CHAPTER IV
DETECTION AND ELIMINATION OF INDIVIDUALS WITHNERVOUS
OR MENTAL DISEASE
PRINCIPLES UNDERLYING NEUROPSYCHIATRICEXAMINATIONS
One of the most important duties of the neuropsychiatrists inthe military service during the war was the elimination, at the time of theirpreliminary examination and before they were actually enlisted or inducted intothe Army, of individuals with mental or nervous disease. Many of the purelyphysical disabilities which were noted and waived by mustering officers, orwhich disqualified recruits from service, were susceptible of improvement orcure by treatment, or got well of themselves under the favorable conditions ofmilitary training. This was rarely the case for any nervous or mental disease.On the contrary, the longer the training period was prolonged, the morepronounced these conditions became; the soldier was more and more constantlyreported at sick call, or was suddenly seized with a nervous or mental collapse,or got into trouble by reason of repeated, and often unnecessary, militarydelinquencies. The strain of actual warfare, particularly of expeditionarywarfare, with the unavoidable homesickness, loneliness, and depression-to saynothing of its actual physical dangers and hardships-brought first to thebreaking point those whose morale, by reason of a general instability of thenervous system, could not be maintained. While such men usually were ultimatelydetected and discharged, it was not until after a considerable period oftraining during which they received pay, maintenance, and equipment, wasted thetime of those endeavoring to instruct them, interfered with the training oftheir brighter or better-adjusted comrades, and occupied hospital beds whichoften were urgently needed for others. Another unfortunate feature of theacceptance of such men for military service was that many of them, while unableto adjust themselves to the military environment, might be useful citizens ifpermitted to remain in their accustomed surroundings. Left on the farm or in thefactory or store, where their associates were accustomed to their peculiarities,they might prove of material service to the country in time of war.
Furthermore, if men of this type became soldiers, they werealmost certain in the future to present a serious economic problem to thecountry. Under the provisions of the selective service act, which was in forceduring the period of the war, all soldiers were regarded as physically andmentally sound when accepted for service. If, after a short period in the Army,a soldier was necessarily discharged by reason of mental or nervous disability,be became a beneficiary of the Bureau of War Risk Insurance (later called theUnited States Veterans' Bureau), and thus was entitled to governmentalcompensation and hospital care. Nervous and mental disorders constituted asubstantial proportion of ultimate disabilities.aMany of the former soldiers discharged by reason
aIn February, 1927,ex-service men with neuropsychiatric disabilities constituted 46.7 Percent ofall patients receiving hospital treatment as beneficiaries of the United StatesVeterans' Bureau. (Hospital Facilities by Coordination Areas for U. S. V. B.Patients, as of Feb. 26, 1927. Issued weekly for administrative purposes byEvaluation Division, Coordination Service, United States Veterans' Bureau.Copy on file, Historical Division, S. G. O.).
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of nervous or mental diseases are drawing compensation fromthe Federal Government, some with a rating of total permanent disability. Alarge proportion of these men rendered practically no service to the country,their time in the Army having been spent in base or general hospitals, or underobservation for the defect which in a short period after induction or enlistmentresulted in discharge.
Before we had entered the World War, the possibility ofconditions was appreciated by only a small group of the civil medicalprofession; it was not surprising, therefore, that they were not accepted attheir face value, immediately, by the regular line and medical officers of theArmy, who exhibited, perhaps, less indifference and less reluctance to acceptingthem, in principle, than civil authorities or general medical organizations werein the habit of doing prior to the demonstrations of their practical importancefurnished by the war. The introduction of novel and special examinations of somany kinds created great administrative difficulties immediately, as theyinterfered with established military routine, and it probably was this factor,rather than any lack of open-mindedness as to their usefulness, that was thebasis of such opposition as was made to them. Division surgeons complained thatspecialists interfered with the prompt getting in order of their camps, whichwas true, and line officers were not hard to find who maintained that if thespecialists did not stop eliminating the unfit, there would be no army left.Many medical officers, not distinguishing between physical and mental disorders,halted considerably before they embraced the belief that the training whichtransformed poor physical specimens into robust fighting men did not have thesame effects upon recruits with nervous or mental disabilities. Occasionallyline officers, taking things into their own hands, looked over candidatesrecommended for rejection, decided that, as the men looked all right to them,they probably were all right, and then waved aside the recommendation forrejection or discharge. Ultimately it was discovered, however, that nervouslyunfit men were a great embarrassment to the American Expeditionary Forces. OnJuly 15, 1918, General Pershing cabled to the Chief of Staff as follows:1
Prevalence of mental disorders in replacementtroops recently received suggests urgent importance of intensive efforts ineliminating mentally unfit from organizations new draft prior to departure fromthe United States. Psychiatric forces and accommodations here inadequate tohandle a greater proportion of mental cases than heretofore arriving, and ifless time is taken to organize and train new division, elimination work shouldbe speeded.
Upon receipt, by the Surgeon General, of this information,the matter was taken under consideration by the chief of the division ofneurology and psychiatry, and the following information, based upon reports madeto the Surgeon General by neuropsychiatric examiners, was submitted to theSurgeon General by the chief of the division, with his recommendations:2
1. Apropos of the attached cablegram fromGeneral Pershing, the following data are submitted: A survey of the records inthis office shows that the divisions that have gone abroad have carried withthem the following number of men who had been recommended for discharge as unfitfor military service by the psychiatric examiners:
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Division | Number | Division | Number | Division | Number | Division | Number |
4th | 48 | 34th | 21 | 77th | 5 | 85th | 45 |
27th | 21 | 35th | 181 | 78th | 208 | 86th | 53 |
28th | 93 | 36th | 138 | 79th | 73 | 87th | 198 |
29th | 166 | 37th | 271 | 80th | 90 | 88th | 29 |
30th | 152 | 38th | 130 | 81st | 3 | 89th | 115 |
31st | 52 | 39th | 244 | 82d | 120 | 90th | 44 |
32d | 32 | 40th | 25 | 83d | 53 | 92d | 70 |
33d | 44 | 42d | 273 | 84th | 38 | Total | 3,035 |
2. The men enumerated above are epileptics,dementia pr?cox, general paretics, tabetics, psychoneurotics, imbeciles, etc.Because of their condition, these men are totally unfit for military service,and become a burden upon the Government either immediately upon landing, orshortly afterwards. The psychiatric service abroad is equipped only to care formen who become incapacitated in line of duty. Three thousand cases thrust uponthis service almost en masse will tax the resources seriously, as it is evidenthas been done from the cable of General Pershing.
3. Attention is called to the fact that thenumbers of cases carried over by different divisions differ markedly. Threedivisions (41st, 76th, 91st) carried no men who had been recommended fordischarge. The 81st carried 3; the 77th, 5; the 42d, 273; the 37th, 271; the39th, 244, etc. It is evident, therefore, that the S. C. D. boards in thedifferent camps vary either in the importance they attach to nervous and mentaldisease, or in the expedition of their work. Complaints have frequently beenreceived on the length of time necessary to discharge men who have beenrecommended to the boards. An inquiry recently made in a few camps shows thefollowing variations in time:
Camp Dix, average time 5 days.
Camp Jackson, previous to July 1, average time24 days; since July 1, 12 days.
Camp Fremont, 21 days.
Base hospital, Alexandria, La., 23 days.
4. In order to obviate the difficultiesarising in the American Expeditionary Forces, as mentioned by General Pershing,it is suggested that an effort be made to expedite S. C. D. proceedings, andthat the importance of excluding recruits who are nervously and mentally unfitfor service be drawn to the attention of S. C. D. boards.
REASONS FOR REJECTION OR DISCHARGE
The War Work Committee of the National Committee for MentalHygiene appointed a subcommittee to study clinical methods and standardizationof examinations and reports. The subcommittee soon rendered a report to the WarWork Committee, which submitted to the Surgeon General, in July, 1917, amemorandum containing various suggestions pertaining to examinations ofrecruits, and giving a list of diseases, symptoms, and groups of symptoms whichit was thought should exclude from military service, regardless of ultimatediagnosis. On August 1, 1917, the Surgeon General issued general directions toexaminers based on these suggestions.3 (Seep. 66).
There was little question about clearly defined types. Nocommanding officer would accept, knowingly, a man who was activelyhallucinating, and an epileptic fit which was verified was equivalent todischarge. More important than the patent nervous and mental diseases, for anunderstanding of the general philosophy of rejection by reason of nervous andmental conditions was a knowledge of the mental states of unstable individualswhose unfitness for service was not on the surface, the advisability of whoserejection frequently was questioned not only by line officers, but by medicalofficers.
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THE PSYCHOPATHIC PERSONALITY
Viewed from the standpoint of personality, human beings of thegroup called psychopathic have been so from youth, and produce, under certainconditions, characteristic behavior. At the time of any single examination thesymptoms they present (and even these may be put down as conclusions on the partof the overzealous examiner) may be no more definite than irritability,inability to control the passions, suspicion, resentfulness, particularly todiscipline, depression, and general egocentric tendencies. These evidences,slight in themselves, gain an additional significance when associated togethercharacteristically, or when, as they usually can be, they are shown ascharacteristics by which the individual has been conditioned throughout hiswhole life. The behavior of such persons under military conditions isinconsistent with military efficiency. They are not of the stuff of whichsoldiers are made-which is the real issue so far as the Army is concerned.They are persons who can not give the service required, and no system yetdevised will make them adequate.
The question to be determined, then, at the examination of arecruit, before the Army assumes charge of him, is whether his make-up is suchthat his behavior, with practical certainty, will be inconsistent with service.These examinations undertake to recognize at the outset, before the Governmentassumes liability, the type of person which the Army will be forced to recognizesooner or later. The behavior aspect is more likely to be noted than the healthaspect, as is shown by the fact that soldiers are so often referred directly topsychiatrists by company commanders. What the psychiatrist attempts to do is todiscover immediately and directly what otherwise it might take several expensivemonths to find out.
