ARMY NEUROLOGICAL HOSPITALS

ARMY NEUROLOGICAL HOSPITAL NO. 1, FIRST ARMY

The hospital at Benoite Vaux, Army Neurological Hospital No.1, which previously had been used by the French as an "ambulance" forvenereal diseases, consisted of 150 beds. The advantages of taking over thishospital for use with neuropsychiatric patients was brought to the attention ofthe corps surgeon, First Corps, by the senior consultant in neuropsychiatry onAugust 26, 1918.⁶

It was first suggested that a corps field hospital bestationed at Benoite Vaux with its own commanding officer, adjutant, andpersonnel, securing the special medical personnel from a "pool" ofneurologists and psychiatrists collected at Base Hospital No. 117 for emergencyservice with advanced formations.⁶ This proved not to be feasible on account ofthe medical and surgical needs of corps troops. The hospital was turned over tothe First Army before the end of August, 1918, and on September 2, 1918, anadvanced neurological hospital was established there.⁷It being impossible to detach the personnel of a corps field hospital, aswas originally suggested, five commissioned officers and eight enlisted men,stationed at Base Hospital No. 117, proceeded to Benoite Vaux for temporaryduty.⁷ The commanding officer atBase Hospital No. 117 furnished a truck for transportation, and on the morningof September 3 the detachment arrived and proceeded to prepare the hospital forthe reception of patients. Seven other enlisted men were secured, and onSeptember 6, it was possible to send the following memorandum to the chiefsurgeon of the First Army:⁸

1. The hospital at Benoite Vaux which has beendesignated Neurological Hospital No. 1, First Army, is ready to receivepatients, the officers and enlisted men being on duty there and all suppliesincluding rations on hand.

2. The hospital at Toul which might bedesignated Neurological Hospital No. 2, First Army, if you approve, will havethe personnel by tomorrow and will be ready to receive patients by Sunday.

3. Staffing these hospitals has greatlydepleted Base Hospital No. 117, which will be called upon to care for at least1,000 patients, the overflow at Rimaucourt being only 500.

4. It is therefore necessary for the hospitalat La Fauche to receive 28 men from your personnel from the special trainingbattalion as soon as convenient.

5. I believe that with these advancedfacilities it will be possible to establish a very different record in the lossof effectives from nervous conditions, which, unfortunately, we were compelledto be content with during the last period of extensive fighting.

6. For several days I will be at Toul and inthe divisions in that vicinity.

Benoite Vaux, a tiny French village, consisted of 45 houses,with a population of not more than 75 civilians. In the village was a church, anabbey, and a few little shops. The abbey, supplemented by some frame barracksacross the road, had been used by the French Army as a hospital for nervousdiseases. During the recent active operations carried on by the French, thevillage had been used as a rest area.

The location of Neurological Hospital No. 1 was particularlywell adapted for the purpose to which it was to be devoted. The main evacuationcenter for

^aExcept as otherwise indicated, the following statements concerning Army Neurological Hospital No. 1, First Army, are based on "History of Army Neurological Hospital No. 1, First Army," by the commanding officer of that hospital. Copy on file, Historical Division, S. G. O.

328

the Verdun front was Souilly, 7? miles away, which was alsothe site of a number of evacuation hospitals.⁹An excellent road connected Benoite Vaux with the main route betweenVerdun and St. Mihiel, while only 9? miles to the west was the main routebetween Verdun and Bar-le-Duc, upon which route a little later the neurologicalhospital at Nubecourt was to be established. At the time of the commencement ofthe St. Mihiel operations, the front line was 5? miles away.

The hospital consisted of 10 French barracks and a number ofsmall outbuildings, which were little more than huts. One barrack was used bothas the admission ward and as a ward for officer patients. It was divided intoseveral rooms accommodating one to four patients each with an additional smallward for six patients. Eight other barracks were used for patients who wereenlisted men. Each contained 25 cots. These barracks were arranged in three rowsof three each. The first two rows were connected by an inclosed corridor. One ofthe barracks was used for bathing purposes and one for a storehouse. The officeof the commanding officer was a small two-room barrack adjoining this group ofbuildings. The hospital personnel were quartered in several small buildingswhich surrounded the group of barracks to the west and to the north. The kitchenwas in the rear of the group. Cooking facilities consisted of French brickstoves, and wood was used for fuel. During the French occupation of thishospital, gardens had been planted in which onions, carrots, and lettuce weregrowing in sufficient amounts to provide fresh vegetables for at least one meala day for the entire hospital.

On September 20, orders were issued to 5 officers and 15enlisted men, who were stationed at Neurological Hospital No. 2 at Toul, toreport for duty at Army Neurological Hospital No. 1 at Benoite Vaux.Accordingly, on the night of September 21, these officers and 30 enlistedpersonnel traveled in ambulances, arriving at 3 o'clock in the morning. Theoriginal 4 officers and 30 enlisted men were synchronously transferred onSeptember 22 from this hospital at Benoite Vaux to Neurological Hospital No. 3at Nubecourt. The newly arrived officers and enlisted men remained for thepurpose of operating this hospital.

During the month of October, this hospital continued itsactivities while the Meuse-Argonne operation was under way, the number of casesadmitted being 608.¹⁰ Of this number, therewere 44 officers, 10 of whom were returned to duty, 1 was transferred to BaseHospital No. 116, 31 to Base Hospital No. 117, and 2 to medical centers.

During the month of November the admissions were considerablyless than during the previous month, or even during September.¹¹This was due to the change in character of the fighting (while battleactivities continued), to the fact that the distance between the hospital andthe front line was constantly increasing and to the cessation of hostilities orNovember 11. The number admitted during November was 152.

Army Neurological Hospital No. 1 operated under considerablephysical disadvantages. There was no laundry connected with the hospital untilthe latter part of October. Until then, the laundry was sent to near-by Americanhospitals. It was done sometimes at the Gas Hospital at Rambluzin, and at

329

other times at Evacuation Hospital No. 6 at Souilly. By theend of October, a laundry was constructed on the grounds, a large fireplace wasbuilt for boiling clothes, and a mammoth tub was constructed in the workhouse ofthe hospital. Tubs were also put in place for rinsing, and convalescent patientswere detailed to attend to this work. The average output a day was approximately900 pieces.

Transportation here, as elsewhere in the AmericanExpeditionary Forces, was a source of great difficulty. To get supplies of fuel,water, and rations it was necessary to go to Souilly, a distance of 7? miles.The evacuation of patients to trains, to organizations, and to the rear stillfurther embarrassed the transportation facilities. Upon every occasion whentransportation was needed, a request had to be sent to the transportationofficer at Souilly that a truck be sent for this purpose. Since a truck was notalways available at the time it was needed, this arrangement was veryunsatisfactory. Later, about the middle of October, a truck was assigned fromSouilly, to be used conjointly with Neurological Hospital No. 3 at Nubecourt,about 15 miles distant. This plan proved to be more satisfactory. An ambulancewas also assigned to the hospital and was used largely for evacuating patientsto Souilly. Sometimes, when the truck was not available, it was used to obtainsupplies.

Except on very few occasions, it was not difficult to obtaina sufficient supply of clothing for the patients. The majority of the men, uponbeing returned to their organizations, were equipped with completely new outfitswith the exception of rifles.

In the latter part of the month of October a workshop was putin operation. A reconstruction aide was detailed from Base Hospital No. 117 toconduct this department.

Over 60 per cent of the patients admitted to ArmyNeurological Hospital No. 1 were restored within an average of 10 to 14 days toa state of apparent stability. By this is meant a condition in which theyacknowledged that they felt well, in which they expressed themselves as willingand anxious to return to their organizations, and in which to all appearancesthey seemed to be able to do so.

The plan employed to bring about these therapeutic resultsincluded every psychotherapeutic device, but emphasis was placed chiefly uponpersuasion, suggestion, and a simple, practical psychological reeducation. Theofficer of the day admitted all patients. It was his duty to explain to thesoldier in the receiving ward upon admission the exact nature of his condition,and to reassure him as to the prognosis. There was discernible almostimmediately a relaxation of the tension characteristic of practically all thepatients. The soldier was relieved of a good part of his anxiety. He was thenbathed, fed, and put to bed; whereupon he usually fell into a profound slumberwhich lasted 36 to 48 hours. Then, after a careful examination of the patient bythe ward neuropsychiatrist, it was the duty of the latter to talk to thesoldier, explaining the mechanism of his condition and treating by suggestion orpersuasion such symptoms as were present. The next step in the therapeuticprocedure was an interview by the commanding officer. The latter took thepatient into a room by himself, went carefully with him over the history of histroubles, explained

330 

the nature of his symptoms in a way that robbed them of anyresidue of horror or mystery, and finally gave reassuring suggestions. After abrief period of rest under these conditions, usually lasting three or four days,the patients were put on a schedule which occupied the whole day. This includedperiods of rest, of exercises and calisthenics graduated according to thecondition of the patient, and of recreation, which included games and groupsinging. In from 12 to 14 days from 60 to 75 per cent were fit for front-lineduty.

Sometimes, unfortunately, it was not possible to evacuate thepatients at once as they should have been when their recovery had reached thispoint, due to the difficulty in obtaining transportation, inability to locatethe headquarters of their organizations, or other similar reasons. As a resultof this delay, in a small number of cases, vague hypochondriacal phenomenadeveloped which became more fixed the longer the patients remained in thehospital.

