Arrangement of standard camp hospital for useas neuropsychiatric hospital (capacity with temporarypersonnel 80; with permanent personnel 300)

All the remaining buildings will be occupied when the arrival of the permanent personnel from the United States permits the hospital to be operated at full capacity.

The suggestions outlined in this correspondence were approved by the chiefsurgeon, A. E. F., and construction of the hospital was begun at once. It wasready for occupancy by the end of February, and since it was highly desirable toplace it in use as soon as possible, recommendation was made to this effect, bythe senior consultant, as indicated in the following letter from him to thechief surgeon, A. E. F.:³

1. In view of the desirability of receiving patients at Base Hospital No. 117at the earliest possible moment, in order that soldiers with psychoneurosesnow in other hospitals

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may receive special treatment and the precedent of returningsuch cases to the United States may be avoided, it is recommended that thishospital be opened with a temporary personnel pending the arrival of the regularpersonnel from the United States.

2. It is recommended that Maj. George B. Campbell, M. R. C.,who has been ordered to report at Neufchateau for duty in the division ofpsychiatry be assigned as commanding officer of this hospital upon his arrival.

3. It is also recommended that the following commissionedmedical officers, noncommissioned officers, and enlisted men of the MedicalDepartment be relieved from duty at the stations set opposite their names andordered to report to Maj. Thomas W. Salmon, M. R. C., for duty at Base HospitalNo. 117:

4. It is recommended that an experienced mess sergeant and 20 enlisted men of the Medical Department, one of whom is an experienced cook, be ordered to report for duty at this hospital.

5. The object of the above recommendations is to prepare thehospital so that patients may be received as soon as the necessary equipmentarrives, to protect property, and to commence the cultivation of gardens and afarm, in order that this important feature of occupational therapy to beemployed later may be successful.

6. It is recommended that all these orders he communicated by telegraph.

The following letter from the director of psychiatry to thechief surgeon, A. E. F., March 19, 1918, gives the main facts in the establishment of Base Hospital No. 117 and the early orders to transfer casesthere:⁴

1. Confirming our telephone conversation of today, Base Hospital No. 117 (Camp Hospital No. 4) is prepared to receive cases of functional nervous diseases, a small, temporary personnel being on duty.

2. A rough draft is inclosed for a letter to be sent by your office to commanding officers of base hospitals regarding the transfer of suitable cases.

3. As it is practicable to care for only 30 patients at the present time, it is suggested that this letter be sent now only to Base Hospitals Nos. 15, 18, 23, 36.

4. As soon as the personnel for this hospital arrives, which will probably be about the middle of April, patients can be received up to its full capacity of 350, including 50 officers. At that time similar letters should be sent to all division surgeons as well as to commanding officers of all base hospitals.

5. It is requested that this office be furnished a copy of the letter in the form in which it is sent out.

1. Base Hospital No. 117 at La Fauche, a special hospital for functional nervous diseases (hysteria, neurasthenia, and the conditions commonly termed "shell shock") is ready to receive patients by transfer from base hospitals. As the full personnel for this hospital has not yet arrived in France, only a limited number of cases can be admitted.

2. You are authorized to transfer to this hospital patients likely to profit by the special treatment provided. It is important not to send mental cases (including not only the insane and feeble minded but patients in whom these conditions are suspected), epileptics, or cases of organic nervous diseases. Patients in whom there is doubt as to whether a nervous disorder is functional or organic should be transferred to this hospital. Cases requiring surgical care should not be transferred.

3. It is desired to emphasize the fact that this hospital is not intended to serve as a step in the evacuation of nervous cases to home territory. It was established and will be operated by a specially trained personnel for active curative treatment with the object of restoring to full military duty as many cases as possible, especially acute neuroses developing at the front.

4. Until provisions for officers have been made only enlisted men can be received.

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The early period of the hospital's service, from March 1 until the middleof June, 1918, is of minor interest. The total personnel consisted of 4 officersand 10 enlisted men.¹ Admissions during March totaled 6; duringApril, 25; and during May, 51. The Base Hospital No. 117 unit arrived in LaFauche, France, June 16, 1918, and then the history of the hospital as anorganization really began.

