CHAPTER VI
THE CARE AND DISPOSITION OF CASES OF MENTALDISEASE
COLLECTING STATION
In Chapter I of this section explanation was made of the factthat, in general, it was planned by the Medical Department not to return to dutyin France soldiers who had been admitted to hospital with psychoses or othermental diseases, but to return all such soldiers to the United States forfurther treatment. In carrying this plan into effect a collecting station forcases of mental disease was established for the forward area, at Base HospitalNo. 116, an integral part of the hospital center at Bazoilles.1Provisions also were made in other hospital centers, and at most base hospitalsnot connected with hospital centers, for suitable care of neuropsychiatric casespending their collection at base ports with the view of their return to theUnited States. For present purposes it will suffice to state briefly, except inso far as the base ports are concerned, the activities of the neuropsychiatricdepartment of the hospital center at Bazoilles.
NEUROPSYCHIATRIC DEPARTMENT, BAZOILLES HOSPITAL CENTERa
This department began to function on July 20, 1918, as a partof Base Hospital No. 116. Though nominally under the administrative supervisionof the commanding officer of the base hospital, the neuropsychiatrist in chargeof the department was permitted to exercise all necessary latitude in theoperation of his department.
The buildings provided for the neuropsychiatric departmentconsisted of six wooden demountable barracks, of the same character as thoseused throughout the center for wards and general purposes. These were 100 feetin length. They were located on relatively high ground, to the rear of SectionIX of the hospital center, occupied by Base Hospital No. 81. Four of thebuildings were used for patients, with a total normal bed capacity of 80. Onebuilding was used for administrative purposes as well as barracks for theenlisted personnel on duty in the department; another was used for kitchen andmess hall. After some months of operation, a building of standard width and 50feet long was added to the group as a dormitory for nurses, thus permittinghousing them at a convenient distance from the wards wherever they were on duty.At times, the patient capacity of the department was inadequate, thusnecessitating using an additional ward of Base Hospital No. 116.
From three to five medical officers were on duty in thisdepartment during the greater part of its existence. The enlisted detachmentconsisted of 4 non-
aThe statements of fact appearing herein are based on the "History of the Bazoilles Hospital Center," prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O.
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commissioned officers, 2 cooks, and 14 privates first class and privates. Tennurses were required for the efficient service of the department, and theirnumber usually was maintained at this figure. Trained personnel was furnishednot only for conducting incoming patients to this hospital, but also for convoysof cases of mental disease proceeding hence to the hospital center at Savenay.
For the period July 20, 1918, the date of establishment of thedepartment, to April 30, 1919, 1,654 patients were admitted. These cases finallywere diagnosed as follows:
Summary of diagnoses of cases admitted to thepsychiatric department
| Psychoses: | ||
| 1. Dementia pr?cox- | ||
| (a) Hebephrenic | 178 | |
| (b) Catatonic | 28 | |
| (c) Paranoid | 62 | |
| (d) Simplex | 127 | |
| Total | 395 | |
| 2. Manic-depressive insanity- | ||
| (a) Depressed | 96 | |
| (b) Manic | 61 | |
| (c) Mixed | 22 | |
| Total | 179 | |
| 3. Simple depression | 24 | |
| 4. General paralysis of the insane | 28 | |
| 5. Psychosis undetermined | 24 | |
| 6. Infective and exhaustive psychosis | 7 | |
| 7. No psychosis | 13 | |
| 8. Toxic psychosis | 5 |
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| Constitutional psychopathic states: | |
| (a) Inadequate personality | 112 |
| (b) Emotional instability | 40 |
| (c) Paranoid personality | 31 |
| (d) Sexual psychopath | 10 |
| (e) Pathological liars | 5 |
| Total | 198 |
Defective mental development: | |
| (a) Moron | 256 |
| (b) Imbecile | 7 |
| Total | 263 |
Psychoneurosis: | |
| (a) Concussion syndrome | 2 |
| (b) Hysteria | 115 |
| (c) Neurasthenia | 37 |
| (d) Psychasthenia | 26 |
| (e) Hypochondriasis | 13 |
| (f) Enuresis | 1 |
| (g) Stammering | 1 |
| (h) Effort syndrome | 5 |
| (i) Anxiety | 4 |
| Total | 204 |
| Inebriety: | |
| (a) Alcohol | 49 |
| (b) Morphine | 16 |
| (c) Cocaine | 1 |
| Total | 66 |
Epilepsy, idiopathic | 156 |
Cerebrospinal syphilis | 36 |
Endocrinopathy, thyroid | 13 |
Meningitis, cerebrospinal, epidemic | 6 |
Miscellaneous: | |
| Acute hallucinations | 4 |
| Traumatic psychosis | 2 |
| Hydrocephalus | 1 |
| Residual birth palsy | 1 |
| Division extensor tendon, ring finger | 1 |
| Embolism, pulmonary | 1 |
| Polyneuritis | 2 |
| Acute confusional state | 4 |
| Pulmonary tuberculosis | 2 |
| Paratyphoid fever | 1 |
| Peripheral nerve palsy | 7 |
| Labyrinthine hemorrhage | 1 |
| Acute bronchitis | 2 |
| Nephritis, acute | 1 |
| Progressive muscular atrophy | 1 |
| Spinal sclerosis | 1 |
| Typhoid fever | 2 |
| Toxemia, acute | 1 |
