Medical Science Publication No. 4, Volume II
HISTORY AND ORGANIZATION OF A THEATER
PSYCHIATRIC SERVICE BEFORE AND AFTER 30 JUNE 1951*
COLONEL ALBERT J.GLASS, MC
As the Korean campaign fades into the past, it is appropriate at thistime to set forth its experiences and lessons before they are obscuredby time or distorted by tricks of memory and the pressure of more recentevents. This presentation proposes to describe the organization of theaterpsychiatry during the Korean conflict, with special emphasis upon the psychologicalproblems that arose during the movement warfare of the first year as contrastedwith the more static combat phase that prevailed after 30 June 1951.
Prior to hostilities in Korea, Army Medical Service in the Far EastCommand was sufficient only for the occupation forces and their dependents.Psychiatric personnel and facilities were similarly lacking in the reservestrength required for the support of combat operations. In all, nine psychiatristswere present for duty in the Far East Command, eight of whom were RegularArmy residents in psychiatry, with from 18 to 24 months of professionaltraining, who had been placed in the theater on a temporary duty statusfrom Fitzsimons and Letterman Army Hospitals. Psychiatric facilities wereavailable in Army hospitals at Tokyo, Yokohama, Osaka, Fukuoka, and Okinawa.They functioned as sections in the respective medical services, exceptat the 361st Station Hospital in Tokyo, the "NP Center" of theFar East Command, where a separate neuropsychiatric service included openand closed wards, EEG and EST apparatus, and trained ancillary personnelin both social work and psychology. The medical consultant to the Surgeon,Far East Command, coordinated psychiatric functions in the theater as partof his supervision of professional activities in internal medicine.
The abrupt entrance of our occupation forces into the Korean fightingmade it necessary to rapidly improvise medical support for the combat troopswhich could only come from the slender medical resources in Japan. Initiallyat least there was no plan or organized program for the care of psychiatriccasualties. All available medical
*Presented 30 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.
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personnel were required for the more urgent needs of first aid, evacuation,and emergency surgical care. However, in the early weeks of the Koreanfighting, intradivisional psychiatric treatment would have been impractical.The constant retrograde movement of the UN forces, who necessarily foughta series of delaying actions, made even emergency medical treatment andevacuation a difficult and dangerous procedure because of enemy attacksupon our flanks, rear, and lines of communication. Psychiatric casualtieswere numerous but not excessive. A neurotic adaptation was of less valuein this desperate and confused tactical situation, in which medical channelswere also under attack, and where movement away from fear was more safelyaccomplished with the withdrawing combat group.
By early August 1950 the UN defenses stiffened to form a relativelystabilized line, the Pusan perimeter, which held firm despite repeatedenemy assaults and penetrations. With relatively new units engaged in heavycombat, little opportunity for rest, and severe battle losses, there wascreated the type of tactical situation which favors the production of numerouspsychiatric casualties. Their incidence during this combat phase was thehighest in the Korean campaign. The holding and treatment of minor disease,injury and psychiatric patients by divisional medical elements now becamea practical possibility and was in fact made mandatory by the grim necessityof rapidly conserving combat personnel to maintain the thinly manned perimeterdefenses. In mid and latter August 1950, division psychiatrists were assignedand became operational in the 2nd, 24th, 25th Infantry and 1st CavalryDivisions. They established psychiatric treatment units in or near divisionclearing stations and salvaged 50 to 70 percent of received patients forcombat duty by a 1- to 4-day period of rest, food, and superficial psychotherapy.
Before and after division psychiatry was established, psychiatric evacueesfrom the combat zone were sent to the one evacuation hospital in Pusan.Although this unit had an assigned psychiatrist, lack of facilities permittedonly the retention of non-transportable seriously ill and injured patientsfor treatment. It was therefore necessary to evacuate the vast bulk ofreceived psychiatric patients to southern Japan, where they were transhippedto the 361st Station Hospital in Tokyo. Approximately 1,800 psychiatriccasualties were evacuated from Pusan during July, August, and early Septemberof 1950. The 361st Station Hospital rapidly expanded its psychiatric facilities,but despite an increase of its professional staff, flown from the Zoneof Interior, only 50 percent of psychiatric patients were salvaged foreven noncombat duty. Bed space limitations forced the evacuation of theremainder to the U. S. A.
