History

CHAPTER I

GENERAL VIEW OF NEUROPSYCHIATRIC ACTIVITIES

As early as the summer of 1917 the chief surgeon, A. E. F.,had been considering the organization of a group of specialists to direct andcoordinate the special medical and surgical professional services in theAmerican Expeditionary Forces. It was realized that, while base hospitals andtactical divisions would be adequately supplied with medical personnel, many ofthem leaders in medicine, surgery, and the specialties in the civil professionin the United States, professional standards throughout all the activities of anarmy could not be maintained at a high level, however efficient the medicalofficers of individual organizations might be, without some provision for thesupervision of professional work by consultants in the main branches ofmedicine. This fact was conclusively demonstrated in the experience of ourallies. Elsewhere in this history there is given an account of the organization,in September, 1917,^b of such a group of consultants.

ORGANIZATION OF THE NEUROPSYCHIATRIC SERVICE

The beginning of a well-defined neuropsychiatric service inthe American Expeditionary Forces may be said to date from December 24, 1917,when a director of psychiatry was appointed. A medical officer, who had beenassigned to duty in England to study the treatment of war neuroses, was shortlyafterward assigned as assistant in the office of the director of psychiatry.

The newly organized neuropsychiatric service found plenty ofurgent tasks. It was apparent that no time could be wasted in providing forneuropsychiatric work in the tactical divisions if the American forces were toescape the heavy toll of casualties from functional nervous disorders that hadbeen borne by the other armies earlier in the field. Although chief reliance hadto be placed upon the assignment of a consultant in each tactical division whocould help in the task of dealing with war neuroses at their very inception,there was no provision in the military organization for such an extra medicalofficer. Early in January, however, the War Department approved the plan¹that had been devised in the American Expeditionary Forces for the provision ofa divisional neuropsychiatrist,²thusmaking it possible to assign to each combat division "one specialist innervous and mental diseases."¹

The instructions in this connection applied to the UnitedStates; however, they permitted division psychiatrists to be detached by thecommander in chief, A. E. F., upon the arrival of divisions in France, if thatseemed to be desirable. It was for this reason that these officers were notincluded in the tables of organization, a factor which gave rise to somedifficulty later on. Fortunately,

^bVol. VIII, pp. 20-21.

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there was no disposition on the part of the chief surgeon, A.E. F., to recommend their detachment, although some of the division surgeonsfelt that, being attached to a field hospital, their work should be confined tosuch an organization and not be broadened so that they could help, if needed, inevery regiment, train, and company. Had it been possible to foresee thishandicap, division psychiatrists would have been attached in the first place tothe office of the division surgeon, as was done later with practically alldivisional consultants by the division surgeons on their own initiative. OnSeptember 8, 1918, a communication from the chief surgeon, A. E. F., to alldivision surgeons directed that divisional consultants "should be attachedto the office of the division surgeon as additional assistants,"³thus confirming a status which, in most instances, had already been granted.

There were in France in January, 1918, five divisions (1st,2d, 26th, 41st, and 42d).⁴All butthe 41st were in training areas centering in Chaumont, the location of generalheadquarters, A. E. F. Neufchateau, headquarters of the professional services,was 40 miles from Chaumont and quite as convenient a center for work in thetraining areas. The problem was to find psychiatrists for assignment as divisionconsultants. Fortunately, in July, 1917, seven medical officers who had hadspecial training in nervous and mental diseases had been sent to England toobserve the treatment of war neuroses in the different British war hospitals.Orders were secured for four of these officers, all of whom were men with highprofessional and personal qualifications, to report to the divisions then inFrance. By the middle of January all four had been assigned to duty. The work ofdivision psychiatrists, as they were always termed, from this small beginninguntil the demobilization of the American Expeditionary Forces, is given indetail in the next chapter.

REORGANIZATION OF THE NEUROPSYCHIATRIC SERVICE

In the latter part of April, 1918, a new plan was put intoeffect by General Orders, No. 88, G. H. Q., under which the directors weretermed senior consultants in the various specialties and the medical andsurgical groups were under the general direction of a chief consultant inmedicine and a chief consultant in surgery, respectively. The former directorsbecame senior consultants, A. E. F.; consultants, A. E. F., were also provided.

In the division of neuropsychiatry, an assistant director ofpsychiatry, A. E. F., who had been appointed April 10, 1918, now becameconsultant in neuropsychiatry, A. E. F. Although the considerations that had ledto the establishment of the immense hospital centers in the AmericanExpeditionary Forces were chiefly of an administrative nature (for example, thegreat amount of material needed in the construction of long sidings for theAmerican hospital trains that brought the wounded from the front), the chiefsurgeon, A. E. F., had not lost sight of the fact that professional services inthe hospitals constituting these centers could be supervised effectively by aconsultant in each of the more important specialties. Some of the mostdistinguished American physicians and surgeons served in this capacity withgreat advantage not only to the sick and wounded but to the other officers intheir specialty who found encouragement to conduct their work on the highestpossible level.

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By August 1, 1918, neuropsychiatric consultants had beenassigned to Base Sections Nos. 1 (St. Nazaire) and 2 (Bordeaux), and to thehospital centers at Bazoilles-sur-Meuse, Paris, Tours, and Vittel-Contrexeville.A station list issued immediately after the armistice was signed showed thatconsultants in neuropsychiatry were on duty in the following base hospitalcenters:⁵ Allerey, Beaune, Bazoilles, Commercy,Limoges, Mars, Nantes, Paris,Tours, Vichy, and Vittel-Contrexeville. Base Sections Nos. 1 (Savenay) and 2(Bordeaux) were similarly provided for. Although no officers had been designatedgeneral consultants for the following centers, each of them had at least onebase hospital to which a neuropsychiatrist was attached: Clermont Ferrand,Dijon, Langres, Mesves, and Rimaucourt.⁵

At the time of the signing of the armistice theadministration of the professional services, as far as neuropsychiatry wasconcerned, was on a very effective and satisfactory basis and could havecontinued so with a very much larger load of responsibility in all activities.There was considerable difficulty in keeping in touch with different officersassigned to this work, but efforts continually were being made to improvemethods of communication. It was planned to have conferences during the winter,in which studies could be made of experiences to date and plans could beprepared for the heavy load that was expected when activities were resumed inthe spring.

Immediately after the armistice began, the medical officerwho had served since January, 1918, as division psychiatrist in the 2d Division,was assigned to duty as consultant, Base Section No. 3 (Great Britain.)

NEUROPSYCHIATRIC HOSPITALIZATION FACILITIES

DURING THE PERIOD OF ACTIVE HOSTILITIES

The realization of the general hospitalization project of theAmerican Expeditionary Forces^c depended upon many uncertain factors, andit was necessary to scrutinize every new demand for hospital beds with theutmost care. To ask for more than a due share for any special class of patientswould be as harmful to the ultimate success of the program as to makerequisition for too few to meet the expected load. The minimum provisions tomeet the neuropsychiatric needs, if the program decided upon was to be carriedthrough, were a special hospital for war neuroses just behind the front line inthe proposed American sector; a psychiatric collecting station for the emergencycare of the psychoses in the training area where it would be equally accessiblefrom the front and from the divisions in training; psychiatric wards and, later,a special neuropsychiatric hospital at the principal base port, to facilitatethe evacuation to home territory of patients who would not be returned to frontline duty or even reclassified for duty in the Services of Supply;neuropsychiatric wards at other base ports; and a few neuropsychiatricdepartments at the hospital centers which it was proposed to establish atconvenient points along the line of communications and which ultimately weredestined to provide the major portion of the hospital beds in the AmericanExpeditionary Forces.

^cConsult Chaps. XV and XVI, Vol. II of this history fordetails concerning the hospitals of the American Expeditionary Forces.

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Within the first 60 days after a professional service inneuropsychiatry was organized, in other words, by the end of February, 1918,there were 16 base hospitals along the American line of communications,receiving, or ready to receive patients.⁶It was not yet possible todetermine which of the projected hospital centers would be the best one in whichto develop the psychiatric collecting station, but there was organized in BaseHospital No. 66 at Neufchateau a special ward for mental patients to meet theimmediate need.⁷A medical officer and enlisted men withneuropsychiatric experience were assigned to care for mental patients. As soonas Bazoilles-sur-Meuse was definitely selected as the site for such a center, itwas determined to place the main psychiatric collecting station there because ofits proximity to the prospective site of Base Hospital No. 117, at La Fauche,and the headquarters of the professional services at Neufchateau and itsnearness to the proposed American front. On February 27, the followingrecommendations regarding neuropsychiatric departments in such centers were madeto the chief surgeon, A. E. F., by the director of neuropsychiatry:⁸

1. Where it has been determined to establish several standardbase hospitals in groups (as at Bazoilles and Vittel-Contrexeville) it isobviously more economical of personnel, special equipment, and construction toprovide a central neuropsychiatric department which can serve all hospitals inthe group than to provide neuropsychiatric wards for each base hospital.

2. An added advantage in the collection of such wards into aunit, is that a classification of patients which will lead to much bettertherapeutic results can be made. It is not uncommon to find at the same time ina neuropsychiatric ward an excited manic-depressive case, several patients withmiddle grade mental defect sent in for observation, a case with febriledelirium, and others who have shown no abnormalities of conduct but have slightdepressions or neurasthenic symptoms. Satisfactory treatment under suchconditions is often impossible. If such wards are grouped, however, each maycare for a different general class of patients.

3. It is recommended, therefore, that in each standard basehospital group a neuropsychiatric department be provided, with from 50 to 60beds.

4. The personnel of such a neuropsychiatric department shouldbe made up in accordance with the suggestions in the appended table. At leastone of the medical officers should be a man of sufficient experience to enablehim to act as consultant in all kinds of difficult cases; the others could beyounger men, capable of doing valuable work under his general direction.

5. The commissioned officers of such neuropsychiatricdepartments can be furnished from the specialists now in the AmericanExpeditionary Forces and those who will come with base hospital units. Thenoncommissioned officers, female nurses, and enlisted men can be supplied fromthose with suitable experience now attached to various hospital organizationsand from Base Hospital No. 117 (neuropsychiatric hospital) which is intended toserve partly as a training hospital and replacement center for neurological andpsychiatric personnel.

NEUROPSYCHIATRIC DEPARTMENT, STANDARD BASE HOSPITAL GROUPPERSONNEL

Commissioned officers
Major^d	In general charge.
Captain^d	Ward physician.
First lieutenant^d	Do.
Noncommissioned officers
Sergeant, first class^d	In general supervision.
Sergeant	Mess and kitchen.
Sergeant	Office.

^dIndicates that special training in the care of mental and nervous cases is required.

