CHAPTER V
OBSERVATION AND TREATMENT
All patients admitted to the neuropsychiatric wards receiveda complete physical, psychiatric, and neurological examination and, whereindicated, psychological and special laboratory examinations. The following"Guide," prepared by the National Committee for Mental Hygiene, wasfound helpful in the psychiatric and neurological examinations:
GUIDE TO THE PSYCHIATRIC AND NEUROLOGICAL EXAMINATION OFPATIENTS AND THE RECORDING OF THE OBSERVATION
The following notes are designed to serve as a guide to thepsychiatric and neurological examination of patients in the military hospitalsof the Government in order to insure uniformity of recording.
PSYCHIATRIC EXAMINATION
In the guide to the psychiatric examination notonly thespecial cases which may be encountered as a result of war, but also all thetypes of psychoses and neuroses which occur during peace time as well havebeen considered; in other words, an attempt has been made to cover allpossibilities in this outline, but to do it with special reference to the needsof a hospital receiving only military patients.
The different aspects to be looked into in cases with mentalsymptoms (be they of the nature of definite psychoses or of psychoneuroses)are grouped under several successive headings. It is by no means necessarily thesequence which is best followed in every instance. We have to be guided in thisby the condition of the patient, but it is important that all of theseaspects should be covered in every case. On the other hand, it should be bornein mind that a given case may be so obviously normal in regard to some of theseaspects that that part can be dismissed with a very brief examination.
The examiner should make use of his own knowledge of militarylife and make constant comparison between the patient's attitude toward thevarious phases of life in barracks, camp, or the field, and his ownobservations as to the attitude of other soldiers. The examiner should make thebest possible use of the fact that all his patients are soldiers.
I. BEHAVIOR, ATTITUDE, AND EMOTIONAL STATE
Observe first the general demeanor of the patient as heenters the room (the condition of his uniform, his hair, hisfinger nails, etc.), and his reactions to a few simple questions of thetype which a physician would naturally ask, such as questions about the patient'shealth, comfort, etc. Note also whether he shows evidence of loss of sleep,having been crying, bruises, suggesting fighting or rough handling. Notewhether he is mindful or unmindful of the attitude of a soldier with anofficer; whether his attitude toward the examiner is respectful, hostile,friendly, puerile. At the end of the examination the preliminary observationsshould he supplemented (in this part of the record) by a summary of theobservations regarding behavior, attitude, and emotional state, which are madethroughout the examination.
A. Accessibility.
(1) Natural, free, alert.
(2) With definite emotional changes.
(a) Depressive: Depressed, gloomy, worried, uneasy, anxious, fearful, etc.
(b) Elated: Satisfied, happy, exuberant, etc.
More complex emotional states: Suspicious, disdainful, perplexed, etc.
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B. Inaccessibility.
(1) Without definite emotion: Apathetic, dull, somnolent.
(2) With more active emotional changes: Depression, anxiousness, uneasiness, tenseness, perplexity, suspiciousness, disdain, etc.
Certain reactions may at once lead naturally into questions as to what isthe trouble; e. g., with an evident worry, one would ask, What is it you worryabout? or, What can we do for you? and the like.
II. MOTOR CONDITION
A. General motility.
(1) Normal.
(2) Overactivity, excitement.
(3) Diminished activity, such as slowness of motion (constant or inconstant), complete inactivity, possibly with catalepsy, resistiveness.
(4) Queer, bizarre actions.
B. Speech.
(1) Normal in amount.
(2) Increased in amount (talkative, singing, shouting, noisy).
(3) Diminished in amount; slow speech (constant, inconstant), mutism.
(4) Disordered (other than defects suggesting organic trouble), stuttering, "baby talk," explosive, accompanied by facial contortions, movements of hands, etc.
III. STREAM OF THOUGHT
In spontaneous speech or answers to questions.
(1) Clear, logical, relevant.
(2) Jumping from topic to topic but with fairly comprehensible associations.
(3) Retarded.
(4) Irrelevant-incomprehensible, disconnected, with queer ideas.
(5) Fragmentary, often disordered words, paraphasia and difficulty in word finding.
All this may be observed in the patient's spontaneous speech and in answersto questions. If he is not spontaneous, then ask further questions. In this itis best to follow the patient's lead.
IV. CONTENT OF THOUGHT
(1) Content of any worry or anxiety regarding present and past situations, physical complaints; apprehensions about the present and future, etc.
(2) Compulsive ideas, obsessions, phobias.
(3) Delusions, hallucinations, peculiar mental attitudes. Some of these may have come out before. In that case it is best to summarize briefly what has been obtained thus far and then to proceed with recording the further study.
It should be remembered that it is not merely a question of recording theexistence of delusions and hallucinations and the like, but a question aboveall of inquiring into and recording their content. Give patient's own wordsregarding hallucinations, etc.
If nothing has thus far been obtained and the patient makes, nevertheless,the impression of being psychotic, the following questions may bring importantideas:
Have you had any peculiar experiences?
Have people said things about you?
Does any underhand work seem to be going on?
How do you fit into the company (battery, mess, wardroom)?
Has anyone made queer remarks? Made veiled references to you?
Do things seem natural or unreal?
Do you hear voices? Or, sometimes one may simply ask: What do they say?
Have people done things to you?
Has everyone been kind to you?
Have you had strange dreams?
Have you had visions?
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Sometimes questions about certain topics bringout peculiar mental attitudes or peculiar ideas, such as:
What do you think about electricity, or magnetism, hypnotism, thought transference, wireless telegraphy? etc.
Sometimes the question, Who are you? leads to importantanswers.
V. ORIENTATION
Does the patient know the day, month and year? Doesheknow what place he is in, who the persons are about him; or does heunderstand, at any rate in a general way, the situation?
VI. MEMORY AND THINKING
(1) With regard to old events.
(a) Inquiry into life history before the advent of the psychosis or neurosis as regards the main data (birthday, positions, dwelling places, as well as inquiry about events since enlistment, etc.), with dates. This gives a good idea of the patient's capacity to think and correlate the different facts (look for discrepancies) as well as of his memory.
(b) Calculation-simple tasks are a matter of memory; more difficult ones test the patient's capacity for concentration and thinking.
(c) Writing-spontaneous and to dictation.
(2) With regard to recent events: Such questions as, How long have you been in this place? Where did you come from? What happened yesterday? What did you have for dinner? etc., will be found useful. (Examiner should use freely his own knowledge regarding military routine.)
Definite tests for retention, such as theremembering of aname and address for two or three or five minutes while questions are askedduring the time intervening. For span of memory, test the patients capacity torepeat series of 8, 6, or 5 digits.
VII. INTELLECTUAL LEVEL
If it is settled that no interference with the thoughtprocesses exists, an attempt should be made to determine this patient'sintellectual level. Test especially the general information regarding thepatient's habitual environment, as well as the knowledge he is supposed tohave gained in his military experience. Refer also to the guide for theexamination and determination of mental deficiency.
The mental tests are often of value even when thepermanent intellectual level can not be obtained, since the details offunctional capacity may prove of diagnostic value if successive spacedexaminations are made.
VIII. THE PATIENT'S OWN ACCOUNT OF THE DEVELOPMENT OF HIS PSYCHOSIS OR NEUROSIS
The object here is to trace in detail the originand development of the condition from which the patient suffers. Even ifinaccurate or obviously inconsistent, the patient's account is, nevertheless,important.
In the case of mental disorders, functional or organic,due to the more specific war causes, it is especially important to inquireinto:
(1) The patient's mental make-up before enlistment as regards success or failure in life; the extent to which he was able to get along with other people; his capacity for adaptation to new situations; his habitual mood; his habitual reactions to difficulties in life, responsibilities, stress, etc.; special traits, such as fear of thunderstorms, fear of going underground, sensitiveness to seeing blood; his attitude toward the suffering of others, dread of special diseases or modes of death, etc.
(2) The patient's adaptation to the life of a soldier; i. e., his attitude toward the war, his adaptation to training, his adaptation to fighting. Note his first reactions to this (fear, horror, disgust). Inquire how these first difficulties were overcome, if they were overcome. Check up patient's story by reference to officers and comrades (see disciplinary record).
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(3) Details of any fatigue-producing situations, special stress or loss of sleep, etc.
(4) Reaction to fatigue ("jumpiness," irritability, tenseness, poor concentration, etc.).
(5) The first symptoms of failure of adaptation, if indicated by the patient's history, such as the wish of deliverance from the situation (note the special form which such wishes took, such as the desire to be wounded, to be taken prisoner, or the desire for death or the war ending); an increase of nervousness and anxiousness about his own safety; specific fears; the development of feelings of horror about the situation (note special supersensitiveness).
(6) Disturbing dreams (note content).
(7) Causes which led to the definite breakdown:
(a) Direct injury, wind concussion, burial, "gassing," etc.
(b) Witnessing unusually distressing sights; or friction with superiors or refusal of leave, or distressing news from home, etc.
(8) Onset of acute symptoms: Loss of consciousness (note duration); dazed condition; clouding of consciousness with variations in intensity, etc.
(9) History of condition since that time.
(10) History of treatment and its effects; also history of military management of patient's illness and the patient's attitude toward this.
In case of psychoses much regarding the development mayalready have been brought out, especially under the heading of content ofthought. It is here gone into more thoroughly if the patient is thought capableof giving it.
IX. ATTITUDE TOWARD THE MENTAL OR NERVOUS DISORDER
In psychoses this refers especially to the question ofwhether the patient understands that he is mentally ill.
In the neuroses it refers more to the attitude in generalwhich he takes toward his symptoms, e. g., does he think they are all due tostress or partly to his own failure in adaptation?
NEUROLOGICAL EXAMINATION
Condition of body
Facies, growth, abnormalities in development, glandulartrophic and vasomotor phenomena, including variations in weight, growth of hair,amount of fat, asymmetries, etc.
In functional cases it is especially important to noticetrophic and vasomotor phenomena such as skin eruptions, pigmentation, pallor,coolness of the skin, edema, cyanosis, increase or diminution of sweating,excessive dryness, peculiar odors and secretions, pulse rate, pain in the head,palpitation, breathlessness on exertion, precordial pains. If unusual trophicor vasomotor symptoms occur it is important to determine whether or not theseare the result of the patient's own actions.
General appearance of patient as regards resemblance to somedisease.
CRANIAL NERVES
First nerve (olfactory).-Anosmia, parosmia.
Second nerve (optic) - Acuteness of vision and, if impairment, description of same; irritating visual phenomena. Pupils, whetherround or irregular; their reactions to light and to movement of eyeballs. Visualfields (note especially in shell-shock cases variations from the normal such asreversion of color fields, etc.). Opthalmoscopic examination; exophthalmos andenophthalmos; irregular size of palpebral fissure.
Third, fourth, and sixth nerves (ocular nerves) - Ptosisor drooping of the upper lid, ocular palsies, description of double vision,convergence.
Fifth nerve (motor) - Muscles of mastication,masseters, temporals, and pterygoids. (Sensory portion.) Note disturbance of sensationfor touch and pain and temperature. Pains in face. Loss or impairment of tastein anterior two-thirds of the tongue. Look for parageusia or perversion of tastesense in shell-shock cases.
Seventh nerve (peripheral facial palsy).-Inability towrinkle forehead, shut the eye, show teeth. With central facial palsy, canwrinkle brow and shut the eye. Note loss of taste on the affected side.Electrical examination to be made if possible.
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Eighth nerve - Cochlear division: Determined degree ofdeafness by tuning fork or voice and then make a closer examination anddetermine whether it is due to the destruction of the nerve itself, or themiddle ear, or if it is functional. Vestibular portion: Examination should bemade by so-called B?r?ny tests either by means of a turning chair orirrigation of the external ear by water.
Ninth nerve - Inability to swallow. If impaired, notedegree of inability to swallow food and regurgitation of same. Loss orimpairment of taste in posterior third of the tongue. Look for parageusia orperversion of taste sense in shell-shock cases.
Tenth nerve - Movements of vocal cords, character ofspeech, and whether or not speech and breathing are interfered with.
Eleventh nerve - Action of sternomastoidand trapezius muscles.
Twelfth nerve - Ability to protrude the tongueand itsdirection and impairment of movement. Atrophy and tremor.
Motor symptoms
Station and gait. Deformities and contractures.Convulsions, local spasms, tics, tremors (coarse or fibrillary), myokymias, etc.
Limbs: Determination of strength by grip andmovements,both voluntary and against resistance. Tonicity, atrophy, or hypertrophy,coordination of extremities and trunk (ataxia), cerebellar asynergy.
Reflexes
Cutaneous - Conjunctival, corneal,epigastric,cremasteric, plantar, Babinski, defense.
Tendon - Biceps, triceps, wrist, patellar, Achilles.
Muscle reflexes - Clonus: Wrist, patellar, ankle.Special: Kernig, Trousseau.
Electrical examination
Faradic response.
Galvanic response and nature of the reaction.
Speech disturbances (organic functional)
Organic.-Motor aphasis: Patient knows whathe wants tosay, understands what is said to him, can read, but is unable to express himself either wholly or in part in spoken words or by writing.
Sensory aphasia: Patient can talk and can write,butneither his speech nor his writing make sense because he is word deaf; that is,he does not understand the meaning of the sound of words.
Sensory motor aphasia: A combination of motorand sensoryaphasia, the extent of the disturbance depending upon the completeness of thelesion.
Functional - In functional or shell-shockcases, lookfor various forms of speech defects such as mutism, stammering, stuttering, and verbalrepetition.
Hearing may be lost often with speech. Hyperacusis or extremesensibility to sound is very common.
Sensation
Studied in head, trunk, upper and lower extremities withfinger tip, cotton-wool, camel's-hair brush, esthesiometers, hot and coldtest tubes, etc.
Epicritic sensibility - Superficialtouch, light pressure, warmth, coolness, tickling (hairy surfaces), tactile localization,and tactile discrimination.
Protopathic sensibility - Painsense, extreme heat,extreme cold.
Deep sensibility - Muscular, tendinous,arthrodial.
Sense of position and passive movement, deep pressure.Astereognosis. Asymbolia.
Vesical, rectal, and sexual functions.