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What lessons in combat psychiatry can be learned from this initial phaseof the Korean conflict? When one considers the extremely unfavorable tacticalconditions, limited facilities and scant personnel, medical support canbe said to have been performed with outstanding effectiveness. Moreover,division psychiatry became operational within 6 to 8 weeks after an unpreparedonset of hostilities, in contrast to an almost 2-year delay in establishinga similar program in World War II. Yet in Korea, as in World War II, stepsto prevent and salvage psychiatric casualties were taken after the needbecame glaringly apparent. With Korea added to our previous experiencesin modern warfare, there is now sufficient evidence accumulated to indicateclearly that psychiatric casualties can be expected to occur with the samecertainty as battle wounds. Moreover, any delay in instituting measuresfor their control and treatment is particularly unfortunate since psychiatriccasualties usually have their highest frequency in the early fighting ofa campaign. Then heavy battle losses are common, the tactical situationis often confused and units new to combat have not yet acquired the groupcohesiveness which sustains the individual soldier against psychologicalbreakdown in battle.
It is therefore evident that for future combat operations medical plansshould include a psychiatric program designed to function at the outsetof fighting. Such a conclusion may seem obvious, but warrants emphasisand repetition because all too often in the past there has been a waitand see attitude. Then the inevitable psychiatric casualties were eitherevacuated out of the combat zone and thus permanently lost to their unitsor hastily improvised salvage efforts gave only imperfect results.
Of special importance in the medical planning for combat operationsis the inclusion of psychiatric treatment facilities at Army level in orderto give the theater psychiatric program the necessary elasticity to functionin unfavorable tactical situations. Normally, Army facilities receive psychiatricevacuees from the division psychiatric units and provide treatment andconsultation for Army and corps troops. But, as in Korea, often intradivisionalpsychiatric treatment is not possible, particularly in the early difficultphase of major combat operations or when there is a rapid withdrawal typeof action. Army facilities must then assume the function of division psychiatryand become the first level of psychiatric care. Such Army psychiatric supportwas lacking early in the Korean campaign. It is the writer's opinion thattwo psychiatrists provided with the simplest of administrative and housekeepingfacilities, to operate either as a separate unit or attached to the oneevacuation hospital in Pusan, could have salvaged at least 50 percent ofthe psychiatric patients that were evacuated to Japan during this period.Field psychiatry is perhaps the most
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economical and effective form of medical care, requiring only a fewpersonnel and a minimum of supplies and equipment.
The large incidence of psychiatric casualties caused efforts to implementan organized psychiatric program for the theater. In late September 1950a senior Regular Army psychiatrist, with previous experience in World WarII, was assigned as psychiatric consultant to the Surgeon, Far East Command.
The next combat phase saw a great UN victory. The successful Inchoninvasion by the 10th Corps coordinated with a break-through by the 8thArmy perimeter defenders from the south destroyed, captured, and dispersedthe bulk of the enemy forces. Psychiatric casualties were numerous duringthe initial severe fighting, but sharply declined with the collapse ofenemy resistance. The 1st Marine Division, who bore the brunt of the fightingfor Seoul, suffered heavy battle losses and consequently incurred a largenumber of psychiatric casualties.
Marine psychiatric patients were first evacuated to a Navy hospitalship in Inchon Harbor, since intradivisional psychiatric treatment wasnot available. Despite the excellent psychiatric staff and facilities aboardthe hospital ship few psychiatric patients were salvaged for combat duty.This was in sharp contrast to the results obtained somewhat later in themore primitive environment of a field hospital, where 50 percent of Marinepsychiatric casualties were recovered for combat duty by a 1- to 3-dayperiod of rest, sedation, and superficial psychotherapy. Obviously, thecomfort and safety of a hospital ship militates against the motivationof psychiatric patients to face again the rigors of combat.
