CHAPTER II
PERSONNEL
PROCUREMENT AND DISTRIBUTION; TRAINING
PROCUREMENT AND DISTRIBUTION
NEUROPSYCHIATRISTS
After the establishment of the division of neurology andpsychiatry the War Work Committee of the National Committee for Mental Hygienecontinued to forward applications of medical men with neurological andpsychiatric training for commissions as medical officers, but, as the warproceeded, the majority of such applications were passed upon directly in theSurgeon General's Office. Some neuropsychiatrists who were commissioned,without being exempted for neuropsychiatry, obtained special work in the fieldthrough their personal applications for transfer from other services; a few,too, requested transfer from neurology and psychiatry to other services. Atfirst many neurologists and psychiatrists hesitated about applying for acommission at all for fear they would be detailed to other duties than those forwhich they were specially qualified. They were given such assurances as werepossible under the circumstances, namely, that they would be used for work forwhich they were best fitted. It was only under exceptional circumstances thatthey were detailed to other activities. Some, as in other professional services,who showed ability in administration, were relieved of professional duties andassigned to administrative work.
At first great care was exercised in regard to thequalifications of physicians seeking commissions for the purpose of doingneuropsychiatric work and for transfer thereto. Estimates of qualifications werebased, in the first place, on clinical experience in civil life and, later, onthe recommendations of superior and commanding officers. When the demand forspecialists of this class became too great, especially from the AmericanExpeditionary Forces, the strictness in regard to qualifications was somewhatrelaxed, and the average in professional ability suffered a decline. It is nowbelieved that this relaxation in professional requirements was a mistake. Itwould have been wiser to have refused to accept for special service all who werenot sufficiently qualified professionally. At best, specialism is a difficultmatter to assimilate within a military organization. In mobile units it may bequite impossible to arrange it, and even in base and general hospitals itconstantly meets obstacles. Those who represent specialties, therefore, if theyare really to prove themselves as specialists, must be high-grade men in twoessential particulars: They must have a clinical familiarity with the classes ofpatients their specialty calls them to treat or to pass upon, and, in addition,they must possess traits in personality which render a man adaptable andself-reliant-traits which distinguish the
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capable medical officer quite independently of hisprofessional qualifications. In actual warfare the latter characteristics areindispensable and outweigh the others. If a man is a failure in eitherparticular he injures the general standing of specialists. It is believed,therefore, that the good of the service is better met by leaving the place of aspecialist vacant, even when one is urgently needed, than it is by assigning toit any but a well-qualified person.
In general, the officers serving in this division were eitherpsychiatrists or neurologists, although a few had been thoroughly educated inboth branches. The psychiatrists were much more numerous and were drawn chieflyfrom State hospitals. They were, as a rule, men of high moral standards, withexcellent experience and ideals in the care of the insane, and were skillfuladministrators. They were, perhaps, somewhat lacking in aggressiveness, and nonetoo familiar with general medical problems. It was a disadvantage, on the onehand, that men intrusted with so novel an experience as the widespreaddissemination of neurological and psychiatrical principles in the Army should belacking in the insistence which might lead to their early adoption. On the otherhand, the fact that psychiatrists reacted to the military situation as a body oftrained men rather than as individuals with a message, may have resulted in moregood in the end than if they had comported themselves as individual reformers.As has already been said, the military system, in its fundamental construction,is opposed to specialism, and it is well within the range of probability thatthe psychiatrists, by reason of their State hospital training, were of anadaptability which finally made psychiatry so welcome to the Medical Departmentof the Army. The neurologists were less homogeneous, as a class, than thepsychiatrists, coming nearer to the type of general practitioner. They were morefamiliar with the world, more aggressive than psychiatrists, and more familiarwith border-line types. Few of them were competent to take charge of the insane,although both neurologists and psychiatrists showed great aptitude in making up,during actual service, whatever defects may have existed in their professionaleducation.
At the time of the creation of the division of neurology andpsychiatry, about 50 neuropsychiatric officers had been commissioned.1Five months later, there were 235, of whom 16 were majors, 71 captains, and 148lieutenants.1 At the time the armistice wassigned, there were 430 officers in this country and 263 overseas, making a totalof 673.2 Of these there were 2 colonels, 2lieutenant colonels, 84 majors, 278 captains, and 307 lieutenants.3After the armistice was signed promotions were stopped for a time and whenresumed were given much less freely than previously.
The distribution of commissioned personnel was made, first,for the purpose of establishing neuropsychiatric examinations in the new Army,and, second, to supply neurologists and psychiatrists to base and other militaryhospitals, in accordance with the plan for detailing officers of the MedicalReserve Corps for duty as specialists in Army camps.4The assignments of these officers during the autumn of 1918 gives an indexto the work accomplished in the execution of this plan:3
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Assignment of neuropsychiatric officers,autumn of 1918
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aTraining.
bDuty.
c35 of this number were still in this country on that date.
Perhaps the most important piece of intensive work done bythe neuropsychiatrists in the early period of mobilization was in connectionwith the examination of candidate officers at the officers' training camps. Itwas not possible to send examiners to many of the first series of trainingcamps, which closed August 1, 1917, although excellent pioneer work was done atsome places. At the second series of camps, August 27, to November 26, 1917,valuable service was rendered by specially selected contract surgeons. Contractsurgeons were chosen for this service partly by reason of a shortage ofcompetent officers, but especially because the specialists selected were men ofmature judgment and long experience, and so better qualified to make successfulapproaches to the educated men who made up the class of student officers.
