^BERKELEY \ 
 
 LIBRARY 
 
 UNlVERSrTYOF 
 k CAUFORNIA J 
 
 S'osclances Natural 
 resources Library 
 
THE CARE AND TREATMENT OF MENTAL 
 
 DISEASES AND WAR NEUROSES ("SHELL 
 
 SHOCK") IN THE BRITISH ARMY 
 
 THOMAS W. SALMON, M. D. 
 
 MAJOR, MEDICAL OFFICERS' RESERVE CORPS 
 UNITED STATES ARMY 
 
 PUBLISHED BY 
 
 WAR WORK COMMITTEE 
 
 OF 
 
 THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, Inc. 
 
 50 UNION SQUARE, NEW YORK CITY 
 
 1917 
 
'I) 
 
 'U)S5f 
 
CONTENTS 
 
 Page 
 
 INTRODUCTION 
 
 Acknowledgments 7 
 
 Scope of Report ^ 
 
 I. MENTAL DISEASES (INSANITY) 
 
 Prevalence 13 
 
 Treatment 15 
 
 Clinical Types of Mental Disease among Soldiers 18 
 
 Outlook in Mental Cases 22 
 
 Summary 22 
 
 II. WAR NEUROSES ("SHELL SHOCK") 
 
 Prevalence 32 
 
 Treatment 34 
 
 Outcome 40 
 
 Medico-legal Relations 42 
 
 III. RECOMMENDATIONS FOR THE UNITED STATES ARMY 
 
 Summary of Recommendations for the Care and Treatment 
 of Mental Diseases and War Neuroses ("Shell Shock") 
 
 in the Expeditionary Forces 48 
 
 Expeditionary Forces — Overseas 49 
 
 Personnel for Special Base Hospital for Neuro-Psychiatric 
 
 Cases 54 
 
 Expeditionary Forces — ^In the United States 59 
 
 Non-expeditionary Forces 64 
 
 APPENDICES 
 
 I. References in English to Mental Diseases and War Neuroses 
 
 ("Shell Shock") and Their Treatment and Management 69 
 II. The Use of Institutions for the Insane as Military Hospitals 81 
 
 III. Special Military Hospitals for Mental Diseases and War 
 
 Neuroses ("Shell Shock") in Great Britain and Ireland 93 
 
 IV. Facilities Needed for Efficient Treatment of Mental Dis- 
 
 eases in a Modern Public Institution 101 
 
 38180.; 
 
INTRODUCTION 
 
THE CARE AND TREATMENT OF MENTAL DIS- 
 EASES AND WAR NEUROSES ("SHELL 
 SHOCK") IN THE BRITISH ARMY 
 
 INTRODUCTION 
 
 NO medico-military problems of the war are more striking than those 
 growing out of the extraordinary incidence of mental and func- 
 tional nervous diseases ("shell shock"). Together these disorders are 
 responsible for not less than one seventh of all discharges for disability 
 from the British Army, or one third if discharges for wounds are ex- 
 cluded. A medical service newly confronted like ours with the task of 
 caring for the sick and wounded of a large army cannot ignore such im- 
 portant causes of invalidism. By their very nature, moreover, these 
 diseases endanger the morale and discipline of troops in a special way 
 and require attention for purely military reasons. In order that as 
 many men as possible may be returned to the colors or sent into civil life 
 free from disabilities which will incapacitate them for work and self- 
 support, it is highly desirable to make use of all available information 
 as to the nature of these diseases among soldiers in the armies of our 
 allies and as to their treatment at the front, at the bases and at the 
 centers established in home territory for their "reconstruction." 
 
 England has had three years' experience in dealing with the medical 
 problems of war. During that time opinion has matured as to the 
 nature, causes and treatment of the psychoses and neuroses which pre- 
 vail so extensively among troops. A sufficient number of different 
 methods of military management have been tried to make it possible to 
 judge of their relative merits. INIy visit to England was for the piu-pose 
 of observing these matters at first hand so that I might contribute infor- 
 mation which might aid in formulating plans for dealing with mental 
 and nervous diseases among our own forces when they are exposed to the 
 terrific stress of modern war. 
 
 Acknowledgments 
 
 I wish, at the outset, to record my appreciation of the many courtesies 
 which enabled me to use the limited time at my disposal to the best 
 advantage. The Army Council, upon the request of Ambassador Page, 
 agreed to place at ray disposal every facility for studying mental and 
 nervous diseases. The medical officers of the special hospitals for mental 
 and nervous cases, through the courtesy of Sir Alfred Keogh, Director 
 General of the Royal Army Medical Corps, gave me opportunities to 
 
 7 
 
8 MENTAL DISEASES AND WAR NEUROSES 
 
 observe the work of the institutions under their charge. Others actively 
 engaged in deahng with various administrative and cHnical phases of 
 these problems not only gave me valuable information but very kindly 
 offered suggestions as to practical means by which our army might profit 
 by the experience of British medical officers. I would mention especially 
 Lt. Colonel William Aldren Turner, the principal advisor to the govern- 
 ment in these matters; Lt. Colonel Sir John Collie, President of the Special 
 Pension Board on Neurasthenics; Sir AVilliam Osier, under whose direc- 
 tion work is carried on in the special hospital for functional disorders of 
 the heart; Dr. C. Herbert Bond of the Board of Control; Dr. Henry 
 Head, who represented the Medical Research Committee in the con- 
 ference upon nervous diseases among soldiers, held in Paris in April, 1916; 
 Dr. H. Crichton Brown who has prepared a thoughtful memorandum on 
 the subject for the War Office; Lt. Colonel Sir Robert Armstrong-Jones 
 and the American liaison officers in London — Brigadier General Bradley 
 and Lt. Colonel Lyster of the army and Surgeon Pleadwell of the navy. 
 Dr. William Morley Fletcher, Secretary of the Medical Research Com- 
 mittee, which from an early period in the war has directed attention to 
 the importance of nervous diseases, presented me with a motion picture 
 film showing some of the more common symptoms in soldiers suffering 
 from the neuroses. Dr. John T. MacCurdy, Associate in Psychiatry at 
 the New York State Psychiatric Institute, who was studying the war 
 neuroses in special hospitals in London, very kindly visited the Moss 
 Side Military Hospital at Maghull and the Craiglockhart Hospital for 
 officers, near Edinburgh, and furnished me with reports on the facilities 
 for treatment at these institutions.* 
 
 It is impossible to examine closely any phase of the work of caring 
 for disabled soldiers in Great Britain without being profoundly im- 
 pressed with the high degree of executive and scientific skill with which 
 the unprecedented medical problems of the war have been met. More 
 than twice as many hospital beds have been provided for soldiers and 
 sailors as existed in the whole United Kingdom in August, 1914, for 
 the civil population. In the stress of war, with all difficulties im- 
 mensely increased, special types of treatment have been provided 
 which the most enlightened civil communities had not yet been able 
 to supply in time of peace. These almost incredible achievements 
 were made possible by the patriotic efforts with which the nation dis- 
 posed of obstacles in every direction. Beneath all this work is the 
 deep sympathy which officials and the public alike bestow upon all 
 those returning from the front who are in need of care or attention. 
 
 •Appendix III. 
 
INTRODUCTION 9 
 
 Scope of Report 
 
 I have omitted entirely from this report any account of the treat- 
 ment of organic nervous diseases and of injuries to the central nervous 
 system or the peripheral nerves. Organic nervous diseases are not 
 especially frequent and seem to present no special military problems. 
 Injuries of the central nervous system are frequent and severe. Those 
 that do not prove fatal very quickly are well cared for at first in gen- 
 eral surgical wards where the services of neurologists and neurological 
 surgeons are available and later in special hospitals or special hospital 
 wards. A very serious difiiculty in dealing with destructive brain and 
 cord lesions is that the patients sooner or later pass from hospitals in 
 which special care and nursing are provided to their homes or to poorly 
 equipped auxiliary hospitals in which many soon get worse or die. 
 Injuries to the peripheral nerves are frequent and important, in fact 
 there are few extensive injuries to the extremities in which important 
 nerves escape. With neurological ad\ace, the surgeons deal with these 
 cases successfully in the base hospitals and their after-treatment is well 
 carried on in the "reconstruction centers" for orthopedic cases. 
 Neither of these classes of injuries concerns us especially in a considera- 
 tion of the treatment and military management of mental and func- 
 tional nervous diseases, except for the fact (to be commented upon 
 later) that the treatment of the war neuroses might be carried out 
 advantageously in home territory in co-operation with orthopedic 
 reconstruction centers. 
 
 Although the problems presented by mental and functional nervous 
 diseases have many clinical and administrative features in common and 
 although these disorders should be dealt with by medical officers with the 
 same kind of special training, it seems desirable to consider their treat- 
 ment in England separately in this report. 
 
 My observations as to the nature of the neuroses met with in war are 
 based partly upon a study of the very extensive literature upon this 
 subject which has come into existence since the commencement of the 
 war,* but chiefly upon personal conversation with medical men engaged 
 in treating these cases in England. It is almost needless to say that 
 during a short period spent largely in securing information regarding 
 facilities for treatment and administrative methods of management 
 and in examining special hospitals for the care of these cases, I had 
 no opportunity to make original clinical observations, although I saw 
 and examined superficially many cases of all degrees of severity. 
 
 * Appendix I. 
 
I. MENTAL DISEASES (INSANITY) 
 
I. MENTAL DISEASES (INSANITY) 
 Prevalence 
 "IVTILITARY life has well been called the "touchstone of insan- 
 -'■*-'- ity" on account of the high prevalence of mental diseases 
 in armies even during peace. Medical statistics of the present 
 war are as yet untabulated and so it is impossible to state the 
 rate per thousand for mental diseases. The only means of 
 estimating their incidence is by considering the number of cases 
 diagnosed officially as "insane" in the military hospitals at a given 
 time. On March 31, 1917, about 1.1 per cent of all patients in 
 military hospitals of Great Britain were officially diagnosed as 
 insane. The percentage among expeditionary patients was 1.3 
 and among non-expeditionary patients 1.1. The enormous prev- 
 alence of wounds in patients from the expeditionary troops reduces 
 the percentage of all other conditions and so the excess of mental 
 cases among expeditionary cases is much greater than is apparent. 
 Among non-wounded expeditionary patients the percentage was 
 about three times that among the non-expeditionary cases. The 
 rate among officers was only one third that among men in expedi- 
 tionary patients and about the same in non-expeditionary patients. 
 This has an important bearing upon the fact that the rate for the 
 war neuroses ("shell shock") is four times as high among officers 
 as among men. About 6,000 patients are admitted annually from 
 both the expeditionary and non-expeditionary forces to the special 
 military hospitals for the insane. As one such hospital with a 
 large admission-rate is a "clearing hospital" and distributes its 
 patients to other special hospitals, some patients are obviously 
 counted twice in the only statistics available. To offset this is 
 the fact that a much larger number of mental cases do not go to 
 special military hospitals at all but are discharged to friends, with 
 or without an official diagnosis of insanity, or are sent directly to 
 local institutions for the insane. This is the rule in the case of 
 non-expeditionary troops. It can be estimated, from all the data 
 available, that the annual admission rate is about 2 per 1,000 
 among the non-expeditionary troops and about 4 per 1,000 among 
 expeditionary troops. The rate in the adult, male, civil popula- 
 tion of Great Britain is about 1 per 1,000. 
 
 13 
 
14 MENTAL DISEASES AND WAR NEUROSES 
 
 There is statistical evidence^^'K /■ eh indicates that the insanity 
 rate in the British Army is less at the present time than it was in 
 the first year of the war, and that it has not reached some of the 
 high rates reported in recent wars. The high and constantly 
 increasing rate for the war neuroses suggests that the latter dis- 
 orders are taking the place of the psychoses in modern war. How 
 much this phenomenon is due to an actual change in incidence 
 and how much to former errors in diagnosis cannot be stated 
 accurately. There is a strong suspicion that the high insanity 
 rate in the Spanish-American War and the Boer War, and per- 
 haps in earlier conflicts, was due, in part at least, to failure to 
 recognize the real nature of the severe neuroses, which are grouped 
 under the term "shell shock" in this war. This may account 
 for the remarkable recovery rate among insane soldiers in other 
 wars. It is certain that in the early months of the present war 
 many soldiers suffering from war neuroses were regarded as insane 
 and disposed of accordingly. When one remembers that the 
 striking manifestations seen in these cases are unfamiliar in men 
 to physicians in general practice, it is not surprising that some of 
 the severer disturbances should have been interpreted as signs of 
 insanity. The benign course and rapid recovery of many of 
 these cases upon their return to England, together with increasing 
 familiarity with the symptoms of functional nervous diseases, 
 soon enabled the medical officers serving with troops to recognize 
 their real nature. Even at the present time, however, it is by 
 no means rare for soldiers with functional nervous diseases to be 
 sent to England as insane or for insane soldiers to be sent to 
 hospitals for the war neuroses. This is shown by the records of 
 the Red Cross Military Hospital at Maghull, a hospital for the 
 treatment of war neuroses. Since this hospital was opened, ten 
 per cent of the 1,749 patients admitted* were found to be suffering 
 from mental diseases and sent to hospitals for the insane. On the 
 other hand, twenty per cent of the 6,755 patients received* from 
 France since the commencement of the war at "D Block" of the 
 Royal Victoria Hospital at Netley, a clearing hospital for mental 
 cases, were subsequently sent to hospitals for functional nervous 
 diseases. On the whole it may be said that medical officers 
 serving with troops are constantly becoming more familiar with 
 
 *To May 31, 1917. 
 
MENTAL DISEASES 15 
 
 the symptoms of functional nervous diseases and that fewer such 
 errors now occur. 
 
 Treatment 
 
 The return to England of considerable numbers of mental cases, 
 commencing early in the war and steadily continuing, soon led 
 to rather difficult questions as to their disposal. Before the war, 
 the army maintained a small department for the insane at the 
 Royal Victoria Hospital at Netley. This department, which is 
 known as "D Block" and constitutes practically an independent 
 unit, accommodated only 125 men and three officers. For years 
 the annual admission rate averaged 120. The only cases received 
 were soldiers who had served at least ten years in the regular army 
 or those with shorter service whose insanity seemed clearly to be 
 due to such causes arising in line of duty as head injuries, tropical 
 fevers, exhaustion, wounds, etc. As it was manifestly impossible 
 to care for more cases at Netley, the insane soldiers who were first 
 sent home from the expeditionary forces, as well as those from the 
 home forces, were "certified" (i. e., legally committed) and sent 
 to the local "county lunatic asylums" as they are called, unless 
 their relatives and friends took them off the hands of the govern- 
 ment and disposed of them otherwise. The appearance of soldiers 
 from the front in the district asylums, where they were burdened 
 by the double stigma of lunacy and pauperism, aroused public 
 disapproval that speedily made itself felt in Parliament. 
 
 About this time arrangements had been made to take over 
 one county or borough asylum in each group of ten in the United 
 Kingdom for use as a general military hospital for medical and 
 surgical cases.* This made it possible to establish special war 
 hospitals for mental cases. A department of the Middlesex 
 County Asylum (re-named the Napsbury War Hospital), was 
 opened for mental cases, and the District Asylum at Paisley, 
 Scotland (re-named the Dykebar War Hospital), was turned over 
 entirely for this purpose as was part of the Lord Derby War Hos- 
 pital at Warrington which had been the Lancashire Asylum. 
 Later the Belfast District Asylum in Ireland was take over as 
 the Belfast War Hospital and still more recently the Perth Dis- 
 trict Asylum was taken over as the Murthley War Hospital, both 
 
 *Appendix II. 
 
16 MENTAL DISEASES AND WAR NEUROSES 
 
 being used entirely for the insane. A pavilion at the Richmond 
 District Asylum, Ireland, accommodates 100 and a small hospital 
 in London (Letchmere House) cares for about 84 officers. An 
 annex in connection with the Dykebar War Hospital has recently 
 been opened so that there are now about 3,400 beds in strictly 
 military hospitals available in Great Britain and Ireland for in- 
 sane soldiers. 
 
 No attempt has been made to care for the insane in France, the 
 policy of the War Office being to send all cases to the clearing hos- 
 pital at Netley and then to the special institutions named as soon 
 as possible. There are available in France only 125 beds, all for 
 the temporary detention of mental cases. 
 
 Of the twenty-one asylums and similar institutions in Great 
 Britain and Ireland which have been converted into military 
 hospitals,* three are used wholly or in part for functional nervous 
 diseases. In spite of the fact that the names of all these asylums 
 were changed when they were taken over for their new use, a sus- 
 picion apparently exists among the public that soldiers with men- 
 tal or nervous diseases are still being sent to district asylums as 
 "pauper lunatics," the official designation of such patients. It 
 is not easy for us in America to understand the importance of this 
 aspect of the question for in most states our state hospitals enjoy 
 a reputation which would no more stigmatize insane soldiers than 
 it does their sisters or daughters when they require treatment 
 obtainable only in these institutions. In England, however, in- 
 sanity and pauperism have been closely linked and it is the latter 
 which is very largely responsible for the stigma attached to these 
 institutions. The government was obliged, therefore, early in 
 1915 to announce that it had adopted the policy of sending to the 
 district asylums onlj' the following groups of cases from the expe- 
 ditionary forces : 
 
 1. Patients with general paralysis of the insane. 
 
 2. Patients with chronic epilepsy. 
 
 3. Patients with incurable mental diseases and those giving a history of in- 
 sanity before enlistment. 
 
 There is power to apply the pension of the soldier toward his 
 support in these cases and he is thereby prevented from coming 
 "on the rates." The separation allowances are discontinued 
 
 •To July 1, 1917. 
 
MENTAL DISEASES 17 
 
 when the pension is commenced. All insane soldiers from the 
 non-expeditionary forces are certified and sent to the district 
 asylums unless it can be shown that the disease was caused or 
 aggravated by military service. 
 
 The results of these arrangements are not wholly satisfactory. 
 There is a strong tendency to adopt an entirely different attitude 
 toward insane soldiers than the wonderfully generous one which 
 the nation has adopted toward the wounded and those suffering 
 from physical disease. In the latter, the government readily 
 admits its responsibility and makes liberal provisions for treat- 
 ment, pension and industrial re-education, while in the former 
 every effort is made to place the burden of responsibility and of 
 support upon the patient or his relatives by magnifying alleged 
 constitutional tendencies and minimizing the effects of military 
 service. It is quite apparent that the conditions of actual service 
 have much to do with the development of mental disease. Even 
 in the case of general paralysis of the insane it is by no means 
 certain that a young soldier with a positive Wassermann test 
 would have developed general paralysis had he not been exposed 
 to the supreme ordeal of service at the front. This official attitude 
 toward mental disease results in an average period of treatment 
 far shorter than is required in even the most benign psychoses in 
 civil life. It is evident that mental cases are insufficiently treated 
 in military hospitals. 
 
 During 1916, the number of mental cases passing through the 
 3,400 beds available for their care in Great Britain and Ireland 
 was about 6,000. The recovery rate in military cases is much 
 higher than in the mental cases admitted to civil hospitals but 
 the rapid movement of population results chiefly from the custom 
 of "passing on" these cases. Insane soldiers of the non-expedi- 
 tionary forces are sent almost invariably directly to district 
 asylums from general hospitals without even going to "D Block" 
 where an inquiry could be made by experts to estimate the part 
 played by military service in the causation of mental illness. 
 When relatives and friends are induced to take insane soldiers 
 from the military hospitals the next step is usually admission to 
 the district asylums. During the year ending May 31, 1917, 900 
 insane soldiers were admitted to the local asylums. A considerable 
 proportion of. the insane, even from the expeditionary forces. 
 
18 MENTAL DISEASES AND WAR NEUROSES 
 
 sooner or later find their way into the institutions out of which 
 Parliament was intent upon keeping them. 
 
 The disposition of mental cases is well illustrated by the follow- 
 ing table showing what was done in the case of 5,-1.73 patients 
 admitted from September 1, 1914, to May 31, 1917, at "D Block," 
 Netley — a clearing hospital for mental diseases. 
 
