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Section II, Chapter IV

Table of Contents

CHAPTER IV

HOSPITAL FOR WAR NEUROSES (BASE HOSPITAL NO. 117)

ORGANIZATION AND ADMINISTRATION

The most important base hospital in connection with the care of war neuroses in the American Expeditionary Forces was the special one, Base Hospital No. 117, at La Fauche. The plan for this hospital was outlined in the report of the neuropsychiatrist detailed to study the care and treatment of mental diseases and war neuroses in the British Army.a As soon as the definite plans for this special base hospital, as outlined in this report, had been accepted by the War Department, efforts were begun at once in the United States to recruit and to organize the necessary personnel.1 The director of the National Committee for Mental Hygiene made a careful search among the various State and private institutions for nervous diseases throughout the country, in the effort to obtain men and women whose training and experience qualified them for this branch of the service. The medical officers thus obtained were sent to special hospitals in the United States and England for intensive training in neuropsychiatry until such time as the hospital in France had begun to operate. The enlisted men and nurses were assigned to duty in neuropsychiatric wards in military hospitals in the United States until March, 1918, when the unit was mobilized.1

Pending the arrival of this unit in France the senior consultant in neuropsychiatry made preparations there for the organization of this special hospital. The following memorandum was sent by him, February 9, 1918, to the chief surgeon, A. E. F. (the letter and inclosure which accompanied the memorandum are also given):2

1. If the attached recommendation for the establishment of a hospital at La Fauche for the treatment of war neuroses is approved, it is recommended that a cabled request be sent to the United States to transfer to that hospital, for duty, all medical officers, female nurses, and enlisted men, attached to Base Hospital No. 117, now on active duty in the United States and awaiting assignment to duty in France.

2. The commanding officer of that organization should be directed to bring all special hydrotherapeutic and electrical equipment in his possession, which is now ready for shipment. It is believed that all other equipment and supplies can be obtained from the medical supply depot here.

3. The medical personnel of Base Hospital No. 117 is made up of specially trained medical officers, female nurses, and enlisted men, and the number is much smaller than that of a military hospital of the same bed capacity, for the reason that patients will be employed extensively. The products of the shops can be used in other hospitals in France.

4. A copy of this memorandum, with inclosures, has been forwarded to the chief surgeon, L. O. C., through the chief surgeon, advance section, L. O. C., for his information.

aThis report is reproduced in full in the Appendix, p. 497, et seq.


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OFFICE OF THE DIRECTOR, DIVISION OF PSYCHIATRY, A. E. F., A. P. O. 731,

February 10, 1918.

From: Maj. Thomas W. Salmon, director, division of psychiatry.

To: The chief surgeon, G. H. Q., A. E. F.

Subject: Use of Camp Hospital No. 4 for treatment of war neuroses.

1. It is recommended that Camp Hospital No. 4 be designated as "Base Hospital No. 117," to be used entirely for the treatment of functional nervous diseases and that it be staffed by the neurological section of the personnel of this hospital upon their arrival in France.

2. It is recommended that, pending the arrival of the permanent personnel, this hospital be used for the treatment of cases of functional nervous diseases now in various hospitals and for the observation of mental cases from the training area. A temporary personnel of experienced medical officers and noncommissioned officers can be provided from members of the American Expeditionary Forces already enrolled for work in this type of hospital. The buildings can be used temporarily as indicated in the attached table and diagram.

3. The functional nervous diseases (hysteria, neurasthenia, psychasthenia) and other conditions to which the term "shell shock" has been applied in the British Army are responsible, in the present war, for a large wastage of otherwise effective men. Three per cent of all casualties and 20 per cent of all discharges for disability from the British Army have resulted from these disorders. Although they are most frequent in soldiers exposed to shell fire, they are not uncommon among officers and men in training. A number of cases among officers and men are now under treatment in hospitals in the American Expeditionary Forces and 4.5 per cent of all officers and men already returned to the United States for discharge have been invalided for these diseases.

