, to distinguish between exhaustion, concussion, fear, and neurosis, and the diagnosis "shell shock" was indiscriminately used when men seemed to be suffering from any of these conditions. The result was that such cases were evacuated to base territory.

Ten American divisions (the 35th, 82d, 33d, 27th, 4th, 28th, 80th, 30th, 77th, and 78th) were designated to operate at one time or another, with the British in northern France and in Belgium.1 There it was impracticable even to attempt to put into effect a plan which had been devised originally for an American sector. Patients suffering from psychoneuroses were evacuated from those divisions along British lines of evacuation and most of them reached England within a relatively short period of time. Here they were treated at first in special British hospitals for war neuroses, where American medical officers often took an important part in their management and, later, in American


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base hospitals in England where their treatment conformed to the principles that are described elsewhere in this volume. (See p. 398.)

The importance of more adequate medical organization to care for neuropsychiatric cases at the front was brought to the attention of the director of professional services, A. E. F., by the senior consultant in neuropsychiatry in the following letter, dated August 6, 1918:11

1. The recent severe fighting has resulted in a very large number of soldiers with war neuroses being evacuated to hospitals in the S. O. S. Base Hospital No. 117, on account of lack of provision, has been obliged to decline to receive cases by transfer from other base hospitals. Until the results of telegraphic inquiry recently sent out are known, it is impossible to say how many of these cases are in the hospitals of the S. O. S. The fact that no less than 350 were present a few days ago in the hospitals in Vittel and Contrexeville and 135 in Base Hospital No. 115 indicates that a considerable part of our hospitalization is devoted to their care.

2. Such a high incidence of these disorders after a brief period of active fighting gives some idea of the efforts that must be made in the A. E. F. if we are to deal with the problem of the war neuroses in an effective way and prevent serious wastage from this cause.

3. It is desired at this time to invite attention to only one phase of the problem-the urgency of affording divisional psychiatrists an opportunity to pass upon these cases whenever practicable before they are evacuated to the S. O. S. It has been reported to me that many of the cases received in base hospitals are not suffering from any kind of psychoneurosis or from the effects of concussion by high explosives. Many of them are cases of physical exhaustion who would have been entirely fit for duty after a short period of rest without hospitalization had their condition been recognized. Most of the cases, not a few of whom I have examined myself, express great surprise that they should be sent to hospitals and their chief desire is to join their organizations as soon as possible.

4. The importance of checking this source of wastage of man power can not be overestimated. I directed attention to it in a report rendered to the Surgeon General in July, 1917, and in many communications since that time. In division psychiatrists our Army has a most effective means of determining what cases shall be evacuated to the S. O. S. It is very unfortunate that services of these officers, many of whom were specifically trained for their duties in reference to this particular task and all of whom are fully aware of what must be done, are not utilized most effectively in the tactical divisions. I believe that every effort should be made, now that actual experience has demonstrated the validity of previous recommendations, to provide them with facilities for their work.

To meet the needs of specialists with divisions at the front, the chief surgeon A. E. F., sent to all division surgeons a communication concerning the duties of certain specialists, the sections of which that deal with neuropsychiatrists being given below, those dealing specifically with other specialists being omitted:

  AMERICAN EXPEDITIONARY FORCES,
France, September 8, 1918.

From: Chief Surgeon.
To: All Division Surgeons.
Subject: Psychiatrists, urologists, and orthopedists in tactical division.

There is apparently some misunderstanding among division surgeons relative to the duties and status of specialists assigned to divisional formations for duty.

During the recent activities one division surgeon assigned the psychiatrists to dressing the slightly wounded. While he was engaged at this work, several hundred cases of slight war neurosis were evacuated that would never have left their division if they had been examined by a trained psychiatrist.


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The above instance is cited to show the importance of properly utilizing the services of these trained specialists with a view in this instance of avoiding a repetition of the experiences during the recent activities when a total of nearly 4,000 cases of slight war neurosis were evacuated to base hospitals that should never have left their divisions.

I. GENERAL STATUS AND DUTIES

Orthopedists, urologists, and psychiatrists are attached to tactical divisions solely to aid in dealing with the medical and surgical problems of the divisions.

Their activities have two objects: (a) to keep the fighting strength of the division at the highest possible point, and (b) to bring about the prompt elimination from the division of those who become unfit for duty.

These three branches of medicine and surgery are represented because they are concerned with those diseases and injuries which experience shows contribute most to noneffectiveness of individual soldiers and troops in general.

The function of these specialists is to help the division surgeon in the clinical work of the division in much the same way that the sanitary inspector does in sanitation and the assistant to the division surgeon in administration. They should be attached to the office of the division surgeon as additional assistants. In no other way can they render most efficient service. Their permanent assignment to any subordinate sanitary formation of the division inevitably curtails their usefulness. In periods of stress, however, they should be stationed by division surgeons in the post in which they can work to the best advantage (e. g., orthopedists and psychiatrists in triages, the urologists in surgical hospital during combat).

They should not be regarded as consultants representing an organization outside divisional control but as integral parts of the division sanitary personnel, wholly concerned with the medical work of the division to which they are attached and directly under the supervision of the division surgeon.

Psychiatrists

Division in training or rest:

1. Elimination of insane, feeble-minded and epileptic (especially among replacements).
2. Mental examination of general prisoners in accordance with sections 11, G. O. 56, C. S.
3. Instruction of medical officers regarding diagnosis, early management, and prevention of war neuroses ("shell shock").

Division in combat:

1. Examination and sorting of officers and men returned to advanced sanitary posts for exhaustion, concussion by shell explosion, and war neuroses in order to control their evacuation.
2. Treatment of light cases of exhaustion, concussion, and war neuroses in divisional sanitary formations so as to preserve the greatest number possible for duty.
3. Mental examination of general prisoners and men suspected of having self-inflicted injuries.

  (Signed) M. W. IRELAND,
Major General, Medical Corps, Chief Surgeon.

When the American Expeditionary Forces plan for caring for psychiatric casualties had been definitely realized and was in actual operation the following circular letter from the office of the senior consultant in neuropsychiatry was issued under date of September 25, 1918 (section dealing with army neurological hospitals and supervision omitted).