In handling the enlisted men it was originally planned tohave an admission ward and then graduate the patients through a series of wardsas they improved, the end ward being occupied by recovered cases awaitingtransportation to duty. With the pressure of case admissions (which notinfrequently ran more than 30 a day, the hospital at times containing more than100 cases over its normal capacity) this plan was found impracticable. And socases were admitted to each ward, with the exception of one reserved forready-for-duty cases. An added advantage in this procedure was that the wardphysician saw his patient all the way through.

The patients on admission were seen by the officer of the dayand obviously unsuitable (medical and surgical) cases were sent to evacuationhospitals near by. "Exhaustion" was the label of most of the medicalcases and often it required a day's observation before a definite diagnosiscould be made and transfer effected. Many of the cases as they were seen in theadmitting office presented coarse tremors and tics and other hystericalsymptoms, and it was soon learned that much therapeutically could be doneimmediately by simple suggestion and explanation and reassurance in theadmitting office. Not infrequently a well-marked coarse tremor of theextremities would be cleared up before the patient had his routine admissionbath. The majority of cases on admission were tired out, and at least a day inbed was a routine necessity, the beneficial effect of which was very striking.As soon as possible afterwards the patient was gotten up and about and assignedto routine duties.

Since the number of hospital enlisted personnel was small,and there was so much of the routine hospital fatigue duty to do, the patientswere never at a loss for occupation, as far as needed work was concerned. Drillsand practice marches were used at first under the charge of an officer patient,but these later were superseded by work detail, with an initial daily setting-upexercise under a sergeant. There was a variable percentage of work dodging, buton the whole the patients were fairly industrious and idleness was not theproblem here that it was in many of the base hospitals. Latterly an occupationshop was started under the supervision of a trained worker, and the activitieswere mainly with wood and metal work; it proved of considerable interest to thepatients, and was valuable, especially for the cases with tremors and difficultyin concentration.

331

The general treatment of the war neuroses, summed up, was thefollowing: Rest when indicated, persuasion, suggestion, work, and psychologicalreeducation. In dealing with the cases fresh from the line, after one'sexperience with the older cases, it was most striking how much more suggestiblethe former were seen to be. Hysterical symptoms that might require hours oftreatment in a base hospital could frequently be cleared up by suggestivetherapy in a few minutes in a fresh case. It was the policy of the hospital notto transfer cases deemed unsuitable for immediate front-line service to BaseHospital No. 117 as long as gross objective, hysterical symptoms persisted. Thissuggestibility worked both ways, and unless the therapeutic side was pressed thesymptoms tended to become rapidly fixed. But the advantage was with thephysician.

Upsetting battle dreams were likewise easier to clear up inthe fresh cases. These battle dreams were among the few symptoms that seemed tobe as marked in the fresh neuroses as in those longer from the line, and theywere the most common complaint. (They were frequent in fresh wounded cases aswell.) Some patients would stay awake night after night to avoid them. Usuallysimply explaining the dream mechanism and urging the patient to ventilate andmentally assimilate his affect-charged battle experiences rather than "tokeep them out of the mind" during waking hours was quite sufficienttherapy; very rarely were hypnotics required.

One of the most valuable assets in the treatment of theneuroses was the creation of a ward atmosphere of cure. The patients were quiteobservant of one another, and a cured case which they had seen from thebeginning was a most useful asset. Once the atmosphere of cure was created apart of the therapy became automatic. The ward atmosphere depended almostentirely on the ward surgeon, and it was most striking how quickly theefficiency of the doctor was reflected in the therapeutic results of his ward.Certain members of the staff had had the advantage of training at Base HospitalNo. 117 under the stimulating influence of the medical director there.

In every soldier probably there was some degree of mentalconflict between, on the one hand, the instinct of self-preservation and, on theother hand, the more socialized "carry-on" urge and desire for socialesteem, with regard to front-line service. There were three possibilities:First, the "carry-on" driving force predominated, which was thecondition of the normal soldier, and of not a few neurotic individuals.Secondly, if the "carry-on" force was weak or absent, a neurosis mightnot develop because the conflicting forces were too unequal and there was littletendency to symptom fixation. These were the fear cases, and certain of themwere very honest individuals in their "I can't stand the gaff"attitude. Thirdly, when the two opposing forces were approximately evenlybalanced, a soldier might perform his duties fairly well until someenvironmental factor, such as a shell explosion, upsetting emotional experience,fatigue, or minor trauma, disturbed that balance in favor of self-preservation,and a neuroses developed. The symptoms of the neurotic, while out ofproportion to the more immediate upsetting event, were usually not out ofharmony with it; for example, the relationship between a slight hip trauma and asubsequent functionally paralyzed leg; between a somewhat thin concussionexperience and a headache and tremor, or, perhaps, deafness;

332

between an upsetting emotional experience and the developmentof an anxiety state, etc.

Undoubtedly many soldiers carried on after the same sort ofexperiences as sent most of the neurotics to hospitals. The cumulative effect ofthese upsetting experiences must have been large and in time might break men ofgood balance and make-up. A number of cases held on until their divisions wererelieved from the line and then snapped when the sustaining power of action wasremoved.

Life itself being represented by a series of adjustments andcompromises between the individual and his environment, the war neurosesfurnished no exception. At one extreme was the pure concussion group, and alliedto this were the cases in which trauma and exhaustion played the most prominentpart; at the other extreme were the fear cases, in which the personal elementpredominated. Between these extremes fell the bulk of the neuroses, theenvironmental and personal factors participating in varying proportions, seizingand fixing on the most available experience, as shell explosion, fatigue,trauma, upsetting emotional event (killed comrades, etc.).

Neurotic symptoms were quite natural after many of theseexperiences, and consciousness probably played a very minor part, if any, intheir incipiency. But into the maintenance of the neuroses, the conscious factorentered to a greater extent. Any doubt as to this was removed by the decidedlyameliorating effect of the armistice on the majority of the cases. Thefear-group cases were largely conscious of the difficulty all the way through,but these were not cases of malingering, because there was no conscioussimulation. There may have been a degree of malingering in some of the neuroses,but pure malingering undoubtedly was rare.

In civilian cases of neuroses, along with changing thepatient's attitude toward himself, it is nearly always possible to modify theenvironment in which the neurosis arose. The problem of the war neuroses wassimpler and more difficult-simpler to the extent that the conflicting forceswere less obscure, and more difficult in that the aim of treatment was to enablethe patient to be sent back to the same precipitating environment, i. e., thefront line. The soldier's neurosis was his reaction and adjustment to anunbearable situation, and it had a double-barreled potency: To get him out ofthe situation and keep him out of it. This last factor probably accounted forthe tendency later to symptom fixation, and this was the more immediatetherapeutic problem. A simple mechanistic explanation of the neuroses washelpful to the patient. But more valuable from a therapeutic standpoint was theeffect of a definite attitude on the part of the ward surgeon that the goal oftreatment of the war neuroses was return to duty.

There were three avenues for the disposal of patients fromthe army neurological hospital: Return to duty; transfer to Base Hospital No.117, the special base hospital for the neuroses; and transfer of the medical,mental, and surgical cases to other hospitals where more appropriate care andsupervision could be given them.

The primary function of the hospital was to return as manycases as possible to duty with their divisions, and in as short a time aspossible. The average

333

duty case was in condition to go back within 10 days,although there were exceptions. It is impossible to estimate from the length ofstay in the hospital the time required for recovery because most of therecovered cases would have to wait over in the hospital, sometimes for severalweeks, until a particular division could be reached. The hospital received mostof its cases from the north and east of Verdun, and the delay in return to dutywas more marked when the divisions moved from sector to sector. Just before thearmistice was signed, arrangements were made to return the duty cases to corpsreplacement camps rather than to their divisions, and this facilitated mattersgreatly.

The question of return to duty was complicated by thepossibility of relapse. On the 532 cases returned to duty, 15 cases were knownto have come back to the hospital with relapses; none of them lasted more thanone day under fire. Soon after the opening of the hospital 22 cases werereturned to duty in one group and within 24 hours 11 of them (included in theabove 15) were sent back with an assortment of hysterical symptoms. They hadspent the night in a village that was heavily shelled. This experience made onemore cautious in the selection of line-duty cases. When a division was in alarge area and participation in heavy fighting followed recoveries were moredurable.

The relapses were all cases of hysteria and hyperemotivity(fear), and these were the two groups that presented the main problem inselection for duty. With the exception of certain of the concussion cases, therewas in the general attitude of the patients in the hospital a distinct absenceof any keenness of desire to return to front-line service. The question beforethe hospital staff with nearly half of the hysteria and fear cases was: Which iswiser from the standpoint of army efficiency, to send these men back to thefront line on the chance that they will carry on or to send them to BaseHospital No. 117 to be reclassified as labor troops? One's first impulse wasto carry out the former alternative, especially if one were dealing with a plaincase of fear. There was another point of view to consider, however, and that wasthe line officer's. Even if the hysterical and fear cases were not contagiousin the front line, the chances were that they would not be individuallydependable. There were exceptions, of course. Furthermore, at a time when everyavailable bit of transportation was needed for wounded men, a seat in anambulance for a relapsed nervous case seemed rather superfluous.

