CHAPTER VII
DISPOSITION OF MENTAL CASES
ARMY REGULATIONS GOVERNING DISCHARGE OF THE INSANE
Arrangements for the care, treatment, and eventual dischargeof insane soldiers in the Army in peace time easily were made, as the number tobe cared for was not large. Decision as to disposition in all cases was made inthe War Department. Discharge by reason of insanity could be made only on orderof the Secretary of War. To facilitate the decision of the Secretary of War, thepapers forwarded to Washington in each case were to contain a statement as towhether the disability was or was not incurred in line of duty; and as towhether the patient, if discharged from the service, could be released frommilitary control without danger to himself or others.1Disposition was made in one of three ways: (1) Soldiers who became insane inline of duty were transferred to St. Elizabeths Hospital in Washington fortreatment and eventual discharge; or, (2) if not considered dangerous, either tohimself or to others, the soldier could be discharged on a certificate ofdisability and furnished transportation to his home or the place of hisenlistment. If he was transferred to St. Elizabeths Hospital, he was accompaniedby a noncommissioned officer.2 If hewas discharged to his home, he might be accompanied, but usually was not. Uponarrival at the hospital, he was placed under treatment and discharged from theservice, remaining a patient of the hospital; or, if he was permitted to returnto his home, he was discharged on leaving his organization; or, if accompanied,upon arriving at his home. (3) Insane soldiers who were regarded as having beeninsane prior to enlistment, and hence not having incurred the disability in lineof duty, were reported to relatives or to the local authorities at their placesof residence. If the relatives expressed a willingness to receive and care forthem, they were sent with attendants to the places where the relatives resided,placed in charge of the relatives, and discharged from the Army. In case therelatives would not agree to receive them, they were sent to their places ofresidence, turned over to local officials, usually the police, and thendischarged. Certain cases not regarded as incurred in line of duty, such asgeneral paralysis of the insane, were at times also sent to St. ElizabethsHospital. The above procedure was provided for by the appended paragraphs of theArmy Regulations: This procedure applied only to the enlisted personnel of theArmy. Commissioned officers who became insane were ordered to appear before aretiring board for the necessary action. If retired, these officers wereentitled to admission to St. Elizabeths Hospital for treatment, or they couldbe cared for in such other manner as their relatives might wish.
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464. The following classes of persons areentitled by law to admission to St. Elizabeths Hospital, Washington, D. C.: (1)Officers, contract surgeons, and enlisted men of the Army who have become insanewhile in the military service, or within three years after their dischargetherefrom, from causes which arose during and were incident to such service; (2)inmates of the Soldier's Home and of the National Home for DisabledVolunteer Soldiers; (3) civilian employees of the Quartermaster Corps who maybecome insane during such employment; (4) general prisoners; (5) internedpersons and prisoners of war, under the jurisdiction of the War Department, whoare or may become insane.
The Secretary of War is authorized by law totransfer from any military hospital to the nearest available public hospital forthe care of the insane any insane patient who is in need of treatment,preference being given to the hospital nearest to the place of the patient'senlistment. The superintendent of such public hospital has the right to retainthe aforementioned class of patients in his hospital in the same manner and tothe same extent as now possessed by the superintendent of St. ElizabethsHospital. The Secretary of War is also authorized by law, during the existingemergency, to transfer to the various public hospitals for the care of theinsane, patients of every class entitled to treatment in St. ElizabethsHospital and that are admitted on order of the Secretary of War. The WarDepartment will from time to time advise department commanders and othersconcerned of the public hospitals designated by the Secretary of War to receiveinsane patients transferred under this authority. (C. A. R., No. 64, Dec. 13,1917.)
464?. Applicants for enlistment and draftedmen who are found to be insane after arrival at depot, post, or camp, and beforethe completion of their enlistment by oath, muster in, or otherwise, will bedisposed of as follows: (1) Those whose liberation will be unattended by dangerto themselves or others will be rejected and disposed of under the regulationsgoverning the disposal of other rejected recruits; (2) those whose insanity isof a type that would probably make their liberation a source of danger tothemselves or others will be delivered to the civil authorities authorized bylaw to apply for the commitment of insane persons, of the place where theyapplied for enlistment or whence they were drafted. The depot, post, or campcommander will provide the necessary escort for such delivery, and issue thenecessary travel orders, transportation, and subsistence (in kind or bycommutation as may be most suitable).