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ARRANGEMENTS FOR CARE AND EVACUATION OF NERVOUS AND MENTAL CASES

I. DIVISIONS

1. Each division in the area has a division psychiatrist who will be stationed at the triage when his division is engaged. There he will sort all nervous cases, returning directly to their organizations those who should not be permitted to go to the rear and resting, warming, feeding, and treating others, particularly exhausted cases, if there is opportunity to do so. He will recommend all others for evacuation as follows:

(a) To a field hospital if all or part of one can be devoted to the care of cases likely to return to their organizations within two to five days.

(b) To Neurological Hospital No. 1 at Benoite Vaux or Neurological Hospital No. 3 at Nubécourt if a field hospital can not receive or care for such cases. Under these circumstances evacuations to the neurological hospitals will be direct; otherwise only cases unsuitable for or unimproved by treatment in a field hospital will be evacuated to them.

2. The advantages of these provisions for dealing with war neuroses and allied conditions in the divisions are:

(a) Control over the evacuation of cases presenting no psychoneurotic symptoms.

(b) Speedy restoration and return to their organizations of those in whom exhaustion is the chief or only factor.

(c) Cure of mild psychoneurotic cases by persuasion, rest, and treatment of special symptoms at a time when heightened suggestibility may be employed to advantage instead of being permitted to operate disadvantageously.

(d) Prevention or removal of hysterical symptoms (such as mutism, paralyses, etc.) so that, even if the patient has to be evacuated, his subsequent treatment will have been rendered easier and his recovery more prompt.

(e) Effective management of severe concussion cases during the first 24 hours, thus shortening their convalescence.

(f) Creating in the minds of troops generally the impression that the disorders grouped under the term "shell shock" are relatively simple and recoverable rather than complex and dangerous, as the indiscriminate evacuation of all nervous cases suggests.

The military organization for the care of war neuroses in the field had the merit of simplicity. No complex scheme could have succeeded. The division psychiatrist was stationed at the advanced field hospital, or triage, and his range of activity extended forward to the ambulance dressing stations and beyond as far as he cared to go and backward as far as the rear field hospital, which was the unit treatment center. The triage, or sorting station, was apt to be anywhere from 2 to 9 miles, or more, from the front line, and the treatment field hospital 4 to 7 miles farther removed. The former was usually an abandoned strong barn; and the latter, generally under canvas, capable of caring for about 150 patients in five or six large tents. At the treatment field hospital the division psychiatrist was generally able to count on one enlisted man, Medical Department (usually without any nursing knowledge), to care for each 15 patients. The necessary medical assistance at the treatment field hospital was rendered by ward officers who were without psychiatric training. In some divisions the authority, as to the management of neuropsychiatric cases, was practically absolute, or, at least, could be readily made so. The fact that the war neuroses presented such unusual problems to commanding officers of field hospitals, who were unfamiliar with their genesis, type and treatment, and who wished to have these problems solved, made it possible in some organizations for the psychiatrist to obtain all necessary cooperation. In other organizations, however, where the commanding officers were hostile to the retention of such cases at the front, the division psychiatrist worked under great handicaps.


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Thus, the work of the division psychiatrist was of such a nature that it required unusual skill in psychotherapy, courage, good nature, and sociability, which a few who were assigned to this work did not have.

An assistant divisional specialist would have proven a valuable adjunct. It is true that even with an active combat division there were times when there was scarcely enough work to keep the division psychiatrist occupied; yet these periods were succeeded by days or weeks of stress and strain in connection with some important military operation when the services of a trained assistant would have been invaluable. The small "pool" of neuropsychiatrists under the control of the corps or army consultant proved to be a useful means of meeting this need. The character of battle activity determined to some extent the number of psychiatric cases occurring in a division. Fighting which obliged men to remain expectantly in trenches or reserve positions under heavy bombardment for considerable periods of time produced many nervous and exhaustion cases. Open warfare, with the men in action and on the move, alert, and watching the enemy, produced fewer cases, although exhaustion was frequent. Artillery fire, with the weird whistling of the approaching shells, the terrific detonations, and the mutilations produced by exploding shells, unnerved many men. On the contrary, rifle and machine-gun fire were not important factors in the production of nervous disorders. In fact, there were practically no cases in which rifle or machine-gun fire was the upsetting factor.

The production of exhaustion cases followed days of constant fighting, with insufficient or no sleep, food, and water. The soldier always started into action with a full canteen and two days' reserve rations. He almost invariably kept his canteen, gun, and ammunition, but everything else in the way of equipment, including his rations, was cast aside as soon as it encumbered him. Consequently, not infrequently men were without food or water for several days at a time. The long-continued fighting, lack of rest and food, together with having to lie out in shell holes all night in the cold and rain, frequently overcame the most courageous of men. Then a shell exploding near them, knocking them over or possibly killing or wounding a comrade, was often the last straw.

A high percentage of men evacuated from the front line as "gassed" were really cases of fatigue, exhaustion, and emotional disturbance. It was necessary, therefore, that from this group the fatigued and exhausted be sorted out for treatment in one of the field hospitals. Of the medical cases reaching the triage the most common diagnoses were "bronchitis," "influenza," and "diarrhea." In many cases the most important factor was fatigue. These cases were also sorted out and retained for treatment in the divisional field hospital.

In the last group there were the neuroses with tremors, speech and hearing disorders, ataxias, and stupors. The severe cases were evacuated as promptly as possible to the army neurological hospitals, while the milder cases were retained treated, and returned to duty. The proportion retained was usually determined by the exigencies of the campaign.

True cases of concussion almost invariably asked not to be evacuated, as they desired to return promptly to their own organization. In the less severe cases this was done.


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Aside from the milder cases of exhaustion, sorted out from among the gassed and medical groups, the largest number of psychiatric cases was the exhausted with nervous symptoms. Men who were worn out, upon seeing their comrades killed or injured, and possibly being knocked over themselves by an exploding shell, lost their nerve, cried, shook all over and felt afraid, crouched and put up their arms as if to protect themselves each time they heard a shell coming or exploding. These responded promptly to treatment at the front.

The sick and wounded were tagged either by a medical officer or, as generally was the case, by enlisted men of the regimental sanitary detachments, indicating in a general way that the man was wounded, gassed, sick, or nervous. The sanitary personnel had all been instructed to use only the term "N. Y. D. (nervous)" for the latter group of cases. This was an important matter, as it was surprising to see with what tenacity men clung to a diagnosis of "shell shock" or "neurosis" even though the tag had been made out by one of the enlisted sanitary personnel. Sometimes soldiers would wander into dressing stations and cheerfully announce that they were "shell shocked." By using the term "N. Y. D. (nervous)" they had nothing definite to cling to and no suggestion had been given to assist them in formulating in their own minds their disorder into something which was generally recognized as incapacitating and as warranting treatment in a hospital, thus honorably releasing them from combat duty. The patients were therefore open to the explanations of the medical officers and to the suggestion that they were only tired and a little nervous, and that with a short rest they would be fit for duty again.