The candidate may have been treated for mental disease andmay be sane now; he may have had epileptic attacks but none for a long period;he may have been addicted to the use of a drug and may have discontinued thehabit; or he may have none of these serious disabilities and still may have metdifficult situations in the past in such an abnormal and unsatisfactory manner-notthrough lack of "will" but because of a fundamental disorganization ofhis personality-that he may be counted on to meet those of the future no moresatisfactorily.
If individuals of this category are not recognized they failthe Army in some of the following ways: By having attacks of mental disease; bythe development of neuroses; by reappearance or increase of epileptic attacks;by the kind of delinquency which results from a mental or temperamentalinability to adjust to the restrictions of military discipline or to profit bypunishment.
Perhaps the most frequent and important reaction of thepsychopathic personality to the trying exactions of war, or even to life in theArmy, is the neurosis-a condition difficult to conceive of dispassionately inactual practice, because the manifestations and complaints of the neurotic seemso closely akin to malingering. A neurosis is the psychopathic means of evadinga difficult situation. It may be primarily mental in character (psychasthenia),or it may present symptoms closely simulating those of organic injuries ordiseases (hysteria).
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Overseas the neuroses developed in large numbers both in thebase sections and at the front. Although the method adopted of treating theacute cases which developed during battle, in the divisional and army hospitals,greatly decreased their numbers, there were still many in whom the symptomspersisted in a disabling way until the armistice was signed, and some in whomthey persisted after that. These persistent symptoms showed plainly that thepersons presenting them were of a psychopathic type and might have beenrecognized at the time of enlistment, and by whose rejection the Army would haveprofited.
As it must now be conceded that there is a large class ofrecruits who are bound by neurotic behavior to be a burden instead of an assetto the Army, the only questions that remain are whether these individuals can berecognized beforehand, and what, if any, distinction should be made between themas to possibilities of service.
METHODS OF ELIMINATION
Owing to the absence frequently of outstanding physicaldefects, the detection of mental and nervous defects in individuals during thephysical examination prior to entry into the Army is frequently rendered mostdifficult. In times of peace, when enlistment is on a voluntary basis, and thenumber being examined at any place each day is not large, it is possible for anexperienced examiner to detect the majority of applicants of this type. Prior toour participation in the World War, however, with the Army recruited in thismanner, the number of discharges each year on account of neuropsychiatricdisease was never large. Following our participation in the World War and theconsequent rapid mobilization of men of draft age, it became evident thatskilled recruit examiners were not available in sufficient numbers. In orderthat qualified examiners might be available at all camps, each professionaldivision of the Office of the Surgeon General, as noted heretofore, designatedcertain of the officers exempted to that division for duty at the camps asexaminers in their particular specialty.
From the beginning of the mobilization the examinations werecarried on at officers' training camps, cantonments, recruit depots, andrecruit depot posts, and at all points where registrants or volunteers werebeing mustered into the service. At first two chief methods were employed:Examination of referred cases, and general surveys.
By the method of referred cases, only such cases as werereferred to the neuropsychiatrist were examined. The references were made byregimental surgeons and company commanders. It soon became obvious that thismethod was inadequate, as by it only men with evident defects were referred, andthen generally after long and unnecessary delay. Further, the officer who madespecial examinations of referred cases was stationed at the base hospital, and,therefore, not readily accessible. Later, upon the appointment of examiningboards at each camp functioning for the examination of all men arriving at thecamps, under the general direction of the camp or division surgeon, every manwas examined for mental or nervous defect by an officer assigned by the divisionof neurology and psychiatry of the Surgeon General's Office.
The first increments of our Army were not all examined byneuropsychiatrists and a considerable number of men unfit for military service,because of
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nervous or mental condition, were carried overseas. Thesepromptly appeared in the hospitals of the American Expeditionary Forces and,later, in General Hospital No. 30, Plattsburg, the majority of them with ahistory of illness of from one to five years' duration previous to theirentrance into the Army. To meet this situation survey boards composed of two ormore neuropsychiatrists were later ordered to examine commands which had beenpreviously accepted for service.
Under the method of surveys, the whole command passed beforethe special officers. On the basis of a brief conversation and observation, andexamination for such physical symptoms as tremors, changed reflexes, etc., therecruit was passed, or if not satisfactory, was deferred for a thoroughexamination. By this method an experienced examiner could dispose of 100 to 150cases a day with reasonable accuracy. Large boards were sometimes sent byrequest of generals commanding divisions, to examine the whole division in ashort space of time.
Neither of these methods being coordinated properly with thephysical examinations, it was difficult for special boards to operate when thecamps first opened, and later it was difficult to get the recruits together, asthey were occupied with their military duties. The examinations did not becomeadequate until they became a part of the routine entrance examination of allrecruits.
But the great practical difficulty for a time was to obtainaction on the recommendations for rejection or discharge. The special examiningboards were composed, for the most part, of officers of little or no militarytraining, who, consequently, were ignorant at first of the procedure to befollowed to insure action on their recommendations. For example, between two andthree hundred privates of the National Guard of New York, examined and foundunfit by psychiatrists in New York, were nevertheless sent to Camp Sevier, S.C., with their organizations. It was only after the useless journey to SouthCarolina that the recommendations found their way to the disability boards, andthe men were finally discharged.
Once the recommendations reached the disability board theywere generally acted on favorably, although the surgeon sometimes disapprovedthe board's findings, and the discharging authority did not always agree withthe surgeon's recommendations. But most of the cases which were retained inthe service in spite of the recommendation of the psychiatrists failed to cometo the attention of the disability boards for the reasons stated above, orbecause troops were being moved too fast to make it possible.
It was never considered desirable that disability boards bemade up exclusively of psychiatrists. Composed, as they were, of general medicalofficers, these officers had the advantage of acquiring a familiarity with themethods and importance of the neuropsychiatric work; furthermore, dischargesrecommended by mixed boards could not be considered as testimonials to theoverenthusiasm of specialists. In August, 1918, an order was issued abrogatingprovisions for separate examining boards for three of the medical specialties,including neuropsychiatry.4 Followingthis, all the camp examinations for the purpose of examining drafted men, andlater for demobilization, were coordinated, and placed under the direction ofthe division of sanitation, Surgeon General's Office.5
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In the beginning there were neuropsychiatric examinations ofcandidate officers at a few of the first series of the officers' trainingcamps, and at many of the second series. In general, however, officers were notexamined for nervous and mental conditions prior to being commissioned and, atthe majority of camps, were not examined when the neuropsychiatric surveys ofthe soldiers already in the service were conducted. This was an outstandingdefect of the neuropsychiatric service, as many officers were later discoveredto have defects of this type rendering their discharge necessary.
On the whole the cooperation existing between theneuropsychiatrists and other medical officers, as well as with officers of theline, was harmonious and attended always by a joint desire to detect andeliminate the mentally or nervously unfit from the service. Attention wasdirected to the importance of the work being done by the neuropsychiatricofficers in the following promulgations:6 7
1. The Surgeon General again invites yourattention to his desire that you make every endeavor to recognize and eliminateall cases of mental disease, all mental defectives, and all cases of nervousdisease. It is believed that not less than 10 per 1,000 of men now in serviceare unfit from one of the above mentioned conditions
2. To aid you, orders have been issued makingthe services of the neurologists and psychiatrists detailed to the basehospitals available for the examination of troops of the division in hisspecialty.
3. It is desired that you use every effort toarrange with the commanding officer for tile inspection of each organization bythe specialist medical officer at some time during the training period, todiscover those soldiers whose general attitude and appearance suggest the needof special neurologic and psychiatric examination. Each organization will beinspected if possible, details of this inspection being left to you, but it issuggested that they may be made advantageously when organizations are gatheredtogether for such general medical purposes as vaccination, inoculation, physicalinspection of various kinds, etc. But if special formations are necessary, youwill endeavor to arrange them.
4. You will recommend to the commandingofficer that general written instructions be issued confidentially to theofficers, to the following effect:
(a) Officers commanding companies,troops, batteries, detachments, or other organizations will note each member oftheir commands for the purpose of forming an opinion as to whether they showevidences suggesting mental disease or defect, or insufficient nervousstability. Organization commanders will require the same observation by theirjunior officers and by noncommissioned officers, who will be directed to reportdoubtful cases to them.
(b) Those havingofficers under their command should secure special examination of any officerwho seems of doubtful mental integrity or nervous stability.
(c) Senior medical officers willrequire those under their command to be on the lookout for mental and nervouscases.
(d) Medical officersserving with regiments or other units, those holding daily "sickcall," those making physical inspections of any kind, and ward surgeonswill bear nervous and mental disease in mind, and refer suspicious cases forexpert examination.
(e) Officerscommanding places where prisoners, garrison or general, are confined, summarycourt officers, judge advocates, and assistant judge advocates ofcourts-martial, and officers who act as counsel for enlisted men, will note thementality of all cases before them and refer all doubtful cases for properexamination.
(f) The observationsherein required should be made quietly and unobtrusively so that if possible noofficer or enlisted man shall know that his mental or nervous condition is underquestion. This is important.
5. The fact that troops are being mentallyexamined will be kept from becoming a matter of gossip if possible.
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6. You should require the neurologicalexaminations of all men known to be suffering from syphilis.
7. You will require the specialist medical officer to make,through you, monthly reports to this office of the special work done. Forms 89,90, and 91 have been prepared for this purpose. The printed copies of theseforms will be sent to the cantonments by the field supply depot in a few days.
Bulletin No.4.