It is not surprising that morale in October 1950 was high. The tableshad been quickly and almost miraculously overturned and everyone expectedthat soon the fighting would be over with return to comfortable Japan.The psychiatric casualty rate for this month, the smallest in the Koreancampaign, reflected the low incidence of battle casualties and the optimismthat pervaded all ranks. But, in November 1950, enemy resistance steadilyincreased, the weather became quite cold, supplies were short, and theoptimism of the previous month began to wane. During this phase of victoryand tactical security, a reorganization of the psychiatric program in Koreawas accomplished.
Reorganization of Psychiatric Program in Korea before 30 June 1951
Psychiatric services at Army level were implemented by the utilizationof small psychiatric teams in evacuation or field hospitals that were strategicallylocated to receive most of the casualties from the combat zone. Separateclearing companies and like facilities were not available for employmentas provisional Army psychiatric units, such
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as were used in World War II. Considering the small number of availablepsychiatric personnel, dispersion of Army psychiatric facilities was perhapsthe most effective method of their employment during the rapid movementwarfare of the first year in Korea. This arrangement provided alternatetreatment sites in the event forward hospital units were dislocated byserious battle reverses, thereby insuring a continuation of Army levelpsychiatry, especially needed in any large-scale withdrawal, when interdivisionaltreatment was not feasible.
Such a dispersion was also better adapted to the vagaries of air evacuationthen commonly used within Korea, which made difficult, if not impossible,the triage of psychiatric patients to any one area. Whether patients werebrought to this or that hospital from the combat zone depended on the stateof the weather, the condition of landing strips, the number of bed vacanciesand even mechanical difficulties in flight. It was necessary to providepsychiatric facilities wherever large numbers of casualties arrived fromthe forward area. At various times during the first year of the Koreanconflict, psychiatric teams were present with the 121st Evacuation Hospitalat Hamhung, Taejon and Yongdongpo, the 4th Field Hospital near Seoul andat Taegu, the 64th Field Hospital at Pongyang and the 8054th EvacuationHospital at Pusan. They operated at the first or second level of psychiatrictreatment, dependent upon the tactical situation. The number of psychiatricevacuees to Japan markedly decreased as patients were recovered for combatand noncombat duty within Korea.
The role of division psychiatry was also enlarged and clarified. Inthe initial phase of the Korean conflict, division psychiatrists remainedat clearing station level and restricted their efforts to the evaluationand treatment of referred or evacuated patients. Their activity was graduallyincreased to include visits to aid stations, liaison with other membersof the divisional staff and orientation discussions with line and medicalofficers of the division. It is a common observation that when the divisionpsychiatrist visits forward areas and makes personal contacts, he and hisideas become more highly regarded by combat medical personnel. The divisionpsychiatrist who remains in the rear is resented as one who fears to sharetheir hardships, even briefly, and is therefore an impractical, theoreticalperson who does not belong in their world of deprivation and trauma. Byvisits to aid stations, the psychiatrist not only brings his professionalknowledge and help to the forward area but obtains first-hand informationof combat psychological problems. His recommendations then display a morepractical appreciation of the difficulties involved in combat adaptation.
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In time, divisional medical officers were influenced to treat casesof mild combat exhaustion at the aid station level whenever the tacticalsituation permitted. Division psychiatrists came to be more and more consultedby line and administrative officers on matters of morale, mental health,and special personnel problems, thus assuming an important role in preventivepsychiatry. Curiously enough, resistance to the comprehensive functionof division psychiatry arose more from senior medical officers than fromline commanders who generally rather welcomed aid and advice on the preventionand management of psychological problems. Moreover, it was evident at leastinitially that some division surgeons were ignorant of the division psychiatrist'sfunction and in some instances insisted upon limiting his efforts to purelytreatment activities at the clearing station. However, once division psychiatrywas firmly established in its larger role, it came to be accepted and eachnew division psychiatrist was expected to perform a similar function.