A similar procedure will be followed in thecase of civilian employees of the Quartermaster Corps who are found to have beeninsane before the beginning of their employment. (C. A. R. No. 64, Dec. 13,1917.)
465. (Changed by C. A. R., No. 46, W. D.,1916.) Except as provided in paragraph 467 of theseregulations the insane of the military service enumerated in paragraph 464 whorequire treatment in institutions for the insane will be promptly transferred tothe institutions designated to receive them respectively.
No person will be transferred under theprovisions of this paragraph except after a critical examination by a board ofat least two medical officers, of whom one shall, if practicable, be aspecialist in nervous and mental diseases. The examination willpreferably be made in hospital, and in the special ward for nervous and mentaldiseases, should there be one; and the board will not make its report untilafter the person being examined shall have been observed for a reasonable periodof time. The report will give the diagnosis, a detailed account of the medicalhistory of the case, and a statement as to whether the disability was or was notincurred in line of duty; also a statement as to whether the patient, ifdischarged from the service, can be released from military control withoutdanger to himself or others, and the board's recommendation for or against thepatient's transfer for treatment to such designated institution; all papers tobe executed in duplicate.
Should the board recommend the patient'stransfer for treatment to a designated institution, its report and all paperstherewith and the medical certificate required by the Department of the Interior(blank form for which is furnished by The Adjutant General of the Army) properlyfilled in will be forwarded for the action of the department or divisioncommander, who will, if he approves the transfer, issue the necessary orderstherefor, and for such escort, transportation, and subsistence as may berequired.
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Commands that are ordinarily exempted from the control ofdepartment and division commanders will forward such papers to the commander ofthe department within the territorial limits of which the command is located,for his action.
The department or division commander will send onecopy of the board's report and the medical certificate to the institution to whichthe patient is transferred, and will forward the second copy of the board'sreport, etc., with a note thereon of his action, to The Adjutant General of theArmy.
If the patient so recommended is an enlisted man, therecord, and the report of the board of examining medical officers, will beprepared on the certificate of disability blank form in duplicate, accompaniedby the necessary attached papers, and, in the event that his transfer isordered, he will be discharged from the service on account of disability. (C.A. R., No. 64, Dec. 13, 1917.)
466. (Changed by C. A. R., No. 13, W. D., 1914; No. 22, W.D., 1915; and No. 55, W. D., 1917.) Upon the departure of the insane patient hisimmediate commanding officer will make and sign an inventory, in duplicate, ofhis effects, and will send one copy of the inventory, together with his moneyand other valuables by registered mail, to the superintendent of the institutionto which he is transferred, retaining the other copy for the records of thecommand. The other effects of the patient, such as clothing, will accompanyhim as baggage. Upon the patient's departure the commanding officer will bytelegraph advise the institution thereof and of the time when the patient willbe due to arrive. (C. A. R., No. 64, Dec. 13, 1917.)
467. The insane of the military service in the Philippineand Hawaiian Islands, who appear to require treatment in institutions for theinsane, except natives, will be sent by the department commanders to LettermanGeneral Hospital, San Francisco, Calif., for observation in that hospital,before action is taken in their cases in accordance with the provisions ofparagraphs 465 and 470. The insane in the Canal Zone and among other forcesoverseas will in like manner be sent to an Army hospital in home country nearthe suitable home port of the Army Transport Service for observationpreliminary to similar action.
Insane natives of the Philippine Islands and Porto Ricoserving in the Army of the United States may, under authority of the Secretaryof War, be sent to asylums in the Philippine Islands and Porto Rico,respectively, (C. A. R., No. 64, Dec. 13, 1917.)
468. Army patients committed to institutions for the insaneunder these paragraphs will, when cured, be released from custody under the lawsand regulations governing the release of other cured patients. To obtain therelease of an Army patient who is not cured, or his delivery to the care offriends, application must be made therefor to The Adjutant General of the Army,accompanied by the recommendation of the superintendent of the institution. (C. A. R., No. 64, Dec. 13, 1917.)