4. These diseases are not only curable in the great majority of instances but their incidence among American troops will be determined very largely by the type of management employed. If they are regarded as incurable, except in special hospitals in the United States, and are all returned for treatment or discharge, several thousand more cases will result through the influence of this suggestion upon soldiers predisposed to these disorders than if they are efficiently treated and cured in France. In certain British "shell-shock" hospitals where the average period intervening between the onset of the disease and admission to a special hospital is about five months, less than 20 per cent are returned to duty of any kind. On the other hand, where these cases receive skilled attention in France, more than 60 per cent recover in an average period of treatment of only a few weeks. In the French neuropsychiatric centers established near the front, the percentage of recoveries is even larger.

5. These facts make it imperative for us to provide facilities for the treatment of this class of cases at the earliest possible date in order to check their incidence and to establish a sound method of management. Failure to do so is certain to open a serious source of wastage for the Army.

6. With this need in mind, a special hospital (Base Hospital No. 117) for the treatment of these cases and to serve as a clearing hospital for mental cases has been organized in the United States. This hospital has a very carefully selected personnel, nearly all of the medical officers having studied the war neuroses in special British military hospitals and all the female nurses and enlisted men having had experience with mental and nervous cases in civil institutions. Arrangements are being made for the attachment of the psychiatric section of this personnel to Base Hospital No. 8 upon their arrival in France, there to serve as a clearing hospital for the insane and mentally defective. This psychiatric section has a personnel of 7 medical officers, 6 female nurses, 7 noncommissioned officers, and 37 enlisted men. The remainder of the personnel constitutes the neurological section referred to in paragraph 2 of this letter.

7. Camp Hospital No. 4, at La Fauche, the location of which is indicated in the attached map, is particularly suited for the special purposes of a hospital for the treatment of the war neuroses for the following reasons:


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(a) It is in the advance section of the line of communications, providing ready access from the front and insuring the absolutely essential impression among patients that their disability is temporary and curable and that they are not going into a long invalidism or necessarily en route to the United States.

(b) It is isolated from other hospitals and from military training camps but near enough to a hospital center (Bazoilles) to permit the ready transfer of organic cases and other patients admitted through errors of diagnosis.

(c) It is on the outskirts of a village of about 20 houses, large enough to provide billets for part of the personnel if needed in future expansions and small enough to be free from the undesirable features of a large town.

(d) It adjoins a small chateau with extensive gardens and a swimming pool, both essential in the occupation and physical training which constitutes an important feature in the treatment of these cases, and providing a separate hospital for officers when operating at full capacity.

(e) It is surrounded by level fields, providing the ample space needed for drills and exercises.

8. It is recommended that the village of La Fauche be placed out of bounds for any other military purpose to permit the most effective development of this special hospital.

9. It is recommended that the observation ward in Base Hospital No. 66 be discontinued as soon as this hospital is ready to receive patients.

THOMAS W. SALMON,
Major, M. R. C., U. S. A.

Arrangement of standard camp hospital for use as neuropsychiatric hospital (capacity with temporary personnel 80; with permanent personnel 300)


Use of buildings in standard camp hospital

 

Use of buildings in neuropsychiatric hospital

Administration

Same.

Officers' quarters

Same.

Clinic

Same.

Operating room, X ray, laboratory

Same (electrical treatment in operating room).

Patients' mess

Same.

Bath house and disinfecting

Same.

Mess, officers and enlisted men

Same.

Barracks, enlisted men

Same.

Ward A (30 beds)

Nurses' dormitory.

Ward C (30 beds)

Ward for 15 acute cases requiring close supervision.

Ward E (30 beds)

Shops and gymnasium.

Ward G (30 beds)

Ward for 10 officers.

Ward I (30 beds)

Ward for 25 acute cases.

Ward K (30 beds)

Ward for 30 convalescent cases.


All the remaining buildings will be occupied when the arrival of the permanent personnel from the United States permits the hospital to be operated at full capacity.

The suggestions outlined in this correspondence were approved by the chief surgeon, A. E. F., and construction of the hospital was begun at once. It was ready for occupancy by the end of February, and since it was highly desirable to place it in use as soon as possible, recommendation was made to this effect, by the senior consultant, as indicated in the following letter from him to the chief surgeon, A. E. F.:3

1. In view of the desirability of receiving patients at Base Hospital No. 117 at the earliest possible moment, in order that soldiers with psychoneuroses now in other hospitals


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may receive special treatment and the precedent of returning such cases to the United States may be avoided, it is recommended that this hospital be opened with a temporary personnel pending the arrival of the regular personnel from the United States.

