CHAPTER II
DIVISION, CORPS, AND ARMY NEUROPSYCHIATRICCONSULTANTS
In the earliest recommendations for combating war neuroses inthe American Expeditionary Forces the greatest emphasis was placed upon the workcarried on in the divisions. The experience of the French and British medicalservices showed, within a very few months after the beginning of the war, thatpatients with war neuroses improved more rapidly when treated in permanenthospitals near the front than at the base, better in casualty clearing stationsand postes de chirurgie d'urgence than even at advanced base hospitals, andbetter still when encouragement, rest, persuasion, and suggestion could be givenin a combat organization itself. It was for the purpose of applying thiswell-established fact that plans were made to station a medical officer withspecial training in psychiatry and neurology in each combat division, since thedivision was to be the great combat unit of the American Army in France. It wasdeemed impracticable to consider detailing a consultant in neuropsychiatry to acombat unit smaller than the division.
Corps and army consultants in neuropsychiatry ordinarily hadmerely organizing and supervisory functions. The actual neuropsychiatric workwith combat organizations in the theater of operations was done by the divisionpsychiatrist and such enlisted personnel as were assigned to assist him.
DIVISION PSYCHIATRISTS
Immediately after the authorization by the War Department of theassignment of specialists in nervous and mental diseases to tactical divisions,as detailed in Chapter I, p. 273, the chief surgeon, A. E. F., issued thefollowing circular outlining the duties of these medical officers:
CIRCULAR No. 5-DUTIES OF MEDICAL OFFICERSDETAILED AS PSYCHIATRISTS IN ARMY DIVISIONS IN THE FIELD
HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
OFFICE OF THE CHIEF SURGEON,
France, January 15, 1918.
1. The following outline naturally does notindicate all the means by which medical officers detailed as psychiatrists inarmy divisions in the field can be of service in dealing with the difficultproblems arising in the diagnosis and management of mental and nervous diseasesamong troops. These officers are under the direction of the chief surgeons ofthe divisions to which they are attached, and they must be prepared at all timesto render such services as he may require. These officers are not members ofdivision headquarters staff. They are attached to the sanitary train.
2. It is essential for such officers to bearin mind the prime necessity of preserving, or restoring for military duty, asmany as possible of the officers and enlisted men who may be brought to theirattention. On the other hand, they should recommend the evacuation, with theleast practicable delay, of all persons likely to continue ineffective or toendanger the morale of the organizations of which they are a part. This isparticularly true in the
304
case of the functional nervous disordersloosely grouped under the term "shell shock" but more properlydesignated as war neuroses. Psychiatrists detailed to this duty have a uniqueopportunity of limiting the amount of ineffectiveness from this cause and ofreturning to the line many men who would become chronic nervous invalids if sentto the base. At the same time they can bring to the attention of other medicalofficers and company commanders individuals who possess constitutional mentaldefects of a type which make it certain that they will break down under stress.
3. Specific duties which may be performed bypsychiatrists in army divisions are as follows:
(a) Examine allofficers and men under observation or treatment for mental or nervous diseasesin regimental infirmaries, field hospitals, camp infirmaries, and other places,and to advise regarding their diagnosis, management, and disposition.
(b) Examine othermental or nervous cases in the divisional areas when directed to by the chiefsurgeons or requested to by other medical officers or company commanders.
(c) Examine and givetestimony regarding officers and men brought before courts-martial or underdisciplinary restraint, when directed or requested by competent authority.
(d) Give informalclinical talks to groups of medical officers in the divisions to which they areattached upon the nature, diagnosis, and management of the mental and nervousdisorders peculiar to troops.
(e) Keep carefulrecords of all cases examined.
(f) Make suchreports to the chief surgeons of divisions as they require and to make monthlyreports of their operations to the director of psychiatry, bringing especiallyto his attention any matters likely to increase the efficiency of this part ofthe medical work of the American Expeditionary Forces.
A. E. BRADLEY,
Brig. Gen., N. A., Chief Surgeon.
Approved:
By command of General Pershing:
J. G. HARBORD,
Chief of Staff.
The duties outlined in Circular No. 5 were amplified in certain respects, byCircular. No. 35,a as follows:
They will examine enlisted men brought beforegeneral courts-martial as provided by W. D. order of March 28, 1918. They willalso examine all other military delinquents brought to their attention,especially those in whom self-inflicted wounds or malingering is suspected.Except under exceptional circumstances, no cases of this kind will be evacuatedto the rear until examined by the division psychiatrists. In the case ofprisoners accused of crimes the maximum punishment of which is death, thedivision psychiatrist should, whenever practicable, have the assistance of aconsultant in psychiatry.
During the spring of 1918, when the combat divisions of theAmerican Expeditionary Forces were engaged in every type of preparation forbattle, many procedures were tested among medical organizations which were toserve combat troops. In addition, the weeding-out of undesirable members of theorganizations, the selection of those best fitted to perform special duties, andthe circulation of useful information, all went on with the utmost vigor.
The reports of division psychiatrists, pertaining to thisperiod, show many interesting and useful activities. In several instances thedivision psychiatrists not only performed work in their own field, but rendereduseful service in practically every type of medical undertaking carried on in adivision. Regarded at first, perhaps, as superfluous members of an organizationdesigned primarily for combat, they won for themselves the favorable opinion oftheir superiors
aFor full text see p. 280.
305
and demonstrated their capacity for usefulness. This had itsvalue later when it became necessary for them to have greater responsibility inconnection with the evacuation of sick and wounded, when the divisions to whichthey were attached were engaged in battle.
During the time under consideration, the 32d, 3d, and 77thDivisions arrived in France.1 Eachwas provided with a competent division psychiatrist who had served with thedivision in the training camp in the United States, directed theneuropsychiatric examination of the personnel and, in each instance, establishedexcellent working arrangements not only with the other medical officers, butalso the organization commanders of the division.2
The division psychiatrists of new divisions arriving inFrance were provided with Circular No. 5, chief surgeon's office, A. E. F.,and informed of the general plans for neuropsychiatric work in the AmericanExpeditionary Forces. Parts of eight other divisions arrived during May1 buttoo late to take part in the plan of training that had been employed for thefirst four and, in a modified way, for the others that had come in April.
There was available, by the end of May, 1918, a good deal ofpractical neuropsychiatric experience, for by this time practically all theneuropsychiatric problems of a division in action had been dealt withexperimentally. In this experience it had been found that many difficultiesarose unless the division psychiatrists scrutinized closely the flow ofexhausted, concussed, and emotionally disturbed soldiers from the front andcontrolled, to a certain extent, their evacuation. Had there been time to do so,these experiences would have led to the establishment of methods certain toavert what happened a little later when a number of our divisions, unprepared bysimilar experience, were suddenly thrown into battle. No such opportunity came,however, for the military situation had become critical following the Germanoffensive of March 21, 1918,3 and because ofthe pressing demand for troops for combat their training had to be considerablycurtailed.4 Preparations forimminent battle conditions quickly replaced all other activities. Thedeficiencies in the organizations of the work of division psychiatrists were tobe revealed by further experiences before they could be remedied.
