CHAPTER I
ORGANIZATION
PRELIMINARY PLANS UPON WHICH TO BASE ORGANIZATION
During the first few months of 1917 it was apparent to theSurgeon General that the Medical Department of the Army was soon to be calledupon to assume the performance of enormous tasks, many of them quite unrelatedto military duties in time of peace, or even to the latest campaigns in whichthe United States Army had taken part. In other volumes of this history are tobe found accounts of the methods by which plans were made for the mobilizationof the medical, sanitary, and nursing resources of the country. Similarpreparations were not lacking in the field of neuropsychiatry. Having in mindthe desirability of being prepared at the earliest possible moment to deal withthe new and formidable problem of war neuroses, the Surgeon General, in March,1917, invited a committee of civilian neuropsychiatristsato Washington, for a conference on the subject.1This committee was part of a larger group, formed by the National Committee forMental Hygiene, for the purpose of studying the possible neuropsychiatric needsof the United States Army in the event of our country's entry into the war.Appreciating the importance of mental disorders as a medico-military problem,and aware of the magnitude of this problem among European armies, this group wasalready at work laying plans for one or more psychiatric hospital units to beplaced at the disposal of the United States Government when needed.
ON THE MEXICAN BORDER
As a result of the Washington conference the Surgeon Generalrequested the committee to visit the Army camps on the Mexican border to studythe provisions made in the United States Army, as then constituted, for thediagnosis of, and the care and treatment of soldiers suffering from, mentaldiseases.2 A careful study was made of the whole situation, includinginspections of the larger military hospitals at San Antonio and El Paso, Tex.,and the military prison at Fort Leavenworth, Kans.
The committee was impressed with the high incidence of mentaldiseases in the Army. These diseases were found to be approximately three timesas prevalent among the troops on the Mexican border during the previous summeras, for example, among the civil population of the State of New York.2 Thecommittee noted also the uniformly high standard which characterized provisionsfor the diagnosis and treatment of physical disorders in the base hospitalsvisited, in contrast with the meager provisions for the care of the mentally
aDr. Stewart Paton, of Princeton University; the late Dr.Pearce Bailey, of the Neurological Institute, New York City; and the late Dr.Thomas W. Salmon, the medical director of the National Committee for MentalHygiene.
6
ill. It was apparent that special provisions would have to bemade to meet adequately the needs that would arise with the participation of theUnited States in the European conflict.
In its report to the Surgeon General (see appendix, p. 491)the committee outlined a plan for a central psychiatric unit of 110 beds to beestablished in connection with base hospitals near the largest concentration oftroops, and a 30-bed unit for base hospitals elsewhere. It was recommended thatsuch units be integral parts of military hospitals and that the psychiatristsand neurologists in charge of them be medical officers of the Army. Diagrams ofthese units, with a description of buildings, equipment, and personnel, weresubmitted. The usefulness of a psychiatric service was pointed out in connectionwith the handling of disciplinary cases, malingering, and other behaviorproblems among the troops. Such a service was deemed to be indispensable to themorale of a modern fighting organization.
IN CANADA
In May, 1917, a member of this committeeb made a trip toCanada in quest of information concerning the management of the numerousproblems arising out of the presence of mental and nervous disorders amongsoldiers. It was believed that valuable lessons could be learned from Canadianexperience with neuropsychiatric cases, particularly in view of the similarityin geographical situation between the United States and Canada with regard tothe scene of war. The transportation of bodies of troops over the seas presentedsimilar difficulties, and the same problems arising in connection with thereception, classification, and distribution of those invalided home would haveto be met by our own Army.
Evidence of strong neuropathic trends or mental diseases wasfound in many of the medical histories of returned Canadian soldiers. Thepredisposition to nervous and mental diseases or the actual existence of theseconditions in slight degree, while readily and quickly demonstrable by aphysician accustomed to look for them, usually passed unnoticed by the surgeon.Yet the frequency with which these disorders occurred, and the certainty oftheir disabling character, made the enlistment of men so affected a direct blowat the efficiency of the Army and a source of unnecessary expense to theGovernment and hardship to the soldier. In his report to the Surgeon General3the member of the committee emphasized the importance of this phase ofrecruiting and recommended the assignment of medical officers of the proposedbase hospital psychiatric units to duty at Army camps during mobilization.
Another member of the committeec about the same time, visitedQuebec, to observe conditions among returned Canadian soldiers at the dischargedepot there. In his report to the Surgeon General4he noted certaindispositions existing in each patient prior to enlistment which, under thestress of war conditions, were particularly favorable for the development ofnervous and mental symptoms, and suggested that it should not be a matter ofgreat difficulty to eliminate from the service, in advance, a large proportionof the cases returned
bDr. Pearce Bailey.
c Dr. Stuart Paton.
7
as "nervous and mental disorders." He also stressedthe importance of bringing any psychological work in the Army into close unionwith the activities of the Medical Department, and described the great varietyof the nervous and mental disorders found among the returned soldiers.