Lumbar puncture
Cell count and Wassermann.
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Physical examination
This should be a general physical examination includingcondition of the heart, lungs, blood pressure, blood for Wassermann, etc.
Active treatment as contrasted with custodial care wasemphasized in all neuropsychiatric wards and hospitals. Diagnosis was notconsidered an end in itself. Individualization of the patient was insisted upon.Patients, in so far as possible, were not permitted to be idle. From the day ofhis entrance into the hospital an effort was made to see that the patient waskept occupied. In this important procedure the occupational therapy worker wasinvaluable.
In most of the hospitals the neuropsychiatric staff met dailyto consider difficult cases, to discuss the advisability of discharging certainpatients, and to review the results of the examination of recently admittedpatients. In some of the hospitals a weekly conference was held, to which allthe medical officers of the hospital were invited. At these conferences paperson such psychiatric subjects as might be of interest or benefit to the generalmedical officer were read and patients were presented and discussed. Theseconferences frequently aroused much interest and were well attended. A furtheropportunity to familiarize the general medical officer with psychiatric casestudies was presented by the regular hospital staff conferences. Theneuropsychiatrists took their turn in presenting to the entire staff of thehospital interesting psychiatric material.
The experience of those responsible for the neuropsychiatricwork at Walter Reed General Hospital, Washington, D. C., is more or less typicalof the experiences elsewhere and is worth recording.
Prior to the World War mental patients at Walter Reed GeneralHospital were cared for in the basement of the administration building alongwith the military prisoners. The place was wholly unsuited for prisoners, letalone patients. But the feature which evidently recommended it was that, havingbeen built for prisoners, it was heavily barred and guarded and the insane couldnot get out. Treatment was impossible and the care in all respects, exceptpossibly food, was about the equal of the county asylum of the old type. Beforethe end of 1917, however, psychiatry at Walter Reed General Hospital hadimproved materially. Five neuropsychiatric wards, of wooden construction, wereopened. The first ward was built in accordance with the building plan of theneuropsychiatric wards of the base hospitals; that is, a ward divided into threesections so as to provide a better classification of patients. The other wardswere dormitory wards similar to the general medical wards. As it was planned touse a section of the first ward for disturbed patients, the rear portion of thisward was screened with iron-wire mesh. The screening was never completed and apart of what had been put up was later taken down.
The five wards at Walter Reed were open wards without bars ormesh, and were comparable in every way with the general medical wards of thehospital. As a matter of fact, it was possible, in showing visitors through thehospital, to take them from the medical to the neuropsychiatric wards withouttheir knowledge of when they had made the change. The same lack of restraint wasto be found at Hospital No. 2, Baltimore-no bars, no bolts, no mesh. The wardphysically was no different from any other ward in the hospital, except
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the ward for military prisoners. The psychiatrist'sdifficulty in conducting this kind of a ward was not so much in keeping patientsin as keeping patients out. The ward in the early days of the hospital was somuch more attractive than the other wards that it was at times difficult to keepother patients from coming over to visit, play the piano, listen to the victrola,or work in the shop.
The standards were equally high at Fort Benjamin Harrison,Fort Sheridan, the Letterman General Hospital, Fort McPherson, Fort Sam Houston,and Fort Des Moines. Each differed somewhat from the others, depending uponlocal conditions. None were as free of bars and mesh as Walter Reed GeneralHospital or General Hospital No. 2, at Fort McHenry, Md., but in each theseevidences of incarceration were much reduced and further reduction wascontemplated, the chiefs of the service being convinced that the bars and themesh were not only unnecessary but that treatment could be carried out muchbetter without them. As a matter of fact, many wards that had originally beenbarred or meshed in order to relieve the anxiety of a commanding officer becameopen wards, with doors unlocked and patients given much freedom.
That the open-ward system was successful there can be noquestion. The success depended upon a number of things. The spirit of the wardswas important. The spirit was distinctly that of a hospital, not that of a jail.The patient was not constantly reminded of his situation by the sight of bars;he realized that at least some one considered him sick and that for that reasonhe had been brought to a hospital where he was under no greater confinement thanother patients in the hospital; at no time was he stung with the humiliation ofimprisonment. Incentive to escape was reduced to a minimum; the patient came toregard himself possibly as sick; his ingenuity was not aroused to out-trick hisjailers or to create out of nothing instruments to remove bolts and bars. Theimportance of careful classification of patients was kept constantly in mind.
CARE OF CASES OF NERVOUS DISEASES
The treatment of organic diseases of the nervous system,under which heading epilepsy is classed at this point for convenience, was oflittle military importance, as these conditions, almost without exception,disqualified for service. Few of them were susceptible of any great degree ofamelioration by such treatment as was afforded in our military hospitals.
The hospital history of all the cases of this general classwas that they were retained in the service for antisyphilitic treatment, fortonic treatment, or for operation, as the case might be, and then weredischarged from the Army. They showed no differences in symptoms, course, orindications for treatment in the military service from similar cases in civillife.
One of the important demonstrations of the war was the greatnumber of men from all walks of life who were conditioned in their practicalusefulness by functional nervous disorders of some kind. These came in fordramatic prominence as cases of shell-shock, developing in both front and basesections in France; but still larger numbers were refused entrance into theArmy, and many were discharged from the camps on surgeon's certificate ofdisability.
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The number of neuropsychiatric cases rejected or dischargedat home may be divided into two general classes-the psychasthenic, orneurasthenic, and the hysteric. In the former the patient was concerned with achain of mental difficulties, and was constantly provided with long explanationsas to why he did not successfully carry on his military duties. Theseexplanations referred to various purely subjective symptoms, which might come tolight when the man was reported as a patient. Under such circumstances he couldbe found in any of the various medical services, as the symptoms might bereferred to any organic system. These cases were especially found in connectionwith the "effort syndrome," and with the whole group of cardiovascularconditions. Symptoms referable to the stomach and intestines were particularlyfrequent.
The cases called hysterical were apt to be associated withmore definite symptoms, such as paralysis, contractures, abnormal gaits, etc. Inthis hysterical group, suggestion as a factor in determining the type of symptomwas much more evident than in the psychasthenic group; also these patients werefrequently noticed to be less intelligent.
The cases returned as neuroses from overseas were so similarto the home cases in their symptoms that it can be said that there appeared tobe no fundamental clinical differences between neuroses developing in actualwarfare and those which developed in the training period. The probability isalso great that there is slight difference, with the exception of some warcoloring, between the neuroses of war and those of civil life.
Practically all of the symptoms reported in France wereobserved in the cantonments at home. But there existed a difference in degree,in that therapeutic efforts to combat functional nervous difficulties could bemade more successful in battle areas than could be done in the zone of theinterior. This was probably because, on the one hand, the discipline and moralewas better near the front, and, on the other, that real war neuroses were moreacute conditions, betraying less fundamental character defects, and appearing asthe immediate results of trauma, especially of an exhaustion brought about bymental strain, physical over-exertion, exposure to cold and lack of food. Thepatients, in other words, if taken immediately in hand, could be brought back tonormal, or to a point approximating normal sufficiently to enable them to bereturned to duty, full or limited.
This relatively favorable prognosis, under proper therapeuticconditions, did not apply, of course, to all of the overseas cases. Most of thepatients returned to the United States during the period of active combatpresented character defects of a prominence that made cure under any militaryconditions most difficult, if not improbable. They should have been detected-manyof them were, but were not discharged-and eliminated before theirorganizations were ordered overseas. But even some of these, who had resistedall efforts at cure overseas, could be brought to the point where at least allsymptoms disappeared in the home hospital. One enlisted man who had displayed auseless arm in several of the hospitals in the American Expeditionary Forcesresumed the use of it at General Hospital No. 2, Fort McHenry, after 48 hours ofdeprivation of tobacco, combined with kindly suggestion.
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But the treatment of these cases which met with such generalsuccess overseas was never tried out in this country. The short duration of thefighting after our entry into the war afforded no opportunity for such a trialhere. Had the war progressed further and had the time come when the UnitedStates was actually pressed for men, some definite plans would doubtless havebeen formulated for the reconstruction of war neurosis cases at home. Planslooking to this end were under consideration in the Surgeon General's Officeat the time the armistice was signed. It would have required a more elaborateand special organization than any that had been put into effect. Developmentbattalions had been organized, particularly for physical disorders, but they didnot provide sufficiently detailed classification to make them serviceable forneurosis cases. Such cases as were assigned to them soon fell out, and sosecured their discharge. Because of early discharge it is difficult to draw anyvery definite conclusions as to the curability of the functional cases whichoccurred in the home camps.
As it was, the neurotic soldiers could not altogether escapebeing regarded in a sense as malingerers. An inquiry initiated by the divisionof neurology and psychiatry1 brought out that the old point of view, that allfunctional cases were malingerers, had given place to a more rational view; thatmost Army surgeons, while noticing the numbers of neurotics among the troops,accused few of being so deliberately and with voluntary intention. But in spiteof this there was some feeling on the part of Army surgeons that such soldiersdid not play the game quite fairly, that they could have done more if theywould. In other words, there seemed to be the general conviction that undercertain circumstances many of these men could have been made useful for someduty.
OCCUPATIONAL THERAPY
It was the consensus of opinion of the officers who came mostclosely in contact with the occupational therapy work that to it must becredited much of the success of the neuropsychiatric wards. One element of thesuccess of occupational therapy in the military hospitals was certainly the highstandard of qualification insisted upon by the training schools that preparedthese workers and later by the Army itself. A second element of success was thatfrom the first the importance of occupational therapy was insisted upon and itwas given an independent and important place in the scheme of hospitalorganization. It was not subordinated to nursing. It was not considered as apart of nursing but as a part of therapy, and, as therapy, it was under theimmediate direction of the physician. The worker was responsible not to thenurse but to the physician. Occupational therapy was introduced into themilitary hospitals by the division of neurology and psychiatry. The firstoccupational therapy workers employed by the Army were the six women included inthe personnel of Base Hospital No. 117.2 So immediate was the success of thesewomen that the demand for similarly trained women grew.
The feasibility of introducing reconstruction procedures intothe neuropsychiatric wards as a whole was doubted, in our earlier experiencebeing considered applicable only to the cases which were less disturbedmentally. The
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benefits of occupational therapy became so pronounced,however, and the aides so skillful in their approach after several months'experience, that the work was given to all except the extremely violent. Thisfurnished systematic employment to restless patients, reduced the introspectionof neurotics and the delusions of the insane, seemed to shorten the duration ofthe pr?cox or manic episode of the psychoses, and decreased the necessity forrestraint in the more disturbed cases.3
Courses were given in bench woodwork, carpentry, painting andstaining, machine work, pattern making, automobile mechanics, English,arithmetic, bookkeeping, stenography, typewriting, drafting and designing,geography, agriculture, history, economics, weaving, basketry, printing,lettering, and poster making. Frequent entertainments of various kinds weregiven, with an effort to have the patients put on their own shows, and a bandwas organized. One hospital maintained an excellent library of nearly 4,000volumes, with the leading periodicals and newspapers from the principal citiesof the country.4 The library was considered to have been an importantfactor in the reconstruction work.
PSYCHIATRIC SOCIAL WORK
Expert consultation in other fields was available at alltimes and was utilized when necessary. In cases in which the diagnosis was notclear for lack of full information, the psychiatric social worker was calledupon, and, in most cases, was soon able to place before the physicians a more orless complete history of the patient's life and condition before entrance intothe Army. The importance of psychiatric social work, and of social workgenerally, was first demonstrated at the special hospital for neuroses atPlattsburg. This demonstration was made by the division of neurology andpsychiatry of the Surgeon General's Office through the cooperation of theAmerican Red Cross. The success of the work at Plattsburg led to the assignmentof from one to three psychiatric social workers (psychiatric aides) to each ofthe general hospitals maintaining neuropsychiatric wards and later to theassignment of medical social workers to all hospitals. Where patients requiredcontinued care after discharge from the Army, the social worker made inquiry inregard to the family conditions to which the soldier would be returned and thepossibilities of local care, and made arrangements with the family, the Stateauthorities, or local Red Cross representatives for the reception of thepatient.
The activities of the neuropsychiatric social service atGeneral Hospital No. 30, Plattsburg, N. Y., were reported as follows:5
Soon after the soldiers began to return from overseas, itwas discovered that many came with reports containing very little medicalinformation. The soldiers sent to the military hospital for war neuroses(United States Army General Hospital No. 30), at Plattsburg Barracks, N. Y.,not infrequently came with only a diagnosis. Some presented symptoms whichindicated that their condition was probably chronic and had existed for yearsprevious to their entrance into the Army. Others came with a diagnosis ofepilepsy, but while in the hospital had no seizures. The medical officers beganto feel the need for information other than that secured from the soldierhimself, and through Major Hutchings, chief of the neuropsychiatric service ofthis hospital, a request was made for the appointment of a social worker atPlattsburg. In consideration of the immediate need for this worker, andthe firm belief of all in the necessity of the worker's having completefreedom in developing her work,
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the American Red Cross was asked by the Surgeon General toassist the Medical Department of the Army in demonstrating the value of thistype of work in military hospitals. The necessity of this request was due to thefact that, under the existing Army provisions, the social worker could beappointed only as a reconstruction aide, giving her a status lower than a nurse.That the success of psychiatric social service in military hospitals woulddepend largely upon the efficacy of its organization was hardly questioned, but the significance of its establishment directlyunder the control of themilitary authorities and the supervision of the medical officers was notappreciated at this time. It was the consensus of opinion, however, that theremight be administrative difficulties if the work was placed under the directauspices of a civilian and nonmedical organization, when the control of thehospital was military. It was also believed that the very character of the worknecessitated its organization as a department of the hospital under medicaljurisdiction and that dual control would ultimately weaken its effectiveness.
In view of these facts, no definite decision was maderegarding the status of the work, but there was a general understanding betweenthe Army and the American Red Cross that it would be an advantage to have theworker considered as an unofficial adjunct to the medical staff and undermilitary authority.