It was so important to eliminate unfit officers at the outsetof their military career that it is unfortunate that so many commissions weregranted-e. g., in the Quartermaster and Medical Corps-without subjecting thecandidate to the thorough and exhaustive examinations which, later, wereestablished at all the camps.
It was attempted to make examinations of the National Guardin the armories before they went to the camps, but this was successful in fewcases,a by reason of the great confusion which existed in allbranches of the service at that time. Examiners were sent later to allcantonments and recruit depots, to all base hospitals, to some generalhospitals, and to all disciplinary barracks.2
As soon as circumstances demanded, officers were detailed tothe ports of embarkation to make examinations of unexamined men orderedoverseas, or to bring before disability boards men recommended for discharge byneuropsychiatrists whose recommendations had not been acted upon.2
aIn the New England States and in the States of New York, New Jersey, Pennsylvania, Maryland, Virginia, North Carolina, and South Carolina.
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By December, 1917, it was realized in the office of the chief surgeon, A. E.F., that the number of troops then in France, many of whom had sailed before theneuropsychiatric examinations had begun, rendered imperative the services of adirector for nervous and mental diseases. Consequently a neuropsychiatrist wasordered overseas as a casual with recommendation that he be placed in charge ofthese matters-a recommendation which was complied with on his arrival.5After that, assignments for service with the American Expeditionary Forcesbecame increasingly frequent, being made to overseas base hospitals, evacuationhospitals, Base Hospital No. 117 (special hospital for war neuroses), and ascasuals and replacements.6 Someyounger officers were assigned to the liaison officer in London for the purposeof studying the methods of management of the war neuroses in the Englishmilitary hospitals.
DIVISION PSYCHIATRISTS
In January, 1918, on the recommendation of the division ofneurology and psychiatry, the War Department created the position of divisionpsychiatrist, with the rank of major,7 onefor each tactical division.
The creation of this position, which was the firstrecognition in the Army of the utility of specialists for troops in the field,proved of the utmost importance. These positions were filled as fast asdivisions were formed. The official detail of each of these officers was to oneof the field hospitals of the division concerned, but they were generally givendesks in the office of the division surgeons, from which points they couldoperate most effectively. Being with and a part of a tactical division, theywere able to exercise the preventive side of their specialty to the utmostadvantage. It was their duty to keep in touch with the mental health of thecommand and to familiarize medical officers serving with sanitary troops withthe methods of neurology and psychiatry. During the training period they wereavailable for all special examining boards. They directed the neuropsychiatricexaminations of their divisions, supervised the preparation of the specialreports to the Surgeon General, and saw to it that the recommendations of theneuropsychiatric examiners were promptly prepared for forwarding to generaldisability boards. They visited the regimental infirmaries and held informalconferences from time to time with regimental surgeons and company commanders.They were generally available for consultation and established a satisfactorycooperation with judge advocates, by means of which the mental state ofprisoners or of those accused was established as a factor in their delinquency.Reports of the functioning of these officers overseas indicate that theyassisted materially in maintaining the integrity of the commands to which theywere attached and expedited the elimination of the unfit.8Without them the prompt treatment of functional nervous disorders in thehospitals attached to the combat forces, which practically eliminated"shell-shock" as a military problem in our troops, would not have beenpossible.
The duties of the divisional psychiatrists were to be asfollows:9 (1) To examine or cause to beexamined all cases of mental and nervous diseases occurring in the command. (2)To be available for all special neuropsychiatric examining boards convened fromtime to time for the purpose of examining
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the command. (3) To ask for the assignment of regimentalsurgeons to assist in the neuropsychiatric examination of recruits; this latterlargely for the purpose of instruction of regimental surgeons. (4) To supervisethe making of all reports of examinations in the specialty and the forwarding ofthem to the Surgeon General. (5) To see to it that the recommendations ofneuropsychiatric examiners were promptly prepared for forwarding to generaldisability boards. (6) To hold from time to time brief informal conferences withregimental surgeons and company commanders in relation to the general subject ofmilitary neuropsychiatry. (7) In cantonments, to be available for consultationwith medical officers stationed at base hospitals. (8) To visit frequentlyregimental infirmaries and, whenever invited, the nervous and mental wards ofbase hospitals. (9) To cooperate with judge advocates for the purpose ofestablishing in every division a method of treatment of delinquents similar tothat in successful operation at the disciplinary barracks, Fort Leavenworth.(10) Consultation service in reference to service battalions should such servicebattalions be established in connection with depot brigades or base hospitals.(11) To cooperate with psychological examiners and, if practicable, to arrangefor psychiatric and psychological surveys of troops to take place at the sametime and place. Division surgeons were to assist in every way possible to theend that the division psychiatrist should have the necessary facilities forcarrying on his work, and especially in regard to desk room, stenographicassistance, and transportation.
