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Section II, Chapter VI

Table of Contents

CHAPTER VI

THE CARE AND DISPOSITION OF CASES OF MENTAL DISEASE

COLLECTING STATION

In Chapter I of this section explanation was made of the fact that, in general, it was planned by the Medical Department not to return to duty in France soldiers who had been admitted to hospital with psychoses or other mental diseases, but to return all such soldiers to the United States for further treatment. In carrying this plan into effect a collecting station for cases of mental disease was established for the forward area, at Base Hospital No. 116, an integral part of the hospital center at Bazoilles.1 Provisions also were made in other hospital centers, and at most base hospitals not connected with hospital centers, for suitable care of neuropsychiatric cases pending their collection at base ports with the view of their return to the United States. For present purposes it will suffice to state briefly, except in so far as the base ports are concerned, the activities of the neuropsychiatric department of the hospital center at Bazoilles.

NEUROPSYCHIATRIC DEPARTMENT, BAZOILLES HOSPITAL CENTERa

This department began to function on July 20, 1918, as a part of Base Hospital No. 116. Though nominally under the administrative supervision of the commanding officer of the base hospital, the neuropsychiatrist in charge of the department was permitted to exercise all necessary latitude in the operation of his department.

The buildings provided for the neuropsychiatric department consisted of six wooden demountable barracks, of the same character as those used throughout the center for wards and general purposes. These were 100 feet in length. They were located on relatively high ground, to the rear of Section IX of the hospital center, occupied by Base Hospital No. 81. Four of the buildings were used for patients, with a total normal bed capacity of 80. One building was used for administrative purposes as well as barracks for the enlisted personnel on duty in the department; another was used for kitchen and mess hall. After some months of operation, a building of standard width and 50 feet long was added to the group as a dormitory for nurses, thus permitting housing them at a convenient distance from the wards wherever they were on duty. At times, the patient capacity of the department was inadequate, thus necessitating using an additional ward of Base Hospital No. 116.

From three to five medical officers were on duty in this department during the greater part of its existence. The enlisted detachment consisted of 4 non-

aThe statements of fact appearing herein are based on the "History of the Bazoilles Hospital Center," prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O.


406

commissioned officers, 2 cooks, and 14 privates first class and privates. Ten nurses were required for the efficient service of the department, and their number usually was maintained at this figure. Trained personnel was furnished not only for conducting incoming patients to this hospital, but also for convoys of cases of mental disease proceeding hence to the hospital center at Savenay.

FIG. 2

For the period July 20, 1918, the date of establishment of the department, to April 30, 1919, 1,654 patients were admitted. These cases finally were diagnosed as follows:

Summary of diagnoses of cases admitted to the psychiatric department

Psychoses:

 

1. Dementia prŠcox-

 
 

(a) Hebephrenic

178

(b) Catatonic

28

(c) Paranoid

62

(d) Simplex

127

Total

395

2. Manic-depressive insanity-

 
 

(a) Depressed

96

(b) Manic

61

(c) Mixed

22

Total

179

3. Simple depression

24

4. General paralysis of the insane

28

5. Psychosis undetermined

24

6. Infective and exhaustive psychosis

7

7. No psychosis

13

8. Toxic psychosis

5


407

Constitutional psychopathic states:

(a) Inadequate personality

112

(b) Emotional instability

40

(c) Paranoid personality

31

(d) Sexual psychopath

10

(e) Pathological liars

5

Total

198

Defective mental development:

(a) Moron

256

(b) Imbecile

7

Total

263

Psychoneurosis:

(a) Concussion syndrome

2

(b) Hysteria

115

(c) Neurasthenia

37

(d) Psychasthenia

26

(e) Hypochondriasis

13

(f) Enuresis

1

(g) Stammering

1

(h) Effort syndrome

5

(i) Anxiety

4

Total

204

Inebriety:

(a) Alcohol

49

(b) Morphine

16

(c) Cocaine

1

Total

66

Epilepsy, idiopathic 

156

Cerebrospinal syphilis

36

Endocrinopathy, thyroid

13

Meningitis, cerebrospinal, epidemic

6

Miscellaneous:

Acute hallucinations

4

Traumatic psychosis

2

Hydrocephalus

1

Residual birth palsy

1

Division extensor tendon, ring finger

1

Embolism, pulmonary

1

Polyneuritis

2

Acute confusional state

4

Pulmonary tuberculosis

2

Paratyphoid fever

1

Peripheral nerve palsy

7

Labyrinthine hemorrhage

1

Acute bronchitis

2

Nephritis, acute

1

Progressive muscular atrophy

1

Spinal sclerosis

1

Typhoid fever

2

Toxemia, acute

1

Chronic prostatitis

1

Periostitis

1

Total

37

Total cases admitted

1,654


Disposition of cases (summary)

