Contents

CHAPTER V

IN HOSPITALS CARING FOR THE MENTALLY DISABLED

Investigations concerning the future policy of the Medical Department in the care of the mentally disabled were initiated in May, 1917, when the chair man of a subcommittee of the National Committee for Mental Hygiene visited Canada to ascertain the methods employed in the Canadian Army.¹ The report of his investigation indicated that 12 per cent of all disabled returning from overseas would be classified as nervous and mental disease; that one-half of these would be war neuroses, one-fourth mental disease, one-seventh head injuries with nervous symptoms, and one-tenth various neurotic conditions, and that a ratio could be expected of something over 13 nervous and mental cases from every 1,000 troops in home territory.
The report further indicated that segregation should be made not only of this class as a whole from other classes of disabled but also men with war neu roses from the insane. This segregation was very advisable for two reasons: The whole class of mental diseases and defects required more individual attention in vocational training than those with normal nervous systems; men with war neuroses were inclined to be faultfinders and troublemakers, and a few cases in a general institution would corrupt the general morale and make vocational training particularly difficult. The value of vocational training for this general class of disabled was emphasized.
Further investigations along the same lines were made in December,1917.² The findings of these investigations coincided approximately with those of the previous spring; however, the following four points in the care of war neuroses were emphasized: (a) The maintenance of military discipline and individualized control was indispensable and of first-rate importance in dealing with these cases; (b) hydro-and electrotherapeutic treatment was considered of great service in many cases; (c) occupation therapy with suitable variety of work was of almost universal importance; (d) in the general policy of caring for the war neuroses it had been demonstrated over and over again that patients while under treatment should be shifted as little as possible from one institution to another.

The study of foreign experiences in handling mental cases showed that the work fell into two main divisions--the care of those with functional derange- ments, the neuroses, and those with organic derangements, principally the insane and those congenitally defective. The methods used were radically different. The neuroses, being largely under the control of the will, required a brief period of rest, encouragement, and reassurance, carried out on or near the front, with an absolute separation from the outset the idea in the mind of the soldiers that the condition was of disabling and pensionable character.³

Neuroses were common during the World War among soldiers with a nervous instability which unfortunately became widely known under the entirely

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misleading term of "shell shock." The general conception of the public as to the meaning of this term was that it applied only to persons whose nervous mechanisms had been so racked by the concussion of high-expolsive shells in their immediate vicinity that they could no longer quietly withstand the impacts on their nervous systems from trivial noises, sudden movements, etc., occurring in their neighborhood. As the active factor usually attributed to the etiology of this condition, shell explosions, was seldom an actual factor, the acute onset of the condition occurring elsewhere than in the front lines in the great majority of cases, it was an early decision that the term "shell shock" had no place in the medical nomenclature. Such cases consisting merely of the more or less sudden manifestation of the inadequate stability of their nervous systems with which they were born, induced by the unaccustomed strains of military life, it was very properly directed that they be classed as psychoneurotics.⁴ The symptoms of which these patients complained had unlimited range-extreme restlessness, extreme susceptibility to sudden noises, convulsive contractures, mutism, deafness, and all other varieties of hysterical symptoms. These cases were not ordinarily given physical reconstruction, as by the time this service was organized other methods of treatment had been found so efficacious that the majority of cases were returned to duty. However, when a case of this nature had been in hospital a long time it was most stubborn in yielding to treatment. On the other hand, patients who had psychoses would never be of use to the Army and required control of their various episodes, with ultimate discharge to friends or to institutions.

Early provision had been made by the Surgeon General for the care of patients with temporary mental derangements in most base hospitals, for the care of epileptics and functional neurotics in special hospitals, and for the care of the insane in special wards at Walter Reed General Hospital, Washington, D. C., Fort McPherson, Ga., Fort Sam Houston, Tex., Fort Des Moines, Iowa, Letterman General Hospital, San Francisco, Calif., General Hospital No. 4, Fort Porter, N. Y., St. Elizabeths Hospital for the Insane, Washington, D. C., and possibly in authorized public institutionsA An elaboration of this list directed that, pending the establishment of special hospitals, cases would be collected as follows: ⁶ Functional neuroses and epileptics at Fort Riley, Kans., and General Hospital No. 9, Lakewood, N. J.; epileptics needing surgical treatment at General Hospital No. 11, Cape May, N. J. A further modification directed that mental cases in which recovery seemed to be improbable be sent to either St. Elizabeths, Washington, D. C., Mendocino State Hospital, Calif., or Fort Crook, Nebr., the choice to be determined by the proximity to the soldier's home.⁷

