CHAPTER XXI
Psychosomatic Medicine
Colonel Albert J. Glass, MC, USA (Ret.)
Part I. During Selection for Military Service
THE PSYCHOSOMATIC APPROACH
Psychosomatic medicine, as the term is used in this chapter,is broadly defined as a professional approach to disease and disabilityconceived as a mind-body whole. This viewpoint, which is held by most workers inthe field of psychosomatic medicine,1 is perhaps most clearlyelucidated by H. Flanders Dunbar2 who comments: "The term 'psychosomatic'is descriptive rather of the observer in his endeavor to apprehend than of theorganism involved. Psyche and soma merely represent two angles ofobservation." Such a concept views every disease as psychosomatic since inall forms of illness the defensive reaction of the individual against threatsfrom within or without involves the interrelationship of the resources of bothpsyche and soma operating together as a unity. In effect, disease is but anotherform of organismal adaptation.
World War II began during a favorable period in thedevelopment of the psychosomatic approach. The previous several decades had seena growing interest in the influence of emotions upon bodily changes. There weremany contributions demonstrating that somatic symptoms arose from psychiccauses, and vice versa, but more important were the increasing efforts todiscover the mechanisms involved. The year 1935 saw the publication of themonumental work by Dunbar, which surveyed the literature on psychosomaticinterrelationships for the years 1910-33. In various symposia and professionalmeetings, the phenomena of total reaction in disease were discussed. In 1939, aregularly issued quarterly journal, PsychosomaticMedicine, came into existence. Despite such progress,the semantic confusion and the dichotomy inherent in the term"psychosomatic" fostered in many a continuation of the traditionalseparation of mind and body and permitted others to assume the complacentovergeneralization that psychosomatic medicine only restated an old andwell-known axiom of medical practice.
1(1) Weiss, Edward, and English, O. Spurgeon: PsychosomaticMedicine. Philadelphia: W. B. Saunders Co., 1943, pp. 1-15. (2) Menninger, W. C.: Psychosomatic Medicine on General Medical Wards. Bull. U.S. Army M. Dept. 4: 545-550, November 1945.
2Dunbar, H. Flanders: Emotions and Bodily Changes. 2d edition.New York: Columbia University Press, 1938.
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Mobilization and war with their severe and unusual stressescreated exceptional conditions for the recognition and utilization ofpsychosomatic concepts. There were produced numerous and obvious manifestationsof mind-body interrelationships that remain latent under ordinary circumstances.This greater opportunity to notice the effect of emotions upon bodily changescould not fail to influence the professional thinking of most physicians engagedin wartime military practice. Another favorable circumstance lay in the closeworking relationship of psychiatrists with their medical colleagues. Not onlywas psychiatric opinion more readily obtained than in civil practice butinformal discussions, among physicians of various medical disciplines who sharedcommon frustrations, helped to dispel the skepticism and mysticism that so oftensurround psychiatrists and their concepts.
On the other hand, certain aspects of World War II militarymedicine militated against acceptance of the psychosomatic viewpoint. Onedeterrent arose from the specialization which, as in civilian medicine, waspracticed in most large army hospitals; that is, the various separate clinicalservices and sections had each its own approach, and medical officers couldreadily avoid psychosomatic considerations by the transfer of patients whosemanifestations did not fall within their specialized sphere. This attitude wasillustrated especially by the almost universal efforts of medical officers totransfer to the psychiatric wards all patients who failed to exhibit asufficient degree of so-called organic disease. It should be stated, however,that the large patient load often carried by the individual ward officer madeunderstandable attempts to lighten this burden by removing puzzling or annoyingpatients.
The administrative necessity of adhering to a standarddiagnostic code also fostered a one-sided attitude toward disease anddisability. Then, as today, diagnosis mainly indicated tissue pathology orpathophysiology rather than the total reaction involved in the disease processfor which there is as yet no adequate terminology.
Another obstacle came from the emotional difficulties thatarose in many of the newly created medical officers by their transition fromcivil to military life. Physicians, like other participants in war, wereseparated from their loved ones, suffered economic losses, and endured varyingdegrees of hardship and danger. But apparently, these vicissitudes were not themajor cause for their mental unrest. This mental unrest was due rather to achange from a status in which there was a high degree of independence, activity,and gratification in professional work and community prestige to the relativelyrestricted role of a subordinate medical officer who was often blocked frompromotion, through no fault of his own, and who was frustrated by periods ofdelay and inactivity and by administrative procedures and other restrictionsthat seemed to be an inevitable part of military medicine. The psychic unrestthus created made it difficult for some medical
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officers to evaluate objectively the manifestations ofdisease unless undoubted structural changes were evident. Psychosomaticinterrelationships were often either overlooked, owing to the closeidentification of the medical officer with the patient's psychologicalproblems, or, if recognized, rejected as not being a legitimate reason forsymptomatology.
In addition to these favorable and unfavorable influences,there were other factors that affected psychosomatic medicine in World War II.Various directives and regulations were issued that periodically altered thephysical and mental standards for the utilization of manpower. Also, there weresituational stresses of different types and intensity, from training to combat,which had a pertinent bearing upon the common clinical syndromes that werepresented to the medical officer. In this chapter, consideration will be givento the development of psychosomatic concepts in relation to the following areasof the military effort; namely, (1) selection at induction or enlistment, (2)training and other service in the Zone of Interior, and (3) oversea duty andcombat.
THE FIRST YEAR
The growth of psychosomatic insight during World War II isperhaps best illustrated by the change that occurred in medical thinkingrelative to the selection of men for military service. Here was a most difficulttask, which not only involved the problem of choosing men capable of performingmilitary duty from a physical, mental, and educational standpoint but which wasfurther complicated by factors such as the motivation of the selecteesconcerned, the possibility of future compensation for disability, and thedemands of a democratic society for equality in the distribution of deprivationand sacrifice. Rules of deferment for age, marital status, number of dependents,essential occupation, and the like could be sharply defined. But, except for theobviously handicapped, no such clear-cut delineation was possible by the knownmethods of medical selection. To meet this problem, MR (Mobilization Regulation)1-9, War Department, 31 August 1940, was issued, prescribing physical andmental standards to be used as a guide for induction and enlistment. Theseregulations, however, soon came to be used mainly as a rigid directive becausethe civilian physicians and the new medical officers, who comprised the vastmajority of medical examiners at local draft boards and Army induction stations,had little or no actual experience with the duties or conditions under whichsoldiers live and work. Moreover, they were strongly influenced by the unanimousopinion of prominent civilian and military medical authorities3who, placing
3(1) Hillman, C. C.: MedicalProblems Encountered in Military Service. Am. Int. Med.13: 2205-2211, June 1940. (Also Army M. Bull. No. 53: 27-35, July 1940.)(2) Editorial: With Emphasis on the Word Selective. Mil. Surgeon 87: 265-266, September 1940. (3)Fox, L. A.: The Medical Officer's Responsibility in the Present Emergency. Army M. Bull. No. 55: 77-86,January 1941. (4) Bowman, K. M.: Psychiatric Examination in the Armed Forces. War Med. 1: 213-218, March1941.
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much emphasis upon the experience and statisticsof World War I, called upon the examining physicians to exclude persons ofsubstandard mentality and physique, on the grounds that they were both uselessto the military and quickly joined the ranks of the compensable. Apparently,expert opinion at this time considered every inductee as a future combatparticipant, and it was considered axiomatic that modern war required only thosewith superior mental and physical stamina. Particularly emphasized was thecareful detection and elimination of unstable persons and mental misfits.4 Mostof the psychiatric authorities held the optimistic belief that potentialemotional breakdowns could be detected at induction by proper mental evaluation,and various outlines for such examination were suggested. Pratt,5 inurging a thorough attempt to rule out mental breakdowns, quoted the Britishmedical publication Lancet as advocating that medical officers turn downall men with a nervous disability, a suggestive family history, or a bad workrecord, and individuals who seemed otherwise doubtful. Kardiner,6 however, wasnot at all certain that combat breakdowns could be predicted at induction andheld that psychoneurosis was not in itself a contraindication to militaryservice.
This emphasis upon elimination at induction in order toremove all possible failures and obtain the best of available manpower had itslogical consequences. In October 1941, Selective Service Headquarters estimatedthat about 50 percent of selectees were disqualified for general militaryservice because of physical, mental, and educational defects.7 Medicalcauses for the first 900,000 rejections for general military service are shownin table 105.
Results of the first year's experience with medicalselection confirmed an increasing awareness that men were being rejected by anunrealistic, compartmentalized, assembly-line type of examination in which eachphysician saw only a part of the whole and thus placed undue emphasis upon minorlocal bodily dysfunction or pathology.8 Little consideration wasgiven to the functioning of the individual as a whole person, and no attentionwas paid to superior motivation of special skills which might offset suchunimportant defects as insufficient teeth or pilonidal sinus. The author, whoserved as examining physician to a local draft board during part of this period,could not adequately explain to himself nor to his layman colleagues therejection, because of insufficient molar teeth or a small perforation of
4(1) Sutton, D. G.: NavalPsychiatric Problems. Am. J. Psychiat. 97: 255-275, September 1940. (2) Circular Letter No. 19, Office of The Surgeon General, U.S.Army, 12 Mar. 1941, subject: Neuropsychiatric Examination of Applicants for Voluntary Enlistment andSelectees for Induction. (3) Madigan, P. S.: Military Psychiatry. Army M. Bull. No. 56:61-69, April1941. (4) Campbell, J. D.: Psychiatry and Military Service. Kentucky M. J. 39: 110-115, March 1941. (5)Porter, W. C.: Military Psychiatry and Selective Service. War Med. 1: 364-371, May 1941. (6) Cutler, E. C.:What Physicians Expect From Psychiatry. War Med. 1: 352-357, May 1941.
5Pratt, J. H.: Psychiatric Factors in Medical Examination. War Med. 1: 358-363, May 1941.
6Kardiner, A.: Neuroses of War. War Med. 1: 219-226, March 1941.
7Plans for Rehabilitation of Rejected Draftees. J.A.M.A. 117: 1364, 18 Oct. 1941.
8Menninger, W. C.: CondensedNeuropsychiatric Examination for Use by Selective Service Boards. War Med. 1: 843-853, November 1941.
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| | Registrants unqualified for general military service | |
| Number | Percent | |
| Dental defects | 188,000 | 20.9 |
| Defective eyes | 123,000 | 13.7 |
| Cardiovascular diseases | 96,000 | 10.6 |
| Musculoskeletal defects | 61,000 | 6.8 |
| Venereal diseases | 57,000 | 6.3 |
| Mental and nervous defects | 57,000 | 6.3 |
| Hernia | 56,000 | 6.2 |
| Defective ears | 41,000 | 4.6 |
| Defective feet | 36,000 | 4.0 |
| Defective lungs (including tuberculosis) | 26,000 | 2.9 |
| Miscellaneous | 159,000 | 17.7 |
| Total |
|
|
an eardrum, of husky, alert, well-motivated men who werecapable of performing strenuous activity and the acceptance of sickly, timidselectees whose entire sedentary life had been supervised carefully by anindulgent mother. As the causes for military rejection became common knowledge,9artificial values of health became established in the community, creating guiltand embarrassment for those rejected (the so-called 4-F group) and permittingpoorly motivated persons consciously and unconsciously to exploit minor defectsand subjective symptoms in order to avoid military service.
REEVALUATION OF INDUCTION STANDARDS
The disclosure of the excessive rejection rates marked thebeginning of a critical reevaluation of induction standards, and with increasingneeds for manpower after the outbreak of hostilities, there was a gradual policychange in the direction of considering the individual as an integratedfunctioning being rather than as a collection of tissues and organs. As early asJuly 1941, when the first 6 months of selective service operations indicated thetrend toward high rejection rates, Darnell10 madea plea for medical examiners to utilize MR 1-9 more as a guide rather than asa comprehensive directive. Also, at this time, Meehan11 pointed out thatmilitary induction standards were designed to obtain individuals of superiorqualifications for
9Koontz, A. R.: Has Psychiatry Failed Us in World War II? Mil.Surgeon 101: 204-208, September 1947.
10Darnell, J. R.: Concerning Physical Standards for Selective Service. Army M. Bull. No. 57: 18-27, July1941.
11Meehan, J. W.: Health of the Nation's Manpower. ArmyM. Bull. No. 57: 13-17, July 1941.
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1 year's service and that they should not be construed asan index of health. Meehan indicated the unrealistic nature of current dentalstandards by quoting from the medical statistics of the Provost Marshal Generalof 1875, which noted that the availability of breech-loading guns and metalliccartridges made unnecessary the biting and tearing of paper required with theold-fashioned cartridges, and thus obviated enlistment requirements for incisorteeth. In February 1942, War Department Circular No. 43 reduced the dental andvisual requirements to conform more with the selectee's overall ability tofunction. Dental elimination rates promptly began to fall, followed somewhatlater by a decline in rejections for defective vision.