Evacuated to Evacuation Hospital No. 31, A.P.O. 731

3

Evacuated to Provisional Base Hospital No. 1, A.P.O. 731

4

Evacuated to Base Hospital No. 79, A.P.O. 731

18

Evacuated to Base Hospital No. 116, A.P.O. 731

24

Evacuated to Base Hospital No. 8, Savenay

623

Evacuated to Base Hospital No. 117, A.P.O. 731

17

Evacuated to Base Hospital No. 214, Savenay

909

Evacuated to Evacuation Hospital, Neufchatau (French)

2

Evacuated to Tours

5

Evacuated to Hospital Center, Angers

27

Evacuated to duty

9

Evacuated to Assistant Provost Marshal

5

Absent without leave

1

Died:

Manic exhaustion

1

Cerebrospinal syphilis

1

Pneumonia, lobar, acute, bilateral

1

Pneumonia, bronchial, acute bilateral

1

Meningitis, acute suppurative

1

Typhoid fever

1

Pulmonary embolism

1

Total cases disposed of

1,654


Summary of monthly disposition of cases

Total number of evacuation by months:

July, 1918

54

August, 1918

132

September, 1918

149

October, 1918

128

November, 1918

200

December, 1918

125

January, 1919

156

February, 1919

257

March, 1919

262

April, 1919

184

Total number of cases evacuated

1,647

Died

7

Total cases disposed of

1,654



409

SPECIAL TREATMENT HOSPITALS

BASE SECTION NO. 1

It was at Base Hospital No. 8, Savenay, in February, 1918, that the first special provisions for mental patients in France were made. Before that time only the roughest makeshift methods existed. In the early period of the existence of the neuropsychiatric department of this hospital, from January 1 to June 1, 1918, it consisted of two wooden barracks of a capacity of 90 beds each. An interesting feature of this organization was that the mess hall for patients suffering from mental and nervous diseases was not separate, but the neuropsychiatric patients, except those who were disturbed, ate with the other patients of the hospital center. One ward was partitioned off to care for patients who were disturbed and consequently needed to be closely supervised.

FIG. 3

The total admissions during the first five months of the existence of the special neuropsychiatric service of Base Hospital No. 8 was 369. After June 1, 1918, the admission rate rapidly increased. The admissions in June were 256, just about two and one-half times the admissions in May.

On June 11, 1918, the personnel of Base Hospital No. 117 arrived at Savenay from the United States.2 This was a very important event in the neuropsychiatric work of the American Expeditionary Forces. Although all the personnel for the long-awaited special base hospital for war neuroses which had been so carefully recruited in the United States could have been used at

bUnless otherwise indicated, the statements of fact appearing herein are based on the "History of the Savenay Hospital Center," prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O.


410

La Fauche, where a nucleus for the new hospital was already in operation, the care of mental patients at Savenay awaiting transportation to the United States also required trained officers, nurses and enlisted men at this base port. Accordingly, 3 medical officers, 28 nurses, and 33 enlisted men were detailed to staff the rapidly growing psychiatric department at Savenay.

This detachment of a goodly portion of the personnel from Base Hospital No. 117 unit was in conformity with the following letter from the senior consultant, neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., which had been written in the preceding February:3

1. The personnel of Base Hospital No. 117 (neuropsychiatric hospital), now under orders to proceed to France, is made up of medical officers, noncommissioned officers, female nurses, and enlisted men who have had experience in the care of mental and nervous diseases. As it was thought wise, in organizing this hospital, to consider the possibility of having to establish it in two sections, "psychiatric section" for the treatment of mental diseases and "neurological section" for the treatment of the neuroses, the personnel was selected with this contingency in mind.

2. As the plan of staffing the psychiatric department established at Base Hospital No. 8 with part of the personnel of this hospital and the hospital for neuroses at La Fauche with the remainder has been decided upon it will be necessary to divide the personnel upon the arrival of the unit in France.

3. It is recommended, therefore, that the plan of division indicated in the inclosed tables be adopted.

4. It is not practicable to suggest the assignment of medical officers until the names of those accompanying the unit from the United States are known. These officers will be the commanding officer, the adjutant, an electrotherapist, and three ward physicians. When this information has been received it will be possible to complete the personnel from medical officers in the American Expeditionary Forces and in the special military hospitals for mental and nervous diseases in Great Britain.

5. It is recommended that the Surgeon General be requested to cable the names of the medical officers who will be sent from the United States with this hospital and the date of their departure, in order that the necessary orders may be requested.

Until the arrival of the new personnel referred to above the psychiatric department had been conducted under the direction of a medical officer, with two or three young medical officers who had had psychiatric training and a few psychiatric nurses and enlisted men who had worked in State hospitals.