Special hospitals were later established at Fort Porter, N. Y., Dansville, N. Y., and East Norfolk, Mass.; special beds for officers at Bloomingdale Hospital in connection with General Hospital No. 1, New York, and special wards at Walter Reed General Hospital, Washington, D. C., Fort McPherson, Ga., Fort Sheridan, Ill., Fort Benjamin Harrison, Ind., Letterman General Hospital, San Francisco, Calif., Fort Sam Houston, Tex., and Madison Barracks, N. Y.⁸ All patients presenting symptoms of insanity, except those who seemed incurable, were to be held in the special wards of military hospitals for not

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over four months; those who recovered within this period were to be discharged for physical disability; those who did not recover were to be transferred to St. Elizabeths Hospital.⁸
General Hospital No. 30, Plattsburg Barracks, N. Y., had been designated to care for patients suffering from functional nervous disorders.⁹ This specialization was not adhered to in sending cases there, with a resultant interference with successful treatment of the functional neuroses. In November, 1918, 48 per cent of all admissions were epileptics, 10 per cent mental defectives, 2 per cent dements, 1 per cent manic depressives, and 1 per cent general paretics.⁹ This state of affairs led to a study of conditions and report by a board of officers as follows: ¹⁰
As a result of our observation and study in United States Army General HospitalNo. 30 of returned soldiers suffering from curable functional nervous diseases we have cometo the following conclusions:

1. Many soldiers, whether they have been on duty in this country or returned fromFrance, suffering from these nervous disorders, have the idea fairly well fixed that theyare incurable and should be discharged. Some are already endeavoring to establish a claimfor compensation, and it may be confidently anticipated that the numbers of such will greatlyincrease.
2. Our experience and that of other physicians in this country and in England, France,and Italy shows that a great majority of these patients can be cured.
3. We are of the opinion that no soldier suffering from this form of disease incurredin line of duty should be discharged from the service. They should be retained under thecontrol of the Medical Department until they are cured.
4. It is evident that unless this plan is adopted a large number of soldiers will be madeinto pensioned, languishing invalids instead of self-supporting and self-respecting individuals.The amount of money needed for the payment of pensions for such discharged soldiers wouldbe a continuous financial drain for many years.
5. The Surgeon General has established in United States Army General HospitalNo. 30, Plattsburg, N. Y., a general hospital of 1,000 beds for the exclusive treatment ofcurable functional nervous diseases. Similar hospitals will have to be established in otherparts of the country, for it is estimated that in a short time many such patients will bereturned to this country.
6. Experience in this hospital since its organization has most emphatically shown thatthe methods of treatment now employed for war neuroses are burdened with the seriousdrawback of encouraging the idea of invalidism and in many cases of preventing cure. Thesepatients are constantly appealing to their relatives and friends, and some even to theirpolitical representatives, to be discharged from the service on the ground that further hospitaltreatment will do them no good.
7. The accumulated experience of this war has proved beyond any doubt that thetreatment of military functional nervous patients must be carried out under strict militarydiscipline. Hospitalization of these patients makes the task hopeless and impossible.
8. The success of such a hospital depends in large part upon its reputation for cure.When a soldier is ordered to such an institution it should be of general knowledge not onlyto him but to the public at large that he is ordered to a place where cure is certain and not toa hospital where incurables are received.
9. We recommend that there should be established in conjunction with United StatesArmy General Hospital No. 30 a training camp to be known as the Plattsburg TrainingCamp. Soldiers, when they are sent to Plattsburg, should be ordered to report to thetraining camp. If they are found to require hospital treatment they will be transferredto the general hospital.
10. It is evident that the success of such a plan would depend very largely upon theproper selection of suitable cases. Incurable patients, such as epileptics, insane and others,should not be sent there. If, by some mistake, they are sent to Plattsburg, authority shouldbe granted for the prompt transfer of such cases.

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11. The plan of the camp management, treatment, and methods to be employed shouldbe along lines of healthful suggestion, with the employment of all sorts of gainful occupations,drills and constructive work of various kinds, under military discipline. A number of officersand noncommissioned officers will be needed, and they should be selected from amongstthose who have been successfully treated in this institution.
12. In order to assist in determining the number of soldiers for whom provision wouldhave to be made in such a camp it is estimated that the average residence would be one ortwo months. At the end of such period the majority of soldiers would be ready for duty.
13. The management of such a camp should be under the exclusive direction of the Medical Department.
14. The importance of the proper management and care of this class of patients can not be overestimated. All of our allies have found this problem particularly difficult ofsatisfactory solution. The plan laid out above and respectfully submitted, we believe, willfurnish as satisfactory a solution as can be offered, and we strongly urge the immediateadoption of such a plan for United States Army General Hospital No. 30 and the construction of similar hospitals in other parts of the country.