| Chronic prostatitis | 1 |
| Periostitis | 1 |
| Total | 37 |
| Total cases admitted | 1,654 |
| |
Evacuated to Evacuation Hospital No. 31, A.P.O. 731 | 3 |
Evacuated to Provisional Base Hospital No. 1, A.P.O. 731 | 4 |
Evacuated to Base Hospital No. 79, A.P.O. 731 | 18 |
Evacuated to Base Hospital No. 116, A.P.O. 731 | 24 |
Evacuated to Base Hospital No. 8, Savenay | 623 |
Evacuated to Base Hospital No. 117, A.P.O. 731 | 17 |
Evacuated to Base Hospital No. 214, Savenay | 909 |
Evacuated to Evacuation Hospital, Neufchatau (French) | 2 |
Evacuated to Tours | 5 |
Evacuated to Hospital Center, Angers | 27 |
Evacuated to duty | 9 |
Evacuated to Assistant Provost Marshal | 5 |
Absent without leave | 1 |
Died: | |
| Manic exhaustion | 1 |
| Cerebrospinal syphilis | 1 |
| Pneumonia, lobar, acute, bilateral | 1 |
| Pneumonia, bronchial, acute bilateral | 1 |
| Meningitis, acute suppurative | 1 |
| Typhoid fever | 1 |
| Pulmonary embolism | 1 |
| Total cases disposed of | 1,654 |
| |
| Total number of evacuation by months: | |
| July, 1918 | 54 |
| August, 1918 | 132 |
| September, 1918 | 149 |
| October, 1918 | 128 |
| November, 1918 | 200 |
| December, 1918 | 125 |
| January, 1919 | 156 |
| February, 1919 | 257 |
| March, 1919 | 262 |
| April, 1919 | 184 |
| Total number of cases evacuated | 1,647 |
Died | 7 |
| Total cases disposed of | 1,654 |
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SPECIAL TREATMENT HOSPITALS
BASE SECTION NO. 1
It was at Base Hospital No. 8, Savenay, in February, 1918,that the first special provisions for mental patients in France were made.Before that time only the roughest makeshift methods existed. In the earlyperiod of the existence of the neuropsychiatric department of this hospital,from January 1 to June 1, 1918, it consisted of two wooden barracks of acapacity of 90 beds each. An interesting feature of this organization was thatthe mess hall for patients suffering from mental and nervous diseases was notseparate, but the neuropsychiatric patients, except those who were disturbed,ate with the other patients of the hospital center. One ward was partitioned offto care for patients who were disturbed and consequently needed to beclosely supervised.
The total admissions during the first five months of theexistence of the special neuropsychiatric service of Base Hospital No. 8 was369. After June 1, 1918, the admission rate rapidly increased. The admissionsin June were 256, just about two and one-half times the admissions in May.
On June 11, 1918, the personnel of Base Hospital No. 117arrived at Savenay from the United States.2 This was a very importantevent in the neuropsychiatric work of the American Expeditionary Forces.Although all the personnel for the long-awaited special base hospital for warneuroses which had been so carefully recruited in the United States could havebeen used at
bUnless otherwise indicated, the statements of fact appearing herein are based on the "History of the Savenay Hospital Center," prepared under the direction of the commanding officer by members of his staff. On file, Historical Division, S. G. O.
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La Fauche, where a nucleus for the new hospital was already in operation, thecare of mental patients at Savenay awaiting transportation to the United Statesalso required trained officers, nurses and enlisted men at this base port.Accordingly, 3 medical officers, 28 nurses, and 33 enlisted men were detailed tostaff the rapidly growing psychiatric department at Savenay.
This detachment of a goodly portion of the personnel from Base Hospital No.117 unit was in conformity with the following letter from the senior consultant,neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., which had beenwritten in the preceding February:3
1. The personnel of Base Hospital No. 117 (neuropsychiatric hospital), nowunder orders to proceed to France, is made up of medical officers,noncommissioned officers, female nurses, and enlisted men who have hadexperience in the care of mental and nervous diseases. As it was thought wise,in organizing this hospital, to consider the possibility of having to establishit in two sections, "psychiatric section" for the treatment of mentaldiseases and "neurological section" for the treatment of the neuroses,the personnel was selected with this contingency in mind.
2. As the plan of staffing the psychiatric department established at BaseHospital No. 8 with part of the personnel of this hospital and the hospital for neurosesat La Fauche with the remainder has been decided upon it will be necessary todivide the personnel upon the arrival of the unit in France.
3. It is recommended, therefore, that the plan of division indicated in theinclosed tables be adopted.
4. It is not practicable to suggest the assignment of medical officers untilthe names of those accompanying the unit from the United States are known. Theseofficers will be the commanding officer, the adjutant, an electrotherapist, andthree ward physicians. When this information has been received it will bepossible to complete the personnel from medical officers in the AmericanExpeditionary Forces and in the special military hospitals for mental andnervous diseases in Great Britain.