WAR DEPARTMENT,
Washington, February 7, 1918
* * * * * * *
Officers with special experience in nervous and mentaldiseases have been added to the Medical Department of the Army. Such officersare detailed at all base hospitals and with many divisions. Most base hospitalshave also special nurses and therapeutic appliances for the care of nervous andmental diseases. The services of these officers and nurses are available,through their superior officers, for consultation in all matters pertaining tosuch diseases. The foregoing facts are announced for the special benefit ofpersons that are brought socially in contact with soldiers, as such persons arein a particularly favorable position to witness the early stages of mentaldisease, and by their prompt and cooperative action may render valuableassistance in preventing nervous breakdowns. Reports from abroad indicate that alarge number of the soldiers who break down nervously (shellshock) had, forseveral days before their final collapse, given evidence that they were fastapproaching the limit of their nervous endurance. It is believed that hadsomething been done for them during those critical days they would havereadjusted themselves quickly and gone back to their duty instead of remainingnervous invalids, with little prospect of recovery before the end of the war.Nervous breakdowns often begin by sleeplessness, persistent homesickness,nervousness, depression, self-reproach, unreasonable fear, suspicion of others,feeling of resentment against others, and general complaints of ill health.These signs often show in the man's social conduct, so that he is remarked byhis companions as being restless, jerky, inclined to stay by himself, badtempered, etc.; in other words, his companions remark that some change has comeover him. The man himself may realize that he is out of sorts, but often he doesnot realize that he is ill and so does not report at sick call; on the contrary,he often resents the idea that he needs the care and supervision of a physician.Yet a little rest, care, and medicine, such as would be provided if his casewere brought to the attention of a medical officer, would in all probabilitysuffice at this time to put the man on his feet again.
(700.7, A. G. O.)
By order of the Secretary of War:
JOHN BIDDLE,
Major General, Acting Chief of Staff
Official:
H. P. MCCAIN,
The Adjutant General.
Clinics and lectures were given for other medical officers, and talks, of asuitable nature, to officers of the line. The following memorandum wasdistributed to company commanders:8
The object of this survey is to find and discharge from theArmy such cases of maladjustment to Army duties or discipline as may be shown tohave a mental or nervous abnormality. The following types of cases should besought out and sent for examination by the survey board:
Cases showing unusual difficulty in learning drill,instructions, etc., not clearly dependent on unfamiliarity with the Englishlanguage.
Persistent delinquents, irresponsible, morally obtuse individuals.
Eccentric, seclusive, taciturn individuals, company "butts."
Those showing marked emotional instability; i. e., too readily moved to tears,anger, or noisy elation.
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Those indulging in or suspected of abnormalsexual practices.
Drug or alcohol addicts.
Those having fainting spells or other evidences of possible epilepsy.
Persistent bed wetters.
Extreme cases of stammering.
Chronic ailers showing no evidences of organic disease, hysterical orneurasthenic individuals, suspected malingerers.
Apathetic, negligent, untidy, or otherwise seemingly inferior or objectionableindividuals.
Those who may be on any other grounds suspected of being mentally unfit.
It is very desirable that each case sent for examination should be accompaniedby a memorandum stating in terms of observed facts or of the soldier'sutterances or conduct the reason for the desired examination.
Company commanders and regimental surgeons cooperated in theneuropsychiatric surveys, as they afforded often the only way of being relievedof problems of administration and discipline arising from the demoralizingeffect of the presence in their organizations of mentally unfit individuals.
All cases about to be tried by court-martial should receive acompetent psychiatric examination to determine not merely their legalresponsibility, but also whether the soldier is afflicted with aneuropsychiatric disorder which would ordinarily lead to his discharge onsurgeon's certificate of disability. If so affected, generally he should bedischarged, rather than tried, and not recommended for reenlistment. Shouldtrial be deemed advisable, no sentence should be imposed which might aggravatehis disability-such as confinement with hard labor in a case of epilepsy-butrather forfeiture of pay or dishonorable discharge.
INSTRUCTIONS TO EXAMINERS
The examinations made by the officers of the neuropsychiatricservice may be divided into two general groups. The first comprised the mentaland nervous examination of applicants for enlistment and of draftees reportingat camps of mobilization. This examination was completed before the men wereactually in the military service and was made with the special object ofexcluding those who failed to reach the required standards. In the second groupfell all examinations made by the neuropsychiatrists after the individuals wereactually in the Army. Included here were the examinations of patients inhospitals; of men referred by medical or line officers; the neuropsychiatricsurveys of troops which had come into the Army without the specialneuropsychiatric examination, as has been explained previously; and theexamination of all men prior to discharge from the service. This latterexamination was conducted at the various camps by the camp examining boardsreferred to above, but the results of the neuropsychiatric examinations at thistime were largely negative, as the majority of soldiers of this type had alreadybeen detected and disposed of. Examinations made at the disciplinary barracksmay be considered as a third group.
While a thorough mental examination of the recruit willeliminate a large proportion of undesirables at the outset, a certain number ofmental and nervous defectives will slip through. From the nature of the diseasesconcerned this can not be avoided, and the neuropsychiatrists must be alert atall times to detect mental or nervous disease in those who have shown unusualdifficulty in learning
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the drill and in following instructions, those who arepersistently delinquent, who are seclusive, eccentric, taciturn, or who exhibitother marked peculiarities of behavior. Such men were carefully sought forduring the war and properly disposed of when discovered.
With the exception of the purely neurological cases thedefects to be identified by the neuropsychiatric officers were more in thesphere of behavior than in that of concrete physical symptoms. The diagnoseswere generally made independently of physical symptoms, and sometimes recruits,at the preliminary examinations, were recommended for rejection as mentallyunsuitable who had been passed by other medical officers as physically sound inother respects. The methods employed during all these special examinations werethose of clinical psychiatry.
Under date of August 1, 1917, as noted heretofore, theSurgeon General issued Circular No. 22, which outlined the nervous and mentalconditions for which the neuropsychiatric examiners should search, and gave thegeneral grouping which should serve as causes for rejection. This circular wasas follows:
Circular No.22.WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, August 1, 1917
EXAMINATIONS IN NERVOUS AND MENTAL DISEASE
1. For the safety, efficiency, and economy of themilitary service it is highly essential that nervous and mental disease berecognized at the earliest possible moment. Nervous and mental diseases may, andfrequently do, exist in persons who are strong, active, and apparently healthyand who make no complaints of disability. Such persons are, however, more thanuseless as soldiers, for they can not be relied on by their commanders, breakdown under strain, become an encumbrance to the Army, and an expense to theGovernment. Disorders of this character are often demonstrable only as theresult of a painstaking and special examination directed toward the mind andnervous system. This circular is published for the special purpose of callingthe attention of medical officers to the particular diseases most frequentlyoverlooked on general examination, and the symptoms most important to theirdiagnosis, and to certain characteristics in personality and in the behaviorwhich might raise the question of the existence of mental disease.
2. The duties of the examiner are to befamiliar with the symptoms and significance of nervous and mental disease andthe means of eliciting them, and to recommend for rejection from service allthose in whom any of the evidences mentioned in paragraph 4 are demonstrated. Heshould determine the importance of slight variations from the ordinary normalstandard and recommend acceptance or rejection on the basis thereof. He shouldsearch for symptoms or tendencies which may be concealed for the purpose ofobtaining service, and he should recognize symptoms which are feigned for thepurpose of avoiding service. Organic nervous disease can not be feigned in a wayto deceive a skillful and careful examiner. To demonstrate feigned insanity aperiod of several weeks' observation may be necessary.
3. It is assumed that the examiner is familiarwith the current methods of examination in neurology and psychiatry, and that hewill make careful employment of them in all cases referred to him forconsultation. But in addition to acting as a consultant to whom cases arereferred, he must also himself select cases for special examination. To thisend, he is directed to be present as often as possible when the recruits aregathered together at times of instruction and training and for such generalmedical purposes as vaccinations, inoculations, group examinations of the heart,lungs, etc. At such times he should discriminatingly observe the appearance andbehavior of the recruits, pass in and out among them, converse with them whenpossible, and report to the camp surgeon the names of any whom his obser-
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vations have led him to consider as requiring a specialneurological and psychiatric examination. By thus learning, in a way, to knowthe recruits personally his special training should enable him now and then topick out one who might pass the general medical examination and yet whomspecial examination would clearly prove to be a hazard to the Army.
Queerness, peculiarities, and idiosyncrasies,while notinconsistent with sanity, may be the beginnings or surface markings of mentaldisease. A soldier is too important a unit for such variations from a standardof absolute normality not to be looked into before the recruit who presentsthem is accepted for service. To aid the neurologist and psychiatrist in theseways the camp surgeon shall direct all medical officers, dental surgeons,instructors, hospital sergeants, and others who come in close contact withrecruits to refer to him (the camp surgeon) all recruits who persistently showany of the following characteristics: Irritability, seclusiveness, sulkiness,depression, shyness, timidity, overboisterousness, suspicion, sleeplessness,dullness, stupidity, personal uncleanliness, resentfulness to discipline,inability to be disciplined, sleepwalking, nocturnal incontinence of urine, and any of the variouscharacteristics which gain for him who displays themthe name of "boob," "crank," "goat," "queerstick," and the like.
The reaction of the pupils to light should be part of everymedical examination, and if this is not systematically provided for, theneurologist and psychiatrist should be directed to determine it. This could bedone at the time of group inoculations and with the help of a hospitalsergeant could be made rapidly. Electric light should be used. It is especiallyimportant in the examination of officers and recruits above 25 years of age.
It is further recommended to camp surgeons to provideneurological examinations for all cases of syphilis.
4. The following are causes of rejection formilitaryservice:
A. Organic nervous diseases.
B. Mental defect.
C. Mental disease and pathological mental states.
D. Confirmed inebriety (alcohol or drugs).
A. ORGANIC NERVOUS DISEASE
Certain after effects of organic nervous disease need notbe causes for rejection provided (1) that the disease is no longer operativeand is not likely to recur, (2) that the effect left by it does not prevent asatisfactory fulfillment of military duties. Examples of such conditions areparalysis of a few unimportant muscles following poliomyelitis, slightunilateral hypertonicity as a result of an infantile hemiplegia in a mannow robust, and various traumatic conditions. A history of hemiplegia occurring afterinfancy should always exclude, even if no symptoms remain.
