CHAPTER III
PROVISIONS FOR CARE OF MENTAL AND NERVOUS CASES
With an army as small and as scattered as ours was before theWorld War, it was difficult to make proper provisions for the care of theinsane. The actual number of cases requiring prolonged treatment at the hands ofthe Government was not large, not exceeding 200 annually.1These cases occurred at widely separated points. Native soldiers in our islandpossessions who became insane were cared for in local institutions, but forothers the only hospital facilities provided were at St. Elizabeths Hospital inWashington, D. C. In the United States the only wards maintained at all for theinsane in the military service, with the exception of a few beds in the basementof Walter Reed General Hospital, were 50 beds in a building, which also heldprisoners, at the Letterman General Hospital, San Francisco,2and in these 50 beds were collected cases from the Western Department, andespecially from the Philippines.
The ultimate destination of all cases in which recovery wasnot prompt was St. Elizabeths,3 and during thelong interval which was required for commanding officers to obtain the necessaryauthority for transfer, the patients were kept in such quarters as wereavailable at the place of their mental breakdown. Some, as long as they could beregarded as harmless, were retained in the wards of the local hospital, but morefrequently they were lodged in prison wards. In certain places portable steelcages were utilized for patients regarded as particularly dangerous. Thepractical result of this whole system was that weeks, sometimes months, elapsedbefore efficacious treatment could be employed.
The great increase of the military forces for the World Warrequired a corresponding enlargement of the provisions for the care of theinsane. The larger Army demanded many receiving hospitals, or wards, speediermethods of disposal of cases which were not a legitimate charge on the FederalGovernment, and the establishment of rational and prompt means of treatment forthe patients whom the Army would be called upon to maintain. Such a programrequired changes in the methods of military hospitalization, in respect ofadmissions to civil hospitals, and in those Army regulations which controlledthe evacuation and final disposal of the insane.
IN BASE HOSPITALS
NEUROPSYCHIATRIC WARDS
During the World War, provision was made for neuropsychiatricwards in all camp, cantonment, and department base hospitals. The first plansdrawn by the War Department for a building for nervous and mental patients werelabeled "Isolation-insane."4 Later,wards in which these patients were cared for were officially designated"Psychiatric wards."a The transition from one to theother was more than a mere change in names.
aSee Vol. V p. 69, for plans of this ward.
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"Isolation-insane" was all the term implies inmisunderstanding and professional discouragement and indifference."Psychiatric ward," on the other hand, approximated, at least, and insome places largely attained, what the term implies in hospitalization-understandingand professional hope and activity. The "isolation-insane" buildingwas a long rectangular building with windows and doors heavily barred on theoutside and heavily screened on the inside, the interior broken into smallcell-like structures stoutly maintained.5 Thepsychiatric wards, as will be more fully described later, were open, bright,airy wards, in some hospitals, without bars or mesh of any kind. The"isolation-insane" building was built in connection with the basehospital in a few of the early cantonments.6The psychiatric ward was built in the majority of the cantonments, andthese early wards represent the first step in the transition that took place inthe Army. It was considered that each cantonment would need a special ward fornervous and mental patients, and plans designed by the National Committee forMental Hygiene for psychiatric units of 30 beds were adopted for the cantonmentbase hospitals.7
The following equipment was proposed and approved for theseunits:7
Electrical: 1 No. 7 galvanic, Faradic, and sinusoidal wall cabinet, oak or mahogany, with meter, for direct current, 35 inches high, 22 inches wide, 11? inches deep, with the following accessories:
1 motor generator set, ? ampere, 110 volts, for operating wall cabinet on alternating current. | Hydrotherapeutic: 1 combination douche apparatus, No. P-2281, without steam connection. |
| Psychological: 1 steel tape. | |
| Diagnostic: 2 reflex hammers. | Miscellaneous: 1 salvarsan administration outfit. |
This new ward was so arranged as to care for any type ofpatient that might be admitted-one portion, for the much disturbed, equippedwith continuous baths, one for the semidisturbed, and another for theconvalescent or quiet patients. Each portion was separated from the others;small dormitories were provided in each with rooms for individual patients inthe disturbed section. It was intended that a medium iron-wire mesh should beused on the windows of these wards and not bars; through an inadvertence,however, some of the early building plans issued by the War Department calledfor bars.4 The situation of the local psychiatric officers withproper ideas as to physical standards was thereby made more difficult and inconsequence the physical standards of the wards varied, depending upon thestandards of the local officer himself, and his ability to convince hiscommanding officer that hospitals and not jails were being built. For alieutenant or captain new to military service to convince a commanding officerof the "isolation-insane" school was no small task. But many of themsucceeded. There were to be found, therefore, wards heavily barred, wards withbars confined to that part of the building used for disturbed patients, withmesh for the rest of the ward, wards with mesh for the disturbed portion andneither bars nor mesh for the part used by convalescent patients.
While the physical standards of the wards varied from camp tocamp, there existed almost throughout a uniformly high standard of care andtreatment. Although some of the wards appeared more like jails than hospitals onthe outside, they were hospitals in fact on the inside.
