APPENDIX
A BIBLIOGRAPHY OF AMERICAN CONTRIBUTIONS TO WARNEUROPSYCHIATRY
Abbot, E. S.: Work of psychiatrists in military camps.The American Journal of Insanity, Utica, 1919, lxxv, 457-65.
Adler, H. M.: The broader psychiatry and the war. MentalHygiene, New York, 1917, i, 364-70.
Adler, H. M.: Disciplinary problems of the Army. Mental Hygiene, New York, 1919, iii, 594-602.
Adler, H. M.: Some observations on disciplinary psychiatry in the Army. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 210-212.
American Legion National Rehabilitation Committee: The American Legion at work for the sick and disabled. Report, October, 1922.
Ames, T. H.: War shock, its occurrence and symptoms. The Journal of Nervous and Mental Diseases, New York, 1918, xlvii, 43-47.
Anderson. M. L.: Mental reconstruction through occupational therapy. The Modern Hospital, St. Louis, 1920, xiv, 326-327.
Atwill, Dorothy: Psychiatric social service for ex-service men. Committee Social Mental Hygiene, 11th Annual Report, 1918-19, 20-24.
Auer, E. M.: Phenomena resultant upon fatigue and shock of the central nervous system observed at the front in France. The Medical Record, New York, 1916, lxxxix, 641-44.
Auer, E. M.: Some of the nervous and mental conditions arising in the present war. Mental Hygiene, New York, 1917, i, 383-88.
Bahr, M. A.: Importance of a neuropsychiatric examination of registrants for military service. Indianapolis Medical Journal, Indianapolis, 1918, xxi, 211-16.
Bailey, Pearce: Applicability of the findings of the neuropsychiatric examinations in the Army to civil problems. Mental Hygiene, New York, 1920, iv, 301-11.
Bailey, Pearce: Care and disposition of the military insane. Mental Hygiene, New York, 1918, ii, 345-58.
Bailey, Pearce: Care of disabled returned soldiers. Mental Hygiene, New York, 1917, i, 345-53. Also, Pacific Medical Journal, San Francisco, 1917, lx, 608-15.
Bailey, Pearce: Incidence of multiple sclerosis in UnitedStates Troops. Archives of Neurology and Psychiatry, Chicago, 1922, vii, 582-83.
Bailey, Pearce: Malingering in U. S. Troops, Home Forces, 1917. The Military Surgeon, Washington, D. C., 1918, xlii, 261-75, 424-49.
Bailey, Pearce: Mental deficiency; its frequency and characteristics in the United States as determined by the examination of recruits. Mental Hygiene, New York, 1920, iv, 564-96.
Bailey, Pearce: Nervous and mental disease in U. S. Troops. The Medical Progress, Louisville, 1920, xxxvi, 193-97.
Bailey, Pearce: Neuropsychiatry and the mobilization. The New York Medical Journal, New York, 1918, cvii, 794-95.
Bailey, Pearce: Prevention of nervous casualties. New Republic, 1918, xiii, 275.
Bailey, Pearce: Psychiatry and the Army. Harpers Monthly, 1917, cxxxv, 251-57.
Bailey, Pearce: Reconstruction in nervous and mental disease. Ungraded, 1920, v, 97-107.
Bailey, Pearce: War and mental disease. American Journal of Public Health, New York, 1918, viii, 1-7.
Bailey, Pearce: War neuroses, shell shock, and nervousness in soldiers. The Journal of the American Medical Association, Chicago, 1918. lxxi, 2148-53.
478
Bailey, Pearce: War's big lesson in mental and nervous disease. National Committee for Mental Hygiene, New York, 1919, 10.
Ball, C. R.: Neurology and psychiatry in the war. The Lancet, 1920, xl, 207-12.
Banguss, J. B.: Drug addiction. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 2, 24.
Barker, L. F.: War and the nervous system. The Journal of Nervous and Mental Diseases, New York, 1916, xliv, 1-10.
Barnes, F. M., Jr.: Out-patient neuropsychiatric clinic as a factor in vocational rehabilitation. Journal of the Missouri State Medical Association, St. Louis, 1924, xxi, 43-46.
Bassoe, Peter: Report of neuroses in soldiers, with presentation of cases. The Journal of Nervous and Mental Diseases, New York, 1919, 1, 170-75.
Beall, C. C.: Functional diseases of nervous system in soldiers and civilians. The Journal of the Indiana State Medical Association, Fort Wayne, 1922, xv, 75-78.
Beck, R. J.: Parkinsonian states of infectious origin, with case reports. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 835.
Benton, G. H.: Some evidences of inadaptability in ex-service psychoneurotics. The Southern Medical Journal, Birmingham, Ala., 1922, xv, 992-1000.
Benton, G. H.: War neuroses and allied conditions in ex-service men, as observed in the U. S. Public Health Service Hospitals for psychoneurotics. The Journal of the American Medical Association, Chicago, 1921, xxvii, 360-64.
Billings, Frank: Leaving too soon; the disabled soldier should remain in the hospital for full restoration, phsycial and mental. Carry On, S. G. O., Washington, D. C., i, No. 5, 8-10.
Billings, Frank: Physical and mental rehabilitation of disabled soldiers of the United States Army. Transactions of the Congress of American Physicians and Surgeons, New Haven, 1919, xi, 105-116. Also, The Institution Quarterly, Springfield, Ill., 1919, x, 97.
Bisch, L. E.: Early recognition of mental disease. The Southern Medical Journal, Birmingham, Ala., 1919, xii, 538-41.
Bisch, L. E.: Eliminating the epileptic from the Navy. United States Naval Medical Bulletin, Washington, 1919, xiii, 5-15.
Bloedorn, W. A.: Hysteria in the naval service. United States Naval Medical Bulletin, 1921, 515-21.
Bowers, P. E.: Psychoneuroses. Santa Clara County Medical Society Bulletin, 1921, ii, No. 4, 4-7, No. 5, 3-6.
Bowman, K. M.: Analysis of case of war neurosis. The Psychoanalytical Review, Lancaster, Pa., and New York, 1920, vii, 317-32.
Bowman, K. M.: Relation of defective mental and nervous states to military efficiency. The Military Surgeon, Washington, 1920, xlvi, 651-69.
Bowman, K. M.: Report of the examination of the - - - - - - Regiment, U. S. A., for nervous and mental disease. The American Journal of Insanity, Baltimore, 1919, lxxiv, 555-67.
Boyd, W. A.: Epilepsy: Differential diagnosis and treatment. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 165.
Brewster, G. F.: Commitment of insane beneficiaries to U. S. Veterans' Bureau Hospitals. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 249.
Briggs, L. V.: Massachusetts Committee for the state care and treatment of soldiers suffering from nervous and mental diseases (letter). The Boston Medical and Surgical Journal, Boston, 1917, clxxvi, 922.
Briggs, L. V.: A plea for more psychiatrists and neurologists for war service. Proceedings Alienists and Neurologists, 1917, vi, 31.
Briggs, L. V.: War neuroses; environment and events as the causes. The American Journal of Insanity, Baltimore, 1920, lxxvi, 285-94.
Briggs, L. V.: Mental conditions disqualifying for military service. The Boston Medical and Surgical Journal, Boston, 1918, clxxviii, 141-46.
Briggs, L. V. and Hodskins, M. B.: Report of neuropsychiatric work at Camp Devens, Mass. The New York Medical Journal, New York, 1921, cxiii, 749-50.
Brophy, J. W.: Social adjustment of psychotic patients. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 1046.
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Brown, L. M.: Drug addiction. U. S. Veterans' Bureau Medical Bulletin, Washington,1926, ii, 691.
Brown, M. W., and Williams, F. E.: Neuropsychiatry and the war; abibliography with abstracts. National Committee for Mental Hygiene, New York,1918, 292.
Brown, M. W., and Williams, F. E.: Neuropsychiatry and the war; Supplement I,October, 1918. National Committee for Mental Hygiene, New York, 1918, 117.
Brown, Sanger II: Nervous and mental disorders of soldiers. The AmericanJournal of Insanity, Baltimore, 1920, lxxvi, 419-36.
Brown, Sanger II: Nervous symptoms in ex-soldiers. The Journal of theAmerican Medical Association, Chicago, 1921, lxxxvii, 113-16.
Brownrigg, A. E.: Neurospychiatric work in the Army. The Boston Medicaland Surgical Journal, Boston, 1919, clxxxi, 458-62.
Burrier, W. P.: Constitutional psychopaths. U. S. Veterans' BureauMedical Bulletin, Washington, 1926, ii, 684.
Caldwell, C. B.: Notes on Army neuropsychiatry. The Institution Quarterly,Springfield, Ill., 1919, x, 60-64.
Campbell, C. McF.: Role of instinct, emotion, and personality in disorders ofthe heart. The Journal of the American Medical Association, Chicago,1918, lxxi, 1622-26.
Carlisle, C. L.: Interpretation of inadequate behaviour throughneuropsychiatric symptoms. U. S. Veterans' Bureau Medical Bulletin, Washington,1926, ii, 230.
Carr, B. W.: Occupational therapy for psychotics. U. S. Veterans' BureauMedical Bulletin, Washington, 1926, ii, 362.
Cohn, A. E.: The effort syndrome. War Medicine, Paris, 1918, ii, 761-66.Report to Research Society, American Red Cross in France.
Covey, C. B.: Speech defects in psychoneurotics. U. S. Veterans' BureauMedical Bulletin Washington, 1925, i, No. 6, 10.
Crouch, E. L.: A preliminary study of occupational therapy for thedeteriorated psychotic. U. S. Veterans' Bureau Medical Bulletin, Washington,1925, i, No. 1, 18.
Cushing, Harvey: Neurological surgery and the war. The Boston Medical andSurgical Journal, Boston, 1919, clxxxi, 549-52.
Cushing, Harvey: Some neurological aspects of reconstruction. Archives ofNeurology and Psychiatry, Chicago, 1919, ii, 493-504.
Davis, T. K.: Status lymphaticus; its occurrence and significance in warneuroses. Archives Neurology and Psychiatry, Chicago, 1919, ii, 414-18.
Dearborn, George Van Ness: An aid in the diagnosis and the prognosis ofmental disease, The British Journal of Medical Psychology, London, 1927,vii, No. 3, 315-320.
Dearborn, George Van Ness: Psychiatry and science. The Journal of MentalSciences, London, lxxiv, 305 (April, 1928), 203-223.
Dearborn, George Van Ness: Psychology in medicine and psychiatry. Americana,New York, 1919, xviii, 584-587.
Dearborn, George Van Ness: Psychometric methods. U. S. Veterans' BureauMedical Bulletin, Washington, iv, No. 5, 426-432; iv, 6 (June, 1928), 539-544;iv, No. 7, 610-615; iv, 8 (August, 1928), 684-691.
Dearborn, George Van Ness: The determination of mental regression andprogression. The American Journal of Psychiatry, Baltimore, vi, No. 4,725-741.
Dercum, F. X.: So-called "Shell Shock": the remedy. Archives ofNeurology and Psychiatry, Chicago, 1919, i, 65-76.
de River, J. P.: Some important ophthalmic signs in diseases of N. S. U.S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 3, 26.
De Schweinitz, G. E.: Concerning the ocular phenomena in psychoneuroses ofwarfare. Archives of Ophthalmology, New York, 1919, xlviii, 419-38.
Dickerson, D. G.: Neurological studies in psychotic cases. U. S. Veterans'Bureau Medical Bulletin, Washington, 1926, ii, 233.
Dishong, G. W.: War psychoneuroses. Nebraska State Medical Journal, Norfolk,1919, iv, 238-43.
480
Drysdale, H. S. and Gardner, J. S. S.: Hysterical hemiplegia; report of a case resulting from a shrapnel wound of the scalp and presenting interesting clinical features. The Journal of the American Medical Association, Chicago, 1919, lxxiii, 1258-82.
Eaton, R. G.: Treatment of excited states in the mentally ill ex-soldier. U. S. Veterans' Bureau Medical Bulletin, Washington, October, 1926, ii, No. 10, 932.
Engleton, D. F., and Riley, W. J.: Preliminary report, treatment of neurosyphilis with tertiary malaria. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 757.
Ernest, F. J.: Standardization of treatment of neurosyphilis. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 5, 13.
Fenton, Norman: Bibliography, in Southard, E. E., "Shell Shock." Leonard, Boston, 1919, 905-82.
Fenton, Norman, and Schwab, S. I.: The factor of anticipation in war neuroses. Proceedings American Neurogical Association, May, 1919.
Fenton, Norman: Anticipation neurosis and army morale. Journal of Abnormal Psychology, Boston, 1925, xxxii, 282-93.
Fenton, Norman, and Thom, D. A.: Amnesias in war cases. Proceedings of the American Medico-Psychological Association, Utica, N. Y., May, 1920. Also, The American Journal of Insanity, Baltimore, 1919, lxxiv, 437-38.
Fenton, Norman: Civilian readaptation of A. E. F. war neurotics. Proceedings of the American Psychological Association (Western Division), July, 1925. Also Psychiatric Bulletin of the New York State Hospitals, Utica, 1926, xxiii, 299.
Fenton, Norman: A survey of war neurosis and its aftermath. A Thesis. Library of Leland Stanford Junior University, 1925, 324.
Fenton, Norman: Shell Shock and Its Aftermath. C. V. Mosby, St. Louis, 1926, 173.
Foley, T. K.: The limp as a manifestation of malingering. International Clinics, J. B. Lippincott Company, Philadelphia, 1929, ii, series 29, 164-70.
Foster, F. A.: Social work in the Veterans' Bureau. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 17.
Frost, L. C.: Treatment in relation to the mechanism of shell shock. The Military Surgeon, Washington, D. C., 1919, xliv, 350-60.
Gordon, Alfred: The problem of "neurotics" in military service. The Medical Record, New York, 1918, xciii, 234-37.
Gregory, M. S.: Neurosychiatry in recruiting and cantonment. Archives of Neurology and Psychiatry, Chicago, 1919, i, 89-94.
Grimberg, L. E.: War traumas of the spinal cord; some clinical features. The Journal of Nervous and Mental Diseases, New York, 1919, xlix, 115-29.
Hadley, E. E.: Mental symptom complex following cranial trauma. The Journal of Nervous and Mental Diseases, New York, 1922, lvi, 453-77.
Hamilton, S. W.: Standard neurosychiatric veterans' hospitals. National Committee for Mental Hygiene, New York, 1925.
Hammond, G. M.: Neurological and mental examination of state troops of the National Guard. The New York Medical Journal, New York, 1917, cvii, 764.
Harrington, M. A.: Mental disease in the field. Mental Hygiene, NewYork, 1918, ii, 407-15.
Harvey, J. G.: Social work as an aid to psychiatry. U.S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 962.
Heldt, T. J.: Some important factors in the hospital treatment ofpsychoneurotic ex-service men. American Journal of Psychiatry, 1923, ii,647-63.
Henry, H. B.: Syphilis as a factor in mental disease. U. S. Veterans'Bureau Medical Bulletin, Washington, 1925, i, No. 4, 32.
Hill, D. S.: Valid uses of psychology in the rehabilitation of war victims. MentalHygiene, New York, 1918, ii, 611-628.
Hoch, August: Recommendations for the observation of mental disordersincident to the war. Psychiatric Bulletin of the New York State Hospitals, Utica,1917, ii, 377-385.
Hodes, R., and Pinto, N. W.: Studies of traumatic psychoses. U. S.Veterans' Medical Bulletin, Washington, 1925, i, No. 3, 44.
Holbrook, C. S.: Shell-shock; psychoneuroses of war. The New OrleansMedical and Surgical Journal, New Orleans, 1918, lxxi, 191-202.
481
Hollingworth, H. L.: Psychological service in reconstruction.Columbia University Quarterly, 1919, xxi, 200-26.
Hollingworth, H. L.: Psychology of the functional neuroses. Appleton, NewYork, 1920, 259.
Hoppe, H. H.: The source of error in neuropsychiatricdiagnosis. U. S. Veterans' Medical Bulletin, Washington, 1926, ii, 745.
Howland, G. W.: Neuroses of returned soldiers. The Medical Fortnightly, St.Louis, xlix, 97-100. Also American Medicine, New York, 1917, xxiii, 313-19.
Huddleson, James H.: Psychotherapy in two hundred cases of psychoneurosis. The Military Surgeon, Washington, 1927, xl, No. 2, 161.
Huddleson, James H., and Bailey, M. Prentiss: The incidence and characteristics of dysthyroidism as an ex-service disability. Archives of Neurology and Psychiatry, Chicago, 1922, vii, 332.
Hulbert, H. S.: Gas neuroses syndrome. The American Journal of Insanity, Baltimore, 1920, lxxvii, 213-16.
Hulbert, H. S.: Military value of psychiatry. Journal of the American Institute of Criminal Law and Criminology. Chicago, 1920, x, 612-14.
Humes, C. D.: War neuroses. The Journal of the Indiana State Medical Association, Fort Wayne, Ind., 1919, xii, 123.
Hunt, J. R.: Exhaustion pseudoparesis; a fatigue syndrome simulating early paresis, developing under intensive military training. The Journal of the American Medical Association, Chicago, 1918, lxx, 11-14.
Hyslop, G. H.: Relation of compensation to neuropsychiatric disability. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 2, 14.
Hutchings, R. H.: Hysteria as manifested in the military service. Psychiatric Bulletin of the New York State Hospitals, Utica, 1919, iv, 293-300.