5. It is recommended that the Surgeon General be requested to cable the namesof the medical officers who will be sent from the United States with thishospital and the date of their departure, in order that the necessary orders maybe requested.
Until the arrival of the new personnel referred to above the psychiatricdepartment had been conducted under the direction of a medical officer, with twoor three young medical officers who had had psychiatric training and a fewpsychiatric nurses and enlisted men who had worked in State hospitals.
Additional wards now became necessary, for, with the increased participationat the front of many American divisions, neuropsychiatric cases increased at amore rapid rate. This is shown by the greater number of mental cases sent toBase Hospital No. 8, at Savenay, for treatment and for evacuation to the UnitedStates. In July, 405 patients were admitted; in August, 588; in September, 887;in October, 658; in November, 809; and in December, 412. In the latter part ofAugust, 1918, three more wooden barracks were added, providing accommodationsfor about 500 patients. In the meantime, 11 wards of special construction hadbeen erected for this service in a locality some distance from the mainhospital. These wards, situated on a slight elevation of ground, consisted ofthe following buildings: One administrative building, in which were located theoffices of the commanding officer, adjutant, and other personnel engaged in theroutine administrative activities of the hospital; one ward for officerpatients; a mess hall; a barrack for enlisted personnel; and a ward fordisturbed patients. The remaining wards were of the uniform type,
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with ample facilities for the care of these patients,including day rooms, shower baths, and toilet facilities. These additionalbuildings provided accommodations for something less than 200 patients, but byusing officers' and enlisted men's barracks, the capacity was expanded toover 250. During this period, however, the barracks connected with Base HospitalNo. 8 were still retained for neuropsychiatric purposes.
In October, 1918, four additional buildings of concrete blockwere added to the 11 wards above mentioned. When these were completed theoriginal barracks of Base Hospital No. 8 were relinquished. No diminutionoccurred in the admission rate after the armistice began and, therefore, theunit, as finally constructed, proved inadequate. Indeed, in the late fall of1918, admissions were so rapid that the commanding officer of the hospitalcenter found it necessary temporarily to designate wards for the reception ofneuropsychiatric cases in adjacent units, i. e., Base Hospitals Nos. 69 and 113.The following letter from the senior consultant in neuropsychiatry to the chiefsurgeon, A. E. F., explained the difficulties and needs of the hospital atSavenay late in October, 1918:4
1. The steady increase in the number of mental casesadmitted to the psychiatric department of Base Hospital No. 8 shows that, inspite of better facilities for their transportation to the United States, moreextensive arrangements for their care are needed than were at one time thoughtdesirable.
2. Some idea of the magnitude of the problem of providingeven temporary care for the insane of the American Expeditionary Forces is shownby the fact that more cases are admitted to the psychiatric department of BaseHospital No. 8 each month than in the psychopathic wards of Bellevue Hospital,which serves a city of more than 5,000,000 people.
3. In order to handle this question in a thoroughlysatisfactory way, to relieve hospitals of these cases, and to evacuate promptlythose collected in the psychiatric departments of the advance and intermediatesections of the S. O. S., it is recommended that one of the hospital units atthe Savenay center now nearing completion be constituted a psychiatric basehospital and devoted entirely to this purpose.
4. Such provisions would increase the efficiency of the work,provide for any increase likely to be expected, and meet certain difficultiesregarding disposition of personnel, care of insane officers, etc., which existwhen such important work is carried on as part of another hospital. Thebuildings now used by the psychiatric department can be used to advantage forother purposes.
5. The personnel for such a psychiatric base hospital can beprovided from the special personnel of medical officers, nurses, and enlistedmen with psychiatric training now at Base Hospital No. 8 and fromNeuropsychiatric Replacement Unit No. 1, which has recently arrived at La Fauche,and Neuropsychiatric Replacement Unit No. 2, which is expected to arriveshortly.
6. The personnel required for such a hospital with a capacityof 1,000 beds is as follows:
Commanding officer | 1 | Nurses, female | 40 |
Medical director | 1 | Reconstruction aides | 4 |
Adjutant | 1 | Noncommissioned | 20 |
Quartermaster | 1 | Privates and privates first class | 80 |
Dentist | 1 |
| 164 |
Chaplain | 1 | ||
Mess officer | 1 | ||
Registrar | 1 | ||
Ward physicians | 12 | ||
| 20 |
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7. The commander of the Savenay Hospital Center fully agrees in these recommendations and was the first to suggest this as a solution of a problem which is growing very rapidly in size and importance.
On November 6, 1918, the neuropsychiatric service at Savenay was organized as an independent unit, taking over the quarters already occupied. Thehospital at this time was officially designated Base Hospital No. 214, A. E. F.
