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In gatherings of men of the size of our military campsfrom 20,000 to 40,000—it is inevitable that illness should arise. For the care of those who become sick there are not only the regimental infirmaries, but also the base hospitals. It is at the latter that the nervous and mental cases can best be cared for, and where part of the work of the psychiatrist lies.
Because the military camps exist to train men for fighting they must eliminate as rapidly as possible those who cannot be so trained. The army must keep its decks clear of incumbrances, of the inefficient. Hence, just as soon as it is determined that a man cannot make a good or enduring soldier, he is discharged. The medical department in these camps does not yet undertake the prolonged care or reconstruction of those citizens who come to camp with conditions which may need more or less prolonged care, unless there is a good chance that the man will eventually be made efficient as a soldier. That is civilian work at present. The attitude will be different, however, towards the men who have seen service, have given health or limbs to the cause, and have become invalided. These men will be cared for in the reconstruction hospitals or camps, presumably, for as long a time as they may need such care. If reconstruction departments shall be added to the base hospitals of the military camps, it is possible that the men who, on coming from civil life and before they have seen service, have chronic conditions needing long care and treatment, will be taken care of in the reconstruction department. Many reconstruction hospitals will be established quite independently of the military camps, however, for they need the proximity of industrial and educational facilities. But because of the advisability of continuing in them the military discipline and atmosphere, some will probably be established in connection with the base hospitals of the military camps, where that atmosphere is so prevalent. But it is doubtful if even then wards will be established for more than emergency work for the strictly psychiatric cases, as it will probably be found that special hospitals for these cases or the civil hospitals for the insane already established can take care of them more adequately. In saying this I am expressing only my own personal opinion and not any official judgment or plans.
I. In the military camps, as distinguished from the reconstruction camps that may be established, the work of the psychiatrists falls into four main types, of which two are in the line, and two at the base hospital.
1. Educative.-This war has brought about many innovations, and among them is a consideration of the individuality and of the mental and nervous condition of the prospective soldier. But the line officer does not always appreciate this nor know what things to be on the lookout for in order to detect the indications of such abnormal conditions in the men as may be detrimental to the service. So a part of the work of the psychiatrist is to give talks to the line officers, telling them how the various mental and nervous conditions interfere with the making or the dependability, or the endurance or the efficiency of the soldier, and what types of behavior he should be on the lookout for. Their cooperation in looking for these conditions and sending men for examination or observation is asked for. Some are very much interested and cooperate, others think it all nonsense, others are indifferent. Such talks have to be arranged for with the regimental commanders. If one wishes to talk to the medical officers only, the arrangements are made with the division surgeon. But it is advisable to talk to the non-medical officers as well, and even to the non-commissioned officers, for they see much more of the men than the medical officers do. Such educative propaganda will have its far-reaching effects in civil life after the war is over, and I regard it as a very valuable opportunity to spread such suggestions in the community as that there are great individual differences in men and that the law-breaker, for example, may be a mental defective who needs different treatment from that of a non-defective, and other more advanced ideas relating to the non-efficient class.
2. Survey.--An important work of the psychiatrist is to make a survey of the whole personnel of the camp. The ideal way to do this would be to have the recruits on arrival at camp come into special barracks where they could be held before being assigned to any organizations until the various special examiners could go over them at reasonable leisure. An approximation to this plan is made by having the recruits very hastily surveyed by the examiners as fast as they come in. The men are stripped and run the gauntlet of the various specialists. The examinations must be very superficial when over 1500 men are looked over in a day. Many slip through with defects which are detected some time later who would have been eliminated in the first place if only half the number were examined in the same period of time. Four neuropsychiatrists have been able to make a superficial examination as fast as the other examiners were making theirs.