A reorganization of the psychiatric facilities in Japan was begun inDecember 1950. The practice of concentrating the bulk of psychiatric evacueesfrom Korea at the 361st Station Hospital in Tokyo proved to have seriousdisadvantages from the standpoint of treatment and disposition. Many psychiatricpatients were adversely affected by the environment of this fixed hospitaleither to maintain a stubborn persistence of symptoms or develop more severemanifestations than were previously noted. This resistance toward improvementand return to any type of duty is not surprising when the comfortable atmosphereof a fixed hospital situated in the midst of peaceful and pleasurable Tokyois compared with the monotonous, primitive, and hazardous existence ofKorea. In addition, they could readily observe and envy the frequent evacuationto the Zone of Interior of other psychiatric patients, who were seeminglybeing rewarded for persistent or severe mental symptoms by being sent home.
The psychiatric casualty evacuated to Japan was especially vulnerableto suggestion. Separated from the positive sustaining forces of his combatunit and often tortured by a sense of guilt for leaving it, he readilyseized upon any support for his symptom defense, the only excuse for hispatient status. The hospital patient group who had similar needs and problemsoffered him such support. Patients reinforced each other in justifyingtheir complaints and contaminated the newcomer with stories of "nothingbeing done" for them. Thus it was that the psychic trauma and itsmanifestations brought about by realistic battle stress were displacedto a hospital setting which became the new battleground as the psychiatricpatient with the support of his hospital fellows fought to maintain thedubious but definite gains of neurotic invalidism.
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Obviously, improvement of the psychiatric program in Japan involvedthe decrease of non-psychotic patient admissions to fixed medical installations.The first step in this direction had already been taken by the implementationof effective psychiatric treatment within Korea. The next step was to circumventthe transfer to the 361st Station Hospital of patients from other areasin Japan by creating local NP facilities. This was accomplished by addingpersonnel and equipment to the psychiatric section of the Osaka Army Hospital,thus increasing its function to that of a service capable of definitivepsychiatric care. Similarly, personnel and facilities were added to theNP service of the newly arrived 141st General Hospital which was placedin operation near Fukuoka and became the neuropsychiatric center of southernJapan.
Further progress was fortunately expedited in December 1950 when twoconvalescent hospitals were established near the major Army hospitalizationcenters of Tokyo and Osaka, respectively. They were designed to relievecongestion in fixed hospitals by removing ill and injured patients whohad recovered sufficiently to require only ambulatory convalescent care,thus making available hundreds of beds vitally needed for those requiringactual medical and surgical care. Convalescent hospitals provided a realisticenvironment for psychiatric treatment. Here patients, in fatigue uniform,instead of hospital garb, participated in an active daily program of calisthenics,supervised athletics, marches, and other training activities. Under thisregimen, there was less benefit from clinging to symptoms and no suggestiveevidence of possible evacuation to the Zone of Interior. A psychiatristwas assigned to each convalescent hospital. Neurotic or open-ward-typepsychiatric patients evacuated from Korea or originating in Japan who arrivedin the Tokyo or Osaka areas were admitted to the nearby convalescent hospital,by-passing the NP centers in fixed hospitals. Such patients were deliberatelydispersed among those recovering from wounds and illness who gave littlesupport to mere neurotic complaints. Less resistance to therapy was encounteredin this milieu and psychiatric patients turned more readily to their therapistfor help. Marching together and performing other group activities againstirred previous feelings of group identification. The far better resultsobtained by psychiatry in convalescent hospitals over those of fixed hospitalsargues strongly for its similar use in future communications zone medicaloperations.
Further improvement of psychiatry in Japan was effected by emphasisof outpatient evaluation and treatment in place of hospitalization wheneverfeasible. Not only were enlarged outpatient services maintained at eachof the three neuropsychiatric centers previously mentioned, but similarfacilities were created at large
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dispensaries, such as in Yokohama or station hospitals that served largetroop populations. In effect, the goal of psychiatry in Japan aimed ata decentralized approach to the handling of psychological problems. Bythis scheme psychiatric evacuees from Korea were placed under treatmentat whatever area they arrived in Japan, preferably at convalescent hospitals,thus eliminating the previous multiple transfers within Japan. Patientsfrom troops stationed in Japan who had psychiatric problems were treatedand evaluated on an outpatient basis if possible, or hospitalized at thenearest convalescent hospital or NP center. Only seriously ill patientsor those presenting diagnostic problems, who required special care andfacilities, were sent to one of the three NP centers in fixed hospitals.