During the latter part of December, evacuations became so rapid andadmissions were delayed to such an extent that for a short time there were but65 patients in the hospital. The closing of Base Hospital No. 117, at La Fauche,however, soon increased the rate of admissions, so that early in January, 1919,the patient population of Base Hospital No. 214 exceeded 700, including 40officers. The admissions during January, 1919, were 885, and in February, theywere 824. This was quite in excess of the capacity, especially since, except asa temporary expedient, the use of wards of adjacent units was not feasible.Under these circumstances, the commanding officer of the center gave directionsthat one of the new 1,000-bed units be taken over as a neuropsychiatrichospital.
This new unit of 1,000 beds was occupied for the first time on January 21,1919. The construction of the wards was not so well adapted as that of the firsthospital, which had been designed for the purpose, and additional constructionwas necessary. A considerable part of this extra work was done by patients. Asitting room was built in one end of the officers' ward and furnished by theAmerican Red Cross. A similar sitting room for nurses was arranged in anotherward. A staff conference room was constructed in the officers' barrack. A dietkitchen, furnished by the American Red Cross, was installed in the building usedfor occupational therapy. Four wards were constituted closed wards, withscreened windows, and in these wards partitions were constructed in such a wayas to make patients' day rooms. One ward building was utilized for a Red Crossrecreation hut, and appropriately furnished. The large building adjacent to themess hall, used in other units for surgery and dressings, was fitted up for awork shop. This work shop was especially well equipped, for in it was placed thematerial formerly used at Base Hospital No. 117, consisting of brass work,tools, lathes, carpenter sets, and an acetylene welding apparatus.
The routine of the hospital was systematized in the following way: Forpurposes of classification all patients were admitted to one large admittingroom of 90 beds. A special nursing force was maintained here. Observations bythe staff were made at once in order to classify the cases as rapidly andaccurately as possible. The ward surgeons and nurses of the receiving ward wereespecially well trained for this work. All patients, upon admission, were seenby the receiving officer and assigned to their proper wards. The case of acutepsychosis, of chronic alcoholism, and of delinquency were sent at once to closedwards. Mild psychoses, epileptics, and mental defectives were kept in open wardsunder supervision. Cases of psychoneurosis were sent to separate wards, and, assoon as space was available, to the specially constructed wards mentioned above.
By examining and classifying every case at once, administrative difficultieswere reduced to a minimum. During this period but two serious accidentsoccurred, although delinquents of every description came through the service. Atthe same time, patients were given as much liberty as possible, indeed,
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liberties which in civil life would have been considered impossible. Asbefore stated, there was no separate mess for many months, patients fromneuropsychiatric wards going to the general mess. The Red Cross recreation hutof the center, likewise, was used by all, and the convalescent patients from theneuropsychiatric service often contributed to the entertainments by musical ordramatic performances.
Patients evacuated to the United States by months | |
January to June, 1918 (not recorded by months) | 116 |
July | 217 |
August | 455 |
September | 839 |
October | 695 |
November | 801 |
December | 650 |
January, 1919 | 697 |
February | 721 |
| Total | 5,075 |
The small proportion returned to duty-4.38 per cent of the total hospitalservice-tells the story of the main functions of this hospital during theperiod of active warfare and immediately thereafter. It served principally as acollecting center for difficult and chronic cases of nervous and mental diseaseswhich were to be returned to the United States. Its problem was to study and todiagnose these cases and to provide specialists to care for them in France andwhile en route to the United States.
The organization continued to operate during the spring of 1919. At one timein April it had a population of 1,018 patients actually resident in thehospital. Evacuations were very rapid thereafter so that at the end of May thepopulation fell to under 400. There were at that time from 60 to 100 cases amongour forces in Germany to be sent to the hospital and a few cases were admitteddaily from various other places. But with the rapid rate at which troops weresent back to the United States, the hospital population soon dwindled. On June21, Base Hospital No. 214 ceased to function. The residue of the patients weretransferred to Brest and to Base Hospital No. 113, where adequateneuropsychiatric services were maintained. Officers, nurses, aides, men, money,and workshop materials were sent to these organizations. The remainder of theunit returned to the United States.
CLINICAL SUMMARY
A large amount of clinical material passed through this hospital, no lessthan 6,093 cases having been admitted up to March 1, 1919. Observations werenecessarily incomplete and the minute recording of cases impossible. The varioustypes, some unusual in civil life, came under observation with such frequencythat they became fairly familiar. The consequence was that clinical pictures,which otherwise would have been uncertain, became well established in theunderstanding of the staff. A statistical summary of the clinical material isgiven in the following tabulation, which likewise provides the major headingsunder which the clinical material will be briefly considered.
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Mental and nervous cases classified D at Savenay in 1918-19
1918 | 1919 January-February | Totala | ||
January-June | July-December | |||
Psychoses | 242 | 1,222 | 452 | 1,916 |
Constitutional psychopathic states | 85 | 434 | 115 | 634 |
Mental deficiency | 87 | 297 | 140 | 524 |
Epilepsy | 79 | 574 | 99 | 752 |
Psychoneuroses | 167 | 766 | 730 | 1,663 |
660 | 3,293 | 1,536 | 5,489 | |
aThere were in addition 124 cases diagnosed "organic nervous diseases," which brings the total to 5,613.