2. It is recommended that Maj. George B. Campbell, M. R. C., who has been ordered to report at Neufchateau for duty in the division of psychiatry be assigned as commanding officer of this hospital upon his arrival.

3. It is also recommended that the following commissioned medical officers, noncommissioned officers, and enlisted men of the Medical Department be relieved from duty at the stations set opposite their names and ordered to report to Maj. Thomas W. Salmon, M. R. C., for duty at Base Hospital No. 117:

Capt. R. W. Hall, M. R. C.

Division of psychiatry, Neufchateau.

First Lieut. E. McConnelly, M. R. C.

Red Cross Military Hospital No. 1, Paris.

Sergt. Hugh J. Rice

Base Hospital No. 66, Neufchateau.

Pvt. Pearl I. Wiley 

Do.

Pvt. Louis H. Tetu

Do.

Pvt. Richard O'Brien

Do.

Pvt. Curtis Senior

Do.


4. It is recommended that an experienced mess sergeant and 20 enlisted men of the Medical Department, one of whom is an experienced cook, be ordered to report for duty at this hospital.

5. The object of the above recommendations is to prepare the hospital so that patients may be received as soon as the necessary equipment arrives, to protect property, and to commence the cultivation of gardens and a farm, in order that this important feature of occupational therapy to be employed later may be successful.

6. It is recommended that all these orders he communicated by telegraph.

The following letter from the director of psychiatry to the chief surgeon, A. E. F., March 19, 1918, gives the main facts in the establishment of Base Hospital No. 117 and the early orders to transfer cases there:4

1. Confirming our telephone conversation of today, Base Hospital No. 117 (Camp Hospital No. 4) is prepared to receive cases of functional nervous diseases, a small, temporary personnel being on duty.

2. A rough draft is inclosed for a letter to be sent by your office to commanding officers of base hospitals regarding the transfer of suitable cases.

3. As it is practicable to care for only 30 patients at the present time, it is suggested that this letter be sent now only to Base Hospitals Nos. 15, 18, 23, 36.

4. As soon as the personnel for this hospital arrives, which will probably be about the middle of April, patients can be received up to its full capacity of 350, including 50 officers. At that time similar letters should be sent to all division surgeons as well as to commanding officers of all base hospitals.

5. It is requested that this office be furnished a copy of the letter in the form in which it is sent out.

1. Base Hospital No. 117 at La Fauche, a special hospital for functional nervous diseases (hysteria, neurasthenia, and the conditions commonly termed "shell shock") is ready to receive patients by transfer from base hospitals. As the full personnel for this hospital has not yet arrived in France, only a limited number of cases can be admitted.

2. You are authorized to transfer to this hospital patients likely to profit by the special treatment provided. It is important not to send mental cases (including not only the insane and feeble minded but patients in whom these conditions are suspected), epileptics, or cases of organic nervous diseases. Patients in whom there is doubt as to whether a nervous disorder is functional or organic should be transferred to this hospital. Cases requiring surgical care should not be transferred.

3. It is desired to emphasize the fact that this hospital is not intended to serve as a step in the evacuation of nervous cases to home territory. It was established and will be operated by a specially trained personnel for active curative treatment with the object of restoring to full military duty as many cases as possible, especially acute neuroses developing at the front.

4. Until provisions for officers have been made only enlisted men can be received.


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The early period of the hospital's service, from March 1 until the middle of June, 1918, is of minor interest. The total personnel consisted of 4 officers and 10 enlisted men.1 Admissions during March totaled 6; during April, 25; and during May, 51. The Base Hospital No. 117 unit arrived in La Fauche, France, June 16, 1918, and then the history of the hospital as an organization really began.

When the American troops were sent to the front in great numbers early in the summer of 1918, the needs of the hospital greatly increased. In consequence, the hospital rapidly grew in capacity, finally having a total capacity of about 1,000 beds.1 The necessity for facilities other than those afforded by the main group of buildings soon became apparent. The first addition to the hospital was a country house (the "officers' chateau") in a wood about a quarter of a mile away.1 This was opened early in June as a ward for officer-patients who had recovered but who needed a short period of convalescence before return to duty. In this more restful milieu, away from the acute cases which filled the barracks-wards at the central group of buildings, these officers could get better hold of themselves and regain the composure and self-confidence which are so imperative for one again to assume responsibilities.

