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Section II, Chapter III

Table of Contents

CHAPTER III

ARMY NEUROLOGICAL HOSPITALS

Early in the medical history of the American Expeditionary Forces, as pointed out in Chapter I, the conclusion was reached that success in dealing with the loss of man power and the menace to morale caused by the war neuroses could not be attained in the American forces unless division psychiatrists had close behind them special hospitals in which could be received cases that promised well for recovery but obviously required longer care than could possibly be given in divisional hospitals. Both the British and French had recommended the establishment of some type of advanced special hospital for the treatment of psychoneurotic reactions among combat troops. For example, Léri,1 who had conducted work in an advanced French neurological center at Nubecourt, reported excellent results in these cases when several weeks' treatment could be instituted within the zone of active military operations. Working in the neuropsychiatric center of the second French Army, he reported that 91 per cent of the cases received from July to October, 1916, were returned to the fighting line.

Roussy and Boisseau,2 describing the work of an army neuropsychiatric center, said the results obtained after six months showed that a neuropsychiatric center could render incontestable services to an army from both a medical and a military point of view. For functional nervous cases it avoided sojourns (more dangerous the more they were prolonged) in the hospitals at the rear, where these patients were generally lost. It allowed of the treatment of other nervous or mental cases that were quickly curable and for the direct evacuation to the special centers in the interior of those more seriously affected. This idea was confirmed by English observers.3 A psychiatrist who had the opportunity of working in a casualty clearing station of the British Expeditionary Force in France reported that of 200 nervous and mental cases which passed through his hands in December, 1916, 34 per cent were evacuated to the base after 7 days' treatment and 66 per cent returned on duty on the firing line after the same average period of treatment. Four of these cases reappeared at the same casualty clearing station.

During the latter part of August, while the St. Mihiel operation was being planned, all medical and surgical arrangements for the care of men at the front were carefully reviewed in terms of the experience of the previous four months of active participation by American troops in the fighting in France. Up to that time American troops had always operated in the British and French organizations,4 which had naturally determined the type of many medical procedures. Now came the opportunity for putting into effect some American plans of work in the field. The beginning of these operations was the first favorable time, therefore, for inaugurating this new type of hospital. Con-


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sequently, it was decided to establish at that time a short distance behind the field hospitals, neurological hospitals for the care of war neurosis patients who required more than a few days rest in the field hospitals, and who at the same time, if kept in the zone of active fighting, would recover, within 2 or 3 weeks, sufficiently to permit them to be returned to their organizations. Three such hospitals were established.5

FIG. 1.-Map showing the locations of army neurological hospitals during the Meuse-Argonne operation


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ARMY NEUROLOGICAL HOSPITAL NO. 1, FIRST ARMY

The hospital at Benoite Vaux, Army Neurological Hospital No. 1, which previously had been used by the French as an "ambulance" for venereal diseases, consisted of 150 beds. The advantages of taking over this hospital for use with neuropsychiatric patients was brought to the attention of the corps surgeon, First Corps, by the senior consultant in neuropsychiatry on August 26, 1918.6

It was first suggested that a corps field hospital be stationed at Benoite Vaux with its own commanding officer, adjutant, and personnel, securing the special medical personnel from a "pool" of neurologists and psychiatrists collected at Base Hospital No. 117 for emergency service with advanced formations.6 This proved not to be feasible on account of the medical and surgical needs of corps troops. The hospital was turned over to the First Army before the end of August, 1918, and on September 2, 1918, an advanced neurological hospital was established there.7 It being impossible to detach the personnel of a corps field hospital, as was originally suggested, five commissioned officers and eight enlisted men, stationed at Base Hospital No. 117, proceeded to Benoite Vaux for temporary duty.7 The commanding officer at Base Hospital No. 117 furnished a truck for transportation, and on the morning of September 3 the detachment arrived and proceeded to prepare the hospital for the reception of patients. Seven other enlisted men were secured, and on September 6, it was possible to send the following memorandum to the chief surgeon of the First Army:8

1. The hospital at Benoite Vaux which has been designated Neurological Hospital No. 1, First Army, is ready to receive patients, the officers and enlisted men being on duty there and all supplies including rations on hand.

2. The hospital at Toul which might be designated Neurological Hospital No. 2, First Army, if you approve, will have the personnel by tomorrow and will be ready to receive patients by Sunday.

3. Staffing these hospitals has greatly depleted Base Hospital No. 117, which will be called upon to care for at least 1,000 patients, the overflow at Rimaucourt being only 500.

4. It is therefore necessary for the hospital at La Fauche to receive 28 men from your personnel from the special training battalion as soon as convenient.

5. I believe that with these advanced facilities it will be possible to establish a very different record in the loss of effectives from nervous conditions, which, unfortunately, we were compelled to be content with during the last period of extensive fighting.

6. For several days I will be at Toul and in the divisions in that vicinity.

Benoite Vaux, a tiny French village, consisted of 45 houses, with a population of not more than 75 civilians. In the village was a church, an abbey, and a few little shops. The abbey, supplemented by some frame barracks across the road, had been used by the French Army as a hospital for nervous diseases. During the recent active operations carried on by the French, the village had been used as a rest area.

The location of Neurological Hospital No. 1 was particularly well adapted for the purpose to which it was to be devoted. The main evacuation center for

aExcept as otherwise indicated, the following statements concerning Army Neurological Hospital No. 1, First Army, are based on "History of Army Neurological Hospital No. 1, First Army," by the commanding officer of that hospital. Copy on file, Historical Division, S. G. O.


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the Verdun front was Souilly, 7½ miles away, which was also the site of a number of evacuation hospitals.9 An excellent road connected Benoite Vaux with the main route between Verdun and St. Mihiel, while only 9¾ miles to the west was the main route between Verdun and Bar-le-Duc, upon which route a little later the neurological hospital at Nubecourt was to be established. At the time of the commencement of the St. Mihiel operations, the front line was 5¼ miles away.

The hospital consisted of 10 French barracks and a number of small outbuildings, which were little more than huts. One barrack was used both as the admission ward and as a ward for officer patients. It was divided into several rooms accommodating one to four patients each with an additional small ward for six patients. Eight other barracks were used for patients who were enlisted men. Each contained 25 cots. These barracks were arranged in three rows of three each. The first two rows were connected by an inclosed corridor. One of the barracks was used for bathing purposes and one for a storehouse. The office of the commanding officer was a small two-room barrack adjoining this group of buildings. The hospital personnel were quartered in several small buildings which surrounded the group of barracks to the west and to the north. The kitchen was in the rear of the group. Cooking facilities consisted of French brick stoves, and wood was used for fuel. During the French occupation of this hospital, gardens had been planted in which onions, carrots, and lettuce were growing in sufficient amounts to provide fresh vegetables for at least one meal a day for the entire hospital.

On September 20, orders were issued to 5 officers and 15 enlisted men, who were stationed at Neurological Hospital No. 2 at Toul, to report for duty at Army Neurological Hospital No. 1 at Benoite Vaux. Accordingly, on the night of September 21, these officers and 30 enlisted personnel traveled in ambulances, arriving at 3 o'clock in the morning. The original 4 officers and 30 enlisted men were synchronously transferred on September 22 from this hospital at Benoite Vaux to Neurological Hospital No. 3 at Nubecourt. The newly arrived officers and enlisted men remained for the purpose of operating this hospital.

During the month of October, this hospital continued its activities while the Meuse-Argonne operation was under way, the number of cases admitted being 608.10 Of this number, there were 44 officers, 10 of whom were returned to duty, 1 was transferred to Base Hospital No. 116, 31 to Base Hospital No. 117, and 2 to medical centers.

During the month of November the admissions were considerably less than during the previous month, or even during September.11 This was due to the change in character of the fighting (while battle activities continued), to the fact that the distance between the hospital and the front line was constantly increasing and to the cessation of hostilities or November 11. The number admitted during November was 152.

Army Neurological Hospital No. 1 operated under considerable physical disadvantages. There was no laundry connected with the hospital until the latter part of October. Until then, the laundry was sent to near-by American hospitals. It was done sometimes at the Gas Hospital at Rambluzin, and at


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other times at Evacuation Hospital No. 6 at Souilly. By the end of October, a laundry was constructed on the grounds, a large fireplace was built for boiling clothes, and a mammoth tub was constructed in the workhouse of the hospital. Tubs were also put in place for rinsing, and convalescent patients were detailed to attend to this work. The average output a day was approximately 900 pieces.

Transportation here, as elsewhere in the American Expeditionary Forces, was a source of great difficulty. To get supplies of fuel, water, and rations it was necessary to go to Souilly, a distance of 7½ miles. The evacuation of patients to trains, to organizations, and to the rear still further embarrassed the transportation facilities. Upon every occasion when transportation was needed, a request had to be sent to the transportation officer at Souilly that a truck be sent for this purpose. Since a truck was not always available at the time it was needed, this arrangement was very unsatisfactory. Later, about the middle of October, a truck was assigned from Souilly, to be used conjointly with Neurological Hospital No. 3 at Nubecourt, about 15 miles distant. This plan proved to be more satisfactory. An ambulance was also assigned to the hospital and was used largely for evacuating patients to Souilly. Sometimes, when the truck was not available, it was used to obtain supplies.

Except on very few occasions, it was not difficult to obtain a sufficient supply of clothing for the patients. The majority of the men, upon being returned to their organizations, were equipped with completely new outfits with the exception of rifles.

In the latter part of the month of October a workshop was put in operation. A reconstruction aide was detailed from Base Hospital No. 117 to conduct this department.

Over 60 per cent of the patients admitted to Army Neurological Hospital No. 1 were restored within an average of 10 to 14 days to a state of apparent stability. By this is meant a condition in which they acknowledged that they felt well, in which they expressed themselves as willing and anxious to return to their organizations, and in which to all appearances they seemed to be able to do so.