Additional wards now became necessary, for, with the increased participation at the front of many American divisions, neuropsychiatric cases increased at a more rapid rate. This is shown by the greater number of mental cases sent to Base Hospital No. 8, at Savenay, for treatment and for evacuation to the United States. In July, 405 patients were admitted; in August, 588; in September, 887; in October, 658; in November, 809; and in December, 412. In the latter part of August, 1918, three more wooden barracks were added, providing accommodations for about 500 patients. In the meantime, 11 wards of special construction had been erected for this service in a locality some distance from the main hospital. These wards, situated on a slight elevation of ground, consisted of the following buildings: One administrative building, in which were located the offices of the commanding officer, adjutant, and other personnel engaged in the routine administrative activities of the hospital; one ward for officer patients; a mess hall; a barrack for enlisted personnel; and a ward for disturbed patients. The remaining wards were of the uniform type,


411

with ample facilities for the care of these patients, including day rooms, shower baths, and toilet facilities. These additional buildings provided accommodations for something less than 200 patients, but by using officers' and enlisted men's barracks, the capacity was expanded to over 250. During this period, however, the barracks connected with Base Hospital No. 8 were still retained for neuropsychiatric purposes.

In October, 1918, four additional buildings of concrete block were added to the 11 wards above mentioned. When these were completed the original barracks of Base Hospital No. 8 were relinquished. No diminution occurred in the admission rate after the armistice began and, therefore, the unit, as finally constructed, proved inadequate. Indeed, in the late fall of 1918, admissions were so rapid that the commanding officer of the hospital center found it necessary temporarily to designate wards for the reception of neuropsychiatric cases in adjacent units, i. e., Base Hospitals Nos. 69 and 113. The following letter from the senior consultant in neuropsychiatry to the chief surgeon, A. E. F., explained the difficulties and needs of the hospital at Savenay late in October, 1918:4

1. The steady increase in the number of mental cases admitted to the psychiatric department of Base Hospital No. 8 shows that, in spite of better facilities for their transportation to the United States, more extensive arrangements for their care are needed than were at one time thought desirable.

2. Some idea of the magnitude of the problem of providing even temporary care for the insane of the American Expeditionary Forces is shown by the fact that more cases are admitted to the psychiatric department of Base Hospital No. 8 each month than in the psychopathic wards of Bellevue Hospital, which serves a city of more than 5,000,000 people.

3. In order to handle this question in a thoroughly satisfactory way, to relieve hospitals of these cases, and to evacuate promptly those collected in the psychiatric departments of the advance and intermediate sections of the S. O. S., it is recommended that one of the hospital units at the Savenay center now nearing completion be constituted a psychiatric base hospital and devoted entirely to this purpose.

4. Such provisions would increase the efficiency of the work, provide for any increase likely to be expected, and meet certain difficulties regarding disposition of personnel, care of insane officers, etc., which exist when such important work is carried on as part of another hospital. The buildings now used by the psychiatric department can be used to advantage for other purposes.

5. The personnel for such a psychiatric base hospital can be provided from the special personnel of medical officers, nurses, and enlisted men with psychiatric training now at Base Hospital No. 8 and from Neuropsychiatric Replacement Unit No. 1, which has recently arrived at La Fauche, and Neuropsychiatric Replacement Unit No. 2, which is expected to arrive shortly.

6. The personnel required for such a hospital with a capacity of 1,000 beds is as follows:

Commanding officer

1

Nurses, female

40

Medical director

1

Reconstruction aides

4

Adjutant

1

Noncommissioned

20

Quartermaster

1

Privates and privates first class

80

Dentist

1

Total

164

Chaplain

1

Mess officer

1

Registrar

1

Ward physicians

12

Total commissioned

20



412

7. The commander of the Savenay Hospital Center fully agrees in these recommendations and was the first to suggest this as a solution of a problem which is growing very rapidly in size and importance.

On November 6, 1918, the neuropsychiatric service at Savenay was organized as an independent unit, taking over the quarters already occupied. The hospital at this time was officially designated Base Hospital No. 214, A. E. F.

During the latter part of December, evacuations became so rapid and admissions were delayed to such an extent that for a short time there were but 65 patients in the hospital. The closing of Base Hospital No. 117, at La Fauche, however, soon increased the rate of admissions, so that early in January, 1919, the patient population of Base Hospital No. 214 exceeded 700, including 40 officers. The admissions during January, 1919, were 885, and in February, they were 824. This was quite in excess of the capacity, especially since, except as a temporary expedient, the use of wards of adjacent units was not feasible. Under these circumstances, the commanding officer of the center gave directions that one of the new 1,000-bed units be taken over as a neuropsychiatric hospital.