It is worth while in this connection, as an example of neuropsychiatric work at the front, to review briefly the military history of the work of the division psychiatrist of the 26th Division,12 and to observe how the curve of neurosis incidence followed the activities of the troops, rising during active campaign and falling again after comparative quiet had been restored. Obviously in times of severe strain the need for a medical assistant to the division psychiatrist was very real.

Between February 5 and 8, 1918, the division entered the line north of Soissons, in the famous Chemin des Dames sector, where we remained until March 21. Only about 18 psychopathic cases were evacuated during this time. The reason for this low incidence was that the sector was a comparatively quiet one, there was not much heavy shelling, the troops were fresh and eager, and we were brigaded with a veteran French division, thus relieving our own men of much anxiety and responsibility. Beginning April 1, 1918, we relieved the 1st Division in the "Boucq" sector, northwest of Toul.

The stay of the division in this sector was marked by several serious encounters with the enemy, where considerable forces were engaged. There were furthermore almost nightly encounters between patrols or ambush parties, and the fire of the artillery on both sides was very harassing. On April 10, 12, and 13 the lines were heavily attacked by the Germans. At first the enemy secured a foothold in some advanced trenches which were not strongly held, but sturdy counterattacks succeeded in driving him out with serious losses, and our line was entirely reestablished. Fifty-two cases resulted. April 20 and 21 the Germans made a second raid on our lines about and in the town of Seicheprey and Remieres Woods, supported by exceptionally severe artillery fire. Forty-three cases developed from this attack. A third raid was launched on June 16 at the village of Xivray-Marvoisin, but failed to get within our defenses. As if in retaliation for the decisive check the enemy had suffered, he delivered throughout the day exceedingly severe artillery fire on the battery positions and rear areas. Thirty-six cases followed the bombardment.


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On July 4 we relieved the 2d Division in the line just to the northwest of Chateau Thierry, taking over the hotly contested and hard-won line from Vaux-Bouresches-Bois de Belleau- to the vicinity of Bussiares. With no system of trenches or shelters, there was great exposure to enemy machine-gun and artillery fire; the woods and villages on the line were drenched with gas; a vigilant and aggressive enemy allowed no rest. The men were tired. They had been in the line almost continuously since February 4.

The great German drive southward between Compiegne and Rheims had reached the Marne River. For the moment it had been stopped, but a renewal of the attack was to be expected. The long-distance guns were dropping shells in Paris, 40-odd miles behind us; the Germans were desperate and promised to reach Paris at the next thrust. The morale of our troops was not topnotch and it was thought that many of them would break if anything serious occurred. These expectations were fulfilled a few days later.

On July 12 and 13 the enemy made a vigorous thrust at our positions in Vaux, but was beaten back with equal vigor. Seventy-one cases resulted. On July 18 the attack of the division, as part of the general operation to reduce the Chateau-Thierry salient, and thereby avert the threatened danger to Paris, was begun. The villages of Belleau, Torcy, and Givry were taken; Hill 193, behind Givry, was twice won, but had to be abandoned because the French on our left had not been able to make rapid enough progress to secure the position. Heavy opposition was encountered, the enemy employing many machine guns and well-placed artillery fire. Sixty-eight cases occurred on July 18 and 74 on July 19. On July 23, with thorough artillery preparation, the division attacked again, endeavoring to penetrate and clear up Trugny Wood, Epieds, and the woods behind it. Although stubbornly opposed and in spite of severe losses, our troops went forward steadily. Forty-nine cases developed.

On July 25 we were relieved. About September 5 we took over the "Rupt" sector. Until September 12 the sector remained quiet. On that date, however, began the great attack in force on the St. Mihiel salient by the American First Army. * * * The principal defense of the Germans was machine guns, well placed in concrete "pill boxes"; but there was very little artillery response. * * * Only 26 cases resulted, probably because of little artillery fire from the enemy.

On September 26, the division was given the mission of executing a heavy raid against the German positions at Marcheville and Riaville, as a diversion in the general attack of the American First Army, which was to start on that date on the whole Meuse-Argonne front. Similar raids were to be executed by the other divisions of the corps at the same hour, the orders being to penetrate the enemy lines, make prisoners, and occupy the position throughout the day, withdrawing under cover of darkness. Heavy enemy resistance and counterattack resulted in six cases of acute mental disturbance.

Shortly afterward we concentrated in and near Verdun. On October 16 we took part in an attack for the purpose of obtaining possession of the Bois d'Haumont, supported by tanks. The tanks failed utterly and heavy casualties resulted. Twenty-one cases resulted.

During our stay in this (Neptune sector) conditions were very severe. Influenza was prevalent; the rain was almost continuous; shelter was insufficient. The enemy occupied positions of great natural strength, and was backed by a numerous artillery.

He valued these positions highly and hung on with bulldog tenacity. Gas was constantly thrown into the valleys and harassing artillery fire was heavy. Attacks were made daily from October 23 to 27 inclusive, in conjunction with the 29th Division against the Rylon d'Etrayes-Bois Belleau-Hill 360 positions, which won for us a considerable advance, in spite of our heavy losses. Thirty-five cases occurred. The next few days passed without any action save vigorous and successful patrolling to make prisoners.

On November 7, with its general axis of advances changed from east to southeast, the division executed a second attack on a wide front toward the Jumelles d'Orne beyond the Chamont-Flabas line. The attack was renewed daily up to and including November 11. Finally, at 11 o'clock, the cessation of hostilities brought the active operations of the division to a conclusion.


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EMERGENCY TREATMENT AT THE FRONT

Stationed, as the division neuropsychiatrists were, in combat areas, all their work being confined to field hospitals, where patients were held only from 3 to 10 days, depending upon military operations, the experience of these officers with the treatment and final outcome of the cases was limited chiefly to the milder forms of the neuroses. The more obstinate and chronic cases, of necessity, were evacuated to the rear areas.