The plan employed to bring about these therapeutic results included every psychotherapeutic device, but emphasis was placed chiefly upon persuasion, suggestion, and a simple, practical psychological reeducation. The officer of the day admitted all patients. It was his duty to explain to the soldier in the receiving ward upon admission the exact nature of his condition, and to reassure him as to the prognosis. There was discernible almost immediately a relaxation of the tension characteristic of practically all the patients. The soldier was relieved of a good part of his anxiety. He was then bathed, fed, and put to bed; whereupon he usually fell into a profound slumber which lasted 36 to 48 hours. Then, after a careful examination of the patient by the ward neuropsychiatrist, it was the duty of the latter to talk to the soldier, explaining the mechanism of his condition and treating by suggestion or persuasion such symptoms as were present. The next step in the therapeutic procedure was an interview by the commanding officer. The latter took the patient into a room by himself, went carefully with him over the history of his troubles, explained


330 

the nature of his symptoms in a way that robbed them of any residue of horror or mystery, and finally gave reassuring suggestions. After a brief period of rest under these conditions, usually lasting three or four days, the patients were put on a schedule which occupied the whole day. This included periods of rest, of exercises and calisthenics graduated according to the condition of the patient, and of recreation, which included games and group singing. In from 12 to 14 days from 60 to 75 per cent were fit for front-line duty.

Sometimes, unfortunately, it was not possible to evacuate the patients at once as they should have been when their recovery had reached this point, due to the difficulty in obtaining transportation, inability to locate the headquarters of their organizations, or other similar reasons. As a result of this delay, in a small number of cases, vague hypochondriacal phenomena developed which became more fixed the longer the patients remained in the hospital.

In handling the enlisted men it was originally planned to have an admission ward and then graduate the patients through a series of wards as they improved, the end ward being occupied by recovered cases awaiting transportation to duty. With the pressure of case admissions (which not infrequently ran more than 30 a day, the hospital at times containing more than 100 cases over its normal capacity) this plan was found impracticable. And so cases were admitted to each ward, with the exception of one reserved for ready-for-duty cases. An added advantage in this procedure was that the ward physician saw his patient all the way through.

The patients on admission were seen by the officer of the day and obviously unsuitable (medical and surgical) cases were sent to evacuation hospitals near by. "Exhaustion" was the label of most of the medical cases and often it required a day's observation before a definite diagnosis could be made and transfer effected. Many of the cases as they were seen in the admitting office presented coarse tremors and tics and other hysterical symptoms, and it was soon learned that much therapeutically could be done immediately by simple suggestion and explanation and reassurance in the admitting office. Not infrequently a well-marked coarse tremor of the extremities would be cleared up before the patient had his routine admission bath. The majority of cases on admission were tired out, and at least a day in bed was a routine necessity, the beneficial effect of which was very striking. As soon as possible afterwards the patient was gotten up and about and assigned to routine duties.

Since the number of hospital enlisted personnel was small, and there was so much of the routine hospital fatigue duty to do, the patients were never at a loss for occupation, as far as needed work was concerned. Drills and practice marches were used at first under the charge of an officer patient, but these later were superseded by work detail, with an initial daily setting-up exercise under a sergeant. There was a variable percentage of work dodging, but on the whole the patients were fairly industrious and idleness was not the problem here that it was in many of the base hospitals. Latterly an occupation shop was started under the supervision of a trained worker, and the activities were mainly with wood and metal work; it proved of considerable interest to the patients, and was valuable, especially for the cases with tremors and difficulty in concentration.


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The general treatment of the war neuroses, summed up, was the following: Rest when indicated, persuasion, suggestion, work, and psychological reeducation. In dealing with the cases fresh from the line, after one's experience with the older cases, it was most striking how much more suggestible the former were seen to be. Hysterical symptoms that might require hours of treatment in a base hospital could frequently be cleared up by suggestive therapy in a few minutes in a fresh case. It was the policy of the hospital not to transfer cases deemed unsuitable for immediate front-line service to Base Hospital No. 117 as long as gross objective, hysterical symptoms persisted. This suggestibility worked both ways, and unless the therapeutic side was pressed the symptoms tended to become rapidly fixed. But the advantage was with the physician.

Upsetting battle dreams were likewise easier to clear up in the fresh cases. These battle dreams were among the few symptoms that seemed to be as marked in the fresh neuroses as in those longer from the line, and they were the most common complaint. (They were frequent in fresh wounded cases as well.) Some patients would stay awake night after night to avoid them. Usually simply explaining the dream mechanism and urging the patient to ventilate and mentally assimilate his affect-charged battle experiences rather than "to keep them out of the mind" during waking hours was quite sufficient therapy; very rarely were hypnotics required.

One of the most valuable assets in the treatment of the neuroses was the creation of a ward atmosphere of cure. The patients were quite observant of one another, and a cured case which they had seen from the beginning was a most useful asset. Once the atmosphere of cure was created a part of the therapy became automatic. The ward atmosphere depended almost entirely on the ward surgeon, and it was most striking how quickly the efficiency of the doctor was reflected in the therapeutic results of his ward. Certain members of the staff had had the advantage of training at Base Hospital No. 117 under the stimulating influence of the medical director there.

In every soldier probably there was some degree of mental conflict between, on the one hand, the instinct of self-preservation and, on the other hand, the more socialized "carry-on" urge and desire for social esteem, with regard to front-line service. There were three possibilities: First, the "carry-on" driving force predominated, which was the condition of the normal soldier, and of not a few neurotic individuals. Secondly, if the "carry-on" force was weak or absent, a neurosis might not develop because the conflicting forces were too unequal and there was little tendency to symptom fixation. These were the fear cases, and certain of them were very honest individuals in their "I can't stand the gaff" attitude. Thirdly, when the two opposing forces were approximately evenly balanced, a soldier might perform his duties fairly well until some environmental factor, such as a shell explosion, upsetting emotional experience, fatigue, or minor trauma, disturbed that balance in favor of self-preservation, and a neuroses developed. The symptoms of the neurotic, while out of proportion to the more immediate upsetting event, were usually not out of harmony with it; for example, the relationship between a slight hip trauma and a subsequent functionally paralyzed leg; between a somewhat thin concussion experience and a headache and tremor, or, perhaps, deafness;


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between an upsetting emotional experience and the development of an anxiety state, etc.

Undoubtedly many soldiers carried on after the same sort of experiences as sent most of the neurotics to hospitals. The cumulative effect of these upsetting experiences must have been large and in time might break men of good balance and make-up. A number of cases held on until their divisions were relieved from the line and then snapped when the sustaining power of action was removed.

Life itself being represented by a series of adjustments and compromises between the individual and his environment, the war neuroses furnished no exception. At one extreme was the pure concussion group, and allied to this were the cases in which trauma and exhaustion played the most prominent part; at the other extreme were the fear cases, in which the personal element predominated. Between these extremes fell the bulk of the neuroses, the environmental and personal factors participating in varying proportions, seizing and fixing on the most available experience, as shell explosion, fatigue, trauma, upsetting emotional event (killed comrades, etc.).

Neurotic symptoms were quite natural after many of these experiences, and consciousness probably played a very minor part, if any, in their incipiency. But into the maintenance of the neuroses, the conscious factor entered to a greater extent. Any doubt as to this was removed by the decidedly ameliorating effect of the armistice on the majority of the cases. The fear-group cases were largely conscious of the difficulty all the way through, but these were not cases of malingering, because there was no conscious simulation. There may have been a degree of malingering in some of the neuroses, but pure malingering undoubtedly was rare.

In civilian cases of neuroses, along with changing the patient's attitude toward himself, it is nearly always possible to modify the environment in which the neurosis arose. The problem of the war neuroses was simpler and more difficult-simpler to the extent that the conflicting forces were less obscure, and more difficult in that the aim of treatment was to enable the patient to be sent back to the same precipitating environment, i. e., the front line. The soldier's neurosis was his reaction and adjustment to an unbearable situation, and it had a double-barreled potency: To get him out of the situation and keep him out of it. This last factor probably accounted for the tendency later to symptom fixation, and this was the more immediate therapeutic problem. A simple mechanistic explanation of the neuroses was helpful to the patient. But more valuable from a therapeutic standpoint was the effect of a definite attitude on the part of the ward surgeon that the goal of treatment of the war neuroses was return to duty.

There were three avenues for the disposal of patients from the army neurological hospital: Return to duty; transfer to Base Hospital No. 117, the special base hospital for the neuroses; and transfer of the medical, mental, and surgical cases to other hospitals where more appropriate care and supervision could be given them.

The primary function of the hospital was to return as many cases as possible to duty with their divisions, and in as short a time as possible. The average


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duty case was in condition to go back within 10 days, although there were exceptions. It is impossible to estimate from the length of stay in the hospital the time required for recovery because most of the recovered cases would have to wait over in the hospital, sometimes for several weeks, until a particular division could be reached. The hospital received most of its cases from the north and east of Verdun, and the delay in return to duty was more marked when the divisions moved from sector to sector. Just before the armistice was signed, arrangements were made to return the duty cases to corps replacement camps rather than to their divisions, and this facilitated matters greatly.

The question of return to duty was complicated by the possibility of relapse. On the 532 cases returned to duty, 15 cases were known to have come back to the hospital with relapses; none of them lasted more than one day under fire. Soon after the opening of the hospital 22 cases were returned to duty in one group and within 24 hours 11 of them (included in the above 15) were sent back with an assortment of hysterical symptoms. They had spent the night in a village that was heavily shelled. This experience made one more cautious in the selection of line-duty cases. When a division was in a large area and participation in heavy fighting followed recoveries were more durable.