The efficiency of selection from the psychiatric standpointalso came under critical scrutiny. Aita,12 Menninger and Greenwood,13and Smith14 allstrongly condemned the 2- to 5-minute psychiatric examination usually performedat induction stations as being superficial and of little practical value. Theycalled for a more comprehensive survey of the background and the current statusof the inductee. In July 1942, Porter,15"taking stock"of the mounting psychiatric rejection rate, warned against overzealousness inpsychiatric screening, seriously questioned the ability to predict psychologicalfailure, and advocated measures such as reassignment and rehabilitation insteadof rejection and discharge.
As the war progressed, it was apparent that the rejection ofa high percentage of men at induction stations had failed to prevent the laterappearance of numerous soldiers who were seemingly unable to perform evennoncombat duties. Williams16 argued that the quality of men selected was proofof the adequacy of induction methods, which could accordingly be measured by therelative numbers of inductees subsequently discharged for reasons of physicaland mental disability. A corps area (later service command) with a highrejection rate for all causes or for a particular cause should have given to theArmy such a well-selected group or category that its respective discharge ratewould be small, but in a survey of the nine corps areas in the United States,Williams found much inconsistency. Only two of the corps areas followed theexpected rule. The best correlation of rejection and discharge rates was forvisual defects; the poorest correlation, for hernia, for defects of the ear,nose, and throat, and for neuropsychiatric and musculoskeletal defects.
Consequent to the mounting evidence that induction methodswere not producing the desired results, various suggestions and policy changeswere
12Aita, J. A.: Problem ofNeurologic and Psychiatric Examination During Military Mobilization; III.Consideration of Guides for Examination. Proc. Staff Meet. Mayo Clin. 16:307-313,14 May 1941.
13Menninger, W. C., and Greenwood, E. D.: ThePsychiatrist in Relation to Examining Boards. Bull. Menninger Clin. 5: 134-138,September 1941.
14Smith, L. H.: PsychiatricAspects of Military Medicine. M. Clin. North America 25: 1717-1759, November1941.
15Porter, W. C.: Military Psychiatry.War Med. 2: 543-550, July 1942.
16Williams, G. D.: U.S. ArmyInduction Board Experience November 1940-September 1942. Army M. Bull. No. 65:105-135, January 1943.
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proposed. Halloran and Farrell17 andMoersch18 called for more intensiveefforts to weed out potential mental disorders at induction. Bloomberg and Hyde19published figures indicating that rigorous priorelimination of neurological and psychiatric disorders reduced the dischargerate. The majority of observers, however, were inclined to doubt the predictivevalue of induction examinations and advocated liberalization of physical andmental standards to include the current effectiveness of the individual ratherthan the future possibility of disability. This attitude was also dictated bythe growing shortage of manpower. Koontz20 causedall roentgenograms of registrants rejected for tuberculosis to be reviewed by apanel of experts. This procedure resulted in a 31-percent reclassification tofull military service. Another 19 percent were considered borderline casesrequiring further study, following which many were declared fit for induction.
Rowntree,21 Chief Medical Officer, SelectiveService System, called for a reexamination of all previous rejectees. He citedone study in which 53 percent of those reexamined were found capable of militaryservice. Rowntree also gave current selective service data which demonstratedthe effect of age upon acceptance for military service, as follows:
Age | Percent accepted |
45 | 15 |
36 | 30 |
21 | 70 |
20 | 74 |
19 | 82 |
18 | 84 |
Reynolds22 noted the benefits of obtaining objective information inmedicalhistories from civilian sources and gave results of using such a method inPennsylvania. He recommended this procedure as of special value withindividuals previously hospitalized for tuberculosis or for neuropsychiatricdisease. A routine procedure, operational in the State of Maryland since thebeginning of Selective Service, checked the name of each selectee against aroster of prior State hospital admissions.23 A similar program hadbeen instituted in New York, N.Y.24
17Halloran, R. D., and Farrell, M.J.: The Function of Neuropsychiatry in the Army. Am. J. Psychiat. 100: 14-20,July 1943.
18Moersch, F. P.: The Psychoneurosesof War. War Med. 4: 490-496, November 1943.
19Bloomberg, W., and Hyde, R. W.:Survey of Neuropsychiatric Work at Boston Induction Station. Am. J. Psychiat.99: 23-28, July 1942.
20Koontz, A. R.: Cases Rejected forArmy Service on the Basis of Chest Films Alone. Mil. Surgeon 91: 440-442, October 1942.
21Rowntree, L. G.: Wartime Problems of Selective Service. Mil. Surgeon 92: 149-162, February 1943.
22Reynolds, C. R.: The Medical andEpidemiological Management of Selective Service Men Rejected for MilitaryService. Mil. Surgeon 92: 140-148, February 1943.
23Koontz, A. R.: Keeping Men WithPsychiatric Records Out of the Army. Mil. Surgeon 91: 313-314, September 1942.
24(1) Kopetsky, S. J.: Validity ofPsychiatric Criteria for Rejection for Service With the Armed Forces: Study of Cases of 696 Registrants With Psychiatric DiagnosesFrom New York City Selective Service Area. War Med. 6: 357-368, December1944. (2) McBee, M., and Stevenson, G. S.: Role of Psychiatric Social Workerin Selection of Men for the Armed Forces. Am. J. Psychiat. 99: 431-434,November 1942.
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Cardiovascular manifestations.-Also noted were manyinstances of mind-body relationships that were characteristic of the inductionexamination itself and that had a pertinent bearing uponacceptance or rejection. Of particular importance were various abnormalcardiovascular manifestations. Kilgore25 andLowry26 found thatexamination excitement produced such variations of pulse rate and blood pressurein young men applying for military service that recordings were deemed to be oflittle value at any given time. Both of these observers recommended that, as abetter guide to determining the cardiovascular status, examiners should considergeneral appearance, coordination, posture, color, and strength and endurance asjudged by action in the present and the past. Lowry pointed out that similar abnormalcardiovascular findings may be present in men who have served successfullyfor many years. He explained the fluctuations as being due to the incompletedevelopment of young men, causing them to be highly responsive to sympatheticstimulation.
Wilburne and Ceccolini27 reviewedblood pressure findings in 25,000 consecutive induction examinations. Using 150mm. Hg systolic and 90 mm. Hg diastolic as the upper limitof normal, they found that even after rest periodshypertension occurred at the rate of 0.96 percent, as compared with 0.47 percentfor insurance examinations and 1.6 percent for examinations of young collegestudents. In this large series, they found that from 18 to 20 percent ofselectees had elevated blood pressures on initial readings if the currentstandard of 140 mm. systolic was used. Rest periods from 15 to 30 minutesreduced the blood pressure of the vast majority of cases to normal levels. Themost marked instance of lability was an initial blood pressure of 230/112which, after 35 minutes of rest, decreased to 146/80. Orenstein,28usinga standard of 140/90, found hypertension without other cardiovascular or renalfindings to be three times more common among Negro selectees than among theirwhite counterparts. Rogers and Palmer29 discussedthe relationship of transient, nervous hypertension to so-called essentialhypertension. Examination of candidates in an officer procurement centerindicated that 14 percent had mild, variable hypertension with no organicchanges at the initial examination. These individuals frequently displayed signsof a nervous pressor reaction, such as tachycardia and sweating. Their reactionto the cold test was greater than normal but less than in early, mild, definitehypertension, and responses to exercise and position were not significant.Prognosis, as revealed by a followup of 25 cases, was excellent. Wilburne andCeccolini concluded that even early signs of essential hypertension need not bedisqualifying, and they recommended ac-
25Kilgore,E. S.: The Heart in Military Service. J.A.M.A. 117: 258-260, 26 July 1941.
26Lowry, E. F.: Evaluation of HeartSigns in Navy Recruiting. Mil. Surgeon 90: 37-44, January 1942.
27Wilburne, M., and Ceccolini, E. M.:Note on the Incidence of Arterial Hypertension in25,000 Army Examinees. Army M. Bull. No. 68: 118-125, July 1943.
28Orenstein, L. L.: Hypertension inYoung Negroes. War Med. 4: 422-424, October 1943.
29Rogers, W. F., and Palmer, R. S.:Transient Nervous Hypertension as a Military Risk; Its Relation to EssentialHypertension, New England J. Med. 230: 39-42, 13 Jan. 1944.
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ceptance of applicants with variable hypertension above thestandard limits under the following conditions: A negativefamily history of death from cardiovascular disease under 60, absence ofpronounced tachycardia, normal fundi, an age of 40 yearsor younger, and a response to cold test of less than 20 systolic and 15diastolic.
A reevaluation of rejectees for cardiovascular reasons30resulted in 17.3 percent being resubmitted as fit formilitary service. From this reevaluation, Fenn and his associates found thatcardiovascular disease accounted for 10 percent of rejectees between the ages of18 and 38. The common categories were as follows:Rheumatic heart disease, 50 percent; hypertension, 21 percent; neurocirculatoryasthenia, 5 percent; and sinus tachycardia, 4percent. These observers recommended that blood pressure standards be raised to160/90 in nervous persons and that the pulse limits be placed between 40 and120. In regard to neurocirculatory asthenia, it has been noted by Britishobservers that this phenomenon was far less frequent than in World War I.31Similar observations were noted in the United States.32
Neurocirculatory asthenia.-Starr33reported on a ballistocardiographic study of draftees who had been rejected forneurocirculatory asthenia. He found that abnormalities ofthe circulation could be demonstrated in 75 percent of the cases and recommendedthe use of the ballistocardiograph for the detection of malingerers who feignedsymptoms of this type. Starr was of the opinion that neurocirculatory astheniawas in no sense a disease for it affects neither health nor duration of life. Heconsidered that the syndrome constituted a maladjustment of the circulation, nodoubt precipitated by emotion but primarily a predisposition which, like clumsymovement of muscles, usually dates from early life and may be hereditary. Henoted that many of those studied had selected certain light occupations andavoided others because they were aware of being made worse by emotion and byphysical stress, which explained why they "quit" or broke down whenplaced at heavy work in the service.
Albuminuria.-Another example of psychosomaticinterrelationships was the frequent occurrence in the young inductees ofalbuminuria without apparent cause. This phenomenon had been observed for manyyears and was variously described as benign, orthostatic, or psychogenic. Itposed a chronic and annoying problem in evaluation formilitary service. Kidney disease was often suspected, andmany individuals were rejected. Young,
30Fenn, G. K., Kerr, W. J., Levy, R.L., Stroud, W. D., and White, P. D.: Reexamination of 4,994 Men Rejected forGeneral Military Service Because of Diagnosis of Cardiovascular Defects. Am.Heart J. 27: 435-501, April 1944.
31Jones, M., and Scarisbrick, R.:Effort Intolerance in Soldiers: A Review of Five Hundred Cases. War Med. 2: 901-911,November 1942.
32Dunn, W. H.: GastroduodenalDisorders; An Important Wartime Medical Problem. War Med. 2: 967-983, November 1942.
33Starr, I.: BallistocardiographicStudies of Draftees Rejected for Neurocirculatory Asthenia. War Med. 5: 155-162, March 1944.
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Haines, and Prince34 stated that intheir experience one out of every four rejections by Armyinduction boards for albuminuria was established by careful clinical andlaboratory tests to be of orthostatic origin, with no renal lesions present.They emphasized the value of obtaining urine specimens after subjects had beenplaced in an exaggerated lordotic position. From their studies, they wereconvinced that albuminuria of this origin is harmless anddisappears with age. A careful study of this problem was also madeby Ahronheim35 in the examination of air cadets. He found that 554outof 1,000 men displayed albuminuria in one or both specimens taken before andafter the routine intravenous withdrawal of blood. Of those who fainted duringblood removal, 100 percent exhibited albuminuria in subsequent specimens.Ahronheim noted that similar observations had been madeon college students36 and onfrightened cats.37 He gave support for histhesis that this type of albuminuria was of psychogenic etiology by citing thefollowing incidents: (1) a cadet fainted during blood withdrawal and fell,striking his head and causing a bloody laceration. Of the17 onlooking candidates awaiting their turn, 15 exhibitedalbumin in the urine specimens collected at this time. (2)A pilot who emerged unharmed from a nerve-rackingcrashlanding had 3+ albuminuria, which cleared by the next morning. (3) Subjectswith albuminuria were given a placebo of a bright color and bitter taste todrink and were told that it was a potent medicine. Inover 50 percent of the cases, the albuminuria promptly cleared. Ahronheim alsofound that this phenomenon decreased with age and that higher age groups did notrespond to emotional stimuli by albuminuria.
REVISED STANDARDS
Toward the latter part of 1943 and in early 1944, theincreasing evidences of failure in medical selection had become crystallizedinto overt admissions of error in aims and methods. A semiofficial editorial38pointed out that currentneuropsychiatric incidence was three times that of World WarI, despite the fact that neuropsychiatric rejections were three to four timesgreater than in World War I. Farrell and Appel,39 emphasizing thelimitations of psychiatric screening, recognized that psychiatric breakdowns incombat could not be predicted at induction since the breakdowns were a complexresultant of failures in group relationships, in leadership, and in training,complicated by fatigue, hunger, and other physiological
34Young, H. H., Haines, J. S., andPrince, C. L.: Orthostatic Albuminuria: The Importanceof Its Recognition by Medical Examining Boards. Mil. Surgeon 92: 353-365, April 1943.