This new unit of 1,000 beds was occupied for the first time on January 21, 1919. The construction of the wards was not so well adapted as that of the first hospital, which had been designed for the purpose, and additional construction was necessary. A considerable part of this extra work was done by patients. A sitting room was built in one end of the officers' ward and furnished by the American Red Cross. A similar sitting room for nurses was arranged in another ward. A staff conference room was constructed in the officers' barrack. A diet kitchen, furnished by the American Red Cross, was installed in the building used for occupational therapy. Four wards were constituted closed wards, with screened windows, and in these wards partitions were constructed in such a way as to make patients' day rooms. One ward building was utilized for a Red Cross recreation hut, and appropriately furnished. The large building adjacent to the mess hall, used in other units for surgery and dressings, was fitted up for a work shop. This work shop was especially well equipped, for in it was placed the material formerly used at Base Hospital No. 117, consisting of brass work, tools, lathes, carpenter sets, and an acetylene welding apparatus.

The routine of the hospital was systematized in the following way: For purposes of classification all patients were admitted to one large admitting room of 90 beds. A special nursing force was maintained here. Observations by the staff were made at once in order to classify the cases as rapidly and accurately as possible. The ward surgeons and nurses of the receiving ward were especially well trained for this work. All patients, upon admission, were seen by the receiving officer and assigned to their proper wards. The case of acute psychosis, of chronic alcoholism, and of delinquency were sent at once to closed wards. Mild psychoses, epileptics, and mental defectives were kept in open wards under supervision. Cases of psychoneurosis were sent to separate wards, and, as soon as space was available, to the specially constructed wards mentioned above.

By examining and classifying every case at once, administrative difficulties were reduced to a minimum. During this period but two serious accidents occurred, although delinquents of every description came through the service. At the same time, patients were given as much liberty as possible, indeed,


413

liberties which in civil life would have been considered impossible. As before stated, there was no separate mess for many months, patients from neuropsychiatric wards going to the general mess. The Red Cross recreation hut of the center, likewise, was used by all, and the convalescent patients from the neuropsychiatric service often contributed to the entertainments by musical or dramatic performances.

Patients evacuated to the United States by months

January to June, 1918 (not recorded by months) 

116

July 

217

August

455

September

839

October

695

November

801

December

650

January, 1919

697

February

721

Total

5,075


The small proportion returned to duty-4.38 per cent of the total hospital service-tells the story of the main functions of this hospital during the period of active warfare and immediately thereafter. It served principally as a collecting center for difficult and chronic cases of nervous and mental diseases which were to be returned to the United States. Its problem was to study and to diagnose these cases and to provide specialists to care for them in France and while en route to the United States.

The organization continued to operate during the spring of 1919. At one time in April it had a population of 1,018 patients actually resident in the hospital. Evacuations were very rapid thereafter so that at the end of May the population fell to under 400. There were at that time from 60 to 100 cases among our forces in Germany to be sent to the hospital and a few cases were admitted daily from various other places. But with the rapid rate at which troops were sent back to the United States, the hospital population soon dwindled. On June 21, Base Hospital No. 214 ceased to function. The residue of the patients were transferred to Brest and to Base Hospital No. 113, where adequate neuropsychiatric services were maintained. Officers, nurses, aides, men, money, and workshop materials were sent to these organizations. The remainder of the unit returned to the United States.

CLINICAL SUMMARY

A large amount of clinical material passed through this hospital, no less than 6,093 cases having been admitted up to March 1, 1919. Observations were necessarily incomplete and the minute recording of cases impossible. The various types, some unusual in civil life, came under observation with such frequency that they became fairly familiar. The consequence was that clinical pictures, which otherwise would have been uncertain, became well established in the understanding of the staff. A statistical summary of the clinical material is given in the following tabulation, which likewise provides the major headings under which the clinical material will be briefly considered.


414

Mental and nervous cases classified D at Savenay in 1918-19

1918

1919 January-February

Totala

January-June

July-December

Psychoses

242

1,222

452

1,916

Constitutional psychopathic states

85

434

115

634

Mental deficiency

87

297

140

524

Epilepsy

79

574

99

752

Psychoneuroses

167

766

730

1,663

660

3,293

1,536

5,489


aThere were in addition 124 cases diagnosed "organic nervous diseases," which brings the total to 5,613.