Before troops went into the front line for the first time itwas a hazardous proposition to predict which individuals would develop"shell shock." Men who had been visibly "on edge" oftencarried on well, and vice versa. The front line itself was the only test. Therewas a history of neuropathic make-up or neuropathic stock in about 40 per centof the cases of war neuroses admitted. In 100 case records selected at randomthe family history was positive in 38 and the personal history in 40. Muchdepends on the criterion for the term neuropathic. This 40 per cent included thecases with any definite history of nervous or mental anomalies whatever in stockor make-up. Certain of the ward surgeons went into this question carefully,others more casually; so the 40 per cent is only an approximation.

The average American soldier's attitude toward "shellshock" had a large proportion of tolerance and curiosity in it. An attemptwas made to abolish

334

the term. Although this could be done in officialcommunications, it was manifestly impossible in ordinary speech. Much moreprofitable was the dissemination of information among the troops as to just what"shell shock" meant. The divisional variation in the number of suchcases was very striking-it occurred in inverse ratio to the morale. Among thepatients themselves there were two main attitudes. The first was to this effect:"You're a long time getting it; but once you get it, it's gotyou"; and the second: "It's easy to get and easy to get over."The majority of them agreed on one point-they were unfitted for futurefront-line service. This attitude was one of the main problems to combat in theneuropsychiatric hospitals.

It was essentially the unfavorable type of neurosis that wasevacuated to Base Hospital No. 117; that is, unfavorable at least as far as anyimmediate return to front-line duty was concerned; and so the army hospitalsmade the work at Base Hospital No. 117 more difficult in this way but operatedfavorably through having exposed these patients early-often a few hours aftertheir breakdown became noticed-to a psychiatric point of view. A number ofcases were sent to Base Hospital No. 117 to be reclassified, inasmuch as onlyclass A duty was possible from the army hospitals. The general level ofintelligence of the neurotic patient was certainly not below the average, andthe vast majority of those who were unfit for front-line service werequite-efficient workers in the base sections.

The officer patients, 66 in number, were included in thefigures already discussed. On the whole they presented distinctly less favorablematerial for return to duty than did the enlisted men. There was one featurecommon to nearly all of them on admission-fatigue. Seventeen of the 66, or 25per cent, were returned to duty as compared with 61 per cent of the enlistedmen. Another factor entered into the selection of duty cases here, for if anenlisted man relapsed it was more or less of an individual problem; while in thecase of relapse of an officer during the prodromal period, his wavering mightaffect more than himself. However, with most of them there was small choice;they were unfit for return to front-line commands.

The following is a summary of officer cases:

There were but two pure concussion cases among the 66officers and both returned to duty, as did the single case of simple exhaustion.The hospital stay of these three cases, in which the causative factor was soacute and strenuous, ranged from three to seven days.

335

Hysterias and neurasthenias predominated and there was adistinct "can't-stand-the-gaff" attitude among these and themajority of the other cases of neuroses among the officer patients.

Some of the crudest cases of hysteria in the hospital werefound among the officers. More striking differences existed in neurasthenia andpsychasthenia; the former was five times as frequent among the officers as amongthe men, and of the latter, three of the four cases seen were officers.

The following list is a comparative percentage list of theneuroses as they occurred among the officers and enlisted men:

The following tabulation summarizes the disposal of cases, bymonths:

In addition to these there were 5 desertions and 3 deaths,making a total of 1,003 cases. The 124 cases which were transferred to otherhospitals (medical, surgical, and mental observation) may fairly be eliminatedas being complications in a hospital that had for its special problem theemergency treatment of the war neuroses. Of the cases which may properly beincluded under the term war neurosis, 61 per cent were returned to front-lineduty.

CLINICAL ASPECTS OF CASES^b

During the period from September 26 to November 11, 1918, 1,003cases passed through Neurological Hospital No. 1 at Benoite Vaux. These patientswere relatively fresh cases, admitted usually within 24 hours after they weresent from their divisions. The more favorable cases-those which could bereturned to duty within a few days, especially cases of exhaustion-weretreated by division psychiatrists in the field hospitals as far as possible.Consequently, few cases of pure exhaustion were received in Army NeurologicalHospital No. 1.

^bBased upon a report made by the commanding officer, Army Neurological Hospital No. 1, First Army, to the senior consultant in neurology, A. E. F., undated. Copy on file, Historical Division, S. G. O.

336

There were five cases of gunshot or shrapnel woundsaltogether, and two of them were too slight to require surgical dressing. One ofthe remaining three had a finger wound (gunshot, right fourth finger). This wasthe only possible self-inflicted wound case admitted and there was nocorroborative evidence here. Another case had multiple shrapnel wounds and wastransferred immediately; and the last case sent in as an epileptic, proved tohave a shrapnel fragment in the right parietal region. The common observationthat wounded men do not develop "shell shock" was well borne out.

The 74 cases which were psychiatric or epileptic, wereevacuated as speedily as possible to a special hospital (Base Hospital No. 116,at Bazoilles) for further mental observation. The 10 neuritis (unwounded) casesshowed the following involvement: Facial, 3; musculospiral, 1; ulnar, 1;multiple (post-diphtheritic), 5. Included among the acute infectious diseaseswere one case of epidemic cerebrospinal meningitis and two cases of acuteanterior poliomyelitis, one of the latter possibly syphilitic in origin. Therewas one case of organic nervous disease (an early amyotrophic lateralsclerosis), and this, together with one uncomplicated case of mental deficiencythat passed through the hospital, speaks well for the efficiency of theneuropsychiatric weeding out in the camps in the United States. A small numberof other mental defectives was admitted, but they were all neurotic as well.

The acute infections were admitted mostly as cases of"exhaustion." This was especially true of the pulmonary cases, eightof which proved to be lobar pneumonia. There were three deaths in all in thehospitals; two from lobar pneumonia, and one case (an Austrian prisoner) died onthe day following admission, from gas poisoning, probably phosgene.

The 10 cases of concussion by explosion were differentiatedfrom the war neuroses because they showed no neurotic feature whatever, and fromtheir histories there was no reason to believe that any factor entered intotheir causation other than concussion. Of these 10 cases, 8 were returned toduty. The other two were transferred to a surgical hospital-one because of thepossibility of a fractured skull and the other because of a complicatingsuperficial abscess of the right temporal region.

^cThe belladonna poisoning cases were caused by eating belladonna berries found in the woods, most of the cases being admitted in a very active toxic delirium.

337

There was no evidence of organic nervous disease in any ofthese cases, and most of them were convalescent when admitted. The diagnosisdepended largely on the history, the patient's condition, and the absence ofneurotic features. The following case is an example:

Pvt. J. C., 4th Infantry. Age, 26; civilianoccupation, locomotive engineer. The patient's family and personal historywere negative and his make-up was normal. He was drafted in May, 1918, went toFrance the following August, and was sent with replacements to the 3d Divisionin September. He carried on well and showed no undue reaction to shelling. OnOctober 10 he was knocked down by a shell but was not unconscious, and continuedhis duties. On October 21, during a barrage, he remembered vaguely running for ashell-hole. "There was a kind of puff and I didn't know any more until Icame to and it was dark "-evidently an initial period of unconsciousnesslasting some hours. He had a violent headache and was dizzy, weak, and shaky. Heremembered vaguely being carried on a stretcher and remembered the triage on thefollowing morning. He lost consciousness again for several hours at the triage.Two days later he was admitted to the neurological hospital in a semicomatosecondition, from which he gradually emerged on the following day. His memory fromthe time he left the triage until his arrival at the hospital was very hazy. Hewas in fair physical condition and there was no sign of organic neurologicaldisease. His main complaints were headache, dizziness, weakness, and shakiness,the last being more subjective than objective, although he had well-markedcoarse hand tremor. He was up and about the third day in the hospital, and bythe sixth day his complaints had cleared up entirely, with no especialtreatment. He was anxious to return to his outfit, and this was done 10 daysafter his admission to the hospital.

As stated above, of the 1,003 cases admitted, 818 wereclassified as war neuroses. The classification followed was essentially thatformulated by the medical director of Base Hospital No. 117. (See p. 355.) Asidefrom the value of this classification (inasmuch as about one-third of the caseswere evacuated to Base Hospital No. 117) it was very helpful to have a commonlanguage. This was primarily a working classification which conformed to theMedical Department diagnosis requirements, and was not merely an attempt topigeonhole the cases. It was fully understood by all that it lacked many of therequirements of accurate psychiatric work.

338

The following list shows the percentages of the various neuroses returned tofront-line duty (based on the preceding table):

It is evident that the more clearly exogenous theprecipitating factors the better were the prospects of return to front-lineduty.

Concussion syndrome was a term applied to cases in which theconcussion factor was the predominant one, but not so exclusive as in theconcussion by explosion group. The distinction is not a sharp one and it had tobe largely from the history of the case; it arose from a desire not to prefacethe undoubtedly pure concussion cases with the term "psychoneurosis"on the field medical card. The following case is illustrative of the concussionsyndrome group:

Pvt. A. B., 4th Inf. Age 21; civilianoccupation, coal miner. There was nothing abnormal in the patient's family orpersonal history or make-up. He enlisted in June, 1917, and came to France inApril, 1918. He served with the 3d Division at Chateau Thierry and in theArgonne, and had no nervous symptoms. On October 22, after 21 days in the sectornorth of Verdun, he was returning to his company after taking some prisonersback. The shelling became hard and he took refuge near a bank. A shell was heardcoming and that was the last he remembered until he pulled himself out of somedirt. He was dazed and had a headache and was nervous, reported to the first-aidstation, and was sent to the rear. On October 25 he was admitted to the hospitalas a walking case. He complained of headache. Physical and neurologicalexaminations were negative. His attitude was good, and he returned to his outfiton November 4.