 DISPOSITION OF CASES ADMITTED TO "D BLOCK," NETLEY, FROM THE 
 BEGINNING OF THE WAR TO DECEMBER 31, 1916 
 
 To institutions [or the insane 
 
 Lord Derby War Hospital, Warrington 1,424 
 
 Murthley War Hospital, Perth 210 
 
 Dykebar War Hospital, Paisley 611 
 
 Shomcliffe (Canadian Clearing Mental Hospital) 147 
 
 District Asylums 128 
 
 Dartford (for insane prisoners of war) 3 
 
 To war hospitals for functional nervous cases 
 
 Moss Side Hospital, Maghull 509 
 
 Springfield War Hospital, London 680 
 
 To hospitals for organic nervous diseases and injuries 
 
 Queens Square 4 
 
 Maida Vale (for pensioners) 2 
 
 To Royal Victoria Military Hospital, Netley (recoveries and nervous diseases) . . 1,007 
 
 To almshouses 2 
 
 To Canadian hospitals or returned to Canada 5 
 
 To Australian hospitals or returned to Australia 33 
 
 To other hospitals and institutions 204 
 
 Discharged to relatives and friends 258 
 
 Died 21 
 
 Furloughed , 110 
 
 Returned to duty 58 
 
 Remaining in hospital 57 
 
 Total 5.473 
 
 Clinical Types of Mental Disease among Soldiers 
 Contrary to popular belief and to some medical reports pub- 
 lished early in the war, no new clinical types of mental disease 
 have been seen in soldiers. There are no " war psychoses." The 
 clinical pictures familiar in civil life are seen, colored often by 
 the experience at the front, but for the most part unchanged 
 in their symptomatology, outcome and course. The distribution 
 of the different psychoses has been strikingly different from that in 
 civil life but this has been chiefly due to the different age periods 
 represented in patients from the army. The absence of the 
 organic mental diseases of the later decades of life — which play so 
 
MENTAL DISEASES 19 
 
 large a part in civil statistics — has resulted in abnormally high 
 percentages for other psychoses. Although no statistics for the 
 whole number of admissions in a single year are available, nearly a 
 thousand admissions from expeditionary troops to the Dyke- 
 bar War Hospital during 1916 have been tabulated by Major 
 R. D. Hotchkis.* 
 
 This series of cases is large enough to make some of the findings 
 significant. They are borne out by observations made by Capt 
 David K. Henderson at the Lord Derby War Hospital at Warring- 
 ton which received 2,042 mental cases during the year ending 
 April 30, 1917. 
 
 Mental Deficiency. About eighteen per cent of the patients ad- 
 mitted to the military hospitals for mental diseases are mentally 
 defective. Only such mental defectives as get into trouble or 
 develop acute psychotic episodes of one sort or another gain ad- 
 mission to these hospitals. It is impossible, therefore, from the 
 point of view of the hospitals for mental diseases, to draw any 
 conclusions as to the relation of mental deficiency to military 
 service. The low grade of many cases received in the special 
 hospitals is very striking and shows an amazing indifference on 
 the part of recruiting officers to this type of disability. It is 
 said that the worst types got in during the first rush of recruits 
 under the voluntary system and that, since then, more pains 
 have been taken to exclude them. Of the 151 mental defectives 
 admitted to the Dykebar War Hospital, 37 were sent there 
 simply because they had been giving trouble to other hospitals 
 where they had been treated for wounds or diseases. Most 
 of these soldiers were defectives of the restless, criminalistic 
 type, many of whom had been civil offenders before entering 
 the army. It is believed that they represent but a small part 
 of the cases of this type in the military service, the majority 
 being dealt with from a disciplinary standpoint without regard 
 to the existence of mental defect, thus following the precedent 
 which, imfortunately, is so firmly established in civil life. The 
 remaining 114 defectives sent to Dykebar had been able to earn 
 their own livelihood before entering the amiy. They had no 
 criminalistic traits but had proved quite valueless in actual fight- 
 ing. Sometimes these men were actually dangerous to their 
 
 *Appendix I (reference No. 48). 
 
20 MENTAL DISEASES AND WAR NEUROSES 
 
 comrades and were permitted to load their rifles only when an 
 attack was made. The very specialized activities of modern 
 fighting discloses such individuals who under former military 
 conditions would not have come to light. It is said that in the 
 Boer War many boys from the special classes of the Birmingham 
 and London schools made good soldiers but apparently the mili- 
 tary usefulness of the mentally defective has disappeared under 
 the conditions of modern warfare — an exceedingly important 
 point for the consideration of a nation engaged in raising a new 
 army. 
 
 Among the defectives received in the military hospitals for 
 mental cases are many in whom attention has been directed to 
 their disability by episodes of confusion or excitement. The 
 outlook is very favorable in such cases, the quiet routine of the 
 hospital having a beneficial eifect in a remarkably short period 
 of time. Mental defectives develop war neuroses, in spite of 
 statements to the contrary, but with striking infrequency. The 
 generally high standard of intelligence among the patients in the 
 "shell shock" hospitals is noticeable. 
 
 There is much difference of opinion as to whether or not men 
 known to be mentally defective should be recruited for any mili- 
 tary service. In favor of their acceptance it is said that they 
 can be assigned to certain kinds of work at the bases for which 
 they are particularly fitted and thereby release soldiers with more 
 intelUgence for duty at the front. When one remembers that not 
 only the army but the whole nation is at war, it seems more 
 advisable, even for military reasons, to leave defectives at work 
 in an environment to which they have already become accus- 
 tomed than to try the experiment of placing them even in a 
 special kind of military service. Certainly the army now has 
 no means of assigning its work with reference to the limitations 
 of such a special group. Moreover, when the army knowingly 
 accepts mentally defective recruits, it assumes a liability for their 
 protection which it can hardly be expected to meet in all the 
 exigencies of war. Much injustice is done in the army by pun- 
 ishing mental defectives for military offenses which would have 
 been condoned had the real mental condition of the offenders 
 been appreciated. There are sufficient grounds for excluding all 
 mental defectives from the military forces except when the last 
 
MENTAL DISEASES 21 
 
 available man-power must be utilized. When this is the case it 
 will doubtless be found that their most effective service will be 
 rendered at the base, under the supervision of non-commissioned 
 officers who have been especially trained in their management. 
 
 Syphilitic Psychoses. About two per cent of the mental cases 
 received in these special hospitals have general paresis. There 
 is convincing evidence that the stress of war accelerates the 
 progress of this disease. As older men enter the army the pro- 
 portion of paresis rises. In the navy, which has been largely 
 augmented by the enlistment of older men in the Naval Reserve, 
 general paresis has attained a rate quite unknown in time of 
 peace. Examinations to determine the prevalence of syphilis in 
 recruits are extremely important and the experience of the 
 British Army and Navy shows that no person presenting the 
 slightest suspicion of syphilis of the central nervous system 
 should be enlisted or commissioned for any military duty. In 
 view of the social distribution of this disease and the generally 
 higher age of officers, paresis is to be borne in mind especially in 
 the examination of candidates for officers' commissions. 
 
 Manic-depressive Insanity. Patients in this group supply about 
 twenty per cent of all admissions to military hospitals for mental 
 diseases. The great proportion of those with depressed phases 
 is very striking. Delusions and hallucinations are almost inva- 
 riably colored by military experiences. 
 
 Alcoholic Psychoses. Soldiers with delirium tremens are ad- 
 mitted to special hospitals for mental diseases if they are stationed 
 near such institutions. This disorder is now confined almost 
 entirely to patients on leave from the front. During the early 
 days of the war it was seen most frequently among those who had 
 just entered military service and found their supply of alcohol 
 restricted. The delusional types of alcoholic psychoses are found 
 in older men stationed at bases who have the opportunity to con- 
 tinue life-long habits of drinking to excess. Attempted suicides 
 are very common among alcoholics seen in mihtary service. 
 Alcoholics should not be accepted for military service even if it is 
 possible to prevent them from securing alcohol at the front. Fur- 
 loughs furnish opportunities for drinking and the time and effort 
 spent in training men are lost through attacks on such occasions. 
 
 Dementia Praecox. Patients with this disorder constitute four- 
 
22 MENTAL DISEASES AND WAR NEUROSES 
 
 teen per cent of those admitted. The histories of these cases show 
 that in most instances symptoms were manifested shortly after 
 entering the military service. It is apparent that many of them 
 had been psychotic before enlistment. There seems to be no 
 special modification of symptoms on account of military service. 
 
 Epilepsy. Seven per cent of cases received at Dykebar War 
 Hospital were suffering from epilepsy. With one exception all 
 had had the disease before enlistment. 
 
 Co7istitutional Psychopathic States. A very large number of 
 these cases are received in the special military hospitals for mental 
 diseases. They probably represent but a small proportion of such 
 soldiers in the army for the percentage is large in the various 
 disciplinary groups. Unfortunately the nomenclature used in 
 the British Army did not permit the use of any term applicable 
 to these cases until February, 1916, when the War OflRce author- 
 ized the addition of "mental instability" to the list of mental 
 diseases. Many cases are now being reported under this heading. 
 The occasion for their admission is usually an acute psychotic 
 episode or a niedico-legal situation. 
 
 Outlook in Mental Cases 
 There are no statistics available to show the outcome in the 
 mental diseases treated in military hospitals. Discharge is much 
 more likely to be regulated by administrative considerations than 
 by clinical ones. Acute conditions seem to recover very quickly. 
 Few return to "first line duty." The statistics indicate a much 
 larger proportion than is actually the case. The number of those 
 who go back to the colors is made up for the most part of patients 
 who have recovered from delirium tremens and those with war 
 neuroses who have been incorrectly admitted to institutions for 
 the insane. Infective-exhaustive psychoses are much more likely 
 to be regarded as "shell shock" than as mental disorders. The 
 hospitals for mental diseases fail, therefore, to get these very 
 recoverable cases and the recovery rate in such institutions suffers 
 correspondingly . 
 
 Summary 
 Sorely pressed to meet the tremendous medical problems of war, 
 England first used her existing civil facilities for caring for mental 
 diseases among soldiers. Public disapproval, based chiefly upon 
 
MENTAL DISEASES 28 
 
 a mistaken attitude toward the insane and toward the local insti- 
 tutions for their care, forced a different method of management. 
 The military hospitals for the insane, created without exception 
 by converting civil institutions for mental diseases, failed to do 
 much more than provide places for receiving mental cases and 
 giving temporary care. The clearing hospital is in size and per- 
 sonnel woefully inadequate to deal with the important issues 
 which should be determined there and a solution to the problem 
 presented by mental diseases among soldiers in England does not 
 seem to be in sight. 
 
 For the United States, this experience carries important lessons. 
 More important than all others is the result of careless recruit- 
 ing. The problem of dealing with mental diseases in the army — 
 difficult at best — has been made still more so by accepting large 
 numbers of recruits, who had been in institutions for the insane or 
 were of demonstrably psychopathic make-up. The next most 
 important lesson is that of preparing, in advance of an urgent need, 
 a comprehensive plan for establishing special mihtary hospitals 
 and using existing civil facilities for treating mental disease in a 
 manner that will serve the army effectively and at the same time 
 safeguard the interests of the soldiers, of the government and of 
 the community. 
 
II. WAR NEUROSES ("SHELL SHOCK") 
 
n. WAR NEUROSES ("SHELL SHOCK") 
 
 ALTHOUGH an excessive incidence of mental diseases has 
 been noted in all recent wars, it is only in the present one 
 that functional nervous diseases have constituted a major medico- 
 military problem. As every nation and race engaged is suffering 
 severely from these disorders, it is ajrgaxent that new xsonditions 
 of warfare are- chiefly responsible for their prevalence. None of 
 these new conditions is more terrible than the sustained shell fire 
 with high explosives which has characterized most of the fighting. 
 It is not surprising, therefore, that the term "shell shock" should 
 have come into general use to designate this group of disorders. 
 The vivid, terse name quickly became popular and now it is ap- 
 plied to practically any nervous symptoms in soldiers exposed to 
 shell fire that cannot be explained by some obvious physical injury. 
 It is used so very looselj^ that it is applied not only to all func- 
 tional nervous diseases but to well-known forms of mental disease, 
 even general paresis. Such a situation is most unsatisfactory and 
 at the present time an attempt is being made to improve the no- 
 menclature of the nervous disorders of war. 
 
 Discussion of clinical features of the war neuroses is not within 
 the scope of this report, which deals with treatment and military 
 management.* It is impossible, however, even to define the 
 problem with which we are dealing without a few general observa- 
 tions on the nature of the disorders which are grouped under the 
 name "shell shock." 
 
 The subject can be clarified a little by dividing the different 
 conditions so designated into some clinical and etiological groups. 
 First should be considered cases in which the patients have been 
 actually exposed to the effects of high explosives. 
 
 1. Not infrequently, just how often it is impossible to say, exploding shells or 
 mines cause death without external signs of injury. Apparently death in these 
 cases is sometimes due to damage to the central nervous system. 
 
 *These extraordinarily interesting medical problems of the war are dealt with in a rapidly 
 expanding volume of special literature. The July number of Mental Hygiene (Vol. I, 
 No. 3) contains a resume of this literature. One hundred and forty-one references in 
 English are given in Appendix I of this report. Attention is directed particularly to the 
 contributions of Major Frederick M. Mott (71 and 72), Prof. G. Elliot Smith (108), 
 Capt. Charles S. Meyers (74), Capt. Clarence B. Farrar (32), Capt. M. D. Eder (28) and 
 to the extensive report by Dr. John T. MacCurdy in the Psychiatric Bulletin (N. Y.) for 
 July, 1917. (The numbers refer to the references in Appendix I.) 
 
 27 
 
28 MENTAL DISEASES AND WAR NEUROSES 
 
 2. In another group of cases severe neurological symptoms follow burial or 
 concussion by explosions in characteristic syndromes suggesting the operation 
 of mechanical factors. The studies of Major Mott*indicate that concussion, in 
 aerial compression and the rapid decompression following it, "gassing" from 
 the drift gases (carbon monoxide and oxides of nitrogen) generated by the ex- 
 plosion and other purely mechanical effects of shell explosion may result in 
 transitory or permanent neurological symptoms of a type unfamiliar in the neu- 
 roses. 
 
 There can be no question of the propriety of supplying the term 
 "shell shock" to these two groups of cases if a specific term is 
 required. 
 
 3. Another group of cases, among those exposed to shell fire, includes patients 
 in whom, while there may or may not be damage to the central nervous system, 
 the symptoms are those of neuroses familiar in civil practice even though colored 
 in a very distinctive way by the precipitating cause. In this group of cases, in 
 which there is possibility but no proof of damage to the central nervous system, 
 the symptoms present which might be attributable to such damage are quite 
 overshadowed by those characteristic of the neuroses. 
 
 It is about these cases that much controversy exists. Mott 
 includes them in his group of "injuries of the central nervous 
 system without visible injury," holding that a physical or a chem- 
 ical change at present unknown to us must underlie such striking 
 disabilities. Others give less weight to the factor of physical 
 damage and yet recognize its existence and reconcile the wide 
 range of neurotic symptoms with the very minute amount of 
 ") damage which may exist by terming these cases "traumatic 
 neuroses." Others again feel that psychogenetic factors deter- 
 mine not only the continuing neurosis but even the initial uncon- 
 sciousness and special sense disturbances. 
 
 4. There is a group of cases in which even the slightest damage to the central 
 nervous system from the direct effects of explosions is exceedingly improbable, 
 the patients being exposed only to conditions to which hundreds of their com- 
 rades who develop no sj'mptoms are exposed. In these cases the symptoms, 
 course and outcome correspond with those of the neuroses in civil practice. 
 
 If all neuroses among soldiers were included in these groups the 
 use of the term " shell shock" might be defended. But many hun- 
 dreds of soldiers who have not been exposed to battle conditions 
 at all develop symptoms almost identical with those in men whose 
 nervous disorders are attributed to shell fire. The non-expedi- 
 tionary forces supply a considerable proportion of these cases. 
 
 *Appendix I, reference 71. 
 
WAR NEUROSES 29 
 
 To state that, in the cases included in the last two groups of 
 cases in which shell explosions play a part, the mechanism is that of 
 a neurosis by no means excludes the operation of physical causes. 
 Very little is known, however, regarding the physiological basis 
 of the disorders in this group or even in those in the first two 
 groups in which the issues are apparently predominantly organic. 
 It may be that in the latter two groups endocrinitic disturbances 
 are important. Minute injuries of the cord may exist and factors 
 such as exposure, exhaustion, vascular disequilibrium and dis- 
 orders of metabolism may enter into their causation. Treatment 
 directed along the lines suggested by such an etiology has thus far 
 proved quite ineffective, however, and there is only the most 
 slender basis of experimental work to show that such factors are 
 important. This is a fertile field for research. It is earnestly 
 hoped by all those consulted in England that the United States 
 Army, coniing freshly into contact with this problem, will or- 
 ganize a working party of psychiatrists, neurologists, neuro-path- 
 ologists and internists and try to clear some of these issues. 
 
 It is the opinion of most psychiatrists and neurologists who have 
 been studying and treating "shell shock" in the British Army 
 that the fourth group is the largest and most important and 
 that, whatever the unknown physiological basis, psychological 
 factors are too obvious and too important in these cases to be 
 ignored. In support of this view there is much evidence, some of 
 which it may be worth while to give. 
 
 1. The striking excess of war neuroses among officers. The ratio of officers to 
 men at the front is approximately 1:30. Among the wounded it is 1:24.* 
 Among the patients admitted to the special hospitals for war neuroses in England 
 during the year ending April 30, 1917, it was 1: 6. 
 
 2. The rarity of war neuroses among prisoners exposed to mechanical shock.f 
 
 3. The rarity of war neuroses among the wounded exposed to mechanical 
 shock. 
 
 4. The clinical resemblance which the war neuroses bear to the neuroses of 
 civil life in which the element of mechanical shock is lacking while the psycho- 
 logical situations are somewhat alike. 
 
 5. The fact that severe war injuries to the brain and spinal cord are not ac- 
 companied by symptoms similar to those in "shell shock," in which injuries of 
 less degree are assumed. 
 
 *Analysis of 381,98." casualties between August 4, 1914, and August 21, 1915, reported 
 in a statement in Parliament, and 901,534 casualties between July, 1916, and July, 1917. 
 jReferences given by Capt. C. B. Farrar (Appendix I, reference 32). 
 
30 MENTAL DISEASES AND WAR NEUROSES 
 
 6. The success attending therapeutic measures employed with reference to 
 the psychological situations discovered in individual cases. 
 
 These suggestive facts require some elaboration. The high 
 prevalence of "shell shock" among officers corresponds with the 
 distribution of the neuroses, with reference to education and social 
 grouping, in civil life. Soldiers who are wounded and those who 
 are taken prisoners in battle are exposed to wind concussion and 
 rapid decompression and other mechanical factors in the same 
 degree as their comrades who suffer from neuroses. One must 
 conclude from the fact that they escape that being wounded or 
 being captured provides them with something which the neurosis 
 provides for others. The symptoms exhibited usually bear a more 
 direct relation to the existing psychological situation than they 
 could possibly bear to the localization of a neurological injury. 
 Thus a soldier who bayonets an enemy in the face develops an 
 hysterical tic of his own facial muscles; abdominal contractures 
 occur in men who have bayonetted enemies in the abdomen ; hys- 
 terical blindness follows particularly horrible sights; hysterical 
 deafness appears in those who find the cries of the wounded un- 
 bearable and men detailed to burial parties develop anosmia. 
 KThe psychological basis of the war neuroses (like that of the 
 neuroses in civil life) is an elaboration, with endless variations, of 
 one central theme : escape from anlntolerable situation in real life 
 to one made tolerable by the neurosis. The conditions which 
 may make intolerable the situation in which a soldier finds him- 
 self hardly need stating. Not only fear, which exists at some time 
 in nearly all soldiers and in many is constantly present, but horror, 
 revulsion against the ghastly duties which must be sometimes per- 
 formed, intense longing for home, particularly in married men, 
 emotional situations resulting from the interplay of personal 
 conflicts and military conditions, all play their part in making 
 an escape of some sort mandatory. Death provides a means 
 which cannot be sought consciously. Flight or desertion is 
 rendered impossible by ideals of duty, patriotism, and honor, by 
 the reactions acquired by training or imposed by discipline and 
 by herd reactions. Malingering is a military crime and is not at 
 the disposal of those governed by higher ethical conceptions. 
 Nevertheless, the conflict between a simple and direct expression 
 in flight of the instinct of self-preservation and such factors de- 
 
WAR NEUROSES 31 
 
 mands some sort of compromise. Wounds solve the problem 
 most happily for many men and the mild exhilaration so often 
 seen among the wounded has a sound psychological basis. Others 
 with a sufficient adaptability find a means of adjustment. The 
 neurosis provides a means of escape so convenient that the real 
 source of wonder is not that it should play such an important 
 part in miUtary life but that so many men should find a satis- 
 factory adjustment without its intervention. The constitu- 
 tionally neurotic, having most readily at their disposal the 
 mechanism of functional nervous diseases, employ it most fre- 
 quently. They constitute, therefore, a large proportion of all 
 cases but a very striking fact in the present war is the number of 
 men of apparently normal mental make-up who develop war 
 neuroses in the face of the unprecedentedly terrible conditions to 
 which they are exposed. 
 