The relapses were all cases of hysteria and hyperemotivity (fear), and these were the two groups that presented the main problem in selection for duty. With the exception of certain of the concussion cases, there was in the general attitude of the patients in the hospital a distinct absence of any keenness of desire to return to front-line service. The question before the hospital staff with nearly half of the hysteria and fear cases was: Which is wiser from the standpoint of army efficiency, to send these men back to the front line on the chance that they will carry on or to send them to Base Hospital No. 117 to be reclassified as labor troops? One's first impulse was to carry out the former alternative, especially if one were dealing with a plain case of fear. There was another point of view to consider, however, and that was the line officer's. Even if the hysterical and fear cases were not contagious in the front line, the chances were that they would not be individually dependable. There were exceptions, of course. Furthermore, at a time when every available bit of transportation was needed for wounded men, a seat in an ambulance for a relapsed nervous case seemed rather superfluous.

Before troops went into the front line for the first time it was a hazardous proposition to predict which individuals would develop "shell shock." Men who had been visibly "on edge" often carried on well, and vice versa. The front line itself was the only test. There was a history of neuropathic make-up or neuropathic stock in about 40 per cent of the cases of war neuroses admitted. In 100 case records selected at random the family history was positive in 38 and the personal history in 40. Much depends on the criterion for the term neuropathic. This 40 per cent included the cases with any definite history of nervous or mental anomalies whatever in stock or make-up. Certain of the ward surgeons went into this question carefully, others more casually; so the 40 per cent is only an approximation.

The average American soldier's attitude toward "shell shock" had a large proportion of tolerance and curiosity in it. An attempt was made to abolish


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the term. Although this could be done in official communications, it was manifestly impossible in ordinary speech. Much more profitable was the dissemination of information among the troops as to just what "shell shock" meant. The divisional variation in the number of such cases was very striking-it occurred in inverse ratio to the morale. Among the patients themselves there were two main attitudes. The first was to this effect: "You're a long time getting it; but once you get it, it's got you"; and the second: "It's easy to get and easy to get over." The majority of them agreed on one point-they were unfitted for future front-line service. This attitude was one of the main problems to combat in the neuropsychiatric hospitals.

It was essentially the unfavorable type of neurosis that was evacuated to Base Hospital No. 117; that is, unfavorable at least as far as any immediate return to front-line duty was concerned; and so the army hospitals made the work at Base Hospital No. 117 more difficult in this way but operated favorably through having exposed these patients early-often a few hours after their breakdown became noticed-to a psychiatric point of view. A number of cases were sent to Base Hospital No. 117 to be reclassified, inasmuch as only class A duty was possible from the army hospitals. The general level of intelligence of the neurotic patient was certainly not below the average, and the vast majority of those who were unfit for front-line service were quite-efficient workers in the base sections.

The officer patients, 66 in number, were included in the figures already discussed. On the whole they presented distinctly less favorable material for return to duty than did the enlisted men. There was one feature common to nearly all of them on admission-fatigue. Seventeen of the 66, or 25 per cent, were returned to duty as compared with 61 per cent of the enlisted men. Another factor entered into the selection of duty cases here, for if an enlisted man relapsed it was more or less of an individual problem; while in the case of relapse of an officer during the prodromal period, his wavering might affect more than himself. However, with most of them there was small choice; they were unfit for return to front-line commands.

The following is a summary of officer cases:

Duty

Transfer

Total

Duty

Transfer

Total

Hysteria

1

14

15

Observation, mental

0

2

2

Neurasthenia

5

8

13

Exhaustion

1

0

1

Hyperemotivity (state of anxiety; funk)

3

5

8

Concussion neurosis

1

0

1

Exhaustion neurosis

3

5

8

Neuritis (musculospiral)

0

1

1

Traumatic neurosis

1

3

4

Pneumonia

0

1

1

Anxiety neurosis

0

3

3

Influenza

0

1

1

Psychasthenia

0

3

3

Gas neurosis

0

1

1

Concussion by explosion

2

0

2

Psychoneurosis

0

1

1

No disease

1

0

1


There were but two pure concussion cases among the 66 officers and both returned to duty, as did the single case of simple exhaustion. The hospital stay of these three cases, in which the causative factor was so acute and strenuous, ranged from three to seven days.


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Hysterias and neurasthenias predominated and there was a distinct "can't-stand-the-gaff" attitude among these and the majority of the other cases of neuroses among the officer patients.

Some of the crudest cases of hysteria in the hospital were found among the officers. More striking differences existed in neurasthenia and psychasthenia; the former was five times as frequent among the officers as among the men, and of the latter, three of the four cases seen were officers.

The following list is a comparative percentage list of the neuroses as they occurred among the officers and enlisted men:

Officers

Enlisted men

Officers

Enlisted men

Per
cent

Per
cent

Per
cent

Per
cent

Hysteria

22

30

Anxiety neurosis

4

2

Neurasthenia

20

4

Psychasthenia

4

.1

Hyperemotivity (state of anxiety; funk)

12

13

Concussion neurosis

1.5

6

Exhaustion neurosis

12

6

Hypochondriasis

0

2

Traumatic neurosis

6

11


The following tabulation summarizes the disposal of cases, by months:

Return to duty

 

To Base Hospital No. 117

To other hospitals

September, 1918

22

17

15

October

230

226

67

November

280

96

42

Total

532

339

124


In addition to these there were 5 desertions and 3 deaths, making a total of 1,003 cases. The 124 cases which were transferred to other hospitals (medical, surgical, and mental observation) may fairly be eliminated as being complications in a hospital that had for its special problem the emergency treatment of the war neuroses. Of the cases which may properly be included under the term war neurosis, 61 per cent were returned to front-line duty.

CLINICAL ASPECTS OF CASESb

During the period from September 26 to November 11, 1918, 1,003 cases passed through Neurological Hospital No. 1 at Benoite Vaux. These patients were relatively fresh cases, admitted usually within 24 hours after they were sent from their divisions. The more favorable cases-those which could be returned to duty within a few days, especially cases of exhaustion-were treated by division psychiatrists in the field hospitals as far as possible. Consequently, few cases of pure exhaustion were received in Army Neurological Hospital No. 1.

bBased upon a report made by the commanding officer, Army Neurological Hospital No. 1, First Army, to the senior consultant in neurology, A. E. F., undated. Copy on file, Historical Division, S. G. O.


336


Clinical summary of 1,003 cases admitted

War neuroses

818

Concussion by explosion

10

Gas

2

Gunshot and shrapnel wounds

3

Psychoses, observation

52

Epilepsy, observation

22

Neuritis

10

Organic nervous disease

1

Belladonna poisoningc

13

Acute infections

52

Miscellaneous

20

Total

1,003


There were five cases of gunshot or shrapnel wounds altogether, and two of them were too slight to require surgical dressing. One of the remaining three had a finger wound (gunshot, right fourth finger). This was the only possible self-inflicted wound case admitted and there was no corroborative evidence here. Another case had multiple shrapnel wounds and was transferred immediately; and the last case sent in as an epileptic, proved to have a shrapnel fragment in the right parietal region. The common observation that wounded men do not develop "shell shock" was well borne out.

The 74 cases which were psychiatric or epileptic, were evacuated as speedily as possible to a special hospital (Base Hospital No. 116, at Bazoilles) for further mental observation. The 10 neuritis (unwounded) cases showed the following involvement: Facial, 3; musculospiral, 1; ulnar, 1; multiple (post-diphtheritic), 5. Included among the acute infectious diseases were one case of epidemic cerebrospinal meningitis and two cases of acute anterior poliomyelitis, one of the latter possibly syphilitic in origin. There was one case of organic nervous disease (an early amyotrophic lateral sclerosis), and this, together with one uncomplicated case of mental deficiency that passed through the hospital, speaks well for the efficiency of the neuropsychiatric weeding out in the camps in the United States. A small number of other mental defectives was admitted, but they were all neurotic as well.

The acute infections were admitted mostly as cases of "exhaustion." This was especially true of the pulmonary cases, eight of which proved to be lobar pneumonia. There were three deaths in all in the hospitals; two from lobar pneumonia, and one case (an Austrian prisoner) died on the day following admission, from gas poisoning, probably phosgene.

The 10 cases of concussion by explosion were differentiated from the war neuroses because they showed no neurotic feature whatever, and from their histories there was no reason to believe that any factor entered into their causation other than concussion. Of these 10 cases, 8 were returned to duty. The other two were transferred to a surgical hospital-one because of the possibility of a fractured skull and the other because of a complicating superficial abscess of the right temporal region.

cThe belladonna poisoning cases were caused by eating belladonna berries found in the woods, most of the cases being admitted in a very active toxic delirium.


337

There was no evidence of organic nervous disease in any of these cases, and most of them were convalescent when admitted. The diagnosis depended largely on the history, the patient's condition, and the absence of neurotic features. The following case is an example:

Pvt. J. C., 4th Infantry. Age, 26; civilian occupation, locomotive engineer. The patient's family and personal history were negative and his make-up was normal. He was drafted in May, 1918, went to France the following August, and was sent with replacements to the 3d Division in September. He carried on well and showed no undue reaction to shelling. On October 10 he was knocked down by a shell but was not unconscious, and continued his duties. On October 21, during a barrage, he remembered vaguely running for a shell-hole. "There was a kind of puff and I didn't know any more until I came to and it was dark "-evidently an initial period of unconsciousness lasting some hours. He had a violent headache and was dizzy, weak, and shaky. He remembered vaguely being carried on a stretcher and remembered the triage on the following morning. He lost consciousness again for several hours at the triage. Two days later he was admitted to the neurological hospital in a semicomatose condition, from which he gradually emerged on the following day. His memory from the time he left the triage until his arrival at the hospital was very hazy. He was in fair physical condition and there was no sign of organic neurological disease. His main complaints were headache, dizziness, weakness, and shakiness, the last being more subjective than objective, although he had well-marked coarse hand tremor. He was up and about the third day in the hospital, and by the sixth day his complaints had cleared up entirely, with no especial treatment. He was anxious to return to his outfit, and this was done 10 days after his admission to the hospital.