IN ENGLAND
In June, 1917, a member of the committee,d through thecooperation of the Rockefeller Foundation, was sent to England to secure, firsthand, the most recent information as to the British and French methods ofdealing with war neuroses in and near the theater of operations, to makeobservations on these methods, and to confer with medical officers in theBritish War Office. His report to the Surgeon General5 (see appendix,p. 497) confirmed observations and impressions of other members of the committeeconcerning neuropsychiatric conditions in the Canadian Army, and contained datathat proved of great value in the preparation of plans for dealing with theproblem of mental and nervous diseases in the United States Army, abroad and athome. The high rate of mental disorders in the British Army (one-seventh of alldischarges for disability had been due to mental conditions), the difficultiesin which the Allies found themselves as a result of failure to prepareadequately for the management of mental and nervous cases developing in combat,and the great problem created by the acceptance of large numbers of recruits whohad been in institutions for the insane or were of demonstrably psychopathicmake-up-these and other significant observations were among the mostimportant factors determining the course of American medico-militarypreparations.
The foremost recommendation contained in this report calledfor rigid exclusion of all insane, feeble-minded, psychopathic, and neuropathicindividuals from the forces which were to be sent to France and exposed to theterrific stress of modern war. Not only medical officers, but the line officersinterviewed in England, had emphasized over and over again the importance of notaccepting mentally unstable recruits for service at the front. As a result ofthese observations, it was believed to be within the power of the United StatesArmy, by the adoption of an exclusion policy, to reduce very materially thedifficult problem of caring for mental and nervous cases in France, to increasethe military efficiency of the expeditionary forces, and to save the countrymillions of dollars in pensions.
The next most important lesson learned was that of preparing,in advance of urgent need, a comprehensive plan for establishing specialmilitary hospitals for mental diseases. Here, again, it was declared that theUnited States could profit vastly by the experience of its allies by having atthe disposal of the Army, before it began to sustain mental and nervouscasualties, a personnel of specially trained medical officers, nurses, andcivilian assistants, and an efficient mechanism for treating these disorders inFrance, evacuating them to home territory, and continuing their treatment, whennecessary, in the United States.
It was estimated that the annual rate of admissions of mentaland nervous cases to British military hospitals at the time of thisobserver's visit was about
Dr. Thomas W. Salmon.
8
2 per 1,000 among the nonexpeditionary troops and about 4 per1,000 among expeditionary troops, compared with a rate of 1 per 1,000 among theadult civil population of Great Britain. The greatest problem, however, bothfrom the standpoint of the welfare of the individual soldier and of militarymorale, was that presented by the excessive incidence of war neurosis, a problemwhich proved to be most serious for all of the allied armies. Of 200,000soldiers on the pension list of England, it was found that one-fifth weresuffering from this condition.
Among the chief recommendations resulting from this studywere: (1) The establishment overseas of special base hospitals of 500 beds forneuropsychiatric cases, and convalescent camps in connection with thesehospitals in the base sections of the line of communications; (2) the provisionof special neuropsychiatric wards of 30 beds for the observation and emergencytreatment of mental and nervous cases in base hospitals in the advance sectionof the line of communications; (3) the assignment of psychiatrists andneurologists from these wards to evacuation hospitals and more advanced stationsas opportunities permitted.
For the United States the following recommendations weremade: (1) The provision of clearing hospitals, and clearing wards in generalhospitals for the reception, emergency treatment, classification, anddisposition of mental cases among enlisted men and officers invalided home; (2)legislation enabling the Surgeon General to contract with public and privatehospitals for the continued care of mental cases prior to discharge; (3) theestablishment of reconstruction centers and special convalescent camps for thetreatment and reeducation of returned soldiers suffering from war neuroses; (4)the appointment of a special medical board to inspect all Government hospitalsand reconstruction centers, public and private institutions caring for mentallydisabled officers and enlisted men. Descriptive plans for hospital personnel andequipment, together with a diagram showing the scheme of care of the disabledsoldier from the field hospitals at the front to his return home, accompaniedthe report.
A concluding observation described the changing point of viewin England and France, brought about by the war, with regard to mental andnervous diseases in civil as well as in military life. Whereas mental illnesshad been almost wholly ignored and the medical advances before the war dealtalmost exclusively with physical diseases, the wide prevalence of the neurosesamong soldiers was apparently leading to a revision of the medical and popularattitude toward mental and functional nervous diseases, and stimulatingwidespread interest in their observation and study.
APPROVED PLANS
The report of the observations on the Mexican border waspromptly accepted and the plans suggested were approved by the Surgeon General,who authorized the National Committee for Mental Hygienee to proceed at once withthe organization of the neuropsychiatric units recommended.1 To this end therewas formed the Committee on Furnishing Hospital Units for Nervous
eThe origin and work of the National Committee for MentalHygiene are described in "A Mind That Found Itself," an autobiography,by Clifford W. Beers. Doubleday, Page & Co., New York.