When the American troops were sent to the front in great numbers early in thesummer of 1918, the needs of the hospital greatly increased. In consequence, thehospital rapidly grew in capacity, finally having a total capacity of about1,000 beds.¹ The necessity for facilities other than those afforded by themain group of buildings soon became apparent. The first addition to the hospitalwas a country house (the "officers' chateau") in a wood about aquarter of a mile away.¹ This was opened early in June as a ward forofficer-patients who had recovered but who needed a short period ofconvalescence before return to duty. In this more restful milieu, away from theacute cases which filled the barracks-wards at the central group of buildings,these officers could get better hold of themselves and regain the composure andself-confidence which are so imperative for one again to assumeresponsibilities.

Some deserted French barracks across the meadows about one-half mile from thehospital were taken over early in August, 1918, and converted into aconvalescent camp.¹ The capacity of this place was originally 125. Patientswho had recovered from their symptoms were assigned there before being sent backto duty. Its routine consisted of daily calisthenics and drills. Any man whosesymptoms developed again was returned to the hospital ward from which he came.The purpose of this place, like that of the "officers' chateau," wasto give the men an opportunity to get hold of themselves and to fall back intomilitary routine, before being returned to their organizations or assigned toduty elsewhere. The work was of such importance that at the time the armisticewas signed the chief surgeon, A. E. F., had approved an increase in size to1,000 beds. But the signing of the armistice put an end to further additions.

The patients were all discharged from this hospital by January 12, 1919, andthe hospital ceased to function then. The personnel and records were transferredelsewhere, and the hospital was abandoned on January 31, 1919.

NURSING^a

Previous to the arrival of the unit, June 16, 1918, there had been no femalenurses on duty at Base Hospital No. 117. The arrival of the chief nurse and herstaff was followed shortly by the organization of systematic daily routine onthe wards. Careful and orderly case records were kept, and the direction of thewards took on the same qualities that would be found in the best neuropsychiatric hospitals in the United States.

In order to familiarize the nursing personnel with the special clinical andtherapeutic features of war neuroses, the medical director of Base Hospital No.117 arranged a series of lectures by members of his staff. It was his purpose

^aThe statements of fact appearing herein are based on a report ofnursing at Base Hospital No. 117, made to the senior consultant inneuropsychiatry A. E. F., by Chief Nurse Adele S. Poston, U. S. Army.Copy on file, Historical Division, S. G. O.

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to make plain to these nurses, who were unfamiliar with warneuroses, the nature and types of these disorders. The lectures includedinformation regarding the general conception, classification, and clinicalaspects of the war neuroses. Emphasis was placed upon the more common methods oftreating these cases and the part of the nurse in their care and equipment.Nurses fresh from hospital experience with civilian cases were unfamiliar withthe war neuroses and this plan enabled them to get an understanding quickly ofthe point of view toward war neuroses which had been developed by the AmericanExpeditionary Forces medical personnel.

The nursing done at Base Hospital No. 117 was not nursing asone usually conceives it. There were few cases requiring bedside care. Patientswho entered in such a condition were usually up and about shortly. The first dayor two of the patient's stay in the hospital were critical ones. It wasimportant, above all, that he receive no false impression regarding the natureof his disability and that those erroneous ideas of it which he held becorrected as soon as possible. The ward surgeon, of course, began to treat him,but it was also very essential to have the nursing personnel alert to theproblem of overcoming his difficulties. The primary requirement for good nursingand successful treatment was not merely the individual attitude of nurse topatient or ward surgeon to patient, but the social atmosphere of the ward wasall important. An atmosphere of cure was necessary in order successfully to copewith the patient's mental attitude. It was essential that the patientrealize that his condition was amenable to treatment and that recovery ofsufficient degree to return to duty was the customary outcome of the hospital'stherapy. Patients were never allowed to settle into a too comfortablesituation at the hospital, but were always kept aware of their responsibilitiesas soldiers.

To maintain the "return-to-duty" attitude in eachman on the ward was the primary nursing problem in caring for war neurotics. Asevere ward routine was maintained. This consisted of regular hours for rising,military inspection by the commanding officer and staff each morning, promptresponse to kitchen and other details, and other military assignments made bythe medical officer of the ward. In some cases the details took the patients outas early as 4 a. m. Competition developed among the various wards, not only inthe matter of decorations and good housekeeping, but in ward morale.

The daily nursing routine of the ward was roughly as follows:As soon as the patients were out of bed, dressed, and had been to mess, ifambulatory, they were assigned to some form of employment. The assignmentsconsisted, as mentioned before, of duties on the wards or in some otherdepartment of the hospital, or assignment to the workshop (occupational therapyhut), an important therapeutic center. The kind of work done by the patients wasdetermined, of course, by the ward surgeon's opinion of his condition. Work onthe wards was directed by nurses and attendants and that in the shops byreconstruction aides. The more arduous physical tasks, such as road building,were overseen by enlisted personnel.