35Ahronheim, J. H.: Emotional Albuminuria. War Med. 5: 267-270,May 1944.
36Diehl, H. S., and McKinlay, C.A.: Albuminuria in College Men. Arch. Int. Med.49: 45-55, January 1932.
37Starr, I., Jr.: The Production of Albuminuria by RenalVasoconstriction in Animals and Man. J. Exper. Med. 43: 31-51, January 1926.
38Neuropsychiatric Disease: Causes and Prevention. Bull. U.S.Army M. Dept. 1: 9-13, October 1943.
39Farrell, M. J., and Appel, J.W.: Current Trends in Military Neuropsychiatry. Bull. U.S. Army M. Dept. 2:44-50, July 1944.
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factors. These authors urged consideration of preventivemeasures rather than elimination. Policy changes were instituted that completelyreversed the former concept of screening out all potentialbreakdowns. War Department Technical Bulletin (TB MED) 33, issuedon 21 April 1944,40 pointed out that the acute need formanpower made imperative the induction of all men who had a reasonable chance ofadjusting themselves to the service. This change was incorporated into MR 1-9,in June 1945. In several studies of successful combat and noncombat soldiers,41individuals were found to have performedsatisfactory or superior service despite a background of psychoneuroticpredispositions.42 Doubts about the value of medical screening becamewidespread, and to some43 it nowseemed best to induct all but the halt and the blind-theobviously incapable-and rely upon basic training as apractical test of fitness.
It was evident that a more sensible viewpoint was needed inthe medical selection of men for military service. Steps were taken in thatdirection by borrowing methods employed by the Canadian Army, which had beenreported on favorably by Meakins44 and by Kubie.45
The Canadian Army system, known as PULHEMS, was a survey ofseven physical and mental qualities numerically graded from one to four, thehigher numbers indicating increasing dysfunction in the particular category: Prepresented overall physical endurance and capacity; U referred to the upperextremities; L, lower extremities; H, hearing; E, eyes or vision; M,mental ability or intelligence; and S, emotional stability.This method embodied the psychosomatic viewpoint of considering the entireindividual, yet paying attention to local defects. It had the advantage ofconsidering in one spectrum the overall capabilities and incapabilities of theindividual. It was introduced in the American Army on a small scale in thespring of 1942 and came to be more widely used in 1944 and 1945.46
40War Department Technical Bulletin(TB MED) 33, 21 Apr. 1944, subject: Induction StationNeuropsychiatric Examination.
41(1) Sheps, J. G.: APsychiatric Study of Successful Soldiers. J.A.M.A. 126: 271-273, 30 Sept.1944. (2) Needles, W.: The Successful Neurotic Soldier. Bull. U.S. Army M. Dept.4: 673-682, December 1945.
42During the postwar period,there appeared various reviews and reflections upon the results of routineinduction examinations, particularly the failures of psychiatric screening (seeMenninger, William C.: Psychiatry in a Troubled World.New York: MacMillan Co., 1948, pp. 134-152). Fry (see Carmichael,L., and Mead, L. C. (editors): The Selection of Military Manpower, a Symposium.Washington, D.C., National Research Council, 1952. A Study of Special Groups byClements C. Fry, pp. 133-148) found that 70 percent of individuals who hadbeen psychiatric patients while in college had rendered satisfactory or betterthan average service during World War II, the majority as officers. J. R. Eagan,L. Jackson, and R. H. Eanes (A Study of Neuropsychiatric Rejectees. J.A.M.A.145: 466-469, 17 Feb. 1951) found that, of men who had previously beenrejected for psychiatric reasons, 79.4 percent performed their duties well,although the number of discharges for disability for the group as a whole wasthree times the Army's average. N. Q. Brilland G. W. Beebe (Follow-UpStudy of Psychoneuroses; Preliminary Report. Am. J. Psychiat. 108: 417-425,December 1951) in followup studies of psychiatric breakdowns during militaryservice concluded that 50 percent of them could not have been predicted by themost thorough psychiatric examination-A. J. G.
43Bloomberg, W.: Plan forScreening, Induction, and Utilization of Man Power. Am. J. Psychiat. 105: 462-465, December 1948.
44Meakins, J. C.: "Pulhems" System of MedicalGrading. Canad. M.A.J. 49: 349-354, November 1943.
45Kubie, L. S.: Special Aspectsof Procedures and Organization for Induction and Discharge in the Canadian Army.War Med. 5: 373-377, June 1944.
46(1) Developments in Military Medicine. Bull. U.S. ArmyM. Dept. 7: 602, July 1947. (2) Supplement to Mobilization Regulations No. 1-9,Physical Profile System, 22 May 1944, revised June 1945.
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Six categories (PULHES) were employed in the U.S. Army, inwhat became known as the Physical Profile Serial System.47
To summarize briefly, it may be saidthat the selection experiences of World War II induced an appreciation of thehuman being as a complex, integrated organism whose futureperformance could be assessed not by a narrow localizedmeasure but only through recognition of somatic and psychicinterrelationships as well as of sociological and cultural factors.
Part II. During Training andService in the Zone of Interior
PSYCHOSOMATIC DISORDERS DURING TRAINING
A primary mission of the World War IImilitary program was the difficult task of transforming raw selectees into aneffective fighting force. For the majority of new soldiers, this processcomprised several distinct phases; namely, basic training, advanced orspecialized training, unit training with battle indoctrination, and oftenparticipation in large-scale maneuvers and preparation for oversea movement.Considerable variation of the training program was necessary during the lateryears of the war because urgent needs for infantry and other replacements oftenpermitted time only for basic training and preparation for oversea shipment. Inaddition, large numbers of troops remained in the Zone of Interior to performthe various necessary logistic and support tasks.
Although each of the phases just mentioned had itsdistinctive physical and emotional stress with consequent characteristicadjustment problems, the initial or basic training produced the largest numberof medical and behavioral disorders. Basic training constituted the criticalperiod of transition from civilian to military life. Here, the trainee wasrequired abruptly to accommodate himself to separation from home, toregimentation, to lack of privacy, to enforced competition, to new dietaryhabits, often to sexual deprivation, and to the useof firearms and explosives, in addition to unusual andstrenuous physical exertion and exposure to a relatively primitive fieldenvironment.48Other types of training also produced discomfort, frustration, and physiologicalstrain which, when added to uncertain or defective
47In September 1950, the PhysicalProfile Serial System was adopted as a common standard for all branches of the armed services (Jacobs, E. C.: Medical Screening of MilitaryMan Power: Utilization of the Physical Profile Serial System. Mil. Surgeon 112:112-118, February 1953; also AR 40-115, 20 Aug. 1948, subject: PhysicalStandards and Physical Profiling for Enlistment and Induction), and its soundnesswas confirmed during the Korean War. With liberal induction standards andemphasis upon proper assignment, rejection and discharge rates were notexcessive. Psychiatric breakdowns increased in number during the severe battlephases, but accent upon rehabilitation and return to duty reversed the World WarII experience of disability. In fact, the discharge rate for neuropsychiatricdisease declined during the Korean War.-A. J. G.
48Menninger, William C.: Psychiatryin a Troubled World. New York: Macmillan Co., 1948, pp. 56-80.
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motivation and complicated by the cultural acceptance ofdisease as an honorable reason for the avoidance of obligations, produced clinicalsyndromes that defied the usual diagnostic and treatment procedures. In general,such psychosomatic disorders were of three related types, all of which hadin common a persistence of somatic complaints.
First, there was a purely psychogenic group in which littleor no objective evidence of significant structural or functional pathology couldbe demonstrated. The patients of this group stubbornly clung to bodily symptomsand, as noted by Menninger,49 were found almost as often on the medical andgastroenterology wards as on the psychiatric wards.Indeed, the bulk of overt psychological disorders had oneor more chief complaints of headache, stomach trouble,chest pain, weakness, palpitation, backache, dizziness, arthralgia, skin rash,or diarrhea.50
Second, there were those well-known clinical entitiesgenerally regarded as having an emotional component ineither etiology or clinical course, such as peptic ulcer,hypertension, asthma, various dermatological syndromes, migraine,and rheumatoid arthritis, which responded relatively poorly to treatment orpromptly recurred upon preparation for, or after return to, duty.51
The third and perhaps most numerous group included personnelwho persistently voiced residual somatic complaints following subsidence of theacute phase of almost any injury, illness, surgical procedure, or even physicalstrain. Thus, there were syndromes of painful discomfort with or withoutlimitation of function following mild lower back injury,52 minor headinjury,53 foot strain,54rheumatic fever,55infectious hepatitis,56surgery for
49Menninger, W. C.: Relationships ofNeuropsychiatry to General Medicine and Surgery in the Army. Mil. Surgeon 96: 134-138,February 1945.
50(1) Brussel, J. A., and Wolpert,H. R.: The Psychoneuroses in Military Psychiatry. War Med. 3: 139-154,February 1943. (2) Altman, L. L.: Neuroses in Soldiers; Use of Sodium Amytal asan Aid to Psychotherapy. War Med. 3: 267-273, March 1943. (3) Pulsifer, L.:Psychiatric Aspects of Gastrointestinal Complaints of the Soldier inTraining. Mil. Surgeon 95: 481-485, December 1944. (4) Casey, J. F.:Disciplinary Problems in a Military Neuropsychiatric Hospital. Mil. Surgeon 97:312-317, October 1945. (5) Incidence of Somatization Reactions inPsychoneurotic Disorders. Bull. U. S. Army M. Dept. 5: 383-384, April 1946.
51(1) Study of Psychosomatic Dermatological Syndromes. Bull. U.S. Army M. Dept. 5: 18-20, January1946. (2) Davis, D. B., and Bick, J. W., Jr.: The Diagnosisof Migraine in Flying Personnel. Mil. Surgeon 98: 17-20, January 1946.(3) Zanfagna, P. E.: Perennial Bronchial Asthma; Analysis of One Hundred Cases. Bull. U.S. Army M. Dept. 3: 100-103, April 1945. (4)McFarland, M. D.: Hypertension in an Army General Hospital.Mil. Surgeon 97: 209-215, September 1945. (5)Sweeney, J. S.: Gleanings From the Medical Service of a General Hospital.Mil. Surgeon 97: 7-13, July 1945.
52Weiss, I. I.: A Study ofCamptocormia With Presentation of 3 Postspinal Cases. Mil. Surgeon 97: 462-474, December1945.
53Denny-Brown, D.: Sequelae ofWar Head Injuries. New England J. Med. 227: 771-780, 19 Nov. 1942;813-821, 26 Nov. 1942.
54(1) Cozen, L. N.: The Treatment of PainfulFeet in the Army. Mil. Surgeon 91: 196-198, August 1942. (2) Burnham, W. H.:Army Foot Disabilities, Mil. Surgeon 95: 20-24, July 1944.
55Hench, P. S., and Boland, E. W.: The Army Rheumatism Centers.Bull. U.S. Army M. Dept. 5: 655-662, June 1946.
56Benjamin, J. E., and Hoyt, R. C.: Disability Following Postvaccinal (Yellow Fever) Hepatitis. J.A.M.A. 128:319-324, 2 June 1945.
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pilonidal sinus,57 abdominal surgery,58 electiveorthopedic surgery,59 removal of herniated nucleus pulposus,60 andeven diagnostic lumbar puncture.61 In these cases, the persistentsymptomatology could not be substantiated by clinical, X-ray, orlaboratory findings, and one could only speculateregarding the probability of adhesions, scar tissue, or altered physiologyas causative mechanisms.
Clearly, these complex medical problems required a totalapproach for proper diagnosis and treatment, but such a psychosomatic viewpointwas lacking in the early years of World War II. The newly commissioned medical officershad little practical knowledge of the military environment. It was difficultfor them to appreciate that somatic symptoms could and frequently did representthe mental, physical, and cultural responses to the stress of a wartime militaryadaptation rather than the presence of structural or psychological disease.Also, there existed a general tendency to hospitalize military personnel forsubjective complaints and relatively minor disorders. Large numbers of theseambulatory cases were admitted or retained in Army hospitals.62 The secondarygain to be derived from illness and hospitalization soon became a familiarfeature of military medicine, fixating symptomatology, vexing medical officers,and creating hostile and resentful patients.63 The more thoroughly symptoms wereinvestigated, the longer was the hospitalization and the more convincedbecame patients that they had valid medical reasons for relief from onerous dutyor even for discharge from the service.