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Nurses, female
Acting chief nurse^d	1.
Ward nurses (day)^d	4.
Ward nurses (night)^d	2.
Ward nurses (relief)^d	1.
Privates and privates, first class
Ward attendants (day)^d	7.
Ward attendants (night)^d	4.
Ward attendants (relief)^d	2.
Mess and kitchen	3.
Office	1.
Recapitulation
Commissioned officers	3
Noncommissioned officers	3
Nurses, female	8
Privates and privates, first class	17
	31

The neuropsychiatric department of the base hospital atBazoilles-sur-Meuse, established in connection with Base Hospital No. 116, becamethe "Psychiatric Collecting Station," the activities of which arereferred to again below.

HOSPITAL FOR WAR NEUROSES (BASE HOSPITAL NO. 117)

Second only in urgency to the provision of a foundation forpsychiatric work with troops in the field was the establishment of a specialhospital for war neuroses as far forward as possible in the advance section, forit was upon these two resources that chief dependence was to be placed foreffective management and treatment of the war neuroses. Fortunately at La Fauche(a tiny village on the main route between Chaumont and Neufchateau) there wasone of the camp hospitals with which each training area was to be provided.⁶The use of this hospital as a special hospital for war neuroses wasrecommended in February, 1918, by the director of neuropsychiatry, A. E. F.⁹The chief surgeon, A. E. F., approved this plan and a provisionalneuropsychiatric personnel immediately occupied it and assisted in itscompletion.

Its activities soon increased to such an extent that by theend of May it was obliged, because of the great increase in the number of warneuroses and the lack of adequate personnel, to refuse new admissions.¹⁰The special hospital care of these cases was the most urgent need in all theneuropsychiatric activities at that time. Though the permanent personnel forBase Hospital No. 117 had been organized early in the year in the United States,they were still detained at Camp Crane, Pa. War neuroses cases were appearing inincreasing numbers in base hospitals throughout the American ExpeditionaryForces, where they were treated without special facilities and in accordancewith many different clinical points of view. It was by no means easy to arrangefor their transfer to Base Hospital No. 117, and thus additional evidence wasprovided that

^dIndicates that special training in the care of mental and nervous cases is required.

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some method of directing the evacuation of these men from thedivisions must be devised or the problem of controlling the incidence of warneuroses would not be solved successfully in our Army. On June 16 the highlytrained personnel of neuropsychiatrists, nurses, and occupational aides for BaseHospital No. 117 arrived at La Fauche and within a few weeks this hospitalbecame an efficiently organized special institution for the treatment of aspecial type of illness-war neuroses.¹⁰ Base Hospital No. 117 rapidlybecame the center for scientific work and training in neuropsychiatry in theAmerican Expeditionary Forces. Its ability to receive patients thereafter waslimited only by its capacity.

By September it was apparent that this hospital would have tobe greatly enlarged and so plans were drawn for the addition of a sufficientnumber of beds to bring the capacity to 1,000. This was accomplished by the timethe armistice was signed.¹⁰ The necessity for a convalescent camp operated inconnection with Base Hospital No. 117 had already been shown by the disastrousresults of allowing convalescent patients to go to general convalescent campswhen they no longer required hospital treatment. An entirely different point ofview as to the nature of war neuroses often prevailed in the generalconvalescent camps, and the result was a large number of relapses just when themaximum improvement could have been expected. The plan for a convalescent campat La Fauche was very carefully thought out. It was intended to provide forabout 1,000 patients under an environment quite different from that of thehospital or of a general convalescent camp. Drill, including machine-gun andhand-grenade practice, were to constitute an important feature, and it was hopedthat a special group of men could be organized into a company of infantry fromthose most nearly ready to return to duty. This plan, of course, was abandonedwith the armistice.

It was apparent that additional hospital provisions for warneuroses would be required if hostilities continued. On September 14, 1918,therefore, the senior consultant recommended a second hospital in the followingletter to the chief surgeon:¹¹

1. The number of troops in France makes it necessary now toconsider the provision of the second hospital in the S. O. S. for the treatmentof war neuroses. In order to have one bed per thousand combatant troops,which is generally agreed to be the minimum required, it is necessary to provideanother hospital as large as Base Hospital No. 117. This hospital should be atleast as near the front as La Fauche and preferably not more than 60 miles tothe west of it in order that a convalescent camp for these cases can beestablished between them which will be easily accessible from each. Perhaps anucleus for such a hospital can be found north of Epinal.

2. If next summer, with the enlargement of our Army, a thirdis necessary, it could be located somewhere in the southern part of France andbe used for a special class of cases-the most unfavorable type-those arisingin training areas and the S. O. S. and others who have had successive relapses,the other two hospitals being employed exclusively for cases from the front.

3. It seems necessary to look this far ahead in order thatthis problem may not get beyond our control.

4. I have great hopes of the results to be obtained in suchadvanced stations for temporary care as those which we have just been able toestablish at Toul and Bennoite-Vaux. The work in tactical divisions is becomingmuch better organized and I think that we may look for a decrease rather than anincrease in these cases as our mechanism for dealing with

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them at an early point develops. I am quitesure that as a result of this method of management we shall have few of the veryintractable cases seen among the British.

5. Has the division of hospitalization an offer of propertyin the region lying north of Epinal and east of Nancy that I might look at soonand report upon as to its suitability?

Had hostilities continued, the personnel of this secondhospital would have been provided by the replacement unit due to arrive inFrance in October.

After the armistice began, new admissions to Base HospitalNo. 117 declined very rapidly and a large number of men were restored to dutywho otherwise would have required a considerable period of treatment.¹⁰ Therewas not, however, as has been stated, any very marked change in the character ofthe war neuroses or in their prognosis. It was simply possible to restore to Aor B status some men who would have been classified C or D, had the warcontinued. By January 9, 1919, the number of patients had diminished to 149,¹²and during the following week those remaining were transferred to Base HospitalNo. 214, Savenay, which from that time on conducted two departments, one forpsychoses and one for psychoneuroses.¹³The total admissions fromthe opening of the hospital were 3,268, 50 per cent of whom were returned tocombat duty and 41 per cent for other military duty in the AmericanExpeditionary Forces.¹⁰

PROVISIONS FOR MENTAL DISEASES (PSYCHOSES)

Although the total number of American troops in France inJanuary, 1918, was only approximately 203,000,¹⁴ the caring for mental patientshad already become a problem. It was obvious at the outset that such patientscould not be cared for in the individual American base hospitals scatteredthroughout France, partly because of the lack in some of them of medicalofficers, nurses, or enlisted personnel who had had experience in the actualcare and treatment of patients suffering from acute mental disorders, butchiefly because of the absence of any special facilities for treatment. In orderto function as a collecting station the neuropsychiatric department at Bazoilleswould have to be provided with an outlet. Therefore, mental patients had beencollected as far as possible at Base Hospital No. 8, at Savenay, near the baseport of St. Nazaire, where two wards were set apart for their reception andtreatment.¹⁵ The growth of these two wards into an efficient hospitalfor mental cases of 1,000 beds, with every modern facility for psychiatricdiagnosis and treatment, is described in detail in Chapter VI of this section.Base Hospital No. 66 at Neufchateau already was serving as a temporarypsychiatric collecting station for the troops in the training area. Most of itsneuropsychiatric patients reported at the time under consideration were mentaldefectives who had been "weeded out" by the divisional psychiatristsas one of their first tasks.

The following recommendations for the care of mental cases,made by the director of psychiatry to the chief surgeon, A. E. F., February 1,1918, indicates the general nature of the plans then being shaped:¹⁶

1. Mental cases (insanity, mental deficiency, andconstitutional psychopathic states) can be expected to furnish a considerableproportion of all soldiers of the Expeditionary Forces who will have to beinvalided home. Already these cases constitute 30 per cent of the total numberso returned. In the Canadian overseas forces, in spite of the enormous

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incidence of disability resulting from battle casualties,about 12 per cent of all soldiers returned during the war have been mentalcases.

2. It is apparent from these facts that arrangements must bemade for dealing with this problem. If a simple and effective mechanism fortreating and evacuating mental cases is devised and put into operation whilethe number to be provided for is still relatively small, much subsequentdifficulty (as well as unnecessary hardships for a class of the sick having veryspecial needs) can be prevented.

3. Any such mechanism must take into account the fact thatpractically no soldier who has had a psychosis and few other mental cases shouldbe returned to duty in France. It is not meant to imply by this statement thatthe psychoses common among soldiers are especially unrecoverable. The reverse isthe case. It is unwise to return to duty such cases, however, until aconsiderable period has elapsed after their recovery. This fact and the longperiod of treatment usually required in mental cases make it undesirable toprovide for continued care in France. Provisions here must be considered assimply preliminary to their return to the United States as promptly as possible.Little more can be undertaken here than to make a careful diagnosis in each caseand to provide for efficient treatment while waiting for a sailing or gettingthe patient into condition to make the journey safely.

4. To provide such a mechanism, the following facilities arerequired: (a) Observation wards in camp hospitals, or in some cases inbase hospitals, favorably situated in the training areas where the psychiatristsattached to divisions can examine cases and make recommendations for theirdisposition. (b) Arrangements for the evacuation to a designated basehospital at a port of all cases requiring emergency treatments, continuedobservation, or return to the United States. (c) A special psychiatricdepartment in a base hospital at St. Nazaire or Bordeaux (or one at each port ifthe number of such cases or transportation difficulties should require it.)

Detailed recommendations as to the size, arrangement,personnel, and equipment of such a psychiatric department were inclosed.

By the end of February, 1918, the above general plan ofproviding for patients with psychoses had been decided upon by the chiefsurgeon. As has been stated, Base Hospital No. 66 was the first hospital in thetraining areas to provide a special ward. It was not until July 20 that theneuropsychiatric department at the Base Hospital No. 116 (Bazoilles hospitalcenter) was able to receive patients.¹⁷It operated continuouslyuntil April 30, 1919.

The other main resource for the treatment of mental diseasewas that provided by the neuropsychiatric department of Base Hospital No. 8, atSavenay. By June, 1918, the new ward buildings to constitute the psychiatricdepartment were well under way.

By June 13, 1918, it was possible for the chief surgeon'soffice to issue a circular letter giving detailed instructions for the care,evacuation, and transportation of neuropsychiatric patients in the AmericanExpeditionary Forces. This circular is given in full because its paragraphsindicate not only the facilities available for care but also the standards ofhumanity which from the very first governed the treatment of this class of sickin the American Expeditionary Forces.

CIRCULAR No. 35.--THE MANAGEMENT OF MENTAL DISEASESAND WAR NEUROSES IN THE AMERICAN EXPEDITIONARY FORCES

AMERICAN EXPEDITIONARY FORCES,
France, 13 June, 1918.