The ratio of nurses to patients during the day was 3 to 35and at night 1 to 35. It was important not to over-nurse a neurosis case, butrather to encourage the patient to do everything he possibly could for himself.The

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success of the nursing personnel, of course, depended upon the individualpersonality of the nurse. There was a great deal of difference between wards. Somuch depended upon the morale of the ward that it was not unusual for cases tobe assigned to special wards because the staff felt that they could not"hold on to a tic or coarse tremor" on a certain ward, the generalattitude of the patients on that ward being such as to discourage the presenceof that type of hysterical symptoms. The type of nurse that accomplished mostwith war neurotics was one who was understanding, cheerful, impartial, andpatient. It was necessary for her to strike a happy medium between severity andexcessive sympathy. Elements of both kindness and firmness were necessary, butin the right proportions.

It has been said that the major problem in caring for war neuroses was themorale of the ward. This was, indeed, a difficult thing to manage. For on theone hand it was the duty of the nurse to be sympathetic and to listen to thepatients' complaints and yet at the same time to counteract their worries andanxieties with firmness and decision. The nurse had to realize that any toosympathetic attitude on her part, any questioning of the successful outcome oftreatment, was liable to render the patient unfit for further military duty.

Another duty of the nurse was her aid in giving the ward surgeon informationof service in determining a diagnosis and military classification. Being withthe patients on the wards so great a part of the day, the nurse had a betteropportunity to study the patient than did the medical officer in charge of theward. Indeed, the main problem, from the military standpoint, of these cases wastheir future army usefulness, and for the determination of this for the patientson her ward the nurse gave the ward surgeon his most valuable information.

OCCUPATIONAL THERAPY^a

The importance of the occupational therapy that was carried on at the BaseHospital No. 117 at La Fauche lies in the fact that it was the first time thatthis form of treatment was put into effect in a military hospital under whatmust be considered forward-area conditions, as in the early days of June, 1918,this hospital was about 30 miles from the front line. The further significanceof the workshop in this hospital is associated with the kinds of patients thatwere treated there. The character of the cases and the fact that an attempt wasmade to treat them with all the methods that were in vogue in the best-equippedhospital in the rear and in the home area formed the two striking features ofthe use of a form of therapy which up to that time had been reserved forhospitals at base ports or for those forming a part of hospital centers.

In describing the methods that were carried out there, it must not beforgotten that Base Hospital No. 117 had a particular problem to solve in amedical way and that the necessity for a proper solution of this problem wasnever permitted to escape the minds and interests of the medical and nursingstaff or the reconstruction aides who managed the workshop.

^aThe statements of fact appearing herein are based on a report ofoccupational therapy at Base Hospital No. 117, A. E. F., by Chief AideMeta Anderson. On file, Historical Division, S. G. O.

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In Base Hospital No. 117 the use of work as a curative agencysprang, in the first place, from the necessities of the hospital in the earlyphase of its development. Before the regular staff had arrived and before theequipment had been brought over from the United States, when the hospital wassimply an old field hospital with a few wards and a few medical officers, itreceived about 50 cases of what were afterwards called anticipation neurosis.These were soldiers who had never seen active service and had never beenanywhere near the front lines but had developed neuroses either in Americabefore sailing or en route to France. They presented a very unfavorable type ofcase, as may well be imagined. They were not war neuroses in the real sense ofthe term, never having been exposed to the traumata of warfare, but theypresented symptomatically all the evidence of the most severe types of thiscondition. Treatment was extremely difficult because there was little either inmake-up or temperament upon which to build. They represented as a whole theso-called neuropathic types of soldiers, the kind that were not at all adaptedto the conditions of warfare. They would have been excluded from the Army ifthere had been in force the methods of elimination adopted later.

The hospital was much handicapped on account of the lack ofroads and pathways between the rows of huts. It had been built on a field, andthe wet and rainy winter had left it in a condition that prevented traffic ofalmost any kind reaching it. The first essential, then, was to build a roadthrough the hospital connecting with the well-made French road leading from thehighway to the village of La Fauche. Patients of all sorts were put to workbreaking up stone and carrying it to make a foundation for a macadam road. Theuse of the stone-breaking hammer and the carting of the stones to the roadbedemployed these patients for a number of weeks until the road was completed sometime in May. The road was a model in its way and showed its value when thehospital grew to a capacity of 1,200 beds.