PSYCHOSES

The number of frank psychoses, amounting in all to 1,916 cases, is probably not excessive considering the forces engaged. Interest in these cases is more in their clinical character than in their numbers. It was soon observed that, in addition to ordinary civil life types, many unusual cases were encountered. Although many familiar types of dementia prŠcox, general paresis, and other diseases were admitted, they were by no means the only types seen. Soon after active hostilities began, cases appeared with which the staff were unfamiliar in their civil life experience. In these unusual cases, the reactions and clinical pictures did not conform to any recognized types. It is possible that a number of these unusual cases might have become clearer by adequate previous histories and longer periods of observation. This, however, was probably not true of all; so that a tentative formulation of these unusual cases deserves mention at this time. They probably do not form a distinct class from every point of view. They doubtless have a common etiology, however, and they have groups of symptoms in common which are sufficiently striking to warrant them being discussed as a group. Such cases at this hospital were referred to by the staff as the "war psychoses," and so this term is somewhat arbitrarily used. The war psychosis, of course, is an interesting "situation" psychosis, and any clinical description of war neuropsychiatry would be incomplete without a discussion of it.

WAR PSYCHOSES

It has been stated by some observers that the war has failed to bring to light any unusual forms of mental disorder, all cases being merely those familiarly met with in civil life, possibly colored by a war setting. This is not in accordance with the observations of the staff of this hospital. Unusual grouping of symptoms, in fact, entire clinical pictures were encountered to such an extent, as stated above, as to warrant separation of these cases into a group.

The cases in question, termed war psychoses, were observed in considerable number. No actual record of their number was kept, but they probably amounted to one-fifth of all the cases diagnosed as psychoses. Many of them improved considerably while at the hospital, and it is quite probable that by the time they reached the United States the acute symptoms had disappeared.

The following clinical picture is a composite of what was most frequently observed. Patients on admission were dazed, confused, and disoriented, and as


415

a rule they were not accessible during the acute period. They generally thought themselves at the front under fire, and were anxious and apprehensive. They wandered about rather aimlessly and showed bewilderment and confusion. Some were quite agitated. Frequently they preferred to be by themselves and volunteered very little in the way of conversation. As a rule they were depressed, at times so profoundly as to attempt suicide. A few cases were observed in which there was an elevation of mood. The possibility of a manic-depressive condition was considered in these particular instances, but was regarded as improbable. In this general setting of clouding of consciousness, confusion, and bewilderment, there were active hallucinations of sight and hearing. Patients complained of seeing shells bursting, and of hearing the whistling of shells and bullets. In their highly emotional state it is probable that a part of this was misinterpretation of noises about the hospital. The symptoms were worse at night, but were by no means confined to the nighttime. This general condition had some features in common with the psychoneuroses, such as anxiety, fearful dreams, visual hallucinations; but the condition differed in that they were inaccessible, disoriented, and confused, with marked mood changes and no insight. Not infrequently there were delusional ideas of transient character and of a changing nature, the content of which had to do with war experiences.

The interpretation of the nature of the conditions above described presents a number of difficulties. In some respects they resembled protracted exhaustive psychoses. It is thought, in view of the anxiety, the depression, the character of the hallucinations and the emotional conditions, that emotion and excitement played quite as prominent a part as exhaustion. Since the patients, as a rule, were inaccessible, no clear idea could be gained as to what they had experienced; however, it is possible that many of them had been under heavy shell fire, but under what circumstances this was experienced can not be stated. It was necessary to return these patients to the United States as soon as their condition warranted transportation. The impression was that the prognosis was good. The psychosis was considered an acute one, having little in common with ordinary civil life types, although many cases bore the diagnosis of dementia prŠcox on their admission tag.

Another small group of cases was observed resembling somewhat those above described, but different in a number of respects. Such patients were admitted in a delirious condition. As a rule these patients had not been at the front, possibly having but recently landed in France. They were confused, rambling in conversion, inaccessible, and restless. They were disoriented and presented the picture of delirium. The thought content was not remarkable. The condition was considered an hysterical delirium, arising in predisposed individuals.

Of the well known psychoses, such as dementia prŠcox, manic-depressive psychoses, and others, a few features of interest were observed. A number of cases of dementia prŠcox appeared to have developed since enlistment. Some gave a history of symptoms previous to enlistment and a fair proportion of these had had previous hospital residence. In the manic depressive cases there were relatively more with depression than with elation. Both showed a


416

war coloring, especially the depressions, and in fact, the thought content of many of the self-accusatory and depressed patients had to do solely with war conditions. They frequently had the idea that they were being accused of betraying their country or of being German spies. It is a noteworthy fact that comparatively few acutely maniacal cases were encountered. Their management was not as difficult as had been anticipated although several very acute cases were admitted.

PSYCHONEUROSES

No attempt will be made to discuss in detail the psychoneuroses at this point, because more favorable opportunities were offered at other hospitals for the observation of these cases. As a rule, when these patients reached this hospital the psychoneurotic symptoms had existed some weeks and even months, and so they presented clinical pictures differing in character and degree from those seen near the front. Only observation as to the general character and disposition of these cases as it pertains to this hospital will be made at this time.