469. The insane who do not require treatment in institutionsfor the insane will, unless permanently incapacitated for military service,be retained under military control. If they are permanently incapacitated forservice and can be liberated without danger to themselves or others they will be discharged on certificate of disability. In case it is necessary to send asoldier to his home with an attendant he should not be discharged until hereaches his destination. (C. A. R., No. 64, Dec. 13, 1917.)
470. An enlisted man who requires treatment in an institutionfor the insane by reason of insanity existing before his enlistment is notentitled under paragraph 464 to be cared for at the expense of the UnitedStates. Each such case will nevertheless be examined and reported on in thesame manner as the cases referred to in paragraph 464. The conclusions ofthe board being approved by the authority who is to take final action thereon,the soldier will be discharged for disability, and the following procedurehad: His immediate commanding officer will communicate with his family orfriends, with the civil authorities authorized by law to apply for thecommitment of insane persons of the State where he was enlisted or whence he was drafted,and with the like civil authorities of the State which he claims as his home, to ascertain whether they will receiveand care for theman at their own expense. Should they agree to do so, the man will be sentunder proper escort to the family or friends, or to the local authoritiesmentioned, as may be appropriate. Should they refuse to take charge of him thesoldier will be sent to a designated public hospital for the insane pending
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the determination of what civil authorities arelegally required to assume his care and treatment. Upon the soldier'sdeparture his commanding officer will by telegraph advise the hospitalthereof and of the time the soldier will be due to arrive.
Whichever action is taken, the effects of the soldier willbe inventoried as under paragraph 467; his money and valuables will besecured for disposition as indicated below; and his other effects, such asclothing, sent with him as baggage to his destination. In case his family orfriends or the local committing authorities agree to receive him, they will beadvised that his money and valuables are subject to the orders of the personlegally authorized to receive the same in the insane man's behalf uponpresentation of proof of such authority. In case he is sent to a designatedpublic hospital for the insane pending the determination of what civilauthorities are ultimately chargeable with his care, his money and valuableswill be sent by registered mail to the superintendent of such hospital,accompanied by one copy of the inventory.
Full report of the action taken in each such case will bemade to The Adjutant General of the Army. (C. A. R., No. 64, Dec.13, 1917.)
With the great increase in the strength of the Army followingthe declaration of war, it was obvious that the procedure formerly followedcould not meet adequately the new needs. St. Elizabeths Hospital could notpossibly provide for all insane soldiers, and, even if it could, thetransportation of large numbers of insane soldiers over long distances wasimpracticable. The sending of papers in all cases to Washington for decision andan order to discharge from the Secretary of War created, under thecircumstances, unsatisfactory conditions in the camps where hospitals werecongested with insane soldiers awaiting transfer or discharge. A general orderwas issued, therefore, which extended authority of discharge to division anddepartmental commanders.3 Certain other changes to facilitateexpedition were likewise made from time to time in the Army Regulations.
In the cantonment two main problems presented themselves: (1)Disposition of soldiers insane in line of duty; (2) disposition of soldierswhose mental condition existed prior to admission into the Army. With a promptexamination of drafted men and volunteers upon their arrival at cantonments andbefore induction into the service, the question of "lineof duty" could be settled with comparative ease. When men were not examinedpromptly on arrival, but only after several weeks or more of service, thequestion was not so easily determined; although from the condition of thepatient, the nature and degree of his illness, and his previous history fairlyaccurate judgment could be made. Diagnoses and recommendations could frequentlybe made more rapidly than transfers or discharges could be arranged.While waiting for transfer or discharge patients were retained (except thosewho, assigned to quarters, could safely remain with their organizations)in the neuropsychiatric wards of the base hospitals. They were likewise caredfor here if discharged until such time as arrangements could be made withrelatives or civil authorities to receive them. In other words, insane soldierswere no longer just turned loose. An insane soldier when returned home wasalways accompanied if his condition demanded it, and in all other cases also ifpossible.