On September 1, 1918, the social worker began her duties atthe military hospital for war neuroses, Plattsburg, N. Y., the American RedCross having agreed to pay her salary and allow her to be considered a part ofthe military r?gime, having no status under the organization of the American Red Cross. She was assignedan office in one of the hospitalbarracks, accessible to the wards and the administrative offices, and wassupplied with sufficient equipment to start her work. Through the courtesyof the military authorities, officers' privileges, such as living in officers'quarters and eating at the officers' club, were extended to the worker.
Her duties were not defined, but she was expected to secureearly histories through correspondence to assist the medical officers in thediagnosis of difficult conditions and to help them in reaching a decision asto whether the soldier's condition occurred in line of duty or prior to his enlistment or inductioninto the Army.
For five months the social work of thehospital wascarried on by one worker, with the assistance of enlisted men from the MedicalDepartment, and convalescent patients, who were assigned for messenger andclerical service. The stenographic assistance was provided by the hospitaluntil the 1st of January (1919), at which time the bureau of camp service ofthe American Red Cross donated the salary of a full-time stenographer. It wasextremely difficult to handle effectively the amount of work referred to thedepartment, owing to the lack of professional and clerical assistance. Thedelay in the appointment of social workers was due to the fact that it wasimpossible for the American Red Cross and the Army to reach a decision as tothe organization under which these workers should be appointed until thelatter part of 1918, and it was not until the latter part of January, 1919, that the provisionsmade by the Surgeon General for the appointment ofpsychiatric social workers in military hospitals under the status ofreconstruction aides became effective. By January 31, 1919, two workers hadreported for duty at Plattsburg.
After the establishment of the department, the followingdivisions of work were developed: (1) Securing early histories; (2) social casework; (3) after-care; and (4) administrative work. The scope of work waslimited, owing to lack of assistance, simply to handling the most urgentcases.
SECURING EARLY HISTORIES
The majority of these investigations have been toestablish,in the cases referred, the diagnosis of epilepsy, hysteria, or otherconditions, prior to the soldier's admission into the Army, in order todecide the Government's liability and the soldier's rights forcompensation. In most instances the soldiers have been interviewed by thesocial worker in her office, and have been questioned regarding their earlyhistory. Special emphasis has been placed upon securing the names andaddresses of individuals who would be in a position to give the necessaryinformation and encouraging the soldier to give his own statement regarding hisillness. Inquiries in general have been addressed to physicians, principals ofschools, former employers, and immediate relatives. In 90 Percent of the casesreplies have been received, the greatest assistance coming from physicians andemployers. The school reports have
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shown that, in most instances, the health records have beenincomplete. The value of the replies can not be statistically given, but in themajority of cases the replies have indicated a past history of nervousinstability, if not a definite history of nervous or mental disorders. Therehave been a number of instances in which soldiers' statements to the medicalofficers and the social worker have been found untrue, generally in the casesof soldiers who were undoubtedly malingerers, desiring to secure compensationor to avoid military service.
Examples:
Case 1 - The soldier claimed his epilepsy occurred inline of duty. The investigation proved that he had been an epileptic for years;that he had had great difficulty in holding positions, and had not been able tosupport his family.
Case 2 - A soldier,having definite seizures ofepilepsy, grand mal type, at the hospital, claimed he had never had thembefore entering the Army. The history he gave showed that he had been awanderer, and had never lived in any place longer than a few months, followingmany occupations. It was felt that it would be impossible to secure any pasthistory, and that his condition would have to be considered in line of duty.This soldier had never been overseas, and had a record of intemperance in theArmy. After considerable questioning the social worker was able to secure thenames of a few former employers, and through the interest and assistance of oneof our western railroads the diagnosis of epilepsy prior to enlistment wasdefinitely established.
Case 3 - A soldier coming from overseas, with a verymeager history and a diagnosis of epilepsy, had no seizures while at thehospital. The investigation showed that he had been an employee in one of ourepileptic institutions, having been discharged for larceny, and had had acourt record. No history of epileptic seizures was obtained, although thesoldier stated that he had had them.
Case 4 - A soldier claimed his condition occurred inline of duty and it was learned from his wife that he had nocturnal attacksof epilepsy.
Owing to the success of the investigations the medicalofficers, prior to the signing of the armistice, were considering referring tothe social worker all overseas cases, classed as epileptics in line of duty,whose histories were inadequate to establish this fact. The cases referred wereso numerous that it was impossible for the social worker to handle them alone,and it was necessary on account of the other important types of work to limitthe number to those which the medical officers felt could not be decidedwithout further information. The scope of this division of work was thereforeconsiderably limited and has not been developed to the extent of its value.
The foregoing facts seem to indicate the value ofinvestigating cases involving the question of compensation prior to dischargefrom the Army, as it would seem logical that histories, asdescribed above, would be almost impossible to obtain after the soldier hadmade a claim for compensation.
SOCIAL CASE WORK
One of the most important functions of thedepartment has been social case work, the assistance rendered the soldiers who have beentroubled with personal or family difficulties. The chief complaint has been inrelation to their financial circumstances. Many of the overseas soldiers, whohad left the United States months ago, having made not only voluntary butcompulsory allotments before they went over, returned to find that theirfamilies had not received their allotments. The number of soldiers applyingfor advice and assistance has been so great that it has been impossible tokeep track of them. In general, the soldiers have been grossly ignorantconcerning the Bureau of War Risk Insurance and its methods of operation. Ofall cases investigated the statements of the soldiers regarding the nonpaymentof allotments were found to be correct, but it was impossible to securereplies to inquiries sent to the Bureau of War Risk Insurance, except throughindirect channels. The reasons given were general and to the effect that theallotments and Government allowances had not been paid owing to faultyexecution of the forms in the beginning or that the wrong forms had been used.It was learned through the investigations made by the American Red Cross, atour request, that a great many of our soldiers' families were in seriousfinancial difficulties as a result of this situation, and that the AmericanRed Cross had been obliged to give financial aid. The need for a workerspecially trained in handling these problems had been demonstrated in thishospital by the number of cases referred to the social worker for
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investigation, not only by the soldiers themselves, but alsoby the officers in charge of this branch of work, who, owing to the pressureof work, have been unable to give the personal attention needed to adjust thesedifficulties.
Another particularly important phase of social case work hasbeen time so-called reeducational, personal talks with the soldiers. Anyone atall familiar with the type of cases which have been under observation andtreatment at this hospital realizes that some of the main symptoms have beenrestlessness and discontent, and a general attitude of lack of sympathy with theGovernment and Army life. The soldiers' complaints, such as the theft of theirpersonal property, the nonpayment of their allotments,etc., seem to be well founded and have resulted in the feeling that theprotection which would have been awarded them in civil life has not been giventhem in military life. Almost all have had one aim; namely, to get out of theservice as soon as possible. The social worker believed that much could be donetoward changing this attitude, at least in the men who came to her forassistance of one sort or another, and has made a special effort to give thesoldiers a somewhat different point of view than they have had regardingthe military system. That the majority of cases treated at Plattsburg showedmental inferiority as well as moral defects is evident. There has been achildlike attitude of the men regarding all phases of their army life andtheir social tendencies, as well as nervous instability. These reports havebeen filed with the soldiers' clinical records, and, although they have not,except in a few instances, influenced directly the disposition of the cases, mayprove of inestimable value to the Government if claims for compensation arefiled. The American Red Cross has been notified of the date of discharge and hasrendered any assistance necessary, such as securing employment, medicalsupervision, and anything which may be required. The assistance given by theAmerican Red Cross can not be overestimated, and the results have beenexceedingly satisfactory. It is evident that the interest taken by the localRed Cross chapters in this group of cases will stimulate a keener communityinterest and appreciation of the mental hygiene movement.
ADMINISTRATIVE WORK
Another division of the work which might have proved ofconsiderable value to the administrative department of the hospital, if it hadbeen possible to have had more assistance, is that of answering inquiries fromrelatives, friends, and civilian organizations concerning the soldiers'condition and circumstances. The replies to these inquiries must of necessity be very carefully considered, for they mustcontain enough information toallay anxiety, and at the same time must not divulge any information which mightgive a false impression or serve as a basis for a claim against the Government.Owing to the fact that the social worker has been asked to answer many ofthese inquiries, it is reasonable to conclude that this work might be handledeffectively by the social service department, whose workers are trained indealing with problems of this type. The social worker has regretted exceedinglyher inability to give information of a medical nature to the American RedCross, because of their cooperation and interest, and the importance of havingthis knowledge in order to be able to give more satisfactorily the assistancerequired.
The social worker has been asked to investigate the need forfurloughs in a number of cases where the reliability of the statements wasquestioned. Requests have also been received to investigate the need for thesoldiers' early discharge from the Army because of dependent relatives,serious illness, etc.
The foregoing report shows in a measure time point of view ofthe social worker regarding the usefulness of social service departments inmilitary hospitals and outlines, in general, the type of organization whichseems necessary and the scope of work which might be undertaken. That adepartment of this type is essential has been established, and the conclusiondrawn, namely, that the effectiveness of the treatment in military hospitalsdepends upon the cooperation and assistance of the community after the soldiers'discharge is undeniably sound and practicable. As to the financial value of sucha department, the reports on early histories of the soldiers have conclusivelyshown that much expense might be saved the Government through the establishmentof departments of investigation at the time the soldiers are under treatment inthe hospital, rather than after the soldiers have been discharged and havefiled their claims for compensation.
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STATISTICAL SHEET
| Number of individuals assisted | 820 |
| Sources from which these cases were referred: | |
| (1) Medical officers | 558 |
| (2) Soldiers | 231 |
| (3) Miscellaneous | 31 |
| Classification of cases according to reason referred. (NOTE.-These figures overlap because in some cases all 4 types of work have been done): | |
(1) Securing early histories | 191 |
| (2) Social case work | 668 |
| (3) After-care | 495 |
| (4) Administrative work | 96 |
| Number of letters sent out | 1,428 |
Number of letters received | 1,166 |
Number of interviews with soldiers | 960 |
ACTIVITIES OF NEUROPSYCHIATRIC SERVICES
The following accounts of the methods of observation andtreatment employed in some of the more typical neuropsychiatric services in baseand general hospitals are taken, without comment, from selected reports to whichthey are credited.
BASE HOSPITAL, CAMP SHERMAN, OHIOb
All cases that could not be decided on at the preliminarysurvey (mental and nervous examinations of troops) were referred to the basehospital, either to be admitted as patients for observation or to be examinedthoroughly at greater leisure. The psychiatrist at the base hospital saw thesemen, made careful examinations, often spending an hour or two at a time on onepatient, applying Binet or other tests where needed. He wrote for information torelatives, employers, or attending physicians; or got information as to the man'sbehavior from commissioned or noncommissioned officers or privates, with a viewof getting such data as might help in the diagnosis of epilepsy, mentaldeficiency, peculiarities, malingering, etc. It was found very helpful to have anoncommissioned officer go to the patient's company to make inquiries abouthis general adaptive reactions or about some special incidents.
Besides the cases thus referred by the surveying examiners,there were sent to the base hospital by the line officers patients in whom theysuspected evidences of nervous or mental disease. In the camps wherepsychological surveys were made, the psychologists also referred cases to thepsychiatrists. These cases were examined in the same way as those sent by thepsychiatric surveyors.
In addition to these, many cases were seen in consultation inthe other wards of the base hospital. Many of these were neurasthenics, in whomthe question of malingering arose. Sometimes the advisability of operating on agiven patient came up, as, for example, in a case of hernia in a defective. Ifhe was too deficient mentally to make a good soldier, operation was advisedagainst.
Another group of cases that came before the psychiatrist wasthat of the men who had been arrested for various offenses, such as theft,desertion, repeated
bBased on The Work of Psychiatrists in Military Camps, by Maj.E. Stanley Abbott, M. C. American Journal of Insanity 1919, lxxv,No. 4, 457.
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absence without leave, in order to determine theirresponsibility for their acts, and whether or not they should be brought totrial by court-martial. In one case a man already had been convicted for refusalto be operated on for hernia. Before sentence was passed, however, the questionof his mentality was raised, and it was found that he was about 9 years olddevelopmentally. His sentence was not carried out; instead, he was dischargedfrom the Army.
The cases of mental disease arising among the men, such asmanic or depressive states, dementia pr?cox, acute alcoholism, delirium tremens,had to be taken care of and treated until some adequate disposition could bemade of them. It fell to the psychiatrist, of course, to exercise the care ofthese, as well as of the cases sent for observation or special examination. Thepsychiatrist had to determine whether the patient should be allowed to go homeor should be sent to an institution for the care of the insane; also, whether heshould be allowed to go home alone or must be accompanied by one or morepersons. And if the patient was sent to a hospital, the psychiatrist preparedand sent adequate records of the case.
BASE HOSPITAL, CAMP DEVENS, MASS.c
The neuropsychiatric service was opened December 4, 1917, forthe reception of patients. During the time draft men were being received, thisservice did all the camp neuropsychiatric work in addition to attending to theward cases.
The class of patients handled by this service includedneurological, psychiatric, feeble-minded, epileptic, and inebriate, and afterthe return of the overseas men, so-called "shell-shock," and varioustraumatic neurological cases. Among the psychiatric cases, dementia pr?cox,manic-depressive, general paralysis of the insane, and various other forms ofpsychiatric cases were under observation and treatment.
The treatments as administered, consisted of medicinaltherapy, hydrotherapy, electrotherapy, and occupational therapy.
The disposition of the cases was variable; some, not in lineof duty, were transferred to the psychopathic hospital, Boston, Mass., and fromthere to the State in which the patient resided. Other patients, whosedisability was incurred in line of duty, were transferred to general hospitalsfor the insane. Some cases were discharged to duty, either well or improved,and the remaining psychopathic or neuropathic cases were discharged on surgeon'scertificate of disability.
The routine of the staff was as follows: There was a dailymorning staff meeting on each case, at which time the diagnosis was made. As theoccasions demanded, consultations were held in the medical and surgical wards ofthe hospital. The enlisted personnel were practically intact from the time ofthe establishment of the ward, most of the men being experienced in the handlingof psychopathic cases.
The total number of admissions during 1918 was 929.
cBased on History of Base Hospital, Camp Devens, Mass., byMaj. W. B. Lancaster, M. C., March 19, 1919. On file. Historical Division, S. G.O.