There were, of course, in this use of occupational therapynone of the refinements that were afterwards developed, and no attempt was madeto emphasize the localization of therapeutic effort. It was occupational therapyin the broadest sense, and it had its effect on the patients simply because itgave them something to do and showed to those with paralysis and tremors that itwas possible for them to carry out coordinated movements and to make use oftheir movements in the production of tangible results. From this very crudebeginning the therapeutic workshop personnel, when they arrived for duty, foundthat the principle of work had already been established. The value to theindividual patient was difficult to establish, as with this class little in theway of permanent improvement could be expected. Some of them did show rathergood effects, and it was interesting to note that very few of them objected tothis rather monotonous and tiresome form of work. The breaking of stone gives agood deal of opportunity to train coordination, and the use of a certain amountof skill is necessary in order to prevent injury to the hand holding the stoneto be broken. The evidence of effort could be measured by the increasing pile ofmaterial, and the fact that this work was supplying a very practical need ofwhich the finished portion of the road was the witness, formed the essentialelements upon which the efficacy of any work scheme in treatment is based.

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It accentuated further the fact that the type and kind of work are not ofimportance, nor is the output, either in quantity or quality. The things thatcount, however, are the physiological and psychological features that resultfrom effort to overcome resistance. The crude and primitive employment ofbreaking into small fragments a bit of stone in order to build a road may betaken as an example upon which to base the principles of a work therapy on amore extensive scale. The very primitiveness of the instruments used and the useof the product suggest that something inherently deep down in man's make-up istouched in this performance. Road making is an ancient calling, and the soldierresponded to this as he perhaps might not have to a more intricate task.

In its therapeutic effect, work is based upon very simple elements and thesesimple elements should always be thought of in planning its application to anyindividual. If the performance of breaking rock for the making of a road isexamined, it will be found that certain necessary elements enter into it, and ifa more intricate kind of work is studied, it, too, will be found to representonly modifications of these very primitive elements. If the problem of worktherapy is studied as far as the neuroses are concerned, there appear certainrequirements that must be met. These features are of two kinds: One is primarilymental or psychological; the other is physiological or mechanical. Thesefeatures apply also to the two sorts of persons with war neuroses that benefitfrom work treatment. One needs it because there is some defect in coordinationin a broad sense, and the other, because there is some psychologicalreadjustment that demands attention. The exercise in coordination is found inthe precision that is essential in using the hammer and in carrying out thenecessary maneuvers in preparing and in handling the crude material. There isadded to this an additional element that tends to produce precision of motion,and that is the danger of hurting the hand if the blow is not struck right. Thismakes for concentration and attention and brings into play the use of the eye atfirst to a great extent, and then develops an automaticity of movement thatovercomes the excessive muscular activity that is associated with tremors andataxic conditions. The development of strength, that is, muscular power, comeswith the practice necessary to perform a definite task. There is, too, a certainamount of noise associated with breaking stones which was found to be a benefitto such cases as complained of being sensitive to sounds. This had to beovercome, and it was often found that the sound of the hammer against the stonewas the best method of training this type of case to the usual hospital noises.The evidence of the productivity of effort could be measured by the pile ofstone that grew up by each patient. The evidence of utility was the road itself,which the patient saw grow under his eyes. The psychological phase of this kindof work was found in the proof to the patient that a defect in muscular powermust be only an evanescent one, if a muscle group that is not acting right iscapable of carrying out effectively so complicated a type of movement ashandling a hammer. The evidence of sufficient muscular strength was there to beseen. The conviction was forced upon the patient, therefore, that his defect wasnot only a temporary one, but that it was easily curable by the simplest ofprocedure-that is, use. The emotionally overloaded state that so many ofthese patients were in could be easily lightened by giving them a muscularoutlet or rather an

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effort outlet. Through their hands and fingers the emotional hypertension wassidetracked or exploded. In such routine work as this, automatic as it becameafterwards in most instances, there was given to the patient an opportunity toface his own experiences, if he had any, or to face his present situation as itwas interpreted to him by his medical officer. He could use his intelligence atthe same time that he was carrying on his task.

This feature of this kind of employment therapy was used effectually in thematerial that came to the hospital later, when the more definite type of warneuroses, fresh from the combat area, arrived.