Under these circumstances of iatrogenic and hospitalistictrauma, an atmosphere was created that stimulated others in and out of thehospital to seek relief, via medical channels, for their unhappiness anddiscomfort. One observer, Eisendorfer,64 commented: "Neurosis is ascontagious as a virulent infection. For every neurotic patient hospitalizedthere are ten more with potential neuroses who do not require much stimulationto react in a similar manner." Altman and his associates65found:
Soldiers lack no opportunity and lose none in comparing noteswhile in the hospital. Enforced idleness, few recreational facilities, andprolonged hospitalization help to en-
57Rogers,H.: Pilonidal Sinus; The Indications for Treatment in the Military Service inTime of War. Mil. Surgeon 95: 454-457, December 1944.
58Bowers, W. F.: Observations in theFirst Six Months of the General Surgical Section of the 1,500 Bed CantonmentType Station Hospital at Fort Leonard Wood, Missouri. Mil. Surgeon 91: 170-176,August 1942.
59(1) Pickett, J. C.: The Diagnosisand Treatment of Internal Derangements of the Knee Joint. Mil. Surgeon 97: 198-203, September 1945. (2) Cozen, L. N.:Malingering Among Soldiers: Orthopedic Aspects. Mil. Surgeon 92: 655-657, June 1943. (3) Willien, L. J.:Second-Year End Result of Arthrotomies of Knee. Bull. U.S. Army M. Dept. 4: 452-456, October 1945.
60Haynes, W. G.: Problem of HerniatedNucleus Pulposus in the Military Service. War Med. 3: 585-595, June 1943.
61Levin, M. J.: Lumbar Puncture Headaches. Bull. U.S. Army M.Dept. 2: 107-110, November 1944.
62Pignataro, F. P.: Experiences inMilitary Psychiatry. Mil. Surgeon 91: 439-460, October 1942.
63(1) Sarlin, C. N.: PsychiatricConsultations in the Army. Mil. Surgeon 97: 139-143, August 1945. (2) See footnote 49, p. 687.
64Eisendorfer, A.: ClinicalSignificance of Extramural Psychiatry in the Army. WarMed. 5: 146-149, March 1944.
65Altman, L. L., Pillersdorf, L.,and Ross, A.T.: Neuroses in Soldiers; Therapeutic Barriers. War Med. 2: 551-560,July 1942.
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courage this tendency. Procedures, results of treatment,death in a ward, disposition of other soldiers or almost any other occurrence inthe hospital rarely escapes them.
Frustrated medical officers defended themselves by blamingtheir patients for having "neurotic predisposition" or"functional overlay" or by such castigations as "misfits,""chronic complainers," "neurotics," "hysterics,"or "slackers." There was a general tendency to refer these cases tothe psychiatrist, as illustrated by Eisendorfer's report that 48 percent ofall patients admitted to Tilton General Hospital, Fort Dix, N. J., for the first6 months of 1943 were examined by the neuropsychiatric service for the purposeof either consultation, treatment, or disposition. But the psychiatry wards werealso congested. Psychiatrists were loath to accept, as transfer patients, thosewho had extensive hospitalization because of either prolonged clinicalinvestigation or residual complaints following disease, injury, or surgery.According to Altman and his coworkers, such patients were not only resistant topsychiatric exploration and treatment but were overtly hostile toward any effortto remove their favorable status of hospitalization with its expectation ofmedical discharge. No one wanted these patients who, inturn, resented their doctors. Thus, an impasse was created.
MEDICAL DISCHARGE
The simple solution to this impasse was medical discharge.Indeed, medical separation was not only the easy way out for both patient andmedical officer but had been recommended by prominent authorities on the groundsthat modern war demanded individuals of "superior mental and physicalstamina."66 Madigan,67considering the recruit's first year, concludes:
There is no place in the Army for the physical and mentalweakling. The Army should not be regarded as a gymnasium for the training anddeveloping of the undernourished and underdeveloped, nor a psychiatric clinicfor the proper adjustment of adolescents who need emotional support.
These sentiments were echoed officially by Circular LetterNo. 1968 and supportedby Billings,69 Porter (p. 680), Harrison,70and othercivil and military medical leaders. As a result, the medical discharge ratesteadily mounted. It was further increased by the influence of War DepartmentCircular No. 161, dated 14 July 1943,71 which required the reevaluation anddischarge of limited service personnel. In September 1943, the medical dis-
66Seefootnote 3 (1), p. 677.
67See footnote 4 (3), p. 678.
68See footnote 4 (2), p. 678.
69Billings, E. G.: The Recognition, Prevention and Treatment ofPersonality Disorders in Soldiers. Army M. Bull. No. 58: 1-37, October 1941.
70Harrison, F. M.: Psychiatry in the Navy. War Med. 3: 113-138, February 1943.
71War Department Circular No. 161, 14July 1943, sec. III, subject: Elimination of the Term Limited Service WithReference to Enlisted Men.
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charge rate approached 70,000 per month, which approximatelyequaled the induction rate.72
A typical picture of this problem in the early years of thewar is given by Kinsey73 who analyzed 1,000 consecutive medical discharges fromthe Station Hospital, Camp Blanding, Fla., over a 6-month period in the latterpart of 1942 and early 1943. The 12 leading causes for medical separation wereas follows:
| Percent |
Psychoneurosis (all types) | 40.2 |
Duodenal ulcer | 7.4 |
Psychoses (all types) | 6.9 |
Arthritis | 5.9 |
Asthma | 3.8 |
Organic and central nervous system disease | 3.6 |
Epilepsy | 2.7 |
Rheumatic heart disease | 2.6 |
Tuberculosis (pulmonary) | 1.7 |
Deformities of extremities | 1.5 |
Bronchitis (chronic) | 1.3 |
Hernia (inguinal, indirect, reducible) | 1.2 |
Similar findings were reported by Pignataro74 from theStation Hospital, Camp Livingston, La., for 1941 and1942. Kinsey commented that almost all the psychoneuroticshad symptoms referable to the gastrointestinal tract or to the cardiovascularsystem. In most of the so-called organic categories, neurotic predisposition,functional overlay, or poor motivation were considered the primary cause ofdischarge. Peptic ulcer promptly recurred when patients were returned to duty.Depression and lack of interest were noted in most cases discharged forarthritis. Asthmatics all admitted that their illness occurred before inductionbut insisted that they could not perform physical work in the service and ifforced to do so would suffer severe impairment of health. It was impossible toattempt a trial of duty for patients with minimal rheumatic heart disease asthey began to complain upon leaving the hospital. The low incidence of dischargefor orthopedic conditions is accounted for by the number of instances in whichassociated psychoneurotic disease was regarded as the primary reason for theirmedical disability.
When these men were questioned just before discharge, 60percent said they should not have been inducted and could not be adjusted in theArmy under any circumstances; 25 percent said they could have been adjusted ifgiven a job to which they were accustomed upon entry in the Army but "theywere too nervous to do any good now." Fifteen percent felt that they couldhave been adjusted if given the right commanding officer or "had been
72Disability Discharges. Bull. U.S.Army M. Dept. 2: 52-55, December 1944.
73Kinsey, R. E,: Study of 1,000 Cases Separated From the Armyon Certificate of Disability for Discharge. Bull. U.S. Army M. Dept. 1: 64-75.October 1943.
74See footnote 62, p. 688.
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given a break" or "if things had gone right athome." Paradoxically, the majority of these menplanned to work soon after discharge in defense plants or on a farm. Kinsey cameto the pertinent conclusion that the major problem in most of these individualswas one of adjustment to army life rather than incapacitating disease.
POLICY OF MAXIMUM UTILIZATION
As the foregoing reports indicate, medical officers, withtime and experience, learned that the purely medical considerations of symptoms,diagnosis, clinical course, and treatment of illness orinjury could not be disassociatedfrom the physiological and psychological problems of military adjustment.Meanwhile, developing manpower shortages demanded the salvage of so-calledweaklings and misfits, if only for limited duty. A reorientationof medical thinking began to make itself felt in late 1942 andearly 1943 in a liberalization of standards for selectionand induction. A policy of maximum utilization wasofficially adopted in November 1943 with the issuance of War Department CircularNo. 293,75 stating that no man should be discharged so long as he could renderadequate service in the Army. This trend was furtherelaborated by War Department Circular No. 81, 13 March 1945,76 which directed against medical discharge for minorconditions,such as flat feet, mild sacrolumbar strain, and mild psychoneurosis, when theprimary cause was defective attitude, inadaptability, andso forth. It warned that the medical defect in itself was not a cause fordischarge unless genuinely disabling and directed that such cases be returned toduty or be administratively separated. In the main, medical efforts to implementthese changes toward maximum utilization of marginal personnel were developed inthree major areas: (1) Prevention of hospitalization, (2) reconditioning, and(3) hospital practice.
Prevention of Hospitalization
As has been noted, there was early recognition of the adverseeffects of hospitalization in creating or perpetuating an adverse adaptation toillness or disability. This deleterious effect was mostpronounced in neurotic disorders or in patients with minoror purely subjective complaints. An obvious solution was the outpatientmanagement and treatment of such cases. Quite early in thewar, Army psychiatrists moved toward the development ofsuch extramural management of adjustment problems among trainees.This concept and practice rapidly expanded to become the replace-
75War Department Circular No. 293, 11 Nov.1943, subject: Enlisted Men-Utilization of Manpower Based on PhysicalCapacity.
76War Department Circular No.81, 13 Mar. 1945, sec. III, subject: Personnel-Administrativeand Medical Disposition of Noneffective Personnel.
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ment training center clinic system which achieved officialrecognition in 194377 and became a prominent feature of military psychiatryin World War II. Its origin, development, and methodology have been welldocumented by Perkins.78
The concepts and methods of outpatient military psychiatrywere soon reflected in many other areas of military medical practice. Rogers79argued against radical excision for pilonidal sinus disorders, pointing out thatsuch procedure required prolonged hospitalization and convalescence during whichactivity was extremely limited, motivation was impaired, new symptoms developed,and return to duty became problematical. He favored conservative treatment withthe patient on duty status.
For gastrointestinal and othercomplaints.-From an extensive experience (1,702 cases) at a large Army post,Loder and Kornblum80 found that mostcases referred for gastrointestinal complaints were best handled on anoutpatient basis with roentgenologic studies. After negative findings by X-ray,78 percent did not return to the clinic. These workers held that such beneficialresults were due not only to reassurance of the patient but also to thereassurance of the referring medical officer, who could then adopt a firm andrealistic attitude toward the repeated complainer.
The treatment on duty status of acute gonorrhea wassuccessfully accomplished by Atcheson,81 using sulfathiazole. Patients wereevaluated periodically on an outpatient basis, and in 92 percent successfulresults were obtained with no increase in complications in comparison withpatients hospitalized for gonorrhea. Similar excellent results were obtained byCampbell and Carpenter.82
An effective plan for avoiding the hospital atmosphere wasdeveloped in 1944 at O'Reilly General Hospital, Springfield, Mo., as reportedby Josey.83 All ambulatory admissions were placed in a group of wards known asthe disposition section, which avoided the usual hospital regimen of nursingcare and medication. These cases were thoroughly worked up in a nearbyclinic building. A decision was then made for hospitalization, reconditioning,return to duty, or discharge from the service. Of approximately 5,000patients admitted to O'Reilly General Hospital during a 6-month period, 52percent were evaluated in the disposition section and 23 percent received finaldisposition to duty or discharge without further hospitalization.
77Halloran, R. D., and Farrell, M. J.: Neuropsychiatrists inthe U.S. Army; Their Functions in General and in Relation to ReplacementTraining Centers. Army M. Bull. No. 65: 151-156, January 1943.
78Medical Department, United StatesArmy. Preventive Medicine in World War II. Volume III. Personal Health Measuresand Immunization. Washington: U.S. Government Printing Office, 1955, pp. 171-232.
79See footnote 57, p. 688.
80Loder, H.B., and Kornblum, S. A.: Duodenal Ulcer in a Large Army Camp; Incidence andStatistical Analysis. Mil. Surgeon 96: 492-497, June 1945.
81Atcheson, D. W.: Duty StatusTreatment of Acute Gonorrhea. Mil. Surgeon 96: 159-163, February 1945.
82Campbell, G., and Carpenter, G. R.:Treatment of Acute Gonorrhea in the Army. Am. J. Syph. 28: 406-412, July 1944.
83Josey, A. I.:Disposition Section for Ambulatory Patients. Bull. U.S. Army M. Dept. 5: 353-355,March 1946.
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In the common problem of foot complaints, Pemberton84found that most of such casescould be cared for by the dispensary medical officer in order to avoidhospitalization and loss of time from training. Pemberton pointed out thatrecent inductees readily developed foot strain, particularly those who had led asedentary life before service. However, these symptoms begin to subside in thefourth week of training, and at the end of 8 weeks the soldier can drill all dayand hike from 15 to 20 miles without strain. Treatment is not required exceptfor a hot footbath at night since continued use is part of the conditioningprocess. Placing such a patient off duty or on light duty only postpones thetime of complete recovery. Pemberton also restated an obvious but importantfinding; namely, that flat feet are subject to strain in the same manner asother feet and may become painful, but relief depends upon treatment of thestrain and not of the flat foot.