CONTRACT SURGEONS
Contract surgeons were employed1from time to time and proved valuable, as by this means were secured themuch needed services of men of exceptional ability who were over age, or who,for other reasons, could not enter the military service for overseas duty.
FEMALE NURSES
Second in importance to the mobilization of neurologists andpsychiatrists was the recruiting of nursing personnel. The number of femalenurses in the country trained for the care of mental and nervous patients wasrelatively small, compared with the great number of such patients in public andprivate hospitals, in contrast to the proportion and number of nursesexperienced in general hospital care available for the physically sick. Everyeffort had to be made to conserve the supply of those experienced inneuropsychiatric work for the needs for the special wards and hospitals setaside for mental and nervous cases in the Army. To this end the Mental HygieneWar Work Committee secured the services of the superintendent of nurses ofBloomingdale Hospital, New York, who from the summer of 1917 until she assumedthe duties of chief nurse of Base Hospital No. 117,10the overseas hospital for war neuroses, devoted many months to the procurementof specially trained nurses for service with neuropsychiatric units in thiscountry and overseas. The need for such nurses proved to be very great, and theNational Committee for Mental Hygiene used all of its resources and contacts anddeveloped others to stimulate recruiting from civil hospitals for mental andnervous diseases. Working arrangements
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for the enrollment of neuropsychiatric nurses were made with theArmy Nurse Corps and the nursing service of the American Red Cross, throughwhich nurses for the psychiatric units were registered. Many of the nurses withthe special training were already enrolled in the Red Cross.
The same difficulty arose in regard to the psychiatric nursesas in regard to the psychiatric officers-proper assignment so that the fullbenefit of their special training and experience could be obtained, and that thepsychiatric nursing needs of the Medical Department of the Army could be met. Itwas obvious that the psychiatric needs would never be met and little ofimportance would be gained by commissioning psychiatrists and enrollingpsychiatric nurses if these officers and nurses were to be swallowed up, as itwere, in the administrative routine and assigned to duties for which they werelittle or not at all fitted, while others equally unfitted were assigned to workwhich only the psychiatric officers and nurses were prepared to do excellently.The problem was met so far as the medical officer was concerned, as previouslynoted, by the plan of exemption to specialized divisions which was early putinto effect in the Office of the Surgeon General.
This problem was more troublesome in the nursing service. Apsychiatric nurse may be of service upon any ward; a nurse, no matter howexcellent her general training may have been, is not only of little use but mayeven be a handicap to the work on a psychiatric ward unless she has hadpsychiatric nursing experience. Not only does she not understand, shemisunderstands, the problems about her, and creates more difficulty-with thebest of intentions-than she appeases. The importance of having available forthe psychiatric wards suitably trained nurses was realized and every effort wasmade not only to recruit these nurses but also to hold them available forpsychiatric work, especially in overseas units, but in home cantonments as well.Efforts were made to keep an exempted list both in the office of the Army NurseCorps and in the reserve list of the American Red Cross, but the plan did notwork well. The pressure for nurses upon both the Army Nurse Corps and theAmerican Red Cross was so great that it was frequently impossible, or seemed tobe, for either organization to adhere strictly to a policy of exemption as wasdone successfully with officer personnel.
MALE ATTENDANTS AND NURSES
Efforts were made to enlist male attendants and nurses trainedin the care of mental and nervous cases for service with the neuropsychiatricunits. These were secured, largely, from the personnel of State hospitals forthe insane. During the early period of hospital organization, the policy hadbeen followed of assigning to the psychiatric wards enlisted men of the MedicalDepartment regardless of their lack of experience in such work. Officers who hadcome from long experience in civil hospitals knew that this would not besatisfactory, but it was not until a number of quite unnecessary, seriousaccidents had occurred in various psychiatric wards that others were convincedthat trained psychiatric attendants were necessary. The number of trainedattendants in
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the country was distinctly limited, and it was necessary thatthose available to the Army should be conserved. It was known that many hadenlisted voluntarily and that hundreds had been called in the drafts. Some ofthese already were serving in the Medical Department, but on assignments notparticularly suited to their training. Others were in different branches of themilitary service. The problem was to locate these men, more particularly thosein the Medical Department, and to make possible their assignment to psychiatricduty. In this, as in the work of procuring officers and female nurses, theMental Hygiene War Work Committee cooperated with the Surgeon General.
The plan of inducting men into the service and assigning themimmediately to psychiatric duty worked well. Thus several hundred excellentlytrained men were obtained for service that was greatly needed and for which theywere specially equipped. The authority to deal directly with local draft boardswith the view of inducting men into special branches of the military service wasrescinded in June, 1918.11 That such a plancould be abused by individuals having themselves inducted into noncombatantservices for which they had no particular fitness is obvious, but such a planproperly safeguarded has the possibilities of great service to the Army. Withoutsuch a plan it would not have been possible for the division of neurology andpsychiatry to have assembled even a nucleus of trained attendants about which itcould build an attendant service out of untrained men supplied by the MedicalDepartment. As the number of trained men available to the division ofneuropsychiatry was far below the number needed, it was necessary to call uponthe Medical Department for the additional men required. These men were sent,when possible, to St. Elizabeths Hospital, Washington, for training, or to oneof the five large neuropsychiatric centers established by the division.