To the treatment hospital at the front the neuropsychiatric patient was sent after he had taken the first important step on the road to recovery. At least no one was sent there until a determined effort had been made to convince him that he could be cured. Of course, there was necessarily a constant and fairly large residuum of refractory cases, but these were not permitted to negative the atmosphere of optimism which existed. Although situated in the field within the range of artillery fire, and subject to the military necessity of moving at an hour's notice, it was still possible to approximate suitable hospital conditions. The first difficulty which presented was the lack of nurses. The group of enlisted men who were selected had in the beginning nothing more than the doubtful merit of curiosity concerning the "shell-shocked" soldiers. Until it was possible to inculcate a certain degree of nursing morale it was necessary to deal with them from the point of view of military discipline. Certain orders were given, and failure to obey them was considered a punishable infraction of a military command. The few simple rules and suggestions utilized at first (in one division) are here quoted:

RULES FOR PSYCHONEUROSIS WARDS

1. Each patient on admission to have a hot drink.
2. Each patient to have three full meals a day unless otherwise ordered.
3. Do not discuss the symptoms with the patient.
4. Be firm and optimistic in all your dealings with these patients.
5. No one is permitted in these wards unless assigned for duty.
6. The rapid cure of these patients depends on food, sleep, exercise, and the hopeful attitude of those who come in contact with them.

From such an elementary beginning there gradually developed among the enlisted men, who acted as nurses, a high degree of interest and efficiency and a generalized and successful effort to intelligently maintain certain therapeutic principles without which success would not have been possible.

Classification was an important function of this hospital. Generally speaking there was an effort to keep the mild cases in one tent, the more severe in another, the physical problems separate, and the recovered awaiting return to the front apart from the others. Soldiers with obstinate symptoms were segregated.

The physical needs of the patients were constantly borne in mind. Hot, abundant meals were provided; exercise, amusements, and work were utilized, not haphazard fashion, but with a certain object in mind.

One finds in current reports on the therapy of war neuroses indefinite allusions to an intangible and mysterious therapeutic influence termed "atmosphere." By this is meant, presumably, the general feeling and understanding which existed among all those who came into medical contact with the war neu-


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roses, and which sought to provide an urge or incentive for the soldier to return to his duty on the firing line. This was necessarily developed at every point in the American Expeditionary Forces where nervous and mental casualties were grouped for treatment. However, it should not have been permitted to remain at a vague and undefined stage, nor should its growth and direction have been left to mere chance. As a matter of fact, it was a thing which could be deliberately created and shaped into a definite and valuable therapeutic agent. As employed in the type of hospitals under consideration, it was separated roughly into positive and negative elements, the first being concerned with the advantages of returning to the front, and the second with the disadvantages of evacuation to the rear. Constantly, and in every conceivable fashion, were emphasized the glory and traditions of the division, of the regiment, and of the company, and the very important part which each soldier played in contributing his share. Further, the personal relation which so frequently existed between officer and soldier was in a sense filial, just as the intimate feeling between man and man was fraternal. In the field with combat troops, where close association under dangerous conditions made for the relaxation of certain features of rigid military discipline, such as ordinarily obtains in a cantonment, or camp, and also erased social barriers, it is exceedingly probable that what might be termed an artificial familial instinct was often developed and replaced in a measure the one of which the individual was at least temporarily deprived. This factor, too, could be utilized as a powerful means for obtaining a healthy therapeutic atmosphere.

On the other hand, evacuation to the rear was painted in gloomy colors. The patients came to realize that leaving the division, or unit, meant probably the opportunity forever lost of having a part in its present victories and consequently in future honors and rewards. It involved a total separation from the paternal officer and brother soldier, and finally becoming that most unhappy of mortals, a lone casual. It was in a sense a desertion, since it left comrades to "carry on" alone. It would be impossible to enumerate all the methods employed to foster and stimulate such impressions. The following sample will serve: Informal talks to groups of soldiers, the announcing and publishing of bulletins recounting the gallant advance of this or that unit, or the exploits of some well-known officer, or soldier, of the division, the reading and discussing of citations which had been received, rumors of a big offensive which was imminent, or of a well-earned rest which soon would be officially ordered, and the relating of incidents and episodes, "gossip" with a personal flavor which had come back by word of mouth from the front. No incidental opportunity was neglected. For instance, during the Meuse-Argonne operation, columns of German prisoners frequently passed the tents. The patients were urged to view the procession, always a stirring event, which often succeeded in evoking an exhibition of satisfaction and even patriotic fervor. It is doubtful whether anyone who has not been an actual witness can appreciate the value of even such simple measures. The whole plan was far from being an uncertain proposition which could be expected to appear and act spontaneously, but was based on an estimate of what emotions and feelings were to be activated and what degree of stimulation was needed to gain the desired object.


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It is difficult to understand why such a personal and concrete thing as the attitude of the psychiatrist toward each of his patients had to be is so often described in such general terms. It was by far the most important feature of practically any form of treatment. Taking its cue chiefly from personality and intellectual capacity, it had to be rapidly defined in the mind of the physician so as to meet the needs of the individual under consideration. Further, frequently it had to be varied from time to time in the same case. It affected every phase of treatment, often dictating the mode in which specific symptoms were removed, modifying the explanation of the neurosis and governing the methods utilized in the final rehabilitation of the soldier before his return to the front.

The particular methods of treatment utilized may be roughly divided into those which were applied to all the patients, or to fairly large groups, and those which had an individual application. The former is largely dependent for its effect on the creation and maintenance of the right kind of military atmosphere, which seeks to produce and encourage a desire to return to the front. In this respect the following observations may be of interest: A certain type of soldier, often of a moderately high intellectual grade, not infrequently presented a curious psychological paradox as the time for his return to the front approached. He had made a good symptomatic recovery, had a considerable degree of insight into the mechanism of his neurosis, may have expressed a wish to go back to his regiment, and yet found a marked difficulty in taking the final step. This was not due to the fact that he was distinctly unwilling to return to duty, for he would have been as much or even more troubled by a decision which would have evacuated him to the rear. Apparently, there was in these cases a temporary volitional paresis. This condition was observed in a small percentage of all the neuroses. Experiments along the lines of logical reasoning and appeal to the individual had little result, and it was decided to try the effect of another plan. When a sufficiently large group had been collected, they were gathered together in a tent and given an informal talk, which was little more than an effort to reach and sway the emotions. Beginning with a recital of the situation at the front with reference to the division, and particularly to the various units which were represented by the soldiers present, it emphasized the acute need for every available man, and the fact that comrades were suffering because of their absence, and finally came to a climax by a dramatic request for volunteers for immediate service. The result was always highly gratifying, and the spontaneous enthusiasm showed that these men were actuated by something more than mere deference to the wishes of an officer. In another group of patients who had made a fairly good symptomatic recovery, or who persistently retained a few insignificant symptoms, the question of volitionally withheld cooperation arose. Two courses were open. The power of the military machine might be invoked to force action, reducing the matter to a choice between front line duty or court-martial. Such a procedure was not employed. Its permanent value is not only questionable, but it is open to objections on ethical grounds. However, it had to be recognized that the problem was no longer strictly a medical one. Without using undue severity and with no trace of malice, such men soon found that an invisible barrier had