Absence of the auxiliary civil facilities that simplify themanagement of mental cases in the Army in home territory and the extraordinaryincidence of functional nervous diseases

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in all armies in the present war have made it necessary toprovide special facilities and methods of procedure in the A. E. F. Thesedisorders, by their very nature, interfere with the morale and efficiency oftroops in war. Their proper management in the hospitals and organizations inwhich they first come to notice and their wise disposition and reclassificationsubsequently will not only increase military efficiency, but, in the case of warneuroses, will tend to diminish to a considerable extent their incidence.

This circular is issued in order that all medical officersmay become familiar with the facilities that have been provided for thediagnosis, transportation, and treatment of soldiers with these disorders. Thesefacilities will be modified from time to time as changing conditionsnecessitate, but the general plan of management here outlined will be followed.

I. Mental cases (insanity, mental deficiency, observationcases).

(a) Provisions for prompt diagnosis and early care.

Tactical divisions: Each tactical division in the A. E. F. and in the United States is provided with a psychiatrist whose duty it is, under the direction of the division surgeon, to examine all mental cases coming to attention in the division and to make recommendations for their evacuation or other disposition. The psychiatrist will be detailed from the division sanitary personnel. Their specific duties are defined in Circular No. 5, C. S. O., A. E. F.
They will examine enlisted men brought before generalcourts-martial as provided by W. D. order of March 28, 1918. They will alsoexamine all other military delinquents brought to their attention, especiallythose in whom self-inflicted wounds or malingering are suspected. Except underexceptional circumstances, no cases of this kind will be evacuated to the rearuntil examined by the division psychiatrists. In the case of prisoners accusedof crimes the maximum punishment of which is death, the division psychiatristshould, whenever practicable, have the assistance of a consultant in psychiatry.
Base hospitals: A neurologist or a psychiatrist has beenassigned to each base hospital or group of base hospitals in the same vicinity.This provision makes it possible for mental cases that first come to attentionin such hospitals to receive early diagnosis and treatment and prompt evacuationto hospitals provided with special facilities for their care.

(b) Provisions for hospital care.

Advance section, S. O. S.: There has been provided in connection with Base Hospital No. 116 a neuropsychiatric department of 72 beds which will act as a collecting and evacuating point for mental cases from other base hospitals, from tactical divisions, and from training areas.
When observation cases or patients with frank mental diseasesor defect are recommended by the division surgeon, upon the advice of divisionpsychiatrists, for transfer to this collecting station, the commanding officerof Base Hospital No. 116 will be notified by telephone or telegraph and willthereupon send a sufficient number of attendants to bring such patients to thehospital in safety. It is necessary, in making such requests, to state thenumber of patients and the amount of supervision that they will require enroute. When practicable, the ambulance service to be established in connectionwith Base Hospital No. 117 will be employed for this purpose. In all such casesthe diagnosis will be "Observation, mental," the type of disease beingadded in parentheses.
It is very important that mental cases be accompanied byrecords in which the circumstances under which their condition came to noticeare fully stated. It is obvious that, without such information, the medicalofficers who have the responsibility of dealing with these cases will often havedifficulty in arriving at a diagnosis or in making suitable recommendations fortheir disposition.
Base hospitals in the advance section will transfer to thiscollecting station all mental cases except those which can readily be retaineduntil sent for by the psychiatric department of one of the base hospitals at abase port and those in whom complications or other reasons render a transferundesirable. Effort will be made to provide all base hospitals with severalnurses or enlisted men of the Medical Department who have had experience in thecare of mental cases. With such attendance it will be unnecessary to placeguards in observation or mental wards. Commanding officers will protect thesecases from the ridicule to which they are sometimes subjected even in hospitals.
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Intermediate section: At least one of the large basehospital centers which it is proposed to establish in this section willultimately have in connection with it a neuropsychiatric department similar tothat at Base Hospital No. 116. Hospitals in this section will, in the meantime,evacuate their mental cases to Base Hospital No. 8 in the manner specified inparagraph I (c) of this circular.
Base Sections Nos. 1 and 2: A psychiatric department witha capacity of 152 patients has been provided in connection with Base HospitalNo. 8. This and a similar one to be established in connection with a basehospital center in Base Section No. 2 will provide the chief facilities for theclassification and continued care of mental cases in the A. E. F.
Base Section No. 3: Mental cases among American troopsserving with British organizations will be evacuated to England in the samemanner as other sick and wounded from the same organizations. In England aneuropsychiatric department will be provided for the reception, continued care,and classification of cases from British clearing hospitals for mental diseasesand from other hospitals in Great Britain.
Base Section No. 4: Any mental cases coming to notice inthis section will be evacuated to Base Section No. 3.
Base Section No. 5: Psychiatric wards will be provided ata base port. These wards will receive only cases which have been classified"Class D" at Base Hospital No. 8 and whose condition is such that theycan be transported to home territory with the minimum of care and supervision.This ward will receive no other cases but will provide temporary care forsoldiers who are found insane upon their arrival from the United States.
Base sections Nos. 6 and 7: Mental cases arising in thesesections will be evacuated to a base hospital at the port of Base Section No. 2.
French hospitals: Mental cases that have been evacuatedfrom the front into French military hospitals will be transferred as soon aspracticable to the most accessible neuropsychiatric department of an Americanbase hospital center.

(c) Transportation.
The neuropsychiatric department at Base Hospital No. 116 willsend for patients to other base hospitals in the Advance Section, S. O. S. andto tactical divisions and training areas as provided in Paragraph I (b) of thiscircular. The neuropsychiatric departments of base hospital centers to beestablished in the Intermediate Section, S. O. S. will send for patients in thesame manner.
The psychiatric departments of Base Hospital No. 8 and thebase hospital center in Base Section No. 2 will send for patients to any basehospital which is nearer to them than to a collecting station.
As mental cases of all degrees of severity can be safely andcomfortably provided for at these collecting stations, they will be retaineduntil a sufficient number have accumulated so that they can be evacuated inparties, the attendance being provided by the psychiatric department at the baseport to which they are sent. Ordinarily, regular passenger trains will be used,but in special instances and where the number of patients warrants it, transferswill be made in a car set aside for this purpose on an American hospital traindestined for a base port to which they are to be sent. In this case, as in allothers, attendance will be provided by the psychiatric department receiving theconvoy.
Evacuation to home territory of patients classified"Class D" will be made in accordance with special arrangement which itis not necessary to outline in this circular.

(d) Disability boards for mental cases.
Disability boards for mental cases will be convened atneuropsychiatric departments of base hospital centers and at psychiatricdepartments at base ports. Other disability boards should not pass upon thesecases, but should refer them to one of the points at which such boards areauthorized. All mental cases to be transported in France will be given thetentative diagnosis of "Observation, mental," except those transportedto their final destination on American hospital trains.
Disability boards will be guided by Circular No. 24, C. S.O., 1918, in passing upon mental cases.

II. Functional nervous diseases and concussion cases.

(a) General consideration.

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The proper management of these conditions which arecommonly included in the designation "shell shock" is regarded bythis office as a matter of much importance. This term, which, unfortunately, isbeing used indiscriminately by medical officers as well as patients, includes anumber of different conditions depending upon many different causes andrequiring for their successful management several entirely different methods ofprocedure. Many patients in whom severe concussion symptoms following beingblown up by shells or buried in dug-outs can be returned to duty, and it ispossible to return a much larger proportion of those cases in which purelypsychoneurotic symptoms develop under shell fire or in training, if they areskillfully managed. The return of these cases to their own organizations after ashort period of treatment has a very favorable effect in lessening theincidence among their comrades of disorders in the second group mentioned. If,on the other hand, a large proportion of these patients are evacuatedindiscriminately to hospitals in the S. O. S. or to home territory, the effectwill be to increase their incidence.
For this reason a special hospital for these cases, BaseHospital No. 117, has been established and an ambulance service has beenprovided us connection with this hospital by which cases can be receiveddirectly from tactical divisions at the front. At this hospital the resourcesfound most useful in the British and French special hospitals for these casesare employed. Success in their treatment depends very largely upon the attitudeof medical officers generally toward the special problems in diagnosis andmanagement which they present. For this reason regimental medical officersshould guard against making an unfavorable prognosis even in cases presentingsevere symptoms.

(b) Treatment.

Tactical divisions: The advice of the division psychiatrist should be utilized to the fullest extent in the early treatment of these cases in division sanitary organizations and in the selection of cases for evacuation to hospitals in the S. O. S. It will be found advisable, whenever practicable, to receive such cases in special wards in one field hospital and to evacuate cases to hospitals in the S. O. S. only upon the recommendation of the division psychiatrist. This officer will advise with regimental medical officers regarding the management of nervous manifestations when they first come to attention at the front.
Hospitals in the S. O. S. in France: It is expected thata very large proportion of these cases will be admitted directly from theirorganizations to Base Hospital No. 117 and that relatively few, unlesscomplicated by wounds, gassing or other conditions, will be received in otherbase hospitals. Other base hospitals will promptly transfer suitable cases toBase Hospital No. 117, except in these instances in which it is thought thatthey can return directly to duty and those in which the outlook seems sounfavorable, from constitutional neuropathic tendencies or other factors, thattheir reclassification is probable. Cases in which there is some doubt as towhether an organic or functional disorder is present should be transferred toBase Hospital No. 117. No cases having wounds requiring much surgical attentionshould be sent to Base Hospital No. 117. All cases in which there is doubt as tothe best disposition should be brought to the attention of the consultant inneuropsychiatry for the hospital.
Hospitals in the S. O. S. in England: A special hospitalfor war neuroses will be provided in England which will be organized andconducted upon the same lines and will perform the same functions as BaseHospital No. 117. American soldiers serving with British organizations will betransferred to this hospital from the British clearing hospital for these casesor from other hospitals in England.
French hospitals: American patients with these disordersin French military hospitals will be evacuated to Base Hospital No. 117 or tothe nearest neuropsychiatric department of a base hospital center.