Inman, T. G.: Some comparisons between war neuroses and those of civil life. California State Journal of Medicine, San Francisco, 1920, xviii, 184.
Ireland, G. O.: Neuropsychiatric ex-service man and his civil reestablishment. American Journal of Psychiatry, 1923, ii, 685-704.
Ireland, M. W.: Care of Army's mental defectives. The Journal of Nervous and Mental Diseases, New York, 1920, lii, 537.
Jacoby, A. L.: Disciplinary problems of the Navy. Mental Hygiene, New York, 1919, iii, 603-08.
Jacoby, A. L.: Psychiatric material in the naval prison at Portsmouth, N. H. United States Naval Medical Bulletin, Washington, 1918, xii, 406-13.
Jarrett, M. C.: Social work as war service. Bulletin of the Massachusetts Commission on Mental Diseases, Boston, 1918, ii, No. 1, 25-29.
Jarrett, M. C.: War neuroses after the war; extra-institutional preparation. National Conference Social Work, 1918, 8.
Johnstone, E. K.: Notes on shell shock. The Military Surgeon, Washington, D. C., 1918, xlii, 531-38.
Kefauver, H. J.: Agriculture as occupational therapy in a neuropsychiatric hospital. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 592.
Kellum, H. J.: The infection, exhaustion and toxic psychoses. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 369.
Kennedy, Foster: Clinical observations on shell shock. The Medical Record, New York, 1916, lxxxix, 338.
Kennedy, Foster: Nature of nervousness in soldiers: The Journal of the American Medical Association, Chicago, 1918, lxxi, 17-21.
Kenyon, E. K.: The stammerer and Army service. The Journal of the American Medical Association, Chicago, 1917, lxix, 664-65.
Kiely, C. E.: Five hundred cases of shell shock. The Ohio State Medical Journal, Columbus, 1919, xv, 711-18.
Kindred, J. J.: Neuropsychiatric wards of the United States Government; their housing and other problems. American Journal of Psychiatry, 1921, i, 183-92.
Klopp, H. I.: War neuroses in general practice. The Hahnemannian Monthly, Philadelphia, 1922, lvii, 91-100.
482
Kolb, Lawrence: Bearing of war neuroses on immigration. Archives of Neurology and Psychiatry, Chicago, 1919, i, 317-32.
Leahy, S. R.: An analysis of cases admitted to the neuropsychiatric services of U. S. Army General Hospital No. 1 (Columbia War Hospital, N. Y.). Archives of Neurology and Psychiatry, Chicago, 1920, iv, 191-97.
Leahy, S. R.: Neuropsychiatric services of the U. S. A. General Hospital No. 1. The Journal of the Nervous and Mental Diseases, New York, 1920,li, 454-56.
Lorenz, W. F.: Delinquency and the ex-soldier. Mental Hygiene, New York, 1923, vii, 472-84.
Lorenz, W. F.: War psychoneurosis. The Wisconsin Medical Journal. Milwaukee, 1920, xviii, 506-11.
Love, A. G., and Davenport, C. B.: Defects found in drafted men. Government Printing Office, Washington, 1920, 1663.
Love, A. G., and Davenport, C. B.: Defects found in drafted men. Statistical information compiled from the draft records. Government Printing Office, Washington, 1919, 359.
Love, A. G., and Davenport, C. B.: Physical examination of the first million drafted recruits. Government Printing Office, Washington, 1919, 54.
McAllaster, B. R.: Hysterical disorders observed in American soldiers in France. Bulletin of Iowa State Institutions, Des Moines, 1921, xxiii, 98-101.
McConnely, E.: Care and treatment of drug addicts. U. S. Veterans' Bureau Medical Bulletin, 1926, ii, 844.
MacCurdy, J. T.: Mental hygiene lessons of the war. Psychiatric Bulletins of the New York State Hospitals, Utica, 1920, v, 205-20.
MacCurdy, J. T.: Psychology of war. Luce, Boston, 1918, 85.
MacCurdy, J. T.: War neuroses. Cambridge (England) University Press, 1918, 132. Also, Psychiatric Bulletins of the New York State Hospitals, Utica, 1917, ii, 243-54.
McDaniel, F. L.: Report of the psychiatric division on recruits entering incoming detention camps. United States Naval Medical Bulletin, Washington, 1919, xiii, 854-58.
MacDonald, Arthur: Disequilibrium of mind and nerves in war. The Medical Record, New York, 1919, xcv, 727-31.
MacDonald, Arthur: Physical and mental examination of American soldiers. Modern Medicine, Battle Creek, Mich., 1921, iii, 129-33.
MacDonald, V. May: Psychiatric social work for the discharged soldiers. Psychiatric Bulletins of the New York State Hospitals, Utica, 1919-20, v, 148-51.
MacFarlane, Andrew: Neurocirculatory myasthenia; a problem of the substandard soldier. The Journal of the American Medical Association, Chicago, 1918, lxxi, 730-33.
MacPherson, D. J.: Neuropsychiatric experiences at Vichy and Savenay. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 215-18.
McPherson, G. E.: Neuropsychiatry in Army camps. The Boston Medical and Surgical Journal, Boston, 1919, clxxxi, 606-11. Also, The American Journal of Insanity, Baltimore, 1919, lxxvi, 35-44.
McPherson, G. E., and Hohman, L. B.: Diagnosis of "war psychoses." Archives of Neurology and Psychiatry, Chicago, 1919, i, 207-24.
Major, H. S.: Work of the neuropsychiatrists in the U. S. Army camps. Journal of Missouri State Medical Association, St. Louis, 1919, xvi, 377-79.
Massonneau, Grace: Social analysis of a group of psychoneurotic ex-service men. Mental Hygiene, New York, 1922, vi, 575-91.
Mayer, A. G.: On the nonexistences of nervous shell shock in fishes and marine invertebrates. Proceedings of the National Academy of Sciences, Baltimore, 1917, iii, 597.
Mayer, C. E.: Report of a case of sensory aphasia in a soldier. The Institution Quarterly, Springfield, Ill., 1919, x, 50-52.
Meagher, J. F. W.: Prominent features of the psychoneuroses in the war. The American Journal of the Medical Sciences, Philadelphia, 1919, clviii, 344-54.
Meagher, J. F. W.: Nervous and mental diseases in the war; a comparison of the results of the examination of recruits in two Army camps. The Journal of Nervous and Mental Diseases, New York, 1919, 1, 331-37.
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Meyer, E. W.: Notes on the work of the neuropsychiatric corps. PacificCoast Journal of Homeopathy, San Francisco, 1920, xxxi, 55-58.
Mills, C. K.: War neurology; an introduction to shell shock and otherneuropsychiatric problems, by E. E. Southard. Leonard, Boston, 1919, 5-18.
Moore, G. S.: Introduction to study of neuropsychiatric problems amongnegroes. U. S. Veterans' Bureau Medical Bulletin, 1926, ii, 1042.
Neyman, C. A.: Some experiences in the German Red Cross. Mental Hygiene, NewYork, 1917, i, 392-96.
Nichols, C. L.: War and civil neuroses; a comparison. Long Island MedicalJournal, Brooklyn, 1919, xiii, 257-68.
Norbury, F. G.: Relation of defective mental and nervous states to militaryefficiency. The Military Surgeon, Washington, D. C., 1920, xlvii, 20-39.
Norbury, F. P.: Mental hygiene and the war. The Journal of the Iowa StateMedical Society, Clinton, 1919, ix, 299-315.
Norbury, F. P.: Mental mechanisms of war neuroses. The Medical Herald, St.Joseph, Mo., 1920, xxxix, 109-13.
Norbury, F. P.: The National Committee for Mental Hygiene and its war workcommittee. The Institution Quarterly, Springfield, Ill., 1917, viii, 34.
Norbury, F. P., and Norbury, F. G.: War neuroses and psychoses; theiraftercare and treatment. The Illinois Medical Journal, DeKalb, 1920,xxxvii, 232-37.
O'Brien, J. F.: Epilepsy or hysteria, a study of convulsive seizures andunconscious states in one hundred ex-service men. The Boston Medical andSurgical Journal, Boston, 1925, clxxxviii, 103-107.
Oppenheimer, G. S., and Rotschild, M. A.: Psychoneurotic factor in theirritable heart of soldiers. The Journal American Medical Association, Chicago,1918, lxx, 550-54.
Parsons, F. W.: War neuroses. Atlantic Monthly, 1919, cxxiii, 335-38.
Patrick, H. T.: Remarks on examination of recruits of nervous and mentaldisorders. The Journal of Nervous and Mental Diseases, New York, 1918,xlvii, 450-53.
Patrick, H. T.: War neuroses. The Journal of the Indiana State MedicalAssociation, Fort Wayne, 1919, xii, 33.
Payne, C. R., and Jelliffe, S. E.: War neuroses and psychoneuroses. TheJournal of Nervous and Mental Diseases, New York, 1919, xlviii, 246-53,325-32, 385-94; xlix, 50-57, 142-48, 234-38, 1, 359-68, 464-67.
Pederson, T. E.: The psychiatric nurse in the Veteran's Bureau. U. S.Veteran's Bureau Medical Bulletin, Washington, 1926, ii, 889.
Penhallow, D. P.: Mutism and deafness due to emotional shock cured byetherization. The Boston Medical and Surgical Journal, Boston, 1916,clxxiv, 131.
Perde, N.: Endocrinopathic constitutions and pathology of war. Endocrinology,1919, iii, 329-41.
Piersol, G. M.: Cardiovasular phenomena associated with war neuroses. The Pennsylvania Medical Journal, Pittsburgh, 1920, xxiii, 258-63.
Pilgrim, C. W.: The State hospitals and the war. State Hospitals Bulletin, Utica, 1918, iii, 223-4.
Pollock, A. J.: An analysis of a number of cases of war neuroses. Illinois Medical Journal, DeKalb, 1920, xxxviii, 208-12.
Pollock, H. M.: Mental diseases in New York State during the war period. Mental Hygiene, New York, 1919, iii, 253-57.
Price, G. E., and Terhune, W. B.: Feigned amnesia as a defense reaction. The Journal of the American Medical Association, Chicago, 1919, lxxii, 565-67.
Prince, Morton: Babinski's theory of hysteria. The Journal of Abnormal Psychology, Boston, 1919, xiv, 312-24.
Prince, Morton: Prevention of so-called shell shock. The Journal of the American Medical Association, Chicago, 1917, lxix, 725-26.
Ratliffe, T. A.: Constitutional inferiority in the Navy. United States Naval Medical Bulletin, Washington, 1919, xiii, 728-33. Also, Government Printing Office, Washington, 1919, 9.
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Raynor, M. W.: Psychiatry at the front in the American armies. Psychiatric Bulletins of the New York State Hospitals, Utica, 1919, iv, 301-06.
Rhein, J. H. W.: Neuropsychiatric problems at the front during combat. The Journal of Abnormal Psychology, Boston, 1919, xiv, 9-14.
Rhein, J. H. W.: Psychopathic reactions to combat experiences in the American Army. The American Journal of Insanity, Baltimore, 1919, lxxvi, 71-78.
Rhein, J. H. W.: Preventive measures in relation to war neuroses in the Army cantonments in America. War Medicine, August, 1918, ii, 47-51.
Rhein, J. H. W.: War neuroses as observed in Army neurological hospital at the front. The New York Medical Journal, New York, 1919, cx, 177-80.
Roberts, R. S.: Use of psychological and trade tests in a scheme for the vocational training of disabled men. Journal Educational Psychology, 1920, xi, 101-08.
Robertson, R. C.: Epilepsy. U. S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 849.
Robinson, G. W.: Neuropsychoses of war and peace. Journal Missouri State Medical Association, St. Louis, 1921, xviii, 435-39.
Rogers, J. C.: Residuals of encephalitis lethargica. U. S. Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 2, 20.
Rosanoff, A. J.: First psychiatric experiences at the national cantonment at Camp Upton. The Medical Record, New York, 1917, xcii, 877-78.
Rosanoff, A. J.: Study of hysteria based mainly on clinical material observed in the U. S. Army Hospital for War Neuroses at Plattsburg Barracks, N. Y. Archives of Neurology and Psychiatry, Chicago, 1919, ii, 419-60.
Salmon, T. W.: American psychiatry and the war. Proceedings of the American Medico-Psychological Association, Utica, 1919, xxvi, 269.
Salmon, T. W.: Care and treatment of mental diseases and war neuroses (shell shock) in the British Army. Mental Hygiene, New York, 1917, i, 509-47.
Salmon, T. W.: Neurology and psychiatry in the Army. Proceedings of the New York Neurological Society, November 13, 1917.
Salmon, T. W.: Psychiatric lessons from the war. Transactions of the American Neurological Association, June, 1919.
Salmon, T. W.: Some new problems for psychiatric research in delinquency. Journal of the American Institute of Criminal Law and Criminology, Chicago, 1919, xx, 375.
Salmon, T. W.: Future of psychiatry in the Army. The Military Surgeon, Washington, D. C., 1920, xlvii, 200-07.
Salmon, T. W.: Insane veteran and a nation's honor. American Legion Weekly, January 28, 1921, 5-6.
Salmon, T. W.: Outline of American plans for dealing with war neuroses. War Medicine, Paris, 1918, ii, 34.
Salmon, T. W.: On shell shock. The Institution Quarterly, Springfield, Ill., 1919, x, No. 4, 105-6.
Salmon, T. W.: Recommendations for the treatment of mental and nervous diseases in the United States Army. National Committee for Mental Hygiene, New York, 1918, 22. Reprint from Psychiatric Bulletins of the New York State Hospitals, Utica, 1917, ii, 355-76.
Salmon, T. W.: Some problems of disabled ex-service men three years after the armistice. Mental Hygiene, New York, 1922, vi, 1-10.
Salmon, T. W.: Urgent need of adequate provision for medical care of insane soldiers. American Red Cross, New York County Chapter News, February, 1921, 3-8.
Salmon, T. W.: Use of institutions for the insane as military hospitals. Mental Hygiene, New York, 1917, i, 354-63.
Salmon, T. W.: War neuroses and their lesson. The New York Medical Journal, New York, 1919, cix, 993-94.
Salmon, T. W.: War neuroses ("shell shock"). National Committee for Mental Hygiene, New York, 1918, 20. Also, The Military Surgeon, Washington, D. C., 1917, xli, 674-93.
485
Salmon, T. W.: The wounded in mind. Carry on, S. G. O., Washington, D.C., i, No. 10, 3-6.
Sands, I. J.: The problem of mentally defective ex-servicemen. U. S. Veterans Bureau Medical Bulletin, Washington, 1926, ii, 32.
Sands, I. J.: Relation of trauma to neuropsychiatric diseases. U. S.Veterans' Bureau Medical Bulletin, Washington, 1925, i, No. 3, 32.
Seymour, W. Y.: Veronal psychosis. U. S. Veterans' Bureau MedicalBulletin, Washington, December, 1926, ii, 1159.
Schwab, S. I., and Fenton, Norman: The factor of anticipation in warneuroses. Proceedings of the American Neurological Association, May, 1919.
Schwab, S. I.: Influence of war upon concepts of mental diseases andneuroses. Modern Medicine, Battle Creek, Mich., 1920, ii, 192-98. Also,Mental Hygiene, New York, 1920, iv, 654-69.
Schwab, S. I.: Experiment in occupationaltherapy at Base Hospital 117, A. E. F. Mental Hygiene, New York, 1919,iii, 580-93.
Schwab, S. I.: Mechanism of the war neuroses. The Journal of AbnormalPsychology, Boston, 1919, xiv, 1-8.
Schwab, S. I.: War neuroses as physiologic conservations. Archives ofNeurology and Psychiatry, Chicago, 1919, i, 579-635.
Sheehan, R. F.: Comment on rehabilitation methods from the neurologicviewpoint. The Military Surgeon, Washington, D. C., 1920, xlvi, 636-45.
Sheehan, R. F.: Neurologic service in naval hospitals. The MilitarySurgeon, Washington, D. C., 1920, xlvii, 295-302.
Sims, R. F.: Problems of the U. S. Veterans' Bureau. The Boston Medicaland Surgical Journal, Boston, 1924, cxci, 189-93.
Sims, T. R.: The psychiatrist and his patient. U. S. Veterans' BureauMedical Bulletin, Washington, 1926, ii, 568.
Sisson, C. E.: The receiving service of a neuropsychiatric hospital. U.S. Veterans' Bureau Medical Bulletin, Washington, 1926, ii, 485.
Skverskv, A.: Lethargic encephalitis in the A. E. F.; a clinical study. TheAmerican Journal of the Medical Sciences, Philadelphia, 1919, clviii, 849.
Smith, R. P.: Mental defects found in the Army. Northwest Medicine, Seattle,1918, xvii, 99-103.
Somerville, W. G.: Shell shock (war neuroses). Memphis Medical Monthly, Memphis, Tenn., 1919, xl, 481-83.
Southard, E. E.: Shell shock and after (Shattuck lecture). The Boston Medical and Surgical Journal, Boston, 1918, clxxix, 73-93.
Southard, E. E.: Shell shock and other neuro-psychiatric problems, presented in five hundred and eighty-nine case histories, 1914-1918, with a bibliography by Norman Fenton. Leonard, Boston, 1919, 982.
Stearns, A. W.: The classification of naval recruits. California State Journal of Medicine, San Francisco, 1919, April.
Stearns, A. W.: The psychiatric examination of recruits. The Journal of the American Medical Association, Chicago, 1918, lxx, 229-31.