As stated above, of the 1,003 cases admitted, 818 were classified as war neuroses. The classification followed was essentially that formulated by the medical director of Base Hospital No. 117. (See p. 355.) Aside from the value of this classification (inasmuch as about one-third of the cases were evacuated to Base Hospital No. 117) it was very helpful to have a common language. This was primarily a working classification which conformed to the Medical Department diagnosis requirements, and was not merely an attempt to pigeonhole the cases. It was fully understood by all that it lacked many of the requirements of accurate psychiatric work.

September

October

November

Total

Duty

Transfer

Duty

Transfer

Duty

Transfer

Duty

Transfer

Concussion syndrome

19

1

21

0

14

0

54

1

Concussion neurosis

0

0

14

24

13

3

27

27

Exhaustion neurosis

0

0

22

8

29

3

51

11

Traumatic neurosis

0

0

51

8

40

7

91

15

Gas neurosis

0

0

1

1

0

1

1

1

Hysteria

2

6

52

93

103

41

157

140

Neurasthenia

0

1

13

14

9

13

22

28

Hypochondriasis

0

0

0

8

6

3

6

11

Anxiety neurosis

0

2

1

18

3

0

4

20

Psychasthenia

0

0

0

3

0

1

0

4

Effort syndrome

0

1

0

3

0

1

0

5

Anticipation neurosis

0

1

0

6

0

0

0

7

Hyperemotivity, state of anxiety (funk)

0

0

28

40

43

24

71

64


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The following list shows the percentages of the various neuroses returned to front-line duty (based on the preceding table):

Number of cases

Percentage returned to duty

Number of cases

Percentage returned to duty

Concussion syndrome

55

0.98

Gas neurosis

2

0.50

Traumatic neurosis

106

.86

Neurasthenia

50

.44

Exhaustion neurosis

62

.82

Hypochondriasis

17

.35

Hysteria

297

.53

Anxiety neurosis

24

.16

Hyperemotivity-state of anxiety (funk)

135

.52

Psychasthenia

4

.0

Concussion neurosis

54

.50

Effort syndrome

5

.0

Anticipation neurosis

7

.0


It is evident that the more clearly exogenous the precipitating factors the better were the prospects of return to front-line duty.

Concussion syndrome was a term applied to cases in which the concussion factor was the predominant one, but not so exclusive as in the concussion by explosion group. The distinction is not a sharp one and it had to be largely from the history of the case; it arose from a desire not to preface the undoubtedly pure concussion cases with the term "psychoneurosis" on the field medical card. The following case is illustrative of the concussion syndrome group:

Pvt. A. B., 4th Inf. Age 21; civilian occupation, coal miner. There was nothing abnormal in the patient's family or personal history or make-up. He enlisted in June, 1917, and came to France in April, 1918. He served with the 3d Division at Chateau Thierry and in the Argonne, and had no nervous symptoms. On October 22, after 21 days in the sector north of Verdun, he was returning to his company after taking some prisoners back. The shelling became hard and he took refuge near a bank. A shell was heard coming and that was the last he remembered until he pulled himself out of some dirt. He was dazed and had a headache and was nervous, reported to the first-aid station, and was sent to the rear. On October 25 he was admitted to the hospital as a walking case. He complained of headache. Physical and neurological examinations were negative. His attitude was good, and he returned to his outfit on November 4.

In the next group, the concussion neurosis, there was a history of a concussion experience, but it was much less definite and the outstanding feature was that the usual post-concussion complaints-headache, dizziness, general aching, tremor, and weakness-showed a tendency to become fixed and often to be elaborated. In other words, a neurosis had developed. The following is an illustrative case and it might well be termed hysteria:

Sgt. E. R., 1st Pioneer Inf. Age 23; civilian occupation, leather worker. The patient's father had diabetes. The personal history was negative. He was earning $24 a week at the time of his enlistment in May, 1917. He came to France in July, 1918, and served in the Chateau Thierry and Verdun sectors. The first time under fire he "was nervous and shook up," and couldn't sleep, and was shaky that night. The other men laughed at him. This passed off after the first day. He was with his regiment in the Verdun sector from September 26, and was very nervous when the shells hit close. Finally, on October 22, he was near a shell explosion that blew up three of his men. He saw the shell explode and the men blown up, and he himself was thrown down and lost consciousness. He came to in a hospital and "felt dizzy and light-headed, had headache, and was shaky." Two days later (October 24) he was admitted to the neurological hospital. His complaints were: "I feel dizzy and have pain in the back of my head." Physical examination was negative. He seemed to be of questionable material and his headache and dizziness persisted. He was transferred to Base Hospital No. 117 on November 8, 1918.


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There were 65 cases in which the history and examination left no doubt that shell concussion was the dominant factor: Concussion by explosion, 10; concussion syndrome, 55. As has been said, two of these cases were transferred because of surgical complications. All but one of the remaining 63 cases returned to front-line duty. Of the concussion neurosis cases-in which the concussion history was less clean-cut and the subsequent fixation symptoms were pronounced-only half the cases were returned to front-line duty. One can not avoid the conclusion that the more dominant and clean-cut the concussion factor, the more likelihood there was of the case being returned to duty. In this connection the individual make-up had to be taken into consideration. The genuine concussion cases were found, on the whole, to be individuals of superior stamina and attitude, compared with the others. Most of them would probably have carried on after a less clean-cut history of concussion, such as one obtained from the concussion neurosis. A shell is no discriminator of the individual make-up. The main thing is the individual's reaction to the situation.

One's estimation of the importance of the concussion factor had to be made largely from the history and the way it was told, and in most of the cases it offered no especial difficulty. When objective findings, such as unconsciousness and unsteadiness, were present, the diagnosis was greatly facilitated. There was one apparently comatose case that offered some doubt as to diagnosis-until he tried to bite the examiner. Usually the real cases had been carrying on well and there was a history of sudden loss of consciousness, with a rather hazy memory for the immediate concussion setting. As a rule the patient did not remember hearing the explosion clearly, but this condition was not invariable. It seems probable that the better the man's fiber the more tenacious he is of consciousness. It was striking, on the wards, how quickly these concussion cases began to improve and ask for activity and duty. This request was not observed particularly in any other type of case in the hospital.

Between the concussion neuroses and the hysterias the distinction is a sliding one. Undoubted cases of hysteria may be precipitated by a concussion experience, although it is usually a fairly safe one. The term hysteria was used in a rather restricted sense and included such symptoms as paralyses, anesthesias, aphonias, stammering, blindness, tremors, tics, gait disorders, amnesias, and fits.

A history of loss of consciousness was rather common in the hysterical cases, but on questioning it was evident that previous symptoms had shown themselves and that the way had been prepared for the final concussion experience. The stories of the explosion in these cases were vivid in detail, and consciousness was usually regained suddenly. In most of them the factor that determined the symptom picture could be elicited, i. e., being thrown on one hip, followed by paralysis of that leg; functional deafness following the sound of an explosion; and arm and shoulder tic developing after a rifle carried on that side had been struck by a piece of shrapnel, etc.

The following case of hysteria was interesting because a longitudinal section of the patient's experience in the American Expeditionary Forces was known, as well as the cross section condition that he presented on admission,


340

and which necessarily had to be the chief criterion in sizing up so many of the cases:

Sgt. L. F., P. W. E. Co. 89, First Army. Age 23. The family history was negative. The patient was graduated from high school at 16, and had been in the Regular Army since 1913. He went to France in June, 1917, and saw much service with the 1st Division. He gave a history of a slight wrist shrapnel wound in October, 1917, and some months later was gassed in the Toul sector. He was treated at Base Hospital No. 15 for this, and was discharged from the hospital in February, 1918. On June 10, 1918, he was blown up, with loss of consciousness, at Chateau Thierry, and was sent to a French hospital, where his chief complaints were headache and abdominal pain. He protested to a passing American officer that he was receiving no treatment from the French and was then transferred to an American hospital. The surgeon in charge decided that he had appendicitis and determined to operate. The patient refused operation and charges were preferred against him for this, and he was brought to Base Hospital No. 117 in this status. (This is largely the patient's own story.) At Base Hospital No. 117 his principal complaint was headache, and he was very solicitous in his attitude, and at times emotionally unstable. (One of his brothers in his own outfit had been killed shortly before.) The headache persisted unimproved for some weeks, and it was difficult to get the patient interested in occupation. It was learned that he was quite fond of horses, and so he was given some light duties in connection with the stables. Within a very short time his neurotic symptoms cleared up (there never was any evidence of organic disease), and he was discharged to class A duty July, 1918. While awaiting assignment at the replacement camp at Is-sur-Tille, a charge of dynamite exploded near him and he became shaky and upset, and when readmitted to Base Hospital No. 117 a few days later he presented coarse tremors of the arms and legs and a very marked stammer. These symptoms were cleared up easily with suggestion. It was felt that he would be unfit for any sort of line service, and so he was reclassified C-1 and sent to back-area duty in September, 1918. He was assigned to a prisoner-of-war escort company, and the next seen of him was on November 17, 1918, when he was admitted to the neurological hospital, presenting coarse tremors, a dodging head tic, and a bad stammer. In the rapid American advance during the week before the armistice was signed, his duties took him close to the retreating Germans, and on November 8 he was caught in a barrage, became shaky and weak, and the above symptoms developed. He "shook like a leaf, wanted to run, and didn't know what he was doing." He remained in a dugout for some days, until discovered by passing soldiers. Under the influence of the armistice and suggestion he cleared up rapidly, and was returned to duty a few days after his admission to the hospital.