Experiences involving the utilization of psychiatric personnel in theKorean campaign may provide useful lessons for future combat operations.During the first year, psychiatrists were not only relatively scarce, buttheir frequent turnover for various reasons constituted a constant problemin maintaining effective psychiatric support. Beginning in October 1950,all psychiatric officer personnel arriving in the theater were temporarilyassigned to the 361st Station Hospital in Tokyo for a 1- to 4-week periodof indoctrination and practical work in the psychological illnesses ofthe Far East Command. Orientation of the new arrivals was supervised bythe theater psychiatric consultant and the staff of the 361st Station Hospital,during which their competence for specific assignments could be evaluated.The fact that most of the newcomers were relatively young in age, trainingand experience in psychiatry, eager to learn, and willing to consider otherviewpoints and methods of therapy, perhaps made the task of indoctrinationeasier than it would have been if older and more experienced psychiatristshad been involved. From this pool of psychiatric personnel, assignmentswere made to various positions in Korea, Japan, and Okinawa. To insurea continuance of experienced division psychiatrists, replacements for thisposition were selected from those psychiatrists who served at Army leveland thus to some degree were familiar with psychological disorders of combat.Each incoming division psychiatrist worked jointly for 7 to 14 days withhis predecessor and was thus personally orientated in his new assignment.
The changing attitude of the psychiatrist as he moved from a rear toa forward function was noteworthy. Initially and in rear assignments, thepsychiatrist new to combat problems is quite impressed by the manifestationsdisplayed by psychiatric casualties. He is prone to over-identify withthe patients and accede to their symptomatic request for further evacuationor removal from combat. He, also, feels guilty when making recommendationsfor a more hazard-
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ous duty than he fortunately must endure. Patients are prone to placetheir wishes on a personal basis with the physician who by refusing theirrequests comes to believe that he is serving a harsh even thoughuseful function. Therefore, while the new psychiatrist may accept the indoctrinationof others as being correct he is far from comfortable in this role. Butas he moves forward to the division, shares to some degree the hazardsof battle and better understands the individual sustaining forces in combat,a reorientation in attitude occurs. This comes about through realizationthat it is best for the individual to overcome fear else there remain aphobic scaring and chronic sense of guilt for failure. Then the psychiatristcan feel he is aiding the individual as well as the group and thus relievedof doubt and guilt he steadily improves in effective performance of hismission.
Because of the limited number of psychiatric personnel available inthe first year of the Korean campaign, economy in their utilization wasnecessary. The majority of the psychiatrists involved had approximately1 to 2 years of professional training in their specialty, a few had lessthan 1 year, but a small minority had completed 3 years or more of trainingand experience. One psychiatrist was assigned to each division insteadof two that were authorized by tables of organization. As in World WarII, actual operations indicated that a single psychiatrist can effectivelyaccomplish this mission provided that he is assigned to the office of thedivision surgeon and thus free to function freely throughout the division.On occasions early in the Korean conflict, when the only psychiatrist ina division was assigned to the medical battalion or clearing company, therewas clearly demonstrated a restriction of his efforts to the purely passiverole of receiving and training patients admitted to the clearing station.This severely curtailed the larger role of the division psychiatrist instimulating the more forward treatment of psychiatric casualties in aidstations and blocked his efforts toward preventive measures.
Whenever assistance was needed by the division psychiatrist, volunteerhelp was always available from the medical officers assigned to the holdingplatoon. However, it is believed that a clinical psychologist and psychiatricsocial worker on either enlisted or officer status could broaden and facilitatethe work of the psychiatrist by virtue of their specialized skills. Whensuch personnel were inadvertently available to the division psychiatristthey were quite profitably employed.
In Japan, economy of psychiatric personnel was also practiced by theuse of neuropsychiatric centers instead of permitting the operation ofseparate psychiatric sections of services in each general or station hospital.Inpatient psychiatric facilities for the Tokyo-
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Yokohama area were provided by the 361st Station Hospital. Similarlythe Osaka Army Hospital was the NP center for its area, which permittedthe deletion of psychiatric personnel from two general hospitals locatedin the vicinity. The 141st General Hospital was the third NP center andserved southern Japan. The saving of professional personnel by such areaemployment of psychiatric services not only decreased the number requiredbut allowed for the assignment of psychiatrists to provisional convalescenthospitals and dispensaries in which there were no authorized vacancies.