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been erected between them and the other patients. They were denied certain privileges and had to do most of the distasteful work, such as policing the grounds, digging latrines, etc. No one was permitted to impugn their motives, yet on every side they were confronted by a questioning attitude. Always the opportunity was afforded, and was indirectly encouraged, to talk over the situation with one of the physicians; always there was the invitation and the temptation to change their status to a happier and more honorable one. About 90 per cent of this group were eventually reached by such a simple method.

For the attack on individual symptoms resort was had to various forms of suggestion which have been described in detail by various authors. Whenever there was a choice between two methods, the simpler was always preferred. Complicated procedures seemed unnecessary. Often nothing more elaborate than passive relaxation of flexion and tension plus appropriate suggestion was needed to remove tremors; indeed, many of them disappeared spontaneously. If a paralysis responded at all to passive movement which gradually became active by the imperceptible withdrawal of the assisting hands of the physician, electricity was not employed. If an hysterical deprivation could be reached by suggestive persuasion or argument, such "tricks" by means of the stethoscope, tongue depressor, mirror, etc., as were in vogue were avoided. There were, of course, times when a degree of mystification was necessary, but it was never the first resort and was usually reserved for more refractory symptoms. Hypnotism was never used. As a preliminary to the consideration of the individual symptoms, there was an estimate of how much of the symptom was real and how much was only apparent. A change of position to one making for greater physical comfort, the removal of constricting clothing or of an external source of irritation, a hot drink, and a reassuring word or two were sometimes in themselves sufficient to decrease materially the range of tremors, to improve an exaggerated posture or movement, or to reveal a seeming paralysis as only a paresis. The amount of amnesia, particularly, always appeared greater than it really was. Before any intensive attempt was made to treat it as a symptom its extent was carefully gauged. A simple and brief series of questions and answers often strikingly diminished its proportions. The selection of a route to gain access to any sign or symptom which presented in a patient was much influenced by the attitude which the psychiatrist had decided on as best suited to meet his needs as an individual.

When more refractory symptoms were to be dealt with, that which seemed the most obvious thing to do was attempted first. Strict segregation had a wholesome effect on obstinate tremors or convulsive movements. Every advantage was taken of possible modifications of classification. A patient with a persistent difficulty would be placed for a short time in the midst of a small group of recovered soldiers awaiting transportation to the front. Occasionally some one who had made a particularly striking recovery was kept for a few days as a sort of hospital "pet" for the sake of the effect on difficult cases. He was taken into the confidence of the psychiatrist and instructed as to what was expected of him. Now and then a "chronic" patient was made to observe the removal of some symptom in a recent case. Sometimes the physician planned to have his conversation and opinions overheard by this or that


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individual. At times, when dealing with troublesome symptoms, it seemed advantageous, after the soldier's curiosity had been aroused, to postpone the final seance a number of times. A few elaborate consultations were staged wholly for their psychic effect. Such instances as the above might be endlessly multiplied; they merely served to intensify suggestion and were therefore useful.

The employment of simple procedures had several advantages. They needed no elaborate paraphernalia and did not demand lengthy preparation. In the field space and time had to be carefully conserved. Further, it must be remembered that the patients, as they came to the triage, were like closed books. The soldier himself was frequently the only source of information available, and consequently there were many gaps in the history. When dealing with an individual whose potentialities were largely unknown it seemed the part of wisdom to restrict oneself, if possible, to things which could do no harm. Some of the more complex forms of technique depend largely for their suggestive value on the veil of mystery which surrounds them. Unless absolutely necessary, in some unusual instances, their exhibition ought to be avoided. They are apt to prove embarrassing when the time comes to give the patient the explanation of his neurosis, when, of all times, the physician needs to be sure of his ground. This explanation, too, must be as simple as possible. However high the educative and intellectual standard of the enlisted men in our Army might have been, it did not reach the point where an involved discussion of psychopathological mechanism could be appreciated. Even primary ideas and illustrations had to be used with caution, and the test of their efficacy rested on whether they were easily comprehended by the patient and satisfied his needs.

Of 400 war neuroses, embracing all types and occurring in different operations at the front, approximately 65 per cent were returned to front line duty after an average treatment period of four days. During the second half of the Meuse-Argonne operation, the recovery rate amounted to about 75 per cent; earlier, along the Ourcq, it had dropped to as low as 40 per cent. This fluctuation was governed by military necessity. In other words, there were four separate hospital-evacuation orders which affected about 70 patients who had had less than 36 hours' treatment. It is reasonable to assume that at least one-half of this number would have recovered if it had been possible to retain them 48 hours longer. After the armistice was signed an effort was made to determine the number of times a second attack had appeared. Only nine recurrences were found-less than 4 per cent of the total returned to duty. It is possible, of course, that a few cases may have passed through the triages of other divisions. However, these would necessarily have been restricted to troops on the flanks of the line and their number therefore could not have been significant.

The recovery rate was influenced by certain factors. From the type of symptom presenting one could often predict the ease or difficulty which would attend its removal. Generally speaking, symptoms which occurred in conditions where there had been a definite trauma, or emotional insult succeeded by a stage of relaxed consciousness, responded readily. They were frequently of


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a hysterical variety. On the other hand, those which belonged to states which had been evolved in the plane of consciousness were not so accessible. They were apt to have a neurasthenic or psychasthenic coloring. Anxiety symptoms of various kinds presented the knottiest problems, and a relatively high percentage of these had to be evacuated to the rear.

When time is necessarily limited the rapidity with which contact can be established between patient and physician is an important consideration. The degree of inaccessibility in the make-up of the soldier will be reflected in the therapeutic failures recorded in the field. The responsibilities of the psychiatrist were clear. He had to return as many men as possible to duty, and during times of great activity it was not always feasible to give each patient the full amount of attention his condition deserved. In this way, and at these times, the individual whose personality involved careful and extended study in order that his neurosis might be reached, sometimes had to be neglected as a matter of military economy.