Stearns, A. W.: The history as a means of detecting the undesirable candidate for enlistment, with especial reference to military delinquents. United States Naval Medical Bulletin, Washington, 1918, xii, 413-15.
Stearns, A. W.: Importance of a history as a means of detecting psychopathic recruits. The Military Surgeon, Washington, 1918, xliii, 652-61.
Steckel, H. A.: War neuroses in combat areas. Psychiatric Bulletins of the New York State Hospitals, Utica, 1919, v, 44-56.
Stein, A. H.: Case of shell shock in civil life. Albany Medical Annals, Albany, 1921, xlii, 48-53.
Stephenson, J. W.: Brief r?sum? of neurologic and psychiatric observations in a hospital center in France. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 61-67.
Strecker, E. A.: Experience in the immediate treatment of war neuroses. The American Journal of Insanity, Baltimore, 1919, lxxvi, 45-69.
486
Sullenger, T. E.: Shell shock. The Psychological Clinic, Philadelphia, 1919, xiii, 33-50.
Swan, J. M.: Analysis of ninety cases of functional disease in soldiers. The Archives of Internal Medicine, Chicago, 1921, xxviii, 586-602.
Swift, H. M.: Neurologic and psychiatric work at Savenay. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 213-15.
Swope, S. D.: Psychoneurosis incident to war experiences. SouthwestMedical Record, Houston, 1926, vi, 26-28.
Taylor, E. C.: Types of neurological and psychiatric cases common in the Navy. United States Naval Medical Bulletin, Washington, 1920, xiv, 191-200.
Taylor, J. M.: Types of men as observed among recruits. The Boston Medical and Surgical Journal, Boston, 1918, clxxix, 646.
Taylor, W. S.: A hypoanalytic study of two cases of war neurosis. The Journal of Abnormal Psychology, Boston, 1922, xvi, 344-55.
Terhune, W. A.: The war neuroses. The Journal of the American Medical Association, Chicago, 1918, lxx, 1369-73.
Thom, D. A., and Fenton, Norman: Amnesias in war cases. The American Journal of Insanity, Baltimore, 1919, lxxvi, 437-48.
Thom, D. A., and Singer, H. D.: Care of neuropsychiatric disabilities among ex-service men. Mental Hygiene, New York, 1922, vi, 23-38.
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Thomas, J. J.; Types of neurological cases seen at a base hospital. The Journal Nervous and Mental Diseases, New York, 1916, xliv, 495-502.
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Williams, T. A.: Tremor following explosions. The Journal of Abnormal Psychology, Boston, 1920, xiv, 393-405.
Woods, L. C.: What is to become of the psychoneurotic? U. S. Veterans' Bureau Medical Bulletin, 1925, i, No. 5, 17.
Wolfe, Samuel: Mental instability in ex-service men; how acquired; how remedied. The Military Surgeon, Washington, D. C., 1922, li, 44-46.
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Wolfsohn, J. M.: The predisposing factors of war psychoneuroses. The Lancet, London, 1918, 177-180. Also The Journal of the American Medical Association, Chicago, 1918, lxx, 303-08.
Wolfsohn, J. M.: Treatment of hysteria; successful results of a rapid reeducation method. The Journal of the American Medical Association, Chicago, 1918, lxxi, 2057-62.
Worch, Margaret: Psychiatric social work in a Red Cross Chapter. Mental Hygiene, New York, 1922, vi, 312-31.
Wright, H. W.: Postbellum neuroses; a clinical review and discussion of their mechanisms. Archives of Neurology and Psychiatry, Chicago, 1920, iii, 429-34.
Ziegler, L. H.: Group of psychoneurotic ex-service men. Mental Hygiene, New York, 1925, ix, 128-56.
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NEW YORK CITY
April 12, 1917
Maj. Gen. W. C. GORGAS,
Surgeon General, U. S. Army, Washington
SIR: In accordance with the planagreed upon in our recent conference with you in Washington relative tosupplying psychiatric hospital units for the Army, we have visited Base HospitalNo. 1, Fort Sam Houston, Base Hospital No. 2, Fort Bliss, and the militaryprison at Fort Leavenworth. All the officers of the Medical Corps whom we mettreated us with great cordiality and kindness and we wish especially to expressour appreciation of the courtesies extended to us by Colonel McCaw, LieutenantColonel Ireland, Lieutenant Colonel Straub, and Captain King. These officersdevoted much of their personal time to us, answered all our inquiries, andplaced much valuable information at our disposal.
From the information thus gained, together with that which wehad already gathered regarding the occurrence of mental and nervous diseasesamong soldiers, we desire to bring to your attention the followingconsiderations:
1. Need and purposes of psychiatric hospital unit.-Theexcessiveprevalence of mental disorders in military life, as compared with civil life, isborne out by statistics drawn from various sources. Mental diseases wereapproximately three times as prevalent among the troops on the Mexican borderlast summer as among the adult civil population of the State of New York. Theexcess among soldiers is still higher under war conditions. In our own Army theinsanity rate rose during the Spanish-American War from 8 per thousand to 20 perthousand; in the German troops during the Boxer Rebellion the rate reached 50per thousand. The statistics available regarding the incidence of mentaldiseases in our own troops indicate that an army of 500,000 may be counted uponto furnish 1,500 insane patients a year in peace and not fewer than 4,500 a yearin war, or even perhaps at times of rapid mobilization. In other words, thenumber of insane patients coming to notice from such an army under theconditions which prevailed on the Mexican border last summer is certain toexceed the entire number of men admitted annually to all public institutions forthe insane in the State of California.
Having in mind the high incidence in armies of such a seriousand disabling disorder as insanity, it is evident that some special provisionsshould be made for the diagnosis and care of such patients. Without specialprovisions it is unavoidable that mental cases will, for the most part, bemaintained in prison wards. This method of dealing with mental diseases isobsolete. It excludes scientific management and deprives the patients of evenfresh air, exercise, and occupation. We were much impressed by the uniformlyhigh standard of provisions for the diagnosis and treatment of all purelyphysical diseases in the base hospitals which we visited. The provision existingfor the mentally ill, however, presented a sharp contrast. We believe specialhospital wards conducted by alienists would not only facilitate more rapid andmore complete recovery from psychoses but would remove disturbing elements fromthe general wards, assist in making important decisions regarding discharges andretirement, and release the regular medical officers for duties for which theirtraining has more specifically fitted them and which they all say are morecongenial.
In addition to cases of insanity and mental deficiency, allarmies have to deal with considerable numbers of soldiers with hysteria andneurasthenia. The prevalence of these disorders increases greatly during war andat times of large mobilization. If, even in civil life, such cases are treatedin general hospital wards, they show little tendency to recovery. Thesuggestions of physical illness inseparable from hospitals often fix theirsymptoms. When, on the other hand, such patients are cared for where suchsuggestions can be eliminated and some special methods of treatment can beemployed they frequently make rapid recoveries. A recent report from a Frenchmilitary neuropsychiatric unit states that many soldiers, after a neuroticinvalidism lasting for months in the general hospital, were returned to thecolors in from two to three weeks when treated in these units.
Physicians experienced in psychiatry could also be of serviceto the Army in making early diagnoses of mental disease when other issues thanthose of treatment are concerned. Such early diagnoses should be especiallyhelpful in disciplinary cases. Many military as well as civil offenders are inreality beginning cases of mental diseases or persons with constitutionalpsychopathic conditions who are better out of the Army than in it. Their prompt
490
recognition by experts would often do not a little for themorale of troops. The experts connected with a psychiatric unit could often aidvery materially in cases where malingering is suspected but can not easily beestablished.
2. General plan.-We believe that a psychiatric unitof 110 beds should be attached to the base hospital nearest the largestconcentration of troops and that smaller units of 30 beds each should beattached to base hospitals elsewhere, as required. The central unit as well aseach smaller unit should be a part of the base hospital and directly under themedical officer in command. To these units should be admitted not onlywell-recognized cases of mental disease and mental deficiency but cases forobservation, hysterics, disciplinary cases, and, in short, soldiers presentingany condition in which diagnosis can best be made and treatment carried on byexperts in this branch of medicine.
3. Personnel.-The psychiatric units can serve thepurposes which have been indicated only if they are integral parts of militaryhospitals and the alienists are medical officers of the Army. The central unitof 110 beds will require eight medical officers, assigned to duty as follows:One in general charge, one as chief of medical service, six as ward physicians.
It is essential that the medical officer in charge shouldhave training and practical experience in medico-military duties. He should beresponsible for all reports, correspondence, and property, and should assign theduties of all medical officers, noncommissioned officers, and privates. Thesmaller units of 30 beds would each require three medical officers. It wouldseem proper, in view of their long special training and their responsibility,that the medical officer in charge of the central unit should have the rank ofmajor and the other officers that of captain.
The success of these units will depend largely upon having asnurses skillful men with long training in the treatment of mental diseases. Ifprovision can be made for enlistment for the duration of the war, the servicesof nurses in responsible positions in some of the best hospitals for mentaldiseases in the country can be secured.
The attached table shows the personnel which will probably berequired for the central unit and for each of the smaller units.
4. Buildings.-The pavilions used in the basehospitals along the Mexican border could be very well adapted for use in theseunits in all except the most severe climate. Attached are sketch plans showing ascheme of general arrangement, a typical pavilion for general cases, a receptionpavilion, and a pavilion for disturbed patients. Plans showing a scheme ofgeneral arrangement for a smaller unit and of the two pavilions constitutingsuch a unit are also attached.
5. Equipment.-Assuming that beds, bedside stands,and other standard articles of equipment can be supplied by the Government, thefollowing special equipment will be furnished by the committee organizing theunits: Hydrotherapeutic outfits, electrical outfits, special diagnosticinstruments, including psychological apparatus, typewriters, books.
6. Organization of committee.-For the purpose ofexpedition in correspondence and executive work, the National Committee forMental Hygiene, 50 Union Square, New York City, has appointed as a committee onfurnishing hospital units for nervous and mental disorders to the United StatesGovernment and the following men have been asked to serve as additional members:
Pearce Bailey, M. D., New York City.
Mr. Otto T. Bannard, treasurer, National Committee for MentalHygiene, New York City.
Lewellys F. Barker, M. D., president, National Committee forMental Hygiene, Baltimore, Md.
Albert M. Barrett, M. D., medical director, StatePsychopathic Hospital, Ann Arbor, Mich.
G. Alder Blumer, M. D., superintendent, Butler Hospital,Providence, R. I.
Owen Copp, M. D., physician in chief, Pennsylvania Hospital,Philadelphia, Pa.
Walter E. Fernald, M. D., superintendent, MassachusettsSchool for Feeble-Minded, Waverley, Mass.
George H. Kirby, M. D., clinical director, Manhattan StateHospital, New York City.
August Hoch, M. D., director, New York State PsychiatricInstitute, New York City.
491
Adolf Meyer, M. D., director, Phipps Psychiatric ClinicBaltimore, Md.
Stewart Paton, M. D., Princeton, N. J.
William L. Russell, M. D., medical director, BloomingdaleHospital, White Plains, N.Y.
Thomas W. Salmon, M. D., medical director, National Committeefor Mental Hygiene, New York City.
Elmer E. Southard, M D., director, Boston PsychopathicHospital, Boston, Mass.
William A. White, M.D., superintendent, St. ElizabethsHospital, Washington, D. C.
Through the generosity of Miss Anne Thomson, daughter of thelate Frank Thomson, of Philadelphia, we have now on hand $15,000, an amountsufficient to defray the expenses of equipping the central unit of 110 beds inaccordance with the list given. Doubtless funds will be forthcoming to supplythe smaller units as they are required. We are prepared to get the central unittogether at once, both as to personnel and equipment.
Will you kindly inform us at your early convenience if theinitial unit is acceptable to the Government and, if so, at what date it isneeded and also kindly give us all information necessary to organize in a way tomeet all Army requirements? Doctor Salmon holds himself in readiness to come toWashington in this connection at any time.
Respectfully,
PEARCE BAILEY, M. D.
STEWART PATON, M. D.
THOMAS W. SALMON, M. D.
ENCLOSURES
1. Outline of facilities for treatment of mental disease in military and civil hospitals.
2. Blue print showing general arrangement of central psychiatric unit of 110 beds.
3. Blue print showing typical pavilions in central psychiatric unit.
4. Blue print showing typical pavilions in central psychiatric unit.
5. Personnel of central psychiatric unit.
6. Blue print showing general arrangement of smaller unit of 30 beds.
7. Blue print showing typical pavilions in smaller unit.
8. Personnel of smaller psychiatric unit.
Military zones | Military hospitals | Facilities for treating mental diseases |
Zone of the interior | Camp hospitals; general hospitals (permanent); hospitals for prisoners of war; convalescent camps; hospital trains; hospital ships (in overseas operations); hospitals at ports of embarkation (in overseas operations.) | Central psychiatric hospital unit (110 beds) attached to camp or base hospital nearest largest concentration of troops; civil institutions; Government Hospital for the Insane (St. Elizabeths Hospital); special wards in State hospitals for the insane; psychopathic hospitals; psychopathic wards in general hospitals. |
Zone of communications | Base hospitals (500 beds); evacuation hospitals (432 beds); evacuation hospital ambulance companies. | Psychiatric pavilions (30 beds) attached to base hospitals in favorable locations. |
Zone of the advance | Field hospitals (216 beds); ambulance companies; dressing stations; first aid. | Psychiatrist and neurologist attached to each field hospital company. |
492
GENERAL ARRANGEMENT
CENTRAL UNIT OF 110 BEDS
493
TYPICAL PAVILIONS
CENTRAL UNIT IF 110 BEDS
494
PERSONNEL OF CENTRAL UNIT, 110 BEDS
| |
Major A1 | In general charge. |
Captain B, M.R.C. | Chief of Medical Service. |
Captain C, M.R.C. | Ward physician. |
Captain D, M.R.C. | Do. |
Captain E, M.R.C. | Do. |
Captain F, M.R.C. | Do. |
Captain G, M.R.C. | Do. |
Captain H,1 M.R.C. | Do. |
| |
Sergeant, first class1 | Acting first sergeant, in general supervision of the hospital and in charge of medical property and records; acting quartermaster sergeant. |
| Do.1 | In charge of mess and kitchen. |
| Do. | In charge of hydrotherapy. |
| Do. | In charge of reception ward. |
Sergeant | Ward master. |
| Do. | Do. |
| Do. | Do. |
| Do. | Do. |
| |
2 acting cooks. | 1 in storeroom. |
22 ward attendants (12 day, 8 night, 2 relief). | 1 in office. |
1 in laboratory. | 1 in outside police. |
4 in kitchens and mess rooms. | 2 supernumeraries. |
1 orderly (to Major A). | |
| |
| Commissioned medical officers | 8 |
| Noncommissioned officers, Hospital Corps | 8 |
| Enlisted men, hospital corps | 35 |
| 51 |
| Patients | 110 |
| 161 |
|
| |
|
| |
Captain A1 | In general charge. |
Captain B | Ward physician. |
Captain C | Do. |
Noncommissioned officers, Hospital Corps | |
Sergeant, first class1 | Acting first sergeant. |
Sergeant | In charge of mess and kitchen |
| Do. | In charge of Ward A. |
| Do. | In charge of Ward B. |
1Previous military training required.
495
|
1 | |
1 acting cook. | 1 orderly (to Captain A). |
6 ward attendants (4 day, 2 night, 1 relief). | 1 in office. |
2 in kitchen and messroom. | 1 supernumerary. |
GENERAL ARRANGEMENT
SMALLER UNIT OF 30 BEDS
| |
Commissioned medical officers | 3 |
Noncommissioned officer, Hospital Corps | 4 |
Enlisted men, Hospital Corps | 12 |
| 19 |
Patients | 30 |
| 49 |
1Previous military training required.
496
TYPICAL PAVILIONS
SMALLER UNIT OF 30 BEDS
497
THE CARE AND TREATMENT OF MENTAL DISEASES AND WAR NEUROSIS ("SHELL SHOCK") IN THE BRITISH ARMY
INTRODUCTION
No medico-military problems of the war are more striking thanthose growing out of the extraordinary incidence of mental and functionalnervous diseases ("shell shock"). Together these disorders areresponsible for not less than one-seventh of all discharges for disability fromthe British Army, or one-third if discharges for wounds are excluded. A medicalservice newly confronted like ours with the task of caring for the sick andwounded of a large army can not ignore such important causes of invalidism. Bytheir very nature, however, these diseases endanger the morale and discipline oftroops in a special way and require attention for purely military reasons. Inorder that as many men as possible may be returned to the colors or sent intocivil life without disabilities which will incapacitate them for work andself-support, it is highly desirable to make use of all available information asto the nature of these diseases among soldiers in the armies of our allies andas to their treatment at the front, at the bases, and at the centers establishedin home territory for their "reconstruction."
England has had three years' experience in dealing with themedical problems of war. During that time opinion has matured as to the nature,causes, and treatment of the psychoses and neuroses which prevail so extensivelyamong troops. A sufficient number of different methods of military managementhave been tried to make it possible to judge of their relative merits. My visitto England was for the purpose of observing these matters at first hand so thatI could contribute information which might aid in formulating plans for dealingwith mental and nervous diseases among our own forces when they are exposed tothe terrific stress of modern war.