PSYCHOSES
The number of frank psychoses, amounting in all to 1,916 cases, is probablynot excessive considering the forces engaged. Interest in these cases is more intheir clinical character than in their numbers. It was soon observed that, inaddition to ordinary civil life types, many unusual cases were encountered.Although many familiar types of dementia pr?cox, general paresis, and otherdiseases were admitted, they were by no means the only types seen. Soon afteractive hostilities began, cases appeared with which the staff were unfamiliar intheir civil life experience. In these unusual cases, the reactions and clinicalpictures did not conform to any recognized types. It is possible that a numberof these unusual cases might have become clearer by adequate previous historiesand longer periods of observation. This, however, was probably not true of all;so that a tentative formulation of these unusual cases deserves mention at thistime. They probably do not form a distinct class from every point of view. Theydoubtless have a common etiology, however, and they have groups of symptoms incommon which are sufficiently striking to warrant them being discussed as agroup. Such cases at this hospital were referred to by the staff as the"war psychoses," and so this term is somewhat arbitrarily used. Thewar psychosis, of course, is an interesting "situation" psychosis, andany clinical description of war neuropsychiatry would be incomplete without adiscussion of it.
WAR PSYCHOSES
It has been stated by some observers that the war has failed to bring tolight any unusual forms of mental disorder, all cases being merely thosefamiliarly met with in civil life, possibly colored by a war setting. This isnot in accordance with the observations of the staff of this hospital. Unusualgrouping of symptoms, in fact, entire clinical pictures were encountered to suchan extent, as stated above, as to warrant separation of these cases into agroup.
The cases in question, termed war psychoses, were observed in considerablenumber. No actual record of their number was kept, but they probably amounted toone-fifth of all the cases diagnosed as psychoses. Many of them improvedconsiderably while at the hospital, and it is quite probable that by the timethey reached the United States the acute symptoms had disappeared.
The following clinical picture is a composite of what was most frequentlyobserved. Patients on admission were dazed, confused, and disoriented, and as
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a rule they were not accessible during the acute period. They generallythought themselves at the front under fire, and were anxious and apprehensive.They wandered about rather aimlessly and showed bewilderment and confusion. Somewere quite agitated. Frequently they preferred to be by themselves andvolunteered very little in the way of conversation. As a rule they weredepressed, at times so profoundly as to attempt suicide. A few cases wereobserved in which there was an elevation of mood. The possibility of amanic-depressive condition was considered in these particular instances, but wasregarded as improbable. In this general setting of clouding of consciousness,confusion, and bewilderment, there were active hallucinations of sight andhearing. Patients complained of seeing shells bursting, and of hearing thewhistling of shells and bullets. In their highly emotional state it is probablethat a part of this was misinterpretation of noises about the hospital. Thesymptoms were worse at night, but were by no means confined to the nighttime.This general condition had some features in common with the psychoneuroses,such as anxiety, fearful dreams, visual hallucinations; but the conditiondiffered in that they were inaccessible, disoriented, and confused, with markedmood changes and no insight. Not infrequently there were delusional ideas oftransient character and of a changing nature, the content of which had to dowith war experiences.
The interpretation of the nature of the conditions above described presents anumber of difficulties. In some respects they resembled protracted exhaustivepsychoses. It is thought, in view of the anxiety, the depression, the characterof the hallucinations and the emotional conditions, that emotion and excitementplayed quite as prominent a part as exhaustion. Since the patients, as a rule,were inaccessible, no clear idea could be gained as to what they hadexperienced; however, it is possible that many of them had been under heavyshell fire, but under what circumstances this was experienced can not be stated.It was necessary to return these patients to the United States as soon as theircondition warranted transportation. The impression was that the prognosis wasgood. The psychosis was considered an acute one, having little in common withordinary civil life types, although many cases bore the diagnosis of dementiapr?cox on their admission tag.
Another small group of cases was observed resembling somewhat those above described, but different in a number of respects. Such patients were admitted in a delirious condition. As a rule these patients had not been at the front, possibly having but recently landed in France. They were confused, rambling in conversion, inaccessible, and restless. They were disoriented and presented the picture of delirium. The thought content was not remarkable. The condition was considered an hysterical delirium, arising in predisposed individuals.
Of the well known psychoses, such as dementia pr?cox, manic-depressive psychoses, and others, a few features of interest were observed. A number of cases of dementia pr?cox appeared to have developed since enlistment. Some gave a history of symptoms previous to enlistment and a fair proportion of these had had previous hospital residence. In the manic depressive cases there were relatively more with depression than with elation. Both showed a
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war coloring, especially the depressions, and in fact, the thought content ofmany of the self-accusatory and depressed patients had to do solely with warconditions. They frequently had the idea that they were being accused ofbetraying their country or of being German spies. It is a noteworthy fact thatcomparatively few acutely maniacal cases were encountered. Their management wasnot as difficult as had been anticipated although several very acute cases wereadmitted.
PSYCHONEUROSES
No attempt will be made to discuss in detail the psychoneuroses at this point, because more favorable opportunities were offered at other hospitals for the observation of these cases. As a rule, when these patients reached this hospital the psychoneurotic symptoms had existed some weeks and even months, and so they presented clinical pictures differing in character and degree from those seen near the front. Only observation as to the general character and disposition of these cases as it pertains to this hospital will be made at this time.