The neuropsychiatric wards of the base hospital served auseful purpose. During the early days of the World War, they were used chieflyfor the examination and observation of recruits referred by the divisionpsychiatrist. Later, they served the mental health needs of the various commandsoccupying the camps at different times. Since it was the understanding from thebeginning that the insane would be discharged from the Army as quickly aspossible, the neuropsychiatric wards were intended for temporary care only.Quite frequently; however, it was found that patients had to be retained in thewards
42
for a considerable length of time, due to various unforeseencircumstances. These wards made expert care and treatment immediately availableto any soldier becoming ill in the camp. With no more formality than obtained inentrance to the medical or surgical wards, patients could be brought to the wardespecially provided for them. Patients who developed nervous or mental symptomsin other wards were transferred without formality to the special wards. Soldierswho, because of a nervous or mental condition, ran counter to the military lawsand arrived at the guardhouse were transferred to the special wards. Generalprisoners, about whose mental condition there was question, were sent to thewards for observation. Recruits found unfit for military service because ofmental disease and awaiting discharge were cared for in the neuropsychiatricwards until such time as proper arrangements could be made for their returnhome. Up to the time of the beginning of the armistice, the neuropsychiatricwards of the base hospitals cared for about 28,000 patients.8
IN GENERAL HOSPITALS
The neuropsychiatric wards of the general hospitals of theArmy were established in order to relieve congestion in the neuropsychiatricwards of the base hospitals. It had been thought that the neuropsychiatric wardsof the base hospitals would be adequate to care for all cases of nervous ormental disease arising in the camps. It was soon found, however, that the rateof admission was such and the delays incident to transfer and discharge so greatthat further provision would be necessary. It was difficult to maintain anadequate personnel with the requisite experience at so many small units. It wasdecided, therefore, to use the base hospital wards as clearing houses and for emergency treatment only and to establish additional neuropsychiatric centersconvenient to the centers of military population to which patients could betransferred for longer periods of treatment.
Two methods for providing these additional facilities wereconsidered: (1) The establishment of special neuropsychiatric hospitals;(2) the establishment of neuropsychiatric wards in connection with the Armygeneral hospitals. Both plans obviously had advantages and disadvantages. Itwould have been easier, no doubt, to staff special hospitals moresatisfactorily, as there needed to be assigned to them only officers withneuropsychiatric training. This would have reduced the friction andmisunderstanding likely to arise when superior officers were unfamiliar with theprofessional problems of their juniors. A greater freedom, probably, might havebeen permitted patients; closer supervision and direction to the immediate needsof the patients might have been had of the local machinery of reconstruction. Onthe other hand, had special hospitals alone been provided, professionalisolation would have been increased and emphasized.
The greatest obstacle to neuropsychiatry in both civil andmilitary practice has been the barrier that tends to separate nervous and mentaldiseases from all other diseases, and it was thought by some that, in so far asthe Military Establishment was concerned, the greatest good, both to thepractice of neuropsychiatry and to the patients who were dependent upon it,would be accom-
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plished if a determined effort were made to break throughthis barrier and to place the mental patient on a par with patientsincapacitated by reason of other diseases. Not until commanding officers andothers in authority realized that their responsibilities for the medical, thesurgical, and the mental cases were the same was it considered possible toaccomplish those things of which the well-trained neuropsychiatric officer iscapable. It was thought that the establishment of neuropsychiatric wards in thegeneral hospitals would emphasize this responsibility.
Such a course, however, was not without its dangers. As apart of a general hospital the neuropsychiatric ward is a section under internalmedicine, and the chief of the medical service has supervision over theneuropsychiatric ward. The success of the ward, therefore, is in part dependentupon the attitude of this officer and the ability of the chief of theneuropsychiatric section to cope with the double opposition that might be met inthis officer and the commanding officer. As a matter of fact, this plan ofhospital organization was a hindrance, in some instances, to the proper conductof the neuropsychiatric work. On the whole, however, it did not cause thedifficulty that might have been expected. In most hospitals the chief of themedical service assumed but a nominal oversight of the neuropsychiatric wardsand placed full responsibility in the hands of the chief of the neuropsychiatricsection.
It is interesting to record, in this connection, that theofficer frequently quickest to appreciate the service of the neuropsychiatricofficer and to give him heartiest support was the line officer. Officers of theMedical Department of the Regular Army also, in most instances, gave theirsupport. The officers with whom the neuropsychiatrists had most frequentdifficulties were the officers of the Medical Reserve Corps, commissioned fromthe civil medical profession. The significance of this observation lay in thesidelight it threw upon the teaching of neuropsychiatry in the American medicalschools. The line officer frequently was faced with problems in personality andconduct that frankly he did not understand. He turned gladly, therefore, to theneuropsychiatric officer when he found that that officer could be of assistanceto him. The officers of the Medical Department of the Regular Army for a numberof years have been given a systematic course in neuropsychiatry. The largerknowledge manifested itself in a quicker understanding and appreciation of theproblems of the neuropsychiatrists. The greater number of the officers in theMedical Reserve Corps, however, had had practically no instruction inneuropsychiatry. In most instances their school instruction had consisted of afew lectures, together with a visit to a neighboring institution, where a fewstriking and bizarre cases of chronic mental disease had been demonstrated tothem. Their experience in practice largely had been limited to the sterile formsof legal commitment. Many medical officers, however, were as frank as lineofficers in admitting their lack of understanding of nervous and mental patientsand spent many hours, when possible, in the wards studying patients in anearnest effort to inform themselves upon a subject in which they found a growinginterest, and a subject of increasing value to them. Aside from the fact thatthe establishment of neuropsychiatric wards in the general hospital would be animportant step in breaking down the barrier that tends to isolate mentalpatients, and that through the presence of these wards the medical officer wouldcome
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to a better understanding of the mental patient, thestandards, methods of treatment, and possibilities of the modernneuropsychiatric clinic, it was realized that expert care would be available forpatients on other wards who were showing nervous and mental symptoms, and that,on the other hand, expert consultation in other fields would be available to theneuropsychiatrists.