The State hospitals for mental diseases throughout thecountry cooperated whole-heartedly with the National Committee for MentalHygiene and the division of neurology and psychiatry in providing the Army withtrained attendants and nurses, as well as physicians. These hospitals seldom hadthe quota of physicians, nurses, and attendants they required, and when to theusual shortage was added the depletion due to personnel entering the Army thesituation in many hospitals became serious. There were few complaints, however.Toward the latter part of the war it became evident that few more could bespared from the attendant services without the situation becoming dangerous; itwas then suggested that trained attendants and male nurses, called in the draft,claim exemption under section 80; section 81, rule 16; section 88, rule 25;section 89, rule 26, of the Revised Selective Service Regulations.
PSYCHIATRIC AIDES
Special women assistants, termed psychiatric aides,12were employed, on civilian status, after a course of training at SmithCollege.
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TRAININGb
NEUROPSYCHIATRISTS
The shortage of competent neuropsychiatrists in the Armybrought to light marked defects in the educational opportunities in America forthis important specialty. As far as psychiatry is concerned, little provisionwas made in the United States before the World War for the proper instruction ofundergraduate students in medical schools. A few clinical lectures were given,but the students were not afforded opportunity for sufficient ward work forthese lectures to be of any great advantage to them. There were also fewprovisions for postgraduate instruction. As stated before, practically all thepsychiatrists of the country were employees of State hospital systems and hadreceived their education through routine performance of their duties. Theirexperience was largely confined to institutional patients, and they had hadlittle opportunity to observe the border-line cases, which constituted, afterall, one of the real problems of the Army. There were, however, a few importantcenters for psychiatric instruction, such as the State Psychopathic Hospital,Ann Arbor, Mich.; the Henry Phipps Psychiatric Clinic of the Johns HopkinsHospital, Baltimore, Md.; the Boston Psychopathic Hospital; the New York StatePsychiatric Institute; and St. Elizabeths Hospital (Government Hospital for theInsane), Washington, D. C.13 Thelast had been used as a center for the instruction of medical officers of theArmy and Navy.
In neurology educational conditions were no better.Practically the only clinical instruction given was on out-patients. Bedservices in connection with medical schools were practically unknown, fewhospitals had any beds set aside for neurological cases, and in few hospitalsdid neurological patients have any real representation.
The Neurological Institute, in New York City, received manystudents, but it had no amphitheater, and the teaching done there, while of highquality, was performed under the greatest difficulty.
The meager educational provisions for these two branchesresulted largely from the lack of acquaintance of the medical profession as awhole with the purposes and methods of neurology and psychiatry and its failureto perceive the clinical and economic importance of these specialties. Fewmedical men, apparently, realized that no clinician ever was great who did notcarry into his practice a good working knowledge of mental pathology; few couldestimate the wastage to be saved by taking it into account. At the beginningthis was true for the medical officers of the Army, but it is believed that theexperiences of the war made them more alive to these matters than are civilianphysicians.
The almost simultaneous opening of many cantonments in 1917created so great a press for neuropsychiatrists that it was rarely possible tosend them to officers' training camps for military training. A few wereordered to these camps, and some officers detailed at these camps who werediscovered to have had neuropsychiatric training were accepted forneuropsychiatric service; but most neuropsychiatrists acquired militaryknowledge by actual field duty.
It was often found desirable to provide additionalinstruction in the professional aspects of their work. It was not infrequent tofind an officer who
bFor a full discussion of Medical Department training, sec Vol. VII, Training.
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had had good neurological training but little psychiatrictraining, or one who had had good psychiatric training but not an adequatefoundation in neurology. It was desirable to round out the training of those menand to better equip others whose training in both fields had been limited. Seveninstitutions, distributed geographically, were asked by the Surgeon General toprovide suitable courses of instruction:13 NeurologicalInstitute, New York City; State Psychopathic Hospital, Ann Arbor, Mich.;Philadelphia General Hospital, Philadelphia, Pa.; Mendocino State Hospital,Talmage, Calif.; Henry Phipps Psychiatric Clinic, Baltimore, Md.; StatePsychopathic Hospital, Boston, Mass.; St. Elizabeths Hospital, Washington, D. C.All responded cordially. The directors of these institutions were commissionedor served under contract and were given the title of military director.1The military directors secured the collaboration of many other representativeteachers of the medical community, with the result that excellent specialneuropsychiatric instruction was provided.1
These courses were usually of six weeks' duration, althoughnot infrequently interrupted by the pressing need for neuropsychiatric officersin the field. Even when courses were not actually in progress there were usuallysome students left on special detail to profit by the usual clinical routine ofthe institution. The course of study included lectures, clinics, demonstrations,and laboratory work.1 The fields covered werepsychiatry, neurology, psychology, personality problems, serology,neuropathology, with collateral instruction in otology and ophthalmology. Inplanning the courses, the amount of time which the exigencies of the servicewould allow to be devoted to the subject was considered, and the rosters andschedules were prepared accordingly.
While it was realized that the instruction given in neurologyshould be and was largely clinical, it was deemed essential to give somedidactic and semididactic instruction in neuroanatomy, neurophysiology, andneurological medicine. The outlines were planned, therefore, to include alimited amount of this work.