In staging areas.-Prevention ofhospitalization was particularly important at staging areas before overseashipment. Lipschutz85 noted thatsoldiers arrive at all hours and the incidence of acute illness isunpredictable. He found that from 40 to 50 percent of sick call cases wereprimarily psychological problems. He noted that sick call was particularlycrowded when a unit was alerted for oversea shipment. Under these circumstances,hospitalization justifies complaints and strengthens the connotation ofdisability. On the other hand, neglect, ridicule, and denial serve the sameattitude. This situation required the vigorous resources of an outpatient clinicwhere the medical officers adopted a psychosomatic approach and made promptdecisions for disposition.
Reconditioning
The development of organized programs of physical and mentalactivity for convalescent and ambulatory patients marked another importantadvance in psychosomatic medicine in World War II. These programs began in 1942as a spontaneous attempt to prepare hospitalized patients for return to duty.Pioneer efforts in this sphere are generally credited to the Army Air Forceshospitals along with British military hospitals.86 The idea and thepractice, in various forms, of active convalescent care were rapidly adopted bymost American military hospitals both in the United States and overseas. Soonthere appeared reports of these successful activities which now became known asreconditioning. Childress,87 in noting the results of an activeconvalescent program begun in 1942 by the orthopedic service of Stark GeneralHospital, Charleston, S.C., found that supervised drilling and field exercises
84Pemberton, P. A.: The Care of Soldier's Feet. Bull. U.S.Army M. Dept. 3: 110-117, January 1945.
85Lipschutz, L. S.: Symposium onPsychiatry in the Armed Forces; Neuropsychiatry in a Staging Area. Am. J.Psychiat. 100: 47-53, July 1943.
86(1) The Reconditioning Program. Bull. U.S. Army M. Dept. 1: 27-30, December 1943. (2) Rusk, H. A.: The Convalescent Training Program in the Army AirForces. Tr. Am. Neurol. A. 70: 19-22, 1944.
87Childress, H. M.: Regulated Group Exercise forConvalescent Patients. Mil. Surgeon 91: 581-584, November 1942.
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prevented anxiety neurosis, "jitters," and"hospitalitis." Thomas,88 also in 1942, stressedthe importance of such a program in maintaining the morale of patients. Piazza,89 in discussing the benefits of reconditioning at Moore GeneralHospital, Swannanoa, N.C., in 1943, remarked that reconditioning was fastbecoming as much a part of Army medicine as typhoid inoculation. To quote fromthis author:
No longer need the patient stare aimlessly at the bareceiling hour after hour, no longer need the ambulatory patient pace the hardfloor or hospital corridor uselessly or spend his time lounging in the postexchange or Red Cross building thinking about his illness or injury, magnifyingit to unendurable proportions to the point of becoming useless to himself andthe service.
Convalescent reconditioning was formally recognized in thesummer of 1943. In August 1943, Maj. (later Lt. Col.) Walter E. Barton, MC, wasappointed the first director of the newly created (June 1943) Reconditioning Division,Professional Service, Office of The Surgeon General, and in September 1943,Circular Letter No, 16890 providedfor the establishment of convalescent reconditioningprograms at all Army hospitals. The Surgeon General's Office laid down broadguidelines for the operation of reconditioning in hospitals, as follows:91
1. Reconditioning to be successful must begin the momentconvalescence begins. This may be while the patient is still confined to bed.
2. The mental attitude of every member of the hospital stafftoward reconditioning is extremely important. There must be at all times theexpectancy that the patient will return to duty.
3. Transfer of the patient from the hospital atmosphere tothe reconditioning section as soon as he is not dependent upon active medicaltreatment is of paramount importance in restoring health.
4. In reconditioning sections, men spend their mornings incalisthenics, ward fatigue, outdoor drills, and marches. Afternoons may be spentin games and sports adapted to the physical strength of patients. In theevenings, movies, camp shows, group singing, quiz programs, and otheropportunities for free choice of recreational outlets should be provided, with amore liberal use of town and weekend pass privileges.
The typical operation of reconditioning procedures in Armyhospitals in World War II is illustrated in the reportsfrom Lawson General Hospital, Atlanta, Ga.,92 and Oliver GeneralHospital, Augusta, Ga.93 As suggested by the Surgeon General'sOffice, convalescent patients were divided into fourclasses, as follows:
88Thomas, H. M., Jr.: Convalescent Careand the Morale of Patients. Mil. Surgeon 93: 453-457. December1943.
89Piazza, F.: The ReconditioningProgram at Moore General Hospital. Mil. Surgeon 96: 81-84, January 1945.
90Circular Letter No. 168, Office ofThe Surgeon General, U.S. Army, 21 Sept. 1943, subject:Convalescent Reconditioning in Hospitals.
91See footnote 86 (1), p. 693.
92Titus, N. E.: Rehabilitation Program atLawson General Hospital. Bull. U.S. Army M. Dept. 1: 88-93, April 1944.
93Bilik, S. E.: Reconditioning Problemat Oliver General Hospital. Bull. U.S. Army M. Dept. 2: 81-93, July 1944.
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Class I: Convalescents capable of being toughened by fullphysical activity.
Class II: Patients capable of limited physical activityrequiring graded training to prepare for progression toClass I.
Class III: Ambulatory patients handicapped to varying degreesby residua of illness or injury.
Class IV: Bed patients.
Classes I and II patients were housed in the reconditioningsections, generally troop barracks or the back wards of the hospital, where theusual hospital atmosphere of nursing and medication wasavoided. Patients were given uniforms and fatigue clothinginstead of hospital garb; they were marched to meals and were responsible forpolicing their barracks or wards, which were inspectedregularly. They were drilled and commanded by convalescent officer patients. Afull day's program of activity was enforced. Failure toabide by the program brought denial of pass, restriction, and even confinement.
All observers agreed that convalescent training should beaccomplished under medical supervision with one or more medical officersdevoting full time to this work, one being in charge ofthe program. Patients were transferred to the reconditioning section with theircompleted clinical record. A final note was placed on theclinical record when convalescent training, which oftenculminated in a 15-mile hike, was completed. Most Class I and Class II patientsrequired from 18 to 21 days of reconditioning. Candidates for medical dischargewere moved early to a "CDD" (certificate of disability for discharge)barracks to avoid "contaminating" return-to-duty patients.
Further organization of the reconditioning program continuedas the war proceeded. Not only were convalescent training facilities at existinggeneral hospitals enlarged, but separate convalescenthospital centers were established.94 The concept was extended to themanagement of psychiatric patients and successful results were reported byRosner95 at Dale MabryField, Tallahassee, Fla., and by Cotton96 at Mason General Hospital,Brentwood,N.Y. On 6 September 1944, the Surgeon General's Officeannounced that one hospital in each service command would be designated as aneuropsychiatric reconditioning center to which anypatient who was considered as having a remote chance ofperforming military service would be sent for a trial of reconditioning.97
Also initiated by the Surgeon General's Office was the ReconditioningNewsletter for monthly distribution to all Armyhospitals in order to dis-
94ConvalescentHospitals. Bull. U.S. Army M. Dept. 2: 19-20, October 1944.
95Rosner, A. A.: TheNeuropsychiatrist and Convalescent Training Program of theArmy Air Forces. Bull. U.S. Army M.Dept. 2: 93-97, July 1944.
96Cotton, H. A., Jr.:Reconditioning Neuropsychiatric Patients in the Army. Mil.Surgeon 97: 450-455, December 1945.
97Reconditioning Notes. Bull. U.S. Army M. Dept. 2: 30-31,October 1944.
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seminate widely new ideas, practices, and procedures.Reconditioning programs were further elaborated and divided into three basiccomponents; namely, educational, physical, and occupational therapy. In each ofthese areas, technical manuals and training films were produced and distributed.98
The extent to which the reconditioning program becameintegrated as part of the psychosomatic development of military medicine ofWorld War II is indicated by an open letter to hospital commanders from Maj.Gen. Norman T. Kirk, The Surgeon General of the Army.99 In this letter, GeneralKirk points out: "If you treat only their bodies and forget their minds youwill have accomplished less than your full duty." The letter urges greaterefforts toward implementing the reconditioning program and comments further:"Treatment of the whole patient, watching closely his progress, encouraginghim to participate, taking pride in his mental as well as physical progress, isan essential of good medical care."
Psychosomatic Concepts in Hospital Practice
Gastrointestinal disorders.-The evolution of thepsychosomatic viewpoint in the management of inpatients is perhaps bestillustrated by the experience with persistent disorders of the uppergastrointestinal tract, chiefly peptic ulcer, probably the most common cause ofmedical disability in World War II.
Before the United States entered the war, there appearednumerous reports of the unusual high rate of functional dyspepsia and pepticulcer in the Armed Forces of England, Canada, and Germany.100Willcox,101Payne and Newman,102 and others found duodenal ulcer to be the major cause formedical invalidism in the British Forces. Curiously enough, it was noted thatpeptic ulcer was only a minor problem of World War I, while neurocirculatoryasthenia was a prominent disorder. The reverse situation obtained in World WarII. Jones and Scarisbrick,103 on the basis of extensive experiencewith cases of neurocirculatory asthenia, believed that the medical profession ofWorld War II viewed "effort syndrome" as a psychiatric disorder. Theythought this change of attitude was responsible for the decreased incidence andargued against retaining the diagnosis, since almost all cases of neurocirculatoryasthenia could be readily placed in the psychiatric category.
98(1) Boeckman, F. P.: TheReconditioning Program; The Army's Answer to the Manpower Shortage. J.A.M.A.125: 280-282, 27 May 1944. (2) Rankin, F. W., and Barton, W. E.: PresentStatus of Rehabilitation in theU.S. Army. J.A.M.A. 125: 256-258, 27 May 1944. (3) Reconditioning of Patients. Bull. U.S. Army M. Dept. 2: 23-24, August 1944.
99Kirk, N. T.: A Letter to Hospital Commanders. Bull. U.S.Army M. Dept. 3, February 1945.
100Pepper, O. H. P.: Disease Expectancy in the New Army.War Med. 1: 463-469, July 1941.
101Willcox, P. H.: Gastric Disorders in the Services. Brit. M.J. 1: 1008-1012, 22 June 1940.
102Payne, R. T., and Newman, C.: Interim Report on Dyspepsiain the Army. Brit. M.J. 2: 819-821, 14 Dec. 1940.
103See footnote 31, p. 683.
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All British reports agreed that most cases of peptic ulceroriginated in civilian life and were only brought forth or exacerbated bymilitary life. Hurst104 expresseda common viewpoint when he flatly blamed the increase of peptic ulcer upon"heavy Army food." With other observers, he advocated the rejection ofindividuals with peptic ulcer at induction and prompt medical discharge whenfound in the service except those military personnel who could obtain specialfood at regular hours. Hinds-Howell105 recommendedthat even cases of functional dyspepsia should be discharged, but Hurst insistedthat such patients could be benefited by early treatment directed to restoretheir ability to eat army food and face army life. Hurst pointed out that iftreatment is not given early in such cases the result is "disordered actionof the stomach," which he believed had replaced the effortsyndrome of World War I.
In sharp contrast was the German attitude as expressed byStehr,106 who stated that only active pepticulcer cases are unfit for work. Then, treatment is indicated, but such patientsshould not be kept too long away from physical activity because dietetictreatment was complemented by exercise and work. Stehr argued that the danger ofrecurrent ulcer or life-threatening hemorrhage is no greater during work than itis during rest. Schindler107 disagreedwith Stehr's back-to-work regime, considering it to beneither practical nor humane. He also advocated the discharge of all patientswith peptic ulcer unless manpower needs became critical.
As the American Army mobilized, particularly after PearlHarbor, the frequency and importance of persistent disorders of the uppergastrointestinal tract soon paralleled the British experiences. Publishedreports indicated that from 30 to 40 percent of admissions to thegastrointestinal wards of Army hospitals were diagnosed as peptic ulcer, mainlyof the duodenal type.108 American observers, like their British colleagues,believed that in the majority of their ulcer patients the illness had originatedin civil life.
As in England, there arose conflicting opinions on the causeof the frequency of peptic ulcer under wartime conditions. One group insistedthat cases came from predisposed persons who had been traumatized by the Armydiet and that psychogenic factors played little or no causative role. Thus, Kirk109reported that the concept of theemotional genesis of peptic ulcer was not suggested by his experience at FortSill, Okla. He found that
104Hurst, A.: Digestive Disordersin Soldiers. Am. J. Digest. Dis. 8: 321-323, September 1941.
105Hinds-Howell, C. A.: A Reviewof Dyspepsia in the Army. Brit. M.J. 2: 473-474, 4Oct. 1941.
106Stehr, L.: Die Beurteilung der Wehrdienst und Arbeitsf?higkeit bein chronischMagenkranken. M?nchen. med. Wchnschr. 87: 1317-1322,29 Nov. 1940. (Abstract in War Med. 1: 730-732,September 1941.)