Some deserted French barracks across the meadows about one-half mile from the hospital were taken over early in August, 1918, and converted into a convalescent camp.1 The capacity of this place was originally 125. Patients who had recovered from their symptoms were assigned there before being sent back to duty. Its routine consisted of daily calisthenics and drills. Any man whose symptoms developed again was returned to the hospital ward from which he came. The purpose of this place, like that of the "officers' chateau," was to give the men an opportunity to get hold of themselves and to fall back into military routine, before being returned to their organizations or assigned to duty elsewhere. The work was of such importance that at the time the armistice was signed the chief surgeon, A. E. F., had approved an increase in size to 1,000 beds. But the signing of the armistice put an end to further additions.

The patients were all discharged from this hospital by January 12, 1919, and the hospital ceased to function then. The personnel and records were transferred elsewhere, and the hospital was abandoned on January 31, 1919.

NURSINGa

Previous to the arrival of the unit, June 16, 1918, there had been no female nurses on duty at Base Hospital No. 117. The arrival of the chief nurse and her staff was followed shortly by the organization of systematic daily routine on the wards. Careful and orderly case records were kept, and the direction of the wards took on the same qualities that would be found in the best neuropsychiatric hospitals in the United States.

In order to familiarize the nursing personnel with the special clinical and therapeutic features of war neuroses, the medical director of Base Hospital No. 117 arranged a series of lectures by members of his staff. It was his purpose

aThe statements of fact appearing herein are based on a report of nursing at Base Hospital No. 117, made to the senior consultant in neuropsychiatry A. E. F., by Chief Nurse Adele S. Poston, U. S. Army. Copy on file, Historical Division, S. G. O.


360

to make plain to these nurses, who were unfamiliar with war neuroses, the nature and types of these disorders. The lectures included information regarding the general conception, classification, and clinical aspects of the war neuroses. Emphasis was placed upon the more common methods of treating these cases and the part of the nurse in their care and equipment. Nurses fresh from hospital experience with civilian cases were unfamiliar with the war neuroses and this plan enabled them to get an understanding quickly of the point of view toward war neuroses which had been developed by the American Expeditionary Forces medical personnel.

The nursing done at Base Hospital No. 117 was not nursing as one usually conceives it. There were few cases requiring bedside care. Patients who entered in such a condition were usually up and about shortly. The first day or two of the patient's stay in the hospital were critical ones. It was important, above all, that he receive no false impression regarding the nature of his disability and that those erroneous ideas of it which he held be corrected as soon as possible. The ward surgeon, of course, began to treat him, but it was also very essential to have the nursing personnel alert to the problem of overcoming his difficulties. The primary requirement for good nursing and successful treatment was not merely the individual attitude of nurse to patient or ward surgeon to patient, but the social atmosphere of the ward was all important. An atmosphere of cure was necessary in order successfully to cope with the patient's mental attitude. It was essential that the patient realize that his condition was amenable to treatment and that recovery of sufficient degree to return to duty was the customary outcome of the hospital's therapy. Patients were never allowed to settle into a too comfortable situation at the hospital, but were always kept aware of their responsibilities as soldiers.

To maintain the "return-to-duty" attitude in each man on the ward was the primary nursing problem in caring for war neurotics. A severe ward routine was maintained. This consisted of regular hours for rising, military inspection by the commanding officer and staff each morning, prompt response to kitchen and other details, and other military assignments made by the medical officer of the ward. In some cases the details took the patients out as early as 4 a. m. Competition developed among the various wards, not only in the matter of decorations and good housekeeping, but in ward morale.

The daily nursing routine of the ward was roughly as follows: As soon as the patients were out of bed, dressed, and had been to mess, if ambulatory, they were assigned to some form of employment. The assignments consisted, as mentioned before, of duties on the wards or in some other department of the hospital, or assignment to the workshop (occupational therapy hut), an important therapeutic center. The kind of work done by the patients was determined, of course, by the ward surgeon's opinion of his condition. Work on the wards was directed by nurses and attendants and that in the shops by reconstruction aides. The more arduous physical tasks, such as road building, were overseen by enlisted personnel.