ACKNOWLEDGMENTS
I wish, at the outset, to record my appreciation of the manycourtesies which enabled me to use the limited time at my disposal to the bestadvantage. The Army Council, upon the request of Ambassador Page, agreed toplace at my disposal every facility for studying mental and nervous diseases.The medical officers of the special hospitals for mental and nervous cases gaveme opportunities to observe the work of the institutions under their charge.Others actively engaged in dealing with various administrative and clinicalphases of these problems not only gave me valuable information but very kindlyoffered suggestions as to practical means by which our Army might profit by theexperience of British medical officers. I would mention especially Lieut. Col.William Aldren Turner, the principal advisor to the Government in these matters;Lieut. Col. Sir John Collie, president of the Special Pension Board onNeurasthenics; Sir William Osler, under whose direction work is carried on inthe special hospital for functional disorders of the heart; Dr. C. Herbert Bond,of the Board of Control; Dr. Henry Head, who represented the Medical ResearchCommittee in the conference upon nervous diseases among soldiers held in Parisin April, 1916; Dr. H. Crichton Brown, who has prepared a thoughtful memorandumon the subject for the war office; Lieut. Col. Sir Robert Armstrong-Jones andthe American liaison officers in London- Brigadier General Bradley andLieutenant Colonel Lyster of the Army and Surgeon Pleadwell of the Navy. Dr.William Morley Fletcher, secretary of the Medical Research Committee, which froman early period in the war has directed attention to the importance of nervousdiseases, presented me with a motion-picture film showing some of the morecommon symptoms in soldiers suffering from the neuroses. Dr. John T. MacCurdy,associate in psychiatry at the New York State Psychiatric Institute, who wasstudying the war neuroses in special hospitals in London, very kindly visitedthe Moss Side Military Hospital at Maghull and the Craiglockhart Hospital forOfficers near Edinboro and furnished me with reports on the facilities fortreatment at these institutions.
1By Maj. Thomas W. Salmon,Medical Officers' Reserve Corps, U. S. Army.
498
SCOPE OF REPORT
I have omitted entirely any account of the treatment oforganic nervous diseases or of injuries to the central nervous system or theperipheral nerves. Organic nervous diseases are not especially frequent and seemto present no special military problems. Injuries of the central nervous systemare frequent and severe. Those that do not prove fatal very quickly are wellcared for at first in general surgical wards where the services of neurologistsand neurological surgeons are available and later in special hospitals orspecial hospital wards. A very serious difficulty in dealing with destructivebrain and cord lesions is that the patients sooner or later pass from hospitalsin which special care and nursing are provided to their homes or to poorlyequipped auxiliary hospitals in which many soon get worse or die. Injuries tothe peripheral nerves are frequent and important, in fact there are fewextensive injuries to the extremities in which important nerves escape. Withneurological advice, the surgeons deal with these cases successfully in the basehospitals and their after-treatment is well carried on in the"reconstruction centers" for orthopedic cases. Neither of these classesof injuries concerns especially the treatment or military management of mentaland functional nervous diseases except for the fact (to be commented upon later)that the treatment of the war neuroses might be carried out advantageously inhome territory in cooperation with orthopedic reconstruction centers.
Although the problems presented by mental and functionalnervous diseases have many clinical and administrative features in common andalthough these disorders should be dealt with by medical officers with the samekind of special training, it seems desirable to consider their treatment inEngland separately in this report.
My observations as to the nature of the neuroses met with inwar are based partly upon the very extensive literature upon this subject whichhas come into existence since the commencement of the war, but chiefly uponpersonal conversation with medical men engaged in treating these cases inEngland. It is almost needless to say that during a short period largely spentin securing information regarding facilities for treatment and administrativemethods of management and in examining special hospitals for the care of thesecases, I had no opportunity to make original clinical observations, although Isaw and examined superficially many cases of all degrees of severity.
MENTAL DISEASES (INSANITY)
PREVALENCE
For many years war military life has been called the"touchstone of insanity" on account of the high prevalence of mentaldiseases in armies even during peace. Medical statistics of the present war areas yet untabulated and so it is impossible to state the rate per thousand formental diseases. The only means of estimating their incidence is by consideringthe number of cases diagnosed officially as "insane" in the militaryhospitals at a given time. On March 31, 1917, about 1.1 Percent of all patientsin military hospitals of Great Britain were officially diagnosed as insane. Thepercentage among expeditionary patients was 1.3 and among nonexpeditionarypatients 1.1. The enormous prevalence of wounds in patients from theexpeditionary troops reduces the percentage of all other conditions and so theexcess of mental cases among expeditionary cases is much greater than isapparent. Among nonwounded expeditionary patients the percentage was aboutthree times that among the nonexpeditionary cases. The rate among officers wasonly one-third that among men in expeditionary patients and about the same innonexpeditionary patients. This has an important bearing upon the fact that therate for the war neuroses ("shell shock") among officers is five timesas high as among men. About 6,000 patients are admitted annually from both theexpeditionary and nonexpeditionary forces to the special military hospitals forthe insane. As one such hospital with a large admission rate is a "clearinghospital" and distributes its patients to other special hospitals, somepatients are obviously counted twice in the only statistics available. To offsetthis is the fact that a much larger number of mental cases do not go to specialmilitary hospitals at all, but are discharged to friends, with or without anofficial diagnosis of insanity, or are sent directly to local institutions forthe insane. This is
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the rule in the case of nonexpeditionary troops. It canbe estimated, from all the data available, that the annual admission rate is about2 per 1,000 among the nonexpeditionary troops and about 4 per 1,000 amongexpeditionary troops. The rate in the adult male civil population of GreatBritain is about 1 per 1,000.
There is statistical evidence which indicates that theinsanity rate in the British Army is less at the present time than it was in thefirst year of the war, and that it has not reached some of the high ratesreported in recent wars. The high and constantly increasing rate for the warneuroses suggests that the latter disorders are taking the place of thepsychoses in modern war. How much this phenomenon is due to an actual changein incidence and how much to former errors in diagnosis can not be statedaccurately. There is a strong suspicion that the high insanity rate in theSpanish-American War and the Boer War was due, in part at least, to failure torecognize the real nature of severe neuroses, similar to those grouped under theterm "shell shock" in this war. This may account for theremarkable recovery rate among insane soldiers in the two wars in question. Itis certain that in the early months of the present war many soldiers sufferingfrom war neuroses were regarded as insane and disposed of accordingly. When oneremembers that the striking manifestations seen in these cases are unfamiliar inmen to physicians in general practice, it is not surprising that some of theseverer disturbances should have been interpreted as signs of insanity. Thebenign course and rapid recovery of many of these cases upon their return toEngland, together with increasing familiarity with the symptoms of functionalnervous diseases, soon enabled the medical officers serving with troops torecognize their real nature. Even at the present time, however, it is by nomeans rare for soldiers with functional nervous diseases to be sent to Englandas insane or for insane soldiers to be sent to hospitals for the war neuroses.This is shown by the records of the Red Cross Military Hospital at Maghull, ahospital for the treatment of war neuroses. Since this hospital was opened, 10Percent of the 1,74 patients admitted1werefound to be suffering from mental diseases and sent to hospitals for the insane.On the other hand, 20 Percent of the 6,755 patients received1from Francesince the commencement of the war at "D Block" of the Royal VictoriaHospital, at Netley, a clearing hospital for mental cases, were subsequentlysent to hospitals for functional nervous diseases. On the whole it may be saidthat medical officers serving with troops are becoming more familiar with thesymptoms of functional nervous diseases and that fewer such errors now occur.
TREATMENT
The return to England of considerable numbers of mentalcases, commencing early in the war and steadily continuing, soon led to ratherdifficult questions as to their disposal. Before the war, the army maintained asmall department for the insane at the Royal Victoria Hospital, at Netley. Thisdepartment which is known as "D Block" and constitutes practically anindependent unit, accommodated only 125 men and 3 officers. For years the annual admission rate averaged 120. The only cases received were soldiers whohad served at least 10 years in the regular army or those with shorter servicewhose insanity seemed clearly to be due to such causes arising in line of dutyas head injuries, tropical fevers, exhaustion, wounds, etc. As it was manifestlyimpossible to care for more cases at Netley, the insane soldiers who were firstsent home from the expeditionary forces, as well as those from the home forces,were "certified" (i. e., legally committed) and sent to the local"county lunatic asylums" as they are called, unless their relativesand friends took them off the hands of the Government and disposed of themotherwise. The appearance of soldiers from the front in the district asylums,where they were burdened by the double stigma of lunacy and pauperism, arousedpublic disapproval that speedily made itself felt in Parliament.
About this time arrangements had been made to take over 1county or borough asylum in each group of 10 in the United Kingdom for use as ageneral military hospital for medical and surgical cases. This made it possibleto establish special war hospitals for mental cases. A department of theMiddlesex County Asylum (renamed the Napsbury War Hospital) was opened formental cases, and the District Asylum at Paisley, Scotland (renamed the Dykebar
1To May 31, 1917.
500
War Hospital), was turned over entirely for this purpose, aswas part of the Lord Derby War Hospital at Warrington, which had been theLancashire Asylum. Later the Belfast District Asylum in Ireland was taken overas the Belfast War Hospital, and still more recently the Perth District Asylumwas taken over as the Murthley War Hospital, both being used entirely for theinsane. A pavilion at the Richmond District Asylum, Ireland, accommodates 100and a small hospital in London (Letchmere House) cares for about 84 officers. Anannex in connection with the Dykebar War Hospital has recently been opened sothat there are now about 3,400 beds in strictly military hospitals available inGreat Britain and Ireland for insane soldiers.
No attempt has been made to care for the insane in France,the policy of the War Office being to send all cases to the clearing hospital atNetley and then to the special institutions named as soon as possible. There areavailable in France only 125 beds, all for the temporary detention of mentalcases.
Of the 21 asylums and similar institutions in Great Britainand Ireland which have been converted into military hospitals,1 3 are usedwholly or in part for functional nervous diseases. In spite of the fact that thenames of all these asylums were changed when they were taken over for their newuse, a suspicion apparently exists among the public that soldiers with mental ornervous diseases are still being sent to district asylums as "pauperlunatics," the official designation of such patients. It is not easy for usin America to understand the importance of this aspect of the question for inmost States our State hospitals enjoy a reputation which would no morestigmatize insane soldiers than it does their sisters or daughters when theyrequire treatment obtainable only in these institutions. In England, however,insanity and pauperism have been closely linked, and it is the latter which isvery largely responsible for the stigma attached to these institutions. TheGovernment was obliged, therefore, early in 1915 to announce that it has adoptedthe policy of sending to the district asylums only the following groups of casesfrom the expeditionary forces:
1. Patients with general paralysis of the insane.
2. Patients with chronic epilepsy.
3. Patients with incurable mental diseases and those giving ahistory of insanity before enlistment.
There is power to apply the pension of the soldier towardthis support in these cases, and he is thereby prevented from coming "onthe rates." The separation allowances are discontinued when the pension iscommenced. All insane soldiers from the nonexpeditionary forces are certifiedand sent to the district asylums unless it can be shown that the disease wascaused or aggravated by military service.
The results of these arrangements are not whollysatisfactory. There is a strong tendency to adopt an entirely different attitudetoward insane soldiers than the wonderfully generous one which the nation hasadopted toward the wounded and those suffering from physical disease. In thelatter, the Government readily admits its responsibility and makes liberalprovisions for treatment, pension and industrial reeducation, while in theformer every effort is made to place the burden of responsibility and of supportupon the patient or his relatives by magnifying alleged constitutionaltendencies and minimizing the effects of military service. It is quite apparentthat the conditions of actual service have much to do with the development ofmental disease. Even in the case of general paralysis of the insane it is by nomeans certain that a young soldier with a positive Wassermann test would havedeveloped general paralysis if he had not been exposed to the supreme ordeal ofservice at the front. This official attitude toward mental disease results in anaverage period of treatment far shorter than is required in even the most benignpsychoses in civil life. It is evident that mental cases are insufficientlytreated in military hospitals.
During 1916, the number of mental cases passing through the3,400 beds available for their care in Great Britain and Ireland was about6,000. The recovery rate in military cases is much higher than in the mentalcases admitted to civil hospitals, but the rapid movement of population resultschiefly from the custom of "passing on" these cases. Insane soldiersof the nonexpeditionary forces are sent almost invariably directly to districtasylums from general hospitals without even going to "D Block," wherean inquiry could be made by
1To July 1, 1917.
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experts to estimate the part played by military service inthe causation of mental illness. When relatives and friends are induced to takeinsane soldiers from the military hospitals the next step is usually admissionto the district asylums. During the year ending May 31, 1917, 900 insanesoldiers were admitted to the local asylums. A considerable proportion of theinsane, even from the expeditionary forces, sooner or later find their way intothe institutions out of which Parliament was intent upon keeping them.
The disposition of mental cases is well illustrated by thefollowing table showing what was done in the case of 5,473 patients admittedfrom September 1, 1914, to May 31, 1917, at "D Block," Netley, aclearing hospital for mental diseases:
DISPOSITION OF CASES ADMITTED TO "D BLOCK," NETLEY, FROM THE BEGINNING OF THE WAR TO DECEMBER 31, 1916
To institutions for the insane: | |
| Lord Derby War Hospital, Warrington | 1,424 |
| Murthley War Hospital, Perth | 210 |
| Dykebar War Hospital, Paisley | 611 |
| Shorncliffe (Canadian Clearing Mental Hospital) | 147 |
| District asylums | 128 |
| Dartford (for insane prisoners of war) | 3 |
To war hospitals for functional nervous cases: | |
| Moss Side Hospital, Maghull | 509 |
| Springfield War Hospital, London | 680 |
| To hospitals for organic nervous diseases and injuries: | |
| Queen Square | 4 |
| Maida Vale (for pensioners) | 2 |
To Royal Victoria Military Hospital, Netley (recoveries and nervous diseases) | 1,007 |
To almshouses | 2 |
To Canadian hospitals or returned to Canada | 5 |
To Australian hospitals or returned to Australia | 33 |
To other hospitals and institutions | 204 |
Discharged to relatives and friends | 258 |
Died | 21 |
Furloughed | 110 |
Returned to duty | 58 |
Remaining in hospital | 57 |
| Total | 5,473 |
CLINICAL TYPES OF MENTAL DISEASES AMONG SOLDIERS
Contrary to popular belief and to some medical reportspublished early in the war, no new clinical types of mental diseases have beenseen in soldiers. There are no "war psychoses." The clinicalpictures familiar in civil life have been seen, colored often by the experienceat the front, but for the most part unchanged in their symptomatology,outcome, and course. The distribution of the different psychoses has beenstrikingly different than in civil life, but this has been chiefly due to thedifferent age periods represented in patients for the army. The absence of theorganic mental diseases of the later decades of life, which play so large a partin civil statistics, has resulted in abnormally high percentages for otherpsychoses. Although no statistics for the whole number of admissions in asingle year are available, nearly a thousand admissions from expeditionarytroops to the Dykebar War Hospital during 1916 have been tabulated by Maj. R. D.Hotchkis.
This series of cases is large enough to make some of thefindings significant. They are borne out by observation made by Lieut. David K. Henderson atthe Lord Derby War Hospital at Warrington, which received 2,042 mental casesduring the year ending April 30, 1917.
Mental deficiency - About18 Percent of patientsadmitted to the military hospitals for mental diseases are mentally defective.Only such mental defectives as get into trouble or
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develop acute psychotic episodes of one sort or another gainadmission to these hospitals. It is impossible, therefore, from the point ofview of the hospitals for mental diseases, to draw any conclusions as to therelation of mental deficiency to military service. The low grade of many casesreceived in the special hospitals is very striking and shows an amazingindifference on the part of recruiting officers to this type of disability. Itis said that the worst types got in during the first rush of recruits under thevoluntary system and that, since then,more pains have been taken to exclude them. Of the 151 mental defectivesadmitted to the Dykebar War Hospital, 37 were sent there simply because they hadbeen giving trouble to other hospitals where they had been treated for wounds ordiseases. Most of these soldiers were defectives of the restless, criminalistictype, many of whom had been civil offenders before entering the army. It isbelieved that they represented but a small part of cases of this type in themilitary service, the majority being dealt with from a disciplinary standpointwithout regard to existence of mental defect, thus following the precedentwhich, unfortunately, is so firmly established in civil life. The remaining 114defectives sent to Dykebar had been able to earn their own livelihood beforeentering the army. They had no criminalistic traits but had proved quitevalueless in actual fighting. Sometimes these men were actually dangerous totheir comrades and were permitted to load their rifles only when an attack wasmade. The very specialized activities of modern fighting discloses suchindividuals who under former military conditions would not have come to light.It is said that in the Boer War many boys from the special classes of theBirmingham and London schools made good soldiers, but apparently the militaryusefulness of the mentally defective has disappeared under the conditions ofmodern warfare-an exceedingly important point for the consideration of anation engaged in raising a new army.
Among the defectives received in the military hospitals formental cases are many in whom attention has been directed to their disabilityby episodes of confusion or excitement. The outlook is very favorable in suchcases, the quiet routine of the hospital having a beneficial effect in aremarkably short period of time. Mental defectives develop war neuroses, inspite of statements to the contrary, but with striking infrequency. Thegenerally high standard of intelligence among the patients in the"shell-shock" hospitals is noticeable.