Officer psychologists and social workers were employed at the threeNP centers in Japan. Initially it was difficult to insure their professionalfunction in Korea, because as MSC officers they were vulnerable for fieldor administrative assignments. However, later in the Korean campaign, selectiveassignments were arranged which permitted their professional function atArmy level.
The emphasis upon field psychiatry in Korea, and the employment of convalescenthospitals and outpatient facilities in Japan markedly decreased the theaterrequirement for psychiatric nurses because they could only be assignedto the three NP centers in Japan. As a result, many psychiatrically trainednurses were employed in the usual spheres of medicine and surgery, bothin Japan and Korea. Thus while requisitions for psychiatric nurses fora wartime theater may be on the basis of table of organization requirementsthey may not represent an actual need for such specialists, although theoverall number of nurses requested by the theater may be quite correct.
An important aspect of the economic employment of psychiatric personnelin the Far East was the close cooperation of the personnel sections ofGeneral Headquarters, Far East Command, Japan Logistical Command and 8thArmy with the psychiatric consultant. This liaison made possible selectiveassignments based upon individual personality and professional qualificationsthat were best suited for the particular position vacancy.
Utilization of Limited-service Personnel
During the first year of the Korean conflict certain innovations weremade in the employment of limited-type personnel that had a pertinent bearingon the theater psychiatric program. The utilization of marginal personswhose mental and physical handicaps preclude their function in battle hasalways represented a difficult medical problem in a combat theater of operations,as was illustrated in World War II. Their number steadily rises with activecombat because of the addition of individuals who either have residualsof or are incompletely recovered from wounds, diseases such as frostbite,and psychological breakdown. As this category of personnel
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grows ever larger more and more difficulty is encountered in arrangingtheir suitable noncombat assignment, especially since many of the personsconcerned have no special skills or training for the technical rear positionsthat are available. Yet some solution to their placement is mandatory,otherwise sizable numbers of individuals capable of performing limitedservice type duty would require return to the U. S. A. for medical or administrativereasons.
A similar problem presented itself during the Korean campaign. Initially,however, service units in Japan were so depleted by personnel sent to Koreathat many vacancies for noncombat positions were present. Existing Armyregulations which permitted a temporary change of the physical profilewere used as a basis for a theater directive, which stipulated that personsso profiled be marked for "non-combat duty in Japan only." Thisprocedure operated satisfactorily until January 1951 when it became difficultto find noncombat assignments within Japan. A combined medical and administrativestudy resulted in the following changes:
(1) The designation "for Japan only" was deleted from theassignment recommendations for limited-type personnel. Instead the specifictask to be limited was to be stated in non-medical terms, such as the avoidanceof "combat duty," "long marches," "lifting heavyweights," and the like. Opportunities were thus opened for assignmentin Korea, at both Army and communications zone level, and Okinawa.
(2) Re-examination within 90 days for all reprofilees was made mandatory.Persons found fit for full duty were removed from the limited service categoryand made available for combat assignment. Those found still incapacitatedhad their limitation continued for another 1- to 3-month period. This constantrescreening of limited personnel served to partially offset their ever-increasingnumber.
As a result of the above changes, all reprofilees in Japan were re-evaluatedin February and March 1951. A surprising result was obtained from thosein the psychiatric category, when from 30 to 50 percent were deemed fitfor full duty. Although the criteria for return to full duty were not uniform,all psychiatrists had been instructed to consider such individuals ableto perform combat function if free of overt anxiety or its somatic displacementsand able to contemplate such a change without strong protestations or recurrenceof disabling symptoms. Examiners reported that many welcomed a decisionrendering them fit for full duty, expressing a desire to prove themselvesand thus be free of feelings of guilt and inferiority that had been presentsince removal from combat. This formal reclaiming of psychiatric casualtiesafter several months of non-combat duty
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was a new procedure in military psychiatry. Unfortunately, no follow-upstudies are available to determine effectiveness of reclaimed individualsafter return to combat duty. However, repeated questioning of divisionpsychiatrists in later months failed to uncover persons with such a historyamong their patients. Perhaps this favorable result was due to the influenceof rotation that became fully operational in May 1951 and gradually removedthe reconverted combat personnel.