The anticipation neuroses were cases which developed the various war neurotic symptoms before getting anywhere near the front line. They were essentially cases of hysteria, but less respectable, and very tenacious of their symptoms, and prone to relapse. They took few chances.

At the instance of the commanding officer of the hospital, the term traumatic neurosis was applied to a somewhat heterogeneous group. In these cases there was a history of a precipitating trauma, separated from the concussion neuroses, because there was no history of associated loss of consciousness. These cases also showed a much smaller tendency to symptom fixation than did the concussion neuroses, and the percentage returned to duty was relatively high (86 per cent). Most of them might be considered as hysteria of a better class. The following case is an example:

Pvt. H. K., 102d Inf. Age 24. Interior painter. His mother was "very nervous-subject to headache." The personal history was negative aside from some alcoholic excess. He was drafted in April, 1918, went to France in June, and was with the 26th Division in the St. Mihiel and Meuse-Argonne operations. On October 25 he was very nervous and shaky during a barrage, but he managed to carry on. On October 27, he said, a machine-gun bullet


341

went through his legging and that same day a shell exploded near him and he was knocked against a tree. He did not lose consciousness but "lost his nerve"; his comrades told him he was "crying and carrying on and shaking." His memory was rather vague at the time. He was admitted to the neurological hospital on October 29, complaining of pain in his back (lumbar region) and under his knees. He was also troubled with insomnia. His physical examination was negative and he appeared to be of fair stuff. His complaints cleared up rapidly, and he was returned to his outfit on November 4, 1918.

As has been stated above, cases of pure exhaustion were nearly all sent back to duty from their divisional hospitals. The exhaustion neuroses comprised the cases in which the fatigue symptoms became more fixed, and between this group and the neurasthenias the distinction was a relative one, depending on the intensity of the precipitating fatigue and on the consequent degree of fixation of the fatigue symptoms. The former was less marked and the latter was more marked in the neurasthenics. These cases usually gave histories of fatigue reaction in the line that was disproportionate and not acute; more than half of the neurasthenic cases were not returned to line duty because of their tendency to symptom-clinging. The following case is of the neurasthenic type:

Pvt. H. C., 102d Trench Mortar Battery. Age 25; occupation in civil life, assistant librarian. The patient's mother "has trouble with her heart anti nerves and is very excitable." He himself had been subject to "palpatation of the heart" for several years. He enlisted in June, 1917, and went to France one year later. His first line experience was in the Verdun sector and he "was much frightened and nervous all the while in action. Shivered and couldn't stop." He "never could hike very well"-his "heart would beat fast." On October 15, after a hike, he "fainted away," and was very weak afterwards. On the following day he was sent to the field hospital, and on October 19 to the neurological hospital. "I don't feel strong at all and have headaches." There was no evidence of organic nervous or heart disease. His pulse rate would increase from 72 to 120 per minute after exercise. Mentally he was "not a strong character." His complaints of weakness persisted and he was transferred to Base Hospital No. 117 on November 8. He seemed to be quite a potential effort syndrome case, but his subjective symptoms were not fixed on his heart-as yet.

The rôle of fatigue in the vast majority of all admissions was an important one. Nearly all the cases came into the hospital in much the same condition in which they left the front line, and their common denominator was fatigue. It is quite probable that many neuroses developed because a patient's resistance was lowered by fatigue, just as sometimes a long argumentative speech is successful for the same reason and not because of any increase of potency in the argument. If fatigue, however, were the only factor, then there would be no disproportionate symptom fixation. One could frequently see just as tired-looking soldiers hiking with their divisions. Many of the cases of exhaustion were associated with the diarrhea that was so prevalent during the Meuse-Argonne operation. The following case is typical of the exhaustion type:

E. M., corpl., 101st Field Signal Btn. Age 21; electrician. The patient's family and personal history were negative. He enlisted in April, 1917, and went to France in June, 1918. He was with the 26th Division during the St. Mihiel and Argonne operations, and showed no undue reaction to shell fire. He had been under fire continuously for nine days previous to his admission to the hospital on October 31, and had had diarrhea for a week. Finally he "fell over and was helped back to the first-aid station." He had had little rest and limited food and heavy work and was "all in," and this was his main complaint on admission. Physically, aside from a slender build and tired-out appearance, he presented no anomaly. He made a quick recovery, and was returned to duty on November 4, 1918.


342

The gas neuroses were by no means the problem during the Meuse-Argonne operation that they were in certain of the earlier and less important operations. This was possibly due, in part at least, to the increased gas morale in the divisions, and perhaps also to the development of gas hospitals. But two of these cases were seen at this hospital. The gas-neurosis symptoms were to the lungs what effort syndrome was to the heart. Visits to gas hospitals by the senior consultant in neuropsychiatry and the corps consultants in neuropsychiatry were helpful means of providing gas medical officers with the psychiatric point of view toward these men.

There were but five cases of effort syndrome altogether among the thousand patients admitted. This low number was rather surprising at first because at Base Hospital No. 117, where the patients filtered from other hospitals, it was not unusual at times to find 5 cases of effort syndrome in a ward of 40 patients; all of which emphasized the rôle of hospitalization as a culture medium for effort syndrome. These cases required special treatment of graded activities and were evacuated with the recommendation that they be sent to our special convalescent camp for effort syndrome at Liffol Le Grand.

The hypochondriases, anxiety neuroses, and psychasthenias were of the same type as those seen in civilian life; they were persistent in character, and this was reflected in the low proportion returned to duty.

A final group was labeled "hyperemotivity" and "state of anxiety." In nearly all of these cases the funk element was predominant and the common attitude was "I can't stand the gaff." The term hyperemotivity was included in the field card diagnosis of these cases at the suggestion of the commanding officer of the hospital. This term was used in reference to the exaggerated jump and emotional reaction shown and occasionally such phenomena as tachycardia and increased sweating, and slight cyanosis of the extremities. There was no definite evidence of thyroid enlargement in any of these cases.a

The state of anxiety was a much more modified picture of anxiety than is seen in a typical anxiety neurosis where the cause of the condition is not so clear to the patient. In these fear cases the anxiety was with reference to the future, especially as it concerned return to front-line duty, for these individuals did not have the symptom alibi of an hysteric or neurasthenic.

The jumpiness to noises, while frequently seen in the other types of neuroses, especially the concussion neuroses and hysterias, was more prevalent in the fear group. Certainly it was much less marked in the true concussion cases. On the whole, there was considerably less of this jump reaction among the fresh war neuroses than among the older cases at Base Hospital No. 117. There was quite a tendency among many of the patients who showed it, not to try to control their jumpiness. It was regarded as demonstrable proof that they were genuinely "shell shocked," and the self-styled "shell-shock" cases fell mostly in this group.

aThe number of enlarged thyroid glands among the war neuroses as a whole was insignificant. This was in contrast to one's experience with the British "shell-shock" cases, in which signs of thyroid enlargement were found sometimes in as high as 10 per cent. Most of the British soldiers had had repeated experiences in the line, while the Americans were relatively fresh. It suggests that thyroid enlargement may be secondary to the emotional reaction and not primary. It is possible, too, that the contrast was increased by the elimination of individuals with enlarged thyroid glands at the training camps in the United States. The facial expression of horror which was not infrequently seen in the British "shell-shock" cases, particularly those with repeated exposure, was seen in just one case at the neurological hospital. This patient proved to be hysterical and recovered within a week.


343

Many of these state-of-anxiety cases gave a story of concussion, but it was more than doubtful. Upsetting emotional experiences-companions killed, etc.-were common and probably very potent factors as the "last straw" in the development of the condition; sometimes such experiences were the "first straw." Fifty-two per cent of this group were returned to front-line duty. The following case is typical:

C. S., private, 61st Infantry. Age 21; drug clerk. A maternal aunt was insane. The patient was "sickly" until 2 years of age, had enuresis until 8, and was regarded as a "nervous child." He finished high school at 18. In July, 1918, he was in a quiet sector, but in September, 1918, during the St. Mihiel operation, he was under fire for two days and became "unnerved and fearful." Beginning October 10, in the Verdun region, his sleep became poor, and he was bothered by battle dreams, horrible sights, etc. October 12 he lost his company (a not infrequent occurrence among these cases) and said he scarcely remembered what he was doing. He remembered, however, wandering about among the organization of the 30th and later the 7th Infantry. Toward night he saw a soldier stagger from the woods, and started to give him first aid when a shell exploded and cut the man in two. The patient dropped his gun and ran terrified until exhausted. He was picked up and sent to the neurological hospital on October 17, complaining mostly of "nervousness, poor sleep, and upsetting dreams." His deep reflexes were increased, but there was no evidence of organic disease anywhere. He asked for work in the rear of the front line and said he could never stand shell fire again. There was some emotional instability; he wept easily; and he was terrified at the prospect of front-line service. He seemed to get a better grip on himself, and was returned to duty several weeks later. The armistice precluded a probable relapse.

ARMY NEUROLOGICAL HOSPITAL NO. 2, FIRST ARMY

Neurological Hospital No. 2, established at Toul, September 7, 1918, became a part of the Justice Hospital Group and occupied one of the series of buildings which had formerly been a French barrack.12 The building was a four-story, stone structure with a capacity of approximately 800 beds. In addition to this building, there were available one small building, which had been employed previously by the French as an infirmary, with facilities for 40 patients, and two other small buildings. Of the latter, one contained three rooms, two of which were used as officers' quarters, and the third, a good-sized room, as a recreation room for officer patients; the other building, situated at the gate, contained seven small rooms which were used as quarters for the female nurses.