In some instances the admission of a soldier to hospital onaccount of a mental or nervous condition was not necessary. Whenever thepeculiar actions of a soldier or his failure to adapt himself to his newenvironment was noticed by his commanding officer he was referred, eitherdirectly or through the regi-
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mental surgeon, to the neuropsychiatric officer who, after asufficient examination, submitted proper recommendation as to the disposition ofthe soldier. If necessary, he was admitted to hospital for further observationor treatment, but frequently, in such conditions as mental deficiency,constitutional psychopathic state, and certain of the psychoneuroses, this wasconsidered unnecessary and the soldier was retained with his company ortransferred to a development battalion, marked "quarters," and actioninitiated with a view to his discharge on account of physical disability. The"course of papers" in the camps (as in a regiment, for example) may be described as follows:(a) Regimental surgeon sent patient to hospital fordiagnosis and observation. (b) Neuropsychiatric service reported patient"insane-should be discharged." (c) Report was made tocommanding officer of hospital. (d) Commanding officer transmitted reportto the man's regimental commander. (e) Regimental commandertransmitted report to (1) company commander or (2) regimental surgeon. (f)Company commander initiated necessary form (S. C. D.)and sent it to regimental surgeon. (g) Regimental surgeon filled in his part ofthe form and transmitted it to the regimental commander. (h) Regimentalcommander made out the necessary papers for final action.
COOPERATION WITH CIVIL AUTHORITIES
Shortly after the mobilization of the World War Army beganthe Surgeon General communicated with the authorities in the different Statesinquiring if they would cooperate in relieving the Federal Government of thecare and responsibility of recruits in whom insanity existed prior toenlistment, or in whom it was not an incident to service, as it was evident thatcases of this character should not be a charge on the Federal Government. OnSeptember 20, 1917, the following communication was sent by the SurgeonGeneral to all the States:4
The Surgeon General is called upon to make immediatearrangements for the care of the military insane in whom the insanity was notincurred in the line of duty. There will probably be one of these forevery thousand troops mobilized, and the Surgeon General is desirous ofmaking arrangements by means of which the different State hospitals willreceive and care for the insane officers and soldiers of the above category fromtheir own States.
It is evident that when the mental disease existed priorto enlistment or was for other reasons not contracted in line of duty, thecost of the care of the patient should not be a charge upon the FederalGovernment. The cost should be borne by the States. Division surgeons andother commanders will be advised that for each case the question of line of duty is to be carefully considered. All thosein whom insanity was notincurred in line of duty will be released from military control on acertificate of disability whenever this can be done without danger to himself or to others. It is for the disposal of patients who can not bereleased from military control without danger to themselves or to others thatthe Surgeon General requests your immediate and hearty cooperation.
He directs me to inquire if you will cooperatewith him tothis end by receiving officers and soldiers of the above class, they beingtransported and delivered to any point or points named by you. In our reply youare requested to state to what point or points such cases should be sent. Aprompt reply will be greatly appreciated.
By the middle of November, 1917, favorable replies had beenreceived from 25 States. The Surgeon General then issued the circularfollowing on the subject for the information of those concerned.
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NOVEMBER 17, 1917.
STATE CARE OF INSANE SOLDIERS
(Subject to amendments and additions)
Authorities of the following States have signifiedtheir willingness to receive, care for, and maintain at State expense soldiersfrom their own State who require institutional care, when the insanityexisted prior to enlistment or arose not in line of duty. No patient will besent to any of the State institutions without assurance having beenobtained from the State authorities that beds are available and without the exactpoint having been indicated to which the patient shall bedelivered by the military authorities.
Arizona.-Communicate with medicalsuperintendent,Arizona State Hospital, Phoenix, Ariz.
Connecticut - Communicatewith medical superintendent, Connecticut Hospital for Insane, Middletown, Conn.
Delaware.-Communicate with medicalsuperintendent, StateHospital for Insane, Farnhurst, Del.
Idaho.-Communicate with medicalsuperintendent, IdahoInsane Asylum, Blackfoot, Idaho.
Illinois.-Communicate with medicalsuperintendent ofmost convenient institution, as follows: Alton State Hospital, Upper Alton; Anna State Hospital, Anna;Chester State Hospital, Menard; Chicago StateHospital for the Insane, Dunning; Elgin State Hospital, Elgin; JacksonvilleState Hospital, Jacksonville; Kankakee State Hospital, Kankakee; Peoria StateHospital, Peoria; Watertown State Hospital, East Moline.