Existent organic nervous disease should always exclude. Forexample, neuritis, of one or many nerves, while susceptible of recovery without resultant defect, isnone the less a cause for rejection as long asit exists. The following organic nervous diseases are mentioned specifically, asthey are the ones which frequently present few symptoms and may pass undetected by even the most skillfulexaminer:
Tabes, or locomotor ataxia - Look forArgyll-Robertsonpupil or pupils, absent knee jerks, Romberg symptom, ataxia of hands or legs(especially with closed eyes), hypotonia, anesthetic areas of skin. Historyis usually that of slow progression, failing sexual power, and pains in thelegs or back, often described as rheumatism. In doubtful cases it is requiredthat the Wassermann reaction of the blood be determined and the cerebrospinalfluid be examined as to the Wassermann reaction, cellular and globulin content, etc.
Multiple sclerosis - Lookfor intention tremor, nystagmus, absent abdominal reflexes, and increasedtendons reflexes. The scanning speech may be mistaken for stammering. No history of pain, butsometimes history of urinary disturbance.
Progressive muscular atrophies, dystrophies, andsyringomyelia - Look for atrophies in the small muscles ofhand and inthe muscles of the shoulder girdle, with fibrillary twitchings. These plusanesthesia for heat and cold (scars on hands from cuts and burnings) =syringomyelia. History usually furnishes little data, although reference may bemade to awkwardness. No history of pains. Syphilitic spinal disease imitatesthese conditions closely.
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Epilepsy.-Look for deep scars on tongue, face, and head.The voice is frequently characteristic. If history alone, verify bycorrespondence with physicians.
Hyperthyroidism - Anervous disease in its effects.Look for persistent tachycardia, exophthalmos, tremor, enlarged thyroid.History of general nervousness.
In addition to the foregoing there are certain sets orcombinations of symptoms which should exclude from service. They may not bythemselves be sufficient for an exact diagnosis, but they prove beyond cavilthat the nervous system is seriously diseased and totally undependable for anycontinuous service.
Pupil or pupils-Argyll-Robertson.
Nystagmus (in one not an albino), absent abdominal reflexes, intention tremor. Combination of any two should constitute a cause for rejection.
Babinski reflex.
Disturbances of station or gait.
Disorders of speech on test phrases (viz, "Third riding artillery brigade") plus facial tremor or any other one symptom of organic disease. Confirmation by laboratory findings is desirable.
Cervical sympathetic syndrome, viz, unilateral narrowing of palpebral fissure, sunken eyeball, flattening of face, unequal pupils.
B. MENTAL DEFECT OR DEFICIENCY
Look for defect in general information withreference to native environment, ability to learn, to reason, to calculate, toplan, to construct, to compare weights, sizes, etc.; defect in judgment,foresight, language, output of effort; suggestibility, untidiness, lack ofpersonal cleanliness, anatomical stigmata of degeneration, muscularawkwardness. Consult psychometric findings. Get history of school and vocationalcareer and disciplinary report.
C. MENTAL DISEASES
A definite corroborated history of a mental diseasethatrequired hospital treatment or observation serves as a cause for rejection in arecruit mentally normal at the time of examination. The circumstances should,however, be inquired into with great care. Few mental diseases presentobjective physical signs, but their manifestations are none the lesscharacteristic and dependable. All mental diseases are causes for rejection. Inaddition to the well-defined clinical types such as paresis, dementia pr?cox,etc., there are various combinations of psychological symptoms which renderthose who suffer from them unstable, unreliable in emergency, and subject toattacks of disabling mental illness from slight emotional causes.
General paralysis (paresis) - Look forArgyll-Robertsonpupil or pupils, facial tremor, speech defect in test phrases, and in theslurring and distortion of words in conversation, writing defects consisting ofomissions and distortion of words. Mood is apathetic or depressed or euphoric.Memory loss, discrepancies in relating facts of life. Knee jerks may be plus,minus, or normal. In doubtful cases it is required that the Wassermannreaction in the blood be determined and that the cerebrospinal fluid beexamined as to Wassermann reaction, cellular and globulin content, etc.
Dementia pr?cox - Look for indifference, apathy,withdrawal from environment, ideas of reference and persecution, feelings ofthe mind being tampered with, and thoughts being controlled by hypnotic,spiritualistic, or other mysterious agencies, hallucinations of hearing, bodilyhallucinations, frequently of electrical or sexual character; meaninglesssmiles; in general, inappropriate emotional reaction and a lack of connectednessin conversation. There may be sudden emotional or motor outbursts. Get historyof family life and of school, vocational, and personal career.
Manic-depressive insanity - Look for mild depressionwith or without feeling of inadequacy or mild manic states with exhilaration,talkativeness, and overactivity.
Psychoneuroses - Look for hysterical stigmata, such ascutaneous anesthesias (especially hemianesthesia), contractions of the visualfields, etc., phobias, morbid doubts and fears, anxiety attacks, compulsions,hypochondriasis. Compare complaints with behavior and obtain history as toformer nervous breakdowns and vocational career.
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Psychopathic characters.-Homosexuals, grotesque liars,vagabonds. Superficially bright oftentimes. These individuals do not last outand never stay at any one thing long. Frequent military and civil offenders.Get history of personal career.
D. CHRONIC INEBRIETY
For alcoholism look for suffused eyes, prominent superficialblood vessels of nose and cheek, flabby, bloated face, red or pale purplishdiscoloration of mucous membrane of pharynx, and soft palate; muscular tremorin the protruded tongue and extended fingers, tremulous handwriting,emotionalism, prevarication, suspicion, auditory or visual hallucinations,persecutory ideas.
For drug addiction look for pallor and dryness of skin. Iftaking drug, the attitude is that of flippancy and of mild exhilaration; ifwithout it, it is cowardly and cringing. There are also, during period ofwithdrawal, restlessness, anxiety, and complaints of weakness, nausea, andpains in stomach, back, and legs. Distortion of al? nasi. Pupils contractedby morphine and dilated by cocaine. All habitual drug takers are liars. They donot drink, as a rule, and are inactive sexually.b Most drug takers use needlesand show white scars on thighs, arms, and trunk. Heroin takers are mostlyyoung men from the cities, often gangsters. They have a characteristicvocabulary and will talk much more freely about their habit if the examiner inhis inquiries uses such words as "deck," "quill,""package," "an eighth," "blowers," "cokie,"etc.
W. C. GORGAS,
Surgeon General, United States Army.
Approved by order of the Secretary of War, August 9, 1917.(702 O. D., A. G. O.)
STANDARDS OF FITNESSc
Circular No. 22, although it set few absolute standards,largely determined the findings of the neuropsychiatric officers throughout thewar. In pronounced cases of definite diseases, such as dementia pr?cox andepilepsy, it was possible to follow a fixed standard, but many of the mentallyand nervously unfit are border-line cases or are types of inadequate personalityimpossible of absolute classification. The actual symptoms are not alwaysdefinite, and the reasons for rejection for military service must frequently liein the judgment of the examiner and his ability to evaluate in terms ofpersonality development or psychopathology the social histories of the men. Forexample, many of the men rejected on account of constitutional psychopathicstate would have been accepted had it not been for the special examination bythe neuropsychiatrists, as no definite tangible physical symptoms existed which,otherwise, would have been observed. Had these men been accepted for militaryservice the majority of them would have been ultimately discharged as inaptunder the provisions of paragraph 148?, Army Regulations, or forphysical disability, or by sentence of a court-martial, after having beenconvicted for some dereliction of duty.
In the consideration of mental deficiency, the standard forrejection was not always uniform, although generally understood to be amentality of or below that of a child of 8 years. It is apparent from reportsreceived in the Office of the Surgeon General that this 8-year standard is toolow.
bThis was proved to be in error.
cA full discussion of physical examinations may be found in Vol. VI, Sanitation, Chaps. XIX, XX, and XXI.
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However, it was not always possible to arrive at a scientificdetermination of the mental age of recruits, as the time required for thenecessary examination was often not available. Even if the psychological grouptests had been applied for all recruits, the problem would not have beensettled, as it was not agreed that psychological rating alone is sufficient towarrant rejection for mental deficiency.
Throughout the entire group of neuropsychiatric disordersmuch latitude was necessarily left to the opinions of the neuropsychiatricexaminers, and the recommendations of these officers with reference to themental or nervous fitness of recruits for the military service came eventuallyto be quite generally followed. This was true for both rejection from andretention in service. Chronic alcoholism, for instance, was a cause ofrejection, yet comparatively few alcoholics were rejected, far less than mighthave been under the existing standards. The standards of physical requirementsplaced subjects of drug addiction in the deferred irremediable group, yet acertain percentage of them were accepted for service.
During the first period of mobilization the acceptance forlimited service of recruits, presenting certain specified neuropsychiatricdefects, was authorized and recommendation to this effect was made in aconsiderable number of cases. With added experience the disadvantages of such aprocedure became evident, as has been mentioned, and upon the recommendation ofthe Surgeon General, recruits presenting neuropsychiatric defects, with a fewminor exceptions, were rejected for all military service. The most important ofthe exceptions mentioned was that certain mental defectives, especially negroes,be accepted for limited service in labor battalions. Reports regarding theservice of men of this class left considerable doubt as to the wisdom of thispolicy.
The subject of aviation opened up a new and important fieldof neuropsychiatric activity, for it was found that even after the minute andprolonged examinations to which aviators were subjected, there was still roomfor special investigation of the nervous system. Three neuropsychiatric officerswere detailed to the medical research laboratory at Mineola, Long Island, tostudy the problems peculiar to this branch of special work.
Because of the high physical and mental standards of fitnessemployed in the selection of men for this arm of the service, theneuropsychiatric problem here was different from that associated with theordinary work of elimination for mental and nervous disease or defect carried onin the other branches of the service. The psychiatric work at Mineola was morethan the mere search for pathological conditions through the observation of moreor less gross signs or symptoms, or even the more extended examination of mensuspected of mental or nervous disease. Because of the superior type of humanmaterial needed for the Air Service and the special stresses and strains ofaerial warfare, this work took on the character of refined personality studiesin which the more difficult and less tangible emotional factors had to beconsidered and dealt with.