 One of the chief objections to the use of the term "shell shock" 
 Is the implication it conveys of a cause acting instantly. The 
 train of causes which leads to the neurosis that an explosion ushers 
 in is often long and complicated. Apparently in many mili- 
 tary cases mental conflicts in the personal life of the soldier 
 that are not directly connected with military situations in- 
 fluence the onset of the neuroses. Thus men who have been 
 doing very well in adapting themselves to war develop "shell 
 shock" immediately after receiving word that their wives have 
 gone away with other men during their absence. 
 
 Approached from the psychological viewpoint, the symptoms 
 in the war neuroses lose much of their weird and inexplicable char- 
 acter. Most of them can be summed up in the statement that 
 the soldier loses a function that either is necessary to continued 
 military service or prevents his successful adaptation to war. The 
 symptoms are found in widely separated fields. Disturbances of 
 psychic functions include delirium, confusion, amnesia, hallucina- 
 tions, terrifying battle dreams, anxiety states. The disturbances 
 of involuntary functions include functional heart disorders, low 
 blood pressure, vomiting and diarrhea, enuresis, retention or 
 polyuria, dyspnoea, sweating. Disturbances of voluntary muscu- 
 lar functions include paralyses, tics, tremors, gait disturbances, 
 contractures and convulsive movements. Special senses may be 
 affected producing pains and anesthesias, mutism, deafness. 
 
32 MENTAL DISEASES AND WAR NEUROSES 
 
 hyperacusis, blindness and disorders of speech. It is highly 
 significant that, in this unprecedented prevalence of functional 
 nervous diseases among soldiers, no symptoms unfamiliar to 
 those who see the neuroses in civil life present themselves. 
 
 In all of these the soldier is afflicted with more or less incapacity 
 without obvious explanation. This is a condition involving grave 
 dangers. His condition is degrading and is often rendered more 
 so by the punishment or ridicule to which he is subjected. For 
 this reason, immediately after the onset of the symptoms of 
 the neurosis, the patient passes through a very critical period. 
 Improper management may add to the primary neurological 
 disability — which is largely beyond our power of preventing — 
 secondary effects which go even further in producing nervous inva- 
 lidism. Long-continued treatment in general hospitals, confusion 
 of the neurosis present with the organic nervous diseases, and 
 unintelligent management, all tend to produce the chronic "shell 
 shock" cases which are so famihar in the special hospitals for 
 these disorders. Symptoms which were at one time quite easily 
 removable become fixed and refractory or new ones are con- 
 stantly produced. The mental attitude — the patient's morale as 
 a soldier and his attitude toward his disorder — reaches a very low 
 level, will is seriously impaired and a chronic invalid replaces a 
 temporarily incapacitated soldier. These are matters in the realm 
 of clinical psychiatry and psycho-pathology and are outside 
 the scope of this report. Space is given to them here only be- 
 cause of their very important bearing upon treatment and mili- 
 tary management. 
 
 Prevalence 
 
 The medical statistics of the war are as yet untabulated. Even 
 if the records contained the information desired it would be very 
 difficult to state the prevalence of the neuroses on account of the 
 defective nomenclature employed. It is doubtful if there is 
 another group of diseases in which more confusion in terms exists. 
 Nervous or mental symptoms coming to attention after the 
 soldier has been exposed to severe shell fire, are almost certain 
 to be diagnosed as "shell shock," and yet when such patients are 
 received in England, well-defined cases of general paresis, epilepsy 
 or dementia praecox are often found among them. This source 
 of confusion tends to swell the number of cases reported under the 
 
WAR NEUROSES S8 
 
 term " shell shock," but there are many other sources of error which 
 tend to diminish the apparent prevalence of the war neuroses. 
 Chief among these is reporting the neuroses under the name of 
 the most prominent somatic symptom. The largest group of 
 cases in which this is done is made up of patients diagnosed 
 officially as having disordered action of the heart ("D. A. H."). 
 Where the only symptoms are cardio-vascular ones of neurotic 
 origin, a legitimate question of medical nomenclature exists, but 
 one sees in the wards or hospitals given over to functional heart 
 disorders, patients with hysterical paralyses, tics, tremors, mut- 
 ism, anxiety states and other severe neurotic symptoms. Another 
 source of error is the practice, made mandatory by a recent order, 
 of returning these cases (when occurring in soldiers engaged in 
 actual fighting) as "injuries received in action." 
 
 With a view to discovering the prevalence of the neuroses and 
 insanity. Sir John Collie, President of the Special Pension Board 
 on Neurasthenics, made an analysis of 170,000 discharge certifi- 
 cates for disability, interpreting the diagnoses given in the light 
 of his very large experience. He found that the neuroses con- 
 stituted 20 per cent of these discharges. 
 
 The number of cases treated in the special hospitals in England 
 gives some idea of the prevalence of these disorders, but the fact 
 that the number of troops in the expeditionary and the non- 
 expeditionary forces is confidential, makes it impossible to give 
 the rates for the two great divisions of the British Army. During 
 the year ending April 30, 1916, approximately 1,300 officers and 
 10,000 men were admitted to the special hospitals for "shell 
 shock" and neurasthenics in Great Britain. The 1,800 beds in 
 these special hospitals constitute less than half the total provisions 
 in Great Britain for such cases, as neurological departments exist 
 in the large territorial general hospitals and in the Royal Victoria 
 Hospital in Edinburgh. Moreover, a constantly increasing num- 
 ber of these cases are being treated in France. The recoveries in 
 the hospitals there diminish, to an unknown degree, the number of 
 cases received in the hospitals in Great Britain. It is the belief 
 of those who have made an effort to ascertain the prevalence of 
 the war neuroses, that the rate among the expeditionary forces 
 is not less than ten per thousand annually, and among the home 
 forces not less than three per thousand. 
 
34 MENTAL DISEASES AND WAR NEUROSES 
 
 Treatment 
 
 General arrangements. When soldiers suffering from func- 
 tional nervous disorders began to arrive in England from the ex- 
 peditionary forces in September, 1914, no special civil or military 
 hospitals existed for their reception. In the case of mental 
 diseases it was an easy task to convert "D Block" at the Royal 
 Victoria Hospital into a clearing hospital and to utilize civil in- 
 stitutions for the insane for continued care, but in England, as in 
 the United States, there are no public civil hospitals that are en- 
 gaged exclusively in the work of treating the neuroses. The 
 special civil hospitals for organic nervous diseases were soon 
 filled with patients suffering from severe neurological injuries and 
 were able to do very little on behalf of those with functional 
 nervous disorders. 
 
 For a short time it was necessary to care for all such cases in 
 general military hospitals for medical and surgical conditions. 
 The rapid increase in the number of such cases during October and 
 November, 1914, led to the detail of a special medical officer to 
 ascertain their special needs and to prepare a plan for meeting 
 them. The recommendations of this officer that special institu- 
 tions be provided for functional nervous diseases was approved 
 and when, in December, 1914, the Moss Side State Institution at 
 Maghull was turned over to the War Office, the first military 
 hospital for functional nervous diseases was available. This 
 institution was particularly suitable for this purpose. It had 
 been completed but not opened for the care of mental defectives 
 of the delinquent type and consisted of detached villas accom- 
 modating 347 patients.* The number of these patients was so 
 great, however, that general hospitals were still called upon to 
 deal with them. The establishment of neurological departments 
 in these hospitals partly met the situation until additional special 
 hospitals could be provided. The second such hospital was 
 secured by using a detached portion of Middlesex County Asy- 
 lum in London. This hospital, accommodating 278 additional 
 patients, was renamed the Springfield War Hospital.* The 
 foresight of Sir Alfred Keogh and his advisors thus enabled Eng- 
 land to make provision for these cases in special military hospitals 
 at an early period in the war. 
 
 *Appendix III. 
 
WAR NEUROSES 35 
 
 With more than one hospital available, it was possible to make 
 different provisions for different classes of patients suffering from 
 war neuroses. A clearing hospital was therefore established early 
 in 1915 at the Foiu-th London Territorial General Hospital where 
 the best disposition could be determined. The Maudsley Hos- 
 pital, a psychopathic hospital for the County of London,* was 
 nearing completion at this time and, as it adjoined the Kings 
 College Hospital which formed the larger part of the Fourth 
 London Hospital, it was utilized as a nucleus for this clearing 
 station. The Maudsley Hospital accommodates 175 men and 
 20 officers; the neurological section — "the Maudsley extension" 
 — accommodates 450 men and 80 officers. Thus by the spring 
 of 1915, England was provided with a clearing hospital for war 
 neuroses and two special institutions for their continued care. 
 Notwithstanding this provision, by far the greater number of 
 cases were cared for in general hospitals in England and no 
 special provision for continued treatment existed in France. 
 The disadvantages of attempting to treat functional nervous dis- 
 orders in general hospitals were very apparent and so neurological 
 sections were established in territorial general hospitals in Eng- 
 land, Scotland and Wales and in the Royal Victoria Hospital at 
 Netley. Other special hospitals have been provided since, a 
 directory and descriptions of those visited being given in Appendix 
 
 m.t 
 
 When the submarines commenced to sink hospital ships indis- 
 criminately last year a great deal of the medical work previously 
 done in England was undertaken in France and so special provi- 
 sions for functional nervous cases were made at Havre, Ireport, 
 Boulogne, Rouen and Etaples. Formerly little more than estab- 
 lishing the diagnosis was done in France. It is likely that the 
 work of caring for these cases will be turned over more and more 
 to the special hospitals in France as the results of treatment there 
 have been, on the whole, so much more successful than in home 
 territory. 
 
 A recent extension of treatment is that of providing care still 
 
 *Appendix III. 
 
 fAn interesting account of the arrangements for the care of soldiers with war neuroses 
 is given in a special article by Lt. Col. William Aldren Turner. (Appendix I, refer- 
 ence 125.) 
 
36 MENTAL DISEASES AND WAR NEUROSES 
 
 nearer the front. The striking results obtained in Casualty Clear- 
 ing Stations and similar advanced posts in the French Sanitary 
 Service (pastes de chirurgie d'urgence) are confirmed by many 
 observers. 
 
 Capt. William Brown, a psycliiatrist, who has recently had the opportunity of 
 working in a Casualty Clearing Station of the British Expeditionary Forces 
 reports that of 200 nervous and mental cases which passed through his hands in 
 December, 1916, 34 per cent were evacuated to the base after seven days' treat- 
 ment and 66 per cent returned to duty on the firing line after the same average 
 period of treatment. Four of these cases reappeared at the same Casualty 
 Clearing Station. 
 
 Capt. Louis Casamajor of the U. S. Army, neurologist to Base Hospital No. 1, 
 British Expeditionary Force, says in a recent letter: "It is a mistake to send 
 these cases to England. We need an intermediate step between the general 
 hospital and the convalescent camp. Of course they never should get into 
 general hospitals at all but should be sent from Casualty Clearing Stations direct 
 to neuro-psychiatric hospitals. ... I hope our army will have a psychia- 
 trist in each Casualty Clearing Station to weed these cases out and send them 
 to their proper places and not have them knock around from one general hospital 
 to another, being pampered into hard-set neuroses."' 
 
 Leri, working in the neuro-psychiatric center of the second French Army, 
 reports that 91 per cent of the cases received from July to October, 1916, were 
 returned to the fighting line. Marie reports that the neuroses are less frequently 
 met with in Paris now that they are treated immediately upon their appearance 
 in the Army neuro-psychiatric centers.* 
 
 Major Frederick W. Mott says: "I regard tliis matter of preventing the fixa- 
 tion of a functional paralysis as of supreme importance both in respect to the 
 welfare of the individual and from the economic point of view of the state." 
 
 Roussy and Boisseau.f describing the work of an army neuro-psychiatric 
 center say : " The results obtained after six months show that a neuro-psychiatric 
 center can render incontestable services to an army both from a medical and a 
 military point of view. For functional nervous cases it avoids sojourns (more 
 dangerous the more they are prolonged) in the hospitals at the rear where these 
 patients are generally lost. It allows of the treatment of other nervous or mental 
 cases that are quickly curable and the direct evacuation to the special centers 
 in the interior of those more seriously affected." 
 
 Captain C. B. FarrarJ says: "Moreover it seems to be a fact that treatment 
 is more satisfactorily carried out and cures more speedily accomplished in hospi- 
 tals close to the front and where the spirit of army discipline is most felt. It is 
 conceded that the worst possible place to treat a case of war neurosis is in his 
 home town, where in so far especially as the more striking objective symptoms 
 are concerned, the sympathetic wonderment and commiseration of friends create 
 
 *Remte neurologique (Nov.-Dec, 1916). 
 
 \Pari3 mldicale, 1:14-20 (.Ian. 1, 1916). 
 
 XAmerican journal of insanity, 73: 711-712 (April, 1917). 
 
WAR NEUROSES 37 
 
 a positive demand which the ideogenic factor of the patient's illness continues 
 faithfully to supply. In hospitals close behind the lines there is still the atmos- 
 phere of the front and a mental tone which comes from mass-suggestion of men 
 striving shoulder to shoulder. This mental tone is eminently supportive and 
 therapeutic, but with the transfer of patients to interior hospitals far behind the 
 lines it naturally gives way. The circumstances which produce it are no longer 
 operative and the nervous relaxation and reaction which ensue are often con- 
 spicuously and painfully evident. Out of danger, far from the front, perhaps 
 among hero-worshipping friends, the invalid is unavoidably conscious of himself 
 more as an individual and less as a link in the battle Ime. All the conditions are 
 favorable for the fixation and reinforcement of the neurosis as an ideogenic 
 process. Too often he is found to be the victim not only of his malady, but of his 
 friends as well, and in more senses than one." 
 
 General principles. Methods of treatment employed in differ- 
 ent special hospitals are described in Appendix III. With so 
 much regarding the war neuroses the subject of controversy, it is 
 not surprising that different methods of treatment have come into 
 existence. The Royal Army Medical Corps has seen fit to leave 
 these matters largely to the specialists in charge of the different 
 hospitals and so the treatment in each reflects, to a certain degree, 
 the conception of the nature of war neuroses held by the medical 
 officer in charge. Certain general principles regarding treatment 
 may be stated. 
 
 The experience of the British "shell shock" hospitals empha- 
 sizes the fact that the treatment of the war neuroses is essentially 
 a problem in psychological medicine. While patients with severe 
 symptoms of long duration recover in the hands of physicians 
 who see but dimly the mechanism of their disease and are unaware 
 of the means by which recovery actually takes place, no credit 
 belongs to the physician in such cases and but little to the type 
 of environment provided. In the great majority of instances the 
 completeness, promptness and durability of recovery depend 
 upon the insight shown by the medical officers under whose charge 
 the soldiers come and their resourcefulness and skill in applying 
 treatment. 
 
 The first step in treatment is a careful study of the individual 
 case. There are no specific formulae for the cure of mutism, 
 paralyses or tremors or other manifestations of war neuroses. 
 These are symptoms and the patient must be treated as well as 
 his symptoms. As in all other psychiatric work, efforts must 
 first be made to gain an understanding of the personality — the 
 
38 MENTAL DISEASES AND WAR NEUROSES 
 
 fabric of the individual in whom the neurosis has developed. 
 His resources and limitations in mental adaptation will deter- 
 mine in a large measure, the specific line of management. The 
 military situation is most striking but the problem which life 
 in general presents to the individual and the type of adaptation 
 which he has found serviceable in other emergencies are of as 
 much importance as the specific causes for failure in the existing 
 situation. The disorder must be looked at as a whole. The 
 incident which seems to have precipitated the neurosis — whether 
 shell explosion, burial or disciplinary crisis — must receive close 
 attention but not to the exclusion of other factors less dramatic 
 but often more potent in the production of the neurosis. It has 
 often been said that some of the symptoms of hysteria are the 
 work of the physician and are created — not disclosed — by neu- 
 rological examinations. This is apparently true, but the question 
 whether analgesia can exist until the pin prick demonstrates it is 
 somewhat like the question whether sound can exist without an 
 ear to receive it. It is not only true, but a fact of great practical 
 importance, that a skilful, searching, psychological examination 
 often constitutes the first step in actual treatment. 
 
 In the analysis of the situation, as well as in the subsequent 
 management of the patient, the medical officer's attitude is of 
 much importance. He must be immune to surprise or chagrin. 
 Although understanding sympathy is nearly as useful as misdi- 
 rected sympathy is harmful, he must always remain in firm con- 
 trol. . 
 
 ^ ^^=^^^The resources at the disposal of the physician in treating the 
 war neuroses are varied. The patient must be re-educated in 
 will, thought, feeling and function. Persuasion, a powerful re- 
 source, may be employed, directly backed by knowledge on the 
 part of the patient as well as the physician of the mechanism of 
 the particular disorder present. Indirectly, it must pervade the 
 atmosphere of the special ward or hospital for "shell shock." 
 Hypnotism is valuable as an adjunct to persuasion and as a 
 means of convincing the patient that no organic disease or 
 injury is responsible for his loss of function. Thus in mutism 
 the patient speaks under hypnosis or through hypnotic suggestion 
 and thereafter must admit the integrity of his organs of speech. 
 The striking results of hypnotism in the removal of symptoms 
 
WAR NEUROSES 39 
 
 are somewhat offset by the fact that the most suggestible who 
 yield to it most readily are particularly likely to be the constitu- 
 tionally neurotic. A mental mechanism similar to that which pro- 
 duced the disorder is being used in such cases to bring about a cure. 
 
 Recovery within the sound of artillery or at least "somewhere 
 in France" is more prompt and durable than that which takes 
 place in England. For severe cases and those which through mis- 
 management have developed the unfortunate secondary symp- 
 toms of "shell shock" and in whom long-continued treatment is 
 nectary, a rural place is best. 
 
 ^^e-education by physical means is a valuable adjunct to treat- 
 ment in recent cases but particularly in chronic cases who have 
 been mismanaged and in those who are recovering from long con- 
 tinued paralyses, tics, mutism and gait disorders. While drills 
 and physical exercises have their specific uses, occupation is the 
 best means. Non-productive occupations should be avoided. 
 
 Occupations are conveniently classified as : 
 
 1. Bed. 
 
 2. Indoor. 
 
 3. Outdoor. 
 
 1. Basket-making and net-making are good bed occupations 
 for cases with extensive paralyses, as are making surgical dress- 
 ings and various minor finishing operations (sandpapering, polish- 
 ing, etc.) on products of the shops. All occupations, and es- 
 pecially those which are carried on by patients seriously incapaci- 
 tated, should be regarded as only steps in a process of progressive 
 education. Every effort must be made to prevent skill acquired in 
 them from being considered as a substitute for full functional 
 activity. Herein is an important difference between the "re- 
 education" of neurotic and orthopedic cases. In the latter the 
 purpose is often to make the remaining sound limb take on the 
 functions of one which is missing or permanently disabled. The 
 function held in abeyance through neurotic symptovis must never be 
 looked upon as lost. It can and must be restored and Lf another 
 function is developed as its surrogate the day of full recovery is 
 thereby postponed. Bed occupations, therefore, must always be 
 regarded as the first steps in a series which is to culminate in full 
 activity. Progress through achievements constantly more diffi- 
 cult is the keynote of re-education in the war neuroses. 
 