It is probable that no cases coming under the care of medical officers wereas imperfectly understood at the beginning of hostilities as the psychoneuroses. As has been pointed out elsewhere, information regarding themhad been sent from the chief surgeon's office, and, likewise, data of greatvalue were available from both French and British sources. Nevertheless, thenature of these conditions was unfamiliar to most medical officers other thanneuropsychiatrists. It was for this reason, as before mentioned, that weekselapsed before plans which had been carefully arranged for the care of thesepatients were in satisfactory operation. During the early period of hostilities,as stated above, the psychoneuroses did not always come under the observation ofthe officers designated to take care of them. Some of these patients were sentfrom advance areas directly to base hospitals, where they were admitted to wardsof the medical or surgical service. The fact that the case was a neurosis andnot an organic disease was not always appreciated. Such cases were retained inbase hospitals without improvement and many of them eventually arrived atSavenay for disposition. Others were classified by medical boards at basehospitals, sent to training camps not fully recovered, and having been foundunfit at these places were transferred to Savenay. It can be readily seen thatthese cases, while relatively few in number, were unfavorable types for earlyrecovery. Fortunately, their number was not great. In a short time steps weretaken by the chief surgeon to insure the sending of psychoneuroses topsychiatrists at the front and not directly to base hospitals in the Services ofSupply.
During the period of active hostilities the number of cases of psychoneuroses arriving at this hospital was not relatively large. Two generaltypes were recognized; namely, those resulting from battle experiences and thoseof ordinary civil life types, the latter probably latent or actually existingprior to enlistment. The civil life types, such as neurasthenia andpsychasthenia, in most instances, came under observation soon after arrival inFrance and never reached the front. A certain portion of these were classifiedfor duty in the Services of Supply and the more severe cases were returned tothe United States.
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The psychoneuroses arising from battle experiences came from two mainsources. At one time a number came from base hospitals or reclassificationcamps, without previously having had special treatment. It was possible toreturn a considerable number of these cases to duty, and some were sent to BaseHospital No. 117. Other cases came from neurological hospitals in the advancesection, mainly from Base Hospital No. 117. Cases arriving from these hospitalswere intended for evacuation to the United States, being consideredconstitutional types with unfavorable outlook for recovery in the immediatefuture. After hostilities ceased, arrangements were made by which thepsychoneuroses of all sources eventually came to this hospital, and thisaccounts for their increase in number during the latter months of the hospital'shistory. It was not the policy, after the armistice began, to classify thesecases for limited service in the American Expeditionary Forces. They werereturned, therefore, to the United States for disposition, the severe casesundergoing a period of treatment before evacuation.
There was one unusual feature of the symptomatology observed in thishospital. It was found that a number of cases of mental deficiency, epilepsy,and mental diseases exhibited war neuroses, such as mutism, tremors, orhysterical hemiplegia. This association of symptoms was not infrequent and thesecases presented very unusual clinical pictures as a result.
EPILEPSY
Cases, in comparatively large number, amounting in all to 752, were diagnosed epilepsy. These cases afforded ample opportunity to observe the various manifestations of epilepsy, such as major seizures, petit mal, and epileptic equivalents. In addition to these well-known manifestations of epilepsy, the constitutional make-up of such patients formed an important part of their disability, and at times was of more significance than the actual seizures. In other words, the seizures themselves occurring at rare intervals, might not have been disqualifying, but the neurotic or defective constitution as a background rendered these patients unfit as soldiers. The vast majority of these cases were highly neurotic, indeed to such an extent that at times it appeared that the disease should be interpreted as a severe aggravated neurosis of which the seizure, while the most apparent symptom, was not the most important.
Many border-line cases were seen, which were thought to belong to this general group. Such cases frequently had slight mental defect and were sluggish in mental reactions. They presented numerous neurasthenic complaints of long standing. With this condition would occur minor attacks of loss of consciousness, with slight confusion and with occasional frank epileptic seizures. In these cases, of which there were many, the mental defect and the constitutional neurotic condition were of more importance than the actual attacks. Many cases came under observation who had had frank seizures at frequent intervals since childhood. These cases were readily recognized. Numerous types of epileptic equivalents were also encountered. Epilepsy was often associated with alcoholism. Where epileptic seizures occurred on an organic basis, the cases were classified as organic brain disease.
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The question of so-called hysteroepilepsy arose at times, especially sincethis diagnosis occasionally appeared on the field card. No great difficulty wasexperienced in distinguishing the seizures of epilepsy from hysteria. A carefulhistory and clinical observation were all that was necessary as the hystericalcases bore only a superficial resemblance to true epilepsy.