Such personality studies were made after the examination ofseveral hundred aviators and after numerous conferences with American officerswho had seen service at the front, and with representatives of our allies. The
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psychiatrist had three definite objects in view in makingthese studies: (1) To detect the presence of nervous and mental diseases whichwould render the aviator temporarily or permanently unfit for service; (2) toform a definite idea as to what extent the aviator could stand the pressure oflife at the front; (3) to determine, and as far as possible to compensate for,the existence of any latent tendencies which, under the strain of actualwarfare, would become so accentuated as to make the aviator either inefficient,or to increase his danger of nervous and mental collapse.
The value of these brief studies in reducing the number ofcasualties due to preventable causes and in increasing efficiency, it isbelieved, was clearly demonstrated. It was felt that the information obtainedhad a direct practical bearing in assisting the aviator to maintain his moraleand to make a rational effort to direct all of his nerve and brain power,without useless dissipation, to the task of winning the war. The following casesare examples of the advantages accruing from a psychiatric service foraviators:9
Case 1.-A typical case of mild manic excitement,marked by motor restlessness, slight but well marked irritability, typicalelation and desire to talk, was examined one forenoon and pronounced unsafe forflying. This aviator, although forbidden to fly, disobeyed orders, took theplane up, and crashed on attempting to land. The machine was partiallywrecked, and by a miracle neither the observer nor the pilot was seriouslyinjured.
Case 2 - One ofthe best pilots, who had had 300 hours in flying, lost nerve and when ordered to fly refused to go, sayinghe wassure an accident would follow. This aviator was referred to the neuropsychiatricdepartment for examination, and it was discovered that his sudden loss of nervewas due to an unsolved personal problem which he had attempted to dodge and toforget. After one week's treatment in which assistance was given in settlingthe difficult situation, his nerve returned and he was practically as efficientas ever.
In a number of cases studied the symptoms of mental stalenessand mental fatigue were present. These symptoms were characterized by loss ofinterest in work, a tendency to analyze details and forget the main object inview, and a certain recklessness, the result of defective inhibition. Seriousaccidents would have followed had these aviators been allowed to fly before theyhad gained their emotional equilibrium. Many serious accidents occurred as theresult of the failure to recognize the importance of the initial symptoms offatigue and staleness.
NEUROPSYCHIATRIC EXAMINATIONS IN CAMPS
The following discussion of neuropsychiatric examinationsmade in camps is based on the reports to which they are credited, withoutcomment as to the findings:
IN RECRUITING AND CANTONMENTd
The neuropsychiatric work in the cantonment presented specialfeatures which were quite different from those in military hospitals. In thelatter, neuropsychiatry was similar to that in civil hospitals, or civilpractice. In base hospitals one found chiefly obvious disorders, which had beenreferred for examination and treatment, by the regimental surgeons, who as arule were not very familiar with such conditions. In the cantonment, cases ofthe same class
dNeuropsychiatry in Recruiting and Cantonment, byMaj. M. S. Gregory, M. C. Archives of Neurology and Psychiatry, 1919,i, No. 1, 89.
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were met with, but, in addition, one encountered a specialtype, which rarely, if ever, found its way to the base hospital, by reason ofthe fact that the true character of such disorders was not recognized and veryfrequently they were regarded as entirely foreign conditions, such asmalingering, carelessness, shiftlessness, delinquency, and inattention to duty.
TYPES OF DISEASES OBSERVED
These cases were not dissimilar to those found in civil life,only modified by the natural differences, such as age, sex, climate,geographical conditions, care in selection, etc. One encountered gross organicnervous diseases, such as early tabes, paresis, multiple sclerosis, peripheralneuritis, neurosyphilis, residual from old poliomyelitis, occasional braintumor, and other conditions, on the one hand, and, on the other, well-developeddementia pr?cox, manic-depressive psychoses, mental deficiency, alcoholism,drug addiction, epilepsy, and well-marked psychoneuroses.
Between these two extremes, there was a host of intermediaryconditions, such as mild neuroses and psychoneuroses, neurasthenias, anxietystates, hysterias and hysteroid episodes, epileptoid conditions, psychopathicpersonalities, inferiors, military misfits, and otherwise near-normalindividuals. Cases of this group were, of course, the most baffling and taxedthe ingenuity and resourcefulness of the examiner to the utmost. Moreover, theyconstituted a greater menace to the military organization, by lowering theefficiency and impairing the general morale, than did the obviously diseasedtypes which were readily recognized and without great difficulty eliminated.They were constant sources of annoyance and trouble to the officers, forming thelarger number of the absentees, the discontented, the inefficients, the inmates of the guardhouse, and the frequenters of the regimental infirmary.These were the cases which complained of being dizzy, faint, and bewildered atcritical moments, while in training or maneuvers.
The psychoneurotic formed the largest and most important ofthis intermediary group. As they presented themselves in the cantonment, andbased on the duration and mode of onset of their malady, they were classified,for practical purposes, into three groups:
The first group consisted of those in whom the diseaseexisted long before their entrance into the Army. These, as a rule, hadneuropathic family histories and had been unstable and more or less shiftless,long prior to the onset of the neuroses. Curiously enough, many of the neuroticsof this type were found among the enlisted men who had been advised, byphysicians, to enter the Army with the assurance that the discipline and outdoorlife would correct their trouble. Others had enlisted without much advice,although they themselves had entertained the hope that they would derive benefitfrom military service. According to their own statements, all seemed to havefelt quite improved for a short period immediately after their enlistment.However, this amelioration was of brief duration. Our experience was that thistype of neurotic was quite unfit for military service and that the entrance ofsuch individuals was detrimental to themselves as well as to the Army.
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The second group comprised those in whom the disease arosewhile they were in the Army, following an accident, injury, or some somaticdisorder, such as rheumatism, bronchitis, etc. The neurosis was referred to andintimately connected with the injury or disease. These men, as a rule, had abetter family and personal history than the former group and recovery of a small proportion might be looked for in camp.
The third group was made up of men whose antecedents had beenapparently free from neurotic taint and in whom the hysterical conversion hadnot been definitely established, remaining latent or just beneath the surfaceand usually corrigible by educative and environmental influences.
METHOD OF APPROACH
One hardly expected to be received with enthusiasm when onearrived at a camp to do neuropsychiatric work. There appeared to be, on thecontrary, with very few exceptions, a lack of interest or an indifference or amanifest skepticism; not infrequently there was a passive, or even an active,antagonism to any examination of this sort. Strangely enough, the medicalofficers were the chief passive obstacles and, in the very beginning, verylittle assistance or cooperation could be obtained from them. So the firsteffort at a cantonment had to be directed to the officers, especially themedical officers, with the view of demonstrating to them the practical valueof such examination in order to enlist their sympathy and cooperation. They hadto be made to appreciate the importance of neuropsychiatric examinations. Inorder to accomplish this, one frequently had to resort to tact, persuasion, oreven strategy.
In dealing with this situation of passive resistance, it wasdesirable in the beginning to report as unfit for military service only men withobvious nervous or mental disturbances in whom one could show the disorder inits early phases and point out how the disease influenced the soldiers'conduct and efficiency. For example, the painstaking demonstration of earlycases of tabes, of disseminated sclerosis, of paresis, of dementia pr?cox, or ofmanic-depressive psychosis, which had been unrecognized and unsuspected, went agreat way in rousing the interest and even the enthusiasm of the medicalofficers. The greatest help to the neuropsychiatrist came, however, from theline officer, and particularly the company commander. It may seem strange, butit is nevertheless true, that the line officers appreciated the value ofneuropsychiatric examinations much more readily than did the medical officers.
The explanation for this was found in the fact that the lineofficer rated his men in terms of conduct, behavior, and efficiency, which,after all, was equivalent to the standard of the neuropsychiatrist, whoestimated conduct from the mental qualities and make-up of the individual. Ifa company of soldiers be carefully examined from the neuropsychiatricstandpoint and the results compared with the reports furnished by the companycommander of men in his organization who have been inapt, inefficient, slow,awkward, easily fatigued, delinquent, insubordinate, and difficult to get alongwith, a striking parallelism will be found between the two sets of observations.
Experiences of this character naturally brought the lineofficer very close to the neuropsychiatrist. The officer eagerly sought counseland aid, as he at
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once recognized that he and the examiner were dealing withsimilar problems. The neuropsychiatrist might be called on by the commandingofficer to give advice in the matter of discipline of the force and even in therating of the efficiency of his officers.
In a hastily formed army like ours, especially under asystem of draft, there was a great demand on the individual soldier for a rapidand violent adjustment. Men without any previous military experience, drawn fromevery walk of life-from distant parts of the country, from farm and factory,bank and bench, the rich and the poor, the illiterate and the educated-allwere thrown together in a heterogeneous mixture and subjected to the samediscipline, the same regulations, and the same daily routine.
It was most astonishing how well and how rapidly they adaptedthemselves under these most difficult conditions. However, there was a smallnumber in whom this adjustment did not readily take place. It was among thisclass of men that one observed pathologic reactions in the form of sluggishness,discontent, inadaptability, lonesomeness, nostalgia, lack of application, lackof initiative and ambition and, therefore, military inefficiency. Some ofthese, of course, were of markedly pathologic make-up, but the great majoritywere men to whom the neuropsychiatrist could be of the greatest assistance.These were the border-line cases, the potential neurotics and psychotics, inwhom preventive psychiatry found a most fertile field.
Many patients of this kind, although able to get along fairlywell in camp, suffered a definite breakdown at some critical time, such as justbefore embarkation; others were returned from overseas before they hadseen any active service at the front.
SUGGESTIONS AS TO PROPER SUPERVISION
It was surprising how much the advice, encouragement,assurances, personal contact and attention, and trivial changes in environmentwould do for these men. That this was not mere theory, but intensely practical,could be readily demonstrated in a military camp or cantonment. The followingare a few brief illustrations:
The attention of the neuropsychiatrist was called to asoldier who was indifferent, inefficient, lazy, and seemingly lacking ininitiative. Examination revealed that he came from a large city, had had ahigh-school education, had worked as a salesman, and had a salary of from $75to $100 a week. He was made assistant in the camp to a kitchen worker, who wasilliterate, far below him socially, and whose earning capacity had never beenmore than $12 a week. The soldier did not complain of this, nor could he giveany conscious reason for the change in his efficiency and conduct, which,however, he acknowledged. His commanding officer was advised to place him inanother department where his talents would find a better expression. Within aweek a striking change had come over his disposition and he was regarded as amost useful, energetic worker and a promising soldier.