In our earlier combat activities, our divisions served as apart of the French forces.3 With theplan of evacuation through American channels abandoned, while our divisions wereserving with the French,5 and corpsand army medical organizations were only partially effective, it was naturalthat a combat division should seek only to free itself of its sick and woundedin the quickest way. Experience already had shown the necessity for makingseparate provisions for gassed cases by designating a divisional field hospitalas a gas hospital,6 but with thelarge number of casualties and the fairly rapid advance of troops, it did notseem possible to designate a field hospital to receive exhaustion, concussion,and neurotic cases, much less to set one aside for their exclusive use. It isnot surprising, therefore, that many of our soldiers evacuated from the frontduring the early months of our participation in active warfare were neitherwounded nor gassed, the majority of whom could have been returned to theirdivisions, had the opportunity been provided, after a few days of rest,encouragement, and psychotherapy.7 Thesubsequent careers of these men were
306
determined by the hospitalization conditions that existed tothe rear of the combat divisions rather than within them. In this connection itis appropriate to state here that, during the German advance in March and April,1918, the French had lost all their evacuation hospitals, totaling approximately45,000 beds.8 Behind the retiringlines of the French, with whom the American divisions were now fighting, therewas insufficient hospitalization to care for the French wounded as well asAmerican; therefore, it was necessary for us to take charge of the medicalservice to the rear of our divisions. Since the number of our evacuationhospitals at this time was far below the authorized quota, and as the sectororiginally selected for occupation by American troops was that facing Lorraine,about 160 miles to the east of Meaux, our stationary hospitals had beenconcentrated largely in that area and to its rear. In consequence, many hundredsof men suffering from exhaustion, concussion neurosis, fear, and other emotionalstates found themselves, within a few days after leaving their organizations, inhospitals a hundred miles or more away from the front. Very few of these menever returned to active duty.
The value of these experiences lay chiefly in thedemonstration of the fact that American divisions (even after a carefulselection, with the elimination of many psychopathic, mentally defective, andunstable men) were capable of furnishing a large number of war neurotics underbattle conditions, and that these patients were as resistant to treatment atpoints distant from the line as those in the armies of the French and British,upon whose experience our plan had been based.
Fortunately, there were some noteworthy activities thatindicated marked progress. For example, during the Aisne operation, the divisionpsychiatrist, 3d Division, effected the establishment of a field hospital formental patients, and the return of a large proportion of his cases to their ownorganizations without the necessity of their leaving divisional control.9During the Aisne-Marne operation, the division psychiatrist, 4th Division,by stationing himself in the triage, and having set aside a field hospital about6 miles farther to the rear, was able to divert from the evacuation hospitals alarge number of men suffering from conditions likely to result in war neuroses,and to return many of them to the front.10 Inmost of the other divisions engaged, however, it was found or thought to beimpracticable for division psychiatrists to station themselves in triages. Noeffort was possible, therefore, to distinguish between exhaustion, concussion,fear, and neurosis, and the diagnosis "shell shock" wasindiscriminately used when men seemed to be suffering from any of theseconditions. The result was that such cases were evacuated to base territory.
Ten American divisions (the 35th, 82d, 33d, 27th, 4th, 28th,80th, 30th, 77th, and 78th) were designated to operate at one time or another,with the British in northern France and in Belgium.1There it was impracticable even to attempt to put into effect a plan whichhad been devised originally for an American sector. Patients suffering frompsychoneuroses were evacuated from those divisions along British lines ofevacuation and most of them reached England within a relatively short period oftime. Here they were treated at first in special British hospitals for warneuroses, where American medical officers often took an important part in theirmanagement and, later, in American
307
base hospitals in England where their treatment conformed to the principlesthat are described elsewhere in this volume. (See p. 398.)
The importance of more adequate medical organization to care forneuropsychiatric cases at the front was brought to the attention of the directorof professional services, A. E. F., by the senior consultant in neuropsychiatryin the following letter, dated August 6, 1918:11
1. The recent severe fighting has resulted in a very largenumber of soldiers with war neuroses being evacuated to hospitals in the S. O.S. Base Hospital No. 117, on account of lack of provision, has been obliged todecline to receive cases by transfer from other base hospitals. Until theresults of telegraphic inquiry recently sent out are known, it is impossible tosay how many of these cases are in the hospitals of the S. O. S. The fact thatno less than 350 were present a few days ago in the hospitals in Vittel andContrexeville and 135 in Base Hospital No. 115 indicates that a considerablepart of our hospitalization is devoted to their care.
2. Such a high incidence of these disorders after a briefperiod of active fighting gives some idea of the efforts that must be made inthe A. E. F. if we are to deal with the problem of the war neuroses in aneffective way and prevent serious wastage from this cause.
3. It is desired at this time to invite attention to only onephase of the problem-the urgency of affording divisional psychiatrists anopportunity to pass upon these cases whenever practicable before they areevacuated to the S. O. S. It has been reported to me that many of the casesreceived in base hospitals are not suffering from any kind of psychoneurosis orfrom the effects of concussion by high explosives. Many of them are cases ofphysical exhaustion who would have been entirely fit for duty after a shortperiod of rest without hospitalization had their condition been recognized. Mostof the cases, not a few of whom I have examined myself, express great surprisethat they should be sent to hospitals and their chief desire is to join theirorganizations as soon as possible.
4. The importance of checking this source of wastage of manpower can not be overestimated. I directed attention to it in a report renderedto the Surgeon General in July, 1917, and in many communications since thattime. In division psychiatrists our Army has a most effective means ofdetermining what cases shall be evacuated to the S. O. S. It is very unfortunatethat services of these officers, many of whom were specifically trained fortheir duties in reference to this particular task and all of whom are fullyaware of what must be done, are not utilized most effectively in the tacticaldivisions. I believe that every effort should be made, now that actualexperience has demonstrated the validity of previous recommendations, to providethem with facilities for their work.
To meet the needs of specialists with divisions at the front, the chiefsurgeon A. E. F., sent to all division surgeons a communication concerning theduties of certain specialists, the sections of which that deal withneuropsychiatrists being given below, those dealing specifically with otherspecialists being omitted:
AMERICAN EXPEDITIONARY FORCES,
France, September 8, 1918.
From: Chief Surgeon.
To: All Division Surgeons.
Subject: Psychiatrists, urologists, and orthopedists in tactical division.
There is apparently some misunderstanding among divisionsurgeons relative to the duties and status of specialists assigned to divisionalformations for duty.
During the recent activities one division surgeon assigned thepsychiatrists to dressing the slightly wounded. While he was engaged at thiswork, several hundred cases of slight war neurosis were evacuated that wouldnever have left their division if they had been examined by a trainedpsychiatrist.
308
The above instance is cited to show theimportance of properly utilizing the services of these trained specialists witha view in this instance of avoiding a repetition of the experiences during therecent activities when a total of nearly 4,000 cases of slight warneurosis were evacuated to base hospitals that should never have left theirdivisions.
I. GENERAL STATUS AND DUTIES
Orthopedists, urologists, and psychiatrists areattached to tactical divisions solely to aid in dealing with the medical andsurgical problems of the divisions.
Their activities have two objects: (a) tokeep the fighting strength of the division at the highest possible point, and (b)to bring about the prompt elimination from the division of those who becomeunfit for duty.
These three branches of medicine and surgeryare represented because they are concerned with those diseases and injurieswhich experience shows contribute most to noneffectiveness of individualsoldiers and troops in general.
The function of these specialists is to helpthe division surgeon in the clinical work of the division in much the same waythat the sanitary inspector does in sanitation and the assistant to the divisionsurgeon in administration. They should be attached to the office of the divisionsurgeon as additional assistants. In no other way can they render most efficientservice. Their permanent assignment to any subordinate sanitary formation of thedivision inevitably curtails their usefulness. In periods of stress, however,they should be stationed by division surgeons in the post in which they can workto the best advantage (e. g., orthopedists and psychiatrists in triages, theurologists in surgical hospital during combat).
They should not be regarded as consultantsrepresenting an organization outside divisional control but as integral parts ofthe division sanitary personnel, wholly concerned with the medical work of thedivision to which they are attached and directly under the supervision of thedivision surgeon.
Psychiatrists
Division in training or rest:
1. Elimination of insane, feeble-minded andepileptic (especially among replacements).
2. Mental examination of general prisoners inaccordance with sections 11, G. O. 56, C. S.
3. Instruction of medical officers regardingdiagnosis, early management, and prevention of war neuroses ("shellshock").
Division in combat:
1. Examination and sorting of officers and menreturned to advanced sanitary posts for exhaustion, concussion by shellexplosion, and war neuroses in order to control their evacuation.
2. Treatment of light cases of exhaustion,concussion, and war neuroses in divisional sanitary formations so as to preservethe greatest number possible for duty.