Iowa.-Communicate with medicalsuperintendent of any of the following State hospitals: Cherokee State Hospital, Cherokee;ClarindaState Hospital, Clarinda; Independence State Hospital, Independence; Mount Pleasant State Hospital,Mount Pleasant; State Reformatory, Anamosa.
Maryland.-Communicate with Dr. Arthur P. Herring, 406-407Professional Building, Baltimore, Md., who will designate proper Stateinstitution.
Massachusetts.-Communicate with medicalsuperintendent,Boston Psychopathic Hospital, Boston, Mass.
Michigan.-Communicate with attorneygeneral'sdepartment, Lansing, Mich., giving county where soldier was enlisted.
Minnesota - Communicatewith Downer Muller,secretary, State Board of Control, St. Paul, Minn.
Nebraska - Communicatewith Henry Gerdes, Board of Commissions of State Institutions, Lincoln, Nebr.
Nevada - Communicate with Commissions for the Care ofIndigent Insane, Carson City, Nev.
New Hampshire - Communicate with medicalsuperintendent, New Hampshire State Hospital, Concord, N. H.
New Mexico - Communicate with medicalsuperintendent, New Mexico Insane Asylum, Las Vegas, N. Mex.
New York - Communicate with E. S.Elwood, secretary,State Hospital Commission, Albany, N. Y.
Ohio.-Communicate with E. F. Brown, secretaryOhio Boardof Administration, Columbus, Ohio.
Oklahoma- Communicate with medicalsuperintendent,East Oklahoma State Hospital, Vinita, Okla.
Oregon - Sendinsane soldiers to State institutionsas follows: Those from Baker, Crook, Gilliam, Grant, Harney, Hood River,Jefferson, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco, andWheeler Counties, to be sent to medical superintendent, Eastern OregonState Hospital at Pendleton, Oreg.; those from Benton, Clackamas, Clatsop,Columbia, Coos, Curry, Douglas, Jackson, Josephine, Klamath, Lake, Linn, Lincoln, Lane, Marion,Multnomah, Polk, Tillamook, Washington, andYamhill Counties to be sent to medical superintendent, Oregon StateHospital, at Salem, Oreg.
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Pennsylvania - Communicate with FrankWoodbury,secretary committee on lunacy, Bulletin Building, Philadelphia, Pa., statingcounty where soldier enlisted.
Rhode Island - Communicate withmedical superintendent, State Hospital for Mental Diseases, Howard, R. I.
South Carolina - Communicate with A. S.Johnson, secretary State Board of Charities and Corrections, Palmetto Building, Columbia, S. C., who will givedirections.
Uta - Communicatewith medical superintendent, State Mental Hospital, Provo, Utah.
Vermont - Communicate with medicalsuperintendent,State Hospital for Insane, Waterbury, Vt.
Virginia - If white soldiers,communicate with J. M. Bauserman, Commissioner of State Hospitals, Woodstock, Va. If colored,communicate with Dr. William F. Drewry, superintendent, Central StateHospital, Petersburg, Va.
Wisconsin.-Communicate with M. J.Tappins, secretaryState Board of Control, Madison, Wis.
In March, 1918, the National Committee for Mental Hygiene wasrequested to take up the matter further with States which had not replied orwhich sent unfavorable replies. The vice chairman of the committee at oncecircularlized the governors of all these States and in certain instancesfollowed up the circular with further correspondence. The circular letterreferred to is as follows:5
As you are doubtless aware, the FederalGovernment is prepared to provide care and treatment for the military insane in whomthe insanity is incurred in the line of duty in the present war.
But it has been held that the cost of caringfor the military insane in whom the mental disease existed prior to enlistment,or was for other reasons not contracted in line of duty, shall be borne by theseveral States. In order to assure absolute fairness and justice in decidingresponsibility for the expense, most careful attention is being given in eachinstance to the question of line of duty.
On September 20, 1917, the Surgeon Generalsent to the appropriate authorities in your State a letter explaining thismatter. A copy of the letter is inclosed.