A visiting consultant agreed with these conclusions,⁹ and also stated that a large proportion of the patients showed hereditary taint, and the difficulties of a disciplinary sort and of treatment alike were increased by the readiness of relatives with similar tendencies to encourage the patient in his faulty attitudes and to enlist the services of Senators and Representatives in the effort to obtain an early discharge from the Army. He also stated that the conditions as outlined bore directly upon the work of physical reconstruction in all its phases and affected it to a degree deplorably adverse to the desired results. This plan for a "reconstruction detachment of patients" was not approved. but the epileptics and insane were removed.¹¹

Instructions were issued in April, 1919, that cases in which recovery was considered improbable after four months' hospital treatment, or which would require a much longer period of hospital treatment to effect a cure, would be transferred to such institution as was designated by the Bureau of War Risk Insurance and discharged on certificate of disability.¹²

Each cantonment base hospital was provided with one or more neuropsychiatric wards, which were especially designed and equipped to care for nervous and mental cases for a short period, after which time they were discharged, or, if necessary, transferred to one of the general hospitals which had adequate facilities for the continued treatment of such cases.¹³

In order to provide for the disposition of mental cases which could not be given continued treatment in the psychiatric ward of the cantonment base hospitals, special neuropsychiatric services were established at the following places:¹³ General Hospital No.1, including Messiah Home, Bloomingdale Hospital (officers only); General Hospital No. 2 (officers only), including Shepherd and Enoch Pratt Hospital (nurses only); General Hospital No. 4, exclusively for mental cases; General Hospital No. 6; General Hospital No. 13, exclusively for mental cases; General Hospital No. 25; General Hospital No. 26; General Hospital No. 28; General Hospital No. 30, exclusively for cases of psychoneuroses; General Hospital No. 34, exclusively for mental cases; General Hospital No. 43, exclusively for mental cases.

With the exception of General Hospitals Nos. 4, 30, 34, and 43, the special neuropsychiatric services were established in these hospitals, first, because they would reduce transportation to the minimum in providing facilities near all

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camps; second, because they would enable all cases to be treated in the vicinity of their homes; third, the system was the most economical utilization of the existing facilities.¹³

General Hospital No. 4 was devoted almost entirely to cases of insanity returned from American Expeditionary Forces.¹³  Because the bed capacity was soon taken up, it was necessary for General Hospitals Nos. 13 and 34 to be taken over for the care of insane cases.¹³ As the number of cases returned from abroad decreased and the population of these hospitals diminished, all the cases were transferred to the Soldiers' Home for Disabled Volunteer Soldiers, Hampton, Va., which previously had been Debarkation Hospital No. 51.¹³ On  May 1, 1919, it was made General Hospital No. 43 for the care and treatment of mental cases. At the time of the transfer of these cases General Hospitals Nos. 13 and 34 were closed.¹³

This change proved very satisfactory because all cases of insanity were now returned from American Expeditionary Forces through the port of debark- ation at Newport News, Va., and taken directly to the hospital without long travel, and economy of personnel resulted, as the patients were now treated in one hospital instead of three. ¹³ The home was very suitable for the treatment of mental cases. There every facility for the modern care and treatment of insane was provided, the hospital being staffed with highly trained specialists, experienced attendants, nurses, and reconstruction aides.

General Hospital No. 30 was established especially for the treatment of cases of psychoneuroses.¹³ Most of the cases treated there were returned from American Expeditionary Forces. This hospital was a decided success, as evidenced by the fact that cases of this class, which were a source of so much trouble to other countries, were handled without any unusual difficulty.¹³

Cases were transferred to and from these hospitals by attendants experienced in the transportation of insane and neurotics.¹³ Reports of the elopement of patients and injuries received while in transit were few, and complaints as to condition of patients arriving were almost negligible.¹³

The patients were treated in these centers for periods of at least four months unless cured, or there was special reason for their disposition earlier.¹³ In this manner Army regulations governing the disposition of the insane were not resorted to until satisfactory period of observation and treatment had elapsed.

Cases which did not recover in four months and which required treatment for an indefinite period were turned over to the War Risk Insurance Bureau.¹³ Arrangements were made for the transfer in such a manner that there was no interval between discharge from the military service and the commencement of the continued care in hospitals near their home provided by the bureau.
On June 25, 1919, 2,859 cases were under treatment in military hospitals.¹⁴ Of these, 1,648 had psychoses, 470 psychoneuroses, 165 were constitutional psychopaths, 238 had mental deficiency, and 89 were epileptics. By August 12, 1919, 8,319 mental cases had been. returned from overseas, and 2,210 cases remained under treatment in the following military hospitals:

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These cases were classified as follows: Insanity 1,447; psychoneuroses, 349; epilepsy, 64; constitutional psychopathic states, 156; and mental deficiency, 194.
When the question of reconstruction in neuropsychiatric hospitals first was taken up the feasibility of introducing such procedures generally into the neuropsychiatric wards was doubted; reconstruction was considered to be applicable only to those cases which were less disturbed mentally.¹⁶ However , after several months' experience in neuropsychiatric hospitals the benefits of occupational therapy became so pronounced and the aides so skillful in their approach that the work was given to all neuropsychiatric patients except the extremely violent.¹⁶ This furnished systematic employment to restless patients, reduced the introspection of neurotics and the delusions of the insane, seemed to shorten the duration of the prawcox or manic episode of the psychoses, and decreased the necessity for restraint in the more disturbed cases.