There is much difference of opinion as to whether or not menknown to be mentally defective should be recruited for any military service. Infavor of their acceptance it is said that they can be assigned to certain kindsof work at the bases for which they are particularly fitted and thereby releasesoldiers of more intelligence for duty at the front. When one remembers that notonly the army but the whole nation is at war it seems better, even for militaryreasons, to leave defectives at work in an environment to which they areaccustomed than to try the experiment of even a special kind of militaryservice. Certainly the army now has no means of assigning its work withreference to the limitations of such a special group. Moreover, when the armyknowingly accepts mentally defective recruits it assumes a liability for theirprotection which it can hardly be expected to meet in all the exigencies ofwar. Much injustice is done in the army by punishing mental defectives formilitary offenses which would have been condoned had the real mental conditionof the offenders been appreciated. There are sufficient grounds for excludingall mental defectives from the military forces except when the last availableman power must be utilized. When this is the case it will doubtless be foundthat their most effective service will be rendered at the base under thesupervision of noncommissioned officers who have been especially trained intheir management.
Syphilitic psychoses - About2 Percent of the mentalcases received in these special hospitals have general paresis. There isconvincing evidence that the stress of war accelerates the progress of thisdisease. As older men enter the army the proportion of paresis rises. In thenavy, which has been largely augmented by the enlistment of older men in theNaval Reserve, general paresis has attained a rate quite unknown in time ofpeace. Examinations to determine the prevalence of syphilis in recruits areextremely important and the experience of the British Army and Navy showsthat no person presenting the slightest suspicion of syphilis of the centralnervous system should be enlisted or commissioned for any military duty. Inview of the social distribution of this disease and the generally higher ageof officers, paresis is to be borne in mind especially in the examination ofcandidates for officers' commissions.
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Manic-depressiveinsanity.-Patientsin this group supply about 20 Percent of all admissions to military hospitalsfor mental diseases. The great proportion of those with depressed phases is verystriking. Delusions and hallucinations are almost invariably colored by militaryexperiences.
Alcoholic psychoses - Soldierswith delirium tremens areadmitted to special hospitals for mental diseases if they are stationed nearsuch institutions. This disorder is now confined almost entirely to patientson leave from the front. During the early days of the war it was mostfrequently seen among those who had just entered military service and foundtheir supply of alcohol restricted. The delusional types of alcoholic psychosesare found in older men stationed at bases who have the opportunity to continuelife-long habits of drinking to excess. Attempted suicides are very commonamong alcoholics seen in military service. Alcoholics should not be accepted formilitary service even if it is possible to prevent them from securing alcohol atthe front. Furloughs furnish opportunities for drinking, and the time andeffort spent in training men are lost through attacks on such occasions.
Dementia pr?cox - Patients with this disorderconstitute 14 Percent of those admitted. The histories of these cases show thatin most instances symptoms were manifested shortly after entering the militaryservice. It is apparent that many of them had been psychotic before enlistment.There seems to be no special modification of symptoms on account of militaryservice.
Epilepsy - Seven Percent of cases received at DykebarWar Hospital were suffering from epilepsy. With one exception, all had had thedisease before enlistment.
Constitutional psychopathic states - Avery large numberof these cases are received in the special military hospitals for mentaldiseases. They probably represent but a small proportion of such soldiers in thearmy, for the percentage is large in the various disciplinary groups.Unfortunately, the nomenclature used in the British Army did not permit the useof any term applicable to these cases until February, 1916, when the War Officeauthorized the addition of "mental instability" to the list of mentaldiseases. Many of these cases are now being reported under this heading. Theoccasion of their admission is usually an acute psychotic episode or amedico-legal situation.
OUTLOOK IN MENTAL CASES
There are no statistics available to show the outcome in themental diseases treated in military hospitals. Discharge is much more likely tobe regulated by administrative considerations than by clinical ones. Acuteconditions seem to recover very quickly. Few return to "first-lineduty." The statistics indicate a much larger proportion than is actuallythe case. The number of those who go back to the colors is made up for themost part of patients who have recovered from delirium tremens and those withwar neuroses who have been incorrectly admitted to institutions for the insane.Infective-exhaustive psychoses are much more likely to be regarded as"shell shock" than as mental disorders. The hospitals for mentaldiseases fail, therefore, to get these very recoverable cases and the recoveryrate in such institutions suffers correspondingly.
SUMMARY
Sorely pressed to meet the tremendous medical problems ofwar, England first used her existing civil facilities for caring for mentaldiseases among soldiers. Public disapproval, based chiefly upon a mistakenattitude toward the insane and toward the local institutions for their care,forced a different method of management. The military hospitals for the insane,created without exception by converting civil institutions for mental diseases,failed to do much more than provide places for receiving mental cases and givingtemporary care, the clearing hospital is woefully inadequate in size andpersonnel to determine the important issues which should be determined there,and a solution to the problem presented by mental diseases among soldiers inEngland does not seem to be in sight.
For the United States, this experience carries importantlessons. More important than all others is the result of careless recruiting.The problem of dealing with mental diseases
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in the army, difficult at best, has been made still moredifficult by accepting large numbers of recruits who had been in institutionsfor the insane or were of demonstrably psychopathic make-up. The next mostimportant lesson is that of preparing in advance of an urgent need, acomprehensive plan for using existing civil facilities for treating mentaldisease in a manner which will serve the army effectively and at the same timesafeguard the interests of the soldiers, of the Government, and of thecommunity.
WAR NEUROSES ("SHELL SHOCK")
Although an excessive incidence of mental diseases has beennoted in all recent wars, it is only in the present one that functional nervousdiseases have constituted a major medicomilitary problem. As every nation andrace engaged is suffering severely from these disorders, it is apparent that newconditions of warfare are chiefly responsible for their prevalence. None ofthese new conditions is more terrible than the sustained shell fire with highexplosives, which has characterized most of the fighting. It is not surprising,therefore, that the term "shell shock" should have come into generaluse to designate this group of disorders. The vivid, terse name quickly becamepopular and now it is applied to practically any nervous symptoms in soldiersexposed to shell fire that can not be explained by some obvious physical injury.It is used so very loosely that it is applied not only to all functionalnervous diseases but to well-known forms of mental disease-even generalparesis. Such a situation is most unsatisfactory and at the present time anattempt is being made to improve the nomenclature of the nervous disorders whichprevail so extensively among soldiers.
Discussion of clinical features of the war neuroses is notwithin the scope of this report, which deals with treatment and militarymanagement.1 It is impossible, however, even to define the problem with whichwe are dealing without a few general observations on the nature of the disorderswhich are grouped under the name "shell shock."
The subject can be clarified a little by dividing thedifferent conditions now included under the term "shell shock" intosome clinical and etiological groups. First should be considered cases in whichthe patients have been actually exposed to the effects of high explosives.
1. There are a number of cases, just how many it is quiteimpossible to say, in which exploding shells or mines cause death withoutexternal signs of injury. Apparently death in these cases results from differentkinds of causes, among them damage to the central nervous system.
2. In another group of cases severe neurological symptomsfollowing burial or concussion by explosions appear in characteristic syndromessuggesting the operation of mechanical factors. The studies of Major Mottindicate that concussion, aerial compression and the rapid decompressionfollowing it, "gassing" from the drift gases (carbon monoxide andnitric oxide) generated by the explosion and other purely mechanical effects ofshell explosion may result in transitory or permanent symptoms of a typeunfamiliar in the neuroses.
There can be no question of the propriety of supplying theterm "shell shock" to these two groups of cases if a specific term isrequired.
3. Another group of cases among those exposed to shell fireincludes patients in which there may or may not be damage to the central nervoussystem but in which the symptoms are those of neuroses familiar in civilpractice even though colored in a very distinctive way by the precipitatingcause. In this group of cases in which there is possibility but no proof ofdamage to the central nervous system, the symptoms present which might beattributable to such damage are quite overshadowed by those characteristic ofthe neuroses.
It is about these cases that much controversy exists. Mottincludes them in his group of "injuries of the central nervous systemwithout visible injury," holding that a physical or a chemical change atpresent unknown to us must underlie such striking disabilities. Others
1These extraordinarily interestingmedical problems of the war are dealt with in a rapidly expanding volume ofspecial literature. The July number of "Mental Hygiene" (Vol. 1, No. 3)contains a r?sum? of this literature. One hundred and forty-one references inEnglish are given in Appendix I of this report. Attention is directedparticularly to the contributions of Maj. Frederick M. Mott (71 and 72), Prof.G. Elliot Smith (108), Capt. Charles S. Myers (74), Capt. Clarence B. Farrar(32), Capt. M. D. Eder (28), and to the extensive report by Dr. John T. MacCurdyin the "Psychiatric Bulletin" (N. Y.) for July, 1917. (The numbersrefer to the references in Appendix I.)
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give less weight to the factor of physical damage and yetrecognize its existence and reconcile the wide range of neurotic symptoms withthe very minute amount of damage which may exist by terming these cases"traumatic neuroses." Others again feel that psychogenetic factorsdetermine not only the continuing neurosis but even the initial unconsciousnessand special sense disturbances.
4. There is a fourth group of cases in which even theslightest damage to the central nervous system from the direct effects ofexplosions is exceedingly unlikely or impossible, the patients being exposedonly to conditions to which hundreds of their comrades who develop no symptomsare exposed. In these cases the symptoms, course, and outcome correspond withthose seen in neuroses in civil practice.
If all neuroses among soldiers were included in these groupsthe use of the term "shell shock" might be defended. But many hundredsof soldiers who have not been exposed to battle conditions at all developsymptoms almost identical with those in men whose nervous disorders areattributed to shell fire. The nonexpeditionary forces supply a considerableproportion of these cases.
To state that, in the cases included in the last two groupsof cases in which shell explosions play a part, the mechanism is that of aneurosis by no means excludes the operation of physical causes. Very little isknown, however, regarding the physiological basis of the disorders in this groupor even in those in the first two groups in which the issues are apparentlypredominantly organic. It may be that in the latter two groups endocriniticdisturbances are important. Minute injuries of the cord may exist and factorssuch as exposure, exhaustion, vascular disequilibrium and disorders ofmetabolism may enter into their causation. Treatment directed along the linessuggested by such an etiology has thus far proved quite ineffective, however,and there is only the most slender basis of experimental work to show that suchfactors are important. This is a fertile field for research. It is earnestlyhoped by all those consulted in England that the United States Army, comingfreshly into contact with this problem, will organize a working party ofpsychiatrists, neurologists, neuropathologists and internists and try to clearup some of these issues.
It is the opinion of most psychiatrists and neurologists whohave been studying and treating "shell shock" in the British Army thatthe fourth group is the largest and most important and that, whatever theunknown physiological basis, psychological factors are too obvious and tooimportant in these cases to be ignored. In support of this view there is muchevidence, some of which it may be worth while to give.
1. The excess of war neuroses among officers. The ratio ofofficers to men at the front is approximately 1 to 30. Among the wounded it is 1 to24.1Among the patients admitted to the special hospitals for war neuroses in England duringthe year ending April 30, 1917, it was 1 to 6.
2. The rarity of war neuroses among prisoners exposed tomechanical shock.2
3. The rarity of war neuroses among the wounded exposed tomechanical shock.
4. The clinical resemblance of the war neuroses to theneuroses of civil life in which the element of mechanical shock is lacking whilethe psychological situations are somewhat alike.
5. The fact that severe war injuries to the brain and spinalcord are not accompanied by symptoms similar to those in "shellshock," in which injuries of less degree are assumed.
6. The success attending therapeutic measures employed withreference to the psychological situations discovered in individual cases.
These suggestive facts require some elaboration. The highprevalence of "shell shock" among officers corresponds with thedistribution of the neuroses, with reference to education and social grouping,in civil life. Soldiers who are wounded and those who are taken prisoners inbattle are exposed to wind concussion and rapid decompression and othermechanical factors in the same degree as their comrades who suffer fromneuroses. One must conclude from the fact that they escape that, being woundedor being captured, provides them with something which the neurosis provides forothers. The symptoms exhibited usually bear a more direct relation to theexisting psychological situation than they could possibly bear to
1Analysis of 381,983 casualtiesbetween Aug. 4, 1914-Aug. 21, 1915, reported in a statement in Parliament, and 901,534 casualties between July, 1916, and July, 1917.
2References given by Capt. C. B.Farrar.
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the localization of a neurological injury. Thus, a soldierwho bayonets an enemy in the face develops a hysterical tic of his own facialmuscles, abdominal contractures occur in men who have bayoneted enemies in theabdomen. Hysterical blindness follows particularly horrible sights, hystericaldeafness appears in those who find the cries of the wounded unbearable, and mendetailed to burial parties develop anosmia.
The psychological basis of the war neuroses (like that of theneuroses in civil life) is an elaboration, with endless variations, of onecentral theme, escape from an intolerable situation in real life to one madetolerable by the neurosis. The conditions which may make intolerable thesituation in which a soldier finds himself hardly need stating. Not only fear,which exists at some time in nearly all soldiers and in many is constantlypresent, but horror, revulsion against the ghastly duties which sometimes mustbe performed, emotional situations resulting from the interplay of personalconflicts and military conditions, all play their part in making an escape ofsome sort mandatory. Death provides a means which can not be sought consciously.Flight or desertion is rendered impossible by ideals of duty, patriotism, andhonor, by the reactions acquired by training, or imposed by discipline or byherd reactions. Malingering is a military crime and is not at the disposal ofthose governed by higher ethical conceptions. Nevertheless, the conflict betweena simple and direct expression of the instinct of self-preservation and suchfactors demands some sort of compromise. Wounds solve the problem most happilyfor many men, and the mild exhilaration so often seen among the wounded has asound psychological basis. Others with a sufficient adaptability find a meansof adjustment. The neurosis provides a means of escape so convenient that thereal cause of wonder is not that it should play such an important part inmilitary life but that so many men should find a satisfactory adjustment withoutits intervention. The constitutionally neurotic, having most readily at theirdisposal the mechanism of functional nervous diseases, employ it mostfrequently. They constitute, therefore, a large proportion of all cases, but avery striking fact in the present war is the number of men of apparently normalmental make-up who develop war neuroses in the face of unprecedentedly terribleconditions to which they are exposed.
One of the chief objections to the use of the term"shell shock" is the implication it conveys of a cause actinginstantly. The train of causes which leads to the neurosis that an explosionushers in is often long and complicated. Apparently in many military casesmental conflicts in the personal life of the soldier which are not directlyconnected with military situations influence the onset of the neuroses. Thus,men who have been doing very well in adapting themselves to war develop"shell shock" immediately after receiving word that their wives havegone away with other men during their absence.
Approached from the psychological viewpoint, the symptoms inthe war neuroses lose much of their weird and inexplicable character. Most ofthem can be summed up in the statement that the soldier loses a function whicheither is necessary to continued military service or prevents his successfuladaptation to war. The symptoms are found in widely separated fields.Disturbances of psychic functions include delirium, confusion, amnesia,hallucinations, terrifying battle dreams, and anxiety states. The disturbancesof involuntary functions include functional heart disorders, low blood pressure,vomiting and diarrhea, enuresis, retention or polyuria, dyspnoa, and sweating.Disturbances of voluntary muscular functions include paralyses, tics, tremors,gait disturbances, contractures, and convulsive movements. Special senses may beaffected producing pains and anesthesias, mutism, deafness, hyperacusis,blindness, and disorders of speech.
In all of these the soldier is afflicted with more or lessincapacity without obvious expansion. This is a condition involving gravedangers. His condition is degrading, and is often rendered more so by thepunishment or ridicule to which he is subjected. For this reason, immediatelyafter the onset of the symptoms of the neurosis, the patient passes through avery critical period. Improper management may add to the primary neurologicaldisability-which is largely beyond our power of preventing-secondary effectswhich go even further in producing nervous invalidism. Long-continued treatmentin general hospitals, confusion of the neurosis present with the organic nervousdiseases, unintelligent management, all tend to produce the chronic"shell-shock" cases which are so familiar in the special hospitals forthese disorders. Symptoms which were at one time quite easily
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removable become fixed and refractory or new ones areconstantly produced. The mental attitude-the patient's morale as a soldierand his attitude toward his disorder-reaches a very low level, will isseriously impaired, and a chronic invalid replaces a temporarily incapacitatedsoldier. These are matters in the realm of clinical psychiatry andpsychopathology and are outside the scope of this report. Space is given to themhere only because of their very important bearing upon treatment and militarymanagement.
PREVALENCE
The medical statistics of the war are as yet untabulated.Even if the records contained the information desired it would be very difficultto state the prevalence of the neuroses on account of the defective nomenclatureemployed. It is doubtful if there is another group of diseases in which moreconfusion in terms exists. Nervous or mental symptoms coming to attention afterthe soldier has been exposed to severe shellfire are almost certain to bediagnosed as "shell shock," and yet when such patients arereceived in England well-defined cases of general paresis, epilepsy, or dementiapr?cox are often found among them. This source of confusion tendsto swell the number of cases reported under the term "shell shock,"but there are many other errors which tend to diminish the apparent prevalenceof the war neuroses. Chief among these is reporting the neuroses under the nameof the most prominent somatic symptom. The largest group of cases in whichthis is done is made up of patients diagnosed officially as having disorderedaction of the heart (" D.A. H."). Where the only symptoms are cardiovascular ones of neurotic origina legitimate question of medical nomenclature exists, but one sees in the wardsor hospitals given over to functional heart disorders patients with hystericalparalyses, tics, tremors, mutism, anxiety states, and other severe neuroticsymptoms. Another source of error is the practice, made mandatory by a recentorder, of returning these cases (when occurring in soldiers engaged in actualfighting) as "injuries received in action."