40 MENTAL DISEASES AND WAR NEUROSES 
 
 2. A wide variety of indoor occupations should be provided in- 
 cluding at the minimum carpentry, wood carving, metal work and 
 cement work. Printing, bookbinding, cigarette making, electric 
 wiring and other work should be added as opportunities permit. 
 
 3. Farming, gardening and building operations are desirable 
 outdoor occupations. Where possible, wood sawing and chopping 
 are very desirable as is the care of stock not requiring much land 
 (squabs, guinea pigs, rabbits, game, frogs). 
 
 Before even the simplest occupation can be engaged in it is 
 sometimes necessary to re-educate paraplegics and ataxics in 
 walking and co-ordination. Just as soon as possible, exercises 
 should be replaced by productive occupations which will accom- 
 plish the same results more quickly and more satisfactorily. The 
 same is true of gymnastic exercises which in the early steps of 
 treatment constitute a valuable resource but which should be 
 replaced by specially devised, useful tasks. Swimming has a 
 unique place in the treatment of gait disturbances, paralyses and 
 tics. One of the first pieces of construction undertaken by the 
 outdoor patients at a reconstruction center should be that of 
 building a large concrete swimming tank. 
 
 Hydrotherapy and electrotherapy have a distinct value when 
 they are applied with absolute sincerity and full realization on 
 the part of patient and medical officer of the role which they 
 actually play in the treatment of functional nervous diseases. 
 
 The experience in English hospitals has demonstrated the great 
 danger of aimless lounging, too many entertainments and relax- 
 ing recreations such as frequent motor rides, etc. It must be 
 remembered that " shell shock" cases suffer from a disorder of will 
 as well as function and it is impossible to effect a cure if attention 
 is directed to one at the expense of the other. As Dr. H. Crichton 
 Miller has put it, " 'shell shock' produces a condition which is 
 essentially childish and infantile in its nature. Rest in bed and 
 simple encoiu-agement is not enough to educate a child. Progress- 
 ive daily achievement is the only way whereby manhood and 
 self-respect can be regained." 
 
 Outcome 
 It was impossible for me to discover the end-results of treat- 
 ment. The following table shows the disposal of 731 discharges 
 
WAR NEUROSES 41 
 
 from the Red Cross Military Hospital at Maghull during the year 
 
 ending June 30, 1917. 
 
 Number Per cent 
 
 To military duty 153 20.9 
 
 Tocivillife 476 65.1 
 
 To other hospitals 88 12.0 
 
 To civil institutions for the insane 7 1.0 
 
 Died 3 0.4 
 
 Deserted 4 0.6 
 
 731 100.0 
 
 It is the opinion of the commanding officer of this hospital that 
 few men (with the severe or chronic types of neuroses there re- 
 ceived) can be sent back to military duty at the front. More 
 could be returned to duty at the base but for the fact that after 
 having been in a "shell shock hospital," they are regarded as 
 being poor material and little effort is taken to train them for their 
 new duties. Under such conditions the men become discouraged 
 and soon show signs of relapse. Those discharged to civil life 
 have done satisfactorily — as might be expected when one bears in 
 mind the genesis of the neuroses in war. 
 
 At the Granville Canadian Special Hospital at Ramsgate, 
 upwards of 60 per cent of the patients admitted were returned to 
 the front. The experience of this hospital is of special value to us 
 because the cases treated are those which seem likely to recover 
 within six months. All others and those who do not improve 
 quickly at Ramsgate are sent to Canada. It would be wise for 
 the United States Army to adopt a similar policy. 
 
 In the special wards established in France the recoveries are 
 still more numerous.* 
 
 It is evident that the outcome in the war neuroses is good from 
 a medical point of view and poor from a military point of view. 
 It is the opinion of all those consulted that, with the end of the 
 war, most cases, even the most severe, will speedily recover, those 
 who do not being the constitutionally neurotic and patients who 
 have been so badly managed that very unfavorable habit-reac- 
 tions have developed. This cheering fact brings little consolation, 
 however, to those who are chiefly concerned with the wastage of 
 
 *Pp. 36-37. 
 
42 MENTAL DISEASES AND WAR NEUROSES 
 
 fighting men. The lesson to be learned from the British results 
 seems clear — that treatment by medical officers with special 
 training in psychiatry should be made available just as near the 
 front as military exigency will permit and that patients who can- 
 not be reached at this point should be treated in special hospitals 
 in France until it is apparent that they cannot be returned to the 
 firing lines. As soon as this fact is established military needs and 
 humanitarian ends coincide. Patients should then be sent home 
 as soon as possible. The military commander may have the satis- 
 faction of knowing that food need not be brought across to feed 
 a soldier who can render no useful military service, and the 
 medical officer may feel that his patient will have what he most 
 needs for his recovery — home and safety and an environment in 
 which he can readjust. 
 
 Looking at the matter from a military point of view alone, one 
 might ask whether it is not desirable to send home all "shell 
 shock" cases — in whom so much effort residts in so few recoveries. 
 Such a decision would be as unfortunate from a military as from 
 a humanitarian standpoint. Its immediate effect would be to 
 increase enormously the prevalence of the war neuroses. In the 
 unending conflict between duty, honor and discipline, on the one 
 hand, and homesickness, horror, and the urgings of the instinct 
 of self-preservation on the other, the neurosis — as a way out — is 
 already accessible enough in most men without calling attention 
 to it and enhancing its value by the adoption of such an admin- 
 istrative policy. 
 
 Medico-legal Relations 
 The sudden appearance of marked incapacity, without signs of 
 injury, in a group of men to whom invalidism means a sudden 
 transition from extreme danger and hardship to safety and com- 
 fort, quite naturally gives rise to the suspicion of malingering. 
 The general knowledge among troops of the more common symp- 
 toms of "shell shock" and of the fact that thousands of their 
 comrades suffering from it have been discharged from the army 
 suggests its simulation to men who are planning an easy exit from 
 military service by feigning disease. It is therefore of much 
 military importance that medical officers be not deceived by such 
 frauds. On the other hand, especially before the clinical charac- 
 ters and remarkable prevalence of war neuroses among soldiers 
 
WAR NEUROSES 4S 
 
 had become familiar facts, not a few soldiers suffering from 
 these disorders were executed by firing squads as malingerers. 
 Instances are also known where hysterics have committed suicide 
 after having been falsely accused of malingering. Mistakes of 
 this kind are especially likely to occur when the patients have not 
 been actually exposed to shell fire on account of the idea so firmly 
 fixed in the minds of most line officers and some medical men that 
 the war neuroses are always due to mechanical shock. 
 
 The diagnosis between neuroses and malingering may some- 
 times be extremely difficult but usually it is easy when the exam- 
 iner is familiar with both conditions. The difficulties arise from 
 the fact that in both, a disease or a symptom is simulated. As 
 Bonnal says, "The hysteric is a malingerer who does not lie." 
 The cardinal point of difference is that the malingerer simulates a 
 disease or a symptom which he has not in order to deceive others. 
 He does this consciously to attain, through fraud, a specific selfish 
 end — usually safety in a hospital or discharge from the military 
 service. He lies and knows that he lies. The hysteric deceives 
 himself by a mechanism of which he is unaware and which is beyond 
 his power consciously to control. He is usually not aware of the 
 precise purpose which his illness serves. This is shown by the 
 fact that, in many cases, all that is necessary for recovery is to 
 demonstrate clearly to the patient the mechanism by which this 
 disability occurred and the unworthy end to which, unconsciously, 
 it was directed. 
 
 There are a number of distinctive points of difference between 
 hysteria and malingering, two of which it may be interesting to 
 mention. 
 
 The malingerer, conscious of his fraudulent intent and fearful 
 of its detection, dreads examinations. The hysteric invites 
 examinations, as is well known to physicians in civil practice. 
 When he has the opportunity he makes the rounds of clinics and 
 physicians, especially delighting in examinations by noted spe- 
 cialists. 
 
 The hysteric, in addition to the symptoms of which he com- 
 plains, often presents objective symptoms of which he is unaware. 
 The malingerer, unless of low intelligence, confines his complaints 
 to the disease or symptom which he has decided to simulate. 
 
 Malingering may follow or prolong a neurosis. This is not 
 
44 MENTAL DISEASES AND WAR NEUROSES 
 
 infrequently the case when mutism is succeeded by aphonia. In 
 such cases the clinical picture presents changes very apparent to 
 the experienced psychiatrist but it must be remembered that 
 malingerers (like criminals in civil Ufe) are often very neuro- 
 pathic individuals. 
 
 The gravity of malingering as a military offense In an army in 
 the field justifies the recommendation that no case in which the 
 possibility of a neurosis or psychosis exists shall be finally dealt 
 with until the subject is examined by a neurologist or psychia- 
 trist. If neuro-psychiatric wards are provided in base hospitals 
 in France as well as in the United States, such an examination 
 will be feasible in practically all cases without causing undue delay. 
 The knowledge that malingerers are subjected to expert examina- 
 tions always tends to discourage soldiers from this practice. 
 
m. RECOMMENDATIONS FOR THE UNITED STATES 
 
 ARMY 
 
in. RECOMMENDATIONS FOR THE UNITED STATES ARMY 
 
 rr^HE following recommendations for the treatment of mental 
 A diseases and war neuroses ("shell shock") in the United 
 States troops are based chiefly upon the experience of the British 
 Army in dealing with these disorders, as outUned in the foregoing 
 report. The advice of British medical officers engaged in this 
 special work has aided greatly in formulating the plans presented. 
 At the same time conditions imposed by the necessity of conduct- 
 ing our military operations three thousand miles away from home 
 territory have been borne in mind. 
 
 It seems desirable to consider separately in these recommenda- 
 tions, expeditionary and non-expeditionary forces. It is neces- 
 sary to deal separately with mental and nervous diseases in the 
 United States but not in France. While facilities existing at home 
 can be utilized for the treatment of mental diseases it is necessary 
 to create new ones for the treatment of the war neuroses. In 
 France, where all facilities for treatment must be created by the 
 medical department, the distinction between psychoses and 
 neuroses need not be drawn so closely. Consequently, simpler 
 and more effective methods of administrative management can be 
 devised. 
 
 The importance of providing, in advance of their urgent need, 
 adequate facilities for the treatment and management of nervous 
 and mental disorders can hardly be overstated. The European 
 countries at war had made practically no such preparations and 
 they fell into difficulties from which they are now only commenc- 
 ing to extricate themselves. We can profit by their experience 
 and, if we choose, have at our disposal, before we begin to sustain 
 these types of casualties in very large numbers, a personnel of 
 specially-trained medical officers, nurses and civilian assistants 
 and an efficient mechanism for treating mental and nervous dis- 
 orders in France, evacuating them to home territory and continu- 
 ing their treatment, when necessary, in the United States. 
 
 Although it might be considered more appropriately under the 
 heading of prevention than under that of treatment, the most 
 important recommendation to be made is that of rigidly excluding 
 insane, feebleminded, psychopathic and neuropathic individuals 
 
 47 
 
48 MENTAL DISEASES AND WAR NEUROSES 
 
 from the forces which are to be sent to France and exposed to the 
 terrific stress of modern war. Not only the medical officers but 
 the line officers interviewed in England emphasized, over and over 
 again, the importance of not accepting mentally unstable re- 
 cruits for miUtary service at the front. If the period of training 
 at the concentration camps is used for observation and examina- 
 tion, it is within our power to reduce very materially the difficult 
 problem of caring for mental and nervous cases in France, in- 
 crease the military eflSciency of the expeditionary forces and save 
 the country millions of dollars in pensions. Sir William Osier, 
 who has had a large experience in the selection of recruits for the 
 British Army and has seen the disastrous results of carelessness 
 in this respect, feels so strongly on the subject that he has recently 
 made his views known in a letter to the Journal of the American 
 Medical Association* in which he mentions neuropathic make-up 
 as one of the three great causes for the invariable rejection of re- 
 cruits. In personal conversation he gave numerous illustrations 
 of the burden which the acceptance of neurotic recruits had un- 
 necessarily thrown upon an army struggling to surmount the 
 difficult medical problems inseparable from the war. 
 
 It is most convenient to summarize the recommendations as 
 follows and then to discuss each one somewhat in detail: 
 
 SUMMARY OF RECOMMENDATIONS FOR THE CARE AND TREATMENT 
 OP MENTAL DISEASES AND WAR NEUROSES (" SHELL SHOCK ") 
 
 IN THE EXPEDITIONARY FORCES 
 Overseas 
 
 1. Base Section of Lines of Communication 
 
 (a) A Special Base Hospital of 500 beds for neuro-psychiatric cases, located at the 
 base upon which each army (of 500,000-600,000) rests. These special base 
 hospitals to be used for cases hkely to recover and return to active duty within 
 six months. Other cases to be cared for while waiting to be evacuated to the 
 United States. 
 
 (b) One or more Special Convalescent Camps in connection with (and conducted as 
 part of) each Special Base Hospital. 
 
 2. Advanced Section of Lines of Communication 
 
 (a) Special Neuro-Psychiatric Wards of 30 beds in charge of three psychiatrists and 
 neurologists for each base hospital having an active ser\ice. These wards to be 
 used for observation (including medico-legal cases) and for emergency treat- 
 ment of mental and nervous cases. 
 
 (b) Detail of a psychiatrist or neurologist attached to the neuro-psychiatric wards 
 of base hospitals, to evacuation hospitals or stations further advanced as op- 
 portunities permit. 
 
 'Journal American medical association. Vol. LXIX, No. 4, p. 290 (July 28, 1917). 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 49 
 
 United States 
 
 1. Mental Diseases (insane) 
 
 (a) One or more Clearing Hospitals for reception, emergency treatment, classifi- 
 cation and disposition of mental cases among enlisted men invalided home. 
 
 (b) Clearing Wards (in connection with general hospitals for officers or private in- 
 stitutions for mental diseases) for reception, emergency treatment, classification 
 and disposition of mental cases among officers invalided home. 
 
 (c) Legislation permitting the Surgeon-General to make contracts with public and 
 private hospitals maintaining satisfactory standards of treatment for the con- 
 tinued care of officers and men suffering from mental diseases imtil recom- 
 mended for retirement or discharge (with or without pension) by a special 
 board. 
 
 (d) Appointment of a special board of three medical officers to ■visit all institutions 
 in which insane officers and men are cared for under such contracts to see that 
 adequate treatment is being given and to retire or discharge (with or without 
 pension) those not likely to recover. 
 
 2. War Neuroses ("shell shock") 
 
 (a) Re-construction centers (the number and capacity to be determined by the 
 need) for the treatment and re-education of such cases of war neuroses as are 
 invalided home. Injuries to the brain, cord and peripheral nerves to be treated 
 elsewhere. 
 
 (b) Special convalescent camps where recovered cases can go and not be subject to 
 the harmful influences for those cases which exist in camps for ordinary medical 
 and surgical cases. 
 
 (c) Employment of the Special Board of medical officers, recommended under " 1 
 (d)," to visit all re-education centers and convalescent camps in which war 
 neuroses are treated to see that adequate treatment is being given and to retire 
 or discharge (with or without pension) those not likely to recover. 
 
 EXPEDITIONARY FORCES 
 I. OVERSEAS 
 
 The plan herein suggested for dealing with mental and func- 
 tional nervous diseases in the expeditionary forces overseas pre- 
 supposes that all sick and wounded soldiers who are not likely to 
 be returned for duty in the fighting line within six months will be 
 evacuated to home territory. The same considerations which 
 led to the adoption of this policy by the Canadian Army are 
 equally valid in the case of American troops. If large numbers 
 of the sick and wounded who are not likely to return to active 
 duty have to be cared for in France during long periods of disa- 
 bility, the amount of food and other supplies which must be sent 
 overseas for them and for those who care for them will diminish 
 the tonnage available for the transportation of munitions required 
 for successful military operations; the great auxiliary hospital 
 facilities available in the United States cannot be utilized and. 
 
50 MENTAL DISEASES AND WAR NEUROSES 
 
 in the case of the severe neuroses, fewer recoveries will take place. 
 If submarine activities seriously interfere with the return of 
 disabled soldiers to the United States and it is necessary to provide 
 continued care, chronic cases should be evacuated to special 
 hospitals established in France for this purpose. It is very desir- 
 able to maintain an active service in base hospitals that receive 
 cases from the front. This is especially true in the case of the war 
 neuroses. 
 
 (a) Base Section of Lines of Communication. The base upon 
 which each army rests should be provided with a special base 
 hospital of five hundred beds for neuro-psychiatric cases. Three 
 years' experience in treating these cases in general hospitals in 
 England and France amply demonstrates the need for such an 
 institution. Few more hopeful cases exist in the medical services 
 of the countries at war than those suffering from the war neuroses 
 grouped under the term "shell shock" when treated in special hos- 
 pitals by physicians and nurses familiar with the nature of functional 
 nervous diseases and ivith their management. On the other hand, 
 the general military hospitals and convalescent camps presented 
 no more pathetic picture than the mismanaged nervous and 
 mental cases which crowded their wards before such special 
 hospitals were established. Exposed to misdirected harshness or 
 to equally misdirected sympathy, dealt with at one time as 
 malingerers and at another as sufferers from incurable organic 
 nervous disease, "passed on" from one hospital to another and 
 finally discharged with pensions which cannot subsequently be 
 diminished, their treatment has not been a wholly creditable 
 chapter in military medicine. As one writer has said, "they 
 enter the hospitals as ' shell shock ' cases and come out as nervous 
 wrecks." To their initial neurological disability (of a distinctly 
 recoverable nature) are added such secondary effects as unfavor- 
 able habit-reactions, stereotypy and fixation of symptoms, the 
 self-pity of the confirmed hysteric, the morbid timidity and anxiety 
 of the neurasthenic and the despair of the hypochondriac. In 
 such hospitals and convalescent homes inactivity and aimless 
 lounging weaken will, and the attitude of permanent invalidism 
 quickly replaces that of recovery. The provision of special facil- 
 ities for the treatment of "shell shock" cases is imperative from 
 the point of view of military efficiency as well as from that of 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 51 
 
 common humanity, for more than half these cases can be returned 
 to duty if they receive active treatment in special hospitals from 
 an early period in their disease. 
 
 British experience indicates that about one hundred of the 
 beds in each such special base hospital would be occupied by 
 mental cases and the rest by those suffering from war neuroses. 
 It is not necessary to make this division arbitrarily in advance, 
 however, as both classes of cases can be cared for in the type of 
 hospital to be proposed and re-distribution of patients can be 
 made from time to time as circumstances require. It should be 
 the object of these special base hospitals to provide treatment for 
 all cases likely to recover and be returned to active duty within 
 six months. Practically all mental cases, even those who recover 
 during this period, as well as functional nervous cases presenting 
 an unfavorable outlook or which are unimproved by special treat- 
 ment, should be evacuated to the United States as rapidly as 
 transportation conditions will permit. 
 
 Each such hospital should be located with reference to its 
 accessibility to other hospitals along the lines of communication 
 of the army which it serves. This will necessitate its being on 
 the main railway line down which disabled soldiers are evacuated 
 from the front. It should also be within convenient reach of, 
 although not necessarily at, the port of embarkation. If it is 
 possible to secure a site in southern France where outdoor work 
 can be continued during the winter many important advantages 
 will be gained. Gardening and other outdoor occupations are so 
 valuable that the amount of ground adjoining each base hospital, 
 or contiguous to it, should be not less than one acre for every six 
 patients of one third its population. Thus, at least thirty acres 
 are required for a hospital with 500 beds. 
 
 The type of general hospital adopted by the American Army for 
 cantonment camps could be used, with certain interior changes, 
 but it would be more advantageous to secure a hotel or school 
 and remodel it to perform the special functions of a hospital of 
 this character. The living arrangements in these special hospitals 
 are simpler than in general hospitals for medical and surgical 
 cases. About five per cent of the bed-capacity will have to be in 
 single rooms. This percentage will be somewhat greater in the 
 psychiatric division and smaller in the neurological division. Less 
 
52 MENTAL DISEASES AND WAR NEUROSES 
 
 than three per cent of the population will be bed-patients. A 
 sufficient number of rooms in both the neurological and psychiatri- 
 cal divisions should be set aside for officers — the higher proportion 
 of officers among patients with neuroses being taken into con- 
 sideration in planning this department. 
 