107Schindler, R.:Gastroenterology in the Army; Methods of Examination and Disposition of Cases.War Med. 2: 263-276, March 1942.
108(1) Chamberlin, D. T.: APlan for Standardization of Diagnosis and Treatment of Peptic Ulcer. Mil. Surgeon 93:157-164, August 1943. (2) Kirk, R. C.:Peptic Ulcer at Fort Sill. Am. J. Digest. Dis. 10: 411-413, November 1943. (3)Berk, J. E., and Frediani, A.W.: Peptic Ulcer Problem in the Army. Gastroenterology 3: 435-442, December 1944.
109See footnote 108 (2).
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the incidence of peptic ulcer in psychoneurotic patients wasnot increased and concluded that intolerance to greasy foods was the greatestobstacle to satisfactory military service. He was partially supported byChamberlin,110 asserting: "It was not safe for a patient withulcer to be on duty. He can do better in civilian life where he can regulate hishours and diet." However, Chamberlin also believed that contributing toulcer breakdown were psychogenic factors which varied from simple dislike of theservice, to difficult adjustment to army life, to toxic psychosis. Cheney,111 ina study of 418 cases at Hammond General Hospital, Modesto, Calif., also failedto find an association between psychoneurosis and peptic ulcer. However, exceptfor 31 cases, he noted that special diets made no difference in treatment andthat a liberal diet made no patient worse.
A majority of American observers ascribed to psychogenicfactors, as their major cause, ulcer breakdowns inmilitary personnel. Flood,112 on the basis of careful clinicalstudies at the Station Hospital, Fort George G. Meade, Md., concluded that thefundamental cause of chronicity of peptic ulcer in most cases was an associatedanxiety state-in fact, an anxiety or fear reaction. Flood found that stablepersonalities responded well to treatment, whereas anxious patients did not. Headvised psychiatric evaluation to rule out neurosis before considering return toduty of any patient with peptic ulcer. Morrison113came to similar conclusions from his extensive experienceas gastroenterology consultant at an Army general hospital. He noted thatgastrointestinal referrals were most common from the neuropsychiatric service.Conversely, psychiatric consultations were most frequently requested from thegastrointestinal wards. A major complaint of both types of patient was aninability to tolerate the Army diet. On this subject, Morrison made thepertinent observation that, for the personnel stationed in the United States,nowhere is there better food than in the Army. Only occasional meals are notsatisfactory. Soldiers are not required to eat all that is offered and canpractically select their own diet. Like others, Morrison noted the disappearanceof gastrointestinal symptoms when patients learned of their contemplateddischarge or when declared unfit for oversea duty. He concluded that theinability to tolerate an army diet was symbolic of maladjustment to militaryservice. Sweeney,114 in summarizing the lessons learned during his 2 yearsas chief of the Medical Service, Bushnell General Hospital, Brigham City,Utah, also found the underlying basis of peptic ulcer to be neurosis oranxiety state, remarking that relief from situational anxiety paralleledimprovement in peptic ulcer. He cited the well-known phenomenon of the patientwith a diagnosis of peptic ulcer
110See footnote 108 (1), p. 697.
111Cheney, G.: Peptic Ulcer and Nutrition. Mil. Surgeon 95:446-454, December 1944.
112Flood, C. A.: Peptic Ulcer atFort George G. Meade, Maryland. War Med. 3: 160-170, February 1943.
113Morrison, S.: Interservice Consultations in One ArmyGeneral Hospital; Comments With Particular Referenceto the Section on Gastroenterology.War Med. 7: 84-94, February 1945.
114See footnote 51 (5),p. 687.
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made overseas, supported by X-ray evidence, who becomesasymptomatic and negative roentgenographically after return to the Zone ofInterior.
Berk and Frediani115 in 3 years of experience ingastroenterology at Tilton General Hospital found further evidence for thepsychological causation of acute breakdown of peptic ulcer. They cited patientswho were asymptomatic until the day before induction or until their first Armymeal. They also noted a remarkable subsidence when discharge was assured, orrecrudescence when soldiers were informed of their impending return to duty.These workers found that the aggressive, conscientious, or perfectionistpersonality types so commonly described in civilian patients with pepticulcer were infrequent in their military subjects, who were more apt tobe slovenly, placid, and slow-moving men. An editorial in the MilitarySurgeon,116 June 1943, perhaps bestexpressed the popular psychosomatic viewpoint relative to peptic ulcer inmilitary personnel by commenting that some soldiers simply had no stomach forwar.
Practically all observers agreed that, in general, treatmentof peptic ulcer in military personnel gave unsatisfactory results and thatdischarge from the service was the preferable and, in fact, the inevitabledisposition for most cases. Flood observed that in contrast with ulcer patientsin civilian life, of whom two-thirds were relieved within 2 weeks of the usualconservative Sippy regimen, only one-third of military patients obtained reliefand one-half continued to have symptoms even after 4 weeks of treatment.Followup X-ray studies confirmed that improvement occurred in only one-half ofthe cases. Best results were obtained in Regular Army personnel who were highlymotivated for return to duty. Reeser and Guthrie117reported that 81 percent of ulcer patients were discharged from the service.Chamberlin118 believed that patients withpeptic ulcer were unfit for service, for "no matter how well peptic ulcerseems at induction or after operation, breakdown in the service is inevitable.For even when well such individuals can be expected to neglect therapy ordiet." Berk and Frediani119 returnedto duty only 25 percent of Regular Army personnel, mainly men with uncomplicatedcases who had some special military skill. They were against the promiscuousemployment of gastric resection since this procedure did not alter the basicpersonal patterns nor did it remedy the emotional disturbance.
This almost uniformly gloomy prognosis for military patientswith peptic ulcer was formally acknowledged in War Department Circular No. 46, 7February 1945,120 which directed that allenlisted men hospitalized for
115See footnote 108 (3), p. 697.
116Editorial: The Stomach in War. Mil. Surgeon 92: 663-665, June 1943.
117Reeser, R., Jr., and Guthrie, M. B.: The Management of Army Personnel With Peptic Ulcer; An Analysis of 200 Cases. Mil. Surgeon 98: 125-131, February 1946.
118See footnote 108 (1), p. 697.
119See footnote 108 (3), p. 697.
120War Department Circular No. 46, 7 Feb. 1945, sec. V, subject: Enlisted Men, Discharge for Chronic Peptic Ulcer.
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chronic symptomatic peptic ulcer be considered for separationexcept those who possessed unusual qualifications for military service.
In the latter phase of the war, because of manpowershortages, occasional efforts were made toward rehabilitation of ulcer patientsfor duty. One such attempt was reported by Goldbloom and Schildkrout,121who were assigned to a staging area medical facility. They noted the high rateof medical discharges in 1943, including 10 percent for gastrointestinaldisorders, mainly peptic ulcer. Stimulated by War Department Circular No. 293,11 November 1943, which directed the retention of personnel who could rendersome type of effective service, they chose for study 100 cases of chronicdisorders of the upper gastrointestinal tract. These patients originated mainlyfrom units in the process of oversea movement, but some were from the stationcomplement. They were given complete examination in the hospital, includingroentgenographic and psychiatric evaluation. All were then assigned to duty onthe post but were brought to the hospital messhall regularly for meals whichwere prepared under the supervision of the dietitian in cooperation with thegastrointestinal service. These patients were all followed by the outpatientservice, and adjustments were made in duty assignments as required. Small groupdiscussions were held to help the patients arrive at an understanding of theirproblems with respect to their digestive disorders, their adjustment in theservice, and their personal difficulties. Of the 50 peptic ulcer cases, goodresults were obtained in 38 (76 percent). The 50 patients with chronicfunctional dyspepsia had poor morale and definite psychoneurotic background ascontrasted with the ulcer group. Of these 50 patients, 30 (60 percent) seemed tofunction reasonably well on duty. Goldbloom and Schildkrout concluded thatapproximately 70 percent of the entire group could be salvaged for militaryservice. A small number were maintained successfully on regular militaryrations, but in a majority of cases attempts at imposing a usual diet resultedin increasing pain and intolerance, forcing return to a special dietary regimen.
By the time the war ended, a good deal of understanding hadbeen achieved insofar as mind-body relationships were concerned in peptic ulcerand chronic dyspepsia. (See pages 710-711.) Most patients in this categoryhowever, were found to be unusable on a duty status and were discharged from theservice.122
121Goldbloom, A. A., and Schildkrout, H.: Dyspepsia Regimen; A Method of Rehabilitation. War Med. 6: 24-26, July 1944.
122After the war, military gastroenterologists pursued the question of diet and the usability of personnel with peptic ulcer, who in other respects exhibited excellent military potential, since many such men had performed superior duty even under stressful conditions. Based on the work of E. D. Palmer, B. H. Sullivan, and E. L. Hamilton (Duodenal Ulcer in Military Personnel: Studies on Military Effectiveness of the Ulcer Patient. III. Review of 350 Cases of Recurrent Duodenal Ulcer. U.S. Armed Forces M.J. 3: 1123-1133, August 1952) and the later work of Sullivan and Hamilton (Peptic Ulcer in Military Personnel; Incidence and Management. U.S. Armed Forces M.J. 6: 1459-1468, October 1955), an entirely different approach was evolved, denying that army diet or any diet was a primary cause of ulcer breakdown and proposing that ulcer patients when improved could and should perform military service provided the psychological factors could be satisfactorily alleviated. This viewpoint prevailed during the Korean War and has now become current operating policy in the Army. In a study (Yessler, P., Reiser, M., and Rioch, D. McK.: Blood Pepsinogen and Peptic Ulcer in Inductees. (To be published.)) on predisposition to peptic ulcer, followup examination of 16 young draftees in whom ulcer had been diagnosed early in the course of their military career showed that 15 remained on duty status after treatment and satisfactorily completed 2 years of military service.-A. J. G.
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Elective surgery.-Another psychosomatic insight thatgained wide recognition in World War II was an awareness that persistentsymptomatology of neurotic type, similar to the well-known compensationneurosis, not infrequently may complicate the results of elective surgery. Atypical sample is found in the report of Butsch and Harberson123on the results of elective surgery for varicosities of the lower extremities. Inthis series, 98 cases were chosen for operation because of complaints referableto the legs, obvious varicose veins and a competent deep venous circulation. Theusual ligation and section procedure was performed. A 3-month followup studyinvolving 35 cases revealed that only 10 had achieved symptomatic relief; theremaining 25 individuals complained of more difficulty with their legs thanbefore the operation. The multiplicity of their complaints seemed incrediblesince careful examination of each soldier found 31 of the 35 subjects to haveperfect surgical results with no instance of postoperative swelling. Acorrelation between maladjustment and the persistence of complaints was evidenton psychiatric evaluation which further elicited unrelated symptoms, such asnervousness, headache, dizziness, gastrointestinal discomfort, and hyperhydrosis.In these cases, varicosities represented only an unimportant part of thesoldiers' difficulties upon which operation had crystallized and fixated arational reason for medical disability. These observers concluded that, whenconsidering operation for varicosities, one should regard with suspicion theyoung soldier with a multiplicity of complaints. The presence of varicose veinsis not in itself an indication for surgical treatment. One must consider theentire person-his past and current adjustment. A similar caution was soundedby Haynes124 in advocating carefulselection of cases for the surgical relief of lumbar herniated-disk syndromes.He warned against enthusiasm for the surgical approach in these cases andinsisted that a "psychiatrically sound" soldier is a paramountprerequisite before considering operative intervention. Experience with electivesurgery of the knee joint also exemplified the need for a careful selection ofcases from the psychological standpoint.125
In contrast to this, Rosenbaum126deliberately employed elective surgery in a psychosomatic approach to improveeffectiveness. He noted that, of 44 soldiers with strabismus, 35 were on alimited-duty status mainly because of their physical appearance and consequentinferiority feelings.
123Butsch, W. L., and Harberson, J. C.: Importance of Careful Selection of Soldiers for Ligation of Varicose Veins. Bull. U.S. Army M. Dept. 4: 226-230, August 1945.
124See footnote 60, p. 688.
125Selection of Cases for Arthrotomy of the Knee. Bull. U.S. Army M. Dept. 4: 4-5, July 1945.
126Rosenbaum, H. D.: Strabismus in the Army. Mil. Surgeon 95: 48-52, July 1944.
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Surgical correction of the cosmetic defect produced increasedself-esteem and self-confidence, and many were raised to a full-duty status.Indeed, two men volunteered and were accepted for Officer Candidate School.