The plan adopted, therefore, was that of special wards in thegeneral hospitals, and five general hospitals suitably situated geographicallywere selected for the purpose:9 The Walter Reed General Hospital, Washington,D. C.; United States Army General Hospital No. 6, FortMcPherson, Ga.; United States Army Base Hospital, Fort Sam Houston, Tex.; UnitedStates Army General Hospital No. 26, Fort Des Moines, Iowa; and the LettermanGeneral Hospital, San Francisco, Calif. United States Army General Hospital No.4, Fort Porter, N. Y., was a special psychiatric hospital opened especially formental patients returning from overseas, although it received also, at times,patients from neighboring camps.9 United States Army General HospitalNo. 13, Dansville, N. Y., and United States Army General Hospital No. 34, EastNorfolk, Mass., were also neuropsychiatric hospitals, but for overseas patients,as were the special wards at United States Army General Hospital No. 1,Williamsbridge, N. Y. United States Army Hospital No. 30, Plattsburg, N. Y., was established for nervous patientsfrom overseas, although some patients were transferred there from Americancamps.9
Later, with the more rapid return of patients from overseas,further neuropsychiatric centers were opened in connection with United StatesArmy General Hospital No. 25, Fort Benjamin Harrison, Ind., and United StatesArmy General Hospital No. 28, Fort Sheridan, Ill.9 There was also a singleneuropsychiatric ward at United States Army General Hospital No. 2, FortMcHenry, Baltimore, Md.9 The original wards, however, and thosedesigned to serve as a reservoir for the neuropsychiatric wards of the camp basehospitals, were those at Walter Reed, Fort McPherson, Fort Sam Houston, Fort DesMoines, and the Letterman General Hospital.
Patients, whether officers or enlisted men, who presentedsymptoms of mental disease were transferred to these centers for care andtreatment in the same manner as other patients. Such transfers were effected asfollows: The patient whose symptoms were considered as requiring specialobservation and treatment was ordered for that purpose to the hospitaldesignated. The orders were obtained from The Adjutant General through theSurgeon General, having been first initiated by the commanding officer at thepoint from which the patient was removed. Thus the patient, whether officer orprivate, with mental symptoms, was transferred not as an insane person, but asany other patient. Except in violent or essentially incurable cases the patientswere retained in these centers for a period of time not to exceed four months.bFor the purpose of preventing the reenlistment of soldiers who hadsuffered from psychoses, it was recommended to the commanding officers of theneuropsychiatric centers to which mental cases were transferred that the fact benoted on the discharge form.
bBy these means, the Army regulations concerning thedisposition of the insane were not resorted to until a reasonable time ofobservation had elapsed. This subject is discussed further in Chap. VII.
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By relieving base hospitals of mental cases in this manner,congestion in the general medical services was lessened and a higher standard ofcare, with a proportionate increase in the ratio and speed of recoveries, wasobtained. There was effected an economy of personnel, for even if it had beenpossible to supply base hospitals generally with a sufficient number ofpsychiatrists to treat mental cases, it would have been extravagant in theextreme. With the speedy evacuation of all cases presenting mental symptoms, itwas possible for the neuropsychiatric work in a base hospital to be performed byone energetic and competent medical officer. As things turned out thisarrangement was imperative, for, with the limited number of neuropsychiatristsavailable, the need of these officers at other points in the medical service didnot permit the detail usually of more than one at a base hospital.
The suddenness of the armistice brought about a great changein many of the arrangements which had been made for the treatment of nervouscases. Except for a geographical rearrangement of hospitals with reference tothe homes of patients, there was no change in the plan of care for mental cases.It was found, however, as will be discussed in greater detail in the followingpages, that war neuroses had ceased to exist as a problem, in that the number ofcases from the American Expeditionary Forces dwindled, and those under treatmentin this country made rapid recoveries. The cases which appeared in the homecamps were less influenced by the change in the military situation. AtPlattsburg Barracks, N. Y., where a special hospital was established for warneuroses, cases were put back on duty status faster than they were received, andconsequently plans for another hospital of 1,000 beds at Carlisle Barracks, Pa.,were abandoned.
The practical end of the war brought into prominence theadvisability, imperfectly realized before, of sending patients who were toundergo continued treatment to hospitals in the immediate vicinity of theirhomes. This required a rearrangement of hospital facilities for neuropsychiatriccases, especially with regard to the cases of epilepsy, and injuries of theperipheral nerves. It was planned, moreover, that cases of this character, aswell as the insane, who required care after discharge from the Army, would beprovided for in the vicinity of their homes by the Bureau of War Risk Insurance.10
CLASSIFICATION AND DISTRIBUTION OF OVERSEAS PATIENTS
The importance of accurate clinical diagnosis as a basis forthe classification and distribution of patients can not be insisted upon tooemphatically as an important feature of treatment. From the dressing stationsand field hospitals at the front, through the base sections and into the homestations, this principle is cardinal to successful functioning of the medicaldepartment of an army.
In this country the two most important sorting points werethe ports of debarkation at Hoboken, N. J., and at Newport News, Va., and ofall the classes of cases returned, perhaps none presented such perplexingclinical problems as the nervous and mental cases. Many, if not most, of thesepatients were returned without records and without notes, the only indicatingsign to the examiners who met them at the ports being a diagnosis written out orinitialed on the field card. Then, in the cases of the psychoses and neuroses, achange
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had often come over the patient since he was last examined bya medical officer, so that what may have been a correct diagnosis on leavingFrance was no longer correct, on arrival. Also, because of the refusal of theNavy, which had charge of all patients at sea, to transport large numbers ofmental cases on any one ship, medical officers stationed at the French portswere forced, in order to evacuate their hospitals, to mark some patients as"N" or nervous, when in reality they were mild mental cases.