(c) Disability boards for functional nervous diseases and concussion cases.
Disability boards for these cases will be convened at BaseHospital No. 117, neuropsychiatric departments of base hospital centers, andpsychiatric departments of base hospitals at base ports. No other disabilityboards should pass upon these cases.
No great difficulties were experienced in putting theprovisions of this circular letter into effect except as regards the mentalcases. Though medical
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officers generally recognized their own lack of experience inthe care of mental patients and were willing to transfer them as soon aspossible, the transfer of such patients from the forward base hospitals to thehospital center at Savenay presented difficulties not apparent at first glance.
In the first place, not only was the number of enlisted menwith training in the care of mental patients very limited but only two Americanhospital trains (converted French trains) were operating until late in thesummer. Thus all the transfers to base ports had to be made on French civiliantrains. However, by deferring such evacuations until a number of patients hadbeen collected and having each convoy accompanied by a medical officer andseveral enlisted men with experience in neuropsychiatry, transportation wasaccomplished without serious disadvantage to the patients. It is appropriate torecord here that during the whole history of the American Expeditionary Forcesno patient suffering from a mental disease committed suicide while undertreatment, was injured or lost during transportation, and (except in rareinstances where methods could not be controlled) no patient being evacuated wassubjected to mechanical restraint.
Secondly, there was never at any time a special vesseldesignated to return neuropsychiatric patients to the United States. They had tobe included in the rather limited space set aside for hospital accommodations onthe westward trips. Again and again a transport filled its hospital beds withthe sick and wounded and found that there was no place left over forneuropsychiatric patients. There was a considerable lack of agreement as to whatconstituted proper provisions for the transportation of these patients.
Another difficulty arose out of the use of the term"neuropsychiatric" to designate patients requiring such widelydifferent types of provision on shipboard as those with acute mental diseases(psychoses), those convalescent from war neuroses, mental defectives,epileptics, insane prisoners, and patients suffering from organic diseases ofthe central nervous system. The shortage of shipboard facilities was, of course,only for those in the first category, but all were refused. Then, often,unexpectedly a transport would be willing to receive a large number of mentalpatients and the population of the 300-bed psychiatric department of BaseHospital No. 8 would be quickly relieved. Congestion, however, was the rule. Forthis reason the provision of a special hospital at Savenay was recommended bythe senior consultant on October 28, 1918.¹⁸
One of the hospitals in the center finally was set aside andopened November 6, 1918, under the designation Base Hospital No. 214.¹³
At Brest a difficult situation was created by the fact thatoccasionally a convoy of mental patients which had arrived from Savenay for thesailing of a designated transport from Brest was refused by the medical officerof the transport because of the lack of suitable accommodations for them. Insuch instances emergency provision had to be made in hospitals at Brest whichhad no special facilities for their care. The outgrowth was a development of aspecial department at Base Hospital No. 65, at the Kerhuon hospital center, atthis base port.¹⁹This department became one of the most effectiveand useful neuropyschiatric resources in France.
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DURING THE ARMISTICE
Just before the armistice was signed the chief surgeon directed the seniorconsultant to submit a full statement as to the adequacy of existing hospitalaccommodations for neuropsychiatric patients in the Services of Supply, with astatement of the additional provisions already under construction or agreed uponand any expansion required. This report is given below in full, because itprovides an excellent summary of the situation as it existed a few weeks beforethe armistice was signed:²⁰

SPECIAL HOSPITAL PROVISIONS FOR MENTAL AND NERVOUS CASES IN THE S. O. S.
Bazoilles center:
Present provisions-

Psychiatric department of Base Hospital No. 116; in seven buildings, including quarters for nurses and enlisted personnel.
Capacity: 72.

Serves as collecting station for mental cases from tactical divisions and all hospitals in advance section east of Troyes.

Disability board for neuropsychiatric cases.

Under construction or agreed upon-

None.

Expansion recommended-

Addition of three ward buildings of type known as "general wards" in present department and enlargement of present nurses' quarters.

Proposed capacity: 150.

La Fauche:

Present provisions-

Base Hospital No. 117 (for war neuroses) consisting of a standard camp hospital, and a small chateau which is used for officer patients.

Village used for billets for medical officers. A dwelling rented for nurses' quarters.

Four French barracks, a mile from hospital, constitute convalescent camp. Disability board for neuropsychiatric cases.
Capacity: Hospital                            405
                 Convalescent camp         125
                                                Total                      530

Receives war neuroses from Army neurological hospitals and all base hospitals in American Expeditionary Forces.

Under construction or agreed upon-

Buildings to bring capacity of hospital to 2,000 beds under construction.

Recommendation made to erect buildings for second 1,000 beds on site now used for convalescent camp.

Expansion recommended-

None after completion of buildings now under construction. Tentage can be added in spring to bring convalescent camp to 2,000.
Proposed capacity: Hospital                            1,000
                           Convalescent camp        1,000-2,000

Allerey Center:

Present provisions-

None.

Under construction or agreed upon-

Plans for a neuropsychiatric department not of the standard type have been submitted by the Engineer's Department. Recommended that psychiatric department of Base Hospital No. 116 at Bazoilles center be duplicated here, and the department thus established serve as collecting station for mental cases for the northeastern part of the intermediate section. Disability board for neuropsychiatric cases recommended.

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Allerey Center-Continued.

Expansion recommended-

Same as for Bazoilles center, when needed.
Proposed capacity: 150.

Mars Center:

Present provisions-

None.

Under construction or agreed upon-

Recommended that a psychiatric department of 250 beds consisting of an adaptation of "A" type base hospital be constructed as soon as possible on site already suggested by center commander. Plan submitted to C. S. O. this date for such a department and for expansion proposed.

The fact that large hospital centers and several depot divisions are near this center make it desirable to centralize the work of observation and collection of mental cases which will otherwise have to be done in small observation wards at base hospitals in the neighborhood and at camp hospitals in depot divisions (as at St. Aignan). Disability board for mental and nervous cases recommended.

Expansion recommended-

Increase of psychiatric department to 500 beds, when needed.

St. Aignan-Noyer:

Present provisions-

Psychiatric wards operated as branch of Camp Hospital No. 26, First Depot Division, in a convent in St. Aignan. Used chiefly for observation of mental cases. Important when all replacements to American Expeditionary Forces came through the First Depot Division, but less so now.

Capacity: 114.

Under construction or agreed upon:

Disability board for neuropsychiatric cases recommended.

Expansion recommended:

None. When proposed psychiatric department at the Mars center is ready to receive patients, these wards may be abandoned.

Base Section No. 1:

Present provisions-

Psychiatric department of Base Hospital No. 8 at Savenay, partly in buildings of special design and partly in other wards of hospital. This department receives and "boards" practically all mental cases and many nervous cases who are subsequently returned to the United States. The increase in population is shown by this table:

Admitted

Returned to U.S.
July
405
348
August
588
601
September
887
585

Under construction or agreed upon-

Additional buildings being constructed but wards are now widely separated, personnel is confused, and the provisions for insane officers are unsatisfactory. It is thought by all desirable to operate this very important department as a separate hospital unit in the Savenay center. The center commander has suggested a unit nearing completion for this purpose. Recommended that a unit of 1,000 beds now about completed be occupied as soon as possible by personnel to be supplied by Psychiatric Replacement Units Nos. 1 and 2. The buildings now used by the psychiatric department can be used to advantage for other purposes.

Expansion recommended-

The psychiatric base hospital recommended above to be enlarged only as absolute necessity demands.