In the next group, the concussion neurosis, there was ahistory of a concussion experience, but it was much less definite and theoutstanding feature was that the usual post-concussion complaints-headache,dizziness, general aching, tremor, and weakness-showed a tendency to becomefixed and often to be elaborated. In other words, a neurosis had developed. Thefollowing is an illustrative case and it might well be termed hysteria:

Sgt. E. R., 1st Pioneer Inf. Age 23; civilianoccupation, leather worker. The patient's father had diabetes. The personalhistory was negative. He was earning $24 a week at the time of his enlistment inMay, 1917. He came to France in July, 1918, and served in the Chateau Thierryand Verdun sectors. The first time under fire he "was nervous and shookup," and couldn't sleep, and was shaky that night. The other men laughedat him. This passed off after the first day. He was with his regiment in theVerdun sector from September 26, and was very nervous when the shells hit close.Finally, on October 22, he was near a shell explosion that blew up three of hismen. He saw the shell explode and the men blown up, and he himself was throwndown and lost consciousness. He came to in a hospital and "felt dizzy andlight-headed, had headache, and was shaky." Two days later (October 24) hewas admitted to the neurological hospital. His complaints were: "I feel dizzy and have pain in the backof my head." Physical examination was negative. He seemed to be ofquestionable material and his headache and dizziness persisted. He wastransferred to Base Hospital No. 117 on November 8, 1918.

339

There were 65 cases in which the history and examination left no doubt thatshell concussion was the dominant factor: Concussion by explosion, 10;concussion syndrome, 55. As has been said, two of these cases were transferredbecause of surgical complications. All but one of the remaining 63 casesreturned to front-line duty. Of the concussion neurosis cases-in which theconcussion history was less clean-cut and the subsequent fixation symptoms werepronounced-only half the cases were returned to front-line duty. One can notavoid the conclusion that the more dominant and clean-cut the concussion factor,the more likelihood there was of the case being returned to duty. In thisconnection the individual make-up had to be taken into consideration. Thegenuine concussion cases were found, on the whole, to be individuals of superiorstamina and attitude, compared with the others. Most of them would probablyhave carried on after a less clean-cut history of concussion, such as oneobtained from the concussion neurosis. A shell is no discriminator of theindividual make-up. The main thing is the individual's reaction to thesituation.

One's estimation of the importance of the concussion factor had to be madelargely from the history and the way it was told, and in most of the cases itoffered no especial difficulty. When objective findings, such as unconsciousnessand unsteadiness, were present, the diagnosis was greatly facilitated. There wasone apparently comatose case that offered some doubt as to diagnosis-until hetried to bite the examiner. Usually the real cases had been carrying on well andthere was a history of sudden loss of consciousness, with a rather hazy memoryfor the immediate concussion setting. As a rule the patient did not rememberhearing the explosion clearly, but this condition was not invariable. It seemsprobable that the better the man's fiber the more tenacious he is ofconsciousness. It was striking, on the wards, how quickly these concussion casesbegan to improve and ask for activity and duty. This request was not observedparticularly in any other type of case in the hospital.

Between the concussion neuroses and the hysterias the distinction is asliding one. Undoubted cases of hysteria may be precipitated by a concussionexperience, although it is usually a fairly safe one. The term hysteria was usedin a rather restricted sense and included such symptoms as paralyses,anesthesias, aphonias, stammering, blindness, tremors, tics, gait disorders,amnesias, and fits.

A history of loss of consciousness was rather common in the hystericalcases, but on questioning it was evident that previous symptoms had shownthemselves and that the way had been prepared for the final concussionexperience. The stories of the explosion in these cases were vivid in detail,and consciousness was usually regained suddenly. In most of them the factor thatdetermined the symptom picture could be elicited, i. e., being thrown on onehip, followed by paralysis of that leg; functional deafness following the soundof an explosion; and arm and shoulder tic developing after a rifle carried onthat side had been struck by a piece of shrapnel, etc.

The following case of hysteria was interesting because a longitudinal sectionof the patient's experience in the American Expeditionary Forces was known, aswell as the cross section condition that he presented on admission,

340

and which necessarily had to be the chief criterion in sizingup so many of the cases:

Sgt. L. F., P. W. E. Co. 89, First Army. Age 23. The familyhistory was negative. The patient was graduated from high school at 16, and hadbeen in the Regular Army since 1913. He went to France in June, 1917, and sawmuch service with the 1st Division. He gave a history of a slight wrist shrapnelwound in October, 1917, and some months later was gassed in the Toul sector. Hewas treated at Base Hospital No. 15 for this, and was discharged from thehospital in February, 1918. On June 10, 1918, he was blown up, with loss ofconsciousness, at Chateau Thierry, and was sent to a French hospital, where hischief complaints were headache and abdominal pain. He protested to a passingAmerican officer that he was receiving no treatment from the French and was thentransferred to an American hospital. The surgeon in charge decided that he hadappendicitis and determined to operate. The patient refused operation andcharges were preferred against him for this, and he was brought to Base HospitalNo. 117 in this status. (This is largely the patient's own story.) At BaseHospital No. 117 his principal complaint was headache, and he was verysolicitous in his attitude, and at times emotionally unstable. (One of hisbrothers in his own outfit had been killed shortly before.) The headachepersisted unimproved for some weeks, and it was difficult to get the patientinterested in occupation. It was learned that he was quite fond of horses, andso he was given some light duties in connection with the stables. Within a veryshort time his neurotic symptoms cleared up (there never was any evidence oforganic disease), and he was discharged to class A duty July, 1918. Whileawaiting assignment at the replacement camp at Is-sur-Tille, a charge ofdynamite exploded near him and he became shaky and upset, and when readmitted toBase Hospital No. 117 a few days later he presented coarse tremors of the armsand legs and a very marked stammer. These symptoms were cleared up easily withsuggestion. It was felt that he would be unfit for any sort of line service, andso he was reclassified C-1 and sent to back-area duty in September, 1918. Hewas assigned to a prisoner-of-war escort company, and the next seen of him wason November 17, 1918, when he was admitted to the neurological hospital,presenting coarse tremors, a dodging head tic, and a bad stammer. In the rapidAmerican advance during the week before the armistice was signed, his dutiestook him close to the retreating Germans, and on November 8 he was caught in abarrage, became shaky and weak, and the above symptoms developed. He "shooklike a leaf, wanted to run, and didn't know what he was doing." Heremained in a dugout for some days, until discovered by passing soldiers. Underthe influence of the armistice and suggestion he cleared up rapidly, and wasreturned to duty a few days after his admission to the hospital.

The anticipation neuroses were cases which developed thevarious war neurotic symptoms before getting anywhere near the front line. Theywere essentially cases of hysteria, but less respectable, and very tenacious oftheir symptoms, and prone to relapse. They took few chances.

At the instance of the commanding officer of the hospital,the term traumatic neurosis was applied to a somewhat heterogeneous group. Inthese cases there was a history of a precipitating trauma, separated from theconcussion neuroses, because there was no history of associated loss ofconsciousness. These cases also showed a much smaller tendency to symptomfixation than did the concussion neuroses, and the percentage returned to dutywas relatively high (86 per cent). Most of them might be considered as hysteriaof a better class. The following case is an example:

Pvt. H. K., 102d Inf. Age 24. Interior painter. His motherwas "very nervous-subject to headache." The personal history wasnegative aside from some alcoholic excess. He was drafted in April, 1918, wentto France in June, and was with the 26th Division in the St. Mihiel andMeuse-Argonne operations. On October 25 he was very nervous and shaky during abarrage, but he managed to carry on. On October 27, he said, a machine-gunbullet

341

went through his legging and that same day a shell explodednear him and he was knocked against a tree. He did not lose consciousness but"lost his nerve"; his comrades told him he was "crying andcarrying on and shaking." His memory was rather vague at the time. He wasadmitted to the neurological hospital on October 29, complaining of pain in hisback (lumbar region) and under his knees. He was also troubled with insomnia.His physical examination was negative and he appeared to be of fair stuff. Hiscomplaints cleared up rapidly, and he was returned to his outfit on November 4,1918.

As has been stated above, cases of pure exhaustion werenearly all sent back to duty from their divisional hospitals. The exhaustionneuroses comprised the cases in which the fatigue symptoms became more fixed,and between this group and the neurasthenias the distinction was a relative one,depending on the intensity of the precipitating fatigue and on the consequentdegree of fixation of the fatigue symptoms. The former was less marked and thelatter was more marked in the neurasthenics. These cases usually gave historiesof fatigue reaction in the line that was disproportionate and not acute; morethan half of the neurasthenic cases were not returned to line duty because oftheir tendency to symptom-clinging. The following case is of the neurasthenictype:

Pvt. H. C., 102d Trench Mortar Battery. Age 25; occupation incivil life, assistant librarian. The patient's mother "has trouble withher heart anti nerves and is very excitable." He himself had been subjectto "palpatation of the heart" for several years. He enlisted in June,1917, and went to France one year later. His first line experience was in theVerdun sector and he "was much frightened and nervous all the while inaction. Shivered and couldn't stop." He "never could hike verywell"-his "heart would beat fast." On October 15, after a hike,he "fainted away," and was very weak afterwards. On the following dayhe was sent to the field hospital, and on October 19 to the neurologicalhospital. "I don't feel strong at all and have headaches." Therewas no evidence of organic nervous or heart disease. His pulse rate wouldincrease from 72 to 120 per minute after exercise. Mentally he was "not astrong character." His complaints of weakness persisted and he wastransferred to Base Hospital No. 117 on November 8. He seemed to be quite apotential effort syndrome case, but his subjective symptoms were not fixed onhis heart-as yet.