To insure speedy distribution of the neuropsychiatric casesreturned from abroad, psychiatrists were assigned to the ports of debarkation atHoboken and Newport News.11 Cases were classified immediately uponarrival and evacuated to the proper hospitals as soon as possible.11The following hospitals were designated by the Surgeon General on December 9,1918, for overseas mental and nervous cases:12
EPILEPTICS AND MENTAL DEFECTIVES
Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
General Hospital No. 1, Williamsbridge, N. Y.
General Hospital No. 6, Fort McPherson, Ga.
General Hospital No. 25, Fort Benjamin Harrison, Ind.
General Hospital No. 26, Fort Des Moines, Iowa.
General Hospital No. 28, Fort Sheridan, Ill.
General Hospital No. 29, Fort Snelling, Minn.
Base Hospital, Fort Sam Houston, Tex.
INSANE
General Hospital No. 1, Williamsbridge, N. Y.
Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
General Hospital No. 4, Fort Porter, N. Y.
General Hospital No. 6, Fort McPherson, Ga.
General Hospital No. 13, Dansville, N. Y.
General Hospital No. 25, Fort Benjamin Harrison, Ind.
General Hospital No. 26, Fort Des Moines, Iowa.
General Hospital No. 28, Fort Sheridan, Ill.
General Hospital No. 34, East Norfolk, Mass.
Base Hospital, Fort Sam Houston, Tex.
NEUROSES, FUNCTIONAL
General Hospital No. 30, Plattsburg Barracks, N. Y.
DRUG ADDICTS AND INEBRIATES
General Hospital No. 31, Carlisle, Pa.
With the exception of General Hospitals Nos. 4, 30, and 34,these hospitals were chosen for the establishment of special neuropsychiatricservices, first, because they would reduce transportation to the minimum and atthe same time give wide geographical distribution; second, because they wouldenable all cases to be treated in the vicinity of their homes; third, this planmade for the most economical utilization of the existing facilities.9
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General Hospital No. 4 was for a time devoted almost entirelyto mental cases returned from France.13 As the bed capacity wassoon taken up, it was necessary for General Hospitals Nos. 13 and 34 to be takenover for the care of insane cases. As the number of cases returned from abroaddecreased and the population of these hospitals diminished, all the cases weretransferred to the Soldiers' Home for Disabled Volunteer Soldiers at Hampton,Va., which previously had been Debarkation Hospital No. 51. On May 1, 1919, itwas made General Hospital No. 43, for the care and treatment of mental cases.This hospital was used also as a classification hospital for other nervousconditions received from overseas through the port of Newport News.14Atthe time of the transfer of these cases, General Hospitals Nos. 13 and 34 wereclosed.13
There was also a neuropsychiatric service in the embarkationhospital at Newport News.14 This service showed a steady increasein mental cases from the local camps from the beginning, augmented by the returnof overseas cases.
Eventually all mental cases from the American ExpeditionaryForces were returned through the port of Newport News and taken directly to thehospital at Hampton, without long travel and with economy of personnel, as thepatients were then treated in one hospital instead of three.13Theprocedure followed is given below.14
PORT OF EMBARKATION, NEWPORT NEWS, VA.
After November 11, 1918, emphasis was placed upon thereception of neuropsychiatric cases from France. This had long been a functionof the embarkation hospital where patients were received in small groups; of 100admissions to the neuropsychiatric ward in August, 1918, for instance, 30 werefrom overseas. By September 4, 1918, the accommodations at this hospital (for38 insane and 60 nervous patients) were manifestly insufficient even for theimmediate future. At this time it was recommended to the surgeon that 180 morebeds be provided, this special need to be merged in the general need of a largedebarkation hospital. The old Soldiers' Home at Hampton, which was transferredto the War Department by act of Congress, when opened as Debarkation HospitalNo. 51, on November 17, 1918, contained 39 beds for the care of acute psychosesand 110 beds for neuroses. In January, 1919, accommodations for 50 morepsychoses were provided and 2 wards of 60 beds each were nearly ready.
Before these new accommodations were available the U. S. S. Aeolusdocked, on October 13, with 243 cases, divided as follows: Psychoses, 127;feeble-minded, 18; epileptics, 55; neuroses, 39; and 3 cases of organic diseaseof the nervous system. No warning was given; the force of attendants atembarkation hospital was crippled because of the influenza epidemic; other shipswere due. Under these circumstances special trains were requested to carry thesepatients directly inland, and after a day's wait the psychoses and mentaldefectives were sent to Fort McPherson, Ga., and the others to Plattsburg, N. Y.Two patients hung themselves on the ship, one on the last day of the voyage andone while the transfer from boat to train was going on. The ship of necessitycarried these patients between decks without lights from sunset to sunrise. Thetrain trips were made without incident.
When the debarkation hospital was opened on November 17, itsfirst large group of patients was a convoy of 300 nervous and mental cases.Notice had been sent ahead and a psychiatrist had gone out to meet the ship andclassify the patients, but unfortunately the ship did not stop to take on apilot. At the pier, a hospital boat was brought alongside, received thepatients, and landed them at a dock inside the hospital grounds. One man doveoverboard but was rescued unharmed. These patients were successfully transferredto interior hospitals.
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Subsequently other ships, each carrying two to three hundred mental cases,were unloaded and a procedure developed which gave very satisfactory resultsin the transfer of these patients from ship to hospital wards. In brief thisplan was as follows:
(1) On advance information theneuropsychiatrist, with adetail of experienced enlisted men, reported at the pier as adviser to themedical superintendent of transports. (2) The medical officer andnoncommissioned officer in charge of the detail boarded the ship and securedall possible information regarding the behavior of the patients from the ship'ssurgeon and attendants. (3) Quarters on the hospital boat or the routes to theambulances were inspected and attendants placed at strategic points, gangways,ports, stairways. (4) Patients from whom trouble could be expected were eachplaced in charge of an attendant and landed first. (5) Milder mental cases weregrouped and taken next with several attendants. (6) At the receiving hospitalpatients were taken off in the same order and thus the more disturbed could beplaced in the most protected ward and the patients who needed no special carecould be admitted to the general medical wards when necessary.