Although the armistice put an end to battle casualties, thus eliminating onegreat increasing demand for hospital beds, the hospital problems of the AmericanExpeditionary Forces were not immediately reduced in their size
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or complexity. The necessity for beds for neuropsychiatricpatients increased for a time instead of diminished, and congestion of suchpatients at Savenay hospital center because of delay in transferring them to theUnited States, became very serious. One of the results of the delay in thetransfer of these patients was to imperil recovery in many of the lighter typesof depression that had occurred in men exhausted by the severe fighting of thefall. This situation was brought to the attention of the chief surgeon, A. E.F., by the senior consultant in neuropsychiatry, in November, 1918.²¹
A number of the more recent cases showed simple depression,in some instances only slightly beyond physiological limits but, nevertheless,accompanied by painful ruminations and often by suicidal ideas. An intenselonging for home was characteristic of this condition. It resembled a set ofreactions to which the term "nostalgia" used to be applied and iscommon in all military expeditions when a period of intense activity issucceeded by an uneventful one.
The cessation of hostilities made it necessary to modifyplans for the care of neuropsychiatric patients. It was upon the followingletter from the senior consultant to the chief surgeon, A. E. F., that theneuropsychiatric work during the armistice, except in the army of occupation,was based:²²
1. The cessation of hostilities and the proposed decreasein the number of expeditionary troops necessitate radical changes in plans forthe care of neuropsychiatric cases in the American Expeditionary Forces.
2. The most convenient method of presenting thesechanges isto consider them with reference to the following three groups into whichpractically all neuropsychiatric cases in the American Expeditionary Forcesfall: Injuries to the central nervous system and peripheral nerves;psychoneuroses, chiefly those termed "war neuroses"; mental diseases(insanity, mental deficiency, etc.).
INJURIES
The possibility of further admissions to this groupterminated with the armistice. In civil accidents-such as will continue inthe American Expeditionary Forces-such injuries are very rare. The wholeproblem of dealing with injuries to the central nervous system and peripheralnerves is their diagnosis and management pending their return to the UnitedStates for continued treatment.
The neurosurgeons having decided that all such cases shouldbe returned to the United States before operation, it is important that everyeffort should be made now to see that each patient with a wound in which injuryto the brain, cord, or peripheral nerves may exist receives a carefulneurological examination and that accurate notes of such examination be made onthe clinical records. It is not sufficient to examine only cases brought toattention by surgeons but all cases should be seen. Negative notes will oftenprove of as much value in the future management of these cases as positiveones.
There are many instances in which a functional element, or a"functional overflow of symptoms" as it has been called, complicatescases in whom organic injury exists. To determine the existence and extent ofthis complication requires a careful examination by one experienced in thediagnosis of functional as well as organic conditions. Neuropsychiatrists inthe American Expeditionary Forces have had unusual opportunities of seeingfunctional disturbances among soldiers. It is important, therefore, that theiropinion should be recorded in all such cases before sending them home. It canreadily be seen that neuropsychiatrists and neurosurgeons in the United Statesmay be misled by the disappearance or modification of functional symptoms whencases arrive at hospitals at home unless careful examinations and clearrecords have been made in the hospitals of the American Expeditionary Forces.
With these considerations in mind, thousands of carefulexaminations of the wounded have been made by neuropsychiatrists in basehospitals in the American Expeditionary Forces. Now a general survey withreference to neurological injuries is being undertaken.
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In every base hospital center this work is being pushed byadditional personnel under the direction of the consultant in neuropsychiatryfor the center. Not only will positive findings be recorded but in all negativecases the clinical records will be stamped "Neurological examinationnegative."
It is realized that the rapid evacuation of patients towardbase ports can not be delayed for such examinations and that many patients willnot be reached. To meet this situation a number of young and energeticneurologists have been sent to Savenay, Brest, and Bordeaux. At these ports,through which all the wounded must flow, efforts will be made to examine allrecords and as far as possible to examine all cases in which a previousexamination was not recorded. Three very experienced officers have been assignedto these ports as consultants in neuropsychiatry to supervise this work.
In about six weeks the work outlined above should becompleted. The medical officers engaged in it may then be returned to the UnitedStates.
PSYCHONEUROSES
It is estimated that the incidence of these disorders will bedecreased not less than 90 per cent through the cessation of hostilities. Theremaining 10 per cent will continue to be contributed in the future as they havebeen thus far, by the factors responsible for psycho-neuroses in civil life.Military experiences other than the hardships and danger of actual warfare willtend to make psychoneuroses not less prevalent in the American ExpeditionaryForces than among a body of men of the same age periods in civil life.
Accompanying the decreased incidence of the psychoneuroseswill be a greatly increased recovery rate among those remaining under treatment. It isestimated that among the 465 cases remaining unclassified at Base Hospital No. 117 onNovember 25, as many as 410 will be discharged to duty.
As nearly as can be estimated, about 200 cases are now inother base hospitals. Steps are being taken to have these cases sent to BaseHospital No. 117 at once. It is very desirable that they should be restored assoon as possible and not returned to the United States still suffering fromfunctional nervous disorders. Spreading the information that this will not bedone has already promoted recovery. It is apparent that Base Hospital No. 117will have seen less than 200 patients, and that with this number of beds all newadmissions to be expected can be provided for. As it is uneconomical to maintaina separate hospital for this number of patients and it is perfectly useless tosend these cases to general hospitals, it is recommended that all cases offunctional nervous disease be cared for in the neuropsychiatric hospitalconsidered under the heading "Mental diseases" in this letter.
MENTAL DISEASES
The elimination of danger, hardship, and exhaustion as causesof mental disease will tend to decrease the number of admissions in this group.The number of mental defectives coming to notice will be diminished on accountof the inevitable lowering of standards of mental fitness in troops not requiredto do combat duty. (Many mental defectives used to come to attention on accountof their inability to put on gas masks or perform outpost duty.) To offset theeffect of these causes of a substantial decrease in the admission rate formental cases, are the lengthening period of service and absence from home,disappointment over not returning immediately and the unavoidable impairment ofmorale that will result when a combatant army becomes one of the occupation. Itis predicted that mental cases will continue to be admitted at an annual rate of3 per thousand enlisted strength-about three times the civil rate for adultmales.
The present provisions for the insane of the AmericanExpeditionary Forces are inadequate. The collecting station provided by thepsychiatric department of Base Hospital No. 116 at Bazoilles has been of muchvalue. It should be continued as well as the wards now set aside at the Allereyand Mars hospital centers, as these centers are within easy reach of the areasin which the troops are quartered. Mars is a particularly favorable location asit is at the point of divergence for the three base ports. A similar ward shouldbe maintained at Bordeaux and one at Brest for convenience in embarking mentalcases and for the collection of new cases from the troops in the vicinity. Allthese wards are being adequately staffed from the personnel now available. Inaddition officers and enlisted men are being congre-
289
gated at the three base ports so that they can be detached toaccompany convoys of mental patients home.
The chief provision for mental cases should continue to be atSavenay or Nantes. These places are nearest the most convenient port and alsonearest to the points from which cases will be collected and afforded temporarycare. The problem of caring kindly and skillfully for mental cases from theAmerican Expeditionary Forces will have to be met at one of these points as longas there are troops in France. When the pressure of caring for the woundedsubmerged everything else it was out of place to dwell upon the kind of careprovided for mental cases. Now, however, it would seem that the matter could betaken up seriously. Insanity is not an occasional occurrence among troops butone of the most important diseases in an army in peace as well as war. It shouldbe provided for not as an emergency but as one of the routine tasks of themedical department of an army.
Although no country has higher standards than the UnitedStates in the care of mental disease, the care of the insane at the present timeat Savenay is below that seen in any British or French military hospital formental diseases. Base Hospital No. 214 is a base hospital only in name. It wascreated by giving this designation to the overcrowded wards already occupied bythe mental cases, without any provisions for personnel, administration, ortreatment being added. The capacity of these wards was rated at 400 by giving upall rooms intended for special patients, for the isolation of special classes,or for day rooms. The enlisted personnel is away from the unit altogether atnight although this is a practice full of danger when mental cases are caredfor. The personnel on night duty should always have assistance at hand in caseof emergency. Only 13 nurses are available for the care of 560 patients. Thirtynurses were assigned to this department when the personnel of Base Hospital No.117 arrived in France in June. Although these nurses were all especially trainedin the care of mental diseases, having been enrolled in the United States forthat purpose, they have been assigned to other work in other hospitals.
The remedy for the conditions under which the insane of theAmerican Expeditionary Forces are cared for is to provide at Savenay or atNantes a separate neuropsychiatric base hospital capable of caring adequatelyfor all mental cases, with proper classification and provision for therelatively large number of insane officers, and for the psychoneurotic casesafter Base Hospital No. 117 has been discontinued. No special provisions otherthan those which can be extemporized by a staff of the hospital are required. Itis necessary, however, that such a hospital should be recognized as a necessityand not a temporary expedient and be permitted to develop the special methods oftreatment and care needed even in the short period in which mental cases areprovided for here. A very large proportion of the mental cases now coming tolight are recoverable. Many can be transported to the United States with muchless danger after a short period of treatment here and in not a few thedifference between permanent mental disease and prompt recovery will depend uponwhat is done for them in that short period. The wards at Savenay constitutenothing but a place of detention now.
By January 14, 1919, certain further modifications werenecessary and Circular No. 35, quoted above, which had provided the officialauthorization for a large proportion of the neuropsychiatric work in France, wassuperseded by Circular No. 35-A:
CIRCULAR LETTER No. 35-A
AMERICAN EXPEDITIONARY FORCES,
                                 January 14 1919.
From: The Chief Surgeon.

To: C. O.'s all base, camp and evacuation hospitals, hospital centers, surgeons of armies, corps, divisions, and sections, and the surgeon, district of Paris.

Subject: Mental and nervous cases.
MENTAL CASES
1. The directions of Circular 35, O. C. S., June 13, 1918,that relate to the care and evacuation of mental cases (insanity, mentaldeficiency, epilepsy, observation cases) are modified as indicated below.
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2. Psychiatric departments for the reception, observation, earlytreatment, and evacuation of mental cases are now in operation at the followinghospital centers:

Hospital center,
Bazoilles.
Allerey.
Mars.
Kerhuon, Brest.
Savenay.
Beau Desert, Bordeaux.

District of Paris, Camp Hospital No. 4, Joinville.
3. All mental cases will be sent to the psychiatric departmentmostaccessible in the manner indicated in Circular 35. It is important thatproper attendance be provided in all cases to prevent accidents duringevacuation. Unless special circumstances make other arrangements moreadvantageous, such attendance will be supplied by the psychiatric departmentto which patients are being sent. No stigma attaches to admissions to thesedepartments and they should be freely used for observation in all doubtfulmental conditions.
FUNCTIONAL NERVOUS CASES
4. Patients with functional nervous diseases (psychoneuroses, warneuroses) will be sent, in the first instance, to the nearest base hospital andthence to Base Hospital No. 214, at Savenay, which has a special departmentfor psychoneuroses. Attendance will be provided for these cases only when thereis some special reason for it. They will not be sent to psychiatricdepartments at hospital centers.
RECORDS
5. In Section I, paragraph (b) of Circular 35, O. C. S.,June 13,1918, the following statement is made regarding records of mental cases:
It is very important that mental cases be accompanied by records in whichthe circumstances under which their condition came to notice are fully stated.It is obvious that, without such information, the medical officers who have theresponsibility of dealing with these cases will often have difficulty inarriving at a diagnosis or in making suitable recommendations for theirdisposition.
These instructions are being generally neglected with the result that thework of the medical officers in the psychiatric departments is unnecessarilyrendered more difficult. Mental cases come from divisions with no record excepttheir diagnosis cards. In some cases these patients have had general courtcharges preferred against them without notations to indicate it. Others havemade suicidal attempts or threats, but without any record of these facts theycan not be properly classified until observation at the hospital has revealedthem.
6. Disability boards will not reclassify mental cases or those withpsychoneuroses. This will be done by the neuropsychiatric disability boardswhich have been established at each psychiatric department and at BaseHospital No. 214 (neuropsychiatric hospital).
WALTER D. McCAW,
Colonel, Medical Corps, Chief Surgeon
PERSONNEL
OFFICERS
SOURCES
When the neuropsychiatric service was organized in the American ExpeditionaryForces medical officers with neuropsychiatric training were widely scatteredamong the organizations there; but the names, assignments, and qualifications ofthose available for professional work in the field had been ascertained by thesenior consultant in neuropsychiatry. This was done by examining the personnelrecords in the chief surgeon's office and by correspond-
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ence with commanding officers of the base hospitals and withdivision surgeons. By the end of January, 1918, the location of about 20 suchofficers had been ascertained and they had been graded into the following threegroups with reference to their training and experience: (a) Those who could beintrusted with important duties in their specialty without supervision. (b) Thosewho, on account of their less thorough training or other reasons, could beutilized as assistants but not placed in charge of the work to be performedindependently. (c) Those who had had so little experience and trainingthat it was inadvisable to use them as specialists.
The most fruitful sources from which these officers wereobtained were base hospitals organized from important medical centers in theUnited States which had come overseas shortly after war had been declared by us.Each of these hospitals had as a member of its staff a neuropsychiatrist who, inmany instances, had been professor of neurology and psychiatry in the universityand a director of those services in the teaching hospital at home from which themilitary hospital had been organized. Other sources were the medical officersstudying the treatment of war neuroses in England and those scattered throughoutvarious organizations where special training could not be well utilized. Planswere made at once to have these officers reassigned to posts where they could bemost useful. It was from the seven officers on duty in England that the firstfour division psychiatrists, the first commanding officer of Base Hospital No.117, and its first medical director were obtained. An effort was made also tosecure a roster of nurses and enlisted men who had had experience in thetreatment of mental patients.
During March, April, and May, 1918, with the advent of manyadditional base hospitals from the United States and the construction ofhospital centers, the organization of the professional services in hospitals inaccordance with the general plan which formed the basis for Circular No. 2,chief surgeon's office, A. E. F., November 9, 1917, became necessary.^e It wasnot difficult to make the reassignments required to provide consultants inneuropsychiatry for nearly all hospital centers. As the personnel to staff newhospitals arrived from the United States the neuropsychiatrist attached to eachwas communicated with or visited by the senior consultant in neuropsychiatry andthe general plan for the care, treatment, and evacuation of mental and nervouspatients explained to him. Such officers differed in their special experienceand training and reassignments were made so that, in general, younger men couldbe detached to serve with troops and those qualified for particular tasks couldbe assigned to them.
The personnel was augmented continually from newly arrivedtactical divisions and hospital units, each with its attached neuropsychiatricspecialists. An unexpected increase in personnel was due to the fact thatevacuation hospitals arriving after the first of August, 1918, each had aneuropsychiatrist attached.²³Since it was not practicable for suchofficers to perform very useful work in the evacuation hospitals under the planof action in the theater of

^eConsult Chap. XVIII, Vol. II, of the history for full details concerning the professional services, A. E. F.