Since the buildings were not in fit condition to receive patients, it was necessary to employ a number of French women, who, with the nurses and enlisted personnel, proceeded to clean up the buildings. In less than a week's time and quite in time for the St. Mihiel operation, which began on the 12th of September, 600 beds were ready for patients.

The St. Mihiel operation lasted about four days, that is from September 12 to 16, and the number of war neurosis cases admitted was surprisingly small, owing to the character of the operation. The rapid retreat of the Germans, the comparatively small amount of exposure to high-explosive shells, and the brevity of the operation which eliminated in a large part the element of exhaustion, were the factors responsible for this small number of cases.

During the month of September, 325 cases were admitted to this hospital. Of this number, 44 per cent were returned to duty, 35 per cent were evacuated


344

to Base Hospital No. 117, 15 per cent were evacuated to Base Hospital No. 116, and 6 per cent to other hospitals.

During the month of October the number of cases admitted was 116, being an average admission of about 4 per day. Of this number 101 were returned to duty. The sources of admissions were other hospitals where the patients had remained various lengths of time. The average duration of the stay in the hospital for these patients was 21 days. This was due to the fact that many of the cases developed acute influenza and other conditions which required modifications of the treatment established for cases of war neuroses.

This hospital was abandoned on November 5, when part of the personnel was transferred to Neurological Hospital No. 1 of the Second Army and others returned to their proper stations.12

ARMY NEUROLOGICAL HOSPITAL NO. 3, FIRST ARMY

When preparations were being made for the Meuse-Argonne operation it was thought that the two neurological hospitals already organized would be insufficient to provide for cases which were expected to develop as the result of this operation. The hospital at Toul was too far removed from the seat of operation to be available. The hospital at Benoite Vaux could not receive men who were evacuated from the American front along the road leading south to the east of Souilly, or admit patients from divisions in the rest area along that road. The senior consultant in neuropsychiatry planned, therefore, to establish a third neurological hospital somewhere in the neighborhood of Souilly, where a group of evacuation hospitals was located. The hospital at Benoite Vaux was then about 15 miles behind the front line. It was the plan to establish Army Neurological Hospital No. 3 somewhere farther to the west and approximately the same distance from the front lines. Thus evacuation from the front could be made directly from field hospitals to Army neurological hospitals without first unloading patients at evacuation hospitals. The Army neurological hospitals were situated parallel to the evacuation hospitals and were within easy reach of the field hospitals by ambulance.

The site chosen for the third neurological hospital was Nubecourt.13 Army Neurological Hospital No. 3 was established in buildings which had been occupied by the French as a neurological unit. This was known as Ambulance 8/V, during the French occupation of the Verdun section. The building consisted of a 12-room dwelling house, 2 barrack wards, and several outbuildings, making possible a total capacity of 220 patients. By the addition of tentage the hospital was further enlarged to a capacity of 400 patients. Army Neurological Hospital No. 3 was situated on the main road from Clermont-en-Argonne to Bar-le-Duc. It was also about 6 miles from Souilly, and thus connected with the road from Verdun to Bar-le-Duc. This unusually favorable situation of the hospital greatly facilitated the evacuation of soldiers from the front areas.

In accordance with verbal orders of the representative chief surgeon of the First Army, on September 22, 1918, this unit was placed in operation.13 Four medical officers were transferred to it from Neurological Hospital No. 1. Thirty enlisted men were transferred from Army Neurological Hospital No. 1; of this number 20, including two sergeants, were on temporary duty from Base Hospital


345

No. 117, while the remaining 10 belonged to Evacuation Hospital No. 10. Supplies were obtained from the advance medical dumps at Souilly.

This hospital, from the moment of its establishment, began to operate actively. As many as 242 cases were admitted during the first eight days of its existence, when the Meuse-Argonne operation began. Of this number, 229 came directly from field hospitals and were transferred by ambulance or trucks directly from the front. This number represented the personnel of 16 different units, of which 12 were divisions.

The memorandum which follows, sent September 30, 1918, by the senior consultant in neuropsychiatry to the chief surgeon of the First Army, is significant as indicating the value and success of this new type of hospital:14

The inclosed table shows the divisions from which patients have been admitted to Neurological Hospital No. 3 at Nubecourt up to noon to-day. It is seen that the 35th Division contributed nearly 60 per cent of all admissions. This is due to the fact that the division psychiatrist was not permitted to retain nervous cases in the divisional hospitals on account of the refusal of the divisional officer having charge of evacuations. The only other two divisions which showed a large number of admissions (37th and 9 1st) had accidents to their triages which somewhat upset the place.

The significance of this table is that 7 officers and more than 100 effective men were needlessly lost to their division at a time when every officer and man was of the utmost value. Nearly all the cases received at this hospital from the 35th Division were of the type which in other divisions are being returned directly to their command after a few days' rest and treatment.

No action is required in this matter on account of the cooperation which has been secured with the division surgeon. I am bringing it to your attention simply as an illustration of the advantage of the plan which you have approved. If all the divisions engaged had contributed an equal number of cases more than 1,000 men would have been lost within the last 5 days from this controllable cause of noneffectiveness. This is certainly important from a military point of view, but more important still is the bearing which the evacuation of such cases has upon morale and the prevalence of these disorders.

During the month of October the activities of this hospital were very great, owing to the character of the Meuse-Argonne operation, and it was necessary to increase its personnel in order to cope with its work.15 The report made by the commanding officer showed, on November 1, an increase in the personnel, consisting of 6 medical officers and 17 enlisted men.15 During the month of October, 868 patients were admitted to this hospital from 32 different organizations, of which 20 were divisions in the line. Of this number, including 242 patients who were held over from the last month's report, 561 were returned to duty and 307 were evacuated to the rear. Of those sent to the rear, 203 were sent to Base Hospital No. 117. The latter were cases that had not recovered during a period of two weeks and required further treatment and observation.

The total number of cases treated at this hospital from September 25 to November 19 was 1,169. Of this number, there were 852 cases which could he diagnosed as psychoneuroses. Of these 852 cases, 614 were discharged as recovered. Of the cases received at this hospital to which the diagnosis of psychoneurosis was made, which did not include the cases of exhaustion from exposure or from overexertion and influenzal conditions, the total percentage of cases returned to duty was 73.12 per cent, the length of stay in the hospital was 10.4 days.


346

The same psychotherapeutic principle which governed treatment in the divisions and at Neurological Hospitals Nos. 1 and 2 were employed. The methods by which they were put into effect at this hospital can be seen best by quoting from a report made by the commanding officer to the senior consultant in neuropsychiatry, as follows:16

As to the description of methods of treatment and management employed, the following may be said: The simplest form of therapeusis, consisting largely of hygienic measures, sufficed in the great majority of cases. These included such measures as food in an easily assimilable form, a hot bath, clean clothes, and absolute rest in bed for a period of from 24 to 72 hours after admission. In the cases exhibiting active motor symptoms, semisequestration, by such means as screening or use of single rooms for a period of one to four days, was found adequate for the removal of these phenomena. During this time of forced rest in bed the patients were not permitted to leave the inclosure, even for brief periods. No intercourse with other patients or with ward masters was allowed except as necessary in the routine of ward management. In no case was this unsuccessful. After a period of primary physical rest had been secured, the patient was provided with a clean outfit of clothing, including a properly fitting uniform. He then engaged in light forms of occupation (for a period of one or two days more), such as assisting in the sanitary care of the ward. At the end of this time he was sent for more advanced treatment into a workshop supplied with tools and materials for woodworking and such metals as tin, copper, brass, and iron. The capacity of the shop was 50 men. It was under military control, and activity in one or more of its departments was insisted upon. Constant supervision, instruction and aid being afforded by instructors. The ward surgeon designating certain patients for this form of therapeusis specified "whole" or "part-time" occupation for them. Each afternoon, weather permitting, the patients designated by the ward surgeon were assembled in military formation and conducted in charge of a commissioned officer on an easy march for a distance of from 3 to 6 kilometers.

Verbal orders for the discontinuance of the unit and the return to the supply stations of material were issued by the chief surgeon, First Field Army, American Expeditionary Forces, on November 19, 1918. The patients were disposed of and the material returned as ordered. The unit handed over to the French authorities the material which had been left by the French Ambulance 8/V when Neurological Hospital No. 3 was organized. The personnel was sent to Base Hospital No. 117 except for a section of 3 officers and 10 enlisted men, who were directed to report to Evacuation Hospital No. 6 for temporary duty in accordance with directions of the chief surgeon, First Field Army, American Expeditionary Forces, dated November 19, 1918.16

PSYCHOSES OBSERVED AT THE FRONTe

The following observations relative to psychoses seen at the front are pertinent:

There was observed in a small number of the cases admitted to the First Army neurological hospitals situated at the front, mental states analogous in their coloring to certain recognized psychoses, but which did not present the complete clinical picture or follow the same evolution of these diseases.

The statement is frequently seen in literature that war does not create any special type of psychoses. To a certain extent this is true. The cases of actual psychoses observed in psychiatric units in the Army fall into groups which

eBased on: Psychopathic Reactions to Combat Experiences in the American Army, by John H. W. Rhein, M. D. American Journal of Insanity, Baltimore, 1919, lxxvi, 71.


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include manic-depressive psychosis, dementia præcox, paresis, epileptic insanity, and alcoholic psychoses. These are, in the main, conditions which are not peculiar to war.

But there are mental states which are seen in soldiers exposed to combat experiences, and who are admitted to the hospitals at the front, which may be considered directly related to war. These have already been described by French, Italian, and Russian observers. They occur in small numbers, only at the front; the symptoms are on the whole of short duration; they are directly related to the severe emotional and exhaustive front-line experiences; they show certain well-defined characteristics, and represent abnormal reactions in the sphere of the psychic, due to severe emotional experiences.