3. Mental examination of general prisoners andmen suspected of having self-inflicted injuries.
(Signed) M. W. IRELAND,
Major General, Medical Corps, Chief Surgeon.
When the American Expeditionary Forces plan for caring forpsychiatric casualties had been definitely realized and was in actual operationthe following circular letter from the office of the senior consultant inneuropsychiatry was issued under date of September 25, 1918 (section dealingwith army neurological hospitals and supervision omitted).
309
ARRANGEMENTS FOR CARE AND EVACUATION OF NERVOUSAND MENTAL CASES
I. DIVISIONS
1. Each division in the area has a divisionpsychiatrist who will be stationed at the triage when his division is engaged.There he will sort all nervous cases, returning directly to their organizationsthose who should not be permitted to go to the rear and resting, warming,feeding, and treating others, particularly exhausted cases, if there isopportunity to do so. He will recommend all others for evacuation as follows:
(a) To a fieldhospital if all or part of one can be devoted to the care of cases likely toreturn to their organizations within two to five days.
(b) To NeurologicalHospital No. 1 at Benoite Vaux or Neurological Hospital No. 3 at Nub?court if afield hospital can not receive or care for such cases. Under these circumstancesevacuations to the neurological hospitals will be direct; otherwise only casesunsuitable for or unimproved by treatment in a field hospital will be evacuatedto them.
2. The advantages of these provisions fordealing with war neuroses and allied conditions in the divisions are:
(a) Control over theevacuation of cases presenting no psychoneurotic symptoms.
(b) Speedyrestoration and return to their organizations of those in whom exhaustion is thechief or only factor.
(c) Cure of mildpsychoneurotic cases by persuasion, rest, and treatment of special symptoms at atime when heightened suggestibility may be employed to advantage instead ofbeing permitted to operate disadvantageously.
(d) Prevention orremoval of hysterical symptoms (such as mutism, paralyses, etc.) so that, evenif the patient has to be evacuated, his subsequent treatment will have beenrendered easier and his recovery more prompt.
(e) Effectivemanagement of severe concussion cases during the first 24 hours, thus shorteningtheir convalescence.
(f) Creating in theminds of troops generally the impression that the disorders grouped under theterm "shell shock" are relatively simple and recoverable rather thancomplex and dangerous, as the indiscriminate evacuation of all nervous casessuggests.
The military organization for the care of war neuroses in thefield had the merit of simplicity. No complex scheme could have succeeded. Thedivision psychiatrist was stationed at the advanced field hospital, or triage,and his range of activity extended forward to the ambulance dressing stationsand beyond as far as he cared to go and backward as far as the rear fieldhospital, which was the unit treatment center. The triage, or sorting station,was apt to be anywhere from 2 to 9 miles, or more, from the front line, and thetreatment field hospital 4 to 7 miles farther removed. The former was usually anabandoned strong barn; and the latter, generally under canvas, capable of caringfor about 150 patients in five or six large tents. At the treatment fieldhospital the division psychiatrist was generally able to count on one enlistedman, Medical Department (usually without any nursing knowledge), to care foreach 15 patients. The necessary medical assistance at the treatment fieldhospital was rendered by ward officers who were without psychiatric training. Insome divisions the authority, as to the management of neuropsychiatric cases,was practically absolute, or, at least, could be readily made so. The fact thatthe war neuroses presented such unusual problems to commanding officers of fieldhospitals, who were unfamiliar with their genesis, type and treatment, and whowished to have these problems solved, made it possible in some organizations forthe psychiatrist to obtain all necessary cooperation. In other organizations,however, where the commanding officers were hostile to the retention of suchcases at the front, the division psychiatrist worked under great handicaps.
310
Thus, the work of the division psychiatrist was of such anature that it required unusual skill in psychotherapy, courage, good nature,and sociability, which a few who were assigned to this work did not have.
An assistant divisional specialist would have proven avaluable adjunct. It is true that even with an active combat division there weretimes when there was scarcely enough work to keep the division psychiatristoccupied; yet these periods were succeeded by days or weeks of stress and strainin connection with some important military operation when the services of atrained assistant would have been invaluable. The small "pool" ofneuropsychiatrists under the control of the corps or army consultant proved tobe a useful means of meeting this need. The character of battle activitydetermined to some extent the number of psychiatric cases occurring in adivision. Fighting which obliged men to remain expectantly in trenches orreserve positions under heavy bombardment for considerable periods of timeproduced many nervous and exhaustion cases. Open warfare, with the men in actionand on the move, alert, and watching the enemy, produced fewer cases, althoughexhaustion was frequent. Artillery fire, with the weird whistling of theapproaching shells, the terrific detonations, and the mutilations produced byexploding shells, unnerved many men. On the contrary, rifle and machine-gun firewere not important factors in the production of nervous disorders. In fact,there were practically no cases in which rifle or machine-gun fire was theupsetting factor.
The production of exhaustion cases followed days of constantfighting, with insufficient or no sleep, food, and water. The soldier alwaysstarted into action with a full canteen and two days' reserve rations. Healmost invariably kept his canteen, gun, and ammunition, but everything else inthe way of equipment, including his rations, was cast aside as soon as itencumbered him. Consequently, not infrequently men were without food or waterfor several days at a time. The long-continued fighting, lack of rest and food,together with having to lie out in shell holes all night in the cold and rain,frequently overcame the most courageous of men. Then a shell exploding nearthem, knocking them over or possibly killing or wounding a comrade, was oftenthe last straw.
A high percentage of men evacuated from the front line as"gassed" were really cases of fatigue, exhaustion, and emotionaldisturbance. It was necessary, therefore, that from this group the fatigued andexhausted be sorted out for treatment in one of the field hospitals. Of themedical cases reaching the triage the most common diagnoses were"bronchitis," "influenza," and "diarrhea." In manycases the most important factor was fatigue. These cases were also sorted outand retained for treatment in the divisional field hospital.
In the last group there were the neuroses with tremors,speech and hearing disorders, ataxias, and stupors. The severe cases wereevacuated as promptly as possible to the army neurological hospitals, while themilder cases were retained treated, and returned to duty. The proportionretained was usually determined by the exigencies of the campaign.
True cases of concussion almost invariably asked not to beevacuated, as they desired to return promptly to their own organization. In theless severe cases this was done.
311
Aside from the milder cases of exhaustion, sorted out fromamong the gassed and medical groups, the largest number of psychiatric cases wasthe exhausted with nervous symptoms. Men who were worn out, upon seeing theircomrades killed or injured, and possibly being knocked over themselves by anexploding shell, lost their nerve, cried, shook all over and felt afraid,crouched and put up their arms as if to protect themselves each time they hearda shell coming or exploding. These responded promptly to treatment at the front.
The sick and wounded were tagged either by a medical officeror, as generally was the case, by enlisted men of the regimental sanitarydetachments, indicating in a general way that the man was wounded, gassed, sick,or nervous. The sanitary personnel had all been instructed to use only the term"N. Y. D. (nervous)" for the latter group of cases. This was animportant matter, as it was surprising to see with what tenacity men clung to adiagnosis of "shell shock" or "neurosis" even though the taghad been made out by one of the enlisted sanitary personnel. Sometimes soldierswould wander into dressing stations and cheerfully announce that they were"shell shocked." By using the term "N. Y. D. (nervous)" theyhad nothing definite to cling to and no suggestion had been given to assist themin formulating in their own minds their disorder into something which wasgenerally recognized as incapacitating and as warranting treatment in ahospital, thus honorably releasing them from combat duty. The patients weretherefore open to the explanations of the medical officers and to the suggestionthat they were only tired and a little nervous, and that with a short rest theywould be fit for duty again.
It is worth while in this connection, as an example ofneuropsychiatric work at the front, to review briefly the military history ofthe work of the division psychiatrist of the 26th Division,12and to observe how the curve of neurosis incidence followed the activitiesof the troops, rising during active campaign and falling again after comparativequiet had been restored. Obviously in times of severe strain the need for amedical assistant to the division psychiatrist was very real.