The War Work Committee has been designated bythe Surgeon General's Office to handle the correspondence about this matter,and we are in receipt of advices from the Surgeon General that a conference cannot be entered into at this time. It would be appreciated if you would advisethe appropriate authorities of the Surgeon General's advices that a quickdecision in this matter is necessary and that a prompt reply at this time isdesired to facilitate arrangements to provide for this class of persons.
A substantial number of the States havealready responded favorably, directing which of their institutions will receivesuch cases and giving the name of the proper authorities with whom tocommunicate. Your early attention to this important matter in your State wouldbe greatly appreciated.
On May 2, 1918, the vice chairman of the War WorkCommittee, National Committee for Mental Hygiene, reported to the SurgeonGeneral the following results:6
On September 20, 1917, you sent a letter tothe boards in control of the institutions for the insane in each State in the Union calling upon them to makearrangements for the care of theirmilitary insane in whom the insanity was not incurred in the line of duty. OnNovember 30 you wrote me that 25 of the States hadreplied favorably as follows: Arizona, Connecticut, Delaware, Idaho, Illinois, Iowa,Maryland, Massachusetts, Michigan, Minnesota, Nebraska,Nevada, New Hampshire, New Mexico, New York, Ohio, Oklahoma, Oregon,Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Wisconsin.
In that same letter (November 30), you statedthat unfavorable replies, or no replies, had been received from: Alabama,Arkansas, California, Colorado, Florida, Georgia, Indiana, Kansas, Kentucky,Louisiana, Maine, Mississippi, Missouri, Montana, New Jersey, North Carolina,North Dakota, South Dakota, Tennessee, Texas, Washington, West Virginia,Wyoming.
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In a letter dated March 16, 1918, you asked that thematter again be taken up with the States which had not taken appropriatesteps. Accordingly, on April 5, letters were sent from this office to thegovernors of all such States calling the matter to their attention and askingthem to take it up. Replies from the governors and boards to which theyreferred the letter have been coming to this office.
On the basis of the replies received by you in November,1917, and the replies received by us in April, 1918, I have compiled an alphabetical list ofthe States, indicating the action which has been taken by the various States,and am inclosing it herewith.b * * * I am also writing againto-day to some of the States which have notyet replied.
Most of the States thus eventually responded and enteredwhole-heartedly into the agreement to care for patients for whom the Army couldnot be expected to provide. The arrangement in general was, with certainvariations, depending upon different methods of handling insane persons in thedifferent States, that the military authorities would send patients of the aboveclass to a point designated by the State authorities, and would then release thepatient to the State authorities. Commanding officers were furnished lists ofthe States and the points to which patients were to be sent. This arrangementwas of great assistance to the Medical Department and did not put a very greatburden on the States. It worked most satisfactorily when there was a centralState board such as a State commission on mental diseases with which allcommanders could communicate and which could, in turn, at once indicate thespecial institution to which the recruit in question should be sent. In Stateswhere there were no central boards, correspondence over a considerable periodfrequently was necessary before it could be determined which of possibly severalhospitals should receive the patient. In certain States not provided withcommitting officers the Medical Department met the moderate fee which was askedby physicians who executed the commitment papers.
CARE OF MENTAL CASES IN GOVERNMENT HOSPITALS
As the number of soldiers with nervous or mental disease whorequired treatment, or for whom it was necessary to care pending dischargeincreased, it was necessary to provide facilities other than those offered bythe neuropsychiatric wards in base hospitals. To relieve the congestion in thesewards and at St. Elizabeths Hospital, a number of neuropsychiatric centers,widely distributed geographically, to which such soldiers could be transferredfor treatment or for care pending discharge, were established in various U. S.Army general hospitals.7
Mendocino State Hospital, Talmage, Calif., was designated bythe Secretary of War to receive patients on the same status as at St. ElizabethsHospital. This was done with a view of relieving congestion at St. ElizabethsHospital, and also of avoiding the unnecessary transportation of the insane. St.Elizabeths Hospital itself was enlarged by 500 beds.