One of the forms of these mental states which were observed in a few cases was that described by Chavigny as aprosexia, or an inability to fix the attention. In this condition the soldier is unable to concentrate his attention upon the questions of the examiner, his eyes constantly move from the face of the medical officer to one or the other side, at times as if he saw some object of a frightful character, making no reply to questions and apparently oblivious to the presence of the examiner. These symptoms persist a few hours to a few days as a rule and finally disappear entirely.

A fairly common type observed was a state of mental confusion associated with what has been termed oneiric delirium, symptoms which were associated with a history of concussion and exhaustive experiences. These symptoms were at the same time susceptible of cure in a short time.

A third form which was observed consisted of a state of stupor associated with negativism and some catatonic phenomena suggestive of dementia præcox. In some cases the symptoms recall the paranoid variety of this disease. This type has been referred to by Davidenkof, who described states of hallucinatory mental confusion with pseudohebephrenic manifestations without the true picture of dementia præcox.

The following cases are interesting as illustrating some of these features:

A. B., private. Aged 31. In civil life a teacher by occupation. His father had suffered from a nervous collapse at the age of 47. The patient had been a stammerer and had suffered from three nervous breakdowns in 1900, in 1903, and in 1915. He enlisted in September, 1917, went to France in July, 1918, and had been in the post office of Dieulard since September 15, 1918, where he had been exposed to shell fire, though none burst nearer than 70 yards. The shelling had upset him and made it difficult for him to concentrate on his work. Two weeks prior to admission an agent for the Stars and Stripes gave him some candy which he later threw away because he believed there was poison on it. Again, a week later, a soldier borrowed his canteen and when he returned it the patient noticed a peculiar taste in the water when he drank from it, and he concluded that his companions were giving him some poison to make him erotic. On admission he complained of "being worn out," of a sense of tension on both sides of his head and the back of his neck, and a tingling in the arms and legs. He was apathetic, suspicious, uneasy in his manner, indifferent, and showed delusions of persecution. There were no hallucinations of sight or hearing. The symptoms improved somewhat during his stay in the army neurological hospital, but he was evacuated to the rear for further treatment.

This case represented a reaction which suggested the paranoid form of dementia præcox.


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J. J., private. Aged 24. Was employed as a locksmith in civil life. He entered service in February and went to France in May, 1918. He was evacuated to the army neurological hospital from the Argonne front. On admission he refused to give any data regarding his family or previous history, nor would he discuss any of his war experiences. He was reticent, suspicious, and his answers to questions were so unsatisfactory that it was possible to obtain only a meager portion of the trend of his thoughts. He was evidently a victim of a conspiracy which had been formed for the purpose of blocking the workings of the Government. He had been in communication with Thomas Edison, but due to the spy system the work in this line had been interfered with. He said that everyone with whom he had come in contact had attempted to do him harm. Because of his persecutory trend he refused to discuss the details of his mental state, believing that the examiner was in league with the gang, who had persistently interfered with his ability to do good work for the United States Government. He was evacuated to the rear after three days' treatment, during which his symptoms had improved to a certain extent.

This case illustrated again a paranoid reaction suggestive of dementia præcox.

G. C., private. It was impossible to obtain the family or previous histories, or any information relative to the origin of his present condition. He was evacuated to the army neurological hospital from the Argonne front. He appeared to be constantly in a confused state, and refused to make any replies to questions put to him. He occasionally would mumble some words in Polish which were evidently of a religious character, assuming at the same time an attitude of prayer. He was rather emotional and would weep without provocation. He lay quietly on his bed showing no interest in his surroundings. Frequently his lips were observed to move as though praying. He was dull, stolid, and stupid in his manner, frequently put his head on the table and wept, occasionally nodded his head in reply to a question but would not talk. When asked why, he pointed to his larynx. He was evacuated to the rear in two days showing no change in his mental state. His condition was one of confusion associated with some negativism and depression.

J. K., corporal, aged 27. In civil life an oiler and coal breaker. The family history was negative. He had arrived at the 5th B grade and had never been sick in his life. He enlisted in April, 1917, and went to France, May, 1918. He went through the Aisne and St. Mihiel operations without mishap. On the Verdun sector he carried on under shell fire for three nights and two days. He then believed that his sergeant had induced him to maladjust his gun, which resulted in the death of three American soldiers. He looked upon the sergeant as either a German sympathizer or a German spy. He was somewhat confused but adhered to this statement over and over again. He complained of a heavy feeling in his head on admission and was unable to recall everything that had transpired previous to his admission. He was very much depressed, the depression centering around the death of his companions which he believed he had caused. The physical condition was negative outside of some stammering. At the end of three days he cleared up entirely.

L. M., private, aged 36. In civil life a railroad worker. The family and previous histories were negative. He enlisted April, 1918, went to France July 12, 1918, and was in the Toul and Verdun sectors. He was sent back from the Argonne front during the operation in October. He believed that he had gotten in bad in the camp from which he had come, and that several of the men were going to kill him. There was a plot going on in the ward also to kill him, and he heard the conspirators planning to make away with him before he went to sleep. He said he had come to the hospital because he did not want to "be shot like a dog. I want to go in some other outfit and get killed for my country." There was some concern and feeling about his situation, but on the whole he lacked insight. He was quite tense, did not understand why his enemies had it in for him, and feared he would be killed or court-martialled. He was evacuated to the rear in four days, somewhat improved.

The manic-depressive reaction was probably seen more frequently than any of the mental states under discussion. As a result of some intense emotional


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trauma a soldier suddenly became wildly excited, associated with tremendous physical agitation and oneiric delirium, a condition suggesting mania.

These cases were seen in small numbers in field hospitals, where they required packs and hypodermic injections of morphine, the excitement subsiding in large part before they arrived at the army neurological hospital.

The following cases illustrate more particularly a mild manic reaction characterized by excitement, and associated with partial amnesic states:

R. D., sergeant, aged 27. In civil life an assistant sales manager. His father died of cancer, but otherwise the family history was negative. He was more or less disturbed by the sight of blood and the killing of animals, but in other respects his previous history was negative. He had spent two years in college. He was drafted in September, 1917, and went to France, May 31, 1918. He was with the British at Arras and then went to the Verdun sector on September 26, where he was obliged to do the work of his sergeant major, who had been killed. He was worried and disgusted by the lack of blankets, lack of artillery support, and the lack of ambulances at this time. Shells made him nervous previously and his nervousness continued to increase until finally a shell killed the adjutant, wounded another man, and threw dirt on himself. He became wild, crying and shaking in an uncontrollable manner, and was evacuated. On admission he presented evidences of fatigue, some tremor, and was physically restless. He recovered entirely and returned to duty at the end of two weeks.

L. B., private. In civil life a clerk. The family and previous histories were negative. He entered the service April 25, 1917, and went to France March 22, 1918. He had been under shell fire at St. Mihiel and gave a good account of himself during this operation. At the Argonne front he had been under shell fire a few days when he was blown over by a shell which killed two of his companions. He was dazed and lost complete control of himself, ran about in an aimless and excited manner, and was so violent and difficult to manage that the medical officer gave him a hypodermic of morphia. Upon admission he complained of tremulousness and nervousness and would start upon hearing sudden, unexpected sounds. He slept with difficulty and dreamed of war scenes. He also complained of a feeling of insufficiency, but otherwise the examination was negative. He returned to duty in three weeks.

A. H., aged 24, private. In civil life a contractor. The family history was negative, except that one sister was nervous and excitable. The patient had finished the first year at high school and presented a negative history, except that he was a bed wetter until 10 years of age, had always been easily frightened, and had suffered from nightmare. He enlisted May, 1917, went to France May, 1918, and to the front in June. Shell fire had always made him a little nervous, and he gave a history of very little rest and not much to eat. In October on the Verdun front a shell landed 25 feet from him. He began to "shake, pant, and sweat," felt chilled, "went wild," and ran around in an excited, confused state, and did not know what he was doing. On coming into the hospital he complained of weakness and headaches. He presented, on examination, a neurotic make-up, cleared up under rest, and returned to duty in a few days.

E. W., private, aged 27. In civil life a laborer in a steel mill. He attended school until 13 years of age, and was able to read and write. His mother was nervous and one sister had "falling spells." He himself had had nightmares and had walked in his sleep. He was drafted in September, 1917, and went to France May 30, 1918. He was in the Elbert sector in the trenches 10 days, went to Verdun September 26 and was blown over October 24. He stated "that the whole thing had practically demoralized him." He was in a shell hole when two shells struck near him. Shortly afterwards he remembered that he was running away greatly excited, yelling and crying. He went to the first-aid station and was evacuated. Upon admission he had recovered largely from his excitement and in a few days was practically well.

L. P., private, aged 23. In civil life a farmer. The family history was negative until June 3, 1917, when he was kicked in the thigh by a horse and was in a hospital for weeks,


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since which time he was easily startled, fearful, and apprehensive. He entered the service April 1, 1918, and went to France June 27, 1918. He was sent to the Argonne front in October, where he encountered his first experiences under shell fire. He was there for eight hours and got along very well, being under heavy fire nearly all the time. He saw several of his officers and men killed and became more and more nervous, until finally was unable to carry on any further and was taken to a dressing station. Here he was very much excited, tremulous, and nervous, and "would become crazy when he heard the explosions." On admission to the neurological hospital he was excited and tremulous, started at unexpected sounds, and could not sleep. He improved greatly under treatment, but was sent to the base neurological hospital for further rest and treatment.