Between February 5 and 8, 1918, the divisionentered the line north of Soissons, in the famous Chemin des Dames sector, wherewe remained until March 21. Only about 18 psychopathic cases were evacuatedduring this time. The reason for this low incidence was that the sector was acomparatively quiet one, there was not much heavy shelling, the troops werefresh and eager, and we were brigaded with a veteran French division, thusrelieving our own men of much anxiety and responsibility. Beginning April 1,1918, we relieved the 1st Division in the "Boucq" sector, northwest ofToul.
The stay of the division in this sector wasmarked by several serious encounters with the enemy, where considerable forceswere engaged. There were furthermore almost nightly encounters between patrolsor ambush parties, and the fire of the artillery on both sides was veryharassing. On April 10, 12, and 13 the lines were heavily attacked by theGermans. At first the enemy secured a foothold in some advanced trenches whichwere not strongly held, but sturdy counterattacks succeeded in driving him outwith serious losses, and our line was entirely reestablished. Fifty-two casesresulted. April 20 and 21 the Germans made a second raid on our lines about andin the town of Seicheprey and Remieres Woods, supported by exceptionally severeartillery fire. Forty-three cases developed from this attack. A third raid waslaunched on June 16 at the village of Xivray-Marvoisin, but failed to get withinour defenses. As if in retaliation for the decisive check the enemy hadsuffered, he delivered throughout the day exceedingly severe artillery fire onthe battery positions and rear areas. Thirty-six cases followed the bombardment.
312
On July 4 we relieved the 2d Division in the line just to thenorthwest of Chateau Thierry, taking over the hotly contested and hard-won linefrom Vaux-Bouresches-Bois de Belleau- to the vicinity of Bussiares. With nosystem of trenches or shelters, there was great exposure to enemy machine-gunand artillery fire; the woods and villages on the line were drenched with gas; avigilant and aggressive enemy allowed no rest. The men were tired. They had beenin the line almost continuously since February 4.
The great German drive southward betweenCompiegne and Rheims had reached the Marne River. For the moment it had beenstopped, but a renewal of the attack was to be expected. The long-distance gunswere dropping shells in Paris, 40-odd miles behind us; the Germans weredesperate and promised to reach Paris at the next thrust. The morale of ourtroops was not topnotch and it was thought that many of them would break ifanything serious occurred. These expectations were fulfilled a few days later.
On July 12 and 13 the enemy made a vigorousthrust at our positions in Vaux, but was beaten back with equal vigor.Seventy-one cases resulted. On July 18 the attack of the division, as part ofthe general operation to reduce the Chateau-Thierry salient, and thereby avertthe threatened danger to Paris, was begun. The villages of Belleau, Torcy, andGivry were taken; Hill 193, behind Givry, was twice won, but had to be abandonedbecause the French on our left had not been able to make rapid enough progressto secure the position. Heavy opposition was encountered, the enemy employingmany machine guns and well-placed artillery fire. Sixty-eight cases occurred onJuly 18 and 74 on July 19. On July 23, with thorough artillery preparation, thedivision attacked again, endeavoring to penetrate and clear up Trugny Wood,Epieds, and the woods behind it. Although stubbornly opposed and in spite ofsevere losses, our troops went forward steadily. Forty-nine cases developed.
On July 25 we were relieved. About September 5we took over the "Rupt" sector. Until September 12 the sector remainedquiet. On that date, however, began the great attack in force on the St. Mihielsalient by the American First Army. * * * The principal defense of theGermans was machine guns, well placed in concrete "pill boxes"; butthere was very little artillery response. * * * Only 26 cases resulted,probably because of little artillery fire from the enemy.
On September 26, the division was given themission of executing a heavy raid against the German positions at Marchevilleand Riaville, as a diversion in the general attack of the American First Army,which was to start on that date on the whole Meuse-Argonne front. Similar raidswere to be executed by the other divisions of the corps at the same hour, theorders being to penetrate the enemy lines, make prisoners, and occupy theposition throughout the day, withdrawing under cover of darkness. Heavy enemyresistance and counterattack resulted in six cases of acute mental disturbance.
Shortly afterward we concentrated in and nearVerdun. On October 16 we took part in an attack for the purpose of obtainingpossession of the Bois d'Haumont, supported by tanks. The tanks failed utterlyand heavy casualties resulted. Twenty-one cases resulted.
During our stay in this (Neptune sector)conditions were very severe. Influenza was prevalent; the rain was almostcontinuous; shelter was insufficient. The enemy occupied positions of greatnatural strength, and was backed by a numerous artillery.
He valued these positions highly and hung onwith bulldog tenacity. Gas was constantly thrown into the valleys and harassingartillery fire was heavy. Attacks were made daily from October 23 to 27inclusive, in conjunction with the 29th Division against the Rylon d'Etrayes-BoisBelleau-Hill 360 positions, which won for us a considerable advance, in spite ofour heavy losses. Thirty-five cases occurred. The next few days passed withoutany action save vigorous and successful patrolling to make prisoners.
On November 7, with its general axis ofadvances changed from east to southeast, the division executed a second attackon a wide front toward the Jumelles d'Orne beyond the Chamont-Flabas line. Theattack was renewed daily up to and including November 11. Finally, at 11 o'clock,the cessation of hostilities brought the active operations of the division to aconclusion.
313
EMERGENCY TREATMENT AT THE FRONT
Stationed, as the division neuropsychiatrists were, in combatareas, all their work being confined to field hospitals, where patients wereheld only from 3 to 10 days, depending upon military operations, the experienceof these officers with the treatment and final outcome of the cases was limitedchiefly to the milder forms of the neuroses. The more obstinate and chroniccases, of necessity, were evacuated to the rear areas.
To the treatment hospital at the front the neuropsychiatricpatient was sent after he had taken the first important step on the road torecovery. At least no one was sent there until a determined effort had been madeto convince him that he could be cured. Of course, there was necessarily aconstant and fairly large residuum of refractory cases, but these were notpermitted to negative the atmosphere of optimism which existed. Althoughsituated in the field within the range of artillery fire, and subject to themilitary necessity of moving at an hour's notice, it was still possible toapproximate suitable hospital conditions. The first difficulty which presentedwas the lack of nurses. The group of enlisted men who were selected had in thebeginning nothing more than the doubtful merit of curiosity concerning the"shell-shocked" soldiers. Until it was possible to inculcate a certaindegree of nursing morale it was necessary to deal with them from the point ofview of military discipline. Certain orders were given, and failure to obey themwas considered a punishable infraction of a military command. The few simplerules and suggestions utilized at first (in one division) are here quoted:
RULES FOR PSYCHONEUROSIS WARDS
1. Each patient on admission to have a hotdrink.
2. Each patient to have three full meals a day unless otherwise ordered.
3. Do not discuss the symptoms with the patient.
4. Be firm and optimistic in all your dealings with these patients.
5. No one is permitted in these wards unless assigned for duty.
6. The rapid cure of these patients depends on food, sleep, exercise, and thehopeful attitude of those who come in contact with them.
From such an elementary beginning there gradually developedamong the enlisted men, who acted as nurses, a high degree of interest andefficiency and a generalized and successful effort to intelligently maintaincertain therapeutic principles without which success would not have beenpossible.
Classification was an important function of this hospital.Generally speaking there was an effort to keep the mild cases in one tent, themore severe in another, the physical problems separate, and the recoveredawaiting return to the front apart from the others. Soldiers with obstinatesymptoms were segregated.
The physical needs of the patients were constantly borne inmind. Hot, abundant meals were provided; exercise, amusements, and work wereutilized, not haphazard fashion, but with a certain object in mind.
