CHAPTER VII
IN THE ARMY OF OCCUPATION
Provisions were made at the very outset for a highlyorganized medical service of the army of occupation. In so far as theneuropsychiatric service is concerned, the division psychiatrist of the 42dDivision, who had been consultant in neuropsychiatry for the First Corps, wasassigned to duty as consultant in neuropsychiatry for the new army. Eachdivision was already provided with a divisional psychiatrist. In some casesthese officers joined their divisions at the time of the organization of theThird Army, others had served with their divisions during the period of activehostilities, were thoroughly familiar with their duties, understood conditionsof actual warfare, and had established themselves in the esteem and respect oftheir officers and associates.
The officers and men of the Third Army had just come from theseverest kind of fighting. Many of them were suffering (without fullyappreciating it) from the effects of fatigue and prolonged emotional excitement.Their new duties were to be of a type decidedly different from their recent onesin active warfare; and although it was considered by every soldier an honor tobecome a unit in the army of occupation, there was, nevertheless, not a littlefeeling of envy and regret as they reflected that long after other divisionswould have returned to their homes those constituting the Third Army wouldremain on duty on foreign soil. Favorable as living conditions were whencompared with those in the field, still, new adaptations would be required, someof which might be rather difficult. In other respects the army of occupationconstituted a miniature American Expeditionary Force and many of its medicalproblems were similar to those of the larger American Expeditionary Forcesduring the latter part of 1917 and the early months of 1918.
Under these conditions it was deemed wise to organize aneuropsychiatric service in the Third Army, at the earliest possible moment,capable of giving immediate and efficient treatment to officers and mensuffering from mental and nervous disorders, of furnishing the divisions with amedical service for diagnosing and eliminating men likely to become useless formilitary service, and of providing adequate care for the evacuation to theUnited States of men not likely to be returned to duty after a period ofhospital treatment. A hospital service of specialists was to be established inorder to be prepared to meet these problems as they arose.
The task of organizing a neuropsychiatric service in theThird Army was assigned to the senior consultant in neuropsychiatry by the chiefsurgeon of the army. Certain officers, experienced in dealing withneuropsychiatric problems, were ordered to report for duty in the Third Army.With this personnel the consultant in neuropsychiatry for the Third Armyorganized his special service.
aThe statements of fact appearing herein are based on a report of the activities of the neuropsychiatric service, Third Army, made by Maj. S. W. Hamilton, M. C., consultant in neuropsychiatry, Third Army. On file, Historical Division, S. G. O.
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NEUROPSYCHIATRIC ORGANIZATIONS IN GERMANY
During the period of advance into German territory only thefield hospitals were available for the care of the sick. These hospitalsevacuated their cases largely to Commercey, where there were two base hospitals(one with a neuropsychiatric ward), and to Souilly, where three evacuationhospitals still remained. Division psychiatrists examined patients coming undertheir observation during this period, but the number was very small. As soon asthe troops arrived in the areas which they were to occupy psychiatric clinicswere established at Coblenz and Trier. These were known, respectively, asNeuropsychiatric Unit No. 1, Evacuation Hospital No. 14, at Coblenz, andNeuropsychiatric Unit No. 12, at Trier. At Coblenz a fine private hospitalconducted by a male religious order had the best available facilities for such aservice and was requisitioned by the army. Although this building constituted aseparate unit physically, it was attached administratively to EvacuationHospital No. 14 and later to Evacuation Hospital No. 16. That part of it devotedto the care of mental and nervous patients was known as Neuropsychiatric UnitNo. 1. It was opened on December 26, 1918. The building was an excellentthree-story and basement structure of brick and stone about 20 years old but ina fine state of repair. The rooms and wards varied in capacity from 2 to 12beds, making proper classification of patients easy. The special equipment ofthe hospital included a good hydrotherapeutic plant, a fair Zander installationfor mechanotherapy, and a gymnasium which was converted into an excellent shopfor occupational therapy. The hospital building, in addition to the psychiatricservice, conducted a general medical service. Sometimes the admissions were sonumerous that the neuropsychiatric patients overflowed into the general medicalwards.
The buildings of Neuropsychiatric Unit No. 2 were barrackswith a capacity of 1,500 which had been used previously by the Germans forhospital purposes. The neuropsychiatric service opened on the third floor ofBuilding V, December 24, 1918. On January 22, the service was moved to BuildingIII where special preparations had been made for the reception of nervous andmental cases. The first floor was used for neurological cases and the mildermental disorders. Quarters for the more serious psychoses were on the secondfloor. There were 57 beds and the construction of the building was such that theproper classification of cases was an easy matter. A room was set apart forhydrotherapy. This center received all neurological and mental cases originatingin the military area around Treves. Early in April, 1919, it began to receivepatients from the organizations farther south in the Luxembourg district, whichformerly had evacuated their cases of mental and nervous diseases to ourhospitals in France. Patients were received also by transfer from the morecongested service established in Evacuation Hospital No. 14 (later EvacuationHospital No. 16) at Coblenz.