RECONSTRUCTION WORK, GENERAL HOSPITAL NO. 2, BALTIMORE, MD. 

The following account of the activities of the neurospychiatric department General Hospital No. 2, Fort McHenry, gives a very good idea of the way in which neuropsychiatric cases generally were cared for: ¹⁷

The care of the patients was accomplished without any of the old-time methods of iron-barred windows and grated doors. The interior of the building was decorated and paintedin soft restful colors, while potted plants and flowers distributed throughout and lace curtains at the windows all combined to make the place as attractive, homelike, and pleasant aspossible. In the rear a spacious porch had been converted into a solarium and made an idealplace for the occupational therapy activities. The building had its own hydrotherapeuticplant, and the soothing effect of the sedative bath, especially in maniacal cases, was successfully demonstrated many times. Full advantage was taken also of the hospital's physiotherapy department, and nearly all of the neuropsychiatric patients were sent daily for somekind of treatment in the more elaborately equipped department.

No effort was spared to provide every therapeutic benefit to be derived from diversionaloccupation and recreation for the patients. A reconstruction aide spent her time entirelywith them, doing all that was possible to keep their minds and hands busy, and splendidresults were achieved. In addition to this occupational therapy, a teacher of calisthenicsspent some time each day giving the patients brisk exercises--lively games, which weregreatly enjoyed. A large pool table, a Victrola, and a well-stocked library, all donations ofinterested friends, were available for use at all times. The fundamental principles underlyingthe treatment of the patients were the use of psychotherapy, hydrotherapy, and occupationaltherapy. The patients were treated individually and not collectively. No routine or systemmethods were used in administering to those who were admitted complaining of the many

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and varied symptoms incident to a nervous or mental disorder. The satisfactory resultsattending the use of these three important agencies, especially in the large group of functionalneuroses and the incident mental disorders, amply justified the principles of nonrestraintwhich were insisted upon.

In the treatment of nervous and mental disorders occupation and recreation were ofparamount importance. An occupational aide who had the happy faculty of exciting interestin a catatonic pr ecox, of arousing the interest of a patient in the depressed phase of a manic-depressive psychosis, of directing the useful and constructive channels the hyperactivity ofa maniac, or who might be able to replace the obsessive idea of a psychasthenic with a healthy,helpful, and interested thought, certainly accomplished a great deal toward the recovery ofsuch a patient. The first occupational aide was assigned to the neuropsychiatric ward, andit was not without some misgivings that additional aides were sent throughout the hospital.It had been demonstrated that occupational therapy had a very definite mission to perform,not only in Army hospitals but in civil hospitals as well. The sun parlor, where basketry,beadwork, and various other light crafts were carried on, and the carpenter shop where willowand reed work, carpentry, painting, modeling and numerous other handicrafts were beingconstantly indulged in, were the most inspiring and interesting parts of the work.

A special feature was made of recreation. Several times a week afternoon parties weregiven for the patients, with music and refreshments, and the various holidays were celebratedby proper decorations and games.

Excellent results which were accomplished by sending patients to a river camp forconvalescent soldiers. The recovery of a number of patients dated from the time they spentat this delightful summer camp, where boating, swimming, fishing, and many other outdoorsports were available. This camp was especially beneficial in allowing the patients the opportunity of getting away from the routine of hospital life and feeling the freedom and stimulating effects of the outdoors.

PSYCHOLOGICAL STUDIES, GENERAL HOSPITAL NO. 30, PLATTSBURG, N. Y.

The results of the following psychological studies made at General Hospital No. 30 are of interest in connection with the reconstruction of patients suffering from psychoneuroses. When the schooling and mental ages of the patients are considered in connection with their neuropsychiatric conditions, the reason for the predominance of the occupational and simpler academic activities is very apparent.
Of 836 neuropsychiatric patients discharged from the Army during the World War, the psychiatric survey showed their schooling to be as follows: 375 had seventh-grade education or less, 130 had eighth grade, 93 had incomplete high school, 30 had completed high school, 51 had one or more years in college, and in 151 the education was undetermined.¹⁸ On the basis of rank, there were 703 privates, 26 privates first class, 54 corporals, 27 sergeants, 4 sergeants first class, 6 second lieutenants, 14 first lieutenants, 2 captains, 2 majors, and 1 colonel.¹⁸ The mental ages of the first 1,173 patients who were given the psycho- logical examination are shown in Table 12. The limit of feeble-mindedness in adults is variously placed at 10 to 12 years, and the average mental age of soldiers in the recruiting camps was 14 years.¹⁹ On the basis of 10 years, the table indicates that approximately 25 per cent of these men had defects of intelli- gence as well as their obvious character defects. If 12 years be accepted as the limit, then almost 50 per cent of these men had less than a normal intelligence. Sixty-four per cent were below the average of 14 years found in the camps.