AMNESIA
These cases are discussed at this time because of the relationship of anumber of them to epilepsy. Cases were encountered in relatively large number,in which patients absented themselves from their organizations for periodsvarying from several days to several weeks. These patients maintained that theyhad no memory whatever of what had transpired. They either returned themselvesor were returned by the military police. Such instances occurred in bothofficers and men. A number of them were frank cases of epilepsy, the period ofamnesia occurring either before or after a seizure or being an epilepticequivalent. Many other cases occurred after the excessive use of alcohol. Afterexcluding both epileptic and alcoholic cases, however, many instances of amnesiaof the type mentioned above remained to be explained. They were considered bymany observers to be instances of hysterical amnesia, and this interpretationappears the most probable one, thus bringing such cases under the general groupof psychoneuroses of the hysterical type. If this view is held, the amnesiacould most readily be explained as a mechanism operating subsconsciously, inwhich the individual escaped from a difficult or intolerable situation by wipingout from memory all circumstances associated with it. It is also probable thatmany such cases were conscious delinquencies, but the number of the latter typeis thought to be comparatively small. All such cases raise medico-legalquestions, as the matter of mental responsibility has to be determined.
CONSTITUTIONAL PSYCHOPATHIC STATE
In this group, amounting to 634 cases, were included patients who, while notsuffering from frank mental disease, nevertheless were in a mental conditionsufficiently abnormal to bring them into serious conflict with those about them.These cases did not differ materially from those seen in civil life, butpresented such additional features as might be expected to develop undermilitary r?gime. Patients of this kind might make fair progress in civil lifewhere they could change occupation and surroundings; but in the military servicethis was not possible, and they broke down nervously, as a result. Indeed, theyfrequently suffered from temporary mental disorders. In this group were includedsome cases of alcoholism and drug addiction in whom such states were consideredas symptoms in those constitutionally predisposed.
MENTAL DEFICIENCY
There were admitted 524 cases diagnosed mental defectives. This number is notrelatively large, and it is probable that many defectives were eliminated beforearrival in the American Expeditionary Forces. The classification of these casesin respect to duty, particularly those with the lesser degrees of
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defect, was a question of considerable importance. It was considered thatwhile defectives as a rule could not be used with combat troops, still many ofthem were serviceable in labor organizations. The disposition, therefore, was toreclassify such cases as were considered fit for duty in rear areas. The recordof how these patients had conducted themselves in the military service wasconsidered in conjunction with their mental age as determined by an intelligencetest, for the emotional constitution of such patients was of considerableimportance. A case with mild defect, if irritable and emotional, was often foundunfit, while a case with stable temperament, even with considerable defect, wasconsidered fit for limited service.
In many instances physical defect was found to accompany the mental defect.The physical defect varied in character and degree, in some cases beingexpressed merely by awkwardness in simple movements, in others making itselfmanifest by the gross, ungainly physical make-up of the mental defective. Instill other cases appeared a constitutional physical defect of ill-defined type.These patients were stooped, had a narrow, ill-developed chest, and often aprominent abdomen. Such cases often complained of numerous neurasthenicsymptoms. They were related to constitutional neurasthenic types frequently seenin civil life, with mental deficiency added. It was soon found that it wasunwise to return these cases to duty of any kind. They went on sick report or inhospital very frequently and they were more of a liability than an asset.
ORGANIC NERVOUS DISEASES
This organization did not receive cases with lesions of the central orperipheral nervous system resulting from battle casualties, such cases beingreceived by the surgical services of the center. However, the other organicnervous cases, amounting in all to 143, were cared for at this hospital.Peripheral neuritis, occurring after diphtheria, influenza, or other toxicconditions, was frequently encountered. Evidence of syphilis of the centralnervous system was found in more cases than might have been expected,considering the average age of the patients. Several cases were diagnosed braintumor. A number of patients presented mental symptoms or epileptiform seizuressubsequent to brain injury. Comparatively few cases of paresis or tabes wereobserved, although other manifestations of syphilis of the central nervoussystem were not infrequent.
ENCEPHALITIS OF UNDETERMINED TYPE
During January and February, 1919, a small number of organic cases of unusualinterest were admitted to this hospital. The clinical features of those caseswere first recognized by the chief of the service at that time. They presentedsymptoms of such unusual interest that it is thought they should be discussedhere, regardless of the fact that the clinical observations could not becompleted. The following observations, made by the chief of service, are givenas nearly as possible in conformity with his characterization of them. In all,there were about one dozen cases of this particular group.
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The most striking feature of these cases was that they bore a rather closeresemblance to paralysis agitans. They showed a stolid mask-like expression, atremor of the head and hands suggestive of paralysis agitans, although differingsomewhat from it, a shuffling gait, and a rigid posture, which suggestedrigidity of the muscles of the neck and trunk. These cases also appeared dullmentally, but this was more in appearance because of their lack of expressionthan in reality. There was no actual paralysis of the facial muscles, merely alack of mobility and of expression. One patient could smile but very slightly,and could not laugh. Another had noticed by looking in the mirror that hisexpression had changed. The head and neck in these cases were held in a stiffand rigid position, but little, if any, true rigidity was found. The arms wereheld in a semiflexure both when the patient was walking and sitting. Here, too,however, there was not actual rigidity. The tremor was of a rather coarse type.The hand, as a rule, was held partly closed, but a pill-rolling motion was notobserved. As a rule, both sides were involved, but one more than the other. Thegait was shuffling and awkward; in fact, all movements were slowly andawkwardly performed. The gait suggested paralysis agitans but was not entirelycharacteristic of that disease.