 It is necessary to allow hberally for examining rooms, massage, 
 hydrotherapy and electrotherapy and to provide one large room 
 which can be used for an amusement hall. When the patients 
 and staff have been suitably housed attention should be directed 
 to the highly important features of shops, industrial equipment, 
 gymnasium and gardens. If no suitable buildings close to the 
 hospital can be secured, perfectly adequate facilities can be 
 provided in cheaply constructed wooden huts with concrete floors. 
 A gymnasium can be erected more cheaply than an existing build- 
 ing can be adapted for this purpose unless a large storehouse, barn 
 or factory is available. 
 
 Hydrotherapeutic equipment should include continuous baths, 
 Scotch douche, needle baths and a swimming pool. The latter is 
 exceptionally valuable in the treatment of functional paralyses 
 and disturbances of gait which disappear while patients are 
 swimming, thus often opening the way for rapid recovery by 
 persuasion. 
 
 Electrical apparatus is necessary for diagnostic purposes and 
 also for general and local treatment. 
 
 Second in importance only to the general psychological control 
 of the situation in functional nervous diseases* is the restoration 
 of the lost or impaired functions by re-education. None of the 
 methods available for re-education are so valuable in the war 
 neuroses as those in which a useful occupation is employed as the 
 means for training. Re-education should commence as soon as 
 the patient is received. Thought, will, feeling and function have 
 all to be restored and work toward all these ends should be under- 
 taken simultaneously. Non-productive occupations are not only 
 useless but deleterious. The principle of "learning by doing" 
 should guide all re-educative work. Continual "resting," long 
 periods spent alone, general softening of the environment and 
 occupations undertaken simply because the mood of the patient 
 suggests them are positively harmful, as shown by the poor re- 
 
 *Pp. 37-38. 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 53 
 
 suits obtained in those general hospitals and convalescent homes 
 in which such measures are employed. 
 
 The industrial equipment needed is relatively simple and in- 
 expensive. It is very desirable to begin with a few absolutely 
 necessary things and to add those made by the patients them- 
 selves. When this is done every piece of apparatus is invested, 
 in the eyes of the patients, with the spirit of achievement through 
 persistent effort — the very keynote of treatment. The fact that 
 it has been made by patients recovering from neuroses will help 
 hundreds of subsequent patients through the force of hopeful 
 suggestion. The following list gives the equipment for the shops 
 which is necessary at the beginning : 
 
 Smiths' shop 
 
 Forges, tools, etc., for ten men 
 Fitting shop 
 
 One screw-cutting lathe, one sensitive drill, one polishing machine, one 
 electric motor Ij h.p., swages and tools for eight men 
 Leather blocking room 
 
 Sewing machine, eyeletting machine, tank, galvanized iron and tools 
 Tailors' shop 
 
 Three sewing machines, tools for ten men 
 Carpenters' shop 
 
 Selected tools for fifteen men, bench screws and special tools not for gen- 
 eral use, wood-turner's lathe 
 Machine shop 
 
 Electric motor 85 h.p., with shafting, brackets, etc. 
 Cement shop 
 
 Metal moulds, tools for twelve men 
 Printing shop 
 
 Press and accessories 
 General 
 
 Drilling machine, grindstone, screw-cutting lathe, fret-saw workers' ma- 
 chine and patterns, circular-saw, bench 
 
 Practically all gymnasium apparatus can be made in the shops 
 after the hospital is opened. 
 
 Each special base hospital should be able to evacuate patients 
 who, although not quite able to return to active duty, no longer 
 require intensive treatment. For this purpose one or more con- 
 valescent camps within convenient distance by motor truck from 
 the main institution should be established. Each of these con- 
 valescent camps should not exceed 100 in capacity. It will re- 
 quire only one medical officer, one sergeant, three female nurses, 
 
54 
 
 MENTAL DISEASES AND WAR NEUROSES 
 
 an instructor and three or four hospital corps men, as the patients 
 will be able to care for themselves and in a short time return to duty. 
 One camp may have to be established for the care of another 
 type of cases. It is conceivable that submarine activity will inter- 
 fere so seriously with the evacuation of chronic and non-recover- 
 able cases to the United States that the special hospital will be 
 overcrowded. Overcrowding will instantly interfere with the 
 success of the work and this will simply mean that men who other- 
 wise might recover and return to military duty at the front will 
 fail to do so. Such a calamity can be averted by transferring 
 chronic and non-recoverable cases to a camp organized upon quite 
 simple lines under direct control of the main hospital and near 
 enough to utilize its therapeutic resources. The beds which 
 such patients would otherwise occupy in the special base hospital 
 can be made available for the use of fresh, recoverable cases. 
 Such developments might better be made naturally as circum- 
 stances require than provided for by any formal arrangements 
 made in advance. 
 
 Each base hospital should have the personnel enumerated in 
 the following table : 
 
 PERSONNEL FOR SPECIAL BASE HOSPITAL FOR NEURO- 
 PSYCHIATRIC CASES 
 
 Commissioned Officers 
 
 
 Major 
 
 M.C. 
 
 Commanding Officer 
 
 Captain 
 
 M.C. 
 
 Adjutant, Surgeon of the Command, Recruiting 
 Officer 
 
 Captain 
 
 Q.C. 
 
 Quartermaster 
 
 Major 
 
 M.R.C. 
 
 Director 
 
 Major 
 
 M.R.C. 
 
 Chief Neurological Division 
 
 Major 
 
 M.R.C. 
 
 Chief Psychiatrical Division 
 
 Major 
 
 M.R.C. 
 
 Chief Occupational Division 
 
 Captain 
 
 M.R.C. 
 
 Pathologist 
 
 Captain 
 
 M.R.C. 
 
 In charge of Convalescent Camp 
 
 Captain 
 
 M.R.C. 
 
 In charge of Electrotherapy and Hydrotherapy 
 
 Captain 
 
 M.R.C. 
 
 Ward Physician (in charge of Transportation of 
 Patients) 
 
 Captain 
 
 M.R.C. 
 
 Ward Physician 
 
 Captain 
 
 M.R.C. 
 
 Ward Physician 
 
 1st Lieutenant 
 
 M.R.C. 
 
 Ward Physician 
 
 1st Lieutenant 
 
 M.R.C. 
 
 Ward Physician 
 
 1st Lieutenant 
 
 M.R.C. 
 
 Ward Physician 
 
 1st Lieutenant 
 
 M.R.C. 
 
 Ward Physician 
 
 1st Lieutenant 
 
 M.R.C. 
 
 Ward Physician 
 
 1st Lieutenant 
 
 San.C. 
 
 Psychologist 
 
 1st Lieutenant 
 
 San.C. 
 
 Registrar 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 55 
 
 NON-COMMISSIONED OFFICERS 
 
 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 General Supervision 
 
 Sergeant, 
 
 1st CI. 
 
 Q.C. 
 
 Quartermaster Sergeant 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 Office 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 In charge of Detachment and Detachment Accounts 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 In charge of Mess and Kitchen 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 General Supervision, Convalescent Camp 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 In charge of Shops 
 
 Sergeant, 
 
 1st CI. 
 
 H.C. 
 
 In charge of Garden and Grounds 
 
 Sergeant 
 
 
 H.C. 
 
 Hydrotherapy Rooms 
 
 Sergeant 
 
 
 H.C. 
 
 Electrotherapy Rooms 
 
 Sergeant 
 
 
 H.C. 
 
 Massage Rooms 
 
 Sergeant 
 
 
 H.C. 
 
 Shops 
 
 Sergeant 
 
 
 H.C. 
 
 Gymnasium 
 
 Sergeant 
 
 
 H.C. 
 
 Mess and Kitchen 
 
 Sergeant 
 
 
 H.C. 
 
 Storerooms 
 
 Sergeant 
 
 
 H.C. 
 
 Office 
 
 Sergeant 
 
 
 H.C. 
 
 Office 
 
 Sergeant 
 
 
 H.C. 
 
 Outside Police 
 
 Sergeant 
 
 
 H.C. 
 
 Wards 
 
 Sergeant 
 
 
 H.C. 
 
 Wards 
 
 Sergeant 
 
 
 H.C. 
 
 Wards 
 
 Sergeant 
 
 
 H.C. 
 
 Wards 
 
 Sergeant 
 
 
 H.C. 
 
 Wards 
 
 Sergeant 
 
 
 H.C. 
 
 Transportation of Patients 
 
 Femai^ Nubses (N.C.^ 
 
 
 
 . Chief Nurse 
 
 
 1 
 
 
 ^. ^ Assistant to Chief 1 
 , Dietist 
 
 *furse. . . 
 
 1 
 
 
 
 1 
 
 46 
 
 Ward Nurses 
 
 
 43 
 
 
 Enusted Men (H.C.) 
 14 Acting Cooks 
 
 115 Privates, 1st CI. and Privates 
 Distributed as follows: 
 Ward Attendants 
 
 Neurological Division ii ] 
 
 Psychiatrical Division 26 [ 52 
 
 Convalescent Camp 4 J 
 
 Shops 10 
 
 Electrotherapy rooms 4 
 
 Hydrotherapy rooms 4 
 
 Massage rooms 6 
 
 Laboratory 2 
 
 Kitchens and mess 14 
 
 Office 5 
 
 Storerooms 6 
 
 Orderlies 4 
 
 Outside Police 4 
 
 Supernumeraries 4 
 
 115 
 
8 
 
 56 MENTAL DISEASES AND WAR NEUROSES 
 
 Civilian Emplotees 
 Instructors 
 
 Outdoor occupations 
 
 Indoor occupations 
 
 Assistant Instructors 
 
 Carpentry and wood carving 
 
 Cement work 
 
 Metal work 
 
 Leather work 
 
 Gardening 
 
 Printing 
 
 Gymnasium 2 
 
 Stenographers 4 
 
 Photographer 1 
 
 Laboratory technician 1 
 
 16 
 Recapitulation 
 
 Commissioned officers 20 
 
 Non-commissioned officers 24 
 
 Female nurses 46 
 
 Enlisted men 129 
 
 Civilian employees 16 
 
 235 
 
 The commissioned medical officers should all be men with ex- 
 cellent training in neurology and psychiatry. The neurologists 
 should have a psychiatrical outlook and the psychiatrists should 
 be familiar with neurological technique. Of importance almost 
 equal to the professional qualifications of these officers is their 
 character and tact, and no man who is unable to adjust his per- 
 sonal problems should be selected for this work. There is no 
 place in such hospital for a "queer," disgruntled or irritable 
 individual except as a patient. Men who are strong, forceful, 
 patient, tactful and sympathetic are required. It is better to 
 permit a medical officer not having these qualifications to remain 
 at home than to assign him to one of these hospitals and allow 
 him to interfere with treatment by his failure to establish and 
 maintain proper contact with his patients. The resources to be 
 employed include psychological analysis, persuasion, sympathy, 
 discipline, hypnotism, ridicule, encouragement and severity. 
 All are dangerous or useless in the hands of the inexperienced, as 
 the records of "shell shock" cases treated in general hospitals tes- 
 tify. In the hands of men capable of forming a correct estimate 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 57 
 
 of the make-up of each patient and of employing these resources 
 with reference to the therapeutic problem presented by each case, 
 they are powerful aids. 
 
 The female nurses should have had experience in the treatment 
 of mental and nervous diseases. Character and personality are 
 as important in nurses as in medical officers. A large proportion 
 of college women will be found advantageous. 
 
 The enlisted men who perform the duties of ward attendants 
 and assistants in the shops, gardens and gymnasium should in- 
 clude a considerable number of those who have had experience in 
 dealing with mental and nervous diseases. The civilian employees 
 who act as instructors should all have had practical experience 
 in the use of occupations in the treatment of nervous and mental 
 diseases. The instructor for bed occupations should be a woman 
 and she should train the female nurses to assist her in this kind of 
 work. 
 
 No work is more exacting than that which will fall to the phy- 
 sicians and chief lay employees in such hospital. Success in 
 treatment depends chiefly upon each person's establishing and 
 maintaining a sincere belief in the work to which he or she is 
 assigned. No hysterical case must be regarded as hopeless. The 
 maintenance of a correct attitude and constant co-operation be- 
 tween physicians, nurses, instructors and men in the face of the 
 tremendous demands which neurotic patients make upon the 
 patience and resourcefulness of those treating them soon bring 
 weariness and loss of interest if opportunities for recreation do not 
 exist. Therefore, it should be the duty of the director to see that 
 the morale and good spirits of all are kept up. His recommenda- 
 tions as to the transfer to other military duties of medical officers, 
 nurses, instructors or men who prove unsuited for this work 
 should be acted upon whenever possible by the chief surgeon under 
 whom the hospital serves. A man or a woman may prove un- 
 adapted to this work and yet be a valuable member of the staff of 
 another kind of hospital. This subject is mentioned so particu- 
 larly because of its great importance. The type of personnel will 
 determine the success of this hospital and hence its usefulness to 
 the army in a measure which is unknown in other military hos- 
 pitals. It does not greatly matter whether the operating surgeon 
 understands the personality of the soldier upon whom he is oper- 
 
58 MENTAL DISEASES AND WAR NEUROSES 
 
 ating or not. Whether or not the physician treating a case of 
 "shell shock" understands the personality of his patient spells 
 success or failure. 
 
 The first special base hospital established for neuro-psychiatric 
 cases should have so highly eflficient a personnel that it will be 
 able to contribute one third of its medical oflBcers and trained 
 workers to the next similar base hospital to be established, filling 
 their places from those on its reserve list. This should be re- 
 peated a second time if necessary and thus a uniform standard of 
 excellence and the same general approach to problems of treat- 
 ment assured in each special base hospital organized in France. 
 
 (b) Advanced Section of Lines of Communication. The French 
 and the British experience shows the great desirability of institut- 
 ing treatment of "shell shock " cases as early as possible. So little 
 has been done as yet in this direction that we do not know much 
 about the onset of these cases and just what happens during the 
 first few days. Such information as has been contributed, how- 
 ever, by the few neurologists and psychiatrists who have had an 
 opportunity of working in casualty clearing stations or positions 
 even nearer the front indicates that much can be done in dealing 
 with these cases if they can be treated within a few hours after the 
 onset of severe nervous symptoms. There are data to show that 
 even by the time these cases are received at base hospitals ad- 
 ditions have been made to the initial neurological disability and a 
 coloring of invahdism given which frequently influences the pros- 
 pects of recovery. It is desirable, therefore, to provide neuro- 
 psychiatric wards for selected base hospitals in the advanced 
 section of the lines of communication. Other base hospitals can 
 send cases to those which possess such wards. The plan of pro- 
 viding such sections, in charge of neurologists and psychiatrists, 
 for divisional base hospitals in the cantonment camps in the United 
 States has been adopted by the Surgeon-General. If it is found 
 practicable to make similar provisions in France, these units can 
 accompany the divisions to which they are attached when they 
 join the expeditionary forces in the spring of 1918. In the mean- 
 time it is essential that each base hospital should have on its 
 staff a neurologist or a psychiatrist. Provision for the care of 
 mental and nervous cases nearer the front, along the lines of com- 
 munication, can best be developed, after the first special base 
 
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RECOMMENDATIONS FOR UNITED STATES ARMY 59 
 
 hospital for neuro-psychiatric cases has been estabhshed, by de- 
 taching from its staff individual officers as actual circumstances 
 require. 
 
 It is undesirable to formulate plans for providing this kind of 
 care still nearer the fighting line until a more careful study has been 
 made of the results obtained by the English and French medical 
 services in this undertaking. 
 
 The foregoing recommendations are illustrated graphically in 
 the upper part of the accompanying chart from Major Pearce 
 Bailey's recent paper.* 
 
 II. IN THE UNITED STATES 
 
 (a) Mental Diseases (Insanity). If the policy is adopted of 
 caring in France for mental cases likely to recover and evacuating 
 all others to the United States at once or at the expiration of six 
 months' treatment, we may expect to receive at the port of ar- 
 rival in the United States not less than 250 insane soldiers per 
 month from an expeditionary force of 1,000,000. We may as- 
 sume that a plan will be adopted for the reception and the dis- 
 tribution of soldiers invalided from France such as proposed by 
 Major Bailey. 
 
 Well-organized facilities for deaHng with mental disease exist 
 in the United States which can be utilized by the government 
 without the necessity of creating expensive new agencies. It is 
 obvious that the first facts to be determined in the case of soldiers 
 reaching the United States while still suffering from mental dis- 
 orders or who have been invalided home after recovery from 
 acute attacks, are: 
 
 1. The cause of the disorder, with special reference to military service. 
 
 2. The probable outcome. 
 
 3. The probable duration. 
 
 4. The special needs in treatment. 
 
 It is quite impossible to ascertain any of these facts by casual 
 examination and so it will be necessary to provide "clearing hos- 
 pitals" for non-commissioned officers and enlisted men where 
 patients may be received and studied upon their arrival with the 
 view of determining these questions. With an average annual 
 admission rate of 3,000 patients, a clearing hospital of three 
 
 •Mental Htgiene, Vol. I, No. 3 (July. 1917). 
 
58 
 
 MEN 
 
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RECOMMENDATIONS FOR UNITED STATES ARMY 59 
 
 hospital for neuro-psychiatric cases has been established, by de- 
 taching from its staff individual officers as actual circumstances 
 require. 
 
 It is undesirable to formulate plans for providing this kind of 
 care still nearer the fighting line until a more careful study has been 
 made of the results obtained by the English and French medical 
 services in this undertaking. 
 
 The foregoing recommendations are illustrated graphically in 
 the upper part of the accompanying chart from Major Pearce 
 Bailey's recent paper.* 
 
 V 
 
 II. IN THE UNITED STATES 
 
 (a) Mental Diseases {Insanity). If the policy is adopted of 
 caring in France for mental cases likely to recover and evacuating 
 all others to the United States at once or at the expiration of six 
 months' treatment, we may expect to receive at the port of ar- 
 rival in the United States not less than 250 insane soldiers per 
 month from an expeditionary force of 1,000,000. We may as- 
 sume that a plan will be adopted for the reception and the dis- 
 tribution of soldiers invalided from France such as proposed by 
 Major Bailey. 
 
 Well-organized facilities for dealing with mental disease exist 
 in the United States which can be utilized by the government 
 without the necessity of creating expensive new agencies. It is 
 obvious that the first facts to be determined in the case of soldiers 
 reaching the United States while still suffering from mental dis- 
 orders or who have been invalided home after recovery from 
 acute attacks, are: 
 
 1. The cause of the disorder, with special reference to military service. 
 
 2. The probable outcome. 
 
 3. The probable duration. 
 
 4. The special needs in treatment. 
 
 It is quite impossible to ascertain any of these facts by casual 
 examination and so it will be necessary to provide "clearing hos- 
 pitals" for non-commissioned officers and enlisted men where 
 patients maj^ be received and studied upon their arrival with the 
 view of determining these questions. With an average annual 
 admission rate of 3,000 patients, a clearing hospital of three 
 
 *Mkntal Hygiene, Vol. I, No. 3 (July, 1917). 
 
60 MENTAL DISEASES AND WAR NEUROSES 
 
 hundred beds would permit an average period of treatment of 
 thirty-six days. This would seem to be sufficient as the Boston 
 Psychopathic Hospital, during an average period of treatment of 
 eighteen days, not only determines similar questions but provides 
 continued care for a considerable number of recoverable cases. 
 Such clearing hospitals should be established near the port of 
 arrival and should be essentially military hospitals, with directors 
 who are not only well trained in their medical duties but are 
 familiar with the requirements of military life and with the 
 institutional provisions in the United States that can be utilized 
 for continued treatment. 
 
 With such active service as a clearing hospital mil have, the 
 number of medical officers should be not less than ten and there 
 should be an adequate clerical force to care for the important 
 administrative matters which would require attention. The 
 organization of civil psychopathic hospitals in this country 
 affords data for determining the proper size of the ward and 
 domestic services. 
 