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BASE HOSPITAL, CAMP WADSWORTH, S. C.d
The neuropsychiatric work at Camp Wadsworth was begun duringthe latter part of September, 1917. At first it consisted in the examination ofthe camp personnel. A number of organizations of the 27th Division had beenexamined before coming to Camp Wadsworth. The examination of the remainder wascompleted during January. Scattered cases and men especially referred by theregimental surgeons were gone over in February. Additional troops began toarrive during March and April, therefore, the number of examinations increased.
It was not until February 15, 1918, that all neurologicalcases in the base hospital were concentrated in one ward, ward No. 15. This wasa regular ward and, therefore, not suitable for the care of insane patients.From the opening of the hospital psychiatric patients were transferred as soonas possible to special institutions; at first to Kings County Hospital,Brooklyn, N. Y., and St. Elizabeths Hospital, Washington, D. C., after December,1917, to General Hospital No. 6, Fort McPherson, Ga. A special psychiatric wardwas constructed and completely equipped.
Ward No. 15 contained 36 beds, most of which were constantlyoccupied. The majority of cases treated were psychoneurotic. Hysteria wasespecially frequent. Patients with this trouble responded well to suggestivetherapy administered through the medium of faradic and sinusoidal electricity.Neurasthenic patients did well under rest, forced feeding, massage and saltrubs. Special attention was paid continually to the mental attitude of thepatients. Cheerfulness was the rule in the ward. Sympathy and understanding,combined with firmness, were maintained. Faulty attitudes and emotionalreactions were explained to the patients and they were encouraged to combatthem. They were made to realize that a personal interest was taken in theirwelfare, that things were done for them, and that much was expected from themin return.
BASE HOSPITAL, CAMP MEADE, MD.e
The personnel of the neuropsychiatric section consisted of 1officer and 12 enlisted men. Of the enlisted men, 3 were male graduate nurses, 5men with previous experience in State hospitals for the insane, and 4orderlies. On February 1, 1918, one ward was assigned for neurological andpsychiatric cases. On March 15, one-half of another ward was assigned to thisservice, and on April 22 the number of cases had increased to such an extentthat it was necessary to assign two full wards to this service. Of these wards,one was used for psychiatric, the other for neurological cases. On December 18,it was found again unnecessary to have two wards, owing to the decreasedpopulation of the camp, and all cases were concentrated in one ward.
The following tabulation shows the movement of patients onthis service for the year:
dBased on History of Base Hospital, Camp Wadsworth, S.C., by Maj. W. Barndollar, M. C., undated. On file, Historical Division, S. G.O.
eBased on annual report, base hospital, Camp Meade, Md., for1918, made to the Surgeon General by the commanding officer. On file,Historical Division, S. G. O.
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Total admissions | 952 |
Average under treatment daily | 51 |
Discharged: | |
| Improved | 166 |
| Recovered | 65 |
| Unimproved | 630 |
| By transfer | 65 |
| Died | 5 |
Remaining Dec. 31, 1918 | 21 |
The percentage of various classifications of diseasesresulting in discharge from the service follows:
| Percent | |
Nervous disease or injury | 24 |
Psychoneurosis | 20 |
Psychosis | 10 |
Inebriety | 9 |
Constitutional psychopathic state | 8 |
It would seem at first glance that the percentage recommendedfor discharge was high; however, it is evident that once a diagnosis of nervousor mental disease was made it was to the best interests of the service, as wellas of the individual, to return him to his home, experience having shown thatsuch men would not stand up under the stress of modern warfare.
Because of limited space, necessitating the expeditioushandling of patients, the insane were transferred to the Government Hospitalfor the Insane, Washington, D. C., for further observation and treatment. Mildlydemented cases which observation showed were not dangerous to themselves, or amenace to society, were sent to their homes in care of an attendant.
Of the 952 patients admitted, 80 Percent were admitted fromcommand and 20 Percent transferred from other wards of the hospital. There wereno suicides or other serious injuries during the year. From each incoming draftwere admitted about 10 cases of drug addiction. These men were immediatelydischarged from the service, experience having shown that no reliance could beplaced on a man so afflicted, and his presence in a company was decidedlydetrimental to the morale. It is interesting to note the high percentage ofcases of hyperthyroidism from the mountainous districts of adjacent States,especially West Virginia. There were surprisingly few cases of attemptedmalingering. The exceptionally low percentage of involvement of the centralnervous system in syphilis in the negroes is also worthy of mention.
BASE HOSPITAL, CAMP JACKSON, S. C.f
The neuropsychiatric ward was opened in November, 1917. Thisbuilding was designed and equipped on the lines of the standard base hospitalward for this special purpose. According to the original plans, heavy iron barson the windows were called for, but were omitted by the War Department upon therequest of the chief of the service, it being his belief that such measures forthe restraint of patients were antiquated.
fBased on History of Base Hospital, Camp Jackson, S. C., fromOctober 22, 1917, to June 1, 1918, by Capt. Martin W. Reidan, M. C. On file, Record Room, S. G.O., 314.7 (Medical History, Camp Jackson) (D).
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The psychiatric portion of the ward was not available for itsproper purpose until March, 1918, because the whole building was commandeeredfor the care of meningitis cases during the severe epidemic of 1917-18.
The growth of the service is shown by the following table forthe first four months of 1918, which presents, however, only patients in theneuropsychiatric ward and does not include cases seen in consultation:
January | February | March | April | |
Number of patients 1st day of month | 8 | 18 | 14 | 27 |
Admissions | 21 | 17 | 42 | 48 |
Total number under treatment | 29 | 35 | 56 | 75 |
Daily average | 14 | 17 | 25 | 27 |
Total number discharged | 11 | 21 | 29 | 48 |
This department performed two distinct functions: First, as a clearing house through which soldiers who were accepted for service could be passed in order to ascertain their fitness for service or responsibility for misconduct, and, second, as a place where the insane or neurologically afflicted might be helped, cared for, and treated until their discharge papers were complete or the type of service for which they were qualified could be determined. With the return to the special ward it became easy to classify the different groups and to begin such a systematic ordering of work and recreation and rest as to show a distinctly remediable effect upon many cases. The patients were kept occupied at work or games as much as possible.
The insane patients were required to do simple tasks whentheir condition permitted. The camisole or other restraint, mechanical ormedicinal, was rarely resorted to; usually enough attendants were available tocare for such cases.
A classification of the various cases follows:
Psychoneurosis | 103 | Cerebral hemorrhage | 3 |
| Mental deficiency | 68 | Manic-depressive psychosis | 19 |
| Epilepsy | 45 | Dementia pr?cox | 9 |
| Tertiary syphilis, cerebrospinal | 12 | General paralysis of the insane | 1 |
| Peripheral nerve lesions | 8 | Conscientious objector | 1 |
| Morphine habit | 9 | Constitutional psychopathic state | 5 |
| Hyperthyroidism | 4 | ||
The neurasthenias and psychasthenias were almost without exception of long standing, and their detection before acceptance would have saved the Government a large sum of money.
The determination of intellectual level in cases of mentaldeficiency presented great difficulties because of the remarkable degree ofilliteracy in the troops, especially the negroes. To apply to these cases anyarbitrary method of examination applicable to communities which were literatewould have given results almost grotesque. The Yerkes-Bridges point scale,modified by leaving out the questions demanding literacy and adding, to thetotal of points thus secured, an average credit for these questions which hadbeen elided gave good results. The sense of relative degrees of wrongdoing wasvery limited, indeed, and it was often a question for deep and ponderous mentaldebate with them
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whether it were worse to kill a man or to curse. Most whitesmeasuring below 8 years were, as a rule, poor specimens physically as well asmentally and morally. On the contrary, amongst the negroes a great many whomeasured imbeciles were excellent workers. These were held for limited service.
The experience with drug addicts was interesting. With veryfew exceptions all of these men had taken "cures" from one to fivetimes. All, upon discharge, were in much improved condition. There was littledoubt that each one resumed the use of his drug soon after return to civil life.These men were unanimous in the belief that the Harrison Act had merelyincreased the price of narcotics and that any addict could readily secure the"dope," usually by means of doctors' prescriptions; less often bythe various underground paths worn smooth by the "dope fiend's"shuffling steps.
The fact that there was only one case of general paralysis ofthe insane was noteworthy.
BASE HOSPITAL, CAMP GRANT, ILL.g
The department of neurology and psychiatry was establishedSeptember 1, 1917. The work of the department consisted of two fairly distinctdivisions: (1) Examining of recruits for nervous and mental disease. Forthis work examiners attached to the camp, as well as those in the base hospital,were used. One examiner worked with each general examining board at the time ofthe initial examinations. Cases considered suspects were sent to anotherexaminer who, with a psychologist, acted as a final deciding board. In examiningthe last 15,000 recruits it was found that this plan was more satisfactory thanthe old method of examining only referred cases or the method of making thepsychiatric examination after the general examination was completed. (2) Care ofpatients requiring hospital treatment and examination of referred cases. Onlysuch patients were kept in the psychopathic ward as required treatment or neededmore supervision while awaiting discharge than could be given them in theircompanies. The new form of certificate of disability materially shortened thestay in the hospital of these cases. Referred cases came from a number ofsources, usually from the regimental surgeon but often originally from thecompany officers on account of inaptitude or peculiarities; cases of misconductreferred for examination preliminary to trial; as a result of letters written byrelatives or friends; and hospital cases referred on account of someneurological or mental condition developing or being first observed while undertreatment for some physical ailment.
A considerable number of conscientious objectors wereexamined. They were classified as religious, intellectual, and the objectorwhose scruples were only means to the end of getting out of a situation that wasdistasteful to him. It was exceedingly difficult to separate the latter from thetwo former groups. Objectors were classified also as to their mental make-up.The majority were found to be normal both as regards disease and defect, but acertain Percent were psychotic. The mentally abnormal were very seldomfeeble-minded. They were usually either hypomanics or paranoid pr?coxes,especially the latter.
gBased on History of Base Hospital, Camp Grant, Ill., byLieut. Col. H. C. Michie, M. C. On file, Historical Division, S. G. O.
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Of the psychoses, dementia pr?cox of the hebephrenic typewas by far the most frequently encountered. Old pr?coxes were especiallyliable to "blow up" in a military environment and were frequently minoroffenders. Syphilitic psychoses were the next most frequent. Of the organicnervous diseases the only one of any great importance, aside from cerebrospinallues, was epilepsy.
Establishing a diagnosis of epilepsy was not always an easymatter, differentiation from hysteria often was difficult, and many cases wereseen in which there was an isolated fit at the beginning of an acute infectionor following typhoid inoculation.
Functional nervous diseases were rather frequent-hysteriaamong the negroes and lower grade of white soldiers, and neurasthenia among thebetter grade of whites. The custom was to recommend men with functional nervousdisease for domestic service and not for discharge from the Army, except in themore advanced and disabling cases.
The diseases, then, that were especially to be dealt withwere dementia pr?cox, cerebrospinal lues, epilepsy, and psychoneuroses.
From September 1, 1917, to April 30, 1918, 319 men wererecommended for discharge by this department. The above plan worked very wellfor several months until the camp had increased largely in population so thatthe number of men who required examination on account of nervous or mentaldiseases, but who did not require admission to the hospital, became so large asto interfere materially with the work of the psychopathic ward itself. Early inJuly, 1918, the division psychiatrist moved his offices to a building in thecamp away from the base hospital, and the psychopathic ward was used only forpatients requiring admission. Nervous and mental cases which did not seem to beserious enough to require admission to the psychopathic ward for care ortreatment were sent first by their regimental officers to a psychiatric examinerstationed at one of the buildings in a part of the camp more easily accessibleto ambulatory cases than was the base hospital.
GENERAL HOSPITAL NO. 1, NEW YORK CITYh
On November 22, 1918, ward 55 of General Hospital No. 1 wasopened for the reception of neuropsychiatric patients arriving at the port ofembarkation, Hoboken, N. J., from overseas and also for such cases as developedin the hospitals under the jurisdiction of this port. This had formerly been theMessiah Home, maintained for the care of children. The general construction wasso good that with but a few alterations it was readily adapted for the class ofpatients with which we had to deal.
The building contained five wards, two of which were devotedto the frank psychoses, one for disturbed patients and the other for quiet,depressed ones. The remaining wards were used for the care of mild mentalstates, psychoneurotics, epileptics, constitutional psychopaths, etc. Thehospital had a total bed capacity of 220. Of this number the ward for disturbedpatients contained 30 beds, the ward for quiet patients 40 beds, and theremaining 3 wards contained 50 beds each.
hBased on Report of General Hospital No. 1, Williamsbridge,N. Y., made by Lieut. Col. P. W. Gibson, M. C., October 18, 1919. On file,Historical Division, S. G. O.
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The staff consisted of an executive medical officer, chief ofservice, five ward surgeons, a mess officer, a registrar, and a dental officer.As this part of the general hospital functioned as an evacuation unit, urgentconditions only could be treated, but detailed reports were made of allpathologic findings, and recommendations for treatment were written thereon.These reports were then forwarded, with the history of the patient, to his finaldestination. In view of the fact that the unit was an integral part of GeneralHospital No. 1, it was possible to arrange for consultation with the members ofthis staff, and their services were always promptly available. As a result ofsuch an arrangement, many patients actually ill with conditions other thanmental could be immediately transferred for treatment. The hospital was equippedwith a complete hydrotherapeutic outfit, consisting of continuous baths,showers, needle spray, douche, etc. An occupation class under the direction of atrained worker and three assistants completed the therapeutic system.
On admission all patients immediately were inspected forlouse infestation, venereal diseases and throat infections. Throat cultures weretaken on all admissions. Following this procedure, a hot shower was given to allbut louse-infested patients, who were given a special tub bath. The clothing ofall patients was sterilized by steam.