The increasing number of Army patients at St. ElizabethsHospital overtaxed the efforts of the regular staff on duty there, and medicalofficers and
bThe list referred to included comments upon the character ofthe response made by each State. It showed only a few States whose response was unfavorable or who had failed to actup to that time. Those indicatingfavorable action were given as follows: Alabama, Arizona, Arkansas, Colorado,Connecticut, Delaware, Florida, Idaho, Illinois, Indiana, Iowa, Kansas, Maine,Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana,Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina,North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, SouthCarolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia,Wisconsin.
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enlisted men of the Medical Department were assigned to dutyat the hospital.8 A detachment was organized and all military recordswere under the supervision of the commanding officer. A few neuropsychiatristswere assigned to assist the medical staff of the hospital in the treatment ofthese patients, and certain of the enlisted men were used as orderlies andhelpers. There was a marked delay in accomplishing the discharge of the soldiersafter their arrival at the hospital, and the detachment of patients wasconstantly increasing in numbers. To relieve this congestion of patients and inorder that only cases of insanity which promised to be of long standing would besent to St. Elizabeths Hospital, the following circular letter was issued fromthe Office of the Surgeon General on November 20, 1918:9
DISPOSAL OF THE INSANE
1. Members of the Military Establishment suffering fromgeneral paralysis of the insane and from insanity complicated by epilepsy(insane epileptics) shall be sent from hospitals at ports of embarkation and from other hospitals to St.Elizabeths Hospital, Washington, D. C., as provided by paragraph 464, Army Regulations, 1918, asamended by C. A. R., No. 64 December 13, 1917.
2. All other patients in the military service who presentsymptoms of insanity shall be retained in the military hospitals fornecessary care and treatment provided the period of care and treatment shallnot exceed four months.
3. All cases of epilepsy which can not be improved bymedical or surgical treatment in the military hospitals shall be recommended for immediatedischarge from the service without transfer to othermilitary hospitals.
As the war proceeded it was considered desirable to requirethat all mental cases be treated for a reasonable period in the militaryhospitals. Directions recommended in June, 1918, sent out November 20, 1918,provided that all except cases which were evidently incurable should be treatedin the military hospitals for a period of at least four months, unless recoverytook place sooner, before being sent to St. Elizabeths Hospital.10 Thisprovision enabled many patients to leave the Army well, without having been sentto an institution identified with the care of the insane, enabled many patientsto pass their period of illness in the neighborhood of their homes, and avoidedmany unnecessary transfers. It also seemed to meet the hearty approval of thecivil population.
The requirements of Army Regulations 470 (as amended), in sofar as they pertained to insanity existing before enlistment, were nullified bythe provisions of that section of the war risk insurance act which stated that"said officer, enlisted man, or other member shall be held and taken tohave been in sound condition when examined, accepted and enrolled forservice."11
The interpretation placed on this proviso during the war wasthat once the officer or soldier was accepted he must be regarded, for purposesof compensation and future hospitalization, as having been mentally andphysically sound when he came into the Army.12Therefore,theoretically, insanity could not have existed before enlistment and the soldiermust be transferred to a public institution for the care of the insane.
After the armistice was signed and demobilization was underway it was possible to determine very closely the number of psychiatric caseswhich re-
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mained to be disposed of. A census of the hospitalaccommodations showed that sufficient beds were available in Army generalhospitals for the care of all insane cases remaining. In view of this fact andof the crowded conditions at St. Elizabeths Hospital, instructions were issueddirecting that no more insane soldiers be transferred to St. Elizabeths, butthat all be retained in military hospitals pending further orders.13
FUNCTION OF THE BUREAU OF WAR RISK INSURANCE WITH RESPECT TOTHE INSANE
The Bureau of War Risk Insurance had been charged by law withthe duty of providing hospital care for the compensable insane after dischargefrom the military service. By that time the bureau was well established and wasable to provide hospital facilities for all discharged soldiers entitled to suchcare. Section VII, General Orders, No. 57, War Department, April 30, 1919,provided as follows for the future disposition of the insane of the Army:
VII. Care of compensable insane (Cir. No. 225, W.D., 1919).-1. The Bureau of War Risk Insurance is charged by law with the dutyof caring for the compensable insane of the military service after theirdischarge from the Army, and has undertaken to provide institutional treatmentafter discharge for cases requiring it. Such cases are to be turned overdirectly to the care and responsibility of the bureau in such a manner thatthere will be no interval between discharge from the military service and thecommencement of the continued care in hospitals near their homes, which is to beprovided by the bureau.