9
and Mental Disorders for the United States Government,fcomposed of representative neurologists and psychiatrists from various parts ofthe country. The American Medico-Psychological Association (now the AmericanPsychiatric Association) appointed a member of the association in each State towork with this committee. The American Neurological Association and the AmericanPsychological Association also appointed special committees to cooperate withthe National Committee for Mental Hygiene. In Massachusetts the committee forwar work in neurology and psychiatry was appointed by the governor with a viewof organizing a neuropsychiatric hospital unit of its own for the use of theGovernment and to cooperate with the National Committee for Mental Hygiene. Soonit became evident that the problem of organizing and equipping hospital unitswould be but one of a number of problems that would have to be considered, sothat the Committee on Furnishing Hospital Units for Nervous and Mental Disordersfor the United States Government widened the scope of its activities and changedits name to War Work Committee, making provision at the same time forsubcommittees for the study of particular problems.
On the authority of the Surgeon General1the War WorkCommittee early set about securing for the Medical Department a specialpersonnel, circularizing the medical profession and special hospitals for thispurpose. There were received in all 795 applications for commission in theMedical Reserve Corps. After considering the special fitness of the applicants,the papers were forwarded to the Surgeon General, with indications as to theaptitude of the candidates, and with recommendations as to rank, based onprofessional standing.6 Commissions were granted to 564 suchapplicants.
The committee also, in much the same manner, secured thenames of nurses and attendants, and cooperated with the Surgeon General inregard to their induction into the service.
It was from plans drawn by this committee that the type ofneuropsychiatric pavilion for the camps was decided on.1 Thecommittee also distributed special literature and, in some instances, equipmentto the neuropsychiatric units and officers. It contributed $2,500 to enable acommittee of psychologists to continue the investigations which resulted in thepsychological tests later adopted by the Medical Department of the Army.g
As the war proceeded, the committee continued to cooperatewith the division of neurology and psychiatry of the Office of the SurgeonGeneral and with the civil community. It assisted in making the arrangements bywhich recruits who became insane prior to or immediately after enlistment wouldbe cared for by their own States; prepared a classified list of State hospitals,showing their standards, medical personnel, and methods of treatment and careof patients; and throughout the war helped in the solution of variousprofessional problems which confronted the Surgeon General.
fThe work of this committee was first made possible through agenerous gift made by Miss Anne Thompson, of Philadelphia. Later it was financedby the Rockefeller Foundation.
gMemoirs of the National Academy of Sciences, Vol. XV.Psychological Examination in the United States Army. Part I. History andOrganization of Psychological Examining and the Materials of Examination. PartII. Methods of Examining: History, and Development, Preliminary Results. PartIII. Measurements of Intelligence in the United States Army. GovernmentPrinting Office, Washington, 1921.
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DIVISION OF NEUROLOGY AND PSYCHIATRY, SURGEON GENERAL'SOFFICE
The Surgeon General, appreciating the highly specializednature of modern medical practice, organized in his office, in addition to theexisting divisions, several others to direct and supervise all matters relatingto the recognized specialties pertaining to medical science. One of these wasthe division of neurology and psychiatry,7 of which the section ofpsychology constituted a part. Later, the section of psychology was made anindependent division.8
With the reorganization of the Surgeon General's Office inthe latter part of 1918, the division of neurology and psychiatry ceased toexist as such, and became a section of medicine, under the direction and controlof the chief of the division of internal medicine.9 Reference is madelater to this arrangement.
Prior to the organization of the division of neurology andpsychiatry there was no neurological or psychiatric organization in the Officeof the Surgeon General or in the Medical Department. A social and psychiatricdepartment, organized at the Fort Leavenworth Disciplinary Barracks, had shownthe value of psychiatry in relation to crime, delinquency, and disciplinaryproblems.10 But no special examinations as to the mental fitness ofvolunteers were made at recruit depots or recruit depot posts, or of applicantsfor commission in the Regular Army. There was a small number of medical officerswho were recognized as having a knowledge of psychiatry, obtained, for the mostpart, during periods of service to which they were detailed at St. ElizabethsHospital (Government Hospital for the Insane, Washington, D. C.). With theexception of service at the Letterman General Hospital, however, the specialequipment of these officers was not utilized by the Medical Department of theArmy as it would have been had their professional interests been in anotherdirection, as, for example, toward bacteriology. The creation of this division,therefore, opened a new field in the Medical Department, concerning which thefollowing announcement was made by the War Department on February 8, 1918:11
Officers with special experience in nervous and mentaldiseases have been added to the Medical Department of the Army. Such officersare detailed at all base hospitals and with many divisions. Most base hospitalshave also special nurses and therapeutic appliances for the care of nervous andmental diseases. The services of these officers and nurses are available,through their superior officers, for consultation in all matters pertaining tosuch diseases.
FUNCTIONS
To the division of neurology and psychiatry was assignedjurisdiction over all problems relative to neuropsychiatry. This involved (1)preparing for the examination of recruits in the mobilization camps in orderthat those unfit for military service because of neuropathic or psychopathicconditions might be discharged; (2) preparing adequate facilities for theobservation, treatment, and care of soldiers ill of nervous or mental diseasespending discharge; (3) preparing for the treatment of soldiers in the AmericanExpeditionary Forces who became incapacitated because of nervous or mentaldisease; (4) preparing for the continued treatment and final disposition ofsoldiers invalided home.