Ocular disorders.-Psychosomatic considerations werealso found to be prominent in other ocular disorders. Birge127described individuals with symptoms of persistent headache, photophobia, loweredvision, with loss of visual acuity up to 50 percent, burning and watering of theeyes due to increased autonomic activity of the lachrymal glands, sweaty palms,tremor, and often a history of nervousness. Such cases were found in personsawaiting shipment overseas and in those who had recently suffered the loss ofone eye because of disease or injury, the other eye being normal. These patientsreceived little benefit from spectacles or eye medication but requiredreassurance in psychiatric treatment. Similarly, McAlpine128noted the frequency of "functional" ocular disorders in militarypersonnel. Common manifestations were blepharospasm, asthenopia, spasm ofconvergence and accommodation, and anomalies of conjugate deviation. Pupillaryreactions were normal and amblyopia a relatively rare phenomenon. McAlpine foundthat such ocular difficulties arose as a result of the patient's inadequacy incoping with an unpleasant or difficult situation. Symptoms could be precipitatedby a mild blow on the head or by a major situational problem.
Rheumatic fever.-In a few notable instances, apsychosomatic or total approach to illness was the basis initiating majorchanges in the overall management of complex disease entities. This is perhapsbest illustrated by the report of Holbrook and van Ravenswaay129on the treatment and management of rheumatic fever. This had become a majorproblem of World War II with 400 cases originating monthly from Army Air Forcespersonnel alone. Generally, 85 percent of patients with rheumatic fever weremedically discharged, many with cardiac neurosis. A new comprehensive programwas begun in 1944, including measures of prevention, treatment, convalescentactivity, and selective assignment to duty. Prevention was accomplished by theadministration of prophylactic doses of sulfathiazole to personnel in areas ofhigh disease incidence. Treatment procedures included the transfer of patientsin litters to hospitals located in geographic areas of low incidence as soon asacute symptoms subsided (usually after the first few weeks). By this move, thelikelihood of recurrence of rheumatic fever was markedly reduced (no recurrencein 1,000 cases). The transfer of patients also concentrated their care in thehands of experienced personnel who avoided the error of undue attention to thecardiac aspects of the disease. This diminished the incidence of cardiacneuroses that had hitherto been almost as important a cause for discharge anddisability as
127Birge, H. L.: Ocular War Neuroses. Arch. Ophth. 33: 440-448, June 1945. (Abstract in War Med. 8: 181-192, September 1945.)
128McAlpine, P. T.: Hysterical Visual Defects. War Med. 5: 129-132, March 1944.
129Holbrook, W. P., and van Ravenswaay, A. C.: The Military Aspects of Acute Rheumatic Fever. Mil. Surgeon 96: 388-391, May 1945.
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organic cardiac sequelae. In the new hospital, an activeconvalescence program was initiated with the quiescence of the rheumaticprocess. Objective tests of physical fitness were employed so that patientscould measure their progress by a practical yardstick that they could see andunderstand. After convalescent activities, those with no sequelae were given a12-day trial of simulated duty, including hikes, bivouacs, drill, and exercises,which demonstrated both to the patients and to their medical officers arealistic appraisal of physical ability to perform duty. Concurrent with thisactivity, job-assignment officers reviewed the patients' capabilities for thedetermination of a suitable military assignment. Then followed on-the-jobtraining for such an assignment under medical supervision. After successfulcompletion of the convalescent phase, patients with no demonstrable sequelaewere returned to limited duty for 6 months in an area of the United States freeof rheumatic fever. If found to be still without residua after this 6 months'assignment, they were returned to full duty. Patients found to have permanentcardiac damage but good cardiac reserve were given a permanent limitedassignment in an area of low incidence in the Zone of Interior. Patients havingin addition to permanent cardiac damage either impaired cardiac reserve or nouseful assignment potential were medically discharged after maximum improvement.The overall results of this program demonstrated a decrease of medicalseparations in rheumatic fever patients from 85 to 25 percent, with a minimum ofcardiac neuroses.
Peripheral nerve injuries.-Another striking exampleof the practical utilization of the psychosomatic viewpoint in the management ofdisease was furnished by the treatment regimen for peripheral nerve injuriesestablished by Lewey and Bowles130 at CushingGeneral Hospital, Framingham, Mass. Known as the work-furlough program, it wasintroduced to provide a practical incentive, during the long convalescentperiod, to improve the use of an impaired extremity by exercise. These patients,while still in the service, were given a 90-day work furlough. With thecooperation of civilian and welfare agencies, a full-time position was found forthem in nearby factories or businesses. After 90 days, patients were againevaluated, usually at weekend periods, in order to avoid loss of time from work.If maximum improvement was found, such patients were medically discharged andcould promptly resume their work and continue their new civilian adjustment. Iffurther improvement was possible, they were given another 90-day furlough andreevaluated at the end of this period. By this method, active convalescence wascarried on in an atmosphere that permitted a gradual transition to civil life,provided the practical incentive of pay, and fostered the return of self-esteemand self-confidence in persons who had temporary or permanent disability.
130Lewey, F. H., and Bowles, G. K.: Work Furloughs for Patients With Peripheral Nerve Injuries. Bull, U.S. Army M. Dept. 4: 683-686, December 1945.
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Part III. During Oversea and Combat Duty
Oversea duty during World War II intensified the probabilityof exposure to a wide variety of frustrations, deprivations, and hazards. Inaddition to prolonged separation from home and family, there were encountered,either singly or collectively, such stressful circumstances as climaticextremes; monotonous diet, work, and recreation; isolated assignments in unusualgeographic locations, such as tropical jungles or barren islands; threats ofstrange and ominous diseases, such as scrub typhus, schistosomiasis, malaria,and filariasis; and the intermittent terror and danger of combat. It may beassumed, however, that men who were sent overseas had achieved some degree ofadjustability to military stress by virtue of their indoctrination and trainingexperiences. Moreover, many of the weaker and presumably more vulnerableindividuals had been eliminated from oversea duty by assignment limitation ordischarge from the service for medical or administrative reasons.
Despite these qualifications, oversea service, particularlyduty involving the cumulative effects of combat or isolated assignment, posedgreater difficulties in adaptation than the transition from civil to militarylife or other vicissitudes of military service in the United States.Disturbances of adjustment under these circumstances were interwoven into thevarious clinical disorders that confronted each medical officer. Therelationship of oversea stress to symptoms and disability was recognized by mostmedical personnel and facilitated acceptance of a holistic mind-body approach tothe management of many disease and injury syndromes.
COMBAT FATIGUE
This growth of psychosomatic concepts in oversea medicalpractice is perhaps best exemplified by the evolution of understanding andmethods of management in so-called combat exhaustion or combat fatigue. It willbe recalled that this entity termed "shellshock" in World War I, wasinitially thought to be an organic brain disorder similar to, if not identicalwith, cerebral concussion. Later in World War I, it was commonly agreed thatshellshock was the result of psychogenic trauma. Subsequently, the observationand treatment of veterans with chronic neurotic symptoms following shellshockgave further confirmation of its psychological origin, and the syndrome wasdesignated as a traumatic neurosis. Thus, the pendulum has swung from a whollyorganic to a completely psychological concept of causation. Early in World WarII, the psychogenic viewpoint continued to prevail. But experience with combatpsychiatric casualties soon made it evident that both psyche and soma wereinvolved. It was found that most psychiatric casualties occurred when units werelocked in heavy combat for several days in either offense or defense.Characteristic syndromes appeared
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in which it was apparent that physical strain played aprominent role in reducing the individual's resistance to the psychologicaltrauma of combat. Indeed, the very terms that came to be applied in such cases,namely, "combat exhaustion" and "combat fatigue," arose fromthis common finding of physical strain. Hanson131graphically described such casualties as follows:
Their faces were expressionless, their eyesblank and unseeing, and they tended to go to sleep wherever they were. The sick,injured, lightly wounded, and psychiatric cases were usually indistinguishableon the basis of their appearance. Even casual observation made it evident thatthese men were fatigued to the point of exhaustion. Most important of thefactors that produced this marked fatigue was lack of sleep. Under almost allcombat conditions the infantryman gets too little sleep. The conditions of hisexistence-the almost continuous shelling, the strange night noises, flares,sentry and patrol duties, rain, snow, cold, heat, insects, and the ever presentthreat of the enemy-conspire to make his sleep at best intermittent andscanty. In spite of this lack of sleep he must undergo long periods of severeexertion, more often than not on a diet that is at best deficient in calories.Often the food is there for him, but he either cannot carry enough of it withhim or is too frightened to eat the proper amount. Sometimes the type availablehas become distasteful through monotony.
Combat troops who were not psychiatric casualties alsodisplayed this characteristic battle weariness, as witness Ernie Pyle's132moving account:
For four days and nights they have foughthard, eaten little, washed none, and slept hardly at all. Their nights have beenviolent with attack, fright, butchery, and their days sleepless and miserablewith the crash of artillery. The men are walking * * *. Their walk isslow, for they are dead weary, as you can tell even when looking at them frombehind. Every line and sag of their bodies speaks their inhuman exhaustion. Ontheir shoulders and backs they carry heavy steel tripods, machine-gun barrels,leaden boxes of ammunition. Their feet seem to sink into the ground from theoverload they are bearing. They don't slouch. It is the terrible deliberationof each step that spells out their appalling tiredness. Their faces are blackand unshaven. They are young men, but the grime and whiskers and exhaustion makethem look middle-aged. In their eyes as they pass is not hatred, not excitement,not despair, not the tonic of their victory-there is just the simpleexpression of being here as though they had been here doing this forever, andnothing else.
The somatic component of combat fatigue was furtherdemonstrated by the not infrequent finding, in these cases, of intercurrentdisease, such as infectious hepatitis, malaria, diarrhea, and the like.133Here was evidence that so-called organic illness had undermined theability of the individual to withstand the inroads of battle terror, since thesepatients had the usual symptoms of combat fatigue; namely, an inability tocontrol their behavior in combat, overt manifestations of anxiety, startlereaction, and the almost invariable complaint of intolerance to the sounds andnearness of shellfire.
The fact that physical fatigue lowered the soldiers'ability to tolerate stress was also confirmed by the dramatic improvement ofcombat psychiatric casualties after 12 to 24 hours of sleep and food. Withphysical re-
131Hanson, F. R.: The Factor of Fatigue in the Neuroses of Combat. Army M. Bull. Supplement No. 9: 147-150, November 1949.
132Pyle, Ernie T.: Here Is Your War. New York: Henry Holt & Co., Inc., 1943, pp. 247-248.
133Glass, A. J.: Combat Exhaustion. U.S. Armed Forces M.J. 2: 1471-1478, October 1951.
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cuperation, overt signs of anxiety diminished or disappeared,confidence was restored, and the former psychiatric casualty was again capableof appropriate behavior in battle. This finding became the cornerstone of thesuccessful forward management of combat psychiatric casualties, which returnedto combat duty from 60 to 70 percent of patients after a 1- to 4-day treatmentperiod.
It should be made clear that physical fatigue did not initself produce psychiatric casualties. This fact was amply demonstrated by themany occasions in which units, advancing rapidly for days against slight enemyopposition and, therefore, enduring little emotional stress, had few or nopsychiatric casualties even though conditions were such as to induce extremephysical fatigue. Conversely, a minority of psychiatric casualties occurredeither immediately before battle or in the early stages of combat before anysignificant degree of physical strain was possible. Such patients were notconsidered to have genuine cases of combat exhaustion because the factor ofphysical fatigue was absent.
OTHER PROBLEMS
Combat fatigue represented an overt breakdown of adaptationto battle stress. Less obvious but more frequent manifestations of inability toendure the combat environment were a wide variety of symptomatic disorderspresented to medical officers as evidence of incapacitating disease or injury.The following three major types of these clinical problems could bedistinguished:
1. Persistent symptoms associated with negative findings ofsomatic disease.-This group included syndromes of constant headache; chroniclower back pain; recurrent digestive upset (dyspepsia); frequent episodes ofweakness, giddiness, or faintness; painful feet; increased sweating,palpitation, or other manifestations of autonomic overactivity; and similarsubjective disorders. Essentially, these complaints could be equated with someaspect of physical or mental discomfort suffered by most combat participants.Here, subjective discomfort was interpreted by the soldier concerned asindicating the presence of illness and, therefore, a legitimate reason for atleast temporary removal from battle.
2. Persistent symptoms associated with minor objectivefindings of somatic disease or injury.-The important characteristic of thisgroup was the disparity between the slight or moderate evidence of structuraldisease and the severity of the symptomatology. These cases posed diagnosticproblems, for indeed there were findings such as scoliosis, shortening of onelower extremity, localized muscle atrophy, purulent discharge from a pilonidalsinus, deviation of the nasal septum with congested nasal mucous membrane andpostnasal discharge, myopia, astigmatism or other visual refractive error,residua of an old knee injury, scars from trauma or sur-
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gery, hypertrophic arthritis, and minor bruises and sprains.The symptomatology was focused upon and systematized around the particularphysical finding. Current difficulties were blamed upon a recurrence orexacerbation of the previous disorder by virtue of strenuous exercise, minorinjury, adverse climate, or primitive living conditions in the field. In thisgroup, also, the drive for medical attention stemmed from a failure of combatadjustment rather than from a minor limitation of bodily function.