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The manner of utilizing the results of psychological surveys in the selection of work for individuals at General Hospital No. 30 is illustrated by the following cases: ²⁰

CASE 1.- Diagnosis, convalescent cerebrospinal meningitis, with mild residual symptoms--stiffness, chill, headache. Age, 24. Education, technical engineering school.
Make-up.- Intelligence quotient, 110. Active and progressive attitude. Spontaneousinterest in vocational activity related to previous work. Competent personality, well balanced, with no psychoneurotic tendencies manifest. Meningitis incurred in line of duty.Recovery well under way. Probable stay in hospital not over six weeks. Probable conditionwhen discharged from hospital, recovered.
Assignment.- Work in mechanical drawing and drafting for occupational as well asvocational purposes.
Functional end.– Activity and distraction from symtoms.
Occupation.- Butter maker, from which work his present and probable future conditionincapacitates him, since his symptoms are intensified by cold and damp conditions.
Probable condition on discharge.- Relief from acute symptoms, with liability to recurrence except under favorable circumstances.
  Assignment.- Physiotherapy for restoration of hemiplegia. Vocational work, in order to permit him to change his occupation on return to civil life and to fit him for limited service in Army. Took up bookkeeping and commercial arithmetic so as to become clerk or inspectorin creamery, with which he is familiar in all branches.
Progress.- Works faithfully, making slow progress because of inadequate native capacity. Symptoms much relieved and he becomes hopeful and relatively ambitious to reenterservice.
Disposition.- After recovery discharged to limited service in Quartermaster Department.

CASE 3.- Psychasthenia on background of infantile personality. Age, 26. Education, grades and lower high school.
Occupation.- Postmaster in small town and grocery clerk,. both as helper to his uncle. 
  Make-up.- Average adult performance in tests. Attitude introspective, evasive, and whimpering. Talks "papa and mama" and displays inability to "get away from the family,""mother complex," masturbatatory fancies and dreams. Complains of inadequacy and inability to see life correctly. Does not think he can ever get well.
Probable condition on discharge.- Much the same as now.
Assignment.- Work as assistant to physicians and psychologist, in endeavor to get himinterested in other's welfare, thus breaking up his morbid hypochondria and egocentric trend.Psychanalysis and conference with psychologist. Finally, vigorous work in carpenter shopas assistant to foreman.
Progress.- None noted in several months. Takes to his bed whenever vigorous work is prescribed, with vague and organically unjustified complaints.
Disposition.-Still in hospital; little gain shown.
CASE 4.- Diagnosis, emotional trauma (shell shock), with speech disturbances, tremor,excitability, and violent contortions at unexpected sound. Age, 30. Education, neglected, grades only.

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Make-up.- Affable and willing, but unable to stand the mild strain of mental tests.Repeats everything said three times. Goes into violent trembling and fear reaction at such noises as hammering, whistling, or being suddenly spoken to. Wants to recover.

History.- Blown over by shell explosion at the Marne and buried for 16 hours withoutfood or drink. Lost consciousness when recovered and subsequently showed presentsymptoms.
Probable condition after recovery.- Will probably recover to at least his previous conditionbefore service, which was probably characterized by neurotic predisposition, tendency tostammer, etc.
Assignment.- Invalid occupation in quiet room working at basketry and light desultorywork. Occasional opportunity to get accustomed to noise which he himself makes, then tonoises the nature of which he fully understands, and finally to general work.   Progress.- Has already improved so that he is steady enough to do creditable work inbasketry, to walk on the road with his face toward coming traffic, and even to take an occa-sional ride in a noisy automobile. Speech disturbance still remains and general attitude of fear still apparent. Tremors clearly reduced.
Disposition.- Still under treatment.

CASE 5.- Diagnosis, epilepsy. The treatment of epilepsy presents many special problems in occupational therapy. For instance, irritation in an epileptic requires very specialhandling, entirely different from that of normal, hysterical, or depressive pupils. Age, 24.Education, can neither read nor write.
Assignment.- Mechanical drawing, English, arithmetic.
History.- Machine-shop worker for Georgia Southern Railroad. Will return to old work when discharged. Psychological record shows traits characteristic of epilepsy. Reasonsfor nature of assignment: (1) Necessary physical exercise therein provided for; this determined previous to assignment; (2) ambition to read and write worthy one and psycho-logical tests showed that it could be realized; (3) ability to use simple arithmetic to readblue prints of direct vocational value; (4) vocational training is the best therapy in caseslike this.