With 40 beds at Coblenz and 57 at Trier, the army ofoccupation had facilities for the reception, observation, and treatment ofneuropsychiatric patients in the proportion of about 1 bed to 2,500 enlistedstrength. In an American city approximately 60 per cent of the total populationare adults. Not only was the proportion of beds available for neuropsychiatricpatients
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in the army of occupation greater than that which wasprovided at that time in the most advanced communities at home, but thepersonnel, medical officers, nurses, reconstruction aides, and enlisted men werevery much above the average.
The neuropsychiatric unit at Evacuation Hospital No. 12, atTrier, received 249 patients during the period between December 24, 1918, andApril 22, 1919, or about 4 per cent of the total number of admissions to thishospital. Of this number, 198 had mental disorders or were admitted for mentalobservation, and 51 showed symptoms of a neurological nature. One hundred andeighty-three patients, or 77 per cent of the total, were evacuated to basehospitals in France, and 37, or 16 per cent, were returned to duty. There weretwo deaths. The mental cases received included a comparatively small number ofsevere psychoses. The greater number had less serious mental disorders. Themajority were cases of psychoneurosis. A systematic effort to eliminate mentaldefectives from the divisions constituting the army of occupation led also tothe admission of a considerable number of such cases.
The operations of the neuropsychiatric service at Coblenzwere more active than those of the above unit, since the hospital was moreconveniently placed as far as transportation was concerned.
During the winter, the hospital services were very busy; inMarch a decline in admission rate began. The following table shows the number ofpatients received in both centers from December, 1918, to June, 1919, inclusive:
December | January | February | March | April | May | June | Total | |
Psychopathic cases: | ||||||||
| Coblenz | 24 | 106 | 174 | 201 | 159 | 115 | 73 | 852 |
| Trier | 16 | 50 | 34 | 21 | 21 | 23 | 9 | 170 |
36 | 156 | 208 | 222 | 180 | 138 | 82 | 1,022 | |
Neurological cases: | ||||||||
| Coblenz | 11 | 31 | 39 | 35 | 24 | 24 | 9 | 173 |
| Trier | 1 | 26 | 21 | 14 | 19 | 7 | 3 | 91 |
12 | 57 | 60 | 49 | 43 | 31 | 12 | 264 |
These cases were grouped with respect to diagnosis asfollows:
Psychiatric: | |
| Defect and psychopathy | 376 |
| Psychoneurosis | 263 |
| Psychosis | 190 |
| Epilepsy | 65 |
| Alcoholism and drug states | 69 |
| Miscellaneous mental problems | 59 |
1,022 | |
Neurological: | |
| Cerebrospinal syphilis (excluding dementia paralytica) | 23 |
| Paralysis | 33 |
| Neuritis | 38 |
| Neuralgia | 27 |
| Brain tumor | 4 |
| Miscellaneous problems of neurology and internal medicine | 139 |
264 |
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A few points concerning the mental group are noteworthy. Themisfits-defectives and psychopaths-came to the hospitals in highestproportion in February and March. This was due to the attempted elimination ofall but class A men from the army. Had not many been evacuated through otherthan hospital channels (replacement depots) the figures would be even higher.Most epileptics appeared in January and March. Psychoses almost held theirincidence, and alcoholic states increased. Syphilis furnished 2.2 per cent ofall our cases.
December | January | February | March | April | May | June | |
Defect and psychopathy | 7 | 54 | 113 | 81 | 68 | 40 | 13 |
Epilepsy | 4 | 17 | 7 | 18 | 10 | 7 | 2 |
Psychosis | 13 | 23 | 28 | 35 | 30 | 28 | 27 |
Alcoholism and drug states | 2 | 6 | 16 | 9 | 8 | 13 | 15 |
From the beginning it was the aim of officers in charge ofthese neuropsychiatric centers to have them serve as more than mere receptionand clearing houses. Every effort was made to employ the therapeutic measuresavailable in the best conducted hospitals in the United States. For thetreatment of neurological patients, massage, baths, electrical and Zanderapparatus were available. For mental cases, reliance was placed first uponindividual treatment by the trained medical and nursing personnel. In theCoblenz center, there were 18 and in the Trier center 6 enlisted men who eitherhad had nursing experience in State hospitals at home for several years or elsehad received previous training in the Army and were selected because of theirspecial qualifications. Likewise, the nurses were chosen with reference to theirprevious experience and personal qualifications. Much use was made of thehydrotherapeutic apparatus at the hospital at Coblenz and at Trier; a specialbathtub was always available for excited or agitated patients. Excellentlaboratory facilities were available and in constant use.