The emphasis on this simple type of work therapy is given because itunderlies so much of the philosophy of reeducation and it opens the way for theproper appreciation of just what can be expected from treatment in the moreexacting sorts of work that were afterwards used. What was lacking, of course,was the effect of the shop spirit as a whole, developed in a well organizedshop, and the personal effect on the patient of skillful reconstruction aide orteacher. These elements can be supplied only by the presence of trained workers.

In the month of June the arrival of the complete staff at La Fauche and theincrease in the number of available beds brought the hospital face to face withthe duty it had been organized to carry out. Numbers of patients began to come,many of them showing the most severe symptoms of the war neuroses, and many ofthem comparatively fresh from the active fighting areas. The therapeutic problemwas focused upon the cure of these patients as promptly as possible, and thereturn to active duty of as high a proportion of them as possible. From early inJune until the end of the war nearly 3,000 cases of war neurosis passed throughthe hospital. A large proportion of these took part in some kind of work in theworkshop as part of their treatment. It was possible to judge, therefore, with afair approach to accuracy, just what this sort of work was able to do for them,and how necessary a part of the hospital for the neuroses is a workshop.

The base hospital unit contained a group of reconstruction aides who soontook over the task of running the workshop. Thus the occupational therapy becamean established part of the routine treatment of Base Hospital No. 117, of whichward surgeons might avail themselves.

Owing to lack of room the workshop was set up at first in an unused part of ahut that had been a storeroom. A few tables were found, benches were made; andin a few hours patients had been assigned to the shop for treatment. Some weekslater a special Red Cross hut was furnished to the hospital and here thepermanent quarters of the shop were established with increased equipment whichwas as satisfactory as could be expected in view of the difficulties in the wayof transportation of such supplies.

The evolution in work therapy from that of stone breaking and road buildingto the craftsmanship that soon developed in the shop was a surprising andinteresting thing. The shop, as a shop, began to have an influence on thepatients in addition to the individual therapeutic effect of a specialized kindof work. It soon became a place where patients liked to be sent, and in its busyatmosphere the patients passed many hours during which they felt relief. Duringthe whole period of the hospital's existence other types of work were

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continued, not only as a therapeutic method, but because the hospital couldnot have functioned without them. The policing of the hospital in the militarysense of the term, that is, cleaning up the wards, kitchens, roads, etc., wasdone by the patients; and the road was kept in repair by them. The chopping ofwood and the cultivation of the farm land surrounding the hospital were alwaysconsidered a part of the patient's duty. They were told that in so doing thesethings they were carrying out in a practical way the prescriptions of thephysicians who were treating them. About 85 per cent of the total sickpopulation of the hospital were always engaged in work of some kind, most of itbeing prescribed by ward surgeons.

The workshop was considered a sort of specialized therapy directed to a moredefinite end, planned to treat some definite symptom or to meet some specialindication, while the other work was regarded as a kind of therapeuticbackground underlying the whole scheme of curative effort. The physiological andpsychological needs were met by the use of muscular effort in the production oftangible articles. The handling of the tools and the various movements ofsawing, nailing, screwing, and hammering, and the finer and more coordinatedmovements of wood carving, metal work of various kinds, weaving, and tinning, aswell as much more delicate and more emotionally inspired technique of painting,sketching, and printing, supplied the essential training that the paralysis,tremors, and other symptoms needed. In a sense all of these defects were due toan intricate psychological process in which disassociation of function was apredominant mechanism. The patient could not properly innervate a muscle groupbecause there was a defect in the proper utilization of that group. The resultwas often exaggerated movements in which the inhibitive control and thehabituated minimum of effort were lacking. In the same way tremors wereprimarily defects in motor control, as were purposeless and ataxic movements ofthe choreiform types.

Motor reeducation, at first conscious and then automatically carried out, wasrequired. The handling of tools awakened a dormant muscle control, shocked outof consciousness for the time being, and tended to restore the normal andhabitual pathways long ago acquired. The familiar grip of a chisel, the friendlyfeel of a hammer or a saw, reestablished the proper integration and the propertonal balance in antagonistic muscle groups. These, as symptoms, were actingwithout any psychological law or purpose. The product that was being worked atgave the necessary interest and permitted the proper concentration. Themovements were allowed to fix themselves in the proper channels and theemotional block which stood in the way was for the time being lost sight of andthe individual used his hands much in the way that was customary with him. Theevidence that this was possible was before him, an evidence that no amount ofpersuasion or explanation alone could at times accomplish. It must not beforgotten that a large proportion of American soldiers had used tools andimplements before in their civilian life, and the traditional pathways, so tospeak, were present and only temporarily out of action as a result of theircondition.