COURSES OF INSTRUCTION

At General Hospital No. 13 courses were given in bench woodwork, carpentry, painting and staining, machine work, pattern making, automobile mechanics, English, arithmetic, bookkeeping, stenography, typewriting, drafting and designing, geography, agriculture, history, economics, weaving, basketry, printing, lettering, and poster making.²¹ Frequent entertainments of various kinds were given, with an effort to have the patients put on their own shows, and a band was organized. One hospital, General Hospital No. 30, Plattsburg Barracks, N. Y., maintained an excellent library of nearly 4,000 volumes, with the leading periodicals and newspapers from the principal cities of the country.²² The library was considered to have been an important factor in the reconstruction work.

VALUE OF RECONSTRUCTION 

Though the recorded statements concerning the value of reconstruction work in the treatment of functional neuroses may not appear to be as enthusiastic in its support as those dealing with other types of mental disease, this is probably due to the fact that good results were more generally expected in the functional neuroses.

At General Hospital No. 30 a part of the cure of functional neuroses was, so to speak, to wear the patients out by paying no attention to their complaints, many of then finally concluding that they would not get a discharge with the expected disability allowance, and therefore recovered. ²³ Thus, with very 

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little active medical work being done, work in the educational service provided a valuable outlet for their excess energy, and their average stay of 29 days in that hospital provided an unusually favorable opportunity for this work to be sufficiently extensive to be of real value to most of the patients. On the other hand, many materially benefited from the instruction given; the employment was an important factor in the maintenance of morale, and the results fully justified the expense and efforts of the Government in maintaining the service.¹⁸

The beneficial results of reconstruction as a whole when applied to neuropsychiatric patients were reported by the commanding officer, General Hospital  No. 43, as follows: ²⁴
The continuous sedative bath, hot packs, Scotch douches, needle showers, electricalheat, occupational therapy, and exercise were the chief modes of treatment. Continuousbaths were installed in three buildings for the treatment of excitable cases who requiredfrequent and rather long-continued baths to control their psychotic episodes. There wereno instances where a patient could not be quieted by the use of the hot pack or continuousbath if the patient was handled judiciously and the treatment repeated at frequent intervals.The patients seldom objected to these treatments and many were glad to return to the baths.

Occupational therapy did much to establish confidence on the part of the patient. Thehelpless and irresponsible patients were coaxed to work on the wards, beginning with simpletasks, such as the winding of string, the unraveling of burlap, basketry, rug weaving, knitting,etc.

As the patient regained his confidence and the control of his faculties and acquired moreresponsibility, he was allowed to do a different class of work requiring more physical andmental ability, such as carpenter work, printing, typewriting, and automobile repairing.

Exercise and recreation were supplied through the medium of walks for the responsiblepatients, varied calesthenic movements for the others; automobile rides were providedthrough the American Red Cross and other civilian agencies.

The commanding officer, base hospital, Fort Sam Houston, Tex., reported :²⁵

Prior to the establishment of this work among the mental and nervous cases of thishospital it was practically impossible to avoid placing the patients who were in the department in an enforced state of idleness. It is a natural consequence that idle insane patientsare prone to continual self-analysis and elaboration of delusions. Likewise, unoccupied,the cases of precocious dementia are very prone to mental deterioration. With the adventof the industrial pursuits and the presence of the reconstruction aides in daily attendanceamong the patients, there is a noticeable improvement, a lessened tendency toward excitement or seclusiveness. In general, it may be said that, together with calisthenics and hydrotherapy, the reeducational effort has brought about a rare spirit of contentment among theseunfortunate people, and we are inspired by the hope that recoveries, as evidenced by universalimprovement, will occur in a great majority of the patients. I regard the work that you arehaving done in this department as being probably the most valuable single therapeuticagent.

The following conclusions reached by the officer in charge of the physiotherapy department, General Hospital No. 30,¹⁹ may help to explain some cases  which were attributed to the increased strain of the war period:

Experience definitely demonstrated the bad effects of a sustained strain of modern warfare on the vagatonic and sympathetic nervous systems in cases showing functional disturbances of the endocrine glands.

A large group of cases manifested a depleted adrenaline system, with the development of a compensatory hyperthyroidism. The various symptoms, such as headache, insomnia, fine tremors, rapid pulse, incoordination, low-blood pressure, fatigability, irritability, taciturnity, etc., responded best to the higher temperatures in thermotherapy, in an average temperature of 350º F., in gas

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and electric ovens, followed by modified pack, shower, and spinal douche, alternating daily with autocondensation or sinusoidal currents to spine.

Further, a number of cases showed evidence of more or less toxemia, either systematic or due to local foci of infection, the latter usually found in the mouth, and over 50 per cent of which were found to be due to infections in roots of teeth or gums. Another large group was also traceable to infected tonsils.  General elimination of these toxic products was facilitated by physiotherapy. It was essential that the local foci be removed also.