With a view to discovering the prevalence of theneuroses andinsanity, Sir John Collie, president of the Special Pension Board onNeurasthenics, made an analysis of 10,000 discharge certificates for disability,interpreting the diagnoses given in the light of his very large experience. Hefound that of these 10,000 consecutive cases the neuroses constituted 10 Percent.
The number of cases treated in the special hospitals inEngland give some idea of the prevalence of these disorders, but the fact thatthe number of troops in the expeditionary and nonexpeditionary forces isconfidential makes it impossible to give the rates for the two great divisionsof the British Army. During the year ending April 30, 1916, approximately 1,300officers and 10,000 men were admitted to the special hospitals for "shellshock" and neurasthenics in Great Britain. The 1,800 beds in these specialhospitals constitute less than half the total provisions in Great Britain forsuch cases as neurological departments exist in the large territorial generalhospitals and in the Royal Victoria Hospital in Edinborough. Moreover, aconstantly increasing number of these cases are being treated in France. Therecoveries in the hospitals there diminish, to an unknown degree, the number ofcases received in the hospitals in Great Britain. It is the belief of those whohave made an effort to ascertain the prevalence of the war neuroses that therate among the expeditionary forces is not less than 10 per thousand annually,and among the home forces not less than 3 per thousand.
TREATMENT
General arrangements.-When soldierssuffering from functional nervous disorders began to arrive in England from theexpeditionary forces in September, 1914, no special civil or military hospitalsexisted for their reception. In the case of mental diseases it was an easy taskto convert "D Block" at the Royal Victoria Hospital into a clearinghospital and to utilize civil institutions for the insane for continued care,but in England, as in the United States, there are no public civil hospitalsthat are engaged exclusively in the work of treating the neuroses. The specialcivil hospitals for organic nervous diseases were soon filled with patientssuffering from severe neurological injuries and were able to do very little onbehalf of those with functional nervous disorders.
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For a short time it was necessary to care for all such casesin general military hospitals for medical and surgical conditions. The rapidincrease in the number of such cases during October and November, 1914, led tothe detail of a special medical officer to ascertain their special needs and toprepare a plan for meeting them. The recommendation of this officer that specialinstitutions be provided for functional nervous diseases was approved and when,in December, 1914, the Moss Side State Institution, at Maghull, was turned overto the war office, the first military hospital for functional nervous diseaseswas available. This institution was particularly suitable for this purpose. Ithad been completed but not opened for the care of mental defectives of thedelinquent type and consisted of detached villas accommodating 347 patients.The number of these patients was so great, however, that general hospitals werestill called upon to deal with them. The establishment of neurologicaldepartments in these hospitals partly met the situation until additional specialhospitals could be provided. The second such hospital was secured by using adetached portion of Middlesex County Asylum in London. This hospital,accommodating 278 additional patients, was renamed the Springfield War Hospital.The foresight of Sir Alfred Keogh and his advisors thus enabled England to makeprovision for these cases in special military hospitals at an early period inthe war.
With more than one hospital available it was possible to makedifferent provisions for different classes of patients suffering from warneuroses. A clearing hospital was therefore established early in 1915 at theFourth London Territorial General Hospital. The Maudsley Hospital, apsychopathic hospital for the County of London, was nearing completion at thistime and, as it adjoined the Kings College Hospital, which formed the largerpart of the Fourth London Hospital, it was utilized as a nucleus for thisclearing station. The Maudsley Hospital accommodates 175 men and 20 officers;the neurological section-"the Maudsley extension"-accommodates 450men and 80 officers. Thus, by the spring of 1915 England was provided with aclearing hospital for war neuroses and two special institutions for theircontinued care. Notwithstanding this provision, by far the greater number ofcases were cared for in general hospitals in England and no special provisionfor continued treatment existed in France. The disadvantages of attempting totreat functional nervous disorders in general hospitals was very apparent, andso neurological sections were established in territorial general hospitals inEngland, Scotland, and Wales, and in the Royal Victoria Hospital at Netley.Other special hospitals have been provided since. * * *
When the submarines began sinking hospital shipsindiscriminately last year, a great deal of the medical work previously done inEngland was undertaken in France and so special provisions for functionalnervous cases were made at Havre, Ireport, Boulogne, Rouen, and Etaples.Formerly little more than establishing the diagnosis was done in France. It islikely that the work of caring for these cases will be turned over more and moreto the special hospitals in France, as the results of treatment there have been,on the whole, much more successful than in home territory.
A recent extension of treatment is that of providing carenearer the front. The striking results obtained in casualty clearing stationsand similar advanced posts in the French Sanitary Service (postes de chirurgie d'urgence)are confirmed by many observers.
Capt. William Brown, a psychiatrist who has recently had theopportunity of working in a casualty clearing station of the BritishExpeditionary Forces, reports that of 200 nervous and mental cases which passedthrough his hands in December, 1916, 34 Percent were evacuated to the baseafter seven days' treatment and 66 Percent returned to duty on the firingline after the same average period of treatment. Four of these cases reappearedat the same casualty clearing station.
Capt. Louis Casamajor, of the United States Army, neurologistto Base Hospital No. 1, British Expeditionary Force, says in a recent letter:"It is a mistake to send these cases to England. We need an intermediatestep between the general hospital and the convalescent camp. Of course, theynever should get into general hospitals at all, but should be sent from casualtyclearing stations direct to neuropsychiatric hospitals. ** * I hope our army will have a psychiatrist in eachcasualty clearing station to weed these cases out and send them to their properplaces, and not have them knock around from one general hospital to another,being pampered into hard-set neuroses."
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Leri, working in the neuropsychiatric center of the SecondFrench Army, reports that 91 Percent of the cases received from July toOctober, 1916, were returned to the fighting line. Marie reports that theneuroses are less frequently met with in Paris, now that they are treatedimmediately upon their appearance in the army neuropsychiatric centers.1
Maj. Frederick W. Mott says: "I regard this matter ofpreventing the fixation of a functional paralysis as of supreme importance bothin respect to the welfare of the individual and from the economic point of viewof the state."
Roussy and Boisseau2, describing the work of anarmy neuropsychiatric center, say: "The results obtained after six months show that aneuropsychiatric center can render incontestable services to an army both froma medical and a military point of view. For functional nervous cases it avoidssojourns (more dangerous the more they are prolonged) in the hospitals at therear where these patients are generally lost. It allows of the treatment ofother nervous or mental cases that are quickly curable and the direct evacuation to the special centers in the interior of those more seriouslyaffected."
General principles - Methodsof treatment employed indifferent special hospitals are described in Appendix III. With so much aboutthe war neuroses the subject of controversy, it is not surprising that differentmethods of treatment have come into existence. The Royal Army Medical Corps hasseen fit to leave these matters largely to the specialists in charge of thedifferent hospitals and so the treatment in each reflects, to a certain degree,the conception of the nature of war neuroses held by the medical officer incharge. Certain general principles regarding treatment may be stated.
The experience of the British "shell-shockhospitals" emphasizes the fact that the treatment of the war neuroses isessentially a problem in psychological medicine. While patients with severesymptoms of long duration recover in the hands of physicians who see but dimlythe mechanism of their disease and are unaware of the means by which recoveryactually takes place, no credit belongs to the physician in such cases and butlittle to the type of environment provided. In the great majority of instancesthe completeness, promptness, and durability of recovery depend upon the insightshown by the medical officers under whose charge the soldiers come and theirresourcefulness and skill in applying treatment.
The first step in treatment is a careful study of theindividual case. There are no specific formul? for the cure of mutism,paralyses, or tremors or other manifestations of war neuroses. These aresymptoms of the disorders and the patient must be treated as well as hissymptoms. As in all other psychiatric work, efforts must first be made to gainan understanding of the personality-the fabric of the individual in whom theneurosis has developed. His resources and limitations in mental adaptation willdetermine in a large measure, the specific line of management. The militarysituation is most striking, but the problem which life in general presents tothe individual and the type of adaptation which he has found serviceable inother emergencies are of as much importance as the specific causes for failurein the existing situation. The disorder must be looked at as a whole. Theincident which seems to have precipitated the neurosis-whether shellexplosion, burial, or disciplinary crisis-must receive close attention but notto the exclusion of other factors less dramatic but often more potent in theproduction of the neurosis. It has often been said that some of the symptoms ofhysteria are the work of the physician and are created-not disclosed-byneurological examinations. This is apparently true, but the question whetheranalgesia can exist until the pinprick demonstrates it is somewhat like thequestion whether sound can exist without an ear to receive it. It is not onlytrue but a fact of great practical importance that a skillful, searching,psychological examination often constitutes the first step in actual treatment.
In the analysis of the situation, as well as in thesubsequent management of the patient, the medical officer's attitude is ofmuch importance. He must be immune to surprise or chagrin. Althoughunderstanding sympathy is nearly as useful as misdirected sympathy is harmful,he must always remain in firm control.
1Revue-Neurologiqe(November-December, 1916).
2Paris medicale, 1:14-20 (Jan. 1, 1916).
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The resources at the disposal of the physician in treatingthe war neuroses are varied. The patient must be reeducated in will, thought,feeling, and function. Persuasion, a powerful resource, may be employeddirectly backed by knowledge on the part of the patient as well as thephysician of the mechanism of the particular disorder present. Indirectly, itmust pervade the atmosphere of the special ward or hospital for "shellshock." Hypnotism is valuable as an adjunct to persuasion and as a meansof convincing the patient that no organic disease or injury is responsible forhis loss of function. Thus in mutism the patient speaks under hypnosis orthrough hypnotic suggestion and thereafter must admit the integrity of hisorgans of speech. The striking results of hypnotism in the removal of symptoms are somewhat offset by the fact that the most suggestible who yieldto it most readily are particularly likely to be the constitutionally neurotic.In such cases we are using to bring about a cure, a mental mechanism similar tothat which produced the disorder.
Recovery within the sound of artillery or at least"somewhere in France" is more prompt and durable than that which takesplace in England. For severe cases and those which through mismanagement havedeveloped the unfortunate secondary symptoms of "shell shock" and inwhom long continued treatment is necessary, a rural place is best.
Reeducation by physical means is a valuable adjunct totreatment in recent cases, but particularly in chronic cases who have beenmismanaged and in those who are recovering from long-continued paralyses, tics,mutism, and gait disorders. While drills and physical exercises have theirspecific uses, occupation is the best means. Nonproductive occupations shouldbe avoided.
Occupations are conveniently classified as:
1. Bed.
2. Indoor.
3. Outdoor.
1. Basket making and net making are good bed occupations forcases with extensive paralyses, as are making surgical dressings and variousminor finishing operations (sand-papering, polishing, etc.) on products of theshops. All occupations, and especially those which are carried on by patientsseriously incapacitated, should be regarded as only steps in a process ofprogressive education. Every effort must be made to prevent skill acquired inthem from being considered as a substitute for full functional activity. Hereinis an important difference between the "reeducation" of neurotic andorthopedic cases. In the latter the purpose is often to make the remaining soundlimb take on the functions of one which is missing or permanently disabled. Thefunction held in abeyance through neurotic symptoms must never be looked upon aslost. It can and must be restored, and if another function is developed as itssurrogate the day of full recovery is thereby postponed. Bed occupations,therefore, must always be regarded as the first steps in a series which is toculminate in full activity. Progress through achievements constantly moredifficult is the keynote of reeducation in the war neuroses.
2. A wide variety of indoor occupations should beprovided, including at the minimum, carpentry, wood carving, metal work, andcementwork. Printing, bookbinding, cigarette making, electric wiring, and other workshould be added as opportunities permit.
3. Farming, gardening, and building operations are desirableoutdoor occupations. Where possible, wood sawing and chopping are verydesirable, as is the care of stock not requiring much land (squabs, guineapigs, rabbits, game, and frogs).
Before even the simplest occupation can be engaged in it issometimes necessary to reeducate paraplegics and ataxics in walking andcoordination. Just as soon as possible exercises should be replaced byproductive occupations which will accomplish the same results more quicklyand more satisfactorily. The same is true of gymnastic exercises, which in theearly steps of treatment constitute a valuable resource but which should bereplaced by specially devised useful tasks. Swimming has a unique place in thetreatment of gait disturbances, paralysis, and tics. One of the first pieces ofconstruction undertaken by the outdoor patients at a reconstruction centershould be that of building a large concrete swimming tank.
Hydrotherapy and electrotherapy have a distinct value whenthey are applied with absolute sincerity and full realization on the part ofpatient and medical officer of the r?le which they actually play in thetreatment of functional nervous diseases.
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The experience in English hospitals has demonstrated thegreat danger of aimless lounging, too many entertainments, and relaxingrecreations such as frequent motor rides, etc. It must be remembered that"shell-shock" cases suffer from a disorder of will as well asfunctions and it is impossible to effect a cure if attention is directed toone at the expense of the other. As Dr. H. Crichton Miller has put it,"shell shock produces a condition which is essentially childish andinfantile in its nature. Rest in bed and simple encouragement is not enough toeducate a child. Progressive daily achievement is the only way whereby manhoodand self-respect can be regained."
OUTCOME
It was impossible for me to discover the end results oftreatment. The following table shows the disposal of 731 discharges from theRed Cross Military Hospital at Maghull during the year ending June 30, 1917:
Number | Percent | |
To military duty | 153 | 20.9 |
To civil life | 476 | 65.1 |
To other hospitals | 88 | 12.0 |
To civil institutions for the insane | 7 | 1.0 |
Died | 3 | .4 |
Deserted | 4 | .6 |
| 731 | 100.0 |
It is the opinion of the commanding officer of thishospital that few men (of the severe or chronic type there received) can besent back to military duty at the front. More could be returned to duty at thebase but for the fact that after having been in a "shell-shockhospital" they are regarded as being poor material, and little effort istaken to train them for their new duties. Under such conditions the men becomediscouraged and soon show signs of relapse. Those discharged to civil life havedone satisfactorily, as might be expected when one bears in mind the genesisof the neuroses in war.
At the Granville Canadian Special Hospital, at Ramsgate,upward of 60 Percent of the patients admitted were returned to the front. Theexperience of this hospital is of special value to us because the cases treatedare those which seem likely to recover within six months. All others and thosewho do not improve quickly at Ramsgate are sent to Canada. It would be wise forthe United States Army to adopt a similar policy.
In the special wards established in France the recoveriesare still more numerous.
It is evident that the outcome in the warneuroses is goodfrom a medical point of view and poor from a military point of view. It is theopinion of all those consulted that with the end of the war most cases, eventhe most severe, will speedily recover, those who fail to being theconstitutionally neurotic and patients who have been so badly managed thatvery unfavorable habit reactions have developed. This cheering fact bringslittle consolation, however, to those who are chiefly concerned with thewastage of fighting men. The lesson to be learned from the British resultsseems clear-that treatment by medical officers with special training inpsychiatry should be made available just as near the front as military exigencywill permit and that patients who can not be reached at this point should betreated in special hospitals in France until it is apparent that they can not bereturned to the firing lines. As soon as this fact is established, militaryneeds and humanitarian ends coincide. Patients should then be sent home assoon as possible. The military commander may have the satisfaction of knowingthat food need not be brought across to feed a soldier who can render nouseful military service, and the medical officer may feel that his patient willhave what he most needs for his recovery-home and safety and anenvironment in which he can readjust.
Looking at the matter from a military point of view alone,one might ask whether it is not desirable to send home all"shell-shock" cases, in whom so much effort results in so fewrecoveries. Such a decision would be as unfortunate from a military as froma humanitarian standpoint. Its immediate effect would be to increaseenormously the prevalence of the
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war neuroses. In the unending conflict between duty, honor,and discipline, on the one hand, and homesickness, horror, and theurgings of the instinct of self-preservation on the other, the neurosis, asa way out, is already accessible enough in most men without calling attention toit by the adoption of such an administrative policy.
MEDICO-LEGAL RELATIONS
The sudden appearance of marked incapacity without signs ofinjury in a group of men to whom invalidism means a sudden transition fromextreme danger and hardship to safety and comfort quite naturally gives rise tothe suspicion of malingering. The general knowledge among troops of the morecommon symptoms of "shell shock" and of the fact that thousands oftheir comrades suffering from it have been discharged from the Army suggests itssimulation to men who are planning an easy exit from military service byfeigning disease. It is therefore of much military importance that medicalofficers be not deceived by such frauds. On the other hand, especially beforethe clinical characters and remarkable prevalence of war neuroses among soldiershad become familiar facts, not a few soldiers suffering from these disordershave been executed by firing squads as malingerers. Instances are also knownwhere hysterics have committed suicide after having been falsely accused ofmalingering. Mistakes of this kind are especially liable to occur when thepatients have not been actually exposed to shell fire on account of the idea sofirmly fixed in the minds of most line officers and some medical men that thewar neuroses are due to mechanical shock.
The diagnosis between neuroses and malingering may sometimesbe extremely difficult but usually it is easy when the examiner is familiar withboth conditions. The difficulties arise from the fact that in both a disease ora symptom is simulated. As Bonnal says, "The hysteric is a malingerer whodoes not lie" Thecardinal point of difference is that the malingerer simulates a disease or asymptom which he has not in order to deceive others. He does this consciously toattain, through fraud, a specific selfish end-usually safety in a hospital ordischarge from the military service. He lies, and knows that he lies. Thehysteric deceives himself by a mechanism of which he is unaware and which isbeyond his power consciously to control. He is usually not aware of the precisepurpose which his illness serves. This is shown by the fact that, in many cases,all that is necessary for recovery is to demonstrate clearly to the patient themechanism by which this disability occurred and the unworthy end to which,unconsciously, it was directed.