The Problem of Character and Behavior Disorders
From another standpoint, psychological difficulties of certain personnelconstituted a special problem in the theater psychiatric program. Thisconcerned individuals with character and behavior disorders who under ordinarycircumstances are considered for administrative seperation from the Serviceunder the provisions of AR 615-368 or AR 615-369. Experience in both WorldWar II and early phases of the Korean campaign illustrated the impracticalityof implementing AR 615-369 for the removal of personnel in a combat unit,first because there is little time for such administrative procedures undercombat conditions, and second because such a discharge under honorableconditions would be regarded as a reward for failure with consequent undesirableeffect upon the morale of the unit involved. In actual practice AR 615-369can seldom be utilized in a wartime theater since it is not an appropriatedisposition for the emotional climate of a combat environment.
In the Far East Command, persons in this category were employed in noncombatpositions as their personality defects were not so severe as to precludetheir function under less stressful conditions. It became unofficial theaterpolicy for division psychiatrists to evacuate those with personality problemswho could not be reassigned within the division. When received at Armylevel such persons were reprofiled and recommended for a rear assignment.It was demonstrated that the vast majority of this category could, anddid, function in noncombat assignments at Army or communications zone levels,when disposition was firmly made and the individual concerned pointedlyreminded of his good fortune. Cases of enuresis were handled by this methodand such patients became useful soldiers when it was made clear to themthat their problem mainly involved the availability of laundry facilitiesof which there was no dearth in Korea and Japan. The provisions of AR 615-369were therefore rarely employed in the Far East Command and only in thoseseriously inadequate individuals who were literally incapable of beingforced to perform effective work of any kind.
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Persons with pathological personalities, as defined under AR 615-368,were not evacuated through medical channels but handled by administrativeor disciplinary measures. This group included narcotic and alcohol addicts,habitual shirkers, chronic petty disciplinary offenders, and the like.This policy was based on the assumption that individuals of this type couldnot be rehabilitated by reassignment. Actually, combat units had relativelyfew persons in this category, since there is little opportunity for antisocialbehavior and AWOL is a serious offense in the combat zone, punishable bygeneral courtmartial. Most individuals of this type were found in rearareas of Korea and Japan. The fact that discharge under AR 615-368 is ofthe undesirable type makes such a disposition acceptable in a combat theater.
The disposition of noneffective officers was also satisfactorily solvedbut only at 8th Army level in Korea. Previously, officers who had demonstratedtheir unsuitability as combat leaders by reason of poor motivation or personalitydefects were either evacuated through medical channels or referred to theirunits for administrative action. Neither course proved to be satisfactory.On the one hand combat units did not have the time or administrative machineryto cope successfully with the unwieldy procedure of AR 605-200. On theother hand medical evacuation was regarded as an obvious reward for poorperformance.
As a result of these difficulties, 8th Army Headquarters establisheda permanent AR 605-200 Board, under the supervision and control of the8th Army JAG, which handled all such cases that arose in Korea. This removedthe administrative burden from the combat units, who were then more willingto recommend this type of action rather than pressure their medical officersto use medical evacuation. By virtue of more expert guidance and accumulatedexperience, the 8th Army Board was more effective in accomplishing theprescribed procedure. This method became a uniform practice for the eliminationof non-effective officers and in the writer's experience, which includedsimilar difficulties in World War II, has proved to be the best solutionto this vexing problem. A major weakness in the procedure still remained,namely, the delay of usually 3 months to await final action from the Departmentof the Army, during which time the officer involved is of little use tohimself or the Service. It would seem reasonable to allow Army or theaterheadquarters to take final action on such problems in a wartime situation,or permit the already boarded officer to return to the USA and there awaita final decision.