It is probable that no cases coming under the care of medical officers were as imperfectly understood at the beginning of hostilities as the psychoneuroses. As has been pointed out elsewhere, information regarding them had been sent from the chief surgeon's office, and, likewise, data of great value were available from both French and British sources. Nevertheless, the nature of these conditions was unfamiliar to most medical officers other than neuropsychiatrists. It was for this reason, as before mentioned, that weeks elapsed before plans which had been carefully arranged for the care of these patients were in satisfactory operation. During the early period of hostilities, as stated above, the psychoneuroses did not always come under the observation of the officers designated to take care of them. Some of these patients were sent from advance areas directly to base hospitals, where they were admitted to wards of the medical or surgical service. The fact that the case was a neurosis and not an organic disease was not always appreciated. Such cases were retained in base hospitals without improvement and many of them eventually arrived at Savenay for disposition. Others were classified by medical boards at base hospitals, sent to training camps not fully recovered, and having been found unfit at these places were transferred to Savenay. It can be readily seen that these cases, while relatively few in number, were unfavorable types for early recovery. Fortunately, their number was not great. In a short time steps were taken by the chief surgeon to insure the sending of psychoneuroses to psychiatrists at the front and not directly to base hospitals in the Services of Supply.

During the period of active hostilities the number of cases of psychoneuroses arriving at this hospital was not relatively large. Two general types were recognized; namely, those resulting from battle experiences and those of ordinary civil life types, the latter probably latent or actually existing prior to enlistment. The civil life types, such as neurasthenia and psychasthenia, in most instances, came under observation soon after arrival in France and never reached the front. A certain portion of these were classified for duty in the Services of Supply and the more severe cases were returned to the United States.


417

The psychoneuroses arising from battle experiences came from two main sources. At one time a number came from base hospitals or reclassification camps, without previously having had special treatment. It was possible to return a considerable number of these cases to duty, and some were sent to Base Hospital No. 117. Other cases came from neurological hospitals in the advance section, mainly from Base Hospital No. 117. Cases arriving from these hospitals were intended for evacuation to the United States, being considered constitutional types with unfavorable outlook for recovery in the immediate future. After hostilities ceased, arrangements were made by which the psychoneuroses of all sources eventually came to this hospital, and this accounts for their increase in number during the latter months of the hospital's history. It was not the policy, after the armistice began, to classify these cases for limited service in the American Expeditionary Forces. They were returned, therefore, to the United States for disposition, the severe cases undergoing a period of treatment before evacuation.

There was one unusual feature of the symptomatology observed in this hospital. It was found that a number of cases of mental deficiency, epilepsy, and mental diseases exhibited war neuroses, such as mutism, tremors, or hysterical hemiplegia. This association of symptoms was not infrequent and these cases presented very unusual clinical pictures as a result.

EPILEPSY

Cases, in comparatively large number, amounting in all to 752, were diagnosed epilepsy. These cases afforded ample opportunity to observe the various manifestations of epilepsy, such as major seizures, petit mal, and epileptic equivalents. In addition to these well-known manifestations of epilepsy, the constitutional make-up of such patients formed an important part of their disability, and at times was of more significance than the actual seizures. In other words, the seizures themselves occurring at rare intervals, might not have been disqualifying, but the neurotic or defective constitution as a background rendered these patients unfit as soldiers. The vast majority of these cases were highly neurotic, indeed to such an extent that at times it appeared that the disease should be interpreted as a severe aggravated neurosis of which the seizure, while the most apparent symptom, was not the most important.

Many border-line cases were seen, which were thought to belong to this general group. Such cases frequently had slight mental defect and were sluggish in mental reactions. They presented numerous neurasthenic complaints of long standing. With this condition would occur minor attacks of loss of consciousness, with slight confusion and with occasional frank epileptic seizures. In these cases, of which there were many, the mental defect and the constitutional neurotic condition were of more importance than the actual attacks. Many cases came under observation who had had frank seizures at frequent intervals since childhood. These cases were readily recognized. Numerous types of epileptic equivalents were also encountered. Epilepsy was often associated with alcoholism. Where epileptic seizures occurred on an organic basis, the cases were classified as organic brain disease.


418

The question of so-called hysteroepilepsy arose at times, especially since this diagnosis occasionally appeared on the field card. No great difficulty was experienced in distinguishing the seizures of epilepsy from hysteria. A careful history and clinical observation were all that was necessary as the hysterical cases bore only a superficial resemblance to true epilepsy.