A development of special importance both at Coblenz and atTrier was occupational therapy. This was started at Neuropsychiatric Unit No. 1,in a small room, by the commanding officer, with the aid of one enlisted man. Afew weeks later three reconstruction aides who had been sent to the AmericanExpeditionary Forces for work with neuropsychiatric patients were on duty ateach center. Shops were finally established in commodious quarters and duringworking hours a very large proportion of the patients under treatment wereassigned there. For patients who were physically infirm, or who were in anuncertain mental state, and so unable to go to the shop, occupational work wasprovided in the ward, and if necessary at the bedside of the patient. Valuableassistance was given by the orthopedic department in getting supplies for theoccupational therapy department. Work with wood, brass, and copper was providedand all sorts of interesting and useful things were made. Other materials wereused, for example, rings were made from silver, bags from leather or beadwork.Likewise, drawing and painting, braiding, and similar crafts were taught.
The dissolution of the Third Army on July 2, 1919, found thenumber of troops in Germany already much decreased. Further embarkations oftroops
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going home occurred at frequent intervals. On July 15,Neuropsychiatric Unit No. 2, at Trier, was closed; Neuropsychiatric Unit No. 1,at Coblenz, was transferred to Evacuation Hospital No. 49 temporarily. On July28, Neuropsychiatric Unit No. 1 was moved to its permanent quarters in what hadbeen the garrison hospital of Coblenz but which was then Evacuation Hospital No.27. The service was located in a building equipped with excellenthydrotherapeutic and electrotherapeutic installations. Some confusion was causedby the fact that all the trained enlisted men were released shortly afterwards,before recruits could be placed under training. In consequence theneuropsychiatric medical officers for a time were handicapped in their work.
ACTIVITIES IN ARMY, CORPS AND DIVISIONS
With the cessation of hostilities, new problems replacedthose of controlling war neuroses; for example, medico-legal activities nowbecame, in a large way, a psychiatric problem. Many men had been placed underarrest during the few months preceding the armistice, charged with differenttypes of military offenses, but had not been brought to trial during activeoperations. In consequence the judge advocate's department was exceedinglybusy during the early part of the period of occupation in disposing of thesemen. In some divisions it was the custom of the judge advocate to request amental examination of prisoners accused of any serious crime. In others, such anexamination was requested only if circumstances connected with the offense, or arough estimate of the mentality of the prisoner, indicated the possible presenceof an abnormal mental condition. In still other divisions, such examinationswere not employed unless mental unsoundness had been definitely advanced indefense of the prisoner.
On January 11, 1919, an order was issued by generalheadquarters, Third Army, for the appointment of boards in all organizations ofthat army to pass upon and eliminate all soldiers physically or mentally unfit.Division psychiatrists were made members of such boards. Patients fromorganizations other than divisions were referred to the army consultant, if ofneurological or psychiatric importance. The policy of the different divisions asto the elimination of men differed somewhat. A division soon to return to theUnited States referred fewer of its personnel than a division which had toremain in Germany for several months. Cases so referred were considered by thedivision psychiatrists and their opinions of men alleged to be mentally unfitwere seldom challenged. In most cases the recommendations were for theevacuation of men found to be mentally defective, of marked psychopathictendencies, or suffering from psychotic or psychoneurotic reactions. Such menwere transferred to the neuropsychiatric centers at Coblenz and Trier and thenceto base hospitals in France. This process was not intended to obstruct theevacuation of neuropsychiatric cases through hospital channels and did not.
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CLINICAL OBSERVATIONS
The following table gives an idea of the distribution ofdiseases among the 1,286 patients received at the centers at Coblenz and Trier:
Psychopathic cases: | |
| Mental deficiency and psychoses | 566 |
| Psychoneuroses | 263 |
| Epilepsy | 65 |
| Alcoholism and drug addiction | 69 |
| Psychiatric conditions not involving definite disorders | 59 |
| 1,022 |
Neurological cases: | |
| Cerebrospinal syphilis (exclusive of general paresis) | 25 |
| Paralysis | 33 |
| Neuritis | 38 |
| Neuralgia | 27 |
| Brain tumor | 4 |
| Miscellaneous neurological and internal medical conditions | 139 |
| 264 |
The largest proportion of patients with mental deficiency andconstitutional psychopathic states came to the hospital in February and Marchdue to the efforts to eliminate unsuitable men referred to above. Had many ofthese men not been evacuated through other channels the admissions at Coblenzand Trier would have been considerably higher. It is noteworthy that during aperiod of seven months a military population which averaged approximately200,000 officers and men contributed 5 psychopathic patients and 1.5neurological patients per 1,000 strength.
The results obtained with many of the cases treated wereexcellent. Although the number returned to duty was small this is because itseemed expedient, even after recovery, especially in the case of the lighterdepressions, not to return a soldier to duty again. Such cases were almostinvariably sent to France to be returned to the United States. In many cases thecourse of the disease was very favorably influenced by the possibility of earlytreatment. It is doubtful whether mental cases which occurred in any similarpopulation have ever been received so quickly and with so little legal oradministrative formality as they were in these neuropsychiatric units of thearmy of occupation.
The number of suicides that occurred in the army ofoccupation was very small. Not one of these suicides occurred in a patient whowas under observation for mental disorders or in the wards at neuropsychiatriccenters. This result is significant, because of the fact that at all times amongthese patients and in the wards states of depression were more frequently seenthan any other psychotic manifestations.