One finds in current reports on the therapy of war neurosesindefinite allusions to an intangible and mysterious therapeutic influencetermed "atmosphere." By this is meant, presumably, the general feelingand understanding which existed among all those who came into medical contactwith the war neu-
314
roses, and which sought to provide an urge or incentive forthe soldier to return to his duty on the firing line. This was necessarilydeveloped at every point in the American Expeditionary Forces where nervous andmental casualties were grouped for treatment. However, it should not have beenpermitted to remain at a vague and undefined stage, nor should its growth anddirection have been left to mere chance. As a matter of fact, it was a thingwhich could be deliberately created and shaped into a definite and valuabletherapeutic agent. As employed in the type of hospitals under consideration, itwas separated roughly into positive and negative elements, the first beingconcerned with the advantages of returning to the front, and the second with thedisadvantages of evacuation to the rear. Constantly, and in every conceivablefashion, were emphasized the glory and traditions of the division, of theregiment, and of the company, and the very important part which each soldierplayed in contributing his share. Further, the personal relation which sofrequently existed between officer and soldier was in a sense filial, just asthe intimate feeling between man and man was fraternal. In the field with combattroops, where close association under dangerous conditions made for therelaxation of certain features of rigid military discipline, such as ordinarilyobtains in a cantonment, or camp, and also erased social barriers, it isexceedingly probable that what might be termed an artificial familial instinctwas often developed and replaced in a measure the one of which the individualwas at least temporarily deprived. This factor, too, could be utilized as apowerful means for obtaining a healthy therapeutic atmosphere.
On the other hand, evacuation to the rear was painted ingloomy colors. The patients came to realize that leaving the division, or unit,meant probably the opportunity forever lost of having a part in its presentvictories and consequently in future honors and rewards. It involved a totalseparation from the paternal officer and brother soldier, and finally becomingthat most unhappy of mortals, a lone casual. It was in a sense a desertion,since it left comrades to "carry on" alone. It would be impossible toenumerate all the methods employed to foster and stimulate such impressions. Thefollowing sample will serve: Informal talks to groups of soldiers, theannouncing and publishing of bulletins recounting the gallant advance of this orthat unit, or the exploits of some well-known officer, or soldier, of thedivision, the reading and discussing of citations which had been received,rumors of a big offensive which was imminent, or of a well-earned rest whichsoon would be officially ordered, and the relating of incidents and episodes,"gossip" with a personal flavor which had come back by word of mouthfrom the front. No incidental opportunity was neglected. For instance, duringthe Meuse-Argonne operation, columns of German prisoners frequently passed thetents. The patients were urged to view the procession, always a stirring event,which often succeeded in evoking an exhibition of satisfaction and evenpatriotic fervor. It is doubtful whether anyone who has not been an actualwitness can appreciate the value of even such simple measures. The whole planwas far from being an uncertain proposition which could be expected to appearand act spontaneously, but was based on an estimate of what emotions andfeelings were to be activated and what degree of stimulation was needed to gainthe desired object.
315
It is difficult to understand why such a personal andconcrete thing as the attitude of the psychiatrist toward each of his patientshad to be is so often described in such general terms. It was by far the mostimportant feature of practically any form of treatment. Taking its cue chieflyfrom personality and intellectual capacity, it had to be rapidly defined in themind of the physician so as to meet the needs of the individual underconsideration. Further, frequently it had to be varied from time to time in thesame case. It affected every phase of treatment, often dictating the mode inwhich specific symptoms were removed, modifying the explanation of the neurosisand governing the methods utilized in the final rehabilitation of the soldierbefore his return to the front.
The particular methods of treatment utilized may be roughlydivided into those which were applied to all the patients, or to fairly largegroups, and those which had an individual application. The former is largelydependent for its effect on the creation and maintenance of the right kind ofmilitary atmosphere, which seeks to produce and encourage a desire to return tothe front. In this respect the following observations may be of interest: Acertain type of soldier, often of a moderately high intellectual grade, notinfrequently presented a curious psychological paradox as the time for hisreturn to the front approached. He had made a good symptomatic recovery, had aconsiderable degree of insight into the mechanism of his neurosis, may haveexpressed a wish to go back to his regiment, and yet found a marked difficultyin taking the final step. This was not due to the fact that he was distinctlyunwilling to return to duty, for he would have been as much or even moretroubled by a decision which would have evacuated him to the rear. Apparently,there was in these cases a temporary volitional paresis. This condition wasobserved in a small percentage of all the neuroses. Experiments along the linesof logical reasoning and appeal to the individual had little result, and it wasdecided to try the effect of another plan. When a sufficiently large group hadbeen collected, they were gathered together in a tent and given an informaltalk, which was little more than an effort to reach and sway the emotions.Beginning with a recital of the situation at the front with reference to thedivision, and particularly to the various units which were represented by thesoldiers present, it emphasized the acute need for every available man, and thefact that comrades were suffering because of their absence, and finally came toa climax by a dramatic request for volunteers for immediate service. The resultwas always highly gratifying, and the spontaneous enthusiasm showed that thesemen were actuated by something more than mere deference to the wishes of anofficer. In another group of patients who had made a fairly good symptomaticrecovery, or who persistently retained a few insignificant symptoms, thequestion of volitionally withheld cooperation arose. Two courses were open. Thepower of the military machine might be invoked to force action, reducing thematter to a choice between front line duty or court-martial. Such a procedurewas not employed. Its permanent value is not only questionable, but it is opento objections on ethical grounds. However, it had to be recognized that theproblem was no longer strictly a medical one. Without using undue severity andwith no trace of malice, such men soon found that an invisible barrier had
316
been erected between them and the other patients. They weredenied certain privileges and had to do most of the distasteful work, such aspolicing the grounds, digging latrines, etc. No one was permitted to impugntheir motives, yet on every side they were confronted by a questioning attitude.Always the opportunity was afforded, and was indirectly encouraged, to talk overthe situation with one of the physicians; always there was the invitation andthe temptation to change their status to a happier and more honorable one. About90 per cent of this group were eventually reached by such a simple method.
For the attack on individual symptoms resort was had tovarious forms of suggestion which have been described in detail by variousauthors. Whenever there was a choice between two methods, the simpler was alwayspreferred. Complicated procedures seemed unnecessary. Often nothing moreelaborate than passive relaxation of flexion and tension plus appropriatesuggestion was needed to remove tremors; indeed, many of them disappearedspontaneously. If a paralysis responded at all to passive movement whichgradually became active by the imperceptible withdrawal of the assisting handsof the physician, electricity was not employed. If an hysterical deprivationcould be reached by suggestive persuasion or argument, such "tricks"by means of the stethoscope, tongue depressor, mirror, etc., as were in voguewere avoided. There were, of course, times when a degree of mystification wasnecessary, but it was never the first resort and was usually reserved for morerefractory symptoms. Hypnotism was never used. As a preliminary to theconsideration of the individual symptoms, there was an estimate of how much ofthe symptom was real and how much was only apparent. A change of position to onemaking for greater physical comfort, the removal of constricting clothing or ofan external source of irritation, a hot drink, and a reassuring word or two weresometimes in themselves sufficient to decrease materially the range of tremors,to improve an exaggerated posture or movement, or to reveal a seeming paralysisas only a paresis. The amount of amnesia, particularly, always appeared greaterthan it really was. Before any intensive attempt was made to treat it as asymptom its extent was carefully gauged. A simple and brief series of questionsand answers often strikingly diminished its proportions. The selection of aroute to gain access to any sign or symptom which presented in a patient wasmuch influenced by the attitude which the psychiatrist had decided on as bestsuited to meet his needs as an individual.
When more refractory symptoms were to be dealt with, thatwhich seemed the most obvious thing to do was attempted first. Strictsegregation had a wholesome effect on obstinate tremors or convulsive movements.Every advantage was taken of possible modifications of classification. A patientwith a persistent difficulty would be placed for a short time in the midst of asmall group of recovered soldiers awaiting transportation to the front.Occasionally some one who had made a particularly striking recovery was kept fora few days as a sort of hospital "pet" for the sake of the effect ondifficult cases. He was taken into the confidence of the psychiatrist andinstructed as to what was expected of him. Now and then a "chronic"patient was made to observe the removal of some symptom in a recent case.Sometimes the physician planned to have his conversation and opinions overheardby this or that
317
individual. At times, when dealing with troublesome symptoms,it seemed advantageous, after the soldier's curiosity had been aroused, topostpone the final seance a number of times. A few elaborate consultations werestaged wholly for their psychic effect. Such instances as the above might beendlessly multiplied; they merely served to intensify suggestion and weretherefore useful.