As soon as possible after admission a complete physical andmental examination was made. The cases were classified and reported to theoffice of the surgeon, Hoboken, N. J., in order that transportation might bearranged. If the diagnosis on the field card accompanying the patient was notconcurred in, the patient was presented at a staff meeting, and the consensus ofopinion determined the diagnosis. In all doubtful cases, blood and spinal fluidexaminations were made. In addition, ophthalmic, aural, surgical, and medicalexaminations were made where there were special indications. Where a diagnosisof mental deficiency was in doubt, an intelligence test by means of the Stanfordrevision was made, and in many cases the diagnosis was changed. This cast noreflection on the work of the psychiatrists overseas, as many of these patientspresented a far different aspect after reaching this country. The psychosespatients, too, often presented a far different appearance from that previouslynoted in their records, and although formerly indifferent and depressed, nowpresented a cheerful, interested aspect. The total number of patients admittedwas 2,750, of which 2,126 were overseas and 624 were local cases.
The patients admitted to the hospital were classified asfollows:
| |
| Amyotrophic lateral sclerosis | 1 |
| Sydenham's chorea | 1 |
| Acute encephalitis | 1 |
| Lateral sclerosis | 2 |
| Tabes dorsalis | 4 |
| Multiple neuritis (following typhoid fever, 1; diphtheria, 2; intravenous | 8 |
| Cerebral syphilis | 33 |
| Peripheral nerve injury | 9 |
| Gunshot wound of the head | 2 |
Head injury without demonstrable fracture of the skull | 7 |
General paresis | 61 |
Fractured skull | 7 |
Brain tumor | 3 |
Progressive muscular atrophy | 1 |
Myotommia congenita | 1 |
Transverse myelitis following intratracheal administration of arsphenamine | 1 |
Nervous disease undiagnosed | 2 |
| Total | 144 |
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It will be seen from the above that 100 of the 144 organicnervous cases were syphilitic diseases of the central nervous system.
The cases classified as "Observation for epilepsy"presented no evidence in the accompanying history that a convulsion had everbeen observed by a medical officer, and as none occurred at this hospital it wasdeemed fair to the patient to leave the diagnosis open.
| Cases of epilepsy and observation for epilepsy | |||
| Observation for epilepsy | 25 | Traumatic | 2 |
Grand mal | 111 | Psychosis | 2 |
Petit mal | 9 | Total | 151 |
Equivalents | 1 | ||
Jacksonian | 1 | ||
The patients listed under the heading "Recovered" had usually had either a mild depression or excitement of the manic-depressive type, or else had had an acute alcoholic hallucinosis from which they had completely recovered. A number of psychoneurotics appeared to have recovered, in that they were free from symptoms during their residence and so were placed in this group because it was felt that further hospital residence was unwise and might produce a recurrence of their symptoms.
Of the recovered cases the subclassifications were asfollows:
| Classification of recovered cases | |||
| Psychoneurosis | 17 | Psychosis following influenza (infective exhaustive) | 3 |
Alcoholic hallucinosis, acute | 7 | Undifferentiated depression | 2 |
Manic-depressive psychosis | 9 | Gunshot wound of the spinal cord | 1 |
Psychosis undiagnosed | 1 | Recovered | 43 |
Alcoholism, acute | 1 | ||
Pathologic intoxication | 1 | ||
Delirium tremens | 1 | ||
| Mental deficiency and manic-depressive psychoses | ||
Mental deficiency with psychosis | 4 | |
Manic-depressive psychoses: | ||
| Manic type | 95 | |
| Depressed type | 213 | |
| Mixed type | 44 | |
| Circular type | 1 | |
| Total | 353 | |
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In the manic-depressive psychoses group, in so far as it waspossible to obtain reliable information, 35 had had a previous attack. It mustbe remembered, however, that the number of patients who had had previousattacks was undoubtedly greater, but as many of the patients were entirelyinaccessible, information in regard to this could not be obtained. Thedepressions predominated.
| Cases of dementia pr?cox | |
Hebephrenic | 256 |
Paranoid | 163 |
Simple | 111 |
Catatonic | 20 |
| Total | 550 |
Many of the patients presented a typical schizophrenichistory, but were in an apparently normal condition and well adjusted. Some ofthem gave quite adequate explanations for their upset, such as nostalgia andworry over misfortune at home. Others stated that they felt they had beenunfairly treated in the Army. The eventual outcome appeared to be problematical.It was felt that the original diagnosis should be left unchanged.
| Cases of paranoid condition, alcoholic and traumatic psychoses, constitutional psychopathic state, and psychoneuroses | ||||
Paranoid condition | 4 | Psychoneuroses: | ||
Psychoses with somatic disease: | Hysteria | 295 | ||
| Following influenza | 20 | Neurasthenia | 282 | |
| Following mumps | 2 | Psychasthenia (compulsion neurosis) | 25 | |
| Following pneumonia | 1 | Anxiety state | 22 | |
23 | Hyperthyroidism | 8 | ||
Traumatic psychosis (head injury) | 5 | Enuresis | 8 | |
Alcoholic psychoses: | Disordered action of the heart | 5 | ||
| Acute hallucinosis | 37 | Traumatic neurosis | 3 | |
| Deterioration | 4 | Stammering | 6 | |
| Pathologic intoxication | 1 | Syphilophobia | 2 | |
42 | Hyperthyroidism | 2 | ||
Constitutional psychopathic state: | Somnambulism | 1 | ||
| Inadequate personality | 110 | Dyspituitarism | 1 | |
| Emotional instability | 8 | Facial tic | 1 | |
| Paranoid personality | 5 | 661 | ||
| Delinquent tendencies | 1 | |||
| Homosexuality | 3 | |||
| Criminal tendencies | 3 | |||
130 | ||||
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Of the neurasthenic group 26 Percent of the patients gave ahistory of having had symptoms of this condition in civilian life, and of thehysteria group 19 Percent gave a history of similar trouble prior to Armyservice.
Cases of inebriety | |
Alcoholism | 111 |
Morphine addiction | 7 |
Heroine addiction | 6 |
Heroine and morphine addiction | 1 |
| Total | 125 |
The small number of drug addictions is notable.
| Cases of mental deficiency, without mental disease and undiagnosed | |||
Mental deficiency: | No mental disease found-Contd. | ||
| Morons | 225 | Deviated nasal septum | 1 |
| Imbeciles | 27 | Diphtheria carrier | 2 |
252 | Malaria, tertian | 1 | |
No mental disease found: | Polyarthritis, rheumatic | 1 | |
| Rheumatic fever, subacute | 1 | Gunshot wound of the right arm | 1 |
| Flat-foot | 1 | Valvular heart disease | 1 |
| Duodenal ulcer | 1 | Diagnosed as epilepsy but not concurred in | 1 |
| Pulmonary tuberculosis | 3 | No physical or mental disease found | 13 |
| Syphilitic cirrhosis of the liver | 1 | 31 | |
| Gastritis, chronic catarrhal | 1 | Psychoses undiagnosed | 148 |
| Syphilis, secondary | 1 | ||
| Acute gonorrhea | 1 | ||
The cases with psychoses undiagnosed were left ungroupedbecause of the lack of data sufficient to make a differentiation possible. Manyof these patients were fearful and refused to answer questions. They were notcatatonic nor did they attitudinize. Hallucinatory reactions were not observed.Other patients appeared quite confused and presented a dreamlike, perplexedstate. At times they appeared quite distressed. They refused to cooperate onexamination. Many of the patients were difficult to differentiate adequately,and it could not be definitely decided as to whether they presented a pr?cox ormanic-depressive reaction. In many cases there was an alcoholic history andcoloring which was difficult to evaluate properly. In a few of the cases therewere pupillary signs, but the residence was too short to permit of blood andspinal fluid examinations, or else they were too disturbed for such procedures.
This part of the United States Army General Hospital No. 1closed officially on September 10, 1919, but no patients were received afterSeptember 1, 1919, so that it was open for the reception of patients for aperiod of 9 months and 22 days.
None of the cases appeared different from those encounteredin civilian life, except that most of them had a military coloring. Of the totalnumber of 2,750 patients, 24 Percent were psychoneurotics, 20 Percent of thedementia
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pr?cox type, 12 Percent were of the manic-depressive group,10 Percent mental defectives, 5 Percent had organic nervous diseases,principally of the syphilitic type, 4 Percent were definitely epileptic, and 4Percent were constitutional psychopaths. There were only 14 cases of drugaddiction, or about 0.5 Percent of the total admissions. Many of the casesapparently of the pr?cox type appeared to be recovered, with excellentinsight. Of the neurasthenic group, 26 Percent of the patients gave a historyof having had symptoms in civilian life, and of the hysteria group 19 Percentgave a history of similar trouble prior to Army service.
A comparison of the group percentages found at this hospital,with the group percentages of the total male admissions for the New York Statehospital service during the year 1919, is interesting. During this year thetotal first admissions were 6,791. Of this number, 3,527 were men. The grouppercentages for the male admissions are as follows:
Classification of men admitted to the New York State hospitals during 1919
Percent | Number of cases | Percent | Number of cases | ||
Traumatic psychoses | 0.5 | 18 | Manic-depressive psychoses | 9.0 | 352 |
Senile psychoses | 9.0 | 324 | Involution melancholia | 1.5 | 56 |
Cerebral arteriosclerosis | 6.0 | 236 | Dementia pr?cox | 27.0 | 1,001 |
General paresis | 20.0 | 710 | Paranoia | 1.5 | 59 |
Cerebral syphilis | .4 | 15 | Epileptic psychoses | 2.7 | 96 |
Organic brain diseases (Huntington's chorea, brain tumor, etc.) | .5 | 19 | Psychoneuroses | 1.0 | 35 |
Alcoholic psychoses | 5.0 | 204 | Constitutional psychopathic state | 1.6 | 66 |
Drug psychoses | .16 | 6 | Psychoses with mental deficiency | 2.5 | 88 |
Psychoses with somatic disease | 2.0 | 76 | Psychoses undiagnosed | 3.9 | 138 |
Not insane | .7 | 28 |
While a strict comparison is not possible, it is interestingto know that there is a close ratio between the percentage of cases of dementiapr?cox, namely, 20 Percent in the Army and 27 Percent in civilian life, andbetween the percentage of cases of manic-depressive diseases, 12 Percent in theArmy and 9 Percent in civilian life. Dementia pr?cox in both instances formsthe largest group of the psychoses. Comparisons between the other groups isimpossible because the civilian State hospitals deal primarily with psychosesoccurring at all ages and with unselected population. In 1918, of the totalremaining population in the New York State hospitals, 59 Percent were of thedementia pr?cox group. It will readily be seen, therefore, that our greatproblem, from the standpoint of psychoses, both civilian and military, was thatof the dementia pr?cox group.
All the acute psychoses among the officer patients receivedat Hoboken requiring close supervision were transferred to the BloomingdaleHospital, White Plains, N. Y., where the Government reserved a limited number ofbeds. An Army medical officer was stationed at Bloomingdale most of the time,and in addition, a psychiatrist from United States Army General Hospital No. 1visited the hospital two or three times a week and supervised the treatment anddisposition of the officer patients.
The mild and recovered psychoses and psychoneuroses amongofficers and some organic nervous cases were excellently handled at the privatepavilion.
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This place afforded not only very desirable private roomingfacilities, with pleasant environment, but also a most up-to-datehydrotherapeutic plant. The treatment of these officer patients consisted ingeneral of hygienic measures, medicinal treatment, special medical and surgicaltreatment, psychotherapy, and hydrotherapy.
As in other hospitals, the importance of the neuropsychiatricdepartment in United States Army General Hospital No. 1 became evident in thesummer of 1918, when there were numerous consultations required by otherdepartments in looking over doubtful cases in other medical services.
The following tabulation of nervous and mental cases treatedat the United States Army General Hospital No. 1 (exclusive of the MessiahHome), between July 1, 1918, and June 30, 1919, shows diagnosis and disposition.
GENERAL HOSPITAL NO. 2,i FORT McHENRY, MD.
The neuropsychiatric service at this hospital was opened inMarch, 1918, but adequate facilities were lacking and it was not until May thatthe patients were moved into the new standard psychiatric building and the real,effective work of the service was begun. Patients were given every benefit ofthe modern school of neuropsychiatry. The interior of the building was decoratedand painted in soft, restful colors, while potted plants and flowers distributedthroughout and lace curtains at the windows all combined to make the place asattractive, homelike, and pleasant as possible. In the rear a spacious porch wasconverted into a sun parlor and made an ideal place for the activities ofoccupational therapy.
iBased on History of General Hospital No. 2,Fort McHenry,Md., by Maj. A. P. Herring, M. C. On file, Historical Division, S. G. O.
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The psychiatric building had its own hydrotherapy roomequipped with showers, continuous tub, etc., and the soothing effect of thesedative bath, especially in manic cases, was successfully demonstrated. Fulladvantage was taken of the hospital's physiotherapy department and nearly allof the neuropsychiatric patients were sent out daily for some kind of treatmentin the more elaborately equipped psychiatric building.
No effort was spared to provide every therapeutic benefit tobe derived from diversional occupation and recreation for the patients. Areconstruction aide spent her time entirely with these patients, doing all thatwas possible to keep their minds and hands busy, and splendid results wereachieved. In addition, a teacher of calisthenics spent some time each day givingthe patients brisk exercises and lively games which were greatly enjoyed. Alarge pool table, a Victrola, and a well-stocked library were available for useat all times.
The patients were treated individually and not collectively.No routine or "system" methods were used in administering to those whowere admitted complaining of the many and varied symptoms incident to a nervousor mental disorder.
The happy results attending the use of the principalagencies of treatment (hydrotherapy, occupational therapy, psychotherapy),especially in the large group of the functional neuroses and the incipientmental disorders, amply justified the principles of "nonrestraint"which were insisted upon when the department was inaugurated, early in 1918.
The neuropsychiatric wards in this hospital were built alongthe plans of those existing in all of the Army general hospitals at that time.There were no locked doors, barred or screened windows. Patients admitted to thedepartment of neuropsychiatry were always treated as sick individuals. On March22, 1919, the scope of the service was considerably broadened by makingarrangements to care for a number of neuropsychiatric officer patients, and award was set aside for their use. In addition to this the Surgeon General gavethis service general supervision over a number of neuropsychiatric cases amongArmy nurses, aides, and others who were sent to the Shepherd and Enoch PrattHospital at Towson, Md., and to Henry Phipps psychiatric clinic at JohnsHopkins Hospital.