The following were special problems to which the divisiongave immediate attention: (1) Mobilization of the psychiatrists, neurologists,and psychologists
11
of the country for service with the Army. (2) Securing theenlistment of specially trained women nurses and male attendants for service inthe neuropsychiatric hospital units. (3) Devising methods of examination wherebylarge numbers of men could be examined by a few specialists in a comparativelyshort time. (4) Determining neuropathic and psychopathic conditions which, inthe light of the European experience, should exclude from military service. (5)Preparing plans for a standardized neuropsychiatric hospital for Army use. (6) Preparing plans for a special standardized 500-bedreconstruction hospital for nervous and mental cases to be located in France.(7) Preparing plans for 30-bed units to be attached to the base and othermilitary hospitals in France. (8) Standardizing equipment for Army neuropsychiatrichospitals. (9) Standardizing neurological, psychiatric, and psychologicalexaminations for Army use. (10) Preparing special report blanks adapted tomilitary use. (11) Arranging for the systematic collection and utilization ofstatistical data. (12) Arranging for special intensive courses in war psychiatryand neurology for the additional training of young neurologists andpsychiatrists. (13) Collecting information pertaining to the situation abroadfor the guidance of those at work upon the problem in this country. (14) Thestudy of disciplinary problems arising in the Army. (15) Developing methods bywhich the work of the neuropsychiatric units could be coordinated with themedical military machinery. (16) Developing plans for the continued treatment in thiscountry of nervous and mental patients invalided home from the AmericanExpeditionary Forces.
ADMINISTRATION
A small administrative force was maintained in the Office ofthe Surgeon General, but for the greater number the neuropsychiatrists wereplaced on duty at the hospitals, camps, cantonments, posts, ports ofembarkation, and disciplinary barracks, both in this country and in France.
The first efforts of the division were directed towardclassifying and exempting for neuropsychiatric service the specialists whoseapplications were received daily in great numbers, in deciding upon assignmentsfor them when commissioned, in recommending orders, and in attempting tocoordinate its own activities with those of other branches of the professionalservices.
The last was a difficult task. The majority of the officersin the Surgeon General's Office at the time were fresh from civil life, mostof them were without military experience, and many were without administrativeexperience. For a long time there was no officer or machinery to coordinatedifferent interests, and many recommendations were made from all sides whichoverlapped or conflicted and which could not be carried out successfully. Theresult was that the different professional divisions in the office operatedindependently, with much inevitable confusion. Ultimately this was corrected,with the development and correlation of the various professional activities ofthe office. With the reorganization of the office, in the latter part of1918, the division of neurology and psychiatry ceased to exist as such, andbecame a section of the division of internal medicine.9 This wasconsidered by the chief of the neuropsychiatric service an undesirable change asit interposed between him and the
12
executive officer of the Surgeon General's Office anotherofficer, who was given authority, but who was not required to possess anyspecial knowledge of nervous or mental diseases, who presented to the SurgeonGeneral recommendations which he did not initiate, and of which he had nofirst-hand knowledge. The stream of execution was also slowed up, as eachinterruption of a channel of action involved, even in intraoffice activities, anadditional delay of at least 24 hours.
Another disadvantage of this arrangement was that by itpsychology was placed under medicine,9 when, in reality, it shouldhave been under neuropsychiatry. While military psychology is ostensiblyconcerned with mental ratings and with the detection of mental deficiency-inother words, with a study of the normal mind and of the mind purely defective-itshould not be forgotten that it constantly encounters medical problems of apsychiatric nature. Both the findings and the recommendations of psychologistsconcern psychopathology and consequently should go through the psychiatricofficer and not the officer directing internal medicine.
CONSULTING SERVICE
No authority was vested in the officers of the division ofneurology and psychiatry, Surgeon General's Office except, on occasions ofspecial detail, to make inspections, all inspection duties normally beingperformed by officers of the division of sanitation, Surgeon General's Office.Certain special inspections, however, which were classed as consultations inreference to professional work, were made by members of the division ofneurology and psychiatry. Some of the professional divisions of the SurgeonGeneral's Office appointed officers known as consultants, who were assigned todifferent geographical regions for the purpose of consulting therein.12Thisplan was not adopted by the division of neurology and psychiatry for the reasonthat it was always possible to secure War Department orders designating anindividual officer as a consultant, and it was deemed wiser to use differentofficers for this purpose as the need arose. For example, when an officerassigned to some particular post developed a particularly successful system oftreatment or management of patients or of making examinations, permission forhis temporary relief was obtained from his commanding officer, and he was sentto posts in his neighborhood to consult with neuropsychiatric officers there, inorder that they might benefit by whatever he had to tell them. Contract surgeonsalso were appointed for consulting purposes when they had special knowledge thatwould prove useful to neuropsychiatric officers on duty in their neighborhood.
Practically all the officers detailed to this division wereordered from time to time to make trips to certain hospitals or camps for thepurpose of ascertaining whether a more or less uniform standard of excellence inthe neuropsychiatric services was being maintained. Consultations in Californiawere made by a member of the staff of Mendocino State Hospital.13 Thismethod of consultation in professional matters proved highly successful. Visitsfrom outside officers to officers working at one point invariably resulted in anincrease of interest, in the removal of any obstacles that may have existed, andin improvement of the standard of professional work.