The ratio of nurses to patients during the day was 3 to 35 and at night 1 to 35. It was important not to over-nurse a neurosis case, but rather to encourage the patient to do everything he possibly could for himself. The


361

success of the nursing personnel, of course, depended upon the individual personality of the nurse. There was a great deal of difference between wards. So much depended upon the morale of the ward that it was not unusual for cases to be assigned to special wards because the staff felt that they could not "hold on to a tic or coarse tremor" on a certain ward, the general attitude of the patients on that ward being such as to discourage the presence of that type of hysterical symptoms. The type of nurse that accomplished most with war neurotics was one who was understanding, cheerful, impartial, and patient. It was necessary for her to strike a happy medium between severity and excessive sympathy. Elements of both kindness and firmness were necessary, but in the right proportions.

It has been said that the major problem in caring for war neuroses was the morale of the ward. This was, indeed, a difficult thing to manage. For on the one hand it was the duty of the nurse to be sympathetic and to listen to the patients' complaints and yet at the same time to counteract their worries and anxieties with firmness and decision. The nurse had to realize that any too sympathetic attitude on her part, any questioning of the successful outcome of treatment, was liable to render the patient unfit for further military duty.

Another duty of the nurse was her aid in giving the ward surgeon information of service in determining a diagnosis and military classification. Being with the patients on the wards so great a part of the day, the nurse had a better opportunity to study the patient than did the medical officer in charge of the ward. Indeed, the main problem, from the military standpoint, of these cases was their future army usefulness, and for the determination of this for the patients on her ward the nurse gave the ward surgeon his most valuable information.

OCCUPATIONAL THERAPYa

The importance of the occupational therapy that was carried on at the Base Hospital No. 117 at La Fauche lies in the fact that it was the first time that this form of treatment was put into effect in a military hospital under what must be considered forward-area conditions, as in the early days of June, 1918, this hospital was about 30 miles from the front line. The further significance of the workshop in this hospital is associated with the kinds of patients that were treated there. The character of the cases and the fact that an attempt was made to treat them with all the methods that were in vogue in the best-equipped hospital in the rear and in the home area formed the two striking features of the use of a form of therapy which up to that time had been reserved for hospitals at base ports or for those forming a part of hospital centers.

In describing the methods that were carried out there, it must not be forgotten that Base Hospital No. 117 had a particular problem to solve in a medical way and that the necessity for a proper solution of this problem was never permitted to escape the minds and interests of the medical and nursing staff or the reconstruction aides who managed the workshop.

aThe statements of fact appearing herein are based on a report of occupational therapy at Base Hospital No. 117, A. E. F., by Chief Aide Meta Anderson. On file, Historical Division, S. G. O.


362

In Base Hospital No. 117 the use of work as a curative agency sprang, in the first place, from the necessities of the hospital in the early phase of its development. Before the regular staff had arrived and before the equipment had been brought over from the United States, when the hospital was simply an old field hospital with a few wards and a few medical officers, it received about 50 cases of what were afterwards called anticipation neurosis. These were soldiers who had never seen active service and had never been anywhere near the front lines but had developed neuroses either in America before sailing or en route to France. They presented a very unfavorable type of case, as may well be imagined. They were not war neuroses in the real sense of the term, never having been exposed to the traumata of warfare, but they presented symptomatically all the evidence of the most severe types of this condition. Treatment was extremely difficult because there was little either in make-up or temperament upon which to build. They represented as a whole the so-called neuropathic types of soldiers, the kind that were not at all adapted to the conditions of warfare. They would have been excluded from the Army if there had been in force the methods of elimination adopted later.

The hospital was much handicapped on account of the lack of roads and pathways between the rows of huts. It had been built on a field, and the wet and rainy winter had left it in a condition that prevented traffic of almost any kind reaching it. The first essential, then, was to build a road through the hospital connecting with the well-made French road leading from the highway to the village of La Fauche. Patients of all sorts were put to work breaking up stone and carrying it to make a foundation for a macadam road. The use of the stone-breaking hammer and the carting of the stones to the roadbed employed these patients for a number of weeks until the road was completed some time in May. The road was a model in its way and showed its value when the hospital grew to a capacity of 1,200 beds.