The following is a brief statistical summary of thedepartment:
| Number of patients admitted during the year 1918 | 231 |
Number of patients admitted during the year 1919 | 388 |
Number of patients admitted from January 1 to April 31, 1920 | 60 |
| Total number admitted | 679 |
Number of patients discharged by surgeon's certificate of disability | 144 |
Number of patients discharged to duty | 120 |
Number of patients transferred | 403 |
| Number of patients deserted | 8 |
| Number of patients died | 4 |
| Total number disposed of | 679 |
| Diagnoses: | |
Nervous disease and injury | 175 |
Psychoneurosis | 129 |
| Psychoses | 170 |
Inebriety | 21 |
| Mental deficiency | 79 |
Constitutional psychopathic state | 86 |
| Other diseases and injuries | 19 |
| Total | 679 |
Consultations | 345 |
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GENERAL HOSPITAL NO. 6, FORT McPHERSON, GA.j
The first collecting wards in the United States to beespecially built and equipped for the neuropsychiatric work of the Army wereopened to receive patients at Fort McPherson on November 7, 1917. In the suburbsof Atlanta United States Army General Hospital No. 6 was centrally located withregard to a great military population, including many cantonments and all theforts along the southeastern coast. Its grounds contained many medical unitspreparing for foreign service. Near by, with through train connections, wereCamps Greenleaf, McClellan, Sheridan, Wheeler, and Hancock. The main line northtapped Camps Sevier, Wadsworth, and Greene.
The neuropsychiatric wards were so placed that the receptionand treatment sections had on three sides medical and surgical wards, while thethree buildings for nervous and insane cases stretched out toward the woods andaway from other structures. Diet kitchens and offices were in the proximal endsof the three buildings for mental diseases and porches made them easilyaccessible from the general mess hall and from each other.
All buildings were new and conformed in appearance to othernew hospital structures. They were sunny, well ventilated, with ample porchspace, which was screened. The door of the reception section opened into a largeroom furnished with center table and settees. This was a meeting place for allthe activities of the service. On one side was the record room and on the otherthe physician's office, housing a collection of books on neuropsychiatry,mental hygiene, and military service furnished by the National Committee forMental Hygiene. Opposite the door were three smaller rooms. The first was formental examinations, fitted with a table and shelves on which were kept thepsychological tests and record blanks. The second contained a high bed forphysical examinations and a blood-pressure instrument, an ophthalmoscope, andother clinical apparatus. The third room was fitted as a ward laboratory, withapparatus chiefly for urinalysis and the collecting and examining of blood andspinal fluid.
Entering the treatment section by a narrow hall from thereception room, one found in a room on the right electrical apparatus with ahigh convenient table for a recumbent patient. Across the hall on a cement floorwere high tables for massage and packs. In front, in a room of manywindows, open on
jBased on History of General Hospital No. 6, FortMcPherson, Ga., by Col. Thomas S. Bratton, M. C. On file, Historical Division, S. G.O.
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three sides, with cement floor sloping 3 inches to a centraldrain, were placed an elaborate combination douche apparatus controlled from thewall and an electric light cabinet bath. In a separate room a Bergonie machinewas set up.
Special articles of therapeutic and diagnostic equipment werefurnished by the National Committee for Mental Hygiene as soon as the buildingswere under construction and, because of this generosity and foresight, were atonce ready for use.
A building adjoining, with small dormitories well separatedfrom each other, was used as an admission ward. At its far end was a large spacefitted with continuous bathtubs and showers, with inclosed porch in connection.
Two other buildings radiated from a common center with thislast building. They were arranged to give isolation with a separate porch andbath to varying groups of patients.
The chief of neuropsychiatric wards, by consent of the chiefof medical service, reported directly to the commanding officer in exclusivelyneuropsychiatric matters. Assistant physicians had duties roughly coordinateand independent. One devoted all his time to teaching enlisted men and tocarrying out meningitis therapy in the medical wards. Another physician hadcharge of physiotherapy, treating patients from all hospital services. He gaveinstruction in his particular field to enlisted men, who assisted him in turn.The third was a specialist in the use of the Bergonie electrical apparatus,demonstrating its use in selected cases. Other physicians had direct charge ofthe wards.
Each ward for the insane was in charge of a nurse orwardmaster who had adequate psychiatric training; a supervising nurse hadgeneral duties in the care of all cases. The neurological ward was in the chargeof nurses with general training; it was open, and run as were other medicalwards.
A sergeant was in charge of occupational activities, beingresponsible for patients received from the wards for outside work. There wasopportunity also to use the occupational classes of the reconstructiondepartment.
A sergeant, first class, was in charge of all enlisted mensent here for training, assigning them to duty and keeping track of their workand character; he also had charge of records, with three clerks to help him.
Enlisted men were supplied by the section of neurology andpsychiatry of the Surgeon General's Office, which selected them because ofspecial experience or fitness. Among them were many attendants with more or lessservice in hospitals for the insane and many college men who had specialized inpsychology or pharmacy. Due to a shortage in experienced personnel, it wasnecessary to take Hospital Corps men and men without hospital experience andtrain them for work on the mental wards. A special course was instituted andlectures were given by the ward physicians on the care and treatment of mentaldiseases.
During the fall and winter (1917-18) the wards werecrowded with dementia pr?cox cases, most of them of long standing. In somecases the conditions of Army life seemed to precipitate mental trouble inpersons who might have remained normal in civil life. Many were returned totheir homes for supervision. Over 50 were returned to hospitals in their homeStates, often to hospitals where they were well known as former patients.
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As a contrast to this group was one formed by patients fromCamp Gordon, Ga., and the other wards of the general hospital, who complained ofheadaches, vertigo, pains. Many of these were carried as consultation cases;those not rather promptly relieved by the fitting of glasses, the cleaning ofteeth, by baths and packs, were found, in general, resistant to treatment, and,under the diagnosis of neurasthenia or constitutional psychopathic state,usually were discharged.
With the spring came a third general group-theorganic-appearing cases, which turned out to be functional, and the acutepsychoses. Electrical apparatus, added to suggestion, made many dumb to talk andmany crippled to walk. The diagnosing of different sorts of fits was a difficultproblem. The malingerer was rare. Cases of feeble-mindedness were few becausethey had been sifted out in the cantonments.
In treatment physiotherapy was used largely and with goodresults. Gardening developed nicely in adjoining spaces and provided many mentalcases with pleasure and exercise. It was the aim to give most of the patientsemployment of some kind. During the spring, summer, and fall months, manypatients worked on the lawn, grading, seeding, planting, and caring for flowers.Others worked in the vegetable garden. On the wards patients were employed underthe supervision of occupational therapists and instructed in basketry, rugweaving, beadwork, hammock making, wood carving, etc. A great deal of interestwas manifested in the work and much benefit was derived from it.
The neuropsychiatric section of the hospital contained, onJanuary 1, 1918, 30 patients, and on December 31, 1918, there were 153 patients.During the year there were 817 admissions. The largest number of patientsadmitted in any one month was during October, when 174 cases were received. Theaverage monthly admission was 68 patients. Up to October (1918) it had beenpossible to care for and treat all mental and nervous cases in the buildingsdesignated and built for this class, namely, wards U, V-1, V-2, and V-3.In October, however, it became necessary to convert medical wards M and L intopsychiatric wards. These gave an additional capacity of 160 beds, making thetotal capacity of the neuropsychiatric wards 276.
About 45 of the admissions to the neuropsychiatric sectionwere psychotic cases. Many of these cases in the early part of the year camefrom the various camps, but the majority came from overseas. About 25 Percentof the cases admitted were functional neuroses, mostly from overseas; about 10Percent were mental defectives. Comparatively few organic nervous cases werereceived. Constitutional psychopathic states represented 6 Percent of themental cases admitted. This class seemingly found it difficult to adjust to Armylife for any length of time, soon ran counter to the necessary discipline, andwere a source of disturbance and trouble. Only a few drug addicts and epilepticswere received.
During the year 692 cases were discharged in various ways.Three hundred and seventy-nine cases were discharged as recovered or improved;125 cases were transferred to Government hospitals for the insane; 116 caseswere discharged to other public and private hospitals. The death rate wascomparatively low, 5 cases in all, or less than 1 Percent of admissions.
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GENERAL HOSPITAL NO. 26, FORT DES MOINES, IOWAk
At General Hospital No. 26, Fort Des Moines, Iowa, there weretwo wards for neuropsychiatric cases. These wards were newly built of thestandard type-wards C and D. Ward D was occupied first on May 17; ward C onMay 28, 1918. By the early fall of 1918 the hospital had approximately 1,300patients, with about equal numbers of general medical and surgical (chieflyorthopedic) cases, and some 80-odd mental cases. By October the daily average ofmental patients had increased to 130.
Patients were received in the neuropsychiatric wards inlarger or smaller numbers at a time from Camps Funston, Dodge, Stuart, andGrant, from Forts Bliss and Omaha, and McCook Field, and in August and laterfrom the debarkation hospitals at New York, Newport News, and Boston.
Sixteen patients (mental) were discharged by the end of July,but from that time to the middle of October only 20 more were discharged.
The diagnoses were about the same as recorded in theliterature for other military hospitals, except that there were not many warneurosis cases-a few epileptics, some manic-depressive cases, some dementiapr?cox cases, a number of moron and border-line defectives, a fewconstitutional psychopaths, and an occasional alcoholic or drug addict. A fewcases of post-meningitic condition were admitted for observation. When theorthopedic and other surgical cases began to come in from overseas, manynerve-injury cases were seen.
The total number of cases admitted to the mental wards up toDecember 4 was 226. An equal number were seen in consultation, but not admittedto the wards. In addition to these, a survey was made in August, 1918, of theenlisted personnel, 241 men altogether, of Base Hospital No. 79, which outfittedand organized at Fort Des Moines.
The nursing personnel of the neuropsychiatric wards wasadequate in numbers and fair as to quality.
GENERAL HOSPITAL NO. 30, PLATTSBURG, N. Y.l
Early in 1918 it became evident that more facilities wouldbe required for the observation and treatment of psychoneurotic disorders thancould be provided in the neuropsychiatric wards of the general hospitals. Thesewards, as well as the wards of base hospitals, had been relieved by theestablishment of a general hospital for psychoses (General Hospital No. 4,Fort Porter, N. Y.), and patients with psychoneuroses had from time to timebeen transferred there. It was obvious, however, that this hospital could not beexpanded to take care of the large number of psychoneurosis cases that wouldcome under treatment, even if this were desirable, and it was not considereddesirable. It was felt that the two types of patients should be separated. Forthe successful treatment of patients with psychoneuroses in large numbers anorganization was required in which could be maintained a spirit of recovery.This meant a hospital to which would be transferred only those patients for whomrecovery
kBased on History of General Hospital No. 26, Fort Des Moines,Iowa, by the commanding officer, Nov. 15, 1918. On file, Historical Division, S.G. O.
lBased on History of General Hospital No. 30, Plattsburg, N. Y., by the commanding officer. On file, Historical Division, S. G. O.
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was reasonably to be expected, and a hospital so located asto be as free as possible from outside distractions, both military and civil,and where military discipline could be maintained or relaxed as the occasiondemanded.
The post hospital at Plattsburg Barracks, N. Y., wasselected. Medical officers specially trained in neurology and psychiatry wereordered to Plattsburg during May, 1918, and the first neuropsychiatric patientwas received May 23, 1918. Ninety-nine patients were transferred to the hospitalduring June and other patients were transferred during July, August, andSeptember, although the hospital continued during this period as a post hospitaland received, in addition to the neuropsychiatric patients, patients from themilitary organizations then stationed at Plattsburg Barracks and from thesecond officers' training camp of 3,454 candidates. Some neuropsychiatricpatients were received also from overseas. September 21, 1918, the original posthospital at Plattsburg Barracks was designated General Hospital No. 30 andexpanded to include the entire group of permanent buildings at this post, theInfantry barracks being converted into hospital wards. There were 28 wards, witha capacity of 1,200 beds.
The hospital was divided for purposes of administration intofour sections. Section 1, for medical and surgical cases, including operatingroom; eye, ear, nose and throat, and genitourinary cases, with X-raylaboratory. Sections 2, 3, and 4, in the Infantry barracks, contained wards forvarious classes of neuropsychiatric cases. The hospital headquarters officeswere moved from the old post hospital to the post administration building in theearly part of October, this building being centrally located and more convenientfor purposes of administration. Medical officers on duty in the hospital andnurses were assigned to quarters upon the post in buildings set aside for thispurpose.
During the months of November and December, various buildingscomprising the hospital were connected by inclosed bridges, making in all acompact, protected area for the transfer and care of patients. During thistime the porches were inclosed and a steam-heating system was installedthroughout.
Although designated as a hospital for war neuroses andprimarily for the reception of patients from overseas, patients with otherneuropsychiatric conditions, through mistake in diagnosis and the exigencies ofthe service, were transferred to the hospital or received from overseas. Therewere later assigned to this hospital, also, at the instance of the division ofneurology and psychiatry of the Surgeon General's Office, patients sufferingfrom convulsive disorders (epilepsies) for special study, drug and alcoholicinebriates, and patients with residuals of epidemic cerebrospinal meningitis.
The first 1,000 patients had been received by November 16,1918. A statistical analysis of this group of 1,000 patients (considered typicalfor the patients received at this hospital) shows the following clinicaldistribution and disposition:
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| Disposition of cases | |
| Percent | |
Discharged on surgeon's certificate of disability | 53.8 |
Returned to duty | 27.0 |
Transferred to other hospitals | 3.7 |
Still in the hospital | 15.4 |
Died by suicide | .1 |
The disposition of cases as shown above is as of January 1,1919. The cases discharged on surgeon's certificate of disability werepractically all not in line of duty, and the same was true of a good many ofthose transferred to other hospitals or who remained under treatment atPlattsburg. These officers and men were unfit for military service. Theirinduction into the service was of no benefit either to the Government or tothem. It was possible in almost all of them to obtain readily a history of theexistence of their disability for a greater or lesser length of time prior toenlistment, and it would have been possible to obtain such a history at the timeof induction into the service.