The r?le of fatigue in the vast majority of all admissionswas an important one. Nearly all the cases came into the hospital in much thesame condition in which they left the front line, and their common denominatorwas fatigue. It is quite probable that many neuroses developed because a patient'sresistance was lowered by fatigue, just as sometimes a long argumentative speechis successful for the same reason and not because of any increase of potency in the argument. If fatigue, however, were the only factor, then therewouldbe no disproportionate symptom fixation. One could frequently see just astired-looking soldiers hiking with their divisions. Many of the cases ofexhaustion were associated with the diarrhea that was so prevalent during theMeuse-Argonne operation. The following case is typical of the exhaustion type:

E. M., corpl., 101st Field Signal Btn. Age 21; electrician.The patient's family and personal history were negative. He enlisted in April,1917, and went to France in June, 1918. He was with the 26th Division during theSt. Mihiel and Argonne operations, and showed no undue reaction to shell fire.He had been under fire continuously for nine days previous to his admission tothe hospital on October 31, and had had diarrhea for a week. Finally he"fell over and was helped back to the first-aid station." He had hadlittle rest and limited food and heavy work and was "all in," andthis was his main complaint on admission. Physically, aside from a slenderbuild and tired-out appearance, he presented no anomaly. He made a quickrecovery, and was returned to duty on November 4, 1918.

342

The gas neuroses were by no means the problem during theMeuse-Argonne operation that they were in certain of the earlier and lessimportant operations. This was possibly due, in part at least, to the increasedgas morale in the divisions, and perhaps also to the development of gashospitals. But two of these cases were seen at this hospital. The gas-neurosissymptoms were to the lungs what effort syndrome was to the heart. Visits to gashospitals by the senior consultant in neuropsychiatry and the corps consultantsin neuropsychiatry were helpful means of providing gas medical officers with thepsychiatric point of view toward these men.

There were but five cases of effort syndrome altogether amongthe thousand patients admitted. This low number was rather surprising at firstbecause at Base Hospital No. 117, where the patients filtered from otherhospitals, it was not unusual at times to find 5 cases of effort syndrome in award of 40 patients; all of which emphasized the r?le of hospitalization as aculture medium for effort syndrome. These cases required special treatment ofgraded activities and were evacuated with the recommendation that they be sentto our special convalescent camp for effort syndrome at Liffol Le Grand.

The hypochondriases, anxiety neuroses, and psychastheniaswere of the same type as those seen in civilian life; they were persistent incharacter, and this was reflected in the low proportion returned to duty.

A final group was labeled "hyperemotivity" and"state of anxiety." In nearly all of these cases the funk element waspredominant and the common attitude was "I can't stand the gaff."The term hyperemotivity was included in the field card diagnosis of these casesat the suggestion of the commanding officer of the hospital. This term was usedin reference to the exaggerated jump and emotional reaction shown andoccasionally such phenomena as tachycardia and increased sweating, and slightcyanosis of the extremities. There was no definite evidence of thyroidenlargement in any of these cases.^a

The state of anxiety was a much more modified picture ofanxiety than is seen in a typical anxiety neurosis where the cause of thecondition is not so clear to the patient. In these fear cases the anxiety waswith reference to the future, especially as it concerned return to front-lineduty, for these individuals did not have the symptom alibi of an hysteric orneurasthenic.

The jumpiness to noises, while frequently seen in the othertypes of neuroses, especially the concussion neuroses and hysterias, was moreprevalent in the fear group. Certainly it was much less marked in the trueconcussion cases. On the whole, there was considerably less of this jumpreaction among the fresh war neuroses than among the older cases at BaseHospital No. 117. There was quite a tendency among many of the patients whoshowed it, not to try to control their jumpiness. It was regarded asdemonstrable proof that they were genuinely "shell shocked," and theself-styled "shell-shock" cases fell mostly in this group.

^aThe number of enlarged thyroid glands among the war neuroses as a whole was insignificant. This was in contrast to one's experience with the British "shell-shock" cases, in which signs of thyroid enlargement were found sometimes in as high as 10 per cent. Most of the British soldiers had had repeated experiences in the line, while the Americans were relatively fresh. It suggests that thyroid enlargement may be secondary to the emotional reaction and not primary. It is possible, too, that the contrast was increased by the elimination of individuals with enlarged thyroid glands at the training camps in the United States. The facial expression of horror which was not infrequently seen in the British "shell-shock" cases, particularly those with repeated exposure, was seen in just one case at the neurological hospital. This patient proved to be hysterical and recovered within a week.

343

Many of these state-of-anxiety cases gave a story ofconcussion, but it was more than doubtful. Upsetting emotional experiences-companionskilled, etc.-were common and probably very potent factors as the "laststraw" in the development of the condition; sometimes such experiences werethe "first straw." Fifty-two per cent of this group were returned tofront-line duty. The following case is typical:

C. S., private, 61st Infantry. Age 21; drug clerk. A maternalaunt was insane. The patient was "sickly" until 2 years of age, hadenuresis until 8, and was regarded as a "nervous child." He finishedhigh school at 18. In July, 1918, he was in a quiet sector, but in September,1918, during the St. Mihiel operation, he was under fire for two days and became"unnerved and fearful." Beginning October 10, in the Verdun region,his sleep became poor, and he was bothered by battle dreams, horrible sights,etc. October 12 he lost his company (a not infrequent occurrence among thesecases) and said he scarcely remembered what he was doing. He remembered,however, wandering about among the organization of the 30th and later the 7thInfantry. Toward night he saw a soldier stagger from the woods, and started togive him first aid when a shell exploded and cut the man in two. The patientdropped his gun and ran terrified until exhausted. He was picked up and sent tothe neurological hospital on October 17, complaining mostly of "nervousness,poor sleep, and upsetting dreams." His deep reflexes were increased, butthere was no evidence of organic disease anywhere. He asked for work in the rearof the front line and said he could never stand shell fire again. There was someemotional instability; he wept easily; and he was terrified at the prospect offront-line service. He seemed to get a better grip on himself, and was returnedto duty several weeks later. The armistice precluded a probable relapse.

ARMY NEUROLOGICAL HOSPITAL NO. 2, FIRST ARMY

Neurological Hospital No. 2, established at Toul, September7, 1918, became a part of the Justice Hospital Group and occupied one of theseries of buildings which had formerly been a French barrack.¹²Thebuilding was a four-story, stone structure with a capacity of approximately 800beds. In addition to this building, there were available one small building,which had been employed previously by the French as an infirmary, withfacilities for 40 patients, and two other small buildings. Of the latter, onecontained three rooms, two of which were used as officers' quarters, and thethird, a good-sized room, as a recreation room for officer patients; the otherbuilding, situated at the gate, contained seven small rooms which were used asquarters for the female nurses.

Since the buildings were not in fit condition to receivepatients, it was necessary to employ a number of French women, who, with thenurses and enlisted personnel, proceeded to clean up the buildings. In less thana week's time and quite in time for the St. Mihiel operation, which began onthe 12th of September, 600 beds were ready for patients.

The St. Mihiel operation lasted about four days, that is fromSeptember 12 to 16, and the number of war neurosis cases admitted wassurprisingly small, owing to the character of the operation. The rapid retreat ofthe Germans, the comparatively small amount of exposure to high-explosiveshells, and the brevity of the operation which eliminated in a large part theelement of exhaustion, were the factors responsible for this small number ofcases.

During the month of September, 325 cases were admitted tothis hospital. Of this number, 44 per cent were returned to duty, 35 per centwere evacuated

344

to Base Hospital No. 117, 15 per cent were evacuated to BaseHospital No. 116, and 6 per cent to other hospitals.

During the month of October the number of cases admitted was116, being an average admission of about 4 per day. Of this number 101 werereturned to duty. The sources of admissions were other hospitals where thepatients had remained various lengths of time. The average duration of the stayin the hospital for these patients was 21 days. This was due to the fact thatmany of the cases developed acute influenza and other conditions which requiredmodifications of the treatment established for cases of war neuroses.

This hospital was abandoned on November 5, when part of thepersonnel was transferred to Neurological Hospital No. 1 of the Second Army andothers returned to their proper stations.¹²

ARMY NEUROLOGICAL HOSPITAL NO. 3, FIRST ARMY

When preparations were being made for the Meuse-Argonneoperation it was thought that the two neurological hospitals already organizedwould be insufficient to provide for cases which were expected to develop as theresult of this operation. The hospital at Toul was too far removed from the seatof operation to be available. The hospital at Benoite Vaux could not receive menwho were evacuated from the American front along the road leading south to theeast of Souilly, or admit patients from divisions in the rest area along thatroad. The senior consultant in neuropsychiatry planned, therefore, to establisha third neurological hospital somewhere in the neighborhood of Souilly, where agroup of evacuation hospitals was located. The hospital at Benoite Vaux was thenabout 15 miles behind the front line. It was the plan to establish ArmyNeurological Hospital No. 3 somewhere farther to the west and approximately thesame distance from the front lines. Thus evacuation from the front could be madedirectly from field hospitals to Army neurological hospitals without firstunloading patients at evacuation hospitals. The Army neurological hospitals weresituated parallel to the evacuation hospitals and were within easy reach of thefield hospitals by ambulance.