The intellectual status of the patient was not without its effect. The relatively ignorant soldier was usually softer clay in the physician's hands than was the one in whom learning and training had sharpened the habit of questioning, scrutinizing, and weighing in the balance. Of course, these two of ten developed different types of neuroses, but, given the same condition in both, the former could be handled with far greater rapidity and more surety of success.

Finally, the recovery rate fluctuated in response to extraneous and wholly accidental factors. It was appreciably higher at periods when the division was about to be relieved, and it was lowered at the beginning of what promised to be a long campaign. During the three or four weeks preceding the armistice, when victory followed victory on every front and definite success seemed assured, it reached its apex. The psychological effect of such incidental happenings, of course, was complex; but in general they lessened the activity and the need of close surveillance on the part of the preservative instinct by the intrusion of new and attractive possibilities; the anticipation of rest and pleasure in different surroundings under safe conditions in the former instance, and in the latter the prospect of an early return to the United States as a member of a victorious fighting division, and a resumption of all those pleasant relations from which the soldier had been cut off by the war.

A statement of experiences with the war neuroses would be incomplete without some reference to gas hysteria and its treatment. A striking instance occurred during the Aisne-Marne operation, when the 3d Division was in the neighborhood of the Vesle River. One morning a large number of soldiers were returned to the field hospital diagnosed as gas casualties. The influx continued for about eight days, and the number of patients reached about 500. The divisional gas officer failed to find any clinical evidence of gas inhalation or burning, and the psychiatrist was given an opportunity to act as consultant. The patients presented only a few vague symptoms. There were, perhaps, four or five instances of aphonia, but in the average case the symptoms presented were a feeling of fatigue, pain in the chest, slight dyspnea, coughing, husky voice, an assortment of subjective sensations referred to the throat, varying from slight tingling to severe burning, and some indefinite eye symp-


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toms. Physical and neurological examination was practically negative, and the mental findings were inconclusive; if anything there was an undercurrent of mild exhilaration. Most of the patients had the fixed conviction that they had been gassed and would usually describe all the details with convincing earnestness and generally with some dramatic quality of expression. Careful inquiry elicited the information that these soldiers came from areas in which there was some desultory gas shelling, which, however, never reached serious proportions. The amount of dilution was practically always great enough to provide an adequate margin of safety. It was further developed that these conditions were always initiated in about the same way. Either following the explosion of a gas shell, or even without this preliminary, a soldier would give the alarm of "gas" to those in his vicinity. They would use their masks, but in the course of a few hours a large percentage of this group would begin to drift into the dressing stations, complaining of indefinite symptoms. It was obvious on examination that they were not really gassed. Further, it was inconceivable that they should be malingerers. They came from battle-tested troops, veterans of the severe action on the Marne and the early hard fighting in the Aisne region. It is exceedingly probable that a number of factors which existed at that time acted together with the general effect of lowering morale and reducing inhibition to a state where any suitable extraneous opportunity was apt to be utilized by many as a route to escape from an undesirable situation. It differed from the manifestation of the personal preservative instinct in that it was in a sense a mass reaction and a subconscious rejection of a situation which, although decidedly uncomfortable, yet was not sharply threatening from the standpoint of physical danger. The troops were more or less inactive, practically merely holding a position, and the small amount of activity which occurred was more irksome and irritating than highly dangerous. Following on the heels of the advance at Chateau Thierry and the first rush in the Aisne region it was comparatively monotonous and lacked all those stirring and dramatic qualities which even in modern warfare attend more important military operations. Further, instead of a definite, easily understood objective such as they had been accustomed to, the minor activity which was not taking place seemed to the soldiers indefinite, uncertain, and apparently not aimed at a clear-cut objective. Again, too, for some time there had been a wide-spread feeling that the division was soon to be relieved and given a well-earned rest. When the day came on which the order for relief was expected, and word arrived that it was to be indefinitely postponed, the feeling of expectation and optimism gave way to disappointment and dissatisfaction. The relative inactivity gave abundant opportunity for endless thought and discussion among the men by which the mental unrest and uncertainty was rapidly disseminated and intensified. Finally the troops were beginning to feel the physical strain of four weeks' exertion under the most exposed and trying conditions. When these factors, no one of which was sufficiently strong to act alone, accumulated and combined they were evidently powerful enough to produce a wholesale effect.

The problem demanded immediate and energetic attention. It was obviously impossible to deal with each patient from the personal angle and give him extended individual attention. The drain on man power was being felt, and


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there was a request from military superiors asking that these men be returned to the line as quickly as possible. Each man on admission was examined, assured that his symptoms were not serious, and given some simple suggestive treatment followed by hot food and a brief rest. Some hours later he was again examined, encouraged to feel that the treatment had had the desired effect, complimented on his improvement, reassured about his condition, and convincingly told that he would be able to return to duty on a certain day at some specified hour. From this point on symptoms were practically ignored. The patient now passed to a second tent where the conditions were rigidly military. Soldiers were usually required to wear their uniforms, and to observe all military courtesies, and they were under strict discipline. There was a round of duties to be performed under the supervision of a noncommissioned officer. In short, the hospital lacked about the only desirable features which were to be found at the front, namely, a relaxation of certain elements of military rule and routine duty. The method was successful. Only an occasional case proved refractory and required more intensive action. The basic idea was an attempt to impress on the patient's conscious mind that his ailment was not serious, and on his subconscious mind that the situation in which he now found himself probably offered no greater advantages over the one which he had recently left. No harshness was permitted, but no opportunity was given to lose contact with the life, duties, and responsibilities of a soldier. The wave of gas "hysteria," as the line officers insisted on designating it, receded from day to day, and ceased spontaneously at the end of eight or nine days.

When hostilities ceased, there was some doubt as to whether the services rendered by division psychiatrists were sufficiently valuable to justify their retention in the divisions. In the army of occupation, where there was a possibility that divisions might again be engaged in combat or at least be liable to a long period of service on foreign soil, no such question was raised. The other divisions, however, went back into areas previously used for training, and as rapidly as possible were sent to various concentration centers in preparation for their return to the United States.