The custom of the hospitals with regard to diagnosis of general cases wasfollowed. This meant the filling in before 9 a. m. on the day followingadmission of a "Classification for distribution" form, of which asynopsis is here given:
1-2. Name and identification.
3. Diagnosis
4. Classed as-
Psychoneurosis.
Epilepsy.
Psychosis.
Mental defect.
Convalescent.
Peripheral nerve injury.
Other medical groups; other surgical groups.
5. Ambulatory or bed patients.
6. Individual attendant Special care of litter.
7. Recommendations
It was obvious that the future care of patients was dependentto a considerable extent upon the accuracy with which the diagnosis was madeprior to entrainment for interior hospitals. If conditions were such as tolimit the time which the neuropsychiatrist might expend in making thediagnosis the ratio of accuracy would be lowered. After numerous experiences the neuropsychiatrist of the port arrived atthe conclusion that while,theoretically, the interests of the patient and the service alike would be bestserved by allowing more time for making the investigations upon which anaccurate diagnosis must rest it was impracticable to secure more time withoutgreatly interfering with general evacuation operations. In other words, a portof debarkation, by its very nature can not become a place for scientificniceties of diagnosis. Therefore an endeavor was made to combine speed withaccuracy. That this succeeded is well illustrated by the experience andexperiments described below.
A large group (300) was landed at the hospital dock at 6 p.m., whence they were enrolled and sent to the ward with Form 55a made out.The ward surgeons assigned each man to a bed and entered the number of the bedon the 55a slip. Supper was then served. Then four men at a time were taken,from each of the five wards, for delousing. Field cards from overseas arrivedat the wards and were matched with the 55a forms, always with somediscrepancies which took time to adjust. A neuropsychiatrist stationed himselfat the door of each ward, called a patient, read the field card, entered adiagnosis, and checked the appropriate class.
Many diagnoses could be confirmed in a few seconds; epilepsy,for instance, by a history of convulsions antedating Army service, orundiagnosed psychosis by the presence of any delusional remnant or behaviordisorder. It should be remembered that such a diagnosis had little of thesignificance that it had in civil life, merely meaning at the port that thepsychotic was going to a hospital with the proper specialists to care for ordischarge him. Therefore, when epilepsy was the term used to describe adisease characterized by convulsions which first appeared under shell fire, achange was made to psychoneurosis in order to make
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sure that the patient would receive specialized treatment.The diagnosis "constitutional psychopathic state" covered such variedconditions that at first it seemed best to change it; later it was retained andits constituents separated by checking under classification, "psychosis,epilepsy, psychoneurosis, mental defect," according to the treatment thepatient required. In questions involving mental defect, patients were referredto a psychologist for individual examination.
After diagnosis and classification had been made by aspecialist, the patient took his papers to the ward surgeon who completedthem. The distribution papers were then ready with the papers from othermedical and surgical wards for early action the next day after admission; fromthem were made up the travel orders which caught the patient in a system whichlanded him at an interior hospital. At times patients would remain severaldays before entraining, and many valuable clinical notes could be entered ontheir field cards. Unless an injustice was being done to a soldier, it wasfound best not to alter his diagnosis, since this meant disarranging complicated travel orders.
Hospital trains formed a medical unit separate fromthe hospitals. For mental patients, however, the hospitals were asked to furnishadditional neuropsychiatric attendants. The 35 enlisted men sent to the port bythe section of neuropsychiatry, "to escort nervous and mental cases fromthe port to the general hospitals," were used here, as well as in thetransfers from ship to ward and from ward to train. Berths were made withoutcurtains and toilet rooms were specially guarded.
Efforts were made to improve this routine.Attention wasfirst centered on the short time allowed for diagnosis in these difficult cases.As stated above, careful consideration made the neuropsychiatrists feel that noincrease in time should be asked if such an increase would give mental patientssecond place in travel arrangements.
Next the question of discharging patients atthe port wasraised in an effort to help clear beds in interior hospitals. Certificates ofdisability for discharge were made out for 30 epileptics whose convulsionsclearly antedated their enlistment and where treatment could not be expected toimprove their condition. Contrary to some presuppositions, no difficulty wasexperienced in getting convincing histories. The result was that these patientswere held about a month and then sent under escort to widely separated homes,a procedure which resulted in a multiplication of travel orders and a tyingup of many Hospital Corps men in travel. The scheme was abandoned as having noadvantage over immediate distribution to hospitals near homes.
PORT OF EMBARKATION, HOBOKEN, N. J.
For a time the neuropsychiatric cases received at theport of New York were debarked at Ellis Island, where they were cared for inspecial wards until they could be transferred to special hospitals for nervousor mental patients. The stay at Ellis Island was usually brief, the patientsbeing transferred in the course of a very few days. Because of this brief stay,little attempt was made at treatment of cases there, though every effort wasmade to provide for their care and for such emergency treatment as was required.Later the Messiah Home for Children in New York City was obtained by the SurgeonGeneral for use as a clearing hospital (as part of United States Army GeneralHospital No. 1) for patients arriving at the port of New York (Hoboken), and thespecial wards at Ellis Islands were given up.15
The neuropsychiatric service at Hoboken was established inJuly, 1917. A director of neuropsychiatry was appointed by the surgeon of theport of embarkation as his personal representative to direct all theneuropsychiatric activities at the port. The duties of this officer, who had foryears previously had charge of the largest psychopathic reception service in thecountry, were as follows: (1) To advise, assist, and cooperate in theorganization of a special hospital for the care and evacuation of nervous andmental cases.