SOCIAL-SERVICE WORK 

The social-service work was also of value along lines somewhat similar to the psychologies but more so as an aid in the diagnosis, classification, disposition, and aftercare through intimate touch with the individual patient, his past history, and future environment. ¹⁶

An account of the social service as carried on at General Hospital No. 30 will serve to show how this work generally was conducted.¹⁹ This service was established September 1, 1918, upon the arrival of one social-service worker furnished by the American Red Cross, the primary demand for such service being due to the very incomplete medical records accompanying many patients, particularly those from overseas. Some patients presented symptoms which indicated that their conditions had existed for many years prior to their entry into the military service, but there was no direct evidence to support this view. Others arrived with a diagnosis only, as "epilepsy," presenting no symptoms of such disease while in the hospital. It was obvious that an early personal history of such cases obtained from relatives, employers, family physicians, etc., would be of great value, not only in determining an accurate diagnosis but in protecting the rights of both the patients and the Government when claims for compensation were filed.

The work gradually developed into four divisions--(1) securing early histories, (2) social case work, (3) aftercare, and (4) administrative work.¹⁹

The object sought in the majority of the investigations was the establishment of the period in life in which the disease originated, in order to decide the question of the Government's liability and the soldier's rights regarding compensation.^l9 The patient was questioned as to his previous history, special emphasis being placed on the securing of names and addresses of individuals who would be in a position to give the necessary information. Replies were received to 90 per cent of the inquiries, the greatest assistance coming from physicians and former employers. It developed that the disease itself, or a nervous instability, had existed prior to Army Service in the majority of cases, and in some cases that the patients' statements were deliberately untruthful. Such results were to be expected in this particular class of cases, especially when the patient was malingering in an effort to secure compensation or to avoid military service.

These investigations were so successful that it was desired, as a routine, to refer all overseas cases to this service, but the large number returning after the armistice began permitted the reference of only those in which such information was felt to be essential.¹⁹

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Assistance rendered to soldiers who were troubled by personal or family difficulties was one of the most important results of the social service.¹⁹ Thechief source of this type of work was the failure to pay allotments made by soldiers for the financial support of relatives, particularly the compulsory family allotments. The soldiers' statements concerning nonpayment almost invariably were found to be correct, but in general the soldiers were grossly ignorant concerning the Bureau of War Risk Insurance and its methods of operation.¹⁸

Another phase of the social case work which was of particular importance was the personal talks with the soldiers who came for assistance.¹⁹ The majority of the cases treated showed mental inferiority and moral defects. Thefts of their personal property, nonpayment of allotments, etc., resulted in a feeling on their part that the protection afforded to them in civil life had not been given to them in their military life, and their main aims were to "get something" from the Government and to be discharged as soon as possible. The social workers made a special effort to give these men a somewhat different. point of view regarding the military system.¹⁹

Attention to the welfare of psychiatric cases after discharge from the Army for disability was particularly necessary, owing to both the character of their disabilities and the probability of their not being entitled to compensation, the diseases having existed before their entry into the military service.¹⁹ The social worker referred such cases to the American Red Cross when their discharges were recommended, and the Red Cross immediately had reports made as to their home conditions and received notice when the men were discharged.  Such assistance as was indicated was then rendered-financial, medical, supervision, securing employment, etc.

Frequently the social service was called upon by the hospital administration to reply to letters from friends and relatives of patients who desired information concerning the patient's condition, surroundings, etc.¹⁹ These replies required careful consideration, for they must contain sufficient information to allay anxiety, and at the same time they must not divulge information which might. give a false impression or serve as a basis of a claim against the Government.

Such questions as the need for furloughs, when the reliability of the statements was questioned, and the need for early discharge from the Army because of dependency or serious illness of relatives, were referred to the service.

REFERENCES

1) Letter from Dr. Pearce Bailey, chairman, committee on furnishing hospital units for nervous and mental disorders to the United States Government, to the Surgeon General, United States Army, Washington, D. C., May 12, 1917. On file, Record Room, S. G. O., 730 (Neurology, General).
(2) Letter from The Adjutant General of the Army to Capt. Charles Bagley, Jr., M. R. C., December 12, 1917. Subject: Orders (and attached papers). On file, Record Room, S. G. O., 730 (Neuropsychiatry).
(3) Annual Report of the Surgeon General, United States Army, 1918, 369.
(4) Letter from Edwin D. Ricketts, to Hon. Newton D. Baker, Secretary of War, Washington, D. C., August 19, 1919 (and attached papers). On file, Record Room, S. G. O., 701-7.