There were, of course, in this use of occupational therapy none of the refinements that were afterwards developed, and no attempt was made to emphasize the localization of therapeutic effort. It was occupational therapy in the broadest sense, and it had its effect on the patients simply because it gave them something to do and showed to those with paralysis and tremors that it was possible for them to carry out coordinated movements and to make use of their movements in the production of tangible results. From this very crude beginning the therapeutic workshop personnel, when they arrived for duty, found that the principle of work had already been established. The value to the individual patient was difficult to establish, as with this class little in the way of permanent improvement could be expected. Some of them did show rather good effects, and it was interesting to note that very few of them objected to this rather monotonous and tiresome form of work. The breaking of stone gives a good deal of opportunity to train coordination, and the use of a certain amount of skill is necessary in order to prevent injury to the hand holding the stone to be broken. The evidence of effort could be measured by the increasing pile of material, and the fact that this work was supplying a very practical need of which the finished portion of the road was the witness, formed the essential elements upon which the efficacy of any work scheme in treatment is based.


363

It accentuated further the fact that the type and kind of work are not of importance, nor is the output, either in quantity or quality. The things that count, however, are the physiological and psychological features that result from effort to overcome resistance. The crude and primitive employment of breaking into small fragments a bit of stone in order to build a road may be taken as an example upon which to base the principles of a work therapy on a more extensive scale. The very primitiveness of the instruments used and the use of the product suggest that something inherently deep down in man's make-up is touched in this performance. Road making is an ancient calling, and the soldier responded to this as he perhaps might not have to a more intricate task.

In its therapeutic effect, work is based upon very simple elements and these simple elements should always be thought of in planning its application to any individual. If the performance of breaking rock for the making of a road is examined, it will be found that certain necessary elements enter into it, and if a more intricate kind of work is studied, it, too, will be found to represent only modifications of these very primitive elements. If the problem of work therapy is studied as far as the neuroses are concerned, there appear certain requirements that must be met. These features are of two kinds: One is primarily mental or psychological; the other is physiological or mechanical. These features apply also to the two sorts of persons with war neuroses that benefit from work treatment. One needs it because there is some defect in coordination in a broad sense, and the other, because there is some psychological readjustment that demands attention. The exercise in coordination is found in the precision that is essential in using the hammer and in carrying out the necessary maneuvers in preparing and in handling the crude material. There is added to this an additional element that tends to produce precision of motion, and that is the danger of hurting the hand if the blow is not struck right. This makes for concentration and attention and brings into play the use of the eye at first to a great extent, and then develops an automaticity of movement that overcomes the excessive muscular activity that is associated with tremors and ataxic conditions. The development of strength, that is, muscular power, comes with the practice necessary to perform a definite task. There is, too, a certain amount of noise associated with breaking stones which was found to be a benefit to such cases as complained of being sensitive to sounds. This had to be overcome, and it was often found that the sound of the hammer against the stone was the best method of training this type of case to the usual hospital noises. The evidence of the productivity of effort could be measured by the pile of stone that grew up by each patient. The evidence of utility was the road itself, which the patient saw grow under his eyes. The psychological phase of this kind of work was found in the proof to the patient that a defect in muscular power must be only an evanescent one, if a muscle group that is not acting right is capable of carrying out effectively so complicated a type of movement as handling a hammer. The evidence of sufficient muscular strength was there to be seen. The conviction was forced upon the patient, therefore, that his defect was not only a temporary one, but that it was easily curable by the simplest of procedure-that is, use. The emotionally overloaded state that so many of these patients were in could be easily lightened by giving them a muscular outlet or rather an


364

effort outlet. Through their hands and fingers the emotional hypertension was sidetracked or exploded. In such routine work as this, automatic as it became afterwards in most instances, there was given to the patient an opportunity to face his own experiences, if he had any, or to face his present situation as it was interpreted to him by his medical officer. He could use his intelligence at the same time that he was carrying on his task.

This feature of this kind of employment therapy was used effectually in the material that came to the hospital later, when the more definite type of war neuroses, fresh from the combat area, arrived.