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(2) To organize and establish special wards in varioushospitals within the port for the brief and temporary care of such cases. (3) Tomake official visits and act as consultant and to assist and advise with thecommanding officers of the various hospitals in the examination, classification,and the general care of nervous and mental patients. (4) To examine and reportspecial psychiatric cases that might arise within the port, including the mentalexamination of those who were charged with criminal offenses and in whom thequestion of mental responsibility arose. (5) To advise the personnel officer inthe office of the surgeon in the assignment of medical officers havingneuropsychiatric training, to various hospitals as the necessity required.
Because of the special and technical character of the work,the relation of the director to the neuropsychiatric service in the port andparticularly to the special hospital, ward 55 (Messiah Home), General HospitalNo. 1, had of necessity to be very intimate.
Owing to the fact that nervous and mental patients werereturned in large groups, the accommodations at the special hospital (MessiahHome) proved temporarily inadequate and, at various times, many of the mildercases had to be distributed to other hospitals until evacuated, whichcomplicated the work of the division considerably. Notwithstanding this, in aservice which is fraught with danger and where accidents, injuries, abuses, andcomplaints are apt to be frequent, such occurrences were happily rare.
In transferring patients from ocean transports to thedebarkation hospitals and from the debarkation hospitals to hospitals in theinterior, patients were accompanied by attendants experienced in thetransportation of mental and nervous cases. Reports of the elopement of patientsand injuries received while in transit were few, and complaints as to conditionof patients arriving were almost negligible.9 The following is a description ofmethods and equipment used in the transportation of mental patients:16
The equipment needed and the arrangements to be made fortransporting mental cases will depend to a great extent on the mode ofconveyance (train, automobile, steamship, etc.), the distance to be traveled,and the types of cases to be transferred. Under all circumstances, it is offirst importance to provide trained attendants and nurses and to have in chargea physician experienced in the management of mental cases.
If a large body of patients is to be transferred an effortshould be made to classify the cases into groups, according to the severity ofthe symptoms and the amount of supervision needed.
Mild and tractable cases - Thesemay be transferred bytrain or ship with little difficulty if their physical condition is good, and ifproperly supervised by trained attendants very little restriction of theiractivity is necessary. In railroad cars the doors should be locked and thewindows kept down, except when opened for purposes of ventilation, and then theyshould be guarded by attendants.
Suicidal cases - Careful watching and considerablerestriction of liberty on train and ship are necessary. Actively suicidal anddisturbed cases must be managed as are excited patients next referred to.
Excited and assaultive cases - Doors must be kept lockedand windows closed and blocked. Wire screens over the windows (on the inside)may be used to prevent breaking of glass. Very disturbed cases should betransferred in a compartment sleeping car so that each patient has a room. Inthese cases canvas camisoles, with long sleeves, should be used to controldestructive tendencies and prevent assaults. Some violently excited cases, orthose with self-mutilative tendencies, require to be kept in bed under aprotection sheet. This can not
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be applied unless an ordinary single bed (hospital style)is available. In transferring excited patients short distances by ambulance,or from hospital to train or ship, stretcher cots should be used and leatherstraps provided for confining the patient to the cot.
Delirious cases - As these patients are usuallyseriously ill, they should not be transported long distances unless it isabsolutely necessary. They should always be moved on a stretcher cot and placedin bed as soon as possible on train or ship.
Other equipment required for the handling of disturbed and uncleanly patients shouldinclude plenty of water and hand basins for cleansing purposes.
Ample supply of underclothing and bedding, and rubbersheets to be used under unclean patients.
A tube feeding outfit, consisting of a rubber tube withfunnel attached (tube should be small enough to introduce through thenostril).
A physician's hand bag or kit containing the usualemergency outfit, including also hypodermic syringe and tablets of morphia,strychnia and hyoscine hydrobromate; paraldehyde, magnesiumsulphate, cascara and compound cathartic pills should be provided. Fountain syringeand bed pans are also needed.