The employment of simple procedures had several advantages.They needed no elaborate paraphernalia and did not demand lengthy preparation.In the field space and time had to be carefully conserved. Further, it must beremembered that the patients, as they came to the triage, were like closedbooks. The soldier himself was frequently the only source of informationavailable, and consequently there were many gaps in the history. When dealingwith an individual whose potentialities were largely unknown it seemed the partof wisdom to restrict oneself, if possible, to things which could do no harm.Some of the more complex forms of technique depend largely for their suggestivevalue on the veil of mystery which surrounds them. Unless absolutely necessary,in some unusual instances, their exhibition ought to be avoided. They are apt toprove embarrassing when the time comes to give the patient the explanation ofhis neurosis, when, of all times, the physician needs to be sure of his ground.This explanation, too, must be as simple as possible. However high the educativeand intellectual standard of the enlisted men in our Army might have been, itdid not reach the point where an involved discussion of psychopathologicalmechanism could be appreciated. Even primary ideas and illustrations had to beused with caution, and the test of their efficacy rested on whether they wereeasily comprehended by the patient and satisfied his needs.
Of 400 war neuroses, embracing all types and occurring indifferent operations at the front, approximately 65 per cent were returned tofront line duty after an average treatment period of four days. During thesecond half of the Meuse-Argonne operation, the recovery rate amounted to about75 per cent; earlier, along the Ourcq, it had dropped to as low as 40 per cent.This fluctuation was governed by military necessity. In other words, there werefour separate hospital-evacuation orders which affected about 70 patients whohad had less than 36 hours' treatment. It is reasonable to assume that atleast one-half of this number would have recovered if it had been possible toretain them 48 hours longer. After the armistice was signed an effort was madeto determine the number of times a second attack had appeared. Only ninerecurrences were found-less than 4 per cent of the total returned to duty. Itis possible, of course, that a few cases may have passed through the triages ofother divisions. However, these would necessarily have been restricted to troopson the flanks of the line and their number therefore could not have beensignificant.
The recovery rate was influenced by certain factors. From thetype of symptom presenting one could often predict the ease or difficulty whichwould attend its removal. Generally speaking, symptoms which occurred inconditions where there had been a definite trauma, or emotional insult succeededby a stage of relaxed consciousness, responded readily. They were frequently of
318
a hysterical variety. On the other hand, those which belongedto states which had been evolved in the plane of consciousness were not soaccessible. They were apt to have a neurasthenic or psychasthenic coloring.Anxiety symptoms of various kinds presented the knottiest problems, and arelatively high percentage of these had to be evacuated to the rear.
When time is necessarily limited the rapidity with whichcontact can be established between patient and physician is an importantconsideration. The degree of inaccessibility in the make-up of the soldier willbe reflected in the therapeutic failures recorded in the field. Theresponsibilities of the psychiatrist were clear. He had to return as many men aspossible to duty, and during times of great activity it was not always feasibleto give each patient the full amount of attention his condition deserved. Inthis way, and at these times, the individual whose personality involved carefuland extended study in order that his neurosis might be reached, sometimes had tobe neglected as a matter of military economy.
The intellectual status of the patient was not without itseffect. The relatively ignorant soldier was usually softer clay in the physician'shands than was the one in whom learning and training had sharpened the habit ofquestioning, scrutinizing, and weighing in the balance. Of course, these two often developed different types of neuroses, but, given the same condition inboth, the former could be handled with far greater rapidity and more surety ofsuccess.
Finally, the recovery rate fluctuated in response toextraneous and wholly accidental factors. It was appreciably higher at periodswhen the division was about to be relieved, and it was lowered at the beginningof what promised to be a long campaign. During the three or four weeks precedingthe armistice, when victory followed victory on every front and definite successseemed assured, it reached its apex. The psychological effect of such incidentalhappenings, of course, was complex; but in general they lessened the activityand the need of close surveillance on the part of the preservative instinct bythe intrusion of new and attractive possibilities; the anticipation of rest andpleasure in different surroundings under safe conditions in the former instance,and in the latter the prospect of an early return to the United States as amember of a victorious fighting division, and a resumption of all those pleasantrelations from which the soldier had been cut off by the war.
A statement of experiences with the war neuroses would beincomplete without some reference to gas hysteria and its treatment. A strikinginstance occurred during the Aisne-Marne operation, when the 3d Division was inthe neighborhood of the Vesle River. One morning a large number of soldiers werereturned to the field hospital diagnosed as gas casualties. The influx continuedfor about eight days, and the number of patients reached about 500. Thedivisional gas officer failed to find any clinical evidence of gas inhalation orburning, and the psychiatrist was given an opportunity to act as consultant. Thepatients presented only a few vague symptoms. There were, perhaps, four or fiveinstances of aphonia, but in the average case the symptoms presented were afeeling of fatigue, pain in the chest, slight dyspnea, coughing, husky voice, anassortment of subjective sensations referred to the throat, varying from slighttingling to severe burning, and some indefinite eye symp-
319
toms. Physical and neurological examination was practicallynegative, and the mental findings were inconclusive; if anything there was anundercurrent of mild exhilaration. Most of the patients had the fixed convictionthat they had been gassed and would usually describe all the details withconvincing earnestness and generally with some dramatic quality of expression.Careful inquiry elicited the information that these soldiers came from areas inwhich there was some desultory gas shelling, which, however, never reachedserious proportions. The amount of dilution was practically always great enoughto provide an adequate margin of safety. It was further developed that theseconditions were always initiated in about the same way. Either following theexplosion of a gas shell, or even without this preliminary, a soldier would givethe alarm of "gas" to those in his vicinity. They would use theirmasks, but in the course of a few hours a large percentage of this group wouldbegin to drift into the dressing stations, complaining of indefinite symptoms.It was obvious on examination that they were not really gassed. Further, it wasinconceivable that they should be malingerers. They came from battle-testedtroops, veterans of the severe action on the Marne and the early hard fightingin the Aisne region. It is exceedingly probable that a number of factors whichexisted at that time acted together with the general effect of lowering moraleand reducing inhibition to a state where any suitable extraneous opportunity wasapt to be utilized by many as a route to escape from an undesirable situation.It differed from the manifestation of the personal preservative instinct in thatit was in a sense a mass reaction and a subconscious rejection of a situationwhich, although decidedly uncomfortable, yet was not sharply threatening fromthe standpoint of physical danger. The troops were more or less inactive,practically merely holding a position, and the small amount of activity whichoccurred was more irksome and irritating than highly dangerous. Following on theheels of the advance at Chateau Thierry and the first rush in the Aisne regionit was comparatively monotonous and lacked all those stirring and dramaticqualities which even in modern warfare attend more important militaryoperations. Further, instead of a definite, easily understood objective such asthey had been accustomed to, the minor activity which was not taking placeseemed to the soldiers indefinite, uncertain, and apparently not aimed at aclear-cut objective. Again, too, for some time there had been a wide-spreadfeeling that the division was soon to be relieved and given a well-earned rest.When the day came on which the order for relief was expected, and word arrivedthat it was to be indefinitely postponed, the feeling of expectation andoptimism gave way to disappointment and dissatisfaction. The relative inactivitygave abundant opportunity for endless thought and discussion among the men bywhich the mental unrest and uncertainty was rapidly disseminated andintensified. Finally the troops were beginning to feel the physical strain offour weeks' exertion under the most exposed and trying conditions. When thesefactors, no one of which was sufficiently strong to act alone, accumulated andcombined they were evidently powerful enough to produce a wholesale effect.