The cases returned to duty had recovered sufficiently fromtheir more acute manifestations to be able to be of some service; but in most ofthere there remained behind, of course, the neuropathic constitution on thebasis of which their nervous breakdown had occurred. They were at best fittedfor limited service.
Some contrasts are to be noted in the above tabulationsbetween the respective groups of cases represented in them.
The psychoses constituted 15.9 Percent of all admissions inofficers and only 4.5 Percent of all admissions in enlisted men. Nosignificance is probably to be attached to the higher percentage of psychosesamong officers, as officers with psychoses were frequently sent to this hospitalin preference to a hospital for the insane, while enlisted men were regularlysent to hospitals designated for the treatment of psychoses.
For reasons that are perhaps sufficiently obvious, there wereno cases of mental deficiency among officers, and there were also none ofcerebrospinal syphilis, although the number of officer patients is too small tobe significant. In a larger group of cases a certain percentage of cerebrospinalsyphilis would undoubtedly be found, although it seems probable that suchpercentage would be lower than in enlisted men owing to greater caution aboutexposure to the infection, more through prophylaxis, and more prompt andthorough treatment in case of infection.
The tabulations show that endocrinopathies-for the mostpart hyperthyroidism-are more than six times as frequent, relatively, in thehome than in the overseas cases. It would seem clear from this that theseendocrinopathic cases are so manifestly unfit for military duty that even in thehasty selection of men for overseas service they were almost completelyeliminated; those cases which had passed the local board and first cantonmentexaminations came to light in the course of their training. Thus is explainedthe fact that endocrinopathies represent 3.9 Percent of all home cases admittedand only 0.6 Percent of all overseas cases.
Residuals of epidemic cerebrospinal meningitis arerepresented in the home cases by no less than 17.3 Percent of all admissions;in the much larger
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number of overseas cases no instance of that condition wasobserved. The underlying fact is that all epidemic infections and, of course,any sequel? or residuals, with the possible exception of influenza, were farmore prevalent in the home cantonments than among the troops overseas. Thereasons for this fact are well known and require no discussion here.
Epilepsy is represented to the extent of only 4.5 Percent ofall home cases and no less than 43.2 Percent of overseas cases. This remarkablecontrast, as far as it has a bearing on the relative incidence of epilepsy introops in the home and overseas service, is more apparent than real. The bulkof all cases of epilepsy discovered in home cantonments were disposed of thereby discharge on surgeon's certificate of disability. No such disposition couldbe made of cases discovered in overseas service; they all had to be sent tohospitals in the United States for final disposition. The figures show merelythat in examination before local boards at time of mustering in and at time ofselection of troops for overseas service epilepsy was often either overlookedor, if known to exist, ignored, and that eventually the necessity arose forthese cases to be sent to hospitals and disposed of by discharge on surgeon'scertificate of disability.
RESIDUALS OF EPIDEMIC CEREBROSPINAL MENINGITIS
An instructive series of cases studied at Plattsburg werethose with residuals of epidemic cerebrospinal meningitis. In the period fromDecember, 1917, to February, 1918, a number of cases of epidemic cerebrospinalmeningitis developed at Camp Beauregard, La. The patients were treated withspecific serum administered both intravenously and intraspinally, and a numberof them made uneventful recoveries from the infection. After a four or fiveweeks' period of convalescence in the base hospital at the camp, as a rule,they were granted a 60-days' furlough at home. On return from their furloughsome of the men were found still to have certain residuals, owing to which theywere unable to go back to duty. Others did go back to duty but were foundwithin a few days to be unable to perform it. Therefore all such patients were readmitted to the base hospital. After afurther period of from five to eightweeks' treatment and rest in the hospital they were still not in condition togo back to duty, and 18 of them were transferred on July 29 to General HospitalNo. 30, Plattsburg Barracks, N. Y.
At various other times and from other camps 13 other post-meningiticpatients were received at this hospital, and thus an unusual opportunity presented itself of studying the residuals of epidemiccerebrospinal meningitis.
In the decade previous to 1917 a great deal had beenpublished on the subject of epidemic cerebrospinal meningitis; but thesepublications dealt almost exclusively with the acute phases of the disease,its bacteriology, modes of transmission, prophylaxis, and specific therapy, andnot with the residuals.
The cases that thus came to the attention of the medicalofficers on duty at General Hospital No. 30 presented a striking and fairlyuniform syndrome made up of the following elements, given here in the order oftheir frequency: (1) Limitation of flexion of the spinal column; (2) unduefatigability; (3) pains in back, legs, and head; (4) tendency toward dizzinessand faintness; (5)
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muscular weakness; (6) tendency toward blurring of vision,associated with photophobia; (7) impairment of appetite and sleep, associatedwith a state of undernutrition.
The limitation of flexion of the spinal column was shown inall cases by inability to stoop over far enough to touch the toes with the tipsof the fingers without bending the legs at the knees. One or two of ourpatients, on arriving at the hospital, were able by special effort to comewithin 6 inches, but most of them could not come within a foot, and one couldstoop but very slightly. All said that prior to the attack of meningitis theyhad been able to do this, and some had been able to stoop far enough to placethe palms of the hands on the ground.
The limitation of flexion was further shown in the cervicalregion by the patients, in the majority of cases, being unable to flex the headon the trunk so as to touch the sternum with the point of the chin-which mostpeople normally can do. Some of the patients could not come within 2 inches oftouching.
Undue and unwonted fatigability was present in all cases,although it varied a good deal in degree. In one case, going up a flight ofstairs or a short distance up a hill or a few blocks even on level groundresulted in getting out of breath, palpitation, weakness, trembling, aches inthe back and legs, and a feeling of exhaustion. In another case the fact ofundue fatigability was to be noted only by comparison with former endurance orwith the endurance of other men in the organization.
Pains in the back, legs, or head were present in all cases.In some cases it was constant and so severe as to make it impossible to maintainwith comfort any position for more than a few minutes. In other cases it wasslight or only occasional, or developed only on stooping or exertion. Thefavorite locations were, in order of frequency, the small of the back, the back of the head and upper part of the neck, the legs behind the knees, and theback between the shoulder blades. In some cases there was tenderness to deeppressure, and in one case the head was so sensitive that laying the handlightly on the top of it caused an increase of pain. In two cases there wasgreat soreness in the tip of the coccyx, the patients having to sit on eitherone buttock or the other.
A tendency toward dizziness and faintness was present inalmost all the patients, but also varied in degree. In some cases any suddenmovement started things whirling or caused black spots to come before the eyes,while severe or prolonged exertion caused the patient to become faint, loseconsciousness, and fall; one patient came with a transfer card diagnosis of"epilepsy following meningitis." In the milder cases even severeexertion would bring on only slight or momentary dizziness. Stooping more thanother movements would excite this symptom. Arising from bed in the morning would often bring it on. It developed more readily in the unshaded sunlight,especially on a warm day.
In the headaches, dizziness, faintness, and losses ofconsciousness, and in the fact of these symptoms being especially apt to bebrought on by exertion, stooping, sudden movements, or exposure to the sun, thepost-meningitic con-
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dition closely resembles the well-known condition thatpersists for years following severe cranial traumatisms.
Muscular weakness, as existing independently of thefatigability and of the pains, was shown particularly by feeble hand grips inmore than half of the cases. Usually both grips were weakened, but often in anunequal degree. One patient, in other respects having a rather mild case,formerly as "strong as a tiger," was hardly able to turn the faucetsin the lavatory.
The tendency toward blurring of vision was very common butalso variable in degree. It became manifest when patients attempted to read,especially if the print was fine. After a few minutes or half an hour theletters would begin to "run together"; if the patient rested a whilehe could continue the reading, but unless he had rested an hour or more theblurring would come on again and more quickly than the first time.
It would seem that this trouble is due to a weakness of theocular muscles; in some cases close application would bring on diplopia; theocular movements, however, as ordinarily tested, as a rule were not impaired. Incases in which the tendency to blurring of vision was most marked there was alsoa degree of photophobia; at least two of the patients had to wear smoked orcolored glasses. In these cases there was sluggishness and limited excursion inthe pupillary reaction to light; moreover, on continued exposure to brightlight, the initial contraction would soon give way to relaxation; and it may bethat the photophobia was dependent at least in part on weakness and fatigability of the concentric muscle fibers of the irides, withresultinglack of shielding of the retina.
The impairment of appetite and sleep, sometimes associatedwith a state of slight subnutrition, was perhaps a secondary phenomenon. Many ofthe patients had formerly been leading active outdoor lives but had since beenforced by their illness to remain almost wholly without exercise for months. Theloss of sleep was almost invariably associated with pain; in some cases thepatients had difficulty in getting into a comfortable position for sleep andwould toss around for hours before finally falling asleep; others would fallasleep quickly but would wake up in the night on account of pain developingfrom the strain of being in one position.
The cases showed considerable variation in severity of thesymptoms and degree of disablement, as compared one with another, but not inthe syndrome considered qualitatively. The quantitative variations seemed todepend in part on severity of the original infection, or possibly the patient'sresistance to it, and in part on the length of convalescence. The usual coursewas characterized by a very pronounced degree of disablement at the beginning ofconvalescence, progressive improvement for about a month or six weeks underrest without special treatment, and from then on an almost stationary residualcondition persisting apparently indefinitely-in the cases at Plattsburg fromthree months to over a year.
Shortly following the admission of these patients to thishospital, they were divided into groups, according to the degree of disablement, and were placed under a regimen of graded marches, hikes, andexercises, such as neck bending and body bending. This was followed by strikingand rapid improve-
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ment in some cases and in distinct though slight improvementin almost all within a month.
All cases eventually recovered from the above-describedsymptoms at least sufficiently to leave the hospital and resume either duty ortheir civilian occupations. There remained in some of the cases lingeringsymptoms, such as stiffness in the spine, pains in back, legs, or head; butthese were present only in slight degree and were in no way disabling.
In the course of observation of these cases, the impressionwas occasionally gained of a psychoneurotic element in the form either ofexaggerations of the disability or of addition of manifestations foreign to thetypical symptom-complex. It was noted that some of the cases showed rathersudden improvement within a few days following the signing of the armistice.The most flagrant case was that of an enlisted man who showed, in addition tothe typical post-meningitis symptom-complex, a persistently labored andgrotesque gait due to contractures at both knees in a position of partialflexion: "Capt. K.--- gave me electrical treatment, and after the secondtreatment I was all cured up."
This is merely added evidence of the well-known fact that apurely functional mental element not infrequently exists as a complicatingfactor in organic disease.
On the whole the group of post-meningitic residualspresented not only a striking uniformity of symptomatology, but also of courseand termination- and that quite regardless of such conditions as prospect ofoverseas duty, and the signing of the armistice, as may be judged from the factthat of the 31 cases admitted 12 had recovered sufficiently to be recommendedfor duty prior to November 11; several were among the more recent admissions.
The following case record is cited as typical of the group:
J. F. B., private, headquarters company, 154th Infantry. Bornin Arkansas; white, aged 22; single, former occupation, farmer. Admitted to UnitedStates Army General Hospital No. 30, Plattsburg Barracks, N. Y., by transferfrom basehospital, Camp Beauregard, La., on July 31, 1918. Transfer card diagnosis: Neurosis,post-meningitic.
Family history - Negativefor mental or nervous disease,inebriety, feeble-mindedness, or criminalism, except that one brother died inconvulsions in childhood.
Personal history - Had measles, whooping cough, andmumps in childhood; "swamp fever" (malaria?) at 15; recovered fullyfrom all; no other diseases or injuries. He went to school irregularly, as hehad to work and did not have much opportunity; reached fourth grade. Thenwent to work on his father's farm, receiving $30 a month and his board.Enlisted June 5, 1917, and was first sent to Fort Logan H. Root, Ark. In September, 1917, was sent to Camp Beauregard, La. He had had no trouble whateverin either place up to the time of onset of his present illness in the latterpart of December, 1917. He had drilled and worked well and reported at sickcall only twice for minor ailments.
Present illness - About the 18th of December, 1917,hebegan having frequent chills, felt weak, and lost appetite; he slept well,however. In the evening of the 20th he developed a very severe headache and"a drawing from the back of the head all the way down"; could notsleep that night. Next morning became unconscious and was taken to the basehospital (Camp Beauregard). Has a vague and incomplete recollection of lumbarpunctures. Clinical history from that hospital states that he had epidemiccerebrospinal meningitis, received intraspinous and intravenous treatment,but did not begin to improve until the latter part of February, 1918. Casenote, March 1, 1918, states: "Up; very thin and weak." April 11: "Hook-wormtreatment given." On April 26 given a furlough. Returned to camp on June
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20, but was not able to do duty; felt weak andfeverish; occasionally had slight headaches; complained of pains in the back and inthe back of thehead; would have dizziness on stooping or "on the least strain"; whenhe tried to read his vision, after a while, would become blurred; he had notregained all the weight he had lost. He was readmitted to the base hospital on June 22; about two weeks laterhe was sent to the convalescentcamp attached to the base hospital. Improved somewhat, but did not fullyrecover and on July 28, 1918, was ordered transferred to Plattsburg Barracks, N.Y.
Examination on admission - Complains of weaknessin the back; states he tires very easily. Eyes are still weak; i. e., on trying to read, visionsoon becomes blurred. Upon exertion, the old pain inthe back and in the back of the head begins to trouble him again. Upon stooping orexertion becomes dizzy, though not so badly asformerly. Walking fast tires him quickly, but if he takes his time he can walk a gooddeal. Is somewhat underweight; weight, 130 pounds inordinary clothing; height, 5 feet 7 inches; his usual weight in ordinaryclothing is 150 pounds. Has scar over sacrum from bedsore. Is unable to touch toes with tips offingers by stooping over without bending the knees on account of pain andstiffness in smallof the back.
Patient was prescribed neck and body bending exercisesand graded hikes. Note of October 8, 1918, states: " He feels now that heis as well as he was before he had meningitis." Recommended forduty by board of medical officers.