STATISTICAL DATA
There is no accurate record of the date and number of thefirst nervous and mental cases returned from the American Expeditionary Forces,but the first mental cases from overseas to be admitted to the first specialhospital for such cases (General Hospital No. 4) was in the month of February,1918, and the first cases of war neurosis were admitted to General Hospital No.30, in May, 1918.17
The following neuropsychiatric cases had been returned fromoverseas up to June 30, 1919:17
Total | Hoboken | Newport News | |
Psychoses (insanity) | 3,597 | 2,715 | 882 |
Constitutional psychopathic states | 504 | 149 | 355 |
Epilepsy | 416 | 302 | 114 |
Mental deficiency | 762 | 410 | 352 |
Psychoneuroses | 2,888 | 1,675 | 1,213 |
Alcoholism | 51 | 51 | --- |
Drug addiction | 6 | 6 | --- |
Recovered | 95 | 95 | --- |
| 8,319 | 5,403 | 2,916 |
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The following is a list of the mental and nervous patients transferred to general, base, and special hospitals from the ports of Hoboken and Newport News, between April, 1918, and June 30, 1919, with the hospitals to which they were admitted:18
Mental | Mental defective | Neurosis | ||||
Hoboken | Newport News | Hoboken | Newport News | Hoboken | Newport News | |
Letterman, San Francisco | 36 | 14 | 10 | --- | 7 | 2 |
Walter Reed, Takoma Park, D.C. | 171 | 41 | 54 | 1 | 11 | 1 |
No. 1, Williamsbridge, N.Y. | 94 | 37 | 62 | 16 | 35 | 9 |
No. 2, Fort McHenry, Md. | 61 | 42 | 4 | 1 | --- | 14 |
No. 3, Colonia, N.J. | --- | --- | --- | --- | --- | 2 |
No. 4, Fort Porter, N.Y. | 784 | 340 | 1 | --- | 57 | 36 |
No. 5, Fort Ontario, N.Y. | 3 | 3 | 1 | --- | 14 | 6 |
No. 6, Fort McPherson, Ga. | 277 | 228 | 86 | 10 | 22 | 1 |
No. 9, Lakewood, N.J. | 1 | --- | --- | --- | 12 | 15 |
No. 10, Boston, Mass. | --- | 1 | --- | --- | --- | 1 |
No. 11, Cape May, N.J. | --- | --- | --- | --- | --- | 9 |
No. 14, Fort Oglethorpe, Ga. | 20 | --- | --- | --- | 1 | --- |
No. 25, Fort Benjamin Harrison, Ind. | 152 | 209 | 38 | 8 | 3 | --- |
No. 26, Fort Des Moines, Iowa. | 112 | 6 | 29 | --- | 7 | 7 |
No. 27, Fort Douglas, Utah | --- | --- | --- | --- | 1 | 1 |
No. 28, Fort Sheridan, Ill. | 154 | 65 | 30 | --- | 23 | 1 |
No. 29, Fort Snelling, Minn. | 17 | --- | 8 | --- | --- | 16 |
No. 30, Plattsburg Barracks, N.Y. | 3 | --- | 3 | --- | 1,161 | 1,024 |
No. 34, East Norfolk, Mass. | 333 | 190 | --- | --- | --- | --- |
No. 41, Fox Hills, Staten Island, N.Y. | --- | 1 | --- | --- | --- | 3 |
No. 43, Hampton, Va. | 393 | --- | 48 | --- | --- | --- |
Camp Bowie, Tex. | 2 | --- | --- | --- | --- | --- |
Camp Custer, Mich. | 13 | --- | --- | --- | 1 | --- |
Camp Devens, Mass. | 10 | --- | 1 | --- | 4 | --- |
Camp Dix, N.J. | 33 | --- | --- | --- | 8 | --- |
Camp Dodge, Iowa | 14 | --- | 3 | --- | --- | --- |
Camp Gordon, Ga. | 2 | --- | --- | --- | --- | --- |
Camp Grant, Ill. | 3 | --- | 2 | --- | --- | --- |
Camp Lee, Va. | 6 | --- | --- | --- | --- | --- |
Camp Lewis, Wash. | 2 | --- | 1 | --- | --- | --- |
Camp Meade, Md. | 2 | --- | 1 | --- | --- | --- |
Camp Pike, Ark. | 2 | --- | --- | --- | --- | --- |
Fort Sam Houston, Tex. | 42 | --- | 24 | --- | 13 | --- |
Camp Shelby, Miss. | 1 | --- | --- | --- | --- | 1 |
Camp Sherman, Ohio | 16 | --- | --- | --- | 1 | --- |
Fort Sill, Okla. | --- | --- | 1 | --- | --- | --- |
Camp Taylor, Ky. | 8 | --- | 1 | --- | --- | 1 |
Camp Upton, N.Y. | 47 | --- | 4 | --- | 11 | --- |
Post hospital, Jefferson Barracks, Mo. | 9 | --- | --- | --- | 1 | --- |
St. Elizabeths Hospital, District of Columbia | 61 | 11 | --- | --- | --- | --- |
| 2,929 | 1,188 | 412 | 36 | 1,393 | 1,150 |
A census of mental and nervous patients in military hospitals taken as of June 25, 1919, showed the following:19
General hospital | Total | Psychoses | Psycho- | Constitutional psychopathic states | Mental deficiency | Epileptics | Others |
No. 1 | 270 | 138 | 44 | 18 | 21 | 18 | 31 |
No. 2 | 51 | 16 | 15 | 6 | 4 | 3 | 7 |
No. 4 | 125 | 95 | 26 | 2 | 2 | --- | --- |
No. 5 | 5 | 1 | 3 | --- | 1 | --- | --- |
No. 6 | 192 | 136 | 21 | 5 | 12 | 3 | 15 |
No. 25 | 186 | 124 | 7 | 11 | 13 | 2 | 29 |
No. 26 | 143 | 83 | 21 | 11 | 3 | 9 | 16 |
No. 28 | 318 | 146 | 40 | 13 | 28 | 18 | 73 |
No. 30 | 205 | 3 | 169 | 9 | 2 | 5 | 17 |
No. 43 | 983 | 693 | 90 | 72 | 117 | 10 | 1 |
Fort Sam Houston | 123 | 59 | 13 | 12 | 4 | 5 | 30 |
Letterman | 116 | 54 | 9 | 3 | 28 | 4 | 18 |
Walter Reed | 142 | 100 | 12 | 3 | 3 | 12 | 12 |
| 2,859 | 1,648 | 470 | 165 | 238 | 89 | 249 |
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Another census taken on August 12, 1919, showed thefollowing:17
Hospital | Total | Psychoses | Psycho- | Epilepsy | Constitutional psychopathic states | Mental deficiency |
Walter Reed | 123 | 67 | 38 | 6 | 7 | 5 |
Fort Sam Houston | 117 | 58 | 29 | 14 | 12 | 4 |
Letterman General | 80 | 53 | 8 | 7 | 9 | 3 |
General Hospital No. 1 | 40 | 21 | 15 | 1 | 2 | 1 |
General Hospital No. 2 | 47 | 12 | 24 | --- | 9 | 2 |
General Hospital No. 4 | 194 | 14 | 131 | 1 | 37 | 11 |
General Hospital No. 6 | 132 | 89 | 23 | 12 | --- | 8 |
General Hospital No. 25 | 178 | 138 | 15 | 7 | 11 | 7 |
General Hospital No. 26 | 95 | 54 | 24 | 5 | 8 | 4 |
General Hospital No. 28 | 117 | 73 | 19 | 9 | 2 | 14 |
General Hospital No. 43 | 1,087 | 868 | 23 | 2 | 59 | 135 |
| 2,210 | 1,447 | 349 | 64 | 156 | 194 |
NEUROSURGICAL CASES
In the winter of 1918-19 officers specially experienced inorganic neurology were ordered to certain of the general hospitals receivingwounded from overseas with the recommendation to the commanding officer thatthey be assigned to the surgical service.20 This recommendation wasnecessary because the organic injuries to the nervous system, although most ofthem had ceased to be surgical, were being treated in the surgical services.That this great mass of neurological material, approximately 5,000 cases, shouldhave been retained under surgical control was not an altogether happy clinicalarrangement from the standpoint of the division of neurology and psychiatry, butit was inevitable in view of the circumstances.