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operations, they were immediately detached and made availablefor other duties. All these sources, however, were inadequate to meet increasingneeds, consequently there were organized in the United States twoneuropsychiatric replacement units of officers, nurses, and enlisted men, allnot only with civil experience in neuropsychiatry but, by that time, with a gooddeal of military training.²⁴Upon their arrival in France they wereimmediately distributed to the different stations in most urgent need, thusincreasing very greatly the usefulness of available neuropsychiatric facilities.There were certain losses of personnel, fortunately, however, few through deathor illness. In order to meet the need for better care during oceantransportation, officers and enlisted men with neuropsychiatric training weredetached from the American Expeditionary Forces to accompany home convoys ofmental patients. Few of these officers or enlisted men returned. It was alsonecessary to release a few officers for general work because they had shown lackof aptitude for the highly specialized tasks that they were called upon toperform. On the other hand, the high administrative capacity of manyneuropsychiatrists who had held responsible positions in civil life made theirservices sought after for executive posts in the American Expeditionary Forces.
TRAINING
The neuropsychiatric work of the American ExpeditionaryForces covered such a wide field that it was possible to make assignments withreference to the special types of training and ability which medical officerspossessed. In general those whose training had been chiefly psychiatric wereassigned to tactical organizations and to hospitals and departments establishedfor the care of mental patients, while those whose training had been chieflyneurologic served as consultants in general base hospital centers. Although itwas one of the outstanding features that neurologists and psychiatrists sharedeach other's duties, responsibilities and point of view to an extent that hadnever existed in civil life, and that the new terms "neuropsychiatry"and "neuropsychiatric" came to have ample justification for their use,it was true, nevertheless, that relatively few medical officers possessed equalqualifications in both these fields. Psychiatrists who had had years ofexcellent training and experience in dealing with mental diseases,psychoneuroses and conduct disorders did not possess the background ofneuroanatomy, neuropathology, and clinical neurology required to deal with theorganic injuries and diseases of the brain, spinal cord, and peripheral nervesthat contributed so many interesting and perplexing questions in diagnosis andtreatment in the base hospitals. On the other hand, many neurologists haddevoted themselves so exclusively to these subjects that they wereinsufficiently prepared to care for patients with acute mental diseases and toapply with much conviction some of the psychological viewpoints upon which thetreatment and prevention of the war neuroses were largely based. During thestrenuous weeks that intervened between the unexpected entry of the Americandivisions into active fighting in May, 1918, and the armistice, little timecould be given to formal medical training. It was intended to remedy this defectduring the winter when neurological training would be afforded for
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psychiatrists and psychiatric training for neurologists. Inthe specialists arriving late in the summer and fall of 1918, however, there wasstriking evidence of results of the breadth and soundness of the training thathad been carried on in the United States in the courses offered at the variousneuropsychiatric centers such as the Michigan Psychopathic Hospital, Ann Arbor,Mich.; Boston State Hospital; Neurological Institute, New York City;Philadelphia General Hospital; Phipps Psychiatric Clinic, Baltimore, Md.;Government Hospital for the Insane, Washington, D. C.; Manhattan State Hospital,New York City.²⁵ These men were indeed neuropsychiatrists; otherswould have been had those who came to the American Expeditionary Forces early inits existence had the opportunity during the winter of 1918-19 to availthemselves of similar educational opportunities. Regular courses for medicalofficers, nurses, occupational aides, and enlisted men were established at BaseHospitals No. 117¹⁰ and No. 214.¹³ A two weeks' course was arranged at American RedCross Hospital No. 1 at Paris where, with the cooperation of French neurologicalclinics, there was an excellent opportunity for the study of brain andperipheral nerve injuries.
ASSIGNMENT
From the beginning the chief surgeon trusted the seniorconsultant in neuropsychiatry, as was the case with other senior consultants, tomake such recommendations as were needed to use the neuropsychiatric personnelto the best possible advantage. Almost without exception, the recommendations ofthe senior consultant in neuropsychiatry were promptly put into effect by anofficial order. There was, unfortunately, one important obstacle-the refusalof commanding officers to grant their approval. Entirely in the interests ofharmony and cooperation, the senior consultant had established the custom ofasking commanding officers in advance if they would approve his making suchrecommendations. It was apparent that the special work for which he was directlyaccountable to the chief surgeon would fail if this custom was continued and ifsmall needs rather than larger issues governed the distribution of personnel. OnJuly 28, 1918, the senior consultant brought this important matter to theattention of the director of professional services,²⁶whereupon hewas given practically free disposition of the neuropsychiatric personnel, and nofurther difficulties, such as those outlined above, were experienced.
PSYCHIATRIC NURSES
As explained in Section I of this volume, the NationalCommittee for Mental Hygiene, at the request of the Surgeon General of the Army,secured a large part of the neuropsychiatric nursing personnel for the Army. Inthe original selection of these nurses, made in the first year of America'sparticipation in the war, only persons were selected for psychiatric nursingservice in the American Expeditionary Forces who had had training and experiencein caring for nervous and mental cases. Applicants were investigated carefullyand only those highly recommended for the service were accepted. After extensivecorrespondence and other lines of inquiry a group of 46 nurses finally wasobtained for duty in the American Expeditionary Forces.
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Until June 8, 1918, when the first contingent of speciallyobtained nurses arrived in France,¹⁰ neuropsychiatric nursing in theAmerican Expeditionary Forces was done by a few nurses selected from among thegeneral nursing personnel. These were usually women who had had previousexperience in special hospitals for nervous and mental diseases, or in wards forthese cases in general hospitals. In addition to the 46 nurses referred to, 20more were added to the unit at the time it sailed for France. These 66 nurseswere assigned for the most part at Base Hospital No. 117, but some were left atBase Hospital No. 8, at Savenay, and others were sent to psychiatric departmentsof hospital centers throughout France.
After the arrival of the unit designated Base Hospital No.117, neuropsychiatric nursing was taken over as much as possible by speciallytrained nurses. Throughout the summer, the neuropsychiatric nursing personnelwas increased in number by the addition of those sent from the United States intwo psychiatric replacement units.

LIAISON WITH THE DIVISION OF NEUROLOGY AND PSYCHIATRY, SURGEON GENERAL'S OFFICE

Liaison with the division of neurology and psychiatry in theSurgeon General's Office was maintained by personal communication in the formof letters and cables between the chief of the division of neurology andpsychiatry, in the Surgeon General's Office, and the consultant inneuropsychiatry, A. E. F. This informal method was first approved by the chiefsurgeon but the restriction of censorship was a formidable barrier.
One of the most valuable aids which the neuropsychiatric workin France obtained during the war came through the visit made by the chief ofthe division of neurology and psychiatry in the Surgeon General's Office. Histemporary assignment to the American Expeditionary Forces was recommended by thesenior consultant to the chief surgeon, A. E. F., on June 18, 1918, in thefollowing letter:²⁷
1. The extensive plans being made in the United Statesfor continued care and social and industrial rehabilitation of disabledreturning soldiers do not in all cases provide for direct continuity betweenmanagement here and at home. It is essential that those responsible for thiswork in the United States be closely in touch with what is done here andfamiliar with the views of those who care for our soldiers during the earliestphase of their illness or disability.
2. This is particularly true in the case ofthe war neuroses and of some forms of mental disease. In their thousands of chronic nervousinvalids resulting from the war-most of them young men-England and Canadahave medical and social problems that will remain unsolved long after the warhas ended. The presence of these men in the homes and in the industrial andsocial life of the community cannot fail to affect unfavorably the mental healthof those who are in daily contact with them. The gravity of this situation isnow being recognized and the Military Commission of Pensions in England andthe Military Hospitals Commission in Canada are making belated efforts to bringagain under treatment, with the object of reclaiming them, the thousands ofsoldiers who were discharged from the army before they had received adequatetreatment and who in consequence remain unrecovered.
3. These considerations indicate the need forthe closestliaison between this office and the division of neurology and psychiatry inthe United States, especially since the Surgeon General's Office has becomethe rallying point for the many official and unofficial agencies that haveinterested themselves in the various phases of reconstruction work amongsoldiers. It
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is suggested, therefore, that it be indicated totheSurgeon General that it would be agreeable to have Col. Pearce Bailey ordered toFrance and England for a short period of observation of neuropsychiatry work inexpeditionary troops.
4. It is believed that nothing will contribute more to closecooperation in this field than the personal contact with the actual problems inmental medicine in the American Expeditionary Forces that such a tour of dutywould provide.
The medical officer concerned visited England first and spentJuly, August, and part of September in the American Expeditionary Forces. He wasable to visit the French neuropsychiatric hospitals and training centers whichthe senior consultant in neuropsychiatry, A. E. F., had been unable to see onaccount of a great pressure of work. The report to the chief surgeon which thechief of the division of neurology and psychiatry rendered, September 5, 1918,on his observations, with his recommendations for the American ExpeditionaryForces, is as follows:

MANAGEMENT OF WAR NEUROSES BY THE FRENCH
Connected with each army the French have a neurologicalcenter which has a capacity of from 100 to 200 beds. The capacity should be inthe ratio of 1.5 beds to 1,000 troops. This army center is located or should belocated with one or two hours motor transport distance from the front. It has three medical officers who have had experience at the front.
The patients, transported as promptly as possible after thedevelopment of symptoms, are placed first in a receiving ward where they arecarefully examined and then sent to different wards, classified as far aspossible in relation not only as to their injury but also as to theirpersonality, the hysterical and malingering types being kept apart from theothers.
The character of the disabilities varies with the activity ofthe sector which the center serves. For example in quiet sectors these centersreceive large numbers of cases of rheumatism, sciatica, etc., while in activesectors the true commotioned cases are in the majority.
The method of treatment and management varies with the classof cases. The true commotionn? is treated with all sympathy and kindness. He iskept in bed until he feels able to get up, which is generally within a week, andis then treated as a convalescent until he leaves, which is ordinarily withintwo or three weeks. Quite a different course is taken toward the emotionn?, ortoward the commitionn? who shows signs of developing neurotic symptoms. Sucha patient is given to understand at once that such symptoms as trembling,failure to move a limb or portion thereof, deaf mutism, etc., are notsymptoms of disease but rather failure in will, a defect in character, thatpersistence in the demonstration will cause the man to be regarded as amalingerer, which will eventuate in his punishment, perhaps by court-martial.Two forms of punishment are available to the neurologist at the center itself.One of these is the threat that the "permission" or leave, to whichevery French soldier is entitled after discharge from the hospital, will betaken away from him if he persists in functional symptoms. He will not beallowed to go home, he is told, but will be returned directly to the front. Theother form of punishment is solitary confinement. The soldier presentinghysterical symptoms is put in a room by himself, locked in, and is notpermitted to read, write, or smoke. He is told that the trouble with him is inhis will and that the best way to recover the will is by silently reflecting inthe dark. In addition to these means of combating the outbreak of hystericalsymptoms, electricity with persuasion is used or the rougher quick method ofsuddenly turning on strong electric currents in the region of the part showingsigns of defaulting function. By these various measures the French maintain thatit is not necessary to send many functional cases back to the interior. Certaincases of true commotionn? who do not recover in the army centers are sent tothe interior for further treatment or convalescence. All organic cases areevacuated to the interior as rapidly as possible.
Different methods are required in the neurological centersof the interior than of the advance. The medical point of view regarding theneuroses is no different, but the patients are under a less rigid control thanin the army centers and more easily accessible to their
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friends, to civil inspection, etc. The neurological centersof the interior are organized as regional, there being 20 regions in France.These centers are complete neurological hospitals, with wards for organic aswell as for surgical cases. In some centers, as at Besancon, the surgical casesare sent to another hospital for operation. In others, as at Lyons, the centerhas a surgical service of its own.
The management of the neuroses in these interior centersvaries considerably with the personality of the director. As a rule, while thereis no different point of view regarding the neuroses than is entertained in thearmy centers, the brusque methods employed near the front have been found lesspractical in the regional centers. Relaxation of discipline, proximity offriends, popular disapproval, etc., explain this. Torpillage, or the suddenelectrization of affected part, is still made use of and is said to produceimmediate cure, but may bring the physician who employs it into trouble.
The most successful of these interior centers, as far as theneuroses are concerned, is the one at Salins. It is remote. The patients arecarefully prepared by various suggestions before they are treated. This stage ofpreparation is extended for several days or weeks, the patients being kept asmuch as possible in company with patients who have already been cured. Thetreatment itself, consisting of persuasion with mild faradization, is completedat one sitting, the sitting requiring from a few minutes to several hours. Whenthe local hysterical manifestation is removed the patients are held in thecenter for two or three weeks, are daily encouraged and made to do exercises andare also made to do such work as farming and carpentry.
The organization at Salins is very carefullythought out andskillfully conducted, but not the least good point about it is the militarytraining which follows the cure. This is conducted at a camp at the foot of themountain peak where the hospital is located. The camp is under the command of acaptain of infantry, wounded and not fit for field service, who is in fullsympathy with the physician of the hospital. The patients on coming from thehospital are grouped in accordance with their capacities. About two-thirds aredrilled with arms and are trained again for full field service. The balance,who will only see service at the rear again, are given hikes and calisthenics.To the evident advantage of training as an after cure the camp offers thephysician the opportunity of seeing his graduates daily, of watching theirprogress in resuming their military careers, and in immediately becomingcognizant of relapses. These occur not infrequently in the camp and then thepatient is taken up on the mountain again and is put in solitary confinementbefore being re-treated. Second relapses are said to be exceedingly rare.
It would seem that the training camp, under the commandof a well-selected line officer, offers the only means of accurateclassification of cases of neuroses which have been hospitalized. Unlesspatients of this class are tried out for several weeks before they are sent toline duty great errors in the evaluation of their capacity are bound to occur.And if they are returned a second time from full duty the chances for theircomplete restoration are very poor.
The French method of handling the neuroses of war hasdoubtless been of great service not only to the army but also the patientsthemselves. As far as the army is concerned, a very large percentage has beenreturned to the line. It is true than many are still to be found in theinterior hospitals who have resisted the treatment of the army centers, butthese are still in the military service and so even now have a better chance ofrecovery than if they had been discharged from the army. Even cases of longstanding, of two or three years, are successfully treated and returned at Salins. It is not true that these patients recover when discharged from thearmy, in the sense that the condition was due to a wish to be out of the war.The many disabled neurotics among discharged British soldiers teach quite thecontrary.

SUGGESTIONS FOR AMERICAN EXPEDITIONARY FORCES
Everything seems to point to our soldiers developing neurosesto a degree even greater than has occurred among the British unless specialmeans are taken to prevent. The conditions of American life have been such thata young man suddenly taken from surroundings where he more or less always hadhis own way, where obedience was never necessary, where he was taught that hewas the equal of every one, suddenly taken from surroundings of that
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character and forced to obedience, forced also to face allthis war has of horror, it would not be surprising if he showed his reaction tothe change by developing a neurosis if he were given a chance. Frenchneurologists with whom I have talked have spoken of the excessive nervousnessof American soldiers who have been under their care.
It would seem then that we should profit as far as we canfrom the experience of the French in this matter. Check the development ofneurosis by denying its existence at the start. Each army should have its owncenter of a capacity of at least 1? beds to each 1,000 troops. It should keepits patients two or three weeks if necessary, and should be entirelyindependent of any hospital of the communication or base.
The treatment of the patients should be calmative andrestorative and any appearance of such symptoms as tremors, paralysis, etc.,should be rigidly discouraged. This idea should run through the whole personnelof the hospital. At first it should be effected by gentle persuasion, but if thepatients persist in the production of hysterical symptoms sterner measuresshould be resorted to. It is not considered desirable to send patients of thisclass to convalescent camps. It would be better for them to have leaves, and thethreat to cut off the leave might persuade many to suppress the self-indulgencewhich is so often the neurosis and give up his symptoms. Isolation and strongfaradization might also be employed with advantage at this stage.
Those patients should be held at the army hospital with thegreatest tenacity. The chances of their permanent military recovery is reducedthe moment they are sent back. It is strongly recommended that none ofthis class be returned to America until after the war. The influence of the homecountry would make it extremely difficult to organize a hospital service wherethese cases could be properly treated, and there would be small hope of everfitting the patients again for military duty. And the fitting for military dutyis the one means of effecting a satisfactory cure. A neurosis which has lastedfor a year or more has established a habit which persists, or is prone to, afterthe cause is removed. This is shown by the numbers of permanently (or apparentlypermanently) disabled men to-day, discharged from the army in England andCanada.

DISABILITY BOARDS
Following the promulgation of General Orders, No. 41, G. H.Q., A. E. F., March 14, 1918, which governed the physical classification of thepersonnel of the American Expeditionary Forces, it proved necessary to havespecial procedures in the care of officers and men suffering from mental andnervous diseases. Accordingly, on April 23, 1918, the chief surgeon, A. E. F.,issued the following circular letter:
CIRCULAR No. 24
AMERICAN EXPEDITIONARY FORCES,
France, April 23, 1918.
Disability boards passing upon mental and nervous cases underSec. I, G. O. 41, G. H. Q., A. E. F., March 14, 1918, will, as far as practicable, begoverned by the following considerations.
GENERAL
In dealing with these cases, there should be borne inmindtheir chronicity, the probability of recurrences or acute episodes inconstitutional disorders, and the bearing which abnormal mental states haveupon questions of responsibility. The special mental stresses of modern warfareand the fact that the safety of many soldiers often depends upon the conduct ofone of their number should be given due weight in considering the fitness of menwith mental or nervous diseases for service at the front. At the same time theimportance of utilizing, in any safe and suitable way, the services of menpartially incapacitated should not be overlooked. The essential question forboards to decide is usually whether, taking all the facts into consideration,the individual before them will be an asset or a liability to the ExpeditionaryForces. Whenever possible a psychiatrist or a neurologist should act as onemember of a board passing upon mental cases.
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PSYCHOSES (INSANITY, MENTAL ALIENATION, MENTAL DISEASES)
All officers and enlisted men in whom frank psychosesexist should be marked "D" and returned to the United States as soon as this can be done without injury or endangering their chances ofrecovery. It will often be advantageous to hold these cases in the psychiatricdepartments of base hospitals at base ports until acute and severemanifestations have passed or, in cases of an especially favorable type, untilrecovery has taken place, but it should not be made the practice to provideextended treatment in hospitals in the American Expeditionary Forces.
In exceptional eases where it seems desirable to depart fromthe rule of returning to the United States soldiers who have or who have hadpsychoses, the patients may be classified "B," and the specialconsiderations which make a departure from the rule desirable must be noted on the report card.

MENTAL DEFICIENCY (FEEBLE-MINDEDNESS, DEFECTIVE MENTAL DEVELOPMENT)

The existence of a readily demonstrable degree of mentaldeficiency should almost invariably be sufficient reason for not classifyingsoldiers as "A," but it should by no means be regarded as sufficient reason in itself for placing them in class "D." In recommending mentally defective soldiers for duty in labor organization atthe rear, especial weight should be given to good physique, emotionalstability, and freedom from such delinquent traits as alcoholism, dishonesty, nomadism, and the like. Military delinquents, of whom the mentallydefective constitute a large proportion, are a source of almost as muchnoneffectiveness as illness and it is important that the Expeditionary Forcesshould not be burdened with their care and supervision. Defective delinquentsshould always be classified "D."