During this period of waiting for return to the United States a great many policies which were considered of importance during the period of combat were reversed. For instance, it was unwise to conduct too vigorous a search for mentally defective psychopathic individuals in organizations about to return to the United States, as their discharge from the Army in any case was only to be a matter of several weeks. The mentally sick, of course, were sent, as before the armistice, to Base Hospital No. 214, at Savenay, for return to home territory, there to be hospitalized further or discharged from the service on surgeon's certificate of disability. The war neuroses had ceased to be a problem.

CORPS NEUROPSYCHIATRIC CONSULTANTS

As soon as the medical service of the corps became sufficiently well organized to require the services of corps consultants in psychiatry these were appointed. These consultants proved a valuable addition to the work of dealing with war neuroses in advanced formations. As it was impossible for a division psychiatrist to care for all the cases coming under his observation under condi-


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tions of unusual stress, it was found feasible to attach to the corps, as temporary assistants to the corps consultant in psychiatry, additional medical officers with neuropsychiatric training. These he could dispose of as exigencies required, and in several instances an unusual flow of exhausted, frightened, and nervous men from the front was checked in triages by the extra officers who were available on this account to examine them and make recommendations as to treatment or other disposition. The corps consultant in psychiatry served an extremely useful purpose and his presence helped to insure the carrying out of a definite policy with reference to the care and evacuation of neuropsychiatric patients during combat. During quiet periods his services were likely to be fully occupied in working out a better organization for the next period of activity, helping in dealing with the medico-legal situations, questions of morale, and psychiatric problems which arose among troops themselves.

The following report of the consultant to the First Army Corps, dated November 25, 1918, covers a period commencing in July, 1918, and ending with November 11, 1918:13

FIRST ARMY CORPS

When the consultant in neuropsychiatry joined the First Army Corps in the latter part of July, 1918, its territory embraced all the area of combat in the Chateau Thierry sector. Two divisions were at that time on the front line-the 28th and 42d. Shortly afterwards the Third Army Corps was organized and part of the sector placed under their command.

There were no precedents to help or hinder, but the needs of the situation were obvious. A series of divisions were coming into the corps, taking up front-line positions, after a time withdrawn and replaced by others. Each division had its psychiatrist. Some of them had been with the division for a considerable period and had their duties well in hand and adequate opportunity to carry them out. In other instances, the work was not well organized and the psychiatrist was called upon to spend his time in doing duties that might be carried on by other medical officers while the duties that only he could perform most satisfactorily were left in abeyance. This all depended on the conception held by the division surgeon of the usefulness and responsibilities of the divisional neuropsychiatrist.

The chief surgeon of the corps held a high opinion of the importance of the work of the neuropsychiatrist, and always insisted that they be given every opportunity to do their work. A fine group of men like these officers needed only the opportunity in order to make themselves most useful. The corps consultant found, therefore, as his chief duty during the period of advance, frequent visiting of the divisions, surveying of the lines of evacuation, and the points at which the psychiatrist could work most effectively, and advice and encouragement to them as various problems came up. Owing to difficulties in getting about over the country, this apparently simple duty required a great amount of time, and until individual means of transportation were available it was frequently impossible to function with even normal speed.

In the St. Mihiel and Meuse-Argonne operations the First Army Corps was given three neuropsychiatrists, who might be moved from unit to unit as one division was replaced by another. It was excellent experience for men who were to become division neuropsychiatrists. Since they were always in active divisions, it tested admirably their ability to stand a long period of stressful activity. It also gave them the benefit of working with several more experienced officers in succession. At times these extra men worked with the division psychiatrist at the triage. In other instances a division might maintain two triages, and then the two officers divided these triages between them. In periods when the corps was not engaged in active combat these officers were withdrawn from the division and assigned to other duties.

The Army corps comprises a number of organizations aside from the divisions. It was highly important that these troops should be known to the corps neuropsychiatrist and that the medical officers and commanders of these troops should know where they could obtain


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help on neuropsychiatric problems. This matter was dramatically illustrated by the case of the 53d Pioneers, an organization comprising a huge number of men unfit for military duties, a considerable number of them because of mental defect. Whenever time permitted, the corps neuropsychiatrist or one of his extra officers devoted some time to examining men in these organizations.

The First Army Corps developed in the Meuse-Argonne operation an institution known as the rest camp. The purpose of this was to take care of men who did not need actual hospitalization but were in need of a period of rest. In such a place there were always patients with mental problems. It is believed that a medical officer with neuropsychiatric training would be of great service in a rest camp. For a few days only was it possible to make such an arrangement, because of the exigencies of the service in the division.

A difficulty encountered was in the matter of evacuating the psychoneurotic patients in the right direction. During active hostilities it is quite impossible to control this matter to one's entire satisfaction, unless the so-called neurological hospital is near a group of hospitals so that ambulances are discharging all patients from a certain area at points from which they may be distributed. However, by following the matter as frequently as possible, we probably got a larger number of psychoneurotic patients into Army Neurological Hospital No. 3 than would have gone there otherwise. Attention was given also to the problem of getting back patients from the neurological hospital for active duty as soon as possible.

The work of the corps neuropsychiatrist was certainly no more taxing than that of the division officers, and probably less so. There were many satisfactions connected with it. It was often possible to give material assistance to the work of division consultants. If the campaign had lasted longer, it would have been possible to hold a larger proportion of neurotic cases in the rest camp, in division field hospitals, and in the field hospital of the Army corps; so that evacuations to the S. O. S. would have been fewer.

ARMY NEUROPSYCHIATRIC CONSULTANTS

Shortly after the organization of the American First Army, on August 10, 1918,14 it was decided that the Army surgeon should have consultants, including one for neuropsychiatry, but no such assignment was made until October 19, 1918, when the corps consultant for the Third and Fifth Corps was appointed consultant in neuropsychiatry, First Army. On the same day, a consultant in neuropsychiatry was appointed for the Second Army. After the armistice was signed, a consultant was appointed for the Third Army.

Army consultants in neuropsychiatry served too short a time to make available many records of their experiences, but the following summary of the conclusions reached as to the services that can be performed by such a medical officer in a field army is of interest. It represents the joint views of the two officers who served in this capacity in the American Expeditionary Forces:a

THE WORK OF AN ARMY CONSULTANT IN NEUROPSYCHIATRY

The army consultant needs some executive ability and preferably a considerable executive experience. His work is no more taxing than that of the consultant in the division or Army corps, but since the projects with which he deals are more numerous and more varied, considerable training in hospital and organization activities will not come amiss.