Physiology of the nervous system, especially as concernscerebral, spinal, and peripheral localization, received particular attention,and an effort was made to follow clearly the outlines, physiological teaching bythe presentation of clinical cases illustrating the subjects taught. Organicneurology was taught by systematic demonstration of organic symptomatologyillustrated by cases which were made to cover a wide range in most of theschools. Many cases of tabes and other forms of sclerosis, syringomyelitis,organic hemiplegia, and other organic nervous diseases were demonstrated. Thedifferentiation of such conditions as hemorrhage, thrombosis and embolism andtheir separation from focal lesions, like tumors and abscesses, were amplyillustrated. Moving-picture demonstrations were used whenever possible.Instruction in syphilis of the nervous system and epilepsy were emphasized.Lectures on war neuroses were given. Pathology of the cerebrospinal fluid andneurohistology were thoroughly gone into. Electrodiagnosis andelectrotherapeutics were covered, including a description of the various formsof electrical apparatus. Close attention was given to those phases ofophthalmology which are associated with neurological work. Instruction in neuro-otologyincluded detailed instruction in the B?r?ny tests.
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The plan for the course of instruction in psychiatry wasbased on suggestions contained in Medical Department Circular No. 22, Office ofthe Surgeon General, Washington, D. C., dated August 1, 1917.cHowever, the instruction given was not confined to those suggestions, and fulladvantage was taken of the very large and varied amount of clinical materialavailable.14
As an illustration of the manner of execution of the plan ofinstruction the course given at the psychopathic hospital, Ann Arbor, Mich., isreproduced here in full:
THE COURSE IN NEUROPSYCHIATRY FOR MEDICALOFFICERS OF THE ARMY, CONDUCTED AT THE PSYCHOPATHIC HOSPITAL OF THE UNIVERSITYOF MICHIGAN
Soon after the organization of the War WorkCommittee of the National Committee for Mental Hygiene, plans were perfected forthe instruction of medical officers assigned to neuropsychiatric service in theArmy. It was planned that this instruction should be given at variousneurological and psychiatric hospitals which were adequately equipped forcarrying this through.
In accordance with this plan such a course wasorganized at the psychopathic hospital of the University of Michigan in thelatter part of July, 1917.
As the period of assignment of officers forinstruction would necessarily be brief, it was essential that the instructionshould be as intensive as possible and also be broad enough in scope to meet thepractical needs of a neuropsychiatric medical service. To this end instructionwas provided in those medical subjects that might form a background forneuropsychiatric training and would have a practical application in neuropsychiatric diagnosis and treatment.
The instruction was arranged to follow out adefinite weekly schedule which was planned to furnish a well rounded out courseto be completed in six weeks.
As officers were continually coming and going,owing to exigencies of the Army requirements, it was found impossible for eachman to follow a prescribed schedule closely. Some were in attendance for onlytwo weeks, while others remained longer than the six weeks' period.Repetitions of the course made it possible to meet these irregularities.
By the time the course was organized it wasknown from the medical experiences of the war what special training was needed,and the course was shaped to meet these requirements.
The following schedule shows the arrangementof the instruction:
9-10 | 10-11 | 11-12 | 1.30-2 | 2-3 | 3-4 | 4-5 | 5-6 | |
Monday | Doctor Camp Clinical neurology | Doctor Barrett Psychiatric clinic | ||||||
Tuesday | Doctor Barrett Psychiatric conference | Clinical psychiatry Hospital staff conference | Doctor Barrett and Doctor Gurd Neuralpathology | |||||
Wednesday | Doctor Slocum Neurological disorders of the eye | Doctor Barrett and Doctor Gurd Neuralpathology | Doctor Camp Neurological clinic | |||||
Thursday | Doctor Jones Psychometric tests | Doctor Barrett Psychiatric conference | Doctor Barrett and Doctor Gurd Neuralpathology | |||||
Friday | Doctor Camp Clinical neurology | Doctor Barrett Psychiatric conference | Doctor Barrett and Doctor Gurd Neuralpathology | |||||
Saturday | Doctor Furstenberg Neurological disorders of the ear | |||||||
cThis circular is quoted in full in Chap.IV.
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The detailed instruction as given in the various divisions of the course wasas follows:
PSYCHIATRY
Psychiatric instruction was given at the psychopathic hospital by DoctorBarrett and the medical staff of the hospital, Dr. Earl Palmer, Dr. B. L. Jones,Dr. Raymond F. Wafer, and Dr. James Stanton. The following subjects werecovered:
1. General survey of the problems of mental disorders in their militaryrelations. Two hours.
2. Discussion of the organization for neuropsychiatric work; of the schemesand methods for diagnosis and recording of data. Two hours.
3. General psychopathology. Didactic lectures, with clinical demonstrations.Ten hours.
4. The functional mental disorders of the present war. Survey of theexperiences published in the German, French, and British literature. Four hours.
5. Shell shock and the psychoneuroses. Two hours.
6. Psychoneuroses; neurasthenia; anxiety neuroses; hysteria; compulsionneuroses. Didactic lecture and clinical demonstrations. Four hours.