AMNESIA

These cases are discussed at this time because of the relationship of a number of them to epilepsy. Cases were encountered in relatively large number, in which patients absented themselves from their organizations for periods varying from several days to several weeks. These patients maintained that they had no memory whatever of what had transpired. They either returned themselves or were returned by the military police. Such instances occurred in both officers and men. A number of them were frank cases of epilepsy, the period of amnesia occurring either before or after a seizure or being an epileptic equivalent. Many other cases occurred after the excessive use of alcohol. After excluding both epileptic and alcoholic cases, however, many instances of amnesia of the type mentioned above remained to be explained. They were considered by many observers to be instances of hysterical amnesia, and this interpretation appears the most probable one, thus bringing such cases under the general group of psychoneuroses of the hysterical type. If this view is held, the amnesia could most readily be explained as a mechanism operating subsconsciously, in which the individual escaped from a difficult or intolerable situation by wiping out from memory all circumstances associated with it. It is also probable that many such cases were conscious delinquencies, but the number of the latter type is thought to be comparatively small. All such cases raise medico-legal questions, as the matter of mental responsibility has to be determined.

CONSTITUTIONAL PSYCHOPATHIC STATE

In this group, amounting to 634 cases, were included patients who, while not suffering from frank mental disease, nevertheless were in a mental condition sufficiently abnormal to bring them into serious conflict with those about them. These cases did not differ materially from those seen in civil life, but presented such additional features as might be expected to develop under military rÚgime. Patients of this kind might make fair progress in civil life where they could change occupation and surroundings; but in the military service this was not possible, and they broke down nervously, as a result. Indeed, they frequently suffered from temporary mental disorders. In this group were included some cases of alcoholism and drug addiction in whom such states were considered as symptoms in those constitutionally predisposed.

MENTAL DEFICIENCY

There were admitted 524 cases diagnosed mental defectives. This number is not relatively large, and it is probable that many defectives were eliminated before arrival in the American Expeditionary Forces. The classification of these cases in respect to duty, particularly those with the lesser degrees of


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defect, was a question of considerable importance. It was considered that while defectives as a rule could not be used with combat troops, still many of them were serviceable in labor organizations. The disposition, therefore, was to reclassify such cases as were considered fit for duty in rear areas. The record of how these patients had conducted themselves in the military service was considered in conjunction with their mental age as determined by an intelligence test, for the emotional constitution of such patients was of considerable importance. A case with mild defect, if irritable and emotional, was often found unfit, while a case with stable temperament, even with considerable defect, was considered fit for limited service.

In many instances physical defect was found to accompany the mental defect. The physical defect varied in character and degree, in some cases being expressed merely by awkwardness in simple movements, in others making itself manifest by the gross, ungainly physical make-up of the mental defective. In still other cases appeared a constitutional physical defect of ill-defined type. These patients were stooped, had a narrow, ill-developed chest, and often a prominent abdomen. Such cases often complained of numerous neurasthenic symptoms. They were related to constitutional neurasthenic types frequently seen in civil life, with mental deficiency added. It was soon found that it was unwise to return these cases to duty of any kind. They went on sick report or in hospital very frequently and they were more of a liability than an asset.

ORGANIC NERVOUS DISEASES

This organization did not receive cases with lesions of the central or peripheral nervous system resulting from battle casualties, such cases being received by the surgical services of the center. However, the other organic nervous cases, amounting in all to 143, were cared for at this hospital. Peripheral neuritis, occurring after diphtheria, influenza, or other toxic conditions, was frequently encountered. Evidence of syphilis of the central nervous system was found in more cases than might have been expected, considering the average age of the patients. Several cases were diagnosed brain tumor. A number of patients presented mental symptoms or epileptiform seizures subsequent to brain injury. Comparatively few cases of paresis or tabes were observed, although other manifestations of syphilis of the central nervous system were not infrequent.

ENCEPHALITIS OF UNDETERMINED TYPE

During January and February, 1919, a small number of organic cases of unusual interest were admitted to this hospital. The clinical features of those cases were first recognized by the chief of the service at that time. They presented symptoms of such unusual interest that it is thought they should be discussed here, regardless of the fact that the clinical observations could not be completed. The following observations, made by the chief of service, are given as nearly as possible in conformity with his characterization of them. In all, there were about one dozen cases of this particular group.


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The most striking feature of these cases was that they bore a rather close resemblance to paralysis agitans. They showed a stolid mask-like expression, a tremor of the head and hands suggestive of paralysis agitans, although differing somewhat from it, a shuffling gait, and a rigid posture, which suggested rigidity of the muscles of the neck and trunk. These cases also appeared dull mentally, but this was more in appearance because of their lack of expression than in reality. There was no actual paralysis of the facial muscles, merely a lack of mobility and of expression. One patient could smile but very slightly, and could not laugh. Another had noticed by looking in the mirror that his expression had changed. The head and neck in these cases were held in a stiff and rigid position, but little, if any, true rigidity was found. The arms were held in a semiflexure both when the patient was walking and sitting. Here, too, however, there was not actual rigidity. The tremor was of a rather coarse type. The hand, as a rule, was held partly closed, but a pill-rolling motion was not observed. As a rule, both sides were involved, but one more than the other. The gait was shuffling and awkward; in fact, all movements were slowly and awkwardly performed. The gait suggested paralysis agitans but was not entirely characteristic of that disease.