There are in the army a number of well-organized units-the divisions-each with a consultant. The army consultant during active operations had to visit these divisions from time to time and to ascertain whether the division psychiatrist had opportunity to function to the best of his ability and whether he was provided with the information that he needed in order to fulfill his duties. The hospital and other facilities that were afforded him, the

aLieut. Col. E. G. Zabriskie, M. C., was appointed consultant in neuropsychiatry, First Army, Oct. 19, 1918; Lieut. Col. John H. W. Rhein, M. C., was appointed consultant in neuropsychiatry, Second Army, on the same date.-Ed.


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obstacles, if any, to his handling of such cases as can be properly treated in the division hospitals, the direct evacuation to the most favorable point of those who must leave the organization, were problems that required attention. Division psychiatrists sometimes have to leave their organizations for adequate reasons, and it is imperative for the army psychiatrist to obtain early information of such changes in order to provide substitutes to fill such vacancies.

If in the army there was an army corps that had a consultant in neuropsychiatry, the relation of the army consultant to him was somewhat similar to that with the division psychiatrist. During active operations a very useful arrangement was found to be the placing of some additional psychiatrists in the army corps. These men could be sent from division to division and located at other strategic points in the corps organization according to the need for them in order that all troops might be able to receive the attention of a psychiatrist. Furthermore, these men were trained in this way for taking posts of independent responsibility themselves later.

The army consultant bore direct responsibility for psychiatric matters in troops that are not included in divisions. This was often a taxing and time-consuming duty, for such troops whether attached to the corps or to the army were scattered and not always easy to locate. Until the acquaintance of their regimental surgeons has once been made, such troops may be sadly neglected, allowing conditions to arise that present a very important element of danger. This may be the case in any branch of medicine. Men have been found in critical military positions suffering from advanced pulmonary tuberculosis, having grave deformities, or serious cardiac disease. Failure by them to carry out military duties might be precipitated by no fault of the man but with considerable embarrassment to his comrades. Likewise, in the mental field, feeble-minded men, unable to tell the right hand from the left, have been intrusted with rifles and put on guard duty, endangering their whole organization through their inability to understand and carry out commands. These situations were quickly relieved by the attention of a medical officer with some knowledge of mental disorders. Furthermore, there were many prisoners to be examined, and this duty fell to the army psychiatrist, except in so far as he could arrange through the chief surgeon to bring the cases to the attention of division or corps psychiatrists.

To the army consultant falls the duty of seeing that prisons are surveyed occasionally, and also the duty of examining general courts-martial prisoners or arranging for their examination by psychiatrists who happen to be located in the neighborhood. Arrangement ought to be made by which a report of the name and location of all such prisoners will be sent to the chief surgeon of the army. These lists will then receive the attention of the army consultant in neuropsychiatry.

Another set of important duties and responsibilities had to be with the hospital organizations of the army. At convenient points neuropsychiatric units were established. Without these the psychiatric problems and in many instances organic neurological problems would not have received the attention that they deserved. Convenient buildings and satisfactory equipment were of some importance, but of far greater importance was trained personnel. Experienced medical officers and enlisted men can convert almost any type of building into a place suitable for the handling of mental problems. Two tendencies had to be combatted: (1) the tendency through lack of understanding to minimize the importance of these organizations and, therefore, not to transfer to them the patients with mental difficulties; and (2) the tendency to take away from these units the very capable personnel and assign them to other duties, important perhaps, but as readily performed by others without special training in neuropsychiatry. Fortunately, when these units were once established there was no question about their continuance or their usefulness. Their value became apparent to the whole medical organization and to the judge advocate's department and the General Staff. It is nevertheless necessary for the army consultant to make rather frequent visits to these hospital units and ascertain if they are permitted and encouraged to function at their highest point of efficiency.

The army consultant had important functions in connection with the problem of evacuation. He had to be on the watch to see that the patients who by temporary treatment could


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soon be returned to duty, were not sent to hospitals at such distant points that return to their organizations would be delayed and the patients' symptoms become fixed through improper handling. This matter was largely one of routes of ambulance evacuation. He had to know about the routing of hospital trains in order to arrange suitable times for the evacuation of patients by the carload or more to neuropsychiatric centers at points distant from the army area. Unless this was done, considerable numbers of neuropsychiatric patients were unloaded in hospital centers that were not equipped to provide for them. This caused much loss of time and delay in the hospital service itself.

REFERENCES

(1) 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.

(2) Reports of Medical Department activities of the 32d, 3d, and 77th Divisions, prepared under the direction of the division surgeon concerned. On file, Historical Division, S. G. O.

(3) Final Report of Gen. John J. Pershing, commander in chief, A. E. F.

(4) Report of the assistant chief of staff, G-5, G. H. Q., A. E. F., on the operations of G-5, made to the chief of staff, A. E. F., June 30, 1919. On file, General Headquarters, A. E. F., Washington, D. C.

(5) 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.

(6) Report of the Medical Department activities, 1st Division, 1917-18, prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. O.

(7) Letter from the senior consultant in neuropsychiatry, A. E. F., to the director of professional services, A. E. F., August 6, 1918. Subject: Preventing evacuation of cases of war neuroses. Copy on file, Historical Division, S. G. O.

(8) Report of the Medical Department activities of the 3d Division, A. E. F., prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. O.

(9) Report of the neuropsychiatric activities of the 3d Division for the month of August, 1918, made by Maj. E. G. Zabriskie, M. C., to the senior consultant in neuropsychiatry, A. E. F. Copy on file, Historical Division, S. G. O.

(10) Report of the neuropsychiatric activities of the 4th Division for the month of August, 1918, made by Maj. Samuel Leopold, M. C., to the senior consultant in neuropsychiatry, A. E. F. Copy on file, Historical Division, S. G. O.

(11) Letter from the senior consultant in neuropsychiatry to the director of professional services, A. E. F., August 6, 1918. Subject: Preventing evacuation of cases of war neuroses. Copy on file, Historical Division, S. G. O.

(12) Report from the division psychiatrist, 26th Division, to the senior consultant, neuropsychiatry, A. E. F., on the activities of the division psychiatrist. Copy on file, Historical Division, S. G. O.

(13) Report of the activities of the corps consultant in neuropsychiatry, First Corps, A. E. F., July, 1918, to November 11, 1918, by the corps consultant in neuropsychiatry, November 25, 1918. Copy on file, Historical Division, S. G. O.

(14) G. O. No. 120, G. H. Q., A. E. F., July 24, 1918.

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