Part 40

For myself, I am convinced that there is no case, excepting those that have gone on to the degenerate class of diseases, which usually appear after fifty, but has some physical derangement the overcoming of which may help very materially in the curing of the case.

So I would like to emphasize this thought: that you have not exhausted the service that you can render, you have not relieved yourselves of the responsibility, you have not acted as loyal doctors of modern times should have acted, excepting that you take the greatest care in the preliminary examination of these patients.

And then I would like to emphasize also that your preliminary examination, by comparison with frequently recurring examinations, so long as they are under your observation, will help you very materially.

I wish you to know that I am impressed with this idea. This is what I believe:

That many of these cases that come to you will be better off outside of institutions than in them, and I want you all, all of you, to help us to try and correct this impression that is now existing, that the Government does not give this class of cases proper attention.

If the Government is not giving them proper attention, it is not because of their disposition to do so, but it is because they have not had time enough to develop resources by which they can handle these cases well.

I would feel that I have not performed my function here as a doctor if I did not say to you to be thus careful in your diagnosis and then help to work out a plan whereby, if this subject cannot be made well, he can at least be made more self-dependent. Use all of your influence to help to cite where these men can find niches into which they can go and make it possible through the influence you can bring to bear upon the people who are associated and connected with them that they are better when they really are established in their homes. There is no case in the world that is more unfairly treated than the neuro-psychiatric case. We all know that by many experiences and observations. So let us give particular and special attention to this subject.

They say to us we have no specialists in this line. I am not so sure but we are better off for that. This is what I do believe: that every man who has broad experience of a general practice of medicine is competent and capable of quickly developing himself to conduct these cases along carefully.

You have no greater field, men, either for yourselves, for the patient, or for your Government, than in this field.

Now as to the tubercular case. The error we find in the matter of the tubercular case is this: We find a great many cases are diagnosed tubercular when really they are not,—a very bad impression, as you can imagine, to give to any subject. So let us be very sure, let us leave no influence, or power, or activity unused that will help us to define the exact attitude of these cases.

We know, as was related here yesterday, that many of the so-called cases of shell shock are really due to other causes. This is my own observation of those cases, we had a number immediately after the war, at the Institution with which I am connected, and we found a most invariably these men were the subject of the toxemias of fatigue, and by relieving the toxemic conditions, whether it be uremic infection, or what not, these cases soon got well and their mental symptoms soon subsided. So be sure that you be perfectly fair with these men, and you are never fair with them until you have exhausted every resource in discovering whether or not, as the basis of their mental or nervous disturbance, there may not be some physical condition.

The meeting is now in charge of Dr. White.

DR. WHITE: I hope there will be free discussion of this matter. There are a good many men who have had charge of neuro-psychiatric hospitals, and I hope you will feel free to get up and briefly set forth such vital problems as you may have in mind. In order that we may cover as many problems as possible, I will, with your permission, let you know when the five minutes is up, so we can cover the ground as fully as possible.

DR. KOLB: In relation to the examinations made of these neuro-psychiatric cases which were sent to us, I want to outline the procedure we use at Waukesha in arriving at correct diagnosis and methods of treatment. The patient is given to one special doctor. This doctor is supposed to make the first preliminary examination, which included a complete physical, neurological and psychiatric examination, and do all the work in connection with these patients while in hospital. In making this examination we have on our staff a number of very competent attending specialists in order that we can obviate the mistake General Sawyer has mentioned of assuming that these men are simply neurotics and passing over important physical conditions. By this method we have caught a number of cases which have been passed over as cases of neurasthenia. For instance, I have in mind a case diagnosed neurasthenia which was treated six months ago, which was a case of brain tumor.

After we have made the first preliminary examination the man is carefully observed in hospital, not only by his own officer but by the clinical director, and notes are made from time to time. Examinations are also made by the dentist, x-ray examinations and various laboratory examinations, including serological and base metabolism. In the end, after all the data is assembled and written up, he is brought to the staff and there his case is thoroughly discussed by all the members of the staff; a diagnosis is arrived at, methods of treatment discussed and afterwards put into effect.