Physical signs indicating disease of the central nervous system, except those described above, were not marked. One case showed a remarkable lateral and rotary nystagmus with exceptionally wide excursions. Otherwise the eye symptoms were negative. There was no actual paralysis of facial muscles. One patient showed considerable tremor of the lips which made it appear that he was about to weep; however, there was no emotional instability. The deep reflexes showed nothing remarkable except in some instances the knee-jerks were very active. There were no sensory disorders and no Babinski or ankle clonus. The superficial reflexes were normal. There was no actual motor weakness, but motor functions were performed awkwardly. The liver showed no evidence of disorder, and other physical findings were negative. Unfortunately, complete serological examinations were impossible. Spinal punctures were done in a few cases. No increase of cells or globulin was found, but as the punctures were done late in the disease nothing definite could be inferred from these negative findings.

While these cases had a fairly close resemblance to each other, sufficient to place them in one group, they did not have that close resemblance throughout which is found in most cases of paralysis agitans. In some the tremor of the hands was the most marked symptom; in others, the gait; and in others the lack of facial expression or the rigid posture. All had to a certain extent some of the symptoms enumerated above. Paralysis agitans is mentioned in connection with these cases for descriptive purposes only, not that they were thought to have any true relationship with that disease. The condition was thought to be encephalitis of unknown origin, the toxic agent showing a selective action, probably for the lenticular nucleus. No etiology could be established. Some cases had had a febrile reaction before admission and had been diagnosed influenza; one occurred after mumps, one after an infection of the antrum and ethnoid sinuses. Others gave no history of any acute illness. Some of the cases had been confused and delirious at the outset of their illness, previous to


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their admission here. In favor of interpreting these cases as encephalitis of selective type is the fact that a number of other cases were admitted about this time in which the cranial nerve nuclei of the brain stem were involved. One such case showed, first, involvement of the seventh nerve on one side; a few days later the other side was involved. Both gradually improved and then a slight ptosis of both sides was observed. Later the sixth nerve on one side showed slight involvement and there was also mental dullness during this period. All serological and physical findings were negative in this case. Other similar cases were observed during this time. Both French and British writers described a condition which they termed lethargic encephalitis. This condition may have had some relationship to the cases of encephalitis observed here. Cases seen here, however, were not particularly dull or lethargic and although ptosis occurred, it was not as constant as that observed by the French and British writers.

BASE SECTION NO. 5

As has been mentioned elsewhere, the hospital center at Kerhuon, Brest, was called upon for many kinds of neuropsychiatric service, especially for those who, after being sent from Savenay in expectation of their prompt return to the United States, had to wait for weeks and even months before they could go any farther.5 This was facilitated in a measure by the fact that large convoys of such mental patients usually had with them medical officers and enlisted men who had had special training in the care and treatment of mental disorders. Ultimately four wards were set aside as a neuropsychiatric section for the Kerhuon hospital center. These wards with a total capacity of 200 beds were located in an attractive area at the south end of the hospital reservation overlooking the bay. The American Red Cross provided two additional barracks, one for recreation, one for occupational therapy, and also a veranda overlooking the harbor. With the closing of Base Hospital No. 214, June 21, 1919, this department became the only neuropsychiatric hospital functioning in France. It then began to receive patients from all of the areas in France in which American troops were still to be found and from the Army of Occupation until a separate line of evacuation for these patients had been provided through Holland. By July, 1919, but very few patients were coming in, the last group being a number of prisoners, who had been found by the psychiatric survey of the prison camps at Gievres to be suffering from mental disorders. When this hospital ceased to function, its remaining patients were evacuated to an annex of Camp Hospital No. 33, which was the last neuropsychiatric unit to render any special service in France.6


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REFERENCES

(1) History of Base Hospital No. 116, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.

(2) History of Base Hospital No. 117, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.

(3) Letter from the senior consultant, neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., February 17, 1918. Subject: Personnel of Base Hospital No. 117. Copy on file, Historical Division, S. G. O.

(4) Letter from the senior consultant, neuropsychiatry, A. E. F., to the chief surgeon, A. E. F, October 28, 1918. Subject: Provisions for mental cases at Savenay. Copy on file, Historical Division, S. G. O.

(5) Report of Medical Department activities, Base Section No. 5, A. E. F., undated, compiled under the direction of the base surgeon from official records in his office. On file, Historical Division, S. G. O.

(6) History of Camp Hospital No. 33, Camp Pontanezen, Brest, by the commanding officer of that hospital. On file, Historical Division, S. G. O.

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