The emphasis on this simple type of work therapy is given because it underlies so much of the philosophy of reeducation and it opens the way for the proper appreciation of just what can be expected from treatment in the more exacting sorts of work that were afterwards used. What was lacking, of course, was the effect of the shop spirit as a whole, developed in a well organized shop, and the personal effect on the patient of skillful reconstruction aide or teacher. These elements can be supplied only by the presence of trained workers.

In the month of June the arrival of the complete staff at La Fauche and the increase in the number of available beds brought the hospital face to face with the duty it had been organized to carry out. Numbers of patients began to come, many of them showing the most severe symptoms of the war neuroses, and many of them comparatively fresh from the active fighting areas. The therapeutic problem was focused upon the cure of these patients as promptly as possible, and the return to active duty of as high a proportion of them as possible. From early in June until the end of the war nearly 3,000 cases of war neurosis passed through the hospital. A large proportion of these took part in some kind of work in the workshop as part of their treatment. It was possible to judge, therefore, with a fair approach to accuracy, just what this sort of work was able to do for them, and how necessary a part of the hospital for the neuroses is a workshop.

The base hospital unit contained a group of reconstruction aides who soon took over the task of running the workshop. Thus the occupational therapy became an established part of the routine treatment of Base Hospital No. 117, of which ward surgeons might avail themselves.

Owing to lack of room the workshop was set up at first in an unused part of a hut that had been a storeroom. A few tables were found, benches were made; and in a few hours patients had been assigned to the shop for treatment. Some weeks later a special Red Cross hut was furnished to the hospital and here the permanent quarters of the shop were established with increased equipment which was as satisfactory as could be expected in view of the difficulties in the way of transportation of such supplies.

The evolution in work therapy from that of stone breaking and road building to the craftsmanship that soon developed in the shop was a surprising and interesting thing. The shop, as a shop, began to have an influence on the patients in addition to the individual therapeutic effect of a specialized kind of work. It soon became a place where patients liked to be sent, and in its busy atmosphere the patients passed many hours during which they felt relief. During the whole period of the hospital's existence other types of work were


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continued, not only as a therapeutic method, but because the hospital could not have functioned without them. The policing of the hospital in the military sense of the term, that is, cleaning up the wards, kitchens, roads, etc., was done by the patients; and the road was kept in repair by them. The chopping of wood and the cultivation of the farm land surrounding the hospital were always considered a part of the patient's duty. They were told that in so doing these things they were carrying out in a practical way the prescriptions of the physicians who were treating them. About 85 per cent of the total sick population of the hospital were always engaged in work of some kind, most of it being prescribed by ward surgeons.

The workshop was considered a sort of specialized therapy directed to a more definite end, planned to treat some definite symptom or to meet some special indication, while the other work was regarded as a kind of therapeutic background underlying the whole scheme of curative effort. The physiological and psychological needs were met by the use of muscular effort in the production of tangible articles. The handling of the tools and the various movements of sawing, nailing, screwing, and hammering, and the finer and more coordinated movements of wood carving, metal work of various kinds, weaving, and tinning, as well as much more delicate and more emotionally inspired technique of painting, sketching, and printing, supplied the essential training that the paralysis, tremors, and other symptoms needed. In a sense all of these defects were due to an intricate psychological process in which disassociation of function was a predominant mechanism. The patient could not properly innervate a muscle group because there was a defect in the proper utilization of that group. The result was often exaggerated movements in which the inhibitive control and the habituated minimum of effort were lacking. In the same way tremors were primarily defects in motor control, as were purposeless and ataxic movements of the choreiform types.

Motor reeducation, at first conscious and then automatically carried out, was required. The handling of tools awakened a dormant muscle control, shocked out of consciousness for the time being, and tended to restore the normal and habitual pathways long ago acquired. The familiar grip of a chisel, the friendly feel of a hammer or a saw, reestablished the proper integration and the proper tonal balance in antagonistic muscle groups. These, as symptoms, were acting without any psychological law or purpose. The product that was being worked at gave the necessary interest and permitted the proper concentration. The movements were allowed to fix themselves in the proper channels and the emotional block which stood in the way was for the time being lost sight of and the individual used his hands much in the way that was customary with him. The evidence that this was possible was before him, an evidence that no amount of persuasion or explanation alone could at times accomplish. It must not be forgotten that a large proportion of American soldiers had used tools and implements before in their civilian life, and the traditional pathways, so to speak, were present and only temporarily out of action as a result of their condition.