There is a small number of cases belonging to this group, on the other hand, in which the symptoms took a depressive coloring. Usually the picture was one of simple depression associated with preoccupation and sometimes with hallucinations and depressive delusions.

J. B., French Canadian, private, aged 31. In civil life a laborer. One brother, an alcoholic, died insane. The patient had an attack of some mental disorder of unknown character in 1911. He was drafted in June, 1918, went to France in September, 1918, and went at once to the Argonne front, where he passed through Clermont and Montfaucon. While helping to bring in food, he said, God's voice said to him, "Leave this place at once before something happens." He started to run and though he heard a sentry say "stop," the voice urged him on, and he ran in spite of the bullets from the sentry's gun, one of which gave him a flesh wound in the left arm. He stayed in the woods one night but was captured the next day, and ran away a second time, on the following day. On admission to the army neurological hospital he appeared to be a simple-minded French Canadian who was in a state of religious excitement in relation to delusions of persecutions and auditory hallucinations. He frequently repeated, "I don't feel quite right, I haven't done right, I didn't keep my promise to the priest to take 10 sacraments when I was sick last time." He believed he would not be pardoned. He improved considerably in a few days but he was sent to the rear, as it seemed advisable to give him a longer treatment than was practicable in the hospital at the front.

C. R., private, aged 25. In civil life a potter. One paternal uncle was insane. The patient had finished the fifth grade. He had always shown fear of the sight of blood and the dead. He confessed to have been depressed on numerous occasions in the past. He was drafted May 18, went to France July, 1918, and went to the Argonne front in October of the same year. Shells did not bother him until he saw many of the boys blown to pieces, when he began to get nervous. He was caught in a barrage and became very excited. Finally, at the end of two days a shell exploded near him. He was unable to tell what happened after that, but he believes he became unconscious. He reached a kitchen, but does not remember how he got there. On admission he was depressed, showed auditory and visual hallucinations, and was retarded in thought and action. He was emotional about his mother being home alone and could not understand why he did not get mail from her. His memories for events previous to the front-line experiences were good, but memories for the front-line experiences were hazy. He sat or lay in bed with his hands folded in his lap, silent, preoccupied, took no interest in his environment, and was somewhat disoriented. He improved considerably, but was evacuated to the rear for further treatment.

T. R., corporal. In civil life a carpenter's helper. Both father and mother died of tuberculosis. One brother was reported killed two days before he was admitted to the hospital. Otherwise the family history was negative. Outside of the fact that he was a bed wetter until 12 years of age and walked in his sleep, his previous history was negative. He enlisted in July, 1917, went to France in June, 1918, and went to the Alsace and Verdun sectors. He was very much exhausted by his first shell-fire experiences. He went to Verdun on October 8, and carried on well until October 10, when he heard of his brother's death from a friend, which upset him very much. He was in a trench when a German barrage was put over, some of the shells landing near him, none of which made him unconscious, however,


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but he became flighty, nervous, and weak. On admission his expressions was strained, his brows wrinkled and he was very much depressed. His depression centered largely around the death of his brother about which he was emotional. His insight was good and he was cooperative. He recovered in 10 days' time and returned to the front.

The front-line experiences which are practically similar as to exhaustion, commotional and emotional factors in all cases which show a reaction in the sphere of the nervous system, gave rise to a variety of reactions. These consisted in some cases of simple hyperemotivity which in itself incapacitated, in others it resulted in the occurrence of actual neuroses, and finally in a small number there occurred symptoms which presented a psychotic coloring.

The cause of this variety of reactions to identical experiences offers an extremely interesting field for speculation. Seemingly, it is due to the mental make-up of the individual. When the individual's balance is upset by certain conditions the reactions take one of a number of directions, the type of the reaction depending upon that particular quality of the mental make-up which predominates. We observe these reactions appearing in civil life in individuals who respond under stress more or less within normal limits. We see individuals who are considered normal, who under strain become depressed, excited or paranoid, conditions which may be looked upon as indicating the character of the mental make-up of the individual. These conditions may be regarded as mild transient psychotic states, peculiar to war, though the possibility of their occurrence in civil life, if the stress is sufficiently great, is not to be denied.

ARMY NEUROLOGICAL HOSPITAL, SECOND ARMY

The consultant in neuropsychiatry for the Second Army reported for duty with that army soon after its organization on October 10, 1918.17, 18 Plans were immediately projected to organize a neuropsychiatric service for this army, which included the establishment of an army neurological hospital to provide for the cases of war neurosis which, it was anticipated, would arise as a result of a military operation scheduled to begin in the latter part of October. The army neurological hospital was organized and established, therefore, on November 5, 1918. It was located at Varvinay,17 an advanced position, within 3½ miles of Mobile Hospital No. 39 and near Field Hospital No. 117, which had been at Commercy, but had been moved in a day from this location to a site on the outskirts of Varvinay. Varvinay was about 7½ miles behind the front line and near the roads which connected St. Mihiel, Commercy, and Toul with the front areas. There were on this site, when it was taken over, three structures consisting of a small German barrack, a small French barrack, and a third building which had been partly destroyed by fire. The latter was at once repaired and was used for storing medical supplies. In addition to these buildings, two tents were erected on the level ground adjoining these buildings. Above this site, on a hill, were three large wooden structures which had been occupied by a French machine gun battalion, and three cottages. These buildings, before the St. Mihiel operation were occupied by the Germans. Two of the large structures were used to house the enlisted personnel, another served as a mess hall, while the cottages were for officers' billets. The hospital had an electric lighting system. On the hill was a spring which afforded an abundant supply of good water to all buildings occupied by the hospital.


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The temporary personnel came from Field Hospital No. 117. This was augmented by men from Neurological Hospital No. 2, First Army, at Toul, upon the abandonment of the latter hospital, as recorded above. At this time two sergeants and six privates, Medical Department, attached for permanent duty to Neurological Hospital No. 2, First Army, were ordered to the neurological hospital of the Second Army for temporary duty.

Since military operations of the Second Army ended with the signing of the armistice on November 11, just a few days after they had begun,19 the activities of this hospital were likewise brief. The total number of admissions amounted to 12, and these were admitted on November 9. Of this number, 9 were returned to duty and 3 evacuated to the Base Hospital No. 117. All of these cases came from the 33d Division which was operating to the north of Varvinay.20 The hospital was closed on November 23, 1918.

REFERENCES

(1) Léri, Andre: Réforme, Incapacités, Gratifications dous les Néuroses de Guerre. Revue neurologique, 1916, xxix, 763.

(2) Roussy, Gustave, and Boisseau, J.: Un centre de neurologie et de psychiatric d'Armée. Paris, medical, 1916, No. 1, 14-20.

(3) Salmon, T. W.: The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army. Mental Hygiene, New York, 1917, i, No. 4, 509-547.

(4) Final Report of Gen. John J. Pershing, Commander in Chief, A. E. F.

(5) Report of the activities of the section of neuropsychiatry, A. E. F., made by Col. Thomas. W. Salmon, M. C., senior consultant, neuropsychiatry. On file, Historical Division, S. G. O.

(6) Letter from the senior consultant in neuropsychiatry, A. E. F., to the corps surgeon, First Corps, August 26, 1918. Subject: Establishment of neurological hospital at Benoite Vaux. Copy on file, Historical Division, S. G. O.

(7) Report of Medical Department activities, Base Hospital No. 117, A. E. F. prepared under the direction of Maj. W. J. Otis, M. C., commanding officer, undated. On file, Historical Division, S. G. O.

(8) Memorandum from the senior consultant in neuropsychiatry, to the chief surgeon. First Army, September 6, 1918. Subject: Neurological Hospital No. 1, First Army. Copy on file, Historical Division, S. G. O.

(9) Final report of the chief surgeon, First Army, upon the St. Mihiel and Meuse Argonne offensives, undated. On file, Historical Division, S. G. O.

(10) Letter from the commanding officer, Neurological Hospital No. 1, A. E. F., to the senior consultant, neuropsychiatry, A. E. F., November 10, 1918. Subject: Report for the month of October. Copy on file, Historical Division, S. G. O.

(11) Letter from the commanding officer, Neurological Hospital No. 1, A. E. F., to the senior consultant, neuropsychiatry, A. E. F. November 30, 1918. Subject: Report for the month of November. Copy on file, Historical Division, S. G. O.

(12) History of the Justice Hospital center, prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O.

(13) Letter from the commanding officer of Neurological Hospital No. 3, to the senior consultant, neuropsychiatry, A. E. F., October 1, 1918. Subject: Résumé of operations of this unit. Copy on file, Historical Division, S. G. O.

(14) Memorandum for Colonel Garcia from the senior consultant, neuropsychiatry, A. E. F., September 30, 1918. Subject: Character of cases admitted to neurological Hospital No. 3. Copy on file, Historical Division, S. G. O.

(15) Letter from the commanding officer of Neurological Hospital No. 3, to the senior consultant, neuropsychiatry, A. E. F., November 1, 1918. Subject: Résumé of operations of this unit. Copy on file, Historical Division, S. G. O.


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(16) Letter from the commanding officer of Neurological Hospital No. 3 to the senior consultant, neuropsychiatry, A. E. F., November 30, 1918. Subject: Report of operations. Copy on file, Historical Division, S. G. O.

(17) Report of Medical Department activities, Second Army, A. E. F., by Col. C. R. Reynolds, M. C., chief surgeon, Second Army, undated. On file, Historical Division, S. G. O.

(18) G. O. No. 175, G. H. Q., A. E. F., October 10, 1918.

(19) Major operations of the American Expeditionary Forces in France, 1917-18, prepared in the Historical Section, the Army War College. On file, Historical Section, the Army War College.

(20) Outlines of Histories of Divisions, U. S. Army, 1917-18, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College.

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