 After a period of observation and treatment the director of 
 such hospital should be prepared to furnish the Special Dis- 
 tributing Board with information and definite recommendations 
 as to the further disposal of each case. 
 
 Some patients will be found at the clearing hospitals to have 
 recovered. Although, as a matter of military policy, these 
 patients will not be available for duty again in France, they are 
 still of military value to the government. Such soldiers should 
 be returned to duty in the United States by the Special Distribut- 
 ing Board in a category which would prevent their being exposed 
 again in the fighting line but which would indicate precisely the 
 work for which they are suited. We can conceive of many such 
 soldiers who are likely to break down again under the stress of 
 actual fighting but who are quite likely to remain in good health 
 if they are not so exposed. These men will have had valuable 
 military experience and could render efficient service as instructors 
 in training camps or in the performance of other military duties 
 in the United States. Others who have recovered will give 
 evidence of possessing such an unstable or inferior mental make-up 
 that no further military life, even in the United States, is desirable. 
 In such cases, recommendations should be made by the directors 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 61 
 
 of the clearing hospitals to the Special Distributing Board to 
 discharge them to their homes, with or without pensions as the 
 circumstances demand. 
 
 There will be found others who have not been benefited at all 
 by treatment in France and who suffer from mental disorders 
 with an extremely unfavorable outlook for recovery. When this 
 conclusion seems justified, the directors of the clearing hospitals 
 should recommend these cases for transfer to a suitable public 
 or private institution in the states from which they enlisted 
 and their discharge from the army, with or without pension as 
 the circumstances demand. 
 
 Another group of cases will be made up of those suffering from 
 psychoses which are probably recoverable. It is equally to the 
 advantage of the army, the community and the patient that 
 such soldiers be given continued treatment. Facilities for the 
 care of mental diseases vary so greatly in many of the states that 
 neither the army nor the patients can receive any assurance that 
 proper treatment will be afforded if such soldiers are discharged 
 to the public institution nearest their homes. In such cases the 
 important question of discharge, with or without pension, should 
 be deferred until every facility has been given, during a reasonable 
 period of time, for recovery to take place. It is recommended, 
 therefore, that these cases be retained in the army until their 
 recovery or until the end of the war and ordered for treatment to 
 state hospitals with which the Secretary of War has made con- 
 tracts. A government hospital for the insane would be the most 
 suitable for carrying out such treatment but the present excellent 
 institution in Washington has reached the size of 3,135 beds and 
 can care for few additional military cases. It is highly desirable 
 that the government should now establish a military hospital 
 for mental diseases for the army and navy and permit the govern- 
 ment hospital to devote all its resources to its civil duties. It 
 would be impossible, however, to have such institution ready 
 within two years. If it were possible to construct such new 
 government hospital in a shorter time, it would still be necessary 
 to provide for treatment by contract, for this institution would 
 probably have to care for not more than 1,500 military cases 
 during peace. A much larger number is to be expected during 
 the war. 
 
62 MENTAL DISEASES AND WAR NEUROSES 
 
 It is wiser to care for insane soldiers during the war under con- 
 tract at ten or twelve first-class hospitals with fully adequate 
 facilities for treatment than to distribute them solely with refer- 
 ence to the location of their homes. This will involve a certain 
 hardship through making it difficult for such men to be visited 
 by their relatives and friends but it is possible to distribute the 
 contract hospitals over the country in such way that there would 
 be few cases more than a day's journey from their homes. The 
 primary object is to insure recovery in all recoverable cases. 
 This should outweigh all other considerations. 
 
 The legislation permitting the Secretary of War to make such 
 contracts should state clearly that they shall be made only with 
 institutions possessing facilities for treatment laid down by the 
 Surgeon-General. A list of such facilities, prepared by The Na- 
 tional Committee for Mental Hygiene for another purpose, is 
 appended* as it may form a useful guide in this connection. The 
 contract hospitals should be required to devote an entire building 
 of approved construction to military cases or to erect temporary 
 structures meeting the necessary requirements for this purpose. 
 
 In order that the army may be able to discharge mental cases 
 cared for under contract promptly upon their recovery or upon 
 ascertaining that recovery is unlikely, it is desirable that a special 
 board of three medical officers should be established to visit the 
 institutions constantly and act as a Board of Survey. If a 
 medical officer in each contract hospital were appointed in the 
 Medical Reserve Corps and assigned to the duty of caring for 
 army patients he could serve as a member of such board when 
 convened at his hospital and make it possible for the three general 
 members to cover much more ground. 
 
 Clearing wards for officers should be established to serve the 
 special purposes indicated in the description of the clearing hos- 
 pitals for enlisted men. Such wards should provide for the recep- 
 tion, classification, and treatment in cases likely to be of short 
 duration. They might be established in connection with general 
 hospitals at the port of arrival or in connection with very effi- 
 cient private institutions for the insane in which full military 
 control of this department could be secured. 
 
 It is equally important to provide for the continued treatment 
 
 *Appendix IV. 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 63 
 
 of officers and not to leave this question, in which the army has so 
 great an interest, to choice or geographical convenience. Arrange- 
 ment similar to those for the continued care of enlisted men in 
 public contract hospitals could easily be made with the best, 
 endowed private institutions for the insane. 
 
 (b) War Neuroses {"Shell Shock"). It is not necessary here to 
 outline the organization of reconstruction centers for the treat- 
 ment of war neuroses in the United States. The general prin- 
 ciples in treatment described in the foregoing report and in the 
 plan recommended for France should be a guide in the develop- 
 ment of those centers. 
 
 It should be remembered that if the policy recommended of 
 evacuating to the United States only the patients who fail to 
 recover in six months in France is adopted, some very intracta- 
 ble cases will be received. For the most part these will be patients 
 with a constitutional neuropathic make-up — the type most fre- 
 quently seen in civil practice. Many of these cases will prove 
 amenable to long-continued treatment and much can be expected 
 from the mental effect of return to the United States. It is very 
 important not to fall into the mistake made in England of dis- 
 charging these severe cases with a pension because of the discour- 
 aging results of treatment. To do so will swell the pension list 
 enormously, as can be seen by the fact that 15 per cent of all 
 discharges from the British Army are unrecovered cases of mental 
 diseases and war neuroses. Quite aside from financial considera- 
 tions, however, is the injustice of turning adrift thousands of 
 young men who developed their nervous disability through mili- 
 tary service and who can find in their home towns none of the 
 facilities required for their cure. It is recommended, therefore, 
 that no soldiers suffering from functional nervous diseases be dis- 
 charged from the army until at least a year's special treatment has 
 been given. Furloughs can be given when visits home or treat- 
 ment in civil hospitals will be beneficial but the government 
 should neither evade the responsibility nor surrender the right to 
 direct the treatment of these cases. A serious social and eco- 
 nomic problem has been created in England already through the 
 establishment in its communities of a group of chronic nervous 
 invalids who have been prematurely discharged from the only 
 hospitals existing for the efficient treatment of their illness. So 
 
64 MENTAL DISEASES AND WAR NEUROSES 
 
 serious is this problem that a special sanitarium "The Home of 
 Recovery"* — the first of several to be provided — has been estab- 
 lished in London and subsidized by the War Ofiice for the treat- 
 ment of such cases among pensioners. 
 
 It is highly important not to permit convalescent cases of this 
 kind to be cared for in the ordinary type of convalescent camp or 
 home. The surroundings so suitable for convalescents from 
 wounds or other diseases are very harmful to neurotic cases. 
 Here much that has been accomplished in special hospitals by 
 patient, skilful work is undone. Therefore, special convalescent 
 camps similar to those recommended for the expeditionary forces 
 in France should be established within convenient reach of the 
 reconstruction centers. 
 
 The special board recommended for the final disposition of 
 mental cases should deal with cases of functional nervous diseases. 
 
 NON-EXPEDITIONARY FORCES 
 
 Facilities for the treatment of neuro-psychiatric cases at the 
 camps in the United States have been approved by the Surgeon- 
 General and are now being provided. These will undoubtedly 
 prove sufficient for dealing temporarily with mental cases devel- 
 oping in the non-expeditionary forces. Their final disposition 
 should be made by means of the same mechanism recommended 
 for expeditionary patients who are invalided home, except that 
 the functions of the clearing hospital for mental diseases can be 
 performed by the neuro-psychiatric wards of divisional hospitals 
 and that of the special board by the Board of Survey composed 
 of the neurologists and psychiatrists stationed at the camps. 
 
 Neuroses are very common among soldiers who have never 
 been exposed to shell fire and will undoubtedly be seen frequently 
 among non-expeditionary troops in this country. In England 
 nearly 30 per cent of all men from the home forces admitted to 
 one general hospital were suffering from various neuroses. f 
 Most of these were men of very neurotic make-up. Many had had 
 previous nervous breakdowns. Fear, even in the comparatively 
 harmless camp exercises, was a common cause of neurotic symp- 
 
 *AppeiKlix III. 
 
 fBurlon-Fanning, F. W. Neurasthenia in soldiers of the home forces. Lancet 
 (London). 1 : 907-11 (June 16, 1917). 
 
RECOMMENDATIONS FOR UNITED STATES ARMY 65 
 
 toms. Heart symptoms were exceedingly common. The same 
 experience in our own training camps can be confidently predicted. 
 The responsibility of the government in such cases is obviously 
 diflterent from that in soldiers returning from duty abroad. In 
 the neuro-pyschiatric wards of divisional hospitals the important 
 and difficult question of diagnosis can be well determined. Most 
 such cases should be discharged from the service. Some can be 
 treated at the reconstruction centers for, unfortunately, there are 
 scarcely any provisions in the United States for the treatment of 
 the neuroses except in the case of the rich. It is freely predicted 
 in England that the wide prevalence of the neuroses among soldiers 
 will direct attention to the fact that this kind of illness has been 
 almost wholly ignored while great advances have been made in 
 the treatment of all others. In civil life one still hears of de- 
 tecting hysteria, as if it were a crime and, although the wounded 
 burglar is carefully and humanely treated in the modern city 
 hospital, the hysteric is usually driven away from its doors. 
 Today the enormous number of these cases among some of 
 Europe's best fighting men is leading to a revision of the medical 
 and popular attitude toward functional nervous diseases. 
 
APPENDICES 
 
 I. REFERENCES EST ENGLISH TO MENTAL DISEASES AND WAR 
 NEUROSES ("SHELL SHOCK") AND THEIR TREATMENT AND 
 MANAGEMENT 
 
 n. THE USE OF INSTITUTIONS FOR THE INSANE AS MILITARY HOS- 
 PITALS 
 
 m. SPECIAL MILITARY HOSPITALS FOR MENTAL DISEASES AND 
 WAR NEUROSES ("SHELL SHOCK") 
 
 1. DiHECTOBT 
 
 2. Deschiption op Hospitals Visited 
 
 rV. FACILITIES NEEDED FOR EFFICIENT TREATMENT OF MENTAL 
 DISEASES IN A MODERN PUBLIC INSTITUTION 
 
APPENDIX I 
 
 REFERENCES IN ENGLISH TO MENTAL DIS- 
 EASES AND WAR NEUROSES ("SHELL 
 SHOCK") AND THEIR TREATMENT 
 AND MANAGEMENT 
 
 This bibliography includes only books, articles and other refer- 
 ences published since the beginning of the war. Abstracts of 
 some of the more important articles in English, French, German, 
 Italian and Russian periodicals were published in Mental Hy- 
 giene, Vol. I, No. 3, July, 1917. A complete review of the lit- 
 erature on the psychoses and neuroses in war will be published 
 as a monograph by the War Work Committee of The National 
 Committee for Mental Hygiene in March, 1918. 
 
APPENDIX I 
 
 REFERENCES IN ENGLISH TO MENTAL DISEASES AND WAR 
 
 NEUROSES ("SHELL SHOCK") AND THEIR TREATMENT 
 
 AND MANAGEMENT 
 
 1. Abrahams, Adolphe. Case of hysterical paraplegia. J. of Roy. 
 
 army med. corps 24: 471-73, May 1915. 
 
 2. Abrahams, Adolphe. Soldier's heart. Lancet, Lond., March 24, 
 
 1917, p. 442-45. 
 
 3. Adler, Herman M. The greater psychiatry and the war. Mental 
 
 hygiene 1: 364-65, July 1917. 
 
 4. Adrian, E. D., and Yealland, L. R. Treatment of some common 
 
 war neuroses. Lancet, Lond., June 9, 1917, p. 867-72. 
 
 5. Armstrong-Jones, Robert. Psychology of fear and effects of panic 
 
 fear in war-time. J. of ment. science, Lond., 63:346-89, July 
 1917. 
 
 6. The army and mental disease (Editorial) J. of Amer. med. assoc. 
 
 63: 1396-97, Oct. 17, 1914. 
 
 7. Auer, E. Murray. Some of the nervous and mental conditions 
 
 arising in the present war. Mental hygiene 1: 383-88, July 
 1917. 
 
 8. Auer, E. Murray. Phenomena resultant upon fatigue and shock 
 
 of the central nervous system observed at the front in France. 
 Med. rec. 89: 641-44, April 8, 1916. 
 
 9. Bailey, Pearce. Care of disabled returned soldiers. Mental 
 
 hygiene 1: 345-53, July 1917. 
 
 10. Bailey, Pearce. Psychiatry and the army. Harper's mag. 90: 
 
 252-57, July 1917. 
 
 11. Ballard, E. Fryer. Epitome of mental diseases. Lond., Churchill, 
 
 1917. 244 p. illus. Pt. 2. 
 
 12. Ballard, E. Fryer. Some notes on battle psychoneuroses. J. of 
 
 ment. science, Lond., 63: 400-05, July 1917. 
 
 13. Barker, Lewellys F. War and the nervous system; address deliv- 
 
 ered at the annual meeting of the American neurological associa- 
 tion, 1916. J. of nerv. and ment. dis. 44: 1-10, July 1916. 
 ^4. Batten, F. E. Some functional nervous affections produced by 
 the war. Quar. j. med., Lond., 9: 73-82, Jan. 1916. 
 15. Beaton, Thomas. Some observations on mental conditions as 
 observed amongst the ship's company of a battleship in war time. 
 J. of Roy. nav. med. service 1: 447-52, Oct. 1915. 
 
70 MENTAL DISEASES AND WAR NEUROSES 
 
 16. Bruce, A. Ninian. Treatment of functional blindness and func- 
 
 tional loss of voice. Rev. of neurol. and psychiatry, Edin., 14: 
 195-98, 1916. 
 
 17. Burton-Fanning, F. W. Neiu-asthenia in soldiers of the home 
 
 forces. Lancet, Lond., June 16, 1917, p. 907-11. Report to 
 the Medical research committee. 
 
 18. Buzzard, E. Farquhar. Warfare on the brain. Lancet, Lond., 
 
 Dec. 30, 1916, p. 1095-99. 
 
 19. Campbell, A. W. Remarks on some neuroses and psychoses in 
 
 war. Med. j. of Australia, April 15, 1916, p. 319. 
 
 20. Campbell, Harry W. War neuroses. Practitioner, Lond., 96: 
 
 501-09, May 1916. 
 
 21. Campbell, Kenneth. Case of hysterical amblyopia. Brit. med. 
 
 j., Sept. 18, 1915, p. 434. 
 
 22. Clarke, J. Michell. Some neuroses of the war. Bristol med.- 
 
 chir. j. 34: 49-72, July 1916; also in Clin. j. 45: 381 and 395, Nov. 
 1, 1916. 
 
 23. Craig, Maurice. Psychological medicine. 3ded. Lond., Church- 
 
 ill, 1917. 496 p. illus. Chapters 15: 254-60; 16: 287-92; 
 18: 300-11. 
 
 24. Culpin, M. Practical hints on functional disorders. Brit. med. 
 
 j., Oct. 21, 1916, p. 548-49. 
 
 25. Dawson, G. de H. Case of shell concussion; treatment by general 
 
 anaesthesia. Lancet, Lond., Feb. 26, 1916, p. 463-64. 
 
 26. Disciplinary treatment of shell shock (Notes from German and 
 
 Austrian journals) Brit. med. j., Dec. 23, 1916, p. 882. 
 
 27. Eder, M. D. Psychopathology of the war neuroses. Lancet, 
 
 Lond., Aug. 12, 1916, p. 264-68. 
 
 28. Eder, M. D. War shock — the psychoneuroses in war; psychology 
 
 and treatment. Lond., Heinemann, 1917. 154 p. 
 
 29. Elliot, T. R. Transient paraplegia from shell explosions. Brit. 
 
 med. j., Dec. 12, 1914, p. 1005. 
 
 30. Emslie, Isabel. War and psychiatry. Edin. med. j. 14: 359, 1915. 
 
 31. Farrar, Clarence B. Problem of mental disease in the Canadian 
 
 army. Mental hygiene 1 : 389-91, July 1917. 
 
 32. Farrar, Clarence B. War and neuroses, with some observations 
 
 of the Canadian expeditionary force. Amer. j. of insanity 73: 
 693-719, April 1917. 
 
 33. Felling, Anthony. Loss of personality from shell shock. Lancet, 
 
 Lond., July 10, 1915, p. 63-65. 
 
 34. Fenwick, P. C. C. Enterospasm following shell shock. Practi- 
 
 tioner, Lond., 98: 391, April 1917. 
 
REFERENCES IN ENGLISH 71 
 
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 Med. rec. 90: 374, Aug. 26, 1916. 
 
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72 MENTAL DISEASES AND WAR NEUROSES 
 
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 56. Jenkins, H. E. Mental defectives at Naval disciphnary barracks. 
 
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 64. MacMahon, C. Shell shock. Practitioner, Lond., 98: 427, May 
 
 1917. 
 
 65. McMullin, J. J. A. Some observations on the examination of 
 
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 66. Marriage, H. J. War injuries and neuroses of otologic interest. 
 
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REFERENCES IN ENGLISH 73 
 
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 1915. lUus. 
 
 71. Mott, Frederick W. Effects of high explosives upon the central 
 
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 after the war (Chadwick lecture) Brit. med. j., July 14, 1917, 
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 73. Mott, Frederick W. Punctiform hemorrhages of the brain in gas 
 
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 74. Myers, Charles S. Contributions to the study of shell shock, 1-4. 
 
 Lancet, Lond., Feb. 13, 1915, p. 317-20; Jan. 8, 1916, p. 65-69; 
 March 18, 1916, p. 608-13; Sept. 9, 1916, p. 461-67; also (except 
 1) in J. of Roy. army med. corps 26: 642-55, 782-97, May and 
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 75. Natier, M. Hysterical mutism caused by shell explosion. Laryn- 
 
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 76. National committee for mental hygiene — Committee on war work — 
 
 Sub-committee on clinical methods and standardization of exam- 
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 N. Y. med. j. 106: 370, Aug. 25, 1917. 
 
 77. Nerves and war; the Mental treatment bill. Lancet, Lond., May 
 
 1, 1915, p. 919-20. 
 
 78. Nervous symptoms in wounded patients (Paris letter, Nov. 25, 
 
 1915) J. of Amer. med. assoc. 65: 2180-81, Dec. 18, 1915. 
 
 79. Nervous system in naval warfare (Editorial) Med. rec. 87: 316, 
 
 Feb. 20, 1915. 
 
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 March 18, 1917, p. 627-28. 
 
 81. Neymann, Clarence A. Some experiences in the German Red 
 
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 82. Nicoll, Maurice. Dream psychology. Lond., Hodder, 1917. p. 
 
 190. 
 
 83. O'Malley, John F. Functional aphonia. Roy. soc. med.. Section 
 
 of laryngol. Proceedings 7: 116, 1915. 
 
 84. O'Malley, John F. Warfare neuroses of the throat and ear. Lan- 
 
 cet, Lond., May 27, 1916, p. 1080-82. 
 
74 MENTAL DISEASES AND WAR NEUROSES 
 
 85. Ormond, A. W. Treatment of "concussion blindness." J. of 
 
 Roy. army med. corps 26: 43^9, Jan. 1916. 
 