No effort was made to select the kind of work from any other point of view than that of the immediate requirement in muscle defect that was present.


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The novelty of producing something that the patient had perchance never thought of doing himself lent an added interest to the carrying out of the job, but further than this no special effort was made to arouse any unusual interest in the thing itself. There was in this way a certain lack of rigidity in the shop that was one of its main features. Patients were sent there not to be amused or to pass the time away, but to be cured; often the therapy was directed to the local defect of the patient and the effort was planned for that symptom and for nothing else. To some of the patients the workshop was a place where they were exposed to a more invigorating influence than was present in the ward. This was particularly so in cases of depression and of apathy; and likewise in cases in which the prominent symptom was amnesia. In such cases the type of work and the product were of no importance whatever, nor was there a question of muscle training or education. Here the attempt was made to reassociate the separated bits of the patient's memory stream, and the stay in the shop was an extension of the effort of reassociation carried out in the medical treatment rooms by the several methods used in the hospital. The social element in the mingling with men and the doing of the bits of accustomed things, the talk and the noise of a shop, the familiar surroundings, all helped to that end. The automatic arousing of interest in the things that went on about him was an important element in the restoration of the patient to his normal condition.

The facing of the situation, a method which implies that the patient is told not to forget, but to remember past experiences and thus learn to compromise with them instead of dodging them, may be most successfully worked out if the patient is set to sketching or drawing the details of his experiences in the front lines, particularly those that preceded or accompanied the occasion when he was shocked or traumatized.

A number of such instances were found among the patients at Base Hospital No. 117, and the therapeutic result was very encouraging. These patients soon learned that it was the turning of their emotionally laden memories of terrifying experiences into pictures and sketches that gave them a definite feeling of relief, and that there was nothing in this kind of exercise that was at all in opposition to the work therapy. It was only a different way of arriving at the same result that was sought each day in their interviews with the medical officers who treated them. Of course, these drawings had a definite meaning and significance and they needed no interpretative mechanism to render them clear and distinct. As a contrast are the artistic productions of the insane which are often symbolically expressed and which act so often as a screen to the real meaning.

Whatever the psychical mechanism may be and whatever the place that emotion in relation to events may have, it is true that emotional states are relieved by muscular expression, if this expression is tangibly directed by the patient. In this truth lies undoubtedly one of the great therapeutic agencies in work.

The need of the articles which a shop could turn out was so great in the neuropsychiatric hospitals of the American Expeditionary Forces and the tendency on the part of those benefiting by these products to judge the value


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of the shop by its production, made it difficult to always keep in mind the fact that the occupational work was a means of treating patients rather than a means of turning out a factory product. The trained occupational worker, however, was able to organize the work in such a manner that activities and tasks were assigned to patients for their therapeutic value alone. It was the duty of the workers in charge of the shop to apply the pressure for production in such a way that it would be a therapeutic agent.

It appears to be good evidence that the medical officers believed thoroughly in the efficacy of occupational therapy when they extended the experiment to a hospital in the forward area with all the conditions and limitations which that implies. Although the experiment lasted but two weeks, the medical director reported that because of the establishment of the workshop with its aid in the treatment of the men, he had been able to send back to duty some men who had been on the list to be sent to base hospitals for further treatment.

REFERENCES

(1) History of Base Hospital No. 117, A. E. F., by Maj. Frederick W. Parsons, M. C., commanding officer, January 22, 1919. On file, Historical Division, S. G. O.

(2) Memorandum for the chief surgeon, A. E. F., from the director of the division of psychiatry, February 9, 1918. Copy on file, Historical Division, S. G. O.

(3) Letter from the director, division of psychiatry, to the chief surgeon, A. E. F., February 26, 1928. Subject: Temporary personnel for Base Hospital No. 117. Copy on file, Historical Division, S. G. O.

(4) Letter from the director of psychiatry to the chief surgeon, Advance Section, A. E. F., March 19, 1918. Subject: Transfer of patients to Base Hospital No. 117. Copy on file, Historical Division, S. G. O.

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