The site chosen for the third neurological hospital wasNubecourt.¹³ Army Neurological Hospital No. 3 was established inbuildings which had been occupied by the French as a neurological unit. This wasknown as Ambulance 8/V, during the French occupation of the Verdun section. Thebuilding consisted of a 12-room dwelling house, 2 barrack wards, and severaloutbuildings, making possible a total capacity of 220 patients. By the additionof tentage the hospital was further enlarged to a capacity of 400 patients. ArmyNeurological Hospital No. 3 was situated on the main road from Clermont-en-Argonneto Bar-le-Duc. It was also about 6 miles from Souilly, and thus connected withthe road from Verdun to Bar-le-Duc. This unusually favorable situation of thehospital greatly facilitated the evacuation of soldiers from the front areas.

In accordance with verbal orders of the representative chiefsurgeon of the First Army, on September 22, 1918, this unit was placed inoperation.¹³ Four medical officers were transferred to it fromNeurological Hospital No. 1. Thirty enlisted men were transferred from ArmyNeurological Hospital No. 1; of this number 20, including two sergeants, were ontemporary duty from Base Hospital

345

No. 117, while the remaining 10 belonged to EvacuationHospital No. 10. Supplies were obtained from the advance medical dumps atSouilly.

This hospital, from the moment of its establishment, began tooperate actively. As many as 242 cases were admitted during the first eightdays of its existence, when the Meuse-Argonne operation began. Of this number,229 came directly from field hospitals and were transferred by ambulance ortrucks directly from the front. This number represented the personnel of 16different units, of which 12 were divisions.

The memorandum which follows, sent September 30, 1918, by thesenior consultant in neuropsychiatry to the chief surgeon of the First Army, issignificant as indicating the value and success of this new type of hospital:¹⁴

The inclosed table shows the divisions from which patientshave been admitted to Neurological Hospital No. 3 at Nubecourt up to noonto-day. It is seen that the 35th Division contributed nearly 60 per cent of alladmissions. This is due to the fact that the division psychiatrist was notpermitted to retain nervous cases in the divisional hospitals on account of therefusal of the divisional officer having charge of evacuations. The only othertwo divisions which showed a large number of admissions (37th and 9 1st) hadaccidents to their triages which somewhat upset the place.

The significance of this table is that 7 officers andmorethan 100 effective men were needlessly lost to their division at a time whenevery officer and man was of the utmost value. Nearly all the cases received atthis hospital from the 35th Division were of the type which in other divisionsare being returned directly to their command after a few days' rest andtreatment.

No action is required in this matter on account of thecooperation which has been secured with the division surgeon. I am bringing itto your attention simply as an illustration of the advantage of the plan whichyou have approved. If all the divisions engaged had contributed an equal numberof cases more than 1,000 men would have been lost within the last 5 days fromthis controllable cause of noneffectiveness. This is certainly important from amilitary point of view, but more important still is the bearing which theevacuation of such cases has upon morale and the prevalence of these disorders.

During the month of October the activities of this hospitalwere very great, owing to the character of the Meuse-Argonne operation, and itwas necessary to increase its personnel in order to cope with its work.¹⁵The report made by the commanding officer showed, on November 1, anincrease in the personnel, consisting of 6 medical officers and 17 enlisted men.¹⁵During the month of October, 868 patients were admitted to this hospitalfrom 32 different organizations, of which 20 were divisions in the line. Of thisnumber, including 242 patients who were held over from the last month'sreport, 561 were returned to duty and 307 were evacuated to the rear. Of thosesent to the rear, 203 were sent to Base Hospital No. 117. The latter were casesthat had not recovered during a period of two weeks and required furthertreatment and observation.

The total number of cases treated at this hospital fromSeptember 25 to November 19 was 1,169. Of this number, there were 852 caseswhich could he diagnosed as psychoneuroses. Of these 852 cases, 614 weredischarged as recovered. Of the cases received at this hospital to which thediagnosis of psychoneurosis was made, which did not include the cases ofexhaustion from exposure or from overexertion and influenzal conditions, thetotal percentage of cases returned to duty was 73.12 per cent, the length ofstay in the hospital was 10.4 days.

346

The same psychotherapeutic principle which governed treatmentin the divisions and at Neurological Hospitals Nos. 1 and 2 were employed. Themethods by which they were put into effect at this hospital can be seen best byquoting from a report made by the commanding officer to the senior consultant inneuropsychiatry, as follows:¹⁶

As to the description of methods of treatment and managementemployed, the following may be said: The simplest form of therapeusis,consisting largely of hygienic measures, sufficed in the great majority ofcases. These included such measures as food in an easily assimilable form, a hotbath, clean clothes, and absolute rest in bed for a period of from 24 to 72hours after admission. In the cases exhibiting active motor symptoms,semisequestration, by such means as screening or use of single rooms for aperiod of one to four days, was found adequate for the removal of thesephenomena. During this time of forced rest in bed the patients were notpermitted to leave the inclosure, even for brief periods. No intercourse withother patients or with ward masters was allowed except as necessary in theroutine of ward management. In no case was this unsuccessful. After a period ofprimary physical rest had been secured, the patient was provided with a cleanoutfit of clothing, including a properly fitting uniform. He then engaged inlight forms of occupation (for a period of one or two days more), such asassisting in the sanitary care of the ward. At the end of this time he was sentfor more advanced treatment into a workshop supplied with tools and materialsfor woodworking and such metals as tin, copper, brass, and iron. The capacity ofthe shop was 50 men. It was under military control, and activity in one or moreof its departments was insisted upon. Constant supervision, instruction and aidbeing afforded by instructors. The ward surgeon designating certain patientsfor this form of therapeusis specified "whole" or"part-time" occupation for them. Each afternoon, weather permitting,the patients designated by the ward surgeon were assembled in military formationand conducted in charge of a commissioned officer on an easy march for adistance of from 3 to 6 kilometers.

Verbal orders for the discontinuance of the unit and thereturn to the supply stations of material were issued by the chief surgeon,First Field Army, American Expeditionary Forces, on November 19, 1918. Thepatients were disposed of and the material returned as ordered. The unit handedover to the French authorities the material which had been left by the FrenchAmbulance 8/V when Neurological Hospital No. 3 was organized. The personnel wassent to Base Hospital No. 117 except for a section of 3 officers and 10 enlistedmen, who were directed to report to Evacuation Hospital No. 6 for temporary dutyin accordance with directions of the chief surgeon, First Field Army, AmericanExpeditionary Forces, dated November 19, 1918.¹⁶

PSYCHOSES OBSERVED AT THE FRONT^e

The following observations relative to psychoses seen at thefront are pertinent:

There was observed in a small number of the cases admitted tothe First Army neurological hospitals situated at the front, mental statesanalogous in their coloring to certain recognized psychoses, but which did notpresent the complete clinical picture or follow the same evolution of thesediseases.

The statement is frequently seen in literature that war doesnot create any special type of psychoses. To a certain extent this is true. Thecases of actual psychoses observed in psychiatric units in the Army fall intogroups which

^eBased on: Psychopathic Reactions to Combat Experiences in theAmerican Army, by John H. W. Rhein, M. D. American Journal of Insanity, Baltimore,1919, lxxvi, 71.

347

include manic-depressive psychosis, dementia pr?cox, paresis,epileptic insanity, and alcoholic psychoses. These are, in the main, conditionswhich are not peculiar to war.

But there are mental states which are seen in soldiersexposed to combat experiences, and who are admitted to the hospitals at thefront, which may be considered directly related to war. These have already beendescribed by French, Italian, and Russian observers. They occur in smallnumbers, only at the front; the symptoms are on the whole of short duration;they are directly related to the severe emotional and exhaustive front-lineexperiences; they show certain well-defined characteristics, and representabnormal reactions in the sphere of the psychic, due to severe emotionalexperiences.

One of the forms of these mental states which were observedin a few cases was that described by Chavigny as aprosexia, or an inability tofix the attention. In this condition the soldier is unable to concentrate hisattention upon the questions of the examiner, his eyes constantly move from theface of the medical officer to one or the other side, at times as if he saw someobject of a frightful character, making no reply to questions and apparentlyoblivious to the presence of the examiner. These symptoms persist a few hours toa few days as a rule and finally disappear entirely.

A fairly common type observed was a state of mental confusionassociated with what has been termed oneiric delirium, symptoms which wereassociated with a history of concussion and exhaustive experiences. Thesesymptoms were at the same time susceptible of cure in a short time.

A third form which was observed consisted of a state ofstupor associated with negativism and some catatonic phenomena suggestive ofdementia pr?cox. In some cases the symptoms recall the paranoid varietyof this disease. This type has been referred to by Davidenkof, who describedstates of hallucinatory mental confusion with pseudohebephrenic manifestationswithout the true picture of dementia pr?cox.