Before even this plan was adopted, and wherever it has not yet been put into practice, a survey of the personnel, regiment by regiment, is made when possible. It is necessary to secure the cooperation of the commanding officer of the regiment for this. It is sometimes easily secured, sometimes he resents it as an interference with his work of training soldiers because it takes the men away from their work. Whenever possible it is advisable to make the survey in cooperation with the tubercular or other examiners, for example, as it causes much less loss of the soldiers' time. After the commanding officer gives his cooperation, arrangements are made with the regimental surgeon and the adjutant to have the men of a given company remain in barracks or report at the regimental infirmary at a given time. There the psychiatric examiners go over each man, testing pupillary and tendon reflexes, coordination and station, looking for tremors and for scars suggestive of epilepsy, and asking a few questions as to heredity, environment, schooling, convulsions, or nervous break-downs, meanwhile noticing any peculiarities. Under the most favorable conditions, with a roster of the company, and a clerk to check off the names and put down findings, one examiner can make a fairly thorough preliminary survey of from 150 to 200 men a day, according to their quality. But in actual practice that number cannot be examined on an average, because of time lost in going from one organization to another, changes in daily orders in the organization, misunderstandings, etc. It was found at Camp Sherman that making allowances for Sundays, holidays and unexpected interruption, interferences, and delays, one examiner could be counted on to go over about 2800 to 3000 men a month. The time available and the size of the command will determine the number of examiners needed to complete a survey in a given time.
This type of survey is unsatisfactory for it can never be complete. Men are transferred out from a company that has been examined and men from unexamined units are often put in to fill up the organization, and it is difficult for the examiners to go back and pick up these men.
3. Observation and Diagnosis.-In such survey there is not time to make thorough examinations, and some cases need continuous observation. All cases that cannot be decided on at the preliminary survey are referred to the base hospital, either to be admitted as patients for observation or to be examined thoroughly at greater leisure. The psychiatrist at the base hospital sees these men, makes careful examinations, often spending an hour or two at a time on one patient, applying Binet or other tests where needed. He writes for information to relatives, employers, or attending physicians; or gets information as to the man's behavior from commissioned or non-commissioned officers or privates, with a view to getting such data as may help in the diagnosis of epilepsy, mental deficiency, peculiarities, malingering, etc. It has been found very helpful to have a non-commissioned officer go to the patient's company to make inquiries about his general adaptive reactions or about some special incidents.
Besides the cases thus referred by the surveying examiners, there are sent over to the base hospital by the line officers patients in whom they suspect evidences of nervous or mental disease. In the camps where psychological surveys have been made, the psychologists have also referred cases to the psychiatrists. These cases are examined in the same way as those sent by the psychiatric surveyors.
In addition to these many cases are seen in consultation in the other wards of the base hospital. Many of these are neurasthenics, in whom the question of malingering arises. Sometimes the advisability of operating on a given patient comes up, as, for example, in a case of hernia in a defective. If he is too deficient mentally to make a good soldier, operation is advised against.
Another group of cases that comes before the psychiatrist is that of the men who have been arrested for various offencesstealing, desertion, repeated absence without leave, etc.—in order to determine their responsibility for their acts, and whether or not they should be brought to trial by court martial. In one case
that recently occurred a man had already been convicted for refusal to be operated on for hernia. Before sentence was passed, however, the question of his mental ability was raised, and it was found that he was about nine years old developmentally. He was not sentenced, but discharged from the army.
4. Treatment.—The cases of mental disease arising among the men, such as manic or depressive states, dementia præcox, acute alcoholism, delirium tremens, etc., have to be taken care of and treated until some adequate disposition can be made of them. It falls, of course, to the psychiatrist to exercise the care of these, as well as of the cases sent for observation or special examination. The psychiatrist has to determine whether the patient should be allowed to go home, or should be sent to an institution for the care of the insane; also, whether he can be allowed to go home alone or must be accompanied by one or more persons. And if the patient goes to a hospital, the psychiatrist should prepare and send adequate records of the case.
5. Discharge. Since the vast majority of the men who are found to have some nervous or mental disease or defect are incapable of making good soldiers or of enduring without breaking down the stresses of warfare, they have to be discharged. It is part of the work of the psychiatrist to make the recommendations for discharge, giving the diagnosis, and stating how the condition interferes with the man's performing general military service. In some camps the psychiatrist makes his recommendation to a general disability board, of which he may or may not be a member. At Camp Sherman three of the psychiatrists themselves constituted a disability board. This gave an opportunity to hold conferences over the cases, to which the other neuropsychiatric examiners and sometimes other physicians were invited.
The judgment as to whether a case should be discharged or retained in the service has often been a puzzling one to make. The decision would be easier if there were no border-line cases. Two recent policies have served to help greatly in this matter. On April 2, 1918, an order from the adjutant general directed that border-line cases in any field) will not be discharged, but that their service records will be endorsed “ fit for domestic service only.” And the surgeon general wrote on May 11, 1918, that it was the opinion of that office that there were no border