The whole question of the proper organization for the care ofthis class of cases was considered important. Battle injuries of the nervoussystem are primarily surgical, being associated not only with open wounds butalso with fractures. The best clinical arrangement for this class of injuries,at the front, is in surgical hospitals which are staffed as far as possible withthe neurosurgeons and neurologists. If neurosurgeons can not be supplied insufficient numbers the cases must be treated at the front by general surgeons.With the healing of the original wound the injury changes its type in themajority of cases. There are some cases which, when they reach the hospitals inthe zone of the interior, still require operation, but these cases are in thegreat minority. At this stage the spinal cord injuries are hardly operable, someof the brain cases require secondary operations, and perhaps 15 per cent of theperipheral nerve palsies require surgical interference. But with theseexceptions, after the original wound has healed, the majority have changedtheir clinical status and, though primarily surgical, now actually presentproblems with which a medical officer who is a neurologist by experience andinterest is best fitted to deal. Those who have sustained cerebral injuries havebeen left irritable and subject to various symptoms, which makes personalitystudy necessary before they can be readjusted to civil life; and the cases ofperipheral nerve injuries which give promise of spontaneous repair require exactneurological diagnosis and treatment.
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Thus, at the close of the surgical wound period, injuries tothe nervous system become, as a class, neurological cases. But a change inclinical status would have been difficult to recognize administratively. It wasnot done in the British medical service and it would have been impossible underthe organization which obtained in our Medical Department. The original plan, asdevised in the Surgeon General's Office, was that all these cases would becared for in the United States in one or more special hospitals, under the brainsection of the division of head surgery.21 But when these casesbegan to be returned in so much greater numbers than had been anticipated, itwas found that the provisions for their care in the special hospitalsestablished for the purpose at Cape May and Colonia, N. J., were inadequate bothas to the number of beds and as to qualified personnel. And, in addition, it wasfound that civil interests demanded a wider distribution than had been providedfor. These patients, like most of all the others, wanted to be somewhere neartheir homes. It became necessary, accordingly, to increase the hospitalsdesignated for their special care. More than a dozen, geographically wellseparated, general hospitals were therefore designated for patients of thisclass on their arrival from overseas, the choice of the particular hospitalbeing made with reference to nearness to the patient's home.21The division of head surgery, Surgeon General's Office, having so many of itsofficers overseas, could not expand its personnel to meet this situation, andas there was no neurological service in the hospital organization of the MedicalDepartment, the patients automatically fell to the division of general surgery,to which were assigned such neurologists and neurosurgeons as were available.
REFERENCES
(1) Annual Reports of the Surgeon General, U. S. Army.
(2) War Diary of commanding officer, Letterman General Hospital, San Francisco, Calif., November 12, 1918. On file, Record Room, S. G. O.
(3) Army Regulations, 1913, par. 464.
(4) Plans on file, Finance and Supply Division, S. G. O.
(5) Plan R2 (neuropsychiatric ward, base hospital). On file, Finance and Supply Division, S. G. O.
(6) Letter from Pearce Bailey (chairman of the Committee on Furnishing Hospital Units for Nervous and Mental Disorders to the United States Government), to neurologists, May 11, 1917. On file, Record Room, S. G. O.
(7) Circular letter, Surgeon General's Office, September 5, 1917.
(8) Based on sick and wounded reports sent to the Surgeon General, U. S. Army.
(9) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1081-83.
(10) G. O. No. 57, W. D., April 30, 1919.
(11) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1083.
(12) List of Hospitals Designated for Overseas Cases, Surgeon General's Office, December 9, 1918.
(13) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1082.
(14) History of Embarkation Hospital, Newport News, Va., by Maj. W. C. Rucker, U. S. P. H. S. On file, Historical Division, S. G. O.
(15) History of the office of the surgeon, Port of Embarkation, Hoboken, N. J. On file, Historical Division, S. G. O.
(16) Memorandum to Dr. Pearce Bailey, from Dr. George H. Kirby (Manhattan State Hospital), July 2, 1917. Subject: Transport and transfer of insane soldiers. On file, Historical Division, S. G. O.
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(17) Letter from the Surgeon General, U. S. Army, to Hon. Edwin D. Ricketts (concerning shell-shocked and insane soldiers of the late war), August 21, 1919. On file, Record Room, S. G. O., 701.7.
(18) Routine reports made by post surgeons to the Surgeon General, U. S. Army. On file, Record Room, S. G. O.
(19) Based on reports made by commanding officers, showing the number of neuropsychiatric cases in the respective hospitals, by classification, as of June 25, 1919.
(20) Correspondence. On file, Record Room, S. G. O., 210.31-1 (Neuropsychiatry assignments).
(21) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1095, 1096.