A soldier serving as a waiter at an officers' mess showedmild mental depression. He was regarded as slow, inattentive, and inefficient.He complained of insomnia, nervousness, headache, dizziness, and inability totake any interest
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in things. He was unable to assign any cause for hisdisability. He was anxious to be a soldier and serve his country. It was furtherfound that he was a recent graduate of a New England college; had been broughtup in affluence and comfort, and was socially equal or superior to many whom heattended as a waiter. He consciously did not resent his position, because hefelt that it was a part of military life. The commanding officer, onrecommendation, assigned him to another kind of work more in keeping with histalents and experience. He soon became active, energetic, and efficient. He wasregarded as good material for a soldier and was rapidly promoted. These actualcases were selected from a large number of records.
RESULTS THAT MIGHT BE EXPECTED
There were many soldiers who voluntarily sought the advice ofthe neuropsychiatrist because of nervousness, dizziness, inability to sleep,poor appetite, indefinite pains, etc., and who, with marvelous rapidity,yielded to treatment by the "nerve specialist" of the camp. Theamount of effective effort which could be achieved in applied neuropsychiatry inthe Army was limited only by the experience, interest, and ability of theneuropsychiatrist. The neuropsychiatrist was no longer one who merely selectedobvious cases of nervous and mental disease for elimination from the Army, butwas one who also healed, repaired, conserved, and reconstructed. He became theguardian of the mental health, just as the sanitary surgeon was responsible forthe physical welfare of the military organization.
AT CAMP PIKE, ARK.e
To the neuropsychiatrists fell the work of eliminating thenervous and mentally unfit among the recruits. This examination was made inconnection with and as a part of the regular physical examination. While it istrue that in some instances the attempt was made to unduly rush the work, and asa result a few men slipped through who should have been rejected, yet, taken inthe aggregate, this number was very small and these few cases were generallydetected later, since the troops had to undergo another neuropsychiatric testbefore being accepted for overseas duty.
The average neuropsychiatric board consisted of five or sixmembers and, as a rule, worked in two sections. In the course of the regularroutine examination the recruit came before the first section of the board wherehe was given a short neurological and psychiatrical examination, and if therewas a suspicion of any abnormality he was referred to the second section, wherehe was subjected to a very careful examination and either accepted or finallyrejected. If there was still doubt regarding his case he was sent to thepsychopathic ward of the base hospital, where he was closely observed and allnecessary tests made to determine his true nervous and mental status.
When the draft first began in the fall of 1917 theinstructions to the local boards were not very clear and explicit and weresometimes difficult to properly interpret; as a result, a number of recruitswere found unfit for service when
eWork of the Neuropsychiatrists in the United States ArmyCamps, by Capt. Hermon S. Major, M. C. Journal of the Missouri State Medical Association, 1919, xvi, No.11, 377.
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they were examined by the special boards at the camp andconsequently were returned to their local boards. As time went on the localboard became more critical and did quite a good deal of eliminating at home. Asan illustration of this, the following results of some neuropsychiatricexaminations, taken from the report of the neuropsychiatric board at Camp Pike,Ark., are given: May 7 to May 26, 1918, number examined, 9,834; numberrejected, 199, or 2.02 Percent. May 26 to June 20, number examined, 10,338;number rejected, 165, or 1.59 Percent. June 21 to July 16, number examined,19,178; number rejected, 190, or 0.99 Percent. July 16 to August 23, numberexamined, 22,020; number rejected, 173, or 0.79 Percent. August 23 toSeptember 21, number examined, 22,649; number rejected, 123, or 0.54 Percent.
The steady decrease in the number of rejections at this onecamp would tend to prove that either the local boards were more carefullyeliminating the nervous and mentally unfit or that the neuropsychiatric boardwas more lax in its examinations, but since practically the same board worked atCamp Pike during this time and under the same instructions, this hardly seemsplausible, especially in view of the fact that the same conditions obtained withthe other special boards at this camp during the above-mentioned time.
AT CAMP DEVENS, MASS.f
The following is a brief summary of the neuropsychiatricexamination of 170,478 soldiers at Camp Devens, Mass. There were rejected forall neuropsychiatric causes 1,787 men. These examinations were conducted fromearly in September, 1917, until November 11, 1918. The classification ofdiseases used is the one furnished by the division of neuropsychiatry of theSurgeon General's Office.
The first subdivision is that of nervous disease or injury.Under this heading were rejected 389 men. As the accompanying table shows, themajority of these rejections were for epilepsy. The diagnosis of epilepsy is byno means so hard as some imagine, if the patient, on physical examination,presents the characteristic mental symptoms and in addition has scars onvarious parts of the body and head caused by injuries while in convulsions, orif the tip and sides of the tongue are scarred; the symptoms were consideredsufficient for rejection. If the patient stated that he had epilepsy and couldshow none of these signs, he was observed in the neuropsychiatric wards of thebase hospital. The orderlies there were trained in the observation of convulsiveattacks, particularly in disturbances of the tendon reflexes, and whether ornot the pupils reacted to light during and after the attacks. In our experiencethe reaction of the pupils to light is the very best single test in thedifferentiation between epilepsy and hysteria. So far as we know, the pupillaryreflex to light is always absent in an epileptic attack and never is in anhysterical attack. The other subheadings under nervous disease and injury willreadily explain themselves. The small number of cases of syphilis of the nervoussystem is no doubt explained by the ages of the men examined. They were rathertoo young to show tabes
fReport of Neuropsychiatric Work at Camp Devens, Mass., byLieut. Col. L. Vernon Briggs, M. C., and Maj. Morgan B. Hodskins, M. C., New York Medical Journal, 1921, cxiii, No. 14, 749.
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dorsalis, and no doubt most of the frank cerebrospinal caseswere rejected by the local draft boards.
Under the heading psychoneurosis, 249 were rejected. Thecases of stammering were rejected at time of examination. The others were alwaysobserved for some time, either in their organization or in the base hospital,before they were rejected.
There was a total of 167 rejections under the headingpsychosis. Some of these cases were rejected immediately, as they came to campwith a frank psychosis. In others, psychosis developed after the patient hadbeen under military training for some time. A psychotic individual does verypoorly in the Army. As soon as he is subjected to military discipline he usuallybreaks down.
Under the heading inebriety there were 57 rejections. Theserejections were made after the patients had been under observation for a fewdays and showed the well-known withdrawal symptoms. The patient listed as a caseof drug addiction, opium, was addicted to the use of camphorated tincture ofopium. His statement was to the effect that he would take more than a pint ofthis a day, and he showed well-marked withdrawal symptoms. Forty-five cases wererejected for chronic alcoholism.
Under the heading mental deficiency, as one would expect,there was a large number rejected, a total of 813. These men were nearly allreturned to their homes.
Under the heading of constitutional psychopathic state therewere 68 rejections. These men were rejected only after they had been observed intheir companies for some time, and had proved themselves so totally unfit formilitary service that it was necessary to reject them.
| NERVOUS DISEASE OR INJURY | PSYCHONEUROSIS | ||
| pilepsy | 261 | Hysteria | 133 |
Cerebrospinal syphilis | 11 | Neurasthenia | 64 |
Congenital syphilis with | 1 | Psychasthenia | 12 |
| Hemiplegia | 7 | Stammering | 40 |
| Paraplegia | 6 | Total | 249 |
Tertiary syphilis with nervous svmptoms | 30 | PSYCHOSIS | |
Multiple sclerosis | 9 | Dementia pr?cox: | |
Multiple neuritis | 10 | Hebephrenic | 79 |
Paralysis, facial | 4 | Paranoid | 31 |
Enuresis | 8 | Katatonic | 11 |
Poliomyelitis, chronic | 3 | Simple | 7 |
| Sciatic neuritis | 3 | Manic-depressive | 25 |
| Chorea | 13 | Traumatic | 1 |
| Migraine | 1 | Epileptic | 1 |
| Myotonia congenita | 2 | Alcoholic- | |
Spinal meningitis, chronic | 1 | Acute hallucinosis | 4 |
Congenital speech defect | 1 | Chronic paranoid | 1 |
Hereditary tremor | 2 | General paralysis of the insane | 6 |
Transverse myelitis | 1 | Psychosis, toxic | 1 |
| Tabes dorsalis | 9 | Total | 167 |
Hereditary ataxia | 1 | INEBRIETY | |
Facial tic | 1 | Drug addiciton: | |
Nystagmus | 1 | Morphine | 48 |
Hyperthyroidism | 1 | Heroine | 4 |
Brachial neuritis | 1 | Cocaine | 4 |
Destructive lesion of red nucleus | 1 | Opium | 1 |
| Total | 389 | Alcoholism, chronic | 45 |
| Total | 102 | ||
| MENTAL DEFICIENCY | CONSTITUTIONAL PSYCHOPATHIC STATE | ||
Imbecile | 258 | Inadequate personality | 48 |
Moron | 555 | Paranoid personality | 11 |
| Total | 813 | Emotional instability | 4 |
Pathological liar | 1 | ||
Sexual psychopathy | 4 | ||
Criminalism | 1 | ||
| Total | 69 | ||
| Total rejections | 1,787 | ||
AT CAMP SHERMAN, OHIOg
This war brought about many innovations, and among them was aconsideration of the individuality and of the mental and nervous condition ofthe prospective soldier. But the line officer did not always appreciate this orknow what things to be on the lookout for in order to detect the indications ofsuch abnormal conditions in the men as might be detrimental to the service. So apart of the work of the psychiatrist was to give talks to the line officers,telling them how the various mental and nervous conditions which interfere withthe making or the dependability, or the endurance or the efficiency of thesoldier, and what types of behavior he should be on the lookout for. Theircooperation in looking for these conditions and sending men for examination orobservation was asked for. Some were very much interested and cooperated; othersthought it all nonsense; others were indifferent. Such talks had to be arrangedfor with the regimental commanders. If one wished to talk to the medicalofficers only, the arrangements were made with the division surgeon. But it wasadvisable to talk to the nonmedical officers as well, and even to thenoncommissioned officers, for they saw much more of the men than the medicalofficers did.