The following cases are interesting as illustrating some ofthese features:

A. B., private. Aged 31. In civil life ateacher byoccupation. His father had suffered from a nervous collapse at the age of 47.The patient had been a stammerer and had suffered from three nervous breakdownsin 1900, in 1903, and in 1915. He enlisted in September, 1917, went to Francein July, 1918, and had been in the post office of Dieulard since September 15,1918, where he had been exposed to shell fire, though none burst nearer than 70yards. The shelling had upset him and made it difficult for him to concentrateon his work. Two weeks prior to admission an agent for the Stars and Stripesgave him some candy which he later threw away because he believed there waspoison on it. Again, a week later, a soldier borrowed his canteen and when hereturned it the patient noticed a peculiar taste in the water when he drankfrom it, and he concluded that his companions were giving him some poison tomake him erotic. On admission he complained of "being worn out," of asense of tension on both sides of his head and the back of his neck, and atingling in the arms and legs. He was apathetic, suspicious, uneasy in hismanner, indifferent, and showed delusions of persecution. There were nohallucinations of sight or hearing. The symptoms improved somewhat during hisstay in the army neurological hospital, but he was evacuated to the rear forfurther treatment.

This case represented a reaction which suggested the paranoidform of dementia pr?cox.

348

J. J., private. Aged 24. Was employed as a locksmith in civillife. He entered service in February and went to France in May, 1918. He wasevacuated to the army neurological hospital from the Argonne front. On admissionhe refused to give any data regarding his family or previous history, nor wouldhe discuss any of his war experiences. He was reticent, suspicious, and hisanswers to questions were so unsatisfactory that it was possible to obtain onlya meager portion of the trend of his thoughts. He was evidently a victim of aconspiracy which had been formed for the purpose of blocking the workings ofthe Government. He had been in communication with Thomas Edison, but due to thespy system the work in this line had been interfered with. He said that everyonewith whom he had come in contact had attempted to do him harm. Because of hispersecutory trend he refused to discuss the details of his mental state,believing that the examiner was in league with the gang, who had persistentlyinterfered with his ability to do good work for the United States Government. Hewas evacuated to the rear after three days' treatment, during which hissymptoms had improved to a certain extent.

This case illustrated again a paranoid reaction suggestive ofdementia pr?cox.

G. C., private. It was impossible to obtain the family orprevious histories, or any information relative to the origin of his presentcondition. He was evacuated to the army neurological hospital from the Argonnefront. He appeared to be constantly in a confused state, and refused to make anyreplies to questions put to him. He occasionally would mumble some words inPolish which were evidently of a religious character, assuming at the same timean attitude of prayer. He was rather emotional and would weep withoutprovocation. He lay quietly on his bed showing no interest in his surroundings.Frequently his lips were observed to move as though praying. He was dull,stolid, and stupid in his manner, frequently put his head on the table and wept,occasionally nodded his head in reply to a question but would not talk. Whenasked why, he pointed to his larynx. He was evacuated to the rear in two daysshowing no change in his mental state. His condition was one of confusionassociated with some negativism and depression.

J. K., corporal, aged 27. In civil life an oiler and coalbreaker. The family history was negative. He had arrived at the 5th B grade andhad never been sick in his life. He enlisted in April, 1917, and went to France,May, 1918. He went through the Aisne and St. Mihiel operations without mishap.On the Verdun sector he carried on under shell fire for three nights and twodays. He then believed that his sergeant had induced him to maladjust his gun,which resulted in the death of three American soldiers. He looked upon thesergeant as either a German sympathizer or a German spy. He was somewhatconfused but adhered to this statement over and over again. He complained of aheavy feeling in his head on admission and was unable to recall everything thathad transpired previous to his admission. He was very much depressed, thedepression centering around the death of his companions which he believed hehad caused. The physical condition was negative outside of some stammering. Atthe end of three days he cleared up entirely.

L. M., private, aged 36. In civil life a railroad worker. Thefamily and previous histories were negative. He enlisted April, 1918, went toFrance July 12, 1918, and was in the Toul and Verdun sectors. He was sent backfrom the Argonne front during the operation in October. He believed that he hadgotten in bad in the camp from which he had come, and that several of the menwere going to kill him. There was a plot going on in the ward also to killhim, and he heard the conspirators planning to make away with him before he wentto sleep. He said he had come to the hospital because he did not want to"be shot like a dog. I want to go in some other outfit and get killed formy country." There was some concern and feeling about his situation, but onthe whole he lacked insight. He was quite tense, did not understand why hisenemies had it in for him, and feared he would be killed or court-martialled.He was evacuated to the rear in four days, somewhat improved.

The manic-depressive reaction was probably seen morefrequently than any of the mental states under discussion. As a result of someintense emotional

349

trauma a soldier suddenly became wildly excited, associatedwith tremendous physical agitation and oneiric delirium, a condition suggestingmania.

These cases were seen in small numbers in field hospitals,where they required packs and hypodermic injections of morphine, the excitementsubsiding in large part before they arrived at the army neurological hospital.

The following cases illustrate more particularly a mild manicreaction characterized by excitement, and associated with partial amnesicstates:

R. D., sergeant, aged 27. In civil life an assistant salesmanager. His father died of cancer, but otherwise the family history wasnegative. He was more or less disturbed by the sight of blood and the killingof animals, but in other respects his previous history was negative. He hadspent two years in college. He was drafted in September, 1917, and went toFrance, May 31, 1918. He was with the British at Arras and then went to theVerdunsector on September 26, where he was obliged to do the work of his sergeantmajor, who had been killed. He was worried and disgusted by the lack ofblankets, lack of artillery support, and the lack of ambulances at this time.Shells made him nervous previously and his nervousness continued to increaseuntil finally a shell killed the adjutant, wounded another man, and threw dirton himself. He became wild, crying and shaking in an uncontrollable manner,and was evacuated. On admission he presented evidences of fatigue, sometremor, and was physically restless. He recovered entirely and returned to dutyat the end of two weeks.

L. B., private. In civil life a clerk. Thefamily andprevious histories were negative. He entered the service April 25, 1917, and went to France March 22, 1918. He had beenunder shell fire at St. Mihieland gave a good account of himself during this operation. At the Argonne front he had beenunder shell fire a few days when he was blown over by ashell which killed two of his companions. He was dazed and lost complete controlof himself, ran about in an aimless and excited manner, and was so violentand difficult to manage that the medical officer gave him a hypodermic ofmorphia. Upon admission he complained of tremulousness and nervousness and would startupon hearing sudden, unexpected sounds. He slept with difficultyand dreamed of war scenes. He also complained of a feeling of insufficiency,but otherwise the examination was negative. He returned to duty in threeweeks.

A. H., aged 24, private. In civil life a contractor. Thefamily history was negative, except that one sister was nervous and excitable.The patient had finished the first year at high school and presented anegative history, except that he was a bed wetter until 10 years of age, hadalways been easily frightened, and had suffered from nightmare. He enlistedMay, 1917, went to France May, 1918, and to the front in June. Shell fire hadalways made him a little nervous, and he gave a history of very little restand not much to eat. In October on the Verdun front a shell landed 25 feetfrom him. He began to "shake, pant, and sweat," felt chilled, "went wild,"and ran around in an excited, confused state, and did not know what he was doing. On coming intothe hospital he complained of weakness andheadaches. He presented, on examination, a neurotic make-up, cleared up underrest, and returned to duty in a few days.

E. W., private, aged 27. In civil life a laborer in a steelmill. He attended school until 13 years of age, and was able to read andwrite. His mother was nervous and one sister had "falling spells." Hehimself had had nightmares and had walked in his sleep. He was drafted inSeptember, 1917, and went to France May 30, 1918. He was in the Elbert sectorin the trenches 10 days, went to Verdun September 26 and was blown over October24. He stated "that the whole thing had practically demoralized him."He was in a shell hole when two shells struck near him. Shortly afterwards heremembered that he was running away greatly excited, yelling and crying. Hewent to the first-aid station and was evacuated. Upon admission he hadrecovered largely from his excitement and in a few days was practically well.

L. P., private, aged 23. In civil life afarmer. Thefamily history was negative until June 3, 1917, when he was kicked in the thighby a horse and was in a hospital for weeks,

350

since which time he was easily startled, fearful,and apprehensive. He entered the service April 1, 1918, and went to France June27, 1918. He was sent to the Argonne front in October, where he encounteredhis first experiences under shell fire. He was there for eight hours and gotalong very well, being under heavy fire nearly all the time. He saw several ofhis officers and men killed and became more and more nervous, until finally wasunable to carry on any further and was taken to a dressing station. Here hewas very much excited, tremulous, and nervous, and "would become crazy when he heard the explosions."On admission to the neurological hospitalhe was excited and tremulous, started at unexpected sounds, and could not sleep.He improved greatly under treatment, but was sent to the base neurologicalhospital for further rest and treatment.

There is a small number of cases belonging to this group, onthe other hand, in which the symptoms took a depressive coloring. Usually thepicture was one of simple depression associated with preoccupation and sometimeswith hallucinations and depressive delusions.

J. B., French Canadian, private, aged 31. In civil life alaborer. One brother, an alcoholic, died insane. The patient had an attack ofsome mental disorder of unknown character in 1911. He was drafted in June,1918, went to France in September, 1918, and went at once to the Argonne front, wherehe passed through Clermont and Montfaucon. While helping tobring in food, he said, God's voice said to him, "Leave this place atonce before something happens." He started to run and though he heard asentry say "stop," the voice urged him on, and he ran in spite of thebullets from the sentry's gun, one of which gave him a flesh wound in the left arm. He stayedin the woods one night but was captured the nextday, and ran away a second time, on the following day. On admission to the armyneurological hospital he appeared to be a simple-minded French Canadian who wasin a state of religious excitement in relation to delusions of persecutionsand auditory hallucinations. He frequently repeated, "I don't feel quiteright, I haven't done right, I didn't keep my promise to the priest totake 10 sacraments when I was sick last time." He believed he would notbe pardoned. He improved considerably in a few days but he was sent to therear, as it seemed advisable to give him a longer treatment than waspracticable in the hospital at the front.