13
Those who acted as consultants in base and general hospitalswere assigned to the medical service and were usually referred to asneurologists, though in general hospitals in which psychiatric wards wereestablished the consultations were conducted generally by the psychiatristsdetailed there. There were many more demands for neurologists to serve in baseand post hospitals and at detached points than could be met. They were suppliedas freely as possible. They aided greatly in evacuation activities and infacilitating hospital business. When nerve injury cases began to be returnedfrom overseas, neurologists were assigned to the various surgical services.
SPECIAL NEUROPSYCHIATRIC REPORTS
The officer in charge of the division of neurology andpsychiatry realized that in view of the large number of neuropsychiatricexaminations which were to be conducted in the Army, an unparalleled opportunitywas at hand for obtaining information concerning a group of diseases of greatsocial importance, the incidence of which was unknown and, further, that, inorder to correlate the data derived from the examinations made, certain reportsmust be prepared and submitted to the Surgeon General for study and compilationby the division. It is true that the examinations conducted in the Army appliedonly to men of military age, but the statistical data elicited from this sourcemust offer a reliable index to the extent to which disease and defects of thischaracter occur throughout the entire population of the country.
It was believed that the time of the neuropsychiatristsshould be largely occupied with their professional duties and that any formsadopted for the report of cases must be brief, concise, and practical. Anotheressential was that the report blank be so devised that the facts contained couldreadily be reduced to statistical form and made available for study.
The following blank forms were adopted and distributed to allstations where neuropsychiatric officers were on duty:h
FORM 89
MEDICAL DEPARTMENT, U. S. A.
(Authorized Sept. 19, 1917.)
RECORD OF NEUROLOGICAL AND PSYCHIATRIC EXAMINATION
Surname of patient Christian name Rank Company Regiment or staff corps
Examiners will record observations in the following sequence:
1. Record history of syphilis, previous diseases (physical ormental), injuries, alcohol and drugs; chief symptom; duration of presentillness; evidence of alcoholic or drug addiction; state of nutrition,flesh, hair, nails, skin, and muscles.
2. If paralysis, note distribution, character,and contracture. If tremor or tics, note distribution and character. Note station and gait. Of reflexes, note knee jerks and abdominals especially; Babinski.Of eyes, note condition of pupils, nystagmus, double vision. If anesthesia, makechart showing distribution and different forms of sensibility affected. Noteataxia, taste, and smell. Note defects not previously mentioned.
hThese forms were prepared with the assistance of Dr.HoratioM. Pollock, statistician of the New York State Hospital Commission, whoseknowledge and experience in this line of work rendered his advice particularlyvaluable.
14-15
3. Note behavior, attitude, emotional state, general motorcondition; stream of thought, content of thought (compulsive ideas,obsessions, phobias, delusions, hallucinations, peculiar mental attitudes); mood(depressed, gay, suspicious, irritable, sulky, resentful); orientation; memoryand thinking (past events, recent events; calculation); intellectual level(always in cases of mental deficiency; in other cases when possible); patient'sinterpretation of the development of the psychosis or neurosis and attitudetoward it.
4. If diagnosis of mental defect is made, state method ofexamination and basis of conclusion.
Form 89 was intended as a clinical record of individualcases. Thousands of these completed forms were received in the Office of theSurgeon General and contained material of great clinical interest and value, butwere too extensive for a thorough statistical study. Form 90 M. D., known as thestatistical data card, contained a complete summary of the facts essential in astudy of neuropsychiatric cases. These forms, as received in the Office of theSurgeon General, furnished the basis of the statistics quoted in this volume anddiscussed in detail in the following chapters. Form 91 M. D. was the monthlysummary of the work done at each station.
At the end of each month the complete forms were forwarded bythe officer who prepared them, through the senior medical officer of the camp orhospital, to the Surgeon General. In the Surgeon General's Office the reportswere studied and classified and from time to time reduced to statistical form.
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The following instructions were issued as a guide in the preparation of thereports:
WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, February 15, 1918.
Memorandum.
INSTRUCTIONS TO DIVISIONAL PSYCHIATRISTS AND OTHER MEDICAL OFFICERS IN CHARGE OF NEUROLOGICAL AND PSYCHIATRICAL EXAMINATIONS RELATIVE TO THE PREPARATION OF STATISTICAL DATA
In order to secure uniformity in the statistics of nervous and mental diseaseand defect the divisional psychiatrists and other medical officers who are incharge of the examinations will submit their reports on Forms 89, 90, and 91,Medical Department, specially provided for this purpose.
Form 89 is for the record of neurological and psychiatricexaminations.
Form 90 the statistical data card will be used in submitting data relative toeach person examined who is found to have nervous or mental disease or defect.
Form 91 is the monthly summary of the work done at the station.
These reports will be sent in at the end of each calendar month unless thework at the station is completed before such time. All reports will be addressedto the Surgeon General and sent to him by the divisional psychiatrist or othermedical officer through the senior medical officer in charge of the station.