There are a number of distinctive points of differencebetween hysteria and malingering, two of which it may be interesting to mention:
1. The malingerer, conscious of his fraudulent intent andfearful of its detection, dreads examinations. The hysteric invitesexaminations, as is well known to physicians in civil practice. When he has theopportunity he makes the rounds of clinics and physicians, especially delightingin examinations by noted specialists.
2. The hysteric, in addition to the symptoms of which hecomplains, often presents objective symptoms of which he is unaware. Themalingerer, unless of low intelligence, confines his complaints to the diseaseor symptom which he has decided to stimulate.
Malingering may follow or prolong a neurosis. This is notinfrequently the case when mutism is succeeded by aphonia. In such cases theclinical picture presents changes very apparent to the experienced psychiatristbut it must be remembered that malingerers (like criminals in civil life) areoften very neuropathic individuals.
The gravity of malingering as a military offense in an armyin the field justifies the recommendation that no case in which the possibilityof a neurosis or psychosis exists shall be finally dealt with until the subjectis examined by a neurologist or psychiatrist. If neuropsychiatric wards areprovided in base hospitals in France as well as in the United States, such anexamination will be feasible in practically all cases without causing unduedelay. The knowledge that malingerers are subjected to such expert examinationwill tend to discourage soldiers from this practice.
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RECOMMENDATIONS FOR THE UNITED STATES ARMY
The following recommendations for the treatment of mentaldiseases and war neuroses ("shell shock") in United States troops arebased chiefly upon the experience of the British Army in dealing with thesedisorders, as outlined in the foregoing report. The advice of British medicalofficers engaged in this special work has aided greatly in formulating the planspresented. At the same time conditions imposed by the necessity of conductingour military operations 3,000 miles away from home territory have been borne inmind.
It seems desirable to consider separately, in theserecommendations, expeditionary and nonexpeditionary forces. It is necessary todeal separately with mental and nervous diseases in the United States but not inFrance. While facilities existing at home can be utilized for the treatment ofmental diseases it is necessary to create new ones for the treatment of the warneuroses. In France, where all facilities for treatment must be created by themedical department, the distinction between psychoses and neuroses need not bedrawn so closely. Consequently simpler and more effective methods ofadministrative management can be devised.
The importance of providing, in advance of their urgent need,adequate facilities for the treatment and management of nervous and mentaldisorders can hardly be overstated. The European countries at war had madepractically no such preparations and they fell into difficulties from which theyare now only commencing to extricate themselves. We can profit by theirexperience and, if we choose, have at our disposal, before we begin to sustainthese types of casualties in very large numbers, a personnel of speciallytrained medical officers, nurses, and civilian assistants and an efficientmechanism for treating mental and nervous disorders in France, evacuating themto home territory and continuing their treatment, when necessary, in the UnitedStates.
Although it might be considered more appropriately under theheading of prevention than under that of treatment, the most importantrecommendation to be made is that of rigidly excluding insane, feebleminded,psychopathic, and neuropathic individuals from the forces which are to be sentto France and exposed to the terrific stress of modern war. Not only the medicalofficers but the line officers interviewed in England emphasized over and overagain the importance of not accepting mentally unstable recruits for militaryservice at the front. If the period of training at the concentration camps isused for observation and examination it is within our power to reduce verymaterially the difficult problem of caring for mental and nervous cases inFrance, increase the military efficiency of the expeditionary forces, and savethe country millions of dollars in pensions. Sir William Olser, who has had alarge experience in the selection of recruits for the British Army and has seenthe disastrous results of carelessness in this respect, feels so strongly on thesubject that he has recently made his views known in a letter to the Journalof the American Medical Association1 in which he mentions neuropathicmake-up as one of the three great causes for the invariable rejection ofrecruits. In personal conversation he gave numerous illustrations of the burdenwhich the acceptance of neurotic recruits had unnecessarily thrown upon an armystruggling to surmount the difficult medical problems inseparable from the war.
It is most convenient to summarize the recommendations asfollows and then to discuss each one somewhat in detail:
SUMMARY OF RECOMMENDATIONS FOR THE CARE AND TREATMENT OFMENTAL DISEASES AND WAR NEUROSES ("SHELL SHOCK") IN THEEXPEDITIONARY FORCES
OVERSEAS
1. Base section of line of communications.-(a) Aspecial base hospital of 500 beds for neuropsychiatric cases, located at thebase upon which each army (of 500,000-600,000) rests. These special basehospitals to be used for cases likely to recover and return to active dutywithin six months. Other cases to be cared for while waiting to be evacuatedto the United States.
(b) One or more specialconvalescent camps in connection with (and conducted as part of) each special base hospital.
1Journal American MedicalAssociation, Vol. LXIX, No. 4, p. 290 (July 28, 1917).
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2. Advanced section of line ofcommunications.-(a) Specialneuropsychiatric wards of 30 beds in charge of three psychiatrists and neurologists foreach base hospital having an active service. These wards to be used forobservation (including medicolegal cases) and for emergency treatment of mentaland nervous cases.
(b) Detail of a psychiatrist or neurologist attached to theneuropsychiatric wards of base hospitals to evacuation hospitals or stationsfurther advanced as opportunities permit.
UNITED STATES
1. Mental (insane).-(a) One or moreclearinghospitals for reception, emergency treatment, classification, and dispositionof mental cases among enlisted men invalided home.
(b) Clearing wards (in connection with a general hospitalfor officers or private institution for mental diseases) for reception,emergency treatment, classification and disposition of mental cases amongofficers invalided home.
(c) Legislation permitting the Surgeon General to makecontracts with public and private hospitals maintaining satisfactory standardsof treatment for the continued care of officers and men suffering from mentaldiseases until recommended for retirement or discharge (with or without pension)by a special board.
(d) Appointment of a special board of three medicalofficers to visit all institutions in which insane officers and men are earedfor under such contracts to see that adequate treatment is being given and toretire or discharge (with or without pension) those not likely to recover.
2. War neuroses ("shell shock").-(a) Reconstructioncenters (the number and capacity to be determined by the need) for the treatmentand reeducation of such cases of war neuroses as are invalided home. Injuries tothe brain, cord, and peripheral nerves to be treated elsewhere.
(b) Special convalescent camps where recovered cases can goand not be subject to the harmful influences for those cases which exist incamps for ordinary medical and surgical cases.
(c) Employment of the special board of medical officers,recommended under "1(d)," to visit all reeducation centers andconvalescent camps in which war neuroses are treated to see that adequatetreatment is being given and to retire or discharge (with or without pension)those not likely to recover.
EXPEDITIONARY FORCES
1. OVERSEAS
The plan herein suggested for dealing with mental andfunctional nervous diseases in the Expeditionary Forces overseas presupposesthat all sick and wounded soldiers who are not likely to be returned for duty inthe fighting line within six months will be evacuated to home territory. Thesame considerations which led to the adoption of this policy by the CanadianArmy are equally valid in the case of American troops. If large numbers of thesick and wounded who are not likely to return to active duty have to be caredfor in France during long periods of disability, the amount of food and othersupplies which must be sent overseas for them and for those who care for themwill diminish the tonnage available for the transportation of munitions requiredfor successful military operations. The great auxiliary hospital facilitiesavailable in the United States can not be utilized and, in the case of thesevere neuroses, fewer recoveries will take place. If submarine activitiesseriously interfere with the return of disabled soldiers to the United Statesand it is necessary to provide continued care, chronic cases should be evacuatedto special hospitals established in France for this purpose. It is verydesirable to maintain an active service in base hospitals that receive casesfrom the front. This is especially true in the case of the war neuroses.
(a) Base section of line of communications - Thebaseupon which each army rests should be provided with a special base hospital of500 beds for neuropsychiatric cases. Three years' experience in treating thesecases in general hospitals in England and France amply demonstrates the needfor such an institution. Few more hopeful cases exist in the medical services
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of the countries at war than those suffering from the warneuroses grouped under the term "shell shock" when treated inspecial hospitals by physicians and nurses familiar with the nature offunctional nervous diseases and with their management. On the other hand,the general military hospitals and convalescent camps presented no morepathetic picture than the mismanaged nervous and mental cases which crowdedtheir wards before such special hospitals were established. Exposed tomisdirected harshness or to equally misdirected sympathy, dealt with at one timeas malingerers and at another as sufferers from incurable organic nervousdisease, "passed on" from one hospital to another and finallydischarged with pensions which can not subsequently be diminished, theirtreatment has been a sad chapter in military medicine. As one writer has said,"they enter the hospitals as 'shell shock' cases and come out asnervous wrecks." To their initial neurological disability (of a distinctlyrecoverable nature) are added such secondary effects as unfavorable habitreactions, stereotypy and fixation of symptoms, the self-pity of the confirmedhysteric, the morbid timidity and anxiety of the neurasthenic and the despairof the hypochondriac. In such hospitals and convalescent homes inactivity andaimless lounging weaken will and the attitude of permanent invalidism quicklyreplaces that of recovery. The provision of special facilities for the treatmentof "shell shock" cases is imperative from the point of view of militaryefficiency as well as from that of common humanity for more than half thesecases can be returned to duty if they receive active treatment in specialhospitals from an early period in their disease.
British experience indicates that about 100 of the beds ineach such special base hospital would be occupied by mental cases and the restby those suffering from war neuroses. It is not necessary to make thisdivision arbitrarily in advance, however, as both classes of cases can be caredfor in the type of hospital to be proposed and redistribution of patients can bemade from time to time as circumstances require. It should be the object ofthese special base hospitals to provide treatment for all cases likely torecover and be returned to active duty within six months. Practically all mentalcases, even those who recover during this period, as well as functionalnervous cases presenting an unfavorable outlook or which are unimproved byspecial treatment, should be evacuated to the United States as rapidly astransportation conditions will permit.
Each such hospital should be located with reference to itsaccessibility to other hospitals along the line of communications of the armywhich it serves. This will necessitate its being on the main railway line down which disabled soldiers areevacuated from the front.It should also be within convenient reach of although not necessarily at theport of embarkation. If it is possible to secure a site in southern France whereoutdoor work can be continued during the winter many important advantages willbe gained. Gardening and other outdoor occupations are so valuable that theamount of ground adjoining each base hospital, or contiguous to it, should benot less than 1 acre for every 6 patients of one-third its population. Thus, atleast 30 acres are required for a hospital with 500 beds.
The type of general hospital adopted by the American Armyfor cantonment camps could be used, with certain interior changes, but it wouldbe more advantageous to secure a large hotel or school and remodel it to perform the specialfunctions of a hospital of this character. The living arrangements in these special hospitals are simpler than in general hospitalsfor medical and surgical cases. About 5 Percent of the bed capacity willhave to be in single rooms. This percentage will be somewhat greater in thepsychiatric division and less in the neurological division. Less than 3 Percentof the population will be bed patients. A sufficient number of rooms in both the neurological andpsychiatrical divisions should be set aside for officers-thehigher proportion of officers among patients with neuroses being taken intoconsideration in planning this department.
It is necessary to allow liberally for examining rooms,massage, hydrotherapy, and electrotherapy and to provide one large room whichcan be used for an amusement hall.
When the patients and staff have been suitably housedattention should be directed to the highly important features of shops,industrial equipment, gymnasium, and gardens. If no suitable buildings closeto the hospital can be secured, perfectly adequate facilities can be providedin cheaply constructed wooden huts with concrete floors. A gymnasium can beerected more cheaply than an existing building can be adapted for this purposeunless a large storehouse, barn, or factory is available.
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Hydrotherapeutic equipment should include continuous baths, Scotch douche,needle baths, and a swimming pool. The latter is exceptionally valuable in thetreatment of functional paralyses and disturbances of gait which disappearwhile patients are swimming, thus often opening the way for rapid recovery bypersuasion.
Electrical apparatus is necessary for diagnostic purposes and also forgeneral and local treatment.
Second in importance only to the general psychological control of thesituation in functional nervous diseases is the restoration of the lost orimpaired functions by reeducation. None of the methods available forreeducation are so valuable in the war neuroses as those in which a usefuloccupation is employed as the means for training. Reeducation should commence assoon as the patient is received. Thought, will, feeling, and function have allto be restored, and work toward all these ends should be undertakensimultaneously. Nonproductive occupations are not only useless but deleterious.The principle of "learning by doing" should guide all reeducativework. Continual "resting," long periods spent alone, general softeningof the environment, and occupations undertaken simply because the mood of thepatient suggests them are positively harmful, as shown by the poor resultsobtained in those general hospitals and convalescent homes in which suchmeasures are employed.
The industrial equipment needed is relatively simple and inexpensive. It isvery desirable to begin with a few absolutely necessary things and to add thosemade by the patients themselves. When this is done every piece of apparatus isinvested, in the eyes of the patients, with the spirit of achievement throughpersistent effort-the very keynote of treatment. The fact that it has beenmade by patients recovering from neuroses will help hundreds of subsequentpatients through the force of hopeful suggestion. The following list gives theequipment for the shops which is necessary at the beginning:
Smiths' shop:
Forges, tools, etc., for 10 men.
Fitting shop:
One screw-cutting lathe; 1 sensitive drill; 1 polishing machine; 1 electric motor, 1? horsepower; swages; and tools for 8 men.
Leather blocking room:
Sewing machine; eyeletting machine;tank; galvanized iron; and tools.
Tailors' shop:
Three Singer machines, tools for 10 men.
Carpenters' shop:
Selected tools for 15 men, bench screws and special tools not for general use, woodturner's lathe.
Machine shop:
Electric motor, 8? horsepower, with shafting, brackets, etc.
Cement shop:
Metal molds, tools for 12 men.
Printing shop:
Press and accessories.
General:
Drilling machine, grindstone, screw-cutting lathe, fret-saw workers' machine and patterns, circular-saw bench.
Practically all gymnasium apparatus can be made in the shops after thehospital is opened.
Each special base hospital should be able to evacuate patients who, althoughnot quite able to return to active duty, no longer require intensive treatment.For this purpose one or more convalescent camps within convenient distance bymotor truck from the main institution should be established. Each of theseconvalescent camps should not exceed 100 in capacity. It will require only 1medical officer, 1 sergeant, 3 female nurses, an instructor, and 3 or4 Hospital Corps men, as the patients will be able to care for themselves andin a short time return to duty.
One camp may have to be established for the care of another type of cases. Itis conceivable that submarine activity will interfere so seriously with theevacuation of chronic and nonrecoverable cases to the United States that thespecial hospital will be overcrowded.
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Overcrowding will instantly interfere with the success of thework and this will simply mean that men who otherwise might recover and returnto military duty at the front will fail to do so. Such a calamity can be avertedby transferring chronic and nonrecoverable cases to a camp organized upon quitesimple lines under direct control of the main hospital and near enough toutilize its therapeutic resources. The beds which such patients would otherwiseoccupy in the special base hospital can be made available for the use of fresh,recoverable cases. Such developments might better be made naturally ascircumstances require than provided for by any formal arrangements made inadvance.