No effort was made to select the kind of work from any other point of viewthan that of the immediate requirement in muscle defect that was present.

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The novelty of producing something that the patient had perchance neverthought of doing himself lent an added interest to the carrying out of the job,but further than this no special effort was made to arouse any unusual interestin the thing itself. There was in this way a certain lack of rigidity in theshop that was one of its main features. Patients were sent there not to beamused or to pass the time away, but to be cured; often the therapy was directedto the local defect of the patient and the effort was planned for that symptomand for nothing else. To some of the patients the workshop was a place wherethey were exposed to a more invigorating influence than was present in the ward.This was particularly so in cases of depression and of apathy; and likewise incases in which the prominent symptom was amnesia. In such cases the type of workand the product were of no importance whatever, nor was there a question ofmuscle training or education. Here the attempt was made to reassociate theseparated bits of the patient's memory stream, and the stay in the shop was anextension of the effort of reassociation carried out in the medical treatmentrooms by the several methods used in the hospital. The social element in themingling with men and the doing of the bits of accustomed things, the talk andthe noise of a shop, the familiar surroundings, all helped to that end. Theautomatic arousing of interest in the things that went on about him was animportant element in the restoration of the patient to his normal condition.

The facing of the situation, a method which implies that the patient is toldnot to forget, but to remember past experiences and thus learn to compromisewith them instead of dodging them, may be most successfully worked out if thepatient is set to sketching or drawing the details of his experiences in thefront lines, particularly those that preceded or accompanied the occasion whenhe was shocked or traumatized.

A number of such instances were found among the patients at Base Hospital No.117, and the therapeutic result was very encouraging. These patients soonlearned that it was the turning of their emotionally laden memories ofterrifying experiences into pictures and sketches that gave them a definitefeeling of relief, and that there was nothing in this kind of exercise that wasat all in opposition to the work therapy. It was only a different way ofarriving at the same result that was sought each day in their interviews withthe medical officers who treated them. Of course, these drawings had a definitemeaning and significance and they needed no interpretative mechanism to renderthem clear and distinct. As a contrast are the artistic productions of theinsane which are often symbolically expressed and which act so often as a screento the real meaning.

Whatever the psychical mechanism may be and whatever the place that emotionin relation to events may have, it is true that emotional states are relieved bymuscular expression, if this expression is tangibly directed by the patient. Inthis truth lies undoubtedly one of the great therapeutic agencies in work.

The need of the articles which a shop could turn out was so great in theneuropsychiatric hospitals of the American Expeditionary Forces and the tendencyon the part of those benefiting by these products to judge the value

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of the shop by its production, made it difficult to alwayskeep in mind the fact that the occupational work was a means of treatingpatients rather than a means of turning out a factory product. The trainedoccupational worker, however, was able to organize the work in such a mannerthat activities and tasks were assigned to patients for their therapeutic valuealone. It was the duty of the workers in charge of the shop to apply thepressure for production in such a way that it would be a therapeutic agent.

It appears to be good evidence that the medical officersbelieved thoroughly in the efficacy of occupational therapy when they extendedthe experiment to a hospital in the forward area with all the conditions andlimitations which that implies. Although the experiment lasted but two weeks,the medical director reported that because of the establishment of the workshopwith its aid in the treatment of the men, he had been able to send back to dutysome men who had been on the list to be sent to base hospitals for furthertreatment.

REFERENCES

(1) History of Base Hospital No. 117, A. E. F., by Maj. Frederick W. Parsons, M. C., commanding officer, January 22, 1919. On file, Historical Division, S. G. O.

(2) Memorandum for the chief surgeon, A. E. F., from the director of the division of psychiatry, February 9, 1918. Copy on file, Historical Division, S. G. O.

(3) Letter from the director, division of psychiatry, to the chief surgeon, A. E. F., February 26, 1928. Subject: Temporary personnel for Base Hospital No. 117. Copy on file, Historical Division, S. G. O.

(4) Letter from the director of psychiatry to the chief surgeon, Advance Section, A. E. F., March 19, 1918. Subject: Transfer of patients to Base Hospital No. 117. Copy on file, Historical Division, S. G. O.

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