The following instructions for the preparation of data will be carefullystudied and scrupulously observed.
All data will be clearly written in black ink, or preferably typewritten.
The data called for by every item on the report blank will be supplied ifpossible. If the information can not be obtained, leave the space blank, butenter a capital "U" (symbol for facts unascertained).
Do not use the interrogation point.
If the information is negative, enter "no" or "none." Donot use the (-) dash for unascertained or for negative.
Give exact data whenever possible. Avoid the use of the term "many"or "several." State information approximately if exact data can not beobtained. In determining the age of subjects, accept figures ending with 5 or 0only after close questioning. Give the age in years and months when possible.
Avoid ambiguous abbreviations. Designate items on the reports byunderscoring. Do not cross out items or use check marks. If the space inconnection with any item on the front of the report blank is too small for acomplete statement, mark the blank "over" and enter the data in theblank space on the back of the blank.
The following instructions and information relate to Form 90. The otherblanks are self-explanatory:
CLASSIFICATION OF DISEASES, INJURIES, AND DEFECTS
Each case reported will be placed with appropriate specific designation underone of the following general heads:
I. Nervous diseases or injuries.
II. Psychoneuroses.
III. Psychoses.
IV. Inebriety.
V. Mental deficiency.
VI. Constitutional psychopathic states.
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The terms given in the following classifications will be used wheneverapplicable to specify the particular disease, injury or defect.
I. NERVOUS DISEASES AND INJURIES
Abscess:
Brain (specify location).
Spinal cord (specify location).
Arteriosclerosis:
Cerebral.
General.
Spinal.
Beri beri.
Bulbar palsy.
Chorea.
Combined sclerosis.
Ear diseases.
Embolism and thrombosis.
Endocrinopathies (specify disorder):
Adrenal.
Thyroid.
Pituitary.
Other ductlessglands (specify glands).
Epilepsy:
Idiopathic.
Jacksonian.
Exophthalmic goiter.
Eye diseases.
Facial palsy.
Hemorrhage (specify location).
Herpes zoster.
Hydrocephalus.
Injury (specify kind).
Brain (specify location).
Spinal cord (specify location).
Peripheral nerve (specify nerve).
Lateral sclerosis.
Lumbago.
M?ni?re's disease.
Meningitis:
Cerebrospinal.
Tuberculous.
Other forms (specify).
Migraine.
Multiple sclerosis (Disseminated sclerosis).
Myasthenia gravis.
Myelitis:
Transverse.
Traumatic.
Myotonia congenita (Thomsen's disease).
Neuralgia (specify nerve).
Neuritis (specify nerve).
Diphtheritic.
Multiple-
Alcoholic.
Traumatic.
Other forms.
Pachymeningitis cervicalis.
Paralysis agitans.
Paramyoclonus multiplex.
Pes planus.
Plumbism.
Poliomyelitis.
Progressive muscular atrophy.
Progressive muscular dystrophies.
Sciatica.
Syphilis of central nervous system.
Syringomyelia.
Tabes dorsalis (locomotor ataxia).
Tics.
Torticollis.
Tremor, chronic progressive.
Tumor:
Brain (specify location).
Spinal cord.
Peripheral nerve (specify nerve).
Vagotonia.
Undiagnosed.
Conditions secondary to other diseases:
Aphasia.
Bulbar syndrome.
Hemiplegia.
Jackson's syndrome.
Optic atrophy.
Paraplegia.
II. PSYCHONEUROSES
Enuresis.
Hysteria.
Neurasthenia.
Psychasthenia.
Stammering.
Other forms (specify).
Undiagnosed.
III. PSYCHOSES
The classification of mental diseases given below is the one adopted by theAmerican Medico-Psychological Association in May, 1917.
In designating the mental disease on the statistical card the group and typeof the psychosis will be given whenever possible.
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1. Traumatic psychoses.
2. Senile psychoses.
3. Psychoses with cerebral arteriosclerosis.
4. General paralysis.
5. Psychoses with cerebral syphilis.
6. Psychoses with Huntington's chorea.
7. Psychoses with brain tumor.
8. Psychoses with other brain or nervous diseases (specify when possible).
9. Alcoholic psychoses:
(a) Pathological intoxication.
(b) Delirium tremens.
(c) Acute hallucinosis.
(d) Korsakow's psychosis.
(e) Chronic paranoid type.
(f) Other types, acute or chronic.
10. Psychoses due to drugs and other exogenous toxins.
(a) Morphine, cocaine, bromides, chloral, etc., alone or combined (to be specified).
(b) Metals, as lead, arsenic, etc. (to be specified).
(c) Cases (to be specified).
(d) Other exogenous toxins (to be specified).
11. Psychoses with pellagra.
12. Psychoses with other somatic diseases (specify disease).
13. Manic-depressive psychoses:
(a) Manic type.
(b) Depressive type.
(c) Stupor.
(d) Mixed type.
(e) Circular type.
14. Involution melancholia.
15. Dementia pr?cox:
(a) Paranoid type.
(b) Katatonic type.
(c) Hebephrenic type.
(d) Simple type.