Physical signs indicating disease of the central nervous system, except thosedescribed above, were not marked. One case showed a remarkable lateral androtary nystagmus with exceptionally wide excursions. Otherwise the eye symptomswere negative. There was no actual paralysis of facial muscles. One patientshowed considerable tremor of the lips which made it appear that he was about toweep; however, there was no emotional instability. The deep reflexes showednothing remarkable except in some instances the knee-jerks were very active.There were no sensory disorders and no Babinski or ankle clonus. The superficialreflexes were normal. There was no actual motor weakness, but motor functionswere performed awkwardly. The liver showed no evidence of disorder, and otherphysical findings were negative. Unfortunately, complete serologicalexaminations were impossible. Spinal punctures were done in a few cases. Noincrease of cells or globulin was found, but as the punctures were done late inthe disease nothing definite could be inferred from these negative findings.
While these cases had a fairly close resemblance to each other, sufficient toplace them in one group, they did not have that close resemblance throughoutwhich is found in most cases of paralysis agitans. In some the tremor of thehands was the most marked symptom; in others, the gait; and in others the lackof facial expression or the rigid posture. All had to a certain extent some ofthe symptoms enumerated above. Paralysis agitans is mentioned in connection withthese cases for descriptive purposes only, not that they were thought to haveany true relationship with that disease. The condition was thought to beencephalitis of unknown origin, the toxic agent showing a selective action,probably for the lenticular nucleus. No etiology could be established. Somecases had had a febrile reaction before admission and had been diagnosedinfluenza; one occurred after mumps, one after an infection of the antrum andethnoid sinuses. Others gave no history of any acute illness. Some of the caseshad been confused and delirious at the outset of their illness, previous to
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their admission here. In favor of interpreting these cases as encephalitisof selective type is the fact that a number of other cases were admittedabout this time in which the cranial nerve nuclei of the brain stem wereinvolved. One such case showed, first, involvement of the seventh nerve on oneside; a few days later the other side was involved. Both gradually improved andthen a slight ptosis of both sides was observed. Later the sixth nerve on oneside showed slight involvement and there was also mental dullness during thisperiod. All serological and physical findings were negative in this case. Othersimilar cases were observed during this time. Both French and British writersdescribed a condition which they termed lethargic encephalitis. This conditionmay have had some relationship to the cases of encephalitis observed here. Casesseen here, however, were not particularly dull or lethargic and although ptosisoccurred, it was not as constant as that observed by the French and Britishwriters.
BASE SECTION NO. 5
As has been mentioned elsewhere, the hospital center at Kerhuon, Brest, wascalled upon for many kinds of neuropsychiatric service, especially for thosewho, after being sent from Savenay in expectation of their prompt return to theUnited States, had to wait for weeks and even months before they could go anyfarther.5 This was facilitated in a measure by the fact that largeconvoys of such mental patients usually had with them medical officers andenlisted men who had had special training in the care and treatment of mentaldisorders. Ultimately four wards were set aside as a neuropsychiatric sectionfor the Kerhuon hospital center. These wards with a total capacity of 200 bedswere located in an attractive area at the south end of the hospital reservationoverlooking the bay. The American Red Cross provided two additional barracks,one for recreation, one for occupational therapy, and also a veranda overlookingthe harbor. With the closing of Base Hospital No. 214, June 21, 1919, thisdepartment became the only neuropsychiatric hospital functioning in France. Itthen began to receive patients from all of the areas in France in which Americantroops were still to be found and from the Army of Occupation until a separateline of evacuation for these patients had been provided through Holland. ByJuly, 1919, but very few patients were coming in, the last group being a numberof prisoners, who had been found by the psychiatric survey of the prison campsat Gievres to be suffering from mental disorders. When this hospital ceased tofunction, its remaining patients were evacuated to an annex of Camp Hospital No.33, which was the last neuropsychiatric unit to render any special service inFrance.6
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REFERENCES
(1) History of Base Hospital No. 116, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.
(2) History of Base Hospital No. 117, A. E. F., by the commanding officer of that hospital. On file, Historical Division, S. G. O.
(3) Letter from the senior consultant, neuropsychiatry, A. E. F., to the chief surgeon, A. E. F., February 17, 1918. Subject: Personnel of Base Hospital No. 117. Copy on file, Historical Division, S. G. O.
(4) Letter from the senior consultant, neuropsychiatry, A. E. F., to the chief surgeon, A. E. F, October 28, 1918. Subject: Provisions for mental cases at Savenay. Copy on file, Historical Division, S. G. O.
(5) Report of Medical Department activities, Base Section No. 5, A. E. F., undated, compiled under the direction of the base surgeon from official records in his office. On file, Historical Division, S. G. O.
(6) History of Camp Hospital No. 33, Camp Pontanezen, Brest, by the commanding officer of that hospital. On file, Historical Division, S. G. O.