CONSTITUTIONAL PSYCHOPATHIC STATES

In making recommendations as to the disposition ofsoldiers found to have constitutional psychopathic states, the considerationsmentioned under the preceding heading should govern. Itshould be remembered that many individuals with volitional defects are amenable tomilitary control. Conditions which should usually indicate thewisdom of returning these cases to the United States are marked emotionalinstability, sexual psychopathies (homosexuality, etc.), paranoid trends, and specificcriminalistic traits. These cases should be classified"D." Excessive fear or timorousness should prevent return to duty atthe front. For military reasons it is especially undesirable, however, toreturn such cases to the United States. They should be recommended for dutyin labor organizations and marked "C."
EPILEPSY
Epileptics should be classed "D," theonlypossible exceptions to this rule being individuals in robust physical healthwho have attacks of moderate severity at long intervals and those in whomtreatment has had this result.
In making the diagnosis of epilepsy the fact should be bornein mind that attacks are likely to be less frequent in the favorableenvironment of the hospital while observation is being carried on than in theorganizations from which patients are received. Great weight should begiven to a well-authenticated history of epileptic seizures, especially whenwitnessed by medical officers or other persons who can give a clear account oftheir character. While the possibility of malingering should notbe overlooked, it should be remembered that attacks similar to those inepilepsy are much more frequently psychoneurotic in their nature than feigned. The high prevalence of epilepsyamong soldiers should be remembered.
DRUG ADDICTION AND ALCOHOLISM
These conditions are essentially curable. Inebriatesanddrug addicts should not be recommended for return to the United States with aview to their discharge until they have failed to respond to adequatetreatment. Then, their disposition should depend upon the type of personalitypresented, the effects of alcohol or drugs in physical deterioration or
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damage to the central nervous system, and theconditionsto which they will be exposed when they are returned to duty. It will often be foundthat these cases do better at the front than in duty at the rear.
PSYCHONEUROSES (HYSTERIA, NEURASTHENIA,PSYCHASTHENIA)
These conditions must be dealt with as disordersamenableto treatment under proper conditions. Individuals who fail to benefit from suchtreatment in the special hospital which has been provided, either becauseof severe defects in make-up or on account of previous mismanagement,should be returned to the United States for continued treatment unless it seemslikely that good results can be obtained from their assignment to duty at the rear.A very large proportion of the severe neuroses seen in war areof the "situation type," rather than psychoneurotic manifestationsin persons who have had many previous episodes of the same kind in civillife.
These instructions had the effect of amending or at leastinterpreting General Orders, No. 41. It was one thing to determine upon such apolicy, however, and another to put it into effect. On account ofmisunderstanding what was contemplated, a good many disability boards in basehospitals passed upon the neuropsychiatric patients before evacuating them tothe hospital center at Savenay. This was done for several reasons besidesmisunderstanding the intent of the order. One technical difficulty came from therequirement by the commanding officers of some base hospitals of the approval ofa disability board before authorization of the travel necessary to take thepatients to the base port. In addition, many mild cases of psychoneurosesrecovered in interior hospitals and were deemed fit for class A duty. Thesecould not be discharged to duty without review by a physical classificationboard, and it seemed unwise to delay it. It is interesting to see how frequentlyindividual opinion tended to govern in these matters and thus defeat a generalpolicy. In one large hospital center the commanding officer formed theapparently fixed opinion that no soldier who had ever developed psychoneuroticsymptoms was fit for military duty in any capacity in France. In consequence hehad ordered disability boards at that center to classify all such patients D andsend them to the hospital at Savenay for evacuation to the United States. Whenit is remembered that a large proportion of all men who broke down at the frontand were treated at army neurological hospitals returned to duty without everhaving left the theater of operations,²⁸and that 91 per cent of allpatients treated at Base Hospital No. 117 were there reclassified for some typeof military duty in France,¹⁰ it can be seen how untenable such anopinion was. These difficulties were largely overcome later through theintervention of the consultants for the hospital centers. These consultantsinterested themselves very actively in the question, served on, or examinedcases for, disability boards, or gave opinions which helped to put theprovisions of Circular Letter No. 24 into practical effect. At the firstreplacement depot established at St. Aignan-Noyer by the 41st Division a verylarge proportion of all reclassified men received in the early activities of theAmerican Expeditionary Forces came before disability board No. 1.²⁹ From May1 to December 31, 1918, 27,437 men appeared before that board, of whom 9,256were classified A.²⁹
The 41st Division was provided with a division psychiatristupon its arrival in France, but it soon became apparent that he would requireadditional
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aid as the reclassification work of the division increased.During the summer of 1918 a neuropsychiatrist was detailed as chairman of thedisability board and, with several assistants, he organized extremely effectiveand practical methods of neuropsychiatric examination and reclassification. Thefollowing report from the medical officer who was in charge of theneuropsychiatric department of Base Hospital No. 8, dated July 9, 1918,indicates the general principles which from that time on governed thereclassification of neuropsychiatric patients at that base port:³⁰
I. In accordance with verbal request, the generalprinciple governing this disability board, with respect to line of duty innervous and mental diseases, is submitted.
The following cases are considered not in line of duty:
1. Psychosis in men who have had a well-establishedpsychosis previous to enlistment.
2. Psychosis in men so psychopathic in constitution that thepsychosis represents merely an episode in a constitutionally psychopathicindividual.
3. Psychoneuroses which were well established beforeenlistment and did not arise as the result of military service.
4. Epilepsy in men who have had well-established epilepsyprevious to enlistment.
5. Mental deficiency.
6. Constitutional psychopathic states in men who have alife history of associated alcoholism, criminal tendencies, and delinquencies.
II. Cases considered in line of duty:
1. All psychoses developing since enlistment, presumablyas the result of military service, without established histories of previousattacks.
2. Epilepsy, with first history of well-established epilepticseizures, occurring since enlistment and presumably as the result of militaryservice, such as traumatic cases, shock, and others.
3. Psychoneuroses (hysterical states, neurasthenia, anxietystates, and others) in which the condition developed since enlistment,presumably as the result of military service.
4. Other diseases of the nervous system-such conditionsas toxic neuritis, traumatic cases, affecting the nervous system-areconsidered in line of duty, unless well-established histories indicate theirpresence previous to enlistment.
III. In a number of cases of syphilis of the central nervoussystem the board has had difficulty in deciding the question of line of duty.These are cases in which the time of the initial infection is unknown and inwhich the invasion of the central nervous system occurred since enlistment andwhere military service may have been an important etiological factor.Instruction is desired as to proper procedure in such cases.
IV. The above general principles are followed and applied toeach individual case, in accordance with the history as established. Inacute psychoses the cases are considered in line of duty when the historyof a previous attack can not be established.
The total work of neuropsychiatrists in connection with theseboards throughout France was very great and represented an extremely usefulcontribution which was not without its effect in the work of rehabilitatingex-service men after the war.
There was established at Blois, in the summer of 1918, anofficers' classification and efficiency board.³¹Here manyperplexing problems were dealt with. The officers who came before this board hadhad no charges preferred against them nor had they been suspected of any mentalor physical disability. They had been judged unfit for combat duty, and theywere to be reclassified and assigned to duty in the Services of Supply. It wassoon apparent that there were cases coming to attention in which the onlyexplanation of serious impairment of judgment, lack of self-control, or decreasein efficiency was
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some form of mental disorder. In several instances the suicide of officersoccurred after they had been reclassified, usually through demotion, by thisboard. Accordingly, a medical officer who had had nearly two years' experiencein the study of war neuroses in British war hospitals and was at the timeserving as division psychiatrist in the 1st Division, was assigned to thisboard, not as a member but as consultant in neuropsychiatry. He reported forduty in November, 1918, and continued his work until January, 1919. His reportsshowed that such a detail was well justified and he was able to bring to theattention of the board a considerable number of cases, some of them officers ofhigh rank, in whom there were definite but quite unsuspected evidence of mentalor nervous diseases. In not a few such instances the result of the board'sinvestigation was the transfer of officers to neuropsychiatric hospitals andtheir evacuation to the United States for retirement or discharge on a surgeon'scertificate of disability.
REFERENCES

(1) Letter from The Adjutant General to the Surgeon General, January 12, 1918. Subject: Assignment of neurologists to tactical divisions. Copy on file, Historical Division, S. G. O.

(2) G. O. No. 81, H. A. E. F., December 24, 1917.

(3) Letter from the chief surgeon, A. E. F., to all division surgeons, September 8, 1918.
Subject: Psychiatrists, neurologists, and ophthalmologists in tactical divisions. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(4) Outlines of Histories of Divisions, U. S. Army, 1917-1919, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College.

(5) Station lists for medical officers assigned to the neuropsychiatric service, A. E. F.

(6) Letter from the chief surgeon, A. E. F., to the Surgeon General, February 23, 1918. Subject: Hospitalization data. On file, Record Room, S. G. O., 322.3 (Med. Dept. Units, France).

(7) History of Base Hospital No. 66, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.

(8) Letter from the director of neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., February 27, 1918. Subject: Neuropsychiatric department, standard base hospital group. On file, Historical Division, S. G. O.

(9) Letter from the director of psychiatry, A. E. F., to the chief surgeon, A. E. F., February 10, 1918. Subject: Use of Camp Hospital No. 4 for treatment of war neuroses. Copy on file, Historical Division, S. G. O.

(10) History of Base Hospital No. 117, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.

(11) Letter from the senior consultant in neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., September 14, 1918. Subject: Second hospital for war neuroses. Copy on file, Historical Division, S. G. O.

(12) Weekly bed reports, chief surgeon's office, A. E. F. On file, Historical Division, S. G. O.

(13) History of Base Hospital No. 214, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.

(14) Monthly returns of the American Expeditionary Forces, made to The Adjutant General of the Army.

(15) History of Base Hospital No. 8, A. E. F., by Lieut. L. G. Payson, S. C. On file, Historical Division, S. G. O.
(16) Letter from the director of psychiatry, A. E. F., to thechief surgeon, A. E. F., February 1, 1918. Subject: Recommendations for the care of mental cases. Copy on file, Historical Division, S. G. O.

(17) History of Base Hospital No. 216, A. E. F., by the commanding officer of the hospital. On file, Historical Division, S. G. O.
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(18) Letter from the senior consultant in neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., October 28, 1918. Subject: Provisions formental cases at Savenay. Copy on file, Historical Division, S. G. O.

(19) Report of Medical Department activities, Base Section No. 5, A. E. F., undated, compiled under the direction of the base surgeon from official records in his office. On file, Historical Division, S. G. O.

(20) Report of special hospital provisions for mental and nervous cases in the Services of Supply, A. E. F., made by the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., October 26, 1918. Copy on file, Historical Division, S. G. O.

(21) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., November, 1918. Subject: Return of mental cases to the United States. Copy on file, Historical Division, S. G. O.

(22) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., November 28, 1918. Subject: Modification of plans for care of neuropsychiatric cases. Copy on file, Historical Division, S. G. O.

(23) Tables of Organization (Medical Department). On file, Record Room, S. G. O., 320.3-1 (Table Organ).

(24) Report of the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., for the period embracing the beginning and end of American participation in hostilities, December 31, 1918. On file, Historical Division, S. G. O.

(25) Correspondence. On file, Record Room, S. G. O., 353 (Training neuropsychiatrists).

(26) Letter from the senior consultant in neuropsychiatry, A. E. F., to the director of professional services, A. E. F., July 28, 1918. Subject: Approval of commanding officers for orders, neurologists and psychiatrists. Copy on file, Historical Division, S. G. O.

(27) Letter from the senior consultant in neuropsychiatry, to the chief surgeon, A. E. F., June 18, 1918. Subject: Observation by Colonel Pearce Bailey, of neuropsychiatric work in France and England. Copy on file, Historical Division, S. G. O.

(28) Final report of the chief surgeon, First Army, November 20, 1918. On file, Historical Division, S. G. O.

(29) Report of the president of Disability Board No. 1, First Replacement Depot No. 1, St. Aignan-Noyers, December 31, 1918. On file, Historical Division, S. G. O.

(30) Letter from Maj. Sanger Brown, II, M. C., to the senior consultant in neuropsychiatry, A. E. F., July 8, 1918. Subject: Line of duty, disability board, neuropsychiatric cases. Copy on file, Historical Division, S. G. O.

(31) G. O. No. 131, G. H. Q., A. E. F., August 7, 1918.
RETURN TO TABLE OF CONTENTS

	Admitted	Returned to U.S.
July	405	348
August	588	601
September	887	585