The problem demanded immediate and energetic attention. Itwas obviously impossible to deal with each patient from the personal angle andgive him extended individual attention. The drain on man power was being felt,and
320
there was a request from military superiors asking that thesemen be returned to the line as quickly as possible. Each man on admission wasexamined, assured that his symptoms were not serious, and given some simplesuggestive treatment followed by hot food and a brief rest. Some hours later hewas again examined, encouraged to feel that the treatment had had the desiredeffect, complimented on his improvement, reassured about his condition, andconvincingly told that he would be able to return to duty on a certain day atsome specified hour. From this point on symptoms were practically ignored. Thepatient now passed to a second tent where the conditions were rigidly military.Soldiers were usually required to wear their uniforms, and to observe allmilitary courtesies, and they were under strict discipline. There was a round ofduties to be performed under the supervision of a noncommissioned officer. Inshort, the hospital lacked about the only desirable features which were to befound at the front, namely, a relaxation of certain elements of military ruleand routine duty. The method was successful. Only an occasional case provedrefractory and required more intensive action. The basic idea was an attempt toimpress on the patient's conscious mind that his ailment was not serious, andon his subconscious mind that the situation in which he now found himselfprobably offered no greater advantages over the one which he had recently left.No harshness was permitted, but no opportunity was given to lose contact withthe life, duties, and responsibilities of a soldier. The wave of gas"hysteria," as the line officers insisted on designating it, recededfrom day to day, and ceased spontaneously at the end of eight or nine days.
When hostilities ceased, there was some doubt as to whetherthe services rendered by division psychiatrists were sufficiently valuable tojustify their retention in the divisions. In the army of occupation, where therewas a possibility that divisions might again be engaged in combat or at least beliable to a long period of service on foreign soil, no such question was raised.The other divisions, however, went back into areas previously used for training,and as rapidly as possible were sent to various concentration centers inpreparation for their return to the United States.
During this period of waiting for return to the United Statesa great many policies which were considered of importance during the period ofcombat were reversed. For instance, it was unwise to conduct too vigorous asearch for mentally defective psychopathic individuals in organizations about toreturn to the United States, as their discharge from the Army in any case wasonly to be a matter of several weeks. The mentally sick, of course, were sent,as before the armistice, to Base Hospital No. 214, at Savenay, for return tohome territory, there to be hospitalized further or discharged from the serviceon surgeon's certificate of disability. The war neuroses had ceased to be aproblem.
CORPS NEUROPSYCHIATRIC CONSULTANTS
As soon as the medical service of the corps becamesufficiently well organized to require the services of corps consultants inpsychiatry these were appointed. These consultants proved a valuable addition tothe work of dealing with war neuroses in advanced formations. As it wasimpossible for a division psychiatrist to care for all the cases coming underhis observation under condi-
321
tions of unusual stress, it was found feasible to attach tothe corps, as temporary assistants to the corps consultant in psychiatry,additional medical officers with neuropsychiatric training. These he coulddispose of as exigencies required, and in several instances an unusual flow ofexhausted, frightened, and nervous men from the front was checked in triages bythe extra officers who were available on this account to examine them and makerecommendations as to treatment or other disposition. The corps consultant inpsychiatry served an extremely useful purpose and his presence helped to insurethe carrying out of a definite policy with reference to the care and evacuationof neuropsychiatric patients during combat. During quiet periods his serviceswere likely to be fully occupied in working out a better organization for thenext period of activity, helping in dealing with the medico-legal situations,questions of morale, and psychiatric problems which arose among troopsthemselves.
The following report of the consultant to the First ArmyCorps, dated November 25, 1918, covers a period commencing in July, 1918, andending with November 11, 1918:13
FIRST ARMY CORPS
When the consultant in neuropsychiatry joined theFirst Army Corps in the latter part of July, 1918, its territory embraced allthe area of combat in the Chateau Thierry sector. Two divisions were at thattime on the front line-the 28th and 42d. Shortly afterwards the Third ArmyCorps was organized and part of the sector placed under their command.
There were no precedents to help or hinder,but the needs of the situation were obvious. A series of divisions were cominginto the corps, taking up front-line positions, after a time withdrawn andreplaced by others. Each division had its psychiatrist. Some of them had beenwith the division for a considerable period and had their duties well in handand adequate opportunity to carry them out. In other instances, the work was notwell organized and the psychiatrist was called upon to spend his time in doingduties that might be carried on by other medical officers while the duties thatonly he could perform most satisfactorily were left in abeyance. This alldepended on the conception held by the division surgeon of the usefulness andresponsibilities of the divisional neuropsychiatrist.
The chief surgeon of the corps held a highopinion of the importance of the work of the neuropsychiatrist, and alwaysinsisted that they be given every opportunity to do their work. A fine group ofmen like these officers needed only the opportunity in order to make themselvesmost useful. The corps consultant found, therefore, as his chief duty during theperiod of advance, frequent visiting of the divisions, surveying of the lines ofevacuation, and the points at which the psychiatrist could work mosteffectively, and advice and encouragement to them as various problems came up.Owing to difficulties in getting about over the country, this apparently simpleduty required a great amount of time, and until individual means oftransportation were available it was frequently impossible to function with evennormal speed.
In the St. Mihiel and Meuse-Argonne operationsthe First Army Corps was given three neuropsychiatrists, who might be moved fromunit to unit as one division was replaced by another. It was excellentexperience for men who were to become division neuropsychiatrists. Since theywere always in active divisions, it tested admirably their ability to stand along period of stressful activity. It also gave them the benefit of working withseveral more experienced officers in succession. At times these extra men workedwith the division psychiatrist at the triage. In other instances a divisionmight maintain two triages, and then the two officers divided these triagesbetween them. In periods when the corps was not engaged in active combat theseofficers were withdrawn from the division and assigned to other duties.
The Army corps comprises a number oforganizations aside from the divisions. It was highly important that thesetroops should be known to the corps neuropsychiatrist and that the medicalofficers and commanders of these troops should know where they could obtain
322
help on neuropsychiatric problems. This matterwas dramatically illustrated by the case of the 53d Pioneers, an organizationcomprising a huge number of men unfit for military duties, a considerable numberof them because of mental defect. Whenever time permitted, the corpsneuropsychiatrist or one of his extra officers devoted some time to examiningmen in these organizations.
The First Army Corps developed in theMeuse-Argonne operation an institution known as the rest camp. The purpose ofthis was to take care of men who did not need actual hospitalization but were inneed of a period of rest. In such a place there were always patients with mentalproblems. It is believed that a medical officer with neuropsychiatric trainingwould be of great service in a rest camp. For a few days only was it possible tomake such an arrangement, because of the exigencies of the service in thedivision.
A difficulty encountered was in the matter ofevacuating the psychoneurotic patients in the right direction. During activehostilities it is quite impossible to control this matter to one's entiresatisfaction, unless the so-called neurological hospital is near a group ofhospitals so that ambulances are discharging all patients from a certain area atpoints from which they may be distributed. However, by following the matter asfrequently as possible, we probably got a larger number of psychoneuroticpatients into Army Neurological Hospital No. 3 than would have gone thereotherwise. Attention was given also to the problem of getting back patients fromthe neurological hospital for active duty as soon as possible.
The work of the corps neuropsychiatrist wascertainly no more taxing than that of the division officers, and probably lessso. There were many satisfactions connected with it. It was often possible togive material assistance to the work of division consultants. If the campaignhad lasted longer, it would have been possible to hold a larger proportion ofneurotic cases in the rest camp, in division field hospitals, and in the fieldhospital of the Army corps; so that evacuations to the S. O. S. would have beenfewer.
ARMY NEUROPSYCHIATRIC CONSULTANTS
Shortly after the organization of the American First Army,on August 10, 1918,14 it was decided that theArmy surgeon should have consultants, including one for neuropsychiatry, but nosuch assignment was made until October 19, 1918, when the corps consultant forthe Third and Fifth Corps was appointed consultant in neuropsychiatry, FirstArmy. On the same day, a consultant in neuropsychiatry was appointed for theSecond Army. After the armistice was signed, a consultant was appointed for theThird Army.