Now as to the organic conditions with which our neurotics suffer. It is true a large proportion of them do have organic disorders in connection with their neuroses. We find that most of them do have functional disorders originating purely in their mind, or because of some constitutional nervous defect and that the real fundamental condition from which they are suffering is not an organic condition but is nervous or mental and must be approached along lines of psycho-therapy.

Now I will not go into the subject of psycho-therapy. We pay special attention to mental questions but we do not neglect the physical by any means. Every physical disorder which is found is corrected, if correction is possible. We have complete physio-therapy and occupational therapy and all other facilities for treating nervous cases. We are careful never to stress too much on the physical treatment we give these patients, because by so doing we suggest to them conditions they really do not have and by that means prolong their functional disorders.

Regarding occupational therapy. We all know that this is a very important method of treatment. It should always, as Colonel Evans said, be directed treatment and should not be given in a hap-hazard way. All of our occupational therapy treatment has been given a definite prescription. For eighteen months we have had a bright young medical officer interested in this subject, whom we have made reconstruction officer and who observes the effect of treatment and changes the prescriptions of the other physicians when he finds the treatment given does not have the desired effect.

With reference to reconstruction aides, every week our reconstruction officer gives them a talk on some phase either of occupational therapy or physio-therapy or of mental disorders. We cover any subject in which the neuro-psychiatrist should be interested. This officer has devised a system of observation which the aides are supposed to make on patients and which they do make on each patient who takes occupational therapy and which is looked over by our reconstruction officer and the officer in special charge of the case. We are getting up data and statistics which we think will be of interest to the general profession when it is finally published,

DR. TREADWAY: I think that the Public Health Service has had a very grave and serious problem affecting the N.P. Veterans of the World War. We have included in that term, besides the mental and nervous cases, the neuro-surgical cases as well.

There are a number of problems which still confront us, and one of these is the question of personnel. I am sorry that Dr. Kolb did not say something about the training school he had started in connection with his hospital. We sent some young officers over to learn technique and methods of handling the psycho-neurotics. We have also sent some officers to the Public Health Service clinic at the Psychopathic Institute in Boston and we hope that some of our other hospitals will start a similar school. The question of personnel is an exceedingly grave one. A great many young men want to become surgeons.

They are not interested in mental or nervous cases. They want to go into general medicine. Last year we sent two officers to the Southern University and to the Northern and Western universities to meet the graduating classes and the internes, and from that we have been recruiting some younger men who are manifesting considerable interest. We hope to get additional personnel by interesting the young graduate.

Another problem is the question of creating, in connection with General hospitals, wards where patients of this sort may receive at the beginning of their treatment, their preliminary examination, where they may be evacuated home with compensation or without compensation, or evacuated to a prolonged treatment hospital for further care.

It has sometimes been difficult to get enough men, trained personnel, to man these wards.

We have believed all along that the proper method of treating the pyscho-neurotic, so-called, is in out-patient clinic and we have attempted to develop out-patient clinics with the old dispensaries maintained by the Public Health Service; but the question of personnel again entered into it, and we were unable to develop as many out-patients clinics as we should like. We think, however, that the mild, mental case, as General Sawyer has said, is far better off in the outside world than he is in an institution. If such cases go to a hospital, it tends to have their symptoms crystallized and they believe they are sicker than they really are. In other words, they seek out some minor physical disability as a peg on which to hang what they think is a grave disorder.

The question of compensation for these cases is an important one which must be worked out. The man who believes he is seriously ill when he has but a minor defect, if he has compensation and has a weak will, will not make a strenuous effort to get back on his feet. The question of maximum compensation for these cases many times interferes with rehabilitation.

We believe that this is a new method of handling mental patients and it may serve as a copy to other States to prevent this enormous building program which every State has had to go through and which has not met the needs of the insane.

Compensation for epileptics and their examination is a very important question and has been a serious problem to us.