An important work of the psychiatrist was to make a survey ofthe whole personnel of the camp. The ideal way to do this would have been tohave the recruits on arrival at camp come into special barracks where they couldbe held before being assigned to any organizations until the various specialexaminers could go over them at reasonable leisure. An approximation to thisplan was made by having the recruits very hastily surveyed by the examiners asfast as they came in. The men were stripped and examined by the variousspecialists. The examinations had to be very superficial when over 1,500
gThe work of Psychiatrists in Military Camps, by Maj. E. Stanley Abbot, M. C., American Journal of Insanity, 1919, lxxv, No. 4, 457.
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men were looked over in a day. Many slipped through withdefects which were detected some time later who would have been eliminated inthe first place if only half the number were examined in the same period oftime. Four neuropsychiatrists were able to make a superficial examination asfast as the other examiners made theirs.
Before even this plan was adopted, and wherever it had notbeen put into practice, a survey of the personnel, regiment by regiment, wasmade when possible. It was necessary to secure the cooperation of the commandingofficer of the regiment for this. It was sometimes easily secured; sometimes heresented it as an interference with his work of training soldiers because ittook the men away from their work. Whenever possible it was advisable to makethe survey in cooperation with the tuberculosis or other examiners, for example,as it caused much less loss of the soldier's time. After the commandingofficer had given his cooperation, arrangements were made with the regimentalsurgeon and the adjutant to have the men of a given company remain in barracksor report at the regimental infirmary at a given time. There the psychiatricexaminers went over each man, testing pupillary and tendon reflexes,coordination and station, looking for tremors and for scars suggestive ofepilepsy, and asking a few questions as to heredity, environment, schooling,convulsions, or nervous breakdowns, meanwhile noticing any peculiarities. Underthe most favorable conditions, with a roster of the company and a clerk tocheck off the names and put down findings, one examiner could make a fairlythorough preliminary survey of from 150 to 200 men a day, according to theirquality. But in actual practice that number could not be examined on anaverage, because of time lost in going from one organization to another,changes in daily orders in the organization, misunderstandings, etc. It wasfound at Camp Sherman that making allowances for Sundays, holidays, andunexpected interruption, interferences, and delays, one examiner could becounted on to go over about 2,800 to 3,000 men a month. The time availableand the size of the command determined the number of examiners needed tocomplete a survey in a given time.
This type of survey was unsatisfactory, for it can never becomplete. Men were transferred out from a company that had been examined and menfrom unexamined units were often put in to fill up the organization, and itwas difficult for the examiners to go back and pick up these men.
Since the vast majority of the men who were found to havesome nervous or mental disease or defect were incapable of making goodsoldiers, or of enduring without breaking down the stresses of warfare, they hadto be discharged. It was part of the work of the psychiatrist to make therecommendations for discharge, giving the diagnosis, and stating how thecondition interferred with the man's performing general military service. Insome camps the psychiatrist made his recommendation to a general militaryservice of which he might or could not be a member. At Camp Sherman three ofthe psychiatrists themselves constituted a disability board. This gave anopportunity to hold conferences over the cases, to which the otherneuropsychiatric examiners and sometimes other physicians were invited.
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Some of the kinds of cases and of difficulties thatconfronted the psychiatrist can be illustrated by the experience at CampSherman:
The feeble-minded made up the largest single group of cases.Up to May 1, 1918, 134 out of 468 cases recommended for discharge were of thisgroup.
Those measuring 12 years old and over were regarded assuitable material for the Army unless they were of unstable make-up, had showneconomic or social inadaptabilities, or had some general physical disability,even though the latter were not sufficient in itself to be a cause forrejection.
At Camp Sherman the epileptics formed the next largest singlediagnostic group. If the epileptics and organic nervous diseases were groupedtogether, this whole group was a trifle larger than that of the feeble-minded.Most of the patients could give a characteristic description of the onset ofattacks, but in two there seemed to be absolute amnesia for them, and for havinghad them. One had a typical grand mal seizure, seen and described by a youngphysician; the other made a suicidal attempt in barracks and later in thehospital; no recollection whatever of either attempt could be elicited either byordinary questioning or when hypnotism was attempted. No other cause for thesuicidal attempt could be unearthed than a probable epileptic crepuscularcondition.
Among the officers referred for examination, manic-depressivedepressions predominated, and these were the most frequent of the actualpsychoses seen at Camp Sherman.
There were many cases of neurasthenia following trauma orsevere illness, and it was often a difficult matter to determine whether it wasa real or an assumed disability. These cases were usually kept under observationseveral weeks, and information was sought from physicians who had attended themin civil life. Consultation with the orthopedists or other specialists wasfrequently held. X-ray examinations were usually negative, as were the resultsof spinal puncture and Wassermann tests. There were other types of neurasthenia,some with a number of vagotonic or hyperthyroid symptoms, without thyroidenlargement. These were recommended for discharge on the ground that they werenot capable of standing the strain of general military service, nor even ofdomestic service. By searching inquiry one could elicit from almost all men anoccasional neurasthenic or fatigue symptom.
When a large number of drafted men was received there werealways a few cases of alcoholism, delirium tremens, and drug addiction. Theconfirmed habitu?s could not be kept in the base hospital long enough to bereconstructed, and once they were in the ranks they could get the drug withcomparative ease.
There were not many constitutional psychopaths (35 in all),but a few-sexual perverts, paranoid personalities, and inadequatepersonalities-were found and recommended for discharge.
The cases examined with reference to whether they should bebrought to trial or not were principally for repeated absences without leave orfor desertion. One case was for forgery, another for stealing, and one, dementiapr?cox case, for refusing to obey orders. Some were clearlyfeeble-minded, and proceedings against them were stopped and the men weredischarged. Two measured between 12 and 13 years, but had good understanding ofwhat they were doing-
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desertion in the one case, stealing in the other-and wereallowed to stand trial. Another, measuring 14 or 15 years, had a long insanehospital and penitentiary record and was also regarded as being sufficientlydeveloped to stand trial for forgery. The decision in these cases had to be madewith different conditions in mind from those which obtain in civil life. Therewas no indeterminate sentence or probation. It was either full acquittal andreturn to the ranks, or sentence to the military prison at Fort Leavenworth.
A number of cases of persistent enuresis was underobservation. Most of these were mental defectives, with rather small bladdercapacity (280 to 350 c. c.). One was a very intelligent fellow whose fathercorroborated all the essentials in his claims of never having been able tocontrol his bladder while asleep. He, like the others, was discharged.
AT FORT OGLETHORPE, GA.h
Recruits were examined as they came up for their physicalexamination at the local recruiting office, and a number were eliminated whomight easily have been passed by the regular examining surgeon.
The most satisfactory work done was in the examining of thecandidates for the second reserve officers' training camp at Camp WardenMcLean. These examinations were held from August 29 to September 4 and wereconducted by a large board of medical officers, including the tuberculosis boardand the nervous and mental board. The routine examination was to test thepupillary reflexes, the superficial and deep reflexes, the gait and station,look for asymmetries and for scars of the head, face, and tongue, and fortremors, and to quiz them as to epilepsy, insanity, nervous trouble, syphilis,etc. The report on these examinations showed the following facts: (1)Eighty-seven noted as having neurological symptoms. (2) Of that number 25 weredisqualified. (3) Each man was given the benefit of any doubt, and only thosedisqualified, whose symptoms were either pathognomonic of a serious nervousdisease, or else of such a kind as to make one reasonably certain that they wereunfitted for the service. (4) Thirteen were disqualified for Argyll-Robertsonpupils, either with or without other symptoms, on the ground that, unlessproperly treated, sooner or later they would be entirely unfitted. (5) Ten werefound with irregular pupils and 10 with unequal pupils; none of these wasdisqualified, though if Wassermanns had been done doubtless many of them wouldhave been disqualified. (6) Of the others disqualified, 1 was a probable case ofgeneral paresis, 2 were psychoneurotics, 1 a case of hyperthyroidism, 1 anepileptic, and the majority of the remainder showed signs of cerebrospinalsyphilis, all of whom were unquestionably unfit for the active duties of anofficer.
AT CAMP UPTON, N. Y., AND CAMP GORDON, GA
From May to September, 1918, inclusive, 54,000 recruits wereexamined at Camp Upton, N. Y. Of this number, 1,050, or 2 Percent, wererejected for
hLetter from Capt. D. R.Gilfillan, M. C., base hospital,Fort Oglethorpe, Ga., Sept. 15, 1917, to Dr. Frankwood E. Williams, NewYork, N. Y. Copy on file, Historical Division, S. G. O.
iNeuro-Psychiatry in Army Camps, by Maj. George E. McPherson,M. C., Boston Medical and Surgical Journal, 1919, clxxxi, No. 21,606.
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nervous and mental disorders. At Camp Gordon, from July toOctober, inclusive, out of 58,850 men, 1,225, or 2.8 Percent, were rejected forsimilar disease and conditions.
At Camp Upton drug addicts constituted 17 Percent of therejections for mental disease, while at Camp Gordon they made up 3.27 Percentof such rejections. A survey of 100 drug addicts gave them a mental age ratingof 12 years, which is not materially different from that of other soldiers ofthe same educational-industrial level. As a rule, however, they were unskilledor poorly trained workers whose schooling, in 50 Percent of the men, did notextend above the fifth grade. Only 10 Percent were foreign born, and the 100were equally divided between two Army drafts-one white, the other black. Inboth classes the drug addict from a rural community seemed to be a rarespecimen.
Out of the 100 cases surveyed, 56 had been committed to penalinstitutions on charges other than drug addiction. Seventy-two men reported 173unsuccessful attempts at a cure. Although not measurably deficient, these menwere certainly inferior in fields other than intellectual.