Each base hospital should have the personnel enumerated inthe following table:
PERSONNEL FOR SPECIAL BASE HOSPITAL FOR NEUROPSYCHIATRIC CASES
|
| ||
Major | M.C. | Commanding officer. |
Captain | M.C. | Adjutant, surgeon of the command, recruiting officer. |
Captain | Q.M.C. | Quartermaster. |
Major | M.R.C. | Director. |
Major | M.R.C. | Chief neurological division. |
Major | M.R.C. | Chief psychiatrical division. |
Major | M.R.C. | Chief occupational division. |
Captain | M.R.C. | Pathologist. |
Captain | M.R.C. | In charge of convalescent camp. |
Captain | M.R.C. | In charge of electrotherapy and hydrotherapy. |
Captain | M.R.C. | Ward physician (in charge of transportation of patients.) |
Captain | M.R.C. | Ward physician. |
Captain | M.R.C. | Ward physician. |
First lieutenant | M.R.C. | Ward physician. |
First lieutenant | M.R.C. | Ward physician. |
First lieutenant | M.R.C. | Ward physician. |
First lieutenant | M.R.C. | Ward physician. |
First lieutenant | M.R.C. | Ward physician. |
First lieutenant | San. C. | Psychologist. |
First lieutenant | San. C. | Registrar. |
NONCOMMISSIONED OFFICERS | ||
Sergeant, 1st class | H.C. | General supervision. |
Sergeant, 1st class | Q.M.C. | Quartermaster sergeant. |
Sergeant, 1st class | H.C. | Office. |
Sergeant, 1st class | H.C. | In charge of detachment and detachment accounts. |
Sergeant, 1st class | H.C. | In charge of mess and kitchen. |
Sergeant, 1st class | H.C. | General supervision, convalescent camp. |
Sergeant, 1st class | H.C. | In charge of shops. |
Sergeant, 1st class | H.C. | In charge of garden and grounds. |
Sergeant | H.C. | Hydrotherapy rooms. |
Sergeant | H.C. | Electrotherapy rooms. |
Sergeant | H.C. | Massage rooms. |
Sergeant | H.C. | Shops. |
Sergeant | H.C. | Gymnasium. |
Sergeant | H.C. | Mess and kitchen. |
Sergeant | H.C. | Storerooms. |
Sergeant | H.C. | Office. |
Sergeant | H.C. | Office. |
Sergeant | H.C. | Outside police. |
Sergeant | H.C. | Wards. |
Sergeant | H.C. | Wards. |
Sergeant | H.C. | Wards. |
Sergeant | H.C. | Wards. |
Sergeant | H.C. | Wards. |
Sergeant | H.C. | Wards. |
Sergeant | H.C. | Transportation of patients. |
FEMALE NURSES (N.C.) | |
Chief nurse | 1 |
Assistant to chief nurse | 1 |
Dietist | 1 |
Ward nurses | 43 |
46 | |
ENLISTED MEN (H.C.) | |
14 acting cooks. | |
115 privates, 1st class, and privates, distributed as follows: | |
| Ward attendants- | |
| Neurological division | 22 |
| Psychiatrical division | 26 |
| Convalescent camp | 4 |
|
| |
| Shops | 10 |
| Electrotherapy rooms | 4 |
| Hydrotherapy rooms | 4 |
| Massage rooms | 6 |
| Laboratory | 2 |
| Kitchens and mess | 14 |
| Office | 5 |
| Storerooms | 6 |
| Orderlies | 4 |
| Outside Police | 4 |
| Supernumeraries | 4 |
| |
CIVILIAN EMPLOYEES | |
Instructors: | |
| Outdoor occupations | 1 |
| Indoor occupation | 1 |
| |
Assistant instructors: | |
| Carpentry and wood carving | 1 |
| Cement work | 1 |
| Metal work | 1 |
| Leather work | 1 |
| Gardening | 1 |
| Printing | 1 |
| Gymnasium | 2 |
8 | |
Stenographers | 4 |
Photographer | 1 |
Laboratory technician | 11 |
| |
|
| |
Commissioned officers | 19 |
Noncommissioned officers | 24 |
Female nurses | 46 |
Enlisted men | 129 |
Civilian employees | 16 |
| |
The commissioned medical officers should all be men withexcellent training in neurology and psychiatry. The neurologists should have apsychiatrical outlook and the psychiatrists should be familiar with neurologicaltechnique. Of importance almost equal to the professional qualifications ofthese officers is their character and tact, and no man who is unable to adjusthis personal problems should be selected for this work. There is no place insuch a hospital for a "queer," disgruntled or irritable individualexcept as a patient. Men who are strong, forceful, patient, tactful, andsympathetic are required. It is better to permit a medical officer not havingthese qualifications to remain at home than to assign him to one of thesehospitals and allow him to interfere with treatment by his failure to establishand maintain proper contact with his patients. The resources to be employedinclude psychological analysis, persuasion, sympathy, discipline, hypnotism,ridicule, encouragement, and severity. All are dangerous or useless in the handsof the inexperienced, as the records of "shell shock" cases treated ingeneral hospital testify. In the hands of men capable of forming a correctestimate of the make-up of each patient and of employing these resources withreference to therapeutic problem presented by each case, they are powerful aids.
The female nurses should have had experience in the treatmentof mental and nervous diseases. Character and personality are as important innurses as in medical officers. A large proportion of college women will be foundadvantageous.
The enlisted men who perform the duties of ward attendantsand assistants in the shops, gardens, and gymnasium should include aconsiderable number of those who have had experience in dealing with mental andnervous diseases. The civilian employees who act as instructors should all havehad practical experience in the use of occupations in the treatment of nervousand mental diseases. The instructor for bed occupations should be a woman andshe should train the female nurses to assist her in this kind of work.
No work is more exacting than that which will fall to thephysicians and chief lay employees in such a hospital. Success in treatmentdepends chiefly upon each person's establishing and maintaining a sincerebelief in the work to which he or she is assigned. No hysterical case must beregarded as hopeless. The maintenance of a correct attitude and constantcooperation between physicians, nurses, instructors, and men in the face of thetremendous demands which neurotic patients make upon the patience and resourcefulnessof those treating them soon brings weariness and lossof interest if opportunities for recreation do not exist. Therefore, it shouldbe the duty of the director to see that the morale and good spirits of all arekept up. His recommendations as to the transfer to other military duties ofmedical officers, nurses, instructors, or men who prove unsuited for this workshould be acted upon whenever possible by the chief surgeon under whom thehospital serves. A man or a woman may prove unadapted to this work and yet be avaluable member of the staff of another kind of hospital. This subject ismentioned so particularly because of its great importance. The type of personnelwill determine the success of this hospital and hence its usefulness to theArmy in a measure which is unknown in other military hospitals. It does notgreatly matter whether the operating surgeon understands the personality of thesoldier upon whom he is operating or not. Whether or not the physician treatinga case of "shell shock" understands the personality of his patientspells success or failure.
The first special base hospital established forneuropsychiatric cases should have such a highly efficient personnel that itwill be able to contribute one-third of its medical officers and trained workersto the next similar base hospital to be established, filling their places fromthose on its reserve list. This should be repeated a second time if necessaryand thus a uniform standard of excellence and the same general approach toproblems of treatment assured in each special base hospital organized in France.
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(b) Advanced section of line of communications.-TheFrenchand the British experience shows the great desirability of instituting treatmentof "shell shock" cases as early as possible. So little has been doneas yet in this direction that we do not know much about the onset of thesecases and just what happens during the first few days. Such information has beencontributed, however, by the few neurologists and psychiatrists who have had anopportunity of working in casualty clearing stations or positions even nearerthe front indicates that much can be done in dealing with these cases if theycan be treated within a few hours after the onset of severe nervous symptoms.There are data to show that even by the time these cases are received at basehospitals additions have been made to the initial neurological disability and acoloring of invalidism given which frequently influences the prospects ofrecovery. It is desirable, therefore, to provide neuropsychiatric wards forselected base hospitals in the advanced section of the line of communications.Other base hospitals can send cases to those which possess such wards. The planof providing such sections, in charge of neurologists and psychiatrists, fordivisional base hospitals in the cantonment camps in the United States hasbeen adopted by the Surgeon General. If it is found practicable to make similarprovisions in France, these units can accompany the divisions to which theyare attached when they join the Expeditionary Forces in the spring of 1918. Inthe meantime it is essential that each base hospital should have on its staffa neurologist or a psychiatrist. Provision for the care of mental and nervouscases nearer the front, along the line of communications, can best bedeveloped after the first special base hospital for neuropsychiatric cases hasbeen established by detaching from its staff individual officers as actualcircumstances require.
It is undesirable to formulate plans for providing this kindof care still nearer the fighting line until a more careful study has beenmade of the results obtained by the English and French medical services inthis undertaking.
2. IN THE UNITED STATES
(a) Mental diseases (insanity).-If thepolicy is adopted of caring in France for mental cases likely to recover andevacuating all others to the United States at once or at the expiration of six months' treatment, we may expect to receive at the port of arrival in theUnited States not less than 250 insane soldiers per month from an expeditionary force of 1,000,000. We may assume that a plan will be adoptedfor the reception and the distribution of soldiers invalided from France suchas proposed by Major Bailey.
Well-organized facilities for dealing with mental diseaseexist in the United States which can be utilized by the Government withoutthe necessity of creating expensive new agencies. It is obvious that the firstfacts to be determined in the case of soldiers reaching the United Stateswhile still suffering from mental disorders or who have been invalided homeafter recovery from acute attacks, are:
1. The cause of the disorder, with special reference to military service.
2. The probable outcome.
3. The probable duration.
4. The special needs in treatment.
It is quite impossible to ascertain any of these facts bycasual examination and so it will be necessary to provide "clearinghospitals" for noncommissioned officers and enlisted men where patientsmay be received and studied upon their arrival with the view of determiningthese questions. With an average annual admission rate of 3,000 patients, aclearing hospital of 300 beds would permit an average period of treatment of 36days. This would seem to be sufficient as the Boston Psychopathic Hospital,during an average period of treatment of 18 days, not only determines similarquestions but provides continued care for a considerable number of recoverablecases. Such clearing hospitals should be established near the port of arrivaland should be essentially military hospitals, with directors who are not onlywell trained in medical duties but familiar with the requirements of militarylife and with the institutional provisions in the United States that can be utilized for continued treatment.
With such an active service as a clearing hospital will have, the number of medical officers should be not less than 10 and there should be an adequate clerical force to care for
521
the important administrative matters which would requireattention. The organization of civil psychopathic hospitals in this countryaffords data for determining the proper size of the ward and domestic services.
After a period of observation and treatment the director ofsuch a hospital should be prepared to furnish the special distributing boardwith information and definite recommendations as to the further disposal ofeach case.
Some patients will be found at the clearing hospitals to haverecovered. Although, as a matter of military policy, these patients will not beavailable for duty again in France, they are still of military value to theGovernment. Such soldiers should be returned to duty in the United States bythe special distributing board in a category which would prevent them beingexposed again in the fighting line but which would indicate precisely the workfor which they are suited. We can conceive of many such soldiers who are likelyto break down again under the stress of actual fighting but who are quitelikely to remain in good health if they are not so exposed. These men willhave had valuable military experience and could render efficient service asinstructors in training camps or in the performance of other military duties inthe United States. Others who have recovered will give evidence of possessingsuch an unstable or inferior mental make-up that no further military life, even in the United States, is desirable. In such cases recommendations shouldbe made by the directors of the clearing hospitals to the special distributingboard to discharge them to their homes, with or without pensions as thecircumstances demand.
There will be found others who have not been benefited at allby treatment in France and who suffer from mental disorders with an extremelyunfavorable outlook for recovery. When this conclusion seems justified, thedirectors of the clearing hospitals should recommend these cases for transferto a suitable public or private institution in the States from which theyenlisted and their discharge from the Army, with or without pension as thecircumstances demand.
Another group of cases will be made up of those sufferingfrom psychoses which are probably recoverable. It is equally to the advantage ofthe Army, the community, and the patient that such soldiers be given continuedtreatment. Facilities for the care of mental diseases vary so greatly in manyof the States that neither the Army nor the patients can receive anyassurance that proper treatment will be afforded if such soldiers are dischargedto the public institution nearest their homes. In such cases the importantquestion of discharge, with or without pension, should be deferred until everyfacility has been given, during a reasonable period of time, for recovery totake place. It is recommended, therefore, that these cases be retained in theArmy until their recovery or until the end of the war and ordered for treatmentto State hospitals with which the Secretary of War has made contracts. AGovernment hospital for the insane would be the most suitable for carrying outsuch treatment but the present excellent institution in Washington has reachedthe size of 3,135 beds and can care for few additional military cases. It ishighly desirable that the Government should now establish a militaryhospital for mental diseases for the Army and Navy and permit the Government hospital to devote all its resources to its civil duties. It wouldbe impossible, however, to have such an institution ready within two years.If it were possible to construct such a new Government hospital in shorter time,it would still be necessary to provide for treatment by contract for such aninstitution would probably have to care for not more than 1,500 military casesduring peace. A much larger number are be expected during the war.
It is wiser to care for insane soldiers during the warunder contract at 10 or 12 first-class hospitals with fully adequatefacilities for treatment than to distribute them solely with reference to thelocation of their homes. This will involve a certain hardship through makingit difficult for such men to be visited by their relatives and friends, but itis possible to distribute the contract hospitals over the country in such a waythat there would be few cases more than a day's journey from their homes.The primary object is to insure recovery in all recoverable cases. Thisshould outweigh all other considerations.
The legislation permitting the Secretary of War tomake such contracts should state clearly that they shall be made only withinstitutions possessing facilities for treatment laid down by the SurgeonGeneral. The contract hospitals should be required to devote an
522
entire building of approved construction to military cases orto erect temporary structures meetingthe necessary requirements for this purpose.
In order that the Army may be able to discharge mental casescared for under contract promptly upon their recovery or upon ascertaining thatrecovery is unlikely, it is desirable that a special board of three medicalofficers should be established to visit the institutions constantly and act as aboard of survey. If two medical officers in each contract hospital wereappointed in the Medical Reserve Corps and assigned to the duty of caring forArmy patients they could serve as members of such a board when convened attheir hospital and make it possible for the three general members to cover agood deal more ground. The headquarters of this board should be in the clearinghospital at the principal port of arrival.
Clearing wards for officers should be established to servethe special purposes indicated in the description of the clearing hospital forenlisted men. Such wards should provide for reception classification, andtreatment in cases likely to be of short duration. It might be established inconnection with a general hospital at the port of arrival or in connectionwith a very efficient private institution for the insane in which full militarycontrol of this department could be secured.
It is equally important to provide for the continuedtreatment of officers and not leave this question, in which the Army has sogreat an interest, to choice or geographical convenience. Arrangement similarto those for the continued care of enlisted men in public contract hospitalscould easily be made with the best endowed private institutions for the insane,such as Bloomingdale Hospital, White Plains, N. Y.; Butler Hospital, Providence,R. I.; Hartford Retreat, Hartford, Conn.; McLean Hospital, Waverley, Mass.;Sheppard and Enoch Pratt Hospital, Towson, Md.; Henry Phipps Psychiatric Clinic,Baltimore, Md.; and the Pennsylvania Hospital for the Insane, Philadelphia, Pa.
(b) War neuroses ("shell shock") - Itis notnecessary here to outline the organization of reconstruction centers for thetreatment of war neuroses in the United States. The general principles intreatment described in the foregoing report and in the plan recommended forFrance should be a guide in the development of those centers. It might bedesirable to follow the plan in the United States which has been so successfulin the Granville Canadian Special Hospital at Ramsgate of treating the warneuroses in a center which also cared for orthopedic cases in which peripheralnerve injuries exist. These latter types of patients constitute a very hopefulgroup of cases and many of the resources for reeducation which are needed intheir treatment are equally useful in the cases of hysterical paralyses,tremors, and disturbances of gait. It should be remembered that if the policyrecommended of evacuating to the United States only the neuroses which fail torecover in six months in France is adopted some very intractable cases will bereceived. For the most part these will be patients with a constitutionalneuropathic make-up-the type most frequently seen in civil practice. Many ofthese cases will prove amendable to long continued treatment and much can beexpected from the mental effect of return to the United States. It is veryimportant not to fall into the mistake made in England of discharging thesesevere cases with a pension because of the discouraging results of treatment.To do so will swell the pension list enormously, as can be seen by the fact that15 Percent of all discharges from the British Army are unrecovered cases ofmental diseases and war neuroses. Quite aside from financial considerations,however, is the injustice of turning adrift thousands of young men whodeveloped their nervous disability through military service and who can find intheir home towns none of the facilities required for their cure. It isrecommended, therefore, that no soldiers suffering from functional nervousdiseases be discharged from the Army until at least a year's special treatment has been given. Furloughs can be given when visits home or treatmentin civil hospitals will be beneficial but the Government should neither evadethe responsibility nor surrender the right to direct the care of these cases. Aserious social and economic problem has been created in England alreadythrough the establishment in its communities of a group of chronic nervousinvalids who have been prematurely discharged from the only hospitals existingfor the efficient treatment of their illness. So serious is this problem that aspecial sanitarium- "The House of Recovery"-the first of severalto be provided, has been established in London and subsidized by the War Officefor the treatment of such cases among pensioners.
It is highly important not to permit convalescent cases ofthis kind to be cared for in theordinary type of convalescent camp or home. The surroundings so suitable toconva-
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lescents from wounds or other diseases are very harmful toneurotic cases. Here much that has been accomplished in specialhospitals by patient, skillful work is undone. Therefore special convalescentcamps similar to those recommended for the Expeditionary Forces in Franceshould be established within convenient reach of the reconstruction centers.
The special board, recommended for the finaldisposition of mental cases, should deal with cases of functional nervous diseases.
NONEXPEDITIONARY FORCES
Facilities for the treatment of neuropsychiatric cases atthe camps in the United States have been approved by the Surgeon General andare now being provided. These will undoubtedly prove sufficient for dealingtemporarily with mental cases developing in the nonexpeditionary forces. Theirfinal disposition should be made by means of the same mechanismrecommended for expeditionary patients who are invalided home except that the functions of theclearing hospitals for mentaldiseases can be performed by the neuropsychiatric wards of divisional hospitalsand that of the special board by the board of survey composed of theneurologists and psychiatrists stationed at the camps.
Neuroses are very common among soldiers who have never beenexposed to shell fire and will undoubtedly be seen frequently amongnonexpeditionary troops in this country. In England nearly 30 Percent of allmen from the home forces admitted to one general hospital were suffering fromvarious neuroses.1 Most of these weremen of very neurotic make-up.Most of these cases had had previous nervous breakdowns. Fear, even in thecomparatively harmless camp exercises, was a common cause of neurotic symptoms.Heart symptoms were exceedingly common. The same experience in our own trainingcamps can be confidently predicted.
The responsibility of the Government in such cases isobviously different from that in soldiers returning from duty abroad. In theneuropsychiatric wards of divisional hospitals the important and difficultquestion of diagnosis can be well determined. Most such cases should bedischarged from the service. Some can be treated at the reconstruction centersfor, unfortunately, there are scarcely any provisions in the United States forthe treatment of the neuroses except in the case of the rich. It is freelypredicted in England that the wide prevalence of the neuroses among soldierswill direct attention to the fact that this kind of illness has been almostwholly ignored while great advances have been made in the treatment of allothers. In civil life one still hears of detecting hysteria, as if it were acrime, and although the wounded burglar is carefully and humanely treated inthe modern city hospital, the hysteric is usually driven away from its doors.To-day the enormous numbers of these cases among some of Europe's bestfighting men is leading to a revision of the medical and popular attitude towardfunctional nervous diseases.
1Burton-Fanning, F. W. Neurasthenia in soldiers of the homeforces. Lancet (London). 1907-11 (June 16, 1917)