16. Paranoia and paranoic conditions.
17. Psychoses with mental deficiency.
18. Psychoses with constitutional psychopathic inferiority.
19. Epileptic psychoses.
20. Undiagnosed psychoses.
IV. INEBRIETY
Alcoholism.
Drug addiction (specify drug).
V. MENTAL DEFICIENCY
Imbecile.
Moron.
Border-line condition.
VI. CONSTITUTIONAL PSYCHOPATHIC STATES
Criminalism.
Emotional instability.
Inadequate personality.
Nomadism.
Paranoid personality.
Pathological liar.
Sexual psychopathy.
Other forms (specify).
Undiagnosed.
IN LINE OF DUTY
In answering this question examiners will be guided by instructions given inparagraph 448, page 141, of Manual for the Medical Department.
DATE OF INJURY OR ONSET OF DISEASE
An exact date will be specified if possible. If the exact date can notbeascertained, give approximate date.
REASON FOR EXAMINATION
It will be determined whether the examination was to determine (a) fitnessfor Army service, (b) responsibility for misconduct, or (c) natureof incapacity or illness.
AGE
The age of the soldier will be stated in years and months. If the exact datecan not be ascertained the examiner should estimate the age as closelyas possible and mark "est." after the number given.
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RACE
In reporting the race of the soldier use the list given below, which is acondensed form of the list adopted by the United States Immigration Service.
African (black).i
American Indian.
Armenian.
Bulgarian.
Chinese.
Cuban.
Dutch and Flemish.
East Indian.
English.
Filipino.
Finnish.
French.
German.
Greek.
Hebrew.
Irish.
Italian (includes "north" and "south").
Japanese.
Korean.
Lithuanian.
Magyar.
Mexican.
Porto Rican.
Portuguese.
Rumanian.
Scandinavian (Norwegians, Danes, and Swedes).
Scotch.
Slavonic.i
Spanish.
Turkish.
Welsh.
Other peoples.
Mixed.
Race unascertained.
NATIVITY
The State or Territory of birth of those born in the United States will begiven. Enter "U. S." only when the State can not be ascertained.
The date of nativity of those of foreign birth will be based on theclassification given below.
Africa.
Asia.k
Atlantic Islands.
Australia.
Austria.
Belgium.
Bohemia.
Canada.l
Central America.
China.
Cuba.
Denmark.
England.
Europe.
Finland.
France.
Germany.
Greece.
Hawaii.
Holland.
Hungary.
India.
Ireland.
Italy
Japan.
Mexico.
Norway.
Philippine Islands.
Poland.
Porto Rico.
Portugal.
Rumania.
Russia.
Scotland.
South America.
Spain.
Sweden.
Switzerland.
Turkey in Asia.
Turkey in Europe.
Wales.
West Indies.m
Other countries.
Born at sea.
LEGAL RESIDENCE
The legal residence is the place in which the home of the soldier is located.If he has no home his place of residence at the time of enlistment will begiven.
iDo not say "colored."
j"Slavonic" includes Bohemian, Bosnian, Croatian, Delmatian,Herzegovinian, Montenegrin, Moravian, Polish, Russian, Ruthenian, Servian,Slovak, Slovenian.
kNot otherwise specified.
lIncludes Newfoundland.
mExcept Cuba and Porto Rico.
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EDUCATION
Report education as none if the soldier could neither read nor write previousto onset of his disease. After the words "grades," "highschool," and "college," insert number of years completed.
HOME ENVIRONMENT
Report places of residence with a population of over 2,500 as"urban"; and all other places as "rural." Care should betaken to ascertain whether the actual environment of the subject previous toentering the Army was that of country or city life. Even though the post officeaddress given be that of a place with a population of over 2,500, if it appearsthat the soldier lived in the open country, the environment will be designatedas "rural."
ECONOMIC CONDITION
The economic condition of the soldier will be designated as"marginal" or "comfortable." "Marginal" includesthose who live on daily earnings but who have not accumulated enough tomaintain themselves without employment for four months. "Comfortable"includes those who have accumulated enough to maintain themselves withoutemployment for four months or more.
PREVIOUS OCCUPATION
Indicate in every case the kind of work done or character of servicerendered. State the occupation of the soldier, not that of his employer.
ARMY SERVICE
The rank and time of service in the various arms of the service will be givenaccurately. In case the soldier has rendered different kinds of service thefacts should be definitely stated.
ACCOMPANYING DISEASES
Every important disease present at the time of examination and not includedunder the heading "Diagnosis" will be specified.
WOUNDS IN ENGAGEMENTS, WITH DATES
"Wounds" include only injuries received in engagements. Specifypart of body injured and extent of injury.
INJURIES NOT RECEIVED IN ENGAGEMENTS, WITH DATES
Those include all injuries of importance received in the Army service notincluded under wounds. State whether injury resulted through accident or wasself-inflicted.
DISEASES DURING ARMY SERVICE
Important facts in the hospital record of the soldier will be given.
Venereal diseases contracted during Army service will be noted whethersubject entered the hospital or not.
DISEASES PREVIOUS TO ADMISSION TO ARMY
Care will be taken to report venereal disease, tuberculosis, or any diseaseor injury that would have bearing on soldier's present condition.