One would have supposed that such cases as epileptics wouldhave been well weeded out by various draft boards with less difficulty thanobtained in many other classes of registrants. However this may appear, largenumbers of epileptics entered camps, later to be discharged when theirdisabilities came to the attention of the neuropsychiatric examiner. Many mencame to camp in the drafts with definite histories of seizures, showing scarson bodies and tongues, while some showed quite marked deterioration. Such wererejected, even on suspicion, some may say, but such a course seemed thecommon-sense one. There was, of course, no defense against the epileptic whowillfully deceived and who showed no evidence of his infirmity. One simply hadto wait for his attacks, and fortunately they generally appeared quickly underthe ardors of drill. Probably about 3.5 Percent of 1,050 rejections werebecause of this disease.
MENTAL DEFICIENCY
Thirty Percent of rejections for nervous and mentaldisabilities were for mental deficiency, about 0.6 Percent of all casesexamined. Such men offered a serious problem, as one had to overcome thedisinclination of others to allow rejection of a man who looked healthy andstrong. Orders from Washington instructed examiners to consider no man unfit formilitary service who should grade up to or over 10 years, mental rating. Onemust also grade 8 years or lower before he was to be considered unfit therebyfor domestic duty.
It was believed that no other class of men made for so muchmischief in the Army as did the feeble-minded. The stories of such soldiersproved the statement that ability to get along in civil life did not, of itself,insure satisfactory Army service. Such an idea was not workable, and a largenumber of cases examined were of just such soldiers who could not get along ina strange and exacting environment.
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Psychological group examinations rendered an importantservice in calling to attention men who graded low, and that earlier thanwithout such rating. All such were referred to the psychiatrist from thepsychological boards, and in many cases were accompanied by a recommendationfor rejection. More careful consideration of these men would find some fit fordomestic duty, but, on the whole, the low raters did not prove "worththeir salt."
The defects in fields other than intellectual were generallybrought to notice when the higher grades of morons, for instance, failed to fitproperly into their several assignments or organizations. Much that wasreckoned as criminality or insubordination can be charged to the mentaldeficiency of these soldiers.
PSYCHOTIC CASES
The psychoses were limited to relatively few varieties.Manic-depressive psychoses were present in very small numbers, especially whilethe drafts were coming in. Most of the insane in the camps fell into theschizophrenic group and were generally called dementia pr?cox. In practicallyall of such soldiers it was possible to obtain outside histories which,together with the patients' stories, appeared to indicate that the acutepsychotic episodes were but other stages in conditions which had existed forsome time, even if below the surface. After worry at home over the draft tocome, many men seemed just to go to pieces once they reached camp.
The alcoholic psychoses were not numerous. There were fewcases of chronic alcoholism. Acute alcoholic hallucinosis was found in but fewmen. Outside of numerous men who had endeavored to accommodate themselves totoo many farewell parties and who came to camp intoxicated and shaky, alcoholdid not cause much concern in the examination of recruits.
Neurosyphilis contributed many cases for rejection, taken inthe aggregate. In one draft of 800, luetic cases amounted to 0.7 Percent of menexamined. The cities seemed to furnish a much larger percentage of lueticdisabilities than did the country.
Experience in camps terminated a bit too early to speak ofthe toxic-infectious psychoses, of which little was seen.
CONSTITUTIONAL PSYCHOPATHIC STATES
Under this heading one may speak of a large group of men,many of whom were accepted for service only to become very unhappy and asource of great concern to everyone interested. At Camp Upton 50 weredischarged during five months, while at Camp Gordon 299 were thrown out infour months. Emotional instability, inadequate personality, and sexualpsychopathy provided the subdivisions under which the majority of psychopathicswere classified. These three classes just mentioned were found to consist ofpoor material to begin with, and the demands of war did not help them in theiradjustments.
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PSYCHONEUROSES
One can hardly describe the amazing story of this class ofrecruits and other men who had entered the service only to fall by the waysidewhen active duty was undertaken. It is difficult to believe the frequency withwhich men were turned down for inability to drill or to march. Enuresis,hysteria, neurasthenia, and stammering furnished a large quota of rejectionsand discharges. It was interesting to learn the frequency with which other formsof the psychoneuroses had previously been afflicted with enuresis. Needless tosay such men were constantly referred for disposition.
RESULTS
For the reasons that have been given, not all the soldiersadmitted to the Army were examined by neuropsychiatrists, but the large majorityof them were examined, by one method or another. Not all who were examined andfound unfit for service were discharged, and not infrequently these came laterto attention not alone through admissions to hospitals but also in moretragic ways.
Prior to February 1, 1919, there had been returned from theAmerican Expeditionary Forces 4,039 cases of nervous and mental disabilites, asmall number when it is considered that nearly 2,000,000 troops had been sentoverseas and especially when deduction is made of the 3,181 soldiers who weresent overseas in the face of psychiatric recommendations to the effect that theywere not fit for military service of any kind. The insane, suicide, anddelinquency mates in the American Expeditionary Forces were extraordinarily lowfor an expeditionary campaign.
The accuracy of the examinations is attested by the fact thatthere was substantial agreement in results at different points, that theycoincided almost exactly with the results recorded in the reports of the localboards as prepared by the Provost Marshal General of the Army, and by the factthat individuals detected and discharged at one camp were later again detectedand discharged from another camp to which they had been sent. Local draft boardsdid not always take as final the rejection of recruits and when called upon foranother increment of men would include in this increment, to be sent to anothercamp, men rejected at the first camp as nervously or mentally unfit. Recordswere received in the Surgeon General's Office of men detected and dischargedfrom as many as five different camps, each time by a different group ofexaminers.
One other factor should be considered-a factor alreadyhinted at, which refers less to the good of the Army than to that of the countryas a whole. It has become clearly apparent that it is not the Army alone whichmakes war in these days. The whole country makes war, and like the Army, it,too, has military necessities which must be recognized. It can make use of manyindividuals who would be useless to the Army, and it should have exempted fromit those whom the Army might take without being able to use. It seems to beincontestably proved that men who would not become insane in civil life, becomeinsane through the suppression of individualism necessary in military life. Ifit can be shown that this is equally true for the neuroses and the militaryoffenders, there will be collected a large class whose members, useless to themilitary, may be counted on for partial service in the civil community.
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Partial service under military control is only moderatelysuccessful with any class, and in the class of psychopaths, in this country atleast, it was a complete failure. The following circular letter was promulgatedby the Surgeon General regarding this matter:10
It is the opinion of this office that there are noborder-line cases in neuropsychiatry with the exception of certain cases ofmental deficiency and drug addiction. The nervous instability of thepsychoneurotics and those suffering from organic nervous diseases is suchthat they soon break down even in domestic service, and become a burden to theArmy. If they are not fitted for full military service, they are fitted for no military service. Many of the cases ofmental deficiency may be foundfitted for labor battalions or domestic service. This is particularly true ofthe negro troops. At present no facilities are available for treating andrehabilitating the drug addicts.
The assignment of psychopathic individuals to thedevelopment battalions was tried but soon given up. It would seem wiser, toleave to the civil community from the beginning these individuals who can not bemade into soldiers.
In addition to the rejection of recruits, it was consideredimportant to prevent from being returned to duty, or discharged on duty status,those who had suffered from psychoses, even if they had recovered from them inthe service. The recommendation was made accordingly by the Surgeon Generalthat cases of this class should be discharged on Form 17, A. G. O., regardlessof any improvement or cure that might have taken place.11
The various types of nervous and mental diseases whichdisqualify from military service will be discussed elsewhere. They are, withthe number of each class rejected as of May 1, 1919:11
Number | Percent | |
1. Psychoses, or mental diseases | 7,910 | 11 |
2. Epilepsy | 6,388 | 9 |
3. Organic nervous diseases | 6,916 | 10 |
4. Glandular disorders affecting growth | 4,805 | 7 |
5. Neuroses, or functional nervous diseases | 11,443 | 17 |
6. Inebriety (alcohol and drugs) | 3,878 | 6 |
7. Mental defect | 21,858 | 31 |
8. Constitutional psychopathic state | 6,196 | 9 |
| 69,394 | 100 |
REFERENCES
(1) Letter from The Adjutant General of the Army, to the Surgeon General, July 22, 1918.
Subject: Mentally unfit in replacement troops. (Transmitting extract from cablegram No. 1464, dated July 15, 1918,from General Pershing.) On file, Record Room, S. G. O., 201.6 (Misc. Div.).
(2) Memorandum for Colonel Howard, S. G. O.,from Frankwood E. Williams, major, M. C., division of neurology and psychiatry, S. G.O., August 14, 1918. Subject: Enlisted men recommended by psychiatricexaminers for discharge already carried abroad with organizations, despiterecommendations to the contrary. Copy on file, Historical Division, S. G. O.
(3) Circular No. 22, S. G. O., August 1, 1917. Subject: Examinations in nervous and mental diseases.
(4) Letter from The Adjutant General of the Army to alldepartment commanders; the commanding generals of all divisions, and ports of embarkation; and the commanding officers of all camps, recruit depots, excepted places, August 22, 1918. Subject: Special examiners.
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(5) Office Order No. 97, S. G. O., November 30, 1918. On file, Record Room, S. G. O., Correspondence File 342.15 (Misc. Div.).
(6) Letter from the Surgeon General, U. S. Army, to the Division Surgeon (name of division and camp) (undated). Subject: Recognitions and elimination of thementally unfit and of those suffering from nervous disease. Copy on file, Historical Division, S. G. O.
(7) Circular Letter from the Surgeon General, U. S. Army, to division surgeons, October 18, 1917. Also: Bulletin No. 4, W. D., February 7, 1918.
(8) Mimeographed memorandum for organization commanders, concerningneuropsychiatric surveys.
(9) Report on Hazelhurst Field, Mineola, L. I., by Maj. Stewart Paton.
(10) Circular Letter, S. G. O., undated.
(11) Circular Letter No. 95, S. G. O., February 19, 1919. Subject: Disposition of insane.