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(5) Memorandum. from the Surgeon General to the Secretary of War, November 7, 1917. Subject: Plan for physical reconstruction and vocational training (and attached papers). On file, Record Room, S. G. O., 356 (Reconstruction).
(6) Memorandum from Lieut. Col. Edgar King, M. C., N. A., for Hospital Division, Surgeon  General's Office, March 1, 1918. On file, Record Room, S. G. O., 353.91-1.
(7) Memorandum from Lieut. Col. Pearce Bailey, M. C., N. A., for Hospital Division,  Surgeon General's Office, April 8, 1918. On file, Record Room, S. G. O., 701-7.
(8) Memorandum from Lieut. Col. Pearce Bailey, M. C., N. A., for Colonel Billings, January  9, 1919. On file, Record Room, S. G. O., 701-7.
(9) Letter from Maj. Charles L. Greene, M. C., consultant, to Col. Frank Billings, M. C., chief of division of physical reconstruction, November 9, 1918. Subject: Reconstruction work at General Hospital No. 30, Plattsburg Barracks, Plattsburg, N. Y.  On file, Record Room, S. G. O., 356 (Reconstruction, General Hospital No. 30), K.
(10) Letter from Maj. R. H. Hutchings, Maj. A. J. Rosanoff, Maj. C. Van Epps, Maj. J. R. Hunt, Maj. Theodore Weisenburg, General Hospital No. 30, Plattsburg Barracks,  N. Y., to the Surgeon General United States Army, Washington, D. C., October 28, 1918. Subject: Plans for a training camp for the cure of functional nervous diseases (and attached papers). On file, Record Room, S. G. O., 353.91-1 (General Hospital  No. 30), K.
(11) Letter from Maj. Charles Lyman Greene, M. C., to Col. Frank Billings, M. C., chief, division of physical reconstruction, undated. Subject: Physical reconstruction work at General Hospital No. 30 (and attached papers). On file, Record Room,  S. G. O., 353.91-1 (General Hospital No. 30), K.
(12) Circular No. 225, War Department, April 30, 1919.
(13) Annual Report of the Surgeon General, United States Army, 1919, ii, 1081-83.
(14) Consolidated table, nervous and mental cases in general hospitals, June 25, 1919, prepared in the neuropsychiatric division, Surgeon General's Office. On file, Historical Division, S. G. O.
(15) Based on weekly reports of sick and wounded made to the Surgeon General.
(16) Letter from Maj. Frank E. Leslie, M. C., General Hospital No. 25, Fort Benjamin Harrison, Ind., to Maj. Frankwood E. Williams, M. C., March 12, 1919. Subject: Observations and suggestions (and attached papers). On file, Record Room, S. G. O., 730 (Neuropsychiatry), K.
(17) History of General Hospital No. 2, Fort McHenry, Md., August 27, 1917, to May 31, 1920, by Maj. Arthur P. Herring. On file, Historical Division, S. G. O.
(18) Report from General Hospital No. 30, in compliance with Circular Letter No. 174. War Department, Office of the Surgeon General, Washington, D. C., April 16, 1919  Subject: Information for the General Staff. On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 30), K.
(19) Letter from commanding officer, General Hospital No. 30, Plattsburg Barracks, N. Y., to the Surgeon General, United States Army, Washington, D. C., March 7, 1919.   Subject: Report of General Hospital No. 30 for the year 1918 (and attached papers).  On file, Historical Division, S. G. O.
(20) Letter from chief of educational service, General Hospital No. 30, Plattsburg Barracks, N. Y., to Maj. A. D. Dean, Teachers' College, New York, N. Y., October 26, 1918.  Subject: Typical cases. On file, Record Room, S. G. O., 356 (General Hospital  No. 30), K.
(21) Memorandum from Lieut. Col. Eugene D. Bondurant, M. C., General Hospital No. 13, Dansville, N. Y., for Colonel Bailey and Major Williams, regarding neuropsychiatric work in the Army, March 1, 1919. On file, Record Room, S. G. O., 702 (Neuropsychiatry, General Hospital No. 13), K.

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(22) Letter from commanding officer, General Hospital No. 30, Plattsburg Barracks, N. Y.,  to the Surgeon General of the Army, April 14, 1919. Subject: History of General Hospital No. 30 (and attached papers). On file, Record Room, S. G. O., 314.7 (General Hospital No. 30), K. (23) Memorandum from Maj. John Bryant, M. C., consultant, to Colonel Billings, May 2, 1919. Subject: Reconstruction work at General Hospital No. 30, Plattsburg Bar racks, N. Y. (and attached papers). On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 30), K.
(24) Letter from commanding officer, General Hospital No. 43, National Soldiers' Home, Va., to the Surgeon General, United States Army, January 9, 1920.  Subject: Report of professional work at General Hospital No. 43 for calendar year 1919. On file, Record  Room, S. G. O., 319.1-2 (General Hospital No. 43), K.
(25) History of Educational Service, Base Hospital, Fort Sam Houston, Tex., from December, 1918, to March, 1919, inclusive, by Benj. F. Pittenger, Major, S. C. (and attached papers). On file, Historical Division, S. G. O.