ALCOHOLIC HABITS
Report as "abstinent" those who do not use alcoholic liquors atall, as "intemperate" those who become intoxicated or show physical ormoral deterioration from the use of alcohol or who have committed unsocial actswhile under the influence of alcohol. All others who use liquors will be classedas "moderate." In case the habits of the subjects in respect toalcohol have changed, the fact will be stated.
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FAMILY HISTORY
Report separately the family history of the soldier inrespect to (a) mental diseases, (b) nervous diseases, (c) inebriety,and (d) mental deficiency.
OTHER ETIOLOGICAL FACTORS
Under this heading will be stated every specific cause of thesoldier's disease or condition not previously indicated. Indefinite ordoubtful factors will not be given. As causes of nervous and mental diseases areoften multiple, it is important that a full statement be given.
RECOMMENDATIONS OF EXAMINING OFFICER
Under this heading will be given the recommendations of the examiner relative to the treatment or disposition of the soldier.
DISPOSITION WITH DATES
State if the soldier is discharged from the Army or sent to acivil hospital or institution, or held for treatment in the camp hospital, or ifdeath ensues. In disciplinary cases, state action taken.
If the case is not disposed of at the end of the month whenthe statistical data cards are sent in, the final disposition of the case willbe reported by letter supplemental to the monthly report.
The records of the cases (Form 89) were of immediatepractical assistance to the medical officers on duty in the Office of theSurgeon General in rendering opinions on special cases which were constantlybeing referred for comment by The Adjutant General of the Army, by the Bureau ofWar Risk Insurance, and by Members of Congress. They further made it possiblefor The Adjutant General to furnish the States with information concerning thenervous and mental conditions of rejected recruits and discharged soldiers whorequired State care, an opportunity of which many States availed themselves. Inmost instances the information recorded on the special forms was more definiteand complete than that contained in the general medical records of the WarDepartment.
In addition to the medical and statistical importance of therecords, they enabled the division to keep in close contact with the work beingdone in the field, to arrive at conclusions, and to form opinions as to thequality and amount of work. The character of the reports and the promptness andmanner with which they were rendered, assisted the division in computing theratings which formed the basis of promotion for these officers. It seemed atfirst that these forms, which were supplemental to those which were stillrequired by the War Department, might be regarded as an additional burden andwould be made out unwillingly. Such, however, was not the case. The officersseldom complained of having to render Forms 89 and 90; on the contrary, manyexpressed satisfaction at thus being kept in professional touch with the centralagency particularly interested in their work. The special forms showed alsowhere the services of specialists were most needed. This was useful informationas the demand for services of this character always exceeded the supply.
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REFERENCES
(1) Correspondence. On file, Record Room, S. G. O., 169005 and 183231 (Old Files).
(2) Report to the Surgeon General, U. S. Army, April 12, 1917, by Pearce Bailey, M. D., Stewart Paton, M. D., and Thomas W.Salmon, M. D. On file, Historical Division, S. G. O.
(3) Report to the Surgeon General, U. S. Army, May 12, 1917, by Dr. Pearce Bailey, of visit to Ottawa, Canada, with reference to the management of mental cases among Canadian soldiers. On file, Historical Division, S. G. O.
(4) Report to the Surgeon General, U. S. Army, June 9, 1917, by Stewart Paton, M. D. On file, Historical Division, S. G. O.
(5) Report to the Surgeons General, U. S. Army, undated, by Dr. Thomas W. Salmon:
The Care and Treatment of Mental Diseases and War Neuroses (" Shell Shock ") in the British Army. On file, Historical Division, S. G. O.
(6) Letter from the Surgeon General, U. S. Army, to the National Committee for Mental Hygiene, June 11, 1917. Subject: Applications of psychiatrists for the Reserve Corps. On file, Record Room, S. G. O., 169003 (Old Files).
(7) S. O. No. 166, W. D., July 19, 1917, par. 137. Also: Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1079.
(8) Fifth indorsement, W. D., A. G. O., to the Surgeon General, U. S. Army, January 19, 1918. On file, Record Room, S. G. O., 702 (Psychological).
(9) Office Order No. 97, S. G. O., November 30, 1918. On file. RecordRoom, S. G. O., 024.17 (Section of Neuropsychiatry).
(10) Report of the work of the class in disciplinary psychiatry, at the U. S. Disciplinary Barracks, Fort Leavenworth, Kansas, to the SurgeonGeneral, U. S. Army, January and February, 1919. On file, Historical Division, S. G. O.
(11) Bulletin No. 4, War Department, February 7, 1918, Par. V.
(12) Memorandum from Brig. Gen. T. B. Lyster, M. C., to the Surgeon General, U. S. Army, August 28, 1918. Subject: Consultants. Approved by the Surgeon General. On file, Record Room, S. G. O. 211 (Consultants).
(13) S. O. No. 214, W. D., October 16, 1917, Par. 59, and S. O. No. 58, W. D., March 11, 1918, Par. 47, detailing Contract Surgeon Robert L. Richards to duty as consultant in neuropsychiatry.