7. Manic-depressive insanity. Didactic lecture and clinical demonstrations.Two hours.
8. Dementia pr?cox. Didactic lecture and clinical demonstrations. Fourhours.
9. Syphilitic mental disorders. Didactic lecture, clinical and anatomicaldemonstrations. Four hours.
10. Epileptic mental disorders. Didactic lecture and clinical demonstrations.Two hours.
11. Psychopathic personalities. Didactic lecture and clinical demonstrations.Four hours.
12. States of mental defectiveness. Two hours.
13. Feeble-mindedness and mental subnormalities. Didactic lecture andclinical and anatomical demonstrations. Two hours.
14. Psychometric tests. Didactic lecture and practical work in makingexaminations of defectives and delinquents. Six hours.
15. Mental disorders of organic brain diseases. Arterio-sclerotic mentaldisorders; mental disorders with tumors of the brain and brain injury. Didacticlecture and clinical demonstrations. Two hours.
16. Serological diagnostic demonstrations. Technique and interpretation. Twohours.
17. Attendance at the psychiatric clinic in the medical school at theuniversity. One and one-half hours each week.
18. Practical work in study of cases and preparation of histories on thewards of the hospital.
NEURALPATHOLOGY
A systematic course in the pathological anatomy of mental and nervousdisorders was given by Doctor Barrett and Dr. Adeline Gurd, pathologist at thepsychopathic hospital. This course covered 14 periods of two hours each. Theschedule followed in this course was as follows:
1. Embryological development of the central nervous system. Surfacetopography of the brain.
2. Study of gross fiber arrangements, and ganglia of brain.
3. Histology of the nerve cell, nerve fiber, neuroglia and corticalarchitecture.
4. Histoloy of the spinal cord.
5. Neuronic arrangements of the nervous system. Fiber paths.
6. Localization of nervous function. Correlation of structure and function.Diaschisis. Theoretical consideration of aphasia and apraxia.
7. General pathology of the nervous system. Malformations. Diseases of themembranes of the nervous system. Pathological changes in nerve cells.Pathological changes in nerve fibers. Secondary degeneration.
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8. Inflammation, repair, and reactive processes in the nervous system.
9. Syphilis of the nervous system. Gummatous formations. Meningitis. Vascularlesions. Histological process of general paralysis.
10. Circulatory disorders of the nervous system. Arteriosclerosis.Haemorrhagic softening.
11. Tumors of the nervous system.
12. Pathology of the spinal cord. Myelitis. Poliomyelitis. Progressivemuscular atrophy. Amyotrophic lateral sclerosis.
13. Tabes. Friedreich's ataxia.
14. Pernicious anemia. Multiple sclerosis. Syringomyelia.Hydromyelia. Peripheral neuritis.
NEUROLOGY
The instruction in neurology was given by Dr. Carl D. Camp, associateprofessor of nervous diseases in the University of Michigan Medical School, inthe neurologic wards of the general hospital.
The course in neurology was divided into three parts:
A. A lecture course designed to cover the subjects systematically.
B. Clinical demonstrations in which the officer was assigned to a case andallowed one hour to examine, his examination and conclusion being criticizedby the instructor before the whole section, and free discussion was encouraged.
C. A series of formal clinics in neurology, the same as given to the seniormedical students in the University of Michigan, with special emphasis on themilitary aspects of the cases under discussion.
OPHTHALMOLOGY
Instruction in this subject was given by Dr. GeorgeSlocum, instructor ofophthalmology in the Medical School of the University of Michigan. Thesubjects covered were as follows:
A
1. A review of the anatomy of the eye as an opticalinstrument.
2. Physiology of the accommodation and physiologic optics.
3. Anatomy and nerve supply and physiology of the eye muscles, withbinocular vision and fusion, and including the deep origin, relation, and courseof the third, fourth, and sixth nerves.
4. Muscular anomalies such as manifest and latent spastic strabismus,including heterophoria.
5. Diplopia and extraocular paralysis and nystagmus.
6. Nerve supply and physiology of the pupillary reflexes includingmiosis, mydriasis, hippus, and Argyle-Robertson pupil.
7. Anatomy and physiology of the retina, optic nerve, chiasm, primary visualganglia, optic tracts and cortical visual centers.
8. Mechanism of production of choked disc and significance.
The foregoing subjects were taught with the aid of drawings, specimens, andanatomical models.
B
1. Diagnosis of optic neuroses and malingering.
2. The eye manifestations of wounds of the motor and sensory nerve oftheeye and of the optic nerve, tracts, radiations, and centers.
3. Visual fields and hemiopia.
4. Eye symptoms produced by intracranial lesions with particular reference totrauma.
5. Eye symptoms of brain tumor, meningitis, multiple sclerosis, myelitis,locomotor ataxia, superior polioencephalitis, general paralysis, exophthalmicgoiter, including the various signs associated with exophthalmic goiter, chorea,migraine, and herpes zoster of the eye.
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OPHTHALMOSCOPY
1. Direct and indirect methods, including examination of theocular media with the ophthalmoscope.
2. Ophthalmoscopic appearance of the fundus and the diagnosisof syphilitic, albuminuric, diabetic, leukemic lesions of the fundus and otherlesions of the fundus dependent upon general diseases.
3. Differential diagnosis of ocular lesions of thechoroid, retina, and the optic nerve with especial reference to theirdifferentiation from those lesions associated with general diseases.