C. R., private, aged 25. In civil life a potter.One paternal uncle was insane. The patient had finished the fifth grade. He hadalways shown fear of the sight of blood and the dead. He confessed to have been depressed onnumerous occasions in the past. He was drafted May 18, wentto France July, 1918, and went to the Argonne front in October of the sameyear. Shells did not bother him until he saw many of the boys blown topieces, when he began to get nervous. He was caught in a barrage and becamevery excited. Finally, at the end of two days a shell exploded near him. He wasunable to tell what happened after that, but he believes he becameunconscious. He reached a kitchen, but does not remember how he got there. Onadmission he was depressed, showed auditory and visual hallucinations,and was retarded in thought and action. He was emotional about his motherbeing home alone and could not understand why he did not get mail from her.His memories for events previous to the front-line experiences were good, butmemories for the front-line experiences were hazy. He sat or lay in bed withhis hands folded in his lap, silent, preoccupied, took no interest in hisenvironment, and was somewhat disoriented. He improved considerably, butwas evacuated to the rear for further treatment.

T. R., corporal. In civil life a carpenter's helper. Bothfather and mother died of tuberculosis. One brother was reported killed twodays before he was admitted to the hospital. Otherwise the family history wasnegative. Outside of the fact that he was a bed wetter until 12 years of ageand walked in his sleep, his previous history was negative. He enlisted in July,1917, went to France in June, 1918, and went to the Alsace and Verdunsectors. He was very much exhausted by his first shell-fire experiences. He wentto Verdun on October 8, and carried on well until October 10, when he heardof his brother's death from a friend, which upset him very much. He was ina trench when a German barrage was put over, some of the shells landing nearhim, none of which made him unconscious, however,

351

but he became flighty, nervous, and weak. On admission hisexpressions was strained, his brows wrinkled and he was very much depressed.His depression centered largely around the death of his brother about which hewas emotional. His insight was good and he was cooperative. He recovered in 10days' time and returned to the front.

The front-line experiences which are practically similar asto exhaustion, commotional and emotional factors in all cases which show areaction in the sphere of the nervous system, gave rise to a variety ofreactions. These consisted in some cases of simple hyperemotivity which initself incapacitated, in others it resulted in the occurrence of actualneuroses, and finally in a small number there occurred symptoms which presenteda psychotic coloring.

The cause of this variety of reactions to identicalexperiences offers an extremely interesting field for speculation. Seemingly, itis due to the mental make-up of the individual. When the individual's balanceis upset by certain conditions the reactions take one of a number of directions,the type of the reaction depending upon that particular quality of the mentalmake-up which predominates. We observe these reactions appearing in civil lifein individuals who respond under stress more or less within normal limits. Wesee individuals who are considered normal, who under strain become depressed,excited or paranoid, conditions which may be looked upon as indicating thecharacter of the mental make-up of the individual. These conditions may beregarded as mild transient psychotic states, peculiar to war, though thepossibility of their occurrence in civil life, if the stress is sufficientlygreat, is not to be denied.

ARMY NEUROLOGICAL HOSPITAL, SECOND ARMY

The consultant in neuropsychiatry for the Second Armyreported for duty with that army soon after its organization on October 10,1918.^{17, 18} Plans were immediately projected to organize a neuropsychiatricservice for this army, which included the establishment of an army neurologicalhospital to provide for the cases of war neurosis which, it was anticipated,would arise as a result of a military operation scheduled to begin in the latterpart of October. The army neurological hospital was organized and established,therefore, on November 5, 1918. It was located at Varvinay,¹⁷ anadvanced position, within 3? miles of Mobile Hospital No. 39 and near FieldHospital No. 117, which had been at Commercy, but had been moved in a day fromthis location to a site on the outskirts of Varvinay. Varvinay was about 7?miles behind the front line and near the roads which connected St. Mihiel,Commercy, and Toul with the front areas. There were on this site, when it wastaken over, three structures consisting of a small German barrack, a smallFrench barrack, and a third building which had been partly destroyed by fire.The latter was at once repaired and was used for storing medical supplies. Inaddition to these buildings, two tents were erected on the level groundadjoining these buildings. Above this site, on a hill, were three large woodenstructures which had been occupied by a French machine gun battalion, and threecottages. These buildings, before the St. Mihiel operation were occupied by theGermans. Two of the large structures were used to house the enlisted personnel,another served as a mess hall, while the cottages were for officers' billets.The hospital had an electric lighting system. On the hill was a spring whichafforded an abundant supply of good water to all buildings occupied by thehospital.

352

The temporary personnel came from Field Hospital No. 117.This was augmented by men from Neurological Hospital No. 2, First Army, at Toul,upon the abandonment of the latter hospital, as recorded above. At this time twosergeants and six privates, Medical Department, attached for permanent duty toNeurological Hospital No. 2, First Army, were ordered to the neurologicalhospital of the Second Army for temporary duty.

Since military operations of the Second Army ended with thesigning of the armistice on November 11, just a few days after they had begun,¹⁹the activities of this hospital were likewise brief. The total number ofadmissions amounted to 12, and these were admitted on November 9. Of thisnumber, 9 were returned to duty and 3 evacuated to the Base Hospital No. 117.All of these cases came from the 33d Division which was operating to the northof Varvinay.²⁰ The hospital was closed on November 23, 1918.

REFERENCES

(1) L?ri, Andre: R?forme, Incapacit?s, Gratifications dous les N?uroses de Guerre. Revue neurologique, 1916, xxix, 763.

(2) Roussy, Gustave, and Boisseau, J.: Un centre de neurologie et de psychiatric d'Arm?e. Paris, medical, 1916, No. 1, 14-20.

(3) Salmon, T. W.: The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army. Mental Hygiene, New York, 1917, i, No. 4, 509-547.

(4) Final Report of Gen. John J. Pershing, Commander in Chief, A. E. F.

(5) Report of the activities of the section of neuropsychiatry, A. E. F., made by Col. Thomas. W. Salmon, M. C., senior consultant, neuropsychiatry. On file, Historical Division, S. G. O.

(6) Letter from the senior consultant in neuropsychiatry, A. E. F., to the corps surgeon, First Corps, August 26, 1918. Subject: Establishment of neurological hospital at Benoite Vaux. Copy on file, Historical Division, S. G. O.

(7) Report of Medical Department activities, Base Hospital No. 117, A. E. F. prepared under the direction of Maj. W. J. Otis, M. C., commanding officer, undated. On file, Historical Division, S. G. O.

(8) Memorandum from the senior consultant in neuropsychiatry, to the chief surgeon. First Army, September 6, 1918. Subject: Neurological Hospital No. 1, First Army. Copy on file, Historical Division, S. G. O.

(9) Final report of the chief surgeon, First Army, upon the St. Mihiel and Meuse Argonne offensives, undated. On file, Historical Division, S. G. O.

(10) Letter from the commanding officer, Neurological Hospital No. 1, A. E. F., to the senior consultant, neuropsychiatry, A. E. F., November 10, 1918. Subject: Report for the month of October. Copy on file, Historical Division, S. G. O.

(11) Letter from the commanding officer, Neurological Hospital No. 1, A. E. F., to the senior consultant, neuropsychiatry, A. E. F. November 30, 1918. Subject: Report for the month of November. Copy on file, Historical Division, S. G. O.

(12) History of the Justice Hospital center, prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O.

(13) Letter from the commanding officer of Neurological Hospital No. 3, to the senior consultant, neuropsychiatry, A. E. F., October 1, 1918. Subject: R?sum? of operations of this unit. Copy on file, Historical Division, S. G. O.

(14) Memorandum for Colonel Garcia from the senior consultant, neuropsychiatry, A. E. F., September 30, 1918. Subject: Character of cases admitted to neurological Hospital No. 3. Copy on file, Historical Division, S. G. O.

(15) Letter from the commanding officer of Neurological Hospital No. 3, to the senior consultant, neuropsychiatry, A. E. F., November 1, 1918. Subject: R?sum? of operations of this unit. Copy on file, Historical Division, S. G. O.

353

(16) Letter from the commanding officer of Neurological Hospital No. 3 to the senior consultant, neuropsychiatry, A. E. F., November 30, 1918. Subject: Report of operations. Copy on file, Historical Division, S. G. O.

(17) Report of Medical Department activities, Second Army, A. E. F., by Col. C. R. Reynolds, M. C., chief surgeon, Second Army, undated. On file, Historical Division, S. G. O.

(18) G. O. No. 175, G. H. Q., A. E. F., October 10, 1918.

(19) Major operations of the American Expeditionary Forces in France, 1917-18, prepared in the Historical Section, the Army War College. On file, Historical Section, the Army War College.

(20) Outlines of Histories of Divisions, U. S. Army, 1917-18, prepared by the Historical Section, the Army War College. On file, Historical Section, the Army War College.

RETURN TO TABLE OF CONTENTS