2. In order to accomplish this, the following procedure willbe observed:
(a) Cases which have been under treatment in militaryhospitals in this country for four months, and which are considered to beincurable or to require a much longer period of hospital treatment to effect acure, will be reported in writing by the commanding officer of the post, camp,or station directly to the chief medical advisor, Bureau of War Risk Insurance,Washington, D. C. (attention section of nervous and mental diseases), who willgive instructions as to the disposition desired by the Bureau of War RiskInsurance. When reporting cases to the Bureau of War Risk Insurance under thisparagraph, the following information regarding the soldier will be furnished:(1) Name, rank, organization, Army serial number, and race; (2) length ofservice; (3) legal residence; (4) name and residence of nearest relative; (5)diagnosis; (6) brief summary of medical history; (7) prognosis.
(b) Upon receipt of instructions from the Bureau of WarRisk Insurance, the soldier will be ordered discharged on certificate ofdisability by the authority designated to order discharge in such cases. Thesame procedure as to preparation and disposition of records will be followed asoutlined in Army Regulations governing the discharge of insane in the militaryservice and their delivery to institutions. The soldier will be delivered to thedesignated institutions accompanied by necessary attendants, and not dischargeduntil his arrival thereat. When the soldier has been delivered to theauthorities of the institution designated to receive him, the senior attendantwill ordinarily telegraph the commanding officer authorized to discharge thesoldier. Upon receipt of this information the soldier will be discharged anddischarge papers mailed to the authorities of the institution to which thesoldier was transferred for delivery to the soldier. When a patient is deliveredto an institution and discharged the Bureau of War Risk Insurance will be soinformed in writing by the commanding officer concerned.
3. The provisions of this order do not in any way amendsubparagraph a, Circular No. 188, War Department, 1918, relative to the discharge of acertain class of patients who possess funds or have relatives or friends who canafford them specialized care after discharge.
By the provisions of this order the whole question of thedisposition of the insane was greatly simplified. After an ample period ofobservation in military hospitals the insane soldiers were transferred directlyto the hospital designated
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by the Bureau of War Risk Insurance, discharged from the Armyupon arrival, and their treatment continued under the jurisdiction of thebureau, which in the future was responsible for their care. The United StatesPublic Health Service, charged with the hospitalization of the beneficiaries ofthe Bureau of War Risk Insurance, opened numerous hospitals throughout thecountry for the care of the insane. In addition the Bureau of War Risk Insurancemade arrangements with the authorities of many States for receiving theex-service insane in the State hospitals provided for the care of this class ofincapacitated. Through these facilities, the Bureau of War Risk Insuranceusually was able to send the insane to some institution near their homes, anarrangement which in itself was a source of great comfort to the patient and hisrelatives. This procedure was most successful, and was continued during theremainder of the period in which the war Army was being demobilized.
REFERENCES
(1) A. R. 465, 1913 (C. A. R., Nos. 10 and 46).
(2) A. R. 467, 1913.
(3) G. O. No. 133, W. D., October 11, 1917.
(4) Letter from the Surgeon General to the governors of the various States, September 20, 1917, relative to State care of the military insane. Copy on file, Historical Division, S. G. O.
(5) Letter from the vice chairman, War Work Committee, National Committee for Mental Hygiene, New York, to the governors of certain States, April 5, 1918, relative to State care of the military insane. Copy on file, Historical Division, S. G. O.
(6) Letter from Dr. Frankwood E. Williams, New York, to Lieut. Col. Pearce Bailey, M. C., May 2, 1918. Subject: State care of military insane. Copy on file, Historical Division, S. G. O.
(7) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1164-1167.
(8) Personnel files. Personnel Division, S. G. O.
(9) Circular Letter, Surgeon General's Office, November 20, 1918.
(10) Circular Letter S. G. O., November 20, 1918.
(11) Act of Congress, approved October 6, 1917.
(12) Opinions, Judge Advocate General, 1918-19.
(13) Circular No. 164, W. D., 1919.