4. Ophthalmoscopic appearance and diagnosis of glaucoma.
Throughout the whole course from one-third to one-half of thetime was devoted to the study of cases with the ophthalmoscope withdemonstration of the ophthalmic changes peculiar to ocular and general diseases,with especial reference to their practical differentiation.
OTOLOGY
A course of lectures and demonstrations of disorders of theear in their neurological relations was given by Dr. Carl Furstenberg,instructor of otolaryngology in the medical school. These were given once eachweek for two hours. The subjects covered were:
1. Functional examination of the internal ear. Disordersof the cochlear portion of the eighth nerve. Vestibular nystagmus.
2. Tests for detecting simulation of deafness.
3. Diseases of the internal ear. M?ni?re's disease.Arteriosclerosis of the internal ear. Injuries to the internal ear. Syphilis ofthe internal ear. Hysterical deafness. Occupational deafness.
SEROLOGY
This course was given by Dr. Sobei Ide, serologist to thehospital, and included:
1. Technique of lumbar puncture.
2. Clinical diagnosis of the pathology of thecerebrospinal fluid, Wassermann and gold solution tests.
There were assigned to the Ann Arbor course 78 medicalofficers. In general it seemed that the plan followed worked out quitesatisfactorily. The chief difficulty encountered was the marked difference inknowledge and neuropsychiatric experience for such special training in thoseassigned to the course. While a considerable number had been actively engaged atsome previous time in neuropsychiatric practice, others hadno more qualifications for this special training than those of the generalpractitioner. There was, however, an earnest interest shown by all in attendanceand the comments made later by those who had been in active service definitelyshowed that the plan followed was of great value.
The student officers ordered to the neuropsychiatric schoolswere on duty status. Between two and three hundred were given this opportunityof acquiring or perfecting neuropsychiatric knowledge.14
ENLISTED PERSONNEL
The enlisted personnel for the care of nervous and mentalcases were made up, as stated, as far as possible from attendants who had hadexperience in State hospitals. They were assigned to the division of neurologyand psychiatry, in some cases by orders, when already enlisted, and in others,by induction into the service, and were sent first, as far as possible, to atraining camp.
The shortage of enlisted men experienced in the ward care ofmental cases, due in part to the exigencies of the selective service draft,which diverted many such men to other branches of the service, and also to thepressing need for attendants in civilian hospitals for the insane, produced asituation which could
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be met only by the utilization of enlisted men of the MedicalDepartment who were not trained in neuropsychiatric work, and in many cases werewithout hospital experience of any kind. Whenever possible, these men were sentto various centers for a period of training before assignment to duty inneuropsychiatric services.
Conditional to some extent upon the varying supply of specialand general hospital personnel, immediate nursing needs, and uncertain timequantities, the training courses gave the attendant an idea of what was expectedof him in later service and added new things to his stock in trade. They alsoallowed a report upon each individual's personality and training to go in tothe Surgeon General's Office; on the basis of these reports, groups wereselected to man other neuropsychiatric services at home or abroad-groups whichhad their preliminary adjustment and which could be fitted out withnoncommissioned officers who knew them.
PSYCHIATRIC AIDES
The advisability of placing specially trained psychiatricsocial workers in military hospitals for soldiers suffering from mental andnervous diseases was considered informally, shortly after the outbreak of thewar, by the Surgeon General and the National Committee for Mental Hygiene. Manyneuropsychiatrists and social workers, who had followed the progress of themental hygiene movement in this country, had watched with interest the rapidlychanging events in the evolution of the comparatively new field of social psychiatry, and especially the work accomplished by social workers at theneurological and psychiatric clinics of general hospitals and at institutionsfor nervous and mental diseases. It was realized that in a few years a new groupof social workers had developed who served ably as assistants toneuropsychiatrists in the various phases of their work. They secured personaland family histories from the patients, relatives, and others, which proved ofconsiderable value to the physicians in the diagnosis of difficult mentalconditions; and their personal work in assisting the patients in the adjustmentof their social difficulties supplemented the therapeutic treatment of thephysicians and thereby achieved more effective results. Their services wereappreciated by the administrative departments of the hospitals which formerlyhad been called upon to perform duties of an essentially social-servicecharacter. It was believed, therefore, that there would be as great a need forthe service of these workers in the military hospitals as in the civilianhospitals, and that psychiatric social workers could be used as aides to thepsychiatrists, to relieve them of duties which could be effectively dealt withby individuals, not physicians, trained along the lines of social psychiatry.The work was still in the experimental stage of its development at the time ofour entrance into the war, but the increasing demand, by neuropsychiatrists,hospital executives, and State welfare departments, for social workersexperienced in dealing with nervous and mental cases showed that these workerswere making a definite contribution in this field of medicine, and were findinga permanent place in the hospital r?gime.
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It was decided, therefore, to arrange for the appointment of a number ofpsychiatric social workers (psychiatric aides) to be placed in reconstructionhospitals under the jurisdiction of the division of neurology and psychiatry ofthe Surgeon General's Office.12 Unfortunately the pressure ofwork in the Surgeon General's Office at this time (1917) prevented animmediate decision regarding the matter, and not until the early spring of 1918was the subject taken under official consideration.