 86. Osier, WUliam. Functional nervous disorders. J. of Amer. med. 
 
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 88. Paton, Stewart. MobiUzing the brains of the nation. Mental 
 
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REFERENCES IN ENGLISH 75 
 
 103. Savage, George. Mental disabilities for war service. Lancet, 
 
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 104. Schier, A. R. Review and possibilities of mental tests in the exam- 
 
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 105. Sheehan, R. Exclusion of the mentally unfit from the military- 
 
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 1917. 135 p. 
 
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 1917. 
 
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 Royal soc. med.. Section of neurol. and psychiatry. Proceedings 
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 116. Thomas, G. E. Value of the mental test and its relation to the 
 
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 118. Thomas, John Jenks. Types of neurological cases seen at a base 
 
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76 MENTAL DISEASES AND WAR NEUROSES 
 
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 134. Welch, W. H. Medical problems of the war. Johns Hopkins 
 
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 135. Whale, H. L. Functional aphonia. Roy. soc. med.. Section of 
 
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REFERENCES IN ENGLISH 77 
 
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 139. Wright, H. P. Classification of cases of so-called shell shock. 
 
 Canadian med. assoc. j. 7: 629, July 1917. 
 
 140. Yerkes, Robert Mearns. Relation of psychology to mihtary activi- 
 
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 141. Zeehandelaar, I. Letter from Berlin; study of functional neuroses 
 
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APPENDIX II 
 
 THE USE OF INSTITUTIONS FOR THE INSANE AS 
 MILITARY HOSPITALS 
 
APPENDIX II 
 
 THE USE OF INSTITUTIONS FOR THE INSANE AS MILITARY 
 
 HOSPITALS 
 
 IN January 1915, when the pressure upon the Royal Army 
 Medical Corps to provide additional hospital beds for 
 wounded soldiers became acute, the Board of Control was asked 
 by the War Office to co-operate in an attempt to secure 50,000 
 beds. All other government departments having institutions 
 under their control were also asked to assist. The Board of 
 Control formulated a plan whereby 92 county and borough asy- 
 lums were to be divided into ten groups and one institution in each 
 group vacated of its patients and turned over to the War Office 
 as a military hospital. It was planned to provide in this way 
 15,000 beds or almost one third of the total number required. 
 The methods by which this plan was put into execution were so 
 thorough and expeditious that an account of how it was done may 
 be useful to those who may be confronted with a similar task in this 
 country if the fortunes of war should demand it.* 
 
 As soon as the plans of the Board of Control had been formu- 
 lated a circular (Circular A — Use of Asylums as Military Hospitals) 
 was sent out to all chairmen and clerks of Visiting Committees 
 and all Medical Superintendents. A copy of this circular, a circu- 
 lar giving the observations of the War Office on the plan (B-Use of 
 Asylums as Military Hospitals), and the letter which accompanied 
 them follows: 
 
 A. USE OF ASYLUMS AS MILITARY HOSPITALS 
 
 Scheme, prepared by the Board of Control, for the general administration of vacated 
 asylums, and the details of reimbursement which the War Office undertakes to make to 
 receiving and vacated asylums. 
 I. Charges arising from the maintenance and treatment of sick and wounded soldiers in 
 Asylum Buildings, which the Army Council undertakes to meet. 
 
 * Very interesting articles by Lt. Col. D. G. Thomson {Journal of Mental Science, 64: 
 109-35, January 1916) and Major R. D. Hotchkis {Journal of Mental Science, 63: 245-49, 
 April 1917) give accounts of the measures taken in England and Wales to convert county 
 asylums into war hospitals and particularly of the conversion of the institutions of which 
 they were superintendents, namely, the Norfolk County Asylum and the Renfrew District 
 Asylum, respectively. In the discussion of Col. Thomson's paper {loc. cit.) other superin- 
 tendents of institutions which had been converted into war hospitals gave their expe- 
 riences. 
 
 6 81 
 
82 MENTAL DISEASES AND WAR NEUROSES 
 
 1. Vacated Astlums 
 
 (a) Charges in connection with buildings and equipment. 
 
 i. Necessary adaptations of the buildings for hospital purposes, 
 ii. Maintenance and repairs of premises. 
 
 iii. Reinstatement of premises at end of occupation by Army Council, 
 iv. Additional equipment found necessary: e. g., hospital requirements, extra 
 beds, etc. 
 Note: — All extra equipment purchased at the expense of the War Office 
 which remains in stock at the conclusion of the war, is to be regarded as the 
 property of the War Office, but may, if the asylum authorities so desire, be 
 taken over by them wholly or in part at a valuation. 
 
 (b) Charges in connection with the maintenance of staff and of soldier patients. 
 
 i. Salaries and wages, including fees to surgeons and other experts, and remun- 
 eration of other persons called in to supplement ordinary staff. 
 ii. Victualling on scales laid down by Army Council, 
 iii. Uniform for staff and clothing for patients, 
 iv. Furniture and bedding. (Renewals and repairs.) 
 V. Medicines, surgical appliances and instruments, 
 vi. Fuel, lighting, washing and other necessaries, 
 vii. Rates, taxes and insurance. 
 
 viii. Incidental expenses, including travelling, burials, etc. 
 i. Receiving Asylums 
 
 Charges in connection with the maintenance of lunatics, 
 i. Additional weekly cost of maintenance, if any. 
 ii. Equipment and stores required for additional numbers and extra cost of 
 
 maintenance and depreciation, 
 iii. Any necessary slight structural alterations necessitated by increased num- 
 bers, extra wear and tear, and reinstatement of premises. 
 3. Cost of all Necessary Travelling and Conveyance of Lunatics 
 n. General Arrangements. 
 
 1. The War Office will be solely responsible for the medical care and treatment of the 
 soldiers and the management of the hospital. 
 
 2. The asylums will be handed over as going concerns mth the whole of their staff, 
 medical, engineering, stores, farms, etc., and such part of the nursing and attendant staff 
 not needed to accompany the patients to the receiving asylums. The portion of the nurs- 
 ing staff retained at the asyliun should be that portion best suited to take up or assist in the 
 care of the sick and wounded. 
 
 3. The War Office will appoint the additional medical and nursing staff required for the 
 hospital. The visiting committee and the medical superintendent will generally, from 
 their local knowledge, be able to suggest suitable persons for employment in addition to 
 those already in War Office service. 
 
 4. Subject to the directions of the committee, the medical superintendent is the head and 
 director of the asylum administration, and in most instances, no doubt, he will be appointed 
 by the War Office to be the officer in charge of the hospital. If so appointed he wiU con- 
 tinue to exercise the general control over the institution and its staff and working, for which 
 his experience specially qualifies him. The other medical officers of the asylum will ordi- 
 narily be quaUfied and willing to become part of the medical staff of the hospital, and to 
 share the duties with the additional professional staff sent by the War Office. 
 
 5. The whole of the asylum staff is in the employment of the visiting committee by whom 
 they are appointed and by whom they can be dismissed. They are in established pension- 
 
INSTITUTIONS AS MILITARY HOSPITALS 83 
 
 able service, and it is necessary that their asylum service should be unbroken, except for 
 misconduct. If in any instance it is expedient that the head of the hospital should be an 
 officer other than the medical superintendent, it is desirable that he should delegate the 
 lay administration of the institution to the committee which, from experience and local 
 knowledge, is obviously the authority best qualified to carry it on. The medical chief will 
 thus be relieved from many laborious administrative tasks. The delegation may be subject 
 to such conditions as are thought reasonable. 
 
 6. The War Office have decided that military rank shall be conferred on the members of 
 the medical staff. If an officer of higher rank than the medical superintendent is sent to the 
 hospital, it is desirable that the general administration of the institution should be delegated 
 to the medical superintendent, or at any rate in practice left in his hands. As regards the 
 male attendants, it may be thought necessary, as has been done at the state institution at 
 Moss Side, to incorporate them in the Red Cross organization. 
 
 7. The committee will continue to make contracts for supplies, and otherwise carry on 
 the business side of the administration, will open a fresh banking account from the date 
 when the War Office are in possession, and the clerk will each mouth present to the War 
 Office an account, certified as the War Office may require, of the expenditure incurred. 
 These accounts will be audited as heretofore by the asylum auditors with any additional 
 precautions which the War Office may require. They should be transmitted to the War 
 Office through the Board of Control who, after such enquiry — if any — as they think neces 
 sary, will append their certificate that the claim is a proper one to be made on the Wa 
 Office. 
 
 The committee will be informed by the War Office what stores, etc., can be s 
 that department, and what must be contracted for locally. 
 
 The necessary funds to meet expenditure on structural alterations, additional e 
 expenses on travelling and conveyance, etc., will be advanced by the War Office as soon as a 
 decision is reached that an asylum is to be vacated. 
 
 Claims for such advances should be transmitted through the Board of Control. 
 
 B. USE OF ASYLUMS AS MILITARY HOSPITALS 
 
 Observations by the War Office supplementary to their general confirmation of the scheme 
 prepared by the Board of Control: 
 1. Vacated Astlums 
 
 (a) Charges in connection with buildings and equipment: 
 
 ii. Maintenance and repairs of premises. 
 
 In case of considerable repairs constituting permanent structural im- 
 provements, the Board of Control will no doubt be prepared to advise to what 
 extent credit can be given to the War Department for these in the final settle- 
 ment. 
 
 iii. Reinstatement of premises at end of occupation. 
 
 It is presumed that a complete inventory will be taken before occupation, 
 iv. Additional equipment. 
 
 It is presumed that complete accounts will be kept of equipment furnished 
 by, or purchased at the expense of, the War Department. 
 
 (b) Charges in connection with the maintenance of staff and of soldier patients: 
 
 i. Salaries and wages. 
 
 It is presumed that the visiting committee mil actually pay (at War Depart- 
 ment expense) the present salaries of the retained asylum staff, and any persons 
 temporarily engaged, and that the War Department will pay direct its own 
 officials. This is merely a matter of machinery, and will be pursued in the 
 
84 MENTAL DISEASES AND WAR NEUROSES 
 
 communication referred to in paragraph 7 below. The rates to be paid for 
 any persons temporarily engaged will be settled by the War (Mice. 
 
 ii. Victualling. 
 
 Presumably consumable stores taken over wiU be valued and the cost 
 credited to the asylum authorities. 
 
 It is presumed that appropriate accounts of consumables, etc., whether sup- 
 plied by the War Department or purchased on their behalf by the asylum 
 authorities will be kept, and that these accounts will be available for inspection, 
 if desired. 
 
 Medicines and medical and surgical equipment when not taken over with the 
 asylum will be provided by the War Office or under arrangements approved by 
 them. 
 
 Receipts Generally. 
 
 It is presumed that the produce of asylum farms will be available for use, 
 and that the War Department will be allowed credit for produce sold. Also the 
 War Department will receive credit for the grants received by the asylum 
 authorities in respect of any harmless patients retained for work on farms or 
 grounds, since they wiU be maintained out of general maintenance of which the 
 War Department is bearing the cost, and generally that any receipts arising out 
 of the ordinary working of those institutions while they are in use by the War 
 Department will be taken in reduction of the working expenses chargeable 
 against the War Office. 
 2. Receiving Asylums. 
 
 (i) Additional weekly cost of maintenance, if any. 
 
 It is presumed that the authorities of the vacating asylum will continue to 
 draw their grants in respect of patients transferred and of patients who would 
 be sent there but for War Department occupation, that the vacating asylum will 
 pay to the receiving asylum the weekly cost of maintenance therein, and that 
 the War Department will refund to the vacating asylum the excess in cases 
 where their grant is less than the weekly cost in the receiving asylum. 
 
 In cases in which the weekly cost is less, this department would not propose 
 that the saving should be taken into account unless the saving is of material 
 amount, in which case the charge under (ii) below should apparently be abated. 
 (ii and iii) Equipment and stores required. 
 
 It is presumed that an account will be kept of the additional equipment, and 
 that such equipment may be taken over on evacuation at a valuation as in case 
 of vacating asylum. This department will readily fall in with your views as to 
 the manner of payment for these services. 
 
 General Arrangements. 
 
 (2) If a portion of the staff is transferred to a receiving asylum, it is presumed that 
 
 the salaries will not be a charge for the War Department. 
 
 (3) After "nursing" in line 1, add "or other." 
 
 (4) After "War Office" in line 3, add "under the general officer commanding-in- 
 
 chief of the command concerned." 
 
 (6) Delete the first three lines and substitute, "If the War Office in any given case 
 should appoint an officer of senior rank to the hospital it is desirable that the 
 general. . . ." 
 
 (7) It is suggested that when an asylum is taken over, an advance be made by the 
 
 War Department on the recommendation of the Board of Control on the basis 
 of a month's (or quarter's) estimated expenditure (plus initial costs in the first 
 
INSTITUTIONS AS MILITARY HOSPITALS 85 
 
 instance) and that periodical accounts should be rendered to the War Depart- 
 ment through the Board of Control as suggested. A further communication 
 will, however, be addressed to the Board of Control as regards the procedure 
 in rendering accounts, but this department will be prepared to make advances 
 as soon as desired. 
 
 "The Board of Control, 
 66 Victoria Street, S. W., 
 
 10th March, 1915. 
 Sir: 
 
 I am directed by the Board of Control to transmit to you a copy, "A," of the scheme 
 prepared by the board for the general administration of the vacated asylums, and the 
 details of reimbursement which the board suggested the War Office should undertake to 
 make to receiving and vacated asylums. 
 
 The board, on the 6th instant, received from the War Office a letter expressing the general 
 concurrence of the Army Council with the detailed financial arrangements mentioned 
 above. A statement was enclosed setting forth some minor points on which it appeared to 
 the Army Council desirable to arrive at a clearer understanding, and on which they thought 
 the statement might perhaps with some advantage be modified. It was also added that 
 the actual details regarding staff requirements, technical equipments, and the like, mil be 
 settled by arrangement i\-ith the War Office in each particular case. 
 
 A copy of the War Office statement — marked "B" — is herewith enclosed. It is to be 
 observed that on page 1, under "Receipts Generally" the ^^ew is entertained that the 
 accounts of the farm at the vacated asylum would be included in those of the War Office. 
 The board, however, contemplated that the asylum farms would be managed by the visit- 
 ing committees; that the accounts would be kept separately from those relating to sick and 
 wounded soldiers; and that supplies of vegetables and other produce to the hospital would 
 be charged for at reasonable prices, say current market rates, and would be debited to the 
 War Office account. Inasmuch as many of the farms are big enterprises with considerable 
 stock (both live and dead) the board think that this course would be preferable and gener- 
 ally more equitable than the alternative of including the entire farm accounts in the ac- 
 coimts for soldiers. The War Office have, however, stated that either of these alternative 
 methods would be agreeable to them; it is a point that easily lends itself to adjustment be- 
 tween now and the date when the asylums are handed over. 
 
 The board agree that it would be right that expenditure in respect of harmless lunatic 
 patients retained at the hospital should be charged in the War Office account and that 
 credit should be taken therein of all sums received from guardians in respect of their 
 maintenance. The effect of this arrangement will be that no charge will fall on the War 
 Office. 
 
 Under No. 6, on page 2, the board understand that the War Office are prepared to grant 
 military rank to certain members of the medical staff, and that the omission of the words 
 "The War Office . . . Medical Staff" in the first lines was not intended to affect the 
 decision. 
 
 With regard to the second paragraph on page 2 commencing "In cases in which the 
 weekly cost is less ..." the board, as some of their members have explained when 
 this question has come up at conferences, are of the opinion that the Lunacy Act appears 
 to require that not more than the actual cost of maintenance be claimed from the guardians, 
 and if this principle is adhered to the question of an abatement to the War Office — as 
 referred to in this paragraph — will not arise. 
 
 The board have given carefij consideration to all the points set out in the War Office 
 statement. They are of the opinion that none of them conflicts with any of those in the 
 
86 MENTAL DISEASES AND WAR NEUROSES 
 
 board's scheme. The latter was based on the conditions upon which the various asylum 
 authorities so w-illingly promised their assistance, and the board have confidence that they 
 will agree that the interests of the ratepayers and the position of the visiting committees 
 have been amply and properly safeguarded. 
 
 In gladly accepting the offer of the nine asylums to be vacated, the War Office have stated 
 how much they appreciate, not only the willingness of the authorities and staff of those in- 
 stitutions to place them at their disposal, but also the hearty co-operation of the authorities 
 and staff of all the receiving asylums, without which they realize that the scheme would not 
 have been practicable. 
 
 I am. 
 Sir, 
 Your obedient Servant, 
 
 (Signed) O. E. Dickinson, 
 Secretary." 
 
 The first employment of this plan made about 12,000 beds 
 available. Since then additional institutions under the Board of 
 Control, and under the boards exercising similar functions in 
 Scotland and Ireland, have been taken over for military purposes. 
 On July 1, 1917, twenty-one such institutions with a total capacity 
 for military patients of 27,158, had been made available for the 
 use of the War Office. A list of these institutions showing their 
 capacity as civil institutions and as military hospitals and indicat- 
 ing those which have been used for mental and nervous cases 
 is given on the following page. 
 
 In all cases, even where the military hospital was to be used for 
 insane soldiers, the name was changed "to escape the asylum 
 tradition." This is a pathetic reminder of the stigma which still 
 clings to mental diseases and institutions for their care in England. 
 The old names of these institutions with their "asylum traditions" 
 are still good enough for the wives, mothers and daughters of 
 soldiers. It is earnestly hoped by the men in England who are 
 striving to change this popular attitude toward mental illness that, 
 when the war is over, the new names will be retained and the 
 word "asylum" will be permanently replaced by the word "hos- 
 pital." 
 
 The transfer of upwards of 15,000 insane patients was success- 
 fully and safely made, although not without distressing incidents. 
 Col. Thomson said that in his institution he was surprised to see 
 the attachment which old patients felt for the place which had 
 been their home for so many years — in some cases from childhood. 
 The other institutions were able to absorb these great additions 
 to their population but only with considerable inconvenience and 
 
INSTITUTIONS AS MILITARY HOSPITALS 
 
 87 
 
 County and Borough Asylums which have been Vacated of their 
 Patients and Converted into Military Hospitals, 
 July 1,1917 
 
 
 
 Capacity 
 
 Former name 
 
 Present name 
 (as a military hospital) 
 
 
 
 (as a civil institution) 
 
 
 
 
 
 Former 
 
 Present 
 
 England: 
 
 
 
 
 Newcastle-on-Tyne City Asy- 
 
 The Northumberland War 
 
 
 
 lum, Gosforth, Newcastle- 
 
 Hospital. 
 
 884 
 
 1,179 
 
 on-Tyne. 
 
 
 
 
 West Riding of Yorks Asylum, 
 
 The Wharneliffe War Hospital 
 
 1,699 
 
 2,265 
 
 Wadsley (New Sheffield). 
 
 
 
 
 Lancashire County Asylum, 
 
 *The Lord Derby War Hospital 
 
 2,248 
 
 2,997 (1) 
 
 Winwick, Warrington. 
 
 
 
 
 Birmingham City Asylum, 
 
 The 1st Birmingham War' 
 
 
 
 Rubery Hill, Birmingham. 
 
 Hospital. 
 
 1,397 
 
 2,363 
 
 Birmingham City Asylum, 
 
 The 2d Birmingham War 
 
 
 
 Hollymoor, Birmingham. 
 
 Hospital. 
 
 
 
 Norfolk County Asylum, 
 
 The Norfolk War Hospital. 
 
 1,045 
 
 1,393 
 
 Thorpe, Norwich. 
 
 
 
 
 West Sussex Asylum, Chi- 
 
 The Graylingwell War Hospital. 
 
 729 
 
 972 
 
 chester. 
 
 
 
 
 Bristol County and City Asy- 
 
 The Beaufort War Hospital. 
 
 937 
 
 1,249 
 
 lum, Fishponds, Bristol. 
 
 
 
 
 London County Asylum, Hor- 
 
 The Horton (County of London) 
 
 2,174 
 
 2.899 
 
 ton, Epsom. 
 
 War Hospital. 
 
 
 
 Middlesex County Asylum, 
 
 tThe County of Middlesex War 
 
 
 
 Napsbury, St. Albans. 
 
 Hospital. 
 
 1,800 
 
 1,520 (2) 
 
 Middlesex County Asylum, 
 
 *The Springfield War Hospital. 
 