DEBARKATION HOSPITAL NO. 51, NATIONAL SOLDIERS' HOME, HAMPTON, VA.m
The neuropsychiatric service of Debarkation Hospital No. 51was organized on or about November 18, 1918. The first large convoy of overseaspatients was received on November 20, 1918. This convoy contained approximately300 mental cases who were placed in wards that were not well prepared for thereception of such cases. Notwithstanding this inadequacy of facilities,however, these patients were handled with only one accident, a minor one, anabortive attempt at self-injury on the part of the patient.
Reception of patients was rather slack during the remainderof the month. From about the middle of December, 1918, the debarkation ofneuropsychiatric patients went on sporadically, large convoys of patientsalternating with small ones. On January 1, 1919, 215 cases arrived and thesewere handled without difficulty.
Up to February 1, 1919, approximately 1,520 mental caseswere cleared through this hospital and in this number, psychoneuroses,psychoses, constitutional psychopathic states, epileptics and mental defectives were found in the order named, organic disease of the centralnervous system being far in the minority.
As this hospital functioned only as a debarkation hospital,none of these overseas cases were retained here for treatment. All cases wereclassified on standard blanks. After the diagnosis and condition of the patientwas determined he was transferred to the hospital treating his specialcondition. Epileptics and mental defectives were sent to the camps nearesttheir homes for demobilization.
The psychoneuroses were all sent to General Hospital No. 30,Plattsburg Barracks, N. Y., and this was routine up to March 22, 1919. At thattime a letter from the Surgeon General authorized the commanding officer tosend to
mBased on report of the neuropsychiatric service, DebarkationHospital No. 51, National Soldiers' Home, Hampton, Va., by Capt. NathanielH. Brush, M. C., May, 1919. On file, Historical Division, S. G. O.
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the nearest camp for demobilization all psychoneurosis caseswho had sufficiently recovered to need no further treatment. This authority notonly relieved the debarkation hospitals of a great burden, but also freedGeneral Hospital No. 30 of many unnecessary cases.
A careful record was kept of the various types of casesreceived from the American Expeditionary Forces, from February 1, 1919, toMarch 31, 1919. During this period 589 neuropsychiatric cases were received.They were classified as follows:
| Psychoneuroses | 250 | Mental defectives | 39 |
Psychoses | 184 | Organic brain disease | 14 |
Constitutional psychopathic states | 54 | Total | 589 |
Epileptics | 48 |
In a general way this classification showed the usual type ofcases received at this hospital. Careful and completely tabulated records werekept of the diagnoses in all cases from the opening of the hospital, but throughan unavoidable accident these records were destroyed. The only records left atthat time showed the clinical difficulties of the above listed group of 589cases, but other statistics were available showing that up to April 27,1919, when it terminated its debarkation activities, a total of 2,419neuropsychiatric cases had been cleared through this hospital.
Early in March, 1919, two representatives of the SurgeonGeneral inspected the hospital with a view to its conversion into a permanenthospital for the continued care and treatment of mental cases exclusively. Thelay-out and plant seemed ideal, and almost immediately plans were formulated forthe functioning of the hospital in its new capacity. On April 20, 1919, itbecame United States Army General Hospital No. 43 (q. v.).
UNITED STATES ARMY GENERAL HOSPITAL NO. 43, NATIONAL SOLDIERS'
HOME, HAMPTON, VA.n
The hospital being designated to care for mental cases only,it is obvious that the neuropsychiatric service embraced the greater proportionof the professional work, but to provide adequate medical and surgical servicefor the patients it was necessary to continue medical, surgical (includinggenitourinary and eye, ear, nose, and throat departments), and dental services.The laboratory and hydrotherapeutic departments also were organized andequipped.
This institution was originally the National Soldiers'Home, and not having been built for mental cases, there were no standard wards.They varied in capacity from 35 to 200 beds. Some of the barracks were providedwith the necessary screening for doors and windows to insure the retention ofthe irresponsible cases. Continuous baths were installed in three buildingsfor the treatment of excitable cases who required frequent and continuousbaths to control their psychotic episodes. There were 22 wards in all, 8 ofwhich were operated as closed wards. It was the policy to give the patient asmuch freedom as possible, and many kept in closed wards at night were paroledduring the day.
nBased on report of professional work at GeneralHospital No.43, for the year 1919, by the commanding officer, January 9, 1920. On file,Record Room, S. G. O., 319.1-2.
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In the treatment of the mental cases the continuous sedativebaths, hot packs, Scotch douches, needle showers, electric heat, occupationaltherapy, and exercise were the chief methods employed. Special efforts were madeto avoid the use of narcotic and sedative drugs and very seldom were they used,and then never for other than temporary relief of an excitable or nervouspatient at a time when it was not feasible to resort to the bath or pack.Probably drugs were not used in one-half dozen instances during the periodcovered by this report. The restraint sheet practically never was used.
One section of ward 18 was used for hydrotherapy. Temporarypartitions were put in, dividing the room into small compartments for beds andstalls in which the patients disrobed. Ten beds were maintained in thisdepartment. The equipment consisted of two Scotch douches, two needle showers,four electric cabinets, and a number of incandescent-light baths for localapplication. A qualified masseur was employed in this department and hisservice in some instances apparently was very beneficial.
The more excitable cases were segregated in the wardsprovided with continuous baths, and the result of these baths in the controlof such cases was very gratifying. There was no instance where a patient couldnot be quieted by the use of the hot pack or continuous bath if handledjudiciously and the treatment was repeated at frequent intervals. Patientsseldom objected to this treatment and many were glad to return to the baths.
Occupational therapy did much to establish confidence inthe patient. The prime factor in this work was to obtain the gradualcooperation of the patient in order not to put him at a task that would berepulsive, and thereby make him worse. There was close cooperation between theward surgeon and the reconstruction aides, and the helpless and irresponsiblepatients were coaxed to work on the wards. In this work they began with simpletasks, such as the winding of string, the unraveling of burlap, basketry, rugweaving, and knitting. As the patient regained his confidence and the control ofhis faculties and acquired more responsibility, he was allowed to do adifferent class of work requiring more physical and mental ability, such ascarpenter work, printing work, typewriting, and automobile repairing.
Through the medium of exercise the patient's physicalcondition was kept as near normal as possible. Exercise was also useful instimulating a desire for food. Care was taken in the selection and grouping ofpatients for the different exercises, giving them all the benefits of open airduring the day. The less responsible patients were taken on walks, while theothers were required to take varied calisthenic movements. Through theAmerican Red Cross and other civilian organizations many automobile rides werearranged for the patients.
The granting of furloughs was very liberal when thecondition of the patient warranted. In many instances a visit homeunquestionably benefited the soldier.
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On December 31, 1919, 3,206 patients had been treated at thishospital, classified as follows:
Psychosis: | |||
| Dementia pr?cox | 703 | Dementia paralytica | 2 |
| Undiagnosed | 223 | Constitutional psychopaths | 229 |
| Manic-depressive | 266 | Mental deficiency (moron) | 298 |
| Due to drugs, alcohol | 158 | Psychoneurosis | 445 |
| With cerebral syphilis | 23 | Epilepsy | 72 |
| With arteriosclerosis | 3 | General paralysis | 277 |
| Traumatic | 9 | Under observation for mental alienation (no disease) | 6 |
| Infectious and exhaustion | 6 | Nervous disease, undiagnosed | 40 |
| Anxiety | 2 | ||
The balance, 444, were not neuropsychiatric patients buttransfer cases handled for the port of embarkation, old soldiers, and civilians.
There probably has been no institution in this country wherethe opportunities to study unusual mental diseases were so excellent as atthis hospital. The material was abundant, and it is unfortunate that thepersonnel of the hospital had to change so frequently and that the pressure wasso steady and the requests so insistent to get cases away to institutions neartheir homes, or otherwise released from the service.
The commanding officer reported that the members of the staffwere impressed with the large number of mental cases that were diagnoseddementia pr?cox and who suggested a typical history of mental deterioration,who later had their mental faculties return almost to normal and weredischarged, cured, or improved to such an extent that they could be released ontheir own responsibility. These cases were depressions of a mixed type whichcould not be differentiated from dementia pr?cox until they had been underobservation for some time.
They were impressed also with the large number of cases thatdeveloped after the armistice was signed, conditions which could not beaccounted for unless the etiological factor was purely anxiety and nostalgia.Many of these soldiers had gone through the worst of the fighting and wereapparently normal a long while after the armistice was signed, then becameconfused and were later sent to hospitals for mental observation. A large numberhad actually returned to this country and were in the demobilization centersbefore they had their psychotic episodes.
A few cases were difficult to determine in persons who drankheavily in France but had been men of exemplary habits in civil life. In thesecases it was the problem to decide whether the psychosis was of alcoholic originor whether the soldier had become a victim of mental deterioration before he hadbegun to indulge in alcoholic debauches.
LETTERMAN GENERAL HOSPITAL, SAN FRANCISCO, CALIF.?
The psychopathic ward, with an authorized capacity of 60beds, was opened to patients on October 17, 1918. Previously the mental patientswere cared for in the detention ward along with general and garrison prisonersand
?Based on War Diary, Letterman General Hospital, SanFrancisco, Calif., November 12, 1918. Also: History of Letterman GeneralHospital, by the commanding officer, June 21, 1920. Also: Annual report,Letterman General Hospital for 1918, by the commanding officer. On file, Historical Division, S. G. O.
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men confined for punishment. The detention ward, with anauthorized capacity of 50 beds was much overcrowded, but the more seriousobjection was the confinement of patients with prisoners behind bars. Theopening of the pyschopathic ward was, therefore, an epochal event. While thedetention ward had a barred entrance, barred windows, barred doors andpartitions and "cells," the psychopathic ward had no barred doors orwindows, and had "rooms" and "dormitories." This improvementin the surroundings was of great advantage in the care and treatment of theinsane. The building was well constructed, with many windows and two large airshafts affording good light and, with the aid of a fan system, adequateventilation. The hallways and offices had good hardwood floors; the other floorswere of colored cement. The single rooms and dormitories were located aroundthe outside, hotel fashion. The ceilings were high and the rooms spacious. Thegeneral impression was pleasing to both patients and visitors. On the secondfloor was the reception or sick dormitory, and near it was a screened porchwhere patients could enjoy the air and a view of the bay and environs.
In the basement was the very complete hydrotherapeuticdepartment. (Control table for needly spray, rain douche, Scotch douche, steamdouche, perineal spray, liver spray, sitz bath; continuous bath with automaticcontrol; electrohydric bath; electric light cabinet; electric coil cabinet; packtables; massage tables; blanket warmer; scales, etc.). A large room adjoiningthe hydrotherapeutic room was utilized as a rest room, where patients wererequired to lie down for an individually designated time following treatment.The "hydro" nurse and his assistants were kept busy throughout theday, and very beneficial results were effected through their efforts. The nature of the treatment depended upon the individual case. Not only healthyfunctioning of the skin was secured, but through individual treatment asedative, restful effect upon an excited, sleepless person and a stimulatingeffect upon a depressed, retarded patient.
Another important form of treatment was occupationaltherapy. Every patient, unless his physical state absolutely contraindicated,was expected to do some form of work morning and afternoon, the nature andduration of which were carefully regulated in each individual case. It was keptclearly in view that the object was to hasten recovery or at least to improve achronic state, rather than to accomplish a set amount of work. Accordingly,variation of employment was given to increase interest, and above all theadvancement from a simple to more complex tasks. Certain patients were notmentally fit to do regular duty, inside or outside the ward. Much attention wasgiven to such patients in an attempt to draw them out to better results. To thatend a large airy room in the basement was used for raffia work, basket weaving,games, or other activities designed to arouse interest and bring the patientinto better contact with his environment. The man's former occupation andinterest were taken into consideration. He was carefully observed for revival ofinterest, and wherever indicated he was drawn in that direction to bettercooperation and eventually to duties on the ward. Patients were urged to take apersonal interest in the cleanliness of the ward and were held responsible forcertain windows, walls, floors, brass work, etc. A record was kept of each man's
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activities, and his duties were varied to suit his condition.The man overcharged with energy was given a useful outlet for his activity,thus bringing him into better accord with his environment and hasteningrecovery.
Another class of patients, if allowed to do so, wouldgradually get out of touch with the world and shut themselves into a littleworld of their own imaginations. Along with this would result a markeddilapidation of personality, untidy appearance, lack of care of person, wettingand soiling, etc. Through proper attention to occupational therapy thisdeterioration could be prevented in marked degree and the patients held to morenormal mental content, more natural appearance, and easier care. Whenever a man'scondition permitted he was given outside work in shops, garden, etc., withgreater liberty and resultant upbuilding of interest. All patients werebenefited through recreation inside or outside the ward, such as athletic games,graphaphone concerts, etc. The work of the educational department along theselines was most thorough and commendable.
Sharing in importance with the above was the work by thephysician with the patient himself, investigating his difficulties, airing themand helping him straighten them out. In order to get best results it wasnecessary to secure the confidence and cooperation of the patient and to makehim feel that the physician was his friend who had his best interest at heart. Acareful record was kept of such investigations and interviews with the patientwere repeated from time to time as indicated.
The psychopathic section of the medical service was extremelybusy during the entire period of the war. The construction of the new andmodern psychopathic ward greatly facilitated the handling of mental cases andenabled proper treatment to be given the patients. Though, as stated above, theward was designed to accommodate 60 patients, at times it had to accommodate asmany as 130, for after the signing of the armistice the hospital began toreceive numbers of cases returned from France and from Siberia.
REFERENCES
(1) Circular letter from the Surgeon General,U. S. Army, December 6, 1917. Subject: Malingerers.
(2) History of Base Hospital No. 117, by thecommanding officer. On file, Historical Division, S. G. O.
(3) Letter from Maj. Frank E. Leslie, M. C., to Maj.Frankwood E. Williams, M. C., March 12, 1919. Subject: Observations andsuggestions. On file, Record Room, S. G. O., 730 (Neuropsychiatry).
(4) History of General Hospital No. 30, Plattsburg, N. Y., by the commanding officer, April 14, 1919. On file, Historical Division, S. G.O.
(5) Report on neuropsychiatric social service atGeneral Hospital No. 30, Plattsburg, N. Y., March 1, 1919, by Margherite Ryther.On file, Record Room, S. G. O., 730 (Neuropsychiatry) (General Hospital No. 30) (K).