Army consultants in neuropsychiatry served too short a timeto make available many records of their experiences, but the following summaryof the conclusions reached as to the services that can be performed by such amedical officer in a field army is of interest. It represents the joint views ofthe two officers who served in this capacity in the American ExpeditionaryForces:a
THE WORK OF AN ARMY CONSULTANT INNEUROPSYCHIATRY
The army consultant needs some executive ability and preferablya considerable executive experience. His work is no more taxing than that of theconsultant in the division or Army corps, but since the projects with which hedeals are more numerous and more varied, considerable training in hospital andorganization activities will not come amiss.
There are in the army a number of well-organized units-thedivisions-each with a consultant. The army consultant during active operationshad to visit these divisions from time to time and to ascertain whether thedivision psychiatrist had opportunity to function to the best of his ability andwhether he was provided with the information that he needed in order to fulfillhis duties. The hospital and other facilities that were afforded him, the
aLieut. Col. E. G. Zabriskie, M. C., was appointed consultant in neuropsychiatry, First Army, Oct. 19, 1918; Lieut. Col. John H. W. Rhein, M. C., was appointed consultant in neuropsychiatry, Second Army, on the same date.-Ed.
323
obstacles, if any, to his handling of suchcases as can be properly treated in the division hospitals, the directevacuation to the most favorable point of those who must leave the organization,were problems that required attention. Division psychiatrists sometimes have toleave their organizations for adequate reasons, and it is imperative for thearmy psychiatrist to obtain early information of such changes in order toprovide substitutes to fill such vacancies.
If in the army there was an army corps thathad a consultant in neuropsychiatry, the relation of the army consultant to himwas somewhat similar to that with the division psychiatrist. During activeoperations a very useful arrangement was found to be the placing of someadditional psychiatrists in the army corps. These men could be sent fromdivision to division and located at other strategic points in the corpsorganization according to the need for them in order that all troops might beable to receive the attention of a psychiatrist. Furthermore, these men weretrained in this way for taking posts of independent responsibility themselveslater.
The army consultant bore direct responsibilityfor psychiatric matters in troops that are not included in divisions. This wasoften a taxing and time-consuming duty, for such troops whether attached to thecorps or to the army were scattered and not always easy to locate. Until theacquaintance of their regimental surgeons has once been made, such troops may besadly neglected, allowing conditions to arise that present a very importantelement of danger. This may be the case in any branch of medicine. Men have beenfound in critical military positions suffering from advanced pulmonarytuberculosis, having grave deformities, or serious cardiac disease. Failure bythem to carry out military duties might be precipitated by no fault of the manbut with considerable embarrassment to his comrades. Likewise, in the mentalfield, feeble-minded men, unable to tell the right hand from the left, have beenintrusted with rifles and put on guard duty, endangering their wholeorganization through their inability to understand and carry out commands. Thesesituations were quickly relieved by the attention of a medical officer with someknowledge of mental disorders. Furthermore, there were many prisoners to beexamined, and this duty fell to the army psychiatrist, except in so far as hecould arrange through the chief surgeon to bring the cases to the attention ofdivision or corps psychiatrists.
To the army consultant falls the duty ofseeing that prisons are surveyed occasionally, and also the duty of examininggeneral courts-martial prisoners or arranging for their examination bypsychiatrists who happen to be located in the neighborhood. Arrangement ought tobe made by which a report of the name and location of all such prisoners will besent to the chief surgeon of the army. These lists will then receive theattention of the army consultant in neuropsychiatry.
Another set of important duties andresponsibilities had to be with the hospital organizations of the army. Atconvenient points neuropsychiatric units were established. Without these thepsychiatric problems and in many instances organic neurological problems wouldnot have received the attention that they deserved. Convenient buildings andsatisfactory equipment were of some importance, but of far greater importancewas trained personnel. Experienced medical officers and enlisted men can convertalmost any type of building into a place suitable for the handling of mentalproblems. Two tendencies had to be combatted: (1) thetendency through lack of understanding to minimize the importance of theseorganizations and, therefore, not to transfer to them the patients with mentaldifficulties; and (2) the tendency to take away from these units the verycapable personnel and assign them to other duties, important perhaps, but asreadily performed by others without special training in neuropsychiatry.Fortunately, when these units were once established there was no question abouttheir continuance or their usefulness. Their value became apparent to the wholemedical organization and to the judge advocate's department and the GeneralStaff. It is nevertheless necessary for the army consultant to make ratherfrequent visits to these hospital units and ascertain if they are permitted andencouraged to function at their highest point of efficiency.
The army consultant had important functions inconnection with the problem of evacuation. He had to be on the watch to see thatthe patients who by temporary treatment could
324
soon be returned to duty, were not sent tohospitals at such distant points that return to their organizations would bedelayed and the patients' symptoms become fixed through improper handling.This matter was largely one of routes of ambulance evacuation. He had to knowabout the routing of hospital trains in order to arrange suitable times for theevacuation of patients by the carload or more to neuropsychiatric centers atpoints distant from the army area. Unless this was done, considerable numbers ofneuropsychiatric patients were unloaded in hospital centers that were notequipped to provide for them. This caused much loss of time and delay in thehospital service itself.
REFERENCES
(1) Outlines of Histories of Divisions, U. S.Army, 1917-1919, prepared by the Historical Section, the Army War College. Onfile, Historical Section, the Army War College.
(2) Reports of Medical Department activitiesof the 32d, 3d, and 77th Divisions, prepared under the direction of thedivision surgeon concerned. On file, Historical Division, S.G. O.
(3) Final Report of Gen. John J. Pershing,commander in chief, A. E. F.
(4) Report of the assistant chief of staff,G-5, G. H. Q., A. E. F., on the operations of G-5, made to the chief of staff,A. E. F., June 30, 1919. On file, General Headquarters, A. E. F., Washington, D.C.
(5) Report of the activities of G-4-B, medicalgroup, fourth section, general staff, G. H. Q., A. E. F., for the periodembracing the beginning and end of American participation in hostilities,December 31, 1918. On file, Historical Division, S. G. O.
(6) Report of the Medical Departmentactivities, 1st Division, 1917-18, prepared under the direction of the divisionsurgeon, undated. On file, Historical Division, S. G. O.
(7) Letter from the senior consultant inneuropsychiatry, A. E. F., to the director of professional services, A. E. F.,August 6, 1918. Subject: Preventing evacuation of cases of war neuroses. Copy onfile, Historical Division, S. G. O.
(8) Report of the Medical Departmentactivities of the 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated. On file, Historical Division, S. G. O.
(9) Report of the neuropsychiatric activitiesof the 3d Division for the month of August, 1918, made by Maj. E. G. Zabriskie,M. C., to the senior consultant in neuropsychiatry, A. E. F. Copy on file,Historical Division, S. G. O.
(10) Report of the neuropsychiatric activitiesof the 4th Division for the month of August, 1918, made by Maj. Samuel Leopold,M. C., to the senior consultant in neuropsychiatry, A. E. F. Copy on file,Historical Division, S. G. O.
(11) Letter from the senior consultant inneuropsychiatry to the director of professional services, A. E. F., August 6,1918. Subject: Preventing evacuation of cases of war neuroses. Copy on file,Historical Division, S. G. O.
(12) Report from the division psychiatrist,26th Division, to the senior consultant, neuropsychiatry, A. E. F., on theactivities of the division psychiatrist. Copy on file, Historical Division, S.G. O.
(13) Report of the activities of the corpsconsultant in neuropsychiatry, First Corps, A. E. F., July, 1918, to November11, 1918, by the corps consultant in neuropsychiatry, November 25, 1918. Copy onfile, Historical Division, S. G. O.
(14) G. O. No. 120, G. H. Q., A. E. F., July24, 1918.