 250 
 
 278 
 
 near Tooting, London, S.W. 
 
 
 
 
 (block for defective chil- 
 dren). 
 Northampton County Asylum, 
 
 
 
 
 Northamptonshire War Hospi- 
 
 997 
 
 1,329 
 
 Berrywood, Northampton. 
 
 tal. 
 
 
 
 The Maudsley Hospital, Den- 
 
 tPart of the 4th London General 
 
 
 
 mark Hill, London, S.E. 
 
 Military Hospital. 
 
 (3) 
 
 200 
 
 Lancashire County Asylum, 
 
 Whalley. 
 Hampshire County Asylum, 
 
 Queen Mary Military Hospital. 
 
 (4) 
 
 3,000 
 
 Park Prewett War Hospital. 
 
 (4) 
 
 1,000 
 
 Park Prewett. 
 
 
 
 
 Moss Side State Institution, 
 
 *Moss Side Red Cross Military 
 
 
 
 Maghull (near Liverpool). 
 
 Hospital. 
 
 (5) 
 
 345 
 
 London (Manor) County Asy- 
 
 Manor (County of London) War 
 
 
 
 lum, Epsom. 
 
 Hospital. 
 
 1,085 
 
 1,447 
 
 Wales: 
 
 
 
 
 Cardiff City Asylum, Whit- 
 
 The Welsh Metropolitan War 
 
 729 
 
 972 
 
 church, Cardifi. 
 
 Hospital. 
 
 
 
 Scotland: 
 
 
 
 
 Renfrew District Asylum, 
 
 Paisley. 
 Perth District Asylum. 
 
 fThe Dykebar War Hospital. 
 
 
 850 
 
 tThe Murthley War Hospital. 
 
 (?) 
 
 400 
 
 Ireland: 
 
 
 
 
 The Belfast District Asylum. 
 
 fThe Belfast War Hospital. 
 
 (?) 
 
 500 
 
 Belfast. 
 
 
 
 
 * For nervous cases. f For mental cases. t For mental and nervous cases. 
 
 (1) 1,000 beds for mental cases. (2) 350 beds for mental cases, (3) New psycho- 
 pathic hospital; never occupied. (4) New institution for the insane; never occupied. 
 (6) New institution for mentally defective delinquents; never occupied. 
 
88 MENTAL DISEASES AND WAR NEUROSES 
 
 some hardships. A few patients were taken home by their 
 friends. Partly as a result of the inability of the overcrowded 
 institutions to take new cases except in emergencies and partly as 
 a result of the reluctance of relatives to send patients to distant 
 institutions, the admission rate from the civil population of 
 England, Scotland and Ireland has shown a considerable reduc- 
 tion. In the United States we have ample evidence of the effect 
 upon the admission rate of the standard of care provided by 
 public institutions and have seen how easy it is, in states which 
 shirk their responsibilities in this matter, to force the insane back 
 upon their homes. In many of the hospitals from twenty to 
 eighty of the quiet male patients able to work remained — usually 
 in detached villas. Such patients are happy and carry on the 
 work with which they are familiar in the novel surroundings of a 
 military hospital. 
 
 The total cost of turning over these institutions was not as- 
 certained. In the case of the Norfolk Asylum it was $90,000.00. 
 
 The capacity of the institutions was almost invariably increased, 
 the average ratio being 4 :3. This is due to the fact that most of 
 the day rooms could be used as wards and dormitories, so large a 
 proportion of medical and surgical patients being bed patients. 
 
 A revolution came into the lives of the personnel of these in- 
 stitutions. The medical superintendents, with one exception, 
 were left in charge of their institutions, receiving commissions as 
 lieutenant colonel or major (temporary) in the Royal Army 
 Medical Corps. Some of the junior physicians who were com- 
 missioned in the Army were retained at their hospitals. A way 
 of "doing their bit" was provided for the male attendants through 
 their enlistment in the Royal Army Medical Corps under a special 
 arrangement. This solved for the superintendents the perplexing 
 problem of keeping their employees. Responsible employees be- 
 came non-commissioned officers, and some helpers, ineligible for 
 military service, were retained as civilian employees. The 
 female attendants became probationers in the nursing corps. In 
 most cases the change was satisfactory. Many of the younger 
 women have been attracted by the work of general nursing and 
 will probably complete their training after the war. All will be 
 better attendants for the training they have received.- In the 
 case of a few older female attendants who had not had the ad- 
 
INSTITUTIONS AS MILITARY HOSPITALS 89 
 
 vantage of a regular nurses' training but had filled places of re- 
 sponsibility, some friction developed. The general spirit, how- 
 ever, has been that of hearty good-will in the new work. This 
 has been due in large measure to the great part which the war has 
 come to play in the lives of Englishmen and Englishwomen and 
 the deep feeling of obligation to serve their country which in- 
 spires people in all stations of life. It is very doubtful if such an 
 enormous and difficult task as the conversion of these institutions 
 to another purpose could have been successfully accomplished 
 without patriotic submergence of self-interest by officers and 
 employees. 
 
 In the institutions which are used as military hospitals for 
 mental cases (see list, p. 87) the changes made were less radical. 
 The War Office agreed to pay each member of the staff his normal 
 salary except in the few instances in which this was less than the 
 compensation of the new rank, in which case the latter amount 
 was paid. The female attendants presented a difficult problem 
 in these hospitals, as female attendants are not yet generally 
 employed in male wards in English hospitals for mental diseases. 
 In one hospital (Dykebar) it was found possible to staff several 
 wards with female nurses although a male orderly is on duty in 
 each. Bed cases are cared for in this hospital by female nurses. 
 A detached villa for convalescent patients is entirely in charge of 
 female nurses. Another villa in this hospital was entirely staffed 
 with female nurses but the type of patients was not just suitable 
 and further complications arose from the fact that the charge 
 nurse married a patient upon his discharge and this interfered 
 with conditions apparently necessary for good discipline. Other 
 wards in the hospital have female nurses and they are assigned 
 to the distribution of food. At night the whole insliitution is 
 under an assistant matron who has three female assistants, a 
 sergeant and ten male orderlies. One outcome of the conversion 
 of the institutions seems likely to be the employment of female 
 nurses in men's wards in civil institutions in England. No one 
 who has seen the success with which this is done in the United 
 States and its rapid extension as a result of its efficiency and the 
 increasing difficulty of securing good male attendants will regret 
 it. 
 
 The impression one gets in visiting the military hospitals which 
 
90 MENTAL DISEASES AND WAR NEUROSES 
 
 have been created out of civil institutions for the insane is that an 
 enormously diflBcult task has been accomplished in a wonderfully 
 efficient way. Great credit for this is due to the Board of Control 
 for the thoughtful planning of the transfer in advance, but its 
 success is due also to the remarkable unanimity with which visiting 
 committees, medical superintendents and employees co-operated 
 in removing obstacles and subordinating all other considerations to 
 the successful solution of the entirely unprecedented problem 
 before them. Most of the institutions are of the cottage type 
 with many small detached buildings. They have proved exceed- 
 ingly desirable general hospitals and it is doubtful whether any 
 other institutions in England would have provided such excellent 
 facilities for ill and wounded soldiers. Nevertheless one's thoughts 
 turn to the helpless insane, never too well provided for, who were 
 turned out of their hospitals and whose comfort as well as chances 
 for recovery must have been seriously impaired by the change. 
 The necessity was so great that these considerations could not be 
 taken into account. If similar pressure comes to the United 
 States and the interests of the insane or any other helpless group 
 must be subordinated to the great object of winning the war, we 
 shall have no choice, but we cannot help feeling that the task of 
 vacating half the beds in the state hospitals of a state like New 
 York would be undertaken with a heavy heart by those who know 
 the needs of the insane, and who realize how little they share, 
 even in time of peace, in the provisions which mitigate the sufiFer- 
 ings of other ill persons. 
 
APPENDIX III 
 
 SPECIAL MILITARY HOSPITALS FOR MENTAL DIS- 
 EASES AND WAR NEUROSES ("SHELL SHOCK") 
 IN GREAT BRITAIN AND IRELAND 
 
 1. DIRECTORY 
 
 2. DESCRIPTIONS OF INSTITUTIONS VISITED 
 
APPENDIX III 
 
 SPECIAL MILITARY HOSPITALS FOR MENTAL DISEASES 
 
 AND WAR NEUROSES ("SHELL SHOCK") IN 
 
 GREAT BRITAIN AND IRELAND 
 
 1. DIRECTORY 
 The hospitals in the following list and descriptions are all special 
 hospitals for the treatment of mental diseases and war neuroses. Neuro- 
 logical departments in general hospitals, as those in the Royal Victoria 
 Hospital, Edinburgh, and the territorial hospitals in England, Scotland 
 and Wales, are not included. The Royal Victoria Hospital, Netley, 
 is included on account of the fact that the department is a clearing hos- 
 pital. 
 
 ENGLAND 
 
 Present name: County of Middlesex War Hospital 
 
 Former name: Middlesex County Asylum 
 
 Location: Napsbury (near St. Albans) 
 
 Name deft, for ment. or nerv.: No special name 
 
 Classes of cases received: Mental diseases (no officers) 
 
 Officer in charge of ment. or nerv. deft.: Lt. Col. (T.) L. Rolles- 
 
 ton 
 Cafodty: 
 
 Mental disease 350 
 
 War neuroses 
 
 Total 350 
 
 Present name: The First Home of Recovery (Branch of Maida 
 
 Vale Hospital for Nervous Diseases) 
 Former name: "Highfields" (a girls' school) 
 Location: Golder's Green, London 
 Name deft, for ment. or nerv.: Whole hospital utiHzed 
 Classes of cases received: War neuroses (pensioners only) 
 Officer in charge of ment. or nerv. deft.: Capt. (T.) — Scott 
 Cafacity: 
 
 Mental disease 
 
 War neuroses 150 
 
 Total 150 
 
 93 
 
94 MENTAL DISEASES AND WAR NEUROSES 
 
 Present name: Fourth London General Hospital 
 
 Former name: Kings College Hospital and Maudsley Hospital 
 
 Location: Denmark HiU, London 
 
 Name depts.fcrr meni. or nerv.: "Maudsley Hospital" \ clearing 
 
 "Maudsley extension" J hospital 
 
 Classes of cases received: War neuroses (officers included) 
 
 Officer in charge of ment. or nerv. deft.: Major (T.) F. W. Mott, 
 R.A.M.C. 
 
 CaTpadty: 
 
 Mental disease 27 
 
 War neuroses 447 
 
 * 
 
 Total 474 
 
 Present name: Granville Canadian Special Hospitalf 
 
 Former name: Granville Hotel 
 
 Location: Ramsgate 
 
 Name dept. for ment. or nerv.: "Medical Department" 
 
 Classes of cases received: War neuroses (no officers) 
 
 Officer in charge of ment. or nerv. dept.: Major Colin Russell, 
 
 C.A.M.C. 
 Capacity: 
 
 Mental disease 
 
 War neuroses 440 
 
 Total 440 
 
 Present name: Letchmere House 
 
 Former name: A private institution 
 
 Location: Ham Common, London 
 
 Name dept. for ment. or nerv.: Whole hospital utiUzed 
 
 Classes of cases received: Mental diseases (officers only) 
 
 Officer in charge of ment. or nerv. dept.: Major (T.) N. H. 
 Ohver, R.A.M.C. 
 
 Capacity: 
 
 Mental disease 50 
 
 War neuroses 
 
 Total 50 
 
 *200 in Maudsley Hospital. 
 
 ■fTo be abandoned and patients sent directly to Canada. 
 
SPECIAL MILITARY HOSPITALS 95 
 
 Present name: Lord Derby War Hospital 
 
 Former name: Lancashire County Asylum 
 
 Location: Warrington (near Liverpool) 
 
 Name deft, for ment. or nerv.: No special name 
 
 Classes of cases received: Mental diseases (no officers) 
 
 Officer in charge of ment. or nerv. dept.: Lt. Col. (T.) Alexander 
 
 Simpson, R.A.M.C. 
 Capacity: 
 
 Mental disease 1,000 
 
 War neuroses 
 
 Total 1.000 
 
 Present name: Red Cross Military Hospital 
 
 Former name: Moss Side State Institution 
 
 Location: Maghull (near Liverpool) 
 
 Name dept. for ment. or nerv.: Whole hospital utilized 
 
 Classes of cases received: War neuroses (Annex for 31 officers) 
 
 Officer in charge of ment. or nerv. dept.: Major (T.) R. G. Rows, 
 
 R.A.M.C. 
 Capacity: 
 
 Mental disease 
 
 War neuroses 377 
 
 Total 377* 
 
 Present name: Royal Victoria Hospital 
 
 Former name: Same 
 
 Location: Netley 
 
 Name dept. for ment. or nerv.: "D Block" for mental diseases; 
 
 "Neurological Wards" for war neuroses 
 Classes of cases received: Mental diseases and war neuroses 
 
 (including officers) 
 Officer in charge of ment. or nerv. dept.: Major (T.) C. Stanford 
 
 Ross, R.A.M.C. for "D Block" and Major (T.) A.,W. 
 
 Hurst, R.A.M.C. for "Neurological Wards." 
 Capacity: 
 
 Mental disease 128 
 
 War neuroses 113 
 
 Total 241 
 
 *Includiiig 31 beds for officers in annex. 
 
96 MENTAL DISEASES AND WAR NEUROSES 
 
 Present name: Special Hospital for Officers 
 
 Former name: A private home 
 
 Location: 10-11 Palace Green, London 
 
 Name dept. for ment. or nerv.: Whole hospital utilized 
 
 Classes of cases received: Mental diseases and war neuroses 
 
 (officers only) 
 Officer in charge of ment. or nerv. dept.: Major (T.) J. C. Wood, 
 
 R.A.M.C. 
 Capacity: 
 
 Mental disease 10 
 
 War neuroses 73 
 
 Total 83 
 
 Present name: Springfield War Hospital 
 
 Former name: Department of Middlesex County Asylum 
 
 Location: Upper Tooting, London 
 
 Name dept. for ment. or nerv.: Springfield War Hospital 
 
 Classes of cases received: War neuroses (no officers) 
 
 Officer in charge of ment. or nerv. dept.: Major (T.) Reginald 
 
 Worth, R.A.M.C. 
 Capacity: 
 
 Mental disease • 
 
 War neuroses 255 
 
 Total 255 
 
 SCOTLAND 
 
 Present name: Craiglockhart War Hospital 
 Former name: "Edinburgh Hydropathic" (a private institu- 
 tion) 
 Location: Slateford (near Edinburgh) 
 Name dept. for ment. or nerv.: Whole hospital utilized 
 Classes of cases received: War neuroses (officers only) 
 Officer in charge of ment. or nerv. dept.: Major (T.) W.H. Bryce, 
 
 R.A.M.C. 
 Capacity: 
 
 Mental disease 
 
 War neuroses 174 
 
 Total 174 
 
SPECIAL MILITARY HOSPITALS 97 
 
 Present name: Dykebar War Hospital 
 
 Former name: Renfrew District Asylum 
 
 Location: Paisley 
 
 Name dept. for ment. or nerv.: Whole hospital utilized 
 
 Classes of cases received: Mental diseases (no officers) 
 
 Officer in charge of ment. or nerv. dept.: Major (T.) R. D. 
 Hotchkis, R.A.M.C. 
 
 Capacity: 
 
 Mental disease 500 
 
 War neuroses 
 
 Total 500 
 
 Present name: Dykebar War Hospital Annex 
 
 Former name 
 
 Location: Paisley 
 
 Name dept. for ment. or nerv.: Whole hospital utilized 
 
 Classes of cases received: Mental diseases (no officers) 
 
 Officer in charge of ment. or nerv. dept.: Major (T.) R. D. 
 Hotchkis 
 
 Capacity: 
 
 Mental disease 350 
 
 War neuroses 
 
 Total 350 
 
 Present name: Miuthley War Hospital 
 
 Former name: Perth District Asylum 
 
 Location: Perth 
 
 Name dept. for ment. or nerv.: Whole hospital utilized 
 
 Classes of cases received: Mental diseases (no officers) 
 
 Officer in charge of ment. or nerv. dept.: Major (T.) Lewis Bruce 
 
 Capacity: 
 
 Mental disease 350 
 
 War neuroses 
 
 Total 350 
 
98 MENTAL DISEASES AND WAR NEUROSES 
 
 IBEIiAJKD 
 
 Present name: Military Hospital 
 
 Former name: Belfast County Asylum 
 
 Location: Belfast 
 
 Name deft, for ment. or nerv.: * 
 
 Classes of cases received: Mental diseases and war neuroses 
 
 Officer in charge of ment. or nerv. dept.: * 
 
 Capacity: 
 
 Mental disease 500 
 
 War neuroses * 
 
 Total * 
 
 2. DESCRIPTIONS OF HOSPITALS VISITED 
 
 Descriptions of special hospitals with detailed accounts of their work 
 cannot be given in the copies of this report which are to be generally 
 distributed, as these hospitals were visited, with the official consent of 
 the British War Office, for the sole purpose of making observations likely 
 to be useful to American miUtary hospitals of similar character. 
 
 •Unascertained. 
 
APPENDIX rV 
 
 FACILITIES NEEDED FOR EFFICIENT TREATMENT 
 
 OF MENTAL DISEASES IN A MODERN PUBLIC 
 
 INSTITUTION 
 
APPENDIX IV 
 
 FACILITIES NEEDED FOR EFFICIENT TREATMENT OF MEN- 
 TAL DISEASES IN A MODERN PUBLIC INSTITUTION 
 
 FOR the treatment of any class of the sick these fundamental 
 provisions are required: sanitary housing, good food, good 
 clothing, skill, kindliness and appreciation of the aims of the 
 hospital on the part of all those charged in any way with the care 
 or supervision of patients. These fundamental provisions must 
 be made effective by a sound administrative system, free from 
 political or other selfish control, in which the medical and scientific 
 purposes of the hospital are primary considerations. With these 
 provisions constituting the absolutely essential ground work for 
 the treatment of any class of the sick, the following may be stated 
 to constitute the facilities needed for the modern treatment of 
 mental diseases in a public institution for the insane : 
 
 1. Direction of the administration of the hospital and leader- 
 ship in its medical work by a physician trained in the diag- 
 nosis and treatment of mental diseases. 
 
 2. An adequate medical staff, organized so that duties are divided 
 in accordance with the training of its different members and 
 with the requirements of the clinical work. 
 
 3. Regular and frequent conferences of the medical staff at 
 which the diagnosis, treatment and prognosis of each new 
 case admitted are considered and at which cases about to be 
 discharged are presented, training in psychiatry for new 
 members of the staff being considered a special object. 
 
 4. The reception of all new cases in a special department or in 
 special wards where they may receive careful individual study 
 and where those with recoverable psychoses may receive con- 
 tinuous individual treatment. 
 
 5. Classification of all patients with reference to their special 
 needs and their clinical condition, such classification being 
 flexible enough to permit frequent changes. 
 
 6. A system of clinical records which permits study and review 
 of the history of cases even after they have been discharged. 
 
 7. A laboratory in which some of the more useful tests required 
 for the study and diagnosis of mental diseases as well as for 
 
 101 
 
102 MENTAL DISEASES AND WAR NEUROSES 
 
 those required in general clinical diagnosis can be made and 
 in which pathological material can be studied. 
 
 8. Provision for special treatment such as hydrotherapy and 
 electrotherapy. 
 
 9. Provision for examination and treatment by dentists, opthal- 
 mologists, gynecologists, and other specialists. 
 
 10. An adequate number of trained nurses and the maintenance 
 of a school for nurses, under the direction of a supervisor of 
 nurses who should have not only training in general niu-sing 
 but special training in nursing patients with mental diseases. 
 
 11. The employment of female nurses in the reception and infirm- 
 ary wards for men. 
 
 12. The systematic use of occupations, for their therapeutic effects 
 under the direction of workers specially trained for this duty. 
 
 13. Special attention to recreation and diversion, with reference 
 to their therapeutic value. 
 
 14. Liberal use of parole especially for quiet, chronic patients who 
 can live in farmhouses. 
 
 15. Special provision for the tuberculous. 
 
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