3. Persistent symptoms during or following convalescence froman acute disease, injury, or battle wound.-These were a problem usually duringhospitalization when it became evident that impending recovery would result in areturn to combat duty. The symptoms of pain, discomfort, or limitation offunction seemed to arise as residual complications of the acute illness. Thus,there were digestive disturbances and pain in the right upper quadrant followingthe subsidence of infectious hepatitis; painful scars or limitation of jointmotion following wounds or indeed elective surgery; weakness, easy fatigability,and chills after recovery from a malarial attack; and headache, irritability,giddiness, and inability to concentrate after head injury, meningitis, or otheracute cerebral syndromes. The gain through illness in these cases wassubstantial. It was apparent to patients and medical officers alike thatcontinued incapacity was rewarded by evacuation to the United States or at leastreturn to duty in a noncombat assignment.
The widespread prevalence of these psychosomatic problems andthe difficulties that they presented in diagnosis, treatment, and dispositionwas a characteristic feature of military medicine in oversea theaters.Symptomatic disorders with negative or minor objective findings were mainlyhandled by the combat medical officer, particularly the battalion surgeon. Here,the physician was truly in a doctor's dilemma. It was easy to identify himselfwith the physical and mental strain of the soldier and his conscious orunconscious drive to obtain relief from battle. The field medical officer couldreadily convince himself that medical evacuation was justified in the interestof accurate diagnosis, which required laboratory and X-ray facilities availableonly in rear medical facilities. But to evacuate soldiers because of subjectivecomplaints would only stimulate many others who were equally uncomfortable toattempt the medical escape route. Moreover, his line and medical superiorofficers would soon question a lenient evacuation policy that materiallydepleted the fighting strength. With time and experience, most combat medicalofficers came to adopt a realistic approach, with the objective findings ofdisease and the overall effectiveness of the individual their main considerationrather than the traditional reliance on symptoms and differential diagnosis. Thefact that the combat medical officer shared to some extent the dangers andhardships of combat troops enhanced his ability to distinguish betweendiscomfort and disease, lessened feelings of guilt for refusing medicalevacuation, and facilitated an identification of
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himself with the needs of the unit rather than with thedesires of the individual.
Not infrequently, however, medical officers yielded to thedemand of subjective symptoms and evacuated persistent complainers. That thispractice was not rare is indicated by an editorial134which argued against evacuation from combat for slight wounds and subjectivecomplaints. Medical officers were urged to ignore what the patient says andevaluate disability almost entirely on objective findings. A new concept,phrased "medical discipline," came into common usage. Loose medicaldiscipline during an active battle period could readily deplete the combatcommand and overload medical evacuation channels at a time when hospitals werefully occupied with the wounded. These uninjured ambulatory patients were eitherneglected at forward hospitals or sent further along the evacuation chain tofixed hospitals at the rear. Return to combat duty from such distant medicalfacilities was not only difficult and time consuming but produced numbers ofresentful, poorly motivated soldiers who had convinced themselves of the meritof their symptoms, were repeatedly on sick call, and, in general, renderedinadequate duty.
A similar but somewhat more complicated problem was producedby the symptomatic disorders that occurred during convalescence from acuteinjury and disease. Here, the hospital medical officer was mainly involved.These physicians had not shared the combat hazards of their patients and haddeveloped positive relationships of varying degrees with patients during theacute phase of their illness. When these hospitalized patients complained ofresidual symptoms during convalescence or before expected return to duty andobjective findings of disease or its complications were not elicited, furthermanagement and disposition became a difficult matter. Often, the medical officerrecommended that the patient be given a noncombat assignment despite the absenceof any physical limitations. Not infrequently, he would reassure the patient andhimself by telling him to report to the battalion surgeon upon return to dutyand request assignment to light tasks or further consideration of hissymptomatology. This procedure almost invariably confirmed the patient'sbelief that he was not fully recovered from his illness or injury and createdchronic sick call problems for the battalion surgeon. At times, the hospitalmedical officer, frustrated by the patient's unexplainable symptoms, respondedwith anger and accusations of malingering. Obviously, this approach helpedneither the patient nor the physician. Many of these complaining patients werereferred to the psychiatrist because of "functional overlay" or"neurotic predisposition." This discharge of responsibility wasrightly regarded as a rejection by the patient, who insisted that his pain anddiscomfort were not "in my head" and remained resistant to anypsychiatric insight or help. Maj. Gen. Morrison C. Stayer,135
134Abuse of Medical Disposition Channels. Bull. U.S. Army M. Dept. 3: 34-35, February 1945.
135Stayer, M. C.: The Necessity of Making Decisions. (Editorial) M. Bull. Mediterranean Theat. Op., January 1945. (Cited in Bull. U.S. Army M. Dept. 3: 28-29, April 1945.)
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Surgeon, Mediterranean Theater of Operations, U.S. Army,commented on this problem in an editorial aptly entitled "The Necessity ofMaking Decisions." He enjoined medical officers not to "pass thebuck" to the battalion surgeons and insisted that they face up to theirresponsibility by informing patients that in view of negative disease findingsthey were considered fit for duty. As the deleterious effects of hospitalizationbecame recognized, active convalescent programs were instituted, much like thosethat had been developed in the Zone of Interior. Kunkel136described a reconditioning program in an oversea general hospital, wherepatients being returned to the Zone of Interior were physically separated fromthose being readied for return to duty. The latter were dressed in fatigueclothing, quartered in tents, and given physical exercise and military trainingunder the command of line officers. Kunkel noted that the patients who had beentransferred from other general hospitals and had been excused from all militarydiscipline were surly and arrogant and had developed symptom patterns againsttheir return to duty. Effective reconditioning programs in oversea hospitalswere also reported by Rathauser and Ulfelder,137and by Neu and Urban.138
SCRUB TYPHUS AND OTHER INFECTIONS
A special convalescent program for scrub typhus patients wasdescribed by Romeo,139 who detailedhis experience with 312 cases in a hospital in New Guinea, from July 1942 toSeptember 1944. Scrub typhus had been considered to warrant a prolonged periodof rest in bed after the acute phase. However, Romeo found that bed rest beyondthe febrile period was productive of flaccidity and loss of muscle tone andfostered a fear of the disease and its sequelae. Patients at bed rest duringconvalescence exhibited tachycardia (55 percent), tremor of the hands (60percent), and vertigo (25 percent), along with constipation, insomnia, andheadache. With the institution of a program of properly graduated activity,apprehension was allayed and most patients recovered completely for full duty inless than 9 weeks.
A similar experience was recorded in the management ofrelapsing (Plasmodium vivax) malaria by Gordon, Lippincott, and theircoworkers.140 These authors treated 435patients evacuated from the Southwest Pacific Area, a majority of whom had hadrepeated attacks of malaria. They dem-
136Kunkel, P.: Reconditioning Program in an Overseas General Hospital. Bull. U.S. Army M. Dept. 4: 586-590, November 1945.
137Rathauser, F., and Ulfelder, H.: Reconditioning Program in a Station Hospital. Bull. U.S. Army M. Dept. 5: 178-181, February 1946.
138Neu, H. N., and Urban, F. K.: Convalescence and Rehabilitation in a General Hospital in the Tropics. Mil. Surgeon 96: 377-385, May 1945.
139Romeo, B. J.: Convalescence From Scrub Typhus. Bull. U.S. Army M. Dept. 6: 167-173, August 1946.
140Gordon, H. H., Lippincott, S. W., and others: Clinical Features of Relapsing Plasmodium Vivax Malaria in Soldiers Evacuated From South Pacific Area. Arch. Int. Med. 75: 159-167, March 1945. (Abstract in War Med. 7: 414, June 1945.)
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onstrated the value of an active reconditioning program indispelling a commonly held anxiety of most patients that repeated attacksseriously compromised present and future health. An active reconditioningprogram coupled with work assignments on the post increased physical stamina,restored self-confidence, and removed the dread of the disease.
A special psychological problem became evident in soldierswho contracted filariasis. Coggeshall141described patients with filariasis in the Southwest Pacific Area who developedfear of permanent lymphedema from seeing natives with elephantiasis. Coggeshalldeveloped the policy of explaining to each patient that the end result offilariasis was good, with eventual recovery. Patients were given a series ofgradually increasing exercises and placed on full duty. The mental response wasprompt and favorable. Men became less apprehensive even though an occasionalflareup of edema or lymphangitis occurred. This observer concluded that soldierswith filariasis should not be permitted to deteriorate mentally and physicallyby prolonged hospitalization.
GASTROINTESTINAL DISORDERS
As in the Zone of Interior, disorders of the uppergastrointestinal tract were a conspicuous problem among oversea and combattroops. Peptic ulcer was apparently of minor importance in comparison with themore numerous cases of functional dyspepsia. Magnes142reported on the operation of an outpatient gastrointestinal service inEngland. He noted that "preinvasion jitters" brought on functionaldisorders and lighted up cases of quiescent peptic ulcer. Vomiting was a commonsymptom. Magnes confirmed the value of outpatient management in lesseninginvalidism and persistence of symptomatology.
Because of the frequency of gastrointestinal disorders in theMediterranean theater, a special field facility was created for the diagnosisand treatment of these conditions. This unit, a platoon of a field hospital, waslocated at the evacuation hospital level, with an experienced gastroenterologist,a psychiatrist, and a radiologist on the staff. Cases were carefully but rapidlyevaluated by means of roentgenographic, gastroscopic, psychiatric, and clinicalstudies. In reporting the results of this specialized hospital, Halsted143noted that, of 110 combat soldiers with chronic gastrointestinal complaints, 59percent were found by gastroscopic examination to have normal mucosa while theremainder showed a mild superficial gastritis. No correlation was observedbetween the appearance of the gastric mucosa and
141Coggeshall, L. T.: The Problems of Filariasis. South. M.J. 38: 186-189, March 1945. (Abstract in War Med. 8: 61, July 1945.)
142Magnes, M.: A Gastro-Intestinal Outpatient Service. Bull. U.S. Army M. Dept. 3: 99-103, February 1945.
143Halsted, J. A.: Clearing Company for Gastro-Intestinal Disease. Bull. U.S. Army M. Dept. 3: 90-95, May 1945.
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the severity of symptomatology. In one 4-week period, 263cases were processed with an average hospitalization of 8.7 days; 80 percentwere returned to duty and only 7 percent evacuated to a general hospital. A vastmajority of cases (84 percent) were considered to be primarily of psychologicalorigin. It was the experience of the author and other division psychiatriststhat peptic ulcer occurred rather infrequently during combat, whereas syndromesreferable to the upper gastrointestinal tract, including nausea, anorexia, andvomiting, were common. It appeared that situations of acute danger were less aptto provoke peptic ulcer than the chronic deprivations and frustrations ofnoncombat situations.
Blumgart and Zetzel (ch. XII, p. 310) have emphasized thatsome 90 percent of all cases of peptic ulcer occurring in the Army originatedduring civilian life. On the other hand, there were men who had endured thestresses of civilian life and the strains of military training and transport andonly then, during oversea service, developed ulcers. The inference was drawnthat, although there may well have been a psychogenic component in such cases,more severe strains were required for their inception. Evidence, though scanty,supported the view that this group responded well to treatment; of 54 patientsreturned to appropriate duty following therapy, only 8 had to be rehospitalized.144
SUMMARY
Medical practice in the relatively slow tempo of peacetimegenerally focuses upon the biological difficulties of the patient and usuallyignores the sociological and psychological aspects of adjustment. The physiciansees the patient in an office, clinic, or hospital, and confines himself tosymptoms and complaints referable to bodily dysfunction or defect. Ordinarily,the physician has little time or opportunity to become familiar with theenvironment or milieu of his patient or its effects upon the symptoms orclinical course of the disease. War, with its characteristic situationalchanges, dramatically brings to the forefront the environmental aspects of man'sstruggle for existence. Thus, a byproduct of modern war has been advances inmedicine stemming from a better understanding of environmental dangers, such asthe control of infectious disease, sanitation, and the surgical treatment ofinjuries. These benefits were also evident in World War II, and in additionmilitary medicine learned to appreciate psychological and sociologicalinfluences upon disease and adjustment. It was this experience in militarymedicine that made possible the growth of the psychosomatic viewpoint. Althoughpsychosomatic concepts originated before World War II, they received a majorimpetus during the war years, for here was a vast laboratory of stress wherephysicians could observe firsthand the effects of
144Report, Head, D. P., Wilen, C. J. W., and Fradkin, N. F., to Surgeon, MTOUSA, subject: Survey of the Peptic Ulcer Problem in MTOUSA, 1943-45.
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mind-body interrelationships upon symptoms, treatment, anddisposition in almost any disease and injury. It can be stated that World War IIproduced no evidence that a psychological trauma caused specific somaticdisease. Amply demonstrated, however, was the fact that in order to obtain goodclinical results in disease and injury it was necessary to take into accountvarious pertinent aspects of the patient's individual reaction to environment,such as motivation, group and cultural attitudes, the influence of the treatmentmilieu upon the effectiveness of improvement or recovery, and personalitycharacteristics of the sick or injured person.