Similar cases that arose in Japan were not handled by the above statedcentralized method; consequently, there was no uniform procedure and notinfrequently officers in this category, particularly
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those with alcohol problems, were repeatedly hospitalized despite recommendationsfor administrative disposition.
Developments after 30 June 1951
After 30 June 1951, the Korean conflict entered into a more static periodwhich continued until the termination of active combat. While there wasrelatively little of the rapid movement warfare that characterized theprevious era, it should not be inferred that the fighting was maintainedat a low level of intensity. On the contrary, there were numerous limitedoffensives by both sides which included fierce struggles for stubbornlydefended hill masses. Patrol actions were commonplace, along with frequentartillery barrages by the ever increasing enemy firepower. U. N. troopslived in and fought from deeply entrenched and dug-in positions. Successivelines of already prepared defenses were available in the event of a withdrawaldue to an enemy break-through. The enemy was similarly prepared with defensesin depth.
As the battle lines stabilized, medical support for the U. N. Forcesbecame more uniformly and systematically applied with less of the improvisedprocedures that were made necessary by the previous erratic tactical situations.Mobile Army Surgical Hospitals were moved even farther forward to betterfulfill their mission of emergency surgery. Evacuation hospitals also werelocated in their usual forward place in the evacuation chain.
Division psychiatry operated with increased efficiency as stable defensivepositions allowed a greater participation of aid and collecting stationsin the treatment of mild psychiatric casualties. This more static periodalso permitted effective modifications in the operation of psychiatry atArmy level. The previous system of utilizing psychiatric teams attachedto evacuation or field hospitals was changed in favor of a separate provisionalpsychiatric unit. This unit, similar in organization, structure, and functionto that of Army psychiatric centers of World War II, was located in Seouland served 8th Army as a focal point for combat psychiatry. All psychiatricevacuees from the combat areas were funneled to this unit where greaterresources facilitated the function of the psychiatric team. As a centerfor 8th Army psychiatry, it served to train psychiatric personnel for moreforward assignments, such as replacements for division psychiatrists. Itwas also utilized for the instruction of ROK medical officers. Noteworthywas the innovation which directed that all possible psychiatric evacueesfrom Korea, even those originating from rear areas, such as Pusan and Taegu,be sent to the Army psychiatric unit at Seoul. This insured standard criteriafor evacuation to Japan, which in actual operation served to decrease theirnumber.
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The incidence of psychiatric casualties after 30 June 1951 was maintainedat fairly constant low levels with slight elevations in rate from the increaseof battle casualties during offensive engagements. Aside from the statictype of combat, perhaps the principal cause for the continued diminishedfrequency of psychiatric breakdowns was the influence of rotation. Forthis reason there was minimal adverse psychological reaction to the longdrawn out and pessimistic peace talks. Relief from combat had become anindividual affair obtainable regardless of the outcome of negotiations,and rotation became the chief topic of conversation among troops in Korea.As practiced in the Korean campaign it was a new phenomenon for Americancombat troops. Undoubtedly it is a long step forward in preventive psychiatryand has proved its value. However, there are certain seemingly inevitableand undesirable by-products. The most pertinent defect of rotation, asidefrom its logistical problems, arises from the disruption of the sustainingpower of group identification which occurs when the combat soldier is notifiedor becomes aware that soon he will go home. The increase of tension thatfollows as the "short-timer" shifts his feelings for the groupto concern for himself often makes battle fear unbearable. In some casesthere is inability to function, with temporary breakdown. For most individuals,anxiety is noticeably increased in the last days of combat, as if it werenow more dangerous to tempt fate. Many stories, undoubtedly exaggerated,are circulated about the unlucky persons who were killed on the day ofrotation. Often the other members of the group readily identify with the"short-timer" by their spontaneous efforts to spare the "rotatee"further hazardous duty. The "short-timer" is also bothered byambivalent feelings toward leaving the group, as ties with his buddiesdo not loosen so readily.
There was no essential change in the organization and operation of psychiatryin Japan. Greater progress was made in implementing the policy of decentralizationin the management and treatment of psychiatric patients. Fewer patientsreached Japan from Korea, and emphasis upon outpatient treatment resultedin less need for hospitalization of psychiatric patients originating withinJapan.