In the meantime, in order to prepare for the increasing need for such workersin anticipation of the early return of mental and nervous cases from France,and to be ready for the work of rehabilitation and readjustment, plans wereformulated for courses of training in psychiatric social work. For several yearsbefore the war there had been a demand for psychiatric social workers that couldby no means be met. Yet no training courses existed, except an apprenticetraining given by the social service of the Boston Psychopathic Hospital to halfa dozen students at a time. The director of this hospitald and the chief ofits social service, believing that soldiers suffering from war neuroses wouldrequire the same treatment as civilian patients, planned to give an emergencytraining course at the hospital. A large number of students could be admitted bythe use of other institutions for practice work. The permanent charity fund ofBoston contributed a sum of money to make the course possible. By chance it waslearned that Smith College wished to use its equipment during the summer forsome educational war work, and was already considering a course for some typeof mental hygiene worker. At the same time the National Committee for MentalHygiene, facing the problem involved in the rehabilitation of returned soldierssuffering from nervous and mental disorders, was convinced of the need oftraining lay workers to assist physicians in the care of neuropsychiatriccases, and a committee was appointed to consider the matter.
A combination with the Boston group was effected, by which the trainingcourse for psychiatric social workers was given by Smith College under theauspices of a committee of psychiatrists appointed by the National Committee forMental Hygiene, with the director of the Boston Psychopathic Hospital aschairman.15
Thus was the first course for the training of psychiatric social workersestablished in this country. Within a month 63 students assembled at SmithCollege to take the course. They represented 21 States and 20 colleges.Thirty-eight previously had been engaged in other occupations, 12 as teachers,16 as social workers, 3 as librarians, 3 as secretaries, and 4 in miscellaneousforms of work. The students for training were distributed among four cities,Baltimore, Philadelphia, New York, and Boston, for six months of practical casework. The term of practice work was made as short as possible because thegraduates would be needed in the military hospitals even before they were ready.
The object of the course was to prepare social workers to perform threefunctions, if necessary, or any one of the three that might be required: (1) Tosecure the social history essential to medical diagnosis by interviews orcorrespondence with informants, or by interviewing patients; (2) to assist thephysician in psychotherapy by such means as encouragement, explanation,reeducation;
dThe late Dr. Elmer E. Southard.
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(3) to promote the social adjustment of patients upondischarge. The technique of social case work, taught by lecture and practice,was the basis of the course. It was recognized that an eight months' course ina subject dealing with something so complex as human personality must be verysuperficial at best. But the aim was to drill the student in the fundamentalhabits of mind required for future development in her work, a professionalattitude, adaptability, the habit of observation, and the psychiatric point ofview.
The graduates of this first course for the most part carriedout their purpose, working in military hospitals until these hospitals weretaken over by the United States Public Health Service, when they continued inthem under the American Red Cross. Some of them took up work in State hospitals,in social agencies, and in mental hygiene societies.
REFERENCES
(1) Semiannual report, Division of Neurology and Psychiatry, S. G. O., January 2, 1918. On file, Record Room, S. G. O., Weekly Report File.
(2) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1080-83.
(3) Personnel Files, Personnel Division, S. G. O.
(4) Circular Memorandum, from the Surgeon General, U. S. Army (on recognition of sections representing specialists), October -, 1917.
(5) Confidential Order No. 128, W. D., November 22, 1917, detailing Major Thomas W. Salmon, M. R. C., to duty overseas. On file, Personnel Division, S. G. O. (Personal Report File).
(6) Report of the consultant in psychiatry to the chief surgeon, A. E. F., by Col. Thomas W. Salmon, M. C., undated. On file, Historical Division, S. G. O.
(7) Letter from The Adjutant General to the Surgeon General, U. S. Army, January 12, 1918. Subject: Assignment of neurologists to tactical divisions. On file, Record Room, S. G. O., 210.3 (Assignment).
(8) Annual Report of the Surgeon General, U. S. Army, 1918, 372.
(9) Circular letter to division surgeons from the Surgeon General, January 25, 1918. Subject: The duties of the divisional psychiatrists.
(10) Letter from Frankwood E. Williams, National Committee for Mental Hygiene, to Miss Dora E. Thompson, Supt., Army Nurse Corps, July 25, 1917. Subject: Miss Adelle S. Posten. Copy on file, Historical Division, S. G. O.
(11) G. O. No. 58, W. D., June 22, 1918.
(12) Assignment of psychiatric aides. On file, Record Room, S. G. O., 231 (Reconstruction Aides).
(13) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1079.
(14) Semiannual report, Division of Neurology and Psychiatry, January 2, 1918. On file, Record Room, S. G. O. Also: Correspondence. On file, Record Room, S. G. O., 353 (Training Neuropsychiatrists) (Boston, Mass., New York City, N. Y., Philadelphia, Pa., Baltimore, Md., Washington, D. C., Ann Arbor, Mich., Talmage, Calif. (F).)
(15) Release to the press, June 4, 1918, concerning War Emergency Training School for Workers to assist Soldiers with Nervous and Mental Diseases, by Frankwood E. Williams, M. D., Associate Medical Director, the National Committee for Mental Hygiene. On file, Historical Division, S. G. O.
